Camden Adult Hair Loss Pathway
Examples of scarring alopecia
With thanks to Dermnetz for images
Queries:camden.pathways@nhs.net
Pathway approved Clinical Cabinet July 18 /CMMC Aug 2018
Review due Aug 21
Non-scarring hair
loss ( Majority)
Are there discreet bald
patches or diffuse, patchy,
hair loss?
No
Consider Traction alopeciayes or
Trichotillomania (self inflicted
hair pulling)- both can lead to
scarring alopecia
Does the patient have
diffuse hair with increase
hair fall?
No
Is hair loss mainly
vertex
No
Are there pustules?
Scarring hair loss is rare and when there are localised
bald patches with no hair follicles. It is usually
diagnosed by a specialist but if suspected should be
referred routinely.
Refer to Dermatology if
Treatment
- severe and widespread
Scalp Seborrheic Ketoconazole or selenium sulphide shampoo twice weekly for >1 month. Once symptoms controlled the frequency may be reduced to weekly or fortnightly
- not resolving or
Remove thick crust or scale with warm mineral or olive oil for several hours and then wash out with a coal tar shampoo e.g. Polytar liquid, Alphosyl 2 in 1 or
dermatitis - immunocompromised
psoriaisis Capasal shampoo
For patients with severe itching of the scalp consider prescribing 4 weeks treatment with a potent corticosteroid scalp application e.g betamethasone
valerate 0.1% scalp application concurrently.
Refer urgently if kerion present (Painful, pustular boggy masses, which may have a thick crust)
Yes Scalp Tinea Capitus Treatment
scaly Take scrapping
Avoid sharing towels, combs, helmets etc.
and clipping Patient leaflet Disinfect or discard objects that can transmit fungal spores e.g. hats, pilllows, hairbrush etc...
Start treatment prior to culture result if highly suspicious and adjust treatment if necessary according to
culture results. Avoid both drugs in pregnancy. Griseofulvin may reduce effectiveness of Combined
contraceptive pill
 Trichophyton Tonsurans -Oral Terbinafine( unlicensed) - 250mg daily for 4 weeks
 Microsporum Canis - Griseofulvin (licensed) 500mg twice daily for 8 weeks.
GP to reassess at 4-8 weeks after treatment for any signs of hair growth
Consider also Ketoconazole shampoo twice weekly for 2-4 weeks by patient and family members.
Alopecia Areata Small patches of hair loss
Treatment
<20% Reassure if evidence of regrowth – no treatment is
Patient leaflet Refer to
required
If no hair regrowth and very mild hair loss discuss option Dermatology if no
>20% hair loss of watchful waiting improvement after
If more significant hair loss consider a potent topical 3-6 months
corticosteroid e.g. betamethasone valerate 0.1% or a
very potent topical corticosteroid e.g. clobetasol
Refer to Dermatology propionate 0.05% for up to 3 months and then review
Note: potent or very potent corticosteroids should not
be used on the beard area or eyebrows.
Telogen Effluvium caused by stress/illness e.g. childbirth, surgery,
high fever, crash diets, drugs. Can occur 2-6 months after event Treatment
that stopped hair growth Reassure-explain can take 6-9 months Refer to
Check - thyroid function tests (TFTs), antinuclear antibody (ANA), for resolution Dermatology If no
Yes
ferritin (aim for ferritin level of >70), vitamin D levels Treat any appropriate abnormalities improvement > 9
(aim for ferritin >70ng/mL) months
Can try minoxidil 5% daily for men or
2% twice daily for women (over the
counter or private prescription)
Treatment (not essential)
Minoxidil 5% daily – Over the counter or on private
script Treatment
Do not refer. Assess response at 6 months. If  Manage underlying causes
Yes
Patient leaflet effective continue long term. If no response after 1  Assess severity.
year discontinue.  If mild or suggestive of PCO,
try 6 months of
Female pattern hair loss cyproterone acetate / Refer to dermatology
Consider day 1-5 follicle stimulating hormone (FSH), luteinising ethinylestradiol if not
Patient leaflet hormone (LH), prolactin, TFTs, testosterone, sex hormone binding If severe or treatment
contraindicated ineffective
Pre-menopausal globulin (SHBG), dehydroepiandrosterone (DHEAS), 17-  Minoxidil 2% twice daily
hydroxyprogesterone, ferritin.
(over the counter or
If other symptoms of polycystic Ovaries (PCO) – consider pelvic private) -review at 6
ultrasound months and continue
indefinitely if effective or
discontinued if there is no
response after 1 year
Treatment
Manage underlying causes
minoxidil 2% twice daily (over the Refer to dermatology
Check ferritin, TFT, ANA
Counter or private prescription) if severe or
distressing
Consider follicultis – Hair scrapings and Please refer to the Summary of Product
clippings for mycology. Treat Characteristics (SPC) of any drug References
Yes Consider folliculitis keloidaris particularly Avoid short or razor hair cut Refer to considered. This pathway has been https://cks.nice.org.uk/fungal-skin-infection-scalp
seen in Afro-Carribean Deep seated /persistent lesions - dermatology developed from published guidance in https://cks.nice.org.uk/seborrhoeic-
Oral Antibiotic e.g. tetracycline or If no improvement collaboration with local dermatologists. This dermatitis#!scenario:1
Erythromycin for 6 weeks guidance is to assist GPs in decision https://cks.nice.org.uk/alopecia-androgenetic-female
Mild lesions may resolve without making and is not intended to replace https://cks.nice.org.uk/alopecia-androgenetic-male
treatment or require topical clinical judgement https://cks.nice.org.uk/alopecia-areata
antiseptic e.g. chlorhexidine
http://www.pcds.org.uk
If mild and localised can also try
topical steroid
Folliculitis keloidaris