ABSTRACT
Background:
The frequencies of the different types of alopecia in hair referral centres have so far been reported in a single multicentre study at multiple specialist hair clinics over a time period of one month.
Aim:
Single center studies over a longer time-frame offer a more representative and homogeneous study population with regard to ethnic, demographic, and climatic factors, and seasonality of hair growth and shedding than multicenter studies over a short time frame.
Materials and Methods:
Retrospective study of patient data at a single centre over 10 years.
Results:
A total of 15’211 patients (73% female, 27% male) were included, and we found the following frequencies: pattern hair loss (67%), alopecia areata (11%), the cicatricial alopecias (11%), and telogen effluvium (7%). Among the cicatricial alopecias, the most frequent diagnosis was frontal fibrosing alopecia (33% of cicatricial alopecias), followed in order of frequency by lichen planopilaris (19%), fibrosing alopecia in a pattern distribution (18%), folliculitis decalvans (8%), discoid lupus (5.5%), and dissecting cellulitis (2%). Some specific types of alopecia were observed more frequently in women, others in men, with a predominance of central centrifugal cicatricial alopecia and traction alopecia in women of African origin, and dissecting cellulitis of the scalp and acne keloidalis in men of African origin. The proportion of patients under the age of 10 years was 2.4%. Among the pediatric hair conditions were in order of frequency: alopecia areata (39%), prepubertal pattern hair loss (24%), telogen effluvium (6%), hereditary hypotrichosis (6%), congenital triangular alopecia (4%), short anagen hair (4%), loose anagen hair (3%), trichotillomania (2%), and tinea capitis (1.4%).
Conclusion:
Knowledge of the main types of alopecia and of their epidemiological and clinical specifics are prerequisite for providing an understanding of the etiologies and appropriate patient care in a respective specialty clinic.
Keywords: Alopecia, frequency, hair referral center, pediatric alopecia
Data are the fabric of the modern world: Just like we walk down pavements, so we trace routes through data and build knowledge and products out of it.
–Ben Goldacre
INTRODUCTION
The frequencies of the different types of alopecia in hair referral centers have so far been reported in a single multicenter study at multiple specialist hair clinics over 1 month.[1]
STUDY DESIGN
For a more representative and homogeneous study population, we performed a retrospective study of patient data at a single center over 10 years [Table 1].
Table 1.
Frequencies of different types of alopecia over a 10-year period
| Type of alopecia | Male, n (%) | Female, n (%) | Total, n (%) |
|---|---|---|---|
| Noncicatricial | 3567 | 9536 | 13,103 (86) |
| PHL | 2925 | 7335 | 10,260 (67) |
| Male pattern (Hamilton-Norwood) | 712 (93) | 671 (11) | 1383 |
| Female pattern (Ludwig) | 54 (7) | 5599 (89) | 5653 |
| Intermediate | 2159 | 1065 | 3224 (31) |
| AA | 574 | 1156 | 1730 (11) |
| Multilocular | 498 | 878 | 1376 (80) |
| Ophiasis | 33 | 109 | 142 (8) |
| Universal | 24 | 62 | 86 (5) |
| Total | 10 | 37 | 47 (3) |
| Diffuse | 9 | 67 | 76 (4) |
| Marie Antoinette/Thomas more syndrome | 0 | 3 | 3 (0.2) |
