Clinico-Dermoscopic Features and Treatment Responsiveness in Pediatric Alopecia – Experience from a Tertiary Care Pediatric Dermatology Clinic

Abstract

Background:

Data on clinical and epidemiologic profile on pediatric alopecia is relatively scarce.

Aims and Objectives:

We aimed to study the clinical, epidemiological, and dermoscopic profile of children presenting with alopecia, and assess the responsiveness to different treatment modalities in a real-life setting.

Materials and Methods:

This cohort study involved analyzing children presenting with hair loss during the study period. After a detailed history, clinical, and trichoscopic examination, treatment offered to patients and follow-up response to treatment along with relapse of symptoms were noted.

Results:

Around 119 children were included. Nearly 90% were of acquired etiology. The most common cause of alopecia was alopecia areata (AA) in 85 (71%) patients followed by tinea capitis 9 (7.5%), lichen planopilaris 4 (3.3%), and other less common causes. In patients of AA, dermoscopy showed the presence of black dots in 68% cases, exclamation mark hair in 54% of patients followed by off-white dots, yellow dots, and vellus hair. Patients with an acute course and black dots on dermoscopy responded better to treatment. Relapse was common in patients with early age of onset and longer disease duration.

Conclusions:

Hair loss is frequently seen in pediatric dermatology clinics. Dermoscopy of pediatric AA shows scarce yellow dots while off-white dots are more frequent; the presence of black dots is a good prognostic indicator.

Introduction

Alopecia is a common dermatologic problem among children and may differ in etiology in comparison to adults.[1] Although less frequently emphasized upon, hair loss can be a significant cosmetic concern, especially in school going children and adolescent population, which may lead to adverse psychological consequences and interfere with their growth and development. Despite its frequency and importance, there is a paucity of data regarding the demographic profile of alopecia in the pediatric age group. In a few previous studies from Asia and Africa studying the common hair disorders among children, infectious diseases, such as folliculitis, pediculosis, tinea capitis, and alopecia areata among noninfective causes were seen as the most frequent dermatoses.[2,3] A better understanding of the common causes leading to hair loss in a particular region is mandatory to develop an evidence-driven clinical approach towards their management. The present study was aimed at providing a detailed clinico-epidemiologic and dermoscopic description of various dermatoses that present as alopecia in the pediatric age group. The secondary objective was to assess the response of various therapeutic modalities as practiced in routine outpatient in the absence of a strict clinical trial setting.

Materials and Methods

This was a cohort study carried out over 1-year duration at the pediatric dermatology clinic at Post Graduate Institute of Medical Education and Research, Chandigarh, India from January 2017 to December 2017. Children aged 0 to 15 years visiting our outpatient department or brought by their parents primarily with presenting complaint of hair loss were included.

A detailed history and clinical examination were undertaken in all children after obtaining consent. The onset of alopecia was arbitrarily defined as acute/chronic with duration less/more than 6 months. After clinical examination, hair microscopy, Gram staining, potassium hydroxide mount, fungal and bacterial cultures were done where required. SALT (severity of alopecia assessment tool) score was calculated in cases of AA at baseline and during follow-up visits.[4] Patients were categorized into limited disease (SALT score less than 25) and extensive disease (SALT score more than or equal to 25). Children were given standard treatment for their disease according to institutional protocol. Trichoscopy was done in all patients using Dermlite II Hybrid M Dermatoscope at 10× magnification in polarized mode. Response to treatment was also studied objectively at 6 months in cases of AA (using SALT score); in the remaining children, treatment response evaluation was more subjective in view of lack of standardized scoring systems. Data were compiled and analyzed with SPSS 22. A P value of less than 0.05 was taken as significant. Predictors of response were analyzed by the multinomial logistic regression model.

