Hair Disorders

Hair diseases are disorders primarily associated with the follicles of the hair. Many hair diseases can be associated with distinct underlying disorders. Hair disease may refer to excessive shedding or baldness (or both). Balding can be localized or diffuse, scarring or non-scarring.

1. Hair Disorders Primary Health Care Dr. Wajahat Mohammad Consultant Family Medicine

2. Disclosure Of Conflict of Interest I Dr. Wajahat Mohammad DO NOT have a financial interest/arrangement or affiliation with anyone in relation to this program/presentation/organization that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation . Purely educational intent Recommendations are based on current evidence References provided where possible

3. Summary Common Hair Loss disorders Primary care management of hair loss disorders Referral Criteria for hair loss disorders Beyond Hair Loss ‘the symptom’

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5. Hair Cycle Anagen - Growth (2-6 years) Catagen - Involution (10-21 days) Telogen - Resting (90-100 days) Exogen - Shedding

6. Hair Disorders More Hair Hypertrichosis ( Ambras Syndrome) Hirsutism Less Hair Hair Loss Trichodystrophy

7. Hair Loss Categorization Non Scarring Alopecia Areata Androgen Alopecia Telogen Effluvium Trcihotillomania Ringworm Traction Alopecia * Visible follicles Scarring Chronic Discoid Lupus Erythematosus Lichen Planus Lichen Scelorosus Morphea ( localised scleroderma) Others cancers/trauma/Infection * Follicles not visible

8. Assessment - History Onset, Duration and Precipitants Pattern ( Diffuse vs Patchy) Scarring Shedding vs Breaking vs Thinning Medical History Drug History Family History Hair Care Diet

9. Assessment - Examination Inspection Scalp: Scarring? Scaly? Erythema? Pattern: Diffuse Patchy Density Hair Quality Pull Test

10. Assessment Investigation Ferritin Hormones Sex Hormones ANA Syphilis Scalp Scraping

11. Clinical Vignette 35 year old male 2 months history of Hair loss No itching No trauma No other medical conditions Diagnosis? Treatment Options Would you Refer onward?

12. Alopecia Areata Chronic Inflammatory Dermatological Disorder Unknown etiology Factors: Autoimmune, Environment and Genetics Non scarring Patchy or Complete 80% regrowth in Mild Alopecia 34-40% Recover in 1 year Progressive 14-25%

13. Prognostication Multiple lesions on scalp margins Involvement of Eyebrows and eye lashes Nail Changes Associated Atopy Childhood Onset Chronic Extensive disease Downs Syndrome Associated Autoimmune diseases

14. Management No Treatment – an option Topical steroids Intralesional Triamcinolone Topical Immunotherapy ( Diphenylcyclopropenone, squaric acid dibutyl ester or dinitrochlorobenzene)) Topical Minoxidil 2% and 5% PUVA Anthralin Methotrexate, azathioprine, oral steroids Less effective- TNF Alpha Inhibitors, Statins, chloroquine Ineffective- Tacrolimus, Cyclosporin –topical

15. Referral Criteria Extensive disease Diagnostic Uncertainty Psychological Distress Pregnant and breast feeding Topical Treatment not helpful Wig is required

16. Clinical Vignette 40 year lady gradual loss of hair over 6 months Diabetes Mellitus Height 155 cm Weight 92 kg What Else do we ask? Diagnosis? Treatment? Will you refer?

17. Female Pattern Hair Loss Andro-Genic Alopecia in women Unclear etiology Suspected disorder of sensitivity to Dihydrotestosterone 3-6% in <30 yrs age, 29-42% in >70 yrs age Frontal Hair line Spared in women Usually progressive once develops Very Rare progression to complete Baldness

18. Management Baseline Testosterone and Dehydroepiandrosterone sulfate Topical Monoxidil is first line, 2% to 5% BD, can take 4 months to show improvement. Antiandrogen medication Spironolactone Cyproterone acetate Finasteride P sychological support S urgical Options

19. Clinical Vignette 25 year lady Losing handsful of hair Sudden onset Has a 2 month old son with her Feeling Tired What else is relevant to ask? Management? What Tests?

20. Telogen Effluvium Acceleration of Hair Loss cycle More hair in telogen phase than anagen phase ( upto 50%) Usually triggers found from history Pull Test Positive

21. Triggers Acute or chronic major illness Febrile illness Major surgery Childbirth (telogen gravidarum ) Rapid weight loss Protein or caloric dietary restriction Congenital or acquired zinc deficiency Significant emotional stress Collagen vascular disease Endocrine disorders ( eg , hypothyroidism or hyperthyroidism) Drugs, supplements, or toxins Inflammatory conditions of the scalp ( eg , seborrheic dermatitis) Infectious conditions that affect the scalp ( eg , fungal, bacterial, or spirochetal ) Iron deficiency anemia Nutritional deficiencies

22. Drugs associated with Telogen Effluvium Allopurinol Androgens Anticholesterol agents (statins) Anticoagulants Anticonvulsants Antifungals Antihistamines (H2) Antiinflammatory agents Antimitotic agents Antithyroid agents Beta blockers Dopa Ergots Heavy metals Hormones (oral contraceptives, hormone replacement therapy) Immunomodulators Retinoids Psychotropics Minoxidil Selective estrogen receptor modulators and phytoestrogen

23. Management of Telogen effluvium Investigate with CBC, CMP, TFT and Ferritin Treat Underlying Cause Psychological Support Cosmetic advice Topical Minoxidil

24. Beyond Hair Loss Effects of hair loss Interpretation of hair loss Socio-economic consequences

25. Quiz

26. Alopecia Areata

27. Androgenic Alopecia

28. Post Cellulitis Scarring Alopecia

29. Morphea

30. Pustular Cellulitis

31. Female Pattern Hair Loss

32. Keroin

33. Folliculitis Related Alopecia

34. Lichen Planus Scarring

35. Androgenic alopecia in men

36. Pemphigoid Associated alopecia

37. Moth Eaten Apperance of syphilitic Alopecia

38. Traction Alopecia

39. Traction Alopecia

40. Tinea Capitis associated alopecia

41. Trichotillomania

42. Female pattern Hair Loss

43. Useful resource

44. References: KARYN SPRINGER,M.D.,MATTHEW BROWN,M.D.,and DANIEL L.STULBERG,M.D. Utah Valley Family Practice Residency,Provo,Utah , Am Fam Physician 2003;68:93-102,107-8 H UNT N, McHale S, Psychological Impact of Alopecia, BMJ 2005, 331(7522):951-953 B LUME-PEYTAARI U et al: Guideline for diagnostic evaluation in androgenetic alopecia in men, women and adolescents, British Journal of Drematology 2011, 164 (1):5-15 U KPDCS G P Notebook U ptodate