The pattern of a child's hair loss is the first clue
Hair on a pillow or in a brush is not a diagnosis by itself. Ask whether there is one defined patch or thinning across the whole scalp. Is hair coming away from the root or breaking at different lengths? Is the skin smooth and normal, or scaly, red, itchy or painful? Have the eyelashes, eyebrows or nails changed? History and examination help the clinician classify loss as focal or diffuse and scarring or nonscarring; that is more useful than counting every shed hair [1, 2, 7, 8].
During the first months of life, losing some newborn hair is common and may be most visible at the back because of the hair cycle and friction; it usually grows again. A patch present from birth, shiny or scarred skin, or continuing loss beyond infancy deserves assessment [1]. In an older child, take a photograph about every two weeks in similar light without pulling the hair, and note when the change began, recent illness or fever, new medicines and tight hairstyles. Do not perform a forceful pull test at home because fragile hair may break and confuse the pattern. Most childhood causes are nonscarring and can be managed once identified, but the word “shedding” alone cannot select the right treatment [2, 7, 8, 11].
A scaly patch with broken hairs: scalp ringworm matters
Tinea capitis, or scalp ringworm, is a fungal infection seen mainly in preschool and school-age children. It may cause a grey scaly patch, diffuse scale that resembles ordinary dandruff, black dots where hairs have broken at skin level, itch, or enlarged glands at the back of the neck. It does not always form a clear ring and can be mistaken for eczema or dandruff. An inflammatory form can produce a tender boggy swelling called a kerion, sometimes with discharge; substantial delay in an inflamed case increases the risk of scarring and permanent loss [2, 3, 9].
Infection can spread through close contact, shared combs, hats or towels, and sometimes from an infected animal. Do not share personal items, clean combs as the clinician advises, and seek veterinary assessment if a pet has missing-fur patches. Antifungal shampoo or cream alone cannot reach infection inside the hair root. Scalp ringworm generally needs an oral medicine selected by the clinician for the child and likely fungus, with shampoo sometimes added to reduce spread [1, 3, 9]. The clinician may use a dermatoscope, examine hairs and scale with potassium hydroxide, or request fungal culture. Do not apply a steroid or oil mixture to an inflamed patch before assessment because its appearance may briefly settle while the cause remains. A painful boggy swelling, pus, fever, or a child who seems unwell needs prompt same-day assessment [2, 3].
A smooth patch without scale: alopecia areata is not an infection
Alopecia areata occurs when the immune system attacks hair follicles. It usually causes one or more round or oval smooth patches without scale or pus. A clinician may see short hairs that narrow toward the scalp or fine pits in the nails. It is not contagious, is not caused by poor hygiene and is nobody's fault. It can involve eyelashes, eyebrows or a larger scalp area, and its course is difficult to predict: many children regrow hair, but new patches or recurrence can occur [1, 4, 5].
A paediatrician or dermatologist can often recognize the pattern by examination and dermoscopy; biopsy is rarely required in a child. Blood tests are not a fixed panel for every case. They are selected when the history or examination suggests an associated issue such as thyroid disease or a specific deficiency [2, 5, 7]. Observation or treatment depends on the child's age, extent and duration of loss, affected sites and impact on the child. Watching a recent limited patch may be appropriate, whereas a dermatologist may discuss topical or other options for broader disease. Do not use an adult's medicine, minoxidil or a steroid without clinical direction. Ask the child calmly about comments or bullying and give them a voice in how the patch is handled; psychosocial support is a real part of care rather than an optional extra [2, 5].
Traction, breakage and hair pulling have different patterns
Repeatedly tight braids, buns and ponytails can cause traction alopecia, especially along the hairline and sides. Pain or scalp stinging during styling means it is too tight. At an early stage, reducing tension, changing the position of styles and allowing hair to rest gives recovery a chance; long-standing traction can scar and become permanent. Choose more comfortable styles, undo a painful style immediately, and reduce heat or chemical straightening on breaking hair [1, 6, 12]. This does not mean banning every braid; it means comfort matters more than a fixed style repeated every day.
