Computer generated transcript
Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.
Dermatology in Primary Care:
Hair Loss
Dr Rajani Tripathi, GPSI in Dermatology
MBBS, MD (Family Medicine, USA)
MRCGP 2018, DPD (distinction)
15 Oct 2024 Hair loss
Non scarring alopecia
Scarring alopecia
Ref: Habif Hair growth cycle
Anagen phase –growth phase
90-95% of hair is in this phase.
Its duration determines the length of hair, and for
scalp hair, it is 2-6 years
Catagen phase - involution phase
< 1% of scalp hair is in this transitional phase.
Acute follicular regression occurs.
Telogen phase- resting phase
5-10% of scalp hair in this resting phase.
It lasts for 2-3 months; club hair is ejected and
replaced by new anagen hair. Ref: Habif
Ref: Rooks
25-100 telogen hair is shed dailyClassification of alopecia
Focal or diffuse and the presence and absence of scarring (Habif, 2010).
Diffuse, non-scarring, e.g. Telogen effluvium, anagen effluvium, diffuse alopecia
areata, male and female pattern baldness, alopecia associated with systemic disease,
e.g. thyroid, iron deficiency, SLE.
Focal, non-scarring, e.g. localized alopecia areata, traction alopecia, trichotillomania,
Syphilis, Tinea capitis.
Focal, scarring e.g. lichen planopilaris, frontal fibrosing alopecia, acne keloidalis,
folliculitis decalvans, dissecting cellulitisTypes of alopecia
SCARRING ALOPECIA NON-SCARING ALOPECIA
Hair follicle is permanently damaged and Hair follicle is not damaged, hair growth
replaced by scar tissue cycle is affected e.g increased shedding or
slowed/reduced growth of new anagen
Hair regrowth will not occur.
hair.
E.g Lichen planopilaris, frontal fibrosing
Hair is likely to grow.
alopecia, folliculitis decalvans, acne
keloidalis, Kerion E.g alopecia areata, androgenetic
alopecia, Telogen effluvium, anagen
effluvium, trichotillomania T elogen Effluvium
Diffuse hair loss, body hair may be involved
About 70% of anagen hair prematurely enters telogen reversing the
usual ratio
Noticed 3-6 months after the triggering event
New hair growth pushes out telogen hair and increases hair fall
Fine new hairs can be seen.
Usually acute and lasts about 6 months but may be chronic
More common in women, e.g. postpartum.
Affects any age group and both sexes
Ref: Dermnet Common causes
ACUTE CHRONIC
Stress Iron deficiency
Acute illness- pyrexia
Thyroid disorder
Postpartum, stopping contraceptive pills
Chronic inflammatory conditions-
Major injury, Recent surgery
malabsorption, hepatic, renal disorders,
Crash diet, weight loss SLE
Jet lag
Drug induced-Acitretin Zinc deficiency
Excessive sun exposure
No trigger is identified in 1/3 of the cases Arrest of hair growth is often mirrored in
nails by Beau line.
Beau’s line can help estimate timing as
fingernails grow out in 5 months.
Telogen effluvium does not cause complete
baldness but may unmask male or female
pattern baldness
Ref: Dermnet Investigation
FBC, Ferritin (aim over 70)
TFT
U&E
LFT
Zinc levels
Vitamin D
Other test depends on history and examination: ANA for suspected lupus, syphilis
serology Dermoscopy: thinning of hair but scalp otherwise normal
Skin biopsy is rarely needed.
Treatment
Gentle handling of hair
Nutritious diet with plenty of protein, fruit and vegetables
Treat the underlying cause.
Psychoogical effects of hair loss can be huge
Unless the trigger is repeated, there will be spontaneous complete regrowth within 3-6 months Anagen effulvium
Abrupt hair shedding during the anagen (growth) phase
Caused by acute injury to the hair follicles due to :
Infection- boils, abscess, Tinea capitis
Drugs
Chemotherapy- recovers fully within 3-6 months
Radiation- regrowth may be incomplete or may not occur
Autoimmune – AA, alopecia totalis, alopecia universalis, pemphigus vulgaris Alopecia areata
• Autoimmune condition affecting hair follicles
• T-cell mediated
• Associated with – stress, atopic dermatitis
• Genetic predisposition
• Can occur at any age peak 2nd -4th decade
• Equal in male and female
• Circumscribed smooth bald patch.
