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Overview |
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Definition |
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Hair disorders broadly include alopecia, hirsutism, and hair shaft disorders.
Alopecia is the loss or thinning of hair and includes both scarring (hair
follicles are destroyed) and non-scarring (potentially reversible) types.
Male-pattern baldness (androgenic alopecia) is the most prominent type of hair
disorder and affects, to varying degrees, 50% of males over 50 years of age.
Hirsutism is male-pattern hair growth in women. It may or may not include
virilization and affects up to 8% of adult women. Hair shaft disorders are
usually hereditary hair shaft abnormalities. Systemic disease and poor prognosis
often accompany these latter disorders. |
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Etiology |
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Alopecia—non-scarring:
- Cutaneous disorders (e.g., alopecia areata, tinea capitis, and
others)
- Drugs (e.g., warfarin, vitamin A, isotretinoin, chemotherapy, and
others)
- Systemic disease (e.g., lupus, secondary syphilis, thyroiditis, and
others)
- Autoimmunity
- Iron deficiency
- Fatty acid deficiency
- Severe stress—major surgery,
anorexia
- Scalp radiation
- Pregnancy
- Self induced hair loss (plucking), psychiatric
disturbance—trichotillomania
- Adrenal compromise
Alopecia—scarring:
- Cutaneous disorders (e.g., lupus, lichen planus, neoplasms, and
others)
- Systemic disease
- Microbial infections
Hirsutism:
- Drugs that would not otherwise promote virilization
- Adrenal or ovarian tumors
- Excessive adrenal or ovarian hormone production
- Polycystic ovarian disease
- Congenital adrenal hyperplasia
- Idiopathic—with apparent normal adrenal
function, ovaries, and menses
Hair shaft disorders:
- Over-processed hair (coloring, permanent waves, excessive
heating)
- Specific shaft disorders—associated with
certain systemic conditions
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Risk Factors |
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Alopecia:
- Male
- Genetic predisposition
- Pregnancy
- Age
- Physical or emotional stress
- Poor diet
Hirsutism:
- Genetic predisposition
- Anovulation
Hair shaft disorders:
- Genetic predisposition
- Damaging grooming practices
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Signs and Symptoms |
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Alopecia—non-scarring:
- Diffuse shedding of normal hair—typically in
male-pattern baldness
- Triangular recession of scalp line
- Broken hairs
- Smooth scalp
- Inflammation
- Fibrosis
- Circular areas of hair loss
- Possible loss of lashes, eyebrows, pubic hair
Alopecia—scarring:
- Circumscribed areas
- Inflammation at periphery, follicle loss toward center of
lesions
- Violet-colored macules
- Scaling
Hirsutism:
- Male-pattern hair growth in women
- Irregular menses, anovulation
- Acne
- Virilization—deepening of voice, balding,
clitorimegaly
Hair shaft disorders:
- Broom-like fracture ends (trichorrhexis nodosa)
- Brittle, coarse, light-colored, spangled hair; grooved shaft twisted
on its axis; cutaneous and systemic abnormalities (pili torti, Menkes' kinky
hair, Björnstad's syndrome)
- Dry, brittle, fragile, beaded hair; cutaneous and systemic
abnormalities (monilethrix)
- Sparse, short, brittle hair; shaft is flattened or folded with
nodules, longitudinal grooving; may be accompanied by receding chin, protruding
ears, raspy voice, and other cutaneous and systemic abnormalities if
trichothiodystrophy
- Bands of light and dark hair that is not fragile (pili
annulati)
- Tight, curly hair; cutaneous and ocular abnormalities (woolly hair
disease)
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Differential
Diagnosis |
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Determine the type of hair disorder through history, physical examination,
and possibly laboratory and microscopic analysis, and treat
accordingly. |
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Diagnosis |
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Physical Examination |
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Alopecia:
- Differentiate scarring from nonscarring and shedding from
thinning.
- Identify systemic illness, course of progression of thinning,
environmental insults.
