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Alopecia

Category: Illness or disabilities

Type

Involuntary

Introduction and description

Alopecia is the general medical term for hair loss.   Hair loss, also known as baldness, refers to a loss of hair from parts of, or in rare cases all, the head or body.  Spot baldness, is a condition in which hair is lost from some of the body. For example, it may result in a few bald spots on the scalp, each about the size of a coin. In a few, all the hair on the scalp or all body hair is lost and loss can be permanent. 

Animals too can suffer from alopecia and the types of causes are often the same as those in humans – stress, fungus, bacteria, viruses, parasites, pharmaceuticals, chemicals, toxins etc.  If we take some examples

  •  Dogs -  Sebaceous adenitis is a disease that targets and destroys sebaceous glands in some dogs. Common clinical signs included alopecia and hypotrichosis [sparse hair which is usually coarse, dry, and tightly curled]. Canine pinnal alopecia is most common in dachshunds, but others, such as Chihuahuas, Boston terriers, whippets and Italian greyhounds, may also be vulnerable.
  • Rabbits -  In rabbits, dermatophytosis [any superficial fungal infection caused by a dermatophyte- a pathogenic fungus] is a prime cause of alopecia in young, newly weaned rabbits.
  • Cats -  Dermatophytosis as a cause of alopecia is common in cats, too, and in long-haired varieties.
  • Ferrets - Ferret adrenal disease is extremely common and is the most common cause of alopecia in ferrets, typically affecting middle-aged animals between three and seven years old. 
  • Mice - Alopecia areata has even been studied in mice.

Hair loss is thus a common problem in many animals. Pattern hair loss by age 50 affects about half of human males and a quarter of human females.

Side effects of other illnesses

A whole host of illnesses can produce alopecia, and in all these cases, the illness itself needs to be investigated and the cause of that illness.  For example:

  • Tumours and skin outgrowths induce localized baldness (sebaceous nevus, basal cell carcinoma, squamous cell carcinoma). 
  • Hypothyroidism (an under-active thyroid) and the side effects of its related medications can cause hair loss, typically frontal. 
  • Hyperthyroidism (an over-active thyroid) can also cause hair loss.
  • Testerone imbalance - Male pattern baldness runs in families and is characterized by a receding hairline, and moderate to extensive loss of hair, especially on the crown area. The hair is lost in an M-shaped pattern, with loss at the crown and temples and sparing of the sides and the back of the head.  The main cause of this condition is the presence of high amounts of the male hormone, dihydrotestosterone (DHT) within the hair follicle. DHT is produced from testosterone in the prostate, the scalp and other organs. As such, DHT imbalance may also be due to problems with these organs.  The abundance of DHT causes the hair follicle to degrade and shortens the active phase of the hair.
  • Androgen imbalance- Androgenetic alopecia –results from androgen imbalance, which itself has its own cause – follow the LINK.  In other words to cure the alopecia one has to cure the androgen imbalance.  Androgenetic alopecia, Diabetes mellitus and heart disease can be co-morbidities.
  • Pregnancy and oestrogen imbalance - Hair loss often follows childbirth in the postpartum period. The hair is thicker during pregnancy owing to an increase in circulating oestrogens, but once birth has taken place -typically between 2 and 5 months afterwards, oestrogen levels drop and hair loss may occur, often particularly noticeably around the hairline and temple area. Once hormone levels have stabilised, hair typically grows back normally.  Treatment is NOT indicated.

Symptoms

Alopecia is a disorder that affects the young and old. Many diagnoses, particularly the scarring alopecias, are more common in adults; however, others, such as tinea capitis, are more common in children, and some, such as alopecia areata, often affect both age groups.

