Alopecia (Hair Loss)

Alopecia (Hair Loss): Excerpt from The 5-Minute Pediatric Consult

Terry Kind, MD, MPH

Alopecia - BASICS

Alopecia - description

• Absence of hair where it normally grows
• Categorized as acquired or congenital
  • Most cases are acquired: Tinea capitis is most common, followed by traumatic alopecia and alopecia areata.
• Diffuse and localized forms
  • Most cases are localized and, of these, tinea capitis is the most common.
• Previous classifications of hair loss have included scarring and nonscarring forms.
  • Scarring may be difficult to appreciate.
  • Some causes of hair loss may cause scarring.
• For diagnostic purposes, it is more useful to classify hair loss as congenital vs. acquired and further as circumscribed (localized) versus diffuse.
• Many normal healthy newborns lose their hair in the first few months of life.
  • It may be exacerbated by friction from bed sheets, especially in atopic infants.
• Normally, 50–100 hairs are shed and simultaneously replaced every day, on average.
• 90% of cases due to the following disorders:
  • Tinea capitis
  • Alopecia areata
  • Traction alopecia
  • Telogen effluvium
    • Alopecia is preceded by a psychologically or physically stressful event 6–16 weeks prior to the onset of hair loss.
    • Growing hairs convert rapidly to resting hairs.

Alopecia - epidemiology

Alopecia - prevalence

• Tinea capitis occurs in ~3–8% of the US pediatric population. Occurs more commonly in blacks and in females.
• Alopecia areata occurs in 1 in 1,000 people. The lifetime risk of developing alopecia areata is ~2%.

Alopecia - risk factors

Alopecia - genetics

• Alopecia areata:
  • Polygenic with variety of triggering factors
  • Family history in 10–42% of cases
  • Males and females equally affected
  • Onset usually before age 30 years
• Monilethrix (also called beaded hair):
  • A rare autosomal dominant disorder

Alopecia - etiology

• Toxic exposures:
  • Antimetabolites
  • Anticoagulants
  • Antithyroid medications
  • Lead
  • Arsenic
• Stress:
  • Trichotillomania
• Infection:
  • Tinea capitis
• Other:
  • Alopecia areata

Alopecia - associated conditions

• May be associated with a genetic, endocrine, or toxin-mediated condition
  • Look for nail, skin, teeth, or gland involvement
• Trichotillomania is frequently associated with a finger-sucking habit

Alopecia - DIAGNOSIS

Alopecia - signs & symptoms

Alopecia - history

• Attempt to classify the alopecia to aid in diagnosis and subsequent treatment plan.
• Assess whether the loss is acquired or congenital.
• Recognize whether the alopecia is treatable or likely to be self-limited.
• Consider most likely diagnoses (tinea capitis, traumatic alopecia, alopecia areata)
• Identify associated abnormalities that may be part of a syndrome.
• Determine if there is an endocrine abnormality or a toxin/medication effect requiring prompt attention.
• Assess hair loss:
  • Increased amount of hair in the brush or in the shower/tub drain?
  • Does hair appear or feel thinner?
  • Patches of hair loss or broken hairs noted?
• When considering trichotillomania, note that patients often deny hair-pulling:
  • Direct confrontation is rarely helpful.

