Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

OK, good evening everybody. Almost 100 and 30 people here. Fantastic. It's great to see everyone and thank you for joining on another middle primary care network event. We are over the over the moon to have Doctor Regani Tripathy with us tonight. Um She is a GPP, so like the rest of us, but with a specialist interest in dermatology and works in community dermatology in Birmingham in the UK. So we are so glad to have you with us or Janny. Uh Welcome to everyone joining us. Um As you know, if you've been here before, you'll be well familiar with the format of our sessions. We will run the presentation for as long as it takes and then we'll have some interaction with question and answer answer at the end. So please please please throughout the interactive in the chat, we will be keeping an eye on the chat um as we go through and I'll try and harbor off our questions to the side. I pop the link in right at the very top of the chat there for the mail all up. And um you can register for all up and everything else that is going on there. Um You can also get your feedback forms and your certificates there too. We are still running three primary care events every week where we're working really hard to get the upcoming, uh, schedule up to Christmas kind of filled up and put together. So we are working hard on that in the background. Please keep an eye um, for the upcoming things. Get registered and get your name and the hat to be there without any further ado though, I'm going to hand over to Doctor Tripathi for tonight's talk. Thank you, Tim. Um Good evening everyone. Um As Tim said, my name is Doctor Tr uh Trar. I'm based in Birmingham and I work in Community Dermatology Service in Birmingham. So when I was asked to talk about dermatology in primary care, I thought we'd talk a bit about hair loss. Uh next slide, please. So when we talk about hair loss, we commonly think of male and female pattern of hair loss. But uh besides that, there's a lot of other types of hair loss and we can be in the broad category, we can divide them into scarring and non scarring type. As we move along. We'll talk about these in more details. So um Timmy can go uh do the whole. Yeah. So before talking about hair loss, we can talk about uh hair growth cycle uh briefly. So hair in our uh body goes through a growth phase called anaphase uh antigen phase, um 90 to 95% of our hair is in this phase and the duration of the antigen determines the length of the hair. So why some people have shorter hand and why some have longer hair, despite not cutting the hair for same duration. So, after the anaphase antigen phase, the hair goes into catagen phase and this there's evolution of the hair follicle. So if you see in the picture on the right, um So cat in the catagen phase, um hair is starting to evaluate and separates from the dermal papilla. And um this usually uh last um about three weeks or so and then comes the resting phase, also called television phase. 5 to 10% of our scalp hair is in the resting phase. This last about 2 to 3 months. So when the new hair then starts growing in the new antigen phase, it pushes the television hair out and the old hair falls in normal situation, we do lose about 25 to 100 television hair um every day and more. So on the days we wash our hair shampoo. Um So classifying hair loss, so we can divide based on the distribution and based on whether they are scarring or not. So, so diffuse nonscarring type would be uh things like telogen EUM and Energen eho um alopecia area that can be diffused and um the common male and female pattern boneless and other hair loss associated with systemic disease can be diffused. So, focal nonscarring would be localized alopecia, areata and traction alopecia. Um syphilis can cause um focal non scarring and tac hepatis as well. Um Initially tinea heit is non scarring, but if you leave it untreated, it can go uh progress to scarring and permanent hair loss and Trillo mania. Uh we'll talk more about it is the spectrum of um obsessive compulsive disorder. Um and the focal scarring type um um uh types like um lichen planopilaris, frontal fibrosing. And we'll talk about this in more detail. As we go along, you can put the whole slide. Thank you. So, scarring alopecia in this, the hair follicle is scarred, so it's damaged and replaced by scar tissue. So the hair regrowth will not occur uh because the hair follicle has been damaged. Whereas in non scarring, the hair cycle growth cycle is interrupted and there's increased hair loss but follicle still healthy and working. So there is a chance that hair will grow back if treated next. So we'll first talk about te aho, this is very commonly seen in uh community dermatology and often patient present with a bag of um collected hair. So they uh they, they collect hair after combing and in shower and they bring it to the clinic. So this is a type of diffuse hair loss and body hair can be involved as well. So often there is a triggering event and then about um 70% of the antigen hair we should have been growing then enters the television for uh phase. So this is usually noticed 3 to 6 months after the triggering event. Paradoxically, hair fall as we discussed in hair cycle is a sign of hair growth. So new hair is growing and it pushes the television hair. So there is hair fall. Um so fine hair can be seen growing. Um The uh telogen