What is the evaluation and treatment approach for a child presenting with a bald spot?

Evaluation and Treatment Approach for a Child with a Bald Spot

The most appropriate initial approach for a child presenting with a bald spot is to determine the specific cause through careful examination of the hair, scalp, skin, and nails, with the five most common causes being tinea capitis, alopecia areata, traction alopecia, telogen effluvium, and trichotillomania. 1, 2

Diagnostic Approach

Initial Assessment

• Carefully examine the pattern of hair loss (focal vs. diffuse)
• Determine if the alopecia is scarring or non-scarring
• Look for secondary changes such as scale, erythema, or broken hairs
• Use dermoscopy/trichoscopy when available for more accurate diagnosis 1

Key Diagnostic Features for Common Causes

1. Tinea Capitis

   • Look for: Scaling, broken hairs, black dots, lymphadenopathy
   • Diagnostic test: KOH preparation or fungal culture

2. Alopecia Areata

   • Look for: Well-demarcated round/oval patches, "exclamation mark" hairs
   • Trichoscopy findings: Yellow dots, black dots, broken hairs

3. Traction Alopecia

   • Look for: Hair loss along the frontal/temporal hairline
   • History of tight hairstyles, braids, or ponytails

4. Telogen Effluvium

   • Look for: Diffuse thinning without scalp abnormalities
   • History of trigger 2-3 months prior (illness, stress, medication)

5. Trichotillomania

   • Look for: Irregular patches with broken hairs of varying lengths
   • Associated with psychological stress or disorders

Treatment Approach

Tinea Capitis

• First-line treatment if confirmed
• Oral antifungal therapy (typically griseofulvin) for 6-8 weeks
• Antifungal shampoo may be used as adjunct therapy

Alopecia Areata

• For limited patchy hair loss:

  • Intralesional corticosteroid injections are first-line for older children who can tolerate the procedure 3, 4
  • Topical corticosteroids for younger children or those who cannot tolerate injections

• For extensive patchy hair loss or alopecia totalis/universalis:

  • Contact immunotherapy may be considered in older children, though many clinicians are reluctant to use this aggressive treatment in children 3, 4
  • Topical minoxidil 5% solution can be used as an alternative, with results taking 3-6 months 4

Traction Alopecia

• Eliminate the cause (change hairstyling practices)
• Hair typically regrows once traction is removed

Telogen Effluvium

• Often self-limited; reassurance is key
• Identify and address the underlying trigger
• Regrowth typically occurs within 6 months

Trichotillomania

• Behavioral therapy is the mainstay of treatment
• Consider psychological referral

Special Considerations

When to Refer to a Dermatologist

• Uncertain diagnosis
• Failed initial treatment
• Evidence of scarring alopecia
• Extensive or rapidly progressing hair loss 5

Psychological Support

• Hair loss can cause significant emotional distress in children
• Consider psychological support and referral to patient support groups 4

Practical Solutions

• For extensive hair loss, wigs or hairpieces may be practical solutions
• Acrylic wigs are cheaper and easier to maintain
• Human hair wigs provide better fit but are more expensive 3, 4

Common Pitfalls to Avoid

• Failing to distinguish between scarring and non-scarring alopecia
• Missing tinea capitis, which requires systemic treatment
• Underestimating the psychological impact of hair loss on children
• Using adult treatment protocols without modification for children
• Performing unnecessary scalp biopsies (rarely needed in children) 1

Remember that most cases of hair loss in children are non-scarring and many are self-limiting. The high rate of spontaneous remission (up to 80% in limited patchy alopecia areata of short duration) means that a "no treatment" approach may be appropriate in some cases, particularly for children with limited patchy hair loss 4.