Hair Loss

Introduction

Hair loss is now a days a very common problem affecting more than 60% of men and in approximately 10% of women. With our changed lifestyles and working environment almost everyone of us have suffered hairloss problem at some point of time.

The market is full of various products that treat hair loss. Many of these products, which include shampoos, hair-care cosmetics, scalp massagers and many more have no proven efficacy. At best they can temporarily increase the volume of existing hair, resulting in a denser appearance than before. Minoxidil and Finasteride are the two US Food and Drug Administration (FDA) approved medications, which have proven limited but definite benefit.

Till date hair transplantation remains the only affordable and the Gold standard treatment for baldness.

Causes of Hairloss In Men

Male Pattern Baldness is a common cause of Hairloss in Men

This is one of the leading causes of baldness in men and is medically known as androgenic alopecia. In androgenic alopecia there is loss of hair over the scalp in “M-shaped” pattern. Over the period of time the baldness will progressively involve more and more areas of scalp pushing the hair line posteriorily. In response to the male hormones the hair growth becomes stunted and the hair follicles shrink, leading to thin and stunted hair which is also called miniaturisation of hair.

Stress can Trigger Hairloss in both men and women

Severe physical stress (like surgery or trauma), severe psychological stress (like a death in the family) or mental tension like sudden financial crisis, job problems or business losses can also lead to rapid hair loss. The exact patho-physiology is still not very clear as how chronic or long-term stress affects hair loss.

 Hairloss can be due to Vitamin and Mineral Deficiency

General malnutrition, crash diet for weight reduction or some vitamin deficiencies can not only make the hair thin and brittle but can also lead to hairloss and baldness. The most common deficiency which is thought to contribute to hair loss is iron-deficiency anemia. Deficiencies in other nutrients like vitamin B deficiencies, Vitamin E deficiency and protein deficiencies can also lead to hair loss. Some of the essential minerals like zinc, magnesium and calcium deficiencies can also trigger hair loss.

Medications can also lead to Hairloss

Many Chemotherapeutic drugs and some other medicines like anti-thyroid medications, hormonal therapies, anti-epileptics, anti-coagulants and beta-blockers can also trigger hair loss. These medications tend to affect the hair growth cycle forcing the hair follicle transition from growth phase (anagen phase) to the resting phase (telogen phase).

Some scalp Infections lead to Generalised or Local Hairloss

The most common scalp infection leading to hair loss is a fungal infection called ringworm or Tinea capitis. This dermatophyte survives in warm and moist conditions which typically arise due to poor hygiene and scalp care. They release chemicals to destroy the hair roots and also compete with them for nutrition. Once they have stayed for some time it is difficult to eradicate them and patient has to undergo long term treatment extending from few weeks to months. It is advisable to visit your dermatologist on regular basis.

Auto Immune Disease

Auto-immune diseases can also cause loss of hair from the scalp and can result in hair loss of various kinds, including cicatricial alopecia and telogen effluvium.

Hypothyroidism

Hypothyroidism can cause atchy hair loss known as alopecia areata (which can affect the whole body and not just the head).

Trichotillomania

Trichotillomania is the name given to the habitual plucking or pulling of the hair from the head. Over time, a bald spot will develop over the involved area of scalp and if this habit is not stopped then there can be permanent loss of hair in that portion.

Tight Bands or Pulled Up Hair

Though more common in women but even in men wearing hair in tight braids (like dreadlocks or cornrows) or having hair tightly pulled back can lead to hair loss. This is also known as traction alopecia. It is caused by chronic pulling of the hair, leading to gradual hair loss, mostly at the hairline.

Causes of Hair Loss In Women

Telogen Effluvium

Telogen effluvium is sudden loss of hair which occurs after pregnancy, major surgery, drastic weight loss, or extreme stress. It can also be caused by various medications such as antidepressants, beta-blockers, and nonsteroidal anti-inflammatory drugs. During telogen effluvium the hair shifts faster than normal from its growing phase into the “resting” phase before moving quickly into the telogen, phase.

Hereditary Hair Loss

This is also known as androgenetic alopecia and this is also an important cause of hair loss. The gene can be inherited from either mother’s or father’s side of the family.

The condition develops slowly and may start as early as in 20s.

Hypothyroidism

Hypothyroidism leads to reduced basal metabolic rate which slows down the growth of hair and can lead to loss of hair in long run. This leads to reduced hair density and diffuse loss of hair. Correction of the cause leads to revival of the lost hair.

Lupus

This is a chronic autoimmune disease in which the body’s immune system attacks the healthy tissues. Many people experience hair loss which can be mild or it may be more severe leading to patchy areas of hair loss accompanied by a rash over the scalp.

