Losing your hair can be very distressing, especially for a woman, but it can often be treated successfully. Getting a correct diagnosis of the cause of the hair loss is the first step and your family doctor can often help.
To make a proper diagnosis, your doctor will likely ask you about your recent history and your family history of hair loss. They will also examine your scalp and check for other symptoms you may have that suggest a disease that could cause hair loss. They may even do some blood tests. While hair loss can be caused by conditions of the scalp, it can also be caused by other conditions in the body.
Some hair loss is normal
Hair grows in a cycle. At any given time, 90% of your hair is actively growing, while about 10% is in a stage of degeneration, eventually resulting in shedding. This is normal. The hair growth phase is called “anagen”, the degenerating phase is “catagen” and the shedding is referred to as “telegen”. We see these terms pop up in the names given to different types of hair loss, described below.
We all lose about 50 to 100 hairs every day. One test for hair loss that is sometimes used (although not highly reliable) is the Pull Test. When 40 to 60 hairs are grasped and pulled gently; not more that 4 to 6 hairs should pull away from the scalp. However, this test is difficult to standardize, and a negative result does not rule out a diagnosis of hair loss. Trying it immediately after shampooing or brushing the hair will result in a false negative, as loose hair is already removed.
Hair loss can occur in patches or diffusely, across the top and sometimes the sides of the head, depending on the cause. In women usually the hairline at the forehead is not affected while men generally have receding of the hairline on both sides, and/or thinning on the top. Some hair loss is self-limiting, regrowing after several weeks or months, while other types of loss can progress for many years. If the hair follicle is lost, it is referred to as scarring of the scalp, and the hair loss can be permanent. This condition is rare and a consultation with a dermatologist is recommended.
What causes increased hair loss?
The most common type of hair loss is caused by hormone changes, usually too much or too little testosterone (an androgen). This is called androgenetic alopecia, and it results in diffuse hair loss in women, “male-pattern” loss in men. In women, too high levels of testosterone [or its metabolite, dihydrotestosterone (DHT)] is often accompanied by acne and oily skin, and can be the result of Polycystic Ovary Syndrome (PCOS), or cysts on the ovaries that produce androgen hormones. Too little testosterone is also associated with scalp and body hair loss (underarms and pubic hair), fatigue and decreased muscle mass. A rapid decrease in female hormones, estrogen and progesterone, such as occurs after a pregnancy or when stopping hormonal birth control, can also cause temporary hair loss.
Thyroid disease (low thyroid), iron deficiency and malnutrition (e.g. lack of protein) are other causes of diffuse hair loss that do not originate in the scalp. Hair products, like dyes and straighteners, and treatments, such as blow dryers and curling irons, can cause diffuse hair loss through breakage close to the root. In these cases, the hair will usually regrow once the cause is corrected or once the woman has overcome or adapted to the stress.
Other causes of hair loss that often result in patchy hair loss, include scalp infections and habitual nervous pulling on the hair, eyebrows or eyelashes. A physical stress, such as an illness with high fever, or an emotional stress can also cause hair loss that often comes out in clumps.
Types of hair loss
The names of types of hair loss are, unfortunately, quite complex and confusing. However, I’ll list them below with their details, causes and treatments.
Androgenetic alopecia – likely a hormonal cause, most common type (mentioned above), often a family history.f
Diffuse hair loss in women, male-pattern loss in men (sides of front hairline and top of head) caused by increased levels of dihydrotestosterone (DHT)
Women usually develop this after menopause when estrogens drop and androgens (male-type hormones) dominate.
Can be treated by using Minoxidil 2% scalp lotion
Note that Minoxidil 5% sometimes works better in men than 2% but gives no extra benefit in women, according to studies.
Alternative treatment for men is the drug finasteride, that blocks conversion of testosterone to its stronger form, dihydrotestosterone (DHT). However, it has many side effects.
Sharp decreases in hormones in women, such as after childbirth or after discontinuing birth control pills, can result in temporary hair loss.
Hair loss due to low thyroid, iron deficiency or malnutrition can mimic androgenetic alopecia. Low testosterone in women is also associated with thinning of hair but often not recognized.
Alopecia areata – autoimmune hair loss (the body attacking itself)
Patchy hair loss, broken hair shafts, short thin hairs, yellow or black dots
Usually sudden, acute onset
Treated with steroid injections into the scalp, creams or ointments, or recovery can be spontaneous
Tinea capitis – fungal infection of the scalp, patches of hair loss, red, scaly, itching, pustules
Although antifungal shampoos are available, in a severe infection they do not reach the infection in the root of the hair adequately, and it is necessary to take a prescription anti-fungal medication by mouth
Telogen effluvium – caused by physical or emotional stress
Non-inflammatory, non-scarring, scalp appears normal
Caused by an intense emotional shock or physical stress, for example, surgery or rapid weight loss
Usually hair will regrow when the cause is resolved (person adapts to stress, recovers from surgery, etc)
Trichotillomania or traction alopecia – physical tension on the root of the hair
Habitual pulling on hair, usually front/sides but can also include eyebrows and eyelashes
Tight hair styles, like buns, ponytails, braids, cornrows, extensions
Treated with cognitive behavioural therapy (CBT) to reverse the damaging habits or changing hairstyle to a looser one
Trichorrexis nodosa – trauma sufficient to cause hair shafts to break
Caused by overuse of hair products (dyes, straighteners, perms) or styling techniques (hairdryers, curling irons)
Treated by changing or stopping use of offending product or tool
Anagen effluvium –interruption of hair growth cycle causing abnormal diffuse hair loss
Common with some chemotherapy, radiation
Can also be due to malnutrition with a nutrient essential for hair growth being missing
Cooling the scalp during treatment sometimes helps reduce hair loss with certain chemotherapies
Hair will regrow when the growth cycle is no longer interrupted
Medications – Certain medications can cause hair to fall out as a side effect
Blood thinners (warfarin), Accutane (a strong acne treatment), antidepressants (Prozac, Zoloft, etc), beta-blockers, some cholesterol drugs
Nutritional deficiencies – Certain nutrients are needed for hair growth
Low protein, iron or vitamins in the diet can result in temporary hair loss
Replacing the nutrient in the diet allows hair growth to return to normal
So, as you see, there are many different causes of hair loss. Some types are treatable while other will resolve on their own once the cause is eliminated. It’s important to get a diagnosis of the cause to give you an idea of what treatment would work best to improve hair growth.
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References:
Hair Loss: Common Causes and Treatment – American Family Physician
How much hair loss is normal? – Medical News Today
Causes and treatments for hair loss – Medical News Today
What’s to know about alopecia areata? – Medical News Today
Finasteride (Propecia) -- RxList
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