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Hair loss in children and adolescents
9 tiair Loss in Children and Ado#esc&mts Ellen Rudy Clore, MSN, RN, FNP, and Antoinette
n
Corey, MSN, RN, PNP
No other body system is more exposed to the public eye than the skin and the hair. Pediatric nurse practitioners (PNPs) frequently encounter patients in their practice settings with the complaint of “hair loss.” The most often diagnosed causes of hair loss include tinea capitis, alopecia areata, traction alopecia, and trichotillomania. This article defines these conditions, explores the causes for them, and describes the incidences. Emphasis is placed on the PNP’s role on making a differential diagnosis based on the presenting clinical manifestations, patient history, and laboratory testing. Treatment for these conditions as well as nursing goals and PNP interventions for management and family education also are discussed. J PEDIATR HEALTH CARE. (1991). 5, 245-250.
H
air loss is a common problem encountered by the pediatric nurse practitioner (PNP) in the clinical setting. Besides being an important appendage of the skin, which is responsible for the protection and regulation of body temperature, the hair is a vital aspect of selfimage. Complaints of hair loss by patients and/or their families must be thoroughly investigated to rule out serious underlying disorders (Phillips, Smith, & Storer, 1986). There are approximately 100,000 strands of hair on the average scalp of an adult and 200,000 to 300,000 strands on the scalp of an adolescent (Amundson & Caplan, 1983). Between 50 and 300 hairs are physiologically shed and replaced each day. Although growth is slightly slower for men, scalp hair grows at the rate of about 0.37 mm per day or 6 inches per year (Phillips et al., 1986). Hair growth proceeds in three distinct phases: anagen, catagen, and telegen. Active hair growth occurs during the anagen phase which lasts 2 to 6 years. At any one time, approximately 80% to 90% of scalp hair is actively growing. Hair follicles then undergo partial degeneration for about 10 to 14 days; 5% of hairs are in this catagen phase. After growth and partial degeneration, the hair follicle enters the telegen or resting phase. About 10% to 15% are in this phase, which lasts up to 4 months. The mechanism, however, for triggering the active growth phase is still unknown (Hurwitz, 1981). The hair is considered an appendage of the integumentry system. No other body parts are more exposed than the skin and hair. A loss of 30% to 50% of scalp Ellen Rudy Clore is assistant of Florida in Orlando.
professor
Antoinette Corey is a pediatric St. Petersburg, Florida. Reprint requests: versity of Florida
in the College of Nursing
nurse practitioner
Ellen Rudy Clore, College of Nursing,
OF PEDIATRIC
at All Children’s
Hospital
in
MSN, RN, FNP, Assistant Professor, Uni711 Lake Estelle Dr., Orlando, FL 32803.
25/I/22794
JOURNAL
at the University
HEALTH
CARE
hair often is required before alopecia is clinically noticeable (Phillips et al., 1986). Tarnowski, Rosen, McGrath, and Drabman (1987) found that alopecia was a course of considerable distress for children and their families. They report negative reactions to the child’s physical appearance and a decrease in social relationships with peers. The most frequent diagnoses of hair loss include tinea capitis, alopecia areata, traction alopecia, and trichotillomania. n
CAUSES
OF HAIR
LOSS
The causes of hair loss are numerous. Infections, febrile illnesses, and crash diets, common to the adolescent population, all have been known to lead to alopecia. Physical stress such as surgery or hemorrhage, as well as severe psychological stress (birth of a sibling, school difficulties, parent-child relationship problems), may cause varying degrees of hair loss. Other causes include such systemic diseases as cancer, leukemia, Hodgkin’s disease, cirrhosis, hypothyroidism, and tuberculosis (Phillips et al., 1986). Medications capable of causing alopecia are included in Table 1.
T
he causes for hair loss are numerous.
n
DEFINITIONS
The term “alopecia” is the “absence of hair from skin areas where it normally is present” (Dorland’s Illustrated Medical Dictionary, 1988). Tinea capitis, alopecia areata, traction alopecia, and trichotillomania are all conditions that result in varying amounts of hair loss. Tinea capitis, known in lay language as ringworm of the scalp, is a dermatophyte infection of the scalp caused by various species of the genera Microspolzlm and Trichpiyton. Arndt (1983) defines alopecia areata as a “unique, often self-limited disorder characterized by plagues of asymptomatic, noninflammatory, nonscarring, complete hair loss most commonly involving 245
246
Volume 5, Number 5 September-October 1991
Clore & Corey
n
TABLE
1 Medications
that may cause alopecia
Adapted from Phillips, I. H., Smith, S. L., & Storer, J. S. (1986). Hair loss: Common congenital and acquired causes. Postgraduate Medicine, 79, 207. 215.