Trichotillomania produces irregular patches containing broken hairs of different lengths, often over normal-looking skin. A young child may twist or pull without awareness while falling asleep or concentrating, whereas an older child may hide the behaviour through embarrassment or stress. Do not punish the child or turn the visit into an interrogation. The clinician first distinguishes pulling from fungal infection, alopecia areata and other causes of breakage, then considers behavioural or mental-health support according to age and impact [1, 2]. Breakage can also follow repeated heat, friction or rough handling of wet hair. Missing eyebrows or lashes, skin wounds, eating pulled hair, abdominal pain, or a clear effect on school or mood should be mentioned honestly so care can be safe and coordinated [2, 8].
Diffuse shedding after illness or with a health problem
Telogen effluvium causes thinning across the scalp rather than one clear bald patch. It often begins some time after a high fever, significant illness, surgery, physical stress or nutritional change; the delay between trigger and shedding makes the connection easy to miss. The scalp itself usually looks normal and new growth appears gradually as the hair cycle settles, but assessment must distinguish this pattern from breakage or another emerging cause [1, 2, 7, 8]. Record illnesses, medicines and changes over the preceding months instead of focusing only on the last few days.
Iron deficiency is one possibility, not the automatic explanation for every shed hair. Pallor, tiredness, a very restricted diet or heavy periods in an adolescent may make testing reasonable, and our guide to iron deficiency in children covers symptoms, tests and treatment without duplicating that topic here [2, 8, 11]. Slower height or weight gain, chronic diarrhoea, recurrent abdominal pain, altered puberty, thyroid symptoms or chronic illness direct attention to the child's overall health; reading a child's growth curve as a trajectory, not one number can help you gather earlier measurements before the visit. A clinician may choose a blood count, ferritin, thyroid studies or other tests according to the history and examination, not as a fixed panel for every child [2, 7, 8]. Do not start iron, zinc or a vitamin merely because hair appears in the brush; need and dose must be established first.
The examination selects tests and treatment, not the reverse
At the visit, the clinician asks when loss began and how quickly it changed, about illness, fever or surgery, medicines and supplements, food, growth, menstruation in an adolescent, family history, hairstyles, itch and pulling habits. Examination includes the scalp, hair, eyebrows, lashes, nails and skin, and may include height, weight and general signs. Dermoscopy, a gentle pull test and fungal sampling are selected according to the pattern; biopsy or broad blood testing is not the routine first step for every child [2, 7, 8, 12]. Bring progress photographs, the names of every product and medicine, and earlier results rather than starting something new before the appointment.
Treatment follows the cause: a clinician-selected oral antifungal for confirmed or likely scalp ringworm, reduced tension for traction, behavioural support for pulling, or a dermatology plan for alopecia areata [1, 2, 3, 5, 6]. A varied diet supports health, and our article on iron-rich food for children offers practical ideas when eating is limited, but it is not a prescription for every type of loss. Biotin supplements are promoted for hair despite limited evidence in people without deficiency, and high doses can produce false results in some laboratory tests, including hormone tests; tell the clinician and laboratory about every supplement [10]. Oils and mixtures can also irritate skin or delay diagnosis. Use gentle shampoo, detangle carefully, and avoid pulling and heat while the cause is clarified, without promises about a fixed date for regrowth.
When should you book, and when is it urgent?
Arrange a timely appointment for a new bald patch, persistent diffuse shedding, unexplained breakage, itch or scale that does not settle, loss of lashes or brows, or an effect on the child's wellbeing or school life. Assessment also matters when loss accompanies pallor, tiredness, weight loss, slowing growth or chronic symptoms. Shiny or scarred skin, rapid loss over a large area, or failure of previous treatment merits faster dermatology review because some uncommon causes can damage follicles if diagnosis is delayed [2, 7, 8].
Seek same-day assessment for a tender boggy scalp swelling, pus, spreading redness, fever, or a child who looks unwell; this could be inflammatory ringworm or another infection needing prompt care [2, 3, 9]. Follow local emergency services for breathing difficulty, facial swelling after a product or medicine, fainting, profound lethargy, or rapidly worsening general condition; the acute illness takes priority over the hair. At the clinic, you can begin by requesting a paediatric and nutrition appointment so the pattern and the child's general health can be reviewed. The treating clinician decides whether fungal sampling, targeted blood tests or dermatology referral is appropriate. Bring photographs, earlier growth measurements, and medicine and supplement names, and do not stop a prescribed medicine before asking its prescriber [1, 2].
