Rhett J. Drugge, MD
Alopecias can be divided into scarring and non-scarring disease. The classical scarring alopecia is cutaneous lupus erythematous, although fungal kerions are the more prevalent form of hair loss. The most common form of hair loss, androgenetic alopecia, is a loss of hair volume consisting of conversion of terminal to vellus hair follicles.
Alopecia areata has the unique distinction among the alopecias for being both non-scarring and an autoimmune process. This is moderately easy for a dermatologist to diagnose with generally a good prognosis except in marginal ophiasis (poor) and generalized disease. The clinical severity of the condition commonly waxes and wanes with time. It can be treated by a variety of methods. Intracutaneous injection of dilute suspensions of Kenalog or Triamcinolone is suitable for small areas of involement in the scalp and eyebrows (usually under 25% of total scalp involvement) . The pain of administration can be minimzed with a skin refrigerant such as ice or ethyl chloride spray prior to the quick insertion of 1 cc/sq. in. (50-50 dilution with water) of triamcinalone acetonide. Repeat it monthly for 3 months, and if this does not grow hair, then switch to daily application of anthralin or contact sensitization with dibutyl squaric acid 1% solution. Many patients have a family history of the disease. Occasional cases progress to alopecia totalis or universalis .
Therapeutic studies in
squaric acid dibutylester therapy
(> 75% hair regrowth) was observed in 68% (13/19) of patients at the end of 20 weeks of treatment.
double-sided patient-controlled study
Glucocorticoid Based Therapies
prednisone plus minoxidil 2%
At the end of 6 weeks of a prednisone taper, 47% (15/32) of patients had more than 25% regrowth, including nine of 20 patients who had had at least 75% hair loss at baseline
a randomized, controlled trial
3% topical minoxidil
(1) a randomized, double-blind, bilateral comparison-controlled study design was used. Of the twenty-one patients, thirteen were women and eight were men; their ages ranged from nineteen to fifty-five years. All the patients had alopecia totalis or alopecia universalis, except for two who had lost two-thirds of their scalp hair.
(2)A 3% topical minoxidil solution was used to treat 31 normotensive persons (13 male, 18 female) with extensive alopecia areata. After 15 months, three patients (14%) had 75%-100% regrowth, 13 (59%) had some form of regrowth, and nine (41%) had no regrowth. In the initial three-month double-blind portion of the study, minoxidil was not shown to be more effective than placebo.
Diffuse hair loss is a very common and insidious thinning of the vertex and frontal scalp in young or middle-aged women who have both male and female relatives demonstrating partial baldness. There is often seborrhea. Preservation of the frontal hairline is much more common in women than in men. Topical minoxidil 2% solution applied twice daily may be of benefit. Systemic treatment includes Propecia.
This non scarring hair loss is most noted for its inconsistency. Therapy options are similar to that for Androgenetic Alopecia.
Follicular degeneration syndrome in black patients
Folliculitis Decalvans (sycosis of the scalp). -- This condition sometimes responds to Betadine shampoo, systemic antibiotics over a long period of time, and locally applied antibiotic creams at night as well.
Perifolliculitis capitis abscedens et suffodiens. -- this is a tunneling pyoderma like hidradenitis suppurativa, and it responds to similar treatment.
Pseudopelade of Brocq. --
Loose anagen syndrome
Traction alopecia Hair loss due to abrasion to an area, trauma to the hair follicle.
Lupus erythematosus. -- Chronic cutaneous (discoid) lupus may respond to intralesional corticosteroids or antimalarials.
Fungal Kerion. -- the scarring induced by a kerion is often permanent.
Scleroderma. -- the striking form, coup de sabre, often induces follicular loss.
Nevus Sebaceous.-- this is a orange-yellow birthmark which becomes warty with puberty and often degenerates to carcinomas of various types. Surgical removal is advised.
