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Am I going to lose all my hair just like Gran?

Case

history

Louise is a 21-year-old who presents to your surgery with a six-week history of a 1.5cm 'bald spot' that her mother had noticed. She has mild hay fever but is otherwise fit and well. She admits some stress from impending exams from her final year of a political science degree. She has been on the Pill for three years. She is feeling rather down because her grandmother lost all her hair at the age of 30 and it did not grow back. She has searched on the internet and brought some information on 'alopecia areata' and asks for a referral to a 'specialist.' Dr Tanvir Jamil discusses.

What exactly is alopecia areata?

Alopecia areata is the umbrella term that refers to patchy hair loss, total (or near total) loss on the scalp (a. totalis) and combined loss of scalp, facial and body hair (a. universalis).

One per cent of the population is affected and characterised by the sudden appearance of a round non-scarring and painless hair loss with spontaneous remissions and exacerbations.

What should I be looking for in the history?

Some of the initial questions include:

·Is the hair coming out by the roots or is it breaking off?

·Is your hair becoming thinner or do you have totally bald spots?

·Do you treat your hair (eg colour or bleach)?

·Is the loss slowing down or worsening?

·Is the loss anywhere else apart from the scalp?

·Is their any family history?

All episodes of previous alopecia including age of onset, duration, remissions, patterns of hair loss, treatments and associated systemic problems or diseases need to be documented, such as eating disorders, heavy menses, hypothyroidism, anaemia.

The history should also date any medication (including the oral contraceptive pill) and events (eg childbirth, life-events) within the six months before the first and subsequent episodes of alopecia.

Ask about her mood and do remember ideas, concerns, expectations. The vast majority of patients suffer a great sense of loss when hair loss first starts. Many will go through the torturous psychological path of denial and depression before learning to accept their condition.

Alopecia often leads to an altered body image, low self-esteem, rejection and embarrassment causing problems at work, in relationships, holidays and sport.

Apart from a look at the bald spot, is there any other worthwhile examination?

Alopecia areata is characterised by a hair shaft that narrows ('exclamation point hairs'). On magnification these show up as broken hairs where the hair 'snaps' at the narrowest point.

In the 'hair pull test' between 50-100 hair are pulled in several directions. Normally two-five hairs will be obtained. An abnormal result is indicated if three-four times this amount are pulled out.

What could be the cause of alopecia in Louise?

It is generally accepted that alopecia areata is an auto-immune disorder. Sufferers carry specific genes that may be triggered by an initial insult such as a virus. There is an overlap between a. areata and other organ specific autoimmune disorders such as atopy (hay fever asthma, eczema) thyroiditis and Addison's disease.

As well as a genetic pre-disposition to disease, some also believe stress and emotional problems can trigger it. This may offer an explanation as to why stress reduction and hypnotherapy helps some patients.

Hair loss is often classified as scarring and non-scarring. In the former, the hair follicles are lost by inflammation and fibrosis which prevents any potential regrowth. Scarred skin looks pale, glazy and smooth. Scarring types of alopecia include infections, systemic diseases (eg SLE, scleroderma,) and physical or chemical trauma (eg burns, trauma, chemical).

In non-scarring alopecia the hair follicles are preserved or resting. This explains the reversible nature of alopecia areata.

Other possible causes of hair loss include crash diets, blood loss (including blood donation), drugs (ACE inhibitors, carbamazepine, cimetidine, danazol, levodopa, lithium, ?-blockers), and endocrine disorders. But these usually tend to cause diffuse hair loss and not patchy loss. Some 20 per cent of cases are hereditary but the severity of involvement in relatives bears no prognostic significance to individual patients.

What about investigations?

Basic investigations in general practice should include a full blood count, ESR, anti-nuclear antibodies, serum iron and thyroid function tests. However, most of the time these turn out to be normal.

Can I give her any treatment?

Treatment for a. areata is generally unsatisfactory and certainly not curative. In general practice you could try topical steroids but there is no convincing evidence they work.

If nothing much can be done, is it worth referring?

Yes, definitely. Young women especially find it difficult to cope with scalp hair loss. Patients always fear the worse and if referral to a dermatologist will help allay their fears a little then it is certainly worth doing. She will also feel you are being supportive and this in itself may help the stress and emotion she is feeling right now.

The specialist also has some investigations and treatments not available in general practice, such as scalp biopsy, and the use of scalp irritants (eg phenol, Dithranol or PUVA) to induce a contact dermatitis and restimulate the hair follicle to grow again. Intralesional topical steroids have also been tried. Given the generally poor outcome of these interventions alopecic sufferers often try alternative remedies also (eg hypnotherapy, herbalism and homoeopathy).

Is there anything else I can do to help?

More often than not the progression is characterised by remissions and exacerbations. So Louise's hair will probably grow back at some stage, but it may well shed again.

Louise also does not have any poor prognostic indicators, for example:

·the younger the patient the higher the probability of progressing to a. totalis or

a. universalis ­ about 50 per cent of sufferers who develop the condition before puberty will progress to a. totalis/universalis compared with 25 per cent who develop it after puberty;

·any patch over one year;

·association with other autoimmune and endocrine conditions;

·the presence of nail involvement (pitting, ridging or spooning);

·loss of eyebrows and eyelashes;

·several patches;

·previous attacks;

·presence of antithyroid antibodies.

There is anecdotal evidence that advice on relaxation and stress reduction may help reduce or stop the problem. Even if does not help the alopecia it might increase her ability to cope with her condition.

If Louise's problem continues to worsen she may need referral to counsellors or psychologists to help come to terms with her 'loss'. When a. areata becomes noticeable many sufferers elect to shave their heads. This has two functions.

First, it gives the scalp a more aesthetic look and, second, it allows the person a degree of control over their condition. The vast majority of women sufferers and children will elect to wear a wig.

Useful reading

Coping with Hair Loss

by Elizabeth Steel

Published by Thomson/Harper Collins

Tanvir Jamil is a GP in Burnham, Bucks

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