Generic placeholder image

Current Pediatric Reviews


ISSN (Print): 1573-3963
ISSN (Online): 1875-6336

Review Article

Pediatric Alopecia Areata

Author(s): Rebecca Afford, Alexander K. C. Leung and Joseph M. Lam*

Volume 17, Issue 1, 2021

Published on: 30 April, 2020

Page: [45 - 54] Pages: 10

DOI: 10.2174/1573396316666200430084825

Price: $65


Background: Alopecia areata (AA) is a non-scarring hair loss disorder of autoimmune etiology.

Objective: To familiarize physicians with the clinical presentation, diagnosis, evaluation, and management of pediatric alopecia areata.

Methods: The search term "Alopecia areata" was entered into a Pubmed search. A narrow scope was applied to the categories of "epidemiology", "clinical diagnosis", "investigations", "comorbidities", and "treatment". Meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews were included. Only papers published in the English language were included. A descriptive, narrative synthesis was provided of the retrieved articles.

Results: AA is an autoimmune disease of unknown etiology. It is the third most common dermatologic presentation in children with a lifetime risk of 1-2%. Diagnosing AA can be made on the basis of the history and clinical findings. Patients will often present with patchy, non-scarring hair loss, generally affecting the scalp. History may reveal a personal or family medical history of autoimmune or atopic disease or a recent stressful event. Tricoscopic examination will classically show “exclamation point hairs” and “yellow dots”. Nonspecific nail changes may be present. Other clinical variants include alopecia totalis, alopecia universalis, ophiasis, sisaipho, and Canitis subita. There are multiple treatment options for AA, including conservative treatment, and topical, oral, and injectable medications.

Conclusion: AA is an autoimmune disease with a heterogeneous presentation and unpredictable clinical course. Although there is no cure for AA, there are many current treatment options available to help manage this disfiguring disease.

Keywords: Alopecia totalis, alopecia universalis, tricopscopy, JAK-STAT inhibitors, areata, autoimmune.

