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since 7th October 2005
Management of Hair loss In General Practice
By
Dr. Atul M. Kochhar MD, DNB, MNAMS, Consultant Specialist, Department of Dermatology & STD, Maulana Azad Medical College & Lok Nayak Hospital, New Delhi
INTRODUCTION
Hair has no vital function in humans, yet its psychological functions are extremely important. It imparts a youthful and attractive look to both males and females. Various studies have revealed that the person with a regular quantity of hair was rated as most attractive, virile, strong, active, and sharp in either sex. .The negative image of pattern baldness is the underlying factor for the multi-million dollar alopecia treatment industry
HUMAN HAIR GROWTH CYCLE
The total number of hair follicles for an adult human is estimated at 5 million with 1 million on the head of which 100,000 alone cover the scalp. In humans, the only external regions of skin devoid of hair follicles are the palms of the hands and soles of the feet. The basic hair follicle structure remains essentially the same throughout the range of mammalian species with modifications for specialized functions.
Hair growth in each hair follicle occurs in a cycle. There are three main phases of the hair growth cycle; anagen, catagen and telogen. Anagen is the active growth phase when hair fiber is produced. In this mature state of proliferation and differentiation the hair follicle consists of a total of eight concentric layers and melanogenesis occurs within pigmented hair follicles. Anagen is followed by catagen, a period of controlled regression of the hair follicle. Ultimately the hair follicle enters telogen, when the follicle is in a so-called resting state.
CAUSES OF HAIRLOSS
There are several hundred different types and subtypes of officially recognized hair diseases that a dermatologist may have to consider. The most common complaints a dermatologist encounters are; androgenetic alopecia, alopecia areata, telogen effluvium, trichotillomania/traction alopecia, Hair shaft defects from cosmetic processing, and excess hair growth (hirsutism or hypertrichosis). The majority of identified hair diseases are very rare occurring in less than 1% of the general population.
Causes of hairloss can be many and varied. Broadly speaking, hairloss can be either diffuse or localized; scarring (cicatricial) or non-scarring (non cicatricial). Androgenetic alopecia or the male pattern baldness is the commonest cause of diffuse non scarring alopecia while alopecia areata results into localized non scarring alopecia.
OTHER CAUSES
There are many potential causes of anagen effluvium. More common causes are listed below :
Genetic hereditary disease - Pollitt's syndrome, Marie Unna type hypotrichosis
Defective hormone production - Anagen effluvium may be associated with hypopituitarism (hypopituitary dwarfism, Simmond's disease, Sheehan's syndrome), thyroid gland defects (hypothyroidism, hyperthyroidism), Cushing's syndrome, and occasionally juvenile diabetes
Nutrient deficiencies - Extreme deficiency of copper, iron, zinc, biotin, essential fatty acids, or vitamin C in the diet may lead to anagen effluvium
Cancer treatments - Drug categories such as cytostatic drugs, alkylating drugs, and antimetabolic drugs cause anagen effluvium
Ionizing radiation - X rays and gamma rays
Toxic agents - Thallium, arsenic, lead, bismuth, vitamin A and derivative drugs
HISTORY TAKING FOR HAIRLOSS
If the hair loss seems to be acquired later in life then the dermatologist may ask a whole series of questions about the nature of the hair loss.
Does the hair progressively expand over time or does it wax and wane?
Does your family have a history of this type of hair loss?
What do you do to your hair?
How do you style your hair?
Questioning may expand to include other areas of your health and lifestyle not directly connected with your hair.
What other physical complaints are you being treated for?
Do you feel healthy, depressed, fatigued?
Do you have gastrointestinal problems?
Any hormonal complications?
Are you taking vitamin or mineral supplements?
The questioning may become quite detailed if the dermatologist suspects an uncommon diagnosis.
DIET AND YOUR HAIR
The quality of your hair reflects in part the adequacy of your diet: regular, well-rounded meals are best for you and your hair. Consuming extra protein or amino acid preparations will not promote hair growth. In fact, there is evidence that megadoses of some vitamins-particularly A and E may contribute to hair loss. Iron deficiency, due to inadequate consumption of red meat or heavy menstrual bleeding in women, could cause hair shedding. Crash diets and eating disorders such as anorexia nervosa can damage hair dramatically. Hair changes have been reported in anorexia nervosa, where low calorie intake is usually associated with diffuse hairloss. Zinc deficiency resulting from a failure in absorption gives rise to alopecia and cutaneous changes in acrodermatitis enteropathica.
