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Alopecia - LCL


									Common dermatology symptoms
                  Dr.CL Lee
           Functions of hair ?
• Reduces heat loss
  through the scalp
• Protects the scalp,
  face from UV solar
• Perception of
  beauty of
                Types of Hair
•   Lanugo hair
•   Vellus hair
•   Intermediate hair
•   Terminal hair
                           Hair cycle
     Anagen           Catagen             Telogen          Shedding

Active growing    Transition phase        Resting phase   Should be < 100
2-6 years cycle   - Hair matrix           Lasts for       pcs of hair / day
0.37mm/day        gradual stop dividing   100 days
85%               - last 3 weeks          10%
Case 1
   • 49-year-old man developed
     gradual thinning of hair on the
     scalp over last several years
       – History ?
           • Family history
       – Diagnosis ?

   • Androgenetic alopecia
          Angrogenetic alopecia
• Etiology: Combined effect of androgen and genetic
   – Genetic factor - as evidenced by frequent positive family history
   – Androgen - Eunuchs and castrated males never develop

• Age of onset:
   – Male >> Female
   – Male: begin anytime after puberty, as early as second decade
   – Female: later, about 40% in sixth decade

• Pattern: frontal/vertex thinning, bitemporal recession
           Angrogenetic alopecia
• In general, males exhibits loss
  in frontaltemporal and vertex
• Women generally lose hair
  diffusely over the crown. This
  produces a gradual thinning of
  the hair rather than an area of
  marked baldness
• Treatment ?
  – Topical minoxidil
  – Oral finasteride
  – Hairpiece
  – Hair transplantation
• Topical minoxidil
  – lengthen the duration of the anagen phase, and it
    may increase the blood supply to the follicle
  – Regrowth is more pronounced at the vertex than in
    the frontal areas and is not noted for at least 4 months
  – Continuing topical treatment with the drug is
    necessary indefinitely because discontinuation of
    treatment produces a rapid reversion to the
    pretreatment balding pattern.
  – marketed as a 2% or a 5% solution, with the 5%
    solution being somewhat more effective
  – In general, women respond better to topical minoxidil
    than men
• Finasteride (1mg daily)
  – given orally and is a 5 alpha-reductase type 2 inhibitor
  – may produce ambiguous genitalia in fetus
  – diminish the progression of androgenetic alopecia in
    males who are treated, or stimulated new regrowth
  – Finasteride must be continued indefinitely because
    discontinuation results in gradual progression of the
  – A study in postmenopausal women indicated no
    beneficial effect of the medication in treating female
    androgenetic alopecia
• Hairpieces
  – Wigs, hair weaves
• Hair transplantation
• 30 years old women
  presented with 6
  months history of hair
• History ?
• Further query?
   – Menstrual disturbance
   – Signs of hirsutism or virulization
• What are you worrying about?
   – Need to rule out excessive androgen activity when
     female pattern alopecia occurs early
   – e.g. androgen secreting tumour
Case II
    • 35-year-old woman complain
      of diffuse hair loss most
      prominent on her temples,
      noted brisk hair shedding for
      the last month
    • History ?
           Telogen effluvium
• Transient increased in shedding of normal
  telogen hair secondary to accerlerated shift of
  anagen into catagen and telogen
• Precipitating event precedes the hair loss by 6-
  16 weeks
            Telogen effluvium
• Etiology: any physical or mental stressors
  – Endocrine: postpartum, thyroid (hyper/hypo), peri-
    postmenopausal state
  – Drugs: Antimitotic drugs, anti-HT: ACEI, betablocker,
    CNS drugs: lithium, valproate, hormonal: OCPs
    withdrawal, retinoid effect: vit A excess, retinoid
  – Nutritional: iron, zinc, essential fatty acid deficiency,
    calory or protein deprivation
  – Physical stress: surgery, systemic disease
  – Psychological stress
  – Idiopathic
            Telogen effluvium
• Any age
• More common in women
• Second most common
  cause of alopecia after
  androgenetic alopecia
• Hair loss diffuse
  throughout the scalp,
  short regrowing new hair
           Telogen effluvium
• Precipitating stimulus for TE results in a
  premature shift of anagen follicles into telogen
• Anagen phase occurs again in 3-4 months if the
  precipitating stimulus removed
• Hair density take 6-12 months to return to
• Remove precipitating cause
• No other intervention is required
• Most will have complete regrowth of hair
• Some severe and recurrent post-partum telogen
  effluvium may be incomplete regrowth
• While topical minoxidil is not proven to promote recovery
  of hair in telogen effluvium, this medication has a
  theoretical benefit and is well tolerated
Case 3