Graphical Abstract
Leung AK, Robson WL. Hair loss in children. J R Soc Health 1993; 113(5): 252-6.
[] [PMID: 8230078]
Hon KL, Leung AK. Alopecia areata. Recent Pat Inflamm Allergy Drug Discov 2011; 5(2): 98-107.
[] [PMID: 21453266]
Nanda A, Al-Hasawi F, Alsaleh QA. A prospective survey of pediatric dermatology clinic patients in Kuwait: an analysis of 10,000 cases. Pediatr Dermatol 1999; 16(1): 6-11.
[] [PMID: 10027990]
Safavi KH, Muller SA, Suman VJ, Moshell AN, Melton LJ III. Incidence of alopecia areata in Olmsted County, Minnesota, 1975 through 1989. Mayo Clin Proc 1995; 70(7): 628-33. [Elsevier]
[] [PMID: 7791384]
Strazzulla LC, Wang EHC, Avila L, et al. Alopecia areata: Disease characteristics, clinical evaluation, and new perspectives on pathogenesis. J Am Acad Dermatol 2018; 78(1): 1-12.
[] [PMID: 29241771]
Sharma VK, Kumar B, Dawn G. A clinical study of childhood alopecia areata in Chandigarh, India. Pediatr Dermatol 1996; 13(5): 372-7.
[] [PMID: 8893235]
Wohlmuth-Wieser I, Osei JS, Norris D, et al. Childhood alopecia areata—data from the National Alopecia Areata Registry. Pediatr Dermatol 2018; 35(2): 164-9.
[] [PMID: 29334143]
Villasante Fricke AC, Miteva M. Epidemiology and burden of alopecia areata: a systematic review. Clin Cosmet Investig Dermatol 2015; 8: 397-403.
[PMID: 26244028]
Barahmani N, de Andrade M, Slusser JP, et al. Human leukocyte antigen class II alleles are associated with risk of alopecia areata. J Invest Dermatol 2008; 128(1): 240-3.
[] [PMID: 17637820]
Colombe BW, Price VH, Khoury EL, Garovoy MR, Lou CD. HLA class II antigen associations help to define two types of alopecia areata. J Am Acad Dermatol 1995; 33(5 Pt 1): 757-64.
[PMID: 7593774]
de Andrade M, et al. Alopecia areata in families: association with the HLA locus. In: J Investig Dermatol Symp Proc. Elsevier 1999; 4: pp. (3)220-3.
Colombe BW, Lou CD, Price VH. The genetic basis of alopecia areata: HLA associations with patchy alopecia areata versus alopecia totalis and alopecia universalis. In: J Investig Dermatol Sym Proc. Elsevier 1999; 4:: pp. (3)216-9.
Akar A, Orkunoglu E, Sengül A, Ozata M, Gür AR. HLA class II alleles in patients with alopecia areata. Eur J Dermatol 2002; 12(3): 236-9.
[PMID: 11978563]
Xiao FL, Yang S, Yan KL, et al. Association of HLA class I alleles with aloplecia areata in Chinese Hans. J Dermatol Sci 2006; 41(2): 109-19.
[] [PMID: 16185849]
Ito T, Saathoff M, Nickoloff BJ, Takigawa M, Paus R. Novel aspects of hair follicle immune privilege and their relevance to alopecia areata. J Invest Dermatol 2005; 124(4): A103-3.
Petukhova L, Duvic M, Hordinsky M, et al. Genome-wide association study in alopecia areata implicates both innate and adaptive immunity. Nature 2010; 466(7302): 113-7.
[] [PMID: 20596022]
Gilhar A, Landau M, Assy B, et al. Transfer of alopecia areata in the human scalp graft/Prkdc(scid) (SCID) mouse system is characterized by a TH1 response. Clin Immunol 2003; 106(3): 181-7.
[] [PMID: 12706404]
Shimizu T, Hizawa N, Honda A, et al. Promoter region polymorphism of macrophage migration inhibitory factor is strong risk factor for young onset of extensive alopecia areata. Genes Immun 2005; 6(4): 285-9.
[] [PMID: 15815686]
Redler S, Albert F, Brockschmidt FF, et al. Investigation of selected cytokine genes suggests that IL2RA and the TNF/LTA locus are risk factors for severe alopecia areata. Br J Dermatol 2012; 167(6): 1360-5.
[] [PMID: 22897480]
Salinas-Santander M, Sánchez-Domínguez C, Cantú-Salinas C, et al. Association between PTPN22 C1858T polymorphism and alopecia areata risk. Exp Ther Med 2015; 10(5): 1953-8.
[] [PMID: 26640579]