eho is usually acute and last about six months, but sometimes it can be chronic. It is commonly seen in women, especially after childbirth, but it can affect any age and both uh gender. So common causes of tele eho in acute ones is the stress. Um any pyrexal illness, postpartum or stopping the contraceptive pills, any major injuries, surgery, a crash diet or weight loss, even jet lag can contribute to it. Medications like acid retin ISOtretinoin and even excessive sun exposures. And the chronic causes uh uh related more to systemic uh conditions like thyroid disorder or iron deficiency and um chronic inflammatory disorders causing malabsorption, zinc deficiency as well in one third of the cases. However, no uh trigger can be identified. So the so the triggering event can be mirrored in the nail. So um by this uh line called bus line, so nail, a fingernail grows out in five months. So it's in the middle. So you can say the triggering event was about um 2.5 months before uh this uh this photo was taken. So, so the patient might be able to rega recall a triggering event around that time that then led to hair fall. So it does not cause complete uh baldness. And if the underlying cause is treated, usually hair grows, but it can unmask the fe male or female pattern baldness. So, for any hair loss, uh we're generally recommend doing this investigation. Uh So uh a full blood count to make sure hemoglobin is normal and ferritin. Um if there's issues with hair loss, Ferri, it is recommended to have aim for ferritin over 70. Given this wide range normal range of ferritin, uh thyroid functions, um basic and liver function, zinc level. And if it's low zinc level, uh just patient takes the over the counter zinc supplement nor and a Vitamin D and um levels should be checked as well. And other tests depends on the history and examinations. Um like syphilis, uh serology if there's um uh suggestive history. So, on examination, um in um te eho scalps generally healthy, but there's um thinning of the hair and a scalp biopsy is rarely needed because it's a clinical diagnosis. The treatment includes gentle handling of the hair and a nutritious diet, um supporting hair growth and treating underlying cause like um thyroid disorder or iron deficiency. Uh based on the investigation, um we should not underestimate the psychological effect of hair loss as it affects the appearance. Patients are usually affected unless the trigger is repeated, it usually makes a full recovery. So, Energen eff uh effi is another form of uh non scarring alopecia. So, this is commonly seen in patient having chemotherapy. So the Energen grew uh hair that is an Energen phase, the growth phase abruptly enters um uh the growth is arrested and it this it starts hair, starts falling so commonly with medications and chemotherapy radiation, sometimes with infections as well. So next we move on to alopecia, areata. As the name suggests, it's the patchy hair loss. So it's an autoimmune condition often. Um It is said to be t cell mediated. Again, this can be caused by stress. Um dermatitis, there is genetic predisposition and often can be seen in families. It is common in second to fourth decades and equal in male and female. The patches on examination are bald with no fuzzy hair or broken hair generally. Um it can affect other hair bearing areas like scalp, beard, eyebrows and other parts of the body. So, um alopecia area, there's three stages. Uh patient discover sudden bald patch. So sudden hair loss, the patches can enlarge and uh the uh neighboring patches can merge and then the hair um grows back, the relapse and Remittance is quite common. So, hair might be growing in one patch and um while they might be developing another patch where hair is um where they're losing hair. So on examinations on dermoscopies, we can see this typical exclamation mark here where it's narrow at the bottom and a bit wide at the top. And these are usually seen in the active disease. Also black dots uh signaling broken hair can be seen in the active um conditions. Yellow dot uh a short vous hair um are seen in non active um disease. So A vs hair is when the hair first grows, it's quite a thin and vi uh type. So there are different types of a uh facial areata. Sometimes it can progress to total scalp, hair loss, totalis and total body hair loss, which is alopecia, universalis and um the hair loss in the back uh in the occipital area, it's called oops. Uh This is associated with poor prognosis opposite to this is the CPO where the hair loss is in the frontal and temporal parietal area. Um initial hair that grows is non pigmented, defined like a willow hair and as they grow, it gains the color and becomes thicker if the patient have gray hair and um colored hair. So it spares the gray hairs. It's called sparing phenomena. Often. Um if a young patient with suggestive history presents with multiple small patches in the scalp, uh you can suspect syphilis and syphilis, serology um should be done. So sometimes uh patchy morph and pattern can be the only presentation of secondary syphilis. So sometimes uh the severe disease is associated with nail cha uh changes. Um The pitting of the nails is common and it's described the appearance is described as a hammered breast uh appearance uh because of the pattern. Um nails can be rough and sometimes they might be red spot in the linea just if left untreated. Most of the patches, they do