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Alopecia

Other types of alopecia

Anagen effluvium

Source: New Hair Science (Japan Hair Science Association) p.82
1) Alopecia areata

It usually starts with one or more small, round, smooth patches (up to chicken-egg sized) on the scalp.
It can sometimes occur with many patches and can progress to total scalp hair loss or complete body hair (eyebrows, .eyelashes, beard, armpit hair, pubic hair and downy body hair) loss in some cases.

Telogen effluvium

Left) Alopecia associated with chronic scalp eczema. A lot of dry dandruff is seen.Right) Alopecia associated with atopic dermatitis
Source: New Hair Science (Japan Hair Science Association) p.103
1) Alopecia caused by contact dermatitis or chronic eczema

If eczema or dermatitis persists for a long time, inflammation can spread to hair bulbs leading to telogen effluvium in rare cases.

Seborrheic keratosis Wet and thick dandruff production is seen.
Source: New Hair Science (Japan Hair Science Association) p.105
2) Alopecia associated with seborrheic dermatitis or seborrheic keratosis

Inflammation caused by seborrheic dermatitis accompanied by increased dandruff production causes telogen effluvium.

Postpartum alopecia
A case where her hair began to fall out around at two months after childbirth.
Source: New Hair Science (Japan Hair Science Association) p.116
3) Postpartum alopecia and alopecia caused by birth control pills

It is a temporary hair loss caused by hormonal imbalances and the hair should return to its normal growth cycle around within 6 months even if left untreated.

Status in telogen effluvium hair loss
A case where her hair began to fall out three weeks after surgery.
Source: New Hair Science (Japan Hair Science Association) p.117
4) Other

Hair follicles in the growth phase rapidly enter into the resting phase due to stress (high fever caused by a disease, difficult delivery, surgery, major bleeding, psychological stress and so on) leading to hair loss.

Systemic disease-induced alopecia

A) Clinical image B) Scanning electron microscope image (×150)
C) Scanning electron microscope image (×300)
Source: New Hair Science (Japan Hair Science Association) p.118
1) Alopecia caused by malnutrition
~Alopecia caused by fasting or starvation diet, the so-called "diet"~

When restricting calories strictly for starvation or obesity therapy and if the diet method is inappropriate, nutritional intake by hair follicles will be reduced leading to thinning and lackluster hair and hair loss or hair breakage.

It was observed in a patient with Graves' disease (hyperthyroidism).
Diffuse hair loss
Source: New Hair Science (Japan Hair Science Association) p.120
2) Alopecia associated with endocrine disease

A) Hyperthyroidism (Graves' disease)

Hyperthyroidism can cause diffuse hair loss in 40% to 50% of patients with the disease. The hair loss involves the entire scalp and it is telogen effluvium. The hair begins to thin and soften. It is thought that excessive thyroid hormone secretion makes it difficult to grow a new hair in the growth phase. It is accompanied by alopecia areata in some cases.

B) Hypothyroidism

Thyroid hormones are essential for hair growth. It is thought that a lack of thyroid hormone is associated with alopecia. 30% to 70% of hair is in the resting phase; it affects the whole head diffusely. Loss of lateral one-third of eyebrows is seen as well as the decrease in armpit hair or pubic hair production.

C) Other

Hare loss rarely occurs due to hypopituitarism, hypoparathyroidism, Addison's disease (endocrine system disorder) and diabetes.

Scarring hair loss caused by scleroderma en coup de sabre
It also affects the area of eyebrows.
Source: New Hair Science (Japan Hair Science Association) p.123
3) Alopecia associated with connective tissue disease

A) Systemic erythematodes (=systemic lupus erythematosus: SLE)

The disease affects connective tissues throughout the body and occurs predominantly in young women. Fever and butterfly rash on the face are commonly seen.
It can lead to diffuse hair loss around in the frontal and lateral areas of the scalp in 20 to 70% of the patients corresponding to the disease progression (onset period of disease and exacerbation period). It is accompanied by alopecia areata in some cases.

