What is Alopecia Areata? Male & Female Pattern Hair Loss

Alopecia means loss of hair from the head or body. Generally, some hair loss is normal but when it is excessive, leading to thinning of hair density, the term ‘Alopecia’ is used. Alopecia is classified into various types, based on the type and pattern of hair loss.

Alopecia Areata Classification:

• A typical balding pattern of a man is called Androgenetic Alopecia.
• Loss of hair from the frontal area in females is called female pattern baldness.
• Loss of hair in a round circular pattern is called Alopecia Areata.
• Sometimes the hair gets pulled out due to tight ponytails or braids – a condition called traction Alopecia.
• Psychological compulsive pulling of hair is called Trichotillomania.
• When the hair loss is without a pattern and just excessive hair falls off, a term called ‘Diffuse hair losses’ is used. It can happen in a variety of systemic diseases, because of drugs or in nutritional and iron deficiency.
• Hair loss may also be classified based on the phases of hair growth namely Anagen effluvium and Telogen effluvium.

Alopecia Signs and Symptoms: 

The symptoms of Alopecia are either excessive hair loss or thinning of hair or the appearance of a bald patch.

Common Causes:

• Genetic: Androgenetic, hereditary disorders, hair shaft defects.
• Infections: Fungal infections (tinea capitis, dissecting cellulitis).
• Hair treatments: Chemicals in relaxers, hair straightness.
• Hormonal changes: Increased androgens in females, hyperthyroidism, hypothyroidism, etc.
• Systemic diseases: Diabetes, collagen vascular diseases (SLE), syphilis.
• Medications: Side effects of drugs, including chemotherapy, anabolic steroids, birth control pills.
• Hypervitaminosis A.
• Scalp diseases like Pseudopelade of Brocq.
• Radiation therapy.
• Due to wrong hairstyling – Traction Alopecia.
• After a severe systemic disease such as Telogen effluvium.
• Psychiatric illness-causing compulsive hair pulling – Trichotillomania.

Clinical Evaluation: A physician should normally examine the following:

• Distribution of hair loss.
• A pattern of hair loss.
• Condition of hairs and hair shaft defects, if any.
• Condition of underlying scalp skin and any scalp diseases.
• Presence of scarring or non-scarring.
• Systemic evaluation of the patient and if he is suffering from any disease.
• Nutritional deficiencies.
• Hormonal evaluation and concerning history.
• Drugs if any, which patient is taking, and if those could be responsible.

Diagnosis:

The diagnosis in most cases is straightforward, based on clinical examination and history. However, in some cases, additional tests may be required to establish the cause of hair loss.

These tests may include:

• The pull test: This test helps to evaluate diffuse scalp hair loss. Gentle traction is exerted on a group of hair (about 40-60) on three different areas of the scalp.

The number of extracted hairs is counted and examined under a microscope. Normally, fewer than three hairs per area should come out with each pull. Roughly, if more than ten hairs are obtained, the pull test is considered positive.

• The pluck test: In this test, the hair is pulled out by the root. The root of the plucked hair is examined under a microscope to determine the phase of growth and used to diagnose the defect.

Telogen hairs have tiny bulbs without sheaths, while Anagen hair has large bulbs with a sheath attached to the roots. Telogen effluvium shows an increased percentage of Telogen hairs and Anagen effluvium has increased Anagen hair on examination.

• Scalp biopsy: This test is done to differentiate between scarring and non-scarring hair loss and sometimes to diagnose the scalp condition causing hair loss.

• Daily loss of hair count: This is normally done when the pull test is negative. It is done by counting the number of hairs lost. The hairs that should be counted are the hairs from the first-morning combing or during washing.

The hair is collected in a clear plastic bag for 14 days. The strands are recorded. If the hair count is more than 100 per day, it is considered abnormal.

• Trichoscopy: Trichoscopy is a non-invasive method of examining hair and scalp. The test may be performed with the use of a handheld dermoscopy or a video dermoscopy it allows differential diagnosis of hair loss in most cases.

Hair Cycle:

Every hair goes through three cycles of growth: A long growing phase called Anagen, a short transitional phase Catagen and a short resting Telogen. At the end of the resting phases (Telogen), the hair falls out and new hair starts growing in the follicle, beginning the cycle again.