grow hair. Uh but patient often wants to try treatment. And so um strong topical steroids like uh dermovit can um can be used for up to three months if that's not working. The next stop. Uh next step would be um to injection of the steroid in the patches. The intralesional steroid has stronger evidence than the topical. But um these uh this is not offered in NHS anymore. It used to be um we used to offer this in our service a few years ago, but um it stopped now, secondary care uh often offers um contact synthesizer like DCP. So it's, it's applied on the scalp to irritate the scalp and stimulate the immune system which then promotes hair growth. Nice. Uh uh Recently recommended drug inhibitors um for a patient above 12 years of age, but it's not yet translated into practice. Last time we checked it, we were still waiting from IV. Um approval. Other options would be P RP uh which doesn't have a great evidence. Uh But these are offered pri in private clinics and wigs poor prognostic factor for alo area that would be childhood onset um and severe hair loss vi like I said before, generally, we expect bald patches to grow even without any treatment. But if they have lasted over a year, then it's associated with poor prognosis. Um nail disease is a sign of a poor prognostic is a poor prognostic factor and family history and other systemic disease as well. So often, uh with the conditions causing hair loss, it can cause um eyebrow and eyelashes loss as well. So, in alopecia area that these areas uh can be affected. So, uh loss of eyelash eyebrow is called Marois and other conditions that affect these uh thyroid disorder or iron deficiency. Um inflammatory conditions like uh psoriasis or eczema infections and uh uh medication induced like uh chemo or radiotherapy Trillo mania where you um person can be pulling it out and other causes of scarring, alopecia can affect the eyebrows and eyelashes as well. So, coming to androgenic alopecia, we commonly call it male pattern baldness as well. So there's diffuse thinning of the hair and balding in adult male. So it is a combination of hormones and genetic predisposition, the scalp hair. Um the areas affected are usually sensitive to dihydrotestosterone and it causes the miniaturization of the hair, follicle and hair um loss. So, it's very common and it is seen in 50% of Caucasians by the age of 50 80% by the age of 70. Luckily, the Japanese and Chinese men are less affected. Usual age of onset is thirties, but it can be seen in um late teens and twenties as well. So, in the male pattern, um you can s you can see the frontotemporal hair loss um and the hair loss starts in the crown. So, so when we look through dermatoscope, no, in normal scalp, there's three or four hair coming out from each follicle and they are roughly the same diameter. But here you can see some thinning and reduced number of hair, Folli hair coming out from each follicle and thinning. So this is called miniaturization, scalp is otherwise healthy and there's no redness, scarring or inflammation. So, treatment uh generally, there's no treatment available in NHS. But for this um male and female patent bonus, uh patients can try Minoxidil. So which is uh available over the counter 5% Minoxidil is licensed in men and can we use it twice a day but it does not work for everyone. So, only 40% of patients see response. Um The response is assessed in six months and if they find it's been helping them, they need to continue using it for a long term effect. If they stop using it, the benefit will be lost and they'll start losing hair again in a couple of months. So, Minoxidil is best to use in early stage. Um private clinics offer other treatments like Finasteride, um oral Minoxidil PRP, which doesn't have great evidence um and hair transplant. But bearing in mind, the transplanted hair can be affected by the same process that affected the original hair. So, graft survival is poor. It's a female patent boneless, similar to male, patent boneless. Um So there is a genetic predisposition to it. And genes can be inherited from either parent. The role of androgen is unclear because in most of the patients, androgen level is normal as people who have polycystic ovary, um they can um uh suffer from aloe um androgenic alopecia as well. So again, rule of estrogen is uncertain, but it's common in patients after menopause, it, however, it can affect any women. So the pattern of hair loss is different in women. So usually the anterior frontal hairline is um is uh preserved and hair loss starts in the vertex. The treatment against in little male is not available at NHS. It's a topical minoxidil. 