Who Gets Alopecia Areata?

Anyone can have alopecia areata. It often begins in childhood. There is a slightly increased risk of having the disease if you have a close family member with the disease.

What Causes Alopecia Areata?

Alopecia areata is an autoimmune disease. Normally the immune system protects the body against infection and disease. In an autoimmune disease, the body's immune system mistakenly attacks some part of your own body. In alopecia areata, the immune system attacks the hair follicles.

The cause is not known. Scientists think that a person's genes may play a role. For people whose genes put them at risk for the disease, some type of trigger starts the attack on the hair follicles. The triggers may be a virus or something in the person's environment.

Will My Hair Ever Grow Back?

There is every chance that your hair will grow back, but it may fall out again. No one can tell you when it might fall out or grow back. You may lose more hair, or your hair loss may stop. The hair you have lost may or may not grow back. Even a person who has lost all of his hair may grow all of his hair back. The disease varies from person to person.

How Is Alopecia Areata Treated?

There is no cure for alopecia areata. There are no drugs approved to treat it. Doctors may use medicines approved for other diseases to help hair grow back. Talk to your doctor about the treatment that is best for you.

The following are some treatments for alopecia areata. They may help hair grow back, but none of them prevent new patches of hair loss or cure the disease.

Corticosteroids:

Corticosteroids are drugs that reduce swelling and pain. They also affect the immune system. Corticosteroids may be given in three ways for alopecia areata:

• Injected in the skin
• Swallowed as pills
• Rubbed on the skin as a cream or ointment.

Drugs that are rubbed on the skin as a cream or lotion include:

• Minoxidil (5%)
• Anthralin
• Squaric acid dibutyl ester (SADBE) and diphenylcyclopropenone (DPCP).

Drugs that affect the immune system include:

• Sulfasalazine
• Cyclosporine.

Photochemotherapy:

In photochemotherapy, a person is given a drug called a psoralen, which is affected by light. The drug can be swallowed or rubbed on the skin. Once the drug is taken or applied, the area with hair loss is exposed to an ultraviolet light source. This combined treatment is called PUVA.

Alternative therapies:

Some people with alopecia areata try other treatments. These alternatives include acupuncture, aroma therapy, evening primrose oil, zinc and vitamin supplements, and Chinese herbs. Because many alternative therapies have not been studied in clinical trials, they may or may not help hair grow back. In fact, some may cause more hair loss. Talk with your doctor before you try alternative therapies.

How Will Alopecia Areata Affect My Life?

Alopecia areata does not make you feel pain and does not make you feel sick. You can't give it to others. People who have the disease are, for the most part, healthy in other ways. Alopecia areata will not shorten your life, and it should not affect activities such as going to school, working, marrying, raising a family, playing sports, and exercising.

How Can I Cope With the Effects of This Disease

Living with hair loss can be hard. There are many things you can do to cope with the effects of this disease, including:

• Learning as much as you can about the disease.
• Talking with others who are dealing with the disease.
• Learning to value yourself for who you are, not for how much hair you have or don't have.
• Talking with a counselor, if necessary, to help build a positive self-image.

Here are some things you can use to reduce the physical dangers or discomforts of lost hair:

• Use sunscreens for the scalp, face, and all exposed skin.
• Wear eyeglasses (or sunglasses) to protect eyes from sun, and from dust and debris, when eyebrows or eyelashes are missing.
• Wear wigs, caps, or scarves to protect the scalp from the sun and keep the head warm.
• Apply antibiotic ointment inside the nostrils to help keep germs out of the nose when nostril hair is missing.

Here are some things you can do to reduce the disease's effects on your looks:

• Try wearing a wig, hairpiece, scarf, or cap.
• Use a hair-colored powder, cream, or crayon applied to the scalp for small patches of hair loss to make the hair loss less obvious.
• Use an eyebrow pencil to mask missing eyebrows.

What Research Is Being Done on Alopecia Areata?

Researchers are seeking a better understanding of the disease. Scientists are studying:

• Genes
• Hair follicle development
• The immune system
• Drugs and treatments for other autoimmune diseases like rheumatoid arthritis and lupus
• Better ways to get drugs directly to the hair follicles
• Stem cells in the skin.

(HealthDay News) -- Pattern baldness in men is the most common type of hair loss, and usually involves a receding hairline and baldness on the crown of the head. The condition is usually caused by hormonal and genetic factors.

Hair loss occurs when the hair follicle, a cavity in the skin, shrinks over time, says the U.S. National Library of Medicine. The individual hair in this follicle then becomes thinner and shorter, until eventually no hair is left in the follicle.

While there are no direct medical complications of pattern baldness, men who are uncomfortable with their physical appearance may opt for prescription medications that may stimulate the regrowth of hair and help reduce additional hair loss.

What Is Alopecia Areata?

Alopecia areata is considered an autoimmune disease, in which the immune system, which is designed to protect the body from foreign invaders such as viruses and bacteria, mistakenly attacks the hair follicles, the tiny cup-shaped structures from which hairs grow. This can lead to hair loss on the scalp and elsewhere.

In most cases, hair falls out in small, round patches about the size of a quarter. In many cases, the disease does not extend beyond a few bare patches. In some people, hair loss is more extensive. Although uncommon, the disease can progress to cause total loss of hair on the head (referred to as alopecia areata totalis) or complete loss of hair on the head, face, and body (alopecia areata universalis).

What Causes It?

In alopecia areata, immune system cells called white blood cells attack the rapidly growing cells in the hair follicles that make the hair. The affected hair follicles become small and drastically slow down hair production. Fortunately, the stem cells that continually supply the follicle with new cells do not seem to be targeted. So the follicle always has the potential to regrow hair.

Scientists do not know exactly why the hair follicles undergo these changes, but they suspect that a combination of genes may predispose some people to the disease. In those who are genetically predisposed, some type of trigger--perhaps a virus or something in the person's environment--brings on the attack against the hair follicles.

Who Is Most Likely To Get It?

Alopecia areata affects an estimated four million Americans of both sexes and of all ages and ethnic backgrounds. It often begins in childhood.

If you have a close family member with the disease, your risk of developing it is slightly increased. If your family member lost his or her first patch of hair before age 30, the risk to other family members is greater. Overall, one in five people with the disease have a family member who has it as well.

Is My Hair Loss a Symptom of a Serious Disease?

Alopecia areata is not a life-threatening disease. It does not cause any physical pain, and people with the condition are generally healthy otherwise. But for most people, a disease that unpredictably affects their appearance the way alopecia areata does is a serious matter.

The effects of alopecia areata are primarily socially and emotionally disturbing. In alopecia universalis, however, loss of eyelashes and eyebrows and hair in the nose and ears can make the person more vulnerable to dust, germs, and foreign particles entering the eyes, nose, and ears.

Alopecia areata often occurs in people whose family members have other autoimmune diseases, such as diabetes, rheumatoid arthritis, thyroid disease, systemic lupus erythematosus, pernicious anemia, or Addison's disease. People who have alopecia areata do not usually have other autoimmune diseases, but they do have a higher occurrence of thyroid disease, atopic eczema, nasal allergies, and asthma.

Can I Pass It on to My Children?

It is possible, but not likely, for alopecia areata to be inherited. Most children with alopecia areata do not have a parent with the disease, and the vast majority of parents with alopecia areata do not pass it along to their children.

Alopecia areata is not like some genetic diseases in which a child has a 50-50 chance of developing the disease if one parent has it. Scientists believe that there may be a number of genes that predispose certain people to the disease. It is highly unlikely that a child would inherit all of the genes needed to predispose him or her to the disease.

Even with the right (or wrong) combination of genes, alopecia areata is not a certainty. In identical twins, who share all of the same genes, the concordance rate is only 55 percent. In other words, if one twin has the disease, there is only a 55 percent chance that the other twin will have it as well. This shows that other factors besides genetics are required to trigger the disease.

To learn more about the genes and other factors involved in alopecia areata risk, the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) is funding an alopecia areata registry. The registry is an organized network of five centers throughout the United States that will identify and register patients with the disease and collect data and blood samples (which contain genes). Data, including genetic information, will be made available to researchers studying the genetic basis and other aspects of disease and disease risk. (For more information about the registry, see "How Can I Take Part In Research?")

