ALOPECIA

Mary Clare Higgins-Chen, MD, MPH

Donna Windish, MD, MPH
Week 25

Educational Objectives:

1. List the most common causes of alopecia in adult patients

2. Employ the appropriate diagnostic evaluation for alopecia
3. Discuss treatment options for the most common causes of alopecia and know how
treatment differs between men and women

CASE ONE:

Ms. A is a 25-year-old African-American woman with vitiligo who presents to the office
with hair loss causing her significant distress.

Questions:

1. What are the three phases of hair growth and how does this relate to hair loss? How
many hairs are normally lost each day?
The three stages of hair growth are:
• Anagen: The growth phase of the hair follicle, ranging in duration from two to six
years. Follicles extend into the subcutaneous fat 2-5 mm below the surface.
• Catagen: During this involution phase, the hair follicle transitions from the growth
phase to the resting phase. This is a short time period, only three weeks. Only
~1% of hair follicles are in this phase at a time.
• Telogen: 5-10% of hair follicles are in this phase. During this two- to three-month
period, hairs are located higher in the epidermis and may easily be removed.

Between 50-100 telogen follicles are shed each day. More than 50% of hairs must be lost
for hair to appear noticeably thinner. Excessive hair loss occurs either when there is a
damaged follicle or the cycling of hair growth is abnormal.

2. What questions do you want to ask Ms. A to help determine the type of hair loss she
is experiencing?
Please see the table below for more context as to why these questions are important as
part of history-taking.
• Over what time period did hair loss begin?
• Is there family history of hair loss and what was the age of hair loss onset?
• Is there a pattern to the distribution of hair loss?

Alopecia. Yale Office-based Medicine Curriculum, Tenth Edition, Volume 5, 2020

 • Has there been any stress or trauma within the last three months?
• Medical history and recent medications?
• Sexual history, including history of STIs?
• Menstrual cycle and recent pregnancies?
• Nutritional status, including recent dieting attempts?
• Recent hair styling or hair treatments?

CASE ONE CONTINUED:

Ms. A denies any recent trauma or stress. She has no family history of hair loss, does not
take any medications, and has not had any recent pregnancies. She is primarily concerned
about one area on her scalp which her hairdresser pointed out at her last appointment. She
does not wear a particularly tight hairstyle.

3. How can you categorize types of hair loss? Which types should be referred to a
dermatologist?
• Scarring vs. non-scarring: The physical exam should begin by assessing for the
presence or absence of hair follicles in the areas of hair loss. If no follicles are
present in the areas of hair loss (i.e., on magnification no empty follicles are
visible) this is cicatricial (scarring) hair loss. Inflammatory disorders such as
discoid lupus are often the cause (see Box 2 from the Ahanogbe paper). Patients
with cicatricial hair loss should be referred to a dermatologist for early scalp
biopsy and treatment as scarring causes permanent hair loss.
• Focal vs. diffuse: Non-cicatricial (non-scarring) hair loss can be further divided
into diffuse or focal loss. Diffuse hair loss includes telogen effluvium. Focal hair
loss includes both patchy areas seen in alopecia areata and the patterned hair loss
seen in androgenic alopecia. Referral to a dermatologist is necessary for either
type only if the diagnosis is unclear or first-line treatments are ineffective.
• Hair breakage vs. coming out at the roots: Most hair loss, whether cicatricial or
non-cicatricial involves hair loss from the roots. Fragile hair fibers are most
commonly caused by hair treatments such as excessive heat or hair dye, but can
result from genetic conditions, tinea capitis, or trichotillomania. Referral to a
dermatologist for either type is necessary only if the diagnosis is unclear.

Alopecia. Yale Office-based Medicine Curriculum, Tenth Edition, Volume 5, 2020

4. What are the most common types of non-scarring alopecia and their features?
Complete the table below:
Lab Tests (if
Clinical the Dx is not
Etiology Clinical Exam
course clear from Hx
and PE)
Focal
Autoimmune Well-circumscribed oval
cause, may be Typically patches of hair loss with
associated with resolves with 6- intact follicles without
other autoimmune 12 months but erythema or scaling.
Alopecia conditions such as can recur. May Exclamation point hairs
Consider ANA
areata Type 1 diabetes, progress to (short hairs which taper
vitiligo, involve all hair towards the end) are
Hashimoto’s follicles on the common. Can be
thyroiditis, or entire body. associated with nail
celiac disease. dystrophy.
Initially, it is
non-scarring but Hair style which pulls on
Mechanical
Traction may become the hair. Loss is typically
traction from hair None
alopecia permanent with at the periphery of the
styles.
repeated scalp.
damage.