• Scalp, beard, eyebrows, eyelashes, axillary and
pubic hair affected
Ref: PCDS Three stages:
1) Sudden hair loss
2) Enlargement of bald patch/patches
3) Hair regrowth
• Relapse and remittance• Dermoscopy: Exclamation mark hair is seen in the
periphery of the lesion during the active phase.
• Black dots and broken hairs are also seen
• Yellow dots and short vellus hair signify non-active
disease.
Ref: Dermatoscopedia• Patches may coalesce or progress to complete loss of scalp
hair (Alopecia totalis) or total body hair (Alopecia Universalis).
Ophiasis- Occipital and lateral scalp affected, bald patch may
encircle the scalp
• Sisaipho- hair loss in the frontal, temporal and parietal scalp
• The initial hair that grows is usually fine and non-pigmented,
Ref: Dermnet
then gradually regains its normal colour and calibre
• Patients with a mixture of grey and pigmented hair, it prefers
pigmented hair. ‘sparing phenomenon’
• Moth- eaten Alopecia is a feature of secondary Syphilis
Ref: PCDS Nail changes like pitting, hammered brass appearance, ridging, trachyonychia,
and red spots on the lunula are present in severe disease.
Treatment:
Spontaneous recovery
Very potent topical steroids like clobetasol cream or scalp application for 3/12.
Intralesional corticosteroids like Triamcinolone. Stronger evidence that topical
Contact sensitizers like DCP (Diphenylcyclopropenone)
NICE recommends a JAK inhibitor like Ritlecitinib in patients 12 years of age
and older, but this recommendation has not yet been translated into practice.
Others: PRP, Wigs
Ref: Rooks Poor prognostic factors
Childhood onset
Severe hair loss
Ophiasis
Bald patch lasting more than a year
Nail disease
Family history of AA
Coexistent autoimmune diseases Madarosis
Loss of eyelashes or eyebrows.
Causes
1. Alopecia areata
2. Hypo/ hyperthyroidism
3. Iron deficiency
4. Eczema, Psoriasis
5. Infection: Staph, Herpes simplex, Syphilis, Leprosy
6. Treatment-induced : chemo, radiotherapy, laser
treatment
7. Trichotillomania
8. Causes of scarring alopeciaAndrogenic alopecia- Male pattern baldness
Diffuse hair thinning and balding in adult male.
Cause- a combination of hormones and genetic predisposition
Sensitivity to the effect of DHT in some areas of the scalp.
DHT reduces the anagen phase to weeks or months
DHT production is regulated by 5-alpha reductase enzyme.
Affects 50% male Caucasian by age 50 and 80% by age 70
Chinese and Japanese men are less affected
Usual onset is mid to late 30s
Ref : PCDS Progressive fronto-temporal hair recession and
thinning over the crown, vertex.
Miniaturization of hair follicles occurs and
progressively fewer and finer hair
No inflammation, no scarring
Ref: Dermatoscopedia Treatment
Not available in NHS
Topical Minoxidil 5% (OTC) BD only works in 40 % of patients.
Response to treatment is assessed in 6 months and needs to be used long-term to
prevent relapse.
Minoxidil is best used in early-stage
Private treatment options- Finasteride 1mg OD, Dutasteride, oral Minoxidil, PRP, Hair
transplant Female pattern baldness
Genetic predisposition, genes inherited from either parent.
