Hair Loss (Alopecia)

More than half of men and women in the United States experience hair loss. About 35% of people have hair loss by age 35 years, and about 50% have hair loss by age 50 years. Hair loss is so common; it is sometime considered a normal variation and not a disease. Other animals closely related to humans, such as the chimpanzee, also lose their hair. Dr. Ghohestani, at the Texas institute of Dermatology, offers the latest treatment options for Alopecia in Men and Women including a new UV laser system.

Is hair loss normal?

There are 3 cycles of hair growth-growing, resting, and shedding. In most animals these cycles change with the season, and all hairs are in the same part of the cycle at the same time. This is why animals grow a thicker coat in the fall and shed most in the spring. Unlike most animals, in humans each hair has its own pattern of growing, resting, and shedding. Each person sheds hair and regrows hair every day. When this balance is disturbed and more hairs are shed than are regrown, alopecia or hair loss results.

Everyone loses some hair every day. Losing up to 100 hairs a day is normal.

But if hair loss runs in your family, you could lose a lot more hair. Over time, you may end up with bald spots or hair that slowly gets thinner. About half of all people have this type of hair loss by around age 50.

Other factors, such as diseases and medicines, also can cause you to lose more hair than normal.

Although hair loss is fairly common, it can be a tough thing to live with, especially when it changes how you look. But there are ways you can treat your hair loss.

What causes hair loss?

Hair-loss is divided into two broad categories:

- 1. Hair loss with scarring (Scarring Alopecia)

- 2. Hair loss without scarring (Non-scarring Alopecia)

Common causes of hair loss include:

- Heredity. In most cases, hair loss is inherited, which means it’s passed down from one or both of your parents. This is called male-pattern or female-pattern hair loss.

- Stress, including physical stress from surgery, illness, or high fever.

- Chemotherapy, which is powerful medicine that destroys cancer cells.

- Damage to your hair from pulling it back too tightly, wearing tight braids or ponytails, or using curling irons or dyes.

- Age, since you grow less hair as you get older. Hair also gets thinner and tends to break more easily as you age.

- Poor diet, especially not getting enough protein, fresh fruit or iron.

- Thyroid diseases, like hypothyroidism and hyperthyroidism.

- Infection for example: Ringworm of the scalp, which is common in children

Rare causes of hair loss include:

- Kidney failure

- Liver Failure

- Infections such as Syphilis

- Hormonal problems

- Cancers

What are the symptoms?

Your symptoms will depend on what kind of hair loss you have.

If your hair is thinning, it happens slowly over time, so you may not notice the hairs falling out. If your hair is shedding, then clumps of hair fall out. You may lose hair all over your scalp, which is called general hair loss. Or you may lose hair only in one area, which is called focal hair loss.

With inherited hair loss, men usually get bald spots around the forehead or on the top of the head, while women have thinning all over the scalp.

Since your hair has a lot to do with your appearance, losing it may cause you to have lower self-esteem if you don’t like how you look. This is especially true in women and teens.

How is hair loss diagnosed?

Dr. Ghohestani will ask you some questions, like how much hair you’re losing, when it started, and whether your parents have hair loss. He will look closely at your scalp and hair-loss pattern and may gently pull out a few hairs for tests.

If it’s not clear what’s causing you to lose your hair, Dr. Ghohestani may do a blood test or look at a sample of your hair or scalp with a microscope.

Androgenic Alopecia (Typical Hair Loss in Men)

By far the most common form of hair loss is determined by our genes and hormones: Also known as androgen-dependent, androgenic, or genetic hair loss. It is the largest single type of recognizable alopecia to affect both men and women. It is estimated that around 30% of Caucasian females are affected before menopause. Other commonly used names for genetic hair loss include common baldness, diffuse hair loss, male or female pattern baldness.

The rate of hair shedding in androgenic alopecia is speeded up by three forces: advancing age, an inherited tendency to bald early, and an over-abundance of the male hormone dihydrotestosterone (DHT) within the hair follicle. DHT is a highly active form of testosterone, which influences many aspects of manly behavior, from sex drive to aggression.

The conversion from testosterone to DHT is driven by an enzyme called 5-alpha reductase, which is produced in the prostate, various adrenal glands, and the scalp. Over time, the action of DHT causes the hair follicle to degrade and shortens the anagen phase. Thought the follicle is technically still alive and connected to a good blood supply–it can successfully nurture a transplanted follicle which is immune to the effects of DHT–it will grow smaller and smaller. Some follicles will gradually die, but most will simply shrink to the size they were when you were born which produce weaker hairs. With a steadily shorter anagen growing cycle, more hairs are shed, the hairs becoming thinner and thinner until they are too fine to survive daily wear and tear. Balding hair gradually changes from long, thick, coarse, pigmented hair into fine, unpigmented vellus sprouts.