Pforr J, Blaumeiser B, Becker T, et al. Investigation of the p.Ser278Arg polymorphism of the autoimmune regulator (AIRE) gene in alopecia areata. Tissue Antigens 2006; 68(1): 58-61.
[] [PMID: 16774540]
Redler S, Brockschmidt FF, Forstbauer L, et al. The TRAF1/C5 locus confers risk for familial and severe alopecia areata. Br J Dermatol 2010; 162(4): 866-9.
[] [PMID: 20030635]
Seok H, Suh DW, Jo B, et al. Association between TLR1 polymorphisms and alopecia areata. Autoimmunity 2014; 47(6): 372-7.
[] [PMID: 24780078]
John KK, Brockschmidt FF, Redler S, et al. Genetic variants in CTLA4 are strongly associated with alopecia areata. J Invest Dermatol 2011; 131(5): 1169-72.
[] [PMID: 21346773]
Betz RC, Pforr J, Flaquer A, et al. Loss-of-function mutations in the filaggrin gene and alopecia areata: strong risk factor for a severe course of disease in patients comorbid for atopic disease. J Invest Dermatol 2007; 127(11): 2539-43.
[] [PMID: 17581619]
Akar A, Orkunoglu FE, Tunca M, Taştan HB, Kurumlu Z. Vitamin D receptor gene polymorphisms are not associated with alopecia areata. Int J Dermatol 2007; 46(9): 927-9.
[] [PMID: 17822494]
Forstbauer LM, Brockschmidt FF, Moskvina V, et al. Genome-wide pooling approach identifies SPATA5 as a new susceptibility locus for alopecia areata. Eur J Hum Genet 2012; 20(3): 326-32.
[] [PMID: 22027810]
Kalkan G, Yigit S, Karakuş N, et al. Methylenetetrahydrofolate reductase C677T mutation in patients with alopecia areata in Turkish population. Gene 2013; 530(1): 109-12.
[] [PMID: 23954881]
Alfadhli S, Kharrat NJ, Al-Tememy B, Nanda A, Rebai A. Susceptible and protective endothelial nitric oxide synthase gene polymorphism in alopecia areata in the Kuwaiti population. Autoimmunity 2008; 41(7): 522-5.
[] [PMID: 18608176]
Welsh EA, Clark HH, Epstein SZ, Reveille JD, Duvic M. Human leukocyte antigen-DQB1*03 alleles are associated with alopecia areata. J Invest Dermatol 1994; 103(6): 758-63.
[] [PMID: 7798612]
Paus R, Cotsarelis G. The biology of hair follicles. N Engl J Med 1999; 341(7): 491-7.
[] [PMID: 10441606]
Westgate GE, Craggs RI, Gibson WT. Immune privilege in hair growth. J Invest Dermatol 1991; 97(3): 417-20.
[] [PMID: 1714928]
Stenn KS, Paus R. Controls of hair follicle cycling. Physiol Rev 2001; 81(1): 449-94.
[] [PMID: 11152763]
Safavi KH, Muller SA, Suman VJ, Moshell AN, Melton LJ III. Incidence of alopecia areata in Olmsted County, Minnesota, 1975 through 1989. Mayo Clin Proc Elsevier 1995; 70(7): 628-33.
Rajabi F, Drake LA, Senna MM, Rezaei N. Alopecia areata: a review of disease pathogenesis. Br J Dermatol 2018; 179(5): 1033-48.
[] [PMID: 29791718]
McElwee KJ, Freyschmidt-Paul P, Hoffmann R, et al. Transfer of CD8(+) cells induces localized hair loss whereas CD4(+)/CD25(-) cells promote systemic alopecia areata and CD4(+)/CD25(+) cells blockade disease onset in the C3H/HeJ mouse model. J Invest Dermatol 2005; 124(5): 947-57.
[] [PMID: 15854035]
Xing L, Dai Z, Jabbari A, et al. Alopecia areata is driven by cytotoxic T lymphocytes and is reversed by JAK inhibition. Nat Med 2014; 20(9): 1043-9.
[] [PMID: 25129481]
Damsky W, King BA. JAK inhibitors in dermatology: The promise of a new drug class. J Am Acad Dermatol 2017; 76(4): 736-44.
[] [PMID: 28139263]
Rinaldi F, Pinto D, Giammaria G, Sorbellini E. Diet and microbiome influence on alopecia areata: experience from case reports. J Nut Med Diet Care 2019; 5(1): 1-8.
Nair L, Dai Z, Christiano AM. Gut microbiota plays a role in the development of alopecia areata. J Invest Dermatol 2017; 137(5): S112.
Wu HJ, Wu E. The role of gut microbiota in immune homeostasis and autoimmunity. Gut Microbes 2012; 3(1): 4-14.
[] [PMID: 22356853]
