alopecia (hair loss, balding)

^[1]^[2]^[3]^[4]^[5]^[6]^[7]^[8]^[9]^[10]^[11]^[12]

Etiology

generalized hair loss
- telogen effluvium
- anagen effluvium
- alopecia totalis or universalis
- secondary syphilis^[9]
- hyperthyroidism
- hypothyroidism
- nutritional deficiencies (protein, iron, zinc, biotin)
- HIV infection
- pharmacologic agents
localized hair loss
- non-scarring alopecia
- scarring alopecia
  - hereditary & developmental
    - aplasia cutis congenica
    - epidermal nevi
    - facial hemiatrophy (Romberg's syndrome)
  - infection
    - fungal
  - microsporum canis
  - Microsporum audouinii
    - bacterial (folliculitis)
    - viral (Herpes zoster)
    - protozoan (leishmaniasis)
  - neoplasm
  - physical or chemical injury
    - burns
    - radiation
    - acidic chemicals
    - alkaline chemicals
  - lupus erythematosus, discoid lupus (may be non scarring)
  - follicular lichen planus (lichen planopilaris)
  - sarcoidosis
  - morphea
  - cicatricial pemphigoid
  - acne keloidalis
  - folliculitis decalvans
  - pseudopalade
  - scleroderma
  - frontal fibrosing alopecia

Pathology

scarring alopecia results in permanent hair loss
- non-scarring alopecia may be reversible^[6]
hair loss in women^[4]
- excessive testosterone & dihydrotestosterone
- insufficient estrogen

Genetics

associated with polymorphism in the androgen receptor

Laboratory

fungal tests
hormonal assays
- dehydroepiandrosterone (DHEA)-sulfate
- testosterone
scalp biopsy, 4 mm punch biopsy^[6]
- can distinguish scarring alopecia from non-scarring alopecia^[6]
- periphery of lesion best site for biopsy

Diagnostic procedures

hair pluck test

Management

inherited disorders
- some men elect to forgo treatment
- topical minoxidil (Rogaine) BID - best results with patients < 30 with < 5 years hair loss
- surgical procedures
  - hair transplant
  - scalp reduction
  - flaps
Fungal infections
- oral terbinafine, fluoconazole or itraconazole for ~6 weeks^[6]
- oral griseofulvin for ~12 weeks^[4]
- 3) ketoconazole is less effective
- topical antifungal agents are generally ineffective
- clean contaminated combs
- evaluate family members
alopecia areata
- most cases resolve spontaneously
- intralesional or topical glucocorticoids
- systemic glucocorticoids for refractory or extensive disease^[6]
- PUVA + prednisolone (recalcitrant alopecia areata)^[5]
  - 20 mg of methoxsalen, followed 2 hours later by total-body irradiation with ultraviolet A light (UVA) in increasing doses 5 days each week for 4 weeks;
  - maximum UVA dose was 80 J/cm2
  - oral prednisolone
    - 20 mg/day for 4 weeks
    - gradually tapered to 0 over 3 months
hair loss in women^[4] {nothing works well}
- minoxidil (Rogaine) only FDA-approved agent
- spironolactone
- finasteride (Propecia)
- flutamide
- Saw palmetto
- oral contraceptives
- estrogen/hormone replacement therapy
- thyroid replacement
traction alopecia
- decrease tension from hair styling practices
- central centrifugal cicatricial alopecia
  - hair straightener or hair relaxer
  - topical glucocorticoids, intralesional gluxocorticoids
frontal fibrosing alopecia
- hydroxychloroquine, 5-alpha reductase inhibitors
nutritional interventions with highest-quality evidence for potential benefit:
- Viviscal, Nourkrin, Nutrafol, Lamdapil, Pantogar, capsaicin & isoflavone, omega-3 fatty acids & omega-6 fatty acids with antioxidants, apple nutraceutical, total glucosides of paeony & compound glycyrrhizin tablets, zinc, tocotrienol, & pumpkin seed oil^[12]

Comparative biology

in older mice, dormant stem cells in hair follicles can be activated by Wnt
in older mice, inhibitors keep the stem cells in a dormant state
stem cell dormancy can be reversed by the nearby macroenvironment of young skin, that is more stem cells are not needed, but rather a change in the stem cell environment