| TE | 61 | 984 | 1045 (7) |
| Dystrophic anagen effluvium | 7 | 61 | 68 (0.4) |
| Chemotherapy-induced | 6 | 60 | 66 |
| Radiation- induced (neuroradiological guided embolization) | 1 | 0 | 1 |
| Heavy metal intoxication | 0 | 1 | 1 |
| Cicatrical | 386 | 1228 | 1614 (11) |
| Primary cicatricial alopecias | 368 | 1157 | 1525 (94) |
| Lymphocytic | 194 | 1076 | 1270 |
| FFA | 36 | 491 | 527 (33) |
| LPP | 91 | 211 | 302 (19) |
| Lassueur-Graham-Little | 2 | 1 | 3 |
| FAPD | 33 | 260 | 293 (18) |
| GvHD | 3 | 11 | 14 |
| Pseudopelade Brocq | 11 | 14 | 25 (1.5) |
| Discoid lupus | 17 | 72 | 89 (5.5) |
| CCCA | 0 | 15 | 15 (1) |
| Mucinosis follicularis | 1 | 1 | 2 |
| Neutrophilic | 122 | 58 | 180 |
| Folliculitis decalvans | 53 | 43 | 96 (8) |
| Tufted hair folliculitis | 31 | 9 | 40 (2.5) |
| Dissecting cellulitis | 29 | 2 | 31 (2) |
| Tinea capitis | 9 | 4 | 13 (1) |
| Mixed | 52 | 23 | 75 |
| Keratosis follicularis spinulosa decalvans | 3 | 1 | 4 |
| Acne miliaris necrotica | 39 | 16 | 55 (3) |
| Acne keloidalis | 6 | 0 | 6 (0.4) |
| Erosive pustular dermatosis | 4 | 6 | 10 (0.6) |
| Secondary cicatricial alopecias | 18 | 71 | 89 (6) |
| Physical | 9 | 64 | 73 |
| Traction alopecia | 4 | 60 | 64 (4) |
| Traumatic alopecia | 3 | 2 | 5 |
| Radiation-induced permanent alopecia | 2 | 2 | 4 |
| Other | 9 | 7 | 16 |
| Carbuncle | 1 | 0 | 1 |
| Sarcoidosis | 2 | 1 | 3 |
| B cell lymphoma | 2 | 1 | 3 |
| En coup de sabre | 3 | 5 | 8 (0.5) |
| Cicatrizing pemphigoid | 1 | 0 | 1 |
| Trichomanias | 8 | 31 | 39 (0.25) |
| Trichotillomania | 6 | 23 | 29 |
| Trichoteiromania | 1 | 7 | 8 |
| Trichotemnomania | 1 | 1 | 2 |
| Pediatric alopecias | 130 | 234 | 364 (2.4) |
| Noncicatricial | |||
| AA | 66 | 75 | 141 (39) |
| Prepubertal PHL | 24 | 64 | 88 (24) |
| TE | 2 | 19 | 21 (6) |
| Trichotillomania | 4 | 3 | 7 (2) |
| Alopecia triangularis | 7 | 7 | 14 (4) |
| Loose anagen hair | 1 | 11 | 12 (3) |
| Short anagen hair | 3 | 13 | 16 (4) |
| Cicatricial | 4 | ||
| Alopecia parvimaculata | 2 | 6 | 8 (2) |
| Tinea capitis | 4 | 1 | 5 (1.4) |
| LPP | 3 | 2 | 5 (1.4) |
| Aplasia cutis congenital | 2 | 1 | 3 |
| Hypotrichosis | 6 | 16 | 22 (6) |
| Simplex | 4 | 14 | 18 |
| Marie Unna | 0 | 1 | 1 |
| Ectodermal dysplasia | 2 | 0 | 2 |
| Trichorhinophalangeal syndrome | 0 | 1 | 1 |
| Hair shaft anomalies | 4 | 16 | 20 (0.1) |
| Trichorrhexis nodosa | 2 | 6 | 8 |
| Matting of the hair | 0 | 1 | 1 |
| Monilethrix | 0 | 1 | 1 |
| Woolly hair | 1 | 4 | 5 |
| Congenital woolly hair | 0 | 1 | 1 |
| Woolly hair nevus | 1 | 0 | 1 |
| Diffuse partial woolly hair | 0 | 3 | 3 |
| Total | 4095 (27) | 11,116 (73) | 15,211 (100) |
GvHD - Graft versus host disease; TE - Telogen effluvium; FFA - Frontal fibrosing alopecia; LPP - Lichen planopilaris; FAPD - Fibrosing alopecia in pattern distribution; CCCA - Central centrifugal cicatrizing alopecia; PHL - Pattern hair loss; AA - Alopecia areata
RESULTS
A total of 15,211 patients (73% females and 27% males) seen at the Center for Dermatology and Hair Diseases Professor Trüeb between 2011 and 2021 were included in this study. We found the following frequencies: pattern hair loss (PHL) (67%), alopecia areata (AA) (11%), cicatricial alopecias (11%), and telogen effluvium (TE) (7%).
