Hair Loss

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Chapter 26 Hair Loss

INTRODUCTION

Description: Patients often experience hair loss in the early stages of pregnancy, in the immediate postpartum period, or in the postmenopausal years. For some this may be of sufficient volume to cause concern or cosmetic problems.

Prevalence: Of postmenopausal women, 37% have some hair loss. Loss of hair 1 to 2 months after delivery (telogen effluvium) is common.

Predominant Age: Older than 50 years.

Genetics: Androgenic alopecia follows autosomal dominance with incomplete penetrance.

ETIOLOGY AND PATHOGENESIS

Causes: Accelerated hair loss may come about any time there is an abrupt change in hormonal patterns and is the result of a higher number of hair follicles entering into the resting, or telogen, phase of hair growth. Hair follicles have cycles of growth (anagen), followed by a resting phase (telogen) of 3 to 9 months, and then resumption of normal growth. Alterations in hormones may induce an increased number of follicles to enter telogen. If this is the situation, the lost hair will be regained in time. Stress and some medications (anticoagulants, retinoids, beta blockers, chemotherapeutic agents) may also cause similar hair loss. The relative androgen dominance found in postmenopausal women not receiving hormone replacement therapy might also cause male pattern hair loss (temporal balding, androgenic alopecia).

Risk Factors: Pregnancy, delivery, hormonal contraception, scalp disease, family history of baldness, nutritional deprivation, drug or toxin exposure.

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Pruritus, scaling, and broken hairs (tinea)

• Tapered, easily removed hair near the edge of patches (alopecia areata)

DIAGNOSTIC APPROACH

Workup and Evaluation

Laboratory: No evaluation indicated except as dictated by specific differential diagnoses being considered.

Imaging: No imaging indicated.

Special Tests: Inspection of hair shafts, skin scraping for fungi.

Diagnostic Procedures: History, physical examination, inspection of hair shafts.

Pathologic Findings

If the base of the hair shaft is smooth, it came from natural (telogen) loss; if the base has the follicular bulb still attached (a white swelling at the end), the loss may be due to dermatologic or other disease conditions, and consultation is suggested.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation, reassurance often is all that is required (telogen effluvium is self-limited).

Specific Measures: Based on cause, most are self-limited or reverse with correction of the underlying problem. For postmenopausal women, hormone replacement therapy often arrests or reverses hair loss.

Diet: No specific dietary changes indicated.

Activity: No restriction.

Patient Education: Reassurance and information about hair growth.

Drug(s) of Choice

For androgenic effluvium: topical minoxidil (Rogaine) 2% (approximately 40% response rate in 1 year).

For alopecia areata: high-potency topical steroids.

For tinea capitis: 6- to 8-week therapy with either griseofulvin (ultramicrosize) 250 to 375 mg PO daily or ketoconazole 200 mg PO daily and careful hand washing.

Contraindications: Griseofulvin is contraindicated in pregnant patients and in those with porphyria and hepatocellular failure. Ketoconazole and itraconazole should not be used concomitantly with cisapride (Propulsid).

Precautions: Topical minoxidil can cause eye irritation. Griseofulvin use is associated with the possibility of photosensitivity, lupus-like syndromes, oral thrush, and granulocytopenia. Ketoconazole and itraconazole may be associated with hepatotoxicity.

Interactions: Minoxidil may potentiate the actions of other antihypertensive agents. Griseofulvin can interact with both barbiturates and warfarin. Ketoconazole and itraconazole may interact with warfarin, histamine H₂ blockers, digoxin, isoniazid, rifampin, and phenytoin.

Alternative Drugs

Finasteride (Propecia) has been used for male pattern baldness in men, but it is ineffective for postmenopausal hair loss for women and is contraindicated during pregnancy.

FOLLOW-UP

Patient Monitoring: Normal health maintenance. With ketoconazole and itraconazole periodic assessment of liver function is prudent.

Prevention/Avoidance: None.

Possible Complications: Social withdrawal.

Expected Outcome: Most hair loss is not permanent; a gradual return may be expected in 3 to 6 months after any causes have been eliminated. Only cicatricial alopecia is associated with permanent damage to the hair follicles.

MISCELLANEOUS

Pregnancy Considerations: No effect on pregnancy, although delivery is often the trigger for increased hair loss.

ICD-9-CM Codes: 704.02 (Telogen effluvium), 704.00 (Alopecia, unspecified), 704.01 (Alopecia areata), 704.09 (Other alopecias).

Burke KE. Hair loss. What causes it and what can be done about it. Postgrad Med. 1989;85:52.

Elewski BE. Clinical diagnosis of common scalp disorders. J Investig Dermatol Symp Proc. 2005;10:190.

Hordinsky MK. Medical treatment of noncicatricial alopecia. Semin Cutan Med Surg. 2006;25:51.

Hunt N, McHale S. The psychological impact of alopecia. BMJ. 2005;331(7522):951.

Powell J, Stone N, Dawber RPR. An Atlas of Hair and Scalp Diseases (The Encyclopedia of Visual Medicine Series). Boston: Blackwell Scientific Publications, 2001.

Roberts WE. Dermatologic problems of older women. Dermatol Clin. 2006;24:271. viii.

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