Alopecia areata in children

How common is alopecia areata?

Alopecia areata is a relatively common condition. About 0.15% of the population experience alopecia areata at any given time, and about 2% of the population will experience it during their lifetime. This condition can present at any age, in children and adults, usually after the age of 12 (it is rare in younger children).
The first presentation usually occurs prior to the age of 20 and the condition is more common in girls.

What are the causes of alopecia areata?

As mentioned above, this is an autoimmune disease, in which the immune system accidentally attacks the hair follicles and leads to inflammation and baldness. The exact reason why this happens is not yet fully understood. However, there are a number of causes that are known to exacerbate the condition and trigger the disease:
Inheritance – genetic factors play a role and therefore it is more common in people who have a family history of alopecia areata or a tendency for additional autoimmune diseases. This is also why we often see it in children who have several other autoimmune diseases, such as thyroid disease, vitiligo (white patches on the skin) and type I diabetes.
Stressful situations – stress and anxiety can trigger the presentation of the disease
Infections and diseases – this condition can present after exposure of the body to febrile illness and different infections.
An association has also been found with atopic diseases such as atopic dermatitis.
This conditions is not associated with food or dietary habits

Is alopecia areata infectious?

No. It is not an infectious disease.

What are the signs and symptoms of alopecia areata?

This condition usually presents suddenly with round areas of baldness on the scalp, that are the size of a coin. This condition can also manifest in other areas such as the beard, eyebrows, eyelashes and other areas in the body. Usually, the person will not experience pain or itchiness and there are no signs of inflammation (redness or dandruff) in the areas of hair loss.
In a small fraction of cases, the injured areas may be larger and sometimes there can be complete loss of hair on the entire scalp. This condition is referred to as ‘alopecia totalis’.
In cases where there is loss of hair in the entire body, including the scalp, eyebrows and eyelashes, we refer to it as ‘alopecia universalis’.
Some patients also have involvement of their nails that manifests as tiny dents or ridges in the nails.

How is alopecia areata diagnosed?

The diagnosis is based on clinical appearance and there usually isn’t any need for additional investigations. In certain cases, if the diagnosis is unclear, we can consider other tests as well as a biopsy of the scalp.

What is the natural course of the disease?

Unfortunately, we are unable to predict which areas will be involved and how extensive the disease will be.
Fortunately, in about 80% of the cases, the hair grows back within a few months. Rarely will the hair loss last longer than that.
The chances that the hair will grow back are better when the size of the bald areas is smaller. However, most people who had one episode of alopecia areata will experience another one in their lifetime.
Sometimes, the hair that grows back is white, especially in the beginning.
Keep in mind that in cases of alopecia totalis and alopecia universalis, the chances of full recovery without therapy is low.

Is this a dangerous condition?

Alopecia areata is not a dangerous condition on its own, but it naturally has an effect on the child’s mental wellbeing. It can lead to low self-confidence, body-image disorder and a feeling of loneliness especially if the symptoms are externally obvious. Therefore, it is important to be attentive to the child’s emotional needs and to consult with professionals as needed.

What are the available therapies for alopecia areata and are there any new ones?

The decision for the type of therapy depends on the severity of the illness and the extent of surface involved. Because this is an autoimmune disease, therapies that carry anti-inflammatory qualities are required to help inhibit the activity of the immune system.

Steroids as a therapy for alopecia areata

In mild disease, the dermatologist will often recommend topical therapies containing steroids on the areas of hair loss for 1-2 months.
In more severe cases, the dermatologist may consider treatment with systemic steroids that are available as pills, injections administered directly to the areas of hair loss or as an intravenous medication.

Methotrexate as treatment for alopecia areata

Methotrexate is a drug that is used to treat a variety of autoimmune and inflammatory illnesses such as intestinal diseases and joint diseases. This drug reduces the activity of the immune system and can therefore be effective in autoimmune conditions such as alopecia areata.
This treatment is not considered first line treatment but can be considered an option when treating certain types of alopecia areata.

JAK inhibitors as treatment for alopecia areata in children

This is a group of medications that are given in the form of tablets and inhibit the enzymes involved in inflammatory processes and autoimmune disease. There are several different drugs in this family, and each one of them acts slightly differently. They are used to treat joint disease, intestinal diseases, hematological diseases, skin diseases and more.
Recently, two drugs belonging to this family of medications were approved for the treatment of alopecia areata. One of these drugs was approved for children over the age of 12. The development of these drugs has led to a significant breakthrough in the field and these drugs are now considered first line treatment for severe cases (defined as loss of hair in more than half the surface area of the scalp).
The advantage of this drug is that it is highly effective, is administered in the form of tablets which makes its use easy and the clinical experience points towards an improvement in emotional and psychological aspects as well as the patient’s quality of life.
Nonetheless, just like any other drug that inhibits the immune system, this drug has potential side effects such as increased risk of infections, liver function abnormalities as well as a decrease in the white blood cells in the body and therefore close medical monitoring is required.

Additional therapies for alopecia areata in children

Treating everything surrounding the condition, especially in children, is very important.
Emotional support will help the child feel safer.
Involvement of the school is required when there is a social effect or insulting behaviour portrayed by the classmates. Use of hats, hair extensions or wigs can be considered in such cases.

In summary, alopecia areata is an autoimmune disease that leads to local or general hair loss. With the right support and medical therapy, most children can cope with the disease and experience significant improvement with new growth of hair.