Alopecia describes hair loss, which may occur in men, women, or children. Hair loss may eventually lead to excessive hair loss, called baldness. Hair loss and baldness can occur for a number of different reasons.
It is normal for some hair to fall out each day. It is estimated that adults lose 50-100 hairs each day because hair only lives two to six years. Once a hair is shed, a new hair grows to replace it. In general, hair grows about one-half inch each month. Hair growth may be less noticeable in patients with curly hair. As individuals age, most people experience hair thinning or loss.
There are two main types of hair loss: alopecia areata and androgenetica alopecia.
Alopecia areata is an immune system disorder. Normally, the immune system helps protect the body against disease and infection. However, the immune system in patients with alopecia areata mistakes the openings in the skin where hair grows, called hair follicles, as harmful invaders. As a result, the immune system launches an attack against the hair follicles, causing hair loss.
Patients with alopecia areata typically receive drugs called corticosteroids for the rest of their lives. These drugs help reduce the body's immune response, limiting the amount of hair follicles that are attacked.
Androgenetica alopecia is an inherited form of baldness. This means the condition is passed down through families. An estimated 60% of patients with androgenetica alopecia are male. When the condition occurs in men, it is called male-pattern hair loss.
Although there is currently no cure for androgenetica alopecia, there are several medical treatments available to replace lost hair. Individuals may also choose non-medical treatments, such as wigs or hairpieces, to replace lost hair. Some patients with androgenetica alopecia prefer to let the hair loss run its course.
In addition, several other factors may lead to temporary hair loss, including medications and medical treatments, poor nutrition, infancy, hair treatments, infections, and illnesses.
General: Symptoms of alopecia vary among patients. Patients may experience subtle hair thinning, extensive hair loss, or baldness. Males, females, and children can experience alopecia.
Alopecia areata: Patients with alopecia areata usually lose small round patches of hair on the scalp, face, and chest. Other parts of the body, including the eyelashes, eyebrows, and genitals, may also be affected.
Androgenetica alopecia: Males with androgenetica alopecia may experience hair loss during adolescence. This type of hair loss usually starts at the temples and crown of the head. Eventually, the patient may be partially or completely bald.
Females with androgenetic alopecia usually experience hair loss at the front, sides, or top of the head. Unlike males, females rarely develop complete baldness. Females usually only experience hair thinning.
Other: Alopecia that is caused by poor nutrition, infancy, hair treatments, infections, or illnesses may cause hair thinning, balding, or patches of hair to fall out. Unlike alopecia areata and androgenetica alopecia, these symptoms are temporary.
General: In most cases, alopecia does not require a diagnosis. The healthcare provider can usually determine the cause of hair loss after a physical examination and medical history. If there is a family history of alopecia, androgenetica alopecia is suspected. The healthcare provider will also ask questions about recent infections, new medications, diet, and hair treatments to determine if such factors are causing hair loss. If alopecia areata is suspected, a fluorescent antinuclear antibody (FANA) test may used to confirm a diagnosis.
Fluorescent antinuclear antibody (FANA) test: The fluorescent antinuclear antibody (FANA) test is a blood test used to detect abnormal antibodies, called autoantibodies. The autoantibodies bind to components of and individual's own cells and cause the immune system to attack the body. If autoantibodies are present, the patient has an autoimmune disorder.
During the procedure, a small sample of blood is taken from the patient and sent to a laboratory. The scientist tests the blood to determine whether or not it contains autoantibodies.
If a patient has a positive FANA result and has symptoms characteristic of alopecia areata, the patient is diagnosed with the disorder.
In rare occasions, the FANA test results can be positive in people who do not have autoimmune disease. This is called a false positive test result. The frequency of false-positive test results increases with age. A false negative result is also possible, but it is uncommon. Patients can be re-tested if a false negative test result is suspected.
Dandruff: If patients develop alopecia as a result of poor nutrition, they may also have dandruff. Dandruff causes dry, itchy, and excessive flaking of skin on the scalp. Improving nutrition will help reduce symptoms of dandruff.
