Original Article Hair Loss in Children: Common and

Uncommon Causes; Clinical and

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Epidemiological Study in Jordan
www.ijtrichology.com
Khitam Al-Refu
DOI:

10.4103/0974-7753.130393 Clinical PhD in Dermatology, Department of Internal Medicine, University of

Quick Response Code: Mutah, Karak, Jordan

ABSTRACT

Background: Alopecia is a common complaint in dermatology clinics, and can be caused

Address for correspondence:
Prof. Khitam Al-Refu,
Department of Internal
Medicine, Clinical PhD in
Dermatology, UK,
Connective Tissue Disease
Specialist, Faculty of
Medicine,
University of Mutah,
Karak, Jordan.
E-mail: alrefukhi@yahoo.com
by a number of conditions, and has patterns that are different from that seen in adults.
Aim of Study: No previous studies investigating the clinical types of hair loss in Jordan and its
epidemiology. The ultimate aim was to provide a guide for the evaluation of hair loss commonly
occurring in childhood in our environment. Patients and Methods: A total of 2800 children
were seen at the dermatology clinics (Karak teaching hospital and Mutah university medical
center) during January 2009 to October 2013 complaining of various clinical dermatological
symptoms. Results: Of these patients, 210 children were complaining of hair loss and
scalp disorders (7.5% of pediatric dermatology cases seen in Jordan). The most common
presentation was asymptomatic patchy hair loss (40%). Other symptoms were scaly scalp
(22.9%), diffuse hair loss (21.4%), change in hair texture and color (8.1%), pruritus (5.7%), and
pain in the scalp (1%). Tinea capitis was the commonest causes of hair loss (40.0%) followed
by alopecia areata (26.2%) and telogen effl uvium (17.6%). Other common causes of hair loss
were observed in this study, these include chronic diffuse form of hair loss, trichotillomania,
and traction alopecia. Conclusions: As has been observed in this study, hair problem may
be due to important nutritional deficiency such as iron and zinc elements, and this is very
important problem to think of especially in developing countries. Therefore, hair examination
by a pediatrician or dermatologist is an important part of the physical examination.
Key words: Hair loss, no scarring alopecia, pattern of hair loss

INTRODUCTION anemia, malnutrition, structural abnormalities of the hair

shaft that usually results in easy breakage and dry brittle hair.

A lopecia or hair loss is a common complaint in

dermatology clinics, and this can be caused by a
number of conditions, reflected in a specific diagnosis.
Although androgenetic alopecia is by far the most common
forms of hair loss in adults,[1] dermatologists also see many
people with other forms of alopecia. Similarly, hair loss
is not uncommon problem in pediatric group[2] but has
patterns that are different from that seen in adults.[2] In
addition, this problem is of particular concern in pediatric
group, as it is associated with more significant psychological
consequences in this growing age group.
Hair types are influenced by ethnic groups[6] and this
varies from region to region and subsequently this may
reflect itself on the variation of common and uncommon
causes of hair loss. Therefore, this study was conducted to
determine clinical types of hair loss in Jordan. There are
no previous studies investigating the clinical types of hair
loss in Jordan and its epidemiology. The ultimate aim was
to provide a guide for the evaluation of hair loss commonly
occurring in childhood in our environment.

