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Folliculitis Decalvans

This is a form of scarring alopecia in which pustular folliculitis of the advancing margin of the patch is a conspicuous feature. The patches occur slowly and destruction of hair follicles cause permanent hair loss.

The cause of folliculitis decalvans is still uncertain, however, a failure in the immune responses or leurocyte (white blood cell) function is a common abnormality in people with this condition. Staphylococcus aureus bacteria may be the source of the pustules but more often, only ordinary non-pathogenic (disease causing bacteria) are present.

This condition occurs in both sexes, women aged 30-60 years and men from adolescense onwards, and is very rare at infancy. Folliculitis decalvans is most common in the scalp but may affect other hair-bearing areas of the body.

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Seborrhoeic Dermatitus/Eczema

Seborrhoeic Dermatitus is an inflammation condition that is seen as areas of redness covered by large, yellow, greasy scales, which may be diffusely spread over the scalp. It may extend beyond the margins of the hair onto the forehead, behind the ears and onto the posterion neck. Scarring and redness may be seen in the beard, ears, naso labial fold (both sides of nose), chest and groin.

Seborrhoeic dermatitus is associated with oilness, which is caused when sebum is acted upon by the yeast, pitrosporum ovale, which is fond in the skin. This results in iching, scaling and redness. Scaling or a dry scalp described by most people can in fact be caused by oilness.

The cause of this condition is unknown but genetic factor is certainly implicated. Androgen production plays a part, which occurs in infants with cradle cap who are under the influence of maternal androgens, and re-appears later in puberty when sebaceous activity has been re-established.

The severity of the condition varies from one individual to another. Lifestyle factors such as stress and dietary factors may also cause the condition to flare up.

Treatment of seborrhoeic dermatitis is directed towards reducing both the scale and inflammation. Frequent (daily) shampooing is essential and the amount of time that the medicated shampoo stays on the scalp is less important than the frequency it is used.

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Folliculitis

Folliculitis is an inflammation of the hair follicles, commonly of a bacterial origin.

It is characterised by pustules found in the nape (folliculitis nuchae) which can gradually progress throughout the scalp. It is a progressive condition starting with one pustule and turning into many as adjacent follicles are infected. These pustules can become nodular (tiny scars) and then can form into hard, elevated scars, called keloids. Left untreated this condition can progress into a condition called cellulites/cicatrising cellulite.

This condition is commonly found on the scalp, but can affect other hair growing areas. Such as pubes (pubic hair), and the axillae (armpits). The face may also be affected often, limited to the area in front of the ears.

Folliculitis is common among young black men, but it can occur on the other races and any age group. Black women can also be affected due to the secondry sensitising of the scalp as a result of heavy usage of hairdressing creams, i.e. lanolin, mineral oil and petroleum based products. Folliculitis can also be due to chemical abrasion, causing itching and bacterial infection.

In men folliculitis is commonly due to razor or infected hair clippers especially when hair is shaved very close to the skin. Use of hairdressing creams can further aggravate the infection.

Treatments used are anti-bacterial creams, lotions and shampoos. These products must be used regulary until the infection clears up. Close shaving must be avoided during the treatment period.

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Lichen Planopilaris

Lichen planopilaris is the specific name given to lichen planus in hair bearing region of skin (usually the scalp) that may cause permanent, scarring alopecia. In fact, up to 40% of scarring alopecia cases that an expert will see are due to lichen planopilaris. Lichen planopilaris is seen in individuals as young as 13 years old.

The hair loss caused by lichen planopilaris presents itself as distinct patches of hair loss that may expand and coalesce over time. The condition develops so slowly that even after several years of the disease the patches of alopecia may be small and inconspicuous.

Lichen planopilaris is a poorly understood form of hair loss and there is much confusion in distinguishing it from systemic lupus erythematosus, frontal fibrosing alopecia, and another disease called mixed inflammatory destructive alopecia. Some experts claim that lichen planopilaris is the same as pseudopelade, however, the majority of experts believe there are subtle distinctions between the two diseases.

Skin biopsies are often employed when diagnosing lichen planopilaris. Within the skin there may be an abnormal infiltration of primary lymphocyte immune cells and deposition of immunoglobulins. Some experts may use direct immunofluorescence staining techniques to look for antibody deposits in the affected tissue. Other experts have found that staining biopsy tissues with dyes specific for elastic fibres significantly help to diagnose lichen planopilaris from other scarring alopecias. Simple biopsy staining procedures can also help in indentifying lichen planopilaris. Sometimes there is inflammation around the affected hair follicles, especially in the early stages of disease development, however, inflammation is not always present. Despite the presence of an immune response, not all experts regard lichen planopilaris as an immune medicated disease.

