Help My Hair Is Falling Out Natasha Atanaskova Mesinkovska MD PhD Department of Dermatology and Dermatopathology University of California, Irvine Natasha A. Mesinkovska MD PHD Disclosures “Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest to disclose.” Human Hair Follicles • Anagen • Growing hair phase (0.37mm/day) • lasts ~3 years • 85-90% scalp hairs * Longer anagen = longer hair • Catagen • Transitional phase • 1-2 weeks • <1% scalp hairs • Telogen • Resting phase • 3-5 months • 10-15% scalp hairs Natasha A. Mesinkovska MD PHD Human Hair Follicles • Scalp hairs – Terminal – daily shed ~100 hairs per day Natasha A. Mesinkovska MD PHD Hair Embryology • First hair follicles at 9 weeks – Eyebrow, upper lip, chin • Rest of follicles at 4-5 months – Cephalad to caudal direction • First hairs are lanugo – soft non-pigmented, fine – shed between 32nd- 36th weeks Natasha A. Mesinkovska MD PHD Evaluation of the Patient with Hair Loss • History of present illness: – How long ago? – Scalp or other areas as well? – How did the patient notice it? • eg. in the shower, hair dresser – How much hair has been lost (%)? – Any associated symptoms? • eg. itching, scaling, redness, pain – Excess hair elsewhere Natasha A. Mesinkovska MD PHD Evaluation of the Patient with Hair Loss • Personal medical history: – Autoimmune /inflammatory – Cancer • Medications: – correlation with onset of hair loss • Hormonal milleu: – Women: oral contraceptives, replacement – Men: testosterone Natasha A. Mesinkovska MD PHD Evaluation of the patient with hair loss • Family history: – Hair loss: • Father, brothers, mother, sisters, children • Find out at what age • Did it ever regrow? – Autoimmune and inflammatory diseases: • Thyroid, Diabetis, Vitiligo, Celiac, Inflammatory Bowel, Rheumatoid Arthritis, Lupus – Neoplastic disease Natasha A. Mesinkovska MD PHD Important Things to Ask • Vitamins and supplements – DHEA, retinoids • Diet – vegan • Exercise – marathon Natasha A. Mesinkovska MD PHD The Exam • Clinical exam of scalp • Pull test – Hair on face – On body – Axilla – Genitals – Nails • Thyroid gland • Wood’s light Natasha A. Mesinkovska MD PHD Diagnosis • Scalp biopsy – 1 or 2 – Vertical or horizontal sections – Dermatopathologist • Laboratory work up: – CBC, Ferritin levels, Thyroid, Vitamin deficiencies Natasha A. Mesinkovska MD PHD Diseases of the Hair Hair loss Non-scarring and Scarring Natasha A. Mesinkovska MD PHD Non-Cicatricial Alopecia Natasha A. Mesinkovska MD PHD Non-Cicatricial Alopecias 1. Androgenetic alopecia 2. Telogen effluvium 3. Anagen effluvium 4. Alopecia areata 5. Trichotillosis (trichotillomania) Natasha A. Mesinkovska MD PHD 1. Androgenetic Alopecia • Male and Female pattern hair loss – Strong genetic link (polygenic) – Family history • Progressive decrease of anagen • increase telogen and miniaturized hair follicles Natasha A. Mesinkovska MD PHD AGA Natasha A. Mesinkovska MD PHD Male Pattern Balding • Frontotemporal region – following puberty • Increases with age – 80% of men by age 70 • Etiology – Androgen driven • DHT greater affinity for androgen receptors • Converted to DHT by 5-alpha reductase – Type 1 in liver and sebaceous glands – Type 2 scalp, beard, and chest hair follicles Natasha A. Mesinkovska MD PHD Hamilton Norwood Classification Fronto-temporal recession with eventual involvement of vertex Natasha A. Mesinkovska MD PHD Female Pattern • 30 years of age onset – as early as during puberty • apical scalp part wider • frontal hairline preserved • Work up – ferritin, TSH, free/total testosterone, DHEAS, zinc, vit D Natasha A. Mesinkovska MD PHD Female Pattern Natasha A. Mesinkovska MD PHD Treatment Caution against unrealistic expectations • Primary goal is to halt progression. • COMBINATION: at least 6 months to assess response, continue treatment to maintain response. Male pattern hair loss Female pattern hair loss • 5% topical minoxidil • 5% topical minoxidil • Oral anti-androgens • Oral finasteride, 1mg (spironolactone, cyproterone • Surgery (hair transplantation)* acetate). – * selected cases • Surgery (hair transplantation) • wigs • wigs Natasha A. Mesinkovska MD PHD Androgenetic Alopecia • Minoxidil • Survival dermal papilla cells • Prolongs anagen phase • Increases shaft diameter • Finasteride (1mg daily) • Type 2 5a-reductase inhibitor • Effects after 6-12 months • Check PSA level prior to initiation • Other: • Dutasteride • Fluridil (topical antiandrogen) • ? PRP Natasha A. Mesinkovska MD PHD 2. Telogen Effluvium • Excessive shedding of telogen club hairs • Usually follows a stressful event – 3 months after event • Usually <50% scalp • Eyebrows and eyelashes usually unaffected – if they are- check thyroid levels • Resolves spontaneously Natasha A. Mesinkovska MD PHD Telogen Effluvium