Hair Loss in Women

Presented by:

Emily M. Altman, MD, FAAD

October 17, 2013

First, this important statement!• Any treatment suggestions discussed in

this lecture must be discussed with your physician.

• Not all treatments are suitable for all patients.

• Your health and well-being is our primary concern.

Disclaimer

• I do not have any conflicts of interest in any products, devices or medications which I mention in this talk

So, why do we care so much about hair?

Why hair loss?

What brought me to be interested in this common dermatologic condition?

Psychosocial Impact of Hair Loss

Hadshiew et al. Burden of Hair Loss: Stress and the Underestimated PsychosocialImpact of Telogen Effluvium and Androgenetic Alopecia. J Invest Dermatol 123: 455–457, 2004

HAIR FACTS

Hair Facts• Hair grows everywhere on the human skin except on the

palms and soles

• Many hairs are so fine they're virtually invisible.

• Hair is made up of a protein called keratin

• As follicles produce new hair cells, old cells are being pushed out through the surface of the skin at the rate of about six inches a year.

Hair Facts• The hair you can see is actually a string of dead keratin

cells.

• The average adult head has about 100,000 to 150,000 hairs and loses up to 100 of them a day; finding a few stray hairs on your hairbrush is not necessarily cause for alarm.

Hair Shaft

• Cuticle• Medulla• Cortex• Sheath

Electron Microscopy of Hair

Sciencebuzz.org

Electron Microscopy of Hair

Damaged hair in the middle of the hair shaft

Damaged hair at the tip of the hair shaft

http://researchnews.osu.edu

Hair Types-Lanugo

• Lanugo hair-fine hair that covers the fetus, shed in utero at about 36 weeks gestation.

• Lanugo hair in adults can signify health problems

Wikipedia.org

Hair Types-Vellus• Vellus hair-short, fine, light-colored,

and barely noticeable hair that develops on most of a person’s body from his/her childhood. 

Wikipedia.org

Hair Types-Vellus

• Hair does not grow on the lips, the back of the ear, palms, soles, some external genital areas and the navel.

• Vellus hair cannot be removed by LHR due to lack of pigment.

Hair Types-Terminal

• Terminal hairs are thick, long, and dark, as compared with vellus hair. 

• During puberty, the increase in androgenic hormone levels causes vellus hair to be replaced with terminal hair in certain parts of the human body.

Hair Types-Terminal

SCALP Layers

• Skin• Connective tissue

(subcutaneous tissue)• Aponeurotica (galea

aponeurotica)• Loose connective tissue• Pericranium

Follicular Units

• 1-4 terminal hairs• 1-2 vellus hairs• Sebaceous glands• Erector pili muscles• Blood vessels• Nerves• Connective tissue

Normal Hair Distribution

Wikipedia.org

Hair Growth Cycle

• Anagen - active hair growth that lasts between two to six years

• Catagen - transitional hair growth that lasts two to three weeks

• Telogen - resting phase that lasts about two to three months; at the end of the resting phase the hair is shed and a new hair replaces it and the growing cycle starts again.

Hair Cycle

From cdc.gov

Hair Growth Cycle

Tressez.com

From longhairhof.com

From anniemany.com

From cloudspun.com

Angora Mutations

Hair Loss

The Basics

Myths About Hair Loss

• Myth #1 Wearing hats causes hair loss

• Myth #2 Frequent washing and blow drying can

lead to hair loss• Myth #3

Hair styling products and dyes cause hair loss

Trueb. R. Female Alopecia: Guide to Successful Management. Springer-Verlag Berlin Heidelberg 2013

Myths About Hair Loss

• Myth #4 Brushing your hair can make it stronger

and more resistant to hair loss• Myth #5

Cutting your hair will make it grow back thicker

• Myth #6 Hair loss can’t be stopped or helped

Trueb. R. Female Alopecia: Guide to Successful Management. Springer-Verlag Berlin Heidelberg 2013

Hair Loss Questionnaire

• How long have you had hair loss?• Have you noticed increased shedding or

just thinning of hair?• Is your hair loss sudden or gradual?• Do you have a rash, pain or itching in

the scalp?• Do you have a longstanding medical

illness?• Do you have bald spots?

Hair Loss Questionnaire

• Are there any family members with hair loss?

• Do you have thyroid disease?• Have you had high fever, surgery,

change in medications or infection in the last 6 months?

• Have you lost weight or been on a diet in the last 6 months?

Hair Loss Questionnaire

• Do you use chemical perms or relaxers on your hair?

