THESIS SYNOPSIS
1. / Name of the candidate and Address / Dr. Sweta Prabhu ,
Post Graduate Student
Department of Dermatology,Venereology & Leprosy ,
A.J.Institute of Medical Sciences , Kuntikana
Mangalore-575004
2. / Name of the Institution / A.J.Institute of Medical Sciences, Kuntikana,
Mangalore-575004.
3. / Course of Study and Subject / M.D. in Dermatology, Venereology & Leprosy
(3 Years Degree Course)
4. / Date of Admission to the Course / 19th April, 2011
5. / Title of the Topic / “ A STUDY OF THE CLINICAL PATTERNS OF HAIR LOSS IN FEMALE PATIENTS ATTENDING DERMATOLOGY OPD IN A TERTIARY HOSPITAL ”
6 / BRIEF RESUME OF THE INTENDED
WORK:
6.1 Need for the study / Many studies have been done on the specific female pattern androgenic hair loss but there are very few studies & very little information which is available about the different clinical patterns of hair loss in females.
Hair loss or alopecia is a very common presenting symptom in which more than one third of the women present with clinically significant hair loss during their lifetime. Thus the effect of hair loss on patients’ emotions is most often greatly underestimated by the physicians. [1] After bone marrow, in the human body, hair is the second fastest growing tissue. Therefore many metabolic derangements could be manifested with alopecia, and thus hair loss might present as the first clinical sign of the underlying systemic disease. [1]
The number of women presenting with the complaints of hair loss are increasing greatly, but whether the condition is becoming more common or is it because of the increasing awareness of their appearance of hair among women is difficult to comment. Hence there is a need for the studies to be conducted to study these patterns of hair loss, to find out their causes, establish an appropriate diagnosis & find the correlation for appropriate treatment.
Determining the cause of hair loss in women can be difficult at times and should be guided by the patient’s history which should include the different patterns of hair loss, other existing medical conditions, the use of hair treatments, and the family history of hair loss as well as the physical examination.[1]
6.2 Review of literature / Hair loss in women is a distressing symptom. Hair growth occurs in cycles, with phases of growth, involution and rest. In normal scalp most follicles are in the growth phase, some are in the resting phase and a few are in involution phase. At the end of resting phase, a new cycle is initiated. The duration of the growth period determines the length of the hair and the volume of the both determines its diameter. Studies show that everyone is born with approximate 100,000 terminal hair follicles on their scalp.[3]
Most normal individuals are expected to lose approximately 50-100 hair from the scalp every day,although the exact estimate of hair lost per day varies from day to day. This is the normal physiological hair loss and is confined only to the hair which has already completed their telogen phase. It usually remains unnoticed except in those individuals who keep long hair. It was observed that during summer and rainy season most Indians even normally, lose a larger number of hair[4]which seems to be similar to the seasonal loss of hair in some animals.[5]
Most hair loss can broadly be categorized into three types:
• Noncicatricial (potentially reversible) type
• Cicatricial type
• Due to hair shaft abnormalities.
Almost all alopecias are noncicatricial implying it is potentially reversible. Its subtypes include conditions like androgenetic alopecia, telogen effluvium, alopecia areata, trichotillomania and also traction alopecia [6]. The genetic factors also do play an important role in alopecia areata, and family history is found to be there in 10% to 42% of cases[7]
The most common cause of non cicatricial type of alopecias ,the female-pattern hair loss also
Known as androgenetic alopecia, the role of androgens in this type is uncertain. This condition is usually familial [8]. The Female-pattern hair loss usually develops any time after the onset of puberty & until 70 years of age, 38% of women would have developed female-pattern hair loss.
Its severity is staged ,based on the Ludwig
classification, wherein increasing stages (I to
III) [9] correspond to increasing widths of the midline part. When hair thinning is evident more in the frontal portion of the scalp, it resembles a fir tree also known as a “Christmas tree pattern” behind the frontal hair line. This pattern is called as the “frontal accentuation.”[10] The most common cause of diffuse hair loss is telogen effluvium (TE) in adult females. The disorders like TE, female pattern hair loss (FPHL) and chronic telogen effluvium (CTE) constitute the majority of diffuse alopecia cases.[11]
It was observed that Telogen effluvium (TE) is the most common cause, followed by female pattern hair loss (FPHL) and chronic telogen effluvium (CTE); the rest of the causes are not so common and can be relatively easily diagnosed through history and examination. The problem arises in differentiating between TE, FPHL, and CTE, which account for the majority of diffuse alopecia cases in females.[1]
Cicatricial hair loss type can be due to various disorders, the common causes being fungal or bacterial folliculitis, discoid lupus erythematosus, lichen planopilaris, pseudopalade of Brocq. Less commonly other causes include trauma, scarring bullous disorders (epidermolysis bullosa), bullous pemphigoid, porphyria cutanea), and neoplastic disease (skin tumors and cutaneous metastasis)[6]
Studies have shown that hair loss is heterogeneous as a component of many systemic disease[12]
In systemic lupus erythematous, a characteristic frontal thinning is often seen which is also known as lupus or brush hair which occurs due to the remaining stubble. Although it is seen most of the times in the frontal areas, shedding and breakage can be more widespread. [13] There are two more conditions that can produce a distinctive pattern of loss. Firstly ,Secondary syphilis, which in its typical form, is poorly defined & the patchy loss occurs mainly from the posterior half of the scalp – which is described as a "moth-eaten" appearance.[13] Although , sometimes there is a more poorly defined loss, and serologic testing becomes necessary & appropriate in which there are grounds for suspecting the diagnosis. Thus the possibility of metastatic cancer should be ruled out. Most often, the primary tumor can be found in the breast.