However, the sebaceous gland attached to it remains the same size. As the hair shafts become smaller, the gland continues to pump out about the same amount of oil. So as your hair thins, you will notice that your hair becomes flatter and oilier.

But the hormonal link in balding is complex. Eunuchs, who produce no testosterone, never go bald — even if carrying a baldness gene. However, if castrated men with a family history of baldness are given testosterone, they lose hair in the classic horseshoe-shaped pattern.

Studies show that while balding men don’t have higher than average circulating testosterone levels, they do possess above-average amounts of a powerful testosterone derivative, dihydrotestosterone in the scalp follicles. In male balding, genetically primed follicles convert circulating testosterone to dihydrotestosterone, which successively diminishes or miniaturizes follicle size, producing ever weaker hairs. With a steadily shorter anagen growing cycle, more hairs are shed, the hairs becoming thinner and thinner until they are too fine to survive daily wear and tear. Balding hair gradually changes from long, thick, coarse, pigmented hair into fine, depigmented vellus sprouts.

Other physiological factors might cause hair loss. Recently, a group of Japanese researcher reported a correlation between excessive sebum in the scalp and hair loss. Excessive sebum often accompanying thinning hair is attributed to an enlargement of the sebaceous gland. They believed excessive sebum causes a high level of 5-alpha reductase and pore clogging, thus malnutrition of the hair root.

Although this condition could be hereditary, they believe diet is a more prominent cause. The researchers note that Japanese hair was thick and healthy, with a small gland and little scalp oil, until the occidental habit of consuming animal fat crept into their diet after World War II. This change has led to a significant height increase in the Japanese population, but it has also resulted in more Japanese men losing hair. To some extent, their observation makes sense since problems with greasy hair have often been noted as much as six months to a year prior to when thinning hair becomes noticeable, but this might be just one of the symptoms, not underlying cause, more research is needed. Most doctors agree that if you have an oily scalp with thinning hair, frequent shampooing is advised. Shampooing can reduce surface sebum, which contains high levels of testosterone and DHT that may reenter the skin and affect the hair follicle.

Hair Loss in Women:

- Many women with hair loss suffer in silence, altering their hairstyle to hide thinning or patches. But the sooner you seek care, the better the chances of successfully treating it. The most common form of hair loss in Women is female-pattern hair loss, which usually has a strong genetic component that can be inherited from either the mother or father. Also referred to as androgeneticalopecia, this type of hair loss can start as early as the late teens — and the earlier it starts, the more severe the hair loss tends to be.

- A woman may not notice hair loss itself but may first notice that her ponytail or braid is getting thinner.

- Women also have a different pattern of balding than men. Most women with pattern hair loss don’t get a receding hairline or bald spot on top of the scalp as is common in men. Instead, there is visible thinning over the crown. In men and women, hairs are miniaturized because of a shortened growth cycle where the hair stays on the head for a shorter period of time. These wispy hairs, which resemble forearm hairs, do not achieve their usual length.

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- How is female hair loss treated?

- The 2% and 5% solutions are available over the counter in a liquid, and the 5% is also available in foam. Minoxidil works by prolonging the growth phase of hair — providing more time for hair to grow out to its full density.

You have to be patient, as noticeable results usually take three to four months and the product must be used twice a day. It tends to work better if started early.

Doctors may also test for levels of ferritin (a protein that indicates the amount of total body iron stores). New research suggests levels may be low in women with hair loss. Iron supplements may help.

Also new is the HairMax Laser Comb. It’s a red light therapy hairbrush-like device that increases circulation and the biological march that makes hair. It’s only approved in men (though some women are using it) and in my experience, is not as good as minoxidil. But in one study, 45% of users reported improvement after eight weeks, and 90% saw improvement after 16 weeks.

In some cases, a hormonal abnormality, such as excess male hormones known as androgens, may be responsible for hair loss in women. One clue that hormones are involved is if the hair loss pattern resembles that of a man’s hair loss. This can be treated with prescription medications such as spironolactone or oral contraceptives.

In men, finasteride (originally marketed as Proscar) is approved for hair loss associated with androgens. In one study, 62% of women also taking oral contraceptives containing the synthetic progestin drospirenone reported improvement. So it may be effective for female hair loss in the setting of increased androgen. But studies are limited and it is harmful to the male fetus so should not be used by women thinking about becoming pregnant or who are pregnant.

Another treatment option is hair transplantation, in which tiny hair follicles taken from one area of the scalp are transplanted into the affected areas. It can be very effective and produce permanent results that are natural looking.

Should I change my hair care regimen?

No. Since there is no structural problem with the hair with female-pattern hair loss, women should continue their regular hair styling regimen. Sometimes women think they should stop washing, coloring, or perming their hair, but these things won’t impact the course of hair loss or speed up the process.

