Abstract: Alopecia areata (AA) is prevalent among children in Kuwait. In ... extensive disease (more than 50% hair loss) was seen in 13% of the children.
Pediatric Dermatology Vol. 19 No. 6 482–485, 2002
Alopecia Areata in Children: A Clinical Profile Arti Nanda, M.D., N.B.E., Abdulwahab S. Al-Fouzan, M.D., Ph.D., and Fowzia Al-Hasawi, M.D. Pediatric Dermatology Unit, Asad Al-Hamad Dermatology Center, Salmiya, Kuwait
Abstract: Alopecia areata (AA) is prevalent among children in Kuwait. In this prospective survey we studied 215 children with AA to determine their clinical and epidemiologic features. Ninety-seven percent of the children were of Arab ancestry. Girls outnumbered boys by a 2.5:1 ratio. The peak age of onset was seen between 2 and 6 years of age with a mean age of onset at 5.7 ± 2.8 years. A majority of the patients (80.5%) had mild disease and extensive disease (more than 50% hair loss) was seen in 13% of the children. A positive family history of AA was obtained in 51.6% of cases and nail changes were seen in 26.5% of the children. The age of onset, a positive family history of AA, and associated atopic disorders were observed to have no influence on the extent and severity of the disease. The results were compared with those reported elsewhere for this age group.
Alopecia areata (AA) is a common autoimmune disease of the scalp that may lead to psychological handicap due to cosmetic concerns. Approximately 20% of the total number of cases occur in children (1–4). A younger age of onset has been reported to herald a poorer prognosis (5,6). In a prospective survey of pediatric dermatology patients from Kuwait (7), AA was observed to be the third most common dermatosis in children, accounting for 6.7% of the total number (N ¼ 10,000) of patients, an incidence much higher than reported from elsewhere (8–11). Although several studies describing the clinicoepidemiologic features of AA are available in the literature (1–5,12–14), only a few focus on the pediatric age group (2,4,5). Data are lacking from the Arabian Gulf area. Our aim was to study the clinicoepidemiologic features of childhood AA patients in Kuwait and to compare the results with those reported from elsewhere. MATERIALS AND METHODS This prospective survey was carried out in the pediatric dermatology unit of a national dermatology center in Address correspondence to Arti Nanda, M.D., N.B.E., P.O. Box: 6759, 22078 Salmiya, Kuwait, or e-mail: artinanda@ hotmail.com
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Kuwait from July 1998 to June 2000. A total of 215 consecutive children less than 12 years of age with AA were enrolled in this study. Diagnosis in all cases was clinical, based on a typical history of abrupt, patchy loss of hair, with or without progression, and an absolutely normal-looking scalp, without any secondary characteristics on examination. The doubtful cases with secondary features on the scalp, for example, scales or inflammation, were not included in the study. Clinical details including age; nationality; sex of the patient; age of onset; duration of disease; site of onset; sites affected; precipitating/aggravating factors; associated diseases with special reference to atopic disorders, thyroid disease, and other autoimmune diseases; and a family history of AA, thyroid disease, or other significant diseases were recorded for all the patients on a specially designed form and were stored in a computerized data file (Fox Pro). Age of onset was defined as the age when the patient or his/her parents became aware of the disease for the first time, which at that time or later was diagnosed as AA.
Nanda et al: Alopecia Areata in Children
All the patients were examined to determine the sites affected, morphologic pattern, extent and severity of the disease, and nail involvement. The disease pattern was defined as patchy when patients had well-circumscribed patches of AA, diffuse, or ophiasic, a pattern described earlier (15). The severity of disease was defined as mild when there was less than 25% hair loss, moderate when 25–50% of hair was lost, and extensive when there was more than 50% hair loss. A total of 100 age- and sex-matched children, presenting with a primary diagnosis of common warts, molluscum contagiosum, nevoid disorders, or superficial fungal infection served as controls. All patients with a present or past history of AA were excluded. After obtaining a formal consent, we requested that the parents of controls complete a questionnaire containing the personal history of atopic disorders, thyroid disease, and other autoimmune diseases, as well as a family history of AA and other autoimmune diseases. Results, wherever indicated, were analyzed by using chi-square methods and Student’s t-test. RESULTS The total of 215 children with AA consisted of 62 boys (29%) and 153 girls (71%) with a male:female ratio of 1:2.5. There were 171 (79.5%) Kuwaiti children, 19 Bedouins (9%), 7 Saudis (3%), 6 Egyptians (3%), 3 Syrians (1%), 2 each (1%) Iranians, Indians, and Bangladeshis, and 1 each (0.5%) Yemeni, Pakistani, and British. The majority (97%) of the children were of Arab ancestry. The ages of the children ranged from 1 month to 12 years (mean 6.7 ± 3.1 years). The age of onset ranged from 1 week to 12 years (mean 5.7 ± 2.8 years). Figure 1 shows the age of onset and sex distribution in the 215 cases of AA. A peak age of onset was seen at between 2 and 6 years. Nine percent of the children had the disease for the first time in infancy.
