Alopecia

Alopecia Overview Definition Etiology Risk Factors Signs and Symptoms Differential Diagnosis Diagnosis Physical Examination Laboratory Tests Pathology/Pathophysiology Treatment Options Treatment Strategy Drug Therapies Complementary and Alternative Therapies Patient Monitoring Other Considerations Complications/Sequelae Prognosis Pregnancy References

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Overview Definition

Alopecia is the absence or thinning of hair in an area of the body where hair formerly grew. It may be caused by physical damage to the hair itself or to the hair follicles, but is most often the result of changes in the natural hair growth cycle.

The average scalp has about 100,000 hairs. Most of these hairs are in the anagen, or growing, phase, which may last as long as five years. In the catagen, or transitional, phase, the hair stops growing and the follicle begins to shrink. The hair then falls out and the follicle lies dormant in the telogen, or resting, phase until a new anagen phase begins. About 10% of the hair follicles on the normal scalp are in the transitional or resting phases, and about 100 hairs are lost every day. In some types of alopecia, the growth cycle is disrupted by some temporary situation such as a chemical imbalance or stress; often the problem may be resolved when the precipitating condition is alleviated. However, 95% of cases of hair loss in both men (male pattern baldness) and women (female diffuse baldness) are genetic in origin. This is called androgenetic alopecia.

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Etiology

Androgenetic alopecia is caused by a genetic predisposition for certain hair follicles to produce the enzyme 5-alpha reductase, which combines with the testosterone in the follicle and transforms it into dihydrotestosterone (DHT). DHT accumulation eventually shuts down the follicle. In the interim, the hairs produced by the follicle gradually become shorter and finer. Female diffuse baldness progresses more slowly than male pattern baldness because of the small amount of testosterone in a woman's body. Androgenetic alopecia may be exacerbated by a hormone imbalance.

Many temporary forms of hair loss result from telogen effluvium, in which approximately 30% of the hair follicles go into the resting phase at once. Any shock to the body's systems, including starvation, systemic infection, childbirth, thyroid or immunologic disorders, drugs, or stress may precipitate such an episode. In anagen effluvium, the growth phase is suddenly halted and all or most of the hair falls out in clumps within a few weeks. The most common cause of this condition is chemotherapy for cancer.

In cicatricial, or scarring alopecia, hair follicles are destroyed by scarring from burns or other trauma, severe scalp infections, X-ray therapy, or skin disorders. Physical damage may also result from tight hairstyles maintained over a long period of time, called traction alopecia. Chemical treatments such as hair coloring or permanents can cause hair loss, as can trichotillomania, the habitual pulling out of the hair. Tinea capitis, or "ringworm of the scalp," a fungal condition, also results in hair loss. Except for scarring alopecia, these conditions are generally temporary.

The causes of alopecia areata, or patchy hair loss, are not well understood. There appears to be a genetic component, and it is sometimes associated with an autoimmune disorder. Onset tends to occur in times of stress. Since white hairs are less affected by alopecia areata than pigmented ones, a patient with this condition may report that areas of hair appear to have "turned gray overnight."

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Risk Factors

• Male gender
• Advancing age
• Close family member with hair loss
• Hormone imbalance
• Stress
• Eczema, asthma or hay fever, thyroid disease, or vitiligo
• Autoimmune disorders such as lupus erythematosus
• Down's syndrome

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Signs and Symptoms

• In male pattern baldness—thinning or absence of hair at the hairline and crown; normal hair growth remains in a "horseshoe" pattern around the sides and back of the scalp.
• In female diffuse baldness—a gradual thinning of hair, especially on the crown; hairline generally remains intact
• Broken hairs, or hairs easily removed
• One or more round or oval bald patches

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Differential Diagnosis

Determine the type of alopecia and treat accordingly.

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Diagnosis Physical Examination

Thin short hairs, tapering at their base ("exclamation point hairs"), easily pulled out, are seen in and near the bald patch or among hairs which have shed. Look for other patches of alopecia on eyebrows, eyelashes, beard or body hair. In alopecia areata, nails may be pitted or deformed.

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Laboratory Tests

Thyroid function tests and complete blood count to rule out immunologic disorder

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Pathology/Pathophysiology

Biopsy will support diagnosis of several forms of alopecia.

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Treatment Options Treatment Strategy

Appropriate treatment options depend upon the type of alopecia. Aggressiveness of the treatment depends on the patient's attitude toward what is fundamentally a cosmetic problem and must be weighed against potential side effects. In many temporary forms of alopecia, the condition will begin to normalize without treatment upon removal of the cause. Surgery may be indicated for highly motivated patients with male pattern baldness for whom medical therapies are contraindicated or ineffective. Options include hair transplants, scalp reduction, and strip or flap grafts.

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Drug Therapies

• Male pattern baldness—Topical minoxidil (Rogaine), 2% to 5% applied bid. Alternatively, finasteride (Propecia), 1 mg/day orally. Either drug must be used indefinitely to maintain regrown hair. Monitor for potential side effects.
• Female diffuse baldness—Topical minoxidil (Rogaine), 2% applied bid. Must be used indefinitely to maintain regrown hair. Monitor for potential side effects.
• Alopecia areata—Intralesional injections of aqueous corticosteroids, triamcinolone suspension 5 mg/ml, 0.05 to 0.1 ml at intervals of 1 to 2 cm. Injections should not be repeated at the same site for three months. Topical steroids (0.5% triamcinolone cream) may be used for children.
• Tinea capitis—Antifungal such as griseovulfin, orally for eight weeks, in combination with antifungal shampoo two to three times per week for eight weeks. Complete entire course of treatment to prevent relapse.

