Hair loss (alopecia) – symptoms and treatment

Hair loss (alopecia) is a common problem in which hair is lost from the scalp. The condition can be emotionally distressing and can cause feelings of unease. Many people worry that hair loss makes them look older than they are. This blog will explain the different types of hair loss, their causes, and treatment options.

Definition of illness. Causes of the disease

Hair loss (alopecia) – partial or complete hair loss on the head or other parts of the body, caused by various external and/or internal causes.

Moderate hair loss is a natural physiological process. Usually, a person loses about 100 hairs daily and may not even notice it. The life cycle of a hair consists of periods that alternate asynchronously, so a small percentage of hair falls out simultaneously. They gradually leave the scalp, and new hairs begin to grow in their place.

Typically, patients are concerned about:

• increased hair loss in any period;
• Aesthetic change: visual expansion of the parting, translucence of the scalp through the hair, the absence of hair in any area, thinning, baldness, and complete loss of hair on the head and other parts of the body [2].

Prevalence

Hair loss problems are common worldwide: according to statistics, about 60-70% of men and 25-40% of women suffer from one form or another of hair loss [1]. Hair diseases account for 8% of all visits to dermatologists and trichologists [3].

Causes of Hair Loss

Causes that can provoke profuse hair loss or thinness:

• Physiological conditions associated with changes in hormonal levels: newborn, postpartum period, post-pubertal period, the advanced age of the patient.
• Neuropsychic overstrain – in stressful situations, the hormone cortisol is produced, negatively affecting the hair.
• Deficient states of the body.
• The period after surgery or injury.
• Diseases accompanied by an increase in body temperature above 38.5 ° C and hair loss may increase even after a short rise in temperature.
• Taking certain medications: fibrates, vitamin A and its derivatives, non-steroidal anti-inflammatory drugs (NSAIDs), antiestrogen drugs, antidepressants, cytostatics, lithium preparations, beta-blockers (selective and non-selective), anticoagulants, 6-aminoquinoline derivatives, thermostatic, interferon preparations alpha, anticonvulsants, antiparkinsonian, anthelmintic, antiherpetic, antiviral and some antibacterial drugs, antipsychotics, hydroxychloroquine derivatives, triazole derivatives, oral contraceptives, dopaminomimetics, etc.
• Problems of the hair apparatus include hereditary hypersensitivity of follicles to the effects of hormones.
• Local diseases of the scalp: seborrheic dermatitis, microsporidia (fungal disease of the skin, hair, and nail plates), erythroderma, etc.
• General diseases of the body: endocrine, immune, hormonal, genetic, etc. [4]
• External injuries and damage to the scalp.

The simultaneous combination of several causative factors and the presence of similar problems in parents increases the risk of active hair loss.

Hair loss symptoms

Hair loss can be physiological and pathological. Physiological hair loss is associated with the life cycle of the hair: in this case, 60 to 100 hairs fall out per day, which is considered the norm [15].

There are situations when the biological balance is normal; no more than 100 hairs are lost per day, but this happens simultaneously, so it seems that the hair began to “crawl in tufts.”

As a rule, this happens in the following cases:

• If the hair was in a tight hairstyle all day.
• If there was a long interval between shampooing or combing.

Sometimes the amount of hair shed is much less than 100, but the overall appearance of the hair deteriorates, and thinning is observed. This is possible in the following cases:

• In place of the fallen hair, new ones do not grow.
• The hair itself is thinning.

Pathological hair loss can occur in different ways depending on the disease. Sometimes the hair condition worsens gradually, and the person does not immediately notice the problem. In this case, you can pay attention to some characteristic features.

Features of hair loss in men:

• The hairline gradually rises higher, moving away from the eyebrows and temples.
• Gradually, the hair becomes thinner and lighter; their number is reduced; visually, this is manifested by thinning areas.
• Without correction, thinning becomes more pronounced and noticeable. Such negative dynamics are observed not over the entire surface of the head but only in certain areas, while in other areas, the hair grows in the same volume and quality [17].

