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__NOTOC__
{{Infobox_Disease |
{{Infobox_Disease |
   Name          = {{PAGENAME}} |
   Name          = {{PAGENAME}} |
   Image          = Alopecia.jpg|
   Image          = Alopecia.jpg|
   Caption        = Alopecia as male pattern baldness at age 40|
   Caption        = Alopecia as male pattern baldness at age 40|
  DiseasesDB    = 14765 |
  ICD10          = {{ICD10|L|65|9|l|60}} |
  ICD9          = {{ICD9|704.09}} |
  ICDO          = |
  OMIM          = |
  MedlinePlus    = 003246 |
  eMedicineSubj  = |
  eMedicineTopic = |
  MeshID        = D000505 |
}}
}}
{{SI}}
{{Alopecia}}
{{CMG}}
'''For patient information, click [[Alopecia (patient information)|here]]'''


==Overview==
{{CMG}}; {{AE}} {{KS}} [[Ogechukwu Hannah Nnabude, MD]]
'''Alopecia''' is the resulting condition from the loss of hair, which is termed ''effluvium.'' It should be distinguished from [[baldness]], which is the ''lack'' of hair, including contexts where that absence is intentional.  (In some cases the terms are used interchangeably, and in some conditions such as [[trichotillomania]], where the loss of the hair is due to intentional acts, but the motive for that act is defined as a medical condition, it can be difficult to determine whether the label "alopecia" is appropriate.)


Alopecia is characterized by scarring or non-scarring. 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.
{{SK}} Atrichia; hair loss; bald; baldness; balding; hypotrichosis
==[[Alopecia overview|Overview]]==


== Vocabulary ==
==[[Alopecia historical perspective|Historical Perspective]]==
*[[Anagen]]:growth phase, lasts 2-3 years (80-90% of follicles at any given time)
*[[Catagen]]:involutional phase, lasts 2-3 weeks (1-3% of follicles)
*Telogen:resting phase, lasts 3-4 months (5-10% of follicles)
:*hair released from shaft and shed at end of telogen new cycle begins
:*mature root sheath of telogen hair = “club” at proximal end
*[[Terminal hair]]s: large shaft diameters, bulbs extend into subcutaneous fat
*[[Vellus hair]]s:smaller in caliber and length, less pigmented
*Indeterminate hairs:size/length between that of terminal and vellus hairs


== Risk Factors ==
==[[Alopecia classification|Classification]]==


*[[Drugs]]:
==[[Alopecia pathophysiology|Pathophysiology]]==
:*[[anticoagulants]]
:*[[anticonvulsants]]
:*[[antidepressants]]
:*[[beta-blockers]]
*[[Medical illness]]
:*[[Hyperthyroidism|Hyper]]/[[hypothyroidism]]
:*[[Nutritional deficiencies]]:  [[iron]], [[zinc]], [[protein]]
:*[[Connective tissue]] disorders:  [[SLE]], [[dermatomyositis]]


