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ALOPECIA

Diagnosing Hair Loss Subtypes

Hair loss (alopecia) can be temporary or permanent on your scalp or your body. At Clinic Dermatology, We are trained to treat various types of alopecia such as CCCA, frontal fibrosing alopecia, alopecia areata, and male or female pattern hair loss.

Central Centrifugal Cicatricial Alopecia

Richardson, who is nurse practitioner (NP), medical dermatology, at the Ruth & Raymond Perelman Center for Advanced Medicine at the University of Pennsylvania in Philadelphia, outlined the key features of central centrifugal cicatricial alopecia (CCCA). She noted it is almost exclusively seen in Black women and has a prevalence rate that varies from 2.7% to 16%.2

Premature loss of inner root sheath, follicular rupture, and follicular degeneration are some of the proposed causes of this hair loss. Other causes include fibroproliferative disorder and persistent low-grade inflammation that results in end stage fibrosis of the follicular unit. Hair care practices also can contribute to the pathogenesis of the disease, according to Richardson.

CCCA manifests as scarring patches or loss of follicular openings beginning on the crown of the head and spreading outward. Additionally, it is characterized by early stage hair breakage, follicular papules, pustules, erythema, scaling, and possibly an absence of overt inflammation, Richardson said.

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Female Pattern Hair Loss

Discussing female pattern hair loss (FPHL), Richardson emphasized looking for gradual, increased scalp visibility, widening midline part, decreased ponytail size, and preservation of frontal hairline. Other symptom to watch include increased miniaturized follicles (T:V ratio < 4:1), a shorter anagen phase, and a longer telogen phase.

She recommended a patient work-up checking:

  • CBC

  • Micronutrients: Vitamin D, ferritin, ESR, zinc

  • Hormones or hormonal levels/: Thyroid-stimulating hormone (TSH), testosterone free/total, dehydroepiandrosterone sulfate (DHEAS)

  • Richardson suggested a biopsy only if there are concerns for concomitant scarring alopecia

Frontal Fibrosing Alopecia

For frontal fibrosing alopecia (FFA), look for a band-like recession of the frontal hairline, loss of eyebrows, lonely hairs, forehead vein prominence, and perifollicular papules and pustules. Additionally, facial papules and occipital scalp may be involved. Itching may be absent in FFA, according to Richardson.

Histological features of FFA include lymphocyte predominant inflammatory infiltrate, and scarring. She recommended biopsy of the affected area, along with testing TSH to determinewhether the patient is prothrombin time (PT) dependent.

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Alopecia Areata

Finally, Richardson described the characteristics of alopecia areata (AA). These characteristics are single or multiple round/oval hairless patches with visible follicular ostia, hairpull, exclamation point hairs, and possible nail dystrophy.

For acute AA, histological features of disease include peribulbar inflammation, melanin incontinence, increased catagen and telogen, miniaturization, and residual inflammatory cells in follicular stalae. Chronic disease features include having most follicles in the telogen phase and miniaturization.

For diagnosing AA, Richardson recommended checking:

  • TSH

  • Vitamin D, Ferritin, ESR, zinc

  • If anemia is suspected, check CBC. If there is a celiac/gluten sensitivity, check TTG Ab (transglutaminase IgA).

  • Baseline labs if systemic therapy is planned.