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(BQ) Part 2 book The difficult hair loss patient - Guide to successful management of alopecia and related conditions presents the following contents: Psychopathological disorders, tackling adverse effects, patient noncompliance, optimizing therapy beyond evidence-based medicine, exemplary case studies of successful treatments, epilogue-faith healing,...
5 Psychopathological Disorders The educated among the physicians make an effort into an understanding of the mind Aristotle (384–322 BC), Nicomachean Ethics It is a common experience among dermatologists that a significant number of their patients have psychological overlays to their chief complaints This particularly holds true for complaints related to conditions of the hair and scalp The exact incidence in any particular dermatologic practice most likely depends on the dermatologist’s interest; however, even for those dermatologists who are not specially interested in the psychological aspects of dermatologic disease, some patients have such overt psychopathologic conditions, such as trichotillomania, factitial dermatitis, or delusions of parasitosis, that even the least psychologically minded dermatologist feels obliged somehow to address the psychological issues Ideally, this would be accomplished simply through referral of the patient to a mental health professional In reality, the majority of psychodermatologic patients are reluctant to be referred to a psychiatrist Many lack the insight regarding the psychological contribution to their dermatologic complaints; others fear the social stigmatization of coming under the care of a psychiatrist The dermatologist is often the physician designated by the patient to handle their chief complaint, even if the main disorder is a psychological one Therefore, it is essential for dermatologists dealing with such patients to expand their clinical acumen and therapeutic armamentarium to effectively handle the psychodermatologic cases in their practice To accomplish this goal, the following steps are required: Learn to classify and diagnose psychodermatologic disorders Because so many different types of conditions lie in between the fields of dermatology and psychiatry, it is paramount to have classification systems that will help clinicians understand what they are dealing with There are two ways to classify psychocutaneous cases: first, by the category of the dermatologic presentation, e.g., neurotic excoriation, and, second, by the nature of the underlying psychopathologic condition, e.g., depressive disorder, generalized anxiety disorder, or obsessive–compulsive disorder © Springer International Publishing Switzerland 2015 R.M Trüeb, The Difficult Hair Loss Patient: Guide to Successful Management of Alopecia and Related Conditions, DOI 10.1007/978-3-319-19701-2_5 139 140 Become familiar with the various therapeutic options available, both nonpharmacologic and psychopharmacologic Recognize the limits of what can be accomplished in a dermatologic practice: Typically, a dermatologist does not have the time, training, or inclination necessary to administer most nonpharmacologic approaches If a dermatologist seriously considers the challenge of treating these patients with psychopharmacologic agents, the selection of appropriate agents is dictated by the nature of the underlying psychopathologies that need to be treated In order to prescribe effectively and safely for these patients, the dermatologist must have a basic understanding of the pharmacology of psychotropic agents Optimize working relationships with psychiatrists, since dermatologists and psychiatrists tend to have different perspectives when analyzing a clinical situation, different styles of communication, and different approaches to management 5.1 Classification Most psychocutaneous conditions of the hair and scalp can be grouped into the following four categories: Psychophysiological disorders, in which the scalp disorder is exacerbated by emotional factors, e.g., hyperhidrosis, atopic dermatitis, psoriasis, and seborrheic dermatitis of the scalp Primary psychiatric disorders, in which there is no real skin condition, but all symptoms are either self-induced or delusional, e.g., trichotillomania, neurotic excoriations, factitial dermatitis, Psychopathological Disorders delusion of parasitosis, or psychogenic pseudoeffluvium Cutaneous sensory disorders, in which the patient has various abnormal sensations of the scalp with no primary dermatologic lesions and no diagnosable internal medical condition responsible for the sensations Secondary psychiatric disorders, in which patients develop emotional problems as a result of hair loss, usually as a consequence of disfigurement 5.2 Psychophysiological Disorders Psychophysiological disorders is the term used for psychocutaneous cases in which specific dermatologic skin disorders, such as psoriasis and eczema, are exacerbated by emotional stress in a significant proportion of patients Examples affecting the scalp include hyperhidrosis, atopic dermatitis, psoriasis, and seborrheic dermatitis In each of these conditions, one comes across two types of patients: those who experience a close chronologic association between stressful experiences and exacerbation of their dermatologic condition and those for whom the emotional state seems not to influence the natural course of their disease These two groups are referred to as “stress responders” and “non-stress responders,” respectively The relative proportion of stress responders versus nonstress responders varies among the different psychophysiological conditions A study involving a large number of subjects from the Harvard health-care system in Boston, Massachusetts, determined the proportion with emotional trigger to be 100 % in patients with hyperhidrosis, 70 % in those with atopic dermatitis, 62 % with psoriasis, and 41 % with seborrheic dermatitis 5.2 Psychophysiological Disorders This category also includes the psychosomatic disorders – the physical symptomatic representation of unsolved emotional conflicts For classification, we may consider the different levels of psychosomatic disorder: The first level is physiological and includes bodily sensations in response to emotional shifts, great or small In health these bodily sensations make little or no impact on consciousness At the second level, the person becomes more or less constantly aware of the somatic sensations, which are of purely functional nature at this time point, attempts to analyze them, and becomes anxious that they might signify some serious organic disease The third level is the important one, at which internal somatic medicine and psychiatry meet The organs and parts of the body have enormous elasticity and rebound, but if the underlying emotional distress is too prolonged, they supposedly lose their elasticity, no longer being able to cope, and finally protest in terms of the psychosomatic organ lesion or organ pathology It has long been recognized that psychosomatic factors play a role in dermatologic disease It has been hypothesized that an organ system is vulnerable to psychosomatic ailments when several etiologic factors are operable These factors include emotional factors mediated by the central nervous system; intrapsychic processes such as self-concept, identity, and eroticism; specific correlations between the emotional drive and the target organ, i.e., social values and standards linked with the organ system; and a constitutional vulnerability of the target organ 5.2.1 141 The disorder is characterized by minute and usually intensely pruritic follicular erythematous papules and pustules of the scalp that may become sore and crusted due to repeated scratching The lesions may concentrate along the frontal hairline but can appear anywhere on the scalp, varying in number from just a few to numerous lesions covering the scalp (Fig 5.1) The disease has been classified into acne necrotica miliaris and acne necrotica varioliformis The former affects the superficial portion of the hair follicle, allowing for hair regrowth after successful treatment Miliaris refers to a millet, a term for a small seed The latter represents deeper lesions that progress to scabs that leave smallpox-like (varioliform) scars in their wake Focal permanent alopecia may occur where the scalp has been scarred Patients with folliculitis necrotica tend to be middle-aged executives, with lesions often triggered by stress Many have jobs that place a lot of responsibility on them Histological studies of early lesions demonstrate lymphocytes centered around a hair follicle, with keratinocytes within the external hair root sheath and surrounding epidermis showing extensive cell necrosis The etiology is unknown; however, an abnormal inflammatory reaction to components of the hair follicle has been postulated, particularly to commensal or pathogenic microorganisms, such Folliculitis Necrotica Folliculitis necrotica is a peculiar dermatosis of the scalp that preferentially affects adult males, with chronic symptoms that wax and wane over time Traditionally, the condition has been nosologically classified among the primary scarring alopecias There is circumstantial evidence to also classify it among the psychophysiological disorders Fig 5.1 Acne necrotica miliaris 142 as Propionibacterium acnes, Malassezia spp., Demodex folliculorum, and, in the more severe cases, Staphylococcus aureus Additionally extreme mechanical manipulation of the scalp due to scratching may be to blame The condition usually responds well to oral antibiotics, particularly long-term tetracyclines, in combination with a topical corticosteroid cream, and a shampoo treatment alternating an antiseptic shampoo containing povidone-iodine with an antidandruff shampoo containing ketoconazole Mild cases may be treated with topical antibiotics such 0.5–1.0 g tetracycline in 70 % isopropyl alcohol (at 100.0 g), % clindamycin solution, or % erythromycin gel Refractory cases usually can be managed with long-term low-dose oral isotretinoin (start with 20 mg daily and taper to the individually required minimal dosage) In particularly tense patients, the addition of oral doxepin