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Home , Acne, Hirsutism

COVER FOCUS Diagnosing and Managing Disorders

From loss to overgrowth, hair disorders may be associated with systemic causes.

BY DANIEL CHANG, MBBS

lopecia can affect the scalp or other parts of the body TABLE 1. CAUSES OF ALOPECIA1-5 and can be localized or widespread. It may be due to hair shedding, poor quality hair, or hair thinning and Alopecia Non- Diffuse Aging can be scarring or non-scarring in nature (Table 1). scarring AHair grows on most parts of the skin surface, except the Drug induced palms, soles, lips, and . Hair thickness and length Pattern varies according to site. is fine, light in colour, Localized Areata and short in length. Terminal or androgenic hair is thicker, Mechanical darker, and longer. A hair shaft grows within a follicle at a Scarring Trauma rate of about one cm per month, due to cell division at the base of the follicle (hair bulb). The cells produce the three erythematosus layers of the hair shaft (medulla, cortex, cuticle), which are essentially made of the protein keratin. Hair growth follows Constitutional a cycle. However, these phases are not synchronised and any Acquired Androgenization hair may be at a particular phase at random. Drug induced The hair cycle can be divided into three main phases: Anagen: This is actively growing hair Catagen: Transition phase of two to three weeks when TABLE 2. growth stops and the follicle shrinks Physiology Telogen: Resting phase for one to four months, up to Telogen effluvium 10 percent of in a normal scalp. Hair length depends on the duration of anagen. Short Autoimmune hairs (eyelashes, eyebrows, hair on arms and legs) have a short anagen phase of one month. Anagen can last up to six Pattern-thinning of hair Androgenic years or longer in scalp hair. can be due to physiologic, autoimmune, hor- Hair shaft abnormalities monal, or medical factors, or associated with hair shaft abnormalities.1-5 (Table 2) Inflammatory skin disease Anagen shedding is known as anagen effluvium and has Medical disease Illness, surgery, anaemia, thyroid variable duration and sudden onset. Anagen effluvium is Trichotillomania caused by autoimmune disease (e.g., severe diffuse alopecia Cancer treatment areata), (e.g., cytotoxic/chemotherapy drugs), or congenital condition (e.g., ). 1. Fever, weight loss, pregnancy Over-shedding is known as telogen effluvium. It occurs 2. Surgical operation, illness, or psychological stress two to six months after an inciting event that stops active 3. Medications, e.g., contraceptives, anticoagulants, anti- hair growth. Telogen effluvium is commonly caused by convulsants stressors, including: 4. Others (unknown)

