Hair Loss: Common Causes and Treatment

 

Am Fam Physician. 2017 Sep 15;96(6):371-378.

  Patient information: See related handout on hair loss.

Author disclosure: No relevant financial affiliations.

Hair loss is often distressing and can have a significant effect on the patient's quality of life. Patients may present to their family physician first with diffuse or patchy hair loss. Scarring alopecia is best evaluated by a dermatologist. Nonscarring alopecias can be readily diagnosed and treated in the family physician's office. Androgenetic alopecia can be diagnosed clinically and treated with minoxidil. Alopecia areata is diagnosed by typical patches of hair loss and is self-limited. Tinea capitis causes patches of alopecia that may be erythematous and scaly and must be treated systemically. Telogen effluvium is a nonscarring, noninflammatory alopecia of relatively sudden onset caused by physiologic or emotional stress. Once the precipitating cause is removed, the hair typically will regrow. Trichotillomania is an impulse-control disorder; treatment is aimed at controlling the underlying psychiatric condition. Trichorrhexis nodosa occurs when hairs break secondary to trauma and is often a result of hair styling or overuse of hair products. Anagen effluvium is the abnormal diffuse loss of hair during the growth phase caused by an event that impairs the mitotic activity of the hair follicle, most commonly chemotherapy. Physician support is especially important for patients in this situation.

Patients with hair loss will often consult their family physician first. Hair loss is not life threatening, but it is distressing and significantly affects the patient's quality of life. The pattern of hair loss may be obvious, such as the bald patches that occur in alopecia areata, or more subtle, such as the diffuse hair loss that occurs in telogen effluvium. As with most conditions, the physician should begin the evaluation with a detailed history and physical examination. It is helpful to determine whether the hair loss is nonscarring (also called noncicatricial), which is reversible, or scarring (also called cicatricial), which is permanent. Scarring alopecia is rare and has various etiologies, including autoimmune diseases such as discoid lupus erythematosus. If the follicular orifices are absent, the alopecia is probably scarring; these patients should be referred to a dermatologist. This article will discuss approaches to nonscarring causes of alopecia.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Topical minoxidil is safe and effective for the treatment of androgenetic alopecia in women.

B

5

Alopecia areata can be treated with intralesional corticosteroids.

B

11

Oral terbinafine (Lamisil), itraconazole (Sporanox), fluconazole (Diflucan), or griseofulvin is recommended for treatment of children with tinea capitis caused by Trichophyton infections.

B

2

Cognitive behavior therapy is effective for the treatment of trichotillomania, and medical therapy may be more effective when combined with cognitive behavior therapy.

B

19


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Topical minoxidil is safe and effective for the treatment of androgenetic alopecia in women.

B

5

Alopecia areata can be treated with intralesional corticosteroids.

B

11

Oral terbinafine (Lamisil), itraconazole (Sporanox), fluconazole (Diflucan), or griseofulvin is recommended for treatment of children with tinea capitis caused by Trichophyton infections.

B

2

Cognitive behavior therapy is effective for the treatment of trichotillomania, and medical therapy may be more effective when combined with cognitive behavior therapy.

B

19


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Physiology of Hair Growth

Hair grows in three phases: anagen (active growing, about 90 % of hairs), catagen (degeneration, less than 10% of hairs) and telogen (resting, 5% to 10% of hairs). Hair is shed during the telogen phase.

Approach to the Patient with Nonscarring Alopecia

The history and physical examination are often sufficient to determine a specific etiology for hair loss. It is convenient to

The Authors

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T. GRANT PHILLIPS, MD, is the associate director of resident education for the Washington (Pa.) Health Systems Family Medicine Residency Program....

W. PAUL SLOMIANY, MD, is the associate program director for the Washington Health Systems Family Medicine Residency Program.

ROBERT ALLISON, DO, is a clinical instructor for the Washington Health Systems Family Medicine Residency Program.

Address correspondence to T. Grant Phillips, MD, Washington Health Systems Family Medicine Residency, 95 Leonard Ave., Washington, PA 15304 (e-mail: tphillips@whs.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

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