hydrochloride 10–50 mg in the evening may be helpful in alleviating the itch–scratch cycle 5.3 Primary Psychiatric Disorders The term primary psychiatric disorders refers to cases in which there is no real skin condition Everything that is seen on the scalp is self-induced, or there are no objective signs of complaints relating to the condition of the scalp and hair This category includes conditions such as trichotillomania, neurotic excoriations, factitial dermatitis, delusions of parasitosis, and psychogenic pseudoeffluvium Since the dermatologic presentations are quite stereotypic, but the underlying psychopathology varies, a critical step in psychodermatology is to try to ascertain the nature of the underlying psychopathologic condition Psychopathological Disorders Any one of the numerous psychopathologies listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) and in the International Statistical Classification of Diseases and Related Health Problems, 10th edition (ICD-10) can be presented by these patients In general, one of the following four types of underlying psychopathology is present: Generalized anxiety disorder Depressive disorder Delusional disorder Obsessive–compulsive disorder Generalized Anxiety Disorder Generalized anxiety disorder is characterized by a sustained, increased free floating anxiety, which is not orientated toward a certain object or situation It expresses itself in the form of anxious expectations and enhanced alertness, combined with hypertension and, as a physiological correlate, vegetative hyperreactivity Subjective symptoms include feelings of restlessness, irritability, feeling “on edge,” tension, dizziness, agitation, and an inability to relax These are frequently associated with physiological correlates such as muscle tension, sweating, shortness of breath, dry mouth, palpitations, abdominal complaints, and frequent urination The uninhibited breakthroughs of tremendous anxiety show that the anxiety defense mechanisms have failed in the affected individuals The causes of anxiety are repressed, but the ongoing arousal and fear are overwhelming The patient’s appearance is clinging and helpless The patients signify a strong demand to be guided and assisted in their surroundings The fixation toward fear of love deprivation may lead to attachments to strong “father figures,” e.g., a physician, and strong emotional reactions on parting situations: a change of physician can cause severe separation anxiety and may therefore seem unbearable 5.3 Primary Psychiatric Disorders When patients with psychophysiological disorders complain that they are “stressed,” they are usually referring to an underlying sense of anxiety In the United States, anxiety disorder represents the most common mental health problem, especially in the over 55 years age group, where the prevalence is approximately one in ten Depressive Disorder In a depressive disorder, the affected individual suffers from the symptoms of a depressive syndrome, which may be interspersed with shorter or longer periods of normal mood Depression is characterized by subjective symptoms, such as depressed mood, crying spells, anhedonia (inability to experience pleasure), a sense of helplessness, hopelessness and worthlessness, excessive guilt, and suicidal ideation Frequently associated physiological correlates are psychomotor retardation or agitation, insomnia or hypersomnia, loss of appetite or hyperphagia, and, especially in older patients, complaints of constipation In a depressive character disorder, affected individuals appear humble, unambitious, and sacrificing They have high self-expectations and avoid close approaches from others; they would rather give up their own intentions and become subordinate to others Usually there are coexisting wishes of dependency that others shall acknowledge the sacrifice and turn their attention and love to them In others this may provoke an aggressive defense mechanism, which may appear as a hostile dissociation These mismatched expectations mainly affect the patient’s partnerships, when self-sacrifice and the excessive demand of love become overbearing Depression is especially common among patients seen in a medical setting In turn, it may affect patient motivation toward recovery and is associated with poorer medical outcomes 143 Delusional Disorder The presence of delusion defines psychosis A delusion is a false idea on which the patient is absolutely fixed A delusion is deemed to be a basic psychotic phenomenon, in which the objective falseness and impossibility of the delusional content are usually easy to realize Delusional convictions are not simple misbeliefs; they are constitutions of an abnormal mind that refer to the individual’s cognitive experiences of his or her environment – their ego–environment relationship Delusions are not voluntarily invented by the patients: they are caused by psychotic experiences From the psychodynamic point of view, a delusional disorder is a special consequence of abnormal selfdevelopment The delusion derives from the patient’s desire to be in a safe place, away from the tension caused by the brittleness and contradictoriness of the patient’s ego–environment relationship The subjective certainty of the delusion’s content causes its incorrectability: patients consistently keep their convictions, without considering their incompatibility with reality Neither contrary experiences nor logical arguing can influence them By definition, delusional patients have no insight, and others cannot talk them out of their belief system The type of delusional patient most often seen by the dermatologist is not the schizophrenic, but the patient with monosymptomatic hypochondriacal psychosis Monosymptomatic hypochondriacal psychosis is characterized by a delusional ideation held by a patient that revolves around one particular hypochrondriacal concern, while with schizophrenia, many other mental functions become compromised, besides the presence of delusional ideation Obsessive–Compulsive Disorder Obsessive– compulsive symptoms may be seen across the whole spectrum of psychopathology In early 144 childhood, they may occur as a temporary phenomenon in response to stress or anxiety, e.g., trichotillomania; they may occur as a psychoneurotic symptom in a person with an obsessive– compulsive personality configuration, e.g., onychophagia or acne excoriée; they may occur as a feature of the obsessive–compulsive disorder; or they may also occur in patients with psychosis Individuals with an obsessive–compulsive personality configuration are rigid, perfectionist, and indecisive for fear of making a mistake; they lack self-confidence, are sensitive to criticism, and are socially reserved Perhaps most importantly, they have profound difficulty in handling anger and aggression, which sometimes is explosive and at other times is displaced into selfdestructive picking of the skin rather than being expressed directly in a modulated fashion The essential feature of obsessive–compulsive disorder required for diagnosis is recurrent obsessions or compulsions that are severe enough to be timeconsuming or cause impairment in relationships, employment, school, or social activities An obsession is a persistent idea, thought, impulse, or image that intrudes into a person’s consciousness uncontrollably and causes distress, anxiety, and often feelings of shame The individual with obsessive–compulsive disorder realizes that the obsession is inappropriate and irrational but cannot resist The obsessional concerns often lead to compulsive acts Compulsions are repetitive, stereotyped motor acts, often ritualized, and designed to reduce intolerable anxiety or distress Obsessions may involve themes of aggression (harming self or others), contamination (dirt, germs, body secretions), sex (forbidden thoughts or impulses), religion (concern with blasphemy or sacrilege), or somatic concerns Patients suffering from obsessive– compulsive disorder have insight into their condition, whereas delusional patients not The clinical manifestations on the hair and scalp of the respective psychopathologic conditions are listed in Table 5.1 Psychopathological Disorders Table 5.1 Psychopathologic conditions and their clinical manifestations on the hair and scalp Manifestations of generalized anxiety disorder: Neurotic excoriations of the scalp Scalp dysesthesia Manifestations of depressive disorder: Neurotic excoriations of the scalp Scalp dysesthesia Imaginary hair loss (psychogenic pseudoeffluvium) Manifestations of delusional disorder: Delusions of parasitosis Imaginary hair loss (psychogenic pseudoeffluvium) Manifestations of obsessive–compulsive disorder: Trichotillomania Neurotic excoriations of the scalp Factitial dermatitis of the scalp 5.3.1 Neurotic Excoriations of the Scalp The term neurotic excoriations refers to patients with self-inflicted excoriations of the scalp in the absence of an underlying specific dermatologic disease condition The etiology is varied, and psychiatrically, patients with neurotic excoriations are not a homogenous group, each requiring an individual therapeutic approach The condition may occur at any time from childhood to old age, with the most severe and recalcitrant cases reportedly starting in the third to fifth decade Because the patients, by definition, can inflict lesions only on those areas of the body that can be reached, and because patients tend to excoriate areas that are easily accessible, the clinical distribution of lesions besides the scalp can give a clue to the diagnosis The lesions may affect the scalp in an isolated manner or may be associated with excoriations of the face and/or of the upper trunk and extensor aspects of the arms The excoriations may be initiated by minor irregularities of the skin surface, such as a keratin plug, insect bite, acne papule (acne excoriée), or irritated hair follicle, or may start de novo There is a decreased threshold for itch with tendency to habitual or neurotic scratching Picking activity may start inadvertently as the hand comes across on an irregularity of the skin, or it may occur in an organized and ritualistic manner, sometimes 5.3 Primary Psychiatric Disorders 145 using an auxiliary