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Home , Acne conglobata, Anagen effluvium, Chest hair, Folliculitis decalvans, Hair transplantation, Hidradenitis

Help My Is Falling Out

Natasha Atanaskova Mesinkovska MD PhD Department of and Dermatopathology University of California, Irvine

Natasha A. Mesinkovska MD PHD Disclosures

“Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest to disclose.” Human Hair Follicles

• Anagen • Growing hair phase (0.37mm/day) • lasts ~3 years • 85-90% * Longer anagen = longer hair • Catagen • Transitional phase • 1-2 weeks • <1% scalp hairs • Telogen • Resting phase • 3-5 months • 10-15% scalp hairs

Natasha A. Mesinkovska MD PHD Human Hair Follicles

• Scalp hairs – Terminal – daily shed ~100 hairs per day

Natasha A. Mesinkovska MD PHD Hair Embryology

• First hair follicles at 9 weeks – , upper lip, chin

• Rest of follicles at 4-5 months – Cephalad to caudal direction

• First hairs are – soft non-pigmented, fine – shed between 32nd- 36th weeks

Natasha A. Mesinkovska MD PHD Evaluation of the Patient with

• History of present illness: – How long ago? – Scalp or other areas as well? – How did the patient notice it? • eg. in the shower, hair dresser – How much hair has been lost (%)? – Any associated symptoms? • eg. itching, scaling, redness, – Excess hair elsewhere

Natasha A. Mesinkovska MD PHD Evaluation of the Patient with Hair Loss

• Personal medical history: – Autoimmune /inflammatory –

• : – correlation with onset of hair loss • Hormonal milleu: – Women: oral contraceptives, replacement – Men:

Natasha A. Mesinkovska MD PHD Evaluation of the patient with hair loss

• Family history: – Hair loss: • Father, brothers, mother, sisters, children • Find out at what age • Did it ever regrow? – Autoimmune and inflammatory : • Thyroid, Diabetis, , Celiac, Inflammatory Bowel, Rheumatoid , – Neoplastic

Natasha A. Mesinkovska MD PHD Important Things to Ask

• Vitamins and supplements – DHEA, • Diet – vegan • Exercise – marathon

Natasha A. Mesinkovska MD PHD The Exam

• Clinical exam of scalp • Pull test – Hair on – On body – – Genitals – Nails • Thyroid gland • Wood’s light

Natasha A. Mesinkovska MD PHD Diagnosis

• Scalp – 1 or 2 – Vertical or horizontal sections – Dermatopathologist

• Laboratory work up: – CBC, Ferritin levels, Thyroid, Vitamin deficiencies

Natasha A. Mesinkovska MD PHD Diseases of the Hair

Hair loss

Non-scarring and Scarring

Natasha A. Mesinkovska MD PHD Non-Cicatricial Alopecia

Natasha A. Mesinkovska MD PHD Non-Cicatricial Alopecias

1. Androgenetic alopecia 2. 3. 4. 5. Trichotillosis ()

Natasha A. Mesinkovska MD PHD 1. Androgenetic Alopecia

• Male and Female – Strong genetic link (polygenic) – Family history • Progressive decrease of anagen • increase telogen and miniaturized hair follicles

Natasha A. Mesinkovska MD PHD AGA

Natasha A. Mesinkovska MD PHD Male Pattern Balding

• Frontotemporal region – following • Increases with age – 80% of men by age 70 • Etiology – driven • DHT greater affinity for androgen receptors • Converted to DHT by 5-alpha reductase – Type 1 in liver and sebaceous glands – Type 2 scalp, , and follicles

Natasha A. Mesinkovska MD PHD Hamilton Norwood Classification

Fronto-temporal recession with eventual involvement of vertex

Natasha A. Mesinkovska MD PHD Female Pattern

• 30 years of age onset – as early as during puberty

• apical scalp part wider • frontal hairline preserved

• Work up – ferritin, TSH, free/total testosterone, DHEAS, zinc, vit D Natasha A. Mesinkovska MD PHD Female Pattern

Natasha A. Mesinkovska MD PHD Treatment

Caution against unrealistic expectations • Primary goal is to halt progression. • COMBINATION: at least 6 months to assess response, continue treatment to maintain response.

