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There is a reason why the hair on your head is called your crowning glory. Luscious, luxuriant hair is a sign of good health as much as it is a mark of beauty. No wonder, then, that we spend so much time, effort and money caring for and styling our hair.
In 2018, the global hair care market was estimated to be worth US$87.9 billion. According to a report by Grand View Research Inc., the numbers are expected to reach US$211.1 billion by 2025.
With such an emphasis on the hair, it is not hard to understand why hair loss is such a devastating condition.
But why would someone lose his hair? What are the causes? Are there viable treatments? Is there hope? We tell you all you need to know.
The medical term for hair loss is alopecia. Often, when the term is mentioned, it is with reference to alopecia areata or patchy baldness.
Alopecia areata, or alopecia for short, is an acquired skin disease that can affect skin that grows hair. This leads to localised areas of non-scarring alopecia or hair loss. Thought to be the result of an autoimmune disorder, it happens when a misguided immune system is unable to recognise the body’s own cells and damages the hair follicles. Hair follicles then become smaller and their production slows down drastically until hair stops growing. Since hair follicles are structures from which hair grows, weakened hair follicles lead to excessive hair fall with no replacement. Baldness results.
Although it can happen anywhere where there is hair, it usually affects the hair on the scalp the most. In most cases, the hair falls out in small patches no larger than the size of a small coin. Because the hair does not fall out uniformly, the result is patches of baldness. For this reason, alopecia is also known as spot baldness. In certain cases, all the hair on the scalp or even all over the body may fall off. In such cases, less than 10 per cent recover from the condition.
Most people who develop alopecia are otherwise healthy apart from the hair loss and changes in their fingernails – red or brittle nails, or dents and ridges forming. Alopecia areata tends to be unpredictable, often developing suddenly over the course of a mere few days. It can happen to anyone. An estimated 0.15 per cent of people are affected at any one point in time. 2 per cent are affected at some point in time. Men seem to be more prone to it. According to a CNA report in 2017, 35 million men and 21 million women worldwide are affected by baldness.
Alopecia can happen at any time although those between 30 and 60 are more susceptible. In 80 per cent of patients, alopecia occurs by age 40. In half of those who suffer from alopecia, the condition appears as early as in childhood although it is rare before the age of three.
It can also be either a temporary or permanent condition. For about half the people with alopecia areata, hair regrows spontaneously without treatment required within a year. This usually happens to those who have only a few patches of hair loss. In instances such as these, the condition does not recur. However, about 30 per cent of the people who have alopecia areata find their condition becomes more extensive or develops into a continuous cycle of hair loss and regrowth. 1 in 10 will go on to develop alopecia totalis or alopecia universalis.
Alopecia areata is different from hair shedding. We all shed between 50 to 100 strands of hair a day. This is normal and not noticeable because new hair is growing at the same time. Sometimes, however, we may end up shedding a lot more of this and new hair does not grow to keep up with the loss. The condition is called telogen effluvium.
Telogen effluvium sometimes happens after the discontinuation of hormonal estrogen and progesterone therapies for birth control or after pregnancy. Stress, weight loss of 10 kilograms or more, illness especially very high fevers, and surgical operations can also cause excessive hair shedding.
Hair shedding often resolves itself without treatment when the cause is eliminated.
There are three types of alopecia areata. It is important to know the type you have because each type has a different prognosis and that will determine the course of treatment.
This is the most common type of alopecia. Areata means patchy and this form of alopecia is characterised by one or more patches of baldness the size of a coin on the scalp or on other parts of the body that has hair such as the face – eyebrows, eyelashes, beard, armpits, and even inside the nose and ears.
If this condition deteriorates and the patches become larger, it may become alopecia totalis or alopecia universalis.
This looks a lot like male- or female-pattern baldness because it is the thinning of hair all over the scalp and not just in one area or in patches. The difference is that it is sudden rather than gradual.
This is when the baldness is confined to only one spot anywhere on the head.
When the patchy hair loss happens in multiple areas, it is known as alopecia multilocularis.
