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Halo Scalp Ring
A Case Series and Review of the Literature
Elizabeth L. Tanzi, MD;
Robin L. Hornung, MD, MPH;
Nanette B. Silverberg, MD
Arch Pediatr Adolesc Med. 2002;156:188-190.
ABSTRACT
Background Halo scalp ring is an uncommonly reported alopecia of the scalp that
arises perinatally.
Objectives To describe 5 new cases of halo scalp ring, and to review the literature.
Setting An outpatient dermatology clinic in an urban area; patients diagnosed
in a 2-year period were included in the study.
Results Halo scalp ring is most commonly a temporary, nonscarring alopecia that
occurs in patients born to primigravidas.
Conclusions Halo scalp ring is a distinctive form of alopecia attributed to caput
succedaneum. It is underreported and generally has a good prognosis. However,
scarring may occur.
INTRODUCTION
UNUSUALLY prolonged pressure on the vertex of the scalp by the cervix
during a difficult delivery, often in primigravidas, may result in caput succedaneum,
a common birth injury associated with contusion and, rarely, necrosis of the
scalp. Caput succedaneum consists of soft tissue swelling and bruising that
often resolve in several days without sequelae. However, hair loss may occur
as a consequence of pressure necrosis. This alopecia has been called halo
scalp ring.1-2 Although usually
a temporary defect, scarring has been reported.1-5
We describe 5 cases of this distinctive annular alopecia and provide a review
of previously reported cases.
PARTICIPANTS AND METHODS
Four cases of halo scalp ring were diagnosed in the pediatric dermatology
clinic at St Luke's–Roosevelt Hospital Center, New York, NY (cases 1-4),
and 1 case was diagnosed at Children's Memorial Hospital, Chicago, Ill (case
5). These cases were seen from March 1999 to March 2001. A MEDLINE review
of the literature, in English and other languages, yielded 5 reports (6 cases)
of halo scalp ring.
PATIENT REPORTS
PATIENT 1
A 2-year-old boy had localized hair loss noticed shortly after birth.
The patient was born to a 24-year-old primigravida who underwent 20 hours
of labor prior to vaginal delivery. At birth, caput succedaneum was noted
by the pediatrician. On examination, the child had a well-defined ring of
nonscarring alopecia (Figure 1). The parents shaved the child's head below the ring of thinned hair in an effort
to make the hair loss less noticeable. Reexamination of the patient at age
4 years revealed complete resolution of the hair loss.
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Figure 1. A 2-year-old boy with a ring of
nonscarring alopecia.
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PATIENT 2
A 6-month-old boy had an area of alopecia noted at birth. The child
was the product of a full-term pregnancy and was delivered vaginally to a
27-year-old primigravida. The pregnancy had been uncomplicated, and the mother
took no prenatal medications. At delivery, mild bruising of the scalp with
caput succedaneum was documented. The child was referred to a dermatology
clinic for atopic dermatitis. On examination, the child had linear patches
of nonscarring alopecia in an annular configuration around the vertex of the
scalp (Figure 2). The hair loss
improved over the next several months.
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Figure 2. A 6-month-old boy with linear
patches of annular, nonscarring alopecia.
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PATIENT 3
A 2-month-old girl had localized alopecia perinatally, which progressed
in size for the first month of life. The patient was a 2.64-kg term infant,
delivered by cesarean section because of failure to progress. The mother,
a primigravida, denied taking any prenatal medications, including methimazole.
Periocular edema and a large caput succedaneum were noted at birth by the
pediatrician (Figure 3). The alopecia
had a "chevron" shape consisting of 2 linear bands on the parieto-occipital
area. Hair regrowth was seen over the next 6 months.
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Figure 3. A 2-month-old girl with alopecia
in a chevron shape.
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PATIENT 4
A 4-month-old boy born vaginally to a 22-year-old primigravida had a
linear pattern of thinned hair noted shortly after birth. No complications
were documented in the medical record. However, the labor had been more than
20 hours. The parents recalled the child having some molding of the head.
On examination, nonscarring hair loss in a linear, bandlike pattern was seen
at the vertex of the scalp.
PATIENT 5
A 6-month-old girl came to a dermatology clinic with hair loss seen
shortly after birth. The patient was born vaginally and without complications
to a primigravida. A caput succedaneum was present at birth. Symmetrical thinning
of the hair in a circular pattern around the parieto-occipital area was noted
at age 2 months.