Male pattern hair loss Female pattern hair loss • 5% topical • 5% topical minoxidil • Oral anti- • Oral , 1mg (, cyproterone • ()* acetate). – * selected cases • Surgery (hair transplantation) • wigs • wigs

Natasha A. Mesinkovska MD PHD Androgenetic Alopecia

• Minoxidil • Survival dermal papilla cells • Prolongs anagen phase • Increases shaft diameter • Finasteride (1mg daily) • Type 2 5a-reductase inhibitor • Effects after 6-12 months • Check PSA level prior to initiation • Other: • • Fluridil (topical ) • ? PRP

Natasha A. Mesinkovska MD PHD 2. Telogen Effluvium

• Excessive shedding of telogen club hairs • Usually follows a stressful event – 3 months after event • Usually <50% scalp • Eyebrows and eyelashes usually unaffected – if they are- check thyroid levels • Resolves spontaneously

Natasha A. Mesinkovska MD PHD Telogen Effluvium

Several mechanisms: : • Illness • Fever • Surgery • labor • CT scan • Medications: amphetamines, , • cimetidine, B-blockers, valproic acid • Hormonal alterations: thyroid, OCP, • Drastic diet regimen • Sudden weight loss – No known cause in many cases

Natasha A. Mesinkovska MD PHD Telogen Effluvium

• Exam: Abnormal pull test • Telogen hair • Depigmented club -shaped bulb • Lacks a sheath

Natasha A. Mesinkovska MD PHD 3. Anagen Effluvium

• Abrupt cessation of mitotic activity in hair matrix – Within days to weeks of stimulus – Hair shaft thins → breaks at surface (fractures) – Entirely reversible*

• Associations • Chemotherapy – antimetabolites and alkylating agents • INH • Thallium • Boron

Natasha A. Mesinkovska MD PHD 4. Alopecia Areata

• Autoimmune –Loss of immune privilege of –Target for activated T cells • ‘swarm of bees’ on pathology

• Types: – Patchy – Totalis - loss of all scalp hair – Universalis → loss of all – - band like pattern

Natasha A. Mesinkovska MD PHD Alopecia Areata – Patchy

Natasha A. Mesinkovska MD PHD

Natasha A. Mesinkovska MD PHD Alopecia Areata

Natasha A. Mesinkovska MD PHD Alopecia Areata – Patchy

Natasha A. Mesinkovska MD PHD Alopecia Areata

• 10% pits (more uniform than )

• Exclamation point hairs - tapering hair shaft

• Associated conditions • Eczema • thyroid • vitiligo • DM • Celiac • Hearing impairment • and

Natasha A. Mesinkovska MD PHD Tx AA

• Patchy alopecia – Intralesional / topical – Topical anthralin – Minoxidil foam

• Extensive or rapidly progressive alopecia – Contact immunotherapy (squaric acid dibutyl ester, diphenylcyclopropenone) – Systemic anti-inflammatory: tofacitinib – Wig or hairpiece

Natasha A. Mesinkovska MD PHD Trichotillomania (Trichotillosis)

• Compulsive desire to pull out hair • Hairs of multiple lengths – localized area – Geometric – Irregular patches – Scalp, and – Even in children • Hairs of varying length – Natasha A. Mesinkovska MD PHD Trichotillosis

• Compulsive desire to pull out hair • OCD • depression • anxiety • – bezoars • Tx: psychotherapy + anti-depressants

Natasha A. Mesinkovska MD PHD

• Scale • Pustules • Broken hairs

Natasha A. Mesinkovska MD PHD Tinea Capitis

• Work up: – KOH scale – Culture the pustules – Biopsy only if above non-diagnostic

• Trichophyton tonsurans • Microsporum canis

• Treatment: – Griseofulvin – Terbinafine – Itraconazole – +/- ketoconazole or selenium sulfide wash

Natasha A. Mesinkovska MD PHD Cicatricial Alopecias

Alopecia accompanied by absence of follicular ostia

Natasha A. Mesinkovska MD PHD Scarring Alopecias • Complex • Rare conditions • Many types • Scalp Biopsy is a MUST – Dermatopathologist • and HPI important

Natasha A. Mesinkovska MD PHD Scarring Alopecias

• Complex • Rare conditions, many 1. Chronic cutaneous lupus 2. Central centrifugal alopecia 3. Lichen planopilaris 4. Frontal fibrosing alopecia 5.