Dandruff and alopecia may also be unrelated. However, dandruff may become more noticeable when the individual loses hair. White flakes of skin may be visible on clothing. Patients can purchase medicated shampoos to treat dandruff. For instance, zinc pyrithione shampoos (Selsun Salon® or Head & Shoulders®), tar-based shampoos (Neutrogena® or T/Gel®), salicylic acid shampoos (Ionil T®), selenium sulfide shampoos (Selsun Blue®), and ketoconazole shampoos (Nizoral®) have been used to treat dandruff.
Quality of life: Some patients with hair loss may have a difficult time coping with their appearance. Some patients may experience a decrease in their quality of life or suffer from low self-esteem. These patients may benefit from medical or non-medical hair replacements. Treatment may include hair pieces, surgery, or medications.
Patients who experience hair loss have an increased risk of developing sunburn, especially if they have light or fare skin. Patients who are bald or have bald patches of skin on the scalp should put sunblock on the scalp to prevent sunburn and skin cancer. Patients should choose a sunblock with a sun protection factor (SPF) of 15 or higher. The sunblock should offer protection against both ultraviolet A (UVA) and ultraviolet B (UVB) rays. Patients with hair loss should wear hats in the sun and try to minimize sun exposure, if possible. An umbrella or parasol may also be beneficial.
General: There is currently no cure for alopecia areata or androgenetica alopecia. However, several treatments are available to replace lost hair. Individuals may also choose non-medical treatments, such as wigs or hairpieces, to replace lost hair. Some patients with androgenetica alopecia prefer to let the hair loss run its course. Patients with alopecia areata typically receive drugs called corticosteroids for the rest of their lives. These drugs help reduce the body's immune response, limiting the amount of hair follicles that are attacked. Patients should consult their healthcare professionals before making any decisions about hair restoration surgeries or medications.
If other factors, such as hair treatments or infancy, are causing hair loss, the condition is temporary, and the hair will begin to grow back over time. If poor nutrition or illness is causing hair loss, the hair will grow back once the underlying cause is treated. If a medication or medical treatment, such as chemotherapy, is causing hair loss, the hair will grow back once the treatment is completed.
Corticosteroids: Patients with alopecia areata may receive injections with corticosteroids, such as betamethasone (Celestone®), into the scalp. Patients typically receive these injections monthly. Some patients with extensive hair loss may take corticosteroid pills. Corticosteroid creams and ointments, such as betamethasone (Diprolene®), have been applied to affected areas of the skin. However, creams and ointments are generally less effective than injections.
Hair replacement: Non-surgical hair replacement is an option for those who suffer from significant hair loss and would like to regain the appearance of having a full head of hair without surgery. Examples of products available include semi-permanent attached hairpieces, temporary adhesive-attached hairpieces, and clip attachments.
Hair replacement/restoration surgery: Hair replacement surgery is used to fill in balding areas with a patient's own hair. New hair growth usually begins six to 12 weeks after surgery. The surgery is usually performed by a licensed dermatologic surgeon and rarely requires a hospital stay. Hair replacement surgery is most commonly used for male-pattern baldness. The second most common use is to treat female pattern baldness. Hair restoration can also be used to treat hair loss caused by scarring, burns, irradiation therapy, or past infections, as well as to restore hair to the eyebrows, eyelashes, beard, and any other area.
During the procedure, a small section of hair-bearing tissue is removed from the patient. The tissue is then dissected into individual follicular units and micro-grafts. These grafts are then inserted into tiny slits in the patient's scalp.
Hair restoration surgery may be performed during a cosmetic procedure such as a facelift or brow-lift. New options and techniques have made hair restoration safer and easier. Most procedures are done in an office setting under local anesthesia
Hair replacement surgery is generally considered safe when performed by a qualified, experienced physician. Still, individuals vary greatly in their physical reactions and healing abilities and the outcome is never completely predictable.
Insurance generally does not cover surgery that is done purely for cosmetic reasons. This means most patients usually have to pay for hair replacement surgeries themselves. It is the patient's responsibility to check with the insurance carrier for information on the degree of coverage.