H FIGURE 1 Alopecia areata. (From Atlas of Pediatric Physical Diagnosis (p. 8.24). 6. J. Zitelli and H. W. Davis (Eds.), 1987, New York: Gower Medical Publishing. Reprinted with permission.)
the scalp” (p. 15). The cause is unknown but is thought to be related to immune mechanisms. Twenty percent of patients wirh alopecia areata have positive family histories for this condition (Behrman & Vaughan, 1987). Traction alopecia, however, is a traumatic hair loss caused by hair dressing styles that maintain prolonged traction or pulling on the hair. Muller (19,87), defines trichotillomania as the “clinical syndrome of alopecia resulting from the repetitive pulling, plucking, and breaking of one’s own hair’ (p. 595). The extracted hair may subsequently be chewed or swallowed (Gupta, Gupta, & Haberman,1987), and patients commonly deny that the hair loss was self-induced. n
INCIDENCES
Tinea capitis occurs mainly in children between the ages of 2 and 10 years. Infections in infants and adolescents are rare. Transmission occurs by human contact,
P
ersons with asthma, Down syndrome, and atopic dermatitis have a higher susceptibility to alopecia areata.
through contact with animals, and through contact with infected objects such as combs. Alopecia areata, on the other hand, may occur at any age, but usually occurs in persons under the age of 25 years. Persons with asthma, Down syndrome and atopic dermatitis have a higher susceptibility to alopecia areata (Phillips et al., 1986). Traction alopecia is most frequently seen in black children and women (Whaley & Wong, 1987). The incidence of trichotillomania has been difficult to calculate. Krishnan, Davidson, and Guajardo (1985) noted no epidemiologic studies surveying the incidence and prevalence. These same researchers also contend that trichotillomania is an overlooked symptom that probably is not as rare as it was once thought to be. Stroud (1983) found that the condition is seven times more common in children than in adults and that affected girls far outnumber boys. Muller (1987) claims that he and his colleagues at the Mayo Clinic see 15 to 20 patients per year in their dermatologic practice who have trichotillomania, yet they maintain that the exact incidence of trichotillomania is unknown. The mean age of onset of trichotillomania is 5 to 12 years (Gupta et al., 1987). n
DIFFERENTIAL DIAGNOSES OF ALOPECIA
In making a diagnosis, the PNP must eliminate conditions that may cause localized or generalized alopecia. Common conditions for consideration in the pediatric population include tinea capitis, alopecia areata, traction alopecia, and trichotillomania. Muller (1987) believes that alopecia areata causes the most confusion in making a diagnosis; 33% of children who are diagnosed with alopecia areata may actually be suffering from trichotillomania. Muller routinely uses the punch biopsy to confirm a diagnosis of trichotillomania. His research on scalp biopsies reveals the following findings: (a) the number of telogen hairs may be increased in trichotillomania; (b) catagen hairs also are seen more often in trichotillomania and may be deformed. They are never
Journal of Pediatric
Hair Loss
Health Care
247
FIGURE 3 Traction alopecia. (From Atlas of Pediatric Physical Diagnosis (p. 8.25). B. J. Zitelli and H. W. Davis (Eds.), 1987, New York: Gower Medical Publishing. Reprinted with permission.)
n
FIGURE 2 Tinea capitis. (From Atlas of Pediatric Physical Diagnosis (p. 8.24). B. J. Zitelli and H. W. Davis (Eds.), 1987, New York: Gower Medical Publishing. Reprinted with permission.)
