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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