Forehead, Skull Reconstruction - Hair Restoration Flashcards
A 19-year-old man who sustained burns to 40% of the total body surface area at 4 years of age comes to the burn clinic for consultation regarding correction of the scalp defect shown. Physical examination shows patchy alopecia of the temporal scalp and hypertrophic scarring. Which of the following is the most appropriate surgical procedure for reconstruction of this patient’s scalp?
A) Hair transplantation with micrografts and minigrafts
B) Orticochea flap
C) Serial excision and closure
D) Temporoparietooccipital (Juri) flap
E) Tissue expansion
Correct answer is E.
The patient shown has a large (>25 cm2) parietal scalp defect that resulted from a flame burn. It is clear that hair transplantation has already been attempted with minimal take and coverage. Hair transplantation with micrografts and minigrafts is a technique that has been described to treat large areas of burn alopecia. However, it is usually reserved for smaller areas, or as a revisional procedure to camouflage incisions that result from rotational flaps.
Tissue expansion is the preferred method for secondary reconstruction of a large parietal scalp defect. Approximately 50% of scalp can be reconstructed with expanded scalp tissue, although this may require multiple stages. Expander complication rates may be as high as 25% and may include infection, exposure, extrusion, and device failure. Scalp expansion in children is difficult. There is a higher incidence of infection and decreased tolerance of pain. Moreover, there is a risk of skull deformation after a prolonged period of expansion. Therefore, deferral until the patient reaches young adulthood is reasonable.
Which of the following is most closely associated with male pattern alopecia?
A) Absence of a genetic predisposition
B) Decreased activity of 5alpha-reductase within genetically susceptible hair follicles
C) Increased serum level of testosterone
D) Prolonged anagen phase
E) Prolonged telogen phase
Correct answer is E.
Male pattern alopecia is associated with a prolonged telogen, or quiescent, phase of the hair growth cycle. During this phase, the follicle becomes inactive, and active hair growth ceases.
Inheritance is the only known cause of male pattern alopecia. Although hereditary alopecia is controlled by a single, dominant, X-linked autosomal gene, polygenetic modifying factors, such as androgen production and age, affect its expressivity.
Male pattern alopecia can only be triggered by a normal adult male serum androgen level if there is genetic predisposition.
Alopecia results from increased 5alpha-reductase activity within genetically susceptible follicles.
It has not been shown to be associated with increased plasma levels of testosterone.
The anagen phase of the hair cycle, during which hair actively grows, is typically shortened in patients with alopecia.
A 27-year-old man has traumatic absence of the lateral third of the right eyebrow one year after sustaining avulsion and laceration injuries to the forehead and cheek. On current physical examination, there is an avulsion scar in the supraorbital region and a laceration extending from the lateral canthus directly posterior to the temporal scalp, both of which are well healed. The patient would like to undergo reconstruction of the avulsed eyebrow.
Which of the following is the most appropriate reconstructive option?
(A) Composite scalp graft containing hair follicles
(B) Median forehead flap containing hair-bearing tissue from the anterior scalp
(C) Temporal scalp flap based on the ipsilateral superficial temporal artery
(D) Washio flap
(E) Microplug hair transplantation
The correct response is Option A.
In this patient who has absence of the lateral third of the eyebrow resulting from trauma, composite grafting from the scalp is the most appropriate reconstructive option. This technique would be associated with the greatest chance for hair growth in this patient; in addition, the donor scar would be inconspicuous.
Reconstruction with a median forehead flap is a procedure that requires multiple stages and would result in an unsightly donor site scar. Both the temporal scalp flap and Washio flap would be based on the posterior temporal branch of the superficial temporal artery; however, this artery was most likely transected when the patient sustained the facial laceration, eliminating the possibility of using these flaps. Microplug hair transplantation is unreliable over scar tissue, especially traumatized soft tissue and radiated scars.
