NON-CICATRICIAL AlOPECIA

1. NON-CICATRICIAL AlOPECIA BY: MOHAMMED ALSAIDAN

3. APPROACH

4. Approach History • Duration • Pattern • Thinningvs. shedding (hair root? Breaking?) • FH • Hair care products • Systemic disease, e.g. thyroid • Heavy mestruation, menstrual irregularity • Child birth, surgery, stress • New medication ? When was started? • Diet : caloric intake

5. Approach Examination • Distribution • Hair line ? • Signs of Androgenism • Inflammation ? Scale ? • Scarring ? • TESTS TO ASSES HAIR

6. How to assess the quantity of hair lost ?

7. Assessment • Daily hair counts • Hair pull test • Hair wash • 60 second hair count • Hair pluck trichogram • Global photography • Dermoscopy • Contrasting felt examination

8. Hair pull test • Scalp: 100 000 hair follicle • Telogen normally=10% (10 000) • Average of daily lost hair =10 000/100day= 100 • Some studies are estimating normality as (10-250) ? • 20-60 hairs are grasped between the thumb, index and middle fingers from the base of the hairs near the scalp and firmly, but not forcefully, pulled away from the scalp. • >10% hairs are pulled away implies active hair shedding. • The patient must not shampoo for at least 24h.

10. Hair wash • Washing hair in closed sink after 5 days of no wash then count hair • Hairs counted and divided into ≤3cm and ≥5 cm in length. • The 'modified hair wash test' demonstrates that in FAGA 58.9% of hair is vellus, whereas in chronic telogen effluvium (CTE), there are only 3.5%

11. 60 second hair count • Before shompooing, comb hair for 60 second over a pillow or white sheet • Start combing from back top of the scalp moving to front and count hair • Repeat it before 3 consequetive shampooing, e.g. every 2nd or 3rd day using the same comb or brush • Repeat it monthly

13. Hair pluck trichogram • 50 hair pulled with a hemostat covered with rubber, along the angel of insertion, on the fifth day after the last shampoo • The hair is cut about 1 cm from the root, placed on a wet-mount microscope slide & viewed at 10X • DACA (4-dimethylaminocinnamaldehye) reacts with an internal root sheath amino acid allowing differentiation of anagen from telogen hairs. (+ve in anagen)

14. Trichogram - 50-80 hairs are grasped with a hemostat covered with rubber and are plucked, twisting and lifting the hair shafts rapidly in the direction of emergence from the scalp

15. Preparing the trichogram slide - the plucked hairs are arranged side by side on a glass slide and taped

16. Anagen hair - showing the darkly pigmented triangular or delta-shaped bulbs with an angle to the hair shaft ('hockey-stick' appearance) and presence of inner root sheath

17. early telogen hair showing the hypopigmented, club-shaped bulb with absence of inner root sheath

18. A Telogen fibers showing a club shape. B Anagen fibers with attached root sheaths, demonstrating pigmented, distorted bulbs appearing like the end of broom sticks. C Ruffled cuticle of loose anagenhair

19. Global Photography • a stereotactic positioning device (with a camera and flash) on which the patient's chin and forehead are fixed • To ensure that the view, magnification and lighting are the same at consecutive study visits. • ask patients to keep the same hair style and color • Four standard views (vertex, midline, frontal and temporal) are advocated

21. CONTRASTING FELT EXAMINATION • After making a parting in the hair, the index card is held along the scalp • miniature hairs can be seen in patients with androgeneticalopecia. • In a regrowingtelogen effluvium, a classic short frontal fringe is seen

23. Approach Labs: • TSH, ferritin +/- (vit.D , Zinc, ESR) • Hormonal essay if needed ( free testosterone + DHEAS) • ANA • Skin Biopsy if needed

24. Male/Female Pattern Hair Loss (AGA) • The most common cause of hair loss , age related, men >women • Almost all caucasian men show recession of hair line after puberty • by age 70, 80% of Caucasian men, 40% of women show evidence of AGA • Association with CAD, DM, HTN ??

28. Etiology • Testosterone: • presence of terminal pubic and axillary hair fibers • increased muscle mass • growth of the phallus and scrotum • voice change, sex drive • DHT : • temporal scalp hair recession • development of terminal hairs in the beard region, external ears, nostrils, and limbs • acne • growth of the prostate gland

29. Etiology • Polygenic • Miniaturization is the hallmark of AGA • Vellus hairs may be present in large amounts prior to permanent shedding • 5α-reductase activity and DHT levels are increased compared to non-balding scalp skin , once low -> reversal of AGA • Absence of type II 5α-reductase prevents development of male androgeneticalopecia

30. Clinical features • Symmetrical and prgressive • Pattern : Hamilton,Norwood, ludweg • Men: Recession of frontal hair line + balding of vertex • Female: involving crown and frontal scalp, maintaining hair line • Signs of androgenisim ?

32. Ludwig grade I : minimal widening of the part width Ludwig grade II : with moderate thinning Ludwig grade III :with significant thinning and widening of the part width

34. Ludwig scale Ludwig 1-1The central parting of a woman with no hair loss. Ludwig 1-2 1-3 1-4The width of the parting gets progressively wider indicating thinner hair along the center of scalp. Ludwig 2-1 2-2Diffuse thinning of the hair over the top of the scalp. Ludwig 3A woman with extensive diffuse hair loss on top of the scalp, but some hair does survive.

35. Ludwig scale Ludwig AdvancedA woman with extensive hair loss and little to no surviving hair in the alopecia affected area. Very few women ever reach this stage and if they do it is usually because they have a condition that causes significant, abnormally excessive androgen hormone production. Ludwig FrontalA woman with a pattern of hair loss that is described as "frontally accentuated". That means there is more hair loss at the front and center of the hair parting instead of just in the top middle of the scalp

37. Differential diagnosis • FPHL vs TE ? • FPHL + TE ? • FPHL + AA • Hyperandrogenism ?

38. Telogen effluvium • TE is the most common form of hair loss seen in association with systemic disease • begins approximately 3 months after an event,Thinningof the hair involving the entire scalp • chronic TE (> 6 months) affects women between the ages of 30 and 60 years without any precipitating cause and is a diagnosis of exclusion • Telgen >15% presumptive, >20% diagnostic (kligman ?)

43. Medical treatment of androgenetic alopecia in men–finasteride (n = 219) versus placebo (n = 15) five-year clinical trial. The figure shows the mean difference in hair count after 5 years (p<0.001).

44. Treatment : • (hairDXtest): CAG repeat score • A smaller CAG test score is associated with • higher risk for significant hair loss • increased response to Finasteride • increased risk of developing BPH

47. Trichotellomania • Usually present in early childhood to adolescence. • The most frequent site of hair pulling is the scalp • grouped under the ‘impulse-control disorders not elsewhere classified causing clinically significant distress or impairment'’

48. Trichotellomania • patchy or full alopecia of the scalp, centrifugal or wave like pattern, hairs in the occiput tend to be spared • bizarre shapes, irregular borders, and contain hairs of varying lengths and hair shaft fractures • ‘hair growth window’ by repeatedly (weekly) shaving a small area of involved scalp to demonstrate normal, dense regrowth, will support the diagnosis

49. Trichotellomania • The differential diagnosis includes tineacapitis and alopecia areata • Histopathology: Trichomalaciaand pigment casts • No specific treatment • Hypnosis, behavioral modification therapy. • The recommended first-line medication is clomipramine or (SSRI) • N-actyl-cysteine ?