What is baldness?

Baldness, also known as alopecia, is hair loss, or absence of hair. Baldness is usually most noticeable on the scalp, but can occur anywhere on the body where hair grows. The condition is more common in men than in women.

What causes hair loss?

Hair loss is believed to be primarily caused by a combination of the following:

• aging
• change in hormones
• illness
• family history of baldness
• burns
• trauma

However, hair loss is not caused by the following:

• poor circulation to the scalp
• vitamin deficiencies
• dandruff
• excessive hat-wearing
• a gene passed on from an individual's maternal grandfather

Generally, the earlier hair loss begins, the more severe the baldness will become.

What are the different types of baldness?

Baldness can be classified into various types, depending on the cause. Several of the many different types of baldness include the following:

• female-pattern baldness
  Although less common, female-pattern baldness differs from that of male-pattern baldness in that the hair generally thins all over the head, but the frontal hairline is maintained. Female-pattern baldness rarely results in total hair loss.
• male-pattern baldness
  Male-pattern baldness usually is a hereditary condition. The condition may begin at any age. Hair loss often begins on the front, sides, and/or on the crown of the head. Some men may develop a bald spot or just a receding hair line, while others may lose all of their hair.
• alopecia areata
  This hair loss disorder is characterized by sudden loss of hair in one particular area, which grows back after several months. However, if all body hair is suddenly lost, regrowth may not occur. The cause of this type of hair loss is unknown.
• toxic alopecia
  Toxic alopecia may occur following a high fever or severe illness. Certain medications, especially thallium, high doses of vitamin A, and retinoids, may cause toxic alopecia. Medical conditions, such as thyroid disease, and after giving birth may also trigger toxic alopecia. The condition is characterized by temporary hair loss. Also, some cancer medications can cause hair loss.
• scarring alopecia
  Scarred areas may prevent the hair from growing back. Scarring may occur from burns, injury, or x-ray therapy. However, other types of scarring that may cause hair loss can be caused by diseases such as lupus, bacterial or fungal skin infections, lichen planus, sarcoidosis, tuberculosis, or skin cancer.
• trichotillomania (hair pulling)
  Hair pulling, a habit most common among children, may cause hair loss.

How is the type of baldness diagnosed?

In addition to a medical history and physical examination, a biopsy of the skin area may help to identify the type of baldness and/or its cause.

Treatment for baldness:

Specific treatment for baldness will be determined by your physician based on:

• your age, overall health, and medical history
• extent of the condition
• your tolerance for specific medications, procedures, and therapies
• expectation for the course of the disease
• your opinion or preference

Most forms of baldness have no cure. Some types of baldness will disappear on their own. Treatment may include:

• certain medications to promote hair growth (such as minoxidil and finasteride)
• corticosteroid injections (when treating alopecia areata)
• treating any underlying condition or disease
• hair transplants
• scalp reduction
• skin lifts and grafts

What is hair replacement surgery?

The interest in hair replacement has significantly increased over the past 10 years. Two out of every three men, and one in five women, suffer from hair loss. For men, the main cause of a diminishing hairline is heredity. Hormonal changes such as menopause can cause both thinning and hair loss in women.

There are a number of hair replacement techniques that are available, although hair replacement surgery cannot help those who suffer from total baldness. Candidates for hair replacement must have a healthy growth of hair at the back and sides of the head. The hair on the back and sides of the head will serve as hair donor areas where grafts and flaps will be taken.

There are four primary different types of hair replacement methods, including the following:

• hair transplantation
  During hair transplantation, the surgeon removes small pieces of hair-bearing scalp grafts from the back or sides of the head. These grafts are then relocated to a bald or thinning area.
• tissue expansion
  In this procedure, a device called a tissue expander is placed underneath a hair-bearing area that is located next to a bald area. After several weeks, the tissue expander causes the skin to grow new skin cells. Another operation is then required to place the newly expanded skin over the adjacent bald spot.
• flap surgery
  Flap surgery is ideal for covering large balding areas. During this procedure a portion of the bald area is removed and a flap of the hair-bearing skin is placed on to the bald area while still attached at one end to its original blood supply.
• scalp reduction
  Scalp reduction is done in order to cover the bald areas at the top and back of the head. This technique involves the removal of the bald scalp with sections of the hair-bearing scalp pulled together filling in the bald area.

Possible complications associated with hair transplantation procedures:

Possible complications associated with hair transplantation procedures may include, but are not limited to, the following:

• patchy hair growth
  Sometimes, the growth of newly placed hair has a patchy look, especially if it is placed next to a thinning area. This can often be corrected by additional surgery.
• bleeding and/or wide scars
  Tension on the scalp from some of the scalp reduction techniques can result in wide scars and/or bleeding.
• grafts not taking
  Occasionally, there is a chance that the graft may not "take." If this is the case, surgery must be repeated.
• infection
  As with any surgical procedure, there is the risk of infection.

We are proud to present the Zamacona video production, "Cicatricial Alopecia," the world's first educational media presentation to serve individuals with cicatricial alopecia, the medical community and the general public. This unique and moving video gives actual documentation by patients and offers current medical information and important references that furnish a better understanding of these disorders. It gives hope that one day there will be a cure and better treatments for this poorly understood group of diseases.

The Cicatricial Alopecia Research Foundation (C.A.R.F.) was formed as a result of one person's experience with scarring alopecia (cicatricial means scarring). When the patient realized that little is known about such disorders, she decided, with the help of her doctor, to initiate a grass roots effort to raise funds to study these problems.

C.A.R.F. began raising money with the following mission in mind:

• to provide funds for research to find effective treatments and a cure
• to support education and advocacy
• to raise public awareness

On average, there are 100,000 to 150,000 hairs on the human scalp. The hairs grow from hair roots, or follicles (saclike structures under the skin). Blood vessels at the base of each follicle provide the nourishment necessary for hair growth. Hair growth in each root occurs in a cycle independent of the other roots. At any time about 90 percent of the hairs on the scalp are in the growth phase, while the other 10 percent are in the resting phase. The growth phase lasts an average of four to five years, after which the follicle enters the resting phase, which lasts about two months to four months. At the end of the resting phase, the hair falls out naturally and is replaced by a new hair. Consequently, some hair loss is a normal part of the hair growth cycle. In fact, on a typical day, about 50 to 150 scalp hairs are lost. Baldness (or alopecia) results when hair loss occurs at an abnormally high rate; when hair replacement occurs at an abnormally slow rate; or when normal hairs are replaced by thinner, shorter ones.

What is male pattern baldness?

About 95 percent of all cases of hair loss are the result of androgenetic alopecia (also known as male pattern baldness in men). Androgenetic alopecia occurs much more frequently in men than in women. It 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.

While some types of hair loss are easily reversible, male pattern baldness is more permanent. It occurs in a characteristic pattern on the scalp: hair loss usually begins at the temples and at the top of the head toward the back, causing a receding hairline and a bald spot. Hair loss may continue until the two sections become joined, leaving a horseshoe-shaped area of hair on the sides and back of the head. Balding may begin at any age after puberty, even in the middle teens, and can range from partial loss to complete baldness. Male pattern baldness progresses slowly and is not associated with redness, itching, or pain. Currently, there is no way to prevent male pattern baldness from occurring.

What causes male pattern baldness?

The causes of male pattern baldness are thought to be complex and are not completely understood. However, as suggested by its medical name (androgenetic alopecia), male pattern baldness seems to involve both hormonal (androgen) and genetic factors. Many different types of hormones play roles in the regulation of scalp hair, but the hormones with the largest effect are the androgens. Testosterone and its more potent derivative dihydrotestosterone (DHT) are responsible for increasing the size of hair follicles in areas such as the beard and underarm during puberty, but can also cause hair follicles in the scalp to decrease in size later in life. These contrasting responses to DHT might be explained by genetic differences in the individual hair follicles. Similarly, in men who are balding, genetically determined characteristics of hair follicles in the scalp may cause the follicles to be more likely to degrade in the presence of androgens. Hair follicles become miniaturized, and the hair consequently becomes thinner and shorter. The growing phase of the growth cycle becomes progressively shorter, which means more hairs are shed. Although the follicles still have an adequate blood supply, they continue to shrink, and some eventually die.

Whatever the exact causes of male pattern baldness may be, it is a hereditary trait. There are multiple genetic factors that influence male pattern baldness. A tendency toward baldness in the men on either the mother's or father's side of a man's family indicates a genetic predisposition to baldness. The speed, pattern, time of onset and degree of balding are all influenced by heredity. Generally, the earlier the onset of balding, the more extensive the degree of hair loss will eventually be.

Contrary to popular myth, balding is not caused by wearing hats. Massaging or brushing the scalp will not help regrow hair, and excessive cleaning of the scalp will not "unclog" follicles and allow hair growth. While extreme psychological stress may contribute to a form of hair loss known as alopecia areata, normal everyday stress does not contribute to balding and is not a cause of androgenetic alopecia.

What are some other types of hair loss?

Aside from male pattern baldness, some of the most common types of hair loss include:

• Alopecia areata, which leads to patchy hair loss on the scalp. While the causes of alopecia areata are not completely understood, the hair loss is thought to be the result of the body's immune system attacking the hair follicle. Alopecia areata often resolves without treatment.
• Traction alopecia, which results from long-term pulling on the hair. This type of hair loss can be caused by certain hairstyles, such as tight braids. The hair loss is usually reversible once the cause of this pulling is eliminated.

Certain diseases, such as diabetes, systemic lupus erythematosus and disorders of the thyroid gland can also cause baldness. Sudden hair loss may be an early warning sign for some diseases and should be reported to a doctor.

Hair loss has many other causes, including illness, poor nutrition, skin damage, some medications, and certain medical treatments such as anticancer chemotherapy and radiation therapy. Ringworm, a fungal infection, may sometimes be the cause of balding in children, but is generally not a problem in adults.

How is the cause of hair loss diagnosed?

Because there are many potential causes of excessive hair loss, consult a dermatologist if you are concerned. Your doctor will ask questions about your family's history of baldness. He or she may also want to examine a few hairs under a microscope or check the scalp for signs of skin damage. You may be asked questions about your diet, hair-care procedures, medications (including vitamins and herbal supplements) that you take, and recent illnesses. In some cases, your doctor may order blood tests or a skin biopsy (taking a small sample of tissue for examination) to help make a diagnosis. He or she may also ask you to monitor the number of hairs lost during a day, by collecting and counting as many as possible.

What are the treatment options for male pattern baldness?

Male pattern baldness is not a medical disorder. Whether treatment is desirable is a personal decision. Many men decide to let the process run its course. However, baldness can be a source of anxiety for others and can have a negative effect on self-image. If you decide that you are not comfortable with your hair loss, you may want to consider the treatment options described below.

Prescription medications

• Minoxidil (Rogaine®)
  Originally used to treat high blood pressure, minoxidil is now widely used as a topical solution applied twice daily to treat male pattern baldness. Studies have indicated that it may help grow hair in 10 percent to 20 percent of those who use it, and it may slow the rate of loss for 90 percent. It is not clear exactly how minoxidil works, but when it is effective, it seems to somehow prolong the growing stage of the hair growth cycle, enlarge the follicles, and cause follicles at rest to grow. Minoxidil is generally more effective for young men and those whose onset of hair loss is recent.

  Minoxidil may take four months or longer to show results. The treatment is relatively expensive and must be applied indefinitely; when application is stopped, regrown hair falls out. Newly grown hair may also not be as long and thick as normal hair. As with most medications, side effects are possible, including irritation of the scalp. The solution was originally available only in a 2 percent solution, but the Food and Drug Administration has recently approved a 5 percent solution, which has shown better results in some cases.

• Finasteride (Propecia®)
  Originally used for the treatment of enlargement of the prostate gland, finasteride was recently approved by the FDA to treat male pattern baldness. It is taken daily in pill form. Finasteride works by inhibiting the conversion of testosterone to DHT, decreasing the levels of DHT in the blood and scalp. In this way, finasteride helps to block androgen-dependent degradation of hair follicles. In a recent study, nearly half of the men who took finasteride grew hair on the scalp, and the drug was even more effective at halting hair loss. A significant percentage did, however, continue to report hair loss.

  Side effects associated with finasteride are mainly related to sexual function, such as loss of sex drive, reversible impotence and a decrease in the quantity of semen. These side effects were experienced by approximately 2 percent to 5 percent of patients in clinical trials. Finasteride is not approved for use by women, because it may cause birth defects. Broken or crushed tablets should not be handled by women who are or may be pregnant.

  Currently, minoxidil and finasteride are the only medications approved by the FDA for use in the treatment of male pattern baldness. Nonprescription preparations are not effective and were banned by the FDA in 1989.

