ANDROGENETIC ALOPECIA

FEMALE PATTERN HAIR LOSS (FPHL)

Female pattern hair loss (FPHL) is a distinctive form of hair loss that occurs in women with Androgenetic Alopecia. Many women are affected by FPHL. Around 40% of women by the age of 50 show signs of hair loss and less than 45% of women reach the age of 80 with a full head of hair.

In FPHL, there is diffuse thinning of hair on the scalp due to increased hair shedding or a reduction in hair volume, or both. It is normal to lose up to 50-100 strands a day. Another condition called chronic telogen effluvium also occurs with increased hair shedding and is often confused with FPHL. It is important to differentiate between these conditions as treatment for both conditions differ.

FPHL appears quite differently from the more easily recognisable male-pattern baldness, which usually begins with a receding frontal hairline progressing into a bald patch on top of the head. It is very uncommon for women to bald in this manner unless there is excessive production of androgens in the body.

FPHL has a strong genetic predisposition. The mode of inheritance is polygenic, indicating that there are many genes that contribute to FPHL, and these genes could be inherited from either parent or both.

The role of oestrogen is uncertain. FPHL is more common after menopause suggesting oestrogens may be stimulatory for hair growth.

A Cochrane systematic review published in 2012 concluded that minoxidil solution was effective for FPHL. Minoxidil is available as 2% and 5% solutions; the stronger preparation is more likely to irritate and may cause undesirable hair growth unintentionally on areas other than the scalp.

Hormonal treatment, i.e. oral medications that block the effects of androgens (e.g. spironolactone, cyproterone acetate, and finasteride) is also often recommended, and has been shown to improve hair growth, reduce hair loss and improve hair density.

Treatment should be continued for a minimum duration of 6 months before results are visible. Long-term treatment is usually recommended to sustain benefits.

Aesthetic camouflages include coloured hair sprays to cover thinning, hair bulking fibre powder and wigs.

Hair transplantation for FPHL has become popular although not every patient can benefit from the procedure and a consultation with a dermatologist with expertise in medical hair loss management and surgical restoration is recommended. Hair loss occurs due to a number of medical conditions and a proper assessment is essential before any treatment is administered.

Studies indicate low-level laser therapy to be a successful option for improving Androgenetic Alopecia. Platelet-rich plasma (PRP) injections are also being studied, but are yet to be approved for use in Singapore for hair loss.

A proper assessment is imperative before considering your treatment options, hence seeing a dermatologist that specialises in hair disorders and hair transplantation surgery is important, as some types of hair loss may not be amenable to surgery, and may in fact aggravate some of these conditions if incorrectly diagnosed and treated.

Dermatologists who are MOH-accredited specialists in managing disorders of the skin, hair and nails primarily manage hair disorders. Dr Angeline Yong is a dermatologist and dermatological surgeon whose subspecialty interests include hair disorders and hair transplantation. She was the founding consultant and lead of the hair transplant service at the National Skin Centre prior to her private practice.

MALE-PATTERN HAIR LOSS

Male-pattern hair loss is the most common type of thinning of the hair and balding that occurs in adult males. It is due to a combination of hormones (androgens) and a genetic predisposition. Male-pattern hair loss is also called Androgenetic Alopecia. It is characterised by a receding hairline and hair loss on the top and front of the head.

Male-pattern hair loss is caused by a genetically determined sensitivity to the effects of Dihydrotestosterone (DHT) in some areas of the scalp. DHT is believed to shorten the growth, or anagen, phase of the hair cycle, from a usual duration of 3–6 years to just weeks or months. This occurs together with miniaturisation of the follicles and progressively fewer and finer hairs. An enzyme called 5-alpha reductase regulates the production of DHT.

Several genes are involved, accounting for differing age of onset, progression, pattern and severity of hair loss in family members. The susceptible genes are inherited from both parents. At this time, genetic testing for prediction of balding is unreliable.

Current treatment options include:

• Minoxidil solution
• Finasteride tablets
• Dutasteride tablets
• Low-level laser therapy
• Hair transplantation surgery
• Cosmetics
• Micropigmentation (tattoo) to resemble shaven scalp
• Hairpieces

A proper assessment is imperative before considering your treatment options, hence seeing a dermatologist that specialises in hair disorders is important. Dermatologists who are MOH-accredited specialists in managing disorders of the skin, hair and nails primarily manage hair disorders. Dr Angeline Yong is a dermatologist and dermatological surgeon whose subspecialty interests include hair disorders and hair transplantation. She was the founding consultant and lead of the hair transplant service at the National Skin Centre prior to her private practice.

