Alopecia

Overview
Alopecia is the resulting condition from the loss of hair, which is termed effluvium. It should be distinguished from baldness, which is the lack of hair, including contexts where that absence is intentional. (In some cases the terms are used interchangeably, and in some conditions such as trichotillomania, where the loss of the hair is due to intentional acts, but the motive for that act is defined as a medical condition, it can be difficult to determine whether the label "alopecia" is appropriate.)

Alopecia is characterized by scarring or non-scarring. Scarring alopecia is caused by numerous dermatologic factors, including glabrous skin (non-hairy), and is very difficult to diagnose and manage. Non-scarring alopecia is characterized by the absence of visible inflammation of the skin involved.

Vocabulary

 * Anagen:growth phase, lasts 2-3 years (80-90% of follicles at any given time)
 * Catagen:involutional phase, lasts 2-3 weeks (1-3% of follicles)
 * Telogen:resting phase, lasts 3-4 months (5-10% of follicles)
 * hair released from shaft and shed at end of telogen new cycle begins
 * mature root sheath of telogen hair = “club” at proximal end


 * Terminal hairs: large shaft diameters, bulbs extend into subcutaneous fat
 * Vellus hairs:smaller in caliber and length, less pigmented
 * Indeterminate hairs:size/length between that of terminal and vellus hairs

Risk Factors

 * Drugs:
 * anticoagulants
 * anticonvulsants
 * antidepressants
 * beta-blockers


 * Medical illness
 * Hyper/hypothyroidism
 * Nutritional deficiencies: iron, zinc, protein
 * Connective tissue disorders: SLE, dermatomyositis

Pathophysiology & Etiology
Non Scarring Diffuse
 * Androgenetic alopecia
 * most common (30-40% of men and women)
 * Genetically determined: polygenic with variable penetrance
 * Shortening of anagen phase follicular miniaturization
 * Men: M-shaped pattern along frontal hairline (temporal loss progresses to midscalp)
 * Women: more diffuse, can be difficult to distinguish from telogen effluvium


 * Telogen effluvium
 * Reversible loss of mature, terminal hairs (few hundred per day)
 * Stressful event (or medication) triggers transition of more anagen hairs into telogen phase
 * Childbirth, fever, severe infection, severe psychologic stress, major surgery, crash diet
 * Drugs: heparin, antithyroid agents, anticonvulsants, hormones
 * Diffuse hair loss peaks 3-4 months after inciting event
 * Up to 30% of hairs must be lost before cosmetically apparent


 * Anagen effluvium
 * Acute loss of anagen hair = 80-90% of hair
 * Occurs 10-14 days after treatment with antimitotic agents (chemo)

Focal
 * Alopecia areata: incidence 1/1000
 * Smooth, discrete, circular areas of complete hair loss occurring over a few weeks
 * Exclamation point hairs: hair root narrower than normal with less pigment
 * Can occur on any hair-bearing area; nails may also have proximal pitting
 * Usually reversible: regrowth occurs over several months; 90% regrow within 2 years
 * Relapse occurs in up to 1/3
 * Decreased chance of regrowth/increased risk relapse if:
 * Prepubertal onset
 * Widespread involvement (alopecia totalis or universalis)
 * Duration > 5 years
 * History of atopy
 * Possible autoimmune mechanism: bx shows T-cell infiltrates around hair follicles
 * Positive family history in 20%


 * Syphilis
 * Moth-eaten, patchy pattern of loss (may be diffuse)
 * May be associated with skin lesions of secondary syphilis, or may occur in latent stage
 * Full hairgrowth occurs after treatment of infection


 * Trauma
 * Traction alopecia: due to hairstyles that impose chronic tension on hair (braids)
 * Hair loss most prominent in areas of greatest tension (margins)
 * Fine, vellus hairs present in areas of absent terminal hairs
 * Regrowth can occur in early disease (few months-yrs), but not in late disease (years)
 * Chemical trauma: repeated use of lye-containing straightening agents or hot oils for styling
 * Trichotillomania: bizarre, asymmetric pattern of broken hairs of varying length

