Just thinking about hair loss can create a sense of anxiety. Suspecting you're losing your hair is far worse. Hair loss can mean different things to different people. But when it comes down to achieving a medical diagnosis, true hair loss involves more than the normal daily shed of 150-200 hairs. And while you may be certain you're far thinner than that once lovely mane you sported at 18, it may take a loss of up to 80 percent of normal hair for even a medically trained eye to appreciate a true thinning condition.

Understanding hair loss and its potential therapy requires understanding the normal biology of hair. Hair follicles go through 3 stages of growth. If they didn't and were all on the same schedule, we'd all go completely bald every so often!

Hair Growth Cycles

• Anagen (hair growth phase) lasts anywhere from 2-6 years on the scalp. The hair itself grows approximately 1/2 to 1 inch a month for Caucasians, but much more slowly for African Americans. The anagen phase is when the hair shaft is at its maximum thickness.
• Catagen (resting phase) lasts just a few weeks.
• Telogen (shedding phase) usually lasts 5-6 weeks during which a new hair is beginning to grow and the telogen hair is shed and replaced by the new hair. Telogen hair is very fine.

Cause And Effect
More common causes of hair loss:

• Androgenic Alopecia
• Thyroid Disease
• Severe Anemia
• Protein Deficiency (often associated with recent significant weight loss)
• Lupus
• Prescription Drug Side Effects
• Hormonal Imbalance
• Zinc Deficiency
• Iron Deficiency
• Biotin Deficiency
• Syphilis
• Chemical & Heat Abuse
• Physical Hair Shaft Trauma (Traction Alopecia)
• Telogen Effluvium

Work It Up

Don't allow yourself to be patronized. And by all means, don't just sit at home watching the hair accumulate in your brush and assume it's the aging process to blame. Maybe it is, but have your dermatologist rule out other more serious (and potentially treatable) causes. Here are labs (involves blood work) you should make certain have been run:

• CBC with Platelet and Differential
• Complete General Chemistry (includes serum protein and albumin)
• Thyroid Panel (including TSH)
• Serum Iron, Biotin, Zinc levels
• VDRL or RPR (checks for syphilis)
• ANA (looks initially for lupus)
• Free and Total Testosterone and DHEAS (not a DHEA as I have seen erroneously drawn).
• Further Autoimmune blood work if a subtype of lupus is suspected.

If the labs are normal or unclear and there is cause to suspect that some disease state is really going on, a simple punch biopsy of the scalp performed under local anesthetic may give you the answer you've so desperately sought. Make certain that the tissue specimen is cut in two and that half is sent for the routine H&E test while the other half is sent for the specialty DIF (direct immunofluorescence) test. This is not automatically done unless ordered.

Androgenic Alopecia

What exactly is androgenic (also sometimes called androgenetic) alopecia? This is a form of hair loss, which is the direct result of the testosterone metabolite DHT (dihidroepitestosterone). In other words, it's the everyday baldness we see on men.

Often mistakenly thought to be the result of having too much testosterone, it's really this metabolite that wreaks such havoc upon our head. Some hair follicles have the DHT receptor, others don't.

Free levels of testosterone are prey to the enzyme 5 alpha-reductase, which in turn metabolizes this "male" hormone to DHT.

A Woman With Male Pattern Baldness?!

Women are not immune to "male" pattern baldness (aka female pattern alopecia). When it comes to women, radically increased levels of free testosterone are often due to a condition known as polycystic ovary disease (PCO). However, not all women who suffer from androgenic alopecia have PCO. Rather, they have hair that is genetically predisposed to being sensitive to the DHT molecule. Biology 101 review: all women have some circulating testosterone just like all men have some circulating estrogens.

Men Are From Mars

While this is such a common cause of hair loss in men accounting for almost 95% of cases all hair loss cases, women, too are very prone to this condition.

Men vs. Women:

Men tend to begin to thin early, often in their late teens or early 20s. I have seen this form of hair loss start as early as 13 in a family with an extremely strong familial background (this is highly unusual). An easy estimate of what percentage of men at any given time suffer from andogenic alopecia is 20% during their 20s, 30% in their 30s, etc. until you reach 80% in their 80s.

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Women on the other hand experience loss somewhat later, beginning in their late 20s to early 30s. And only between 20-30% of women tend to experience this condition, although many might argue the numbers are really much higher.

Remember that androgenic alopecia involves the testosterone metabolite, DHT's effects upon the hair follicle in genetically predisposed individuals (and hairs, for that matter). In men, these hairs susceptible to DHT tend to lie along the front of the scalp, temples and vertex, leading to the stereotypical male balding loss and remnant rim of hair surrounding the head.

