Pediatric Examination and Board Review (39 page)

8.
(C)
It is unclear how significant stress is in the activity of this condition. Affected individuals do report flares during periods of stress. This is generally one of the most difficult variables to control, however so, it is usually not very helpful to the patient to focus on this factor. There is not generally a role for antidepressants in children with alopecia areata. Hair care practices are not thought to be the cause of alopecia areata, although traumatic practices can additionally weaken residual hair, leading to easy breakage and the impression of additional hair loss.

9.
(A)
Exclamation point hairs are short hairs found at the periphery of the areas of alopecia that are very narrow at their base and wider at the distal end. It is thought that these changes may be the effect of the dense perifollicular lymphocytic infiltrate that is observed microscopically on biopsies from active areas of alopecia areata. Question mark hairs do not exist. Trichoschisis refers to hairs that are split because of trauma, and bubble hair refers to hair shafts that develop bubbles as the result of trauma from heat (blow dryers, curling irons). Hair casts are bits of keratin that adhere to hair shafts and can be mistaken for the nits of a lice infestation.

10.
(B)
Alopecia areata is a waxing and waning condition that may improve spontaneously; therefore, the direct effect of treatment is hard to document. Likewise then, observation is an acceptable option. Intralesional administration of corticosteroids has been very effective for some individuals and may work when the areas involved are limited in size and extent. However, most young children do not react favorably to this option. Potent topical steroids have been effective for some people and are more acceptable to children, especially early in the course of the disease. Calcineurin inhibitors have not shown to be effective for this condition.

11.
(C)
It is believed that autoimmune conditions tend to cluster in families and individuals. Therefore, in the setting of alopecia areata, it is important to consider the possibility of coexistent autoimmune diseases. Thyroid function tests are often ordered because this is such a common autoimmune disease. An ANA is not recommended as a screening test in this setting. Iron deficiency has been associated with global hair thinning but is not likely a factor in alopecia areata. A CBC is not necessary for screening unless other symptoms are present. A glucose tolerance test is not indicated unless other findings are present to suggest diabetes.

12.
(D)
The findings are most suggestive of trichotillomania. One is obligated to ask the patient and her parents about any habits involving hair pulling or twisting, although very often no one will admit to having observed this behavior. The hair manipulation may be occurring in private, or during sleep, so very often the family is truly unaware of it. The patient often is not fully cognizant of what is occurring. It often takes multiple visits to convince families of this difficult to accept diagnosis.

13.
(D)
No further workup is indicated when the findings are diagnostic.

14.
(C)
The most successful management of trichotillomania involves behavior modification techniques, which are probably most effective in conjunction with a therapist. There are self-help books written for children to help them to break this habit if they are motivated and have the insight to recognize the problem. The condition is classified as an obsessive-compulsive disorder.

15.
(A)
SSRIs have been used in the management of trichotillomania, but most authors suggest that this is most successful in conjunction with behavior modification techniques. Treatment is similar to other obsessive-compulsive disorders, and patients may have periods of improvement and periods of regression. Intralesional corticosteroid injections are a treatment for alopecia areata. Permethrin cream rinses are used in the treatment of head lice. Ivermectin has been advocated for the treatment of scabies in some settings.

16.
(B)
The patient is describing a telogen effluvium: a sudden loss of more telogen hairs than is typical. It is normal to lose up to 100 telogen hairs daily. Telogen effluvium can occur for numerous reasons, including following a significant illness, surgery, postpartum, following a significant psychological stress, such as a death in the family, secondary to medications, in the setting of lupus or thyroid disease, as a result of iron deficiency, or in the setting of nutritional deficiency resulting from erratic dieting. It is sometimes difficult for a clinician to appreciate the degree of hair loss that concerns the patient. Gentle hair pull tests in the office can be helpful. Additionally, asking patients to collect the hair lost in the normal course of hair styling can provide objective evidence of the degree of loss.

17.
(C)
Ferritin levels may be low in women who otherwise have a normal hemoglobin level. It has been observed that ferritin levels less than 40, although often reported by labs as normal, may still have an effect on hair shedding, and therefore iron supplementation may be indicated. Some authors advocate screening thyroid studies and ANA for all patients with hair loss, but unless the patient is additionally symptomatic it is unclear what one would do with an abnormal value in this setting.

18.
(C)
Birth control pills are well-known causes of hair loss, and often this is a temporary phenomenon and does not indicate changing the type of birth control pill until the condition has been followed for about 6 months. Other common medications causing hair loss are beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, some anticonvulsants, lithium, and retinoids.

S
UGGESTED
R
EADING

Friedlander SF. Fungal infections. In: Schachner LA, Hansen RC, eds.
Pediatric Dermatology.
3rd ed. Edinburgh, United Kingdom: Mosby; 2003:1093-1100.

Harrison S, Sinclair RL. Optimal management of hair loss (alopecia) in children.
Am J Clin Dermatol.
2003;4(11):757-770.

Norris D. Alopecia areata: current state of knowledge.
J Am Acad
Dermatol.
2004;51(1 suppl):S16-17.

Tay YK, Levy ML, Metry DW. Trichotillomania in childhood: case series and review.
Pediatrics.
2004;113(5):e494-498.

CASE 21: A 6-MONTH-OLD BOY WITH BIRTHMARKS

A 6-month-old Hispanic boy presents for routine child care. His parents report no concerns, but do note that they are becoming more aware of birthmarks on the child’s skin. They feel that the spots were present at birth but are getting larger and perhaps more numerous. They believe that there is no associated symptomatology.

On examination, the child is well appearing and vigorous, but not able to sit independently. Over the trunk and extremities there are about 8 tan-brown welldemarcated patches measuring 5-10 mm in diameter (
Figure 21-1
).

FIGURE 21-1.
See color plates.

1.
This patient is most likely at increased risk for

(A) melanoma

(B) optic glioma

(C) retinal phakomas

(D) periungual fibromas

(E) basal cell carcinoma

2.
Multiple café-au-lait macules may be seen in all of the following except

(A) Bloom syndrome

(B) neurofibromatosis

(C) McCune-Albright syndrome

(D) Sturge-Weber syndrome

(E) Turner syndrome

3.
Further skin evaluation of this patient is most likely to reveal

(A) axillary freckling

(B) a Shagreen patch

(C) ash leaf spots

(D) periungual fibromas

(E) mucosal lentigines

4.
Additional workup at this stage should include

(A) renal ultrasound

(B) head MRI

(C) cutaneous examination of family members

(D) echocardiogram

(E) skin biopsy

5.
Additional diagnostic criteria might be identified by a consultative visit to

(A) an ophthalmologist

(B) a nephrologist

(C) a cardiologist

(D) a gastroenterologist

(E) a podiatrist

6.
Examination of older patients with this disorder often reveals scattered soft flesh-colored papules (
Figure 21-2
). This finding most likely represents

(A) nevi

(B) epidermal cysts

(C) angiofibromas

(D) neurofibromas