Introduction
Hair disorders are a broad category that includes the following conditions:
Alopecia
Alopecia is a general medical term used for all types of hair loss, partial or complete, localized or diffuse, due to a structural or functional defect of the hair or loss of hair follicles. There are two types of alopecia: Scarring, in which hair follicles are destroyed and the same cannot be revived to induce the hair growth and Nonscarring in which hair follicles remain intact and the same can be revived to induce the hair growth.
Treatment: There are many treatments for these varying conditions and that are often specific to the particular condition.
Non-scarring alopecia
Non-scarring alopecias are more common than scarring alopecias and include male and female pattern hair loss (also known as androgenetic alopecia), alopecia areata, telogen effluvium, and trichotillomania as well as other less common conditions. Sometimes diseases such as secondary syphilis, thyroid disease, and systemic lupus erythematosus can lead to non-scarring hair loss also. Non-scarring hair thinning can also occur with natural aging, which is known as senescent alopecia.
Treatment: Identification of underlying inciting causes through history, examination and investigations and elimination of the same. Additionally, some of topical medications may also be helpful.
Androgenetic alopecia(Male or Female Pattern Baldness )
Androgenetic alopecia is the most common type of hair loss and is so common that many experts believe it should be considered a normal variant such as blue eyes or brown hair. It is inherited in a complex manner from either or both parents. Androgens are hormones including testosterone that are present in both males and females. They also play an important role in the development of pattern hair loss. Even though increased androgen activity leads to hair loss, the majority of males and females with pattern hair loss do not have abnormal levels of testosterone. For males, the pattern typically involves loss of the frontal hairline with or without hair loss at the vertex (or top of the scalp) and may or may not progress over time. For females, the pattern is more variable, but most often spares the frontal hairline and involves diffuse thinning of hair over the crown of the scalp, sparing the back. This again may or may not progress over time.
It is important to note that this pattern of hair loss can be caused by an abnormal increase of androgens due to polycystic ovarian disease or less commonly due to a malignancy. These causes are usually associated with other symptoms such as abnormal periods. Testosterone and other hormone levels can be checked to aid in the diagnosis of these conditions.
Treatment : for androgenetic alopecia includes topical minoxidil solution or foam, finasteride pills by mouth, or hair transplant surgery.
Alopecia areata
Alopecia areata is a type of non-scarring hair loss that can affect men and women, adults and children. The hair is usually lost in round or oval patches initially. Less often, the patches can grow larger and hair loss can include the entire scalp or even the entire body. It is thought to be an autoimmune disease in which the affected hair follicles are mistakenly attacked by a person's own immune system. About 20% of those with alopecia areata also have a relative with alopecia areata. Sometimes, nail changes can also occur in this condition.
The hair may grow back on its own in alopecia areata.
Treatment : There are treatments that ensure and hasten the recovery. Topical steroids, corticosteroid injections into the skin are typically used first. Many other topical treatments can be used. For more extensive disease, sometimes medication by mouth can be prescribed. These act by suppressing the immune system, but also are not always effective.
Telogen effluvium
Telogen effluvium is a common, transient form of hair loss that can be due to medication, pregnancy, hypothyroidism, or some type of physical or psychological stressor such as surgery or a severe illness. In the normal scalp, hairs are on varying cycles of resting (telogen) and growing (anagen) phases. With one of the above or other stresses to a person, it is possible for a significant number of hairs to convert to the resting phase. This usually is seen about 3-6 months after the stressor. Some medications that commonly cause telogen effluvium are anti-seizure medications, beta-blockers for high blood pressure, and anti-thyroid medications. Many chemotherapy drugs are expected to cause hair loss. Growing hairs in anagen phase are affected in this case. This type of hair loss is reversible.
Treatment: In these situations, the medications that are culprit should only be stopped after discussion with your doctor. Management of Telojen effluvium is based on identification of underlying inciting causes through history, examination and investigations and elimination of the same. Additionally, some of topical medications may also be helpful.
Trichotillomania
Trichotillomania is self-induced plucking or breakage of hair that is often done subconsciously. It often occurs in children or adolescents. In young children, this is often more like a habit that will eventually resolve on its own, but in adolescents, psychiatric treatment may be indicated.
Traction Alopecia
Traction alopecia is a form of acquired hair loss that results from prolonged or repetitive tension on the scalp hair. Alopecia due to traction can be caused by regularly wearing tight chignon, cornrows, dreadlocks, weaves and braids, using hair extensions and using chemical relaxers and rollers. There is a large variation in the pattern of clinical presentation of traction alopecia. It there is no suspicion of traction, it can be difficult to diagnose. Patients may present with itching, redness, scaling, folliculitis or pustules. Multiple short broken hairs, thinning and hair loss may also be presented.
Treatment: options reported to have been used in traction alopecia include:
Excessive Hair Growth
Hirsutism
Introduction
Excessive hair growth of terminal (course) hairs in a female with a male like pattern is referred as hirsutism. In simple words, If you are a woman and you have excessive hair growth at locations where hair growth in a woman is normally minimal such as upper lip area, chin to sideburns, circumareolar to chest, linea alba, upper abdomen, lower abdomen, lower back to buttock and upper back then that is a condition called hirsutism.