The mechanism of action of finasteride (Propecia) involves inhibition of which of the following enzymes?
(A) 2beta-hydroxylase
(B) 5alpha-reductase
(C) 6beta-hydroxylase
(D) 7alpha-hydroxylase
The correct response is Option B.
Finasteride is a competitive and specific inhibitor of type II 5alpha-reductase that converts testosterone into dihydroxytestosterone (DHT). Type I 5alpha-reductase is predominant in the sebaceous glands of the skin, scalp, and liver; type II 5alpha-reductase is also found within the liver, as well as in the prostate, seminal vesicles, epididymides, and hair follicles. The conversion of approximately one-third of circulating DHT is mediated by type I, and type II is responsible for the conversion of the remaining circulating DHT.
In men with androgenetic alopecia, hair follicles within the balding areas of scalp are miniaturized, and DHT levels are increased. The mechanism of action of finasteride involves preferential inhibition of the type II isozyme. Administration of finasteride rapidly decreases the concentrations of DHT within the scalp and serum, reaching a suppression percentage within the serum of 65% during the first 24 hours after oral administration of 1 mg.
The relative contributions of these decreases to the overall treatment effect of finasteride have not been defined. Finasteride appears to interrupt a key factor in the development of androgenetic alopecia in patients who are genetically predisposed to this condition.
2beta-hydroxylase converts testosterone to 2beta-hydroxytestosterone, 6beta-hydroxylase converts testosterone to 6beta-hydroxytestosterone, and 7alpha-hydroxylase converts testosterone to 7alpha-hydroxytestosterone.
A 70-year-old man comes to the office because of a 6-month history of a wound in the right supraorbital region that is draining fluid. Photographs are shown. History includes type 1 diabetes mellitus, chronic obstructive pulmonary disease, and basal and squamous cell carcinoma in the supraorbital area, which was treated with Mohs micrographic surgery, cranial burring, split-thickness skin grafting, and radiation. He has smoked one pack of cigarettes daily for 60 years. Physical examination shows a 4 × 2-cm area of exposed bone with no mobility in the immediately adjacent skin. Echocardiography shows an ejection fraction of 25%. Examination of a specimen obtained on biopsy shows recurrence of squamous cell carcinoma. After excising the tumor, a bony deformity of the supraorbital rim and exposed dura are present. Which of the following is most appropriate to correct this patient’s defect?
A) Alloplastic reconstruction and a local flap
B) Rib graft with local soft-tissue coverage
C) Scalp flap
D) Skin graft
Correct answer is C.
In the scenario described, bony reconstruction will not impact function, and therefore soft-tissue coverage is adequate. A scalp flap is the most appropriate option because it will bring in blood supply and soft-tissue coverage without the risks associated with extended general anesthesia.
Skin grafting would likely not heal in a radiated bed. The long history of a draining wound is a contraindication to the use of alloplastic material. Although a rib graft would provide bony support, it would also increase risk because of the donor site morbidity in the patient described, who has chronic obstructive pulmonary disease and is at high risk for postoperative pneumonia.
Which of the following best characterizes male-pattern alopecia?
The correct response is Option B.
Male-pattern alopecia is characterized by a decrease in the anagen, or active, phase of the hair follicle and an increase in the telogen, or resting, phase. Patients with this condition have more of their hair follicles in the resting phase, and those in the active phase produce hair growth for a shorter time. Hair follicles can also be classified as either terminal, which produce larger, pigmented fibers, or villous, which produce finer fibers that have less pigmentation and are more difficult to visualize. Terminal fibers are found typically on the adult scalp, eyebrows, axilla, and pubic region, while villous fibers are noted on the forehead, bald scalp, and along the hairline itself. In patients with male-pattern alopecia, many follicles in the scalp are transformed from terminal to villous.
Minoxidil is the recommended treatment of male-pattern alopecia. This agent halts the hair loss and increases the number of hairs as well as the diameter of the existing hairs, but is only effective in patients with mild to moderate baldness.
