Hair Disorders: Current Concepts in Pathophysiology, Diagnosis and Management

Contents
Preface xiii
Jerry Shapiro

The Basic Science of Hair Biology: What Are the Causal Mechanisms for the Disordered
Hair Follicle? 1
Trisia Breitkopf, Gigi Leung, MeiYu, Eddy Wang, and Kevin J. McElwee
A hair disorder can be difficult to define, but patients are typically motivated to seek
treatment when their hair growth patterns are significantly different from their cultural
group or when growth patterns change significantly. The causes of hair disorders are
many and varied, but fundamentally the disorder is a consequence of aberrant alter-
ations of normal hair biology. The potential trigger factors for hair disorders can be
attributed to inflammation, genetics, the environment, or hormones, of which the
relative contributions vary for different diagnoses, between individuals, and over
time. This article discusses the causal mechanisms for the disordered hair follicle.

How to Diagnose Hair Loss 21

Adrianna J. Jackson andVera H. Price
This review presents a systematic approach to the diagnosis of hair loss. An accu-
rate diagnosis is based on history, clinical examination, laboratory tests, and scalp
biopsy. Whether the hair loss is a cicatricial or noncicatricial alopecia guides one’s
history taking. After assessing the patient’s global appearance, the hair and scalp
are evaluated, aided by a hair pull, hair tug, Hair Card, and hair mount. Scalp biop-
sies can confirm a diagnosis and are essential in all cases of cicatricial alopecia. In all
patients with hair loss a complete blood count, ferritin, thyroid stimulating hormone,
and vitamin D 25OH should be ordered.

Trichoscopy: How It May Help the Clinician 29

Lidia Rudnicka, Adriana Rakowska, and Malgorzata Olszewska
Trichoscopy (or dermoscopy of hair and scalp) is an easy in-office technique that
may be performed with a handheld dermoscope or a digital videodermoscopy
system. This method is gaining increasing popularity, because it may be applied
in differential diagnosis of multiple hair and scalp diseases. The focus of this article
is application of trichoscopy in differential diagnosis of the most frequent hair and
scalp diseases in dermatologic practice. Trichoscopy of genetic hair shaft abnormal-
ities are briefly addressed. A new classification of perifollicular and interfollicular skin
surface abnormalities is proposed.

Histopathology of Scarring and Nonscarring Hair Loss 43

John M. Childs and Leonard C. Sperling
This article reviews the histologic findings of alopecia, preceded by a brief discus-
sion of biopsy and processing techniques, the normal follicular anatomy and cycle,
and expected findings in transverse sections. Subtle histologic abnormalities will be
missed unless the normal follicular anatomy and follicular cycle, when viewed in
transverse sections, are understood.
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How to Diagnose and Treat Medically Women with Excessive Hair 57

Ulrike Blume-Peytavi
Excessive hair growth in women is common and due to a broad spectrum of causes.
Management options comprise different pharmaceuticals, epilation methods, and
aesthetic approaches. Because excessive hair growth in women may cause psy-
chological and psychosocial problems, a holistic treatment approach, including
support and emotional coping strategies, should be recommended. In this article,
diagnostic procedures and treatment options for excessive hair growth in female
patients are discussed.

Drugs and Hair Loss 67

Mansi Patel, Shannon Harrison, and Rodney Sinclair
Hair loss is a common complaint, both in men and women, and use of prescription
medications is widespread. When there is a temporal association between the onset
of hair loss and commencement of a medication, the medication is commonly
thought to have caused the hair loss. However, hair loss and in particular telogen
effluvium may occur in response to a number of triggers including fever, hemor-
rhage, severe illness, stress, and childbirth, and a thorough exclusion of these
potential confounders is necessary before the hair loss can be blamed on the med-
ication. Certain medications are known to cause hair loss by a variety of mecha-
nisms including anagen arrest, telogen effluvium, or accentuation of androgenetic
alopecia by androgens.

Autoimmune Disease and Hair Loss 75

Siamak Moghadam-Kia and Andrew G. Franks Jr
Once systemic disease is in remission, it is prudent to recognize the importance of
alopecia in the patient’s overall sense of well-being and quality-of-life clinical out-
come. Scarring alopecia (scalp discoid lupus erythematosus) can be the presenting
manifestation of lupus in more than half of affected individuals. Diffuse nonscarring
alopecia in lupus is usually responsive to treatment of the systemic disease. Severe,
often intractable burning pruritus of the scalp is a frequent complaint in dermato-
myositis. Lichen planopilaris may mimic other autoimmune forms of scarring alope-
cia. Alopecia can also be caused by medications used to treat systemic autoimmune
disease and fibromyalgia.

Alopecia Areata Update 93

Abdullah Alkhalifah
Alopecia areata (AA) is a common nonscarring alopecia. It affects 1.7% of the pop-
ulation at some point in their lives. AA is an autoimmune condition characterized by
dense peribulbar lymphocytic infiltrate. The exact cause and triggering factors are
still unknown. The scalp is the most commonly affected area but any hair-bearing
area can be involved. All available treatment options are neither curative nor preven-
tive. This article will discuss updates in AA with focus on etiopathogenesis, clinical
presentation, and treatment options and suggest treatment plans based on the
age of the patient and extent of the disease.

