|Year : 2019 | Volume
| Issue : 4 | Page : 320-324
A clinical profile of childhood alopecia areata in a tertiary care hospital in Chennai, India
Naveen Chandra Atluru, Vritika Gaddam, Sudha Rangarajan, Krishnakanth Muralidhar, Mahalakshmi Veeraraghavan
Department of Dermatology, Sri Ramachandra University and Research Institute, Chennai, Tamil Nadu, India
|Date of Web Publication||30-Sep-2019|
Dr Naveen Chandra Atluru
Department of Dermatology, Sri Ramachandra University and Research Institute, Porur, Chennai - 600 116, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Data of Clinical profile of childhood alopecia areata (AA) is inadequate in India. Hence this study was carried out. Materials and Methods: All new cases of childhood alopecia areata (AA) were studied from September of 2015 to September 2016, for a total duration of 1 year. In this prospective study, a total of 150 patients were diagnosed with AA, out of which 39 pediatric patients were enrolled in our study. Results: A total of 23 girls (58.97%) and 16 boys (40.02%) were seen with a ratio of 1.4:1 (female:male). All 39 patients are of South Indian decent and had an age of onset ranging from 2- to 18-year-old with the mean being 10.7 years. Twenty-four patients (61.5%) had a rapid onset of the disease, <6 months duration and only one patient had a previous episode of patchy hair loss. The majority of patients, 30 (76.9%), had a mild type of involvement, which was <25% of the scalp. A positive family history of AA was observed in 3 (7.7%) patients. A total of 17 (43.6%) patients had a history of atopy while only 7 (17.95%) patients had family members with a history of atopy. A positive family history of AA was seen in 3 (8.3%). Other systemic associations such as vitiligo, lichen planus, and Down's syndrome were rare. Conclusions: The age of onset, a positive family history of AA, and associated autoimmune diseases or atopic disorders were observed to not have any influence on the severity of the disease. The results were compared with those reported elsewhere for the similar age group.
Keywords: Alopecia areata, autoimmune, ophiasis
|How to cite this article:|
Atluru NC, Gaddam V, Rangarajan S, Muralidhar K, Veeraraghavan M. A clinical profile of childhood alopecia areata in a tertiary care hospital in Chennai, India. Indian J Paediatr Dermatol 2019;20:320-4
|How to cite this URL:|
Atluru NC, Gaddam V, Rangarajan S, Muralidhar K, Veeraraghavan M. A clinical profile of childhood alopecia areata in a tertiary care hospital in Chennai, India. Indian J Paediatr Dermatol [serial online] 2019 [cited 2020 Jan 17];20:320-4. Available from: http://www.ijpd.in/text.asp?2019/20/4/320/268390
| Introduction|| |
Alopecia areata (AA) is an autoimmune skin disease with a highly unpredictable course, resulting in patches of hair loss on the scalp and elsewhere on the body. AA is frequently associated with autoimmune thyroiditis, vitiligo, lichen planus and pernicious anemia. Approximately 1.7% of the general population is affected by this common yet challenging and unpredictable disease. Yet the disease patterns and epidemiology in children have not been adequately studied. The disease itself is not life threatening, but the consequences can have a massive impact on one's self-esteem and life, both at work or at school. Misconceptions and ignorance of the condition may lead to psychological stigma in those affected.
AA can cause different types of hair loss. Each of these types has a different name:
- AA (hair loss in patches)
- Alopecia totalis (loss of all hair on scalp)
- Alopecia universalis (loss of all hair on the body).
We here present the results of 39 children below the age of 18 years of age.
| Materials And Methods|| |
The data was collected from a single questionnaire provided to each patient with clinically proven AA. This included clinical details including age, sex, age on onset, duration of disease, site of onset and sites affected, precipitating or aggravating factors, associated diseases, nail changes, and family history [Table 1]. Age of onset was defined as the time at which the patient or parent of the patient noticed the hair loss, at which time or later was diagnosed as AA. Informed consent was obtained from all patients in English or in their native language. A detailed history, a complete general and systemic examination, and a precise dermatological examination was done in each case.
