Hair Loss Information
The understanding about hair and hair follicle has improved tremendously in the last decade. But in terms of treatment options nothing much has changed apart from refinement of surgocal techniques. As the percentage of men and women, who suffer from hair loss grows, proportionally, the number of products sold for hair loss also grows. These products (growth factors, stem cell preparation, vitamin pills, and peptides) are advertised widely in the media and on the net and by late night pitches via infomercials. They prey on those who may be concerned about recent or dramatic hair loss. We urge caution when considering these products and always maintain that be suspicious of treatments that offer a large benefit for very little in return. Usually these products do not have any scientific studies backing them.
At HAIRREVIVE, we practice evidence based hair restoration which integrates the best available research evidence with clinical expertise and patient values.
As it is our endeavor to educate people affected by hair issues, this website will have basic details about the biology of the hair follicle and how it undergoes changes to cause hair problems. We intend to do this through a series of question and answers.
Hair loss causes
Hair loss and thinning hair are common problems in both men and women. Almost all people experience some form of hair loss in their lifetime. For some of these people the psychological effects are by far the worst elements of their hair loss. Though hair loss is often seen as a part of ageing, but when it is premature it brings depression and anxiety. For many people just knowing about the basic reasons for hair loss and understanding how the treatments works (making sense out of something inexplicable), helps a lot and that, is the primary purpose of the consultation in our center.
Common causes of hair loss seen in our practice are:
- Pattern hair loss (progressive and permanent)
- Telogen effluvium (temporary)
- Alopecia areata (remissions & exacerbations)
- Post burn hair loss (permanent)
- Traction hair loss (permanent)
- Trichotillomania (permanent)
What is effluvium?
Some hair loss conditions go by the name "effluvium," which means an outflow. Effluviums characteristically affect different phases of the hair growth cycle.
What is telogen effluvium (TE)?
The hair follicle is an anatomical structure which evolved to produce and extrude (push out) a hair shaft. Hair is made up of proteins called keratins. Human hair follicles on the scalp do not continuously produce hair but rather in a continuous cyclic pattern of growth and rest known as the "hair growth cycle."
They cycle through a growth stage (anagen phase) that can last two to six years, and then undergo degradation (Catagen phase 2-4 weeks) and then regress to a resting stage (telogen phase) for up to two months before starting to grow a new hair fiber again. At any time on a healthy human scalp, about 80% to 90% of the hair follicles are growing hair. That leaves up to 10% to 20% percent of scalp hair follicles in a resting state called telogen, when they don't produce any hair fiber. This is known as the Anagen-Telogen ratio (A/T ratio).
Shedding of the hair occurs only after the next growth cycle (anagen) begins and a new hair shaft begins to emerge. Roughly, we have about 100,000 follicles on the scalp and about 10-20% are in the resting phase. That makes it about 10,000 -20,000 hairs and due to this on average 50-100 telogen hairs are shed every day. This is normal hair loss and accounts for the hair loss seen every day in the shower and with hair combing. These hairs will regrow. Not more than 10 percent of the follicles are in the resting phase (telogen) at any time.
A variety of factors can affect the hair growth cycle and cause increased shedding. Commonly the causes are stress due to any reason – major illness, surgery, injury, childbirth, nutritional deficiencies (especially iron deficiency) etc.
TE happens when the ratio of growing to resting hair follicles is altered and more follicles are in resting phase. If the number of hair follicles producing hair drops significantly for any reason during the resting, or telogen phase, there will be a significant increase in dormant, telogen stage hair follicles. The result is shedding, or TE hair loss.
TE appears as a diffuse thinning of hair on the scalp, which may not be even all over. It can be a bit more severe in some areas of the scalp than others. Most often, the hair on top of the scalp thins more than it does at the sides and back of the scalp. There is usually no hair line recession, except when TE is superimposed on a developing male pattern or female pattern hair loss.
The shed hairs are typically telogen hairs, which can be recognized by a small bulb of keratin on the root end. Whether the keratinized lump is pigmented or unpigmented makes no difference; the hair fibers are still typical telogen hairs.
People with TE never completely lose all their scalp hair, but the hair can be noticeably thin in severe cases. While TE is often limited to the scalp, in more serious cases TE can affect other areas, like the eyebrows or pubic region. Whatever form of hair loss TE takes, it is fully reversible. The hair follicles are not permanently or irreversibly affected; there are just more hair follicles in a resting state than there should normally be.
What is anagen effluvium?
As a rule the follicle does not shed hair in the growing phase (anagen). Anagen effluvium is a diffuse hair loss like telogen effluvium, but it develops much more quickly and can cause individuals to lose all their hair.
The hair follicle along with the bone marrow and most cancers exhibits a rapid cellular turnover. So, when patients of cancer undergo chemotherapy, the chemotherapeutic drug hits the rapidly dividing cells of the cancer. But a collateral damage occurs in the bone marrow and the hair follicles. This is the time when follicles in the growing phase are hit with the chemotherapeutic drug and end up shutting down and causing hair fall which is typically seen in patients undergoing chemotherapy.The onset of anagen effluvium is very rapid. Some individuals who start taking anti-cancer drugs can literally pull their hair out in clumps within the first two weeks. Because these drugs act so quickly and are so potent, the hair follicles have no time to enter into a telogen resting state, as with telogen effluvium, a response to a more moderate environmental challenge.Instead, in anagen effluvium the hair follicles enter a state of suspended animation, frozen in time. The hair fibers fall out quickly, but instead of looking like typical telogen hairs with little bulbs of keratin on the root end, the hairs that fall out are mostly dystrophic anagen hairs with a tapered or sometimes feathered root end.