Genetic Basis of Alopecia Areata: A Roadmap forTranslational Research 109

Ali Jabbari, Lynn Petukhova, Rita M. Cabral, Raphael Clynes, and Angela M. Christiano
Alopecia areata (AA) is a recurrent autoimmune type of hair loss that affects about
5.3 million people in the United States alone. Despite being the most prevalent
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autoimmune disease, the molecular and cellular mechanisms underlying this com-
plex disease are still poorly understood, and rational treatments are lacking. Further
efforts are necessary to clearly pinpoint the causes and molecular pathways leading
to this disease and to find evidence-based treatments for AA. The authors focus on
the central role of genetics for gaining insight into disease pathogenesis and setting
the stage for the rational development of novel effective therapeutic approaches.

Hair: What is New in Diagnosis and Management?: Female Pattern Hair Loss Update:
Diagnosis and Treatment 119
Natasha Atanaskova Mesinkovska andWilma F. Bergfeld
Female pattern hair loss (FPHL) is the most common cause of alopecia in women.
FPHL is characterized histologically with increased numbers of miniaturized, vel-
luslike hair follicles. The goal of treatment of FPHL is to arrest hair loss progression
and stimulate hair regrowth. The treatments for FPHL can be divided into andro-
gen-dependent and androgen-independent. There is an important adjuvant role
for nutritional supplements, light therapy, and hair transplants. All treatments
work best when initiated early. Combinations of treatments tend to be more
efficacious.

Pattern Hair Loss in Men: Diagnosis and Medical Treatment 129

Nusrat Banka, M.J. Kristine Bunagan, andJerry Shapiro
Androgenetic alopecia is a common cause of hair loss in both men and women. The
exact pathogenesis of androgenetic alopecia is not well understood. As the name
implies, the role of androgens and genetic susceptibility predisposes to pattern
hair loss due to gradual conversion of terminal hair into vellus hair. Male and female
pattern hair loss are clinically distinct entities but histologically indistinguishable. The
role of sex hormones in females is less understood. This article discusses current
understanding of the etiopathogenesis of hair loss in men, diagnostic tests available,
and its medical management.

HairTransplantation Update: Procedural Techniques, Innovations, and Applications 141

M.J. Kristine Bunagan, Nusrat Banka, andJerry Shapiro
The advances in hair transplantation, particularly the advent of follicular unit trans-
plantation, have greatly elevated the outcome of this procedure. Various modifica-
tions to the basic technique as well as innovations focused on the different
aspects of the hair transplantation procedure have further enhanced this type of
hair restoration surgery. In addition, there is ongoing expansion of the indications
and applications of this procedure beyond the usual male pattern hair loss.

Primary Cicatricial Alopecias 155

Nina Otberg
Primary cicatricial alopecias refer to a group of rare, idiopathic, inflammatory scalp
disorders that result in permanent hair loss. Primary cicatricial alopecias comprise
a diverse group of inflammatory diseases and can be classified via different
approaches, such as clinical presentation, histopathologic findings, or both. Primary
cicatricial alopecias are rare scalp disorders. Whiting found a prevalence of 7.3% in
all patients who sought advice for hair and scalp problems at the Baylor Hair
Research and Treatment Center in Dallas between 1989 and 1999.
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Nutrition and Hair: Deficiencies and Supplements 167

Andreas M. Finner
Hair follicle cells have a high turnover. A caloric deprivation or deficiency of several
components, such as proteins, minerals, essential fatty acids, and vitamins, caused
by inborn errors or reduced uptake, can lead to structural abnormalities, pigmenta-
tion changes, or hair loss, although exact data are often lacking. The diagnosis is
established through a careful history, clinical examination of hair loss activity, and
hair quality and confirmed through targeted laboratory tests. Examples of genetic
hair disorders caused by reduced nutritional components are zinc deficiency in acro-
dermatitis enteropathica and copper deficiency in Menkes kinky hair syndrome.

Shampoos, Conditioners, and CamouflageTechniques 173

Zoe Diana Draelos
This article examines hair care in persons with hair loss. The use of shampoos, con-
ditioners, and hair styling products to camouflage hair loss is discussed. Because
hair is nonliving, medical treatments are limited to only inducing change in the folli-
cles within the scalp skin and do not improve the hair loss actually witnessed by the
patient. There is therefore a need to accompany medical treatment of hair loss with
cosmetic hair treatment to optimize patient satisfaction.

Long-Term Removal of Unwanted Hair Using Light 179

Soodabeh Zandi and Harvey Lui
Laser (or light) hair removal, also referred to as photoepilation, is the most commonly
used laser or light-based cosmetic medical procedure. The extended theory of
selective photothermolysis is the basic principle for destruction of hair follicles using
light. In this type of laser application the chromophore is follicular melanin. Several
types of lasers and light sources have been effective for hair reduction, including
the ruby, alexandrite, diode, and neodymium:yttrium-aluminum-garnet lasers and
broadband, intense pulsed light sources. This article provides a broad overview of
how hair can be removed using light, with an emphasis on practical considerations.

Utilizing Electromagnetic Radiation for Hair Growth: A Critical Review of

Phototrichogenesis 193
Sunil Kalia and Harvey Lui
Hair loss has a high prevalence in the general population and can have significant
medical and psychological sequelae. Pattern hair loss and alopecia areata represent
the major reasons patients present to dermatologists in relation to hair loss. Because
conventional treatment options are generally incompletely effective, novel methods
for hair grown induction are being developed. The role of using electromagnetic
radiation, including low-level laser therapy for the management of hair loss through
phototrichogenesis, is reviewed in this article.

Index 201