Trichotillomania: Scalp Health & Emotional Health

Scalp Health & Emotional Health

Trichotillomania is an impulse control disorder whereby patients pull out their own hair. Many have underlying psychological or emotional issues including stress, anxiety, depression and obsessive compulsive disorders.

Treating or addressing the underlying psychological component is often most helpful in treating more chronic cases of trichotillomania. However, reatment of the inflammation, papules and pimples (ie acneiform eruptions and pseudofolliculitis) that accompany trichotillomania can also be important and helpful to patients. Chronic plucking and pulling of hairs leads to damage to hairs, inflammation and a resultant “itch-scratch-itch” cycle which is tough to stop.

In 2011, Oon and Lee published an interesting study showing that managing the actual dermatological issues can help a bit - irrespective of any focus on the underling psychological issues. The authors showed that use of topical steroids, topical and oral antibiotics reduced symptoms of itching and assisted with hair regrowth. Treatments included topical clobetasol, topical clindamycin, erythromycin, topical betamethasone, selenium sulphide shampoos, coal tar shampoos, oral doxycycline. These patients were not on antidepressants or antipsychotics.

The accompanying photo here shows a typical patient with trichotillomania. There are many broken and distorted hairs which has given rise to chronic inflammation - some of which has caused scarring to also occur. 
This is a nice study which reminds us that focus on both the dermatological and emotional issues are both important in treating trichotillomania.

Reference

Hazel H Oon and Joyce SS Lee. Treatment of Pseudofolliculitis in Trichotillomania improves Outcome. Int J Trichology. 2011 Jul-Dec; 3(2): 92–95.
 

Risk of Fibroids Increased in Women with CCCA

Five Fold increased Risk of Fibroids in Women with CCCA  

A new study, published in JAMA Dermatology, has given evidence that women with central centrifugal cicatricial alopecia (CCCA) are at increased risk of developing benign uterine tumors known as fibroids.  The medical terms for these are uterine leiomyomas.

CCCA is a type of scarring alopecia that occurs predominantly in women with afro-textured hairs. This new data suggests that a genetic predisposition to develop excessive scar tissue in other area of the body may be central to the underlying mechanisms that cause these two diseases.  

The researchers analyzed data from over 487,000 black women and examined the incidence of fibroids in women with CCCA and those without CCCA. Out of 486,000 women in the general population,  3.3 % had fibroids. However, 13.9 % of women with CCCA were found to have fibroids. Taken together, this works out to a five fold increased risk of fibroids in women with CCCA.

Conclusion

There is an increased risk of uterine fibroids in women with CCCA.  Whether there is an increased risk of other scarring related diseases of the body warrants further study.

REFERENCE

 
Dina et al. Association of Uterine Leiomyomas With Central Centrifugal Cicatricial Alopecia. JAMA Dermatology, 2017; DOI: 10.1001/jamadermatol.2017.5163

My hair was ripped off: Will it grow back?

Traumatic Hair Pulling:  Full Regrowth May or May Not Occur

I am often asked if hair that is pulled out forcefully will regrow. Examples of this are the pulling of hair by children on the playground, hair getting caught in doors, machines etc or cases of hair pulling during assault or abuse-related situations (for example domestic abuse).

Without actually seeing the scalp, and knowing details of the patient's story, it is impossible to determine if hair will or will not grow back in any particular case. This requires an in person examination so that the scalp can be properly examined.

Hair regrowth is not a guarantee

There is no guarantee that hair regrowth will occur. One will know in 6-9 months if they will acheive full regrowth or not because that is how long it takes for hair to grow back following any type of injury.

It is certainly possible for repeated pulling to give permanent hair loss. However, in the vast majority of cases where hair is pulled from the scalp, hair grows back.  If you or I were to reach up a pluck a hair, it will grow back. However, if pulling is repeated many times or is excessive with bleeding a greater chance exists for scarring to develop. Hair pulling that is accompanied by injury to the skin layers (i.e. that creates an actual wound) has a markedly increased chance of being associated with permanent scarring.  It is such scarring that blocks the regrowth of hair.  Scar tissue is permanent and, if present,  generally destroys stems cells. 

