What is alopecia?
Alopecia means hair loss which is a common problem which results in consultation with dermatologists to control the loss. Alopecia can be divided into scarring or non-scarring alopecia and localized or diffuse alopecia.
Diffuse non-scarring hair loss can be due to the commonest androgenic alopecia (male pattern hair loss) and also the female patter hair loss (fphl). Other causes include alopecia totalis (loss of all head hair), alopecia universalis (loss of all body hair including eyelashes and eyebrows), telogen effluvium (hair loss as the hair follicles are in telogen phase i.e. resting phase), secondary syphilis, medical conditions (thyroid diseases, SLE and iron deficiency), drug induced (e.g. chemotherapy drugs) and senile alopecia (hair loss due to ageing).
Localized non-scarring alopecia can be due to alopecia areata (patchy bald areas), trichotillomania (a psychiatric disorder whereby people has irresistible urge to pull out their own hair), syphilis and Tinea capitis (fungal infection of scalp).
Scarring alopecia can affect men and women; it involves inflammation processes and irreversible destruction of hair follicles which are replaced by scar tissue. The exact cause is not well understood. The different types of scarring alopecia are lichen planopilaris (LPP), frontal fibrosing alopecia, central centrifugal alopecia and pseudopelade of Brocq.
Normal Hair growth cycle
Before we proceed to discuss further, let’s understand what the normal growth cycle of a hair follicle is first. All hair follicles go through normal process of hair cycling. Hair growth cycle alternates between phases of rest and activity. The Anagen phase is the growth phase which lasts for two to six years. During the Anagen phase, the follicle is long and deep, and produces thick, well-pigmented hair. Approximately 90% of all scalp hairs are in the Anagen phase at any one time.
Anagen phase is the followed by a brief transition catagen phase, which lasts a few weeks. During this time, the base of the follicle shrivels. Then comes the telogen phase (rest phase) which lasts for two to four months. In this phase, the follicle withers further. After the telogen phase, the next anagen phase commences, and the old hair is dislodged and falls out to give way for a new hair to begin growing in its place.
Before the dermatologist can conclude the cause of the alopecia (hair loss), a detailed history, physical examination and laboratory tests will be carried out.
A good clinical history will aid the dermatologists to determine the possible causes of hair loss. Patient will be asked about the onset of hair loss (rapid or gradual), location of hair loss (localized or diffuse), quantity of hair loss, whether other body hair is also involved, nutritional deficiency status, recent illness/stress event, crash diet/anorexia symptoms, symptoms of thyroid diseases, detailed medication history, family history of hair loss, previous hair-care products/treatment, symptoms of polycystic ovarian syndrome in women, risk factors for syphilis and also symptoms of Tinea capitis.
Examine the pattern of hair loss to see if it is diffused pattern or localized hair loss and also whether there is any scar tissue.
Patients with androgenic alopecia (male pattern hair loss) will have vellus hair (fine, short hairs, not more than 1-2 cm long). The hair loss will be at the vertex, frontal and temporal region.
Patients with female pattern hair loss will have sparse hair over the crown area. Vellus hair may also be present.
Patients with alopecia areata will have bald patches. There will be exclamation mark hairs (short hairs with tapered ends towards the scalp). Hair pull test will be positive.
Patients with syphilis will have patchy baldness but no exclamation mark hair. Hair pull test will be positive. There will be other signs of syphilis like enlarged lymph nodes, genital ulcers, skin rash (palms and soles) and tongue ulcers.
Patients with trichotillomania will have irresistible urge to pull out hairs resulting in hairs of different lengths, hair loss pattern is often bizarre. Other hair like eyebrows and pubic hair may also be involved.
Patients with Tinea capitis can present as scarring or non-scarring hair loss. There will be patchy hair loss with short broken hairs.
Usually blood tests are not necessary unless other systemic diseases are suspected to be the cause of hair loss (alopecia).
1.Heamoglobin and ferritin levels to rule out iron deficiency anemia to be the cause of alopecia.
2.Thyroid function tests Free T4 and TSH levels to exclude thyroid disorders.
3.ANA to rule out auto-immune causes e.g. SLE.
4.RPR to rule out syphilis.
5.Blood testosterone and DHEA levels may be tested if suspected high androgen conditions like polycystic ovarian syndrome.
6.Trichogram may be used to determine the anagen: telogen phase ratio to aid diagnosis of telogen effluvium.
7.Scalp biopsy maybe performed if diagnosis is in doubt.
8.Fungal culture can be done if patient suspected to have fungal infection of scalp.
