|Year : 2021 | Volume
| Issue : 6 | Page : 17-25
Hair loss in children: A clinicoetiological study from South India
Varsha M Shetty, Asha Gowrappala Shanmukhappa, HV Nataraj, Sacchidanand Sarvajnamurthy Aradhya
Department of Dermatology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
|Date of Submission||01-Jun-2019|
|Date of Decision||19-Jul-2020|
|Date of Acceptance||13-Oct-2021|
|Date of Web Publication||22-Nov-2021|
Varsha M Shetty
Department of Dermatology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Scalp hair loss in children is one of the common complaints encountered in dermatological practice. Accurate diagnosis of hair loss in children is of major significance as it can have severe psychological implications given the cosmetic importance of hair. Aims: This study aims to study the different causes and clinical presentations of scalp hair loss in children. Materials and Methods: This was a hospital-based descriptive study that enrolled a total of 170 children with scalp hair loss. A detailed history, scalp, and hair examination were done. Bedside investigations such as KOH mount, hair shaft microscopy, and hair pull tests were conducted. Scalp biopsy and dermoscopy were done wherever necessary to confirm the diagnosis. Results: Majority of the children with scalp hair loss were school going and adolescents accounting for 62.4% of cases; 52.4% of patients were male and 47.6% were female. Asymptomatic hair loss was the most common presenting complaint contributing to 71.2% of cases. Patchy pattern of scalp hair loss formed a majority (86.5%) compared to diffuse pattern (13.5%). Around 89.4% of scalp hair loss were of acquired type and remaining 10.6% were of congenital type. Neonatal occipital alopecia (38.9%) was the most common cause of congenital hair loss. However, in the acquired group, 90.1% had nonscarring and 9.9% had scarring alopecia. In the nonscarring group, tinea capitis, alopecia areata, and telogen effluvium accounted for 47.4%, 37.9%, and 8.8% of cases, respectively. Conclusion: Childhood alopecia is different from adult alopecia in terms of causes and the pattern of presentation. There is a scarcity of literature on childhood alopecia from India, hence, this study can serve as a useful guide in understanding the different causes and its presentation in our population. In addition, this study signifies the importance of simple diagnostic tests such as KOH and hair shaft microscopy in the diagnosis of common hair loss conditions in children.
Keywords: Alopecia, alopecia in children, hair loss, hair loss in children
|How to cite this article:|
Shetty VM, Shanmukhappa AG, Nataraj H V, Aradhya SS. Hair loss in children: A clinicoetiological study from South India. Int J Trichol 2021;13:17-25
| Introduction|| |
Hair is a unique structure which greatly influences our appearance in the society. Hence, hair losses whether complete or partial are considered as a major physical handicap more so in children. The growth and development of a child is greatly hampered by the hair loss. Hence, the psychological consequences of hair loss in children and their parents cannot be ignored. The causes of hair loss in children are different in different regions and are determined by the hair type and ethnicity. Androgenetic alopecia is the most common cause of hair loss in adults, however, the pattern and causes of hair loss differ in adults and pediatric age group., Alopecia is classified into congenital and acquired, scarring and nonscarring, and patchy and diffuse. Nonscarring acquired alopecia is the most common type of hair loss in children accounting for 90% of the cases. As per Western world, the common causes of hair loss in children are tinea capitis, alopecia areata, and trichotillomania. In majority of the cases, the hair loss in children is preventable thus calling for an early diagnosis and management to avoid complications including scarring.
The aim of this study was to observe the different causes and clinical presentations of scalp hair loss in the pediatric population. As there is a paucity of studies regarding pediatric hair loss in Indian scenario, this study was an attempt to determine the common and uncommon causes of scalp hair loss in children.
| Materials and Methods|| |
This hospital-based descriptive study was approved by the Institutional Human Ethics Committee and it was conducted during January 2013–January 2015.
A total of 170 children below 19 years of age presenting with the complaints of scalp hair loss to the dermatology outpatient clinics were included in the study.