With chemotherapy medications, the degree of hair loss varies from person to person. Some people may have a mixture of anagen effluvium and telogen effluvium and have more limited hair loss.
Some cancer treatment centers try to block the hair loss using a cold therapy. More popular in Europe than North America, cold therapy involves covering the scalp with ice packs or using a special hood filled with cold water while the anti-cancer drugs are given. The cold sends the hair follicles into suspended animation prior to contact with the drug. This stops the hair follicle cells from taking up the drug and being damaged by it. The result is much less drug-induced hair loss. However, doctors worry that any cancer cells in the skin may also avoid the anti-cancer drugs if cold therapy is given during drug treatment.
Depending upon the type of anti-cancer medication used, one can see complete regrowth to partial regrowth to no regrowth. On completion of an anti-cancer drug treatment course, a person may start to see new hair growth within a month. The hair follicles are not destroyed, so there should be a normal hair growth density. Typically the hair which grows back may have a different character – like the original straight hair may become curly hair.
What is androgenetic alopecia (AGA)?
It was Hippocrates who first made the connection between hair loss and male hormones. He noted that eunuchs did not go through the balding process. It took us almost 2400 years to realize that Hippocrates was correct in his assumption. However, it took a Psychiatrist by the name of Dr Hamilton who actually managed to connect testosterone, genetics and balding.
The etiology is genetic (inheriting the gene from either parent) and thepathogenesis is androgen (male hormone) mediated, Alopecia is a general term for loss of hair – Androgenetic alopecia means loss of hair induced by genes and male hormone. So, for a person to get AGA there has to be genetic predisposition, sufficient levels of male hormone and adequate time for these two factors to work together.
How do androgens (male hormones) cause hair loss?
Hamilton first noted that androgens (testosterone, dihydrotestosterone) are necessary for the development of male pattern baldness. The amount of androgens present does not need to be greater than normal for male pattern baldness to occur. If androgens are present in normal amounts and the gene for hair loss is present, male pattern hair loss will occur.
Testosterone converts to Dihydrotestosterone(DHT) with the aid of the enzyme Type II 5-alpha-reductace, which is present in the hair follicle cells (outer root sheath and dermal papilla). Dihydrotestosterone (DHT) is a derivative or by-product of testosterone binds to the androgen receptors (receptors exist on cells that bind androgens). These receptors have the greatest affinity for DHT followed by testosterone, estrogen, and progesterone. After binding to the receptor, DHT goes into the cell and interacts with the nucleus of the cell altering the production of protein by the DNA in the nucleus of the cell. Ultimately growth of the hair follicle ceases.
While the entire genetic process of male pattern baldness is not completely understood, we do know that DHT shrinks hair follicles, and that when DHT is suppressed, hair follicles continue to thrive. Hair follicles that are sensitive to DHT must be exposed to the hormone for a prolonged period of time in order for the affected follicle to complete the miniaturization process (Miniaturization is the hormone-driven biological process in which hairs shrink in size over time, eventually leaving a bald scalp). Today, with proper intervention this process can be slowed or even stopped if caught early enough.
If androgens are present in normal amounts and the gene for hair loss is present, male pattern hair loss will occur. Axillary (under arm) and pubic hair are dependent on testosterone for growth. Beard growth and male pattern hair loss are dependent on dihydrotestosterone (DHT). Finasteride acts by blocking this enzyme and decreasing the amount of DHT.
In men who develop male pattern baldness the hair loss may begin any time after puberty when blood levels of androgens rise (physiologic – as part of developing secondary sexual characteristics). The first change is usually recession in the temporal areas which may or may not include a thinning crown. Hair in these areas including the temples and mid-anterior scalp appear to be the most sensitive to DHT. This pattern eventually progresses into more apparent baldness throughout the entire top of the scalp, leaving only a rim or "horseshoe" pattern of hair remaining in the more advanced stages of MPB. For some men even this remaining rim of hair can be affected by DHT.In some areas of the scalp, most or all of the follicular units have the genetic predisposition to be immune to the effects of DHT. As a result, these areas might never become miniaturized, and so hair will remain on these parts of the scalp for the person’s entire life. This happens most often in the back and sides of the scalp, aptly known as the “permanent zone,” while the front and top of the scalp are the first areas to experience thinning and baldness.
Do the androgens affect all hair follicles on the body in the same way?
The androgens have somewhat of a paradoxical effect on the hair follicles on hair follicles on different parts of the body. This response is based on the inherited androgen sensitivity in individuals.
The hair follicles of the face, especially in the beard and mustache area, respond positively to the male hormone. This is typically seen at puberty, when follicles producing fine vellus hair start producing thicker terminal hair.
Male pattern baldness is generally characterized with the onset of a receding hairline and thinning crown. Hair in these areas including the temples and mid-anterior scalp appear to be the most sensitive to DHT. This pattern eventually progresses into more apparent baldness throughout the entire top of the scalp, leaving only a rim or "horseshoe" pattern of hair remaining in the more advanced stages of MPB. For some men even this remaining rim of hair can be affected by DHT. Therefore the same hormone (androgens) can have different effects on follicles in different parts of the body.
How does AGA differ from Male Pattern Hair Loss (MPHL)?
Male hair loss has suffered from inconsistent terminology. It has been called - Hereditary/ Familial Baldness/Common Baldness/Male Pattern Baldness (MPB)/AndroGenetic Alopecia (AGA).
