Look it’s only death. It’s not like losing your hair.
HAROLD BRODKEY UPON LEARNING HE HAD AIDS, NEW YORKER MAGAZINE 1994
The hair of our scalp is referred to as our crowning glory and the threat of hair loss in both sexes provokes extraordinary anxiety bordering on grief in some people. It behoves us as medical practitioners to treat the patient presenting with ‘I’m losing my hair’ with appropriate support and understanding. Likewise, the problem of hirsutism provokes similar anxiety and concerns about body image. Interestingly, women present with hair loss more than men.
Key facts and checkpoints
There are two types of hair: terminal hair, which is coarse and well pigmented, and vellus hair, which is fine, soft and relatively unpigmented.
Alopecia is a generic term for hair loss.
Hair loss (alopecia) generates considerable anxiety and the fear of total hair loss should be addressed with the patient and a realistic prognosis given.
Androgenic alopecia is the most common cause of human hair loss, affecting 50% of men by age 40 and up to 50% of women by age 60.1 Other common causes are alopecia areata, seborrhoeic dermatitis and tinea capitis (see TABLE 126.1).
In telogen effluvium, the traumatic event has preceded the hair loss by about 2 months (peak loss at 4 months).
Although severe stress could precipitate alopecia areata, day-to-day stressors are not considered to be a trigger. Stress seems to be a consequence of alopecia rather than the cause of it.2
Hair loss can be patchy or diffuse where it involves the entire scalp.
Patchy loss—alopecia areata and trichotillomania.
Generalised loss—telogen effluvium, systemic disease, drugs (see TABLE 126.2).
Alopecia areata has a poor prognosis if it begins in childhood, if there are several patches and there is loss of eyebrows or eyelashes.
Scarring alopecia can be an indicator of lupus erythematosus or lichen planus.
Table 126.1Hair loss: diagnostic strategy model |Favorite Table|Download (.pdf) Table 126.1 Hair loss: diagnostic strategy model
Androgenetic alopecia (male pattern baldness)
Telogen effluvium (incl. postpartum)
Anagen effluvium (esp. cytotoxic therapy)
Scars (e.g. trauma, burns)
Serious disorders not to be missed
Pitfalls (often missed)
Heavy metal poisoning
Seven masquerades checklist
Drugs (cytotoxics, anticoagulants, antiepileptics, amphetamines, anti-thyroid agents, various hormones, cessation OCP)
Thyroid/other endocrine (hypothyroidism)
Is the patient trying to tell me something?
Emotional stress → telogen effluvium; trichotillomania
Table 126.2Causes of diffuse hair loss |Favorite Table|Download (.pdf) Table 126.2 Causes of diffuse hair loss
|Androgenetic alopecia |
|Telogen effluvium |
|Postpartum telogen effluvium |
|Alopecia areata (diffuse type) |
|Drugs—cytotoxics and others |