Hair transplants: Hair transplant surgery is a procedure in which a physician transplants hair from an area of thick growth to bald areas. A person's own hair must be used because hair from others will be rejected and will not grow. Hair grows in clusters containing one to five individual hairs called follicular units. Grafting involves removing small strips of the hair-bearing scalp. The harvested strips of hair-bearing scalp are divided into grafts for placement in the balding areas. These grafts may be processed into a variety of different sizes, depending on the patient's specific needs. Very small grafts are useful, particularly at the hairline, and they can be undetectable when they grow out. Larger grafts containing more hairs are used to obtain greater density behind the hairline. The areas from which the strips are taken are carefully repaired, usually resulting in a very narrow scar easily hidden by overlying hair. Recently, body hairs have been transplanted to the scalp.
A variety of medications may be taken for hair loss. Some of these medications may work for both women and men. Others, however, are restricted in their use to one sex.
Spironolactone (Aldactone®) was originally marketed as a diuretic (water pill) for patients suffering from congestive heart failure. This medication is a pill that is taken once or twice daily. Women now take the drug because its anti-androgen properties may stop and sometimes reverse hair loss. This medication may take many months to show results in women. It may also be more effective in post-menopausal women and may be taken with a hormone replacement pill.
Minoxidil (Rogaine®) is available with a doctor's prescription to treat androgenetic alopecia. Once used to treat high blood pressure, minoxidil is now used to treat hair loss in both men and women. This medication is applied directly to the area of hair loss at least two times a day for at least four months. The medication usually does not take effect until four months to one year. Patients who discontinue use of minoxidil
likely lose the hair that they have already grown. Minoxidil works by enlarging hair follicles.
Another prescription drug called finasteride (Propecia®) is indicated for the treatment of mild to moderate male pattern hair loss in men only. This pill must be taken daily to re-grow hair. Finasteride works by inhibiting high levels of a hormone called dihydrotestosterone (DHT) around hair follicles. High amounts of DHT cause hair follicles to shrink and hair falls out as a result.
Finasteride (Proscar®) was initially designed to treat an enlarged prostate, but it is now known to reduce hair loss in men. It is usually taken with minoxidil. This medicine decreases the body's production of DHT, the chemical responsible for shrinkage of hair follicles (opening in the skin where hair grows). The manufacturer states that Propecia® should not be used in women or children, and that pregnant women should not handle crushed or broken Propecia® tablets because the active ingredient may cause genital abnormalities in male fetuses.
Cimetidine (Tagamet®) was initially used as a prescription drug to treat heartburn and stomach ulcers. This medication is now available over-the-counter. While primarily used a histamine-blocking agent, it is also an anti-androgen and thus only works for women. Tagamet has been used to treat androgenetic alopecia in women.
Scalp extension or scalp expansion: Scalp expanders or tissue expanders may be used to increase the effectiveness of a scalp reduction. The extender acts like a large rubber band, while the expander acts like a balloon. During the procedure, the extender or expander is inserted under the scalp for about three to four weeks to stretch the hair-bearing areas so they can replace the balding areas. This allows for an even greater reduction in the balding regions. Scalp reduction surgery can be performed alone or in combination with a hair transplant.
Scalp lifts and scalp flaps: Scalp lifts and scalp flaps are surgical procedures that involve rotating larger sections of the hair bearing scalp to cover bald areas. This is mainly used to treat scarring or during trauma repair.
Scalp reduction: Scalp reduction is a treatment option for patients that are balding. It may be used to treat areas of hair loss that develop on the top and/or back of the head. The bald areas are reduced or eliminated by removing several inches of bald skin, pulling the sides together and stitching up the skin.
Other: There are many other hair restoration products available, including sprays, gels, and creams. These products vary in their effectiveness. Patients should consult their healthcare providers to determine whether or not such products are safe and effective for them.
Aromatherapy: Aromatherapy refers to many different therapies that use essential oils. The oils are sprayed in the air, inhaled, or applied to the skin.
Essential oils are usually mixed with a "carrier" oil, usually a vegetable oil or alcohol. Massage is often used to deliver oils into the body because it is considered the most effective method. A well-designed human study in patients with alopecia areata examined the effects of massaging a mixture of essential oils into the scalp daily for seven months. The mixture included oils of cedarwood, lavender, rosemary, and thyme in carrier oils of grapeseed and jojoba. A significant improvement was seen in photographs of the skin of patients using the mixture of oils compared to patients using carrier oils alone. Although these results are promising, further research is needed before a firm conclusion can be made.
