Hair Loss Overview
Describing and explaining “hair loss” in a brief overview is a difficult task. It is estimated that over 56 million individuals in the United States alone currently suffer from hair loss, and over 50% of men may experience some level of hair loss by age 50. There are also dozens, if not hundreds, of medical and genetic conditions, medication side effects, and physical events which may contribute to hair loss. The most common types of hair loss and the treatments for them also differ in men, women, and children. While it can be a complex and psychologically taxing problem, accurate diagnosis and proper treatment from a hair loss specialist can often improve the condition. In order to identify and seek the proper help, however, it is important to understand a little bit more about hair loss, what may be causing it, and what may help you treat it.
What is “Hair Loss?”
Hair loss, described medically as “alopecia,” refers to the loss or absence of hair follicles from a region where they should be, or the dysfunction of previously healthy hair follicles. Alopecia can affect any hair follicle on the body. This refers not only to hair follicles on the scalp, but also those on the face or any other region of the body – arms, legs, et cetera. Hair loss may present as a gradual, progressive thinning; it may also present in a more dramatic fashion where defined “patches” of hair seem to disappear suddenly. To understand what “is” hair loss, it is also important to understand what is “not” hair loss.
A human hair follicle is a complex organ comprised of numerous stem cells. These stem cells continuously communicate with one another, and this unique and complicated interaction is responsible for growing hair. This communication occurs in transitional “phases;” the “anagen” phase, also known as the growth phase, lasts (in healthy scalp follicles) for 3-4 years on average and is responsible for continually growing hair. Anagen growth allows for approximately 0.5 inches of hair growth per month – meaning a healthy follicle will grow around 6 inches of hair per year. The “telogen” phase, also known as the resting phase, lasts for around 3-4 months and represents a period of follicular cessation or no hair growth. During this period (and partially the transitional “catogen” phase) hair follicle activity briefly stops and the hair shafts shed. At any given point in time, approximately 10% of hair follicles are in the telogen or resting phase. Why is this important to know? Because a “resting” follicle releases its hair shaft and the hair subsequently “sheds” from the scalp. This means a normal, healthy scalp sheds around 50-150 hair shafts per day. These shafts are usually noticed while washing or combing or appear on the pillow in the morning. Many people see these naturally shedding hairs and believe they are experiencing true hair loss. However, this is normal and not indicative of any underlying pathology or problem. Noticing more than 50-150 shafts shedding per day, large clumps of hair falling out at the same time, a large number of hairs shedding with minimal touching, or the sudden appearance of patches or skin changes in the scalp is not normal and should be evaluated by a hair loss doctor.
Hair Loss in Men
Adult males are most commonly affected by hair loss. It typically begins subtly in the late teens – though it can start much later – and approximately 30% of males suffer from hair loss by age 30. That number increases to 50% by age 50 and to 80-90% as men reach the eighth decade of life. The overwhelming cause of hair loss in men is genetic male pattern hair loss, also known as “androgenic or androgenetic alopecia” or more colloquially as “male pattern baldness.” The term “andro” refers to hormones, specifically male hormones like testosterone; “genic” refers to human genes. This means “androgenic alopecia” is hair loss caused by your own genes but carried out by a hormone. There are a variety of genes associated with androgenic alopecia. In fact, most experts believe we have not yet identified all genes which may play a role. The genes can be inherited from both the maternal (mother) and paternal (father) side and are uniquely “expressed” in different individuals – meaning people with the same genes can have different levels of hair loss. The hormone actually responsible for the hair loss is called dihydrotestosterone or “DHT” — a normal byproduct of the common male hormone testosterone.
Genetic male pattern hair loss presents most commonly as thinning and eventually baldness in classic “patterned” areas of the scalp. It usually begins in the corners of the frontal hairline and the vertex or “crown” region near the back of the scalp. Androgenic alopecia is graded by the level of hair loss using a tool called the Norwood/Hamilton Scale. Patients with minimal hair loss limited to the frontal hairline are low on the scale; typically a Norwood I or II. Patients with advanced hair loss throughout the entire scalp (aside from the sides and back where the follicles are immune and will never shed regardless of severity of androgenic alopecia) are high on the Norwood scale; typically a Norwood VI or sometimes even a Norwood VII – the highest and most advanced grade. Androgenic alopecia is unpredictable and very progressive. It is typically very active between the ages of 20 – 50, and tends to stabilize slightly after this time – though many men continue to see a diffuse thinning of the hair shafts called “Senile Alopecia.”