B) Chronic discoid lupus erythematosus (DLE)

It most commonly afflicts young to middle-aged adults. It commonly presents with localized, atrophic erythematous and keratotic papules occurring on sun-exposed areas. It is accompanied by mica flakes. The most affected areas include cheeks, ear flaps, bridge of nose, upper lip, and ends of the fingers. It rarely affects the scalp leading to skin atrophy and scarring alopecia in the affected area.

C) Progressive sclerosis and scleroderma en coup de sabre

■ Progressive systemic sclerosis
It is a systemic connective tissue disease. Skin thickening starts from the distal part of the extremities spreading gradually to the central part of the body.
In patients with progressive disease, diffuse hair loss can occur.

■ Localized scleroderma
It causes one or more patches of hard skin. If it involves the frontal scalp and forehead, scarring hair loss occurs on the scalp. It is called as scleroderma en coup de sabre because it looks as if the person has been struck by a sword.

D) Other

Diffuse hair loss can be caused by Sjogren's syndrome, rheumatoid arthritis, arthropathic psoriasis and so on.

Alopecia caused by drugs (medication-induced alopecia)

Medication-induced alopecia by anticancer drugs
Left) Clinical image (at 2 weeks after drug administration)
Right) Hair begins to grow rapidly after anticancer drugs are stopped.
Source: New Hair Science (Japan Hair Science Association) p.124
1) Anticancer medications (anticancer drugs)

It causes diffuse hair loss; it occurs in several days or weeks after the use of anticancer drugs leading to severe hair loss. As it temporarily inhibits the growth phase of hair, it generally resolves after treatment is stopped.

2) Adrenocortical hormones (steroids)

Steroids are necessary for the treatment of serious illnesses. On the other hand, prolonged use of steroids can cause many side effects. One of the side effects is telogen effluvium resembling male pattern baldness. It can occur because discharge of sebum is increased due to androgenic effects. As it often affects the top of the head, it is necessary to distinguish from male pattern baldness. It is possible to distinguish from male pattern baldness because the hair remained is the same in thickness and length and no vellus hair is seen.

3) Other

As for the causes of anagen effluvium, there are reports on incidents including thallium poisoning (which inhibits keratin synthesis) and absorption of large amounts of boric acid. Regarding the causes of telogen effluvium, there are reports on the use of heparin or heparinoid (anticoagulants) and excessive intake of vitamin A.

Inflammation-induced alopecia

Alopecia caused by tinea capitis
Source: New Hair Science (Japan Hair Science Association) p.126
1) Alopecia caused by mycosis

Tinea capitis (scalp ringworm) mainly affects children and martial arts fighters. Its symptoms vary according to the type of causative organism. It causes brittle hair and breakage and looks like rice fields after harvest. A lot of tiny black dots corresponding to hair follicles may appear on the surface of the scalp. Flakes may also be seen. Trichophyton fungi infect the epidermal horny cell layer and also invade hair shafts which have the same features as horny cell layer leading to the destruction of hair shafts. This is how hair loss occurs by trichophyton fungi. The fungi invade the deeper part of the horny cell layer causing folliculitis by trichophyton fungi. When folliculitis occurs, hair follicles are destroyed leading to scarring hair loss in some cases. It is called as Celsus kerion. As trichophyton fungi can be transmitted from animals to humans, it may be necessary to perform the test and treatment for the pet if a person has a pet dog or cat. It can be treated by topical agent in mild cases, while folliculitis requires treatment with oral drugs prescribed by a dermatologist. When tinea corporis occurs on the face, it may cause folliculitis by trichophyton fungi and affect the beard area, especially lower part of the nose, which is called as sycosis trichophytica.

