Sat 1025-hair-management-too-much-too-little- -park

5/28/2014

1

Dr Shehla Ebrahim. MD,CCFP,FCFP.( special interest dermatology)

I have no relevant conflicts of interest.

I have received an honorarium from the BCcollege for presenting this talk.

5/28/2014

2

A full day of Hair loss.

Its going to be a long day

Non scarring Alopecia-MPHL/FPHL-Telogen Effluvium.-Alopecia Areata.

When is it more than just hair loss.

Clinical Scenarios and Key Messages

5/28/2014

3

5/28/2014

4

Onset and duration.

“ When was the last time you had anormal head of hair”?

5/28/2014

5

Strong Family history is supportive of MPHL

5/28/2014

6

5/28/2014

7

5/28/2014

8

Regularity of menses.

Fertility.

NOTE PATTERN OF HAIR LOSS. Examine the scalp skin for inflammation,

scaling, patches.

Examine the eyebrows, facial axillary andpubic hair.

Check for hirsuitism is suspected by history.

5/28/2014

9

HAIR CYCLEANAGEN 3 YEARS

CATAGEN 3 Weeks

TELOGEN 3MONTHS

ANAGENANAGEN

ANAGEN

TELOGEN

FEMALE PATTERNHAIR LOSSMALE PATTERN HAIRLOSS

TELOGENEFFLUVIUM

ALOPECIAAREATA

ANDROGENEXCESS

5/28/2014

10

95% of hair loss .

50% of men and 40% of women.

CLINICAL PEARL They have completely normal androgen levels.

CLINICAL PEARLRetention of the frontal hair line

5/28/2014

11

5/28/2014

12

HAIR CYCLEANAGEN 3 YEARS

CATAGEN 3 WEEKS

TELOGEN 3 MONTHS

ANAGENANAGEN

ANAGEN

TELOGEN

TSH.

Ferritin- No studies showing reversal of hair

loss with iron supplementation.

- Keep Ferritin above 50 ug/L

Trost et al JAAD 2006;54(4) 824-844.

5/28/2014

13

Topical Minoxidil 2% and 5%

Mainly acts on the hair cycle bylengthening the duration of the anagen plusenlarges the miniaturized hair follicles

Messenger,AG Brit J dermatology2004;150:186:194.

Adverse effects (higher 5%)- Irritation.

- Contact Dermatitis (propyleneglycol)

-Non Virilising Hypertrichosis.

- High degree of variability in cosmeticacceptance.

- 5% foam OD vs. 2% BID.Lucky et al JAAD 2004:50;541-553

5/28/2014

14

Androgen receptor blocker and inhibitssteroid androgen production. Threshold of response acne>Hirsuitism>

FPHL Concurrent BCP

-breast tenderness.- Feminization of male foetus

200 mg per day.Sinclair, R Brit J dermatology

2005;152:466-473

5/28/2014

15

Thinning is Bitemporal +/-the crown of thescalp.

CLINICAL PEARL• The sides are spared

5/28/2014

16

Type 11, 5 alpha reductase inhibitor. Inhibits the conversion of testosterone to

DHT. 1 mg in MPHL.( Kaufman et al)

-benefits are temporary.- Decreased libido and ED.

Not indicated for use in women.

Canadian Family Physician Vol 46 July 2000

FEMALE PATTERNHAIR LOSSMALE PATTERN HAIRLOSS

TELOGENEFFLUVIUM

ALOPECIAAREATA

ANDROGENEXCESS

5/28/2014

17

Febrile illness

Childbirth

Severe psychological

stress

Major surgery

Hypo or

hyperthyroidism

Iron deficiency

anaemia

Crash diets

Drugs

HAIR CYCLEANAGEN 3 YEARS

CATAGEN 3 WEEKS

TELOGEN 3 MONTHS

ANAGEN

TELOGEN

5/28/2014

18

5/28/2014

19

Identify specific cause.

Complete recovery occurs in 4-6 months.

Minoxidil 5%

5/28/2014

20

FEMALE PATTERNHAIR LOSSMALE PATTERN HAIRLOSS

TELOGENEFFLUVIUM

ALOPECIAAREATA

ANDROGENEXCESS

Polygenic Autoimmune disorder.

It attacks the anagen hair follicles of thescalp,face and body

Majority Appear sporadically and it can appearwithout a family history.

Canadian family Physician Vol 46,July 2000

5/28/2014

21

AA is associated with other AA diseases such asvitiligo,Diabetes,Thyroid disease, pernicious anemia

Spontaneous remissions can occur.

Dermatology in Practice Vol 11 no 5

Patchy. (Most common)

Diffuse.

Confluent.

Aphyiais.

5/28/2014

22

5/28/2014

23

5/28/2014

24

T cell mediated disorder.

Immune privilege of the hair follicle is lost.