Surgical treatments

• Hair transplantation
  In hair transplantation, productive hair follicles are removed from a donor area on the scalp and transplanted to a balding area. The follicles are commonly taken in plugs of one hair to two hairs (called micrografts) from the sides or back of the head and moved to the front and/or top, with the hairline being slowly reconstructed. Larger plugs of up to 10 hairs are also sometimes used. Donor sites with full hair make transplants more successful. In the flap technique of transplantation, areas of hair are removed from the sides and back of the scalp and transplanted to the top.

  Some scarring in the donor site may result. Transplanted follicles may be permanent, or they may last only for a few years. The implantation of synthetic hair fibers has a high rate of infection and has been banned by the FDA.

• Scalp reduction
  Balding areas of the scalp may be surgically removed to decrease the appearance of baldness. Scalp reduction is usually used in conjunction with grafts or flaps. Devices may be used to stretch the scalp, expanding areas where hair grows. The effectiveness of scalp reduction depends on the degree of hair loss and the elasticity of the scalp.

As with any surgical procedure, hair transplantation and scalp reduction present certain risks, including scarring and infection. If you are considering one of these treatments, discuss the risks with your doctor.

Cosmetic treatments

• Synthetic hair
  A hairpiece (or toupee) can be custom made to cover a balding area. Hairpieces may fade and loosen over time. Certain organizations specialize in cleaning, coloring and tightening hairpieces. It is important not to neglect the scalp under the hairpiece, which should continue to be washed regularly. Another option is a weave, in which synthetic hair is sewn into existing hair.
• Hair products
  Be wary of hair-care products that claim to thicken and strengthen hair. This is accomplished simply by waxes or oils that build up on hair, creating the illusion of thickening.

While male pattern baldness presents no physical risks, your emotional well-being is an important part of your complete health. If hair loss causes you anxiety and negatively affects your self-image, treatment can be beneficial. Consider the treatment options and discuss them with your doctor.

Question 1: What does the term alopecia come from?
Answer 1: It's from the Greek alopekia which means "fox".

Question 2: If my child has lost all his hair except his upper eyelashes two different times, what is this called? And also I'd like you if you would expand and give us the real definitions for alopecia areata, totalis and universalis, and also possibly, I'm going to give you a little bit more here, if you could also tell us the difference between alopecia areata and its many forms and androgenetic alopecia.
Answer 2: Now, alopecia areata differs from androgenetic alopecia. Generally male pattern hair loss starts out in the front, usually bi-temporal. In women it looks different. It can be bi-temporal but more commonly they thin in the front and they thin in the back and fortunately women don't get the same degree of complete hair loss. Usually they just get thinning in the front and thinning in the back. This is actually very normal for women. When they're in their 50s they start to notice some. Alopecia areata can sometimes mimic androgenetic alopecia but as you know tends to cause very complete hair loss, very smooth hair loss. It starts off often but not always in round patches. And androgenetic alopecia can sometimes progress rapidly. It's not a linear disease as it previously was, but as you know it usually doesn't progress the way alopecia areata can. Regarding terminology, this classic terminology is that patches of hair loss in the scalp is called alopecia areata. If you lose all the hair on the scalp that's classically alopecia totalis; all the hair on the body would be alopecia universalis. Now if you lose all your hair on the scalp and one eyebrow, it's obviously a bit more than alopecia totalis. I think it's just nomenclature, it's not really critical what you call it, you know what you have. There are real biological differences however between those people who get patchy hair loss and the people with alopecia universalis. First of all the more extensive the hair loss the worse the prognosis. Second, there seems to be something different biologically between people who get patchy hair loss and people who lose all their hair. I'm not an expert on the genetics but those genetic studies that have been done showed different genetic associations between the patchy alopecia areata and the alopecia universalis. In fact it was reported at the World Congress of Dermatology in Paris just two weeks ago that there is a gene found in some patients with alopecia universalis which is associated with that condition. So at least a sub-population of patients with alopecia universalis have a gene that's now been identified. Very interestingly, this gene is on chromosome 21. The reason that is interesting is because with Down's syndrome have a very high incidence of alopecia areata; approximately 10%. Down's syndrome is trisomy chromosome 21; there are three copies of 21, and this gene that they found associated with universalis is on chromosome 21, near the area on 21 which seems to be most critical for Down's syndrome. And this particular gene is also associated with other auto-immune diseases. So there apparently are biological differences between alopecia universalis and patchy alopecia, and these biological differences are more than the obvious extent of the disease.

Question 3: Are the number of cases of alopecia areata increasing?
Answer 3: I have no reason to think that there are more patients with alopecia areata today than there ever were.

Question 4: What are the chances of alopecia areata developing into totalis or universalis?
Answer 4: I don't know the exact number. I think in general in alopecia areata the figure is about 2-3% develop totalis or universalis.

Question 5: If alopecia areata gets so severe that it can't be hidden anymore and a prosthesis is needed, will wearing the prosthesis prevent the hair re-growth?
Answer 5: A cranial prosthesis will not prevent anything, a cranial prosthesis really has no relevance. It's a great way to hide your problem, it will not prevent any hair regrowth at all because the problem, it's underneath the skin. It's at the level of the bulb so a hair prosthesis is irrelevant.

Question 6: On a cellular level, is the body reacting the same way with alopecia areata, totalis and universalis, and what are the cellular differences?
Answer 6: At the level of the t-lymphocytes that I was talking about we do not yet know if there is any difference. We haven't identified that there's any difference in the antigen but we haven't really broken it down and looked at it. The only difference that I could remark about are these genetic studies showing that there seems to be a genetic difference between alopecia universalis and alopecia areata in its milder forms.

Question 7: Is it possible for alopecia areata to just go away on its own?
Answer 7: Yes. Actually this ability of alopecia areata to turn itself on and off is so pronounced that it makes doing studies with new treatments very challenging because you have to be sure you either have a control group or treat only half the scalp so you have the other half of the scalp as a control, to try and get over the fact that alopecia areata can flip flop very frequently on its own and even patients who have had universalis can reverse. In fact one of the things I was going to do was just ask if any of you have ever had for any length of time in your life an episode of totalis and universalis, and has it ever regrown? I'm not saying permanently, but has it ever regrown. Would you put up your hands if you've ever had totalis or universalis and had it regrow, whether it fell out again or not? Yes. So I think it's important for all of you to know that. And I stress to my patients, I'm the eternal optimist and I say I can never say to someone that your very extensive alopecia areata or totalis or universalis won't revert, won't regrow. I think that's very important

Folliculitis decalvans, also known as alopecia folliculitis or acne decalvans, is an inflammatory reaction in hair follicles on the scalp that causes redness (erythema) and pus-filled blisters (pustules). It leads to scarring and permanent hair loss.

Traction alopecia occurs as a result of improper hair care and prolonged use of certain hair-styling techniques. Cosmetic treatments (e.g., dyes, tints, bleaches, permanents) are generally safe; however, if treatments are done incorrectly, or if the chemicals are used for too long, the hair becomes brittle and breaks easily.

Hairstyles that pull the hair tightly, and excessive shampooing or brushing can also cause hair loss. Braiding, permanents, excessive heat, and hair straightening cause hair shaft weakness. Hair styling techniques such as hair weaving, corn rowing, and the use of hot combs to straighten hair can cause permanent hair thinning and scarring.

Stress alopecia, a type of telogen effluvium, is temporary, reversible, diffuse hair loss on the scalp that results from severe emotional or physiological stress. Normally, about 90% of scalp hair follicles are in the growing anagen phase, and about 10% to 15% are in the resting catagen and telogen phases. Stress causes anagen hairs to convert prematurely into telogen hairs, which means that more than the normal number of hairs are in the telogen phase and ready to shed.

Exposure to various drugs can induce a temporary alopecia. Patients concerned about hair loss or thinning should notify their doctor or other health care provider about medications they are taking. A number of prescription drugs, including certain medicines for arthritis, depression, heart problems, and high blood pressure can cause hair loss. Spontaneous regrowth usually occurs after the drug is stopped. The hair loss effect of some drugs can be prevented by cooling the scalp with a tight-fitting ice bag for 20 minutes or so while receiving the drug treatment.

Toxic alopecia (anagen effluvium) occurs when hair growth is disrupted during the anagen phase. The newly synthesized hair shafts weaken, and the hair breaks. Hair loss is usually quick and involves all the hairs in the anagen phase. Chemotherapy, radiotherapy to the scalp, and overdoses of vitamin A can cause toxic alopecia. Chemotherapy can cause 90% hair loss. The hair regrows when treatment ends.

During hormonal changes after childbirth, when the hormones revert to normal levels, all of the hair that has not been cycling suddenly enters the resting, telogen phase. For several months following childbirth, women may notice that more hair than usual falls out when they comb or brush.

Women who are susceptible to androgenetic alopecia and take birth control pills may experience hair loss. Switching birth control pills sometimes helps. Women who stop using oral contraceptives may notice their hair thinning 2 or 3 months later. The hair starts to grow normally after about 6 months.

Illness can cause hair loss. Often, for the first couple of months after serious illness, the hair enters a resting phase and starts to shed. Hair loss also may follow major surgery. Patients with a chronic illness may lose hair continually. Hypothyroidism can lead to diffuse hair loss on the scalp and dry, brittle hair. Syphilis can sometimes cause spotty hair loss.

Ringworm (tinea capitas), a contagious childhood disease, can lead to the development of inflammatory, boggy masses full of broken hairs and ooze (called kerions). Kerions usually heal but can leave permanent bald patches.

Seborrheic dermatitis, or eczema, is often associated with diffuse hair thinning and greasy, yellow scales on the scalp. Treatment usually involves tar shampoo and topical steroids.

Trichotillomania, compulsive hair pulling, can eventually lead to alopecia. As many as 6 to 8 million Americans suffer from this condition.

If a person does not eat enough protein, the body tries to make up for the deficiency by stimulating an abnormally large number of hairs to enter the resting phase of the hair growth cycle. A couple months later, those hairs shed.

Iron deficiency also can produce hair loss. For example, a woman who bleeds heavily during her periods may develop iron deficiency and associated hair loss.

Questions and Answers about Hair Loss

Q. Why does hair loss happen?
A. Hair loss from chemotherapy treatment occurs for a very simple reason: hair follicles are weakened by chemotherapy which causes your hair to fall out much more quickly than it would normally

Q. When does hair loss happen?
A. Depending on the type of treatment you receive, hair loss may start anywhere from seven to 21 days after treatment begins. Your hair will start to grow back when you are finished with chemotherapy but it may take six to 12 months to grow back completely. It may even have a different texture – for example, curly hair can grow back straight and dark hair can become lighter. These changes are usually not permanent. Radiation to the head or scalp, however, can cause permanent hair loss.

Q. Where does hair loss happen?
A. Depending on where radiation is directed, you may also experience hair loss on your legs, arms, underarms, pubic area, chest, eyelashes, and eyebrows, in addition to your head.

Tips for Obtaining, Wearing, and Paying for a Wig

1. Buy a wig before all of your hair falls out so that you will have a good match to your own hair color and will be prepared when hair loss starts.
2. Keep in mind that there are full-service wig salons that fit and style wigs, some of which specialize in hair loss from chemotherapy.
3. Wig salons also sell turbans and scarves that come in a variety of colors and fabrics so that you can look good even when you're lounging around the house or at bedtime.
4. Wear stickies to keep your wig on. They are so effective that you'll forget you're wearing a wig.
5. If you can't afford a wig, contact CancerCare at 800-813-HOPE (4673), or a local cancer organization or support group for one that is free of charge.
6. Bear in mind that some health insurance plans cover the cost of wigs. Check into this.
7. If you buy a wig, save your receipt. It can be a medical tax deduction.

Getting Emotional Support

Talking to others who have experienced hair loss, or who have professional experience, will help you during this difficult period. Here are some suggestions: Join a support group. You'll get emotional support and feel less alone. Plus, you can share valuable tips for coping and receive helpful guidance. Find a buddy who understands what you are going through and call this person when you're feeling sad or uncertain about what to do.

Talk to a counselor who can assist you in finding resources, guide you through difficult decision-making, and help you feel more in control.

CancerCare’s staff of professional oncology social workers can also help you cope with the side effects of cancer treatment. Our social workers offer people with cancer and their loved ones individual counseling and support groups via the telephone, online, or in person. You can contact us at 1-800-813-HOPE (4673).

In Their Words: One Woman’s Personal Experience with Hair Loss

Jane Read Martin, supporter of CancerCare and children’s book author, went through chemotherapy treatment for ovarian cancer four years ago. Every year around Halloween time, she is reminded of the difference between wearing a wig for fun and wearing one to cover-up hair loss. In this essay, she details her personal experiences with one of the most common – and most trying – side effects of chemotherapy.

