A Clinico-Epidemiological Study of Scalp Hair Loss in Children (0-18 Years) in Kota Region, South-East Rajasthan.

BACKGROUND: Currently, the studies related to hair loss in children showed the variable prevalence of different clinical patterns and causes of scalp hair loss, that had regional variation. AIMS: The aim of this study is to evaluate the epidemiology and clinical pattern of scalp hair loss in children (0-18 years age group).
MATERIALS AND METHODS: A total of 300 children presenting with scalp hair loss were studied during a period of 1 year from April 2015 to March 2016. The results were recorded and analyzed.
RESULTS: The most common disorder found in this study was tinea capitis seen in 166 (55.33%) cases followed by alopecia areata, seborrheic dermatitis, pediculosis with secondary infection. Other uncommon causes were lichen planopilaris, tractional alopecia, telogen effluvium, nevus sebaceous, occipital neonatal alopecia, ectodermal dysplasia, scalp psoriasis, trichotillomania, and alopecia due to nutritional deficiency. Several other rare causes were identified in this study.
CONCLUSION: This study showed that hair loss in children in our region is not an uncommon problem and results from a variety of causes. Early diagnosis and treatment are needed to prevent further hair loss and to avoid irreversible hair loss and scarring alopecia. As has been observed in this study, hair problem may be due to important nutritional deficiency. We should be aware of such presentation. These may be a clue to the diagnosis of systemic illness.

Introduction

The term “alopecia” is used to describe hair loss.[1] Alopecia or hair loss is a common problem encountered in dermatology clinics and may constitute a complex clinical problem in infants and children.[2] Hair loss in children has a profound psychological impact on the affected child as well as on parents. Alopecia can be classified into congenital and acquired, noncicatricial and cicatricial, focal (patchy), and diffuse. Common causes of hair loss in children[34] include tinea capitis, alopecia areata, bacterial infectiSons, traction alopecia, trichotillomania, seborrheic dermatitis, pediculosis capitis, telogen effluvium, and folliculitis. In addition, other less common causes of hair loss can be seen including[4] lichen planopilaris, thyroid disorders, iron deficiency, any nutritional deficiency, and congenital hair disorders.

Most of the causes of hair loss in the pediatric age group are treatable and preventable. Therefore, early diagnosis is crucial for proper management to prevent further hair loss and complications including scarring alopecia.

There are few studies done related to scalp hair loss in India. None has been done in our region. In our study, we evaluated epidemiology and clinical aspects of scalp hair loss in children (age 0–18 years) in southeast Rajasthan.

Materials and Methods

This was a cross-sectional, study conducted on a total of 4150 children attending the Department of Dermatology, Venereology and Leprology, Government Medical College, Kota, Rajasthan during the period of 1 year from April 2015 to March 2016. Of these, 300 (7.22%) patients of age <18 years and presenting with scalp hair loss were included in this study. Patients were thoroughly examined, and data were recorded. When the diagnosis was made clinically, it was confirmed by two senior dermatologists. After obtaining consent from the parents or guardian, data were recorded including patient name, age, sex, onset, characteristic of the lesion, the presence of any skin diseases, prolonged illness, family history in predesigned pro forma. Photographs were taken for documentation.

Scalp examination was done to see the presence of erythema, scaling, oozing, pustules, and follicular plugging. Hair examination included the recording of hair color, texture, fragility, hair shaft abnormalities, and examination of the hair root. In addition to the scalp, other hairy sites were examined for hair loss (including eyebrows, eyelashes, and other body hair). Nail and teeth were examined for any abnormalities.

Samples were taken for relevant investigations, liver function test, kidney function test, T3, T4, and thyroid-stimulating hormone test. Results of the investigations were collected and assessed for the causes. Skin biopsy was done in doubtful cases of alopecia areata, cicatricial alopecia, etc. Woods lamp examination was done in the suspected cases of tinea infection. Potassium hydroxide mount was done to see the fungal elements. Complete hemogram was done to rule out any nutritional deficiency and hematological abnormality.

Results

Out of 300 patients, 156 (52%) were female and 144 were male (48%) with a female-to-male ratio as 1.08:1. Mean age of the study population was 8.79 ± 4.26 years. The mean age for female was 8.8 and male was 8.75 years. The most common age group was found to be 7-12 years with 141 cases (47%), followed by 2–6 years with 85 (28.33%), 13–18 years with 58 (19.33%), and 0–2 years with 16 (5.33%). Youngest case in this study was 5 month old, and the oldest case was 18 year of age.

The most common presentation was scaly, pruritic, patchy hair loss (180 patients, 60%). Others were asymptomatic nonscaly patchy hair loss (60 patients, 20%), diffuse hair loss (45 patients 15%), followed by hair color, and textural changes (9 patients, 3%) [Table 1].

