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A clinical and investigative study of loss in adult female

ORIGINAL ARTICLE A clinical and Investigative study of in adult female

Krina B. Patel1*, Avni V. Gandhi2, Ruchin B. Patel3, Venu R. Shah4, Sudhir B. Pujara5

1Associate Professor, GMERS Medical College & Hospital, Sola 2Consultant Dermatolgist, Surat 3Medical Graduate, BJ Medical College, Ahmedabad 4Assistant Professor, P & SM Department, GCS Medical College, Ahmedabad 5Professor & Head (Retired) Smt. SCL Hospital, Ahmedabad

ABSTRACT BACKGROUND: Hair is a typical mammalian skin appendage which has more of cosmetic significance at present. Alopecia meaning absence or loss of hair in female can be associated with poor quality of life in affected patients. Material and methods: This study was done in 100 female patients of age above 18 years presenting with complain of diffuse hair loss. Detail history and complains of all patients were recorded. General examination, local examination and investigations including semi-investigative tests were done to classify the patient in different hair loss types. Observation: Out of 100 patients of hair loss, most common age group affected was 30-40years (42%), 58% patients presented with complains of diffuse hair loss and more than 50% presented within 6 months of onset of symptoms. either acute or chronic was most common diagnosis (53%) followed by chronic diffuse hair loss and Female . Specific etiological factors were found in 52% of patients. Trichogram abnormalities were found in 60% patients. As opposed to common belief, anemia was not found to be statistically significant in patients with hair loss. Conclusion: Detailed history, clinical examination and investigations reveal multiple types of hair loss which can have many systemic associations also. Successful treatment of hair loss condition requires perfect diagnosis of type and etiological factor associated with hair loss in female. Key Words: Diffuse hair loss, alopecia, adult female.

INTRODUCTION than growth of body or in excess Hair is a cutaneous appendage typical to of the culturally acceptable norm; even mammalian skin. In the present day, hair has subtle loss in women may be much greater lost much of its biological significance but problem than overt loss in man.3 The impact its cosmetic and psychological value is of hair loss in women is so high that about much enhanced. 40% women report marital problems, 63% Hair loss is a common complain for which women claim to have career related patients of both sexes and any age present to problems. They also suffer lower self the skin specialist. Alopecia defined as esteem, poorer quality of life and poorer “absence or loss of hair”1 is a benign body image.2 condition but it causes substantial Anything that interrupts the normal cycle of psychological damage. It reduces the quality hair growth can trigger diffuse hair loss. of life of patient and leads to profound Triggers include wide variety of emotional suffering, personal, social and psychological or emotional stress, work related problems.2 Female patients nutritional deficiencies, endocrine presenting for hair loss are grave sufferers. imbalances and others. In addition, hair loss Inevitability of baldness in men; genetically may be a manifestation of more general predisposed to male pattern hair loss is to an medical problem. It can be a manifestation extent acceptable to man while loss of hair of systemic disease and its study leads to from scalp in women is no less distressing insight into many systemic disorders.3 The first step in effective management of *Corresponding Author hair loss is to identify the cause, which may Dr. Krina B Patel, be complicated by one or more secondary Associate Professor, factors; the second is to find effective GMERS Medical College, treatment options and the third is to establish Sola, Ahmadabad, plans for long term management.4 E-mail: [email protected]

