Hair loss

Alopecia
Classification and external resources
Hair loss in a 33-year-old man.
ICD-10	L65.9
ICD-9	704.09
DiseasesDB	14765
MedlinePlus	003246
MeSH	D000505

Hair loss^[1] or baldness (technically known as alopecia^[2]) is a loss of hair from the head or body. Baldness can refer to general hair loss or male pattern baldness specifically. Some types of baldness can be caused by alopecia areata, an autoimmune disorder. The extreme forms of alopecia areata are alopecia totalis, which involves the loss of all head hair, and alopecia universalis, which involves the loss of all hair from the head and the body.

Baldness can have many causes, including fungal infection (tinea capitis), traumatic damage, such as by compulsive pulling (trichotillomania), as a result of radiotherapy or chemotherapy, and as a result of nutritional deficiencies such as iron, and as a result of autoimmune phenomena, including alopecia areata and hair loss associated with systemic lupus erythematosus.^[3]

Terminology

Baldness is the partial or complete lack of hair growth, and part of the wider topic of "hair thinning". The degree and pattern of baldness varies, but its most common cause is androgenic alopecia, alopecia androgenetica, or alopecia seborrheica, with the last term primarily used in Europe. ^{[citation needed]}

Signs and symptoms

Symptoms of alopecia include hair loss in patches usually in circular patterns, dandruff, skin lesions, and scarring. Alopecia areata (mild - medium level) usually shows in unusual hair loss areas e.g. eyebrows, backside of the head or above the ears where usually the male pattern baldness does not effect. In male-pattern hair loss, loss and thinning begin at the temples and the crown and either thins out or falls out. Female-pattern hair loss occurs at the frontal and parietal.

Excessive daily hair loss

People have between 100,000 and 150,000 hairs on their head. The number of strands normally lost in a day varies, but on average is 100.^[4] In order to maintain a normal volume, hair must be replaced at the same rate at which it is lost. The first signs of hair thinning that people will often notice are more hairs than usual left in the hairbrush after brushing or in the basin after shampooing. Styling can also reveal areas of thinning, such as a wider parting or a thinning crown.

Skin conditions

A substantially blemished face, back and limbs could point to cystic acne. The most severe form of the condition, cystic acne arises from the same hormonal imbalances that cause hair loss, and is associated with DHT production.^[5] Seborrheic dermatitis, a condition in which an excessive amount of sebum is produced and builds up on the scalp (looking like an adult cradle cap) is also a symptom of hormonal imbalances, as is an excessively oily or dry scalp. Both can cause hair thinning.

Psychological

Hair thinning and baldness cause psychological stress due to its effect on appearance. Although societal interest in appearance has a long history, this particular branch of psychology came into its own during the 1960s and has gained momentum as messages associating physical attractiveness with success and happiness grow more prevalent.^[6]

The psychology of hair thinning is a complex issue. Hair is considered an essential part of overall identity: especially for women, for whom it often represents femininity and attractiveness. Men typically associate a full head of hair with youth and vigor. Although they may be aware of pattern baldness in their family, many are uncomfortable talking about the issue. Hair thinning is therefore a sensitive issue for both sexes. For sufferers, it can represent a loss of control and feelings of isolation. People experiencing hair thinning often find themselves in a situation where their physical appearance is at odds with their own self-image and commonly worry that they appear older than they are or less attractive to others. Psychological problems due to baldness, if present, are typically most severe at the onset of symptoms.^[7]

Hair loss induced by cancer chemotherapy has been reported to cause changes in self-concept and body image. Body image does not return to the previous state after regrowth of hair for a majority of patients. In such cases, patients have difficulties expressing their feelings (alexithymia) and may be more prone to avoiding family conflicts. Family therapy can help families to cope with these psychological problems if they arise.^[8]

Causes

Although not completely understood ,^{[citation needed]} alopecia can have many causes:

Male pattern hair loss

More than 95% of hair thinning in men is male pattern hair loss (also known as androgenic alopecia).^[9] Male pattern hair loss is characterized by hair receding from the lateral sides of the forehead (known as a "receding hairline") and/or a thinning crown (balding to the area known as the ‘vertex’).^[10] Both become more pronounced until they eventually meet, leaving a horseshoe-shaped ring of hair around the back of the head.