Wash with an anti-dandruff shampoo that contains ketoconazole (an antifungal) or zinc pyrthione (an antifungal and antibacterial).

Hair loss can be a sign of a more serious problem?

Yes. Hyperandrogenism, a medical condition characterized by excessive production of male hormones called androgens, can cause hair loss in affected women. The most common cause of hyperandrogenism in women is functional ovarian hyperandrogenism, also known as polycystic ovary syndrome. In addition to hair loss, other signs include obesity, acne, and irregular menstruation, and it is one of the most common causes of infertility.

Many of these women have metabolic syndrome — a combination of five medical conditions including belly fat and high blood pressure that increase the risk of diabetes, heart attack, and stroke.

Although hair loss stemming from hyperandrogenism can be treated with minoxidil, you need to seek care for the other conditions.

How your hair loss treated?

With inherited hair loss (androgenetic alopecia), you have options to treat or not. If your hair loss has another cause, talk with Dr. Ghohestani about your treatment choices.

Everyone has some hair loss every day. But for some, hair loss becomes excessive, and treatment with medicines may slow hair loss and help to regrow hair. Before talking to your doctor, consider the followings:

How you choose to treat your hair loss depends on the cause. It also depends on your feelings. You may decide that you need treatment, or you may not be worried about thinning hair or baldness. The choice is up to you.

Hair loss that runs in the family can be treated with medicines or with surgery, such as a hair transplant. Some people choose to wear hairpieces, like wigs or toupees. Finding different ways of styling your hair, like dyeing or combing, also can help. If hair loss is caused by something you can control, like stress or medicines, you can treat it by getting rid of the cause.

When you are deciding about treatment, think about these questions:

· Which treatment is most likely to work?

· How long will it take?

· Will it last?

· What are the side effects and other risks?

· How much will it cost, and will insurance cover it?

Will your hair grow back?

When your hair loss is inherited, your hair won’t grow back naturally. Treatment can help some hair grow back and prevent more from falling out, but you probably won’t get all your hair back. And treatment doesn’t work for everyone.

When medicines, stress, or hair damage cause you to lose your hair, it often will grow back after you take away the cause. If this doesn’t help, you may need other treatment.

If you’re unhappy with how hair loss makes you look, treatment may boost your self-esteem. It’s natural to want to like the way you look.

But keep in mind that treatment, especially medicines and surgery, can have some side effects and risks. Be sure to discuss your decision with Dr. Ghohestani.

Prevention

Prevention can be accomplished only by early treatment. Sometimes what you think may be hair loss is actually just hair breakage from overuse of hair dryer. Women of child bearing age should take enough iron to prevent iron deficiency alopecia.

Outlook

The ability to stop hair loss most often depends on the underlying cause.

- If taking a certain medication was the cause, stopping the medication would stop the hair loss.

- The most common type of hair loss, androgenic alopecia, usually follows a pattern with hair thinning in the front of the scalp first and progressing on to involve the back and top of the head. This type tends to be progressive.

- Finasteride helps stop hair loss in about 60% of men, and minoxidil decreases hair loss in about 50% of men and women.

- The best prevention of hair loss is early treatment. Research has shown that minoxidil is most useful for people who have been losing hair for less than 5 years.

- A doctor who can help determine if the medications are working and who can watch for side effects of the medications should follow up with people who are being treated with minoxidil or finasteride.

What you can do at home?

Home treatment for hair loss includes hair care and hairstyling techniques that may help you cover thinning or bald spots on the scalp. This may be easier for women because inherited hair loss (Androgenetic Alopecia), causes a general thinning that is usually not as severe as it is in men. Hair sprays, dyes, and perms can help make the hair appear fuller.

In women with inherited hair loss, hair care and the occasional use of grooming products or frequent washing will not necessarily increase hair loss. However, perms and dyes may contribute to more hair loss.

For both men and women, hair thinning and baldness increase the risk of sunburn and skin cancer on the scalp. When in the sun, wear a hat and use a sunscreen with an SPF of 30 or more to prevent sun damage to the scalp.

Hair Loss – Medications

Medicines for hair loss can slow thinning of hair and increase coverage of the scalp by growing new hair and enlarging existing hairs. But they need to be taken continuously. If the medicines are stopped, any hair that has grown in will gradually be lost, and within 6 to 12 months your scalp will most likely appear the same as before treatment.

What medicines are available to treat inherited hair loss?

Medicine for treating inherited hair loss slows thinning of the hair and increases coverage of the scalp by growing new hair and enlarging existing hairs. Currently, medicines used to treat hair loss caused by heredity include:

1. Minoxidil (Rogaine) is available without a prescription and is sprayed on and/or rubbed into the scalp twice a day. In men, the 5% solution appears to be more effective than the 2% solution, but it costs more and may have more side effects.2

Minoxidil seems to work best on people younger than 30 years of age who have been losing hair for fewer than 5 years. Minoxidil 2% is the only topical medication approved by the FDA for female-pattern hair loss. We find that the stronger minoxidil 5%, approved only for male-pattern hair loss, is very effective in women as well. But it can sometimes increase facial hair growth.

