Non scarring hair loss

Last updated
Non scarring hair loss
Other namesNoncicatricial alopecia
Specialty Dermatology

Non scarring hair loss, also known as noncicatricial alopecia is the loss of hair without any scarring being present. [1] There is typically little inflammation and irritation, but hair loss is significant. This is in contrast to scarring hair loss during which hair follicles are replaced with scar tissue as a result of inflammation. Hair loss may be spread throughout the scalp (diffuse) or at certain spots (focal). The loss may be sudden or gradual with accompanying stress.

Contents

The most common cause is androgenetic alopecia, also known as male pattern or female pattern hair loss due to the effects of dihydrotestosterone (DHT) on the hair follicles. A variety of factors may lead to this condition such as hormonal effects, age, diet, autoimmunity, emotional stress, physical stress, drug effects, genetics, or infections.

Depending on the cause, treatment options include: topical minoxidil, oral finasteride, anti-fungal medications, steroids, hair transplantation, or platelet rich plasma (PRP) therapy. [2] [3] Alternatives for total hair loss include the use of hairpieces or hair fibers.

Signs and Symptoms

Patients will notice either focal or diffuse loss of hair. This may occur due to thinning or shedding of the hair over a sudden or gradual period of time. Stress may be present, and the emotional impact of hair loss is important as it may cause significant distress. [3] Other signs may point to specific causes of the condition. Poor diet may lead to tiredness, other side effects of chemotherapy drugs may be seen, infection can cause itching, stress may lead to pulling of hair or falling of hair. Hair loss may be present in the family, highlighting genetic causes.

Causes

Causes of noncicatricial alopecia can be separated based on focal or diffuse hair loss: [3]

Diffuse:

Focal:

Diagnosis

There are a number of conditions that may cause non scarring hair loss and the first step is to determine the pattern: focal or diffuse. [3] The next step is to identify if the hair loss is scarring or non scarring. A history and physical examination is necessary as this will provide clues to the ultimate diagnosis. It is essential to ask about the onset, observed pattern, hairstyles, family history, diet, and social history. [10]

Diffuse:

Focal:

Pull Test

This test is performed to estimate the severity of hair loss and refine the differential diagnosis. A clinician grabs sections of hair and observes for active hair loss. A positive pull test is usually caused by telogen effluvium, androgenetic alopecia, and alopecia areata. [10]

Tug Test

A doctor holds the top and bottom of a strand of hair and observes for a break in the middle which may be caused by a hair shaft abnormality. [10]

Card Test

A part in the hair is created and a small card is placed to contrast the color of the hair and visualize thin strands of hair (seen in telogen effluvium) vs short broken strands (seen in hair shaft abnormalities). [10]

Fungal Culture

Scalp is scraped and the specimen is incubated for fungal growth commonly seen in tinea capitis. [10]

Scalp biopsy

If the diagnosis of hair loss is unclear or not responsive to the treatment, a scalp biopsy may be required. Scalp biopsy will show evidence of inflammation, location, and change in the follicles. This will frequently refine the diagnosis. [3]

Blood Tests

In the case of suspected iron deficiency, thyroid disease, or androgen excess a blood test may be necessary to rule in these causes. [10]

Trichoscopy

A new technique which allows for magnified visualization of the hair and scalp, providing a high definition, detailed look at follicles. [10]

Treatment

Steroids

Steroids may be used for the short-term treatment of autoimmune causes of hair loss such as alopecia areata. Topical or oral preparations may be used for a few weeks to reduce inflammation. Long term use of topical steroids has not shown benefits for growth and the use of long term oral steroids has many risks that typically outweigh the benefits. [3]

Immunotherapy

Diphenylcyclopropenone or squaric acid may be used topically for the treatment of alopecia areata as an alternative to steroids. This treatment may cause a local skin reaction. [3]

Minoxidil

Minoxidil is a topical treatment that comes in a solution or foam. The foam provides increased delivery of the drug and less irritation. [11] This drug has been shown to decrease telogen and increase anagen phase of hair follicles, increase VEGF expression, and have indirect vasodilation effects. [11] FDA has approved this drug for use in androgenetic alopecia, but frequent offlabel uses include alopecia areata, chemotherapy induced alopecia, telogen effluvium, and traction alopecia. [11]

Redensyl

Redensyl is emerging as an alternative hair loss treatment containing a newly discovered molecule called dihydroquercetin-glucoside (DHQG), a compound derived from plant extracts known to target the stem cells in hair follicles and encourages the division of the cells. [12] Still in the development stage, it has been approved by the FDA as many of its medications are already widely available.[ citation needed ]

