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A CLINICOPATHOLOGICAL STUDY OF LOCALISED ALOPECIA

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Table of Contents I: INTRODUCTION .................................................................................................................. 3 II: AIMS AND OBJECTIVES.................................................................................................. 5 III: LITERATURE REVIEW ................................................................................................... 7 History .................................................................................................................................... 7 Classification .......................................................................................................................... 8 Epidemology..................................................................................................................... 11 Pathogenesis ..................................................................... Error! Bookmark not defined. Clinical Features ............................................................................................................... 16 Histopathology.................................................................................................................. 19 Diagnosis and Evaluation ................................................................................................. 22 Treatment .......................................................................................................................... 25 Empirical studies .................................................................................................................. 27 Research Gap........................................................................................................................ 38 IV: MATERIAL AND METHOD ........................................................................................... 39 V: RESULTS ........................................................................................................................... 41 VI: DISCUSSION AND CONCLUSION ............................................................................... 59 Analysis of Demographic variables ..................................................................................... 59 Aetiology of localised alopecia ............................................................................................ 61 Conclusion............................................................................................................................ 64 References ................................................................................................................................ 67 © 2017-2018 All Rights Reserved, No part of this document should be modified/used without prior consent Phd Assistance™ - Your trusted mentor since 2001 I www.phdassisatnce.com UK: The Portergate, Ecclesall Road, Sheffield, S11 8NX I UK # +44-1143520021, Info@Phdassistance.com

I: INTRODUCTION Hair is an important component of human body which defines the characteristic features of an individual such as health, lifestyle and physical perception. Loss of hair is known as alopecia which is derived from the Greek word for Fox, “alopex”. When foxes are afflicted with „mange‟ a skin disease, their hairs begin to fall away resembling balding humans. Diseases that result in hair loss lead to disorders relating to psycho-social interactions and significant differences were found in the scale of emotional problems, social functioning, general health, social activity and fatigability compared to normal individuals1. Hence, timely diagnosis and necessary therapeutic interventions are of extreme importance 2. Localized alopecia is a condition in which hair is lost from some or all areas of the body usually the scalp. It is further classified into cicatricial or non cicatricial alopecias 3. Hair is an important component of human body which defines the characteristic features of an individual such as health, lifestyle and physical perception. Loss of hair is known as alopecia which is derived from the Greek word for Fox, “alopex”. When foxes are afflicted with „mange‟ a skin disease, their hairs begin to fall away histologic inflammation may be present. Causes of non-cicatrical alopecia include- Alopecia areata(AA), TineaCapitis, Trichotilomania4. Cicatrical alopecia(CAs), also called as scarring alopecia, refers to a group of rare disorders that destroy hair follicles which is permanent & replaced with scar tissue5. Extensive loss of visible follicular ostia predominantly in the scarring area is the Hair is an © 2017-2018 All Rights Reserved, No part of this document should be modified/used without prior consent Phd Assistance™ - Your trusted mentor since 2001 I www.phdassisatnce.com UK: The Portergate, Ecclesall Road, Sheffield, S11 8NX I UK # +44-1143520021, Info@Phdassistance.com

important component of human body which defines the characteristic features of an individual such as health, lifestyle and physical perception. Loss of hair is known as alopecia which is derived from the Greek word for Fox, “alopex”. When foxes are afflicted with „mange‟ a skin disease, their hairs begin to fall away developmental/hereditary cicatricial alopecias

8,9

. Of which, PCA is a consequence of

devastating inflammation of the hair follicle resulting in an irreversible hair loss,

the

antigenic inflammation trigger is not clear and there is loss of follicular stem cells and sebaceous glands which further leads to hair loss in a permanent basis10. Patients with PCA suffer from pain, burning sensation, and severe itching11 PCAs are further classified based on the type of infiltrating primary cells of innate immunity (Lymphocytes/Neutrophils/Mixed) as determined by the scalp biopsies. 12,13. Nonspecific CA is characterized by uncertain clinical and histopathological findings of the scarring initiated in response to disease state15. SCA is a consequence of widespread destruction of hair follicles confined to the skin, ending up with loss of regeneration capacity of hair follicle stem cells (HFSC) 9. As the name signifies, the root cause for SCA are the secondary factors such as trauma occurring due to burns and radiations, microbial infections and various infiltrative processes viz. neoplasias 8. Thus identification of the type of CA is a pre-requisite for any surgical treatment under consideration and a confirmation on quiescence of diseased condition for at least one year would help in attenuating the CAs successfully even before the initiation of scarring 14 Hair loss is a common problem and a source of distress to the patient, and diagnosing the exact cause of hair loss is challenging. This study will help in delineating the various

causes of localised alopecia and increasing our awareness to prevent progression of scarring alopecia by diagnosing at an early stage.

II: AIMS AND OBJECTIVES RESEARCH QUESTION What is the etiology, clinical and pathological findings and prevalence of localized alopecia in patients coming to a tertiary care centre? AIMS AND OBJECTIVES The study has following aims and objectives Hair is an important component of human body which defines the characteristic features of an individual such as health, lifestyle and physical perception. Loss of hair is known as alopecia which is derived from the Greek word for Fox, “alopex”. When foxes are afflicted with ‘mange’ a skin disease, their hairs begin to fall away

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III: LITERATURE REVIEW History Hair is an important component of human body which defines the characteristic features of an individual such as health, lifestyle and physical perception. Loss of hair is known as alopecia which is derived from the Greek word for Fox, “alopex”. When foxes are afflicted with „mange‟ a skin disease, their hairs begin to fall away „De Medicina‟, Census argued the existence of two different forms of alopecia namely alopecia areata and alopecia totalis15. In the early 1800s, the condition of hair loss, especially Alopecia Areata was associated with parasitic infections or due to nervous disorders. Furthermore, clinical observations revealed stress and trauma to be linked with alopecia. However in the 20th century, Alopecia areata was thought to be related with hormonal disorders, especially with the malfunctioning of thyroid glands which further led to the belief that alopecia could be associated with hormonal imbalance or malfunctioning of glands15. However, it is identified that Alopecia areata is an autoimmune disease wherein the immune system of human body is triggered to attack its own healthy tissues instead of disease causing agents or germs.

Classification Classification of Localized Alopecia

Localised Alopecia

Non cicatricial or non-scarring alopecia

Cicatricial or scarring alopecia

Primary cicatricial alopecia

Secondary cicatricial alopecia

Localised hair loss

Lymphocytic group

Traumatic

Neutrophilic group

Sclerosing disorders

Mixed group

Granulomatous disorders

Non – specific

Infections

Neoplastic

Generalised form

Alopecia areata

Androgeneti c alopecia

Trichotillomania

Tellogen effluvium

Pressure alopecia

Hair shaft disorders

Loose anagen syndrome

Hair shaft disorders

Source: Adopted from Stefanato 16 andMoure et al. 17 Classification of Primary Cicatrical Alopecia

DISCOID LUPUS ERYTHEMATOSUS

PRIMARY CICATRICAL ALOPECIA

LICHEN PLANOPILARIS LYMPHOCYTIC GROUP CLASSIC PSEUDOPELADE OF BROCQ CENTRAL CENTRIFUGAL CICATRICIAL

FOLLICULITIS DECALVANS NEUTROPHILIC GROUP DISSECTING CELLULITIS

MIXED GROUP

FOLLICULITIS KELOIDALIS

NON – SPECIFIC

Source: Adopted from Stefanato 16 andMoure et al. 17 Classification of Secondary Cicatrical Alopecia

SECONDARY CICATRICAL ALOPECIA

RADIODERMA TITIS

MECHANICAL TRAUMA

BURNS

POSTOPERATIVE

TRAUMATIC

•DERMATITIS ARTEFECTA ACCIDENTAL ALOPECIA

TRACTION ALOPECIA SCLERODERMA

SCLEROSING DISORDERS

MORPHEA

SARCOIDOSIS

LICHEN SCLEROSUS

GRANULOMATOUS DISORDERS

NECROBIOSIS LIPODICA

INFECTITIOUS GRANULOMAS

INFECTIONS (BACTERIAL, FUNGAL, VIRAL, PROTAZOAL, TREPONEMAL, MYCOBACTERIAL)

BENIGN

NEOPLASTIC MALIGNANT

Source: Adopted from Stefanato 16 andMoure et al. 17 © 2017-2018 All Rights Reserved, No part of this document should be modified/used without prior consent Phd Assistance™ - Your trusted mentor since 2001 I www.phdassisatnce.com UK: The Portergate, Ecclesall Road, Sheffield, S11 8NX I UK # +44-1143520021, Info@Phdassistance.com

Epidemology Hair is an important component of human body which defines the characteristic features of an individual such as health, lifestyle and physical perception. Loss of hair is known as alopecia which is derived from the Greek word for Fox, “alopex”. When foxes are afflicted with „mange‟ a skin disease, their hairs begin to fall away women is greater than men in 20 - Pressure alopecia is more common in patients immobilised due to surgery or prolonged rest in the Intensive Care Unit 21 - Loose anagen hair syndrome is predominant in young girls in between the ages of 2 and 6 years, and some cases in boys. The condition is underdiagnosed in males because of hairstyle differences between boys and girls 22 - Discoid lupus erythematosus occurs more common in women than men in 20-40 years age group. It is more prevalent in Afro-Americans than Asians and Whites23,24 - Lichen planopilaris women are more affected between the age group of 30-70 years 25. - Classic pseudopleade of broque primarly affects womens of middle age group between 3050 year26

- Hair is an important component of human body which defines the characteristic features of an individual such as health, lifestyle and physical perception.

