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A simple and reliable clinical indicator for rapid evaluation of neuropathy in busy diabetes clinics: “Hair loss sign”
Sarosh Katrak1, Amit Chaudhari2, Riddhi Patel2, Satish Khadilkar2
1 Department of Neurology, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India
2 Department of Neurology, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
Diabetes mellitus (DM) currently affects more than 62 million Indians.[1] Studies show that approximately 20% of the patients with diabetes have peripheral neuropathy. Evaluation of diabetic neuropathy is important as it has a bearing on the comprehensive management. Conventional evaluation involves testing the sensory, motor and autonomic functions along with deep tendon reflexes. This is a time consuming process.
The huge workload in Diabetes Outpatient clinics in India calls for a simple indicator towards the neuropathic process. One of us (S M Katrak) had observed that the loss of hair on the legs, signifying autonomic neuropathy gives a lead to the extent of somatosensory neuropathic deficits. To test this clinical observation, we designed this study. The study was approved by the Institutional Ethics Committee.
Patients with DM reporting paresthesias were included in the study. After obtaining informed valid consent, history was recorded (age, sex, duration of DM, peripheral and autonomic symptoms viz. paresthesias, constipation, urinary complaints, abnormal sweating, and exercise intolerance) and clinical examination was performed (motor system, sensory system viz. fine and crude touch, pain and temperature, vibration and position sense were noted; reflexes and autonomic system viz. resting tachycardia, orthostatic hypotension and the level of hair loss was documented).[2]
For the measurement of sensory deficit and hair changes, malleolus was taken as point zero. Toronto Clinical Scoring System (TCSS) was used for grading the severity of neuropathy.[3]
In this cohort of 107 patients, mean age was 61.9 years and mean duration of DM was 8.7 years. Twenty four patients had no neuropathy (TCSS score ≤5), 41 had mild neuropathy (TCSS 6-8), 14 had moderate (TCSS 9-11) and 28 patients had severe neuropathy (TCSS ≥12).
Of the 83 patients documented to have neuropathy (TCSS score ≥6), 36 (43%) had a distal stocking hair loss which correlated with the level of pain and temperature loss or the level of impaired fine or crude touch [Figure 1].
Of these 36 patients, 11 had moderate and 25 had severe neuropathy. Thus, 79% patients with moderate and 89% with severe neuropathy had hair loss over the distal part of the legs which corresponded with the level of sensory impairment. None of the patients with mild, pure sensory neuropathy exhibited any hair loss.
Figure 1: Correlation of level of sensory loss (black line) to absence of hair (hair loss sign)
Click here to view
Thus the level of hair loss, when present, can be used as a rapid and reliable clinical indicator of moderate to severe diabetic peripheral neuropathy.
The somatic components of sensory neuropathy appear to correlate well with this component of autonomic neuropathy (hair loss).
The finding of hair loss and its level on the leg (hair loss sign) can serve the clinician well in his busy diabetes clinic. Further, this could potentially be used in follow-up studies of these individuals with diabetes.
The limitations of this study are that patients with mild neuropathy may not exhibit this sign and in female patients who wax their hair, the utility of the sign is lost.
Sarosh Katrak1, Amit Chaudhari2, Riddhi Patel2, Satish Khadilkar2
1 Department of Neurology, Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India
2 Department of Neurology, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
Diabetes mellitus (DM) currently affects more than 62 million Indians.[1] Studies show that approximately 20% of the patients with diabetes have peripheral neuropathy. Evaluation of diabetic neuropathy is important as it has a bearing on the comprehensive management. Conventional evaluation involves testing the sensory, motor and autonomic functions along with deep tendon reflexes. This is a time consuming process.
The huge workload in Diabetes Outpatient clinics in India calls for a simple indicator towards the neuropathic process. One of us (S M Katrak) had observed that the loss of hair on the legs, signifying autonomic neuropathy gives a lead to the extent of somatosensory neuropathic deficits. To test this clinical observation, we designed this study. The study was approved by the Institutional Ethics Committee.
Patients with DM reporting paresthesias were included in the study. After obtaining informed valid consent, history was recorded (age, sex, duration of DM, peripheral and autonomic symptoms viz. paresthesias, constipation, urinary complaints, abnormal sweating, and exercise intolerance) and clinical examination was performed (motor system, sensory system viz. fine and crude touch, pain and temperature, vibration and position sense were noted; reflexes and autonomic system viz. resting tachycardia, orthostatic hypotension and the level of hair loss was documented).[2]
For the measurement of sensory deficit and hair changes, malleolus was taken as point zero. Toronto Clinical Scoring System (TCSS) was used for grading the severity of neuropathy.[3]
In this cohort of 107 patients, mean age was 61.9 years and mean duration of DM was 8.7 years. Twenty four patients had no neuropathy (TCSS score ≤5), 41 had mild neuropathy (TCSS 6-8), 14 had moderate (TCSS 9-11) and 28 patients had severe neuropathy (TCSS ≥12).
Of the 83 patients documented to have neuropathy (TCSS score ≥6), 36 (43%) had a distal stocking hair loss which correlated with the level of pain and temperature loss or the level of impaired fine or crude touch [Figure 1].
Of these 36 patients, 11 had moderate and 25 had severe neuropathy. Thus, 79% patients with moderate and 89% with severe neuropathy had hair loss over the distal part of the legs which corresponded with the level of sensory impairment. None of the patients with mild, pure sensory neuropathy exhibited any hair loss.
Figure 1: Correlation of level of sensory loss (black line) to absence of hair (hair loss sign)
Click here to view
Thus the level of hair loss, when present, can be used as a rapid and reliable clinical indicator of moderate to severe diabetic peripheral neuropathy.
The somatic components of sensory neuropathy appear to correlate well with this component of autonomic neuropathy (hair loss).
The finding of hair loss and its level on the leg (hair loss sign) can serve the clinician well in his busy diabetes clinic. Further, this could potentially be used in follow-up studies of these individuals with diabetes.
The limitations of this study are that patients with mild neuropathy may not exhibit this sign and in female patients who wax their hair, the utility of the sign is lost.