Common causes of hair loss in children[3,4] include telogen
effluvium, tinea capitis, bacterial infections, traction
alopecia, trichotillomania, alopecia areata. In addition to
the previous, other less common causes of hair loss can be
seen including[5] thyroid disorders, illnesses, such as systemic
lupus erythematosus, diabetes mellitus, or iron deficiency
International Journal of Trichology / Oct-Dec 2013 / Vol-5 / Issue-4
MATERIALS AND METHODS
A total of 2800 children were seen consecutively
at the dermatology clinics (Karak teaching hospital
and Mutah university medical center) during
January 2009 to October 2013 complaining of various
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 Al-Refu: Hair loss in children: Common and uncommon causes
clinical dermatological symptoms. Of these patients, 210
children who were complaining of hair loss and scalp
disorders were included in the study. Informed consent
was obtained from all patient parents. The data collected
included age, sex, and clinical presentations (patchy or
diffuse hair loss, presence of itching or scales, affected
site, and the progression of the problem, and hair loss
in the body other than the scalp). In addition, detailed
history was taken about and hair grooming/habit tics, nail
changes, other cutaneous changes, systemic diseases, family
history of similar condition or autoimmune disease, and
drug history.
Scalp examination included the skin of the scalp (presence of
erythema, scales, and follicular plugging). Hair examination
included the recording of hair color, texture, fragility, and
examination of the hair root. In addition, Wood’s light
examination, skin and scalp scrapings for KOH (potassium
hydroxide) smear and mycologic studies, and bacteriology
were done for specific diagnostic cases. Microscopy for the
shed hair and dermoscopy was done in some cases.
In addition to the scalp, other hairy sites were examined
for hair loss (including eyebrows, eyelashes). Nail and teeth
were examined for any abnormalities.
Other investigations carried out included complete blood
count (CBC), serum iron, serum zinc, thyroid function test,
antinuclear antibody (ANA), and autoantibodies, which
were performed for further confirmation where necessary
in some cases.
RESULTS
Of 2800 patients attending dermatology clinics at Karak
teaching hospital and Mutah University Medical Center,
210 children (females, 120 (57.1%); males, 90 (42.8%))
had scalp and hair disorders. The age range was from
2 month to 16 years. This has been summarized in Table 1
and correlated with some of known clinical differential
diagnosis for each symptom.
The most common presentation was asymptomatic patchy
hair loss (86 patients, 40%). Other symptoms were scaly
scalp (48 patients, 22.9%), diffuse hair loss (45 patients,
21.4%), change in hair texture and color (17 patients 8.1%),
pruritus (12 patients, 5.7%), and pain in the scalp (two
patients, 1%).
Tinea capitis was the most prevalent form of hair
loss (85 patients, 40.5%). Males were affected more than
females (males 49 cases, females 36 cases) with mean age
186
of 6.4 years. The presentation was commonly as patchy
hair loss with scales and erythema and solitary or multiple
patches. Other presentations of tinea capitis were hair loss
with black dot, seborrheic form, and kerion formation.
Some of these patients had some elements of scarring
due to delay in diagnosis and proper management. The
diagnosis of these cases of tinea capitis was confirmed by
KOH scrapping for the scales. Concurrent dermatophytosis
affecting other parts of the body (face, trunk, and nails)
occurred in 28% of cases.
Alopecia areata was the second form of hair loss,
affecting (52 patients) 26.2% of the cases, with a
male:female ratio of 3:2 and with mean age of 3.6 years.
The earliest age of reporting alopecia areata in this
study was 3 months (presented with multiple patches).
The duration of the disease varied from 1-3 months at
presentation. The presentation of patients was commonly
with single or multiple patches of hair loss with no scales
or erythema and with normal scalp appearance. Five cases
of them had a diffuse hair loss at the time of the diagnosis
of alopecia areata. Family history was positive for alopecia
areata in 12 cases (seven of them had brothers or sisters
with the same complaint). All cases were examined for
body involvement with alopecia areata, which was positive
in 10% of cases. Nail changes with pitting was seen in
27% of cases with the disease. All of the cases with alopecia
areata were examined for other autoimmune diseases.
Hypothyroidism was seen in three cases, diabetes mellitus
in one case. Other autoimmune disease like vitiligo was
seen in three cases.
Table 1: Presenting symptoms of hair loss
in children (210 cases), correlated with the
differential diagnosis for each presenting symptom
Symptoms Number of Differential diagnosis
cases
Asymptomatic 86 patients, Tinea capitis, alopecia areata, trichotillomania,
patchy hair 40% traction alopecia, folliculitis, nevus sebaceous,
loss and congenital aplasia cutis
Scaly scalp 48 patients, Tinea capitis, seborrheic dermatitis, cradle cap,
22.9% psoriasis, folliculitis, lichen planopliaris, discoid
lupus erythematosus, and other connective
tissue diseases
Diffuse hair 45 patients, Alopecia areata, trichotillomania, telogen
loss 21.4% effluvium, congenital hair abnormalities,
systemic diseases (i.e. iron deficiency anemia,
zinc deficiency, and connective tissue diseases)
Change in hair 17 patients, Atopic dermatitis, icthysosis, chronic
texture and 8.1% zinc deficiency, congenital structural hair
color abnormalities
Pruritus 12 patients, Scalp folliculitis, pediculosis
5.7%