Loss of hair is known as alopecia which is derived from the Greek word for Fox, “alopex”. When foxes are afflicted with „mange‟ a skin disease, their hairs begin to fall away - Tinea capitis affects school going boys more and is mainly prevelant in Africans countries54 - Cicatricial Pemphogoid is more common in elderly womens and is endemic in areas such as Tunisia and brazil59 - Scalp pyoderma is more common in children in sub-saharan Africa63

Alopecia, especially Alopecia areata is found to be associated with autoimmunity wherein the T-cell responses turn to become inappropriate and affects the self- antigens of hair follicles1. Autoimmune factors of localised alopecia are often associated with other autoimmune diseases. Previous studies have suggested the melanogenesis-associated peptides which are expressed by the melanin-producing anagen hair-follicles target the autoreactive cytotoxic T cells2 3. Observations of melanogenesis-associated autoantigens in localised alopecia, especially Alopecia areata are greying of hair follicles, regrowth of hair shafts and repigmentation, and overnight greying. Follicular melanocytes are also targeted which reveals ultrastructural and histological aberrations4. Genetic factors There are possibilities of genetic susceptibility in the development of localised alopecia associated with the alleles of the Human leukocyte antigen5. The genetic predisposition

Antibodies to hair follicles in alopecia areata. Tobin DJ, Orentreich N, Fenton DA, Bystryn JC J Invest Dermatol. 1994 May; 102(5):721-4. 2 R. Paus, A. Slominski, and B. M. Czarnetzki, “Is alopecia areata an autoimmune-response against melanogenesis-related proteins, exposed by abnormal MHC class I expression in the anagen hair bulb?” Yale Journal of Biology and Medicine, vol. 66, no. 6, pp. 541–554, 1993. View at Google Scholar · View at Scopus 3 A. Gilhar, M. Landau, B. Assy, R. Shalaginov, S. Serafimovich, and R. S. Kalish, “Melanocyte-associated T cell epitopes can function as autoantigens for transfer of alopecia areata to human scalp explants on Prkdcacid mice,” Journal of Investigative Dermatology, vol. 117, no. 6, pp. 1357–1362, 2001. View at Publisher · View at Google Scholar · View at Scopus 4 D. J. Tobin, D. A. Fenton, and M. D. Kendall, “Ultrastructural observations on the hair bulb melanocytes and melanosomes in acute alopecia areata,” Journal of Investigative Dermatology, vol. 94, no. 6, pp. 803–807, 1990. View at Google Scholar · View at Scopus 5 Ito T. Advances in the management of alopecia areata. J Dermatol. 2012 Jan;39(1):11-7. doi: 10.1111/j.13468138.2011.01476.x. Review.[PMID: 22211297] © 2017-2018 All Rights Reserved, No part of this document should be modified/used without prior consent Phd Assistance™ - Your trusted mentor since 2001 I www.phdassisatnce.com UK: The Portergate, Ecclesall Road, Sheffield, S11 8NX I UK # +44-1143520021, Info@Phdassistance.com

implies that people with localised alopecia may have genetically derived the condition from their predecessors.

Hair is an important component of human body which defines the characteristic features of an individual such as health, lifestyle and physical perception. Loss of hair is known as alopecia which is derived from the Greek word for Fox, “alopex”. When foxes are afflicted with „mange‟ a skin disease, their hairs begin to fall away include Zinc, chromium, magnesium and calcium6. Hormonal factors Stress hormone is associated with the condition of localised alopecia in many instances. Homeostasis should be maintained by the human body wherein external stressors such as UV light, injury through mechanical impact and chemical influences may lead to hair loss. Hypothalamicpituitary-adrenal (HPA) axis which responds to stress releases corticotropinreleasing hormone (CRH) wherein CRH and CRH-R1 gene transcriptions mostly occur in the hair bulb. Human hair bulb gets affected by skin stress response7 8. Neurological factors

http://hair-loss-centre.com.au/Hair%20Loss%20in%20Women.pdf N. Ito, T. Ito, A. Kromminga et al., “Human hair follicles display a functional equivalent of the hypothalamicpituitary-adrenal axis and synthesize cortisol,” FASEB Journal, vol. 19, no. 10, pp. 1332–1334, 2005 8 file:///C:/Users/user_2/Downloads/CDI2013-348546.pdf 7

response. There could be possible association of neuropeptides and neuropeptide receptors with the nervous system triggering hair loss9.

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Clinical Features Hair is an important component of human body which defines the characteristic features of an individual such as health, lifestyle and physical perception. Loss of hair is known as alopecia which is derived from the Greek word for Fox, “alopex”. When foxes are afflicted with „mange‟ a skin disease, their hairs begin to fall away seen at the margins. The Atopic type lesions begin in childhood or adolescence and progress over many years with patches lasting for an year. The Autoimmune type begins in middle years and has a prolonged course. The Prehypertensive type begins in young age whoe one or both parents were hypertensive it progress faster. Different patterns such as AA universalis (loss of all body hairs), AA subtotalis ( when almost all haed hair falls) ophiasis, reticularis, alopecia totalis ( when entire scalp is affected), loss of hair in band like pattern on occipital region progressing to temporal region knowns as Ophiasis the reverse of this is Sisaipho, AA of eyebrow, AA eyelashes, AA of beard, AA incognito18 - Trichotilomania- Loss of scalp hair with fuzzy borders often in bizarre or angular pattern are seen usually on frontopariteal areas. Short and broken hair with varying lengths will be visible in these patches.37 -Pressure alopecia- localised ischemic injuries to the blood vessels and hair follicles, ceasing follicular activity and leading to hair loss. Some patients prior to hair loss havetenderness, swelling or ulceration at the site38 Hair is an important component of human body which defines the characteristic features of an individual such as health, lifestyle and physical perception. Loss of hair is known as alopecia which is derived from the Greek word for Fox, “alopex”. When foxes are afflicted with „mange‟ a skin disease, their hairs begin to fall away - Discoid © 2017-2018 All Rights Reserved, No part of this document should be modified/used without prior consent Phd Assistance™ - Your trusted mentor since 2001 I www.phdassisatnce.com UK: The Portergate, Ecclesall Road, Sheffield, S11 8NX I UK # +44-1143520021, Info@Phdassistance.com

lupus erythematous- the characteristic lesions are round or discoid which begins as erythematous scaly patches, later they presents with sclerotic, atrophic smooth white ivory– colored plaques with telangiectases in the centre and hyperpigmentation at the periphery of lesion is the classical lesion. Clinical findings are found in the center of alopecic patch rather than around the hair rim. 5,40 Hair is an important component of human body which defines the characteristic features of an individual such as health, lifestyle and physical perception. Loss of hair is known as alopecia which is derived from the Greek word for Fox, “alopex”. When foxes are afflicted with „mange‟ a skin disease, their hairs begin to fall away slight scaling 25.FFA resembles androgenetic alopecia with frontal recession, but their is loss of follicular orificies, perifollicular erythema and hyperkeratosis at marginal hairline. Lassueur Graham-Little Piccardi Syndrome has a traid of patchy cicatrical alopecia of scalp, noncicatricial alopecia of axilla and groin and follicular spinous papules on body, scalp or both32 - Pseudopelade of Broque- there are multiple, discrete, small, asymmetrical, smooth, ﬂeshtoned or white patches with scarring hair loss and little inﬂammation.5 - Central centrifugal cicatrical alopecia(CCCA) is slowly progressive in an symmetrical fashion wherein the disease activity occurs in a variable width thereby surrounding the central alopecia zone similar to female pattern hair loss 31usually involving the vertex.Final stages of CCCA may lead to irreversible effects 41,42

- Folliculitis decalvans- multiple crops of pinhead sized follicular pustules are followed by round or oval patches of scarring hair loss is usually seen on the vertex and

occipital area of Hair is an important component of human body which defines the characteristic features of an individual such as health, lifestyle and physical perception. Loss of hair is known as alopecia which is derived from the Greek word for Fox, “alopex”. When foxes are afflicted with „mange‟ a skin disease, their hairs begin to fall away - Tinea capitis is of four types.Gray patch types presents with patches of partial hair loss which are circular in shape and shows broken off hairs that are grey and lustreless due to overcoating of arthrospores. Kerion type presents with an inflamed boggy indurated tender swelling studded with broken hairs, vesicles,pustules. their may be sinus tract formation with matting of adjacent hair.Lymphoadenopathy is common. Black dot type hair shaft is extremely brittle and remain at level of scalp which appear lack dot on examination.Favus type presents with diagnostic yellow cupshapped crust composed with dense mycelia and epithelial debris called scutulum45

Histopathology The histopathological interpretation of the scalp biopsy specimens of the patients with alopecia, whether scarring or non – scarring, may represent a challenging task, especially in the absence of a good, definitive clinical history, adequate tissue sampling, and an appropriate grossing technique. But different features are seen on biopsy with different diseases which helps us to make the diagnosis. Alopecia areata- we see perifollicular and intrafollicular inflammatory of T lymphocytes in an around the hair bulb.No infiltrate is seen around the isthmus of hair follicle which is seen in scarring alopecia. Number of follicles are normal but more of catagen and telogen follicles.Hair follicle miniaturization with minimal inflammation is seen in chronic stages66 Trichotilomania- there are empty follicles with soft keratin or deformed hairs (Trichomalacia).Many catagen follicle and aggregation of melanin pigment casts in catagen follicle without significant inflammation is seen71 Loose anagen hair syndrome- Premature keratinization of the inner root sheath layers of Huxley and Henle layer.Cleft formation between hair shaft and inner root sheath and fragmentation of the inner root sheath may be sometimes seen46 DLE shows Hyperkeratosis, Basal cell vacuolization, Collagen damage, Epidermal atrophy, Perivascular inflammation, Periappendageal inflammation, Follicular plugging, Acanthosis, Pigmentary incontinence, Parakeratosis, and Sebaceous granulomas 47

LPP shows Infundibular hyperkeratosis along with hypergranulosis, bandlike infiltrate of lymphocytes around the infundibulum and isthmus. Vacuolar changes are seen in the basal layer. In later stages follicles are replaced by fibrous tracts 48 PPB- absence of marked inflammation except for lymphocytic infiltrate around upper two-third of the follicle.