Will My Hair Ever Grow Back?

There is every chance that your hair will regrow, but it may also fall out again. No one can predict when it might regrow or fall out. The course of the disease varies from person to person. Some people lose just a few patches of hair, then the hair regrows, and the condition never recurs. Other people continue to lose and regrow hair for many years. A few lose all the hair on their head; some lose all the hair on their head, face, and body. Even in those who lose all their hair, the possibility for full regrowth remains.

In some, the initial hair regrowth is white, with a gradual return of the original hair color. In most, the regrown hair is ultimately the same color and texture as the original hair.

What Can I Expect Next?

The course of alopecia areata is highly unpredictable, and the uncertainty of what will happen next is probably the most difficult and frustrating aspect of the disease. You may continue to lose hair, or your hair loss may stop. The hair you have lost may or may not grow back, and you may or may not continue to develop new bare patches.

How Is It Treated?

While there is neither a cure for alopecia areata nor drugs approved for its treatment, some people find that medications approved for other purposes can help hair grow back, at least temporarily. The following are some treatments for alopecia areata. Keep in mind that while these treatments may promote hair growth, none of them prevent new patches or actually cure the underlying disease. Consult your health care professional about the best option for you.

• Corticosteroids--Corticosteroids are powerful anti-inflammatory drugs similar to a hormone called cortisol produced in the body. Because these drugs suppress the immune system if given orally, they are often used in the treatment of various autoimmune diseases, including alopecia areata. Corticosteroids may be administered in three ways for alopecia areata:

  • Local injections--Injections of steroids directly into hairless patches on the scalp and sometimes the brow and beard areas are effective in increasing hair growth in most people. It usually takes about 4 weeks for new hair growth to become visible. Injections deliver small amounts of cortisone to affected areas, avoiding the more serious side effects encountered with long-term oral use. The main side effects of injections are transient pain, mild swelling, and sometimes changes in pigmentation, as well as small indentations in the skin that go away when injections are stopped. Because injections can be painful, they may not be the preferred treatment for children. After 1 or 2 months, new hair growth usually becomes visible, and the injections usually have to be repeated monthly. The cortisone removes the confused immune cells and allows the hair to grow. Large areas cannot be treated, however, because the discomfort and the amount of medicine become too great and can result in side effects similar to those of the oral regimen.

  • Oral corticosteroids--Corticosteroids taken by mouth are a mainstay of treatment for many autoimmune diseases and may be used in more extensive alopecia areata. But because of the risk of side effects of oral corticosteroids, such as hypertension and cataracts, they are used only occasionally for alopecia areata and for shorter periods of time.

  • Topical ointments--Ointments or creams containing steroids rubbed directly onto the affected area are less traumatic than injections and, therefore, are sometimes preferred for children. However, corticosteroid ointments and creams alone are less effective than injections; they work best when combined with other topical treatments, such as minoxidil or anthralin.

• Minoxidil (5%) (Rogaine*)--Topical minoxidil solution promotes hair growth in several conditions in which the hair follicle is small and not growing to its full potential. Minoxidil is FDA-approved for treating male and female pattern hair loss. It may also be useful in promoting hair growth in alopecia areata. The solution, applied twice daily, has been shown to promote hair growth in both adults and children, and may be used on the scalp, brow, and beard areas. With regular and proper use of the solution, new hair growth appears in about 12 weeks.

  *Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

• Anthralin (Psoriatec)--Anthralin, a synthetic tar-like substance that alters immune function in the affected skin, is an approved treatment for psoriasis. Anthralin is also commonly used to treat alopecia areata. Anthralin is applied for 20 to 60 minutes ("short contact therapy") to avoid skin irritation, which is not needed for the drug to work. When it works, new hair growth is usually evident in 8 to 12 weeks. Anthralin is often used in combination with other treatments, such as corticosteroid injections or minoxidil, for improved results.

• Sulfasalazine--A sulfa drug, sulfasalazine has been used as a treatment for different autoimmune disorders, including psoriasis. It acts on the immune system and has been used to some effect in patients with severe alopecia areata.

• Topical sensitizers--Topical sensitizers are medications that, when applied to the scalp, provoke an allergic reaction that leads to itching, scaling, and eventually hair growth. If the medication works, new hair growth is usually established in 3 to 12 months. Two topical sensitizers are used in alopecia areata: squaric acid dibutyl ester (SADBE) and diphenylcyclopropenone (DPCP). Their safety and consistency of formula are currently under review.

• Oral cyclosporine--Originally developed to keep people's immune systems from rejecting transplanted organs, oral cyclosporine is sometimes used to suppress the immune system response in psoriasis and other immune-mediated skin conditions. But suppressing the immune system can also cause problems, including an increased risk of serious infection and possibly skin cancer. Although oral cyclosporine may regrow hair in alopecia areata, it does not turn the disease off. Most doctors feel the dangers of the drug outweigh its benefits for alopecia areata.

• Photochemotherapy--In photochemotherapy, a treatment used most commonly for psoriasis, a person is given a light-sensitive drug called a psoralen either orally or topically and then exposed to an ultraviolet light source. This combined treatment is called PUVA. In clinical trials, approximately 55 percent of people achieve cosmetically acceptable hair growth using photochemotherapy. However, the relapse rate is high, and patients must go to a treatment center where the equipment is available at least two to three times per week. Furthermore, the treatment carries the risk of developing skin cancer.

• Alternative therapies--When drug treatments fail to bring sufficient hair regrowth, some people turn to alternative therapies. Alternatives purported to help alopecia areata include acupuncture, aroma therapy, evening primrose oil, zinc and vitamin supplements, and Chinese herbs. Because many alternative therapies are not backed by clinical trials, they may or may not be effective for regrowing hair. In fact, some may actually make hair loss worse. Furthermore, just because these therapies are natural does not mean that they are safe. As with any therapy, it is best to discuss these treatments with your doctor before you try them.

In addition to treatments to help hair grow, there are measures that can be taken to minimize the physical dangers or discomforts of lost hair.

• Sunscreens are important for the scalp, face, and all exposed areas.
• Eyeglasses (or sunglasses) protect the eyes from excessive sun, and from dust and debris, when eyebrows or eyelashes are missing.
• Wigs, caps, or scarves protect the scalp from the sun and keep the head warm.
• Antibiotic ointment applied inside the nostrils helps to protect against organisms invading the nose when nostril hair is missing.

How Will Alopecia Areata Affect My Life?

This is a common question, particularly for children, teens, and young adults who are beginning to form lifelong goals and who may live with the effects of alopecia areata for many years. The comforting news is that alopecia areata is not a painful disease and does not make people feel sick physically. It is not contagious, and people who have the disease are generally healthy otherwise. It does not reduce life expectancy and it should not interfere with the ability to achieve such life goals as going to school, working, marrying, raising a family, playing sports, and exercising.

The emotional aspects of living with hair loss, however, can be challenging. Many people cope by learning as much as they can about the disease; speaking with others who are facing the same problem; and, if necessary, seeking counseling to help build a positive self-image. To address quality-of-life issues for alopecia areata and all other skin diseases, the NIAMS sponsored a scientific meeting in September 2002 on the burden of skin diseases.

How Can I Cope With the Effects of This Disease?

Living with hair loss can be hard, especially in a culture that views hair as a sign of youth and good health. Even so, most people with alopecia areata are well-adjusted, contented people living full lives.

The key to coping is valuing yourself for who you are, not for how much hair you have or don't have. Many people learning to cope with alopecia areata find it helpful to talk with other people who are dealing with the same problems. More than four million people nationwide have this disease at some point in their lives, so you are not alone. If you would like to be in touch with others with the disease, the National Alopecia Areata Foundation (NAAF) can help through its pen pal program, message boards, annual conference, and support groups that meet in various locations nationwide. To find contact information for NAAF and other organizations that can help people with alopecia areata, see "Where Can I Learn More About Alopecia Areata?".

Another way to cope with the disease is to minimize its effects on your appearance. If you have total hair loss, a wig or hairpiece can look natural and stylish. For small patches of hair loss, a hair-colored powder, cream, or crayon applied to the scalp can make hair loss less obvious by eliminating the contrast between the hair and the scalp. Skillfully applied eyebrow pencil can mask missing eyebrows.