Alopecia is a symptom and not a cause, there are many types of hair loss with different symptoms.  The many names allocated by the medical profession are exceptionally confusing - they have not been tremendously systematic [or helpful] in their choice of names in this area, especially given that the causes follow a well ordered pattern.  Examples include:

  • Anagen effluvium is the abnormal diffuse loss of hair during the growth phase - anagen are growth-phase hairs - caused by an event that impairs the mitotic activity of the hair follicle.  “Classically, it is caused by radiation therapy to the head and systemic chemotherapy, especially with alkylating agents.” – so the cause here is either radiation or chemotherapy [pharmaceuticals]
  • Alopecia areata  - Alopecia areata (AA) is characterized by non-scarring alopecia with T-cell infiltration at the affected hair follicle.  The underlying mechanism apparently involves failure by the body to recognize its own cells with subsequent immune mediated destruction of the hair follicle.  About 2% of people develop alopecia areata at some point in time.  Alopecia areata  is classified as an Autoimmune disease, of which more shortly.
  • Alopecia mucinosa - also known as "Follicular mucinosis," "Mucinosis follicularis,", "Pinkus’ follicular mucinosis," and "Pinkus’ follicular mucinosis–benign primary form" is a skin disorder that generally presents, but not exclusively, as erythematous [red andinflamed] plaques or flat patches without hair primarily on the scalp, neck and face.  Alopecia mucinosa occurs when mucinous material - material covered with mucus - accumulates in the hair follicles and sebaceous glands. This triggers an inflammatory response, and affects the follicles ability to produce hair. This hair loss is reversible in the early stages, but once the disease advances, the hair follicles are destroyed, and Scarring alopecia occurs.  The key here of course is to find out what is causing the mucus to be produced.  Note that it may not be a pathogen, in some cases it may simply be pressure from those confined to wheelchairs or hospital beds.  So the cause may be Physical hurt
  • Cicatricial alopecia – is scarring hair loss, the loss of hair which is accompanied with scarring. ... It can be caused by a diverse group of disorders that destroy the hair follicle, replace it with scar tissue, and cause permanent hair loss. Both primary and secondary forms of cicatricial alopecia have been described. The hair follicles are the specific target of inflammation in primary cicatricial alopecias. Hair follicles are destroyed randomly with surrounding structures in secondary cicatricial alopecia. Disorders causing primary cicatricial alopecias include :

·       chronic cutaneous lupus erythematosus – see SLE
·       lichen planopilaris - Lichen planus occurs when your immune system mistakenly attacks cells of the skin or mucous membranes.  Again there is a link with apparent auto-immunity - Autoimmune disease, of which more shortly.

  • Alopecia cicatrisata – also known as Pseudopelade of Brocq is a flesh- to pink-coloured, irregularly shaped alopecia that may begin in a moth-eaten pattern with eventual coalescence into larger patches of alopecia.
  • Dissecting cellulitis (DC) also referred to as to as perifolliculitis capitis abscedens et suffodiens (Hoffman) causes large, painful sores (ulcers) to develop on your skin, most often on your legs, that evolve into scarring alopecia.  Interestingly there are links with pigmented casts, black dots, and "3D" yellow dots, as well as Crohn’s disease, IBS, arthritis and pyoderma gangrenosum [An ulcerating condition of skin that results in heaped borders where the skin at the edge is purple-red. The ulcers can become quite large].  Pathogens are implicated – principally bacteria, fungi and parasites
DC likely involves both follicular dysfunction and a …. cutaneous immune response to commensal bacteria, such as coagulase negative staphylococci.  PMID: 24852785