With Halloween approaching I am reminded of the last time I wore a wig. Not because I wanted to but because I had to. It was four years ago at our building’s annual Halloween party and the wig I wore was a multi-colored clown’s wig sent to me by my father and intended to lift my spirits. Nobody at the party mentioned it and, mercifully, a few other adults wore costumes as well. Still, I felt terribly self-conscious and lived in fear that a child would pull it off.  You see, earlier that day, Ruben, the man who has cut my hair for twenty years, had come over to our apartment to shave my head.  Due to a recent diagnosis of ovarian cancer I was rapidly losing my hair to chemotherapy. For the sake of our four and a half year old son, my husband and I decided to make it as “fun” as possible and asked Ruben to give me a Mohawk first. We even took before and after pictures.  I have never had to try so hard to smile when all I wanted to do was sob.  Then my son wrapped his arms around me and told me he liked me better bald. A few hours later we went downstairs to the party, thus beginning my seven months of going out in public without hair.

I had heard that when your hair starts falling out—as it invariably does with the kinds of chemos I was given—it is less traumatic if the clumps are shorter.  Since I did not relish the thought of waking up each morning to a pillow with more hair than me, this made sense. The day after my first chemo I went to Ruben’s salon and got a pixie cut. It was my way of preparing myself--and my son--for my new look. Shortly thereafter a friend took a picture of us that to this day sits prominently on my husband’s desk. I call it my East German swimmer phase. My husband calls it my Halle Berry phase and wishes I’d kept it that way.

“Listen, it is what it is,” my friend Barbara told me after the last hair had fallen out and I was complaining that the wig I’d purchased itched like hell and looked like a pelt. “Skip the wig and wear a scarf,” she suggested with exactly the right mix of encouragement, practicality and empathy.  “This is New York City.  Every day I pass a woman wearing one.” Of course she was right. But most decorative scarves are made of silk and don’t stay tied well. So, having wasted entirely too much time and energy on the subject, I marched over to Ninth Avenue, bought three bandanas from a man selling his wares from a card table on the street, and with the exception of a beautiful black cap with three silver buttons that another friend had given me for evening wear, decided that would be my public look. At home I went bald, a decision that worked well for me.  For starters, I had already cut my hair so donning a shoulder-length wig at that point would have surely confused my son. What was I supposed to do if he had a nightmare in the middle of the night?  Make him wait while I threw on my wig?  Forget it.

It was what it was.

It goes without saying that it’s beyond unsettling when all your hair falls out over the course of just a few weeks.  I remember hating my reflection—in a mirror, a store window, silhouetted against a wall—because it was a constant reminder that I was sick.  It was my reflection, yet I didn’t recognize myself. I could have been having a perfectly lovely day feeling utterly healthy and then, oops! I’d catch a glimpse of my bald head and be reminded that, Oh, yeah. I have cancer!

And, of course, I had to contend with my friends’ Hair Questions. First they’d ask if I was going to lose all my hair.  (Yes.) Then, a bit more incredulously, “All, all your hair?”  (“Yes,” I’d say. “All, all my hair. Arms. Legs. Armpits. Eyebrows. Eyelashes.”) I always stopped at that and then watched as their eyes inevitably drifted south and a slight pall crept over their face. When we both stopped blushing I would add, “You forgot nasal hair.”

Not long ago on Third Avenue I noticed a striking woman walking ahead of me. She was radiant.  Late fifties, early sixties.  Beautiful, bold earrings.  Luminous skin. And completely bald.

“Wow!” I said, without even thinking.  “You look beautiful! Not too long ago I looked exactly the same,” I said, running my hand over my head. “It does come back.”

 “I’m so afraid it won’t,” she said. “How long does it take?”

So there we stood, two strangers bound by something we never would have wished for,
carrying on an intimate discussion ten seconds after meeting.  That evening when I told my husband the story he was amazed at my chutzpah.  What if she’d been offended, he’d asked.  I assured him that it wasn’t I who had the chutzpah.  It was she.  And she looked damn good. 

Later that night I found myself wondering why I hadn’t gone bald in public. Was it vanity? I guarantee you my head is not nearly as perfectly shaped as hers.  Had I gone through chemo in the summer, would I, too, have had the guts? Perhaps the chemo had zapped some of my spunk as well. And then I realized it was simply a matter of inner comfort as well as outer comfort. I chose to journey through ovarian cancer in a bandana.

It has been four years since that uncomfortable Halloween party. My son is now eight and planning what to wear to this year’s party. And I am cancer-free and in need of a haircut.

Jane Read Martin is the author of two children’s books and a made-for-TV movie. She lives in New York City with her filmmaker husband Douglas McGrath (“Emma,” “Infamous”) and their son.

Female Hair Loss Often Linked to Hormones

Q:   I have a question regarding female baldness. I am in my early 70s and for about the last five years, I've been gradually losing my hair. I've always had thick naturally curly hair. Now I'm developing a pattern of losing my hair the exact opposite way men lose their hair. I'm losing it like a halo effect above the forehead and around the lower sides above the ears and the back. The top and lower edges are still thick and curly.

Because of breast cancer in my family, I do not take any hormones as my doctor advised against it. I have been coloring my hair for about 20 years and was wondering if that might cause baldness. I am getting quite concerned because I seem to be losing it at a faster rate the last year or so. I am sure many other women are experiencing the same problems as many of my friends are also. Thank you for any help you can give me.

A:   Women have thinning hair as they get older, but it is usually on the top and sides of the scalp, so your hair loss pattern is most unusual. Unlike men who have receding hairlines on the forehead, women tend to retain the frontal hair. Hair has three growth cycles: anagen, the stage of active growth; catagen, a transition stage; and telogen, when the follicle releases the hair fiber. Of the 100,000 hairs on the average person, about 100 are in the telogen phase and fall out every day.

Hormones have a great effect on hair, which is why many women notice changes during and after pregnancy and around menopause. After menopause, the ovaries may produce more androgens (male hormones) than estrogen and this can result in hair loss. (Male baldness is related to increased testosterone). A dermatologist or plastic surgeon can do scalp biopsies and have the hair follicles studied, which may be helpful in determining androgen effects. Some medications, severe stress, malnutrition, iron deficiency and an underactive thyroid may all cause hair loss, so blood tests also are useful.

Repeated permanents and harsh bleaching may contribute to hair damage. Contrary to advertising claims, there are no herbs or hair products that thicken hair. In 1980 an advisory panel to the US Food and Drug Administration evaluated a number of substances used in hair products, including amino acids, aminobenzoic acid, ascorbic acid, benzoic acid, B vitamins, hormones, jojoba oil, lanolin, polysorbates, sulphanilamide, tetracaine hydrochloride, urea and wheat germ oil, and found that none of them prevented hair loss.

Minoxodil or Rogaine for women can be purchased over the counter. It may take applications twice a day for at least four months to see any hair growth, and most people are not satisfied with the "peach fuzz" results. When it's stopped, the hair gained usually will fall out within six months.

Hair Restoration Surgery encompasses numerous Procedures & Terms:

ALOPECIA: The medical term for baldness.

ANDROGENIC ALOPECIA: The most typical pattern of balding whereby the balding pattern is controlled by hormones and passed along via heredity.

ALOPECIA REDUCTION: A procedure that involves removal of a strip of balding upper scalp in the crown and vertex areas. The natural flexibility of the scalp is used to stretch the surrounding hairy scalp into place. It can be repeated in certain cases. See also "Scalp Reduction."

CROWN AREA: The area in the top/back portion of the head which contains a swirl or spiral pattern of hair growth. Also called the 'vertex,' it may be the first area where male pattern baldness is noticed.

DONOR AREA: The fringe above the ears and around the back of the head where hair follicles are genetically programmed to remain intact and grow throughout life.

DONOR DOMINANCE: The concept that hair follicles transplanted from the donor area will continue to grow in the recipient area.

FEMALE PATTERN BALDNESS: A hereditary pattern of baldness found in women typically characterized by a diffuse thinning of hair and/or hair loss at the front portion of the scalp behind the frontal hairline. May or may not include a slight recession or thinning in the temples and only very rarely ends in complete baldness at the top of the scalp. Also called "Female Hereditary Hair Thinning."

FOLLICULAR UNIT: A follicular unit is a naturally occurring grouping of one, two, or three (and rarely, four) hair follicles found in the skin. The average follicular unit contains about 2.4 hairs.

FOLLICULAR UNIT EXTRACTION (FUE or FOX): Follicular Unit Extraction is a method of extracting single follicular units, one at a time, from the donor site by using a tiny punch excision. A punch used to extract single follicular units is typically 1mm diameter or less.

FOLLICULAR UNIT GRAFT: A graft consisting of a single follicular unit. In appropriate patients, artistic planning - in addition to the correct angulation, orientation, and positioning of follicular unit grafts - can yield an exceptionally "natural" appearance of the transplanted hair.

FOLLICULAR UNIT MICROGRAFTING: A method by which large numbers of follicular units are harvested from the donor site (usually in a long strip or ellipse) and then microscopically dissected into grafts containing single follicular units.

GRAFTING: A variety of procedures where hair-bearing skin is removed from the lower scalp at the back of the head-the "donor area"-and transferred to thinning or balding areas. The most popular varieties are micrografting (1-2 hairs) and minigrafting (3-8 hairs). A few surgeons selectively use round grafts which have 10-20- hairs each.

HAIR ECONOMICS: A theory that states only a limited or decreasing supply of hair exists, but the demand for hair increases as balding patterns develop.

HAIR FLAPS: Techniques to rotate large portions of hair from the sides and back of the scalp to the front and central areas of the head. Most effective when used with a tissue expander. See also "Scalp Rotation Flaps."

HAIR FOLLICLE: A strand of hair and its root which is extracted from the donor area and transplanted to the recipient area during hair restoration surgery.

HAIR GRAFTS: Hair follicles that have been harvested from the donor area and are ready for transplantation into the recipient area of the scalp. The numbers of hair follicles per graft vary widely depending upon the transplantation technique used. A graft may contain a single hair follicle, a single follicular unit, multiple follicular units, or even 20 or more follicles (as in a large round graft).

HAIR "PLUGS": A slang term typically used to describe the large round grafts that were used more commonly years ago.

HAIR TRANSPLANT: A surgical technique that transfers hair follicles from the donor area to the recipient area.

HAIRLINE REFINEMENT: Hairline Refinement or "Hairline Correction" refers to the use of a variety of newer, more delicate grafting techniques to alter, camouflage or soften the "pluggy" looking results of older hair transplant techniques.

MALE PATTERN BALDNESS: An inherited condition in men which is triggered by the hormone Dihydrotestosterone which causes gradual miniaturization (and eventual loss) of hair follicles. Starting anytime after puberty with a recession of the hairline and thinning of the crown areas, it can eventually lead to complete baldness at the top of the scalp. The areas around the sides and back of the scalp are not typically affected by male pattern baldness.

MICROGRAFT: A graft containing 1 or 2 hairs, obtained from the donor area with a micropunch or sliced off from a round graft (see below). A micrograft is typically placed into holes made in the scalp with a microneedle or punch.

MINIGRAFT: A graft containing 3 or 4 hairs (small minigraft) or 5 or 6 hairs (large minigraft). There are many variations of minigrafts derived from round grafts.

MULTI-UNIT GRAFTS (MUG): Grafts that contain two or more follicular units in a single graft. This term replaces the older "minigraft". In practice today, MUGs contain 2-6 follicular units per graft.

MULTI-UNIT GRAFTING: Hair transplantation using multi-unit grafts. In practice, these grafts may be placed into small round holes, slots, or slits. This would always be in combination with the use of FUT in the same procedure.

RECIPIENT AREA: Area where hair loss has occurred and hair follicles will be implanted during a hair transplant procedure.

ROUND GRAFT: The first type of graft used in hair transplantation, a round graft has many variations. Harvested with punches of various sizes, a large round graft may contain many hairs (20 or more). The round graft is obtained from the donor site by surgical removal and may be used "as is" or may be sliced into smaller sections for micro-, mini- or slit grafts.

SCALP REDUCTION: A procedure that removes bald scalp and brings the edges of hair-bearing scalp closer together. Scalp reduction is most often used in patients with crown baldness. See also "Alopecia Reduction."

SCALP ROTATION FLAPS: A type of procedure that involves the lifting and rotation of a strip of hairy scalp which is placed into an area of simultaneously removed balding skin.

SLIT GRAFT: Hair obtained from a donor site directly or sectioned from a larger round graft is inserted into a slit made in the scalp by the tip of a scalpel blade.

TEMPLES/TEMPORAL AREA: The two upper outer corners where the forehead meets the hairline. This is usually the first area where male pattern baldness is observed, causing the hairline to recede.

TEMPORAL POINT: The two triangular shaped areas of hair located in the lower outer corners of the forehead, where the temporal hairline meets the sideburns.

TISSUE EXPANDER: A reconstructive balloon-like device which can be used to enlarge hair-bearing scalp on the sides of the head, providing a larger supply of hair with which to replace the bald areas. Often used in hair flap techniques and scalp reductions.