Children with alopecia areata may prefer to wear bandanas or caps. There are many styles available to suit a child's interest and mood-some even have ponytails attached.

For women, attractive scarves can hide patchy hair loss; jewelry and clothing can distract attention from patchy hair; and proper makeup can camouflage the effects of lost facial hair. If you would like to learn more about camouflaging the cosmetic aspects of alopecia areata, ask your doctor or members of your local support group to recommend a cosmetologist who specializes in working with people whose appearance is affected by medical conditions.

Is Research Close to Finding Better Treatments or a Cure?

While a cure is not imminent, researchers are making headway toward a better understanding of the disease. This increased understanding will likely lead the way to better treatments for alopecia areata and eventually a way to prevent or even cure it.

Alopecia research ranges from the most basic studies of the mechanisms of hair growth and hair loss in mice to testing medications and ways to apply medications to help regrow hair in people. Both the National Institutes of Health and the National Alopecia Areata Foundation support research into the disease and its treatment. Here are some areas of research that hold promise.

• Developing an animal model--This is a critical first step toward understanding the disease, and much progress has been made. By developing a mouse with a disease similar to human alopecia areata, researchers hope to learn more about the mechanism of the disease and eventually develop immune system treatments for the disease in people.

• Mapping genes--Scientists are studying the possible genetic causes and mechanism of the disease both in families that have one or more persons with the disease and in the general population. An understanding of the genetics of the disorder will aid in disease prevention, early intervention, and development of specific therapies.

• Studying hair follicle development--By studying how hair follicles form in mouse embryos, researchers hope to gain a better understanding of hair cycle biology that may lead to treatments for the underlying disease process.

• Targeting the immune system--Several new agents found to be effective in treating psoriasis may prove to be effective in alopecia areata. These drugs work by blocking certain chemical messengers that play a role in the immune response, or by interfering with the activity of white blood cells (called T-cells) that are involved in the immune system's attack on hair follicles. New therapies for treating other autoimmune diseases like rheumatoid arthritis and lupus may also benefit patients with alopecia areata.

• Finding better ways to administer drugs--One limitation of current topical therapies is getting the drug to the source of the problem. Scientists are looking for a substance that penetrates the fat under the skin to deliver medication directly to hair follicles. In laboratory animals, topically applied synthetic sacs called liposomes seem to fill the bill. Studies are still needed to show whether liposomes do the same for people.

• Understanding cytokines--Chemical messengers called cytokines play a role in regulating the body's immune response, whether it is the normal response to a foreign invader such a virus or an abnormal response to a part of the body. Researchers believe that by giving certain inflammation-suppressing cytokines, they may be able to slow down or stop the body's abnormal response to the hair follicles. Because giving the cytokines systemically may cause adverse effects, they believe a topical medication using liposomes to get the agents to the root of the hair inside the follicle may be preferable.

• Understanding stem cell biology--Epithelial stem cells are immature cells that are responsible for regenerating and maintaining a variety of tissues, including the skin and the hair follicles. Stem cells in the follicle appear to be spared from injury in alopecia areata, which may explain why the potential for regrowth is always there in people with the disease. By studying the biology of these cells, and their immediate offspring, which seem to be targeted by the immune system, scientists hope to gain a better understanding of factors that trigger the disease.

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Information Clearinghouse National Institutes of Health

1 AMS Circle
Bethesda,  MD 20892-3675
Phone: 301-495-4484
Toll Free: 877-22-NIAMS (226-4267)
TTY: 301–565–2966
Fax: 301-718-6366
Email: NIAMSinfo@mail.nih.gov
Website: http://www.niams.nih.gov

The registry has been established by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the National Institutes of Health (NIH). The new registry will be located at the University of Texas M.D. Anderson Cancer Center in Houston, with affiliated centers at UCSF, the University of Colorado, University of Minnesota, and Columbia University.

Vera H. Price, MD, professor of clinical dermatology, is the UCSF collaborator for the national project.

Alopecia areata is an autoimmune disease, one in which the body's natural defense system attacks healthy cells. In alopecia areata, the target of the attack is the hair follicle, and the result is hair loss ranging from patchy baldness to complete loss of all scalp and body hair. It affects both males and females of all races, and often begins in childhood. There is no known permanent cure.

Registry scientists will seek out and classify medical and family history data for patients with three major forms of alopecia areata: alopecia areata (patchy scalp hair loss); alopecia totalis (100 percent scalp hair loss); and alopecia universalis (100 percent scalp and 100 percent body hair loss). Families with multiple affected members will be especially helpful to further research studies. The project will offer a future central information source where researchers can obtain statistical data associated with the disease. A website is currently being developed for the registry.

The registry will serve as a liaison between affected families and investigators interested in studying this disorder. Scientists hope the registry will be useful in locating the gene or genes associated with alopecia areata. It will also link patients with other researchers studying the cause or treatment of this disease.

Hair loss can be further classified as localized or diffuse and scarring or nonscarring.

History and physical examination, including determination of the pattern of hair loss
Localized, Nonscarring Alopecia
Tinea capitis presents with erythema, scaling and broken hair shafts on exam. Evaluation includes KOH or fungal culture of broken hair shaft and appropriate oral antifungal treatment.
Alopecia areata presents as smooth round bald patches in the scalp, beard area, or eyebrows. Evaluation includes TSH, CBC, and RPR to evaluate for associated autoimmune disease or syphilis.  The condition is self limited but referral for treatment is appropriate for multiple areas of involvement or large surface area involved.
Traumatic alopecia includes trichotillomania and traction alopecia.  Treatment involves pinpointing the underlying cause and emphasizing behavior modification.

Diffuse, Nonscarring Alopecia
Telogen effluvium is diffuse hair loss caused by any condition or situation that shifts the normal distribution of follicles in anagen (growing phase) to a telogen (hair no longer living phase)-predominant distribution. Usually begins two to four months after the causative event and lasts for several months.  If telogen effluvium is suspected, a thorough history should be obtained to elucidate recent event (childbirth, crash or liquid protein diets, high fever, major surgery, severe psychological stress) Condition is self-limited and treatment is based on identifying and treating or correcting the underlying cause.
Androgenetic alopecia (common balding). Male pattern alopecia is characterized by a receding hairline and/or hair loss on the top of the head. A similar type of hair loss in women, female pattern alopecia, results in thinning hair on the vertex (top) of the scalp  or widening of the part but is generally less severe than occurs in males; no medical treatment required; patient may purchase minoxidil lotion (over the counter) for cosmesis and should use it for up to 4 months to see if it is effective.
Other causes of diffuse nonscarring alopecia: systemic lupus, syphilis (moth-eaten alopecia), hypothyroidism, anemia, low iron states, poor nutrition, and medications.

Scarring Alopecia
Discoid lupus, folliculitis decalvans, dissecting cellulitus, lichen planus, central centrifugal scarring alopecia (follicular degeneration syndrome).

Primary care treatment should include documented assessment of hair loss pattern and whether scarring (loss of follicular orifices) is noted. 
Appropriate lab work-up may include: TSH, RPR, ANA, CBC, iron panel, ferritin.

1. Scalp exam for any scars, erythema, scaling, or inflammation Density and distribution of hair Hair shaft exam for caliber, length, shape, and fragility Thyroid palpation to determine thyroid size, nodularity, or vascularity

If a patient demonstrates positive hair-pull tests all over the scalp, he/she may be warned he/she will most likely lose all of their hair. Next, provide anticipatory guidance during the period of extensive hair loss as the cycle reestablishes and regrowth begins.

Finally, determine if eyebrow, eyelash, axillary, or body hair is affected. Examine hair density in other areas such as the face and extremities. A female patient who presents with thinning scalp hair and demonstrates increased facial, thigh, chin, or chest hair may have an androgen excess.

