help my hair is falling out

Help My Hair Is Falling Out

Natasha Atanaskova Mesinkovska MD PhDDepartment of Dermatology and Dermatopathology

University of California, Irvine

Natasha A. Mesinkovska MD PHD

Disclosures

“Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest

to disclose.”

Human Hair Follicles

• Anagen• Growing hair phase (0.37mm/day)• lasts ~3 years• 85-90% scalp hairs* Longer anagen = longer hair

• Catagen• Transitional phase• 1-2 weeks• <1% scalp hairs

• Telogen• Resting phase• 3-5 months• 10-15% scalp hairs


Human Hair Follicles

• Scalp hairs

– Terminal

– daily shed ~100 hairs per day


Hair Embryology

• First hair follicles at 9 weeks– Eyebrow, upper lip, chin

• Rest of follicles at 4-5 months– Cephalad to caudal direction

• First hairs are lanugo – soft non-pigmented, fine

– shed between 32nd- 36th weeks


Evaluation of the Patient with Hair Loss

• History of present illness:– How long ago?

– Scalp or other areas as well?

– How did the patient notice it?• eg. in the shower, hair dresser

– How much hair has been lost (%)?

– Any associated symptoms?• eg. itching, scaling, redness, pain

– Excess hair elsewhere


Evaluation of the Patient with Hair Loss

• Personal medical history: – Autoimmune /inflammatory

– Cancer

• Medications:– correlation with onset of hair loss

• Hormonal milleu: – Women: oral contraceptives, replacement

– Men: testosterone


Evaluation of the patient with hair loss

• Family history:

– Hair loss:

• Father, brothers, mother, sisters, children

• Find out at what age

• Did it ever regrow?

– Autoimmune and inflammatory diseases:

• Thyroid, Diabetis, Vitiligo, Celiac, Inflammatory Bowel, Rheumatoid Arthritis, Lupus

– Neoplastic disease


Important Things to Ask

• Vitamins and supplements

– DHEA, retinoids

• Diet

– vegan

• Exercise

– marathon


The Exam

• Clinical exam of scalp• Pull test

– Hair on face

– On body

– Axilla

– Genitals

– Nails

• Thyroid gland

• Wood’s light


Diagnosis

• Scalp biopsy

– 1 or 2

– Vertical or horizontal sections

– Dermatopathologist

• Laboratory work up:

– CBC, Ferritin levels, Thyroid, Vitamin deficiencies



Diseases of the Hair

Hair loss

Non-scarring and Scarring


Non-Cicatricial Alopecia

Non-Cicatricial Alopecias

1. Androgenetic alopecia

2. Telogen effluvium

3. Anagen effluvium

4. Alopecia areata

5. Trichotillosis (trichotillomania)


1. Androgenetic Alopecia

• Male and Female pattern hair loss

– Strong genetic link (polygenic)

– Family history

• Progressive decrease of anagen

• increase telogen and miniaturized hair follicles


AGA


Male Pattern Balding

• Frontotemporal region

– following puberty

• Increases with age

– 80% of men by age 70

• Etiology

– Androgen driven• DHT greater affinity for androgen receptors

• Converted to DHT by 5-alpha reductase

– Type 1 in liver and sebaceous glands

– Type 2 scalp, beard, and chest hair follicles



Hamilton

Norwood

Classification

Fronto-temporal recession with

eventual involvement of vertex

Female Pattern

• 30 years of age onset

– as early as during puberty

• apical scalp part wider

• frontal hairline preserved

• Work up

– ferritin, TSH, free/total testosterone, DHEAS, zinc, vit D


Female Pattern


Treatment

Caution against unrealistic expectations• Primary goal is to halt progression.• COMBINATION: at least 6 months to assess response,

continue treatment to maintain response.

Female pattern hair loss

• 5% topical minoxidil

• Oral anti-androgens (spironolactone, cyproteroneacetate).

• Surgery (hair transplantation)

• wigs

Male pattern hair loss

• 5% topical minoxidil

• Oral finasteride, 1mg

• Surgery (hair transplantation)*

– * selected cases

• wigs


Androgenetic Alopecia

• Minoxidil• Survival dermal papilla cells• Prolongs anagen phase• Increases shaft diameter

• Finasteride (1mg daily)• Type 2 5a-reductase inhibitor• Effects after 6-12 months• Check PSA level prior to initiation

• Other: • Dutasteride• Fluridil (topical antiandrogen)• ? PRP


2. Telogen Effluvium

• Excessive shedding of telogen club hairs

• Usually follows a stressful event

– 3 months after event

• Usually <50% scalp

• Eyebrows and eyelashes usually unaffected

– if they are- check thyroid levels

• Resolves spontaneously


Telogen Effluvium

Several mechanisms: stress:• Illness• Fever• Surgery• labor• CT scan• Medications: amphetamines, lithium,• cimetidine, B-blockers, valproic acid• Hormonal alterations: thyroid, OCP, menopause• Drastic diet regimen• Sudden weight loss

– No known cause in many cases


Telogen Effluvium

• Exam: Abnormal pull test

• Telogen hair• Depigmented club -shaped bulb

• Lacks a sheath


3. Anagen Effluvium

• Abrupt cessation of mitotic activity in hair matrix –Within days to weeks of stimulus

–Hair shaft thins → breaks at surface (fractures)

