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Medical hair loss guide: Scarring alopecia needs a dermatologist’s expertise, while non-scarring alopecias can be managed by family physicians. Hair loss can be a distressing experience for patients and significantly impact their quality of life. When individuals encounter diffuse or patchy hair loss, they often seek help from their family physician.
One common form of hair loss, known as androgenetic alopecia, can be diagnosed clinically and treated using minoxidil. Alopecia areata, characterized by distinct patches of hair loss, is usually self-limited and can be identified through typical presentation. On the other hand, tinea capitis, causing patches of alopecia accompanied by erythema and scaling, necessitates systemic treatment.
Telogen effluvium, a non-scarring and non-inflammatory alopecia, occurs suddenly due to physiological or emotional stress. Fortunately, removing the precipitating cause often leads to hair regrowth. Trichotillomania, an impulse-control disorder involving hair pulling, requires treatment addressing the underlying psychiatric condition.
Trichorrhexis nodosa is a condition where hairs break due to trauma, commonly caused by excessive hair styling or the overuse of hair products. Anagen effluvium, a diffuse hair loss during the growth phase, is typically associated with chemotherapy or events that hinder hair follicle mitotic activity.
Patients experiencing hair loss need compassionate support from their physicians, particularly when dealing with hair loss due to chemotherapy.
Given the non-life-threatening nature of hair loss, many patients will initially consult their family physicians. Determining whether the hair loss is scarring or non-scarring is crucial, as it dictates the approach to management. Scarring alopecia, though rare, requires careful evaluation by a dermatologist, especially if follicular orifices are absent. In contrast, non-scarring causes of alopecia can be effectively addressed within the family physician’s scope.
Understanding the various forms and etiologies of hair loss is essential for appropriate diagnosis and management, and this article will focus on approaches to nonscarring causes of alopecia.
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PHYSICAL EXAMINATION
During the physical examination, special attention should be given to the hair and scalp, while also considering physical signs of any concurrent conditions mentioned in the review of systems. If the scalp is the primary area of concern, the physician should observe for typical male or female pattern hair loss, which may indicate androgenetic alopecia. If hair loss is widespread across the entire body, it could be indicative of alopecia totalis. Trichorrhexis nodosa might be suspected when dry and broken hair is observed, whereas signs of infection, such as scaling, pustules, crusts, erosions, redness, and local swelling, should be noted.
To aid in diagnosing hair loss conditions, the pull test can be employed. This involves the examiner gently pulling approximately 40 to 60 hairs from the scalp using the thumb, index, and middle fingers. A positive result occurs when more than 10% of hairs (around four to six hairs) are pulled out, indicating active hair shedding and suggesting conditions like telogen effluvium, anagen effluvium, or alopecia areata. However, a negative result does not necessarily rule out these conditions entirely. It’s important to note that standardizing the pull test can be challenging due to variations in pulling force and difficulty in accurately estimating the number of hairs grasped, which may lead to potential misinterpretations.
LABORATORY STUDIES
As there are numerous potential causes for hair loss, routine tests to evaluate hair loss are not generally recommended. However, if the patient’s history or physical examination findings suggest an underlying comorbidity, laboratory testing may be indicated.
Specific Disorders
ANDROGENETIC ALOPECIA
Androgenetic alopecia, a common form of hair loss in both men and women, is considered a normal physiologic variant. It primarily affects white men, with approximately 30%, 40%, and 50% experiencing androgenetic alopecia at 30, 40, and 50 years of age, respectively. Many patients with androgenetic alopecia have a family history of this condition.
Hair thinning in cases of androgenetic alopecia follows a sex-specific pattern. Men typically experience bitemporal thinning, thinning of the frontal and vertex scalp, or complete hair loss with some hair remaining at the occiput and temporal fringes. Women, on the other hand, often present with diffuse hair thinning at the vertex, while the frontal hairline remains relatively unaffected. Some women may also experience thinning over the lateral scalp. It’s important to consider other conditions that may mimic androgenetic alopecia, such as thyroid disease, iron deficiency anemia, and malnutrition. This Medical hair loss guide for alopecia will help understand hair loss.
Treatment for androgenetic alopecia is based on patient preference. For men, topical minoxidil in either a 2% or 5% solution is approved for treatment. Hair regrowth is typically more noticeable at the vertex, and it may take six to twelve months to see improvements. Continued treatment is necessary as hair loss tends to resume if minoxidil is discontinued. For women, the recommended treatment is a 2% minoxidil solution. Adverse effects may include irritant and contact dermatitis.
In cases where topical minoxidil has not been effective for men, oral finasteride (Propecia) at a daily dose of 1 mg can be prescribed. However, it’s essential to note that finasteride may come with adverse effects such as decreased libido, erectile dysfunction, and gynecomastia.
