Hair Disorders
Background - importance and magnitude of problem
Diagnostic goals - for overall category
- androgenic alopecia
- postpartum alopecia
- hormonal alopecia
- drug/chemical induced
- systemic illness induced
- trichotillomania
- inheritable syndromes
A small degree of hair loss is always present. Usually random hairs shed or break off so that with every brush of the hair, some hairs are at the end of their natural cycle. There is a natural cycle of hair growth (telogen phase) in which growth takes as long as 5-6 years. This is followed by a resting, nonmetabolic phase (anagen) that lasts for 6 weeks to 6 months. A third phase is the catagen phase or time of hair separation and loss.
These phases are important because many substances, medications or diseases may cause change in phase duration and thus accelerate hair loss or cause much of the hair to be in synchronous growth and then slough. For example, estorgens during pregnancy prolong the telogen growth phase and when pregnancy is over, a large number of hairs go into the anagen resting phase. As expected, 6 weeks to 6 months later large amounts of hair break or slough. It gives the impression that one's hair is all falling out. Actually hairs gradually go back to their random pattern of growth and rest and the "hair loss" problem subsides.
Once a hair loss pattern has been determined to be diffuse and nonscarring, a hormonal or medication cause should be suspected. Knowing the different phases of hair growth helps determine when the substance might have had an effect and therefore what substance is suspect.
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Localized nonscarring hair loss (alopecia)
Background - importance and magnitude of problem
Diagnostic goals - for overall category
- traction alopecia
- alopecia areata
- acne neoplastica
- trauma
This is an infrequently occuring category of disease. Local factors are often the cause but the effect is usually mild.
Alopecia areata must be ruled out because the other diagnoses can be treated. The etiology of alopecia areata is unknown.
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Diffusely distributed, scarring hair loss (alopecia)
Background - importance and magnitude of problem
Diagnostic goals - for overall category
- discoid lupus erythematosus
- systemic lupus erythematosus
- dissecting cellulitus of the scalp
- acne necrotica miliaris
- lichen planus
- fiber hair implants
- factitial alopecia
- trichotillomania
Diffuse, scarring alopecia is mostly due to systemic disease rather than local insults due to physical, chemical or traumatic factors.
Lupus erythematosus is the major systemic disease which causes this type of hair loss. Facticial alopecia and trichotillomania are very difficult to distinguish from other entities because of their psychological components.
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Localized scarring hair loss (alopecia)
Background - importance and magnitude of problem
Diagnostic goals - for overall category
- lichen planus
- lupus erythematosus
- chemical burn
- thermal burn
- infection
- kerion
- vasculitis
- factitial alopecia
- trichotillomania
When generalized inflammatory conditions start out, they may just affect localized areas. For the most part, however localized scarring alopecia is due to physical, chemical or traumatic causes.
Most of the diseases in this category can be easily diagnosed unless the woman is trying to hide some information. Specific diagnosis determines the therapy so that is the major goal.
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Excess hair growth - hirsutism
(increased androgen production)
adrenal origin
Background - importance and magnitude of problem
Diagnostic goals - for overall category
- adenoma (virilizing)
- adenoma (corticoid-producing, virilizing)
- adenocarcinoma (virilizing)
- congenital adrenal hyperplasia
- adrenal hyperplasia (Cushing's disease)
- adrenal hyperandrogenism (idiopathic)
Hirsutism is defined as excessive growth of androgen (male hormone) dependent sexual hair. These physical areas would include the upper lip, sideburns, tip of the nose, chin, earlobes, upper pubic triangle, trunk and limbs.
An adrenal source of excess androgen is less common than an ovarian source but it should be checked for.
Dehydroepiandrosterone (DHEA) and its sulfate form, DHEA-S are the most common adrenal androgens measured to confirm an adrenal source. Once an adrenal source of excess androgen is determine, the primary goal is to first rule out a malignant or benign tumor of the adrenal gland.
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Excess Hair Growth - hirsutism
(increased androgen production)
ovarian origin
Background - importance and magnitude of problem
Diagnostic goals - for overall category
- Sertoli-Leydig (arrhenoblastoma) tumor
- granulosa-theca tumor
- lipoid cell tumor
- gynandroblastoma
- hilus cell tumor
- luteoma
- Brenner tumor
- Krukenberg tumor
- cystadenoma
germ cell neoplasm- teratoma
- dysgerminoma
- gonadoblastoma
- polycystic ovarian disease
- ovarian hyperthecosis
- hilus cell hyperplasia
Hirsutism is defined as excessive growth of androgen (male hormone) dependent sexual hair. These physical areas would include the upper lip, sideburns, tip of the nose, chin, earlobes, upper pubic triangle, trunk and limbs.
Serum testosterone levels are usually drawn as a marker for increased ovarian androgens. Ingested sources of testosterone or any androgenic substances should be ruled out.
As with the adrenal source of excess androgen, a malignant or benign tumor of one or both ovaries is the first category to rule out. Non-tumor, ovarian sources can often be treated with medications to reduce the androgens and thus reduce hirsutism.
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Excess Hair Growth - hirsutism
(mixed ovarian-adrenal hyperandrogenism)
Background - importance and magnitude of problem
Diagnostic goals - for overall category
- mixed ovarian-adrenal hyperandrogenism
- testicular source
- iatrogenic source
From 25-40% of patients with hirsutism are thought to have excess androgens from both the adrenal gland and ovary, i.e., a mixed source. Rarely, women may have some testicular tissue as a result of a congenital birth defect. Ingested sources of androgenic substances is the more common cause of excess hair growth. It can come from supplements such as DHEA, birth control pills, and even poorly conceived nutritional supplements proporting to treat menopause, PMS, fatigue etc.
The specific cause is important in determining treatment. Ingested sources of androgens can sometimes be difficult to determine if it is not currently being taken.
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Excess hair growth - hypertrichosis
(nonandrogenic hair growth)
Background - importance and magnitude of problem
Diagnostic goals - for overall category
- increased androgen sensitivity in hair follicles
drug induced- phenytoin (Dilantin®)
- streptomycin
- hexachlorobenzene
- penicillamine
- diazoxide
congenital disease states- porphyria
- epidermolysis bullosa
- Hurler's syndrome
- trisomy E
- congenital macrogingivae
- Cornelia de Lange's syndrome
acquired disease states- malnutrition due to infection or malabsorption
- hypothyroidism (especially in children)
- dermatomyositis
- anorexia nervosa
- head injury
- familial hypertrichosis
Hypertrichosis also means more than normal hair growth but it is different than hirsutism. It refers to growth of nonsexual hair and is more generalized than hirsutism. Hirsutism due to excessive androgens almost always is accompanied by anovulation and thus irregular menses. Rarely, some women have skin and hair follicles that are just very sensitive to normal levels of androgens.
The most common category of hypertrichosis is that of a familial tendancy to excessive hair growth. Thus the hair growth profile of close relatives is important. Certain congenital and acquired disease states can also cause hypertrichosis but with the exception of hypothyroidism, treatment of the underlying disease does not greatly lessen the excess hair growth. Medication-induced hypertrichosis is the most important to correctly diagnose because it is the most treatable.
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