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Background: The frequency of different types of alopecia is not clearly reported in recent studies. Objective: To analyze the frequency of the types of alopecia in patients consulting at specialist hair clinics (SHC) and to assess for global variations. Methods: Multicenter retrospective study including data from patients evaluated at referral SHC in Europe, America, Africa and Australia. Results: A total of 2,835 patients (72.7% females and 27.3% males) with 3,133 diagnoses of alopecia were included (73% were non-cicatricial and 27% were cicatricial alopecias). In all, 57 different types of alopecia were characterized. The most frequent type was androgenetic alopecia (AGA) (37.7%), followed by alopecia areata (AA) (18.2%), telogen effluvium (TE) (11.3%), frontal fibrosing alopecia (FFA) (10.8%), lichen planopilaris (LPP) (7.6%), folliculitis decalvans (FD) (2.8%), discoid lupus (1.9%) and fibrosing alopecia in a pattern distribution (FAPD) (1.8%). There was a male predominance in patients with acne keloidalis nuchae, dissecting cellulitis and FD, and female predominance in traction alopecia, central centrifugal cicatricial alopecia, FFA, TE, FAPD and LPP. Conclusion: AGA followed by AA and TE were the most frequent cause of non-cicatricial alopecia, while FFA was the most frequent cause of cicatricial alopecia in all studied geographical areas.
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Research Article
Skin Appendage Disord
Frequency of the Types of Alopecia at Twenty-Two
Specialist Hair Clinics: A Multicenter Study
Sergio Vañó-Galván a David Saceda-Corralo a Ulrike Blume-Peytavi b Jose Cucchía c
Ncoza C. Dlova d Maria Fernanda Reis Gavazzoni Dias e Ramon Grimalt f Daniela Guzmán-Sánchez g
Matthew Harries h Anthony Ho i Susan Holmes j Jorge Larrondo k Anisa Mosam d
Rui Oliveira-Soares l, m Giselle M. Pinto n Bianca M. Piraccini o Rodrigo Pirmez p
Daniel De la Rosa Carrillo q Lidia Rudnicka r Jerry Shapiro i Rodney Sinclair s, t Antonella Tosti u
Ralph M. Trüeb v Annika Vogt b Mariya Miteva w
a Dermatology Department, Ramon y Cajal Hospital, University of Alcala, IRYCIS, Trichology Unit, Grupo Pedro Jaen Clinic,
Madrid, Spain; b Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany; c Private
Trichology Practice, Santa Ana Medical Center, Bogotá, Colombia; d Department of Dermatology, Nelson R Mandela School
of Medicine, University of KwaZulu-Natal, Durban, South Africa; e Fluminense Federal University – UFF, Niterói, Brazil;
f Dermatology Department, Universitat Internacional de Catalunya, Barcelona, Spain; g School of Medicine, Universidad de
Guadalajara, Guadalajara, Mexico; h The Dermatology Centre, University of Manchester, Salford Royal NHS Foundation Trust,
Salford, UK; i The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, NY,
USA; j Alan Lyell Centre for Dermatology, Queen Elizabeth University Hospital, Glasgow, UK; k Department of Dermatology,
Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile; l Department
of Dermatology, Hospital Cuf Descobertas, Lisbon, Portugal; m Department of Dermatology, Hospital Cuf Torres Vedras,
Torres Vedras, Portugal; n Hair and Scalp Diseases, Outpatient Clinic, Division of Dermatology, Santa Casa de Misericórdia,
Porto Alegre, Brazil; o Division of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, University
of Bologna, Bologna, Italy; p Department of Dermatology, Instituto de Dermatologia Professor Rubem David Azulay, Santa
Casa da Misericórdia do Rio de Janeiro, Rio de Janeiro, Brazil; q Department of Dermatology, Oslo University Hospital, Oslo,
Norway; r Department of Dermatology, Medical University of Warsaw, Warsaw, Poland; s Sinclair Dermatology, East Melbourne,
VIC, Australia; t Department of Medicine, University of Melbourne, Parkville, VIC, Australia; u University of Miami, Miami, FL,
USA; v Center for Dermatology and Hair Diseases Professor Trüeb, Wallisellen, Switzerland; w Department of Dermatology and
Cutaneous Surgery, University of Miami L. Miller School of Medicine, Miami, FL, USA
Received: November 5, 2018
Accepted: January 3, 2019
Published online: April 2, 2019
Sergio Vañó-Galván, MD, PhD
Dermatology Department, Ramon y Cajal Hospital
Carretera Colmenar Viejo km 9.100
ES–28034 Madrid (Spain)
E-Mail drsergiovano @ gmail.com
© 2019 S. Karger AG, Basel
E-Mail karger@karger.com
www.karger.com/sad
DOI: 10.1159/000496708
Keywords
Hair diseases · Alopecia · Androgenetic alopecia · Alopecia
areata · Frontal fibrosing alopecia · Telogen effluvium ·
Folliculitis decalvans · Lichen planopilaris · Epidemiology
Abstract
Background: The frequency of different types of alopecia is
not clearly reported in recent studies. Objective: To analyze
the frequency of the types of alopecia in patients consulting
at specialist hair clinics (SHC) and to assess for global varia-
tions. Methods: Multicenter retrospective study including
data from patients evaluated at referral SHC in Europe,
America, Africa and Australia. Results: A total of 2,835 pa-
tients (72.7% females and 27.3% males) with 3,133 diagno-
ses of alopecia were included (73% were non-cicatricial and
27% were cicatricial alopecias). In all, 57 different types of
alopecia were characterized. The most frequent type was an-
drogenetic alopecia (AGA) (37.7%), followed by alopecia
areata (AA) (18.2%), telogen effluvium (TE) (11.3%), frontal
fibrosing alopecia (FFA) (10.8%), lichen planopilaris (LPP)
(7.6%), folliculitis decalvans (FD) (2.8%), discoid lupus (1.9%)
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and fibrosing alopecia in a pattern distribution (FAPD) (1.8%).
