Alopecia/Hirsutism

Differential Overview

Alopecia

❑ Androgenetic

❑ Telogen effluvium

❑ Drugs/hair loss

❑ Anagen effluvium

❑ Alopecia areata

❑ Tinea capitis

❑ Traction

❑ Hypothyroidism

❑ Seborrheic dermatitis

❑ Discoid lupus

❑ Systemic lupus erythematosus

❑ Lichen planus

❑ Scleroderma

❑ Dietary deficiency

❑ Trichotillomania

❑ Syphilis

Hirsutism

❑ Idiopathic hirsutism

❑ Drugs/hair growth

❑ Hypertrichosis

❑ Hyperprolactinemia

❑ Polycystic ovary syndrome

❑ Cushing syndrome

❑ Adrenal tumor

❑ Ovarian tumor

❑ Ovarian hyperthecosis

Diagnostic Approach

Nonscarring alopecia includes androgenetic, telogen effluvium, trichotillomania, traction, aerata, and syphilis. Scarring alopecia is characterized by fibrosis, inflammation and loss of follicles, occurring with inflammatory dermatoses, deep infections, neoplasms, burns, and genodermatoses. Broken hair shafts are seen in fungal infections, traction, and trichotillomania.

Most hirsutism is familial. If a woman with hirsutism has normal menses, a family history of hirsutism, no virilization, and gradual onset, no further evaluation is needed.

Signs of androgen excess include defeminization with amenorrhea, decrease in breast size, or loss of female body contours more often than virilization. Other signs include acne, increased libido, clitoromegaly, temporal hair loss, deepened voice, and increased muscle mass. Acute onset of hirsutism and virilization suggests an androgen-producing adrenal or ovarian tumor, or exogenous androgen ingestion.

Clinical Findings

Androgenetic  Male pattern baldness with typical patterns of frontoparietal receding hairline or diffuse thinning over the crown with retention of frontal hair. In women, it may result from pathologic androgen excess, accompanied by hirsutism, virilization, or oligomenorrhea. Severe vertex balding (androgenetic) is a marker for cardiovascular risk, with a relative risk of 3.4 of cardiovascular mortality.

Telogen effluvium  Diffuse thinning occurs with loss of mature hairs having a club-shaped base on close inspection. It occurs 2 to 3 months after an acute illness (especially with fever), rapid weight loss, or pregnancy. A transverse white nail line (Beau line) may also be seen as nail growth is affected. Hair can be readily pulled out (approximately half of those grasped).

Drugs/hair loss  Antineoplastic drugs, heparin, warfarin, allopurinol, propylthiouracil, vitamin A, quinine, lithium, beta-blockers, colchicine, amphetamines, and thallium have all been associated with hair loss.

Anagen effluvium  This is typical with chemotherapy (daunorubicin, fluorouracil, and cyclophosphamide) or heavy metal toxicity. The hair loss pattern may be diffuse and moth-eaten or complete. There is tapered narrowing of the hair fiber with breakage, producing diagnostic “arrow ends.”

Alopecia areata  The hair is completely lost in a circumscribed circular patch without inflammation or scar, with “exclamation point” hairs at the edge. Remaining hairs within the patch are depigmented. Fine nail pitting occurs. A family or personal history of autoimmune disease is often found, with concurrent vitiligo or hypothyroidism being the most common.

Tinea capitis  The alopecia/rash typically has a raised erythematous border with a clear center. The area will fluoresce on examination with a Wood lamp. The appearance may also vary from discrete patches with “black dots”(broken hairs) to a boggy plaque with pustules (kerion).

Traction  Patterned hair loss accompanies the use of tight braids or rollers. Hairs are short and broken.

Hypothyroidism  The hair becomes coarse, brittle, and diffusely thin, with thinning of the lateral eyebrows.

Seborrheic dermatitis  Hair loss occurs with scaling and weeping, and there will be patches behind the ears, in the nasolabial fold, in the eyebrows, and on the midchest.

Discoid lupus  Scarring is seen in the bald patches. Follicles are absent.

Systemic lupus erythematosus  Nonscarring alopecia occurs with erythema, scaling, and broken hairs, often localized to the frontal scalp as short “lupus hairs.”

Lichen planus  Scarring alopecia is associated with white lace on the buccal mucosa, and violet, flat-topped papules on the wrists.

Scleroderma  This appears as a linear forehead scar with a violaceous edge (“coup de sabre”).

Dietary deficiency  Zinc, biotin, iron, and protein deficiency can each cause diffuse hair loss.

Trichotillomania  Typically it appears as a “tonsure” pattern with a rim of hair around the edges of the scalp. Hair shafts are twisted and broken.

Syphilis  “Moth-eaten” alopecia appears as scattered, poorly circumscribed patches in 20% of cases of secondary syphilis. It is accompanied by fever, sore throat, and adenopathy.

Idiopathic hirsutism  A familial trait, in young adult women, 25% have noticeable facial hair, 33% have hair along the linea alba (male escutcheon), and 17% have periareolar hair. Weight gain can accelerate hirsutism. Menopause increases terminal hair growth on the face.

Drugs/hair growth  Oral contraceptives with androgenic progestins, phenytoin, minoxidil, diazoxide, penicillamine, glucocorticoids, and exogenous anabolic steroids in female athletes all cause hirsutism.

Hypertrichosis  Hair is vellus (fine, downy) and grows evenly over the body, not just in androgen-responsive areas. Causes include anorexia nervosa, hypothyroidism, dermatomyositis, porphyria cutanea tarda, malnutrition, and drugs.

Hyperprolactinemia  Galactorrhea and amenorrhea are the principal symptoms, but 25% also have hirsutism. Drugs that cause hyperprolactinemia can also cause hirsutism, including metoclopramide, methyldopa, phenothiazines, thioxanthenes, reserpine, estrogens, and opiates.

Polycystic ovary syndrome  This presents with peripubertal onset of hair growth, menstrual irregularities, obesity, and infertility. Ovaries are usually enlarged (2 to 5 times normal size) and cystic, but may be normal sized.

Cushing syndrome  Hirsutism occurs in 80% of cases, and is characteristically vellus, on the face and shoulders. Cardinal features of Cushing syndrome  are hypertension, central obesity, moon facies, striae, proximal muscle weakness, and abundant, easy bruising. Virilization along with the hirsutism suggests an adrenocortical carcinoma.

Adrenal tumor  There may be a palpable abdominal mass.

Ovarian tumor  Most cases have a palpable adnexal mass.

Ovarian hyperthecosis  Hirsutism is found in association with acanthosis nigricans and insulin resistance.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Hair symptoms: Introduction (review 645 causes)
• Next Book Extract About Hair symptoms: Alopecia (Handbook of Diseases)
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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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