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| ORIGINAL ARTICLE |
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| Year : 2019 | Volume
: 11
| Issue : 5 | Page : 207-212 |
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Hair and scalp disorders in children below 2 years: An unremarked sphere
Balvinder Kaur Brar1, Sukhmani Kaur Brar2, Rajvir Kaur1, Naveen Sethi1
1 Department of Dermatology, GGS Medical College, Faridkot, Punjab, India
2 Department of Dermatology, Adesh Institute of Medical Science and Research, Bathinda, Punjab, India
| Date of Web Publication | 16-Oct-2019 |
Correspondence Address:
Dr Naveen Sethi
Opposite Guru Nagar, Sunny Enclave, Zira Road, Ferozepur, Punjab
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijt.ijt_77_16
 Abstract | | |
Context: Hairs contribute significantly to our appearance and are mirror to many systemic diseases. Hair and scalp disorders in children are associated with profound psychological effects arising from concerns of chronicity, severity, and contagiousness, in addition to cosmetic outline. Studies have documented children below 2 years as the most common age group affected by hair and scalp disorders in the pediatric population; however, to the best of our knowledge, none has been carried out exclusively on this age group, so far. Aims: To determine the pattern of hair and scalp disorders and their underlying etiologies in children below 2 years. Settings and Design: Observational and analytical. Subjects and Methods: Fifty consecutive patients, aged 0–24 months presenting with complaints of hair and scalp disorder, to the outpatient department of dermatology of a tertiary care hospital in North India, constituted the study population. Results: The most common disorder was seborrheic dermatitis (SD) 56%, followed by transient neonatal hair loss 22%. We also came across interesting cases of plica neuropathica (PN) 4%, trichotillomania 2%, and traction alopecia 6%, apart from a list of other disorders noted. The most common age group was 0–6 months. Conclusions: Hair and scalp disorders vary greatly with different demographic areas. In this region of the world, we came across cases of PN due to religious practices. SD was the most prevalent disorder as seen elsewhere. Trichotillomania noted in such a young child was not as a mere habit (as popularly believed), rather an act of anger. Hence, with this study, we want to emphasize the role of detailed history and examination, besides outlining the spectrum of disorders in this age group.
Keywords: Children below 2 years, hair, plica neuropathica, scalp disorders, trichotillomania
How to cite this article:
Brar BK, Brar SK, Kaur R, Sethi N. Hair and scalp disorders in children below 2 years: An unremarked sphere. Int J Trichol 2019;11:207-12 |
| Introduction | |  |
Hairs contribute significantly to our appearance and form an integral part of our personality. Besides, these are mirror to many systemic, psychological, and autoimmune disorders. Although hair and scalp disorders in children do not cause any physical handicap, hese do have profound cosmetic and psychological concerns for the families and later on for the child as well, as he/she grows.[1] This brings the parents to seek consultation, and they often put forward their worries in context to the disorder being contagious, hereditary, lifelong, and whether it will affect the child's growth and development in any form.
Over years, studies have been undertaken to identify causes of hair loss in children, and it has been found that, in majority of the cases, hair loss is nonscarring and acquired. Various studies from the western world identifies alopecia areata (AA), tinea capitis, and trichotillomania to be the most common causes.[2] Studies of hair loss in the pediatric age group have illustrated that more than 50% of patients fall in the age group of 0–24 months.[3] However, studies describing the prevalence and etiology of hair and scalp disorders in the pediatric age group (especially below 2 years), in the Indian subcontinent, have not been documented so far. We aim to identify the pattern of hair and scalp disorders and their underlying etiologies in patients of ages 0–24 months.
| Subjects and Methods | | |
This was an observational and analytical study, conducted in the outpatient department of dermatology at a tertiary health care center in North India, on fifty consecutive patients of ages 0–24 months presenting with the complaints of hair and scalp disorders. Informed consent was taken from all the patients.
The data collected included, age, sex, chief complaints, and detailed history of the disorder, i.e., duration of disease, treatment taken, and associated disorder if any. Family history (similar complaints and educational and social status of the family) and personal history (diet, behavior, hygiene, and hair grooming habits/habit tics) were duly noted.
