Hair Loss Diagnosis & Treatment for the Family Physician

Hair Loss Diagnosis & Treatment for the Family Physician


Thanks very much for that introduction
and I’m pleased to be back to be able to speak to this audience. Our audience
today, as you may recognize, is a diverse audience. We have a group of family
practitioners with us because today our focus is going to be on a practical
approach to the diagnosis and treatment of some common hair loss disorders. I
don’t have any conflicts of interest about anything I’m going to talk to you
today about. But what I’d like to review if you is a very practical approach to a
patient with hair loss. We’ll examine some very common treatments, how they’re used, some contraindications and the kind of advice you may counsel your patients
on when considering these treatments. One of the key messages that I’d like to
give to you today is what type of patient do you need to consider referral
to a dermatologist for further evaluation. So in many ways the title of
this lecture could be “What do I do?” “Hair Loss – What do I do?” From your
patient’s perspective, what your patient is looking for is how you can improve
their density how you can stop their hair loss and how you can get them back
more hair. Of course from the perspective of the treating physician – the most
important aspect is the diagnosis because it’s the diagnosis which then
governs the type of treatment that’s going to be used and different types of
hair loss disorders have different treatments. It would be rather convenient
if all hair loss was treated the same ! – then the same types of treatments could
be recommended universally but they’re not. Different hair loss conditions have
different treatments and really when approaching a patient with hair loss one
of the first things that you want to determine is are you dealing with a “non
scarring” hair loss condition or are you dealing with a “scarring” hair
loss condition. These are the two big groups of hair loss conditions. In the
left side of this panel you can see some examples of non scarring hair loss. The
key to non scarring hair loss is that the follicular openings or these pores
can be clearly seen when you examine the scalp the scalp. Generally looks
relatively normal in these conditions. In a scarring hair loss condition which
seen here on the right side of the panel the hair follicle openings are missing
the scalp appears smooth – rather like a skating rink. These are very typical of
scarring hair loss conditions. So when you first meet a patient with hair
loss it’s important to form a differential diagnosis or some sort of
differentiation between whether you’re dealing with non scarring hair loss or
scarring hair loss. In many ways what we’re dealing with is two groups of
conditions that are more common and less common! So interestingly the non scarring
hair loss conditions tend to be the more common and the scarring hair loss
conditions tend to be less common. What really matters when you’re
evaluating a patient with hair loss well these are the so-called five “S’s” that I
frequently use when evaluating a patient with hair loss. It’s these five s’s
which allow you to break down that list of those many entities in the more
common group or the less common group into the actual diagnosis. So if you
determine that you think you’re dealing with a non scarring alopecia how do you
then determine whether it’s androgenetic alopecia or telogen effluvium or
alopecia areata or tinea capitis or traction.
The 5s is is a tool that can help you to determine that. What really matters when
you’re dealing with a patient with hair loss is information on the sites that
are involved (is it the crown is it the front is at the back) … what’s the speed of
the patient’s hair loss (is it fast, is it slow… does the patient look the same as
six months ago… do they look different) .. do they have any symptoms like itching
burning or pain are they taking any medications and if any medication has
been started recently that can account for their hair loss. Finally are they
shedding? Are they shedding at a normal amount that all humans do between 50 and
100 hairs every day or are they shedding excessively. So when you listen to a
patient story and you gather all this information about the five s’s we can
generally determine the cause of the patients hair loss. So let’s take a look
at how we can put these five s’s into actual practice let’s begin with a focus
on male patients. You know the vast majority of your male patients who come
through the door are going to be coming through the door with concerns about
male pattern balding or androgenetic alopecia. Of course a small proportion
will have scarring alopecia. A small proportion will have alopecia areata. But
the vast majority of your patients will have androgenetic alopecia. The
approach that I would recommend you give consideration to would be this approach.