Anyone with concerns about incomplete growth after episodes of hair pulling should see a physician who specializes in hair loss for consideration of a scalp biopsy.

Hair Loss at the Nape of the Neck: What are the main causes?

Losing Hair at the Nape: What are the main Causes?

Hair loss can either be localized (meaning one area of the scalp) or diffuse (meaning all over the scalp). There are many causes of hair loss at nape of the neck and the back of the scalp. 

1. Traction alopecia (photo 1)

Traction alopecia refers to a type of hair loss due to the tight pulling of hair. The back of the scalp is particularly susceptible to loss of hair.  Hair styling practices can frequently lead to traction including braids and weaves and pony tail.  If traction alopecia is of recent onset, hair regrowth can occur even without treatment. If traction is longer standing, the hair loss can often be permanent.  Some women with hair loss that looks like traction actually have a scarring alopecia known as cicatricial marginal alopecia. 

PHOTO 1: Traction alopecia presenting as hair loss in the nape

2. Alopecia Areata (photo 2)

Alopecia areata is an autoimmune disease that affects about 2 % of the world. Hair loss can occur anywhere. Alopecia areata can frequently cause hair loss specifically at the nape in some patients. The particular form that causes loss at a the back of the scalp is the 'ophiasis' form. The ophiasis form is frequently resistant to standard treatments although topical steroids, steroid injections and diphencyprone are typically first line. 

PHOTO 2: Alopecia areata presenting as hair loss in the nape

 3. Androgenetic Alopecia (photo 3)

Androgenetic alopecia (male and female thinning) typically causes hair loss at the top of the scalp. In men, the temples and crown are most often affected. In women, the mid-scalp region is generally affect first. The back of the scalp can also be affected although this is not typically thought of. Hair thinking along the nape is not uncommon in advancing balding in men and women. 

PHOTO 3: Androgenetic alopecia (AGA) presenting as thinning in the nape

 

4. Frontal Fibrosing Alopecia (photo 4)

Frontal fibrosing alopecia (FFA) is a type of scarring alopecia. FFA typically affects women between 45-70. Most often hair is lost along the frontal hairline and eyebrow. However the back of the scalp (at the nape) and frequently be affected. The hair loss in the nape typically starts at the sides (left side and right side) just behind the ears. Treatments for FFA include topical steroids steroid injections, topical calcineurin inhibitors. Oral drugs include finasteride, doxycycline and hydroxychloroquine at the top of the list.

PHOTO 4: Frontal fibrosing alopecia (FFA) presenting as hair loss in the nape

5.  Heat and Chemicals

Heat and chemical treatments can lead to hair shaft damage and hair loss at the nape. Frequently, heat and chemical overuse leads to an increased tendency to develop traction alopecia which si discussed above. 

6. Acne keloidalis nuchae

Acne keloidalis nuchae (AKN) is a condition that can affect both men and women. Small papule or bumps develop along the posterior scalp and are accompanied by hair loss in the region as well.  The hair loss in AKN is often permanent and can lead to thicken and thicker scars some of which are disfiguring. 

7. Hair shaft disorders

Some individuals are born with abnormalities in how the hair shaft is produced. This frequently leads to hair breakage. Monilethrix is one of the hair shaft disorders that frequently leads to hair loss along the nape. 

Broken hairs vs new growth?

Is my hair breaking off? Or is it new growth? How can I tell?
 

Short small hairs can be confusing. So many times when short hairs are seen a conclusion is made that these hairs are short on account of breaking off.

New growth is pointy

In many situations, a careful and magnified view of the hairs will reveal that they are actually newly regrown hairs rather than broken hairs. Newly regrown hairs can be readily identified by their "pointed" ends. Broken hairs on the other hand have blunt often jagged ends.

Broken hairs in scarring alopecia

"Broken" hairs have blunted, straight or jagged ends. In contrast to newly growing hair, they are not pointed.

This particular photo shows a broken hair in a patient with lichen planopilaris.