Hair today

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Hair Today Gone TomorrowManagement of Alopecia

• Dr Phillip Artemi
• Dermatologist, Sydney Australia

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Management of alopecia

• Alopecia introduction
• Hair - facts and physiology
• Classification of alopecia
• Type 5 causes of alopecia

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Alopecia why bother?

• 90 will experience some form of alopecia by age
  70
• Hairstyle is a non verbal expression of our
  personality
• Hair conforms to the norms of physical appearance
  in society
• Hair perceived as a marker of youthfulness
• Alopecia a/w career and/or relationship problems
  in 40-60
• Patients vulnerable to exploitation e.g. internet
  sites, hair clinics
• Slow relentless loss of hair ? depression,
  anxiety, social phobia

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Alopecia why bother?

• when I look in the mirror the person I see
  looking back at me is not me. It is someone else.
  I am now a different person and I behave
  differently with people. Inside I still remember
  who I was but in everything I do I think I am
  someone else
• Ms JM, 27 years, extensive alopecia areata scalp

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Alopecia why bother?

• I remember my long black hair. People used to
  comment on how thick it was. I now it sounds
  crazy but I mourn the loss of my hair like a
  friend who has passed away. I think of going on a
  cruise ship and jumping off in the middle of the
  night. I dont want my body found. I dont want
  people looking in my coffin and seeing my balding
  head
• Mrs GS, age 57 years, female pattern hair loss

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Hair facts

• Hair growth and loss is random (not cyclic or
  seasonal)
• 100,000 hairs on the scalp
• 5,000,000 hairs on the body
• Scalp hair grows 0.3-0.4 mm per day (1cm every 28
  days)
• 100-150 scalp hairs lost per day as normal
  process

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Hair growth cycle

• Anagen phase
• Catagen phase
• Telogen phase

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Hair growth cycle anagen (scalp)

• 85-95 of hairs
• Growth phase
• Duration 2-6 years (scalp)
• cf 30-45 days (eyelashes, eyebrows, limbs)

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Hair growth cycle catagen

• 2-3 of hairs
• Hair death
• Lasts 2-3 weeks

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Hair growth cycle telogen

• 5-10 of hairs
• Resting or dormant phase
• Lasts 2-3 months

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Alopecia classification

• Scarring alopecia (cicatricial)
• Non-scarring

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Scarring (cicatricial) alopecia

• 5 of alopecia cases
• Permanent and irreversible destruction of hair
  follicles
• Hair follicles replaced with scar tissue
• Non-inflamed versus inflamed presentation
• Invariably biopsy required to accurately diagnose
• Rapid course ? burns out after many years
• Aggressive treatment required

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Scarring (cicatricial) alopecia

• Localised

• Diffuse

• Congenital atrichia
• Trauma
• Burns
• Traction

• Discoid lupus
• Lichen planopilaris
• Pseudopalade
• Alopecia mucinosis
• Frontal fibrosing alopecia
• Erosive pustular dermatosis

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Non-scarring alopecia

• 95 of alopecia cases
• Hair shaft falls out but the hair follicles still
  alive
• Non-inflamed gt inflamed presentation
• Diffuse gt localised types
• Biopsy seldom required
• Unpredictable course
• Treatment usually desired

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Non-scarring alopecia

• Diffuse

• Localised

• Alopecia areata
• Tinea capitus
• Trichotillomania

• Androgenetic alopecia
• Male (MAGA)
• Female pattern hair loss
• Telogen effluvium
• Medication
• Systemic
• Hair shaft disorders

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Male androgenetic alopecia (MAGA)

• Commonest type of hair loss
• Affects up to 50 of all men by the age of 50
• Can commence at any age
• Genetically determined shortening of the anagen
  phase
• Rate of progression and end point varies
• Norwood Hamilton male baldness classification
  system

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Male aga normal physiology

• Androgen sensitive vs androgen independent scalp
  hair follicles
• Androgen sensitive ? front and top of scalp
• Androgen independent ? sides and back of scalp
• Testosterone 5-a reductase ? dihydrotestosterone
  (DHT)
• DHT ? androgen receptors (dermal papillae) ?
  stimulate hair growth

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Male aga what goes wrong?

