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Scalp problems and alopecia: treatment in primary care

Thomas F Poyner
FRCP MRCGP DPD
GP and Hospital Practitioner
Queens Park Medical Centre
Stockton-on-Tees
E:thomas.poyner@nhs.net

Hair is constantly undergoing various cycles: most follicles are in the growing phase (anagen), while some are in either a resting phase (catogen) or a shedding phase (telogen). Patients usually complain of either an itchy scalp or hair loss. In extreme conditions patients can experience chemotherapy-induced alopecia (CIA), caused by the drugs used in chemotherapy, which affect the hairs undergoing anagen; or hair loss can occur after pregnancy due to a moult (telogen effluvium).

Scalp treatments
When treating scalp conditions, the formulation of treatment applied is important. Shampoos are easy to use but have only a short contact time. Scalp applications and lotions are cosmetically acceptable, but any alcoholic preparation can sting if the scalp is excoriated. Ointments give a long contact time but can be messy to apply and difficult to wash out.

Scalp problems

Dandruff
Scaly scalp is a frequent problem (see Figure 1). Dandruff is common and is the mildest form of seborr-hoeic eczema. The classical presentation is of an itchy scalp and a facial rash. The scale in the scalp is yellowish in colour and greasy in appearance. There is some scalp erythema. The facial rash involves the nasolabial folds, eyebrows and ears. It is itchy, red and scaly. There can be a petaloid-shaped rash on the chest over the sternum and also in the flexures.

[[NIP14_fig1_31]]

Seborrhoeic eczema
Seborrhoeic eczema is associated with increased colonisation with the pityrosporum yeast, and therapy directed against this yeast results in an improvement in the rash. Ketoconazole shampoo can be used twice weekly on the scalp and ketoconazole cream on the face. Alternatives for the scalp are tar-based shampoos or topical steroids.

Psoriasis
Psoriasis presents in the scalp with silvery scaly plaques. The rash often involves the hairline and has a well-defined edge. Hair loss is uncommon. The diagnosis can be aided by looking for plaques of psoriasis at other sites, such as the elbows, knees and lower back.
Scalp psoriasis can be treated with tar, topical vitamin D analogues and topical steroids. A tar, salicylic acid and coconut shampoo provides a simple treatment for mild cases. In moderate disease add in either a topical steroid scalp application or steroid mousse in the morning. Side-effects from topical steroids are uncommon on the scalp. An alternative would be a vitamin D analogue scalp application, such as calcipotriol. In severe cases it is worth tolerating the time and mess of applying an ointment to the scalp. Cocois ointment contains tar, salicylic acid and coconut. The ointment is carefully applied to a selected area of the scalp, left on for one hour and then washed out. The frequency of application can be reduced as the rash improves.

Ringworm
Tinea capitis (ringworm of the scalp) usually presents in children with areas of scale and hair loss (see Figure 1). There are two main ways the infection is transmitted: either from animals or from other humans. Microsporum canis is the usual animal species, and the rash in the scalp will fluoresce if exposed to a Wood's light. The species Trichophyton tonsurans is transmitted from other humans and does not fluoresce under Wood's light. The number of people infected with Trichophyton tonsurans is increasing, and the infection is most common in those of Afro-Caribbean extraction.
Many small, mobile, battery-powered Wood's lights are available, and they emit a bluish-purple light. These lamps can be used in the surgery or classroom to screen for cases of animal ringworm. Diagnosis is confirmed by taking samples of the hair and scale for mycology. Various techniques have been employed, taking scrapings using a scalpel or a nonsterile toothbrush. Hairs can also be sent to the laboratory. The advantage of sending samples on black paper is that they can be easily seen.
Treatment of tinea capitis in children is with a 4-6-week course of oral griseofulvin. Although some physicians use oral terbinafine, this drug does not have a product licence in the UK for treating children. Regular shampooing with ketoconazole can help reduce the spread of infection from child to child.

