Alopecia

HAIR LOSS (ALOPECIA)
  • Shedding of hair is termed effluvium or defluvium
  • The two major forms of alopecia are scarring and nonscarring
  • Scarring alopecia there is associated fibrosis, inflammation, and loss of hair follicles.
  • Scarring alopecia is more frequently the result of a primary cutaneous disorder such as:
  • Lichen planus(Cicatrising alopecia with perifollicular blue-gray patches and hypopigmented macular lesions over trunk and oral mucosa )
  • Staphylococcal folliculitis
  • Herpes simplex and zoster
  • Lupus vulgaris
  • Lupus erythematosus
  • Sarcoid
  • Scleroderma
  • Basal cell carcinoma
  • In nonscarring alopecia the hair shafts are gone, but the hair follicles are preserved, explaining the reversible nature of nonscarring alopecia. The most common causes of nonscarring alopecia include:
  • Telogen effluvium,
  • Androgenetic alopecia,
  • Alopecia areata,
  • Tinea capitis, 
  • Traumatic alopecia.
  • Trichotillomania
  • Psoriasis
ALOPECIA AREATA
  • Autoimmune disorder of hair follicles causing loss of hair in sharply defined areas of skin
  • Results from arrest of hair follicles in late anagen phase.
  • 10-20% patients give a family history
  • Polygenic inheritance
  • HLA DR4, DR5, DQ3 are associated with severe alopecia
  • HLA DQ3 and DR11 – associated with alopecia totalis & universalis
  • 'Exclamation mark' hairs at the margin of the lesions.
  • Non scarring & non patterned alopecia
  • Particularly common between the ages of 15 and 30 years. Alopecia totalis is total or almost total loss of scalp hair.
  • Alopecia universalis is loss of all body hair.
  • Sites of Predilection: Scalp, eyebrows, eyelashes, pubic hair, beard.
  • Nails: Fine pitting ("hammered brass") of dorsal nail plate, mottled lunula, trachyonychia (rough nails),onychomadesis (separation of nail from matrix). Ophiasis is alopecia along scalp margin. (band-like hair loss in the occipital and temporal scalp),
  • Sisaipho (predilection for parietal scalp mimicking androgenetic alopaecia),
  • Classical feature is sparing of gray/white hairs.
  • Positively associated with autoimmune disorders
  • Alopecia Aerata + Vitiligo + Uveitis Vogt Koyanagi syndrome
  • Dense 'bee swarm'-like cluster of lymphocytes can be seen around the follicles in biopsies.
  • Treatment: Potent topical steroids or systemic steroids, PUVA, dithranol, allergic sensitization with diphencyprone and topical minoxidil
TELOGEN EFFLUVIUM
  • Transitory increase in the number of hairs in the telogen (resting) phase of the hair growth cycle.
  • This may occur spontaneously, may appear at the termination of pregnancy, may be precipitated by crash dieting, high fever, stress from surgery or shock, malnutrition, or hormonal contraceptives.
  • Telogen effluvium usually has a latent period of 2-4 months
  • The prognosis is generally good
PATTERN ALOPECIA or MALE ALOPECIA or ANDROGENIC ALOPECIA
  • Most common type
  • Autosomal dominant
  • Progressive form of alopecia
  • Mostly seen in men
  • The earliest changes occur at the anterior portions of the calvarium on either side of the "widow's peak" and on the crown (vertex).
  • Loss of hair starts in both temporal regions.
Treatment:
  1. Chemical castration with anti-androgen-prostagen combination in women by cyproterone acetate & ethinylestranol – Dianette.
  2. Anti hypertensive (Vasodilator) – Minoxidil & Tretinoin
  3. 5-alpha-reductase inhibitor – Finasteride.
Exam Question
  • Rapid, diffuse, excessive hair loss after 3 months of pregnancy is due to Telogen Effluvium.
  • An 8-yrs-old male presents with multiple patches of alopecia and severe pruritus. A bright blue-green fluorescence is seen on examination of the scalp with a wood lamp. Pathogen most likely responsible is Microsporum Canis.
  • Pitting of nails can be seen in Alopecia Areata.
  • Causes of scarring alopecia: Tinea capitis infection and kerion, Staphylococcal folliculitis, Syphilis, Herpes simplex and zoster, Lupus vulgaris ,Lichen planus ,Lupus erythematosus, Sarcoid, Scleroderma, Basal cell carcinoma.
  • Non scarring alopecia occur in: Androgenic type ,Telogen effluvium, Alopecia areata ,Trichotillomania,Psoriasis.
  • Cicatrising alopecia with perifollicular blue-gray patches is likely to be associated with whitish lesions in buccal mucosa which is characteristic of Lichen planus. Favus is a form of Tinea capitis . It is caused by Tinea schoenlein .It causes cicatricial alopecia.
  • The Hamilton Norwood scale is used for Male Androgenetic Alopecia.
  • A woman presents to a dermatologist because she has lost almost all the hair on her body, including scalp hair, eyebrows, eyelashes, armpit and groin hair, and the fine hairs on her body and extremities. She most likely has a variant of Alopecia Areata.
  • A 40 year old, formerly obese woman presents to her physician. She was very proud of having lost 36Kg. during the previous 2 years, but now noticed that her "hair is falling out." On questioning, she reports having followed a strict fat-free diet. Her alopecia is probably related to a deficiency of Vitamin A.
  • Severe painful sensorimotor and autonomic neuropathy along with alopecia may suggest poisoning with Thallium.
  • A female patient presents with diffuse alopecia to you. She had suffered from typhoid fever 4 months back. Most probable diagnosis is Telogen Effluvium. A 30 year old female developed diffuse hair loss 3 months after delivery of her first child. The probable diagnosis is Telogen Effluvium.
  • Pseudo pelade is synonym of Cicatrical Alopecia.
  • In DLE (a form of SLE) there is cicatrial alopecia & in SLE there is non cicatrial alopecia; thus SLE has both forms of alopecia.
  • Alopecia aerate is presumed to be Autoimmune in etiology.
  • Exclamation mark hairs is seen in Alopecia Areata.
  • Male with patchy loss of scalp hair and grey hair in the eyebrows and beard diagnosis is Alopecia Areata.
  • Alopecia areata is treated by Minoxidil.
  • An 8 yr old boy presents with boggy swelling and easily pluckable hair, Diagnosis is Tinea Capitis.
  • A 8 year old child has localized non cicatrial alopecia over scalp with itching and scales. The diagnosis is Tinea Capitis.
  • Moth eaten alopecia is seen with Syphilis.
  • Hypogonadism, reduced immunity and alopecia may be a deficiency manifestation of Zinc.
  • Most common type of non scarring alopecia is Androgenic.
  • Alopecia thin brittle nail, sparse hair with thin enamel diagnosis is Ectodermal Dysplasia.
  • Patchy hair loss with velvety skin points to the diagnosis of Hyperthyroidism.
  • A child presenting with localized patches of complete hair loss with normal appearance of scalp. Diagnosis is Tinea Capitis.
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