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Alopecia – Information for GPs

Background

From April 2013, NHS England took over responsibility for commissioning activity in primary care, where initial conservative treatment takes place.

NHS Scarborough and Ryedale CCG is responsible for commissioning activity in secondary care, and this policy sets out the referral criteria for the referral to secondary care for the management of Alopecia.

Definition

Alopecia = hair loss

General points

Alopecia areata (AA):

Round bald patches that appear suddenly, it is an auto-immune form of hair loss and may be associated with other autoimmune disorders, there is a positive FH in 1 in 12.

Children with alopecia areata tend to do less well than adults.

Prognosis is worse with:

  • Early age of onset
  • Increased extent of areas affected
  • Occipital pattern of loss
  • Associated nail dystrophy
  • Associated atopy

70% regrow within 12 months. Regrowth may be initially white/grey but the pigment usually returns later.

Management

  • Encourage smoking cessation
  • Encourage weight loss (if appropriate)
  • Check TFTs ferritin levels. Good levels are beneficial for subsequent hair regrowth

For more profuse hair loss

  • Check medication - stopping contraceptive pill can cause hair loss (but the hair would have been gradually lost without the pill anyway), statins. Medication can often be implicated. Medication known to cause alopecia include*:-
    Amphetamines,  Hypolipidaemics, Anticoagulants (warfarin, heparin, heparinoids), Interferons, Antidepressants, Leflunomide, Antithyroid drugs, Lithium, Beta-blockers, Oral Contraceptives, Carbamazepine, Phenytoin, Cimentidine, Retinoids, Cytotoxic agents, Tamoxifen, Valproate

*this list is not exhaustive

See BNF for more information and include details of medication in referral letter, including any treatments stopped in the last 4 months. If you think a medication may be causing hair loss, please email rdtc.rxsupp@nuth.nhs.uk for advice.

Treatment options

  • If there is evidence of hair regrowth (short, fine, tapered hair or white hair), there is no need for treatment
  • If there is no hair regrowth and the person has less than 50% hair loss, discuss the option of watching and waiting, with no treatment
  • If there is no hair regrowth and the person has more than 50% hair loss, or treatment is preferred:
    • Refer to a dermatologist.
  • If the person has less than 50% hair loss, there is better evidence to support the use of intralesional corticosteroids than other treatments.
  • If the person has more than 50% hair loss, there is better evidence to support the use of topical immunotherapy than other treatments, although its availability may be limited.
  • For more information on these and other treatments see Specialist Treatments
  • If the diagnosis is certain, for an adult who is not pregnant and is waiting to see a specialist or declines referral:

Consider a trial of a potent topical corticosteroid (such as betamethasone valerate 0.1% (as Betnovate®), fluocinolone acetonide 0.025% (as Synalar® 0.025% cream) or very potent topical corticosteroids (such as clobetasol propionate 0.05% scalp application (as Dermovate®* scalp)) for 3 months (off-label use).  *topical steroids should be prescribed by brand name

Do not use on the face (such as on the beard or eyebrows)

  • For children and pregnant or breastfeeding women, discuss with a dermatologist before starting interim treatment.

Treatment options for alopecia areata which might be used by a specialist, but are not recommended for use in primary care include:

  • Intralesional corticosteroids (available on the NHS and used by local Consultant Dermatologists)
  • Topical immunotherapy (available on the NHS and used by local Consultant Dermatologists)
  • Topical minoxidil (only available privately. Not on NHS)
  • Topical dithranol (now rarely used)
  • Topical or systemic psoralen plus ultraviolet A light therapy (PUVA) (available on the NHS)
  • Oral ciclosporin (available on the NHS)
  • Dermatography (tattooing) – (only available privately not on NHS)
  • Wigs (available on the NHS and used by local Consultant Dermatologists)

Alopecia Totalis (where all the hair on the scalp is lost) and universalis (where all body hair is lost) – only a very small proportion recover

Telogen effluvium – an increase in the number of hairs shed with associated thinning of the hair; usually occurs 2-3 months after an event such as childbirth, serious illness, fever, operation, accident or other form of stress.  Recovery occurs over 6-9 months but may be incomplete.

Traction alopecia – an acquired form of hair loss due to prolonged or repeated tension on the hair e.g. with tight braiding, tight ponytails etc.  Usually affects frontal and temporal areas but depends on hairstyle.  Can be temporary or permanent.

Female pattern hair loss (androgenetic alopecia)

40% of women by the age of 50 show evidence of hair loss; usually presents as hair thinning over the vertex rather than a bald patch and hair won’t grow as long as previously; there is a strong genetic component which can be inherited from either parent.

Consider causes such as PCOS, congenital adrenal hyperplasia or androgen producing tumours if there are other signs of virilisation.

Check TFT, ferritin (aim for 60+).  Check LH/FSH/testosterone only if indicated

Assess psychological impact

  • Doing nothing may be the best option in many women
  • Using a medical treatment.

Topical minoxidil 5%(Regaine®) is the only drug licensed for use in female androgenetic alopecia  It is not prescribable on the NHS but can be bought over the counter or prescribed privately

  • To gain and maintain benefit, twice-daily application must continue indefinitely – cessation of treatment will lead to loss of all results within 4 months

Do not offer other medications

•             Finasteride is contraindicated in women

Androgenetic alopecia male (male pattern baldness)

Options for private treatment include minoxidil 5% and finasteride 1mg tablets but these are not available on the NHS.

Indications for referral

Scarring alopecia

Investigations prior to referral

(see Management)

Information to include in referral letter

  • Appearance of the scalp
  • Tests undertaken
  • Site(s) affected and size of area(s)
  • Length of time alopecia has affected the patient and the emotional impact
  • Any treatments tried

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