2% is licensed in women. We do recommend 5% to be used as well, but it's off license. Uh But if women are using 5% generally, it's once a day. Um other treatments available in private clinic, uh spironolactone, um oral minoxidil. Um patient can buy uh a hair spray with a bulking powder that makes the hair look a bit thicker PRP um is also offered privately but it doesn't have great evidence. So, moving on, um another type of um non scarring alopecia is traction. Alopecia is due to the repeated p uh pulling on the hair. So in the top photo, you can see the hair loss along the sides um because the person is um tying the hair in the front to put it under the turban. So uh and in the other photos that is from the braiding, so you can still, it's not completely bald, like in alopecia areata. So you can still see some hair um but uh hair loss is significant. So it is caused by prolonged and repeated tensions. Um And sometimes it can even be due to excessive weight of very long hair. As, as the patient grow older, the incidence is more common because of repeated practice of hair care uh and fringes. So the hair that you can still see some hair in the margins. So that's called fringe sign. So, scalps generally um healthy but sometimes there can be redness uh or folic light just due to repeat pulling of the hair. Um So there is no exclamation hair like in alopecia areata. Initially, this is non scarring. But if, if it's continued for a long time, it can lead to permanent destruction of hair follicle. So um treatment would be avoiding uh hairstyle that's putting tension on the hair follicles um and avoiding heat and chemicals. So, so next we move on to Trty mania is it's a um it falls under the op compulsive disorder. Uh Patients have irresistible urge to pull on hair and uh they get satisfaction after pulling uh uh the hair. It is more common in Children in preschool years and early ADOS um equal in male and female. But as, as the patient grow older, is seen more common in female, there may be genetic tendency and psychological association like anxiety, um OCD and depression. It can even be a coping mechanism to anxiety and may be associated with other um habits like nail biting or skin picking, et cetera. It's often virtualized and patient do it uh in similar situation like reading book or watching TV, or talking on the phone. Uh So the urge to pull hair is relieved by hair pulling and patient, it's often pleasurable. As the patient don't complain of pain, it can be seen in scalp, eyebrows, eyelashes, other hair bearing part, so often they, there will be hair bearing length in the patch, there may be hair, uh split hair, broken hair and these patches are usually accessible to dominant hand. So if you see the patch on the top, it's not completely bald, there's little bit of hair um in the middle and in the second picture. So you can see broken hair. So that's due to uh pulling. Um if associated with psychological disorders, sometimes patient can uh eat the hair and a rare complication is the trach of. So management, a patient will benefit from multidisciplinary approach, education of parents and carers um and um psychological input um behavior modifications and a antidepressants uh um as appropriate, usually benign and self limiting in Children. But uh but in adults, it can be episodic and chronic. So, moving on to um uh so these uh so now we're starting the scarring type of alopecia, the frontal fibrosing alopecia. Um I'm not sure if it's clear in the picture. So the anterior hairline is receding due to scarring. So, um typically seen in postmenopausal women, but it can be seen in others like younger men and women and Children of all ethnic groups. Um Again, the um this multifactorial so genetic um component along with hormonal and autoimmune, um factors have been suggested. Um patients with some systemic disorders like um rheumatoid arthritis, lupus can also develop this condition and it there has been also suggestion of um using sun cream. So uh it is um said that sun cream causes contact irritation to the hair follicle. So advises to make sure it doesn't touch the hairline while applying sun cream. So, contact irritation from fragrance, sun cream um cosmetics. So, in this, there's linear band of hair loss along the frontal hairline and uh sideburns will be lost as well. And um these are symmetrical. Um the venous hair can be affected like hairs on the cheeks, um the small hairs. So if you look at the top photo, the there are signs of sun damage on the forehead, but there's a band of clear skin above it. So that's the receded hairline and signs of sun damage is not seen in those um area. So there's also a peri follicular erythema. So, as you see in the second photo and hyperkeratosis, the follicles can look quite prominent. Um If you, especially when you look from the side, you can uh make that out. And if the venous hair is affected, you can see the skin color papules on the cheeks as well. It can affect any hair bearing part of the bodies and eyebrows may be affected even before the scalp itch and pain are common. Um and sometimes um they may have some rash on the face. So, uh when you look um at the scalp dermoscopies, so you can see the scales around the hair follicles, often tubular perifollicular scales, uh like tubular cast and in the bald area, they may be sparing like one or two lonely hairs might be present for most of the sca um scarring alopecia. Um So we do do scalp biopsy to differentiate different types, um types of alopecia. So, treatment um so you can start with the topical steroids, um anti-inflammatory antibiotics like tetracycline, Lymecycline, doxycycline have a role. So usually they are given for three months and if these are not working patient, uh this is quite active and patient losing hair actively, the referral to secondary care for consideration of other treatments like hydroxychloroquine. Um So it is slowly progressive. Um a lot of scarring elevation. They, they are self-image and they burn out after several uh years. So, lichen planus is another type of um scarring alopecia is uh the lichen planus of the scalp. It mostly affects young adult women. So female to male ratio is is to one like