Results

Of the 69,397 new patients attending the dermatology outpatient department during the study period, 2674 (3.8%) were of age group below 15 years. Of these, 119 children presented with the chief complaint of hair loss, accounting for 4.4% of all children. Fifty-two (43.7%) were boys and 67 (56.3%) were girls, with a mean age of 7.7 ± 3.5 years. The mean age at onset of alopecia and mean disease duration was 5.7 ± 3.3 years and 22.3 ± 25.6 weeks, respectively.

Etiology of alopecia

In 108 (90.7%) children, alopecia was acquired in etiology [Table 1]. These included AA in 85 (71%) patients, followed by tinea capitis in 9 (7.6%), lichen planopilaris in 4 (3.3%), trichotillomania in 3 (2.5%), and pseudopelade of Brocq, trichotemnomania, morphea, traction alopecia, telogen effluvium, folliculitis decalvans, and atopic dermatitis in one (0.8%) patient each. Among the congenital causes, the common causes were woolly hair in 3 (2.5%) patients, loose anagen hair syndrome in 3 (2.5%), ectodermal dysplasia in 2 (1.6%), and one each (0.8%) of monilethrix, hypotrichosis simplex and aplasia cutis.

Table 1.

Frequency of disorders presenting with alopecia among children

Etiology of alopecia	Period prevalence among pediatric patients per 1000 population (0-15 years) over the study period
Pediatric patients with hair loss	0.44
Alopecia areata	0.31
Tinea capitis	0.03
Lichen planopilaris	0.03
Trichotillomania	0.01
Loose anagen hair syndrome	0.01
Woolly hair	0.01
Ectodermal dysplasia	0.007
Pseudopelade of Brocq	0.003
Trichotemnomania	0.003
Morphea	0.003
Tractional alopecia	0.003
Telogen effluvium	0.003
Folliculitis decalvans	0.003
Atopic dermatitis	0.003
Monilethrix	0.003
Hypotrichosis simplex	0.003
Aplasia cutis	0.003

Table 2 summarizes the differences between the various etiologies of alopecia in our study group. There were significant differences in the mean age at presentation and mean age at onset but not in the disease duration. As expected, children with congenital disorders had a significantly early age at presentation/onset compared to alopecia due to acquired disorders (P = 0.03). The acute course of the disease was significantly more common in tinea capitis and trichotillomania in comparison to AA (P = 0.001). Other associated disorders were seen in 16 (18.8%) patients of AA, 1 (25%) patient of lichen planopilaris, 1 (11.1%) patient of tinea capitis, and 4 (23.5%) patients with other hair disorders. These included hypothyroidism, autoimmune polyendocrinopathy, atopic dermatitis, vitiligo, anemia, scabies, appendicitis, vitamin D deficiency, pleural effusion, and nephrotic syndrome in AA. In addition, the various dermatoses differed significantly in terms of frequency of personal/family history of atopy, nail involvement, presence of scarring, and/or scaling [Table 2]. Histologic diagnosis was required in 7 patients including 4 patients with lichen planopilaris, and one each of pseudopelade of Brocq, AA, and morphea.

Table 2.

Characteristics of children with various hair disorders presenting with alopecia

Demographic and clinical characteristic	Alopecia areata n=85 (71.4%)	Tinea capitis n=9 (7.6%)	Lichen plano-pilaris n=4 (3.3%)	Trichotillomania n=3 (2.5%)	Others n=18 (15.1%)	P value
Boys	40 (47.1%)	5 (55.6%)	3 (75%)	1 (33.3%)	3 (16.7%)	0.10
Girls	45 (52.9%)	4 (44.4%)	1 (25%)	2 (66.7%)	15 (83.3%)
Mean age at presentation	8.2	6.2	8.2	9.2	5.6	0.03
Mean age at onset	6.2	6.2	6.2	8.5	2.4	0.001
Mean duration	23.1	3.6	35.5	9	27.8	0.09
Acute course	23 (27.1%)	9 (100%)	2 (50%)	2 (66.7%)	3 (16.7%)	0.001
Chronic course	62 (72.9%)	0 (0%)	2 (50%)	1 (33.3%)	15 (83.3%)
Associated disorders	16 (18.8%)	1 (11.1%)	1 (25%)	0 (0%)	4 (23%)	0.80
Family history	7 (8.2%)	0	0	0	1 (12.5%)	0.81
Atopy	24 (28%)	0	0	0	1 (5.9%)	0.04
Recurrent disease	52 (61%)	0	0	0	0	0.001
Scarring	0	5 (55%)	4 (100%)	0	4 (23.5%)	0.001
Scaling	1 (1.2%)	8 (89%)	4 (100%)	0	0	0.001
Nail changes	40 (47%)	1 (11.1%)	0	0	1 (5.9%)	0.01
Hair pull test positive	41 (48%)	9 (100%)	0	0	5 (29%)	0.01

