88  Alopecia

88.1 Introduction

Alopecia refers to hair loss occurring in areas where hair is normally present. In children, alopecia can cause significant psychosocial distress to both the child and caregivers, especially in settings where cultural perceptions link hair with health, beauty, or spiritual meanings. In Ghana and West Africa, common causes of alopecia include tinea capitis, traction alopecia, and alopecia areata, but nutritional deficiencies, chronic illnesses, and harmful hair practices also contribute. Early recognition and appropriate management are essential to prevent permanent hair loss and improve quality of life.

This chapter reviews the etiologies, clinical evaluation, differential diagnosis, and management of alopecia in children, incorporating local epidemiology and resource-sensitive approaches suitable for clinical practice in Ghana and the subregion.

88.2 Epidemiology

Alopecia is relatively common in childhood, though prevalence estimates vary depending on population characteristics.

• Tinea capitis is the most common cause of alopecia in school-aged children in Ghana and West Africa. Trichophyton soudanense and Microsporum audouinii predominate.
• Traction alopecia is highly prevalent due to common hairstyling practices such as tight braiding, weaving, and repeated use of hair extensions.
• Alopecia areata affects approximately 1–2% of children globally, with cases reported across West Africa.
• Nutritional alopecia is associated with iron deficiency, kwashiorkor, and other micronutrient deficiencies, particularly in rural or food-insecure communities.
• Telogen effluvium is often under-recognized but can occur after severe illness, malaria, surgery, emotional stress, or protein-energy malnutrition.

88.3 Classification of Alopecia

Alopecia in children can be classified into:

88.3.1 Non-scarring Alopecia

Hair follicles remain intact and regrowth is possible.

• Tinea capitis
  
• Alopecia areata
  
• Telogen effluvium
  
• Traction alopecia (early stage)
  
• Nutritional deficiencies
  
• Endocrine causes (e.g., hypothyroidism)

88.3.2 Scarring Alopecia

Hair follicles are permanently destroyed.

• Chronic untreated tinea capitis (kerion, favus)
  
• Late traction alopecia
  
• Lichen planopilaris
  
• Discoid lupus erythematosus
  
• Severe bacterial scalp infections

88.4 Aetiology and Pathophysiology

88.4.1 Tinea Capitis

Dermatophyte infection of the scalp leads to superficial fungal invasion of the hair shaft, inflammation, and patchy alopecia. Inflammatory types (kerion) may result in scarring if not treated early.

88.4.2 Alopecia Areata

An autoimmune condition targeting the hair follicle bulb, leading to non-scarring hair loss. Trigger factors include genetics, stress, and associations with atopy or thyroid disease.

88.4.3 Traction Alopecia

Prolongged tension from hairstyles commonly seen in young African girls leads to perifollicular inflammation and eventual follicular damage.

88.4.4 Telogen Effluvium

Stressors cause premature shift of hair follicles from anagen (growth phase) into telogen (resting phase), resulting in diffuse shedding typically 2–3 months after the trigger.

88.4.5 Nutritional Deficiencies

Iron deficiency, zinc deficiency, biotin deficiency, and protein-energy malnutrition impair hair growth and structure, resulting in brittle hair and shedding.

88.4.6 Endocrine Causes

Hypothyroidism and hyperthyroidism can cause diffuse hair thinning due to alterations in hair cycle regulation.

88.5 Clinical Features

• Diffuse thinning of hair
  
• Patchy hair loss
  
• Broken hairs and “black dots”
  
• Scaling of the scalp
  
• Pustules or crusting
  
• Smooth, circular bald patches (alopecia areata)
  
• Pain or tenderness (kerion)
  
• History of stressful events (telogen effluvium)
  
• Frontal hairline recession (traction alopecia)
  
• Associated dermatological signs (e.g., nail pitting)
  
• Signs of systemic illness (e.g., edema in kwashiorkor)

88.6 Differential Diagnosis

• Tinea capitis
  
• Alopecia areata
  
• Traction alopecia
  
• Telogen effluvium
  
• Trichotillomania
  
• Bacterial folliculitis
  
• Seborrhoeic dermatitis
  
• Psoriasis
  
• Discoid lupus erythematosus
  
• Lichen planopilaris

88.7 Investigations

88.7.1 Basic Investigations

• KOH microscopy
  
• Fungal culture
  
• Full blood count
  
• Serum ferritin
  
• Thyroid function tests

88.7.2 Additional Investigations

• Dermatoscopy
  
• Scalp biopsy (rare)
  
• Zinc levels (where available)

88.8 Management

88.8.1 Tinea Capitis

• Systemic antifungals:
  • Griseofulvin (first-line where available)
    
  • Terbinafine (effective for Trichophyton species)
    
• Adjunctive shampoos: ketoconazole or selenium sulfide
  
• Treat household contacts and reinforce hygiene.

88.8.2 Alopecia Areata

• Topical corticosteroids
  
• Topical minoxidil
  
• Intralesional steroids (specialist level)
  
• Systemic therapy only for severe disease
  
• Provide psychological support

88.8.3 Traction Alopecia

• Modify hairstyling practices
  
• Topical antibiotics for secondary infection
  
• Early intervention prevents permanent scarring

88.8.4 Telogen Effluvium

• Remove underlying triggers
  
• Nutritional support
  
• Gentle hair care
  
• Reassurance

88.8.5 Nutritional Alopecia

• Iron, zinc, biotin supplementation
  
• Management of protein-energy malnutrition
  
• Nutrition counselling

88.8.6 Endocrine Causes

• Treat underlying thyroid disease
  
• Monitor regrowth

88.9 Complications

• Permanent scarring alopecia
  
• Secondary bacterial infections
  
• Psychological distress and reduced self-esteem
  
• Social stigma
  
• Delay in underlying disease diagnosis

88.10 Prevention

• Promote safe hairstyling practices
  
• Improve hygiene to reduce tinea transmission
  
• Screen at-risk children for nutrient deficiencies
  
• Encourage early health-seeking behaviour
  
• Community education to dispel myths

88.11 Key Points

• Alopecia in children is common and often treatable.
  
• Tinea capitis is the leading cause in Ghana and West Africa.
  
• Early traction alopecia is reversible; late disease causes scarring.
  
• Alopecia areata may resolve spontaneously.
  
• Proper evaluation ensures targeted management.
  
• Psychosocial support is essential.

88.12 Further Reading

1. Hay RJ, et al. Curr Opin Infect Dis.
   
2. Olsen EA. Hair disorders in children. Pediatr Clin North Am.
   
3. Ogunbiyi A. Traction alopecia in African children. Int J Dermatol.
   
4. Messenger AG, Sinclair R. Br J Dermatol.
   
5. Ghana Health Service. Dermatological care guidelines.