Why is my hair falling out?!?

Hair loss, a distressing issue for patients and doctors.

Diagnosing and treating hair loss can be very challenging. Often there is not one cause and the treatment options are limited. However, hair loss should be reported to your doctor to ensure it isn’t a sign of a serious condition and some hair loss can be easily treated. In this article I will review the most common causes of hair loss and briefly discuss treatment. This article should not be used to replace a visit to your doctor because every case of hair loss is unique.

• Alopecia areata. This type of hair loss causes patches of hair to fall out, leaving a completely bald spot. It usually happens in small areas but can affect any hair follicle including facial hair, eyebrows and eyelashes. This is an easy diagnosis for most doctors. It is caused by your immune system attacking the hair follicles. We don’t know why this occurs. In most cases it is not associated with any other autoimmune conditions, but in a few cases it can be associated with diabetes or a thyroid problem. In the majority of cases it will resolve without treatment in 12 months. Certain locations can be treated with topical steroids or steroid injections but these treatments just suppress the inflammation and allow the hair to grow back. They need to be repeated every 4-8 weeks or the hair will fall out again. On a personal note, I experienced alopecia areata of my eyelashes on one eye in college. It was not treatable with steroids, but they grew back and hasn’t recurred (yet).

• Male Pattern Hair Loss. Another easy one to diagnose. Most men will experience hair loss. It is hereditary but comes from both mom and dad (contrary to the myth that it is through the mom) and most men will look most like their father. I feel a little bad for my son. Male pattern hair loss is treated with finasteride (also called Propecia) and minoxidil (also called Rogaine). Hair transplants can also be used where hair from the back of the head is moved to the front. Finasteride works by blocking the hormone (a type of testosterone) responsible for hair loss- it is preventative. Minoxidil (Rogaine) works by stimulating hair growth. They work best when used together. They are not curative and if they are stopped the natural trajectory of hair loss will continue.

• Telogen Effluvium. This is a generalized sudden loss of scalp hair. Usually people notice lots of hair in the drain or on the floor and hair seems overall thinner. This can be caused by a long list of conditions. The most common are: childbirth, surgery or illness, weight loss or weight gain, nutritional deficiency, life stress and medications. Often there are multiple factors playing a role. Telogen effluvium occurs 3-4 months after the inciting event. It can continue for 3-4 months after the body “stressor” has ended. Often people never regain the fullness they had, though the shedding usually stops. A doctor may test your iron reserves (called ferritin) and thyroid levels to ensure this is not playing a role. I have experienced telogen effluvium, it can be stressful.

• Female Pattern Hair Loss. This is the most difficult to diagnose and treat, and probably the most common cause of hair loss that I see. Similar to men, most women experience hair loss as they age. The hair gets less full and the texture of the hair changes with age. This change can be very distressing if it starts at a young age (the definition of young is subjective). It can start in the twenties for some women. Sometimes there is a telogen effluvium event that unmasks female pattern hair loss earlier than it would otherwise be noticeable. In most cases it presents during perimenopause or menopause and in the majority of cases all hormones are normal. In some cases there are elevated testosterone, but most often not. Female pattern hair loss is challenging to treat and usually not completely reversible. Rogaine, spironolactone (a blood pressure pill that can block the hormones contributing to hair loss) and finasteride can be used with variable success. Finasteride is not used by all doctors as it is not FDA approved in women. I see quite a few women for this condition.

• Other types of hair loss. This category is the least common (in my practice) but potentially the most serious. Autoimmune conditions such as lupus and lichen planus can present with hair loss. Psoriasis and eczema can cause hair loss. Infections such as ringworm and syphilis can cause hair loss. These conditions obviously need treatment and are beyond the scope of this discussion, but just reinforces that hair loss should be reported to your doctor.

I hope this article has been helpful in discussing this very large topic. Again, see your doctor if you are having hair loss and make sure to mention it early in the visit- it is often the last topic mentioned in a visit in my office, which makes complete evaluation difficult.