• Do you use dye on your hair?• Do you wear braids in your hair?• Do you wear a hair weave of any kind?

Types of Hair Loss in Women

• Non-Scarring Telogen Effluvium Seasonal Hair Shedding Female Androgenetic Alopecia* Alopecia Areata Hair Aging

• Scarring Frontal Fibrosing Alopecia Central Centrifugal Cicatricial Alopecia

Hair Loss Examination• Assessment of the patient's global

appearance• What is the texture, color, and length of

the hair? • Hair distribution over the rest of the

Is there too little or too much hair in other areas?

• Acne or other signs of virilization are also noted

Hair Loss Examination• Are the follicles healthy?

Are there visible follicular openings?

Hair Loss Examination• Is the hair shaft healthy?

Tapered tips = new growth Blunt tips = cut or broken hairs

Hair Loss Examination• Is the hair cycle

regular or disturbed?

• Pull test• 50 hairs are grasped

and gentle traction is applied

• Normal to get 2-5 hairs

• More = excessive shedding

Hair Loss Examination• Is the scalp affected?• Is there redness, drainage or scaling?

Hair Loss Examination• Labs:

Thyroid function Iron studies Hormone studies if needed Antinuclear antibodies

Non-Scarring Hair Loss

Alopecia Areata

• Immune system attacks the hair follicles causing hair loss.

• This disease most often occurs in otherwise healthy people.

• May be associated with other autoimmune conditions:

Thyroid, vitiligo, pernicious anemia, etc• Hair falls out in patches

Alopecia Areata

Alopecia Areata

• Diagnosis Often just by examination Sometimes scalp biopsy is necessary to

differentiate from other scalp conditions• Treatment

Cortisone injections Anthralin Diphencyprone (DPCP) Minoxidil

Alopecia Areata

• Close examination is required to differentiate alopecia areata from another common scalp condition – tinea capitis (fungal infection of hair follicles)

Androgenetic Alopecia

• Also known as pattern hair loss• Androgenetic alopecia is a genetically

determined disorder characterized by the gradual conversion of terminal hairs into indeterminate, and finally into vellus, hairs.

• It is an extremely common disease that affects men and women.

Androgenetic Alopecia

Androgenetic Alopecia

Androgenetic Alopecia

• Gradual onset• Increased hair shedding• Transition in the involved areas from large,

thick, pigmented terminal hairs to thinner, shorter, indeterminate hairs and finally to short, wispy, nonpigmented vellus hairs

• End result can be an area of total denudation; this area varies from patient to patient and is usually most marked at the vertex

• Total hair loss is rare

Androgenetic Alopecia

• In women hair generally is lost diffusely over the crown

• Gradual thinning of the hair rather than an area of marked baldness; the part is widest anteriorly

• The frontal hairline is often preserved in women

• Bitemporal recession does occur in women but usually to a lesser degree than in men

Androgen Action in Hair Follicle

Ludwig Classification

Modified Ferriman–Gallwey Hirsutism Scoring System

Sinclair Hair Loss Scale

Savin Hair Loss Scale

Androgenetic Hair Loss

Normal Scalp Miniaturization

• Thick terminal hair• Fine vellus hair

• Thick terminal hair• Fine vellus hair• Intermediate diameter hair

Comparison of beard hair, normal scalp and balding scalp

Found on google.com attribution unknown

Dermatologic Manifestations of PCOS

• Hirsutism on chin and upper lip• Acne vulgaris, lower face, chest and

back• Androgenetic alopecia

Frontal and vertex scalp Frontal hairline preserved

• Acanthosis nigricans

Lee et al. Dermatologic Manifestations of Polycystic Ovary Syndrome. Am J Clin Dermatol 2007; 8 (4): 201-219

Pathophysiology of PCOS

Health Ramifications of PCOS

• Young Adult Obesity Hirsutism (excess hair growth) Acne Oligomenorrhea/Amenorhea Acanthosis Nigricans Miscarriages Infertility Anovulation Gestational diabetes Type II diabetes

• Adult Obesity Hirsutism Acne Oligomenorrhea/Amenorhea Acanthosis Nigricans Miscarriages Infertility Anovulation Gestational diabetes Type II diabetes Increased heart disease Increased stroke

http://www.jewishhospitalcincinnati.com/cholesterol/Research/PCOS-Body_Owners_Guide

Treatment of Androgenetic Alopecia

Mesinkovska, Bergfeld. Hair: What is New in Diagnosis and Management? Female Pattern Hair Loss Update: Diagnosis and Treatment. Dermatol Clin 31 (2013) 119–127

Treatment of Androgenetic Alopecia

• What’s on the horizon? Bimatoprost (Latisse) – ongoing studies Laser treatments – no proof that they have

any significant effect, but promising for the future

Topical estrogens

Telogen Effluvium• A form of nonscarring alopecia characterized

by diffuse hair shedding, often with an acute onset.