MEDICAL HAIR LOSS

Hair loss can result from a myriad of factors and may be due to varying conditions. It is essential that you seek consultation with a dermatologist with expertise in managing hair disorders in order to accurately assess and evaluate your form of hair loss. Successful treatment hinges on proper evaluation, and the following describes some of the more common forms of hair loss. It is not uncommon for a patient to have more than one condition contributing to hair loss and a thorough assessment is essential.

Some of the common forms of hair loss:

ALOPECIA AREATA

The term alopecia means hair loss. In Alopecia Areata, one or more round bald patches appear abruptly, most often on the scalp, affecting any hair-bearing site including the beard area, eyebrows and body hair. It occurs in men and women of all ages but is commonly observed in children and young adults.

Alopecia areata is classified as an autoimmune disorder, where the body’s own immune cells attacks hair follicles resulting in hair loss. Genetic predisposition plays a significant role in its occurrence. It is histologically characterised by T cells around the hair follicles. These immune cells release pro-inflammatory cytokines and chemokines that reject the hair.

The onset or recurrence of hair loss is sometimes triggered by:

Alopecia Areata may also be associated with other autoimmune conditions like Vitiligo or thyroid disease. It is a form of non-scarring alopecia, and the affected hair follicles may recover over a period of months or even years with appropriate treatment.

FRONTAL FIBROSING ALOPECIA

Frontal fibrosing alopecia is hair loss and scarring in the frontal region of the scalp. The exact cause of frontal fibrosing alopecia is unknown. There is a disturbed immune response to some component of the intermediate-sized and vellus scalp hair follicles. Genetic, hormonal and environmental factors may be involved. Contact allergy or photo contact allergies to cosmetics, hair dye and sunscreens have been indicated as possible but unconfirmed contributing factors.

Characterised by a usually symmetrical band of hair loss on the front and sides of the scalp, and loss of eyebrows, frontal fibrosing alopecia causes the edge to appear moth-eaten leaving single ‘lonely’ strands in bald areas.

The skin in the affected area usually looks normal but is sometimes pale, shiny or mildly scarred, without visible follicular openings. At the margins of the bald areas, close inspection or dermatoscopy shows signs of redness and scaling around hair follicles. In some cases, skin coloured or yellowish follicular papules are seen on the forehead and temples. Some women with frontal fibrosing alopecia also have female-pattern hair loss.

Trichoscopy reveals absent follicles, white dots, perifollicular scale and perifollicular erythema. In skin that’s easily tanned, perifollicular pigmentation may be observed.

Early diagnosis is essential as this is a form of scarring alopecia and delayed treatment may lead to permanent hair loss.

LICHEN PLANOPILARIS

Lichen planopilaris is a rare inflammatory condition that results in patchy progressive permanent hair loss mainly on the scalp. Lichen planopilaris usually affects young adult women, although the age range is wide and it also affects men. It commonly develops in association with lichen planus affecting the skin, mucosa and nails.

Lichen planopilaris typically appears as smooth white patches of scalp hair loss. No hair follicle openings can be observed in the areas of hair loss. At the edges of these patches, there may be scaling and redness around each hair follicle. Strands lose strength and are easily pulled out. It is multifocal and small areas may merge to form larger irregular areas. Lichen planopilaris is a gradually progressing condition.

Common sites of involvement are the sides, front and lower back of the scalp.

Symptoms are often absent, but they may include:

TELOGEN EFFLUVIUM

Telogen effluvium is the name for a common cause of temporary hair loss due to excessive shedding of resting, or telogen, hair after some shock to the system.

Acute telogen effluvium can affect people of all age groups and both sexes. Chronic telogen effluvium with no clear precipitating cause tends to present in otherwise healthy women 30–60 years of age. In a normal healthy person’s scalp, about 85% of the hair follicles are actively growing hair (anagen hair) and about 15% are resting hair (telogen hair). A hair follicle usually grows anagen hair for 4 years or so, then rests for about 4 months. Thus, it is normal to lose up to about 100 hairs a day as a result of the normal scalp hair cycle.

