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Common Ambulatory Topics

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Men only (women of childbearing potential should not even touch the pills) ... Most common cause of diffuse hair loss ... time course?) pull test' = grasp 2-3 ... – PowerPoint PPT presentation

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Title: Common Ambulatory Topics


1
Hair Loss
  • Common Ambulatory Topics
  • October 28, 2008
  • Jason L. Morris, MD

2
Alopecia
  • Common disorder
  • Affects both men and women
  • Affects social and psychological well-being

3
Alopecia
  • Systematic approach to diagnosis
  • Understanding of hair growth cycle
  • Careful history
  • Examination of hair loss
  • Few quick studies
  • Treatment

4
Hair Growth Cycle
  • Growth phase (Anagen) lasts 2-3 years
  • 80-90 of hair follicles
  • Involutional phase (Catagen) lasts 2-3 weeks
  • 1-3 of hair follicles
  • Resting phase (Telogen) lasts 3-4 months
  • 5-10 of hair follicles
  • Hair released at end of telogen w/mature root
    sheath (club) at the proximal end.

5
Hair Growth Cycle
  • FUN FACTS
  • ALL terminal hair follicles are present at birth
  • Scalp hair grows 0.35mm daily (6 inches/yr)
  • Everyday 75 hairs (telogen) are shed
  • Everyday 75 hair follicles enter anagen

6
Hair Growth Cycle
  • Amount of hair normally lost in one year

7
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8
Androgenetic Alopecia
  • Most common type of hair loss
  • Affects 30-40 of adult men women
  • men women
  • camouflaged better in women
  • Genetically determined shortening of anagen
    w/subsequent shorter, thinner hair shaft
  • Follicular miniaturization

9
Androgenetic Alopecia
  • Men
  • Classic male pattern baldness
  • Hair loss in M-pattern and at vertex
  • Women
  • Hair loss typically more diffuse w/maintenance of
    frontal hair line

10
Androgenetic Alopecia - Male
11
Androgenetic Alopecia - Male
12
Androgenetic Alopecia
  • Men
  • Hair loss in M-pattern and at crown
  • Women
  • Hair loss typically more diffuse w/maintenance of
    frontal hair line
  • If signs of androgen excess, measure
    testosterone, DHEAS, prolactin

13
Androgenetic Alopecia - Female
14
Androgenetic Alopecia - Treatment
  • Minoxidil (Rogaine)
  • 5 Topical solution (more effective than 2) BID
  • Can be used in men women
  • OTC, not covered by insurance
  • Used indefinitely - if stopped, any regrowth will
    be lost
  • Apply to scalp, not hair
  • Results in 4 months
  • Better results if start treatment early, crown
    location, lt10cm
  • Spironolactone may be added to minoxidil in
    women

15
Androgenetic Alopecia - Treatment
  • Finastaride (Propecia)
  • 1 mg PO daily
  • Men only (women of childbearing potential should
    not even touch the pills)
  • More effective than Minoxidil 2, but no direct
    comparisons with Minoxidil 5
  • Hair transplantation

16
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17
Alopecia Areata
  • Chronic inflammatory disorder affecting hair
    sometimes nails
  • 1 in 1000 people
  • men women
  • Any age, but usually lt 30
  • 20 have family history
  • Probable autoimmune etiology

18
Alopecia Areata
  • Smooth, circular, discrete areas of complete hair
    loss
  • May enlarge and coelesce into bizarre patterns
  • Exclamation point hairs short hairs broken
    off a few mm from the scalp at periphery of
    lesions

19
Alopecia Areata
20
Alopecia Areata
21
Alopecia Areata Treatment
  • 80 can expect spontaneous regrowth
  • Intralesional corticosteroids (triamcinolone)
  • If lt50 scalp involvement
  • Results in 4 weeks
  • Topical corticosteroids (betamethasone
    dipropionate)
  • Anthralin
  • Others (PUVA, Immunotherapy, Minoxidil)

22
Alopecia Areata Treatment
  • In the meantime
  • Women wig or hairpiece
  • Men shave the entire scalp!

23
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24
Telogen Effluvium
  • Most common cause of diffuse hair loss
  • Stressful event causes increased number of hair
    follicles to enter into telogen phase ? diffuse
    hair loss 3-4 months after stressor
  • Pregnancy
  • Severe weight loss (including with dieting)
  • Major illnesses and surgery
  • Traumatic psychological events.