– Entirely reversible*

• Associations• Chemotherapy

– antimetabolites and alkylating agents

• INH

• Thallium

• Boron


4. Alopecia Areata

• Autoimmune

–Loss of immune privilege of hair follicle

–Target for activated T cells

• ‘swarm of bees’ on pathology

• Types:– Patchy

– Totalis - loss of all scalp hair

– Universalis→ loss of all body hair

– Ophiasis- band like pattern


Alopecia Areata – Patchy


Alopecia Totalis


Alopecia Areata


Alopecia Areata – Patchy


Alopecia Areata

• 10% nail pits (more uniform than psoriasis)

• Exclamation point hairs - tapering hair shaft

• Associated conditions• Eczema

• thyroid

• vitiligo

• DM

• Celiac

• Hearing impairment

• Depression and anxiety


Tx AA

• Patchy alopecia– Intralesional / topical corticosteroids– Topical anthralin– Minoxidil foam

• Extensive or rapidly progressive alopecia– Contact immunotherapy (squaric acid dibutyl ester,

diphenylcyclopropenone)– Systemic anti-inflammatory: tofacitinib– Wig or hairpiece


• Compulsive desire to pull out hair

• Hairs of multiple lengths

– localized area

– Geometric

– Irregular patches

– Scalp, Eyebrows and eyelashes

– Even in children

• Hairs of varying length– folliculitis

Trichotillomania (Trichotillosis)


http://162.129.70.33/images/Trichotillomania_1_051205.jpg

Trichotillosis

• Compulsive desire to pull out hair

• OCD

• depression

• anxiety

• Trichophagia– bezoars

• Tx: psychotherapy + anti-depressants


Tinea Capitis

• Scale• Pustules• Broken hairs


• Work up:– KOH scale– Culture the pustules– Biopsy only if above non-diagnostic

• Trichophyton tonsurans• Microsporum canis

• Treatment: – Griseofulvin– Terbinafine– Itraconazole– +/- ketoconazole or selenium sulfide wash

Tinea Capitis



Cicatricial Alopecias

Alopecia accompanied by absence of follicular ostia

• Complex

• Rare conditions

• Many types

• Scalp Biopsy is a MUST

– Dermatopathologist

• Comorbidities and HPI important

Scarring Alopecias


Scarring Alopecias

• Complex

• Rare conditions, many

1. Chronic cutaneous lupus

2. Central centrifugal alopecia

3. Lichen planopilaris

4. Frontal fibrosing alopecia

5. Folliculitis decalvans


Chronic Cutaneous Lupus Erythematosus

• Clinical:

– Most commonly face, ears, scalp• Erythema

• Atrophy

• Follicular plugging

• Mottled hyper-hypopigmentation

• 50% of pts with skin disease have scalp disease

• ~5% develop Systemic Lupus

• Difficult to distinguish from lichen planopilaris



• Diagnosis:

• Biopsy

• Laboratory SLE work up

• treatment:

– Intralesional or topical steroids

– Systemic (antimalarials, mycofenolate mofetil, methotrexate, retinoids, dapsone, sulfasalazine, thalidomide)


2. Central Centrifugal Cicatricial Alopecia


2. Central Centrifugal Cicatricial Alopecia

• Overlapping entities• Hot comb alopecia/Follicular degeneration syndrome

• Begins in crown → advances centrifugally

• Difficult treatment–Discontinue chemical treatment

–Discontinue heat

–Discontinue traction

– Intralesional stroids

– Increased risk Diabetes melitus type 2


2. Lichen Planopilaris (LPP)

• Female >Male

• Caucasian

• Clinical• Perifollicular erythema/scale + progressive scarring

• Small follicular papules

• Pruritus and tenderness

• Variants• Frontal fibrosing alopecia – women, 50 years old

• Graham Little-Piccardi Syndrome?– LPP + keratosis pilaris + pubic/axillary alopecia (not scarring)


Lichen Planopilaris


Perifollicular Erythema in LPP


Frontal Fibrosing Alopecia


5. Folliculitis Decalvans


http://www.dermis.net/bilder/CD151/550px/img0098.jpg

5. Folliculitis Decalvans

• Crops of pustules → scarring alopecia • Abnormal suppurative immune response

• Treatment:– Responds to long term tetracyclines– Combine with ketoconazole and clindamycin lotion

• Other: – Rifampin + Clindamycin x 10 weeks– Topical corticosteroids– Dapsone– Selenium sulfide shampoo


Dissecting Cellulitis


Dissecting Cellulitis (Perifolliculitis Capitis Abscessens et Suffodiens of Hoffman)

• Isolated or part of follicular occlusion tetrad 1. Acne conglobata2. Hidradenitis suppurativa3. Pilonidal cyst

• Deep, boggy, suppurative lesions• Start as firm nodule• Treatment

• Isotretinoin• Dapsone• Intralesional corticosteroids• Oral antibiotics


Other Causes of Hair Loss

• Traction Alopecia

• Neoplastic

• Cysts

• Sarcoidosis

• Pressure alopecia

• Genodermatosis


Traction Alopecia

• Frontal and parietal scalp

• Hair loss secondary to tight braids, hair styles with traction


Cutaneous T Cell Lymphoma


Temporal Triangular Alopecia

• Congenital, usually present at birth

• Temporal scalp

• Fine, vellus hairs

– Normal number of follicles but all are vellus

• Permanent


The Psychosocial Burden of Hair Loss


The End


help my hair is falling out

Documents