Ralph M. Trüeb. Female Alopecia. Guide to Successful Management

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4 Ralph M. Trüeb Female Alopecia Guide to Successful Management

5 Ralph M. Trüeb Center for Dermatology and Hair Diseases Wallisellen Switzerland ISBN ISBN (ebook) DOI / Springer Heidelberg New York Dordrecht London Library of Congress Control Number: Springer-Verlag Berlin Heidelberg 2013 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, speci fi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on micro fi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied speci fi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a speci fi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (

6 Preface My heart thought of my love of you, When half of my hair was braided; Skull of Anhapu I came at a run to fi nd you, And neglected my hairdo. Now if you let me braid my hair, I shall be ready in a moment. Papyrus Harris 500 (Ramesside Period) Old Myths and New Insights into Female Hair Loss Few dermatologic problems carry as much emotional overtones as the complaint of hair loss in women. In general, the best way to alleviate the emotional distress related to hair loss is to effectively treat it. In fact, one of the oldest medical professions, according to Greek historian Herodotus ( BC), was the Egyptian Physician of the Head who specialized in disorders of the scalp. Even if the complaint of hair loss may at times seem disproportionate to the extent of recognizable hair loss, the proportion of women suffering of truly imaginary hair loss is negligible. A detailed patient history focusing on chronology of events, examination of the pattern of hair loss and the scalp, few simple diagnostic techniques, dermoscopy of the hair and scalp (trichoscopy), pertinent screening blood tests, and a scalp biopsy in selected cases will usually establish a speci fi c diagnosis. Once the diagnosis is certain, treatment appropriate for that diagnosis is likely to control the problem. Ultimately, patients need to be educated about the basics of the hair cycle and why considerable patience is required for effective cosmetic recovery. Success relies on patient compliance that, on its part, relies on con fi dence in the physician and treatment. Rather than being a failure of the patient, patient noncompliance results from failure of the physician to build up that con fi dence. Adding to the patient s worry may be prior frustrating experiences with physicians, who tend to trivialize complaints of hair loss or dismiss them completely. This attitude on the part of physicians may result from lack of knowledge or from old myths regarding hair loss in women. Prerequisite for delivering appropriate patient care is an understanding of the pathologic dynamics of hair loss and the multitude of cause relationships. v

7 vi Preface New insights focus on the role of internal and external factors on hair loss in women, such as nutrition (proteins, energy, vitamins, and trace metals), hormones, aging, seasonality of hair growth and shedding, cigarette smoking, UV radiation, and hair care. It must be borne in mind that hair loss often does not result from a single cause effect but from a combination of factors that all need to be addressed simultaneously in an individualized manner for success. The aim of this monograph is to deliver to specialists as well as to primary care physicians with interest in hair the practical know-how to successful management of hair loss in female patients of all ages. Wallisellen, Switzerland Prof. Ralph M. Trüeb

8 Author Ralph M. Trüeb is a Professor of Dermatology. He received his MD and Swiss Board Certi fi cation for Dermatology and Venereology as well as for Allergology and Clinical Immunology from the University of Zurich, Switzerland. In , he spent a year at the University of Texas Southwestern Medical Center at Dallas with Rick Sontheimer and at the Howard Hughes Medical Institute in Dallas with Bruce Beutler to complete his Fellowship in Immunodermatology. After a 20-year tenure at the Department of Dermatology, University Hospital of Zurich, where he established and was head of the Hair Consultation Clinic, he established in 2010 his private Center for Dermatology and Hair Diseases in Wallisellen, Zurich. He is past President of the European Hair Research Society ( ) and founding President of the Swiss Skin and Hair Foundation (2011). His clinical research interests focus on hair loss in women, in fl ammatory phenomena, hair aging and antiaging, and patient expectation management. He is currently author of 166 peer-reviewed scienti fi c publications and author and editor of 4 textbooks on hair. vii

10 Acknowledgements A thankful heart is not only the greatest virtue, but the parent of all other virtues. Cicero ( BC) With great respect and thankfulness, I would like to acknowledge my international fellow colleagues who have either inspired me or have been companions and friends over the years in the quest for excellence in the management of female alopecia (in alphabetical order): Bruno Bernard, Ulrike Blume- Peytavi, Pierre Bouhanna, Francisco Camacho, Zoe Draelos, Juan Ferrando, Tobias Fischer, Ramon Grimalt, Marcella Guarrera, Rudolf Happle, Rolf Hoffmann, Maria Hordinsky, Daisy Kopera, Steven Kossard, Won-Soo Lee, Andrew Messenger, Sundaram Murugusundram, Elise Olsen, Ralf Paus, Gérald Piérard, Bianca-Maria Piraccini, Vera Price, Valerie Randall, Pascal Reygagne, Lidia Rudnicka, Hugh Rushton, Jolanta Schmidt, Jerry Shapiro, Rodney Sinclair, Kurt Stenn, Antonella Tosti, Dominique van Neste, David Whiting, Hans Wolff, Xingqi Zhang, and Abraham Zlotogorski. Without the support of the pharmaceutical and hair cosmetic industry, we would have not had the many opportunities to meet and share our knowledge all over the globe: Johnson & Johnson, Merz Pharmaceuticals, MSD, L Oréal, and Procter & Gamble. Furthermore, I would like to acknowledge: Maria Barraud-Klenovsek, Amadé Bregy, Nadja Galliker, Marguerite Krasovec, Michael Kunz, Nadine Lengg, Alexander Navarini, Patrick Oberholzer, Marcus Pericin, Stefan Trachsler, Barbara Willimann, and Martin Zinkernagel (in alphabetical order) who have performed the studies referred to in the book Simon Koch, my coworker at the Center for Dermatology and Hair Diseases, with whom I share many experiences with female hair loss patients My mother, Mrs. Helen Trüeb Michaelides, who at the age of 87 years has proven to me that 5 % topical minoxidil is safe and also (very) effective My Parson Jack Russell Terrier Lautrec for having drawn my attention to seasonal growth and shedding of hair in women, since my female patients tend to come in complaining of increased hair shedding whenever my pet dog is molting Finally, the holy Patron Saint Agnes of Rome, who s icon stands in my office ix

