Hair loss can range from mild hair thinning to total baldness. Hair can fall out for many different reasons. Medically, hair loss falls into several categories, including:

Telogen effluvium — This common form of hair loss happens two to three months after a major body stress, such as a prolonged illness, major surgery or serious infection. It also can happen after a sudden change in hormone levels, especially in women after childbirth. Moderate amounts of hair fall out from all parts of the scalp, and may be noticed on a pillow, in the tub or on a hairbrush. While hair on some parts of the scalp may appear thinner, it is rare to see large bald spots.

Drug side effects — Hair loss can be a side effect of certain medications, including lithium, beta-blockers, warfarin, heparin, amphetamines and levodopa (Atamet, Larodopa, Sinemet). In addition, many medications used in cancer chemotherapy — such as doxorubicin (Adriamycin) — commonly cause sudden hair loss affecting the entire head.

Symptom of a medical illness — Hair loss can be one of the symptoms of a medical illness, such as systemic lupus erythematosus, syphilis, a thyroid disorder (such as hypothyroidism or hyperthyroidism), a sex-hormone imbalance or a serious nutritional problem, especially a deficiency of protein, iron, zinc or biotin. These deficiencies are most common in people on restrictive diets or in women who have very heavy menstrual flow.

Tinea capitis (fungal infection of the scalp) — This form of patchy hair loss happens when certain types of fungi infect the scalp. This causes the hair to break off at the scalp surface and the scalp to flake or become scaly. Tinea capitis is a common form of patchy hair loss in children.

Alopecia areata — This is an autoimmune disease that causes hair to fall out in one or more small patches. The cause of this condition is unknown, although it is more common in people who have other autoimmune diseases. When the same process causes total loss of hair from the scalp it is known as alopecia totalis.

Traumatic alopecia — This form of hair loss is caused by hairdressing techniques that do one of the following: pull the hair (tight braiding or cornrowing), expose hair to extreme heat and twisting (curling iron or hot rollers) or damage the hair with strong chemicals (bleaching, hair coloring, permanent waves). In addition, some people have an uncommon psychiatric disorder (trichotillomania) in which compulsive hair pulling and twisting can cause bald spots.

Hereditary pattern baldness, or androgenetic alopecia — In men, hair loss may follow the typical male pattern (receding front hairline and/or thinning hair at the top of the head). This is the most common type of hair loss, and it can begin at any time in a man's life, even during his teen years. It usually is caused by the interaction of three factors: an inherited tendency toward baldness, male hormones and increasing age. Many women will develop some degree of female-pattern baldness. In women, thinning occurs over the entire top or crown of the scalp, sparing the front of the scalp.

                           

1. Improper hair cosmetic use or improper hair care - Many men and women use chemical treatments on their hair, including dyes, tints, bleaches, straighteners and permanent waves. These treatments rarely damage hair if they are done correctly. However, the hair can become weak and break if any of these chemicals are used too often. Hair can also break if the solution is left on too long, if two procedures are done on the same day, or if bleach is applied to previously bleached hair. If hair becomes brittle from chemical treatments, it is best to stop until the hair has grown out.
   
   
2. Diseases like diabetes, lupus and thyroid disorders can cause hair loss. Both an over-active thyroid and an under-active thyroid can cause hair loss. Your doctor can diagnosis thyroid disease with laboratory tests. Hair loss associated with thyroid disease can be reversed with proper treatment.
   
   
3. Poor nutrition. Having inadequate protein or iron in your diet or poor nourishment in other ways can cause you to experience hair loss. Fad diets, crash diets and certain illnesses, such as eating disorders, can cause poor nutrition. Inadequate protein in diet - Some people who go on crash diets that are low in protein, or have abnormal eating habits, may develop protein malnutrition. The body will save protein by shifting growing hair into the resting phase. Massive hair shedding can occur two to three months later. Hair can then be pulled out from the roots fairly easily. This condition can be reversed and prevented by eating the proper amount of protein and, when dieting, maintaining adequate protein intake.
   
   
4. Medications. Certain drugs used to treat gout, arthritis, depression, heart problems and high blood pressure may cause hair loss in some people. Taking birth control pills also may result in hair loss for some women.
   
   
5. Medical treatments. Undergoing chemotherapy or radiation therapy may cause you to develop alopecia. After your treatment ends, your hair typically begins to regrow.
   
   
6. Recent high fever, severe flu or surgery. You may notice you have less hair three to four months after events such as an illness or surgery. These conditions cause hair to shift rapidly into a resting phase (telogen effluvium), meaning you'll see less new hair growth. A normal amount of hair typically will appear after the growth phase resumes.
   
   
7. Infancy. Newborns often lose hair during the first several months of life. This baby hair (vellus) is eventually replaced by more permanent hair. It's also common for babies to lose a patch of hair on the back of their heads from rubbing against mattresses, playpens and car seats. Hair will grow back once a baby begins to spend more time sitting up.
   
   
8. Hairstyles that pull on the hair, like ponytails and braids, should not be pulled tightly and should be alternated with looser hairstyles. Constant pull causes some hair loss, especially along the sides of the scalp.
   
   
9. Shampooing, combing and brushing too often can also damage hair, causing it to break. Using a cream rinse or conditioner after shampooing will make it easier to comb and more manageable. When hair is wet, it is more fragile, so vigorous rubbing with a towel, and rough combing and brushing should be avoided. Do not follow the old rule of 100 brush strokes a day that damages hair. Instead, use wide toothed combs and brushes with smooth tips.
   
   
10. Hereditary thinning or balding - Hereditary balding or thinning is the most common cause of hair loss. The tendency can be inherited from either the mother's or father's side of the family. Women with this trait develop thin hair, but do not become completely bald. The condition is called androgenetic alopecia and it can start in the teens, twenties or thirties.
    
    
11. Alopecia areata - In this type of hair loss, hair usually falls out, resulting in totally smooth, round patches about the size of a coin or larger. It can, rarely, result in complete loss of scalp and body hair. This disease may affect children or adults of any age. The cause of alopecia areata is unknown. Apart from the hair loss, affected persons are generally in excellent health. In most cases, the hair regrows by itself. Dermatologists can treat many people with this condition. Treatments include topical medications, a special kind of light treatment, or in some cases pills.
    
    
12. Childbirth - When a woman is pregnant, more of her hair will be growing. However, after a woman delivers her baby, many hair enter the resting phase of the hair cycle. Within two to three months, some women will notice large amounts of hair coming out in their brushes and combs. This can last one to six months, but resolves completely in most cases.
    
    
13. Cancer treatments - Some cancer treatments will cause hair cells to stop dividing. Hair become thin and break off as they exit the scalp. This occurs one to three weeks after the treatment. Patients can lose up to 90 percent of their scalp hair. The hair will regrow after treatment ends. Patients may want to get wigs before treatment.
    