Male pattern baldness is characterized by which of the following growth phase disturbances?
The correct response is Option A.
Male pattern baldness follows an X-linked dominant inheritance pattern. The anagen phase of hair growth is the active growth phase and lasts approximately 1000 days in men. In the anagen phase, follicular cells are actively multiplying and becoming keratinized. In men with normal hair growth, 85 to 90% of hairs are in this phase, with hair growing 1 cm per month. The catagen phase is known as the transitional or degradation phase and typically lasts 2 to 3 weeks and is characterized by atrophy of the bulb, with keratinization of the hair base, and separation of the hair base from the dermal papilla. The telogen phase of hair growth usually lasts 3 to 4 months and is also known as the resting phase and is characterized by the inactivation of the hair follicle, cessation of hair growth and hair shedding.
In men with normal hair growth, 10% of hair follicles are in the telogen phase, causing approximately 50 to 100 hairs to be shed on average per day. In male pattern baldness there is an increased percentage of hairs in the telogen phase and a decreased percentage of hairs in the anagen phase.
Which of the following terms represents the primary active phase of hair growth?
(A) Anagen
(B) Anaphase
(C) Metaphase
(D) Telogen
(E) Telophase
The correct response is Option A.
Normal hair growth involves two primary phases. The active phase, anagen, is the phase of hair growth. In this phase, which can last three to five years, approximately 85% of hair follicles produce hair. The resting phase, telogen, heralds the loss of the hair shaft and affects approximately 15% of hair follicles at any given time. Balding occurs when the anagen phase is shortened and the telogen phase is prolonged.
Anaphase, metaphase, and telophase are all phases in cell division and the replication of deoxyribonucleic acid. They are not specifically related to hair growth.
Which of the following is most closely associated with the anagen phase of the hair growth cycle?
(A) Active hair growth
(B) Destruction of the follicular bulb
(C) Duration of two to three weeks
(D) Keratinization of the base of the hair
(E) Lack of hair growth
The correct response is Option A.
Inheritance is the only known cause of male pattern alopecia. Although hereditary alopecia is controlled by a single, dominant, X-linked autosomal gene, polygenetic modifying factors, such as androgen production and age, affect its expressivity.
The growth cycle of hair follicles is divided into three distinct phases Ð anagen, catagen, and telogen. In the anagen phase, which lasts approximately three years, the hair actively grows through division and keratinization of the follicular cells. Approximately 90% of the scalp hairs are involved in this phase. In the catagen phase, the follicular bulb is destroyed and the base of the hair is keratinized; this phase lasts approximately two to three weeks. Finally, in the telogen phase, the follicle is inactive and active hair growth ceases. Approximately 10% of the scalp hairs are in this phase at one time.
A 4-year-old patient with a full head of hair requires reconstruction of a congenital nevus to the vertex of the scalp. The lesion covers 30% of the scalp. Which one of the following is the best reconstructive option?
A) Serial excision and direct closure
B) Tissue expansion and local flap reconstruction
C) Transposition flap and skin graft to the donor site
D) Orticochea flaps with galeal scoring
E) Free tissue muscle transfer and split-skin graft
Correct answer is B.
The primary aim in this case is to fully remove the nevus and provide soft tissue cover while retaining a full head of hair. Two approaches to the management of congenital nevi on the scalp are serial excision or excision and tissue expansion. Serial excision is best suited to smaller defects that can be excised within three or four sessions. A defect of 30% is best treated with tissue expansion and local flap closure. Defects up to 50% of the hair-bearing scalp can be closed with tissue expansion and avoid bald patches. A transposition flap and skin graft would create a large bald area and would not be aesthetically pleasing. Free tissue transfer would be reserved for near-total scalp defects, particularly where bone is exposed. The Orticochea flap is not well suited to vertex defects because the location does not allow a large third flap to cover the donor defect.
