Hair loss is characterized by the decreased number of hairs as a result of increased hair shedding and decreased density of hairs. This can ultimately lead to patches of hair loss and balding, especially with a lack of hair regrowth. The type of hair loss is categorized by the presence of scarring and distribution of hair loss. Non-scarring alopecia is defined by hair loss without the permanent damage of the hair follicle. As a result, there is a greater chance of hair regrowth. Examples of non-scarring alopecia include alopecia areata, androgenic alopecia, and telogen effluvium. Scarring alopecia is hair loss with damage of the hair follicle, which could result in permanent hair loss.
Hair loss is due to a variety of factors, including genetic predisposition, emotional stressors, hormonal changes. diet, nutritional deficiencies, medications such as chemotherapy, surgeries, traumatic styling practices, and infection.
Alopecia Areata – Alopecia areata represents patches of hair loss, usually on the scalp and occasionally on the eyebrows and beard area. Hairs on the margins of these patches appear as exclamation points, as the radius of the hairs is smaller than at the ends. The patches of hair loss are a result of inflammation around the hair follicle, usually triggered by emotional stressors. Alopecia areata can be associated with other inflammatory conditions such as atopic dermatitis, allergies, Hashimoto’s thyroiditis, inflammatory bowel disease, and vitiligo. Treatment of mild cases includes addressing the primary trigger and performing in-office cortisone injections on the patches of hair loss. Moderate to severe cases are best treated outside of New Bloom Dermatology by a hair loss specialist who may prescribe anti-inflammatory medications such as oral steroids and JAK inhibitors.
Androgenic Alopecia – Androgenic alopecia results in thinning of the hair shaft along the midline and occasionally the front of the scalp. The hair cycle is switched from growth or anagen phase to resting or telogen phase. As a result, thicker terminal hairs become thinner vellus hairs. It is not primarily associated with inflammation. Androgenic alopecia is due to hormonal changes and patients usually have a family history of this type of hair loss. In males, there is an increased conversion of testosterone to dihydrotestosterone. The pathology of female pattern hair loss is unknown.
Scarring alopecia – Scarring alopecia is characterized by loss of hair follicles due to the development of scar tissue. Scarring alopecia includes conditions such as central centrifugal cicatricial alopecia (CCCA), discoid lupus, frontal fibrosing alopecia (FFA), and lichen planopilaris (LPP). CCCA is characterized by hair loss starting at the crown of the scalp and spreading peripherally. Discoid lupus features patches of hair loss with generalized redness and loss of hair follicles. LPP is characterized by tender and itchy patches of hair loss and follicular ostia with redness around the remaining hair follicles. FFA features hair loss on the frontal scalp and eyebrows. Patients with this type of hair loss can have their diagnosis confirmed with a punch biopsy.
Telogen Effluvium – Telogen effluvium is the shedding of hairs, usually at the frontal and temporal scalp or throughout the scalp. This type of hair loss is a result of emotional and physical stressors on the body, including hormonal changes (especially after pregnancy or discontinuing oral contraceptives), poor nutrition from dieting, surgeries, illnesses, and medication intake. If a primary cause remains unknown, bloodwork can be performed to rule out certain medical conditions.
Traction alopecia – Styling practices such as tight braids and weaves pull the hair, inflame the base of the hair follicle, and cause hair loss. Furthermore, relaxers made of sodium hydroxide can destroy the hair shaft and cause hair breakage. Traction alopecia is usually located on the front of the scalp, adjacent to the temples, but can also appear on the midline of the scalp. Treatment includes avoiding these hair care practices and performing in-office cortisone injections on the areas of hair loss.
Hair loss is diagnosed by history, location of hair loss on the scalp, shedding patterns, and determination of decreased hair density and hair diameter. There are diagnostic tests that can be done, including a hair pull test done when the patient’s hair is not washed for 24 hours. If hairs are pulled with the appearance of roots, it is likely characteristic of telogen effluvium. Trichoscopy can be used to visualize the hairs and follicles to determine the type of hair loss. Decreased hairs on the crown of the scalp without loss of the follicle and increased hair thinning is usually characteristic of androgenic alopecia. Patches of hair loss without loss of hair ostia is characteristic of alopecia areata. Scarring alopecia can be verified with a punch biopsy.