TISSUE EXTENDER: A device used to stretch scalp. Often used to speed up the process of scalp reductions by stretching the sides of the scalp that contain hair to achieve rapid elimination of bald areas. The tissue extender is temporarily inserted below the scalp and remains in place for a three-week period.

VERTEX AREA: The area in the top/back portion of the head which contains a swirl or spiral pattern of hair growth. Also called the 'crown,' it may be the first area where male pattern baldness is noticed.

Facts about normal hair growth:

About 90 percent of hair on the scalp grows continually. The other 10 percent of scalp hair is in a resting phase that lasts two to three months. At the end of the resting stage, this hair is shed.

Shedding 50 to 100 hairs a day is normal. When a hair is shed, it is replaced by a new hair from the same follicle and the growing cycle starts again. Scalp hair grows about one-half inch a month.

As people age, the rate of hair growth slows.

What causes excessive hair loss?

Most hair shedding is due to the normal growth-rest cycle, and losing 50 to 100 hairs a day is no cause for alarm. When concerned about excessive loss of hair or dramatic thinning, consult a dermatologist. Excess loss of hair may be due to many different causes, including:

• a high fever, severe infection
• thyroid disease
• inadequate protein in diet
• certain medications
• cancer treatments
• low serum iron
• major surgery/chronic illness
• alopecia areata
• hereditary thinning or balding
• a fungus infection (i.e., ringworm) of the scalp
• improper hair cosmetic use/improper hair care

Can hair loss be prevented?

Hair loss from some causes will regrow naturally. Other causes may be treated successfully by a dermatologist. There are several causes of hair loss for which there is no successful treatment at present.

Non-surgical hair replacement with medication:

• Finasteride (Propecia)
  
  Finasteride, produced by Merck and Company under the name Propecia, was approved by the FDA in December 1997, as a treatment for male pattern baldness. It is the first drug available in pill form for the treatment of baldness.
  
  In men with mild to moderate hair loss, clinical trials showed that 83 percent of the male patients had kept their hair or grown more after one year of treatment. Propecia (finasteride) works by blocking an enzyme called 5-alpha reductase, which is responsible for the formation of dihydro-testosterone in a man's body. The enzyme converts testosterone to DHT (dihydrotestosterone). It is believed that DHT is a key factor in male pattern hair loss, and finasteride decreases the concentration of DHT in a man's scalp by about two-thirds.

Finasteride is available by prescription only.

• minoxidil (Rogaine)
  
  Minoxidil, a drug produced by Upjohn under the name of Rogaine, has been available since 1988 for the treatment of hair loss. It is currently available as an over-the-counter drug.

  Minoxidil is topical solution that must be applied by applicator or fingers to the balding area twice a day, every day. Decreasing the dosage to once a day results in some hair loss, and discontinuing application causes regression to pretreatment baldness within 3 to 6 weeks. It can take 4 to 12 months to see results.

  According to the Food and Drug Administration (FDA), clinical studies show that 26 percent of men between 18 and 49 reported moderate to dense hair regrowth after four months of Rogaine treatment. An additional 33 percent had minimal hair regrowth. Almost 20 percent of women between 18 and 45 had moderate regrowth, while an additional 40 percent showed minimal regrowth.

Surgical hair replacement:

When experiencing thinning hair or baldness, men (and some women) consider hair transplantation, a permanent form of hair replacement. Anyone who has permanent hair loss may be a candidate for hair transplantation, including:

• men with male pattern baldness
• some women with thinning hair
• persons who have lost hair as a result of burns or other scarring injuries to the scalp, eyebrows, or eyelashes

Types of hair replacement surgery:

There are a number of techniques used in hair replacement surgery. Sometimes two or more techniques are used to achieve the best results.

• punch grafts - usually contain about 10-15 hairs
• mini-grafts - contain about 2 to 4 hairs
• micro-grafts - contain 1 to 2 hairs
• slit grafts - contain about 4 to10 hairs each
• strip grafts - contain 30-40 hairs

Complications of hair replacement surgery:

Individuals vary greatly in their physical reactions and healing abilities, and outcome is never completely predictable. Complications may include:

• infection
• excessive bleeding
• wide scars, called stretch-back scars
• some of the grafts may not take
• bumps that form at the transplant sites
• unnatural, patchy look may result
• additional surgery may be required

Surgical hair replacement procedures:

Treatment may be performed in a surgeon's office, an outpatient surgery center, or, rarely, a hospital as an outpatient or an inpatient.

Hair replacement surgery is usually performed using a local anesthesia along with sedation to make the patient relaxed, although general anesthesia may be used for more complex cases involving tissue expansion or flaps.

• hair transplantation
  Several surgical sessions are usually needed to achieve satisfactory fullness, with a healing interval of several months recommended between each session. It may take up to two years before seeing the final result with a full transplant series.

The number of large plugs transplanted in the first session may vary, but the average is about 50. For mini-grafts or micro-grafts, the number can be up to 700 per session.

• tissue expansion
  A balloon-like device, called a tissue expander, is inserted beneath the hair-bearing scalp next to a bald area. The device is gradually inflated with saline over a period of weeks, causing the skin to expand and grow new skin cells. When the skin beneath the hair has stretched enough -- usually after about two months -- another procedure is performed to move the expanded skin over to cover the bald area.

• flap surgery
  A section of bald scalp is removed. A flap of hair-bearing skin, still attached at one end, is lifted off the surface and moved into its new position where the bald scalp was removed. It is sewn into place, but remains tethered to its original blood supply.

• scalp-reduction
  This technique is sometimes referred to as advancement flap surgery because sections of hair-bearing scalp are pulled forward or advanced to fill in a bald crown. Scalp reduction is designed for coverage of bald areas at the top and back of the head. It is not beneficial for coverage of the frontal hairline.

Resuming normal routines depends on the length, complexity, and type of surgery.

Follow-up procedures for surgical hair replacement:

A surgical touch-up procedure may be needed to create more natural-looking results after the incisions have healed. This may involve blending, a filling-in of the hairline using a combination of mini-grafts, micro-grafts, or slit grafts.

If a small bump, called a dog ear, remains visible on the scalp, it can be surgically removed after complete healing has occurred.

• Tinea capitis: is a scalp infection that is caused by a fungus. It can cause patches of hair loss, with broken off hairs (black dot ringworm), scales, enlarged lymph glands, or the formation of a kerion, a large, red, boggy nodule on the scalp. Your doctor may do a KOH examination of the hairs, have a fungal culture done, or he may just treat your child with an antifungal agent, such as griseofulvin. These medicines are taken for at least 6 weeks, usually with fatty meals which can help it to be absorbed better. You can also wash your child's hair with a shampoo that contains selenium sulfide at least twice a week to make him less contagious.
• Trichotillomania: this is a condition in which a child actually pulls the hair out, leaving an irregular patch of hair loss with broken off hairs of different sizes. It can be a habit, especially in times of stress.
• Traction alopecia: this occurs when hair is braided too tight, or other tight hairstyles.
• Alopecia areata: children with this condition have a complete loss of hair in one to three areas of the scalp, without scalp redness or scaling. Another finding can be pitting of the nails in children with this condition. Although there is no reliable treatment for this condition, most children will have regrowth of the hair on their own within a year.
• Telogen effluvium: this usually occurs in young infants as a part of the normal process in which mature hair replaces baby hair. It can also occur in older children, usually a few months after an illness, and it is caused by the hair growth cycle being interrupted, with many hairs moving from a growing state to a resting state. As many hairs are shed, you may notice diffuse hair loss and it may seem like all of your child's hair is falling out, but there should be no other signs of infection or inflammation. The hair usually grows back in about 6 months.
• Congenital alopecia: newborns can have small areas of hair loss that are present from birth from a few different conditions, including aplasia cutis congenita and nevus sebaceous, a yellow-orange birthmark.
• Scarring alopecia: some conditions, including trauma or inflammatory reactions on the scalp can lead to scar formation, inside which hair does not grow, causing a bald spot on the scalp.

If clumps of your hair start to fall out from a common form of baldness, a new review of existing research unfortunately offers little comfort.

Patients who are afflicted by the condition known as alopecia areata -- patchy hair loss -- should understand that there is "no reliable, safe, effective, long-term treatment," said review co-author Dr. Mike Sladden, a dermatologist and senior lecturer at the University of Tasmania in Australia.

Alopecia areata accounts for an estimated one in every 50 dermatologist visits in the United States and the United Kingdom, and one study suggests that 1.7 percent of people will be afflicted by it during their lives.

The condition often causes patchy hair loss; meaning hair in some parts of the body falls out while remaining in others. In some cases, however, affected patients can lose all of their scalp hair or even all of their body hair.

Most affected people begin developing bald spots before the age of 20. Many cases of alopecia areata get better over time, although hair loss often returns.

Research suggests that alopecia areata is caused when the immune system attacks the hair follicle. Some cases are linked to physical or emotional stress, but others do not have an apparent trigger.

In the new review, Sladden and colleges examined 17 randomized controlled trials of treatments for alopecia areata.

The review appears in a recent issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews like this one draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

The studies, which looked at 540 patients, measured the effectiveness of several treatments, including topical and oral corticosteroids and topical cyclosporine. These drugs dampen the immune system to try to stop it from becoming confused and attacking the body.

Other treatments examined in the studies include photodynamic therapy (which exposes the skin to light) and topical minoxidil (Rogaine).

The researchers could not find any randomized controlled studies of other treatments, including diphencyprone, dinitrochlorobenzene, intralesional corticosteroids and dithranol.

According to the review, none of the studies showed long-term "beneficial hair growth" -- the return of more than half of the missing hair.

"Few treatments for alopecia areata have been well evaluated in randomized trials and we found none that addressed participant-focused measures of success or measurements of quality of life," the review authors wrote.

The reviewers had hoped to look at 11 other studies, but were not able to do so. In some cases, the researchers could not obtain copies of the studies. In others, the studies have not yet been published.

One small, unpublished study found that hair regrew in almost half of 60 subjects who applied onion juice to their heads. They all had mild cases of the condition affecting less than a quarter of their heads. Onion juice, an alternative medicine, has been used to treat infections.

Sladden said patients should balance their desire to resolve their hair loss with the risks of the available treatments.

"Although there is no proven treatment, some people might choose to try a 'safe' treatment -- such as a topical steroid -- even in the absence of good evidence of the treatment's benefit," he said. "Doctors and patients need to talk openly about the condition and discuss treatments and likely outcomes. And they need to avoid those treatments which might be harmful."

Dr. Amy McMichael, an associate professor of dermatology at Wake Forest University School of Medicine, said there has been little high-quality research because no agencies are willing to pay hundreds of thousands of dollars to study a nonfatal disease that affects the skin and hair.

Still, many of the available treatments do work very well in some cases, she said. However, "there is no way to predict who will respond to treatment or how long the response will hold."

Another dermatologist, Dr. Paradi Mirmirani of the Permanente Medical Group in Vallejo, Calif., said patients should not be discouraged by the review findings or assume that "nothing works."

"It's true if they do nothing, the hair may spontaneously regrow," Mirmirani said. "But there are treatment options that they should at least discuss with a physician."

Dr. Judith Reichman, the TODAY show's medical contributor on women's health

Q: I'm in my early 40s and I've noticed sudden hair loss. I'm devastated. Why is this happening and what can I do?

A: Women don't expect to lose their hair (unlike men), so when it happens it's extraordinarily traumatic.

We normally have, on average, 100,000 hairs on our scalp. And as evinced by our changing hair lengths, roots and visits to our hairdressers, those hairs grow; in fact, 90 percent of our hair is actively growing at any given time. Hair is the second fastest growing tissue in our body after (I'd love for you to guess) ... bone marrow. To keep its place on your head, your hair needs the right conditions. (Note I didn't say conditioner.) You may find that you're unexpectedly losing hair if you impose restrictions on hair growth or if your genes are such that continued hair growth is not in your destiny.

There's a simple test you can do to help determine whether you are losing hair, it's just thinning or you are damaging it by abusive hair products or pulling it too tight (which can occur with braiding). Pull on several strands of your hair - do they come out easily at the root? If so, it suggests that the hairs are indeed "shedding" and have gone into what we call an excess telogen phase.

To explain this telogen phenomenon, I must first go into hair physiology 101. As hair actively grows, it's in the anagen phase. Each hair is connected to a hair shaft (or follicle), which remains in its secure position in the scalp for three to seven years before falling out and being replaced by a new follicle. Once the anagen phase naturally runs its course, there's a two-week catagen phase, in which the hair follicle dies. The hair then goes into the telogen phase for the next three months, during which time it falls out. Normally we lose 100 telogen hairs a day, but in certain cases (and this sounds like your situation), many, if not most, of the hairs go into the telogen phase. This causes alopecia (balding). The condition of overwhelming telogen loss is termed telogen effluvium; the anagen to telogen ratio has gone from its normal 90:10 to 70:30 or less. If I do the math correctly, this means you lose at least 300 hairs a day, compared to 100 hairs.