Iron Deficiency Anemia

Polycystic Ovarian Syndrome

The condition can begin as early as 11 years of age and is caused by a hormonal imbalance due to production of male hormones by the ovaries. PCOS may cause hair loss over scalp facial hair growth, irregular periods, acne, and cysts on the ovaries.

Skin Conditions of the Scalp

Skin conditions that lead to hair loss include seborrheic dermatitis (dandruff), psoriasis, and fungal infections such as ringworm.

Alopecia Areata

Alopecia areata is an autoimmune disorder which may be triggered by stress or illness leading to development of round, smooth patches of baldness on the scalp, eyebrows, or legs. Total loss of hair over the head is known as Alopecia Totalis, while hair loss from all over the body is called Alopecia Universalis.

Excessive Styling

Too much shampooing, using strong shampoos without hair conditioning, some hair styling procedures and excessive and frequent dyeing can harm lead to hair loss. Heat and chemicals used over hair lead to weakening of the hair structure and loosening of the root of hair.

Anatomy of Scalp & Hair

Anatomy of Scalp

The scalp is divided into five layers, which are the skin, connective subcutaneous tissue, galea aponeurosis, loose connective tissue, and periosteum over the cranium.

The skin contains all the epidermal appendages, including the hair follicles which extend into the underlying connective subcutaneous layer. How deep the hair follicle is also depends on the stage of hair cycle. Just before fall the hair follicle is quiet superficial in the scalp. In areas which have undergone hair loss, there is thinning of the outer two layers. This can be better appreciated on comparing the skin punch biopsy from the scalp in recipient areas with that in donor areas.

Blood supply to the hair follicles come through the vascular channels in the subcutaneous layer. This has importance while harvesting hair from the donor areas where one has to stay superficial along the connective subcutaneous tissue layer to avoid compromising hair density or hair loss at the donor area. One must not try to reach galea during graft harvesting to avoid compromising scalp blood supply and future neuroma formation (sensory innervation of the scalp closely follows the vascular supply). Deeper penetration might on occasions can lead to reduced scalp sensation over few weeks when a large number of graft recipient slits are made along the hairline.

Anatomy of Hair

Scalp hairs mostly do not grow individually; they are often found to grow in tiny follicular-unit bundles, which usually contain 2-3 hairs and occasionally 1 or 4 hairs. An individual follicular unit contains on an average 2-3 terminal hairs, a sebaceous gland element, and insertions of the arrector pili muscles wrapped in a tissue sheath. There are few areas having stem cells in the follicular unit and this is the area of great research and hope for hair transplant patients. While separating individual hair follicles one should try to inflict minimal damage to the tissue adhered to the hair bud so that maximum number of live stem cells can be transferred to the bald areas of scalp.

Classification

Scalp of a normal adult contains around 1 million hairs. By the middle age you lose about 30% of your hair. For hair thinning to become noticeable, at least 50% of the hairs must have fallen out in that particular area. In addition to the loss of the number of hairs, the thinning of hair also make that area look bald.

The most widely accepted classification system for androgenic alopecia is the Norwood Classification System. This classification recognizes and categorizes the typical sequence of the hair loss process in men in seven stages. In early stages, the hairline recedes, typically led by fronto-temporal recessions. In the latter stages (types 4-7), progression of hair loss at the vertex (crown) gradually meets and joins the progressive hairline recession, resulting in varying shapes & sizes (in both coronal and sagittal dimensions) of the confluent vertex with fronto-temporal regions of baldness.

In women, the development of androgenic alopecia is classified into three stages. The typical pattern of hair loss in women is progressive diffuse thinning of an oval area over the top of the scalp. Hair loss along the hairline is usually spared.

Personal & Social Implications

For millions of people around the globe, hair loss is a major problem associated with low self-esteem, insecurity, social reclusiveness and even depression. Loss of scalp hair gives an individual older or aged looks as it is regarded as one of the common signs of ageing. Men start getting inferiority complex in their peer group and friend circles specially in presence of girls. Baldness in young age leads to reduced social interactions specially with opposite sex. Men become shy of talking to girls. Sometimes they get ridiculed for their bald looks. Sometimes they get rejected by the opposite sex. They also face rejections in marriage proposals and find it hard to get a good life partner. Even after marriage baldness can make you feel slightly less wanted. Your children also start asking you about your bald head and start comparing you with father of their friends and start saying how handsome that uncle is. In social gatherings and family functions a bald look can force you to be with people with much elder age group. You are not able to enjoy with the younger lot in the party. You become photophobic because of your bald looks. You start hiding from the cameras. You stop uploading your photos on social networking sites.