While there are various types of hair loss with different presentations, treatment for hair loss starts with addressing emotional stressors, as stress has been shown to decrease anagen or growth phase and increase inflammation around the hair follicle. After clinical examination, blood tests may be indicated to rule out any systemic reasons for hair loss. These tests include checking a hormone panel, iron panel, thyroid function panel, complete blood count, complete metabolic panel, and vitamins. Addressing hormonal changes and vitamin deficiencies has been shown to decrease hair loss, stimulate hair regrowth, and consequently increase hair growth. Females with ferritin levels under 40, even with a normal iron panel, are recommended to take ferrous gluconate supplements.
Oral and topical minoxidil has been shown to increase anagen or growth phase or switch hairs from telogen or resting phase to anagen phase. It can be used in most types of hair loss, including scarring alopecia. Minoxidil is thought to inhibit fibroblast proliferation, which is responsible for causing scarring. Oral and topical minoxidil have been shown to increase hair shedding in the first four to six weeks of treatment, which is a temporary finding due to the hairs shifting to growth phase. Furthermore, women can experience increased hair growth on the face, especially the sideburns and temples. Side effects of topical minoxidil include headaches and allergic contact dermatitis. Side effects of oral minoxidil can cause a mild decrease of blood pressure, chest pain, pericardial effusion, and swelling of the hands and feet.
A treatment option for all types of non-scarring alopecia is ViviscalTM Pro, a dietary supplement containing AminoMarTM or shark cartilage, biotin, apple extract, and amino acids. Studies have shown use of the supplement increases hair diameter, density, and strength while decreasing hair breakage, thinning, and shedding. There were no reported adverse events. ViviscalTM Pro should not be taken in individuals with allergy to seafood or shellfish.
Other treatment options for each type of hair loss are listed below.
Alopecia Areata – Treatment of mild cases includes addressing the primary trigger and performing in-office cortisone injections on the patches of hair loss. Moderate to severe cases are best treated outside of New Bloom Dermatology by a hair loss specialist who may prescribe anti-inflammatory medications such as JAK inhibitors.
Androgenic Alopecia – Male pattern hair loss has been successfully treated with finasteride 1 milligram per day to block testosterone from converting into dihydrotestosterone, preventing further thinning of the hairs. Premenopausal women may benefit from treatment with spironolactone, as studies have shown increased hair regrowth and decreased hair loss. Procedures performed at New Bloom Dermatology that may help stimulate hair regrowth in cases of androgenic alopecia include platelet rich plasma injections and a combination of radiofrequency microneedling, infrared light, and topical exosomes. These treatments are considered cosmetic and not FDA approved. Other treatment options offered by hair loss specialists outside of New Bloom Dermatology include higher doses of finasteride for both men and postmenopausal women and hair transplants.
Scarring alopecia – In-office cortisone injections can be performed to decrease inflammation associated with the hair loss. Oral antibiotics such as doxycycline can also be used to decrease progression of hair loss. Further treatment is best sought by a hair loss specialist outside of New Bloom Dermatology.
Telogen Effluvium – Treatment includes addressing the underlying condition and physical and emotional stressors. Furthermore, replacement of vitamins and minerals can help stimulate hair regrowth if there are nutritional deficiencies.
Traction alopecia – Treatment includes avoiding traumatic hair practices including tight braids, weaves, and relaxers and performing in-office cortisone injections on the areas of hair loss.
Patients are advised to treat any signs of hair loss during the early stages to minimize permanent balding. Furthermore, patients are recommended to address emotional stress patterns. Patients are also advised to increase solid protein intake, as a decrease in protein intake has been shown to increase hair loss.
Untreated hair loss can lead to permanent hair loss, especially in patients who are in the later stages of scarring alopecia.
Hair loss is multifactorial and can be associated with a number of factors affecting our health, such as hormonal changes and diet. Patients with alopecia areata may have thyroid disorder and should have their thyroid function checked.
Individuals are recommended to see a board-certified dermatologist for further evaluation and management of hair loss. Blood tests may be performed to check for systemic reasons for hair loss. Individuals are also advised to address emotional stressors, as they can contribute to worsening hair loss.
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