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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.
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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
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Onset and duration.
“ When was the last time you had anormal head of hair”?
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Strong Family history is supportive of MPHL
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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.
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HAIR CYCLEANAGEN 3 YEARS
CATAGEN 3 Weeks
TELOGEN 3MONTHS
ANAGENANAGEN
ANAGEN
TELOGEN
FEMALE PATTERNHAIR LOSSMALE PATTERN HAIRLOSS
TELOGENEFFLUVIUM
ALOPECIAAREATA
ANDROGENEXCESS
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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
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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.
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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
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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
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Thinning is Bitemporal +/-the crown of thescalp.
CLINICAL PEARL• The sides are spared
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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
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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
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Identify specific cause.
Complete recovery occurs in 4-6 months.
Minoxidil 5%
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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
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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.
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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
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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
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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?
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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
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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
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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)
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Weight loss
Oral Contraceptives
Anti androgen medications-Spironalactone-Cyproterone Acetate
Insulin Sensitizing medications.-Metformin
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A 20 year old female with steadily thinninghair over the past several years.
Otherwise in good health.
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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
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TELOGEN EFFLUVIUM
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36 year old man has noticed bald patches ofhair loss on his scalp and more recently hisbeard area.
He is otherwise in good health.
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ALOPECIA AREATA
23 year old overweight female complainingof scalp thinning,increased facial hair.
History of irregular periods since puberty.
Family history balding.
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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
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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.
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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
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Trichotillomania.
Traction Alopecia.
•A compulsion to pull/pluck hair repetitively.
•Impulse control disorder
•7x more frequent in children.
•With increasing age, girls
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Spontaneous resolution.
Clomipramine vs desipramine.
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