Bald spots on scalp
An 8-year-old girl was brought to see her physician by her mother, who noticed 2 bald spots on the back of her daughter’s scalp while brushing her hair. The child had no itching or pain. The mother was worried that her daughter would go bald. The child was otherwise healthy. When the mother lifted the hair in the back, 2 round areas of hair loss were evident. On closer inspection, there was no scaling or scarring.
What's your diagnosis?
Alopecia areata (AA) is a common, chronic skin disorder manifested as a sudden loss of hair without accompanying inflammation or scarring. AA may extend to involve the whole scalp (alopecia totalis) or the whole body (alopecia universalis). The average age of onset is 25 to 27 years.
AA is secondary to an autoimmune phenomenon involving antibodies, T-cells, and cytokines. Microscopic evaluation of the hair from the periphery of the involved skin reveals "exclamation point" hairs, which are characterized by proximal thinning while the distal portion remains of normal caliber. Thyroid abnormalities, vitiligo, and pernicious anemia may accompany AA and hence screening laboratory tests (eg, thyroid stimulating hormone, hemoglobin) may be helpful to exclude thyroid disorders and anemia. Biopsy is usually not needed unless the diagnosis is uncertain.
The treatment of choice in patients older than 10 years of age with <50% scalp involvement is intralesional steroids. Triamcinolone acetonide 5 to 10 mg/mL is injected into multiple areas not to exceed 40 mg/mL per visit. For patients who are younger than 10 years of age, mid-potency topical steroids can be used. One randomized controlled trial showed aromatherapy with topical essential oils to be a safe and effective treatment for alopecia areata. Although spontaneous recovery usually occurs, the course of AA is unpredictable and often characterized by recurrent periods of hair loss and regrowth.
In this case, the mother and child were reassured that alopecia areata is a condition in which the hair is likely to re-grow without treatment. Neither of them wanted intralesional injections or topical therapies. One year later during a well-child exam, the physician noted that the girl’s hair had fully regrown.
Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Haynes, J. Alopecia areata. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. The Color Atlas of Family Medicine. New York, NY: McGraw-Hill; 2009:807-810.
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