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Scalp Biopsy

Scalp biopsies can be used to make or confirm a diagnosis of alopecia and can be essential in guiding therapy. A four millimeter punch biopsy which includes subcutaneous fat is needed to ensure sampling of the entire follicular unit and any anagen follicles. Horizontal sections are becoming the method of choice for dermatopathologists as they offer the advantage of evaluating large numbers of follicles simultaneously, de termining hair density, telogen/vellus ratio, anagen to telogen ratio, and location of inflammatory infiltrate (Whiting, 1990).

Laboratory Tests

A careful history can help in directing what laboratory tests to order. A basic evaluation including thyroid stimulating hormone, serum iron, and ferritin may be necessary to exclude thyroid dysfunction and iron deficiency anemia. In women with androgenetic alopecia and virilizing signs such as acne, hirsutism, and/or irregular menses, a basic endocrine panel consisting of free testosterone, prolactin, 17-hydroxy progesterone, and cortisol to rule out hyperandrogen states is advised (Ehrmann, 2005). In cases of scarring alopecia secondary to discoid lupus erythematous, an antinuclear antibody analysis is warranted. If there is any clinical suspicion of syphilitic alopecia, a rapid plasma reagin test is necessary.

The differential diagnoses for hair loss are grouped into three categories: disturbances of the hair cycle, damage to the hair shaft, or disorders affecting the follicle. The following is not meant to be an exhaustive review of possible causes of hair loss, but instead common causes of hair loss in woman are highlighted.

Disturbances of the Hair Cycle

Telogen effluvium:

The shedding often starts months after the inciting cause but is always self-limited and reversible if the offending cause is corrected or resolved. Using the analogy that the hair cycle is much like a menstrual cycle may help the patient understand the biology of telogen effluvium. Furthermore reassuring her that the hair shaft and hair follicle are healthy and normal can give a positive focus to the visit.

Damage to the Hair Shaft

Hair breakage:

Treatment of hair breakage usually requires alteration of the hair care routine. Hairstyles that pull on the hair, like ponytails and braids, should be put in as loosely as possible and should be alternated with looser hairstyles. If there is a constant pull on the hair, damage to the hair follicle can occur, resulting in traction alopecia (see Figure 3), which is seen especially along the sides of the scalp. Shampooing, combing, and brushing too often can also damage hair, causing it to break. Recom mending a cream rinse, conditioner, or leave-in conditioner with silicone will make the hair more manageable and easier to comb. When hair is wet, it is more fragile, so vigorous rubbing with a towel, and rough combing and brushing should be avoided. Instead, the use of wide-toothed combs and brushes with smooth tips should be recommended. Also, using heat (blow-dryer, curling iron, flat iron) on wet hair can cause increased damage. Hair loss is reversible if the cosmetic procedure is stopped and the hair is handled gently; this is true even in early stages of traction alopecia. Stressing this reversibility should be the "take home message" for the office visit.

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