Hair diseases are disorders primarily associated with the follicles of the hair. Many hair diseases can be associated with distinct underlying disorders. Hair disease may refer to excessive shedding or baldness (or both). Balding can be localized or diffuse, scarring or non-scarring.

1. Hair Disorders
Primary Health Care
Dr. Wajahat Mohammad
Consultant Family Medicine

2. Disclosure Of Conflict of Interest
I Dr. Wajahat Mohammad
 DO NOT have a financial interest/arrangement or affiliation with anyone in relation
to this program/presentation/organization that could be perceived as a real or
apparent conflict of interest in the context of the subject of this presentation.
 Purely educational intent
 Recommendations are based on current evidence
 References provided where possible

3. Summary
 Common Hair Loss disorders
 Primary care management of hair loss disorders
 Referral Criteria for hair loss disorders
 Beyond Hair Loss ‘the symptom’

4. 4

6. Hair Cycle
 Anagen - Growth (2-6 years)
 Catagen - Involution (10-21 days)
 Telogen - Resting (90-100 days)
 Exogen - Shedding

7. Hair Disorders
More Hair
 Hypertrichosis (Ambras Syndrome)
 Hirsutism
Less Hair
 Hair Loss
 Trichodystrophy

8. Hair Loss Categorization
Non Scarring
 Alopecia Areata
 Androgen Alopecia
 Telogen Effluvium
 Trcihotillomania
 Ringworm
 Traction Alopecia
* Visible follicles
Scarring
 Chronic Discoid Lupus
Erythematosus
 Lichen Planus
 Lichen Scelorosus
 Morphea ( localised scleroderma)
 Others
cancers/trauma/Infection
* Follicles not visible

9. Assessment - History
 Onset, Duration and Precipitants
 Pattern ( Diffuse vs Patchy)
 Scarring
 Shedding vs Breaking vs Thinning
 Medical History
 Drug History
 Family History
 Hair Care
 Diet

10. Assessment - Examination
 Inspection
Scalp: Scarring?
Scaly?
Erythema?
Pattern: Diffuse
Patchy
Density
Hair Quality
 Pull Test

11. Assessment Investigation
 Ferritin
 Hormones
 Sex Hormones
 ANA
 Syphilis
 Scalp Scraping

12. Clinical Vignette
 35 year old male
 2 months history of Hair loss
 No itching
 No trauma
 No other medical conditions
 Diagnosis?
 Treatment Options
 Would you Refer onward?

13. Alopecia Areata
 Chronic Inflammatory Dermatological Disorder
 Unknown etiology
Factors: Autoimmune, Environment and Genetics
 Non scarring
 Patchy or Complete
 80% regrowth in Mild Alopecia
 34-40% Recover in 1 year
 Progressive 14-25%

14. Prognostication
 Multiple lesions on scalp margins
 Involvement of Eyebrows and eye lashes
 Nail Changes
 Associated Atopy
 Childhood Onset
 Chronic Extensive disease
 Downs Syndrome
 Associated Autoimmune diseases

15. Management
 No Treatment – an option
 Topical steroids
 Intralesional Triamcinolone
 Topical Immunotherapy ( Diphenylcyclopropenone, squaric acid dibutyl ester or
dinitrochlorobenzene))
 Topical Minoxidil 2% and 5%
 PUVA
 Anthralin
 Methotrexate, azathioprine, oral steroids
 Less effective- TNF Alpha Inhibitors, Statins, chloroquine
 Ineffective- Tacrolimus, Cyclosporin –topical

16. Referral Criteria
 Extensive disease
 Diagnostic Uncertainty
 Psychological Distress
 Pregnant and breast feeding
 Topical Treatment not helpful
 Wig is required

17. Clinical Vignette
 40 year lady
 gradual loss of hair over 6
months
 Diabetes Mellitus
 Height 155 cm
 Weight 92 kg
 What Else do we ask?
 Diagnosis?
 Treatment?
 Will you refer?