There was a male predominance in patients with acne keloi-
dalis nuchae, dissecting cellulitis and FD, and female pre-
dominance in traction alopecia, central centrifugal cicatricial
alopecia, FFA, TE, FAPD and LPP. Conclusion: AGA followed
by AA and TE were the most frequent cause of non-cicatricial
alopecia, while FFA was the most frequent cause of cicatricial
alopecia in all studied geographical areas.
© 2019 S. Karger AG, Basel
Introduction
Androgenetic alopecia (AGA) is the most frequent
cause of hair loss in both genders [1–3], followed by alo-
pecia areata (AA) [4]. Regarding cicatricial alopecias, li-
chen planopilaris (LPP) has been described as the most
frequent cicatricial alopecia [5, 6]. However, most papers
published over recent years suggest that the incidence of
frontal fibrosing alopecia (FFA) may be increasing com-
pared with other types of cicatricial alopecias [7–9], al-
though this observation has not yet been confirmed in
large epidemiological studies. Some alopecias may have a
marked difference in their prevalence depending on the
geographical location and ethnicity (i.e., central centrifu-
gal cicatricial alopecia [CCCA] is typical of females with
African ancestry [7]); thus, a worldwide analysis of the
frequency of the different alopecias seen at specialist hair
clinics (SHC) may provide useful insights into disease ep-
idemiology. Regarding the healthcare setting, no data ex-
ist regarding possible disparities in the frequency of hair
disorders seen in private versus public centers.
There are no recent studies describing the frequency
of different types of alopecia among patients treated at
different SHC. The objective of this study was to analyze
the frequency of the different types of alopecia in patients
evaluated at SHC across the globe and to analyze the pos-
sible differences in frequencies between geographical ar-
eas, gender and age.
Methods
A multicenter retrospective study was designed, and local in-
stitutional review board approval was obtained. Data were collect-
ed at SHC in several countries between September 1st, 2017, and
November 30th, 2017. The referral centers were located in Austra-
lia, Brazil, Chile, Colombia, Germany, Italy, Mexico, Norway, Po-
land, Portugal, South Africa, Spain, Switzerland, USA and UK.
Each investigator included the following data: gender, age, setting
(private vs. public healthcare), first visit versus follow-up visit and
type of alopecia: AGA, telogen effluvium (TE), AA, FFA, LPP, dis-
coid lupus, folliculitis decalvans (FD), CCCA, traction alopecia,
dissecting cellulitis (DCS), acne keloidalis nuchae (AKN), fibros-
ing alopecia in a pattern distribution (FAPD), trichotillomania and
others including hair shaft disorders and hair weathering changes.
AA was subclassified into: patchy AA, ophiasis, diffuse AA, AA
incognita, alopecia totalis, alopecia universalis and beard AA. Each
investigator included data on a minimum of 100 consecutive pa-
tients consulting for any hair disorder in the study period. If a pa-
tient presented 2 or more concomitant alopecias, all were regis-
tered in the database.
The obtained data were anonymized and handled in accor-
dance with the European General Data Protection Regulation (EU
2016/679).
For all continuous variables, median and range were calcu-
lated, but for categorical variables, frequencies were reported.
The Mann-Whitney and χ2 tests were used to assess the statistical
significance of differences observed between groups for continu-
ous and categorical variables, respectively. p < 0.05 was consid-
ered statistically significant. For all statistical analyses, a software
package was used (SPSS 21.0; IBM Corp., Armonk, NY, USA).
