DANDRUFF & HAIR LOSS

DR RAJA AHSAN AFTAB

COMMUNITY PHARMACY PRACTICE I
LEARNING OBJECTIVE

 Discuss the etiology of hair loss.

 Describe the signs & symptoms of common skin
disorders on scalp.
 Discuss drug management for common skin
disorders on the scalp.
 DANDRUFF –INTRODUCTION (pityriasis
capitis)

 Is a chronic, non inflammatory scalp condition that

results in excessive scaling of the scalp

 It is uncommon in children & generally appears at

puberty, reaches a peak in early adulthood, levels off in
middle age, & declines in advancing years

 It has been estimated to affect 1–3% of the population

AETIOLOGY

 It is characterized by accelerated epidermal cell

turnover(twice faster than normal scalp), an irregular breakup
pattern, & the shedding of cells in the form of large scales
 Cause associated with ↑ yeast Malassezia ovale, as in
seborrheic dermatitis
 It has been shown that M. ovale makes up more of the scalp
flora of dandruff sufferers
 fungal organisms thrive in warm and moist environments that
exist on the scalp due to wearing of hats and caps).
 SIGNS & SYMPTOMS

 The scalp will be dry, itchy and flaky.

 Diffuse rather than patchy & is not inflammatory

 Scaling, the only visible manifestations (greyish-white flakes or scales)

 In seborrheic dermatitis the scales are yellowish & greasy-looking & usually some
inflammation with reddening & crusting of the affected skin.
 In psoriasis the scales are silvery-white & associated with red, patchy plaques &
inflammation

Itchy skin
 Pruritus is common
DANDRUFF -LOCATION

 Scalp is the only area affected

 Seborrheic dermatitis affects the areas where there is greatest

sebaceous gland activity so it usually involves other areas
(eyebrows, eyelashes, moustache, behind the ears, neck, forehead
& chest).

 In infants, seborrheic dermatitis is common & occurs as cradle cap,

appearing in the first 2 months of life

 Psoriasis can affect the scalp but other areas (knees & elbowsare
common; face is rare)
DIFFERENTIAL DIAGNOSIS

 Most patients will diagnose and treat dandruff without seeking medical
help
DANDRUFF TREATMENT GOALS

 Reduce the epidermal turnover rate of the skin of the

scalp.
 Minimize the cosmetic embarrassment of visible scaling.
 Minimize rash
TREATMENT TIMESCALE

 Dandruff treatments need to be applied to the scalp &

to be left for at least 5 mins for best effect

 Should start to improve within 1-2 wks of beginning

treatment

 If an appropriate treatment has been correctly used

with no improvement, referral should be considered
TREATMENT

 Use of a hypoallergenic shampoo on a daily basis will

usually control mild symptoms
 In more persistent and severe cases a ‘medicated’
shampoo can be used to control the symptoms
 Treatment options include
 coal tar
 selenium sulphide
 zinc pyrithione
 ketoconazole
DANDRUFF –COAL TAR

 Mechanism of action unclear but it appears that tars

affect DNA synthesis and have an antimitotic effect

 Modern formulations are pleasant than the traditional

ones but some people still find the smell of coal tar
unacceptable

 Coal tar can cause skin sensitization & is a

photosensitizer
DANDRUFF -KETOCONAZOLE

 Ketoconazole, an azole antifungal, inhibits M. ovale

replication by interfering with cell membrane formation
 Formulation avalable is ketoconazole 2% shampoo.
Should be used twice a week for 2-4 weeks, after which
usage should reduce to weekly or fortnightly as needed
to prevent recurrence.
 Ketoconazole has also been shown to act as a
prophylactic agent in preventing relapse
 The shampoo can also be used in seborrheic dermatitis.
DANDRUFF –SELENIUM SULPHIDE 2.5%

 Reducing cell turnover rate

 Twice weekly for the first 2 weeks is followed by weekly use for next
2 weeks; then it can be used as needed

 Hair & scalp should be thoroughly rinsed after using selenium

sulphide shampoo, otherwise discoloration can result

 Frequent use can make the scalp greasy & can therefore
exacerbate seborrheic dermatitis
DANDRUFF –ZINC PYRITHIONE

 Zinc pyrithione, like selenium also reduces cell

turnover rates

 Should be used twice weekly for first 2 weeks &

then once weekly as required.
SUMMARY OF TREATMENT
PRACTICAL POINTS

 Continuing treatment
 Pts need to understand that the Treatment will not cure their
dandruff permanently & that it will sensible to use the
Treatment on a less frequent basis to prevent their dandruff
coming back.
 Treating the scalp
 It is the scalp rather than the hair that needs to be treated.
 Treatment should be applied to the scalp & massaged
gently.
 Product need to be left on the scalp for 5 min before rinsing.
HAIR LOSS
DR RAJA AHSAN AFTAB
COMMUNITY PHARMACY PRACTICE I
HAIR LOSS (ANDROGENETIC ALOPECIA)

