1. NON-CICATRICIAL AlOPECIA
BY:
MOHAMMED ALSAIDAN

3. APPROACH

4. Approach History Duration Pattern
Thinning vs. shedding (hair root? Breaking?) FH
Hair care products
Systemic disease, e.g. thyroid
Heavy mestruation, menstrual irregularity
Child birth, surgery, stress
New medication ? When was started?
Diet : caloric intake
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

5. Approach Examination Distribution Hair line ? Signs of Androgenism
Inflammation ? Scale ?
Scarring ?
TESTS TO ASSES HAIR
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

6. How to assess the quantity of hair lost ?

7. Assessment Daily hair counts Hair pull test Hair wash
60 second hair count
Hair pluck trichogram
Global photography
Dermoscopy
Contrasting felt examination
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

8. Hair pull test Scalp: 100 000 hair follicle
Telogen normally=10% (10 000)
Average of daily lost hair =10 000/100day= 100
Some studies are estimating normality as (10-250) ?
20-60 hairs are grasped between the thumb, index and middle fingers from the base of the hairs near the scalp and firmly, but not forcefully, pulled away from the scalp.
>10% hairs are pulled away implies active hair shedding.
The patient must not shampoo for at least 24h.
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

10. Hair wash
Washing hair in closed sink after 5 days of no wash then count hair
Hairs counted and divided into ≤3cm and ≥5 cm in length.
The 'modified hair wash test' demonstrates that in FAGA 58.9% of hair is vellus, whereas in chronic telogen effluvium (CTE), there are only 3.5%
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

11. 60 second hair count
Before shompooing, comb hair for 60 second over a pillow or white sheet
Start combing from back top of the scalp moving to front and count hair
Repeat it before 3 consequetive shampooing, e.g. every 2nd or 3rd day using the same comb or brush
Repeat it monthly
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

13. Hair pluck trichogram
50 hair pulled with a hemostat covered with rubber, along the angel of insertion, on the fifth day after the last shampoo
The hair is cut about 1 cm from the root, placed on a wet-mount microscope slide & viewed at 10X
DACA (4-dimethylaminocinnamaldehye) reacts with an internal root sheath amino acid allowing differentiation of anagen from telogen hairs. (+ve in anagen)
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

14. Trichogram hairs are grasped with a hemostat covered with rubber and are plucked, twisting and lifting the hair shafts rapidly in the direction of emergence from the scalp

15. Preparing the trichogram slide - the plucked hairs are arranged side by side on a glass slide and taped

16. Anagen hair - showing the darkly pigmented triangular or delta-shaped bulbs with an angle to the hair shaft ('hockey-stick' appearance) and presence of inner root sheath

17. early telogen hair showing the hypopigmented, club-shaped bulb with absence of inner root sheath

18. A Telogen fibers showing a club shape
A Telogen fibers showing a club shape. B Anagen fibers with attached root sheaths, demonstrating pigmented, distorted bulbs appearing like the end of broom sticks. C Ruffled cuticle of loose anagen hair

19. Global Photography
a stereotactic positioning device (with a camera and flash) on which the patient's chin and forehead are fixed
To ensure that the view, magnification and lighting are the same at consecutive study visits.
ask patients to keep the same hair style and color
Four standard views (vertex, midline, frontal and temporal) are advocated
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

21. CONTRASTING FELT EXAMINATION
After making a parting in the hair, the index card is held along the scalp
miniature hairs can be seen in patients with androgenetic alopecia.
In a regrowing telogen effluvium, a classic short frontal fringe is seen
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

23. Approach Labs: TSH, ferritin +/- (vit.D , Zinc, ESR)
Hormonal essay if needed ( free testosterone + DHEAS)
ANA
Skin Biopsy if needed
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

24. Male/Female Pattern Hair Loss (AGA)
The most common cause of hair loss , age related, men >women
Almost all caucasian men show recession of hair line after puberty
by age 70, 80% of Caucasian men, 40% of women show evidence of AGA
Association with CAD, DM, HTN ??

28. Etiology Testosterone: DHT :
presence of terminal pubic and axillary hair fibers
increased muscle mass
growth of the phallus and scrotum
voice change, sex drive
DHT :
temporal scalp hair recession
development of terminal hairs in the beard region, external ears, nostrils, and limbs
acne
growth of the prostate gland
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

29. Etiology Polygenic Miniaturization is the hallmark of AGA
Vellus hairs may be present in large amounts prior to permanent shedding
5α-reductase activity and DHT levels are increased compared to non-balding scalp skin , once low -> reversal of AGA
Absence of type II 5α-reductase prevents development of male androgenetic alopecia
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

30. Clinical features Symmetrical and prgressive
Pattern : Hamilton, Norwood, ludweg
Men: Recession of frontal hair line + balding of vertex
Female: involving crown and frontal scalp, maintaining hair line
Signs of androgenisim ?
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