The most popular treatment methods involve use of corticosteriods. However, the effectiveness of these treatments varies considerably from person to person.

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Lichen Planus

The exact cause of lichen planus is not known, but it may have a significant autoimmune component as it is most frequently observed in individuals who have other organ specific autoimmune diseases. it is qiute a common condition comprising of up to 1% of cases in dermatology clinics. It may occur at any age but most cases of lichen planus develop in people betwen 30 and 70 years old.

There are several different types of lichen planus but the most common type is papular lichen planus. This type usually presents as papulas on the skin that have a shiny, smooth flat surface. Over time the papules can expand and coalesce to form plaques which can be pink, violet or brown in color. The hair inside these plaques can be lost.

There are other less common forms of lichen planus:

Aactinic Lichen Planus that is only found in warm countries and only affects sun exposed areas.

Lichen Planus Spinulosis presents itself in various ways sometimes with hair loss, and occupational lichen planus develops in people exposed to chemicals such as those used in color film development. It is suggested that exposure to gold, mepacine, aminophenazole, beta-blockers, methyldopa, penicillamine, quinidine, and quinine may play a role in promoting the lichen planus condition for some people who are genetically susceptible to the condition.

Lichen planopilaris also called lichen planus folicularis is a desciptive term given to any instance of lichen planus where hair loss is associated with lichen planus papule development.

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Persistant Dandruff (Pityriasis)

Dandruff is a widespread problem that affects most of us at some time in our lives.

For some it is an embarrassing but temporary inconvenience, but for many it is a persistant problem. Dandruff is characterised by the formation of fine, white or greyish loose scales and there are variations in the severity and form of this condition.

With some types of dandruff the flakes leave the scalp surface easily, falling onto the clothes and shoulders. In other cases the scale is more adherent to the scalp, and rather than the flakes leaving the skin's surface, they build up to form a thick covering over the scalp.

Irritation of the scalp is a common accompaniment to dandruff, and often leads to an increase in the quantity of flakes falling onto clothing, as the scalp is scratched in a attempt to relieve the irritation.

Dandruff is caused by skin cells that divide too quickly. The epidermis, or outer, protective layer of skin, is constantly changing. The cells begin to grow from the base layer deeper in the skin and gradually move to the surface, this is called the epidermal turnover. Normally it takes approximately 28 days for the cells to move through the skin and to reach the surface. These dead cells are washed away when we shampoo our hair.

In cases of dandruff, the epidermal turnover is much faster than normal, with the cells taking perhaps only 12 to 15 days to accomplish their journey rather than the usual 28 or so. This proliferation of skin cells results in the formation of scale on the surface of the scalp. When this occurs there is an increase in the level of bacteria on the scalp because with the abundance of scale, comes an improvement in their enviroment. The increase in the level of bacteria can then cause even more scale to form, resulting in the creation of a vicious circle.

Washing the hair and scalp with one of the many anti-dandruff shampoos that you can buy over the counter, sometimes helps in the removal of scale, but often this is superficial and short-term answer to the solution because most of these products treat the sympton and not the cause. Also, some of these products are so harsh and abrasive, that they can actually exacerbate the problem in the long term. It is the much more complex 'underlying' problem that must first be dealt with.

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Psoriasis

A common skin disease characterised by thickened patches of inflamed red skin, often covered by silvery scales. Although psoriasis does not usually cause itching, the affected area may be so extensive that a great physical discomfort and social embarrassment may result.

Psoriasis frequently affects the scalp. In severe cases there may be a solid cap extended beyond the hair margin. There may be patchy diffused scaling, or alternatively thick asbestos like scales. Some increased shedding of telogen hairs is common in psoriasis plaques.

The exact cause of psoriasis is not known but it tends to run in famillies. Psoriasis occurs in about 2% of white people and is less common in black and asian people. It affects men and women equally. Psoriasis usually occurs between the ages of 10 and 30 and can be recurrent throughout life, but infants occasionally suffer from the condition and it may also sometimes develop in old age. Outbreaks may be triggered by emotional stress, skin damage and physical illness.

The underlying abnormality in psoriasis is that new skin cells are produced ten times faster than normal. As a result, live cells accumulate and form characteristic thickened patches covered with dead, flaking cells.

