Information ⬇
Editors
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.
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
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
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.
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.
Treatment
- Usually treatment is not crucial as regards prognosis but may increase regrowth to some extent.
- Topical Class 1 or 2 (potent or superpotent) glucocorticoid solutions http://www.dynamed.com/condition/alopecia-areata#TOPICAL_MEDICATIONS, for example a course lasting for 3-4 weeks
- Also glucocorticoid injections have been used (scarce evidence).
- For example, triamcinolone acetonide is diluted to up to 2.5-10 mg/ml. Injections are performed very superficially, intradermally, in doses of 0.05-0.1 ml, at maximum 20 mg during a treatment session. If needed, the treatment is repeated at 4-12-week intervals. Bear in mind the possibility of pit-forming atrophy of the skin.
- Dermatologists occasionally employ topical immunotherapy http://www.dynamed.com/condition/alopecia-areata#CONTACT_IMMUNOTHERAPY based on the deliberate induction of contact allergy.
- A patient with severe alopecia areata may wish to wear a wig, the cost of which may be eligible for reimbursement depending on local policies.
- Herbal products, vitamins, trace elements etc. have not been shown to be of benefit.
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]
Evidence Summaries ⬆