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Alopecia

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Iqra Mazhar

Overview

Physicians have been using the term &ldquo;alopecia&rdquo; to describe hair loss since the time of Hippocrates. The term originated from the Greek word alōpēx which translates to &#39;fox&#39; in English<a href="#accordion">[1]</a>. This was because the condition appeared similar to the fur loss seen in foxes due to a skin disease called mange.

Alopecia is defined as a dermatologic condition characterized by a sudden or gradual loss of hair from one or more areas of the body, usually the scalp<a href="#accordion">[2]</a>.

The distressing medical condition affects both men and women. It can result from genetic factors, medical conditions, hormonal changes, or as a normal part of aging. Moreover, the different types of alopecia vary in severity.&nbsp;

The incidence and prevalence of alopecia depend on the cause of hair loss, geographical location, ethnicity, and age of the person. As per a study conducted among numerous ethnicities at Barnes Jewish Hospital in St Louis, United States, black participants had a higher incidence of hair loss (45.8%) than white participants (39.2%)<a href="#accordion">[3]</a>.

Although hair loss affects both men and women, it is not accepted equally by these two genders. For men, any form of hair loss or baldness is seen as a sign of aging. For women, hair loss is mostly perceived negatively.

This is not surprising considering that hair has long been associated with beauty, femininity, and sexual desirability in females. Women often relied on their luscious locks to attract men and secure good husbands.&nbsp;

Moreover, in several cultures, a shaved head was meant to point out &#39;dishonorable&#39; women. During the Battle of France (1940), French women had to shave their heads as punishment for having relationships with German soldiers.

While hair loss is something personal, its social connotations often lead to psychological distress in people, especially women even though the notion of beauty and the importance of hair has significantly altered with time<a href="#accordion">[5]</a>. Both women and men have come to realize that one&rsquo;s beauty is not defined by their hair. And nor are they limited in any way by their hair loss. But, if left untreated or poorly treated, the experience remains traumatic.&nbsp;

&nbsp;

Alopecia is of several types. Hair loss is broadly classified into scarring and nonscarring alopecia<a href="#accordion">[6]</a>.

<h5> 
Non-Scarring Alopecia</h5>

In non-scarring alopecia, the hair follicles have the potential to grow hair. The different types of non-scarring alopecia are: 
&nbsp;

<ul>
	<li>Androgenic Alopecia - Also called &lsquo;male pattern baldness&rsquo; and &lsquo;female pattern baldness&rsquo;, it is the most common type of hair loss. It affects up to 50% of men and women<a href="#accordion">[7]</a>.</li>
</ul>

&nbsp;

The genetic condition is linked to excess levels of male hormones (androgens). In women, thinning of hair occurs all across the scalp whereas in men, hair loss occurs above the temples, and thinning of hair affects the crown of the head.&nbsp;<a href="https://www.merisehat.pk/disease/polycystic-ovary-syndrome-pcos" target="_blank">Polycystic ovarian syndrome (PCOS)</a> can also result in this type of alopecia.&nbsp; 
&nbsp;

<ul>
	<li>Alopecia Areata - This is an autoimmune condition characterized by the immune system attacking the body&rsquo;s hair follicles. People can lose hair not only from the scalp but also from the eyebrows, eyelashes, and other parts of the body. Patches of baldness can even affect the entire body (alopecia universalis). Both adults and children can develop alopecia areata. Moreover, people with other autoimmune diseases such as lupus can also develop this type of alopecia.&nbsp; 
	&nbsp;</li>
	<li>Telogen Effluvium - Telogen effluvium is temporary hair loss that occurs due to changes in the hair&rsquo;s growth cycle. A greater proportion of the hair enters the telogen phase of growth, the state at which hair typically falls out. This type of alopecia can be brought on due to medications, pregnancy, stress, diets, or even after surgery. It typically resolves on its own after a few months. 
	&nbsp;</li>
	<li>Trichotillomania - This is a psychiatric disorder where the person plucks out their hair. It is frequently seen in children, but the habit resolves over time. Adults and adolescents indulging in this habit are often recommended psychiatric treatment&nbsp; 
	&nbsp;</li>
	<li>Traction Alopecia - Tight hairstyles such as braids, ponytails, or buns exert excessive pressure on the hair follicles, loosening them from the shaft and resulting in hair loss.&nbsp;</li>
</ul>

&nbsp;

<h5>Scarring Alopecia</h5>

In scarring alopecia, the hair follicles are irreversibly destroyed and replaced by fibrous scar tissue. As a result, the follicles lose the ability to regrow hair, causing permanent hair loss. The common types of scarring alopecia are: 
&nbsp;