All children below 19 years of age presenting with scalp hair loss and or sparse hair growth were included in the study.
Those who refused to give consent were excluded from the study.
An informed assent was taken from the parents and/or guardians of all the children enrolled in the study. A detailed history was taken regarding the duration, onset, and type (patchy/diffuse) of scalp hair loss. An enquiry was made regarding the associated symptoms such as itching, pain, scaling, and any change in the hair color/texture. A family and personal history of similar complaints and autoimmune conditions were obtained. History regarding precipitating events such as physical or emotional triggers, drug intake, and atopy was noted. Hair care and grooming practices were enquired.
A detailed cutaneous and systemic examination was conducted. Local examination included the pattern of hair loss (patchy/diffuse), scarring or nonscarring type of hair loss, and hair-pull test. The scalp was examined for the presence of erythema, scales, pustules, and follicular plugging. A detailed hair examination was conducted which included recording of hair color, texture, fragility, and examination of hair root. Other hair-bearing areas were observed for hair loss. Skin, nail, teeth, and mucosa were examined. In addition, Wood's lamp examination, scalp scrapings and hair for KOH mount, culture, and bacteriology were done wherever deemed necessary for confirming the diagnosis. Adjuvant investigations such as hair shaft microscopy, dermoscopy, complete hemogram, thyroid profile, anti-nuclear antibody test, and scalp biopsy were performed in accordance with the underlying suspected condition for diagnostic confirmation.
The Statistical software, namely, SPSS Statistics for Windows, version 15.0 (SPSS Inc., Chicago, Ill., USA) was used for the analysis of the data, and Microsoft Word and Excel have been used to generate graphs and tables.
| Results|| |
The age of presentation ranged from 2 days to 19 years with the average being 9.5 years. Majority of the children with scalp hair loss were in the school-going (6–10 years) and adolescent age group (10–19 years) contributing 31.2% (53) of cases each. The age distribution of children with scalp hair loss is depicted in [Table 1]. Out of the total 170 children, 89 (52.4%) were males and 81 (47.6%) females giving a male-to-female ratio of 1.09:1. Hence, there was a slight male preponderance. The asymptomatic hair loss was the most common presenting complaint accounting for 121 (71.2%) cases. The other presenting complaints being itchy scalp (20.6%), scaling of scalp (5.3%), painful pustules (2.4%), and change in hair color or texture (0.6%). The duration of scalp hair loss ranged from less than a month to more than a year [Figure 1]. The hair loss was secondary to an infectious etiology in 74 (43.5%) cases (53 males and 21 females) and to a noninfective etiology in the remaining 96 (56.5%) cases (36 males and 60 females). The pattern of hair loss was patchy in 147 (86.5%) children and 23 (13.5%) children presented with a diffuse pattern of hair loss.
A total of 152 (89.4%) children out of 170 had acquired type and 18 (10.6%) children had congenital type of alopecia. Neonatal occipital alopecia was the most common cause of congenital type of scalp hair loss constituting 7 (38.9%) out of 18 cases [Figure 2]. The other causes of congenital alopecia and the clinical profile of all patients with hair loss are depicted in [Table 2] [Figure 3] and [Figure 4]. Out of the total 117 children who were under 10 years of age, 100 of them had acquired type of hair loss and the remaining 17 presented with congenital type of hair loss. In the adolescent age group (10–19 years of age), out of the total 53 cases, all but one presented with acquired form of hair loss indicating that most of the congenital form of hair loss are picked up before they reach adolescence. The adolescent girl with congenital hair loss was found to have trichorrhexis nodosa from early childhood and she had consulted multiple centers before presenting to us. [Table 3] illustrates the differences in clinical profile of children below 10 years and those above 10 years of age presenting with hair loss. Nonscarring (90.1%) alopecia was the predominant type in the acquired group with scarring alopecia contributing to the remaining 9.9% of cases.
