Hair Loss and its Management in Children

Vibhu Mendiratta; Masarat Jabeen


Expert Rev Dermatol. 2011;6(6):581-590. 

In This Article

Abstract and Introduction


Hair loss in children can cause psychological stress to the parent and patient alike. Alopecia can be classified into congenital and acquired. Commonly encountered causes of pediatric alopecia (tinea capitis, alopecia areata, traction alopecia and trichotillomania) are reversible if diagnosed early. Special note should be made of the extent and type of alopecia (scarring or nonscarring), any hair shaft anomalies and signs of inflammation. Diagnostic evaluation includes a bewildering array of age-old simple bedside tests (e.g., potassium hydroxide preparation) to state-of-the art accurate instruments (e.g., trichoscan). Systemic antifungal therapy is required for tinea capitis. Topical and systemic immunomodulators are currently being employed for treating alopecia areata. A holistic approach would include not just therapeutic intervention but also an active search for associated nutritional deficits, underlying psychosocial disturbances and behavioral problems, the latter two requiring counseling and behavior therapy. Children with permanent hair loss can be offered surgical hair transplantation or camouflage devices, such as wigs.


Though losing hair is not usually health threatening, it can scar a young child's vulnerable self esteem by causing immense psychological and emotional stress; not just to the patient, but also to the concerned parents and siblings. Thus, management of hair disorders can be quite a daunting task for the attending physician and mandates a holistic approach to the patient. Nevertheless, an organized diagnostic and management strategy can turn this challenging task into an interesting and fruitful exercise.

To fully understand hair loss in childhood, a basic knowledge of normal hair growth is necessary. The normal hair cycle is divided into four phases: the active growth anagen phase, followed by a brief catagen phase, the resting telogen phase and finally the shedding exogen phase.[1] Typically, 85–95% of hairs are in the anagen phase, which lasts approximately 3 years. Less than 1% of hairs are in catagen, the transitional phase, which lasts from a few days to weeks. The telogen phase (which accounts for 5–15% of hairs and lasts about 3 months) ends when the new anagen hair emerges from the follicle.

For the classification of pathological hair loss in children, two major groups should be differentiated: congenital and acquired hair loss.[2,3] This distinction is the first step in diagnosis (Box 1 & Figure 1). Pathological hair loss, although rare in the first year of life, may be a symptom of an underlying congenital syndrome or clue to an underlying metabolic disorder which may have a bearing on the mental and physical development of a child.[4–6]

Figure 1.

Approach to common causes of pediatric alopecia.

Hair loss on the scalp can also be classified as focal or diffuse (Box 2). Focal hair loss is secondary to an underlying disorder that may cause nonscarring or scarring alopecia.[3]

Patient's personal and family history, a thorough clinical examination, as well as general and specific diagnostic procedures aid in correct diagnosis and early treatment.[3]

The key points in a patient's history are:

  • Age of onset of the patient: congenital or acquired;

  • Onset of hair loss: sudden or insidious;

  • Extent of alopecia: localized or diffuse;

  • Subsequent development of the disease and associated symptoms;

  • Physical and mental development (may be affected as a part of a genotrichosis);

  • Psychological problems of the child;

  • Obvious physical or emotional triggers in the previous 2–5 months, and any accompanying complaints (e.g., fatigue, weight changes, and nail or skin abnormalities);

  • Past medical history including chronic illnesses, surgeries, medication, autoimmune, dermatologic and psychiatric disorders (e.g., anxiety and obsessive–compulsive tendencies);

  • Family history of alopecia, autoimmune disease, dermatologic or psychiatric disorders;

  • Hair grooming practices (chemicals, tight braiding).

Examination should have the following components:

  • Sparsing of hair (hypotrichosis) or loss of hair (alopecia);

  • Thorough examination of scalp as well as the other hair-bearing areas of the body, especially loss of axillary and pubic hair, eyelashes, eyebrows and body hair;

  • Type of alopecia: localized or diffuse, scarring or nonscarring;

  • Any hair shaft anomalies, hair quality, color, roughness and tendency to breakage, 'exclamation-point' hairs;

  • Presence of erythema, edema, papules, pustules, scaling, atrophy, telangiectasias, follicular hyperkeratosis, ulceration and scarring;

  • Hair pull test:

    • Approximately 20 hairs are grasped and firmly tugged away from the scalp;

    • The number of extracted hairs is counted;

    • >10% of grasped hairs or two hairs suggests positive pull test and active hair shedding.

  • The skin, nails, oral or genital mucous membranes (e.g., for evidence of associated dermatoses, such as lichen planus);

  • Thorough clinical examination of the entire head and body is necessary in order to evaluate impaired vision, defective hearing, dysmorphic features, clues to autoimmune or metabolic diseases, or ectodermal anomalies.


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