Several mechanisms: stress: • Illness • Fever • Surgery • labor • CT scan • Medications: amphetamines, lithium, • cimetidine, B-blockers, valproic acid • Hormonal alterations: thyroid, OCP, menopause • Drastic diet regimen • Sudden weight loss – No known cause in many cases Natasha A. Mesinkovska MD PHD Telogen Effluvium • Exam: Abnormal pull test • Telogen hair • Depigmented club -shaped bulb • Lacks a sheath Natasha A. Mesinkovska MD PHD 3. Anagen Effluvium • Abrupt cessation of mitotic activity in hair matrix – Within days to weeks of stimulus – Hair shaft thins → breaks at surface (fractures) – Entirely reversible* • Associations • Chemotherapy – antimetabolites and alkylating agents • INH • Thallium • Boron Natasha A. Mesinkovska MD PHD 4. Alopecia Areata • Autoimmune –Loss of immune privilege of hair follicle –Target for activated T cells • ‘swarm of bees’ on pathology • Types: – Patchy – Totalis - loss of all scalp hair – Universalis → loss of all body hair – Ophiasis- band like pattern Natasha A. Mesinkovska MD PHD Alopecia Areata – Patchy Natasha A. Mesinkovska MD PHD Alopecia Totalis Natasha A. Mesinkovska MD PHD Alopecia Areata Natasha A. Mesinkovska MD PHD Alopecia Areata – Patchy Natasha A. Mesinkovska MD PHD Alopecia Areata • 10% nail pits (more uniform than psoriasis) • Exclamation point hairs - tapering hair shaft • Associated conditions • Eczema • thyroid • vitiligo • DM • Celiac • Hearing impairment • Depression and anxiety Natasha A. Mesinkovska MD PHD Tx AA • Patchy alopecia – Intralesional / topical corticosteroids – Topical anthralin – Minoxidil foam • Extensive or rapidly progressive alopecia – Contact immunotherapy (squaric acid dibutyl ester, diphenylcyclopropenone) – Systemic anti-inflammatory: tofacitinib – Wig or hairpiece Natasha A. Mesinkovska MD PHD Trichotillomania (Trichotillosis) • Compulsive desire to pull out hair • Hairs of multiple lengths – localized area – Geometric – Irregular patches – Scalp, Eyebrows and eyelashes – Even in children • Hairs of varying length – folliculitis Natasha A. Mesinkovska MD PHD Trichotillosis • Compulsive desire to pull out hair • OCD • depression • anxiety • Trichophagia – bezoars • Tx: psychotherapy + anti-depressants Natasha A. Mesinkovska MD PHD Tinea Capitis • Scale • Pustules • Broken hairs Natasha A. Mesinkovska MD PHD Tinea Capitis • Work up: – KOH scale – Culture the pustules – Biopsy only if above non-diagnostic • Trichophyton tonsurans • Microsporum canis • Treatment: – Griseofulvin – Terbinafine – Itraconazole – +/- ketoconazole or selenium sulfide wash Natasha A. Mesinkovska MD PHD Cicatricial Alopecias Alopecia accompanied by absence of follicular ostia Natasha A. Mesinkovska MD PHD Scarring Alopecias • Complex • Rare conditions • Many types • Scalp Biopsy is a MUST – Dermatopathologist • Comorbidities and HPI important Natasha A. Mesinkovska MD PHD Scarring Alopecias • Complex • Rare conditions, many 1. Chronic cutaneous lupus 2. Central centrifugal alopecia 3. Lichen planopilaris 4. Frontal fibrosing alopecia 5. Folliculitis decalvans Natasha A. Mesinkovska MD PHD Chronic Cutaneous Lupus Erythematosus • Clinical: – Most commonly face, ears, scalp • Erythema • Atrophy • Follicular plugging • Mottled hyper-hypopigmentation • 50% of pts with skin disease have scalp disease • ~5% develop Systemic Lupus • Difficult to distinguish from lichen planopilaris Natasha A. Mesinkovska MD PHD Chronic Cutaneous Lupus Erythematosus Natasha A. Mesinkovska MD PHD Chronic Cutaneous Lupus Erythematosus • Diagnosis: • Biopsy • Laboratory SLE work up • treatment: – Intralesional or topical steroids – Systemic (antimalarials, mycofenolate mofetil, methotrexate, retinoids, dapsone, sulfasalazine, thalidomide) Natasha A. Mesinkovska MD PHD Natasha A. Mesinkovska MD PHD 2. Central Centrifugal Cicatricial Alopecia Natasha A. Mesinkovska MD PHD 2. Central Centrifugal Cicatricial Alopecia • Overlapping entities • Hot comb alopecia/Follicular degeneration syndrome • Begins in crown → advances centrifugally • Difficult treatment –Discontinue chemical treatment –Discontinue heat –Discontinue traction –Intralesional stroids –Increased risk Diabetes melitus type 2 Natasha A. Mesinkovska MD PHD 2. Lichen Planopilaris (LPP) • Female >Male • Caucasian • Clinical • Perifollicular erythema/scale + progressive scarring • Small follicular papules • Pruritus and tenderness • Variants • Frontal fibrosing alopecia – women, 50 years old • Graham Little-Piccardi Syndrome? – LPP + keratosis pilaris + pubic/axillary alopecia (not scarring) Natasha A. Mesinkovska MD PHD Lichen Planopilaris Natasha A. Mesinkovska MD PHD Perifollicular Erythema in LPP Natasha A. Mesinkovska MD PHD Frontal Fibrosing Alopecia Natasha A. Mesinkovska MD PHD Natasha A. Mesinkovska