    
14. Birth control pills - Women who lose hair while taking birth control pills usually have an inherited tendency for hair thinning. If hair thinning occurs, a woman can consult her gynaecologist about switching to another birth control pill. When a women stops using oral contraceptives, she may notice that her hair begins shedding two or three months later. This may continue for six months when it usually stops. This is similar to hair loss after the birth of a child.
    
    
15. Low serum iron - Iron deficiency occasionally produces hair loss. Some people do not have enough iron in their diets or may not fully absorb iron. Women who have heavy menstrual periods may develop iron deficiency. Low iron can be detected by laboratory tests and can be corrected by taking iron pills.
    
    
16. Major surgery/chronic illness - Anyone who has a major operation may notice increased hair shedding within one to three months afterwards. The condition reverses itself within a few months but people who have a severe chronic illness may shed hair indefinitely.
    
    
17. Fungus infection (Ringworm) of the scalp – This is caused by a fungus infection. Ringworm (which has nothing to do with worms) begins as small patches of scaling that can spread and result in broken hair, redness, swelling, and even oozing. This contagious disease is most common in children and oral medication will cure it.
    
    
18. Hair pulling (Trichotillomania) - Children and sometimes adults will twist or pull their hair, brows or lashes until they come out. In children especially, this is often just a bad habit that gets better when the harmful effects of that habit are explained. Sometimes hair pulling can be a coping response to unpleasant stresses and occasionally is a sign of a serious problem needing the help of a mental health professional.

Who Gets Alopecia Areata?

Anyone can have alopecia areata. It often begins in childhood. There is a slightly increased risk of having the disease if you have a close family member with the disease.

What Causes Alopecia Areata?

Alopecia areata is an autoimmune disease. Normally the immune system protects the body against infection and disease. In an autoimmune disease, the body's immune system mistakenly attacks some part of your own body. In alopecia areata, the immune system attacks the hair follicles.

The cause is not known. Scientists think that a person's genes may play a role. For people whose genes put them at risk for the disease, some type of trigger starts the attack on the hair follicles. The triggers may be a virus or something in the person's environment.

Will My Hair Ever Grow Back?

There is every chance that your hair will grow back, but it may fall out again. No one can tell you when it might fall out or grow back. You may lose more hair, or your hair loss may stop. The hair you have lost may or may not grow back. Even a person who has lost all of his hair may grow all of his hair back. The disease varies from person to person.

How Is Alopecia Areata Treated?

There is no cure for alopecia areata. There are no drugs approved to treat it. Doctors may use medicines approved for other diseases to help hair grow back. Talk to your doctor about the treatment that is best for you.

The following are some treatments for alopecia areata. They may help hair grow back, but none of them prevent new patches of hair loss or cure the disease.

Corticosteroids:

Corticosteroids are drugs that reduce swelling and pain. They also affect the immune system. Corticosteroids may be given in three ways for alopecia areata:

• Injected in the skin
• Swallowed as pills
• Rubbed on the skin as a cream or ointment.

Drugs that are rubbed on the skin as a cream or lotion include:

• Minoxidil (5%)
• Anthralin
• Squaric acid dibutyl ester (SADBE) and diphenylcyclopropenone (DPCP).

Drugs that affect the immune system include:

• Sulfasalazine
• Cyclosporine.

Photochemotherapy:

In photochemotherapy, a person is given a drug called a psoralen, which is affected by light. The drug can be swallowed or rubbed on the skin. Once the drug is taken or applied, the area with hair loss is exposed to an ultraviolet light source. This combined treatment is called PUVA.

Alternative therapies:

Some people with alopecia areata try other treatments. These alternatives include acupuncture, aroma therapy, evening primrose oil, zinc and vitamin supplements, and Chinese herbs. Because many alternative therapies have not been studied in clinical trials, they may or may not help hair grow back. In fact, some may cause more hair loss. Talk with your doctor before you try alternative therapies.

How Will Alopecia Areata Affect My Life?

Alopecia areata does not make you feel pain and does not make you feel sick. You can't give it to others. People who have the disease are, for the most part, healthy in other ways. Alopecia areata will not shorten your life, and it should not affect activities such as going to school, working, marrying, raising a family, playing sports, and exercising.

How Can I Cope With the Effects of This Disease

Living with hair loss can be hard. There are many things you can do to cope with the effects of this disease, including:

• Learning as much as you can about the disease.
• Talking with others who are dealing with the disease.
• Learning to value yourself for who you are, not for how much hair you have or don't have.
• Talking with a counselor, if necessary, to help build a positive self-image.

Here are some things you can use to reduce the physical dangers or discomforts of lost hair:

• Use sunscreens for the scalp, face, and all exposed skin.
• Wear eyeglasses (or sunglasses) to protect eyes from sun, and from dust and debris, when eyebrows or eyelashes are missing.
• Wear wigs, caps, or scarves to protect the scalp from the sun and keep the head warm.
• Apply antibiotic ointment inside the nostrils to help keep germs out of the nose when nostril hair is missing.

Here are some things you can do to reduce the disease's effects on your looks:

• Try wearing a wig, hairpiece, scarf, or cap.
• Use a hair-colored powder, cream, or crayon applied to the scalp for small patches of hair loss to make the hair loss less obvious.
• Use an eyebrow pencil to mask missing eyebrows.

What Research Is Being Done on Alopecia Areata?

Researchers are seeking a better understanding of the disease. Scientists are studying:

• Genes
• Hair follicle development
• The immune system
• Drugs and treatments for other autoimmune diseases like rheumatoid arthritis and lupus
• Better ways to get drugs directly to the hair follicles
• Stem cells in the skin.

We are proud to present the Zamacona video production, "Cicatricial Alopecia," the world's first educational media presentation to serve individuals with cicatricial alopecia, the medical community and the general public. This unique and moving video gives actual documentation by patients and offers current medical information and important references that furnish a better understanding of these disorders. It gives hope that one day there will be a cure and better treatments for this poorly understood group of diseases.

The Cicatricial Alopecia Research Foundation (C.A.R.F.) was formed as a result of one person's experience with scarring alopecia (cicatricial means scarring). When the patient realized that little is known about such disorders, she decided, with the help of her doctor, to initiate a grass roots effort to raise funds to study these problems.

C.A.R.F. began raising money with the following mission in mind:

• to provide funds for research to find effective treatments and a cure
• to support education and advocacy
• to raise public awareness

Hair changes, including thinning, color loss, dryness, changes in texture, and hair loss, are common features of autoimmune disease. Of these, hair loss can be the most devastating. Overall, hair loss can have many medical causes including hormonal imbalances, medication effects, and autoimmune diseases. Among the autoimmune diseases that cause hair loss or baldness, aleopcia areata is the most common. Alopecia areata may affect small localized scalp patches (alopecia areata molocularis) or it may affect the entire body (alopecia areata universalis). Treatment is available for alopecia areata although, in general, the more hair lost, the less successful the treatment will be.

