Alopecia (Alopecias)

Alopecia is characterized by loss of hair from the scalp and body. Such a type of condition is also commonly referred to as hair loss.

Presentation

Alopecia is characterized by excessive hair loss of more than 100 per day. Affected individuals may complain of pruritus, and burning sensation in that area. The pattern of hair loss is mostly to the sides, and lower back region of the scalp. Alopecia totalis occurs with complete loss of hair on the scalp. Alopecia universalis is defined as total hair loss on all the hair bearing areas of the body. The occurrence of alopecia can be focal or diffuse in pattern. 

Yellow spots are the clinical signs of alopecia, which are reported in few cases. Other clinical presentations are broken hair, clustered short and tapering hair. In long standing cases of alopecia the phase of telogen hair reaches to 100% [5]. Individuals with alopecia also undergo psychological distress, due to excessive loss of hair that affects their cosmetic appearance.

Workup

The following methods are employed for diagnosing alopecia.

  • Pull test: In this test, by applying gentle extraction hair is pulled from 3 different areas of the scalp, are counted, and examined under microscope. Such a kind of test is helpful for determination of diffuse scalp hair loss.
  • Pluck test: A test of this kind is used for analyzing abnormalities in the 3 phases of hair growth cycle.
  • Biopsy: Scalp biopsy is indicated, when diagnosis is unclear and cause is unknown.
  • Hair counts: This is employed when the pull test gave negative results.
  • Trichoscopy is used for differential diagnosis of alopecia.
  • The condition of female pattern baldness can be detected using two methods namely Savin scale and Ludwig scale.

Treatment

Alopecia is a benign condition. Treatment has a little or no role in preventing this condition to recur. Remissions and reoccurrences are seen in most of the cases. Methods employed for treating alopecia help in arresting further hair loss, and has little effects in hair regrowth [7] [8].

  • Minoxidil: Minoxidil 1% cream, a vasodilator shows some improvement in alopecia, but recurrence rate is higher. The medication is available in liquid or foam forms, and needs to be applied at least twice a day on scalp. 
  • Corticosteroid: Corticosteroid therapy may be effective in some cases which includes Betamethasone Dipropionate cream 0.05%. Corticosteroid injections can improve the condition. These are injected every 4 to 6 weeks before growth is noted.
  • Immunosupressants: Immunosuppresants are proven to be effective in few cases of alopecia. However these are known to present with side effects and therefore their efficacy is questionable.
  • Hair transplant: Hair transplantation surgery is also carried out for correcting alopecia. Several transplants may be necessary.

Prognosis

Alopecia can predispose an individual to develop psychological problems. The prognosis of the condition is poor; however hair loss is arrested, with medications and topical ointments to manage symptoms [6]. But, new hair growth occurs at a slower pace.

Etiology

The exact cause of alopecia is unknown. However, several factors such as febrile illnesses, pregnancy, trauma, drugs, chemotherapy and autoimmune conditions, can trigger an episode of hair loss. Individuals with family history of alopecia are at increased risk of developing the same.

Alopecia can also be associated with certain conditions like Down syndrome, Collagen vascular diseases, vitiligo, atopic dermatitis and thyroid disease. In few patients, a gene DQ3 is found that could be responsible for the predisposition of this condition. In some studies, Interleukinin 1 and tumor necrosis factor were found to play an important role in inhibiting hair growth [2].

Epidemiology

Males and females are equally affected. Alopecia can occur at any age, but its peak incidence is seen from 15 to 29 years of age. Several other abnormalities like koilonychia, onycomedesis and Beau lines are common abnormalities of nails, seen in individuals with alopecia. Frequency of involvement from high to low is as follows, scalp, beard, eyebrows, and extremities [3].

Sex distribution
Age distribution

Pathophysiology

The hair growth cycle follows 3 distinct phases, anagen, catagen and telogen phase. The anagen is the growing phase, followed by short transitional phase, and then resting phase which is known as telogen. After the telogen phase, hair fall occurs, and new hair begins to grow in the follicles again. Under normal circumstances, about 40 to 100 hair fall each day, which is natural. However, when the number exceeds more than 100, then it is termed as clinical hair loss – tellogen effluvium [4].

Prevention

Alopecia cannot be prevented. However, the underlying disease conditions should be promptly treated to stop aggravating the condition [9].

