Hair loss affects both the young and old. There are myriad potential etiologic factors that can culminate in clinical hair loss or alopecia, including endocrine abnormalities, genetic predisposition, systemic illness, drugs, psychological abnormalities, diet, trauma, infections, autoimmunity, and structural hair defects. Because of the multiplicity of factors, the evaluation of a patient through history, physical examination, and laboratory work-up must be thorough.
ANDROGENETIC ALOPECIA
Androgenetic alopecia (male/female pattern hair loss) is the most common cause of hair loss worldwide. A genetic predisposition is usually present, and the hairs progressively miniaturize under the influence of dihydrotestosterone. Gradual patterned hair loss is the classical clinical presentation. Accepted classifications of androgenetic alopecia exist, such as the Norwood-Hamilton classification, which divides the severity of hair loss into seven stages. Women typically present with diffuse hair thinning, where the central portion of the scalp shows increased parting width over time.
TELOGEN EFFLUVIUM
Telogen effluvium occurs when a large amount of hair enters the telogen phase prematurely, shedding within 2-4 months after the offending insult. The list of causative triggers is extensive, including high fever, pregnancy, medications, malnutrition, severe infections, and endocrine diseases.
Common causative medications include retinoids, anticoagulants, anticonvulsants, and beta blockers. The most common clinical presentation is a sudden onset of diffuse hair shedding. Patients often notice clumps of hair falling out while shampooing or brushing their hair. History and physical examination are crucial to identifying the underlying aetiology. Treatment for telogen effluvium is usually self-limiting and involves eliminating the underlying cause.
ALOPECIA AREATA
Alopecia areata is classified as an autoimmune hair loss condition. It often presents as patchy alopecia, but its diffuse form can be confused with male/female pattern hair loss. Patients usually complain of the sudden onset of hair loss, and a hair-pull test is positive during the active phase. Loss of facial/body hair and nail pitting may also occur. Treatment depends on the severity and may include intralesional scalp triamcinolone acetonide, topical medications, phototherapy, and immunotherapy.
ANAGEN EFFLUVIUM
In anagen effluvium, the hair cycle is abruptly interrupted, resulting in rapid, diffuse hair loss. The hair shafts appear to be narrow and fragile, leading to significant hair thinning over a short period.
Easily fractured hair is a common issue triggered by the use of chemotherapy drugs, levodopa, allopurinol, tamoxifen, arsenic, bromocriptine, and other medications.
TRICHOTILLOMANIA
Trichotillomania is a self-inflicted hair-pulling condition that can lead to localized or diffuse hair loss. It occurs more frequently during childhood and adolescence. A combination of medications and cognitive behavioral therapy may be more effective in treating this condition.
TREATMENT OF HAIR LOSS
Treatment options depend on a patient’s diagnosis and treatment preferences. An individualized approach and in-depth discussion with the patient are crucial to achieving the desired treatment goals.
MINOXIDIL
Minoxidil was originally used in the 1970s as an antihypertensive medication. It is a biologic response modifier thought to promote hair growth through vasodilation and stimulation of hair follicle growth. In cases of androgenetic alopecia, topical minoxidil helps reduce hair shedding and, in some cases, reverses the miniaturization of hair follicles, resulting in hair thickening.
The 2% minoxidil solution was approved by the US FDA in 1988 for treating androgenetic alopecia in men, and in 1996 it was approved as an over-the-counter medication for use by people of all genders.
In a 2003 one-year observational study conducted in Germany, it was found that twice-daily application of 1ml of 5% minoxidil solution in 984 male patients with androgenetic alopecia resulted in two-thirds of participants experiencing mild to moderate hair regrowth. Similarly, a 2004 randomized, placebo-controlled trial comparing 5% and 2% topical minoxidil solutions for the treatment of female pattern hair loss found that the 5% formulation was more effective than the 2% formulation. However, the side effects of 5% minoxidil may not be as well tolerated as those of the 2% formulation.
Topical minoxidil (2% and 5%) is approved for treating androgenetic alopecia in people of all genders. Clinical improvement usually takes between 6 to 12 months to become apparent, and long-term use is necessary, as hair loss will recur if minoxidil is discontinued. Side effects of minoxidil are uncommon but may include headaches, palpitations, scalp irritant contact dermatitis, and hypertrichosis.
Besides androgenetic alopecia, topical minoxidil can also be used to treat various other hair loss conditions, such as alopecia areata, telogen effluvium, anagen effluvium, and trichotillomania.
FINASTERIDE
Finasteride 1mg is an FDA-approved oral medication for the treatment of androgenetic alopecia in men. It competitively inhibits the enzyme 5-alpha reductase type II, which in turn inhibits the conversion of testosterone to dihydrotestosterone (DHT). DHT is the potent androgen responsible for hair follicular miniaturization and the transformation of terminal hairs into vellus hairs.
In clinical studies, finasteride 1mg was shown to slow down the rate of hair shedding and possibly stimulate regrowth in cases of mild to moderate hair loss. If discontinued, the effects of the drug wear off within three months, and the previous pattern of hair loss resumes.
Finasteride is generally well tolerated. Rare complications (sexual) may include erectile dysfunction and decreased libido. Post-finasteride syndrome has been described in recent years, where side effects may continue despite discontinuation of the medication. The incidence was reported to be higher in patients using higher doses of finasteride.
LOW LEVEL LASER LIGHT THERAPY (LLLT)
LLLT is FDA-approved to treat alopecia. It is believed to stimulate mitochondrial activity and activate follicular cellular metabolism. Clinical observations have indicated that LLLT administered two to three times a week shows clinical benefits in terms of reducing hair shedding and increasing hair shaft diameter. Multiple treatment sessions are necessary. LLLT is an alternative treatment option for individuals seeking a non-drug approach or for those who do not want to undergo hair transplant surgery.
SURGICAL HAIR RESTORATION
Individuals with sufficient donor hair from the back of the scalp can undergo hair transplant surgery, which is most commonly used to treat androgenetic alopecia. It can also be used to restore traumatic scars, eyebrows, mustaches, sideburns, and even the pubic region.
Hair transplant surgery techniques have improved over the past 20 years. In modern follicular unit transplantation, follicular units (small naturally occurring hair bundles) are surgically removed from scalp donor sites and transplanted to the desired recipient areas. It is performed as an outpatient procedure in most cases. There is minimal discomfort, and patients can shower and shampoo the next day. In general, patients can return to work within three to five days.
There are two donor harvesting techniques. One involves surgically removing a linear strip of hair, after which the follicular units are individually dissected. The wound is closed with stitches, and the hair above the incision covers the area, so it is not visible. Sutures are removed 12-14 days postoperatively. The other technique is follicular unit extraction, where follicular units are individually extracted from the donor site. The tiny excisions are left to heal without sutures.
The depth and angle of insertion of follicular hair grafts are critical aspects of hair transplantation to ensure the results look natural. Proper placement depends on the expertise of the hair transplant surgeon. PRIME
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