Common causes of hair loss - Amazon AWS

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protein called keratin. There are two types of ..... from the British Association of Dermatologists website at tinyurl.c
Clinical Normally between 25 and 100 telogen hairs are shed each day. This article discusses the conditions where this cycle is disrupted, causing noticeable hair thinning or loss.

Module 1853

Common causes of hair loss From this pharmacy CPD module on the common causes of hair loss you will learn about: • The hair growth cycle • The different types of alopecia (hair loss) and their causes, symptoms and treatment • Advice pharmacists can give to patients suffering from alopecia • The effect smoking has on prescribed medicines

Androgenetic alopecia This is also known as male pattern hair loss (MPHL). It affects half of men aged over 50 years, but can start in the late 20s or early 30s. Women can also be affected, and this is referred to as female pattern hair loss. MPHL is hereditary and follows a pattern of thinning and loss of hair from the crown of the head, with a receding hairline at the front. Complete baldness can occur, but is rare. Cells in the scalp convert testosterone to dihydrotestosterone (DHT). In MPHL, the hair follicles have an increased sensitivity to DHT,

FIONA PARAGPURI, PHARMACIST Hair is formed of three layers – the medulla, cortex and outer cuticle – all made from a hard protein called keratin. There are two types of human hair: • vellus hair – the short, fine, light-coloured hair mainly found on the body • terminal hair – this tends to be darker and longer, and includes scalp hair. On average, adults have about 100,000 hairs on their head, which grow at a rate of around 0.3-0.4mm a day. In humans, hair growth and shedding is random (unlike other mammals, where it may be seasonal or cyclical in nature). There are three stages to the hair growth cycle: • anagen – the active growth phase. Scalp hair can stay in this phase for between two and six years, with around 85% of hair in this stage at any one time • catagen – a transitional stage lasting two to three weeks, where growth stops and what is known as club hair is formed • telogen – the resting phase, which lasts for about 100 days. Hair is shed when a new hair grown during the anagen phase pushes out the club hair.

which causes them to shrink in size. The hair becomes thinner, more like vellus hair, and grows for a shorter time before falling out. Eventually, a much smaller follicle remains, with a thin stump of hair that does not grow out to the skin surface. Around 50% of women over the age of 65 are affected by androgenic alopecia, which usually only presents as thinning of hair on the top of the head. A hereditary link is not clear, but it tends to be more noticeable after menopause. Other causes of androgenic alopecia in women include polycystic ovary syndrome, due to an increase in testosterone levels. MPHL is part of the natural ageing process for men, and for most no treatment is required, or even wanted. However, patients may be at risk of sunburn and sun-related skin damage, so should be advised about using adequate protection, such as sunscreen and hats.

Treatments Some patients may find their hair loss distressing, especially if it occurs early in life. Treatments are not available on the NHS and can be expensive in the long run, as they need to be continued to prevent the hair loss process from resuming.

In humans, there are three stages to the hair growth cycle: anagen, catagen and telogen

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Minoxidil This topical product can be purchased over the counter as a lotion or foam in two strengths: 2% for men and women, and 5% for use by men only. Minoxidil should be applied twice daily to the scalp (although there is a once-daily foam formulation available for women). Patients should be advised to wash their hands after application. After four months of use, about a third of male users with partial hair loss will experience hair growth, which develops into good growth within 12 months of continued use. Another third will have soft downy growth. Treatment needs to be continued, as any new growth will fall out two months after treatment is stopped. Side effects of minoxidil are uncommon, but can include skin rashes or irritation. Module 1853 | Common causes of hair loss  | 1 of 4

Mild cases of alopecia areata often clear within a few months to a year without any treatment. However, the condition commonly recurs over many months or years, with patches of baldness coming and going. The more extensive the hair loss, the less likely it is to regrow. Some people develop total hair loss on the scalp (alopecia totalis) or body (alopecia universalis). Both of these are rare, but more common with: • childhood onset • more than half the scalp affected • atopic eczema also present • eyelash and/or eyebrow hair loss • family history • hair loss around the scalp margin • changes in nail shape or texture • another autoimmune disease also present. Treatment of alopecia areata often involves watchful waiting – the approach to a medical

problem in which time is allowed to pass before medical intervention is implemented – especially in mild cases. But this may prove difficult for patients who are distressed by their hair loss. Otherwise, treatments include: Steroid injections can be made into bald patches of the scalp to suppress the immune response and allow the hair to grow back. This is more suitable for small to medium-size patches, as treatment is limited by pain. Injections are repeated every four to six weeks, while hair regrowth takes one to two months. Topical steroids can be used where steroid injections are not suitable, but they are not as effective. Hair regrowth occurs after three to six months; if no improvement is seen in this time then treatment should be discontinued. Topical minoxidil can be used, but it is unlicensed for this condition and success rates are not high.