At puberty and menopause, was well as during pregnancy, there may be temporary spurts in hair growth, which often are self-correcting. There are certain families who are hirsute, and all their endocrine studies are normal. There are other cases of hirsutism, however, associated with acne, menstrual disorder, obesity and even, on occasion, hypertension, where an endocrine explanation has to be considered. Cushing's syndrome, adrenal virilism, polycystic ovary (Stein-Leventhal syndrome), ovarian tumors and basophilic adenoma of the pituitary are some of the entities producing hirsutism. Elevation of the entities producing hirsutism. Elevation of the urinary 17-ketosteroid level indicates that an endocrine testis needed. Treatment. -- Shaving with an electric razor is often suitable for elderly women with bristles. Depilatories, applied for a definite time and then washed off, destroy the hair chemically, though they can be irritating to the skin. Plucking is the usual method, although poor eyesight and inaccurate plucking may lead to inflamed papules and scarring. Electrolysis is tedious with the galvanic current, and the diathermy can leave pits. however, a skilled operator can achieve satisfactory results if the work is repeated carefully. Wax depilatories strip the hair off by pulling it out. Bleaching with peroxide and ammonia, equal parts, produces transparent bleached hair that sometimes is acceptable cosmetically.
Fransway AF, Muller SA
Department of Dermatology, Mayo Clinic, Rochester, Minnesota 55905.
The efficacy of a 3 percent topical minoxidil solution (2,4-diamino-6-piperidinopyrimidine-3-oxide) in a propylene glycol-water-ethanol base applied twice daily for one year to half the scalp was evaluated in patients with severe chronic alopecia areata. A randomized, double-blind, bilateral comparison-controlled study design was used. Of the twenty-one patients, thirteen were women and eight were men; their ages ranged from nineteen to fifty-five years. All the patients had alopecia totalis or alopecia universalis, except for two who had lost two-thirds of their scalp hair. The mean disease duration was 11.5 years (range, one to forty years). Transient regrowth of sparse vellus hair occurred in twelve patients, bilaterally in eight, but it was not significant in any. No cosmetically acceptable results were achieved. No significant side effects were noted, except for a moderately severe bilateral dermatitis in one patient. The results indicate that 3 percent topical minoxidil solution is ineffective as treatment for severe chronic alopecia areata.
Cleve Clin J Med 1989 Mar-Apr;56(2):149-54
Extensive alopecia areata. Results of treatment with 3% topical minoxidil.
Ranchoff RE, Bergfeld WF, Steck WD, Subichin SJ
A 3% topical minoxidil solution was used to treat 31 normotensive persons (13 male, 18 female) with extensive alopecia areata. After 15 months, three patients (14%) had 75%-100% regrowth, 13 (59%) had some form of regrowth, and nine (41%) had no regrowth. In the initial three-month double-blind portion of the study, minoxidil was not shown to be more effective than placebo. Biopsy specimens from eight patients who underwent biopsy prior to treatment, after three months, and posttreatment showed no significant change in peribulbar or perivascular inflammation. Prominent, new anagen follicles were observed. The 3% topical minoxidil was generally well tolerated and skin irritation was minimal. Blood pressure monitoring revealed no significant changes in diastolic or systolic pressures. Minoxidil is a relatively safe treatment for extensive alopecia areata and may be effective in the treatment of some cases of recalcitrant disease.
Arch Dermatol 1992 Nov;128(11):1467-73
Systemic steroids with or without 2% topical minoxidil in the treatment of alopecia areata.
Olsen EA, Carson SC, Turney EA
Department of Medicine, Duke University Medical Center, Durham, NC 27710.