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A clinical and investigative study of hair loss in adult female Methods: This study was done on 100 Investigations included complete hemogram, female patients presenting in skin OPD of a Serum VDRL test and Serum HIV antibody teaching institute between September 2007 test in all patients and serum ferritin level, to August 2011. All female patients above thyroid function tests, hormone levels 18 years of age who presented for chief (Dihydroepiandrostenidione (DHEAs) , complain of scalp hair loss were included in Serum Follicle stimulating hormone(FSH), the study. Patient data were recorded on a Serum Luteinizing hormone( LH), Total standard proforma. plasma testosterone) as and when required. The demographic data included age, marital KOH examination of scrapings of scalp and status, religion, diet and occupation. Other scalp biopsy were done when indicated and relevant data recorded were height, weight required. Other relevant investigations done and habits. in indicated patients were ANA titer, renal Complains of the patients recorded were and liver function tests and USG diffuse hair loss, visible thinning, patchy examination of abdomen and pelvis. hair loss or decrease in hair density or Specific non-invasive and semi-invasive combination of any of these. Important investigations included daily hair count, hair history points recorded were duration of hair pull test and trichogram. loss, origin and progress of hair loss, Daily hair count is a quantitative assessment episodic or continuous hair shedding, of actual hair loss. The patient is asked to identification of triggering factors and their collect all possible hair lost throughout the temporal relationship to hair loss, associated day including those on shoulder, pillow etc.; symptoms like scalp itching, seborrhea, then all hair are counted and recorded. This headache were recorded. History also is done for consecutive 7 days. Normal hair included acute or chronic blood loss, atopy, lost per day is average 30-70. If total hair stress, thyroid disorder if already diagnosed, lost in a day is more than 100 it is crash diets, anorexia nervosa or bullemia. considered significant and lost hair can be History of recent illness, surgical examined for any pathology in bulb or shaft intervention, blood loss, hospitalization or anomaly.5,6 chronic illness was noted. Any medicines Hair pull test is a test where approximately taken in recent past, history of diabetes 60 are pulled with a constant traction. mellitus, hypertension, malabsorption, renal Bulbs are examined for number of telogen disease, any other systemic illness were hair. If telogen hair present are more than noted. History related to recent childbirth 10% it is considered positive sign for hair and abortions were noted. History of use of loss. Patients are advised not to wash hair hair cosmetics, hair products or hair one day before coming for test. If anagen procedures was recorded. History of mood hair are pulled during pull test, it is a sign of disorder, hair pulling habit etc. was also cicatricial or other causes of anagen hair loss noted. Any past history of similar complains and is always pathological.5,6 in patient or family members were recorded. Trichogram is done to study the hair cycle Menstrual and obstetric history of patient more accurately. 50-100 hairs from different was noted. parts of the scalp are taken for evaluation. All patients‟ general examination was Patients are asked to wash hair three to five carried out to look for any abnormality days before coming to clinic. 5-10 hair are present. Local examination of scalp included selected from different parts of scalp. Then type of hair loss – whether diffuse or holding in artery forceps with rubber tubing; localized, scarring or non-scarring or hair are pulled in direction of natural hair patterned, color of hair lost, presence of growth. Hair pulled are cut 1 cm away from scaling, crusting, pustules, seborrhea, any bulb and are arranged on slide and examined other infection or infestation of pediculosis. under microscope to determine percentage Loss of , , loss of hair of hairs in anagen, catagen and telogen. from any other body site, nail changes, signs Ratio of anagen to telogen (A/T ratio) is of virilization etc. if present were noted. calculated. Upto 10% telogen hair frequency 29 Int J Res Med. 2014; 3(4);28-36 e ISSN:2320-2742 p ISSN: 2320-2734

A clinical and investigative study of hair loss in adult female on trichogram is considered normal, upto obvious thinning, widening of parting or 25% is found in diffuse hair loss and more frontot-temporal recession. Hormonal than 35% telogen hair is considered severe abnormality on hematological investigations problem.6 and USG abdomen showing signs of PCOS Depending upon the history, clinical associated with other signs of findings and results of semi-invasive hyperandrogenism like may be investigations; patients were diagnosed as present. having acute telogen effluvium(ATE), AA – sudden hair loss which is generally chronic telogen effluvium(CTE), chronic patchy, on examination exclamation mark diffuse telogen hair loss(CDTHL), female hair present, no scalp abnormality detected. pattern hair loss(FPHL), alopecia Trichogram from advancing age showing areata(AA), cicatricial alopecia(CA), exclamation mark hair, biopsy showing traumatic alopecia(TA), local infection typical perifollicular . Other induced alopecia, anagen effluvium(AE) and signs like nail pitting, history of atopy, others. history of other autoimmune disease like Diagnostic features considered for each type vitiligo, peptic ulcer, diabetes mellitus of hair loss were as follows – patchy and uneven hair ATE – history of recent acute illness or loss from reachable sites, no scalp pregnancy or any other triggering event abnormality except occasionally signs of within past 6 months with acute onset of hair scratching, obvious mental disorder like loss. obsessive compulsive disorder. Scalp biopsy No scalp abnormality, no associated showing pigment cast. findings, Hair pull test strongly positive, Cicatricial alopecia – history of itching or trichogram showing reverse anagen to tenderness on scalp with patchy hair loss, telogen ratio ( 1:6 or more)/ telogen hair scalp showing changes of inflammation and more than 15% atrophy or scarring. History of or signs of CTE – hair loss for more than 6 months, or discoid lupus erythematosus history suggestive of ATE which continued or other inflammatory disorder. to chronic hair loss, no scalp abnormality, Infection associated hair loss – signs and hair looks normal but bitemporal recession symptoms of bacterial or fungal infection. may be noted, hair pull test positive from KOH examination of scalp scrapping vertex and occiput. Trichogram showing showing hyphae and spores in tinea capitis. chiefly telogen hair. Statistical analysis was done on Epi info CDTHL – history of persistent hair loss for version 7 and word excel. The Chi-square more than 3 months; on investigation iron test with Yates correction ws used to find deficiency or thyroid dysfunctions or zinc the significance of difference in more than deficiency or other causes like drug history, two proportions. Test was used where ever crash dieting, malabsorption disease, liver or applicable according to the sample size and chronic renal dysfunction, other chronic type of data. illnesses including HIV infection may be RESULTS found. Hair pull test may or may not be Table: 1 Age distribution positive. Trichogram shows decreased Age in years Number of patients anagen to telogen ratio. (8:1, normal 14:1) 18 – 30 years 33 (33%) Terminal to ratio (Normal 8:1) is 30 – 40 years 42 (42%) 40 -50 years 20 (20%) preserved on scalp biopsy with decreased 50-60 years 3 (3%) anagen to telogen ratio. Above 60 years 2(2%) AE- history of drug which may cause AE Total 100 like cytotoxic medicines, allopurinol, This study was done on 100 patients above colchicine etc. Trichogram showing chiefly 18 years of age presenting to skin OPD with anagen hair. complain of scalp hair loss. 78% women FPHL – positive family history, middle aged were married and 16% were unmarried; female, gradual imperceptible hair loss with 30 Int J Res Med. 2014; 3(4);28-36 e ISSN:2320-2742 p ISSN: 2320-2734