<ul>
	<li>Primary Scarring Alopecia - In primary scarring alopecia, the hair follicle gets replaced by fibrous scar tissue. It includes central centrifugal alopecia, frontal fibrosing alopecia, lichen planopilaris, tinea capitis, and folliculitis decalvans.&nbsp; 
	&nbsp;</li>
	<li>Permanent Scarring Alopecia - The hair follicles are damaged due to external reasons such as straightening irons, radiotherapy, chemical straightening, and trauma to the scalp.&nbsp;</li>
</ul>

&nbsp;

Signs And Symptoms

<ul>
	<li>Hair Loss - People may notice excessive hair in their comb/brush, pillows, or shower drains. In women, hair loss typically occurs at the crown of the head. For men, a receding hairline due to hair loss from the temples is the most common sign. 
	&nbsp;</li>
	<li>Thinning Of Hair - Women with a family history of alopecia often notice a gradual thinning of hair. 
	&nbsp;</li>
	<li>Pain Or Itchiness - In certain types of alopecia, people also experience an itchy scalp and a burning or painful sensation. 
	&nbsp;</li>
	<li>Bald Patches - Due to hair loss, people may develop bald patches across their scalp, beard, or even eyebrows. 
	&nbsp;</li>
	<li>Full Body Hair Loss - Hair loss can affect the whole body especially due to medical treatments such as chemotherapy.&nbsp;</li>
</ul>

&nbsp;

Causes

The life cycle of the hair follicle is divided into 3 phases: 
&nbsp;

<ul>
	<li>Anagen - This is a period of active hair growth and lasts between 2-8 years</li>
	<li>Catagen - A period of transitional hair growth and lasts 2-3 weeks</li>
	<li>Telogen - Also called the resting phase, it can last 2-3 months. At the end of the telogen phase, hair sheds and new hair takes its place. 
	&nbsp;</li>
</ul>

Normally, an adult loses 40-100 hair on a non-shampoo day and 200-300 hair on a shampoo day 8. However, if this fallen hair is not replaced, it can lead to hair loss.&nbsp; 
&nbsp;

The most common causes of hair loss are: 
&nbsp;

<ul>
	<li>Hereditary Factors - A family history of hair loss&nbsp;</li>
	<li>Medications - Steroids, antidepressants, chemotherapy drugs, anti-hypertensives, and birth control pills&nbsp;</li>
	<li>Medical Conditions - Hormonal changes (PCOS, pregnancy, thyroid disorders), infections (fungal infection, syphilis, folliculitis), fever, menopause, chronic kidney failure, and allergies&nbsp;</li>
	<li>Diet &ndash; Low-protein consumption and calorie-restricted diets, i.e. any unhealthy diet that leads to iron deficiency anemia causes hair loss.&nbsp;</li>
	<li>Hairstyles And Cosmetic Procedures - Tight hairstyles (braids and buns), bleaching and dyeing hair, and excessive hair styling with curlers and straighteners&nbsp;</li>
	<li>Stress - Physical or emotional stressors can lead to temporary hair loss.</li>
</ul>

&nbsp;

There are currently no screening tests for alopecia

&nbsp;

Diagnosis

A combination of the patient&rsquo;s complete history and physical examination can help narrow down the cause of hair loss. The doctor can also ask you to get the following tests done: 
&nbsp;

<ul>
	<li>Blood Tests - A blood test helps diagnose any nutritional deficiencies (such as iron deficiency anemia) and underlying medical conditions (e.g. thyroid issues, PCOs) that can cause hair loss. 
	&nbsp;</li>
	<li>The Pull Test - Gentle pressure is applied to a group of hair in different areas of the scalp. The number of pulled-out hair is then counted. Less than 3 hairs per area are normal, but anything more than 10 is considered positive.&nbsp; 
	&nbsp;</li>
	<li>The Pluck Test - Hair is pulled out from the root and the plucked hair is then examined under the microscope. It helps detect systemic diseases or any defects in the telogen or anagen phase of the hair follicle.&nbsp; 
	&nbsp;</li>
	<li>Scalp Biopsy - In case of difficulty diagnosing the cause, a scalp biopsy is conducted. Typically, samples of hair are taken from around the bald patch. A scalp biopsy helps determine whether an infection is causing the hair loss. 
	&nbsp;</li>
	<li>Trichoscopy - This noninvasive method uses a derma scope to examine the scalp and hair.</li>
</ul>

&nbsp;

Treatment

Treatment depends on the type of alopecia. Treating the underlying medical condition or stopping the drug that is causing hair loss is often the key step in the management of alopecia.&nbsp;

In certain cases, the alopecia may reverse on its own within a year without the need for any medications or procedures. On the other end of the continuum, treatment cannot reverse hair fall or regrow lost hair.&nbsp;

However, there are options available for slowing the rate of hair loss. Based on the underlying cause of alopecia, doctors would either prescribe medications or advise surgery. 
&nbsp;

