Hair Loss: Common Causes and Treatment

Hair loss is often distressing and can have a significant effect on the patient's quality of life. Patients may present to their family physician first with diffuse or patchy hair loss. Scarring alopecia is best evaluated by a dermatologist. Nonscarring alopecias can be readily diagnosed and treated in the family physician's office. Androgenetic alopecia can be diagnosed clinically and treated with minoxidil. Alopecia areata is diagnosed by typical patches of hair loss and is self-limited. Tinea capitis causes patches of alopecia that may be erythematous and scaly and must be treated systemically. Telogen effluvium is a nonscarring, noninflammatory alopecia of relatively sudden onset caused by physiologic or emotional stress. Once the precipitating cause is removed, the hair typically will regrow. Trichotillomania is an impulse-control disorder; treatment is aimed at controlling the underlying psychiatric condition. Trichorrhexis nodosa occurs when hairs break secondary to trauma and is often a result of hair styling or overuse of hair products. Anagen effluvium is the abnormal diffuse loss of hair during the growth phase caused by an event that impairs the mitotic activity of the hair follicle, most commonly chemotherapy. Physician support is especially important for patients in this situation.

Genetic alterations in thyroid tumors from patients irradiated in childhood for tinea capitis treatment

OBJECTIVE

Exposure to ionizing radiation at young age is the strongest risk factor for the occurrence of papillary thyroid carcinoma (PTC). RET/PTC rearrangements are the most frequent genetic alterations associated with radiation-induced PTC, whereas BRAF and RAS mutations and PAX8-PPARG rearrangement have been associated with sporadic PTC. We decided to search for such genetic alterations in PTCs of patients subjected in childhood to scalp irradiation.

DESIGN

We studied 67 thyroid tumors from 49 individuals irradiated in childhood for tinea capitis scalp epilation: 36 malignant (12 cases of conventional PTC (cPTC), two cPTC metastases, 20 cases of follicular variant PTC (FVPTC), one oncocytic variant of PTC and one follicular carcinoma) and 31 follicular thyroid adenomas.

METHODS

The lesions were screened for the BRAF(V600E) and NRAS mutations and for RET/PTC and PAX8-PPARG rearrangements.

RESULTS

BRAF(V600E) mutation was detected in seven of 14 (50%) cPTC and two of 20 FVPTC (10%) (P=0.019). NRAS mutation was present in one case of FVPTC (5%). RET/PTC1 rearrangement was found, by RT-PCR, in one of 17 cases (5.9%) and by fluorescence in situ hybridization in two of six cases (33%). PAX8-PPARG rearrangement was not detected in any carcinoma. None of the follicular adenomas presented any of the aforementioned genetic alterations.

CONCLUSIONS

The prevalence of BRAF(V600E) mutation in our series is the highest reported in series of PTCs arising in radiation-exposed individuals. The prevalence of RET/PTC1 rearrangement fits with the values recently described in a similar setting.

Severe kerion celsi due to Trichophyton mentagrophytes: a case report

We report on a 5-year-old girl with a severe kerion celsi, caused by Trichophyton mentagrophytes, probably acquired from a pet guinea pig. The lesions had started as small irritating squamous lesions that had been accurately diagnosed as skin infection, but had only been treated with local antifungal agents. The lesions progressed and developed into a kerion celsi that had to be treated with long-term systemic griseofulvin. Nevertheless, reinfection occurred and treatment had to be restarted. The girl is left with areas of alopecia, as a result of which she is required to wear a wig.

CONCLUSION

Tinea capitis is a common skin infection that should be considered in any type of scalp lesion. It requires systemic treatment, and inappropriate and delayed treatment can result in the development of kerion celsi, with sometimes devastating consequences.

Scalp hyperkeratosis and alopecia in children of color

BACKGROUND

Scalp hyperkeratosis and/or alopecia are common pediatric dermatologic findings. In Caucasian children, scalp hyperkeratosis of childhood is most often associated with atopic and seborrheic dermatides. Recent data is lacking on the clinical meaning of scalp hyperkeratosis and alopecia in children of color.

