SCOTTSDALE, ARIZ. — Alopecia areata can be emotionally devastating for young girls and boys, so treatment should include psychological support, Dr. Ronald C. Hansen said at a pediatric update sponsored by Phoenix Children's Hospital.
This is especially true in little girls, said Dr. Hansen, professor of pediatrics and dermatology at the hospital. “This is just as devastating to a little girl as a 60-year-old woman undergoing chemotherapy.” They may need a referral to a psychologist.
Some boys don't mind the baldness because many male athletes shave their heads. But there are very few role models for little girls, Dr. Hansen said.
To make matters worse, wigs aren't manufactured for 5-year-old children, and most insurance won't pay for wigs, he said.
Alopecia areata affects 1% of Americans, half of whom are children. It is characterized by a sudden appearance of a round or oval patch of hair loss. The resulting bald spots are smooth, pink bald patches with sharply marginated hair loss.
Usually, there are one or two bald patches on the scalp. However, in the alopecia totalis variant, the head is completely bald. In alopecia universalis, there is no body hair including eyebrows, eyelashes, or pubic hair.
Another form of alopecia is the ophiasis pattern in which there is a long band passing above the ear, occurring in 5% of childhood cases. In 25% of the cases, there is fingernail involvement with pits, stippling, and ridging of the nails, with nail thickening.
“This form heralds a bad prognosis,” Dr. Hansen said. “If the child has fingernail involvement, you can be quite confident of the diagnosis.”
Before a final diagnosis of alopecia areata, physicians must rule out trichotillomania, a compulsion to pull one's hair out, and tinea capitis, a scalp fungal infection.
In trichotillomania, children have more satellite patches with incomplete hair loss and broken terminal hairs of different lengths, he said. “This diagnosis is made more with your fingers than your eyes,” with a lot of “broken-off hair, and you can feel the stubble.”
Most parents can't believe that their child has such a habit, he said. But there is a simple, convincing test for the condition.
Just shave off a little area and then see the child each week for a few weeks, and hair growth in those areas will return because it is too short to pull out. “It's a good test,” he said.
Tinea capitis is characterized by inflammation and scaling. A simple culture with any inflammation will prove the diagnosis, he said.
Once alopecia areata is diagnosed, the treatment is based on the severity, Dr. Hansen said.
If there are only a few patches—one or two—then there is a 95% chance that the hair will grow back, even without treatment.
But if the diagnosis is alopecia totalis or universalis, the chances of permanent regrowth are almost nonexistent without treatment “Even with treatment, the chances of permanent retention once there is regrowth is troublesome,” he said.
Those with a poor prognosis are patients diagnosed at a young age, those with extensive baldness, the ophiasis pattern, and nail dystrophy.
With limited disease, there should be just watchful waiting, Dr. Hansen advised, but in more severe disease, treatment is recommended.
Topical steroids result in a poor response because the drugs have limited penetration on the scalp, he said.
Intralesional steroids are advised in patients old enough to tolerate it, he said. “It hurts and scares kids to have needle sticks. Children must agree to this.”
Intralesional steroids, triamcinolone acetonide 3–10 mg/cc, injected into the entire alopecia patch, will regrow hair in a month or two.
In children, the injections need to be limited to 3 mL or less per session and repeated every 4–8 weeks. Topical anesthetics can alleviate injection pain, Dr. Hansen said.
Usually this can be done in girls at about 7–9 years old and in boys about 10–12 years old, when they start becoming concerned about alopecia.
Topical sensitizers, such as squaric acid dibutylester (SADBE) or diphenylcyclopropenone (DPCP), can be rubbed on the scalp, creating an allergic response and resulting in hair growth, Dr. Hansen said. Both are about 60% effective.
“This is the best treatment for little kids who can't tolerate needles,” he said. The sensitizers also are effective in more extensive disease.
Severe itching caused by the sensitizer can be treated with topical steroids, he said, but there needs to be a little rash to make the treatment work.
Dr. Hansen warned against using minoxidil 2% in children because it can cause extensive hair growth over the body.