A practical guide to diagnosis and treatment. Adult women represent a large majority of patients seeking care for hair loss in the dermatology practice. It is precisely this group who are intensely aware of changes in hair density, texture and loss, especially loss over the crown of the scalp or frontal and vertex of the scalp. Those in this group are also the ones who tend to have the most complicated diagnoses, with more than one form of hair loss occurring at the same time. For this reason, it is important to carefully document the medical history of the patient, the specific concerns of the patient, the expectations of the patient, and the treatments that may best fit the lifestyle and diagnosis of the patient. After completing these steps, the most likely combinations of diagnoses for forms of hair loss that are demonstrated as diffuse thinning over the frontal and vertex scalp will likely include: female pattern hair loss (FPHL), telogen effluvium, with less likely, scarring hair loss, such as frontal fibrosing alopecia, central centrifugal cicatricial alopecia, and lichenplanopilaris (See Table 1).
GETTING THE PERTINENT HAIR LOSS HISTORY
All dermatologists have their own style of obtaining the history from their patients, but hair loss patients tend to want to discuss every potential factor that may shed light on why they are experiencing hair loss, whether it is helpful or not. Questionnaires Hair loss histories seem to lend themselves easily to questionnaires, which can speed along the process for the physician. A brief “yes/no” questionnaire can be given to patients in the waiting area; it can also be mailed to them prior to their appointment, although this risks a forgotten questionnaire at home.(Download PDF of Example of Hair Loss Intake Questionnaire.) Questionnaires that are too long or too detailed can be confusing to patients and take too much time to review. A one-page synopsis is all that is necessary, although a patient may have difficulty believing this. Essential Information Whatever method is used to gather the information, the following essential information must be elicited. 1. Duration of hair loss. Most important to uncover is the duration the hair loss. Patients will often write one duration down on a questionnaire, but answer differently when asked verbally. Always double-check this answer. If the hair loss is acute (occurred within the last year), the most important diagnosis to rule out is telogen effluvium. This is why the survey to the patient or history should include recent medications (stopped or started), recent surgeries, recent dieting/weight loss, hormone use and pregnancies. 2. Associated symptoms. Next, associated symptoms are key. Is there pruritus, pain, scaling, burning, pustule formation or rash in the scalp? This will help to determine if you must treat symptoms as well as hair loss. Many patients have pain, but feel that the pain is a lesser problem than the hair loss, even though the two problems may be inextricably linked. 3. Family history. Family history seems to be the least important part of the history. Patients seem to be disproportionately concerned with the fact that their parents or other siblings do not have hair loss. This is particularly true when patients are told they have female pattern hair loss (FPHL), formerly known as androgenetic alopecia. The term FPHL is more appropriate, because the genetic component is so often questioned. This term also distinguishes between the frontal and vertex scalp hair loss that is seen in women and the bi-temporal and vertex hair loss seen in men. Another consideration is that many patients believe an old myth that has propagated into the lay press delineating hair loss as something that must come from the mother’s father and his genetic pool. It may be necessary to discuss with patients that the genetics of hair loss come from both sides of the family and that there is no direct inheritance from one relative, but a mixed inheritance from all family members, complicated by the patient’s own genetic makeup.
FEMALE PATTERN HAIR LOSS
Most patients with FPHL over age 40 suspect their diagnosis before they even come in. Many patients under this age consider themselves too young for this diagnosis, although is it not unusual for patients in their 20s and 30s to have this form of hair loss. Younger vs. Older Patients Most commonly, very young women with FPHL have polycystic ovarian syndrome or other form of androgen abnormality, although many may not be aware of this diagnosis. In the younger patients, it is very important to ask about regularity of menses, acne and facial hair to make sure there is no other hormonal abnormality that must be concomitantly treated. Older women typically present with a slow onset of thinning hair over the frontal scalp with widening of the part, thinning down of the ponytail, or patient commenting about seeing through their hair to the scalp while styling the hair. Patients who are very observant may even notice episodic loss of hair shedding with the progressive thinning. Clinical Exam Findings The physical examination should reveal a thinning over the frontal scalp or vertex scalp as compared to the posterior or occipital scalp, usually sparing the frontal hair line. There is usually no thinning at the bitemporal areas of the frontal scalp in this form of hair loss. If hair loss is seen in the bitemporal areas, telogen effluvium may need to be considered. A closer look at the scalp in the affected areas of loss shows smaller caliber hair fibers and often a thinning in the frontal area just behind the frontal hairline. Some women also may have thinning that progresses down the sides of the scalp into the preauricular areas. Diagnostic Tests A pull test may be positive in the area of hair loss, but should be negative in the posterior scalp. If the diagnosis is still in question, a biopsy can be performed. Typically, two 4-mm punch biopsies can be taken from the affected areas with one being cut for horizontal staining and the other cut for vertical staining. Dermascopy users may be able to visualize the miniaturized hairs among hairs that are normal caliber as compared to the occipital scalp hairs. For those very familiar with the use of the dermatoscope, this may save your patient a biopsy. Often, patients themselves prefer to have a biopsy before they are convinced of their true diagnosis. Treatment with Minoxidil Once FPHL is diagnosed, treatment consists of modalities that can slow the process of miniaturization or potentially increase the time the hair stays on the head, thereby allowing it to grow into a thicker hair shaft that contributes to the density on the scalp. The only FDA-approved medication for use in women with FPHL at this time is minoxidil 2% topical solution. This medication prolongs the anagen or growth phase of the hair, allowing it to become thicker over time and contribute to more cover on the scalp. Barriers to Ongoing Treatment with Minoxidil There are several barriers that stand in the way of the use of minoxidil in women, which merit discussion here and with the patient. 