COMMENT
Halo scalp ring is a diagnosis that has never before been reported in
the pediatric literature. Five reports (6 cases) have been described in the
dermatology literature.1-5
This type of alopecia is forme fruste of caput succedaneum and represents
a pressure necrosis phenomenon of the neonatal scalp at the rim of the cervical
os. Pressure necrosis with caput succedaneum is a result of prolonged pressure
leading to reduced blood flow and hypoxic-ischemic tissue damage.6-7 A halo scalp ring can be as wide as
9 cm and may manifest as full-thickness necrosis or just mild alopecia, as
seen in our patients. A review of the literature reveals that cases of permanent,
scarring alopecia are associated with premature rupture of membranes and a
hemorrhagic, necrotic caput succedaneum (Table 1). Caput succedaneum is more common with prolonged labor
in primigravidas. This clue can aid the diagnosis of halo scalp ring.
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Previously Reported Cases of Halo Scalp Ring*
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Halo scalp ring is a diagnosis that requires no further investigation
for congenital anomalies. However, it mimics other causes of scarring alopecia
of infancy, which can be worrisome and require extensive evaluation.8 Traumatic and pressure necrosis alopecias may also
be related to the birthing process or perinatal care, such as fetal scalp
monitors or lack of positional movement.9 These
diagnoses can be excluded easily based on location and shape of the alopecia
and ulcerations, as well as history of the traumatic event.
The incidence of halo scalp ring is unknown, but it is most likely underreported,
as we observed 5 cases over 2 years. We posit that the diagnosis is often
not made because halo scalp ring has not been reported in the pediatric literature
and is therefore not familiar to pediatricians. Furthermore, referrals to
a pediatric dermatologist may not be made because the hair will often regrow
with time. Three of our patients and 2 patients in the literature2 had complete regrowth in a few months to years.
Recognition of halo scalp ring can prevent unnecessary work-up. Halo
scalp ring is a benign process that has no systemic associations and does
not warrant further investigation. Although the natural course of the alopecia
is gradual regrowth, a hemorrhagic or necrotic caput succedaneum present at
birth may portend a poor prognosis because deep ulceration can destroy hair
follicles, resulting in scarring alopecia. Autologous keratinocyte grafts
can be used to treat large ulcerations, although this will not improve the
associated hair loss. Observation is the most appropriate initial therapy,
and tissue expansion and surgical excision should be considered for any residual
areas of scarring alopecia at school age to prevent the psychological trauma
that can occur in children with cutaneous abnormalities.
| What This Study Adds
Halo scalp ring is an annular scalp alopecia that appears in the first
year of life. Pediatricians are not familiar with this form of alopecia because
reports have not appeared in the pediatric literature.
We describe 5 patients with halo scalp ring. The alopecia develops because
of pressure of the cervical os on the scalp and is associated most commonly
with a history of prolonged labor and caput succedaneum. While permanent scarring
and scalp necrosis may occur, 3 of our patients had complete hair regrowth.
We believe that halo scalp ring is common in infants and that it is important
for pediatricians to be aware of this form of alopecia.
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AUTHOR INFORMATION
Accepted for publication October 8, 2001.
Corresponding author: Nanette B. Silverberg, MD, Department of Dermatology,
St Luke's–Roosevelt Hospital Center, 1090 Amsterdam Ave, Suite 11D,
New York, NY 10025 (e-mail: nsilverberg{at}slrhc.org).
From the Department of Dermatology, St Luke's–Roosevelt Hospital
Center, New York, NY (Drs Tanzi and Silverberg); and the Department of Dermatology,
Seattle Children's Hospital, Seattle, Wash (Dr Hornung).
REFERENCES
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3. Beutner KR. Halo ring scarring alopecia. Pediatr Dermatol. 1985;3:83.
4. Prendiville JS, Esterly NB. Halo scalp ring: a form of scarring alopecia. Arch Dermatol. 1987;123:992-993.
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6. Smits TM, Aarnoudse JG. Variability of fetal scalp blood flow during labour: continuous transcutaneous
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9. Gershan LA, Esterly NB. Scarring alopecia as a consequence of hypoxaemia-hypoperfusion. Arch Dis Child. 1993;68:591-593.
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THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Serious Sequelae of Perinatal Scalp Injury
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AAP Grand Rounds 2007;17:29-29.
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