instrument, such as the point of a knife, etc Tissue damage itself may again trigger itching, and the itch–scratch cycle may take on a life of its own This activity typically takes place when the patient is unoccupied, and precipitating psychosocial stressors are usually present Neurotic excoriations occur across the spectrum of psychopathology In mild and transient cases, it may be a response to stress, particularly in the younger patient, such as examination stress (thinker’s itch), mainly in someone with obsessive–compulsive personality traits In the more severe and sustained cases, psychiatric evaluation may diagnose a generalized anxiety disorder, depression, or obsessive– compulsive disorder The inflicted lesions are rather nonspecific Varying in size from a few millimeters to several centimeters in the well-developed case, lesions are seen in all stages of evolution, from small superficial saucerized excoriations, to deep scooped-out skin defects (Fig 5.2), to thickened hyperpigmented nodules, and finally to hypopigmented atrophic scars Secondary bacterial infection may lead to regional lymphadenopathy The histology is that of an excoriation with nonspecific inflammatory changes Microbiological studies may reveal secondary bacterial infection, usually with S aureus Since other dermatologic conditions can lead to similar lesions as neurotic excoriations of the scalp, clinicians must be careful not to make this diagnosis on the basis of the morphology of lesions alone Specifically, pruritic skin conditions of dermatologic or other origins need to be excluded Examples are atopic dermatitis, folliculitis necrotica, chronic cutaneous lupus erythematosus, pemphigus vulgaris, pemphigoid, parasitic Fig 5.2 Neurotic excoriations of the scalp infestation, neurologic disorders, and other psychiatric disorders, such as cocaine intoxication, delusions of parasitosis, and factitial dermatitis Most importantly, one needs to confirm the diagnosis by ascertaining the presence of psychopathology through both clinical observation and direct patient questioning Dermatologic treatment includes the prescription of non-irritating or “sensitive” shampoos, topical glucocorticoid–antibiotic cream preparations, and sedative antihistamines, such as hydroxyzine or doxepin, preferably given at nighttime Cool compresses are soothing, provide hydration, and facilitate debridement of crusts When followed by the application of an emollient, they reduce any contribution that xerosis makes to itching When present, secondary bacterial infection must be treated appropriately, usually with a short course of oral antibiotics Psychiatric treatment includes nonpharmacologic and pharmacologic therapeutic options In both, the choice of the appropriate technique or 146 pharmacologic agent depends on the underlying mental disorder Although behavioral modification, cognitive psychotherapy, psychodynamic psychotherapy, and an eclectic approach have met variable success, many patients who present to the dermatologist are reluctant to agree to the psychiatric nature of their skin disorder and lack insight into the circumstances that trigger the drive to excoriate Unless the patient is managed in a liaison clinic where dermatologists and psychiatrists can confer, it is the dermatologist who will take the responsibility for treatment If the patient is suffering from excessive stress, there are specific and nonspecific approaches Those individuals who can find specific, real-life solutions to the difficulties they report are the more fortunate ones Many patients experience stress from work or home relationships for which there is no easy way out For these patients, a nonspecific solution to the stress can still be beneficial Among the nonspecific solutions to stress, there are nonpharmacologic and pharmacologic means The nonpharmacologic means include exercise, biofeedback, yoga, self-hypnosis, progressive relaxation, and other techniques learned in stress-management courses Some patients not have time to take stress-management courses, and others have special difficulty benefiting from this type of approach, for example, those who are not psychologically minded For these patients, cautious use of antianxiety agents may be an alternative In general, there are two types of anxiolytics: a quick-acting benzodiazepine type that can be sedating and produce dependency, such as alprazolam, and a slow-acting non-benzodiazepine type that is nonsedating and does not produce dependency, such as buspirone Alprazolam differs from the older benzodiazepines such as diazepam and chlordiazepoxide because its halflife is short and predictable Another advantage is that it has an antidepressant effect, whereas most other benzodiazepines generally have a depressant effect Because of the possible risk of addiction with long-term use, the most prudent way of using alprazolam would be to restrict its use to 2–3 weeks If the patient requires Psychopathological Disorders long-term therapy for anxiety, buspirone may be considered However, it must be kept in mind that the effect of buspirone is usually not experienced by the patient for the first 2–4 weeks of treatment Also, buspirone cannot be used on an “as-needed” basis If buspirone does not work for a patient with chronic anxiety disorder, an alternative would be the use of low-dose doxepin Even though doxepin is a tricyclic antidepressant, in low doses, it has been compared to benzodiazepines in terms of its anxiolytic effects Sometimes, also a low dose of a lowpotency antipsychotic agent such as thioridazine can be used Although there are a number of nonpharmacologic treatment options for depression, most dermatologists have neither the time nor the training to execute these treatment modalities Nonetheless, it is advantageous to be conscious of these options, especially for those patients who agree to a referral to a mental health professional Individual psychotherapy can be useful if there are definable psychological issues to be discussed, e.g., frustrations at work, a maladaptive style in interpersonal relationships, and the presence of maladaptive views of oneself, such as unrealistic expectations or fear of failure Other patients have neurobiological predispositions to depression, and their depressive episodes may not be associated with any identifiable psychosocial difficulties For these patients, the use of specific psychopharmacologic agents may in fact correct the primary cause of their depression There are a number of antidepressants to choose from for the treatment of depression pharmacologically Among the tricyclic antidepressants, again doxepin is probably the most suitable for the treatment of depressed patients with neurotic excoriations If the patient cannot tolerate the sedative side effect of doxepin, desipramine or one of the newer, nontricyclic antidepressants such as fluoxetine, sertraline, and paroxetine are alternatives Finally, for the obsessive–compulsive patient with neurotic excoriations, there are, once again, nonpharmacologic and pharmacologic therapeutic options However, if the dermatologist were to follow a nonpharmacologic approach for patients 5.3 Primary Psychiatric Disorders who reject referral to a mental health professional, it would have to be a technique that is simple enough to perform in a dermatologic setting One such technique is the invocation of a “1- or 5-minute rule,” a simple behavioral technique to try to interrupt the progression from obsessive thoughts to compulsive behavior The patient is asked to try to put an interval of 1–5 between the occurrence of the obsessive thought and the execution of the compulsive behavior Once the patient is successful in refraining for min, the time is gradually increased to 5, 10, or even 15 min, and, eventually, with such a long interruption between the obsessive thought and the compulsive behavior, one anticipates to break the natural progression from one to the other In a dermatologic setting, the pharmacologic approach may be most feasible for patients who refuse to be referred elsewhere Moreover, the recognition that serotonin pathways are involved and that the SSRI group of antidepressant agents reduces compulsive activity has made it more likely that the dermatologist will meet with success Frequent short visits should be scheduled for supervision of the dermatologic regimen and for emotional support, and either clomipramine (an older antidepressant with extensive documentation about its anti-obsessive–compulsive efficacy in the medical literature) or one of the newer SSRIs (fluoxetine or fluvoxamine maleate) should be prescribed 5.3.2 Imaginary Hair Loss (Psychogenic Pseudoeffluvium) Patients with imaginary hair loss or psychogenic pseudoeffluvium are frightened of the possibility of going bald or are convinced they are going bald without any objective findings of hair loss Basically they suffer from what Cotterill has termed “dermatologic nondisease.” Although dermatologists are used to seeing patients with minor skin and hair problems in significant body areas that cause disproportionate anxiety and cosmetic distress, with dermatologic nondisease, there is no dermatologic pathology 147 It is important to realize that imaginary hair loss only makes up for a minority of patients complaining of hair loss and that patients with psychogenic pseudoeffluvium have varied underlying mental disorders The most common underlying psychiatric problems present are depressive disorder and body dysmorphic disorder The clinical spectrum is wide, and the majority of patients are at the neurotic end of the spectrum and merely have overvalued ideas about their hair, whereas a minority of patients are truly deluded and suffer from delusional disorder These patients lie at the psychotic end of the psychiatric spectrum Those parts of the body that are important in body image are the focus of the preoccupation and concern True telogen effluvium resulting from androgenetic alopecia, telogen effluvium, or involutional alopecia must carefully be excluded Differential diagnosis of psychogenic pseudoeffluvium is particularly challenging, since there is a considerable overlap between hair loss and psychological problems Patients