Any reversible medical conditions should be treated accordingly and the hair loss issue will improve. Any medications/drugs that could have caused hair loss should be stopped or kept to minimal effective dosage. As for other specific alopecia causes’ treatment will be discussed in details topic by topic below.
Treatment of androgenic alopecia
Androgenic alopecia is a male pattern gradual hair loss which usually involves the frontal, temporal and vertex area. The hair over occiput area is usually normal. Vellus hairs (fine, short hairs, not more than 1-2 cm long) are usually present. The degree of hair loss can be graded by the Hamilton- Norwood Grades 1 to 7.
Androgenic alopecia is a very common disorder affecting up to 50% of men with an onset before age 40. It is a cosmetic disorder which may be associated with benign prostatic hypertrophy and increased risk of myocardial infarction.
Causes of androgenic alopecia: Androgenic Alopecia is a genetically inherited disorder. It is also associated with the effects of dihydrotestosterone (DHT) on the scalp. DHT shorten the growth phase of hair follicles (anagen phase) from 3-6 years to weeks-months resulting transition of large, thick, pigmented terminal hairs to thinner, shorter, indeterminate hairs and finally to short, wispy, non-pigmented vellus hairs. The production of DHT is regulated by an enzyme called 5-alpha reductase.
Tests: Usually tests are not required as diagnosis is clinical. Unless patient present with more rapid hair loss and the hair pull test is positive then other medical conditions and telogen and effluvium maybe considered. Trichogram may be done to determine the anagen: telogen ratio. In telogen effluvium the increased telogen hair ratio is diagnostic.
1.Minoxidil solution (2% and 5%) can be used for men above 18 years old. It helps to maintain the current hair density and prevent further hair loss. It appears to work by lengthening the anagen phase. Hair regrowth will be observed by patients in 3-6 months after usage. If treatment is stopped then hair loss may recur after 3 months.
About 1ml of the topical solution is applied twice daily on dry scalp.
Local side effects include scalp itch, dryness, redness or scaling. The 5% solution will cause more itch than the 2% however the 5% solution promoted more hair regrowth. Try not to drip the solution onto face as it may stimulate facial hair growth.
2.Oral Finasteride 1 mg daily can be prescribed to patient above 18 years old. It is a 5-alpha reductase type 2 inhibitor which will slow progression of the male pattern hair loss and also induce hair growth. If discontinued, any hair regrowth will be lost within 12 months. Side effects include sexual dysfunction about 2 % in younger men (<40 years) and 8 % in older men (> 40 years) which will resolve after stopping treatment. Finasteride will also decrease the Prostate specific antigen (PSA) levels in men.
3.Hair Transplant: For those with high grade Hamilton grading > 5, hair transplant is a possible option. Patient needs to consult with a specialized dermatologist to determine suitability for procedure. Possible side effects are keloids, scarring and infection.
4.Cosmetic Modality: Hair Spray, Hair styling methods and wigs to cover the hair thinning areas.
Treatment of Alopecia Areata
Alopecia Areata are non-scarring round bald patches on the scalp that occur suddenly and at any age. The exact pathophysiology is unknown but theories have attributed it to be an autoimmune cause. It is a T cell mediated process and the antibodies target hair follicles and produce cytokines that inhibit hair growth. It may be associated with other autoimmune condition like Vitiligo, Thyroid diseases and Pernicious anemia. It is also common in people with Down syndrome.
There is also a genetic predisposition for alopecia areata. It can occur in more than one family member. Major stressful life events, pregnancy, drugs, trauma, febrile infections may also be triggering factors for alopecia areata. On examination there will be exclamation mark hairs (short hairs with tapered ends towards the scalp) and hair pull test will be positive over the hair thinning affected areas. There may be other hair loss involved like the eyebrows, axillary hair, beard and pubic hair.
On examination of the scalp with dermoscopy, there will be yellow dots (95% of cases), black dots, tapering hair and broken hairs. In severe form of alopecia areata, there will be nail involvement in 6.8-49.4% of cases. Nail pitting is commonly seen. Other not so common nail findings are leukonychia, red lunulae, koilonychia, onychorrhexis, onychomadesis, Beau Lines and trachyonychia.
Diagnosis is usually clinical. No laboratory tests are needed. If in doubt of diagnosis, scalp biopsy can be performed.
1.Intralesional Triamcinolone Injection: 0.05-0.1 ml of triamcinolone 10mg/ml with a maximum dose of 2 ml per site is injected into the affected scalp area. Possible side effects are pain on injection and mild transient atrophy. The procedure can be repeated every 4-6 weeks. For those who respond to treatment hair regrowth can be seen in 4-6 weeks. Hair growth may persist 6-9 months after injection.