|Table 3: Differences in the clinical profile of children below 10 years and those above 10 years of age presenting with hair loss|
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|Figure 3: Aplasia cutis congenita showing absence of skin over the scalp|
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Tinea capitis accounted for majority (47.4%) of the cases in the nonscarring acquired group of alopecia followed by alopecia areata and telogen effluvium constituting 37.9% and 8.8%, respectively. Trichotillomania, patterned hair loss, and loose anagen hair syndrome contributed 1.5% each [Figure 5] and [Figure 6]. Anagen effluvium and traction alopecia constituted the remaining 0.7% each. The sex distribution of tinea capitis, alopecia areata, and telogen effluvium is illustrated in [Figure 7]. Tinea capitis was more common in school-going children (6–10 years) while alopecia areata and telogen effluvium were common in adolescent age group (10–19 years). The various patterns of tinea capitis and alopecia areata encountered in the present study are shown in [Table 4] and [Table 5], respectively. Among the scarring causes under acquired alopecia group; scarring following infection (kerion) was the majority forming 60% of the cases [Figure 8]. That following trauma and lichen planopilaris formed 13.3% of cases each. Localized scleroderma and pseudopelade of Brocq accounted for the remaining 6.7% each of the cases [Figure 9].
|Figure 5: Loose anagen hair syndrome showing sparse hair with easy pluckability|
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|Figure 6: Hair shaft microscopy in loose anagen hair syndrome showing “floppy sock appearance”|
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|Figure 7: Graph illustrating the gender distribution in tinea capitis, alopecia areata, and telogen effluvium|
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Out of 170 children, only 14 children (8.2%) gave a previous history of scalp hair loss. A positive family history of hair loss was obtained from 17.1% (n = 29) children. Only 4.7% (n = 8) of children gave a history of atopy. All eight atopic children were found to have alopecia areata thus implying the autoimmune nature of the disease.
History of triggering factors before the onset of hair loss could be elicited in 12.4% (n = 21) of children. The common events preceding hair loss being fever in 3.5% (6), drug intake and itchy scaly scalp in 1.8% (n = 3) each, surgery in 1.2% (n = 2), stress in 1.2% (n = 2), tonsuring in 1.2% (n = 2), and 0.6% (n = 1) each had nutritional deficiency, hypothyroidism, and polycystic ovarian syndrome.
Involvement of other hair-bearing areas such as eyebrows, eyelashes, and body hair was present in 8.8% (n = 15) of children. Poor hair grooming practices such as infrequent washing of hair, sharing of combs, and combing wet hair were observed in 13.5% (n = 23) of children.
Nail changes were observed in 28 (16.5%) patients, of whom 15 (8.8%) had patchy leukonychia, 5 (2.9%) had pitting, 4 (2.4%) had longitudinal ridges, 1 (0.6%) each had 20 nail dystrophy, pallor, combination of pitting, patchy leukonychia and longitudinal ridges, and combination of pitting and patchy leukonychia.
| Discussion|| |
The causes of hair loss in children are varied and it is a challenge for dermatologists and pediatricians to accurately diagnose and treat the same to prevent further hair loss., The etiology of childhood alopecia can be classified as congenital and acquired type, as well as scarring and nonscarring type. In addition, the presentation in children can range from subtle to disfiguring resulting in significant psychosocial morbidity and depression. Congenital type of alopecia may occur as an isolated entity or as a part of a multisystem syndrome. Some of the common causes of childhood alopecia include tinea capitis, alopecia areata, telogen effluvium, trichotillomania, and traction alopecia.