It can be defined as “Patterned, progressive and potentially reversible hair miniaturization limited to the frontal and central areas of the scalp in genetically predisposed individuals”. The term which is commonly used is Male Pattern Hair loss and is in fact easy to identify even for somebody with no clinical experience as it only affects hair on the top of the scalp and not the sides, causing a horseshoe-shaped pattern of hair loss. There are a number of different common patterns of hair loss – a receding hairline, a thinning crown, or general thinning spread over the top area of the head.
It is generally recognized that men in their 20’s have a 20 percent incidence of male pattern baldness, in their 30’s a 30 percent incidence of male pattern baldness, in their 40’s a 40 percent incidence of male pattern baldness, etc. Using these numbers one can see that a male in his 90’s has a 90 percent chance of having some degree of male pattern baldness.
How does one diagnose male pattern hair loss?
Typical male pattern baldness is usually diagnosed based on the appearance and pattern of the hair loss, along with a detailed medical history, including questions about the prevalence of hair loss in your family.
At Hairrevive we try and arrive at a diagnosis of hair loss in every patient. The diagnosis depends on various steps:
- History: The onset of hair loss, pattern of hair loss and family history of male pattern hair loss in close family members (both from paternal and maternal side)
- Examination: Scalp examination revealing a typical pattern of hair loss – fronto-temporal thinning/recession and/or thinning in the crown area
- Trichoscopy: Revealing a variability of diameter of hair shafts in the affected area and no variability of diameter in the permanent zone of the scalp (the back and sides of the scalp)
- Haircheck: This revolutionary device reveals the cross sectional volume of hair in a unit area. The difference between the affected areas and the non-affected areas is demonstrated. Haircheck is a new patented technology that provides the answers to all your hair loss and hair breakage questions. It’s a scientific instrument designed to precisely and accurately measure hair loss, growth and breakage on any area of the scalp. No hair needs to be cut and testing takes about 5 minutes. When hair loss or breakage is detected, your hair professional can make appropriate suggestions and measure the response to take-home products and salon treatments.
How does hair loss progress in males?
Male pattern hair loss (Androgenetic Alopecia) is an inherited condition manifested when androgens are present in normal amounts. The gene can be inherited from the mother or father’s side. The onset, rate, and severity of hair loss are unpredictable. The severity increases with age and if the condition is present it will be progressive and relentless.Men with male-pattern hair loss may have an expectation of hair loss if they have male relatives who lost hair in a recognizably male pattern.Hair loss is graded as per severity according to the Norwood Hamilton Classification:
Grade 1 – Normal adolescent hair line with no evidence of thinning or recession
Grade 2 – Slight progress to mature hair line incorporating mild fronto-temporal recession. This is not a stage of baldness.
Grade 3 – The fronto-temporal recession gets deeper leading to the earliest stage of male pattern hair loss.
Grade 3 Vertex - Same as grade 3 but with some thinning of the crown area.
Grade 4 –Further recession of fronto-temporal angles, but solid transverse band of hair in the centre.
Grade 5 - The recession in the front and the thinning in the crown continue to enlarge and the bridge of hair separating the two areas begins to break down.
Grade 6 – When the hair loss progresses and the connecting central bridge of hair disappear the frontal and crown areas get connected into one large bald area. The hair on the sides of the scalp remains relatively high.
Grade 7 – The most advanced form of male pattern hair loss where only a fringe to hair bearing area remains on the back and sides of the head.
The anterior or “A” pattern of hair loss are when the hair loss is more in the front (anterior) as compared with the crown areas. The frontal or anterior patterns of male pattern hair loss are less common than the regular pattern but these patterns make the hair loss look worse even if the hair loss is not very severe.As this variety of hair loss compromises the hair line and the person loses facial framing, these persons are good candidates for hair transplantation.
Can male hair loss be present in non-patterned manner?
Male hair loss can present in a manner different from the usual patterns of hair loss described above. The two known variants of this – Diffuse Patterened Alopecia (DPA) and Diffuse Unpatterened Alopecia (DUPA).
Diffuse Patterned Alopecia is an androgenetic alopecia manifested as diffuse thinning in the front, top and crown, with a stable permanent zone; the hair line does not show recession. In spite of significant hair loss in the middle of the scalp and crown areas the hair line and framing of the face remains intact. On the other hand, Diffuse Unpatterned Alopecia (DUPA) has diffuse hair loss but the permanent hair bearing area on the sides and back of the head is also impacted. It is less common than the DPA. DUPA tends to advance faster than DPA and end up in a horseshoe pattern resembling the Norwood class VII. However, unlike the Norwood 7, the DUPA horseshoe can look almost transparent due to the low density of the back and sides. Presence of significant miniaturization in the permanent zone signifies the possibility of DUPA
Differentiating between DPA and DUPA is very important because DPA patients may be eligible for a hair transplant by the virtue of an intact permanent donor zone, whereas DUPA patients almost never do, as they eventually have extensive hair loss without a stable zone for harvesting hair follicles.
Female hair loss
There are a number of possible reasons for female hair loss. Causes of female hair loss can range from androgenetic alopecia (female pattern hair loss) to diffuse thinning caused by telogen effluvium which in turn can be nutritional, hormonal or stress induced. Mistakenly thought to be a strictly male disease, women actually make up significant percentage of hair loss sufferers. Hair loss in women can be absolutely devastating for the sufferer's self-image and emotional wellbeing.
While hair loss itself can present psychological and emotional problems for a woman, failure of others to recognize the seriousness of these problems may contribute additionally to psychological and emotional effects that can range from decreased self-esteem to anxiety and depression.
Hair loss can be temporary or long lasting and progressive. Temporary hair loss can be treated when its cause is identified and dealt with, or difficult when it is not immediately clear what the cause is. Hair loss that could possibly have been temporary may become long lasting as a result of an incorrect diagnosis. The potential for such misdiagnoses is perhaps the most frustrating aspect of hair loss for women.Hair loss in a woman should never be considered "normal", however. The cause should be pursued until a diagnosis is established. Usually extensive assessment is needed to ascertain the cause of hair fall/hair loss in women.
