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alopecia (hair loss, balding)

Etiology: 1) generalized hair loss a) telogen effluvium b) anagen effluvium c) alopecia totalis or universalis d) secondary syphilis [9] e) hyperthyroidism f) hypothyroidism g) nutritional deficiencies (protein, iron, zinc, biotin) h) HIV infection i) pharmacologic agents 1] cytotoxic drugs 2] ethionamide 3] heparin 4] oral contraceptive withdrawal 2) localized hair loss a) non-scarring alopecia 1] androgenic alopecia (male balding pattern) 2] alopecia areata 3] hirsutism 4] trichotillomania 5] traction alopecia - central centrifugal cicatricial alopecia 6] Tinea capitis - Trichophyton tonsurans most common [11] b) scarring alopecia 1] hereditary & developmental a] aplasia cutis congenica b] epidermal nevi c] facial hemiatrophy (Romberg's syndrome) 2] infection a] fungal 1] microsporum canis 2] Microsporum audouinii b] bacterial (folliculitis) c] viral (Herpes zoster) d] protozoan (leishmaniasis) 3] neoplasm a] basal cell carcinoma b] squamous cell carcinoma c] lymphoma d] metastatic tumor 4] physical or chemical injury a] burns b] radiation c] acidic chemicals d] alkaline chemicals 5] lupus erythematosus, discoid lupus (may be non scarring) 6] follicular lichen planus (lichen planopilaris) 7] sarcoidosis 8] morphea 9] cicatricial pemphigoid 10] acne keloidalis 11] folliculitis decalvans 12] pseudopalade 13] scleroderma 14] frontal fibrosing alopecia Pathology: - scarring alopecia results in permanent hair loss - non-scarring alopecia may be reversible [6] - hair loss in women [4] a) excessive testosterone & dihydrotestosterone b) insufficient estrogen Genetics: - associated with polymorphism in the androgen receptor Laboratory: 1) fungal tests a) KOH preps b) Woods lamp c) fungal culture 2) hormonal assays a) dehydroepiandrosterone (DHEA)-sulfate b) testosterone 3) scalp biopsy, 4 mm punch biopsy [6] a) can distinguish scarring alopecia from non-scarring alopecia [6] b) periphery of lesion best site for biopsy Special laboratory: - hair pluck test Management: 1) inherited disorders a) some men elect to forgo treatment b) topical minoxidil (Rogaine) BID - best results with patients < 30 with < 5 years hair loss c) surgical procedures - hair transplant - scalp reduction - flaps 2) Fungal infections - oral terbinafine, fluoconazole or itraconazole for ~6 weeks [6] - oral griseofulvin for ~12 weeks [4] - 3) ketoconazole is less effective - topical antifungal agents are generally ineffective - clean contaminated combs - evaluate family members 3) alopecia areata a) most cases resolve spontaneously b) intralesional or topical glucocorticoids c) systemic glucocorticoids for refractory or extensive disease [6] d) PUVA + prednisolone (recalcitrant alopecia areata) [5] - 20 mg of methoxsalen, followed 2 hours later by total-body irradiation with ultraviolet A light (UVA) in increasing doses 5 days each week for 4 weeks; - maximum UVA dose was 80 J/cm2 - oral prednisolone - 20 mg/day for 4 weeks - gradually tapered to 0 over 3 months 4) hair loss in women [4] {nothing works well} - minoxidil (Rogaine) only FDA-approved agent - spironolactone - finasteride (Propecia) - flutamide - Saw palmetto - oral contraceptives - estrogen/hormone replacement therapy - thyroid replacement 5) traction alopecia - decrease tension from hair styling practices - central centrifugal cicatricial alopecia - hair straightener or hair relaxer - topical glucocorticoids, intralesional gluxocorticoids 6) frontal fibrosing alopecia - hydroxychloroquine, 5-alpha reductase inhibitors 7) nutritional interventions with highest-quality evidence for potential benefit: - Viviscal, Nourkrin, Nutrafol, Lamdapil, Pantogar, capsaicin & isoflavone, omega-3 fatty acids & omega-6 fatty acids with antioxidants, apple nutraceutical, total glucosides of paeony & compound glycyrrhizin tablets, zinc, tocotrienol, & pumpkin seed oil [12] Comparative biology: - in older mice, dormant stem cells in hair follicles can be activated by Wnt - in older mice, inhibitors keep the stem cells in a dormant state - stem cell dormancy can be reversed by the nearby macroenvironment of young skin, that is more stem cells are not needed, but rather a change in the stem cell environment

Related

hair pluck test Tinea capitis

Specific

alopecia areata alopecia universalis congenita Mari type anagen effluvium pattern alopecia scarring alopecia; cicatricial alopecia telogen effluvium traumatic alopecia trichorrhexis nodosa

General

hair disease scalp disorder sign/symptom

Database Correlations

OMIM 109200

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 916
  3. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 291-292
  4. Prescriber's Letter 10(3):17 2003
  5. Ito T et al Combination therapy with oral PUVA and corticosteroid for recalcitrant alopecia areata. Arch Dermatol Res 2009 Jun; 301:373. PMID: 19301021
  6. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2022.
  7. Mounsey AL, Reed SW. Diagnosing and treating hair loss. Am Fam Physician. 2009 Aug 15;80(4):356-62. PMID: 19678603
  8. Dahl MV Stemming Hair Loss? NEJM Journal Watch. Aug 13, 2014 Massachusetts Medical Society (subscription needed) http://www.jwatch.org - Chen C-C et al. Regenerative hair waves in aging mice and extra-follicular modulators follistatin, Dkk1, and Sfrp4. J Invest Dermatol 2014 Aug 15; 134:2086. PMID: 24618599 http://www.nature.com/jid/journal/v134/n8/full/jid2014139a.html - Reddy SK and Garza LA. The thinning top: Why old people have less hair. J Invest Dermatol 2014 Aug 15; 134:2068 PMID: 25029319 http://www.nature.com/jid/journal/v134/n8/full/jid2014172a.html
  9. Moshiri AS, Moxam A Syphilitic Alopecia N Engl J Med 2018; 379:1657 PMID: 30354954 https://www.nejm.org/doi/full/10.1056/NEJMicm1804118
  10. Mubki T, Rudnicka L, Olszewska M, Shapiro J. Evaluation and diagnosis of the hair loss patient: part I. History and clinical examination. J Am Acad Dermatol. 2014 Sep;71(3):415.e1-415.e15. Review. PMID: 25128118 - Mubki T, Rudnicka L, Olszewska M, Shapiro J. Evaluation and diagnosis of the hair loss patient: part II. Trichoscopic and laboratory evaluations. J Am Acad Dermatol. 2014 Sep;71(3):431.e1-431.e11. Review. PMID: 25128119
  11. Elston CA, Elston MD Identifying Lesions on Skin of Color. Medscape. 2021. May 10 https://reference.medscape.com/slideshow/identifying-lesions-6007985
  12. Drake L, Reyes-Hadsall S, Martinez J et al Evaluation of the Safety and Effectiveness of Nutritional Supplements for Treating Hair Loss. A Systematic Review. JAMA Dermatol. Published online November 30, 2022 PMID: 36449274 https://jamanetwork.com/journals/jamadermatology/fullarticle/2798840