In women, the process, as a rule, has its characteristic features:

• Unlike men, hair thinning begins in the parking area. Sometimes it can take on the characteristic appearance of a “Christmas tree”: thinning and thinning of the hair is more pronounced in the central part, closer to the forehead, then the thinning area narrows along the parting, acquiring a triangular shape.
• Without correction, the negative dynamics intensify, the hair becomes sparse and thinner, and it is more difficult for patients to grow the length.
• Gradually, the parting expands, the scalp is visible through the hair, and the length of the hair does not grow [16].

Another variant of the process development is when the hair begins to fall out very sharply and abundantly. In this case, these are the symptoms:

• A large amount of hair remains on the comb, bedding, towels, bathroom drain, and household items.
• There are areas of thinning or lack of hair.
• Rashes and redness appear on the skin of the scalp.

Patients can independently check whether the prolapse is pathological. For this, you need:

1. Recall what happened a few months ago. Was there serious stress or fever? Did the patient take any medications or dietary supplements?
2. Analyze how long ago the active loss began. Does this period exceed 3-4 months?
3. Take a small strand of hair (about 50-100 hairs) in the temple area, pass it between your fingers, and pull it slightly to the side. Then do the same with the strand in the crown area. If, after such a test, more than 5-7 lost hairs remain in the hands, then the problem exists [14].
4. Collect hair and pay attention to the state of the time zones (especially important for men and women in menopause). There is likely a problem if there are bitemporal bald patches (at the temples).
5. For men. Compare the density of hair on different areas of the head. If there are areas where the hair is much smaller, then the condition is considered pathological.
6. For women. Divide the hair on the head into two parts and evaluate the resulting parting. If it expands as it approaches the forehead, there is a problem.

The pathogenesis of hair loss

Hair growth is a natural cyclical process. The scalp has about 150,000 hair follicles. Each follicle goes through certain recurring phases:

• anagen – the period of active hair growth;
• Cartagena – the period of transition from active growth to rest;
• telogen – dormant period.

Some modern authors also distinguish between the exogenous phase, when the hair falls out, and the Neogene, the period of recovery after hair loss [8].

The anagen phase is the period of synthesis and formation of the follicle, as well as the active growth of the hair shaft itself. The hair is in the anagen phase most of the time. Its length depends on the duration of this stage.

Stages of anagen:

1. RNA synthesis and growth of cells make up the papilla of the hair – the place where the rod will grow from.
2. The lower part of the follicle begins to cover the papilla hair.
3. The cell division of the matrix, part of the hair follicle, continues, and a structure resembling a cone is formed.
4. Melanocyte cells begin to produce melanin pigment; a keratogenic zone is formed near the mouth of the sebaceous gland.
5. The future hair shaft begins to rise above the internal root sheath.
6. Internal processes are completed, and the hair appears on the surface of the skin of the scalp.

The duration of the active growth phase is determined genetically but may also depend on the influence of external and internal factors. On average, in this phase, the hair growing on the head lasts 2 to 6 years. For hair on the hands, this phase is only 2-3 months; on the legs – up to 6 months.

The catagen phase lasts an average of 7-14 days. Gradually, all stages of the growth phase stop: for example, melanocytes stop producing melanin pigment, so the hair root area may be lighter. The follicle undergoes many changes: it shrinks by 70%, and the hair root separates from the papilla and begins to move outward.

The telogen phase can last 2-4 months. The hair falls out; the follicle is removed along with the hair shaft. After this, the Neogene phase begins – preparation for the active growth of a new hair. Further, all phases are repeated.

Because of this staging of the hair life cycle, increased hair loss is not observed immediately but 2-4 months after exposure to an unfavorable factor.

Normally, at some point in time, 85% of all scalp follicles are in the growth phase, 1% are in the catagen stage, and 14% are in the telogen stage [9].