It’s a simple approach to dealing with hair loss and men. The very first
consideration is for you to decide do you think this is male pattern hair loss. And if you think it’s male pattern hair loss then considering ordering some
blood tests – a basic CBC, thyroid and iron panel ….and then start treatment. I’d
like to encourage you to consider a to consider starting treatment with agents
such as minoxidil or finasteride or refer them for hair restoration. If you
don’t think it’s male pattern balding then give consideration to whether you
think it’s localized alopecia areata. If if you think it’s localized alopecia
areata then order some blood and start treatment. I’d like to give
you some tools today whereby you can feel confident about starting treatment
with agents such as topical steroids minoxidil or beginning steroid
injections. If you don’t think it’s alopecia areata then consider referral
for treatment. This is a very simple approach to dealing with a patient with
male balding but it works quite well and gives you an algorithm for thinking
about who to refer and who to begin treatment. Lwt’s take a look at some
prototypical conditions which involve specific sites on the scalp with hair
loss. This is a patient who’s 29 and is developing some hair loss in a very slow
manner. But the key thing about this patient when we go through these five
s’s is the sites that are involved. This patient has hair loss starting in the
temples and in the crown and then the mid scalp becomes involved. As well he’s
shedding a bit more than normal but nothing too alarming. He doesn’t
really have anything in terms of scalp symptoms. This is very typical of
androgenetic alopecia or male pattern balding. One of the key things about
male pattern balding is that the hair follicles themselves (when you look up
close) are becoming thinner. We call this miniaturization. So male pattern
balding is about both specific sites on the scalp that are involved and when you
examine those sites… the hair follicles are miniaturizing. T rest of the S’s
are relatively unremarkable. Now that you have a diagnosis … how then do
begin treatment? ….. As you think about treatment of male balding (and as we go
through some of the treatments for male balding) … I’d like you to give thought
about how you would treat a patient who’s relatively healthy – and how you
would treat a patient who presents with a history of depression – and how you
would treat a patient who indicates that he wants to start a family. Are there any
differences in your approach? These are the treatments for male pattern hair
loss. We think about non-surgical treatments and we think about surgical
treatments. The Health Canada and FDA-approved treatments are minoxidil
and finasteride. We’ll come back to them. These are two treatments that are
very important to have a basic approach to as you’re thinking about how you
treat male pattern hair loss because they really are some of the first-line
treatments in male pattern hair loss. But there are other non-surgical treatments.There are a number of low-level laser devices on the market that can be
purchased .. and patients can use at home. There are five randomized double-blind
sham device trials which show that these low-level laser devices are better than
placebo. They do lead to some degree of benefit for patients with
androgenetic alopecia and can be considered and are relatively safe.
Platelet-rich plasma is also an option for treating androgenetic alopecia. The
thing to remember about platelet-rich plasma is there’s over 1000
different protocols so there’s no one treatment for platelet-rich plasma.
Platelet-rich plasma involves taking a person’s blood spinning it down to get
their plasma and then injecting this into the patient’s scalp. A number of
clinical studies support that platelet-rich plasma can be effective
for male balding. Scalp micropigmentation is a technique where the scalp is
tattooed with small dots to reduce the “see-through” appearance of the scalp. Hair systems can also be used. Hair systems are not uncommon as a
consideration for the treatment of male balding. Certainly the other non-surgical
treatments are much more common .. but hair systems involve shaving parts of
the scalp and applying the “hair system” to the scalp with the use of an adhesive.
Hair transplantation is an option for many men with androgenetic alopecia.
Generally hair restoration is considered in men over the age of 25 who are
appropriate candidates – meaning they have a good
donor area, are relatively healthy and have relatively stable hair loss ( …meaning
that they’re not rapidly balding). Let’s talk about minoxidil and let’s
talk about finasteride. It’s very important for treating male balding that
you have some understanding of these two agents.Minoxidil is a topical treatment. It was approved in the mid-1980s. There is a minoxidil solution and there’s
minoxidil foam. Minoxidil solution at 5% is used 1 mL twice a day it’s
more effective than 2% minoxidil. Patients rarely develop headaches,
dizziness and heart palpitations. Shedding can occur in the first months
but minoxidil is a reasonably good option. It helps about 20 to 30 %
of men – so it clearly doesn’t help everyone with male pattern balding. The
foam was introduced in 2006. The dose for men is one half cap twice daily. The foam
does not have propylene glycol in it so the foam is less likely to irritate… but the
efficacy is very similar compared to the minoxidil solution. The dose for men is
twice a day. (The dose for women is once a day). Oral finasteride is the most
effective treatment for male balding but it’s the side effects of finasteride
which limits its its universal use for male balding. The drug is an inhibitor of
5 alpha reductase and the drug reduces the levels of DHT in the blood by about
70% — and it reduces the levels in the scalp by about 50%. The medication stops
hair loss in men in about 90% of males and about 40% of men would be expected
to get an improvement. The side effects of finasteride are very important to
know about in prescribing this medication. The medication causes mood
changes in a proportion of users including depression. The sexual side
effects are the most focused on and they occur in anywhere from 1 to 4 percent of
men – being more common in men over 40 than men under 40. These sexual
side-effects include decreased libido, erectile dysfunction, and ejaculatory
problems. Gynecomastia can occur in about 1 in 300 to 1 in 1000 men that are using the medication. It’s
important to remember that finasteride has undergone several post marketing
label changes since its FDA approval in 1997. In 2011, the label changes
included the indication that 1) finasteride can cause persistent
erectile dysfunction that continues in some men after the medication is stopped
and 2) also male infertility or poor semen quality that did seem to improve after
the medication was stopped. So it’s very important to know about these and to
advise your patients about the possibility of persisting dysfunction as
well as the possibility of infertility as well. Although we don’t have time to
discuss it in greater detail today it’s very important to understand the concept
of post finasteride syndrome or “PFS” which is a constellation of physical,
psychological, sexual and neurological symptoms that occur in some users of
finasteride even after the medication is stopped. It’s very important to
understand these in detail if you’re going to recommend finasteride in your
practice. When we return to this patient the considerations that you may
want to give are slightly different in a healthy patient versus a patient with
depression versus a patient who wants to start a family….. A patient with depression
finasteride presents a relative contraindication to starting finasteride.