Pain in the Two Nonspecific as it may be associated with all of
scalp patients, 1% the above-mentioned cases
International Journal of Trichology / Oct-Dec 2013 / Vol-5 / Issue-4
 Al-Refu: Hair loss in children: Common and uncommon causes
Telogen effluvium, which occurs as diffuse non-scarring
alopecia characterized by the shedding of hair resulting
from the early entry of hair in the telogen phase, occurred
in 37 children (17.6%). The concern in the study was to
report the cases of telogen effluvium other than the cases
of “telogen effluvium of the newborn,” which is common
phenomena and considered as a physiological one. All of
the cases had normal scalp and normal hair texture. This
complaint was commonly from the females, as this problem
more noticeable due to the habit of keeping hair long
comparing to the males. The mean age of the presentation
was 8 years and with duration of 4-6 months before the
presentation to the clinic. To confirm the diagnosis of
telogen effluvium, a microscopic examination of the shed
hair revealed a typical bulb (i.e. depigmented bulb) of
telogen hair. All the cases were investigated well for the
causes of this. The most common cause was the frequent
illnesses and high-grade fever that preceded the hair loss
by 2-3 months, followed by iron deficiency anemia.
A total of 22 patients (10.5%) (mean age 6.2 years,
20 females and two males) had chronic diffuse hair loss with
abnormal hair texture (with hair dryness and brittleness)
with no other cutaneous manifestations. Specific history
was taken to rule out other causes of hair loss (such as
acute or chronic telogen effluvium). They have been healthy
with no significant medical history. Skin examination
revealed diffuse patchy alopecia (non-scarred) with very
dry hair. Otherwise nothing was significant in the physical
examination of these groups of patients, and similarly
laboratory results with the exception of zinc level with the
mean level of 52.3 μg/dl.
Trichotillomania was another and significant form of patchy
hair loss in this study. A total of 15 cases (7%) presented of
hair loss with broken hairs of varying lengths arranged in a
circular pattern, with unaffected hairs surrounding the area
of hair loss. The skin of the scalp was normal with no signs
of inflammation. Some of the cases have severe degree of
involvement in the entire scalp, sparing only marginal areas
at the periphery. The mean age of presentation was 10 years
with female predominance (10 cases are females). In addition
to the scalp, three cases had eyebrows involvement. All cases
of trichotillomania underwent dermoscopy examination.
A recent article by Lencastre and Tosti[7] reviewed the role of
dermoscopy in childhood hair disorders and noted fraying
of ends, breakage at different lengths, and scratching and
hemorrhaging as possible signs of trichotillomania. All cases
in this study showed positive results by dermoscopy.
Traction alopecia was seen commonly in this study, most
of the cases did not present specifically for this problem
International Journal of Trichology / Oct-Dec 2013 / Vol-5 / Issue-4
and all of them are females. But by physical examination,
nearly 20% of the cases had some elements of this type
of hair loss, occurring mainly around hair line. In some
cases, hair cast had been identified. In addition, some cases
showed follicular pustules and inflammation along the
margin of alopecia.
There are several uncommon causes of hair loss identified
in this study: Atopic dermatitis in 10 cases, folliculitis
decalvans in 10 cases, congenital icthyosis in eight cases, nevus
sebaceous in seven cases, Netherton syndrome in four cases,
lichen planopliaris in four cases, aplasia cutis congenita in one,
and large congenital melanocytic nevus in one.
DISCUSSION
Hair loss in children is an important complaint in
dermatology clinics and considered as a challenge for
dermatologists and pediatrician for reaching a proper
diagnosis and therapy for their patients. In addition, this
problem is annoying problem for the parents who are
worrying from the total and irreversible hair loss to their
children. There are common and uncommon causes for
this complaint,[8,9] and this usually covers a broad differential
diagnosis, and correct diagnosis is an important issue for
proper diagnosis and prevention of further hair loss. Early
management is needed, as this has its effect on development
of normal mental and physical growth of children.
There are very few studies investigating the common and
uncommon causes of hair loss in children,[9,10] and none to
investigate this in Jordan. Specific environmental and cultural
factors may reflect itself on the prevalence of specific types
of hair loss in children. The clinical manifestations profile
including age, sex, and clinical presentation (patchy or diffuse
hair loss, presence of itching or scales, affected site, and the
progression of the problem, and hair loss in the body other
than the scalp) are important factors for the classification of
the hair disease.[8-10] In this research, a classification of hair
loss was based initially on the initial presentation and the
differential diagnosis of this [Table 1], and this was considered
as a guide for the evaluation of hair loss.
Hair loss and alopecia occur frequently in children. Scalp and
hair disorders accounted for 7.5% of pediatric dermatology
cases seen in Jordan. Both common and uncommon causes
of hair loss were found in our series [Table 2].
Tinea capitis was the commonest causes of hair loss (40.0%)
and followed by alopecia areata (26.2%) and telogen
effluvium (17.6%). Other common causes of hair loss
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 Al-Refu: Hair loss in children: Common and uncommon causes

