Article Content

Hair loss can be classified by its cause and presentation in all cases and, in some cases, by patient gender. In this article, the author focuses on four common hair loss disorders that occur in both men and women. The author discusses research findings related to androgenetic alopecia (AGA), telogen effluvium (TE), alopecia areata (AA), and scarring alopecia (SA) and provides details on how to approach and manage these diseases according to patient gender. Notably, there is some overlap in the causes and symptoms of the disorders, which highlights the need for obtaining a clear differential diagnosis (Malkud, 2015). There are a range of tools and tests that can assist with the diagnostic process and help ensure that relevant and high standards of patient care are provided and maintained. In some cases, the patient may choose not to proceed with medical intervention. However, appropriate medical treatments, although still relatively limited in some cases, are safe and have proven efficacy. Hair loss has immense emotional and psychological impact in both genders. It is always important to consider this when planning hair loss management pathways (Ruiz-Doblado, Carrizosa, & Garcia-Hernandez, 2003). Following is a discussion of common hair loss disorders that occur in both men and women.

 

ANDROGENETIC ALOPECIA

Androgenetic alopecia, as its name suggests, is thought to be androgen-dependent (National Institute for Health and Care Excellence [NICE], 2016a, 2016b). This condition presents as diffuse hair loss in both genders but is more likely to occur in postmenopausal women, affecting about 33% of genetically predisposed Caucasian women 70 years or older. In women with AGA, hair loss usually affects the top of the scalp (NICE, 2016b). As many as 58% of men aged 30-50 years may experience AGA. In men, hair loss typically starts with bitemporal hairline recession and hair thinning at the crown (i.e., vertex) and frontal parietal areas (NICE, 2016a). According to the Hamilton-Norwood Scale (Norwood, 1975), the amount of hair loss increases with age. Men with Grade I-III hair loss can benefit from medical intervention. Men with Grade IV-VI hair loss generally show good response to hair transplant procedures (Shankar, Chakravarti, & Shilpakar, 2009). In both men and women, the underlying pathological process involves pigmented terminal hairs gradually being replaced by smaller, less pigmented hairs with a similar appearance to the short, thin, barely noticeable vellus hairs that develop on the body during childhood (NICE, 2016a, 2016b). See Table 1 for signs and symptoms, diagnostic tools, investigations, and management of AGA in men and women.

  

TABLE 1 Androgenetic Alopecia

TELOGEN EFFLUVIUM

Telogen effluvium is a nonscarring form of hair loss. It generally occurs about 3 months after a triggering event when up to 70% of the anagen-phase hairs are precipitated into telogen hairs, with a bulb or club at their tip. After a few months, new hair pushes the club hairs up and out. This disorder is usually self-limiting, lasting for about 6 months before the hair regrows, provided the trigger is not repeated. There is a diffuse, but temporary loss of these hairs in both genders, and there is often a noticeable change in fingernail growth that occurs at the same time (DermNet NZ, 1997; Trueb, 2008).

 

Known triggers for TE include stress, shock, acute fever, invasive surgery, severe infection or trauma, thyroid disorder, low protein diet or extreme dieting, iron deficiency, and certain medications (e.g., chemotherapy drugs, [beta]-blockers, retinoids, anticoagulants, propylthiouracil, carbamazepine, immunizations; Hughes & Saleh, 2019). Hormonal changes in pregnancy, particularly a decrease in estrogen levels, can lead to postpartum TE (MedicineNet.com, n.d.); however, the studies supporting this information are small and additional investigation is necessary to establish a connection (Mirallas & Grimalt, 2016). A subtype of TE, known as chronic TE, occurs more commonly in middle-aged women with long, thick hair (Cunliffe, 2019). See Table 2 for signs and symptoms, diagnostic tools, investigations, and management of TE in men and women.