with hair loss have lower self-confidence, higher depression scores, greater introversion, and higher neuroticism and feelings of being unattractive A careful medical history, including medications, hormones, and crash diets, clinical examination of the hair and scalp (no alopecia, normal scalp), hair calendar (normal counts of hairs shed), trichogram (normal anagen and telogen rates), and laboratory work-up should be performed to exclude real effluvium and if necessary repeated In addition to the relentless complaint of hair loss, patients suffering from body dysmorphic disorder adopt obsessional, repetitive ritualistic behavior and may come to spend the majority of the day in front of a mirror, repeatedly checking 148 Psychopathological Disorders their hair Another aspect of this behavior is a constant need for reassurance about the hair, not only from the immediate family but also from the medical profession and from dermatologists in particular These patients may become the most demanding types of patient to try to manage The first step in the treatment is to establish a good rapport with the patient group of drugs takes up to months, and not all patients with body dysmorphic disorder will respond to treatment with SSRIs In patients who fail to respond to SSRIs given for months, it has been suggested to add either buspirone to the SSRIs or, if the patient has delusional body dysmorphic disorder, to add an antipsychotic agent such as pimozide It is important to recognize that patients with psychogenic pseudoeffluvium are expecting the clinician to treat them with respect as a trichologic patient and not as a psychiatric case The most effective approach to psychogenic pseudoeffluvium is to take the chief complaint seriously and give the patient a complete trichologic examination Patients with body dysmorphic disorder expect the solutions to their problems in dermatologic (trichotropic agents) or surgical terms (hair transplantation) Patients with overvalued ideas may respond to a sympathetic and unpatronizing dermatologist Psychotherapy is aimed at any associated symptomatology of depression, regardless of whether there is a causal relationship between the psychiatric findings and the imagined hair loss, because it is possible that patients who are depressed perceive even normal hair shedding in an exaggerated manner Patients with anxiety related to the fear of hair loss may also benefit from anxiolytic therapy with alprazolam or buspirone Many different treatments have been advocated to treat patients with body dysmorphic disorder: a wide variety of psychotropic agents (including tricyclic antidepressants and benzodiazepines) and antipsychotic drugs (including pimozide and thioridazine) have been tried in this condition, with poor results Although there have been no controlled clinical trials of the treatment of patients with body dysmorphic disorder, preliminary data indicate that SSRIs, such as fluoxetine and fluvoxamine maleate, may be effective, though the effective dosage of the SSRI drugs needs to be higher than the dosage conventionally employed to treat depression, and the duration of treatment is long term Response to this Accordingly, following an initial consultation, it is common for a patient with body dysmorphic disorder to be given dermatologic treatment for alopecia After repeated consultations with the patient, the dermatologist realizes that he or she is dealing with dermatologic nondisease The result is often a frustrated dermatologist and a patient who eventually defaults from follow-up The long and tough consultations, repeated telephone calls, and constant need for reassurance can put a significant strain on the dermatologist involved Finally, a minority of patients with dysmorphic body disorder are angry, and these patients can direct this anger not only at themselves but also at the attending physician, with reproachful letters (Fig 5.3), threats, and even physical violence It is important not to reject these patients and treat them mechanistically, but to adopt an empathetic approach The prognosis depends on the underlying psychopathology, its appropriate treatment, and the attending physician’s capability to reassure and guide the patient 5.3.3 Dorian Gray Syndrome The recently proposed Dorian Gray syndrome denotes a cultural and societal phenomenon characterized by extreme pride in one’s own appearance accompanied by difficulties coping with the Subject Index A Acne necrotica miliaris (s varioliformis), 141 See also Folliculitis necrotica Adams Oliver syndrome, 205, 207 Adjustment disorders associated features, 162 subtypes, 162 support organization, 163 Adverse effects cosmetic hair treatments, 186–189 allergic contact dermatitis, 187–189 bubble hair, 187 cosmetically induced hair beads, 187 matting, 186, 187 corticosteroids, 90–92 atrophy, cutaneous, from topical corticosteroid treatment, 115 atrophy, subcutaneous, from intralesional triamcinolone acetonide, 92 Bateman’s purpura, from topical corticosteroid treatment, 92 osteoporosis risk, from intralesional triamcinolone acetonide, 91 striae (stretch marks), from topical corticosteroid treatment, 92 DCP, in treatment of alopecia areata, 93 finasteride, oral, 179–182 depression, 179 fertility, 179 nocebo reaction, 190 persistent sexual side effects, 179 post-finasteride syndrome, 181, 182 Prostate Cancer Prevention Trial (PCPT), 180 PSA levels (monitoring), 182 transsexuals, in, 46 hair transplantation surgery, 182–186 folliculitis decalvans, 185, 186 lichen planopilaris, 186 recipient area folliculitis, 184, 185 risk factors, 183, 184 minoxidil, topical solution, 173–179 allergic contact dermatitis, 175, 176 cardiovascular, 176–178 children, 174 fetal malformation, 176, 177 hypertrichosis, 174 irritant contact dermatitis, 174, 176 shedding phase, 174 systemic absorption, 177 trichostatis spinulosa, 177 nocebo reaction, 189, 190 personality disorder, 190 risk patient profile, 190 somatoform disorder, 190 AEC (ankylolepharon, ectodermal dysplasia, clefting) syndrome, 205 Afro-textured hair (ethnic hair) acne (s folliculitis) keloidalis nuchae, 43, 113 treatment, 116, 117 breakage, 42, 43 SEM studies, 42, 43 central centrifugal cicatricial alopecia (CCCA), 43–45, 114 etiopathogenetic factors, 45 prevalence, 44 risk factors, 45 treatment, 265, 268, 269 dissecting cellulitis of the scalp, 43, 44, 113 treatment, 116 hair grooming habits, 43, 44 lipedematous scalp (spongy scalp syndrome), 45 pseudofolliculitis barbae (razor bumps), 43, 44 structural peculiarities, 42 traction alopecia, 43, 44 Aging hair botanicals, for treatment of aging hair, 79, 80 Ayurvedic medicine, from, 79 Ginseng, 80 Ho Shou Wu (Polygonum multiflorum), 79 traditional chinese medicine (TCM), from 79, 80 Traditional Oriental Medicine Database, 79 coenzyme Q10, 78, 79 cosmetic anti-aging treatments, 79 CNPDA, 79 © Springer International Publishing Switzerland 2015 R.M Trüeb, The Difficult Hair Loss Patient: Guide to Successful Management of Alopecia and Related Conditions, DOI 10.1007/978-3-319-19701-2 317 318 Aging hair (cont.) Curshmann-Steinert syndrome (myotonic dystrophy), 73, 76 alopecia in, 76 dementia, 41 neglect of hair, in, 42 pseudodementia, 42 depression, in elderly, 41 DHEA(S) endocrine disorders,77 extrinsic aging, 72 environmental factors, 75 oxidative stress, 75 UV radiation (UVR), 75 finasteride, oral, 78 adverse effects in aging male, 78 efficacy in aging male, 78 postmenopausal women, in, 78 graying, 70, 71 cigarette smoking, 70 H2O2-mediated oxidation, 70 premature, 70 structural changes of graying hair, 71 hormone replacement therapy (HRT), 78 estrogen, topical application, 78 Women’s Health Initiative, 78 human growth hormone (hGH), 75 deficiency, 75 treatment, 75 insulin-like growth factor (IGF-1), 74–77 Laron syndrome, in, 75 liposomal gel fromulation, 77 transdermal application, 76 intrinsic aging, 72 Laron syndrome, 73, 75 minoxidil solution, topical, 77 case studies of successful treatments (male, female), 236–241 eyebrow enhancement, for, 77 prognostic factors for treatment in males, 77 senescent alopecia, for treatment of, 77 mitochondrial damage, 73 multimorbidity, 40, 41 blood tests, recommended routine, 41 drug-related adverse effects, 41 endocrine disorders, 40 nutritional deficiency, 41 prevalence, 40 psychological problems, 41 NFATc1-pathway, 77 p53 pathway, 74, 75 phenotype of aging hair, 40, 69, 70 frizziness, 71 hair breakage, 72 hair diameter changes, 71 hair fiber curvature, changes in, 71 lipid levels and composition changes, 72 relative scalp coverage, 72 Subject Index premature aging syndromes (progerias), 73, 74 Hutchin-Gilford syndrome, 73 Werner syndrome, 73, 74 senescent (or senile involutinal) alopecia, 72, 73 case studies of successful treatments, 236–241 gene expression profile (microarray analysis), 73 stem cells, 73 telomerase, 75 telomeres, 74, 75 apoptosis, 74 cellular senescence (Hayflick limit), 40, 74 telomere length, 74 telomere shortening, 74 Werner’s syndrome, in, 74 thyroid hormones, 78 hyperthyroidism, 78 hypothyroidism, 78 thyroid receptor agonists, for treatment of hair loss, 78 thyroid receptor hormone receptor beta 1, 78 triiodo-L-thyronine, 78 Alopecia and related conditions acute diffuse and total alopecia of the female scalp, 87, 256 adjustment disorders, related to hair loss, 162 adverse effects of molecularly targeted therapies for cancer, 103–107 alopecia areata, 89–100 androgenetic alopecia, 54–69 antitumor necrosis factor-alpha therapy-induced alopecia, 118 case studies of successful treatments, 225–285 chemotherapy-induced alopecia, 100–103 permanent chemotherapy-induced alopecia 101 cicatricial pattern hair loss, 69 comorbidities in hair disease, 205, 206 congenital disorders, in, 205 non-scarring alopecias, in, 205, 206 scarring alopecias, in, 206 congenital atrichia and hypotrichosis, 49–54 Online Mendelian Inheritance in Man (OMIM), 51 with associated abnormal features, 51–53 definition, 49 factitial dermatitis of the scalp, 156–157 graft-versus-host disease, 115–118 neurotic excoriations of the scalp, 144–147 personality disorders, in androgenetic alpecia, 168 pseudoeffluvim, psychogenic (imaginary hair loss), 147 red scalp, 118–123 scarring alopecias, 