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Shedding can persist for years (chronic telogen effluvium), during which scalp hair continues to grow, but has a shorter Hair shaft defects can be congenital natural length than normal. is due to hormonal influence and increas- or acquired due to disease or injury. es with age. Male pattern alopecia affects vertex and tempo- ral scalp. Female pattern alopecia affects the anterior scalp. Hair shaft abnormalities can be diag- Hair shaft defects can be congenital or acquired due to nosed by dermatoscopy or more disease or injury. Hair shaft abnormalities can be diagnosed by dermatoscopy or more intensive examination of the hair. intensive examination of the hair. They include, fractures, irregularities, coiling, and twisting. Conditions resulting in reversible patchy hair thinning include: Medicine. Medication6,7 can be divided into local and • Localized alopecia areata systemic. is FDA approved for treating male • , , seborrhoeic , atopic hair loss. It mechanism of action includes stopping the dermatitis, , cutaneous lupus production of , hence encouraging hair erythematosus, cutaneous T-cell lymphoma regrowth. A topical for the scalp is 5% min- • Generalized skin disease (erythroderma), severe ill- oxidil. It can stop hair thinning and stimulate hair growth. ness, iron, thryoid deficiency Concurrent use of a topical can enhance . Scarring alopecia can be due to injury, infections or Corticosteroids can be used topically or injected into your inflammatory skin diseases. It is secondary to damage of the scalp to stop the during conditions like alope- . Infections may be viral, bacterial, or fungal. cia areata. Inflammatory skin diseases like lupus, , and Alternatives with weak evidence include tacrolimus 0.1%, can contribute to scarring alopecia. dithranol, and bimatoprost. Bimatoprost has been used to increase eyelash hair, but scalp application is not approved APPROACH TO HAIR LOSS or widely published. Hair loss can be frustrating, reducing quality of life and Systemic drugs include immunosuppressants like steroids, causing emotional problems. Loss of normal scalp hair cyclosporin, and methotrexate, but are not recommended. increases the risk of UV exposure and related injury. A care- Of special mention is a marine protein derivative, Viviscal, ful history and full skin examination can help to identify which has been FDA approved for hair loss. It is purported the cause. Further tests may include hair pluck test with to enhance the hair cycle growth phase. Not much is known trichogram to determine relative proportion of anagen and about the mechanism of action. That said, feedback from telogen hairs, Wood’s lamp examination, swabs of pustules my patients has been positive. for culture, skin scrapings, hair clippings, and blood tests. Prevention of hair loss is important. It is prudent to mini- Medical Devices. is safe and used to treat mize injury to the hair shaft through lifestyle changes. For androgenetic alopecia. It is postulated to enhance blood example, patients may be instructed to dry their hair with flow in the scalp. It has also been suggested to improve a towel or naturally, rather than with a heat dryer; reduce the wound healing process in post hair transplant chemical treatments; and avoid tight hairstyles to reduce patients and hasten hair growth. However, the evidence mechanical damage.The prognosis for hair loss depends on is weak. the cause. Scarring alopecia is irreversible. Anagen and telo- A multicenter trial reported that male patients with gen hair loss will cease with time. Early treatment of pattern androgenic alopecia exhibited a statistically significant alopecia can help slow down hair thinning. Finally, treat- increase in average hair density (p <0.0001).8 Similar results ment of inflammatory disease is essential. were shown in a study comprising women with androgenic Management1,4-7 can be divided into surgical and non- alopecia.9 surgical measures. Basically, infections and inflammation In a second study of 103 males and 122 females with should be treated, dietry deficiencies fixed, and causative pattern alopecia that completed the study, HairMax® drugs identified and discontinued. LaserComb (with 12, nine and seven beams) was reported 1. Medicine: Anti-, steroids, to result in increase in terminal hair density versus trial sub- 2. Medical devices jects in the control group.10 Ongoing trials are investigating 3. Lifestyle modifications the efficacy of other light therapy devices in various types of 4. Surgical and Injectibles alopecia.11

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Lifestyle Changes. Good scalp care to keep hair clean TABLE 3. SITES OF HIRSUTISM with stimulating massage, and the safe use of a hair dryer are important. Maintaining exercise and stress control, and hair Moustache, , eyebrows eating healthy food rich in protein, vitamins, and minerals, Abdomen Diamond shape of extending like iron, also help. Patients should avoid pills, to umbilicus anabolic steroids, alcohol, and smoking. Finally camouflage with wigs and hair pieces are options. Chest Around nipples or more extensive growth Upper back Surgery and Injectables. Surgical treatment for hair loss will not be discussed in this paper, though these are sup- Inner thighs ported by accumulated evidence.12 TABLE 4. CAUSES OF HIRSUTISM16-20 Platelet Rich Plasma (PRP) warrants close consideration. The use of platelet growth factors to stimulate hair growth Polycystic and reduce hair loss has achieved quite effective results for medications both androgenic alopecia and alopecia areata, noted in Congenital Adrenal Hyperplasia small scale studies.13,14 We await large scale randomized con- Tumor of or trolled studies on the use of this modality. This area is prom- Cushing’s syndrome ising, but it is clear that with the lack of intellectual property potential, pharmaceutical companies would hesitate to fund Increase androgen resistance a large . sensitivity

Botulinum Toxin. The science behind use of neurotoxins TABLE 5. TECHNIQUES for hair loss is the relaxation of scalp musculature, hence decompressing blood vessels in the scalp and increasing Temporary removal Temporary to perma- Permanent oxygen delivery. DHT is converted to in oxygen- nent reduction removal rich medium. A 60-week study has reported increase in hair -assisted Electrolysis growth and reduction in hair loss in males with androgenic Chemical depilation alopecia.15 Physical Epilation

