What is Alopecia (Hair Loss)?
Alopecia is a hair loss condition that can affect any area of the body where you’d typically expect hair. It can happen gradually or suddenly, be either temporary or permanent, and affect all people regardless of age or sex. Alopecia, which can be caused by a variety of factors, is generally categorized into two groups: nonscarring (the most common kind) and scarifying (also known as cicatricial). People suffering from alopecia often have a significant emotional toll that can lower their quality of life.
In order to pinpoint the cause of alopecia and plan the best treatment, thorough patient history and physical examinations are needed. Please note that while the terms used to describe types of alopecia can vary in scientific literature, in this explanation we’re using ‘nonscarring’ and ‘scarifying’ to keep things simple, unless the term ‘cicatricial’ is part of the name of a specific disorder.
What Causes Alopecia (Hair Loss)?
Alopecia, or hair loss, can occur for different reasons based on the type and category of alopecia. Here are some causes:
Nonscarring Alopecias
In nonscarring alopecia, hair follicles are not damaged, so hair loss is potentially reversible and it’s possible for hair to grow back. This type can include androgenetic alopecia, alopecia areata, and telogen effluvium, among others.
Androgenetic alopecia is also known as male-pattern or female-pattern hair loss, and it’s the most common type of hair loss in men, women, and teens. Men typically lose hair in the top part of the scalp, and women usually see thinning hair throughout the center of the scalp.
Alopecia areata is an immune disease that typically involves sudden hair loss in patches on the scalp in people of any age or sex. In extreme cases, people may lose all scalp hair or all body hair. Individuals may deal with a single instance or a pattern of hair loss and regrowth.
Telogen effluvium usually affects the entire scalp and can occur due to various reasons like stress, illness, pregnancy, malnutrition, infections, certain medical conditions, surgery, or certain medications. It typically occurs three months after a triggering event, and the hair loss usually lasts around six months.
Scarring Alopecias
In scarring alopecia, hair follicles are permanently damaged, leading to permanent hair loss. There are different types of scarring alopecias, like lymphocytic, neutrophilic, and mixed.
Lymphocytic alopecias include diseases like frontal fibrosing alopecia (FFA), which is a slow, progressive hair loss that usually affects women after menopause. Another condition, lichen planopilaris (LPP), typically affects women and presents with redness and roughness around the hair follicles and results in patches of hair loss.
Scarring alopecia can also be caused by skin conditions, tumors, radiation therapy, injury, and bacterial or fungal infections.
Risk Factors and Frequency for Alopecia (Hair Loss)
In 2019, a study was conducted across multiple centers to understand how common different types of hair loss are among patients at hair specialist clinics, and how these rates vary globally. Over 3000 diagnoses of alopecia, a medical term for hair loss, were analyzed.
About 73% of these hair loss cases were nonscarring, meaning the hair can potentially regrow, and 27% were scarring, where the hair loss is permanent.
The study also offered an insight into the frequency of specific types of non-scarring and scarring alopecia:
- Androgenetic alopecia: 37.7%
- Alopecia areata: 18.2%
- Telogen effluvium: 11.3%
- Frontal fibrosing alopecia (a type of scarring hair loss): 10.8%
- Lichen planopilaris (another form of scarring hair loss): 7.6%
- Folliculitis decalvans (a rare form of scarring hair loss): 2.8%
All other types of alopecia had a frequency of less than 2%. The study also looked at differences in hair disorders based on gender, median age, and location.
Signs and Symptoms of Alopecia (Hair Loss)
When assessing hair loss, doctors might look at several factors, such as:
- If hair is thinning excessively (effluvium) or if there are bald patches (alopecia)
- The patient’s age when the hair loss began
- How the hair loss has progressed over time
- The pattern of hair loss: patchy, specific areas, or all over the head
- Any other accompanying symptoms
- Women’s gynaecological or obstetric history
- Dietary habits
- Family history of hair loss
- Current or recent medications
- Environmental exposure or surgical history that may be relevant
After taking a thorough history, a complete examination of the skin, scalp, face, and nails should be done. To properly check the scalp, the patient should be seated, and a bright light and possibly a magnifying glass should be used.
A hair-pull test may be performed to assess hair shedding. The procedure involves pulling a group of about 40 to 60 hairs gently, and if more than 3 hairs are removed, it could possibly indicate excessive hair loss.