Results
Results are summarized in Tables 1–3.
Demographic Data
In total, 2,835 patients were included (USA: n = 303,
Spain: n = 412, Mexico: n = 100, Chile: n = 137, Colombia:
n = 295, Norway: n = 100, Brazil: n = 312, Portugal: n =
100, Italy: n = 200, Germany: n = 100, Switzerland: n =
100, South Africa: n = 114, Australia: n = 107, UK: n = 202
and Poland: n = 253). 298 patients (10.5%) presented with
two concomitant types of alopecia. A total of 3,133 alope-
cia diagnoses with 57 different types of alopecia were re-
corded and showed the following distribution: 2,293 were
non-cicatricial alopecias (73.2%) while 840 were cicatri-
cial alopecias (26.8%). The median age of patients was
43.5 years (range 1–92 years), and 2,062 patients were fe-
males (72.7%) and 773 were males (27.3%). 915 (32.3%)
were evaluated as a first visit and 1,920 (67.7%) as a fol-
low-up visit, and 1,925 (67.9%) were seen in a private
healthcare setting, while 910 (32.1%) were seen in a pub-
lic healthcare setting.
Frequency in Alopecia by Type and Healthcare Setting
The most frequent type of alopecia was AGA (37.7%),
followed by AA (18.2%), TE (11.3%) and FFA (10.8%).
There were statistically significant differences in the fre-
quency of hair disorders depending on the healthcare set-
ting (Table 1). In the private healthcare setting, the most
frequent alopecia was AGA (48% of cases), followed by
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DOI: 10.1159/000496708
TE (14.6%), AA (13.6%) and FFA (8.5%). In the public
healthcare setting, the most frequent alopecia was AA
(28% of cases), followed by FFA (16%), AGA (14%) and
LPP (12%) (p = 0.003).
Frequency of Alopecia by Gender and Age
Regarding gender (Table 2), the most frequent alope-
cias in male patients were: AGA (48% of males), fol-
lowed by AA (25%), FD (6.9%), LPP (5%), TE (3.8%),
DCS (2.7%), FFA (1.9%), AKN (1.8%), discoid lupus
(0.9%) and FAPD (0.7%). The most frequent alopecias
in female patients were: AGA (34.2%), AA (15.7%), FFA
(14%), TE (13.5%), LPP (8.5%), discoid lupus (2.3%),
FAPD (2.2%), traction alopecia (1.9%), FD (1.4%) and
CCCA (1.3%).
The following alopecias were most frequent in male
patients: AKN (88% were males), DCS (76% were males),
FD (64% were males). A female predominance was ob-
served in: traction alopecia (98% were females), CCCA
(97% were females), FFA (95% were females), chronic
and acute TE (93 and 90% were females, respectively),
FAPD (89% were females), discoid lupus (88% were fe-
males) and LPP (83% were females).
Globally, male patients were younger than female pa-
tients (median age of 33 and 47 years, respectively; p <
0.001). Analyzing the different alopecias by the age of pa-
tients (Table 2), the youngest median age was observed in
patients with hair shaft disorders (14 years), followed by
patients with trichotillomania (25 years), AKN (32 years),
AA (32 years), DCS (37 years), FD (40 years) and AGA
(40 years). The oldest median age was observed in pa-
tients with FFA (60 years), FAPD (59 years), discoid lupus
(56 years) and LPP (54 years).
Non-Cicatricial Alopecia
The most frequent type of non-cicatricial alopecia was
AGA (51.5% of non-cicatricial alopecias), followed by AA
(24.9%) and TE (15.5%). Other types of alopecia such as
trichotillomania, hair shaft disorders, hair weathering,
syphilitic alopecia, scalp psoriasis, tinea capitis or anagen
effluvium were present in less than 3% of patients. The
most frequent hair shaft disorder was monilethrix (6 out of
12 patients), followed by trichorrhexis nodosa (3 out of 12
patients). Of the total of patients with AA (n = 568), the
most frequent subtype was patchy AA (62.1% of patients
diagnosed with AA), followed by alopecia totalis (16.6%),
alopecia universalis (9.5%), ophiasis (5.8%), diffuse AA
(4.1%), AA incognita (1.4%) and beard AA (0.5%).
Cicatricial Alopecia
Regarding cicatricial alopecias (n = 840, 26.8% of the
total of alopecias), FFA was the most frequent (40.1% of
cicatricial alopecias), followed by LPP (28.4%), FD
(10.5%), discoid lupus (7.1%), FAPD (6.8%), traction alo-
pecia (5.2%), CCCA (3.6%) and DCS (3.4%).