Unclear if androgens play a role, mostly normal
Women with hyperandrogenism e.g. PCOS, are affected
Role of estrogen is uncertain, but common after menopause
Can affect women at any age
Presentation: increased hair shedding
Frontal hairline margin is usually preserved with thinning over
the middle part, progressing from vertex to frontal scalp
Ref: PCDS Treatment
Not available in NHS
Topical Minoxidil 2%, 5% OD - OTC
Block effect of androgens: Spironolactone, cyproterone, finasteride
Low-dose oral minoxidil (0.625mg OD)
Hair bulking fibre powder, wigs, hair transplantation
PRP Traction Alopecia
Hair loss caused by prolonged and repetitive tension on
scalp hair, e.g. tight corn rows, ponytails, weaves, braids,
hair extensions, hot irons, and tight hair rollers.
Can also be due to the weight of excessively long hair.
Incidence increases with age due to prolonged history of
the hair care routine
Hair loss occurs at the site of maximum traction,
commonly along the hair margins – “marginal alopecia”
Fringe sign- retention of hair in frontotemporal margin
Ref: Rooks Can present with itching, redness, scaling, folliculitis,
broken hairs and thinning.
It is differentiated from alopecia areata by the lack of
exclamation mark hairs.
Initially, it is non-scarring, but prolonged excessive tension
leads to the destruction of hair follicles
Treatment:
Ref: Dermnet
Avoid high-tension hairstyles and treatments.
Cut long hair
Avoid heat and chemical Trichotillomania
• Irresistible urge to pull own hair
• Affects 4% of general population
• More common in children, peak in pre-
school years and early adolescence. M=F
• As age increases, it is seen more in
females.
• Cause: possible genetic tendency
• Psychological associations include anxiety,
obsessive-compulsive disorder, and
depression.
• Can be a coping mechanism for anxiety
and is commonly associated with other
habits like nail biting, nail/skin picking, lip
biting, etc.• The behaviour is often ritualized to a similar place, time of day, or situation, e.g. reading,
watching TV, or talking on the phone.
• There may be a compulsive urge that is relieved by the act of hair-pulling.
• Pleasurable and not described as painful
• Hair loss is seen in the scalp, eyebrows, eyelashes, and pubic hair.
• Hairs of varying lengths giving ‘ wire brush appearance, and normal-appearing areas.
• Split hair, broken hair, newly growing hair with tapered ends
• Normal underlying scalp, but scratches, and erythema from pulling may be seen
• Areas that are accessible to the dominant hand• If hair is repeatedly pulled out, damage to the hair follicles
can cause irreversible scarring, folliculitis even keloid
• Rare complication: trichobezoar and the Rapunzel syndrome
with gastrointestinal obstruction.
• Mx- Education of parents/caregivers.
-Behavior modification, habit reversal
- reducing stressors
-TCS, SSRI.
Usually benign and self-limiting in children. In adolescents and
adults, it is episodic and chronic and associated with more
psychopathology
Ref: Dermoscopedia Frontal fibrosing alopecia
Scarring alopecia in which there is recession of the frontal hairline.
Typically seen in postmenopausal women. Younger men, women, and
children of all ethnic groups can be affected.
Genetic, hormonal, autoimmune, inflammatory and environmental factors
have been suggested.
Seen in patients with hypothyroidism, autoimmune diseases like lupus
and RA and regular sunscreen use!
Contact allergy to fragrances, cosmetics, moisturising cream, suncream
Ref: PCDS
suggested but unconfirmed Linear band of hair loss and sideburns are also lost. Symmetric.
There may be a recession of the posterior hairline also.
Loss of vellus hair
Skin in the affected area is pale, and shiny and does not show sun damage
seen in the forehead
Perifollicular erythema and hyperkeratosis at the hairline.
Papules may be seen on the cheeks due to the involvement of vellus hairs
Hair loss can affect all parts of the body. Eyebrows may be affected before
scalp
Itch and pain are common early symptoms, and sometimes may have a
facial rash- skin-coloured or yellowish follicular papules
Ref: Dermnet• Dermoscopy: absent follicles, tubular perifollicular
scale, perifollicular erythema. Perifollicular
pigmentation. ‘Lonely hair’ in the bald area.