Follicular hyperkeratosis. Thickening of the basement membrane and prominent perifollicular fibrosis36 CCCA shows a superficial perivascular and perifollicular lymphocytic infiltrate in early stages. Their is premature disintegration of the inner root sheath, but is not always seen. Hair follicle destruction is severe and widespread and leaves prominent concentric lammelar fibrosis.49

Follculitis Decalvans- there is follicular abscess with dense perifollicular neutrophilic infiltrate and scattered eiosinophils and plasma cells. Foreign body granuloma occur in response to follicular disruption which is followed by scarring.Biopsy from tuffed folliculities reveals follicular fusion involving agjacent follicles43 Dissecting cellulitis shows characterised lymphocytic, neutrophilic, and plasma cellular infiltrate in early stages. Chronic granulomas in later stages with foreign body giant cells, lymphoid and plasma cells. Abscess formation is seen which leads to the destruction of pilosebaceous follicle and other appendages. Fibrosis and scaring is seen in final stages 50 Follicular keloidalis shows dense perifollicular and follicular inflammatory infiltrate of lymphocytes and neutrophils52,53 Tinea capitis shows arthrospores in the follicles of hair or stratum corneum 53

Cicatricial pemphigoid shows a subepithelial blister without acantholysis. Lamina propria shows inflammatory infiltrate compose of lymphocytes, histiocytes, neutrophilis and eosinophils. Later stages shows firbosis54

Diagnosis and Evaluation There are many resources available for the assessment of patients who presents with hair loss. Diagnostic procedures can be categorized as follows I. Invasive includes scalp biopsies II. Semi invasive diagnosis includes trichogram III. Non-invasive diagnosis includes hair counts, microscopic evaluation, trichoscopy, Woods Lamp, Mycological analysis Each of the approaches, when interpreted with the comprehensive clinical pictures can provide valuable insights into patients diagnosis, treatment and monitoring. I. INVASIVE PROCEDURES Punch biopsy is a quick and easy method of obtaining specimen for histological skin lesion assessment55.The features of sclap biopsies of every disease are already discussed in the histopathological section above. II.SEMI INVASIVE PROCEDURES Trichogram is a procedure in which hair is plucked in order to examine the root and hair shaft. This is performed to examine the presence of fungi and other ectoparasites. This is an easy way of identifying a skin condition56. Loose anagen hair syndrome the tricogram reveals abnormally large percentages of anagen hairs lacking inner and outer root sheath39

Culture and sensitivity is usually done in cases such as Folliculitis Decalvans, Dissecting Cellulitis, Scalp Pyoderma to find out the causative organism and sensitivity against drugs which helps the course of treatment44,48,65 III.NON INVASIVE PROCEDURES Woods Lamp used in the practice of dermatology for fungal infection detection in hair. The device is small, inexpensive, durable, sage and easy to use. Very recently, the apparatus is used to diagnose skin cancers57. In cases of Tinea capitis wood lamp show green fluorescence in ectothrix variety58 Dermoscopy/Trichoscopy is also an non invasive procedure use in the diagnosis of alopecia.LPP shows lack of follicular oriﬁces on the centre of bald areas with peri-follicular inflammation on the margin on dermoscopy34 Tricoscopy folliculitis decalvans show presence of multiple hairs emerging from single dilated follicular opening is seen 43 In AA Trichoscopy reveals dystrophic hairs with fractured tips( exclamation mark hairs) and these hair fractured before emergence from scalp( cadaverized hair)66 Loose anagen hair syndrome Hair-pluck trichogram reveals abnormally large percentages of anagen hairs lacking inner and outer root sheath79 Microscopic evaluation of hairs in loose anagen hair syndrome shows most hair in anagen phase with lack of inner and outer root sheath, distorted hair bulb which makes an acute angle with the shaft, the cuticle has a characteristic rippled or ruffled, sawtooth, baggy stocking appearance( rumpled sock appearance) andElectron microscopy shows abnormal ridging and fluting of hair shaft. Microscopic evaluation is also helpfull in cases of Tinea Capitis to see the spores58. © 2017-2018 All Rights Reserved, No part of this document should be modified/used without prior consent Phd Assistance™ - Your trusted mentor since 2001 I www.phdassisatnce.com UK: The Portergate, Ecclesall Road, Sheffield, S11 8NX I UK # +44-1143520021, Info@Phdassistance.com

Mycological Analysis is also done in cases of Tinea Capitis to see causative organism and confirm the disease58 Hair pull test in cases of AA shoe dystrophic anagen hair as compared to telogen hairs found in Telogen effluvium66. In cases of Trichotillomania hair pull test show large number of anagen hair extracted without pain which shows a rumpled sock cuticle79

Treatment A number of treatment options are available for the management of both cicatricial and non-cicatricial forms of localised alopecia. Treatment options in general include the following: Administration of Topical corticosteroid, Intralesional corticosteroids and Systemic corticosteroids, Contact immunotherapy, Phototherapy and photochemotherapy, Minoxidil, Dithranol and other options such as oral zinc and Isoprinosine 58. The treatment methods for localised alopecia may tend to induce growth of hair in hair loss locations; however, there are no viable evidences of change in the disease course. The administration of high dosages of intravenous steroids, topical steroids, topical immunotherapy, and phototherapy has been proven to be effective treatment methods. Corticosteroids have been used for the treatment of alopecia for many years and are administered mostly to patients with progressive Alopecia areata. The administration of the drug is mostly through single dose, alternating dose for both short and long terms10. Potent and midpotent topical corticosteroids are also used for the treatment of alopecia. There is no clear evidence of the treatment method found to be effective in the treatment of the condition; however, folliculitis and skin atrophy are common side effects11. Minoxidil is conventionally used to treat both Alopecia areata and Androgenetic alopecia. However the effectiveness of the substance in the treatment of localised alopecia is not known. Positive response could be seen after 3 months and complete effect within a year. However, the common side effects of the drug are hypertrichosis and Contact dermatitis12 13.

file:///C:/Users/user_2/Downloads/Systemic_steroids_in_the_treatment_of_alopecia_are.pdf Alkhalifah A, Alsantali A, Wang E, McElwee KJ, Shapiro J. Alopecia areata update: part II. Treatment. J Am Acad Dermatol 2010: 62: 191–202, quiz 3–4 12 Olsen EA, Dunlap FE, Funicella T, et al. A randomized clinical trial of 5% topical minoxidil versus 2% topical minoxidil and placebo in the treatment of androgenetic alopecia in men. J Am Acad Dermatol 2002: 47: 377–385. 13 Lucky AW, Piacquadio DJ, Ditre CM, et al. A randomized, placebo-controlled trial of 5% and 2% topical minoxidil solutions in the treatment of female pattern hair loss. J Am Acad Dermatol 2004: 50: 541–553 11

Contact immunotherapy is an effective treatment method for alopecia. The guidelines of the US, Japan and the Great Britain recommend this therapy as the first-line treatment method14. The therapy utilises three sensitisers- diphencyprone (DPCP), dinitrochlorobenzene (DNCB), and squaric acid dibutylester (SADBE)15. Dithranol is used to treat severe conditions of alopecia in patients, especially children. The application of the cream drug involves rubbing the substance in hair, leaving it atleast for an hour and washing it with shampoo. Positive effects could be seen after 60 weeks; however side effects include folliculitis, erythema, and scaling16. Psoralen application used in conjunction with ultraviolet (UV)-A irradiation (PUVA) has been utilised for the treatment of alopecia areata which restricts immunological attack on hair follicles by altering the function of r T lymphocyte17. Side effects include scalp burning, nausea, and squamous cell carcinoma18. The surgical method tends to restore hair which is a viable option for the patients above the age of 25 years. Front and mid frontal hair loss patients are normally treated using surgical methods. Furthermore, the natural architecture of the hair is also preserved19.

MacDonald Hull SP, Wood ML, Hutchinson PE, Sladden M, Messenger AG. Guidelines for the management of alopecia areata. British Association of Dermatologists. Br J Dermatol 2003; 149: 692–699 15 file:///C:/Users/user_2/Downloads/Advances_in_the_management_of_alopecia_areata.pdf 16 http://www.haaronline.com/onderzoek/finasteride%20en%20minoxidil%20effecten.pdf 17 Taylor C, Hawk J. PUVA treatment of alopecia areata, partialis totalis and universalis: audit of 10 years experience at St Johns Institute. Br J Dermatol 1995; 133: 914-8 18 http://www.haaronline.com/onderzoek/finasteride%20en%20minoxidil%20effecten.pdf 19 https://www.researchgate.net/publication/51563330_Alopecia_Evaluation_and_treatment © 2017-2018 All Rights Reserved, No part of this document should be modified/used without prior consent Phd Assistance™ - Your trusted mentor since 2001 I www.phdassisatnce.com UK: The Portergate, Ecclesall Road, Sheffield, S11 8NX I UK # +44-1143520021, Info@Phdassistance.com

