ail Disorder

Definition:  “Keloidlike” papules and plaques on the occipital scalp and the posterior part of the neck, almost exclusively in African American men.
Etiology: Not really known.  Believed to be due injury caused by short haircuts along with a chronic low-grade bacterial infection.  Exacerbating factors are the curvature of the hair & follicle along with the course nature of black hair.
Clinical Features: Initially itchy round small bumps appear within or close to the hair-bearing area of the back of the neck (occipital scalp). Sometimes there are pustules around the hair follicles (folliculitis). If untreated, as time goes on the bumps form small scars and then the small scars may greatly enlarge to become keloids. The scars are hairless and can form a band along the hairline.
Clinical Approach: A bacterial culture and sensitivity from any pustular or draining lesions should be taken intermittently. If pathogens are present, appropriate antibiotics should be prescribed.
Treatment: The first line of defense against AKN is prevention. People with AKN should not get the occipital part of their hairline edged with a razor. Reduce inflammation of follicles with topical/intralesional steroids, as well as treat underlying bacterial infection with oral/topical antibiotics. If scar formation occurs, surgery may be the final option.

Definition: Alopecia Areata is a condition affecting humans, in which hair is lost from areas of the body, usually from the scalp. Because it causes bald spots on the scalp, especially in the first stages, it is sometimes called spot baldness. In 1%–2% of cases, the condition can spread to the entire scalp (Alopecia totalis) or to the entire epidermis (Alopecia universalis).
Etiology: Current evidence suggests that alopecia areata is caused by an abnormality in the immune system. This particular abnormality leads to autoimmunity. As a result, the immune system attacks particular tissues of the body. In alopecia areata, for unknown reasons, the body's own immune system attacks the hair follicles and disrupts normal hair formation.
Clinical Features: First symptoms are small, soft, bald patches which can take just about any shape but are most usually round. It most often affects the scalp and beard but may occur on any hair-bearing part of the body.[3] There may be different skin areas with hair loss and regrowth in the same body at the same time. It may also go into remission for a time, or permanently.
Clinical Approach: One diagnostic technique applied by medical professionals is to gently tug at a handful of hair along the edge of a patch with less strength than would be required to pull out healthy hair. In healthy hair, no hair should fall out or ripped hair should be distributed evenly across the tugged portion of the scalp. In cases of alopecia, hair will tend to pull out easier along the edge of the patch where the follicles are already being attacked by the body's immune system than away from the patch where they are still healthy.
Treatment: In approximately 50% of patients, hair will regrow within a year without any treatment. The longer the period of time of hair loss, the less likelihood that the hair will regrow. A variety of treatments can be tried. Steroid injections, creams, and shampoos (such as clobetasol or fluocinonide) for the scalp have been used for many years.

Definition: Cicatricial Alopecia refers to a diverse group of rare disorders that destroy the hair follicle, replace it with scar tissue, and cause permanent hair loss. The inflammation that destroys the follicle is below the skin surface and there is usually no "scar" seen on the scalp. Cicatricial alopecia occurs in otherwise healthy men and women of all ages and is seen worldwide.
Etiology: The cause of the various cicatricial alopecias is poorly understood. In broad terms cicatricial or scarring alopecias are of two types:

    * Primary
    * Secondary

Primary cicatricial alopecia involves destruction of the hair follicle and their openings from which the hair fibers emerge. As the alopecia causes is primarily focused on the hair follicles it does not affect other tissues and organs of the body.

Primary scarring alopecia is further sub categorized into three types on the basis of the inflammatory cells. The various types are:

    * Lymphocytic
    * Neutrophilic
    * Mixed alopecias

The exact diagnosis of the different types of primary scarring alopecia is necessary as different types of categories have a different identification and treatments.

