Arch Dis Child: first published as 10.1136/adc.63.6.666 on 1 June 1988. Downloaded from

666 Archives of Disease in Childhood, 1988, 63 equation increased r to 0(79. Age added little more a threefold increase of insulin dosage to maintain (r=080). euglycaemia and an acceptable growth spurt. As growth hormone secretion decreases after puberty it Discussion is possible that insulin requirements will also fall in adulthood. These data show a simple linear relation between height velocity and fasting serum insulin concentra- tion. This association is probably indirect and References secondary to changes in IPirart J. Dilabctcs ilcilittis and its dcgcncrativc complications: a circulating growth hormone propcctivc study ol 4 400 patients observed betwccn 1947 and concentration. Growth in mid childhood is growth 1973. Diabetes Care 1978X:1:6-1 883252-63. hormone dependent while that of puberty results I Iiiilndiirsh P. Sillth PJ, Brook CGD. Matthiews DR. The from synergism between growth hormone and cir- relationship betwcen hcight velocity and growthi hormilone sex sccrction in short prcpubcrtal childrcn. Clin LEdaocrinol (Ox]') culating steroids.2 -High circulating concentra- 1987 ;27:58 1-9 1. tions of growth hormone are known to increase 3 Brook CGD. Growth ars.sessmenit in childhood a1t(1 adlolescence. fasting insulin concentrations and to promote insulin Oxford: Blackwcl SciCiltific PuLblications. 1982. resistance at peripheral tissues.' Morgan CR. Lazarow A. Imimiunoassav of insuilin: two aintibody The model proposed supports systciem. Diabetes 1963:12:115-216. the observation of Mauras N. Blizzard IRM. Link K. Johnson ML. Roi,ol AD. an increase in serum insulin concentrations associ- VcidhuLis JD. Augimnciitation of growth hormilonc sccrctioni ated with puberty. It suggests that a two to threefold duirinig puLberty: cvidcncc for a pulsc arnplitudc-modulatcd rise in fasting serum insulin concentration occurs as phenomcnon. 'J Clin Eldocrinol Metaib 1987;64:590-60)1. Roscnfeld RG, Wilson DM. Dollar LA, Bcnnctt A. Hintz RE. a result of a change in growth velocity from pubertal Both humiian pituitary growth hormonc and rccomnbinant DNA values of about 5-5 cm/year to that seen during the dcrivcd humilan growth hornionc cause inisulin resistance at a pubertal growth spurt of 10 cm/year or more. These postrcccptor sitc. J C/lin lnlocriiiol Metab 1982;54:1033-8. data may have importance for clinicians caring for pubertal diabetic patients. If the findings of this Corrcspondcncc to Dr CGD Brook. Endocrinc Unit. Middlcscx Mortimer WIN copyright. study were extrapolated as an index to total daily Hospital, Strect. L.ondon 8AA. insulin requirement, such patients might need up to Acceptcd 21) January 1988.

Prepubertal hypertrichosis: normal or abnormal? http://adc.bmj.com/

J H BARTH, J D WILKINSON, AND R P R DAWBER Departments of Dermatology, Slade Hospital, Oxford, and Wycombe General Hospital, High Wycomnbe

ported because the excess hair growth is the primary

SUMMARY The pattern of hair growth, morphology disorder. on September 28, 2021 by guest. Protected of the hair shafts, and the hair root state are We report a series of children with hypertrichosis described in four girls and two boys with prepubertal as this pattern appears to have been ignored or, hypertrichosis. The exact nosology ot this form of conversely, given the diagnostic label of hirsuties: excessive hair growth is discussed in relation to the latter is a diagnosis that suggests an aetiology of hirsuties and the possibility of it representing an androgen hormone excess. 'atavistic' trait. Case reports Hypertrichosis in childhood may be seen in a variety Six children with noticeable congenital generalised of congenital and metabolic disturbances, after hypertrichosis were seen. There were two boys (ages administration of therapeutic agents in utero, and 31/2 and 71/4) and four girls (ages 2-1/4, 6, 61/2, and 8). after birth and in association with chronic disease.' Two boys and one girl were Asian; one of the other In most of these disorders the excess hair growth is three girls had a Celtic father, the other parents not considered to be a major component and is were Anglo Saxon. Five of the children had dark usually noted only for completion. In contrast, most hair and only one had blonde hair. Five of the cases of hypertrichosis lanuginosa have been re- children had no family history of excess hair. One of Arch Dis Child: first published as 10.1136/adc.63.6.666 on 1 June 1988. Downloaded from