It may be possible to still start but one needs to be aware of this – one needs
to monitor changes in mood and it may be for some patients that finasteride is, in
fact, not an option. Finasteride can be used by
men who wish to start a family and are trying to father a child. The important
thing to remember is that finasteride can lower sperm count and create
infertility in a proportion of men. For any couple who is unable to get
pregnant after a period of time certainly one needs to consider that
finasteride could be reducing sperm quality and creating infertility….. What
about your female patients? The thing that I’d like you to be aware of today
is that the number of hair loss conditions that your female patients are
likely present with is much greater than your patients with male hair loss. Androgenetic hair loss is much less common in women at each of the age
groups compared to men. In evaluating a female patient with hair loss it’s
very important to be able to differentiate between genetic hair loss,
telogen effluvium (or hair shedding) and alopecia areata. These are very important
skills for you to have as a physician who’s evaluating patients with hair loss. If your patient has something else that doesn’t fit in these categories you may
consider referral. A very basic approach to treating hair loss and
evaluating prepare loss in women is the following. First, I’d recommend that you
ask is this alopecia areata, telogen effluvium or female pattern hair loss?
What you’ll notice is that regardless of what you think the patient may have ordering blood tests is absolutely paramount. All women with hair loss need
blood tests! We’ll review some of the blood tests that are important to
consider. If it’s localized alopecia areata or telogen effluvium or
female pattern hair loss consider ordering blood tests. We’ll consider
beginning treatments. (we’ll review some of the treatments in just a second). If
it’s female pattern hair loss but the patient has irregular periods or there’s
acne or hirsutism or you think the patient has
thing else … you might consider ordering blood tests nevertheless and referring. We’ll review these algorithms in a moment. The basic blood tests for
anybody with hair loss is CBC, TSH, ferritin and vitamin D. These basic blood
tests are reasonable to consider in women with regular periods or
postmenopausal women. Based on the patient’s story or history you may order
other blood tests if the patient has a history of autoimmunity or there’s
things in the history which make you concerned. If they have headaches,
photosensitivity, joint pains you might consider ordering an ANA. Patients with
gastrointestinal symptoms (like diarrhea) you might consider ordering zinc. In
patients undergoing bariatric surgery, I extend that panel to consider things
like selenium and copper! So so you’re by no means limited to this panel. But CBC TSH
and ferritin and vitamin D are your main parameters. Patients with regular periods
but acne and hirsutism (signs of hyperandrogegism) might consider ordering a total testosterone (which is a measure of androgen function of the ovaries) … as
well as DHEAS (which is a measure of hormone androgen function of the adrenal
gland). Patients with irregular periods pre menopausal women it’s important to
consider ordering the following panel which is done on day 3 to 4 of
the menstrual cycle. It’s very important to consider the diagnosis of
polycystic ovarian syndrome in patients with irregular periods and hair loss.