Hormone modulating

Androgenetic alopecia is routinely treated with drugs that alter hormonal function, in particular DHT's effects. Male pattern hair loss is treated with oral finasteride which is a 5-alpha reductase inhibitor that blocks the formation of DHT from testosterone. Finasteride may cause sexual dysfunction, but it is typically reversed upon discontinuation of the treatment. [13] Female pattern hair loss is treated with spironolactone or flutamide that block the effects of DHT receptors. [14]

Anti-fungal

Topical anti-fungal treatments such as ketoconazole and pyrithione zinc shampoo are sometimes effective for male pattern hair loss. Topical therapy is not usually effective for tinea capitis for which oral therapy with terbinafine, fluconazole, or griseofulvin is superior. [3]

PRP

Patients may benefit from injections of plasma into the scalp to promote the delivery of nutrients in the plasma to the hair follicles. This has been shown to promote growth, blood supply, and collagen production. [15]

Surgical

The two common surgical methods to treat hair loss are hair transplantation and scalp reduction. Hair transplantation involves the transfer of intact growing hair follicles from areas such as the back of the head to balding spots. This occurs in multiple visits as the number of transplanted follicles increased to restore a natural look. [15] [16] Scalp reduction is a technique that removes balding spots of skin and stretches the remaining skin that has normal hair growth. This is typically only possible in the back and top of the head and may cover up to half of the balding area. [15]

Prognosis

It is important to note that treatment response to hair loss may be unpredictable and variable depending on the cause. 8.5% of patients with alopecia totalis may achieve complete recovery. [2] Certain conditions such as tinea capitis and trichotillomania usually respond once the infection or hair pulling behaviors are stopped. [3] Despite this many patients will achieve at least a temporary or partial recovery of hair loss. [17]

Complications

Patients with hair loss are at risk for psychological conditions such as increased anxiety and depression. Autoimmune causes of hair loss may put patients at risk for other autoimmune conditions such as hypothyroidism, hyperthyroidism, and vitiligo. [2] Alopecia areata patients may develop insulin resistance putting them at a risk for type 2 diabetes. [2]

Related Research Articles

<span class="mw-page-title-main">Alopecia areata</span> Medical condition

Alopecia areata, also known as spot baldness, is a condition in which hair is lost from some or all areas of the body. It often results in a few bald spots on the scalp, each about the size of a coin. Psychological stress and illness are possible factors in bringing on alopecia areata in individuals at risk, but in most cases there is no obvious trigger. People are generally otherwise healthy. In a few cases, all the hair on the scalp is lost, or all body hair is lost. Hair loss can be permanent, or temporary.

<span class="mw-page-title-main">Hair loss</span> Loss of hair from the head or body

Hair loss, also known as alopecia or baldness, refers to a loss of hair from part of the head or body. Typically at least the head is involved. The severity of hair loss can vary from a small area to the entire body. Inflammation or scarring is not usually present. Hair loss in some people causes psychological distress.

<span class="mw-page-title-main">Hair follicle</span> Organ found in the dermal layer of the mammalian skin that regulates hair growth

The hair follicle is an organ found in mammalian skin. It resides in the dermal layer of the skin and is made up of 20 different cell types, each with distinct functions. The hair follicle regulates hair growth via a complex interaction between hormones, neuropeptides, and immune cells. This complex interaction induces the hair follicle to produce different types of hair as seen on different parts of the body. For example, terminal hairs grow on the scalp and lanugo hairs are seen covering the bodies of fetuses in the uterus and in some newborn babies. The process of hair growth occurs in distinct sequential stages: anagen is the active growth phase, catagen is the regression of the hair follicle phase, telogen is the resting stage, exogen is the active shedding of hair phase and kenogen is the phase between the empty hair follicle and the growth of new hair.

<span class="mw-page-title-main">Telogen effluvium</span> Medical condition

Telogen effluvium is a scalp disorder characterized by the thinning or shedding of hair resulting from the early entry of hair in the telogen phase. It is in this phase that telogen hairs begin to shed at an increased rate, where normally the approximate rate of hair loss is 125 hairs per day.

<span class="mw-page-title-main">Alopecia universalis</span> Medical condition

Alopecia universalis(AU), also known as alopecia areata universalis, is a medical condition involving the loss of all body hair, including eyebrows, eyelashes, chest hair, armpit hair, and pubic hair. It is the most severe form of alopecia areata (AA). People with the condition are usually healthy and have no other symptoms and a normal life expectancy.

