Hair Loss: Common Causes and Treatment T. GRANT PHILLIPS, MD; W. PAUL SLOMIANY, MD; and ROBERT ALLISON, DO Washington Health Systems Family Medicine Residency, Washington, Pennsylvania Hair loss is often distressing and can have a significant effect on the patient’s quality of life. Patients may present to their family physician first with diffuse or patchy hair loss. Scarring alopecia is best evaluated by a dermatolo- gist. Nonscarring alopecias can be readily diagnosed and treated in the family physician’s office. Androgenetic alopecia can be diagnosed clinically and treated with minoxidil. Alopecia areata is diagnosed by typical patches of hair loss and is self-limited. Tinea capitis causes patches of alopecia that may be erythematous and scaly and must be treated systemically. Telogen effluvium is a nonscarring, noninflammatory alopecia of relatively sudden onset caused by physiologic or emotional stress. Once the precipitating cause is removed, the hair typically will regrow. Trichotillomania is an impulse-control disorder; treatment is aimed at controlling the underlying psychiatric condition. Trichorrhexis nodosa occurs when hairs break secondary to trauma and is often a result of hair styling or overuse of hair products. Anagen effluvium is the abnormal diffuse loss of hair during the growth phase caused by an event that impairs the mitotic activity of the hair follicle, most commonly chemotherapy. Physician support is especially important for patients in this situation. (Am Fam Physician. 2017;96(6):371-378. Copyright © 2017 American Academy of Family Physicians.) CME This clinical content atients with hair loss will often Approach to the Patient conforms to AAFP criteria consult their family physician with Nonscarring Alopecia for continuing medical education (CME). See first. Hair loss is not life threaten- The history and physical examination are CME Quiz Questions on ing, but it is distressing and sig- often sufficient to determine a specific eti- page 360. Pnificantly affects the patient’s quality of ology for hair loss. It is convenient to divide Author disclosure: No rel- life. The pattern of hair loss may be obvi- the various causes into focal (patchy) and evant financial affiliations. ous, such as the bald patches that occur in diffuse etiologies, and proceed accordingly. ▲ Patient information: alopecia areata, or more subtle, such as the Patchy hair loss is often due to alopecia A handout on this topic is diffuse hair loss that occurs in telogen efflu- areata, tinea capitis, and trichotillomania. available at http://www. vium. As with most conditions, the physi- Diffuse hair loss is commonly due to telo- aafp.org/afp/2009/0815/ cian should begin the evaluation with a gen or anagen effluvium. Androgenetic alo- p373.html. detailed history and physical examination. pecia may be diffuse or in a specific pattern, It is helpful to determine whether the hair and may progress to complete baldness. loss is nonscarring (also called noncicatri- cial), which is reversible, or scarring (also HISTORY called cicatricial), which is permanent. Important clues to the etiology of differ- Scarring alopecia is rare and has various ent patterns and types of hair loss are listed etiologies, including autoimmune diseases in Tables 1 and 2. Hair that comes out in such as discoid lupus erythematosus. If the clumps suggests telogen effluvium. Sys- follicular orifices are absent, the alopecia is temic symptoms such as fatigue and weight probably scarring; these patients should be gain suggest hypothyroidism, whereas a referred to a dermatologist. This article will febrile illness, stressful event, or recent discuss approaches to nonscarring causes of pregnancy may account for the diffuse hair alopecia. loss of telogen effluvium. The use of hair products such as straightening agents or Physiology of Hair Growth certain shampoos suggests a diagnosis of Hair grows in three phases: anagen (active trichorrhexis nodosa. A family history of growing, about 90% of hairs), catagen hypothyroidism may warrant laboratory (degeneration, less than 10% of hairs) and testing for this condition, whereas a family telogen (resting, 5% to 10% of hairs). Hair is history of hair loss supports the diagnosis shed during the telogen phase. of androgenetic alopecia. SeptemberDownloaded 15, from 2017 the American◆ Volume Family 96, NumberPhysician website6 at www.aafp.org/afp.www.aafp.org/afp Copyright © 2017 American Academy of FamilyAmerican Physicians. Family For the Physician private, noncom 371- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Hair Loss SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Topical