Prepubertal hypertrichosis: normal or abnormal? 667 the girls had a brother with 'hairy elbows.' All the particularly noticeable in the temporal regions children had normal physical and mental develop- where the scalp hair merged into bushy eyebrows. ment and were entirely healthy. None of the The faces were covered with fine but densely children had been exposed to drugs known to cause pigmented hair (fig 1). hypertrichosis either in the prenatal or postnatal periods. Only the four girls presented with the Trunk problem of excess hair; one of the boys was seen The hair was more pronounced over the back and when he attended a dermatology clinic with his there was only minimal growth on the front of the brother, the other was coincidentally seen with chest and abdomen. The hair streams flowed around insect bites. the sides of the chest to the back, met in the midline and continued towards the sacrum, and gave an PATTERN OF HAIR GROWTH appearance of an inverted fir tree. In three of the The pattern of hair growth was similar in all cases, children a whorl was present overlying the spine although there were varying degrees of severity. In between the scapulae (fig 2). the two boys, there were sparse fine pigmented hairs around the root of the penis but this was not Limbbs progressive. In none of the other cases was there any The arms and legs were covered with long hair shafts suggestion of axillary or pubic hair development. which had the nature of thick, coarse, and curly The external genitalia were normal and appropriate terminal hair; these differed from other sites which for the age of the children and there was no breast were covered with vellus hair. This was appreciable development in the girls. The pattern of hair growth on the legs and at the elbow region where the hair was as follows: growth was profuse. Face There was a dense growth of terminal hair over the scalps, which had a low anterior hair line. This was copyright. http://adc.bmj.com/ on September 28, 2021 by guest. Protected

1.Fig I Lateral view oftheaetce aond slholulder ooflte Asiani lig 2 Later view oJ the irunk Of tre Asian girl snowinig girl showing blushly eyebrows anid hyipertrichosis on the liyperrtrichosis of the back and shoulder, and dense growth forehead, sicde of the face, ear, and11 .shoulder. on the arm particlilarly aroioid the elbow. Arch Dis Child: first published as 10.1136/adc.63.6.666 on 1 June 1988. Downloaded from

668 Archives of Disease in Childhood, 1988, 63

EXAMINATION OF HAIR obscure. It has been suggested that body hair is an Hairs plucked from the upper back and either thigh 'atavistic relic'.' This concept, however, is not or elbow region were examined by light microscopy. supported by detailed observations of hair patterns In all cases, the hair shafts had normal morphology in many species of animals, including primates, all of with well formed medullas. Examination of the hair whom have completely different patterns,> the most roots showed both anagen and telogen bulbs from prominent being the direction of hair growth on the all sites: unfortunately, many hairs had fractured back. In animals the hair grows from the midline above the roots preventing an accurate assessment towards the belly so that, in a quadruped, the hair of the ratio of anagen to telogen bulbs. acts as a watershed; in hypertrichotic children the direction is reversed. Discussion It is often held that 'racial hirsuties,' which is probably identical to the hypertrichosis described The pattern of hair growth in these otherwise above, is common among Asians.' It is clear from healthy children is quite unlike that seen in hirsuties. this report, however, that hypertrichosis does occur Hirsuties is the pattern seen in adults with cutaneous in white children, although it may appear to be more or systemic virilism; it is only seen in children prevalent among Asian children as their dark hair is suffering from virilising disorders-for example, more noticeable. The relative absence of body hair congenital adrenal hyperplasia or hormone secreting in the Mongoloid races further confirms that racial tumours. In hirsuties the hair growth is predomi- differences do occur.6 nantly on the upper lip, chin, abdomen, and inner It is unknown if the pattern of hypertrichosis thighs. described represents an abnormal entity or whether The main difference between the hypertrichotic it occurs as an extreme form of the normal range of pattern described in this report and hirsuties was the hair growth. Larger population studies of children hair growth on the face and trunk. The described will be required to determine this issue. facial hair pattern was dominated by bushy eye- brows, a low frontal hairline, and a hairy forehead. References copyright. The hair on the trunk was predominantly on the Rook AJ. Dawhcr RPR. Diseases of the liair tid( scalp. Oxford: back and extended to the shoulders and upper arms: Blackwell Scientific Publications, 1982:78-80,233-59. both these sites are the last *to be affected in 2 Barth JH. Normal hair growth in children. Pediatr Derinatol 1987;4: 173-84. hirsuties. The hair shafts on the face and trunk in 3 Broster LR. Hypertrichosis: a report of three cases. Br Med J hypertrichosis are fine, silky, and straight whereas in 195);i: 1 171-4. hirsuties they are thick, coarse, and curly.2 4 Eckes LK. Korperbehaarung: ein atavistisehes relikt? Der Such a detailed description of the pattern of hair Hautarzt 1987:;38:125-30. http://adc.bmj.com/ Kidd W. Trle directiot of hair itn antimnals anid mnatn. London: growth has only been given in a single previous Adam and Charles Black, 1903. report of uncomplicated hypertrichosis. 3 Other re- 6 Eckes LK. Bemerkungen zur ethnischen variation des ports in the paediatric and genetic literature are kopfhaares. Der Hattarzt 1985:36:381-5. difficult to interpret because of the seemingly Correspondence to Dr J H Barth, Department of Dermatology, interchangeable use of the terms hypertrichosis and Oxford OX3 7JH. hirsuties. Slade Hospital, Headington, is Accepted 8 February 1988 The aetiology of this form of hypertrichosis on September 28, 2021 by guest. Protected