Natasha A. Mesinkovska MD PHD Chronic Cutaneous Lupus Erythematosus • Clinical: – Most commonly face, ears, scalp • • Atrophy • Follicular plugging • Mottled hyper-hypopigmentation

• 50% of pts with skin disease have scalp disease • ~5% develop Systemic Lupus • Difficult to distinguish from lichen planopilaris

Natasha A. Mesinkovska MD PHD Chronic Cutaneous Lupus Erythematosus

Natasha A. Mesinkovska MD PHD Chronic Cutaneous Lupus Erythematosus • Diagnosis: • Biopsy • Laboratory SLE work up • treatment: – Intralesional or topical steroids – Systemic (antimalarials, mycofenolate mofetil, methotrexate, retinoids, dapsone, sulfasalazine, thalidomide)

Natasha A. Mesinkovska MD PHD Natasha A. Mesinkovska MD PHD 2. Central Centrifugal Cicatricial Alopecia

Natasha A. Mesinkovska MD PHD 2. Central Centrifugal Cicatricial Alopecia • Overlapping entities • alopecia/Follicular degeneration syndrome • Begins in crown → advances centrifugally • Difficult treatment –Discontinue chemical treatment –Discontinue heat –Discontinue traction –Intralesional stroids –Increased risk Diabetes melitus type 2

Natasha A. Mesinkovska MD PHD 2. Lichen Planopilaris (LPP)

• Female >Male • Caucasian • Clinical • Perifollicular erythema/scale + progressive scarring • Small follicular • Pruritus and tenderness • Variants • Frontal fibrosing alopecia – women, 50 years old • Graham Little-Piccardi Syndrome? – LPP + pilaris + pubic/axillary alopecia (not scarring)

Natasha A. Mesinkovska MD PHD Lichen Planopilaris

Natasha A. Mesinkovska MD PHD Perifollicular Erythema in LPP

Natasha A. Mesinkovska MD PHD Frontal Fibrosing Alopecia

Natasha A. Mesinkovska MD PHD Natasha A. Mesinkovska MD PHD 5. Folliculitis Decalvans

Natasha A. Mesinkovska MD PHD 5. Folliculitis Decalvans

• Crops of pustules → scarring alopecia • Abnormal suppurative immune response

• Treatment: – Responds to long term – Combine with ketoconazole and lotion

• Other: – Rifampin + Clindamycin x 10 weeks – Topical corticosteroids – Dapsone – Selenium sulfide

Natasha A. Mesinkovska MD PHD Dissecting

Natasha A. Mesinkovska MD PHD Dissecting Cellulitis (Perifolliculitis Capitis Abscessens et Suffodiens of Hoffman) • Isolated or part of follicular occlusion tetrad 1. conglobata 2. suppurativa 3. Pilonidal

• Deep, boggy, suppurative lesions • Start as firm • Treatment • • Dapsone • Intralesional corticosteroids • Oral

Natasha A. Mesinkovska MD PHD Natasha A. Mesinkovska MD PHD Other Causes of Hair Loss

• • Neoplastic • • Sarcoidosis • Pressure alopecia •

Natasha A. Mesinkovska MD PHD Traction Alopecia

• Frontal and parietal scalp • Hair loss secondary to tight , hair styles with traction

Natasha A. Mesinkovska MD PHD Natasha A. Mesinkovska MD PHD Cutaneous T Lymphoma

Natasha A. Mesinkovska MD PHD Temporal Triangular Alopecia

• Congenital, usually present at birth • Temporal scalp • Fine, vellus hairs – Normal number of follicles but all are vellus • Permanent

Natasha A. Mesinkovska MD PHD The Psychosocial Burden of Hair Loss

Natasha A. Mesinkovska MD PHD The End

Natasha A. Mesinkovska MD PHD