The incidence of pattern baldness varies from population to population and is based on genetic background. Environmental factors do not seem to affect this type of baldness greatly. One large scale study in Maryborough, Victoria, Australia showed the prevalence of mid-frontal baldness increases with age and affects 73.5 percent of men and 57 percent of women aged 80 and over. A rough rule of thumb is that the incidence of baldness in males corresponds to chronological age. For example, according to Medem Medical Library's website, male pattern baldness (MPB) affects roughly 40 million men in the United States. Approximately 25 percent of men begin balding by age 30; two-thirds begin balding by age 60.

There is a 4 in 7 chance of receiving the baldness gene.^[11] Onset of hair loss sometimes begins as early as the end of puberty, and is mostly genetically determined. It was previously believed that baldness was inherited from the maternal grandfather. While there is some basis for this belief, both parents contribute to their offspring's likelihood of hair loss. Most likely, inheritance is technically "autosomal dominant with mixed penetrance".^{[citation needed]}

The trigger for this type of baldness is dihydrotestosterone, a more-potent form of testosterone often referred to by its acronym DHT. DHT is an androgenic hormone, body- and facial-hair growth promoter that can adversely affect the prostate as well as the hair located on the head.^[12] The mechanism by which DHT accomplishes this is not yet fully understood. In genetically prone scalps (i.e., those experiencing male or female pattern baldness), DHT initiates a process of follicular miniaturization, in which the hair follicle begins to deteriorate. As a consequence, the hair’s growth phase (anagen) is shortened, and young, unpigmented vellus hair is prevented from growing and maturing into the deeply rooted and pigmented terminal hair that makes up 90 percent of the hair on the head.^[13] In time, hair becomes thinner, and its overall volume is reduced so that it resembles fragile vellus hair or "peach fuzz" until, finally, the follicle goes dormant and ceases producing hair completely.

Nutrition

Studies have shown that poor nutrition, limited food intake, and deficiencies in certain nutrients can cause thinning. These include deficiencies of biotin, protein, zinc and poor human iron metabolism, although complete baldness is not usually seen. A diet high in animal fats (often found in fast food) and vitamin A is also thought to have an effect on hair loss.

• Hypervitaminosis A
• Iron deficiency or malnutrition in general

Infection

• Dissecting cellulitis
• Fungal infections (such as tinea capitis)
• Folliculitis
• Secondary syphilis^[14]
• Demodex folliculorum, a microscopic mite that feeds on the sebum produced by the sebaceous glands, denies hair essential nutrients and can cause thinning. Demodex folliculorum is not present on every scalp and is more likely to live in an excessively oily scalp environment.

Drugs

• Temporary or permanent hair loss can be caused by several medications, including those for blood pressure problems, diabetes, heart disease and cholesterol.^[15] Any that affect the body’s hormone balance can have a pronounced effect: these include the contraceptive pill, hormone replacement therapy, steroids and acne medications.^[16]
• Some treatments used to cure mycotic infections can cause massive hair loss.^[17]
• Medications (side effects from drugs, including chemotherapy, anabolic steroids, and birth control pills^[18][19])

Trauma

• Traction alopecia is most commonly found in people with ponytails or cornrows who pull on their hair with excessive force. In addition, rigorous brushing and heat styling, rough scalp massage can damage the cuticle, the hard outer casing of the hair. This causes individual strands to become weak and break off, reducing overall hair volume.
• Trichotillomania is the loss of hair caused by compulsive pulling and bending of the hairs. Onset of this disorder tends to begin around the onset of puberty and usually continues through adulthood. Due to the constant extraction of the hair roots, permanent hair loss can occur.
• Traumas such as childbirth, major surgery, poisoning, and severe stress may cause a hair loss condition known as telogen effluvium,^[20] in which a large number of hairs enter the resting phase at the same time, causing shedding and subsequent thinning. The condition also presents as a side effect of chemotherapy – while targeting dividing cancer cells, this treatment also affects hair’s growth phase with the result that almost 90% of hairs fall out soon after chemotherapy starts.^[21]
• Radiation to the scalp, as when radiotherapy is applied to the head for the treatment of certain cancers there, can cause baldness of the irradiated areas.