Front hair line recession,

Androgeni Hair loss is follicle miniaturization,
Progressive hair
c alopecia hereditary, with and progressive hair loss None
line recession.
- Male hyperandrogenism mostly along the front
pattern contributing for and vertex of the scalp.
hair loss some women.
Androgens Consider free and
Preservation of the front
shorten the total testosterone,
Androgeni hair line, follicle
anagen phase and DHEA, prolactin
c alopecia miniaturization, and
DHT shrinks hair Progressive hair level for patients
-Female diffuse thinning on the
follicles causing thinning. with evidence of
pattern top of the scalp often
hair loss. hyperandrogenism
hair loss with a “Christmas tree”
such as acne,
appearance at the part.
irregular menses
Diffuse
Early entry of
anagen follicles
Hair loss Consider TSH and
into telogen,
spontaneously Diffuse hair thinning ferritin as iron
triggered by
improves over without scarring or deficiency and
Telogen medications,
several months if erythema, can appear thyroid hormone
effluvium stress, childbirth,
the inciting similar to androgenic balance may be
or severe illness
cause is alopecia in women. associated with
with the inciting
removed. telgoen effluvium
event 2-4 months
prior to hair loss.

Alopecia. Yale Office-based Medicine Curriculum, Tenth Edition, Volume 5, 2020

 Chemotherapeutic
agents or radiation
At cessation of
cause an abrupt
treatment, hair
cessation of Copious hair loss starting
Anagen regrows. None
mitosis, 1-2 weeks after treatment
effluvium Changes in hair
preventing onset
color or texture
keratinization and
are common.
causing hair
breakage
Focal or Diffuse
Non-cicatricial. Can be
Alopecia should
diffuse or patchy hair
Alopecia Secondary resolve within 3
loss (described as “moth VDRL, RPR
syphilitica syphilis months of
eaten”) May be the only
treatment
symptom of syphilis

5. How should you approach the physical exam, including specific tests?
• Assess for braiding or styles that pull on the hair, which could cause traction
alopecia
• Assess the front hairline and eyebrows/eyelashes. Conditions such as alopecia
areata may involve hair outside of the scalp.
• Thoroughly examine the entire scalp, specifically looking for erythema, scales, or
scars (bare areas without openings for follicles)
• Assess the thickness of the hairs and number of hair follicles. If the scalp is easily
visualized, more than 50% of the hair has been lost.
• Pull test: This is used to detect active hair shedding. Near an affected area, grasp
50-60 hairs and pull gently perpendicular to the scalp. A positive result is removal
of more than the 10% of hairs typically in telogen at any given time (thus five to
six hairs). This should be repeated in four areas. A positive result can be seen in
telogen effluvium or alopecia areata.
• Tug test: This test assesses hair fiber fragility. Grasp a group of hairs with one
hand and pull gently away at the distal ends with the other hand. Any breakage is
abnormal and can be seen with chemical or heat damage most commonly.

6. When should patients be referred to a dermatologist? When and where should a

scalp biopsy be performed?
All cicatricial hair loss should be referred to a dermatologist for prompt diagnosis and
treatment because scarring permanently damages the hair follicles. A full body exam is
important as other sites of hair on the body may also be affected in these cases. A punch
biopsy of should be performed at the margin of balding patches as this is the site of
active disease. Areas of complete baldness will show only non-specific fibrosis.

Alopecia. Yale Office-based Medicine Curriculum, Tenth Edition, Volume 5, 2020

CASE ONE CONTINUED:

On exam, you note that Ms. A has a smooth patch of hair loss on her scalp with intact
follicles, no scaling or erythema. There are several short hairs with tapered ends at the
edges of the hairless patch. You diagnose her with alopecia areata.

7. What are some treatment options for alopecia areata?

Hair loss resolves spontaneously within one year for 55% of patients. Longer lasting
alopecia and more diffuse hair loss are poor prognostic factors. Screening for co-existent
autoimmune thyroid disease could also be considered.

Given the psychological distress of hair loss, many patients opt for treatment including:
• Intralesional triamcinolone injection, repeated every four to six weeks usually
performed by referral to a dermatologist’s office
• High potency topical steroids applied twice daily
• Topical immunotherapy typically performed by dermatologists for refractory
cases

If patients desire treatment and do not improve with topical steroids or have a large area
of hair loss, they should be referred to dermatology.