Of the many causes of hair loss in women, only a few such as aging, hormonal changes associated with pregnancy, and hereditary pattern hair loss may be considered "normal". Treatment is available for hair loss due to these "normal" conditions, and treatment should be considered when hair loss influences the woman’s quality of life. Diffuse thinning in women in the fertile age group is usually caused by iron deficiency. The common scenario is that these women may have normal hemoglobin levels but still have some iron deficiency (non-anemic iron deficiency).
Other potential causes of hair loss in women require medical treatment. These include cystic ovaries, hypothyroidism, autoimmune disease, chemotherapy, psychological or physical stress, and dietary deficiencies. Prescription drugs that commonly cause hair loss include beta-blockers, coumarin, anti-depressants and others. Medications may need to be changed or dosages adjusted due to hair loss. Damage to hair and scalp caused by tight braiding, corn-rowing, or chemicals used in hair styling are causes of hair loss that require change in life-style. Compulsive hair-pulling - a condition called trichotillomania that can cause unusual patterns of hair loss - may require psychological counseling.
Female Pattern Hair Loss (FPHL)
FPHL has been defined as non-scarring progressive miniaturization of the hair follicle, usually with characteristic pattern distribution that occurs in genetically predisposed women. Female pattern hair loss is the commonest cause of hair loss in women and prevalence increases with advancing age. FPHL may or may not have an androgenic basis. Generally it is sensitivity to androgens or androgen precursors that causes female androgenetic alopecia (FAGA). In these patients, clinical signs of increased androgen sensitivity (normal levels of male hormone) or hyperandrogenism (increased levels of male hormones) may be evident like – excessive facial or body hair, acne, irregular menses, weight gain etc. along with scalp hair loss. The inheritance
The hair loss is usually diffuse in naturewith progressive hair follicle miniaturization and conversion of terminal follicles into vellus-like follicles (producing fine/thin hair). These vellus-like follicles have a shortened hair cycle because their anagen phase is reduced and produce hair shafts that are short and fine. Unlike in men, the miniaturization is not uniform and intense, therefore, except for very rare cases; there are no complete areas of baldness.
The genetic inheritance of FPHL is still unclear. FPHL is possibly a multigenic disease, but the causative genes are not established and can come from either the mother’s or father’s side of the family.
Comparison of MPHL and FPHL
- Starts a little later than the males
- Often very gradual, Increases in severity with age
- Pattern differs from the male type as the hair line is maintained but there is diffuse thinning( less hair all over)
- More often cyclical than in men, with seasonal changes, and it is more easily affected by hormonal changes, medical conditions, and external factors
Factors impacting development of female hair loss
There are a number of medical conditions and factors that can cause temporary hair loss that are treatable without hair restoration surgery.
The following are a few of the common, underlying cause that may explain temporary hair loss.
Hypothyroidism: Another term for this is an underactive thyroid. Under normal circumstances, the thyroid gland regulates how your body uses energy and how sensitive your body is to other hormones. With hypothyroidsim, the thyroid gland doesn’t produce enough of certain hormones, which in turn upsets your normal chemical balance. One of the results can be thinning hair. Fortunately, when properly diagnosed, hypothyroidism can be controlled and any hair loss that has occurred can be reserved.
Pregnancy: Hormonal changes during and after pregnancy can lead to a number of changes in your body. Following pregnancy, women can experience an abnormal amount of hair loss when the hair follicles shift into a phase called shedding. This condition typically ends three to four months after pregnancy. However, if hair loss continues well after pregnancy, it may be a sign of a more significant hormonal imbalance that requires a consultation with your physician.
Stress: Extreme physical stress, such as crash dieting or a high fever, can shift the hair follicles into a premature shedding phase. The reasons for this connection are not well understood but your hair restoration surgeon or physician can provide treatment or therapy for your underlying condition. Once the stress is under control, your hair follicle cycle may return to the more normal phase.
Other list of factors which may impact hair loss in women
- Polycystic ovary syndrome
- Crash dieting,
- Traumatic emotional event.
- Thyroid disorders,
- Chronic illness or the
- Certain medications
Grading of female hair loss
Female-pattern hair loss has been classified by Hamilton using the Norwood-Hamilton classification, by Ludwig using a different classification of Grades 1 to 3 types of female-pattern hair and the Savin Scale. For all intents and purposes, they are identical except that the Savin Scale also measures overall thinning.
The Ludwig classification emphasizes the diffuse nature of much female-pattern hair loss.
The patterns of hair loss due to androgenetic alopecia tend to be less clearly defined than those in men. Hair loss due to causes other than androgenetic alopecia is also more frequent in women but often closely resemble hair loss due to androgenetic alopecia. Hair loss in a woman-even when there is a family history of androgenetic alopecia-should never be assumed to be due to androgenetic alopecia.
Three general patterns of female-pattern hair loss are:
- A "Christmas tree" pattern of diffuse hair loss, with the "base" of the "tree" at the hairline and the "tip" of the "tree" at the center of the scalp, was first described in the 1990s. Since that time, the "Christmas tree" pattern has been identified as perhaps the dominant diffuse pattern of female-pattern hair loss.
- Diffuse hair loss illustrated in the Ludwig classification. Some studies have indicated that a diffuse thinning of hair is experienced to some degree by a majority of premenopausal women and by a large majority of postmenopausal women. Whether postmenopausal hair loss is due to androgenetic alopecia may be difficult to determine as hair loss may also occur in association with aging in older women.
