Alopecia

Question 1

Dx

Answer 1

Frontal Fibrosing Alopecia

Progressive hair loss along the frontotem-
poral hairline. Note eyebrow hair loss as well as the presence of isolated “lonely”
hairs on the upper forehead

Question 2

Describe and Dx

Answer 2

Perifollicular erythema
Fine scale
Loss of hair follicles
Lonely hairs

Dx: FFA

Question 3

Ddx

Answer 3

Dissecting cellulitis of the scalp
Acne keloidalis niche

Question 4

Describe and DX

Answer 4

Hair tufting
Perifollicular scale
Erythema
Yellow crust

Dx folliculitis de calvans

Question 5

DX

Answer 5

Disecting cellulitis of the scalp

Question 6

Describe and Dx?

Answer 6

Irregularly shaped areas of
scarring alopecia along the midline - minimal inflammation.

“foot prints in the snow” appearance.

= Pseudopelade of Broq

Ddx: Central centrifugal alopecia

Question 7

Describe and Ddx?

Answer 7

Discoid lupus erythematosus.

Coalescing areas of cicatricial alopecia in which there is obvious erythema.

Central hypopigmentation is accompanied by peripheral hyper-
pigmentation.

Trichoscopy shows follicular plugs (large yellow dots) and arborizing vessels.

Question 8

Describe and Dx?

Answer 8

Vertex of the scalp
Patch of alopecia
Perifollicular erythema
Loss of follicular ostia
Perifollicular scale

Dx: Lichen Planopilaris

Question 9

DDx?

Answer 9

Appear scarring at this power:

Dx: Central Centrifugal alopecia
Ddx: Lichen planopilaris, pseudopalade of brocq

If non scarring: androgen alopecia,

Question 10

Answer 10

Health hairs

Follicular unit contains 1 -4 hairs.

No erythema
no Scale
Uniform colour and shape of the hair shaft

Question 11

Answer 11

Exclamation mark hair

Seen in
AA
Trichotillomania
Chemotherapy induced hair loss

Question 12

Answer 12

Comma hair

Seen in Tinea Capitus

Question 13

Answer 13

Broken hair

Seen in
Trichotillomania
Tinea Capitus
AA

Question 14

Answer 14

Yellow dots

Seen in
alopecia areata
androgenetic alopecia

Question 15

Black dots

Answer 15

Seen in
alopecia areata,
tinea capitis,
trichotillomania,
anagen effluvium

Question 16

Answer 16

Perifollicular pustules

Question 17

Answer 17

Hair tufts (>5 hairs per follicular unit)

Folliculitis de calvans

Question 18

Answer 18

Full thickness hair
Intermediate hairs
Thin Vellus hairs

= AGA

Question 19

Triggers of telogen effluvium

Answer 19

Question 20

Trichoscopy findings of AGA

Answer 20

Hair shaft diameter variability
Increased number of vellus hairs
Yellow dots (representing empty follicular units)
Follicular units with only one (<4) terminal hairs

Question 21

Screening tests for hyperandrogegism?

Answer 21

Total and free testosterone
DHEA-S
17 Hydroxyprogesterone

Question 22

Describe the Sinclair staging for Female AGA

Answer 22

5 stages

1 = normal hair density
2 = widening of the central part
3 = widening of the central part, with translucency of hairs at its borders
4 = Development of bald areas anteriorly + widening of the part and increased translucency
5 = advanced hair loss

Question 23

What is finasteride?

Answer 23

Type II 5 Alpha Reductase Inhibitor

Halts hair loss in 90% of men and results in partial hair regrowth in 65% of men

Question 24

Finasteride does for AGA for men and women?

Answer 24

Men: 1 mg per day

Women: 2.5 - 5 mg per day.

Question 25

Finasteride side effects:

Answer 25

1. Reversible loos of libido 2. Reduced volume of ejaculate fluid 3. Erectile dysfunction (2% of men) 4. Possible increased risk of high grade prostate carcinoma (overall reduced risk of prostate cancer) 5. Lowers PSA (makes test more difficult to interpret) 5. Teratogen 6. Allergic reaction 7. Low mood and suicidal ideation

Question 26

What is Dutasteride, what does is used for AGA?

Answer 26

A type I and II 5 alpha reductase inhibitor. Dose = 0.5 mg / day

Question 27

List treatment options of AGA?