ANDROGENETIC ALOPECIA: Introduction
Medicine has long recognized androgenetic alopecia as an inherited systemic disease associated with sexual development. Ancient Greek doctors realized that male pattern baldness can develop in men of any age after puberty. They recorded that young boys castrated before puberty did not develop androgenetic alopecia regardless of their genetic family history. However, boys castrated during or after puberty could develop androgenetic alopecia.
Despite its standard name of “male pattern baldness”androgenetic alopecia is also the most common form of hair loss in women. Androgenetic alopecia develops as a gradual reduction of scalp hair follicle size, and reduced time in the anagen active growth phase, leading to more hair follicles in the telogen resting stage of the hair cycle. In men, the hair loss is limited to the top of the head and can involve thinning and/or receding hair lines. In women the presentation is different with just diffuse thinning over the top of the head and sometimes thinning over the entire scalp. Of course this is the prime form of hair loss for which treatments are under development by commercial companies.
EPIDEMIOLOGY
Androgenetic alopecia affects between 50 and 80% of Caucasian men. A rule of thumb is for men in their thirties, 30% have androgenetic alopecia. For men in their forties, 40% have alopecia and so on until 80% of men are affected when 80 or more years old. Different ethnic backgrounds have different susceptibility levels towards the development of androgenetic alopecia. These frequency differences between races suggests genetic predisposition is important in pattern baldness susceptibility.
Hair loss is first observed in women in their late twenties to early forties, somewhat later in age than first onset in men. Unlike men the frequency of women affected does not continue to increase with increasing age. After the fifth decade of life the numbers of women with androgenetic alopecia does not increase. Androgenetic alopecia has been suggested to be present in the general female population at a rate anywhere between 20 to 40%. It is perhaps one of the best kept secrets that female androgenetic alopecia is so common.
By far the most common form of hair loss is determined by our genes and hormones: Also known as androgen-dependent, androgenic, or genetic hair loss. It is the largest single type of recognizable alopecia to affect both men and women. It is estimated that around 30% of Caucasian females are affected before menopause. Other commonly used names for genetic hair loss include common baldness, diffuse hair loss, male or female pattern baldness.
Male Pattern Baldness (MPB)
Signs and Symptoms
· Receding hairline
· Moderate to extensive loss of hair, especially on the crown
2. Female pattern Baldness (FPB)
Signs and Symptoms
· General thinning of hair all over the head
· Moderate loss of hair on the crown or at hairline
MPB is the hair loss most frequently encountered. It usually starts with the hair at the temples, which gradually recedes to form an "M" shape. You also may find your hair is finer and does not grow as long as it once did. The hair on the crown of your head begins to thin out and eventually at the top points of the "M" meet the thinned spot on your crown. Over time, you are left with a horse-shoe pattern of hair around the sides of your head. Any remaining hair in the balding areas usually manifests some miniaturization - it is thinner and grows at a below-normal rate, changing from long, thick, coarse, pigmented hair into fine, unpigmented sprouts.
Female pattern baldness usually begins about age 30, becomes noticeable around age 40, and may be even more noticeable after menopause. Female hair loss is usually an overall thinning -- two hairs where five used to be--rather than a bald area on top of the head, though women may have a receding hairline, too. It's thought that about 20 million American women have such hair loss. As in males, hair follicles simply shut down, with hormones playing some role in the process.
A receding hairline reflects age, but not necessarily great age, since some men start balding quite young. With the spurt in androgen secretion at puberty, the hairline moves back a little in 96 per cent of boys and 80 per cent of girls. Most boys continue to shed hair as they mature and, if baldness runs in the family, lose increasing amounts. By age 35 to 40, two thirds of Caucasian men are noticeably bald. The loss may begin at age 20, then stop, only to start up again a few years later. Since this type of baldness is largely hereditary, a man can usually, although not always, predict the extent of his future baldness by examining family portraits. About 50 per cent of children with a balding parent of either sex will inherit the dominant baldness gene.
