Alopecia, or hair loss, affects a large proportion of the population and the Institute of Trichologists state that there are 50 different reasons for hair loss. The most common form of hair loss is androgenetic alopecia, and it can affect both men and women. In men, it is commonly referred to as male pattern hair loss, and in women is referred to as female pattern hair loss. In this article, which is aimed at both men and women, I will refer to androgenetic alopecia as pattern hair loss. 50% of men are affected by pattern hair loss by 50 years of age, whilst for women, it takes until 65 years of age before 50% are affected. However, an article in the British Medical Journal has stated that if all stages of pattern hair loss are considered, the actual figures may be as high as 98% of men and 86% of women. So what is pattern hair loss? Is there anything that can be done about it? This article will help you to understand what pattern hair loss is, and also to recognise if it is affecting you, before exploring the treatment options available and whether they will restore your crowning glory. First, let’s understand how hair grows.
Of the one hundred thousand hairs on our heads, it is normal to lose between 50 and 100 hairs per day. It is only when we lose 50% of the total number of hairs on our heads that hair loss becomes apparent. But why do we lose hair each day? Let’s consider the hair-growth cycle. The hair cycle is comprised of 4 distinct phases: anagen, catagen, telogen and exogen.
The anagen phase refers to the time when the hair is actively growing, the hair root is rapidly diving and adding to the hair shaft. Hair typically grows 1 cm every 28 days. For each individual hair, this phase may last between 2-7 years and so anagen is responsible for controlling the length of your hair.
The catagen phase occurs next and is a phase of regression, the hair follicle is shrinking and detaches from the blood supply that allowed it to be nourished and grow during the anagen phase. This phase typically lasts for 10 days.
The catagen phase is followed by the telogen or resting phase of the hair. This resting phase typically lasts for around 3 months and around 10-15% of the hair on your head will be in this phase at any one time. The ‘old’ hair is resting, still attached to the head whilst ‘new’ hair, produced by the anagen phase, grows.
Finally, the hair in the telogen phase detaches, resulting in hair shedding and so completing the hair cycle with the exogen phase.
On our bodies, we have two types of hairs, terminal hairs and vellus hairs. Terminal hairs are thick, strong and carry lots of pigment. By contrast, vellus hairs are short, thin and lightly coloured. Vellus hairs are the ones we normally attribute to being ‘body hair’ and terminal hairs are the hairs we expect on our heads.
In pattern hair loss our pigmented terminal hairs are gradually replaced with hairs more similar to vellus hairs. The hair follicle also undergoes a process of miniaturisation, getting smaller with each successive hair-growth cycle. As the follicles miniaturise there is a shift in the ratio of hairs in the telogen (resting phase) and anagen (active growth phase). The result is more hairs in the telogen resting phase. As the anagen growth phase is responsible for the hair length, the subsequent shortening of the anagen phase results in hairs getting successively shorter with each hair-growth cycle. Eventually, the hair fails to reach the skin’s surface. Telogen resting hairs are more loosely attached to the scalp and so shed more easily. This, combined with an increase in the time period between the telogen resting phase and anagen growth phase, results in an overall reduction in hairs on the head.
Pattern hair loss rarely results in an individual losing all their hair. The hair loss that occurs is best described as a thinning, with the potential for denuding in areas. The hair loss occurs gradually. The appearance of the hair loss varies between men and women- read on to find the best description for you.
Pattern hair loss and men
If you are male, pattern hair loss generally occurs at the front and sides of the scalp, progressing towards the back of the head.
Around 10% of men will experience hair loss which is more similar to female pattern hair loss with hair becoming thinner all over, but especially around the crown and the central parting tends to widen.
Hair loss is believed to occur due to hormones called androgens (hence the official name of androgenetic hair loss). Androgens are a group of hormones and the one of interest is dihydrotestosterone, a breakdown product of testosterone. From puberty onwards, testosterone levels rise. Testosterone is broken down in certain hair follicles by an enzyme called 5-α-reductase to form dihydrotestosterone. It is the effects of dihydrotestosterone on the hair follicle that causes it to produce finer and shorter hairs with each cycle of hair growth.
Other factors which increase your likelihood of hair loss are your age and genetics. While hair loss can occur at any age, most men will be aware around the age of 30. Some ethnic groups are more susceptible to hair loss than others. If you are Caucasian or Afro-Caribbean, then you are more likely to be affected by male pattern hair loss than other ethnicities. 30% of Caucasian men will be affected by the age of 30 years, and 80% affected by the age of 70 years. For Asian men, the hair loss occurs more slowly and gradually with it taking until 70 years of age for 50% to be affected.
If you are female, pattern hair loss presents itself as diffuse thinning to the front of the hair and the crown. The parting of the hair seems to widen and the scalp becomes more noticeable from the front and top of the head. Female pattern hair loss is often described as being less apparent than the male pattern as the hair loss is more diffuse.
Despite still being referred to as androgenetic alopecia by medics, it is unknown as to whether androgens always plays a role in female pattern hair loss. The lowering of oestrogen levels following the menopause is thought to be precipitating factor for the onset of hair loss, although other times when the female bodies hormone levels change can also initiate the hair loss such as puberty and pregnancy. If you suffer from polycystic ovaries there is an increased likelihood of pattern hair loss, but this hair loss tends to be reversible if the polycystic ovaries are treated effectively. In the UK less than 10% of premenopausal women suffer from pattern hair loss whilst by the age of 70, one third may be affected.
Your ethnic origin also influences the likelihood of hair loss, oriental women appear to be less affected than Caucasian women.