A 15-year-old boy is referred to the office for management of alopecia areata. Physical examination shows that more than 50% of the scalp is involved. Which of the following is the most appropriate management?
(A) Administration of finasteride
(B) Construction of a scalp rotation-advancement flap
(C) Injection of a corticosteroid
(D) Transplantation of follicular units
(E) Observation
The correct response is Option C.
Alopecia areata (AA) is a recurrent nonscarring type of hair loss that can affect any hair-bearing area. Clinically, AA can present with many different patterns. Although medically benign, AA can cause tremendous emotional and psychosocial stress in affected patients and their families. The pathophysiology of AA remains unknown. The most widely accepted hypothesis is that AA is a T-cell mediated autoimmune condition that is most likely to occur in genetically predisposed individuals.
Because AA is believed to be an autoimmune condition, corticosteroids have been used to treat this condition. Few studies are available regarding the efficacy of intralesional corticosteroids, but they are used widely in the treatment of AA. Intralesional corticosteroids are the first-line treatment in localized conditions. In a study including 84 patients, regrowth on treated areas was present in 92% of patients with patchy AA and 61% of patients with alopecia totalis (AT). Regrowth persisted three months after treatment in 71% of patients with patchy AA and 28% of patients with AT. Regrowth usually is seen within four to six weeks in responsive patients. Patients with rapidly progressive, extensive, or long standing AA responded poorly. Another study showed regrowth in most patients (480) treated with intralesional corticosteroids, except in two patients with alopecia universalis (AU). Hair growth may persist for six to nine months after a single injection. Injections are administered intradermally using a 3 cm3 syringe and a 30 gauge needle. Triamcinolone acetonide (Kenalog) is used most commonly; concentrations vary from 2.5 to 10 mg/cm3. Less than 0.1 cm3 is injected per site, and injections are spread out to cover the affected areas (approximately 1 cm between injection sites). Adverse effects mostly include pain during injection and minimal transient atrophy (10%). The atrophy rarely can be severe or permanent. Injections are administered every four to six weeks.
For patients with extensive AA (>40% hair loss), little data exist on the natural evolution. The rate of spontaneous remission seems to be less than in patients with less than 40% involvement. In one review of 50 patients with extensive AA, 24% experienced spontaneous complete or nearly complete regrowth at some stage during the observation period of 3 to 3.5 years. Without therapy, the relapse rate is high in patients with severe forms of AA. Surgery does not have a role in this condition.
Finasteride (Propecia) works on alopecia secondary to male pattern baldness by affecting the 5 €‘alpha reductase enzyme.
A 27-year-old man comes to the office for hair restoration to correct alopecia of the scalp. He sustained a burn injury to the scalp when he was a child and underwent split-thickness skin grafting to treat the burn. Micrograft hair transplantion to restore the hairline is planned. Which of the following is the most likely percentage of micrograft survival and ultimate hair growth in this patient?
A) 10%
B) 25%
C) 50%
D) 85%
E) 95%
The correct response is Option D.
Because of their small size, micrografts and minigrafts appear to have a lower metabolic requirement to thrive. They tend to grow in areas of fibrosis and burn scars and over skin grafts and flaps, including split-thickness skin grafts. The rate of survival and ultimate hair growth under these circumstances appears to be approximately 85%, compared with approximately 95% on unscarred, healthy tissue. More recently, follicular unit grafts have been used in hair transplantation.
A 37-year-old woman who has Fitzpatrick type I skin requests intense pulsed-light therapy for reduction of blond hairs over the upper lip. Compared with a person with darker hair, which of the following best describes the outcome of this procedure?
(A) Decreased risk for permanent scar
(B) Decreased risk for prolonged erythema
(C) Increased risk for hyperpigmentation
(D) Increased risk for malignant transformation
(E) Less effective hair reduction
The correct response is Option E.