Some sort of stress or medication that started three months before you see the actual hair loss usually causes telogen effluvium. And there are many stresses that can lead to this condition. These include all major illnesses, especially if you're bedridden and/or have a high fever, surgery, childbirth (giving birth can be stressful, but the hair loss is also due to the body's reaction to a sudden loss of hormones after delivery), rapid weight loss, nutrition deficiencies (we see this more in vegetarians who don't get enough iron or protein), or hemorrhage and subsequent anemia. Hormonal changes often have a negative effect on hair. Hair loss occurs with thyroid disorders or in instances when there is a sudden cessation or change in hormones (such as stopping the birth control pill, surgical menopause, discontinuing hormone therapy and, as I stated above, after childbirth).

Then there's the hair loss effect of taking certain medications, rather than stopping them. There is a long list of drugs associated with hair loss, but here are the most common ones (in which hair loss occurs in more than 5 percent of people taking it):

• Heparin, interferon, Accutane (for acne), Altace, certain anticonvulsant drugs such as Klonopin and valproic acid

Drugs that less commonly lead to hair loss (but can cause this side effect) include:

• Acyclovir, Lupron, Cyclosporin, certain anti-arrhythmia medications, high doses of naproxen, and antidepressants such as Paxil, Zoloft, and Effexor

You may wonder about chemotherapy drugs and their impact on hair loss. These drugs don't actually change the status of hair, because they cause hair to fall out during the anagen phase. The hair loss from chemo usually occurs 7 to 14 days after onset of treatment.

The good news is that hair loss associated with telogen effluvium is temporary, and usually the hair will grow back within six months of the initial hair loss trigger. That said, there are individuals in whom it takes years for full hair recovery, possibly due to ongoing hair loss triggers or subsequent triggers that added insult to hair injury.

I suspect that your hair loss is due to one of these hair stressors. But we should go over other causes of hair loss that are usually more gradual. The most common is female pattern hair loss (hair thinning), which can occur any time between puberty and old age. Although we associate thin hair and balding with male gender, female pattern hair loss (called androgenic alopecia) occurs in 38 percent of women. Usually the center part of the scalp goes first, though hair on the lateral sides can also start to thin. A topical 2 percent minoxidil solution applied twice a day helps treat this type of hair loss. It has been found to increase "minimal" hair growth in 50 percent of women who use it and "moderate" hair growth in 13 percent. However, you need to wait 32 weeks to see these results. For women who've waited patiently and don't see any growth, doctors can prescribe a 5 percent solution. (Please note, however, although this is quite commonly prescribed, the FDA hasn't approved this concentration for use in women.) If long-term female pattern hair loss does not respond to topical therapy, the option of hair transplantation can be considered.

Finally, some of my patients complain of what they think is "typical" male pattern hair loss. If they also have acne and hair growth on other parts of their body, I will check their male hormone levels. If they are high or they are diagnosed with a condition called PCOS, I might prescribe medications that block male hormones. One that is commonly used is the mild diuretic spironolactone.

Dr. Reichman's Bottom Line: If you have sudden hair loss and you've had previous physical stress, don't freak. Once the stress is gone, you'll see regrowth of the hair in six months. If you're taking a new medication, find out if it causes hair loss. If it does, ask your doctor if you can stop taking that drug or change to another.

A man can read a lot about male-pattern baldness (androgenetic alopecia) without learning what HE wants most to know: “How about my baldness, specifically?”

If he has close male relatives with male-pattern baldness, specific questions a man might ask are:

“I know that male-pattern baldness runs in families. So, how soon should I expect to begin losing hair like my male relatives?”

“If I begin to lose hair, how fast will I lose it?”

“How much hair will I eventually lose?”

“If I lose hair, will I lose it in a pattern similar to that of [my father] [my brother] [my uncle]?”

“If I get to be 40 years old and have not developed male-pattern baldness, does that mean I have dodged the bullet despite a family history of male-pattern baldness?”

“If I begin to develop male-pattern baldness, how soon should I begin to consider hair transplantation?”

How Soon Should I Begin to Consider Hair Transplants?

For men who are concerned at the earliest indication of hair loss, it might be well to consider the last question first: “If I begin to develop male-pattern baldness, how soon should I begin to consider hair transplants?”

The decision to have hair transplantation should not be made as a snap judgment. No ethical physician hair restoration specialist would allow you to do so. No one should use your concern about hair loss to sell or pressure you into a decision to have hair transplants.

Many men are concerned at the earliest sign of male-pattern hair loss, and are not sure what to do about it. Consultation with a physician hair restoration specialist is a logical step in your quest for (1) answers about the cause and probable course of your hair loss, and (2) options for treatment. [See About hair lossHair loss analysis and diagnosis to learn what a physician hair restoration specialist may want to know about your individual case of hair loss before making any recommendations for treatment.] and

Based on a medical examination, scalp examination, your medical history and family medical history, a physician hair restoration specialist can make recommendations such as:

Some men with very early male-pattern hair loss may not be good candidates for hair transplantation until they have had a trial of medical treatment with a hair restoration drug—minoxidil (Rogaine®) or finasteride (Propecia®). In most men with early male-pattern hair loss, these hair restoration agents will slow or reverse hair loss and delay the need for hair transplantation. In fact, the earlier a hair loss sufferer begins medical therapy, the more hair he will preserve. He may be able to delay hair restoration surgery for many years using these medications.

Hair transplant surgery is a well accepted procedure with a high rate of success and reliable esthetic results when planned and carried out by an experienced hair restoration surgeon. It is a surgical procedure with potential side effects and complications that should be fully explained and discussed before the procedure is undertaken. Hair transplantation should be undertaken only when it is the best treatment for you at this time.

While androgenetic alopecia is by far the most common cause of hair loss in men, it is not the only cause. Some conditions associated with hair loss require medical treatment. Hair transplantation should not be undertaken until the cause of hair loss has a confirmed diagnosis.

Male-Pattern Baldness Runs in My Family. How Soon Should I Expect to Begin Losing Hair?

While male-pattern baldness is known to have hereditary factors, no specific “baldness gene” has yet been identified in humans. Even in families with many bald males, inheritance patterns are unpredictable. No one can tell you with certainty when male-pattern hair loss may begin, no matter how many of your close male relatives are bald or balding. Generally speaking, male-pattern baldness can be expected to occur in 25% of men aged 25-30 years, in 40% of men aged 40, and in 50% of men 50 years old or older. Male-pattern hair loss can begin to occur as early as mid to late teens. It may be that several genes, interacting with one another and with environmental factors, are involved in male-pattern hair loss.

If I Begin to Lose Hair, How Fast Will I Lose It?

“How Fast” is usually as unpredictable as “How Soon” for an individual. A physician hair restoration specialist may be able to predict “how fast” with some degree of certainty on the basis of years of experience in diagnosing and treating male-pattern hair loss. Hair loss that begins early and progresses rapidly is likely to continue relentlessly, sometimes with occasional pauses. The rate and progression of male-pattern hair loss are influenced by genetic and environmental factors that are not well understood.

If I Lose Hair, Will I Lose It in a Pattern Similar to That of Male Relatives?

Even in its most complete form, male-pattern baldness spares the hair at the temples, over the ears, and at the back of the head. These areas are under genetic control that is different from the factors that influence hair loss over other areas of the scalp. [See male pattern baldness and look at the Norwood-Hamilton Scale for illustrations of the patterns of male androgenetic alopecia]. The sequence of male-pattern hair loss usually starts at the frontal hairline (above the forehead), and moves in an “M” pattern from the frontal area into the central area of the scalp. Simultaneously or later, there may be loss of hair over the vertex (crown) of the scalp. The frontal and vertex patterns may enlarge until they merge. In some men, the progression of male-pattern baldness may halt temporarily at any stage, giving the false impression that hair loss has ceased. In some cases, the progression is relentless until hair has been lost over the entire scalp except for those “protected” areas at the temple, over the ears, and at the back of the head.

The rate of progression is an important factor when a physician hair restoration specialist is planning hair transplantation. When a patient wants hair transplantation to keep pace with relentlessly progressive hair loss, enough donor hair in the “protected” areas must be conserved to furnish grafts for future transplantation. While the rate of progression is not predictable with 100% certainty, the physician hair restoration specialist can usually make an educated guess based on information such as (1) rate and progression of hair loss to date, (2) family history of hair loss, and (3) experience with many previous cases.

If I Get to Be 40 Years Old and Have Not Developed Male-Pattern Baldness, Does That Mean I have Dodged the Bullet Despite a Family History of Androgenetic Alopecia?

Almost everyone can cite an instance of a man whose father was bald, but who went through life with a full head of hair. When true, such a story confirms the unpredictability of genetic and environmental factors in male-pattern baldness. A person with male-pattern baldness can’t be certain he has “dodged the bullet” if he reaches age 40. A substantial number of men begin to have recognizable male-pattern hair loss after age 40. A man may also begin to have early signs of male-pattern hair loss without recognizing them. Onset can be minimal and gradual. The typical onset of male-pattern baldness is a gradual shortening of the anagen (growth) phase of hair. Terminal hairs in affected areas become progressively finer and shorter, with loss of color. The process nay be rapid, but it can be so slow that it is not recognized as the beginning of permanent, progressive hair loss.

For you, the individual person, the ultimate question is not about hair loss but how you FEEL about hair loss. Some men are simply not concerned that they are losing hair. If you are concerned about hair loss and the way it affects your appearance, you should seek a consultation with a physician hair restoration specialist to discuss options (for diagnosis and treatment).

On average, there are 100,000 to 150,000 hairs on the human scalp. The hairs grow from hair roots, or follicles (saclike structures under the skin). Blood vessels at the base of each follicle provide the nourishment necessary for hair growth. Hair growth in each root occurs in a cycle independent of the other roots. At any time about 90 percent of the hairs on the scalp are in the growth phase, while the other 10 percent are in the resting phase. The growth phase lasts an average of four to five years, after which the follicle enters the resting phase, which lasts about two months to four months. At the end of the resting phase, the hair falls out naturally and is replaced by a new hair. Consequently, some hair loss is a normal part of the hair growth cycle. In fact, on a typical day, about 50 to 150 scalp hairs are lost. Baldness (or alopecia) results when hair loss occurs at an abnormally high rate; when hair replacement occurs at an abnormally slow rate; or when normal hairs are replaced by thinner, shorter ones.

What is male pattern baldness?

About 95 percent of all cases of hair loss are the result of androgenetic alopecia (also known as male pattern baldness in men). Androgenetic alopecia occurs much more frequently in men than in women. It 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.

While some types of hair loss are easily reversible, male pattern baldness is more permanent. It occurs in a characteristic pattern on the scalp: hair loss usually begins at the temples and at the top of the head toward the back, causing a receding hairline and a bald spot. Hair loss may continue until the two sections become joined, leaving a horseshoe-shaped area of hair on the sides and back of the head. Balding may begin at any age after puberty, even in the middle teens, and can range from partial loss to complete baldness. Male pattern baldness progresses slowly and is not associated with redness, itching, or pain. Currently, there is no way to prevent male pattern baldness from occurring.

What causes male pattern baldness?

The causes of male pattern baldness are thought to be complex and are not completely understood. However, as suggested by its medical name (androgenetic alopecia), male pattern baldness seems to involve both hormonal (androgen) and genetic factors. Many different types of hormones play roles in the regulation of scalp hair, but the hormones with the largest effect are the androgens. Testosterone and its more potent derivative dihydrotestosterone (DHT) are responsible for increasing the size of hair follicles in areas such as the beard and underarm during puberty, but can also cause hair follicles in the scalp to decrease in size later in life. These contrasting responses to DHT might be explained by genetic differences in the individual hair follicles. Similarly, in men who are balding, genetically determined characteristics of hair follicles in the scalp may cause the follicles to be more likely to degrade in the presence of androgens. Hair follicles become miniaturized, and the hair consequently becomes thinner and shorter. The growing phase of the growth cycle becomes progressively shorter, which means more hairs are shed. Although the follicles still have an adequate blood supply, they continue to shrink, and some eventually die.

Whatever the exact causes of male pattern baldness may be, it is a hereditary trait. There are multiple genetic factors that influence male pattern baldness. A tendency toward baldness in the men on either the mother's or father's side of a man's family indicates a genetic predisposition to baldness. The speed, pattern, time of onset and degree of balding are all influenced by heredity. Generally, the earlier the onset of balding, the more extensive the degree of hair loss will eventually be.

Contrary to popular myth, balding is not caused by wearing hats. Massaging or brushing the scalp will not help regrow hair, and excessive cleaning of the scalp will not "unclog" follicles and allow hair growth. While extreme psychological stress may contribute to a form of hair loss known as alopecia areata, normal everyday stress does not contribute to balding and is not a cause of androgenetic alopecia.