32. Ludwig grade I : minimal widening of the part width Ludwig grade II : with moderate thinning Ludwig grade III :with significant thinning and widening of the part width

34. Ludwig scale
Ludwig 1-1 The central parting of a woman with no hair loss. Ludwig The width of the parting gets progressively wider indicating thinner hair along the center of scalp. Ludwig Diffuse thinning of the hair over the top of the scalp. Ludwig 3 A woman with extensive diffuse hair loss on top of the scalp, but some hair does survive.
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

35. Ludwig scale
Ludwig Advanced A woman with extensive hair loss and little to no surviving hair in the alopecia affected area. Very few women ever reach this stage and if they do it is usually because they have a condition that causes significant, abnormally excessive androgen hormone production. Ludwig Frontal A woman with a pattern of hair loss that is described as "frontally accentuated". That means there is more hair loss at the front and center of the hair parting instead of just in the top middle of the scalp
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

37. Differential diagnosis
FPHL vs TE ?
FPHL + TE ?
FPHL + AA
Hyperandrogenism ?
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

38. Telogen effluvium
TE is the most common form of hair loss seen in association with systemic disease
begins approximately 3 months after an event, Thinning of the hair involving the entire scalp
chronic TE (> 6 months) affects women between the ages of 30 and 60 years without any precipitating cause and is a diagnosis of exclusion
Telgen >15% presumptive, >20% diagnostic (kligman ?)
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

43. Medical treatment of androgenetic alopecia in men–finasteride (n = 219) versus placebo (n = 15) five-year clinical trial. The figure shows the mean difference in hair count after 5 years (p<0.001).

44. Treatment : (hairDX test): CAG repeat score
A smaller CAG test score is associated with
higher risk for significant hair loss
increased response to Finasteride
increased risk of developing BPH
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

47. Trichotellomania Usually present in early childhood to adolescence.
The most frequent site of hair pulling is the scalp
grouped under the ‘impulse-control disorders not elsewhere classified causing clinically significant distress or impairment'’
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

48. Trichotellomania
patchy or full alopecia of the scalp, centrifugal or wave like pattern, hairs in the occiput tend to be spared
bizarre shapes, irregular borders, and contain hairs of varying lengths and hair shaft fractures
‘hair growth window’ by repeatedly (weekly) shaving a small area of involved scalp to demonstrate normal, dense regrowth, will support the diagnosis
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

49. Trichotellomania
The differential diagnosis includes tinea capitis and alopecia areata
Histopathology: Trichomalacia and pigment casts
No specific treatment
Hypnosis, behavioral modification therapy.
The recommended first-line medication is clomipramine or (SSRI)
N-actyl-cysteine ?
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

52. Temporal Triangular Alopecia
Could be congenital or acquired during the first decade of life then persist for life.
rarely, occur outside the temporal area
Lesions appear hairless, but very fine vellus hairs can be seen with magnification.
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

53. Temporal Triangular Alopecia
The lancet-shaped lesions are a few centimeters in width, may be unilateral or bilateral, and are oriented so that that the tip of the ‘lancet’ points superiorly and posteriorly.
Hair transplant can help
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

54. Lipedematous Alopecia (Lipedematous Scalp)
thick boggy scalp and hair
primarily in women with darkly pigmented skin.
doubling of scalp thickness as a result of edema and subsequent expansion of the subcutaneous fat layer.
in scalp biopsy specimens, follicular structures appear normal but ectatic lymphatic vessels are sometimes found
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

56. Postoperative (Pressure-Induced) Alopecia
in patients who have undergone lengthy surgical procedures, usually the upper occiput.
Less commonly, 2ry to blunt trauma to the scalp.
Early on, erythema and induration are found in the central portion of the affected area.
Few weeks later typically presents as a solitary, oval patch
Usually, complete hair regrowth occurs, although ( cicatricial) hair loss have been reported.
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

58. Alopeia areata
BY:
MOHAMMED ALSAIDAN

59. Alopecia areata
Alopecia areata affects all age groups and different ethnicities, with equal sex distribution
occur in 0.1% to 0.2 % of the general population
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

60. Clinical features
Classic AA lesions are well demarcated, round or oval, completely bald, smooth-surfaced patches
Patches can be mildly reddened or peachy in color
A characteristic finding that is frequently seen in (or at the border of) the patches is ‘‘exclamation mark hairs.’’
hair pull test may be positive at the periphery of lesions
Initial sparing of white hairs in patients with graying hair
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

61. Pattern
ophiasis type, band-like hair loss in parieto-temporo-occipital area
Ophiasis inversus (sisapho), very rare band-like hair loss in the fronto-parieto-temporal area
Reticular patches of hair loss
diffuse thinning over part or all of the scalp.
Acute diffuse and total alopecia: rapid progression and extensive involvement, along with a favorable prognosis
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

