Not the lasting impression I’d hoped to leave burning questions on... loss and alopecia

In this article, the author looks at issues around baldness and alopecia and considers the treatments that are available

Associate Professor Mehmet Q What is the pathophysiology of Veli Karaaltin alopecia and baldness? Acibadem Hospitals Group A The pathophysiology of (alopecia) may include infectious, nutritional, congenital, autoimmune or environmental causes and can be temporary or long-lasting. Non-scarring alopecia includes androgenic alopecia (common hair loss), telogen effluvium (thinning of the hair), (spot baldness) and scarring alopecia discoid lupus erythematosus (a group of rare disorders that destroy hair follicles) or lichen planus (a type of non-infectious rash) caused by trauma or infections. Other disorders include (hair pulling disorder), traction alopecia (gradual hair loss caused by pulling of hair), tinea capitis (fungal infection affecting the scalp) and hair shaft abnormalities. In androgenetic alopecia (male- or female-pattern baldness), hair follicles diminish in size over time in both male and females until they become cosmetically insignificant. This happens in specific patterns over the scalp area and there can be a significant gap between hair shedding and regrowth in affected individuals. The result is very short and follicles devoid of hair shafts and pigmentation. In advanced androgenetic alopecia some follicles are completely replaced by fibrous tracts. Another common form of alopecia, telogen effluvium, manifests itself as widespread thinning of the hair rather than specific bald patches, and can be caused by the body reacting to external factors, such as: hormonal changes for example, caused by pregnancy; intense emotional or physical stress; changes in diet; short or long-term illnesses, such as infections or cancer; or reactions to medications. Other is usually not affected and although hair may feel thinner, it is unlikely that patients would lose all their hair, and in many cases hair would grow back within six months. Alopecia areata on the other hand tends to lead to patches of baldness, usually on the scalp but can be anywhere on the body. In most cases hair will grow back in a few months. Hair growth occurs in phases; growth (anagen), cessation (catagen), and rest (telogen), and these bald patches occur when cells of the anagen hair bulb (the actively growing hair bulbs) are attacked by blood lymphocytes and as a result the hair shaft breaks off. In rare cases the condition can lead to further hair loss. It most commonly occurs The only licensed oral treatment for hyperhidrosis in teenagers and young adults, but can affect any age. Alopecia areata is an autoimmune disorder and 1 Offers easy-to-use oral administration1 so mostly occurs in patients with other autoimmune conditions such as hyperthyroidism, diabetes or Down’s syndrome.2 As it is an abnormal immune response from the body against substances and tissues 1 Provides a quick onset of antimuscarinic effects within 1 hour found in the body, it is often found in those who have a family history of the condition, so is thought to An inexpensive treatment for hyperhidrosis, costing less than 20p per tablet2 have a genetic basis.

