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Unexplained Hair Loss in a 4-Year-Old Boy

Unexplained Hair Loss in a 4-Year-Old Boy

  • Dr Jon’s Medical Mystery Tour—Final Stop

  • Presenting history: A 4-year-old boy presents with 3-4 mo history of hair loss from top of head. Parents deny hair pulling; negative for chemicals, drugs, dermatologic disorders.

  • Physical examination: Diffuse thinning on the top portion of head; hairs of varying lengths; KOH – negative; no anomalies under magnification, but hair ends are frayed, slight increase in telogen hairs.

  • Presentation: Hair loss confined to the top of head; no inflammatory changes, no scale.

  • Physical examination: Broken hairs with frayed ends; no suggestion of fungi; no nail pitting; no other skin lesions

  • Tentative diagnosis: Trichotillomania; recommended head covering at night; no change on follow-up after 3 weeks.

  • Missing history: Occupational history for children is their play; patient likes to imitate a snow plow, pushing top of head along the carpet.

  • Diagnosis: Cross between traction alopecia and trichotillomania, in this case, "snow plow scalp."

  • Lessons learned: Try to interview the parent who is the best historian; always query about play history (children’s occupation); when appropriate, you may not need to refer immediately

  • Presenting history: 19-year-old sailor requesting medical evacuation for 4-5 wks gradual hair loss; denies hair pulling; diet normal.

  • Physical examination: Results are normal except for hair loss from top of head, hairs of varying lengths; hair ends frayed on magnification.

  • Presentation: Patterned hair loss with hairs that are broken and of varying lengths.

  • Diagnosis: A new one: “red rubber raft roof rot.” Self-induced baldness not unlike trichotillomania, secondary to repetitive bouncing of a rubber raft off the top of the head.

The Mysterious Case of the Boy with Unexplained Hair Loss is the final case in October’s 4-part Medical Mystery Tour Special Report by Dr Jonathan Schneider.

Hair loss is not an uncommon problem in children; causes include telogen effluvium, tinea capitis, bacterial infections, traction alopecia, trichotillomania, and alopecia areata. Thyroid disorders, malnutrition, and diabetes are also found causative but are less common.

The 4-year-old patient in this case is completely well other than the bald patch on the top of his head. After ruling out physical and medical etiologies, Dr Schneider had to return to the history to determine if he had overlooked a vital clue – and, he had.

Dr Schneider is a primary care physician with special interests in dermatologic disease and adolescent medicine who began his career in the US Navy as a young physician. When you've complete this case, visit our large collection of his other intriguing cases.

Scroll down for resources.








Alves R, Grimalt R. Hair loss in children. Curr Probl Dermatol. 2015;47:55-66. doi: 10.1159/000369405. Epub 2015 Feb 20.

Atton AV, Tunnessen Jr, WW. Alopecia in children: the most common causes. Peds in Review. 1990;12:25-30.

Castelo-Soccio L. Diagnosis and management of alopecia in childhood. Ped Clin N America. 2014;61:427-442.

França K, Rodrigues TS, Ledon J, Savas J, Chacon A. Comprehensive overview and treatment update on hair loss. J Cosmetics, Dermatol Sci App. 2013;3. DOI:10.4236/jcdsa.2013.33A1001

Mendiratta V, Jabeen M. Hair loss and its management in children. Expert Rev Dermatol. 2011;6:581-590.

Mounsey AL, Reed SW. Diagnosing and treating hair loss. Am Fam Physician. 2009;80:356-374                                    


can't get the program to work.

diana @

Fantastic case!

Steven @

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