COMMON HAIR LOSS CONDITIONS

Acne Keloidalis Nuchae

Acne (Folliculitis) Keloidalis (AKN) is a progressive scarring alopecia.  It presents with small, smooth, firm bumps with occasional puss on the posterior scalp and nape of the neck.  Over time lesions result in scarring hair loss and keloid scars.  The exact cause is unknown.  Some associated factors include hair grooming, trauma, friction, heat, humidity, infections, and androgen hormones.  Treatment includes avoiding potential triggers (close shaving, frequent haircuts, shirts with high collars, helmets, chains, etc.), anti-inflammatories (topical and/ or injection), antimicrobials, destruction (liquid nitrogen, laser, etc), and surgery.

References: 

- Maranda EL, et al.  Treatment of Acne Keloidalis Nuchae: A Systematic Review of the Literature. Dermatol Ther (Heidelb). 2016 Sep;6(3):363-78. doi: 10.1007/s13555-016-0134-5. Epub 2016 Jul 18. Review. 

- Al Aboud DM, Badri T. Acne, Keloidalis Nuchae. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-.2017 Dec 3.

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Discoid Lupus

Discoid lupus erythematosus (DLE) is an inflammatory scarring alopecia.  It is an autoimmune condition and a type of chronic skin lupus. It presents as a sharply-demarcated red, scaly plaque with a central depressed scar, central skin lightening, follicle scale plug, and a surrounding dark patch.  It occurs 4-5 times more common in black women compared to white women.  Systemic lupus erythematosus (SLE) may develop in 5-25% of people with DLE. It may be associated with other autoimmune conditions and increased risk for squamous cell carcinoma.  Management includes the use of sun protection, anti-inflammatory medications (i.e. steroids (topical/ oral/ injection), tacrolimus, methotrexate, etc.)

References: 

- Gro¨nhagen CM et al. Increased risk of cancer among 3663 patients with cutaneous lupus erythematosus: a Swedish nationwide cohort study. Br J Dermatol 2012;166:1053e9.

- Jessop S et al.  Drugs for discoid lupus erythematosus.  Cochrane Database Syst Rev. 2017 May 5;5:CD002954.

- McDaniel B, Tanner LS.  Lupus Erythematosus, Discoid.  StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan 2018 Sep 26. 

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Frontal Fibrosing Alopecia

Frontal Fibrosing Alopecia (FFA) is a rare chronic progressive primary scarring alopecia. FFA is a clinical variant of lichen planopilaris.  It presents with the progressive recession/ smooth balding of the frontal and temporal hairline. It can also be associated with eyebrow and body hair loss, and facial bumps and dark marks.  FFA is seen more commonly in postmenopausal Caucasian women but upwards of 12% of FFA cases occur in women of African descent (majority premenopausal).  The exact cause of FFA is unknown.  However, some proposed mechanisms include genetic predisposition (HLA-B*07:02 allele), autoimmune dysfunction, decreased levels of androgens, reduction in peroxisome proliferator-activated receptor gamma (PPAR-γ), and possible environmental exposures.  Management includes anti-androgen (i.e finasteride), anti-inflammatories (i.e. steroids, oral tetracyclines, oral antimalarials, other immunosuppressants), minoxidil, retinoids, and scalp camouflage. There have been limited case reports using platelet rich plasma and one should use caution with hair transplantation as reactivation of the disease may occur. 

References

- Strazzulla LC et al.  Prognosis, treatment, and disease outcomes in frontal fibrosing alopecia: A retrospective review of 92 cases.  J Am Acad Dermatol. 2018 Jan;78(1):203-205

- Murad A, Bergfeld W.  5-alpha-reductase inhibitor treatment for frontal fibrosing alopecia: an evidence-based treatment update.  J Eur Acad Dermatol Venereol. 2018 Mar 10.

- Tziotzios C. et al. Genome-wide association study in frontal fibrosing alopecia identifies four susceptibility loci including HLA-B*07:0. Nat Commun. 2019 Mar 8;10(1):1150

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Telogen Effluvium

Telogen effluvium (TE) is the most common cause of diffuse hair loss/ shedding and can affect men and women.  It can be acute (<6 months) or chronic (>6 months). TE occurs when an increased amount of anagen hairs (hair in the growth phase) are triggered to enter the resting/ telogen phase. Triggering factors include but are not limited to post-partum, febrile states, stress, medications, systemic disease, nutritional deficiencies. Management includes watchful waiting, removing triggering factors, nutritional supplementation, and minoxidil.