== Pathophysiology & Etiology==
==[[Alopecia causes|Causes]]==
'''Non Scarring'''<br>
''Diffuse''
*[[Androgenetic alopecia]]
:*most common (30-40% of men and women)
:*Genetically determined:  [[polygenic]] with [[variable penetrance]]
:*Shortening of anagen phase follicular miniaturization
:*Men: M-shaped pattern along frontal hairline (temporal loss progresses to midscalp)
:*Women:  more diffuse, can be difficult to distinguish from telogen effluvium
*[[Telogen effluvium]]
:*Reversible loss of mature, terminal hairs (few hundred per day)
:*[[Stress]]ful event (or [[medication]]) triggers transition of more anagen hairs into telogen phase
::*[[Childbirth]], [[fever]], severe [[infection]], severe [[psychologic stress]], major [[surgery]], [[crash diet]]
::*[[Drugs]]:  [[heparin]], [[antithyroid agents]], [[anticonvulsants]], [[hormones]]
:*Diffuse hair loss peaks 3-4 months after inciting event
:*Up to 30% of hairs must be lost before cosmetically apparent
*Anagen effluvium
:*Acute loss of anagen hair = 80-90% of hair
:*Occurs 10-14 days after treatment with [[antimitotic agents]] ([[chemo]])
''Focal''
*[[Alopecia areata]]:  incidence 1/1000
:*Smooth, discrete, circular areas of complete hair loss occurring over a few weeks
:*Exclamation point hairs:  hair root narrower than normal with less pigment
:*Can occur on any hair-bearing area; nails may also have proximal pitting
:*Usually reversible:  regrowth occurs over several months; 90% regrow within 2 years
:*Relapse occurs in up to 1/3
:*Decreased chance of regrowth/increased risk relapse if:
::*Prepubertal onset
::*Widespread involvement ([[alopecia totalis]] or [[Alopecia universalis|universalis]])
::*Duration > 5 years
::*History of [[atopy]]
:*Possible [[autoimmune]] mechanism:  bx shows [[T-cell]] infiltrates around hair follicles
:*Positive [[family history]] in 20%
*[[Syphilis]]
:*Moth-eaten, patchy pattern of loss (may be diffuse)
:*May be associated with [[skin lesions]] of [[secondary syphilis]], or may occur in [[Latent syphilis|latent stage]]
:*Full hairgrowth occurs after treatment of [[infection]]
*[[Trauma]]
:*[[Traction alopecia]]:  due to hairstyles that impose chronic tension on hair (braids)
:*Hair loss most prominent in areas of greatest tension (margins)
:*Fine, [[vellus hair]]s present in areas of absent [[terminal hair]]s
:*Regrowth can occur in early disease (few months-yrs), but not in late disease (years)
:*Chemical trauma:  repeated use of [[lye]]-containing straightening agents or hot oils for styling
:*[[Trichotillomania]]:  bizarre, asymmetric pattern of broken hairs of varying length
'''Scarring'''
*uncommon; hair loss is permanent
*erythematous papules, pustules, or scaling centered around follicles
*polytrichia = multiple hair shafts exiting a single enlarged orifice
*eventual obliteration of follicular orifices
*[[Tinea capitis]]
:*Scaling and [[inflammation]] in patchy areas of hair loss, +/- [[lymphadenopathy]]
:*Usually in children
:*KOH prep positive
*Central, centrifugal scarring alopecia (a.k.a. follicular degeneration syndrome, pseudopelade)
:*Symmetric involvement of central portion of scalp with outward expansion over months/yrs
:*May be associated with pustules (folliculitis decalvans)
:*Cause unknown-> emipiric [[Rx]] with [[steroids]], [[antibiotics]]
*[[Discoid lupus]]
:*[[Inflammation]] with plugged follicles, scale, abnormal scalp pigmentation
:*May have discoid [[lesion]]s elsewhere on body


== Diagnosis ==
==[[Alopecia differential diagnosis|Differentiating Alopecia from other Diseases]]==


*Pull test:  firm pull on 20-40 hairs should yield fallout of no more than 1 in 10 hairs
:*Increased # telogen hairs with depigmented proximal bulb:  [[telogen effluvium]]
:*Increased # hairs with no bulb:  breakage (hair fragility due to exogenous injury)
:*[[Anagen hair]]s with pigmented root:  likely excessive force
*Follicular units:  number of hairs produced per follicular orifice
:*Threes = normal for ages 20-40
:*Twos = normal for ages 40-60
:*Ones = normal for ages >60
:*Voids = follicular orifices w/o hairs suggests advanced [[androgenetic alopecia]] if no scarring


*Testing:minimal
==[[Alopecia epidemiology and demographics|Epidemiology and Demographics]]==
:*[[Medical illness]] suspected:  [[CBC]], [[TSH]], possibly [[ferritin]]
:*[[RPR]] if patchy or unexplained loss
:*KOH prep if patchy alopecia with scaling or [[inflammation]]


==Complete Differential Diagnosis for Alopecia==
==[[Alopecia risk factors|Risk Factors]]==
=== Non-Scarring Alopecia ===
* [[Adrenocortical insufficiency]] (primary or secondary)
* [[Anagen]] effluvium (anagen=growing hair)
* [[Cushing's syndrome]]
* Diffuse hair thinning due to [[metabolic]] causes
* [[Hyperthyroidism]]
* [[Hypoparathyroidism]]
* [[Hypothyroidism]]
* [[Pituitary insufficiency]]
* [[Secondary syphilis]]
* [[Sheehan's syndrome]]
* Temporary hair loss
*:* [[Pregnancy]]
*:* [[Malnutrition]]
*:*:* [[Malabsorption]]
*:*:* [[Protein deficiency]]
*:*:* [[Tryptophan]] deficiency
*:*:* [[Nontropical sprue]]
*:*:* [[Vitamin A deficiency]]
*:*:* [[Vitamin B deficiency]]
*:*:* [[Vitamin D deficiency]]
*:*:* [[Rickets]]
* [[Telogen effluvium]] (telogen=resting hair)
* [[Thyroiditis]]
* [[Trichotillomania]]