CASE TWO:

Mr. B is a 40-year-old Caucasian man who presents with a receding hairline and fronto-
temporal thinning. Many male members of his family are bald. He wants to know how to
slow or stop his hair loss.

8. What treatments are available for male pattern baldness? For the pharmacologic
agents, what is their mechanism of action?
Minoxidil and finasteride are the first-line treatments for male pattern baldness. If
tolerated, combination therapy is superior to monotherapy.

Minoxidil is a potassium channel opener which relaxes smooth muscle and increases
blood flow. Minoxidil increases hair diameter rather than increasing hair number. It
should not be used in those younger than 18 or in women intending to become pregnant
or lactating. It is available over the counter ($13 for a 60 mL bottle on GoodRx). Either
the 2% or 5% strengths can be used. Minoxidil is applied to a dry scalp (not the hair) with
a dropper and gloved hands twice daily (daily for 5%). Minoxidil should remain on the
scalp for several hours. It works by increasing the length of time the hair spends in the
anagen phase, getting hairs out of the catagen phase, and enlarging the hair follicles.

Alopecia. Yale Office-based Medicine Curriculum, Tenth Edition, Volume 5, 2020

 Patients may begin to see hair growth in as early as one month, however, the greatest
changes are noted several months to one year after starting the medication. Treatment
should last indefinitely as hair loss is observed with treatment cessation.

Finasteride is a 5-alpha reductase inhibitor, preventing conversion of testosterone to DHT

which promotes androgenic hair loss. It is given at a low dose of 1 mg daily ($10 for 90-
day supply on GoodRx). Erectile dysfunction may be noted by a small number of
patients. Finasteride should be continued for 1 year to assess its full effect.

Non-pharmacologic treatments include cosmetic aides such as wigs, hairsprays, and

hairpieces. Severely affected patients may consider hair transplantation surgery.

CASE THREE:

Ms. B is Mr. B’s 45-year-old sister. She has noted hair thinning for the past several years.
On exam, she has preservation of her hairline and a “Christmas tree pattern” (greater
thinning at the front of the scalp so that when her hair is parted in the middle it resembles
a triangle or Christmas tree).

9. You diagnose Ms. B with androgenic hair loss, also known as female pattern hair
loss. What treatment options does Ms. B have? Are the treatments any different for
Ms. B compared to Mr. B?
Minoxidil is the first-line treatment for women with androgenic hair loss. Cosmetic aids
and hair transplantation are additional options. Evidence for finasteride use in female
pattern hair loss is unclear, but finasteride pills should not be touched by women of
reproductive age as they may inhibit male fetus urogenital development.

CASE FOUR:

Ms. C is a 25-year-old woman who noticed hair loss two months after delivery. On exam,
she has diffuse hair thinning without scaling, erythema, or scarring. You diagnose her with
postpartum telogen effluvium. Over the next several months, her hair gradually returns to
its prior condition.

10. Ms. A wants to know if she should take any vitamins or change her diet to prevent
future hair loss?
Hair is predominantly composed of the protein keratin. Severe protein malnutrition or
crash dieting can lead to telogen effluvium. The role of micronutrients in hair
development is incompletely understood. Some studies have shown iron supplementation
improves telogen effluvium, but the data is inconclusive. Supplementation of other
Alopecia. Yale Office-based Medicine Curriculum, Tenth Edition, Volume 5, 2020
 micronutrients such as biotin, B12, zinc, and Vitamin E are unclear. Hypervitaminosis A
and selenium toxicity can both cause hair loss.

11. Ms. C decides to start an oral contraceptive agent. Which classes of medications are
most commonly associated with telogen effluvium and what is the prognosis?
Numerous classes of medications have been associated with telogen effluvium. Removal
of the offending agent or a reduction in dose often leads to resolution of symptoms.
Classes with their most common offending agents are listed below:

• Psychotropic medications: lithium, valproate, fluoxetine

• Anticoagulants: heparin (often several weeks after exposure)
• Cardiovascular: metoprolol, propranolol, captopril
• Oral contraceptives (often observed on withdrawal of therapy)
• Antimicrobials: isoniazid, indinavir
• Androgen hormones: testosterone, anabolic steroids

Cicatricial hair loss has been noted with biologic agents such as TNF-alpha inhibitors.

