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SOME COMMON CAUSES OF ALOPECIA
DR RAKESH NEWAJ SPECIALIST DERMATOLOGIST MBBCh(Wits) FC derm (SA)
ALOPECIA
• Refers to a decrease in density of hairs on the scalp or body
• An increase in hair fall coupled with a decrease in the diameter of the hairs
• Becomes apparent when more than 25% of the hairs have been lost
• Affects both males and females
ALOPECIA
CICATRICIAL
Non
-‐ cicatricial • Alopecia areata
• AndrogeneLc alopecia
• Telogen Effluvium
• TrichoLllomania
Cicatricial • TracLon alopecia
• FolliculiLs decalvans and AKN
• Hot-‐comb alopecia
• Discoid lupus
• Frontal fibrosing alopecia
Hair shaR
diso
rder
• Beaded hair
• Pilli torL
• Trichorrhexis invaginata(bamboo hair)
Anagen 2-‐6yrs
Catagen 3 weeks
Telogen 3 months
Early Anagen
DIAGNOSIS
• Good history including onset, systemic symptoms, family history, medicaLons • Trichoscopy • Hair pull test • Systemic examinaLon • Swabs • Microscopy of the hair • Biopsy for histology
NON-‐ CICATRICIAL ALOPECIAS
ANDROGENETIC ALOPECIA ( Male and female pa[ern of hair loss)
• GeneLcally determined sensiLvity of scalp hair follicles to adult levels of androgens
• MiniaturizaLon of hairs in a symmetric pa[ern • More common in men and increases with age • Women who develops this type of alopecia in the perimenauposal period may be developing hair loss, not only due to geneLcs, but also due to alteraLons in androgen metabolism
ANTIANDROGEN THERAPY
Classic androgen receptor antagonist
(prevents testosterone and DHT from binding to their
receptors)
Peripheral anGandrogens
(alter androgen levels in the hair follicle)
PRODUCT MECHANISM OF ACTION DOSE
Spironolactone AnLandrogen, reduces testosterone levels and compeLLve AR blocker
100-‐200 mg by mouth daily in divided doses
Cyproterone acetate
AnLandrogen, AR blocker, testosterone levels by suppressing luteinizing hormone and follicle sLmulaLng hormone
2mg by mouth daily generally prescribed together with an oral contracepLve or cyproterone acetate 25-‐50mg/d on days 1-‐10 of menstrual cycle
Finasteride 5-‐alpha reductase blocker 0.2-‐5mg by mouth daily
Minoxidil Unknown-‐ possible anLandrogenic, vasodilatory and anLinflammatory effects
5% applicaLon once or twice daily
Ketoconazole Decreases DHT levels at the hair follicle Shampoo scalp every alt days. Wash aRer 5mins
Flutamide AnLandrogen compeLLve AR blocker 62.5mg-‐250mg by mouth daily
Durasteride 5-‐alpha reductase blocker
0.25-‐0.5mg by mouth daily
PRODUCT MECHANISM OF ACTION TREATMENT
Caffeine Counteracts testosterone effects on hair
Caffeine loLon and shampoo, potenLal increase in hair tensile strength and numbers
CimeLdine H2 blocker, peripheral anLandrogen-‐ blocks binding of DHT to AR
300g by mouth 5 Lmes daily
FerriLn Unclear Maintain serum ferriLn level > 40ng/ml.
