Alopecia

Alopecia is the medical term for hair loss. There are 4 main types which have distinct casuses and patterns of hair loss

  1. Alopecia Areata
  2. Pattern hair loss - male and female types
  3. Scarring alopecia
  4. Chronic telogen effluvium

Basic biology to aid understanding

All hair follicles contain a number of stem cells. These cells can regenerate over and over again and are essential for continued hair growth. Hairs have three stages in their life cycle-

  1. Anagen ( growth) , the length of anagen varies between individuals ( 4-7 years generally). Some women can grow their hair down to their waist whereas others never manage this as their anagen duration is shorter. There is a condition called short anagen syndrome characterised by hair that only grows for 1-2 years. Children present to clinic having never needed a haircut.
  2. Catagen ( present but not growing, lasts 2 -4 weeks)
  3. Telogen ( falling out)

 

What is this condition?

Hair loss can occur for a number of reasons. Diagnosis can be difficult. It is unlikely that you are going to make a precise diagnosis using a website. If you think that you have a hair problem, SkinCompare recommends that you see either your GP or a Dermatologist who will be able to guide you further. You need to get a precise diagnosis which may involve scalp biopsies and blood tests.

Due to the unregulated nature of much of the UK cosmetic and food supplement industry you will come across all manner of products making very bold claims about they can benefit your hair. Do not be taken in. In some cases of hair loss some simple blood tests may be needed to exclude iron deficiency or an underactive thyroid. Taking hair supplement tablets, often bought at great expense online, is not the correct approach. If there was an easy solution to hair loss by taking supplements, the medical profession would tell you about it and would have evidence from clinical trials to prove the benefits.

There are four main  groups of hair disorders that can occur. Some are easier to recognise than others. Some can be treated but in some cases treatment is very challenging and other options such as wigs or hair weaves such as the intralace system ©  may be needed.

 

1.Alopecia areata

Alopecia areata (AA). The classical form of AA is where small circles of hair loss appear on the scalp. The hair will often regrow without treatment. This can take 2-3 months.  A small proportion of patients become more severely affected. Eye brows, eye lashes and body hair may be affected. There is sometimes a family history. Studies have identified gene variations that are linked to AA. It remains unclear what the triggers are for the condition and why the severity varies so much between individuals.

Treatment by injection of steroid into the scalp can speed up the regrowth in many cases. Some clinicians advocate treating as soon as possible to minimise the development of abnormal immune memory cells although this theory has not been proven. Steroid creams are generally unhelpful due to a lack of penetration. Various systemic immune modifying tablets that reduce the activity of the immune system have been used to treat alopecia. Most are not officially licensed for alopecia and are generally not used in the NHS. It is difficult to balance the risks of infection and side effects against the psychological harm of hair loss.

2. Pattern hair loss

Male and female pattern hair loss share some features but have many differences. In female pattern hair loss ( FPHL) the hair becomes thinner on the top of the scalp. In contrast to male pattern hair loss the frontal hair line is normally preserved and recession at the frontal hair line whilst possible is unusual. As with male pattern hair loss hormonal factors including an increased sensitivity of the follicles to testosterone are thought to be involved but the precise mechanism is not clear. Some hair scientists feel that female pattern hair loss is not simply the female version of male pattern hair loss. Female pattern hair loss can affect young women but becomes more common in older post-menopausal women.

The only licensed treatments for FPHL are topical Regaine ( minoxodil) and hair transplantation.

In men finasteride ( Propecia) is widely used. When used early on it can have a significant impact on reducing further hair loss. It does seem to have a bigger impact in younger men. When treatment is stopped the hair loss will progress to the stage that it would have been without treatment.  Hair transplants work well for some men although the need for top up treatments must be acknowledged especially if having surgery at a young age. Many men accept hair thinning by buying some clippers and focussing on other aspects of their life. This is a very efficient choice with many benefits but is clearly not suitable for everyone. Hair loss can clearly be a distressing process and it is understandable that many patients make an attempt to delay or stop it. The time and effort spent on a very common and physically non life threatening process does need to be balanced against the other more invasive and expensive options.

