Hair loss 101

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Hair loss facts

  • ¬†Hair loss is very common condition and affects most people at some time in their lives.
  • Androgenetic hair loss is seen in both men and women but worse in men.
  • Health issues like thyroid disease anemia and low vitamins levels may cause hair loss.
  • Alopecia areata is very common coin shape temporary hair loss patch that usually resolves at its own.
  • Medications for hair regrowth include (Rogaine), finasteride (Propecia) and dutasteride (Avodart).
  • Prevention includes good hair hygiene, regular shampooing and good nutrition.
  • Medical health screening for hair loss may include blood tests such ascomplete blood count (CBC), iron level, vitamin B, and thyroid function tests (TFT).

What are the causes of hair loss?

There are so many types of scalp hair loss, determining the precise cause of hair loss in an individual can be challenging. The medical term for hair loss is alopecia.

Most hair loss is not associated with systemic or internal disease, nor is poor diet a frequent factor. Hair may simply thin as a result of predetermined genetic factors, family history, and the overall aging process. Many men and women may notice a mild and often normal physiologic thinning of hair starting in their thirties and forties. Other times, normal life variations including temporary severe stress, illness, nutritional changes, and hormonal changes like those in pregnancy, puberty, and menopause may cause a reversible hair loss.

Several health conditions, including thyroid disease and iron deficiency anemia, can cause hair loss. t is important to exclude underlying causes in sudden or severe hair loss. If you are concerned about some other underlying health issues, you may start by seeing your family physician, internist, or gynecologist for basic health screening. Dermatologists are doctors who specialize in problems of skin, hair, and nails and may provide more advanced diagnosis and treatment of hair thinning and loss. Sometimes a scalp biopsy may be taken to help in diagnosis of severe or unexplained hair loss.

Although many medications list “hair loss” among their potential side effects, most drugs are not likely to induce hair loss. On the other hand, with cancer treatments and immune suppression medications, hair loss is a very common side effect. Complete hair loss often occurs after a course of major chemotherapy for cancer. Usually, hair regrows after six to 12 months.

How to classify hair loss?

Hair Growth cyclesThere are numerous ways to categorize hair loss. One must first examine the scalp to determine if the hair loss is due to the physical destruction and loss of hair follicles. If the scalp appears perfectly normal with plenty of follicular structures (which seem to be simply unoccupied) this is called non-scarring hair loss. On the other hand, the follicles are permanently destroyed in scarring hair loss. Localized, small areas, large areas or the whole scalp may be affected in scarring and non-scarring hair loss. Occasionally, it may be necessary to do a biopsy of the scalp to distinguish these conditions. Sometimes, a physician may pull a hair to examine the percentage of hairs in the growth (anagen phase). This article will concentrate on the non-scarring types of hair loss.

Some conditions produce small areas of hair loss, while others affect large areas of the scalp. Common causes of patchy hair loss are

  • alopecia areata (small circular or coin size patches of scalp baldness that usually grow back within months),
  • traction alopecia (thinning from tight braids or ponytails),
  • trichotillomania (the habit of twisting or pulling hair out),
  • tinea capitis (fungal infection).

What is alopecia areata?

A common condition, alopecia areata usually starts as a single quarter-sized circle of perfectly smooth baldness. Alopecia patches usually regrow in three to six months without treatment. Sometimes, hair temporarily regrows in white where it was previously dark.

Alopecia areata is an autoimmune condition in which the body attacks its own hair follicles. Most alopecia patients, however, do not have systemic problems and need no medical tests. While alopecia areata is frequently blamed on “stress,” in fact, it may be the other way around; that is, having alopecia may cause stress.

Treatments for alopecia areata include injecting small amounts of steroids like triamcinolone into affected patches to stimulate hair growth. Although localized injections may not be practical for large areas, often this is a very effective treatment in helping the hairs return sooner. Other treatments such as oral steroids or other immunosuppressives, or ultraviolet light therapy are available for more widespread or severe cases but may be impractical for most patients because of potential side effects or risks.

What is traction alopecia?

This is a small or localized hair loss area caused by repetitive or persistent pulling or force on hair roots. Tight braids and ponytails can pull hard enough on hairs to make them fall out. If this happens, it’s best to choose hairstyles that put less tension on hair. The sooner this is done the better to avoid permanent damage.

What is trichotillomania?

This refers to the habit of someone voluntarily pulling at their own hairs or twisting them, sometimes without realizing it. The scalp and eyelashes are often affected. Unlike alopecia areata patches, which are perfectly smooth, hair patches in trichotillomania show broken-off hairs. Treatment is often entirely behavioral: You have to notice that you’re doing it and then consciously stop. Severe or resistant cases may require stress counseling with a therapist or psychologist or medical treatment with a psychiatrist. Several antidepressant or anxiety medications have been shown to help with this condition.

What is tinea capitis?