n
inflamed as they are in alopecia areata; and (c) melanin pigment casts and granules are common in the upper follicles and infundibulurn (funnel-shaped portion of the hair shaft) with trichotillomania. This finding in conjunction with the catagen hairs are the most distinctive findings in trichotillomania (Mullet-, 1987). After the diagnosis of trichotillomania is confirmed by biopsy, it is necessary to determine whether the “hairpulling” behavior is a mild habit, a “tic,” or whether it is a symptom of a more serious psychological problem such as depression or obsessive-compulsive disorder. A mental health referral probably will be necessary if the problem results from a significant psychological problem. Tinea capitis is’ so frequently seen among children that some researchers (Phillips et al., 1986) recommend a potassium hydroxide (KOH) mount and culture for any pediatric patient with hair loss. A thorough history
of hair styling techniques is usually ample to diagnose traction alopecia, while fingernail changes and family history may be the key points for confirming a diagnosis of alopecia areata. n
CLINICAL
MANIFESTATIONS
Table 2 contains a listing of signs and symptoms seen in these four diagnoses. Patchy hair loss and broken hairs are seen in all conditions except alopecia areata (Fig. 1). Patients with alopecia areata may have a round or oval area of total hair loss. Erythema and scaling often are associated with both tinea (Fig. 2) and traction alopecia (Fig. 3), whereas pruritis is common to tinea and pustules are often characteristic of traction alopecia. Figure 4 shows an example of trichotillomania. w TREATMENT MODALITIES PNP’s ROLE
AND THE
Traction alopecia is probably the most easily treated cause of alopecia. PNPs simply need to educate the family about hair-styling techniques. Avoiding tight
Volume 5, Number
248
Clore
w TABLE
& Corey
2 When
September-October
a patient
complains
of “hair
symptoms the client is experiencing. History that gathered, and the PNP can further decide which the diagnosis is confirmed, the PNP can proceed
References
used: Whaley
& Wang,
1987; Ardt,
1983.
loss,”
the
is pertinent laboratory with goals
PNP
can
use
this
chart
to the specific signs tests to order to make and interventions.
to distinguish
which
and symptoms a differential
can then diagnosis.
signs
and be Once
5 1991
Journal of Pediatric Health
Care
FIGURE 4 irichotillomania. (From Atlas of Pediatric Physical Diagnosis (p. 8.25). B. J. Zitelli and H. W. Davis (Eds.), 1987, New York: Cower Medical Publishing. Reprinted with permission.) n
ponytails, braids, “corn-rowing,” and night-time curlers will allow the hair to grow back. If the diagnosis of tinea capitis is made, the PNP will need to prescribe griseofulvin orally, 10 mg I kg I day. This should be divided into two doses and given after a meal that contains fat (Peter, 1988). This medication should be given for 6 to 8 weeks or until two weeks after the KOH preparation is negative. The PNP must also be aware of the untoward effects of griseofulvin. Common minor reactions include headache, dryness of the mouth, nausea, vomiting, diarrhea, arthralgia, peripheral neuritis, vertigo, and fever. Occasionally, syncope, blurred vision, insomnia, photosensitivity, and rash may occur. Serious reactions include leukopenia, granulocytopenia, serum sickness, confusion, lapses of memory, and hepatotoxicity (AMA Drug Evaluations, 1983). Therefore, follow-up by the PNP is extremely important for the purpose of monitoring these side effects as well as for the purpose of preventing the spread of infection by teaching the family proper hygiene.
Hair Loss
249
n FIGURE 5 Nail changes occurring with alopecia areata. (From Atlas of Pediatric Physical Diagnosis (p. 8.26). B. J. Zitelli and H. W. Davis (Eds.), 1987, New York: Cower Medical Publishing. Reprinted with permission.)
Treatments for alopecia areata have not proved to be very successful. The PNP’s main goal for treatment of this condition is providing psychological support for both the patient and the family. Referring the patient to the National Alopecia Areata Foundation may be helpful. Referral to a dermatologist, who may prescribe topical, oral, and/or intralesional steroids is also helpful. Photochemotherapy is estimated to stimulate the regrowth of scalp hair in 70% of patients (Arndt, 1983). Trichotillomania, in most instances is chronic, and symptoms have lasted up to 17 years (Gupta et al., 1987). Treatment often is difficult; the validity and reliability of the assessment of trichotillomania often is questioned because the child or adolescent will not usually admit to “hair pulling” and because the behavior is not usually exhibited in the presence of other persons. Although the PNP must refer this patient for psychotherapy, continued emotional support must be offered to the family. Many treatment modalities for trichotillomania have been reported in the literature. Until recently, psychoanalysis was a commonly used approach. However, this required extended time periods and results were often
250
Volume 5, Number 5 September-October 199 1
Clore & Corey
unsatisfactotry (Hall & McGill, 1986). Friman, Finney, and Christopherson (1984) and Tarnowski et al. (1987) concluded that the most efficacious treatment procedure is habit reve:rsal. This treatment consists of a number of components including awareness of hair pulling behavior training,, identification of habit-prone situations, prevention training (use of hats, scarves, braiding hair), habit interruption, competing response procedure (substituting another activity), and recruitment of a social support. Otlher therapies include a combination of psychotherapy and family counseling, hypnosis, and relaxation and imagery training (Gupta et al., 1987; Krishnan et al., 19%). ‘Thought-stopping” is another technique that may be somewhat useful; the child is told to stop before he or she demonstrates the actual hair pulling behavior. Lutzker and Lamazor (1985) also report the use of positive reinforcement and punishment procedures with maintenance of treatment results at 16month follow-ups. . COMPLICATIONS
Complications rarely are seen in three of the four conditions causing hair loss. However, the most serious and life-threa.tening complication of trichotillomania is the presence of trichobezoars (hair balls) in the gastrointestinal system. The client chews and swallows (trichophagy) the plucked hairs and masses are formed. Most of thes’e masses are palpable and freely movable in the midepigastrium or left upper quadrant of the abdomen. Sy:mptoms of trichobezoars include abdominal and epigastric pain, nausea, and vomiting, hematemesis, foul breath, anorexia, constipation, diarrhea, and flatulence. These symptoms may be intermittent and coincide with periods of obstruction (Muller, 1987). More serious complications include gastrointestinal bleeding, perforation, obstruction, acute pancreatitis, and obstructive jaundice (Muller, 1987).