Manfredo Vieira S, Hiltensperger M, Kumar V, et al. Translocation of a gut pathobiont drives autoimmunity in mice and humans. Science 2018; 359(6380): 1156-61.
[] [PMID: 29590047]
Manzel A, Muller DN, Hafler DA, Erdman SE, Linker RA, Kleinewietfeld M. Role of “Western diet” in inflammatory autoimmune diseases. Curr Allergy Asthma Rep 2014; 14(1): 404.
[] [PMID: 24338487]
Ouchi N, Parker JL, Lugus JJ, Walsh K. Adipokines in inflammation and metabolic disease. Nat Rev Immunol 2011; 11(2): 85-97.
[] [PMID: 21252989]
Jackow C, Puffer N, Hordinsky M, Nelson J, Tarrand J, Duvic M. Alopecia areata and cytomegalovirus infection in twins: genes versus environment? J Am Acad Dermatol 1998; 38(3): 418-25.
[] [PMID: 9520023]
Rodriguez TA, Duvic M, Registry NA. Onset of alopecia areata after Epstein-Barr virus infectious mononucleosis. J Am Acad Dermatol 2008; 59(1): 137-9.
[] [PMID: 18329131]
Ito T, Tokura Y. Alopecia areata triggered or exacerbated by swine flu virus infection. J Dermatol 2012; 39(10): 863-4.
[] [PMID: 22142460]
Morales-Sánchez MA, Domínguez-Gómez MA, Jurado-Santa Cruz F, Peralta-Pedrero ML. [Immunization and bacterial pathogens in the oropharynx as risk factors for alopecia areata] Actas Dermosifiliogr 2010; 101(5): 437-43. [English Edition]
[] [PMID: 20525487]
Willemsen R, Vanderlinden J, Roseeuw D, Haentjens P. Increased history of childhood and lifetime traumatic events among adults with alopecia areata. J Am Acad Dermatol 2009; 60(3): 388-93.
[] [PMID: 19026463]
Ruiz-Doblado S, Carrizosa A, García-Hernández MJ. Alopecia areata: psychiatric comorbidity and adjustment to illness. Int J Dermatol 2003; 42(6): 434-7.
[] [PMID: 12786868]
Picardi A, Pasquini P, Cattaruzza MS, et al. Psychosomatic factors in first-onset alopecia areata. Psychosomatics 2003; 44(5): 374-81.
[] [PMID: 12954911]
Manolache L, Benea V. Stress in patients with alopecia areata and vitiligo. J Eur Acad Dermatol Venereol 2007; 21(7): 921-8.
[] [PMID: 17659001]
Stankler L. Synchronous alopecia areata in two siblings: a possible viral aetiology. The Lancet 1979; 131(8129): 1303-4.
Skinner RB Jr, Light WH, Bale GF, Rosenberg EW, Leonardi C. Alopecia areata and presence of cytomegalovirus DNA. JAMA 1995; 273(18): 1419-20.
[] [PMID: 7723153]
Ito T. Hair follicle is a target of stress hormone and autoimmune reactions. J Dermatol Sci 2010; 60(2): 67-73.
[] [PMID: 20943348]
Gupta MA, Gupta AK, Watteel GN. Stress and alopecia areata: a psychodermatologic study. Acta Derm Venereol 1997; 77(4): 296-8.
[PMID: 9228223]
Seo J, Lee JW, Choi MJ, Cho S, Kim DY. Serial trichoscopy vs. modified hair pull test for monitoring the disease activity and treatment response of localized alopecia areata. J Eur Acad Dermatol Venereol 2017; 31(3): e149-50.
[] [PMID: 27557441]
Choi JW, Loh SH, Lew BL, Sim WY. Histopathologic feature of ophiasis-type alopecia areata. J Am Acad Dermatol 2017; 76(6): AB156.
Muñoz MA, Camacho FM. Sisaipho: a new form of presentation of alopecia areata. Arch Dermatol 1996; 132(10): 1255-6.
[] [PMID: 8859050]
Tosti A, Whiting D, Iorizzo M, et al. The role of scalp dermoscopy in the diagnosis of alopecia areata incognita. J Am Acad Dermatol 2008; 59(1): 64-7.
[] [PMID: 18440667]
Wu JJ, Huang DB, Tyring SK. Postherpetic poliosis. Arch Dermatol 2006; 142(2): 250-1.
[] [PMID: 16490864]
Tosti A, Bellavista S, Iorizzo M. Alopecia areata: a long term follow-up study of 191 patients. J Am Acad Dermatol 2006; 55(3): 438-41.
[] [PMID: 16908349]
Kasumagic-Halilovic E, Prohic A. Nail changes in alopecia areata: frequency and clinical presentation. J Eur Acad Dermatol Venereol 2009; 23(2): 240-1.
[] [PMID: 18540984]