lichen planus ulcer. It's autoimmune and rarely, they may be genetic component or drug induced uh patches commonly seen in the vertex, the neighboring patches can merge. So initially there may be redness, itching, pain, perifollicular scales, um and in advance it, the scalp will look quite shiny, clear. Um It can affect other hair bearing parts, like eyelashes, eyebrows. Again, on dermatoscopy, you can see perifollicular scales. Um if it's early on, we can see redness um as well. So, skull biopsy is done and these will show lymphocytic folliculitis along with other features. So, aim of the treatment because these are scarring hair will not grow from the areas that's lost hair, but aim is symptom control and slowing the progression. So again, um topical steroids, anti-inflammatory antibiotics have a role and if these are not working and then a referral to secondary care for things like hydroxychloroquine and other treatment, the prognosis for lichen planar pleur is unpredictable but it can burn out like frontal fibrosing alopecia. So this is another type of scarring alopecia, um commonly seen in Afro Carribean women. Um it may be seen in men as well um to cause again, multifactorial. Um there may be autoimmune component and genetic component. Infection may have a role, hair loss starts in the crown and then it spreads in centrifugal uh pattern hair may start breaking early on in the condition. So, if lots of hair has um been lost, the scalp, usually clear and shiny. Um no redness in the advanced stage. Um tenderness is common itching um especially in the early stage. The diagnosis based on clinical feature and scalp biopsies. The when we do biopsies is always from the active edge, the margin of the area with some hair and some bald area. Again, goal is to uh of treatment is to stop progression. So, topical steroids, um if they, those are not working, then intralesional steroid injections, um tacrolimus or anti-inflammatory antibiotics and uh other treatment from secondary care. Um as also patients should be advised to avoid hairstyles that push pre uh pressure attention or cause discomfort in the affected area. So all the previous ones, the scarring ones, those are lymphocytic inflammation. So, moving on to the neutrophilic inflammation. So, folliculitis, the os. So it is a neutrophilic inflammation causing hair loss, commonly seen in 4th 50 decades in May uh in most common in men. So it is uh said to be abnormal immune response to staph aureus, to staph aureus can cause infection in the scalp causing folliculitis. But with exacerbated response, it can lead to folliculitis dect, it can affect um other hair bearing areas and in scalp is commonly starts around crown because it causes the damage to the hair follicle. Uh so there's scarring and there might be induration in the scalp as well because it's the Folly clots, they can be pustules in the scalp. So it gives a typical appearance, what we call doll's hair. So if you see there's tuft of hair, um so like the doll's hair. So that's quite common and itch pain discomfort because of the inflammation. So, diagnosis clinical and then if there's any discharge or any suggestion of infection, then um swab for microbiology, mycology as appropriate and skin biopsy done for diagnosis. So treatment again because it's inflammation. So anti uh antibiotics like tetracyclines. Uh it's the first line if they are not working, then Erythromycin, um Clarithromycin, azithromycin can be used if these are not working. Then a combination of rifampicin and clindamycin. So 300 mg twice a day for up to three months. If these are not helping, then they'll need referral to secondary care for further treatment. So there is fluctuating exacerbation and remission over many years. Um treatment with antibiotics and these things, it help in the short term, but it's not clear if it affects the long term prognosis. So next is acne keloidalis, um which is a misnomer because it's not an acne, it's actually folliculitis. So it's also called folliculitis keloidalis. Um It's the chronic inflammation of the hair follicle of the neck, then it then leads to hypertrophic scarring. It's most common in Afro Carrian male with curly hair, male to female ratio is 20 is to one. So it's caused by um chronic inflammation of the hair follicle. So, injury of the hair follicle during close shaving and then there will be ingrown hair which can irritate the hair follicle. It can also be exacerbated by chronic irritation from like shirt collar or helmet. So there's low grade um bacterial infection. So often there will be itchy red papules at the back the of the scarring. Um scratching can lead to secondary infections and develop pustules. Um and the area will develop into kilo like hairless area. The hypertrophic scars diagnosis is usually clinical and biopsy is not usually needed, but sometimes if there's diagnostic uncertainty, biopsy can be done. So, treatment is it is difficult condition to treat. But uh so there are general measures affect um with advice on lifestyles, ensuring um avoiding helmets or color. I irritating the back of the hair, avoiding shaving, avoiding the greasy hair products and uh anti micro cleansers like dermal or Hibiscrub to wash. Specific measures would be der in the hypertrophic areas. If there's active infection, uh follicle, then um te um tetracyclines or a Clindamycin and Rifampicin for 33, up to three months and then reviewing