A clinical and investigative study of hair loss in adult female while 6% women were widowed or Table: 4 Incidence of average hair loss per divorcee. Most common age group day presenting for complain of hair loss was 30 Average number of Number of patients – 40 years (42%). (Table 1) Most of the hair lost per day (%) patients 78% were Hindu while 22% % were 70 -100 14 100 - 150 38 Muslim and other religion patients. 68% 150 -200 17 women were vegetarian; while rests were 200- 250 4 consuming mixed foods. 61% were >250 4 housewives, 20% were students and 19% <70 or not applicable 23 were working women. Total 100 Table: 2 incidences of different clinical Table 1to 4 showing age wise distribution, presentations of hair loss presenting complains, duration of hair loss Pattern of hair loss at Number of and average number of hair loss respectively presentation patients(%) in study population Diffuse hair loss (dhl) 46 Table: 5 Incidence of disease Visible thinning (vt) 21 Diagnosis Number of patients Dht + vt 8 (%) Dhl + decreased hair density (dhd) 10 Ate 31 Patchy hair loss with/without dhl 15 Cte 22 Total 100 Cdhl 16 Table:3 Incidence of duration of hair loss Fphl 10 Duration of hair loss Number of patients (%) Aa 6 < 1 month 16 Ca 3 1 month – 6month 36 Traumatic alopecia 4 6months – 1year 22 Local infection 4 1- 2years 9 induced 2 – 5 years 15 Others 4 >5years 2 Total 100 Total 100 Table: 6 Age distribution of specific disorders No. Of pt 18-30 years 30-40 years 40-50 years 50-60 years >60 years Total Ate 13 17 1 0 0 31 Cte 10 9 3 0 0 22 Cdhl 2 7 6 1 0 16 Fphl 0 4 6 0 0 10 Aa 4 2 0 0 0 6 Ca 0 2 1 0 0 3 Ta 2 0 0 1 1 4 Li 2 1 1 0 0 4 Other 0 0 2 1 1 4 Total 33 42 20 3 2 100 Chi square value 75.7 , p value< 0.0001 (difference is significant) Table: 7 Comparison between duration of hair loss and type of disease Disease/ number < 1 month 1 -6 month 6month – 1year 1 -2 years 2-5 years > 5 years Ate n=31 11 20 0 0 0 0 Cte n=22 0 12 2 0 8 0 Cdhl n=16 0 0 11 0 4 1 Fphln=10 0 0 4 4 2 0 Aan=6 3 1 1 1 0 0 Ca n=3 0 0 2 1 0 0 Ta n=4 0 0 1 2 1 0 Local infection n=4 2 2 0 0 0 0 Others n=4 0 1 1 1 0 1 Total n=100 16 36 22 9 15 2 Chi square value 132.7, p value <0.0001 (difference is significant)

