Tinea Capitis (Ringworm of the Scalp)

Tinea capitis is a fungal infection affecting the scalp and hair and is one of the more common causes of childhood hair loss. Despite its name, ringworm is not caused by a worm. It results from infection with dermatophyte fungi and is particularly common among school-aged children.

The condition may produce round or irregular patches of hair loss, scalp scaling, itching and hairs that break close to the skin. Broken hairs can sometimes appear as small black dots within the affected areas. Some children develop more widespread scaling or relatively subtle signs that resemble dandruff or other scalp disorders.

Tinea capitis is contagious and can spread through close contact with infected individuals, shared hairbrushes, hats and other personal items. Certain fungal species can also spread from infected animals. Some individuals may carry the infection without obvious symptoms, making household contacts an important consideration when infections recur or multiple family members are affected.

Because its appearance varies, the diagnosis may be supported by microscopic examination, fungal culture or other laboratory testing when appropriate. A Wood’s lamp may help identify certain fungal species, but many common causes of scalp ringworm do not fluoresce under ultraviolet light. A negative Wood’s lamp examination therefore does not rule out tinea capitis.

Tinea capitis generally requires prescription oral antifungal medication. Topical antifungal shampoos alone do not adequately eliminate an infection involving the hair shafts and follicles. Medications such as griseofulvin or terbinafine may be prescribed depending on the suspected organism, the child’s age and other clinical considerations. Treatment duration varies, and antifungal shampoos may sometimes be recommended as an additional measure to reduce fungal shedding and transmission.

In more severe cases, a child may develop a kerion, an intensely inflamed and sometimes painful area of scalp swelling that may produce pustules, crusting or drainage. This requires prompt medical attention because significant inflammation can occasionally lead to scarring and permanent follicular damage. However, permanent hair loss is not the usual outcome when the infection is recognized and appropriately treated.

With appropriate treatment, hair commonly regrows after the infection has been controlled, provided the follicles have not sustained permanent damage. Families should follow their healthcare professional’s guidance about completing treatment and limiting transmission rather than relying on over-the-counter hair-growth products.

Alopecia Areata

Alopecia areata is an autoimmune disorder in which the immune system mistakenly targets hair follicles, disrupting normal hair growth. It is an important cause of childhood hair loss and can develop in very young children as well as adolescents.

The condition commonly produces one or more round or oval patches of hair loss. These patches are often smooth, with little visible inflammation or scaling. However, alopecia areata can also present with more widespread thinning or extensive hair loss, making it important not to assume that every child with this condition will develop clearly defined bald patches.

Some children experience loss of nearly all scalp hair, known as alopecia totalis, while others may lose hair from the scalp and other areas of the body, a condition known as alopecia universalis. Eyebrows and eyelashes may also be affected. Changes in the fingernails, including small pits or surface irregularities, can sometimes accompany the disease.

Alopecia areata is not contagious, and it is not caused by poor hygiene. Although emotional stress is frequently blamed for sudden hair loss, the development of alopecia areata involves immune-system dysfunction and cannot simply be explained as a psychological response.

The course of alopecia areata is unpredictable. Some children experience spontaneous regrowth, while others develop recurring episodes or more extensive disease. Even when hair regrows, the condition may return. The likelihood of recovery depends on several factors, including the extent and duration of hair loss and the individual child’s disease course.

Treatment may include topical corticosteroids or other approaches selected according to the child’s age and disease severity. Intralesional corticosteroid injections may be considered for selected older children or adolescents with limited disease, although discomfort, tolerability and the extent of hair loss can restrict their use. These injections are not routinely appropriate for younger children. Topical minoxidil is sometimes used as an adjunct under medical supervision, but it does not address the underlying autoimmune process and should not be considered a primary treatment for the disease.

Targeted immune-modulating therapies have expanded treatment options for some adolescents with severe alopecia areata. Ritlecitinib (Litfulo) and baricitinib (Olumiant) are FDA-approved in the United States for severe alopecia areata in patients 12 years of age and older. These medications act on immune-signaling pathways involved in the disease and require specialist assessment, appropriate monitoring and careful consideration of potentially serious adverse effects, including risks associated with infections and other complications.