• Genetic predisposition
• No androgens ? no AGA possible
• Testosterone 5-a reductase ? dihydrotestosterone
  (DHT)
• DHT ? androgen receptors (dermal papillae) ?
  shortening the anagen phase ? miniturisation of
  the follicle ? hair becomes thinner and thinner ?
  eventually falls out

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Male aga treatment

• General (explanation, dispel myths)
• Specific
• Nil
• Minoxidil
• Finasteride
• Hair transplantation
• Camouflage
• Follow up (12 months)

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Male Aga minoxidil

• 2,6 diamino-4-piperidinopyrimidine
• 5 vs 2 minoxidil twice daily application
• 45 more regrowth after 48-52 weeks with 5 (men)
• Half life of 5 concentration 3-4 hours
• Cleared after 12-20 hours
• Discontinuation of drug ? loss of recruited hairs

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mAGA minoxidil mechanism of action

• Vasodilatory properties
• Angiogenic properties
• Enhance cell proliferation and DNA synthesis
• Anti-androgen effects
• Immunosuppressive effects

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Agam minoxidil benefits

• Reverses miniturisation of the hair follicle
• Increases the number of follicles in the anagen
  phase
• Increases diameter of hair shafts

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Maga minoxidil lotion

• Contains propylene glycol
• Greater incidence of pruritus, ACD
• Accurate dosage of 1 ml bd
• Some c/o difficulty maneuvering dropper within
  scalp
• Greased up texture, hair thinner and matted for
  hours
• Mens forums suggest liquid more effective

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Maga minoxidil foam

• No propylene glycol
• Lower incidence pruritus, ACD
• Dosage imprecise half a capful bd
• Easier to apply via hands but
• Foam at room temperature ? liquifies quickly ?
  lost in hair
• No residue left on hair ? Hair feels thicker
• Mens forums suggest liquid is more potent

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Minoxidil report card?

• Essential to start as soon as possible
• 5 liquid once daily if tolerated
• Minimum treatment period of 12 months
• Regrowth occurs in 10-20 but seldom significant
• 60-70 notice reduction in hair fall
• complete arrest in 30

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mAGa topical minoxidil side effects

• Hypertrichosis
• 5 (10 females), face gt limbs, resolves 1-3
  months after treatment withdrawal
• Pruritus gt ICD gt ACD (propylene glycol gt
  minoxidil)
• Worsening of existing dermatitis (seborrhoeic,
  psoriasis)
• Palpitations, hypotension, chest pain
• Sudden unexplained weight gain
• Swollen hands

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mAga finasteride pharmacology

• Finasteride inhibits type II 5-a reductase
• ? serum and scalp levels DHT - ? scalp levels
  testosterone
• 5-a reductase type I and type II both convert
  testosterone ? dihydrotestosterone
• Type I predominates in the skin (including the
  scalp)
• Type II present in hair follicles and the
  prostate

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mAga finasteride pharmacology

• Optimal dose of finasteride for regrowth in male
  AGA is 1mg/day
• Vertex, anterior and mid scalp (9/10 hair loss
  ceased and/or regrowth)
• Hair growth peaks at 1-2 years
• Metabolised extensively in the liver
• No drug interactions recognised

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mAga Finasteride side effects

• Sexual side effects (2)
• Gynecomastia
• 50 reduction in prostate specific antigen levels
• Exfoliative dermatitis
• Lymphadenopathy
• No effect on sperm count or morphology
• Miscellaneous (sinusitis, bronchitis, depression)
• Pregnancy category X

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Female pattern hair loss

• Common cause of alopecia in women
• Prevalence of 30 in women over 20 years of age
• 40 of women by age 50
• Strong genetic predisposition
• More common after menopause
• Presents with diffuse thinning over mid-frontal
  scalp
• No bitemporal recession vertex baldness very
  rare
• Stages of FPHL described by Ludwig (grades I,II
  and III)