This type of hair loss is referred to
As alopecia neoplastica. [13] More commonly diffusethinning is seenin systemic disease. It is also an expectedfeature of the Cronkhite-Canada syndrome and the Sezary syndrome. Also Diffuse loss ofhair is seen sometimes in hypothyroidism.[14] This loss is gradual, in keeping with the pace of myxoedema.[15]
In Traction alopecia the hair is sparse and there is break in the frontal area. [6] Clinical presentation of trichotillomania is areas of incomplete hair loss and short hair, most commonly seen on the scalp. Althougheyelashes, eyebrows, and other hairy areas can also be affected.[6] Alopecia areata clinically presents as isolated or recurrent patchy hair loss ,although multiple patches, complete scalp hair loss(alopecia totalis), and complete scalp andBody hair loss (alopecia universalis) can be other clinical presentations. [6] Telogen Effluvium presents with the primary sign of an increase in the number of hair that are shedding usually seen on the shower drain, clothes or pillow. Although normally, people shed up toapproximately 100 hair on days they do not shampoo, people with telogen effluvium tend to lose 150to 400 hair per day. [16] Some patients also notice adecrease in their hair volume only when the hair density is reduced as much as 30% to 50%. [16] In androgenetic alopecia the event may start as a telogen shed, but the primary sign reported by the patient is thinning. This progressive thinning is as a result of both a gradual miniaturization of the hair follicle and a shortened growth (anagen) phase. This pattern of hair loss is quite variable.
Very common in both men and women is the M pattern, which is characterized by frontal recession with thinning or absent hair in the temples. Another pattern which is more common in women is the decreased density of scalp hair in the central area, with retention of the frontal hairline. [6] Hair shaft abnormalities like trichoptilosis, trichoclasis produce fragile and brittle hair. Patients may present with diffuse or patchy areas of short hair and a history of hair that will not grow beyond a certain length.[6]
Apart from the routine complete blood count and routine urine examination, levels of serum ferritin and T3, T4, and TSH need to be checked in all cases of diffuse hair loss without a discernable cause, as iron deficiency and thyroid hormone disorders are the two common conditions often associated with diffuse hair loss, and at most times, there are no apparent clinical features to suggest them [17]. Most of the times CTE is confused with FPHL and can be reliably differentiated from it through biopsy which shows a normal histology in CTE and miniaturization with significant reduction of terminal to vellus hair ratio (T:V < 4:1) in FPHL [18]. The guiding principles toward management are repeated assurance, support, and explanation that the condition represents excessive shedding and not the actual loss of hairs, and it does not lead to baldness [11]
6.3 Objective of the study / 1) To study the clinical patterns of the hair loss which manifest in the various disorders.
2) To establish appropriate and early diagnosis & correlate the patterns of hair loss with the diagnosis, for appropriate management.
7 / Material and Methods :
7.1 Source of Data / Hospital based study
Patients attending the Dermatology OPD in A J institute of medical sciences, Mangalore will be enrolled in the study.
Inclusion Criteria
1)Patients presenting with complaints of hair loss without visible hair loss to the dermatology OPD.
2)Patients presenting with complaints of hair loss with visible hair loss patch/ baldness to the dermatology OPD.
Exclusion criteria
1)Patients who complain of hair loss but already on treatment for the same or taken treatment for the same previously.
7.2 Method of the collection of the Data / It is a cross sectional study. Patients attending the Dermatology OPD in A J Institute of Medical Sciences, Mangalore will be enrolled in the study. Detailed history, general physical and detailed hair, scalp &cutaneous examination will be performed in all patients included in the study. CBC , Hb %, ESR, RBS, TC, DC, AEC, TSH, T3,T4,USG abdomen & pelvis, chest x-ray, skin biopsy .Clinical tests like Hair pull test,Daily hair counts, Hair feathering, Wood’s lamp examination , Microscopic examination like Trichogram & Light microscopy will be performed.