Other Janus kinase (JAK) inhibitors have different approved age ranges. Deuruxolitinib (Leqselvi), for example, is FDA-approved for adults with severe alopecia areata, not children under 18. Other treatments may be investigated or prescribed off-label in selected circumstances, but experimental or off-label approaches should never be presented to families as established pediatric cures.

There is currently no treatment that guarantees permanent recovery from alopecia areata. For children with persistent or extensive disease, knowledgeable medical care, realistic expectations and appropriate emotional support are essential.

Telogen Effluvium

Telogen effluvium occurs when an unusually large number of hair follicles enter the resting phase of the hair growth cycle, leading to increased shedding. Unlike conditions that produce distinct bald patches, telogen effluvium generally causes diffuse shedding across the scalp.

In children, telogen effluvium may follow a fever, significant infection, surgery, injury, rapid weight loss, inadequate nutritional intake or certain medications. Even an illness from which a child has fully recovered can temporarily alter the hair growth cycle and result in noticeable shedding weeks or months later.

One characteristic of telogen effluvium is that shedding often begins approximately two to three months after the triggering event, although timing can vary. This delay can make the cause difficult for parents to recognize. A child who experienced a febrile illness months earlier may suddenly begin losing noticeably more hair during washing or brushing, even though they now appear healthy.

It is important to distinguish excessive shedding from hair shaft breakage. Telogen effluvium involves the release of hairs from their follicles, while infections, inherited hair shaft abnormalities and physical damage may cause hairs to break along their length or near the scalp. Both can reduce the apparent volume of hair, but the underlying mechanisms are different.

Diagnosis generally involves reviewing the child’s medical history, the timing of shedding and the appearance of the hair and scalp. A hair pull test or magnified scalp examination may help assess active shedding and distinguish telogen effluvium from other hair loss disorders.

When the triggering factor is resolved, shedding usually improves and hair growth gradually returns. However, restoration of the child’s previous hair density may take several months or longer because the hair growth cycle requires time to recover. Persistent shedding, continued thinning or unusual scalp findings should prompt further evaluation rather than an assumption that telogen effluvium is the only possible explanation.

Treatment primarily focuses on identifying and addressing the underlying cause. Hair-growth supplements and medications are not routinely necessary for uncomplicated telogen effluvium, and there is no established benefit to using adult hair-loss treatments in otherwise healthy children simply to accelerate recovery.

Nutritional Deficiency

Nutritional deficiencies can contribute to hair shedding, changes in hair texture and, in some circumstances, impaired hair growth. However, they are not responsible for every case of childhood hair loss, and parents should be cautious about assuming that thinning hair indicates a vitamin or mineral deficiency.

Iron deficiency, inadequate protein intake, zinc deficiency and certain other nutritional problems may interfere with normal hair growth. Children with restrictive eating patterns, significant dietary limitations, malabsorption disorders or medical conditions affecting nutrition may be at greater risk.

Hair loss can also occur in children experiencing rapid weight loss or inadequate caloric intake. In adolescents, significant dietary restriction or disordered eating may contribute to excessive shedding and should be evaluated sensitively, with attention to overall physical and psychological health.

Biotin deficiency is sometimes mentioned in discussions of hair loss, but clinically significant deficiency is uncommon. Despite aggressive marketing, there is insufficient evidence that biotin supplementation improves hair growth in children who do not have a deficiency.

Both inadequate intake of essential nutrients and excessive exposure to certain vitamins or minerals can affect hair growth. For example, excessive amounts of vitamin A or selenium may contribute to hair loss and other health problems. This is one reason supplements should not be given simply because a child is losing hair.

When a nutritional problem is suspected, a healthcare professional may recommend selected laboratory tests based on the child’s diet, growth, medical history and examination findings. Supplementation should be directed toward correcting an identified deficiency rather than giving multiple vitamins or commercial hair-growth products without a clear medical reason.