Stress

• Stress has been shown to restrict the blood supply to capillaries, inhibiting oxygen and nutrient uptake of hair follicles and inhibiting hair growth, in an effect similar to that from having poor circulation.
• Worrisome hair loss often follows childbirth without causing actual baldness. In this situation, the hair is actually thicker during pregnancy due to increased circulating oestrogens. After the baby is born, the oestrogen levels fall back to normal prepregnancy levels, and the additional hair foliage drops out. A similar situation occurs in women taking the fertility-stimulating drug clomiphene.

Other

• Air and water pollutants as well as minerals in water and the phototoxic effects of sunlight can cause thinning by aging the scalp skin and damaging hair.
• Alopecia areata is an autoimmune disorder also known as "spot baldness" that can result in hair loss ranging from just one location (Alopecia areata monolocularis) to every hair on the entire body (Alopecia areata universalis). Although thought to be caused by hair follicles becoming dormant, what triggers alopecia areata is not known. In most cases the condition corrects itself, but it can also spread to the entire scalp (alopecia totalis) or to the entire body (alopecia universalis).
• Localized or diffuse hair loss may also occur in cicatricial alopecia (lupus erythematosus, lichen plano pilaris, folliculitis decalvans, central centrifugal cicatricial alopecia, postmenopausal frontal fibrosing alopecia, etc.). Tumours and skin outgrowths also induce localized baldness (sebaceous nevus, basal cell carcinoma, squamous cell carcinoma).
• Hypothyroidism (an under-active thyroid) and the side effects of its related medications can cause hair loss, typically frontal, which is particularly associated with thinning of the outer third of the eyebrows (also seen with syphilis). Hyperthyroidism (an over-active thyroid) can also cause hair loss, which is parietal rather than frontal.^[22]
• Temporary loss of hair can occur in areas where sebaceous cysts are present for considerable duration (normally one to several weeks).
• Congenital triangular alopecia – It is a triangular, or oval in some cases, shaped patch of hair loss in the temple area of the scalp that occurs mostly in young children. The affected area mainly contains vellus hair follicles or no hair follicles at all, but it does not expand. Its causes are unknown, and although it is a permanent condition, it does not have any other effect on the affected individuals.^[23]
• Gradual thinning of hair with age is a natural condition known as involutional alopecia. This is caused by an increasing number of hair follicles switching from the growth, or anagen, phase into a resting phase, or telogen phase, so that remaining hairs become shorter and fewer in number.
• An unhealthy scalp environment can play a significant role in hair thinning by contributing to miniaturization or causing damage. Air and water pollutants, environmental toxins, conventional styling products and excessive amounts of sebum have the potential to build up on the scalp. This debris can block hair follicles and cause their deterioration and consequent miniaturization of hair. It can also physically restrict hair growth or damage the hair cuticle, leading to hair that is weakened and easily broken off before its natural lifecycle has ended.

Causes of alopecia include:

• Alopecia mucinosa
• Biotinidase deficiency
• Chronic inflammation
• Diabetes^[24]
• Hair treatments (chemicals in relaxers, hair straighteners)
• Lupus erythematosus
• Pseudopelade of Brocq
• Telogen effluvium
• Tufted folliculitis

Pathophysiology

Hair follicle growth occurs in cycles. Each cycle consists of a long growing phase (anagen), a short transitional phase (catagen) and a short resting phase (telogen). At the end of the resting phase, the hair falls out (exogen) and a new hair starts growing in the follicle beginning the cycle again.

Normally, about 40 (0–78 in men) hairs reach the end of their resting phase each day and fall out.^[25] When more than 100 hairs fall out per day, clinical hair loss (telogen effluvium) may occur.^{[citation needed]} A disruption of the growing phase causes abnormal loss of anagen hairs (anagen effluvium).