Secondary alopecias are more generalized disease mechanisms. They occur in various organs of the body and damage several tissues, organs as well as induce scarring alopecia. The causes of secondary cicatricial alopecia include radiation, drugs, surgeries, tumors, etc.However, all cicatricial alopecias involve inflammation directed at the hair follicle, usually the upper part of the follicle where the stem cells and sebaceous gland (oil gland) are located. If the stem cells are destroyed, and the sebaceous gland as well, there is then no possibility for regeneration of the hair follicle and permanent hair loss results.
Clinical Features: The bald areas are usually left devoid of any hair follicles. Sometimes hair follicles, at the boundary of a bald patch, are not completely destroyed and they can regrow. But generally hair regrowth is not possible and all that is left are just a few longitudinal scars deep in the skin. These scars indicate that the hair follicles were present in that place.
Clinical Approach: A scalp biopsy is essential for the diagnosis of cicatricial alopecia and is the necessary first step. Findings of the scalp biopsy, including the type of inflammation present, location and amount of inflammation, and other changes in the scalp, are necessary to diagnose the type of cicatricial alopecia, to determine the degree of activity, and to select appropriate therapy. Clinical evaluation of the scalp is also important. Symptoms of itching, burning, pain or tenderness usually signal ongoing activity.
Treatment: As mentioned above there are primary and secondary cicatricial alopecias, which are classified by the predominant type of inflammatory cells that attack the hair follicles: i.e., lymphocytes, neutrophils, or mixed inflammatory cells. Treatment strategies are different for each subtype. However, certain general principals apply to all treatments, such as use of potent topical steroids to prevent further hair loss.

Cradle Cap

Definition: Is a yellowish, patchy, greasy, scaly and crusty skin rash that occurs on the scalp of recently born babies. It is usually not itchy, and does not bother the baby. Cradle cap most commonly begins in the first 3 months.
Etiology:
Clinical Features: The rash is often prominent on the scalp and around the ears, eyebrows, or eyelids. It may appear in other locations as well, where it is called seborrhoeic dermatitis rather than “cradle cap”.
Clinical Approach: Diagnosis is made by history & clinical examination.  The cause of cradle cap is not clearly defined but it is not caused by infection, allergy or poor hygiene. Possibly it has to do with overactive sebaceous glands in the skin of newborn babies, due to the mother's hormones still in the baby's circulation. The glands release a greasy substance that makes old skin cells attach to the scalp as they try to dry and fall off. There may be a relationship with skin yeasts (malassezia).
Treatment:  Remove crusts with olive oil compresses, followed by antifungal shampoo, and application of corticosteroid creams.

Dandruff

Definition:  Is due to the excessive shedding of dead skin cells from the scalp
Etiology:  The top layer on the scalp continually replaces itself, cells are pushed outward where they eventually die and flake off. In most people, these flakes of skin are too small to be visible. However dandruff causes cell turnover to be unusually rapid, especially in the scalp. For people with dandruff, skin cells may mature and be shed in 2 - 7 days, as opposed to around a month in people without dandruffClinical Features:
Clinical Approach: . Dead skin cells are shed in large, oily clumps, which appear as white or grayish patches on the scalp, skin, and clothes.
Treatment:  Medicated “dandruff” shampoos containing zinc pyrithione, selenium sulphide, tar, or antifungals.

Hair Loss – Female (Androgenic Alopecia)

Definition: In women as in men, the most likely cause of scalp hair loss is androgenetic alopecia—an inherited sensitivity to the effects of androgens (male hormones) on scalp hair follicles.
Etiology: Androgenic alopecia in women is due to the action of androgens, male hormones that are typically present in only small amounts. Androgenic alopecia can be caused by a variety of factors tied to the actions of hormones, including, ovarian cysts, the taking of high androgen index birth control pills, pregnancy, and menopause.
Clinical Features: Women with permanent hair loss usually have hair loss limited to thinning at the front, sides or crown. Women usually maintain their frontal hairline and rarely experience complete baldness.
Clinical Approach: Your iron and thyroid levels may be tested, but in most cases, your history is the most important factor for diagnosis.
Treatment: The best results from treatment happen when you begin treatment as soon as possible after the hair loss begins because prolonged androgenetic alopecia may destroy many of the hair follicles. The use of anti-androgens after prolonged hair loss will at least help prevent further hair loss and encourage some hair regrowth from those follicles that have been dormant but are still viable, Stopping treatment will result in the hair loss resuming if the androgens aren't kept in check in some other way. Medications with anit-androgen properties are Minoxidil 2% Topical,  Aldactone / Spironolactone, and Tagamet / Cimetidine,  Oral contraceptive, & Propecia.

