Alopecia

Types of Hair Loss/Alopecia

Types of Alopecia

Type of Alopecia	Pathology	Age of Onset	Symptoms	Risk Factors	Differentials	Diagnosis	Treatment
Androgenetic Alopecia	Miniaturization of hair follicles influenced by androgens	Varies; men in their 20s-30s, women usually post-menopausal	Thinning in the crown area in men, diffuse thinning in women	Genetics, androgens	Telogen effluvium, alopecia areata	Clinical presentation, family history, pattern of hair loss, scalp biopsy if uncertain	Minoxidil, finasteride, hair transplantation
Alopecia Areata	Autoimmune destruction of hair follicles	Any, often in childhood or young adults	Sudden loss of hair in patches, potential progression to total scalp (alopecia totalis) or body hair loss (alopecia universalis)	Autoimmune diseases, family history	Tinea capitis, trichotillomania	Exclamation mark hairs, spontaneous regrowth, biopsy for definitive diagnosis	Corticosteroids, topical immunotherapy, JAK inhibitors, wigs
Telogen Effluvium	Shift of hair follicles into the telogen phase	Common in women, especially postpartum	General thinning of hair, often temporary	Major surgery, childbirth, severe illness, extreme stress	Androgenetic alopecia, anagen effluvium	History of triggering event, diffuse shedding, trichogram	Address underlying cause, gentle hair care, nutritional support
Anagen Effluvium	Rapid loss of anagen hairs due to toxic insult (e.g., chemotherapy)	During exposure to causative agent	Sudden, diffuse hair loss	Chemotherapy, radiation	Alopecia areata, telogen effluvium	History of drug exposure or radiation, diffuse hair loss	Removal of causative agent, gentle hair care
Traction Alopecia	Hair loss due to pulling force	More common in women and individuals with certain hairstyles	Gradual hair loss, primarily around the hairline	Tight hairstyles, hair extensions	–	Clinical examination, history of hairstyle	Avoid tight hairstyles, change to less damaging hair practices
Tinea Capitis	Fungal infection of the scalp	Common in children	Scaly, itchy scalp, hair breakage	Close contact, poor hygiene	Alopecia areata, seborrheic dermatitis	Clinical presentation, Wood’s lamp examination, KOH preparation, culture	Antifungal medications (oral and topical)
Scarring Alopecia	Destruction of hair follicles leading to permanent hair loss	Variable, depending on underlying cause	Patchy hair loss with signs of skin changes (redness, scaling)	Autoimmune diseases, infections	Non-scarring alopecias, cutaneous lupus erythematosus	Clinical examination, biopsy to confirm scarring and identify pathology	Immunosuppressive treatments, avoidance of further damage

Androgenetic Alopecia:

• Pathology: Miniaturization of hair follicles influenced by androgens.
• Differentials: Telogen effluvium, alopecia areata.
• Age of Onset: Varies; men in their 20s-30s, women usually post-menopausal.
• Diagnosis: Clinical presentation, family history, pattern of hair loss. Consider scalp biopsy if diagnosis is uncertain.

Alopecia Areata:

• Pathology: Autoimmune destruction of hair follicles.
• Symptoms: Sudden loss of hair in small patches, which can progress to total scalp hair loss (alopecia totalis) or complete body hair loss (alopecia universalis).
• Risk Factors: Autoimmune disease, family history.
• Differentials: Tinea capitis, trichotillomania.
• Age of Onset: Any, often in childhood or young adults.
• Diagnosis: Exclamation mark hairs, spontaneous regrowth. Biopsy for definitive diagnosis.

Telogen Effluvium:

• Who Gets It: Common in women, especially postpartum.
• Symptoms: General thinning of hair, often temporary and related to a stressful event.
• Risk Factors: Major surgery, childbirth, severe illness, extreme stress.
• Pathology: Shift of hair follicles into the telogen phase.
• Differentials: Androgenetic alopecia, anagen effluvium.
• Diagnosis: History of triggering event, diffuse shedding. Trichogram can be useful.

Anagen Effluvium:

• Pathology: Rapid loss of anagen hairs due to toxic insult (e.g., chemotherapy).
• Differentials: Alopecia areata, telogen effluvium.
• Age of Onset: During exposure to causative agent.
• Diagnosis: History of drug exposure or radiation, diffuse hair loss.

Traction Alopecia:

• Who Gets It: More common in women and individuals with certain hairstyles.
• Symptoms: Gradual hair loss, primarily around the hairline, due to pulling force being applied to the hair.
• Risk Factors: Tight hairstyles, hair extensions.

Tinea Capitis:

• Pathology: Fungal infection of the scalp.
• Differentials: Alopecia areata, seborrheic dermatitis.
• Age of Onset: Common in children.
• Diagnosis: Clinical presentation, Wood’s lamp examination, KOH preparation, culture.

Scarring Alopecia:

• Pathology: Destruction of hair follicles leading to permanent hair loss.
• Differentials: Non-scarring alopecias, cutaneous lupus erythematosus.
• Age of Onset: Variable, depending on underlying cause.
• Diagnosis: Clinical examination, biopsy to confirm scarring and identify underlying pathology.

Clinical History and Examination

• History Taking: Investigate onset, progression, pattern of hair loss, associated symptoms (itching, burning), family history, systemic diseases, medications, stressors, nutritional habits.
• Physical Examination: Examine the scalp for pattern of hair loss, signs of inflammation, scarring, and the presence of hair in different growth phases. Also, assess other body hair.

Signs and Symptoms

• Androgenetic Alopecia: Thinning in the crown area in men, diffuse thinning in women.
• Alopecia Areata: Round, smooth patches of baldness.
• Telogen Effluvium: Generalized hair thinning without bald patches.
• Anagen Effluvium: Sudden, diffuse hair loss.
• Tinea Capitis: Scaly, itchy scalp, hair breakage.
• Scarring Alopecia: Patchy hair loss with signs of skin changes (redness, scaling).

Investigations

• Blood Tests: FBC, thyroid function tests, iron studies, hormonal profile.
• Scalp Biopsy: Essential for diagnosing scarring alopecias, helpful in others if diagnosis is uncertain.
• Trichoscopy: Non-invasive, can distinguish between different types of hair loss.
• Hair Pull Test: To assess the activity of the disease.
• Dermoscopy: For identifying specific patterns and features of hair loss.

Treatment Considerations

• General Approach: Based on the specific type, severity, and patient preference.
• Medications: Minoxidil, finasteride (in men), corticosteroids – For alopecia areata.

(intralesional, topical, or systemic for alopecia areata or inflammatory conditions).

• Surgical Options: Hair transplantation for androgenetic alopecia.
• Behavioral & Lifestyle Modifications: Stress management, nutritional support.
• Alternative Therapies: Limited evidence but includes essential oils, low-level laser therapy.
• Referral: Dermatology referral for uncertain diagnosis or treatment resistant cases.
• Gentle Hair Care: Avoid tight hairstyles.
• Wigs or Hairpieces: To cover hair loss.

Management of Side Effects

• Minoxidil: Skin irritation, allergic contact dermatitis.
• Finasteride: Sexual dysfunction, mood changes.
• Corticosteroids: Skin atrophy, telangiectasias with prolonged use.

Follow-Up and Monitoring

• Regular follow-up to monitor response to treatment.
• Adjusting treatment based on efficacy and side effects.
• Screening for underlying systemic conditions if indicated.