Tinea is the medical word for fungal infection, and capitis means head. Tinea capitis is fungal infection of the scalp that for the most part affects school-age children. Tinea capitis is more common in black African or African-American scalps. This condition is rare in healthy adults. Bald spots usually show broken-off hairs and is accompanied by dermatitis. Oral antifungals can penetrate the hair roots and cure the infection, after which hair grows back. Sharing hats or combs and brushes may transmit tinea capitis.

What is generalized (diffuse) hair loss?

This is an overall hair thinning without specific bald spots or patterns. While this type of hair loss may not be noticeable to others, often the individual will feel their hair is not as thick or full as it previously was. Common conditions in this category are

  • telogen effluvium (rapid shedding after childbirth, fever, or sudden weight loss);
  • androgenetic or androgenic hair loss (“male-pattern baldness,” “female-pattern baldness)

What is telogen effluvium?

Under normal conditions, scalp hairs live for about three years (the anagen, or growing, phase); they then enter the telogen, or resting, phase. During the three-month telogen period, the hair root shrivels up into a small white “club,” then the hair falls out. It is therefore normal to lose about 100 hairs every day, more of them on days when shampooing loosens the hairs that are ready to fall out. The hairs are then replaced by the body.

There are several circumstances that produce a “shock to the system” that alters the hair growth rhythm. As a result, as much as 30%-40% of the hairs can cycle into telogen. Three months later, hairs come out in a massive shedding (effluvium), especially near the front of the scalp. These include

  • childbirth,
  • high fever,
  • sudden weight loss (crash dieting),
  • surgery,
  • severe illness,
  • Severe emotional stress or loss.

None of these need be life-threatening, nor does hair loss usually follow them. (Moreover, it can happen after one pregnancy, but not the next.) But when the hair falls out, it’s all over the place — covering the pillow, clogging the drain, and so forth. Paradoxically, the more dramatic the hair loss, the better the prognosis, because when the body gets back into normal rhythm, most if not all of that hair comes back; these people need no special treatment.

Normal shampooing can continue, because this only loosens hairs that were going to come out anyway.

What is androgenetic or androgenic alopecia (“male-pattern baldness,” “female-pattern baldness”)?

This type of alopecia is often attributed to genetic predisposition and family history. Androgenic alopecia is seen in both men and women. The hair loss in men is often faster, earlier onset, and more extensive.

Doctors refer to common baldness as “androgenetic alopecia” or “androgenic alopecia,” which implies that a combination of hormones and heredity (genetics) is needed to develop the condition. The exact cause of this pattern is unknown. (The male hormones involved are present in both men and women.)

Male-pattern baldness

Even men who never “go bald” thin out somewhat over the years. Unlike those with reversible telogen shedding, those with common male-pattern hair loss don’t notice much hair coming out; they just see that it’s not there anymore. Adolescent boys notice some receding near the temples as their hairlines change from the straight-across boys’ pattern to the more “M-shaped” pattern of adult men. This normal development does not mean they are losing hair.

Some “myths” about male-pattern baldness

  • People inherit baldness through their mother’s male relatives. Actually, baldness can come from either side of the family or both. Looking at one’s family can give someone at best an educated guess about how he or she will turn out. Studies are ongoing in this field, and current research has been inconclusive about the inheritance patterns.
  • Longer hair puts a strain on roots. It doesn’t. And hats don’t choke off the circulation to the scalp to cause hair loss either.
  • Shampooing does not accelerate balding.
  • “Poor circulation” does not cause hair loss, and massaging doesn’t stop it.

What treatment is there for hair loss in men?

There are very few scientifically proven treatments for hair loss. There are thousands of unproven claims and products to help with hair regrowth. Many conditioners, shampoos, vitamins, and other products claim to help hair grow in some unspecified way. To slow down hair loss, there are at least four potentially effective, basic options.

These include medications like Minoxidil, Propecia, and Avodart which are maintenance-type medications and are for long-term use. Stopping these drugs does not seem to worsen or exacerbate the prior hair loss. In other words, stopping the medication will not leave someone worse than he started out prior to the medication.

Minoxidil (Rogaine): This topical medication is available over the counter, and no prescription is required. It can be used in men and women. It works best on the crown, less on the frontal region. Minoxidil is available as a 2% solution, 4% solution, an extra-strength 5% solution, and a new foam or mousse preparation. Rogaine may grow a little hair, but it’s better at holding onto what’s still there. There are few side effects with Rogaine. The main problem with this treatment is the need to keep applying it once or twice daily, and most men get tired of it after a while. In addition, minoxidil tends to work less well on the front of the head, which is where baldness bothers most men. Inadvertent application to the face or neck skin can cause unwanted hair growth in those areas.