=== Scarring Alopecia ===
==[[Alopecia natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
* [[Amyloidosis]]
* Chronic disciform [[lupus erythematosis]]
* [[Congenital defect]]s
* [[Discoid Lupus Erythematosus]]
* Dissecting [[cellulitis]]
* [[Herpes zoster infection]]
* [[Infection]]
*:* [[Favus]]
*:* [[Typhoid Fever]]
*:* [[Leptospirosis]]
*:* [[Secondary syphilis]]
* Inflammatory [[dermatoses]]
* [[Lichen planopilaris]]
* [[Lymphoma]]
* [[Morphea]]
* [[Mycosis fungoides]]
* [[Neoplasm]]
* [[Neurodermatitis]]
* Physical or chemical agents:
*:* [[ACE inhibitors]]
*:* [[Allopurinol]]
*:* [[Androgens]]
*:* [[Anticoagulants]]
*:* [[Anticonvulsants]]
*:* [[Antimycotic agents]]
*:* [[Arsenic]]
*:* [[Azathioprine]]
*:* [[Beta blockers]]
*:* [[Borates]]
*:* [[Cadmium]]
*:* [[Chemotherapeutics]]
*:* [[Chlorambucil]]
*:* [[Cisplatin]]
*:* [[Clofibrate]]
*:* [[Cyclophosphamide]]
*:* [[Cytarabine]]
*:* [[Estrogens]]
*:* [[Fluororacil]]
*:* [[Gentamycin]]
*:* [[Gold compounds]]
*:* [[Heparins]]
*:* [[Indomethacin]]
*:* [[Levodopa]]
*:* [[Linolic acid]]
*:* [[Mercury]] and derivatives
*:* [[Methotrexate]]
*:* [[Niacin]]
*:* [[Oral contraceptives]]
*:* [[Propranolol]]
*:* [[Retinoids]]
*:* [[Salicylates]]
*:* [[Selenium]]
*:* [[Squalenes]]
*:* [[Steroids]]
*:* [[Thallium]]
*:* [[Undecylenic acid]]
*:* [[Vitamin A overdose]]
*:* [[Warfarin]]
* [[Pseudofolliculitis barbae]]
* [[Psoriasis]]
* [[Sarcoidosis]]
* [[Scleroderma]]
* [[Systemic Lupus Erythematosus]]


=== Miscellaneous ===
==Diagnosis==
* [[Addison's Disease]]
[[Alopecia diagnostic study of choice|Diagnostic study of choice]] | [[Alopecia history and symptoms|History and Symptoms]] | [[Alopecia physical examination|Physical Examination]] | [[Alopecia laboratory findings|Laboratory Findings]] | [[Alopecia electrocardiogram|Electrocardiogram]] | [[Alopecia x ray|X-Ray Findings]] | [[Alopecia echocardiography and ultrasound|Echocardiography and Ultrasound]] | [[Alopecia CT scan|CT-Scan Findings]] | [[Alopecia MRI|MRI Findings]] | [[Alopecia other imaging findings|Other Imaging Findings]] | [[Alopecia other diagnostic studies|Other Diagnostic Studies]]
* [[Anemia]]
* [[Cancer]]
* [[Diabetes Mellitus]]
* [[Pneumonia]]
* [[Scarlet Fever]]
* [[Schmidt's Syndrome]]
* [[Stress (medicine)|Stress]]
*:* [[Childbirth|Labor]]
*:* [[Surgery]]
* [[Androgen insensitivity syndrome|Testicular feminization syndrome]]
* [[Turner's Syndrome]]
* [[Typhoid fever]]
* Mechanical effects
:* Traction alopecia
:* Pressure alopecia
:*: Alopecia after extended bed rest
:* Trichotillomania (compulsion to pull out one’s own hair)
 
== History and Symptoms ==
*Age
:*Childhood: only 2 common diagnoses [[tinea capitis]], [[alopecia areata]]
:*Adulthood: [[tinea capitis]] rare; all the rest possible
*Duration
:*<1 year:  suggests [[telogen effluvium]] if diffuse loss
:*>1 year:  suggests [[androgenetic alopecia]] if diffuse loss
:*Pattern of loss
:*Shedding: “lots of hair coming out,” may be due to hair breakage or loss by the root
:*Thinning: scalp more visible without noticeable hair fallout, suggests [[androgenetic alopecia]]
:*[[Family history]]:  may be positive in [[androgenetic alopecia]], [[alopecia areata]]
:*Grooming practices:  can cause hair fragility/breakage
:*Chemical treatments (relaxers, perms, bleaching) most damaging; hair dye less so
Traction styling<br>
 
== Physical Examination ==
 
=== Appearance of the Patient ===
*[[Scalp]]
:*Normal or with features of [[scarring]]  
:*if scalp abnormal provide clues to dx
::*scaling
::*[[erythema]]
::*[[pustules]]
::*dyspigmentation
*Pattern:  diffuse or patchy
:*Male pattern (diffuse):bitemporal recession +/or vertex loss
:*Female pattern (diffuse):coronal thinning with preserved anterior hairline
:*Patchy:with preserved hair of variable length (breakage)
::*with exclamation point hairs ([[alopecia areata]])
::*with no hair ([[scarring]], traction, [[syphilis]], [[tinea]])
*Patient may also have nails that have a hammered brass appearance.
 