A balanced diet is important for normal growth and development, but nutritional supplements should not be presented as a treatment for autoimmune hair loss, fungal scalp infections or inherited follicular disorders.

Endocrine Problems

Hormonal and endocrine disorders can affect hair growth in children, although they are less common causes of pediatric hair loss than conditions such as tinea capitis, alopecia areata and telogen effluvium.

Thyroid disorders are among the endocrine conditions that may contribute to hair thinning or excessive shedding. Hypothyroidism occurs when the thyroid gland produces insufficient thyroid hormone, while hyperthyroidism involves excessive thyroid hormone activity. Both can disrupt normal hair growth.

Children with thyroid dysfunction may also experience fatigue, unexplained weight changes, altered growth patterns, constipation, temperature intolerance or other symptoms. When thyroid disease is suspected, blood tests such as thyroid-stimulating hormone (TSH) and free thyroxine (free T4) can help establish the diagnosis.

During adolescence, changes in androgen activity can also contribute to hair loss in genetically susceptible individuals. Although hereditary pattern hair loss is primarily associated with adults, androgenetic alopecia can begin in teenage boys and girls.

In adolescent boys, androgenetic alopecia may begin with recession around the temples or thinning at the crown. In girls, it more commonly presents as widening of the central part or reduced density across the top of the scalp, although individual patterns vary. Unlike the sudden patches associated with alopecia areata, hereditary pattern hair loss generally involves progressive miniaturization of susceptible follicles.

An adolescent with progressive thinning should be evaluated for follicular miniaturization rather than automatically being diagnosed with stress-related shedding. In girls, menstrual irregularities, significant acne or excessive facial and body hair growth may warrant assessment for androgen excess or another endocrine condition. However, normal circulating androgen levels do not exclude hereditary pattern hair loss.

Treatment depends on the underlying disorder. Correcting a thyroid or other endocrine abnormality may improve related shedding, but it will not necessarily reverse an independent hair loss condition occurring at the same time. Treatment options for adolescent androgenetic alopecia also require careful consideration because medications commonly used in adults may not be approved or appropriate for younger patients.

Newborn Hair Loss

Hair loss during the first several months of life is common and usually represents a normal transition in the infant hair growth cycle. Many newborns shed some or much of the hair present at birth, and the replacement hair may differ in thickness, color or texture.

This shedding does not ordinarily indicate a nutritional deficiency or underlying disease. Hair regrowth generally occurs naturally as the child’s hair growth cycle develops, although the timing and density of regrowth can vary.

Not all hairless areas present during infancy are the result of normal shedding. Some children are born with localized areas where hair follicles are absent or the skin has developed differently. Conditions such as congenital triangular alopecia or aplasia cutis congenita may produce persistent areas without hair and require a different diagnostic assessment.

Parents should discuss unusual findings with their pediatrician, particularly when an area has been completely hairless since birth, the skin appears scarred or otherwise abnormal, or the hair loss is accompanied by inflammation or other concerning symptoms. These findings should not automatically be attributed to ordinary newborn shedding.

Rubbing

Some infants develop an area of reduced hair density on the back of the scalp during the first several months of life. Although this has traditionally been attributed to friction against bedding, car seats or other surfaces, normal changes in the infant hair growth cycle may also be an important contributing factor.

This pattern is generally temporary in otherwise healthy infants. Hair density commonly improves as the infant grows and the normal hair growth cycle progresses, although the timing of regrowth varies.

Hair loss on the back of an infant’s head is not a reason to change recommended safe-sleep practices. Parents should continue placing infants on their backs for sleep and should not use special pillows, positioning devices or alternative sleeping arrangements in an attempt to prevent hair loss.

Medication or scalp treatment is generally unnecessary for uncomplicated infant hair shedding. However, persistent hairless areas, unusual skin findings, inflammation or an atypical pattern of hair loss should be evaluated by a pediatrician.