All the patients were examined to determine the sites affected, the morphological pattern, extent, and severity of the disease, and nail involvement. Patients were divided based on their disease pattern which was either patchy, diffuse, ophiasic, or alopecia totalis/alopecia universalis. The severity of the disease was determined by the amount of patches present and was defined as mild if <25%, moderate 25%–50%, and severe if >50%. Parents were also questioned in regards to their child's reaction to dust, pollen or any allergens, by sneezing or breathlessness. Difficulty in breathing associated with urticarial or atopic dermatitis or infantile eczema was also noted.
| Results|| |
For the period of 1 year, a total of 150 new patients with AA attended the dermatology out-patient department in our hospital. They included 94 males (62.67%) and 56 females (37.33%). This included 39 children (26.0%) who were newly diagnosed patients with AA. All 39 patients were of Indian nationality (100%). There were 16 boys (40.02%) and 23 girls (58.97%). With a female:male ratio of 1.4:1. Their age and sex distribution is shown in [Table 2]. The youngest child was 2-year-old.
AA was present for a duration of <6 months in 24 patients (61.5%) and >6 months in 15 patients (38.5%). The mean duration was 6.7 months with a range of 5 days to 2 years. The mean age of onset was 10.18-year-old. All but one patient were asymptomatic with no early symptoms prior to the onset of lesions (97.43%). Only one (2.56%) patient had presented with pruritus prior to the onset of their scalp lesions and one patient (2.56%) had a prior history of AA. Three patients (8.33%) had a history of prior infection, all of which were dental caries.
Patients who gave a history of wheeze, running nose, breathlessness, or atopic dermatitis associated with AA were 17 (43.59%), whereas only 7 (17.94%) patients had family members with a history of atopy. Autoimmune thyroiditis was seen in 3 patients (7.69%) while no patients had any family members with affected thyroid disorder. Diabetes mellitus was not seen in the patients themselves, rather 8 patients (20.51%) had family members with diabetes. Family members of 11 (28.20%) patients had history of hypertension. Other skin infections were seen in six patients (15.38%), which were acne vulgaris, fungal infections, pediculosis, and lichen planus (one patient–2.56%). Family members of three patients (7.69%) had a positive history of AA, with two sisters and one mother being affected. Based of peripheral smear examination, we were able to conclude that six patients (15.38%) had a microcytic hypochromic anemia.
The scalp was the site of the primary patch of hair loss in 38 patients (97.43%). One patient (2.56%) had patchy alopecia over the beard region. A total of 29 patients (74.36%) has patchy involvement of the scalp <25% [Figure 1], while 6 (15.38%) patients had patchy involvement of 25%–50% of the scalp [Figure 2] and [Figure 3]. Two patients (5.12%) presented with ophiasis type of hair loss [Figure 4], one patient (2.5%) had ophiasis inversus, and one patient (2.5%) had alopecia totalis.
|Figure 1: Clinical photograph showing alopecia areata affecting <25% of the scalp in a 11-year-old female patient|
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|Figure 2: Clinical photograph - left side - showing alopecia areata affecting >25% of the scalp in a 14-year-old male patient|
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|Figure 3: Clinical photograph - right side - showing alopecia areata affecting >25% of the scalp with ophiasis inversus in a 14-year-old male patient|
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|Figure 4: Clinical photograph showing an ophiasis pattern of alopecia areata in a 12-year-old male patient|
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Nail changes were recorded in 15 patients (38.46%), with fine pitting being the most commonly observed change present in 11 (73.3%), followed by longitudinal striations in 3 (20%), and trachyonychia and onychodystrophy in one patient each (6.67%). The extent of AA seemed to have a significant relationship to nail involvement. Patients who had moderate to severe disease, had a higher frequency of nail involvement compared to the patients with mild disease.
| Discussion|| |
In today's practice, AA is one of the common problems encountered by the dermatologist. Its hallmark characteristic feature is an initial lesion that is well-circumscribed, totally bald, and smooth patch. To identify one single cause is in itself is a mystery, as there are a plethora of etiological factors. The patient's genetic constitution, atopic state, nonspecific immune and organ specific autoimmune reaction, and possible emotional stress are just a few of the many.
