Alopecia Areata in Children under 4: Does the amount of hair loss at the time of the appointment predict future loss

Alopecia Areata in Children Under 4: Mild Degrees of Loss Likely to Stay Mild; Moderate/Severe Likely to Worsen

Alopecia areata occurring in young children is known to be associated with lower chances for spontaneous regrowth and recovery compared to alopecia areata in older children and adults. In fact, alopecia areata starting at young ages is known to be one of the recognized poorer prognostic factors.

Castelo-Soccio’s group from Children’s Hospital Philadelphia published an helpful paper in 2019 showing that although young age of onset is generally a poorer prognostic factor, we can provide even more helpful information to parents based on the amount of hair loss the child has at the time of the appointment.

The authors performed a retrospective chart review of 125 pediatric patients who presented to clinic under the age of 4 with Alopecia Areata. Most children under 4 had mild disease severity at the time of their first visit and and for these children it was quite unlikely that progression was going to occur over the next 2 years to a more severe type of disease. In other words, mild AA stayed mild.

In contrast, children with more than 50 % loss at the time of their first visit were more likely to go on to develop more severe disease and worsening hair loss. In other words, moderate/severe AA got worse.

Comments/ Summary

This is a helpful study because it equips hair specialists with information to better counsel patients. Children presenting to clinic with Alopecia Areata generally have poorer prognosis compared to adults. However, children with mild disease are not likely to progress to severe hair loss states - especially over the periods of short term follow up.

Reference

Rangu et al. Understanding Alopecia Areata Characteristics in Children Under the Age of 4 Years. Pediatr Dermatol 2019 Nov;36(6):854-858.

Prognostic Factors for Alopecia Areata

Age of Onset, and Extent of Hair Loss are Among Most Important Prognostic Factors

Alopecia Areata is an autoimmune disease that affects about 2% of the world. About 1/3 of patients with limited alopecia will regrow hair in 6 months and about 1/3 will regrow by the end of 1 year. However, for about one third of patients, a more chronic form of alopecia areata is likely to develop. This includes 18 % of patients who will develop a relapsing remitting alopecia Areata, 10 % who will develop alopecia totalis and 5 % who will develop alopecia universalis.

Prognostic Factors for Alopecia Areata

Over the past 30 years, several factors have been found to be associated with poorer prognosis for regrowth of hair. These factors are not absolute but do enable clinicians to be able to better predict the ilkelihood of whether patients will regrow hair.

The most important prognostic factors for alopecia areata are:

1] Extensive loss (especially alopecia totalis and universalis)

2] Early age of onset (especially under 5)

3] Ophiasis variant (hair loss at the back regions of the scalp)

4] Nail changes suggestive of alopecia areata

5] History of alopecia areata in a family member

6] Presence of other autoimmune diseases in the patient (eg, atopy, Hashimoto thyroiditis)

Reference

1. Tosti A, Bellavista S, Iorizzo M. Alopecia areata: a long term follow-up study of 191 patients. J Am Acad Dermatol. 2006;55(3):438–41. Epub 2006 Jun 27.

2. Tan E, Tay YK, Goh CL, Chin Giam Y. The pattern and profile of alopecia areata in Singapore—a study of 219 Asians. Int J Dermatol. 2002;41(11):748–53. 

3. De Waard-van der Spek FB, Oranje AP, De Raeymaecker DM, Peereboom-Wynia JD. Juvenile versus maturity-onset alopecia areata—a comparative retrospective clinical study. Clin Exp Dermatol. 1989;14(6):429–33.

4. Yang S, Yang J, Liu JB, Wang HY, Yang Q, Gao M, et al. The genetic epidemiology of alopecia areata in China. Br J Dermatol. 2004;151(1):16–23. 

5. Goh C, Finkel M, Christos PJ, Sinha AA. Profile of 513 patients with alopecia areata: associations of disease subtypes with atopy, autoimmune disease and positive family history. J Eur Acad Dermatol Venereol. 2006;20(9):1055–60.

Oral Steroids for Paediatric Alopecia Areata

Prednisone in Paediatric Alopecia areata

The decision to use prednisone for children with alopecia areata is always an important one. Generally, this decision comes at an important time where parents and their physician have found that topical steroids, and other more localized treatments have not worked well or in some cases have not worked at all. 