- Hair loss that resembles, in some degree, male-pattern hair loss of Norwood-Hamilton Types I to VII. Female-pattern hair loss rarely progresses to Type VI and VII severity. Studies have found that a mild Norwood-Hamilton Type II recession of the hairline is experienced by many women in young adulthood, but the recession is less prominent in women than in men and may go unnoticed unless hair loss progresses. Progression to Norwood-Hamilton Type IV by age 50 to 60 was seen in some of the women studied.
Hair loss due to androgenetic alopecia occurs at all ages after puberty in women. However, onset of female-pattern hair loss appears to be most frequent at ages 20 to 30 and 40 to 50.
How does one diagnose female pattern hair loss?
Female pattern baldness is usually diagnosed based on the appearance and pattern of the hair loss, along with a detailed medical history, menstrual history, dietetic history, including questions about the prevalence of hair loss in your family, .
At Hairrevive we try and arrive at a diagnosis of hair loss in every patient. The diagnosis depends on various steps:
- History: The onset of hair loss, pattern of hair loss and family history of pattern hair loss in close family members (both from paternal and maternal side). Detailed menstrual history, obstetric history, history of excessive facial and body hair, weight gain, difficulty in conception will help in pointing towards androgenic basis as well as ruling out Poly Cystic Ovarian Syndrome (PCOS)
- Examination: Scalp examination revealing a typical pattern of hair loss – fronto-temporal thinning/recession and/or thinning in the crown area
- The hair pull test is a simple diagnostic test in which the physician lightly pulls a small amount of hair (approx 50-60 simultaneously) in order to determine if there is excessive loss. Normal range is one or no hairs per pull.
- Trichoscopy: Revealing a variability of diameter of hair shafts in the affected area and no variability of diameter in the permanent zone of the scalp (the back and sides of the scalp)
- Biochemical tests: Women in the fertile age group (especially those on vegetarian diet) have non anemic iron deficiency and also suboptimal protein intake. These issues as well as the androgenic hormone and thyroid hormone levels can be checked with simple blood tests.
- Scalp biopsy: Sometimes accurate diagnosis is not possible due to unclear signs and in these patients it is best to confirm the diagnosis with a scalp biopsy. A small section of scalp usually 4mm in diameter is removed and examined under a microscope to help determine the cause of hair loss.
Is diet linked to hair loss?
The knowledge that nutrition (what we choose to eat and drink) – inﬂuences our health, well-being, and quality of life, is as old as human history. Deprivation of calories (energy), proteins, minerals, and vitamins in deficiency states can potentially lead to structural changes in the hair shaft, loss of pigmentation or hair loss. But this fact should not be extrapolated to suggest that by consuming all these substances (nutrients) in a non-deficiency state will alter the quality and quantity of hair. There is a huge discrepancy between number of claims supporting supplementation with nutrients/diets/organic foods etc. for hair health and the number of controlled studies in assessing the same. Also, we must acknowledge, that most of our hair attributes like caliber, color, distribution and number are genetically programmed. And it is not possible to override the genetic influences by following a certain diet or increasing supplementation of nutrients to get great looking hair.
The hair follicle is a metabolically active miniature organ with a high cellular turnover. Obviously, with such a high metabolic rate, there is need for constant supply of nutrients and energy. Due to this fact signs of nutritional deficiencies are predictably seen in hair. Either because of intelligent design or evolutionary pressure, in deficiency states, nutrient supply is prioritized towards vital organs away from hair. Also, today we are faced with a situation where we are apparently well fed but technically malnourished (Malnutrition has another meaning – obesity, which is a common problem in todays’ society due to consuming processed foods, sugary drinks etc.). This is further compounded by poor lifestyle, lack of physical exercise and environmental pollution. These factors affect the whole body and obviously also, the hair follicle.
One of the ways to deal with this issue of losing weight is dieting. To lose weight (adipose tissue) one has to reduce calories and some of the diets recommend a caloric intake as low as 1000 Kcal/day. Increased hair shedding is a common feature in the people who follow such diets (crash diets) losing weight in a short span of time. The weight loss diets are essentially those that either restrict fats (anti fat) or those that restrict calories (anti carbohydrate). Most of these diets have some impact on the hair which can lead to increased shedding, poor caliber (thinning) etc.
It is important to understand that overall pattern of food eaten is more important than one type of food or meal. As I have always maintained, all types food, if consumed in moderation and in appropriate portions, combined with regular exercise, can be considered as healthy food.
Categorizing foods as good or bad promotes wrong kind of thinking. Most of the so called diet fads are not sustainable in the long term and can also have harmful effects on the body. A particular type of food which is considered a good food – for e.g. egg whites-a source of good quality protein, if used as the sole source of protein may actually cause zinc deficiency.
Hence, from all the above, it can be seen that people who have a poor diet or eating disorders such as anorexia and bulimia, are at an increased risk of temporary hair loss due to nutritional deficiencies that weaken their hair shafts and follicles. Thus it is important to have a proper diet. A healthy and balanced diet will definitely help in improving your hair condition as well as stop it from falling due to any diet related deficiency.
Nutritional deficiencies (or as you put it, restrictive diet) can cause hair loss. In addition, this may trigger a stress response and turn on a gene that may kick start your male pattern hair loss. Unfortunately, after the process has started it is difficult to stop the progression of hair loss.
In our practice we do recommend nutrition supplements but only when there is an indication of deficiency associated with hair symptoms and signs.Excess or deficiency of any kind will affect the system and thereby affect the hair follicle. Including fresh fruits, leafy vegetables, sprouts and cutting down oil and refined sugar will go a long way in tackling hair loss. Crash dieting is one of the major reasons for accelerated hair fall in females.
