Alopecia / Hair loss disorder/ Baldness

What is it?

Alopecia is partial or complete loss of hair. It usually develops gradually and may be patchy or diffuse (all over). One can lose up to 100 hair from the scalp everyday.

Baldness is not usually caused by disease. It is also related to aging, heredity or changes in the hormones. There may be male pattern baldness or female pattern baldness.

Who get affected?

• Alopecia can affect males and females in equal numbers. 
• Can occur at any age, but most people get it in their teens, twenties, or thirties. 
• When it occurs in children younger than age 10, it tends to be more extensive and progressive.
• Affects all racial and ethnic groups. 
• If you have a close family member with the disease, you may have a higher risk of getting it, but for many people, there is no family history.

What are the causes?

There are many reasons which include the following:

Hair Disorders

Hereditary thinning or baldness: 

• Also called androgenetic alopecia. 
• Regarded as the most common cause of hair loss. 
• In men, it is seen as a receding hairline as well as hair loss on top of the scalp. 
• In women, tends to have their hairline and have visible thinning of hair  over the front and top of the scalp.

Alopecia areata:

• An autoimmune disease that causes hair loss on the scalp and elsewhere on the body. 
• Develops in people of all ages and hair is lost in patches.
• Persons with certain autoimmune diseases, such as psoriasis, thyroid disease, or vitiligo, are more likely to get alopecia areata, and with allergic conditions such as hay fever. 

Cicatricial (scarring) alopecia: 

• Can develop in  otherwise healthy men and women, 
• A rare condition that destroys hair follicles. 
• Scar tissue forms where the follicles once were and re-growth is not possible. 
• Treatment attempts to stop the inflammation that destroys the hair follicles.

Diseases:

Underlying medical condition: 

• Hair loss is regarded as warning sign for about 30 diseases. 
• Hair loss often can be stopped or reversed with treatment for the underlying disease. 
• Medical conditions that lead to hair loss are thyroid disease and anemia caused by an iron deficiency. 

Cancer treatments: 

• Radiation therapy and some chemotherapeutic medications can also cause hair loss. 
• While hair loss is usually temporary, it can be the most distressing part of therapy. 

Ringworm of the scalp: 

• Hair loss can also be caused due to  fungal infection, which is most common in children, can cause balding and scaling on the scalp. 

Trichotillomania:

• In this people repeatedly pull out their own hair. 
• Aside from a constant urge to pull out the hair on the scalp, sufferers often say they feel compelled to pull out their eyelashes, nose hair, eyebrows, and other hair on their bodies.

Stress and Hormones:

Stress: 

Hair loss can also occur 

• If a person is mentally or physically stressed, 
• After a major surgery, 
• High fever, 
• Severe infection, 
• or even flu. 

Hormone fluctuations: 

• Any change in hormonal levels especially in women. 
• Common during menopause and after childbirth due to falling oestrogen levels. 
• The loss is usually temporary. 
• Hair can be re grown .

Diet:

Weight loss: 

• People having weight issues. 
• Very common, and hair growth does return to normal with proper diet and weight. 

Vitamin A excess: 

• Intake of too much vitamin A through vitamin supplements or medications can also lead to hair loss. 

Protein intake too low:   

• When the body is not getting enough protein, it conserves the protein. 
• It does get by shifting hair growth into the resting phase. 
• Within 2 to 3 months, the person usually sees visible hair loss. 
• This can be reversed and prevented by eating enough protein.  

Iron intake too low: 

• Consuming too little iron can lead to hair loss. 
• Good vegetarian sources of iron are iron-fortified cereals, soybeans, pumpkin seeds, white beans, lentils, and spinach. 
• Clams, oysters, and organ meats top the list of good animal sources of iron. 

Eating disorder:

• An eating disorder such as anorexia or bulimia is the other cause of hair loss.

Medication:
Medications that can cause hair loss include:

• Blood thinners
• High-dose vitamin A
• Medicines for arthritis, depression, gout, heart problems, and high blood pressure
• Birth control pills: Usually occurs in women with an inherited tendency toward hair thinning.

Hair Care Practices:

Hair cosmetics:  

• Frequent coloring of hair. 
• Regular or improper use of dyes, gels, relaxers, and sprays.
• Dermatologists recommend limiting use of these hair cosmetics to reduce hair breakage. 

