# Skin Diseases of Children/Alopecia Areata

PLATE I.
ALOPECIA AREATA.
From the collection of photographs of
Dr. GEORGE HENRY FOX.
ALOPECIA AREATA.
Alopecia areata is an affection of frequent occurrence in childhood, and one which the family physician should be competent to recognize and to treat. To say that he should be able to treat a case as successfully as any specialist is not making a great claim, when we consider how little positive knowledge is possessed by the latter concerning the cause and cure of this not uncommon disease.
As the name indicates, alopecia areata implies the occurrence of baldness in spots; but all bald areas are not necessarily cases of alopecia areata. Before describing the affection itself it may be well to refer briefly to certain forms of baldness, areate or complete, which are often improperly classed as cases of the disease in question.
When infants are born without hair, and for years, perhaps, exhibit but a sparse capillary growth, coincident usually with imperfect dental development, this condition is not to be regarded as alopecia areata and the term is not apt to he applied.
When, as a result of injury, fright, or intense mental excitement, the hair falls suddenly from the scalp, or from the whole body in the case of adults, we have a condition which is by no means one of true alopecia areata, although in such cases the name is very apt to be misapplied.
When, from injury to a nerve, an irregular patch of baldness develops upon the portion of hairy skin which the nerve supplies, the condition is one which strongly resembles the disease in question. It differs, however, from true alopecia areata in several essential points. It usually lacks the rounded outlines, it does not tend to spread or duplicate itself at other points, and the hairs at the margin of the bald area are not loosened. It is a bald patch of evident neurotic origin, but should be distinguished from alopecia areata.
A rare form of scalp disease, known as folliculitis decalvans, ​occurs in children as well as in adults, and is very apt to be mistaken for the commoner disease, to which it may bear a strong resemblance. Its distinguishing features are the signs of inflammation in incipient patches, the groups of dark plugged follicles, and the atrophied or cicatrized appearance of the bald patches, which are usually numerous and small. In very rare cases of ringworm of the scalp a smooth, bald patch results (Fig. 1). Whether this is to be regarded as a peculiar form of ringworm (so-called bald ringworm), or as a case of alopecia
Fig. 1.—Bald ringworm.
areata developing on the site of trichophytosis, is a vexed question.
In true alopecia areata we have as essential clinical features the development of the disease in one or more small, rounded patches; the extension of these patches by a loosening and falling of the hair at a portion or the whole of the periphery; and a marked tendency to spontaneous recovery. The first bald spot in this affection may occur upon any portion of the scalp, and is usually the size of a ten- cent piece or larger when first ​discovered. It is unaccompanied by itching or any sign of inflammation, and may have existed for many weeks before cutting of the hair or a casual examination of the scalp brings it to light. In exceptional cases tenderness upon pressure, anaesthesia, hypersemia, oedema, marked pallor or depression of the patch, are symptoms which have been noted, but ordinarily a partial or complete loss of hair is all that can be seen. The original patch sometimes remains single, but usually other patches develop near the original one, and frequently, by increase
Fig. 2.–Serpiginous form of alopecia areata.
in size and coalescence, denude a considerable portion of the scalp, as is shown in the accompanying plate and in Fig. 2. The irregular area from which the hair has fallen is smooth and soft, and, unlike a patch from which the hair has been epilated or shaven, the mouths of the hair follicles are scarcely perceptible. In some cases the bald patches are numerous, of varying size, and show little tendency to run together. The affection is by no means limited to the scalp, and in severe cases the eyebrows and lashes also suffer. In adults the bearded portion ​of the face and other hairy parts may present bald areas or appear completely denuded.
When first discovered the patch is usually tending to increase slowly in circumference, and the hairs at the margin of the disc are so loosened in their follicles that several can be pulled out at a time without giving the patient the slightest pain. Often the loose hairs will only be found on one side of the patch, and extension in this direction is certain to follow. Examined beneath the microscope these loose hairs will be found to be atro-
Fig. 3.—Growth of white hair on patches.
phied toward the root, and in some cases they will break near the surface of the skin. This breaking of the hairs does not leave a short, stiff stubble like that which is characteristic of the patches of ringworm, but as the broken-off roots of the affected hairs in alopecia areata project from the scalp near the margin of the patch, they may be noted as short, fine hair tapering downward and sometimes suggesting a crop of exclamation points.
The extent to which alopecia areata will develop in a given case it is difficult to determine in advance, but sooner or later in ​most cases, and especially in those cases occurring in childhood, the cause seems to have ceased to act and the hair returns. A fine, downy growth may be seen over a portion or the whole extent of the bald patch, and gradually the baldness disappears. In some cases, and especially in children with dark hair, the new growth is at first colorless and presents quite a contrast with the normal hair (Fig. 3). If this new hair persists in growing, it is certain to become pigmented in due time and assume a natural color. But unfortunately in some cases this new growth does not persist. It grows just enough to
Fig. 4.—Complete loss of hair.
delude one into a hope of speedy recovery, and then begins to loosen and fall out. Even a temporary growth, however, is encouraging and warrants the prediction that sooner or later the disease will come to an end. In many cases two or three months will find the hair growing naturally over the whole scalp, while in other cases the affection, through a stubborn persistence or a succession of relapses, may last a year or two. In adults a complete loss of hair is often irremediable, but in ​children the prognosis is comparatively favorable even when the head is as hairless as a billiard ball (Fig. 4).