107–117 seasonality of hair growth and shedding, 84, 85 impact on studies with hair growth promoting agents, 201, 202 short anagen hair, 85 senescent (or senile involutional) alopecia, 72, 73 Subject Index telogen effluvium, 80–89 chronic telogen effluvium, 86 inflammatory telogen effluvium, 88 trichodynia, 159–161 trichoteiromania, 161, 162 trichotillomania, 153–156 Rapunzel syndrome, 153 Alopecia areata acute diffuse and total alopecia of the female scalp, 256 case study of successful treatment, 256, 259 antitumor necrosis factor-alpha therapy, association with alopecia areata, 98 case studies of successful treatments, 241–258 successful treatment of beard area, 258, 260 comorbidities, 95 APECED syndrome, 97 celica disease, in children, 97 comorbidities screening, proposed, 98 depression, 99 Hashimoto’s thyreoiditis, 95 HIV infection, 95 iron deficiency, 96 pernicious anemia, trichotillomania, 99 vitamin D deficiency, 95, 96 genome-wide associaton studies, 98 Marie Antoinette syndrome, 247 case study of successful treatment, 244, 246 prognosis, 90 Ikeda classification (I-IV), 96 Thomas More syndrome, 247 case study of successful treatment, 244, 248 treatment abatacept (CTLA4-Ig fusion protein), 98 algorithm, 89, 90 antidepressants, 99 clobetasol, topical (ointment under occlusion, or foam), 91, 92, 247, 249, 251 complementary and alternative mecial remedies (CAM), 99, 100 efalizumab, 98 fexofenadine, oral, in atopic alopecia areata, 94 fumaric acid esters, oral, 94 gluten-free diet, 97 hypnotherapy, 99 immunotherapy, topical, with diphenylcyclopropenone (DCP), 92, 93, 252, 253 intralesional triamcinolone acetonide, 90, 91, 241, 243, 247, 250 isoprinosine, in alopecia areata associated with autoantibodies, 94 metanalysis of treatments, 89, 241 methotrexate, s.c., 95, 252, 254–256 mometasone furoate, in children, 256, 257 platelet rich plasma (PRP), 99 pulsed corticosteroid therapy, i.v (methylprednisolone) or oral (betamethasone), 91, 241, 244, 245 319 ruxolitinib (JAK inhibitor), 98 statin therapy, oral, 94, 95 tofacitinib (JAK inhibitor), 98 vitamin D, 97 zinc gluconate, oral 96 Alopecia neoplastica scalp metastasis, 114 Alopecia parvimaculata (Dreuw), 114, 115 American College of Rheumatology (ACR) criteria See Lupus erythematosus Androgenetic alopecia case studies of successful treatments, 226–236 challenges in, 56 androgenetic alopecia with follicular inflammation and fibrosis, 66–69 comorbidities in androgenetic alopecia, 57–65 early female androgenetic alopecia, 57 premature alopecia, 56, 57 comorbidities, in female androgenetic alopecia, 57 adjustment disorders, 162, 163 endocrine disorders, 57–61 hormonal treatments, 57, 61 hyperprolactinemia, 58, 59 iron deficiency, 57 metabolic syndrome, 60 nutritional status and deficiencies, 61, 62 polycystic ovary syndrome (PCOS), 59, 60 pregnancy, 60, 61 thyroid dysfunction, 57, 58 comorbidities, in male androgenetic alopecia, 57 adjustment disorders, 162, 163 cardiovascular disease, 63 insulin resistance, 63 obesity, 62 personality disorders, 168 smoking status, 63, 64 dutasteride, oral, 56 5-alpha reductase, dual inhibition, 56 case study of successful treatment, 233, 234, 271, 274, 277 dihydrotestosterone (DHT), 56 efficacy in female androgenetic alopecia, 56 efficacy in male androgenetic alopecia, 56 plasma half-life time (3-5 weeks), 56 female androgenetic alopecia, 54 case study of successful treatment, 228, 229 criteria for diagnosis, 57 evidence based treatments, 54 frequency, 54 pattern, 54 trichoscopy, value of, for diagnosis, 57 finasteride, oral, 55, 56 adverse effects, 179–182 5-alpha reductase type inhibition, 55 androgen receptor (AR) gene, 55 case studies of successful treatments, 226–228, 232, 233, 235, 236 dihydrotestosterone (DHT), 55 efficacy in female androgenetic alopecia, 55, 233, 235, 236 320 Androgenetic alopecia (cont.) plasma half-life time (5-8 h), 56 post-finasteride syndrome, 181, 182 splitting mg finasteride tablets, 180, 228, 232, 233 HairMax LaserComb®, 215, 216 case studies of successful treatments, 236, 237, 276, 278, 279 male androgenetic alopecia, 54 case study of successful treatment, 226, 227 evidence based treatments, 54 frequency, 54 pattern, 54 inflammation and fibrosis, follicular, 66–69 anterolateral leg-like alopecia, 68 cicatricial pattern hair loss, 69 facial papules, 68, 69 fibrosing alopecia in a pattern distribution, 66 microinflammation, follicular, 66 male frontal fibrosing alopecia, 68, 69 postmenopausal frontal fibrosing alopecia, 66 minoxidil, topical, 54, 55 adverse effects, 173–179 ATP-sensitive potassium channel, 54 case studies of successful treatments, 228–231 sulfonylura receptor 2B, 54 sulfotransferase activity and assay, 55 premature androgenetic alopecia, 56, 57 case studies of successful treatments, 228, 230, 231 differential diagnosis, 56 minoxidil topical, in, 57 pattern, 56 psychological effects, 32 treatment antinflammatory agents, 219, 278, 280–282 cosmetic treatments, value of, 216–218 CG210®, 219 dutasteride, oral, 56 evidence based medicine (EBM) guidelines, 199 finasteride, oral, 55, 56 hair transplantation, autologous, 182, 183, 226, 228 low level laser therapy (LLLT), 215, 216 minoxidil, topical, 54, 55 miscellaneous treatments, 200 multitargeted treatment, 202, 203 nutritional therapies, 204, 206, 212, 213 UV radiation (UVR), effects of, 65 Anterolateral leg alopecia, 205 Anterolateral leg-like alopecia in frontal fibrosing alopecia, 68 Antitumor necrosis factor-alpha therapy-induced alopecia, 118 Anxiety disorder, generalized, 142–144 Aplasia cutis congenita comorbidities, 205 Aromatase inhibitors, 6, 103 Atopic dermatitis, head and neck type, 119, 120 Atrichia, congenital universal, 49, 50 Subject Index Autoimmune polyendocrinopathy-candidiasisectodermal dystrophy (APECED) syndrome, 97, 98 B Bazex syndrome, 205 Beauty, concept of androgenetic alopecia, impact of, 151 attractiveness, 150 body image, 150 body image dissatisfaction, 151 self-esteem, 150 sexual selection, 150 youthfulness, 150 Biotin (vitamin H) biotin deficiency, 212, 213 biotinidase deficiency (inborn error of biotin metabolism), 205 holocarboxylase deficiency (inborn error of biotin metabolism), 205 Bird’s nest hair, 187 Björnstad syndrome, 205 Bloch-Sulzberger syndrome, 205 Body dysmorphic disorder, 158 Botulinum toxin (BTX), for treatment of trichodynia, 161 BRAF, 106 BRAF inhibition, 106 BRAFomas colorectal carcinoma, 104, 106 hairy cell leukemia, 104, 106 melanoma, 104, 106 papillary thyroid carcinoma, 104, 106 prostate cancer, 104, 106 serous ovarina carcinoma, 104, 106 Brocq, pseudopelade of, 25, 112, 113, 115 See also Pseudopelade Bubble hair, 187 Burnout, of scalp, 122 C Cantu’s syndrome (hypertrichotic osteochondrodysplasia), 54 Carvajal syndrome, 53 Central centrifugal cicatricial (scarring) alopecia (CCCA) case study of successful treatment, 265, 268, 269 etiopathogenesis, 45 medical terminology, in, 25 prevalence, 44 risk factors, 45 synonyms, 44 follicular degeneration syndrome, 44, 114 hot comb alopecia, 44, 114 Chemotherapy induced hair loss case study of successful treatment, 258, 260, 261 cytotoxic agents and frequency of hair loss, 100 patterns, 101 Subject Index permanent alopecia, 101 prevention and treatment, 102, 103 investigations in, 102 minoxidil, topical solution, 102, 103 recommendations for hair care, 103 scalp cooling, 102, 103 Cigarette smoking, effects of on hair, 8, 63, 64 CNPDA (caffeine, nicotinamide, panthenol, dimethicone, acrylate polymer), 79 Coenzyme Q10 (CoQ10), 78, 79 Communication skills communication, patient-centered, 18 do’s and don’ts, 19 in special situtions, 19 angry patient, 19 disappointed patient, 19 patient with unrealistic expectations, 19, 20 patient adherence, to establish, 20, 21 four steps (based on health communication research), 20 open-ended questions (Bayer Institute for Health Care Communications), 20, 21 Comorbidity case study of successful treatment, 256, 258, 259 congenital disorders, in, 205, 207–210 definition, 204 non scarring alopecias, in, 205, 206, 210, 211 psychological, 206 scarring alopecias, in, 206, 211, 212 Compliance issues, patient compliance, 196 long-term, 196 short-term, 196 major barriers, 196 recommendations for improvement, 196 Contact dermatitis, allergic contact allergens (hair dressing series), 188 ammonium persulfate (in relaxers), 188 ammonium thioglycolate (in bleaching agents), 188 fragrances, 188 p-phenylendiamine (PPD) (in hair dyes), 188 preservatives, 188 p-toluenediaminde (PTD) (in hair dyes), 188 minoxidil, to, 175, 176 ROAT, 176 hair dyes, to, 187–189 patch testing, 188, 189 telogen effluvium, inflammatory, 188 treatment, 189 Conversion disorder, 158 Cosmetic hair treatments CNPDA, 217 hair fiber diameter, effects on, 217, 218 mechanical properties, effects on, 217, 218 conditioning agents, 217 dimethicone, 217 proteins, hydrolyzed, 217 quats and polyquaternium, 217 silicones, 217 321 shampoos, 217 styling aids, 218 value of, 216–218 Crandall syndrome, 205 Curschmann-Steinert’s myotonic dystrophy, 76 CYP (cystine, medicinal yeast, and pantothenic acid)-complex, 212, 213 Cyproterone acetate (CPA), 58, 60 Cystine, L-, 206, 212, 213 D Delusional disorder definition 143 delusion of parasitosis (Ekbom’s disease), 144, 151–153 chronic tactile hallucinosis, 152 differential diagnosis, 152, 153 in substance abusers (cocaine bugs), 152 monosymptomatic hypochondriacal psychosis, 152 treatment, 153 ICD-10, in, 142 imaginary hair loss (psychogenic pseudoeffluvium), 144, 147, 148 differential diagnosis, 147 treatment, 148 Dementia, 41, 42 Demodex case studies of successful treatment, 271–274 Demodex folliculorum and D brevis, 122 diagnostic methods, 122 infestation of scalp, 122 treatment, 122 Dermatitis papillaris nuchae (see Folliculitis keloidalis nuchae) Dermatology Life Quality Index (DLQI), 34 in male androgenetic alopecia treated with oral finasteride, 33, 34 Dermoscopy of scalp (trichoscopy) clinical evaluation, use in, 9, 10 female androgenetic alopecia, in 57 diagnostic criteria, 57 diversity of hair shaft diameter, 57 empty follicles, 57 peripilar signs, 57 hair shaft abnormalities, recognition of, 12 minoxidil-induced trichostatis spinulosa, 177 monilethrix, 51 red scalp, in, 119, 