As of now, the U.S. Food and Drug Administration has approved only minoxidil and oral finasteride as treatments for androgenetic alopecia. Both medications can stimulate hair regrowth in some men and are more effective at halting further hair loss. While other treatments may be mentioned in various sources, the evidence supporting their use is not strong.
ALOPECIA AREATA
Alopecia areata is characterized by acute and patchy hair loss, affecting up to 2% of the population with no gender difference. Approximately 20% of affected patients are children.10 The etiology is unknown, but the pathogenesis is likely autoimmune. Patients may have a single episode, or they may have remission and recurrence. The diagnosis can usually be made clinically.
Hair loss in alopecia areata occurs in three different patterns: patchy alopecia is circumscribed, oval-shaped, flesh-colored patches on any part of the body; alopecia totalis involves the entire scalp; and alopecia universalis involves the whole body. Evaluation of the scalp may reveal short vellus hairs, yellow or black dots, and broken hair shafts (which are not specific to alopecia areata). Microscopic examination of the hair follicles demonstrates exclamation mark hair
In adults with less than 50% of scalp involvement in alopecia areata, the recommended treatment is intralesional triamcinolone acetonide injected intradermally using a 0.5-inch, 30-gauge needle. The maximum volume per session is 3 mL. Treatment sessions can be repeated every four to six weeks until resolution or for a maximum of six months. It’s important to note that local adverse effects, such as transient atrophy and telangiectasia, may occur.
Various other therapies are available for treating alopecia areata, including the use of topical mid- to high-potency corticosteroids, minoxidil, anthralin, immunotherapy with diphenylcyclopropenone or squaric acid dibutylester, as well as systemic corticosteroids. However, the results from these therapies are often unsatisfactory, and spontaneous remission rates are relatively high. If remission does not occur, some clinicians may recommend the use of a hairpiece or wig as an alternative.
Tinea capitis, a fungal infection affecting the hair shaft and follicles, primarily affects children. The infection is often contracted through household exposure, contact with contaminated hats, brushes, or barber instruments. In North America, Trichophyton tonsurans is the most common causative agent. Transmission can occur person-to-person or from asymptomatic carriers, and infectious fungal particles can remain viable for an extended period. Other vectors may include fallen infected hairs, animals, and fomites. Microsporum audouinii is frequently spread by dogs and cats. This Medical hair loss guide for alopecia will help understand hair loss.
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Patients with tinea capitis typically exhibit patchy alopecia, sometimes accompanied by scaling, with potential involvement of the entire scalp. Other noticeable findings may include adenopathy (enlarged lymph nodes) and pruritus (itching). In children, an associated kerion may be present, characterized by a painful, erythematous, boggy plaque, often with purulent drainage and regional lymph node enlargement. Distinguishing tinea capitis from other inflammatory causes of alopecia can be aided by checking for posterior auricular lymphadenopathy. To confirm the diagnosis, a skin scraping taken from the inflamed patch’s active border can be microscopically examined for the presence of hyphae using a potassium hydroxide preparation. While fungal culture is less helpful due to its lengthy incubation period (up to six weeks), it can also be done.
For tinea capitis, systemic treatment is necessary, as topical antifungal agents do not effectively penetrate hair follicles. Treatment options for infections caused by Trichophyton species include oral terbinafine (Lamisil), itraconazole (Sporanox), fluconazole (Diflucan), and griseofulvin. These options have similar efficacy rates and potential adverse effects, but griseofulvin requires a longer treatment course. For infections caused by Microsporum species, griseofulvin is the preferred treatment, although there is a lack of definitive studies in this area. Empiric treatment before obtaining culture results is sometimes considered, but it’s essential to be aware that griseofulvin may have lower cure rates for T. tonsurans infections, reducing its effectiveness when used empirically. In cases of tinea capitis, all close contacts of the affected patients should be examined for signs of infection and treated as necessary.
TELOGEN EFFLUVIUM
Telogen effluvium is characterized by nonscarring, noninflammatory alopecia that appears relatively suddenly. It affects both sexes and various age groups. This condition occurs when a large number of hairs enter the telogen (resting) phase and fall out three to five months after exposure to a physiological or emotional stressor. Possible triggers include severe chronic illnesses, pregnancy, surgery, high fever, malnutrition, severe infections, and endocrine disorders. Some medications, such as retinoids, anticoagulants, anticonvulsants, beta blockers, antithyroid medications, and discontinuation of oral contraceptive agents, can also lead to telogen effluvium.
Patients with telogen effluvium may not always exhibit specific symptoms of an underlying condition but often notice clumps of hair shedding during showering or brushing. To diagnose the condition, patients should be asked to recall any potential triggers experienced two to five months before the onset of hair loss.