<h5>Medications</h5>

The common medications used to treat hair loss or baldness are: 
&nbsp;

<ul>
	<li>Minoxidil - Available over-the-counter, minoxidil can slow the rate of hair loss and help regrow hair. Topical medication is also available in the form of shampoos and foams.&nbsp;It typically takes 6 months for the medication to show its effect. Although quite effective, the drug must be used indefinitely for the maintenance of hair regrowth. It&#39;s not as effective in men with extensive male pattern baldness. Common side effects include scalp irritation, unwanted hair growth in other parts of the body, and allergic contact dermatitis.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Finasteride - Originally used for treating benign prostatic hyperplasia, the pill is also effective at treating male pattern baldness. It works by reducing levels of dihydrotestosterone (DHT), which then increases the amount of hair entering the anagen phase. However, men taking finasteride are at an increased risk of decreased libido, sexual dysfunction, and prostate cancer. Moreover, it is contraindicated in pregnant women due to its potential of causing birth defects in the developing baby.</li>
</ul>

&nbsp;

<ul>
	<li>Spironolactone - This diuretic works by reducing the production of androgens, thus, slowing the hair loss in androgenic alopecia.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Antifungal Medications - In tinea capitis (ringworm infection of the scalp), antifungal medications are administered.</li>
</ul>

&nbsp;

<ul>
	<li>Corticosteroids - In some cases of alopecia areata, doctors prescribe steroids. They may be injected directly into the scalp or given as an oral pill. Although effective in treating alopecia areata, steroids can cause side effects such as acne, weight gain, and menstrual irregularities.</li>
</ul>

&nbsp;

<ul>
	<li>Immunosuppressants - These temporarily reverse alopecia areata. However, their use is often debated due to the associated adverse reactions.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Supplements - Biotin, a type of vitamin, is often taken in the form of supplements to strengthen nails and hair. Moreover, iron and zinc supplements also promote hair growth.&nbsp; 
	&nbsp;</li>
</ul>

<h5>Surgical Procedures</h5>

In severe cases, surgery might be the only option. 
&nbsp;

<ul>
	<li>Hair Transplantation - During the procedure, a surgeon or dermatologist relocates plugs of skin containing active hair follicles to a bald spot. Several hundred plugs may need to be implanted for best results. Per session, 10-60 plugs may be transplanted. The procedure is conducted under local anesthesia and does not require hospitalization.&nbsp;</li>
</ul>

&nbsp;

<ul>
	<li>Scalp Reduction - The surgical procedure is often conducted in combination with hair transplantation. It involves removing bald areas on the scalp and closing the gap with a piece of scalp with hair. 
	&nbsp;</li>
</ul>

<h5>Non-Surgical Procedures</h5>

These include:

&nbsp;

<ul>
	<li>PRP Therapy - Platelet-rich plasma (PRP) therapy has recently gained popularity among dermatologists. Due to its ability to improve hair regrowth in several types of alopecia, it is often described as an &lsquo;elixir&rsquo; for hair growth<a href="#accordion">[9]</a>.</li>
</ul>

&nbsp;

<ul>
	<li>Light Therapy - Blue light therapy is a non-invasive procedure that involves exposing the scalp tissues to blue light-emitting diodes (LEDs). It has been shown to increase hair density and hair shaft width in 90% of androgenic alopecia patients<a href="#accordion">[10]</a>.</li>
</ul>

&nbsp;

<ul>
	<li>Scalp Micropigmentation - Also called a hair tattoo, the treatment is often used for hair loss or thinning of hair. Although the procedure does not regrow hair, tiny pigmented dots give the illusion of thicker hair. 
	&nbsp;</li>
</ul>

<h5>Alternate Options</h5>

<ul>
	<li>Over the years, alternate treatments including the use of essential oils such as peppermint and rosemary have gained popularity for treating hair loss.&nbsp;</li>
	<li>Wigs are also available as an alternative to surgery and medications. They can help cover up bald spots and thinning of hair</li>
</ul>

&nbsp;

One of the most common complications of alopecia is baldness or permanent hair loss.&nbsp;Alopecia also increases one&rsquo;s risk of mental health disorders such as <a href="https://www.merisehat.pk/disease/anxiety" target="_blank">anxiety </a>and <a href="https://www.merisehat.pk/disease/depression" target="_blank">depression</a><a href="#accordion">[7]</a>.