   • 40-year-old woman
     complained of a hairless
     patch on the mid scalp for
     8 weeks
   • Diagnosis ?
      – Alopecia areata
   • History ?
      – Association with other
        autoimmune disease
          Alopecia areata
• An autoimmune disease causing localized
  loss of hair in round or oval areas
             Alopecia areata
• Young adults < 25yrs old
• Equal in both sex
• Associate with other autoimmune disease –
  vitiligo, familial autoimmune polyendocrinopathy
  syndrome, Addison’s disease, thyroid disease
• Follicular damage occurs in anagen followed by
  rapid transformation to telogen
           Alopecia areata
• Characteristics:
  – as bald patches, may be discrete or
  – Nail pitting may be present
  – Broken hair with tapering shaft
    (exclamation mark hair)
           Alopecia areata
• Spontaneous remission is common
• If occur after puberty, 80% regrow hair,
  33% completely regrow hair within 1 year
• Recurrences are frequent
            Alopecia areata
• Management
  – No curative treatment is currently available
  – Glucocorticoid
  – Immunomodulators
  – Minoxidil
Case 4
   • 8-year-old girl developed
     alopecia with broken hairs,
     family own a new kitten in
     recent month
   • Description
      – Patchy alopecia over the
        frontal and occipital
      – scattered scale on the
        right side of her scalp
        associated with pruritis
      – No scarring
      – Minimal redness
      – Subsequently multiple
        annular patches
        appeared on the back
        and neck
• Provisional diagnosis ?
• Any futher investigation ?
Tinea capitus
     • Wood light examination
        – Multiple 1-2 mm blue-green
          fluorescent papules
     • KOH preparation
        – long strands of hyphae &
          spores on the exterior of the
          fractured hair shafts
     • Tinea capitus
        – most common organism
          cultured in this setting is
          Microsporum canis
        – Usually acquired from pet
        – Oral antifungal agents are
          required to treat tinea in hair
          bearing areas such as the
Case 5

 • This 3-year-old toddler was
   brought by her mother for
   evaluation of hair loss
 • Description:
    – hair thinning around plaits & the
      periphery of the scalp
    – Non-scarring, no inflammation
    – Elder sister got similar problem
    – She kept her hair in tight plaits
      resulting in hair loss at the
      edges of the parts and the
      periphery of the scalp
 • Traction Alopecia
          Traction Alopecia
• The physician must identify traction
  alopecia early. Failure to do so places the
  patient at risk for irreversible alopecia
Case 6
    • 35-year-old woman reddish
      plaques for 1 year
         – Thick adherent scales on her
         – Similar lesions over her nose,
           cheeks, ears and upper back
           for a duration of two years

    • Differential diagnosis ?
        Scarring alopecia DDx
•   Congenital e.g. aplasia cutis, naevus sebaceus
•   Post-trauma e.g. burn, injury, radiotherapy
•   Post-infection e.g. kerion, herpes zoster
•   Inflammatory dermatosis e.g. DLE, lichen planus,
    morphoea: common cause of scarring alopecia
•   Neoplasm e.g. squamous cell carcinoma of skin
•   Idiopathic


          Scarring                                  Non-scarring

1.   Congenital                          Diffuse                   Patchy
2.   Post-trauma
3.   Post-infection
4.   Inflammatory dermatosis
5.   Neoplasm                                                  1. Trichotillomania
6.   Idiopathic                                                2. Traction alopecia
                     1. Androgenic alopecia
                                                               3. Tinea capitis
                     2. Telogen effluvium
                                                               4. Alopecia acreta
                         - post-partum, severe illness,
                           major operation, malnutrition
                     3. Anagen effluvium, eg chemotherapy
                     4. Alopecia areata totalis/universalis
                     5. Drugs
                     6. Systemic disease, SLE, thyroid, iron deficiency

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