Alopecia/Hair loss

Hair loss is one of the most common conditions which doctors are asked to treat. When seeing your doctor, he/she will be thinking of your problem more or less in the following manner.

There are two groups of hair loss, namely: 

  • diseases of the hair shaft and
  • all other forms of hair loss.

  • A. Disorders of the hair shaft are very uncommon and are usually seen in practice as a complication of chemical treatment of the hair. The hair is fragile and the shafts break off. Very uncommon genetic variants are also seen.
  • B. All the other forms of hair loss are divided into two groups, namely scarring and non-scarring hair loss.

Scarring hair loss is usually permanent and can affect only parts of the scalp or the whole scalp. These are conditions which are diagnosed and treated by dermatologists.

Non scarring hair loss is fortunately not permanent and can also affect only parts of the scalp or the whole scalp. 

For the impression of fullness on the scalp, you need about 140,000 blond hairs, 110,000 brown hairs, 108,000 black hairs and 90,000 red hairs. This difference is due to the fact that blond hair shafts are the thinnest and red hair shafts are the thickest.

The average scalp has about 100,000 hairs and it is normal to lose up to 100 hairs per day. 

The most common forms of hair loss that doctors see in practice, are the following:

  1. Alopecia areata

  2. Trichotillomania

  3. Chronic, diffuse, non scarring hair loss and

  4. Male and female pattern baldness (Androgenic alopecia)

A. Alopecia areata is a common form of hair loss where the patient has well defined, usually circular areas of hair loss, mostly on the scalp. Children are mostly affected. The condition can become more widespread to involve the whole scalp (alopecia totalis) or even the whole body(alopecia universalis). This is an outo-immune disease where the body “attacks” its own hair roots.

Treatment of alopecia areata varies from topical corticosteroid creams to oral corticosteroids and even a topical sensitizer.

B. Trichotillomania is less common. It is self induced, compulsive plucking or pulling of the hair and is regarded as an “impulse control disorder”. Bizarre shapes of hair loss can be seen. Any area of hair can be affected, including the eyebrows. The majority of patients will deny the plucking. It is usually done to relieve stress or tension.
Treatment will be towards relieving the latter.

C. Diffuse, non-scarring forms of hair loss are mainly two distinct types.

Firstly, anagen effluvium which is seen a rapid form of hair loss usually after chemotherapy (anti-cancer) drugs were administered.

Secondly, telogen effluvium which is seen after severe, acute or chronic illness, after high fever, after severe emotional stress, after major surgery, due to crash- or liquid- or starvation diets, after delivering a baby, due to certain glandular diseases and due to certain drugs (medicines). There is always a lag time of about three months between the incident and the beginning of the hair loss. Fortunately patients do not become totally bald. As long as the patient recovers from the illness, the hair will re-grow. No treatment is necessary except support to help the patient recover from the original condition.

D. Androgenic alopecia

This is an inherited disorder of the scalp hair roots. The roots are genetically programmed to gradually become smaller and smaller over a period of many years under the influence of male hormones. The number of hairs do not decrease until very late in the disease. It is so common that some doctors think of it more as a physical trait than a disease.
According to some studies, 80% of Caucasian men above the age of 70 years show male pattern baldness. Miniaturization of the normally strong hairs results in fine hairs distributed in a horseshoe shape around the scalp.

Treatments used are the following: Topical minoxidil lotion and/or oral finasteride.

This same condition is also described in women, where it is known as female pattern baldness. In women the most common pattern is that of diffuse central thinning of the crown, but the hairline on the forehead is retained. Balding in women can happen during or after puberty, around the menopause or after the menopause. 
Estrogen replacement can stop the hair loss, but unfortunately does not promote regrowth. Drugs most often used are the following: oral contraceptives, cyproterone acetate or spironolactone orally. Topical minoxidil is usually added to the above oral medications.

While evaluating your hair loss problem, your doctor will take the following into account.

  1. Family history of baldness
  2. History of febrile illness, starvation, emotional stress, the birth of a baby or surgery.
  3. Medication taken, including over the counter medicines and drugs and supplements.
  4. Crash diets
  5. After hair treatments at home or in the salon.
  6. Oral birth control pills or steroid medicines.
  7. Pre existing or associated skin conditions
  8. Review of your glands
  9. History of menstruation and infertility problems.
  10. Anemia

Your doctor will then proceed to do an examination of the following:

  1. General skin exam to look for associated skin diseases
  2. Scalp exam to look for diseases of the scalp
  3. Hair exam to look for diseases of the hair shaft

Hair loss is normally a clinical diagnosis. Limited blood tests are usually requested, depending on the above findings. A scalp biopsy, during which a small piece of skin is taken from the scalp, is seldom indicated. This is usually only done when one of the scarring forms of hair loss is suspected.

Treatment of alopecia

Treatment is as discussed under the above headlines. However, surgical treatment of some forms of hair loss has become very successful. Hair transplantation can achieve permanent cosmetic improvement. It is a tedious and expensive procedure but the results can be very gratifying. Scalp reductions and scalp flaps are also done for very specific indications.