Oral steroids are an option for short term use but generally not an option for long term use. Long-term corticosteroid therapy can lead to growth retardation, metabolic dysregulation and reduced bone mineral density, and other side effects. But short term used is possible and reserved for patients with rapid onset or rapidly progressive extensive, active AA.

 

Options for Corticosteroids in Children

There are two main options for corticosteroids in children - prednisone and dexamethasone. Each has their unique benefits. Prednisone has a short half life (quickly metabolized in the body) and so one needs to take daily whereas dexamethasone has a longer half life and use is generally twice weekly. 

Dosing Algorithms

There are many ways that steroids can be used. Common ways include the following 

1. Daily Prednisone

Daily prednisone is among the most common ways of prescribing steroids. While older children will generally take Prednisone pills, younger children can use prednisolone liquid which comes at a strength of 15 mg for every 5 mL of the syrup.  Typically a physician will prescribe 0.5 to 0.8 mg of the prednisone for every kilogram of body weight initially and then taper the dose over a period of time. This taper is generally for 3-12 weeks - with the shorter periods being generally safer but less effective. Most uses of oral steroids perform a slow taper over 12 weeks. 

2. Dexamethasone

Twice weekly use of dexamethasone is another way of prescribing steroids to children with alopecia areata. Dexamethasone dosing is different than prednisone and generally 1 mg of dexamethasone equates to 6.25 mg of prednisone. In 1999, Sharma and colleagues performed a study of twice weekly dexamethasone and included children in that study. Children under 12 received 2.5 to 3.5 oral biweekly dexamethasone whereas older individuals received 5 mg.

3. Monthly therapy

Monthly pulsed therapy with intravenous corticosteroid therapy or oral therapy is also an option. Doses tend to be larger on the one day that they are given and therefore concerns about safety do exist. Generally studies to date support good safety for this methodology but the protocol tends to be less commonly used. Lalosevic J, et al performed a study of monthy dexamethasone pulse therapy along with topical steroids in children with alopecia areata. Outcomes were quite good with nearly two thirds having complete regrowth. 

Side effects

One needs to carefully review all the side effects of oral steroids with their physician. For each side effect, one needs to really ask the prescriber  "okay - is that side effect common or uncommon?" The reality is that most children do very well on steroids. Weight gain, poor sleep, poor concentration, hyperactivity, heart burn, nausea are among the more common side effects.  Suppression of the adrenal glands ability to make prednisone itself is always a discussion but this is uncommon and  if it does occur it is generally temporary.  Within the 12 week period that they are generally used, many of the long term side effects are not typically seen. With every side effect, parents need to ask, "Is that a short term side effect you are mentioning or is that one that develops with long term use?"

Conclusion

It's a big decision as to wether or not to use oral steroids in alopecia. However, it's certainly an option to help reset the immune system and when done for appropriate times and appropriate doses the changes of side effects are low. 

REFERENCES
 

Sharma VK, et al. Twice weekly 5 mg dexamethasone oral pulse in the treatment of extensive alopecia areata.  J Dermatol. 1999.

Lalosevic J, et al. Combined oral pulse and topical corticosteroid therapy for severe alopecia areata in children: a long-term follow-up study.  Dermatol Ther. 2015 Sep-Oct.

Minoxidil Use in Children

Can minoxidil be used in Children?

Minoxidil is formally approved for adults with genetic hair loss. Minoxidil can be used as an 'off label' indication in children with several types of hair loss including alopecia areata and early onset androgenetic alopecia.  Its use should generally be monitored by a specialist. Children can be sensitive to minoxidil and side effects such as headaches, dizziness, poor concentration, swelling in the feet can occur. Rarely some children develop excess hair on the back or arms. 

 

Minoxidil Dosing

There is no standard dosing schedule for children and much of the dosing recommendations rely on the experience of the physician and the type of hair loss being treated.  Our typical dosing schedule for children who are prescribed minoxidil is shown below. Generally speaking, any child starting minoxidil should be followed by a physician.  These doses may be altered depending on a variety of factors such as the weight of the child, height, previous treatments used and extend of hair loss. These doses are generally regarded as maximal doses. 