In addition to examination of the scalp skin and hair, dermoscopy was also done to confirm the diagnosis, wherever needed. Systemic examination was carried out to analyze associated disorders and pertinent investigation was carried out where indicated.
| Results | | |
Of the 50 patients examined with hair and scalp disorders, 31 were male and 19 were female. Age range of the patients enrolled was from 0 to 24 months. [Figure 1] shows the relationship between hair and scalp disorder and the age of presentation. | Figure 1: Age distribution of the patients in relation to the hair and scalp disorders
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Majority (72%) of the patients were in the age group of 0–6 months. The disorders observed and their respective frequency are listed in [Table 1].
There was no associated dermatological condition in any of the patients except one, where hair loss was due to lamellar ichthyosis. None of the patients had any associated systemic disease.
Seborrheic dermatitis (SD) was the most prevalent form of scalp disorder accounting for 56% of the cases. Males and females were almost equally affected. Most of the patients presenting with SD were in the age group of 0–6 months except seven, which were of age between 6 months and 24 months. Typical cradle cap type of SD affecting the frontal and or vertex region of the scalp was noted in 19/28 patients, all below 6 months of age. Rest of the patients complained of greasy to nongreasy, pale, fine scaling of the scalp commonly termed as “dandruff.”
The second most common disorder was transient neonatal hair loss (TNHL), seen in 22% of the cases. The mean age of the affected patients was 2.95 months. In our study, most of the cases were noted in the occipital region of the scalp, which may be due to supine sleeping position.
Traction alopecia (TA) was seen in three patients and it affected both temporal and frontal regions. Of these three patients, two were male and one was female, all above 12 months of age.
One patient of age 8 months was diagnosed of temporal triangular alopecia (TTA). The patch was persistent, stable, and nonprogressive in nature. Plica neuropathica (PN) presenting as matted hair was observed in two patients, both males, aged 12 and 21 months each.
One case each of trichotillomania, hemangioma, AA, and ichthyosis were seen. Age and sex of the patients were 15 months and female, 5 months and male, 4 months and female, and 19 months and male, respectively.
| Discussion | | |
Hair and scalp disorders in this early life can be mentally exhausting for the parents, considering their lasting concern about etiology, severity, and chronicity of the disorder. Of the few studies undertaken to analyze and document pediatric scalp diseases, none has been done either exclusively on those below 2 years or in the Indian subcontinent. It is thus arduous to make comparisons (in some disorders) with the existing studies, in view of the broad differences in the study population attributed to the environment and cultural diversities, which play a noteworthy role in the etiology of certain disorders.
SD has been reported as the most common scalp disorder in children below 2 years of age, which parallels our findings.[3],[4] It typically occurs at 2–6 weeks of life and can present as late as 5 months. We found majority of the cases to be below 6 months of age. Three cases had associated lymphadenopathy of head and neck region. Alike findings have their mention in the literature.[4] Studies reveal a significant decrease in the prevalence of SD after the age of 1 year, which is comparable to our findings.[5]
TNHL presents as loss of hair from the scalp, characteristically around 3 months of age, and is attributed to the physiological hair shedding, contrary to the popular belief of friction being the culprit.[6] Supine position and friction merely aids the hair shedding.[7] It has been reported as the most common hair loss variant and the second most common scalp disorder (14/69).[3] These results are analogous to those of ours (11/50). Another study cited the incidence of TNHL to be 12%.[6] Three variants (diffuse, frontal, and temporal) were documented in a study whereas we came across only the classic hair loss in the occipital area [Figure 2].[3] Guardians must be reassured and explained the temporary nature of the hair loss.
Constant pull and tension to the hair leads to damaged hair follicles with resultant hair loss, termed as TA. Individuals wearing tight ponytails, braids, and similar hairstyles that cause constant tension are the ones affected. Besides the physical trauma, heat and chemical usage aid hair fall by causing breakage in hair shaft.[8] It is mostly seen in female patients with high prevalence among those with African descent. Nnoruka et al. reported TA in 7.1% of the cases, which is similar to our results of 6% of cases. All their patients were female, in contrast to ours where both the patients were male.[9] The reason for males being affected in the Indian subcontinent is due to the religious practice of growing long hair in males, which are tied into a bun in the frontal region of the scalp [Figure 3]. This is commonly seen in followers of Sikh religion. On examination under dermoscopy empty follicles were seen [Figure 4]. Parents must be explained the reason for hair loss and advised to amend the tight hair tying practices.