Examination of the scalp in telogen effluvium patients typically reveals uniform hair thinning. However, the presence of erythema, scaling, inflammation, altered or uneven hair distribution, or changes in shaft caliber, length, shape, or fragility may suggest other diagnoses. Laboratory investigations are indicated when the history and physical examination findings point to underlying systemic disorders, such as iron deficiency anemia, zinc deficiency, renal or liver disease, or thyroid disease.
Telogen effluvium usually resolves on its own within two to six months. The mainstay of treatment involves identifying and eliminating the underlying cause, providing reassurance to the patient. If potentially causative medications are involved, they should be discontinued if possible. In cases where the underlying stress persists, telogen effluvium may last for years.
TRICHOTILLOMANIA
Trichotillomania is an impulse-control disorder characterized by patients consciously or unconsciously pulling, twisting, or twirling their hair. It typically begins around the age of 13 and is reported to affect up to 4% of the population, with the highest incidence in childhood and adolescence. This Medical hair loss guide for alopecia will help understand hair loss.
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Trichotillomania can be challenging to diagnose if patients do not openly admit to pulling at their hair. Typically, patients present with frontoparietal patches of alopecia that gradually extend backward and may also involve the eyelashes and eyebrows. These bare patches are characteristic, and the hair may appear uneven, with twisted or broken-off hairs. Trichotillomania can negatively impact self-esteem and lead to social avoidance. Complications may include infection, skin damage, and permanent scarring.
The optimal treatment for trichotillomania is not well-established, and psychiatric referral may be necessary. Treatment options include cognitive behavior therapy and selective serotonin reuptake inhibitors, although robust evidence for treatment efficacy is lacking. Preliminary studies suggest potential positive effects with acetylcysteine, olanzapine (Zyprexa), and clomipramine (Anafranil). Combining cognitive behavior therapy with medications may yield more significant benefits.
Trichorrhexis nodosa is a condition where hair shafts break due to trauma or inherent fragility. Traumas such as excessive brushing, heat application, tight hairstyles, trichotillomania, and scalp scratching can cause it. Harsh chemical treatments (e.g., excessive use of bleach, dye, shampoo, perms, or relaxers) and prolonged exposure to salt water can also contribute. There are also genetic conditions like trichorrhexis invaginata (bamboo hair) and Menkes disease that may lead to trichorrhexis nodosa. Rarely, hypothyroidism can be associated with it. On examination, hairs exhibit white nodes, which are actually fracture sites along the shaft and cortex that split into several strands. Dermoscopy may reveal hairs resembling two brooms or paint brushes thrust together.
When the diagnosis is unclear, laboratory testing should include a complete blood count, iron studies, copper level, liver function testing, thyroid-stimulating hormone level, and serum and urine amino acid levels. Treatment involves minimizing or avoiding physical and chemical trauma.
Anagen effluvium is characterized by abnormal diffuse hair loss, usually occurring abruptly during the anagen (growth) phase of hair due to an event that disrupts the mitotic or metabolic activity of hair follicles. It often results from chemotherapy, especially cyclophosphamide, nitrosoureas, and doxorubicin (Adriamycin). Other medications like tamoxifen, allopurinol, levodopa, bromocriptine (Parlodel), and certain toxins can also cause anagen effluvium. Medical and inflammatory conditions like mycosis fungoides or pemphigus vulgaris may lead to it as well.
Patients typically experience diffuse hair loss beginning days to weeks after exposure to the causative agent, becoming most apparent after one or two months. For many women with cancer, hair loss is one of the most distressing aspects of chemotherapy. However, anagen effluvium is usually reversible, and regrowth typically occurs one to three months after stopping the offending agent. Permanent alopecia is rare. Scalp cooling has been shown to reduce the risk of chemotherapy-induced anagen effluvium, but it should be discouraged due to concerns about potentially reducing the effectiveness of chemotherapy and increasing the risk of scalp metastases.
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Whether you’re looking for premium European wigs or hairpieces, Peggy Knight Wigs and Peggy’s Choice have you covered, especially for those dealing with alopecia or medical hair loss. Our private, in-person hair wig consultations are available nationwide. With a wide selection of short, long, and medium wigs, you can choose the perfect option for yourself.
If you’re feeling concerned about hair loss or have already experienced it, rest assured that we are here to support you in finding the right solutions. Give us a call today to schedule a consultation with me or one of my team members, and let us help you through this journey.
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Hair loss is nothing to hide or feel ashamed about, especially when it can give us clues about what is happening with our health and well-being. Some women may not even be aware of their hormonal or thyroid issues until they go to the dermatologist looking to be treated for hair loss. To get an in-depth understanding of the different types of hair loss and the possible reasons behind it, we went to the experts.
Hair loss is more common than you might think. According to the American Hair Loss Association, women make up to 40 percent of those who experience hair loss in the U.S. It is important to be attuned to what is happening with your hair because it can be indicative of your hormones, your thyroid, your metabolism, and your overall health