Author
Barbara Chernow, Ph.D.
Freelance Medical Writer
New York, NY
Disclosure: Barbara Chernow, Ph.D., has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Stephen Soreff, MD
Faculty
Metropolitan College of Boston University
Boston, Massachusetts
Disclosure Stephen Soreff, MD, has disclosed no relevant financial relationships.
Hair loss is a problem that affects millions of men and women in the United States. The majority of hair loss is due to age-related hormonal changes or in some cases there is a genetic contribution. However there are a number of alopecia (the medical term for hair loss) conditions that develop due to underlying systemic, oncologic, psychiatric, or infectious disorders. Not all hair loss is usual and physicians must remain vigilant for cases in which hair loss is the first presenting symptom of serious underlying pathology. The image shown is from a child with trichotillomania, a psychiatric condition that produces bizarre patterns of hair loss as patients continually pull hair from their heads.
Perifolliculitis capitis abscedens et suffodiens, or dissecting cellulitis of the scalp, is a suppurative scalp disease of unknown etiology. It predominately occurs in 20- to 40-year-old black men. The proposed mechanism is follicular blockage, which causes dilation and rupture inducing a neutrophilic and granulomatous response. Dissecting cellulitis typically begins as simple folliculitis in the vertex or occiput with the subsequent development of perifollicular pustules followed by abscess and sinus tract formation. Painful firm or fluctuant nodules appear (shown) and seropurulent fluid may sometimes be expressed.
As the nodules of dissecting cellulitis heal, they leave behind a patchwork of scarring alopecia (shown). Hair may be preserved between the areas of inflammation. Bacterial infection, commonly Staphylococcus aureus, is a frequent secondary complication. The disease is chronic with an unpredictable course, but spontaneous resolution has been reported. Chronically inflamed areas are at risk for squamous cell carcinoma and permanent alopecia. No treatment options have proven to be consistently effective in resolving symptoms, and secondary infections may require frequent antibiotic therapy. The prognosis for complete recovery is poor.
Discoid lupus erythematosus (DLE) is a chronic, scarring, atrophy-producing, photosensitive dermatosis of unclear etiology. It may occur in patients with systemic lupus erythematosus (SLE) and a minority of patients with DLE may experience progression to SLE. Patients rarely have serologic abnormalities. The primary lesion is an erythematous papule or plaque with scaling (shown). Over time, the scale may thicken with central hypopigmentation and peripheral hyperpigmentation. The scalp is a common area of involvement, producing permanent alopecia.
Lesions often spread centrifugally and merge. This may lead to near complete alopecia of the scalp (shown). As the lesions mature, there is dilation of the follicular openings with keratinous plugging. Resolution of active lesions results in atrophy and scarring. Localized DLE refers to head and neck involvement only, while widespread DLE affects other areas. Treatment involves sun protection, corticosteroids (topical or intralesional), and antimalarial drugs. Antimalarial drugs have been shown to decrease the risk for progression to SLE and thromboembolic disease. Early treatment of lesions has the best prognosis for recovery.
Alopecia mucinosa is a dermatologic condition that results in diffuse, nonscarring hair loss. The superficial eruption is characterized by follicular papules and/or indurated plaques (shown). Inflammatory mucinous material accumulates in damaged hair follicles, leading to degeneration and hair loss. The mechanistic pathology of these changes is not well understood. Three distinct forms exist. The primary disorder of young people consists of focal lesions with limited progression and spontaneous resolution. The primary chronic disorder of older people is more widespread and may persist or recur indefinitely. Image courtesy of Dirk M. Elston, MD.
Secondary alopecia mucinosa is present in older patients and may be associated with a number of disease processes: SLE, lichen simplex chronicus, angiolymphoid hyperplasia, mycosis fungoides, Kaposi sarcoma, and Hodgkin disease. The presence of alopecia mucinosa is associated with the subsequent development of lymphoma in 15%-40% of adults. The hair loss that develops is nonscarring (shown) and the face and scalp are the most common sites. Diagnosis is made via skin biopsy and no uniformly effective therapy is available, although corticosteroids, radiation therapy, nitrogen mustard, and psoralen plus ultraviolet A light have been utilized. Courtesy of San Antonio Uniformed Services Health Education Consortium teaching files.
