Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr...
Transcript of Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr...
![Page 1: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/1.jpg)
Adult Hair Loss – what to
do in primary care?
Dr Ben Esdaile MBBS BSc FRCP
Consultant Dermatologist and Clinical Lead
Whittington Hospital
![Page 2: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/2.jpg)
Outline
Hair cycle and hair basics
How to assess and examine a patient with
hair loss
Scarring v. non-scarring alopecia
Non-scarring alopecias
Questions?
![Page 3: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/3.jpg)
![Page 4: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/4.jpg)
Hair cycle
Growing Transition Resting/Shedding
![Page 5: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/5.jpg)
Hair Basics
100,000 scalp hairs
10% in Telogen
Telogen usually lasts around 100 days
Normal to lose upto 100 hairs/day
![Page 6: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/6.jpg)
How to examine for hair loss?
1) Sit patient in chair
2) Look down on
scalp/parting and assess
hair density and areas of
alopecia
3) Assess hair scalp margin
4) Assess skin on scalp
5) Consider hair pull test
6) Rest of skin
![Page 7: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/7.jpg)
Hair Pull Test
![Page 8: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/8.jpg)
![Page 9: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/9.jpg)
How to assess a patient with hair
loss?
1) Is there scarring? – needs to be referred to Derm
2) If non-scarring (the majority)
Discrete patches Diffuse hair loss
Alopecia areata Telogen effluvium
(Tinea capitis) Androgenetic alopecia
(Folliculitis kelodailis)
![Page 10: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/10.jpg)
Question 1) Is there scarring?
![Page 11: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/11.jpg)
Scarring alopecias
If Scarring
suspected –
Refer Routinely
![Page 12: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/12.jpg)
**Frontal Fibrosing Alopecia
Unknown cause
Incidence increasing.
Loss of frontal scalp
margin and outer
eyebrows.
![Page 13: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/13.jpg)
NON SCARRING ALOPECIA
DIFFUSE or PATCHES
![Page 14: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/14.jpg)
Alopecia Areata
Autoimmune
Patients have higher rates of thyroid diseases, vitiligo
and atopic eczema.
![Page 15: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/15.jpg)
Alopecia Areata – clinical patterns
Patchy
Alopecia totalis
Alopecia universalis
Ophiasis
![Page 16: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/16.jpg)
Alopecia Areata – patchy
![Page 17: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/17.jpg)
Alopecia Areata – trichoscopy
![Page 18: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/18.jpg)
Alopecia Areata – totalis
![Page 19: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/19.jpg)
Alopecia Areata – universalis
![Page 20: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/20.jpg)
Alopecia Areata – ophiasis
![Page 21: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/21.jpg)
Alopecia areata - Diagnosis
Usually straight forward.
Trichoscopy can help.
![Page 22: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/22.jpg)
Alopecia areata – Management
When to refer
>20% refer to Dermatology.
![Page 23: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/23.jpg)
Alopecia areata – Management
Localised. Less than 20%Options:
1) If re-growing no treatment
2) Potent or super-potent
topical steroid once daily
for up to 12 weeks
![Page 24: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/24.jpg)
Alopecia areata – Management
Localised. Less than 20%
At 3 months – if no improvement – refer
Options in secondary care:
Intralesional steroid injections
Immunotherapy
?JAK inhibitors
![Page 25: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/25.jpg)
AA – Poor prognostic features
Unpredicatable
80% regrowth in one year if solitary patch.
Poor prognostic factors:
Extensive disease
Ophiasis pattern
Onset before puberty
Family members with AA
![Page 26: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/26.jpg)
Alopecia areata – key points
1) If >20% refer to Derm
2) If <20% and want to treat – Potent /Super potent
topical steroids for 3 months (Scalp only)
3) If no response in 3-6 months refer.
![Page 27: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/27.jpg)
Diffuse alopecia
• Telogen Effluvium
• Androgenetic Alopecia – Male and Female
pattern hair loss
![Page 28: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/28.jpg)
Telogen Effluvium
Temporary hair loss
![Page 29: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/29.jpg)
Telogen Effluvium
Shock to the system:
Illness
Surgery
Childbirth
Accident
Severe weight loss
Up to 70% of
anagen hairs
go into telogen
phase.
![Page 30: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/30.jpg)
Telogen Effluvium - management
1) Explain diagnosis – explain hair fall a sign of regrowth.
1) Check no other contributing factors:
• Ferritin (aim for >70ng/ml).
• Thyroid function tests
• Vitamin D, B12/folate
3) Consider minoxodil (2% women 5% men)
***If no response in 9 months refer to derm**.
![Page 31: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/31.jpg)
Androgenetic Alopecia
Male pattern hair loss Female pattern hair loss
40% of women by age of 50
50% of men by age of 50
![Page 32: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/32.jpg)
Androgenetic Alopecia (Male)Caused by combination of hormones and
genetics.
Genetically determined sensitivity to
dihydrotestosterone (DHT).
![Page 33: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/33.jpg)
![Page 34: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/34.jpg)
Androgenetic Alopecia
Normal scalp AGA
![Page 35: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/35.jpg)
Androgenetic Alopecia (Female)
Genetics (polygenic).
? Androgens as most normal circulating
testosterone levels.
![Page 36: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/36.jpg)
AGA – management (men)
1) 5% minoxodil daily
2) Assess response at 6-9 months (if improved continue
indefinitely)
Other options outside pathway:
Finasteride (5 alpha-reductase inhibitor)ProsthesesHair transplant/ PRP
![Page 37: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/37.jpg)
AGA – management (women)
1) Bloods – FSH/LH, prolactin, TFTs, testosterone,
SHBG, DHEAS, 17-hydroxyprogersterone.
2) ?Pelvic USS if signs of PCOS – cyproterone
acetate/ethinylestradiol.
3) Treat underlying cause
4) Minoxodil 2% twice daily.
**Refer to Derm if Severe or treatment ineffective**
Spironolactone
Finasteride (5 alpha-reductase inhibitor)
Prostheses
Hair transplant/ PRP
![Page 38: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/38.jpg)
![Page 39: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/39.jpg)
Tinea capitis
1) Take scrapings or hair pluck/brush
2) Avoid sharing towels/combs
3) Terbinafine 250mg od 4 weeks (Trichophyton tonsurans)
4) Griseofulvin 500mg bd 8 weeks (Microsporum canis)
Ketoconzole shampoo to patient and relatives for 1 month
**Refer to derm if not responding**
![Page 40: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/40.jpg)
Folliculitis Keloidalis
1) Avoid rubbing of clothing
2) Avoid razor hair cut
3) Chlorhexidine wash
4) Oral antibiotic –
tetracycline/erthromycin for 6
weeks.
5) Topical steroid – Betnovate lotion
od for 4 weeks
**Refer to derm if not responding**
![Page 41: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/41.jpg)
Resources
https://gps.camdenccg.nhs.uk/pathways/hair-loss
http://www.bad.org.uk/for-the-public/patient-information-leaflets
https://www.dermnetnz.org
http://www.pcds.org.uk
![Page 42: Hair Loss – what to do in primary care?€¦ · Adult Hair Loss –what to do in primary care? Dr Ben Esdaile MBBS BSc FRCP Consultant Dermatologist and Clinical Lead ... If re-growing](https://reader036.fdocuments.in/reader036/viewer/2022070804/5f0360517e708231d408e8cd/html5/thumbnails/42.jpg)
Questions?