2.Topical Corticosteroids: It is suitable for children who cannot tolerate injections of corticosteroids. Treatment should be continued for 3 months for regrowth to be seen. Maintenance therapy may be necessary. Topical corticosteroids that can be used include clobetasol propionate 0.05% foam, betamethasone dipropionate 0.05% cream and flucinolone acetonide cream. Possible side effects are atrophy, folliculitis and telangiectasia.
3.Topical Immunotherapy: It can be used in patients above 10 years old with extensive alopecia areata or those who failed intra-lesional or topical steroids treatment. Pregnant and breast-feeding women should not use topical immunotherapy. The available topical immunotherapies are Diphencyperone/diphenylcycloperone (DCP) or squaric acid dibutylester (SADBE).
Starting at lower concentrations topical immunotherapy is applied every 1-2 weeks then at higher concentrations every 2-4 weeks. After a minimum of 4 hours post application if the effects are intolerable, wash off the topical cream. If able to tolerate the effects, tolerate for 24-48 hours. Avoid exposure to light while on treatment.
The topical side effects include localized itch, redness and scaling contact dermatitis reaction. Other swelling of regional lymph nodes and pigmentation changes i.e. Vitiligo.
The efficacy of this treatment is 60% and results can be seen in 3 months. However the relapse rate after reaching significant regrowth is about 63%.
4.Topical Anthralin 0.2%-0.5% cream: It is not effective in alopecia universalis and totalis cases. It is a safe treatment and the effects can be seen in 3 months. Side effects include irritant contact dermatitis (redness, itchy rash), scaling folliculitis, enlarged lymph nodes and local pyoderma. It may also stain the skin and clothes.
5.Topical Minoxidil: Does not work so well for those with alopecia totalis/universalis. The 5% concentration is more effective. Local side effects include scalp itch, dryness, redness or scaling. It may also stimulate facial hair growth if it is dripped onto the face.
6.Oral Steroids: It is effective in those with rapid onset extensive alopecia areata. The rate of regrowth ranges from 27% to 89%. Starting dose can be 0.5mg to 0.8mg per kg per day. The dose is then tailored down by every 5-10 mg every 6 to 8 weeks. After stopping medications, the relapse rate is about 25%.
Side effects include raised in serum glucose levels (especially in diabetes patient), weight gain, and raise in blood pressure, mood changes, striae, acne and myalgia. Long term side effects include osteoporosis and immune suppression.
7.Cyclosporine: Topical cyclosporine is not effective. Oral cyclosporine is effective but long term treatment is limited due to its adverse effects i.e. immunosuppression and renal impairment.
8. Photo chemotherapy Psolaren Plus UV-A: The response rate varies from 20-73%. However there is high relapse rate is high about 50-88% after 4-8 months after stopping treatment. Patients can be treated 2-3 times a week with gradual increase in UV-A dose.
Treatment of female pattern hair loss
Female pattern hair loss is a common balding issue in women. It is also can be classified under androgenic alopecia like men. About 40% of females by age 50 will show some signs of hair loss. Less than 45% of women will reach 80 with a full head of hair. It occurs commonly in post-menopausal women.
In female pattern hair loss, there is diffuse hair thinning at the crown area Hair over the occiput area and frontal hairline is well maintained unlike in men with androgenic alopecia. There will also be vellus hair (fine, short hairs, not more than 1-2 cm long). Hair pull test maybe negative. The grading system used is Ludwig Grades 1 -3.
Causes: There is strong genetic predisposition to develop female pattern hair loss. The role of androgens and estrogens is uncertain. In female pattern hair loss there is increase hair shedding or decrease in hair volume resulting in diffuse thinning of hair.
1.Minoxidil 2% topical solution: Only the 2% solution is FDA approved for use in women above 18 years old. It is not advisable to use it on pregnant and lactating women. Hair regrowth will be seen in 3-4 months. Side effects include: scalp itch, dryness, redness or scaling. It may also stimulate facial hair growth if it is dripped onto the face.
2.Hormonal therapy: Medications like oral contraceptives, spironolactone, and cyproterone have been used as off-label usage in females who have high androgen levels. There are side effects involved and tests should be done for monitoring. Oral Finasteride is generally not used in women. Consultation with endocrinologist to deal with Hyperandrogenism conditions will be necessary before these drugs are started.
3.Hair Transplant: For those with extensive hair loss, hair transplant is a possible option. Patient needs to consult with a specialized dermatologist to determine suitability for procedure. Possible side effects are keloids, scarring and infection.
4.Cosmetic Modality: Hair Spray, Hair styling methods and wigs to cover the hair thinning areas.