Melatonin AnLandrogenic effects at the hair follicle
1mg topical compounded in alcohol and glycerin-‐no evidence that oral suppliment help
BioLn Reduces carboxylase enzymes in hair roots
No clinical trials
Zinc Unclear Supplement 8-‐15mg by mouth daily
Zinc pyrithium shampoo Zinc ions have anLinflammatory and anLoxidant effects and inhibit 5-‐alpha reductase in vitro
1% pyrithione shampoo daily
TELOGEN EFFLUVIUM
• Increased shedding of normal telogen hairs in response to a pathologic or physiologic change in health status
• A chronic form with no discernible precipitaLng factor is observed in some women
• The hair loss involves the enGre scalp
• A higher percentage of telogen hairs ( more than 20%)
• Telogen hair fibres show a club-‐shape at the boSom
• Prognosis is rather good with recovery taking place within months to years
CAUSES OF TELOGEN EFFLUVIUM • Postpartum • Chronic telogen effluvium • Posiebrile • Severe infecLons • Chronic illnesses • Post surgical • Hypothyroidism and other endocrine abnormaliLes
• Severe stress • Crash or liquid protein diets/ starvaLon • Drugs: ReLnoids,AnLcoagulants, AnL-‐thyroid, anLconvulsants, Beta-‐blockers,chemotherapy
TREATMENT
• Minoxidil 5%
• TreLnion soluLons
• Caffeine shampoos
• A good history and eliminaLon of the precipitaLng factors are important
ALOPECIA AREATA
• Non-‐scarring pa[erned alopecia, most commonly presenLng as circular areas of alopecia
• Organ-‐ specific autoimmune disease involving the T-‐cells
• Can lead to total scalp hair loss( alopecia totalis) or complete scalp and body hair loss( alopecia universalis
• RelanLonship with other autoimmune diseases
Scalp alopecia areata
Age Topical CorLcosteroids 5% minoxidil
Short contact anthralin
ILCS+-‐ Minoxidil+-‐
Topical CorLcosteroids
Scalp involvement
Topical immunotherapy DPCP or SADBE
ConLnue Excimer laser
Hair regrowth
ConLnue as needed Add ILCS to
refractory patches every 4 weeks
Minoxidil 5% CorLcosteroids
under occlusion or short contact anthralin or
systemic therapy
Hair regrowth
Hair regrowth
ConLnue Short contact anthralin
Minoxidil soluLon
<10yrs >10yrs
Good Poor
Good Poor
<50% >50%
6-‐12months
Good ParLal
Poor
TRICHOTILLOMANIA
• Self-‐ induced plucking or breakage of hair
• ORen associated with a psychologic or personality disorder
• Histology can help
• Has a DSM IV classificaLon
CICATRICIAL ALOPECIA • TracLon alopecia
• FolliculiLs decalvans/ dissecLng folliculiLs
• Acne keloidalis nuchae
• Discoid lupus erythematosus
• Central centrifugal cicatricial alopecia (CCCA or Hot-‐comb alopecia)
TRACTION ALOPECIA
Cause and management
• Hair styles
• Very difficult to treat
• 5% Minoxidil and TreLnoin
DISSECTING FOLLICULITIS, FOLLICULITIS DECALVANS AND ACNE
KELOIDALIS NUCHAE
FOLLICULITIS DECALVANS
• It is very difficult to manage as inflammatory process damage the hair roots and scars are formed
• Oral anLbioLcs ( rifampicin with or without clindamycin), oral zinc sulphate, oral reLnoids
• Repeated treatment
ACNE KELOIDALIS NUCHAE Causes: • Shaving of Lghtly curled hairs resulLng in the emerging hair curling
back into the skin. This can lead to inflammaLon and scars. • Constant irritaLon with the shirt collars, chronic infecLon of the
hair roots and any other causes of irritaLon of the scalp
• TREATMENT OPTIONS • PrevenLon of lesions -‐ stop irritaLon of the scalp and stop-‐ shaving
the scalp • TreLnoin gel and corLcosteroid • Intralesional steroids • Cryotherapy regime • AnLbioLcs use for infecLons • Punch excision • Laser hair reducLon and scar reducLon • Surgical excision and repair
DISCOID LUPUS ERYTHROMATOSUS
• Commonly involves the scalp • PASTE-‐ Plugging, Atrophy, Scale, Telangiectasia and Erythema • Scarring is permanent • Can be diagnosed on histology • Treatment involves potent topical corGcosteroids, intralesional steroids and
systemic therapy( anGmalarials, thalidomide, methotrexate)
HOT COMB ALOPECIA CCCA
• Starts in the central scalp region and increases in size with Gme
• Common in african females and may be associated with hair straitening processes
• Shiny with a burning sensaGon or pruritus in the area of hair loss
• Diagnosis can be made on histology
• Topical corGcosteroids and tetracyclines
Contact Details: Dr Rakesh Newaj Specialist Dermatologist MBBCh (Wits) FC Derm (SA) www.dermatologistjohannesburg.com 266 Polaris ave, Waterkloof ridge Pretoria Tel: (+2712)-‐7514001 Arwyp medical centre, 3rd floor, Medical suites Kempton Park, Johannesburg Tel: (+2711)-‐9221565
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