Alopecia

Overview of Alopecia

• Human skin bears approximately 5 million hair follicles of which around 100,000 hair follicles are located on the scalp.
• The hair grows in a cyclical manner and exhibit four phases: Firstly Growth (anagen), Secondly regression (catagen), Thirdly resting (telogen), and Lastly shedding (exogen).
• Furthermore, Hair disorders may result from defects in either hair cycle, or hair growth (excess—hirsutism; sparse—hypotrichoses), and from hair follicle destruction by per follicular inflammation (Lichen planus, Lupus erythematosus). [2]

Causes of Alopecia 

Nonscarring type

1.Primary cutaneous disorders, for example

• Androgenetic
• Telogen effluvium
• Alopecia areata
• Tinea capitis
• Traumatic alopecia

2.Drugs

3.Systemic diseases, for example

• Systemic lupus erythematosus
• Secondary syphilis
• Hypothyroidism
• Hyperthyroidism
• Hypopituitarism
• Deficiencies of protein, biotin, zinc, also perhaps iron

Scarring type

1.Primary cutaneous disorders, for example

• Cutaneous lupus (especially chronic discoid lesions)
• Lichen planus
• Central centrifugal cicatricial alopecia
• Folliculitis decalvans
• Linear scleroderma (especially morphea)

2. Systemic diseases, for example

• Discoid lesions in the setting of systemic lupus erythematous.
• Sarcoidosis
• Cutaneous metastases [1]

Classification

1. Alopecia areata:

• The usual presentation of this common autoimmune disorder is as well-defined, localized, non-inflammatory, non-scarring patches of alopecia, usually on the scalp.
• Pathognomonic ‘exclamation mark’ hairs are seen (like broken hairs, tapering towards the scalp) during active hair loss.
• A diffuse pattern can uncommonly occur on the scalp. Additionally Eyebrows, eyelashes, beard and body hair can be affected.
• Alopecia totalis describes complete loss of scalp hair.
• Alopecia universalis is complete loss of all hair.
• Nail pitting may occur.
• Spontaneous regrowth is usual for small patches of alopecia but the prognosis is less good for larger patches, more extensive involvement, early onset also an association with atopy.
• In addition to atopy, alopecia areata is associated with other autoimmune diseases, especially thyroid disease, and with Down’s syndrome.

2. Androgenetic alopecia:

• Male-pattern baldness is physiological in men over 20 years old, although it can also occur in teenagers.
• Surprisingly It is also found in women, particularly post-menopause.
• Characteristically, this involves bitemporal recession initially and subsequent involvement of the crown (‘male pattern’), although it is often diffuse in women.

Risk factor

Person having i.e.:

• Atopy,
• Type 1 diabetes mellitus,
• Autoimmune thyroid disease,
• Autoimmune polyendocrinopathy syndrome,
• Vitiligo,
• Pernicious anaemia,
• Inflammatory bowel disease also
• Down’s syndrome [3]

Pathogenesis of Alopecia 

• The autoimmune assault targets anagen-stage hair bulbs, inducing premature catagen development and subsequent hair shedding. [11]

Pathophysiology 

1. Alopecia areata:

• It is postulated to be a T-cell mediated autoimmune disease directed against hair follicles in late-anagen phase.
• Basically Alopecia Areata is believed to be a polygenic condition with environmental also lifestyle factors acting as triggers and causing aggravation.
• It is associated with atopy, type 1 diabetes mellitus, autoimmune thyroid disease, autoimmune polyendocrinopathy syndrome, vitiligo, pernicious anaemia, inflammatory bowel disease also Down’s syndrome.[1]

2. Androgenic Alopecia:

• Increased sensitivity of affected hairs to the effects of androgens Increased levels of circulating androgens (either ovarian or adrenal source in women) [3]

Sign & Symptoms of Alopecia 

1. Alopecia areata i.e.:

• Well-circumscribed, circular areas of hair loss, 2–5 cm in diameter
• Occasionally, In extensive cases, coalescence of lesions or involvement of other hair-bearing surfaces of the body
•  Either Pitting or sandpapered appearance of the nails. [1]
• Alopecia areata is common in people of all genders
• A solitary patch is the initial presentation in 80%, and spontaneous regrowth in 3 to 6 months is the rule.
• The natural course is variable as well as unpredictable.
• Recurrences are common and, with each recurrent episode, the severity tends to increase whereas probability of spontaneous re-growth diminish.
• The presence of ‘exclamation mark hair’ at the margin of the alopecia is indicative of activity.
• Re-growth in Alopecia Areata patches commences from the center, after that progresses centrifugally.
• Alopecia Areata patches are typically skin coloured also asymptomatic.
• Based on distribution and severity, several clinical patterns are recognized, i.e., focal, reticular, ophiasis (in other words band-like hair loss in the occipital and temporal scalp), sisaipho (as an illustration predilection for parietal scalp mimicking androgenetic alopecia), totalis (loss of all scalp hair), also universalis (loss of all scalp and body hair).
• Nail involvement, such as pitting, has been noted in 6.8 to 49.4%.
• Lastly, Alopecia Areata significantly impacts the quality of life[3]