Hirsutism:
- Pelvic examination for ovarian tumors and clitorimegaly
- History of anovulation—polycystic ovarian
disease
Hair shaft disorders:
- Microscopic examination—distinguishes
type
- Identify systemic illness or environmental
insults
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Laboratory Tests |
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Alopecia:
- Scalp biopsy with immunofluorescence and microscopic
examination—identify microbials, distinguish type
- CBC (immunologic disorders), hormonal evaluation, thyroid function
tests, and others—determines any underlying
disorder
Hirsutism:
- Serum and urinary androgens
- Urinary cortisol screening—Cushing's
disease
- Elevated LH/FSH ratio—polycystic ovarian
disease
- ACTH stimulation test—adrenal
hyperplasia
Hair shaft disorders:
- Test for systemic disorder (e.g., low serum
copper—Menkes' disease)
- Scanning electron microscopy—distinguishes
specific shaft disorder
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Pathology/Pathophysiology |
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Alopecia:
- Large numbers of anagen (growing) hairs entering the telogen (dying)
phase
- Possibly elevated dehydroepiandrosterone levels
- Pustules with Staphylococccus aureus
- Trichophyton tonsurans—with
tinea
- Postinflammatory hyperpigmentation—with
lichen planus
- Lymphocytic infiltrate around hair bulbs
Hirsutism:
- Increased levels of androgens
- Dihydrotestosterone—increases facial hair and
decreases scalp hair
Hair shaft disorders:
- Distinctive shaft appearance for each disorder
Imaging:
- Hirsutism—laparoscopy or MRI diagnosis of
possible adrenal or ovarian tumors
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Other Diagnostic
Procedures |
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Alopecia:
- Wood's light—fluorescent glow with fungal
infections
- Pluck test—ease of hair shaft removal
differentiates between normal and excessive hair
loss
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Treatment Options |
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Treatment Strategy |
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- Treat underlying cause
- Hair regrowth drugs or steroids as indicated
- Teach healthy grooming practices, correct damaging
practices
- Cosmetic therapies, such as surgical placement of follicle-supporting
plugs or folds
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Drug Therapies |
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Alopecia
- Topical 2% minoxidil (Rogaine)—encourages
hair regrowth, may prevent further loss; six months of use for optimal benefit;
must be used indefinitely thereafter; local irritation and other side effects
possible
- Tretinion (Retin-A)—decreases thick scalp
layer and increases minoxidil penetration
- Topical fluorinated steroids (Synalar HP)—bid
for at least three months; no systemic but some local side effects
- Finasteride (Propecia)—may be effective for
hair regrowth (1 mg/day) but teratogenic (feminizes a male fetus)
- Triamcinolone coticosteroid injections, 3 mg/mL
- Psoralen with ultraviolet A (PUVA) therapy—20
to 40 sessions; nausea possible
- Anthralin 0.5% or 1.0% creme—for alopecia
areata; six months of use for optimal benefit; local side effects
- Griseofulvin—for tinea; 5 mg/kg/d for
children, 250 to 375 mg/d for adults for six to eight weeks; side effects may
include headache; best to use with selenium sulfide
shampoo
Hirsutism
- Glucocorticoids—suppress ACTH and androgen
secretion
- Oral contraceptives
- Dexamethasone—0.125 to 0.250 mg at bedtime
for at least six months
- Spironolactone—inhibits androgen production;
75 to 200 mg/d for at least six months
Hair shaft disorders
- Minoxidil—possibly for monilethrix
- Copper-histidine injections—for Menkes'
disease; 50 to 150 mg/kg/d for life
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Surgical Procedures |
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Hirsutism—tumor removal if due to adrenal or ovarian
tumor |
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Complementary and Alternative
Therapies |
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Nutritional supplements may be helpful in optimizing hair health. In
addition, nutrients and herbs can be used to address the underlying cause of
hair loss. |
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Nutrition |
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- Avoid sugar, caffeine, and refined foods. Include foods high in B
vitamins and minerals, such as whole grains, dark leafy greens, and sea
vegetables. Maintain adequate intake of protein, especially during times of
stress or illness.
- B-complex vitamins, especially B5 (100 mg/day), biotin (300
mcg/day), PABA (30 to 100 mg tid), and inositol (250 to 1,000 mg/day), are
essential for normal hair growth.
- Minerals, especially calcium (1,000 mg/day), magnesium (400 mg/day),
selenium (100 to 200 mcg/day), manganese (10 mg/day), and zinc (20 to 30 mg/day)
are necessary for hair health.
- Vitamin C (500 to 1,000 mg tid), vitamin E (400 IU/day), and vitamin A
(10,000 IU/day) or beta carotene (25,000 IU/day) are needed for skin
health.
- Omega-3 fatty acids (EPA, DHA, flaxseed oil, fish oil) or omega-6
fatty acids (borage or evening primrose oil), 1 tbs. or equivalent bid to
tid
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Herbs |
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Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or
tinctures (alcohol extraction, unless otherwise noted). Dose is 1 heaping tsp.
herb/cup water steeped for 10 minutes (roots need 20 minutes). Herbs that
support circulation facilitate the transport of nutrients to the scalp. Combine
the following herbs in equal parts and use as a tea (2 to 3 cups/day) or
tincture (20 to 30 drops bid to tid).
