Professional Guide to Signs and Symptoms
5th Edition

Alopecia [Hair loss]
Alopecia usually develops gradually and affects the scalp; it may be diffuse or patchy and can be classified as scarring or nonscarring. Scarring alopecia (permanent hair loss) results from hair follicle destruction, which smoothes the skin surface, erasing follicular openings. Nonscarring alopecia (temporary hair loss) results from hair follicle damage that spares follicular openings, allowing future hair growth.
One of the most common causes of alopecia is the use of certain chemotherapeutic drugs. Alopecia may also result from the use of other drugs; radiation therapy; a skin, connective tissue, endocrine, nutritional, or psychological disorder; a neoplasm; an infection; a burn; or exposure to toxins.
Normally, everyone loses about 50 hairs per day, and these hairs are replaced by new ones. However, aging, genetic predisposition, and hormonal changes may contribute to gradual hair thinning and hairline recession. This type of alopecia occurs in about 40% of adult men and may also occur in postmenopausal women.
In both sexes, hair loss may also occur on the trunk, pubic area, axillae, arms, and legs. Another normal pattern of alopecia occurs 2 to 4 months postpartum. This temporary, diffuse hair loss on the scalp
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may be scant or dramatic and possibly accentuated at the frontal areas. Anxiety, high fever, and even certain hair styles or grooming methods may also cause alopecia. (See Recognizing patterns of alopecia, page 36.)
HISTORY AND PHYSICAL EXAMINATION
If the patient isn’t receiving a chemotherapeutic drug or radiation therapy, begin by asking when he first noticed the hair loss or thinning. Does it affect the scalp alone, or does it occur elsewhere on the body? Is it accompanied by itching or rashes? Then carefully explore other signs and symptoms to help distinguish between normal and pathologic hair loss. Ask about recent weight change, anorexia, nausea, vomiting, excessive stress, and altered bowel habits. Also ask about urinary tract changes, such as hematuria or oliguria. Has the patient been especially tired or irritable? Does he have a cough or difficulty breathing? Ask about joint pain or stiffness and about heat or cold intolerance. Inquire about exposure to insecticides. If the patient is female, ask if she has had menstrual irregularities and note her pregnancy history. If the patient is male, ask about sexual dysfunction, such as decreased libido or impotence.
Next, ask about hair care. Does the patient frequently use a hot blow dryer or electric curlers? Does he periodically dye, bleach, or perm his hair? If the patient is black, ask if he uses a hot comb to straighten his hair or a long-toothed comb to achieve an Afro look. Does he ever braid the hair in cornrows? Check for a family history of alopecia, and ask what age relatives were when they started experiencing hair loss. Also ask about nervous habits, such as pulling the hair or twirling it around a finger.
Begin the physical examination by taking vital signs and then assessing the extent and pattern of scalp hair loss. Is it patchy or symmetrical? Is the hair surrounding a bald area brittle or lusterless? Is it a different color than other scalp hair? Does it fall out easily? Inspect the underlying skin for follicular openings, erythema, loss of pigment, scaling, induration, broken hair shafts, and hair regrowth.
Then examine the rest of the skin. Note the size, color, texture, and location of any lesions. Check for jaundice, edema, hyperpigmentation, pallor, or duskiness. Examine nails for vertical or horizontal pitting, thickening, brittleness, or whitening. As you do so, watch for fine tremors in the hands. Observe the patient for muscle weakness and ptosis. Palpate for lymphadenopathy, enlarged thyroid or salivary glands, and masses in the abdomen or chest.
MEDICAL CAUSES
  • Alopecia areata. Alopecia areata is usually marked by well-circumscribed patches of nonscarring hair loss on the scalp without skin changes. Occasionally, the patches also appear on the beard, axillae, pubic area, arms, legs, or the entire body (alopecia universalis). “Exclamation point” hairs—loose hairs with rough, brushlike tips on narrow, less-pigmented shafts—typically border expanding patches of alopecia. Although this disorder is recurrent, hair growth usually returns after several months. In about 20% of patients, alopecia areata also causes horizontal or vertical nail pitting.
  • Arsenic poisoning. Most common in chronic poisoning, alopecia is diffuse and mainly affects the scalp. Related signs and symptoms include muscle weakness and wasting, areflexia, partial or total vision loss, and bronze skin.
  • Arterial insufficiency. Patchy alopecia occurs in arterial insufficiency, typically on the lower extremities, and is accompanied by thin, shiny, atrophic skin and thickened nails. The skin turns pale when the patient’s legs are elevated and dusky when they’re dependent. Associated findings include weak or absent peripheral pulses, cool extremities, paresthesia, leg ulcers, and intermittent claudication.
  • Burns. Full-thickness or third-degree burns completely destroy the dermis and epidermis, leaving translucent, charred, or ulcerated skin. Scarring or keloid formation
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    associated with these burns causes permanent alopecia.