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A clinical and investigative study of hair loss in adult female

Table 5,6 and 7 showing incidence of hair 100% 90% disorders, comparison with age and duration 80% 70% of hair loss with type of hair disorder. 60% 50% DHL+PATHCY Table: 8 Etiological factors of hair loss 40% 30% DHL+DHD Causes Number of patients(%) 20% 10%

Febrile illness 7 0% DHL+VT CA

Stress 5 AA VT

CTE

ATE

FPHL CDHL

Telogen gravidarum 4 OTHERS DHL

Infections 4 TRAUMATIC

Severe anemia 9 INFECTION LOCAL Thyroid dysfunction 6 Chronic illness 4 Figure: 1 – different patterns of Drug induced 5 presentation. a – diffuse hair loss, b – Trauma 4 visible thinning, c – visible thinning + Scarring disorders 4 patchy hair loss, d – FPHL – widening of Idiopathic 48 parting, e – alopecia with scarring1.5 Total 100 A B Table: 9 Trichogrm result Trichogram findings Number of patients T – 10%-15% 12 T > 15 -20% 15 T > 20 -25% 5 T > 25% 2 T + d 8 Hair shaft anomaly 2 c D Predominant anagen 2 Normal 54 Total 100 T = telogen, d = dystrophic Table: 10 Incidence of anemia with specific disorders Diagnosis Severe Moderate Mild Normal anemia anemia anemia hemoglobin hb<8gm Hb8-10 Hb10- level % gm % 12gm% Ate 2 2 22 5 Cte 2 2 15 3 E Cdhl 3 4 9 0 Fphl 1 1 8 0 Aa 1 0 4 1 Ca O 0 2 1 Ta O 0 3 1 Li O 0 3 1 Figure: 2 – Diffenent types of hair loss Others O 1 2 1 a,,a’–ATE, b–CTE, c,c –CDHL, d – AA, Total 9 10 68 13 Chi square value 17.0, p value 0.8 ( difference is not a a’ significant) ’ Table 8,9, and 10 showing etiological factors, results of trichogram and incidence of anemia in study population respectively. Chart: 1 showing incidence of disease specific clinical presentation

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A clinical and investigative study of hair loss in adult female

b b’ a b

c d Figure: 6 – Traumatic hair loss due to a – procedure, b – a b

Figure: 3 – CA due to a – LE associated CA with skin lesions of SCLE on chest, b –Brunsting Perry pemphiogid, c – Figure: 7 – biopsy findings in a – alopecia a a‘ areata showing perifollicular lymphocytic infiltrate (H& E 40X) , Brunsting Perry pemphigoid showing subepidermal blister with eosinophilic infiltrate (H&E 10X) a b

b c

We found maximum number of patients presenting with complain of diffuse hair loss (58%). Other presentations were found in Figure: 4 – anagen effluvium due to variable number of patients (Table 2). cancer chemotherapy (Figure 1 a,b,c,d,e ) More than 50% patients presented within 6 months of onset of symptoms. (Table 3) Average hair loss per day was 100-150 in 38% patients (Table 4) Most patients were diagnosed as having telogen effluvium either acute or chronic (53%) followed by CDHL (16%) and FPHL (10%). (Figure 2 a,b,c,d) Other types of hair loss were found in 3% -6% patients. (Table Figure: 5 – hair shaft deformity on 5) Correlating the type of hair loss with trichogram a – , b – clinical presentation of patients (Chart 1) it trichoclasis was found that 100% patients of ATE presented with complain of diffuse hair loss while in other disorders various 33 Int J Res Med. 2014; 3(4);28-36 e ISSN:2320-2742 p ISSN: 2320-2734