OBJECTIVE

To determine diagnosis associated with scalp hyperkeratosis and/or alopecia in a predominately Black and Hispanic pediatric patient population.

METHODS

A retrospective chart review was conducted for all children (0-17 years of age) seen at our institution who had a scalp fungal culture for the evaluation of scalp hyperkeratosis and/or alopecia from January 2007 to September 2009. Fungal culture was performed using cotton swab technique, plating onto Sabouraud's and Mycosel media. Demographic features, fungal culture results, clinical symptoms, physical findings and final diagnosis were reviewed.

RESULTS

164 children were identified who were eligible for inclusion in the study, 75 of whom were Black and 56 Hispanic/Latino. Scalp hyperkeratosis was noted in 106 patients and alopecia was noted in 71 subjects. Tinea capitis was the final diagnosis in 50 out of 80 children who had hyperkeratosis without alopecia (60%), 16 of 43 children with alopecia alone (37.2%) and 23 of 28 children with both hyperkeratosis and alopecia (82.1%, P=0.0007). The odds ratio of tinea capitis in the presence of hyperkeratosis with alopecia was 7.49 with a 95 percent confidence limit of 2.19-25.70.

CONCLUSION

Scalp hyperkeratosis, especially when accompanied by alopecia, is usually associated with tinea capitis in Black and Hispanic children. Fungal culture and empirical anti-fungal therapy are warranted in children of color with scalp hyperkeratosis.

Erythema nodosum induced by kerion celsi of the scalp in a woman

A 35-year-old woman, with a 3-week history of an enlarging erythematous, scaly plaque of the scalp vertex associated with the onset of some painful, subcutaneous nodules on her pretibial regions. Trichophyton mentagrophytes was isolated from the scalp lesion and the histological examination of one of the nodular lesions of the legs showed a septal panniculitis. The diagnosis of erythema nodosum (EN) induced by kerion celsi was made and the patient started therapy with oral terbinafine 250 mg per day for 4 weeks associated with naproxene per os 1 g per day for 2 weeks. Erythema nodosum is considered a reaction pattern to a wide variety of microbial and non-microbial stimuli: dermatophytic infections are rarely associated with EN.

Central centrifugal cicatricial alopecia: Superimposed tinea capitis as the etiology of chronic scalp pruritus

We discuss a patient with central centrifugal cicatricial alopecia (CCCA) who developed severe scalp pruritus that was initially attributed to the cicatricial alopecia and ultimately diagnosed as tinea capitis. The rarity of severe pruritus in CCCA should prompt a search for a fungal infection in these patients.

Tinea capitis: no incision nor excision

Tinea capitis is a fungal infection of the scalp and hair shaft that mainly affects prepubescent children. Its clinical aspects range from a mild noninflammatory infection resembling seborrheic dermatitis to a highly inflammatory swelling reaction (kerion). We report the cases of 2 children who underwent surgical treatment of their kerions under general anesthesia. One lesion had been incised and the other excised. This inappropriate treatment made conservative treatment after surgery more difficult. We recommend that abscesslike lesions on the scalps of children be carefully investigated by surgeons and dermatologists to determine whether they are the result of a dermatophytic infection in order that the appropriate conservative treatment can be initiated.

[Acquired effluvium of head hair: common conditions in women]

Acquired disorders of hair growth in women may present clinically either as effluvium or alopecia. The relevant pathologies include androgenetic alopecia, postpartum effluvium, tinea capitis, trichotillomania and alopecia areata.

Tiña de la cabeza en un adulto. A propósito de un caso

A tinea capitis and tinea faciei case in an elderly female patient with diabetes mellitus type 2 is presented. Her dermatological illness began on her face and later disseminated to her scalp. She received multiple medications which aggravated her condition. The diagnosis was established by means of direct examination and the isolation of Trichophyton tonsurans in culture. Treatment with 200 mg daily dose of itraconazol for two months resulted in clinical and mycological cure.