Abbreviated Prescribing Information. Please refer to the full Summary May induce fever and heat stroke in patients in a high environmental palpitations and arrhythmias, urinary hesitancy and retention, of Product Characteristics before prescribing. temperature due to decreased sweating. Caution in Down’s syndrome. constipation, reduced bronchial secretions, occasional confusion in Name: Pro-Banthine Tablets 15 mg. Form: Tablets. Indications: Caution in gastrointestinal reflux disease, acute myocardial infarction, the elderly, occasional nausea and vomiting, and occasional dizziness. Adjunct in GI disorders characterised by smooth muscle spasm, cardiac insufficiency and pyrexia. Interactions: antimuscarinics tend Overdose: Intensification of the usual side effects. In severe intoxication Q What is the Alopecia is a general medical term referring to the decline and loss of visible hair Hyperhidrosis, Adult enuresis. Dosage and Administration: Oral use. to delay gastric emptying so may alter the absorption of concomitant disturbances of the central nervous system may occur; convulsions, A Adults: Starting dose one tablet before each meal and two tablets at medication. Risk of antimuscarinic side effects increase with nefopam, coma, circulatory failure, respiratory , delirium, hallucinations and there are many types with different symptoms and causes. bedtime. Subsequently, dosage adjusted to individual response and disopyramide, MAOIs, tricyclics, tricyclic-related antidepressants, and restlessness. Toxic doses of propantheline bromide may product difference tolerance; up to 120 mg may be required. Elderly: More susceptible , clozapine, phenothiazines, amantadine and memantine. non-depolarising neuromuscular blocking effects with paralysis of Baldness is the name given to the most common type of hair loss, androgenetic to antimuscarinic side effects; glaucoma and urinary retention may May reduce absorption of paracetamol, and levodopa. voluntary muscle. Overdose; empty stomach and give activated between and alopecia. This type of hair loss is commonly seen in both males and females (male- and occur. Consider presence of other disease and concomitant drug May enhance absorption of nitrofurantoin. Antimuscarinics antagonise charcoal, control excitement with diazepam, provide supportive therapy. Children: Safety and efficacy not established. Caution: Food the effects of domperidone and metoclopramide on GI activity; may treatment: oxygen, assisted ventilation, administer fluids. In severe cases alopecia and female-pattern baldness), and causes the hair to recede starting from both temples and reported to reduce the bioavailability; take at least one hour before antagonize effects of parasympathomimetics. Excessive blockade may (convulsions, hyperpyrexia, respiratory depression) use of intravenous vertex in men and the crown and temples in females. Less commonly it can progress meals. Contraindications: Obstructive diseases of the gastrointestinal occur if given with belladonna alkaloids, synthetic and semi-synthetic physotigmine (0.5 mg to 2 mg) should be considered. Since it has a brief baldness? or urinary tract, pyloric stenosis, paralytic ileus, intestinal atony, severe antimuscarinics agents or other drugs with antimuscarinic activity. May duration of action of about 1 to 2 hours, it may be necessary to repeat to complete baldness. Male-pattern baldness is hereditary and linked to an excess of ulcerative colitis or toxic megacolon, hiatus hernia associated with reduce effects of haloperidol and may reduce the plasma concentration injections up to a total dose of 5 mg.Special Precautions for Storage: Do reflux oesophagitis, unstable cardiovascular adjustment in acute of phenothiazines. Concurrent use with slow-dissolving digoxin tablets not store above 25°C. Legal category: POM. Marketing Authorisation testosterone though the causes of female-pattern baldness are less understood. haemorrhage, myasthenia gravis, prostatic enlargement, closed-angle may cause increased serum digoxin levels. May reduce effects of Holder: Archimedes Pharma UK Limited, 250 South Oak Way, Green glaucoma or those with shallow anterior chamber, since it may raise sublingual nitrate tablets (due to dry mouth). Pregnancy and Lactation: Park, Reading, Berkshire, RG2 6UG, UK. Marketing Authorisation Most people lose 60-100 hairs per day and this is a normal level of hair loss intra-ocular pressure, patients who are hypersensitive to propantheline Do not administer in pregnancy unless essential; association with minor Number: Pro-Banthine Tablets 15 mg: PL 12406/0026; Quantities and that we all experience throughout our lives. However, when the level of hair loss bromide. Warnings and Precautions: Patients especially with ileostomy malformations. Do not administer during breast-feeding unless essential; Packs: 112-tab pack = £20.74. Date of API preparation: February 2014. or colostomy, diarrhoea may be a symptom of incomplete intestinal unknown whether excreted in breast milk. Suppression of lactation may exceeds this normal level, or is concentrated in certain areas, this is referred to as obstruction: avoid in such patients. Patients with severe heart disease occur. Driving and using machines: May cause drowsiness or blurred Adverse events should be reported. Reporting forms and where heart rate increase undesirable; observe closely. Caution in vision, do not drive or operate machinery if affected. Undesirable information can be found at www.mhra.gov.uk/yellowcard. pathological hair loss. Thus both male and female-pattern baldness are considered ulcerative colitis, may lead to paralytic ileus and precipitate or aggravate Effects: Dryness of the mouth with difficulty in swallowing and thirst, Adverse events should also be reported to pathological states. toxic megacolon. Caution in the elderly and all patients with autonomic dilatation of the pupils with loss of accommodation and sensitivity Archimedes Pharma either by phone to 0118 931 5094 or neuropathy, hepatic or renal disease, hyperthyroidism, coronary heart to light, increased intra-ocular pressure, flushing, dryness of the skin, email to [email protected] disease, congestive heart failure, cardiac arrhythmias or hypertension. decreased sweating, heat stroke, bradycardia followed by tachycardia,

References: 1. Pro-Banthine Summary of Product Characteristics. 2. British National Formulary. Available at: www.bnf.org | September/October 2015 | 11 Date of preparation: March 2015. Pro-B/0002 burning questions on...