Other autoimmune conditions in which localized or diffuse hair loss (cicatricial alopecia) can occur include: systemic lupus erythematosus (SLE), Hashimoto's thyroiditis, Graves' disease, central centrifugal cicatricial alopecia, and postmenopausal frontal fibrosing alopesia. In systemic lupus malar rash can cause scarring of the scalp that leads to permanent hair loss. Hashimoto's thyroiditis causes hair to coarsen and become dry, contributing to hair loss, which is seen in more than 50 percent of patients. In Graves' disease, hair tends to become fine and brittle with a reluctance to hold curl and a tendency towards hair loss. Hair loss is reported in 20-40 percent of patients with Graves' disease.

Besides the abovementioned conditions, hair loss can occur in nearly every autoimmune disease, especially conditions in which oral corticosteroids are the mainstay of treatment. Hair loss is one of the undesirable side effects associated with the use of prednisone. Chemotherapeutic agents, such as methotrexate, used in many of the systemic rheumatic conditions, can also cause hair loss. Hair loss is also caused by the following drugs: cimetidine (Tagamet), ranitidine (Zantac), coumadin, heparin, allopurinol for gout, penicillamine, indomethacin, naproxen, isotretinoin, trimethadione, tricyclic antidepressants, atenolol, metoprolol, naldolol, propranolol, timolol, levodopa, and clofibrate.

In vitiligo, autoantibodies that destroy melanin cause pigment loss in both the skin and hair. Conditions affecting hair usually affect the skin in a similar fashion. For instance, the skin in hypothyroidism tends to become thick and dry, and in hyperthyroidism it becomes thin and moist. In patients with relapsing polychronditis, antibodies to cartilage proteins may contribute to hair loss and well as joint damage.

Cartilage hair hypoplasia is a rare autosomal recessive disorder causing short-limbed dwarfism and fine fragile hair, with a tendency toward hair loss. Cartilage hair hypoplasia has been reported in conditions of idiopathic thrombocytopenic purpura and autoimmune hemolytic anemia.

TREATMENT

In endocrine disorders, correcting the hormone imbalance helps restore hair growth and improve its texture. Hair growth also responds to dietary changes. In particular, adding high quality protein to the diet can help restore hair growth. When hair loss suddenly increases it can reflect inadequate dietary protein or malabsorption, a condition of poor nutrient absorption from dietary sources. Malabsorption is common in thyroid disorders, Crohn's disease, pernicious anemia, and celiac disease.

A nutrient-rich diet with adequate protein and dietary supplements, particularly vitamin B complex, can help promote hair growth. Biotin promotes hair and scalp health and can help prevent hair loss. Excellent sources of biotin include nuts, brown rice, brewer's yeast and oats. Iron deficiency (confirmed by blood tests) can also cause hair loss and restoring iron levels can reverse hair loss. Foods rich in iron include green leafy vegetables, leeks, cashews, berries, dried fruits and figs. Vitamin C is necessary for iron absorption. Eating citrus foods after an iron-rich meal helps absorption. Vitamin E, zinc, methylsulfonylmethane (MSM), and essential fatty acids, such as flaxseed and fish oils, are also important for hair growth. A greens formula containing chlorella, spirulina, barley and wheatgrass also promotes hair growth.

The drugs minoxidil (Rogaine) and finasteride (Proscar) promote hair growth in some patients. Proscar is also reported to stop hair loss. Rogaine is applied topically and finasteride is taken orally, using 1 mg daily. Other topical hair stimulators include the oxygen radical scavenger, superoxide dismustase (SOD) Surgical procedures include hair transplantation and scalp reduction. Dr. Peter Proctor's Hair Regrowth Shampoo is reported in Life Extension to be superior to Rogaine and the only FDA-approved hair-treatment product on the market. A world-renowned expert on balding, Dr. Proctor has developed several preparations for restoring hair growth. Rosemary essential oil used as a scalp massage ingredient or added to shampoo can help hair growth by improving the scalp circulation.

Antibiotics such as co-trimoxazole and sulfasalazine help restore autoimmune hair loss in alopecia by inhibiting nuclear factor beta signaling activation, which contributes to anti-inflammatory and immunosuppressive effects.

In his book on Natural Healing, Gary Null reports experiencing regrowth of hair following the use of colonics. He attributes this to increased absorption of nutrients including chlorophyll in green juices. Other recommendations for hair growth include aromatherapy, Bach flower remedies, homeopathic preparations, particularly Natrum muriaticum and silicea, and stress reduction techniques.

Los Angeles, California, June 21^st, 2008 –Richard Farrell, owner of Farrell Hair Replacement announced today that he is adding an extra stop on his personal design tour. Richard will be at his Hair Salon & Production Center Los Angeles, CA on June 27^th and 28^th.

The Farrell Los Angeles location (which is conveniently located at 5059 W. Pico Boulevard, Los Angeles, CA 90019) has an artistic factory/loft type atmosphere dedicated to hair system perfection. The trendy location is dedicated to making Farrell Hair clients feel comfortable and cared for, Richard went on to say that “along with our very private salon rooms and our plush consultation area, one just can’t help but feel relaxed when they come in for a no cost/no obligation consultation”.

Richard Farrell who is always striving for completely undetectable and natural looking hair systems says: “Hair systems need to be produced under watchful eyes.” And no one is more precise in Hair system making than Richard Farrell himself.

The Farrell Los Angeles personal design tour is scheduled for June 27^th and June 28^th, since this is only a 2 day tour Richard has added a free registration page on his website where anyone can set their own appointment to see Richard in person. All of this and the Los Angeles appointment page are all posted on Richard’s website at: http://www.farrellhair.com/meetrichardcut.asp.

The Hair...
What do people look at first? The Hair... Is your real hair fine & limp? Well, that is the type of hair that needs to be on your hair replacement system. 99% of the companies who want to sell you a system buy inexpensive systems for overseas factories that produce their systems with Indian or Asian hair. If you want beautiful, natural looking hair, Farrell Hair Replacement will make your hair system with hair that matches your own hair texture, behaviors and characteristics.

The Front Hairline...
Not all women want to wear their hair with bangs on their forehead. With most factory hair systems you will be condemned to wearing bangs because those bangs are necessary in order to cover a thick base which could never pass for a natural hairline. Farrell hair systems are renown for their undetectable hairlines. Our hairlines can be brushed straight back from your hairline - exposing your hairline - enabling you to create most of today's fashionable hairstyles.

The Side Hairline...
This area is very important. Women might want to brush their hair back into a ponytail. With a Farrell system you will be able to wear many hairstyles which are brushed, pinned or clipped back from the face.

Hair Density...
If hair is too dense it simply has no room to move into certain hairstyles. When other companies use their thinning shear in order to adjust the density of a factory system they lose the scalp-like appearance that the system should have. A system needs to be made with approximately the same amount of hair tied into the base as the hair you have in the area that the system will be placed against. This is necessary because an undetectable hair replacement system requires that a certain amount of scalp be seen through the hair system.

The Right Base Material...
We at Farrell Hair Replacement custom make all of our own systems which allow us to offer you many options in regard to base materials or combinations of materials. Each material has plusses and minuses which we can discuss during your consultation.