  

TABLE 2 Telogen Effluvium (Continued)

ALOPECIA AREATA

Alopecia areata presents as nonscarring hair loss. In AA, the hair loss occurs as a solitary patch or as several well-demarcated patches (Camacho, 1997; Tan, Tay, Goh, & Chin Giam, 2002). This type of hair loss occurs when the hairs are prematurely converted from the growth (i.e., anagen) phase to the loss (i.e., telogen) phase (NICE, 2018). The specific cause of AA is unknown, although 20% of people with AA have a positive family history (Messenger, McKillop, Farrant, McDonagh, & Sladden, 2012). Alopecia areata is associated with other autoimmune conditions (e.g., thyroid disease). Men with relevant family history and boys 10 years or younger are more likely to experience AA, but the incidence is generally higher in women, with peak occurrence between 10 and 20 years of age (Lundin et al., 2014). Hair regrowth is common in clients with only minor hair loss and usually regrows within a year; however, regrowth can be unpredictable (NICE, 2018). Some researchers have reported that emotional stress triggers AA (Baker, 1987), whereas other researchers completely refute this (Colon, Popkin, Callies, Dessert, & Hordinsky, 1991). Additional research related to AA is warranted. See Table 3 for signs and symptoms, diagnostic tools, investigations, and management of AA in men and women. Figure 1 provides a treatment protocol for AA in different age groups.

  

TABLE 3 Alopecia Areata

 

FIGURE 1. Treatment protocol for alopecia areata is licensed under Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported [no modifications]. From "Alopecia Areata: A Review," by S. S. Amin and S. Sachdeva, 2013,

SCARRING ALOPECIA

Scarring alopecia is irreversible and is more commonly seen in women, especially European Caucasian women with a mean age of 51-53 years (Villablanca, Fischer, Garcia-Garcia, Mascaro-Galy, & Ferrando, 2017). Scarring alopecia is divided into two subgroups.

 

Primary scarring alopecia (PSA) occurs due to an underlying disease (Patterson, 2014) that leads to a lack of follicular ostia and replacement of hair follicles with fibrous tissue. It is associated with conditions that include chronic cutaneous lupus erythematous, pseudopelade of Brocq, lichen planopilaris, folliculitis decalvans, and dissecting folliculitis. In some cases, the type of underlying disease can be identified by the type of inflammatory infiltrate around the hair follicles (Olsen et al., 2003; Villablanca et al., 2017). Figure 2 provides a classification system for identifying the underlying disease associated with PSA, which can help determine treatment and management for both men and women.

  

FIGURE 2. Primary scarring alopecias. From "Summary of North American Hair Research Society (NAHRS)-Sponsored Workshop on Cicatricial Alopecia, Duke University Medical Center, February 10 and 11, 2001," by E. A. Olsen, W. F. Bergfeld, G. Cotsarelis, V. H. Prince, J. Shapiro, R. Sinclair, et al., 2003,

Secondary scarring alopecia (SSA) is so named because it results from exogenous factors such as trauma caused by burns or radiation or by endogenous inflammatory processes caused by disorders such as sarcoidosis, pemphigus vulgaris, or scleroderma (Villablanca et al., 2017). Although controversial, there is evidence to suggest that central centrifugal cicatricial alopecia (CCCA) is a type of SSA largely caused by hair treatments such as straightening with hot irons and using products with chemicals that damage hair follicles. This type of alopecia is seen predominantly in women of Afro-Caribbean descent (Nicholson, Harland, Bull, Mortimer, & Cook, 1993; Sperling & Sau, 1992). There is some evidence to suggest that CCCA possesses an autosomal mode of inheritance (Diova, Jordaan, Sarig, & Sprecher, 2014). One small study showed some correlation between the incidence of CCCA and diabetes mellitus (Kyei, Bergfeld, Piliang, & Summers, 2011). To correctly classify CCCA, more large-scale and widespread investigation is necessary.

 

Figure 3 provides a two-step algorithm that can be used with both scarring and nonscarring forms of alopecia where the presence or absence of follicular miniaturization and raised or normal catagen/telogen counts are used as markers for differential diagnosis. See Table 4 for signs and symptoms, diagnostic tools, investigations, and management of SA in men and women.