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Fphl pathogenesis

• Shortening of anagen phase elongation of the
  telogen phase
• Ratio anagen to telogen ? from 121 to lt 81
• Each successive hair cycle ? length of anagen is
  progressively reduced
• Endpoint is decrease in fibre length and also
  fibre diameter
• Long terminal hairs are replaced by short fine
  vellus hairs

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Fphl pathogenesis

• Role of androgens not clearly established
• Decreased oestrogens after menopause may be
  implicated
• Relative hyperandrogenism or hypersensitivity to
  physiological concentrations of androgens

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FPhl clinical features

• More common after menopause
• Less severe hair loss than male AGA
• May be a/w loss hair volume (thinning)
• Hair loss not constant
• Bursts of hair loss (3-6 months), followed by
  slow down (6-18 months) ? increasing severity
  over decades
• Severe psychological distress

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Fphl treatment

• General (explanation, no cure, natural
  progression, manage expectations, exclude iron
  defiiciency, thyroid disorders, medication cause)
• Specific (minoxidil solution, hormonal treatment,
  hair transplant surgery, camouflage)
• Follow up (minimum 12 months)

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Fphl minoxidil solution

• Randomised placebo controlled trial comparing
  topical 2 and 5 solution with placebo
• 2 and 5 concentration increased hair growth cf
  placebo
• No statistically significant difference in hair
  growth b/w 2 and 5 concentration
• Increased occurrence of pruritus, irritation and
  hypertrichosis in 5 strength cf 2

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Fphl minoxidil report card

• Essential to start as soon as possible
• 5 liquid once daily if tolerated
• Minimum treatment period of 12 months
• Regrowth occurs in 10-20 but seldom significant
• 60-70 notice reduction in hair fall
• complete arrest in 30

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Fphl antiandrogens

• Best in women with FPHL and signs of androgen
  excess
• Spirinolactone and cyproterone acetate
• Pregnancy precautions
• Concurrent oral contraceptive
• Contraception
• Increase therapeutic effect
• Minimise menstrual irregularities due to
  antiandrogens

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Fphl spironolactone

• Aldosterone antagonist ? competitively blocks
  androgen receptors ? Inhibits androgen synthesis
• Useful in hirsutism, acne, FPHL
• 200mg daily effective in preventing further hair
  loss (gtgt inducing hair growth in FPHL)
• 6-12 months to elicit response
• Combine with minoxidil ? increase potential for
  hair growth
• Pregnancy category B3

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Fphl spironolactone side effects

• Naussea, diarrhoea
• Headache, dizzyness, drowsiness, lethargy
  (hyperkalaemia)
• Menstrual cycle irregularities
• Thrombocytopenia, agranulocytosis
• Breast pain
• Alopecia !!!!

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Fphl cyproterone acetate

• Blocks androgen receptors and inhibits GnRH
• 100mg daily for 10 days per month in
  premenopausal women
• Combined with CPA/ethinyloestradiol or other OCP
• 50mg daily in postmenopausal women
• Can also be combined with minoxidil
• Side effects weight increase, fatigue,
  depression, abnormal liver function tests, GIT
  upset, increased thrombosis, striae

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Fphl finasteride

• Specific inhibitor of type 2, 5-a reductase
  (testosterone ? DHT)
• Contraindicated in pregnancy (category X) ?
  feminise the male foetus
• 1-year double blind, placebo-controlled,
  randomised study
• 1mg finasteride daily, 137 women
• Disease progression unchanged
• No hair growth

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Fphl other treatments

• Hair transplantation
• Cosmetic products
• Tinted hair spray and lotions
• Hair extension
• Wigs

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Alopecia Telogen effluvium

• Up to 70 of anagen hair follicles precipitated
  into telogen phase simulataneously
• 2-3 months after trigger new hairs form? push
  out dead hairs
• May result in loss of 30-70 scalp hairs in a
  short period
• Paradox hair fall indicates hair regrowth
• Nail change (Beaus line) may be a clue to time
  of trigger