Laboratory Studies

Once other causes such as malnutrition, androgenetic, hereditary conditions (by history, progression, and presentation), trauma (trichotillomania, traction alopecia), and drugs (telogen effluvium) have been ruled out, consider labs for secondary conditions:

• For female alopecia with symptoms of hyperandrogenism (such as menstrual irregularities, infertility, cystic acne, virilization, or galactorrhea), check total testosterone, free testosterone, dehydroepiandrosterone sulfate (DHEA-S), or prolactin levels. For male and female alopecia without symptoms of hyperandrogenism, consider measurement of serum thyroid stimulating hormone concentration to rule out thyroid disease; venereal disease research laboratory (VDRL) technique to rule out syphilis; serum ferritin to rule out anemia; antinuclear antibody test (ANA), RF (rheumatoid factor) to rule out autoimmune disease; potassium hydroxide (KOH) examination to rule out tinea capitis; swab a wound culture to rule out infections; and scalp biopsy as needed to rule out neoplasm.

Disorders Causing Hair Loss in Adults

• Androgenetic alopecia
  • Male: Hereditary. Dihydrotestosterone compels follicles into perpetual telogen phase. The earlier oral or topical treatment is started, the better results one may expect. Female: Female androgenetic pattern incidence increases with age. Incidence is approximately 6% in women under 50, but increases to 38% in women over 70. Female pattern hair loss typically demonstrates a lower density of hair but maintains a relatively even distribution, known as "Ludwig" distribution. Even thinning across the crown is typical, while the frontal line maintains position.
  Telogen effluvium
  • Telogen effluvium is the most common form of diffuse alopecia. It is often diagnosed from a history of an initiating event 3 months before the onset of shedding. Causes include childbirth, sustained high fever, surgery, systemic disease exacerbation, crash low protein diets, severe emotional stress, and drug reactions. Pull tests are positive all over the scalp. Bitemporal recession is a useful diagnostic sign in women. The acute form normally subsides in 3 to 6 months. In true telogen effluvium, the hair invariably regrows within a short time.
  Postpartum telogen effluvium
  • This condition is associated with postpartum hormone-related changes that temporarily prolong hair resting phase. It is most commonly seen 2 to 4 months postpartum.
  Anagen effluvium
  • Anagen effluvium is drug or toxin-induced and may mimic diffuse alopecia areata. Chemotherapy is the most common cause.
  Trichotillomania
  • Trichotillomania is the manifestation of a psychogenic behavioral pattern of frequent hair-pulling by the patient. It is frequently related to obsessive-compulsive disorder and can be seen in males and females of all ages, but most commonly in preadolescent and early adolescent girls. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The bald area manifests as a distinct, unnatural geometric shape. Hair may be pulled from a secondary site, such as the eyelashes, eyebrows, underarms, body, or pubis. Assess for other psychosocial factors and disorders and refer for counseling as indicated. Diagnostic and Statistical Manual-IV (DSM-IV) Criteria for Trichotillomania:
    • Recurrent pulling out of one's hair, resulting in untreatable hair loss Increasing sense of tension immediately before pulling out the hair or when attempting to resist behavior Pleasure, gratification, or relief when pulling out the hair The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatologic condition).
  Alopecia areata
  • Alopecia areata is an inherited autoimmune condition of varying severity. In some patients, hair loss is confined to one or more small oval patches; in others, the scalp is essentially denuded except for a few tufts of hair. It may involve the entire scalp (alopecia totalis) or the surface of the whole body (alopecia universalis). The condition is marked by exacerbation and recovery with high variability among individuals.
  Tinea capitis
  • Tinea capitis is a contagious fungal infection of the scalp mostly seen in ages 4 to 14 years. There are fine, scaly, circumscribed areas that are frequently itchy and inflamed. Hair is dull and brittle, breaking off at scalp. In more extensive cases, there may be fever and cervical lymphadenopathy. In the United States, over 90% of cases are from the nonfluorescent Trichophyton fungus. Potassium hydroxide (KOH) examination shows hyphae. Antifungals such as terbinafine, fluconazole, itraconazole, or griseofulvin are used for treatment.
  Systemic lupus erythematosus (SLE)
  • SLE is a chronic autoimmune inflammatory disease affecting collagen. It involves multiple systems of the body including hair loss.
  Secondary syphilis
  • Secondary syphilis usually begins 2 to 8 weeks after chancre type lesions appear. It can present with patchy hair loss, mostly on the scalp and often elsewhere on the body. This hair loss is often described as having a moth-eaten appearance. High-risk clients should also be questioned regarding past rashes, especially on the palms, soles, and any chancroid lesions or condyloma. Diagnosis is serologic (VDRL or rapid plasma regain [RPR]), and hair regrowth occurs after penicillin therapy. Penicillin remains the first choice, but if an allergy exists, intramuscular Rocephin (x 10 days), tetracycline, or doxycycline may be tried for 2 weeks.
  Side effects of medications
  • Medications such as cytotoxic agents, colchicine, heparin, oral anticoagulants, hydroxyurea therapy, vitamin A, captopril, protease inhibitors such as indinavir and nelfinavir, amphetamines, anticancer agents, gout medication, isotretinoin (Accutane), lithium, male hormones, propranolol hydrochloride (Inderal), and valproic acid (Depacon, Depakene, Depakote), can all induce nonscarring hair loss.
  Birth control pills
  • Women who lose hair while taking birth control pills may have an inherited tendency for hair thinning. If hair thinning occurs, a woman can consult her gynecologist about switching to another birth control pill. When a woman stops using oral contraceptives, she may notice that her hair begins shedding two or three months later. This may continue for six months when it usually stops. This is similar to hair loss after the birth of a child.
  Caustic chemicals
  • Anyone who curls, straightens, colors, or dyes their hair may cause hair loss. Repeated exposure to these substances can injury hair follicles, weaken hair, or even damage the scalp. It is most often seen in African women, and inflammation is not always obvious.
  High fever or severe infection
  • Acute and some chronic illnesses may cause hairs to enter a prolonged resting telogen phase (also known as telogen effluvium). It is not uncommon to experience a higher incidence of hair loss up to three months after high fever, severe illness, or infection. This resting phase typically resolves after several months and normal hair growth rebounds when the growth cycle returns.
  Other causes of hair loss
  • Other causes of hair loss include anemia, hypoalbuminemia, malnutrition, Lichen planus, Staphylococcal folliculitis, scleroderma, psoriasis, seborrhoeic dermatitis, menopause, hypothyroidism, herpes zoster, and others.

Treatment Recommendations

The choice of therapeutic intervention for alopecia depends on several factors:

• The underlying cause The goals of therapy The long-term risks, benefits, costs

The evaluation and treatment of alopecia should begin as early as possible after the onset of symptoms. Many conditions causing alopecia or reduced hair density may be reversed or minimized with prompt intervention.

Pharmacologic – Treatment of the Underlying Illness

• Hypothyroidism
  • Thyroid replacement or adjustment as indicated
  Fungal infection
  • Ketoconazole, oral antifungal agents such as griseofulvin (Grifulvin), itraconazole (Sporanox), terbinafine (Lamisil), and fluconazole (Diflucan) may be used. Oral steroids may be necessary to decrease inflammation and scarring.
  Hormone imbalance
  • If female androgen excess is suspected (hirsutism, acne) or menses is irregular, check DHEA-S and free testosterone levels first to rule out adrenal or ovarian cancer. Once ruled out, consider spironolactone, flutamide, or finasteride. Spironolactone competes with testosterone and dihydrotestosterone at the androgen receptor level. Spironolactone 100 mg per day can be given in divided doses; this dose may be increased to 200 mg. Flutamide (Eulexin), an antiandrogen that blocks androgen uptake and nuclear binding, is a very effective drug in treating hyperandrogenism. Give 250 mg daily and monitor hepatotoxicity. Finasteride (Propecia) blocks the conversion of testosterone to dihydrotestosterone. The plasma levels of testosterone may increase during treatment, whereas the dihydrotestosterone level decreases. Of utmost importance, the patient should be aware that she must avoid pregnancy during treatment with finasteride because of the potential for causing ambiguous genitalia in a male fetus.
  Drug-induced hair loss (effluvium)
  • Drugs that induce hair loss include antihypertensive agents, anti-gout medications, etc. Consider tapering or discontinuing the medication if untoward risks are low.
  Chemotherapy
  • Recommend nonpharmacologic therapy (wig, hairpiece).
  Psychological causes of hair loss (Trichotillomania)
  • Consider behavioral therapy, antianxiety or antidepressant medication, or any combination of the two.
  Physical stress from surgery/acute illness
  • Reassure patient hair regrowth once stress removed.
  Lupus and diabetes
  • Treat underlying diseases.
  Traction alopecia
  • Hair loss that is secondary to grooming such as tight braids, "cornrows," pony tail: Change hair styling technique.
  Drug therapy for alopecia (alopecia with no underlying disease)
  • Minoxidil (Rogaine 2% for women, Rogaine 5% for men): Apply 1 mL twice a day (BID) regardless of the extent of the affected area; one year of use may be needed before obvious efficacy. Minoxidil is mainly for hair loss at vertex, not for frontal baldness. Propecia (finasteride 1 mg): Food and Drug Administration (FDA) approved; for MEN ONLY Monotherapy or synergistic use:
    • For women - May add estrogen to any therapy For men/women - May add tretinoin (Retin-A) topical as an adjunct/synergistically with minoxidil

