Introduction

Alopecia areata occurs when a person’s immune system destroys the structures that form their hair i.e., the hair follicles and causes hair loss. This disease usually affects the head and the face and causes the hair to fall in small round patches and may become excessive in some cases. Most people with alopecia areata usually do not show any other symptoms. Alopecia areata can progress in different ways for different people. Some people might have hair loss periods throughout their lives while some have only one hair loss period. On similar lines, recovery too varies from person to person with some people recovering completely while others do not. There is no known cure for alopecia areata but existing treatments help increase hair growth. While alopecia areata can affect all age groups, most people get it in their teenage years. When children below the age of 10 get alopecia areata, the hair loss is extreme. Alopecia areata affects about 1 in every 1,000 children. Though alopecia is not as common in children, it can be very upsetting for the parents and the children and may require support.^1,2,6

Overview of alopecia areata

Types

There are three types of alopecia:¹

1. Alopecia areata is the most common type of alopecia. The hair loss occurs in patches across the whole body and scalp
2. Alopecia totalis: This type of alopecia areata causes loss of all the hair on the scalp
3. Alopecia universalis: This is the rare type of alopecia areata which causes complete loss of hair on the scalp and body

Causes and diagnosis

While alopecia areata seems to have a genetic component and people with a family member with the disease have a higher chance of getting the disease, many people with the disease have no family history. Many genes that are important for the normal functioning of the immune system have been linked to the disease. People with autoimmune diseases like psoriasis, thyroid, or vitiligo and people with allergic conditions like hay fever are more prone to get alopecia areata. Alopecia areata is diagnosed by a physical examination and evaluating the family history. This diagnosis is confirmed by a trichoscopy.^1,4

In children, additional causes of alopecia could be:^2,3

• Fungal infections (tinea corporis) and ringworm infections (tinea capitis) that affect the skin or hair. These conditions are contagious and infections on the scalp can cause hair loss in patches. This is usually diagnosed by microscopic examination
• Endocrine problems like hypothyroidism, where the thyroid is not producing enough hormone, can cause hair loss and can be diagnosed by blood tests³
• Newborn babies can face hair loss from constant rubbing of their head against the crib mattress
• Nutritional deficiency like biotin and zinc deficiency though less common in children can lead to hair loss. This can be diagnosed by blood tests
• Extreme stress can damage the hair follicles and lead to excessive hair loss, leading to partial or total baldness

Symptoms

People with alopecia areata are usually healthy and have no other symptoms apart from hair loss. In severe cases of hair loss, some changes in the nail structure are also observed.¹ 

Hair loss begins with sudden loss of hair in patches. Some people feel a burning sensation just before the hair falls out. This bare patch can take various routes including:¹

1. Regrow hair within a few months
2. Additional bare patches may develop while the initial bare patch regrows hair
3. Small bare patches merge and form larger bare patches and in extreme cases this may cause hair loss from the entire scalp and is called alopecia totalis
4. This may progress to complete loss of hair from the body and is called alopecia universalis

The hair tends to regrow if the age of onset of alopecia was late and there is no family history of the disease.¹

Treatment

Usually, alopecia areata in children does not need specific treatment as the missing hair grows back in a few months. However, if treatment is needed, the first step usually involves steroid-containing topical ointments which are applied to the patches to decrease activity of the immune system. Other options are oral treatment and topical immunotherapy.^2,3 

Other causes of hair loss like hormonal problems and nutritional deficiencies can be overcome by consulting a doctor. In case of fungal and ringworm infections, antifungal medications are prescribed and care should be taken to not share any items that touch the head (like hats, pillowcases etc).³

Complications

While hair loss in children can have a serious impact on the quality of their life, alopecia has a significant impact on the family as a whole. Children often face:^4,6

• Social isolation 
• Humiliation by friends
• Reduced self-esteem 
• Anxiety
• Stress
• Depression 

Social impact on children below 5 years of age: Children in this age group usually do not pay much attention to their physical appearance or how they look different from others. Hence, the social impact from their hair loss is lesser. 

Social impact on children above 5 years of age: As children cross the age of 5, they interact with more people and start noticing differences between themselves and others. They become conscious of how others see them. Their self-confidence can drop. A ​study published in 2017 found the following: 

• 48% of teens felt embarrassed about their hair loss 
• 7% of children said that their condition affected their friendships 
• 59% said that they have felt uncomfortable by being stared at or being talked about 
• 52% said that their condition made them restrict their outdoor activities

Children with alopecia areata are often victims of bullying and is seen more commonly with older children. 13% of children between 12 and 14 years of age and 40% of those between 15 and 19 years of age have been bullied because of their different appearance. ​​​​​​

FAQs

When does one need to see the paediatrician?

It is normal for most newborns to lose hair after birth, so there is usually no need to see a doctor. However, any ongoing hair loss that is affecting the child should be discussed with the paediatrician.²

How does hair loss by alopecia areata affect a child’s life?

Though the hair loss is not physically painful or life-threatening, living with hair loss can be challenging, both socially and emotionally. This is especially true for children. Seeking counselling can help the child build a positive self-image.³

What are the lifestyle changes that can be implemented to manage alopecia in children?

Some recommended options to make the child’s life easier are:⁵

1. The child should use sunscreen on the bald spots when outdoors
2. If the child is embarrassed about their hair loss, they may want to cover the bald spots. Schools usually let children with conditions causing hair loss wear hats or scarves within classrooms
3. Some children might prefer wearing a wig
4. Create a safe space for the child to be able to express their feelings. If they are teased or bullied, let the school know so they can work on ways to help them
5. Children may feel better after talking to a professional counsellor or joining a support group
6. The National Alopecia Areata Foundation can help reach out to others who have alopecia areata

Summary

Alopecia areata is an autoimmune disorder that causes hair loss, usually on the scalp and face. In this condition, hair falls out in small, round patches. The condition generally does not show any symptoms apart from hair loss. The path of alopecia areata varies from person to person. Some show cycles of hair loss and regrowth, while others lose hair permanently. Though there is no cure, treatments such as topical steroids, oral medications and immunotherapy help increase hair regrowth.

In children, alopecia areata can be very challenging. Hair loss is sudden and can become more severe in younger children. Social and emotional impacts, such as low self-esteem, experiencing bullying and anxiety, are common, especially as children become more conscious of their appearance. Adolescents and teens are vulnerable to the psychological effects of hair loss, which may lead to social isolation and depression. Support from parents, schools and doctors is important. Creating a safe environment for children to express their feelings and giving access to resources like counselling and support groups can help them become resilient. While treatments can aid hair regrowth, the emotional support provided by professionals is just as important in helping children cope with alopecia areata.