121 rosacea-like dermatosis of scalp, 121 telangiectatic erythema of scalp, 119 Diagnostic and Statistical Manual of Mental Disorders (DSM), 142 Difficult (hair loss) patient causes, communication, importance of, definition, evidence based medicine (EBM), role of, good medical practice (GMP), significance of, 322 Difficult (hair loss) patient (cont.) imaginary hair loss, delusional disorder, overvalued ideas, management, prerequisites for successful, 1, psychological level, on, technical level, on, 1, psychopathological diagnosis, Dihydrotestosterone (DHT), levels in women, 58 Dimethicone in shampoos absence of effects on hair loss rates, 6, 186 conditioning agent, 217 Diphenylcyclopropenone (DCP) adverse effects, 93 dyschromia in confetti, 93 erythema multiforme-like eruption, 93 case study of successful treatment, 252, 253 children, in, 93 prognostic factors of therapy, 93 remission rates, 93 risks, 93 sensitization of staff, 93 topical immunotherapy of alopecia areata, 93 Direct immunofluorescence (DIF) studies cutaneous lupus erythematosus, in, 13, 109 diagnostic yield, 13 scarring alopecia, in, 13 Dissecting cellulitis of scalp afro-textured hair, in, 43, 44 case study of successful treatment (adalimumab), 265, 268 classification, 108, 115 comorbidities (follicular occlusion triad), 113, 206 acne conglobata, 113, 206 hidradenitis suppurativa (acne inversa), 113, 206 pilonidal sinus, 206, 212 perifolliculitis capitis abscedens et suffodiens (Hoffman), 113 treatment, 116 DLQI See Dermatology Life Quality Index Dorian Gray syndrome definition, 148, 149 diagnostic criteria, 149 prevalence, 149 D(P)CP See Diphenylcyclopropenone Drospirenone polycystic ovary syndrome, in, 60 thromboembolus risk, 60 Drug-induced hair loss ACE inhibitors, agents with antithyroid action, 6, 86 amiodarone, 86 antithyroid drugs (carbimazole, propylthiouracil), 6, 86 analgesics, nonsteroidal, anticoagulant drugs, 6, 86 anticonvulsants, valproic acid, anti-infectious agents, antimetabolites (methotrexate, azathioprine, cyclophosphmide), 86 Subject Index antimitotic/cytotoxic agents, 6, 100 which sometimes cause hair loss, 100 which unusually cause hair loss, 100 antitumor necrosis factor-alpha therapy, 98, 118 aromatase inhibitors, 6, 103 case study of successful treatment, 258, 260, 261 beta-adrenoreceptor antagonists, for treatment of glaucoma, clinical identification of culprit,7 elderly, in the, 40 hypolipidemic agents (fibrates), 6, 86 interferon, 86 lichenoid drug reaction, 108 antimalarials, 108 beta-blockers, 108 furosemide, 108 gold salts, 108 metformin, 108 penicillamin, 108 spironolactone, 108 thiazide diuretics, 108 molecularly targeted therapies for cancer, 103–107 EGFR inhibitors, 104, 105 management, 104 MEK inhibitors, 104, 106 mTOR inhibitors, 104, 106 multikinase inhibitors, 104–106 RAF inhibitors, 104, 106 vismodegib (hedgehog signaling pathway inhibitor), 104, 106 progestogens with net androgenic activity in contraceptive pills or hormonreplacement therapies (HRT), levonorgestrel, norethisterone, tibolone, psychotropic drugs, antidrepressants, tricyclic, lithium, retinoids (acitretin, isotretinoin), 86 Dutasteride female androgenetic alopecia, in, 56 frontal fibrosing alopecia, in, 116 male androgenetic alopecia, in, 56 case study of successful treatment, 233, 234 plasma half-time, 56 Dystrophic anagen effluvium, 101 E EBM See Evidence-based medicine Ectodermal dysplasia anhidrotic (Christ-Siemens-Touraine), 52 ectodermal dysplasia with ectrodactyly and clefting (EEC syndrome), 208, 209 scalp dermatitis in EEC syndrome, 208 twisting dystrophy and folliculitis decalvans in EEC syndrome, 209 hidrotic (Clouston), 52 Online Mendelian Inheritance in Man (OMIM), 51 Subject Index Rapp-Hodgkin/Hay-Wells syndrome (with clefting), 52 EEC (ectrodactyly, ectodermal dysplasia, clefting) syndrome, 205, 208, 209 Erosive pustular dermatosis of scalp, 110, 113, 114 Evidence based medicine (EBM) aims, 36, 199 guidelines, androgenetic alopecia, for treatment of, 199, 200 limitations, 36, 200, 201 ethnic minorities, 36, 42–45 multitargeted treatments, 274 people with comorbid conditions, 36, 204 special age groups (children, elderly), 36–42 Examination techniques clinical examination, assessment of hair part width, black and white felt examination, hair feathering test, hair pull, 9, 14 computer assisted image analysis, 15, 16 dermoscopic examination of hair and scalp (trichoscopy), 9, 10 hair analysis, chemical, 12 misuse of, 12 hair data base sheet, laboratory testing, 9, 12 limitations, 12 microbiological studies, 12, 13 Gram’s stain, 12 KOH preperation, 12 microbiological culture (bacterial, fungal), 12 tests for species identification, 12 Wood lamp examination, microscopic hair analysis light microscopy, 11 polarization microscopy, 11 photographic methods, 16, 17 global photographic assessment, 16, 17 quantify hair loss, to, 14–17 contrast enhanced phototrichogram (CEPTG), 15 hair count, daily, 14 hair pull, 9, 14 TrichoScan®, 15, 16 wash test, 14, 15 wash test, modified, 15 scalp biopsy, 13, 14 direct immunofluorescence (DIF) studies, 13 histopathology, 13, 14 trichogram (hair pluck), 10, 11 F Factitial dermatitis of scalp differential diagnosis, 157 etiology, 156 factitious disease, 156 treatment, 157 trichotemnomania, 156 323 Faith healing autosuggestion therapy, symptom-orientied, in alopecia areata, 310 Buddhist perspective, 304 Catholicism, in, 295–300 Blessed Virgin Mary, sites of apparition of, 296 Patron Saint, 296, 297 relic, 295, 299 reliquary, 300 Saints, intercession of, 296, 297 suffering, 295 Christian Eastern Orthodox tradition, 300 Ethiopia, 303 healing scroll, Ethiopian, 303, 304 icon, 301 pilgrimage, 306 Santiago di Compostela, 306 Egypt, ancient, 291, 292 amulet, 291 Ebers, papyrus, 291 Edwin Smith, papyrus, 291 magic, 291 priest, 291 fetish, 289, 290 Zuni bear fetish, 290 fraud, 310, 311 financial conduct, inappropriate, 311 public staging of miraculous healings, 311 healing, miraculous, 287 Holy Spirit, 295 Lourdes, Sanctuary of, 288 Naaman, of (in the Bible), 288 Nehushtan (serpent of bronze), 293 India, 304 philosophy, Indian (Hinduism), 304 Conch Shell Shankha, 304, 305 Om, 304 mental medicine, 310 neuroscience, 288, 309 New Age movement, 288 spirituality, definition of, 288 Pentecostals, 294, 311 Church of God with Signs Following, 294 HIV patients, 311 snake handling, 294 power animal, 290, 291 bear, 290, 291 Bear Dance, 290 dancing bear, 291 Bear Society, 290 psychosomatic illnesses, 310 functional back pains and headaches, 310 hysterical blindness and paralysis, 310 Shamanism, 289 European-based neo-shamanic traditions, 289 Testament Old Testament, 292–294 New Testament, 294, 295 Zuni mythology, 290 324 Ferritin, serum levels women with hair loss, in, 213 Fibrosing alopecia in a pattern distribution, 66, 67, 69, 108 case studies of successful treatments, 278, 280–282, 284, 285 Finasteride, oral adverse reactions, 179–182 breast tenderness and gynecomastia, 181 depression, 179 fertility, 179 male breast cancer, 181 nocebo reaction, 190 persistent sexual side effects, 179 post-finasteride syndrome, 181, 182 Prostate Cancer Prevention Trial (PCPT), 180 PSA levels (monitoring), 182 sexual dysfunction, 179, 181 testicular pain, 181 transsexuals, in, 46 DLQI, effect on, 33, 34 female androgenetic alopecia, in, 55, 233, 235, 236 case study of successful treatment, 233, 235, 236 male androgenetic alopecia, in, 54 case study of successful treatment, 226, 227 mechanism of action, 55 off-label use, 221 post-finasteride syndrome, 181, 182 allopregnanolone (ALLO), 181 GABA-barbiturate receptor, 181 incidence, 181 registry (www.propeciahelp.com), 181 prostate cancer, 180, 181 splitting mg-tablets, 179, 180 case study, 228, 232, 233 Follicular unit extraction (FUE), 183 Folliculitis decalvans case studies of successful treatments, 265–267 classification, 108, 115 clinical presentation, 109–112 etiopathogenesis, 112 biofilm, 112 Staph aureus, 112 following hair restoration surgery, 184 mimicking laceration injury, 110 treatment, 116 Folliculitis (s acne) keloidalis nuchae, 43, 113, 116, 117 Folliculitis necrotica See Acne necrotica miliaris Frontal fibrosing alopecia body hair, involvement of, 68, 69 case studies of successful treatments, 281, 283 chronic cutaneous lupus erythematosus mimicking frontal fibrosing alopecia, 109, 111 cicatricial pattern hair loss, 69 comorbidities, 206 facial papules, 68 female frontal fibrosing alopecia, 66, 68 postmenopausal frontal fibrosing alopecia, 66 Subject Index male frontal fibrosing alopecia, 69 anterolateral leg-like alopecia, 68 sideburns, loss off, 68, 69 nail involvement (lichen-planus like), 68 patterned lichen planopilaris, 108 treatment, 116 FUE See Follicular unit extraction Fumaric acid esters (fumarates), in treatment of alopecia areata, 94 G Gender dysphoria See Transsexualism Gender identity disorder See Transsexualism Global photographic assessment, 16, 17 GMP See Good medical practice Good medical practice (GMP), 2, 201 Graft-versus-host disease (GvHD), 115, 117, 118 H Hair beads, cosmetically induced, 187 Hair cycle anagen phase, 80, 81 catagen phase, 80, 81 control of, 80–82 derangements (telogen effluvium), 83, 84 delayed anagen release, 83 delayed telogen release, 84 immediate anagen release, 83 immediate telogen release, 83 short anagen, 85 exogen, 81, 82 kenogen, 81, 82 neogen, 81, 82 telogen phase, 80, 81 teloptosis, 81, 82 Hair data base sheet, Hairdressing series (patch test), 188 Hair dyes allergic contact dermatitis, 188 p-phenylendiamine (PPD), 188 p-toluylendiamine (PTD), 188 telogen effluvium, 188 Hair matting, 186 Hairmax LaserComb® androgenetic alopecia, in treatment of, 215 FDA clearance for use in men, 215 FDA clearance for use in women, 215 case studies of successful treatments female androgenetic alopecia, in, 236, 237 male androgenetic alopecia, in, 276, 279 efficacy, 216 low level laser therapy (LLLT), 215, 216 mechanisms of action, 215 Subject Index Hair shaft anomalies corkscrew hairs, 205 pili torti, 205 Björnstad syndrome, 205 Crandall syndrome, 205 Menkes syndrome, 205 trichorrhexis invaginata, 205 Netherton syndrome, 205 trichorrhexis nodosa, congenital, 205 argininosuccinic aciduria, 205 citrullinemia, 