A more recent article on hair loss is available. ANNE L. Patient information: See related handout on hair loss , written by the authors of this article. Physicians should be careful not to underestimate the emotional impact of hair loss for some patients.
Patients may present with focal patches of hair loss or more diffuse hair loss, which may include predominant hair thinning or increased hair shedding. Focal hair loss can be further broken down into scarring and nonscarring. Scarring alopecia is best evaluated by a dermatologist. The cause of focal hair loss may be diagnosed by the appearance of the patch and examination for fungal agents.
A scalp biopsy may be necessary if the cause of hair loss is unclear. Alopecia areata presents with smooth hairless patches, which have a high spontaneous rate of resolution.
Tinea capitis causes patches of alopecia that may be erythematous and scaly. Male and female pattern hair losses have recognizable patterns and can be treated with topical minoxidil, and also with finasteride in men.
Sudden loss of hair is usually telogen effluvium, but can also be diffuse alopecia areata. In telogen effluvium, once the precipitating cause is removed, the hair will regrow. Hair loss is a common problem that affects up to 50 percent of men and women throughout their lives. Family physicians need to be able to distinguish hair loss that represents true disease from the more common age-related hair loss. Hair loss is commonly categorized into scarring and nonscarring alopecia.
Scarring alopecia is rare, and most cases of hair loss seen in primary care will be nonscarring. Hair loss on the scalp can be further classified as focal or diffuse. This distinction is the first step in diagnosis. In alopecia areata, there is no long-term benefit of topical steroids, minoxidil Rogaine , cyclosporine, oral steroids, or photodynamic therapy.
Women presenting with hair loss associated with abnormal menses, history of infertility, hirsutism, unresponsive cystic acne, virilization, or galactorrhea should have a targeted endocrine work-up i. Discontinuation of finasteride or minoxidil results in loss of any positive effects of treatment hair growth in 12 and six months, respectively. The causes of hair loss can be broadly divided into focal or diffuse hair loss Table 1. Focal hair loss is secondary to an underlying disorder that may cause nonscarring or scarring alopecia.
Nonscarring focal alopecia is usually caused by tinea capitis or alopecia areata, although patchy hair loss may also be caused by traction alopecia or trichotillomania.
Scarring alopecia is rare and has a number of causes, usually discoid lupus erythematosus. Diffuse hair loss can be further categorized into conditions that cause hair shedding, of which the most common is telogen effluvium, and predominant hair thinning caused by male or female pattern hair loss previously called androgenetic alopecia.
Female pattern hair loss. Presents with hair thinning; frontal hairline intact; negative pull test away from hair loss. Alopecia areata. Tinea capitis. Traction alopecia. Alopecia areata is characterized by areas of nonscarring hair loss that range from single oval patches to multiple patches that can become confluent. Men and women are equally affected, and, although it can occur at any age, the most common presentation is in children and young adults, with 30 to 48 percent of patients affected before 20 years of age.
In case series, alopecia totalis and universalis are less common than alopecia areata and account for 4. The lifetime risk of developing alopecia areata is 1.
In most studies, 20 to 42 percent of those affected have a family history of the disease. Alopecia is associated with autoimmune conditions, such as vitiligo, diabetes, thyroid disease, rheumatoid arthritis, and discoid lupus erythematosus. Patients with a history of atopy are also at an increased risk of developing alopecia.
The patient with alopecia areata Figure 1 typically presents with bald patches on the scalp that often have developed rapidly with sudden loss of hair. In diffuse alopecia, there is more widespread hair loss, often associated with graying of the hair. The classic finding is a smooth, hairless patch surrounded by so-called exclamation point hairs.
These are 2- to 3-mm broken hairs that have a club-shaped root with a thinner proximal shaft and a normal caliber distal shaft on microscopic examination Figure 2. Exclamation point hair showing distal broken end of shaft and proximal club-shaped hair root. Treatment may induce hair growth, but usually does not change the course of the disease. When treatment is stopped, hair loss recurs.
Many patients with one or two small patches can be managed without treatment and with reassurance of the benign nature of the condition.
A systematic review of 17 randomized controlled trials of topical and oral steroids, topical minoxidil Rogaine , topical cyclosporine, and photo-dynamic therapy found no long-term benefit of these interventions.
Evidence for short-term growth, but none for long-term growth 5. Unlicensed treatment; may cause severe dermatitis 7. Continued treatment is needed to maintain hair growth; risks of prolonged steroid use outweighs the benefits 6. Triamcinolone acetonide Kenalog 5 to 10 mg per mL; 0. Hair regrowth lasts a few months; effect on long-term outcome is unknown 6. Hair staining prevents use in fair-haired patients 6.
Treatment for one year resulted in a modest improvement in alopecia; 32 percent of participants experienced elevated liver function tests while taking the medication, resulting in some safety concerns Promotes hair growth for more than two years, with the effect waning by year three 12 , 13 ; does not significantly affect sperm production and poses no risk to a female sex partner; when screening men on finasteride for prostate cancer, the upper limit of normal prostate specific antigen levels should be doubled to ensure appropriate interpretation 14 , Consistent evidence showing moderate to dense regrowth of hair Increased hair density, size, and proportion of anagen follicles after shampooing two to four times per week for 21 weeks Information from references 5 through Children are most likely to be affected by tinea capitis and typically present with a round patch of hair loss, often with scaling, erythema, and lymphadenopathy.
