Hair Loss

Hair growth on the head is individual, i.e. it depends on genetic predisposition and the person’s sex. Each hair grows in a certain rhythm. Of the 100,000 to 150,000 hairs on the head, about 50 to 100 fall out daily, depending on age, and are replaced by new ones. The hairs on the head grow on average about 1 cm per month, and each has a life span of 2 to 6 years. Alopecia is the name for the hair loss that exceeds this natural rate of hair exchange and, depending on severity, results in hair thinning, bald patches or even complete hair loss. A distinction is made between reversible and permanent alopecia. The following article will discuss hormone-related hair loss in women and androgenic hair loss in both men and women.

Hormonally caused diffuse hair loss (alopecia diffusa) in women is reversible and is observed after taking the pill, after giving birth to children and at the start of the menopause. The termination of pregnancy through abortion or birth and the discontinuation of or a change in oral contraceptives (the “pill”) influences the follicle growth of the hair, resulting in diffuse hair loss (telogenic effluvium). Usually 2 – 4 months after the end of a pregnancy, increased hair loss occurs over the whole scalp, include the temples and the back of the head. This condition normalises spontaneously again after a few months. This hair loss is explained by the fact that during pregnancy the hairs stay longer in the growth phase, so the normal rate of hair exchange is reduced. After the birth, however, up to 30 % of the hair follicles enter into an excessive telogenic (hair exchange) phase, which ultimately results in increased hair loss. In nearly all cases, however, short new hairs, which are finer than the old hairs and are pointed at the ends, can be seen growing near the skin’s surface.

Oral contraceptives (the “pill”) can result in slightly increased hair loss during the first 2 – 4 months in which they are taken; this is only a result of hormonal adjustment; however, and subsequently normalises again. As is the case following a pregnancy, so also when women stop taking the pill increased hair loss occurs after a period of 2 – 4 months, but this then normalises again.

During the menopause, the hormonal changes result in a drop in oestrogen levels and to a relative rise in the level of androgens (male hormones).

In the case of hair loss after pregnancy or after a change in or discontinuation of the pill, there is no urgent need for therapy. As the hair follicles remain fully functional, the normal hair cycle returns once the hormone level is back to normal. As a supportive measure, combination medication containing vitamins, cystine and gelatine, biotin or biotin and zinc can be given internally for at least 3 – 6 months. External treatment with scalp tinctures containing oestrogen, e.g. oestradiol benzoate or 17-alpha oestradiol, can be tried, which reduces hair loss in some patients.

The external use of scalp tinctures containing oestrogen (oestradiol benzoate, 17-alpha oestradiol) also appears advisable during the menopause . The oestrogen deficit can be offset by taking oestrogen medication internally.

Androgenetic alopecia of both men and women is a genetically inherited condition involving permanent hair loss. This form usually occurs in men, but can also affect women. The cause in both men and women is an inherited hypersensitivity of the hair follicles to androgens, and in particular dihydrotestosterone. The hair cycle is shortened, the new hair growth is thinner, and then new hairs stop growing altogether as the hair follicles cease to function.

This form of alopecia is responsible for about 95 % of all hair loss in men and up to 90 % in women. In the case of male-type hair loss, the hair follicles increasingly enter into a telogenic phase, or the telogenic phase is prolonged. In the following hair cycles, the anagenic (growth) phase becomes shorter and shorter. The new hairs become shorter and thinner, until finally only very fine, colourless vellus hair is produced. Androgenic hair loss and the resulting baldness in men is irreversible. Hair loss of the male alopecia type begins in early adulthood. Its occurrence is largely due to inherited factors. The increase in androgens, the male sex hormones, during puberty also plays a crucial role. The hair loss usually begins with a receding hairline at the forehead and temples. This is followed by loss of hair on the crown of the head (tonsure). The hair loss then spreads backwards from the forehead, until only the sides and back of the head still have a horseshoe-shaped ring of hair.