Breathability & Washability...
I believe in designing and producing systems for women that breathe. Today's women are very active. So, whether you are training for a triathlon or jogging on a treadmill, your system must be as breathable as you own hair. Farrell system can be shampooed in the shower, worn in a pool or a hot tub. When you are laying on a chaise lounge by a hotel pool it should look as good as growing hair would when damp or wet. Only at Farrell will you find hair with these characteristics.

Lightweight...
Base materials need to be thin and lightweight. If they are too thin they can wear out quickly. If they are too thick then they are too detectable to the touch. We will help you choose base materials that make sense for you and will give you the longevity you might expect from Farrell Hair Replacement systems. Our systems for women are ultra custom, comfortable and undetectable to both sight and touch in most situations.

The registry has been established by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the National Institutes of Health (NIH). The new registry will be located at the University of Texas M.D. Anderson Cancer Center in Houston, with affiliated centers at UCSF, the University of Colorado, University of Minnesota, and Columbia University.

Vera H. Price, MD, professor of clinical dermatology, is the UCSF collaborator for the national project.

Alopecia areata is an autoimmune disease, one in which the body's natural defense system attacks healthy cells. In alopecia areata, the target of the attack is the hair follicle, and the result is hair loss ranging from patchy baldness to complete loss of all scalp and body hair. It affects both males and females of all races, and often begins in childhood. There is no known permanent cure.

Registry scientists will seek out and classify medical and family history data for patients with three major forms of alopecia areata: alopecia areata (patchy scalp hair loss); alopecia totalis (100 percent scalp hair loss); and alopecia universalis (100 percent scalp and 100 percent body hair loss). Families with multiple affected members will be especially helpful to further research studies. The project will offer a future central information source where researchers can obtain statistical data associated with the disease. A website is currently being developed for the registry.

The registry will serve as a liaison between affected families and investigators interested in studying this disorder. Scientists hope the registry will be useful in locating the gene or genes associated with alopecia areata. It will also link patients with other researchers studying the cause or treatment of this disease.

1. Scalp exam for any scars, erythema, scaling, or inflammation Density and distribution of hair Hair shaft exam for caliber, length, shape, and fragility Thyroid palpation to determine thyroid size, nodularity, or vascularity

If a patient demonstrates positive hair-pull tests all over the scalp, he/she may be warned he/she will most likely lose all of their hair. Next, provide anticipatory guidance during the period of extensive hair loss as the cycle reestablishes and regrowth begins.

Finally, determine if eyebrow, eyelash, axillary, or body hair is affected. Examine hair density in other areas such as the face and extremities. A female patient who presents with thinning scalp hair and demonstrates increased facial, thigh, chin, or chest hair may have an androgen excess.

Laboratory Studies

Once other causes such as malnutrition, androgenetic, hereditary conditions (by history, progression, and presentation), trauma (trichotillomania, traction alopecia), and drugs (telogen effluvium) have been ruled out, consider labs for secondary conditions:

• For female alopecia with symptoms of hyperandrogenism (such as menstrual irregularities, infertility, cystic acne, virilization, or galactorrhea), check total testosterone, free testosterone, dehydroepiandrosterone sulfate (DHEA-S), or prolactin levels. For male and female alopecia without symptoms of hyperandrogenism, consider measurement of serum thyroid stimulating hormone concentration to rule out thyroid disease; venereal disease research laboratory (VDRL) technique to rule out syphilis; serum ferritin to rule out anemia; antinuclear antibody test (ANA), RF (rheumatoid factor) to rule out autoimmune disease; potassium hydroxide (KOH) examination to rule out tinea capitis; swab a wound culture to rule out infections; and scalp biopsy as needed to rule out neoplasm.

Disorders Causing Hair Loss in Adults

• Androgenetic alopecia
  • Male: Hereditary. Dihydrotestosterone compels follicles into perpetual telogen phase. The earlier oral or topical treatment is started, the better results one may expect. Female: Female androgenetic pattern incidence increases with age. Incidence is approximately 6% in women under 50, but increases to 38% in women over 70. Female pattern hair loss typically demonstrates a lower density of hair but maintains a relatively even distribution, known as "Ludwig" distribution. Even thinning across the crown is typical, while the frontal line maintains position.
  Telogen effluvium
  • Telogen effluvium is the most common form of diffuse alopecia. It is often diagnosed from a history of an initiating event 3 months before the onset of shedding. Causes include childbirth, sustained high fever, surgery, systemic disease exacerbation, crash low protein diets, severe emotional stress, and drug reactions. Pull tests are positive all over the scalp. Bitemporal recession is a useful diagnostic sign in women. The acute form normally subsides in 3 to 6 months. In true telogen effluvium, the hair invariably regrows within a short time.
  Postpartum telogen effluvium
  • This condition is associated with postpartum hormone-related changes that temporarily prolong hair resting phase. It is most commonly seen 2 to 4 months postpartum.
  Anagen effluvium
  • Anagen effluvium is drug or toxin-induced and may mimic diffuse alopecia areata. Chemotherapy is the most common cause.
  Trichotillomania
  • Trichotillomania is the manifestation of a psychogenic behavioral pattern of frequent hair-pulling by the patient. It is frequently related to obsessive-compulsive disorder and can be seen in males and females of all ages, but most commonly in preadolescent and early adolescent girls. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The bald area manifests as a distinct, unnatural geometric shape. Hair may be pulled from a secondary site, such as the eyelashes, eyebrows, underarms, body, or pubis. Assess for other psychosocial factors and disorders and refer for counseling as indicated. Diagnostic and Statistical Manual-IV (DSM-IV) Criteria for Trichotillomania:
    • Recurrent pulling out of one's hair, resulting in untreatable hair loss Increasing sense of tension immediately before pulling out the hair or when attempting to resist behavior Pleasure, gratification, or relief when pulling out the hair The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatologic condition).
  Alopecia areata
  • Alopecia areata is an inherited autoimmune condition of varying severity. In some patients, hair loss is confined to one or more small oval patches; in others, the scalp is essentially denuded except for a few tufts of hair. It may involve the entire scalp (alopecia totalis) or the surface of the whole body (alopecia universalis). The condition is marked by exacerbation and recovery with high variability among individuals.
  Tinea capitis
  • Tinea capitis is a contagious fungal infection of the scalp mostly seen in ages 4 to 14 years. There are fine, scaly, circumscribed areas that are frequently itchy and inflamed. Hair is dull and brittle, breaking off at scalp. In more extensive cases, there may be fever and cervical lymphadenopathy. In the United States, over 90% of cases are from the nonfluorescent Trichophyton fungus. Potassium hydroxide (KOH) examination shows hyphae. Antifungals such as terbinafine, fluconazole, itraconazole, or griseofulvin are used for treatment.
  Systemic lupus erythematosus (SLE)
  • SLE is a chronic autoimmune inflammatory disease affecting collagen. It involves multiple systems of the body including hair loss.
  Secondary syphilis
  • Secondary syphilis usually begins 2 to 8 weeks after chancre type lesions appear. It can present with patchy hair loss, mostly on the scalp and often elsewhere on the body. This hair loss is often described as having a moth-eaten appearance. High-risk clients should also be questioned regarding past rashes, especially on the palms, soles, and any chancroid lesions or condyloma. Diagnosis is serologic (VDRL or rapid plasma regain [RPR]), and hair regrowth occurs after penicillin therapy. Penicillin remains the first choice, but if an allergy exists, intramuscular Rocephin (x 10 days), tetracycline, or doxycycline may be tried for 2 weeks.
  Side effects of medications
  • Medications such as cytotoxic agents, colchicine, heparin, oral anticoagulants, hydroxyurea therapy, vitamin A, captopril, protease inhibitors such as indinavir and nelfinavir, amphetamines, anticancer agents, gout medication, isotretinoin (Accutane), lithium, male hormones, propranolol hydrochloride (Inderal), and valproic acid (Depacon, Depakene, Depakote), can all induce nonscarring hair loss.
  Birth control pills
  • Women who lose hair while taking birth control pills may have an inherited tendency for hair thinning. If hair thinning occurs, a woman can consult her gynecologist about switching to another birth control pill. When a woman stops using oral contraceptives, she may notice that her hair begins shedding two or three months later. This may continue for six months when it usually stops. This is similar to hair loss after the birth of a child.
  Caustic chemicals
  • Anyone who curls, straightens, colors, or dyes their hair may cause hair loss. Repeated exposure to these substances can injury hair follicles, weaken hair, or even damage the scalp. It is most often seen in African women, and inflammation is not always obvious.
  High fever or severe infection
  • Acute and some chronic illnesses may cause hairs to enter a prolonged resting telogen phase (also known as telogen effluvium). It is not uncommon to experience a higher incidence of hair loss up to three months after high fever, severe illness, or infection. This resting phase typically resolves after several months and normal hair growth rebounds when the growth cycle returns.
  Other causes of hair loss
  • Other causes of hair loss include anemia, hypoalbuminemia, malnutrition, Lichen planus, Staphylococcal folliculitis, scleroderma, psoriasis, seborrhoeic dermatitis, menopause, hypothyroidism, herpes zoster, and others.