This refers to total hair loss on the scalp. It affects 5 per cent of people with alopecia areata.
This is the complete loss of hair not only on the scalp but on the face and the rest of the body. This is rare. Only 1 per cent of those with alopecia aerate develops this.
Sometimes, the condition appears only in the beard area. When this happens, it is called alopecia areata barbae.
This refers to hair loss that follows a band along the sides and lower back of the scalp, affecting the occipital and lateral scalp. The bald area can end up encircling the scalp.
Although alopecia areata can happen to men and women alike, the condition presents itself differently in each gender.
Men, rather than women, are more likely to suffer from alopecia areata. In addition, the hair loss is likely to be more significant in men. Men with alopecia areata might experience hair loss on the scalp as well in on their chest and back.
Alopecia areata is different from male-pattern baldness or female-pattern baldness in two ways. One, the latter is a gradual thinning of hair while alopecia areata tends to occur quite suddenly. Two, male- or female-pattern baldness involves the thinning of hair all over rather than in patches.
Alopecia areata can occur in children, too. For most with the condition, the symptoms often appear before they turn 30. While family history does play a part in the development of alopecia areata, those who display signs of the condition early do not seem to have inherited the condition from their parents. In children, alopecia areata is accompanied more often by nail defects. This happens in adults as well but is more common in children.
The condition can go into remission for a time for children.
According to the National Alopecia Areata Foundation, when alopecia areata occurs in children younger than five, there is little emotional impact. However, if the condition appears after the age of five, the loss of hair can be traumatic for the child. This is because past five, they begin to notice that they look different from their peers.
Alopecia areata is a systemic autoimmune disorder in which the body attacks its own anagen hair follicles and suppresses or stops hair growth. This can happen when T cell lymphocytes cluster around affected follicles, causing inflammation and subsequent hair loss.
Hair follicles in a normal state are said to be kept secure from the immune system in a phenomenon known as immune privilege. When this immune privilege state is breached, alopecia areata occurs. There are a few cases of babies born with congenital alopecia areata.
As to why this autoimmune disorder happens causing the body to target hair follicles is unclear although there are several possibilities.
Genetics is the most popularly believed cause of alopecia areata because the condition occurs most frequently in people who have family members who are similar affected. The hereditary factor is further bolstered by studies that looked at families with two or more members with alopecia areata. One study identified at least four regions in the genome that are likely to contain these genes, lending credence to the genetic factor in increasing the risk of developing alopecia areata.
In a 2010 genome-wide association study, 129 single nucleotide polymorphisms were identified that were associated with alopecia areata. The genes that were identified include those involved in controlling the activation and proliferation of regulatory T cells, cytotoxic T lymphocyte-associated antigen 4, interleukin-2, interleukin-2 receptor A, and Eos (also known as Ikaros family zinc finger 4) as well as the human leukocyte antigen. The study also identified two genes - PRDX5 and STX17 - that are expressed in the hair follicle. This added to the belief that endogenous retinoids metabolic defect is a key part of the pathogenesis of the alopecia areata.
In another study, researchers found that Caucasians with allergies such as eczema who also had alopecia areata tended to have a more extensive form of the condition or suffered more prolonged hair loss. However, such a link did not exist with Indian subjects in a similar study. This points to a possibility that the different genetic compositions of the races had a part to play in how the condition develops.
In addition, if a parent or close blood relative has or had alopecia areata, the child has a greater risk of developing the condition. Between 10 per cent and 25 per cent of people with alopecia areata have a family history of the condition or other autoimmune diseases.
However, alopecia areata is known as a polygenic disease. This means that both parents must contribute a number of specific genes in order for their child to develop alopecia. As a result, most parents with the condition do not pass it on to their children.
Even in identical twins, there is a 55 per cent chance that if one has alopecia areata, the other would develop the condition. Though the percentage is high, it is not a certainty. This is why scientists believe that it takes more than just genetics to cause the disease.
People with slightly higher incidence of conditions related to the immune system may have a higher risk of developing alopecia areata. These include conditions such as:
Because of this link, researchers lean more towards genetics as a contributory factor of developing alopecia areata.
