Although I am a surgical oncologist, I have listened to all sorts of patients complaining about hair loss, and what can be done to solve it. Most of the time the patients have really pressing health issues and the hair is the least of the trouble. However, hair is one of the least discussed medically, but most important feature regarding personal appearance. Hair loss can contribute significantly to anxiety, loss of self esteem, and emotional distress. Having a full head of hair contributes to our sense of well-being. We often speak about hair loss in the cancer patient, but hair loss in women is very prevalent. In the US there are over 21 million women affected by female pattern hair loss. The incidence in women in their 30s is approximately 12% and rises to 30-40% for postmenopausal women.
Each hair follicle undergoes continuous cycles of growth (anagen), resorption (catagen) and rest (telogen). The portion that is visible is called the hair shaft. That which is below the surface of the skin is called the follicle. Hair loss can be a result of disturbances to the hair cycle, damage to the hair shaft, or disorders affecting follicle. We lose normally between 100-200 hairs per day.
The cause of hair loss is multi-factorial. A detailed medical history is important in identifying the cause.
Some questions to think about:
When the hair loss start? sudden or gradual
Have you noticed the most hair loss localized or diffuse? Near the part, or in round patches?
What is my normal hair care routine? Do I bleach, color and perm my hair? Do I blow dry and shampoo daily?
Some Medications can lead to hair loss:
- Chemotherapy such as Adriamycim
- Anticoagulants i.e. blood thinners can cause hair loss that affects the entire scalp usually begins 12 weeks after taking the medication
- Gout medications allopurinol
- Beta-blockers including atenolol, metoprolol,propanolol
- Angiotensin-converting enzyme inhibitor- captopril, enalapril
- Female hormones or contraceptives and hormone replacement therapy and lead to hormone changes
- Antidepressants; including Prozac and Zoloft
- Anticonvulsants
Clinical patterns of female pattern hair loss: non-scarring progressive miniaturization of the hair follicle
TYPE I: Diffuse thinning of the crown region with preservation of the frontal hairline (Ludwig’s type)
TYPE II: frontal mid-line recession with thinning and widening of the central part of the scalp without diffuse hair loss this pattern also involves the superior part of the scalp with thinning is wider in the frontal scalp giving the hair loss area triangular-shaped figure resembling a Christmas tree.
TYPE III: Thinning associated with bi-temporal recession
Diagnosis: mainly a clinical diagnosis
Examination of the scalp: With a magnifying glass, to determine the health and density of the hair follicles
Hair pull test: In which the examiner gently pull on tufts of hair along the scalp.
Hair Density: Devices including Hairquick, Dermatoscope
Other skin: acne, excessive hair, elevated BMI
If the patient’s have generalized signs of hirsutism and acne irregular menses infertility, galactorrhea insulin resistance then polycystic ovarian syndrome is a consideration.
Laboratory tests: Thyroid function, ferritin and vitamin D levels to exclude factors that can increase shedding and aggravate the disease. Patients with a history of irregular menses, elevated body mass or skin signs of hyperandrogenism should be referred to an endocrinologist for diagnosis of PCO S
Other diagnoses that need to be considered in hair loss
Telogen effluvium: Normally the majority of the scalp hair is in the growth phase with a small percentage of hair in the resting phase being shed daily 100-200 daily. Under certain circumstances higher percentage of hair cycles into the resting phase and the woman may notice a sudden onset of marked shedding. The exam usually reveals normal hair density and good scalp coverage on global exam but because more than 50% of the hairs must be lost before hair loss is clinically apparent. The patient is examined while the hair loss is still active, the pull test might be positive otherwise hair regrowth with tapered ends might be seen. The common cause of hair loss could include a high fever, childbirth, severe infections, severe flu, severe chronic illness, major surgery, thyroid disorder crash diets, inadequate protein and certain drugs. Shedding often starts months before the inciting cause but is self-limited and reversible if the offending causes corrected.
Hair breakage: Hair is composed primarily of keratin damage to the hair shaft by improper cosmetic techniques can cause hair breakage. There is little damage from normal dying, bleaching and wave and straightening her breakage can occur with too much tension during the waving, waving solutions left on too long or improperly neutralized waving and bleaching on the same day. Other causes of hair breakage including tension from braids, ponytails, and cornrows. Treatment of hair breakage usually requires alteration of the hair care routine. Hair styles should be looser hair bands. Recommending a cream rinse conditioner with silicone will make the hair more manageable and easier to comb. When the hair is wet its more fragile so vigorous rubbing with a towel and rough combing and brushing should be avoided. Using of wide tooth combs and brushes with smooth tip should be recommended. Also using heat on wet hair causes increased damage hair loss. It is reversible if the cosmetic procedures stopped and the hairs are handled gently.
Androgenic alopecia: Gradual diminution of the hair follicle which occurs during the influence of androgens. Woman with hereditary thinning first noticed the thinning of the hair on the top of their heads scalp becomes more visible over time the hair on the sides may become thinner the patient. Many women notice that the ponytail is smaller.
Alopecia areata: An autoimmune disease effect the most 2% of the population inflammatory cells target hair follicles preventing hair growth. Typically a small round patch of hair is noticed. It is important to identify this because steroids and other immune therapy medications can be used to treat this.
Treatment:
The good news is that there are lots of options for treatment.
1. Changing hair care routine to decrease heat treatments, blow-dry, frequency of shampoo
2. Include products that maintain the health of the hair, and some which increase the diameter of the hair shaft.
3. Medications including minoxidil which stimulate follicle growth
4. Laser light therapy which stimulate hair growth
5. PRP ( platelet rich plasma) to promote hair growth
6. Hair transplantation
If you are interested in a consultation please contact us: Shyamali Singhal MD
doc@surgical-oncologist.com (650) 641-7861.