1. Concept of lifelong treatment. The first such barrier is the patient’s resistance to the idea that she will need to use this drug for the rest of her life. For some reason, patients often think that there should be a short-term answer to a lifelong problem. Taking the time to address FPHL as a chronic disease with a reasonable treatment that only works when you use it can help compliance. Make analogies to other things that have to be completed everyday, like brushing the teeth or taking a medication for chronic conditions like high blood pressure or diabetes. While the topical minoxidil will not save a life, it can improve the quality of life. 2. Twice-daily application. Another barrier to use of topical minoxidil is the difficulty of using it twice daily as recommended. Some patients get irritation using the medication twice daily, and some simply can not fit two dosing sessions into their lifestyle. Many patients can use the medication once daily with good results, though these are anecdotal results and not supported by clinical studies. Topical steroid solution to the scalp can be used intermittently if there is a significant amount of irritation. 3. Hypertrichosis concerns. Hypertrichosis can be a moderate concern for some patients. In this author’s experience, hypertrichosis occurs more frequently and more noticeably in women of color. It is best to discuss this potential with patients before the start of treatment. Then if it occurs, patients can deal with the hair in a rational way, instead of immediately discontinuing the medication. Stress the fact that those who get hypertrichosis with the minoxidil are those who are definite responders to the treatment. Discuss treatments to combat further hypertrichosis, such as, topical eflornithine, typical hair removal methods, or backing down to daily use of the minoxidil instead of twice daily use. 4. Time length until results are seen. The last barrier to staying on the minoxidil is the time it takes to see results. It can take 9 to 12 months to see thickening of the hair shafts and fuller coverage with the minoxidil. Most patients with hair loss who seek the care of a dermatologist have a difficult time waiting this long to see a change. Discussing this long wait, and scheduling appointments strategically to check progress and followup can be key in helping the patient stay compliant with treatment. Other Treatments for FPHL Minoxidil 5% solution or foam may also be used in women with FPHL daily or twice daily as long as patients understand these drugs are not FDA-approved for women. Oral medication. Other treatments that have been used in women with FPHL include: spironolactone, flutamide, oral contraceptives, and finally, in women no longer able to have children, finasteride.1,2 None of these medications are FDA-approved for this use, but can be helpful for thickening hair in patients with FPHL when the topicals alone fail. Unfortunately, they must all be monitored in some way. Surgical hair restoration. The last treatment that can work for women with FPH is surgical hair restoration. Women often do not think of this surgical procedure as an option, but it often works better for women than for men since there is less to cover and women often require a smaller number of grafts. And, because women usually maintain their frontal hairline, grafts can be placed where they contribute most on the fronto-vertex scalp.
TELOGEN EFFLUVIUM
This is perhaps the most difficult to diagnose form of hair loss since it is constantly changing. This form of hair loss is defined as diffuse shedding all over the scalp triggered by a physiologic stress to the patient’s system. Most patients note a sudden increase in hair loss when styling and caring for the hair. Often patients are baffled by what is causing telogen effluvium because the onset of the hair loss is usually several months after the initial trigger. Triggers The most common triggers are new medications, changes in oral contraceptive dose, surgery, general anesthesia, childbirth, strict diets, significant weight loss and severe illness to name a few. Chronic disease states can also cause this form of hair loss. Examples of chronic processes include: anemia, thyroid disease, chronic malnutrition, etc. For this reason, historical information is paramount to the intake examination. Timing of Onset The dermatologist must press the patient for the timing of the very first time that hair loss was noticed, then count back to 3 to 6 months. This is to identify the start of the process, taking into account the time that it takes for the hair to enter the telogen phase from the anagen phase. Most patients incorrectly believe that the timing of the hair loss is associated with something that happened close to the beginning of the hair loss. Clinical Examination The examination of patients with telogen effluvium is characterized by a positive pull test all over the scalp in the active phase, positive pull test from the bitemporal areas in the later stages, diffuse thinning over the entire scalp often with increased thinning over the crown of the scalp. The bitemporal scalp may show more thinning than the rest of the scalp as well. Some patients will even report that they have hair loss in the eyebrows and eyelashes. Usually, the scalp is asymptomatic. It may be necessary to identify causes of the telogen effluvium with laboratory tests. It is always important to rule out thyroid disease, anemia, iron deficiency, or other easily identifiable medical conditions with the appropriate laboratory tests. Biopsy Biopsy of the scalp may be necessary to establish a diagnosis if the pull test is not positive or there is no identifiable inciting event. The biopsy will show increased cycling with hair follicles in the telogen phase. If the differential diagnosis is female pattern hair loss versus telogen effluvium, a 4-mm punch biopsy from the vertex and one from the posterior scalp may be helpful to compare the cycling of the hair in the two areas. Treatment The objective of treatment for telogen effluvium is to remove the initial stimulus that triggered the loss.3 If the stimulus has already passed, a discussion must ensue about the time frame for the slowing of the shedding of hair, and the time it will take to regrow the hair to normal levels. With the slow growth of hair, the hair will stop shedding approximately 4 to 6 months after the stimulus is removed. Then, regrowth close to normal levels of hair will occur another 6 months later. Most patients have difficulty hearing about the time it will take to regrow hair, so it is important to encourage patients to check in with their dermatologist at 6 month intervals (at least) to keep a check on the status of shedding and thickening of hair that is growing. Serial pull tests can help to show this as can part width examination. Chronic Telogen Effluvium While a complete discussion of this entity is beyond the scope of this article, chronic telogen effluvium is a diagnosis of exclusion. If the hair loss has persisted longer than 1 year, is definitely a non-scarring form of hair loss, is diffuse, and cannot be categorized as female pattern hair loss or telogen effluvium, chronic telogen effluvium should be considered.
