Hair Loss

Hair loss, or alopecia, is a very common presenting symptom, and more than one third of women have clinically significant hair loss during their lifetime. The effect of hair loss on patients’ emotions is often greatly underestimated by physicians.

After bone marrow, hair is the second fastest growing tissue of the body. As a result, many different metabolic changes can manifest as hair loss being the first clinical sign of systemic disease.

We can assist with finding a cause for your hair loss. Hormones can sometimes be the cause but many times there are no specific or targeted therapies for hair loss. The hormones that can be checked are thyroid, pituitary, male hormones, and adrenal hormones, We can also check for some vitamins deficiencies like iron levels. If these levels are abnormal, they should be treated first. The most common cause of hair loss is telogen effluvium or stress-induced hair loss. Below are your general treatment options.

A. Vitamins: Biotin 5000 units per day for 6 months (do not take within 5 days of any blood testing as this changes the assays) can sometimes help but data is anecdotal and not well studied. Most vitamins do not work as well as their claims. Good documentary on the murky and lucrative world vitamins https://www.vitamaniathemovie.com/

B. Minoxidil: Over the counter topical (rogaine) minoxidil which is a liquid topical daily medication or prescribed daily oral Minoxidil. Pros: Low cost, effectiveness is good. Cons: Liquid can be messy as application is daily to scalp hairs. Effect wears off and hair falls off as soon as medication stopped. If medication stopped, the hairs that grew will fall out.

C. Spironolactone: Some times off-label use of a prescribed blood pressure medication called sprionolactone can help. The medication has a side effect of an androgen blockade in the scalp. Pros: Cheap. Dosed as a tablet once or twice per day Cons Can cause low blood pressures and dizziness. Effectiveness is poor to moderate and usually requires high doses. Can cause potassium elevation which should be monitored as it can cause heart dysfunction. Causes birth defects if taken by women, so must be used with birth control medication in women of child bearing age.

D. Platelet Rich Plasma (PRP) for hair loss. This treatment is Injections of a persons own blood growth factors back into their scalp done once a month for 3 months and then yearly after the initial visit if desired. Pros: Does not require much up-keep. 70% response rate for hair growth Cons: Could be expensive.

E. Hair Transplants. These can be expensive and are usually considered after other therapies have not worked.

Hair Biology

The scalp contains, on average, 100,000 hairs. More than 90% of these hairs are actively growing (anagen hairs). Anagen hairs are anchored deeply into the subcutaneous fat and cannot be pulled out easily. Hair is constantly cycling and regenerating on the scalp. Each hair shaft can persist on the scalp for 3 to 7 years before falling out and being replaced by a new hair. This anagen phase is followed by a 2-week phase of catagen, during which there is programmed cell death; the trigger factor for catagen phase is unknown. After catagen, the hair goes into telogen, a resting phase that lasts about 3 months. As compared with anagen hair, telogen hair is located higher in the skin and can be pulled out relatively easily. Normally, the scalp loses approximately 100 telogen hairs per day. In addition to the ratio of anagen hair to telogen hair, the diameter of the hair follicles determines scalp coverage. Vellus hairs have a hair-shaft diameter of less than 0.03 mm and terminal hairs have a diameter greater than 0.06 mm. The optimal hairs for scalp-hair growth and scalp coverage are anagen and terminal hairs.

Causes of Hair Loss Hair loss

1. Scarring (which occurs in discoid lupus, lichen planopilaris, and folliculitis decalvans). Patients should see a dermatologist about this type of hair loss, or 2. Non-scarring (see below)

Androgenetic alopecia

Androgenetic alopecia is the most common cause of such hair loss, female-pattern hair loss. The role of male hormones like androgens in this type of non-scarring hair loss remains unclear. This condition often runs in families. Female-pattern hair loss can develop any time after the onset of puberty. By age 70 years of age, 38% of women have female-pattern hair loss. It affects the central portion of the scalp, sparing the frontal hairline. Male patterns of hair loss may be associated with hyperandrogenism, but the majority of women with female-pattern hair loss have normal serum androgen levels.