What are some other types of hair loss?

Aside from male pattern baldness, some of the most common types of hair loss include:

• Alopecia areata, which leads to patchy hair loss on the scalp. While the causes of alopecia areata are not completely understood, the hair loss is thought to be the result of the body's immune system attacking the hair follicle. Alopecia areata often resolves without treatment.
• Traction alopecia, which results from long-term pulling on the hair. This type of hair loss can be caused by certain hairstyles, such as tight braids. The hair loss is usually reversible once the cause of this pulling is eliminated.

Certain diseases, such as diabetes, systemic lupus erythematosus and disorders of the thyroid gland can also cause baldness. Sudden hair loss may be an early warning sign for some diseases and should be reported to a doctor.

Hair loss has many other causes, including illness, poor nutrition, skin damage, some medications, and certain medical treatments such as anticancer chemotherapy and radiation therapy. Ringworm, a fungal infection, may sometimes be the cause of balding in children, but is generally not a problem in adults.

How is the cause of hair loss diagnosed?

Because there are many potential causes of excessive hair loss, consult a dermatologist if you are concerned. Your doctor will ask questions about your family's history of baldness. He or she may also want to examine a few hairs under a microscope or check the scalp for signs of skin damage. You may be asked questions about your diet, hair-care procedures, medications (including vitamins and herbal supplements) that you take, and recent illnesses. In some cases, your doctor may order blood tests or a skin biopsy (taking a small sample of tissue for examination) to help make a diagnosis. He or she may also ask you to monitor the number of hairs lost during a day, by collecting and counting as many as possible.

What are the treatment options for male pattern baldness?

Male pattern baldness is not a medical disorder. Whether treatment is desirable is a personal decision. Many men decide to let the process run its course. However, baldness can be a source of anxiety for others and can have a negative effect on self-image. If you decide that you are not comfortable with your hair loss, you may want to consider the treatment options described below.

Prescription medications

• Minoxidil (Rogaine®)
  Originally used to treat high blood pressure, minoxidil is now widely used as a topical solution applied twice daily to treat male pattern baldness. Studies have indicated that it may help grow hair in 10 percent to 20 percent of those who use it, and it may slow the rate of loss for 90 percent. It is not clear exactly how minoxidil works, but when it is effective, it seems to somehow prolong the growing stage of the hair growth cycle, enlarge the follicles, and cause follicles at rest to grow. Minoxidil is generally more effective for young men and those whose onset of hair loss is recent.

  Minoxidil may take four months or longer to show results. The treatment is relatively expensive and must be applied indefinitely; when application is stopped, regrown hair falls out. Newly grown hair may also not be as long and thick as normal hair. As with most medications, side effects are possible, including irritation of the scalp. The solution was originally available only in a 2 percent solution, but the Food and Drug Administration has recently approved a 5 percent solution, which has shown better results in some cases.

• Finasteride (Propecia®)
  Originally used for the treatment of enlargement of the prostate gland, finasteride was recently approved by the FDA to treat male pattern baldness. It is taken daily in pill form. Finasteride works by inhibiting the conversion of testosterone to DHT, decreasing the levels of DHT in the blood and scalp. In this way, finasteride helps to block androgen-dependent degradation of hair follicles. In a recent study, nearly half of the men who took finasteride grew hair on the scalp, and the drug was even more effective at halting hair loss. A significant percentage did, however, continue to report hair loss.

  Side effects associated with finasteride are mainly related to sexual function, such as loss of sex drive, reversible impotence and a decrease in the quantity of semen. These side effects were experienced by approximately 2 percent to 5 percent of patients in clinical trials. Finasteride is not approved for use by women, because it may cause birth defects. Broken or crushed tablets should not be handled by women who are or may be pregnant.

  Currently, minoxidil and finasteride are the only medications approved by the FDA for use in the treatment of male pattern baldness. Nonprescription preparations are not effective and were banned by the FDA in 1989.

Surgical treatments

• Hair transplantation
  In hair transplantation, productive hair follicles are removed from a donor area on the scalp and transplanted to a balding area. The follicles are commonly taken in plugs of one hair to two hairs (called micrografts) from the sides or back of the head and moved to the front and/or top, with the hairline being slowly reconstructed. Larger plugs of up to 10 hairs are also sometimes used. Donor sites with full hair make transplants more successful. In the flap technique of transplantation, areas of hair are removed from the sides and back of the scalp and transplanted to the top.

  Some scarring in the donor site may result. Transplanted follicles may be permanent, or they may last only for a few years. The implantation of synthetic hair fibers has a high rate of infection and has been banned by the FDA.

• Scalp reduction
  Balding areas of the scalp may be surgically removed to decrease the appearance of baldness. Scalp reduction is usually used in conjunction with grafts or flaps. Devices may be used to stretch the scalp, expanding areas where hair grows. The effectiveness of scalp reduction depends on the degree of hair loss and the elasticity of the scalp.

As with any surgical procedure, hair transplantation and scalp reduction present certain risks, including scarring and infection. If you are considering one of these treatments, discuss the risks with your doctor.

Cosmetic treatments

• Synthetic hair
  A hairpiece (or toupee) can be custom made to cover a balding area. Hairpieces may fade and loosen over time. Certain organizations specialize in cleaning, coloring and tightening hairpieces. It is important not to neglect the scalp under the hairpiece, which should continue to be washed regularly. Another option is a weave, in which synthetic hair is sewn into existing hair.
• Hair products
  Be wary of hair-care products that claim to thicken and strengthen hair. This is accomplished simply by waxes or oils that build up on hair, creating the illusion of thickening.

While male pattern baldness presents no physical risks, your emotional well-being is an important part of your complete health. If hair loss causes you anxiety and negatively affects your self-image, treatment can be beneficial. Consider the treatment options and discuss them with your doctor.

Why am I Losing My Hair?
Alopecia is a general term and can refer to hair loss from any cause. Indeed many diseases can cause hair loss but most are quite rare. Only two are common: alopecia areata which is due to the immune system attacking the hair follicles and androgenic alopecia, which is hormonal.

Androgenic alopecia is extremely common. A reasonable estimate is 20% of women prior to menopause and up to 40% after that. In early stages it so mild as to escape notice by others but most affected women are only too aware that it is happening. A common abbreviation is AGA. Sometimes it is referred to as “androgenetic alopecia” to emphasize the genetic component but I do not like this term because some women with androgenic alopecia do not have it in their family.

As the name implies, androgenic alopecia is due to the effect of androgens, the family of hormones which includes testosterone. One effect of testosterone is to inactivate hair follicles on the scalp. Oddly, it makes follicles on the face and body more active. It’s not fair but the same hormone takes hair away from where it is wanted and puts it where it is not wanted. Yet this is the unfortunate truth about what testosterone does to hair follicles. These effects are very obvious and familiar in men. The much higher testosterone levels give us less hair on the scalp and more on the body than women.

As if this were not enough, testosterone also makes the skin more oily, which in turn can trigger acne. Many women with AGA have only the alopecia but some also have other unwanted effects of testosterone – hirsutism, that is, increased facial and body hair (Hormones and Unwanted Hair) and oily skin or acne. These can be part of PCOS (polycystic ovary syndrome) (PCOSupport  The Polycystic Ovarian Syndrome Association Web Site) but many women with AGA have only the alopecia without any other hormonal changes.

In my practice I’ve seen women who have been told they have PCOS but only have androgenic alopecia. But then, I’ve seen some with alopecia whose PCOS had not been diagnosed. A woman with alopecia who is overweight and/or has irregular periods, should get checked to see if she has PCOS because then additional treatments may be helpful.

Estrogen and female alopecia
While androgens are often the cause of female alopecia, there is another hormonal factor – estrogen. This is hardly surprising, considering that abundant hair is clearly a female characteristic. In contrast to testosterone, estrogen helps hair. It does this by helping the hair grow faster and stay on the head longer – resulting in thicker hair. This is the reason women’s hair gets fuller during pregnancy when estrogen levels are quite high, then sheds several weeks after the baby is born.

Estrogen deficiency alopecia generally starts some months before menopause, that is during perimenopause or shortly after menopause. Because estrogen levels start to fall before periods stop, this form of alopecia can be the first sign of approaching menopause. Women vary in this regard however. Sometimes the alopecia does begin until a few months or even a few years after menstruation has ended. Not all women get noticeable alopecia after menopause but most have at least mild thinning.

The alopecia due to low estrogen has the same pattern of distribution as that due to testosterone and dermatologists generally fail to make a distinction. Estrogen deficiency as a cause of hair loss has not found its way into medical textbooks but this does not stop it from happening.

What androgenic alopecia looks like
Androgenic alopecia is distinguished from other forms of alopecia primarily by the pattern of hair loss on the scalp. For this reason, it usually needs to be diagnosed by a physician experienced with female hair loss, of whom there are unfortunately very few.

There is some individual variation of course, but androgenic alopecia tends to affect the temples, the crown and the vertex; the sides are least affected. Sometimes AGA is said to be the female equivalent of male pattern baldness but this is only partially accurate. Though female androgenic alopecia  is caused by testosterone, unlike male pattern baldness, the front hair line is usually preserved. Nor does the top of the scalp lose all hair as often happens to men.

Female AGA tends to be much milder than male hair loss but this is not much consolation for the women who experience it. Hair loss is expected for men, though we don’t like it, but is not supposed to happen to women.

What is telogen effluvium (TE)
This elegant-sounding term simply refers to an increased rate of hair shedding and implies that the hair will eventually grow back. Some dermatologists make a distinction between telogen effluvium and androgenic alopecia. However the only way to tell if the hair will grow back is to wait and see. In my experience, it usually does not and waiting many months simply delays treatment.

There are some situations however in which hair loss is common and regrowth usual. These include childbirth, substantial weight loss (typically 30 or more pounds over a few months) and illness with high fever (but not a mild case of flu). In those cases it may be reasonable to wait some months to see if the hair grows back. Be careful though: most of the women I see who have been told they have TE actually have AGA.

Alopecia areata is less common than androgenic alopecia. It occurs when the immune system attacks the hair follicle. As the name alopecia areata implies, hair is lost in discrete areas. There will be a patch or patches of shiny scalp with no hair at all, but the rest of the hair is unaffected. However it can spread to other areas or sometimes involve the entire scalp (alopecia totalis) or all the hair on the body (alopecia universalis). When only a small area is affected, the hair usually grows back but then may fall out again. Unfortunately, we have no way to predict which way things will go with alopecia areata.

A usual treatment for alopecia areata is injection of cortisone-like medications into the scalp. Taking similar medications orally does not help in the long term and can cause weight gain and other undesirable side effects. (Similar medications are sometimes used for adrenal conditions but in much lower doses which do not cause these side effects. These conditions should be managed by an endocrinologist.) Treatment of areata is not always effective, unfortunately. The medications which help androgenic alopecia do not help areata. Sometimes both forms can occur together and then treatment for androgenic alopecia may be appropriate.

The thyroid and alopecia
Alopecia areata is not caused by hormones but can be associated with under activity of the thyroid, which can also be damaged by the immune system. When areata first appears, thyroid testing should be done and then about every one to two years after that. Though treatment of the thyroid condition is important for overall well being, it does not help with the hair loss, unfortunately.

Many women whom I see in my practice ask me whether their alopecia may be due to a thyroid problem. This is rarely the case nowadays because thyroid disorders are usually picked up at a very early, mild stage. Still checking the thyroid with the very sensitive TSH test is an important part of the workup. If you are on thyroid medication, too high a dose can make alopecia worse so it is important to be sure that your TSH is normal on the dose you are taking. If it is lower than normal, you should discuss the situation with your physician.

What Does It Feel Like to Have Alopecia?
A renowned but unsympathetic dermatologist once said to me, chuckling, “We know hair is totally unnecessary.” Some in my profession just cannot understand why hair matters so much to women. While it’s true that hair is not necessary for survival in the way the heart or kidney is, human life is more than survival.

Most take their hair for granted and have no particular reason to reflect on what it means to them. When it starts to fall out however, everything is different. Women with alopecia tell me that they are embarrassed and ashamed. Though there is no reason for this -- alopecia is not the woman’s fault. -- these feelings seem nearly universal with AGA. Some women with alopecia are even reluctant to go out of the house for fear that someone, even a stranger, might notice her hair is thin. When women share these  feelings with their doctors some end up being told to see a psychiatrist – but psychotherapy or psych meds will not make hair grow back. I am certainly not against these treatments for people who need them but my view is that women with alopecia deserve to be offered effective treatment, not simply be told to “learn to live with it.”

The meaning of hair
Hair represents youth, vitality, energy, even fertility -- attributes no woman wants to be without. By youth I do not mean any particular age but a sense of freshness and enthusiasm for life. My patients in their seventies value their hair quite as much as do twenty-five year olds.