minoxidil is safe and effective for the B 5 PHYSICAL EXAMINATION treatment of androgenetic alopecia in women. The physical examination should focus Alopecia areata can be treated with intralesional B 11 on the hair and scalp, but attention should corticosteroids. be given to physical signs of any comorbid Oral terbinafine (Lamisil), itraconazole (Sporanox), B 2 fluconazole (Diflucan), or griseofulvin is disease indicated by the review of systems. recommended for treatment of children with If only the scalp is involved, the physician tinea capitis caused by Trichophyton infections. should look for typical male or female pattern Cognitive behavior therapy is effective for the B 19 to determine the presence of androgenetic treatment of trichotillomania, and medical alopecia. Whole body hair loss is consistent therapy may be more effective when combined with cognitive behavior therapy. with alopecia totalis. Dry, broken hair sug- gests trichorrhexis nodosa, whereas scaling, A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited- pustules, crusts, erosions, or erythema and quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual local adenopathy suggest infection. practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort. The pull test may be used to diagnose hair loss conditions.1 The examiner grasps Table 1. Summary of Nonscarring Alopecia Type Significant features Treatment and comments Alopecia areata Acute, patchy hair loss; examination shows short, vellus Intralesional triamcinolone acetonide injected intradermally hairs, yellow or black dots, and broken hair shafts High rate of spontaneous remission Anagen Diffuse hair loss days to weeks after exposure No pharmacologic intervention has been proven effective; effluvium to a chemotherapeutic agent; incidence after scalp cooling not recommended chemotherapy is estimated at 65% Minoxidil may help during regrowth period Androgenetic Family history of hair loss; gradually progressive course Men: topical minoxidil (2% or 5% solution) alopecia Men: bitemporal thinning of the frontal and vertex Women: topical minoxidil (2% solution) scalp, complete hair loss with some hair at the Treatment should continue indefinitely because hair loss occiput and temporal fringes reoccurs when treatment is discontinued Women: diffuse hair thinning of the vertex with Adverse effects include hypertrichosis (excessive hair growth sparing of the frontal hairline for age, sex, and race) and irritant or contact dermatitis Telogen Clumps of hair come out in the shower or in Treatment involves removing the underlying cause and effluvium hairbrush; associated with physiologic or emotional providing reassurance stress Condition is usually self-limited and resolves within two to six months Tinea capitis Dermatophyte infection of the hair shaft and follicles; Requires systemic treatment because topical antifungals patients present with patchy alopecia with or do not penetrate hair follicles without scaling Trichophyton species: oral terbinafine (Lamisil), itraconazole (Sporanox), fluconazole (Diflucan), or griseofulvin Microsporum species: griseofulvin Trichorrhexis Hairs break secondary to trauma or because of fragile Stop offending actions nodosa hair (congenital or genetic); causative traumas include excessive brushing, heat application, hairstyles that pull on hairs, and conditions that cause excessive scalp scratching Trichotillomania Patches of alopecia, typically frontoparietal, that Optimal treatment is unknown; strong evidence is lacking progress backward and may include the eyelashes for selective serotonin reuptake inhibitors; cognitive and eyebrows behavior therapy with habit reversal and medications may be more effective than either approach alone Psychiatric referral may be indicated 372 American Family Physician www.aafp.org/afp Volume 96, Number 6 ◆ September 15, 2017 Hair Loss approximately 40 to 60 hairs at their base pulling force is not distributed uniformly using the thumb, index, and middle fingers and because it is difficult to approximate the and applies gentle traction away from the number of hairs grasped, thereby leading to scalp. A positive result is when more than false interpretations. 10% of hairs (four to six) are pulled from the scalp; this implies active hair shedding LABORATORY STUDIES and suggests a diagnosis of telogen efflu- Because many conditions can cause hair loss, vium, anagen effluvium, or alopecia areata. there are no routine tests to evaluate hair However, a negative test result does not nec- loss. Laboratory testing is indicated when essarily exclude those conditions. The pull the history or physical examination