A clinical and investigative study of hair loss in adult female combinations of presentations were found. patients while mild anemia was found in Correlating type of hair loss with duration it 68% patients, rest having normal was found that all patients of ATE presented hemoglobin level. As serum ferritin level within 6 months while most patients of estimation could not be carried out in all FPHL presented after 1 year of starting of patients due to unavailability in hospital, 27 hair fall (Table 6) patients with mild anemia got it done and in In comparison to age and specific hair 3 patients it was found to be decreased. disorder; 47% patients of ATE were of 20- Results of incidence of anemia with specific 30 years of age group. CTE was found in 20 disease is shown in Table 10. Out of 42 -40 years age group. 63% patients of FPHL patients of age group 30 – 50 years; were between 30 -50 years of age. 80% of subjected to hormonal assay and pelvic traumatic hair losses were between 18 – 22 sonography; significant hormonal years age group. (Table 7) Specific abnormalities were found in 7 patients etiological factor was found in 52% patients (16.66%) with increase in DHEAs, reverse while in 48% no definite cause could be FH:LSH ratio and increase/ normal found. (Table 8) In patients with ATE 16 testosterone level and PCO disease was patients (51.6%) had precedent febrile detected in 3 patients (7.1%) on sonography. illness, while mental stress, anemia, Serum VDRL was found reactive in one childbirth were other causes found in 11 patient with CDHL (titre >1:16) and HIV patients (35.4%) patients while in rest 16% infection was detected in one patient with patients no cause could be identified. In CD4 count >500 at the time of detection. patients with CTE thyroid dysfunction was Biopsy was done in one patient with diffuse found in 9 (41%) patients, while chronic and patchy hair loss in which AA was illness, anemia and drug induced were found confirmed, in patients of CA, diagnosis were in 31.8% patients, in 27.2% patients no confirmed in all three cases on cause could be identified. was histopathology and in case of the culprit drug in both patients of drug trichotillomania were also classical findings induced CTE. Discoid Lupus were found. (Figure 7 a, b, c) erythematosus, pseudopelade of Brocq and CONCLUSION Burnstring Perry Pemphigoid(variant of Diffuse hair loss is frequently encountered Bullous pemphigoid) (figure3 a,b) were condition for which adult female patients etiological factors in patients with cicatricial present to OPD. Hair loss can alopecia. Chemotherapy was responsible for have many etiological factors – obvious or anagen effluvium in 2 patients (figure 4) and hidden. Presenting complain of patient may hair shaft anomaly found in 2 patients were also vary and diagnosis of hair loss depends trichorrhexis nodosa and trichoclasis (Figure upon consideration of multiple factors in a 5 a,b). Local infections like tinea capitis patient aided by required hair specific wers found in 4 patients, associated investigations. was present in 23% In present study, most common age group patients but that could not be directly presenting with complain of hair loss was 30 correlated to hair loss. Traction alopecia, – 40 years and most of the patients (55%) trichotillomania and permanent hair fall under 18-40 year group. In studies by straightening were found to be causative Santamaria et al[7] and Lee et al[8] most factors in patients with traumatic frequent age group reported were between alopecia.(figure 6 a,b) 21-40 years and 3rd to 4th decade Results of trichogram is shown in Table 9 respectively. Diffuse hair loss was the most which shows that in 40% of patients no common presenting complain (46%) in our trichogram abnormality was found. patients. This highlights the fact that overt Moderate to severe anemia was found in 19 baldness is generally rare in female patients

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A clinical and investigative study of hair loss in adult female though they always fear of the same. Most responsibility of child do not come forward of the patients in our study (74%) presented for their own problems. Various causes for within 1 year of starting of hair fall which hair loss reported in various studies like coincides with the finding of appreciable stress, drugs, thyroid dysfunction, anemia, thinning in patients with diffuse hair fall. childbirth/abortion, hormonal imbalances Only patients presenting within 1 month of were also found in our study. starting of symptoms were in ATE or AA In our study mild anemia was present in and local infection induced hair loss. majority of study population (68%) which Average hair loss was above 100 in most of could be coincidental finding or added factor the patients in our study but it is also for hair loss. As per study Bentley et al15 in worthwhile to note that 23% women do not Indian women, 46.5% women of child had significant hair loss as per daily hair bearing age were having mild to moderate count still they were concern with diffuse anemia. As per „Family welfare statistics in hair loss which again emphasize the India 201116, 44% women registered under importance of hair for psychological well- antenatal care program were found to have being. Most of the patients of ATE, CTE Hemoglobin level below 11gm%. Although and CDHL were below 40 years of age moderate to severe anemia in 19% patients while most of the patients of FPHL were in our study could have hair loss related to above 30 years of age. All patients of AA anemia; we could not find any significant were also falling in younger age group. association with serum ferritin level in our While patients with CA, TA and LI induced study. Sinclair reported similar finding in his hair loss presented at any age. In various study.12 Even relation of anemia with hair studies telogen effluvium is reported to be loss is not statistically significant in present 28% - 92% 9,10,11 and FPHL is reported to be study. between 7% to 60%9,10,12 depending upon Amongst the rarer causes of hair loss, it is the age group studied. In present study also interesting to note that in CA group, apart we found most of the patients (53%) with from Discoid LE and pseudopelade of Brocq TE either acute or chronic and patterned hair which is commonly found in other studies loss in 10% of our patients. Only 1 of our also, we found one patient with CA related patient with patterned hair loss had to Brunsting Perry type of Bullous significant temporal and vertex balding pemphigoid which is very rare disorder. In while in all other patients bitemporal or TA, hair straightening was factor frontal balding associated with diffuse responsible for hair loss in one patient, apart thinning was found. 1 patient with AA from trichotillomania associated with mental rapidly turned into within 3 disorder. Untreated Secondary syphilis months while others had only patchy hair associated diffuse hair loss was detected in loss. Febrile illness as precipitating factor one patient and one patient was detected for TE is found in 2% - 33%9,13,14 in various having unsuspected HIV serology positivity. studies and telogen gravidarum is found in In patients who were suspected of having 9.33 to 21% patients in various hormonal imbalance, investigations revealed studies7,9,13,14. In our study febrile illness 16.66% patients having significant hormonal was etiological factor of hair loss in 7% imbalance which could be associated with patients while telogen gravidarum was hair loss. found in 4% patients. Lower incidence of Trichogram done in all patients by using Telogen gravidarum reporting in our study standard technique revealed diagnostic could be due to cultural difference in study findings in 60% patients and served as population. Most of the women in our simple yet effective diagnostic aid in cases society probably accept the post-partum hair of diffuse hair loss. loss as natural phenomenon or due to added

