NEW YORK – Dr. Paradi Mirmirani has an elegant way of explaining hair loss to her postmenopausal patients.
"Think about [hair production] like an orchestra. When your body is making hair, a whole group of musicians are coming together to make music. But when you’re postmenopausal, the estrogen isn’t there, the head violinist isn’t there, and it’s not going to be the same, but you’re still making music. It’s not going to be same sound, but it’s still there," she said.
Dr. Mirmirani of the University of California, San Francisco, is well recognized for her research in hair disorders, and during her presentation at the American Academy of Dermatology’s summer meeting, she shared her tips on diagnosing and treating different types of hair loss and alopecia in women:
• Telogen effluvium (I’m shedding gobs of hair!)
Find out whether the patient has a history of weight loss or is on new oral contraceptives, Dr. Mirmirani said. Use a hair shaft contrast card and search the scalp for scarring or scaling. Also, perform a "pull test" (for bulb) and "tug test" (for shaft), she advised. For laboratory data, she recommended ferritin and TSH, and possibly tests for antinuclear antibodies and vitamin D levels, and a biopsy of the area. Treat the underlying problem, not the hair, and assure patients that they will not go bald, she said.
• Traction alopecia (I’ve got a bald spot!)
Start by asking these patients what they do for hair care and styling, said Dr. Mirmirani. On exam, look for a telltale "fringe sign," which she and her colleagues described in a paper as "the presence of retained hairs along the frontal and/or temporal rim." (J. Clin. Exp. Dermatol. Res. 2011;2:117).
She recommended ordering ferritin and TSH tests for these patients, and possibly vitamin D. Also, treat any inflammation; consider nonspecific hair growth treatments such as minoxidil, and surgical hair restoration, and remind patients to treat their hair gently, she said.
• Alopecia areata
Ask alopecia areata patients about a personal or family history of atopic disorders, Dr. Mirmirani advised. Treatment options include intralesional corticosteroids (10 mg/cc to 2 cc total); topical corticosteroids; topical minoxidil 5% twice daily; short-contact anthralin (up to 30 minutes); topical immunotherapy; or psoralen + ultraviolet A (PUVA) treatment. Finally, remind patients that alopecia areata is an autoimmune condition that is not contagious, Dr. Mirmirani said. Compare it to an unwelcome house guest, she suggested.
• Female pattern hair loss (midlife hair crisis)
Start care for these patients by ordering (only if virilized) free and total T, dehydroepiandrosterone sulfate, and prolactin tests, Dr. Mirmirani said. Her recommended treatment protocol: minoxidil 2% or 5% solution twice daily, or 5% foam once daily; finasteride (1 mg) or spironolactone. Also, consider hair restoration or cosmetics that bring the scalp’s color closer to hair color and make hair loss less apparent, she suggested. This is when to remind patients that "the orchestra is still playing" (hair may still be produced) although estrogen (the first violinist) is absent, so it may not be quite the same.
• Acquired trichorrhexis nodosa (My hair just won’t grow!)
Acquired trichorrhexis nodosa is the most commonly reported hair shaft defect, Dr. Mirmirani said. It often results from excessive chemical processes and heat applied to hair. She described her typical acquired trichorrhexis nodosa patient as a 24-year-old black woman who washes her every 2 weeks and straightens every 6 weeks, her hair has been breaking off in the back, started after a recent color, with no symptoms.
In these patients, and exam usually shows that the overall hair density is good, no alopecia, a localized area of short hair with blunt ends, and a positive tug test (hair breaks off easily). The scalp often has mild scaling, but no pustules.
Make a hair mount, and show the patient her hair under the microscope; "it’s the easiest and most satisfying thing you can do," said Dr. Mirmirani.
Advise patients to use gentle hair care, trim unhealthy hair, and avoid heat and chemicals, she said. Wigs are fine for these patients, and most will recover the condition of their hair within a year or 2, she added.
• Cicatricial alopecia
Start with a biopsy around the margin of early active area, and then culture the pustules, said Dr. Mirmirani. Dermatopathology can show whether sebaceous glands are absent, and the degree of inflammatory infiltrate.
Explain to these patients that the hair roots or bulbs have been damaged, she added. Tell them regrowth is not possible, but they can relieve the signs and symptoms of the condition and prevent it from spreading. Describe it as "like a wildfire; we want to contain it, and halt the spread," she suggested.