If there is some shock to the system, as many as 70% of the anagen hairs can be precipitated into telogen, thus changing the usual ratio. Typical triggers include:

• Childbirth: postpartum hair loss
• Acute or chronic illness
• Surgical operation
• Accident
• Psychological stress
• Weight loss
• Unusual diet, or nutritional deficiency
• Certain medications
• Skin disease affecting the scalp

A proper assessment is imperative before considering your treatment options, hence seeing a dermatologist that specialises in hair disorders is important. Dermatologists who are MOH-accredited specialists in managing disorders of the skin, hair and nails primarily manage hair disorders. Dr Angeline Yong is a dermatologist and dermatological surgeon whose subspecialty interests include hair disorders and hair transplantation. She was the founding consultant and lead of the hair transplant service at the National Skin Centre prior to her private practice.

NAIL DISORDERS

PINCER NAILS

SURGICAL NAIL AVULSION

Nails can also be partly or completely removed by surgical nail avulsion. It is used to remove a nail that is causing symptoms that are not improving by other means.

Conditions requiring surgical nail avulsion:

• Complete nail destruction due to fungal infection
• Thickened nail due to multiple causes, e.g. congenital, ageing, tight shoes, psoriasis
• Ingrown nail

Surgical nail avulsion however is not completely successful at curing fungal nail infection, as fungi may be growing in the nail matrix under the proximal nail fold. This becomes obvious as the nail begins to grow out again, hence concurrent treatment with topical and/or oral antifungal agents may also be required. It is also not an effective treatment for an inflammatory nail disease such as psoriasis.

CO2 LASER LATERAL MATRICECTOMY

Ingrowing nails are also a common problem and occur when the edge of the nail grows into flesh at the side of the nail, causing a painful injury. The punctured skin can become inflamed and infected. Sometimes a CO2 lateral matricectomy may be performed on top of a partial or complete surgical nail avulsion to relieve symptoms and prevent regrowth of the nail edge or recurrence of the ingrowing nail.

PARONYCHIA

Paronychia is inflammation of the skin around a finger or toenail, and can be broadly classified into acute (< 6 weeks) or chronic (persisting > 6 weeks).

Acute paronychia develops rapidly over a few hours, and usually affects a single nail fold. Symptoms are pain, redness and swelling.

Chronic paronychia on the other hand is a more gradual process which may start in one nail fold (typically the proximal nail fold), but often spreads laterally and to several other fingers. Each affected nail fold is swollen and lifted off the nail plate. This allows entry of organisms and irritants. The affected skin may be red and tender from time to time, and the main complication of chronic paronychia is nail dystrophy. The distorted, ridged nail plates may be yellow and brittle, and it can take up to a year for the nails to grow back to normal.

Treatment depends on the cause of the paronychia. For acute paronychia, topical antibiotics may be prescribed for localised, minor infection, whilst oral antibiotics may be needed for more severe bacterial infection. Oral acyclovir may be needed in the case of herpes simplex infection and a surgical incision and drainage may even be required if an abscess develops.

For chronic paronychia, addressing predisposing factors is essential. This includes avoiding wet work, or using waterproof gloves during washing if needed. Topical steroid and/or tacrolimus ointments may be applied for dermatitis, and intralesional steroid injections may be used in resistant cases. Surgical excision of the proximal nail fold or eponychial marsupialisation may even be needed in some cases.

FUNGAL INFECTION

Fungal infections of the skin are also known as ‘mycoses’. They are common and generally mild. However, in very sick, immune-suppressed people, fungi can cause severe disease. Superficial fungal infections are, however, most common and typically affect the outer layers of the skin, the nails and hair.

The 3 main groups of fungi causing superficial fungal infections are:

• Dermatophytes
  • Tinea corporis, pedis, manuum, cruris, capitis
  • Onychomycosis
• Yeasts
  • Candida
  • Malassezia
• Moulds

Dermatophyte infection: Tinea corporis, pedis, manuum, cruris, capitis

Dermatophyte fungi are the ringworm fungi. They invade and multiply within keratinized tissue and are caused by 3 main categories of dermatophytes – Trichophyton, Microsporum and Epidermophyton. T. rubrum is the commonest cause of dermatophytosis.

Tinea infections commonly can include tinea capitis (scalp), corporis (trunk), cruris (groin), manuum (hands), pedis (feet), and incognito.

