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Differential Diagnosis & Pitfalls

• Tinea capitis – Acute presentation with patchy hair loss associated with pruritus. Physical examination shows erythematous patches with scale and black dots indicating broken hair shafts. Kerions are common in patients aged 5-10 years. Posterior cervical lymphadenopathy increases suspicion of the diagnosis.
• Alopecia areata – Well-demarcated hair loss, often in round and band-like distributions.
• Anagen effluvium – Acute onset hair loss days to weeks after an inciting event. Significant alopecia results, as approximately 90% of hair is in anagen at a given time.
• Telogen effluvium – Acute onset hair loss usually occurring 3-4 months after an inciting event. A positive hair-pull test is suggestive of the diagnosis.
• Trichotillomania – Presents as focal patches of non-scarring alopecia with irregular borders and broken hair shafts of varying lengths.
• Traction alopecia – Examination commonly shows hair loss along the temporal hairline with fringe sign and tenting of hair follicles.
• Discoid lupus erythematosus – Erythematous scaly plaques that lead to scarring alopecia on the scalp. Uncommon in the pediatric population.
• Drug-induced alopecia
• Loose anagen syndrome
• Hypotrichosis simplex – Possible genetic basis, presents with sparse or normal hair at birth with onset of hair loss at puberty.
• Marie-Unna hypotrichosis – Autosomal dominant inheritance, presents as sparse hair at birth with further hair loss during puberty.
• Monilethrix – Possible genetic basis, presents as sparse hair that grows slowly.
• Short anagen syndrome – Presents as abnormally short hair in children aged 2-4 years with positive hair-pull test.

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