Studies have found that people with certain autoimmune diseases like multiple sclerosis or rheumatoid arthritis, have a Vitamin D deficiency. Since alopecia areata is also an autoimmune disease, scientists then looked at the vitamin D levels of people who have alopecia areata. Some did have a vitamin D deficiency but others did not. So, more research needs to be done in this area to determine the role of Vitamin D deficiency in causing this condition.
Chromosomal abnormalities such as Down syndrome are associated with an increased occurrence of alopecia areata.
Changes in hormonal levels due to pregnancy, childbirth, menopause and thyroid problems are risk factors as well.
Hair loss can be a side effect of certain medication for cancer, arthritis, depression, heart problems, gout and high blood pressure. A few cancer patients who have been put on a drug called nivolumab developed alopecia areata. The drug is used to treat lung cancer and melanoma that has spread.
There are suggestions as well of links between alopecia and the use of Zidovudine, which is used to treat HIV, and the antidepressant Fluvoxamine. They reported hair loss a few months after they started treatment. The hair loss is actually a good sign because it is an indication that the drug is working.
Allergies to dust mites were found to potential triggers of alopecia areata or can exacerbate it. In a 2015 study conducted by researchers at the Sun Yat-sen University, Guangzhou, China, this was observed to be the case. Because all the subjects were Chinese, more studies need to be done with other ethnicities to see if this is also the case with them.
Scientist have linked an outbreak of alopecia areata in workers at a water treatment to long term exposure to the chemical acrylamide. Other chemicals that have also been linked to alopecia include formaldehyde and certain pesticides.
More studies need to be done though because the links have, so far, been theoretical.
The changing season appears to have an effect on those with alopecia areata, causing their condition to worsen or abate. Patients note that their condition seem to intensify in the winter while regrowth tends to happen in the summer.
Though this indicates a link, the different seasons may not be a direct cause of alopecia areata.
Injuries to the scalp – cuts, scrapes, and other types of damage – can lead to the onset of a patch of hair loss in people already susceptible to alopecia. It is worth noting that the same type of damage done to an area of the scalp already affected by alopecia seems to cause hair to grow back temporarily. It appears that the injury promotes anagen hair follicle growth in the skin around the site of the damage.
Race may predispose you to alopecia areata. In a large study that spanned several years, researchers found that black and Hispanic nurses were more likely than white nurses to develop alopecia areata.
The study, however, has limitations because it only looked at female nurses in America. Research with a wider and more diverse pool of participants needs to be conducted to see if the findings are true of people in other countries as well.
There is a debate going on as to whether stress can cause alopecia. Some say psychological stress may result in alopecia areata although others maintain there is little to no scientific evidence of this.
Alopecia areata presents itself differently in different people. Because it is spontaneous and unpredictable, it is difficult to tell how the pattern of hair loss and regrowth will take place or how severely the condition will progress.
However, there are some common symptoms of the condition.
The first and most telling sign of alopecia areata is patchy hair loss the size of coins, mainly on the scalp although it can include the beard area and even eyelashes and eyebrows as well as other parts of the body. The patches may be few or many, depending on the person. Sometimes, the patches become so large they merge to form one large bald spot.
If the baldness happens on the scalp, it is common for it occur more on one side than the other. The patches can be any shape though they usually are round or oval. The skin beneath looks normal with no redness, rashes or scarring though. In fact, the bald patches often look almost clean-shaven.
The hair loss is significant and sudden, often over a few days or a few weeks.
Fingernails and toenails can change when the condition is developing because keratin forms both hair and nails. This happens to 10 per cent to 20 per cent of people with alopecia areata. Some sources say nail defects can affect up to half of those with alopecia areata.
Some changes to note include:
In the area before the hair begins to fall, people may experience itching, tingling or a burning sensation known as trichodynia. Sometimes, the feeling may intensify and be experienced as pain. This is a sign that the hair follicles are inflamed. The condition may subside when the inflammation does.
Exclamation mark hairs appear. This happens when a few short hairs get narrower at their base and grow in or around the edges of bald spots. These hairs are also very short – 3 to 4 millimetres.
Cadaver hairs may develop as well. This is where hairs break before reaching the skin surface.
Grey and white hair may also grow in areas affected by hair loss.
In addition, the hair becomes easier to pull out along the edges of the bald patch. This is where the follicles are already being attacked by the body's immune system and have been compromised compared to those away from the patch where the follicles are still healthy.
The damaged hair is different from healthy hair which, when pulled, only a few should come out. The ripped hair also does not distribute evenly across the tugged portion of the scalp.
Different areas of the skin may have hair loss and regrowth at different times. So, while hair may begin to appear again where it had fallen out, other bald spots may appear elsewhere.
The hair that is regrown may be white or grey initially and may even curly even with people who have straight hair.
Bald spots may appear more during the colder months. This is because the cold triggers the condition. In one study, researchers found that people with alopecia areata experienced hair loss most often in November, followed by October and January.
These people saw less hair loss in the warmer months of May and August.
While it is good to recognise the signs and symptoms of alopecia areata, they are still only indications that you may have the condition. To be certain, it is best to seek a diagnosis from a doctor.
Consult a doctor if your hair loss is persistent and you want to pursue a course of treatment that will best suit you. Sudden patchy hair loss may also be a sign of an underlying medical condition such as thyroid disease and lupus. Seeing a doctor will help you ascertain if these more serious illnesses are the cause and allow you to be treated accordingly.
To make your consultation with your doctor as productive as possible, you need to:
Tell him if there have been any major changes or stressors in your life, or any recent lifestyle changes.
If you have family members who suffer from hair loss, make sure to include this information during your visit. Hereditary factors can cause alopecia areata so this is something that may help your doctor provide an accurate diagnosis.
If you have been ill recently, make sure your doctor knows. If you experience any changes in your nail condition, tell your doctor as well because nail change is one of the indications of alopecia areata.
Tell him what kind of medication you have been on as well. Include all health supplements. You may also want to tell him if you have had any recent medical procedures or dietary changes.
If you changed your hair care product or have gone for hair treatments recently, include the information during your visit.
Prepare a list of questions for him:
- What is the best course of action?
- Should I change my diet or hair care routine?
- Are there any restrictions that I need to follow?
- Should I see a specialist? What will that cost?
- Where else can I go to find out more about the condition?
There are some questions you may be expected to answer:
Diagnosis is done is a variety of ways:
The doctor may be able to diagnose your condition by simply examining your scalp and looking at the extent of the hair loss. Oftentimes, reddening of the skin known as erythema may be present in the blading area.
This is to performed to ascertain the stage of the shedding process. Your doctor may gently grasp several dozen strands of hair from different parts of the scalp, usually about 40 strands, and tug at them. If three or more strands fall out in the process, you have active hair loss.
Examining the roots of the hair from your scalp under the microscope may also reveal the condition.
This refers to the dermoscopic imaging of the scalp and hair by placing the hair against a light background and visualising the roots at higher magnification. In alopecia areata, regularly distributed yellow dots or hyperkeratotic plugs, small exclamation-mark hairs and black dots which are destroyed hairs in the hair follicle opening may be observed.
Blood tests may be ordered as well to discover if other autoimmune diseases or medical conditions are the cause of your hair loss.
Some of these tests include a test to check for the presence of one or more abnormal antibodies. If these antibodies are found in your blood, it is likely that you have an autoimmune disorder.
Other blood tests that can help rule out other conditions include the following:
If initial clinical examinations fail to yield a definitive diagnosis, your doctor may ask for a scalp biopsy to rule out other causes such as fungal infections like tinea capitis. He will scrape samples from the skin on your scalp to examine it. Biopsies, however, are rarely required for a diagnosis.
Your doctor may refer you to a dermatologist since alopecia areata is a skin problem rather than a hair problem. The dermatologist can also offer you self-care tips that can help if you lose your eyelashes, eyebrows, the hair inside your ears, or on other parts of your body.