THE MECHANISM OF BALDING
The rate of hair shedding in androgenic alopecia is speeded up by three forces:
Advancing age,
An inherited tendency to bald early, and
An over-abundance of the male hormone dihydrotestosterone (DHT) within the hair follicle. DHT is a highly active form of testosterone, which influences many aspects of manly behavior, from sex drive to aggression
The conversion from testosterone to DHT is driven by an enzyme called 5-alpha reductase, which is produced in the prostate, various adrenal glands, and the scalp. Over time, the action of DHT causes the hair follicle to degrade and shortens the anagen phase. Thought the follicle is technically still alive and connected to a good blood supply--it can successfully nurture a transplanted follicle which is immune to the effects of DHT--it will grow smaller and smalle. Studies show that while balding men don't have higher than average circulating testosterone levels, they do possess above-average amounts of a powerful testosterone derivative, dihydrotestosterone in the scalp follicles. With a steadily shorter anagen growing cycle, more hairs are shed, the hairs becoming thinner and thinner until they are too fine to survive daily wear and tear. Balding hair gradually changes from long, thick, coarse, pigmented hair into fine, unpigmented vellus sprouts.
But the hormonal link in balding is complex. Eunuchs, who produce no testosterone, never go bald -- even if carrying a baldness gene. However, if castrated men with a family history of baldness are given testosterone, they lose hair in the classic horseshoe-shaped pattern.
Other physiological factors might cause hair loss. Recently, correlation between excessive sebum in the scalp and hair loss has been reported. Excessive sebum often accompanying thinning hair is attributed to an enlargement of the sebaceous gland. They believed excessive sebum causes an high level of 5-alpha reductase and pore clogging, thus malnutrition of the hair root.
Although this condition could be hereditary, they believe diet is a more prominent cause.
Most doctors agree that if you have a oily scalp with thinning hair, frequent shampooing is advised. shampooing can reduce surface sebum, which contains high levels of testosterone and DHT that may reenter the skin and affect the hair follicle.
DRUG INDUCED HAIR LOSS:
Common Drugs That Cause Hair Loss
It is well known that many cancer chemotherapy medications cause baldness. Most people are willing to put up with hair loss when accepting treatments for life-threatening diseases. But a large number of popular medications can alsocause hair loss :
Cholesterol-lowering drug: clofibrate and gemfibrozil
Parkinson Medications: levodopa
Ulcer drugs: cimetidine, ranitidineand famotidine
Anticoagulents: Coumarin and Heparin
Agents for gout: Allopurinol
Antiarthritics: penicillamine, auranofin , indomethacin , naproxen , sulindac, and methotrexate
Drugs derived from vitamin-A: isotretinoin and etretinate
Anticonvulsants for epilepsy: trimethadione
Antidepressants: tricyclics, amphetamines
Beta blocker drugs for high blood pressure: atenolol, metoprolol, nadolol, propranolol and timolol
Antithyroid agents: carbimazole, Iodine, thiocyanate, thiouracil
Others: Blood thinners, male hormones (anabolic steroids)
TREATMENT OPTIONS FOR BALDNESS
Motivation to avoid baldness is not confined to this century. In 1150 BC Egyptian men smear their pates with fats from ibex, lions, crocodiles, serpents, geese, and hippopotamuses. In modern society, this aversion is readily evident from the many available remedies such as creams, hormones, vitamins, hairpieces, wigs, scalp reduction and hair transplants.
NON-SURGICAL TREATMENTS FOR BALDNESS/HAIR LOSS
Balding men and women seem to go to almost any lengths to re-grow thinning hair. Until now, inherited balding in either sex has not responded well to any anti-balding stimulants, applications, injections, or other treatments. Specific foods or vitamins don't re-grow hair -- although good nutrition is essential for healthy hair.
MINOXIDIL
By far the most publicized medical treatment available for male pattern baldness is minoxidil. The idea of using minoxidil topically to grow hair was serendipitous. This drug was originally developed to treat high blood pressure and had the unanticipated side effect of stimulating hair growth, sometimes in unwanted areas. This observation led to the testing of topical minoxidil on balding areas of the scalp.