25
Telogen Effluvium
  • 20 of hair must be lost before it becomes
    cosmetically apparent
  • Diagnosis
  • take a good history (inciting event? time
    course?)
  • pull test grasp 2-3 dozen hairs and gently
    tug. Abnormal if gt5 telogen (club) hairs
  • review medications
  • check TSH, iron

26
Medications ? Telogen Hair Loss
  • Acitretin
  • Heavy metals
  • Amantadine
  • Hormones
  • Amiodarone
  • Isotretinoin
  • Anticoagulants
  • Ketoconazole
  • Anticonvulsants
  • Lithium
  • Captopril
  • Penicillamine
  • Cholesterol lowering drugs
  • Propanolol
  • Cimetidine
  • Valproic acid
  • Colchicine 

27
Telogen Effluvium
3 months post-partum
28
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29
Traumatic Alopecia
  • Trichotillomania
  • Nervous, self-induced hair pulling
  • Asymmetric, bizarre, irregular pattern of hair
    loss
  • Traction alopecia
  • Hairstyles requiring chronic tension on the hair
  • Chemical alopecia
  • Hair straighteners (lye-containing), hot-oils

30
Trichotillomania
Mother daughter. www.dermatology.org
Primary Psychiatry 2006
31
Traumatic Alopecia
  • Trichotillomania
  • Nervous, self-induced hair pulling
  • Asymmetric, bizarre, irregular pattern of hair
    loss
  • Traction alopecia
  • Hairstyles requiring chronic tension on the hair
  • Chemical alopecia
  • Hair straighteners (lye-containing), hot-oils

32
Traction Alopecia
UpToDate
33
Traumatic Alopecia
  • Trichotillomania
  • Nervous, self-induced hair pulling
  • Asymmetric, bizarre, irregular pattern of hair
    loss
  • Traction alopecia
  • Hairstyles requiring chronic tension on the hair
  • Chemical alopecia
  • Hair straighteners (lye-containing), hot-oils

34
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35
Tinea Capitus
  • Fungal infection (Trichophyton gt Microsporum)
  • Typically found in children
  • Erythematous, scaling lesion(s) of scalp
  • Increased fragility of hair with frequent
    breakage
  • Circular areas of alopecia

36
Tinea Capitus
UpToDate. Black dot tinea capitas
37
Tinea Capitus
  • Diagnosis
  • Can confirm with KOH
  • Trychophyton (most common form in U.S.) does not
    fluoresce under Woods lamp

38
Tinea Capitus
UpToDate
39
Tinea Capitus
  • Diagnosis
  • Can confirm with KOH
  • Trychophyton (most common form in U.S.) does not
    fluoresce under Woods lamp
  • Treatment
  • Griseofulvin 250mg PO BID x 6-12 weeks

40
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41
Alopecia Differential Diagnosis
www.dermatology.org
42
References
  • Springer, K, Brown, M, Stulberg,DL. Common Hair
    Loss Disorders. Am Fam Physician 2003 6893.
  • Ross, E, Shapiro, J. Management of Hair Loss.
    Derm Clinics 2005 23 227-243.
  • Madani, S, Shapiro, J. Alopecia areata update.
    J Am Acad Dermatol 2000 42 259.
  • Olsen, E, et al. Evaluation and treatment of
    male and female pattern hair loss. J Am Acad
    Dermatol 2005 52 301.
  • UpToDate

43
Alopecia Differential Diagosis
www.dermatology.org
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