There is no cure for alopecia areata. The prognosis for each person is also different because the condition is unpredictable. So, alopecia areata may persist throughout a person’s life or it may happen just once.
Spontaneous recovery without treatment have been known to occur as well, usually within a few months to a year. The likelihood of this happening is higher if the person is suffering from alopecia areata monolocularis where the baldness is limited to just one spot. According to research, 40 per cent of people with a single patch of hair loss fully regrow their hair within six months.
Hair can regrow because while the immune system may have damaged the hair follicles, it has not destroyed it. The hair follicles are still alive, enabling hair growth to take place. This can happen even after a long time of baldness and even if the baldness is extensive – more than 50 per cent of the hair is affected. Research shows that 27 per cent of people with multiple patches of hair loss fully regrow their hair within a year.
Because there is no cure, even after the hair grows back, the immune system can continue to attack the hair follicles leading to another cycle of hair loss. Some people may experience several such cycles of hair loss and hair growth. Research have found that this occurs in 33 per cent of people with alopecia areata.
Poor outcomes of alopecia areata are associated with several factors:
If the condition happens before puberty, it is like to be worse.
The condition, however, is not contagious.
If spontaneous recovery does not take place, there are several forms of treatment for alopecia areata. These treatments are meant to encourage the re-growth of hair. They do not prevent the re-emergence of new bald spots.
Though treatment options exist, there is no one definitive treatment that has guaranteed results. This is because spontaneous hair growth, especially in the early stages of the condition, sometimes impedes research into treatment methods.
With a greater understanding of genetics and molecular mechanisms of alopecia areata, there have been new treatments such as those that use monoclonal antibody biologic agents that target cytokine pathways. These biological drugs offer more targeted therapies that may promise better results.
One such revolutionary treatment is the use of oral JAK inhibitors drugs such as tofacitinib, ruxolitinib, and baricitinib. They belong to a family of medicine called DMARDs (disease-modifying antirheumatic drugs) and work by inhibiting the activity of one or more of the Janus kinase family of enzymes which then interferes with the JAK-STAT signalling pathway.
This suppresses the inflammatory response of the body which is what causes the hair follicles not to grow hair. JAK inhibitors also encourage hair growth by stimulating hair follicle stem cells. However, in the studies, when the patients stopped the medication, the hair loss resumes.
The use of cortisone is the most common treatment for alopecia areata.
Cortisone injections can be given on the scalp to speed up hair growth. Cortisone reduces inflammation which happens when the immune system attacks the hair follicles and damages it. When inflammation is reduced, the hair follicles can function properly and cause hair to grow.
The injections are usually given every four to eight weeks by a dermatologist. Thus far, it is considered the most effective treatment for people with alopecia areata. In one study of 127 patients with the condition, more than 80 per cent who were treated with these injections had at least half of their hair regrow within 12 weeks.
Steroid injections is another type of injection that can be used to treat alopecia areata. This is usually done on areas of hair loss that are small such as the eyebrows. Their effectiveness is uncertain.
Cortisone pills such as clobetasol or fluocinonide may be prescribed as well. They may take longer than an injection to work though. In addition, cortisone can cause certain side effects and so it is best taken only if prescribed by a doctor. Cortisone pills also have shown limited success.
Immunosuppressants like methotrexate and cyclosporine may be prescribed, too. These work by blocking the immune system’s response, preventing it from attacking the hair follicles. However, there are risks of side effects that include high blood pressure, liver and kidney damage, and an increased risk of serious infections and lymphoma. As such, they should not be used for long periods of time.
In a small study of patients who had complete loss of hair on their scalp or entire body, 57 per cent had complete regrowth with methotrexate. If it works, it may take three months before hair growth is experienced. Full regrowth may take up to 12 months.
However, in a 2008 meta-analysis of oral and topical corticosteroids, topical ciclosporin, photodynamic therapy, and topical minoxidil where data from several studies were combined, no benefit of hair growth was shown.
Cortisone creams, ointment or foam may be applied to the scalp once or twice a day. Like the pills, this method is less effective than a cortisone injection directly in the areas affected. This is because the cortisone often does not penetrate the skin deeply enough to affect the hair follicles. In children, the effects tend to be better.