Can we improve hair health through our diet, and if so, what do we need to eat for good hair quality?
Diet is shown to have a major influence on the composition of the hair. When it comes to healthy hair, what we put in our bodies is just as important as what we put on our hair.
First and foremost what is needed is a healthy, well-balanced diet that includes plenty of growth-promoting protein, iron and a right mixture of vitamins & trace elements.
- High quality, lean protein is one of the best nutrients for great hair (Chicken, turkey, fish, and eggs are great sources of protein). Specifically foods those are high in cysteine. Cysteine is the main amino acid that forms keratin and is present in Pork, poultry, eggs, red peppers, garlic, onions, Brussels sprouts, dairy products, oats and broccoli.
- Iron - Prunes and dates (great sources of iron)
Beans like kidney beans, lima beans, pinto beans, etc. (good source of biotin, protein,
iron, and zinc.),
- Vitamins - Leafy, green vegetables (excellent sources of vitamins A and C, besides being full of calcium and iron, dark green veggies like spinach, broccoli, kale, and salad greens), Green peas (multivitamins + iron) and carrots (vit A), Eggs - loaded with essential nutrients such as proteins, Vitamin B12, iron, zinc and Omega 6 fatty acids in large amounts and also a good source for biotin. Shrimps - high concentration of Vitamin B12, iron and zinc
- Trace elements and minerals - Nuts (natural source of zinc). Oats (full of fiber plus zinc, iron and omega-6 fatty acids polyunsaturated fatty acids (PUFAs)). Walnuts also contain Selenium which is important for the hair.
- Omega 6 fatty acids - Fish (salmon, herring, tuna, mackerel, sardines, and bluefish), flaxseed, canola oil, pumpkin seeds and walnuts are great sources of omega-3 fatty acids.
- Low fat dairy products (skim milk and yogurt) are sources of calcium also contain whey and casein, two high-quality protein sources and probiotics
Is there a link between smoking and hair loss?
Tobacco smoking-especially long-term and heavy tobacco smoking-has numerous ill effects on the body including increased risk for lung cancer, chronic obstructive pulmonary disease, heart disease and systemic circulatory disease. The nicotine and other chemicals in smoked tobacco may cause or contribute to disorders of blood circulation that can increase risk for excessive bleeding. They may also reduce elasticity of small blood vessels in the skin, diminishing the blood supply to hair transplants and thus increasing risk for transplant failure.
The mechanisms by which smoking causes hair loss are multifactorial and are probably related to effects of cigarette smoke on the microvasculature of the dermal hair papilla, smoke genotoxicants causing damage to DNA of the hair follicle, smoke-induced imbalance in the follicular protease/antiprotease systems controlling tissue remodeling during the hair growth cycle, pro-oxidant effects of smoking leading to the release of pro-inflammatory cytokines resulting in follicular micro-inflammation and fibrosis and finally increased hydroxylation of oestradiol as well as inhibition of the enzyme aromatase creating a relative hypo-oestrogenic state.
Which medications can cause hair loss?
The following is the list of drugs which may lead to hair loss usually with long-term use:
- Cholesterol-lowering drug: clofibrate and gemfibrozil
- Parkinson Medications: levodopa
- Ulcer drugs: cimetidine, ranitidine and famotidine
- Anticoagulents: Coumarin and Heparin
- Agents for gout: Allopurinol
- Antiarthritics: penicillamine, auranofin, indomethacin, naproxen, sulindac and methotrexate
- Drugs derived from vitamin-A: isotretinoin and etretinate
- Anticonvulsants for epilepsy: trimethadione
- Antidepressants: tricyclics, amphetamines
- Beta blocker drugs for high blood pressure: atenolol, metoprolol, nadolol, propranolol and timolol
- Antithyroid agents: carbimazole, Iodine, thiocyanate, thiouracil
- Others: Blood thinners, male hormones (anabolic steroids)
What are other types of hair loss?
The word "alopecia" is the medical term for hair loss. Alopecia does not refer to one specific hair loss disease -- any form of hair loss is alopecia. There are hair loss disorders arising from pathology in the skin or from mechanical disturbances to hair or due to psychiatric problems. Probably the most common forms of non-pattern hair loss are alopecia areata, scarring alopecia, traction alopecia, trichotillomania and hair loss due to over processing of hair.
Alopecia areata (AA)
Alopecia areata is considered an autoimmune disease, in which the immune system, which is designed to protect the body from foreign invaders such as viruses and bacteria, mistakenly attacks the hair follicles, the structures from which hairs grow. This can lead to hair loss on the scalp and elsewhere (it can affect any hair bearing area). It is one of the most common hair loss disorders after pattern hair loss and effluviums.
In most cases, hair falls out in small, round patches about the size of a quarter. In many cases, the disease does not extend beyond a few bare patches. In some people, hair loss is more extensive. Although uncommon, the disease can progress to cause total loss of hair on the scalp (referred to as alopecia areatatotalis) or complete loss of hair on the scalp, face, and body (alopecia areatauniversalis).
The lifetime incidence of AA is approximately 2% worldwide. Both formal population studies found no sex predominance. First onset is most common in the third and fourth decades of life but may occur at any age. An earlier age of first onset corresponds with an increased lifetime risk of extensive disease.Alopecia areata often occurs in people whose family members have other autoimmune diseases, such as type 1 diabetes, rheumatoid arthritis, thyroid disease, systemic lupus erythematosus, pernicious anemia, or Addison’s disease. People who have alopecia areata do not usually have other autoimmune diseases, but they do have a higher occurrence of thyroid disease, atopic eczema, nasal allergies, and asthma.