Scarring
 * uncommon; hair loss is permanent
 * erythematous papules, pustules, or scaling centered around follicles
 * polytrichia = multiple hair shafts exiting a single enlarged orifice
 * eventual obliteration of follicular orifices
 * Tinea capitis
 * Scaling and inflammation in patchy areas of hair loss, +/- lymphadenopathy
 * Usually in children
 * KOH prep positive


 * Central, centrifugal scarring alopecia (a.k.a. follicular degeneration syndrome, pseudopelade)
 * Symmetric involvement of central portion of scalp with outward expansion over months/yrs
 * May be associated with pustules (folliculitis decalvans)
 * Cause unknown-> emipiric Rx with steroids, antibiotics


 * Discoid lupus
 * Inflammation with plugged follicles, scale, abnormal scalp pigmentation
 * May have discoid lesions elsewhere on body

Diagnosis

 * Pull test: firm pull on 20-40 hairs should yield fallout of no more than 1 in 10 hairs
 * Increased # telogen hairs with depigmented proximal bulb: telogen effluvium
 * Increased # hairs with no bulb: breakage (hair fragility due to exogenous injury)
 * Anagen hairs with pigmented root: likely excessive force


 * Follicular units: number of hairs produced per follicular orifice
 * Threes = normal for ages 20-40
 * Twos = normal for ages 40-60
 * Ones = normal for ages >60
 * Voids = follicular orifices w/o hairs suggests advanced androgenetic alopecia if no scarring


 * Testing:minimal
 * Medical illness suspected: CBC, TSH, possibly ferritin
 * RPR if patchy or unexplained loss
 * KOH prep if patchy alopecia with scaling or inflammation

Non-Scarring Alopecia

 * Adrenocortical insufficiency (primary or secondary)
 * Anagen effluvium (anagen=growing hair)
 * Cushing's syndrome
 * Diffuse hair thinning due to metabolic causes
 * Hyperthyroidism
 * Hypoparathyroidism
 * Hypothyroidism
 * Pituitary insufficiency
 * Secondary syphilis
 * Sheehan's syndrome
 * Temporary hair loss
 * Pregnancy
 * Malnutrition
 * Malabsorption
 * Protein deficiency
 * Tryptophan deficiency
 * Nontropical sprue
 * Vitamin A deficiency
 * Vitamin B deficiency
 * Vitamin D deficiency
 * Rickets
 * Telogen effluvium (telogen=resting hair)
 * Thyroiditis
 * Trichotillomania

Scarring Alopecia

 * Amyloidosis
 * Chronic disciform lupus erythematosis
 * Congenital defects
 * Discoid Lupus Erythematosus
 * Dissecting cellulitis
 * Herpes zoster infection
 * Infection
 * Favus
 * Typhoid Fever
 * Leptospirosis
 * Secondary syphilis
 * Inflammatory dermatoses
 * Lichen planopilaris
 * Lymphoma
 * Morphea
 * Mycosis fungoides
 * Neoplasm
 * Neurodermatitis
 * Physical or chemical agents:
 * ACE inhibitors
 * Allopurinol
 * Androgens
 * Anticoagulants
 * Anticonvulsants
 * Antimycotic agents
 * Arsenic
 * Azathioprine
 * Beta blockers
 * Borates
 * Cadmium
 * Chemotherapeutics
 * Chlorambucil
 * Cisplatin
 * Clofibrate
 * Cyclophosphamide
 * Cytarabine
 * Estrogens
 * Fluororacil
 * Gentamycin
 * Gold compounds
 * Heparins
 * Indomethacin
 * Levodopa
 * Linolic acid
 * Mercury and derivatives
 * Methotrexate
 * Niacin
 * Oral contraceptives
 * Propranolol
 * Retinoids
 * Salicylates
 * Selenium
 * Squalenes
 * Steroids
 * Thallium
 * Undecylenic acid
 * Vitamin A overdose
 * Warfarin
 * Pseudofolliculitis barbae
 * Psoriasis
 * Sarcoidosis
 * Scleroderma
 * Systemic Lupus Erythematosus

