08. Approach to Alopecia

Resident Editor: Juliana Macri, M.D.

Faculty Editor: Ryan Arakaki, M.D.

BOTTOM LINE

✔ Assess hair loss pattern and acuity, as well as associated triggers to determine etiology

✔ Non-scarring alopecia can be treated in primary care

✔ Refer scarring or refractory alopecia

Background

  • Alopecia describes baldness. Effluvium or defluvium describes the shedding of hair
  • Hair grows in three phases: Anagen (active growing), catagen (degeneration), and telogen (resting)
  • Hair loss can be non-scarring (aka. non-cicatricial), which is reversible, versus scarring (aka. cicatricial), which is permanent and requires a dermatologic referral
  • Alopecia is not inherently dangerous but can cause social and psychological distress, and affect the quality of life.

Differential

  • Scarring alopecia (rare): Primary or secondary. Includes autoimmune causes (e.g. discoid lupus)
  • Focal/patchy: Alopecia areata, tinea capitis, trichotillomania
  • Diffuse: Telogen or anagen effluvium, androgenic alopecia, systemic disease (e.g. hypothyroidism, iron or other nutritional deficiency), alopecia totalis (if involvement beyond scalp)

Evaluation

History

  • The onset of hair loss: Abrupt suggestive of anagen or telogen effluvium; gradual onset suggestive of alopecia areata, androgenetic alopecia, or scarring alopecias
  • Pattern of hair loss: patchy vs. diffuse, male or female pattern
  • Associated conditions/triggers
    • Hair product use and tight hairstyles
    • Medications: chemotherapy, retinoids, anticoagulants, anticonvulsants, beta-blockers, thyroid medications, OCP discontinuation (drug-induced alopecia manifests as telogen or anagen effluvium)
    • Recent physical or emotional stressors, in the past 2-5 months (can cause telogen effluvium)
    • History of anxiety or psychiatric disease (consider trichotillomania)
    • Systemic symptoms (e.g. hypothyroidism, recent health concerns), other skin conditions
  • Family history

Physical Exam

  • Evidence of tissue destruction (inflammation, atrophy, scarring), particularly absence of follicular orifices à dermatology referral
  • Pattern:
    • Male pattern: Varies between thinning bi-temporally, to loss at frontal and vertex hairline to complete loss except for the preservation of hair at the occiput and temporal fringes
    • Female pattern: diffuse thinning at the vertex with sparing of frontal hairline, does not result in complete baldness (as compared to men)
  • Hair quality: assess for dry, broken, or thin hair
  • Evidence of infection: Scaling, pustules, crusts, erosions, erythema, adenopathy
  • Pull test: Grasp 40-60 hairs at their base, and apply gentle traction. Positive if > 10% of hairs are pulled, suggestive of active hair loss (e.g. telogen or anagen effluvium, or alopecia areata). Not fully sensitive, and difficult to standardize.

Testing

  • No routine testing
  • Depending on the history and physical exam, consider CBC, TSH, ALT, Cr, iron studies, testing for copper or zinc deficiency, vitamin D
  • If concern for virilization and male pattern hair loss in women, consider free and total testosterone, DHEAS, and prolactin
  • Fungal culture if itching, scaling, pustules, lymphadenopathy
  • Can consider referral for a scalp biopsy, trichogram

Diagnosis and Treatment of Common Causes

  • Scarring alopecia should be referred to dermatology
  • Non-scarring alopecias can be treated in primary care (see Table 1)
  • Consider the psychological impact of hair loss and offer support (online support groups, etc).
    • Some patients may consider a wig, hairpiece, tattoos, or makeup to obscure hair loss.

Table 1: Common Non-Scarring Alopecias

Condition

Notable Features

Treatment

Alopecia areata (etiology unknown, possibly autoimmune)

Acute, patchy hair loss (but can become confluent or generalized); exam with short, thin, and broken hairs, yellow or black dots; “exclamation mark” hair. Can cause hair loss anywhere, not just scalp.

Often self-limited. Consider intralesional triamcinolone every 4-6 weeks for up to 6 months

Anagen effluvium

Acute onset, diffuse hair loss days-weeks after triggering event that interrupts mitosis of the hair follicle (e.g. chemotherapy)

Limited options – provide psychosocial support. Regrowth expected 1-3 months after offending agent stopped. Minoxidil may help during regrowth.

 

Androgenic alopecia – aka. Male- or female- pattern hair loss (the most common cause of hair loss in men and women)

 

Gradual and progressive onset.  + family history. Residual hair becomes finer, vellus. Male or female pattern (see physical exam). Consider thyroid disease, IDA, nutritional deficiency, endocrine disease (see virilization in females)

Treatment is better at preventing progression than stimulating hair regrowth.

 

Topical minoxidil (2% or 5%); vertex > frontal response, takes 6-12 months; indefinite treatment recommended. Best evidence. Side effects of contact/irritant dermatitis. Increased shedding in the first 2 months of treatment.

 

Finasteride 1 mg daily: second line, approved in men. Side effects of decreased libido, ED, gynecomastia. Maybe long-lasting even after d/c of med. Not as effective for women.

Telogen effluvium

Acute onset, diffuse, uniform loss; report clumps of hair loss with brushing or in the shower; triggered by a physical or emotional stressor, 3-5 months prior. May see associated nail findings (Transverse or Beau Lines)

Self-limited (2-6 months)

Offer reassurance and treat underlying stressor

Tinea capitis (most commonly Trichophyton tonsurans; less likely Microsporum audouinii)

Patchy pattern. May have associated scaling, pruritis, erythema, lymphadenopathy. Caused by dermatophyte infection – often household or fomite exposure (e.g. brushes, hats). Consider skin scraping of the active border with KOH exam

Systemic treatment (topicals will not penetrate)

Oral terbinafine, itraconazole, fluconazole or griseofulvin; examine and treat close contacts

 

Trichorrhexis nodosa

Dry, broken hair. Can have a genetic component, but frequently caused by trauma (e.g. tight hairstyling, excessive brushing, heat, or harsh chemical products)

Adjustment of hairstyling routines

Trichotillomania

 

Uneven, patchy pattern, especially frontoparietal, with twisted or broken off hair. May involve eyelashes and eyebrows. Caused by pulling, twisting, or twirling of hair; associated with anxiety and impulse-control issues

 

Combination of CBT and medications more effective than medications alone; consider psych referral

References

Phillips TG, Slomiany WP, and Allison R. Hair Loss: Common Causes and Treatment. Am Fam Physician. 2017; 96(6): 371-378.

Wolff K et. Al. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. 8th Edition, 2017.