65. DDx
Trichotillomania and tinea capitis are the most important differential diagnoses in children
Lupus , secondary syphilis and congenital atrichia
diffuse AA can be easily misdiagnosed as telogen effluvium
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

66. Prognosis
the most important prognostic factor is the extent of AA involvement or an ophiasis pattern
Other factors: long duration , atopy, a positive family history, other autoimmune diseases, nail involvement, and young age of first onset
Up to 50% of patients will recover within 1 year even without treatment
Approximately 5% of cases will progress to AT/AU.
In AT/AU, the chance of full recovery is less than 10%
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

67. Associations
AA can be associated with nail changes in as many as 66% of patients
Autoimmune diseases, particularly thyroiditis, are the most significant association (8% and 28%)
Other associations include vitiligo, atopy, down syndrome, psychiatric and asymptomatic ophthalmologic changes 41%
IDDM ?
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

68. Labs Routine testing is not indicated in AA
Potassium hydroxide, fungal culture, lupus serology, syphilitic screening, and a scalp biopsy may be necessary
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

69. Pathology
A peribulbar lymphocytic infiltrate ‘‘swarm of bees’’ characterizes the acute phase of AA
In subacute cases, large numbers of catagen and telogen hairs will be present
Hair follicle miniaturization with minimal or no inflammation is seen in chronic cases
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

73. Treatment : INTRALESIONAL CORTICOSTEROIDS
Intralesional corticosteroids are the treatment of choice for adults
triamcinolone acetonide 5mg/mL to the scalp and 2.5mg/mL to the face every 4 to 6 weeks
Treatment should be stopped if there is no improvement after 6 months
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

74. Treatment : TOPICAL CORTICOSTEROIDS
Topical midpotent corticosteroids are the treatment of choice in children
The authors combine topical corticosteroids with minoxidil 5%
Minoxidil 5% is mainly used as adjuvant treatment to conventional therapy
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

75. Treatment :
Anthralin
Anthralin 0.5% to 1% short contact therapy is used as alternative treatment
Mild irritation should develop in order for it to work
Anthralin should not be combined with corticosteroids
Treatment may be stopped if there is no improvement after 3 months
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

76. Treatment : TOPICAL IMMUNOTHERAPY
Diphenylcyclopropenone (DPCP) is the treatment of choice for adults with more than 50% scalp involvement
Treatment should be stopped if there is no improvement after 6 months
Squaric acid dibutylester is an alternative in patients who do not develop allergic reaction to DPCP (DNCP: MUTAGENIC)
The success rate is 50% to 60%, with a relapse rate up to 62% at a median period of 2 and a half years
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

77. Initially, 2% DPCP in acetone is applied to a 4- 4-cm circular area of the scalp Two weeks later, a 0.001% DPCP solution is applied to the same half of the scalp The concentration of DPCP is increased gradually each week until a mild dermatitis reaction is obtained. The goal is to achieve a low-grade erythema and mild pruritus DPCP should be left on the scalp for 48 hours, with sun avoidance Lag for evident clinical improvement 3-12 month

78. Treatment :
Capsaicin
Capsaicin was previously shown to induce vellus hair regrowth in AA
More recently, a study showed that topical capsaicin and clobetasol 0.05% are comparable
Bexarotene
In a single recently published study, bexarotene 1% gel resulted in a 26% hair regrowth rate
Dermal irritation is a common side effect
Topical calcineurin inhibitors
failed to show hair regrowth in AA
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

79. Treatment : Systemic corticosteroids
Daily, weekly, and monthly pulse corticosteroids have been used with varying success
The use of systemic corticosteroids is limited by their side effect profile and a higher rate of relapse
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

80. Treatment : Cyclosporine
Cyclosporine has been used alone or in conjunction
with corticosteroids with a success rate up to 76.6%
Cyclosporine use is limited by its side effects and high relapse rate
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

81. Treatment : Sulfasalazine
Sulfasalazine up to 1.5 g twice daily is successful in about quarter of the patients
The relapse rate is 45.5%
One in three patients may have side effects
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

82. Treatment : Methotrexate
Methotrexate in conjunction with low-dose prednisone showed success in 64% of patients with AT/AU in one study
Biologics
Several reports of multiple biologics, including etanercept, efalizumab, adalimumab, and infliximab failed to show improvement in AA
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

83. Treatment : Photochemotherapy
Systemic and topical psoralen plus ultraviolet A light phototherapy have been used with limited success
Long-term safety, side effects, and a high relapse rate have curtailed the use of psoralen plus ultraviolet A light phototherapy
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

84. Treatment : Other phototherapies
Excimer laser may be helpful in limited patchy AA
Infrared irradiation as monotherapy or adjunctive to conventional therapy showed some success
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

85. Treatment : Psychological support
resulting in down-regulation of pathogenic antibodies production .
Fc Fc (Fragment, crystallizable) region
Fab antigen binding

87. Thank you