**2. Diagnosis**

**Telogen effluvium** is characterized by diffuse loss of telogen hair. Telogen effluvium is a non‐inflammatory disease. The main reason for this disease is still unknown, but it is most frequent reason for hair loss. In a normal scalp, 90–95% of the hair follicles are in the anagen phase, and 5–10% are in the telogen phase. It is normal to lose 100 hairs in a day. In telogen effluvium disease, the ratio or the number of hair follicles increases. According to various follicular cycles, five types of functional telogen effluvium have been found. The types include the immediate anagen release, delayed anagen release, immediate telogen release, delayed telogen release and short anagen phase. The pathological causes of this disease are exogenous factors, inflammatory diseases, some drugs and connective tissue disorders such as systemic lupus erythematous, stress, organ dysfunctions, endocrine dis‐

This disease can be seen as acute and chronic and it is classified according to its duration. If the duration of disease is shorter than 6 months, it is known as acute telogen effluvium; if the hair loss is longer than 6 months, it is accepted as chronic telogen effluvium. The hair loss can be apparent 2 or 3 months later in acute telogen effluvium disease. The aetiologic factors or events of telogen effluvium may not be detected in 33% of the patients. Some tests can be applied to patients such as the hair‐pull test and the result of this test is positive. In addition to that, inflammation is not found in telogen effluvium. In the trichogram test, the telogen hair ratio reaches above 25% in telogen effluvium. A fine evaluation is to be done to understand the real cause and the most substantial factors: to treat telogen effluvium is to find the natural process of telogen effluvium. If the triggering factor of this disease can be found and stopped,

**Trichotillomania** was observed several years ago, but there have been little data about treatment and its etiology. It can be described as an impulse control disorder and it is identified by chronic hair pulling. Trichotillomania (hair‐pulling disorder) is a type of trac‐ tional alopecia. In every types of hair loss, this disease has also affected the quality of life and relations in a negative way. When we look at the history of the disease, it was identified in *DSM‐III‐R* (*Diagnostic and Statistical Manual of Mental Disorders*, Third Edition) in 1987; in that study, continual hair pulling was described as a psychiatric disorder. Hair pulling is not known as rational behaviour in medical condition (e.g., dermatological problems) and it is a psychiatric disorder. The repeated attitude cannot be stopped and finally it causes hair loss. The reason for this disease can also be subjective nuisance and deterioration in social life. The patients not only pull the hair from the scalp but they also pull the hair from other body areas such as the eyebrows, beard, eyelashes, arms, groin and moustache.

The symptoms of trichotillomania resemble the obsessive‐compulsive spectrum, so this dis‐ ease is mainly included among psychiatric diseases [17]. Trichotillomania usually begins in early ages and become chronic with gradual events. It can also be seen in adolescence at the beginning of 12 years. The adults can also face this disease at old ages. Trichotillomania can be confused with AA in older patients in the first phase of the disease because it appeared mostly in females [18, 19]. When we observe more than a third of paediatric patients with trichotil‐ lomania, there have been many psychiatric disorders such as attention deficit‐hyperactivity disorder, anxiety disorder, obsessive‐compulsive disorder and depression. But unfortunately,

orders, syphilis and nutritional causes.

6 Hair and Scalp Disorders

hair loss will generally decrease within 3–6 months [15, 16].

It has been understood that there have been many reasons for hair loss. Dermatologists always apply different methods for finding the main evidence of the disease. The dermatologist also will carefully look at patient's scalp and hair. For instance, they have to pull their patients' hair to get the true results, and it is named as 'pull test'. Pulling hair test can be helpful to describe the process of hair loss. And dermatologists should sometimes observe the whole body to understand the ratio of hair loss. To make sure about the evidence, they also use blood tests. By using blood tests, they can find other reasons for hair loss such as iron defi‐ ciency, anaemia, thyroid disease or vitamin deficiencies. The dermatologists can also apply punch biopsy to detect histopathological reasons. All of the applications should be done to find out some clues in your scalp [22].

Although medical treatment is a useful method for patients and physicians, the results of treatment could be unsuccessful. Instead of other techniques, hair transplantation should be used for androgenetic alopecia. Hair transplantation method is essential not only for androge‐ netic alopecia but also good for other kinds of hair loss. The other kinds of problems include cicatricial alopecias, congenital alopecias, post‐burn sequelae and alopecia areata [23]. Lately, hair transplantation has been common for treating hair loss. 'Follicular unit transplantation' and 'Follicular unit extraction' are the main types of this method. In follicular unit transplan‐ tation, occipital region is the main area for taking skin patches; they can be separated manu‐ ally to grafts and put to the recipient area. 'Follicular unit extraction' is the other method in order to treat hair loss. In this method, 1‐mm diameter micrografts are taken from the donor area and they are transferred to predrilled holes. This technique is less painful and more comfortable for patients because it does not cause a linear scar. The essential disadvantage of this treatment is that patients should spend much more time for extracting grafts. Due to the 'punched–out' sites, donor transferring into the area can be limited [24, 25].