Head lice
Head lice are common. Physical treatment such as the regular use of nit combs should be encouraged as it reduces the number of live head lice. Physical means of controlling head lice include the use of shampoo, conditioner and combing to damage and kill the live lice. Many patients request prescriptions for chemical treatments. When deciding on which preparation to prescribe, one needs to be guided by current local patterns of drug resistance. Treatments include the pediculicides malathion, carbaryl and permethrin.

Alopecia
The hair loss may be either local or diffuse, and it is important to enquire whether it actually involves increased shedding of hair or whether there are specific areas of hair loss. While one should always strive to make a diagnosis, many conditions respond poorly to therapy, while others resolve spontaneously. It is always worth looking for treatable causes, such as iron deficiency or myxoedema, and routine investigations include a full blood count, serum ferritin and thyroid function tests.
Male pattern hair loss (androgenetic alopecia) results from a genetic predisposition followed by exposure to physiological androgens. There is recession of the hairline and loss in the vertex area of the scalp. Female pattern hair loss is less well understood. Whether hormone replacement therapy is beneficial is not proven. There is diffuse loss with preservation of the hairline.  Female patients are frequently scared of going bald; however, they can be reassured that it is very unlikely.
Topical minoxidil is used in both female- and male-type baldness. Females can use 2% minoxidil twice daily, while males can apply both the 2% and 5% solutions twice daily. It is available only on private prescription. Low-dose oral finasteride (1mg daily) is used only in the male patient, and it too is available only on private prescription. It is an inhibitor of the enzyme type II 5-alpha reductase. It can reduce further hair loss and sometimes actually improves hair density. Therapy is slow to work and has to be continued. A small number of patients on finasteride complain of erectile dysfunction and loss of libido, which is reversible on cessation of therapy.
Alopecia areata presents as localised areas of hair loss on the scalp (see Figure 1). The appearance of the scalp in the areas of hair loss is normal, without any scale or erythema. The classical exclamation mark hairs are found, which taper as they approach the scalp. There can also be loss of hair from eyebrows and, in males, the beard area. It is worth looking at the nails for any associated pits. There may be a family history of alopecia areata and autoimmune diseases (eg, pernicious anaemia or thyroid disease). Many cases of alopecia areata resolve spontaneously. No therapy alters the natural history of the disease, so the risks as well as the benefits of any active treatment have to be carefully considered. Intralesional injection of steroids (triamcinolone) is quite popular, but scalp atrophy can result. Other treatments include immunotherapy and topical diphencyprone applied weekly after initial sensitisation.
Traction on hair can result in alopecia. This condition usually occurs in females, and there may be an overt mechanical problem (plaits or bands) or an underlying psychological problem. The usual areas affected are the frontal and temporal areas. On examination there is hair loss and some damaged hairs.
Scarring alopecia (cicatricial alopecia) is less common but frequently more difficult to treat. The patient usually presents with localised areas of scarring and hair loss within the scalp; there may also be some erythema. Many causes of scarring alopecia exist, including lichen planus and discoid lupus erythematosus. Frequently, a scalp biopsy is required to make or confirm the diagnosis. A common theme is that all causes are difficult to treat. Once hair loss occurs due to scarring it cannot be reversed. When it has proved impossible to reverse or improve baldness then a wig is worth considering, but that can be followed up only in secondary care.

Conclusion
If you believe that we should start at both the physical and anatomical top of a patient list and work down, then treating scalp problems should be high on the healthcare agenda. For the majority of patients, making an accurate diagnosis should not be too difficult. Then there are a wide range of cosmetically acceptable therapies that can be prescribed, which should improve the quality of many patients' daily lives.

Resources
New Zealand Dermatology Society
W:www.dermnetnz.org
Primary Care Dermatology Society
W:www.pcds.org.uk
British Dermatology Nursing Group
W:www.bdng.org.uk/utilities/about/index.asp

Further reading
Poyner TF. Common skin diseases.
Oxford: Blackwell Science; 2000