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A clinical and investigative study of hair loss in adult female Thus to conclude diffuse hair loss in female 7. Santamaria JR, Spoladore R, Ribeiro patients requires accurate history, clinical AM. An bras Dermatologia, examination and investigations to arrive at 1992;67(4):195-197 diagnosis. There could be multiple factors 8. Lee HJ, Kim JW. Assessment of the acting upon in one patient which need to be Association of Iron deficiency and delineated before starting treatment. Frequencies of Autoantibodies and Investigating patients for hair loss which is Abnormal Thyroid function tests in generally regarded as more of a patients with . Korean J psychological importance; could lead to Dermatol. 2002;40(1):8-13. finding of many underlying disorders like 9. Jain VK, Kataria U, Dayal S. Study of anemia, connective tissue disease, syphilis, diffuse alopecia in females. Indian J polycystic ovarian syndrome etc. Only Dermatol Venereol Leprol 2000;66:65- thorough accurate diagnosis; targeted 68. therapy can be initiated which will give 10. Kantor J, Kessler LJ, Brooks DG, satisfactory results. Cotsarelis G. Decreased serum ferritin is REFERENCES associated with alopecia in women. J 1. Stedman‟s Medical Dictionary,27thed. Invest Dermatol 2003;121:985-8. Lippincott Williams, Baltimore. 11. Bergfeld WF. Diffuse hair loss in 2005:50. women. Cutis. 1978;22(2):190-5. 2. Hadshiew IM, Foitzik K, Arck PC, Paus 12. Sinclair R. There is no clear association R. Burden of hair loss: stress and the between low serum ferritina and chronic underestimated psychological impact of diffuse telogen hair loss. Br J Dermatol telogen effluvius and androgenetic 2002;147:982-4. alopecia. Journal of Investigative 13. Eckert J, Church RE, Ebling FJG: Hair Dermatology 2004;123:455-57. loss in women. Br J Dermatol 3. Dawber R, Van Neste D. Hair and Scalp 1967;79:543-548. Disorders. Common Presenting Signs, 14. Rustom A, Pasricha JS. Causes of Differential Diagnosis and Treatment, diffuse alopecia in women. Indian J 2nd edn. Martin Dunitz, Taylor & Dermatol Venereol Leprol 1994; 60:266- Francis group, London and New 71. York, 2004: 1–294. 15. Bentley ME, Griffiths PL. The burden of 4. Rushton DH. in anemia among women in India. women. Dermatol Clin. 1993;11(1):47- European Journal of Clinical 53. Nutrition 2003; 57: 52–60. 5. Dhruat R, Saragoi P. Hair Evaluation 16. Family welfare statistics in India, 2011 Methods: Merits and Demerits Int J by Statistics Division, Ministry of Health Trichology. 2009;1(2):108–119. and family welfare, Government of 6. Chamberlain AJ, Dawber RP. Methods India. Website - of evaluating hair growth. Australas J http://www.khubmarriage18.org/sites/de Dermatol. 2003; 44(1):10-8. fault/files/statistical_information/Family %20welfare%20statistics%20in%20Indi a_2011.pdf posted on August 2011.

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