Treatment Recommendations

The choice of therapeutic intervention for alopecia depends on several factors:

• The underlying cause The goals of therapy The long-term risks, benefits, costs

The evaluation and treatment of alopecia should begin as early as possible after the onset of symptoms. Many conditions causing alopecia or reduced hair density may be reversed or minimized with prompt intervention.

Pharmacologic – Treatment of the Underlying Illness

• Hypothyroidism
  • Thyroid replacement or adjustment as indicated
  Fungal infection
  • Ketoconazole, oral antifungal agents such as griseofulvin (Grifulvin), itraconazole (Sporanox), terbinafine (Lamisil), and fluconazole (Diflucan) may be used. Oral steroids may be necessary to decrease inflammation and scarring.
  Hormone imbalance
  • If female androgen excess is suspected (hirsutism, acne) or menses is irregular, check DHEA-S and free testosterone levels first to rule out adrenal or ovarian cancer. Once ruled out, consider spironolactone, flutamide, or finasteride. Spironolactone competes with testosterone and dihydrotestosterone at the androgen receptor level. Spironolactone 100 mg per day can be given in divided doses; this dose may be increased to 200 mg. Flutamide (Eulexin), an antiandrogen that blocks androgen uptake and nuclear binding, is a very effective drug in treating hyperandrogenism. Give 250 mg daily and monitor hepatotoxicity. Finasteride (Propecia) blocks the conversion of testosterone to dihydrotestosterone. The plasma levels of testosterone may increase during treatment, whereas the dihydrotestosterone level decreases. Of utmost importance, the patient should be aware that she must avoid pregnancy during treatment with finasteride because of the potential for causing ambiguous genitalia in a male fetus.
  Drug-induced hair loss (effluvium)
  • Drugs that induce hair loss include antihypertensive agents, anti-gout medications, etc. Consider tapering or discontinuing the medication if untoward risks are low.
  Chemotherapy
  • Recommend nonpharmacologic therapy (wig, hairpiece).
  Psychological causes of hair loss (Trichotillomania)
  • Consider behavioral therapy, antianxiety or antidepressant medication, or any combination of the two.
  Physical stress from surgery/acute illness
  • Reassure patient hair regrowth once stress removed.
  Lupus and diabetes
  • Treat underlying diseases.
  Traction alopecia
  • Hair loss that is secondary to grooming such as tight braids, "cornrows," pony tail: Change hair styling technique.
  Drug therapy for alopecia (alopecia with no underlying disease)
  • Minoxidil (Rogaine 2% for women, Rogaine 5% for men): Apply 1 mL twice a day (BID) regardless of the extent of the affected area; one year of use may be needed before obvious efficacy. Minoxidil is mainly for hair loss at vertex, not for frontal baldness. Propecia (finasteride 1 mg): Food and Drug Administration (FDA) approved; for MEN ONLY Monotherapy or synergistic use:
    • For women - May add estrogen to any therapy For men/women - May add tretinoin (Retin-A) topical as an adjunct/synergistically with minoxidil

Nonpharmacologic Treatment

• Cosmetic measures (hairstyle adjustments, wigs, extensions, hair pieces, hats, scarves) Cessation of wearing tight braids, buns, pins In chemical/allergic causes, avoidance of the identified sources

Monitoring Treatment/Discontinuation of Treatment

Patients with Hypothyroidism

Initiate thyroid hormone replacement therapy to obtain thyroid-stimulating hormone (TSH), triiodothyronine (T3), and thyroxine (T4) in the normal range. Treatment will be long term, even as hair regrowth occurs. Monitor hair regrowth in each follow up with hypothyroidism.

Patients Considered for Treatment Related to Fungal Infection

If long-term antifungal treatment is required, monitor liver function and gastrointestinal (GI) symptoms. Obtain baseline alanine aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin before treatment. Reevaluate in 4 to 8 weeks. Discontinue if there are any GI symptoms or signs of liver dysfunction such as fatigue, nausea, anorexia, vomiting, dark urine, or pale stools. Monitor drug interactions when patients have comorbidities and are using other medications. Check safety of different antifungals on women in childbearing ages.

Patients with Androgenetic Imbalance

Monitor hepatotoxicity if the patient is treated with flutamide. Monitor irregular menses, reduced libido, mood swings, and electrolytes if treated with spironolactone.

Patients on Medications for Hair Loss

Minoxidil (Rogaine) - Topical use

Since its mechanism of action is to stimulate hair growth by vasodilation, it may exacerbate angina pectoris. Use with caution in patients with pulmonary hypertension, congestive heart failure, coronary artery disease, and significant renal failure. Topical use may also cause pruritus, and Stevens-Johnson syndrome.