Many patients with polycystic ovarian syndrome will first present to a
dermatologist for acne or hirsutism or to other clinics for diabetes or
hypertension. But they may present for hair loss and it’s important to be aware
of the appropriate workup for PCOS! I would encourage you to consider ordering
some baseline blood tests even if you’re considering referring this patient on to
an endocrinologist or gynaecologist. These are the
parameters that we often order. 17 hydroxy progesterone is ordered on day 3 as well as part of the panel to evaluate for the rare congenital adrenal
hyperplasia (CAH) which can very much mimic polycystic ovarian syndrome as well. So
consider this patient 29 years old who has slow hair loss. The sites that are
involved is the central scalp. She’s shedding just a bit but she doesn’t have
any symptoms. This is very much in keeping with androgenetic alopecia. In
women of these so-called “5 Ss” the things that are important to be aware of in
Androgenetic alopecia in women are the sites that are involved. It’s
typically the central scalp as opposed to the temple and crown (which is more
typical of men). Shedding is sometimes increased a bit in women with
androgenetic alopecia and that’s very very important to be aware of! Androgenetic alopecia in women can sometimes “mimic” a telogen effluvium but
generally patients have no itching or burning or pain and generally it tends
to be much slower than patients with classic telogen effluvium or
alopecia areata or scarring alopecia. Consider the treatment that you would consider in a patient who’s healthy …. and
consider for a moment the treatment you’d consider in a patient with
irregular periods …and in patients who want to start a family. This is a female
with androgenetic alopecia on the left side of the panel and a male with androgenetic alopecia on the right side of the panel. What you can notice first and
foremost is that the pattern or the location of hair loss differs. Women with
androgenetic alopecia develop hair loss more in the central areas of the scalp
with a relative preservation of the very very front of the scalp. Men however
develop hair loss and the temples and the crown initially and then the mid
scalp can be involved. We call it androgenic alopecia in both but the
pattern of hair loss is very different in women! These stages
of hair loss follow a number of different stages. Most commonly either
the “Ludwig” stage or the “Olsen” pattern. Some women do follow a male pattern of
balding but that’s the least common. In the so-called “Ludwig” scale (shown here) …
you can see that there is progressive loss of hair in the central scalp as the
stages of the Ludwig scale become greater. Men follow the so-called
“Hamilton Norwood” scale where hair loss starts at the temples in stage 1 and
then progresses to stage 7 where hair is lost completely in the front,
middle and crown and just a thin rim of hair remains around the back of the
scalp. The treatments for female pattern hair loss are shown here. It’s important
to remember that even in the present day the only formally FDA-approved and Health
Canada approved treatment for female pattern hair loss is minoxidil. The other
treatments are second line and third line. Minoxidil dosing is a one-half cap
once a day or 1 mL twice a day of the 2% lotion. We’ll review this in just a minute.
Spironolactone is a second line agent. It is a common treatment for female
pattern hair loss in premenopausal women. It can be combined with a birth control
pill and frequently is combined with a birth control pill to prevent pregnancy.
Spironolactone is Class D and can cause birth defects in women using if they were to become pregnant – so it’s very important to counsel your patients about
not becoming pregnant. Spironolactone can cause dizziness, changes in libido, hair
shedding can occur initially, breast tenderness can occur, changes in mood,
dizziness. It’s important to be aware of how to prescribe Spironolactone. We
typically begin at 50 milligrams a day working up to
100 milligrams twice a day slowly over time. Finasteride can be used in
menopausal women and postmenopausal women. The dose is generally 2.5 milligrams per day. A number of studies have shown that 1 mg
per day of finasteride is relatively ineffective in women with androgenetic
alopecia. Dutasterude can also be considered in postmenopausal women as
well. Side effects of finasteride would include changes in mood, changes in the
libido, depression. It’s very important to be aware of finasteride-related side
effects. There is no good indication that finasteride increases
the risk of cancer at the present time. But because of its effects on hormones –
because of its effects on both androgens and estrogens – the presence of breast
cancer, ovarian cancer or gynecologic cancer may present a “relative”
contraindication to finasteride. That’s important to discuss with the
patient and possibly with their oncologist as well. Low level laser (LLLT) is
also an option for treating female pattern hair loss as is platelet-rich
plasma (PRP). The use and benefit of these treatments is very similar in male
androgenetic alopecia as well as female. Scalp micropigmentation and hair pieces
are also an option for women. I’d like you to be aware that hair
transplantation is less commonly an option for women. Of all the hair
transplants that are performed yearly about 85-90 % are performed on
men and 10 % on women. There’s a good reason for that! Women commonly are not good candidates for hair restoration either they have
miniaturized hair in the back of the scalp which makes their donor area less
suitable or they have a widespread type of thinning whereby the placement of
grafts into the front of the scalp just leads to less of a change or they