[Erythema nodosum induced by kerion celsi in a child with hypomelanosis of Ito]

A 3-year-old boy presented with an 8 week history of inflammatory nodular lesions on the scalp. Shortly afterwards painful subcutaneous nodules developed on the lower legs. Epidermophyton floccosum was isolated from the scalp lesions and a diagnosis of erythema nodosum induced by kerion celsi of the scalp was made. The patient was started on oral therapy with 250 mg/day griseolfuvin, associated with topical eosine and myconazol. Erythema nodosum represents a reaction pattern to a wide variety of inflammatory stimuli. The interest of this case lies in the unusual association of kerion celsi and erythema nodosum and in the identification of Epidermophyton floccosum in the lesions of the scalp.

Lupus-erythematosus-like eruption induced by Trichophyton mentagrophytes infection

BACKGROUND

Several factors are known to trigger acute manifestations of lupus erythematosus (drugs, ultraviolet radiation, bacterial or viral infections, pregnancy), but fungal infections have never been reported to induce lupus-like lesions. We describe 2 children with tinea capitis caused by Trichophyton mentagrophytes(TM), who developed transient skin and serological manifestations of systemic lupus erythematosus.

PATIENTS

Case 1, a 3-year-old girl, had a kerion due to TM transmitted by an octodon, and a facial skin eruption suggestive of systemic lupus erythematosus. Antinuclear antibodies (ANA) were positive at 1:250. After griseofulvin treatment, the lupus-like rash completely regressed, and the ANA titre decreased. Case 2, a 4-year-old girl, had occipital kerion and an annular scaly erythema on the shoulder caused by TM. She also had a non-scaly rash on the face and a recent history of photosensitivity. The ANA titre was positive at 1:8,000. Cutaneous lesions disappeared after an 8-week griseofulvin therapy, and ANA titres decreased progressively.

CONCLUSIONS

'New pets' are usually the vectors of TM, especially familiar rodents like the degu of Chile (also named octodon). In our 2 cases, lupus-like rashes began before the onset of griseofulvin treatment, suggesting a pathogenic role of the dermatophyte. A wide variety of lesions named 'mycides' was described several decades ago associated with TM infections. We hypothesize that these mycides and the TM-induced lupus-like lesions reported in our 2 cases could represent the same entity.

Secondary bacterial infections complicating skin lesions

Secondary bacterial infection in skin lesions is a common problem. This review summarises a series of studies of the microbiology of several of these infections: scabies, psoriasis, poison ivy, atopic dermatitis, eczema herpeticum and kerion. Staphylococcus aureus and group A beta-haemolytic streptococci were the most prevalent aerobes and were isolated from all body sites. In contrast, organisms that reside in the mucous membranes close to the lesions predominated in infections next to these membranes. In this fashion, enteric gram-negative bacilli and Bacteroides spp. were found most often in buttock and leg lesions. The probable sources of these organisms are the rectum and vagina, where they normally reside. Group A beta-haemolytic streptococci, pigmented Prevotella and Porphyromonas spp. and Fusobacterium spp. were most commonly found in lesions of the head, face, neck and fingers. These organisms probably reached these sites from the oral cavity, where they are part of the normal flora. This review highlights the polymicrobial aerobic-anaerobic microbiology of secondarily infected skin lesions.

Unusual presentation of Microsporum canis in human hair

This study reports an unusual presentation of Microsporum canis in infected human hair in a three-year-old boy. Infected hairs showed ectothrix colonization with a mass of small conidia and numerous macroconidia typical of the genus Microsporum. The infected hairs also showed strong invasion by hyphae bearing small numbers of arthroconidia. These hyphae were thinner and longer than those normally found in hair and scalp. It is well known that in cases of tinea capitis due to M. canis, ectothrix arthroconidia formation is extrapilary and arises from intrapilary hyphae. In this case it seems that unusual quantities of hyphae were formed, and not all of them broke down into arthroconidia. They appeared to remain in the hair and to produce macroconidia, which were not formed outside the hair in contact with air, but instead seemed to remain in a deeper layer of the hair than the arthroconidia seen.