Trichotillomania is a self-induced psychiatric disorder in which repetitive hair manipulations induce alopecia. Trichotillomania is among the impulse-control disorders with 2 subtypes: focused and nonfocused pulling. In focused pulling there is an intentional act to control negative emotional states such as anxiety or anger. This is relieved when the hair is pulled. In nonfocused pulling, patients have difficulty acknowledging the act of hair-pulling. The actions are automatic, nonintentional, and habitual. The classic presentation is a geometric shape with incomplete, nonscarring alopecia (shown). In some cases, the hair loss is diffuse and shows generalized thinning. Trichotillomania may also be a manifestation of an anxiety or mood disorder.
Close examination may reveal newly growing short hairs, broken short terminal hairs, empty follicular orifices, or indeterminate hairs. With severe long-standing lesions, the hairs will regress to vellus type hairs with a smooth base (shown) similar to scarring alopecia. Diagnosis is typically made based on clinical history and examination. The most effective form of treatment is cognitive behavioral therapy, even for younger patients. Long-term prognosis is very good for children and adolescents but worsens significantly for adults.
Telogen effluvium is a nonscarring alopecia characterized by diffuse hair shedding. It is a reactive process caused by metabolic or hormonal derangements in which hairs are shifted to the last stage of their life cycle. Telogen effluvium is found in a number of disease processes including malignancy, lupus, end-stage liver or renal disease, hormonal changes, hypothyroidism (shown), protein and calorie malnutrition, heavy metal toxicity, or iron deficiency. The onset is often insidious without any identifiable inciting event so physicians must take care to ensure that the etiology is not an undiagnosed pathologic process.
Tinea capitis, or ringworm, is a superficial fungal infection of the scalp that leads to hair loss in a characteristic pattern. It is caused by the fungi Trichophyton and Microsporum and is the most common pediatric dermatophyte infection worldwide. Infection beings with a small erythematous papule around a hair shaft that develops to become pale and scaly. The hairs become discolored, lusterless, and brittle, causing them to break off a few millimeters above the scalp surface. The lesions spread to form larger rings that may coalesce with other infected areas (shown).
The diagnosis of tinea capitis is based on KOH preparation of skin scrapings with fungal cultures providing species identification. A Wood lamp examination can be used to identify cases of Microsporum that will fluoresce green-yellow (shown). Trichophyton species unfortunately do not fluoresce with a Wood lamp so the ability to quickly screen patients is limited. The mainstay of treatment is systemic griseofulvin. Topical treatment is usually ineffective, however; selenium sulfide shampoos may reduce the risk of spreading the infection early in the course of therapy. Household contacts should be screened, because asymptomatic carriers may require treatment to prevent further infection.
Tufted hair folliculitis is a progressive pattern of scarring alopecia that affects the scalp. It is characterized by 10-15 hairs emerging from a single follicular opening (shown) similar to a doll's hair. It is thought to represent an advanced stage of follicular injury seen in several types of scarring alopecia. Patients report slow, progressive hair loss over years accompanied by pain and swelling of the scalp. Crust and scales may be adherent to the scalp and hair. Staphyloccus can frequently be cultures from the sites, but the role is not established. The process is chronic and no consistently effective therapy is available for resolution; however, tar derivate shampoos may reduce scaling and oral antistaphyloccal antibiotics are used when exudates develop.
Traction alopecia is a form of scarring alopecia caused when prolonged traction is placed on the hair. It is common in patients with tight cornrows (shown), pigtails, or ponytails. The long-term application of tensile forces induces an irritant folliculitis that leads to follicular scarring and alopecia. Perifollicular erythema, scales, pustules, or seborrhea may be present. Broken hairs are a common finding. The pattern of hair loss is entirely dependent on the specific grooming pattern of the patient. Changes in patient behavior can prevent additional hair loss, but if fibrosis has occurred, then the lost hairs will not return.
Alopecia areata is a recurrent non-scarring form of hair loss of uncertain etiology. The most widely accepted hypothesis is a T-cell-mediated autoimmune condition that develops in genetically predisposed individuals. It predominately affects the scalp but can affect any hair-bearing area and multiple areas can be affected at once (shown). Localized patches are the most common manifestation but there is great heterogeneity. Alopecia totalis is a subset in which there is complete hair loss over the entire body. Conditions associated with alopecia areata include atopic dermatitis, vitilitgo, thyroid disease, collagen vascular disease, diabetes mellitus, Down syndrome, and psychiatric disorders characterized by stress. Steroids and immunomodulating drugs have been used for treatment, but are not consistently effective.
Author
Barbara Chernow, Ph.D.
Freelance Medical Writer
New York, NY
Disclosure: Barbara Chernow, Ph.D., has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Stephen Soreff, MD
Faculty
Metropolitan College of Boston University
Boston, Massachusetts
Disclosure Stephen Soreff, MD, has disclosed no relevant financial relationships.
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