Other types of alopecia such as AKN, erosive pustular
dermatosis of the scalp, lamellar ichthyosis, permanent
post-chemotherapy alopecia, temporal triangular con-
Table 1. Frequency of hair disorders and differences by setting (private/public healthcare)
Type of alopecia Public setting, n (%) Private setting, n (%) Total, n (%)
Androgenetic alopecia 136 (14) 1,044 (48) 1,180 (37.7)
Alopecia areata 274 (28) 294 (13.6) 568 (18.2)
Telogen effluvium 38 (4) 317 (14.6) 355 (11.3)
Frontal fibrosing alopecia 152 (16) 185 (8.5) 337 (10.8)
Lichen planopilaris 118 (12) 121 (5.5) 239 (7.6)
Folliculitis decalvans 61 (6.3) 27 (1) 88 (2.8)
Discoid lupus 42 (4.3) 18 (<1) 60 (1.9)
FAPD 42 (4.3) 15 (<1) 57 (1.8)
Traction alopecia 10 (1.0) 34 (1.6) 44 (1.4)
CCCA 9 (1) 21 (1) 30 (1)
Dissecting cellulitis 12 (1) 17 (<1) 29 (0.9)
Acne keloidalis nuchae 13 (1.4) 4 (<1) 17 (0.5)
Trichotillomania 5 (<1) 7 (<1) 12 (0.4)
Hair shaft disorders 1 (<1) 11 (<1) 12 (0.4)
Other alopecias 47 (4.9) 48 (2.2) 95 (3)
Total 962 (30.7) 2,171 (69.3) 3,133 (100)
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genital alopecia, pemphigus-induced alopecia, Graham-
Little syndrome, alopecia mucinosa or coupe de sabre al-
opecia were present in less than 3% of patients.
Global Variations
The different frequency of alopecias in each continent
(Europe, America, Africa and Australia) was also ana-
lyzed (Table 3). We could not find any statistically sig-
nificant difference in the frequency of AGA, TE, FFA and
LPP. However, a higher frequency of some alopecias was
found in some continents: AA in Europe (23 vs. < 14% in
the rest of continents), traction alopecia in Africa (18 vs.
< 1% in the rest of continents), AKN in Africa (9 vs. < 1%
in the rest of continents), CCCA in Africa (6 vs. < 1% in
the rest of continents), FD in Africa (7.5 vs. < 3.5% in the
rest of continents) and FAPD in America (3.5 vs. < 2% in
Table 2. Differences in the frequency of hair disorders by gender and age
Type of alopecia Gender Median age (range), years
by gender total
Androgenetic alopecia (n = 1,180) male: 33% male: 33 (11–76) 40 (11–91)
female: 67% female: 45 (12–91)
Alopecia areata (n = 568) male: 36% male: 28 (1–63) 32 (1–82)
female: 64% female: 37 (3–82)
Acute telogen effluvium (n = 183) male: 10% male: 35 (18–65) 41 (9–76)
female: 90% female: 41 (9–76)
Chronic telogen effluvium (n = 172) male: 7% male: 31 (17–86) 42 (13–92)
female: 93% female: 43 (13–92)
Frontal fibrosing alopecia (n = 337) male: 5% male: 45 (31–70) 60 (31–89)
female: 95% female: 61 (31–89)
Lichen planopilaris (n = 239) male: 17% male: 43 (13–74) 54 (8–86)
female: 83% female: 56 (8–86)
Folliculitis decalvans (n = 88) male: 64% male: 40 (19–73) 40 (17–75)
female: 36% female: 41 (17–75)
Discoid lupus (n = 60) male: 12% male: 39 (27–58) 56 (19–81)
female: 88% female: 59 (19–81)
FAPD (n = 57) male: 11% male: 57 (24–73) 59 (21–82)
female: 89% female: 59 (21–82)
Traction alopecia (n = 44) male: 2% male: 44 (1 case) 41 (11–67)
female: 98% female: 40 (11–67)
CCCA (n = 30) male: 3% male: 56 (1 case) 47 (27–72)
female: 97% female: 46 (27–72)
Dissecting cellulitis (n = 29) male: 76% male: 33 (19–69) 37 (18–83)
female: 24% female: 57 (18–83)
Acne keloidalis nuchae (n = 17) male: 88% male: 32 (22–55) 32 (22–62)
female: 12% female: 51 (40–62)
Trichotillomania (n = 12) male: 42% male: 25 (14–41) 25 (8–41)
female: 58% female: 25 (8–35)
Hair shaft disorders (n = 12) male: 42% male: 15 (8–70) 14 (3–70)
female: 58% female: 4 (3–61)
Total (n = 3,133) male: 26.4% male: 33 (1–86) 43 (1–92)
female: 73.6% female: 47 (2–92)
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the rest of continents). Analyzing each continent by
countries, there were no significant differences in the fre-
quency of hair disorders. In the American continent, we
performed a subanalysis between North America (n =
352) and South America (n = 934). We found a statisti-
cally significant higher number of patients consulting for
these alopecias in North America: FFA (16% of patients
in North America vs. 8.4% of patients in South America,
p < 0.001), CCCA (2.8 vs. 0.5%, p = 0.002). On the con-
trary, more patients consulted for these alopecias in South
America: FAPD (4.7% of patients in South America vs.