A hair loss physician can diagnose androgenic alopecia after a brief medical history and scalp examination. Treatments for androgenic alopecia include both medical and surgical intervention. The US FDA has approved two preventive medications for the treatment of androgenic alopecia: finasteride (sold under the brand names “Propecia” and “Proscar”), a medication which inhibits the conversion of testosterone to dihydrotestosterone, and topical minoxidil (sold under the brand name “Rogaine). Other popular, but not tested and approved, treatments for androgenic alopecia include shampoos containing ketoconazole (an anti-fungal and anti-inflammatory agent), herbal and holistic supplements, and low level laser therapy (LLLT) therapy.
One of the most effective and popular treatments for androgenic alopecia is surgical hair restoration or hair transplant surgery. Modern hair transplant surgery performed via the gold standard Follicular Unit Transplantation technique (also known as “FUT” or “Follicular Unit Strip Surgery” – “FUSS”) or Follicular Unit Excision (also known as “FUE” or “Follicular Unit Extraction”) offers appropriate patients the opportunity to restore large areas of hair loss with thick, refined results. Those interested in surgical hair restoration should review patient cases presented by hair transplant experts on the Hair Loss Help Forums/Hair Loss Doc (www.hairlosshelp.com/forums, www.hairlossdoc.com) and Hair Transplant Web (www.hairtransplantweb.com). Another popular in-office procedure for androgenic alopecia is Platelet Rich Plasma or “PRP.” During a PRP treatment, a sample of a patient’s blood is taken, placed in a test tube, spun in a centrifuge to concentrate natural growth factors, and reinjected back into the patient’s scalp. PRP is a somewhat controversial treatment; the procedure itself is far from standardized and results are variable (and mostly temporary).
Although androgenic alopecia is responsible for the vast majority of hair loss in adult men, other possible culprits include: auto-immune conditions, other hormonal imbalances, medication side effects, infection, or chronic health conditions (like Psoriasis). All patients with atypical alopecia should be evaluated by a dermatologist – as further diagnosis and treatment may be necessary.
Hair Loss in Women
Much like their male counterparts, hair loss affects a significant number of females. In fact, it is estimated that up to 40% of women may experience some type of hair loss by age 40. While hair loss in men is typically straightforward and well understood, hair loss in female patients is often much more complicated. Like males, the most common cause of hair loss in women is “genetic female pattern hair loss” or “FPHL.” While often described as analogous to genetic male pattern hair loss, the mechanism behind this condition is different, much more complicated, and poorly understood. While FPHL is most typically caused by hormones, the imbalances are not simple and direct like the mechanism of dihydrotestosterone (DHT) in genetic male patterned hair loss. Most FPHL patients present with abnormalities of both the “male” androgen hormones like testosterone, and the “female” hormones like estrogen. In fact, many patients first notice the hair loss after an event involving a large hormonal shift like pregnancy or menopause.
Female patients usually first describe the hair loss as a “widening of their part.” Unlike male patterned hair loss, female hair loss begins in the center of the scalp and spreads outwards. The severity of the hair loss is graded by the “Ludwig” scale. A slight spreading in the center is defined as a Ludwig level I; whereas a diffuse spreading pattern reaching the hairline in the front and the posterior region beyond the crown and the lateral regions above the ears is defined as a Ludwig level III (the most severe on the scale).