AA can be seen in all age groups of patients. It has a lifetime risk of approximately 1.7% and it is estimated that the risk for AA occurring in children is around 10x greater than that in the general population. There are very few reports on the demographic patterns and clinical profiles of children with AA. Our study aimed to review the clinical profile of pediatric patients with AA in Chennai, India.
We found that in our study, children with AA had accounted for 26.0% of the total number of cases of AA seen during the same time. This was slightly higher when compared to similar studies from China (12.80%) and Singapore (11.1%). But when compared to a study done from Chandigarh, India it was very similar (23.9%).,,
From the 4th month of life till even the late 70's, AA can start at any time. The youngest patient in the current study was 2-year-old and the eldest being 18-year-old. This study contained a higher age range when compared to the other studies who were from 2 to 15 years old only. The majority of patients in our study belonged to the age group between 7 and 18 years old (74.36%). This was consistent with other studies done in China and Singapore. The average age of onset of disease in our study was 10.18 years old. This was slightly higher from a similar study done in Kuwait (6.7 years old) but similar to a study in Singapore (11.2 years old).
It was also demonstrated that AA had a predilection to affect females greater than males. There were 23 girls (58.97%) and 16 boys (40.02%). This was relatively consistent in the following two studies. In Chandigarh, there were a total of 201 patient in which 58.2% were females and 41.8% were males. In Kuwait, a total of 215 patients were enrolled out of which 71% were females and 29% were males. The female:male ratio being 1.4:1 in the studies alike. The study from China and Singapore had shown a higher male population than female.
In the present study, 24 (61.5%) patients presented within 6 months of onset of the alopecia lesions. While 15 (38.5%) patients had a more insidious onset of >6 months. When compared to studies, Chandighar too had 142 (70.6%) patients present within 6 months and 59 (29.4%) patients present after 6 months up to 3 years. A Singapore study showed an average of 5.6 months in 281 (71.7%) of their patients. As compared to other studies ours was well within a comparable limit as seen above.
There were not many patients across all the studies that really demonstrated any symptoms prior to the onset of the disease. The few that were present were usually pruritus, which was seen in one patient (2.56%) from our study. The Chandighar study showed 18 (8.9%) of their patients having a triggering factor, which was fever and infection in 6 patients, school stress in 3 patients, and drugs in 2 patients. The history of prior infection was also seen in our study in 3 (7.69%), and all presented with dental caries. Slightly higher than the Kuwait study, where 10 (4.7%) patients all had tonsillitis.
Atopic history was seen in 17 (43.59%) patients themselves, whereas only 7 (17.94%) patients had family members with a history of atopy. The other studies varied with their results in that Kuwait showed 53 (24.7%), China 2 (0.88%), Chandigarh 35 (17.5%), and Singapore 24 (6.1%) patients with atopy. In regards to their family members having a history of atopy, only the study in Singapore showed 130 (33.2%) patients. This was almost double of what we showed from our study.
Associated autoimmune diseases like autoimmune thyroiditis was seen in 3 (7.69%) which was higher than studies done in Kuwait (0.9%), China (0.88%), and Singapore (0.3%). A study from Chandigarh showed 10.7% of their patients with AA having autoimmune thyroiditis. Vitiligo was not seen in any of the patients from our study, but that may be due to the low sample size. In Kuwait there were 3 (1.4%) patients, China 1 (0.44%), and Singapore 1 (0.33%) patients who had vitiligo along with AA. Lichen planus was seen only in one patient (2.56%) in our study, which was much higher than that seen in Kuwait, which only had 1 patient (0.56%) as well. No other studies demonstrated patients with lichen planus.