Tinea capitis in two elderly women: transmission at the hairdresser

Tinea capitis is rare in the elderly. We report cases of two elderly women who presented to our dermatology clinic within 8 weeks of each other, with scalp scaling and alopecia. In both cases, Microsporum canis grew on fungal culture of their hair, and required prolonged treatment with terbinafine. Neither of them gave a history of contact with young children or any animals. Both were fairly fit and not systemically immunocompromised. However, both had been regularly visiting the same hairdresser, during the presumed period of infectivity, making this the most likely source of infection.

Erythema nodosum induced by kerion celsi of the scalp

A 5-year-old girl presented with a 2-week history of a sharply demarcated, inflammatory, granulomatous lesion on the right side of her scalp. Shortly afterward, painful, subcutaneous nodules developed on her shins and thighs. Trichophyton mentagrophytes was isolated from the scalp lesion and a diagnosis of erythema nodosum induced by kerion of the scalp was made. The patient was started on oral therapy with 18 mg/kg/day griseofulvin, associated with topical crystal violet. Her erythema nodosum regressed in 10 days, while the kerion healed 6 weeks later, leaving residual scarring alopecia. Erythema nodosum represents a reaction pattern to a wide variety of inflammatory stimuli. The interest of this case lies in the unusual association of kerion erythema nodosum, of which only nine cases have been reported in the international literature.

Tinea faciei due to Microsporum canis abscess formation

Superficial dermatophyte infections are common in children; however, complications are encountered rarely. We describe a child with tinea faciei caused by Microsporum canis, who subsequently developed an abscess. Complete resolution occurred after treatment with oral terbinafine.

A case of black dot ringworm with a review of Japanese cases

Black dot ringworm (BDR), caused by Trichophyton violaceum var. glabrum (T. glabrum), was observed in a 28-year-old Japanese female who had been treated with prednisolone (22.5 mg/day) for systemic lupus erythematosus. It was successfully treated with oral terbinafine (125 mg/day) for 12 weeks. The causative fungus was identified by molecular analysis as well as morphological and biochemical examination. The chitin synthase 1 (CHS1) gene cleavage pattern of the clinical isolate with restricted enzyme HinfI was identical to that of T. violaceum. We reviewed previous reports of BDR to determine the historical trend of this infection in Japan. Since 1974, 93 Japanese cases have been reported. The age distribution was bi-modal: the higher peak consisted of children (aged 0-15 years), and the lower peak was composed of the elderly (aged 60-75 years). In the elderly group, females were predominant (M:F=1:22, p<0.001). T. violaceum, including T. glabrum, was identified as the most common causative fungus of BDR (75.3%). Sixty percent of cases showed slight erythema. In 8 families, 16 cases were found to be intrafamilial infections. A history of previous steroid treatment was described in about 40%.

Practical management of hair loss

OBJECTIVE

To describe an organized diagnostic approach for both nonscarring and scarring alopecias to help family physicians establish an accurate in-office diagnosis. To explain when ancillary laboratory workup is necessary to confirm the diagnosis.

QUALITY OF EVIDENCE

Current diagnostic and therapeutic interventions for hair loss are based on randomized controlled studies, uncontrolled studies, and case series. MEDLINE was searched from January 1966 to December 1998 with the MeSH words alopecia, hair, and alopecia areata. Articles were selected on the basis of experimental design, with priority given to the most current large multicentre controlled studies. Overall global evidence for therapeutic intervention for hair loss is quite strong.

MAIN MESSAGE

The most common forms of nonscarring alopecias are androgenic alopecia, telogen effluvium, and alopecia areata. Other disorders include trichotillomania, traction alopecia, tinea capitis, and hair shaft abnormalities. Scarring alopecia is caused by trauma, infections, discoid lupus erythematosus, or lichen planus. Key to establishing an accurate diagnosis is a detailed history, including medication use, systemic illnesses, endocrine dysfunction, hair-care practices, and family history. All hair-bearing sites should be examined. A 4-mm punch biopsy of the scalp is useful, particularly to diagnose scarring alopecias. Once a diagnosis has been established, specific therapy can be initiated.

CONCLUSIONS

Diagnosis and management of hair loss is an interesting challenge for family physicians. An organized approach to recognizing characteristic differential features of hair loss disorders is key to diagnosis and management.