  • Folliculitis et perifolliculitis capitis abscedens et suffodiens is a rare disease that involves the scalp, eventually resulting in painful abscesses, extensive scarring and irreversible alopecia. The condition is also known as 'acne necrotica miliaris' or 'Proprionibacterium' folliculitis.   Pathogens enter the hair follicle and result in inflammation and hair loss.   There is no one pathogen that is the root cause.  Instead the micro-organism may be bacteria (especially Propionibacterium acnes, but in severe cases, also Staphylococcus aureus), Yeasts (Malassezia species) and mites (Demodex folliculorum).
  • Frontal fibrosing alopecia - alopecia and scarring on the scalp near the forehead. In some cases, the eyebrows, eye lashes and/or other parts of the body may be involved, as well.
  • Graham-Little syndrome - Graham-Little-Piccardi-Lasseur syndrome (GLPLS) is a rare lichenoid dermatosis defined by the triad of multifocal cicatricial alopecia of the scalp; noncicatricial alopecia of the axilla and groin; and a follicular lichen planus eruption on the body, scalp, or both.  Again there is a link with apparent auto-immunity - Autoimmune disease, of which more shortly.
  • Frictional alopecia is hair loss caused by rubbing of the hair or follicles, for example, around the ankles of men from socks, where even if socks are no longer worn, the hair often will not grow back.  In horses, human contact with the horse and the rubbing of the saddle across the mane can cause patches of hair loss.
  • Involutional alopecia  - Gradual thinning of hair with age is a natural condition known as involutional alopecia. This is caused by an increasing number of hair follicles switching from the growth, or anagen, phase into a resting phase, or telogen phase, so that remaining hairs become shorter, thinner,  more liable to break and fewer in number.
  • Traction alopecia is most commonly found in people with ponytails or pigtails who pull on their hair with excessive force. In addition, rigorous brushing and heat styling, rough scalp massage can damage the cuticle, the hard outer casing of the hair. This causes individual strands to become weak and break off, reducing overall hair volume.  Here the cause is obvious and easily corrected
  • Trichotillomania is the loss of hair caused by compulsive pulling and bending of the hairs. Onset of this disorder tends to begin around the onset of puberty and usually continues through adulthood. Due to the constant extraction of the hair roots, permanent hair loss can occur.  Trichotillomania is thus an ‘impulse-control disorder’; treatment is aimed at controlling the underlying psychiatric condition.
  • Telogen effluvium – is caused by trauma but in this case unlike Trichotillomania is not self inflicted trauma, the trauma may be childbirth, major surgery, even poisoning.  The shock results in the hair ceasing to grow – “a large number of hairs enter the resting phase at the same time, causing shedding and subsequent thinning”. The condition also presents as a side effect of chemotherapy – which is a form of poisoning.  Chemotherapy affects the hair’s growth phase with the result that almost 90% of hairs fall out soon after chemotherapy starts.  In essence, Telogen effluvium is a nonscarring, noninflammatory alopecia of relatively sudden onset caused by physiologic or emotional stress. Once the precipitating cause is removed, the hair typically will regrow.
  • Tinea capitis - is a cutaneous fungal infection (dermatophytosis) of the scalp. The disease is primarily caused by dermatophytes in the Trichophyton and Microsporum genera that invade the hair shaft. The clinical presentation is typically single or multiple patches of hair loss, sometimes with a 'black dot' pattern (often with broken-off hairs), that may be accompanied by inflammation, scaling, pustules, and itching. Uncommon in adults, tinea capitis is predominantly seen in pre-pubertal children, more often boys than girls.  At least eight species of dermatophytes are associated with tinea capitis.
  • Trichorrhexis nodosa occurs when hairs break secondary to physical trauma and is often a result of hair styling or overuse of hair products. Toxins

 

The role of Intestinal Dysbiosis and 'Autoimmunity'


 As can be seen from the above descriptions, fungi, bacteria, viruses, toxins, parasites and so on can be a major cause of alopecia.  On many occasions, when the disease is classified as an autoimmune disease, the body is not attacking cells, it is attacking pathogens that have been gradually expelled by the immune system to the skin's surface.  It is however, then worth asking the question where did all these pathogens come from?  How did they get into the blood stream, when the gastrointestinal system is intended to keep them out?  And the answer is that they got into the blood stream via a 'leaky gut'.

The use of antibiotics and a number of other pharmaceuticals can not only can cause a leaky gut but may result in catastrophic changes to the intestinal flora.  In this research, the dysbiosis created resulted in biotin deficiency.  Antibiotic treatment induced the accumulation of detrimental bacteria in the gut, which consumed residual biotin and depleted available biotin in the gut. :


Metabolism by the gut microbiota affects host physiology beyond the gastrointestinal tract. Here, we find that antibiotic-induced dysbiosis, in particular, .... impaired gut metabolic function and led to the development of alopecia. While deprivation of dietary biotin per se did not affect skin physiology, its simultaneous treatment with vancomycin resulted in hair loss ...... Collectively, our results indicate that luminal metabolic alterations associated with gut dysbiosis and dietary modifications can compromise skin physiology.  PMID:  28813664

Causes

Where no disease or trauma is present the cause is almost always genetic, certain genes predispose certain people – particularly men – to baldness.