Definition: Hirsutism is a condition of unwanted, male-pattern hair growth in women.
Etiology: About half of women with mild hirsutism have high androgen levels, and the other half do not. Hirsutism that is severe is usually due to high androgen levels. Conditions that can cause high androgen levels include Polycystic ovary syndrome, Cushing's syndrome, Congenital adrenal hyperplasia, and some medications. Some medications such danazol (Danocrine), which is used to treat women with endometriosis.

Clinical Features:  The major sign of hirsutism is coarse and pigmented body hair, appearing on places of the body where hair is not commonly found in women — primarily the face, chest and back.
Clinical Approach:  Diagnosis is made from history, clinical exam, and  blood tests for certain hormones in your blood, including testosterone, which may help determine whether hirsutism is caused by elevated androgen levels.
Treatment: Treatment for hirsutism often involves a combination of self-care methods, hair-removal therapies (laser/electrolysis) and using medications( oral contraceptive pill, antiandrogen pills, and VaniqaCream) .

Definition: An irreversible alopecia of the scalp occurs in women of African descent who straighten their hair with hot combs.
Etiology: Occurs as a consequence of the effects of longstanding use of a hot comb with vigorous traction.
Clinical Features: Permanent alopecia pictured here followed on the effects of hot comb use over the course of many years. The periphery of the hair-bearing scalp is involved predominantly in these women, the predilection for that site being the result of the pull on hair having been greatest there.
Clinical Approach:  Diagnosis based on history and clinical examination.
Treatment: Hot comb practices must be discontinued.  Traction alopecia is entirely preventable, but when permanent is resistant to any treatment. 

Definition: Hypertrichosis is excessive hair growth over and above the normal for the age, sex and race of an individual, in contrast to hirsutism, which is excess hair growth in women following a male distribution pattern. It can develop all over the body or can be isolated to small patches.

Hypertrichosis may be congenital (present at birth) or acquired (arises later in life).
Etiology: The cause of hypertrichosis is unknown. Congenital hypertrichosis is believed to be a genetic disorder that is inherited or occurs as a result of spontaneous mutation. Acquired hypertrichosis lanuginosa sometimes occurs in people who at a later stage are diagnosed with a cancer of some form.
Clinical Features: Commonly, hypertrichosis is classified as generalized hypertrichosis or localized hypertrichosis. Generalized means excessive hair growth all over the body or at multiple sites on the body. Localized refers to abnormal hair growth at a single site or just a few sites. These two types are further sub-divided into congenital (present from birth) and acquired (develops over time) categories of hypertrichosis.
Clinical Approach: Diagnosis based on jistory and clinical examination.
Treatment: The treatments range from camouflage (e.g., bleaching with hydrogen peroxide), to temporary removal by waxing, or permanent removal by electrolysis or laser destruction of hair follicles.

Definition: Male hair loss is the most common type of hair loss. It is caused by increased sensitivity to male sex hormones (androgens) in certain parts of the scalp, and is passed on from generation to generation.
Etiology: Some men have areas on the scalp that are very sensitive to the male sex hormones that circulate in men's blood. The hormones make the hair follicles - from which hair grows - shrink. Eventually, they become so small that they cannot replace lost hairs. The follicles are still alive, but are no longer able to perform their task.
Clinical Features: For men, pattern baldness can begin very early, even in the teens or early 20s. It's typically characterized by a receding hairline at the temples and balding at the top of the head. The end result may be partial or complete baldness.
Clinical Approach:  Diagnosis is based on history and clinical examination.
Treatment: Treatment  consists of medical and surgical.  Medical options are Minoxidil lotion (Regaine regular strength or Regaine extra strength) that is applied twice daily to the scalp.   Also, Finasteride (Propecia) is a medicine taken in tablet form that partially blocks the effects of the male hormones (an 'anti-androgen'). It is used in a higher dose to reduce the size of the prostate gland in men with benign prostatic hypertrophy. Propecia has been shown to halt further hair loss and promote re-growth of scalp hair in approximately 80 per cent of patients after three to six months.  Surgical options consist of hair transplants,  scalp reduction, and flap-surgery, which involves making the part of the scalp that still contains hair larger.