0.3% of patients in North America, p < 0.001), discoid lu-
pus (4.3 vs. 0.3%, p < 0.001) and FD (2 vs. 0.3%, p = 0.014).
We did not find any statistically significant difference in
the age of the different alopecias between continents.
Discussion
This is the first multicenter study to analyze the fre-
quencies of the different types of alopecia in patients from
reference SHC in different continents. An understanding
of the frequency with which different types of alopecia are
seen in different geographical areas could provide useful
insights into disease epidemiology.
In concordance with previous studies [1–3, 10], AGA
was the most frequent cause of consultation in both gen-
ders. Male patients that consulted with AGA in our study
were younger than female patients (33 vs. 45 years, re-
spectively), similar to other studies [1]. This could be ex-
plained because female patients present two peaks of con-
sultation for AGA: early adults and menopause, while
male patients usually consult in the early adulthood.
The second most frequent global cause of consultation
in our study was AA. This was the most frequent type of
alopecia in the public healthcare setting. The median age
in patients with AA was 32 years, in accordance with pub-
lished studies (30–35 years) [4, 11, 12]. AA seems to affect
both genders equally [11], although in our study we found
a female predominance (64% females vs. 36% males),
probably because female patients tend to consult more
than male patients.
TE was the third most frequent cause of consultation,
with a clear female predominance, in concordance with
previous reports [13]. Other types of non-cicatricial alo-
pecia such as trichotillomania, tinea capitis or scalp pso-
riasis were less frequent. Monilethrix represented the
most frequent hair shaft disorder in our study.
Regarding gender, patients consulting with AKN, FD
and DCS were most frequently males, while patients
consulting with traction alopecia, CCCA, FFA, FAPD
and LPP were most frequently females, in accordance
with the literature [7, 9, 14–20]. The most frequent alo-
pecias in both genders were AGA followed by AA. Re-
markably, the third most frequent alopecia in male pa-
tients was FD, while in female patients was FFA, sup-
porting the already reported gender predominance in
both alopecias [9, 15].
Table 3. Differences in the frequency of hair disorders by continent
Type of alopecia Europe, n (%) America, n (%) Australia, n (%) Africa, n (%) Total, n (%)
Androgenetic alopecia 558 (35) 531 (41.2) 85 (69) 6 (4.5) 1,180 (37.6)
Alopecia areata 365 (22.9) 172 (13.3) 17 (14) 14 (10.5) 568 (18.2)
Telogen effluvium 175 (11) 175 (13.6) 0 5 (3.7) 355 (11.3)
Frontal fibrosing alopecia 177 (11) 134 (10.4) 9 (7.3) 17 (12.7) 337 (10.8)
Lichen planopilaris 115 (7.2) 93 (7.2) 3 (2.4) 28 (21) 239 (7.6)
Folliculitis decalvans 55 (3.4) 20 (2.5) 3 (2.4) 10 (7.5) 88 (2.8)
Discoid lupus 15 (1) 41 (3.2) 0 4 (3) 60 (1.9)
FAPD 11 (<1) 45 (3.5) 0 1 (1) 57 (1.8)
Traction alopecia 9 (<1) 10 (<1) 1 (<1) 24 (18) 44 (1.4)
CCCA 7 (<1) 15 (1) 0 8 (6) 30 (1)
Dissecting cellulitis 16 (1) 13 (1) 0 0 29 (0.9)
Acne keloidalis nuchae 3 (<1) 2 (<1) 0 12 (9) 17 (0.5)
Trichotillomania 6 (<1) 5 (<1) 0 1 (1) 12 (0.4)
Hair shaft disorders 8 (<1) 4 (<1) 0 0 12 (0.4)
Other alopecias 65 (4.1) 24 (1.9) 4 (3.3) 2 (1.5) 95 (3.0)
Total 1,592 (50.8) 1,286 (41) 122 (4) 133 (4.2) 3,133 (100)
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Regarding age, we also found similar results to previ-
ous reports [6, 9, 14–18, 21, 22] (youngest patients in
AKN, AA, DCS and FD, and oldest patients in FFA,
FAPD, discoid lupus and LPP).
The group of cicatricial alopecias represented the 27%
of patients consulting at SHC in our study, a significantly
higher percentage than the 7% published by Whiting in
2001 [22] or the 3% reported by Tan et al. in 2004 [21].