Psychological trauma and stress

From the list of the different types of alopecia, we can see that a considerable number of types are caused by either ongoing stress or psychological trauma.  Stress and trauma inhibit the immune system and prevent it from fully fighting pathogens.  Amongst the more obvious ones of physical or mental abuse or work related stress one new cause  of stress has emerged

Climate change contributes to the increase in severity and frequency of flooding, which is the most frequent and deadly disaster worldwide. Flood-related damage can be very severe and include health effects. Among those health impacts, dermatological diseases are one of the most frequently encountered. Both infectious and noninfectious dermatological conditions are increasing after flooding.
We searched PubMed using the search term climate change OR global warming OR rainfall OR flooding OR skin. Articles published in the English-language literature were included. We also searched the International Society of Dermatology website library on climate change for additional articles.
There is an increased risk of trauma during the course of a natural disaster. The majority of post-tsunami wound infections were polymicrobial, but gram-negative bacteria were the leading causes. Infectious diseases with dermatological manifestations, such as impetigo, leptospirosis, measles, dengue fever, tinea corporis, malaria, and leishmaniasis, are important causes of morbidity among flood-afflicted individuals. …… Dermatological conditions such as alopecia areata, vitiligo, psoriasis, and urticaria can be induced or exacerbated by psychological conditions post disaster. PMID:  29377078

Hypoxia

Cells need oxygen to function, and the hair follicle is just another group of cells.  Thus is the cells are deprived of oxygen as a consequence of atherosclerosis, endothelial dysfunction, environmental pollution or even just smoking, the hair is going to suffer:

…..the association of tobacco smoking with various adverse effects on the skin and hair has long been recognized. Increasing public awareness of the association between smoking and hair loss seems to offer a good opportunity for the prevention or cessation of smoking, since the appearance of hair plays an important role in the overall physical appearance and self-perception of people. PMID: 26370649

Bacteria

Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum subspecies pallidum.  One of its symptoms is alopecia.

A 42-year-old patient, HIV negative, presented with a 2-month history of progressive generalized thinning of the hairs and small non-scarring irregular alopecia patches of the parietal-occipital areas of the scalp. The patient was under sertraline hydrochloride therapy for a recent diagnosis of bipolar disorder, and expressed the concern that the drug was causing the hair-loss. Accurate anamnesis and visiting of the patient revealed asymptomatic pale pink speckles of the trunk and limbs, and a bilateral psoriasis-like palmo-plantar hyperkeratosis, suggestive of secondary syphilis, further confirmed by serology. Specific antibiotic treatment healed all skin and scalp manifestations, but also the moodiness disorders, which allowed complete psychiatric drug dismissing. PMID:  28906089

Other bacteria are also implicated in causing alopecia – especially Propionibacterium acnes, but in severe cases, also Staphylococcus aureus.

Radiation

Radiation-induced alopecia after fluoroscopically guided procedures is becoming more common due to an increasing use of endovascular procedures. It is characterized by geometric shapes of nonscarring alopecia related to the area of radiation. We report a case of a 46-year-old man presenting with asymptomatic, sharply demarcated rectangular, nonscarring alopecic patch on the occipital scalp following cerebral angiography with fistula embolization under fluoroscopy. His presentations were compatible with radiation-induced alopecia. Herein, we also report a novel scalp dermoscopic finding of blue-grey dots in a target pattern around yellow dots and follicles, which we detected in the lesion of radiation-induced alopecia.  PMID:  28074164

Pharmaceuticals including chemotherapy and other toxins or poisons

As we saw above, antibiotics are a major cause of alopecia because of their effect on the intestine and the resulting gut dysbiosis.  Another major cause is immunosuppressants.  Clearly where the attacking agent is a pathogen, the immunosuppressants suppress the immune system allowing the pathogen to attack the skin from within, destroying hair and hair follicles in the process

Trichodysplasia spinulosa is a rare disease that occurs in the setting of immunosuppression, …... Clinically, it is characterized by a centrofacial cutaneous eruption of erythematous papules with a central keratinous spicule, often associated with variable degrees of alopecia. Histologic findings are characteristic, and electron microscopy reveals the presence of trichodysplasia spinulosa associated polyomavirus.  PMID:  29806684

Fluconazole is an antifungal medication, it has very serious side effects including liver problems, QT prolongation, and seizures. During pregnancy it may increase the risk of miscarriage while large doses may cause birth defects.  And it also causes alopecia:

Fluconazole-induced alopecia is a significant problem for patients receiving long-term therapy. …. Human patients with alopecia attributed to fluconazole underwent detailed assessment and in both our murine model and human cohort fluconazole induced telogen effluvium. PMID: 30455235

Any pharmaceuticals that affect the body’s hormone balance can have a pronounced effect on hair gain or loss: these include the contraceptive pill, hormone replacement therapy, acne medications and anabolic steroids.