Male pattern hair loss affects half of men aged over 50 years, but can start in the late 20s

Finasteride This 5-alpha reductase inhibitor can also be used, but is only available on private prescription. It acts by blocking the conversion of testosterone to DHT. It can take up to four months for an effect to be seen, and one to two years for full hair growth. As with minoxidil, hair loss will recommence if treatment is stopped. Side effects, which can include loss of libido and erectile dysfunction, are rare. Other treatments Patients who suffer from MPHL may consider variable options including wigs, camouflage (spray preparations with small, pigmented fibres) and surgery such as hair transplants. These are not available on the NHS.

Alopecia areata Alopecia areata affects around 15 in 1,000 people in the UK. Men and women are affected equally and it can occur at any age, but commonly first develops during childhood or

adolescence. It is not well understood, but is thought to be an autoimmune condition. Patches of baldness suddenly appear; mainly on the scalp, but the beard area, eyebrows, eyelashes and patches of body hair can also be affected. These patches develop quite quickly, and may enlarge or join up. The skin within the bald patches is smooth and appears healthy, with no signs of scarring, although some patients do experience reddened or irritated skin. Around the edges of the bald patches may be seen ‘exclamation mark hairs’ – short, broken hairs 3-4mm in length, which are typically wider at the top and become progressively thinner as they meet the scalp. The hair within the bald patches often grows back within a few months, but this regrowth may be grey or white in colour. However, normal colour typically returns after several months. Sometimes more bald patches develop after the initial ones. In around 10% of patients, the nails are also affected, becoming pitted or ridged.

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In alopecia areata, patches of baldness suddenly appear on the scalp, although other areas can be affected

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Topical immunotherapy is the most effective treatment for people with extensive alopecia areata. It involves applying increasing strengths of a substance (usually diphencyprone) that causes an allergic reaction in the skin. This reaction somehow interferes with the immune response and allows the hair to regrow. Side effects include severe skin reactions, and regular maintenance treatment is required to prevent hair loss returning. Wigs, hair weaves and false eyelashes can also be used to help patients cope with alopecia areata. Semi-permanent tattoos are useful for eyebrow loss. In addition, counselling can be helpful for patients who are struggling with their hair loss.

Telogen effluvium This occurs where there is a higher amount of shedding of hair in the telogen (resting) phase

than usual, causing widespread thinning, rather than the bald patches seen in other types of hair loss. The hair may feel thinner, but complete baldness is unlikely and body hair is not affected. It normally occurs two to three months after a triggering event, such as: • hormone changes eg pregnancy • emotional stress • physical stress eg childbirth or an operation • a short-term illness, especially if a high fever is experienced • crash dieting, or sudden weight loss after bariatric (weight loss) surgery More gradual causes of telogen effluvium include: • iron deficiency • zinc deficiency • thyroid disorders • increasing age

• medications such as anticoagulants, beta blockers, retinoids, lithium, and carbamazepine • chronic illness eg cancer, systemic lupus erythematosus, kidney or liver disease. Most cases resolve by themselves and the hair will start to grow back within six months. No treatment is usually required, although sometimes minoxidil may be prescribed. Any deficiencies should be corrected, although there is some debate about the link between iron deficiency and hair loss. However, if iron levels are low, a trial of supplementation is probably worth trying. You should also give advice about following a healthy diet. You should reassure patients that their hair loss is likely to be temporary, and will grow back. You can advise them to try new hairstyles, such as layers or curly styles, as these may disguise thinner hair better than straighter, long styles. Hair accessories such as headbands, scarves and bandannas can also be useful. Charities such as Alopecia UK – at alopeciaonline.org.uk – have support groups and online forums that patients may find helpful.

Anagen effluvium

Steroid injections can be made into bald patches of the scalp to suppress the immune response

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In anagen effluvium there is a widespread, rapid loss of hair from the scalp, face and body, due to the growth of hair in the anagen phase being stopped. The main causes are chemotherapy, radiotherapy or immunosuppression, with the hair loss usually occuring a few weeks after treatment begins. In some cases, the hair loss can be reduced by using cooling scalp caps during treatment, but these are not always effective and may not be widely available. Again wigs – cancer patients undergoing chemotherapy are entitled to free NHS wigs – hairpieces, hats and scarves can be useful, and patients should also be reminded about using adequate sun protection. You can reassure

patients that their hair will grow back, usually a few months after the chemotherapy has stopped. You should make them aware that the hair may grow back in a different texture, colour or thickness.

Traction alopecia Trauma from tight hairstyles, such as tight ponytails or plaits, and the use of hair curling tongs and straighteners can also cause a form of alopecia known as traction alopecia. It may initially present as little bumps on the scalp, and is more common around the front and sides of the scalp. In its initial stages traction alopecia is reversible, and by removing the cause hair will grow back normally. However, long-term use of tight hairstyles may cause permanent damage to the follicles, and the hair will not grow back. Patients should be advised to regularly change their hairstyle, not to use rubber or elastic bands to tie the hair back, and plait hair into thick braids that do not pull on the hair as much as thinner ones.