Nonpharmacologic Treatment

• Cosmetic measures (hairstyle adjustments, wigs, extensions, hair pieces, hats, scarves) Cessation of wearing tight braids, buns, pins In chemical/allergic causes, avoidance of the identified sources

Monitoring Treatment/Discontinuation of Treatment

Patients with Hypothyroidism

Initiate thyroid hormone replacement therapy to obtain thyroid-stimulating hormone (TSH), triiodothyronine (T3), and thyroxine (T4) in the normal range. Treatment will be long term, even as hair regrowth occurs. Monitor hair regrowth in each follow up with hypothyroidism.

Patients Considered for Treatment Related to Fungal Infection

If long-term antifungal treatment is required, monitor liver function and gastrointestinal (GI) symptoms. Obtain baseline alanine aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin before treatment. Reevaluate in 4 to 8 weeks. Discontinue if there are any GI symptoms or signs of liver dysfunction such as fatigue, nausea, anorexia, vomiting, dark urine, or pale stools. Monitor drug interactions when patients have comorbidities and are using other medications. Check safety of different antifungals on women in childbearing ages.

Patients with Androgenetic Imbalance

Monitor hepatotoxicity if the patient is treated with flutamide. Monitor irregular menses, reduced libido, mood swings, and electrolytes if treated with spironolactone.

Patients on Medications for Hair Loss

Minoxidil (Rogaine) - Topical use

Since its mechanism of action is to stimulate hair growth by vasodilation, it may exacerbate angina pectoris. Use with caution in patients with pulmonary hypertension, congestive heart failure, coronary artery disease, and significant renal failure. Topical use may also cause pruritus, and Stevens-Johnson syndrome.

Finasteride (Propecia)

Give 1 mg daily (QD) with or without food to MALE patients only. Pregnant women or women who may potentially become pregnant should not touch crushed tablets because of teratogenic effects on male fetus. Monitor hepatic function. Potential side effects include decreased libido and erectile dysfunction.

Steroids (e.g. prednisone)

Side effects of steroids include diabetes, weight gain, hypertension, electrolyte and fluid imbalance, osteoporosis, striae, acne, renal function impairment, avascular necrosis, and immunosuppression. Abrupt discontinuation may cause adrenal crisis.

Individualization of Therapy

• The Women's Androgenetic Alopecia Quality of Life Questionnaire (WAA-QOL) is useful in evaluating health-related quality of life (HRQOL) specific to women. It is self-completed in about 10 minutes and may serve both to indicate the impact on the patient (and potential indication for intervention) and evaluate therapeutic responses to therapy. Decide whether the patients want to use topical treatment or oral treatment. Patients at different ages may have preferences. The hair growth cycle is slow. Affected changes take time to notice. Once therapy is selected, stick with it for 3 to 6 months and then reevaluate. Treatment follow-up (3- to 6-month intervals). Adjust therapy and identify causes if inadequate response.

Important Considerations

Cosmetic management and psychosocial adaption

• Regrowth of new or thicker hair for larger scalp coverage Decreased rate of hair loss (i.e., slow down balding progression) Surgical reconstruction Cost and side effects of drug therapy Tolerability of therapy (patient satisfaction with care, quality of life, and adherence to treatment regimen) Final assessment and evaluation including hair density readings Assessment of patient satisfaction as measured by quality of life index

Screening and diagnosis

Routine laboratory tests help to determine the presence of underlying causes and risk factors that would affect treatment. Optional tests may be used, depending on findings obtained in the history and physical examination and previously known conditions. A greater, more inclusive assessment can be determined by referral to dermatology.

Informed guidance to treatment options

Clinicians should begin by providing the patient with a summary of information on:

• Causes of hair loss and their respective potential to respond to medical therapies Details of what therapeutic options involve, including directions for use, potential side effects, interactions, timeline for responses, follow-up visits, financial expense, and long-term outcomes

Evaluate treatment goals

The primary objective of treatment is to reach therapeutic responses as closely to patient goals within budget and expectation that is both understood and acceptable by the informed patient. To modify drug therapy and maximize response toward patient goals, clinicians should consider cost where therapeutic effect is equal. To facilitate compliance, clinicians should choose medications with simple regimens.

Therapeutic adjustment and further individualization

• Titrate drug or add another agent if there is good tolerance but poor response. Allow for several weeks to two months before drug or dosage changes are made. If the response remains less than anticipated, substitute with a drug of a different class or action. Always consider alternative explanations for poor response to drug therapy to explore secondary causes. In each patient encounter, reassess adherence, quality of life, and patient goals. Assess the long-term response to therapy. Reassess side effects that might complicate therapy or limit efficacy. Monitor the development of target organ damage. Reinforce lifestyle modification.

Evaluate the efficacy of therapy

• To assess adequacy of hair growth, use an objective measurement tool such as a scalp chart, comparison with before-treatment photos, and a subjective self-assessment of quality of life before and after treatment. Patients should be seen within 1 or 2 months after the initiation of therapy to determine therapeutic response, degree of patient adherence, and presence of adverse effects. Earlier follow-up may be necessary for patients with underlying comorbid conditions. Once the patient's response is observed, follow-up at 3- or 6-month intervals (depending on the patient status) is generally appropriate. Consider referral or consultation in unresponsive or complex comorbid cases.

by Devera Pine

"It's one of the leading ways people can establish their individuality and express their style," says Jerome Shupack, M.D., professor of clinical dermatology at New York University Medical Center in New York City. "Hair has had sociological importance throughout the ages."

Because of its importance, anything that happens to our hair that we can't control--falling out or turning gray, for instance--can be the source of much anxiety.

In the United States, some 35 million men are losing or have lost their hair from male-pattern baldness, according to the American Hair Loss Council. Approximately 20 million women have experienced a similar loss of hair (from female-pattern hair loss), and an estimated 2.5 million Americans have lost their hair due to other causes.

THE BASICS

Hair is produced by hair follicles--indentations of the epidermis (outer skin layer) that contain the hair root, the muscle attached to it, and sebaceous, or oil, glands. Hair is made up of dead cells filled with proteins, most of which are known as keratins. The cells are woven together like a rope to form the hair fiber. The hair fiber, in turn, has three layers: the outer cuticle with its fish-scale-like structure; the cortex, which contains the bulk of the fiber; and the center, or medulla. Hair color is determined by melanocytes, cells that produce pigment. When these cells stop producing pigment, hair turns gray.

Although it seems as if the hair on your head is always growing, hair actually has active and rest phases. The growth phase, known as anagen, lasts for two to six years. At any given time, about 90 percent of scalp hair is in the growth stage. The remainder is in the rest phase, known as telogen; this lasts from two to three months.

Once the rest phase is over, the hair strand falls out and a new one begins to grow. As a result, it's considered normal to lose from 20 to 100 hairs a day, says Diana Bihova, M.D., a dermatologist in private practice in New York City. Only a change in your regular pattern of loss is considered abnormal--but many things, including genetic factors, diet, stress, and medications, can change that pattern.

BALDNESS: MANIFEST DESTINY?

The most common cause of hair loss in both men and women is rooted in a genetic predisposition. Called androgenic alopecia, it is known as male-pattern baldness in men and female-pattern hair loss in women (alopecia is the scientific term for baldness). According to the American Hair Loss Council, genetics accounts for 95 percent of all cases of hair loss in this country.