Alopecia - physical exam

• Localized versus diffuse hair loss
• Evaluate associated systemic signs or any nonscalp findings:
  • May signify a genetic syndrome or endocrine abnormality
• Scalp:
  • Alopecia areata: Except for hair loss, scalp appears normal.
  • Tinea capitis: Scalp is often scaly and may be erythematous; areas of hair loss with broken hair stubs amidst scaly and/or erythematous scalp. Referred to as “black-dot” alopecia
• Bizarre configuration and irregular outline of hair loss. Hairs of varying lengths:
  • Distinguishes traction/traumatic alopecia from alopecia areata
• Short broken hairs but not black dots:
  • Short hairs are usually associated with trichotillomania, whereas black dot alopecia is seen with tinea capitis.
• Frontal, vertex, or bitemporal decreased hair density in adolescents
  • May be adolescent-onset androgenetic alopecia
• Hair shaft varies in thickness, with small nodelike deformities (like beads), increased breakage, and partial alopecia:
  • Monilethrix
  • Other hair-shaft abnormalities with increased fragility include pseudomonilethrix, trichorrhexis, pili torti, pili bifurcati, Menkes kinky hair syndrome, and trichothiodystrophy.
• Nail defects such as dystrophic changes and fine stippling:
  • Nail defects are seen in 10–20% of cases of alopecia areata.
  • Nail defects accompanying localized alopecia along with syndactyly, strabismus, and dermal hypoplasia may be found in Goltz syndrome.
  • In ectodermal dysplasias, the nails, hair, teeth, or glands may be affected.
• Pubic hair and eyebrow hair loss:
  • Found in a form of alopecia areata called “alopecia universalis,” where nearly all body hair is lost (alopecia totalis involves the loss of all scalp hair).
  • Body hair loss such as pubic hair or eyebrow hair may also occur in trichotillomania.

Alopecia - tests

Hair-pluck test:

• Used to determine the ratio of telogen (resting) to anagen (growing) hairs
• >25% telogen hairs is indicative of telogen effluvium.
• ~50 hairs are plucked (with 1 firm tug using a hemostat clamped around the hair ~1 cm from the scalp) and examined under the low-power lens of a microscope.

Alopecia - lab

• Fungal culture:
  • Recommended when assessing for tinea capitis as a cause of alopecia
  • Definitive results may take up to several weeks, may treat pending results.
  • Using a cotton-tipped applicator, culturette, toothbrush, or direct plating on Sabouraud dextrose agar, culture will be positive for T. tonsurans in >90% of cases in North America.
  • Less common are Microsporum canis, Microsporum audouinii, Trichophyton mentagrophytes, and Trichophyton schoenleinii
• Potassium hydroxide (KOH) exam thyroid testing, glucose levels:
  • Another way to assess for tinea capitis.
  • Hyphae and spores within hair shaft indicate tinea capitis.
  • With Microsporum, spores surround the hair shaft.
  • With alopecia areata or diffuse alopecia, consider endocrine tests if other relevant symptoms occur.

Alopecia - diag proced-surgery

• Dermatophyte testing medium (DTM):
  • Assessing for tinea capitis
  • Definitive results may take from days to weeks.
  • If dermatophyte colonies grow on the medium, the phenol red indicator in the agar will turn from yellow to red.
• Wood’s light (lamp) examination:
  • M. canis, M. audouinii, or T. schoenleinii, fluoresces green.
  • T. tonsurans does not fluoresce.
• Scalp biopsy:
  • Can help to distinguish alopecia areata and trichotillomania
  • In alopecia areata, hair follicles become small but continue to produce fine hairs; there is mitotic activity in the matrix, and often inflammation is present.
  • In trichotillomania, however, follicles are not small. They are usually in a transitional (catagen) phase and no longer produce normal hair shafts. Keratinous debris, fibrosis, and clumps of dark melanin pigment are present. Significant inflammation is absent.

Alopecia - differencial diagnosis

• Consider the most likely diagnoses 1st.
• Infectious:
  • Tinea capitis
  • Varicella
  • Syphilis
• Congenital:
  • Aplasia cutis congenita
  • Incontinentia pigmenti
  • Oculomandibulofacial syndrome (sparse hair, hypoplastic teeth, cataracts, short stature)
  • Goltz syndrome (alopecia, focal dermal hypoplasia, strabismus, nail dystrophy)
  • Triangular alopecia of the frontal scalp
  • Focal dermal hypoplasia
  • Hair-shaft defects (trichodystrophies)
  • Ectodermal dysplasias
  • Nevi
  • Progeria
• Nutritional:
  • Zinc deficiency
  • Marasmus
  • Kwashiorkor
  • Hypervitaminosis A
  • Celiac disease
• Endocrinologic:
  • Androgenetic alopecia
  • Hypothyroidism
  • Hyperthyroidism
  • Hypoparathyroidism
  • Hypopituitarism
  • Diabetes mellitus
• Rheumatologic:
  • Systemic lupus erythematosus
  • Scleroderma
• Trauma:
  • Traction alopecia
  • Trichotillomania
  • Scalp electrode scar from in utero monitoring
• Toxin:
  • Radiation
  • Medications (e.g., anticoagulants, antimetabolites)
  • Heavy metals (e.g., arsenic, lead)
• Miscellaneous:
  • Alopecia areata (autoimmune)
  • Telogen effluvium
  • Darier disease (keratotic crused papules, keratosis follicularis)
  • Lichen planus
  • Burn

