So let's jump into our case.
So this is a 57-year old woman with a history of
hypertension who presents with a chief concern of hair loss.
She states that she's seen an increasing quantity
of hair shedding once she takes a shower.
This has been fairly stable
over the past 6 months
but she's now concerned that her hair is just
thinning out particularly on the top of her head.
Now she denies any pruritus or pain,
there's no paresthesias on the scalp
No recent trauma or surgery either.
She is anxious though about her hair loss,
but otherwise reports no acute stressors.
She takes only hydrochlorothiazide and has
not started any new medications lately.
There's no recent weight loss or fever
or chills nor myalgias, no arthralgias.
A pretty benign review of systems.
Social and family history - there's
no history of autoimmune diseases.
I mentioned the review of systems.
And when we performed our exam of the scalp, we see
mild, diffuse, symmetric thinning of the scalp hair.
with no evidence of erythema or scaling or scarring.
A hair pull test that we mentioned before
yields 3 hairs which is pretty normal
There's no exclamation point hairs
present and there are no nail findings.
So highlighting a few specific features,
the time course sounds pretty indolent.
It's just been slowly stable for
the past 6 months - nothing acute.
The pattern of skin involvement, it appears to be a
symmetric involvement the scalp particularly on the top
Regions of her scalp were the vertex of the scalp.
It doesn't look like any systemic involvement
based on a completely negative review of systems.
And in terms of skin inflammation, we have none of those
evidence, findings for erythema, scaling or scarring.
Alright, so which of the following
is the most likely diagnosis?
First off, alopecia angiogenetica.
Now that's a very fancy term for one of the
most common causes of hair loss that there is.
Just basic male pattern or female
pattern balding or hair loss.
It is a benign, common pattern of
baldness seen in both men and for women.
With men it's most commonly in the
vertical or the vertices of the scalp
Whereas for women it may
be a bit more diffuse.
It's mediated by androgens.
That's why it happens more on men than in women
but it does happen over time in women as well.
As I said, it is the most
common cause of hair loss.
We're certainly gonna consider it in our patient particularly
with the lack of any inflammatory findings on exam.
This is pretty typical picture of a
man with alopecia androgenetica.
So this picture in contrast shows very
severe hair loss in just one discreet patch
in contrast to the diffuse hair loss
that we saw in the prior slide.
This is called alopecia areata.
Now this is an immune-mediated
destruction of the hair follicles.
It's associated with a number
of other autoimmune diseases,
more commonly vitiligo, Hashimoto's
thyroiditis or Addison's disease.
And essentially what's happening is an immune
attack on the anagen follicles that are damaged,
they transition to telogen phase and
then very quickly to the exogen phase,
Now you might think with an immune-mediated destruction of
hair follicles, that you might see some scalp inflammation
but it turns out that it's really
happening at a microscopic level.
So you're not gonna see erythema or scaling
or folliculitis or anything like that.
One thing that you may find on physical exam other than
that discreet patch or several patches of hair loss
is this finding called exclamation point hairs which
is just an indication of deceased, broken hair cells
at the site of prior hair follicles.
While most patients classically just
have these little patches of hair loss,
it is important to recognize that there are some very severe cases
where all the hair cells on the entire body are being attacked
and that's a condition called alopecia universalis
where every hair cell has been wiped out
and there's no eyebrows, no eyelashes,
no hair on the scalp either.
Now our patient has mild diffuse hair
loss rather than any dense patches
so I think it's safe that we
can x-out alopecia areata.
As we x-out alopecia areata, I do want to just draw your
attention to the link between some hair loss etiologies
and some nail findings.
For unclear reasons, you might sometimes see nail pitting or
other forms of nail dystrophy in patients with alopecia areata
Again, presumably an
So these nails can provide clues to a number of different diagnoses
and we'll see that in one of the next diagnosis on our list.
So telogen effluvium is transient, diffuse
hair loss cause by a systemic stressor,
a variety of different stressors
and we'll talk about in a moment.
What's happening is a premature shift from
the anagen phase to the telogen phase
and again to the exogen phase ultimately.
And usually what's happening is after an inciting event,
it's 2-4 months later before you start to see the hair loss
which can be very disconcerting for patients
because the stressor was months ago
and it's hard for them to associate that
stressor with what's going on today.