3. Scarring alopecia

There are many types of scarring aloecia

  1. Frontal fibrosing
  2. Lichen planopilaris
  3. Folliculitis Decalvans
  4. Central centrifugal
  5. Traction

There are a number of different disease processes that can lead to scarring alopecia. These include discoid lupus, lichen planopilaris, frontal fibrosing alopecia (FFA) , folliculitis decalvans, traction alopecia, central centrifugal alopecia and pseudopelade . These conditions all have different clinical characteristic features but they all share the problem that follicle stem cells are damaged and the hair follicles lose the ability to produce new hairs leading to the appearance of scalp scarring with absent hair follicles. Once the stem cells are destroyed they cannot be replaced. Scarring alopecias can be very difficult to treat. Early diagnosis is important but treatment is not always effective.

 

Frontal Fibrosing Alopecia (FFA) was first described in the 1980s and was initially rare. It is now diagnosed more frequently and there are various theories as to why it may be becoming more common.  This form of hair loss is almost exclusively seen in women with only very rare cases in men. The main theory currently is that frequent use of sun screens is triggering the activation of the immune system in the skin. Most sunscreens contain chemicals that dissipate the energy within the UV light and prevent sun damage. This is currently an unproven theory.

In the early stages redness (erythema) and dry skin (scaling) is seen around the hair follicles along the frontal hair line. The temples , eyebrows and arms can also be affected. Inflammation occurs in the hair follicle. If the inflammation is severe enough the hair follicle stem cells are destroyed which means that a new hair cannot grow from the follicle. The follicle disappears and the skin takes on a scarred appearance . FFA is classified as a scarring alopecia.

The following images show a case of FFA.

 

Treatment.

There are no proven treatments for FFA. Any local treatments need to be targeted at the affected hair follicles and the hair behind the affected area to try and preserve these hair follicles. The main principles of treatment are to reduce the inflammation and prevent stem cell death.

Options include

  1. Topical steroid creams
  2. Injected steroids.
  3. Tablets to suppress the immune system such as hydroxychloroquine.

It can be very difficult to assess whether treatments are working. The clinical course for many cases of FFA is not for complete hair loss. The inflammation occurs for a period of time, damage is don and then everything stops. Patients will often present quite late having noticed their hair loss. If they then start a treatment they may think it is working when actually their diseases process was simply coming to a natural end. There is no way of telling how long FFA inflammation will last so many patients opt for treatment so that they are doing all they can to limit further hair loss.

It is important to take structured photos to monitor the progression of the disease and the response to treatment. Patients can do this themselves using skin monitoring apps such as MySkinSelfie.

4. Chronic telogen efluvium

Telogen effluvium. Hairs are normally found in different phases of the growth cycle. Under some conditions such as pregnancy or illness, the hair growth can become synchronised and lots of hairs enter anagen at the same time. This means that following the end of the pregnancy or illness large number of hairs enter telogen at the same time and all fall out together. Following the pregnancy or during recovery from the illness the hair usually returns to normal.

Chronic telogen effluvium. In this condition women notice a generalised thinning of the hair all over the scalp. This condition has not been totally unravelled. What seems to happen is that the growth cycle of the hair is adversely affected by various factors. These include conditions such as iron deficiency or an underactive thyroid, various medicines, possibly stress and probably other unknown triggers. The proportion of hairs entering telogen increases and possibly the proportion entering anagen reduces. In other words, there are more hairs falling out than growing. There are still some new hairs growing so complete balding does not occur but over time a general thinning of the hair is seen.

This can be one of the most challenging forms of hair loss. If a precise cause is not found do not be tempted to waste money on supplements. Make sure iron stores and thyroid function are normal and possible medication triggers have been removed. Eat a healthy diet.

You may want to try Regaine although the results are sometimes disappointing.