Having a full head of hair is a symbol of youth, health, and vitality.

However, having too much or too little hair can negatively impact our self-esteem and sense of self-worth¹, proving that our hair goes beyond just its physical benefits.

Unfortunately, hair loss can occur to anyone at any age and it can be triggered by a long list of factors:

• Genetics: you have a higher chance of experiencing hair loss if a family member has it.
• Certain medications (e.g. retinoids, birth control pills, and high blood pressure medications)
• Stress-induced (e.g. pregnancy and undergoing extreme weight loss)
• Certain illnesses (e.g. thyroid disorders)
• Nutritional deficiencies
• An excessive amount of male hormones
• Getting older
• Hair styling and harsh chemicals from products

In essence, hair loss can be attributed to either genetic, hormonal, or environmental factors. While the typical person shed around 50 – 100 hairs a day, a person experiencing hair loss can lose way more – causing significant emotional distress. 

The Hair Growth Cycle

In order to get a full picture of hair loss, it is important to first understand the 3 stages of the hair growth cycle:

• Anagen (active growth stage: about 90% of hairs)
• Catagen (transition stage between growth and rest: less than 10% of hairs)
• Telogen (resting stage: 5 – 10% of hairs)

Everyone goes through this continuous cycle of growth and rest throughout their lives – the only problem is when there is a disruption such as experiencing an abnormally long telogen phase.

Types of Hair Loss Disorders:

Alopecia (a.k.a. hair loss) can be categorized into two main groups: scarring and non-scarring alopecia.

Under non-scarring alopecia, we have the three most common types of hair loss – androgenetic alopecia, telogen effluvium, and alopecia areata. In this article, we aim to cover hair loss disorders that are not often talked about, yet are vital to address as it can play a role in whether or not a patient receives prompt treatment.

Alopecia Areata

An autoimmune disorder that causes unpredictable hair loss – alopecia areata is defined by small round or oval patches of hair fall on the scalp. In some cases, it can sometimes lead to complete hair loss on the scalp (alopecia totalis) or the entire body (alopecia universalis).

Patients may notice that the hair loss is sudden, and there might be some itching or burning in the area before the onset of hair loss. The nails can also be affected, including the appearance of white spots and lines or pinpoint dents on your fingernails and toenails.

It is still unknown as to why the white blood cells (T-lymphocytes) mistakenly attacks the hair follicles cells, causing them to miniaturize and grow at a slower rate. In addition, research closely links the condition to genetics and other autoimmune diseases such as vitiligo.

The most common therapy includes the use of corticosteroids and anti-inflammatory drugs to help suppress the immune system and reduce inflammation, where they can be administered via a topical ointment, oral medications, or a local injection.

Unfortunately, a rough 30% of individuals who develop alopecia areata will experience a relapse as there is currently no cure for the condition. However, with proper treatment, patients can still largely manage and control the condition to minimize hair loss and promote faster hair regrowth.  

Telogen Effluvium

Being the second most common type of hair loss, telogen effluvium occurs when a largely disproportionate percentage of the hairs enter the resting stage (telogen) too early.

People often notice that their hair feels thinner than usual, especially after going through a period of significant stress 3 – 6 months prior. This can be events such as pregnancy, surgery, or even extreme dieting, where hair loss can go on for weeks to months. It is not uncommon for patients to notice clumps of hair coming out in the shower or in their hairbrush.

In addition, having an overactive or inactive thyroid gland can cause a “shock” to the system that results in the condition – given that the hormones produced by the thyroid plays a significant role in the development and maintenance of the hair follicles.

Compared to alopecia areata which causes patches of hair to fall out, telogen effluvium comes out in handfuls, where it is most noticeable on the scalp.

Thankfully, your hair will eventually grow back, although it may take up to 6 – 12 months to get it back to normal. However, if stress is not managed, this condition can continue to last for years.

Scarring Alopecia

Scarring alopecia is much harder to treat than non-scarring alopecia as the hair follicles are destroyed and replaced with scar tissues – causing permanent hair loss.

Scarring can occur from incidents such as burns, x-ray therapy, and surgery, or diseases such as skin cancer, lupus, and a bacterial infection.

Although scarring alopecia is much less common, early treatment is the best step forward in order to prevent the condition from being irreversible. 

Lichen Planopilaris

This condition is an inflammatory autoimmune skin condition that causes itching accompanied with patches of rough, scaly skin on the scalp.

A gradually progressing condition, the main form of treatment is to control the itching, rash, and inflammation using injectable steroids, oral corticosteroids or other immunosuppressive medications.

