Case

A 4 year old African American girl comes to your office with the complaint that her hair is falling out. How would you approach this problem?

Important questions to ask in the history

1. How long has it been going on?
2. Any associated illnesses?
3. How does the child usually wear her hair?
4. Has the child been ill lately?
5. Has the child been observed pulling hair out and possibly eating it
6. Does the child take any medications and are there any exposures to toxins?
7. Are any other children losing their hair? Any children in the house with ringworm?
8. Is this the first time this has occurred?

1. loss associated with seborrhea dermatitis of the scalp. Usually see waxy scales and evidence of seborrhea on the face, neck, behind the ears, or in the diaper area.
2. Tinea capitis. Usually see some scaliness and broken hairs. More common in African American and may have positive family history.
3. Trichotillomania. Child pulls their hair out. Often associated with thumbsucking and putting hair in the mouth.
4. Traction causing hair loss. Tight braids or ponytails
5. Telogen effluvium. Hair stops in resting phase. Often follows illness or stressful event 6 weeks to 3 months before. The hair loss is diffuse.
6. Endocrinopathies like thyroiditis and Addison's disease
7. Exposure to toxins-radiation, chemotherapy, heparin and coumadin( rat poison), hypervitaminosis A.
8. Friction. Common in infants especially in occipital area
9. Alopecia areata. Usually no redness or broken hairs and rapid onset of hair loss in oval area. May extend to involve all the hair on the body ( alopecia totalis and universalis). Etiology unknown but thought to have autoimmune relationship.
10. Collagen vascular diseases.
11. Malnutirition including anorexia nervosa, gluten enteropathy, Zinc deficiency (acrodermatitis enteropathica), iron deficiency.
12. Normal newborn shedding of hair.

1. Observe child's hairstyle
2. Distribution of hair loss
3. Evidence of inflammation and scaling
4. Check nails
5. Check entire body for hair loss, not only scalp

1. Seborrhea-treat with dandruff shampoo
2. Capitis- treat with Griseofulvin orally for 6-8 weeks
3. Change hairdo if due to tight braids or pigtails
4. Behavior modification or other modalities to alter pulling hair out 
5. Look for toxins or possible underlying etiologies 
6. Alopecia areata. Some have tried topical, intradermal, and oral steroids with varying results. Often self limiting although if involves other area besides scalp or is recurrent, less likely to have hair regrowth. Minoxidil has been tried with mixed results. Reassurance. Often regrowth of hair in 6-12 months.
7. Telogen effluvium does not require treatment.

1. Atton, AV. Tunnenessen, WW. Alopecia in Children. The most common causes. Pediatrics in Review 1990 12(1) 25-30.
2. Leung, Alexander. Hair Loss in Children. Journal of the Royal Society of Helath 113:5 Oct 1993.
3. Rietschel RL. A Simplified Approach to the Diagnosis of Alopecia. Dermatologic Clinics. 1996; 14(4):691-695
4. Vasiloudes  Bald Spots: Remember the big three.  Contemporary Pediatrics October 1997
5. Yong-Kwang. Trichotillomania in Chidhood: Case Series and Review.  Pediatrics e494 May 2005