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SPOT DIAGNOSIS
Professor Dedee Murrell is head of dermatology at St George Hospital , Sydney , and conjoint professor at UNSW Sydney . This article was co-authored by Henry Tseng , a medical student at UNSW Sydney ; and Dr Corey Stone , a dermatology research fellow at Premier Specialists and St George Hospital , Sydney .
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What is behind this hair loss ?
A 30-YEAR-old woman presents with sudden-onset hair loss that began as a small round patch on the back of her head . The patch has gradually increased in size , with additional patches appearing on other areas . There is no redness , itching or pain . The hair loss began three weeks after she lost her job . She reports feeling self-conscious and experiencing distress because of the hair loss . On examination , the affected areas are smooth and non-uniform and the remaining hair is easily pulled . There are no signs of inflammation or scarring in the patches , and the remaining scalp hair appears healthy . There is no hair breakage or thinning elsewhere on the body and no evidence of underlying systemic or infectious causes . Investigations — including FBC , thyroid function and iron studies — are normal .
During another brief hospital admission , with her blood glucose hovering around 30mmol / L , Frankie notices blurred vision . Her vision improves once she returns to her now-usual diet and improved blood glucose levels .
Talking with her GP friend , Frankie learns more about how to manage type 2 diabetes through dietary change . Over several months , Frankie loses 12kg and then stops insulin altogether .
Initially , normal blood glucose levels caused hypoglycaemic symptoms ; however , Frankie now tolerates blood glucose levels in the range of 4.5-8mmol / L .
Feeling better , she becomes interested in exercise , walking around her house and across
the street without the wheelie walker . She spends up to 30 minutes a day using a pedal exerciser .
Eight months after starting the low-carb diet , Frankie ’ s HbA1c has fallen to 6.5 %. Her blood pressure is 130 / 75mm / Hg and weight is 61kg .
Discussion
The adverse metabolic effects of antipsychotic drugs are well known . In one prospective study , 36.6 % of patients on clozapine developed type 2 diabetes within five years of starting treatment . 1 Unhealthy lifestyle habits in people with major mental illness also contribute to high rates of obesity and metabolic disease .
Type 2 diabetes remission may be achieved through bariatric surgery , very low-calorie meal replacements and low-carbohydrate dietary approaches . 2 Diabetes remission can be achieved in the context of primary care , with UK data showing an overall remission rate of 51 % among patients adopting the low-carbohydrate approach . 3 The remission rate is higher among those who adopt this approach within a year of diagnosis and lower among those diagnosed more than 15 years previously . That said , people with long-term diabetes can still achieve clinically important improvements in HbA1c even if they do not achieve drug-free remission . 3
Many patients who use low-carb diets feel unsupported by their doctors . 4 Advice from a trusted GP friend helped Frankie succeed , particularly during the first weeks of dietary change when rapid falls in blood glucose necessitate close supervision and tailored reduction of medication . 5
A strong support system and patient education are among the predictors of success with
The type 2 diabetes remission rate is higher among those who adopt a low-carbohydrate approach within a year of diagnosis .
this approach . 6 Frankie ’ s experience of better glucose control motivated her to continue , and the adverse effects from acute hyperglycaemia in the setting of a high-carbohydrate hospital diet were an additional incentive . 7
Diets provided by hospitals and similar institutions are determined by the Australian Dietary Guidelines . They promote a high-carbohydrate approach , meaning 45-65 % of daily energy as carbohydrate . 8 This equates to a metabolic load of around three glucose tolerance tests daily , which often undermines glucose control for people with diabetes ( see figure 1 ).
Outcome
Frankie still has multiple health problems and recognises that a low-carb diet will not resolve all her afflictions . But for the first time in years , she is more optimistic about her health and her future . Meanwhile , Frankie ’ s usual GP remains astonished by her progress .
References on request from kate . kelso @ adg . com . au
Figure 1 . Hospital meal for a patient with diabetes , providing 73g of carbohydrate , as well as likely elevated blood glucose .
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What is the most likely diagnosis ? a Trichotillomania b Alopecia areata c Telogen effluvium d Traction alopecia
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ANSWER The answer is B . Alopecia areata is an autoimmune condition characterised by sudden patchy hair loss , which can progress to total scalp and / or body hair loss . 1 The affected skin appears normal , without any signs of inflammation or scarring . Telltale ‘ exclamation point hairs ’ — broken strands with a relatively thick distal portion and thin proximal portion — may be evident at the periphery of bald patches . An additional suggestive diagnostic feature is a positive hair pull test , whereby gentle traction results in easy removal of more than 10 % of a group of 40-60 closely grouped hairs . 2
The aetiopathogenesis is complex . Multiple factors may play a role , including genetic predisposition , atopy and background autoimmune disease , with hair loss potentially triggered by stressors , including viral infections , local trauma or psychosocial stress . 3
Diagnosis is typically clinical , based on the presentation , trichoscopy and hair pull test , but skin biopsy may be warranted in cases of diagnostic uncertainty .
Mild cases can be managed with potent topical corticosteroids , intralesional steroids , topical minoxidil or dithranol . Systemic options for severe disease include topical immunotherapy , systemic corticosteroids and Janus kinase inhibitors . 2
Trichotillomania is a compulsive hair-pulling disorder that can cause patchy hair loss . 4 This is suggested by a history of hair pulling or other self-injurious behaviours . Telogen effluvium is characterised by excessive shedding of hair from the scalp as a result of disruption to the normal hair growth cycle . It is often associated with a physical or emotional trigger event , which causes the hair follicles to enter the telogen ( resting ) phase prematurely . 5 The resulting hair loss is typically diffuse , affecting the entire scalp . Traction alopecia is caused by prolonged tension on the hair follicles from tight hairstyles or hair extensions . 6 It typically affects the front and sides of the scalp , although the location varies depending on individual hair care practices . There is usually associated inflammation and itching , and scarring may occur . 6
References on request from kate . kelso @ adg . com . au