2. Androgenic Alopecia i.e.:

• Miniaturization of hairs along the midline of the scalp
• Recession of the anterior scalp line in men and some women [1]

Clinical Examination

Appearance of the Patient

The appearance of the patient can provide clues to the diagnosis of alopecia.

Head

Scalp i.e.

• Normal or with features of scarring
• If the scalp is abnormal it provides clues to the differential diagnosis
• Scarring, which is a feature of many irreversible causes of hair loss such as tufted hair folliculitis [1]
• Scaling
• Erythema, which may be seen in vitamin A toxicity
• Pustules
• Dyspigmentation

Pattern: Diffuse or patchy i.e.

• Male pattern (diffuse): Bitemporal recession +/or vertex loss
• Female pattern (diffuse): Coronal thinning with preserved anterior hairline
• Patchy: With preserved hair of variable length as seen in trichotillomania
• With exclamation point hairs (alopecia areata)
• With no hair (scarring, traction, syphilis, tinea)[9]

Diagnosis of Alopecia

• Alopecia Areata is a clinically distinctive disease.
• The prognosis is variable, being good in mild disease also initial episodes.
• However, recurrent disease, severe disease (particularly ophiasis, totalis and universalis), early age at onset, nail involvement, and comorbidities such as atopy, are adverse. [3]

Differential Diagnosis

Conditions that may be confused with alopecia areata include i.e.:

• Traction alopecia
• Trichotillomania
• Tinea capitis
• Secondary syphilis
• Aplasia cutis
• Temporal triangular alopecia[7]

Complications of Alopecia

• Some patients experience only one episode, whereas others have multiple recurrences.
• Some patients progress to alopecia totalis (complete loss of scalp hair) or alopecia universalis (complete loss of body hair). [11]

Investigations of Alopecia 

• Important investigations include full blood count, renal also liver function tests, iron studies, thyroid function.
• Autoantibody screen and syphilis serology, as several systemic diseases, particularly iron deficiency also hypothyroidism, can cause diffuse non-scarring alopecia.
• Hair pull tests may help to establish the ratio of anagen to telogen hairs but require expertise for interpretation.
• Scrapings and plucking are sent for mycology if there is localized inflammation.
• Scalp biopsy and direct immunofluorescence of a scarring alopecia may confirm a diagnosis of lichen planus or discoid lupus erythematosus, but expert interpretation is needed.[2]

Treatment

• The impact of alopecia on quality of life must not be underestimated, on the other hand psychological support is required as treatment is difficult.
• It is important to establish realistic expectations.
• Underlying conditions must be treated.
• Alopecia areata may respond to either topical or intralesional corticosteroids.
• Some males with androgenetic alopecia may be helped by systemic finasteride.
• Topical minoxidil can be used in males and females with androgenetic alopecia but, if an effect is obtained, treatment must be continued and is expensive.
• In females, anti-androgen therapy, such as cyproterone acetate, can be used.
• Wigs are often appropriate for extensive alopecia.
• Scalp surgery also autologous hair transplants are expensive but can be used for androgenetic alopecia.[2]

Prevention

Tips to prevent baldness before it starts depends on what type of hair loss you have.

Switch up your hairstyles i.e.— In terms of hair loss prevention tips, frequently styling your hair in ways that pull it tight (braids, tight ponytails, or using hair rollers) can cause a type of hair loss called traction alopecia.

Quit Smoking or Vaping 

Eat a Healthy also Varied Diet

Take Care of Your Hair also Scalp[8]

Homeopathic Treatment of Alopecia

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?.

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. No a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improved with homeopathic medicines.