Baldness results from a combination of genetic factors and levels of testosterone (a hormone produced by the adrenal gland in both sexes and also by the testes in men). If hormone levels are right, then the hair follicles will express their genetic destiny by growing for shorter periods and producing finer hairs. In men, who have higher levels of testosterone than women, this eventually results in a bald scalp at the crown of the head and a horseshoe-shaped fringe of hair remaining on the sides. In women, the hair thins all over the scalp; the hairline does not recede. This type of hair loss doesn't usually show up in women until menopause; until then, estrogen tends to counteract the effects of testosterone.

TRANSPLANTS

Baldness can also be treated with hair transplants, in which plugs of "donor" follicles from the patient's scalp are used to fill the hairline. Although hair transplants work well in both men and women, the treatment tends to have a more dramatic effect on appearance in men with bald spots than it does on women with thinning hair.

"The less hair you have, the more drama in the change," says Robert Auerbach, M.D., associate professor of clinical dermatology at New York University School of Medicine. However, the American Hair Loss Council warns against attempting to replace lost hair with hair pieces sutured to the scalp. FDA has not approved any products specifically intended for this purpose, however, this does not preclude a physician from using sutures, which are approved devices, for this purpose. According to the council, although the procedure is legal, it can result in scars, infections and even brain abscesses.

Another treatment for male-pattern baldness, hair implants made of high-density artificial fibers surgically implanted in the scalp, was banned by the FDA in 1984 because it causes infection. This is the only device FDA has ever banned.

PRODUCTS THAT DON'T WORK

So-called "thinning hair supplements," "hair farming products" and "vasodilators" for the scalp will not promote hair growth, says Mike Mahoney, a spokesperson for the American Hair Loss Council.

Thinning hair supplements are nothing more than hair conditioners that temporarily make your hair feel or look a little thicker. The main ingredient in these products--polysorbate--is also found in many shampoos. Promotional materials for hair farming products claim that they will release hairs that are "trapped" in a bald scalp. Mahoney says these products, many of which are herbal preparations, can do no such thing. And so-called vasodilators do not increase the blood supply to the scalp and do not promote hair growth.

EVERYDAY HAZARDS

While male- and female-pattern baldness results in permanent hair loss, other factors can cause temporary loss of hair. For instance, the drop in the level of estrogen at the end of pregnancy can cause a woman's hair to shed more readily. Two or three months after a woman stops taking birth control pills, she may experience the same effect, since birth control pills produce hormone changes that mimic pregnancy. A major physical stress, such as surgery, or a major emotional stress--positive or negative--can cause hair loss.

"I've seen women start losing their hair before getting married," says Bihova. Even jet lag can have a similar effect.

In most of these cases, the hormonal imbalance or stressful situation will correct itself, and the scalp will soon begin growing hair again. But, says Bihova, since most women are extremely upset by even a temporary hair loss, many dermatologists treat these conditions with either topical steroid preparations or localized injections of low doses of steroids. Bihova emphasizes that these are local, not systemic, injections of steroids, therefore, the shots do not have the same risk of dangerous side effects as systemic steroids. However, only a board-certified dermatologist should administer this treatment, she says.

The list of causes of temporary hair loss goes on: pressure on the scalp from wigs or hairdos that pull too tightly can cause it. A fever of 103 degrees Fahrenheit or more often causes hair loss six weeks to three months later. And some medications can cause a temporary loss. These include vitamin A derivatives such as Accutane, cough medicines with iodides, anti-ulcer drugs, some antibiotics, beta blockers, antidepressants and amphetamines, anti-arthritis drugs, blood thinners, some cholesterol-lowering agents, aspirin taken over long periods, some thyroid medications, and chemotherapy.

YOU HAIR WHAT YOU EAT?

Although nutrition does play a role in hair loss and in the overall health of your hair, only extreme nutritional deficiencies or excesses will cause hair loss. For instance, people with anorexia and bulimia may temporarily lose hair. So will others suffering from malnutrition.

"It's pretty rare in the United States," says Bertolino. "If someone was on a real strange, restrictive diet, it could happen to them."

Megadoses of some vitamins--particularly A and E--and an iron deficiency may lead to hair loss. People who claim they can determine which vitamins are lacking in your diet by analyzing your hair, however, are not speaking from a scientifically sound basis. The test used with this type of hair analysis--atomic absorption spectrophotometry--is a legitimate analytical chemistry method; however, used on hair, the results of this test do not correlate with nutritional status, says Shupack. "Because of the sociological importance of hair, a lot of people try to cash in on it," he says. "Hair analysis is all witchcraft as far as I'm concerned."

There are, however, a few legitimate hair tests for substances such as arsenic and lead.

FOR BEAUTY'S SAKE

Every time you shampoo, blow dry, perm, straighten or dye your hair, you damage it slightly, says Bertolino. For the most part, hair can withstand this type of treatment. But overzealous beautifying can damage the hair fiber, resulting in many broken strands, and a frizzy, split-end look. For instance, if you bleach your hair and then have a bunch of perms done in a short time, you're heading for trouble.

Misuse of hair cosmetics can cause the hair to break as it comes out of the scalp, says Frances Storrs, M.D., professor of dermatology at the Oregon Health Sciences University. Permanent wave solutions break the bonds that hold hair together and then reform them. But with a perm that is not diluted right or not rinsed off properly, for instance, those bonds may not re-form and the hair would soon fall out as a result. Fortunately, most professional hair dressers know how to use perms correctly, says Storrs.

Most hair dyes are not as irritating as permanent solutions, mostly because they do not break the bonds between hair fibers and are therefore not likely to cause a hair loss, she says. However, a severe allergic reaction to hair dye could cause hair loss. "The allergy is pretty common, actually," says Storrs. Permanent solutions can also cause allergic reactions, though that's a rare side effect.

Other beauty-related manipulations of the hair can cause problems, too: hot irons, corn rows and braids may bring on temporary or permanent hair loss. If the hair breaks often enough, the follicles may eventually not be able to produce normal hair, says Bihova. "If someone has a problem with thinning and excessive loss, we advise being gentle," she says. "Don't use rollers; don't use blow dryers on a hot setting; don't wear tight hair styles." Rough shampooing may accelerate any loss, though it's usually not a problem in people with healthy hair.

THE MEDICAL SIDE

Some hair loss is the result of a type of immune disorder known as alopecia areata--some 2.5 million people suffer from this condition in which antibodies attack the hair follicle, causing the hair to fall out. Alopecia areata often causes small, oval or circular areas of hair loss. However, in some forms of the condition, all the scalp hair falls out; in other forms, all body hair is lost. Although the loss is usually temporary, the condition can recur. Treatments include topical steroids or the use of chemicals to produce an allergic reaction to start the hair growing again.

Finally, chronic, systemic conditions--including one form of lupus, abnormal kidney and liver function, and hypothyroidism or hyperthyroidism--can affect the hair. If you're experiencing hair loss, see a doctor. He or she will want to order some basic blood tests to rule out any medical cause of the condition.

Devera Pine is a freelance writer in New York City who frequently writes about health and science.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service, Food and Drug Administration
Office of Public Affairs, 5600 Fishers Lane, Rockville, MD 20857

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.

Can vaccines cause hair loss?
A recent study suggests that hair loss may occur in a few persons who have received vaccinations. This side effect, if confirmed by other studies, would be considered very rare. Other studies to further investigate these findings are underway.

From 1983 to 1995, 60 reports of hair loss were identified and evaluated among persons who had received vaccines. These few cases of hair loss were out of the hundreds of millions of doses of vaccine that have been given to the general population. This study alone cannot prove that vaccines cause hair loss. There may be other health conditions responsible for the hair loss that could not be identified. The study of these cases was conducted using information gathered from the Vaccine Adverse Event Reporting System (VAERS). VAERS reports can be submitted by anyone who has received a vaccine and has concerns about health problems that occur afterwards.

Which vaccines were looked at in the study?
All vaccines with reports of hair loss were investigated. The hepatitis B vaccine appeared more often than other vaccines to suggest an association with these rare cases of hair loss.

Of the cases reported, 46 of the 60 persons who reported loss of their hair had received hepatitis B vaccine. A few patients lost hair again when they received additional doses of the hepatitis B vaccine (3 doses are recommended).