Alopecia and hair shaft disorders:
- Ginkgo leaf (Ginkgo biloba), rosemary (Rosemarinus
officinalis), and prickly ash bark (Xanthoxylum clava-herculis),
horsetail (Equisetum arvense), yarrow (Achillea millefolium), and
elderberry (Sambucus nigra).
- With concurrent infection, add coneflower (Echinacea purpurea)
with goldenseal (Hydrastis canadensis) for bacterial infections or
oregano (Origanum vulgare) for fungal infections.
- With associated stress, substitute oatstraw (Avena sativa) for
elderberry.
Hirsutism:
- Saw palmetto (Serenoa repens) 200 mg bid to tid to reduce
androgen uptake
Topical applications of essential oils may be beneficial in cutaneous
infections and for stimulating new hair growth. Use three to four drops each of
chamomile (Matricaria recutita), rosemary, and sage (Salvia
officinalis) in 1 tbs. vegetable oil (i.e., flax, borage, or olive). Massage
gently into affected area one to two times daily. |
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Homeopathy |
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An experienced homeopath would consider the individual's constitution. Some
of the most common acute remedies are listed below. Acute dose is three to five
pellets of 12X to 30C every one to four hours until symptoms
resolve.
- Ignatia for hair loss or excessive hair growth following a
grief
- Pulsatilla for excessive hair growth, especially with hormonal
imbalance
- Sepia for hirsutism, especially with skin conditions and
hormonal changes
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Acupuncture |
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May be beneficial in addressing underlying cause. |
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Massage |
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May aid in enhancing circulation and relieving the effects of
stress. |
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Patient Monitoring |
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- As underlying condition necessitates
- Monitor drug side effects and liver
toxicity
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Other
Considerations |
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Complications/Sequelae |
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- Complications can be caused by underlying conditions or by the
treatment.
- Poor self-image may result with hair
loss.
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Prognosis |
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Alopecia:
- Androgenic alopecia, untreated or unsuccessfully treated, will result
in a continuous loss of hair, but at an unpredictable rate.
- Alopecia due to injury or underlying condition is dependent on the
circumstances.
Hirsutism:
- Ongoing drug treatment slows hair
growth—reversal unlikely
- Surgical treatment of possible tumor may show high rates of
success
Hair shaft disorders:
- Spontaneous improvements—at puberty,
pregnancy, or with oral contraceptives
- Menkes' disease presents with other complications
- No effective treatment exists for some
disorders
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Pregnancy |
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Delay any drug treatment until after pregnancy. Hirsutism may be related to
underlying conditions that may lead to infertility. Diffuse but primarily
frontotemporal hair loss can occur one to four months after childbirth; recovery
occurs in less than one year. |
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References |
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Behrman RE, ed. Nelson Textbook of Pediatrics. 15th ed. Philadelphia,
PA: W.B. Saunders; 1996.
Cecil RI, Plum F, Bennett JC, eds. Cecil Textbook of Medicine.
20th ed. Philadelphia, PA: W.B. Saunders; 1996.
Dambro MR. Griffith's 5-Minute Clinical Consult. 1999 ed. Baltimore,
MD: Lippincott Williams & Wilkins, Inc.; 1999.
Dawber RPR. An update of hair shaft disorders. Dermatologic Clinics.
1996; 14(4).
Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles
of Internal Medicine, 14th ed. New York, NY: McGraw-Hill;
1998.
Fiedler VC, Alaiti S. Treatment of alopecia areata. Dermatologic
Clinics. 1996; 14(4).
Goroll AH, ed. Primary Care Medicine. 3rd ed. Philadelphia,
PA: Lippincott-Raven Publishers; 1995.
Habif TP. Clinical Dermatology. 3rd ed. St. Louis, MO:
Mosby-Year Book; 1996.
Lawless J. The Encyclopedia of Essential Oils. The Complete Guide
to the Use of Aromatics in Aromatherapy, Herbalism, Health &
Well-being. New York, NY:Barnes & Noble, Inc.; 1992:199.
Morrison R. Desktop Guide to Keynotes and Confirmatory
Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993.
Rakel RE, ed. Conn's Current Therapy. 50th ed.
Philadelphia, PA: W.B. Saunders;
1998. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |