The pathogenesis of the alopecias involves a range of genetic, endocrine, immune, and inflammatory processes, each of which calls for its own form of treatment. Hair is of both physiological and psychological importance. It is thus hardly surprising that people with excessive hair loss often seek medical help. Hair is composed of keratin and is produced in the hair follicles. All hair follicles go through repeated cycles of growth and rest 2.
During the growth anagen phase, which is 2—6 years long, a hair grows at a rate of about 0. The maximum attainable hair length depends on the duration of the anagen phase. A brief transitional catagen phase follows, and then a rest telogen phase lasting 2—4 months, after which the hair falls out 2. Normally, the ca.
Intrinsic or extrinsic factors can synchronize the hair follicles by inducing a premature transition from the anagen to the telogen phase, leading to noticeable hair loss 2—4 months later 2. These factors include hormones, growth factors, drugs, and the seasons 2 , 3. Up to hairs normally fall out every day 3.
It is important to ask patients about the drugs they are taking. For example, hair loss 2—4 months after the administration of multiple heparin injections is not at all rare e2. Women should be asked about gynecological factors such as the initiation or discontinuation of hormonal contraceptive drugs.
Transient postpartum effluvium is normal: the stress of delivery, and the hormonal changes afterward, cause many hair follicles to undergo a transition from the anagen to the telogen phase, so that hair loss is seen 2—4 months later 2. Highly toxic factors such as chemotherapeutic drugs can induce severe follicular damage, causing hairs to break off in their follicles within one to three weeks. As a consolation, patients can be told that this process synchronizes the growth phases of the follicles, so that the hair, once it has grown back, is often thicker than before.
Structural changes can occur in which originally straight hair regrows as curly hair, or vice versa 4. Inspection of the scalp capillitium reveals whether there is a visible reduction of the amount of hair alopecia and, if so, in what pattern. Any inflammatory redness or scaling should be noted, as psoriasis and eczema can cause effluvium e3.
Dermatoscopic examination of the scalp is helpful as well 5.
A clinical hair-pull test is supplemented by a tricho rhizo gram, in which 20—50 hairs are epilated with a rubber-shod artery clamp and then analyzed under a microscope. The differently formed roots in each of the growth phases can then be counted.
Hair Loss in Women | Cleveland Clinic
A non-invasive phototrichogram can also yield an estimate of the anagen-to-telogen ratio e5 but cannot reveal root anomalies such as dystrophic hairs. In patients with effluvium of unknown cause, laboratory testing should be performed to exclude, in particular, the following:. Syphilis is very rarely detected, but omitting to take the relevant history or to perform the TPPA test in a patient with hair loss can have serious consequences for the patient, and for the physician as well, if neurosyphilis should later develop.
Histological examination reveals diminished size of terminal hair follicles in genetically predisposed areas of the scalp, shortening of hair growth phases, and decreased thickness of hair shafts 8. The pattern of hair loss is characteristic: in men, receding temporal hairlines and hair loss in the region of the whorl at the back of the head Norwood—Hamilton type ; in women, diffuse midline thinning on the top of the scalp Ludwig type Figure 1.
Androgenetic alopecia in men is ascribed to genetic variants of the androgen receptor 8 , 9. There is no association of male-pattern baldness and androgen levels in the blood; rather, the condition is thought to reflect a genetically variable sensitivity of hair follicles in the affected areas to normal levels of circulating androgen. Multiple genes are apparently involved 9. The data on androgenetic alopecia in women are sparse, but here, too, there is clear evidence of a genetic predisposition e7.
The appropriate diagnostic evaluation of androgenetic alopecia, including a diagnostic algorithm, was presented in a European consensus statement in 11 , with the following main conclusions:. The evidence-based European guideline for the diagnostic evaluation and treatment of androgenetic alopecia recently became available The main goal is to stop hair loss and, if possible, reverse the shrinking of hair follicles, in order to promote the resumption of hair growth The success or failure of treatment should be objectively documented with standardized photographic documentation and, optionally, a phototrichogram.
Minoxidil solution is the only topically applied drug against androgenetic alopecia whose efficacy has been documented by high-level level 1 evidence Its side effects include redness and scaling of the scalp; rarely, contact dermatitis; and hypertrichosis in women—mostly at the temples. Level 1 evidence documents its efficacy against androgenetic alopecia It is relatively well tolerated, with a mildly elevated rate of reversible loss of libido and erectile dysfunction appr.
