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Scalp is made of 5 layers: · Skin · Superficial fascia · Deep fascia · Loose areolar tissue · pericranium



Blood supply:

Scalp is supplied from before backwards: · Supratrochlear · Supraorbital · Superficial temporal arteries · Posterior auricular · Occipital arteries


Hair follicle



· Growth cycle: Hair grows in cycles. Each cycle consists of a long growing phase (anagen), a brief transitional apoptotic phase (catagen), and a short resting phase

(telogen). At the end of the resting phase, the hair falls out (exogen) and a new hair starts growing in the follicle, beginning the cycle again. Normally, about 100 scalp hairs reach the end of resting phase each day and fall out. When significantly more than 100 hairs/day go into resting phase, clinical hair loss (telogen effluvium) may occur. A disruption of the growing phase causing abnormal loss of anagen hairs is an anagen effluvium.




· Alopecia is defined as loss of hair. Hair

loss is often a cause of great concern to the patient for cosmetic and psychologic reasons, but it can also be an important sign of systemic disease.



· The most common cause of alopecia is · Androgenetic alopecia (male-pattern or female-pattern hair loss) · · · · ·

Androgenetic alopecia is an androgen-dependent hereditary disorder in which dihydrotestosterone plays a major role. Other common causes of hair loss are Drugs (including chemotherapeutic agents) Infection Systemic illnesses (particularly those that cause high fever, systemic lupus, endocrine disorders, and nutritional deficiencies) Less common causes are primary hair shaft abnormalities, autoimmune disease, heavy metal poisoning, and rare dermatologic conditions.



Alopecia can be classified as focal or diffuse and by the presence or absence of scarring. Scarring alopecia is the result of active destruction of the hair follicle. The follicle is irreparably damaged and replaced by fibrotic tissue. Several hair disorders show a biphasic pattern in which nonscarring alopecia occurs early in the course of the disease, and then permanent hair loss occurs as the disease progresses. 9

Non scarring diffuse hair loss: · Anagen effluvium · Androgenetic alopecia · Telogen effluvium · Primary hair shaft abnormalities · Congenital disorders


Non scarring focal hair loss: · Alopecia areata · Trichotillomania · Tinea capitis · Traction alopecia


Scarring focal hair loss: · Cutaneous lupus · Lichen planus of scalp · Secondary scarring alopecia, caused by burns, trauma, skin cancers etc.


Alopecia Areata

Definition: It is an autoimmune inflammatory disease characterized by patchy or total hair loss from any hairy area of the body Epidemiology: · The third most common cause of hair loss (after AGA & Telogen Effluvium) · Life time risk is 1.7% of population 13

Presentation of disease

· Usually presents as sudden hair loss in well· · · ·

demarcated, localized area Usually round or oval patch May be isolated or numerous May progress quickly to significant hair loss Usually patches are seen in the scalp, but can also see involvement of beard area, body, eyebrows, and eyelashes, nose hairs 14

Appearance of the patch/patches

· Redness may be present · Usually no scaling, but there may be red

or inflamed hair follicles · Pigmented hairs are often shed while the unpigmented or white hairs are spared · "Going gray overnight"




Patchy disease with hair regrowing


AA may mimic male patterned baldness


Alopecia Totalis


Universalis Type


Hair fall associated with down's syndrome and vitiligo


Exclamation hairs

· Difficult to photograph · Often seen at the margins of the active

patch of hair loss · A sign of active disease · Inflammation has affected the growth of a hair that was in a mid-anagen (midgrowth) phase · Pull test may be positive adjacent to the exclamation point hairs 23

Exclamation Point Hairs


Other sites of loss

· · ·

Eyebrows Eyelashes Beard


Common nail changes in AA

· Pitting · Trachyonychia · Beau's lines · Thinning or loss of nails · White spots and lines or red spots


Alopecia areata with nail changes

Patient with alopecia totalis and severely affected nails

Nail involvement was not responsive to antifungals


Nails Pitting




Pull test

· Pull test is a test for activity of hair loss · Can be used in other diseases as well · 30-40 hairs pulled between thumb and

forefinger from scalp to end of hair · 0-2 hairs is normal hair loss · Difficult to perform on extremely long or short hair, and extremely curly hair · Only situation in AA where counting hairs may be helpful 30

Pull Test


Pluck test

The pluck test pulls individual hairs out abruptly ("by the roots"). The roots of the plucked hairs are examined microscopically to determine the phase of growth. Normally, 85 to 90% of hairs are in the anagen phase; about 10 to 15% are in telogen phase; and < 1% are in catagen phase. Telogen effluvium shows an increased percentage of telogen-phase hairs on microscopic examination, whereas anagen effluvium shows a decrease in telogen-phase hairs and an increased number of broken hairs. Primary hair shaft abnormalities are usually obvious on microscopic examination of the hair shaft. 32

Scalp biopsy

Scalp biopsy is indicated when alopecia persists and diagnosis is in doubt. Biopsy may differentiate scarring from nonscarring forms. Specimens should be taken from areas of active inflammation, ideally at the border of a bald patch. Fungal and bacterial cultures may be useful; immunofluorescence studies may help identify lupus erythematosus, lichen planopilaris, and systemic sclerosis 33

Daily hair counts

Daily hair counts can be done by the patient to quantify hair loss when the pull test is negative. Hairs lost in the first morning combing or during washing are collected in clear plastic bags daily for 14 days. The number of hairs in each bag is then recorded. Scalp hair counts of > 100/day are abnormal except after shampooing, when hair counts of up to 250 may be normal. Hairs may be brought in by the patient for microscopic examination 34


· Onycholysis · Nail pitting · Alopecia · Folliculitis · Arterio venous fistula · Pyogenic granuloma. 35

Conditions worsening the disease:

· Childhood onset of alopecia · Hair loss occurs more than half of the

scalp. · Down's syndrome · Atopic eczema · Loss of hair from eyelashes, eyebrows etc. · Family history of alopecia areata. 36

Differential diagnosis:

· Trichotillomania: hair loss due to

compulsive hair pulling, twisting or teasing. Pattern of hair loss is incomplete. Seen in psychological conditions. · Tinea capitis: hair loss accompanied by scaling. Black dots or discolorations seen in the areas of the hair loss. Caused by trychophytons. 37

· Early scarring alopecia: · Chronic cutaneous lupus : lesions are

present on other parts of body also. Usually discoid lupus leisions are seen on the scalp. · Secondary syphylis: Moth eaten pattern of hair loss seen on the scalp. 38

· Telogen effluvium: Due to hormonal

imbalance. Loss of hairs entering resting phase. Seen in conditions like oral contraceptives, menopause, post partum, pregnancy, endocrine problems. · Anagen effluvium: caused by agents that impair or disrupt anagen cycle. Usually caused by medicines taking against cancer. 39


· Medicinal:

Topical corticosteroids Systemic corticosteroids Surgical: Punch graft hair transplantation Micrografts and minigrafts Scalp reduction Tissue expansion Transposition flaps 40

What you present to the world is your hair

"This is my hair with gum in it" "This is my hair when my braids are too tight" "This is my hair with curlers..."

"This is me with no hair"



· Head ,hair baldness young peoples

--Bar-c,Lyco,Sil Hair brittleness --- Kali ­c ,Fl- acid,Ars Hair curly becomes ---Mezerium Hair thin --- Tuberculinum


· Hair falling after acute exhausting diseases

--- Carbo veg ,Thallium · Grief from ­ Phos ­acid · Injury from ­ Hypericum · Lactation agg ­ Natrum- m · Menopause ­ Lyco ,Sepia · Pregnancy during -- Lachesis





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