Alopecia is not a diagnosis



Alopecia, latin for partial or complete absence of hair from an area which normally grows hair, is a diagnosis term but is not a final diagnosis. It is an umbrella term under which there are numerous subsets and reasons for hair loss. I often hear people tell me they were told by physicians and stylists that they have alopecia. This is a broad term similar to saying, “you would like a beverage.” There are many types of beverages of all variations, flavors, consistency, and contents. This also pertains to alopecia. Having a specific diagnosis is important for not only knowing the prognosis of your hair loss but also tailoring treatment towards the pathology, or reason, for the hair loss. For example, if you have hair loss secondary to an auto immune condition, treating with oral supplements and stopping all of your medications is not targeting the reason for the hair loss.

A large part of treating hair loss is education and increasing awareness so individuals present to a dermatologist earlier in their course with hopes to stop the progression and if possibly restore the hair. When I speak at salons and cosmetology schools I explain the umbrella term of alopecia. I also categorize hair loss into different types to show that not all hair loss is the same and should not be treated the same.

There are primary inflammatory conditions where the immune system is the initial cause of inflammation attacking the follicles/sebaceous glands (anatomy of hair follicle unit) causing permanent destruction.  Then there are secondary inflammatory conditions which there is an inciting trigger to cause inflammation, such as traction, chemicals, heat, and trauma. Another way to categorize hair loss is by scarring and non-scarring which helps with prognosis.  Scarring hair loss definitely requires medical intervention to stop the inflammatory process and to prevent progression of further follicle damage and hair loss.  Non-scarring conditions are usually environmental or changes in the body- hormones, stress, medications, infections, etc and are reversible sometimes on their own and sometimes with medical intervention.

In this series I will explain the following types of hair loss and the natural progression of each condition if it isn’t diagnosed and treated earlier in its course.


Scarring hair loss:

  1. Frontal fibrosing alopecia:
  2. Central centrifugal cicatricial alopecia:
  3. Lichen planopilaris
  4. Pseudopelade (Brocq)
  5. Discoid lupus erythematosus
  6. Dissecting cellulitis
  7. Acne keloidalis nuchae
  8. Folliculitis decalvans
  9. Traction alopecia


Non-Scarring hair loss:

  1. Alopecia areata
  2. Telogen effluvium
  3. Trichorrhexis nodosa
  4. Seborrheic dermatitis
  5. Lipedematous alopecia




Could you be allergic to your shampoo?

To continue with the theme of itching and scaling scalps, yes you can develop allergies to your shampoo and other hair products. This is called allergic contact dermatitis. Things to look for are dry scaly patches, itching, redness, pus bumps, weeping and oozing on the scalp within 24-48 hours after using a product. If you are experiencing these symptoms after you wash your hair or perform any other chemical process, there is a chance you may be allergic to a substance in the product.

The best way to identify the culprit product is to take a product vacation. Copious rinsing will help remove any excess chemical residue left on the scalp and hair. If your symptoms do not resolve and are persistent or painful seek medical attention. After the symptoms resolve (and if they were mild), add each one of your hair products back into your regimen on a weekly schedule. For example, first add your shampoo, then wait a week and add your conditioner, and follow suit with each styling product. I call this the slow restart method. You may have to find alternative ways to style your hair without the use of your normal regimen of products during this time.

If the symptoms recur after re-entry of a product (the symptoms will return usually within 24-48 hours), try substituting that product for a hypoallergenic (no fragrances or dyes) one. There are many hypoallergenic brands that make hair products as listed below but be cautious manufacturers constantly change their product formulations.  The basics include shampoos, conditioners, and styling products that are functional but may not have all the bells and whistles such as a luxurious lather, all day hold, and fragrances. You can also try natural products but again be cautious because some natural ingredients may cause allergic reactions as well.  Some common hair product allergens and alternatives to those products are listed below:

hair product

As a dermatologist, I frequently see allergic contact dermatitis. Any obvious culprit products or those discovered with the slow restart method are eliminated and product substitutions are made. If a reaction recurs despite substitutions, there may be a chance that the patient has an allergy to a substance common to several hair products. At this time we discuss performing a patch test.  The patch test entails placing strips of paper tape containing 25 to150 of the most common allergens in products (unlike the pinprick allergy test which tests for food and environmental allergens) in your back.  The patch test strips are left on for 48 hours and the back is evaluated for a reaction at 2 days, then again at 5 days and for certain chemicals, at 10 days. For more information on patch testing, visit http://dermnetnz.org/dermatitis/standard-patch.html. If there is a positive test the patient then brings in their products and we sit and read and eliminate any products containing the allergens that were positive on the patch test. I also caution while patch testing can be helpful, it can be misleading at times and may not always reveal an answer.

A common misunderstanding is that you cannot become allergic to a product you’ve used for years. You most certainly can. Every product should be subjected to the slow restart method. So remember, product vacation, then slow restart method to see if you can find the culprit.  If you identify the product causing the symptoms, replace it with a similar hypoallergenic product and hopefully the problem will resolve.



Is dandruff a medical condition?

Ever wondered if your scaling scalp is a medical condition?

Well, it is a medical condition and is extremely common. Dandruff is described as oily flaking skin on the scalp with or without itching. You can think of it as cradle cap (occurs in infants) for adults. While dandruff does not cause hair loss, itching can lead to chronic scratching and inflammation which can cause hair breakage. Chronic inflammation can eventually lead to reduced hair growth in the area.

Dandruff can also affect the face primarily along the forehead and eyebrows, around the nose, in the beard region and the ears. Dandruff can be a chronic condition requiring intermittent treatment and tends to flare with season changes.

Dandruff can be caused by many things including eczema (dry skin), oily skin, allergies to hygienic products, other scaling conditions such as psoriasis, or a yeast called malasezzia. This yeast is practically on everyone’s scalp and face but some people become sensitive to the yeast and develop symptoms of flaking, itching, and redness.

Risk factors to developing dandruff include nutritional deficiencies,  leaving oils on the scalp for a long duration of time (weeks), infrequent hair washing, neurological conditions and immune suppression.

Treatment entails eating a healthy diet, managing stress (stress flares psoriasis and eczema), and washing the hair more frequently (daily most optimal, weekly if more feasible) with medicated shampoos. To alleviate itching, there are prescription medicated solutions that can applied to the scalp. It may be necessary to purchase two or three different medicated shampoos and rotate them every 3rd wash. Common over the counter medicated shampoos include the following ingredients:

1. Tea tree oil (natural)

2. Zinc pyrithione

3. Selenium sulfide

4. Tar (natural)

5. Ketoconazole

6. Salicylic acid

Have you found any natural or chemical products to help? Please share your experience with us.