Hair Shaft Damage and Traction Alopecia

Physical damage to the hair or repeated tension on hair follicles can cause breakage, thinning and, in some cases, permanent hair loss. Common contributing factors include tight ponytails, braids, buns, extensions, repeated pulling and excessive tension during styling.

Traction alopecia develops when hairstyles repeatedly place tension on the same follicles. It often affects the frontal or temporal hairline, although other areas may be involved depending on the hairstyle. Early signs can include broken hairs, thinning along the edges of the scalp and discomfort associated with tight styling.

When excessive tension is removed early, hair regrowth is often possible. However, longstanding traction can cause inflammation, follicular injury and ultimately permanent scarring. Once follicles have been permanently destroyed, removing the source of tension will not restore hair growth in those areas. Children should not be expected to tolerate painful hairstyles, and persistent scalp discomfort or thinning should not be dismissed as a normal consequence of hair care.

Hair shaft breakage can also result from aggressive brushing, repeated heat styling, chemical processing or certain inherited hair shaft abnormalities. These problems may reduce the apparent length and volume of the hair without necessarily producing the same pattern of shedding seen in telogen effluvium.

Some children have hair that is unusually fragile, grows poorly or can be pulled out with very little resistance because of an underlying hair shaft or hair growth disorder. One example is loose anagen hair syndrome, in which growing hairs are inadequately anchored within their follicles and may be extracted easily, often with little or no discomfort. Affected children may have sparse hair that appears not to grow normally, even without obvious scalp inflammation.

Loose anagen hair syndrome is distinct from traction alopecia and ordinary hair breakage. Diagnosis may involve examination of easily extracted hairs and assessment by a dermatologist experienced in pediatric hair disorders. The condition often improves with age, although the course varies. Recognizing it can help families avoid unnecessary testing, inappropriate treatments and the mistaken assumption that the child’s hair is being damaged through poor care.

Gentle hair care, avoiding excessive tension and reducing damaging styling practices are important preventive measures. If thinning persists despite these changes, the child should be evaluated for other causes rather than assuming that all hair loss is related to grooming.

Trichotillomania

Trichotillomania, also known as hair-pulling disorder, is a condition characterized by recurrent pulling out of one’s own hair. It is classified among obsessive-compulsive and related disorders, although it is not the same condition as obsessive-compulsive disorder.

Hair pulling may involve the scalp, eyebrows, eyelashes or other body areas. It can produce irregular patches of thinning with hairs broken at different lengths, sometimes creating an appearance that differs from the smooth, well-defined patches commonly associated with alopecia areata.

Some children are aware of the behavior and experience an urge to pull, while others engage in hair pulling automatically, particularly during periods of concentration, boredom or emotional distress. In younger children, repetitive hair touching, twisting or pulling may occur as a developmental behavior without necessarily meeting the diagnostic criteria for trichotillomania.

Persistent or recurrent hair pulling that produces noticeable hair loss, distress or functional difficulties warrants appropriate assessment. The behavior should not automatically be interpreted as evidence of an underlying psychological disorder without considering the child’s age, developmental stage and circumstances.

Trichotillomania should not be treated as deliberate misbehavior, and punishment, blame or repeated criticism can increase embarrassment and distress without addressing the underlying problem. Some children may attempt to conceal their hair pulling because they feel ashamed or fear negative reactions.

Diagnosis may involve examination of the hair and scalp, discussion of the child’s behavior and assessment for associated emotional or behavioral concerns. Trichoscopy can sometimes help distinguish hair pulling from alopecia areata, fungal infection and other causes of irregular hair loss.

Treatment often involves behavioral interventions, including habit reversal training, which helps the individual recognize pulling behaviors and develop alternative responses. Cognitive behavioral therapy and other supportive approaches may be appropriate depending on the child’s age and circumstances. Family involvement can be important, particularly when helping younger children manage the behavior without shame or punishment.

Hair often regrows when pulling stops and the follicles remain intact. However, prolonged or severe repetitive trauma can occasionally produce permanent follicular damage. Children with persistent hair pulling should receive appropriate professional support rather than being offered hair-growth medications as the primary solution.