Telogen Effluvium

Chronic Telogen Effluvium versus Acute Telogen Effluvium are another VERY common cause of non-scarring hair loss. This results from an abrupt shift of large numbers of anagen hairs to telogen hairs on the scalp, with a corresponding change in the ratio of anagen hair to telogen hair from the normal ratio of 90:10 to 70:30. It is not unusual for women with telogen effluvium to lose more than 300 hairs per day. This form of alopecia generally begins approximately 3 months after a major illness or other stress (e.g., surgery, parturition, rapid weight loss, nutritional deficiency, high fever, or hemorrhage) or hormonal derangement (e.g., thyroid dysfunction); it has also been reported after the initiation of treatment with certain medications. Chronic telogen effluvium refers to hair loss lasting more than 6 months. In some patients, this type of hair loss lasts for years.

Gastric Bypass is associate with hair loss. There are numerous mechanisms that cause this loss. Vitamin deficiencies is a main issue.

Acute Telogen Effluvium after a pregnancy cause can cause a lot of distress.

COVID 19 infection and COVID 19 vaccines are associated with hair loss.

Iron deficiency is a vitamin Disorder that can cause hair loss. Testing for iron levels can be helpful

Associated (non exhaustive list) drugs

Acetretin, heparin, interferon alfa, isotretinoin, lithium, ramipril, terbinafine, timolol, valproic acid, warfarin >5 Acyclovir, allopurinol, buspirone, captopril, carbamazepine, cetirizine, cyclosporine, gold, lamotrigine, leuprolide, lovastatin, nifedipine 1–5 Amiodarone, amitriptyline, azathioprine, dopamine, naproxen, omeprazole, paroxetine, prazosin, sertraline, venlafaxine, verapamil

Anagen Effluvium

This is hair loss associated with chemotherapeutic agents that cause immediate destruction and release of anagen hair. If the cause of telogen effluvium is removed, hair loss lasts for up to 6 months after removal of the trigger.

Associated (non exhaustive list) drugs

Bleomycin, busulfan, cisplatin, cyclophosphamide, daunorubicin, doxorubicin, fluorouracil, vasopressin, vinblastine, vincristine

Alopecia Areata

This is a less frequent cause of nonscarring hair loss. The estimated lifetime incidence of this condition is 1.7%. 11 It is usually manifested as round patches of alopecia that may become multifocal and may coalesce into large areas. This is frequently reversible, but it tends to be recurrent, and it can progress to total loss of scalp hair (alopecia totalis) in 5% of women and total loss of body hair (alopecia universalis) in 1% of women. The cause is unknown, but it is thought to be autoimmune.

Other causes of nonscarring alopecia are certain

1. Compulsive hair pulling (trichotillomania),

2. Severe bacterial infections

3. Fungal infections like tinea capitis,

4. In some cross-sectional studies, iron deficiency and reduced iron levels have been associated with hair loss, including female-pattern hair loss and telogen effluvium, but data are limited.

Testing

Ferritin level to rule out iron deficiency (particularly in menstruating women, vegetarians, and women with a history of anemia) . Generally If the ferritin level is less than 70 ng per milliliter, iron supplementation is recommended.
TSH blood testing to rule out thyroid dysfunction in women with diffuse hair loss, although the yield of such universal testing has not been proved.
In women with female-pattern hair loss and other conditions suggesting androgen excess (e.g., hirsutism, acne, or irregular menses), assessment of male hormones like free testosterone is done.
Also check for Syphilis.
If fungus is suspected, scale from the area of alopecia should be examined by a dermatologist with interest in hair loss

Treatments

We recommend evaluation and management of treatment with a board certified dermatologist with experience in hair loss. Here is a short video to explain all the treatment options.
Oral medications such as minoxidil
Rosemary Oil
PRP (platelet rich plasma) using your own blood can have a high success rate 70% in most cases. See some before and after photos using PRP
Hair Transplant
Low Level Laser

Hair loss key points

Determining the cause or causes of hair loss in women can be difficult and should be guided by the patient’s history
There are numerous possible causes for hair loss
Thyroid disease is not the most common cause of hair loss