== Laboratory Findings ==
* [[Viral culture|Viral]] and [[bacterial cultures]]
* [[Prolactin]]
* [[Thyroid function tests]]
* [[Iron]] studies
* [[Dehydroepiandrosterone-sulfate]] ([[DHEA-S]])
* [[Testosterone]]
* [[Rapid plasma reagin]] ([[RPR]])
* [[Erythrocyte sedimentation rate]] ([[ESR]])
* [[Antinuclear antibodies]] ([[ANA]])


==Treatment==
==Treatment==
* Goal of [[treatment]] is to avoid future hair loss. 
[[Alopecia medical therapy|Medical Therapy]] | [[Alopecia surgery|Surgery]] | [[Alopecia primary prevention|Primary Prevention]] | [[Alopecia secondary prevention|Secondary Prevention]] | [[Alopecia cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Alopecia future or investigational therapies|Future or Investigational Therapies]]
* [[Scarring]] hair loss prevents hair from going back.
* Wigs and [[hair transplants]]
* Anagen effluvium
*:* Treat [[illness]] or withdraw [[drug]]
* [[Telogen effluvium]]
*:* [[Stress]] the recovery is normal
* Treat underlying cause of alopecia
 
== Pharmacotherapy ==
 
=== Acute Pharmacotherapies ===
* [[Androgenetic alopecia]]
*:* For men, oral [[finasteride]] or [[topical]] [[minoxidil]]
*:* For women, [[antiandrogens]] if [[adrenal]] [[androgens]] are increased
* [[Tinea capitus]]/[[kerion]]
*:* Oral [[antifungals]]
* [[Alopecia areata]]
*:* [[Glucocorticoids]]
*:* [[Psoralen and ultraviolet A]] ([[PUVA]])
*:* Superpotent [[steriods]]
*:* [[Cyclosporine]]
*:* Intralesional [[steriod]] [[injections]]
 
=== Chronic Pharmacotherapies ===
*Topical [[minoxidil]] ([[Rogaine]], generic): 
:*only [[Rx]] approved for women as well as men
:*Increases duration of [[anagen]] and enlarges miniaturized follicles
:*Mechanism unclear
*Efficacy:
:*hair counts ~5x higher than placebo with use of 5% solution (men)
:*hair counts 45% higher with use of 5% solution compared with use of 2% solution (men)
:*hair counts returned to those of placebo group within 24 weeks after discontinuation [[Rx]] (men)
:*women:  increased hair growth in 60% vs. 40% with use of 2% soln vs. placebo
:*'''Advice for patients:'''
::*1 mL bid applied to dry [[scalp]] with spray or dropper; spread lightly w/finger
::*expect decreased loss w/in 2 mos, growth w/in 4-8 mos; stable at 1-1.5 yrs
::*best results if baldness present at vertex x < 5 years and < 10 cm diameter
::*cosmetically notable growth occurs in only 30-40%
::*Rx must continue indefinitely or regrown hair will be lost
::*[[Side effect]]s = rare contact or irritant dermatitis; no change [[blood pressure]], [[heart rate]] or weight


== Acknowledgements ==
== Acknowledgements ==
The content on this page was first contributed by: Steven Wiviott, M.D.
The content on this page was first contributed by: Steven Wiviott, M.D.
==References==
[http://www.calosol.com/alopecia.php Alopecia Types] - More information about alopecia and the various different types{{reflist}}
<br>


[[ro:Alopecia]]
[[ro:Alopecia]]

Latest revision as of 20:34, 15 December 2020

Alopecia
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2] Ogechukwu Hannah Nnabude, MD

Synonyms and keywords: Atrichia; hair loss; bald; baldness; balding; hypotrichosis

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Alopecia from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

Diagnostic study of choice | History and Symptoms | Physical Examination | Laboratory Findings | Electrocardiogram | X-Ray Findings | Echocardiography and Ultrasound | CT-Scan Findings | MRI Findings | Other Imaging Findings | Other Diagnostic Studies

Treatment

Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Acknowledgements

The content on this page was first contributed by: Steven Wiviott, M.D.

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