SCARRING ALOPECIA OVER THE CENTRAL SCALP
This form of hair loss can be deceiving, since scarring can be delicate and not clinically different than female pattern hair loss, which is nonscarring. Differential Diagnosis Scarring alopecia over the central scalp can be caused by a number of different diagnoses. Central centrifugal cicatricial alopecia, lichen planopilaris, discoid lesions of lupus, dissecting cellulitis, folliculitis decalvans and pseudopalade of Broc. Determining which of these diagnoses is the culprit is sometimes as simple as taking a biopsy, but sometimes it is more difficult. If the patient presents at a late stage, the biopsy may simply show end stage alopecia. Patient History As with other forms of alopecia, the history can be helpful in determining the etiology of the hair loss. Historical information like history of pustule or cyst formation may be a hint to dissecting cellulitis. Discoid lesions on other areas of the body may give a hint to the diagnosis of chronic cutaneous lupus, and lichen planus of the mouth or vaginal area may suggest a closer look for lichenplanopilaris. Biopsy Most scarring alopecias should be biopsied in order to classify the type of hair loss and choose the appropriate treatment. Another scenario that can occur is that it may be difficult to tell if the alopecia is scarring or non-scarring. A biopsy is absolutely necessary in this case. The biopsy is also important for examining the type of inflammatory infiltrate seen in the given alopecia process, since this will impact treatment choice as well. Two 4-mm punch biopsies should be obtained in the most active area of loss. If there is clinically visible inflammation or active loss by pull test, this is the location for the biopsy. Rarely is there much information gleaned from a biopsy that is taken from the middle of scarred, non-inflammatory area. Clinically, the exam of the scarring alopecias over the fronto-vertex scalp can be very similar in the late stages of disease. Biopsy results in this instance can be frustrating, but can be helpful in ruling out lupus or other inflammatory infiltrate. Treatment of Scarring Alopecia Once a diagnosis of a scarring alopecia is made via clinicopathologic correlation, choice of treatments is varied, dependent on the type of hair loss diagnosed.4 For those forms of hair loss with pustule and inflammatory nodule formation, oral antibiotics, topical antibiotics and/or isotretinoin may be good options. Hair loss forms that are scarring with significant scaling and erythema may benefit from topical corticosteroids, oral antimalarials and/or isotretinoin. Forms of hair loss with extreme perifollicular inflammation may improve with topical corticosteroids, oral antimalarials, and stronger antiinflammatory agents like mycophenolate mofetil, methotrexate or dapsone. Almost any of the scarring alopecias can be treated with intralesional corticosteroids.
DIAGNOSIS AND TREATMENT OF MIXED FORMS OF FRONTO-PARIETAL ALOPECIA
Treating one simple diagnosis of hair loss is challenging enough, but mixed forms present a particularly difficult challenge to the dermatologist. FPHL and Telogen Effluvium Many women have a small component of FPHL and develop telogen effluvium as well. When this occurs, there are two nonscarring forms of loss with both miniaturization and positive pull. This combination is suspected when the pull test is positive bitemporally or in the posterior scalp and the part width is much wider than expected on the frontal scalp. Many times a biopsy is difficult to interpret if the telogen effluvium is late stage. In this case, the biopsy will be read as FPHL only and is not a true representation of what is happening. Thus, it is imperative to have a good clinicopathologic correlation. For this patient, a 6-month course of minoxidil 2% or 5% is reasonable along with removal of potential trigger of the telogen hair loss. Rechecking the patient in 6 months would be reasonable for further pull tests and regrowth at the bitemporal scalp. Scarring Hair Loss and FPHL in Fronto-Paretal Scalp The next combination that is frequently seen is scarring hair loss and FPHL in the fronto-parietal scalp. The biopsy can usually sort this out, with pathological fibrosis and miniaturization occurring in the same biopsy. Again, this is so common because FPHL is so common. In this case, the treatment is to treat the underlying inflammatory scarring alopecia along with the FPHL with long-term minoxidil. Scarring Alopecia Plus Telogen Effluvium From the Inflammatory Process Causing the Scarring The last commonly occurring, but often unrecognized, combination is scarring alopecia along with telogen effluvium from the inflammatory process causing the scarring. This is best diagnosed by biopsy and clinicopathologic correlation. When this combination occurs, the hair loss manifests with shedding only in the affected areas of the inflammation and improves when the inflammatory infiltrate is subdued with the appropriate treatment. In this case, minoxidil may make matters worse with the inflamed areas of skin becoming further irritated by the components of the solution. The best course is to treat the inflammation and monitor the success of your therapy by the incremental decreases in shedding.
SUMMARY
Fronto-parietal alopecia in women can be considered an entity all its own. It is one of the top concerns of patients and one of the most confusing to approach because of the similarities in clinical appearance of all the diagnoses leading to the hair loss in this area. Separating out the clinical picture, the pathologic picture, and using the history, can allow for delicate teasing out of the correct diagnosis. Treatment can be tricky and patients are often impatient when waiting on hair regrowth in the case of telogen effluvium or on treatment effect in the case of FPHL and scarring hair loss. Patients should be reminded of the amount of growth of hair per month, and counseled on how long to wait for appreciable differences in hair growth. Dr. McMichael is with the Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC. Disclosure:Dr. McMichael has consulted with Johnson and Johnson.
A practical guide to diagnosis and treatment. Adult women represent a large majority of patients seeking care for hair loss in the dermatology practice. It is precisely this group who are intensely aware of changes in hair density, texture and loss, especially loss over the crown of the scalp or frontal and vertex of the scalp. Those in this group are also the ones who tend to have the most complicated diagnoses, with more than one form of hair loss occurring at the same time. For this reason, it is important to carefully document the medical history of the patient, the specific concerns of the patient, the expectations of the patient, and the treatments that may best fit the lifestyle and diagnosis of the patient. After completing these steps, the most likely combinations of diagnoses for forms of hair loss that are demonstrated as diffuse thinning over the frontal and vertex scalp will likely include: female pattern hair loss (FPHL), telogen effluvium, with less likely, scarring hair loss, such as frontal fibrosing alopecia, central centrifugal cicatricial alopecia, and lichenplanopilaris (See Table 1).
GETTING THE PERTINENT HAIR LOSS HISTORY
All dermatologists have their own style of obtaining the history from their patients, but hair loss patients tend to want to discuss every potential factor that may shed light on why they are experiencing hair loss, whether it is helpful or not. Questionnaires Hair loss histories seem to lend themselves easily to questionnaires, which can speed along the process for the physician. A brief “yes/no” questionnaire can be given to patients in the waiting area; it can also be mailed to them prior to their appointment, although this risks a forgotten questionnaire at home.(Download PDF of Example of Hair Loss Intake Questionnaire.) Questionnaires that are too long or too detailed can be confusing to patients and take too much time to review. A one-page synopsis is all that is necessary, although a patient may have difficulty believing this. Essential Information Whatever method is used to gather the information, the following essential information must be elicited. 1. Duration of hair loss. Most important to uncover is the duration the hair loss. Patients will often write one duration down on a questionnaire, but answer differently when asked verbally. Always double-check this answer. If the hair loss is acute (occurred within the last year), the most important diagnosis to rule out is telogen effluvium. This is why the survey to the patient or history should include recent medications (stopped or started), recent surgeries, recent dieting/weight loss, hormone use and pregnancies. 2. Associated symptoms. Next, associated symptoms are key. Is there pruritus, pain, scaling, burning, pustule formation or rash in the scalp? This will help to determine if you must treat symptoms as well as hair loss. Many patients have pain, but feel that the pain is a lesser problem than the hair loss, even though the two problems may be inextricably linked. 3. Family history. Family history seems to be the least important part of the history. Patients seem to be disproportionately concerned with the fact that their parents or other siblings do not have hair loss. This is particularly true when patients are told they have female pattern hair loss (FPHL), formerly known as androgenetic alopecia. The term FPHL is more appropriate, because the genetic component is so often questioned. This term also distinguishes between the frontal and vertex scalp hair loss that is seen in women and the bi-temporal and vertex hair loss seen in men. Another consideration is that many patients believe an old myth that has propagated into the lay press delineating hair loss as something that must come from the mother’s father and his genetic pool. It may be necessary to discuss with patients that the genetics of hair loss come from both sides of the family and that there is no direct inheritance from one relative, but a mixed inheritance from all family members, complicated by the patient’s own genetic makeup.
FEMALE PATTERN HAIR LOSS
Most patients with FPHL over age 40 suspect their diagnosis before they even come in. Many patients under this age consider themselves too young for this diagnosis, although is it not unusual for patients in their 20s and 30s to have this form of hair loss. Younger vs. Older Patients Most commonly, very young women with FPHL have polycystic ovarian syndrome or other form of androgen abnormality, although many may not be aware of this diagnosis. In the younger patients, it is very important to ask about regularity of menses, acne and facial hair to make sure there is no other hormonal abnormality that must be concomitantly treated. Older women typically present with a slow onset of thinning hair over the frontal scalp with widening of the part, thinning down of the ponytail, or patient commenting about seeing through their hair to the scalp while styling the hair. Patients who are very observant may even notice episodic loss of hair shedding with the progressive thinning. Clinical Exam Findings The physical examination should reveal a thinning over the frontal scalp or vertex scalp as compared to the posterior or occipital scalp, usually sparing the frontal hair line. There is usually no thinning at the bitemporal areas of the frontal scalp in this form of hair loss. If hair loss is seen in the bitemporal areas, telogen effluvium may need to be considered. A closer look at the scalp in the affected areas of loss shows smaller caliber hair fibers and often a thinning in the frontal area just behind the frontal hairline. Some women also may have thinning that progresses down the sides of the scalp into the preauricular areas. Diagnostic Tests A pull test may be positive in the area of hair loss, but should be negative in the posterior scalp. If the diagnosis is still in question, a biopsy can be performed. Typically, two 4-mm punch biopsies can be taken from the affected areas with one being cut for horizontal staining and the other cut for vertical staining. Dermascopy users may be able to visualize the miniaturized hairs among hairs that are normal caliber as compared to the occipital scalp hairs. For those very familiar with the use of the dermatoscope, this may save your patient a biopsy. Often, patients themselves prefer to have a biopsy before they are convinced of their true diagnosis. Treatment with Minoxidil Once FPHL is diagnosed, treatment consists of modalities that can slow the process of miniaturization or potentially increase the time the hair stays on the head, thereby allowing it to grow into a thicker hair shaft that contributes to the density on the scalp. The only FDA-approved medication for use in women with FPHL at this time is minoxidil 2% topical solution. This medication prolongs the anagen or growth phase of the hair, allowing it to become thicker over time and contribute to more cover on the scalp. Barriers to Ongoing Treatment with Minoxidil There are several barriers that stand in the way of the use of minoxidil in women, which merit discussion here and with the patient. 1. Concept of lifelong treatment. The first such barrier is the patient’s resistance to the idea that she will need to use this drug for the rest of her life. For some reason, patients often think that there should be a short-term answer to a lifelong problem. Taking the time to address FPHL as a chronic disease with a reasonable treatment that only works when you use it can help compliance. Make analogies to other things that have to be completed everyday, like brushing the teeth or taking a medication for chronic conditions like high blood pressure or diabetes. While the topical minoxidil will not save a life, it can improve the quality of life. 2. Twice-daily application. Another barrier to use of topical minoxidil is the difficulty of using it twice daily as recommended. Some patients get irritation using the medication twice daily, and some simply can not fit two dosing sessions into their lifestyle. Many patients can use the medication once daily with good results, though these are anecdotal results and not supported by clinical studies. Topical steroid solution to the scalp can be used intermittently if there is a significant amount of irritation. 3. Hypertrichosis concerns. Hypertrichosis can be a moderate concern for some patients. In this author’s experience, hypertrichosis occurs more frequently and more noticeably in women of color. It is best to discuss this potential with patients before the start of treatment. Then if it occurs, patients can deal with the hair in a rational way, instead of immediately discontinuing the medication. Stress the fact that those who get hypertrichosis with the minoxidil are those who are definite responders to the treatment. Discuss treatments to combat further hypertrichosis, such as, topical eflornithine, typical hair removal methods, or backing down to daily use of the minoxidil instead of twice daily use. 4. Time length until results are seen. The last barrier to staying on the minoxidil is the time it takes to see results. It can take 9 to 12 months to see thickening of the hair shafts and fuller coverage with the minoxidil. Most patients with hair loss who seek the care of a dermatologist have a difficult time waiting this long to see a change. Discussing this long wait, and scheduling appointments strategically to check progress and followup can be key in helping the patient stay compliant with treatment. Other Treatments for FPHL Minoxidil 5% solution or foam may also be used in women with FPHL daily or twice daily as long as patients understand these drugs are not FDA-approved for women. Oral medication. Other treatments that have been used in women with FPHL include: spironolactone, flutamide, oral contraceptives, and finally, in women no longer able to have children, finasteride.1,2 None of these medications are FDA-approved for this use, but can be helpful for thickening hair in patients with FPHL when the topicals alone fail. Unfortunately, they must all be monitored in some way. Surgical hair restoration. The last treatment that can work for women with FPH is surgical hair restoration. Women often do not think of this surgical procedure as an option, but it often works better for women than for men since there is less to cover and women often require a smaller number of grafts. And, because women usually maintain their frontal hairline, grafts can be placed where they contribute most on the fronto-vertex scalp.
TELOGEN EFFLUVIUM
This is perhaps the most difficult to diagnose form of hair loss since it is constantly changing. This form of hair loss is defined as diffuse shedding all over the scalp triggered by a physiologic stress to the patient’s system. Most patients note a sudden increase in hair loss when styling and caring for the hair. Often patients are baffled by what is causing telogen effluvium because the onset of the hair loss is usually several months after the initial trigger. Triggers The most common triggers are new medications, changes in oral contraceptive dose, surgery, general anesthesia, childbirth, strict diets, significant weight loss and severe illness to name a few. Chronic disease states can also cause this form of hair loss. Examples of chronic processes include: anemia, thyroid disease, chronic malnutrition, etc. For this reason, historical information is paramount to the intake examination. Timing of Onset The dermatologist must press the patient for the timing of the very first time that hair loss was noticed, then count back to 3 to 6 months. This is to identify the start of the process, taking into account the time that it takes for the hair to enter the telogen phase from the anagen phase. Most patients incorrectly believe that the timing of the hair loss is associated with something that happened close to the beginning of the hair loss. Clinical Examination The examination of patients with telogen effluvium is characterized by a positive pull test all over the scalp in the active phase, positive pull test from the bitemporal areas in the later stages, diffuse thinning over the entire scalp often with increased thinning over the crown of the scalp. The bitemporal scalp may show more thinning than the rest of the scalp as well. Some patients will even report that they have hair loss in the eyebrows and eyelashes. Usually, the scalp is asymptomatic. It may be necessary to identify causes of the telogen effluvium with laboratory tests. It is always important to rule out thyroid disease, anemia, iron deficiency, or other easily identifiable medical conditions with the appropriate laboratory tests. Biopsy Biopsy of the scalp may be necessary to establish a diagnosis if the pull test is not positive or there is no identifiable inciting event. The biopsy will show increased cycling with hair follicles in the telogen phase. If the differential diagnosis is female pattern hair loss versus telogen effluvium, a 4-mm punch biopsy from the vertex and one from the posterior scalp may be helpful to compare the cycling of the hair in the two areas. Treatment The objective of treatment for telogen effluvium is to remove the initial stimulus that triggered the loss.3 If the stimulus has already passed, a discussion must ensue about the time frame for the slowing of the shedding of hair, and the time it will take to regrow the hair to normal levels. With the slow growth of hair, the hair will stop shedding approximately 4 to 6 months after the stimulus is removed. Then, regrowth close to normal levels of hair will occur another 6 months later. Most patients have difficulty hearing about the time it will take to regrow hair, so it is important to encourage patients to check in with their dermatologist at 6 month intervals (at least) to keep a check on the status of shedding and thickening of hair that is growing. Serial pull tests can help to show this as can part width examination. Chronic Telogen Effluvium While a complete discussion of this entity is beyond the scope of this article, chronic telogen effluvium is a diagnosis of exclusion. If the hair loss has persisted longer than 1 year, is definitely a non-scarring form of hair loss, is diffuse, and cannot be categorized as female pattern hair loss or telogen effluvium, chronic telogen effluvium should be considered.
SCARRING ALOPECIA OVER THE CENTRAL SCALP
This form of hair loss can be deceiving, since scarring can be delicate and not clinically different than female pattern hair loss, which is nonscarring. Differential Diagnosis Scarring alopecia over the central scalp can be caused by a number of different diagnoses. Central centrifugal cicatricial alopecia, lichen planopilaris, discoid lesions of lupus, dissecting cellulitis, folliculitis decalvans and pseudopalade of Broc. Determining which of these diagnoses is the culprit is sometimes as simple as taking a biopsy, but sometimes it is more difficult. If the patient presents at a late stage, the biopsy may simply show end stage alopecia. Patient History As with other forms of alopecia, the history can be helpful in determining the etiology of the hair loss. Historical information like history of pustule or cyst formation may be a hint to dissecting cellulitis. Discoid lesions on other areas of the body may give a hint to the diagnosis of chronic cutaneous lupus, and lichen planus of the mouth or vaginal area may suggest a closer look for lichenplanopilaris. Biopsy Most scarring alopecias should be biopsied in order to classify the type of hair loss and choose the appropriate treatment. Another scenario that can occur is that it may be difficult to tell if the alopecia is scarring or non-scarring. A biopsy is absolutely necessary in this case. The biopsy is also important for examining the type of inflammatory infiltrate seen in the given alopecia process, since this will impact treatment choice as well. Two 4-mm punch biopsies should be obtained in the most active area of loss. If there is clinically visible inflammation or active loss by pull test, this is the location for the biopsy. Rarely is there much information gleaned from a biopsy that is taken from the middle of scarred, non-inflammatory area. Clinically, the exam of the scarring alopecias over the fronto-vertex scalp can be very similar in the late stages of disease. Biopsy results in this instance can be frustrating, but can be helpful in ruling out lupus or other inflammatory infiltrate. Treatment of Scarring Alopecia Once a diagnosis of a scarring alopecia is made via clinicopathologic correlation, choice of treatments is varied, dependent on the type of hair loss diagnosed.4 For those forms of hair loss with pustule and inflammatory nodule formation, oral antibiotics, topical antibiotics and/or isotretinoin may be good options. Hair loss forms that are scarring with significant scaling and erythema may benefit from topical corticosteroids, oral antimalarials and/or isotretinoin. Forms of hair loss with extreme perifollicular inflammation may improve with topical corticosteroids, oral antimalarials, and stronger antiinflammatory agents like mycophenolate mofetil, methotrexate or dapsone. Almost any of the scarring alopecias can be treated with intralesional corticosteroids.
DIAGNOSIS AND TREATMENT OF MIXED FORMS OF FRONTO-PARIETAL ALOPECIA
Treating one simple diagnosis of hair loss is challenging enough, but mixed forms present a particularly difficult challenge to the dermatologist. FPHL and Telogen Effluvium Many women have a small component of FPHL and develop telogen effluvium as well. When this occurs, there are two nonscarring forms of loss with both miniaturization and positive pull. This combination is suspected when the pull test is positive bitemporally or in the posterior scalp and the part width is much wider than expected on the frontal scalp. Many times a biopsy is difficult to interpret if the telogen effluvium is late stage. In this case, the biopsy will be read as FPHL only and is not a true representation of what is happening. Thus, it is imperative to have a good clinicopathologic correlation. For this patient, a 6-month course of minoxidil 2% or 5% is reasonable along with removal of potential trigger of the telogen hair loss. Rechecking the patient in 6 months would be reasonable for further pull tests and regrowth at the bitemporal scalp. Scarring Hair Loss and FPHL in Fronto-Paretal Scalp The next combination that is frequently seen is scarring hair loss and FPHL in the fronto-parietal scalp. The biopsy can usually sort this out, with pathological fibrosis and miniaturization occurring in the same biopsy. Again, this is so common because FPHL is so common. In this case, the treatment is to treat the underlying inflammatory scarring alopecia along with the FPHL with long-term minoxidil. Scarring Alopecia Plus Telogen Effluvium From the Inflammatory Process Causing the Scarring The last commonly occurring, but often unrecognized, combination is scarring alopecia along with telogen effluvium from the inflammatory process causing the scarring. This is best diagnosed by biopsy and clinicopathologic correlation. When this combination occurs, the hair loss manifests with shedding only in the affected areas of the inflammation and improves when the inflammatory infiltrate is subdued with the appropriate treatment. In this case, minoxidil may make matters worse with the inflamed areas of skin becoming further irritated by the components of the solution. The best course is to treat the inflammation and monitor the success of your therapy by the incremental decreases in shedding.
SUMMARY
Fronto-parietal alopecia in women can be considered an entity all its own. It is one of the top concerns of patients and one of the most confusing to approach because of the similarities in clinical appearance of all the diagnoses leading to the hair loss in this area. Separating out the clinical picture, the pathologic picture, and using the history, can allow for delicate teasing out of the correct diagnosis. Treatment can be tricky and patients are often impatient when waiting on hair regrowth in the case of telogen effluvium or on treatment effect in the case of FPHL and scarring hair loss. Patients should be reminded of the amount of growth of hair per month, and counseled on how long to wait for appreciable differences in hair growth. Dr. McMichael is with the Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC. Disclosure:Dr. McMichael has consulted with Johnson and Johnson.
A practical guide to diagnosis and treatment. Adult women represent a large majority of patients seeking care for hair loss in the dermatology practice. It is precisely this group who are intensely aware of changes in hair density, texture and loss, especially loss over the crown of the scalp or frontal and vertex of the scalp. Those in this group are also the ones who tend to have the most complicated diagnoses, with more than one form of hair loss occurring at the same time. For this reason, it is important to carefully document the medical history of the patient, the specific concerns of the patient, the expectations of the patient, and the treatments that may best fit the lifestyle and diagnosis of the patient. After completing these steps, the most likely combinations of diagnoses for forms of hair loss that are demonstrated as diffuse thinning over the frontal and vertex scalp will likely include: female pattern hair loss (FPHL), telogen effluvium, with less likely, scarring hair loss, such as frontal fibrosing alopecia, central centrifugal cicatricial alopecia, and lichenplanopilaris (See Table 1).
GETTING THE PERTINENT HAIR LOSS HISTORY
All dermatologists have their own style of obtaining the history from their patients, but hair loss patients tend to want to discuss every potential factor that may shed light on why they are experiencing hair loss, whether it is helpful or not. Questionnaires Hair loss histories seem to lend themselves easily to questionnaires, which can speed along the process for the physician. A brief “yes/no” questionnaire can be given to patients in the waiting area; it can also be mailed to them prior to their appointment, although this risks a forgotten questionnaire at home.(Download PDF of Example of Hair Loss Intake Questionnaire.) Questionnaires that are too long or too detailed can be confusing to patients and take too much time to review. A one-page synopsis is all that is necessary, although a patient may have difficulty believing this. Essential Information Whatever method is used to gather the information, the following essential information must be elicited. 1. Duration of hair loss. Most important to uncover is the duration the hair loss. Patients will often write one duration down on a questionnaire, but answer differently when asked verbally. Always double-check this answer. If the hair loss is acute (occurred within the last year), the most important diagnosis to rule out is telogen effluvium. This is why the survey to the patient or history should include recent medications (stopped or started), recent surgeries, recent dieting/weight loss, hormone use and pregnancies. 2. Associated symptoms. Next, associated symptoms are key. Is there pruritus, pain, scaling, burning, pustule formation or rash in the scalp? This will help to determine if you must treat symptoms as well as hair loss. Many patients have pain, but feel that the pain is a lesser problem than the hair loss, even though the two problems may be inextricably linked. 3. Family history. Family history seems to be the least important part of the history. Patients seem to be disproportionately concerned with the fact that their parents or other siblings do not have hair loss. This is particularly true when patients are told they have female pattern hair loss (FPHL), formerly known as androgenetic alopecia. The term FPHL is more appropriate, because the genetic component is so often questioned. This term also distinguishes between the frontal and vertex scalp hair loss that is seen in women and the bi-temporal and vertex hair loss seen in men. Another consideration is that many patients believe an old myth that has propagated into the lay press delineating hair loss as something that must come from the mother’s father and his genetic pool. It may be necessary to discuss with patients that the genetics of hair loss come from both sides of the family and that there is no direct inheritance from one relative, but a mixed inheritance from all family members, complicated by the patient’s own genetic makeup.