In a study of the predictive signs and symptoms of tinea capitis in children, those with occipital adenopathy were more likely to have cultures positive for fungi positive likelihood ratio of 7.
Skin scrapings can also be sent for fungal culture, but this is less helpful because the fungi can take up to six weeks to grow. Tinea is caused by the microsporum species, which fluoresces under a Wood lamp; however, in the United States, most tinea is caused by trichophyton, which does not fluoresce, so this test is less useful. In its most severe form, tinea capitis causes a boggy inflammatory mass called a kerion, which may heal with scarring and subsequent localized alopecia.
Tinea capitis can be treated with oral terbinafine Lamisil , fluconazole Diflucan , itraconazole Sporanox , or griseofulvin Grifulvin ; topical treatments by themselves are not effective. Dosing of griseofulvin is 10 to 20 mg per kg per day for six to eight weeks in children 21 or mg per day for six to eight weeks in adults. Traction alopecia is a form of unintentional hair loss associated with specific social, cultural, and cosmetic practices.
Patients primarily women wearing wigs, tight braids, or using curling rollers are at risk. Hair processing including bleaching, coloring, and waving also puts patients at risk. Hair loss usually occurs in the frontotemporal area, although it can vary. Eliminating the stressor or source of traction on the hair commonly cures the problem and returns hair growth to normal.
Trichotillomania is a psychiatric compulsive disorder that involves repeated hair plucking. It is most common in children, but may persist into adulthood. On close inspection, twisted and broken off hairs are visible in patchy areas across the scalp. In chronic cases, scarring alopecia may result. Cicatricial or scarring alopecia causes permanent hair loss from destruction of the hair follicles by inflammatory or autoimmune diseases.
The most common cause of this is discoid lupus erythematosus, which produces atrophied erythematous patches, sometimes with telangiectasia. Telogen effluvium occurs when an increased number of hairs enter the telogen resting phase of the hair cycle from the anagen growing phase, and these hairs are lost approximately three months later.
Usually, an average of hairs are lost each day, but this becomes significantly more in telogen effluvium, in which 30 to 50 percent of body hair can be lost. Telogen effluvium may be precipitated by severe illness, injury, infection, surgery, crash diets, psychological stress, giving birth, thyroid disorders, iron deficiency, anemia, or drugs.
Hyperthyroidism and hypothyroidism can cause telogen effluvium, which is usually reversible when the thyroid status is corrected except in long-standing hypothyroidism. Severe iron deficiency anemia may be associated with it, but this remains controversial. Scroll down to learn more. Get more information on regrowing your hair! Which picture most closely resembles your hair loss? I acknowledge that listing the phone number and email is not a condition of receiving any property, goods, or services.
You are not required to make a purchase as a condition to this consent. Email ClientRelations Restorehair. Alopecia Alopecia is a fancy word for hair loss, but this more specifically refers to a disorder that creates baldness that is not patterned or orderly — hair comes off in clumps in various parts of the scalp without much rhyme or reason.
Male Pattern Baldness As the name suggests, male pattern baldness is, unlike alopecia, occurs in a … pattern. Get a quick quote. Testimonial statements and photographs seen on this website do not constitute a warranty or prediction of the outcome of your individual hair restoration results. Not all patients can achieve the results depicted here. For a natural look, choose wig colors, styles, and textures that look similar to your original hair.
Professional wig stylists can help style and fit wigs for an even more natural look. Hair weaves are wigs that are sewn into your natural hair. You must have enough hair to sew the weave into.
The advantage to weaves is they always stay on, even during activities such as swimming, showering, and sleeping. The disadvantages are they must be sewn again whenever new hair growth occurs, and the sewing process can damage your natural hair. Minoxidil Rogaine is a topical medication applied to the scalp. Minoxidil slows hair loss for some men and stimulates the hair follicles to grow new hair.
Minoxidil takes four months to one year to produce visible results. Hair loss often happens again when you stop taking the medication. Possible side effects associated with minoxidil include dryness, irritation, burning, and scaling of the scalp. You should visit the doctor immediately if you have any of these serious side effects:. Finasteride Propecia, Proscar is an oral medication that slows hair loss in some men.
It works by blocking the production of the male hormone responsible for hair loss. Finasteride has a higher success rate than minoxidil. When you stop taking finasteride, your hair loss returns. You must take finasteride for three months to one year before you see results. If no hair growth occurs after one year, your doctor will likely recommend that you stop taking the medication.
The side effects of finasteride include:. You should have any breast pain or lumps evaluated by a doctor immediately. Finasteride may affect prostate-specific antigen PSA tests used to screen for prostate cancer. The medication lowers PSA levels, which causes lower-than-normal readings.
Any rise in PSA levels when taking finasteride should be evaluated for prostate cancer. A hair transplant is the most invasive and expensive treatment for hair loss. Hair transplants work by removing hair from areas of the scalp that have active hair growth and transplanting them to thinning or balding areas of your scalp. Multiple treatments are often necessary, and the procedure carries the risk of scarring and infection.
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