Who is at risk for experiencing hair loss after vaccination?
Specific risk factors are not known at this time. The study found more women than men reporting the hair loss but there could be other reasons for this such as: 1) Men may not report hair loss as often as women because they typically wear their hair shorter, and hair loss may not be as noticeable as it would be in women with longer hair. In addition, some men expect to lose their hair as they age (e.g. male pattern baldness). 2) Women and health care workers who reported hair loss are more in touch with their health care providers about health concerns.

Did the hair grow back?
Yes, in more than half of the cases that could be evaluated. However, a few cases had only partial regrowth of hair. Severe hair loss over more than half of the head or body was reported to have occurred in 16 of 37 cases that could be evaluated. Of the 16 reports of severe hair loss, eight persons recovered most or all of their hair, and four reported persistent baldness. Also, of those 37 cases, 18 reported mild to moderate hair loss with most of the hair still intact. Nine (or half of these) had complete recovery. One did not have a complete recovery, and the outcomes of eight cases were unknown.

What are other possible causes of hair loss?
Hair loss can be caused by many things, including some medications, high fevers, hormonal changes, pregnancy, surgical shock, transplant surgery, poor diet (lacking in essential fatty acid, biotin, zinc, iron deficiency), anemia, aging, male pattern baldness, thyroid disease causing decreased thyroid levels (hypothyroidism), severe emotional stress, and autoimmune disease (disease that affects the body's ability to recognize its own tissues, causing it to gradually destroy them).

What is being done to investigate the hair loss finding or other reactions from vaccine?
The Centers for Disease Control and Prevention (CDC), in collaboration with the Food and Drug Administration (FDA), will continue to investigate the possible association between vaccine and hair loss along with other vaccine reaction questions.

CDC and FDA will continue to evaluate the results of this study using more detailed and powerful statistical methods. Researchers plan to check the results of the original research and investigate the risk factors. Information from the Vaccine Safety Datalink (VSD) project will be used to conduct a follow-up study.

What is hepatitis B?
Hepatitis B is a virus that attacks the liver and can cause serious illness or death. The virus, which is called hepatitis B virus (HBV), can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death. For more information, visit Viral Hepatitis B.

What is in the hepatitis B vaccine?
Two types of hepatitis B vaccines are currently licensed in the United States: the recombinant hepatitis B vaccine and the plasma-derived vaccine, which is no longer being produced in the United States. The commonly used vaccine is recombinant hepatitis B vaccine, which is produced using common baker's yeast. The vaccines contain no more than 95% hepatitis B surface antigen protein, and no more than 5% yeast-derived protein. The vaccine also includes very tiny amounts of other additives such as aluminum hydroxide, which help to stabilize and preserve the vaccine.

What other side effects are associated with the Hepatitis B vaccine?
Most persons who receive hepatitis B vaccine have no side effects at all. Of persons who do experience side effects, the most common include pain at the injection site (3% to 29% of persons vaccinated), and mild fever (1%- to 6% of persons vaccinated). As with any medication or vaccine, there is a very small risk that serious problems, even death could occur from someone having a serious allergic reaction.

Is it still a good idea to get a hepatitis B shot?
Yes. Immunizations are the best protection against vaccine-preventable diseases, such as hepatitis B. These findings about hair loss do not change the current recommendations for children and adults to receive the hepatitis B vaccine. Getting the disease is much more likely to cause serious illness than getting the vaccine. Each year, an estimated 4,000 persons die of hepatitis B-related cirrhosis, and more than 800 die of hepatitis B-related liver cancer.

What should I do if I have a reaction to, or side effects from, hepatitis B or any vaccine?
You should contact your health care provider if you suspect you have had a reaction or side effects from a vaccine. You or your health care provider should also report this information to the Vaccine Adverse Event Reporting System (VAERS) at 1 (800) 822-7967.

by Devera Pine

From the shaved heads of medieval monks, to the long-haired hippies of the '60s, to the spiked hairdos of today's punk rockers, hair has always made a personal statement.

"It's one of the leading ways people can establish their individuality and express their style," says Jerome Shupack, M.D., professor of clinical dermatology at New York University Medical Center in New York City. "Hair has had sociological importance throughout the ages."

Because of its importance, anything that happens to our hair that we can't control--falling out or turning gray, for instance--can be the source of much anxiety.

In the United States, some 35 million men are losing or have lost their hair from male-pattern baldness, according to the American Hair Loss Council. Approximately 20 million women have experienced a similar loss of hair (from female-pattern hair loss), and an estimated 2.5 million Americans have lost their hair due to other causes.

THE BASICS

Hair is produced by hair follicles--indentations of the epidermis (outer skin layer) that contain the hair root, the muscle attached to it, and sebaceous, or oil, glands. Hair is made up of dead cells filled with proteins, most of which are known as keratins. The cells are woven together like a rope to form the hair fiber. The hair fiber, in turn, has three layers: the outer cuticle with its fish-scale-like structure; the cortex, which contains the bulk of the fiber; and the center, or medulla. Hair color is determined by melanocytes, cells that produce pigment. When these cells stop producing pigment, hair turns gray.

Although it seems as if the hair on your head is always growing, hair actually has active and rest phases. The growth phase, known as anagen, lasts for two to six years. At any given time, about 90 percent of scalp hair is in the growth stage. The remainder is in the rest phase, known as telogen; this lasts from two to three months.

Once the rest phase is over, the hair strand falls out and a new one begins to grow. As a result, it's considered normal to lose from 20 to 100 hairs a day, says Diana Bihova, M.D., a dermatologist in private practice in New York City. Only a change in your regular pattern of loss is considered abnormal--but many things, including genetic factors, diet, stress, and medications, can change that pattern.

BALDNESS: MANIFEST DESTINY?

The most common cause of hair loss in both men and women is rooted in a genetic predisposition. Called androgenic alopecia, it is known as male-pattern baldness in men and female-pattern hair loss in women (alopecia is the scientific term for baldness). According to the American Hair Loss Council, genetics accounts for 95 percent of all cases of hair loss in this country.

Baldness results from a combination of genetic factors and levels of testosterone (a hormone produced by the adrenal gland in both sexes and also by the testes in men). If hormone levels are right, then the hair follicles will express their genetic destiny by growing for shorter periods and producing finer hairs. In men, who have higher levels of testosterone than women, this eventually results in a bald scalp at the crown of the head and a horseshoe-shaped fringe of hair remaining on the sides. In women, the hair thins all over the scalp; the hairline does not recede. This type of hair loss doesn't usually show up in women until menopause; until then, estrogen tends to counteract the effects of testosterone.

ONE APPROVED DRUG
(See updated information below)

The only drug approved by the Food and Drug Administration to treat pattern baldness or hair loss is minoxidil topical solution (Rogaine), which is rubbed into the scalp. Originally approved for hereditary male-pattern baldness in 1988, it was also approved for treating female-pattern hair loss in August 1991. However, it should not be used by pregnant or nursing women.

In his dermatological practice, Arthur P. Bertolino, M.D., Ph.D., director of the hair consultation unit at New York University, says that this lotion helps hair grow in 10 to 14 percent of the people who try it. He estimates that approximately 90 percent of the time, Rogaine at least slows down hair loss. (Minoxidil is also available in tablet form to treat severe high blood pressure. Oral minoxidil has a potential for serious side effects and is not approved to treat baldness.)

No one is certain yet just how topical minoxidil works to promote hair growth. "One theory is that it dilates the blood vessels, so it may stimulate nourishment of follicles," says Bihova. Alternatively, Rogaine may convert tiny hair follicles that produce peach fuzz into large hair follicles that produce normal-size hairs. Again, no one knows for sure.

What is certain is that, at least in men, Rogaine works better on patients who fit a certain profile: they've generally been bald for less than ten years, have bald spots on top of the head that are less than four inches in diameter, and they still have fine hairs in their balding areas. "The process begins very early," says Bihova. "I see 19-, 20-year-old males who have it."

The most common side effects with this medication are itching and skin irritation. Also, according to Bertolino, once you stop using it, any hair that grew as a result will fall out. Finally, the drug is expensive: in 1990, it cost about $600 a year to use it twice a day.