18. Female Pattern Hair Loss
 Andro-Genic Alopecia in women
 Unclear etiology
 Suspected disorder of sensitivity to Dihydrotestosterone
 3-6% in <30 yrs age, 29-42% in >70 yrs age
 Frontal Hair line Spared in women
 Usually progressive once develops
 Very Rare progression to complete Baldness

19. Management
 Baseline Testosterone and Dehydroepiandrosterone sulfate
 Topical Monoxidil is first line,
2% to 5% BD, can take 4 months to show improvement.
 Antiandrogen medication
Spironolactone
Cyproterone acetate
Finasteride
 Psychological support
 Surgical Options

20. Clinical Vignette
 25 year lady
 Losing handsful of hair
 Sudden onset
 Has a 2 month old son with
her
 Feeling Tired
 What else is relevant to ask?
 Management?
 What Tests?

21. Telogen Effluvium
 Acceleration of Hair Loss cycle
 More hair in telogen phase than anagen phase (upto 50%)
 Usually triggers found from history
 Pull Test Positive

22. Triggers
 Acute or chronic major illness
 Febrile illness
 Major surgery
 Childbirth (telogen gravidarum)
 Rapid weight loss
 Protein or caloric dietary restriction
 Congenital or acquired zinc
deficiency
 Significant emotional stress
 Collagen vascular disease
 Endocrine disorders (eg,
hypothyroidism or hyperthyroidism)
 Drugs, supplements, or toxins
 Inflammatory conditions of the scalp
(eg, seborrheic dermatitis)
 Infectious conditions that affect the
scalp (eg, fungal, bacterial, or
spirochetal)
 Iron deficiency anemia
 Nutritional deficiencies

23. Drugs associated with Telogen Effluvium
 Allopurinol
 Androgens
 Anticholesterol agents (statins)
 Anticoagulants
 Anticonvulsants
 Antifungals
 Antihistamines (H2)
 Antiinflammatory agents
 Antimitotic agents
 Antithyroid agents
 Beta blockers
 Dopa
 Ergots
 Heavy metals
 Hormones (oral contraceptives,
hormone replacement therapy)
 Immunomodulators
 Retinoids
 Psychotropics
 Minoxidil
 Selective estrogen receptor modulators
and phytoestrogen

24. Management of Telogen effluvium
 Investigate with CBC, CMP, TFT and Ferritin
 Treat Underlying Cause
 Psychological Support
 Cosmetic advice
 Topical Minoxidil

25. Beyond Hair Loss
 Effects of hair loss
 Interpretation of hair loss
 Socio-economic consequences

26. Quiz

27. Alopecia Areata

28. Androgenic
Alopecia

29. Post Cellulitis
Scarring Alopecia

30. Morphea

31. Pustular Cellulitis

32. Female Pattern Hair
Loss

33. Keroin

34. Folliculitis Related
Alopecia

35. Lichen Planus
Scarring

36. Androgenic
alopecia in men

37. Pemphigoid Associated alopecia

38. Moth Eaten
Apperance of
syphilitic Alopecia

39. Traction
Alopecia

40. Traction
Alopecia

41. Tinea Capitis
associated
alopecia

42. Trichotillomania

43. Female pattern
Hair Loss

44. Useful resource

45. References:
 KARYN SPRINGER,M.D.,MATTHEW BROWN,M.D.,and DANIEL L.STULBERG,M.D.
Utah Valley Family Practice Residency,Provo,Utah, Am Fam Physician 2003;68:93-
102,107-8
 HUNT N, McHale S, Psychological Impact of Alopecia, BMJ 2005, 331(7522):951-
953
 BLUME-PEYTAARI U et al: Guideline for diagnostic evaluation in androgenetic
alopecia in men, women and adolescents, British Journal of Drematology 2011, 164
(1):5-15
 UKPDCS
 GP Notebook
 Uptodate