• Chronic form with a more insidious onset and a longer duration also exists

• Telogen effluvium is a reactive process caused by a metabolic or hormonal stress or by medications.

• Generally, recovery is spontaneous and occurs within 6 months if cause is eliminated.

Telogen Effluvium• Triggered when a physiologic stress or

hormonal change causes a large number of hairs to enter telogen at one time. 

Telogen Effluvium

Hair Loss From Drugs

• Telogen Effluvium – shedding of resting, or bulb hairs

• Anagen Effluvium – shedding of actively growing hairs

• Please do not stop any medications without consulting with your physician.

Hair Loss From Drugs

• Anagen Effluvium usually due to chemotherapy drugs and

rarely with gold, colchicine or poisoning with arsenic, bismuth, thallium or boric acid.

Hair Loss From Drugs

• Telogen Effluvium anti-coagulants – heparin, warfarin anti-hypertensives – beta-blockers, ACE

inhibitors hormones – oral contraceptive pill

(during/after/changing), hormone replacement therapy, androgens

anticonvulsants – valproic acid 12-28% (dose-dependent), carbamazepine up to 6%, phenytoin

Hair Loss From Drugs

• Telogen Effluvium mood stabilizers and antidepressants – most,

e.g. lithium 12-19% others – cimetidine, retinoids (acitretin > 

isotretinoin), antithyroid drugs, cholesterol lowering drugs, interferons, anti-infective agents, amphetamines, nonsteroidal anti-inflammatory drugs (NSAIDs), bromocriptine, levodopa, some antipsychotic and anti-anxiety drugs, rarely tricyclic antidepressants such as amitriptyline.

Scarring Hair Loss• Hair follicles are destroyed by

inflammation and replaced by scars.

• The earlier the treatment is started, the more hair follicles we can save!

Frontal Fibrosing Alopecia

• Peri- or postmenopausal women over the age of 50.

• Characterized by symmetrical band of hair loss on the front and sides of the scalp, and loss of eyebrows.

• The edge may appear moth-eaten, and single hairs may persist in the alopecic areas.

• Cause is unknown

Frontal Fibrosing Alopecia

From Dermatology Online Journal 11(4):6

Frontal Fibrosing Alopecia

• Difficult to treat• 5-alpha-reductase inhibitors (45%)• Hydroxychloroquine (30%)• Topical medications

Topical steroids-not effective Topical tacrolimus

• Cyclosporine• Systemic steroids

Central Centrifugal Cicatricial Alopecia (CCCA)

• Former names• Hot comb alopecia• Follicular Degeneration Syndrome• Pseudopelade in African Americans

Central Centrifugal Cicatricial Alopecia (CCCA)

• Progressive and dramatic form of scarring alopecia that occurs almost exclusively in African American women.

• Slow onset developing over years• Patients present with hair loss and

thinning in their 2nd to 4th decade 

Central Centrifugal Cicatricial Alopecia (CCCA)

• May have few symptoms and signs of follicular inflammation

• Some patients complain of itch, tingling, burning or tenderness on affected scalp

• May see slight hyperpigmentation around hair follicles

• Central and/or vertex scalp is involved, starting in midline

• Gradual symmetrical outward spreading of hair loss

Central Centrifugal Cicatricial Alopecia (CCCA)

• Cause of CCCA is poorly understood. • Found in approximately 6% of AA women• Certain factors have been implicated

Thermal straightening (blow drying and curling irons) Traction or excessive tension on the hair Chemical straightening/relaxers Infection (possibly previous scalp fungal infections)

• However, there is no conclusive evidence proving a direct causative relationship between any of these factors and CCCA.

Central Centrifugal Cicatricial Alopecia (CCCA)

• No consistently successful treatments• What has been tried?

Changing hair grooming practices Avoidance of tension-producing hair styles

• Braids, heavy extensions, weaves Avoidance of oils or ointments on the scalp Decreasing chemical relaxers to every 8-10 wks Topical anti-inflammatory medications Intralesional steroid injections Oral antibiotics

Other Treatments For Hair Loss

• Biotin• Vitamin D3

So what’s our goal?

Questions?

Thank you