Alopecia areata is not a life-threatening disease. It does not cause any physical pain, and people with the condition are generally healthy otherwise. But for most people, a disease that unpredictably affects their appearance the way alopecia areata does is a serious matter.
The effects of alopecia areata are primarily socially and emotionally disturbing. In alopecia universalis, however, loss of eyelashes and eyebrows and hair in the nose and ears can make the person more vulnerable to dust, germs, and foreign particles entering the eyes, nose, and ears.
Diagnosis of alopecia areata:
Sometimes a hair transplant surgeon can diagnose alopecia areata by looking at the patchy nature of hair loss preceded by sudden onset.If the patch of hair loss is expanding, the doctor may pull out a few hairs. These hairs will be looked at under a microscope.
Trichoscopy has some specific findings associated with alopecia areata –Exclamation mark hairs, Black Dots, Broken hairs represent severity as well as activity and yellow dots are observed in every stage of AA. Short vellous hairs represent hair re-growth, and hence they negatively correlate disease activity. And finally, honey comb pattern and white dots are observed in alopecia totalis of longer duration.
The course of the disease varies from person to person. Some people lose just a few patches of hair, then the hair regrows, and the condition never recurs. Other people continue to lose and regrow hair for many years. A few lose all the hair on the scalp; some lose all the hair on the scalp, face, and body. Even in those who lose all their hair, the possibility for full regrowth remains. The course of alopecia areata is highly unpredictable, and the uncertainty of what will happen next is probably the most difficult and frustrating aspect of the disease.
In some, the initial hair regrowth is white, with a gradual return of the original hair color. In most, the regrown hair is ultimately the same color and texture as the original hair.
Treatment of alopecia areata:
There are a range of treatments for AA, but none are effective for everyone and some people with AA don't respond to any treatment. Because some of the available treatments have a high risk of side effects, they are often not used for children.
The most common AA treatment involves the use of corticosteroids. Corticosteroid creams applied to the bald patches are popular. A more potent approach is to inject corticosteroid solutions into the bald patches. This can work well for some people, but close monitoring is required to ensure that side effects, such as skin thinning at the site of injection, do not occur.In extensive cases, systemic corticosteroids (those taken in pill or other form to affect your body) are used, though not continuously since they can cause significant side effects like bone thinning. But short-term "pulse therapy" often has good results.
More specialized treatment approaches involve the application of contact sensitizing chemicals to the skin. These cause an allergic reaction that can help promote hair growth. That may sound counterintuitive but it seems to work. A variety of experimental approaches are currently in laboratory and clinical trials. One group of drugs being tested are "biologics," which have bits of protein that interfere in a very specific way with the activity of immune cells. Biologics are injected systemically to damp down the immune activity and allow hair to regrow. The results of these trials are awaited with much interest.
Scarring alopecia (Cicatricial alopecia)
Scarring alopecia, also calledCicatricial alopecia, refers to a group of rare disorders that destroy hair follicles. The follicles are replaced with scar tissue, causing permanent hair loss. However, scarring may be due to other reasons like injury to the scalp caused by physical trauma or burns, bacterial infections such as folliculitis, fungal infections, and viral infections such as shingles (herpes zoster) etc.
Cicatricial alopecia has two forms. In the primary form, the hair follicle is the target of the destructive process. In the secondary form, the hair follicle is an innocent bystander, destroyed by another cause. This can be a severe burn, an infection, radiation, or a tumor.
The cause of cicatricial alopecia is not well understood. What is known is that redness, heat, pain, or swelling occurs at the upper part of the hair follicle. That is the place where stem cells and sebaceous (oil) glands are located. Stem cells are cells that can develop into different kinds of cells. If the stem cells and oil glands are destroyed, the hair follicle cannot regrow, and hair is permanently lost.
Cicatricial alopecia is not contagious. It occurs worldwide in otherwise healthy men and women. It affects all ages, but is not common in children.
This condition usually affects only one family member. One exception is central centrifugal alopecia. It most commonly affects women of African ancestry, and may occur in more than one family member.
Types of CicatricialAlopecias
- Those involving mostly lymphocytes:
- Lichen planopilaris (LPP)
- Frontal fibrosing alopecia
- Central centrifugal alopecia
- Pseudopelade of Brocq
- Those involving mostly neutrophils:
- Folliculitis decalvans
- Tufted folliculitis
- Those involving both (called mixed inflammatory infiltrate):
- Dissecting cellulitis
- Folliculitis keloidalis
Symptoms of scarring alopecia
In some cases, hair loss happens quickly, and there is severe itching, pain, and burning. In other cases, hair loss is gradual, and there are no other symptoms.
Diagnosis of scarring alopecia:
A clinical evaluation of the scalp, noting symptoms such as itching, burning or tenderness; signs of inflammation including redness, scaling, and pustules; and overall extent and pattern of hair loss.
Trichoscopy helps in diagnosis of cicatricial alopecia. Trichoscopy reveals typical features seen in scarring alopecias - loss of follicles, Blue gray dots or large yellow dots,Peripilar erythema, crusting and scaling, perifollicular whitish halo, follicular keratotic plugs and telangiectasias.
Final confirmation is possible by scalp biopsy.
The hair loss is permanent in scarring alopecia and it is important to start aggressive treatment at the earliest.
The treatment is essentially medical and involves topical and oral medications. The specific treatment used varies, depending largely on whether lymphocytes, neutrophils, or both are predominantly responsible for the hair follicle destruction.
