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 Dr Shehla Ebrahim. MD,CCFP,FCFP.
( special interest dermatology)
 I have no relevant conflicts of interest.
 I have received an honorarium from the BC
college for presenting this talk.

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 A full day of Hair loss.
 Its going to be a long day
 Non scarring Alopecia
-MPHL/FPHL
-Telogen Effluvium.
-Alopecia Areata.
 When is it more than just hair loss.
 Clinical Scenarios and Key Messages

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 Onset and duration.
“When was the last time you had a
normal head of hair”?

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 Strong Family history is supportive of MPHL

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 Regularity of menses.
 Fertility.
 NOTE PATTERN OF HAIR LOSS.
 Examine the scalp skin for inflammation,
scaling, patches.
 Examine the eyebrows, facial axillary and
pubic hair.
 Check for hirsuitism is suspected by history.

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HAIR CYCLE ANAGEN 3 YEARS
CATAGEN 3 Weeks
TELOGEN 3MONTHS
ANAGENANAGEN
ANAGEN
TELOGEN
FEMALE PATTERN
HAIR LOSS
MALE PATTERN HAIR
LOSS
TELOGEN
EFFLUVIUM
ALOPECIA
AREATA
ANDROGEN
EXCESS

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 95% of hair loss .
 50% of men and 40% of women.
CLINICAL PEARL
 They have completely normal androgen levels.
CLINICAL PEARL
Retention of the frontal hair line

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HAIR CYCLE ANAGEN 3 YEARS
CATAGEN 3 WEEKS
TELOGEN 3 MONTHS
ANAGENANAGEN
ANAGEN
TELOGEN
 TSH.
 Ferritin
- No studies showing reversal of hair
loss with iron supplementation.
- Keep Ferritin above 50 ug/L
Trost et al JAAD 2006;54(4) 824-844.

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 Topical Minoxidil 2% and 5%
 Mainly acts on the hair cycle by
lengthening the duration of the anagen plus
enlarges the miniaturized hair follicles
Messenger,AG Brit J dermatology
2004;150:186:194.
 Adverse effects (higher 5%)
- Irritation.
- Contact Dermatitis (propyleneglycol)
-NonVirilising Hypertrichosis.
- High degree of variability in cosmetic
acceptance.
- 5% foam OD vs. 2% BID.
Lucky et al JAAD 2004:50;541-553

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 Androgen receptor blocker and inhibits
steroid androgen production.
 Threshold of response acne>Hirsuitism>
FPHL
 Concurrent BCP
-breast tenderness.
- Feminization of male foetus
 200 mg per day.
Sinclair, R Brit J dermatology
2005;152:466-473

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 Thinning is Bitemporal +/-the crown of the
scalp.
CLINICAL PEARL
• The sides are spared

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 Type 11, 5 alpha reductase inhibitor.
 Inhibits the conversion of testosterone to
DHT.
 1 mg in MPHL.( Kaufman et al)
-benefits are temporary.
- Decreased libido and ED.
 Not indicated for use in women.
Canadian Family PhysicianVol 46 July 2000
FEMALE PATTERN
HAIR LOSS
MALE PATTERN HAIR
LOSS
TELOGEN
EFFLUVIUM
ALOPECIA
AREATA
ANDROGEN
EXCESS

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 Febrile illness
 Childbirth
 Severe psychological
stress
 Major surgery
 Hypo or
hyperthyroidism
 Iron deficiency
anaemia
 Crash diets
 Drugs
HAIR CYCLE ANAGEN 3 YEARS
CATAGEN 3 WEEKS
TELOGEN 3 MONTHS
ANAGEN
TELOGEN

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 Identify specific cause.
 Complete recovery occurs in 4-6 months.
 Minoxidil 5%

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FEMALE PATTERN
HAIR LOSS
MALE PATTERN HAIR
LOSS
TELOGEN
EFFLUVIUM
ALOPECIA
AREATA
ANDROGEN
EXCESS
 Polygenic Autoimmune disorder.
 It attacks the anagen hair follicles of the
scalp,face and body
 Majority Appear sporadically and it can appear
without a family history.
Canadian family PhysicianVol 46,July 2000

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 AA is associated with other AA diseases such as
vitiligo,Diabetes,Thyroid disease, pernicious anemia
 Spontaneous remissions can occur.
Dermatology in PracticeVol 11 no 5
 Patchy. (Most common)
 Diffuse.
 Confluent.
 Aphyiais.

