Alopecia 2024 Pre-lecture.pdf

Alopecia Presented by Daisy Cheung The University of Sydney Case Study A female in her 30’s visits your pharmacy, wearing a cap. She is pushing a pram with her 3-month old infant inside. She is seeking your advice regarding her recent h...

Alopecia Presented by Daisy Cheung The University of Sydney Case Study A female in her 30’s visits your pharmacy, wearing a cap. She is pushing a pram with her 3-month old infant inside. She is seeking your advice regarding her recent hair loss. She tells you that she’s finding hair everywhere on the floor and when she brushes her hair daily, the bristles pull out a whole clump of hair. When she washes her hair, she finds bunches of hair in between her fingers that’s fallen off her head and the drain is covered with hair. This has never happened before and she’s normally healthy with no medical conditions and doesn’t take any medications. The hair loss has been happening for at least a week now and she is starting to get a bit worried that something’s wrong with her and that she’s going to go bald. The University of Sydney Page 2 Case Study continued… You ask her if she would like to go to a private consulting room and if she could show you her scalp, she doesn’t want to. Instead, she shows you these photos on her phone. The University of Sydney Page 3 Case study continued… – What condition does the woman have? – What do you think might be the cause? – What is the management/treatment for this type of condition? – What counselling points can you give to the woman? Let’s find out. The University of Sydney Page 4 Learning Outcomes – Identify different stages of the hair growth cycle – Define alopecia – Identify and understand the different types of alopecia – Understand the pathophysiology of different types of alopecia – Determine the appropriate management and treatment of different types of alopecia The University of Sydney Page 5 Hair Growth Cycle Image: Griffin, D. (2020). Your Hair Growth Cycle. Retrieved from https://hairrestorationphilly.com/growth-cycle/ The University of Sydney Page 6 Definition Alopecia is the absence of hair from an area in which it normally grows Hair Loss Disorders 1. Patterned alopecia e.g. androgenic or androgenetic alopecia (male and female pattern hair loss) 2. Diffuse alopecia e.g. telogen effluvium, anagen effluvium 3. Localised/patchy e.g. alopecia areata, tinea capitis, some scarring alopecias Rutter, P., & Newby, D. (2020). Community pharmacy : symptoms, diagnosis and treatment (4e. Australian and New Zealand edition. ed.). Chatswood, NSW: Elsevier Australia 1. Dermatology: Hair loss disorders [Internet]. Therapeutic Guidelines Limited. 2024. Available from: https://www.tg.org.au. The University of Sydney Page 7 Diagnosis History taking and physical examination: – Age of onset of hair loss – Temporal relationship of onset to a physiologic or psychosocial stressor – Visible shedding vs. no significant shedding – Anatomic location/s of hair thinning – Duration of hair loss – Usual hairstyle or hair care practices – Scalp discomfort – Medical history and review of symptoms – Family medical history Rutter, P., & Newby, D. (2020). Community pharmacy : symptoms, diagnosis and treatment (4e. Australian and New Zealand edition. ed.). Chatswood, NSW: Elsevier Australia. The University of Sydney Page 8  Androgenic Alopecia: Female Pattern Hair Loss (FPHL) - Around 40% of women by age 50 show signs of hair loss - Less than 45% of women reach the age of 80 with a full head of hair - Less likely to affect Asian women compared with Caucasian women Cause: - Strong genetic predisposition - Role of androgen is uncertain, majority of women have normal levels of androgens in bloodstream - Role of oestrogen is uncertain Rutter, P., & Newby, D. (2020). Community pharmacy : symptoms, diagnosis and treatment (4e. Australian and New Zealand edition. ed.). Chatswood, NSW: Elsevier Australia. The University of Sydney Page 9 Yip, L. (2024). Female pattern hair loss. Retrieved from https://dermnetnz.org/topics/female-pattern-hair-loss Female Pattern Hair Loss Presentation: diffused thinning, widened part line on the crown, smaller ponytail volume, frontal hairline is more sparse, episodic bursts of excessive hair shedding Ludwig and Savin Scale Therapeutic guidelines : dermatology. (2024). (Version 4. ed.). West Melbourne, Vic: Therapeutic Guidelines Limited. Image: Clinic, U. H. (2022). Female pattern baldness. Retrieved from https://www.ultrahairclinic.co.uk/hairloss-types/female-pattern-baldness/ The University of Sydney Page 10 Androgenic Alopecia: Male Pattern Baldness - Affects nearly all men at some point in their lives - Caucasians experience some degree of hair loss by age 50, 80% by age of 70 - Japanese and Chinese far less affected Cause: - Genetic predisposition - Direct effect of androgen on hair follicle Pathophysiology: 1. Testosterone is metabolised by action of 5α-reductase to dihydrotestosterone (DHT) 2. DHT binds to androgen receptors in hair follicles 3. DHT activates genes that shortens the growth/anagen phase to weeks to months 4. Leads to follicular miniaturisation of hair follicles to produce fewer and finer hairs Yip, L. (2024). Female pattern hair loss. Retrieved from https://dermnetnz.org/topics/female-pattern-hair-loss Rutter, P., & Newby, D. (2020). Community pharmacy : symptoms, diagnosis and treatment (4e. Australian and New Zealand edition. ed.). Chatswood, NSW: Elsevier Australia. Image: Capillus. (2022). HOW DOES HAIR LOSS OCCUR? Retrieved from https://www.capillus.com/pages/how-does-hair-loss-occur The University of Sydney Page 11 Male Pattern Hair Loss – Presentation: receding hairline on both temples, advances to baldness on the scalp vertex – Hamilton-Norwood Scale Therapeutic guidelines : dermatology. (2024). (Version 4. ed.). West Melbourne, Vic: Therapeutic Guidelines Limited. Image: UpToDate. (2022). Hamilton-Norwood scale for male androgenetic alopecia. Retrieved from https://www.uptodate.com/contents/image/print?imageKey=DERM%2F86709 The University of Sydney Page 12 Examples Image source: https://www.lordhair.com/blog/15-celebrities-hair-loss-baldness The University of Sydney https://www.businessinsider.com/why-did-prince-william-shave-his-balding-head-2018- Page 13 1 Androgenic Alopecia: Treatment Overview – Does not need treatment – Cosmetic reasons – Treatment choice based on patient preference, side effects, cost and likely concordance with therapy – Aim: slow down further hair loss and stimulate regrowth – Most treatments take 6-12 months to show an effect – Need to continue treatment for years or indefinitely – Counselling required to have realistic expectations of therapy Dermatology: Hair loss disorders [Internet]. Therapeutic Guidelines Limited. 2024. Available from: https://www.tg.org.au. The University of Sydney Page 14 Androgenic Alopecia: Topical Treatment Minoxidil – Exact mechanism of action unknown – Vasodilator that increases the duration of anagen, shortening telogen, and enlarging miniaturized follicles Minoxidil 5% foam 1g Topically to the (approximately half a scalp to cover capful) sparse areas OR TWICE daily for at Minoxidil 5% lotion 1 mL least 6-12 months Dermatology: Hair loss disorders [Internet]. Therapeutic Guidelines Limited. 2024. Available from: https://www.tg.org.au. The University of Sydney Page 15 Regaine Australian Product Information. (2024). Johnson & Johnson Pacific Image: Regaine Products. (2024). Retrieved from https://www.regaine.com.au/products Counselling Points for Minoxidil – Apply to dry scalp – Apply twice a day (as per PI) – Maximum dose 2mL/day – A temporary increase in hair shedding may occur within the first 2 to 6 weeks of treatment – At least 4 months before evidence of hair regrowth – Common S/E: local erythema, itching, dry skin/scalp flaking – Rare cases of hypertrichosis Regaine Australian Product Information. (2021). Johnson & Johnson Pacific The University of Sydney Page 16 Counselling Points for Minoxidil continued – Solution must remain in contact with scalp for up to 4 hours – Do not use hairdryer as it will decrease effectiveness of solution – Allow 1 hour before covering the head with any protective headgear e.g. wig, scarf, hat – Do not use in pregnancy or breastfeeding – Following discontinuation, relapse will occur within 3 to 4 months – Stop treatment if hair regrowth not evident after 6 months of treatment Regaine Australian Product Information. (2021). Johnson & Johnson Pacific The University of Sydney Page 17 Androgenic Alopecia: Male Specific Treatment – 5α-reductase inhibitor Finasteride 1mg orally, once daily – Inhibits conversion of OR testosterone to DHT and inhibits follicular Finasteride 5mg orally, once a week miniaturisation Counselling: – Continuous treatment is required to maintain response – Maximum improvement seen within 1-2 years – Low risk of sexual dysfunction e.g. erectile dysfunction, reduced libido – Generally not all hair loss is recovered – Stop treatment if no benefit by 12 months Australian medicines handbook [Internet]. Adelaide: Australian Medicines Handbook Pty Ltd. 2024. Available from: https://amhonline.amh.net.au/. Dermatology: Hair loss disorders [Internet]. Therapeutic Guidelines Limited. 