Definition: Piedra, which means "stone" in Spanish, is an asymptomatic superficial fungal infection of the hair shaft.  There are 2 types, black & white piedra. Black piedra usually affects scalp hair, whereas white piedra more commonly affects pubic hair, axillary hair, beards, mustaches, and eyebrows and/or eyelashes.
Etiology: The environment and typical skin flora are the 2 main sources of infectious agents that cause piedra. The source of infection in black piedra, P hortae, appears to be in the soil; however, infection also has been traced to organisms in stagnant water and crops.6, 7 The source of infection for white piedra, typically T asahii, can be present in the soil, air, water, vegetable matter, or sputum or on body surfaces.4 However, the mode of infection in man is not clear.
Clinical Features:

Findings in black piedra may include the following:
   

1. Black piedra consists of darkly pigmented, firmly attached nodules that vary in size to as large as a few millimeters in diameter. The nodules feel hard.
2. The most commonly affected area of the body is the scalp hair. Black piedra less frequently affects beards, mustaches, and the pubic hair.
3. The fungus grows into the hair shaft; ultimately, it may cause hair breakage because of structural instability.

Findings in white piedra may include the following:

1. White piedra consists of lightly pigmented, loosely attached nodules or gelatinous sheaths that have a soft texture.
2. The most commonly affected areas of the body are beards, mustaches, pubic and axillary hair, and eyelashes and eyebrows.

• Hair breakage occurs in both forms of piedra.
• In both varieties of piedra, the surrounding skin is healthy.

Clinical Appproach: Diagnosis mades from history and clinical examination. Confirmation by fungal staining & culture.

Treatment: Shaving or cutting the hair is the treatment of choice. Antifungal agents and terbinafine also are used in the treatment of piedra.  Black piedra is treated by using oral terbinafine. White piedra can be treated by using topical antifungals, including imidazoles, ciclopirox olamine, 2% selenium sulfide, 6% precipitated sulfur in petroleum, chlorhexidine solution, Castellani paint, zinc pyrithione, and amphotericin B lotion.

Definition: Pseudofolliculitis barbae is a type of folliculitis. It also known as shaving rash or razor bumps. It is a foreign-body inflammatory reaction surrounding ingrown facial hair, which results from shaving. The problem occurs more commonly in people of African descent.
Etiology: PFB is most common on the male face, but it can also happen on other parts of the body where hair is shaved or plucked, especially areas where hair is curly and the skin is sensitive, such as genital shaving . After a hair has been shaved, it begins to grow back. Curly hair tends to curl into the skin instead of straight out the follicle, leading to an inflammation reaction
Clinical Features: *The primary lesion is a flesh-colored or erythematous papule with a hair shaft in its center. If the hair shaft is gently lifted up, the free end of the hair comes out of the papule.  These inflammatory papules are seen in shaved areas adjacent to the hair follicul.  Pustules and abscess formation can occur from secondary infection.  Postinflammatory hyperpigmentation, scarring, and keloid formation may occur in chronic or improperly treated cases.
Clinical Approach: Diagnosis based on history and clinical examination.
Treatment:  Initially the beard is allowed to grow to eliminate ingrown hairs.
When shaving resumes electric hair clippers should be used.  In addition a topical retinoids and a mild topical steroid are used each day.  Laser hair removal should be considered in some cases, this is much more effective than any other measure.
   