  • Cutaneous T-cell lymphoma. More common in older patients, cutaneous T-cell lymphoma may be associated with alopecia mucinosa in its first, or premycotic, stage. Scattered papules or plaques may occur on clothed areas, such as breasts and buttocks, or a zebralike pattern of scaly erythema may form on the trunk. Alopecia may persist through the plaque and tumor stages.
  • Dissecting cellulitis of the scalp. Resulting from skin infection, dissecting cellulitis of the scalp is characterized by small nodules that eventually rupture and drain. Keloid formation during healing causes permanent alopecia.
  • Exfoliative dermatitis. Exfoliative dermatitis is a transient disorder in which loss of scalp and body hair is preceded by several weeks of generalized scaling and erythema. Nail loss commonly occurs along with pruritus, malaise, fever, weight loss, lymphadenopathy, and gynecomastia.
  • Fungal infections. Tinea capitis (scalp ringworm), the most common fungal infection, produces irregular balding areas, scaling, and erythematous lesions. As these lesions enlarge, their centers heal, causing the classic ring-shaped appearance. Surrounding the balding areas are broken scalp hairs. When they break off at the scalp surface, hairs resemble black dots. Other findings include pruritus and thick, whitish nails.
  • Hodgkin’s disease. Permanent alopecia may occur if the lymphoma infiltrates the scalp. It’s accompanied by edema, pruritus, and hyperpigmentation. Associated signs vary with the degree and location of lymphadenopathy.
  • Hypopituitarism. In adults, hypopituitarism varies greatly, depending on its severity and the number of deficient hormones. Gonadotropin deficiency in the female causes sparse or absent pubic and axillary hair accompanied by infertility, amenorrhea, and breast atrophy. A similar deficiency in the male decreases facial and body hair and causes infertility, decreased libido, impotence, poor muscle development, and undersized testes, penis, and prostate gland. A human growth hormone deficiency at an early age may cause short stature. Deficiency of thyroid-stimulating hormone produces signs of hypothyroidism; deficiency of corticotropin produces signs of adrenocortical insufficiency.
  • Hypothyroidism. In hypothyroidism, the hair on the face, scalp, and genitalia thins and becomes dull, coarse, and brittle. Most characteristic, though, is loss of the outer third of the eyebrows. Typically, alopecia is preceded by fatigue, constipation, cold intolerance, and weight gain. Other signs and symptoms include dry, flaky, inelastic skin; puffy face, hands, and feet; hoarseness; thick, brittle nails; slow mental function; bradycardia; menorrhagia; and myalgia.
  • Lichen planus. Occasionally, lichen planus disorder produces patchy hair loss on the scalp with skin inflammation. Angular, flat, purple papules typically develop on the lower back, genitalia, arms, and lower legs. Related findings include pruritus and nail changes, ranging from grooves to nail loss. Scarring alopecia may develop with scalp skin atrophy.
  • Lupus erythematosus. Hair loss is a chief complaint in patients with either discoid or systemic lupus. Hair tends to become brittle and may fall out in patches; short, broken hairs (known as lupus hairs) commonly appear above the forehead. Both types of lupus are characterized by raised, red, scaling plaques with follicular plugging, telangiectasia, and central atrophy. Facial plaques typically assume a distinctive butterfly pattern.
    In systemic lupus, however, the rash may vary in severity from malar erythema to discoid lesions. Unlike discoid lupus, systemic lupus affects multiple body systems. It may produce photosensitivity, weight loss, fatigue, lymphadenopathy, arthritis, emotional lability, and other signs and symptoms.
  • Myotonic dystrophy. Premature baldness characterizes the adult form of this muscular dystrophy. However, myotonia—the inability to normally relax a muscle after its contraction—is its primary sign. Associated
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    signs include muscle wasting and cataracts.
  • Protein deficiency. Protein deficiency produces brittle, fine, dry, and thinning hair and, occasionally, changes in its pigment. Characteristic muscle wasting may be accompanied by edema, hepatomegaly, apathy, irritability, anorexia, diarrhea, and dry, flaky skin.
  • Sarcoidosis. Sarcoidosis may produce scarring alopecia if it infiltrates the scalp. Accompanied by various lesions on the face and the oral and nasal mucosa, it may also produce fever, weight loss, fatigue, lymphadenopathy, substernal pain, cough, shortness of breath, visual muscle weakness, arthralgia, myalgia, and cranial nerve palsies.
  • Scleroderma (progressive systemic sclerosis). A late sign in scleroderma, permanent alopecia is accompanied by thickening and tightening of the skin, especially on the arms and hands. The skin appears taut and shiny and loses its pigment. Other findings include dysphagia, dyspepsia, abdominal pain, altered bowel habits, cough, dyspnea, and signs of renal failure.