BACKGROUND AND DESIGN--Thirty-two patients with mild to extensive alopecia areata, including 16 patients with alopecia totalis or universalis, entered a randomized, controlled trial of a 6-week taper of prednisone followed by either 2% topical minoxidil or vehicle applied three times daily for an additional 14 weeks. The results of this study were compared with an open trial of 48 patients with alopecia areata treated with a similar taper of prednisone with concomitant 2% topical minoxidil applied twice daily. Only terminal hair growth was considered and was quantitated as 1% to 24%, 25% to 49%, 50% to 74%, and 75% to 100%: only those with more than 25% terminal hair regrowth were considered to have had an objective response. RESULTS--At the end of 6 weeks of prednisone, 47% (15/32) of patients had more than 25% regrowth, including nine of 20 patients who had had at least 75% hair loss at baseline. Side effects of prednisone were primarily weight gain and mood changes/emotional lability. At 3 months, six of seven minoxidil-treated patients vs one of six vehicle-treated patients who had an objective response to prednisone maintained or augmented this hair growth: at the 20-week visit, these numbers were three of seven and zero of four patients, respectively. In the open trial, objective hair growth with prednisone was 30%, related to the extent of hair loss at baseline, and this growth persisted in more than 50% of patients at 6 months with the use of 2% topical minoxidil. CONCLUSIONS--A 6-week taper of prednisone offers potential for more than 25% regrowth in 30% to 47% of patients with alopecia areata with predictable and transient side effects. Two percent topical minoxidil three times daily appears to help limit poststeroid hair loss.
Ann Acad Med Singapore 1996 Nov;25(6):842-7
Topical squaric acid dibutylester therapy for alopecia areata: a double-sided patient-controlled study.
Chua SH, Goh CL, Ang CB
National Skin Centre, Singapore.
In this prospective, double-sided patient-controlled therapeutical trial involving 20 patients with alopecia areata, we investigated the efficacy of topical acid dibutylester (SADBE) in the treatment of alopecia areata. Sensitisation was achieved with 2% SADBE in acetone followed by weekly application of topical SADBE to designated alopecia sites for 20 weeks. Untreated alopecia sites on the same patient acted as controls. Nineteen of the twenty patients completed 20 weeks of treatment. On the SADBE treated sites, excellent response (> 75% hair regrowth) was observed in 68% (13/19) of patients at the end of 20 weeks of treatment. On the untreated control sites, the corresponding figure was 11% (2/19). The difference in response between SADBE treated and untreated sites was statistically significant (P < 0.001). Mean onset of hair regrowth was 6 weeks after starting treatment. Patients with duration of alopecia 12 months or longer fared poorer compared with patients with a shorter duration of the disease. The extent of involvement did not appear to influence treatment outcome. Side effects were mainly local and were mainly local and were well tolerated. At 6 months follow-up, 33% (2/6) of responders with alopecia totalis relapsed compared to 11% (19) of those with patchy alopecia areata. We conclude that topical immunotherapy with SADBE is effective in inducing hair regrowth in alopecia areata.
Int J Dermatol 1998 Aug;37(8):617-21
Department of Dermato-Venereology, Academic Hospital Rotterdam-Dijkzigt, Rotterdam, The Netherlands.
BACKGROUND: Alopecia areata is considered to be an autoimmune disease. It consists of patchy hair loss of the scalp and the eyebrows, making it a disfiguring condition. This 10-year study was designed to assess the usefulness of the treatment of the eyebrows with dermatography as a relatively quick and simple method to obtain a cosmetically satisfactory result. MATERIALS AND METHODS: The eyebrow areas were covered with a halftone pattern of tiny dots of color pigments, using a Van der Velden Derma-injector, without anesthesia. On average, two to three dermatography sessions of 1 h were required. The follow-up was 4 years. RESULTS: Thirty three patients, most of whom had been previously treated with a sensitizer such as dinitrochlorobenzene (DNCB), were treated with dermatography. Four patients had also been treated by a beautician with a crude form of tattooing. The results in 30 patients were excellent. In three patients the results were good. CONCLUSIONS: Dermatography is a technique offering a good alternative for time-consuming, troublesome treatment modalities that often have considerable side-effects. With dermatography, no side-effects were found.