Alopecia Areata in children under the age of 4

Hair loss is a fairly common condition that sadly does not exclude children, and can also affect very young minors, even those under the age of four. Although for a young child, hair loss might not be as distressing as it can be for adults (as a toddler that age is still learning about his or her social appearance) hair loss in a child will likely have a more significant impact on the child’s parents. This could especially happen when a child is suffering from Alopecia Areata, a type of hair loss that is associated with other underlying conditions.

What is Alopecia Areata (AA)?

Alopecia Areata (AA) is a chronic autoimmune condition that is characterized by a non‐scarring type of hair loss. This condition, which commonly presents on the scalp, can also affect eyebrows, eyelashes and other hairy parts of the body. This shedding of the hair may start in the form of patches which with time can merge to involve the whole scalp, predisposing the individual to early balding. This T cell-mediated autoimmune disease can also be found in association with other autoimmune infectious or inflammatory conditions.

 AA is a globally prevalent complaint affecting around 2% of the world’s population. It specifically targets hair follicles, and it usually results in severe premature hair loss. 

Alopecia Areata in children under 4 years of age

Alopecia Areata is vastly becoming a common diagnosis in children too, and it is estimated that approximately 40.2% of patients have their first presentation by the age of 20. According to analytical data collected in Kuwait and India, it is also the third most common non-inflammatory skin disease observed in children, with 20% of all Alopecia Areata cases estimated to be reported in infancy. Although AA can manifest itself at any age, its presentation before the age of 2 is still unheard of.

Similar studies conducted in Ohio and Florida found Alopecia Areata to be more prevalent in female children (6.5) than in male children (3.3) of the same age group (age 1-5). However, another study proved that girls have a better prognosis than boys.

The literature on Alopecia Areata in children is generally sparse. A single study was found focusing on the progression of this condition in children under the age of 4. This study, published in 2019, evaluated the clinical presentation of 125 children diagnosed at Children’s Hospital Philadelphia. Researchers assessed the severity and progression of the disease using the Severity of Alopecia Tool (SALT) over 4 intervals, from initial presentation, 3-6months, 1 year and then after 2 years. The study found the initial presentation of Alopecia Areata was more common between ages 2-4 years (<50%hair loss). The severity was also noted to continue on the same level for the succeeding two years. However, the children initially suffering with 50% of hair loss had progressive worsening SALT scores over time.

Children with Alopecia Areata are generally asymptomatic, with their scalp examination showing no signs of scarring, scaling or inflammation.

The pattern of hair loss in children

Several patterns of hair loss are observed in children. These range from the insidious onset of hair loss with a round or oval pattern, to sharply defined patches of hair loss that gradually merge and enlarge by peripheral extension. A common feature of AA in children is the presence of hair around the borders of patchy hair, known as the ‘exclamation point’. The hair at the periphery of the patches can easily be plucked out even with gentle traction and serve as a clue for diagnosis. Other patterns of Alopecia Areata include a diffuse type of hair loss with 20% or more occurring evenly over the scalp, without the formation of well-defined patches. 

Association of Alopecia Areata with other conditions

Alopecia Areata in young children is likely to be associated with other autoimmune diseases and skin conditions such as atopic dermatitis, vitiligo, celiac disease, type 1 diabetes, and thyroid disease. 

Almost 25% of patients with AA in one study were found to have abnormal thyroid function tests. Another study involving 125 children under the age of four, showed that approximately 41% of the children suffered from atopic dermatitis, 28% had a family member with Alopecia Areata, and 27% had a first-degree family member with one or more autoimmune diseases.


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