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Alopecia telogen effluvium triggers

• Illness, particularly fever
• Blood loss (donating blood, trauma)
• Trauma (surgery, MVA, jetlag, psychological)
• Child birth
• Weight loss (extreme diet, anorexia)
• Medication
• Deficiency (iron, thyroid)

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Telogen effluvium treatment

• General
• Explain condition
• Explain hair loss peaks at 3-4 months ? resolves
  9-12 months
• Correct triggers, rest, ideal diet
• Avoid over vigorous hair styling, excessive
  traction
• Specific (not required)
• Follow up (6 months)

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Telogen effluvium Chronic

• Telogen effluvium rarely becomes chronic
• Hair shedding continues intermittently or
  continuously for years
• Hair cycle appears to reset resulting in a
  shortened anagen phase
• Iron levels, thyroid function, vitamin B12,
  folate need checking
• Add Minoxidil lotion as treatment
• Prognosis still good

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Alopecia drug induced

• Reversible, diffuse, non-scarring
• Occurs days/weeks to months after starting new
  drug or changing the dose
• Tendency depends on both the drug and the patient
• Two types of drug induced hair loss
• Anagen effluvium loss of actively growing hairs
• Telogen effluvium increased telogen hairs ?
  later lost

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DRUG INDUCED ALOPECIA CLINICAL

• Drug induced anagen effluvium
• Often whole body hair
• Within days to weeks of starting chemotherapy
• Clears 6-18 months after trigger withdrawn
• Drug induced telogen effluvium
• Scalp most commonly affected
• Within 2-4 months of triggering agent
• Clears 6-12 months after trigger withdrawn

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drug induced anagen effluvium

• Chemotherapy drugs
• Gold
• Colchicine
• Toxins (arsenic, boric acid, bismuth, thallium)

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drug induced telogen effluvium

• Anticoagulants heparin, coumadin
• Antihypertensives ACE inhibitors, beta-blockers
• Antithyroid propylthiouracil
• Anticonvulscents benzodiazepines, carbamazapine,
  valproic acid, gabapentin, lamotrigine
• Hormones OCP (during/after/changing), androgens,
  HRT
• Other lithium, isotretinoin, cimetidine, lipid
  lowering, NSAID, bromocryptine, levodopa, TCA

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Drug induced hair loss treatment

• Follow the normal approach
• Hand holding
• Good prognosis with time

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Alopecia areata epidemiology

• Affects 0.1-0.2 of the population
• All age groups (peak incidence b/w 2nd-4th
  decades)
• All races, males females
• 60 present with first episode before age of 20
  years
• Affects the scalp in 90 cases

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Alopecia areata clinical classification

• Classic alopecia areata (gt 90 cases)
• Ophiasis pattern (1 cases) temporal-parietal
  loss
• Alopecia totalis (5 of cases) all scalp hair is
  lost
• Alopecia universalis (lt 1 cases) entire body
  hair is lost

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Alopecia areata classic type

• Asymptomatic
• Well defined round-oval patches
• Completely bald
• Smooth surface (consistent with non-scarring
  nature)
• Patches are usually skin coloured

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Alopecia areata pathogenesis

• Lymphocyte cell-mediated inflammatory form of
  hair loss
• Underlying autoimmune pathogenesis
• Inappropriate presentation of antigens to the
  immune system during normal hair follicle cycling
• Genetic susceptibility to the development of AA
• Susceptibility to development of AA may be
  modified by environmental factors including viral
  infection, stress and diet

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Alopecia areata prognosis

• Unpredictable
• Classic type
• 50 recover within 12 months WITHOUT treatment
• 10-20 recurrence rate
• Treatment does not change prognosis

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Alopecia areata poor prognosis

• Extent of AA involvement (extensive AA, AT and
  AU)
• Long duration
• Atopy
• Onset lt 10 years
• Positive FHx
• Nail involvement

