DHL-Diffuse Hair Loss

Definition:  Its a reversible, non-scaring sudden hair loss from all over the scalp characterised decreased density of hair.

           Fig-Diffuse Hair Loss

Description: A normal hair cycle is persisting of 3-5 yrs with falling of 60-100 hair strands on daily basis.

There may be some variation in this number due to seasonal  changes. 

Each hair has a hair cycle of its own. This hair cycle has 3 stages-

1) Anagen -: This is called Growth Phase where most of the hairs are in growing state which lasts for 

2) Catagen( Resting Phase) 

3) Telogen(Falling Phase) 

Characteristics Features of DHL

1) Women are more frequently affected with it.

2) It occurs without any inflammation & scarring. 

3) Diffuse Hair Loss may be the cause of some underlying systemic conditions like anaemia, hypothyroidism, hypothyroidism. 

4) It affects 50% of the female as well male . 

Type: Diffuse Hair Loss may be further divided on the basis of shedding of hairs like loose Anagen Syndrome, Anagen Effluvium & Telogen Effluvium.

1) Loose Anagen Syndrome:

It generally affects the young children and observed that hairs easily epilate and comes out very easily in Anagen phase. Diffuse or patchy hair loss mostly seen on the back of the head. There is increased shedding of hairs and does not grow as they used to grow. This condition recovers usually within few years. 

                   Fig-Loose Anagen Syndrome

Causation:

1) Malnutrition

2) Seborrhoeic Dermatitis 

3) Iron deficiency 

4) Chronic infections

5) Some drugs 

2) Anagen Effluvium

Excessive shedding of hairs from scalp actively in Anagen phase. Onset is rapid and hairs regrow spontaneously. 

                       Fig-Anagen Effluvium

  Causation:-

1) Chemotherapy drugs

2) Radiotherapy 

3) Malnutrition 

4) Seborrhoeic Dermatitis

5) Oral contraceptive pills 

6) Iron deficiency 

7)  Chronic infection 

8) Some drugs 

3) Tellogen Effluvium 

Eviction of hair follicles which entered prematurely in resting phase is called Telogen Effluvium. 

This is explained in following way:-

1) Hair follicles prematurely terminate in the Anagen phase 

2) Catagen phase of hair cycle is omitted

3) Hair follicles prematurely enter the Telogen phase 

4) Hairs are lost in great numbers.

5) It is the most common cause of hair loss in females.

6) Rapid & generalised shedding of normal hair club ,2-3 months after a triggering events like parturition, high fever, major surgery, indicates Telogen Effluvium.

Causation:-

1) Pyrexia (body temperature above 103 F) 

2) Severe infection 

3) Major surgery 

4) Protein deficiency due to crash diet

5) Drugs like beta blockers & anti-suppressant 

6) Psychological stress

Etiology of DHL:

1) Nutrition

2) Hormonal 

3) Metabolic

4) Iatrogenic

5) Auto-immune disorders

6) Acute or Chronic Diseases

7) Stress

1) Nutrition

One of the commonest cause of DHL is malnutrition. Different types of anaemia are also the reason behind DHL. Investigations show that deficiency of vitamins like Vit-A, Vit-D, Vit-E and Vit-B12 can cause the DHL. 

Deficiency of certain essential elements can cause hair loss like zinc, copper and trace element cobalt can also cause hair loss in children. Chronic malnutrition can cause diffuse alopecia or FPB(Female Pattern Baldness).

2) Hormonal

Hormones can also influence for hair loss. Hypothyroidism is directly related to DHL due to to Thyrotoxicosis. Thyroid disorder associated with Telogen effluvium. Adrenal hormones also cause hair loss due to adrenal or pituitary tumor. Sex hormones like androgens & estrogen have great effect on hair and cause MPT & FPT( link). Change of hormone also cause hair loss especially in female during pregnancy & menopause.

3) Metabolic

Metabolic disorder can also cause hair loss such as phenyleketonuria & G6PD.

4) Iatrogenic

After taking some drugs persons may face some hair loss problem.

a) Cytostatic drugs used in neoplastic growth during cancerous condition.

b) Anticoagulant like heparin

c) Antithyroid drugs for thyroid disorder

d) Allopurinol for gout 

e) Hypolipedemic agents long term use in hypercholestrimia cause leas lilid synthesis in epidermis leading to dry ecthyotic  skin which will cause hair loss.

f) Retinoids use ling term for skin treatment may cause lack of sebum leading to hair loss.

g) Anticonvulsant drugs may also cause hair loss.

h) NSAIDs also found to be associated with hair loss. 

i) Antihypertensive drugs 

j) OCP pills 

5) Auto-Immune Diseases

SLE, RA & Psoriasis associated with hair loss.