Fungal infection may be suspected clinically or with the help of dermatoscopy. The presence of a dermatophyte infection is typically confirmed by:

• Microscopy and culture of skin scrapings
• Histopathological examination of skin or nail biopsy using stains to reveal fungal elements

Onychomycosis

Onychomycosis encompasses all fungal infections of the nail, and includes those caused by dermatophytes and non-dermatophytes.

Dermatophytes actually account for the majority of onychomycosis, with T. rubrum and T. metagrophytes amongst the most common causes. Although onychomycosis is often asymptomatic and of cosmetic concern, patients with the condition can complain of discomfort associated with trimming the nails. Toenail infections are more common than fingernail infections, and clinical features include onycholysis, nail plate thickening, nail plate destruction, subungal debris, surface changes to the nail (e.g. roughening), and changes in nail colour.

Direct microscopy and cultures from nail clippings should be performed if onychomycosis is suspected, and especially if oral antifungal treatment is likely to be administered.

Yeast infection: Candidiasis

Superficial skin infections can also be caused by non-dermatophyte species such as candidal yeasts and Malassezia furfur.

Common examples of cutaneous candidiasis include intertrigo, vulvovaginal candidiasis and oral candidiasis. C. albicans is responsible for the majority of superficial and systemic candidiasis. Chronic or relapsing infection should provoke a search for relapsing factors which include diabetes, obesity, systemic steroid or antibiotic therapy, HIV infection or other forms of immunodeficiency.

Yeast infection: Malassezia infections

Malassezia infections typically present in the form of pityriasis versicolor or as pityrosporum folliculitis.

Pityriasis versicolor typically presents with scaly hypo- or hyperpigmented macules affecting the trunk, neck, abdomen or proximal limbs. Pigmentary abnormalities may even persist for months post pityriasis versicolor infection. Risk factors include humid, warm environments and immunosuppression.

P. folliculitis on the other hand, is characterized by monomorphic, follicular, erythematous papules and pustules on the trunk, upper arms and neck. P. folliculitis is most often mistaken for truncal acne, and can in fact be exacerbated by oral antibiotic or topical steroid use. Dr Yong will be able to provide an accurate assessment of your condition and may recommend taking a skin scrape for further diagnosis.

SCALP CONDITIONS

There are a myriad of conditions that can affect the scalp and cause common symptoms like itching, redness, discomfort, scaling and even contribute to hair fall. It is therefore essential that you seek consultation with a dermatologist to accurately assess and evaluate the condition of your scalp. Successful treatment hinges on proper evaluation, and the following describes some of the more common conditions that can affect the scalp.

FOLLICULITIS

Folliculitis is the name given to a group of skin conditions in which there are inflamed hair follicles. This results in painful red spots, often with a surface pustule.

Folliculitis may affect anywhere where there are hairs, and this can include the scalp, chest, back, armpits, arms and legs. Acne and its variants are also types of folliculitis. Folliculitis can be due to infection, occlusion and irritation.

The following are some of the common types of folliculitis.

Scalp folliculitis

Scalp folliculitis is an inflammatory disorder affecting the hair follicles in the scalp. This is characterised by small, occasionally itchy pustules on the scalp. There may be few scattered lesions or sometimes there could be extensive involvement. They often become sore and crusted, and may lead to scarring alopecia if left untreated.

Antidandruff shampoos containing antifungal agents such as ketoconazole are sometimes helpful. Other medications that are useful in the treatment of this condition include topical antibiotics, mild topical steroid lotions, oral antibiotics and even oral isotretinoin.

Pseudofolliculitis barbae

Pseudofolliculitis barbae is an inflammatory reaction surrounding ingrown facial hairs, which typically results from shaving. It can also occur on any body site where hair is shaved or plucked, including the chin, upper lips, axilla, pubic area, and legs. It is also known as shaving rash.

Pseudofolliculitis barbae can be treated with mild steroid creams, topical acne treatments.

Pityrosporum folliculitis

Pityrosporum folliculitis is an itchy acne-like condition usually affecting the upper trunk of a young adult. There are typically very monomorphic folliculocentric pustules scattered over the trunk and upper limbs, and this condition is usually also associated with a history of heat and sweating with outdoor sports.

Treatment typically includes topical antifungal or oral antifungal medication for several weeks.

