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Alopecia

Common term for Alopecia is Hair Loss. Hair loss or Baldness results from loss of hair from the head or body. Baldness may be in terms of general hair loss or ‘male pattern baldness’ in particular. Certain types of hair loss can be caused due to ‘alopecia areata’ which is an autoimmune disorder. ‘Alopecia totalis’ and ‘Alopecia universalis’, being the extreme forms of alopecia areata involve loss of all head hair and loss of all hair from the head and body respectively.

Baldness can be caused as a result of fungal infection (tinea capitis), damage caused as a result of trauma, such as by compulsive pulling (trichotillomania), as a result of chemotherapy or radiotherapy, as a result of nutritional deficiencies like iron, and also as a result of autoimmune phenomena, which includes alopecia areata and hair loss linked with systemic lupus erythematosus (SLE).

Types:

  • Alopecia areata – a hair condition where hair are lost from some or almost all areas of body; particularly scalp.
  • Alopecia totalis – in this, hair are lost from the entire scalp.
  • Alopecia universalis – Hair loss may be spread to the entire epidermis.
  • Androgenic alopecia – Also referred to as “male pattern baldness”. Hair loss occurs as a result of underlying susceptibility of hair follicles to androgenic miniaturization. People typically come up with hairline recession at the temples and vertex.
  • Traction Alopecia – Is a form of alopecia, or gradual hair loss, caused mainly by pulling force being applied to the hair. This commonly results from the sufferer frequently wearing their hair in a particularly tight ponytail, pigtails, or braids. Sometimes t is also seen in long-haired people who use barrettes to keep hair out of their faces. Traction alopecia is recession of the hairline as a result of chronic traction, or hair pulling, and is characterized by a fringe along the marginal hairline on physical exam.

Clinical Presentation:

Signs & symptoms:

Affected people present with hair loss in patches generally in circular patterns, skin lesions, dandruff, scarring. Alopecia areata shows hair loss in unusual areas such as backside of the head, eyebrows or above the ears where usually the male pattern baldness does not effect. Loss of hair and thinning generally commences at the temples and the crown and either of the two falls out or thins out, in case of male-pattern baldness. Female-pattern hair loss takes place at the parietal and frontal.

  • Excessive daily hair loss – The first sign of hair thinning is that more hair than usual left in the hairbrush after brushing or in the basin after shampooing.
  • Skin disorders – A significantly blemished face, limbs and back could indicate ‘cystic acne’. This being the most severe form, results from the same hormonal imbalances that cause hair loss, and is linked with DHT (Dihydrotestosterone) production.

‘Seborrheic Dermatitis’ (a condition wherein excessive amount of sebum is formed and builds up on the scalp) is also a symptom of hormonal imbalances, as is an excessively oily or dry scalp. This can cause hair thinning.

  • Psychological – The psychology of hair thinning is a complex issue. Hair is said to be an important part of overall identity; particularly for women, for whom it generally signifies femininity and attractiveness. Men may be aware of a male pattern baldness in the family, but most of them are not very comfortable talking about this issue. For sufferers, it may represent a feeling of isolation and loss of control.

Hair loss as a result of chemotherapy may result in causing changes in self-concept & body image. Body image does not return to the earlier state after regrowth of hair in a good number of individuals. Patients find it difficult to express their feelings (alexithymia) in such cases. They may develop a tendency to avoiding family conflicts.

Predisposing factors:

  • Male pattern hair loss – More than 95% of hair thinning in men is male pattern hair loss (also known as androgenic alopecia). Male pattern hair loss is characterized by hair receding from the lateral sides of the forehead (known as a “receding hairline”) and/or a thinning crown (balding to the area known as the ‘vertex’). Both become more pronounced until they eventually meet, leaving a horseshoe-shaped ring of hair around the back of the head.

The incidence of pattern baldness is linked with genetic background.

    • Nutrition – Poor nutrition, deficiencies in certain nutrients, limited food intake may result in thinning. These include deficiencies of protein, zinc, biotin and poor human iron metabolism. A diet high in vitamin A and animal fat is also considered to have an effect on hair loss.
      Hypervitaminosis A
      Iron deficiency or malnutrition
    • Infections which may include :
      • Fungal infections (tinea capitis)
      • Folliculitis
      • Dissecting cellulitis
      • Secondary syphilis
      • Demodex folliculorum, a microscopic mite which feeds on the sebum that is produced by the sebaceous glands, denies nutrients essential for hair and may cause thinning. This mite may be most likely to live in an excessively oily scalp environment.

Drugs :

      • Some medications used for treating fungal infections may lead to massive hair loss.
      • Medications for blood pressure problems, heart disease, cholesterol and diabetes may cause temporary or permanent hair loss.
      • Medications such as chemotherapy, anabolic steroids and birth control pills.

Trauma/injury :

      • Traction alopecia – found in people with ponytails or those who tie up their hair with extreme force. Also, heat styling, rigorous brushing may damage the cuticle. The overall hair volume reduces as individual hair strands become weak and break off.
      • Trichotillomania – Loss of hair due to compulsive pulling and bending of hair.
      • When Radiotherapy is applied to the head for treating certain cancers, it may result in baldness of the irradiated areas.
      • Traumas like childbirth, poisoning, major surgery and severe stress may lead to hair loss. The condition is termed as ‘telogen effluvium’.

Pregnancy – Hair loss often follows childbirth without resulting in baldness. The hair is thicker during pregnancy due to increased circulating estrogens. The estrogen level falls back to normal, after the child is born, and the additional hair foliage drops out.

Other :

    • Hypothyroidism and the side effects of its related medications may result in hair loss, especially frontal.
    • Temporary hair loss may take place in areas where sebaceous cysts are present for a significant period of time.
    • Water and air pollutants as well as minerals in the water and phototoxic effects of sunlight may cause thinning by aging the scalp skin and damaging hair.

Diagnosis:

If hair loss is seen in a young man without any significant family history, drug use may be the cause responsible.

  • The pull test – helps to assess diffuse scalp hair loss. Gentle traction is applied on a group of hairs (about 40–60) on three different areas of the scalp. The number of withdrawn hair is counted and examined under a microscope. Normally, fewer than three hair per area should come out with each pull. If more than ten hair are obtained, the pull test is considered positive.
  • The pluck test – is carried out by pulling hair out “by the roots”. The root of the plucked hair is examined under a microscope to deduce the phase of growth, and is used for diagnosing a defect of telogen, anagen, or systemic disease. Telogen hair have tiny bulbs without sheaths at their roots. Telogen effluvium shows an increased percentage of hair upon examination. Anagen hair have sheaths attached to their roots. Anagen effluvium shows a reduction in telogen-phase hair and an increased number of broken hair.
  • Scalp biopsy – It allows to distinguish between scarring and non-scarring type of alopecia. Hair samples are taken from the areas of inflammation, generally around the bald patch border. Scalp biopsy is done when there is no surety of diagnosis.
    Trichoscopy – A noninvasive method for examination of hair and scalp. This test may be carried out using a handheld dermoscope or a video dermoscope. It allows differential diagnosis of hair loss in majority services.
  • Daily hair counts – are carried out when the pull test is negative. It is done by counting the number of hair lost. The hair from the first morning combing or during washing must be counted. The hair are collected in a transparent plastic bag for a period of 14 days. If the count is >100 per day, it is considered abnormal. However, after shampooing, hair count may reach up to 250 which is said to be normal.