Itraconazole oral solution for the treatment of tinea capitis using the pulse regimen

A 7-year-old boy with Trichophyton tonsurans tinea capitis was cured following the administration of itraconazole oral solution. He had difficulty swallowing tablets or capsules, so the availability of the oral solution was particularly advantageous. The itraconazole was given once daily in a fasting state at a dosage of 3 mg/kg/day as a pulse lasting 1 week. The first two pulses were separated by 2 weeks and the second and third pulse by 3 weeks. The decision whether or not to administer the third pulse was guided by the presence of clinical symptoms and signs of tinea capitis just prior to the scheduled administration. The availability of the oral solution will enable more young children to be considered for treatment of tinea capitis with itraconazole than was possible when only tablets or capsules were available.

Tinea capitis in two black african adults with HIV infection

Tinea capitis is rare in adults, although a few cases have been described in HIV-infected patients. We present two cases in black African adults who were HIV positive. In one, the condition led to the diagnosis of HIV infection. It is possible that the rarity of tinea capitis in HIV-positive adults could be related to increased colonization of their scalp by Pityrosporum (Malassezia) spp. In patients well controlled with an antiviral therapy, the treatment of tinea capitis seems no more difficult than in non-immunosuppressed patients. There is possibly a relation between clinical presentation and degree of immunodeficiency.

[Bulky superinfected tinea capitis of the scalp. Treatment by surgical resection and reconstruction by cutaneous expansion]

BACKGROUND

Tinea capitis are usually cured by medical treatment. We present an unusual case which required a surgical treatment.

CASE REPORT

A bulky infected kerion ignored for several weeks extended to a large part of the scalp of a 4-year-old girl. Antibiotics and antifungal agents were ineffective so that a total resection was necessary. The loss of substance was covered by a cutaneous graft; the large alopecia was secondarily repaired by a cutaneous expansion. Evolution has been followed for the past 10 years.

CONCLUSION

It is exceptional that surgical treatment should be required for this condition.

[An unusual "black-dot" trichophytosis corporis in a man]

The authors describe an infectious disease, rarely occurring in the Slovak Republic-superficial trichophytia caused by Trichophyton tonsurans var. sulphureum-in a 37-year-old male patient with psoriasis. Untreated oval to circular foci 4-10 x 5-12 cm in size were localised on the forearms and knee, gradually developing black dots remaining after broken hair (parasitismus endothrix). After a failure in local and overall therapy by imidazole antibiotics, the peroral therapy by terbinafine (Lamisil) was successful. (Fig. 2, Ref. 19.)

Tinea capitis in adults

Invasion of keratin of the hair by dermatophytes is a rare event after puberty. A study of 2200 patients affected by various mycotic cutaneous infections during 6 years of observation brought to our attention three cases of tinea capitis in adults. Confirming the studies of other authors, we also found that this disease mostly affected females. In all cases the isolated aetiological agent was Microsporum canis, the fungus species most frequently responsible for tinea capitis in Italy.

Tinea capitis: epidemiology, diagnosis, treatment, and control

Since the 1970s there has been a steady rise in the number of cases of tinea capitis in the United States, most of them caused by Trichophyton tonsurans. Although the infection is seen most frequently in black children, it can occur in white persons and can affect persons of all ages. Control of tinea capitis is difficult for several reasons, including subtle clinical infection, asymptomatic carriage of fungus, fomite spread, and the need for weeks to months of oral medications. Although griseofulvin remains the mainstay of therapy, preliminary studies of itraconazole and terbinafine suggest that these compounds may also be useful in the treatment of tinea capitis. Selenium sulfide shampoo, prednisone, and oral antibiotics are frequently used as adjunctive therapy. The role of fomites in the spread of tinea capitis has yet to be fully understood, as does the best means of decontamination.

Management errors leading to unnecessary hospitalization for kerion

OBJECTIVE

Tinea capitis is a common problem in the inner city, outpatient population. It is known that some children were being admitted for treatment of the kerion type of tinea capitis. The purpose of this study was to determine why these children were being admitted and whether hospitalization was justified.