Figure 1. Age of onset and sex distribution in 215 cases of alopecia areata.
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TABLE 1. Site of Onset and Sites Affected in 215 Children With Alopecia Areata Sites
Onset, N (%)
Affected, N (%)
Scalp Eyebrows Eyelashes Body hair
206 6 1 2
207 28 21 12
(95.8) (2.8) (0.5) (0.9)
(96.3) (13) (9.8) (5.6)
Table 1 shows the sites of onset and sites affected in all patients. The scalp was the most common site of onset and site affected (95.8% and 96.3%, respectively), followed by the eyebrows. The disease was restricted to the eyebrows in five patients, eyelashes in two, and extremities in one. A history of precipitating/ aggravating factors was obtained in 122 children (57%), including stress in 93 (43%), infection (upper respiratory, ear, or tooth) in 35 (16.3%), physical trauma in 3 (1.4%), and menarche in 1 (0.5%). The various stressful events that were related to the disease included hospitalization of the mother, sibling rivalry, death in the family, and parental conflicts. The progress of the disease was described as slow or stationary in 181 children (84%) and rapid in 34 (16%). Among the associated diseases, atopic disorders (atopic dermatitis, bronchial asthma, allergic rhinitis) were recorded in 53 patients (24.7%) followed by recurrent tonsillitis in 10 (4.7%), common warts in 5 (2.3%), psoriasis and Down syndrome in 4 patients each (2%), vitiligo in 3 (1.4%), thyroid disease and sickle cell anemia in 2 patients each (0.9%), and lichen planus, lichen sclerosus et atrophicus, common variable immune deficiency, molluscum contagiosum, annulus migrans, scabies, lip licking, tinea capitis, folliculitis, and hemangioma in 1 patient each (0.5%). A positive family history of AA was obtained in 111 children (51.6%). This included first-degree relatives in 67 patients (60%), second degree in 34 (31%), and third degree in 20 patients (18%). Ten children (9%) had more than one family member affected. A positive family history of thyroid disease was recorded in 23 children (11%), vitiligo in 13 (6%), and psoriasis in 10 (5%). A mild severity of disease (less than 25% hair loss) was seen in 173 children (80.5%), moderate (25–50% hair loss) in 14 children (6.5%), and extensive (more than 50% hair loss) in 28 children (13%). The 28 patients with extensive disease included 7 with diffuse involvement of the scalp with few remnant patches of hair, 3 with alopecia totalis, 10 with semi-universalis, and 8 with alopecia universalis. The age of onset and a positive family history of AA were observed to have no bearing on the extent and severity of disease (p > 0.05). Nail changes were recorded in 57 cases (26.5%), with pitting being the
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TABLE 2. Salient Features of Alopecia Areata in Patients (N ¼ 215) Compared to Controls (N ¼ 100) Clinical parameters
Patients
Controls
No. studied Sex distribution Males Females M:F
215
100
62 (29%) 153 (71%) 1:2.5
34 (34%) 66 (66%) 1:1.94
1 month)12 years 6.7 ± 3.1 years
6 months)12 years 6.94 ± 2.96 years
Age distribution (years) Range Mean Associated diseases Atopic disorders Autoimmune diseases Thyroid disease Vitiligo Psoriasis Lichen planus Down syndrome Family history Alopecia areata Thyroid disease Vitiligo Psoriasis
43 (20%) 2 3 4 1 4 111 23 13 10
34 (34%)
(0.9%) (1.4%) (2%) (0.5%) (1.4%)
0 0 0 0 0
(51.6%) (11%) (6%) (5%)
30 15 13 15
(30%) (15%) (13%) (15%)
most common feature in 52 children (91%), followed by longitudinal striations in 7 (12.3%), leukonychia in 3 (5.3%), pterygium formation and brownish discoloration in 2 patients each (3.5%), and onycholysis, koilonychia, trachyonychia, median nail dystrophy, and thinning of the nail plate in 1 patient each (1.8%). The extent of AA was observed to have a significant relationship to nail involvement (p ¼ 0.0004). Patients with severe disease (more than 50% hair loss) were observed to have a higher frequency of nail involvement (54%) compared to the remaining patients (20%). The hundred control subjects included 34 boys (34%) and 66 girls (66%). The primary diagnosis in these cases included common warts in 62 patients, molluscum contagiosum in 26, impetigo in 4, tinea capitis in 2, and traumatic alopecia, nevus sebaceus, milia, insect bites, pityriasis rosea, and acne vulgaris in 1 patient each. Table 2 shows salient features of children with AA compared with controls. DISCUSSION Alopecia areata was observed to be prevalent in our pediatric dermatology clinics, constituting 6.7% of the total number of cases (7). Ninety-seven percent of the patients in the present report were of Arab ancestry. A female predominance in this study confirms our earlier observations (7) and is comparable to the observations made in childhood AA patients from the Indian subcontinent (4,14). An equal sex distribution has been