Various internal and external factors can influence the life cycle of hair. For example, increased hair loss may occur after taking certain medications. It’s not completely clear how this effect works. However, it is assumed that the preparations’ components negatively affect follicular keratinocytes – cells that cause hair growth. In high doses, cytostatic ( antineoplastic) drugs can slow down the division of hair follicle cells. Antiviral and antibacterial drugs can disrupt the connection between the matrix and the hair papilla, reducing hair nutrition’s intensity and shortening the growth phase.

It is worth noting that these drugs are prescribed by doctors of various specialties for correcting life-threatening conditions, and the risk of hair loss is not a contraindication for taking them. After the drug is discontinued, the hair loss will stop, and hair growth will resume in the same volume.

Sex hormones can also influence the hair’s life cycle, as they regulate this process. Increased content of sex hormones can trigger the disorder, but this is rare. Usually, this condition is accompanied by additional complaints about the absence of the menstrual cycle, sexual dysfunction, congenital pathologies, etc. Also, pathological prolapse may be associated with increased sensitivity of the scalp receptors to the normal level of sexual hormones. In this case, tests for sex hormones will be normal.

Diseases of the scalp can also aggravate hair loss. For example, the manifestations of seborrheic dermatitis and the presence of dandruff negatively affect the nutrition of the papilla hair, shorten the hair growth phase and cause a faster transition to the shedding phase.

Stress and mental strain very often cause increased hair loss. During a stressful situation, the body releases substances to protect vital organs; the nutrition of peripheral tissues at this moment goes by the wayside. In addition, during an emotional shock, the muscles that hold the hair involuntarily contract, squeeze the root of the hair papilla, deprive the blood flow, and disrupt its nutrition. If the event was a single event, then a significant effect on hair growth may not occur, but if such situations occur regularly, this can provoke diffuse alopecia.

Classification and stages of development of hair loss

There is no single, universal classification of hair diseases. However, they can be conditionally divided into cicatricial and non-cicatricial alopecia.

1. Cicatricial alopecia occurs in  20% of cases. With alopecia in this group, tissue nutrition is disrupted, and the follicles atrophy, so hair loss is irreversible. To have time to stop the pathological process, diagnosing it as early as possible is important. This group includes the following diseases:

• Broca’s pseudopelade. The disease is characterized by the appearance of small areas of baldness in the parietal and frontal zones. There is reddening of the skin in the affected areas, and the mouths of the hair follicles are absent. In the central part of the focus, 1-2 long, unchanged hairs can be located. The course is long, while the hair is lost irretrievably.
• Abscessing undermining folliculitis of Hoffmann. Characterized by the occurrence of numerous abscesses, different in size. After their resolution, cicatricial atrophy is observed in areas of scalp inflammation. Hair growth in such areas does not resume.
• Lupus erythematosus. It is characterized by the appearance of areas of alopecia on the scalp in the form of discs with atrophy in the center. Usually, hair loss in lupus erythematosus is combined with a typical clinical picture of the disease. Specific skin lesions include a red rash on the cheeks, nose, and chin. The presence of antibodies to DNA and antinuclear antibodies confirm the diagnosis [6].
• Scleroderma of the “saber strike” type is characterized by the appearance of a focus of sclerosis in the form of an ivory-colored band resembling a scar. As a rule, it is located in the frontal zone of the scalp. The disease’s cause is still not well understood.
• Follicular mucinosis. This is a skin disease in which the structure of the hair follicles and sebaceous glands is destroyed due to the deposition of mucin, the secretion of the mucous glands of the body. Manifested by follicular papules and dense plaques, leading to hair loss.
• Physical damage to the scalp, leaving scars.