Androgenic hair loss also accounts for about 90 % of all alopecia cases in women. As in men, the genetically inherited hypersensitivity of the hair follicles to androgens is responsible for this. During puberty, about 80 % of women have slight thinning of the hair in the area of the temples. In about 25 % of women, hair thinning in the area of the parting occurs after the menopause. In severe alopecia in women, marked hair loss occurs above the parietal bones, with receding at the temples. In women, however, in contrast to men, a front ring of hair remains above the forehead.

Treatment for men: Balding in men is a secondary sex characteristic and is ultimately not an illness. It can only be seen as in illness insofar as it may cause emotional distress. When providing therapy for androgenic alopecia, the patient should be clearly informed that treatment must be continued consistently for years, or more often decades, and that hair loss will continue as soon as the therapy stops.

For mild forms of hair loss, tinctures containing sabal extract are applied externally, sometimes in combination with zinc sulphate, vitamins and amino-acid complex. A slowing in the androgenic effluvium is frequently observed.

Pentadecanic acid monoglyceride is applied one to two times daily and is reported to slow down the androgenic effluvium rate, or even bring it to a standstill, in about 2/3 of patients. There is, however, no growth of new hair. Minoxidil, applied one or two times daily as a 2 % solution, slows down the alopecia or stops it from progressing. New hair have been seen to grow in about 30 % of patients on patches which were already bald. However, hair loss resumes about 4 months after application of the solution is discontinued. Internal therapy with finasteride , 1 mg per day, is able to stabilise hair loss in men in the early stages of androgenic alopecia. Fine vellus hair and normal hair can be observed to grow on patches that were previously bald. The therapy should start as early as possible, so as to stabilise the hair loss. After the discontinuation of finasteride, hair loss can be expected to resume within about 2 years. Receding of the hair at the forehead and temples cannot be prevented by finasteride.

Own-hair transplantation can be used as a form of therapy for people with severe baldness. In this treatment, small bundles of hair or even single hairs, known as mini- or micrografts, are transplanted from the remaining areas of hair growth to the areas of alopecia. This is today an established and safe method, and sometimes results in lasting hair preservation. However, it achieves only a low level of hair density. Moreover, the costs of treatment are relatively high. The implantation of artificial hair has proved only moderately successful, is it is frequently accompanied by severe inflammatory foreign body responses. Toupets or wigs often produce a more satisfactory cosmetic result. Another possibility is hair weaving using false hair. Advice on this can be provided by hairdressers.

Unlike the case with men, androgenic alopecia in women must be viewed as a serious health condition because of the “disfigurement” and the emotional distress this causes. Before any therapy is started, tests must first be carried out in order to rule out any hormone imbalance, with increased androgen levels or other endocrinal disturbances. External treatment of alopecia androgenetica in women is done externally with scalp tinctures containing oestrogens, namely oestradiol benzoate or 17-alpha oestradiol . The latter does not have a systematic effect, but only a local one. The oestrogens act as antagonists at the androgen receptors of the hair follicles. Another possibility is therapy using minoxidil, which can be applied one or two times daily as a 2 % solution; however, this has not yet been officially approved for use by women.

The most effective form of therapy for women is internal treatment with oestrogens or anti-androgens. This inhibits the conversion of testosterone into dihydrotestosterone. It is possible that the androgen receptors on the hair follicles are also blocked. In most cases, ovulation inhibitors with cyproterone or chlormadinone are used. These contraceptive pills can be safely used by most women before the menopause. In the case of moderately severe or severe forms of hair loss, cyproterone can be given cyclically in addition to the ovulation inhibitors. For post-menopausal women, cyproterone alone is often prescribed. Every internal hormonal treatment must be carefully monitored for side-effects. Therapy should always be done in consultation with the patient’s gynaecologist.

Note: Many people who suffer or are afraid of hair loss lengthen the intervals between washing their hair in case this makes the problem worse. This is unnecessary and will not save a single hair. The only result is that the next time the hair is washed, even more hairs will fall out. Infrequent washing also fosters dandruff and, depending on skin types, make the scalp excessively greasy. This can cause irritation and inflammation of the scalp, and this in itself is detrimental to hair growth. Even people with normal hair growth lose more hairs on the day they wash their hair, but then fewer on the day after. So even people with alopecia are strongly recommended to wash their hair regularly – even daily, if desired – using mild shampoos..