Essential oils should be administered in a carrier oil to avoid toxicity. Avoid with history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.
Beta-sitosterol: Beta-sitosterol is found in plant-based foods, such as fruits, vegetables, soybeans, breads, peanuts, and peanut products. It is also found in bourbon and oils, such as olive oil, flaxseed, and tuna. Early research suggests that beta-sitosterol may help treat androgenetic alopecia. However, further research is needed to determine whether or not this treatment is safe and effective in humans. Avoid if allergic or hypersensitive to beta-sitosterol, beta-sitosterol glucoside, or pine. Use cautiously with asthma, breathing disorders, diabetes, primary biliary cirrhosis (destruction of the small bile duct in the liver), ileostomy, neurodegenerative disorders (such as Parkinson's disease or Alzheimer's disease), bulging of the colon, short bowel syndrome, celiac disease, or sitosterolemia. Use cautiously with a history of gallstones. Avoid if pregnant or breastfeeding.
Cedar: Cedar is native to the mountains of the western Himalayan and the Mediterranean regions. In one clinical study, patients with alopecia areata who were massaged with a combination of cedarwood oil, other aromatic oils, and carrier oils had significantly improved symptoms.
Avoid if allergic or hypersensitive to cedar, its pollen, wood dust, constituents, or members of the Pinaceae family. Avoid if pregnant or breastfeeding.
Hypnosis, hypnotherapy: Hypnosis is a trance-like state in which a person becomes more aware and focused and is more open to suggestion. Hypnotherapy has been used to treat health conditions or to change behaviors. Based on early study, hypnosis may help improve psychological well-being and physiological outcome in patients with alopecia areata. In other words, hypnotherapy may help patients cope with the effects of their hair loss. Larger, well-designed studies are needed before a firm conclusion can be drawn.
Use cautiously with mental illnesses, such as psychosis/schizophrenia, manic depression, multiple personality disorder, or dissociative disorders. Use cautiously with seizure disorders.
Lavender: Lavender is grown around the world. Oils from the flowers are used in aromatherapy, baked goods, candles, cosmetics, detergents, jellies, massage oils, perfumes, powders, shampoo, soaps, and teas. Small studies have shown that patients who massage essential oils (thyme, rosemary, lavender, and cedarwood) into their scalps daily experienced an improvement in alopecia. More research of lavender alone is need before a firm conclusion can be made.
Avoid if allergic or hypersensitive to lavender. Avoid with a history of seizures, bleeding disorders, eating disorders (anorexia, bulimia), or anemia (low levels of iron). Avoid if pregnant or breastfeeding.
Onion: Onion juice applied topically was shown to increase hair regrowth in alopecia areata patients, especially women. More research is needed to confirm these results. Avoid if allergic or hypersensitive to onion (Allium cepa), its constituents, or members of the Lilaceae family. Use cautiously with hematologic (blood) disorders, diabetes, hypoglycemia (low blood sugar), and hypotension (low blood pressure). Use cautiously if taking anticoagulants or antiplatelets (blood thinners). Avoid if pregnant or breastfeeding in medicinal doses.
Para-aminobenzoic acid: Also known as PABA, para-aminobenzoic acid is a naturally occurring amino acid that has been studied in the treatment of hair loss. Additional clinical study is needed before a firm conclusion can be made. PABA is typically shown to be safe when used topically in concentrations of 1-15% in adults and children. However, some people may have hypersensitivity to its use, especially children.
Rosemary: Rosemary (Rosmarinus officinalis Linn.) is a common evergreen aromatic shrub that is grown in many parts of the world. The fresh and dried leaves are used frequently in traditional Mediterranean foods as a flavoring agent and as a food preservative. Historically, rosemary has been used to stimulate the growth of hair. Rosemary oil has been shown to increase circulation and possibly promote hair growth in patients with alopecia areata. Additional study is warranted to confirm these findings.