Hair is the only part of the body which can be altered and shaped. Styling and coloring hair are forms of self-expression. Even the choice to do nothing with one’s hair but wash and comb it is still a way of showing one’s individuality.

Does it show?
Women with androgenic alopecia live in fear that others will notice I had a patient who would never go to the theater because she feared everyone would stare at the back of her head. (Her alopecia responded well, she started going out, got married, had children and now is quite content with her life.)

Yet most of the time, no one notices. This is not always reassuring to women with alopecia because they still worry that someone might notice. And if you have alopecia, you notice. We tend to think of our appearance as something for other people but it is oneself who first has to be pleased by how one looks.

Men seem not to notice if their wives or girlfriends have alopecia and are not much bothered by it if they do. On the other hand, many are sympathetic to the distress it causes and try to aid in finding help. Often, it is the patient’s partner who has heard of me and comes along for the first visit. This is not because they mind the alopecia; rather, they want to ease their partner’s distress by helping her find effective treatment.

Sexual orientation does not seem to affect how important hair is to a woman. Nor does personal style have much to do with it. One of my less conventional patients keeps her head shaved but is just as troubled by her alopecia. Even though her hairs are very short, she still wants them all there.

What Causes Female Alopecia?
Androgenic alopecia is caused by testosterone which is carried by the blood to the hair follicles of the scalp. There it is converted to a more active form called DHT (dihydrotestosterone) which somehow inactivates the follicle. Strictly speaking, the hair follicles still produce hairs but they are too tiny to be visible. This process is called miniaturization. After many years, the follicles disappear. For this reason, the sooner treatment can be started the better, but even when alopecia has been present for years there can still be some response to treatment.

Falling estrogen is the main cause of alopecia in menopause and beyond. If alopecia begins in the forties or later, there is good chance that it is due to lower estrogen levels, though occasionally the effect of androgens does not show up until this age. Sometimes both are involved.
What happens at menopause both biochemically and personally is discussed in the menopause article.

Iron deficiency Some believe that subtle iron deficiency can contribute to alopecia. I suggest taking a standard woman’s multiple vitamin with iron. Too much iron can be harmful so larger doses should only be taken by women whose tests have shown they are deficient.

Hair Care and Alopecia / Androgenic Alopecia
Many women wonder whether hair care products might be damaging their hair. With products now available in North America and Europe, this is most unlikely. In any case, they would only cause the hairs to break, not damage the follicle itself. If hair breaks off due to a bad perm, it will eventually grow back. Still, no one wants breakage so it is best to have your hair handled gently.

Hair Care with Androgenic Alopecia
Heat makes hair fragile. Use your blow dryer with the heat turned off.
Use a loose comb, not a brush. Don’t tug at your hair but separate tangles gently with your fingers.
Don’t bleach unless you absolutely must make your hair color lighter. Bleaches are hard on hair.
If your style requires pulling your hair back, as with a pony tail, braids or corn rows, do so extremely gently. Most women with these styles pull out some hairs inadvertently.

Many women with alopecia dread washing their hair because then they notice how much has come out. Hair washing does not cause shedding but it does make you more aware of it. Frequent washing keeps your hair in good condition.

The Workup for Androgenic Alopecia
For alopecia, the work-up starts with measuring total and free testosterone as well as DHEA-S. It’s a good idea also to check your blood count and iron levels. If you have other changes such as increased hair growth, oily skin and acne, irregular periods, more extensive workup is often indicated. These are discussed in the sections on hirsutism and on PCOS.

Most women with AGA have normal levels of testosterone and other androgens. Their problems is that their follicles over-react to testosterone. If you want to know more about this, check the section on unwanted hair. (Hormones and Unwanted Hair). However, even if testosterone and all other lab is normal, alopecia can still be successfully treated. Don’t believe it if you are told, “All your tests are normal; there’s nothing which can be done.”

Treatment
Oral contraceptives (OCs) These can lower free testosterone levels by about half. Some OCs seem to be better than others for women with androgenic alopecia. Though they sometimes help, OCs by themselves are not adequate treatment for AGA. Additional therapy is necessary.

Medications to block testosterone Because androgenic alopecia is due to the effects of testosterone, the logical treatment is to block testosterone. Several prescription medications have this action, though they are approved by the FDA for uses other than female alopecia. The most widely useful is spironolactone (Aldactone®). Finasteride (Propecia® and Proscar®) also seems to help androgenic alopecia but pregnancy must be absolutely avoided with this medication – or with spironolactone. These are discussed in more detail in the and PCOS sections. [Hormones and Unwanted Hair]

Minoxidil (Rogaine®) is the one medication officially approved for alopecia in women. Rogaine is non-prescription and comes in two strengths: 2% and 5%. The 5% is not usually recommended for women because if it gets on other skin, such as the forehead, it can cause hair to grow there. A more common problem is scalp flaking and irritation. Still, some women benefit from this higher strength. To tell if minoxidil is working takes three to nine months; not everyone sees a benefit.

The main problem with minoxidil is that it must be applied to the entire scalp twice a day. For men, this is not too difficult, but for women whose hair is almost always longer, it is easier said than done. Also, whatever hair comes in because of the minoxidil will fall out if it is discontinued. Minoxidil has its place in treatment of female alopecia, but I do not usually recommend it as the first choice unless nothing else is available for you.

Estrogen for alopecia If the problem is not testosterone but declining levels of estrogen, then estrogen is the logical treatment. It is important to point out that women under forty who are having normal cycles or who are on an OC are not likely to be estrogen deficient. Estrogen begins to fall only as menopause approaches, usually after age forty-five. Irregular or absent cycles can be a sign of lower estrogen but can also be due to PCOS or other conditions, so evaluation is necessary to tell which is going on.

Whether to take estrogen is a serious decision for women. The menopause section gives more information to help with this decision. as does my recent [What's Happening?  What Do I Do? A Guide To Menopause] One of the oddities of estrogen replacement is that different parts of the body require different amounts. The usual doses are based on what the bones and blood vessels seem to need. More is sometimes needed to fully control symptoms such as hot flashes, and hair follicles seem to need even more. This means that the dose of estrogen needed to help alopecia is sometimes more than the usual one. I frequently see women on low estrogen doses who continue to have hair shedding and progression of their alopecia. An increase in estrogen dose often stabilizes the hair and sometimes promotes regrowth.

Hormone replacement needs to be individualized; there is no one dose or form which is right for all women. It is important to work out what is right for you with a physician experienced with the subtle changes of menopause. For this reason, I do not here recommend specific forms or doses.

Women who have not had a hysterectomy also need to take a form of progesterone. The natural form is probably better for hair than some of the synthetics. If you want to know more about hormone replacement, check the article on this website. (What's Happening?  What Do I Do? A Guide To Menopause)

Alternative treatments Saw palmetto is thought to inhibit 5 alpha reductase, the enzyme which activates testosterone. It is mainly used by men for prostate enlargement and sometimes for male alopecia. It may work to some degree but experience in women is too limited to be sure. The problem with herbs is that there is no assurance that the preparation you buy is actually active. Herbs and supplements however are extremely valuable for certain other female conditions such as PMS and menopause. (Escaping The PMS Maze)

What not to take Anything with testosterone can make alopecia worse. Testosterone is sometimes used to help restore sex drive. The most popular form is a combination with estrogen called Estratest® and Estratest HS®. This sometimes helps libido but it can cause hair loss. Testosterone creams obtained from compounding pharmacies may produce very high blood levels and should be avoided.

DHEA, popular as a supplement, is converted in the body to testosterone and so should be avoided by women with androgenic alopecia.

What to Expect
There are no studies about overall effectiveness of treatment of alopecia since it gets little research attention. I can only go by my personal experience treating several thousand women in my practice over the past twenty years.

Is There Any Hope?
Many of the women who come to the Hormone Center of New York for alopecia have been told so often that nothing can be done that they are stunned when they find out that alopecia, whether androgenic or due to estrogen decline, can be helped. I’ve said this many times but it is so important that I must state it again: female hair loss is treatable. There are several treatments and while no medical treatment works for everybody, the odds are good that one will help. The important thing is to search for a doctor knowledgeable about hair loss – there are a few – have the necessary workup and then choose the treatment which makes sense to you.

Some Final Words
Alopecia is one of the most disturbing and at the same time, most neglected of female hormone problems. It is sad that so many women who desperately want help are told that nothing can be done, that they must just learn to live with it. However, the cause can usually be determined and there are treatments which usually help. The knowledge exists; why the medical profession ignores it is a mystery to me. If you have alopecia, do not let the common medical pessimism demoralize you.

Why Does Hair Loss Occur During Treatment? The normal scalp has 100,000 hairs! Some people have thin hair; others are blessed with thick hair. Ten to fifteen percent of your hair is in the resting phase. Eighty-five to ninety percent is actively growing and is susceptible to chemotherapy and radiation. The degree of hair loss depends on the chemotherapy drug, the dosage of chemotherapy or radiation, and how it is given.

Hair loss, or alopecia, occurs because anticancer drugs can also affect normal cells, including the cells responsible for hair growth. This effect, however, is not permanent, and healthy cells grow back normally once chemotherapy is completed.

What Are The Symptoms Of Hair Loss?

Chemotherapy: Hair loss, alopecia, will start approximately 2-3 weeks after your first dose of chemotherapy, but won't be total until 1-2 months have elapsed. Hair loss is reversible and will be back totally about 3-4 months after the last chemotherapy dose. Your hair may even grow while you're on chemotherapy. This doesn't mean that the chemotherapy isn't working. Unfortunately, some of this regrown hair may also fall out. Hair on the head is most commonly affected, but hair loss may also occur on the face, arms, legs, underarms, and pubic area. The scalp may become tender and hair that is still growing may become dull and dry.

Radiation: Only hair that is in a treatment field will be affected with hair loss. Generally, the hair loss will begin approximately 2-3 weeks after the start of treatments. This hair will grow back after the treatments are completed. If a higher dose of radiation is delivered, there is a chance that the hair loss will be permanent. Please check with your Radiation Oncologist or nurse if you have questions and concerns about this.

Some Suggestions about Hair Loss: Hair loss, even when expected, can be very discouraging and depressing. Many cancer support groups can offer advice and services to help you understand and handle all the effects of cancer, chemotherapy, and radiation.

• If you know hair loss is possible, shop for a wig before hair loss is experienced. You can always buy it when the hair loss occurs. It's easier to match hair color and style with your present head of hair.

• Sometimes hats, scarves, or turbans are more comfortable for indoor use. Get a variety.

• If you have long hair, you might consider getting a shorter haircut to minimize the trauma of hair loss. Shorter hair is easier to manage under a wig. A shorter style will make your hair look thicker and fuller. It will also make your hair loss easier to manage if it occurs.

• Use mild shampoos and conditioner.

• Use soft hairbrushes.

• Use low heat when drying your hair.
• You may use a dye rinse on your hair.
• Don't use permanent dye on your hair or get a permanent.
• Don't use brush rollers to set your hair.

• Remember that a hairpiece needed because of cancer treatment is a tax-deductible expense and may be at least partially covered by your health insurance. Be sure to check your policy and ask us for a wig prosthesis perscription.
  

Losing hair from your head, face, or body can be hard to accept. It's common and perfectly all right to feel angry or depressed about this loss. Talking about your feelings can help. Remember that the hair lost during treatment may grow back even thicker than ever.

Hair Stucture

Hair is composed of strong structural protein called keratin. This is the same kind of protein that makes up the nails and the outer layer of skin.

Each strand of hair consists of three layers.

Structure of the hair root

Below the surface of the skin is the hair root, which is enclosed within a hair follicle. At the base of the hair follicle is the dermal papilla. The dermal papilla is feed by the bloodstream which carries nourishment to produce new hair. The dermal papilla is a structure very important to hairgrowth because it contains receptors for male hormones and androgens. Androgens regulate hairgrowth and in scalp hair Androgens may cause the hair follicle to get progressively smaller and the hairs to become finer in individuals who are genetically predisposed to this type of hair loss.

The Hair Growth Cycle

Hair follicles grow in repeated cycles. One cycle can be broken down into three phases.

Each hair passes through the phases independent of the neighboring hairs.

Anagen Phase - Growth Phase

Approximately 85% of all hairs are in the growing phase at any one time. The Anagen phase or growth phase can vary from two to six years. Hair grows approximately 10cm per year and any individual hair is unlikely to grow more than one meter long.

Catagen Phase - transitional phase

At the end of the Anagen phase the hairs enters into a Catagen phase which lasts about one or two weeks, during the Catagen phase the hair follicle shrinks to about 1/6 of the normal length. The lower part is destroyed and the dermal papilla breaks away to rest below.

Telogen Phase - resting phase

The resting phase follows the catagen phase and normally lasts about 5-6 weeks. During this time the hair does not grow but stays attached to the follicle while the dermal papilla stays in a resting phase below. Approximately 10-15 percent of all hairs are in this phase at an one time.

