CASE
A 10-year-old boy was referred to dermatology for evaluation of a 4-month history of hair loss that had grown large enough to alarm his mother, who accompanied him to the clinic. The child's primary care provider had diagnosed alopecia areata and prescribed 0.1% triamcinolone solution. After a month, the patient experienced even more hair loss.
The patient had no family history of alopecia areata or other autoimmune diseases. The child was under the care of a psychiatrist for attention-deficit disorder and chronic anxiety, for which he was taking two medications the mother could not name. He was otherwise healthy. The mother denied the presence of any skin changes in the area, and the patient denied any symptoms associated with the condition. However, the patient's mother emphasized the fact that she had seen her son manipulating the area with his hand on several occasions, despite her attempts to make him stop. When pressed, the patient admitted that he twirled and pulled on his hair many times a day, though he denied actually pulling hairs out.
On inspection, an 1138-cm oval area of distinct and sharply demarcated hair loss was noted in the vertex of the scalp (Figure 1). Many hairs of different lengths with thin, tapering ends were noted in the central portion of the site. There was no scaling, redness, or edema, but the area was a dark brown shade. No other areas of hair loss were noted on the scalp or face.
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