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  1. ACT
    Anagen: Telogen
    12 : 1
    90% of our terminal hairs are at anagen phase which is the growing phase. It lasts for 2-6 years. The scalp hair on average grows at the rate of 0.4 mm per day.
    Catagen is a transient period. Hair matrix cells stop dividing. As a result, there is no hair growth.

    Less than 10% of our hairs should be in telogen phase which lasts for 100 days (about 3 months). Since on average, each person has about 100,000 hairs. Therefore, less than 10,000 should be in telogen phase and on each day less than 100 hairs fall off physiologically.
Differences between cicatricial and non-cicatricial alopecia
Cicatricial alopecia Non-cicatricial alopecia
•  Due to scarring
•  Hair follicles destroyed, so generally irreversible
•  Skin shiny and follicular opening absent
•  Signs of inflammation visible, i.e., papules, pustules, scaling, hyperpigmentation
•  Scarring absent
•  Hair follicles not destroyed, so generally reversible
•  Follicular opening visible
•  Absent
    1. Telogen Effluvium
    2. Post-Partum
    3. Severe Illness
    4. Major Operations
      1. Malnutrition
        Anagen Effluvium e.g. chemotherapy
      2. Male Pattern Baldness [Androgenetic alopecia]
      3. Female Pattern Baldness
      4. Diffuse Alopecia Areata
      5. Drugs e.g. heparin, antithyroid drugs, etretinate, isotretinoin, steroids
      6. Systemic Disease e.g. iron deficiency, thyroid disease, secondary syphilis, SLE
      7. Ageing: usually causes thinning of hairs
Causes of Scarring alopecia (Cicatricial alopecia)
Primary cutaneous disorders Systemic disorders
•  Cutaneous lupus (DLE)
•  Lichen planus
•  Folliculitis decalvans
•  Linear scleroderma (Morphea)
•  Lupus vulgaris
•  Leprosy
•  Injury, bums, radiation
•  Central centrifugal cicatracial alopecia
•  Alopecia cutis
•  Congenital atrictia
•  SLE
•  Sarcoidosis
•  Cutaneous metastasis

  1. Telogen Effluvium
    1. When a severe insult striking our bodies (severe infection, delivery, major operation) the anagen hairs (> 90% of hair population) will all simultaneously shift to telogen phase.
    2. As a result, about 3 months after the insult, more than 35% of the hairs will fall off at the same time giving rise to the condition which is called telogen effluvium. (Rarely goes beyond 50%).
    3. The diagnosis can be made from a detailed history of the past health. In case when the diagnosis is in doubt, it can be confirmed by the telogen hair count test. It is done by plucking a bundle of hairs and counting for the percentage of telogen hairs present.
    4. Normally, the telogen hair count should not exceed 10% of the total hair count. Unfortunately, this test is not available in most centres.
    5. For telogen effluvium, no specific treatment is needed since spontaneous remission is the rule.
  2. Anagen Effluvium: Chemotherapy attacks the rapidly dividing cells i.e. anagen hairs. As a result, more than 90% of hairs fall off soon after chemotherapy. Usually, there is no problem with the diagnosis since it is obvious from the history.
  3. Male Pattern Baldness (Androgenetic Alopecia)
    1. Pathogenesis : Even though the exact aetiology is unknown, there are proofs that genetic factor, as evidenced by frequent positive family history, and androgen play an important role in the development of the disease. Eunuchs and castrated males never develop baldness.
    2. Under the influence of androgen in a genetically predisposed person, the terminal hairs are gradually transforming into vellus hairs and they eventually fall off.
    3. Clinical Features : Typically, it starts off with bitemporal recession and subsequently, thinning or complete loss of hair at the crown. Hair on the occiput and around the sides of the scalp is seldom affected and it seems that hair in those areas are more resistant to the effect of androgen.
    4. The diagnosis can often be made by the characteristic pattern of hair loss and the frequently presence of a positive family history.
    5. Grading in females- LUDWIG & Olsen SCALE
  4. Treatment
    1. No good treatment is available at present.
    2. Topical minoxidil may be useful in minority of cases but the effect disappears soon after stopping the treatment and yet it is expensive. It is the only FDA approved drug at presence for the treatment of androgenetic alopecia.
    3. Finasteride 1mg.
    4. Hair Transplant: based on donor dominance theory which states that hairs from growing areas will survive and grow when transplanted to bald areas. The operation is tedious and requires expertise.
    5. Wigs: quite practical if it is acceptable by the patient.
  5. Female Pattern Baldness
    1. It is characterized by thinning of hairs at the crown or a diffuse hair loss. Unlike male pattern baldness, there is no bitemporal and frontal recession.
    2. If female pattern baldness occurring in a young female, especially with the presence of menstrual disturbance, signs of hirsutism or virilization, excessive androgen activity needs to be excluded e.g. androgen-secreting tumour.
    3. Treatment is difficult but one may try cyproterone acetate which is an anti-androgen.
  6. Treatment of Androgenetic Alopecia
    1. Therapeutic Option in Males
    2. Topical minoxidil 2%,5%(US FDA approved)
    3. Oral finasteride 1mg(US FDA approved)
    4. 2% ketoconazole shampoo
    5. Topical tretinoin
    6. Combination treatment of finasteride and topical minoxidil
  7. Causes of Patchy Alopecia Without Scarring
    1. Alopecia areata/totalis/universalis    
    2. Trichotillomania
    3. Traction alopecia                  
    4. Tinea capitis (excluding favus)
  8. Alopecia Areata/Totalis/Universalis: These 3 conditions all belong to a spectrum of the same disease. They only differ in the degree of severity. When all the scalp hair is lost, it is called alopecia totalis. If both scalp and body hair are involved, it becomes alopecia universalis.
    Alopecia areata is the commonest cause of patchy alopecia.
    1. Aetiology: The exact aetiology is unknown. Genetic factor and atopy play some role as some patients may have positive family history or history of atopy.
    2. It is considered as a kind of autoimmune disease since it has an association with other organ-specific autoimmune disease (e.g. Vitiligo, Hashimoto thyroiditis).
    3. The incidence of alopecia areata is high in patients with Down's syndrome and those who are under stress.
  9. Clinical Features
    1. The disease affects male and female equally at all age. It is presented as discrete patches of baldness with no scarring and no sign of inflammation.
    2. Broken hairs with tapering shafts (i.e. exclamation mark hairs) are diagnostic.
    3. Nail pitting may also be present.
  10. Treatment
    1. Local Steroid
      1. Topical Steroid e.g. 0.025% fluocinolone, halometasone
      2. Intralesional Steroid e.g. triamcinolone  These treatment modalities may be useful in dealing with localized disease.
    2. Irritants or Contact Sensitizers e.g. dithranol, diphencyprone. DNCB is no longer recommended because of its carcinogenic potential.
    3. PUVA/UVB: May show response in some cases but need many treatment sessions. The actual beneficial effect is controversial.
    4. Topical minoxidil: effect is doubtful.
    5. Oral prednisolone: it is effective in some cases but has to be reserved for resistant or severe cases (e.g. alopecia universalis or alopecia totalis) because of its potential side effects.
    6. SADBE (Squaric acid dibutyl ester)
    7. Wigs wearing: last solution.

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