were observed in this study but to a lesser degree than
the previous three mentioned cases. These causes include
chronic diffuse of hair loss, trichotillomania, and structural
hair abnormalities. Traction alopecia was seen commonly
in this study and was seen in association with other entities.
Tinea capitis (ringworm of the scalp) is one of the more
common causes of hair loss,[10] but it is not difficult to recognize
because of the association scalp findings (redness, hair loss,
and a scaly border that may be itchy). But sometimes signs
and symptoms can be more subtle though, with no scaling or
itching, and broken hairs instead of hair loss (black dot tinea
capitis). For these cases (KOH) mounted preparation may be
needed to prove the diagnosis and to differentiate from alopecia
areata.[11] Alopecia areata is one of the differential diagnoses of
tinea capitis, although the diagnosis is not difficult to be done,
as the scalp examination is normal in alopecia areata. But this
story is not straightforward in our community in which parents
may use some herbal products that may causes changes in the
clinical picture and subsequently may affect early diagnosis.
The presentation with hair loss due to telogen effluvium
was seen in nearly 17% of cases and was commonly due to
preceding history of fever. Generally, telogen effluvium[12]

Table 2: Common and uncommon causes of hair loss in children (210 cases), correlated with the sex, age,
common presentation, and specific diagnostic tests
Cause of hair loss Age and sex
Tinea capitis 85 patients, 40.5%
Males more than females
Mean age 6.4 years
Alopecia areata 52 patients, 26.2%
Females more than males
Mean age 3.6 years
Telogen effluvium 37 children, (17.6%)
Mainly females
Mean age of 8 years
Diffuse hair loss with 22 patients (10.5%)
abnormal texture Mainly females
Mean age 6.2 years
Trichotillomania 15 cases (7%)
Female predominance
Mean age of 10 years
Traction alopecia 20% of cases
Female predominance
was seen in some patients
with other causes of hair loss
Hair abnormalities with 10 cases
atopic eczema All are male cases
Mean age 3.2 years
Folliculitis decalvans 10 cases
Eight cases are females
Mean age 9.4 years
Congenital icthyosis Eight cases
Four cases are females
Mean age 1 year
Nevus sebaceous Seven cases
Five cases are males
Mean age 1 year
Netherton syndrome Four cases
All are males
Mean age 2.7 years
Lichen planopliaris Three cases
One case is male
Mean age 4.3 years
Aplasia cutis congenita One case
Male, 1.5 year
Large congenital One case
melanocytic nevus Male, aged 3 months
CBC – Complete blood count; KOH – Potassium hydroxide
Common presentation
Patchy hair loss with scales and
erythema, black dot, seborrheic
form, kerion formation, scarring
Patchy or diffuse hair loss with
normal scalp
Diffuse non-scarring alopecia
Chronic diffuse hair loss with
abnormal hair texture
Hair loss with broken hairs of
varying lengths
Hair loss at hair margins and
sometimes with hair cast and
perifollicular inflammation
Diffuse hair loss with structural hair
abnormalities
Folliculitis with scarring alopecia
Sparse hair with scales and
structural hair abnormalities
Patch of hair loss with thickened
skin with yellowish discoloration
Diffuse hair loss
Patchy hair loss with follicular
plugging and scarring alopecia
Specific diagnostic tests
KOH scraping for the scales
Wood’s light examination
History of anemia, thyroid diseases,
diabetes mellitus, other cutaneous or
systemic autoimmune diseases
A microscopic examination of the shed hair
CBC, serum iron, serum zinc, thyroid
function test
Zinc deficiency
Dermoscopy examination
None
History of other atopy
Bacteriology
None
None
Examination of abnormal hair under
microscope shows trichorrhexis invaginata
Skin biopsy