Q Is alopecia areata A Alopecia areata is an autoimmune disorder that usually associated with affects the scalp, though it can occur anywhere on the body’s hair-bearing areas, and causes partial or total hair other autoimmune loss. The condition causes lymphocytes of the immune conditions? system to attack hair follicles in a process similar to that following chemotherapy and is most common in teenagers and young adults. Triggering factors can be either stress or an infection and it can also be symptomatic of other autoimmune illnesses such as diabetes, vitiligo or thyroid disorders. There is also thought to be a genetic disposition.

Q What investigations should Q Are alopecia and baldness we perform on someone treatable? presenting with alopecia areata and how common A Male-pattern baldness may be treated medically are thyroid disorders in this with either oral or topical , with the latter also used for female-pattern baldness. group? Depending on the cause, several treatment options are available for alopecia areata including steroid injections, which are the most effective steroid The first investigation for alopecia areata is usually A treatment, or steroid creams or ointments. If there is conducted by looking at the hair loss and examining a link to an autoimmune disease, anti-inflammatory some of the hairs from the areas of hair loss under drugs (injections, pills or cream) or immunotherapy a microscope. Sometimes it may be necessary to can be used to treat the condition and to help the hair perform a fungal culture skin biopsy to identify the grow back. Immunotherapy involves the creation of condition as alopecia areata. If another autoimmune an intentional allergic reaction on the affected areas of disease is suspected or apparent, then further blood skin to stimulate hair growth. tests may be necessary. Patients will then need to be monitored through The incidence of thyroid disease varies from treatment as everything depends on how the body and 8% to 28% in patients with alopecia areata, with immune system react to the treatment and whether hypothyroidism being most frequently associated. hair loss is stemmed or not. In many cases hair will Characteristic clinical signs of myxoedema are grow back within a few months. changes in the texture of the hair as well as alopecia Surgical options include hair transplants. Globally, of the scalp, and other body hair. about 80% of hair transplants are successful. Reversible alopecia has also been observed in Follicular Unit Transplantation (FUT) and Follicular iatrogenic hypothyroidism that is prevalent during Unit Extraction (FUE) are the most common the treatment of thyrotoxicosis (Grave’s disease). This procedures and the technique for each patient is type of temporary hair loss has been attributed to the determined upon a consultation session evaluating toxic effects of anti-thyroid drugs such as carbimazole patients’ skin and hair structure. These techniques are and propylthiouracil. After replacement therapy with performed under local anaesthesia and the transplant thyroid hormone hair growth resumes. process usually takes four to six hours. Some recent advances in hair transplant include the use of Platelet Rich Plasma (PRP) with the aim of increasing the survivability of the hair following a hair transplant to improve future growth.

12 | September/October 2015 | hair loss and alopecia

Q How effective are Q What are the side effects treatments for baldness of oral finasteride in treating associated with PCOS? male-pattern baldness?

A Thinning hair in females caused by the effects A Finasteride is a drug that counteracts the of male hormones () is called androgenic androgenic hormone testosterone by blocking its alopecia and is frequently observed in women with conversion to (DHT). It is mainly polycystic ovary syndrome (PCOS), congenital adrenal used to treat benign prostate enlargement and is hyperplasia, and other conditions of excessive male also prescribed for androgenic alopecia in males. hormones. The medical management of baldness Finasteride is not available on the NHS but can be associated with PCOS consists of a number of options obtained on private prescription from your GP. of combination therapy. Options commonly used The NHS reports that it usually takes 3-6 months include oral contraceptive (OCP) in combination of continuous use before any results are witnessed, with , Diane-35, OCP in combination and hair loss may return within six to 12 months if with finasteride, OCP with , multiple drug treatment is stopped. modalities or in combination with minoxidil. Medical Studies have shown that side effects are rare in relation to PCOS can but may include such sexual problems as erectile be much more difficult than some of the others and ejaculatory dysfunction, and the loss of libido. problems related to PCOS, such as acne or hirsutism, Other side effects can include enlargement of breasts, and a combination of drugs is likely only to slow the dizziness, fatigue, migraines, skin rash and swelling of progress of androgenetic alopecia rather than reversing hands and feet. It can also lead to an increased risk of it. A first step is to control the overproduction of male breast cancer and prostate cancer. hormones before further treatment for baldness. It can also affect the prostate specific antigen (PSA) Finasteride works by preventing testosterone blood test used in prostate cancer screening as it (an ) from becoming a stronger form of has been found to reduce PSA levels in the blood by testosterone inside the cells. Few side effects have 50%.4 been reported by the NHS when finasteride is used in women.