Table 1

Distribution of cases according to presenting symptoms

Presenting symptoms	Number of patients (n=300)	Causes
Scaly, pruritic patchy hair loss	180	TC, pediculosis with secondary infection, scalp psoriasis
Asymptomatic patchy, nonscaly hair loss	60	AA, aplasia cutis, nevus sebaceous, trichotillomania
Diffuse hair loss	45	Seborrheic dermatitis, telogen effluvium, tractional alopecia, atrichia congenita, Ectodermal dysplasia, alopecia due to nutritional deficiency, occipital neonatal alopecia, monilethrix, SLE alopecia
Hair color and texture changes with hair loss	9	Ectodermal dysplasia, alopecia due to nutritional deficiency, monilethrix, SLE alopecia

SLE: Systemic lupus erythematosus, TC: Tinea capitis, AA: Alopecia areata

The most common site of scalp hair loss was on vertex region in 97 cases (32.33), followed by parietal region in 58 (19.33%), occiput region 53 (17.33%), all over the scalp 39 (13%), frontal region 34 (11.33%), and temporal region 19 (6.33%) cases.

The causes of scalp hair loss were infectious in 179 (59.66%) cases, (99 females, 80 males). Hair loss due to noninfectious etiology was found in 121 (40.33%) cases, (57 females, 64 males). Hair loss was due to acquired causes in 287 (95.56%) patients and due to congenital causes in 13 (4.33%) patients. The pattern of scalp hair loss was patchy in 255 (85%) cases and diffuse in 45 (15%) cases. Patchy hair loss pattern was more common than a diffuse pattern with 5.6:1 ratio. Scalp hair loss was noncicatricial in 275 (91.66%), and cicatricial in 25 (8.33%) cases, with the ratio of being 11:1, emphasizing that noncicatricial alopecia was much more common. Pruritus was major complaint associated with presenting lesion in 208 (69.33%) patients. Scaling was present in 198 (66%) patients [Table 2].

Table 2

Demographic and clinical profile of patients of scalp hair loss (n=300)

Features	Out of 300 cases
Age (years) (mean±SD)	8.79±4.26
Sex (female:male)	1.08:1 (156:144)
Prevalence of common causes (%)
TC	55.33
AA	17.66
Infectious causes (%)
Yes	59.66
No	40.33
Pattern of alopecia (%)
Diffuse	15
Patchy	85
Causes of alopecia (%)
Acquired	95.55
Congenital	4.33
Type of alopecia (%)
Noncicatricial	91.66
Cicatricial	8.33
Pruritus (%)	69.33
Hair color and textural changes (%)	3
Scaling (%)	66

TC: Tinea capitis, AA: Alopecia areata, SD: Standard deviation

Most common disorder found in this study was tinea capitis in 166 (55.33%) cases [Figure 1] followed by alopecia areata in 53 (17.66%) [Figure 2], seborrheic dermatitis in 16 (5.33%), pediculosis with secondary infection in 11 (3.66%); uncommon causes were lichen planopilaris in 8 (2.66%), tractional alopecia in 7 (2.33%) [Figure 3], telogen effluvium in 6 (2%), nevus sebaceous in 6 (2%) [Figure 4], occipital neonatal alopecia in 4 (1.33%), ectodermal dysplasia in 4 (1.33%) [Figure 5], scalp psoriasis in 3 (1%), trichotillomania in 3 (1%), and alopecia due to nutritional deficiency in 3 (1%). Several rare causes were identified in this study such as folliculitis decalvans in 2 cases, pseudopelade of Brocq in two cases, and one case each of alopecia due to lamellar ichthyosis, aplasia cutis congenita, atrichia congenita, discoid lupus erythematosus, monilethrix [Figure 6], systemic lupus erythematosus alopecia [Table 3].

Figure 1

(a) Tinea capitis (gray patch). (b) Tinea capitis (black dot). (c) Tinea capitis (kerion)

Figure 2

(a) Alopecia areata (bald patch). (b) Alopecia totalis

Figure 3

Tractional alopecia

Figure 4

Nevus sebaceous

Figure 5

(a) Ectodermal dysplasia (typical facial features and hair changes). (b) Ectodermal dysplasia (abnormal dentition)