Treatment of Telogen Effluvium
Telogen effluvium is a temporary hair loss state whereby hair loss as the hair follicles are in telogen phase i.e. resting phase due to some metabolic or hormonal stress or pharmaceutical medications. Usually recovery will be seen in 6 months. It can occur in both sexes and at any age. Hair pull test is usually positive throughout the scalp. When there is an arrest in hair growth, it may be mirrored in the nails to form Beau Lines which are groves running across the nail coinciding with the time of metabolic/hormonal stress.
Acute telogen effluvium is relatively sudden onset of hair loss lasting less than 6 months. Chronic telogen effluvium is insidious hair loss lasting more than 6 months.
Causes: In normal hair scalp about 85% of hair follicles are in anagen state (actively growing hair) and only 15% is in telogen state (resting hair). When there is hormonal/physiologic stress to the body, then as many as 70% of anagen hairs will switch to telogen state. Paradoxically, hair fall is a sign of hair regrowth because the emerging actively growing hair helps to push out the resting hair out of the follicles.
Possible stress events that trigger telogen effluvium include infective illnesses, accidents/trauma, childbirth, surgery, weight loss or unusual diet, nervous shocking event, discontinuation of oral contraceptives, medications or overseas travel with jetlag.
Laboratory tests: tests are usually unnecessary if the history and physical findings are consistent with telogen effluvium. A scalp biopsy is the most useful test to confirm diagnosis if in doubt. However if hair loss exceeds 6 months, then tests should be carried out to exclude chronic diseases or endocrine/autoimmune conditions.
Treatment: Acute telogen effluvium is often self-limiting and resolves spontaneously so no treatment required. Chronic telogen effluvium patients should be reassured that it will take longer for condition to resolve. Topical Minoxidil can be used as treatment for those with chronic telogen effluvium. Any chronic illnesses such as thyroid diseases, nutritional deficiencies and acute illness should be treated accordingly.
Treatment of Tinea Capitis
Tinea capitis is fungal infection of the scalp. It is common among children under 10 years old peaking at ages 3-7. The hair can be infected by microsporum (abbreviated “M”) or trichophyton (abbreviated “T”) fungus.The fungal infection can be classified by how the fungal invade the hair shaft.
Ectothrix infection is due to infection with M. canis, M. audouinii, M. distortum, M. ferrugineum, M. gypseum, M. nanum, and T. verrucosum. The fungal spores (arthroconidia) and branches (hyphae) around the hair shaft or beneath the cuticle of hair. Ectothrix infections can be identified by Woods light (long wave ultraviolet light) examination of the affected. The fur will turn fluoresces green under woods light if infected with M. canis.
Endothrix infection is due to infection with T. tonsurans, T. violaceum and T. soudanense. The hair shaft is filled with spores (arthroconidia) and fungal branches (hyphae) during both anagen and telogen phases. Endothrix infections do not turn fluoresce green with Woods light. These infections tend to become chronic and progresses into adulthood.
Favus is caused by T. schoenleinii infection which results in a honeycomb-like destruction (crusts and scutula) of the hair shaft and also corresponding hair loss.
Clinical features: Patients may present with red papules initially which then turn into grayish- ring patches. Some may have dry scaling, pustules with yellow crusts or black dot Tinea capitis (fracture of hair shaft leaving infected dark black stubs). Kerions are infected inflammatory abscesses which progress to patchy diffuse hair loss with or without scarring. Alopecia in Tinea capitis will usually be patchy with short broken hairs. Regional cervical lymph nodes will also be swollen and inflamed.
Diagnosis: Diagnosis is confirmed by direct microscopy and culture of the skin scrapings and hair pulled out by the roots.
Treatment: Treatment is effective with oral antifungals like griseofulvin, terbinafine, Itraconazole and ketoconazole. Griseofulvin is most effective. Dosage is 10mg per kg per day for children and 250mg to 500 mg twice daily for adults. Topical antifungal application is generally ineffective. Carriers of Tinea infection can use topical antifungal shampoos twice weekly for 4 weeks. The shampoos available are 2.5% selenium sulfide, 2% ketoconazole, povidone-iodine and 1-2% zinc pyrithione.
Treatment of Trichotillomania
Trichotillomania is a psychiatric disorder whereby the patient has a compulsion to pull their hair repeatedly resulting in hair loss. In Greek it is called the hair pulling madness. In adolescent, girls are affected more than boys. In adults, patents are normally females.
The affected hair distribution is bizarre and there will be short stubby broken hair. Other areas like pubic and eyebrows maybe affected too. The remaining hair will be growing at different lengths.
Treatment: Patients should be referred to psychiatrists for behavioral therapy plus minus anti-psychotic medications.