Alopecia areata and suicide of children

To the Editor: Alopecia areata is the most prevalent human autoimmune disease.1 Hair follicle inflammation produces disfiguring circular patches of hair loss or total alopecia. Suicidal ideation is considered to be uncommon among people with alopecia areata.2 In 2011, there were four deaths of young Australian males affected by alopecia areata that were recorded by the coroner as suicide: two aged 14 years from Victoria, one aged 16 years from Queensland and one aged 17 years from Western Australia.

All four boys had been recently diagnosed with multifocal alopecia of the scalp. One had involvement of the eyebrows. There were no preceding psychological disorders and all were said to be popular among their peers and capable students. Social withdrawal and school avoidance began after the alopecia. All were under the care of a psychologist or psychiatrist at the time of death.

Suicide deaths of boys under the age of 15 years are rare. In Victoria, there were 12 such cases reported between 2007 and 2011.3 The age-specific rate is 0.4 per 100 000 population.3

The Australia Alopecia Areata Foundation provides an online registry of affected individuals.4 Between 2010 and 2012, there were 196 new registrations, including 22 males aged under 18 years. Among these, there were four suicides in 2011, and three boys aged 15–17 years are currently considered at risk of suicide by their psychiatrists.

Alopecia areata leads to a rapid and profound alteration in physical appearance. In boys with short hair, there is no opportunity to disguise hair loss. In contrast, young women with long hair may be able to conceal significant hair loss through hair styling.

Physicians should be aware that young men and boys with rapid-onset alopecia areata represent a particular at-risk group for self-harm and psychological distress. Common issues identified among young men and boys with alopecia areata include poor self-image, grief and loss, and sleeping disorders. The chronic relapsing nature of the condition, the unknown triggers and sudden, unpredictable relapse are major frustrations. Affected individuals commonly describe alopecia areata as a life-changing event.