Tinea Capitis

Definition: Tinea capitis is the name used for infection of the scalp with a fungus. Although common in children, tinea capitis is less frequently seen in adults.
Etiology: Tinea capitis is caused by fungi of species of alled Trichophyton and Microsporum. Tinea capitis is the most common pediatric fungal infection worldwide.
Clinical Features: Tinea capitis may present in several ways.

1. Dry scaling – like dandruff but usually with moth-eaten hair loss
2. Black dots – the hairs are broken off at the scalp surface, which is scaly
3. Smooth areas of hair loss
4. Kerion – very inflamed mass, like an abscess
5. Favus – yellow crusts and matted hair
6. Carrier state no symptoms and only mild scaling.

Clinical Approach: Wood's light fluorescence is helpful but not diagnostic as it is only positive if the responsible organism fluoresces, and fluorescence is sometimes seen for other reasons.  The diagnosis should be confirmed by microscopy and culture of skin scrapings and hair pulled out by the roots
Treatment: Tinea capitis requires treatment with an oral antifungal agent. Griseofulvin is probably the most effective agent for infection. Scalp fungal infections may successfully be eradicated using oral terbinafine, itraconazole or fluconazole for 4 to 6 weeks.

Definition: Traction alopecia is a common cause of hair loss due to pulling forces exerted on the scalp hair. This excessive tension leads to breakage in the outermost hairs. This condition is seen in children and adults, but it most commonly affects African American women.
Etiology: Typically, traction alopecia is associated with sustained tension on the scalp hair. In theory, this phenomenon can also occur on areas of the face where hair is grown and styled. Traction causes hair to loosen from its follicular roots; however, hair loss also occurs secondary to follicular inflammation and atrophy. Hair loss is often symmetric and along the frontotemporal hairline; occipital scalp involvement is less common. Vellus hair is usually spared in the affected area.
Clinical Features: Patients usually have patchy areas of hair loss.
Clinical Approach: Traction alopecia is usually diagnosed with thorough history taking and meticulous physical examination without laboratory testing. History of tight braids, "pulled-back" hairstyle, or chemical straightening suggests a diagnosis of traction alopecia.
Treatment: The physician must identify traction alopecia early. Immediately after traction alopecia is diagnosed, any practices that exert traction on the hair must be discontinued. Discontinuing any such practices leads to complete reversal of the hair loss and regrowth within several months. When traction alopecia is detected later in its natural course, hair loss may be irreversible. Currently, no medical treatment is available to reverse late-stage traction alopecia.

Trichotillomania (TTM)

Definition: Trichotillomania (TTM), or "trich" as it is commonly known, is an impulse control disorder or form of self-injury characterized by the repeated urge to pull out scalp hair, eyelashes, facial hair, nose hair, pubic hair, eyebrows or other body hair, sometimes resulting in noticeable bald patches.
Etiology: TTM is diagnosed in all age groups; it is more common during the first two decades of life, with mean age of onset usually reported between 9 and 13 years of age. Among preschool children the genders are equally represented; there appears to be a female predominance among preadolescents to young adults, with between 70% and 93% of patients being female.[13] Evidence now points to a genetic predisposition
Clinical Features: Signs and symptoms of trichotillomania include:

    * Patchy bald areas on the scalp or other areas of the body
    * Sparse or missing eyelashes or eyebrows
    * Chewing or eating pulled out hair
    * Playing with pulled-out hair
    * Rubbing pulled-out hair across the lips or face

Clinical Approach:

Criteria for diagnosis of trichotillomania include:

1. Repeatedly pulling out your hair, resulting in noticeable hair loss
2. An increasing sense of tension before pulling, or when you try to resist pulling
3. Pleasure or relief when pulling
4. Your hair loss isn't attributed to another medical or dermatologic condition
5. Hair pulling causes you significant distress

Treatment: Habit Reversal Training or HRT, has been shown to be a successful adjunct to medication as a way to treat TTM.[10] With Habit Reversal Training, doctors train the individual to learn to recognize their impulse to pull and also teach them to redirect this impulse. Treatment with Clomipramine, a tricyclic antidepressant, was shown to significantly improve symptoms.