The following link should take you to the eHealthme website which lists all the pharmaceuticals implicated in causing – directly or indirectly – alopecia.  The lists are drawn up from Adverse Drug Reports submitted to SEDA and the FDA by doctors. LINK

Several thousand drugs are listed, indicating that doctor prescribed drugs are a major cause of alopecia.

Fungus infection

By definition, Tinea capitis is a cutaneous fungal infection (dermatophytosis) of the scalp. The disease is primarily caused by dermatophytes in the Trichophyton and Microsporum genera that invade the hair shaft. At least eight species of dermatophytes are associated with tinea capitis. 

We report a case of a healthy 19-year-old Hispanic male presenting with a 2-month history of a large, painful subcutaneous boggy plaque on the scalp with patchy alopecia, erythematous papules, cysts and pustules. ….. A punch biopsy of the scalp demonstrated endothrix consistent with tinea capitis, but with a brisk, deep mixed inflammatory infiltrate as can be seen with chronic dissecting cellulitis. Fungal culture revealed Trichophyton tonsurans.  PMID:  23582018

Microsporum canis is a worldwide diffused zoophilic dermatophyte which causes clinical conditions often characterised by multifocal alopecia, scaling, and circular lesions in many animal species, including humans.  [PMID: 30189676] It is largely resistant to pharmaceuticals – though not to plants.  There are also a number of yeasts implicated in causing alopecia including the Malassezia species.

Viral infection

HPV and Polyomavirus have been implicated in causing alopecia, as has Herpes Zoster – shingles.

Viral associated trichodysplasia spinulosa (VATS) is a rare cutaneous eruption characterized by folliculocentric papules, keratin spicules, and alopecia associated with trichodysplasia spinulosa-associated polyomavirus (TSPyV) infection. PMID: 28654466

Vaccines

Our aim was to study the potential link between hepatitis B virus (HBV) antigen exposure and Alopecia areata - AA.

METHODS: Two pediatric patients with AA following hepatitis B vaccination were identified in a general dermatology clinic. A bioinformatics analysis and an electronic medical record (EMR) database query were performed at the University of Rochester Medical Center to identify patients with AA, coexisting viral infections, vaccinations, or interferon (IFN) therapy in order to determine if the presence of AA and these conditions was higher than in AA patients without these associated conditions or therapy.
RESULTS: An increased frequency of AA among those who received the HBV surface protein antigen [odds ratio (OR) 2.7, p < 0.0001] was identified, and an independent analysis revealed an increased frequency of AA in those receiving IFN-β treatment (OR 8.1, p < 0.05). One potential antigenic target identified was SLC45A2, a melanosomal transport protein important in skin and hair pigmentation. The longest potential vaccine peptide fragment match (8-mer) was to a segment of natural killer (NK) cell inhibitory receptors, KIR3DL2 and KIR3DL1. Predictive modeling of major histocompatibility complex (MHC)-peptide binding demonstrated potential binding of this peptide to MHC relevant to AA.
LIMITATIONS: The results will need to be verified in additional patient databases allowing analysis of temporal relationships, and with molecular experiments of the identified antigens.
CONCLUSIONS: Our data confirm associations between viral infection and IFN treatment with AA. It establishes that the hepatitis B surface protein antigen has shared epitopes with human killer immunoglobulin-like receptors.  PMID:  28801732

Physical hurt

Constant pressure, friction, and rubbing of the skin can damage the hair follicle and the skin resulting in blisters and ulcers as well as hair loss.  There may also be bruising.

Parasites

Mites and other skin parasites have a very damaging record for producing hair loss, principally because they attack the hair follicle – often in their attempts to obtain food.  Demodex folliculorum, for example is a microscopic mite that feeds on the sebum produced by the sebaceous glands, denies hair essential nutrients and can cause thinning and hair loss.