Causes
Causal factors include genetic factors, hormonal factors and certain drugs.
Genetic Factors : Hirsutism may run in families. Family history of hirsutism makes an individual more susceptible to the same. Higher prevalence of hirsutism has been seen amongst the people from living in South Asia, Middle East, and the Mediterranean.
Hormonal Factors: It is natural for normal healthy woman to produce male hormones(androgens) at low levels however sometimes a woman may start synthesizing the same at very high levels that induce excess hair growth(hirsutism), acneform eruptions or androgeneic alopecia in them. High levels of male hormones and hirsutism may frequently be associated with:
Management
We have very carefully selected the word ‘management’ instead of the word ‘treatment’ here and that is because the management of hirsutism is far more sensible and meaningful and viable than the later one in as far as the finding the final and complete solution of hirsutism is concerned.
Since long the idea dominated amongst the clinician was that the majority of the cases of hirsutism are idiopathic, however, with the advent of modern ultrasensitive endocrinological assay techniques and improved scientific understanding of biological functions of endocrine glands, the idea at present dominate is that majority of the cases of hirsutism has a underlying inciting cause. It is therefore you have to treat hirsutism as also the cause of the hirsutism both in most of the cases. It is therefore management of hirsutism has become more relevant approach today.
It is therefore we at Derma Treat Center manage the cases of hirsutism on the following principles that have now evolved into most acceptable and classic approach :
Identification of an underlying inciting cause involves :
History : include the following queries and components:
Age of First onset & Mode of progression, Obstetric & Gynecological History such as h/f oligomenorrhea, amenorrhea ,DUB, pregnancy, infertility and contraception, Drug History, Family H/o ethnic background, Special H/f galactorrhea, weight gain, pituitary tumors, cushinoid features and hypothyroidism.
Examination: incude :
Determining BMI,BP & Waist Circumference, Looking for Signs of Hyperandrogenism such as Virilization, Masculinization Defeminization, Examination of Hair including typing of hair, distribution pattern and quantifying the hair growth by Hirsutism Score, Examination of Skin for seborrhea, androgenic acne, acanthosis nigricans, purple striae on the abdomen, Examination of Breast & Genitelia (in selected cases only) to determine the size breast and clitoris, Pelvic examination (in selected cases only)and Examination of Eye (in selected cases only)
Investigations: Range of investigations is selected on the basis of presentation of history and revelations on examinations of a patient specific. It may usually vary minimum from few (2 to 3) to some (4 to 5) . Rarely, only in few cases wider range of investigations are required. We at Derma Treat Center (DRAK) request following investigations in the order :
In All Cases (minimum 2 out of the following 3)
In Selected Cases (we may request few to some more from mentioned below)
In Special Cases (we may request few to some yet more from mentioned below)
Diagnosis:
Based on history, examination and investigations as mentioned above we diagnose a case of hirsutism under one of the following classes:
Treatment:
FIRST AND FOREMOST
We at Derma Treat Center (DRAK) strictly follow and adhere to Consensus Statement of the Androgen Excess and Polycystic Ovary Syndrome Society 2012 which is highest authority on Androgen Excess in the world.
There are three components of treatment :
Modification of Life Style: such as diet restriction and promotion of physical exercise.
Cosmetic Measures: include:
Pharmacological Intervention: include:
Topical Eflornithine: often used as an adjunct. Usually in combination with microneedling and/or one of the temporary methods as mentioned above. Topical Eflornithine may also be combined with electrolysis or laser therapy or intense pulse light therapy or with an oral pharmacological intervention. Topical Eflornithine is available at DRAK
Oral Contraceptives (OCP): Based on many scientific considerations we at DRAK prescribe a low dose neutral or antiandrogenic OCP of 3rd or 4th generation as first line therapy. It is very safe and effective and recommended as First Line Therapy by a consensus statement of the Androgen Excess and Polycystic Ovary Syndrome Society 2012 which is highest authority on Androgen Excess in the world.
Antiandrogens : Varios options such as spironolactone, cyproterone acetate, finesteride and flutamide are available. However we at DRAK follow and prescribe as per the consensus statement of the Androgen Excess and Polycystic Ovary Syndrome Society 2012.
Insulin Senstizers : such as metformin or thiazolidinediones are prescribed only to selective individuals.
We at DRAK use Lasers & IPL only as an adjuvant to oral pharmacological intervention.
Warning: It has become customary to see commercial cosmetic salons and clinics being run by beauticians, cosmetologists and occasionally even by some medical practitioners who are either not qualified or not adequately qualified to address the real endocrinal issues related to hirsutism. Such centers are irrationally overinvested with cosmetic equipments such as cosmetic lasers, lights etc. It is usual for the common people to feel attracted to the ambience of such set ups. However, the patients of hirsutism visiting such centers may suffer immensely. First they pay far more than required and second that they may live their entire life with their hair removed but the underlying disease (the real cause) left untreated. It is always easier to operate such machines than to address meticulously the real endocrinal issues related to hirsutism. Finally, business is business, no one wants to lose a paying patient.