• Treatment depends on the underlying cause of alopecia.
  • There may be helpful treatments.
  • The pediatrician’s role may be only diagnostic and supportive.

Trichorrhexis nodosa

• A gentle approach results in gradual improvement.
• Eliminate any noxious exposure.

Monilethrix

• No treatment is known.
• Some degree of recovery may occur spontaneously, particularly after puberty or during pregnancy.

Alopecia areata

• Spontaneous regrowth
  • About one-third of patients will regrow hair spontaneously in 6 months.
  • About one-third will regrow hair spontaneously within 5 years.
  • About one-third must be treated to stimulate hair growth.
• Cortisone cream
  • Topical applications have been used with some success.
• Cortisone injection
  • Direct injection into the scalp or eyebrow hair follicles can be effective.
  • The process is painful.
  • Large areas (> 50% scalp hair loss) that require infiltration present difficulty.
  • Use with caution in the older, more cooperative child.
  • The pediatrician must carefully assess the impact of the disease and the treatment on the child before selecting this procedure.
  • The patient should be referred to a dermatologist for consideration of this intervention.
• Oral corticosteroid therapy
  • Risks serious complications, but is occasionally used
• Minoxidil
  • 5% minoxidil solution twice daily
  • Can be effective for small, stubborn alopecic areas
• Irritants
  • Used for extensive alopecia
  • Dinitrochlorobenzene immunotherapy
  • Tars, such as short-contact anthralin
  • Psoralen with ultraviolet A light (PUVA therapy)
  • Use only in children > 12 years.
  • Should be performed only by a knowledgeable dermatologist in controlled circumstances
• Efficacy of treatment
  • Difficult to assess because of the waxing and waning nature of alopecia areata
  • Pediatricians should remind patients and families that this process is nonscarring, which always has the potential for full regrowth.

Androgenetic alopecia

• No therapy is reliably effective.
• Some patients may be helped by:
  • Topical minoxidil twice daily
  • Hair transplant micrografts
• Finasteride
  • Can be given after 18 years of age in male patients
  • Contraindicated in female patients because of the possibility of genital defects in exposed male fetuses if a pregnancy occurs

Trichotillomania

• Petroleum jelly
  • The primary care pediatrician can paint the attacked areas in an attempt to frustrate the habit.
• Imipramine
• Fluoxetine
• Psychiatric intervention
  • Without attention to the possibility of an underlying emotional issue, other treatments are temporary.
  • Family structure and interaction with siblings and parents and with friends at home and at school should be explored in an effort to find stressors.
  • Consulting a psychiatrist should also be considered.
• Surgery or endoscopy
  • Referral for removal of a trichobezoar

Traumatic alopecia

• Simply discontinuing the stress will help.
• Injured hair follicles will often require ≥ 3 months to return to an anagen phase.

Loose anagen syndrome

• Management is limited to reassurance and the passage of time.
• The hair eventually grows thicker and longer, and its pigmentation increases.

Tinea capitis

• Griseofulvin is the standard of care.
  • Topical antifungal agents do not provide adequate treatment.
  • Several other systemic fungistatic agents are effective.
  • The long course of oral therapy with griseofulvin (~2 months) may present difficulties with compliance in a young child.
• Terbinafine
  • This fungicidal drug appears effective when given for 2–4 weeks but is currently not approved for this use by the US Food and Drug Administration (FDA).
• Itraconazole and fluconazole
  • May be safe for short courses in children but are not FDA approved for this use
  • Liquid itraconazole has been associated with diarrhea in children and with pancreatic adenocarcinoma in laboratory animals and should be avoided.
• Prednisone
  • Oral, tapered over 10 days
  • Rapidly decreases tenderness and inflammation of a kerion
  • Prevents widespread id reaction
• Secondary infection
  • With M canis or after treatment with an irritant
  • Inflammation may require treatment with an antibiotic.

Lupus erythematosus

• Discoid variant
  • Early treatment with topical or intralesional steroids may prevent scarring.
• Systemic variant
  • Loss of hair is generally temporary.

Acrodermatitis enteropathica

• Oral zinc sulfate is the treatment of choice.
• Strategies for the patient to hide noticeable loss of hair
  • Suggest that the child wear a baseball cap or other concealing adornment if appropriate.
  • A hairpiece can be designed for a child.
  • These steps serve in the interim while practitioners:
    • Attempt potentially helpful treatments
    • Wait expectantly if their role is diagnostic and supportive
• Management if recovery of hair is questionable
  • Work with and listen to the patient and family to:
    • Achieve an emotional balance consistent with reality
    • Adopt suitable coping mechanisms
  • Plastic surgery
    • Expertise should be sought for consideration of hair transplants and scalp reduction (for scarred areas) when possible.

• Rapid, diffuse hair loss
• Chronic, progressive, localized, or diffuse hair loss without regrowth
• Scarring alopecia
• Inability to grow hair as a result of breakage, loss, or abnormal texture of hair
• Appearance of scalp mass or plaque affecting localized hair loss