Complications four conditions
rarely are seen in three of the causing hair loss.
Laboratory studies may anemia, mild leukocytosis, ler, 1987). Ultrasoiograihy phy (CT) are very useful (Tamminen & Rosenfeld,
demonstrate iron deficiency and hairs in the stool (Muland computed tombgrain diagnosing trichobezoar 1988).
. SUMMARY
Assessment of hair loss in children and adolescents presents a challenging situation for the PNP. A careful
history must be taken, a thorough inspection performed, and laboratory tests ordered if necessary. Differential diagnoses such as tinea capitis, alopecia areata, traction alopecia, and trichotillomania must be considered. The PNP must aim nursing care at preventing infection, promoting comfort and a positive self-image, and supporting the child and family emotionally. l
REFERENCES AMA Drug Evaluations. (1983). Philadelphia: W. B. Saunders Co. Amundson, L. H., & Caplan, R. (1983). The skin and subcutaneous tissues. In R. B. Taylor (Ed). Famify Medic& Principh and Practice. (pp. 1135-1139). New York: Springer-Verlag. Arndt, K. A. (1983). Manual of akmutoluak thevapeutics. Boston: Little, Brown and Co. Behrman, R. E. & Vaughan, V. C. (1987). Neh textbook ofpediatrics. (pp. 1707-1709). Philadelphia: W. B. Saunders Co. Dorland’s IllustratedMedical Dt&ma~. (1988). (p. 52). Philadelphia: W. B. Saunders Co. Friman, P. C., Finney, J. W., & Christophersen, E. R. (1984). Bchaviorai treatment of trichotillomania: An evaluative review. BPhati Therapy, 15, 249-266. Gupta, M. A., Gupta, A. K., & Haberman, H. F. (1987). The selfinflicted dermatoses: A critical review. General Hospital Psychiaq. 9, 45-52. Hall, J. R. &McGill, J. C. (July, 1986). Hypnobehavioral treatment of self-destructive behavior: Trichotillomania and bulimia in the same patient. Am&an Jowmal of Clinical H,ypnos+ 29, 39-46. Hurwitz S. (1981). Clinicalpediatidwnatolo~. Philadelphia: W. B. Saunders Co. Krishnan, K. R. R., Davidson, J. R. T., & Guajardo, C. (1985). Trichotillomania-A review. Comprehensive Pg&atq 26, 123128. Lutzker, J. R., & Lamazor, E. A. (1985). Behavioral pediatrics: Rcsearch, treatment, recommendations. PmHress in Behavior Mod@cation, 19, 217-234. Muller, S. A. (July, 1987). Trichotillomania. Dewnatolo~ic Clinics, 5, 595601. Peter, G. (Ed.) (1988). Report of the Committee on Infectious Disease. Evanston, IL: American Academy of Pediatrics. Phillips, J. H., Smith, S. L., & Storer, J. S. (1986). Hair loss: Common congenital and acquired causes. Postgraduate Medicine, 79, 207-215. Stroud, J. D. (1983). Hair loss in children. Pediatric Clinics of No& America, 30, 641-657. Tamminen, J., & Rosenfeld, D. (1988). CT diagnosis of a gastric trichobezoar. ComputerizedMediazlZwqqin~and Graphics, 12,339. 341. Tarnowski, K. J., Rosen, L. A., McGrath, M. L., & Drabman, R. S. (1987). A modified habit reversal procedure in a recalcitrant cast of trichotillo-mania. Journal ofBehkor Therapy and Eqetimental Psycbiat~, 18, 157-163. Whaiey, L. F., & Wong, D. L. (1987). Nu&pg care of infants and children. St. Louis: The C. V. Mosby Co.