2024. Available from: https://www.tg.org.au. The University of Sydney Page 18 Androgenic Alopecia: Female Specific Treatment Spironolactone 50 to 100 mg, once daily, increasing to 200mg daily if no benefit is apparent after 6-12 months – Aldosterone antagonist- competitively blocks androgen receptors and inhibits androgen synthesis Counselling: – Contraindicated in pregnancy – S/E: dizziness, diuresis, irregular menstrual bleeding, postmenstrual spotting, breast tenderness or lumpiness – Baseline monitoring: blood pressure, kidney function, liver biochemistry before starting treatment then every 6-12 months Australian medicines handbook [Internet]. Adelaide: Australian Medicines Handbook Pty Ltd. 2024. Available from: https://amhonline.amh.net.au/. Dermatology: Hair loss disorders [Internet]. Therapeutic Guidelines Limited. 2024. Available from: https://www.tg.org.au. The University of Sydney Page 19 Telogen Effluvium Definition: – Reactive hair condition that causes excessive hair shedding – Anagen prematurely terminated by a triggering event (physiologic event or psychosocial stressor) and a large number of hair follicles enter telogen rest phase – Does not cause baldness – Acute or chronic Rutter, P., & Newby, D. (2020). Community pharmacy : symptoms, diagnosis and treatment (4e. Australian and New Zealand edition. ed.). Chatswood, NSW: Elsevier Australia. Therapeutic guidelines : dermatology. (2024). (Version 4. ed.). West Melbourne, Vic: Therapeutic Guidelines Limited. The University of Sydney Images: Chang, F.-L. C. (2019). Telogen effluvium. Retrieved from https://dermnetnz.org/topics/telogen-effluvium Page 20 Acute Telogen Effluvium – Occurs 3 months after a trigger – Examples: childbirth, acute severe illness, major surgery, crash dieting, sudden weight loss, starting a new drug, changing or stopping an oral contraceptive – Patients shedding their hair "in clumps" – If trigger known, no treatment needed, reassure patient that shedding should resolve within 6-9 months Therapeutic guidelines : dermatology. (2024). (Version 4. ed.). West Melbourne, Vic: Therapeutic Guidelines Limited. The University of Sydney Page 21 Chronic Telogen Effluvium – Excessive hair shedding lasting more than 6 months – Typical patient is female patient 30 to 50 years old with long hair – May overlap with female pattern hair loss – Most cases idiopathic Causes: Metabolic disorders e.g. thyroid disease, severe liver or kidney impairment Malnutrition e.g. severe iron deficiency, severe zinc deficiency Drugs e.g. ACEI, antidepressants, antiepileptics, ß-blockers, COCPs, statins, retinoids, warfarin Severe infections Therapeutic guidelines : dermatology. (2024). (Version 4. ed.). West Melbourne, Vic: Therapeutic Guidelines Limited. The University of Sydney Page 22 Telogen Effluvium Treatment – Identify trigger – Reassure patient, wait for condition to resolve spontaneously – Gentle handling of hair, avoid over-vigorous combing/brushing – Drug therapy usually not required unless reversible underlying cause is identified (e.g. iron deficiency, thyroid disorder, drug adverse effect) – If patient motivated, can try topical minoxidil to hasten regrowth Rutter, P., & Newby, D. (2020). Community pharmacy : symptoms, diagnosis and treatment (4e. Australian and New Zealand edition. ed.). Chatswood, NSW: Elsevier Australia. Therapeutic guidelines : dermatology. (2024). (Version 4. ed.). West Melbourne, Vic: Therapeutic Guidelines Limited. The University of Sydney Page 23 Anagen Effluvium Definition: – Abrupt loss of hair from follicles in the anagen phase – Occurs 1-4 weeks after physiologic insult – Most commonly associated with chemotherapy Pathophysiology: – metabolic damage to rapidly dividing cells of growing hair shaft – Weakening/fracture near hair bulb – Entire hair shaft may be shed Cause: - Cytotoxic cancer chemotherapeutic agents - Radiation therapy Therapeutic guidelines : dermatology. (2024). (Version 4. ed.). West Melbourne, Vic: Therapeutic Guidelines Limited. The University of Sydney Images: Oakley, A. (2019). Anagen effluvium. Retrieved from https://dermnetnz.org/topics/anagen-effluvium Page 24 Alopecia Areata – A complex polygenic autoimmune disorder – Unknown environmental triggers cause its expression – Triggers signal the anagen hairs in the affected area to convert to telogen phase – Hair prematurely stops growing and sheds rapidly, causing patches of alopecia – Sudden onset over few weeks that may relapse through patient’s life Dermatology: Hair loss disorders [Internet]. Therapeutic Guidelines Limited. 