Blow dryers, flat irons, and similar devices:

• Regular use of a blow dryer tends to damage hair. 
• The high heat from a blow dryer can boil the water in the hair shaft leaving the hair brittle and prone to breakage. 
• Allowing the hair to air dry and styling  it only when dry will lessen this risk. 
• Dermatologists also recommend limiting the use of flat irons, which straighten hair by using high heat, and other devices such as curling irons.

Hairpins, clips, and rubber bands: 

• If hair are held tightly with hairpins, clips, and rubber bands, it can break hair. 
• One should use loosely fitting clips and wear them in different areas of the scalp so that hair breakage is not localized in a specific area.

Too much or vigorous grooming: 

• Regular shampooing, combing, or brushing (100 strokes or more a day) or doing any of these too vigorously can cause hair breakage. 
• When hair breakage occurs, the hair appears shaggy or too thin. 

How diagnosis is done?

Dermatologists can diagnose hair loss by asking questions about medical history, family history. A dermatologist may also carefully look at the scalp  to know the condition of scalp.

Key history: 

• Onset, duration, quantity and rate of loss 
• Localized or generalized loss 
• Associated symptoms (e.g. pruritus, scaling, pustules) 
• Systems review including fever, acute illness, surgery, stressors 
• Endocrine features 
• Past history including skin disorders, cancer, thyroid disorders 
• Family history of hair loss

Key examination:

• General review with emphasis on endocrine system and examination of scalp 
• Look for exclamation mark hair, ‘white bulb’ hair, state of bald patch (clean, scaly, scarred or inflamed) and the unusual pattern of trichotillomania

Key investigations: 

• FBE/ESR 
• Pituitary hormones (FSH/LH/prolactin/FSH) 
• Hair pull test 
• Trichogram 
• Scalp biopsy 
• Skin scrapings and hair sample for fungal microsurgery and culture

How management is done?

Treatment of hair loss depends upon the cause of disease. 

Minoxidil: 

• Applied to the scalp. 
• Can stop hair from getting thinner and also stimulate hair growth on the top of the scalp. 
• Only hair re-growth product approved for men and women. 
• A dermatologist generally combine minoxidil with another treatment.

Laser devices: 

• Brushes, combs, and other hand-held devices that emit laser light also stimulate hair growth. 
• These devices might make hair look more youthful in some people. 
• The long-term effectiveness and safety for these devices are not known.

Prescription medicine:

Finasteride: 

• FDA approved 
• Treat men with hair loss. 
• Slow hair loss in most (about 88%) men. 
• Helps stimulate hair re-growth in many (about 66%) men. 
• Works by stopping the body from making a male hormone, dihydrotestosterone (DHT).

Corticosteroid: 

• If hair loss is caused by inflammation in body, a dermatologist may inject a medicine called a corticosteroid into scalp. 
• This can help stop the inflammation that happens when a person has alopecia areata. 
• A corticosteroid is different from an anabolic steroid.

Procedures:
The type of procedure will depend on how much hair you have lost. To achieve the best results, a dermatologist may use one or more of the following procedures:

Hair transplantation: 

• Skin on the scalp that has good hair growth is removed and transplanted to areas of the scalp that need hair.

Scalp reduction: 

• Bald scalp is surgically removed and hair-bearing scalp is brought closer together to reduce balding. 
• Scalp reduction surgery can be performed alone or in conjunction with a hair transplant.

Scalp expansion: 

• Devices are inserted under the scalp for about 3 to 4 weeks to stretch the skin. 
• This procedure may be performed before a scalp reduction to make the scalp more lax. 
• It also can be performed solely to stretch hair-bearing areas, which reduces balding.

Scalp flaps: 

• A hair-bearing segment of scalp is surgically moved and placed where hair is needed.

References:

1. Atkinson K. John Murtagh's general practice companion handbook 6th edition. Australian Journal of General Practice. 2016 Jul 1;45(7):528.
2. https://www.nhp.gov.in/disease/skin/alopecia-hair-loss
3. https://rarediseases.org/rare-diseases/alopecia-areata/
4. https://www.niams.nih.gov/health-topics/alopecia-areata