• Diagnosis: skin biopsy to rule out other causes of
scarring alopecia
• Treatment:
• Topical steroids like betacap scalp application
• Anti-inflammatory antibiotics like Tetracyclines. REF: Starace M, Orlando G, Iorizzo M, Alessandrini A, Bruni F,
• Hydroxychloroquine S, Lobato-Berezo A, Mernissi FZ, Paoli J, Patrí A, Sabban ENC,
Sławińska M, Sobjanek M, Zaar O, Pellacani G, Piraccini BM.
• Rituximab, Adalimumab Clinical and Dermoscopic Approaches to Diagnosis of Frontal
• Hair transplant once the disease activity has settled International Dermoscopy Society. Dermatol Pract Concept. 2022
Jan 1;12(1):e2022080. doi: 10.5826/dpc.1201a80. PMID:
35223189; PMCID: PMC8824238.
• Prognosis- slowly progressive, self-limiting, burns out
after several years Lichen planopilaris
• Lichen planus of hair follicles
• Scarring hair loss
• Mostly affects young adult women F:M::8:1
• Cause- autoimmune and rarely genetic or drug-induced.
• Patch commonly in vertex and patches can merge
• Associated redness, itching, pain, perifollicular scales Ref: Habif
•
Shiny waxy scalp
• Can affect scalp, eyelashes, eyebrows, axillae
• Dermoscopy: tubular perifollicular scaling. Erythema, white dots.
• Skin biopsy- lymphocytic folliculitis
• Treatment aim is symptom control and slow progression
• Potent topical steroid, high dose Lymecycline 408 mg BD or
Doxy 100 mg BD.
• Hydroxychloroquine
• Other; Acitretin, Ciclosporin, Methotrexate
• Prognosis unpredictable- may burn out or be progressive
Ref: PCDSCentral centrifugal cicatricial alopecia (CCCA)
Scarring alopecia
Most common form seen in Afro-Caribbean women, may
be seen in men
Middle-aged women are most affected
Cause- unknown, multifactorial- genetic autoimmune,
fungal/bacterial infection
Hair loss in the crown and extends in a centrifugal
manner, incomplete alopecia as some hair remains
Hair breakage is an early sign
Ref: Dermnet Scalp may appear shiny
Tenderness, itching and burning is common
Diagnosis- clinical feature + scalp biopsy from active edge
Treatment goal is to stop the progression
Dermovate or intralesional steroids
Tacrolimus
Tetracyclines- Doxycycline, Lymecycline if pustules present
Hydroxychloroquine, ciclosporin
Avoid hairstyles causing discomfort and scalp irritation Folliculitis DeCalvans
Chronic neutrophilic inflammation causes scarring hair loss
th th
4 -5 decade, Male predominance
Cause: Abnormal immune response to Staph aureus
Affects scalp around crown, may affect beard, axillae, limbs,
pubic hair
Irregular scarring and hair loss, scalp induration
Follicular pustules and crusts
Ref: Dermnet
Tufting giving a ‘doll’s hair’ appearance
Itch, discomfort, pain Diagnosis- swab for microbiology and Mycology
Skin biopsy- neutrophilic infiltrate
Treatment: -Antibiotics- oral tetracyclines, azithromycin, Rifampicin and Clindamycin
-Others: Isotretinoin, TNFi, IVIG
-Photodynamic therapy
Fluctuating exacerbation and remission over many years.
Treatment reduces inflammation in the short term, but unclear if it affects long term
prognosisAcne Keloidalis nuchae/folliculitis keloidalis
Chronic inflammation of the hair follicles of the neck
leading to hypertrophic scarring.
Most prevalent in Afro-Caribbean males with curly hair.
M:F::20:1
Causes
Injury during close shaving of hair
Ingrown hair irritating the hair follicles Ref: Dermnet
Irritation from shirt collar
Chronic low-grade bacterial infection Itchy round small papules at the back of the neck
Scratching can lead to secondary bacterial infection and develop pustules
Leads to scarring, and scars can develop into keloid-like hairless areas.
Diagnosis is clinical
Biopsy if diagnostic uncertainty.