2. Non-scarring alopecia occurs in 80% of cases. They differ in that the prolapse occurs without previous damage to the skin, and the follicles do not atrophy. This means that it is theoretically possible to re-grow in place of the lost hair. This group includes:

• Diffuse alopecia. It is the most common reason for visiting trichologists. In this type of alopecia, there is more hair in the shedding phase than usual, and the growth phase is shorter. Clinically, this is manifested by a sharp, abundant hair loss from all parts of the scalp. The most common causes of diffuse alopecia are neuropsychic overexertion, conditions accompanied by an increase in body temperature above 38.5 ° C, and taking certain medications (NSAIDs, fibrates, antiestrogenic drugs, antiviral drugs, immunomodulators, antidepressants).
• Androgenetic alopecia. It is characterized by thinning and thinning of hair in areas with an increased number of androgen receptors: in men – the parietal and frontal regions; in women – the area of ​​​​the central parting of the head with spread to the lateral surfaces. The reasons for the development of this type of alopecia are at the genetic level and consist of the negative effect of dihydrotestosterone on hair follicles [11].
• Alopecia areata (focal) alopecia . It is characterized by the appearance of smooth areas devoid of hair on the scalp. The areas can be single or multiple. A total form of alopecia can develop with the loss of all hair on the skin of the scalp and the body [11]. The risk of developing alopecia areata during life is 1.7%, while the prevalence of pathology is 0.1% [1]. This alopecia is often associated with autoimmune conditions such as vitiligo, thyroid disease, rheumatoid arthritis, and discoid lupus erythematosus. Sometimes the disease is accompanied by damage to the nail plates ( punctate onychodystrophy ).
• Hair loss in various diseases: secondary syphilis, leprosy (leprosy), fungal diseases, anemia, hypothyroidism, myxedema, etc. [5]

Complications of hair loss

The main complication of hair loss is a decrease in the quality of life and emotional dissatisfaction of patients with their appearance. This can affect self-confidence.

Increased hair loss and thinning do not directly threaten health, but in many patients, especially emotionally labile ones, it can form an overvalued attitude towards the problem. A constant focus on the amount of hair that has fallen out and its quality, stress due to the expectation of a deterioration in the dynamics of the process, and the spread of foci contribute to even greater psycho-emotional stress and can form a vicious circle. All this can lead to social maladjustment, depressive states, and apathy [12].

Hair loss diagnostics

Various methods are used to diagnose diseases characterized by hair loss, such as history taking, examination, and laboratory and instrumental studies.

Collection of anamnesis

When questioning the patient, attention is paid to those factors that could provoke one or another type of alopecia. These can be passed, concomitant or chronic diseases, taking medications and dietary supplements, and the presence of similar problems in close relatives.

Inspection

A visual examination of the scalp is done to check for any signs of skin lesions and to assess the severity of thinning and the general condition of the hair. Examining other parts of the patient’s body, including the nails, is also important. Nail plate changes can be an important diagnostic criterion.

The pull or tension test is a subjective method for assessing hair loss activity. The doctor takes a strand of 50-70 hairs and, slightly pulling, passes it between his fingers along the entire length of the hair. The test is considered positive if more than six hairs fall out. Allows you to pre-evaluate hair loss activity in different areas of the scalp [14].

Instrumental diagnostics

Diagnostic trichoscopy is performed using a special device – a trichoscopy. The image from it is displayed on the computer screen. The technique allows you to get an image of the hair structure and assess the condition of the scalp, the degree of hair loss, the condition of the follicle, and the activity of the sebaceous glands. Trichoscopy is painless and does not cause discomfort or adverse reactions. There is no need to do anything special to prepare for the study.

If necessary, a phototrichogram is performed. This type of trichoscopy allows you to get more accurate data. Using this technique, it is possible to identify the initial manifestations of androgenetic alopecia, conduct differential diagnostics in more complex clinical cases, and evaluate the quality and rate of hair growth. The study is based on the performance of technographic images and computer data processing.

To exclude formations in the area of ​​the Turkish saddle ( a bone formation in the middle of the skull), it is possible to conduct overview radiography of the skull. Neoplasms in this part cause neuroendocrine disorders, which are sometimes manifested by hair loss.