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 T cell mediated disorder.
 Immune privilege of the hair follicle is lost.
 Once activated, the cytotoxicT cells produce
inflammatory cytokines and IL which attack
the anagen hair follicles of the scalp,
eyebrows, eyelashes and body
 Nail Dystrophy (pitting, ridging, thinning)
 Exclamation marks, are seen at the periphery
of the patch
 Color changes in the hair

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 ADULTS WITH < 50% HAIR LOSS
-Observe for several months
- Intralesional steroids.kenalog q4-6 weeks
- Potent topical steroids.OD for 3 months
- +/- Minoxidil
 ADULTS WITH > 50% HAIR LOSS.
-Topical immunotherapy with DPCP
(diphenylcyclopropenone)
-Psoralen and Ultraviolet A (PUVA)
- Pulsed Oral Steroids

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FEMALE PATTERN
HAIR LOSS
MALE PATTERN HAIR
LOSS
TELOGEN
EFFLUVIUM
ALOPECIA
AREATA
ANDROGEN
EXCESS
 Most women with FPA show no clinical or
biochemical evidence of hair loss.
-Hypersensitive to physiologic
concentration of androgens
 When to evaluate for PCOS or metabolic
Syndrome?

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 Increased Facial Seborrhea
 Acne that fails to respond to standard
therapies. Localized to the jaw line and neck
 Hirsuitism; upper lip, chin breast and linea
alba
 Androgenic Alopecia, early onset < 35 years.
 Menstrual Irregularities.
 Infertility.
 Galactorrhea
 Virilization

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 Polycystic ovary Syndrome(90%)
Prevalence 5-10%
 Tumours of the ovary or adrenal gland(<0.5%
 Hyperprolactinemia(2.3%)
 Congenital adrenal hyperplasia (1.3%)
 Cushings syndrome
 Androgenic medications (danazol, anabolic steroids, progestin
releasing IUD
Glint &Anderson,gynecol
endocrinol 2010:26:281-96
 Testosterone (free and total)
 Sex hormone binding globulin (SHBG)
 Dehydroepiandrosterone sulphate(DHEAS)
 Prolactin
 LH/FSH
 Fasting Glucose/insulin
 Lipid profile.
Ding,EL et al NEJM 2009:361:1152-1163

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MH.Age 23
 Testosterone 2.0 nmol/L (0.5-3.2)
 Testosterone Free 180 pmol/l ( 5-60)
 SHBG 3 nmol/L ( 5-100)
 Cholestrol 7.16 H ( 2-4.60 nmol/L)
 LDL 4.83 H (1.50-3.00)
 TGA 3.9 (<2.21)
 HDH 0.19 nmol/L (1.19)

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 Weight loss
 Oral Contraceptives
 Anti androgen medications
-Spironalactone
-Cyproterone Acetate
 Insulin Sensitizing medications.
-Metformin

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 A 20 year old female with steadily thinning
hair over the past several years.
 Otherwise in good health.

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FEMALE PATTERN HAIR
LOSS
 45 year old woman with considerable hair
loss during the last 6 months.
 “Massive” amounts of hair are clogging the
shower drain every day
 During the same period of time she has felt
“depressed "fatigued and lacking in her usual
energy

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TELOGEN EFFLUVIUM

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 36 year old man has noticed bald patches of
hair loss on his scalp and more recently his
beard area.
 He is otherwise in good health.

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ALOPECIA AREATA
 23 year old overweight female complaining
of scalp thinning,increased facial hair.
 History of irregular periods since puberty.
 Family history balding.

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ANDROGEN EXCESS
MPHL/FPHL
 Patients with FPHL/MPHL have Normal
androgen levels.
 Pattern of hair loss isTHINNING
-Retention of frontal hair line FPA
- Sides are spared in MPHL

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Telogen Effluvium
 Pattern of hair loss is diffuse shedding and
involves the entire scalp
 Re growth occurs in 4-6 months
 Alopecia Areata
 Look for exclammation marks,white hairs
and nail changes.
 Wait for 6-9 months as spontaneous
resolution is common.

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 Suspect androgen excess if:
-Features of SAHA are present
- Screen for PCOS/FreeTestosterone
- Treat with weight loss, Antiandrogen
 Do not underestimate the psychological impact
that Hair loss has on your patients.
 These patients feel vulnerable as hair gives them
character and definition.
 National AA foundation.
 Local wig makers.
 Eyebrow and Eyelid tattooing

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Thank you
Photo courtesy of www.DermNet NZ.org
sebrahim@telus.net

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 Trichotillomania.
 Traction Alopecia.
•A compulsion to pull/pluck hair repetitively.
•Impulse control disorder
•7x more frequent in children.
•With increasing age, girls

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 Spontaneous resolution.
 Clomipramine vs desipramine.

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