COVER FOCUS Diagnosing and Managing Hair 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 Telogen effluvium AHair grows on most parts of the skin surface, except the Drug induced palms, soles, lips, and eyelids. Hair thickness and length Pattern varies according to site.Vellus hair 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 Lichen planus base of the follicle (hair bulb). The cells produce the three Lupus erythematosus layers of the hair shaft (medulla, cortex, cuticle), which are essentially made of the protein keratin. Hair growth follows Hirsutism 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 Anagen effluvium Telogen: Resting phase for one to four months, up to Telogen effluvium 10 percent of hairs in a normal scalp. Pregnancy Hair length depends on the duration of anagen. Short Autoimmune Alopecia areata 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. Hair loss 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), medications (e.g., cytotoxic/chemotherapy drugs), or congenital condition (e.g., loose anagen syndrome). 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) 58 PRACTICAL DERMATOLOGY SEPTEMBER 2017 COVER FOCUS 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. Pattern hair loss 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. Finasteride is FDA approved for treating male • Tinea capitis, psoriasis, seborrhoeic dermatitis, atopic hair loss. It mechanism of action includes stopping the dermatitis, pityriasis rubra pilaris, cutaneous lupus production of dihydrotestosterone, hence encouraging hair erythematosus, cutaneous T-cell lymphoma regrowth. A topical medication 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 retinoid can enhance efficacy. 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 inflammation during conditions like alope- hair follicle. Infections may be viral, bacterial, or fungal. cia areata. Inflammatory skin diseases like lupus, scleroderma, and Alternatives with weak evidence include tacrolimus 0.1%, cellulitis 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. Light therapy 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-androgens, steroids, minoxidil 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 SEPTEMBER 2017 PRACTICAL DERMATOLOGY 59 COVER FOCUS 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 Facial hair Moustache, beard, eyebrows eating healthy food rich in protein, vitamins, and minerals, Abdomen Diamond shape of pubic hair extending like iron, also help. Patients should avoid birth control 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 Hyperandrogenism Polycystic Ovaries and reduce hair loss has achieved quite effective results for Androgen 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 adrenal gland or ovary 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 Insulin resistance a large clinical trial. sensitivity Obesity Botulinum Toxin. The science behind use of neurotoxins TABLE 5. HAIR REMOVAL 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 estradiol in oxygen- nent reduction removal rich medium. A 60-week study has reported increase in hair Shaving Laser-assisted Electrolysis growth and reduction