n
Corey, MSN, RN, PNP
No other body system is more exposed to the public eye than the skin and the hair. Pediatric nurse practitioners (PNPs) frequently encounter patients in their practice settings with the complaint of “hair loss.” The most often diagnosed causes of hair loss include tinea capitis, alopecia areata, traction alopecia, and trichotillomania. This article defines these conditions, explores the causes for them, and describes the incidences. Emphasis is placed on the PNP’s role on making a differential diagnosis based on the presenting clinical manifestations, patient history, and laboratory testing. Treatment for these conditions as well as nursing goals and PNP interventions for management and family education also are discussed. J PEDIATR HEALTH CARE. (1991). 5, 245-250.
H
air loss is a common problem encountered by the pediatric nurse practitioner (PNP) in the clinical setting. Besides being an important appendage of the skin, which is responsible for the protection and regulation of body temperature, the hair is a vital aspect of selfimage. Complaints of hair loss by patients and/or their families must be thoroughly investigated to rule out serious underlying disorders (Phillips, Smith, & Storer, 1986). There are approximately 100,000 strands of hair on the average scalp of an adult and 200,000 to 300,000 strands on the scalp of an adolescent (Amundson & Caplan, 1983). Between 50 and 300 hairs are physiologically shed and replaced each day. Although growth is slightly slower for men, scalp hair grows at the rate of about 0.37 mm per day or 6 inches per year (Phillips et al., 1986). Hair growth proceeds in three distinct phases: anagen, catagen, and telegen. Active hair growth occurs during the anagen phase which lasts 2 to 6 years. At any one time, approximately 80% to 90% of scalp hair is actively growing. Hair follicles then undergo partial degeneration for about 10 to 14 days; 5% of hairs are in this catagen phase. After growth and partial degeneration, the hair follicle enters the telegen or resting phase. About 10% to 15% are in this phase, which lasts up to 4 months. The mechanism, however, for triggering the active growth phase is still unknown (Hurwitz, 1981). The hair is considered an appendage of the integumentry system. No other body parts are more exposed than the skin and hair. A loss of 30% to 50% of scalp Ellen Rudy Clore is assistant of Florida in Orlando.
professor
Antoinette Corey is a pediatric St. Petersburg, Florida. Reprint requests: versity of Florida
in the College of Nursing
nurse practitioner
Ellen Rudy Clore, College of Nursing,
OF PEDIATRIC
at All Children’s
Hospital
in
MSN, RN, FNP, Assistant Professor, Uni711 Lake Estelle Dr., Orlando, FL 32803.
25/I/22794
JOURNAL
at the University
HEALTH
CARE
hair often is required before alopecia is clinically noticeable (Phillips et al., 1986). Tarnowski, Rosen, McGrath, and Drabman (1987) found that alopecia was a course of considerable distress for children and their families. They report negative reactions to the child’s physical appearance and a decrease in social relationships with peers. The most frequent diagnoses of hair loss include tinea capitis, alopecia areata, traction alopecia, and trichotillomania. n
CAUSES
OF HAIR
LOSS
The causes of hair loss are numerous. Infections, febrile illnesses, and crash diets, common to the adolescent population, all have been known to lead to alopecia. Physical stress such as surgery or hemorrhage, as well as severe psychological stress (birth of a sibling, school difficulties, parent-child relationship problems), may cause varying degrees of hair loss. Other causes include such systemic diseases as cancer, leukemia, Hodgkin’s disease, cirrhosis, hypothyroidism, and tuberculosis (Phillips et al., 1986). Medications capable of causing alopecia are included in Table 1.
T
he causes for hair loss are numerous.
n
DEFINITIONS
The term “alopecia” is the “absence of hair from skin areas where it normally is present” (Dorland’s Illustrated Medical Dictionary, 1988). Tinea capitis, alopecia areata, traction alopecia, and trichotillomania are all conditions that result in varying amounts of hair loss. Tinea capitis, known in lay language as ringworm of the scalp, is a dermatophyte infection of the scalp caused by various species of the genera Microspolzlm and Trichpiyton. Arndt (1983) defines alopecia areata as a “unique, often self-limited disorder characterized by plagues of asymptomatic, noninflammatory, nonscarring, complete hair loss most commonly involving 245
246
Volume 5, Number 5 September-October 1991
Clore & Corey
n
TABLE
1 Medications
that may cause alopecia
Adapted from Phillips, I. H., Smith, S. L., & Storer, J. S. (1986). Hair loss: Common congenital and acquired causes. Postgraduate Medicine, 79, 207. 215.