Finasteride (Propecia)

Give 1 mg daily (QD) with or without food to MALE patients only. Pregnant women or women who may potentially become pregnant should not touch crushed tablets because of teratogenic effects on male fetus. Monitor hepatic function. Potential side effects include decreased libido and erectile dysfunction.

Steroids (e.g. prednisone)

Side effects of steroids include diabetes, weight gain, hypertension, electrolyte and fluid imbalance, osteoporosis, striae, acne, renal function impairment, avascular necrosis, and immunosuppression. Abrupt discontinuation may cause adrenal crisis.

Individualization of Therapy

• The Women's Androgenetic Alopecia Quality of Life Questionnaire (WAA-QOL) is useful in evaluating health-related quality of life (HRQOL) specific to women. It is self-completed in about 10 minutes and may serve both to indicate the impact on the patient (and potential indication for intervention) and evaluate therapeutic responses to therapy. Decide whether the patients want to use topical treatment or oral treatment. Patients at different ages may have preferences. The hair growth cycle is slow. Affected changes take time to notice. Once therapy is selected, stick with it for 3 to 6 months and then reevaluate. Treatment follow-up (3- to 6-month intervals). Adjust therapy and identify causes if inadequate response.

Important Considerations

Cosmetic management and psychosocial adaption

• Regrowth of new or thicker hair for larger scalp coverage Decreased rate of hair loss (i.e., slow down balding progression) Surgical reconstruction Cost and side effects of drug therapy Tolerability of therapy (patient satisfaction with care, quality of life, and adherence to treatment regimen) Final assessment and evaluation including hair density readings Assessment of patient satisfaction as measured by quality of life index

Screening and diagnosis

Routine laboratory tests help to determine the presence of underlying causes and risk factors that would affect treatment. Optional tests may be used, depending on findings obtained in the history and physical examination and previously known conditions. A greater, more inclusive assessment can be determined by referral to dermatology.

Informed guidance to treatment options

Clinicians should begin by providing the patient with a summary of information on:

• Causes of hair loss and their respective potential to respond to medical therapies Details of what therapeutic options involve, including directions for use, potential side effects, interactions, timeline for responses, follow-up visits, financial expense, and long-term outcomes

Evaluate treatment goals

The primary objective of treatment is to reach therapeutic responses as closely to patient goals within budget and expectation that is both understood and acceptable by the informed patient. To modify drug therapy and maximize response toward patient goals, clinicians should consider cost where therapeutic effect is equal. To facilitate compliance, clinicians should choose medications with simple regimens.

Therapeutic adjustment and further individualization

• Titrate drug or add another agent if there is good tolerance but poor response. Allow for several weeks to two months before drug or dosage changes are made. If the response remains less than anticipated, substitute with a drug of a different class or action. Always consider alternative explanations for poor response to drug therapy to explore secondary causes. In each patient encounter, reassess adherence, quality of life, and patient goals. Assess the long-term response to therapy. Reassess side effects that might complicate therapy or limit efficacy. Monitor the development of target organ damage. Reinforce lifestyle modification.

Evaluate the efficacy of therapy

• To assess adequacy of hair growth, use an objective measurement tool such as a scalp chart, comparison with before-treatment photos, and a subjective self-assessment of quality of life before and after treatment. Patients should be seen within 1 or 2 months after the initiation of therapy to determine therapeutic response, degree of patient adherence, and presence of adverse effects. Earlier follow-up may be necessary for patients with underlying comorbid conditions. Once the patient's response is observed, follow-up at 3- or 6-month intervals (depending on the patient status) is generally appropriate. Consider referral or consultation in unresponsive or complex comorbid cases.

Alopecia, which means hair loss, is of epidemic proportion for many women of color. Although there have been magazine articles and television segments about alopecia, it continues to be poorly understood by many women. There are many different causes of alopecia that affect women with brown skin. However, there are two types of hair loss that women with curly or tightly coiled hair are plagued with: central centrifugal cicatricial alopecia (Figure 1 and Figure 2).

Fig 1. Mild CCCA	Fig 2. Traction alopecia

Alopecia is a devastating condition for all women, despite the cause. All women want to have their own healthy hair. Hair loss effects self-esteem, social interactions and relationships.

Central centrifugal cicatricial alopecia (CCCA) was previously called follicular degeneration syndrome or hot comb alopecia. CCCA is a form of hair loss that has the following features:

• Central (crown) portion of the scalp is were the problem begins
• Centrifugal (circular) pattern is the outward pattern in which this problem progresses
• Cicatricial (scarring) of the hair follicles occurs
• Alopecia (hair loss) is progressive

Fig 3. Moderate CCCA

With CCCA, the hair loss may appear suddenly and progress relentlessly (Figure 3). It occurs in women of all ages, from as young as 20 to as old as 60. The cause of CCCA is unknown but it is felt to be related to repeated and frequent but unnoticed damage to the hair follicles. There may be a hereditary component to CCCA and for Black and some Latina women, a combination of hair care habits and practices may cause or contribute to the condition. Some dermatologists theorize that the following factors may play a role in the cause or CCCA:

• Genetics
• Hot combing (microscopic droplets of hot hair oil drip onto and damage the hair follicles)
• Chemical relaxing (the severe tingling and burning that occurs when the application directions are not followed may produce inflammation and destruction of the hair follicles)
• Tight rollers or curlers used to set the hair (the chronic pulling or traction of the hair may produce inflammation and destruction of the follicles)
• Braids with extensions or weaves to style the hair (the chronic pulling or traction of the hair may produce inflammation and destruction of the follicles)
• Blow drying (excessive heat applied to the scalp and hot oil droplets may destroy the follicles)
• “Oiling or greasing the scalp” (may block the follicles and cause inflammation in the follicles)

Once the hair follicles become damaged or destroyed, scar tissue (cicatrix) forms and hair will never regrow. Therefore, if you suspect that you may have CCCA, it is important to see your dermatologist immediately. An evaluation by the dermatologist will include blood tests to eliminate other causes of hair loss and a scalp biopsy. A scalp biopsy is a simple procedure in which a small area of the scalp is removed after numbing medication is administered. A stitch is then placed to close the areas. When the biopsy is analyzed by the pathologist, features typical of CCCA may be seen: a decrease or absence of hair follicles, scar tissue formation and inflammatory cells surrounding the hair follicles.

Treatment
Since dermatologists do not know the exact cause of CCCA, outlining a treatment is difficult. The first step is to stop any styling practice that may be causing or contributing to the hair loss. Often that means no hot combs, no tightly applied rollers or braids, blow drying or relaxers for a period of time. If the hair follicles have not been damaged beyond repair, you may, for example, be able to resume your hair care practices but with modifications. Your dermatologist can help you determine when—and if—you can resume these styling practices. Taking a break from harsh styling and substituting gentler techniques may allow the inflammation to resolve, the scalp to heal and hair growth to resume.

