ALOPECIA

• Alopecia is the loss of hair from any hair-bearing area of the body, but most often the scalp. It may be diffuse or patch, scarring or non scarring.
• Androgenetic alopecia, a type of diffuse, nonscarring, acquired alopecia, is the most common, affecting > 70% of the general population by 70 years of age. Alopecia areata, an acquired, circumscribed, nonscarring alopecia, is the next most common type

• Endocrine and nutrition related: Abnormalities of the thyroid, pituitary or adrenals can cause diffuse alopecia. Malnutrition , zinc deficiency, iron deficiency may also cause diffuse alopecia
• Telogen effluvium: certain events can induce hair follicles to enter the telogen phase. It commonly follows birth of a child, high fever, stress and drugs such as enalapril, beta blockers lithium etc.
• Auto immunity – probably associated with alopecia areata
• Increased androgen sensitivity of hair follicle in genetically predisposed individuals in androgenetic alopecia
• Congenital adrenal hyperplasia
• Androgen-producing tumors: Leydig cell tumor, arrhenoblastoma

DIFFUSE ALOPECIA

Congenital diffuse alopecia

• Trichorrhexis nodosa: A hair shaft deformity characterized by the development of weak points in the shaft due to physical/chemical trauma in genetically predisposed individuals
• Pili torti: The hair shaft is flattened and has multiple twists which lead to fragile hair that breaks easily
• Monilethrix(beaded hair): Autosomal dominant disorder with beaded hair shafts which break easily, close to the scalp, a few months after birth
• Genetic syndromes: Menkes disease, Netherton's syndrome etc.

Acquired diffuse alopecia

• Androgenetic alopecia : It is a progressive, nonscarring alopecia that affects the regions of the scalp with the most androgen-sensitive hair follicles, resulting in a characteristic pattern of balding (bitemporal scalp in men and vertex and frontal scalp in women).
• Terminal hair is converted into vellus hair. In men recession of the frontal hairline near the temples and thinning over the vertex occurs. In women, the scalp hair is generally diffuse but more so in the vertex area
• Differential diagnosis of androgenetic alopecia includes Diffuse alopecia areata , Telogen effluvium 

PATCHY NON SCARRING ALOPECIA 

Congenital circumscribed alopecia

• Temporal triangular alopecia: A well-defined oval/triangular patch of alopecia in the temporal part of the scalp. Usually seen before 5 years of age. It mimics alopecia areata and is differentiated from it by the presence of vellus hair and the absence of exclamation point hair

Acquired circumscribed alopecia

• Alopecia areata :is an unpredictable usually patchy, non-scarring hair loss condition. It affects men and women equally and any hair bearing surface may be affected
• The characteristic initial lesion is commonly a round or oval, totally bald, smooth patch involving the scalp on any hair bearing area on the body
• A frequent feature in alopecia areata patch is Exclamation mark hairs that are broken short hairs tapering proximally. The pull test may be positive at the margins of the patch indicating very active disease
• Alopecia araeata can occur as diffuse loss of hair form scalp but spares the grey hair

Various patterns of distribution

• Ophiasis: hair loss localized to the back and sides of the scalp( so called from its resemblance to snake)
• Sisiapho: sparing of the sides and back of the scalp
• Extensive alopecia areata: hair loss affecting > 50% of the scalp
• Alopecia universalis : All hair-bearing sites are affected, Total hair loss from whole body (mimics telogen effluvium)
• Alopecia totalis: Complete baldness 
• Nail involvement (up to 40% of cases): nail pitting, onycholysis, Beau lines, etc.
• Other autoimmune disorders may be present (e.g., vitiligo, autoimmune disorders of the thryoid, etc.)
• Differential diagnosis includes Tinea capitis, Trichotillomania( Compulsive pulling out of one's own hair with ill-defined patchy hair loss and hairs of different lengths) and Secondary syphilis

• Usually clinical diagnosis
• Biopsy, histology, and trichogram may be performed to confirm the diagnosis
• Hair pull test: About 50 strands of hair are lightly tugged away from the scalp; if > 5 strands can be pulled out, the test is positive. 
• Dermoscopy: examination of the scalp skin, follicle size, and hair shaft diameter by magnification
• Trichograms: aids diagnosis and prognosis of nonscarring alopecia 

Internal medicines

• Tiktaka kashaya
• Nirgundyadi kashaya
• Guggulu panchapala choorna
• Krimighna vati
• Avipathi choorna in samana matra
• Narasimha rasayanam with milk – later stages
• Mandoora vataka – to correct nutritional deficiency

Procedures

• Virechana
• Prachana followed by application of Indralupta mashi for 3-4 days
• Lekhana with gojihwa/Theraka(Ficus racemosa) patra followed by Triphala gharshana
• Chiravilwa patra lepa
• Malathyadi kera - application on scalp