Across all the studies that were compared, no patients themselves had diabetes mellitus, but their family members did. In our study we saw 8 (20.51%) patients who had family members with diabetes mellitus. Our results were comparative to other studies which showed similar results. In Chandigarh there were 37 (18.4%) patients and Singapore showed 65 (16.6%) patients who had family members with diabetes mellitus. History of hypertension was also seen in family members, and not in patients themselves. Out study showed 11 (28.20%) patients, while Chandigarh showed 50 (24.9%) patients who had family members with hypertension. Both studies were relatively within the same range.
Only in the Kuwait and Singapore study were there patients who had Down's syndrome with AA. Kuwait a total of 4 patients who made up 2.0% of their study population, while Singapore had 5 patients who made up 1.3%. Our study did not demonstrate any patient with Down's syndrome.
Family history of AA was not as prominent as expected. In our study, 3 patients (7.69%) presented with family members whom have also had similar complaints of patchy hair loss over their scalp. This was much lower than the study done in Kuwait, wherein they showed 111 (51.6%) patients with family members with AA. China and Singapore showed similar results to our study, 11.06% and 12.4%, respectively.,
The common patterns of AA noticed in the order of decreasing frequency were limited (<25%) patchy involvement, diffuse (25%–50%) patchy involvement, ophiasis, ophiasis inversus, and alopecia totalis. A pure form of alopecia totalis was not found in our patients, as the patient presented to us after partial scalp hair regrowth., This is not comparable with other studies, which showed an increase 10–15-folds in the incidence of alopecia totalis and universalis. AT/ATU made up 6.19% in the China study, and 16.9% in the Chandigarh study, and 30.8% in the Italy study. In our present study, ophiasis showed a significant association with both the severity and duration of the disease.
The commonest site involved in our study was the scalp (97.43%). This corresponded to studies done in Kuwait (96.3%), Chandigarh (80.6%), and Singapore (99.7%). The most commonly affected area next in other studies were the eyebrows, then the eyelashes.
Nail involvement in our study was considerably on par when compared to other studies. In our study, 15 patients (38.46%) had nail changes, with fine pitting being the most commonly observed change present in 11 (73.3%), followed by longitudinal striations in 3 (20%), and trachyonychia and onychodystrophy in one patient each (6.67%). These nail changes revealed a significant association with the severity of the disease, as has been observed in the Chandighar, Kuwait, and Italy study.,, They demonstrated pitting being the most common nail change seen in approximately 91% of patients in Kuwait, 19.4% in Chandighar study, and 73.02% in the Italian study.
The major limitation to this study was the small sample size of patients taken over a 1 year duration. For had this number been greater, a better understanding and better comparison could be done in relation to other studies done across Asia and the rest of the world.
The lack of a control study group is also a limitation to this study.
| Conclusion|| |
This comprehensive, yet small study of childhood AA in a South Indian tertiary care hospital showed that patients usually presented with milder forms of the disease. The indicators of bad prognosis were ophiasis, nail changes, and prior infections. Though increased prevalence of atopy was observed in patients family members of AA, it did not affect or alter the severity of the disease.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Xiao FL, Yang S, Liu JB, He PP, Yang J, Cui Y, et al.
The epidemiology of childhood alopecia areata in China: A study of 226 patients. Pediatr Dermatol 2006;23:13-8.
Tan E, Tay YK, Giam YC. A clinical study of childhood alopecia areata in Singapore. Pediatr Dermatol 2002;19:298-301.
Sharma VK, Kumar B, Dawn G. A clinical study of childhood alopecia areata in Chandigarh, India. Pediatr Dermatol 1996;13:372-7.
Nanda A, Al-Fouzan AS, Al-Hasawi F. Alopecia areata in children: A clinical profile. Pediatr Dermatol 2002;19:482-5.
Muralidhar S, Sharma VK, Kaur S. Ophiasis inversus: A rare pattern of alopecia areata. Pediatr Dermatol 1998;15:326-7.
Muller SA, Winkelmann RK. Alopecia areata. An evaluation of 736 patients. Arch Dermatol 1963;88:290-7.
Tosti A, Morelli R, Bardazzi F, Peluso AM. Prevalence of nail abnormalities in children with alopecia areata. Pediatr Dermatol 1994;11:112-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]