There are different types of alopecia with varying symptoms and characteristics. For example, male and female pattern hair loss (Androgenetic alopecia) tends to affect certain areas of the scalp, while Alopecia areata results in patchy hair loss.
The Severity of Alopecia Tool or SALT score is used to determine the percentage of hair loss. It classifies hair involvement into five categories from no hair loss to 100% hair loss.
Telogen effluvium causes hair loss all over the scalp, while different categories of scarring alopecia may involve distinct diagnostic criteria and present with symptoms such as itchy, patchy areas of hair loss with inflammation. In case of uncertain diagnosis an activity index and other tools might be employed for more precision.
Testing for Alopecia (Hair Loss)
If a doctor suspects an underlying health issue or the cause of hair loss isn’t clear, some tests may need to be done. These could include a complete blood count, complete metabolic panel, checks on your iron levels, thyroid-stimulating hormone levels and vitamin D levels. Iron and vitamin D are particularly important for normal hair growth.
A scalp biopsy can provide more information for hair loss conditions. During this process, 1 or 2 small samples are taken from your scalp. By looking at these, doctors can check hair density, the balance of growing and resting hairs, and if there’s any inflammation.
For specific conditions:
Androgenetic alopecia (commonly known as male or female pattern hair loss) is usually diagnosed based on the symptoms. Some tests may be helpful like blood count, metabolic panel, iron levels, TSH, and 25(OH)D. Women displaying signs associated with high levels of male hormones, such as excessive body hair, irregular periods, skin darkening, and adult acne, may need further tests. If another scalp condition is suspected, a scalp biopsy might be useful, as it can reveal certain changes happening to the hairs.
Alopecia areata, which causes patches of baldness, is usually diagnosed based on history and physical examination. If it’s not clear, additional tests may need to be performed for other autoimmune diseases or infections. A scalp biopsy might be taken from the edge of the bald patch for further analysis.
Telogen effluvium is another hair loss condition, which often happens after stress. This is typically diagnosed based on symptoms. If needed, extra tests may include a complete blood count, iron studies, TSH, T3, and T4, as it’s often associated with low iron levels or thyroid disorders. They might also check your zinc levels and antinuclear antibody titer. A scalp biopsy can also help by showing the amount of telogen (resting phase) follicles.
In the case of scarring alopecias (hair loss resulting in scarring), a biopsy is the most reliable method of diagnosis but it’s invasive, so it’s not ideal for monitoring the condition. FFA and LLP are examples of scarring alopecias. They’re usually characterized by a certain kind of inflammation around the hair follicle. Specific tests don’t exist for FFA or LLP but basic tests like thyroid function tests, antinuclear antibodies, and sex hormone levels may be ordered, although results are usually normal.
Treatment Options for Alopecia (Hair Loss)
The way to manage baldness differs based on the type of baldness you’re dealing with.
For non-scarring hair loss, which is where hair follicles stay intact and can potentially regrow hair:
Androgenetic alopecia, or common baldness, typically centers on stopping hair loss and encouraging new hair growth. The usual treatments for men are topical minoxidil (applied directly to the scalp) and oral finasteride (a pill). For women, topical minoxidil is the first recommended treatment. Other options include medication, plasma injections, low-level laser treatments, microneedling and hair transplants. It can also be useful to treat related conditions and nutritional deficiencies that might be affecting hair growth.
Alopecia areata is treated with medicines that lower the immune system’s activity. Topical corticosteroids are a go-to treatment, applying it on the area of the head with limited patchy hair loss. Corticosteroid injections can also be useful. For more severe cases of the disease, oral corticosteroids are recommended. Other treatments involve triggering an allergic reaction on the scalp with medicines like DPCP or anthralin, or taking methotrexate. The FDA has also approved the use of a drug named baricitinib for adults suffering from severe alopecia areata. Children with the condition can sometimes just be monitored as many experience hair regrowth within a year. Different treatments could be used based on the age of the child and responsiveness to previous treatments.
Telogen effluvium, or sudden hair loss, is fully reversible. Very important in dealing with it is by identifying and dealing with the root cause, and reassuring the patient that it takes 3 to 6 months for hair shedding to stop, and growth usually resumes within 12 to 16 months.
