An Algorithm for the Diagnosis of Female Hair Loss

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1 An Algorithm for the Diagnosis of Female Hair Loss AK Gupta, MD, PhD, FRCP(C) 1,2 ; KA Foley, PhD 2 1 Department of Medicine, University of Toronto, Toronto, Canada 2 Mediprobe Research Inc., London, Canada

2 Background and Objective Women with hair loss often experience psychological or social distress and will seek medical advice or assurance from physicians. Numerous etiologies exist that can have similar clinical presentations. This can create difficulties for practitioners in arriving at a diagnosis. PubMed and Scopus databases, Hair Transplant Forum International, reference lists of publications, and relevant textbooks were searched. Objective: To create an algorithm that could aid physicians in differentiating the many hair loss conditions, with a focus on defining clinical characteristics.

3 Diagnostic Tools Detailed Patient History: Lines of Inquiry Family history of hair loss Hair loss progression Nature of hair loss Location Physical symptoms/ signs Hair care practices Recent trauma or surgery Medication use/recent illness Hormone or contraceptive use Trichoscopy: Acute (recent) vs. Chronic (steady or sporadic) Shedding, thinning, or breaking Diffuse vs. Localized (temporal, central part, other body areas) Acne, hirsutism, psoriasis, blisters, dermatitis Chemical treatment, excessive heat or brushing, hair style e.g., parturition e.g., chemotherapeutic agents Dermatoscopic investigation of the hair and scalp that is non-invasive and is instrumental to assessing hair loss in an outpatient setting Pull test: Determine hair shedding (positive test) vs. hair thinning (negative test) Hair card: Determine growing hair from broken hair Hair Mount and Scalp Biopsy: Microscopic examination of hair to detect structural abnormalities, hair density, and presence of inflammatory infiltrate Han and Mirmirani, SeminCutanMedSurg 2006, 25:11-23; Miteva and Tosti, JAAD 2012, 67:1040-8; Mubki et al., JAAD 2014, 71:415

4 Algorithm Non-Scarring Alopecias Diffuse Patchy Pattern Telogen Effluvium Anagen Effluvium Alopecia Areata (AA) Tinea Capitis Female Pattern Hair Loss (FPHL) Alopecia Areata (AA) Loose Anagen Syndrome Trichotillomania Traction Alopecia (Peripheral Scalp)

5 Narrowing the Diagnosis Cicatricial (Scarring) Alopecias (CAs) The absence of follicular ostia and presence of inflammation distinguishes CA from AA and FPHL. Symptoms may include pain, itching, burning sensations, as well as blistering, scaling, and/or erythema. Certain CAs may be more common in women: Frontal fibrosing alopecia (FFA, particularly postmenopausal women), Central centrifugal cicatricial alopecia (CCCA, particularly in African American women), Discoid lupus erythematosus (DLE) Non-Scarring Alopecias Diffuse Hair Loss Clinical Presentation Defining Characteristics Telogen Effluvium Anagen Effluvium Alopecia Areata Excessive hair shedding over entire scalp, may be precipitated by external events in the months prior. Hair breakage, large amount of hair loss within a short period of time, including multiple body areas. Complete alopecia of the entire scalp (alopecia totalis, AT) or body (alopecia universalis, AU). Can also cause diffuse thinning and look similar to FPHL or TE. Pull test: club hairs present Dermatoscopy: empty follicles and short re-growing hairs may appear Dermatoscopy (chemotherapy-induced): Black dots and/or monilethrix-like hairs may be present in some cases Presence of dystrophic anagen hair or a scalp biopsy can confirm AA Dermatoscopy: see patchy hair loss Loose Anagen Syndrome Tends to affect children Hair pull test will show loosely anchored and painless removal of hair Dermatoscopy: Sparse hairs, decreased number of hair shafts per follicular unit Miteva and Tosti, JAAD 2012, 67:1040-8; Mubki et al., JAAD 2014, 71:415; Mubki et al., JAAD 2014, 71:431

6 Narrowing the Diagnosis Non-Scarring Alopecias Patchy Hair Loss Clinical Presentation Defining Characteristics Alopecia Areata Tinea Capitis Trichotillomania Increased hair shedding resulting in one or more clearly defined patches of hair loss, patches appear smooth with normal follicles, may include eyebrows Round patch of hair loss with hair breakage, with/without inflammation, erythema, pruritus, and/or pustules Rough patches of hair loss with broken or twisted hairs of varying lengths found in the bald areas. Usually begins in childhood, can include skin or nail picking. Dermatoscopy: Exclamation hairs, black dots, broken hairs (active disease); Yellow dots, vellus hairs (severe long-term and low disease activity) Mycological examination to confirm Dermatoscopy: Comma and corkscrew hairs Broken or twisted hairs in scalp or other body areas. Dermatoscopy: Coiled hairs (not in all cases) Pattern Hair Loss Clinical Presentation Defining Characteristics Female Pattern Hair Loss Traction Alopecia Thinning in the central crown area, sparing the frontal hairline OR a Christmas tree pattern along central part, with frontal accentuation of hair thinning. Along the outer hair line, usually in frontal and temporal areas. Mostly affects African American women with tight hairstyles. Miniaturized hair, Christmas tree pattern Dermatoscopy: Varying hair shaft diameters Dermatoscopy: Hair casts around shafts at periphery of patches with active traction Miteva and Tosti, JAAD 2012, 67:1040-8; Mubki et al., JAAD 2014, 71:415; Mubki et al., JAAD 2014, 71:431

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