Design: The duration of the study is one
year from November 2011 to November
2012.The study will be conducted in
A.J.Institute Of Medical Sciences ,
Mangalore.
DATA COLLECTION
With the help of my Guide ,I
would study the patients coming to dermatology Opd with complaints of hair loss. The patients would be explained regarding the objectives as well as the method of study. Consent would be taken from the patients before carrying out any examination.
DATA PROCESSING AND ANALYSIS
Data processing and statistical analysis
would be done with the help of a staff
statistician and using SPSS 17.0.1 (
Statistical Package , Software for windows ,
Chicago :SPSS.Inc)
7.3 Does the study require any investigation or intervention to be conducted on patients or other humans or animals? If so, please describe briefly. / Yes; details included in point 7.2
7.4 Has the ethical clearance obtained for your investigation? / Approved by the AJIMS Ethical Committee.
8 / List of references / ( 1 ) New England journal of medicine 357;16 org October 18, 2007, 1620 -1630.
(2) British Journal of dermatology, volume 79, Issue 10, pages 543-548, October 1967.
(3) Patel JC. Hair loss. Indian Journal of Medical Science 2000;54:106-9( 4 ) Pasricha JS. Treatment of Skin Diseases. Fourth edition, Oxford and IBH Publishers, New Delhi, 1991; 220-32
(5) Rustom A, Pasricha JS. Causes of diffuse alopecia in women. Indian Journal of Dermatology, Venereology, Leprology; issue 5; 1994;60:266-71
( 6 ) CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 70 • NUMBER 8 AUGUST 2003 , 705-712
( 7 ) Madani S, Shapiro J. Alopecia areata
Update. Journal of American Academy of Dermatology 2000;42:549-66
(8) Birch MP, Lalla SC, Messenger AG. FemalePattern hair loss. Journal of Clinical
Experimental Dermatology
2002; 27:383-8.
(9) Ludwig E. Androgenetic alopecia. Arch
Dermatol 1977;113:109
(10) Olsen EA. Female pattern hair loss.
J Am Acad Dermatol 2001;45:Suppl 3:S70-
S80.
(11) Shrivastava SB. Diffuse hair loss in an adult female: Approach to diagnosis and management. Indian J Dermatol Venereol Leprol 2009;75:20-8
( 12 )PortnoV B, Molokhia M. Acrodermatitis Enteropathica treated by zinc. Br. J Dermatol1974;91:701-3
(13) Schorr WF, Swanson PMI, Gomez F, Reyes CN. Alopecia neoplastica. Hair loss resemblingalopecia areata caused by
Metastatic breast cancer. AImA
1970; 213:1335-7.
( 14 ) Freinkel RK, Freinikel N. Hair growth
And alopecia in hypothyroidism. Arch Dermatol1972; 106:349-52.
( 15 ) Canadian Family Physician VOL 38: April 1992 ,863-936
(16) Rebora A. Telogen effluvium. Dermatology 1997; 195:209–212.
(17) Trost LB, Bergfeld WF, Calogeras E. The diagnosis and treatment of iron deficiency and its potential relationship to hair loss.J Am Acad Dermatol 2006;54:824-44
(18) Rebora A, Guarrera M, Baldari M, Vechhio F. Distinguishing androgenetic alopecia from chronic telogen effluvium when associated in the same patient. Arch Dermatol 2005;141:1243-5 .
9 / Signature of the candidate
10 / Remark of the guide
11 / 11.1 Name & designation of the guide / Dr. Girish.P.N ,
MD, DNB Dermatology, Associate professor
Department of Dermatology , Venereology & Leprosy ,
A.J Institute of Medical Sciences , Kuntikana ,
Mangalore.