Empirical studies The evaluation and treatment methods of alopecia are investigated by Gordon45. The previous paper talks about the clinical approaches and diagnostic tests which are useful in the evaluation of patients with alopecia. The treatments for noncicatricial alopecias, androgenetic alopecia, alopecia areata, telogen effluvium, cicatricial alopecias, lichen planopilaris, its clinical variant frontal fibrosing alopecia and discois lupus erythematosus are reviewed. There are many useful approaches to help in the diagnosis of both cicatricial and noncicatricial alopecias. They are scalp biopsies, microscopic evaluation, trichoscopy or hair counts to name a few. There are many treatment methods available which will follow diagnosis. Some new treatment modalities are really promising. Some of them target hair follicle stem cells for the treatment of androgenetic alopecia or the peroxisome proliferatoractivated receptor pathways for the treatment of lichen planopilaris. The etiological and pathogenic mechanisms, clinical features, diagnosis and management of alopecia areata were thoroughly reviewed by Amin and Sachdeva67.Alopecia areata (AA) is nothing but a nonscarring, autoimmune hair loss on the scalp, and/or body. Etiology and pathogenesis remain unknown. Scalp is the most affected site where solitary or multiple patches of alopecia will be seen. Histopathology shows an increased number of telogen follicles and the presence of inflammatory lymphocytic infiltrate in the peribulbar region. The most popular drugs for the treatment of this disease are corticosteroids. Minoxidil, anthralin, DNCB, SADBE, PUVA and cyclosporine are other treatments that are used and have some success. We must consider the side effects and cosmetically acceptable improvement with each treatment. In order to provide counselling for the affected patients support mechanisms in the form of support groups should be formed. The psychiatric comorbidities of the patients should also be resolved. ÂŠ 2017-2018 All Rights Reserved, No part of this document should be modified/used without prior consent Phd Assistanceâ&#x201E;˘ - Your trusted mentor since 2001 I www.phdassisatnce.com UK: The Portergate, Ecclesall Road, Sheffield, S11 8NX I UK # +44-1143520021, Info@Phdassistance.com

The methods for diagnosis and management of alopecia in children have been analysed by Castelo-Soccio

.It is important to describe types of alopecia and those which

are chronic or potentially related to underlying medical problems. There are 5 types of hair loss which are commonly seen in children. They are alopecia related to tinea capitis, alopecia areata

spectrum/autoimmune

alopecia,

traction

alopecia,

telogen

effluvium

and

trichotillomania/trichotillosis. Hair-cycle anomalies include loose anagen syndrome which leads to sparse-appearing hair. Pressure-induced alopecia, alopecia related to nutritional deficiency or toxic ingestion and androgenetic alopecia are the rarer reasons for alopecia in children. Localized alopecia occurring at birth will happen because of congenital lesions. In order to identify and treat alopecia in children an astute clinician must differentiate between the common types of hair loss. A thorough history, review of systems, systematic hair and scalp examination with a comprehensive skin examination will be necessary for the exact diagnosis of alopecia in children. Further the ability to counsel patients and parents will ease the prognosis and treatment. It will also reduce anxiety. The demographic pattern, clinical aspects, associations and therapeutic response of AA are assessed by Panda et al. 18 in a tertiary care teaching hospital in India. Alopecia areata can occur in any hair bearing site of the body but has a great psychosocial impact. The study included patients attending the dermatology OPD with patchy or diffuse hair loss with smooth bald surface. No features of scarring, scaling or inflammation on the bald area were included in this particular study. The participants included all age groups, both male and female and who had not received any treatment for the last 3 months. The detailed history like demographic data, drug history, personal history, family history, present and past medical history, history of emotional stress, exposure to STD and drug intake was collected. Patients who had other causes of hair loss were excluded from this study. The clinical pattern,

extent and severity of alopecia areata were assessed by doing a thorough clinical evaluation. Nail changes in all patients were noted. Baseline investigations constituted complete hemogram, blood sugar, serum electrolytes, renal and liver function tests, chest X-ray, urine analysis and examination of stool for occult blood. An ophthalmological test was done for all the patients before starting the therapy. Blood pressure and body weight were recorded in the beginning of the treatment and every month they were monitored. The treatment is an enigma according to the results of this study. The large number of treatment modalities show the lack of adequate efficacy. The researchers concluded that intralesional steroid and OMP steroids are effective for the treatment of alopecia areata with fewer side effects. A comparative study on the Prevalence of Depression and Suicidal Ideation in Dermatology Patients Suffering from Psoriasis, Acne, Alopecia Areata and Vitiligo was conducted by Layegh et al.69.The chronic nature, influences on the body image, hopelessness toward complete recovery, frequent occurrences, dermatological diseases are all the potential factors in depression and suicidal ideation. This study focused on evaluating the degree of depression and suicidal ideation in psoriasis patients and patients with acne, alopecia areata and vitiligo. 300 patients with psoriasis, acne, alopecia and vitiligo who were referred to the dermatology clinic of Ghaem Hospital in Mashad were the respondents of this study. The data collected through a beck depression questionnaire were statistically analysed with ANOVA and T-test with the help of SPSS software. 35.7% (107) subjects were female and 64.3%(193) were male and the mean age was 26.55Âą10.81 years. In patients with acne the rate of clinical depression was found to be 47.4%. The prevalence rate of depression was 69.4% in patients with psoriasis, 70.1% in patients with vitiligo, 50% in diffuse alopecia areata, 60% with universalis alopecia areata, 100% in ophiasis alopecia areata and 68.3% in ÂŠ 2017-2018 All Rights Reserved, No part of this document should be modified/used without prior consent Phd Assistanceâ&#x201E;˘ - Your trusted mentor since 2001 I www.phdassisatnce.com UK: The Portergate, Ecclesall Road, Sheffield, S11 8NX I UK # +44-1143520021, Info@Phdassistance.com

patients with localized alopecia areata. With regard to suicidal ideation there was no sign in 88.3% (265) patients; but 6.3% (19) of the patients were said to have thought of suicide. They had no desire for the attempt whereas 4%(12) of them had some desire for suicide and 1.3% (4) was serious to commit suicide if they would have the appropriate situation. The findings of the study showed the presence of a close relationship between dermatological diseases and psychological factors. Concurrent psychological effects should be immediately diagnosed in the case of patients with depression and suicidal ideation. The prevalence rate of dermatological conditions and psychological effects had a significant relationship which can be numerically said as follows- depression (P=0.008) and suicidal ideation (P=0.001). Patients with universalis alopecia had the highest rate of suicide attempt followed by those with diffuse alopecia areata and vitiligo respectively. In order to find out the concordance between trichoscopic and histopathological diagnosis Thakur et al.

analyzed the clinical, trichoscopic and histopathological

characteristics of primary cicatricial alopecias of the scalp. A retrospective analysis of the clinical, trichoscopic and histopathological features of 24 PCA patients was also part of the study. Fisher‟s Chi-square exact test helped in finding the significant trichoscopic and histopathological features. The agreement between histopathological and trichoscopic diagnosis was determined by Cohen‟s kappa coefficient. 24 patients of PCA with a male : female ratio of 2:1 were seen. They were 10 (41.7%) patients of discoid lupus erythematosus (DLE), 5 (20.8%) of lichen planopilaris (LPP), 3 (12.5%) of dissecting cellulitis of scalp, and 2 (8.3%) each of pseudopelade of brocq, folliculitis decalvans and frontal fibrosing alopecia. Follicular plugging, vacuolar changes in the basal layer, necrotic keratinocytes and superficial and deep perifollicular and perivascular lymphocytic infiltrate were the important histopathological findings of DLE. Vacuolar changes in the basal layer and lichenoid

infiltrate involving the infundibulum and isthmus were shown by the histopathology of LPP. Trichoscopy of DLE was visible with follicular plugging, yellow dots and thick arborizing blood vessels. In LPP the peripilar cast was the important finding. In dissecting cellulitis of the scalp the characteristic yellow dot with three-dimensional structure was observed. The Cohenâ&#x20AC;&#x;s kappa agreement was measured and found to be 0.89 between histopathological and trichoscopic diagnosis. Clinically and histopathologically overlapping features made the diagnosis of PCA very challenging. The necessity of scalp biopsy will be avoided by resorting to trichoscopy which may provide quick and reliable diagnosis. A clinical and histopathological study of cicatricial alopecia was conducted by Puri 10. The clinical variants and histopathology of cicatricial alopecia were studied using 40 patients. The major causes of cicatricial alopecia were lichen planopilaris (27.5%), discoid lupus erythematosus (25%), pseudopelade of Brocq (20%), systemic lupus erythematosus (5%). They were followed by scleroderma, dermatomyositis, keratosis follicularis spinulosa decalvans, aplasia cutis, kerion, follicular mucinosis, pemphigus, dissecting cellulitis of scalp/pyogenic folliculitis and acne keloidalis nuchae in 2.5% cases each. The morphological features were found in varying degrees. There were epidermal atrophy in 90%, erythema in 55%, follicular plugging in 40%, telangiectasia in 27.5%, diffuse scaling in 25% and mottled hyperpigmentation in 20% patients. The most common histopathological features were the following- perifollicular fibrosis in 65%, basal cell vacuolization in 52.5%, perifollicular lymphocytic infiltrate in 50%, epidermal atrophy in 35% and hyperkeratosis in 20% patients. In the studied population the common causes of cicatricial alopecia were lichen planopilaris, discoid lupus erythematosus, pseudopelade of Brock. Al-Hilo et al.

did a descriptive clinicopathological study (review of cases) which

was carried out in the outpatient clinic of dermatology and venereology in Al-Kindy ÂŠ 2017-2018 All Rights Reserved, No part of this document should be modified/used without prior consent Phd Assistanceâ&#x201E;˘ - Your trusted mentor since 2001 I www.phdassisatnce.com UK: The Portergate, Ecclesall Road, Sheffield, S11 8NX I UK # +44-1143520021, Info@Phdassistance.com