The etiology of alopecia areata is a vexed question. Despite the great amount of study and careful observation which has been devoted to this interesting affection, there is much difference of opinion as to its pathology, and its true nature still remains obscure. For a long time it was believed to be a neurotic affection, the bald patch resulting from a faulty innervation of the affected area. With the development of the germ theory of disease there has arisen a strong belief on the part of many dermatologists that the affection is parasitic in character. Clinical facts are not wanting in support of either view, but, while the facts are indisputable, it cannot be admitted that they prove beyond all shadow of a doubt the truth of either the neurotic or parasitic hypothesis. Recently it has been suggested, in view of the conflicting facts and theories, that there are two varieties of the affection, one of which, occurring in epidemic form, must certainly be parasitic. Without attempting to introduce evidence and argue the question, it is sufficient to state that the nature of this disease is still subjudice and will doubtless so remain until more careful observations have been made or stronger arguments presented upon one side or the other. The disease occurs in both sexes, but is said to be somewhat more frequent among boys than among girls. It has been claimed that cats and other domestic animals suffer from the affection, and cases have been reported of its transmission from these to their human playmates; but in this connection the question naturally arises as to the correctness of the diagnosis between alopecia areata and ringworm, which not infrequently originates in this manner.
In the treatment of alopecia areata no brilliant results have been obtained. Many cases recover spontaneously in a short time, while in other cases the most assiduous and persistent treatment fails to effect any notable result. Many remedies are recommended and certain methods of treatment are warranted to cure in so many weeks, but, however valuable these methods may be in the hands of their originators, they often fail utterly when employed by other hands. I have photographed many cases and have observed that a few of these have gotten well speedily without further treatment. But photography will not cure all cases ; neither will some of the vaunted methods of treatment, as I have had occasion to learn from experience. In fact it must be frankly confessed that the ​treatment of alopecia areata is in many cases by no means as satisfactory as one might wish. Patients sometimes go from one physician to another, and fortunate is he who happens to take charge of the case at the time when the unknown cause has ceased to act and the hair is disposed to return. Unfortunate is he, however, if he jumps at the baseless conclusion that his plan of treatment in this case is wonderfully efficacious and will cure other cases with equal rapidity.
But treatment in alopecia areata, although it may not be productive of brilliant results, is capable of doing some good in the way of hastening a cure; and since the patient usually demands some kind of treatment, the physician is certainly justified in doing the best he can under the circumstances. The practical question at once arises, "What is the best thing that he can do?"
The first step to be taken is to prevent any possible spread of the disease to those who come in contact with the patient. If only in deference to the view held by excellent authorities that the affection is of a contagious nature, it is well to insist that every patient should have his or her own brush and comb and use no others. As to whether children with alopecia areata should be allowed to attend school, a difference of opinion might arise according to the opposite views held as to its contagious nature. But since the disease is only slightly, if at all, contagious, it would hardly seem justifiable to keep a child at home who is undergoing proper local treatment.
Whatever will stimulate the scalp and draw the blood to the pale, hairless patches will tend, in my opinion, to promote the growth of hair. And this can be done without the infliction upon the patient of either pain or discomfort. Nearly all of the powerfully stimulating applications are parasiticide in their action, and are therefore indicated, whether one believes in the neurotic or the parasitic origin of the disease. The beneficial effect results from the artificial congestion of the patch, whether the action of this be to arouse the dormant nerve filaments or to check the development of a micro-organism.
The galvanic current is perhaps the best stimulant that can be used; but as the patient cannot conveniently have electricity applied two or three times a day, it is more advisable to prescribe some stimulating lotion or ointment. The liquor ammoniae fortior U. S. P. I have used for many years and in many cases; and, while it may be no better than other stimulating applications which tend to redden the skin, it has certainly ​appeared to do as much good as any one of the many other remedies which I have tried. If something more parasiticidal in its action is desired, an ointment of chrysarobin from three to ten per cent in strength can be recommended as an effective application. In prescribing this the physician must not forget to mention the fact that it will stain the bed linen, and caution the patient not to get any ointment in his eyes lest a severe conjunctivitis result.
The plan long recommended and often practised of shaving the scalp and blistering the patches with cantharis, croton oil, or pure carbolic acid, may be of some value, but not enough to compensate for the suffering which it involves. Although patients will sometimes stand any amount of painful treatment in order to get cured, there is no justice in submitting them to harsh measures when milder ones are of equal value.
Epilation of the loose hair at the margin of the bald patch is advisable, since it seems in some cases to prevent the spread of the disease; but general epilation is unnecessary, and, so far as I know, is never practised in America.
A patient seen recently by the writer has had alopecia areata for ten years. Two months after marriage his wife found three bald spots upon her own head. At a European health resort the physician who was consulted, evidently believing in the parasitic origin of the disease, ordered the hair to be epilated not only on the scalp but on other hairy parts of the body. The spots persisted, and complete epilation was repeated in the case of both husband and wife. The lady's maid complained of slight falling of the hair, and her scalp was ordered to be thoroughly epilated, in spite of her indignant protest. In these cases, which illustrate the absurd extreme to which theoretical therapeutics may be carried, the vigorous treatment would have been pardonable had it been successful, but the gentleman, an extremely nervous individual, has still bald patches upon his scalp and chin.
Of internal medication it need only be said that neither arsenic, jaborandi, nor any other drug in the pharmacopoeia is capable of producing any manifest result in most cases. They may be of some value, as has been claimed, but reliance upon them is usually disappointing. The restoration of hair after administration of a drug is no proof of its value in a single case. The absence of improvement after its use in repeated cases is at least suggestive of its inertness. Any internal medication which will improve the physical condition of the patient is of ​course advisable and may tend to hasten the cure of alopecia areata. But in this affection impairment of health rarely seems to be a predisposing cause, and in many cases the patient is apparently in perfect health.
The uncertain result of treatment in alopecia areata should always lead to a guarded prognosis. In most cases a cure can be promised, but it is never advisable to specify any given time at which it may be expected. The younger the patient, the less the extent of baldness, and the more recent its development, the better will be the prospect of a speedy return of hair.