The notion, which appears in some Internet fora, that finasteride might increase the risk of prostate cancer, breast cancer, or infertility has made patient education about this drug increasingly difficult but is not supported by valid scientific evidence 16 , e8. Finasteride is not approved for use by women, as it can cause developmental genital defects in male fetuses 10 and is ineffective against androgenetic alopecia in postmenopausal women Therefore, we advise against its off-label use to treat alopecia There is as yet inadequate evidence for the topical use of natural estrogens, progesterone, or antiandrogens to treat androgenetic alopecia in women who do not have hormonal dysregulation Table Nor is there adequate evidence to support the use of systemic antiandrogens in women with androgenetic alopecia whose menstrual cycles are normal, other than a proof-of-principle study in which these hormones were given at very high doses In women who do have hormonal dysregulation, androgenetic alopecia can be treated with antiandrogens such as cyproterone acetate, chlormadinone acetate, or dienogest level 3 evidence Table Autologous hair transplantation is a supplementary treatment for advanced androgenetic alopecia.
Hair is removed from the occipital androgen-insensitive scalp and transplanted into the affected areas. Hair follicle transplantation can thicken the hair not only in men with androgenetic alopecia, but also in women level 4 evidence. A further measure—the easiest of all, and one that affected persons can carry out for themselves—is the comb-over, i.
Results of the modified Steiner stain did not reveal spirochetes in any of the patients and failed to differentiate between alopecia syphilitica and alopecia areata. Comparing the alopecia syphilitica patients with 13 patients with alopecia areata, the authors found only a few differentiating features. They concluded that the presence of peribulbar eosinophils strongly suggests alopecia areata. Elston et al 8 observed several cases of syphilis with numerous eosinophils in the peribulbar infiltrate and noted that it can be indistinguishable from alopecia areata. When an associated skin rash or lymphadenopathy is present, the diagnosis of syphilis may be suggested and confirmed by positive serology test results.
If such findings are not present, a biopsy specimen to differentiate from other forms of alopecia should be obtained. Because moth-eaten alopecia and alopecia areata have similar resemblance microscopically, syphilis serologic tests are needed.
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The treatment of syphilis also has been shown to be a cause of alopecia. Pareek 9 described the association of syphilitic alopecia and Herxheimer reaction. A year-old man presented with syphilis with widespread thinning of the scalp hair, eyebrows, and pubic area; the scalp showed patchy moth-eaten alopecia. He was treated with 1 to 2 megaunits of procaine penicillin daily for 10 days. All the symptoms disappeared by the next day. Two to 3 weeks later, the lymphadenopathy had disappeared, and the patient's eyebrows and pubic hair started to regrow. The scalp hair was fully regrown 10 weeks from the onset of treatment.
The author concluded that diffuse and extensive hair loss after the first injection of penicillin was part of the Herxheimer reaction. Skip to main content.
Clinical Review. Piedra are fungal diseases. See also [ edit ] List of cutaneous conditions References [ edit ]. Disorders of skin appendages L60—L75 , — Hirsutism Acquired localised generalised patterned Congenital generalised localised X-linked Prepubertal. Perioral dermatitis Granulomatous perioral dermatitis Phymatous rosacea Rhinophyma Blepharophyma Gnathophyma Metophyma Otophyma Papulopustular rosacea Lupoid rosacea Erythrotelangiectatic rosacea Glandular rosacea Gram-negative rosacea Steroid rosacea Ocular rosacea Persistent edema of rosacea Rosacea conglobata variants Periorificial dermatitis Pyoderma faciale.
Folliculitis Folliculitis nares perforans Tufted folliculitis Pseudofolliculitis barbae Hidradenitis Hidradenitis suppurativa Recurrent palmoplantar hidradenitis Neutrophilic eccrine hidradenitis. Acrokeratosis paraneoplastica of Bazex Acroosteolysis Bubble hair deformity Disseminate and recurrent infundibulofolliculitis Erosive pustular dermatitis of the scalp Erythromelanosis follicularis faciei et colli Hair casts Hair follicle nevus Intermittent hair—follicle dystrophy Keratosis pilaris atropicans Kinking hair Koenen's tumor Lichen planopilaris Lichen spinulosus Loose anagen syndrome Menkes kinky hair syndrome Monilethrix Parakeratosis pustulosa Pili Pili annulati Pili bifurcati Pili multigemini Pili pseudoannulati Pili torti Pityriasis amiantacea Plica neuropathica Poliosis Rubinstein—Taybi syndrome Setleis syndrome Traumatic anserine folliculosis Trichomegaly Trichomycosis axillaris Trichorrhexis Trichorrhexis invaginata Trichorrhexis nodosa Trichostasis spinulosa Uncombable hair syndrome Wooly hair Wooly hair nevus.
Body odor Chromhidrosis Fox—Fordyce disease.