Screening for thyroid disease in children with alopecia areata

Alopecia areata and Thyroid Disease

It's clear that the risk of thyroid disease is increased in individuals diagnosed with alopecia areata.   It is generally recommended that children and adults with alopecia areata undergo blood tests to determined if thyroid function is normal. 

Kurtev and colleagues performed a study in 46 children with a mean age of around 10 years.  63 % of children had enlarged thyroid glands (known as thyromegaly).  Thyroid autoantibodies were present in about 1/3 of children. Ultrasound studies showed evidence of autoimmune thyroiditis in nearly one-half of the children. 

A more recent study by Patel and colleagues examined 298 children with alopecia areata. Thyroid disease was most common in children with atopic dermatitis, children with Down syndrome and those with a family history of thyroid disease.

 

Conclusion

Thyroid disease is common in children with alopecia areata. While all children are typically screen for thyroid disease through measurement of serum TSH, this may be most important in children with atopic dermatitis, children with Down syndrome and those with a family history of thyroid disease.

REFERENCES

Patel D et al. Screening Guidelines for Thyroid Function in Children With Alopecia Areata. JAMA Dermatol. 2017;153(12):1307-1310.

Kurtev A et al. Thyroid autoimmunity in children and adolescents with alopecia areata.Int J Dermatol. 2005 Jun;44(6):457-61.

How can we differentiate trichotillomania from alopecia areata in children?

Differentiating trichotillomania from alopecia areata 

It can be challenging in some children to distinguish alopecia areata (an autoimmune condition) from trichotillomania (an impulse control disorder whereby individuals pull out their own hair). Sometimes even both coexist in the same patient! 

Exclamation mark hairs are frequently seen in both alopecia areata and trichotillomania and are therefore not specific (arrow). Several dermatoscopic signs, however, are more common in trichotillomania than alopecia areata including flame hairs, split ends, hairs of different lengths, v-sign (shown here with yellow circle), hair powder.

Trichotillomania in Children

Always on the Lookout

"Trichotillomania" refers to a form of hair loss where an individual pulls their own hair. It can sometimes be simply a habit - especially in very young children. In adolescents, the diagnosis of trichotillomania may signify underlying psychological illness including depression, anxiety, and eating disorders.

Trichotillomania, alopecia areata and tinea capitis are the three most common diagnoses in children followed by telogen effluvium and androgenetic alopecia. One must always at least consider this diagnosis as it is easy to miss. The presence of broken hairs, black dots, hairs of different length, and other trichoscopic features a v-sign, tulip hairs, and exclamation hairs are helpful in arriving at the diagnosis. The picture shows numerous scattered broken hairs (see green dots) in a young child with trichotillomania.

Happy International Alopecia Day

Happy IAD !

The first Saturday in August marks International Alopecia Day! Alopecia areata is an autoimmune condition affecting 2 % of the world's population. Hair loss can occur anywhere on the body but typically affects the scalp.

Children and adults can both be affected and a high proportion of individuals experience their first episode of hair loss before age 20.

DPCP for Children and Adolescents: Is it Effective?

DPCP for Children and Adolescents

Diphencyprone or “DPCP” is frequently prescribed for individuals with alopecia areata who develop more extensive amounts of hair loss or for individuals who aren’t improving with steroid injection treatments.  As shown in the photo to the right, DPCP is a liquid and is applied to the scalp weekly, usually in a dermatology clinic setting.  It causes a mild allergic reaction in the scalp skin, which in turn promotes hair regrowth in some individuals. In adults, DPCP treatment promotes hair regrowth in approximately 30-50 % of individuals. 

What about DPCP in Children & Adolescents?

We decided to examine this question. Prior to our study, the use of DPCP in children had not been thoroughly explored is whether DPCP is effective for children with alopecia areata. In fact, the use of DPCP in children has been the focus of only a 3-4 of research studies - and these studies were quite small.  One previous research study of 26 children indicated that DPCP helped with hair regrowth in 35% of patients. A second study of 12 patients indicated hair re-growth in 67% of patients.  