It is rare for female pattern hair loss to result in becoming bald. Female pattern hair loss can be treated, however, no cure is available, therefore once treatment is initiated it will have to be continued in order for regrowth to be maintained.
Diagnosing pattern hair loss
In order to confirm that your hair loss is correctly being associated with pattern hair loss and not another cause, there are some tests which can be performed.
A pull test may be carried out. This is where an experienced healthcare professional will tug a bundle of 50-100 hairs firmly, but not forcefully. If 3 or more of the 50-100 hairs come away then this would suggest there is active shedding. In pattern hair loss we would expect the result of this test to be negative, so if the result is positive tests can be conducted for other types of hair loss. Please note, that this test is only of value if conducted by a healthcare professional who is experienced in interpreting the results.
Your clinician may make other assessments, such as checking for infections, hormone disorders such as thyroid or looking for deficiencies (including vitamin B12 and iron). They may also check your history of taking medicines including antidepressants, anticoagulants, chemotherapy agents, anabolic steroids and carbimazole, all of which have been associated with hair loss. It is also important to let your clinician know if you have been dieting recently as excessive dieting can be associated with hair loss.
Women with pattern hair loss may also be tested for androgen excess. Symptoms of androgen excess are hirsutism (a male-pattern of unwanted hair growth in women), severe acne, greasy or oily skin and scalp, development of male physical characteristics, menstrual irregularities, infertility, galactorrhoea (a milky discharge from the nipple, unrelated to breastfeeding) and polycystic ovaries.
Treatment options for pattern hair loss
The British Medical Journals Good Practice Guidelines for Androgenetic Alopecia advise that all patients are made aware of 5 different ways of managing their hair loss:
Medical treatment- see drug treatment section of this article to help you explore your options further
When considering drug treatment, it is important that you are aware of your options. For men there are two options available 1) topical minoxidil or 2) oral finasteride. For women, topical minoxidil is the only licensed treatment. Both finasteride and minoxidil work best when used early on in the treatment of hair loss and tend to be less effective when hair loss is already established. It is important to note that both finasteride and minoxidil require you to use them indefinitely to maintain their effectiveness. Both finasteride and minoxidil have good safety profiles, but different adverse effects.
How does it work?
Finasteride is believed to work by inhibiting the enzyme 5-α-reductase, which is responsible for converting testosterone to dihydro-testosterone. As previously mentioned it is the presence of dihydro-testosterone which is associated with hair loss.
How can I obtain it?
Finasteride is a ‘Prescription Only Medicine’ as such you require a prescription in order to obtain it. Finasteride for hair loss is not available on the NHS so you will need to obtain a private prescription.
Who is it suitable for?
Finasteride is suitable for men between the ages of 18 and 41 years.
How should it be taken?
A 1mg tablet should be taken daily. It may be taken with or after food. It should be taken at the same time each day.
Does it work?
It is the best treatment for producing regrowth excluding hair transplant. After 1-2 months of use you can expect a reduction in hair loss by 50%. After 6 months 50% of men will have new hairs growing around the edge of the thinning area and after 12 months there may be regrowth over the entire thinning area. Your response to finasteride should be assessed 6 months after starting treatment by which time you will know if the product will work for you.
If your decide to stop taking finasteride, your hair loss will resume as previous to you taking finasteride and any benefit you may have had from the treatment will gradually be lost.
Is there anyone who should not use it?
Finasteride should not be used in severe liver disease and should be used in caution in all forms of liver disease. Doctors will also be more cautious if you have obstructive uropathy (a kidney problem).
Women should not take finasteride.
Are there any side effects?
All medication has the potential for side effects and whilst finasteride is generally well tolerated the most commonly reported side effects are:
-sex problems occurring within the first year of treatment, these generally decrease in frequency after the first year of treatment.
-hypersensitivity reactions- swollen lips, face and itchy rash
-breast tenderness and enlargement: any changes to breast tissue during treatment should be reported to your prescriber due to the small risk of breast cancer
-depression and suicidal thought- you should stop taking the medication immediately and inform your prescriber.
I’ve heard it can affect my partner, is it true?
Women of a child bearing age should avoid handling crushed or broken tablets due to the risk of abnormalities developing in a male foetus.
When taking a 1mg dose of finasteride, a small amount of the drug will enter your semen. It is advisable that you discuss the risk associated with your prescriber.
When and where to seek further help
You should seek further help and advice with your hair loss if:
Your hair loss develops suddenly
You have bald patches
Your hair is being lost in clumps
Your head burns and itches
You are worried by your hair loss
Your hair loss is making you feel depressed or anxious
Referral to a qualified trichologist (hair specialist) can be helpful but is not available on the NHS.
Hints and tips for healthy hair
Advice for healthy hair includes
Avoid unnecessary trauma to hair (e.g. using straighteners or hair dyes)
Eat a balanced diet
Consider hair styling (short haircuts will draw less attention to thinning or receding hair in men)
Other factors which may increase your likelihood of experiencing hair loss are:
high alcohol consumption
being a smoker
suffering from stress
timing of puberty
suffering from severe acne
Whilst the evidence behind these factors is not concrete, it does suggest that following a healthy diet and lifestyle is likely to have a positive influence on pattern hair loss.
The following websites may be helpful to you, for additional advice and support: www.bad.org.uk www.alopecia.org.uk www.trichologists.org.uk
So can hair loss be reversed?
Whilst the hair loss that you have already experienced may not be completely reversed by the treatments discussed, the hair loss process can be halted and regrowth of hair is possible. There are also many other ways for you to managing hair loss to keep you feeling good.
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