Transcript Hair Problems in Women

Hair Problems in Women
Chad Fowler, MD
5/23/05
CASE 1
A 19 yo Caucasian woman appears
distressed in the exam room. She has
difficulty expressing her presenting complaint
so she pulls back her hair to show an oval
patch of smooth, hairless skin on the back of
her head. She explains that she has been
feeling fine, but that all of a sudden her hair
fell out. She noticed clumps of hair in the
shower for the last two days. Her mother
died two months ago in a motor vehicle
accident, and she wants to know if that has
caused her hair to fall out.
CASE 1 Discussion Q’s
1. What is the condition? What confirmatory
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bedside observations might help?
How often is the condition seen in women at
this age, as compared to older women?
Does stress have anything to do with this
condition?
What do you tell her about the cause of this
condition?
What can she expect with regards to hair
regrowth?
What treatment, if any, would you
recommend?
Alopecia Areata
Alopecia Areata of the Beard
Alopecia Totalis
CASE 2
21 yo college student presents with hair loss. She
has a hx of anxiety and depression, and her only
current medications is Zoloft. She has a history of
excoriations and picking at her skin, and she has a
few scars on the arms. You notice that she has been
biting her nails. You ask to see her scalp, but she
wants to keep talking. She offers that her scalp
sometimes aches and itches. When she finally
permits examination, you notice a circular area of
alopecia on the vertex. The patch almost appears
tonsular (like the shaved medieval monks who had a
bald patch), but the area contains hairs of varying
length. When you look at the hairs, the ends appear
fractured (not tapered). A stubbly sensation is noted
as the hand is lightly passed over the area.
CASE 2 Discussion Q’s
1. What is the condition?
2. What would you ask next?
3. Is this condition more common in women?
4. Should your examination include anything
else?
5. What treatment would you recommend?
Trichotillamania
CASE 3
A 24 yo woman in your practice has a long-standing
hx of hypothyroidism, and has taken low dose
thyroxine (50 mcg) for years. She delivered a
beautiful baby boy 12 months ago, and she appears
very content when bringing the baby in for WCC’s.
Unfortunately, she reports that in the last two weeks
her hair has been falling out in clumps. Her shower
drain is clogged with hairs. She has felt well; her last
illness was a severe bout of the flu 2-3 months ago
(several days of high fever). She says that there is
some stress with the toddler at home, but that she
really feels OK except for her hair falling out. Her
examination reveals diffuse, uniform hair thinning
without any bald spots and without scarring.
CASE 3 Discussion Q’s
1. What is the likely cause of this sudden hair
loss? How do you explain this condition to
her.
2. What could you do in the examination room
to help confirm the diagnosis?
3. If she had experienced this two months after
delivering the baby, would your diagnosis
change? What advice would you give her if
the hair loss occurred postpartum?
4. Is any treatment advised?
CASE 4
A 46 yo woman comes in complaining of diffuse hair
loss. She is somewhat overweight, and you have
made the diagnosis of Polycystic Ovarian Syndrome
in the past. She has some facial and neck hirsuitism.
Her exam demonstrates a diffuse reduction in her
hair density over the crown and frontal scalp. She
has maintained the frontal hairline. She denies any
excess shedding or sudden hair loss; she has just
experienced a slow, steady hair loss over several
years duration.
CASE 4 Discussion Q’s
1. What is the diagnosis? Does this condition
have a counterpart in men?
2. As there is evidence of androgen excess,
what would you recommend as the
treatment for this woman? What would you
recommend if there is no clinical evidence of
androgen excess?
CASE 5
A 48 yo African American woman presents with
patchy hair loss over the temporoparietal areas of the
scalp. Her changes appear bilaterally. The hair loss
has been chronic; in fact, she can’t remember when it
has not been there. She denies any trauma, twirling
her hair, or any significant medical problems.
Examination reveals patchy, diffuse hair loss without
sharply demarcated borders. Unlike totally bald
areas of alopecia areata, she does exhibit a few
scattered hairs and in fact has small patches of
normal hair growth in the center of her involved scalp.
She just had bloodwork performed that revealed a
normal TSH, metabolic panel, sed rate, and CBC.
CASE 5 Discussion Q’s
1. What is this?
2. How do you treat it?
Traction Alopecia
Take Home Points:
 Alopecia Areata
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Autoimmune
Most get hair back (depigmented)
Alopecia Totalis (up to 20%), Aloecia
Universalis (1%)
Steroids
 Trichotillomania (TTM)
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Gentle! Avoid frontal assault. May take
multiple visits.
Not happy that they’re doing it, BUT they’re
happy when they’re doing it. Hair
pulling=stress release
Embarrassed
Cognitive Behavior Therapy/SSRI’s (Prozac)
 Telogen Effluvium
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Sudden hair loss…Hair will come back!
Anagen/Telogen
Causes: Physiologic or Metabolic stress
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Febrile illness/Viral syndrome
Major injury/surgery
ICU
Meds (coumadin, heparin, propanolol)
Pregnancy/Delivery
 Androgenic Alopecia
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Difficult to treat
Keep your eyes/ears open for AVODART
 Traction Alopecia
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Compliment, educate, spend the time with the
patient/family
Intervention
The clock is ticking…permanent damage after
1 cycle (3 months)
That’s all folks!