More general terms

More specific terms

Additional terms

References

↑ Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 916
↑ Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 291-292
↑ ^4.0 ^4.1 ^4.2 ^4.3 Prescriber's Letter 10(3):17 2003
↑ ^5.0 ^5.1 Ito T et al Combination therapy with oral PUVA and corticosteroid for recalcitrant alopecia areata. Arch Dermatol Res 2009 Jun; 301:373. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19301021
↑ ^6.0 ^6.1 ^6.2 ^6.3 ^6.4 ^6.5 Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2022.
↑ Mounsey AL, Reed SW. Diagnosing and treating hair loss. Am Fam Physician. 2009 Aug 15;80(4):356-62. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19678603
↑ Dahl MV Stemming Hair Loss? NEJM Journal Watch. Aug 13, 2014 Massachusetts Medical Society (subscription needed) http://www.jwatch.org
Chen C-C et al. Regenerative hair waves in aging mice and extra-follicular modulators follistatin, Dkk1, and Sfrp4. J Invest Dermatol 2014 Aug 15; 134:2086. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24618599 <Internet> http://www.nature.com/jid/journal/v134/n8/full/jid2014139a.html
Reddy SK and Garza LA. The thinning top: Why old people have less hair. J Invest Dermatol 2014 Aug 15; 134:2068 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25029319 <Internet> http://www.nature.com/jid/journal/v134/n8/full/jid2014172a.html
↑ ^9.0 ^9.1 Moshiri AS, Moxam A Syphilitic Alopecia N Engl J Med 2018; 379:1657 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30354954 https://www.nejm.org/doi/full/10.1056/NEJMicm1804118
↑ Mubki T, Rudnicka L, Olszewska M, Shapiro J. Evaluation and diagnosis of the hair loss patient: part I. History and clinical examination. J Am Acad Dermatol. 2014 Sep;71(3):415.e1-415.e15. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25128118
Mubki T, Rudnicka L, Olszewska M, Shapiro J. Evaluation and diagnosis of the hair loss patient: part II. Trichoscopic and laboratory evaluations. J Am Acad Dermatol. 2014 Sep;71(3):431.e1-431.e11. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25128119
↑ ^11.0 ^11.1 Elston CA, Elston MD Identifying Lesions on Skin of Color. Medscape. 2021. May 10 https://reference.medscape.com/slideshow/identifying-lesions-6007985
↑ ^12.0 ^12.1 Drake L, Reyes-Hadsall S, Martinez J et al Evaluation of the Safety and Effectiveness of Nutritional Supplements for Treating Hair Loss. A Systematic Review. JAMA Dermatol. Published online November 30, 2022 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36449274 https://jamanetwork.com/journals/jamadermatology/fullarticle/2798840

Database

OMIM: https://mirror.omim.org/entry/109200

[ref1-1] Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39

[ref2-2] Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 916

[ref3-3] Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 291-292

[ref4-4] 4.0 ^4.1 ^4.2 ^4.3 Prescriber's Letter 10(3):17 2003

[ref5-5] 5.0 ^5.1 Ito T et al Combination therapy with oral PUVA and corticosteroid for recalcitrant alopecia areata. Arch Dermatol Res 2009 Jun; 301:373. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19301021

[ref6-6] 6.0 ^6.1 ^6.2 ^6.3 ^6.4 ^6.5 Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18, 19. American College of Physicians, Philadelphia 2012, 2015, 2018, 2022.

[ref7-7] Mounsey AL, Reed SW. Diagnosing and treating hair loss. Am Fam Physician. 2009 Aug 15;80(4):356-62. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19678603

[ref8-8] Dahl MV Stemming Hair Loss? NEJM Journal Watch. Aug 13, 2014 Massachusetts Medical Society (subscription needed) http://www.jwatch.org
Chen C-C et al. Regenerative hair waves in aging mice and extra-follicular modulators follistatin, Dkk1, and Sfrp4. J Invest Dermatol 2014 Aug 15; 134:2086. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24618599 <Internet> http://www.nature.com/jid/journal/v134/n8/full/jid2014139a.html
Reddy SK and Garza LA. The thinning top: Why old people have less hair. J Invest Dermatol 2014 Aug 15; 134:2068 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25029319 <Internet> http://www.nature.com/jid/journal/v134/n8/full/jid2014172a.html

[ref9-9] 9.0 ^9.1 Moshiri AS, Moxam A Syphilitic Alopecia N Engl J Med 2018; 379:1657 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30354954 https://www.nejm.org/doi/full/10.1056/NEJMicm1804118

[ref10-10] Mubki T, Rudnicka L, Olszewska M, Shapiro J. Evaluation and diagnosis of the hair loss patient: part I. History and clinical examination. J Am Acad Dermatol. 2014 Sep;71(3):415.e1-415.e15. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25128118
Mubki T, Rudnicka L, Olszewska M, Shapiro J. Evaluation and diagnosis of the hair loss patient: part II. Trichoscopic and laboratory evaluations. J Am Acad Dermatol. 2014 Sep;71(3):431.e1-431.e11. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25128119

[ref11-11] 11.0 ^11.1 Elston CA, Elston MD Identifying Lesions on Skin of Color. Medscape. 2021. May 10 https://reference.medscape.com/slideshow/identifying-lesions-6007985

[ref12-12] 12.0 ^12.1 Drake L, Reyes-Hadsall S, Martinez J et al Evaluation of the Safety and Effectiveness of Nutritional Supplements for Treating Hair Loss. A Systematic Review. JAMA Dermatol. Published online November 30, 2022 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36449274 https://jamanetwork.com/journals/jamadermatology/fullarticle/2798840

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alopecia (hair loss, balding)

Contents

Etiology

Pathology

Genetics

Laboratory

Diagnostic procedures

Management

Comparative biology

More general terms

More specific terms

Additional terms

References

Database

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alopecia (hair loss, balding)

Etiology

Pathology

Genetics

Laboratory

Diagnostic procedures

Management

Comparative biology

More general terms

More specific terms

Additional terms

References

Database

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