Ihm CW, Han JH. Diagnostic value of exclamation mark hairs. Dermatology (Basel) 1993; 186(2): 99-102.
[] [PMID: 8428055]
Eckert J, Church RE, Ebling FJ. The pathogenesis of alopecia areata. Br J Dermatol 1968; 80(4): 203-10.
[] [PMID: 5647966]
Lima CDS, Lemes LR, Melo DF. Yellow dots in trichoscopy: relevance, clinical significance and peculiarities. An Bras Dermatol 2017; 92(5): 724-6.
[] [PMID: 29166518]
Ito T, Tokura Y. The role of cytokines and chemokines in the T-cell-mediated autoimmune process in alopecia areata. Exp Dermatol 2014; 23(11): 787-91.
[] [PMID: 25040075]
Dy LC, Whiting DA. Histopathology of alopecia areata, acute and chronic: Why is it important to the clinician? Dermatol Ther (Heidelb) 2011; 24(3): 369-74.
[] [PMID: 21689247]
Giordano CN, Sinha AA. Cytokine pathways and interactions in alopecia areata. Eur J Dermatol 2013; 23(3): 308-18.
[] [PMID: 23797621]
Tobin DJ, Fenton DA, Kendall MD. Ultrastructural observations on the hair bulb melanocytes and melanosomes in acute alopecia areata. J Invest Dermatol 1990; 94(6): 803-7.
[] [PMID: 2355182]
Peckham SJ, Sloan SB, Elston DM. Histologic features of alopecia areata other than peribulbar lymphocytic infiltrates. J Am Acad Dermatol 2011; 65(3): 615-20.
[] [PMID: 21684037]
Hashimoto T, Kazama T, Ito M, et al. Histologic and cell kinetic studies of hair loss and subsequent recovery process of human scalp hair follicles grafted onto severe combined immunodeficient mice. J Invest Dermatol 2000; 115(2): 200-6.
[] [PMID: 10951236]
Messenger AG, Slater DN, Bleehen SS. Alopecia areata: alterations in the hair growth cycle and correlation with the follicular pathology. Br J Dermatol 1986; 114(3): 337-47.
[] [PMID: 3954954]
Chu S, et al. Comorbidity profiles among patients with alopecia areata: the importance of onset age, a nationwide population-based study. J Am Acad Dermatol 2011; 65(5): 949-56.
Sorrell J, Petukhova L, Reingold R, Christiano A, Garzon M. Shedding light on alopecia areata in pediatrics: a retrospective analysis of comorbidities in children in the national alopecia areata registry. Pediatr Dermatol 2017; 34(5): e271-2.
[PMID: 28884897]
Garzorz N, Alsisi M, Todorova A, et al. Dissecting susceptibility from exogenous triggers: the model of alopecia areata and associated inflammatory skin diseases. J Eur Acad Dermatol Venereol 2015; 29(12): 2429-35.
[] [PMID: 26416203]
Patel D, Li P, Bauer AJ, Castelo-Soccio L. Screening guidelines for thyroid function in children with alopecia areata. JAMA Dermatol 2017; 153(12): 1307-10.
[] [PMID: 28973128]
Liu LY, King BA, Craiglow BG. Health-related quality of life (HRQoL) among patients with alopecia areata (AA): a systematic review. J Am Acad Dermatol 2016; 75(4): 806-12. E3
Bilgiç Ö, Bilgiç A, Bahalı K, Bahali AG, Gürkan A, Yılmaz S. Psychiatric symptomatology and health-related quality of life in children and adolescents with alopecia areata. J Eur Acad Dermatol Venereol 2014; 28(11): 1463-8.
[] [PMID: 24237476]
Mulinari-Brenner F. Psychosomatic aspects of alopecia areata. Clin Dermatol 2018; 36(6): 709-13.
[] [PMID: 30446192]
Okhovat JP, Marks DH, Manatis-Lornell A, Hagigeorges D, Locascio JJ, Senna MM. Association Between Alopecia Areata, Anxiety, and Depression: A Systematic Review and Meta-analysis. J Am Acad Dermatol . 2019; S0190-9622((19)): 30890-4.
[] [PMID: 31163237]
Tosti A, Iorizzo M, Botta GL, Milani M. Efficacy and safety of a new clobetasol propionate 0.05% foam in alopecia areata: a randomized, double-blind placebo-controlled trial. J Eur Acad Dermatol Venereol 2006; 20(10): 1243-7.
[] [PMID: 17062039]