Dermoscopic/trichoscopic features

The frequencies of dermoscopic features in various disorders are illustrated in Table 3. In monilethrix, beaded hair with equidistant nodes and internodes were seen along with follicular papules. In traction alopecia, follicular papules and thinning of hair were seen. Dermoscopy of trichotillomania showed broken hair in all patients followed by tulip hair, frayed-end hair, and flame figures.

Table 3.

Dermoscopic findings in pediatric alopecia

Dermoscopic feature	Alopecia areata	Tinea capitis	Lichen plano- pilaris	Trichotillomania	Other diseases: No of patients (disease)
Black dots	39 (40.6%)	6 (66%)	-	2 (75%)	1 (Tractional alopecia)
Yellow dots	18 (18.7%)	-	-	-	1 (Hypotrichosis simplex)
					1 (Loose anagen hair syndrome)
Exclamation mark hair	30 (31.2%)	-	-	-	-
Off-white dots	36 (37.2%)	-	-	-	-
Pigtail hair	-	4 (44%)	-	-	-
Comma-shaped hair	-	3 (33%)	-	-	-
Pustules	-	3 (33%)	-	-	1 (Folliculitis decalvans)
Perifollicular scaling	-	-	3 (75%)	-	1 (Atopic dermatitis)
Blue-grey dots	-	-	3 (75%)	-	-
Branching vascular pattern	-	-	2 (50%)	-	1 (Aplasia cutis) 1 (Morphea)
Broken hair	-	-	-	3 (100%)	-
Fraying ends	-	-	-	2 (75%)	-
Tulip hair	-	-	-	2 (75%)	-
Flame figures	-	-	-	2 (75%)	-
Hair shaft thickness variability	-	-	-	-	1 (Hypotrichosis simplex)
Tufting of hair	-	-	-	-	1 (Folliculitis decalvans)
Follicular papules	-	-	-	-	1 (Tractional alopecia)
Absence of follicular openings	-	-	-	-	1 (Morphea) 1 (Pseudopelade of Brocq)
Follicular units with single hair	-	-	-	-	1 (Ectodermal dysplasia)
Sharply cut hair	-	-	-	-	1 (Trichotemnomania)
Normal scalp and hair	-	-	-	-	1 (Telogen effluvium)

Alopecia areata

AA accounted for 3.1% among all pediatric dermatology patients. Among these, 45 (53%) were girl and 40 (47%) were boy, with more than three-fourth of the children having a chronic course. The mean SALT score of patients of AA was 18 ± 8.7. The pattern and type of AA was patchy in 53 (62%), ophiasis in 20 (23%), totalis in 4 (4.7%), universalis in 6 (7%), and diffuse AA in 2 (2.3%) [Figure 1a and c]. Nail changes observed in AA included fine pitting (22 patients), longitudinal ridging (8), punctuate leuconychia (9), trachyonychia (4), onychoschizia (1), and clubbing (1 patient). Dermoscopic findings included black dots followed by off-white dots, yellow dots, and exclamation mark hair [Figure 1b and d]. Forty-eight children (56%) had limited and 37 (43%) had extensive disease. On comparing the characteristics of the children with limited versus extensive AA, the two groups differed significantly with respect to the mean age at the onset which was earlier in limited AA group (P = 0.01). Mean duration of illness was 18 weeks in limited AA compared to 28 weeks in extensive AA (P = 0.05), and patients with extensive disease had a chronic course as compared to limited disease (P = 0.01), which signified that the disease started as limited AA and tended to become extensive as it progressed.

