Diagnosing Scarring and Nonscarring Hair Loss

In his presentation at the 2021 Fall Clinical Dermatology Conference for PAs & NPs, Matt L. Leavitt, DO, FAOCD, FISHRS, highlighted the methods to diagnose scarring and nonscarring alopecias.

When sitting down with a patient with hair loss, it’s important to acknowledge the emotional toll that accompanies such loss, according to Matt L. Leavitt, DO, FAOCD, FISHRS, who spoke on the topic of diagnostic and therapeutic approaches to hair loss at the 2021 Fall Clinical Dermatology Conference for PAs & NPs, held November 12 to 14, in Orlando, Florida, and virtual.

Leavitt is the founder and executive chairman of Advanced Dermatology and Cosmetic Surgery, founder of Medical Hair Restoration, executive medical advisor at Bosley Hair Restoration and Transplant, chairman of KCU/ADCS Orlando Dermatology Residency, and an associate clinical professor at UCF in Orlando, Florida and associate clinical professor at KCUM.

He gave a 3-pronged approach to gaining rapport with these patients:

  1. Ask the patient for permission to examine the area of loss. This establishes an initial relationship with the patient and shows that the clinician understands the emotional impact of hair loss.
  2. Provide reassurance to the patient. This acknowledges how important the loss is to the patient.
  3. Conduct the initial evaluation. In the examination, Leavitt said to look at the general shine and volume of the hair, scalp health, whether the loss is localized, patterned or nonpatterned, and whether it is scarred or nonscarred.

In his presentation, he detailed pearls for diagnosing both scarring/cicatricial and nonscarring alopecias.

He categorized cicatricial alopecias as having a visible loss of follicular ostia, destruction of the follicle when seen during a hematoxylin and eosin (H&E) stain exam, inflammatory infiltrate targeting the hair follicle, replacement with fibrous tissue, and progressive permanent hair loss.

Scarring alopecia types include:

Lymphocytic

  • Chronic cutaneous discoid lupus erythematosis
  • Lichen planopilaris
  • Classic pseudopelade (Brocq)
  • Central centrifugal cicatricial alopecia
  • Alopecia mucinosa
  • Keratosis follicularis spinulosa decalvans

Neutrophilic

  • Folliculitis decalvans
  • Dissecting cellulitis/folliculitis

Mixed

  • Folliculitis keloidalis
  • Folliculitis (acne) necrotica
  • Erosive pustular dermatosis

Non-specific

In addition, he gave specific diagnostic traits that pertain to particular scarring alopecia types.

Lichen planopilaris (LPP), he explained, mostly manifests in women between the ages of 40 to 60. While the etiology is unknown, it could correlate to antigenic stimulus.

Leavitt described the types of lesions present in LPP:

  • Perifollicular erythematous/violaceous papules and spinous/follicular keratotic papules
  • Atrophic, smooth shiny patches
  • Multifocal/scattered areas throughout the scalp
  • Disease activity limited to the hair bearing periphery of scarred patches
  • Slow progressive disease that can lead to an extensive area of hair loss

Another scarring alopecia type he highlighted in his presentation was frontal fibrosing alopecia. Frontal fibrosing alopecia is a specific-patterned clinical variant of LPP that affects the front hairline, according to Leavitt. This type of hair loss typically impacts postmenopausal women older than 40 years, and rarely men. Known as progressive alopecia, it creates a band-like area on the scalp with 3- to -8cm-wide contrasts with photodamaged skin and thinning or completely absent eyebrows. Axillary hair loss has been reported and keratosis pilaris like papules can also be seen on the forehead and temples, he said.

Traction alopecia was another scarring type he addressed. This type, which is caused by hairstyles that put excess tension on the hair, is most common in Black patients. It is categorized by hair breakage and patches of baldness, with the potential addition of erythema, scaling, and pustules. Traction alopecia is most common in the frontal or temporal areas of the scalp and can manifest in the persistence of short hairs along the anterior margins. Leavitt also explained that long-term traction can cause scarring.