Figure 6

Hair shaft of monilethrix patient showing regular beading on light microscopy

Table 3

Distribution of patients according to prevalence of causes

Diagnosis	Female	Male	Total (%)
TC	88	78	166 (55.33)
AA	23	30	53 (17.66)
Seborrheic dermatitis	7	9	16 (5.33)
Pediculosis capitis + S.I.	10	1	11 (3.66)
Lichen planopilaris	5	3	8 (2.66)
Tractional alopecia	7		7 (2.33)
Nevus sebaceous	2	4	6 (2)
Telogen effluvium	3	3	6 (2)
Occipital neonatal alopecia	1	3	4 (1.33)
Ectodermal dysplasia		4	4 (1.33)
Scalp psoriasis	2	1	3 (1)
Alopecia due to nutritional deficiency	1	2	3 (1)
Pseudopelade of Brocq		2	2 (0.66)
Folliculitis decalvans	1	1	2 (0.66)
Alopecia due to lamellar ichthyosis		1	1 (0.33)
Aplasia cutis	1		1 (0.33)
Atrichia congenita		1	1 (0.33)
DLE	1		1 (0.33)
Monilethrix		1	1 (0.33)
SLE alopecia	1		1 (0.33)
Total (%)	156 (52)	144 (48)	300 (100)

DLE: Discoid lupus erythematosus, SLE: Systemic lupus erythematosus, TC: Tinea capitis, AA: Alopecia areata, S.I.: Secondary infection

Discussion

Hair loss in children is not an unusual complaint in routine practice and considered as a challenge for dermatologists. The causes of scalp hair loss in children have been classified according to the pattern of alopecia, namely focal (patchy), diffuse and on the basis of scarring, noncicatricial, and cicatricial.[5] Hair loss can be caused by a variety of underlying conditions. Some of them are inflammatory disorders, fungal infections,[67] autoimmune disorders such as alopecia areata,[8] trichotillomania,[910] and genetic diseases, where the hair abnormality can be one of the major signs composing a clinical syndrome, like ectodermal dysplasia syndromes.[1112] Alopecia may be associated with hair shaft defects such as trichorrhexis invaginata[13] (Netherton syndrome), monilethrix,[14] follicle damage, or develop secondary to an external factor.

A practical approach to evaluate hair disorders in children is crucial to ensure the correct diagnosis. A correct diagnosis is an important issue for proper prevention and management of further hair loss.

In our study, tinea capitis 166 (55.33%) was the most common disorder followed by alopecia areata 53 (17.66%), seborrheic dermatitis 16 (5.33%), pediculosis with secondary infection 11 (3.66%). Several other uncommon causes were also found, whereas in other studies nonscarring alopecia, 60 (31.57%), benign neoplasias, hamartomas or vascular malformations of the scalp, 56 (29.47%);[15] tinea capitis 86 (40.0%) followed by alopecia areata 52 (26.2%);[16] alopecia areata (36.8%), tinea capitis (21%), and nevus sebaceous (13.2%)[17] were found [Table 4].

Table 4

Comparison of studies related to the topic

Author	Title of study	Sample size	Common causes
Rossana Conti et al. (Italy, 2015)[15]	Clinical and epidemiological evaluation on hair and scalp disorders in a Tuscan Pediatric Dermatology clinic Itly	190	Nonscarring alopecia: 31.57
			Benign neoplasm: 29.4
			Inflammatory disorders: 26.8
			Scarring alopecia: 2.63
Khitam Al-Refu (Jordan, 2013)[16]	Clinical and epidemiological study on common and uncommon causes of hair loss in children in Jordan	210	TC: 40
			AA: 26.2
			Telogen effluvium: 17.6
Corte GA et al. (Chile, 2015)[17]	Clinical and epidemiological study on etiology of childhood alopecia	345	AA: 56.8
			TC: 21
			Nevus sebaceous: 13.2
			Telogen effluvium: 8.7
Nnoruka EN et al. (Nigeria, 2007)[18]	Common and uncommon causes Hair loss in children in South-East Nigeria	113	TC: 54.9
			AA: 38.1
			Psoriasis: 4.4
Chander Grover et al. (India, 2010)[19]	Tinea capitis in pediatric population: A study from North India	214	Noninflammmatory TC: 56.5
			Endothrix: 41.5
Sarifakioglu E et al. (Turkey, 2012)[20]	Prevalence of scalp disorders and hair loss in children	69	Seborrheic dermatitis-most common
Kalla G et al. (India, 1995)[21]	Clinicomycological study of TC in desert district of Rajasthan, Jodhpur	200	In male: 64.5
			In urban: 88
Our study	Epidemiological and clinical study of scalp hair loss in children (0-18 years)	300	TC: 55.33
			AA: 17.66

AA: Alopecia areata, TC: Tinea capitis

Tinea capitis was the most prevalent form. There were three different presentations of tinea capitis patients. The most common was scaly, pruritic, single or multiple gray patchy [Figure 1a] hair loss seen in 111 (66.86%) patients; other presentations were black dot [Figure 1b] in 28 (16.8%), kerion [Figure 1c] in 26 (15.6%) patients, in one patient, both varieties, gray patch and black dot were present [Table 5]. Some of these patients got a secondary bacterial infection and had some elements of scarring due to delayed presentation and lack of proper management.