Diagnosis

Because they are not usually associated with an increased loss rate, male-pattern and female-pattern hair loss do not generally require testing. If hair loss occurs in a young man with no family history, drug use could be the cause.

• The pull test helps to evaluate diffuse scalp hair loss. Gentle traction is exerted on a group of hairs (about 40–60) on three different areas of the scalp. The number of extracted hairs is counted and examined under a microscope. Normally, fewer than three hairs per area should come out with each pull. If more than ten hairs are obtained, the pull test is considered positive.^[26]
• The pluck test is conducted by pulling hair out "by the roots". The root of the plucked hair is examined under a microscope to determine the phase of growth, and is used to diagnose a defect of telogen, anagen, or systemic disease. Telogen hairs have tiny bulbs without sheaths at their roots. Telogen effluvium shows an increased percentage of hairs upon examination. Anagen hairs have sheaths attached to their roots. Anagen effluvium shows a decrease in telogen-phase hairs and an increased number of broken hairs.
• Scalp biopsy is used when the diagnosis is unsure; a biopsy allows for differing between scarring and nonscarring forms. Hair samples are taken from areas of inflammation, usually around the border of the bald patch.
• Daily hair counts are normally done when the pull test is negative. It is done by counting the number of hairs lost. The hair from the first morning combing or during washing should be counted. The hair is collected in a clear plastic bag for 14 days. The strands are recorded. If the hair count is >100/day, it is considered abnormal except after shampooing, where hair counts will be up to 250 and be normal.^{[citation needed]}
• Trichoscopy is a noninvasive method of examining hair and scalp. The test may be performed with the use of a handheld dermoscope or a video dermoscope. It allows differential diagnosis of hair loss in most cases.^[27]

There are two types of identification tests for female pattern baldness: the Ludwig Scale and the Savin Scale. Both track the progress of diffused thinning, which typically begins on the crown of the head behind the hairline, and becomes gradually more pronounced. For male pattern baldness, the Hamilton–Norwood scale tracks the progress of a receding hairline and/or a thinning crown, through to a horseshoe-shaped ring of hair around the head and on to total baldness.

In almost all cases of thinning, and especially in cases of severe hair loss, it is recommended to seek advice from a doctor or dermatologist. Many types of thinning have an underlying genetic or health-related cause, which a qualified professional will be able to diagnose.

Management

Medications

Treatments for the various forms of hair loss have limited success. Three medications have evidence to support their use in male pattern hair loss: finasteride, dutasteride and minoxidil.^[28] They typically work better to prevent further hair loss than to regrow lost hair.^[28]

• Minoxidil (Rogaine) is a nonprescription medication approved for male pattern baldness and alopecia areata. In a liquid or foam, it is rubbed into the scalp twice a day. This is the most effective method to treat male-pattern and female-pattern hair loss.^{[citation needed]} However, only 30–40% of patients experience hair growth. Minoxidil is not effective for other causes of hair loss. Hair regrowth can take eight to 12 months. Treatment is continued indefinitely because, if the treatment is stopped, hair loss resumes again. Most frequent side effects are mild scalp irritation, allergic contact dermatitis, and increased facial hair.^{[citation needed]}
• Finasteride (Propecia) is used in male-pattern hair loss in a pill form taken on a daily basis. It is not indicated for women and is not recommended in pregnant women. Treatment is effective within six to eight months of treatment. Side effects include decreased sex drive, erectile dysfunction, ejaculatory dysfunction, gynecomastia, and myopathy. Treatment should be continued as long as positive results occur. Once treatment is stopped, hair loss resumes again.
• Corticosteroids injections of into the scalp can be used to treat alopecia areata. This type of treatment is repeated on a monthly basis. Oral pills for extensive hair loss may be used for alopecia areata. Results may take up to a month to be seen.
• Immunosuppressants applied to the scalp have been shown to temporarily reverse alopecia areata, though the side effects of some of these drugs make such therapy questionable.^[29][30]
• Dithranol (anthralin, Dritho-Scalp) is available as a cream or ointment, applied to the scalp and washed off daily. More commonly, it is used to treat psoriasis. Results may take up to 12 weeks to be seen.
• Hormonal modulators (oral contraceptives or antiandrogens such as spironolactone and flutamide) can be used for female-pattern hair loss associated with hyperandrogenemia.

