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At the heart of general practice since 1960

Young woman distressed to find bald patch

Case

history

Louise, 21, presents with a six-week history of a 1.5cm 'bald spot'. She has mild hay fever, is otherwise fit and well, but admits some stress from impending exams. She has been on the COC for three years. She is feeling rather down because her grandmother lost all her hair at the age of 30. She has brought some information from the internet 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 (alopecia totalis) and combined loss of scalp, facial and body hair (alopecia universalis).

One per cent of the population is affected and it is 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:

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

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

lDo you treat your hair (colour or bleach)?

lIs the loss slowing down or worsening?

lIs the loss anywhere else apart from the scalp?

lIs there 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 COC – and events (such as childbirth, life-events) within the six months before the first and subsequent episodes of alopecia.

Ask Louise about her mood and do remember ideas, concerns, expectations. The vast majority of patients suffer a great sense of loss when hair first starts to fall out. 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 are broken hairs where the hair 'snaps' at the narrowest point.

In the 'hair pull test' some 50-100 hairs are pulled in several directions. Normally two to five will come out. It is abnormal if three times this amount are pulled out.

What could be the cause of alopecia in Louise?

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

As well as a genetic predisposition to disease some also believe stress and emotional problems can also trigger it. This may explain why stress reduction and hypnotherapy help 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 (systemic lupus erythematosus, scleroderma,) and physical or chemical trauma (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) and drugs (ACE inhibitors, carbamazepine, cimetidine, danazol, levodopa, lithium, ß-blockers), endocrine disorders. But these usually tend to cause diffuse hair loss and not patchy loss.

Approximately 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 is generally unsatisfactory and certainly not curative. In the 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 her?

Yes definitely. Young women especially find it very difficult to cope with scalp hair loss. Patients always fear the worst and if referral to a dermatologist will help allay their fears a little 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 access to investigations and treatments not available in general practice, such as scalp biopsy, and the use of scalp irritants – for instance phenol, dithranol or PUVA – to induce a contact dermatitis and stimulate the hair follicle to grow again. Intralesional topical steroids have also been tried.

Given the generally poor outcome of these interventions alopecia sufferers often also try alternative remedies such as 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 (see above).

There is anecdotal evidence that advice on relaxation and stress reduction may reduce or stop the problem, or at least increase her ability to cope.

If Louise's problem continues to worsen she may need referral to counsellors or psychologists. When alopecia areata becomes noticeable many sufferers 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 wear a wig.

Poor prognostic indicators

lThe younger the patient the higher the probability of progressing to alopecia totalis or alopecia universalis – about 50 per cent of sufferers who develop the condition before puberty will progress to alopecia totalis/universalis, compared with 25 per cent who develop it after puberty

lAny patch being present for more than one year

lAssociation with other autoimmune and endocrine conditions

lNail involvement (pitting, ridging or spooning)

lLoss of eyebrows and eyelashes

lSeveral patches

lPrevious attacks

lPresence of anti-thyroid antibodies

Useful reading

Coping with Hair Loss

by Elizabeth Steel

Published by

Thomson/Harper Collins

Tanvir Jamil is a partner

in Burnham, Buckinghamshire –

he is on a year's sabbatical in Vancouver where

he's working at the University of British Columbia, Department of Family Medicine

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