Majority of children in our study belonged to school-going (6–10 years) and adolescent age group (10–19 years) contributing 31.2% each. This contrasts with Sarifakioglu et al. who reported 50% of childhood alopecia occurring below 24 months of age. However, the results of our study correlated well with another Indian study and the one by Nnoruka et al. wherein majority of the cases (47%) occurred in 7–12 years of age., Thus, this goes on to indicate that racial factors can influence the age of presentation in childhood alopecia. There was a slight male preponderance noted in our study which was like the study by Nnoruka et al., however, Khitam Al-Refu and Sharma et al. reported a female preponderance.,,
The present study highlights the fact that acquired nonscarring alopecia is the most common cause of hair loss in children (n = 137). Tinea capitis (n = 65) was the most common diagnosis overall accounting for 38.23% followed by alopecia areata and telogen effluvium constituting 30.6% (n = 52) and 7.05% (n = 12), respectively. Some of the rare causes encountered in our study were atrichia with papular lesions, monilethrix, pseudopelade of Brocq, and loose anagen hair syndrome. [Table 6] illustrates the comparison of the present study with some of the earlier studies conducted on childhood alopecia.,,,,
Tinea capitis is a fungal disease of the scalp caused by dermatophytes and is contagious in children. It is commonly encountered below 12 years with a peak between 3 and 7 years of age., Tinea capitis was commonly seen in preschool (n = 18) and school-going children (n = 35) in our study. This age group is commonly affected as children of this age engage in several activities of close contact such as rubbing of heads while playing, sharing of hair combs, and caps [Figure 10] and [Figure 11].
|Figure 11: KOH mount in tinea capitis-ectothrix variety with fungal spores present outside the hair shaft|
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Out of the total 65 tinea capitis cases, 48 were males and 17 females; moreover, all seven cases of tinea capitis in adolescent age group were males, implying that shorter hair in males facilitates easier spread of spores compared to long hair in females. [Table 7] depicts the clinical profile of patients with tinea capitis in comparison with the previous studies.,,,, There were four patients manifesting with more than 1 clinical type of tinea capitis in the present study which was labeled as the mixed type. Grover et al. also reported the occurrence of mixed pattern of tinea capitis in 10% of their patients. Similarly, Sharma et al. also reported the occurrence of a combination of gray patch and black dot in 0.6% of cases. Coexistence of more than 1 morphological type of tinea capitis at a given time is considered quite rare. We did not encounter the seborrheic type of tinea capitis in any of our patients unlike Nnoruka et al. and Grover et al. who reported it in 16.3% and 1.8% of their cases, respectively., Favus was not seen in any of our patients in concordance with other studies.,,, A total of 5 patients (7.69%) had previous episode of tinea capitis. Around 21 patients (32.3%) had one or more members of their family afflicted with tinea capitis who were mostly siblings of the patients. Thus, tinea capitis, though being a common cause of hair loss in children, is an easily preventable condition by ensuring proper scalp hygiene and prompt treatment to prevent the spread of infection among siblings.
|Table 7: Clinical profile of patients with tinea capitis in comparison with other studies|
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Alopecia areata was the second most common prevalent disorder in the present study (30.6%) which is a type of nonscarring alopecia with a lifetime prevalence of 2% with childhood alopecia areata contributing to 20% of the total alopecia areata cases., Alopecia areata was commonly seen in the adolescent age group (10–19 years) in our study constituting 50.9% of cases with the earliest age of presentation being 1 year. In a study by Farajzadeh et al., the most common age groups affected were 6–8 years and 15–16 years with the earliest age of presentation being 1 year which was in concordance with our study. There were 25 males and 27 females with a slight female preponderance in our study which was not in accordance with the study by Nnoruka et al. which reported a higher incidence in males (59.3% of males vs. 40.7% of females). In addition, the study by Al-Refu and Sharma et al. also reported a male preponderance., However, since all the above reports including ours are a hospital-based study, the results cannot not be extrapolated to the general population.