205 trichoschisis, 205 trichothiodystrophy, 205 twisting dystrophy (pili torti et canaliculi), 205, 211 ectodermal dysplasia, 205 uncombable hair (pili trianguli et canalicli), 205, 209 woolly hair, 205, 210 Carvajal syndrome, 205 Naxos disease, 205 Hair styling aids, 216, 218 adverse effects, 187 Hair transplantation surgery adverse effects, 183, 184 folliculitis decalvans, 185 lichen planopilaris, 185, 186 recipient area folliculitis, 184 case studies of successful treatments, 281, 283–285 eyebrows, 281, 283 contraindications, 183 methods for harvesting donor hair, 182 follicular unit extraction (FUE), 182, 183 strip harvesting, 182 male and female androgenetic alopecia, in, 182 patient selection, 182, 183 scarring alopecia, in, 182 smoking status, 184 Hamamelis virginiana (North American Virginian witch hazel), 122 Harry Benjamin’s syndrome See Transsexualism History taking, patient’s family history, monogenic traits, polygenic traits, personal history, associated symptoms, relating to the condition of the scalp, associated symptoms, relating to the general health status, cigarette smoking, 7, contraceptive pills, dietary behavior, drugs, intake of, hair care and grooming habits, hormone replacement therapies, medical history, sexual risk behavior, stressful life events, 7, UV exposure, 7, 325 HIV infection, 8, 95 Human growth hormone (hGH), 75 Hutchinson-Gilford syndrome, 73 Hyperprolactinemia, 58 Hypothyroidism, 78 Hypotrichosis, hereditary comorbidities, 205 localized autosomal recessive congenital hypotrichosis, 51 Marie Unna type, 50, 51 simplex, 50, 51 Hypoxia-inducible transcription factor (HIF1), 82 Hysteria See Conversion disorder I Insulin-like growth factor I (IGF-1) hair growth promotin agent, as, 76 liposomal topical gel formulation, 77 transdermal application (dermaroller), 76 Laron syndrome, 73–75 Iron deficiency chronic telogen effluvium, in, 86 daily allowance, recommended, 62 female androgenetic alopecia, in, 57 hair loss, and, 213 iron replacement therapy, 214, 215 pro-oxidative capacity, 214 risks of intravenous iron therapy, 214, 215 K Ketoconazole atopic dermatitis of the head and neck type, in, 120 seborrhoeic dermatitis of scalp, in 120 L Laron syndrome, 80, 121 Lassueur-Graham Little syndrome See Lichen planopilaris Lichen planopilaris classification, 108, 115 clinical presentation, 109 etiopathogenesis, 108 drug-induced, 108 graft-versus-host disease, in, 108 hepatitis, association with hepatitis, 108 following hair restoration surgery, 185, 186 treatment, 116 pioglitazone, 113, 221 variants, 108 fibrosing alopecia in a pattern distribution, 108 frontal fibrosing alopecia, 108 Lassueur-Graham Little syndrome, 108 Pseudopelade (Brocq), delineation from, 112 Low level laser therapy (LLLT) See Hairmax LaserComb® 326 Lupus erythematosus case studies of successful treatments, 260, 262–265 chronic cutaneous (CCLE), discoid (CDLE), 108, 109 classification, 108, 115 frontal fibrosing alopecia, presenting as, 109, 111, 260, 264 systemic involvement, 111 ACR (American College of Rheumatology) criteria, 111 treatment, 116 belimumab, 260, 263 Lysine, 212 M Malassezia spp dermatitis, of scalp, in atopic (head and neck type), 120 seborrhoeic, 120 specific IgE antibodies, 120 treatment, 120 ciclopirox olamine, topical (shampoo), 120 itraconazole, oral, 120 ketoconazole, topical (shampoo), 120 Marie Antoinette syndrome See Alopecia areata Marie Unna hereditary hypotrichosis, 50, 51 Matting of hair, 186, 187 Melatonin, topical, 65 Menkes syndrome, 205 Mental traps arrogance, 23 attribution error, 22 avoidance of mental traps, 21–26 attention to language, 24 compromise, 23 creativity, 22 faith, 26 feedback, 23 inaction, 24 lateral thinking, 22 classification schemes, 22 clinical algorithms, 22 clinical prototypes, 22 commission bias, 24 computer-aided diagnostic systems, 24 culture of conformity and orthodoxy, 23 denial of uncertainty, 23 fear, patient’s, 25 side-effects of treatment, 25 herd instinct, 21 intuition, perils of, 23 mental templates, 22 patient templates, 22 premature conclusion, 21 representative error, 22 search sastisficing, 24 snap judgement, 21 stereotypical thinking, 21 Subject Index terminology, medical, 25 vertical line failure, 24 Methionine, 212 Microsporum canis, 13 Minoxidil, topical adverse reactions, 173–179 allergic contact dermatitis, 175, 176 cardiovascular, 176–178 children, 174 irritant contact dermatitis, 174, 176 fetal malformation, 176, 177 hypertrichosis, 174 shedding phase, 174 systemic absorption, 177 trichostatis spinulosa, 177 alopecia areata, in, 89 androgenetic alopecia, in, 54 evidence levels for therapeutic use in males and females, 54 case studies of successful treatments, 236–241 female androgenetic alopecia, in, 228, 229 fibrosing alopecia in a pattern distribution, in, 278, 280–282 male androgenetic alopecia, in (combination treatments), 271, 275–279 premature androgenetic alopecia, in, 228, 230, 231 senescent alopecia, in, 236, 239–242 switch from oral finasteride, successful, 236, 238 eyebrow enhancement, for, 77 mechanism of action, 54 ATP-sensitive potassium channel, 54 sulfonylura receptor 2B, 54 premature androgenetic alopecia, in, 56, 57 prognostic factors for, 55, 77 sulfotransferase activity and assay, 55 treatment in males, for, 77 propylene glycol-free compound of minoxidil, 174 senescent alopecia, in, 77 telogen effluvium, in, 88 immediate telogen release (shedding phase), 83 Molecularly targeted therapie for cancer effects on hair and scalp, and recommendations for management, 104 EGFR inhibitors, 104, 105 MEK inhibitors, 104, 106 mTOR inhibitors, 104, 106 multikinase inhibitors, 104–106 RAF inhibitors, 104, 106 vismodegib (hedgehog signaling pathway inhibitor), 104, 106 Monilethrix dermoscopy, 51 localized autosomal recessive congenital hypotrichosis, in, 51 Multimorbidity elderly, in the, 40–42, 204 blood tests, recommended routine, 41 drug-related adverse effects, 41 Subject Index endocrine disorders, 40 nutritional deficiency, 41 prevalence, 40 psychological problems, 41 Multitargeted treatment, concept of comorbidity, 204–206 cosmetic treatments, value of, 216–218 CNPDA, 217, 218 conditioning agents, 216, 217 shampoos, 216, 217 nutritional therapies, value of, 204, 206, 212–215 adverse effects and toxicities, 213–215 amino acids, in hair, 204 B-complex vitamins, 212 biotin (vitamin H), 212, 213 case studies of successful treatments, 274, 276, 278 CYP (cystine, medicinal yeast, pantothenic acid)-complex, 212 cysteine, 206 cystine, 206, 212 essential fatty acids, 213 iron, 213, 214 keratin, 204 lysine, 212 methionine, 212 micronutrients, recommended daily allowances, 62 protein, 204, 206 protein, recommended daily allowances, 61 rhinoceros horn, 204 vitamin A, 213 zinc, 213 optimizing therapy beyond evidence-based medicine, 201 case studies of successful treatments, 271, 274–282 combinations regimens for treatment, 201 multitude of cause-relationships underlying hair loss, 201 targeting the inflammatory component in androgenetic alopecia, 218–220 case studies of successful treatments, 278, 280–282 CG210®, 219 corticosteroids, topical, 219 doxycycline, oral, 219 hydroxychloroquine, oral, 219 ketoconazole shampoo, 219 pyrithione zinc shampoo, 219 Münchausen syndrome (laparotomophilia migrans), 156 See also Factitial dermatitis N N-acetylcysteine, in trichotillomania, 155, 156 Naxos disease 53 Netherton syndrome, 205 Neurotic excoriations of scalp 327 acne excoriée, 144 differential diagnosis, 145 psychopathologic conditions, underlying, 144 anxiety disorder, generalized, 142, 144, 146 depressive disorder, 143, 144, 146 obsessive-compulsive disorder, 143, 144, 146, 147 thinker’s itch, 145 treatment, 145–147 dermatologic, 145 psychiatric, 145–147 Nocebo reaction definition, 189 finasteride treatment, to, 190 risk patient profile, 190 personality disorder, in, 190 somatoform disorder, in, 190 symptoms, 190 Noncompliance, patient, 195, 196 See also Compliance issues, patient Non-scarring alopecias See also Individual entries aging hair, 69–80 alopecia areata, 89–100 androgenetic alopecia, 54–69 chemotherapy-induced alopecia, 100–103 molecularly targeted therapies for cancer, from, 103–107 telogen effluvium, 80–88 Nutritional deficiencies adolescent females and young women, in, 62 biotin, 212, 213 dietary behavior and alcohol abuse, elderly population, in, 41, 62 essential fatty acids, 212, 213 iron, 213 zinc, 213 Nutritional therapies, 204, 206, 212–215 adverse effects and toxicities, 213–215 iron, 213, 214 selenium, 213 vitamin A, 213 amino acids, 204 cysteine, 206 cystine, 206, 212 lysine, 212 methionine, 212 B-complex vitamins, 212 biotin (vitamin H), 212, 213 case studies of successful treatments, 274, 276, 278 CYP (cystine, medicinal yeast, pantothenic acid)complex, 212 iron, 213, 214 keratin, 204 rhinoceros horn, 204 micronutrients, recommended daily allowances, 62 protein, 204, 206 protein, recommended daily allowances, 61 328 O Off-label prescription dermatology, in, 219 liability risks, 221 Online Mendelian Inheritance in Man (OMIM), 51 P Patch testing (hair dressing series), 188, 189 Patient expectation management patient education, 34 psychological effects of androgenetic alopecia, 32 coping strategies, 33 in men, 32 in women, 32 risk factors, 33 psychological effects of treatment of male androgenetic alopecia, 33 finasteride, oral, with, 33 minoxidil, topical, with, 33 satisfaction survey, 36 special patient groups chidren, 36–39 elderly, 40–42 ethnic (afro-textured hair), 42–45 transsexuals, 45, 46 women of childbearing age, pregnancy, and lactation, 39, 40 tuto, celeriter, et iucunde (safely, swiftly, and gladly), 35 Personality disorders androgenetic alopecia, in, 168 definition, 163, 164 diagnosis, 166 DSM (Diagnostic and Statistical Manulal of Mental Disorders) classification, 164 nocebo reaction, in patients with personality disorder, 168 patient compliance issues, in patients with personality disorder, 168 prevalence, 167 treatment, 167 types, 165, 166 antisocial, 165 avoidant, 166 borderline, 165, 166 dependent, 166 depressive, 166 histrionic, 166 narcisstic, 166 obsessive-compulsive, 166 paranoid, 165 passive-aggressive, 166 sadistic, 166 schizoid, 165 schizotypical, 165 self-defeating (masochistic), 166 Pioglitazone bladder cancer, risk of, 221 liability issues, 221 Subject Index lichen planopilaris, treatment, 113 off-label prescription, 221 Polycystic ovary syndrome (PCOS) alopecia, in, 60 long-term compications, 60 cardiovascular disease, 60 endometrical carcinoma, 60 metabolic syndrome, 60 prevalence, 59 Rotterdam criteria, for diagnosis, 59 treatment, 60 metformin, 60 Post-finasteride syndrome incidence, 181 Post-Finasteride Syndrome Foundation (www pfsfoundation.org), 182 registry (www.propeciahelp.com), 181 symptoms, 181 Postoperative pressure alopecia, 22 Postpartum hair loss, persistent, 61 p-phenylendiamine (PPD), 188 Premature (androgenetic) alopecia (alopecia praecox), 56 PRP (platelet rich plasma), 99 Pseudopelade classic, of Brocq, 25, 112, 113, 115 pseudopeladic state, of Degos, 25, 108, 114, 115 Psychocutaneous disorders adjustment disorders, 162–163 chronic cutaneous sensory disorders, 157–162 body dysmorphic disorder, 158 conversion disorder, 158 hypochondriacal disorder, 158 somatization disorder, 159 somatoform pain disorder, 159 trichodynia, 159–161 trichoteiromania, 161, 162 classification, 140 hair and scalp manifestations of primary psychiatric disorders, 144–157 delusions of parasitosis (Ekbom’s disease), 151–153 Dorian Gray syndrome, 148–151 factitial dermatitis of scalp, 156, 157 neurotic excoriations of scalp, 144–147 psychogenic pseudoeffluvium (imaginary hair loss), 147, 148 trichotillomania, 153–156 personality disorders, 163–168 androgenetic alopecia, in, 168 nocebo reaction, in patients with personality disorder, 168 patient compliance issues, in patients with personality disorder, 168 primary psychiatric disorders, 142–157 delusional disorder, 143 depressive disorder, 143 generalized anxiety disorder, 142 obsessive-compulsive disorder, 143, 144 psychophysiological (psychosomatic) disorders, 140, 141 Subject Index atopic dermatitis, 140 folliculitis necrotica, 141, 142 hyperhidrosis, 140 psoriasis, 140 seborrhoeic dermatitis, 140 stress-responders, 140 Prostate Cancer Prevention Trial (PCPT), 180 Prostate-specific antigen (PSA) monitoring in men undergoing oral finasteride treatment, 182 Psychogenic pseudoeffluvium (imaginary hair loss) body dysmorphic disorder, in, 144, 147 delusional disorder, in, 2, 143, 147 depressive disorder, in, 143, 144, 147 differential diagnosis, 147 overvalued ideas, 2, 147 treatment, 148 Psychosis, monosymptomatic hypochondriacal, 152 p-toluylendiamine (PTD), 188 Q Quantification, of hair loss global photographic assessment, 16, 17 hair counts, daily, 14 hair pull, 9, 14 hair wash test, 14, 15 modified hair wash test, 15 TrichoScan®, 15, 16 R Rapp-Hodgkin/Hay-Wells syndrome, 52 Rapunzel syndrome See Trichobezoar Recipient area folliculitis, 184 Red scalp case studies of successful treatments, 268, 270, 271 definition, 119 differential diagnosis, 120, 121 allergic contact dermatitis, 120, 121 seborrhoeic dermatitis, 120 pathogenesis, 119 atopic dermatitis of the head and neck type, 119–121 rosacea-like dermatosis of the scalp, 121, 122 scalp burnout, 122 treatment itraconazole, oral, 120 shampoo special care ingredients, 122 North American Virginian witch hazel (Hamamelis virginiana), 122, 123 tetracyclines, oral, 121 S SCALP syndrome, 205 Scarring alopecias See also Individual entries alopecia neoplastica, 114 primary alopecia neoplastica, 114 secondary alopecia neoplastica, 114 alopecia parviamaculata Dreuw, 110, 114 329 antitumor necrosis factor-alpha therapy-induced alopecia, 118 central centrifugal scarring alopecia, 114 cicatricial pattern hair loss, 69 fibrosing alopecia in a pattern distribution, 66 frontal fibrosing alopecia, 66–69 classification, 107, 108, 115 graft-versus-host disease, 115–118 hot comb alopecia, 114 primary scarring alopecia, 107–114 chronic cutaneous lupus erythematosus, 108, 109, 111 dermatitis papillaris capillitii, 110, 113 dissecting cellulitis of scalp, 110, 113 erosive pustular dermatosis of scalp, 110, 113, 114 folliculitis decalvans, 109–112 folliculitis keloidalis nuchae, 110, 113 lichen planopilaris, 108, 109 pseudopelade (Brocq), 110, 112, 114 pseudopeladic state, of Degos, 114 secondary scarring alopecia, 114 autoimmune (pemphigoid, temporal arteritis, scleroderma), 114 granulomatous (necrobiosis lipoidica, sarcoidosis), 114 infectious (bacterial, fungal, viral), 114 neoplastic (primar, metastatic, malignant lymphoma), 114 treatment, 114, 116, 117 case studies of successful treatments, 260, 262–269 Seasonality of hair growth and shedding impact on treatments and clinical studies with hair growth promoting agents, 201–203 telogen effluvium, 84, 85 in women, 84 in men, 84, 85 Seborrhoeic dermatitis differential diagnosis, 23 Langerhans cell histiocytosis, 23 pemphigus foliaceus, 23 Malassezia spp., 120 treatment, 120 Selenium, toxicity, 213 Senescent alopecia case studies of successful treatments, 236, 239–242, 274, 276, 278 characterstics, of, 73 definition, 72, 73 environmental factors, 75 microarray analysis of gene exression profiles, 73 mitochondrial damage, 75 NFATc1 pathway, 77 stem cells, in, 73 telomeres, 74 treatment, 77–80 Ayurveda, from, 79 botanicals, 79 CNPDA, 79 coenzyme Q10 (CoQ10), 78 330 Senescent alopecia (cont.) finasteride, oral, 78 hGH (human growth hormone), 75 hormonal replacement therapy (HR), 78 Ho Shou Su (Polygonum multiflorum), 79, 80 IGF-1 (insulin-like growth factor 1), 77 minoxidil, topical, 77 nutritional therapies, value of, 204 TCM (Traditional Chinese medicine), from 79, 80 thyroid hormones and thyroid receptor agonists, 78 Sex reassignment therapy (SRT), 46 Shampoos, 216, 217 Siemens syndrome (keratosis follicularis), 205 Skills, acquiring, for effective treatment of alopecia and related conditions guideposts, four (Dale Garnegie), 225, 226 Short anagen hair, 85, 86 Somatoform pain disorder, 159 Stemoxydine®, 82 Sulfotransferases, 55 Syphilis alopecia areata comorbidities screening, in, 98 sexual risk behavior, 7, telogen effluvium, in, 86 T Telogen effluvium acute diffuse and total alopecia of the female scalp (see Alopecia areata) acute telogen effluvium, 82 post-febrile, 83 post-interventional, 83 postpartum effluvium, 83 post-traumatic, 83 psychogenic, 83 seasonal hair shedding, 84, 85 shedding phase, from minoxidil, 83, 84 UV radiation, from, 65 chronic telogen effluvium, 86 primary chronic telogen effluvium, 86 secondary chronic telogen effluvium, causes, 86 classification in functional types, 83–85 delayed anagen release, 83 delayed telogen release, 84 immediate anagen release, 83 immediate telogen release, 83 short anagen, 85 definition, 80 diagnosis, 86, 87 modified wash test, 87 differential diagnosis, 87 diffuse cyclic hair loss in women, 86 hair cycling, 80–82 derangements, of, 83–85 inflammatory telogen effluvium, 87, 88 allergic contact dermatitis to PPD, from, 88 erythroderma (of psoriasis or lymphoma), from, 88 Subject Index interface dermatitis (in lupus erythematosus or dermatomyositis), from, 88 seborrhoeic dermatitis, from, 88 pathodynamics, of, 82 synchronization phenomena of hair cycling, 82–84 decrease of anagen phase duration, 82, 85 short anagen hair, 85, 86 treatment, 88 corticosteroids, topical and systemic, 88 CYP (cystine, medicinal yeast, pantothenic acid)-complex, 88 minoxidil, topical, 88 psychological support, 88 Thersites complex See Body dyspmorphic disorder Thomas More syndrome See Alopecia areata Thinker’s itch, 145 Tinea capitis (children) Microsporum canis, 13 treatment, 39, 117 Transient neonatal hair loss, 38 Transplantation See Hair transplanation surgery Transsexualism, 45 Traumatic alopecia from child abuse (battered child), 154, 155 Trichobezoar, 153 Trichodynia definition, 159 pathogenesis, 160 inflammation, neurogenic, 160 neuropeptide substance P, 160, 161 overtreatment, topical, 161 psychiatric disorder, 160 vascular changes, 160 prevalence, 159 treatment, 161 antidepressants, tricyclic, 161 botulinum toxin (BTX), 161 capsaicin, topical, 161 gabapentin, 161 pregabalin, 161 reassurance, patient, 161 Trichoglyphics cowlick, 38 ridgeback, 38 scalp whorls, 38 Trichogram (har pluck), 10, 11 Trichophagia, 153 Trichorhinophalangeal syndrome, 52, 53 TrichoScan®, 15, 16 Trichoscopy See Dermoscopy of scalp Trichoteiromania, 161, 162 Trichotillomania associated features, 153 onychophagia, 153 pica, in iron deficiency,153 trichobezoar, with gastrointestinal obstruction (Rapunzel syndrome), 153 trichophagia, 153 Subject Index definition, 153 diagnosis, 154 differential diagnosis, 154 alopecia areata, 154 traumatic alopecia from child abuse (battered child), 154 treatment, 154–156 dronabinol, 156 N-acetylcysteine, 155, 156 psychotherapy, 154 relaxation training, 154 selective serotonin reuptake inhibitors (SSRI’s), 155 topiramate (anticonvulsant), 155 tricyclic antidepressants, 155 U Ultraviolet radiation (UVR), effect of androgenetic alopecia, photoaggravation of, 65 elastosis of scalp, 7, 8, 65 erosive pustular dermatosis of scalp, 110, 113, 114 photocarcinogesis of scalp, 7, 65 red scalp, 118–123 telogen effluvium, 7, 65 331 V Vitamin A, toxicity, 213 Vitamin B12, levels in women, 58 Vitamin D alopecia areata, deficiency in, 96, 97 substitution therapy, calculation formulas for, 97 maintenance dose, 97 saturation dose, 97 Vitamin H See Biotin W Wash test, 14, 15 modified wash test, 15 Werner’s syndrome (progeria adultorum), 73, 74 Witch hazel, North American Virginian (Hamamelis virginiana), 122, 123 case study of successful treatment, 268, 270 Z Zinc alopecia areata, in, 96 daily allowance, recommended, 62 deficiency, 213 Zinc pyrithione (pyrithione zinc), in shampoo, 219 ... pain, or paresthesia of the scalp related to the complaint of hair loss Rebora found that 34 .2 % of female patients, who had their hair consultation because of hair loss, complained of this phenomenon... activity of hair loss It was found that 17 % of patients complaining of hair loss, i.e., 20 % of female patients and % of male patients, reported hair pain,” pain or discomfort of the scalp, not otherwise... proportion of patients complaining of hair loss The aim of the study was to assess the frequency of trichodynia in patients complaining of hair loss and its correlation with gender, age, cause, and