Table 5

Distribution of Tinea capitis cases according to clinical types and gender

Types of TC	TC		Total (%)
	Female	Male
Black dot	12	16	28 (16.8)
Gray patch
Gray patch	48	42	90 (54.21)
Gray patch + S.I	12	9	21 (12.6)
Gray patch + black dot	0	1	1 (0.6)
Kerion	16	10	26 (15.6)
Total	88	78	166 (100)

S.I.: Secondary infection, TC: Tinea capitis

Concurrent dermatophytosis affecting other parts of the body (neck, face, back, and upper extremities) was seen in 8 (4.8%) cases, and cervical lymphadenopathy was found in 51 (30.7%) cases. Sixty patients (36.14%) had positive family history of dermatophytosis.

The hair loss was due to acquired causes in 287 (95.66%) patients and congenital causes in 13 (4.33%) patients; the infectious causes (179, 59.66%) were much more prevalent as compared to noninfectious causes (121, 40.33%). As the acquired and infectious disorders are treatable, early diagnosis is needed to prevent further irreversible hair loss and proper management of alopecia.

Alopecia areata [Figure 2a] was the second most prevalent disorder, 53 (17.66%) patients found in our study with a male-to-female ratio of 1.3:1 (30 males, 23 females) and with mean age 11.0 ± 4.01 years. Five (9.43%) patients had alopecia totalis [Figure 2b]. Thirteen out of 53 (24.66%) cases of alopecia areata had a positive family history. The earliest age of reporting alopecia areata was 2 year. Whereas, a study[16] stated that alopecia areata was the second most common form of hair loss, affecting 52 patients (26.2%), with a male:female ratio of 3:2 and with a mean age of 3.6 years. The earliest age of reporting alopecia areata in this study was 3 month.

During examination of other hairy sites, we observed that loss of eye lashes, eyebrows, and pubic hair were seen in 4 (7.5%) patients with alopecia universalis. Nail changes such as nail pitting, leukonychia were observed in 14 (26.41%) cases. Association of nail changes with alopecia areata was statistically significant, (P = 0.0001). Atopic dermatitis was found in 3 (5.6%) cases of alopecia areata, vitiligo in 1 (1.8%) case, urticaria in 1 (1.8%) case [Table 6]. Whereas in a study,[17] alopecia areata was statistically associated with autoimmune diseases, thyroid disease, nail disorder, psychiatric disease, and Down's syndrome. Moreover in another study,[18] 17 patients with alopecia areata had atopic dermatitis and vitiligo was seen in 3 cases.

Table 6

Distribution of alopecia areata cases with associated clinical condition

Associated conditions	AA		Total (%)
	Female	Male
AD	3		3 (5.6)
Nail changes
LN	2	1	3 (5.6)
NP	1	3	4 (7.5)
NP, LN	3	4	7 (13.2)
Urticaria		1	1 (1.8)
Vitiligo patches over back for 2 years		1	1 (1.8)
None	14	20	34 (64.15)
Total	23	30	53 (100)

AA: Alopecia areata, AD: Atopic dermatitis, LN: Leukonychia, NP: Nail pitting

In this study, 6 (2%) patients of telogen effluvium presented as diffuse nonscarring alopecia. The most common cause was the frequent illnesses and high-grade fever that preceded the hair loss by 2–3 months. A study[16] stated that the presentation of hair loss due to telogen effluvium was seen in 37 (17%) cases.

We observed that 9 (3%), (7 males, 2 females) patients presented with diffuse hair loss with hair color and textural changes associated with nutritional deficiency, iron deficiency, and ectodermal dysplasia. According to one study,[16] 22 patients (10.5%) (mean age 6.2 years, 20 females and 2 males) had chronic diffuse hair loss with abnormal hair texture. So as a physician we should be aware of such presentation that may be an only sign of systemic illness or any deficiency.

Trichotillomania found in three patients (all female with mean age 13 years), presented with patchy hair loss, broken hair of varying lengths, with unaffected hairs surrounding the area of hair loss. A study[16] found that 15 cases (7%) presented with trichotillomania.

Tractional alopecia was seen in 7 (2.3%) patients. All patients were female. Mean age of presentation was 12.28 ± 2.75 years. It may occur due to habits of traction of hair, and it is unintentionally induced and is usually related to hairdressing styles or techniques such as tight braiding.[22] In a study,[16] traction alopecia was seen in 20 cases with a female predominance.

There are differences in findings of our study from the findings of studies from other countries. These differences may be due to low awareness about health in children and their parents, low education levels and environmental conditions in our context. They reach health centers when the diseases advance. The proper counseling and early diagnosis can help patients to prevent further irreversible hair loss. It concludes that still the infectious causes are more prevalent in the developing country like ours.

Conclusion

This study showed that hair loss in our region is not an uncommon problem and results from a variety of causes. Early diagnosis and treatment are needed to prevent further hair loss and to avoid the irreversible hair loss and scarring alopecia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.