Melanin is the target chromophore for laser and intense pulsed-light (IPL) hair reduction. Melanin pigment is responsible for skin and hair color and absorbs energy at wavelengths of 250 to 1200 nm. Thermal injury to the melanin €‘containing cells of the bulb and matrix results in destruction of the hair follicle. Patients with greater melanin content have darker hair and are more likely to have effective laser or IPL hair reduction. In very fair-haired individuals, the limited melanin content makes hair reduction less effective. At higher energy levels, fair-skinned patients can have prolonged erythema. In patients with darker pigmentation, surrounding skin can absorb energy, resulting in blistering or pigment changes.
A 25-year-old woman comes to the clinic to discuss eyebrow reconstruction. She reports that she tweezed her eyebrows several times a day because of perceived asymmetry, and she now has complete loss of eyebrows. She insists on receiving hair transplants and says that she is depressed because of her lack of eyebrows. Which of the following is the most likely DSM-5 diagnosis?
A) Body dysmorphic disorder
B) Borderline personality disorder
C) Excoriation (skin-picking) disorder
D) Major depressive disorder
E) Trichotillomania
The correct response is Option A.
Body dysmorphic disorder is considered an obsessive compulsive and related disorder in the DSM-5. Criteria include preoccupation with perceived appearance flaws for at least an hour a day, repetitive behaviors related to the preoccupation, clinically significant distress as a result of the preoccupation, and exclusion of an eating disorder.
The differential diagnosis includes major depressive disorder, trichotillomania, excoriation disorder, agoraphobia, eating disorders, and dysmorphic concerns. What differentiates body dysmorphic disorder from excoriation disorder and trichotillomania is the underlying preoccupation with symmetry and appearance seen in body dysmorphic disorder. In some cases, patients report a pleasurable sensation during hair pulling in trichotillomania. Thus, patients with body dysmorphic disorder can engage in skin picking and hair pulling, but the underlying motivation is different. Excoriation disorder is a body-focused repetitive behavior, on the obsessive compulsive spectrum, but it is not motivated by perceived asymmetry or appearance as is body dysmorphic disorder.
Depression can coexist with body dysmorphic disorder, but it does not have a preoccupation with appearance as a criterion.
Borderline personality disorder is a Cluster B personality disorder, characterized by unstable emotional responses to stimuli and relationships.
Which of the following is most closely associated with male pattern alopecia?
(A) Absence of a genetic predisposition
(B) Decreased activity of 5alpha-reductase within genetically susceptible hair follicles
(C) Increased serum level of testosterone
(D) Prolonged anagen phase
(E) Prolonged telogen phase
The correct response is Option E.
Male pattern alopecia is associated with a prolonged telogen, or quiescent, phase of the hair growth cycle. During this phase, the follicle becomes inactive, and active hair growth ceases.
Inheritance is the only known cause of male pattern alopecia. Although hereditary alopecia is controlled by a single, dominant, X-linked autosomal gene, polygenetic modifying factors, such as androgen production and age, affect its expressivity. Male pattern alopecia can only be triggered by a normal adult male serum androgen level if there is genetic predisposition.
Alopecia results from increased 5alpha-reductase activity within genetically susceptible follicles. It has not been shown to be associated with increased plasma levels of testosterone. The anagen phase of the hair cycle, during which hair actively grows, is typically shortened in patients with alopecia.
Male-pattern alopecia is typically caused by which type of genetic pattern?
(A) Autosomal dominant
(B) Autosomal recessive
(C) Multifactorial
(D) X-linked dominant
(E) X-linked recessive
The correct response is Option D.
Male-pattern alopecia is a genetically triggered condition in susceptible men. It is caused by a single X-linked dominant gene. This condition occurs in 60% to 80% of Caucasian men; hair loss can begin as early as age 20 years. In men with male-pattern alopecia, a genetically determined increase in the activity of 5-alpha-reductase in the susceptible follicles has been observed. Plasma testosterone levels are normal in these patients.