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Complementary and Alternative Therapies

Alopecia is a multi-factorial condition. Correcting the underlying cause is the primary goal of treatment. Complementary therapies have limited success in treating male pattern baldness in men.

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Nutrition

• Optimizing diet by reducing intake of pro-inflammatory foods (saturated fats, dairy, and other animal products) and increasing fresh vegetables, whole grains, essential fatty acids, and, in particular, protein will help to provide essential nutrients for normal hair growth.
• Biotin (300 mcg/day) may be helpful in relieving alopecia. Trace minerals, such as those found in blue green algae (2 to 6 tablets/day), are also needed for hair growth.
• For androgenetic alopecia: Vitamin B6 (50 to 100 mg/day), zinc (30 mg/day), and GLA (1,000 mg bid) helps to inhibit 5-alpha reductase. Hormone imbalance: Essential fatty acids (1,000 mg bid), B6 (50 to 100 mg/day), vitamin E (400 IU/day) and magnesium (200 mg bid) enhance hormone production.

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Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Herbs that support circulation may aid in bringing nutrients to the scalp. Combine the following herbs in equal parts and use as tea (2 to 3 cups/day) or tincture (20 to 30 drops bid to tid).Ginkgo (Ginkgo biloba), rosemary (Rosmarinus officinalis), prickly ash bark (Xanthoxylum clava-herculis), black cohosh (Cimicifuga racemosa), yarrow (Achillea millefolium), and horsetail (Equisetum arvense). Ginkgo should be used with close supervision if pharmaceutical circulatory (anticoagulation) agents are employed (e.g., coumadin or aspirin).
• Androgenetic alopecia: Green tea (Camelia sinensis), 2 cups/day, and saw palmetto (Serenoa repens), 100 mg bid, have anti-androgenic effects.
• Hormone imbalance: Chaste tree (Vitex agnus cactus), 200 to 300 mg/day, has a normalizing effect on the pituitary and may help correct hormonal imbalances.
• Viral or immune etiology: Herbs that support the immune function are helpful to treat the underlying cause of this type of alopecia. Echinacea (Echinacea angustifolia), astragalus (Astragalus membranaceus), and Siberian ginseng (Eleutherococcus senticosus) may be helpful.

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Physical Medicine

Effective stress reduction techniques are helpful to reduce stress, which will lead to increased blood flow to the scalp.

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Massage

Therapeutic massage increases circulation and reduces stress by enhancing overall sense of well-being.

Scalp massage using essential oils of rosemary, lavender, sage, thyme, and cedarwood may be helpful in increasing circulation. Add 3 to 6 drops of essential oil to 1 tbsp. of jojoba and/or grapeseed oils. Massage into scalp daily. Essential oils may also alleviate cases of tinea capitis.

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Patient Monitoring

Patients on minoxidil should be cautioned to use as directed, to prevent possible side effects from systemic absorption (uncommon). More likely side effects include irritation of the scalp. A small percentage of men using finasteride may experience decreased libido, difficulty in achieving an erection, or a decrease in ejaculate volume. Tinea capitis may be transmitted among family members. Support groups may help patients deal with the emotional effects of alopecia.

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Other Considerations Complications/Sequelae

Twenty four percent of adults and 54% of children diagnosed with alopecia areata progress to alopecia totalis, the loss of all scalp hair. Alopecia universalis, the loss of all body hair, is rare.

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Prognosis

Minoxidil and finasteride result in reduced hair loss and/or new hair growth within a few months if they are going to be effective in the patient with androgenetic alopecia. In alopecia areata, the onset of the condition is generally sudden. The more extensive the hair loss, the less likely that recovery will be complete. However, in most cases, hair begins to regrow within a few months to a few years. With corticosteroid injections hair regrowth should occur in four to six weeks. New hair growth is fine and sometimes unpigmented, but normalizes over time.

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Pregnancy

Treatment should be delayed until after pregnancy.

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References

Guendert DV. Management of Alopecia. February 1, 1995. Department of Otolaryngology, UTMB. Accessed at Neuropathy Research at the Medical College of Georgia, www.npntserver.mcg.edu/html/alopecia/documents/BALDNESS_95.html on January 13, 1999.

Hay IC, Jamieson M, Ormerod AD. Randomized trial of aromatherapy: successful treatment for alopecia areata. Arch Dermatol. 1998;134:1349-1352.

Lebwohl M. New treatments for alopecia areata. Lancet. 1997;349:222-223.

Whiting DA. The Diagnosis of Alopecia. Dallas, Tex: University of Texas. Baylor Hair Research and Treatment Center. Accessed at Neuropathy Research at the Medical College of Georgia, www.npntserver.mcg.edu/html/alopecia/documents/DiagnosisAA.html on January 13, 1999.

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