E-Case #5-B

Angelina A. Platas, M.D.

July 9, 2001

A 39 year old woman presents to establish care, with the complaint of hair loss over the last 4 months. In February, when she was coloring her hair, she noticed a patch of thin hair on her crown about the size of a silver dollar. A month later, a friend and her hairstylist also noticed. The area hasn't changed, she has been covering it by pulling her hair back to cover her crown, and the rest of her hair seems fine. Her mother has "very thin hair" and her father has androgenic alopecia (both appreciated in the family photo that the patient brought to clinic). ROS is essentially negative. The patient is very nervous and scared about the hair loss.

PMH:

• Attention Deficit Disorder, followed by a psychiatrist for years

• Seasonal allergies

• Upper extremity DVT after a motor vehicle accident in 1993 (pt states that she saw a hematologist, all blood tests were "normal", and she was treated for six months on coumadin)

Meds:

• Dexedrine (has been on this for ADD for years)

• Tylenol, vitamins, TUMS and ASA prn

Exam shows a somewhat nervous appearing woman, nl vital signs. Scalp shows a 2.5 cm circular patch of alopecia over occiput at the end of the part. There is no scarring, there are some fine hairs in the patch, no broken hairs. Otherwise the scalp hair is somewhat fine, the part is mildly generous. Eyebrows, lashes and other body hair appears normal. Skin is without rashes.

1. What is the differential diagnosis and the causes of alopecia?

2. What is a reasonable workup?

3. Treatment?

Differential diagnosis and causes of alopecia

The two most common types of alopecia are androgenic alopecia (never say "male-pattern baldness" to a woman) and alopecia areata. Tinea capitis should present with erythema and scaling. Lupus erythematosis should have other skin lesions and scarring. Traumatic (traction) and self-induced hair loss (trichotillomania) should both have broken hairs of varying lengths in the affected area.   Androgens regulate hair growth by helping to control the length of the growing phase, anagen, and the size of the hair follicles.

Androgenic alopecia is hereditary thinning of hair induced by androgens; it actually occurs in women as often as in men, they just usually hide it with styling. In men, this can be thinning of frontal and vertex scalp, bitemporal hair recession, or complete baldness. Women usually have a milder process with diffuse hair loss and sparing of the frontal hairline. Other causes of this pattern of hair loss should be investigated based on the history: hyper or hypothyroidism, iron deficiency, chronic illness.

Alopecia areata is an autoimmune disease causing round patches of hair loss which can regrow spontaneously, or sometimes cause loss of all body hair (alopecia totalis). Both sexes are affected equally, but it is more common in children and young adults. Atopy, thyroid disease and vitiligo are more common in these patients than in the general population.

Workup of alopecia

The workup of alopecia should be guided by the patient's history and physical exam findings. Studies to consider are TSH, and iron studies. Androgenic alopecia in women is most often present without androgen excess and measurement of testosterone level is only likely to be fruitful if the patient has irregular menses, hirsuitism, infertility, or physical exam signs of virilization.

Treatment of alopecia

The treatments for androgenic alopecia and alopecia areata are fairly similar. Topical minoxidil is approved for men or women with either type of hair loss. Minoxidil encourages hair growth by increasing the length of anagen and enlarging small follicles. Finasteride is a 5-a-reductase inhibitor (blocking the effects of androgens), therefore is contraindicated in women who may become pregnant. Alopecia areata can also be treated with topical glucocorticoids or intralesional corticosteroids (4-6 weeks for regrowth, 66% have improvement). Anthralin, an immunomodulating topical medication, is also a safe alternative for alopecia areata.

Follow-up from case presentation

The patient above had nl testosterone, iron studies. Rheumatologic screening tests and hypercoagulability studies were sent because of her history of DVT which showed ANA+ 1:160, and APC resistance. She also had a low TSH, consistent with hyperthyroidism (wonder about her diagnosis of ADD).

References

Arndt KA. Ch 2: Alopecia Areata in: Manual of Dermatologic Therapeutics, 5th Ed. Little Brown and Co, Boston. 1995; pp 16-19. Price VH.

Treatment of hair loss. NEJM 1999;341:964-973. Rycroft RJ.

Hair Disorders in: A Color Handbook of Dermatology. Appleton & Lange, Stamford. 1999; pp 196 200.