TRANSPLANTS

Baldness can also be treated with hair transplants, in which plugs of "donor" follicles from the patient's scalp are used to fill the hairline. Although hair transplants work well in both men and women, the treatment tends to have a more dramatic effect on appearance in men with bald spots than it does on women with thinning hair.

"The less hair you have, the more drama in the change," says Robert Auerbach, M.D., associate professor of clinical dermatology at New York University School of Medicine. However, the American Hair Loss Council warns against attempting to replace lost hair with hair pieces sutured to the scalp. FDA has not approved any products specifically intended for this purpose, however, this does not preclude a physician from using sutures, which are approved devices, for this purpose. According to the council, although the procedure is legal, it can result in scars, infections and even brain abscesses.

Another treatment for male-pattern baldness, hair implants made of high-density artificial fibers surgically implanted in the scalp, was banned by the FDA in 1984 because it causes infection. This is the only device FDA has ever banned.

PRODUCTS THAT DON'T WORK

So-called "thinning hair supplements," "hair farming products" and "vasodilators" for the scalp will not promote hair growth, says Mike Mahoney, a spokesperson for the American Hair Loss Council.

Thinning hair supplements are nothing more than hair conditioners that temporarily make your hair feel or look a little thicker. The main ingredient in these products--polysorbate--is also found in many shampoos. Promotional materials for hair farming products claim that they will release hairs that are "trapped" in a bald scalp. Mahoney says these products, many of which are herbal preparations, can do no such thing. And so-called vasodilators do not increase the blood supply to the scalp and do not promote hair growth.

EVERYDAY HAZARDS

While male- and female-pattern baldness results in permanent hair loss, other factors can cause temporary loss of hair. For instance, the drop in the level of estrogen at the end of pregnancy can cause a woman's hair to shed more readily. Two or three months after a woman stops taking birth control pills, she may experience the same effect, since birth control pills produce hormone changes that mimic pregnancy. A major physical stress, such as surgery, or a major emotional stress--positive or negative--can cause hair loss.

"I've seen women start losing their hair before getting married," says Bihova. Even jet lag can have a similar effect.

In most of these cases, the hormonal imbalance or stressful situation will correct itself, and the scalp will soon begin growing hair again. But, says Bihova, since most women are extremely upset by even a temporary hair loss, many dermatologists treat these conditions with either topical steroid preparations or localized injections of low doses of steroids. Bihova emphasizes that these are local, not systemic, injections of steroids, therefore, the shots do not have the same risk of dangerous side effects as systemic steroids. However, only a board-certified dermatologist should administer this treatment, she says.

The list of causes of temporary hair loss goes on: pressure on the scalp from wigs or hairdos that pull too tightly can cause it. A fever of 103 degrees Fahrenheit or more often causes hair loss six weeks to three months later. And some medications can cause a temporary loss. These include vitamin A derivatives such as Accutane, cough medicines with iodides, anti-ulcer drugs, some antibiotics, beta blockers, antidepressants and amphetamines, anti-arthritis drugs, blood thinners, some cholesterol-lowering agents, aspirin taken over long periods, some thyroid medications, and chemotherapy.

YOU HAIR WHAT YOU EAT?

Although nutrition does play a role in hair loss and in the overall health of your hair, only extreme nutritional deficiencies or excesses will cause hair loss. For instance, people with anorexia and bulimia may temporarily lose hair. So will others suffering from malnutrition.

"It's pretty rare in the United States," says Bertolino. "If someone was on a real strange, restrictive diet, it could happen to them."

Megadoses of some vitamins--particularly A and E--and an iron deficiency may lead to hair loss. People who claim they can determine which vitamins are lacking in your diet by analyzing your hair, however, are not speaking from a scientifically sound basis. The test used with this type of hair analysis--atomic absorption spectrophotometry--is a legitimate analytical chemistry method; however, used on hair, the results of this test do not correlate with nutritional status, says Shupack. "Because of the sociological importance of hair, a lot of people try to cash in on it," he says. "Hair analysis is all witchcraft as far as I'm concerned."

There are, however, a few legitimate hair tests for substances such as arsenic and lead.

FOR BEAUTY'S SAKE

Every time you shampoo, blow dry, perm, straighten or dye your hair, you damage it slightly, says Bertolino. For the most part, hair can withstand this type of treatment. But overzealous beautifying can damage the hair fiber, resulting in many broken strands, and a frizzy, split-end look. For instance, if you bleach your hair and then have a bunch of perms done in a short time, you're heading for trouble.

Misuse of hair cosmetics can cause the hair to break as it comes out of the scalp, says Frances Storrs, M.D., professor of dermatology at the Oregon Health Sciences University. Permanent wave solutions break the bonds that hold hair together and then reform them. But with a perm that is not diluted right or not rinsed off properly, for instance, those bonds may not re-form and the hair would soon fall out as a result. Fortunately, most professional hair dressers know how to use perms correctly, says Storrs.

Most hair dyes are not as irritating as permanent solutions, mostly because they do not break the bonds between hair fibers and are therefore not likely to cause a hair loss, she says. However, a severe allergic reaction to hair dye could cause hair loss. "The allergy is pretty common, actually," says Storrs. Permanent solutions can also cause allergic reactions, though that's a rare side effect.

Other beauty-related manipulations of the hair can cause problems, too: hot irons, corn rows and braids may bring on temporary or permanent hair loss. If the hair breaks often enough, the follicles may eventually not be able to produce normal hair, says Bihova. "If someone has a problem with thinning and excessive loss, we advise being gentle," she says. "Don't use rollers; don't use blow dryers on a hot setting; don't wear tight hair styles." Rough shampooing may accelerate any loss, though it's usually not a problem in people with healthy hair.

THE MEDICAL SIDE

Some hair loss is the result of a type of immune disorder known as alopecia areata--some 2.5 million people suffer from this condition in which antibodies attack the hair follicle, causing the hair to fall out. Alopecia areata often causes small, oval or circular areas of hair loss. However, in some forms of the condition, all the scalp hair falls out; in other forms, all body hair is lost. Although the loss is usually temporary, the condition can recur. Treatments include topical steroids or the use of chemicals to produce an allergic reaction to start the hair growing again.

Finally, chronic, systemic conditions--including one form of lupus, abnormal kidney and liver function, and hypothyroidism or hyperthyroidism--can affect the hair. If you're experiencing hair loss, see a doctor. He or she will want to order some basic blood tests to rule out any medical cause of the condition.

Devera Pine is a freelance writer in New York City who frequently writes about health and science.

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Hair loss is highly variable. Some people experience it and others do not, even when they are taking the same drugs. While some drugs can cause hair loss on the scalp and elsewhere on the body, others can cause only the loss of head hair. If hair loss does occur, it usually begins within 2 weeks of starting chemotherapy and gets worse 1 to 2 months after the start of therapy. It may come out in clumps that appear on the pillow in the morning or while shampooing or brushing your hair. Hair re-growth often begins even before therapy is completed.

Like chemotherapy, radiation therapy to the head often causes scalp hair loss. Unlike hair lost because of chemotherapy, however, hair lost as a result of radiation therapy to the head may not grow back naturally.

It is normal for someone undergoing cancer treatment to feel distressed about hair loss. But it can help to understand why it happens, to know that hair will probably grow back, and to take some steps to minimize the problem.

What to Do

• Choose a wig or toupee before treatment begins or at the very start of treatment, before hair loss begins, so that hair color and texture can be matched
• Get a prescription for the wig from the doctor, because the cost is often covered by insurance
• Obtain a list of wig shops in your area from the doctor, nurse, or the Yellow Pages
• If you have long hair, consider getting a stylish short cut and then having a beautiful wig made from your own hair
• Try on different wigs until you find one that you really like
• Consider buying 2 wigs, 1 for everyday wear and 1 for special occasions
• Before you need to wear the wig, be gentle when brushing and shampooing your own hair
• Wear a hat or scarf outdoors in cold weather to prevent loss of body heat
• Avoid too much brushing or pulling of hair, and avoid heating it with a hair dryer, electric rollers, or curling iron to help reduce hair loss and damage
• Use a sunscreen, sunblock, or hat to protect your scalp from the sun
• Choose turbans or scarves as alternatives to wigs

Do Not

• Wait to go shopping for a wig; try to have it ready when you need it
• Forget your hair will grow back and that a good wig looks very natural