DESIGN

A retrospective study of all children hospitalized at Children's Hospital of Wisconsin between January 1990 and December 1992 with the diagnosis of tinea capitis was performed.

RESULTS

Twenty-nine children who were hospitalized with tinea capitis were identified. In 10 cases, tinea capitis was the primary reason for admission, in 19 patients it was a secondary diagnosis. All of the patients with a primary diagnosis of tinea capitis were presumed to have a secondary bacterial infection of the kerion; however, this was not verified by the workup of any patient. Numerous deviations from optimal treatment were noted in both groups of patients. Although tinea capitis had been correctly diagnosed before admission in seven primary tinea capitis patients, only two of these patients received oral griseofulvin. The patients in whom tinea capitis was a secondary diagnosis also had a number of therapeutic deficiencies including failure to prescribe griseofulvin (16%), failure to administer griseofulvin with a fatty food or meal (58%), and failure to prescribe a sporicidal shampoo (63%).

CONCLUSIONS

Although all patients were assumed to have a secondary bacterial infection, this could not be documented. With the possible exception of one patient all the symptoms described by the patients could be explained by the highly inflammatory nature of a kerion. A better understanding of the degree of inflammation that may accompany a kerion, as well as its proper treatment, may prevent unnecessary hospitalization of children.

Dermatophyte pseudomycetoma: a case report

A 25-year-old man presented with several prominent subcutaneous masses in the occipital region of the scalp. He had a long history of tinea capitis and tinea corporis infection. Histopathology of the occipital lesions showed mycelial aggregates in the deep dermis and subcutis. Cultures of the excised material and superficial scales grew a fungus identified as Microsporum ferrugineum. We propose the term 'dermatophyte pseudomycetoma' to describe this distinctive mycosis.

Fungus invasion of human hair tissue in tinea capitis caused by Microsporum canis: light and electron microscopic study

Previously, we reported a morphological change of Trichophyton violaceum in hair tissue in black dot ringworm. To investigate the morphology of Microsporum canis in human hais tissue, three cases of tinea capitis by M. canis were examined by both light and electron microscopy. The fungal elements, which were located deeplyin the keratogenous zone, showed nonseptate hyphae in the outer part of the hair cortex. With the upward development of hair tissues, some hyphae invaded the keratinized inner root sheath and were there transformed into arthrospores, which then occupied the large volume of the inner root sheath; each spore was surrounded by an electron-lucent halo. In some affected hair follicles, at the follicular isthmus level, a microabscess composed of polymorphonuclear leukocytes was often formed in the outer root sheath adjacent to the arthrospores in the keratinized inner root sheath. On the other hand, the remaining hyphae in the cortex became degenerated. Fungi did not invade the hair-germinative cells. There is a distinct relationship between the morphological change of fungi and the differentiation of hair cells in tinea capitis by M. canis as well as in that by T. violaceum, although the direction of invasion and pathological roles of fungal elements within hair tissue are significantly different between the two species of fungi.

Scalp infections in black children: think kerion

Treatment of tinea capitis consists of a 5-week course of griseofulvin. A 1-week course of a systemic corticosteroid may be considered in addition to griseofulvin therapy to accelerate the subsidence of inflammation in kerion lesions. Kerion is an inflammatory form of tinea capitis which may progress rapidly into a fulminant infection if untreated. This case report underscores the need for prompt recognition and appropriate treatment of this disorder.

Tinea capitis in the adult: two case studies

The authors describe two cases of tinea capitis in adults, one due to Microsporum canis and the other to Trichophyton rubrum. The atypical clinical presentation of the dermatophytosis in these two cases is stressed. It is hypothesized that in both cases the disease spread from primary lesion on the face.

Hair loss. Common congenital and acquired causes

Hair loss is a common problem likely to be encountered by a clinical practitioner. The most frequent causes of hair loss in pediatric patients include tinea capitis, alopecia areata, traction alopecia, and trichotillomania. In the adult population, causes to be considered are alopecia areata and hair loss associated with systemic disease and hormonal influence. The clinician must be able to separate the types and causes of hair loss into those that reflect primary dermatologic conditions and those that represent reaction to systemic disease.