We recently published our research findings in the journal Archives of Dermatology. We looked back through the medical charts of 108 children who received DPCP at Sunnybrook Hospital in the past 10 years.    Children ranged in age from 4 months to 18 years. Most children had tried other treatments, such as steroids or minoxidil, prior to starting DPCP. However, none of those treatments were helpful and so DPCP was started.

Does DPCP have side effects in Children and Adolescents?

Overall, treatment with was safe, but minor side effects did occur in about one-half of patients. These included swelling, hives, small blisters and skin breadkdown and swollen lymph nodes.  About 13 % of patients stopped treatment after 2 months owing to a variety of factors, such as these side effecsts, difficulties commuting to the treatment center, and/or the disruption caused by weekly absences from school.

Was DPCP Beneficial ?

Overall, our research data showed that about one-third of children benefitted from DPCP treatment. 25 % of children had a partial improvement and 10 % had full regrowth.   

Conclusion

Our study is one of the largest research studies looking at whether DPCP is beneficial for children and adolescents with alopecia areata. It is a valuable study because it provides us helpful information that we can share with parents who bring their child to the DPCP clinic. Overall,  DPCP will help about 1 out of every 3 children who go through treatment.  However, only 1 out of every 10 children will experience full regrowth with treatment.  Right now, it’s not possible to predict which children will benefit from DPCP and who will not.  Certainly, more research is needed to understand how to make DPCP even more effective for children.

 References of Interest

1. Salsberg, J and Donovan, J. The Safety and Efficacy of Diphencyprone for the Treatment of Alopecia Areata in Children.  Archives of Dermatology 2012; 148: 1084-5.

2. Schuttelaar ML, Hamstra JJ, Plinck EP, et al. Alopecia areata in children: treatment with diphencyprone. Br J Dermatol. 1996;135(4):581-585.

3. Hull SM, Pepall L, Cunliffe WJ. Alopecia areata in children: response to treatment with diphencyprone. Br J Dermatol. 1991;125(2):164-168.

4. Mukherjee N, Burkhart CN, Morrell DS. Treatment of alopecia areata in children. Pediatr Ann. 2009;38(7):388-395.

 

Genetic Balding in a 6 and 8 year old?

Genetic Balding: How young does it  affect?

Androgenetic alopecia ( also known as genetic /hereditary balding) occurs in 50 % of men and 30 % of women by age 50.  Genetic balding can occur in teenagers but rarely occurs under age 11.

Italian dermatologists recently published an interesting report in the journal Pediatric Dermatology.  They described two healthy sisters aged 6 and 8 years who presented with a one year history of hair thinning which the dermatologists diagnosed as androgenetic alopecia.  Lab tests were normal in these two girls.Treatment with 2% minoxidil was successful in improving hair density.

Comment:

Although androgenetic alopecia is rare in the pre-teen years, it may rarely occur.  In these rare situations the first occurance is just before puberty during a period of hormonal change called "adrenarche." A strong genetic predisposition is often found... and the mother of the two girls in the study also had early onset of androgenetic alopecia at age 18.

Reference

Familial Androgenetic Alopecia in Siblings with Normal Endocrinologic Status. Pediatric Dermatology. Vol 29.  p 534-35.

Mattel to Design Friend of Barbie with Alopecia

Mattel Inc, the makers of the Barbie doll, announced last week that they would be designing a doll without hair in order to support children with cancer or alopecia.

An important driving force for Mattel to create the doll comes from a Facebook group “Beautiful and Bald Barbie.” The group was founded by Jane Bingham of Sewell, New Jersey after she lost her hair during cancer chemotherapy treatment and realized how upset it made her 9 year old daughter. The group petitioned Mattel to produce a doll without hair.

The Facebook group originally declared their goals on their Facebook page long before Mattel took note:

We would like to see a Beautiful and Bald Barbie made to help young girls who suffer from hair loss due to cancer treatments, alopecia or trichotillomania. Also, for young girls who are having trouble coping with their mother’s hair loss from chemo. Many children have some difficulty accepting their mother, sister, aunt, grandparent or friend going from long-haired to bald.