Since 100 hairs reach the end of the Telogen phase every day, hence, hair loss of up to 100 per day is normal. When more than 100 hairs fall out every day, it is abnormal. Most hair loss occurs as Telogen effluvium, but if the disruption of hair occurs in the Anagen phase it is called Anagen effluvium.

Systemic Investigation:

A physician will have to do a systemic investigation based on the clinical evaluation and these tests may include:

• Hemoglobin
• Thyroid function test
• Serum Iron and ferritin levels
• Testosterone and androgen levels
• FSH LH levels
• ANA
• Drug history
• Any other tests, as the doctor may seem fit

If hair loss occurs in a young man with no family history, the physician should question the patient on illicit drug use.

Management of Male Pattern Baldness:

1. Minoxidil: This is a medication approved for Androgenetic Alopecia and Alopecia aerate. Minoxidil comes in a liquid or foam form that is rubbed into the scalp twice a day. This is one of the most effective methods to treat male-pattern and female-pattern hair loss.

However, only 30-40 percent of patients experience hair growth. Hair re-growth can take eight to 12 months. Treatment is continued indefinitely because if the treatment is stopped, hair loss resumes again. The most frequent side effects are mild scalp irritation, allergic dermatitis, and increased facial hair.

2. Finasteride: It is used in male-pattern hair loss in a pill form taken on a daily basis. Finasteride is not indicated for women and is not recommended in pregnant women Treatment is effective within six to eight months of treatment.

Side effects may include decreased libido, erectile dysfunction, gynecomastia, and myopathy. Treatment should be continued as long as positive results occur. Once treatment is stopped, hair loss resumes again.

3. Nutritional Supplements: Nutritional supplements like biotin, selenium, amino acids, and iron can help in hair growth by strengthening the hair from within. This may be especially relevant for people known to be deficient in these.

Other Hair Supplements:

Using supplements with AminoMar C for 4-6 months is clinically proven to encourage normal healthy hair growth, making hair stronger and more vibrant.

Treatment of Alopecia Areata:

• Minoxidil (both 2% and 5%), when applied locally, helps Alopecia Areata.
• Corticosteroids: injections of cortisone into the scalp can be used to treat Alopecia Areata. This type of treatment is repeated on a monthly basis. Physicians may prescribe oral pills for extensive hair loss due to Alopecia Areata. Results may take up to a month to be seen.
• Anthralin: Available as a cream or ointment that is applied to the scalp and washed off daily. More commonly used to treat Alopecia Areata and Psoriasis of the scalp. Results may take up to 12 weeks to be seen.
• Topical calcineurin inhibitors: Tacrolimus and pimecrolimus ointments have shown promise in curing Alopecia Areata.
• Phototherapy: Tropical PUVAsol therapy can also be tried in Alopecia Areata.

Management of Female Pattern Hair Loss:

• Minoxidil 2% and 5% are prescribed based on the severity of hair loss.

• Iron and Nutritional (folic acid, biotin) supplements.

• Hormonal modulates: Oral contraceptives or anti-androgens like spironolactone and flutamide can be used for female-pattern hair loss associated with hyperandrogenemia.

• Surgical options: Various surgical options such as follicle transplant, scalp flaps, and alopecia reduction are available. These procedures are generally chosen by those who are self-conscious about their hair loss.

• Hair transplant: A dermatologist or plastic/cosmetic surgeon takes tiny follicles from the scalp and implants them into bald sections. The plugs are generally taken from the back or sides of the scalp and implanted in frontal bald areas. Several transplant sessions may be necessary.

• Scalp reduction: This process is the decreasing of the area of bald skin on the head. After the hairless scalp is removed, space is closed with a hair-covered scalp. Scalp reduction is generally done in combination with hair transplantation to provide a natural-looking hairline, especially for those with extensive hair loss.

Camouflage:

Wigs: As an alternative to medical and surgical treatments, some patients wear a wig or hairpiece. They can be used permanently or temporarily to cover hair loss. Good quality and natural-looking wigs and hairpieces are available.

Hair Weaving: A wig is weaved with natural hair and the advantage is that it is fixed to the scalp and thus looks more natural than a general wig. However, these natural wigs have to be tightened every 2-3 months.