2024. Available from: https://www.tg.org.au. The University of Sydney Page 25 Alopecia Areata Presentation: circular, anywhere on body (likely on scalp, eyebrows or beard) – Types/patterns of distribution: Areata: patchy areas of hair loss Ophiasis: hair loss localized to the back and sides of the scalp Sisaipho: sparing of the sides and back of the scalp Extensive: affects > 50% of scalp Totalis: total loss of scalp hair Universalis: complete loss of all body hair Therapeutic guidelines : dermatology. (2024). (Version 4. ed.). West Melbourne, Vic: Therapeutic Guidelines Limited. Images: DermNet. (2022). Alopecia areata images. Retrieved from https://dermnetnz.org/images/alopecia-areata-images The University of Sydney Page 26 Alopecia Areata: Treatment Aim: – Prevent patch of hair loss from expanding and to stimulate regrowth within it – Provide emotional and social support Limited hair loss of recent onset: betamethasone dipropionate 0.05% lotion Topically once or OR twice daily for mometasone furoate 0.1% lotion 3 to 4 months Rutter, P., & Newby, D. (2020). Community pharmacy : symptoms, diagnosis and treatment (4e. Australian and New Zealand edition. ed.). Chatswood, NSW: Elsevier Australia. Dermatology: Hair loss disorders [Internet]. Therapeutic Guidelines Limited. 2024. Available from: https://www.tg.org.au. The University of Sydney Page 27 Alopecia Areata: Treatment Extensive hair loss: – Refer to an expert for specialist treatment – Diphencyprone (DCP) immunotherapy – Oral corticosteroids – Immunosuppression – Psychological counselling – Camouflage options e.g. wig – Topical and oral Janus kinase (JAK) inhibitors Rutter, P., & Newby, D. (2020). Community pharmacy : symptoms, diagnosis and treatment (4e. Australian and New Zealand edition. ed.). Chatswood, NSW: Elsevier Australia. Therapeutic guidelines : dermatology. (2024). (Version 4. ed.). West Melbourne, Vic: Therapeutic Guidelines Limited. The University of Sydney Page 28 Tinea Capitis Cause: - Infection of hair shaft and follicle by dermatophytic fungi of microsporum or trichophyton genus - Spread by person-to-person contact, animal vectors, or fomites Treatment: - Eliminate infection - Terbinafine or Griseofulvin Rutter, P., & Newby, D. (2020). Community pharmacy : symptoms, diagnosis and treatment (4e. Australian and New Zealand edition. ed.). Chatswood, NSW: Elsevier Australia Images: Oakley, A. (2020). Tinea capitis. Retrieved from https://dermnetnz.org/topics/tinea-capitis The University of Sydney Page 29 Scarring Alopecia – Active scalp inflammation that leads to permanent scarring alopecia – Examples: chronic cutaneous discoid lupus erythematosus, lichen planopilaris Treatment: – Require biopsy in addition to dermatoscopy for accurate diagnosis – Need to refer – Same treatment as alopecia areata with potent topical corticosteroid while waiting for expert advice Therapeutic guidelines : dermatology. (2024). (Version 4. ed.). West Melbourne, Vic: Therapeutic Guidelines Limited. Image (L): Oakley, A. (2021). Cutaneous lupus erythematosus. Retrieved from https://dermnetnz.org/topics/cutaneous-lupus-erythematosus The University of Sydney Image (R): Dyall-Smith, D. (2022). Lichen planopilaris. Retrieved from https://dermnetnz.org/topics/lichen-planopilaris Page 30 Trichotillomania – Impulse control disorder – Mental health condition – Compulsive recurrent, irresistible urges to pull or pluck hair from scalp, eyebrows, eyelids or other parts of body – In children, resolves with age but sometimes due to stress at home or school – Treatment: Referral to child psychologist or psychiatrist Habit reversal therapy, cognitive behavioural therapy, group therapy Therapeutic guidelines : dermatology. (2024). (Version 4. ed.). West Melbourne, Vic: Therapeutic Guidelines Limited. Image: Charleson, K. (2021). What is Trichotillomania? Retrieved from https://www.verywellhealth.com/trichotillomania-hair-pulling-disorder-5089316 The University of Sydney Page 31 Case study from beginning of lecture – What condition does the woman have? – What do you think might be the cause? – What is the management/treatment for this type of condition? – What counselling points can you give to the woman? The University of Sydney Page 32  Questions? [email protected] The University of Sydney