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In women vulnerable to the effects of DHT; however, all scalp hair is potentially at risk, leading to a more generalized loss across the scalp with the aging process. In addition to androgenic alopecia, most women do tend to recede their hairline with age. Take a look at that high school yearbook picture if you've got any doubt.

I have read that thinning for women tends to stabilize by their 50s, but I would personally dispute this point. How many elderly women can you recall being able to see through their hairdo and visualize the entire scalp?

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Postpartum Alopecia occurs post-pregnancy and is fortunately a temporary disorder. Eventually the hair follicles manage to re-organize themselves, the new hairs replace the old ones, and the normal growth cycle is resumed. That said, there can also be lasting effects. For those with certain types of hair, the new growth may be both thinner and sparser than before. was made specifically for this process - delivering both immediate and long-term benefits.

Although the diagnosis is usually straightforward with male patients, this generalized pattern of hair loss seen in female patients may require a work-up to verify the diagnosis and rule out an underlying internal cause.

Therapy Options

By now you know what you have, but don't know what to do. Understanding why you have androgenic alopecia will again help you determine what therapy will be most beneficial. Hair follicles preprogrammed to become sensitive to DHT shrink upon exposure to the hormone until they are no longer capable of producing hair. At the same time the follicles are shrinking, the growth stage becomes shorter and Catagen and Telogen become longer. This ultimately results in very thin, short hair until growth ultimately stops altogether.

Rogaine

It all began with a pill for high blood pressure. Some perceptive soul realized that the medication controlling the hypertension was causing hair to sprout randomly, thus leading to the development of Rogaine. Minoxidil itself is inactive and incapable of growing hair. But when used topically, it must be able to penetrate the epidermis and be converted enzymatically into an active metabolite, minoxidil sulphite. It is this metabolite that activates cellular potassium channels resulting in hair growth.

The exact steps that result in the hair growth remain unknown (although there have been several recent theories). Suffice it to say, however that the commonly held belief that increases in blood flow to the hair follicle is not the cause. First, Rogaine does not increase blood flow. And second, even if this were true, then all medications that increased blood flow to the skin would cause hair growth and they simply don't. The myriad of products on the market claiming hair growth abilities based upon increased blood flow don't have science to back them.

Confused by your choices? Rogaine comes in 2 strengths and for marketing purposes their packaging is different for men vs. women. Two percent remains 2 percent no matter what color the box may be or which sex is listed on the label. However, the manufacturer emphatically maintains that women stick with VitaMedica Super EPA/DHA Fish Oil which contains 2% as opposed to men who have the more potent Rogaine For Men, Extra Strength 5% Minoxidil, 3 - 60 mL bottles option. The reason they say is to minimize women's risk of growing hair elsewhere, such as the face.

Some doctors have prescribed Retin A with Rogaine For Men, Extra Strength 5% Minoxidil, 3 - 60 mL bottles in an attempt to increase the ability of the Rogaine to penetrate the skin.

DS Laboratories

DS Laboratories Spectral.RS - Treatment for Thinning Hair is a topical medication that combines both Minoxidil and Aminexil SP94 with other compounds that have been shown effective at boosting the effectiveness of Minoxidil. Another remarkable innovation of Spectral DNC is the use of Liposomes developed by DS Laboratories that act as a carrier agent to deliver the active ingredients deeper into the affected area along with a vitamin and mineral complex and herbal extracts.

Propecia

Treatment used to be limited to topical Rogaine, but has become more promising since the advent of Propecia. Propecia is an prescription pill taken once a day. It helps both regrow hair recently lost as well as slow down or stop hair loss. As with all hair loss therapies, the earlier the treatment is started, the better.

The FDA has only approved its use in men. Concerns related to possible fetal birth defects if taken by pregnant women are to blame. Finasteride may cause genital abnormalities for the developing male fetus. Pregnant women who live in a home where finasteride is used (whether Proscar or Propecia) are urged not to handle the medication and stay clear of its dust. For those women unable to conceive (whether through tubal ligation, hysterectomy or menopause), Propecia has been used with good results. I have had some female patients however who reported breast tenderness or discharge. One patient finally discontinued the medication due to her discomfort although she was loathe to do so as her hair was growing back nicely.

Propecia (generic name Finasteride) prevents the formation of DHT by blocking the enzyme responsible for metabolizing testosterone. There are actually 2 forms of 5a-reductase (types I and II). Type I is the main concern in humans and is most concentrated within the hair follicles of the scalp as well as the sebaceous glands. Finasteride blocks Type I 5a-reductase.

