5/28/2014
1
 Dr Shehla Ebrahim. MD,CCFP,FCFP.
( special interest dermatology)
 I have no relevant conflicts of interest....
5/28/2014
2
 A full day of Hair loss.
 Its going to be a long day
 Non scarring Alopecia
-MPHL/FPHL
-Telogen Effluvium....
5/28/2014
3
5/28/2014
4
 Onset and duration.
“When was the last time you had a
normal head of hair”?
5/28/2014
5
 Strong Family history is supportive of MPHL
5/28/2014
6
5/28/2014
7
5/28/2014
8
 Regularity of menses.
 Fertility.
 NOTE PATTERN OF HAIR LOSS.
 Examine the scalp skin for inflammation,
s...
5/28/2014
9
HAIR CYCLE ANAGEN 3 YEARS
CATAGEN 3 Weeks
TELOGEN 3MONTHS
ANAGENANAGEN
ANAGEN
TELOGEN
FEMALE PATTERN
HAIR LOSS...
5/28/2014
10
 95% of hair loss .
 50% of men and 40% of women.
CLINICAL PEARL
 They have completely normal androgen lev...
5/28/2014
11
5/28/2014
12
HAIR CYCLE ANAGEN 3 YEARS
CATAGEN 3 WEEKS
TELOGEN 3 MONTHS
ANAGENANAGEN
ANAGEN
TELOGEN
 TSH.
 Ferritin
- No...
5/28/2014
13
 Topical Minoxidil 2% and 5%
 Mainly acts on the hair cycle by
lengthening the duration of the anagen plus
...
5/28/2014
14
 Androgen receptor blocker and inhibits
steroid androgen production.
 Threshold of response acne>Hirsuitism...
5/28/2014
15
 Thinning is Bitemporal +/-the crown of the
scalp.
CLINICAL PEARL
• The sides are spared
5/28/2014
16
 Type 11, 5 alpha reductase inhibitor.
 Inhibits the conversion of testosterone to
DHT.
 1 mg in MPHL.( Ka...
5/28/2014
17
 Febrile illness
 Childbirth
 Severe psychological
stress
 Major surgery
 Hypo or
hyperthyroidism
 Iron...
5/28/2014
18
5/28/2014
19
 Identify specific cause.
 Complete recovery occurs in 4-6 months.
 Minoxidil 5%
5/28/2014
20
FEMALE PATTERN
HAIR LOSS
MALE PATTERN HAIR
LOSS
TELOGEN
EFFLUVIUM
ALOPECIA
AREATA
ANDROGEN
EXCESS
 Polygenic...
5/28/2014
21
 AA is associated with other AA diseases such as
vitiligo,Diabetes,Thyroid disease, pernicious anemia
 Spon...
5/28/2014
22
5/28/2014
23
5/28/2014
24
 T cell mediated disorder.
 Immune privilege of the hair follicle is lost.
 Once activated, the cytotoxicT...
5/28/2014
25
5/28/2014
26
 ADULTS WITH < 50% HAIR LOSS
-Observe for several months
- Intralesional steroids.kenalog q4-6 weeks
- Poten...
5/28/2014
27
FEMALE PATTERN
HAIR LOSS
MALE PATTERN HAIR
LOSS
TELOGEN
EFFLUVIUM
ALOPECIA
AREATA
ANDROGEN
EXCESS
 Most wome...
5/28/2014
28
 Increased Facial Seborrhea
 Acne that fails to respond to standard
therapies. Localized to the jaw line an...
5/28/2014
29
 Polycystic ovary Syndrome(90%)
Prevalence 5-10%
 Tumours of the ovary or adrenal gland(<0.5%
 Hyperprolac...
5/28/2014
30
MH.Age 23
 Testosterone 2.0 nmol/L (0.5-3.2)
 Testosterone Free 180 pmol/l ( 5-60)
 SHBG 3 nmol/L ( 5-100)...
5/28/2014
31
 Weight loss
 Oral Contraceptives
 Anti androgen medications
-Spironalactone
-Cyproterone Acetate
 Insuli...