References

- Rebora A. Telogen effluvium: a comprehensive review.  Clin Cosmet Investig Dermatol. 2019 Aug 21;12:583-590.

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Alopecia Areata

Alopecia areata (AA) is an autoimmune disease of the hair follicles that is thought to affect approximately 2% of the population. Blacks and Hispanics demonstrated almost 3-fold and 2-fold increased odds of having AA compared to Whites.  It can present with small patches (alopecia areata), band line hair loss on the hairline (ophiasis), widespread shedding (alopecia areata incognito), total scalp hair loss (alopecia totalis), total hair scalp and body hair loss (alopecia universalis).  It may be associated with other autoimmune diseases (i.e. thyroid disease). Nail changes (pitting) may be associated with a worse prognosis.  Treatment includes steroids (topical, oral, injection), other anti-inflammatory oral/ topical (i.e. janus kinase inhibitors, methotrexate, tacrolimus, etc. ), contact immunotherapy (i.e. squaric acid), minoxidil, platelet rich plasma, excimer laser.

References: 

- Darwin E, Hirt PA, Fertig R, Doliner B, Delcanto G, Jimenez JJ. Alopecia Areata: Review of Epidemiology, Clinical Features, Pathogenesis, and New Treatment Options. Int J Trichology. 2018 Mar-Apr;10(2):51-60.

- Bokhari L, Sinclair R. Treatment of alopecia Universalis with topical Janus kinase inhibitors - a double-blind, placebo, and active-controlled pilot study. Int J Dermatol. 2018 Aug 30

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Dissecting Cellulitis

Dissecting cellulitis of the scalp (DC) is an uncommon scarring scalp hair loss disorder characterized by painful nodules, drainage of puss, sinus tracts, keloid/ thick scar formation, and scarring alopecia. It most commonly affects black males between the ages of 20 and 40.  The cause of DC is unknown but may have a genetic predisposition with autosomal dominant inheritance. It may be triggered shaving and other scalp irritants (i.e. helmets).  DC may be associated with Hidradenitis suppurativa, acne conglobata, pilonidal cysts, and secondary bacterial infections.  It can be managed with oral antibiotics, oral isotretinoin, tumor necrosis factor (TNF) inhibitors, and surgical excision.

References: 

- Martin-Garcıa RF, Rullan JM. Refractory dissecting cellulitis of the scalp successfully controlled with adalimumab.P R Health Sci J 2015;34(2):102–104.

- Badaoui A et al. Dissecting cellulitis of the scalp: a retrospective study of 51 patients and review of literature.  Br J Dermatol. 2016 Feb;174(2):421-3

- Powers MC, Mehta D, Ozog D.  Cutting Out the Tracts: Staged Excisions for Dissecting Cellulitis of the Scalp. Dermatol Surg. 2017 May;43(5):738-740

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Male Pattern Hair Loss

Male pattern hair loss (MPHL) is a chronic progressive non-scarring alopecia.  It typically presents thinning of the frontal, temporal, vertex scalp and deep recession of the fronto-temporal hairline. Hair thinning may lead to complete baldness in affected areas. It is the most common hair loss disorder affecting all men.  The exact cause of MPHL is unknown and is likely multifactorial and may include genetic predisposition and follicular androgen sensitivity.  Management includes anti-androgen (i.e. finasteride), minoxidil (oral/ topical), low level light therapy, platelet rich plasma, scalp camouflage (i.e. scalp micropigmentation, hair fibers, wigs), essential oils (i.e. rosemary), and nutritional supplementation.

References: 

- Panahi Y. et al.. Rosemary oil vs minoxidil 2% for the treatment of androgenetic alopecia: A randomized comparative trial. Skinmed. 2015;13(1):15-2

  - Farris PK et al. A Novel Multi-Targeting Approach to Treating Hair Loss, Using Standardized Nutraceuticals.  J Drugs Dermatol. 2017 Nov 1;16(11):s141-s148

- Kanti V, et al. . Evidence-based (S3) guideline for the treatment of oandrogenetic alopecia in women and in men - short version. J Eur Acad Dermatol Venereol. 2018 Jan;32(1):11-22.