H FIGURE 1 Alopecia areata. (From Atlas of Pediatric Physical Diagnosis (p. 8.24). 6. J. Zitelli and H. W. Davis (Eds.), 1987, New York: Gower Medical Publishing. Reprinted with permission.)
the scalp” (p. 15). The cause is unknown but is thought to be related to immune mechanisms. Twenty percent of patients wirh alopecia areata have positive family histories for this condition (Behrman & Vaughan, 1987). Traction alopecia, however, is a traumatic hair loss caused by hair dressing styles that maintain prolonged traction or pulling on the hair. Muller (19,87), defines trichotillomania as the “clinical syndrome of alopecia resulting from the repetitive pulling, plucking, and breaking of one’s own hair’ (p. 595). The extracted hair may subsequently be chewed or swallowed (Gupta, Gupta, & Haberman,1987), and patients commonly deny that the hair loss was self-induced. n
INCIDENCES
Tinea capitis occurs mainly in children between the ages of 2 and 10 years. Infections in infants and adolescents are rare. Transmission occurs by human contact,
P
ersons with asthma, Down syndrome, and atopic dermatitis have a higher susceptibility to alopecia areata.
through contact with animals, and through contact with infected objects such as combs. Alopecia areata, on the other hand, may occur at any age, but usually occurs in persons under the age of 25 years. Persons with asthma, Down syndrome and atopic dermatitis have a higher susceptibility to alopecia areata (Phillips et al., 1986). Traction alopecia is most frequently seen in black children and women (Whaley & Wong, 1987). The incidence of trichotillomania has been difficult to calculate. Krishnan, Davidson, and Guajardo (1985) noted no epidemiologic studies surveying the incidence and prevalence. These same researchers also contend that trichotillomania is an overlooked symptom that probably is not as rare as it was once thought to be. Stroud (1983) found that the condition is seven times more common in children than in adults and that affected girls far outnumber boys. Muller (1987) claims that he and his colleagues at the Mayo Clinic see 15 to 20 patients per year in their dermatologic practice who have trichotillomania, yet they maintain that the exact incidence of trichotillomania is unknown. The mean age of onset of trichotillomania is 5 to 12 years (Gupta et al., 1987). n
DIFFERENTIAL DIAGNOSES OF ALOPECIA
In making a diagnosis, the PNP must eliminate conditions that may cause localized or generalized alopecia. Common conditions for consideration in the pediatric population include tinea capitis, alopecia areata, traction alopecia, and trichotillomania. Muller (1987) believes that alopecia areata causes the most confusion in making a diagnosis; 33% of children who are diagnosed with alopecia areata may actually be suffering from trichotillomania. Muller routinely uses the punch biopsy to confirm a diagnosis of trichotillomania. His research on scalp biopsies reveals the following findings: (a) the number of telogen hairs may be increased in trichotillomania; (b) catagen hairs also are seen more often in trichotillomania and may be deformed. They are never
Journal of Pediatric
Hair Loss
Health Care
247
FIGURE 3 Traction alopecia. (From Atlas of Pediatric Physical Diagnosis (p. 8.25). B. J. Zitelli and H. W. Davis (Eds.), 1987, New York: Gower Medical Publishing. Reprinted with permission.)
n
FIGURE 2 Tinea capitis. (From Atlas of Pediatric Physical Diagnosis (p. 8.24). B. J. Zitelli and H. W. Davis (Eds.), 1987, New York: Gower Medical Publishing. Reprinted with permission.)