Your dermatologist may prescribe medications to decrease the inflammation that is seen in the hair follicles of those affected by CCCA. Oral or topical antibiotics are sometimes prescribed because they help to reduce inflammation. Likewise, topical cortisones applied to the scalp or cortisones directly injected into the scalp may also be used to treat or reduce scalp inflammation. Finally, once the inflammation is minimized, your dermatologist may recommend over-the-counter Minoxidil (Rogaine) to stimulate grow of follicles that have not been destroyed.

Fig 4. Severe CCCA

With severe CCCA (Figure 4), the hair follicles are destroyed and neither topical or injected medications will help the condition. Hair transplantation may be a solution for some women although the severe scarring may make this procedure technically difficult.

Sometimes CCCA is confused with the hereditary form of alopecia, called androgenic alopecia. This form of alopecia is also characterized by thinning in the central portion of the scalp with extension toward the hairline. With androgenic alopecia, the underlying scalp appears normal and the follicles are not scarred. Therefore, there is a greater likelihood that hair will regrow. The over the counter medication, Minoxidil (Rogaine), may help improve the particular condition.

Bottom line
CCCA is a devastating condition for women with brown skin and the best chance of reversing the process and restoring hair is early diagnosis and prevention. Therefore, it is important to see a dermatologist who is knowledgeable in tightly coiled or curly hair at the first sign of hair loss.

  Traction Alopecia

Traction alopecia is hair loss that occurs as a result of continuous pulling of the hair. Pulling may occur from hairstyles such as tight cornrows or braids, weaves, ponytails or even hair rollers or curlers. Traction alopecia may also be due to excessive weight from long extensions or locks. Signs that the hair is being pulled too tightly are difficulty moving your forehead or temples, headache, and scalp soreness. Side effects of pulling too hard are breakage of hair strands and hair loss from the follicle. An even more serious side effect of chronically pulling the hair is an inflammation of the follicle and the appearance of small bumps (folliculitis). Inflammation can lead to destruction of the hair follicle and permanent hair loss. Over time, bald spots may develop along the hairline and in the area above the ears. Since the hair loss happens gradually, you may not even notice it until the bald spot develops or your hairline recedes significantly. If traction alopecia continues for a prolonged period of time, the follicles may become destroyed and hair loss permanent.

Treatment
It may seem obvious but it’s time to stop pulling your hair out. To save your hair, you may need to switch hairstyles altogether. However, if your hair loss is minimal and you want to continue to braid your hair or plait your child’s hair, for instance, you can make adjustments, such as wearing looser braids, plaiting the hair loosely and wearing shorter weaves or locks. Women of color often pull tightly on hair to make it look smooth or straighter in a ponytail or bun. A better solution might be to apply a hair gel or a dab of conditioner to the hair to help it to lie flatter and straighter. More manageable hair will look smooth and neat without all that pulling, so wash and deep condition regularly. To camouflage bald spots or a receding hairline you might consider brushing your hair towards the hairline or coloring the scalp with a scalp pencil. You can find scalp pencils at a local beauty supply store; apply as you would an eyebrow pencil, with short strokes in the direction of hair growth.

Once the pulling and tension have been eliminated, if there is active folliculitis, your dermatologist may prescribe an oral or topical antibiotic to reduce the inflammation. In addition, potent cortisone containing creams or cortisone injections may reduce inflammation. If severe scarring is present, hair transplantation may be an effective treatment.

Bottom Line

Traction alopecia can also be a devastating condition for women with brown skin in much the same way as CCCA. Although women may think that they look terrific with tight hair styles, they can and do lead to permanent loss of hair. The key with traction alopecia is simply to avoid tight hair styles. Also, it is important to see a dermatologist at the first sign of hair loss.

Also known as:  Scarring Alopecia

What is it?

Alopecia is the term used for hair loss. Cicatricial alopecia, also known as scarring alopecia, is hair loss that occurs in areas where there is scarring or other tissue damage.

Who gets it?

People whose skin has been scarred by burns, certain diseases, radiation therapy, or other injuries may develop cicatricial alopecia.

What causes it?

Scar tissue forms when some part of the dermis is destroyed. The dermis is the second layer of the skin, and contains the hair follicles. In addition to burns and other injuries, cicatricial alopecia can be caused by certain types of infections, called granulomas; lupus erythematosus; recurring bacterial or fungal infections; a skin disease called lichen planus; and scalp ringworm.

What are the symptoms?

People with cicatricial alopecia have bald spots on the part of the body where the tissue damage occurred.

How is it diagnosed?

Cicatricial alopecia can be diagnosed by studying the patient’s medical history and examining the affected areas. The cause of the scarring is usually easy to identify. In some cases, your doctor may want to remove a small sample of skin, called a skin biopsy, to examine under a microscope. He or she may also use a skin sample to grow a tissue culture to look for fungi or bacteria.

What is the treatment?

To treat cicatricial alopecia, your doctor will look to identify and eliminate the cause. However, if there is severe scarring, it is unlikely that hair will grow again.

Self-care tips

There are many forms of alopecia, so it is important to determine the type of alopecia before treating the condition. People with all forms of alopecia usually find support groups dedicated to their condition helpful.  Visit the Cicatricial Alopecia Research Foundation for more information.

What is cicatricial alopecia or scarring alopecia?

The term "cicatricial alopecia" refers to a diverse group of rare disorders that destroy the hair follicle, replace it with scar tissue, and cause permanent hair loss. In some cases, hair loss is gradual, without symptoms, and is unnoticed for long periods. In other cases, hair loss is associated with severe itching, burning and pain and is rapidly progressive. The inflammation that destroys the follicle is below the skin surface and there is usually no "scar" seen on the scalp. Affected areas of the scalp may show little signs of inflammation, or have redness, scaling, increased or decreased pigmentation, pustules, or draining sinuses. Cicatricial alopecia occurs in otherwise healthy men and women of all ages and is seen worldwide.

Are there different kinds of cicatricial alopecia?

Yes, cicatricial alopecias are classified as primary or secondary. This discussion is confined to the primary cicatricial alopecias in which the hair follicle is the target of the destructive inflammatory process. In secondary cicatricial alopecias, destruction of the hair follicle is incidental to a non-follicle-directed process or external injury, such as severe infections, burns, radiation, or tumors.

Primary cicatricial alopecias are further classified by the type of inflammatory cells that destroy the hair follicle during the active stage of the disease. The inflammation may predominantly involve lymphocytes or neutrophils. Cicatricial alopecias that predominantly involve lymphocytic inflammation include lichen planopilaris, frontal fibrosing alopecia, chronic cutaneous lupus erythematosus, central centrifugal alopecia, pseudopelade (Brocq), alopecia mucinosa, and keratosis follicularis spinulosa decalvans. Cicatricial alopecias that are due to predominantly neutrophilic inflammation include folliculitis decalvans, tufted folliculitis, and dissecting cellulitis. Sometimes the inflammation shifts from a predominantly neutrophilic process to a lymphocytic process. Cicatricial alopecias with a mixed inflammatory infiltrate include folliculitis keloidalis and erosive pustular dermatosis.

Please see the sidebar for examples.

What causes cicatricial alopecia?