Demodex mites are ectoparasites often found in follicles of facial skin. ….. a growing number of studies indicated that they contribute to chronic inflammatory conditions of the skin, such as rosacea, blepharitis, otitis externa, alopecia and folliculitis. PMID: 21715284

The Sebaceous adenitis that destroys sebaceous glands in some dogs is often caused by mites.

Nutritional deprivation

Hair and the hair follicles need nutrients to work correctly. 

the quantity and quality of hair are closely related to the nutritional state of an individual. Normal supply, uptake, and transport of proteins, calories, trace elements, and vitamins are of fundamental importance in tissues with high biosynthetic activity, such as the hair follicle. In instances of protein and calorie malnutrition as well as essential amino acid, trace element, and vitamin deficiencies, hair growth and pigmentation may be impaired.  PMID: 26370649

Treatment

Find and address the cause.

References and further reading

  • Acta Microbiol Immunol Hung. 2011 Jun;58(2):145-55. doi: 10.1556/AMicr.58.2011.2.7. - Risk factors and prevalence of Demodex mites in young adults. - Horváth A1, Neubrandt DM, Ghidán Á, Nagy K.
  • Indian J Dermatol. 2011 May;56(3):318-20. doi: 10.4103/0019-5154.82492.  Folliculitis et perifolliculitis capitis abscedens et suffodiens controlled with a combination therapy: systemic antibiosis (metronidazole plus clindamycin), dermatosurgical approach, and high-dose isotretinoin.  Tchernev G1. PMID:  21772598
  • Cell Rep. 2017 Aug 15;20(7):1513-1524. doi: 10.1016/j.celrep.2017.07.057.  Intestinal Dysbiosis and Biotin Deprivation Induce Alopecia through Overgrowth of Lactobacillus murinus in Mice.  Hayashi A1, Mikami Y2, Miyamoto K1, Kamada N3, Sato T2, Mizuno S2, Naganuma M2, Teratani T2, Aoki R4, Fukuda S5, Suda W6, Hattori M7, Amagai M8, Ohyama M9, Kanai T10.
  • Syphilitic Alopecia.  Moshiri AS, Moxam A.  N Engl J Med. 2018 Oct 25;379(17):1657. doi: 10.1056/NEJMicm1804118.  PMID: 30354954
  • Nonspecific diffuse alopecia as a single manifestation of syphilis infection: clinical and trichoscopic features.  Costa MC, Peres AS, Queiróz AJR, Souza Medeiros N, Costa IMC.  Int J Dermatol. 2018 May;57(5):593-595. doi: 10.1111/ijd.13892. Epub 2018 Jan 16.  PMID:  29336022
  • Int J Dermatol. 2018 Aug;57(8):901-910. doi: 10.1111/ijd.13901. Epub 2018 Jan 29. Impact of climate change on dermatological conditions related to flooding: update from the International Society of Dermatology Climate Change Committee.  Dayrit JF1, Bintanjoyo L1, Andersen LK2, Davis MDP3.

·       1Department of Dermatology, Research Institute for Tropical Medicine, Muntinlupa City, Philippines.

·       2Department of Dermatology and Venereology, Aarhus University Hospital, Aarhus, Denmark.

·       3Department of Dermatology, Mayo Clinic in Minnesota, Rochester, Minnesota, USA.

  • Case Rep Dermatol Med. 2016;2016:8202469. doi: 10.1155/2016/8202469. Epub 2016 Dec 15. Radiation-Induced Alopecia after Endovascular Embolization under Fluoroscopy. - Ounsakul V1, Iamsumang W1, Suchonwanit P1.1Division of Dermatology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
  • Am J Clin Dermatol. 2018 Feb;19(1):119-126. doi: 10.1007/s40257-017-0312-y.  Evaluation of the Relationship between Alopecia Areata and Viral Antigen Exposure.  Richardson CT1, Hayden MS2, Gilmore ES3, Poligone B4,5.
  • J Dermatol. 2013 Aug;40(8):672. doi: 10.1111/1346-8138.12174. Epub 2013 May 20.  Alopecia areata associated with Herpes zoster.  Baek JH, Hong KC, Lee DY, Kim MS, Lee UH, Park HS. PMID: 23682830

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