Results tend to take approximately 6 months to show, and the medication is taken indefinitely. Propecia can only block the enzyme that forms DHT if you take it. If you don't, the enzyme will have the opportunity to transform testosterone and the hair loss will bein again.

You may expect to pay about $50.00 per month for your Propecia prescription and is usually not covered by health insurance. The company does make a Propack, a 3-month supply that the Wal-Mart pharmacy tends to sell for less than the $150.00 usual cost.

FNS Follicle Nutrient Serum

Osmotics FNS Follicle Nutrient Serum - Step 3 helps address hair loss and promotes healthy hair for both men and women. The product addresses hair loss concerns on the entire scalp, not just the frontal or vertex regions. It is new to the market and claims to be a natural, safe, non-hormonal formula promoting the proper environment for growing healthy hair.

The serum is an enriched cell culture media containing amino acids essential to the healthy growth of hair including cystein targets the hair follicle.

FNS was developed by a female researcher, Dr. Ella Lindenbaum at Israel's Technion University. Like anything new to market, we need to see how the product works compared with the studies, but the initial photos seem impressive.

FNS is applied once a day. Once the product is opened, refrigeration is recommended to extend the shelf life. FNS can be used as a stand alone product or in conjunction with other hair loss products. I would personally recommend not layering your topicals. Instead, use each at a different time of the day.

Flutamide

Flutamide is a prescription pill used to block the effects of androgenic hormones. It literally blocks androgen receptors on hair follicles and sebaceous glands, preventing the hormone from reaching its targets. Most commonly used for excessive facial hair growth in women, particularly those with polycystic ovary disease, flutamide can help reduce androgenic alopecia in women. As it is systemic, it's not really an option for men, although there are periodically murmurs throughout the medical community of a doctor here and there who has tried it topically for a male patient. Potential side effects associated with oral Flutamide include high blood pressure, diarrhea and liver concerns.

Hair Transplant

There is certainly a time to consider a surgical intervention to androgenic alopeica. In hair transplantation, plugs of healthy hair are removed from elsewhere (usually the remaining strip of hair around the scalp) and literally transplanted into the area of hair loss. If you are going to undertake such a procedure, do go to a reputable, board certified hair transplant surgeon (usually a dermatologist or plastic surgeon) who devotes a significant amount of time just to this procedure. It's like anything else, the more one performs a procedure, the more skilled one becomes. It's your scalp. Do you really want hair plugs that resemble a doll or are you after a natural, "surgically untouched" look?

Hair Bank

Another venture capital idea straight from the Silicon Valley: create an underground hair vault located under a Portland, Oregon hair salon (in a cave, presumably?), keeping hair plugs suspended in time in climate controlled vacuum packaging. Hairogenics premise: to preserve hair samples until science can devise a way to "clone" hair from DNA. This isn't completely new. The theory that more youthful cells will replicate and be more active than more elderly cells has been used for Isolagen, a filler agent for wrinkles using fibroblasts harvested from the recipient. Isolagen cells are kept in the deep freeze and grown in culture. Hairogenics apparently will clone from cellular DNA if and when the technology is there. But is paying $50 plus a ten dollar annual storage fee the real way to go? Time and science will tell.

Nature & Nuture

Just like any other condition, providing a nurturing environment to your hair follicles can go a long way to reduce the rate of loss and/or breakage. Dietary options are frequently a source of controversy. I know of no foods that will make a true difference to your hair, although a diet high in fish oils (omega-3 fatty acids-Triswim Shampoo) (certainly heart healthy) is purported by the beauty community to add gloss to your hair. Does it add strength and nourishment to the hair shaft and follicle? Probably not. Your best option is to try a well rounded multivitamin such as Aquis Microfiber Hair Towel - Pink that contains biotin along with other necessary nutrients to support your hair follicles.

You apply sun protection to your skin, but often the hair is forgotten. Protect your hair daily from damaging rays sun with a sun protective spray/lotion. Newly exposed skin of the scalp is extremely vulnerable to sunburn. If your hair has already thinned, don't neglect protecting the scalp with SPF such as DS Laboratories Spectral.DNC - Breakthrough Hair Loss Treatment and a sun protective hat by Physician Endorsed.

Chlorine can be extremely drying to the hair. If you swim in chlorinated water, it is important to make sure your hair has as little chlorine exposure as possible. Wear a swimming cap. If a swimming cap is not for you, wet your hair down prior to getting in the water so less chlorine is absorbed. After swimming, rinse your hair thoroughly and cleanse with a chlorine removing shampoo such as Fekkai Apple Cider Clarifying Shampoo.