Hamilton €™s system has been used to classify male-pattern alopecia based on the appearance of the anterior hairline and the hair loss at the vertex. There are seven major classifications; each is used to draw conclusions regarding the potential for further hair loss and is helpful for planning surgical management.
A 25-year-old man has burn alopecia after sustaining a burn wound involving 35% of the hair-bearing scalp. Which of the following is the most appropriate method of reconstruction in this patient?
A) Free flap reconstruction
B) Micrografting
C) Minigrafting
D) Strip grafting
E) Tissue expansion
Correct answer is E.
In patients with burn alopecia, the hair-bearing area of the scalp is amenable to tissue expansion; therefore, it is most appropriate for reconstruction in this patient. With this technique, large areas of the scalp can be resurfaced with similar tissue, resulting in reliable, consistent hair growth.
Grafting techniques, such as the use of micrografts, minigrafts, or strip grafts, are appropriate for management of male pattern alopecia but are unreliable in a patient with a compromised recipient site, such as a burn wound. Free flap reconstruction will allow rapid wound healing in a patient who has acute extensive and/or deep injuries involving exposed, devitalized skull.
Which one of the following statements is correct regarding scalp innervation
A) The supraorbital nerve has both superficial and deep divisions.
B) The zygomaticofacial nerve is a branch of the ophthalmic division of trigeminal nerve.
C) The auriculotemporal nerve supplies the posterior and lateral scalp.
D) The lesser occipital nerve emerges from the semispinalis muscle, 3 cm below the occipital protuberance.
Correct answer is A.
The supraorbital nerve has superficial and deep divisions. The superficial component supplies sensation to the forehead anterior to the hairline. The deep component supplies sensation posterior to the hairline. This has clinical relevance in brow-lift procedures, bicoronal cranial flaps, and trauma in which the nerves may be damaged, leaving an area of paresthesia.
The zygomaticofacial nerve derives from the maxillary division (not the ophthalmic division) of the trigeminal nerve. It supplies a region of skin lateral to the brow.
The auriculotemporal nerve derives from the mandibular division of the trigeminal nerve and supplies the lateral scalp.
The greater and lesser occipital nerves supply the occipital territory, but it is the greater occipital nerve that emerges from the semispinalis 3 cm below the occipital protuberance.
The facial nerve supplies the scalp muscles.
The trigeminal nerve supplies the muscles of mastication and the tensor tympani.
A 55-year-old man who has had stable hair loss for the past several years wishes to undergo hair transplantation. Conservative management with administration of finasteride has not been successful. On examination, he has Hamilton’s class 6 male pattern alopecia that extends from the anterior hairline to the vertex. He has dense, curly hair in the parieto-occipital region of the scalp and excellent scalp vascularity and elasticity.
Which of the following is the most appropriate initial management?
(A) Psychological profile and screening
(B) Trial therapy with minoxidil
(C) Establishing the anterior hairline with punch grafts
(D) Establishing the anterior hairline with scalp flaps
(E) Sagittal scalp reduction
The correct response is Option E.
Scalp reduction is currently the most appropriate management of male pattern alopecia. This technique is simple and associated with few complications. Surgical removal of the hairless scalp will diminish the total area that requires grafting and will assist with conservation of donor sites. Although various excision patterns can be used based on baldness pattern, sagittal excision patterns are preferred because they will remove the greatest amount of bald skin due to the excess of scalp laxity seen in the sagittal plane. The surgeon should perform scalp reduction before surgically re-establishing the anterior hairline.
Minoxidil is an antihypertensive drug that has been shown to increase hair growth when applied to the scalp of men who have thinning hair. However, this drug does not work in patients who have extensive hair loss, such as those
Psychological screening is not routinely performed in patients who request treatment of male pattern alopecia.