Biopsy will show neutrophilic inflammationTreatment- is difficult
GENERAL MEASURES SPECIFIC MEASURES
Ensure the helmets and collars do not Topical steroids like Dermovate, intralesional steroid
Antibiotics-Tetracycline or Doxycycline for 3
rub the back of the neck.
months
Avoid shaving hair For more severe cases Clindamycin300 mg BD
+Rifampicin 300 mg BD for 3-6 months
Stop grease and pomades Oral Isotretinoin,
Laser ablation
Antimicrobial cleansers like Dermol or
Hibiscrub Pseudopelade of Broq
Unusual form of permanent hair loss of unknown cause.
Caused by atrophy of hair follicles rather than scarring.
Affects middle-aged and older women commonly
Affects vertex, parietal scalp and rarely beard
Single or multiple smooth patches, may merge
Patches described as ‘footprint in snow’
Ref: Dermnet
No scales, skin normal colour. Perifollicular redness in early
stage.
Hair may be easily pulled from the edges if active Diagnosis reached by excluding other scarring alopecia
Scalp biopsy shows thin epidermis, sclerotic dermis and fibrotic streamers down to the fat
layer.
No inflammation is seen in the biopsy.
No known treatment to stop the process or regain hair.
Usually, it is a slow process with a small area of hair loss.Dissecting cellulitis/Perifolliculitis capitis abscedens et
suffodiens
Uncommon cause of scaring alopecia.
Most common in Afro-Caribbean men in their 30s-50s
Cause: A defect in follicular keratinisation causes occlusion and
Ref: Dermnet
inflammatory destruction of the follicle.
It mainly affects the vertex and posterior scalp.
Follicular and perifollicular pustules, nodules, pseudocysts with
purulent exudate and pain
Interconnecting sinuses
Hair loss and keloid Patients may have follicular occlusion syndrome- HS, nodulocystic acne and pilonidal
disease
Dx: clinical
Treatment:
- Antibiotics- Tetracyclines, Erythromycin
- Isotretinoin
- Oral/intralesional corticosteroids
- Analgesia, topical antiseptic
- Others: TNFi, Laser , Surgical Tinea capitis/ Kerion
Fungal infection of the scalp involving skin and hair
Trichophyton tonsurans and Microsporum canis (pets)
predominate
Affects preadolescent children, seen in siblings, peak age
3-7 years Ref: PCDS
Also affects immunocompromised adults
Risk factors: animal contact, household crowding, warm
humid environment
Ref: Dermnet Single or multiple patches
Hair loss, broken, black dots ringworm
Scaling, w/ or w/o hair loss
Yellow crusting and matted hair.
Ref: Habif, 2010
Itching maybe present
Cervical lymphadenopathy
Kerion- boggy mass of inflammatory tissue with
pustules. Dermoscopy: scale, broken hair, loss of pigment. Comma
hair, corkscrew hair
Skin scraping and plucked hair follicle for mycology
Risk of scarring alopecia, start treatment
Contagious- sharing hairbrush, pillow, hat, helmet, towel
Ref: Dermnet Treatment
Terbinafine for 4 weeks, first choice
weight > 40 kg =250 mg OD
weight 20-40 kg = 125 mg OD
weight up to 20 kg = 62.5 mg OD (Ref: PCDS)
Itraconazole is an alternative for adults
Griseofulvin in children 6-8 weeks, more effective against M. canis
Griseofulvin is the only licensed oral antifungal agent for the treatment of fungal scalp infection in
children in the UK (Ref: NICE CKS)
Itraconazole is not licensed for the treatment of fungal scalp infection in the UK(Ref: NICE CKS). Kerion: Terbinafine for 12-16 weeks
Treat patient and family members with Ketoconazole
shampoo 2x week for 2 weeks. Reduces infectivity and
shedding of spores
Pet should be examined by Vet and treated if indicated .
Ref: PCDS Charities and support group
Alopecia UK; Alopecia UK
British Association of Dermatologists (bad.org.uk) for PILs