Q We’re seeing a rise in celebrities undergoing hair transplants. Are these successful and what should patients know before they consider going down this route?

A is an increasingly popular cosmetic trend among celebrities (UK celebrities include Wayne Rooney, Robbie Williams, James Nesbitt and Elton John) and the number of patients undergoing this procedure has increased significantly over the years. Patients should know that the technique used depends on the patient’s skin and hair structure as this directly affects the outcome of any transplantation. Some recent advances, such as the PRP technology, may also boost the success of the long term hair growth. With hair transplantation, bald areas can be once more covered in hair, albeit less densely. In recent decades, hair transplantation has evolved into a microsurgical procedure with local rather than general anesthetic. Follicular units of 1 to 4 hairs are transplanted in large numbers and high densities and so, unlike the Strip (FUT) procedure, no stitches are required after the treatment. Hence the FUE technique (Follicular Unit Extraction) today has become the gold standard surgical treatment for hair transplantation together. For patients with progressive alopecia, hair transplantation can only be performed if additional surgery is possible to harvest more hair from the proper donor areas where hair follicles are inherently resistant to hair loss. To ensure the best treatment for the patient’s condition is provided, thorough consultation is recommend from the outset. This would include information on the possible outcomes and the progressive nature of androgenetic alopecia, which may go on to require further surgery and/or medical treatment.

| September/October 2015 | 13 burning questions on...

A Topical minoxidil is a hair regrowth medicine used for Q How effective is treating pattern baldness in men, and thinning hair and topical minoxidil in hair loss in women. Several studies have shown that topical minoxidil yields successful results in women.3 Minoxidil women? 2% topical solution twice daily appears to be an effective and safe treatment for female hair loss. Minoxidil 5% concentration used once daily has also been reported to be as effective as the 2% used twice daily, but further research Acibadem Health Group specialises is required for conclusive results. in hair transplants and the treatment Minoxidil stimulates hair growth and results can be of hair loss. Acibadem Health observed between three to six months after the start of Group’s surgical treatments include treatment. Minoxidil is not recommended for those under Follicular Unit Extraction (FUE). The 18 years of age. It’s not available on the NHS, but can be technique suitable for each patient 3 prescribed privately or bought over the counter. at Acibadem is determined after a consultation session where the patient’s skin and hair structure is evaluated. Performed under local Q When should a GP refer a patient anaesthesia, a hair transplant process takes four to six hours, with hairs with alopecia? emerging in three months following treatment and reaching their normal length within six months. A In general, hair loss is often the symptom of the natural ageing process and For more information on Acibadem does not pose a health risk, but it can be distressing and may be the result of other and on hair transplants visit http:// underlying causes so patients should see their GP if they have concerns. GPs can www.acibademinternational.com/ easily diagnose the type of hair loss via examination and, if necessary, screen for treatment/hair-transplant-center/ systemic diseases then make suitable recommendations regarding the various http://www.acibademinternational. treatment options available, or refer them to a specialist dermatologist. If a patient com/ or call +44 808 238 0043 wants to treat hair loss for aesthetic reasons, GPs can refer them to a specialist to (toll‑free UK) discuss patient suitability for hair transplantation.

References Q What is the best treatment 1 http://www.nhs.uk/Conditions/Diabetes/Pages/ for telogen effluvium? Diabetes.aspx (last accessed Sept 15) 2 http://www.nhs.uk/conditions/Downs- syndrome/Pages/Introduction.aspx (last accessed Sept 15) A Telogen effluvium, an extremely common form of alopecia, is a condition that causes hair to shed 3 van Zuuren EJ, Fedorowicz Z, Carter B, Andriolo RB, et al, Interventions for female excessively and can be caused by a number of factors. , Cochrane Database of Causes include sex hormone imbalances, which can Systematic Reviews, 2012 occur due to a variety of reasons such as pregnancy, 4 Anitha B1, Inamadar AC, Ragunatha S., J menopause, toxins or an unbalanced lifestyle, which Cutan Aesthet Surg, 2012 can be diagnosed through blood tests. Other reasons For more burning questions may include reactions to medications, short or on baldness and alopecia visit long-term illnesses or psychological issues as stress, www.bjfm.co.uk dietary problems or other external factors. If the root cause can be isolated, the best method is to treat that condition – for example, by using stress reduction techniques or mental health advice, or supplements or dietary advice if a dietary deficiency appears on a blood test. A deficiency in thyroid hormones can be treated with hormone supplements.

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