A 65-year-old woman who has undergone multiple resections for recurrent lentigo maligna melanoma with repeated central advancements of the remaining scalp via skin grafting over the past 10 years has frequent irritation of the skin at the grafting sites (image shown). No evidence of further disease has been noted over the past four years. Which of the following is the most appropriate management at this time?
A) Full-thickness skin grafting
B) Micrograft hair transplantation
C) Rerotational flap advancement
D) Staged excision and primary closure
E) Tissue expansion
Correct answer is E.
Because of continued skin breakdown in this area of postsurgical alopecia, tissue expansion followed by adjacent tissue transfer is the most appropriate surgical procedure at this time. This patient has had multiple excisions with repeated advancement followed by skin grafting. The remaining native vessels should be sufficient to supply the expanded scalp skin. Tissue expansion and coverage are usually tolerated well by patients of this age.
Hair transplantation is unlikely to be successful in this patient because of extensive scars in the area. Staged excision of the prior skin grafts and primary closure will not improve this patient’s alopecia and are unlikely to relieve the skin irritation caused by the thinned skin over the calvaria. Because advancement has already been done, little additional advancement can be achieved without back-grafting exposed areas. Full-thickness grafts will not allow sufficient hair growth or replacement.
Which one of the following statements is correct regarding the blood supply to the scalp?
A) The anterior scalp is supplied by the supraorbital and supratrochlear vessels from the external carotid artery.
B) The supratrochlear vessels are lateral to the supraorbital vessels.
C) The posterior territory is the largest area and is supplied by the occipital vessels.
D) The lesser occipital artery supplies the posterolateral scalp.
E) The lateral territory is supplied by the superficial temporal artery, which arises from theexternal carotid artery.
Convert answer is E.
The lateral territory is supplied by the superficial temporal artery, which arises from the external carotid artery.
The scalp derives its blood supply from both the internal and external carotid systems. It is divided into four zones: anterior, posterior, lateral, and posterolateral. Each zone has its own blood supply, with collateralization between zones. This is clinically relevant with respect to scalp reconstruction using local flaps.
The anterior scalp is supplied by the supraorbital and supratrochlear vessels. These derive from the internal carotid vessels (not the external carotid vessels). The supratrochlear vessels lie medial (not lateral) to the supraorbital vessels.
The posterior territory is supplied by the occipital vessels and perforators from the splenius capitis and trapezius, but it is not the largest territory.
The largest is the lateral territory, which is supplied by the superficial temporal arteries. A lesser occipital artery does not exist. The greater and lesser occipital nerves supply sensation to the occipital territory.
The posterolateral scalp is the smallest territory and is supplied by the posterior auricular artery.
A 35-year-old woman with diffuse hair thinning comes to the office for evaluation of hair transplantation. Physical examination shows facial hirsutism, acne, and diffusely decreased hair density over the crown and frontal scalp, except for the frontal hairline, which is quite well preserved. The scalp skin appears normal. Which of the following is the most likely underlying cause?
A ) Alopecia totalis
B ) Polycystic ovary syndrome
C ) Psoriasis
D ) Tinea capitis
E ) Trichotillomania
The correct response is Option B.
Although all options listed can cause hair loss, psoriasis and tinea capitis would be associated with visible scalp changes, such as scaling or crusting. Trichotillomania, which is traction alopecia from compulsive hair pulling, would be unlikely to show a diffuse hair loss with sparing of the frontal hairline. Alopecia totalis, by definition, is total hair loss over the entire scalp, and does not fit the patient’s description.
This woman has female pattern hair loss (FPHL), which is the preferred term for androgenetic alopecia in females. Typically there is a reduction in hair density over the crown and frontal scalp, with relative sparing and preservation of the frontal hairline, as described for this patient. Between 10 and 40% of women with FPHL have been found to be hyperandrogenic. The presence of menstrual irregularities, marked acne, or hirsutism in this patient should prompt an investigation for polycystic ovary syndrome or other underlying causes.