12 Contents 1 Introduction Historical Myths: Experiments on Hair Loss Cures Age-Old Myths: Popular or Layman s Myths Physician s Myths: Don t Believe Everything You Hear on Hair Suggested Reading Examining Hair Loss in Women Patient History Family History Personal History Drug History History of Hair Cosmetic Procedures Clinical Examination Pattern Recognition Black and White Felt Examination Assessment of Hair Part Width Hair Pull Hair Feathering Trichoscopy Using the Dermatoscope for Diagnosing Hair and Scalp Disorders Patterns of Scalp Disease Revealed by Dermoscopy Follicular Patterns Interfollicular Patterns (Vascular, Pigment) Scaling Hair Shaft Patterns Exogenous Materials Summary of Dermoscopic Features in Common Conditions Trichogram Trichogram Procedure Trichogram Evaluation Trichogram Interpretation xi

13 xii Contents 2.5 Laboratory Evaluation Biochemical Investigations Microbiologic Studies Scalp Biopsy Quantifying Hair Loss Daily Hair Counts and Hair Wash Test Office-Based Computer-Assisted Image Analysis Hair Database Sheet Suggested Reading Diagnosis and Treatment Telogen Effluvium Pathologic Dynamics of Hair Loss Acute Telogen Effluvium Psychogenic Effluvium Chronic Telogen Effluvium Treatment Iron Deficiency Postpartum Hair Loss Persistent Postpartum Effluvium Treatment Seasonal Hair Shedding Female Androgenetic Alopecia Pathobiology of Androgenetic Alopecia Androgens, Androgen Metabolism, and the Androgen Receptor Estrogens, Estrogen Metabolism, and the Estrogen Receptor Genetic Involvement Role of Oxidative Stress Clinical Presentations Treatment Menopause Postmenopausal Frontal Fibrosing Alopecia Treatment Effect of Cigarette Smoking and UV Radiation Effect of Cigarette Smoking on Hair Effect of UV Radiation on Hair Hair Aging Graying Possibilities and Limitations for Reversal of Age-Related Pigment Loss Rare Premature Aging Syndromes Senescent Alopecia Possibilities and Limitations for Reversal of Age-Related Hair Loss

14 Contents xiii 3.9 Alopecia with Scarring Phenomena Androgenetic Alopecia with Histological Evidence of Follicular Inflammation and Fibrosis Fibrosing Alopecia in a Pattern Distribution Targeting the Inflammatory Component in Androgenetic Alopecia Inflammatory Scarring Alopecias Treatment Alopecia Neoplastica Traumatic Alopecia Traction Alopecia Chignon Alopecia Postoperative Pressure Alopecia Trichotillomania and Related Disorders Trichotillomania Neurotic Excoriations of the Scalp Factitial Dermatitis of the Scalp and Trichotemnomania Trichoteiromania Imaginary Hair Loss (Psychogenic Pseudoeffluvium) Treatment Trichodynia and Red Scalp Trichodynia Red Scalp Concept of Multitargeted Treatment Multimorbidity Value of Nutritional Supplementation Therapy Dystrophic Anagen Effluvium Chemotherapy-Induced Hair Loss Possibilities for Prevention or Reversal of Chemotherapy-Induced Hair Loss Radiation-Induced Alopecia Treatment Toxic Alopecia Amalgam Illness Misuse of Hair Analysis as a Diagnostic Tool Alopecia Areata Acute Diffuse and Total Alopecia of the Female Scalp Marie Antoinette Syndrome Treatment Loose Anagen Hair and Short Anagen Hair of Childhood Loose Anagen Hair Short Anagen Hair Suggested Reading

15 xiv Contents 4 Follow-Up Global Photographic Assessment Hair Loss-Related Life Quality Index Patient Compliance Issues Suggested Reading Patient Expectation Management Listening to the Patient Adjustment Disorders Hypochondriacal Disorder and Body Dysmorphic Disorder Tackling Side Effects Nocebo Effect Hair Prosthesis Suggested Reading Hair Care and Cosmetics Hair Weathering Shampoos Shampoo Surfactants Shampoo Additives Shampoo-Conditioning Agents Shampoo Active Ingredients Product Safety Methods for Measuring Efficacy of Hair Care Products Conditioners Hairstyling Aids Hair Dyes Cosmetic Treatment for Aging Hair Adverse Effects of Cosmetic Hair Treatments Hair Matting Bubble Hair Cosmetically Induced Hair Beads Others (Peculiar to African Hair) Suggested Reading Epilogue: Female Hair in Christian Iconography Hair as Martyrdom: Saint Margaret of Antioch Hair in Martyrdom: Saint Perpetua Facial Hirsutism: Saint Wilgefortis Long and Disheveled Hair: Saint Mary of Egypt Long and Beautiful Hair: Saint Mary Magdalene Saint Agnes of Rome: Patron Saint for Women with Hair Loss Suggested Reading Index

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