n
inflamed as they are in alopecia areata; and (c) melanin pigment casts and granules are common in the upper follicles and infundibulurn (funnel-shaped portion of the hair shaft) with trichotillomania. This finding in conjunction with the catagen hairs are the most distinctive findings in trichotillomania (Mullet-, 1987). After the diagnosis of trichotillomania is confirmed by biopsy, it is necessary to determine whether the “hairpulling” behavior is a mild habit, a “tic,” or whether it is a symptom of a more serious psychological problem such as depression or obsessive-compulsive disorder. A mental health referral probably will be necessary if the problem results from a significant psychological problem. Tinea capitis is’ so frequently seen among children that some researchers (Phillips et al., 1986) recommend a potassium hydroxide (KOH) mount and culture for any pediatric patient with hair loss. A thorough history
of hair styling techniques is usually ample to diagnose traction alopecia, while fingernail changes and family history may be the key points for confirming a diagnosis of alopecia areata. n
CLINICAL
MANIFESTATIONS
Table 2 contains a listing of signs and symptoms seen in these four diagnoses. Patchy hair loss and broken hairs are seen in all conditions except alopecia areata (Fig. 1). Patients with alopecia areata may have a round or oval area of total hair loss. Erythema and scaling often are associated with both tinea (Fig. 2) and traction alopecia (Fig. 3), whereas pruritis is common to tinea and pustules are often characteristic of traction alopecia. Figure 4 shows an example of trichotillomania. w TREATMENT MODALITIES PNP’s ROLE
AND THE
Traction alopecia is probably the most easily treated cause of alopecia. PNPs simply need to educate the family about hair-styling techniques. Avoiding tight
Volume 5, Number
248
Clore
w TABLE
& Corey
2 When
September-October
a patient
complains
of “hair
symptoms the client is experiencing. History that gathered, and the PNP can further decide which the diagnosis is confirmed, the PNP can proceed
References
used: Whaley
& Wang,
1987; Ardt,
1983.
loss,”
the
is pertinent laboratory with goals
PNP
can
use
this
chart
to the specific signs tests to order to make and interventions.
to distinguish
which
and symptoms a differential
can then diagnosis.
signs
and be Once
5 1991
Journal of Pediatric Health
Care
FIGURE 4 irichotillomania. (From Atlas of Pediatric Physical Diagnosis (p. 8.25). B. J. Zitelli and H. W. Davis (Eds.), 1987, New York: Cower Medical Publishing. Reprinted with permission.) n
ponytails, braids, “corn-rowing,” and night-time curlers will allow the hair to grow back. If the diagnosis of tinea capitis is made, the PNP will need to prescribe griseofulvin orally, 10 mg I kg I day. This should be divided into two doses and given after a meal that contains fat (Peter, 1988). This medication should be given for 6 to 8 weeks or until two weeks after the KOH preparation is negative. The PNP must also be aware of the untoward effects of griseofulvin. Common minor reactions include headache, dryness of the mouth, nausea, vomiting, diarrhea, arthralgia, peripheral neuritis, vertigo, and fever. Occasionally, syncope, blurred vision, insomnia, photosensitivity, and rash may occur. Serious reactions include leukopenia, granulocytopenia, serum sickness, confusion, lapses of memory, and hepatotoxicity (AMA Drug Evaluations, 1983). Therefore, follow-up by the PNP is extremely important for the purpose of monitoring these side effects as well as for the purpose of preventing the spread of infection by teaching the family proper hygiene.
Hair Loss
249
n FIGURE 5 Nail changes occurring with alopecia areata. (From Atlas of Pediatric Physical Diagnosis (p. 8.26). B. J. Zitelli and H. W. Davis (Eds.), 1987, New York: Cower Medical Publishing. Reprinted with permission.)
Treatments for alopecia areata have not proved to be very successful. The PNP’s main goal for treatment of this condition is providing psychological support for both the patient and the family. Referring the patient to the National Alopecia Areata Foundation may be helpful. Referral to a dermatologist, who may prescribe topical, oral, and/or intralesional steroids is also helpful. Photochemotherapy is estimated to stimulate the regrowth of scalp hair in 70% of patients (Arndt, 1983). Trichotillomania, in most instances is chronic, and symptoms have lasted up to 17 years (Gupta et al., 1987). Treatment often is difficult; the validity and reliability of the assessment of trichotillomania often is questioned because the child or adolescent will not usually admit to “hair pulling” and because the behavior is not usually exhibited in the presence of other persons. Although the PNP must refer this patient for psychotherapy, continued emotional support must be offered to the family. Many treatment modalities for trichotillomania have been reported in the literature. Until recently, psychoanalysis was a commonly used approach. However, this required extended time periods and results were often
250
Volume 5, Number 5 September-October 199 1
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unsatisfactotry (Hall & McGill, 1986). Friman, Finney, and Christopherson (1984) and Tarnowski et al. (1987) concluded that the most efficacious treatment procedure is habit reve:rsal. This treatment consists of a number of components including awareness of hair pulling behavior training,, identification of habit-prone situations, prevention training (use of hats, scarves, braiding hair), habit interruption, competing response procedure (substituting another activity), and recruitment of a social support. Otlher therapies include a combination of psychotherapy and family counseling, hypnosis, and relaxation and imagery training (Gupta et al., 1987; Krishnan et al., 19%). ‘Thought-stopping” is another technique that may be somewhat useful; the child is told to stop before he or she demonstrates the actual hair pulling behavior. Lutzker and Lamazor (1985) also report the use of positive reinforcement and punishment procedures with maintenance of treatment results at 16month follow-ups. . COMPLICATIONS
Complications rarely are seen in three of the four conditions causing hair loss. However, the most serious and life-threa.tening complication of trichotillomania is the presence of trichobezoars (hair balls) in the gastrointestinal system. The client chews and swallows (trichophagy) the plucked hairs and masses are formed. Most of thes’e masses are palpable and freely movable in the midepigastrium or left upper quadrant of the abdomen. Sy:mptoms of trichobezoars include abdominal and epigastric pain, nausea, and vomiting, hematemesis, foul breath, anorexia, constipation, diarrhea, and flatulence. These symptoms may be intermittent and coincide with periods of obstruction (Muller, 1987). More serious complications include gastrointestinal bleeding, perforation, obstruction, acute pancreatitis, and obstructive jaundice (Muller, 1987).