188 International Journal of Trichology / Oct-Dec 2013 / Vol-5 / Issue-4

 Al-Refu: Hair loss in children: Common and uncommon causes
resulting from a traumatic stimulus, which shows diffuse
hair loss that does not produce clear areas. There are no
broken-off hairs or exclamation-point hairs. There are no
previous studies investigating this phenomena in children
thoroughly, and it may be higher than what seen in adult
population, as the common causes of telogen effluvium
and iron deficiency anemia are common in children.
The new thing in this study was the chronic type of hair loss
that was observed in this study and was due to zinc deficiency
that was seen in our children despite absence of characteristic
signs of zinc deficiency, and this may highlight the idea of
how much was common the phenomena of zinc deficiency
in Jordanian children, and there were no previous studies
investigating this deficiency in our children, and this may be a
future study investigating zinc deficiency in Jordanian children
and the effect of this on the skin and the hair of children.
Trichotillomania was another form of hair loss seen in this
research. It is a compulsive hair pulling,[13] which manifests
with irregular areas of hair loss, and hairs of different
lengths, and with no clear area of baldness. This type
of disease has particular concern as it is associated with
psychological abnormalities in children with this complain
and need to be assessed by psychologist in addition to
dermatologist; the skin is a mirror to many of internal
disease and one of these is how we think.
Traction alopecia, which was seen in 20 of our cases and
was associated with other types of hair loss, was usually
not associated with internal pathology and was due to
habits of traction of hair, and this was common in our
environment in which there is trend to keep the hair of
girls long and subsequently the hair should be tightened
as a rule of the school.
Other uncommon causes of hair abnormalities have been
observed in this study, and one of these was the lichen
planopliaris in four cases (the sole presentation was scalp
redness and hair loss with no involvement of glabrous skin).
Atopic dermatitis is common disease in Jordan; 10 cases
of our patients had hair abnormalities and three cases
diagnosed to have Netherton syndrome (characterized
International Journal of Trichology / Oct-Dec 2013 / Vol-5 / Issue-4
by chronic skin inflammation, universal pruritus, severe
dehydration, and a hair shaft defect (trichorrhexis
invaginata) also known as “bamboo hair”).
In summary, hair loss in Jordan is not an uncommon
problem and results from variety of causes. Early treatment
and diagnosis is needed to prevent further hair loss and to
avoid the irreversible hair loss and scarring alopecia. As
has been observed in this study, hair problem may be due
to important nutritional deficiency such as iron and zinc
elements, and this is very urgent thing to think of especially
in developing countries.
REFERENCES
1. Banka N, Bunagan MJ, Shapiro J. Pattern hair loss in men: Diagnosis and
medical treatment. Dermatol Clin 2013;31:129-40.
2. Hamm H. Acquired alopecia in childhood. Hautarzt 2013;64:371-9; quiz
380-1.
3. Sch Schroeder TL, Levy ML. Treatment of hair loss disorders in children.
Dermatol Ther 1997;2:84-92.
4. Mandt N, Vogt A, Blume-Peytavi U. Differential diagnosis of hair loss in
children. J Dtsch Dermatol Ges 2004;2:399-411.
5. Castelo-Soccio LA. Hair manifestations of systemic disease. Curr Probl
Pediatr Adolesc Health Care 2012;42:198-203.
6. Morand JJ. Skin color, hair types and phenotype diversity: Races, ethnic groups
and populations in the medical literature. Med Trop (Mars) 2008;68:213-4.
7. Lencastre A, Tosti A. Role of Trichoscopy in children’s scalp and hair
disorders. Pediatr Dermatol 2013;30:674-82.
8. Nnoruka EN, Obiagboso I, Maduechesi C. Hair loss in children in
South-East Nigeria: Common and uncommon cases. Int J Dermatol
2007;46:18-22.
9. Sarifakioglu E, Yilmaz AE, Gorpelioglu C, Orun E. Prevalence of scalp
disorders and hair loss in children. Cutis 2012;90:225-9.
10. El-Khalawany M, Shaaban D, Hassan H, Abdalsalam F, Eassa B, Abdel
Kader A, et al. A multicenter clinicomycological study evaluating the
spectrum of adult tinea capitis in Egypt. Acta Dermatovenerol Alp Panonica
Adriat 2013;22:77-82.
11. Mochizuki T. Diagnosis of cutaneous fungal infection. Nihon Ishinkin
Gakkai Zasshi 2009;50:195-8.
12. Grover C, Khurana A. Telogen efflivium. Indian J Dermatol Venereol Leprol
2013;79:591-603.
13. Huynh M, Gavino AC, Magid M. Trichotillomania. Semin Cutan Med Surg
2013;32:88-94.
How to cite this article: Al-Refu K. Hair loss in children:
Common and uncommon causes; clinical and epidemiological
study in Jordan. Int J Trichol 2013;5:185-9.
Source of Support: Nil, Conflict of Interest: None declared.
189
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