Finasteride (Propecia): This medication is FDA approved for use in only men with androgenic hair loss. Although not FDA approved in women, it has been used “off label” in women with androgenic hair loss who are not pregnant or planning to become pregnant while on the medication. Finasteride is in a class of medications called 5-alpha reductase inhibitors. It is thought to help reduce hair loss by blocking the action of natural hormones in scalp hair follicles. Propecia is a lower-dose version of a commercially available drug called Proscar that helps shrink enlarged prostates in middle-aged and older men. Women, especially those who are or may become pregnant, should not handle finasteride capsules. Touching the contents of the capsules may potentially harm a male fetus and females who accidentally touch leaking capsules should wash the area to avoid side effects. Propecia 1 mg tablets are available by prescription and taken once daily. Propecia may grow and thicken hair to some extent for some people, but its main use is to keep (maintain) hair that’s still there. Studies have shown that this medication works well in some types of hair loss and must be used for about six to 12 months before full effects are determined. This medication does not “work” in days to weeks, and its onset of visible improvement tends to be gradual. It may be best for men who still have enough hair to retain but also can help some regrow hair. Possible but very unlikely side effects include impotence or a decreased sex drive (libido). Studies have shown that these side effects were possibly slightly more common than seen in the general population and are reversible when the drug is stopped. Taking Propecia once a day seems to be easier than applying minoxidil, but the prospect of taking a pill daily for years doesn’t sit well with some.

Dutasteride (Avodart) has recently been used as “off label” to treat hair loss in men. It is FDA approved and primarily used to treat an enlarged prostate (benign prostatic hyperplasia, or BPH) only in men. Dutasteride is similar to finasteride (Propecia, Proscar) and is in a class of medications called 5-alpha reductase inhibitors. Dutasteride may help in hair loss by blocking the production or binding of a natural substance in the scalp hair follicles. Although not FDA approved in women, it has been used “off-label” in women with androgenic hair loss who are not pregnant or planning to become pregnant while taking the medication. Women, especially those who are or may become pregnant, should not handle dutasteride capsules. Touching the contents of the capsules may potentially harm a male fetus, and females who accidentally touch leaking capsules should wash the area with soap and water immediately. There is a six-month clearance time required after taking this medication before being permitted to donate blood.

A group of topical medications called prostaglandin analogs have recently began undergoing testing for potential hair regrowth. They may be used in men and women. These drugs are not currently FDA approved for scalp hair loss. Currently, these are primarily used for eyelash enhancement. One of the new medications is called bimatoprost (Latisse). Further testing and studies are required to assess the efficacy of these products in scalp hair loss. Bimatoprost solution is sometimes used off-label for help in selected cases of hair loss. It is currently FDA approved for cosmetic eyelash enhancement. Studies have shown it can treat hypotrichosis (short or sparse) of the eyelashes by increasing their growth, including length, thickness, and darkness. This medication is also commercially available as Lumigan, which is used to treat glaucoma. It is not known exactly how this medication works in hair regrowth, but it is thought to lengthen the anagen phase (active phase) of hair growth. Interestingly, during routine medical use of Lumigan eyedrops for glaucoma patients, it was serendipitously found that eyelashes got longer and thicker in many users. This led to clinical trials and the approval of cosmetic use of Latisse for eyelashes.
What other options do people have for hair loss?

There are many options and alternative cosmetic treatments for hair loss. Some of these are listed here and include hair-fiber powders, hairpieces, synthetic wigs, human hair wigs, hair extensions, hair weaves, laser, and surgery.
Hair-fiber powders: Colored, powdery fiber sprinkles are commercially available and may work really well to cover up thinning hair areas. These colored sprinkles have special properties that help them attach to hair and give a fuller appearance. Toppik is one manufacturer of these products and can be found online. These cosmetic products are available without a prescription, are fairly inexpensive and quite safe with minimal risk. Often these may be used in addition to medical treatments like Rogaine, Propecia, and hair transplants, and they are a great temporary measure to tide you over for special occasions.

Hairpieces: Among the time-honored ways to add hair temporarily are hairpieces or hair weaving, in which a mesh is attached to your remaining hair and artificial or human hair of similar color and texture is woven with existing hair. Quality varies considerably with price; also, hairpieces and weaves may stretch, oxidize, and loosen.

Surgery or hair transplants: Surgical hair restoration approaches include various versions of hair transplantation (taking hair from the back and putting it near the front) or scalp reduction (cutting away bald areas and stitching the rest together). Transplant procedures have improved greatly in recent years. They can produce much more attractive and natural-looking results than older methods that sometimes leave a “checkerboard” or hair plug look. Many transplant patients now take Propecia to maintain or keep what they’ve transplanted. When considering a hair transplant, check the surgeon’s credentials and experience carefully. Micrografts are some of the newest techniques whereby surgeons transplant single one to two hair follicles. Hair transplants may be very expensive and time-consuming procedures ranging widely anywhere depending on the number of hair grafts transplanted. Typically 500 or more hairs may be transplanted in a session.

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