Figure 1.

a) Non-scarring alopecia of frontal and temporal sisaipho representing about pattern alopecia areata. (b) Trichoscopic examination shows presence of exclamation mark hair (inside circle), black dots (empty arrow), yellow dots (solid arrow) and empty hair follicles (Dermlite II Hybrid M, ×10). (c) Non-scarring alopecia involving whole scalp and body hair. (d) Trichoscopy shows the presence of empty follicles, black dots (empty arrows), exclammation mark hair (inside a circle), and off-white dots (solid arrows) (Dermlite II Hybrid M, ×10)

Tinea capitis

Nine patients were diagnosed with tinea capitis. There were five boys and four girls with age ranging from 5 to 8 years with duration of disease 1 week to 6 weeks. One patient had associated tinea corporis and one had onychomycosis. Three cases were grey patch type and 5 were inflammatory type [Figure 2a]. Potassium hydroxide mount was positive in about 50% of patients. The most common dermoscopic finding was black dots followed by pigtail hair, comma-shaped hair, and pustules [Figure 2b].

Figure 2.

(a) Diffuse hair loss over the frontal scalp. (b) Trichoscopy shows the presence of pigtail hair (inside a circle) and comma hair (empty arrow) (Dermlite II Hybrid M, ×10)

Lichen planopilaris

Lichen planopilaris was observed in 4 children in our study with the age range of 5 to 10 years. Duration of illness ranged from 5 to 96 weeks. One patient had cryptorchism. In all patients, perifollicular scaling and scarring were present [Figure 3a]. Histopathology was done in all patients, which revealed perifollicular interface dermatitis and perifollicular fibrosis in all patients. Most common dermoscopic findings were perifollicular scaling and blue-grey dots followed by branching vascular patterns [Figure 3b].

Figure 3.

(a) Scarring alopecia with perifollicular scaling over the temporal and parietal scalp. (b) Trichoscopy shows the presence of perifollicular cylindrical scales (empty arrow), blue-grey dots in the perifollicular area (solid arrow), white dots (inside a circle), structureless white areas (star) and absence of follicular ostia (Dermlite II Hybrid M, ×10)

Treatment administered and follow-up

Treatment modalities administered for AA included topical minoxidil (43 patients), topical steroids (36), systemic steroids as oral mini pulse therapy (31), weekly methotrexate (15), intralesional steroids (12), DPCP (diphencyclopropenone) immunotherapy (13), and azathioprine (3). The posttreatment response was observed in 51 children with AA. No response was seen in 5 (9.8%), mild in 2 (3.9%), moderate in 9 (17%), and good in 31 (68%) patients. On multinomial logistic regression, when predictors of response to treatment were studied, it was found that a total disease duration less than 48 weeks (P = 0.04) was the statistically significant factor associated with the positive response to treatment. Dermoscopic presence of black dots was significantly more common in responders compared to nonresponders (P = 0.02). Among children with AA who followed up for at least 6 months, 18 (43.9%) experienced disease relapse after initial improvement. Factors associated with relapse were early age of onset (P = 0.01) and longer disease duration (P = 0.02). Relapse had no statistically significant relationship with gender, atopy, associated disorders, nail changes, family history, and baseline SALT score.

