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Alopecia . Anoop Agrawal, M.D. Baylor College of Medicine Med-Peds Continuity Clinic. Objectives. Review normal hair growth physiology Know how to evaluate a patient with alopecia Know the causes of alopecia Be familiar with available treatment options. Physiology of normal hair growth.

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  • Anoop Agrawal, M.D.
  • Baylor College of Medicine
  • Med-Peds Continuity Clinic
  • Review normal hair growth physiology
  • Know how to evaluate a patient with alopecia
  • Know the causes of alopecia
  • Be familiar with available treatment options
physiology of normal hair growth
Physiology of normal hair growth
  • A human is born with all of their terminal hair follicles.
  • Hair growth is a cyclical process:
    • Anagen - the growth phase, lasts 2 to 3 years
    • Catagen - the involutional phase, lasts 2 to 3 weeks
    • Telogen - the resting phase, lasts 3 to 4 months
physiology continued
Physiology continued
  • Hair follicle is released from the shaft at the end of the telogen phase and the cycle begins anew.
  • At any given time, 80 to 90% of follicles are in anagen, 5 to 10% are in telogen, 1 to 3% are in catagen.
  • Up to 75 hairs are shed each day.
evaluation of hair loss
Evaluation of Hair Loss
  • History:
    • Onset - gradual vs. rapid (‘handfuls of hair’)
    • History of physical, mental or emotional stressors in the past 3 to 6 months
    • Hair thinning vs. shedding
    • Pattern of hair loss - focal vs. diffuse
evaluation continued
Evaluation continued
  • Physical exam:
    • Scarring vs. Nonscarring
      • Scarring alopecia refers to hair loss associated with fibrosis and permanent damage to hair follicles
      • Examples: bullous disease, discoid lupus, chemical alopecia, dissecting cellulitis, tumors, lichen planopilaris
evaluation cont
Evaluation cont...
  • Physical:
    • Pattern of hair loss - classic ‘M’ or central pattern vs. diffuse vs. focal areas
name the types of alopecia
Name the types of alopecia
  • Androgenetic alopecia
  • Alopecia areata
  • Telogen effluvium
  • Traumatic alopecia: traction alopecia and trichotillomania
  • Cicatricial Alopeica (irreversible alopecia - mostly the etiologies resulting in scarring)
androgenetic alopecia in men
Androgenetic Alopecia in men
  • Key to diagnosis: hair thinning in distinct pattern - ‘M’ shaped pattern in men (temporal, crown, known as male pattern baldness); gradual onset
  • Onset of changes begin in puberty with androgens shortening the anagen phase and promoting follicular miniaturization
  • Treatment: Minoxidil (topical - 5% better than 2%), or finasteride 1mg qd; both require continued use to maintain growth
androgenetic alopecia stages in men
Androgenetic Alopecia: Stages in Men

Stage 4

Stage 5

Stage 6

Stage 7

androgenetic alopecia in women13
Androgenetic Alopecia in women
  • In women, hair thinning occurs in central scalp
  • If the patient also has clinical signs of hirsutism, menstrual irregularities, acne, infertility, etc, then need to evaluate for hyperandrogenism.
  • Treatment options: Minoxidil 2%; also estrogens and spironolactone - these two slow hair loss, do not promote regrowth
alopecia areata15
Alopecia Areata
  • Incidence of 1 in 1000 people, cause is unknown though an autoimmune factor is suspected.
  • Rarely, other autoimmune diseases such as vitiligo, thyroiditis or pernicious anemia may be associated.
  • 20 % have a family history
  • Key features: smooth, discrete, circular areas of complete hair loss, exclamation point hairs!
alopecia areata16
Alopecia Areata
  • Other keys: black dots of broken off hairs found at expanding edges, multiple patches can coalesce to form bizarre shapes
  • Alopecia totalis - hair loss of entire scalp
  • Alopecia universalis - hair loss of entire scalp and body
  • Prognosis: 90% of the hair loss will regrow within 2 years; however, recurrence occurs in 1/3 of cases
what is the treament for alopecia areata
What is the treament for Alopecia areata?
  • Intralesional corticosteroids - new hair growth can be seen within 4 weeks
  • Topical corticosteroids - better for totalis
  • Anthralin - an immunomodulator, nonsteroid, safe for children and those with universalis
  • Topical immunotherapy - for chronic severe cases
telogen effluvium19
Telogen Effluvium
  • Keys to diagnosis: hair loss is diffuse, onset abrupt
  • Pt has experienced a stressful or inciting event 3-4 months prior. The event disrupts normal hair growth cycle, more hair is prematurely shifted into the telogen phase.
  • Consider events such as pregnancy, weight loss, illness, surgery, psychological trauma...
  • The pull test - grab a few dozen hair follicles and gently pull - more than 5 telogen (club) hairs is abnormal.
telogen effluvium20
Telogen Effluvium
  • No therapy required, condition fully reversible
  • Other causes of diffuse hair loss to consider if an inciting event cannot be identified: medications, thyroid disease, connective tissue disease, syphilis (moth-eaten appearance), hypervitamintosis A, nutritional deficiency of zinc or biotin.
  • Anagen Effluvium - involves growing hair, thus results in a loss of 80 to 90% of hair; seen with chemotherapy.
12 yo male with sudden loss of hair 2 weeks ago what is the diagnosis
12 yo male with sudden loss of hair 2 weeks ago, what is the diagnosis?
  • Trichotillomania - the intentional pulling of hair
  • characterized by hairs of varying lengths and stubble
and don t forget cicatricial alopecia
And don’t forget Cicatricial alopecia
  • Results in scarring, often irreversible alopecia thought due to stem-cell failure at base of follicle, causes include:
    • autoimmune diseases - discoid lupus, lichen planopilaris (variant of lichen planus)
    • dissecting cellulitis, folliculitis decalvans
    • follicular degeneration syndrome in blacks
  •, “Practical Management of Hair Loss”, accessed February 15, 2009.
  • Springer K, et al. “Common Hair Loss Disorders”, American Family Physician, July 1, 2003, 68:1:93-102.