The facts are astounding: In the US alone, 80 million people are affected by hair loss and 50% of all women will experience some form of hair loss in their lifetime. Every day I see women who are devastated, sometimes to the point of feeling suicidal over the thought of going bald. Hair is not just a simple irrelevant appendage or accessory; it is very strongly tied to a person’s self-esteem and nothing makes a person feel more confident and beautiful than thick, healthy, flowing hair. This is why it’s no surprise that each year, more than $2 billion is spent trying to avoid or reverse the effects of hair loss and thinning.
With such a wealth of information that exists today on beauty, aesthetics, and treatments for women of every age and ethnicity, I still see hair loss as an issue that remains misunderstood. I believe it is because there is no “silver bullet solution” and it remains a highly emotional, embarrassing and private issue for so many women. Because of this, I think it’s important that everyone be armed with the available facts and a strong base level of knowledge. This includes understanding simple predictable changes in hair versus true hair loss and what to expect from your first appointment through to diagnosis and treatment.
UNDERSTANDING COMMON CHANGES IN YOUR HAIR:
- Common shedding. Yes, some patients come to us as a result of regular shedding rather than “true” hair loss (though to the person suffering it makes little difference because what they see on their floor and in their brush is excess hair and they see it disappearing off their scalp!). But remember that it’s normal to shed up to 50-150 hairs a day (that’s significant!) and it’s also common to see more shedding after the summer. The medical name for this is telogen effluvium and it’s one of the most common diagnoses a dermatologist will make when it comes to hair.
- Hair aging. Just as with the rest of us, our hair ages. Seventy-five percent of women are affected by the age of 65 as estrogen levels decrease and the natural depletion of protein causes hair to get thinner and more fragile. By the time we reach our 30s the hair’s natural pigment has changed ever so slightly and the first signs of gray have set in. It’s natural for hair to change in individual hair thickness and form sometimes going from curly to wavy to frizzy, and also for overall hair density to decrease as you age.
- Stressed and over-processed hair. What else could be physically altering and weakening the hair? Think: over bleaching or highlighting, grooming habits like aggressively pulling on the hair with a brush while blow drying, sun exposure, diet (often overlooked!) and excessively using hot rollers or flat irons for styling. These typically cause more breakage than hair loss with the exception of hair relaxers which may cause both breakage and also affect hair growth. Hair extensions, tight braids and ponytails can also cause hair loss and over years it can even cause scarring of the follicles which is a permanent form of loss.
- Hormonal factors. It can be easy to forget how much hormones can affect the health and life cycle of hair. Some women may be alarmed to see a rise in excess shedding after discontinuing hormonal contraceptives or if they are experiencing hyperthyroidism from accelerated hair cycling. Dryness and breakage is also common for those with hypothyroidism. Any hormonal fluctuation can affect the way hair grows but typically the effect resolves and the hair regrows as normal once the hormonal issue is resolved. If you’re prone to genetic hair loss the hormonal or stress fluctuations may accelerate the pattern leading to less than optimal hair regrowth.
THE DOCTOR’S VISIT: WHAT TO EXPECT
Getting to the root cause of hair loss and thinning generally involves a physical exam and sometimes blood work and possibly a biopsy of the scalp before an official diagnosis can be made. Here’s what to expect from your appointment:
- Your dermatologist will start with a general exam of the skin on your scalp. They will examine your scalp with a lighted magnifier looking for redness, scale, irritation and scarring of the skin as a clue to any condition that might be affecting hair growth. They will also notice any obvious patterns or patches of hair loss.
- In examining the hair they will look for even the most subtle changes of shifts in your frontal hairline, spotting recession at the temples, increased spacing between the hairs and patchy sections of thinner hair. In some instances, a gentle pull test may be required (don’t worry, it’s painless!).
- Don’t be surprised if your dermatologist also examines your face and other parts of your body. They’re looking for other areas of visible follicular hair loss, scarring, acne and hirsutism (excessive and unwanted abnormal hair growth) or any correlation of other conditions affecting other parts of the skin and body that might also be causing or contributing to the hair loss.
- Sometimes the diagnosis is followed with a series of blood tests to check essential hormone, thyroid and vitamin levels. In some instances scalp biopsies will also be recommended if the dermatologist is concerned about scarring or a specific condition causing the hair loss.
THE FOUR MOST COMMON FORMS OF HAIR LOSS
Once a physical exam and blood work up is complete a dermatologist will be able to assess the core (or collective) factors that are related to the hair loss type and source.
- For 95% of men and women the diagnosis will be hereditary hair loss (officially called androgenetic alopecia). This can begin to present as early as during your early 20s and for women this starts with the slow widening of your hair part causing a thinning in the crown region (at the top of the scalp). You won’t notice any change in your frontal hairline.