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Central Centrifugal Cicatricial Alopecia

Central Centrifugal Cicatricial Alopecia (CCCA) is a chronic progressive inflammatory scarring alopecia. It is the most common cause of scarring alopecia in women of African descent. Hair loss may start as breakage or change in hair texture on the central scalp and spread outward.  It can progress to patchy hair loss or large areas of balding.  It may or not be associated with itching, pain, and soreness. The exact cause of CCCA is unknown but a new study has identified a gene variant of peptidyl arginine deiminase 3, PADI3, present in approximately one-quarter of studied patients with CCCA. One study also demonstrated a 5-fold increase in the occurrence of uterine fibroids in women with CCCA.  It may be managed with anti-inflammatory medications (topical/ oral/ injections), minoxidil, avoidance of tension producing hairstyles, platelet rich plasma, and hair transplantation).

References: 

- Callender VD, Lawson CN, Onwudiwe OC. Hair transplantation in the surgical treatment of central centrifugal cicatricial alopecia. Dermatol Surg 2014;40:1125-31. 

- Dina Y., Okoye G.A., Aguh C. Association of uterine leiomyomas with central centrifugal cicatricial alopecia. JAMA Dermatol. 2018;154(2):213–214

- Malki L, Sarig O, Romano MT, et al. Variant PADI3 in central centrifugal cicatricial alopecia. N Engl J Med. 2019;380:833-841

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Female Pattern Hair Loss

Female pattern hair loss (FPHL) is a chronic progressive non-scarring alopecia.  It typically presents as a diffuse hair loss in the mid and frontal regions of the scalp with preservation of the frontal hairline. It is the most common hair loss disorder affecting all women.  The exact cause of FPHL is unknown and is likely multifactorial and may include genetic predisposition, follicular androgen sensitivity, and micro-inflammation.  Management includes anti-androgen (i.e spironolactone, finasteride), minoxidil (oral/ topical), low-level light therapy, platelet rich plasma, scalp camouflage (i.e. scalp micropigmentation, hair fibers, wigs), essential oils (i.e rosemary), and nutritional supplementation.

 

References: 

- Panahi Y. et al.. Rosemary oil vs minoxidil 2% for the treatment of androgenetic alopecia: A randomized comparative trial. Skinmed. 2015;13(1):15-2

-  Redler S. et al. Genetics and other factors in the aetiology of female pattern hair loss.  Exp Dermatol. 2017 Jun;26(6):510-51  

- Farris PK et al.. A Novel Multi-Targeting Approach to Treating Hair Loss, Using Standardized Nutraceuticals.  J Drugs Dermatol. 2017 Nov 1;16(11):s141-s148

- Kanti V, et al. . Evidence-based (S3) guideline for the treatment of androgenetic alopecia in women and in men - short version. J Eur Acad Dermatol Venereol. 2018 Jan;32(1):11-22.

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Traction Alopecia

Traction alopecia (TA) is caused by excessive pulling forces, leading to mechanical damage of the hair follicles. This can eventually lead to inflammation and scarring of the scalp. In its early stages is it reversible and presents with bumps, "puss" bumps, mild thinning and hair breakage.  In its late stages, it presents with scarred balding of the scalp.  It is one of the most common causes of hair loss in women of African descent.  It may be managed by avoiding potentially tension producing hairstyles  (i.e. tight ponytails, extensions, braids, etc.), steroids, (topical/ injection), minoxidil, scalp camouflage (scalp micropigmentation, hair fibers, wigs),  platelet rich plasma, and hair transplantation.

 

References: 

- Callender VD, et al. Medical and surgical therapies for alopecias in black women. Dermatol Ther. 2004;17(2):164–176.

- Aguh C, Okoye G, eds. Fundamentals of Ethnic Hair: The Dermatologist's Perspective. Cham: Springer, 2017

- Billero V, Miteva M. Clin Cosmet Investig Dermatol.  Traction alopecia: the root of the problem  2018 Apr 6;11:149-159

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