2) Bacterial infection-induced alopecia

Scalp folliculitis by Staphylococcus aureus or streptococci generates abscesses within the follicles leading to hair loss. It may destroy hair follicles causing scarring hair loss or keloid scars. In rare cases with chronic pyoderma of the scalp, skin abscesses may develop under the skin causing scarring alopecia in multiple sites later or keloid scars similarly.

3) Syphilitic alopecia

It is one of the symptoms seen in the 2nd period of syphilis resens. It occurs around at 5 months after infection with syphilis. Its symptoms include hair loss that can present in a diffuse pattern laterally and posteriorly. It appears as patchy "moth-eaten" alopecia. Hair loss does not spread to the top of the head. Even cuts or scrapes (cracked skin, hangnail) in the hand become infected with bacteria or viruses causing unpredictable disease, so that it is important to protect your hands.

Mechanical alopecia (traumatic alopecia)

1) Neonatal occipital alopecia

The fetus develops hair follicles around at 3 months of gestation and the hair follicles in the front and the top of the head enter into the next hair cycle at 7 to 9 months of gestation, while the hair follicles at the back of the head enter the resting phase after the baby is born. Thus, hair falls out by rubbing against a pillow. However, as hair enter the growth phase, this type of alopecia will resolve naturally.

Traction alopecia
Source: New Hair Science (Japan Hair Science Association) p.127
Trichotillomania
Left) Irregular patches and diffuse hair loss
Right) The child not only plucked his hair but also tore it.
Source: New Hair Science (Japan Hair Science Association) p.130
2) Traction alopecia

Hair may fall out by pulling force being applied for a long time such as a hair style like tight ponytail or the use of hair curlers. When stopping traction, hair begins to recover.

3) Pressure alopecia

Hair may fall out at a few days or 2 to 3 weeks after prolonged pressure on the part of the scalp for several hours. As pressure alopecia is temporary circulatory disturbance, it will resolve even if untreated.

4) Trichotillomania (hair-pulling disorder)

The word trichotillomania derives from the Greek trich- ("hair") and tillein ("to pull or pluck"), along with the suffix -mania (from mainesthai, meaning "to be mad"). It is termed as hair-pulling mania in Japanese, but it is not an official disease name. Thus, the term trichotillomania or hair-pulling disorder is used. The term hair-pulling habit is also used. People with trichotillomania look bald by pulling out their hair but trichotillomania is not automatic hair loss. However, it is alopecia caused by pulling out mechanically (traumatically) in a sense. It frequently occurs in children. Although a child is "nice, obedient, and helps with the housework" from a parent's point of view, the child suffers from strong psychological stress.
The child pulls out or tears his or her hair involuntarily and even swallows it causing hair mass in the stomach. It is a kind of "habit" which is performed involuntarily in children same as common "nail biting" or "finger sucking". However, at the same time, it is thought to be a sign of asking for help by a child who has some psychological stress and cannot understand why it occurs and moreover cannot tell anybody it. Older children or adults may do so when reading a book or being absorbed in deep thought.
Its symptoms are characterized by irregular patches that move during a short period of time. It may cause diffuse hair loss. It goes without saying that remaining hairs are terminal hairs in the growth phase (even though they are short). It affects one patch of the skin in some cases or the entire scalp in others.

Scarring alopecia (cicatricial alopecia)

Scarring hair loss due to severe burns
Skin cancer occurs.
Source: New Hair Science (Japan Hair Science Association) p.133

Because of various causes, scarring alopecia destroys the hair follicle, replace it with scar tissue, and cause permanent hair loss. Its causes include infection with trichophyton fungi or bacteria, connective tissue disease such as DLE and sclerodermic encoup de sabre, severe burns, injuries (trauma), radiation damage, folliculitis decalvans and atrophic alopecia.
A small patch of baldness is formed more frequently than expected. When finding it one day, not a few people worry about it, "Is this alopecia areata?" It is important to explain that it is just trace of folliculitis when it was small, so that it will not spread to other areas after confirming no abnormal hair loss.

Source: New Hair Science
(Japan Hair Science Association)

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