Who is the best candidate for this drug?
1) young man (20 to 30 years old), who only recently (within 5 years) had begun to bald
2) not completely bald, and
3) not bald at the temples
This drug works best on small areas of vertex baldness (smaller than 1 square inch). There is no evidence that topical minoxidil could regenerate hair on the receding temple area.Topical minoxidil was as effective at a concentration of 2% as at 3%. A 1% formulation was less effective.
Successful treatment, however, does require a lifetime commitment. The topical solution must be applied to the balding area twice a day, every day. Decreasing the dosage to once a day results in some hair loss, and discontinuing application causes regression to pretreatment baldness within 3 to 6 weeks.
Why minoxidil works remain a mystery. It is know to be a powerful vasodilator, but other drugs the dilate blood vessels do not promote hair growth. It is postulated that it delays or prevents some follicles' entry into the next anagen phase for long periods of time and stimulate these follicles back into active production. But this theory remains to be vindicated.
MINOXIDIL :THE DISADVANTAGES :
1) lifetime commitment;
2) high cost : It is not covered by health insurance schemes as it's considered a cosmetic;
3)Its side effects; including itching and prickling, headaches (in 40 per cent), dizzy spells and, in some, heartbeat irregularities. Although apparently safe when rubbed into the scalp - since little is absorbed into the bloodstream - it is a vasodilator and not recommended for anyone with heart trouble. Its safety in men over age 49 and its long-term safety remain unknown. Some scientists believe that minoxidil is more effective in preventing hair loss than in promoting re-growth, but no controlled trials are available.
ANTI-ANDROGEN THERAPY
The most commonly used anti-androgen for women is CPA (cyproterone acetate) in combination with ethinyl-estradiol. Where CPA is not available, the aldosterone antagonist spironolactone has been given in dosages from 75 to 100 mg per day with some benefit. However, higher doses (150 to 200 mg per day) appear necessary to produce a significant increase in cosmetically useful hair, as occurs with CPA therapy.
Anti-androgen treatment must be continued for at least 12 months. Often two years is required before a subjective improvement is observed. Complete reversal of the hair loss can never be achieved unless treatment is instigated within two years of its onset. This is probably due to the atrophy of the miniaturized hair follicles with time. The degree of benefit observed is dependent upon the subject's age and the duration of alopecia; however, most patients are satisfied with the thought that no further hair loss will occur. Some improvement in hair quality should be expected in all cases, although withdrawal of therapy results in further progression of the alopecia.
Nonhormonal aspects are critical to ensure an optimal therapeutic response is achieved. And, the need to maintain vitamin and serum ferritin levels above values previously thought adequate has recently been demonstrated.
The side effects of oral CPA therapy in combination with ethinyl-estradiol are well documented and are similar to those associated with other oral contraceptive regimens. Spironolactone disrupts the menstrual cycle and increases menstrual bleeding in some patients; but, in general, it is well tolerated.
ORAL FINASTERIDE
One anti-androgenic drug now being tried as a baldness remedy is oral finasteride. It inhibits the 5-alpha reductase (enzyme) that transforms testosterone into the dihydrotestosterone (DHT) form responsible for hair loss. Blocking the action of DHT seems to stimulate growth of stronger, thicker and more pigmented hair. In one multicentre study, 200 males aged 18 to 35 with distinct baldness had a one-inch circle of scalp shaved and periodically examined for hair growth. The report states that "men taking 5 mg per day of oral finasteride had significantly increased hair growth.
Side effects - such as impotence, loss of libido and reduced sperm counts - were not widespread, and often decreased with time, affecting about three per cent of the sample." Ideal candidates for finasteride treatment are men who have already fathered all the children they wish, as its use for baldness might be lifelong and it could harm any fetus conceived (while taking it). Further studies are needed to assess the drug's efficacy, dosage and long-term safety.
OTHER BALDNESS SOLUTIONS
WIGS
Wigs made from artificial or, increasingly, real hair, kept in place by adhesives, are becoming more natural-looking. Sutured hair pieces may be permanently stitched into the scalp, i.e., synthetic hair fibers or the real hair of others is permanently attached, sewn in or "shot" (like tiny barbs) into the bald scalp by non-medical technicians. Although claimed to be safe, it is not, because whenever a foreign object is permanently placed in the body there's almost always a consequent infection or skin allergy.
