My hair is falling out!

Hair loss is a common medical problem, and can encompass many different diagnoses. The general medical terminology for hair loss is “alopecia.” Alopecia can be divided into scarring and non-scarring alopecia. The distinction is important as scarring alopecia may lead to permanent hair loss whereas non-scarring alopecia, when appropriately treated, has chance for hair regrowth.

Scarring alopecia 

Scarring alopecias are due to chronic inflammation around the hair structures leading to scarring over time and permanent hair loss. Imagine pouring cement over a grassy lawn making it very difficult for the grass to continue to grow. The common types of scarring alopecia include lichen planopilaris (LPP), discoid lupus erythematosus (DLE), morphea, traction alopecia, folliculitis decalvans, and dissecting cellulitis. Diagnosis is made clinically by physical examination with trichoscopy and may be confirmed by biopsy. Depending on the diagnosis and severity, patients may be treated with a mix of topical, intralesional, and/or oral steroids along with systemic treatments such as antibiotics, anti-malarials (i.e. hydroxychloroquine (Plaquenil), and/or immunosuppressive medications.

Non-scarring alopecia 

Non-scarring alopecia is more common than scarring alopecia and include conditions such as alopecia areata, telogen effluvium, and androgenetic alopecia. 

Alopecia areata is an autoimmune disease with 3 main subtypes alopecia areata localized (few small circular/oval areas of hair loss), totalis (total loss of hair of scalp, sometimes eyebrows and eyelashes), and universalis (total loss of hair all over body). Treatment involves intralesional injections for localized disease. For widespread, patients may require systemic treatments such as JAK/STAT inhibitors (i.e. tofacinitib (Xeljanz)). 

Telogen effluvium is also known as stress-induced hair loss and can be due to either physical or psychological stress. Usually this presents anywhere between 6-12 months after initial stressor. Common triggers may include post-partum hair loss, acute/chronic illness, surgery, accident, divorce, weight loss, exercise, medications, etc. To identify the cause of telogen effluvium, comprehensive blood tests are required to exclude medical illnesses such as low red blood counts (anemia) or thyroid disease (hyper- or hypo-thyroidism). Hair regrowth occurs upon removal of the trigger (i.e. stress) and treating underlying cause but can take period of several months-years after the initial shedding.

Image: engin akyurt

Androgenetic alopecia is also known as hormonal hair loss or male/female pattern hair loss.  This hair loss is characterized by specific patterns in males – for example, receding hair line and bald spot at the vertex. For women, hair starts to thin at the crown making hair part more visible. Usually there is a strong family history of similar patterns of hair thinning/shedding in grandparents, parents and/or siblings. Treatment is supportive to prevent further hair loss. Some common treatments for women include topical minoxidil (Rogaine), oral minoxidil, oral contraceptives, spironolactone, and in post-menopausal women, finasteride. Hair transplantation is often reserved for end-stage disease. Hair powders may be used to minimize the appearance of thinning. 

Sinclair Scale – Female Pattern Hair Loss

Thus, not all hair loss is the same, nor all hair loss is permanent. There is hope but one has to make the correct diagnosis to get to the correct treatment.

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