Surgery

Hair Transplantation is usually carried out under local anaesthetic. A surgeon will move healthy hair from the back and sides of the head to areas of thinning. The procedure can take between four and eight hours, and additional sessions can be carried out to make hair even thicker. Transplanted hair falls out within a few weeks, but regrows permanently within months. **Hair transplants, takes tiny plugs of skin, each which contains a few hairs, and implants the plugs into bald sections. The plugs are generally taken from the back or sides of the scalp. Several transplant sessions may be necessary.^[31]

• Surgical options, such as follicle transplants, scalp flaps, and hair loss reduction, are available. These procedures are generally chosen by those who are self-conscious about their hair loss, but they are expensive and painful, with a risk of infection and scarring. Once surgery has occurred, six to eight months are needed before the quality of new hair can be assessed.
  • Scalp reduction is the process is the decreasing of the area of bald skin on the head. In time, the skin on the head becomes flexible and stretched enough that some of it can be surgically removed. After the hairless scalp is removed, the space is closed with hair-covered scalp. Scalp reduction is generally done in combination with hair transplantation to provide a natural-looking hairline, especially those with extensive hair loss.
  • Hairline lowering can sometimes be used to lower a high hairline secondary to hair loss, although there may be a visible scar after further hair loss.
  • Micro-Needling is a painless treatment that can stimulate hair growth with the use of needles on a roller.
• Wigs are an alternative to medical and surgical treatment; some patients wear a wig or hairpiece. They can be used permanently or temporarily to cover the hair loss. High-quality, natural-looking wigs and hairpieces are available.

Hiding hair loss

Head

One method of hiding hair loss is the "comb over", which involves restyling the remaining hair to cover the balding area. It is usually a temporary solution, useful only while the area of hair loss is small. As the hair loss increases, a comb over becomes less effective.

Another method is to wear a hat or a hairpiece—a wig or toupee. The wig is a layer of artificial or natural hair made to resemble a typical hair style. In most cases the hair is artificial. Wigs vary widely in quality and cost. In the United States, the best wigs—those that look like real hair—cost up to tens of thousands of dollars. Organizations also collect individuals' donations of their own natural hair to be made into wigs for young cancer patients who have lost their hair due to chemotherapy or other cancer treatment in addition to any type of hair loss.

Lastly a number of alternative topical camouflages exist such as Nanogen (Europe) and Toppik (U.S.) and these are very popular as non-wig cosmetics which add electrostatic microfibres to your own hair.

Eyebrows

Though not as common as the loss of hair on the head, chemotherapy, hormone imbalance, forms of hair loss, and other factors can also cause loss of hair in the eyebrows. Loss of growth in the outer one third of the eyebrow is often associated with hypothyroidism. Artificial eyebrows are available to replace missing eyebrows or to cover patchy eyebrows. Eyebrow embroidery is another option which involves the use of a blade to add pigment to the eyebrows. This gives a natural 3D look for those who are worried about an artificial look and it lasts for two years. Micropigmentation (permanent makeup tattooing) is also available for those who want the look to be permanent.

Embracing baldness

Instead of concealing hair loss, one may embrace it. A shaved head will grow stubble in the same manner and at the same rate as a shaved face. The general public has become accepting of the shaved head as well, though female baldness can be considered less socially acceptable in various parts of the world.^{[citation needed]}

Alternative medicine

Many people use unproven treatments.^[28] Egg oil, in Indian,^[32] Japanese, Unani (Roghan Baiza Murgh)^[33] and Chinese^[34] traditional medicine, was traditionally used as a treatment for hairloss.