  • Seborrheic dermatitis. Erupting in areas with many sebaceous glands and in skin folds, seborrheic dermatitis may produce hair loss on the scalp. Alopecia begins at the vertex and frontal areas and may spread to other scalp areas. The patient’s skin is reddened and dry with branlike scales that flake off easily. Pruritus is common.
  • Skin metastasis. Occasionally, cancer from an internal site, such as the lung, metastasizes to the skin, causing scarring alopecia that may develop slowly along with scalp induration and atrophy. Related findings include weight loss, fever, altered bowel habits, abdominal pain, and lymphadenopathy.
  • Syphilis, secondary. This sexually transmitted disease produces temporary, patchy hair loss that gives the scalp and beard a “moth-eaten” appearance. It also produces loss of eyelashes and eyebrows and a pruritic rash. Associated signs and symptoms include slight fever, weight loss, sore throat, malaise, anorexia, lymphadenopathy, nausea, vomiting, headache, a maculopapular rash, and condyloma latum.
  • Thyrotoxicosis. Diffuse hair loss, possibly accentuated at the temples, occurs in this disorder. Hair becomes fine, soft, and friable. The skin becomes uniformly flushed and thickened, marked by red, raised, pruritic patches. Characteristically, this disorder produces fine tremors, nervousness, an enlarged thyroid, sweating, heat intolerance, amenorrhea, palpitations, weight loss despite increased appetite, diarrhea, and possibly exophthalmos.
OTHER CAUSES
  • Drugs. Chemotherapeutic agents—such as bleomycin, cyclophosphamide, dactinomycin, daunorubicin, doxorubicin, fluorouracil, and methotrexate—may cause patchy, reversible alopecia a few weeks after administration. Hair loss is usually limited to the scalp, but with long-term chemotherapy, it may also affect the axillae, arms, legs, face, and pubic area. New hair—which may differ in thickness, texture, and color from the patient’s original hair—may begin to grow after the drug is discontinued or between successive treatments.
    Other common drugs may cause diffuse hair loss on the scalp a few weeks after administration. These include allopurinol, antithyroid drugs, beta-adrenergic blockers, carbamazepine, colchicine, gentamicin, heparin, hormonal contraceptives, indomethacin, lithium, trimethadione, valproic acid, excessive doses of vitamin A, and warfarin. Hair growth usually resumes when these drugs are discontinued.
  • Radiation therapy. Like certain drugs, radiation therapy produces temporary reversible hair loss a few weeks after exposure. Because X-rays damage hair follicles at the site of therapy, head or scalp X-rays cause the most obvious hair loss.
  • Thallium poisoning. Thallium poisoning produces diffuse but temporary hair loss on the scalp. Nausea and vomiting are also common. In acute poisoning, the patient may experience arm and leg pain,
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    bilateral ptosis, ataxia, fever, nasal congestion, conjunctival injection, and abdominal pain. In chronic poisoning, he may experience translucent, thin, and shiny skin and signs of renal damage such as oliguria.
SPECIAL CONSIDERATIONS
Alopecia can have a devastating impact on the patient’s self-image, especially if it’s extensive and occurs suddenly, as with chemotherapeutic drugs. Make sure you explain to the patient that this hair loss is reversible. Occasionally, scalp hypothermia methods—such as a cryogen, an ice-filled cap, or a scalp tourniquet—may be used before, during, and after drug administration to cause scalp vasoconstriction, thus decreasing drug delivery to the hair follicles and minimizing hair loss. However, these methods are contraindicated in patients with circulating malignant cancer cells (for example, patients with lymphoma) or scalp metastases.
A skin biopsy may be performed to determine the cause of the alopecia, especially if skin changes are evident. Microscopic examination of a plucked hair may also aid diagnosis.
For patients with partial baldness or alopecia areata, topical application of minoxidil (a common antihypertensive that also produces hair growth) for several months stimulates localized hair growth. However, hair loss may recur if the drug is discontinued.
PEDIATRIC POINTERS
Alopecia normally occurs during the first 6 months of life, as either a sudden, diffuse hair loss or a gradual thinning that’s hardly noticeable. Reassure the infant’s parents that this hair loss is normal and temporary. If bald areas result because the infant is left in one position for too long, advise the parents to change his position regularly.
Common causes of alopecia in children include use of chemotherapy or radiation therapy, seborrheic dermatitis (known as cradle cap), follicular mucinosis, tinea capitis, and hypopituitarism. Tinea capitis may produce a kerion lesion—a boggy, raised, tender, and hairless lesion. Trichotillomania, a psychological disorder more common in children than adults, may produce patchy baldness with stubby hair growth due to habitual hair pulling. Other causes include progeria and congenital hair shaft defects such as trichorrhexis nodosa.
PATIENT COUNSELING
Encourage gentle hair care to avoid further hair loss. Also, suggest wearing a wig, cap, or scarf, if appropriate. Remind the patient to cover his head in cold weather to prevent loss of body heat. Encourage patients who are frequently exposed to the sun to use sunblock to decrease the risk of skin cancer.