Disorders of the Hair and Nail: Diagnosis and Treatment

Chapter 48: Hair Breakage

Sasini Bentota; Antonella Tosti

SUMMARY

There are multiple etiologies of hair breakage.
Fungal infections, anagen effluvium (chemotherapy, radiotherapy, alopecia areata), trichotillomania, congenital or acquired hair shaft disorders, friction, tension hairstyling, and overprocessing of hair are some of the main etiologies.

TIPS FOR DIAGNOSIS

For diagnosis, review the patient’s history, family history, nutritional status, hairstyles, and social history.
The tug test is an easy way to confirm acquired breakage from trichorrhexix nodosa.
Trichoscopy is a wonderful diagnostic tool to identify sites of hair breakage.

TIPS FOR TREATMENT

If caused by tinea capitis, treat with oral and topical antifungals.
If caused by trichotillomania, treat with cognitive behavioral therapy and SSRIs.
If caused by anagen effluvium, discontinue insult if appropriate.
Gentle management with avoidance of friction, chemical, and heat are necessary in the case of acquired trichorrhexis nodosa.

DON’T FORGET

Not all hair-shaft disorders are associated with hair breakage.

PITFALL AND CAUTION

Patients with hair breakage usually complain of increased shedding or of arrested hair growth.

EXPERT PEARLS

Always examine the hair strands that are extracted with pull and tug test by dermoscopy to detect if the shaft is broken or has a tip.
Ask the patient if they find hair fragments in the sink when brushing or combing.
The patients rarely complain of breakage. The more likely complaint is typically of hair not growing long or unusual hair texture or appearance.

PATIENT EDUCATION POINTS

Treating hair gently lessens damage to the hair follicles and strands.
Adequate protein intake is necessary for hair health.

Hair breakage has multiple etiologies, including genetic and acquired conditions. Hair breakage has major implications on patients’ self-esteem and may have a high psychological impact. It is important that physicians recognize the difference between hair breakage and hair loss, as sometimes hair breakage can be readily mistaken for alopecia. This condition may also provide clues towards other health concerns.

EPIDEMIOLOGY

Certain etiologies have higher incidences among certain populations. Trichotillomania is more common in women. The male to female ratio is 1:10.¹ Tinea capitis is more common in prepubertal children of 3 to 7 years of age, especially those living in poverty and crowded living conditions.² Hair breakeage due to acquired trichorrhexis nodosa is more common in populations that use chemical treatments or thermal devices to straighten and/or bleach the hair (Figs. 48.1, 48.2, 48.3).