This difference may be explained by the increasing inci-
dence and improved diagnostic of FFA in the recent
years. In fact, FFA was the most frequent cause of cicatri-
cial alopecias in all the analyzed areas in our study, sup-
porting the apparent increasing incidence in the recent
years [9, 10, 23]. This finding would also support the con-
cept that environmental factors with worldwide distribu-
tion might play a role in the pathogenesis of FFA. An-
other interesting finding was the increasing number of
patients diagnosed with FAPD (57 cases, 6.8% of cicatri-
cial alopecias). This entity was described by Zinkernagel
and Trüeb in 2000 [18] and has been rarely reported in
other epidemiological studies [14, 21, 24, 25] being prob-
ably underdiagnosed. In our study, FAPD patients were
predominantly females (89%) with a median age of 59
years, which is in concordance with earlier reports
(Zinkernagel and Trüeb [18]: 19 patients, 79% females,
median age 60 years; Mardones et al. [26]: 12 cases, 70%
females, median age 48 years). In our opinion, FAPD
should be included in future classifications of cicatricial
alopecias.
We analyzed the differences in the frequency of hair
disorders depending on the healthcare setting private
versus public. Interestingly, AA and FFA were the most
frequent cause of consultation in SHC at public centers.
Besides the potentially great impact on quality of life of
these alopecias [27, 28], the symptomatic presentation
(FFA) or the requirement in some patients with AA for
complex therapies such as immunosuppressive drugs,
contact immunotherapy or corticosteroid injections
may explain the frequency of these alopecias at public
centers.
When we compared the frequency of alopecias by con-
tinents, we found results concordant with the literature
(traction alopecia, AKN, CCCA and FD more frequent in
Africa) [7, 14]. Interestingly, we found a higher frequency
of FFA in North America compared with South America,
with an opposite result for FAPD, which was more fre-
quent in South America. Another difference between
continents was the higher frequency of AA in European
patients compared to the rest of continents, a finding not
previously described in the literature to our knowledge.
Our study has some limitations. Firstly, the subgroups
of patients evaluated at SHC located in Australia and Af-
rica were small. Secondly, we did not include patients
evaluated in Asia. It should be noted that the presented
data in our study do not reflect the incidence or preva-
lence of alopecias, either in the general population, or in
the general practitioner setting, but the frequency of hair
disorders in patients seeking expert specialist hair opin-
ion or referred to tertiary centers. Thus, although the pre-
sented frequencies of alopecias should not be considered
as synonymous with “incidence” or “prevalence,” it does
provide valuable information on the current frequency of
hair disorders in patients consulting at specialist hair cen-
ters, which may be useful for clinicians and epidemiolo-
gists.
Conclusions
The most frequent type of alopecia evaluated at SHC
was AGA, followed by AA, TE and FFA. Patients con-
sulting with AKN, DCS and FD were predominantly
males, while patients consulting with traction alopecia,
CCCA, FFA, TE, FAPD and LPP were predominantly
females. FFA was the most frequent cicatricial alopecia
in all the studied geographical areas, followed by LPP
and FD.
A total of 57 different diagnoses of alopecia were per-
formed, showing the complexity of the diagnosis of hair
disorders. It highlights the importance of medical and
dermatologic evaluation in the management of patients
with hair loss.
Acknowledgements
A donation from Novartis (NF 516/2016) to the Dermatology
Department of Ramon y Cajal Hospital was used for financial sup-
port of statistical analysis and data management services.
We want to acknowledge Dr. Hudson Dutra for his help in the
acquisition of data.
Statement of Ethics
The study protocol was reviewed and approved by Ramon y
Cajal Ethical Committee.
Disclosure Statement
The authors declare no conflicts of interest.
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Frequency of the Types of Alopecia
7
Skin Appendage Disord
DOI: 10.1159/000496708
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... It was not found in those less than 30 years. Also, the median age of the participants is comparable to that reported in other 3,9,26 studies. Androgenetic alopecia is said to occur as a result of genetic influence 6 and the effects of androgens on the hair. ...
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... The increased severity of FAGA with age is in keeping with reports from similar 1 studies. Increasing chronological age and androgen levels have been identified as contributors to severe androgenetic 1,3,26 alopecia. The duration of FAGA was more than 10 years in half of the participants and this may have contributed to the increased severity with age. ...
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... Androgenetic alopecia is a common type of hair loss 1,2 in males. The prevalence of androgenetic alopecia in this study was low compared to what is reported in 1,3,11,18 Caucasians and Asians but higher than that reported in other epidemiological studies of hair loss 10,19 in Africans. ...