HAIR WEAVING
The procedure is not surgical but merely cosmetic in that it attaches extensions, either natural or synthetic, to existing hairs. On the downside, the extensions must be repositioned every four to six weeks as the hair grows out. Apart from the expense this poses two problems: first, it may be difficult to keep your hair and scalp clean. And second, it stresses existing hair and may cause it to fall out.
Only people with plenty of healthy hair should consider hair weaving. And even they should plan to keep the "intensified" hair for only a few weeks.
COSMETIC REMEDIES
To reduce the visual effect of you thinning hair, you can always resort to camouflage. The universal rule in dealing with thinning hair is, less is more. Cut it short, cut it blunt. It will make your hair look fuller and less patchy, and will be easier to maintain. With longer hair, it would bunch together and the bunches would separate, showing wide expanses of scalp.
SURGICAL TREATMENTS
Surgical hair restoration is the only truly permanent solution to baldness. It involves a series of operations that extract plugs of scalp from the sides an back of your head, where hair grows densely, and implant them on top and in front, where you're going bald.
Restoration is possible because the hair follicles on the sides and back of the scalp are insensitive to the hormones that cause androgenic alopecia, so the hairs are immune to fallout. During surgical hair transplantation, hair follicles are redistributed in balding areas, where they grow hairs that continue to grow for the rest of the individual's life.
Hair Transplantation
There are two type of donor grafts taken from the hair-bearing posterior scalp: cylindrical, elliptical (also macrografts) and micrografts or minigrafts.
The most common type of Macrografts is cylindrical plug. Using a device like a hole puncher, the surgeon removes 1/8-inch-round graft containing about 12 to 20 hairs and placed into a smaller cylindrical hole in the anterior balding region of the scalp. Depending on the degree of baldness, 1 to 4 sessions of transplantation are required, with placement of 50 to 60 plugs at each session. Successive transplantation sessions are scheduled with at least a 3-month interval between procedures. The number of grafts depends on the hair coverage desired.
Elliptical grafts are used for large posterior areas of baldness. Nowadays macrografts are no longer used by most surgeons, since these techniques tend produce artificial appearance.
Micrografts (1 to 2 hairs) or Minigrafts (3 to 4 hairs) are implanted along the anterior hairline to mask the "doll's hair" look of the cylindrical plugs and give a natural appearance to the hairline.
A narrow two-inch section of scalp is removed from the back of the head. It is then divided into 1 to 2 millimeter grafts and implanted in tiny incisions made in the bald area. When used with other procedures, at least two sessions may be required.
After transplantation, the recipient area is covered with a scab for several days, the donor hairs fall in 2 to 4 weeks, and new definitive hairs grow within 3 months. If topical minoxidil is applied twice daily beginning within 48 hours after hair transplantation, the hair in the grafts will stay and re-growth of hair begins immediately.
Typically, men with hair loss limited to the frontal area of the scalp are the best candidates for hair transplantation. However, the patient's age and the potential for more extensive baldness must be considered carefully. These factors may dictate that other procedures should be performed in addition to hair transplantation.
Principles of Hair Care
Each year, millions of individuals spend billions of rupees on hair-care products and treatments. Unfortunately, some of these efforts are too rough or done frequently. The result is hair damage rather hair care. Damaged hair stays damaged until it grows out and is cut off. This can take many months, because hair grows only about 1/2 inch each month.
SHAMPOOS AND CONDITIONERS
Choosing the right conditioner or shampoo for hair can be a matter of trial and error. Some products may make your hair limp, while others may even dull it with a film. Hair gets dirty when sebum, coats the shaft. Dead skin cells and airborne dirt stick to the sebum.
Shampoos do not penetrate hair, but they do coat it, giving hair more bulk. A protein shampoo acts as a shampoo and conditioner in one. The shampoo should be followed with a cream rinse or conditioner. These products lubricate hair between washings and help minimize damage from brushing or combing.