haven’t developed significant amount of hair loss that would really lead well to
hair restoration. Sometimes performing hair transplant in an area with too high of a density can lead to increased risks of
shedding in women and further acceleration of their genetic hair loss. Hair restoration in women is more challenging than hair restoration
and men and certainly if one is going to refer a patient for hair restoration in
women …one should refer to a provider who performs hair restoration surgery in
women quite commonly. Minoxidil is approved for use in women. The dose of
the foam is one half cap once daily. Side effects are similar. Shedding in the
first one or two months, headaches dizziness, heart palpitations. These can
rarely occur. In women, hair growth on the face occurs in 1 out of every 20 women
and so important to be aware of this as well. Here’s a picture of a common response
that we see in probably about 25 or 30 percent of women with androgenetic
alopecia- not in everyone! So minoxidil does not work in all patients with with
hair loss …. but you want to give it a good six to nine months and preferably a year
to determine if minoxidil is going to work. It’s a long time but it does
take that long to determine if the treatment is going to work. Here’s a
patient with a very positive response after using minoxidil. The
approach that we’ll take in this patient who presents with what we believe is
female pattern hair loss hair loss is evaluating a full history. Do they have
acne? … Do they have regular periods? Do they have hirsutism? .. do they have any
other health considerations? ordering blood tests and if they have regular
periods then we might consider beginning treatment with minoxidil. A patient with
irregular periods as we saw – we can consider ordering that extended panel on
day 3 to evaluate further for PCOS. There are many reasons for irregular
periods other than PCOS of course and so we may consider referral to a
gynecologist or endocrinologist to further evaluate the cause of those
irregular periods. S patient who wants to start a family we
need to be aware that most of the treatments for female pattern hair loss
are contraindicated during pregnancy. Low-level laser can be used but
minoxidil cannot be used during pregnancy. Spironolactone cannot be used
during pregnancy nor can PRP. One needs to be aware of this and if a
patient is planning pregnancy within the next short while certainly I may not
recommend the use of minoxidil or Spironolactone or PRP. We may start
treatment with laser or we may delay treatment. Let’s take a look at some of
the prototypical conditions that are associated with a rapid speed of hair
loss – one of these so-called S’s. Alopecia areata and telogen effluvium are two
conditions that can give a relatively quick type of hair loss. Let’s take a
look at this 16 year old male who presents with hair loss over a period of
two weeks. Two weeks ago he had complete hair (full hair on his scalp)… and now he
has these distinct patches of hair loss. Alopecia areata can involve any site of
hair loss so it’s not localized to any specific area. Patients sometimes notice
increased amounts of shedding. Typically they don’t have any symptoms but they
can develop a little bit of burning in these patches or itching before the
patches develop. If you’re going to treat alopecia areata it’s important to be
aware of three definitions …because your patients will want you to be aware of
these. Alopecia areata refers to loss of scalp hair
but there is still some scalp hair remaining. If ALL of the scalp hair is
gone, the appropriate term would be alopecia totalis. If ALL of the scalp
hair body hair is universally gone the appropriate term is alopecia universals.
The treatment that I would like you to be aware of for alopecia areata is the
use of topical steroids, minoxidil and steroid injections. I’d like you to
be aware of how to perform steroid injections and I’d like to encourage you
to consider performing steroid injections! When performed properly
they can they can be quite effective and quite safe and your patients will be
very appreciative of your ability to help them in this manner in their
alopecia areata as opposed to referring to a dermatologist. You may (as you begin)
decide it you want to refer for eyebrows or other areas but the scalp you can
often begin treatment yourself! How do we treat alopecia areata? Remember that
many of your patients will regrow their hair spontaneously within one year even
without treatment! So not performing any treatment is an
option. But the first-line treatment for alopecia areata with one patch or two
patches is the combination of steroid injections, topical steroids or minoxidil. Spontaneous regrowth is much less likely
in a patient with two or three patches than in one patch and so you may decide
to begin treatment with a patient with many patches. In a patient with one patch
you may decide to approach begin a sort of a “watch and wait” type approach as
well but typically I may recommend treatment with a class 1 steroid. Clobetasol is appropriate either a lotion, a foam or a cream. We might use it
daily for a period of eight weeks then give the patient a period of time off
the medication (… say two weeks) and then repeat the cycle.
I’ll frequently have the patient apply minoxidil every night to this area of
hair loss without a break. Provided they’re not using more than a half a cap
of the minoxidil foam or they’re not using more than one milliliter of the
lotion this is a very good option. We may have steroid injections at the same
time. The other treatments are second-line! There are many treatments
that one can consider. W use certainly all of the treatments on this
list at some point in the clinic. My view is that treatments like DPCP, anthralin,
methotrexate, prednisone are “second-line” agents.