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Article
Alopecia areata (AA) is a chronic, immune-mediated disease characterized by acute or chronic non-scarring hair loss, with a heterogeneity in clinical manifestations ranging from patchy hair loss to complete scalp and body hair loss. An overview of the up-to-date pathophysiology and the underlying signaling pathways involved in AA together with diagnostic and therapeutic recommendations will be provided. Current treatments, including topical, systemic and injectable interventions show varying response and frequent relapses reflecting the unmet clinical need. Thus, the new emerging concepts and therapeutic approaches, including Janus kinase inhibitors are eagerly awaited. Traditional and emerging therapies of AA will be discussed, in order to provide physicians with guidance for AA management. Since the latter is so challenging and often tends to take a chronic course, it can have an enormous psychosocial burden on patients, compromising their quality of life and often causing depression and anxiety. Therefore, the psychosocial aspects of the disease need to be evaluated and addressed, in order to implement appropriate psychological support when needed.
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Alopecia has a negative association with health-related quality of life (HRQOL).¹,2 To our knowledge, there are no large studies focusing on HRQOL in patients with frontal fibrosing alopecia (FFA). The aim of our study was to describe the association between HRQOL, psychological distress, and perception of disease in a large series of patients with FFA.
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Acne keloidalis nuchae, a type of folliculitis involving the back of the neck, is common in black men, although rare cases have been reported in patients of other ethnicities. We analyzed the clinicopathological features of acne keloidalis nuchae in 17 Asians. Patients’ age at the time of presentation ranged from 20 to 69 years. Most patients experienced the disease over 2 years (range, 3 months–20 years); follow-up data were available for 11 (65%) patients (range, 2–95 months). Nine (53%) patients had comorbidities, but none had a history of other skin disease or a family history of acne keloidalis nuchae. Macroscopically, seven (41%) patients had multiple erythematous pustulopapular lesions, and 10 (59%) had a single large plaque. Histopathologically, deep scarring folliculitis containing naked hair shafts was identified. In all cases, inflammation was most severe in the upper two-thirds of the dermis, and the differences in pustulopapular and plaque lesions were more prominent in the peri-inflammation area. Of the seven patients with plaque lesions treated with steroids alone or steroids and cryotherapy, three experienced plaque reduction. Acne keloidalis nuchae occurring in Asian patients frequently present with typical clinicopathological features, and therefore in spite of very low incidence the diagnosis of this disease entity should be considered in idiopathic scarring folliculitis of the posterior neck.
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Full-text available
BACKGROUND: Androgenetic alopecia (AGA) is a patterned hair loss occurring due to systemic androgen and genetic factors. It is the most common cause of hair loss in both genders. In recent years, many studies investigating the relation between systemic diseases and androgenetic alopecia presented controversial results. OBJECTIVES: In this study we aimed to investigate the frequency of androgenetic alopecia, the presence of accompanying systemic diseases, the relation between body mass index and androgenetic alopecia severity and the association of hyperandrogenemia signs with androgenetic alopecia in patients who referred to our outpatient clinic. METHODS: Patients who referred to our clinic between October 2013 and May 2014 were included in the study. Diagnosis of androgenetic alopecia was made upon clinical findings. Presence of seborrhea and acne in both genders, and hirsutism in women, were examined. Age, gender, smoking habit and alcohol consumption, age of onset of androgenetic alopecia, family history, accompanying systemic diseases and abnormalities of menstrual cycle were recorded. RESULTS: 954 patients (535 women, 419 men) were included in the study. Androgenetic alopecia prevalence found was 67.1% in men and 23.9% in women. Androgenetic alopecia prevalence and severity were correlated with age in both genders (p=0,0001). Frequency of accompanying systemic diseases were not significantly different between patients with and without androgenetic alopecia (p=0,087), except for hypertension, which was significantly more frequent in men with androgenetic alopecia aged between 50 and 59 years. Study limitations: Despite the exclusion of other causes of alopecia, differentiation of Ludwig grade 1 AGA from telogen effluvium based on clinical features alone is difficult. CONCLUSIONS: In our study the rate of androgenetic alopecia was found to be higher than the other studies made in Asian and Caucasian populations.
