Hair Loss in Children: Clinical Approach Learning Tool
Clinical History Assessment
Systematic approach to history taking for a child presenting with hair loss
Physical Examination Guide
Systematic approach to examining a child with hair loss
Diagnostic Approach
Initial Assessment
Upon presenting with hair loss, initial evaluation should include:
- Detailed pattern assessment: diffuse vs. patchy, scarring vs. non-scarring
- Hair pull test to assess severity and activity
- Evaluation of hair shaft and scalp condition
Laboratory Studies
| Investigation | Clinical Utility | Key Findings |
|---|---|---|
| Complete Blood Count | Assess for nutritional deficiencies, chronic disease | Anemia, low WBC or platelets may suggest systemic disease |
| Ferritin, Iron, TIBC | Evaluate iron status | Low ferritin (< 30 ng/mL) may contribute to hair loss |
| Thyroid Function Tests | Screen for thyroid dysfunction | Elevated TSH, low T4 in hypothyroidism; low TSH, high T4 in hyperthyroidism |
| Zinc Level | Assess for zinc deficiency | Low serum zinc in acrodermatitis enteropathica or nutritional deficiency |
| Autoimmune Markers | Screen for autoimmune conditions | ANA, anti-thyroid antibodies in autoimmune alopecia |
| Fungal Culture/KOH Prep | Identify fungal infections | Positive for dermatophytes in tinea capitis |
Specialized Tests
| Investigation | Clinical Utility | Key Findings |
|---|---|---|
| Scalp Biopsy | Definitive diagnosis of scarring alopecia, unclear etiology | Inflammation pattern, follicular architecture, scarring changes |
| Dermoscopy | Non-invasive assessment of scalp and hair follicles | Black dots, exclamation mark hairs, yellow dots, broken hairs |
| Trichogram | Assess hair growth phase | Increased telogen hairs in telogen effluvium |
| Hair Mineral Analysis | Screen for heavy metal exposure | Elevated levels of arsenic, thallium, or mercury |
| Genetic Testing | Identify hereditary conditions | Mutations in LPAR6, LIPH genes in hypotrichosis |
| Nutritional Panel | Comprehensive nutritional assessment | Deficiencies in biotin, vitamins D, B12, folate, protein |
Imaging Studies
| Investigation | Clinical Utility | Key Findings |
|---|---|---|
| Trichoscopy | Digital dermoscopy with image storage | Pattern recognition and monitoring of treatment response |
| Ultrasonography | Evaluation of scalp thickness and masses | Inflammatory changes, abscesses, cysts |
Diagnostic Algorithm
A stepwise approach to diagnosing the cause of hair loss in children:
- Determine pattern - Patchy vs. diffuse
- Assess for scarring - Presence of follicular ostia
- Hair pull test - Positive in active conditions
- KOH preparation/fungal culture - For suspected tinea capitis
- Laboratory screening - Based on clinical suspicion
- Consider biopsy if:
- Scarring alopecia
- Unclear diagnosis after initial evaluation
- Unusual presentation
- Advanced testing based on initial findings
Common Pediatric Hair Loss Conditions
| Condition | Key Features | Diagnostic Clues |
|---|---|---|
| Tinea Capitis | Scaly patches, broken hairs, lymphadenopathy | KOH positive, fungal culture confirms species |
| Alopecia Areata | Well-demarcated round/oval patches, exclamation mark hairs | Smooth, non-scaly surface; nail pitting may be present |
| Trichotillomania | Bizarre patterns, broken hairs of different lengths | Normal scalp, history of stress/psychiatric triggers |
| Telogen Effluvium | Diffuse shedding, history of trigger (illness, stress, medication) | Positive hair pull test, increased telogen hairs on trichogram |
| Traction Alopecia | Marginal/frontal loss, history of tight hairstyles | Fringe sign, follicular preservation early, scarring late |
| Nutritional Deficiency | Diffuse thinning, dietary history, systemic symptoms | Laboratory evidence of deficiency (iron, zinc, protein) |
| Androgenetic Alopecia | Rare in children, family history, pattern thinning | Miniaturization on dermoscopy, usually adolescents |
Management Strategies