or isotretinon is an option laser ablation of the hair follicle to prevent uh worsening. So, se blader broke, this is an uncommon cause of hair loss. So the the all the hair uh scarring type of hair loss. I previously, those are due to scarring, but this is due to atrophy of the hair follicle rather than scarring. It affects the middle aged and older women commonly and uh commonly seen in the vertex. They may be single or multiple patch and the patches are described as footprint in snow. So, sca scalp is generally generally healthy. So there's no inflammation and there's normal color. Um there might be redness only in the early stage, but there's no active inflammation, there's atrophy um and the diagnosis is done by a scalp biopsy. The biopsy shows typical features of thin epidermis of sclerotic dermis and the fibrotic tumors go down the fat layer. Uh there's no inflammation and there's no known treatment to stop the progress, the progression of the hair loss. But generally, it is a slow process and only affects small area of um scalp. So, dissecting cellulitis um of the scalp. So it's uncommon cause of scarring alopecia. Again, commonly seen in Afro Caribbean men in their thirties to fifties. There is a defect in follicular keratinization that causes occlusion and inflammation of the hair follicle. It mainly affects the crown, the posterior scalp. The they will be pustules in follicle and perifollicular, the cyst and the su the cyst and they may communicate through the interconnecting sinuses. Um in advanced stages, there will be scarring and hair loss and um can lead to colloid formation. The patient may have others. Uh other symptoms of follicle occlusion symptoms. Um syndrome like hidradenitis, uh tuber nodular cystic acne pilonidal sinus that these are part of follicle occlusion syndrome. Um diagnosis is usually clinical and because it is um infection. So, treatment would be antibiotics like tetracycline or Erythromycin isotretinon may have a role and um steroids um for the treatment of kilos and scarring later on and other treatments offered in secondary care. So, I've included tinea capitis as well in the hair loss. So this is commonly seen like we discussed earlier is initially it's non scarring and if treated, then hair will continue to grow. But if left untreated, it can lead to scarring and permanent hair loss. So this is the fungal infection of the scalp and the hair follicles. So often we get patients referred, who's only been treated with topical antifungal, but that's not gonna work because the infection is all the way down in the hair follicle as well. So common uh causes would be trichophyte and tonsil runs and microsporum microsporum. Um you can contract it from the pets common in Children, preadult and Children often you can see it in siblings and PK ages 3 to 7 years and it can affect immunocompromised adult. The risk factors would be animal contact, overcrowding, warm humid environment. So they may be single or multiple patches in the patch, the hair, um there might be broken hair, black dots, scaling uh with or without hair loss or in arteries, there won't be hair loss later, hair loss, itching may be common as in tinea infection elsewhere, cervical lymphadenopathy helps in the diagnosis. So, if you're not sure whether it's um psoriasis or tinea hepatis, and if there's cervical lymphadenopathy, it's most likely the tinea hepatis. If left untreated, it can lead to curing which is a boggy mass of inflammatory tissues. So when seen through dermoscopy, you can see uh scales and broken hair, uh comma. So hair can be comma shaped or corkscrew uh types. So when sending sample for mycology, that we need to send the scales, the scraping and also pluck some hair roots for hair sample. So just cutting the uh distal part of the hair is not gonna be enough. So it should, the root should be taken for the sample as well. Um And if untreated, so it will lead to scarring. It is contagious and often seen in siblings because they share the hairbrushes, a pillow, um hat, helmet towels, those are common uh source. So treatment um um commonly we use terbinafine, oral, oral terbinafine. So top topical like I said, will not reach the hair root. Um So it has to be oral. So this is the weight um as given a weight based dose as um given in pcds guidelines as the Primary Care Dermatology Society. Itraconazole is an alternative for adults. Grise evolving is the only licensed medication in UK for tinea capitis. But because of the availability and uh expense, usually Terbina in a and Itraconazole is not um licensed uh for insurance So for car, the treatment uh the terbinafine should be continued for 12 to 16 weeks. And the patient and the family member should be treated with um ketoconazole shampoo um twice a week for the initial two weeks. So it reduces the shedding of the spores. And if there's a family pet, they uh and they have symptoms, they should be examined by vet and treated if appropriate. So these are the support groups that help people with hair loss, alopecia, U uh UK and uh so Bridge Association of Dermatologists there, there's a lot of i um helpful patient information leaflet that I often send out to the patients after the clinic appointment. Thank you everyone. Thank you so much, Roen. That was fantastic. Very in depth coverage of all causes of hair loss. There have been um quite a lot of questions coming through. So, if you don't