Chu TW, AlJasser M, Alharbi A, Abahussein O, McElwee K, Shapiro J. Benefit of different concentrations of intralesional triamcinolone acetonide in alopecia areata: An intrasubject pilot study. J Am Acad Dermatol 2015; 73(2): 338-40.
[] [PMID: 26183987]
Cowley BJ, Dong J. Use of oral corticosteroids in the treatment of alopecia areata. Arch Dis Child 2020; 105(1): 96-8.
[PMID: 31473601]
Vañó-Galván S, Hermosa-Gelbard Á, Sánchez-Neila N, et al. Pulse corticosteroid therapy with oral dexamethasone for the treatment of adult alopecia totalis and universalis. J Am Acad Dermatol 2016; 74(5): 1005-7.
[] [PMID: 27085229]
Kurosawa M, Nakagawa S, Mizuashi M, et al. A comparison of the efficacy, relapse rate and side effects among three modalities of systemic corticosteroid therapy for alopecia areata. Dermatology (Basel) 2006; 212(4): 361-5.
[] [PMID: 16707886]
Royer M, Bodemer C, Vabres P, et al. Efficacy and tolerability of methotrexate in severe childhood alopecia areata. Br J Dermatol 2011; 165(2): 407-10.
[] [PMID: 21517797]
Landis ET, Pichardo-Geisinger RO. Methotrexate for the treatment of pediatric alopecia areata. J Dermatolog Treat 2018; 29(2): 145-8.
[] [PMID: 28627278]
Phan K, Ramachandran V, Sebaratnam DF. Methotrexate for alopecia areata: A systematic review and meta-analysis. J Am Acad Dermatol 2019; 80(1): 120-127.e2.
[] [PMID: 30003990]
Zakaria W, Passeron T, Ostovari N, Lacour JP, Ortonne JP. 308-nm excimer laser therapy in alopecia areata. J Am Acad Dermatol 2004; 51(5): 837-8.
[] [PMID: 15523373]
Happle R, Klein HM, Macher E. Topical immunotherapy changes the composition of the peribulbar infiltrate in alopecia areata. Arch Dermatol Res 1986; 278(3): 214-8.
[] [PMID: 2873796]
Wiseman MC, Shapiro J, MacDonald N, Lui H. Predictive model for immunotherapy of alopecia areata with diphencyprone. Arch Dermatol 2001; 137(8): 1063-8.
[PMID: 11493099]
Chiang KS, Mesinkovska NA, Piliang MP, Bergfeld WF. Clinical efficacy of diphenylcyclopropenone in alopecia areata: retrospective data analysis of 50 patients. J Investig Dermatol Symp Proc 2015; 17(2): 50-5.
[] [PMID: 26551948]
Kim BJ, Lee S, Lee CH, Lee WS. Home-based contact immunotherapy with diphenylcyclopropenone improves compliance with the recommended follow-up for patients with alopecia areata: A retrospective cohort study. J Am Acad Dermatol 2019; S0190-9622(19): 32966-4-.
[] [PMID: 31678469]
Craiglow BG, Liu LY, King BA. Tofacitinib for the treatment of alopecia areata and variants in adolescents. J Am Acad Dermatol 2017; 76(1): 29-32.
[] [PMID: 27816292]
Wang E, Lee JS, Tang M. Current treatment strategies in pediatric alopecia areata. Indian J Dermatol 2012; 57(6): 459-65.
[] [PMID: 23248364]
Katoulis AC, Alevizou A, Bozi E, et al. Biologic agents and alopecia areata. Dermatology (Basel) 2009; 218(2): 184-5.
[] [PMID: 19018127]
Aschenbeck KA, McFarland SL, Hordinsky MK, Lindgren BR, Farah RS. Importance of group therapeutic support for family members of children with alopecia areata: A cross-sectional survey study. Pediatr Dermatol 2017; 34(4): 427-32.
[] [PMID: 28512762]
Nanda A, Al-Fouzan AS, Al-Hasawi F. Alopecia areata in children: a clinical profile. Pediatr Dermatol 2002; 19(6): 482-5.
[] [PMID: 12437546]
Lee YB, Jun M, Lee WS. Alopecia areata and poliosis: A retrospective analysis of 258 cases. J Am Acad Dermatol 2019; 80(6): 1776-8.
[] [PMID: 30502419]
Asz-Sigall D, Ortega-Springall MF, Smith-Pliego M, et al. White hair in alopecia areata: Clinical forms and proposed physiopathological mechanisms. J Am Acad Dermatol 2019; S0190-9622(19): 30010-6.
[] [PMID: 30630022]

Rights & Permissions Print Export Cite as
© 2023 Bentham Science Publishers | Privacy Policy