PATTERN HAIR LOSS
Of men with PHL, 93% presented with the Hamilton–Norwood pattern and 7% with the Ludwig pattern, of women with PHL, 89% with the Ludwig pattern and 11% with the Hamilton–Norwood pattern. Thirty-one percent had an intermediate pattern, underscoring the need for a more comprehensive classification beyond Hamilton–Norwood, Ludwig, and Sinclair, such as the BASP classification as originally proposed by Lee et al.[2]
ALOPECIA AREATA
AA presented as multilocular AA in 80%, ophiasis in 8%, alopecia universalis in 5%, diffuse AA in 4%, alopecia totalis in 3%, and Marie Antoinette/Thomas More syndrome in 0.2%. The Maria Antoinette syndrome is the eponym for overnight whitening of the hair in women, while Thomas More syndrome has been proposed for the respective condition in men.[3]
CICATRICIAL ALOPECIAS
Among the cicatricial alopecias, the most frequent diagnosis was frontal fibrosing alopecia (FFA) (33% of cicatricial alopecias), followed in order of frequency by lichen planopilaris (LPP) (19%), fibrosing alopecia in a pattern distribution (FAPD) (18%), folliculitis decalvans and tufted hair folliculitis (8%), discoid lupus (5.5%), acne miliaris necrotica (3%), dissecting cellulitis (2%), pseudopelade of Brocq (1.5%), tinea capitis (1%), central centrifugal cicatricial alopecia (CCCA) (1%), graft versus host disease (GvHD) (0.9%), erosive pustular dermatosis (0.6%), morphea en coup de sabre (0.5%), acne keloidalis (0.4%), keratosis follicularis spinulosa decalvans (0.2%), and mucinosis follicularis (0.1%). Particularly, FFA and FAPD have significantly gained in importance since their original description by Kossard[4] in 1994, and by Zinkernagel and Trüeb in 2000.[5] GvHD presented as FAPD, suggesting a model for the pathophysiological understanding of cicatricial PHL.[6]
GENDER AND ETHNICITY
FPHL, TE, diffuse AA, chemotherapy-induced alopecia, FFA, FAPD, LPP, discoid lupus, CCCA, traction alopecia, trichotillomania, trichoteiromania, and diffuse partial woolly hair were observed more frequently in women, with a predominance of CCCA and traction alopecia in patients of African origin. MPHL, tufted hair folliculitis, dissecting cellulitis, acne miliaris necrotica, and acne keloidalis were seen more often in men, with a predominance of dissecting cellulitis and acne keloidalis in patients of African origin.
PEDIATRIC ALOPECIA
The proportion of patients under the age of 10 years was 2.4%. Among the pediatric hair conditions were in order of frequency: AA (39%), prepubertal PHL (24%), TE (6%), hereditary hypotrichosis (6%), congenital triangular alopecia (4%), short anagen hair (4%), loose anagen hair (3%), trichotillomania (2%), alopecia parvimaculata (2%), tinea capitis (1.4%), ectodermal dysplasia (0.5%), and trichorhinophalangeal syndrome (0.25%). Prepubertal PHL presented with the Ludwig pattern in both sexes. As formerly proposed, the observation of Ludwig pattern FPHL in prepubertal children suggests that the condition in women may not be necessarily androgen dependent.[7]
Alopecia parvimaculata represents scarring alopecia in small patches, that was originally reported by Dreuw in 1911 in small epidemics suggesting an infectious agent, while today, it is more frequently observed sporadically and represents unspecific scarring alopecia following diverse conditions of the scalp in children, including infections of bacterial (folliculitis), fungal (tinea), or viral origin (varicella), and parasitosis. Among the conditions peculiar to the pediatric population are the loose anagen hair and the more recently described short anagen syndrome.[8] Both were observed more frequently in girls than in boys, with usually spontaneous remission with coming of age.
CONCLUSION
Knowledge of the main types of alopecia and their epidemiological and clinical specifics are prerequisites for providing an understanding of the etiologies and appropriate patient care in a respective specialty clinic. Single-center studies over a longer time frame offer a more representative and homogeneous study population than multicenter studies over a short time frame with regard to ethnic, demographic, and climatic factors, and seasonality of hair growth and shedding.[9]
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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