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Alopecia areata nail changes

• Found in 10-50 patients
• Poor prognostic indicator
• Pitting
• Ridging

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Alopecia areata treatment

• General
• Specific
• Follow up

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Alopecia areata general treatment

• Explanation of AA
• Prognosis
• High spontaneous remission
• Poor prognostic indicators
• No treatment is curative or preventative
• Aim of therapy is to stimulate regrowth
• Psychological support

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Alopecia areata specific treatment

• Intralesional corticosteroids
• Topical therapy
• Corticosteroids
• Minoxidil
• Anthralin
• Topical immunotherapy
• Phototherapy and systemic (corticosteroids,
  cyclosporin, methotrexate, biologics,
  sulfasalazine)

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Alopecia areata intralesional c/s

• Treatment of choice for adults
• Triamcinolone acetonide 5mg/ml (scalp) and
  2.5mg/ml (face) every 4-6 weeks
• 0.1 ml injections at 1 cm intervals
• Withdraw if no response after 6 months
• Side effects transient atrophy and
  telangiectasia

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AA topical corticosteroids

• Treatment of choice in children
• Midpotent superpotent
• Ointment formulation
• Under occlusion
• Commonest side effect folliculitis gtgt skin
  atrophy and telangiectasia
• Pulsed therapy best

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Alopecia areata minoxidil 5

• Proven effectiveness in early localised alopecia
  areata (80)
• False positive (? Placebo)
• Ineffective in AT and AU
• Minimum 6 months treatment duration
• Best combined with intralesional or topical
  steroids
• MOA ? immunosuppressive (? reduced T-cell
  infiltration)
• Side effects you should know by now

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Alopecia areata dithranol

• Dithranol 0.5-1.0 short contact therapy
• Initially 20-30 minutes daily increase 10 minutes
  every 2 weeks up to 1 hour or until mild
  dermatitis develops
• Mild irritation should develop in order to be
  effective
• Dithranol should not be combined with
  corticosteroids
• Cease treatment if no improvement after 3 months
• Adverse effects contact dermatitis,
  folliculitis, regional lymphadenopathy, staining
  of skin, clothes and fair hair

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AA topical immunotherapy

• Diphencyprone is the treatment of choice for
  adults with gt 50 scalp involvement
• Sensitisation with 2 DCP followed by initial
  weekly application of 0.001
• Increase concentration gradually
• Aim to induce low grade erythema and pruritus
• Wash off scalp after 48 hours

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AA topical immunotherapy

• Mode of action unclear ? antigen competition ?
  perifollicular lymphocyte apoptosis ? change in
  CD4/CD8 ration (41 untreated cf 11 treated)
• Treatment should be stopped if there is no
  improvement after 6 months
• Side effects eczema, facial and scalp oedema,
  contact urticaria, erythema multiforme,
  pigmentation alterations

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ALOPECIA AREATA TREATMENT FOLLOW-UP

• Treatment response may take 4-6 months
• Extension of disease development of poor
  prognostic indicators
• Monitor for side effects
• Psychological support

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Alopecia tinea capitus

• Infection of the scalp by Trichophyton and
  Microsporum fungi
• Children (boys gt girls, peak 3-7 years)
• Resultant hair loss can be non-scarring or
  scarring
• Associated features differentiate from alopecia
  areata and trchotillomania
• Dry scaling, black dots, moth eaten or well
  defined hair loss, kerion
• Requires skin scrapings and hair samples for
  diagnosis and culture
• Treatment of choice Griseofulvin (usually for 3-
  6 months)

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MANAGEMENT OF ALOPECIA

• Non-scarring alopecia (95) cf scarring (5)
• Magnification required to differentiate between
  non scarring and scarring types
• Scarring alopecia ? refer always
• Non-scarring diffuse alopecia without sinister
  symptoms or signs ? pharmacist first line
• Honest about prognosis
• Dispel myths and refute hair gurus

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