Hair loss may not seem like an Emergency to you… but it is! (Ok… maybe my perspective has changed as I’ve aged.) Seriously though, Alopecia will certainly catch a parent’s attention and they may just come to the ED for answers. Not that you need to have all of the answers pertaining to Alopecia, but let’s take a minute to ensure we have a useful perspective of Alopecia affecting Children:

Alopecia: Basics

  • Hair consists of shaft and root, which is anchored in the hair follicle. [Xu, 2017]
    • Hair follicles contain rapidly dividing cells.
    • Hair follicles can produce different types of hair over their lifespan: [Atton, 1990]
      • Lanugo (soft hair newborns have)
      • Vellus (downy, fine hair that replaces lanugo)
      • Terminal Hair (thicker, pigmented hair)
  • Every day 50-150 hairs fall out normally. [Xu, 2017]
  • Terminal Hair goes through 3 growth phases: [Xu, 2017]
    • Anagen phase – active growth, 90% of hair
    • Catagen phase – brief involutionary phase
    • Telogen phase – dormancy, 5-10% of hair is in telogenic phase
    • Hair falls out after 2-3 months of telogen phase… and the cycle repeats.
  • Hair loss can occur due to any disturbance in the development of a hair.

Alopecia: Considerations

  • Alopecia is due to heterogenous etiologies. [Xu, 2017; Atton, 1990]
  • Pediatric Alopecia is typically related to different causes than in adults. [Xu, 2017]
    • Majority of pediatric alopecia is due to acquired causes.
    • Although, it can even be present at birth (ex, aplasia cutis congenita).
  • The common causes of Alopecia in children that should be considered: [Xu, 2017; Atton, 1990]
    • Tinea Capitis
      • Commonly due to Trichophyton tonsurans or Microsporum canis.
        • Microsporum species deposit a product that is fluorescent under UV light.
        • Trichophyton does NOT fluoresce and can produce lots of scaling and can be confused with seborrheic dermatitis.
      • Initially not scarring, but can lead to Kerion, which due to its local inflammatory reaction, can be scarring.
      • See broken hairs (i.e., Black Dot sign), scaling, erythema, and posterior cervical lymphadenopathy.
    • Alopecia Areata
      • Common form of autoimmune alopecia.
      • May have family history or personal history of other autoimmune disorders, like vitiligo or thyroid disease.
      • Typically has patchy hair loss that is well demarcated.
      • Has positive Hair Pull Test.
    • Trauma related:
      • Traction Alopecia
        • Due to constant tensile force on scalp from certain hairstyles (ex, braids, ponytails, tight buns, cornrows, etc).
        • Usually does not scar, but can if allowed to go one too long.
      • Trichotillomania
        • Associated with impulse control issues.
        • Non-scarring alopecia with patches of hair loss with irregular borders and hairs of various lengths.
        • Usually not including the occipital area (more painful to pull hair from this region.
    • Hair Cycle Disturbances
      • Telogen Effluvium – abnormal amount of hairs in the telogen phase leading to increased shedding and diffuse thinning without scale.
      • Anagen Effluvium – Rapid hair loss due to radiation/chemotherapy or malnutrition.
    • Transient Neonatal Hair Loss
      • Often concerning for first time parents, but is benign and common.
      • Occurs in first two months of life.
      • Previously thought to be due to friction of scalp on bedding, but this is unclear.
    • Numerous other odd and interesting causes that would delight a dermatologist (but that I can’t truly comprehend).
  • Physical Exam can help distinguish etiologies: [Xu, 2017]
    • Look closely at scalp, lashes, dentition, and nails.
    • Try the Tug Test and Pull Test. [Xu, 2017]
      • Tug Test
        • Attempt to fracture the hair shaft… is the hair fragile?
        • Grasp the base of the hair and then tug the distal end with the other hand.
      • Pull Test
        • Gently pull a bundle of 20-60 hairs from multiple locations.
        • Positive Test if >10% are pulled out.

Moral of the Morsel

  • Hair loss is not funny. (Stop laughing at me people!)
  • Alopecia in Pediatric patients is often acquired. Look closely for clues and have a low threshold for covering for fungal infection.
  • Hair Loss is not always simple. Think about related disorders and consider thyroid testing.


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Sean M. Fox
Sean M. Fox
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