On the other hand, scarring hair losses, where hair follicles are damaged and hair can’t grow, are rarer and harder to treat.
For two types named FFA and LPP, the goal is to slow hair loss and relieve symptoms. As there are no specific guidelines for their treatment, it is often recommended to use high-strength topical corticosteroids and other medicines. It can also be helpful for people to employ psychological support and techniques for covering thin hair.
Remember, it’s important for anyone dealing with any type of hair loss to receive psychological support as it can be quite a stressful experience.
What else can Alopecia (Hair Loss) be?
Diagnosing different types of hair loss can be complex because many seem similar to each other. To correctly determine the type of hair loss, detailed tests such as dermoscopy (skin examination using a special magnifying tool) and biopsy (removing a small piece of skin for testing) may be required. Here are a few examples of possible diagnoses to consider:
- Androgenetic alopecia (common hair loss): Can be mistaken for alopecia areata (patchy hair loss), telogen effluvium (temporary hair shedding), traction alopecia (hair loss from tension on the hair), trichotillomania (hair-pulling disorder), and other conditions such as frontal fibrosing alopecia (scarred areas at the front of the hairline) and lichen planopilaris (scarred areas on the scalp).
- Alopecia areata: Could be confused with ringworm of the scalp, trichotillomania, or triangular hair loss for patchy types of alopecia areata. It could also be confused with female-pattern hair loss, telogen effluvium, and drug-induced hair loss for more widespread types of alopecia areata.
- Telogen effluvium: Might be mistaken for androgenetic alopecia or diffuse forms of alopecia areata.
- Frontal fibrosing alopecia and lichen planopilaris: Can be misdiagnosed as chronic cutaneous lupus erythematosus (a skin disorder), central centrifugal cicatricial alopecia (hair loss that starts at the crown of the head), or folliculitis decalvans (a damaging inflammation of hair follicles).
What to expect with Alopecia (Hair Loss)
The future outcomes of hair loss can differ greatly depending on the type of hair loss, as well as other health conditions the patient might have.
Androgenetic Alopecia: This refers to hair loss that typically gets worse over time, causing less hair in the affected areas. It sometimes leads to complete baldness in men, but this is uncommon in women. If caught and treated early, this type of hair loss can often be slowed down, saving more hair.
Alopecia Areata: This type of hair loss is unpredictable. It can come and go, over time. Certain things may suggest a worse outcome, including starting in childhood, lasting a long time, affecting a large area, nail involvement, other autoimmune diseases, and a family history of the condition.
Telogen Effluvium: The future outcomes for this type of hair loss depend upon the possibility to eliminate the cause. If the root cause can be addressed spontaneously or removed, then this condition is usually temporary.
FFA: Predicting outcomes for FFA, or Frontal Fibrosing Alopecia, is difficult. Things that might suggest a poor outcome include skin bumps on the face, loss of eyelashes or body hair, and widespread involvement of the forehead and temples. A less severe outcome might be possible with a younger age at onset, slight involvement of eyebrows and a sporadic pattern of hair loss.
LPP: Also known as Lichen Planopilaris, this type of hair loss can be unpredictable; it might stabilize or continue to worsen slowly.
Possible Complications When Diagnosed with Alopecia (Hair Loss)
Although hair loss, or alopecia, doesn’t typically have harmful physical effects, it can have serious mental health impacts like anxiety and depression in anyone, regardless of their age or gender. However, it’s been noted that women tend to have a harder time dealing with these negative effects compared to men. It can lead to a reduction in social interactions and lower self-esteem. Furthermore, young people struggling with alopecia areata, a specific type of hair loss, may face social isolation or bullying from those around them.
Preventing Alopecia (Hair Loss)
There isn’t a lot of information out there about how educating patients affects hair loss, or alopecia. In a study from 2018, they gave half of the people involved information about a specific type of alopecia called androgenetic alopecia and then compared whether they were more willing to undergo treatment than the group that didn’t receive that information. It turned out that the ones who were informed about androgenetic alopecia were 1.7 times more likely to want treatment.
It’s unclear if these findings can be applied to other types of alopecia. However, a 2022 study did show that using video-based education on social media greatly improved patients’ understanding of different hair loss disorders. This study included men and women of all ages who had not only androgenetic alopecia, but also other types such as alopecia areata, telogen effluvium, FFA, and LPP.