mind, I'm going to stop sharing the presentation and run through a few of them with you. So, um we'll start from the start. Farhan has asked, is there any reason why you would check LFTs for her hair loss? What abnormalities would you be likely to see? Uh RFs? I'm assuming maybe renal function tests. Yeah. So the T is usually it will give albumin as well as a general indicator of good health and nutrition. So with albumin and R FT s, um to make sure they are generally in good health condition. So not looking for any specific electrolyte abnormalities for hair loss but um a more um a glomera filtration rate. Um Sure and indicator of good health. Sure. So it's like a general health overview, I guess a bit of an M OTI yeah, in general practice we do that so often it's just checking, checking for other causes. Um Please folks do post any other questions that you have in the chat even as we're going through. I am, I am watching those two add them to the pool. Um Rosette started a series of a few questions about the use of steroids. So, um they've asked how do steroids actually help with hair growth? Maybe what is the kind of process behind that? So if it is going back to alopecia areata, then yeah. Yes. So, so steroid does not help with hair growth and this is what I explained to patients. So what's happening in he alopecia areata is the body's immune system is attacking the hair follicle and it's causing the hair loss. So, steroids used to calm down dampen that immune reaction and if that attack is stopped, then hair should grow normally. So steroids, not like oxygen causing the hair growth, but it's calming down that immune attack. Sure. So it's actually it's, it's suppressing the the autoimmune response. Mhm. Um And then secondly, about the steroids and as I had asked about, what do we actually advise patients in terms of correct application of steroid and treat the scalp. So it depends on which one you're using. If you're using dermoid, it's once a once daily for up to three months. If you're using Elocon, it once daily, if you're bet, then twice a, uh, twice a day. But generally we do use Alo Dermovit once daily for up to three months for scalp. Scalp is quite thick. So you don't have to worry about thinning of the skin with long term steroid use. That's one side effect. We don't have to have to worry so much about that. Rosette also asked, there's obviously, I mean, anyone who watches certainly here in the UK, anyone who watches, um TV will see endless advertisements about different treatments for things in rosette. Um Also kicked off a series of questions about those other treatments that are available and asks Rosanne, what are your thoughts about the use of caffeine based shampoos? Can they help? II, I'll be honest. I I'm not sure. So we don't really recommend this as a medical treatment. And uh I'm not sure of the evidence behind caffeine use. Sure. Perhaps the, perhaps the jury is out on that. If anybody does know of anything off the top of their head, please, um, pop it in the chat there. Um And then she be following on for that evidence. Is there any evidence for the use of rosemary oil um in benefit in alopecia? Similarly, I have no idea. We don't recommend these, um, as a medical treatment in our clinic. So, I don't know, I suppose. So these are more like cosmetic types of uh treatment, isn't it? Sure? And I suppose as with, as with so many alternative treatments that maybe don't make their way into guidelines for things and don't make their way into treatments. So we have to, I guess we have to take what our patients tell us sometimes and only if we know confidently to the alternative. Do we challenge that Royce? Um also asked them about diet and supplements and there were a couple of comments about even the use. I wanted to ask even about the use of nutritional supplements. Is there any evidence to sort of suggest either of those? So, biotin supplement and nutritional supplements. So going back to all the patient areas and investigations. So what we're looking is there's no deficiency or obviously iron deficiency will cause it. Vitamin D deficiency will cause it. So those supplements will help in maintaining the nutritional level and good nutrition as needed for hair growth. Um But uh individually with, we don't recommend taking those supplements. Uh often patient come and ask about herbal supplements and this and Chinese um medication. And uh yeah, so we don't know, but uh having a good nutritional status is important for hair growth. So all these supplement fall under those categories. Sure. And then for, for Lindy, um we're, we're not sponsored tonight by any dermatology companies. I know, I was, I don't know if any of anyone on the call was, uh, was present at the UK Royal College of GPS conference last week. I was there and there certainly are a lot of, uh dermatology companies to be there. But li had asked about the use of, are there any specific, you know, counter over the counter shampoos, like a plan that you see on the TV, all the time? Um, Those buying things. Is there anything you know about those? No, no, if there's like scalp inflammation, uh uh um Seric dermatitis or risk of fungal infection, we do sometimes recommend ketoconazole shampoo or if there's psoriasis, then we use other shampoo. But for hair loss as such, no, sure, I'm going to combine the next couple of questions from Mal Zada and Rosette together. Um a very