Alopecia

(Hair Loss, Baldness)

In this condition factsheet:

• The Facts
• Causes
• Symptoms and Complications
• Making the Diagnosis
• Treatment and Prevention

The Facts

Alopecia refers to hair loss from any part of the body for any reason. There are several types, ranging from thinning hair to complete baldness. Alopecia is broadly classified into 2 categories. In non-scarring alopecia, the hair follicles are still alive and hair can be grown. In scarring alopecia, the hair follicles are destroyed and will not regrow hair.

Diffuse alopecia (thinning scalp hair) is common among seniors, both men and women alike.

Androgenic alopecia, also known as "male pattern baldness" and "female pattern baldness," can strike younger as well as older people. It's genetic, so having a family history can predict if you might inherit it. In both men and women, it's linked to having an excess of male hormones (androgens) around the hair follicles, which can block hair growth. Women are more likely to develop androgenic alopecia after menopause, when they have fewer female hormones.

Most cases of hair loss are due to androgenic alopecia. Approximately 50% of men and women by the age of 50 years have some degree of androgenic alopecia. By the age of 70, up to 80% of men and women may be affected.

Alopecia areata typically causes a few temporary bald patches on the scalp. It tends to run in families and often occurs in childhood. The hair loss seems to be part of an immune system problem, in which the body's natural defences mistakenly attack its own tissue. Once the hair has fallen out in certain spots, new growth is suppressed for weeks or months. This type of alopecia sometimes affects people who have other "autoimmune" diseases like thyroid disease, lupus, or pernicious anemia. Sometimes, it may produce complete scalp baldness (alopecia totalis) or total loss of body hair (alopecia universalis).

Telogen effluvium is a form of hair loss often associated with pregnancy, medication use, life stress, diets, or surgery. It results in a larger amount of hair cycling into the resting (telogen) state where the hairs are ready to fall out. This type of alopecia usually improves on its own after several months. While it usually resolves, it can become chronic without regrowth of hair.

Scarring alopecia is a form of hair loss that results in scarring, where scarred areas will not regrow hair. This type of alopecia may have several causes. For example, fungus can leave permanent bald patches.

Causes

There are many different potential causes of alopecia. Hair loss – temporary or permanent – can be triggered by any number of factors. These can include allergies, irritants, toxins, burns, injuries, and infections. We also know that certain medications (especially anabolic steroids), chronic kidney failure, radiation, and chemotherapy can cause hair to fall out. Sometimes, hair loss may be due to a vitamin A overdose, iron deficiency anemia, a malfunctioning thyroid gland, fever, hormonal imbalances, or pregnancy.

Symptoms and Complications

Thinning hair is the most obvious symptom of androgenic alopecia. In men, it begins at the crown, temples, or both. They also tend to get a "high forehead" that's associated with a receding hairline. For women, hair loss begins on the top of the head. While men can go completely bald, women don't usually lose all the hair on the crown of the head.

Alopecia areata appears as sudden losses of small round patches of hair, usually from the scalp, but sometimes from the face or body. The fingernails may be lightly pitted or stippled. The disease often comes and goes in cycles, with regrowth in between.

Making the Diagnosis

While hair loss can be very distressing, alopecia by itself isn't harmful – the damage is cosmetic. But there's always a chance that alopecia might be a secondary effect or symptom of some other illness. To be sure, only medical tests and a full discussion with your doctor can ensure the right diagnosis. Always see a doctor if you start to lose hair.

Family history will often tell the doctor what type of alopecia a person has. Occasionally, a punch biopsy may be necessary to determine the type of hair loss. Looking at plucked hairs under a microscope can help to tell the difference between alopecia areata and androgenic alopecia. Other tests might be done to check for autoimmune diseases like lupus that can accompany alopecia.

Treatment and Prevention

While there's no way to prevent most types of hair loss, the goal of treatment is to slow or stop the loss of hair and then grow new hair.

Medications are available that encourage regrowth of hair. These medications, such as minoxidil*, and finasteride, are not appropriate for everyone with hair loss. Hair growth medications work to varying degrees in different people, and only trigger complete regrowth in a minority of individuals. They work best for people who have smaller amounts of hair loss. Hair loss returns if you stop taking the medication. Finasteride is not appropriate for women who may become pregnant, as it can cause severe birth defects. Spironolactone, although not approved by Health Canada for this purpose, is a medication that may help women who are losing hair due to excess testosterone. Biotin is a vitamin that makes hair and nails stronger and is often used as an adjuvant therapy.

Corticosteroids are another type of medication that may be used for some types of hair loss. Less severe cases of alopecia areata are sometimes treated with corticosteroids injected into the affected area or applied to the skin for people who cannot tolerate the injections. Systemic (pill-form) corticosteroids have long-term side effects and are reserved for more severe cases.

Another treatment for unresponsive alopecia areata is to deliberately provoke an allergic reaction (contact dermatitis) with a chemical applied to the scalp. A rash develops, and hair often grows back in the same spot a few months later. It can be uncomfortable, though.

Some people with hair loss have slightly low iron or zinc levels and may benefit from iron and zinc supplements.

If there is a systemic disease leading to hair loss, then treating the underlying disease may aid in hair growth.

For severe alopecia of any type, medication may improve the condition, but not cure it. The remaining options are to undergo surgery or wear a wig or hairpiece. The other option is to learn to live with the condition and not pursue medical options.

Surgery usually means a hair transplant. Small plugs of scalp, each with 2 or 3 hairs attached, are taken from areas of thick hair, and planted in the affected part of the scalp. Fewer hairs per square inch are needed for people with wavy or curly hair, or people whose hair and skin colours match.

Unfortunately, further hair loss can ruin any transplant, and leave you without enough donor hairs. The least successful candidates for transplant are men in their 20s who are balding fast.

Although wigs may not sound like the best option, they often are. Good quality modern hairpieces can be undetectable (though expensive). Many grip by vacuum and won't fall off – even during contact sports.

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