amc clinical exam
Your next patient in general practice is a 28 year old Mr. Troy Neilson who noticed quite significant hair loss at the back of his head leaving him with a bald spot and he is very concerned that this might spread and cause him to become totally bald. YOUR TASK IS TO:
• Take a further history
• Examine the patient
• Explain the most likely diagnosis, differential diagnoses and your management plan to the patient
HOPC: Troy noticed a sudden hair loss at the back of your head starting about 2 weeks ago and now he is very concerned that this might spread all over his scalp and that he might become bald.
PHx.: unremarkable
SHx.: married accountant, 2 children, no problems, non smoker, non drinker, NKA, no medication.
FHx.: His father had similar problems and finished up with total baldness at age 50.
Examination: Troy looks generally quite well, His vital signs are normal.
The characteristic finding of alopecia areata is the “exclamation point hair” in form of unusual hairs which demonstrate short, broken off hairs under examination with a magnifying glass and they are narrower closer to the scalp (appearing like an exclamation point). His scalp otherwise is normal.
Investigations:
A biopsy of the scalp is sometimes necessary for a diagnosis. They reveal immune cells inside of the hair follicles where they are not normally present.
QUESTIONS you should ask if not covered by candidate:
“What causes this hair loss?”
“Am I going to be bald soon?”
“Is there any place for treatments like Shane Warne had, like hair transplants?”
“Are my children at risk to develop this?”
“Is this condition contagious?”
“Will it affect my chance to grow a beard?”
DIAGNOSIS: ALOPECIA AREATA
Alopecia areata is a patchy type of hair loss caused by an abnormality in the body’s own immune system leading to attack on the hair follicles and disruption of normal hair formation, although this damage is usually not permanent. Alopecia areata is sometimes associated with other autoimmune conditions such as allergic disorders, thyroid disease, vitiligo, lupus, rheumatoid arthritis, and ulcerative colitis. Sometimes, alopecia areata occurs within family members, suggesting a role of genes and heredity.
It usually involves the scalp, but it sometimes affects other areas of the body or even the whole body (alopecia universalis) or it may be a diffuse, generalized thinning of the scalp hair (“diffuse alopecia areata”).
Hair loss tends to be rather rapid and is usually unilateral on the scalp. It occurs commonly in younger patients with equal gender distribution.
Differential diagnosis:
• male-pattern baldness, an inherited condition
• hair loss after stopping the OCP
• hair loss at the end of pregnancy
• tinea capitis
• trichotillomania (compulsive pulling or twisting of the hair)
• discoid lupus
MANAGEMENT:
1. In about 50% of cases hair growth returns spontaneously within a year, but there is a high chance of recurrence.
2. Generally there is no cure for alopecia areata but it can be treated. Several method have been tried with varying success like:
a) Steroid injections into the lesion with triamcinolone (10 mg/mL) or betamethasone acetate
b) Creams (steroid like betamethasone)
c) Shampoos
d) Medications like minoxidil
e) Irritants like topical anthralin (dithranol) or topical tar
f) Topical immunotherapy with cyclosporine
g) Aromatherapy with essential oils (cedarwood, lavender, thyme and rosemary oils)
h) !stress reduction!
i) Induction of allergic contact dermatitis using diphencyprone or squaric acid dibutylester leads to hair growth due to unknown mechanisms, but this treatment is best reserved for patients with diffuse involvement who have not responded to other therapies.
3. Counselling, alopecia areata support groups
4. Wigs, hair pieces (if larger areas involved)
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