6) Acute & Chronic Diseases

Any acute illnesses can cause DHL as immediate hair effects and most probably seen in Telogen Effluvium after 3 months, its called magical 3 months. It can be explained in the name of  pohl-pinkus phenomenon where time of illness cause sudden development of telogen phase. 

  

7) Stress

Stress can cause unexplained hair loss due to hormonal and metabolic changes in body.

Diagnosis of DHL

We can diagnose the DHL clinically by case history, scalp check-up, and some also confirm the DHL .

Case History-

By case history we can identify the triggering or causative factors and generic one.

Scalp Check-up-

a) It gives access to degree of hair loss.

b) Any inflammation, redness of scaling can be found out.

c) Hair shaft damage, hair breakage can be identified. 

d) Hair Pull Test- hairs are pulled out by thumb & index finger to check out the strength of hair and its positive in case of tellogen effluvium. 

 e) Trichogram- 20-50 hairs taken and then seen under microscope to evaluate the Anagen/Telogen percentage. In normal study Anagen/Telogen ratio is 8:2 or 9:1.

On examination:-

a) Nail changes are seen like Beau line in telogen effluvium. 

b) Blood Investigation- CBC & ferritin to find out anaemia.

c) Thyroid Function Test to rule out any abnormality.

d) Renal & Liver Function Tests

e) Antinuclear antibodies suggest SLE

f) Hormones evaluation like free androgen index, SHBG, Prolactin, etc in women too confirm the hyperandrogenism if symptoms are seen. 

Differential Diagnosis:

Hair loss can be classified into 2 major categories like Focal & Diffuse Hair Loss.

So, here we are discussing about the Diffuse Hair Loss but sometime doctors get confuse with other hair loss conditions similar to DHL.

Here, we should have a fair knowledge how to differentiate between DHL & Others.

1) Male Patter Thinning:-

Presents with receding hair line, frontal hair thinning, M pattern hair loss and negative pull test away from hair loss.

2)Female Pattern Thinning:-

Presents with hair thinning , no receding hair line and negative pull test away from hair loss.

3) Diffuse Alopecia Areata:-

Presents with patchy distribution and positive hair pull test.

4) Alopecia Totalis or Universalis:-

Presents with total scalp hair loss and/or body.

Investigation: 

By doing the following investigations we can figure out the underlying cause of DHL. 

 Blood:-

-Complete blood count and ferritin to find out anaemia & iron deficiency.

-Thyroid Function Test to rule out hyper or hypothyroidism.

-Renal & Liver function test

-Serum zinc level as it is related to coeliac disease.

-Hormonal evaluation like free androgen, sex hormone binding globulin and prolactin may be the clinical signs of hyperandrogenism in women.

Management:

1) Identification of underlying cause:-

The underlying cause should be properly identified like high fever, severe infection, history of any past illness then it is treated in a proper way.

2)Reassurance & Explanation:-

 Patients should be made very clear and understood that all these shedded hairs that they have lost, would regrow again and it will not going to make you bald.

It is just a matter of time period like 3-6 months till the stimulating factor is present. So, when triggering factor is removed, it will restore automatically. 

But it does not mean that you should not be careful about it so any of triggering factor you see just consult the Trichologist first because your doctor is the best person who can help in that.

3) Monthly Assessment of case:-

Each and case should be monitored on regular basis depending upon their cause so monthly review of the case very much important to be taken care. 

Every month Trichologist should follow up the case and how is it going on like in a better way or it is in standstill condition. If its better , should proceed the way it was and if its not then Doctor should take his thought in other way. 

Medical Treatment:

As I always say, there are many modes of treatment available in our great country India for any kind of diseases.

But people mostly prefer to take it from Old School of Medicine(Allopathy) as their first choice and when some percentage of them do not get any satisfied results , they would take a move to other options available in medical field.

Yes, here we are talking about the world's 2nd largest practising system of medicine called Homoeopathy.But it does not mean that you should not take Old School of Medicine in your first choice because here I am just expressing the people's thought that I have been seeing in my day to day practice.

Homoeopathy has a great scope for treating the every kind of disease for last 200 years. And had been giving the wonderful satisfied results so DHL can be also treated & managed very well in Homoeopathy.And yes, it does mean that you would get hairs back in your area of scalp from where it has fallen.

If other health conditions is not a cause,medical treatment is not necessary. 

Medically there are many treatments available in market as of now with different names as per the different company establishments but motive of  all those treatments available in the medical field is only to give a better coverage of scalp.

Following ones you may opt for your hair loss after getting suggestion from a Trichologist. So, before opting any kind of treatment you should have a proper consultation with Dr.

               *HaveGoodHair & LiveGoodLife*