Article
Background Topical minoxidil and oral finasteride are the only drugs approved for the treatment of androgenetic alopecia (AGA) in Spain. However, the management of this condition is highly variable because numerous treatments are used off-label. The main aim of this study was to describe the prescribing habits of dermatologists in Spain for male AGA (MAGA) and female AGA (FAGA). Material and methods Descriptive cross-sectional study using online questionnaires completed by dermatologists working in Spain. Results The responses of 241 dermatologists were analyzed. The most common treatments prescribed for MAGA were minoxidil (98%), oral finasteride (96%), nutricosmetics (44%), topical finasteride (37%), oral dutasteride (33%), platelet-rich plasma (14%), and low-level laser therapy (8%). For premenopausal FAGA, the most common treatments were topical minoxidil (98%), oral contraceptives (81%), nutricosmetics (72%), cyproterone acetate (58%), oral finasteride (39%), topical finasteride (39%), spironolactone (27%), platelet-rich plasma (20%), oral dutasteride (20%), oral flutamide (18%), and low-level laser therapy (7%). Finally, for postmenopausal FAGA, the most common treatments prescribed were topical minoxidil (98%), oral finasteride (84%), nutricosmetics (68%), topical finasteride (50%), oral dutasteride (35%), platelet-rich plasma (21%), spironolactone (16%), cyproterone acetate (16%), oral flutamide (9%), and low-level laser therapy (9%). A limitation of our study is that we did not analyze novel AGA treatments such as oral minoxidil and dutasteride mesotherapy. Conclusions The most common treatments prescribed for AGA by dermatologists in Spain are topical minoxidil, oral finasteride, and nutricosmetics for MAGA and postmenopausal FAGA and topical minoxidil, oral contraceptives, and nutricosmetics for premenopausal FAGA.
Article
Background: Topical minoxidil and oral finasteride are the only drugs approved for the treatment of androgenetic alopecia (AGA) in Spain. However, the management of this condition is highly variable because numerous treatments are used off-label. The main aim of this study was to describe the prescribing habits of dermatologists in Spain for male AGA (MAGA) and female AGA (FAGA). Material and methods: Descriptive cross-sectional study using online questionnaires completed by dermatologists working in Spain. Results: The responses of 241 dermatologists were analyzed. The most common treatments prescribed for MAGA were minoxidil (98%), oral finasteride (96%), nutricosmetics (44%), topical finasteride (37%), oral dutasteride (33%), platelet-rich plasma (14%), and low-level laser therapy (8%). For premenopausal FAGA, the most common treatments were topical minoxidil (98%), oral contraceptives (81%), nutricosmetics (72%), cyproterone acetate (58%), oral finasteride (39%), topical finasteride (39%), spironolactone (27%), platelet-rich plasma (20%), oral dutasteride (20%), oral flutamide (18%), and low-level laser therapy (7%). Finally, for postmenopausal FAGA, the most common treatments prescribed were topical minoxidil (98%), oral finasteride (84%), nutricosmetics (68%), topical finasteride (50%), oral dutasteride (35%), platelet-rich plasma (21%), spironolactone (16%), cyproterone acetate (16%), oral flutamide (9%), and low-level laser therapy (9%). A limitation of our study is that we did not analyze novel AGA treatments such as oral minoxidil and dutasteride mesotherapy. Conclusions: The most common treatments prescribed for AGA by dermatologists in Spain are topical minoxidil, oral finasteride, and nutricosmetics for MAGA and postmenopausal FAGA and topical minoxidil, oral contraceptives, and nutricosmetics for premenopausal FAGA.
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Alopecia areata (AA) is a common, inflammatory, nonscarring type of hair loss. Significant variations in the clinical presentation of AA have been observed, ranging from small, well-circumscribed patches of hair loss to a complete absence of body and scalp hair. Patients affected by AA encompass all age groups, sexes, and ethnicities, and may experience frustration with the unpredictable nature of their disease for which there is currently no definitive treatment. The cause of AA remains incompletely understood, though it is believed to result-at least in part-from a loss of immune privilege in the hair follicle, autoimmune-mediated hair follicle destruction, and the upregulation of inflammatory pathways. Patients with AA frequently experience marked impairment in psychological well-being, self-esteem, and may be more likely to suffer from psychiatric comorbidities. Part one of this two-part continuing medical education series describes the epidemiology, clinical evaluation, prognosis, and recent advancements in the understanding of the pathogenesis of AA.
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Frequent coexistence of frontal fibrosing alopecia (FFA) and androgenetic alopecia (AGA) has been reported in the literature, but little attention has been given to the pathogenetic mechanisms underlying this potential association. FFA is characterized by progressive cicatricial fronto-temporal hairline recession, mostly affecting peri-menopausal women. Immune mechanisms seem to play a pivotal pathogenetic role. This article is protected by copyright. All rights reserved.
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Frontal fibrosing alopecia, described just over 20 years ago, has become one of the most frequently seen causes of scarring alopecia at many specialist hair clinics. Considered a clinical variant of lichen planopilaris (LPP), it has distinctive features and associations which distinguish it from LPP. Although largely affecting postmenopausal women, a small but increasing number of men and premenopausal women are affected. The spectrum of the disease has expanded from involvement of the frontal hairline and eyebrows, to potentially affecting the entire hairline, facial and body hair. Genetic and environmental factors have been implicated but the aetiology remains uncertain. A range of treatments have been used in management of the condition, but clinical trials are required to establish effectiveness.