HIRSUTISM General examination may point to the cause of hir- Hirsutism refers to excessive hair growth in women in a sutism. Acanthosis nigricans suggests . male type pattern. Hirsutism can involve a single site or mul- Galactorrhoea suggests hyperprolactinaemia. Purple striae, tiple sites. (Table 3) thin skin, bruising, and facial plethora suggest Cushing syn- A hirsute pattern of hair growth is usually pre-determined drome. Virilisation suggests hyperandrogenism. Signs include genetically. The degree varies across culture, ethnicity, and deepening voice, balding, , decrease in breast size, race. Late onset hirsutism may be due to hyperandrogen- increased muscle bulk. ism. Hyperandrogenism is often associated with polycystic Diagnostic features for polycystic ovary syndrome include ovaries, insulin resistance, and obesity. Rare causes include, signs of hyperandrogenism, oligo, or anovulation and the androgenic medications, congenital adrenal hyperplasia, pressure of sizeable follicles in each ovary, increased ovarian tumour of adrenal gland or ovary, and Cushing’s syndrome. volume on ultrasound. Different genes expressed in individual hair follicles vary in Hirsutism is diagnosed clinically. Investigations are not their response to androgens. Hair follicles in the secondary usually necessary, unless a Ferriman-Gallwey score is >15. hair growth sites are more sensitive to androgens than those Blood tests are done to evaluate male levels and in other areas. Severity of hirsutism may be assessed using underlying diseases. This can be followed by ovarian ultra- the Ferriman-Gallwey visual scale or a modified version, sound scan. which assesses nine areas of the body. Management of hirsutism can be divided into mechanical The score varies from 0 (no hair) to 4 (extensive hair and medical methods, aimed at removing hair and/or modi- growth) in each area: fying any underlying causes. Total score <8: normal hair growth Total score 8–14: mild hirsutes Mechanical Treatment. Depilatory creams commonly Total score ≥15: moderate to severe hirsutes contain thioglycolate, and can irritate skin. Shaving is anoth-