My view is that for most patients other things like the JAK inhibitors (tofacitinib ruxolitinib) are “third-line” agents. Despite their popularity we have
to remember that that decades of use support the use of topical steroid,
steroid injections, and minoxidil for the vast majority of patients with alopecia
areata. Your patients may present with questions about the use of JAK
inhibitors. These are certainly options …and we use them in the clinic … but these
are NOT first-line agents for alopecia areata. I’d like to review with you how
to inject steroids because when done properly they can be quite effective for
many of your patients that present to you with alopecia areata. This condition
affects 2 % of the world … and the vast majority of patients present
with patchy alopecia areata. You have the opportunity to assist many
patients with alopecia areata. What I’d like you to consider as you begin
injecting steroids is to begin with 2.5 mg/mL (rather than 5 mg/mL) because this can be very very helpful for your patients and presents a
an increased margin of safety in reducing the chance of atrophy and
side-effects compared to using 5 or 10 mg/mL. So to inject 2.5 mg/mL you get a bottle of 10 milligrams per mil (which
usually comes standard) … get out two 3 cc syringes. Put an
18-gauge needle on it and draw up 0.75 mL of the triamcinolone acetonide. Then get out your saline and draw up another 2.25 mL. This will bring your volume up to 3 mL ….. and now you have a 2.5 mg/mL syringe you can make up another one which will be two and
this these two syringes can be injected into the scalp! You’d put a thirty gauge
needle on it and you can perform steroid injections one centimeter apart 0.1 mL
in each of these zones. By using 2.5 milligrams per mL
…. you reduce your chances of “atrophy” or these indentations that
can occur – and it could still be very very beneficial!
Who should you refer? … Well, I would recommend you consider referring
children who don’t respond to either a “watch and wait” approach or children who
don’t respond to topical steroids. We generally don’t do steroid injections
and children less than 10 11 or 12 years. (It depends on the child.) In adults you might
consider referring a patient who doesn’t respond to 3 sessions of steroid
injections or topical steroids and minoxidil. Let’s take a look at some
prototypical conditions that involve shedding. This is a patient who presents
with massive shedding about three months after using a new medication. In this
case a medication lithium. The shedding is everywhere. The shedding is marked.
There can be 300, 400 … 800 hairs per day being lost at its peak intensity! There
may be slight tingling …but usually symptoms are relatively mild. When
you ask about supplements you’d see that a new drug has, in fact, been introduced!
The key about telogen effluvium is the shedding and the speed of the
patient’s hair loss .. but particularly the shedding. Patients with telogen effluvium
typically lose more than 100 hairs per day but I’d like you not to be
focused on the number of hairs per day because that’s where people often get
into trouble! If a patient says that “I can tell you doc – I typically lose 30
hairs a day and now I’m losing 50” …. that’s abnormal!!
If a patient used to lose 50 and now they lose 75 …. that’s abnormal!! …… and so we
typically are focused on this number 100 but but that’s really not correct. Patients know their hair the best and if they feel they’re shedding more than
their ‘average’ …. this is abnormal. What are the triggers of telogen effluvium?
The triggers of telogen effluvium. I use the so called “S.E.N.D” mnemonic! These are
the things that SEND a delicate hair follicle from the growing phase
to the shedding phase. T S stands for stress and scalp diseases – things like
the stress of a surgery, psychological stress, death of someone in the family
severe emotional stress can trigger shedding. Scalp disease. Severe scalp disease like
psoriasis can also trigger shedding. Any endocrine disorder can trigger shedding.
Hypothyroidism, the birth of a baby …. these are common triggers of sheddin. “N” stands
for the nutritional issues. Low iron, crash diets, bariatric surgery… these are
well known triggers of shedding. Drugs can trigger shedding. ANY drug can
theoretically trigger shedding!!! When clinical trials of medications are done
patients are given surveys. To evaluate the side effects they
experience patients fill out surveys about side effects.
Because hair loss is so common invariably patients are going to report
hair loss!!! So ANY medication can theoretically trigger hair loss. But
certain medications are more likely like lithium, beta blockers, antidepressants
some anticoagulants. How do we treat telogen effluvium?
We treat telogen effluvium by identifying first and foremost the
trigger… and if we can figure out what triggered it then we fix that trigger.
It’s important to order some basic blood tests in anyone with telogen effluvium.