Patchy pattern was the most frequent type encountered in the present study followed by ophiasis in accordance with Farajzadeh et al. [Figure 12]. However, none of the children presented with sisaphio or alopecia totalis patterns in our study. According to a study, around 34% of alopecia areata cases had associated disorders such as eczema, vitiligo, and thyroid disorder. Atopy was found in 8 patients (15.38%) of alopecia areata and two patients had concomitant vitiligo in the present study. Nnoruka et al. reported 5 patients (18.5%) of alopecia areata with atopy and 2 patients (7.4%) with vitiligo. Al-Refu reported three cases of vitiligo with alopecia areata. These findings were in accordance with our study thus implying the autoimmune nature of the disease. A total of 9 patients (17.30%) gave a previous history of alopecia areata in our study, thus indicating that it can be a recurrent condition in some. Only one patient had a family history of alopecia areata. This did not correlate with the study by Al-Refu and Farajzadeh et al. with a reported positive family history in 23% and 21% of patients, respectively., Involvement of other hair bearing areas such as eyebrows, eyelashes, and body hair was seen in 11 patients (21.15%%) of alopecia areata. Al-Refu reported 10% of patients with hair loss affecting areas other than scalp. Similarly, a study from Iran also reported involvement of body hair, eyebrows, and eyelashes in 11%, 10%, and 7% of their patients, respectively. Around 6.8%–49.4% of patients with alopecia areata are known to have nail involvement. Concomitant nail involvement was observed in 42.3% of patients in the present study with patchy leukonychia as the most common finding.
Telogen effluvium presents as a diffuse nonscarring alopecia resulting from large number of hairs transitioning from anagen to telogen manifesting as increased shedding of hair. It can occur as a result of several causes such as illness, surgery, medications, and nutritional deficiency which induces an abnormality in hair cycling. In one-third of cases, the inciting factor may not be identified. Out of the total 12 cases of telogen effluvium, 83.3% of cases occurred in adolescent age group with a mean age of 16 years and all 12 patients were females. This was in accordance with the study by Al-Refu who reported a higher incidence of telogen effluvium in females. There were five cases of acute telogen effluvium whereas the remaining seven had chronic telogen effluvium. The most common cause in our study was high-grade fever followed by mental stress. Al-Refu as well as Sharma et al. attributed the cause of majority of cases of telogen effluvium to frequent illnesses and high-grade fever similar to the present study.,
Trichotillomania is an impulse control disorder in which there is a compulsive urge to pull out the hair followed by a sense of transient relief., It generally presents as a nonscarring patchy alopecia exhibiting hairs of different lengths, broken hairs, and evidence of scalp trauma such as hemorrhagic spots. There were only 2 cases (1.17%) of trichotillomania encountered in the present study. Both were female, one being a 2-year-old girl and the other 13 years old. The peak age of incidence for trichotillomania is reported to be 9–13 years, though it can also occur in children below 6 years of age, and there is a definite female preponderance. Trichotillomania was observed in 7% and 4.21% of cases in the studies conducted on childhood alopecia.,
Acquired scarring alopecia constituted 15 out of 152 cases of acquired hair loss, with 60% of these cases occurring following infections such as kerion. The common causes of scarring alopecia as reported by Al-Refu included folliculitis decalvans (n = 10) and lichen planopilaris (n = 4). On the other hand, Nnoruka et al. and Sharma et al. reported one case of acquired scarring alopecia due to discoid lupus erythematosus.,
Poor hair grooming practices such as infrequent washing of hair, sharing combs, towels, caps, and brushing wet hair were found in 13.5% (n = 23) of our patients. All 23 belonged to acquired group indicating that the incidence of acquired form of hair loss is influenced by hair care practices. A total of four out of 23 had scarring and 19 had nonscarring alopecia.
| Conclusion|| |
The demographic profile of hair loss varies with respect to different epidemiological setup. Hair is an important appendage of skin which adds to the esthetic appeal of an individual. It is important to understand that childhood alopecia is different from alopecia in adults. Hence, it is imperative for dermatologists to keep a set of differentials in mind while dealing with childhood alopecia. Moreover, hair loss in children is of special concern as it can significantly influence their mental and physical development. Our study highlights the various causes and presentations of scalp hair loss in children which will serve as a useful guide in the appropriate diagnosis and management of hair loss.
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Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]