Teaching Hospital in Baghdad from December 2010 to April 2011. This study included 42 patients with cicatricial alopecia with the age ranging from 17 to 62 years with a mean age 35.07±11.23years. In fourteen male patients (33.3%) primary cicatricial alopecia was seen. There were twenty eight females (66.7%) and hence the female to male ratio was 2:1. In 17(40.5%) patients discoid lupus erythematosus was diagnosed and the female to male ratio was 4:6:1 with the age range 18-49 (32.2±8.44). In 12 patients (28.6%) lichen planopilaris was diagnosed with female to male ratio 2:1; their age ranged from 17-62 years (41.613.29). In 8 patients (19%) pseudopelade of Brocq was identified with female to male ratio 1:6:1. Their age ranged from 22-53 years (33.7±9.53). In 3 patients (7.1%) folliculitis decalvans was diagnosed with their ranging from 21-31 years (24.67±5.51). In 2 male patients (4.8%) acne keloidalis nuchae was diagnosed, their age range was 31-51 years (41±14.14). As per the findings of the study the pathogenesis of neutrophilic cicatrizing alopecia is not known. The usual process is to culture staphylococcus aureus from pustules, but whether it is a primary or secondary process is not clear. In neutrophilic cicatrizing alopecia the possible role of bacterial superantigens or a defect in cell-mediated immunity has been propagated. They observed preferential involvement of the posterior half of the scalp though the sites of occurrence may change. Follicular papules, plaques and areas of fibrosis on the posterior scalp are seen in folliculitis keloidalis. From a histopathological angle FD and folliculitis keloidalis may be the two clinical types of the same spectrum. The different clinical manifestations may happen due to the underlying differences in follicular anatomy or host response. Burnt-out or quiescent stages of neutrophilic cicatrizing alopecia have made some confusion with pseudopelade. A clinical and histological study of permanent alopecia after bone marrow transplantation was conducted by Basilio et al.71. The occurrence of permanent alopecia after

bone marrow transplantation is very rare but more cases involving high doses of chemotherapeutic agents used in the conditioning regimen for the transplant have been described. Busulfan stays associated in recent cases though it is classically described in cases of irreversible alopecia. Whether the pathogenesis is involved in hair loss is not clear. There are hardly any studies available in this regard. Besides the chemotherapeutic agents there is another factor which is a cause for alopecia. It is chronic graft-versus-host disease. There are no histopathological criteria for defining this diagnosis till date. The previous study aimed to examine clinical and histological aspects in the cases of permanent alopecia after bone marrow transplantation. The identifying features of permanent alopecia were triggered by myeloablative chemotherapy. Such alopecia was a manifestation of chronic graft-versus-host disease. Medical records of 7 patients served as the source of data. The description of the clinical features and review of slides and paraffin blocks of biopsies also figured in the dataset. Of the two distinct histological patterns, one was similar to androgenetic alopecia of non-scarring pattern and the other was similar to lichen planopilaris of scarring alopecia. The literature cases of permanent alopecia induced by chemotherapeutic agents were corroborated in the first pattern. The second pattern is in line with the manifestation of chronic graftversus-host disease on scalp which has not been described till date. The results facilitate the elucidation of factors involved in these cases including the development of therapeutic methods. Qi et al. 72 investigated the clinical features of primary cicatricial alopecia in Chinese patients. On primary cicatricial alopecia (PCR) there were few reports from Asia (PCA). The previous study attempts to study the clinical, pathological and dermoscopic characteristics of PCA among Chinese patients. The clinical data of 59 patients with PCA was retrospectively analysed. The dermoscopic, pathological treatment and prognosis characteristics were

analysed. The tests performed were Fisherâ&#x20AC;&#x;s Chi-square exact test and Kruskal-Wallis and Spearman rank correlation test. In this group the ratio neutrophilic to lymphocytic cicatricial alopecias was 1:3:1. Folliculitis decalvans was the most frequent disorder. Except alopecia mucinosa follicular openings were absent on dermoscopy in all cases. The characteristic feature of alopecia mucinosa was the presence of patulous follicular openings. The earliest feature after the treatment was an increase in short vellus hair. Other features like telangiectasia, epidermal scale, follicular hyperkeratosis, pustules and hair diameter diversity slowly decreased or even disappeared. In discoid lupus erythematosus after treatment improvement in the areas of hair loss was seen. Second in improvement was the case of folliculitis decalvans followed by patients with classic pseudopelade of Brocq. After the therapy was stopped, in nine patients (13.6%) the disease relapsed. For female patients treatment was needed for longer times. The major factors for the relapse of the disease were long duration, large areas of hair loss and shorter treatment courses. A rapid, practical and useful aid for the diagnosis of PCA will be given by dermatoscopy. It will also help to assess disease activity. The specific dermoscopic sign of alopecia mucinosa is the presence of patulous follicular openings. In China lichen planopilaris is less common compared to its incidence in the West. Lichen Planopilaris is a Common Scarring Alopecia among the Iraqi population which was studied by Sharquie et al.25. Discoid lupus erythematosus, lichen planopilaris and scarring folliculitis are the scarring alopecia which are also the common skin problems. The differentiation of these types is most often difficult. The descriptive studies were done at the Department of Dermatology- Baghdad Teaching Hospital from January 2010 to November 2012. Histological and dermatological examinations were carried out on sixty seven patients. All relevant points related to the disease were collected. For histopathological study punch

biopsies were done from ten patients. The mean age of onset of the disease was 36.7 ± 5 years whereas the mean duration of the disease was 4.4 ± 3 years. 1:4:1 was the male to female ratio. Pigmented scarring moth eaten alopecia surrounded by pigmented hyperkeratotic follicular papules was the characteristic lesions which involved mainly the fronto-vertical and parietal scalp. The common cause of scalp scarring alopecia in adults is lichen planopilaris. Its many characteristic clinical features facilitate the differentiation of it from other pathologic scalp conditions like discoid lupus erythematosus. Beheshtiroy et al.

conducted an epidemiological study of 97 cases of primary

cicatricial alopecia in Iran. This alopecia can cause major psychosocial disturbance. An evaluation of epidemiological features of primary cicatricial alopecia (PCA) was the aim of this study. The study determined epidemiological and histological types of scarring alopecia. Chi-squared test and t-test examined the relationship between different variables using SPSS16. 35 (36.1%) men and 62 (63.9%) women with an average age of 37 (SD=12.7) and a total of 97 cases constituted the subjects of the study. For total cases the female/male (F/M) ratio was 1:7:1, 1.92:1 for the lymphocytic type and 1:1.5 for the neutrophilic type. There was no relationship between the type of job (indoor or outdoor), clinical findings and histological types. The most common histological type (63.9%) was discoid lupus erythematous (DLE). Middle-aged individuals mainly got afflicted with PCA. The high percentage of DLE in this study reaffirmed some similar studies. A clinical, histopathologic and immunopathologic study on Scarring alopecia in discoid lupus erythematosus was performed by Fabbri et al.74.The very frequent feature of chronic discoid lupus erythematosus (DLE) is scarring alopecia. Only clinic-pathologic features or histopathologic-immunopathologic traits of DLE scarring alopecia (DLESA) have been reported till date. The most significant features of clinical morphology, histopathology, © 2017-2018 All Rights Reserved, No part of this document should be modified/used without prior consent Phd Assistance™ - Your trusted mentor since 2001 I www.phdassisatnce.com UK: The Portergate, Ecclesall Road, Sheffield, S11 8NX I UK # +44-1143520021, Info@Phdassistance.com

serum and tissue immunopathology of 36 DLESA patients (41% of all the referred scarring alopecia patients) were described in the previous paper. 33.3% of the patients had a single lesion and 52.7% of them presented multiple lesions of scarring alopecia clinically. 13.8% of them showed a picture which resembled pseudopelade of Brocq with the classic „footprints in the snow‟ appearance. Sclero-atrophy (80.5%) and erythema (63.8%) were the most frequent morphologic features. The main histopathologic aspects were fibrosis (100%), follicular hyperkeratosis (91.4%), epidermal atrophy (88.5%), thickened basement membrane (77.1%) and basal vacuolar degeneration (74.2%). In 42.8% patients antinuclear antibodies were present. In 17-21% of patients‟ antigastric mucosa, antithyroid and anticardiolipin antibodies were present. A positive lupus band test was showed in 81.8% of cases and perivascular deposit in 30.3% of patients. In 68.5% of cases histopathology alone showed a correct diagnosis. In other cases immunopathologic findings were also taken into account. The clinic, histopathologic and immunopathologic features of DLESA patients are defined in the previous study. It also shows that a multiparametric approach is obligatory in order to assess the diagnosis of DLESA. A clinic-pathological study of acquired primary cicatricial alopecias was conducted by Sowjanya et al.

. Alopecias are the skin conditions of hair loss are dominantly seen.

They are broadly classified into two type‟s namely non-scarring and scarring/cicatricial alopecias. A diverse group of diseases can be characterized by a lack of follicular ostia and irreversible alopecia which constitute the umbrella term cicatricial alopecias. The main purpose of why hair exists can be associated with social interactions as hair has a vital role to play in that case. That is precisely the reason that hair loss leads to significant psychological and emotional distress. An accurate and early diagnosis along with prompt intervention is necessary to prevent further follicular destruction. 50 patients with acquired primary

cicatricial alopecias constituted the study population and the study was conducted in the Dermatology Outpatient Department during the period from September 2008 to September 2010. In order of frequency the diagnosis was like the following- lichen planopilaris (LPP, 50%), discoid lupus erythematosus (DLE, 20%) and pseudopelade of Brocq (POB, 12%). 7:3:1 was the ratio of lymphocytic to neutrophilic cicatricial alopecias. There was a female predominance of lymphocytic cicatricial alopecias. Middle-aged people got predominantly affected by both LPP and DLE. The common cicatricial alopecias were LPP and DLE followed by pseudopelade. LPP is the most frequent cause of adult primary scarring alopecia in this study as opposed to the previous large scale studies which had showed DLE and/or pseudopelade as the foremost diagnosis. A careful clinicopathologic evaluation will ease an accurate diagnosis of cicatricial alopecia. In all cases early scalp biopsy is mandatory. When compared to the western population our setting witnesses an increased prevalence of alopecia. Additional large scale studies are necessary to establish a cause and pathogenesis in this regard. Kumar

did a Prospective Study on The Spectrum of Histopathological Lesions in

Scarring Alopecia. The malformation, damage or destruction of the pilosebaceous follicles lead to scarring or cicatricial alopecias. Pilosebaceous follicles get replaced by cicatricial tissue in a way that they cannot produce hair again. 32 biopsy-proven cases of SA who had attended the above mentioned hospital formed the subjects of the study. Primary SA was classified in accordance with the North American Hair Research Society. The consents of the subjects were very informative. The institutional ethical clearance also was obtained for the study. In order to analyse the data SPSS version 14 software was used. Frequencies and percentages described the data. 32 cases of scarring alopecia were diagnosed during the study period. 24 of them were primary SA and 8 were secondary SA. In the primary SA category

