The Open Dermatology Journal, 2008, 2, 77-82 77 Open Access Hairy Concerns: Use of Instructional/Informational Sheets for Assistance with Disorders of Hair Craig G. Burkhart*,1 and Craig N. Burkhart2 1University of Toledo College of Medicine, USA; Ohio University College of Osteopathic Medicine, 5600 Monroe Street, Suite 106B, Sylvania, OH 43560, USA 2Department of Dermatology, Northwestern University, Chicago, Illinois, USA Abstract: Hair serves as a social sign of gender, age, status, values, and group membership. Hair is a major part of one's self-identity, and central to one's feeling of personal attractiveness. Treating a patient with hair loss and/or hair issues is not easy because of psychosocial overtones and patients' distress and body image concerns. In this paper, several common hair diseases will be discussed in consort with sample patient instructional sheets. They include trichorrhexis nodosa, te- logen effluvium, pattern alopecia, alopecia areata, excess facial hair in females, and male pattern baldness. This paper therefore presents a template from which individual physicians can assess whether any portion of the material is worth be- ing incorporated into their individual practices. Scalp hair has been endowed with greater social and psy- In this paper, several common hair diseases will be dis- chological significance than biological importance. Medi- cussed in consort with sample patient instructional sheets. cally, it merely provides some shielding from ultraviolet rays This paper therefore presents a template from which individ- and some cushioning of the cranium from head gear. Histori- ual physicians can assess whether any portion of the material cally and culturally, hair serves as a social sign of gender, is worth being incorporated into their individual practices. age, status, values, and group membership. As stated previ- One option is to allow patients time to read the informational ously, "from monks to skinheads, prisoners of war to warri- sheet after completing the history and physical, and there- ors, bigwig European aristocrats to mop top Beatles, and fore, before outlining the treatment program. hippies to head-shaven celebrity athletes, hair makes a statement whether chosen or imposed [1]". TRICHORRHEXIS NODOSA Hair is a major part of one's self-identity, and central to Unlike most physical characteristics, hair can be altered one's feeling of personal attractiveness. Physical appearance and manipulated to the dictates of culture and fashion. The symbolizes one's perceptions, thoughts, feelings, and behav- chemical reactions from coloring, perming, and straightening iors. People use this physical attribute to express one's indi- hair affect the normal structure of the hair shaft. Many hair viduality. Hair styling is a major part of one's daily grooming cosmetics are used without any visual effects on the integrity ritual. Quoting a psychologist, "Preparing one's hair is prepa- of hair, they nonetheless cause microscopic weathering ren- ration to face one's social world. The expression 'bad hair dering the hair structure weaker and more prone to breakage. When hair breakage occurs with visible hair loss, the term day' is testimony to the psychological importance of hair. Hair loss can turn every day into a bad hair day [1]". that is utilized is ‘trichorrhexis nodosa [2]’. Treating a patient with hair loss and/or hair issues is not The trichorrhexis nodosa sheet (informational sheet 1) is easy because of psychosocial overtones and patients' distress very informative as patients with this entity often question and body image concerns. These patients often require con- the validity of this disease entity. Hair styling and hair cos- siderable support. They need education on their condition as metic habits are hard to change, but after reading through well as a realistic appraisal of possible treatments, length of this synopsis, my patients are more receptive to considering time before resolution, and alternatives in terms of hair re- altering their hair style and using fewer chemicals. placement. After discussing the 'hairy' situation, patients who TELOGEN EFFLUVIUM remain greatly distressed and/or are totally unrealistic with expectations of magical cures, one might ask them to go to When presenting telogen effluvium (informational sheet the internet or book store and research their stated hair dis- 2) to patients, one has to familiarize patients with the con- ease as well as the topic of 'body image.' In short, for some cept that our hair grows in cycles. At any given time, a small individuals, the loss of hair represents a body image impair- percentage of our hair follicles are in the stage in which hair ment which can undermine self-esteem and quality of life. is shed in preparation for new hair that follows. One loses hair every day. Evidence for shedding is noted in one’s hair brush as part of one’s normal grooming routine. With telo- gen effluvium, there is a shift in the growth cycle in which *Address correspondence to this author at the