<span class="mw-page-title-main">Finasteride</span> Antiandrogen medication

Finasteride, sold under the brand names Proscar and Propecia among others, is a medication used to treat pattern hair loss and benign prostatic hyperplasia (BPH) in men. It can also be used to treat excessive hair growth in women. It is usually taken orally but there are topical formulations for patients with hair loss, designed to minimize systemic exposure by acting specifically on hair follicles.

The management of hair loss, includes prevention and treatment of alopecia, baldness, and hair thinning, and regrowth of hair.

<span class="mw-page-title-main">Alopecia totalis</span> Medical condition

Alopecia totalis is the loss of all hair on the head and face. Its causes are unclear, but believed to be autoimmune. Research suggests there may be a genetic component linked to developing alopecia totalis; the presence of DRB1*0401 and DQB1*0301, both of which are human leukocyte antigens (HLA), were found to be associated with long-standing alopecia totalis.

Trichology is the study of the hair and scalp. The term derives from Ancient Greek θρίξ (thríx), "hair" and -λογία -logia. In most jurisdictions the title of a trichologist, not the field of trichology, is considered a para-medical discipline.

<span class="mw-page-title-main">Pattern hair loss</span> Medical condition

Pattern hair loss is a hair loss condition that primarily affects the top and front of the scalp. In male-pattern hair loss (MPHL), the hair loss typically presents itself as either a receding front hairline, loss of hair on the crown and vertex of the scalp, or a combination of both. Female-pattern hair loss (FPHL) typically presents as a diffuse thinning of the hair across the entire scalp.

Madarosis is a condition that results in the loss of eyelashes, and sometimes eyebrows. The term "madarosis" is derived from the ancient Greek "madaros", meaning "bald". It originally was a disease of only losing eyelashes but it currently is the loss of both eyelashes and eyebrows. Eyebrows and eyelashes are both important in the prevention of bacteria and other foreign objects from entering the eye. A majority of patients with madarosis have leprosy, and it was reported that 76% of patients with varying types of leprosy had madarosis.

<i>Microsporum audouinii</i> Species of fungus

Microsporum audouinii is an anthropophilic fungus in the genus Microsporum. It is a type of dermatophyte that colonizes keratinized tissues causing infection. The fungus is characterized by its spindle-shaped macroconidia, clavate microconidia as well as its pitted or spiny external walls.

Anagen effluvium is the pathologic loss of anagen or growth-phase hairs. Classically, it is caused by radiation therapy to the head and systemic chemotherapy, especially with alkylating agents.

<span class="mw-page-title-main">Loose anagen syndrome</span> Medical condition

Loose anagen syndrome, also known as loose anagen hair syndrome, is a hair disorder related to dermatology. It is characterised by the easy and pain free detachment of anagen staged hairs from the scalp. This hair condition can be spontaneous or genetically inherited.

Scarring hair loss, also known as cicatricial alopecia, is the loss of hair which is accompanied with scarring. This is in contrast to non scarring hair loss.

Tufted folliculitis presents with doll's hair-like bundling of follicular units, and is seen in a wide range of scarring conditions including chronic staphylococcal infection, chronic lupus erythematosus, lichen planopilaris, Graham-Little syndrome, folliculitis decalvans, acne keloidalis nuchae, immunobullous disorders, and dissecting cellulitis.

<span class="mw-page-title-main">Frontal fibrosing alopecia</span> Medical condition

Frontal fibrosing alopecia is the frontotemporal hairline recession and eyebrow loss in postmenopausal women that is associated with perifollicular erythema, especially along the hairline. It is considered to be a clinical variant of lichen planopilaris.

<span class="mw-page-title-main">Topilutamide</span> Chemical compound

Topilutamide, known more commonly as fluridil and sold under the brand name Eucapil, is an antiandrogen medication which is used in the treatment of pattern hair loss in men and women. It is used as a topical medication and is applied to the scalp. Topilutamide belongs to a class of molecules known as perfluoroacylamido-arylpropanamides.

Scalp reduction is a surgical procedure in which the hairless region of the scalp of a bald person is reduced. This procedure can reduce the area of the scalp in which hair transplantation is needed, or even eliminate the need for hair transplantation.