23 cases of lymphocyte were associated with primary scarring alopecias where 19 of them were of lupus erythematosus, 3 of lichen planopilaris (LPP) and one of non-specific SA. One case of neutrophil associated primary scarring (folliculitis decalvans) was also noticed. Among the secondary SA 4 cases of morphea and one case each of lupus vulgaris, congenital absence of skin, burn and sarcoidosis were also found. In conclusion histopathology is a reliable tool to identify the underlying cause in scarring alopecia. It is also helpful in an early diagnosis and treatment. Research Gap Hair loss is a common problem across the globe. There are no specific causes for hair loss being found till date as several factors and medical conditions challenge clinical experts to identify the real reasons behind hair loss. Additionally, the condition has no bias over gender, geographical location and so on. There is a lacuna in previous literature on the clinicopathological correlation in alopecia. Hence, the present study will identify the various causes of localized alopecia and will increase the awareness to prevent progression of scarring alopecia.

IV: MATERIAL AND METHOD Study Design Observational( cross sectional study) Source of Data Patients of either of the sex and of any age, coming in the dermatology OPD with Localized alopecia of scalp. Sample Size No. of patients with localized alopecia over a period of 18 months. Study Variables 

Age



Sex



Diabeties mellitus



Thyroid diseases



Atopic dermatitis.

Inclusion Criteria



All patients of localized alopecia affecting scalp.



Patients willing to undergo study.

Exclusion Criteria 

Patients of diffuse hair loss.( Androgenitic Alopecia., Anagen Effluvium, Telogen Effluvium, hair shaft abnormalities, congenital atrichia, congenital hypotrichosis) and patterned hair loss.

Appatarus & Materials The following materials and medical apparatus are used to diagnose the condition of alopecia in sample population1. Trichogram: Hair is plucked in order to examine the root and hair shaft. This is performed to examine the presence of fungi and other ectoparasites. This is an easy way of identifying a skin condition56. 2. WoodsLamp: used in the practice of dermatology for fungal infection detection in hair. The device is small, inexpensive, durable, sage and easy to use. Very recently, the apparatus is used to diagnose skin cancers57. 3. CultureSensitivity 4. PunchBiopsy: A quick and easy method of obtaining specimen for histological skin lesion assessment55. Data Collection Procedure 

All patients with features of localized alopecia who will be coming in the OPD will be subjected to Cutaneous examination.



Daily data collection will be done in a pre designed proforma and will be recorded.



The data will be compiled and analyzed and appropriate statistical test will be applied.

Study Outcome 

It will give an idea about the etilogical factor of localized alopecia.



The study will show clinical and pathological aspects of patients of localized alopecia.



It will give an idea of the demographic profile and prevelance of localized alopecia at dermatology OPD at a tertiary care centre

V: RESULTS The study design is Observational (Cross sectional study). Patients of either of the sex and of any age, coming in the Skin OPD, Peoples Hospital with Localized alopecia of scalp. The number of patients with localized alopecia in skin OPD is n= 150. All the analysis was carried out using SPSS 20.0 version. The results are presented in mean±SD and percentages. The chi-square test was used to compare the categorical/dichotomous variables among the groups. The p-value <0.05 was considered as significant. Table 1: Sex distribution of patients (n=150) S.no Sex

Number of patients Percentage

Male

39.3

Female 91

60.7

Total

100.0

150

Table 1 shows that there were 61% females and 39% males and female: male ratio was 1.5:1 Figure 1: Percentage of sex distribution of patients

39% 61%

Male Female

Table 2: Age distribution of patients (n=150) S.no Age group

Number of patients

Percentage

Below 10 years

25.3

11-20 years

31.3

21-30 years

22.7

31-40 years

8.7

41-50 years

7.3

51-60 years

4.0

61-70 years

Total

150

100.0

Table 2 shows that the maximum numbers of patients with cicatricial alopecia were between 11-20 years (31.3%), followed by 25% patients below 10 years, 23% between 21-30 years, 8.7% between 31-40 years, 7.3% between 41-50 years, 4% between 51-60 years and least 0.7% between 61-70 years. Figure 2: Percentage of age distribution of patients

Percentage

31.3 25.3

22.7

25 20 15

8.7

7.3 4

0.7

0 Below 10 years

11-20 years

21-30 years

31-40 years

41-50 years

51-60 years

61-70 years

Age group (in years)

Table 3: Descriptive statistics for duration (in months)

Duration (in months)

Mean

Maximum Minimum

5.68

9.27

60.00

.23

Table 3 presents the descriptive statistics for duration in months. The average duration is 6 months, SD 9.27 with maximum 60 months and minimum 0.23 months (approximately 7 days). Table 4: Aetiology of localised alopecia (n=150) S.no Disease

Number of cases Percentage

Alopecia Arreata 98

65.3

Tinea Capitis

16.7

LPP

12.0

DLE

2.0

Scalp Pyoderma 3

2.0

Pemphigus

Scalp Psoriasis

Post burn

Total

150

100.0

Table 4 shows that the maximum number of cases of non-cicatricial alopecia were of Alopecia Arreata (65%), followed by 16.7% of Tinea Capitis, 12% patients had LPP, DLE and Scalp Pyoderma in 2.0% cases each followed by Pemphigus, Scalp Psoriasis and Post burn in 0.7% cases each.

Percentage

Figure 3: Percentage of Aetiology of cicatricial alopecia 65.3

16.7

12 2

0.7

Scalp Pyoderma

Pemphigus

Scalp Psoriasis

Post burn

LPP

Tinea Capitis

Alopecia Arreata

2 DLE

70 60 50 40 30 20 10 0

Disease

Table 5: Localised alopecia disease based on different age group Disease

Age group

Frequency

Percent

(n)

(%)

Below 10 years

18.4

11-20 years

36.7

21-30 years

27.6

31-40 years

10.2

41-50 years

7.1

Total

100.0

Below 10 years

72.0

11-20 years

20.0

31-40 years

4.0

51-60 years

4.0

100.0

11-20 years

22.2

21-30 years

33.3

31-40 years

11.1

41-50 years

11.1

51-60 years

22.2

100.0

41-50 years

66.7

51-60 years

33.3

Total

100.0

Below 10 years

33.3

Alopecia Arreata

Tinea Capitis

Total

LPP

Total

DLE

Scalp Pyoderma

11-20 years

33.3

61-70 years

33.3

Total

100.0

Pemphigus

11-20 years

100.0

Scalp Psoriasis

Below 10 years

100.0

Post burn

21-30 years

100.0

Table 5 presents the number of patients with localized alopecia in different age group. A majority 36 patient with Alopecia Arreata is affected in the age group 11-20 years and 27 patients in 21-30 years. While majority 18 patients with Tinea Capitis is affected in the age group below 18 years and 5 patients in 11-20 years. 6 patients affected with LLP in the age group 21-30 years, 4 patients in 11-20 years and 51-60 years in each. While only 2 patients with DLE is affected in the age group 41-50 years. Only 1 patient with Scalp Pyoderma is affected in the age group below 10 years, 11-20 years and 61-70 years in each. 1 patient each with Pemphigus, Scalp Psoriasis and Post burn in the age group 11-20 years, below 10 years and 21-30 years respectively. Table 6: Aetiology of Cicatricial and Noncicatricial alopecia S.no Localised alopecia

Number of cases Percentage

Cicatricial Alopecia

Noncicatricial Alopecia/Non Scarring Alopecia 120

80.0

Total

100.0

150

20.0

Table 6 shows that the maximum number of cases of 80% was non-cicatricial alopecia while 20% were of Cicatricial Alopecia.

Figure 4: Percentage of Aetiology of cicatricial alopecia and noncicatricial alopecia

140

120

No. of Cases

120 100 80 60 30

40 20 0

Ciratricial Alopecia

Nonciratricial Alopecia/Non Scarring Alopecia

Localised alopecia

Figure 5: Percentage of Aetiology of cicatricial alopecia and noncicatricial alopecia by sex

70 No. of Cases

60 47

Ciratricial Alopecia

40 30 20

18 12

Nonciratricial Alopecia/Non Scarring Alopecia

0 Male

Female Sex

Figure 6: Percentage of Aetiology of cicatricial alopecia and noncicatricial alopecia by age group

61-70 years

51-60 years

Age group

41-50 years

5 4

31-40 years

21-30 years

11-20 years

Below 10 years

Nonciratricial Alopecia/Non Scarring Alopecia

11 27 40 33

5 0

Ciratricial Alopecia

No. of Cases

No.of cases

Figure 7: Percentage of Aetiology of cicatricial alopecia

20 18 16 14 12 10 8 6 4 2 0

7 3 1 Tinea Capitis

LPP

DLE

Pemphigus Post burn

Disease

Figure 8: Percentage of Aetiology of Noncicatricial alopecia

120

No.of cases

100

80 60 40 18

Scalp Pyoderma

Scalp Psoriasis

0 Alopecia Arreata

Tinea Capitis

Disease

Table 7: Number of cases with Diabetes patients (n=150) S.no

Diabetes

Number of cases

Percentage

Absent

141

94.0

Present

6.0

Total

150

100.0

Table 7 presents that minimum number of cases (9) was noticed diabetes and 141 cases without diabetes.

