Hair Loss and Balding

Essentials

• Diagnosis is based on clinical presentation and history.
• Androgenetic hair loss (androgenetic/androgenic alopecia) is diagnosed in both men and women on the basis of its typical clinical picture.
• Relatively rapid, diffuse hair loss usually indicates telogen hair loss (telogen effluvium).
• It is important to distinguish between diffuse and patchy hair loss and to check whether the scalp skin is healthy.
• Alopecia areata is a common cause of patchy hair loss.

Patient history

• Consider the possibility of a causative factor during the preceding 3-6 months.
  • Serious infection
  • Certain medicines http://www.dynamed.com/approach-to/hair-loss-in-adults-approach-to-the-patient#MEDICATION_HISTORY
  • Hypothyroidism http://www.dynamed.com/approach-to/hair-loss-in-adults-approach-to-the-patient#THYROID_DYSFUNCTION_DIAGNOSIS
  • Child birth, stress
  • External causes, e.g. hair styling procedures http://www.dynamed.com/approach-to/hair-loss-in-adults-approach-to-the-patient#TRACTION_ALOPECIA_DIAGNOSIS, hair treatments

Diagnosis

• Differentiate between diffuse hair loss (throughout) and patchy hair loss http://www.dynamed.com/approach-to/hair-loss-in-adults-approach-to-the-patient#ALGORITHMIC_APPROACH_TO_DIAGNOSING_HAIR_LOSS_AND_UNUSUAL_HAIR_CONDITIONS.
• Examine the scalp (redness, scaliness, folliculitis).
• Do the hair pull test: grasp a few dozen hairs and pull lightly. Normally less than 5 hairs should come out.
• Laboratory tests are used, as necessary, to exclude most common diseases that cause hair loss: anaemia (basic blood count with platelet count), hypothyroidism (TSH).
• Other examinations are performed, as necessary, in a targeted manner according to justified clinical suspicion. Hair loss may be caused, for example, by iron deficiency (ferritin), kidney disease (creatinine), liver disease (ALT), zinc deficiency in conditions involving malabsorption (zinc level) or secondary syphilis (Treponema pallidum antibodies).

Male-pattern baldness (androgenetic alopecia)

• Often hereditary
• Diagnosis is based on clinical presentation
• Hair thinning is typically most extensive at the vertex and on the temples with a receding frontal hairline.
• Pharmacotherapy
  • Topical minoxidil (50 mg/ml) twice daily http://www.dynamed.com/condition/androgenetic-alopecia-in-men#MINOXIDIL and/or
  • systemic finasteride (1 mg/day) http://www.dynamed.com/condition/androgenetic-alopecia-in-men#FINASTERIDE or dutasteride (0.5 mg/day) http://www.dynamed.com/condition/androgenetic-alopecia-in-men#DUTASTERIDE
  • The effect only lasts for as long as they are used, and treatment response does not become evident until after several (6-12) months.Before commencing the treatment with minoxidil or finasteride the patient should be informed about the possible adverse effects and the cost of the treatment and that it is a long-term treatment, and that discontinuation of the treatment results in the loss of any results achieved. Rare adverse effects of finasteride include, among others, erectile dysfunction, decreased libido, gynaecomastia and depression.

Female-pattern baldness (androgenetic alopecia)

• Pathogenesis corresponds with the male-pattern baldness and is due to hereditary factors.
• Starts mostly at a later age than in men (40-60 years).
• Hair thinning is relatively even without causing the hairline recession or the bald vertex as seen in men.
• In the absence of other signs of hyperandrogenism (hirsutism Excessive Hair Growth (Hirsutism), polycystic ovaries Polycystic Ovary Syndrome (PCOS), abnormal menstrual bleeding Abnormal Menstrual Bleeding, infertility Infertility) no laboratory tests are needed.
• Treatment
  • Topical minoxidil (20 mg/ml) twice daily http://www.dynamed.com/condition/female-pattern-hair-loss#MINOXIDIL Interventions for Female Pattern Hair Loss.
  • If the symptoms are distressing, anti-androgenic oral contraceptives (oestrogen and cyproterone acetate, drospirenone or desogestrel) http://www.dynamed.com/condition/female-pattern-hair-loss#ANTI_ANDROGENS or drugs with anti-androgenic properties (e.g. spironolactone http://www.dynamed.com/condition/female-pattern-hair-loss#ANTI_ANDROGENS) may be tried for 6-12 months (no official indication in hair loss) Interventions for Female Pattern Hair Loss
    • The optimal dose of spironolactone is 75-100 mg/day, once daily or divided into two doses. Plasma sodium, potassium and creatinine levels should be checked 1 month after treatment onset, and thereafter as necessary.
    • If a woman in fertile age has intermenstrual bleeding during spironolactone treatment, spironolactone should be taken only during the 3 first weeks of the menstrual cycle. Continuous use causes intermenstrual bleeding to about one fifth of patients. Women using hormonal IUD and those beyond menopause can use spironolactone every day.

Other treatments

• Hair transplantation and other plastic surgery therapies have been used for both female- and male-pattern boldness.
• There is no strong evidence on the efficacy of laser treatments (low level laser therapy, LLLT) or PRP injections (platelet rich plasma).
• There is no evidence on the efficacy of vitamins, trace elements, hair care products and scalp massage.

