Adult Hair Loss – what to

do in primary care?

Dr Ben Esdaile MBBS BSc FRCP

Consultant Dermatologist and Clinical Lead

Whittington Hospital

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?

Hair cycle

Growing Transition Resting/Shedding

Hair Basics

100,000 scalp hairs

10% in Telogen

Telogen usually lasts around 100 days

Normal to lose upto 100 hairs/day

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

Hair Pull Test

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)

Question 1) Is there scarring?

Scarring alopecias

If Scarring

suspected –

Refer Routinely

**Frontal Fibrosing Alopecia

Unknown cause

Incidence increasing.

Loss of frontal scalp

margin and outer

eyebrows.

NON SCARRING ALOPECIA

DIFFUSE or PATCHES

Alopecia Areata

Autoimmune

Patients have higher rates of thyroid diseases, vitiligo

and atopic eczema.

Alopecia Areata – clinical patterns

Patchy

Alopecia totalis

Alopecia universalis

Ophiasis

Alopecia Areata – patchy

Alopecia Areata – trichoscopy

Alopecia Areata – totalis

Alopecia Areata – universalis

Alopecia Areata – ophiasis

Alopecia areata - Diagnosis

Usually straight forward.

Trichoscopy can help.

Alopecia areata – Management

When to refer

>20% refer to Dermatology.

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

Alopecia areata – Management

Localised. Less than 20%

At 3 months – if no improvement – refer

Options in secondary care:

Intralesional steroid injections

Immunotherapy

?JAK inhibitors

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

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.

Diffuse alopecia

• Telogen Effluvium

• Androgenetic Alopecia – Male and Female

pattern hair loss

Telogen Effluvium

Temporary hair loss

Telogen Effluvium

Shock to the system:

Illness

Surgery

Childbirth

Accident

Severe weight loss

Up to 70% of

anagen hairs

go into telogen

phase.

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**.

Androgenetic Alopecia

Male pattern hair loss Female pattern hair loss

40% of women by age of 50

50% of men by age of 50

Androgenetic Alopecia (Male)Caused by combination of hormones and

genetics.

Genetically determined sensitivity to

dihydrotestosterone (DHT).

Androgenetic Alopecia

Normal scalp AGA

Androgenetic Alopecia (Female)

Genetics (polygenic).

? Androgens as most normal circulating

testosterone levels.

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

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

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**

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**

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

Questions?