TINEA CAPITIS

Cutaneous fungal infections are non-invasive infections of the skin, hair and nails causing pathologic changes in the host. The fungi can be yeast-like, causing infections such as Candidiasis, or mould-like, causing Tinea infections. It is common and generally mild. However, in extreme cases or otherwise immune suppressed patients, fungi can cause severe disease.

Tinea capitis is the name used for infection of the scalp with a dermatophyte fungus. Although common in children, tinea capitis is less frequently seen in adults. Tinea capitis is most prevalent between the ages of three to seven. It is slightly more common in boys than girls.

Tinea capitis may present in several ways.

• Dry scaling
• Black dots — hairs are broken off at the scalp surface
• Smooth areas of hair loss
• Kerion — a very inflamed mass
• Favus — yellow crusts and matted hair
• Carrier state — no symptoms and only mild scaling

SEBORRHOEIC DERMATITIS

Most commonly seen in babies (Usually clears up by 2 months of age), Seborrhoeic dermatitis also affects adults with a more chronic/relapsing form of eczema/dermatitis that mainly occurs in the sebaceous, gland-rich regions of the scalp, face, and trunk. Dandruff is a non-inflammatory, milder version of Seborrhoeic dermatitis.

Causes of Seborrhoeic Dermatitis:

• Proliferation of various species of the skin commensal Malassezia, in its yeast (non-pathogenic form).
• In infants, the condition is related to developing oil glands.
• In adults, the condition occurs due to inflammatory reaction to overgrowth of Malassezia yeasts.

Infantile Seborrhoeic dermatitis causes cradle cap (diffuse, greasy scaling on scalp), and the rash may also affect armpit and groin folds. Typically there are salmon-pink patches that may flake or peel, and these are not particularly itchy, so babies often seem undisturbed by the rash, even when generalised.

A proper assessment is imperative before considering your treatment options, hence seeing a dermatologist that specialises in hair disorders is important. Dermatologists who are MOH-accredited specialists in managing disorders of the skin, hair and nails primarily manage hair disorders. Dr Angeline Yong is a dermatologist and dermatological surgeon whose subspecialty interests include hair disorders and hair transplantation. She was the founding consultant and lead of the hair transplant service at the National Skin Centre prior to her private practice.

SCARRING ALOPECIA & SURGICAL SCARS

UNWANTED HAIR GROWTH AND HIRSUTISM

Unwanted hair and excessive hair growth due to hypertrichosis and hirsutism can be removed through laser treatments. Treatments typically require 4-6 sessions, with adequate healing time in between depending on area being treated.

The treatment involves highly concentrated light beamed into hair follicles causing the melanin pigment within the follicles to absorb the light, leading to destruction of follicles. A less painful procedure, which is much quicker than electrolysis, the lasers selectively target melanin, thereby heating up the basal stem cells in the follicle that causes excessive hair growth.

Melanin is considered the primary chromophore for all hair removal lasers currently on the market. Because of the selective absorption of laser light, only hair with colour such as black, brown, reddish-brown and dirty blonde can be removed. White hair cannot be removed by this method as it lacks the melanin pigment.

Some medical indications for hair removal include:

• Hirsutism
  • Hirsutism is a male-pattern of secondary or post-pubertal hair growth occurring in women. It arises in the moustache and beard areas at puberty while hair also appears in non-hirsute women in the underarm and pubic areas. Hirsute women may also develop thicker, longer hair than usual on their limbs and trunk.
• Hypertrichosis (congenital or acquired)
• Pseudofolliculitis

Suitable devices include the long-pulsed Alexandrite lasers and long-pulsed Nd:YAG lasers – both of which are used at our clinic. The choice is made based on the skin type of the patient, with fairer skin types being more suited to the long-pulsed Alexandrite laser and darker skin types more suited to the long-pulsed Nd:YAG laser.

A non-laser device such as the intense pulsed light is another option.

A proper assessment is imperative before considering your treatment options, hence seeing a dermatologist that specialises in hair disorders is important. Dermatologists who are MOH-accredited specialists in managing disorders of the skin, hair and nails primarily manage hair disorders. Dr Angeline Yong is a dermatologist and dermatological surgeon whose subspecialty interests include hair disorders and hair transplantation. She was the founding consultant and lead of the hair transplant service at the National Skin Centre prior to her private practice.