At the end of the Telogen phase the hair follicle re-enters the Anagen phase. The dermal papilla and the base of the follicle join together again and a new hair begins to form. If the old hair has not already been shed the new hair pushes the old one out and the growth cycle starts all over again.

Because of significant surgical advances with improved results, interest in hair replacement surgery has increased significantly during the past decade. Hair loss affects two out of every three men, and one in five women. Some people begin to lose hair in their twenties. Frequent shampooing, poor circulation, wearing hats or any other personal habits are not factors that cause hair loss. For men, heredity is the major factor in hair loss. For women, hormonal changes, including those that occur in menopause, are mainly responsible for female "pattern changes," which include thinning and loss. Accidents, burns, and disease can also trigger hair loss. The key factor in hair replacement is the presence of donor hair on the side or the back scalp, which is then used to replace hair where loss has occurred. Total baldness makes replacement surgery impossible. Hair quality is another factor. Light-colored hair, as well as coarse-textured hair, produce a look of greater density than fine or dark hair.

If you've wondered how hair replacement surgery could improve your appearance and your self-confidence, you need to know how this surgery is performed and what you, as an individual, can expect from this procedure. This pamphlet can address many of your concerns and provide you the information to begin considering hair replacement surgery.

As with all facial plastic surgery, good health and realistic expectations are prerequisites. Understanding the limitations of the surgery is crucial. No ideal in hair replacement surgery exists. The goal is to improve your appearance as much as possible. Before deciding on hair replacement surgery, ask your facial plastic surgeon to explain the options available for your particular type of hair loss.

Male pattern baldness often begins with a receding hairline or thinning at the crown, and is the easiest condition to correct. It is progressive over a lifetime and is a major consideration for your surgeon. Hair replacement surgery frequently requires multiple grafts of hair being implanted during multiple sessions, generally spacing each session at least four months apart to allow for adequate healing.

The surgeon will explain which type of anesthesia is indicated. Facial plastic surgeons usually decide on a local or twilight anesthesia for grafting, but many surgeons choose general anesthesia for the more involved surgical procedures for replacing hair. The surgical facility to be used will also be determined by the extent of the procedure.

It is not essential to be bald or nearly bald before undertaking hair transplantation. Age also is no contraindication for hair transplantation. The younger the person, though, the more conservative the approach must be for transplantation, because the permanent donor site may not yet be established. Ideally, the patient should have dense growing hair in the donor sites to sufficiently fill any present or future areas of baldness.

The color of the hair in contrast to the skin color will be discussed with you by your surgeon. The texture of your hair, coarse or fine, will also determine the final result in hair transplantation.

However, the patients most satisfied with hair transplantation are those who will accept the estimate of improvement as given by the surgeon.

If you opt for surgery, your surgeon will describe the technique indicated, the type of anesthesia to be used, the surgical facility, any additional surgery, and risks and costs.

The most commonly known hair replacement surgery requires taking a strip of hair-bearing scalp from the back of the head. The strip is then divided into several hundred smaller grafts. These grafts are then inserted into tiny slits in the scalp, and must be placed in such a way that hair all grows in the same, natural direction. While some of the grafts may contain up to five or six hairs, it is sometimes necessary to use a number of grafts containing only one or two hairs to create a natural appearance. This is known as mini- and micrografting.

Skin flap surgery is another efficient technique used to cover balding areas. After a piece of bald scalp is removed, a section of hair-covered scalp is moved and sutured into place. Scars are generally covered by new hair growth. Bald spots at the crown of the head can be covered by removing the hairless area of skin and then stretching the hair-covered scalp adjacent to the bald spot over the opening. This is known as scalp reduction surgery.

A newer technique involves the use of tissue expanders. This allows stretching of the skin which aids in the reduction of the size of the bald scalp.

After surgery, your surgeon may choose to apply a dressing for a day or two. If stitches are used, they are usually removed within 10 days. The second or third day after surgery, you will probably be allowed to shampoo. Your head and scalp may feel tight with some aching, but this can be controlled by medication. It is crucial that you follow the instructions for post-operative visits and care. Swelling or bruising in the area treated is likely. Cold compresses may be recommended by the surgeon.

The newly transplanted hair often falls out in the six weeks following the procedure. This, however, is absolutely normal. New hair growth will take about six to 12 weeks to develop. To attain a look of natural hair growth, it is often necessary to fill in patchy areas, adjust the hairline, or remove excess tissue from areas that have been treated with flap surgery. These touch-up procedures are to be expected and are an essential part of the whole picture of hair replacement surgery.

Your facial plastic surgeon is the best source of information on what may be required for you as an individual and for your specific surgery. Facial plastic surgery makes it possible to correct many facial flaws and signs of premature aging. By changing how you look, cosmetic surgery can help change how you feel about yourself.

Insurance does not generally cover surgery that is done purely for cosmetic reasons. Surgery to correct hair loss from accidents, burns, disease, or trauma may be reimbursable in whole or in part. It is the patient's responsibility to check with the insurance carrier for information on the degree of coverage.

What causes hair loss?

Hair loss is believed to be primarily caused by a combination of:

• aging
• change in hormones
• illness
• family history of baldness
• burns
• trauma

Generally, the earlier hair loss begins, the more severe the baldness will become.

Hair loss is not caused by:

• poor circulation to the scalp
• vitamin deficiencies
• dandruff
• excessive hat-wearing
• a gene passed on from an individual's maternal grandfather

What is hair replacement surgery?

The interest in hair replacement has significantly increased over the past ten years. Two out of every three men and one in five women suffer from hair loss. For men, the main cause of a diminishing hairline is heredity. Hormonal changes such as menopause can cause both thinning and hair loss in women.

There are a number of hair replacement techniques that are available, although hair replacement surgery can not help those who suffer from total baldness. Candidates for hair replacement must have a healthy growth of hair at the back and sides of the head. The hair on the back and sides of the head will serve as hair donor areas where grafts and flaps will be taken.

There are four primary different types of hair replacement methods, including:

• hair transplantation - during hair transplantation the surgeon removes small pieces of hair-bearing scalp grafts from the back or sides of the head. These grafts are then relocated to a bald or thinning area.

• tissue expansion - in this procedure, a device called a tissue expander is placed underneath a hair-bearing area that is located next to a bald area. After several weeks, the tissue expander causes the skin to grow new skin cells. Another operation is then required placing the newly expanded skin over the adjacent bald spot.

• flap surgery - flap surgery is ideal for covering large balding areas. During this procedure a portion of the bald area is removed and a flap of the hair-bearing skin is placed on to the bald area while still attached at one end to its original blood supply.

• scalp reduction - scalp reduction is done in order to cover the bald areas at the top and back of the head. This technique involves the removal of the bald scalp with sections of the hair-bearing scalp pulled together filling in the bald area.

Possible complications associated with hair transplantation procedures:

• patchy hair growth
  Sometimes the growth of newly placed hair has a patchy look especially if it is placed next to a thinning area. This can often be corrected by additional surgery.

• bleeding and/or wide scars
  Tension on the scalp from some of the scalp reduction techniques can result in wide scars and/or bleeding.

• grafts not taking
  Occasionally there is a chance that the graft may not "take". If this is the case, surgery must be repeated.

• infection
  As in any surgical procedure there is the risk of infection.

About the procedure:

• Location options include:

• surgeon's office-based surgical facility
• outpatient surgery center
• hospital outpatient
• hospital inpatient

• Anesthetic options include:

• general anesthesia
• local anesthesia, combined with a sedative (allows the patient to remain awake but relaxed) for adults

• Probable length of procedure: Several surgical sessions are usually needed to achieve satisfactory fullness, with a healing interval of several months recommended between each session. It may take up to two years before seeing the final result with a full transplant series.

• Recovery period: Plugged or grafted hair falls out within a month or two after surgery, which is normal and almost always temporary. After hair falls out, it generally takes another month or more before hair growth resumes. A surgical touch-up procedure may be needed to create more natural-looking results after the initial incisions have healed. This may involve blending, a filling-in of the hairline using a combination of mini-grafts, micro-grafts, or slit grafts.

Your hair goes through a cycle of growth and rest. The course of each cycle varies by individual. But in general, the growth phase of scalp hair, known as anagen, typically lasts two to three years. During this time, your hair grows about 1 centimeter (just less than 1/2 inch) a month. The resting phase is called telogen. This phase typically lasts three to four months. At the end of the resting phase, the hair strand falls out and a new one begins to grow in its place. Once a hair is shed, the growth stage begins again.

Most people normally shed 50 to 100 hairs a day. But with about 100,000 hairs in the scalp, this amount of hair loss shouldn't cause noticeable thinning of the scalp hair.

Gradual thinning is a normal part of aging. However, hair loss may lead to baldness when the rate of shedding exceeds the rate of regrowth, when new hair is thinner than the hair shed or when hair comes out in patches.

Causes of specific types of hair loss

• Pattern baldness (androgenetic alopecia).
  • In male- and female-pattern baldness, the time of growth shortens, and the hairs are not as thick or sturdy. With each growth cycle, the hairs become rooted more superficially and more easily fall out. Heredity likely plays a key role. A history of androgenetic alopecia on either side of your family increases your risk of balding. Heredity also affects the age at which you begin to lose hair and the developmental speed, pattern and extent of your baldness.
  • Cicatricial (scarring) alopecia. This type of permanent hair loss occurs when inflammation damages and scars the hair follicle. This prevents new hair from growing. This condition can be seen in several skin conditions, including lupus erythematosus or lichen planus. It's not known what triggers or causes this inflammation.
  • Alopecia areata. This is classified as an autoimmune disease, but the cause is unknown. People who develop alopecia areata are generally in good health. A few people may have other autoimmune disorders including thyroid disease. Some scientists believe that some people are genetically predisposed to develop alopecia areata and that a trigger, such as a virus or something else in the environment, sets off the condition. A family history of alopecia areata makes you more likely to develop it. With alopecia areata, your hair generally grows back, but you may lose and regrow your hair a number of times.
  • Telogen effluvium. This type of hair loss is usually due to a change in your normal hair cycle. It may occur when some type of shock to your system — emotional or physical — causes hair roots to be pushed prematurely into the resting state. The affected growing hairs from these hair roots fall out. In a month or two, the hair follicles become active again and new hair starts to grow. Telogen effluvium may follow emotional distress, such as a death in the family, or after a physiological stress, such as a high fever, sudden or excessive weight loss, nutritional deficiencies, surgery, or metabolic disturbances. Hair typically grows back once the condition that caused it corrects itself, but it usually take months.
  • Traction alopecia. Excessive hairstyling or hairstyles that pull your hair too tightly cause traction alopecia. If the pulling is stopped before there's scarring of your scalp and permanent damage to the root, hair usually grows back normally.

  Other causes of hair loss

  • Poor nutrition. Having inadequate protein or iron in your diet or poor nourishment in other ways can cause you to experience hair loss. Fad diets, crash diets and certain illnesses, such as eating disorders, can cause poor nutrition.
  • Medications. Certain drugs used to treat gout, arthritis, depression, heart problems and high blood pressure may cause hair loss in some people. Taking birth control pills also may result in hair loss for some women.
  • Disease. Diabetes and lupus can cause hair loss.
  • Medical treatments. Undergoing chemotherapy or radiation therapy may cause you to develop alopecia. Under these conditions, healthy, growing (anagen) hairs can be affected. After your treatment ends, your hair typically begins to regrow.
  • Hormonal changes. Hormonal changes and imbalances can cause temporary hair loss. This could be due to pregnancy, having a baby, discontinuing birth control pills, beginning menopause, or an overactive or underactive thyroid gland. The hair loss may be delayed by three months following a hormonal change, and it'll take another three months for new hair to grow back. During pregnancy, it's normal to have thicker, more luxuriant hair. It's also common to lose more hair than normal about three months after delivery. If a hormonal imbalance is associated with an overproduction of testosterone, there may be a thinning of hair over the crown of the scalp. Correcting hormonal imbalances may stop hair loss.
  • Hair treatments. Chemicals used for dying, tinting, bleaching, straightening or permanent waves can cause hair to become damaged and break off if they are overused or used incorrectly. Overstyling and excessive brushing also can cause hair to fall out if the hair shaft becomes damaged.
  • Scalp infection. Infections, such as ringworm, can invade the hair and skin of your scalp, leading to hair loss. Once infections are treated, hair generally grows back. Ringworm, a fungal infection, can usually be treated with a topical or oral antifungal medication.
  • Trichotillomania (hair-pulling disorder). Trichotillomania is a type of mental illness in which people have an irresistible urge to pull out their hair, whether it's from their scalp, their eyebrows or other areas of their body. Hair pulling from the scalp often leaves them with patchy bald spots on their head, which they may go to great lengths to disguise. Causes of trichotillomania are still being researched, and no specific cause has yet been found.

Is there any treatment for hair loss?