Children with lichen planopilaris were administered topical steroids, systemic steroids (as oral mini pulse), and once weekly methotrexate. Cosmetically acceptable regrowth was seen in 2 patients. Tinea capitis was treated with oral griseofulvin in 2 patients and oral terbinafine in 7 patients with a favorable response and complete hair growth in all children. For trichotillomania, counseling along with habit reversal training was done successfully. Morphea was treated with topical calcipotriol and systemic steroids. For genetic disorders, counseling was done.

Discussion

The clinical presentation of hair loss and scalp disorders in children varies widely, often ranging from subtle to disfiguring forms, and may be acquired or congenital.[5] The reported number of patients with scalp and hair disorders range from 1.1% to 7.5% of pediatric dermatology clinics.[2,6] Frequency of pediatric alopecia cases among pediatric dermatology patients in our study was 4.4%. This study highlights that pediatric alopecia constitutes an important cause of morbidity and disease burden among children.

The most common cause of pediatric alopecia in our study was AA, at par with previous studies.[7] Pediatric AA accounted for 71.4% of all alopecia cases, reflecting the predominance of noninfective alopecia in our region, which is in contrast to the findings by Nnoruka et al. who found tinea capitis to be the commonest etiology.[6] This could represent a changing epidemiologic trend of disease etiology towards autoimmune diseases rather than infective. It has been observed that the frequency of tinea capitis is higher in developing countries compared to developed countries, and the rapid urbanization and development that our country has experienced in the last two to three decades could have contributed to this epidemiologic shift.[8] This is even more interesting due to the fact that our region is in the middle of an epidemic of chronic dermatophytosis of the skin.[9] However, despite the rise in frequency of tinea corporis and cruris, we observed a decrease in the frequency of tinea capitis. The other reason may be tertiary care bias as infective causes may get treated at primary level care. Finally, we included patients presenting primarily with hair loss in our study, and at times, infective alopecia may present only with pustules or crusts in the scalp, and not primarily with hair loss.

AA runs a chronic and recurrent course as shown in previous studies,[10] and is commonly associated with atopy and other autoimmune disorders.[11] We observed that extensive disease is common in those patients who have an early age of onset and those having a longer total duration of disease. Dermoscopy helps in differentiating different causes of hair loss and is an important tool in diagnosing AA.[12] Most of the findings were in accordance with previous published data.[12] An important finding that we observed was the rarity of yellow dots in pediatric AA in comparison to adult AA,[13] which might be attributed to the fact that sebaceous glands are in an inactive state in children. We observed “off-white dots” as a common trichoscopic feature in place of yellow dots Figure 1b. Presence of black dots was a favorable prognostic sign. Early age of onset and chronic disease were the two indicators of disease relapse.

The second most common cause found was tinea capitis, often cited as the most common hair disorder in children.[14] As expected, patients with tinea capitis respond well to treatment with complete regrowth.[15] Lichen planopilaris (LPP) is rarely reported in the pediatric population although it is not uncommon in adults.[16,17] In some of the large case series on pediatric LP from our and few other centers, LPP was conspicuous by its absence. In our study, it was observed predominantly in boys; perifollicular scaling and presence of scarring were commonly seen in lichen planopilaris which was similar to the one reported by Christensen et al.[16]

Trichotillomania patients presented at the age range of 6 to 15 years with female preponderance in our study while it has been shown previously that in childhood it is common in males.[18] Patients were treated with psychotherapy (habit reversal training). In the pediatric population, psychotherapy should be offered to all patients rather than pharmacotherapy. Patients with congenital hair disorders are very few in number and there is an important role of counseling of parents and patients in these disorders.

Conclusions

Pediatric alopecia is a significant health concern in children with AA as the commonest cause. Early age of onset and chronic disease may be the two poor prognostic markers. Use of dermoscopy helps in diagnosis and determines the prognosis in children with AA, and obviates the need for diagnostic biopsy in most cases. Its use, however, requires some experience as in comparison to adults, yellow dots are rarely seen. Presence of black dots may indicate a good prognosis, possibly due to an early disease presentation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.