Etymology

The term alopecia /ˌæloʊˈpiːʃə/ is formed from the Greek alópex (αλώπηξ), meaning fox. The origin of this usage is because this animal sheds its coat twice a year, or because in ancient Greece foxes often lost hair because of mange.

The term bald likely derives from the English word balde, which means "white, pale", or Celtic ball, which means "white patch or blaze", such as on a horse's head.^[35]

Research

There is evidence that the gene SOX21 may play a role in hair loss in humans.^[36] There may also be a link between elevated levels of prostaglandin D2 (PDG2) and male pattern hairloss. Abnormally high levels of PDG2 (a nearly three-fold increase) were discovered in tissue samples of balding areas compared to haired areas of the scalp. A PDG2-binding receptor, GPR44, has also been discovered. Compounds aimed at targeting the GPR44 receptor are currently being studied.^[37]

Research is looking into connections between hair loss and other health issues. While there has been speculation about a connection between early-onset male pattern hair loss and heart disease, a review of articles from 1954 to 1999 found no conclusive connection between baldness and coronary artery disease. The dermatologists who conducted the review suggested further study was needed.^[38]

Environmental factors are under review. A 2007 study indicated that smoking may be a factor associated with age-related hair loss among Asian men. The study controlled for age and family history, and found statistically significant positive associations between moderate or severe male pattern hairloss and smoking status.^[39]

Vertex baldness is associated with an increased risk of coronary heart disease (CHD) and the relationship depends upon the severity of baldness, while frontal baldness is not. Thus, vertex baldness might be a marker of CHD and is more closely associated with atherosclerosis than frontal baldness.^[40]

See also

• Alopecia in animals
• Lichen planopilaris

Footnotes

External links

Wikimedia Commons has media related to Alopecia.

• Hair loss on the Open Directory Project
• 5-Minute Clinical Consult Alopecia images

v t e Human hair List of hairstyles List of facial hairstyles Classification Type Lanugo Androgenic Terminal Vellus Location Head Nose Ear Eyebrow Eyelash Underarm Chest Abdominal Pubic Leg Hairstyles Afro Afro-textured hair Asymmetric cut Beehive Big hair Blowout Bob cut Bouffant Bowl cut Braid or Plait Brush cut Bun (Odango) Bunches Burr Business-man cut Butch cut Buzz cut Caesar cut Chignon Chonmage Comb over Conk Cornrows Crew cut Crop Croydon facelift Curtained hair Devilock Dice Bob Dido flip Digital perm Dreadlocks Duck's ass Extensions Fade Fauxhawk Feathered hair Finger wave Flattop Flip Fontange French braid French twist Bangs / Fringe Full crown Half crown Harvard clip High and tight Highlights Hime cut Historical Christian hairstyles Hi-top fade Induction cut Ivy League Jewfro Jheri curl Layered hair Liberty spikes Lob Long hair Marcelling Mod cut Mohawk Mop-Top Mullet 1950s hairstyles Oseledets Pageboy Part Perm Pigtail Pixie cut Pompadour Ponytail Princeton Professional cut Queue Quiff Rattail Razor cut Regular haircut Regular taper cut Ringlets Shag Shape-Up Short back and sides Short brush cut Short hair Spiky hair Standard haircut Surfer hair Taper cut Tonsure Updo Waves Weave Wings (haircut) Facial hair Beard Beard Liberation Front Chin curtain Chinstrap Designer stubble English moustache Fu Manchu Goatee Handlebar Horseshoe Hulihee Moustache Neckbeard Pencil moustache Shenandoah Sideburns Soul patch Toothbrush moustache Van Dyke Walrus moustache Hair loss Cosmetic Glabrousness Hair removal waxing threading plucking chemical electric laser IPL Shaving head leg Razor safety razor straight razor Other Baldness Alopecia areata totalis universalis Androgenic alopecia management experimental management Hypertrichosis Trichophilia Trichotillomania Pogonophobia Related Hairstyle Hairdresser Barber Barber pole Long hair Hair color Backcombing Hair coloring Hair crimping Hair straightening Bearded lady Hair fetishism Pubic hair fetishism Category Hair

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