- Temporary but aggressive stress hair shedding called telogen effluvium can occur following three to four months of physiologic stress. It is generally ‘self-limited’ meaning the hair will all grow back (unless you do present with hereditary hair loss in which case it may not grow back quite as fully). Factors such as hormonal shifts from pregnancy along with crash dieting and certain medications have been shown to trigger this form of temporary loss.
- Traction alopeica is a permanent form of scarring hair loss from years of tight braids, extensions, or any process that adds excess pull and weight on the hair. It can take years to occur but once it happens the follicles are lost and the hair will not regrow. It is important to minimize trauma and pulling on the hair as much as possible. Newer hair pieces are much lighter and gentler on the scalp and help reduce the risk of traction. They are temporary and have to be used on a daily basis but they are preferable to hair extensions.
- Finally there is immune-related hair loss, the most common being alopecia areata, a type of hair loss that occurs when the immune system mistakenly attacks hair follicles. Telltale signs are visible clumps of hair that have fallen out, resulting in totally smooth, round hairless patches on the scalp or other parts of the body. In some cases this can progress to involve all the hair on the scalp and face which is called alopecia totalis or all the hair on the entire body which is called alopecia universalis.
TREATMENTS AVAILABLE TODAY
Whether you’re experiencing changes in your hair due to age, hormones or stress, or you are facing true hair loss that is genetic or immune-related, it can be debilitating. Today, there are an increasing host of treatments available (and more research being done every day!). Don’t be surprised if you don’t receive one prescription and one treatment: research shows that combination treatments perform best!
- Minoxidil. As the active ingredient in Rogaine, minoxidil is proven to help stimulate hair growth in men and women. Over the counter options are available up to a 5% concentration though your physician can prescribe higher strengths based on your need. Don’t forget, this is a lifelong commitment to daily use! No exceptions, I’m afraid. The good news is it keeps working as long as you use it. If you ever do decide to stop you simply revert back to where you would have been without it, it doesn’t make more hair fall out.
- Low Level Light Therapy (LLLT). There are several in-office laser devices as well as at home devices which are FDA-cleared for hair growth. There are several different brands and types so be sure to ask your dermatologist which one is best for you before investing in a device for home use.
- Platelet Rich Plasma (PRP) Treatment. You’ve probably heard of this in relation to the face (aka the vampire facial) but it’s also now effectively used as part of hair regrowth treatments. The dermatologist will take a small amount of your own blood, spin it down to separate out the pure platelet rich plasma which is then injected into the scalp to stimulate regrowth by harnessing the power of your body’s own stem cells and growth factors!
- Antiandrogens. Slight shifts in your hormones can wreak havoc on your hair. The prescription drug spironolactone may be prescribed as an off-label use to help offset any imbalance depending on the pattern and severity of hair loss as well as other findings such as acne and unwanted hair growth on other parts of the body.
- Experimental Drugs. There is much active research on new classes of drugs called JAK inhibitors that have shown great promise for the auto-immune form of hair loss but possibly also hereditary hair loss. This could be a hair-changer for those suffering from these conditions.
- Hair Transplantation. We’ve come a long way when it comes to providing natural hair transplant grafts that grow to be long and strong after 12-15 months. This can be an effective treatment for women as long as you have good donor hair (i.e. areas of your scalp with hair that is strong and healthy).
- Supplements. Diet is absolutely critical for healthy hair so your physician will need to make sure you’re getting adequate levels of vitamins (especially B and D), and a proper balance of proteins and healthy fats. This makes the difference between a full, thick shiny head of hair and thin, brittle dull hair that sheds and breaks easily! Targeted hair supplements you’ll likely come in contact with are:
- Viviscal – An over the counter supplement containing Amino Mar, vitamin C, and silica.
- Nutrafol – A high-performing cocktail of ingredients including bioactive keratin, hyaluronic acid, collagen, Vitamin E and other specialized actives.
If you are suffering from hair loss, know you are not alone and be sure to see your dermatologist to learn of the newest and most promising treatments. This is an area of very active research and recent advances give hope for long-lasting cures for all types of hair loss in the near future. For the present the treatments newly available over the past few years have offered impressive lasting results in helping to minimize hair loss and optimize growth until permanent treatment is available.
Doris Day, MD, is a board certified dermatologist who specializes in laser, cosmetic and surgical dermatology on the Upper East Side in New York City. Her private practice includes national and international celebrities. She is a clinical associate professor of dermatology at the New York University Langone Medical Center where she was presented with the award for Dedication and Excellence in the Teaching of Dermatology. As a highly respected and sought-after media personality, Dr. Day is a frequent guest expert on Good Morning America, The View and Dr. Oz and has been featured in numerous national magazines including Allure, InStyle, Vogue, Glamour, W Magazine, New Beauty and Cosmopolitan. When she is not working or teaching, Dr. Day hosts a bi-monthly two-hour live dermatology call-in radio show through Doctor Radio on SiriusXM 110 and dedicates herself to writing; she is the proud author of Forget the Facelift and is currently working on an upcoming book called Skinfluence.