A "good" shampoo leaves hair manageable, easy-to-comb and glossy. Most modern shampoos are synthetic detergents called surfactant. Surfactant molecules surround a tiny glob of oil, forming a package called a "micelle." Rinse water carries the micelle away. Coloring, perming, combing, teasing and shampooing can break the cuticle's long protein chains. The cuticle gets shaggy, and hair becomes rough. Static, due to combing, can develop.
Most modern conditioners contain cationic quaternary ammonium compounds that provide a positive charge, which reduces static and makes hair more manageable. Some products, particularly those containing benzalkonium chloride as the active ingredient, are good conditioners. Those with added polymers, collagen, balsam, silicones or resins that bond with and coat the hair shaft, may provide a protective film, smooth out the cuticle, reducing snarls and tangles. Conditioners that give "extra body" may contain waxes that, when dry, make it look fuller, some contain oil/fats (e.g., lanolin, mineral) to smooth hair, and a few have humectants that supposedly hold in water content. Price and exotic ingredients bear little or no relation to efficacy. Most conditioning products that claim to nourish hair do nothing of the sort as the ingredients cannot enter the hair .
It is a myth that shampooing increases hair loss. Whether dry or greasy, hair should be washed as often as required to look good, even every day. Most experts recommend at least once a week washing to prevent dandruff from clogging the scalp. If you have an oily scalp, frequent shampooing will keep the hair from lying flat, weighted down by the fats in sebum. Shampoo will also reduce surface sebum, which contains high levels of testosterone and DHT that may re-enter the skin and affect the hair follicle. Very dry hair may be improved by massaging with a little olive or almond oil, covering and leaving on overnight, washing out next morning. If done gently, daily shampooing will not damage your hair. The amount of washing will depend on the type of your hair, the weather, your physical activity, and perhaps even your occupation.
A proper and thorough brushing should precede every shampooing. For proper washing, wet your hair completely with warm water. The first rinsing acts as a pre-wash to remove dust and water-soluble dirt and hair-care products.
HAIR CARE
The hair requires gentle handling. Wet hair is especially fragile because it might become stretched. After washing, hair should be towel dried by patting gently. Since heat from curling irons and blow dryers are notorious hair destroyers, to prevent damage, the hair should be dried naturally. If a blower is necessary, it should be used on a lowest setting, which leaves the hair slightly damp. An occasional massage with the fingertips enhances blood flow to the scalp.
A natural bristle brush is preferred over a synthetic one because the synthetic material may create static and cut the hair. Brush the hair gently from the scalp to disperse scalp oil over the hair. Brushing is especially important for long hair because the natural oils do not normally reach the ends, but it's equally beneficial for short hair. It increases circulation to the scalp and stimulates hair growth
STYLING
Certain hairstyles and treatments can cause breakage or root damage.
· Avoid excessively tight braiding, buns, or ponytails.
· do not roll your hair too tightly in curlers.
· Teasing and backcombing should be done gently or not at all.
· To much exposure to sun, wind, or swimming pool chemicals will dry out your hair and cause it to knot.
· A styling gel or mousse can give your hair more body or thickness. They do not necessarily damage your hair, but you may experience extra dryness, especially at the hair ends.
· Hair dyes work more like paint by covering hair strands with color or by mixing with the melanin granules without altering them. Dyes come in temporary form, which eventually washes out, and semi-permanent and permanent forms, conduct a patch test to check for possible irritation, because a severe allergic reaction to hair dye could cause hair loss.
· Curling is safest if you twist your hair into pin curls overnight. Use of hot rollers or curling irons gives the best results for coarse hair, but they may damage strands or roots when used to excess. When you use a curling iron always roll in the ends last. For safe curling of fine hair, let it air dry and wind it loosely around sponge rollers.
· Permanent waving rearranges the inner hair molecules, breaking and reforming its sulfur bonds, in a step-wise chemical process (that gives off the familiar sulfide odor which wafts off the head being waved). Permanent waving is safe for healthy hair, but you may find it results in increased dryness and splitting. Straightening and permanent waving use the same chemical methods to change the properties of hair strands.
SUGGESTED READING
Diseases of the Hair and Scalp, 3rd Edn. Dawber R Oxford: Blackwell Science, 1997.
Hair and Scalp Disorders :Dawber RPR, Van Neste D.. London: Dunitz, 1995.