<span class="mw-page-title-main">Minoxidil sulfate</span> Chemical compound

Minoxidil sulfate, also known as minoxidil sulfate ester or minoxidil N-O-sulfate, is an active metabolite of minoxidil and is the active form of this agent. Minoxidil acts as a prodrug of minoxidil sulfate. Minoxidil sulfate is formed from minoxidil via sulfotransferase enzymes, with the predominant enzyme responsible, at least in hair follicles, being SULT1A1. Minoxidil sulfate acts as a potassium channel opener, among other actions, and has vasodilating, hypotensive, and trichogenic or hypertrichotic effects. Its mechanism of action in terms of hair growth is still unknown, although multiple potential mechanisms have been implicated.

References

  1. ↑ James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. Chapter 3. ISBN   0-7216-2921-0.
  2. 1 2 3 4 Al Aboud, Ahmad M.; Zito, Patrick M. (2020), "Alopecia", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   30844205 , retrieved 2020-08-27
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Mounsey, Anne; Reed, Sean W. (2009-08-15). "Diagnosing and Treating Hair Loss". American Family Physician. 80 (4): 356–362. ISSN   0002-838X. PMID   19678603.
  4. 1 2 3 Cranwell, William; Sinclair, Rodney (2000), Feingold, Kenneth R.; Anawalt, Bradley; Boyce, Alison; Chrousos, George (eds.), "Male Androgenetic Alopecia", Endotext, South Dartmouth (MA): MDText.com, Inc., PMID   25905192 , retrieved 2020-08-20
  5. ↑ "Alopecia Areata Signs, Treatment, Symptoms, Causes, In Children". MedicineNet. Retrieved 2020-08-20.
  6. 1 2 "Alopecia totalis | Genetic and Rare Diseases Information Center (GARD) – an NCATS Program". rarediseases.info.nih.gov. Retrieved 2020-08-20.
  7. 1 2 Fitzpatrick's dermatology in general medicine. Fitzpatrick, Thomas B. (Thomas Bernard), 1919-2003., Freedberg, Irwin M. (6th ed.). New York: McGraw-Hill, Medical Pub. Division. 2003. ISBN   0-07-138076-0. OCLC   49526920.{{cite book}}: CS1 maint: others (link)
  8. 1 2 3 4 5 6 James, William D. (William Daniel), 1950- (2006). Andrews' diseases of the skin : clinical dermatology. Berger, Timothy G., Elston, Dirk M., Odom, Richard B., 1937- (10th ed.). Philadelphia: Saunders Elsevier. ISBN   0-7216-2921-0. OCLC   62736861.{{cite book}}: CS1 maint: multiple names: authors list (link) CS1 maint: numeric names: authors list (link)
  9. ↑ Franklin, Martin E; Zagrabbe, Kathryn; Benavides, Kristin L (August 2011). "Trichotillomania and its treatment: a review and recommendations". Expert Review of Neurotherapeutics. 11 (8): 1165–1174. doi:10.1586/ern.11.93. ISSN   1473-7175. PMC   3190970 . PMID   21797657.
  10. 1 2 3 4 5 6 7 "Diagnosing Hair Loss". nyulangone.org. Retrieved 2020-08-20.
  11. 1 2 3 Suchonwanit, Poonkiat; Thammarucha, Sasima; Leerunyakul, Kanchana (2019-08-09). "Minoxidil and its use in hair disorders: a review". Drug Design, Development and Therapy. 13: 2777–2786. doi: 10.2147/DDDT.S214907 . ISSN   1177-8881. PMC   6691938 . PMID   31496654.
  12. ↑ Katoulis, A. C.; Liakou, A. I.; Koumaki, D.; Vakirlis, E.; Tsantes, A. G.; Mortaki, D.; Bozi, E.; Ioannides, D. (2020). "A randomized, single-blinded, vehicle-controlled study of a topical active blend in the treatment of androgenetic alopecia". Dermatologic Therapy. 33 (4): e13734. doi: 10.1111/dth.13734 . PMID   32473084. S2CID   219156291.
  13. ↑ McClellan, K. J.; Markham, A. (January 1999). "Finasteride: a review of its use in male pattern hair loss". Drugs. 57 (1): 111–126. doi:10.2165/00003495-199957010-00014. ISSN   0012-6667. PMID   9951956.
  14. ↑ "Thinning hair and hair loss: Could it be female pattern hair loss?". www.aad.org. Retrieved 2020-08-27.
  15. 1 2 3 "Treatment Options For Hair Loss". WebMD. Retrieved 2020-08-27.
  16. ↑ "Hair Transplantation".
  17. ↑ "Laser Hair Therapy".
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