Hair Loss and its Management in Children

Vibhu Mendiratta; Masarat Jabeen


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

In This Article

Focal Noncicatricial Alopecia (Acquired)

Tinea Capitis

Tinea capitis is the commonest cause of patchy hair loss in children in the developing world owing to poor socioeconomic conditions.[15] It is an infection of the scalp and associated hair, caused by dermatophytes (genera Trichophyton and Microsporum except Trichophyton concenticum). The most common cause is Trichophyton tonsurans in the USA and UK and Microsporum canis in the rest of the world.[16,17] A clinician should be aware of its variable morphological presentations such as circular patches of alopecia and marked scaling (grey patch type), black dots indicating broken hair (black dot type), diffuse widespread scaling (seborrheic type), boggy nodules studded with pustules (kerion type) and yellow crusts (scutula) that surround hair follicles with a peculiar musky odour (favus type caused by Trichophyton schoenleinii).

Tinea capitis, once proven by culture or potassium hydroxide, requires systemic treatment. Flouroscence by woods lamp is only displayed by a few species, so it is not a very sensitive tool in detection of tinea capitis. Treatment is outlined in Table 1.[18–21]

Alopecia Areata

Alopecia areata (AA) is a chronic, organ-specific autoimmune disease, mediated by autoreactive T cells, which affects hair follicles and sometimes the nails. Evidence of the autoimmune nature includes reported associations between AA and other autoimmune disorders (e.g., Hashimoto thyroiditis) and, histopathologically, the presence of lymphocytes around the hair bulb in a pattern resembling a swarm of bees.[22–23]

The characteristic lesion of AA is commonly an oval, totally bald, smooth patch involving the scalp or any hair-bearing area on the body. A characteristic feature of an AA patch is 'exclamation-mark' hairs (broken, short hairs that taper proximally) that may be present at its margin. The clinical presentation of AA is subcategorized according to pattern or extent of the hair loss. It can be classified according to pattern as classical patchy AA (most common), reticulated pattern of AA, ophiasis band like AA (hair loss in the parietal temporo-occipital scalp) and sisaphio (a band of hair loss in the frontal parieto-temporal scalp).[24] If categorized according to extent of involvement, the following forms may be seen: alopecia areata with partial loss of scalp hair; alopecia totalis (100% loss of scalp hair) and alopecia universalis (100% loss of hair on the scalp and body).[22]

Indicators of a poor prognosis are the presence of other immune diseases, atopy, family history of AA, young age at onset, nail dystrophy, extensive hair loss and ophiasis pattern.[23]

In the majority of patients, hair regrows entirely within 1 year without treatment. Because of the chance for spontaneous resolution, it is often reasonable to do watchful waiting and reassurance initially. Should the alopecia continue to worsen or persist, a therapy can be considered. It is helpful to get the patient involved in a support group and/or counseling from the very first visit. The treatment of alopecia depends on the extent of involvement and the age of the patient. In localized involvement, commonly used agents include topical and intralesional corticosteroids, topical anthralin and minoxidil. In widespread involvement, contact sensitization (e.g., diphenylcyclopropenone) and oral immunosuppressives are usually resorted to.

Various treatment options are discussed in Table 2.[22,25–52]


Sometimes preferentially referred to as trichotillosis (as the suffix mania can connote insanity) trichotillomania refers to compulsive habit or desire to pull out the hair.[53–55] The clinical manifestation is usually quite distinctive, with a confluence of twisted and broken off hairs within an otherwise normal area of the scalp. Counselling, psychotropic drugs such as clomipramine or sertraline, N-acetyl cysteine and behavior modification techniques (e.g., habit-reversal therapy) are effective treatment options.[56–62] As glutamatergic dysfunction has been implicated in the pathogenesis of obsessive–compulsive disorder; N-acetylcysteine, a glutamate modulator, is a novel therapeutic agent found to be effective in trichotillomania.

Traction Alopecia

Traction alopecia is caused by prolonged traction of scalp hair by use of hair styles, such as tight braids and high pony tails, among others. Though usually the alopecia is reversible, if the traction is continued over years, mechanical damage to hair follicles may result in permanent hair loss.[63,64] Cessation of the offending hair practice is the treatment.

Syphilitic Alopecia

It may be the first sign of syphilis and can present as typical motheaten alopecia, generalized thinning of the hair or may mimic alopecia areata. A high index of suspicion is required to diagnose this entity, especially in sexually active adolescents.[65]


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: