1. Hair Examination and Hair Diseases MUDr. M. Arenbergerová, PhD.

2. PICTURE Hair is composed of strong structural protein called keratin.
This is the same kind of protein that makes up the nails and the outer layer of skin.

3. PICTURE

4. PICTURE

5. PICTURE Each strand of hair consists of three layers.
An innermost layer or medulla which is only present in large thick hairs.
The middle layer known as the cortex. The cortex provides strength and both the color and the texture of hair.
The outermost layer is known as the cuticle. The cuticle is thin and colorless and serves as a protector of the cortex.

6. PICTURE Hair can absorb water, fluids or chemicals
Hair can be coated with different materials
PICTURE

7. PICTURE Dermal papilla
At the base of the hair follicle is the dermal papilla. The dermal papilla is feed by the bloodstream which carries nourishment to produce new hair. The dermal papilla is a structure very important to hairgrowth because it contains receptors for male hormones and androgens. Androgens regulate hairgrowth and in scalp hair Androgens may cause the hair follicle to get progressively smaller and the hairs to become finer in individuals who are genetically predisposed to this type of hair loss.

8. Hair examination Medical history Lost hair count Traction test
Trichogramm (hair pluck test)
Mycological examination
Biopsy
Hormonal examination
Microscopic examination of hair structure
Digital Phototrichogramm

9. Hair Number of hairs: 100 000 – 150 000 Density: 175-300/cm²
Thickness: 0,1-0,25 mm
Hair growth: 0,35 mm/day (1 cm per month)
Hair lost: /den
Hair can grow: cm in length
Hair growing: %
Hair resting: %

10. Hair cycle Phase Duration Percent anagen 2-6 years 80-90% catagen
1-2 weeks
1-3%
telogen
2-4months
10-20%
Hormons
Scalp hair
Body hairs
androgens
estrogens

11. PICTURE Hair cycle Phase Duration Percent anagen 2-6 years 80-90%
catagen
1-2 weeks
1-3%
telogen
2-4months
10-20%
PICTURE

12. PICTURE anagen catagen telogen
1-epidermis, 2-infundibulum, 3-sebaceous gland, 4-m. arrector pili,
5-hair shaft, 6-hair matrix, 7-blood vessel, 8-dermal papilla

13. PICTURE

14. PICTURE

15. Androgenetic alopecia (AGA)
Most frequent disease of hair follicle
50 % men > 40 is affected with MAGA
50 % women > 50 is affected with FAGA
PICTURE

16. Androgenetic alopecia-ethiology
Genetic disposition (polygenic inheritance x
AD heredity?)
Androgen level (1 % free androgen, 99 % bound to plasmatic proteins)
Number of androgen receptors
Age (higher age: physiologic lost of hair follicle density)
79 % SHBG
20 % albumin
0,5 % CBG
50 % more androgen receptors than women
SHBG: sex hormone-binding globulin, CBG: steroid hormone receptors

17. Hair follicle-androgen metabolism
5 alpha-reductase
testosterone (T)
dihydrotestosterone (DHT)
3x higher content
of 5 alpha reductase

18. PICTURE

19. 3x higher content
of 5 alpha- reductase
PICTURE

20. Effect of androgens on hair follicles
Binding of androgens to androgen receptors on follicle keratinocytes
Active complex
Active complex migrates to cell nucleus
Modificated protein synthesis in cells
Different dynamics of hair cycle in hair follicle
Reduction of anagen phase
Regressive metamorphosis

21. PICTURE Regressive metamorphosis
Hair follicles sensitive to DHT begin to miniaturize, shortening the lifespan of each hair follicle affected. Eventually, these affected follicles stop producing cosmetically acceptable hair.

22. Clinical image of MAGA
PICTURE
Hamilton-Norwood scale

23. PICTURE Klinický obraz FAGA
Slow recession in frontal region, distinct centre parting, front hairline is still present
Ludwig scale
FPHL - female pattern hair loss

24. PICTURE

25. Vlasový cyklus u AGA Anagen 2-7 years
In MAGA anagen phase shortens from years to months
Telogen phase is expanding
Anagen/telogen ratio changes form 6 to 8 : 1 to abnormal ratio 0,1 to 3 : 1
Finally the anagen phase is so short, that the hair doesn´t reach the skin surface - alopecia

26. Follicle miniaturization
Change of follicle structure: follicle miniaturization
Terminal hair becomes thin, short, velus-like

27. Diagnostics Traction test +/- Trichogram, fototrichogram
Histological examination
Hormonal examination
man: T, DHT, SHBG
woman: T, DHT, SHBG, prolactin, follicle
stimulating hormone (FSH), dihydroepiandrosterone (DHEA), dihydroepiandrosterone-sulphate (DHEAS), +/-cortisol. Examination: day of menstruation cycle, min. 3 month after stop of contraceptives

28. Diagnostics-women Family history Gynecological history
Pharmacological history
Examination:
Signs of hirsutism, acne, hypetrichosis, seborrhea
tumors, hormonal syndromes
SAHA syndrome (female hyperandrogen syndrome):
seborrhea
acne
hirsutism
alopecia AGA (mamle type of AGA)

29. Diferential diagnostics of AGA
PICTURE
Acute telogen effluvium

30. PICTURE

31. PICTURE
Alopecia
areata

32. Alopecia
universalis
PICTURE

33. PICTURE
alopecia areata in a child

34. PICTURE
Scarring
alopecia

35. PICTURE
Diffuse effluvium

36. Trichogram Preparation 5 days NOT wash hair, NO hair cosmetics
Hair collection
Diffuse effluvium frontal and occipital part
Androgenetic alopecia
Alopecia areata spot-edge and opposite site

37. Collection
Forceps
Ca. 50 hairs
Epilation
Method
Microscopic examination of hair bulb and hair shaft
Slide- turpentine-cover slip
After 24 h microscopic examination (HP 25 x)

38. PICTURE Trichogram anagen hair 80% dysplastic anagen hair up to 30%
medulla
cortex
PICTURE
anagen
hair
80%
dysplastic
anagen hair
up to 30%
catagen
hair
1-3%
telogen
hair
20%
dystrofic
hair
up to 2%

39. PICTURE Hair structural defect normal hair pilus anulatus monil-
ethrix
pilus
tortus
trichor-
rhexis
trichoptilosis

40. Trichorrhexis nodosa Symptoms of TN include: hair that breaks easily,
patches of hair loss or extremely short hair,
thickened or thinned areas along the hair shaft,
chronically split ends with whitish discoloration.
hair straightening, overheating by a hair dryer, frequent swimming in chlorinated water

41. PICTURE Trichotillomania
Trichotillomania: obscessive pulling out of own hair.

42. PICTURE

43. PICTURE

44. Alopecia areata Autoimunne disease Polygenic inheritance
Focus: chronic infection
More frequent in chromosomal defects (chromosome 21)
metabolic x emotional influence?

45. Pathogenesis
Cell lymphocyte cluster around affected anagen follicles, causing inflammation
Relase of cytotoxic substances
Apoptosis of hair follicle keratinocytes
Toxic disruption of hair follicle
Telogen phase prolongation
Exclamation mark (!) type of hair

46. Alopecia areata
PICTURE

47. Alopecia areata
PICTURE
Peribulbar T- lymphocyte infiltration

48. Clinical picture Bald spots (spot baldness) Not painful
alopecia areata monolocularis
alopecia areata multilocularis
alopecia areata barbae
alopecia totalis
alopecia universalis
Not painful
Fall out over a short period of time
Frequent association with asthma bronchiale, atopic dermatitis, hypothyroidism

49. PICTURE Nails in Alopecia areata
Onychodystrophy - trachyonychia, koilonychia, leukonychia, pitting

50. Alopecia areata multilocularis
PICTURE

51. Alopecia areata-ophiatic type
PICTURE

52. PICTURE

53. PICTURE
Syphilitic Alopecia

54. PICTURE
Scarring Alopecia

55. PICTURE
Aplasia Cutis Congenita

56. Trichoscopy
trichoscopy shows regularly distributed "yellow dots" (hyperkeratotic plugs), small exclamation-mark hairs, and "black dots" (destroyed hairs in the hair follicle opening)
Trichoscopy is method of dermoscopy
for visualization of scalp at 10 to 70-fold
magnification.

57. Therapy
PICTURE

58. Therapy Spontaneous regression Corticosteroids Immunosupressants
Diphenylcyclopropenone (diphencyprone)
Diphencyprone
Acts as a local irritant, triggering a local sensitization
Triggers an immune response that opposes the action of the autoreactive cells that otherwise cause hair loss
Regrowth of 40% pts. at 6 months, being sustained in two thirds of these after a 12-month-follow up-period

59. after
PICTURE
before

60. after
PICTURE
before

61. Phototrichogram Phototrichogram Non-invasive method
2 pictures of a certain spot at the scalp
Time span (24-72 h)
Comparison of pictures with digital software
Anagen hair grow

62. Digital phototrichogram

63. Digital phototrichogram
camera extension
spot
1 cm2

64. Digital phototrichogram

65. Digital phototrichogram
Epilation: 2 mm

66. Digital phototrichogram

67. Digital phototrichogram