Chapter 054. Skin Manifestations of Internal Disease (Part 4) a Most patients with trichotillomania, pressure-induced alopecia. The most common causes of nonscarring alopecia include telogen effluvium, androgenetic alopecia, alopecia areata, tinea capitis, and some cases of traumatic alopecia (Table 54-5). In women with androgenetic alopecia, an elevation in circulating levels of androgens may be seen as a result of ovarian or adrenal gland dysfunction. When there are signs of virilization, such as a deepened voice and enlarged clitoris, the possibility of an ovarian or adrenal gland tumor should be considered. Table 54-5 Nonscarring Alopecia (Primary Cutaneous Disorders) Clinical Characteristics Pathogenes is Treatment Telogen effluvium Diffuse shedding of normal hairs Follows either major stress (high fever, severe infection) or change in hormones (post partum) Reversible without treatment Stress causes the normally asynchronous growth cycles of individual hairs to become synchronous; therefore, large numb ers of growing (anagen) hairs simultaneously enter the dying (telogen) phase Observation; discontinue any drugs that have alopecia as a side effect; must exclude underlying metabolic causes, e.g., hypothyroidism, hyperthyroidism Androgeneti c alopecia (mal e Miniaturizatio n of hairs along the Increased sensitivity of If no evidence of hyperandrogen pattern; female pattern) midline of the scalp Recession of the anterior scalp line in men and some women affected hairs to the effects of testosterone Increased levels of circulating androgens ( ovarian or adrenal source in women) state, then topical minoxidil; finasteride a ; hair transplant Alopecia areata Well- circumscribed, circular areas of hair loss, 2– 5 cm in diameter In extensive cases, coalescence of lesio ns and/or involvement of other hair- bearing surfaces The germinative zones of the hair follicles are surrounded by T lymphocytes Occasional associated diseases: hyperthyroidism, hypothyroidism, Topical anthralin; intralesional glucocorticoids; topical contact sensitizers of the body Pitting of the nails vitiligo, Down syndrome Tinea Varies from scaling with minimal hair loss to discrete patches with "black dots" (broken hairs) to boggy plaque with pustules (kerion) Invasion of hairs by dermatophytes, most commonly Trichophyton tonsurans Oral griseofulvin or terbinafine plus 2.5% selenium sulfide or ketoconazole shampoo; examine family members Traumatic alopecia b Broken hairs Irregular outline Traction with curlers, rubber bands, braiding Exposure to hea t or chemicals (e.g., hair straighteners) Discontinuatio n of offending hair style or chemical treatments; trichotillomania may require hair clipping and observation of shaved hairs or biopsy for diagnosis, Mechanical pulling (trichotillomania) possibly fol lowed by psychotherapy . Chapter 054. Skin Manifestations of Internal Disease (Part 4) a Most patients with trichotillomania, pressure-induced alopecia. The most common causes of nonscarring alopecia. (mal e Miniaturizatio n of hairs along the Increased sensitivity of If no evidence of hyperandrogen pattern; female pattern) midline of the scalp Recession of the anterior scalp line. circular areas of hair loss, 2– 5 cm in diameter In extensive cases, coalescence of lesio ns and/or involvement of other hair- bearing surfaces The germinative zones of the hair follicles