Alopecia - TREATMENT

Alopecia - general measures

• Treatment of alopecia is guided by the underlying cause.
• If alopecia signifies a toxic exposure or an endocrine abnormality, the underlying condition may require prompt diagnosis and treatment.
• Infectious causes of alopecia (such as with tinea capitis) should be treated promptly.
• Most patients with alopecia areata do not need treatment, as regrowth will occur spontaneously.

Alopecia - comp alt-medicine

Hypnotherapy, massage, acupuncture, and onion juice are among the complementary therapies that have been tried for conditions like alopecia areata and trichotillomania with some success.

Alopecia - medication

• Treatment of alopecia is guided by underlying etiology.
• Other than reassurance and waiting, there is no proven therapy for alopecia areata (although topical or intralesional steroids may show some benefit).
• Topical antifungals alone are not adequate to treat tinea capitis.
• A topical shampoo, such as selenium sulfide or ketoconazole shampoo, is recommended for tinea capitis to decrease fungal shedding and risk of spread to others

Alopecia - first line

• For tinea capitis: Microsize griseofulvin 10–25 mg/kg/d (maximum 1g) or ultramicrosize griseofulvin 5–15 mg/kg/d (maximum 750 mg) orally once per day for 4–6 weeks. Approved for children >2 years of age.
• For alopecia areata requiring treatment: Intralesional corticosteroids may be used for isolated patches under consultation with a dermatologist.

Alopecia - second line

• For tinea capitis: Terbinafine, Itraconazole, or Fluconazole may be effective, although none are FDA approved for this condition.
• For alopecia areata: Potent topical corticosteroids may be tried, although there is limited evidence for their effectiveness.

Alopecia - FOLLOW UP

Alopecia - disposition

For tinea capitis, once treatment with a systemic antifungal has begun, the child may return to school.

Alopecia - issues for referral

• Refer or consult with a specialist when necessary.
• Consider referral to dermatology with any case of alopecia that is not acquired and localized.
• Treatment may require a multidisciplinary approach.

Alopecia - prognosis

• Tinea capitis, alopecia areata, and traction alopecia:
  • Hair will regrow.
• Telogen effluvium:
  • Spontaneous regrowth is expected unless the stressful event recurs.
• Alopecia areata may recur.
• Watch for hair regrowth, may take months.

Alopecia - bibliography

1. Hunt N, McHale S. The psychological impact of alopecia. BMJ. 2005;331(7522):951–953.
2. Kar BR, Handa S, Dogra S, et al. Placebo-controlled oral pulse prednisolone therapy. Am Acad Dermatol. 2005;52:287–290.
3. Ross EK, Shapiro J. Management of hair loss. Dermatol Clin. 2005;23(2):227–243.

Alopecia - CODES

Alopecia - icd10

• 704.00 Alopecia
• 704.01 Alopecia areata
• 110.0 Tinea capitis

Alopecia - PATIENT TEACHING-MED

• National Alopecia Areata Foundation (http://www.naaf.org)
• National Library of Medicine’s health information site http://medlineplus.gov

Alopecia - FAQ

• Q: When can children with tinea capitis return to school?
  • – A: Once treatment with a systemic antifungal has begun, the child may return to school. A topical shampoo, such as selenium sulfide or ketoconazole shampoo, is recommended to decrease fungal shedding and risk of spread to others.
• Q: Will the hair grow back?
• – A: For the 3 most common causes of childhood alopecia (accounting for 90% of cases; tinea capitis, alopecia areata, and traction alopecia), hair will regrow.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Alopecia Areata

• Back to disease: Alopecia Areata: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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