Bald patches in children: alopecia areata, fungal infection or hair pulling
Not every bald patch in a child is alopecia areata. Telling it apart from tinea capitis and trichotillomania decides the treatment and prevents months of wasted time.
Parents usually find it while combing or after a haircut: a smooth circle where hair used to be. The first question is always the same, is it permanent. In children the answer depends entirely on which of three common causes is behind it, and the three are treated in completely different ways.
Key points
- Three causes explain most bald patches in children and each needs different treatment
- A scaly patch with broken hairs suggests fungal infection and needs oral antifungal medicine
- Steroid creams on an undiagnosed patch can make a fungal infection worse
- Children with alopecia areata are treated with topical options first, not injections
- Photographs every two weeks help the dermatologist judge progress accurately
The three common causes
Alopecia areata gives smooth, well-defined patches with no scaling, sometimes with nail pitting. Tinea capitis, a fungal infection, gives scaly patches with broken stubby hairs, sometimes with redness, tenderness or swollen neck glands. Trichotillomania, a habit of pulling or twisting hair, gives irregular patches with hairs of different lengths, often on the side of the dominant hand.
Tinea capitis is the one that spreads. It passes between children through combs, caps, pillows and barbershop clippers, which makes it common where households and classrooms are crowded. It needs oral antifungal medicine because creams do not reach the hair root, and family members are checked at the same time.
- Smooth patch, no scale: think alopecia areata
- Scaly patch, broken stubby hairs, itch: think fungal infection
- Irregular patch, hairs of mixed length: think pulling or twisting
- Any patch with pus, pain or swelling needs urgent assessment
Why the diagnosis should not be guessed
A steroid cream applied to a fungal patch can make the infection spread and blur its appearance. An antifungal given for alopecia areata simply wastes weeks. A scalp examination with trichoscopy, and a fungal sample when needed, settles it in one visit.
Long standing untreated tinea capitis can leave scarring and permanent bald areas, so a scaly patch in a child is treated as urgent rather than cosmetic.
Treating alopecia areata in a child
Treatment is gentler than in adults. Potent topical corticosteroids, topical minoxidil, and in some cases topical immunotherapy are preferred, and steroid injections are usually avoided in young children [1].
Children with a single patch have a good chance of regrowth. Extensive loss, very early onset, or loss involving the whole scalp is less predictable, and those children benefit from specialist follow up rather than repeated pharmacy purchases [2].
Ritlecitinib is approved for severe alopecia areata from the age of 12, which gives adolescents with extensive loss a real option under specialist supervision [3].
School, bullying and confidence
Children notice how others look at them long before they can explain it. Practical steps help: a short, honest explanation the child can repeat to classmates, a word with the teacher, and a hat or scarf the child chooses rather than one imposed on them.
Watch for withdrawal, refusing school and disturbed sleep. These are part of the medical picture and should be raised at the consultation.
What parents should bring to the appointment
Photographs taken every two weeks are the most useful thing a parent can bring, because they show whether the patch is growing, static or filling in. Note when the patch was first seen, whether anyone at home or school has a similar patch, and any medicines or oils already used on the scalp.
Bring a list of the child's other conditions. Eczema, asthma, thyroid problems and vitiligo in the child or close relatives all matter for alopecia areata.
Frequently asked questions
Is my child's bald patch permanent?
Usually not. Alopecia areata does not scar the follicle, and fungal infection resolves with the right medicine. Scarring happens mainly when a fungal infection is left untreated for a long time.
Can my child go to school?
Alopecia areata is not contagious, so yes. With fungal scalp infection, treatment should start before returning to close-contact activities, and combs, caps and towels should not be shared.
Should we cut or shave the hair?
Shaving does not treat alopecia areata. In fungal infection the doctor may advise trimming around the area, but medicine is what clears it.
Do vitamins help?
Only when a deficiency is proven. Iron and vitamin D are checked when there is a reason, and treated if low. Routine high-dose supplements are not a treatment.
References and sources
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