Telogen effluvium

• Telogen effluvium http://www.dynamed.com/approach-to/hair-loss-in-adults-approach-to-the-patient#TELOGEN_EFFLUVIUM_DIAGNOSIS is a condition where a greater than usual proportion of hair switches over from the growth phase to the resting phase simultaneously; this leads to hair loss 2-4 months after the occurrence of the causative factor.
• Common causes
  • Early phase of male-pattern baldness
  • Severe febrile diseases
  • Chronic diseases
  • Hypothyroidism
  • Anaemia
  • Poor nutritional state
  • Stress
  • Surgery
  • Childbirth
  • Medications
    • For example, stopping or starting oral contraceptives, use of antiepileptics, heparin, antithyroid medication, anabolic steroids (picture 1), some antirheumatic agents, especially chloroquine, methotrexate
• The acute form of the condition may be caused by cytostatic drugs http://www.dynamed.com/approach-to/hair-loss-in-adults-approach-to-the-patient#ANAGEN_EFFLUVIUM__CHEMOTHERAPY_INDUCED_ALOPECIA__DIAGNOSIS Adverse Effects of Antineoplastic Agents, medicines or radiotherapy Management of Adverse Effects of Radiotherapy.
• Hair is lost evenly throughout the scalp and no bald patches are formed.
• The hair pull test will yield more than normal amounts of hair with each pull.
• Regrowth usually commences within 6 months.
• Chronic idiopathic telogen effluvium is encountered in middle-aged women and may last for several years.

Alopecia areata

• An autoimmune disease affecting about 2% of the population at some point during their life.
• Diagnosis is based on typical bald patches that have developed over a few weeks with no associated scaling or redness (pictures 2 3 4).
• The smallish patches recover spontaneously over several months, but the condition may recur once or several times over the years.
• Prognosis is poor if hair loss is extensive, particularly if the eyelashes, eyebrows and beard are also affected (pictures 5 6).
• Alopecia areata may be associated with atopy, coeliac disease or autoimmune thyroiditis.
  • A clinical suspicion should prompt the evaluation of TSH and free T4 levels as well as anti-thyroid peroxidase and anti-transglutaminase antibodies.
• Alopecia areata may also be associated with nail abnormalities (picture 7), and detecting these may be helpful in differential diagnosis.

Scalp ringworm (tinea capitis)

• See Dermatomycoses.
• An important differential diagnosis in patchy hair loss.
• There is erythema, scaling and sometimes pustule formation on the scalp.
• More common in children.
• Diagnosis is based on positive result in fungal samples.
• Treatment consists of systemic antifungal drugs.

Traction alopecia

• Caused by physical or chemical factors that damage hair (excessive combing, too tight ponytail, dread hairstyle, local use of heat, e.g. for straightening hair, hair dyeing, etc.).
• Causes patchy incomplete alopecia, usually in the frontal and temporal hairline.
• Treatment is based on avoiding any traction and irritation of hair shafts.

Trichotillomania

• A rare obsessive-compulsive disorder that involves pulling ones hair from limited scalp areas.
• Usually causes incomplete patchy alopecia near the frontal or temporal hairline. There are, however, healthy hairs growing through the scalp stubble in the middle of the patches. The scalp skin is usually normal.
• Most common in children and adolescents, but can be encountered in any age group.
• Treatment is based on treating the obsessive-compulsive symptoms Obsessive-Compulsive Disorder (OCD) Obsessive-Compulsive Disorder (OCD) in Children.

Scarring (cicatricial) alopecia

• A heterogenic group of conditions of unknown aetiology.
• Symptoms include patchy hair loss with redness and scaling of the affected scalp areas with later scar formation (the hair follicles are destroyed).
• The most common associated conditions are discoid lupus erythematosus Discoid Lupus Erythematosus (pictures 8 9) and lichen planus Lichen Planus (picture 10).
• Requires the intervention of a dermatologist.

References

• Kanti V, Messenger A, Dobos G ym. Evidence-based (S3) guideline for the treatment of androgenetic alopecia in women and in men - short version. J Eur Acad Dermatol Venereol 2018;32(1):11-22. [PubMed]
• Schmidt TH, Shinkai K. Evidence-based approach to cutaneous hyperandrogenism in women. J Am Acad Dermatol 2015;73(4):672-90. [PubMed]
• Varothai S, Bergfeld WF. Androgenetic alopecia: an evidence-based treatment update. Am J Clin Dermatol 2014;15(3):217-30. [PubMed]
• van Zuuren EJ, Fedorowicz Z, Carter B. Evidence-based treatments for female pattern hair loss: a summary of a Cochrane systematic review. Br J Dermatol 2012;167(5):995-1010. [PubMed]
• Phillips TG, Slomiany WP, Allison R. Hair Loss: Common Causes and Treatment. Am Fam Physician 2017;96(6):371-378. [PubMed]
• Burns LJ, De Souza B, Flynn E ym. Spironolactone for treatment of female pattern hair loss. J Am Acad Dermatol 2020;83(1):276-278. [PubMed]