The cause of the various cicatricial alopecias is poorly understood. However, all cicatricial alopecias involve inflammation directed at the hair follicle, usually the upper part of the follicle where the stem cells and sebaceous gland (oil gland) are located. If the stem cells are destroyed, and the sebaceous gland as well, there is then no possibility for regeneration of the hair follicle and permanent hair loss results.

Cicatricial alopecias are not contagious.

Who is affected by cicatricial alopecias?

Cicatricial alopecias affect both men and women, most commonly young adults although all ages may be affected. Keratosis follicularis spinulosa decalvans usually manifests itself in the teenage years. Epidemiologic studies have not been performed to determine the incidence of cicatricial alopecias. In general, they are not common.

There have been a few reports of cicatricial alopecia occurring in a family. However, the majority of patients with cicatricial alopecia have no family history of a similar condition. Central centrifugal alopecia may affect black women most commonly. Frontal fibrosing alopecia is seen most commonly in post-menopausal women. While it is possible to have more than one type of hair loss condition, non-scarring forms of hair loss do not turn into scarring forms of hair loss.

Are cicatricial alopecias associated with other illnesses?

In general, cicatricial alopecias are not associated with other illnesses. Patients with chronic cutaneous lupus erythematosus may have an increased personal and family history of autoimmune disorders.

How are cicatricial alopecias diagnosed?

A scalp biopsy is essential for the diagnosis of cicatricial alopecia and is the necessary first step. Findings of the scalp biopsy, including the type of inflammation present, location and amount of inflammation, and other changes in the scalp, are necessary to diagnose the type of cicatricial alopecia, to determine the degree of activity, and to select appropriate therapy.

Clinical evaluation of the scalp is also important. Symptoms of itching, burning, pain or tenderness usually signal ongoing activity. Signs of scalp inflammation include redness, scaling, and pustules. However, in some cases there are few symptoms or signs and only the scalp biopsy demonstrates the active inflammation. The overall extent and pattern of hair loss is noted and sometimes photographed for future comparison. A hair "pull test" is performed to identify areas of active disease in which follicles are easily pulled out. The pulled hairs are mounted on a slide and the hair bulbs are viewed with a microscope to determine how many are growing hairs and how many are resting hairs. In addition, if pustules are present, cultures may be performed to identify which microbes, if any, may be contributing to the inflammation. A thorough evaluation that includes all of these parameters is important in diagnosing a cicatricial alopecia and in identifying features in individual patients that will help the selection of therapy.

Diagnosis and treatment of cicatricial alopecias is often challenging. For this reason, it is helpful to be evaluated by a dermatologist with a special interest or expertise in scalp and hair disorders, and who is familiar with current diagnostic methods and therapies. A hair specialist who is experienced in the evaluation and treatment of patients with cicatricial alopecias may be found by contacting the American Academy of Dermatology (www.aad.org) or the North American Hair Research Society (www.nahrs.org).

How are cicatricial alopecias treated?

As mentioned above, primary cicatricial alopecias are classified by the predominant type of inflammatory cells that attack the hair follicles: i.e., lymphocytes, neutrophils, or mixed inflammatory cells. Treatment strategies are different for each subtype and detailed treatment options are beyond the scope of this discussion. However, certain general principals are reviewed below.

Treatment of the lymphocytic group of cicatricial alopecias (including lichen planopilaris, frontal fibrosing alopecia, chronic cutaneous lupus erythematosus, central centrifugal alopecia, pseudopelade (Brocq), alopecia mucinosa, and keratosis follicularis spinulosa decalvans ) involves use of anti-inflammatory medications. The goal of treatment is to decrease or eliminate the lymphocytic inflammatory cells that are attacking and destroying the hair follicle. Oral medications may include hydroxychloroquine, doxycycline, mycophenolate mofetil, cyclosporine, or corticosteroids. Topical medications may include corticosteroids, topical tacrolimus, topical pimecrolimus, Derma-Smoothe/FS scalp oil; Triamcinolone acetonide (a corticosteroid) may be injected into inflamed, symptomatic areas of the scalp.

Treatment of the neutrophilic group of cicatricial alopecias (folliculitis decalvans, tufted folliculitis, and dissecting cellulitis) is directed at eliminating the predominant microbes that are invariably involved in the inflammatory process. Oral antibiotics are the mainstay of therapy, and topical antibiotics may be used to supplement the oral antibiotics. Isotretinoin is sometimes helpful in controlling the neutrophilic group, especially dissecting cellulitis.

Treatment of the mixed group of cicatricial alopecias (folliculitis keloidalis and erosive pustular dermatosis) may include antimicrobials, isotretinoin (especially for folliculitis keloidalis), and anti-inflammatory medications.

You should discuss any treatment with your dermatologist who will also explain potential side effects, as well as laboratory tests that are needed before starting treatment and sometimes are monitored during treatment.

The course of cicatricial alopecia is usually prolonged. Treatment is continued until the symptoms and signs of scalp inflammation are controlled, and progression of the condition has been halted. In other words, itching, burning, pain and tenderness have cleared, scalp redness, scaling, and/or pustules are no longer present, and the hair loss has not extended. Treatment may then be stopped. Unfortunately, the cicatricial alopecias often re-activate after a quiet period of one or more years, and treatment must be started again.

Because of the above last statement, surgical treatment is not an option in most cases except under certain conditions: if the disease has been inactive for many years and the area of hair loss is small, then surgical removal of the scarred scalp and/or hair transplants may be considered for cosmetic benefit. Folliculitis keloidalis is one exception in that excision of the affected scalp at the back of the head (scalp reduction) may provide relief for the patient.

Will my hair grow back?

Hair will not regrow once the follicle is destroyed. However, it may be possible to treat the inflammation in and around surrounding follicles before they are destroyed and for this reason it is important to begin treatment as early as possible to halt the inflammatory process. Minoxidil solution (2% or 5%) applied twice daily to the scalp may be helpful to stimulate any small, remaining, unscarred follicles. The progression of hair loss is unpredictable. In some cases, progression is slow and there is always sufficient hair remaining to cover the affected scalp areas; in other cases, progression can be rapid and extensive.

What signs and symptoms should I watch for?

It is important to continue to watch for symptoms and signs of active disease during and after treatment to ensure that the disease is responding adequately and has not re-activated after therapy has been discontinued. Response to therapy may be indicated by the resolution of scalp symptoms such as itching, burning, pain or tenderness, by improvement in the signs of scalp inflammation such as decreased redness, scaling or pustules, and by halting the progression of hair loss. A dermatologist can follow your cicatricial alopecia using these guidelines, and with the pull test. Photographs of the scalp may be useful in monitoring the progression and halting of progression of the disease.

How should I care for my hair?

Hair care products and shampoos can generally be used with any frequency desired, as long as the products are gentle and non-irritating to the scalp. Dermatologists may recommend specific shampoos and products to decrease scalp symptoms, scaling and inflammation. Hair pieces, wigs, hats, scarves may be used freely