Robert A Norman and Reena Rupani - Clinical Cases in Integrative Dermatology
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- Lupus: In systemic lupus, hair loss/thinning is often described by patients. Serum ANA is typically positive, and by review of systems or laboratory analysis, the patient should also meet other criteria for lupus. A scalp biopsy may help confirm the diagnosis if clinically suspicious.
- Trichotillomania: This condition is defined by patients (either consciously or not) pulling out their own hair, often in conjunction with anxiety or depression. In a more subtle version of this condition, patients may pull or twist their hair habitually, gradually leading to loss. Patterns of hair loss are typically more focal.
- Telogen effluvium: The hair growth cycle consists of three phases: anagen (active growth), catagen (transition/resting), and telogen (shedding). Following severe stress, illness, hospitalization, surgery, or pregnancy, patients may notice dramatic shedding of telogen hairs. This typically occurs approximately 3 months after the inciting event. Laboratory workup should be within normal limits, and while this is typically a clinical diagnosis, a scalp biopsy may reveal greater proportions of telogen hairs. A hair pull test should be performed on a day when the patient has not shampooed, and a positive result would be the extraction of 6 or more hairs out of a group of 40 hairs pulled. While typically a self-limiting problem (with resolution of normal hair thickness and growth within 36 months), some cases of telogen effluvium can become chronic and unmask an underlying tendency towards androgenetic alopecia (Fig. ).
Figure 1.1Diffuse hair loss as can been seen in advanced telogen effluvium - Androgenetic alopecia: Commonly referred to as male pattern baldness, androgenetic alopecia can occur in female patients as well, and can be seen in younger age groups. Male pattern is typically more over the bitemporal region and vertex, whereas female pattern preserves the anterior hairline and begins as widening of the part, progressing to diffuse thinning over the top of the scalp. Thyroid function, iron status, and vitamin D levels should be assessed and optimized. The etiology of androgenetic alopecia is thought to be multifactorial, with components of genetics, hormone levels, and environmental factors playing a role. Onset is usually insidious and progressive.
- Time : The natural course of telogen effluvium is resolution, typically within 36 months, although some cases can become chronic (particularly if the patient has underlying androgenetic alopecia which becomes unmasked). Most often, however, if the inciting factor was an isolated event or occurrence, then full resolution without intervention is typical.
- Counseling : If telogen effluvium is secondary to (or accompanied by) severe stress or anxiety, referral for professional counseling may help break the vicious cycle.
- Minoxidil : Topical minoxidil is available in 2 and 5 % formulations, and while the approved indication is for androgenetic alopecia, may help promote hair growth in telogen effluvium as well (use is off-label). One caution with minoxidil is that, for androgenetic alopecia, cessation of treatment leads to shedding of any regained hairsthis phenomenon, however, is not clear-cut in acute telogen effluvium but remains a possibility of which patients should be aware. Additionally, minoxidil is available in solution and foam formulations, and many patients report irritation with the former (likely from the propylene glycol in the vehicle).
- Avoidance of products containing parabens, sulphates, and phthalates : To generally support healthy hair and discourage breakage of newly growing strands, it is advisable to use hair care products that are as free of potential irritants and carcinogenic or endocrine-disrupting chemicals as possible.
- Eucalyptus oil : The benefits of eucalyptus oil are more in supporting the elasticity and shine of existing hair, rather than promoting new hair growth [], but this effect in turn can improve the patients perception of their hair and reduce the surrounding anxiety of telogen effluvium. Eucalyptus is presently available in commercial root awakening formulas.
- Coconut oil : Contrary to some cultural beliefs, coconut oil does not demonstrate the ability to grow new hair, but rather supports the health of that which is already existing. This oil has the highest ability to penetrate inside the hair shaft based on low molecular weight and linear structure, thus preventing protein loss and improving hair strength and appearance [].
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