11.2 Signature of the guide
11.3 Head of the Department / Dr. Narendra J Shetty ,
MD Dermatology , Professor & HOD ,
Department of Dermatology , Venereology & Leprosy ,
A.J Institute of Medical Sciences , Kuntikana ,
Mangalore
11.4 Signature of the Head Of the Department
12 / 12.1 Remarks of the chairman & principal
12.2 Signature
BUDGET ANALYSIS
TITLE : “ A STUDY OF THE CLINICAL PATTERNS OF HAIR LOSS IN FEMALE PATIENTS ATTENDING DERMATOLOGY OPD IN A TERTIARY HOSPITAL ”
PRINCIPAL INVESTIGATOR: Dr. Sweta Prabhu
Post Graduate Student
Department of Dermatology, Venereology & Leprosy
A.J.Institute of Medical Sciences, Kuntikana, Mangalore-575004
DETAILED BUDGET FOR THE WHOLE PROJECT:-
SL NO. / PARTICULAR / TOTAL COST Rs.1. / Printing & Copying supplies / 2000
2. / Miscellaneous / 5000
Total / 7000
TIMELINE
TITLE : “A STUDY OF THE CLINICAL PATTERNS OF HAIR LOSS IN FEMALE PATIENTS ATTENDING DERMATOLOGY OPD IN A TERTIARY HOSPITAL ”
Phase / Time Period / Activity1. / June - 2011 to
December – 2011 / 1. Identification of the problem
2. Review of literature
3. Preparing of proforma
4. Preparation and submission of synopsis
2. / January 2012 To
November 2012 / Collection of Data
3. / December 2012
To
November 2013 / Analysis and Discussion of collected data
Proforma
Study of clinical patterns of hair loss in females
Name: Date:
Age: Hosp no:
Sex: Marital status :
Occupation: Address:
History:
a.Complaint
b.Onset
c.Duration
d.Associated Symptoms .
A] Hair loss
1) Diffuse / patchy . If patchy mention number of patches
2)Recession of hairline – yes /no .
3)No. of hair lost / day .
4)Hair on pillow : yes/ no . If yes number of hair :
5)Excessive hair loss during head bath :yes/no.
6)Associated With seasonal variation- yes/no, if yes present during: summer / winter.
7)Relation with menstrual cycle : yes/no
8)Associated with sun exposure : yes/no
9)H/o Use / change of hair products: yes/no, if yes: Shampoo/ oil/conditioner/hair gels/ dyes/hair serum/ ayurvedic solutions/ medicated products.
10)H/o cosmetic procedures undergone: yes/no. if yes describes .
a) Hair curling
b) Hair straightening – chemical/heat pressing
c) Hair colouring-temporary/ permanent
d) Permanent Hair plaiting/ knotting
e) Hair dryers
f) Hair bleaching
g) Others
11) Dryness of hair – frizzy/rough.
12) Oiliness of hair – associated. with sweating / not associated .
13) Dandruff in hair: yes/no. if yes - falling or presence of flakes on eyebrows/lashes- yes/no .
14) Presence of lice in hair – yes/no.
15) No. of times patient oils hair/ week , application of warm oil- yes/no
16) Number of times patient combs the hair /day, uses comb/ hair brush, traction combing- yes/no.
17) Trichophagia/ trichotillomania /trichotemnomania/ trichodynia/ trichoteiromania
18)Discolouration of hair : greying / other colour, all hair/individual hair .
B] Itching – yes/no
associated with sweating – yes/no
Localized to scalp / other areas involved .
C] Cutaneous symptoms
Itching, peeling or scaling of skin, burning sensation, appearance of lesions/rashes over skin, excess facial hair. If any describe .
D] Nail changes – yes/no
If yes: discolouration/ disfigurement/ infolding/ swelling surrounding nail
E] Oral & mucosal symptoms – yes/no
If yes : burning/ lesions in the mouth , discolouration of tooth/gums/buccal mucosa.
F] Systemic symptoms – weight loss/gain , joint pains , heat or cold intolerance, increased sweating/ dryness , generalized weakness, pain abdomen.
G] H/o exposure to heavy metals – yes/no
If yes - gold/arsenic/ bismuth
H] H/o concurrent systemic diseases/disorders- yes/no . if yes – diabetes, TB,HIV,Malignancies, thyroid disorders , fungal infections , febrile illness.
I] Menstrual & obstetric history –
Reproductive/ perimenopausal/menopausal .
Age of menarche/ menopause.
Past & present menstrual cycles- regular/ irregular .
Obstetric history – pregnant- yes/no
G - /P - /L - , last child birth.
If pregnant – Last Menstrual period,Estimated date of delivery, trimester.
H/o recent miscarriages/childbirth/stillbirth/abortions.
J] Past history – H/o any chronic illnesses-yes/no if yes- name: Tuberculosis ,HIV, Diabetes mellitus, Hypertension,PCOD,Thyroid disorders, cancers; If any: onset, duration & drugs taken.
H/o allergies.
H/o recent major trauma/ major surgeries .
K ] Family history – Similar complaints in the family/ baldness in family members- yes/no.
If yes – father/ mother/brother/sister/others.
Baldness- onset , complete/partial .
H/o pets at home .
L] Drug history- yes/no.
If yes- name of drug. Dose, since when, for which disease.
M] Personal history –
Diet – good/poor, veg/mixed . Food fads-yes/no
Appetite – normal/reduced/increased .
Alcohol consumption- yes/no
Smoking- yes/no .
Bowel/ bladder habits .
Examination
General physical examination
Built, nourishment/ state of mind
Pallor/clubbing/edema/icterus/cyanosis/lymphadenopathy