Once activated, the cytotoxic T cells produceinflammatory cytokines and IL which attackthe anagen hair follicles of the scalp,eyebrows, eyelashes and body

Nail Dystrophy (pitting, ridging, thinning)

Exclamation marks, are seen at the peripheryof the patch

Color changes in the hair

5/28/2014

25

5/28/2014

26

ADULTS WITH < 50% HAIR LOSS

-Observe for several months

- Intralesional steroids.kenalog q4-6 weeks

- Potent topical steroids.OD for 3 months

- +/- Minoxidil

ADULTS WITH > 50% HAIR LOSS.- Topical immunotherapy with DPCP

(diphenylcyclopropenone)

-Psoralen and Ultraviolet A (PUVA)

- Pulsed Oral Steroids

5/28/2014

27

FEMALE PATTERNHAIR LOSSMALE PATTERN HAIRLOSS

TELOGENEFFLUVIUM

ALOPECIAAREATA

ANDROGENEXCESS

Most women with FPA show no clinical orbiochemical evidence of hair loss.

-Hypersensitive to physiologicconcentration of androgens

When to evaluate for PCOS or metabolicSyndrome?

5/28/2014

28

Increased Facial Seborrhea

Acne that fails to respond to standardtherapies. Localized to the jaw line and neck

Hirsuitism; upper lip, chin breast and lineaalba

Androgenic Alopecia, early onset < 35 years.

Menstrual Irregularities.

Infertility.

Galactorrhea

Virilization

5/28/2014

29

Polycystic ovary Syndrome(90%)Prevalence 5-10%

Tumours of the ovary or adrenal gland(<0.5%

Hyperprolactinemia(2.3%)

Congenital adrenal hyperplasia (1.3%)

Cushings syndrome

Androgenic medications (danazol, anabolic steroids, progestinreleasing IUD

Glint &Anderson,gynecolendocrinol 2010:26:281-96

Testosterone (free and total)

Sex hormone binding globulin (SHBG)

Dehydroepiandrosterone sulphate(DHEAS)

Prolactin

LH/FSH

Fasting Glucose/insulin

Lipid profile.

Ding,EL et al NEJM 2009:361:1152-1163

5/28/2014

30

MH.Age 23

Testosterone 2.0 nmol/L (0.5-3.2)

Testosterone Free 180 pmol/l ( 5-60)

SHBG 3 nmol/L ( 5-100)

Cholestrol 7.16 H ( 2-4.60 nmol/L)

LDL 4.83 H (1.50-3.00)

TGA 3.9 (<2.21)

HDH 0.19 nmol/L (1.19)

5/28/2014

31

Weight loss

Oral Contraceptives

Anti androgen medications-Spironalactone-Cyproterone Acetate

Insulin Sensitizing medications.-Metformin

5/28/2014

32

A 20 year old female with steadily thinninghair over the past several years.

Otherwise in good health.

5/28/2014

33

FEMALE PATTERN HAIRLOSS

45 year old woman with considerable hairloss during the last 6 months.

“Massive” amounts of hair are clogging theshower drain every day

During the same period of time she has felt“depressed "fatigued and lacking in her usualenergy

5/28/2014

34

TELOGEN EFFLUVIUM

5/28/2014

35

36 year old man has noticed bald patches ofhair loss on his scalp and more recently hisbeard area.

He is otherwise in good health.

5/28/2014

36

ALOPECIA AREATA

23 year old overweight female complainingof scalp thinning,increased facial hair.

History of irregular periods since puberty.

Family history balding.

5/28/2014

37

5/28/2014

38

ANDROGEN EXCESS

MPHL/FPHL

Patients with FPHL/MPHL have Normalandrogen levels.

Pattern of hair loss is THINNING-Retention of frontal hair line FPA- Sides are spared in MPHL

5/28/2014

39

Telogen Effluvium

Pattern of hair loss is diffuse shedding andinvolves the entire scalp

Re growth occurs in 4-6 months

Alopecia Areata

Look for exclammation marks,white hairsand nail changes.

Wait for 6-9 months as spontaneousresolution is common.

5/28/2014

40

Suspect androgen excess if:

-Features of SAHA are present

- Screen for PCOS/Free Testosterone

- Treat with weight loss, Antiandrogen

Do not underestimate the psychological impactthat Hair loss has on your patients.

These patients feel vulnerable as hair gives themcharacter and definition.

National AA foundation.

Local wig makers.

Eyebrow and Eyelid tattooing

5/28/2014

41

Thank youPhoto courtesy of www.DermNet NZ.org

sebrahim@telus.net

5/28/2014

42

Trichotillomania.

Traction Alopecia.

•A compulsion to pull/pluck hair repetitively.

•Impulse control disorder

•7x more frequent in children.

•With increasing age, girls

5/28/2014

43

5/28/2014

44

5/28/2014

45

Spontaneous resolution.

Clomipramine vs desipramine.

5/28/2014

46