Instead of steroid injections, steroid creams can be used as well. Topical immunotherapy like ciclosporin may be applied, too.
Other topical medications include Minoxidil (Rogaine). This is a non-prescriptive formula that comes in liquid, foam or shampoo forms. Minoxidil is meant to both encourage hair to grow back and slow the rate of hair loss. Minoxidil has to be applied two to three times a day.
Anthralin is another topical medication for alopecia aerate. Applied to the bald spot, the medication is left to work for a while before it is washed off. Anthralin works by slowing down the growth of skin cells.
When alopecia areata is associated with celiac disease, a long-term immune disorder that affects the small intestine, a gluten-free diet seems to aid complete and permanent regrowth of hair in some people.
Preliminary research in animals has also found that quercetin, a naturally occurring bioflavonoid found in fruits and vegetables, can protect against the development of alopecia areata and effectively treat existing hair loss. More research needs to be done, including human clinical trials, before quercetin can be considered as a treatment for people with alopecia areata.
Photochemotherapy or PUVA is a UV light therapy for skin diseases. Used in combination with psoralen either orally or topically, the treatment has some benefit for alopecia aerate.
Also known as topical immunotherapy, this treatment alters the immune system so that it stops attacking the hair follicles. Some 60 per cent to 70 per cent of those given this treatment have experienced some hair regrowth.
Chemicals are applied to the bald spots with a small amount applied to the body so it can react to the chemical. Once there is a rection, the chemical will be applied weekly to the bald areas and left there for 48 hours. During this time, a rash will appear that will last 36 hours. The process is repeated weekly till there is complete regrowth of hair. If there are no results in six months, it means the treatment has not worked.
A combination of the lipid-lowering medications simvastatin and ezetimibe (which have immunomodulating effects) has been reported to be effective. However, more research needs to be done because the results were only in a single case where substantial hair growth was reported in the patient with longstanding alopecia totalis.
Given that alopecia areata can be recurring and treatments, if they work, take time, there may be seasons when you may have to live with alopecia areata and cope with its effects.
We list some ways you can do so.
Hair does not just beautify, it protects as well. Scalps sans hair are vulnerable to excessive sun exposure. Eyelashes and eyebrows are meant to protect your eyes from dust and glare. So, if you begin to bald in these areas, protection is necessary.
Wear sun screen on your head. Alternatively, wear protective gear such as a cap, hat or scarf. You could also wear a wig or hair piece to cover the bald spots.
Invest in a pair of good sunglasses to shield your eyes from UV rays and debris. False eyebrows and eyelashes are readily available, too.
If you have lost your nose hair, apply antibiotic ointment just inside each nostril to keep out small particles. This is because nose hairs keep out dust, germs and small airborne particles. Without them, you have lost a layer of protection.
Although harmless to health, hair loss can be damaging to the psyche. The condition can be very isolating and can lead to anxiety and depression because hair loss can affect self-image and lower self-esteem. Though research into the psychological problems associated with hair loss is limited, there is evidence to show that hair loss can cause intense emotional suffering that often leads to personal, social and work-related problems.
Compared to the general population, people with hair loss experience greater incidences of psychiatric disorders including a major depressive episode, an anxiety disorder, social phobia, or a paranoid disorder.
So, masking the effects of alopecia aerate can help. Headwear and hairpieces not only protect, they camouflage, too. In addition to false eyebrows, eyebrow tattoos and eyebrow pencils can colour in non-existent brows.
Avoid things that may trigger alopecia areata. Foods that contain sugar or are processed, and alcohol may increase inflammation in the body so avoid them. Instead, eat foods that are known to ease inflammation such as fruits like blueberries, nuts, seeds, broccoli, beets, and lean meats like wild-caught salmon.
Some 2 per cent of the world suffer from alopecia areata. While it may seem that you live in a world of hirsute people, this is not necessarily the case. Get in touch with others who have the same condition so you know that you are not alone. They can provide support and tips to manage the condition as well.