Localized Hair Loss

1. Alopecia areata

2. Discoid lupus erythematosus

3. Fungal infections (e.g., kerion)

4. Lichen planopilaris

5. Nevoid abnormalities

6. Traction (e.g., corn-rows, ponytails)

7. Trichotillomania

Nonscarring Alopecia: Intact Hair Follicles

1. Telogen effluvium (TE)

2. Alopecia areata (AA)

3. Anagen effluvium (following chemotherapy)

4. Androgenetic alopecia (AGA): male or female pattern baldness

5. Trichotillomania

6. Infections: fungal (i.e., tinea capitis, kerion)

7. Hair shaft abnormalities

Scarring alopecia: Loss of Hair Follicles

1. Discoid lupus erythematosus (DLE)

2. Lichen planopilaris (LPP)

3. Infections: fungal, bacterial, TB, leprosy

N.B.: If scalp biopsy performed (e.g., scarring alopecia), ideally a 4-mm punch biopsy is taken of a symptomatic or early active disease for transverse sectioning and H&E; if lupus suspected, take additional 4-mm punch biopsy — bisect this piece vertically, and submit half for vertical sectioning, and half for DIF.

*In general, scarring alopecias should be referred to a dermatologist.

Autoimmune T-cell mediated disease in genetically predisposed persons. Uncommon association with other autoimmune diseasesdiabetes, vitiligo, thyroid disease

Physical: Well-circumscribed areas of complete hair loss on any hair bearing surface (scalp = 90%); may see nail pitting; "exclamation point" hairs at periphery of bald patch

■ Totalis = entire scalp; universalis = all hair-bearing areas; ophiasis = hair loss confluent along temporal & occipital scalp

DDx: androgenetic alopecia, tinea capitis, trichotillomania, telogen effluvium

Investigations: ferritin, TSH, ANA, scalp biopsy if unsure

Management

■ High-potency topical steroids; intralesional triamcinolone acetonide (5-10 mg/cc) q 4-6 wk in adults has best outcome.

■ Some benefit reported with topical anthralin, topical minoxidil.

■ Less commonly: Topical immunotherapy (i.e., diphencyprone), oral steroids (use in early rapidly progressing widespread disease), cyclosporine.

■ Course: 95% regrow in 1 yr (except totalis or universalis, which have poor prognosis); 30% recurrence.

■ Poor prognostic signs: Atopic dermatitis, childhood onset, duration > 5 yr, onychodystrophy, ophiasis, widespread involvement.

Androgenetic Alopecia (Male and Female Pattern Baldness)

Androgenetic Alopecia (Male and Female Pattern Baldness)

Etiology: Heredity (polygenic); androgen stimulation

Physical: Different pattern for men and women; men—temporal areas affected, progressing to vertex; females—diffuse pattern.

DDx: Alopecia areata, anagen/telogen effluvium

Investigations: ferritin, TSH, androgen profile (if suspicious of virilization).

Management

■ Topical minoxidil lotion (Rogaine®; 2% or 5%) use daily to stabilize hair loss and regrowth in some cases.

■ Finasteride (Propecia®) 1 mg po qd in men (inhibits synthesis of dihydrotestosterone).

■ Spironolactone 100-200 mg po daily in women.

■ Hair transplantation (from occipital scalp).

Spironolactone Hair Loss Women

Diffuse decrease in hair density secondary to rapid conversion of anagen to telogen hair. Precipitated by stressful events, illness, fever, pregnancy, crash diet, medications; hair can be shed 2-6 mo after precipitant.

Physical: Diffuse hair loss; positive hair pull test (>10% club hairs).

Investigations: CBC, ferritin, TSH; punch biopsy if unsure. DDx: Alopecia areata, anagen effluvium, androgenetic alopecia.

Management

Reassurance. Wait for regrowth, and treat any underlying cause. Topical minoxidil may be beneficial.

Trichotillomania

Trichotillomania

Self-induced (neurotic) compulsive hair pulling/plucking.

Physical: Circumscribed area of alopecia with irregular borders and broken hairs of different length. May find scalp excoriations and perifollicular petechiae; usually only one area (frontoparietal or frontotemporal) affected. Eyebrows and eyelashes may also be plucked.

Investigations: Punch biopsy if unsure.

DDx: Alopecia areata, traction alopecia, tinea capitis.

Management

■ When in doubt, biopsy confirms diagnosis.

■ Ask about traumatic events (death, separation, school troubles)

■ Difficult problem; look for precipitant; may need referral to psychiatry (psychotherapy, behavior therapy, SSRIs).

■ Most children outgrow condition, but can be difficult to manage in adults.

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