Miscellaneous

 * Addison's Disease
 * Anemia
 * Cancer
 * Diabetes Mellitus
 * Pneumonia
 * Scarlet Fever
 * Schmidt's Syndrome
 * Stress
 * Labor
 * Surgery
 * Testicular feminization syndrome
 * Turner's Syndrome
 * Typhoid fever
 * Mechanical effects
 * Traction alopecia
 * Pressure alopecia
 * Alopecia after extended bed rest
 * Trichotillomania (compulsion to pull out one’s own hair)

History and Symptoms

 * Age
 * Childhood: only 2 common diagnoses tinea capitis, alopecia areata
 * Adulthood: tinea capitis rare; all the rest possible


 * Duration
 * <1 year: suggests telogen effluvium if diffuse loss
 * >1 year: suggests androgenetic alopecia if diffuse loss
 * Pattern of loss
 * Shedding: “lots of hair coming out,” may be due to hair breakage or loss by the root
 * Thinning: scalp more visible without noticeable hair fallout, suggests androgenetic alopecia
 * Family history: may be positive in androgenetic alopecia, alopecia areata
 * Grooming practices: can cause hair fragility/breakage
 * Chemical treatments (relaxers, perms, bleaching) most damaging; hair dye less so

Traction styling

Appearance of the Patient

 * Scalp
 * Normal or with features of scarring
 * if scalp abnormal provide clues to dx
 * scaling
 * erythema
 * pustules
 * dyspigmentation


 * Pattern: diffuse or patchy
 * Male pattern (diffuse):bitemporal recession +/or vertex loss
 * Female pattern (diffuse):coronal thinning with preserved anterior hairline
 * Patchy:with preserved hair of variable length (breakage)
 * with exclamation point hairs (alopecia areata)
 * with no hair (scarring, traction, syphilis, tinea)

Laboratory Findings

 * Viral and bacterial cultures
 * Prolactin
 * Thyroid function tests
 * Iron studies
 * Dehydroepiandrosterone-sulfate (DHEA-S)
 * Testosterone
 * Rapid plasma reagin (RPR)
 * Erythrocyte sedimentation rate (ESR)
 * Antinuclear antibodies (ANA)

Treatment

 * Goal of treatment is to avoid future hair loss.
 * Scarring hair loss prevents hair from going back.
 * Wigs and hair transplants
 * Anagen effluvium
 * Treat illness or withdraw drug
 * Telogen effluvium
 * Stress the recovery is normal
 * Treat underlying cause of alopecia

Acute Pharmacotherapies

 * Androgenetic alopecia
 * For men, oral finasteride or topical minoxidil
 * For women, antiandrogens if adrenal androgens are increased
 * Tinea capitus/kerion
 * Oral antifungals
 * Alopecia areata
 * Glucocorticoids
 * Psoralen and ultraviolet A (PUVA)
 * Superpotent steriods
 * Cyclosporine
 * Intralesional steriod injections

Chronic Pharmacotherapies

 * Topical minoxidil (Rogaine, generic):
 * only Rx approved for women as well as men
 * Increases duration of anagen and enlarges miniaturized follicles
 * Mechanism unclear


 * Efficacy:
 * hair counts ~5x higher than placebo with use of 5% solution (men)
 * hair counts 45% higher with use of 5% solution compared with use of 2% solution (men)
 * hair counts returned to those of placebo group within 24 weeks after discontinuation Rx (men)
 * women: increased hair growth in 60% vs. 40% with use of 2% soln vs. placebo
 * Advice for patients:
 * 1 mL bid applied to dry scalp with spray or dropper; spread lightly w/finger
 * expect decreased loss w/in 2 mos, growth w/in 4-8 mos; stable at 1-1.5 yrs
 * best results if baldness present at vertex x < 5 years and < 10 cm diameter
 * cosmetically notable growth occurs in only 30-40%
 * Rx must continue indefinitely or regrown hair will be lost
 * Side effects = rare contact or irritant dermatitis; no change blood pressure, heart rate or weight

Acknowledgements
The content on this page was first contributed by: Steven Wiviott, M.D.