Photo Essay: Childhood Alopecia

The mother of this 3-month-old girl was concerned about her baby's diffuse, gradual loss of scalp hair. The infant was otherwise healthy and was feeding normally.

Hair loss is common in the neonatal period. Typically, hair growth follows 3 phases: the anagen, or growth, phase (the hair grows approximately 1 cm per month); the catagen phase, during which the end of the hair forms a keratinized "club" and the hair follicle separates from the dermal papillae and moves upward toward the epidermis; and the telogen, or resting, phase, in which mitotic activity in the hair matrix ceases and hair growth stops. Hair in the telogen phase falls out in a random fashion.¹ Most newborn hairs are in the anagen phase at birth; however, within the next few days, there is an abrupt physiologic conversion to the telogen phase. Consequently, a high proportion of neonatal scalp hairs are shed during the first few months of life. The hair loss may be rapid or gradual and is usually diffuse and symmetric.

The physiologic shedding of newborn hair is self-limited.¹ The hairs usually grow back by 6 months of age.

During the past 6 months, this 1-year-old child had progressive hair loss that extended in a band configuration around the temporo-occipital scalp margin. This condition, called ophiasis, is a form of alopecia areata that occurs mainly in children. The pattern of hair loss is characteristic.¹ Compared with other forms of alopecia areata, ophiasis has a worse prognosis and is associated with more persistent, severe, and recurrent disease.¹

The effectiveness of topical minoxidil is variable. Minoxidil needs to be applied twice a day for at least 4 months before a response can be observed.

This 6-week-old infant had a scaling eruption and crusting on the scalp. She also had loss of hair on the vertex in the same location as the scaly lesion and crusting. The infant was otherwise in good health and did not seem to be in discomfort.

Diffuse or focal scaling and crusting of the scalp, sometimes referred to as cradle cap or milk crust, may be the initial--and at times--the sole manifestation of seborrheic dermatitis. The condition can lead to hair loss in the affected area. Seborrheic dermatitis usually responds promptly to topical corticosteroid therapy and anti-seborrheic shampoo.

This patient was treated with topical desonide twice a day and an anti-seborrheic shampoo daily. The scaly lesion and crusting resolved in 2 weeks. Her hair grew back in 2 months.

A 12-year-old girl was brought for evaluation of an ovoid patch of hair loss that had suddenly appeared in the right parietal area. There was no history of habitualpulling of the hair. No scaling, scarring, or erythema was noted on the scalp.

The hallmark of alopecia areata is the sudden appearance of one or more well-circumscribed, round, or oval patches of hair loss on the scalp. A common reason for hair loss in school-age children, alopecia areata usually begins after 5 years of age, and approximately 50% of cases appear in patients younger than 20 years.¹ Both sexes are affected.

Apart from the hair loss, the scalp appears normal, without scaling or scarring. Hairs at the periphery of the lesions can be pulled out easily. Variations include alopecia areata totalis (the loss of all scalp hair) and alopecia universalis (the loss of all body hair).

The exact cause of alopecia areata is unknown. In affected persons, there is an increased incidence of atopy and a history of familial occurrence (in 10% to 20%).¹ Its occasional association with Hashimoto thyroiditis, chronic adrenocortical insufficiency (Addison disease), diabetes mellitus, vitiligo, pernicious anemia, autoimmune hemolytic anemia, myasthenia gravis, and collagen vascular disease suggests an autoimmune process.

The course is variable and highly unpredictable. An onset before puberty, extensive or prolonged hair loss, ophiasis, and coexisting atopic dermatitis or nail defects may indicate a poor prognosis.

Treatment consists mainly of reassurance. Topical corticosteroids or minoxidil may be helpful in some cases. This patient's alopecia was managed conservatively with no treatment. Her hair grew back within 6 months.

This 7-year-old girl was evaluated for frontal baldness. The examination revealed an otherwise healthy child. On further questioning, the child admitted that she often pulled her hair.

Trichotillomania is characterized by compulsive pulling, twisting, and breaking of hair. The scalp is the most common site of involvement, but the eyebrows and eyelashes may also be affected. The irregularly shaped areas of partial alopecia with broken hairs of varying lengths give the scalp a "moth-eaten" appearance. The scalp is otherwise normal. The condition is slightly more common in girls. In young children, trichotillomania may develop as a consequence of a disturbance in the parent-child relationship or as a result of other forms of stress.

Most children discontinue the habit spontaneously. A short hair cut and hair cream applied to the scalp may help discourage the habit. In older children and adolescents, trichotillomania may be associated with more serious psychological problems, especially if trichophagy (habitual biting/ingestion of the hair) is also present. Professional psychological or psychiatric counseling is recommended.

This patient had begun pulling her hair about 6 months earlier with the arrival of a new sibling. The parents were advised to spend more time with the child. The problem resolved within a few months.

This 7-month-old infant was noted to have baldness in the occipital area. There was no loss of scalp hair elsewhere. She was otherwise healthy.

Hair loss in the occipital region is common in infants who lie prone and rub their occiputs on a pillow or bed. In this situation, the trauma potentiates the physiologic shedding of newborn hair. Although worrisome to parents, frictional alopecia--also known as pressure alopecia--is self-limited.

When the child was examined 8 months later, hair growth in the occipital area was normal.

References:

REFERENCE:

1. Leung AK, Robson WL. Hair loss in children.

J R Soc Health.

1993;113:252-256.

REFERENCE:

1. Leung AK, Choi MC. Ophiasis.

Consultant.

1998; 38:1611.

REFERENCE:

1. Leung AK, Robson WL. Hair loss in children.

J R Soc Health.

1993;113:252-256.