Answer 27

Explain the diagnosis Investigate for and treat any underlying disorders of hyperandrogegism 1. Cosmetic Camouflage 2. Topical Minoxidil (2% or 5%) 3. Oral Minoxidil (0.5 - 2.5 mg / day) 4. 5 Alpha reductase inhibitors - Finasteride 1mg / day (men), 5mg /day (women) - Dutasteride (0.5mg / day) (NB: topical agents currently in trials) 5. Spironolactone (WOMEN only) - up to 200mg / day 6. Platelet rich plasma 7. Hair transplant 8. light therapy

Question 28

How long does anlagen phase last for?

Answer 28

2 - 4 years

Question 29

Number of hairs shed per day

Answer 29

50 - 200

Question 30

Clinical features of Telogen Effluvium?

Answer 30

Affects the whole scalp Fewer terminal hairs An increased percentage of follicular units with only one hair is the most characteristic feature. More Telogen hairs (>20% on trichoscopy is diagnostic) Evidence of re-growth = multiple short regrowing hairs

Question 31

Bloods for Hair loss panel

Answer 31

FBC UEC LFTs TFT Iron Studies (Aim for Ferritin > 40) ESR B12 / Folate

Question 32

Histo findings of Telogen Effluvium

Answer 32

Normal total number of hairs Normal number of terminal hairs Increase in the telogen count to >20% (>15% is suggestive); telogen count seldom exceeds 50%; >80% is inconsistent with telogen effluvium) Absence of inflammation or scarring

Question 33

Medication causes of Telogen Effluvium

Answer 33

Acitretin Anti-tyroid drugs (propylthiouracil) Lithium Beta Blockers Immunosuppressants - Methotrexate, Azathioprine NSAIDs - Ibuprofen Levodopa Allopurinol Anticonvulsants Endocrine therapies (oral contraceptive)

Question 34

What is this?

Answer 34

A Telogen Hair

Question 35

The lifetime risk of developing Alopecia Areata in 1%

Answer 35

False - 2 %

Question 36

Describe the subtypes of Alopecia Areata?

Answer 36

Patchy AA Totalis (scalp) Universalis (whole body) Ophiasis pattern sisaipho pattern Diffuse (widespread thinning)

Question 37

Prognosis of Alopecia Areata?

Answer 37

Generally reversible Late stage disease can have follicular drop out (normally >10 years) Prognosis is worse if persistent beyond 5 year

Question 38

Nail changes associated with alopecia aerata?

Answer 38

Pitting (grid like pattern) Trachonychia (sandpaper like roughness) Brittle nails Onycholysis koilonychia Onychomadesis

Question 39

Trichoscopy findings of alopecia areata

Answer 39

(1) exclamation point hairs – proximal hair shaft thinning due to episodes of arrested mitotic activity within the germinal matrix; (2) black dots – when the exclamation point hairs break off, the residual dark hair shaft is visible in the follicular opening (3) yellow dots – empty hair follicles filled with keratotic material and sebum

Question 40

Alopecia areata associations

Answer 40

Thyroid dysfunction Atopy SLE Metabolic syndrome Depression Anxiety Vitamin D Dependant rickets Down syndrome Autoimmune polyendocrinopathy-candidiasis ectodermal dystrophy syndrome (APECED) Satoyoshi syndrome (hair loss represents the syndrome’s major criterion while intermittent painful muscle spasms, diarrhea, and anti-nuclear antibodies are the minor criteria (2 of 3 required for diagnosis0

Question 41

Treatment of alopecia areata

Answer 41

Education Cosmetic camouflage Topicals agents - Ultrapotent corticosteroids - Calcinurin inhibitors - Minoxidil - Anthralin - Bimatoprost - latanoprost - topical JAK inhibitors Intralesional corticosteroids - triamcinolone acetonide (2.5 to 5 mg/ml) every 3–4 weeks. Systemic agents: 1. Oral corticosteroids - prednisolone: 0.4 to 0.6 mg/kg/day with a gradual taper over at least 12 weeks - Pulse steroids: dexamethasone 0.1 mg/kg twice weekly 2. Methotrexate (5 - 20mg weekly) 3. Cyclosporin (3 - 5 mg / kg / dose) 6. Oral JAK inhibitors: baracitinib 5. Aza, MMF, Dapsone, sulfasalazine, IL-17 inhibitors Adjunct: oral minoxidil