1. Hair Problems in Women Chad Fowler, MD 5/23/05

2. CASE 1 A 19 yo Caucasian woman appears distressed in the exam room. She has difficulty expressing her presenting complaint so she pulls back her hair to show an oval patch of smooth, hairless skin on the back of her head. She explains that she has been feeling fine, but that all of a sudden her hair fell out. She noticed clumps of hair in the shower for the last two days. Her mother died two months ago in a motor vehicle accident, and she wants to know if that has caused her hair to fall out.

3. CASE 1 Discussion Q’s 1. What is the condition? What confirmatory bedside observations might help? 2. How often is the condition seen in women at this age, as compared to older women? 3. Does stress have anything to do with this condition? 4. What do you tell her about the cause of this condition? 5. What can she expect with regards to hair regrowth? 6. What treatment, if any, would you recommend?

4. Alopecia Areata

5. Alopecia Areata of the Beard

6. Alopecia Totalis

7. CASE 2 21 yo college student presents with hair loss. She has a hx of anxiety and depression, and her only current medications is Zoloft. She has a history of excoriations and picking at her skin, and she has a few scars on the arms. You notice that she has been biting her nails. You ask to see her scalp, but she wants to keep talking. She offers that her scalp sometimes aches and itches. When she finally permits examination, you notice a circular area of alopecia on the vertex. The patch almost appears tonsular (like the shaved medieval monks who had a bald patch), but the area contains hairs of varying length. When you look at the hairs, the ends appear fractured (not tapered). A stubbly sensation is noted as the hand is lightly passed over the area.

8. CASE 2 Discussion Q’s 1. What is the condition? 2. What would you ask next? 3. Is this condition more common in women? 4. Should your examination include anything else? 5. What treatment would you recommend?

9. Trichotillamania

10. CASE 3 A 24 yo woman in your practice has a long-standing hx of hypothyroidism, and has taken low dose thyroxine (50 mcg) for years. She delivered a beautiful baby boy 12 months ago, and she appears very content when bringing the baby in for WCC’s. Unfortunately, she reports that in the last two weeks her hair has been falling out in clumps. Her shower drain is clogged with hairs. She has felt well; her last illness was a severe bout of the flu 2-3 months ago (several days of high fever). She says that there is some stress with the toddler at home, but that she really feels OK except for her hair falling out. Her examination reveals diffuse, uniform hair thinning without any bald spots and without scarring.

11. CASE 3 Discussion Q’s 1. What is the likely cause of this sudden hair loss? How do you explain this condition to her. 2. What could you do in the examination room to help confirm the diagnosis? 3. If she had experienced this two months after delivering the baby, would your diagnosis change? What advice would you give her if the hair loss occurred postpartum? 4. Is any treatment advised?

12. CASE 4 A 46 yo woman comes in complaining of diffuse hair loss. She is somewhat overweight, and you have made the diagnosis of Polycystic Ovarian Syndrome in the past. She has some facial and neck hirsuitism. Her exam demonstrates a diffuse reduction in her hair density over the crown and frontal scalp. She has maintained the frontal hairline. She denies any excess shedding or sudden hair loss; she has just experienced a slow, steady hair loss over several years duration.

13. CASE 4 Discussion Q’s 1. What is the diagnosis? Does this condition have a counterpart in men? 2. As there is evidence of androgen excess, what would you recommend as the treatment for this woman? What would you recommend if there is no clinical evidence of androgen excess?

14. CASE 5 A 48 yo African American woman presents with patchy hair loss over the temporoparietal areas of the scalp. Her changes appear bilaterally. The hair loss has been chronic; in fact, she can’t remember when it has not been there. She denies any trauma, twirling her hair, or any significant medical problems. Examination reveals patchy, diffuse hair loss without sharply demarcated borders. Unlike totally bald areas of alopecia areata, she does exhibit a few scattered hairs and in fact has small patches of normal hair growth in the center of her involved scalp. She just had bloodwork performed that revealed a normal TSH, metabolic panel, sed rate, and CBC.

15. CASE 5 Discussion Q’s 1. What is this? 2. How do you treat it?

16. Traction Alopecia

17. Take Home Points: Alopecia Areata Autoimmune Most get hair back (depigmented) Alopecia Totalis (up to 20%), Aloecia Universalis (1%) Steroids

18. Trichotillomania (TTM) Gentle! Avoid frontal assault. May take multiple visits. Not happy that they’re doing it, BUT they’re happy when they’re doing it. Hair pulling=stress release Embarrassed Cognitive Behavior Therapy/SSRI’s (Prozac)

19. Telogen Effluvium Sudden hair loss…Hair will come back! Anagen/Telogen Causes: Physiologic or Metabolic stress Febrile illness/Viral syndrome Major injury/surgery ICU Meds (coumadin, heparin, propanolol) Pregnancy/Delivery

20. Androgenic Alopecia Difficult to treat Keep your eyes/ears open for AVODART

21. Traction Alopecia Compliment, educate, spend the time with the patient/family Intervention The clock is ticking…permanent damage after 1 cycle (3 months)

22. That’s all folks!