Complications four conditions
rarely are seen in three of the causing hair loss.
Laboratory studies may anemia, mild leukocytosis, ler, 1987). Ultrasoiograihy phy (CT) are very useful (Tamminen & Rosenfeld,
demonstrate iron deficiency and hairs in the stool (Muland computed tombgrain diagnosing trichobezoar 1988).
. SUMMARY
Assessment of hair loss in children and adolescents presents a challenging situation for the PNP. A careful
history must be taken, a thorough inspection performed, and laboratory tests ordered if necessary. Differential diagnoses such as tinea capitis, alopecia areata, traction alopecia, and trichotillomania must be considered. The PNP must aim nursing care at preventing infection, promoting comfort and a positive self-image, and supporting the child and family emotionally. l
REFERENCES AMA Drug Evaluations. (1983). Philadelphia: W. B. Saunders Co. Amundson, L. H., & Caplan, R. (1983). The skin and subcutaneous tissues. In R. B. Taylor (Ed). Famify Medic& Principh and Practice. (pp. 1135-1139). New York: Springer-Verlag. Arndt, K. A. (1983). Manual of akmutoluak thevapeutics. Boston: Little, Brown and Co. Behrman, R. E. & Vaughan, V. C. (1987). Neh textbook ofpediatrics. (pp. 1707-1709). Philadelphia: W. B. Saunders Co. Dorland’s IllustratedMedical Dt&ma~. (1988). (p. 52). Philadelphia: W. B. Saunders Co. Friman, P. C., Finney, J. W., & Christophersen, E. R. (1984). Bchaviorai treatment of trichotillomania: An evaluative review. BPhati Therapy, 15, 249-266. Gupta, M. A., Gupta, A. K., & Haberman, H. F. (1987). The selfinflicted dermatoses: A critical review. General Hospital Psychiaq. 9, 45-52. Hall, J. R. &McGill, J. C. (July, 1986). Hypnobehavioral treatment of self-destructive behavior: Trichotillomania and bulimia in the same patient. Am&an Jowmal of Clinical H,ypnos+ 29, 39-46. Hurwitz S. (1981). Clinicalpediatidwnatolo~. Philadelphia: W. B. Saunders Co. Krishnan, K. R. R., Davidson, J. R. T., & Guajardo, C. (1985). Trichotillomania-A review. Comprehensive Pg&atq 26, 123128. Lutzker, J. R., & Lamazor, E. A. (1985). Behavioral pediatrics: Rcsearch, treatment, recommendations. PmHress in Behavior Mod@cation, 19, 217-234. Muller, S. A. (July, 1987). Trichotillomania. Dewnatolo~ic Clinics, 5, 595601. Peter, G. (Ed.) (1988). Report of the Committee on Infectious Disease. Evanston, IL: American Academy of Pediatrics. Phillips, J. H., Smith, S. L., & Storer, J. S. (1986). Hair loss: Common congenital and acquired causes. Postgraduate Medicine, 79, 207-215. Stroud, J. D. (1983). Hair loss in children. Pediatric Clinics of No& America, 30, 641-657. Tamminen, J., & Rosenfeld, D. (1988). CT diagnosis of a gastric trichobezoar. ComputerizedMediazlZwqqin~and Graphics, 12,339. 341. Tarnowski, K. J., Rosen, L. A., McGrath, M. L., & Drabman, R. S. (1987). A modified habit reversal procedure in a recalcitrant cast of trichotillo-mania. Journal ofBehkor Therapy and Eqetimental Psycbiat~, 18, 157-163. Whaiey, L. F., & Wong, D. L. (1987). Nu&pg care of infants and children. St. Louis: The C. V. Mosby Co.