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Alopecia (hair loss) is a health and aesthetic issue. Statistics show that hair loss will likely affect one in two women and men during their lifetime. Although it can appear anywhere on the body, alopecia causes the most concern when it occurs on the scalp.

For further information on this topic, you may be interested to learn more about the HealthCert Professional Diploma program in General Dermatology.

Primary care physicians are on the frontline of alopecia management. It is their job to distinguish the cause of hair loss (disease vs. age-related), recommend a treatment plan, or refer patients to hair loss specialists.

Hair loss is a physical, cosmetic, and psychological problem. While the impact on physical health is usually not severe, the emotional stress due to a deterioration in aesthetic appeal is significant in most patients.

Primary care physicians must not underestimate the psychological effect of hair loss. However, their first job is to categorize presenting alopecia as scarring or non-scarring. Next, they need to classify hair loss as focal or diffuse. Last but not least, they need to determine the exact cause of hair loss.

Diagnosing alopecia

Doctors in primary care are much more likely to encounter non-scarring alopecia. The scarring type is rare and has many potential causes. It usually requires a referral to a dermatology specialist.

We can categorize causes of hair loss as focal and diffuse.

There are several potential causes of focal non-scarring alopecia. Alopecia areata and fungi-related tinea capitis are two common causes.

Alopecia areata produces round and smooth lesions. With tinea capitis, the skin may appear erythematous. It may become scaly and show signs of fungi-related occipital adenopathy. Scraping the lesion can help physicians with adequate training in general dermatology to eliminate the fungi as the cause.

Other causes of focal non-scarring hair loss may include traction alopecia and trichotillomania.

Traction alopecia is a type of unintended hair loss that occurs due to certain cosmetic, cultural, or social practices. These may include:

• Hair bleaching, coloring, or waving
• Wearing wigs or tight braids
• The use of curling rollers

Trichotillomania is a psychiatric disorder. It usually affects children and causes compulsive, repetitive hair plucking. The patient’s scalp inspection clearly shows patches of broken and twisted hair.

The most common diffuse (generalised) hair loss causes are androgenetic alopecia (male and female pattern hair loss) and telogen effluvium.

Telogen effluvium is usually a consequence of underlying health issues, such as:

• Anemia,
• Thyroid disorders,
• Infections,
• Trauma,
• Crash diets,
• Psychological stress, or
• Radical surgery

Many hairs enter the resting (telogen) phase of the hair cycle and fall off after about three months. Some patients may lose between thirty to fifty percent of body hair due to telogen effluvium.

Male and female pattern baldness is the most common hair loss type doctors will encounter in primary care. The causes are hormonal.

In women, hair thinning occurs in the central part of the scalp, excluding the frontal hairline. In men, it begins as a bitemporal recession of hair line and continues into the frontal region of the scalp (“the M pattern”).

Treatment options for alopecia

Certain types of hair loss are beyond the reach of primary care. These often require changes in the patient’s lifestyle habits, psychiatric evaluation, and referral to a dermatology specialist.

However, the three leading causes of hair loss are treatable in a primary hair setting. These are:

• Alopecia areata,
• Female pattern baldness, and
• Male pattern baldness

Here’s an overview of treatment options:

Alopecia Areata

Topical treatments:

• Steroids
• Minoxidil
• Diphenylcyclopropenone
• Squaric acid
• Anthralin creme

Oral steroids, such as Triamcinolone acetonide or Prednisone, and intralesional corticosteroids (injections) are also used.

Female Pattern Baldness

Usually, the treatment consists of topical Minoxidil (2%) in combination with oral Spironolactone (100 to 200 mg) or Flutamide (250 mg).

Male Pattern Baldness

Treatment options for male pattern baldness may include:

• Topical Minoxidil (2% or 5%),
• Ketoconazole shampoo (2%),
• Pyrithione Zinc shampoo (1%), and
• Oral Finasteride

– Dr Rosmy De Barros

Read another article like this one: How to manage acne patients in primary care

References:

• Peyravian N, Deo S, Daunert S, Jimenez JJ. The Inflammatory Aspect of Male and Female Pattern Hair Loss. J Inflamm Res. 2020;13:879-881. Published 2020 Nov 10. doi:10.2147/JIR.S275785
• Phillips TG, Slomiany WP, Allison R. Hair Loss: Common Causes and Treatment. Am Fam Physician. 2017;96(6):371-378.
• Zhou C, Li X, Wang C, Zhang J. Alopecia Areata: an Update on Etiopathogenesis, Diagnosis, and Management. Clin Rev Allergy Immunol. 2021;61(3):403-423. doi:10.1007/s12016-021-08883-0
• Billero V, Miteva M. Traction alopecia: the root of the problem. Clin Cosmet Investig Dermatol. 2018;11:149-159. Published 2018 Apr 6. doi:10.2147/CCID.S137296