General Approach
Principles for managing pediatric hair loss:
- Accurate diagnosis: Treatment depends on correct identification of cause
- Address underlying condition: Treat the primary disorder
- Maintain scalp health: Gentle hair care practices
- Psychosocial support: Address emotional impact on child and family
- Age-appropriate treatment: Consider safety profile in pediatric patients
- Regular monitoring: Assess response and adjust treatment as needed
Specific Management Approaches
| Condition | Medical Management | Additional Interventions |
|---|---|---|
| Tinea Capitis |
- Oral antifungals (griseofulvin 20-25 mg/kg/day, 6-12 weeks) - Alternative: terbinafine, itraconazole, fluconazole - Antifungal shampoo (2% ketoconazole) |
- Treat household contacts with antifungal shampoo - Wash pillowcases frequently - Check for infected pets |
| Alopecia Areata |
- Topical steroids (mid-potency for face/young, high-potency for scalp) - Intralesional steroids (triamcinolone 2.5-5 mg/ml) for older children - Topical immunotherapy (diphenylcyclopropenone) for extensive cases |
- Psychological support and counseling - Support groups - Hairpieces/wigs for extensive cases - JAK inhibitors for severe cases (under specialist supervision) |
| Trichotillomania |
- Cognitive behavioral therapy - Habit reversal training - SSRI medications for comorbid anxiety/OCD (specialist referral) |
- Child psychology/psychiatry referral - Family therapy - Stress management techniques - Barrier methods (hats, gloves at night) |
| Telogen Effluvium |
- Address underlying trigger - Nutritional supplementation if deficient - Gentle hair care |
- Reassurance about self-limiting nature - Regular follow-up to monitor recovery - Avoid further triggers |
| Traction Alopecia |
- Change hairstyling practices - Topical minoxidil 2% for persistent cases - Topical anti-inflammatories for early cases |
- Education about gentle hair care - Cultural sensitivity regarding hairstyling practices - Early intervention to prevent scarring |
| Nutritional Deficiency |
- Iron supplementation (deficiency confirmed) - Zinc supplementation (2-3 mg/kg/day) - Multivitamin supplementation - Protein supplementation |
- Dietary counseling - Address eating disorders if present - Monitor growth parameters - Regular laboratory follow-up |
| Scarring Alopecia |
- Early aggressive anti-inflammatory therapy - Systemic antibiotics for folliculitis decalvans - Systemic corticosteroids for inflammatory conditions |
- Dermatology referral - Long-term monitoring - Hair transplantation after disease stabilization |
Long-term Management
Considerations for ongoing care:
- Regular follow-up: Monitor for regrowth and disease recurrence
- Scalp care education: Gentle cleansing, avoiding trauma
- Nutritional guidance: Balanced diet rich in protein, iron, zinc
- Growth monitoring: Track overall growth and development
- Hormonal assessment: For persistent or late-onset cases
- Adjust treatment: Based on response and changing presentation
- Transition to adult care: For chronic conditions requiring long-term management
Psychosocial Support and Education
- Address emotional impact: Hair loss can significantly affect self-image and confidence
- School support: Educate teachers and peers about condition
- Camouflage techniques: Scarves, hats, hairpieces when appropriate
- Support groups: Connect with other children and families
- Manage expectations: Clear communication about prognosis and timeline
- Bullying prevention: Strategies to address potential teasing
- Family counseling: Help parents support child effectively
When to Refer
- Scarring alopecia or suspected scarring
- Diagnostic uncertainty after initial evaluation
- Failure to respond to first-line treatments
- Extensive or rapidly progressive hair loss
- Associated systemic symptoms suggesting underlying disease
- Significant psychological impact requiring specialized support
- Need for advanced treatments (JAK inhibitors, immunotherapy)