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4. França, Katlein, et al. “Comprehensive Overview and Treatment Update on Hair Loss.” (2013) er option. would need to be done every six weeks. 5. Gordon, Katherine A., and Antonella Tosti. “Alopecia: evaluation and treatment.” Clin Cosmet Investig Dermatol 4 (2011): 101-6. All these carry a risk of , which may take time to 6. Ohyama, Manabu. “Management of hair loss diseases.” Dermatologica Sinica 28.4 (2010): 139-145. - finasteride resolve.18-24 7. Rogers, Nicole E., and Marc R. Avram. “Medical treatments for male and female pattern hair loss.” Journal of the American Academy of Dermatology59.4 (2008): 547-566. Electrolysis or thermolysis consists of a small probe insert- 8. Leavitt M, Charles G, Heyman E, Michaels D. HairMax LaserComb laser phototherapy device in the treatment of male ed along each hair, and a small electrical discharge destroys androgenetic alopecia: A randomized, double-blind, sham device-controlled, multicentre trial. Clin Drug Investig. 2009;29(5):283-92 the hair. This carries a risk of scarring. 9. Treatment of Androgenetic Alopecia in Females, 9 beam – ClinicalTrials.gov and intense pulsed light are the most effective 1 0. Jimenez JJ, Wikramanayake TC, Bergfeld W, Hordinsky M, Hickman JG, Hamblin MR, Schachner LA. Efficacy and safety of a low-level laser device in the treatment of male and female pattern hair loss: a multicenter, randomized, sham device- devices for hair removal. The long pulse 1064nm ND Yag controlled, double-blind study. Am J Clin Dermatol. 2014 Apr;15(2):115-27. doi: 10.1007/s40257-013-0060-6. PubMed laser is ideal for darker skin patients Fitzpatrick 4 to 6 , while PMID: 24474647; PubMed Central PMCID: PMC3986893. 11. Kalia S, Lui H. Utilizing electromagnetic radiation for hair growth: a critical review of phototrichogenesis. Dermatol Clin. the 755nm alexandrite and IPL can be used for lighter skin 2013 Jan;31(1):193-200. types. Multiple treatments are required, spaced six weeks 12. A review of surgical methods (excluding hair transplantation) and their role in hair loss management today. Journal of cutaneous and aesthetic surgery. Sattur SS.2011;4:89-97.15;80(4):356-362. 21-24 apart. 13. Trink, A., et al. “A randomized, double-blind, placebo and active controlled, half-head study to evaluate the effects of platelet-rich plasma on alopecia areata.” British Journal of Dermatology 169.3 (2013): 690-694 14. Schiavone, Giovanni, et al. “Platelet-rich plasma for androgenetic alopecia: a pilot study.” Dermatologic Surgery 40.9 Medical Treatment of Hirsutism. Medical treatment (2014): 1010-1019. options for hirsutism18-20 include or rosiglitazone, 15. Freund BJ, Schwartz M. Treatment of male pattern baldness with botulinum toxin: A pilot study. Plast Reconstr Surg 2010;126:246e-8 which can be prescribed to women with polycystic ovarian 16. Rosenfield RL. Hirsutism. The New Journal of Medicine. 2005;353:2578-2588. syndrome. Hormonal treatment with medi- 17. Hirsutism Review Article Obstetrics, Gynaecology & , Volume 25, Issue 8, August 2015, Pages 213-216. Tülay Karasu, Mostafa Metwally cines may be useful for women with hirsutism. Effects may 18. Escobar-Morreale HF, Carmina E, Dewailly D, et al. , diagnosis and management of hirsutism: a consen- take six to 12 months, and the medicine needs to be contin- sus statement by the androgen excess and polycystic ovary syndrome society. Hum Reprod Update 2012; 18: 146e70 19. Evaluation and treatment of hirsutism Review Article. Apollo Medicine, Volume 10, Issue 2, June 2013, Pages 138-145. ued for years. Kalpana Dash can reduce excessive hair growth. A syner- 20. Somani, N., Harrison, S. and Bergfeld, W. F. (2008), The clinical evaluation of hirsutism. Dermatologic Therapy, 21: 376–391 gistic effect is achieved when combined with a contraceptive 21. Tremaine, Anne Marie, and Mathew M. Avram. “FDA MAUDE data on complications with lasers, light sources, and pill. Combined birth control pills that contain and energy-based devices.” Lasers in surgery and medicine 47.2 (2015): 133-140. 22. Babilas, Philipp, et al. “Intense pulsed light (IPL): a review.” Lasers in Surgery and Medicine 42.2 (2010): 93-104. progesterone: are effective. Side effects include 23. Dierickx, Christine C. “: Scientific Principles and Practical Aspects.” Coherent Medical, USA (1999): mood swings, loss of libido, and weight gain. 1-8. 24. Lepselter, J., and M. Elman. “Biological and clinical aspects in laser hair removal.” Journal of Dermatological Treatment 15.2 (2004): 72-83. LOOKING FORWARD In the realm of hair loss, low level light therapy is a fasci- nating area deserving of further research. With the interest in non-invasive treatments growing, per- sonally I believe with minoxidil, anti androgens and low level light therapy would be the gold standard treatment for hair loss in the future. As for hirsutism, it is not yet possible to prevent a geneti- cally predetermined cause. Insulin resistance associated with obesity can be reduced by diet and lifestyle changes. Prognosis is dependent on the cause. The most common types of excessive hair growth is permanent. Hirsutism has a tendency to worsen with age. FOLLOW Dr. Daniel Chang specializes in Aesthetic and Regenerative Medicine and is a Key Opinion Leader PRACTICAL and Regional Trainer. Dr. Chang founded Asia Aesthetic Academy in 2015 and has developed a number of signature treatments, including the DC DERMATOLOGY 3D-Dreamlift and the DC 3D-Noselift. He maintains a Korean Aesthetics site and can be reached at drdanielchang.com ON TWITTER 1. Diagnosing and Treating Hair Loss – Am Fam . 2009 Aug 2. Alopecia in general medicine.Nalluri R1, Harries M2. Clin Med (Lond). 2016 Feb;16(1):74-8. doi: 10.7861/clinmedi- @Practical_Derm cine.16-1-74. 3. Evaluation and diagnosis of the hair loss patient. Mubki T1, Rudnicka L2, Olszewska M3, Shapiro J4.J Am Acad Dermatol. 2014 Sep;71(3):415.e1-415.e15. doi: 10.1016/j.jaad.2014.04.070.

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