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Evaluation and Management of Pediatric Patients with Alopecia Areata
Evaluation and Management of Pediatric Patients with Alopecia Areata
Evaluation and Management of Pediatric Patients with Alopecia Areata
Evaluation and Management of Pediatric Patients with Alopecia Areata
Announcer:
Welcome to ReachMD.
This medical industry feature, titled “Evaluation and Management of Pediatric Patients with Alopecia Areata” is sponsored by Pfizer Medical Affairs. This video is for U.S. residents only and is intended to be viewed as it was originally produced by Pfizer. The information provided is for educational purposes only and is not intended to replace discussions with a healthcare provider.
Pfizer does not have an FDA approved treatment for Alopecia Areata.
Drs. King and Craiglow are consultants for Pfizer.
Dr. Brett King:
Hello, everyone. I'm Dr. Brett King, associate professor of dermatology at the Yale School of Medicine in Connecticut. In the past episode of this discussion series called "Alopecia Areata: Misperceptions and Facts", we discussed some common misperceptions of alopecia areata and reviewed the potential underlying autoimmune mechanisms. I'm excited to have Dr. Brit Craiglow with us today to discuss the evaluation and management of pediatric patients with alopecia areata.
She is a renowned pediatric dermatologist who specializes in this disease. Dr. Craiglow, please tell us about yourself and your background. Tell us about your clinical practice, in particular, how many patients do you see with alopecia areata?
Dr. Brittany Craiglow:
Thanks so much for having me. Yes, I have found myself seeing a lot more alopecia areata over the past several years. My practice has become largely, actually, a hair loss practice. So I see children, primarily children, some adults from all over, with mostly severe alopecia areata, but also some patients with more, more mild disease.
Dr. Brett King:
Well, that's great. Thank you for the introduction. Can you give us a little bit more? How did you get into this?
Dr. Brittany Craiglow:
Yeah. I mean, this, this really happened very organically. I certainly did not set out to, to be someone who takes care of hair loss patients. But, you know, there's a huge unmet need there. And you start seeing patients, you kind of learn how to do it. You try things and then more patients come your way. So this is a population, I think that, you know, often unfortunately feels dismissed and they're told that there's nothing to do for you. But, you know, it is, it's really rewarding. It's a good challenge, and I love the relationships I get with these patients and their families over time.
Dr. Brett King:
Yeah, I ask that question because I think, the you know, the epidemiology of alopecia areata, you know, tells us that, you know, possibly about 2% of the population is affected over their lifetime.
But my impression of your practice is that, is that, actually, there are a lot of people out there. And I think, as there is more and more advancement and innovation and understanding of this disease, that, that just like in your practice, we're all going to be seeing more of these patients. In previous discussions with Dr. Jerry Shapiro and Dr. Melissa Piliang, we discussed the various ways alopecia areata presents in adults. And alopecia areata commonly presents in children
We again, kind of going back to the epidemiology, right? We know that, you know, probably in the majority of people, presents in the first, you know, three decades of life, certainly the first four decades of life. And so that means that there's a lot of... a lot of disease in children And so, can you tell us a little bit how does AA present in these age groups? And, are there differences in the presentation of disease in adult versus pediatric populations?
Dr. Brittany Craiglow:
Yeah, I think AA in kids is really similar to that in adults in that it's very heterogeneous. You know, we can see kids with a patch or two and then we have children who have complete hair loss.
And as we often say, really the only predictable thing about the course of disease is that it's unpredictable. So, one thing I do think that I see maybe a little bit more frequently in children is the diffuse form of alopecia areata. So it's sort of just this mild, generalized thinning, which I think can sometimes go unnoticed. And perhaps it actually is more common than we think but people just sort of think it's the way their child is, they have thin hair.
But I see that not infrequently. And I have to say, I think that actually tends to be a little bit easier to treat. But usually it's a clinical diagnosis. It's really uncommon that, you know, we need to do a skin biopsy. Sometimes, you know, there will be a question of hair pulling.
And I will say that that is something to think about,. A lot of kids will be brought in and they'll have a patch of hair loss or relative hair loss, and their family will describe them kind of touching their hair or twirling it more often. And there is a question of are, you know, is this, is this hair pulling?