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Scalp Ringworm

Tinea Capitis is a clinical diagnosis more commonly known as scalp ringworm. One of the most common scalp infections that dematologists encounter. Tinea capitis has been known about for several centuries but it has taken a long time for fungi to be recognized as the cause. Only for the last ninety years or so has an infectious agent been widely accepted as the cause of tinea capitis. With the development of microscopes came the realization that foreign bodies could be indentified in the skin and hair of people with tinea capitis. Eventually these foreign bodies were identified as fungal colonies

Mechanism of scalp ringworm development

Fungal infectious agents are opportunists. The fungi like to enter the scalp skin through a cut or scrape. Once they get underneath the outer skin barrier they multiply and spread out in a circle much like ripples from a stone thrown in a pond. Fungi particularly like to locate themselves in and around growing hair follicles. The fungi get right into the hair fibre itself. This weakens the hair fibre and infected fibers can be very brittle and liable to break off. The condition can take many forms depending on the agent involved, the individual's immune response, and the type of hair they have. Some forms of tinea capitis may involve significant inflammation and possibly even scarring on the skin. Some infections may expand very rapidly to affect the scalp wherea others may progress very slowly and the individual may experience scaly skin and mild hair loss for several months or years before seeking the diagnosis from a dermatologist.

Typically, an infection spreads to cover a patch up to four centimeters in diameter but for some people the infection can be much larger. The patch may resolve in about 7 months from first infection but again some people can have tinea capitis for much longer. In general tinea capitis involves flaking, scaling skin that may involve inflammation. The condition can look a lot like dandruff or seborrheic dermatitis. Along with the skin changes there can be some loss of hair. The infected hair is brittle and easy to break off. Affected individuals may have small patches of hair loss on their scalp and broken hairs may be observed. There are more severe presentations including the development of a kerion. This looks like a crusty mass of dead hair. Still others have intense inflammation associated with the fungal infection.

Scalp ringworm detection

In the past, other disorders that involved patchy hair loss were often confused with tinea capitis. Even today, some dermatologists may confuse tinea capitis with alopecia areata. However, there are now techniques to test for the presence of fungi in scalp disease. The simplest method is to use a Wood's lamp. This is a small lamp that emits ultraviolet light of a limited wavelength. When the light is shone on infected hair and skin, the fungi absorb the light and remit it as a fluorescent green light. It can be quite diffiult to find the fungi using this lamp so it can take a careful examination to find the fungi. There are some cases where the fungi involved does not show up as fluorescent under the Wood's lamp. Dermatologists will usually make a culture from hair to skin scrapings when they suspect tinea capitis infection whether or not the Wood's lamp test was positive or not.

Tinea capitis spreads quite easily. It may be spread from person to person through physical contact. However, the fungi in hair that breaks off or falls out can also spread infections. Hairs on brushes, hats, or chairs may spread tinea capitis. Ther can be cycles of expression with epidemics occuring from time to time. Epidemics in schools are quite common where up to 50% of those children exposed can catch tinea capitis.

Scalp ringworm treatment

Treatment varies depending on what the infection looks like and what particular fungus is causing. Some types of infections will resolve spontaneously and so no treatment may be given. Most commonly though an antibiotic called Griseofulvin is used. Griseofulvin is very effective against fungi in hair and skin but is not very effective at treating yeast or bactrial infections. The Griseofulvin gradually accumulates in the skin and hair, it especially likes to bind with keratin which is a common componant of hair and nails. Most people tolerate Griseofulvin very well. Side effects can include upset stomach, headaches, and fatigue.

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Scleroderma

Scleroderma is an autoimmune disease. In the early stages of scleroderma in the skin, inflammatory cells can be seen in the dermis. However, this inflammation gradually diminishes over time as the skin beciomes increasingly abnormal. Scleroderma involves a gradual hardening and tightening of the skin due to excessive collagen production. The excessive collagen stops the normal functioning of hair follicles in a way that might be described as 'suffocation' or 'strangulation'. Although there is a lot of collagen in the skin and there is a trophy of affected hair follicles, there is very little actual scar tissue formation.

Excess collagen production occurs in patches and consequently hair loss also develops in distinct areas. The first symptoms of localized skin scleroderma in hair bearing areas may involve a premature graying of the hair shortly followed by hair loss. Hair loss may be progressive with patches gradually expanding in size over years. When hair loss occurs on the scalp in a linear fashion it is given the description 'en coup de sabre'. It was apparantly given this name because the strip of hair loss resembles the scar of a sabre cut. Treatment of en coup de sabre involves surgery to remove the affected area of skin.

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