5/28/2014
32
 A 20 year old female with steadily thinning
hair over the past several years.
 Otherwise in good health.
5/28/2014
33
FEMALE PATTERN HAIR
LOSS
 45 year old woman with considerable hair
loss during the last 6 months.
 “Massive...
5/28/2014
34
TELOGEN EFFLUVIUM
5/28/2014
35
 36 year old man has noticed bald patches of
hair loss on his scalp and more recently his
beard area.
 He i...
5/28/2014
36
ALOPECIA AREATA
 23 year old overweight female complaining
of scalp thinning,increased facial hair.
 Histor...
5/28/2014
37
5/28/2014
38
ANDROGEN EXCESS
MPHL/FPHL
 Patients with FPHL/MPHL have Normal
androgen levels.
 Pattern of hair loss isTHI...
5/28/2014
39
Telogen Effluvium
 Pattern of hair loss is diffuse shedding and
involves the entire scalp
 Re growth occurs...
5/28/2014
40
 Suspect androgen excess if:
-Features of SAHA are present
- Screen for PCOS/FreeTestosterone
- Treat with w...
5/28/2014
41
Thank you
Photo courtesy of www.DermNet NZ.org
sebrahim@telus.net
5/28/2014
42
 Trichotillomania.
 Traction Alopecia.
•A compulsion to pull/pluck hair repetitively.
•Impulse control diso...
5/28/2014
43
5/28/2014
44
5/28/2014
45
 Spontaneous resolution.
 Clomipramine vs desipramine.
5/28/2014
46
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Transcript of "Sat 1025-hair-management-too-much-too-little- -park"

  1. 1. 5/28/2014 1  Dr Shehla Ebrahim. MD,CCFP,FCFP. ( special interest dermatology)  I have no relevant conflicts of interest.  I have received an honorarium from the BC college for presenting this talk.
  2. 2. 5/28/2014 2  A full day of Hair loss.  Its going to be a long day  Non scarring Alopecia -MPHL/FPHL -Telogen Effluvium. -Alopecia Areata.  When is it more than just hair loss.  Clinical Scenarios and Key Messages
  3. 3. 5/28/2014 3
  4. 4. 5/28/2014 4  Onset and duration. “When was the last time you had a normal head of hair”?
  5. 5. 5/28/2014 5  Strong Family history is supportive of MPHL
  6. 6. 5/28/2014 6
  7. 7. 5/28/2014 7
  8. 8. 5/28/2014 8  Regularity of menses.  Fertility.  NOTE PATTERN OF HAIR LOSS.  Examine the scalp skin for inflammation, scaling, patches.  Examine the eyebrows, facial axillary and pubic hair.  Check for hirsuitism is suspected by history.
  9. 9. 5/28/2014 9 HAIR CYCLE ANAGEN 3 YEARS CATAGEN 3 Weeks TELOGEN 3MONTHS ANAGENANAGEN ANAGEN TELOGEN FEMALE PATTERN HAIR LOSS MALE PATTERN HAIR LOSS TELOGEN EFFLUVIUM ALOPECIA AREATA ANDROGEN EXCESS
  10. 10. 5/28/2014 10  95% of hair loss .  50% of men and 40% of women. CLINICAL PEARL  They have completely normal androgen levels. CLINICAL PEARL Retention of the frontal hair line
  11. 11. 5/28/2014 11
  12. 12. 5/28/2014 12 HAIR CYCLE ANAGEN 3 YEARS CATAGEN 3 WEEKS TELOGEN 3 MONTHS ANAGENANAGEN ANAGEN TELOGEN  TSH.  Ferritin - No studies showing reversal of hair loss with iron supplementation. - Keep Ferritin above 50 ug/L Trost et al JAAD 2006;54(4) 824-844.
