Treatment options in alopecia

Specialist nurse Jenny Bostock looks at the management of this psychologically distressing disorder.

Alopecia can occur in a variety of patterns and can be due to a variety of causes, although it is often idiopathic.

It is not gender-, race- or age-specific.1

It is distressing for both sexes and its main impact is psychological. Hair loss can lead to a significant change in appearance and patients may experience social phobia, anxiety and depression.2

Although hair loss may be a problem for some men, it is more generally accepted, whereas female baldness is considered unsightly and is not a socially-accepted norm.

One study found that 40 per cent of women with hair loss had relationship problems, while 63 per cent reported career-related problems.2

Assessing the patient
Most patients with alopecia are physically well, but may be anxious about their prognosis. It is important to take a thorough history, including details of the medical and family history, allergies and current medication.

To eliminate underlying causes, a blood test is indicated to check thyroid function, exclude anaemia and measure inflammatory markers.3

On examination, the typical patch of alopecia is uninflamed, with no scaling but with easily seen empty hair follicles. Pathognomonic exclamation mark hairs may be seen around the edge of enlarging areas.

Patches are most common on the scalp and beard, but other areas, especially eyebrows and lashes, can be affected. There may be ridging or fine pitting of the nails, which often indicates a more severe or prolonged prognosis.1

Regrowth is unpredictable and often erratic; in a first attack, it usually occurs within a few months. Subsequent episodes tend to present with more patches and slower regrowth.

The prognosis is poor if onset precedes puberty and is associated with atopy, if the alopecia is widespread and if the scalp margin is involved.1 Patients with progressive hair loss should be referred to a dermatologist.

Treatment
The more severe the hair loss, the less response there is to treatment; no treatment guarantees success.4 Corticosteroids can be applied as topical creams to bald areas or injected around bald areas, although hair often falls out after treatment stops.

Tretinoin is used to treat alopecia areata and androgenic alopecia. It is most effective in combination with minoxidil.5 Psoralen plus UVA treatment has also shown positive results when used on small areas.6

Irritants or allergens may be applied to the scalp to cause an allergic reaction. This is thought to confuse the immune system by drawing T-lymphocytes away from the hair follicle, allowing hair to regrow. However, it can be uncomfortable for the patient and the degree of allergy needs to be monitored.3

Surgical options, such as hair transplants, are expensive and can have poor cosmetic results.

Anecdotally, some improvement has been observed with non-clinical treatments, such as natural anti-inflammatory agents, particularly blackcurrant and borage oil capsules, as well as zinc supplements.

Massage and acupuncture have anecdotally shown positive results, but no research-based evidence supports this.

When prognosis is poor
When prognosis for regrowth is poor, patients need support and guidance.3 Exposed areas of skin need protection from the cold, heat and sun.

Practical advice on disguising alopecia includes using an eyebrow pencil, colour-matched for the patient's hair, to make bald areas less obvious, adopting different hairstyles or partings to cover bald patches, and the use of volumising shampoos and conditioners.

Loss of lashes and eyebrows increases the risk of foreign bodies in the eyes, as well as glare from the sun, and can cause excessive watering, so glasses or sunglasses are advised. Loss of nasal hair can result in a permanently runny nose.

Cosmetic eye pencils can be used to define eyebrows (using hairspray over the eyebrow pencil makes it more resistant to perspiration). Temporary eyebrow tattoos, lasting two to three days, and fake eyebrows lasting up to three days are also available. Semi-permanent tattoos, lasting three to five years, are an option, but can be costly. False lashes are widely available.

Alopecia is erratic, with the possibility of further regrowth and hair loss. Referral to a dermatologist may help to reinforce any information provided in primary care.

Discussion forums and support groups will benefit some patients and counselling may help,7 but others may develop depressive symptoms that will require treatment or referral to psychiatric services.

Accepting the condition and finding ways of adjusting to an altered body image is the key to living with this condition.

  • Jenny Bostock is a nurse practitioner in Canterbury, Kent

REFERENCES

1. Hunter J, Savin J, Dahl M (eds). Clinical dermatology. Oxford: Blackwell Science, 2002.

2. Weitz R. Rupunzel's daughters. New York: Farrar, Straus & Giroux, 2004.

3. MacDonald Hull S P, Wood M L, Hutchinson P E et al. Guidelines for the management of alopecia areata. Br J Dermatol 2003; 149: 692-9.

4. Randall V. Is alopecia areata an autoimmune disease? Lancet 2001; 358: 1,922-4.

5. Price V H, Trancik R, Rundegren J. Topical minoxidil 5% in the treatment of alopecia areata. J Invest Dermatol Symp 1999; 4: 252.

6. Healy E, Rogers S. PUVA treatment for alopecia areata - does it work?. Br J Dermatol 1993; 129: 42-4.

7. Fox J. Case study of alopecia universalis and web-based news groups. Br J Nurs 2003; 12: 550-8.

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