comprehensive overview tonight. Some uh Malz had commented about being uh a little overwhelmed from the point of view of not being able to take everything in of all the different types of alopecia and all the different causes of hair loss loss. However, what piece of advice would you have for Dermatology college in primary care? If they have, if they have tried simple things like checking blood tests, possibly a topical steroid. When should we then go? Ok, let's refer. Yeah, so, so often television, they, they don't need, normally need referral to secondary care. Um s because it's just about if, if you're quite happy with the history that it's what it is and is identified triggering event. Uh and you've done the blood test and all and sometimes you may find some low thyroid or thyroid and treating them. And if patients happy you don't need to refer. But if you're not quite sure of the diagnosis at any stage, like even alopecia area, so you can use topical steroids, but if the hair is not growing and you're unsure of the diagnosis, always uh feel free to refer. Sure, that's what our our specialist colleagues are there for, I guess. Yeah. And yeah, and some of the treatment is not available in P primary care. So if it's diffuse alopecia area to DCP, we used to offer in our service um before but now we don't. So even we have to refer on to the hospital for DCP and which can work. So sure, um going back to uh androgenic alopecia, does ketoconazole have any role in the treatment of the androgenic subtype? No, the ketoconazole shampoo? No. So if there's scales and like like I said, so if there's seic dermato is a risk of fungal infection, then um it has a role in uh reducing the sh uh spore shedding those sort but not for androgenic alopecia. Excellent. Perfect. Um We'll make this our last couple of questions. The chat has, the chat is drying up a little bit which um is in good. Perfect timing. Um Divya has asked about with male pattern hair loss. What say of Medil would you recommend um 2% 5%? What's the difference? So for the men, it will be 5%. Obviously, the effect, if it's working for them, uh the effect will be better from 5% compared to uh women. Uh for women, it's 2% which is licensed, but we often have this conversation in the clinic with um uh female patients saying it's off license, but you can use the 5%. And if women are using it, it's usually once a day, 5%. Men. Um it's twice a day. But for women, you have to make it clear that 2% is licensed and 5% is off license. But we norm, we generally use it. So, and then they make a choice whether they want to use or not. Sure. Um And we'll make it. Verdana had asked a cheeky second question there. So we'll cover it as well. But two last questions then when you're using antibiotics with tetracyclines, should we be switching them after three months or so? So, depending on what you're using it. So, so if um if for the scarring, especially if you're using tetracycline for uh three months, um if there's good response, there might be a point in uh switching, but if there isn't a good response, then they might need stepping up treatment. So then you may need a combination of Clindamycin Rifampicin or other treatments. So if there is no response, then no point switching them. Sure thing. And then our last question for this evening, folks. Thank you. I do see a few more coming in there, but in the interest of time, unfortunately, um, we're not going to get to the end this evening. I know here I am in northern Ireland. I know there have been some issues with that as well as far as I'm aware. Um It being unavailable in supply, is there an alternative that we can be prescribing? Uh So, um I think it might be quite patchy, isn't it where I am? I haven't heard of the shortage, but um I think uh we used to use selenum sulfide uh to help, but that's been not available as well. So, uh shampoo wise, I'm not quite sure what else is available. So we'll have to check with the pharmacy colleague to see what's available in the area. Sure. So perhaps uh perhaps everyone should link in with a local, friendly uh either practice, practice based pharmacist if you have them or uh pharmacy in your, in your local uh secondary care service. Um Rosanne, I want to say an absolutely massive thank you for coming along this evening on behalf of up on 200 people I think we've had there at the, at the maximum this evening um for coming along a really comprehensive of overview and, and we really, really enjoyed it. Thank you. So much lovely, lovely, lovely commentary in the chat as well. Thank you for those um can see them what would be even more appreciated. However, would be if you fill out the feedback form, the QR code to the apps on screen screen, I'm also gonna share the link to the feedback form into the chat there as well and you will also receive that by email. Um As you know, we are working really hard on our upcoming events. Um So they will be available on the app as soon as we have them confirmed. Um I know our next one so far is Jane mcauley back with us uh for primary care end of life care updates and I very quickly just get you the link for that and pop that in just for the next upcoming one. There we go now. Um Danny, thank you so much. Uh We will forward all the fantastic feedback to you. Um Thank you for coming along. Sure. Thank you. Thank you so much. Good night everyone and we will see you next time. Thanks, bye.