Miscellaneous disorders affecting the hair

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TRICHORRHEXIS NODOSA. This is probably the most common hair-shaft abnormality and is usually caused by traumatic hairdressing procedures. Clinically, one sees circumferential tiny white specks on the hair shaft. When viewed under the microscope these areas prove to be transverse fractures resembling the bristles of two brooms interlocked in appearance. These fracture points often lead to breaking off of the hairs and the complaint that the hair does not grow as long as it used to. There may be inherited causes of trichorrhexis nodosa, but these are much more rare. An association with hypothyroidism is of interest. Clinically, these fracture points on the hair shaft may be confused with nits of head lice or hair casts.

UNCOMBABLE HAIR SYNDROME ("SPUN GLASS HAIR"), This interesting hair-shaft abnormality is characterized by hair shafts that are triangular on cross-section. On electron microscopy, longitudinal grooves are seen. Clinically, onset is usually around 3 years of age, when the hair seems totally wild and unable to be combed or brushed. The hair is usually a silvery blond color. Although usually generalized, it can be localized. Eyebrows and eyelashes are normal. Spontaneous improvement may occur during childhood. Oral biotin may prove helpful. Some cases may be inherited.

The same triangular hair-shaft abnormality has been described in loose anagen syndrome and after spironolactone therapy.

ACQUIRED PROGRESSIVE KINKING OF THE HAIR. This odd and rare entity arises during the teens or early adult years in young men. Gradually and progressively in a Caucasian person the hair becomes kinky, dry, and more unmanageable. It is unassociated with internal disease. Unlike uncombable hair syndrome, the hair shaft in this disorder is not triangular but is elliptical with partial twists at irregular intervals. The duration of anagen (growth phase) is said to be reduced. Oral retinoids or local radiation may induce a clinically similar problem.

Interestingly, a seemingly converse clinical picture has been described in African-American patients with the acquired immunodeficiency syndrome, who develop softer, silkier hair that replaces the previously kinky hair. In addition, the color is said to become ashen and the hair is sparse.

TRICHOPTILOSIS ("SPLIT ENDS"). Longitudinal splitting of the distal hair shaft is usually a result of weathering and is seen with overuse of cosmetic hairstyling. Hair pulling and scratching may be causative. Hair-shaft defects that cause increased hair fragility are more likely to promote "split ends."

BUBBLE HAIR. Excessive heat from hair dryers and perhaps other chemical treatment of the hair may cause distinctive "bubbles" in the hair shaft. Clinically, these hairs may appear brittle and broken off.

PSEUDOFOLLICULITIS BARBAE. This problem is usually seen in the beard area of African American men. Close shaving in people with kinky or curly hair may cause the newly emerging hair shaft to grow back into the skin surface or pierce the follicular wall causing inflammation and a foreign body reaction. Clinically, it presents as papulopustules, which may lead to hyperpigmentation and scarring. Hair plucking and electrolysis can induce this same problem.

The best treatment is to avoid shaving; if that is not possible, avoid close shaving and clip the beard. Rubbing the area to be shaved with a course washcloth or sponge may be helpful prior to shaving. Topical retinoic acid may be of some benefit.

TRICHOSTASIS SPINULOSA. This is a common condition in adults that clinically resembles comedones ("blackheads") and occurs on the face or upper body. Retention of multiple vellus hairs (up to 50) is the cause of this problem. It may be treated with topical tretinoin (Retin-A) or waxing.

GREEN HAIR. The deposition of copper on the hair, from tap water used to wash the hair (or from swimming pool water), may cause a greenish hue in blond hair. Pretreating the hair with some types of conditioners may help prevent the discoloration. Shampooing with a penicillamine-containing mixture may reduce the green color.

*Assistant Professor, Department of Medicine, Division of Dermatology, University of Kansas Medical Center, Kansas City, Kansas BIBLIOGRAPHY

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Dawber R. Hair and scalp disorders: Common presenting signs, differential diagnosis and treatment. Philadelphia, Lippincott-Raven, 1995. Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for androgenetic alopecia. J Am Acad Dermatol 1996;35:465. Elston DM, et al. Bubble hair. J Cutan Pathol 1992;19:439.

Headington JT. Telogen effluvium: New concepts and review. Arch Dermatol 1993;129:356.

Kossard S, Lee MS, Wilkinson B. Postmenopausal frontal fibrosing alopecia: a frontal variant of lichen planopilaris. J Am Acad Dermatol 1997;36:59.

Leonidas JR. Hair alteration in black patients with the acquired immunodeficiency syndrome. Cutis 1987;39:537.

Leung AKC, Robson WLM. Hirsutism. Int J Dermatol 1993;-32:773.

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Sharma VK. Pulsed administration of corticosteroids in the treatment of alopecia areata. Int J Dermatol 1996:35.

Sommer S, Render C, Burd R, Sheehan-Dare R. Ruby laser treatment for hirsutism: Clinical response and patient tolerance. Br J Dermatol 1998;138:1009. Sperling LC, Sau P. The follicular degeneration syndrome in black patients: hot comb alopecia revisited and revised. Arch Dermatol 1992;128:68. Whiting D. Update on hair disorders. Dermatol Clin 1996;14. Whiting DA. Male pattern hair loss: Current understanding. Int Dermatol 1998:37.

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