2. Finasteride (Propecia), which is available by prescription, is a pill taken once daily. Finasteride is recognized as a successful therapy for inherited hair loss for men. Research reports that it slows hair loss on the scalp and helps regrow hair.3, 4, 5 But bald spots may not be completely covered, and visible results may take from a few months to a year. Finasteride has not been proved effective in women and is not approved for women by the U.S. Food and Drug Administration (FDA). Finasteride should never be taken or handled by women who are or may become pregnant, because it can cause birth defects.

With these medicines, hair coverage tends to improve on the top of the head but not on the forehead area.

How effective are these medicines in treating inherited hair loss?

The effectiveness of finasteride or minoxidil depends on your age and the location of the hair loss. These medicines do not work for everyone, and you should not expect to regrow a full head of hair.

These medicines slow thinning of the hair and increase coverage of the scalp by growing new hair and enlarging existing hairs. They need to be taken every day, and if you stop taking them, any hair that has grown in will gradually be lost. Both medicines must be taken daily. It may take 6 months of treatment before you see results.

What are the side effects of these medicines?

- Side effects of minoxidil include skin irritation, dandruff, and an itchy scalp. In women, minoxidil may cause facial hair growth, especially on the forehead and cheeks. If you have heart problems, ask your doctor about using this medicine.

- Finasteride should not be taken or handled by women who are or may become pregnant, because it can cause birth defects. Possible side effects in men include sexual problems, such as difficulty getting an erection.

Medicines used to treat alopecia areata, which is caused when the immune system attacks hair follicles , include:

- Corticosteroids injected into the scalp. The corticosteroid is injected many times about 1cm apart every 4 to 6 weeks. This is the most common treatment in adults and is best used for treating patchy hair loss. Limited research reports that hair grows back at the site of injection in some people.

- Corticosteroid ointments or creams you put on the scalp. There is little evidence that they cause hair growth when used alone. Corticosteroids may be used along with injected steroids or with other medicines such as minoxidil (Rogaine).

- Corticosteroids you take by mouth (oral). Although this does result in hair growth, it is rarely used because of the side effects of oral corticosteroids.

- Contact immunotherapy, which may be the most effective treatment for severe alopecia areata.4 A common medicine used is diphenylcyclopropenone (DPCP), which is “painted” on the scalp once a week at increasing strengths. The DPCP irritates the skin, making it itchy and scaly. This treatment is not widely available; recent studies suggest that the procedure’s side effects are significantly higher than expected.

- UV and/or Psoralen with ultraviolet A light (PUVA) therapy. UV has shown to help patients with Alopecia Areata. We offer a high powered UV laser for treating patients with Alopecia Areata. For PUVA, a medicine, called a psoralen, is used to make the skin more sensitive to ultraviolet A (UVA) light. Then the skin is exposed to UVA light.

- Laser Comb. It’s a red light therapy hairbrush-like device that increases circulation. It’s only approved in men (though some women are using it) and in my experience, is not as good as minoxidil, further independent studies are necessary to confirm its efficacy in treating Alopecia.

Hair loss can be a sign of a more serious problem?

Hyperandrogenism, a medical condition characterized by excessive production of male hormones called androgens, can cause hair loss in affected women. The most common cause of hyperandrogenism in women is functional ovarian hyperandrogenism, also known as polycystic ovary syndrome. In addition to hair loss, other signs include obesity, acne, and irregular menstruation, and it is one of the most common causes of infertility. Ovarian tumors can occasionally cause a male pattern hair loss.

Many of these women have metabolic syndrome — a combination of five medical conditions including belly fat and high blood pressure that increase the risk of diabetes, heart attack, and stroke.

Although hair loss stemming from hyperandrogenism can be treated with minoxidil, you need to seek care for the other conditions.

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At the Texas Institute of Dermatology, we want you to have an excellent outcome and to feel that your needs and concerns have been promptly addressed in a caring and sensitive fashion. We strive diligently to ensure your satisfaction, your comfort, your privacy, and your safety. All treatments are supervised or performed by a dermatologist with many years of successful experience in a large variety of procedures. Many treatment modalities are available, and we can recommend the one or two that are most likely to meet your needs; we’re here to meet your needs and help you realize your aspirations. At our clinic in San Antonio, Texas, we serve communities throughout the Bexar County and the Kendall County, including San Antonio, Boerne, Leon Spring, Ralph Fair Ranch, Canyon Lake city; many of our patients also come from San Marcos, New Braunfels, Kerrville, Austin, Wimberley and Corpus Christi.