The Mattel company has announced that the doll will come with wigs hats and scarves.  The doll won’t be sold in stores but rather Mattel will donate the dolls to children’s hospitals in the United States and Canada as well as the National Alopecia Areata Foundation. For now, it will be difficult for young children with parents who have alopecia from chemotherapy or parents with alopecia areata to get a doll, but that could possible change in the future. For now, the dolls are only given to children with hair loss from cancer chemotherapy, alopecia areata (areata, totalis and universalis)  or trichotillomania.

Although the news release has been met with some criticism, there are certainly many benefits of a doll for children with alopecia and for children with parents or relatives with alopecia.  Talking about hair loss can be difficult for many people and talking about it openly can sometimes be difficult. This doll has the potential to open up conversation not only between parents and young children but with other siblings and friends as well. I have many young 2-6 year old girls in my practice who love and adore their dolls with hair and use the doll as source to open conversation with their parents, grandparents or friends.  I can only image how a doll without hair will further help young children cope with their hair loss.

The dolls will likely be distributed to children in early 2013.

Hair Loss in the Infant: Does Sleeping Position Matter?

2 to 3 months after birth, some babies start losing hair at the back of the scalps.  The medical term for this hair loss pattern is "Neonatal Occipital Alopecia." 

For years, it was thought that this occurs because of pressure on the back of the scalp from babies sleeping on their backs.  It’s now understood that this hair loss occurs as a normal physiological phenomenom in some babies and has nothing to do with pressure. The condition always improves on its own and some parents don’t pay much attention to it at all.

But why do some babies develop this temporary hair loss condition and others do not?

Researchers in Korea set out to answer this question by examining 338 newborns over a time period of 1.5 years. They found that 20 % of babies developed hair loss in the back of the scalp.  Moreover, babies born to younger moms less than 35 years, moms who did not have C-sections and babies born after 37 weeks were most likely to develop this condition.

Conclusion: It is important for parents and grandparents to understand that hair loss at the back of the scalp occurring in a 2-4 month old baby has nothing to do with sleeping positions. It occurs as a normal phenomenon.  Babies should sleep on their backs rather than their stomachs, according to recommendations from the American Academy of Pediatrics.  The recommendation was put forth in order to reduce the incidence of Sudden Infant Death Syndrome (SIDS).

References of Interest

Kim MS et al. Prevalence and factors associated with neonatal occipital alopecia: a retrospective study.  Ann Dermatol 2011; 23: 288-92.

American Academy of Pediatrics AAP Task Forice on Infant Positioning and SIDS: Positioning and SIDS. Pediatrics 1992; 89: 1120-26

Gibson E et al. Infant sleep position following new AAP guidelines. American Academy of Pediatrics. Pediatrics 1995; 96: 69-72

Dr. Seuss and Coping Strategies in Children

Some people are surprised to learn that children can be affected by hair loss. Conditions such as alopecia areata, tinea capitis, trichotillomania, traction aloepcia and telogen effluvium can affect children. Most of the very young patients in my practice have alopecia areata, an autoimmune condition which can lead to hair loss in circular patches, or total hair loss (alopecia totalis) or total body hair loss (alopecia universalis).

Children, like adults, develop strategies to cope with their hair loss.  These coping strategies change as the child ages.  Many children with hair loss find going back to school especially stressful. It’s a time when the coping strategies they have developed are put to the test.

Parents usually tell me if their child is having problems coping with hair loss.  When I am concerned about how a child is coping I sometimes ask the child an indirect question. In the months of August and September I frequently ask:

“What would you say to another child who had hair loss and was worried about starting back up at school?”

When most children hear this question, there is a pause. Most children smile or laugh and then look at their parents. Some start their sentence only to pause for an extended period. One child had clearly thought about this in great detail and had developed some useful coping skills. The child answered:

I would tell them ... to be who you are and say what you feel, because those who mind don't matter, and those who matter don't mind.  

I knew right away that these could not be the original thoughts of the child. Not the words of the parents, the grandparents, the teacher or a friend.  I soon learned from the child that these were the words of Dr. Seuss.  Today marks the 20th anniversary of the loss of Theodor Seuss Geisel (March 2, 1904 – September 24, 1991), better known as Dr. Seuss. The words in his 46 children’s books impacted millions of children, including at least one child who used these words as a coping strategy for hair loss. Every now and then I find myself quoting Dr. Seuss when talking to children and their parents about hair loss.