  13. 13. 5/28/2014 13  Topical Minoxidil 2% and 5%  Mainly acts on the hair cycle by lengthening the duration of the anagen plus enlarges the miniaturized hair follicles Messenger,AG Brit J dermatology 2004;150:186:194.  Adverse effects (higher 5%) - Irritation. - Contact Dermatitis (propyleneglycol) -NonVirilising Hypertrichosis. - High degree of variability in cosmetic acceptance. - 5% foam OD vs. 2% BID. Lucky et al JAAD 2004:50;541-553
  14. 14. 5/28/2014 14  Androgen receptor blocker and inhibits steroid androgen production.  Threshold of response acne>Hirsuitism> FPHL  Concurrent BCP -breast tenderness. - Feminization of male foetus  200 mg per day. Sinclair, R Brit J dermatology 2005;152:466-473
  15. 15. 5/28/2014 15  Thinning is Bitemporal +/-the crown of the scalp. CLINICAL PEARL • The sides are spared
  16. 16. 5/28/2014 16  Type 11, 5 alpha reductase inhibitor.  Inhibits the conversion of testosterone to DHT.  1 mg in MPHL.( Kaufman et al) -benefits are temporary. - Decreased libido and ED.  Not indicated for use in women. Canadian Family PhysicianVol 46 July 2000 FEMALE PATTERN HAIR LOSS MALE PATTERN HAIR LOSS TELOGEN EFFLUVIUM ALOPECIA AREATA ANDROGEN EXCESS
  17. 17. 5/28/2014 17  Febrile illness  Childbirth  Severe psychological stress  Major surgery  Hypo or hyperthyroidism  Iron deficiency anaemia  Crash diets  Drugs HAIR CYCLE ANAGEN 3 YEARS CATAGEN 3 WEEKS TELOGEN 3 MONTHS ANAGEN TELOGEN
  18. 18. 5/28/2014 18
  19. 19. 5/28/2014 19  Identify specific cause.  Complete recovery occurs in 4-6 months.  Minoxidil 5%
  20. 20. 5/28/2014 20 FEMALE PATTERN HAIR LOSS MALE PATTERN HAIR LOSS TELOGEN EFFLUVIUM ALOPECIA AREATA ANDROGEN EXCESS  Polygenic Autoimmune disorder.  It attacks the anagen hair follicles of the scalp,face and body  Majority Appear sporadically and it can appear without a family history. Canadian family PhysicianVol 46,July 2000
  21. 21. 5/28/2014 21  AA is associated with other AA diseases such as vitiligo,Diabetes,Thyroid disease, pernicious anemia  Spontaneous remissions can occur. Dermatology in PracticeVol 11 no 5  Patchy. (Most common)  Diffuse.  Confluent.  Aphyiais.
  22. 22. 5/28/2014 22
  23. 23. 5/28/2014 23
  24. 24. 5/28/2014 24  T cell mediated disorder.  Immune privilege of the hair follicle is lost.  Once activated, the cytotoxicT cells produce inflammatory cytokines and IL which attack the anagen hair follicles of the scalp, eyebrows, eyelashes and body  Nail Dystrophy (pitting, ridging, thinning)  Exclamation marks, are seen at the periphery of the patch  Color changes in the hair
  25. 25. 5/28/2014 25
  26. 26. 5/28/2014 26  ADULTS WITH < 50% HAIR LOSS -Observe for several months - Intralesional steroids.kenalog q4-6 weeks - Potent topical steroids.OD for 3 months - +/- Minoxidil  ADULTS WITH > 50% HAIR LOSS. -Topical immunotherapy with DPCP (diphenylcyclopropenone) -Psoralen and Ultraviolet A (PUVA) - Pulsed Oral Steroids
  27. 27. 5/28/2014 27 FEMALE PATTERN HAIR LOSS MALE PATTERN HAIR LOSS TELOGEN EFFLUVIUM ALOPECIA AREATA ANDROGEN EXCESS  Most women with FPA show no clinical or biochemical evidence of hair loss. -Hypersensitive to physiologic concentration of androgens  When to evaluate for PCOS or metabolic Syndrome?