CBC, TSH, ferritin and vitamin D are the first-line agents but in a patient with
telogen effluvium it’s absolutely critical to perform a very thorough
history. That panel of blood tests that we ordered can be extended to a
number of tests including zinc, VDRL copper, selenium the list can actually be quite
extensive as you properly evaluate a patient’s history. The important
point is that once you identify the trigger …( if you can identify the trigger)
the shedding will stop in most patients in about 6-9 months. One needs to
be aware that in 50% of patients with telogen effluvium we can’t
identify the trigger. But if the patient’s iron is low then we prescribe iron.
If their thyroid is is abnormal, we fix the thyroid. If you identify the
trigger and fix it …the patient’s hair loss likely improves. Who should you
refer? Cconsider referring patients who have shedding that they’re troubled with
and the blood work is normal or refer patients who have shedding and they have
marked scalps symptoms like burning and pain. I’m often asked about patients who
have shedding and all the blood work comes back normal. What do you consider
in these patients? Remember that some patients with shedding are actually in
the early stages of androgenetic alopecia. And so some of your patients
who you think have a telogen effluvium actually have early androgenetic
alopecia. So be aware of that. Some patients have chronic telogen effluvium.
Some patients have this condition “CTE” where they continue to shed despite
blood tests being abnormal. Sorry blood test being normal. That’s very typical of
chronic telogen effluvium. Some patients may have a scarring alopecia. Some
patients may have diffuse alopecia areata. So remember that
some of your patients who present with what you think is a telogen effluvium
may actually have other scalp conditions going on. Remember they may have telogen
effluvium … but you haven’t identified the trigger. There’s over 2,000 causes of
telogen effluvium. Low iron, crash diets, stress, surgery … these
are the MOST common causes. Remember there are over 1000 conditions in
the body that theoretically could trigger a telogen effluvium,,,
and we may not be able to diagnose those in all patients. The other non scarring
alopecia is traction alopecia this patient on the right presents with early
traction alopecia where there’s some hair loss along the front this is due to
the use of a hairstyling methods including braids, braids, weaves, cornrows
tight ponytails man buns .. these are common causes of traction alopecia
the woman on the left has traction alopecia as well. A biopsy was done and
that’s why we see this small blue circle here. The thing that’s so important to
remember about traction alopecia is that early traction alopecia may be regrowable ..
but traction alopecia that’s been around for many weeks or months may not
be regrown. There’s no definite timeline that we we give to that but generally if
it’s been six months or more with traction alopecia and the patient’s not
seeing an improvement you may consider minoxidil or steroid injections or use
of a cortisone … but the chances of regrowth go down quite a bit
compared to someone who’s just had hair loss for three or four or five weeks.
Trichotillomania is another non scarring alopecia which has many presentations.
Again trichotillomania in the early stages is
identifiable regrowable. This patient is a young child who presents with hair
loss at the back of the scalp after severe emotional stress. If we can stop
this child from pulling her hair we can regrow the hair in a large percentage of
patients. Many patients with trichotillomania especially older
individuals 12 13 15 may have underlying depression, anxiety, obsessive compulsive
disorders, attention deficit hyperactivity disorder … and so it’s very
important to perform a full history and consider referral in patients with
trichotillomania who have these underlying emotional issues.
Trichotillomania in very young children 3 4 5 6 years can be more in keeping with a
habit and is less associated with these severe underlying psychological
disorders. Finally what about the S that’s associated with symptoms. This is a patient 65 who presents with
itching, burning, pain in the scalp. The speed of the hair loss is moderate. The
hair loss is occurring more in the central scalp but patients with scarring
alopecia like she has can have hair loss anywhere.
She may be shedding a bit more than normal but the predominant “S” in these
five s’s is the symptoms. The thing I’d like to leave you with is that patients
with severe burning and pain and itching as well but especially burning and
tenderness and pain ….should really have referral to a dermatologist to rule out
the possibility of a “scarring alopecia.” These scarring alopecias are a diverse
group of conditions and we saw the list in the beginning things like lichen
planopilaris, frontal fibrosing alopecia, discoid lupus, central
centrifugal alopecia – these are generally autoimmune in nature and they’re treated
with various anti-inflammatory agents like topical cortisones cortisone
injections as well as various immunosuppressant agents as well. But a
biopsy is frequently needed to exclude scarring alopecia. You will see many
patients with ‘red scalps’. There’s a multitude of causes of red scalp. For
most patients who are itchy and have a red scalp … you need to consider things
like seborrheic dermatitis (dandruff is a close relative of seborrheic dermatitis).
