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Hair Loss – What to Do in Primary Care?

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Hair Loss – What to Do in Primary Care? Adult Hair Loss – what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead Whittington Hospital Outline .Hair cycle and hair basics .How to assess and examine a patient with hair loss .Scarring v. non-scarring alopecia .Non-scarring alopecias .Questions? Hair cycle Growing Transition Resting/Shedding Hair Basics 100,000 scalp hairs 10% in Telogen Telogen usually lasts around 100 days Normal to lose upto 100 hairs/day How to examine for hair loss? 1) Sit patient in chair 2) Look down on scalp/parting and assess hair density and areas of alopecia 3) Assess hair scalp margin 4) Assess skin on scalp 5) Consider hair pull test 6) Rest of skin Hair Pull Test How to assess a patient with hair loss? . 1) Is there scarring? – needs to be referred to Derm . 2) If non-scarring (the majority) Discrete patches Diffuse hair loss Alopecia areata Telogen effluvium (Tinea capitis) Androgenetic alopecia (Folliculitis kelodailis) Question 1) Is there scarring? Scarring alopecias If Scarring suspected – Refer Routinely **Frontal Fibrosing Alopecia Unknown cause Incidence increasing. Loss of frontal scalp margin and outer eyebrows. NON SCARRING ALOPECIA DIFFUSE or PATCHES Alopecia Areata . Autoimmune . Patients have higher rates of thyroid diseases, vitiligo and atopic eczema. Alopecia Areata – clinical patterns .Patchy .Alopecia totalis .Alopecia universalis .Ophiasis Alopecia Areata – patchy Alopecia Areata – trichoscopy Alopecia Areata – totalis Alopecia Areata – universalis Alopecia Areata – ophiasis Alopecia areata - Diagnosis . Usually straight forward. Trichoscopy can help. Alopecia areata – Management . When to refer . >20% refer to Dermatology. Alopecia areata – Management . Localised. Less than 20% Options: 1) If re-growing no treatment 2) Potent or super-potent topical steroid once daily for up to 12 weeks Alopecia areata – Management . Localised. Less than 20% . At 3 months – if no improvement – refer Options in secondary care: . Intralesional steroid injections . Immunotherapy . ?JAK inhibitors AA – Poor prognostic features . Unpredicatable . 80% regrowth in one year if solitary patch. Poor prognostic factors: Extensive disease Ophiasis pattern Onset before puberty Family members with AA Alopecia areata – key points 1) If >20% refer to Derm 2) If <20% and want to treat – Potent /Super potent topical steroids for 3 months (Scalp only) 3) If no response in 3-6 months refer. Diffuse alopecia • Telogen Effluvium • Androgenetic Alopecia – Male and Female pattern hair loss Telogen Effluvium . Temporary hair loss Telogen Effluvium Shock to the system: Illness Surgery Childbirth Accident Severe weight loss Up to 70% of anagen hairs go into telogen phase. Telogen Effluvium - management 1) Explain diagnosis – explain hair fall a sign of regrowth. 1) Check no other contributing factors: • Ferritin (aim for >70ng/ml). • Thyroid function tests • Vitamin D, B12/folate 3) Consider minoxodil (2% women 5% men) ***If no response in 9 months refer to derm**. Androgenetic Alopecia Male pattern hair loss Female pattern hair loss 40% of women by age of 50 50% of men by age of 50 Androgenetic Alopecia (Male) .Caused by combination of hormones and genetics. .Genetically determined sensitivity to dihydrotestosterone (DHT). Androgenetic Alopecia Normal scalp AGA Androgenetic Alopecia (Female) .Genetics (polygenic). .? Androgens as most normal circulating testosterone levels. AGA – management (men) 1) 5% minoxodil daily 2) Assess response at 6-9 months (if improved continue indefinitely) Other options outside pathway: Finasteride (5 alpha-reductaseinhibitor) Prostheses Hair transplant/ PRP AGA – management (women) 1) Bloods – FSH/LH, prolactin, TFTs, testosterone, SHBG, DHEAS, 17-hydroxyprogersterone. 2) ?Pelvic USS if signs of PCOS – cyproterone acetate/ethinylestradiol. 3) Treat underlying cause 4) Minoxodil 2% twice daily. **Refer to Derm if Severe or treatment ineffective** Spironolactone Finasteride (5 alpha-reductase inhibitor) Prostheses Hair transplant/ PRP Tinea capitis 1) Take scrapings or hair pluck/brush 2) Avoid sharing towels/combs 3) Terbinafine 250mg od 4 weeks (Trichophyton tonsurans) 4) Griseofulvin 500mg bd 8 weeks (Microsporum canis) Ketoconzole shampoo to patient and relatives for 1 month **Refer to derm if not responding** Folliculitis Keloidalis 1) Avoid rubbing of clothing 2) Avoid razor hair cut 3) Chlorhexidine wash 4) Oral antibiotic – tetracycline/erthromycin for 6 weeks. 5) Topical steroid – Betnovate lotion od for 4 weeks **Refer to derm if not responding** Resources https://gps.camdenccg.nhs.uk/pathways/hair-loss http://www.bad.org.uk/for-the-public/patient-information-leaflets https://www.dermnetnz.org http://www.pcds.org.uk Questions?.
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