Figure 9: Percentage of cases with Diabetes patients

Present Diabetes

Absent

100

Percentage

Table 8: Number of cases with Thyroid patients (n=150) S.no

Thyroid

Number of cases

Percentage

Absent

137

91.3

Present

8.7

Total

150

100.0

Table 8 presents that minimum number of cases (13) was noticed Thyroid and 137 cases without Thyroid.

Figure 10: Percentage of cases with Thyroid patients

Present Thyroid

8.7

Absent

91.3

100

Percentage

Table 9: Number of cases with Atopic Dermatitis patients (n=150) S.no Atopic Dermatitis

Number of cases

Percentage

Absent

145

96.7

Present

3.3

Total

150

100.0

Table 9 presents that minimum number of cases (5) was noticed Atopic Dermatitis and 145 cases without Atopic Dermatitis.

Atopic Dermatitis

Figure 11: Percentage of cases with Atopic Dermatitis patients

Present

3.3

Absent

96.7

100

120

Percentage

Table 10: Association between sex and number of cases with diabetes Diabetes Chi-square Sex

Absent

Present Total (p-value)

n(%) Male

57 (40.4)

2 (22.2)

59 (39.3)

Female 84 (59.6)

7 (77.8)

91 (60.7)

1.175 (0.278) Total

141 (100.0) 9 (100.0) 150 (100.0) Table 10 compares the sex and diabetes. It is observed that 61% of the participants

were female. Majority of both gender groups did not pertain diabetes. However only 7 females and 2 males were identified diabetes. From the observed chi square value of 1.175 and p value of 0.278 which is greater than 0.05 so it is declared that there is no association between the sex and diabetes.

Table 11: Association between sex and number of cases with thyroid Thyroid Chi-square Sex

Absent

Present

Total (p-value)

n(%) Male

58 (42.3)

1 (7.7)

59 (39.3) 5.972

Female

79 (57.7)

12 (92.3)

91 (60.7) (0.015*)

Total

137 (100.0)

13 (100.0) 150 (100.0)

*p<0.05 Table 11 compares the sex and thyroid. It is observed that 61% of the participants were female. Majority of both gender groups did not pertain thyroid. However only 12 females and 1 male were identified thyroid. From the observed chi square value of 5.972 and p value of 0.015 which is less than 0.05 so it is declared that there is an association between the sex and thyroid. Table 12: Association between sex and number of cases with atopic dermatitis Atopic Dermatitis Chi-square Sex

Absent

Present

Total (p-value)

n(%) Male

59 (100.0)

0 (0.0)

59 (39.3) 3.354

Female 86 (59.3)

5 (100.0) 91 (60.7) (0.067)

Total

145 (100.0) 5 (100.0) 150 (100.0) Table 12 compares the sex and atopic dermatitis. It is observed that 61% of the

participants were female. Majority of both gender groups did not pertain atopic dermatitis. However only 5 females were identified atopic dermatitis. From the observed chi square ÂŠ 2017-2018 All Rights Reserved, No part of this document should be modified/used without prior consent Phd Assistanceâ&#x201E;˘ - Your trusted mentor since 2001 I www.phdassisatnce.com UK: The Portergate, Ecclesall Road, Sheffield, S11 8NX I UK # +44-1143520021, Info@Phdassistance.com

value of 3.354 and p value of 0.067 which is greater than 0.05 so it is declared that there is no association between the sex and atopic dermatitis. Table 13: Association between Age group and number of cases with Diabetes Diabetes Chi-square Age group

Absent

Present

Total (p-value)

n (%) Below 10 years

38 (27.0)

0 (0.0)

38 (25.3)

11-20 years

47 (33.3)

0 (0.0)

47 (31.3)

21-30 years

33 (23.4)

1 (11.1)

34 (22.7)

31-40 years

13 (9.2)

0 (0.0)

13 (8.7)

61.063

41-50 years

7 (5.0)

4 (44.4)

11 (7.3)

(0.000**)

51-60 years

3 (2.1)

3 (33.3)

6 (4.0)

61-70 years

0 (0.0)

1 (11.1)

1 (0.7)

Total

141 (100.0)

9 (100.0)

150 (100.0)

**p<0.01 Table 13 compares the age group and diabetes. It is observed that 31% of the participants belong to 11-20 years of age group. Further 41-50 years (44.4%) age group pertain diabetes while 11-20 years (33.3%) age group did not pertain diabetes. From the observed chi square value of 61.063 and p value of 0.000 which is less than 0.01 so it is declared that there is an association between the age group and diabetes.

Table 14: Association between Age group and number of cases with Thyroid Thyroid Chi-square Age group

Absent

Present

Total (p-value)

n(%) Below 10 years 38 (27.7)

0 (0.0)

38 (25.3)

11-20 years

47 (34.3)

0 (0.0)

47 (31.3)

21-30 years

29 (21.2)

5 (38.5)

34 (22.7)

31-40 years

11 (8.0)

2 (15.4)

13 (8.7)

25.741

41-50 years

7 (5.1)

4 (30.8)

11 (7.3)

(0.000**)

51-60 years

4 (2.9)

2 (15.4)

6 (4.0)

61-70 years

1 (0.7)

0 (0.0)

1 (0.7)

Total

137 (100.0) 13 (100.0) 150 (100.0)

**p<0.01 Table 14 compares the age group and thyroid. It is observed that 31% of the participants belong to 11-20 years of age group. Further 21-30 years (38.5%) age group pertain thyroid while 11-20 years (34.3%) age group did not pertain thyroid. From the observed chi square value of 25.741 and p value of 0.000 which is less than 0.01 so it is declared that there is an association between the age group and thyroid.

Table 15: Association between Age group and number of cases with Atopic Dermatitis Atopic Dermatitis Chi-square Age group

Absent

Present Total (p-value)

n(%) Below 10 years 37 (25.5)

1 (20.0)

38 (25.3)

11-20 years

43 (29.7)

4 (80.0)

47 (31.3)

21-30 years

34 (23.4)

0 (0.0)

34 (22.7)

31-40 years

13 (9.0)

0 (0.0)

13 (8.7)

6.209

41-50 years

11 (7.6)

0 (0.0)

11 (7.3)

(0.400)

51-60 years

6 (4.1)

0 (0.0)

6 (4.0)

61-70 years

1 (0.7)

0 (0.0)

1 (0.7)

Total

145 (100.0) 5 (100.0) 150 (100.0) Table 15 compares the age group and atopic dermatitis. It is observed that 31% of the

participants belong to 11-20 years of age group. Majority of 11-20 years age group did not pertain to atopic dermatitis. However only 43 did not have atopic dermatitis and 4 have atopic dermatitis. From the observed chi square value of 6.209 and p value of 0.400 which is greater than 0.05 so it is declared that there is no association between the age group and atopic dermatitis.

VI: DISCUSSION AND CONCLUSION The present chapter discusses the findings of the present research wherein the following are the objectives to recap- To study the clinical and pathological aspects of patients with localized alopecia, to find out aetiology of localized alopecia, to study the demographic profile and prevalence of patients of localized alopecia in skin Out Patient Department at Peoples college of medical science and research centre, Bhopal. In this regard, the results of the present research are discussed as follows:

Analysis of Demographic variables A total of 150 patients both male and female representatives are considered as the sample size of the present research. The study area is the skin Out Patient Department at Peoples college of medical science and research centre, Bhopal wherein the inclusion and exclusion criteria for the selection of patients have been extensively covered in Chapter III. The number of male and female patients considered in the present study is found to be 59 and 91 respectively and the percentage distribution is found to be 39.3 and 60.7 percentage. The increased number of female patients with localised alopecia treated in hospitals is evident even in a previous research by Puri

which states that female patients outnumber male

patients with the ratio of 1.5:1. Female predominance of localised alopecia is also discerned by Wu et al.

wherein the previous study denoted the male/ female ratio of localised

alopecia in the selected patients to be 1:2. Furthermore, the prevalence of localised alopecia in selected patients in terms of age is analysed which revealed the maximum number of patients (n=47, 31.3 %) to be found within the age group of 11-20 years. This is in line with the study findings of Price

which states that more than 60 per cent of the patients

considered in the previous research developed the first patch before the age of 20. However, Panda et al.

revealed that the onset of baldness arrives before 40 years of age when

considering the male participants of the previous study. On a general note, Camacho 78 states the prevalence of the condition to be within the age of 20-40 years. However, combining the findings of the previous works and the present research, it is clear that the onset of localised alopecia occurs during the age frame of 11-40 years on the whole. Hair loss during the period of adolescence has become a common issue and the prevalence of alopecia in the teenage group is evident from previous researches. According to Messenger et al.

and Hordinsky and Donati

, the incidence of localised hair loss is

different in various nations. A study by Gonzalez et al.

revealed that androgenetic

alopecia is the common hair loss condition in adolescence; however, Alopecia areata (AA) is common in patients aged between 11 and 20, according to a study by Tan et al.

and

Sharma et al. 83. The next highest distribution of localised alopecia cases could be seen within the „less than 10 year olds‟ (n=38, 25.3 %), following which are , 22.7 % between 21-30 years (n=34), 8.7% between 31-40 years (n=13), 7.3% between 41-50 years (n=11), 4% between 51-60 years (n=6) and least 0.7% between 61-70 years (n=1). The results reveal the peak incidence of localised alopecia which occurs during the adolescence and persist throughout the life (chronic condition) which is in line with the findings of Bergfeld and Mulinari-Brenner

. However, a considerable amount of paediatric onset is also seen in the

present research. Paediatric cases in this regard would be more challenging for its management and a cocktail of therapies would benefit the treatment

. However, only one

patient was found to be within the age group of 60-70 years. Only rare cases of localised alopecia, especially Alopecia areata are found in previous reports. A 10-Year Retrospective Study to examine the prevalence of Alopecia areata in elderly population of Korea was conducted by Jang et al. 86 which concluded the decreased immune system ability in old aged population that is associated with decreased incidence of the condition after 60 years. The

descriptive statistics of the duration of disease witness by patients revealed a mean of 6 months, a maximum of 60 months and a minimum of 7 days.