described in children from the West (1,5,16). The peak age at onset (2–6 years) (Fig. 1) and the mean age of onset (5.7 ± 2.8 years) were relatively younger than those reported earlier (2,4,5,16). We observed a greater number of children (9%) having the onset of their disease in infancy than described earlier (1,4). The youngest infant in the present report was 1 month old. Although AA is rare in early infancy, there have been isolated reports of even congenital AA (17,18). Psychological stress has been reported to play an important role in precipitation and exacerbation of AA (2,19–21). The percentage of patients whose alopecia may be exacerbated by stress in various studies ranges from 5 to 96% (4,5,20). Forty-three percent of the subjects in the present series were reported to have precipitation or aggravation of their disease by stressful events. However, correlation with stress is a subjective phenomenon and requires more planned, subject-oriented surveys. A positive family history of AA has been reported in 9–42% of the total number of patients of all ages (3,14,22,23) and in 10–18% of children with AA (2,4,5). A positive family history of AA was elucidated in 51.6% of our patients. We observed a high familial incidence(30%) of AA in our controls as well, but the finding was significantly more common in AA patients (p ¼ 0.0005). The reason for a higher familial incidence of AA in our patients is unclear. Probably a higher incidence of consanguineous marriages among Arabs may be a contributing factor for a higher prevalence of the disease as well as a higher familial occurrence in this region. However, the issue needs to be settled by surveys more focused on the genetic aspects of the disease. The relationship between AA and atopic disorders remains obscure and needs to be explored further. With atopic disorders being so common in the community, it becomes difficult to interpret the relationship and results may be biased. Atopic disorders have been reported to be associated with AA in 10–52% of patients (2–4,12,14,24,25). An association with atopy has been related to an earlier age of onset, longer duration, and more severe disease (2,5). In the present series, a history of atopic disorders was elicited in 24.7% of the children, but the figures were not statistically different from the controls (34%) (p > 0.05). Comparable to some earlier observations, we observed no relationship of associated atopic disorders with age of onset and severity of disease. The association of AA with various autoimmune diseases has been reported in 5–17% of patients (3,14). We observed an association with autoimmune diseases in 10 children with AA (Table 1). Although none of our controls had an autoimmune disease, the results were not statistically significant (p > 0.05). However, no inference can be drawn at this stage. Autoimmune diseases are
Nanda et al: Alopecia Areata in Children
rare in children less than 12 years of age, thus the appearance of a disease later in some of these children cannot be ruled out. Severe and extensive disease (alopecia totalis/universalis) has been reported in 17–66% of children (2,4,5,12). In the present series, a majority of the children (80.5%) were observed to have mild disease and extensive disease (more than 50% hair loss) was seen in only 13% of the patients. That the difference in the prevalence of extensive disease is related to ethnic variations or selection bias in various surveys needs to be confirmed. The age of onset and a positive family history of AA were observed to have no relationship to the severity and extent of disease in our study (p > 0.05). Nail changes have been described in 30–40% of children with AA, with pitting being the most common feature (4,5,15). We observed nail changes in 26.5% of our cases and pitting was the most common finding. Comparable to earlier reports (4,5,15,26), nail changes were seen more often in children with a severe form of the disease (p ¼ 0.0004). To conclude, AA is prevalent among children in Kuwait. Females were affected more often than males and both a younger mean age of onset and a peak age of onset were observed. We also documented a high familial incidence. A positive family history of AA and associated atopic disorders were observed to have no influence on the course and severity of the disease. Whether these differences in the prevalence and other features are related to ethnic variations, environmental conditions, or other factors remains to be determined. REFERENCES 1. Walker SA, Rothman S. Alopecia areata. A statistical study and consideration of endocrine influences. J Invest Dermatol 1950;14:403–413. 2. Muller SA, Winkelmann RK. Alopecia areata. Arch Dermatol 1963;88:290–297. 3. Shellow WVR, Edwards JE, Koo JYM. Profile of alopecia areata: a questionnaire analysis of patient and family. Int J Dermatol 1992;31:186–189. 4. Sharma VK, Kumar B, Dawn G. A clinical study of childhood alopecia areata in Chandigarh, India. Pediatr Dermatol 1996;13:372–377. 5. De Waard-Van Der Spek FB, Oranje AP, de Raeymaecker DMJ, Peereboom-Wynia JDR. Juvenile versus maturityonset alopecia areata—a comparative retrospective clinical study. Clin Exp Dermatol 1989;14:429–433.
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