Seborrheic dermatitis presents with scalp redness, greasy scale. Patients
develop itchiness especially if they’ve gone many days without washing their
their scalps. Psoriasis is also common and so these are the most common
causes of a red scalp but remember scarring alopecias and autoimmune diseases
also need to be considered. So consider referring patients for a biopsy
in patients with a red itchy scalp that’s associated with hair loss!!!
If you’re comfortable performing biopsies it’s a valuable skill to to
know how to do …. but it has to be a 4 mm punch biopsy and it has to be
taken from the right area the area which is showing these key morphological
features of the disease you think the patient has! A “random” biopsy anywhere on
the scalp is NOT useful. You may consider referring a patient for a scalp
biopsy and so the approach that I would recommend that you consider in women
again is determining if you think it’s androgenetic alopecia or alopecia areata
in a localized form or telogen effluvium. Always order blood tests if the
patient’s androgenetic alopecia is associated with some signs of
hyperandrogegism or if you’re just not sure what this is
consider referral to a dermatologist. I’m gonna leave you with one more case which
i think is a very important point to be aware of and that’s chemotherapy induced
hair loss. This is a 42 year old female who has a history of breast cancer. She
completed her chemotherapy one year ago but her hair hasn’t grown back fully. She
developed hair loss a few months into the chemotherapy she was on track
saying she was waiting for her hair to grow back and it didn’t grow back
completely. I’d like you to give thought to how this situation differs from a
patient who’s about to undergo chemotherapy and wants to know how she
can PREVENT hair loss. These are two different situations. These two
situations are different because they allow you to think carefully about two
scenarios – one is transient chemotherapy induced alopecia
the second is permanent chemotherapy induced alopecia. Transient chemotherapy
induced alopecia is probably what you’re most familiar with. It’s the type of hair
loss that about two-thirds of patients with who are undergoing chemotherapy
experience. We expect that within weeks of chemotherapy that hair loss will
develop …but we expect hair to grow back within six months after their
chemotherapy. That’s what we expect. Permanent chemotherapy induced alopecia is a type of hair-loss where the hair does not
regrow back to the same thickness after the patient’s chemotherapy is done after
six months. Permanent chemotherapy induced alopecia is becoming recognized
now as occurring with a number of chemotherapy agents but especially
with the “taxanes” that are used in the treatment of breast cancer. There are a
proportion of women that are developing permanent chemotherapy induced alopecia
whereby they don’t quite get back all their hair after chemotherapy. For some
it’s a mild amount of hair loss. For some it’s a marked amount of hair loss but in
the transient chemotherapy induced alopecia the first scenario I’d like you
to be aware of these new FDA-approved agents called the scalp cooling agents
which are now known to prevent chemotherapy induced alopecia. These
have led to quite remarkable changes in how patients undergoing chemotherapy are
treated. There’s two FDA approved devices shown here in this picture. The DIGNICAP
cap was approved in 2015 and the Paxman device was approved in 2017. These two
scalp cooling devices can reduce the chances of women developing hair loss in
the first place after chemotherapy and these two these studies that led to
their approval show that they can reduce noticeable hair loss or hair loss that
would otherwise prompt a woman to wear a wig in a significant proportion of
people using these scalp cooling devices. So they’re important to be aware of. We
can in some women reduce the chances of hair loss after chemotherapy we don’t
yet know how we can reduce the chances of persistent chemotherapy induced
alopecia and this remains an ongoing subject of research.
In conclusion anybody who presents with hair loss consider please ordering CBC
TSH, ferritin, vitamin D. Other blood tests may be relevant but they’re guided by
the patient’s history. Minoxidil remains the key starting point as a first line
agent for female androgenetic alopecia minoxidil and finasteride are important
first-line agents for androgenetic alopecia in males. Topical steroids,
steroid injections and minoxidil our first line agents for alopecia areata. I’d like
you to give thought to the possibility of using steroid injections at 2.5
milligrams per mL in limited amounts for your patients with alopecia areata
in patchy form. It can be for tremendously helpful for your patients
and by reducing the time that it’s required for referral to a dermatologist….
you may be able to assist these patients tremendously and assist them with with
hair growing back. Consider referring patients with burning and pain in the
scalp these are symptoms which may indicate a possible scarring alopecia or
underlying issue. Of course they may have seborrheic dermatitis – they may have
psoriasis – but you have to have a heightened awareness for a larger
differential diagnosis in patients with scalp burning and pain. With that I’d
like to conclude. I’d like to thank you very very much for your attention and I
hope this presentation was useful.

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