Scarring alopecia Scarring alopecia, also known as cicatricial alopecia, occurs where the hair follicle is destroyed, meaning the hair will never grow back. It is usually a complication of another condition, such as: • scleroderma – a condition that affects connective tissue • lupus disease – a long-term condition causing inflammation to the joints, skin and other organs • lichen planus – a non-infectious, itchy rash that can affect many areas of the body • infections such as folliculitis, boils or scalp ringworm (tinea capitis).

Trichotillomania Trichotillomania is a psychological condition where a person feels compelled to pull their hair out. Hair is most commonly pulled out

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from the scalp, but some patients pluck hair from their eyebrows, eyelashes, pubic hairs and other parts of the body. It can occur at any age, but usually starts in adolescence. Patients often feel a compulsion to pull the hair out and may experience boredom, tension or anxiety beforehand. Afterwards they often experience relief. Trichotillomania can cause negative feelings – such as guilt, embarrassment or shame – about pulling out their hair, and try to cover it up. It may also make them feel unattractive, leading to low self-esteem. Trichotillomania can be linked to other mental health disorders such as anxiety, depression, eating disorders, drug use, and obsessive compulsive disorder. First-line treatment is with psychotherapy

– ie non-medical means – and cognitive behavioural therapy (CBT). Selective serotonin reuptake inhibitors (SSRIs) and clomipramine are sometimes prescribed, but this is an unlicensed use. Pharmacists may want to refer patients to support websites, such as trichotillomania.co.uk, that allow individuals to share their experiences and advice for those with the condition.

Tinea capitis The symptoms of tinea capitis, or scalp ringworm, include small patches of scaly skin and an itchy scalp, as well as patchy hair loss. Severe symptoms include bald patches, pusfilled sores and crusting on the scalp. Patients should be referred to their GP for

Common causes of hair loss CPD Reflect What are the side effects of finasteride? How is alopecia areata treated? Which medicines can cause hair thinning or loss? Plan This article contains information about hair loss, including the hair growth cycle, and the causes, symptoms and treatment of different types of alopecia. Advice that pharmacists can give to patients suffering from this condition is also discussed. Act

• Read more about alopecia on the NHS Choices website at tinyurl.com/alopecia20 • Find out more about pattern hair loss in men and women from the British Association of Dermatologists website at tinyurl.com/alopecia21 and tinyurl.com/alopecia22

• Read more about alopecia areata on the Patient website at tinyurl.com/alopecia23 • Find out about useful sources of information for your patients, support groups in your area, and support forums such as Alopecia Online at tinyurl.com/alopecia24 Evaluate Are you now confident in your knowledge of alopecia and its causes and symptoms? Could you give advice to patients about treatments and ways to cope with hair loss?

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treatment. They will normally be prescribed either oral terbinafine, or griseofulvin combined with an antifungal shampoo containing selenium sulphide or ketoconazole.

Other causes of hair loss Other medical conditions that can cause hair loss or bald patches include: • psoriasis • seborrhoeic dermatitis • atopic eczema.

How can pharmacists help? In some cases, the cause of hair loss or thinning may be easy to detect: a middleaged man with classic male pattern baldness, for example, or a cancer patient undergoing

chemotherapy. But pharmacists should be familiar with other causes, such as medication and underlying disease, and know when to refer patients to their GP – such as when a patient wants to stop their medication because of a hair loss-related side effect. Patients with hair loss or thinning hair may be anxious or embarrassed, so make sure you have the right information for signposting patients to hairdressers for styling advice, counsellors for CBT, and local or online support groups. Ensure you and your staff are familiar with the treatment regimes for over-the-counter treatments such as minoxidil, and that you are prepared to lend a sympathetic ear to a patient who may well be self-conscious about their condition.

Take the 5-minute test online 1. On average, adults have about 100,000 hairs on their head. True or false 2. In the hair growth cycle, hair actively grows during the telogen phase. True or false 3. Androgenetic alopecia affects threequarters of men aged over 50 years. True or false 4. Around 50% of women over the age of 65 are affected by androgenic alopecia. True or false 5. After four months of minoxidil use, about a third of male users with partial hair loss will experience hair growth. True or false

6. Alopecia areata is more common in women, usually starting at around the age of 20-30 years. True or false 7. Topical immunotherapy is the most effective treatment for people with extensive alopecia areata. True or false 8. The main causes of telogen effluvium are chemotherapy, radiotherapy or immunosuppression. True or false 9. In scarring alopecia, the hair follicle is destroyed and the hair will never grow back. True or false 10. The symptoms of tinea capitis include small patches of scaly skin, an itchy scalp, and patchy hair loss. True or false

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