Patient Presentation
A 3-year-old female came to clinic because of hair loss. The mother said that the child was shedding a large amount of hair over the past 2 weeks with noticeable thinning.
The mother denied any skin changes to the scalp or rest of body. The mother reported that the hairs were not broken and just appeared to pull out from her head easily even when running her fingers through the child’s hair.
The mother said that the hair had a normal texture. “See. I just brushed her hair before we came and look at this brush,” the mother said as she showed a hairbrush with complete hairs of uniform composition and normal hair bulbs on the ends.
The mother also denied any recent illnesses, weight or eating changes, vision, muscle or joint problems. She denied using any other hair care products than a baby shampoo and the patient was not taking any medication or was exposed to toxins.
The past medical history showed a healthy female that did have a viral illness with significant fever about 3 months ago.
The rest of the review of systems was non-contributory.
The family history was positive for atopic dermatitis but negative for any other skin or autoimmune problems.
The pertinent physical exam showed a thin female with growth parameters in the 10%. She had normal weight gain since her prior visit.
Her general physical examination was normal. Her skin showed some bruising on her shins and a 0.5 cm cafe au lait lesion on her back. She had fine hair on her legs and arms and normal eyelashes and eyebrows. Her scalp had thinning hair without localized areas of alopecia. The underlying skin was normal.
A few hairs pulled out easily during finger combing. She had normal dentitia and nails.
The diagnosis of telogen effluvium was made. The mother was counseled regarding the natural history of the problem, physical signs to monitor and reasons to return.
Discussion
Hair is an epidermal appendage. It has a regular cycle of phases where hair grows (anagen), rests (telogen) and has a transition phase (catagen) in between.
Normal hair loss is ~50-100 hairs lost/day on the scalp. Normal hair grows about 2.5 mm/week.
The history should include details about general health, health stressors especially in last 4-6 months including fevers, surgeries, new medication and life events are important.
Review of systems for possible anemia, diabetes, and hypothyroidism and other autoimmune diseases should be obtained including fatigue, constipation, weight changes, night sweats, eye, muscle or other skin changes.
A specific history of drugs and possible toxins is also helpful. On physical examination specific attention should be paid to other dermal appendages (teeth and nails) and a complete skin examination.
Texture of the hair and underlying skin should be noted. Some hair should be pulled to see if it can be pulled out intact, breaks or does not pull out. Exclamation hairs (thinner at base with an abnormal bulb) should be noted.
A review of localized hair loss can be seen here. Some of the most common causes of localized patchy hair loss is tinea capitus, alopecia aerata and tricotillomania.
Alopecia areata causes localized hair loss, with usually round or oval in shape and no inflammation. It is often found on the scalp but may affect other areas of the body. If all of the scalp is involved this is called alopecia totalis and if all of the body hair is involved this is called alopecia universalis. It is often associated with autoimmune diseases.
The differential diagnosis of hair loss or alopecia includes:
- Congenital (non-scarring)
- Diffuse
- Hair shaft anomalies
- Pili torti
- Tricchorrhexis nodosa
- Many others
- Alopecia congenita
- Ectodermal dysplasia
- Hair shaft anomalies
- Localized or patchy
- Alopecia areata
- Aplasia cutis congenita
- Congenital temporal alopecia
- Nevus sebaceous
- Triangular alopecia
- Diffuse
- Acquired
- Non-scarring
- Diffuse
- Alopecia areata
- Anagen effuvium
- Drugs – often seen with chemotherapy
- Toxin
- Radiation
- Telogen effuvium
- Physiologic in newborn
- Parturition
- Drug induced
- Hypothyroidism
- Abnormal nutrition – low protein or zinc levels
- Stress
- Anesthesia and surgery
- Febrile illness
- Life events
- Localized or patchy
- Tinea capitus – broken hairs, scaling and redness
- Trichotillomania – irregular patches with broken hairs without scaling
- Traction alopecia – broken hairs of irregular length
- Alopecia areata – regular, circumscribed patches with exclamation hairs
- Pressure induced or friction alopecia
- Scarring
- Graft vs host disease
- Incontinentia pigmenti
- Lichen planus
- Systemic lupus erythematosus
- Tinea capitus
- Trauma
- Diffuse
- Non-scarring
Learning Point
Effluvium means to outflow.
Telogen effluvium is one of the most common causes of diffuse hair loss. Telogen effluvium occurs when there is an abrupt shift from anagen into telogen phases. The hairs are then synchronously shed with more than the normal amount of hair loss over a relatively short period of time.
Diffuse hairs are lost over weeks to months and more hairs are shed if pulled. There is a generalized density decrease in the hair. A wide variety of stresses appear to cause the shift from anagen to telogen with the shedding occurring usually around 3-4 months after the stressor and regrowth generally over the next 6-12 months
Treatment is to treat any underlying process and also reassurance about the normal natural history of the problem.
Questions for Further Discussion
1. What are signs of hypothyroidism?
2. What is the role of trichoscopy in scalp disorders?
Related Cases
- Disease: Hair Diseases and Hair Loss
- Symptom/Presentation: Hair Loss
- Specialty: Dermatology
- Age: Preschooler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Hair Loss.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Rudolph CD, et. al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1210-1213. – double check reference here.
Lencastre A, Tosti A.Role of trichoscopy in children’s scalp and hair disorders. Pediatr Dermatol. 2013 Nov-Dec;30(6):674-82.
Castelo-Soccio L. Diagnosis and management of alopecia in children. Pediatr Clin North Am. 2014 Apr;61(2):427-42.
Sethuraman G, Bhari N. Common skin problems in children.
Indian J Pediatr. 2014 Apr;81(4):381-90.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 