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  1. Cause
    The hair loss is due to self-induced twisting and pulling of hairs.
    It usually occurs in children or adolescents. It may be due to a bad habit, attention seeking or a manifestation of psychological problem.
  2. Clinical Features
    Patches of alopecia with no sign of inflammation are seen.
    Unlike alopecia areata, the margin of the lesion is less well defined and there is no exclamation mark hairs. The hair loss is never complete. Short broken hairs of varying length are characteristic.
  3. Diagnosis
    The disease can be diagnosed clinically. A detailed social and psychological history are essential.
  4. Treatment
    Often, the disease is self-limiting upon reassurance.
    Parents have to be interviewed so that the problem can be addressed. Sometimes, referring patient to clinical psychologist or psychiatrist may be helpful.
Summary of Nonscarring Alopecia
Clinical Characteristics     Pathogenesis Treatment
Telogen effluvium Diffuse shedding of normal hairs Follows either major Stress (high fever, Severe infection or Change in hormones (post-partum) Reversible without treatment Stress causes the normally asynchronous growth cycles of individual hairs to become synchronous; therefore, large numbers of growing (anagen) hairs simultaneously enter the dying (telogen) phase Observation; discontinue any drugs that have alopecia as a side effect; must exclude underlying metabolic causes, e.g., hypothyroidism, hyperthyroidism
Androgenetic alopecia Miniaturization of hairs along the midline of the scalp Recession of the Anterior scalp line in men and some women Increased sensitivity of affected hairs to the effects of testosterone Increased levels of circulating androgens (ovarian or adrenal source in women If no evidence of hyperandrogen state, then topical minoxidil ± tretnoin; finasteride; hair transplant
Alopecia areata circular areas of hair Well-circumscribed, loss, 2-5 cm in diameter In extensive cases, Coalescence of lesions and/or involvement of other hair-bearing surfaces of the body Pitting of the nails The germinative zones intralesional surrounded by T lymphocytes Occasional associated diseases: hyperthyroidism, hypothyroidism, vitiligo, Down’s syndrome Topical anthralin; glucocorticoids; topical contact sensitizers
Tinea Varies from scaling With minimal hair loss To discrete patches With “black dots” (broken hairs) to boggy plaque with pustules (kerion) Invasion of hairs by dermatophytes, most commonly Trichophyton tonsurans Oral griseofulvin or terbinafine plus 2.5% selenium sulfide or ketoconazole shampoo;
Traumatic alopecia Broken hairs Irregular outline Traction with curlers, rubber bands, braiding Exposure to hear or chemicals Mechanical pulling (trichotillomania) Discontinuation of offending hair style or chemical treatments; Trichotillomania may require hair clipping and observation of shaved hairs or biopsy for diagnosis, followed by psychotherapy
  1. Causes Of Discrete Patchy Alopecia With Scarring
    1. Congenital e.g. aplasia cutis, naevus sebaceus
    2. Post-trauma e.g. burn, injury, radiotherapy
    3. Post-infection e.g. herpes zoster
    4. Inflammatory dermatosis e.g. DLE, lichen planus, morphoea: common cause of scarring alopecia
    5. Neoplasm e.g. squamous cell carcinoma of skin
    6. Idiopathic
  2. Aplasia Cutis
    This is a very rare congenital disease and the alopecia is present since birth.
  3. Naevus Sebaceus
    1. It is a kind of epidermal naevus which presents at birth as a yellowish hairless plaque on the scalp. It becomes more warty after puberty.
    2. The diagnosis can be confirmed by skin biopsy.
    3. It has potential of undergoing malignant change (e.g. basal cell carcinoma). For this reason, excision of the lesion after puberty is recommended.
  4. Inflammatory Dermatosis Causing Alopecia (Pseudopealde)
    1. DLE, lichen planus and morphoea are common causes of patchy scarring alopecia.
    2. One should examine the rest of the body to look for other sign of these 3 diseases., skin biopsy of the lesion on scalp is usually helpful.
  5. Idiopathic Scarring Alopecia (Pseudopelade)
    Occasionally, despite thorough examination and investigation, no cause can be attributed to patient's scarring alopecia. If the disease is still active, topical steroid can be tried.

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