The lymphocytic form of scarring hair loss usually is managed by use of anti-inflammatory medications. Common medicines used topically are corticosteroids, immunomodulators like Tacrolimus. Also antibiotics and antimalarials have been shown to be useful. Sometimes injecting corticosteroids directly into the bald patches may be required or helpful. Recently,a class of diabetes medications called thiazolidinediones has been shown to be useful.
The scarring alopecia due to neutrophilic infiltrate is treated with antibiotics, anti-inflammatory medications, and retinoids (isotretenoin). More experimentally, drugs like methotrexate, tacrolimus, cyclosporin, and even thalidomide have been used to treat some forms.
Although hair cannot grow back after a follicle has been destroyed, it may be possible to stimulate follicles in the affected area before permanent damage occurs. Applying Minoxidil (medicine that promotes hair growth) may stimulate viable follicles.
Treatment is usually long term. It usually continues till there is remission of symptoms and no new patches are seen or the existing patches have stabilized. The disease is also known to have periods of remission followed by sudden exacerbation even after many years. Even when the disease is in remission some hair loss may continue.
Is there a role for hair transplantation in treatment of scarring alopecia?
Can surgical hair restoration be helpful in people suffering from scarring hair loss?
Once a scarring alopecia has reached the burnt-out stage (of complete remission where there are no new patches or existing patches have remained the same size for a few years) and there has been no more hair loss for a few years, bald areas can be either surgically removed (alopecia reduction) if they are not too big or the bald patches can be transplanted with hair follicles taken from unaffected areas. In alopecia reduction, the affected bald patch of the scalp is removed, and the part of the scalp next to it is pulled together and sutured to cover the gap. In hair transplantation surgery, follicles from the back of the head are surgically removed and transplanted into bare areas of the scalp.
When a hair transplant is performed in patients of scarring alopecia a few points should always be kept in mind
- The disease should not be active
- Always better to perform a small test patch of hair transplant to assess if the follicles would indeed grow in the affected scarred area. It is ideal to wait for six months before an assessment can be made.
- While implanting the follicular unit grafts the spacing between the grafts is a little more than that when hair transplant is performed in non-scarred skin.
- Multiple stages may be needed to achieve optimal density
- There is always a possibility of disease reactivation which may lead to new areas of scarring hair loss or loss of implanted hair follicles.
Traction hair loss
Traction alopecia results from tension applied persistently to hair, such as in the case of certain hairstyles including one or more of the following...
- Very tight ponytails or pigtails
- Tight braids or cornrows
- Extension (single) braids
- Hair weaves or wigs attached with glue, clips or tape
- Certain hair clips, slides or barrettes that hold the hair tightly and are worn in the same position every day
- Headbands - even fabric ones - worn day after day
- Tight hairpieces
- Tight headgear like cycling helmets that are worn frequently or for long stretches of time and tend to rub or pull repeatedly on the same area of hair
- Repeated use of hair rollers
- Repeated pulling of the hair with the hands (this is an emotional condition called trichotillomania)
This kind of hair loss is seen among Sikh males as a result of stress on the hair from wearing a turban.
The constant tension in the affected area either pulls out the hairs' roots completely, or causes the follicles to become inflamed. As time goes by, the damage to the follicles causes them to become atrophied (wasted away)... and if you don't put a stop to the cause of the problem, they will reach the point where they no longer produce hair at all.Affected areas correspond to areas under the greatest amounts of pressure, and usually hair loss occurs at scalp margins.
Traction alopecia is common in people who wear hair piece/wigs/weaves. Wigs are generally applied through braiding, weaving, fusion, netting or bonding - and the sad fact is that any or all of these methods can lead to traction alopecia if used extensively, over long periods of time.The same goes for hair extensions, which can also cause hair loss problems in the lower half of the scalp.
Sikhism is a religion followed primarily by inhabitants of Punjab, a state in India.As part of their religious practice, males as well as females are forbidden to cut their hair. Males more specifically are required to wear a turban on their head. The turban is a long scarf which is wrapped tightly in a particular way around the long hair and placed atop the head. Before wrapping the cloth around the hair, the hair is tied into a tight knot resting on the frontal region of the scalp. Most Sikhs will wear this style for a full 24 hours or longer, after which the turban will be removed and the hair combed. The frontal scalp region is where the alopecia will usually occur given that it experiences the bulk of the trauma. Traction alopecia can also arise in the submandibular area because the majority of the followers of Sikhism will also practice a similar method of knotting their beard. Beard hair, like scalp hair, is grown long and never cut. The hair is put into a ponytail, twisted, and tightly tied into a knot under the chin. In time, alopecia over the mandible can be seen.
Treatment of traction hair loss
To prevent permanent alopecia, patients are advised to switch to more relaxed hairstyles as soon as possible to relieve the stress on their hair. Pharmacological treatments include minoxidil, which has been beneficial for some patients, as well as antibiotics and corticosteroids in the event of folliculitis or inflammation, respectively. Surgical intervention remains an option for patients with advanced hair loss.
Treatment of traction alopecia in Sikh patients can be a difficult process. Religious laws forbid the cutting of hair and require the wearing of the turban. Therefore cutting the hair is not an option. Patients can be advised to allow their hair to be tied loosely and free of a turban for as long as possible during the day. At night they should refrain from wearing the turban and tie their hair in a loose ponytail without the knot. When wearing the turban, the hair should be tied loosely at the scalp to decrease the tension. Patients can be treated with topical steroids, however, unless the tension is relieved, these treatments will prove ineffective. Patients should also be advised that traction alopecia may lead to permanent alopecia, which is progressive if the traction is not removed.
When cutting of the hair is permitted, hair restoration using hair transplantation is possible.