Importantly however, you can reassure patient
that spontaneous recovery should occur
if it was simple episodic stressor and a few months after
the initial loss of hair, it should start to regrow.
Most common causes or precipitants for telogen effluvium would
be pregnancy, major surgery particularly bariatric surgery,
severe illnesses of any sort, malnutrition, iron deficiency.
varieties of hypo or hyperthyroidism,
severe psychologcial stress not just feeling anxious about hair
loss, and a number of different medications can do this as well.
Now we talked before about the association
between nail findings and hair loss.
The same applies for telogen effluvium.
While stressors can manifest with
telogen effluvium in the hair,
it can also manifest as either palpable transverse
ridges on the nail plate or what you call Beau's lines
or as non-palpable alternating white and red
transverse lines depicted here in the nail bed.
Those are called Muehrcke's line.
So again, just something else to look for on the physical
exam when you're seeing somebody having hair loss.
Now in our case, our patient again
does have diffuse hair loss
but we're not getting any obvious precipitants,
stil lwe should kepe it on the list for now.
The next one on our list s called Anagen Effluvium.
It simply stated this is just an extreme form of
telogen effluvium with an abrupt loss of hair.
In contrast to waiting 1-3 months or 2-4 months after a
stressor, this can happen over the span of a few days.
And the most common etiology is chemotherapies.
Promising interventions nowadays are to try and
actually freeze the scalp during chempotherapy
in order to try and avoid hair follicles from
absorbing all those toxic chemotherapies,
and hopefully mitigating some of the downstream
anagen effluvium which used to occur relentlessly.
And so, we'll take that off of our list, we have to presume
she would've told us if she's getting chemotherapy.
So that brings us to discoid
lupus, which gets its own slide.
Discoid lupus erythematosus is
a type of cicatricial alopecia.
Cicatriacial is a fancy word derived from latin
which means scarring, a scarring type of alopecia.
Now it is a subtype of chronic cutaneous lupus.
Actually about 15-30% of patients with systemic
lupus erythematosus will have discoid lupus.
And it is of higher risk in women, in
African-Americans and in those ages 20-40,
which doesn't really meet the
demographics for our patient at all.
Patients with this type of lesion have well-demarcated,
erythematous plaques with adherent scale.
So in contrast to our patient which
has no evidence of inflammation,
this is an inflammatory leison, it's not subtle.
It does have a predilection for this
scalp but you may also see on the face
where there wouldn't be hairloss, there would
just be scarring and same wise with the neck.
What you can see in phyical exam is a
slowly-expanding rim of inflammation
leaving some depressed areas of central scarring
where the hair may not grow back at all.
So this picture really doesn't look
at all like what our patient presents with,
so I think we can safely take this one off our list
So let's revisit our case and highlight
some of the most significant features.
Her age does support androgenetic causes,
That is just female pattern baldness rather
than any other immune-mediated etiology.
The typical location for alopecia androgenetica is
again, on the top of her head which is consistent
and the absence of pruritus, pain, or
paresthesias on the scalp really steers us away
from things like tinea or any of those
cicatricial alopecias that we mentioned.
Likewise, we're not seeing any
evidence of any stressors.
No trauma, no surgery, not starting any new medications,
no recent weight loss to suggest malnutrition.
So that's gonna make telogen effluvium less likely.
And again, the absence of any autoimmune diseases,
the absence of any exclamation point hairs,
the absence of nail findings,and this diffuse
picture, leads us away from alopecia areata,
which would not typically look like this.
So barring any surprises, it looks like she's got
a case of basic female alopecia androgenetica.
So let's talk about the treatment, how
are we gonna help our patient out?
The treatment for alopecia androgenetica is typically just
topical minoxidil, oral finasteride or just reassurance.
It's obviously a benign condition.
The treatment for alopecia areata in contrast
since this is an immune-mediated condition,
would benefit from either topical
or intralesional glucocorticoids.
You can also try cyclosporin.
Telogen effluvium, you can check some basic
lab test like a TSH, maybe an iron panel
but ultimately, you're just gonna avoid
further triggers and further stressors
and just reassure the patient that your
hair's gonna grow back with watchful waiting.
Tinea captiis in contrast, you're gonna use a topical azole
shampoo to try and eradicate the hair follicles there.
Some of these patients actually
require systemic antifungal therapy.
And lastly, scarring alopecia
You really just gonna try and treat the underlying
cause, whether it's lupus or something else.