FEMALE PATTERN HAIR LOSS
Most patients with FPHL over age 40 suspect their diagnosis before they even come in. Many patients under this age consider themselves too young for this diagnosis, although is it not unusual for patients in their 20s and 30s to have this form of hair loss. Younger vs. Older Patients Most commonly, very young women with FPHL have polycystic ovarian syndrome or other form of androgen abnormality, although many may not be aware of this diagnosis. In the younger patients, it is very important to ask about regularity of menses, acne and facial hair to make sure there is no other hormonal abnormality that must be concomitantly treated. Older women typically present with a slow onset of thinning hair over the frontal scalp with widening of the part, thinning down of the ponytail, or patient commenting about seeing through their hair to the scalp while styling the hair. Patients who are very observant may even notice episodic loss of hair shedding with the progressive thinning. Clinical Exam Findings The physical examination should reveal a thinning over the frontal scalp or vertex scalp as compared to the posterior or occipital scalp, usually sparing the frontal hair line. There is usually no thinning at the bitemporal areas of the frontal scalp in this form of hair loss. If hair loss is seen in the bitemporal areas, telogen effluvium may need to be considered. A closer look at the scalp in the affected areas of loss shows smaller caliber hair fibers and often a thinning in the frontal area just behind the frontal hairline. Some women also may have thinning that progresses down the sides of the scalp into the preauricular areas. Diagnostic Tests A pull test may be positive in the area of hair loss, but should be negative in the posterior scalp. If the diagnosis is still in question, a biopsy can be performed. Typically, two 4-mm punch biopsies can be taken from the affected areas with one being cut for horizontal staining and the other cut for vertical staining. Dermascopy users may be able to visualize the miniaturized hairs among hairs that are normal caliber as compared to the occipital scalp hairs. For those very familiar with the use of the dermatoscope, this may save your patient a biopsy. Often, patients themselves prefer to have a biopsy before they are convinced of their true diagnosis. Treatment with Minoxidil Once FPHL is diagnosed, treatment consists of modalities that can slow the process of miniaturization or potentially increase the time the hair stays on the head, thereby allowing it to grow into a thicker hair shaft that contributes to the density on the scalp. The only FDA-approved medication for use in women with FPHL at this time is minoxidil 2% topical solution. This medication prolongs the anagen or growth phase of the hair, allowing it to become thicker over time and contribute to more cover on the scalp. Barriers to Ongoing Treatment with Minoxidil There are several barriers that stand in the way of the use of minoxidil in women, which merit discussion here and with the patient. 1. Concept of lifelong treatment. The first such barrier is the patient’s resistance to the idea that she will need to use this drug for the rest of her life. For some reason, patients often think that there should be a short-term answer to a lifelong problem. Taking the time to address FPHL as a chronic disease with a reasonable treatment that only works when you use it can help compliance. Make analogies to other things that have to be completed everyday, like brushing the teeth or taking a medication for chronic conditions like high blood pressure or diabetes. While the topical minoxidil will not save a life, it can improve the quality of life. 2. Twice-daily application. Another barrier to use of topical minoxidil is the difficulty of using it twice daily as recommended. Some patients get irritation using the medication twice daily, and some simply can not fit two dosing sessions into their lifestyle. Many patients can use the medication once daily with good results, though these are anecdotal results and not supported by clinical studies. Topical steroid solution to the scalp can be used intermittently if there is a significant amount of irritation. 3. Hypertrichosis concerns. Hypertrichosis can be a moderate concern for some patients. In this author’s experience, hypertrichosis occurs more frequently and more noticeably in women of color. It is best to discuss this potential with patients before the start of treatment. Then if it occurs, patients can deal with the hair in a rational way, instead of immediately discontinuing the medication. Stress the fact that those who get hypertrichosis with the minoxidil are those who are definite responders to the treatment. Discuss treatments to combat further hypertrichosis, such as, topical eflornithine, typical hair removal methods, or backing down to daily use of the minoxidil instead of twice daily use. 4. Time length until results are seen. The last barrier to staying on the minoxidil is the time it takes to see results. It can take 9 to 12 months to see thickening of the hair shafts and fuller coverage with the minoxidil. Most patients with hair loss who seek the care of a dermatologist have a difficult time waiting this long to see a change. Discussing this long wait, and scheduling appointments strategically to check progress and followup can be key in helping the patient stay compliant with treatment. Other Treatments for FPHL Minoxidil 5% solution or foam may also be used in women with FPHL daily or twice daily as long as patients understand these drugs are not FDA-approved for women. Oral medication. Other treatments that have been used in women with FPHL include: spironolactone, flutamide, oral contraceptives, and finally, in women no longer able to have children, finasteride.1,2 None of these medications are FDA-approved for this use, but can be helpful for thickening hair in patients with FPHL when the topicals alone fail. Unfortunately, they must all be monitored in some way. Surgical hair restoration. The last treatment that can work for women with FPH is surgical hair restoration. Women often do not think of this surgical procedure as an option, but it often works better for women than for men since there is less to cover and women often require a smaller number of grafts. And, because women usually maintain their frontal hairline, grafts can be placed where they contribute most on the fronto-vertex scalp.
TELOGEN EFFLUVIUM
This is perhaps the most difficult to diagnose form of hair loss since it is constantly changing. This form of hair loss is defined as diffuse shedding all over the scalp triggered by a physiologic stress to the patient’s system. Most patients note a sudden increase in hair loss when styling and caring for the hair. Often patients are baffled by what is causing telogen effluvium because the onset of the hair loss is usually several months after the initial trigger. Triggers The most common triggers are new medications, changes in oral contraceptive dose, surgery, general anesthesia, childbirth, strict diets, significant weight loss and severe illness to name a few. Chronic disease states can also cause this form of hair loss. Examples of chronic processes include: anemia, thyroid disease, chronic malnutrition, etc. For this reason, historical information is paramount to the intake examination. Timing of Onset The dermatologist must press the patient for the timing of the very first time that hair loss was noticed, then count back to 3 to 6 months. This is to identify the start of the process, taking into account the time that it takes for the hair to enter the telogen phase from the anagen phase. Most patients incorrectly believe that the timing of the hair loss is associated with something that happened close to the beginning of the hair loss. Clinical Examination The examination of patients with telogen effluvium is characterized by a positive pull test all over the scalp in the active phase, positive pull test from the bitemporal areas in the later stages, diffuse thinning over the entire scalp often with increased thinning over the crown of the scalp. The bitemporal scalp may show more thinning than the rest of the scalp as well. Some patients will even report that they have hair loss in the eyebrows and eyelashes. Usually, the scalp is asymptomatic. It may be necessary to identify causes of the telogen effluvium with laboratory tests. It is always important to rule out thyroid disease, anemia, iron deficiency, or other easily identifiable medical conditions with the appropriate laboratory tests. Biopsy Biopsy of the scalp may be necessary to establish a diagnosis if the pull test is not positive or there is no identifiable inciting event. The biopsy will show increased cycling with hair follicles in the telogen phase. If the differential diagnosis is female pattern hair loss versus telogen effluvium, a 4-mm punch biopsy from the vertex and one from the posterior scalp may be helpful to compare the cycling of the hair in the two areas. Treatment The objective of treatment for telogen effluvium is to remove the initial stimulus that triggered the loss.3 If the stimulus has already passed, a discussion must ensue about the time frame for the slowing of the shedding of hair, and the time it will take to regrow the hair to normal levels. With the slow growth of hair, the hair will stop shedding approximately 4 to 6 months after the stimulus is removed. Then, regrowth close to normal levels of hair will occur another 6 months later. Most patients have difficulty hearing about the time it will take to regrow hair, so it is important to encourage patients to check in with their dermatologist at 6 month intervals (at least) to keep a check on the status of shedding and thickening of hair that is growing. Serial pull tests can help to show this as can part width examination. Chronic Telogen Effluvium While a complete discussion of this entity is beyond the scope of this article, chronic telogen effluvium is a diagnosis of exclusion. If the hair loss has persisted longer than 1 year, is definitely a non-scarring form of hair loss, is diffuse, and cannot be categorized as female pattern hair loss or telogen effluvium, chronic telogen effluvium should be considered.