The use of GHK Copper Peptides in hair care has been very popular in helping assist hair loss therapy. Copper naturally helps inhibit 5a-reductase which in turn reduces the formation of DHT. It also helps stimulate the formation of collagen. As we age, the levels of copper within the skin begin to drop. Tricomin Follicle Therapy Spray can be applied twice daily to help restore copper levels. For those looking for body and shine along with supplementing some additional GHK Copper Peptides, Tricomin Revitalizing Shampoo and Tricomin Restructuring Conditioner may be worth considering.

Finally, it is very important that physical trauma to the hair be minimized. Back off your chemical treatments a week or two. In the long run, this may result in dropping 1-4 sessions a year. It will save some money and your hair. Wrap your hair in an Rogaine For Women, 2% Minoxidil, 3- 60 mL bottles. It will absorb the excess moisture and cut the dryer time significantly. Daily hot rollers, hair dryers, flat iron use, chemical therapies (including perms, dyes and straightening agents) be reduced in use. If you cannot LIVE without the blow dryer or straightening iron - consider adding in Warren-Tricomi Close to your hair care routine. The active ingredient in Close is a heptahydrate formulation with strengthening properties. When rinsing with Close, you cause open cuticles, caused by blow-drying, coloring, elements and other damaging processes to the hair, to lie down, thereby closing them. This healing affect of the cuticle makes the hair more durable and visibly healthier.

OTHER CAUSES OF HAIR LOSS

Telogen Effluvium

Telogen Effluvium is a temporary shedding of the hair caused by a transitional push of more anagen hairs than usual into the telogen phase. Major stressors to the system such as post childbirth, major surgery and severe illness can all result in telogen effluvium. It is unlikely that everyday stress encountered through work, family and life in general will cause this form of hair loss. Telogen effluvium actually takes place anywhere from 3-9 months after the insult to the system, and can go on for several months (up to a year at worst). The hair usually regrows within months, however. No treatment is required for telogen effluvium.

Sometimes telogen effluvium occurs coincidentally with the natural onset of androgenic alopecia. This can make both work-up, diagnosis and therapy decisions a little more complicated. There is no absolute answer here, but if the situation makes sense and the diagnosis is not obvious, a temporary trial of a product such as Rogaine may be helpful if not reassuring to the patient who will appreciate trying something to help improve the situation.

Alopecia Areata

Alopecia areata is a form of an autoimmune disease, where the body gets "confused" and thinks the hair is essentially a germ and tries to destroy it. Any hair on the body can be targeted, but it is most likely seen as a chronic condition affecting the scalp of young women. Patients featured on talk shows who have lost every hair on their body are extremely unusual, and these patients often develop their disease early in childhood.

Typically, a few random round bald patches will develop periodically. They may be hidden by the rest of the hair or expose in more severe cases. Swaths of hair loss located at the nape of the neck and behind the ears tend to be more resistant to therapy than scattered coin shaped patches.

Treatment is aimed at stopping the local reaction. My favorite therapy is to locally inject a dilute steroid solution directly into the lesions. Early hair regrowth will often occur within a few weeks.

Unfortunately, many insurance companies no longer pay for this therapy, unfairly labeling this autoimmune disease a "cosmetic" condition. Therapy with topical anthralin, an irritant, has also been used with some success, especially in small children who would never tolerate scalp injection. Other therapies are being currently being researched.

Other therapy options include PUVA (light therapy with the use of oral prescription oxpsoralen ultra) and immunotherapy such as the application of topical cyclosporin, Protopic, and Elidel.

If there is one thing to count on with alopecia areata is that it tends to recur. Most patients become very skilled at knowing when a new area of hair loss is about to form and quickly get back to their doctor for therapy. Stress which has a way of depressing the iimmune system seems to be a frequently reported stimulus to alopecia areata.

Traction Alopecia

This category refers to harsh pulling upon the hair such as from braiding or severely drawn hairstyles. The first step to take is stop pulling the hair and treat it gently. Don't overwash it, try not to over treat wtih chemicals (dyes, perms, straighteners) and keep heat exposure to a minimum.

If it appears that inflammation has become severe within the scalp itself from this chronic trauma, a dermatologist may inject steroid solution into the area to help settle this down and try to prevent permanent destruction of the hair follicles.

Hair loss is scary. But don't feel you have to sit at home and accept it without a fight. Make sure your doctor understands that the dermatologist has methods of diagnosis and therapy at their disposal and a working knowledge of scalp. Seeing a specialist for hair loss can help increase your chances of putting a stop to hair loss.

Thank you for taking the time to read my newsletter. I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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