&nbsp;

The following factors increase the risk of hair loss: 
&nbsp;

<ul>
	<li>Age</li>
	<li>Family history of alopecia or balding</li>
	<li>Significant weight loss</li>
	<li>Stress</li>
	<li>Poor diet</li>
	<li>Hormonal disorders, such as PCOS and thyroid problems</li>
	<li>Autoimmune conditions, such as lupus</li>
	<li>Pregnancy and childbirth</li>
	<li>Tight hairstyle</li>
	<li>Hair products, such as dyes</li>
	<li>Scalp infections, such as tinea capitis</li>
</ul>

&nbsp;

Although there is no way to prevent some types of alopecia, the following practices can help reduce hair loss:

&nbsp;

<ul>
	<li>Avoid tight hairstyles.</li>
	<li>Eat a healthy diet rich in protein.</li>
	<li>Avoid heating tools such as blow dryers, straighteners, and curling rods.</li>
	<li>Avoid chemicals, such as bleaching agents, hair dyes, and relaxers.</li>
	<li>If undergoing chemotherapy, use a cooling cap.</li>
	<li>Take supplements based on the doctor&rsquo;s recommendation.</li>
</ul>

&nbsp;

Researchers are always on the lookout for effective treatments for hair loss. Recently, a team from Yale University conducted two phase-3 trials for a common arthritis drug called baricitinib. According to the results, the drug causes hair regrowth in one-third of the study patients with alopecia areata<a href="#accordion">[11]</a>.

&nbsp;

Key Points

<ul>
	<li>Alopecia is defined as a dermatologic condition characterized by a sudden or gradual loss of hair from one or more areas of the body, mostly the scalp.&nbsp;</li>
	<li>The distressing medical condition can result from a variety of genetic factors, medical conditions, hormonal changes, or as a normal part of aging.&nbsp;</li>
	<li>Alopecia is of several types and is broadly classified into scarring and nonscarring alopecia.&nbsp;</li>
	<li>In non-scarring alopecia, the hair follicles have the potential to grow hair, while in scarring alopecia, the hair follicles are irreversibly destroyed and replaced by fibrous scar tissue. As a result, the follicles lose the ability to regrow hair, causing permanent hair loss.</li>
	<li>Examples of non-scarring alopecia are androgenic alopecia, alopecia areata, telogen effluvium, and traction alopecia. Scarring alopecia can be divided into centrifugal alopecia, frontal fibrosing alopecia, lichen planopilaris, and folliculitis decalvans.</li>
	<li>In women, hair loss typically occurs at the crown of the head. For men, a receding hairline due to hair loss from the temples is the most common sign.&nbsp;</li>
	<li>Other symptoms include bald patches, hair loss from all over the body, and an itchy scalp.&nbsp;</li>
	<li>Some cases of alopecia may reverse on their own within a year. However, in some types of alopecia, medications such as minoxidil, finasteride, steroids, immunosuppressants, and supplements may be administered.&nbsp;</li>
	<li>In severe cases, doctors may conduct surgical procedures, such as hair transplants and scalp reduction.</li>
</ul>

&nbsp;

[1] Callander J, Yesudian PD. Nosological Nightmare and Etiological Enigma: A History of Alopecia Areata. Int J Trichology. 2018;10(3):140-141. doi:10.4103/ijt.ijt_23_18

[2] Jamerson TA, Aguh C. An Approach to Patients with Alopecia. Med Clin North Am. 2021;105(4):599-610. doi:10.1016/j.mcna.2021.04.002

[3] Osemwota O, Herbosa CM, Zhong C, Kwatra SG, Kim BS, Semenov YR. Ethnic variations in scalp pruritus and hair loss. J Am Acad Dermatol. 2021;84(3):792-794. doi:10.1016/j.jaad.2020.05.116

[4] Bible gateway passage: 1 corinthians 11:15 - king James Version. Bible Gateway.

[5] Hunt N, McHale S. The psychological impact of alopecia. BMJ. 2005;331(7522):951-953. doi:10.1136/bmj.331.7522.951

[6] Lin J, Saknite I, Valdebran M, et al. Feature characterization of scarring and non-scarring types of alopecia by multiphoton microscopy. Lasers Surg Med. 2019;51(1):95-103. doi:10.1002/lsm.23017

[7] Ho CH, Sood T, Zito PM. Androgenetic Alopecia. [Updated 2021 Nov 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

[8] Jackson AJ, Price VH. How to diagnose hair loss. Dermatologic Clinics. 2013;31(1):21-28. doi:10.1016/j.det.2012.08.007

[9] Garg S, Manchanda S. Platelet-rich plasma-an 'Elixir' for treatment of alopecia: personal experience on 117 patients with review of literature. Stem Cell Investig. 2017;4:64. Published 2017 Jul 18. doi:10.21037/sci.2017.06.07

[10] Lodi G, Sannino M, Cannarozzo G, et al. Blue light-emitting diodes in hair regrowth: the first prospective study. Lasers Med Sci. 2021;36(8):1719-1723. doi:10.1007/s10103-021-03327-9

[11] King B, Ohyama M, Kwon O, et al. Two phase 3 trials of baricitinib for alopecia areata. New England Journal of Medicine. 2022;386(18):1687-1699. doi:10.1056/nejmoa2110343