SCARRING ALOPECIA OVER THE CENTRAL SCALP
This form of hair loss can be deceiving, since scarring can be delicate and not clinically different than female pattern hair loss, which is nonscarring. Differential Diagnosis Scarring alopecia over the central scalp can be caused by a number of different diagnoses. Central centrifugal cicatricial alopecia, lichen planopilaris, discoid lesions of lupus, dissecting cellulitis, folliculitis decalvans and pseudopalade of Broc. Determining which of these diagnoses is the culprit is sometimes as simple as taking a biopsy, but sometimes it is more difficult. If the patient presents at a late stage, the biopsy may simply show end stage alopecia. Patient History As with other forms of alopecia, the history can be helpful in determining the etiology of the hair loss. Historical information like history of pustule or cyst formation may be a hint to dissecting cellulitis. Discoid lesions on other areas of the body may give a hint to the diagnosis of chronic cutaneous lupus, and lichen planus of the mouth or vaginal area may suggest a closer look for lichenplanopilaris. Biopsy Most scarring alopecias should be biopsied in order to classify the type of hair loss and choose the appropriate treatment. Another scenario that can occur is that it may be difficult to tell if the alopecia is scarring or non-scarring. A biopsy is absolutely necessary in this case. The biopsy is also important for examining the type of inflammatory infiltrate seen in the given alopecia process, since this will impact treatment choice as well. Two 4-mm punch biopsies should be obtained in the most active area of loss. If there is clinically visible inflammation or active loss by pull test, this is the location for the biopsy. Rarely is there much information gleaned from a biopsy that is taken from the middle of scarred, non-inflammatory area. Clinically, the exam of the scarring alopecias over the fronto-vertex scalp can be very similar in the late stages of disease. Biopsy results in this instance can be frustrating, but can be helpful in ruling out lupus or other inflammatory infiltrate. Treatment of Scarring Alopecia Once a diagnosis of a scarring alopecia is made via clinicopathologic correlation, choice of treatments is varied, dependent on the type of hair loss diagnosed.4 For those forms of hair loss with pustule and inflammatory nodule formation, oral antibiotics, topical antibiotics and/or isotretinoin may be good options. Hair loss forms that are scarring with significant scaling and erythema may benefit from topical corticosteroids, oral antimalarials and/or isotretinoin. Forms of hair loss with extreme perifollicular inflammation may improve with topical corticosteroids, oral antimalarials, and stronger antiinflammatory agents like mycophenolate mofetil, methotrexate or dapsone. Almost any of the scarring alopecias can be treated with intralesional corticosteroids.
DIAGNOSIS AND TREATMENT OF MIXED FORMS OF FRONTO-PARIETAL ALOPECIA
Treating one simple diagnosis of hair loss is challenging enough, but mixed forms present a particularly difficult challenge to the dermatologist. FPHL and Telogen Effluvium Many women have a small component of FPHL and develop telogen effluvium as well. When this occurs, there are two nonscarring forms of loss with both miniaturization and positive pull. This combination is suspected when the pull test is positive bitemporally or in the posterior scalp and the part width is much wider than expected on the frontal scalp. Many times a biopsy is difficult to interpret if the telogen effluvium is late stage. In this case, the biopsy will be read as FPHL only and is not a true representation of what is happening. Thus, it is imperative to have a good clinicopathologic correlation. For this patient, a 6-month course of minoxidil 2% or 5% is reasonable along with removal of potential trigger of the telogen hair loss. Rechecking the patient in 6 months would be reasonable for further pull tests and regrowth at the bitemporal scalp. Scarring Hair Loss and FPHL in Fronto-Paretal Scalp The next combination that is frequently seen is scarring hair loss and FPHL in the fronto-parietal scalp. The biopsy can usually sort this out, with pathological fibrosis and miniaturization occurring in the same biopsy. Again, this is so common because FPHL is so common. In this case, the treatment is to treat the underlying inflammatory scarring alopecia along with the FPHL with long-term minoxidil. Scarring Alopecia Plus Telogen Effluvium From the Inflammatory Process Causing the Scarring The last commonly occurring, but often unrecognized, combination is scarring alopecia along with telogen effluvium from the inflammatory process causing the scarring. This is best diagnosed by biopsy and clinicopathologic correlation. When this combination occurs, the hair loss manifests with shedding only in the affected areas of the inflammation and improves when the inflammatory infiltrate is subdued with the appropriate treatment. In this case, minoxidil may make matters worse with the inflamed areas of skin becoming further irritated by the components of the solution. The best course is to treat the inflammation and monitor the success of your therapy by the incremental decreases in shedding.
SUMMARY
Fronto-parietal alopecia in women can be considered an entity all its own. It is one of the top concerns of patients and one of the most confusing to approach because of the similarities in clinical appearance of all the diagnoses leading to the hair loss in this area. Separating out the clinical picture, the pathologic picture, and using the history, can allow for delicate teasing out of the correct diagnosis. Treatment can be tricky and patients are often impatient when waiting on hair regrowth in the case of telogen effluvium or on treatment effect in the case of FPHL and scarring hair loss. Patients should be reminded of the amount of growth of hair per month, and counseled on how long to wait for appreciable differences in hair growth. Dr. McMichael is with the Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC. Disclosure:Dr. McMichael has consulted with Johnson and Johnson.