Frontal fibrosing alopecia is a variant of lichen planopilaris that is defined by a straight narrow band of hair loss right at the front of the head. Just like with most types of hair loss, the cause is still unknown – although it commonly affects postmenopausal women and those experiencing female pattern hair loss.

In both conditions, treatment aims to preserve the remaining hair and scalp and control any existing symptoms, although not necessarily cause regrowth.

Folliculitis Decalvans

Folliculitis decalvans is a chronic inflammatory condition of the scalp and hair roots. Due to prolonged inflammation, this leads to scarring and an itchy and painful scalp.

The affected area is red and swollen, and may form scaly areas, pustules, and scabs. A key characteristic is several hairs (‘tufts’) seen coming out of a single follicle on the scalp skin – similar to what you might find on the bristles of a toothbrush.

Although the exact cause is not known, research points to an abnormal reaction to a

bacteria known as staphylococcus aureus. Whilst this bacteria is also present on healthy skin, it is due to an altered immune response that causes the symptoms.

Folliculitis may eventually stop and burn itself out, but patients often experience flareups for months or years.

Despite not being a cure, early treatment can reduce inflammation and prevent further scarring and hair loss. Anti-inflammatory and antibacterial scalp solutions or oral antibiotics are currently the first-line of therapy.

Folliculitis Decalvans (FD) is a rare neutrophilic infammation of the scalp characterized by painful, recurrent purulent follicular exudation resulting in primary cicatricial alopecia. However, unclear etiology makes FD treatment a difficult task. A wide variety of topical and systemic agents have been tried previously, with varied results. We present here a case series report of a set of 13 patients with FD on antimicrobial therapy.

Keywords: Folliculitis decalvans, antimicrobial, primary cicatricial alopecia 

Diagnosing Hair Loss Disorders

In most cases, a doctor will start by asking you a list of questions to better understand your condition such as what’s your diet, any preexisting medical conditions, and when you started to notice hair loss.  

They will then conduct a visual examination using a trichoscope, or request for a scalp biopsy or blood tests in order to eliminate any underlying conditions such as an iron or zinc deficiency or thyroid issues.

Once doctors are able to pinpoint the cause, it is much easier to decide whether to immediately start treatment, or wait till an underlying condition is fully-treated before tackling hair loss.

Best Treatment Options

Majority of treatments are mainly used for reducing inflammation, modulating hormone levels, and minimizing hair loss as much as possible.

Regardless of what treatment, they either aim to:

• Slow down hair loss
• Stimulate hair growth
• Disguise hair loss 

There are plenty of treatment options available to patients today, and these include:

• Topical medications (e.g. topical minoxidil)
• Oral medications (e.g. oral finasteride)
• Steroid injections
• Light and laser therapy treatments
• Surgical hair transplant (FUE or FUT)
• Immunotherapy

As with any other treatment, each one comes with their own list of pros and cons, as well as downtime and side effects.

In the case of surgical hair transplant, it is typically recommended only for patients whose disease has been inactive for one to two years, or aren’t seeing results with conventional treatments.

You should ensure that you undergo surgery with a highly-competent professional – as both FUE and FUT hair transplant requires years of training and knowledge in order to do it well.

Not every option is suitable for your condition and lifestyle, and it is always wise to seek advice from a professional dermatologist who is adept in treating a variety of hair loss disorders.

Ultimately, the treatment that you should go will depend on your health, hair loss condition, lifestyle, and goals.

Key Takeaways

Hair loss is a multi-faceted problem that can be difficult and complex to solve. It is pertinent that you maintain the hair that you have and if you are experiencing sudden or gradual hair loss to seek treatment as soon as you can.

At our dermatology clinic, we offer the most innovative and rigorously-tested techniques to deliver optimal results for our patients that are fully-customized to their needs and goals. This includes topical and oral medications, LED light therapy, low-level laser therapy, FUT and FUE hair transplant, and even biologics – a solution that shows great promise in treating scarring and non-scarring alopecia that may not have responded well with conventional treatments.

Dr. Angeline was an essential member at the National Skin Centre, where she was the founding consultant and lead of the hair transplantation service prior to opening her own private practice.

With a keen interest in treating all kinds of hair disorders, Dr. Angeline collaborates with all her patients and utilizes a combination treatment approach in order to help them achieve natural-looking and enduring results!

If you find that you are losing more hair than usual, or experiencing a burning, itchy, and painful scalp – do not hesitate to contact us and book a consultation today!

References:
1.Tosti, A., & Gray, J. (2007). Assessment of hair and scalp disorders. Journal of Investigative Dermatology Symposium Proceedings, 12(2), 23-27. https://doi.org/10.1038/sj.jidsymp.5650051.