Alopecia. Yale Office-based Medicine Curriculum, Tenth Edition, Volume 5, 2020

Primary References:

1. Ahanogbe I, Gavino ACP. Evaluation and management of the hair loss patient in the
primary care setting. Prim Care. 2015;42(4):569-89.
http://dx.doi.org/10.1016/j.pop.2015.07.005
2. Mubki T, Rudnicka L, Olszewska M, Shapiro J. Evaluation and diagnosis of the hair loss
patient: part I. history and clinical examination. J Am Acad Dermatol.
2014;71(3):415.e1-415. http://dx.doi.org/10.1016/j.jaad.2014.04.070

Additional References:

1. Almohanna HM, Ahmed AA, Tsatalis JP, Tosti A. The role of vitamins and minerals in
hair loss: A review. Dermatol Ther (Heidelb). 2019;9(1):51–70. doi:10.1007/s13555-018-
0278-6
2. Patel M, Harrison S, Sinclair R. Drugs and hair loss. Dermatol Clin. 2013;31(1):67-73.
doi: 10.1016/j.det.2012.08.002
3. Yang MB, Cohen PR, Robinson FW, Gray JM. Alopecia syphilitica-reports of a patient
with secondary syphilis presenting as a moth-eaten alopecia and a reveiw of its common
mimickers. Dermatol Online J. 2009;15(10)6.
4. Minoxidil non-prescription. GoodRx. https://www.goodrx.com/minoxidil-non-
prescription (Accessed June 15, 2020).
5. Finasteride. Healthcare Blue Book.
https://www.healthcarebluebook.com/ui/proceduredetails/med/32?g=Finasteride
(Accessed June 15, 2020).
6. York K, Meah N, Bhoyrul B, Sinclair R. A review of the treatment of male pattern hair
loss. Expert Opin Pharmacother. 2020 Apr;21(5):603-612. doi:
10.1080/14656566.2020.1721463
7. Chan L, Cook D. Female pattern hair loss. Aust J Gen Pract. 2018 ul;47(7):459-464. doi:
10.31128/AJGP-02-18-4498.

Mary Clare Higgins-Chen completed medical school at the University of Michigan and her
residency at the Yale Internal Medicine Primary Care Program where she is currently a chief
resident. Her scholarly interests include healthcare payments and care of the underserved.

Donna Windish completed her residency at the University of Rochester, Strong Memorial
Hospital, and general internal medicine fellowship at Johns Hopkins University School of
Medicine. She is currently on faculty at Yale University in General Internal Medicine. Her
scholarly interests include medical education and faculty development.

Alopecia. Yale Office-based Medicine Curriculum, Tenth Edition, Volume 5, 2020

Knowledge Questions:

1. A 45-year-old woman is diagnosed with androgenetic hair loss. After a discussion,

she decides to begin treatment with minoxidil. Which of the following factors should
she NOT be counseled on?

a. Advise applying minoxidil to the scalp, not the hair

b. Advise her to use gloves when applying the medication
c. Leave the solution in place for five to 10 minutes and then wash out
d. Use for six months before assessing efficacy

2. A 30-year-old man presents with patchy, non-scarring hair loss in a “moth-eaten”

appearance. What is the next best step in management?

a. Measuring ANA titer

b. Apply a topical high potency steroid twice daily
c. Perform a scalp biopsy
d. Measuring VRDL

3. A 50-year-old man presents with diffuse, non-scarring hair loss over the past few
weeks. All of the following are appropriate next steps EXCEPT:

a. Asking about recent stressors

b. Thorough medication review
c. Measuring TSH and T4
d. Starting finasteride

Answers:

1. c The solution should be left on for several hours. Gloves should be worn while
applying minoxidil or hands should be washed immediately after as it may cause hair
growth in unintended locations. Efficacy should be assessed at six months to a year.
Minoxidil should be directly applied to the scalp.
2. d Secondary syphilis can present with patchy hair loss, commonly described as “moth-
eaten.” Topical steroids are an appropriate treatment for alopecia areata. ANA
testing could be indicated if the patient had other symptoms of SLE. Similarly, scalp
biopsy is not indicated at this time as the hair loss is non-scarring.
3. d The patient’s symptoms are most consistent with telogen effluvium, which may be
triggered by a wide variety of factors, including recent stressors, medications, and
hyper- or hypothyroidism. Finasteride is not effective for telogen effluvium but can be
used to treat androgenic alopecia in men.

Alopecia. Yale Office-based Medicine Curriculum, Tenth Edition, Volume 5, 2020