Along with his explanation of scarring alopecias, Leavitt also discussed the different nonscarring variants.

Diffuse

  • Breakage: Anagen effluvium, hair shaft disorder, physical or chemical processing.
  • Telogen effluvium
  • Androgenetic alopecia (women)
  • Alopecia areata, totatis, or univeralis
  • Loose anagen syndrome

Focal

  • Infection
  • Traumatic
  • Alopecia areata
  • Hair breakage
  • Androgenetic alopecia (men and women)
  • Developmental

He highlighted the manifestations of nonscarring telogen effluvium, which is a visible and rapid progression of hair loss with an increase from 10% to 30% to 50% telogen hairs per day (150 to 700 hairs/day). These hairs are easy to comb out. Telogen effluvium also lags the inciting event by approximately 3 months, Leavitt explained.

Causes of telogen effluvium include:

  • Acute stress (hemorrhage)
  • Childbirth (postpartum)
  • Chronic systemic illness: Cancer, leukemia, Hodgkin’s disease, tuberculosis, cirrhosis.
  • Crash dieting
  • Chronic iron definiency
  • Psychogenic stress
  • Thyroid disease
  • Drugs: Allopurinol (Zyloprim; Casper Pharma, LLC), clofibrate (Atromid-S; Ayerst Laboratories), cocaine, warafin (Coumadin), heparin, oral contraceptives, and propylthiouracil.
  • Febrile illness
  • Influenza
  • Lobar pneumonia
  • Pertussis
  • Scarlet fever
  • COVID-19

The most common cause of telogen effluvium is childbirth (postpartum) which is called telogen gravidurum. Leavitt explained that one-third to one-half of postpartum people report mild to moderate hair loss that corrects itself in about 6 to 18 months without physician intervention. However, if it persists longer then 6 months, he said, the hair loss is then categorized as chronic.

Chronic telogen effluvium can have a subtle onsite in women 40 to 60 years old and show as continuous shedding with fluctuations, normal appearing densities, and a shortened anagen phase.

Knowing the subtle differences in alopecias helps clinicians better diagnose and treat patients to the best of their abilities, he concluded.

Adam Leavitt, MD, Matt L. Leavitt’s son who helped him compile the presentation for the conference, highlighted trichoscopy as a useful diagnostic tool.

“Trichoscopy has become an essential tool for the diagnosis of both scarring and nonscarring alopecias,” said Adam Leavitt, who is a practicing dermatologist specializing in alopecia, and hair restoration surgery fellow at Advanced Dermatology and Cosmetic Surgery and Bosley, Orlando, Florida. “In many cases, trichoscopy can replace the need for a scalp biopsy and trichoscopic findings are well established and conserved regardless of gender, hair type, or ethnicity.”

He mentioned many examples of trichoshopic findings to help diagnose different types of hair loss.

“The trichoscopic findings of androgenetic alopecia include miniaturized follicles and decreased follicular unit number,” he said. “The trichoscopic findings of alopecia areata include exclamation point hairs and perifollicular yellow globules. The trichoscopic findings of lichen planopilaris and frontal fibrosing alopecia include perifollicular erythema, perifollicular scale, and milky red/ white areas. The trichoscopic findings of central centrifugal cicatricial alopecia include perifollicular grey-white halos. In tinea capitis, we can see corkscrew hairs and in trichotillomania, we can see broken hairs of varying lengths.”of Medical Hair Restoration

Disclosure:

1. Leavitt is on the advisory board for Eli Lilly and Company and obtains royalties from A-Z Surgical.

Reference:

1. Leavitt, ML. Diagnostic and therapeutic approach to hair loss. 2021 Fall Clinical Dermatology Conference for PAs & NPs; November 12 to14, 2021. Orlando, Florida and virtual.