And oftentimes it's alopecia areata, but that's sort of a that's a sign of it in kids. You know, anybody with AA can actually have a sensation when they're losing hair. And I think in children, you know, that presents as them touching their scalp more often or twirling. So they're feeling the sensation, but not maybe able to kind of verbalize it and that leads to them, you know, manipulating the hair.
Dr. Brett King:
This concept that alopecia areata, that presents early in life, that it has a poor prognosis, do you agree with it? Can you tell us a little bit more?
Dr. Brittany Craiglow:
Yeah. I mean, I think what's hard is that, you know, we really aren't able to predict the future in these patients. I would say that kids who present with severe disease at a young age, they're intuitively just kind of make sense, right? They're more likely to have a prolonged and chronic course. There are other things, I think, that are useful to kind of, to also look at, to maybe help, you know, prognosticate for patients.
Do they have associated atopy? Do they have nail changes? Is there a family history? Like, those are all things and often when I see a patient, you know, I say, okay, you have in this sort of negative prognostic, prognostic bucket, you have that this is an early onset and tends to be more chronic. But your child is not atopic. She doesn't have nail pitting.
It's relatively mild at this point. So those are some of the things that we look at, but it is, it's really I think that's one of the hardest things as a physician, but also for patients and their families that it's, you know, there's so much unknown. But for sure, if a patient has severe disease at a early age, that's a patient who I'm more concerned about and thinking about treating more aggressively earlier, earlier on.
Dr. Brett King:
Yeah. And something else that you, that you just commented about, you said "the patient and their family". I'm really, I'm, I'm really interested in this. You know, we, we know we're going to talk more about this. But, you know, the effect that alopecia areata has on patients. I think, speaking to you, we, we have a unique, you know, insight or possible insight into how this disease can affect the family as well.
Dr. Brittany Craiglow:
Yeah. I mean, for sure. When a child has alopecia areata, the whole family has it, really. And I think that, oftentimes, in children, it's a lot harder on the parents, actually, than it is on the child. And, you know, I think it starts to affect the child probably earlier than most people might think.
But self-esteem is kind of largely being formed by age four or five years old. But one of my kind of guiding principles is that we need to treat the patient and not ourselves, meaning not me and not the parents. And if we have a, you know, a two year old in front of us who has, you know, significant AA, but they're really unaware and it's not affecting their life, well, then maybe that's a child we, we pause on therapy or do something more benign initially.
But I think what's so, so useful now is that we have hope for these patients in a totally different way. You know, ten years ago when I met these families, it was not a fun discussion.
You know, it was sort of like talking about coping and support groups and all these things. And now all of a sudden, it's like, well, this might not be the time, you know, that we're going to treat. But if and when this becomes more severe, like all of a sudden we have options. And so that has really, you know, changed, changed that interaction, I think, for the better.
And there's, you know, there's actually hope in a way that there wasn't previously. But I do think it's really important to always remember to treat the patient, right? And how is that patient experiencing the alopecia areata? Is it changing the way they interact with the world in a meaningful way? And sometimes it is more than parents even realize, right?
So sometimes it's the parents who are more interested in treatment, sometimes it's the child. A lot of times it really, everybody kind of gets it, it's important. But I think understanding how it's sort of affecting everybody is really useful and an important part of our, you know, of our kind of shared decision making.
Dr. Brett King:
Yeah. And, and I love that, that, that you, you've framed that as, you know, these are the things that we all need to know. What are the other things that we need to know? You know, thinking about the clinical presentation and the diagnosis in the pediatric age group, what do, what do providers need to know? What can we learn from you?
Dr. Brittany Craiglow:
So, you know, I think usually, again, this is going to be a clinical diagnosis. I, for me, I find dermoscopy to be really helpful, actually, especially in those cases that may be more subtle, more, you know, thinking about diffuse alopecia areata or ruling out, you know, concomitant hair pulling. So this is something I always tell the residents start, you know, when you know, someone has alopecia areata, look at it with your dermatoscope.
And that way you're going to be able to start to identify those features so that when you have someone where you're not sure, then you can know what you're actually looking for, right? So exclamation mark hairs, yellow globules, which are representing open follicles. These are, you know, common features that we see and, you know, can help in the diagnosis.
I always want to look outside the scalp also, right? You want to look at eyebrows and eyelashes, you know, hair on the extremities, look for nail pitting. Ask about family history, is there a family history of autoimmunity? Anyone else have AA? These are kind of all things that help you. Again, it's usually going to be really straightforward, but in those cases that maybe it's a little trickier, you may be able to avoid a biopsy actually by kind of looking at these other areas or using your dermatoscope.