Aetiology of localised alopecia From the total number of cases considered for the present research (n=150), more number of cases were recorded with the condition of Alopecia Areata wherein 65 per cent of the cases witnessed the same. Alopecia areata is the common cause of localised hair loss almost in all researches confined with the analysis of localised alopecia

. Following the

cases of Alopecia Areata, the next maximum number of cases fall within the category of Tinea Capitis (n=25, 16.7 per cent), 18 patients with Lichen planopilaris, 3 patients each in both DLE and Scalp Pyoderma. However, only one patient with 0.7 per cent each falls with Pemphigus, Scalp Psoriasis, and post burn. In terms of separating localised alopecia into cicatricial and non-cicatricial alopecia, 120 cases (80 per cent) were found to be affected by Non-cicatricial Alopecia/Non Scarring Alopecia whereas the rest (30 cases, 20 per cent) had cicatricial alopecia. Considering the number of cases of cicatricial and non-cicatricial alopecia in terms of gender based distribution, it is revealed that more number of cases in both scaring and non-scaring alopecia is found in female patients than male population considered in the study. The results of Table 5 reveal the frequency of localised alopecia based on its categories with respect to age ranges. To begin with, Alopecia Areata has the more number of cases wherein the incidence of the disease according to the present research reveals the age group of 11-20 years. However, bald localised patches may occur within the age frame of „below 10 years‟ to ‟31-40 years‟ which is in line with the results of Panda et al.

. A

previous study by Bhat et al. Bhat et al. (2014) also revealed that fact that though the onset

age is not exactly known; more than 50-60 per cent of Alopecia Areata cases belong to the „less than 20 years‟ range, which is compatible with the findings of the study. Tinea Capitis is identified to be the second most cause of localised alopecia in the present research with the onset of the disease majorly on the „below 10 years‟ age group. Tinea Capitis occurs mostly in children and the prevalence is more common in female children 89. In a study conducted in Africa, around 10-30 per cent of children below 10 years of age are affected by Tinea capitis 90

. Moto et al.

also revealed the prevalence of Tinea Capitis in children belonging to the

age group of 3-8 years. With the findings, it is further revealed that the condition occurs more predominantly in children below the age of 10. The occurrence of Lichen planopilaris (LPP) in the Indian context according to the present research reveals the onset predominantly in the age group of 21-30. This is similar to the findings of Parihar et al.

which claims the majority of Indian cases of LPP to be

belonging to the age group of 21-40. Furthermore, only 3 cases of Discoid Lupus Erythematosus (DLE) were identified in the research wherein out of 3, 2 cases belonged to the age group of 41-50 years. The onset of the condition according to Al-Saif et al.

around 36.5 years which could also align with the findings of the present research. Among different populations, the onset of DLE could be found after 30 years

94–97

. Scalp Pyoderma

was found in 3 cases belonging to „Below 10 years‟, „11-20 years‟, and „61-70 years‟. One case of pemphigus was found in the age group of 11-20 years, one case of scalp psoriasis in „below 10 years‟, and one case of post burn in „21-30 years‟.‟ The cases of localised alopecia are examined on the basis of age group which specified more number of cases in the non-cicatricial alopecia 11-20 year age group. The Aetiology of cicatricial alopecia and noncicatricial alopecia with respect to age group revealed more number of cicatricial alopecia in the age group of 51-60 years. However,

previous researches claimed cicatricial alopecia to occur in the age group between 20-50 years. A study by Bharathi 98 revealed a majority of cicatricial alopecia cases in the age group of 20-40 years whereas in the Iraqi population Sharquie et al.

claims the mean onset of

cicatricial alopecia to be within 36.7 Âą 5 years. However, in the Indian context, the present study reveals majority of cicatricial alopecia cases in the age group of 51-60 years. Noncicatricial alopecia is found to be the most prevalent type of alopecia in patients and the condition of Alopecia areata is the most common form of alopecia found in the study population with a number of 98 patients affected from the overall sample size of 150. The present study however hypothesised the prevalence of localised alopecia which may be associated with other diseases such as diabetes, thyroid conditions, and atopic dermatitis. It is revealed that on the overall population, only 9 out of 150 patients were noticed with diabetes. Furthermore, 13 out of 150 patients suffer from thyroid dysfunction and 5 out of 150 patients were noticed with Atopic dermatitis. Hormonal imbalances have been long claimed to be the reasons for hair loss and localised alopecia in human beings which includes the role of hypothyroidism and hyperadrenocorticism. However, these imbalances are often associated with the pattern baldness scenario (androgenetic alopecia)

which is not the purview of the present research. In this regard, it is discerned that in the present study, with the specified inclusion criteria neglecting the cases of diffuse and patterned hair loss there is no significant relationship existing between localised alopecia and diseases such as diabetes, thyroid dysfunction and atopic dermatitis. However, previous literature claimed that autoimmune factors such as the presence of thyroid disorders and diabetes may contribute to the pathogenesis of alopecia

100

. Shahzadi et al.

101

discerned the

fact that autoimmune factors such as atopic dermatitis, family history, hypothyroidism and diabetes are important factors which needs to be examined so as to treat patients

appropriately. However, the present study revealed the association of age group and number of cases with diabetes, thyroid dysfunction and atopic dermatitis. Diabetes and thyroid dysfunction cases were found in the age group above 20 years; however, the number of cases of Atopic Dermatitis is found in the below ten years group (n=1) and 11-20 years (n=4). The onset of atopic dermatitis occurs during the paediatric stages and may progress to teenage or adult years

102

and hence the results of the study reveal the commonness of the condition in

the age group and are not associated with hair loss. The most common cause of Cicatricial alopecia in the present research population is Lichen planopilaris which is a common form of cicatricial alopecia. The condition occurs with lymphocytic inflammation which destroys the follicle germ cells. Early intervention in this condition is required so as to treat it accordingly

103

. However, the most common cause

of non-cicatricial alopecia in the research population considered is Alopecia Areata. Alopecia Areata is a chronic condition which affects the nails and pilar follicles. The disease aetiology is commonly unknown; however, the condition is normally auto-immune

104

. Hence, the

present research claims alopecia areata to be the most common condition of localised alopecia and the category of non-cicatricial alopecia is more prevalent in the study region of the present research.

Conclusion Localised hair loss or localised alopecia is a common condition in India. A dire need persisted to examine the prevalence of localised hair loss in the Indian context wherein the present research is a clinicopathological study of localised hair loss. The most common condition in the present clinicopathological study is Alopecia Areata. A 18-month period of study collected data about the patients arriving at the skin outpatient department of the at Peoples College, Bhopal which was analysed so as to obtain information with regard to the ÂŠ 2017-2018 All Rights Reserved, No part of this document should be modified/used without prior consent Phd Assistanceâ&#x201E;˘ - Your trusted mentor since 2001 I www.phdassisatnce.com UK: The Portergate, Ecclesall Road, Sheffield, S11 8NX I UK # +44-1143520021, Info@Phdassistance.com

clinical and pathological aspects of patients with localized alopecia, the aetiology of localised alopecia and the prevalence in the study region. The study is an analysis of patients belonging to both genders with the cases of localised alopecia neglecting other cases such as diffused and patterned hair loss. The most common cases of localised alopecia combining both cicactricial and noncicatricial forms revealed 8 distinct conditions that lead to localised alopecia in patients satisfying the inclusion criteria- Alopecia Arreata, Tinea Capitis LPP, DLE, Scalp Pyoderma, Pemphigus, Scalp Psoriasis, and Post burn. The findings of statistical analysis on the prevalence of the aforementioned conditions/ causes of localised alopecia were compared with previous literature which revealed similar results. However, the study further revealed lack of association between diseases such as diabetes, thyroidal dysfunction and atopic dermatitis which is attributed to the fact that these autoimmune diseases are important factors, yet their association with the condition of hair-loss is not related. Analysis of previous researches in this context revealed hormonal imbalance to be associated with diffused and patterned hair loss which is not associated with localised alopecia and hence the number of patients suffering from these disorders are less in the considered population. Similarly, the number of atopic dermatitis cases is also less which shows lack of association between the condition and localised alopecia. Furthermore, the number of non-cicatricial alopecias is higher than that of cicatricial alopecias and alopecia areata is the common condition of noncicatricial alopecia. The study attempts to provide novel findings on the basis of prevalence of localised alopecia. Localised alopecia, other than diffused alopecia is hard to treat and requires careful examination of the disease nature which in turn aids appropriate treatment. It is discerned in the present study that localised alopecia is found to be prevalent more in age groups such as ÂŠ 2017-2018 All Rights Reserved, No part of this document should be modified/used without prior consent Phd Assistanceâ&#x201E;˘ - Your trusted mentor since 2001 I www.phdassisatnce.com UK: The Portergate, Ecclesall Road, Sheffield, S11 8NX I UK # +44-1143520021, Info@Phdassistance.com

11- 20 years, 21- 30 years, and 31- 40 years. With reference to the literature review, it is however clear that several factors such as genetics, autoimmunity, nutritional factors and so on contribute to the disease. Considering these factors with the age groups reveals a close association with the onset of disease and the developmental phases of the human body which could be conducted as a future study. Furthermore, the present research recommends future studies to be conducted so as to analyse the causes and treatment methods of non-cicatricial alopecia with special emphasis to be laid upon the treatment of Alopecia areata.

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