What You Need to Know About Hair Loss

HAIR LOSS FACTS FROM DERMATOLOGIST, DR. MICHAEL TOMEO

Luxurious, loose, flowing, soft, shiny, sun-kissed. All are adjectives used to describe  hair. From the time we’re children, we’re taught, if only subliminally, the causal relationship between a woman’s hair and her overall beauty. Rapunzel used her long, luxurious tresses to escape from a high tower in which she’d been imprisoned. Snow White’s raven locks were the envy of an evil Queen. According to legend, Lady Godiva in a political statement against her husband’s levying taxes upon the people of Coventry, rode naked through the town cloaked only in her hair. We spend billions of dollars on shampoos, conditioners, styling products, color and accessories to make our hair look as beautiful as possible. When it doesn’t we complain about bad hair days which prompt some of us to hide under hats or scarves. One of the first things a new mother is asked about her baby is what color and how much hair does it have. We complain about our hair when it doesn’t behave, torture it into submission on a regular basis and fuss over it several times during the course of a day. It is, after all, our crowning glory.

But what if it isn’t? What if, as in the case of about forty percent of American women, according to the website americanhairloss.org, it’s sparse and thin and balding?

Hair loss for both sexes can be a devastating blow to one’s self-image – but, while men of a certain age who retain their hair are in the minority, women with hair loss are perceived as less beautiful, less vibrant, less … womanly. Hair loss in women is, generally, not life-threatening and women are often told to style it differently, bleach it a lighter color so the demarcation between scalp and remaining hair is not as drastic, wear a hairpiece – or just live with it.

I spoke with dermatologist Michael A. Tomeo, M.D; Advanced Dermatology Center, Meadowbrook, PA, to learn the facts about hair loss, including available treatments and what’s new on the horizon. Here, the facts and fictions about hair loss in women …

EverBeautiful.com: What is the definition of hair loss?

Dr. Michael Tomeo: When we refer to hair loss, we often use the term alopecia which simply means hair loss and, in extreme cases, baldness. There are many forms of alopecia or hair loss, however, in the majority of cases hair loss in females and males is hereditary or genetically based. Millions upon millions of people in the US suffer some form of alopecia. But, even though your father or mother may not have experienced hair loss doesn’t mean that you won’t experience it. It’s a multi-factorial and multi- generational trait.

EB: I’d always heard that if you want to see how your husband’s hair will fare, you should look at his father. Is there any truth to this? And, do genetics affect hair loss in women?

MT: We inherit genes from our parents but we are only starting to find out how to test for them so we can’t know from whom they’re inherited. It could be either mom’s or dad’s side or both and it’s a combination of inheritance patterns that result in that type of hair loss. So let’s talk about the types of hair loss. Other than androgenetic (or androgenic) alopecia, which is a common form of hair loss in both men and women, Alopecia Areata (AA) is one of the most common forms of hair loss that I see as a dermatologist. AA, which affects both men and women, is an autoimmune process whereupon one’s own body attacks the hair at the root with an inflammatory response. As such, those hair follicles become loosened and shed. AA appears on the scalp, typically, as well defined or demarcated areas of hair loss, almost as if someone drew a complete circle on the scalp. It can be pretty extensive and can mimic other types of hair loss, which we’ll get to in a minute. The more extreme cases of AA, where one loses hair all over the head is referred to as Totalis or Universalis when it occurs as hair loss on the body.

EB: What causes Alopecia Areata?

MT: Alopecia Areata is an autoimmune disease and affects about one to two percent of the world’s population or about five million Americans. We don’t know the cause but there does appear to be a genetic component and there is an association with autoimmune thyroid disease (in about four percent of the cases.)

EB: Does a woman’s diet affect Alopecia Areata?

MT: Diet has nothing to do with AA whatsoever.

EB: What about stress?

MT: Now stress is interesting because we really don’t understand the association between stress and AA although there seems to be some relationship in some individuals. Stress can precipitate any disease, particularly those diseases that an individual has a propensity towards. We all have weaknesses. Stress brings those weaknesses to the forefront.

EB: Ok, so how do we treat AA?

MT: The first thing is not to panic. The second thing is to go to your dermatologist. Often, he or she can inject those areas with Kenalog suspension, which is a steroid that decreases the inflammation and allows the hair to grow back.

EB: Does that always work?

MT: Usually, however, if you have extreme or extensive hair loss, it’s much more difficult logistically to do the injections. Your prognosis for total regrowth depends on how much hair loss there is.

EB: Let’s talk about other types of hair loss that affect women.

MT: Although the vast majority of female hair loss is androgenetic, there are other causes as well. There is a form of hair loss called Chronic Hair Loss of Females which is a diffuse thinning of the hair that we can’t attribute to any other cause. It however may be another form of genetic hair loss. In this country, where we have so much access to food, we rarely see hair loss as a result of nutritional deficiency. But there are cases where individuals are deprived or deprive themselves, such as anorexics or bulimics, who may experience diffuse hair loss or shedding. There’s also hair loss associated with metabolic diseases such as thyroid disease or anemia. Lastly, hair loss has been associated with autoimmune disease such as Lupus. So you see, there can be a number of causes and, as such, part of the work up for hair loss is to rule out certain metabolic and systemic diseases. A complete medical history and physical are necessary to determine the cause of hair loss. What’s important is talking to the patient to figure out what’s happening and what’s going on. That often determines the diagnosis. We talked about stress earlier. There have been cases of people losing their hair from stress, which can not only exacerbate AA, but can also cause a more diffuse hair loss. Keep in mind that stress is not always just emotional. There are physical stressors such as pregnancy, drugs, extreme diets, etc. Usually this type of hair loss occurs after the physical stress is over. For example, pregnancy is a jolt to the body. Being in the hospital can be a jolt. Having surgery is a jolt. So any major jolt to the system can cause hair loss. The good news is that those types of insults are temporary. They go away and most times the hair can come back. When there’s a systemic jolt or insult to the system, you can experience hair loss, such as that caused by chemotherapy or other drugs.