Dr. Brett King:
And how often you need, how, how often is the clinical exam with your dermatoscope, you're bringing all of your, you know, all of your kind of simple, if you will, tools are simple as long as you know how to use them. But you bring all of your your clinical acumen and you're still unsure and you need to do a biopsy in a child.
How often, how often do you think that happens?
Dr. Brittany Craiglow:
I would say it's extraordinarily rare. I mean, I can't actually remember the last time I've needed to do, you know, a biopsy. I think the one cases, you know, maybe where there is hair pulling, you know, I have to say, I've actually seen concomitant alopecia areata and pulling. You can actually see features of both on, on dermoscopy.
I think oftentimes because there is this little sensation. But I mean, I, I almost never have to do it. And I think that's... that's great because, you know, scalp biopsy is not really fun for anybody, but especially a child. And this is going to be a child who probably is going to be having multiple visits to my office.
And so, if we color their experience right away with it, you know, a needle and discomfort and having to go back for sutures and all that kind of stuff, it can really make make it a lot harder. So we try to avoid it when we can. Of course, you know, if you really aren't sure, then, you know, it's not unreasonable. We do, you know, try to avoid it more, I think, in kids than in adults.
Dr. Brett King:
When you think about, you know, the patient who comes in, you referred a little bit to this patient earlier. But you know, sort of, like, you know, kind of mild but, you know, diffuse and, you know, there's hair pull test, maybe sort of weakly positive diffusely. Do you struggle with separating telogen effluvium from alopecia areata in that patient or in some other patient?
Dr. Brittany Craiglow:
Yeah, I think personally, I think that telogen effluvium is probably overdiagnosed. I don't think it's really very common in children at all. And you know, really most of these patients who have, you know, in TE, usually, if it happens, there's going to be a pretty clear history of some, you know, clear change in health status preceding this really rapid increase in shedding.
And I think, you know, there's where dermoscopy is really useful. And I, and I don't think I've ever had a patient with true diffuse alopecia areata, no matter how mild, where I wasn't able to see exclamation mark here under the dermatoscope, or some nail pitting, or there was a family history, something else to kind of to, to guide that.
Dr. Brett King:
Yeah. It's interesting to hear you, to hear you sort of comment how rarely you, you do a biopsy. I think I probably, you know, rely on a biopsy maybe 10% of the time. But I think the other part of it, as you point out, is we, we don't mind using that tool as much in adults. So, you know, I might not be relying on my other tools like dermoscopy as much as as you are.
Dr. Brittany Craiglow:
So the differential diagnosis in adults is usually broader, right? So, scarring alopecias in kids are extraordinarily unusual, especially in young children. And so I think, you know, a lot of times when we're doing a biopsy, it's a question of is, is this a scarring process or not? And that's not something we see very often, like really almost never in, in children.
And so I think that's also part of it is that our, you know, the differential is a lot more narrow.
Dr. Brett King:
Great. So, Dr. Craiglow, I just can't thank you enough for joining the program today. It's, you know, your insights, your experience are, are just so important for all of us to hear. And so, thank you so much.
Dr. Brittany Craiglow:
Sure. I mean, thanks so much for having me.
Dr. Brett King:
Thank you to everybody who tuned in. We really appreciate you doing so and hope that you are getting something out of this discussion series on alopecia areata. Thank you so much for your attention and please tune in to the next episode.
Announcer:
This program was sponsored by Pfizer Medical Affairs. If you missed any part of this discussion, visit Reachmd.com/IndustryFeature. This is ReachMD. Be part of the knowledge.
From pediatric presentation to misdiagnosis—find out what you need to know about alopecia areata.
Evaluation and Management of Pediatric Patients with Alopecia Areata
Evaluation and Management of Pediatric Patients with Alopecia Areata
Evaluation and Management of Pediatric Patients with Alopecia Areata
Alopecia areata (AA) can manifest in several different ways—especially for pediatric patients. To help us better understand this, Drs. Brett King and Brittany Craiglow dive into this disease and discuss pediatric care, the impact on the family, and how AA can be easily misdiagnosed.
Continuing medical education credits are not available for this program.
© 2022 Pfizer Inc. All rights reserved. PP-RIL-USA-0298 December 2022
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