There are a variety of other issues which may contribute to hair loss in women. Other hormonal imbalances, like those related to the thyroid, or deficiencies in certain vitamins or minerals may cause hair loss as well. Females with this type of diffuse spreading pattern in the scalp are encouraged to undergo extensive bloodwork and consult with an endocrinologist. Many times simple treatments like oral estrogen pills or fixing a blood level deficiency can dramatically improve female hair loss. Female patients are also more prone to a temporary, but nevertheless dramatic, shedding called “telogen effluvium.” This occurs when some sort of external stressor “shocks” a greater than usual number of hair follicles into the resting or telogen state. Thankfully, this typically resolves within 3-4 months on its own.
Another somewhat common cause of hair loss in females is immune-mediated alopecia, or hair loss related to the immune system. While this does occur in men as well, it does seem to have a higher incidence in women. Immune mediated hair loss presents in a more abnormal and obvious pattern; usually as “patches” of hair that all seem to fall out at once and leave behind very smooth, bald, and well-defined areas. Other types of hair loss related to the immune system may present with both hair loss and inflammation or a hardening of the skin. Female patients with other immune-related conditions (such a thyroid problem or Lupus) may be more prone to these types of hair loss or may even experience hair loss as a recurring symptom of their primary immune disease. Female patients with these types of hair loss should consult with a dermatologist and undergo a thorough evaluation. Many of these conditions can be treated, but expert diagnosis and specific testing must be completed first.
Female patients also frequently suffer hair loss secondary to hair styling and hair treatments. Females who wear their hair in tight braids or tightly pulled back for extended periods of time develop “Traction Alopecia,” where hair loss occurs from the chronic tension on the hair follicles. Patients who use harsh styling or treatment chemicals may also develop disorders of the hair shafts. These hair shaft disorders result in excessive shedding and create a thinned appearance with visible scalp.
Because female hair loss is more complicated and diverse compared to classic male pattern hair loss, surgical hair restoration is also more complicated in female patients. Those females considering hair transplant surgery must see a trusted hair restoration physician for a thorough evaluation. These patients will also likely be referred to a dermatologist or endocrinologist for additional testing and to “rule out” other treatments before proceeding with surgery.
Hair Loss in Children
Alopecia in children is complex and broad. Very young children often experience alopecia secondary to genetic conditions. Many of these complex genetic conditions cause abnormalities of the hair shafts. The hair shafts are often misshaped or poorly anchored to the hair follicles, and therefore create a thin appearance in the scalp and shed easily and frequently. Children are also prone to hair loss secondary to scalp infections; most commonly fungal infections. These usually present as a large, often raised, circular, and well-defined patch of hair loss. These infections are typically treatable and many times the hair loss dramatically improves or completely reverses afterwards. Children are also prone to the same immune-related types of hair loss seen in adults. Frequently children experience a specific type of immune-mediated hair loss called “Alopecia Areata,” which presents as circular patches in the scalp. The skin in the patch is usually very smooth and completely devoid of any hair. These often resolve on their own or can be treated with steroid injections. Children are also more prone to chronic hair pulling or “Trichotillomania.” This is usually related to a psychological issue or some type of life stressor, but the chronic pulling or plucking of scalp, eyebrow, and sometimes eyelash hair results in patches of missing hair. Often times the hair regrows once the compulsive behavior stops, but permanent hair loss is possible. Hair loss in older children, like teenagers, may be hormone related. Teenage females experiencing hair loss may suffer from thyroid hormone abnormalities or conditions related to estrogen and testosterone — like polycystic ovarian syndrome (PCOS). These are often treatable with oral hormone replacement therapies. Hair loss in teenage boys may also be early androgenic alopecia. Young men with strong family histories of advanced hair loss often see thinning as early as high school. While hair transplant surgery is typically not advisable in patients this young, preventive medications like finasteride and minoxidil may be appropriate. However, starting a medication at a young age is a serious decision and should be discussed with a hair loss doctor and the patient’s primary care physician.
Hair loss is a tricky subject. It is sometimes straightforward and treatable; other times it is complex, poorly understood, and difficult to treat. Regardless of your age, sex, or type of hair loss, the first step in understanding and potentially treating this issue is seeing an experienced physician. We hope this hair loss primer provides a basis for identifying what may be occurring and finding the right expert for your situation. And, of course, we hope this overview helps hair loss sufferers regrow their hair and regain their identity.