Laboratory diagnostics

• If necessary, a clinical and biochemical blood test is performed: ALT, AST, total protein, bilirubin, cholesterol, blood sugar, and alkaline phosphatase are checked.
• Often it is necessary to exclude iron deficiency states; for this, hemoglobin, ferritin, transferrin, and the total iron-binding capacity of blood serum are determined.
• Sometimes it is necessary to determine the level of thyroid-stimulating hormone ( TSH), triiodothyronine (T3), thyroxine (T4) and their free fractions, antibodies to the structures of the thyroid gland.
• If the patient has additional complaints, additional studies may be prescribed, including determining the level of sex hormones, antibodies to DNA, and antinuclear antibodies to rule out lupus erythematosus.

A histological examination can be performed for differential diagnosis and diagnosis in diagnostically difficult cases.

Hair Loss Treatment

The choice of tactics for treating hair loss depends on the type and activity of the process. There are temporary factors; after the termination of their exposure, hair growth resumes in the same volume. Other factors require correction and treatment, and the sooner therapy is started, the fewer hair follicles will be involved in the pathological process.

Medical treatment

For the treatment of hair problems, use:

• Androgen metabolism inhibitors are the first-line drugs for the treatment of androgenetic alopecia.
• Growth factor stimulants. The only substance from this group successfully used to correct androgenetic alopecia is minoxidil [20]. To achieve a visible effect, it is necessary to use the drug for at least nine months. But after the abolition, the hair begins to fall out again [6]. 
• Hormonal and non-hormonal antiandrogenic drugs [21].
• Glucocorticosteroids. Successfully used to treat alopecia areata.
• Antimetabolites and immunosuppressants for the treatment of common forms of alopecia areata.
• Biologic agents such as Janus kinase inhibitors may be used in special cases.
• PRP (plated rich plasma) – platelet -rich plasma . The technique consists of the use of blood plasma enriched with platelets. To do this, the patient’s blood is placed in a special tube and centrifuged. As a result, a layer rich in platelets and growth factors is separated, stimulating tissue repair in the body. The resulting solution is administered intradermally or subcutaneously.
• Mesotherapy. The method is based on the introduction of various drugs intradermally. Efficiency is based on a combination of reflexogenic action from the injections and the drug’s pharmacological action.

Surgery

In addition to therapeutic methods, surgical methods are also used – and utotransplantation of hair follicles from areas where the hair growth and quality are not impaired. The disadvantage of the method is the unguaranteed survival of follicles in new areas [12].

Physiotherapy treatment

Physiotherapeutic methods are used as part of the complex therapy of alopecia. These include cryo massage, darsonvalization, PUVA therapy, galvanization, electrophoresis, and light therapy. However, reliable scientific data proving the effectiveness of these techniques is still not enough.

1. Prevention

It is impossible to reliably predict the course of the disease will be. With timely identification of the problem and the beginning of treatment, the prognosis in most cases will be favorable. However, in many ways, the prognosis for hair loss depends on the disease that caused it:

• With diffuse alopecia, the prognosis is favorable. After identifying the negative factor and stopping its impact, the hair can independently resume growth in the same volume and quality.
• With androgenetic alopecia, the process will be favorable in case of a timely correction. The sooner treatment is started, the more healthy follicles will remain.
• With alopecia areata, the prognosis will depend on the area of ​​the lesion and the presence of damage to the nail plates [18]. If single lesions are observed on the skin of the scalp, then the prognosis is favorable: after medical correction, the hair will grow back in the same amount. If the patient has subtotal, total or universal forms, the probability of complete hair regrowth is 10%.
• With a persistent, persistent course of hair loss, the absence of rational treatment, the prognosis may become unfavorable, and the patient may become completely bald.

Hair will grow worse if the patient has comorbidities or negative family history. The late start of alopecia treatment and psycho-emotional stress caused by worries about hair loss negatively affects.

As a preventive measure for hair loss, you can recommend:

• Promptly treat comorbidities.
• Take medications only as prescribed by a doctor.
• Avoid stress [22].
• Include more fresh herbs and vegetables in your diet [23].
• Do a head massage [24].

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