 Each hair follicle goes through a growth cycle, which consists of a long
growing phase (anagen) followed by a short resting phase (catagen)
 At the end of resting phase, the hair falls out (telogen) and a new hair
starts growing in the follicle, beginning the cycle again.
 The normal hair loss from the adult scalp is approximately 100 hairs per
day
 The rate is greater than this then the clinical signs of hair loss can be
observed
 As people age, hair tends to gradually thin
 Other causes of hair loss include hormonal factors, medical conditions
and medications
HAIR LOSS (ANDROGENETIC ALOPECIA)
HORMONAL FACTORS

 The most common cause of hair loss is a hereditary condition called

male-pattern baldness or female-pattern baldness ---alopecia
androgenetica

 Clinicians use the Ludwig Classification to describe female pattern hair

loss.
 -Type I is minimal thinning that can be camouflaged with hair styling
techniques.
 -Type II is characterized by decreased volume and noticeable
widening of the mid-line part.
 -Type III describes diffuse thinning, with a see through appearance on
the top of the scalp.
HORMONAL FACTORS

 In genetically susceptible people, certain sex hormones

(e.g. DHT) trigger a particular pattern of permanent
hair loss

 Most common in men, this type of hair thinning can

begin as early as puberty

 Hormonal changes and imbalances can also cause

temporary hair loss
 MEDICAL CONDITIONS

 A variety of medical conditions can cause hair loss, including:

 Underlying endocrine disorder Diabetes mellitus and hypothyroidism can result in
poor hair growth.
 Alopecia areata This disease occurs when the body's immune system attacks hair
follicles —causing smooth, roundish patches of hair loss. The condition is usually self-
limiting and regrowth of hair is often observed but repeated episodes are not
unusual
 Scalp infections Infections, such as ring worm, can invade the hair and skin of your
scalp, leading to hair loss. Once infections are treated, hair generally grows back.
 Other skin disorders Diseases that can cause scarring, such as lichen planus and
some types of lupus, can result in permanent hair loss where the scars occur
 Trichotillomania Trichotillomania is a psychiatric disorder, which refers to patients who
have an impulsive desire to twist and pull scalp hair, but often deny it
ALOPECIA AREATA
MEDICINE-INDUCED HAIR LOSS

 Medicine-induced causes. Many medicines can interfere with the

hair cycle and cause transient hair loss, cytotoxic medicines being
one of the most obvious examples
 Chemotherapy drugs that tend to cause hair loss include
 Adriamycin
 Cyclophosphamide
 Cactinomycin
 Docetaxel, Doxorubicin, Eroposide, Ifosfamide, Irinotecan,
Paclitaxel, Topotecan, vinorelbine
HOW DO DRUGS CAUSE HAIR LOSS?

 Medications can lead to two types of hair loss: telogen effluvium and
anagen effluvium
 Telogen effluvium is the most common form of drug-induced hair loss. It
usually appears within two to four months after taking the drug. This
condition causes the hair follicles to go into their resting phase (telogen)
and fall out too early. People with telogen effluvium usually shed between
100 and 150 hairs a day.
 Anagen effluvium is hair loss that occurs during the anagen phase of the
hair cycle, when the hairs are actively growing. It prevents the matrix cells,
which produce new hairs, from dividing normally. This type of hair loss
usually occurs within a few days to weeks after taking the medication. It's
most common in people who are taking chemotherapy drugs for cancer
and is often severe, causing people to lose most or all of the hair on their
head, as well as their eyebrows, eyelashes, and other body hairs
OTHER CAUSES

 Physical or Emotional shock

 Many people experience a general thinning of hair
several months after a physical or emotional shock.
Examples include sudden or excessive weight loss, a
high fever, or a death in the family

 Certain hairstyles
 Traction hair loss can occur if the hair is pulled too tightly
into hairstyles such as pigtails or cornrows
TEST THAT MAY BE DONE

 Thyroid function tests

 Hair shaft exam to look at the shape, length,
and fragility of the hairs
 Pull test: gently pulling on about 60 hairs to see
how many come out
 Biopsy: removing a piece of scalp tissue for
examination
 Hormone tests
HAIR LOSS -TREATMENT

 Alopecia androgenetica
 Topical minoxidil 2% or 5%
 May take up to 4 months to show full effect.
 The earlier minoxidil is used in balding, the more likely it is to be successful.
 Oral finasteride 1mg
 May take more than 3 months to see the effect
 Alopecia areata
 Steroid cream: clobetasol or fluocinonide
REFERENCES

 Pray WS. Nonprescription product therapeutics. Lippincott Williams &

Wilkins. 1999. Chapter 20
 Nathan A. Nonprescription medicines. 2ndedition, Pharmaceutical Press.
London pages 287-294