Alopecia overview On the Web
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Editor-In-Chief: C. Michael Gibson, M.S., M.D.  Ogechukwu Hannah Nnabude, MD
Alopecia is defined as the loss of hair regardless of the cause. It can occur anywhere on the body. The hair cycle consists of three phases: the anagen phase, which is the growth phase, the catagen phase, which is the resting phase, and the telogen phase, which is the shedding phase. This is the phase where hair falls out. Ninety percent of hair is in the anagen phase and the remaining ten percent are in the catagen phase and telogen phases. In the telogen phase, hair is going to recycle, and it starts growing again in the anagen phase.
The use of the word alopecia stretches back to the era of the Greek physician Hippocrates. Minoxidil and finasteride are the only FDA approved medications for treating alopecia. Hair transplant surgery originated in the 1900s and some of the major advancements in hair transplantation took place in Japan in the 1930s.
Alopecia is classified as either scarring or non-scarring. Over all, non-scarring alopecias tend to have better outcomes than scarring alopecias, which tend to be irreversible. The most common type is androgenetic alopecia. The majority of men start to lose hair in the third decade of life, while women begin to lose their hair in the fifth or sixth decade of life. As an individual ages, they will lose hair. Men more often lose hair in the front and the temporal regions of the scalp, while women tend to lose hair from the central area of the scalp. Also, female hair loss rarely results in complete baldness while male hair loss can end up with complete baldness. Males tend to retain hair at the posterior area of the scalp because the hair in this region is more resistant to the effects of androgenic hormones.
There are several pathophysiologic mechanisms responsible for alopecia, each related to the specific cause. For example, alopecia areata, is related with CD8+ T-cell autoimmunity, while androgenetic alopecia is related to the effects of androgen hormones on hair follicles.
Scarring alopecia is caused by numerous dermatologic factors, including glabrous skin (non-hairy), and is very difficult to diagnose and manage. Non-scarring alopecia is characterized by the absence of visible inflammation of the skin involved. Medications, endocrine diseases, infectious diseases, and autoimmune diseases can also cause hair loss.
Differentiating Alopecia From Other Diseases
There is a very wide list of diseases and conditions that can lead to alopecia. Proper history taking and physical examination, along with laboratory, microbiology, and in some cases, imaging studies, are helpful in narrowing down the diagnosis.
Epidemiology and Demographics
The epidemiology and demographics of alopecia varies by age, race, sex, and health status. Androgenetic alopecia is the most common cause of alopecia. Traction alopecia is seen most often in black populations and is associated with tight hair braids. Tinea capitis commonly seen in the pediatric population. Trichotillomania is more common in males among younger patients and females among adults.
There are multiple risk factors for alopecia including family history, medications, sex, age and illness. Androgenetic alopecia is more common in males and prevalence increases with age. People with a family history of hair loss are at greater predisposition to developing alopecia. Psychosocial stress, hormonal imbalance, and illness also increase the risk of alopecia.
Natural History, Complications and Prognosis
The progression and severity of alopecia is based on the cause. Patients with alopecia are at increased risk of psychosocial complications such as anxiety and depression. In addition, these patients need to be evaluated for other medical conditions. Outcomes vary with the type of alopecia. Non-scarring alopecias such as androgenetic alopecia, anagen effluvium and early tinea capitis may be reversible while scarring alopecias such as traction alopecia and favus may not be reversible.
Biopsy, laboratory tests, trichoscopy, and hair pull test are some of the techniques used in diagnosis. MRI can be used in mycosis fungoides staging and is useful for alopecia mucinosa while microscopic testing and Wood's lamp is useful for the diagnosis of fungal infection.
Diagnostic Study of Choice
The diagnostic test of choice varies with the cause of alopecia. Biopsy, laboratory tests, trichoscopy, and hair pull test are some of the techniques used in diagnosis. MRI can be used in mycosis fungoides staging and is useful for alopecia mucinosa while microscopic testing and Wood's lamp is useful for the diagnosis of fungal infection
History and Symptoms
The quantity, pattern, timing, and onset of hair loss can be important clues in narrowing down a diagnosis. For example. androgenetic alopecia affects the frontal hair line and crown of the hair while alopecia areata affects a small, round area of the scalp.
The presence of scarring, scaling or erythema are all helpful clues in determining the cause of the hair loss.
Some causes of alopecia may present with abnormal laboratory findings such as abnormal TSH, ESR or RPR levels.
There are no ECG findings associated with alopecia.
There are no X-ray findings associated with alopecia.
Echocardiography and Ultrasound
There are no echocardiogram or ultrasound findings associated with alopecia.
There are no CT scan findings associated with alopecia.
MRI is used in staging of mycosis fungoides. This is useful in the case of alopecia mucinosa.
Other Imaging Findings
Among all the imaging modalities, MRI is the most useful in mycosis fungoides staging. This is can be used in the case of alopecia mucinosa
Other Diagnostic Studies
There are tests that can be conducted outside of the laboratory that will help to confirm the diagnosis. Examples include potassium hydroxide test and biopsy
Currently, there are only two FDA-approved medical treatments for androgenetic alopecia and these are finasteride and minoxidil. Topical corticosteroids, immunosuppressants like cyclosporine Psoralen and ultraviolet A can all be used in the treatment of alopecia areata, topical antifungals can be used in tinea capitis.
Surgery is another option for the treatment of alopecia, although it is often seen as the last resort. it involves hair transplantation of hair follicles from one site to another.
Proper diet, hygiene, and avoidance can decrease the risk of developing certain types of alopecia such as tinea capitis and traction alopecia.
Treatment of underlying conditions such as hyperthyroidism, switching from medications that may cause hair loss such as beta blockers and certain antidepressants and avoidance offending agents such as certain types of hairstyles such as tight braids may limit further hair loss and, in some cases, reverse the hair loss.