TTA also known as congenital triangular alopecia is a noncicatricial, well-circumscribed patch of hair loss present in the frontotemporal region. Sarifakioglu et al. reported TTA in 5/69 (7.2%) patients of hair and scalp disorder, whereas in the present study, TTA was seen in 4% of cases.[3] Yamazaki et al. in their study on TTA noted its occurrence on the right side in 30.8%, on the left side in 55.8%, and bilaterally in 13.5% of cases.[10] Only the right side of the scalp was affected in our patients [Figure 5]. On trichoscopy fine vellus hair were noticed in the patch [Figure 6].
PN presents as a mass of twisted, tangled, matted hair, commonly termed as dreadlocks. In India, these are seen in Hindu religious sadhus, which otherwise is uncommon in the general population. Hair when not combed and washed regularly eventually leads to dreadlocks [Figure 7]. In both our patients, the hair were not combed or cut since birth due to the religious beliefs. The patients were otherwise healthy with no behavioral disturbances. PN due to religious reasons finds a sparse mention in the literature. It has been reported separately in a 2-year-old and 11-month-old boy.[11],[12] Guardians should be advised to maintain scalp hygiene as much as possible in such cases.
Trichotillomania is classified under impulse control disorder, where the patient has a “morbid impulse to pull one's own hair.”[13] It is often classified into automatic and focused types and many of the children fall under the category of automatic hair pullers.[14],[15] The peak age in children is 9–13 years, with depression, agitation, and anxiety being some of the triggering factors. In children below the age of five, trichotillomania is said be more or less similar to thumb-sucking behavior.[8] Our patient was a 15-month-old female; to the best of our knowledge, this is the youngest case of trichotillomania (not resulting as result of obsessive behaviour) reported so far [Figure 8]. Al-Refu highlighted the female predominance in trichotillomania.[16] Parents were asked to keenly observe the child's hair-pulling behavior, in an attempt to find out any triggering factor. Contrary to the popular thought of it being similar to thumb-sucking behavior in those below 5 years of age, this child resorted to hair pulling as an act of anger and resentment when her toys when taken away from her or her “little demands” were ignored [Figure 9]. The parents were referred to the department of psychiatry, where the child was put on fluoxetine and the parents were counseled to avoid such situations where the child would react and handle such situations tactfully. | Figure 8: Trichoscopy of trichotillomania showing decreased density, different lengths, vellus hair, and black dot
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 | Figure 9: Trichotillomania on the right side of the scalp, as an act of anger
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One study documented AA to be the most common cause of hair loss in children aged 3–6 years and another stated it as the second most common cause with 3.6 years as the mean age of affected patients, with the youngest being 3 months of age.[3],[16] In the current study, a 4-month-old female presented with patchy hair loss. On examination, classical exclamation mark hairs were seen. Detailed examination was done to find any associated autoimmune disease, but there was none. Family history for AA was negative.
Hemangioma was noted in one patient. In addition to the scalp, forehead and nose were also affected [Figure 10]. The parents were explained the nature and course of the lesion and medical management was done with topical steroids. Scanty hairs were seen in a child with lamellar ichthyosis. On examination under the microscope, no hair shaft defect was noted.
Hair and scalp disorders vary with age, population, demographic area, and cultural practices. Studies so far have reported 0–2 years as the pediatric age group most commonly affected with hair and scalp diseases. Therefore, we studied this population singularly, to gain a better understanding. Dermoscopy was not done in all the cases, which is a limitation of our study and also a study on a larger scale would be helpful in obtaining a better picture.
| conclusion | | |
The most common age group affected was 0–6 months and the most prevalent disorder was SD followed by TNHL. Besides these, PN as a result of religious cultural practices was seen, which is not the case elsewhere in the world. Furthermore, with this case of trichotillomania, we want to highlight that this rather than being a mere habit can be an act of anger and umbrage, even by such a young child, hence emphasizing the need and significance of detailed history and examination. Dermatologic examination should form a part of routine examination in pediatrics along with the milestones, to ensure early recognition and management of disorders.
What is new?
The most common age group affected with hair and scalp disorders below 2 years of age is 0–6 months. Trichotillomania is an act of resentment and anger, in a child below 2 years.
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.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1]
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