University of Toledo College of Medicine, 5600 Monroe Street, Suite 106B, Sylvania, OH 43560, USA; an abnormal number of follicles have moved into the telo- Tel: 419-885-3403; Fax: 419-885-3401; gen, or resting, phase of the growth cycle. E-mail: [email protected] 1874-3722/08 2008 Bentham Open 78 The Open Dermatology Journal, 2008, Volume 2 Burkhart and Burkhart Nutritional factors are mentioned on the informational a treatment would be repeated every 6 weeks, if proving suc- sheet for this condition. Rather than elaborate studies, our cessful. minimal knowledge on the subject comes from studies of The other options which I consider in recalcitrant cases protein-energy malnutrition, starvation, and eating disorders includes sulfasalazine [5, 6]. This is an anti-inflammatory [3]. Otherwise healthy individuals may not find great benefit drug composed of sulfonamide and a salicylate which has in dietary supplementation. However, there is medical evi- shown to be of benefit for rheumatoid arthritis, arthritis, in- dence that major deficiencies in zinc and biotin can cause flammatory bowel disease, psoriasis, and dermatitis herpeti- hair loss, so it doesn’t hurt to offer patients these inexpensive formis. It has numerous immunological effects including agents that may be somewhat helpful. In the very least, it immunosuppression and immunomodulation. It leads to in- allows more time for the body to return to normal hair cy- hibition inflammatory cell chemotaxis, cytokine production, cling and reduce the amount of hair shedding. To a great antibody proliferation, and IL-2 release. Other alternatives extent, time heals telogen effluvium, especially if the stresses for treatment include topical glucocorticoids, anthralin that caused the hair shedding are eliminated. (Dithranol, Drithocreme), and topical minoxidil. PATTERN ALOPECIA IN WOMEN Topical immunotherapy has been recommended for ex- Pattern alopecia is the result of genetics, aging, and hor- tensive alopecia areata that fails with conventional therapy monal changes that combine to cause changes in the hair [7]. The three contact sensitizers that have been used are follicle, namely, miniaturization of the terminal hair into dinitrochlorobenzene (DNCB), squaric acid dibutyl ester vellus hair. The end result is generalized thinning of hair (SADBE), and diphenylcyclopropenone (DPCP). DNCB has over the crown and top areas of the head. The patient hand- shown mutagenic effects and is rarely used presently. The out (informational sheet 3) divides the condition into pattern contact sensitizer is applied weekly trying to put a concentra- alopecia secondary to low estrogen levels and pattern alope- tion of the sensitizer to maintain a low-grade tolerable cia secondary to an increase in (what is often referred to as) erythema, scaling, and pruritus on the treated side for 36 male hormones (specifically testosterone and 5- hours after application. Side effects of such treatment in- dihydroxyepiandrosterone). The sheet further outlines the cluded eczema, possible extention of the dermatitis to other options of treatment for patients experiencing low estrogen. body parts, itching, edema, lymphadenopathy, and pigmen- tary alterations. ALOPECIA AREATA EXCESS FACIAL HAIR IN A WOMAN Alopecia areata (informational sheet 4) is a non-scarring hair loss condition which can affect any hair-bearing surface. While hair loss is devastating to women, an equally trou- The only predictable thing about the progress of the condi- bling problem is unwanted hair growth. Our society has tion is that it is unpredicatable. Several episodes of hair loss deemed body hair on women is undesirable, and women and hair regrowth are not unusual in this condition. It is re- have developed a habit of shaving such unwanted hairs as on ported that as many as 7% of individuals with alopecia areata the underarms and legs. Indeed, the sight of a woman with develop permanent hair loss in patches or in significant por- natural hair development that is unshaven is considered gro- tions of their scalp. Alopecia areata is due to a hair cycle tesque. Thus, this is another example of multimillion dollar dysfunction, but the pathogenesis of the condition is still industries motivating women to try to alter their bodies to unknown, with non-specific immune factors appearing to be match some ideal seen in fashion magazines. Thus shaving contributory. joins dieting, exercise, cosmetics, hair dying, and cosmetic surgeries as the method to achieve beauty in our society. At present, there is no cure that works every time. Be- These body-altering behaviors certainly attest to the fact that cause of the chronic nature of the disease, any mode of a woman’s body is not acceptable the way it naturally is [8]. treatment needs to be used for prolonged periods of time. The prognosis tends to be worse when the condition begins Millions of women experience what could be considered in early childhood and when extensive areas of the scalp as heavy hair growth on the face. Some ethnic background and involved.