  

FIGURE 3. Algorithm for differential diagnosis of alopecia. From "Primary Scalp Alopecia: New Histopathological Tools, New Concepts and a Practical Guide to Diagnosis," by A. Kolivras and C. Thompson, 2017,

 

TABLE 4 Scarring Alopecia (Continued)

DIAGNOSTIC TOOLS

Differentiation in the diagnostic process is difficult but essential and is achieved with a variety of tools including biopsy with histopathology. Histopathology of AGA will show prominent sebaceous glands, miniaturization of existing hair follicles, and reduced follicular diameter (Soeprono, 2012a). Telogen effluvium histopathology will show abnormally high telogen follicles with empty follicular sheaths known as "stele" (Malkud, 2015; Soeprono, 2012b). Alopecia areata histopathology typically presents with a "swarm of bees" appearance caused by inflammatory infiltrate around terminal hair follicles (Amin & Sachdeva, 2013). Scarring alopecia histopathology will be identical in both genders and is characterized by collagen cells becoming translucent and highlighted by wide, tree trunk-like tracts and preservation of the elastin sheaths surrounding these tracts (Blattner, Polley, Ferritto, & Elston, 2013).

 

The use of dermoscopy or trichoscopy may be invaluable in aiding differential diagnosis (Xu, Liu, & Senna, 2017) as this examines the follicular and interfollicular patterns, as well as the hair shaft characteristics (Jain, Doshi, & Kopkar, 2013). Refer to Table 5 for a comparison of the different histopathology and trichoscopy patterns in these four diseases.

  

TABLE 5 Histopathology and Trichoscopy of Hair Loss Disorders

In addition to obtaining a complete personal and family history, various physical tests such as the "pluck" and "wash" tests (Amin & Sachdeva, 2013; Trueb, 2016) and certain laboratory blood tests can help to specifically identify underlying causes of alopecia (Hughes & Selah, 2019).

 

PSYCHOLOGICAL EXPLORATION AND MANAGEMENT

Psychological exploration and management must be incorporated in all cases of hair loss. It has been reported that in AA patients, there is a high prevalence of mood, adjustment, depressive, and anxiety disorders, regardless of gender (Ruiz-Doblado et al., 2003). In another study that included women experiencing both scarring and nonscarring forms of alopecia, the researchers found that the women with SA scored higher on the Dermatology Life Quality Index, Hospital Anxiety and Depression Scale, and UCLA Loneliness Scale compared with women with non-SA (Katoulis et al., 2015). In a multinational study that included men experiencing hair loss, the men reported feeling less attractive and confident, and this negatively impacted their social life and increased feelings of depression (Alfonso, Richter-Appelt, Tosti, Viera, & Garcia, 2005). These findings emphasize the need for psychological management of men and women experiencing hair loss.

 

CONCLUSION

There are some gender differences in the clinical signs and diagnosis pathway and management of hair loss disorders. Scarring and nonscarring forms of alopecia generally have a higher prevalence in adult women; however, this may be due to a tendency for women to visit their specialist and seek help earlier than men. It is possible there may be an increase in the number of men seeking treatment in the future (Malkud, 2015). Women with AA are more likely to have nail symptoms than men. The diagnostic tools for AGA differ by gender, and finasteride as a hair-rejuvenating agent is only safe for male patients with hair loss (NICE, 2016a). Characteristic clinical and pathological findings may allow for a precise diagnosis in some cases; however, certainty is often difficult to achieve and reflects the limits of current dermatological knowledge of these disorders (Villablanca et al., 2017). Biopsy with histopathology and various hair tests are helpful in differentiating during the diagnostic process. Moving forward, the classification of alopecia will continue to evolve and change, with diagnostic clarity based primarily on trichoscopy findings (Kolivras & Thompson, 2016). As successful treatment of hair loss disorders in many cases is specific to the underlying disease type, it is important for clinicians to use currently available diagnostic tools and stay abreast of fresh, evidence-based approaches.

 

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