Summary

Alopecia is hair loss, which can exhibit many patterns in appearance. It is a medically benign condition, but can also cause psychological distress to the subject, and his family. The onset of alopecia is mostly in the early years of life. Patients may find themselves depressed and stressed due to this condition [1].

Patient Information

  • Definition: Alopecia is defined as hair loss. The pattern of hair loss can be localized or diffuse. Hair is lost in tufts and patches. Thinning of hair, broken hair and yellow spots are common findings. Alopecia is not only confined to the scalp, but it can also occur in any hair bearing area of the body.
  • Cause: Some causes include drugs, chemotherapy, pregnancy and trauma. A positive family history is one of the main underlying causes of alopecia.
  • Symptoms: Yellow spots on the scalp and itching on the affected area may occur. Loss of hair in patches is the common symptom. Hair loss mainly occurs on the side or in the centre of the scalp. Individuals with alopecia often undergo psychological distress, due to baldness.
  • Diagnosis: Diagnosis is mostly made on the basis of clinical symptoms. A positive family history points out towards a positive diagnosis. Pull test, pluck test, daily hair counts and trichoscopy are employed, for diagnosis of the condition. Scalp biopsy is required in very few cases.
  • Treatment: There is no specific treatment guideline in alopecia. Immunosuppressants, corticosteroids and vasodilators play an important role in the treatment. No treatment is found to be completely effective in alopecia. Recurrence rates are very high. Significant remissions occur in many cases [10].

Self-assessment

References

  1. van der Steen P, Traupe H, Happle R, Boezeman J, Sträter R, Hamm H. The genetic risk for alopecia areata in first degree relatives of severely affected patients. An estimate. Acta Derm Venereol. Sep 1992;72(5):373-5
  2. Colombe BW, Lou CD, Price VH. The genetic basis of alopecia areata: HLA associations with patchy alopecia areata versus alopecia totalis and alopecia universalis. J Investig Dermatol Symp Proc. Dec 1999;4(3):216-9.
  3. Price VH, Colombe BW. Heritable factors distinguish two types of alopecia areata. Dermatol Clin. Oct 1996;14(4):679-89. 
  4. Werth VP, White WL, Sanchez MR, Franks AG. Incidence of alopecia areata in lupus erythematosus. Arch Dermatol. Mar 1992;128(3):368-71.
  5. Karadag Köse O, Güleç AT. Clinical evaluation of alopecias using a handheld dermatoscope. J Am Acad Dermatol. Aug 2012;67(2):206-14. 
  6. Tosti A, Piraccini BM, Pazzaglia M, Vincenzi C. Clobetasol propionate 0.05% under occlusion in the treatment of alopecia totalis/universalis. J Am Acad Dermatol. Jul 2003;49(1):96-8.
  7. Taylor CR, Hawk JL. PUVA treatment of alopecia areata partialis, totalis and universalis: audit of 10 years' experience at St John's Institute of Dermatology. Br J Dermatol. Dec 1995;133(6):914-8.
  8. Ross EK, Bolduc C, Lui H, Shapiro J. Lack of efficacy of topical latanoprost in the treatment of eyebrow alopecia areata. J Am Acad Dermatol. Dec 2005;53(6):1095-6.
  9. Willemsen R, Haentjens P, Roseeuw D, Vanderlinden J. Hypnosis in refractory alopecia areata significantly improves depression, anxiety, and life quality but not hair regrowth. J Am Acad Dermatol. Mar 2010;62(3):517-8.
  10. Joly P. The use of methotrexate alone or in combination with low doses of oral corticosteroids in the treatment of alopecia totalis or universalis. J Am Acad Dermatol. Oct 2006;55(4):632-6.

  • Alopecia areata treated with topical minoxidil. - VC Weiss, DP West, TS Fu, LA Robinson - Archives of , 1984 - ncbi.nlm.nih.gov
  • A previously undescribed hereditary hair anomaly (pseudo‐monilethrix) - B BENTLEY‐PHILLIPS - British Journal of , 1973 - Wiley Online Library
  • Alopecia areata is a T-lymphocyte mediated autoimmune disease: lesional human T-lymphocytes transfer alopecia areata to human skin grafts on SCID mice - A Gilhar, R Shalaginov, B Assy - Journal of Investigative , 1999 - nature.com


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