Avoid if allergic or hypersensitive to rosemary, its constituents, or members of the Labitae/Lamiaceae family. Use cautiously if prone to atopic or hypersensitivity reactions. Use cautiously with a history of iron deficiency anemia. Use cautiously with coagulation disorders, hypotension, diabetes, or peptic ulcer disease. Use cautiously if taking anticoagulants, antiplatelet agents, anti-hypertensive agents, anti-cancer drugs, medication for high cholesterol, herbs or drugs that are broken down by the liver, diuretics, estrogen or estrogenic herbs, or medications for osteoporosis. Avoid if taking lithium. Avoid if pregnant or breastfeeding.
Saw palmetto: Saw palmetto (Serenoa repens or Sabal serrulata) is commonly used in Europe to treat symptoms of enlarged prostate. It has been suggested that saw palmetto may reduce inherited male-pattern hair loss, as well as hair loss for women, similar to the medication finasteride (Propecia®). More studies are necessary before saw palmetto can be recommended for this use.
Avoid if allergic or hypersensitive to saw palmetto. Use cautiously with a history of health conditions involving the stomach, liver, heart, or lungs, hormone-sensitive conditions, or bleeding disorders. Use cautiously with drugs that thin the blood, hormonal drugs, or birth control pills. Avoid if pregnant, possibly pregnant, or thinking about becoming pregnant. Avoid if breastfeeding.
Selenium: Selenium is a trace mineral found in soil, water, and some foods. Studies report that selenium-containing shampoos may help improve dandruff and selenium is included in some commercially available products.
Avoid if allergic or sensitive to products containing selenium. Avoid with a history of non-melanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.
Tea tree oil: The tea tree (Melaleuca alternifolia) is a small tree with narrow, soft, alternate leaves and yellowish flowers the shape of bottlebrushes. It is one of more than 30 species of paperbark trees that are found throughout Australia. Tea tree oil is obtained by steam distillation of the leaves of the tea tree. Preliminary research reports that the use of 5% tea tree oil shampoo on mild-to-moderate dandruff may be effective and well tolerated. Further research is needed to confirm these results.
Avoid use if allergic to tea tree oil or plants of the Myrtle (Myrtaceae) family, Balsam of Peru, or banzoin. Use cautiously with a history of eczema. Avoid taking tea tree oil by mouth because cases of toxicity have been reported. Avoid if pregnant or breastfeeding.
Thyme: Thyme is a common herb used in cooking. It has also been used for thousands of years to treat medical conditions. Thyme has been suggested as a possible treatment for alopecia areata. However, further research is needed to confirm these claims.
Avoid if allergic or hypersensitive to thyme, constituents of thyme, members of the Lamiaceae (mint) family, or rosemary (Rosmarinus officinalis). Avoid oral ingestion or non-diluted topical application of thyme oil due to potential toxicity. Avoid topical preparations in areas of skin breakdown or injury or in atopic patients, due to multiple reports of contact dermatitis. Use cautiously with gastrointestinal irritation or peptic ulcer disease due to anecdotal reports of gastrointestinal irritation. Use cautiously with thyroid disorders due to observed anti-thyrotropic effects in animal research of the related species Thymus serpyllum. Avoid if pregnant or breastfeeding.
Thymus extract: Thymus extracts for nutritional supplements are usually derived from young calves (bovine). Thymus extract is commonly used to treat primary immunodeficiencies, bone marrow failure, autoimmune disorders, chronic skin diseases, recurrent viral and bacterial infections, hepatitis, allergies, chemotherapy side effects, and cancer. Preliminary evidence suggests that thymus extract may be useful for alopecia and/or hair re-growth. More clinical trials are required before recommendations can be made involving thymus extract for this use.
Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid with thymic tumors, myasthenia gravis (neuromuscular disorder), or untreated hypothyroidism. Avoid if receiving immunosuppressants or hormonal therapy. Avoid if pregnant or breastfeeding. Thymic extract increases human sperm motility and progression.
Zinc: Zinc formulations have been used since ancient Egyptian times to enhance wound healing. A few studies that examined the efficacy of oral zinc for the treatment of alopecia reported contradictory results. Additional studies are needed before a conclusion can be made. In addition, shampoo containing 1% of zinc pyrithione has been shown to reduce dandruff in some people.
Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride, since studies have not been done on its safety or effectiveness. While zinc appears safe during pregnancy in amounts lower than the established upper intake level, caution should be used, since studies cannot rule out the possibility of harm to the fetus.
There is currently no known method of prevention of alopecia areata, androgenetic alopecia, or hair loss that is caused by aging.
Patients who are concerned that certain medications may lead to hair loss should talk to their healthcare providers. It may be possible for the patient to take a different drug or dose of the medication to prevent or reduce symptoms of hair loss.
Patients should maintain a healthy and well-balanced diet because poor nutrition may lead to temporary hair loss.
Patients should use hair treatments, such as hair dye, cautiously because they may cause temporary hair loss.
Aging: Hair loss is a common sign of aging. The body slowly loses its ability to replace hairs that are shed. Males and females may experience hair thinning or baldness as a result of aging. This type of hair loss is permanent.
Genetics: Researchers believe that several genes play a role in the development of androgenetica alopecia. Hair loss that is inherited is permanent. An estimated 60% of patients with androgentica alopecia are male. This is because one of the genes associated with the condition is located on the X chromosome. Males have only one X chromosome. Therefore, if a male inherits the defective X chromosome he will develop alopecia. A male can look to his mother's father to determine whether or not he is likely to develop alopecia. If a male's maternal grandfather has alopecia, he has an increased risk of developing alopecia.
Females are less likely to develop alopecia because they have two X chromosomes. If the female inherits only one defective X chromosome, the other X chromosome will prevent alopecia from developing. Females need to inherit two defective X chromosomes in order to develop alopecia. In other words, a female may experience hair loss if her father has hair loss and her mother either has hair loss or carries the mutated chromosome, but does not have hair loss.
Hair treatments: Chemicals used for dying, tinting, bleaching, straightening, or perming the hair may damage the hair or cause breakage, especially if they are used excessively or incorrectly. Also, too much hairstyling that involves pulling on the hair may lead to some hair loss. This type of hair loss is temporary.
Infancy: Newborns often lose hair during the first several months of life. This baby hair, also called vellus, is replaced with more permanent hair. Also, many babies lose patches of hair on the back of their heads. This condition is often caused by rubbing against playpens, car seats, or mattresses. However, once the baby learns how to sit up, the hair will begin to grow back.
Immune system: Alopecia areata is an autoimmune disorder in which the body's immune system attacks hair follicles resulting in unpredictable patches of hair loss on the scalp, face, and other parts of the body. In healthy individuals, the immune system helps fight against disease and infection. However, for unknown reasons, the immune system in patients with alopecia areata mistakes the hair follicles for harmful invaders. The immune system then attacks the hair follicles as if they were disease-causing substances, such as bacteria. This type of hair loss can be managed with treatment.
Illness or surgery: Some patients may experience hair loss three to four months after an illness or surgery. These conditions do not cause the body to lose more hair than normal. Instead, they reduce the amount of new hair that is produced. Over time, the hair will begin to grow normally. Also, infections, such as ringworm, may infect the hair and skin on the scalp. As a result, the patient typically experiences hair loss. Once infections are treated, the hair will begin to grow back.
Medications and medical treatments: Temporary alopecia is a side effect of many medications, including some drugs that are used to treat arthritis, gout, depression, heart problems, cancer, and high blood pressure. In some female patients, birth control pills may cause hair loss. The hair will grow back once the medication is stopped.
Medical treatments may also lead to hair loss. For instance, patients who undergo chemotherapy or radiation therapy to treat cancer may develop temporary alopecia.
Poor nutrition: Poor nutrition may lead to alopecia. Patients who do not consume enough protein or iron in the diet may experience hair loss. Once the diet is corrected, the hair will grow back.
The information in this monograph is intended for informational purposes only, and is meant to help users better understand health concerns. Information is based on review of scientific research data, historical practice patterns, and clinical experience. This information should not be interpreted as specific medical advice. Users should consult with a qualified healthcare provider for specific questions regarding therapies, diagnosis and/or health conditions, prior to making therapeutic decisions.