EB: So besides injecting steroids into an inflamed bald spot, such as those resulting from Alopecia Areata, how else is hair loss treated?

MT: Obviously the first thing we need to do is find the cause of the hair loss  because that will determine the course of treatment. If the hair loss is nutritionally or metabolically related then we need to correct those deficiencies.

EB: Tell me about how hair grows.

MT: There are three phases of the hair cycle: anagen, catagen and telogen. The growing phases are anagen and catagen. At any given time, many hairs are in the telogen or resting phase. If there’s a disruption in the cycle of hair growth, you’ll see shedding or effluvium. When you stop hair in the growing phase, you lose it all. That’s the type of hair loss you get from chemotherapy, for instance.  After pregnancy you may experience telogen effluvium, which is not as dramatic. A lot of the androgentic hair loss we see is in the telogen effluvium realm. So, the type of hair loss you have is dependent on what phase in the cycle is affected.

EB: But some hair loss is normal, right? How many hairs should we lose in a typical day?

MT: No more than 50 to 100 hairs per day. If you’re experiencing loss of more than 100 hairs a day you’re going through a period of significant hair loss. And then you need to determine what the cause is.

EB: What about all those products on the market that purport to grow hair?

MT: Most have no utility or effectiveness. However, the most promising are laser technologies and Viviscal® tablets.The laser comb and cap devices are FDA cleared and are reported to decrease inflammation in the scalp and promote hair growth. Viviscal is a marine-complex vitamin supplement that has been shown, in a variety of published research studies, to nourish and stimulate thinning hair resulting in thicker and longer growing hair. Viviscal Professional is the most potent form and can be purchased from physicians only.

EB: So what does help women who are experiencing hair loss?

MT: The old standby is Rogaine® (Minoxidil). Traditionally we used a 2% formulation applied twice daily.  More conveniently, a 5% foam has been approved for once daily use. Propecia® (Finasteride) may also be effective in females, but this is ONLY approved for men. It should not be handled by women of childbearing years. However, there have been studies showing the positive effects of Propecia in post-menopausal woman with hair loss.

EB: Anything else?

MT: The newest and most exciting potential hair growth products are in the category of prostaglandin analogs. You may have heard of Lumigan and the rebranded version, Latisse. Those are products used to grow eyelashes and eyebrows and they work. But they’re not approved for use on the scalp or other areas, as of yet.

EB: How do they work?

MT: We don’t fully understand the mechanism but we do know that they stimulate hair growth.

EB: What can you do cosmetically to, if not stimulate growth, then to at least prevent hair from falling out?

MT: In general, over brushing the hair does not cause hair loss. Wearing a hat does not cause hair loss. Processing your hair does not cause hair loss. However, over-processing your hair, putting it in braids, certainly can cause breakage of the hair. And in extreme cases, Traction Alopecia, which is caused by over-straightening and over-braiding may cause permanent scarring.  But normal hair care does not cause alopecia. It’s important to note that the OTC products that promise to grow hair probably don’t. But it is important to keep your hair clean and if you do have a scalp condition, such as psoriasis or seborrhea, it  should be treated.

EB: What about Biotin? I’ve heard that helps revitalize hair.

MT: It wouldn’t be harmful to take a good multi-vitamin, particularly one representing all the B vitamins, and supplement that with Biotin which seems to strengthen hair. (You want to take about 1500-5000 mcgs/day.) And if it doesn’t grow hair, at least it will strengthen the hair you do have and also enable you to grow thicker fingernails.

EB: Do hair transplants work for women?

MT: They are another reasonable hair treatment option, particularly for females with permanent or significant hair loss.

EB: Does female hair loss differ from hair loss in men?

MT: Women typically lose hair at the crown and retain it at the front of the head, but they rarely lose it all. Hair loss is more diffuse in women; men actually have bald areas, unless it’s an Alopecia Areata situation which we talked about earlier.

EB: What about the emotional toll hair loss takes on women?

MT: In my practice I often see women who present with hair loss and they’re very concerned about it. They don’t understand why it’s happening and it doesn’t really help to tell them that a considerable part of the female population does experience androgenetic alopecia. My job is to diagnose them properly and to rule out other causes. It’s a fact that women with hair loss have fewer options than men. One thing we haven’t yet mentioned are wigs. We call a wig a cranial prosthesis in the medical profession. The good news is that they are often covered under insurance for women with extensive Alopecia Areata.

EB: Thank you Dr. Tomeo.

About Dr. Michael A. Tomeo

Michael A. Tomeo, MD is a Fellow of the American Academy of Dermatology (FAAD). He is the former Chief of Dermatology at Holy Redeemer Hospital in Meadowbrook, PA and is a Clinical Instructor at Hahnemann University Hospital in Philadelphia.  His practice, Advanced Dermatology Center, 215-938-8771, is located in the Holy Redeemer Medical Office Building located in suburban Philadelphia. Dr. Tomeo’s website address is http://www.doctorderm.net.

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