  28. 28. 5/28/2014 28  Increased Facial Seborrhea  Acne that fails to respond to standard therapies. Localized to the jaw line and neck  Hirsuitism; upper lip, chin breast and linea alba  Androgenic Alopecia, early onset < 35 years.  Menstrual Irregularities.  Infertility.  Galactorrhea  Virilization
  29. 29. 5/28/2014 29  Polycystic ovary Syndrome(90%) Prevalence 5-10%  Tumours of the ovary or adrenal gland(<0.5%  Hyperprolactinemia(2.3%)  Congenital adrenal hyperplasia (1.3%)  Cushings syndrome  Androgenic medications (danazol, anabolic steroids, progestin releasing IUD Glint &Anderson,gynecol endocrinol 2010:26:281-96  Testosterone (free and total)  Sex hormone binding globulin (SHBG)  Dehydroepiandrosterone sulphate(DHEAS)  Prolactin  LH/FSH  Fasting Glucose/insulin  Lipid profile. Ding,EL et al NEJM 2009:361:1152-1163
  30. 30. 5/28/2014 30 MH.Age 23  Testosterone 2.0 nmol/L (0.5-3.2)  Testosterone Free 180 pmol/l ( 5-60)  SHBG 3 nmol/L ( 5-100)  Cholestrol 7.16 H ( 2-4.60 nmol/L)  LDL 4.83 H (1.50-3.00)  TGA 3.9 (<2.21)  HDH 0.19 nmol/L (1.19)
  31. 31. 5/28/2014 31  Weight loss  Oral Contraceptives  Anti androgen medications -Spironalactone -Cyproterone Acetate  Insulin Sensitizing medications. -Metformin
  32. 32. 5/28/2014 32  A 20 year old female with steadily thinning hair over the past several years.  Otherwise in good health.
  33. 33. 5/28/2014 33 FEMALE PATTERN HAIR LOSS  45 year old woman with considerable hair loss during the last 6 months.  “Massive” amounts of hair are clogging the shower drain every day  During the same period of time she has felt “depressed "fatigued and lacking in her usual energy
  34. 34. 5/28/2014 34 TELOGEN EFFLUVIUM
  35. 35. 5/28/2014 35  36 year old man has noticed bald patches of hair loss on his scalp and more recently his beard area.  He is otherwise in good health.
  36. 36. 5/28/2014 36 ALOPECIA AREATA  23 year old overweight female complaining of scalp thinning,increased facial hair.  History of irregular periods since puberty.  Family history balding.
  37. 37. 5/28/2014 37
  38. 38. 5/28/2014 38 ANDROGEN EXCESS MPHL/FPHL  Patients with FPHL/MPHL have Normal androgen levels.  Pattern of hair loss isTHINNING -Retention of frontal hair line FPA - Sides are spared in MPHL
  39. 39. 5/28/2014 39 Telogen Effluvium  Pattern of hair loss is diffuse shedding and involves the entire scalp  Re growth occurs in 4-6 months  Alopecia Areata  Look for exclammation marks,white hairs and nail changes.  Wait for 6-9 months as spontaneous resolution is common.
  40. 40. 5/28/2014 40  Suspect androgen excess if: -Features of SAHA are present - Screen for PCOS/FreeTestosterone - Treat with weight loss, Antiandrogen  Do not underestimate the psychological impact that Hair loss has on your patients.  These patients feel vulnerable as hair gives them character and definition.  National AA foundation.  Local wig makers.  Eyebrow and Eyelid tattooing
  41. 41. 5/28/2014 41 Thank you Photo courtesy of www.DermNet NZ.org sebrahim@telus.net
  42. 42. 5/28/2014 42  Trichotillomania.  Traction Alopecia. •A compulsion to pull/pluck hair repetitively. •Impulse control disorder •7x more frequent in children. •With increasing age, girls
  43. 43. 5/28/2014 43
  44. 44. 5/28/2014 44
  45. 45. 5/28/2014 45  Spontaneous resolution.  Clomipramine vs desipramine.
  46. 46. 5/28/2014 46

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