Homeopathic Medicines for Alopecia :

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

Medicines:

1.  Arsenic:

• Touching the hair is painful.
• Bald patches at or near the forehead; besides this scalp covered with dry scabs and scales,
• Looking rough and dirty, extending sometimes even to forehead, face and ears.[4]
• Scalp very sensitive, as a result cannot brush hair.
• Hair become gray early;
• Falling of hair.
• Dandruff [5]

2. Fluoric Acid:

• Itching of the head and falling off of the hair.
• The new hair is dry also breaks off.
• Large patches entirely denuded of hair.
• New hair dry and breaks off.
• Must comb the hair often, it mats so at the end.[4]

3. Natrum Mur.:

• Hair falls out if touched.
• Mostly on forepart of head, temples also beard.
• Scalp very sensitive.
• Face shining as if greasy. [4]
• Nodding motions of the head.
• Headaches of school children.
• Migraine
• Falling hair. [5]

4. Lycopodium:

• Hair becomes gray early.
• Hair falls off after abdominal diseases; after parturition.
• Burning, scalding, itching of the scalp, especially on getting warm from exercise during the day.[4]
• Premature baldness, after abdominal affections, parturition.
• Catarrhal headache agg. when discharge from nose is slacked up.
• Throbbing after every spell of cough, pains when pressing at stools.[5]

5. Phosphorus:

• Generally, Round patches on scalp completely deprived of hair.
• Falling off of the hair in large bundles especially on the forehead and on the sides above the ears.
• The roots of the hair seem to be dry.
• The denuded scalp looks clear.
• White also smooth; dandruff copious, falls out in clouds. [4]

6. Vinca Minor:

• It affects skin and hair and is effective for uterine haemorrhages.
• Furthermore, Weakness and prostration, accompany many sufferings;
• Weakness also faintness as if he would die.
• Mental exertion causes tremulous feeling and tendency to start
• Spots on scalp oozing foul moisture, matting hair together.
• Corrosive itching of scalp.
• Plica polonica (in other words, matted hair).
• Bald spots covered with short wooly hair.
• Hair falls out and is replaced by gray hair.[5]

7. Thuja Occidental:

• In general, Headache aggravate by sexual excess, from tea.
• Amelioration bending head backwards.
• Tearing, jerking pain.
• White scaly dandruff.
• Hair at first dry, then split; and at last falls out.
• Sweat smelling like honey. [5]

Diet & Regimen

For Managing Alopecia, Dietary precautions:

• Prioritize:

  • Iron-rich foods: Red meat, spinach, lentils. Iron deficiency can contribute to hair loss.
  • Zinc-rich foods: Oysters, beef, pumpkin seeds. Zinc is essential for hair growth and repair.
  • Biotin-rich foods: Eggs, almonds, sweet potatoes. Biotin supports healthy hair growth.
  • Protein-rich foods: Lean meats, fish, beans, nuts. Hair is primarily made of protein.
  • Vitamin D: Fatty fish, fortified foods, or supplements. Vitamin D may play a role in hair follicle health.

• Consider:

  • Anti-inflammatory foods: Fruits, vegetables, and omega-3 fatty acids may help reduce inflammation that could contribute to alopecia areata.

Regimen for Managing Alopecia

• Reduce Stress:

  • Practice stress management techniques like yoga, meditation, or deep breathing exercises. Stress can exacerbate hair loss.

• Scalp Health:

  • Gentle scalp massage to improve blood circulation to hair follicles.
  • Avoid harsh hair treatments and hairstyles that pull on the hair.

• Medical Treatments:

  • Consult a dermatologist or trichologist for diagnosis and treatment options.
  • Potential treatments include topical medications, injections, or oral medications.

Important:

• Underlying causes: Alopecia can have various underlying causes, including genetics, autoimmune conditions, and medical conditions.
• Individualized approach: It’s crucial to consult a healthcare professional for personalized advice and treatment options tailored to your specific type of alopecia and needs.

The Do’s & Don’ts

Terminologies

References

1. Harrison’s Principle of Internal Medicine 19^th edition
2. Davidsons Principles and Practice of Medicine 22^nd edition
3. API Textbook of Medicine 9^th edition
4. Lilienthal Book of Therapeutics
5. Textbook of Homoeopathic Materia Medica By Dr. S. R. Phatak
6. https://timesofindia.indiatimes.com/life-style/health-fitness/diet/21-foods-for-healthy-hair/articleshow/22575168.cms
7. https://www.ncbi.nlm.nih.gov/books/NBK537000/
8. https://www.webmd.com/connect-to-care/hair-loss/how-to-prevent-balding-before-it-starts
9. https://www.wikidoc.org/index.php/Alopecia_physical_examination
10. Alopecia areata: An update -Indian Journal of Dermatology, Venereology, and Leprology, 2021
11. Bolognia, Jean L., et al. Dermatology. 4th ed., Elsevier, 2018.

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