3 Common Misconceptions About Hair Loss

Hair loss is a very troubling condition for many who experience it.  For others, it can be seen as a normal sign of aging.  However, because the majority of both men and women will experience some form of hair loss by the age of 60, we all have our ideas and misconceptions about what causes it and how we can treat it.

1)       It’s your mom’s fault that you’re balding.

The most common type of hair loss is androgenetic alopecia, otherwise known as male or female patterned hair loss.  In men, if often starts with progressive hairline recession and often thinning at the crown.  In women, their part may simply appear wider over time with an increased ‘see-through’ nature of the scalp.  We now know that at the cellular level, androgenetic alopecia is caused by the developmental failure of hair-making cells, termed dermal papillae cells.  We also know that this failure is influenced by dihydrotestosterone.  However, contrary to the popular belief that balding is passed down the maternal lineage; an individual's likelihood of balding is a combination of genetic, environmental, and systemic factors.  This fact can be illustrated in twins.  We would expect that if one twin is balding, then the other should be as well.  This is termed the twin concordance rate.  Some studies have shown that balding happens in both twins only about 88% of the time.

2)      Rogaine and Propecia do not work.

Rogaine and Propecia are the only FDA approved medications for the treatment of male and female pattern hair loss.  Rogaine is a topical medication applied to the scalp.  It is unclear how Rogaine works, but it may act on prostaglandin synthesis.  Studies have shown that it can slow down the rate of hair loss and rethicken hair in 85-90% of users.  Propecia is an oral medication that works by blocking the formation of dihydrotestosteone.  It can slow down hair loss in 88-92% of users.  Used in conjunction, Rogaine and Propecia act synergistically and increase the efficacy than using either medicines alone.  Both medications take at least 6-9 months to start working.  Therefore, those who quit using them before 6-9 months may feel not have seen the full effects yet.  In addition,  many will not experience regrowth or rethickening of hair; they may simply see the rate of hair loss decrease. 

3)      Your hair sheds more than normal.

Hair grows in three phases: 1) Anagen (growing) 2) Catagen (resting) 3) Telogen (shedding).  The majority (85-88%) is in the growing phase and about 10-15% of hairs is in the shedding phase.  Therefore, we should expect that we are going to lose at least 100-150 hairs daily.  Sometimes stressors can cause the hair to shed more.  This is called telogen effluvium.  Instead of 10-15% of hairs shedding daily it increases to 20-40% of hairs shedding.  The most common causes for telogen effluvium are post-pregnancy, change in hormones, thyroid disease, iron deficiency, change in medication, or serious illness or hospitalization.  There is good news! Telogen effluvium is typically temporary.  Most individuals will experience less shedding within 6-12 months.

These are just three of the many misconceptions that we have about our hair and hair loss.  As a dermatologist who specializes in medical and surgical treatments for hair loss, I have heard it all! Hopefully this article helps to clear up some of the more common myths that I hear.

 

 

Advance in the Treatment for Alopecia Areata: Platelet-rich Plasma

Platelet Rich Plasma or PRP is a preparation taken from a patient’s own blood, in which the platelets are enriched in concentrated plasma.  Most think of platelets as the component of blood that coagulates wounds.  However, the function of platelets is far more than just forming clots.  When activated, they secrete cytokines and growth factors, acting as an integral part of wound healing.  

Recent animal studies show that PRP increases dermal papilla cells, which are decreased in individuals with balding.  Potent hair growth stimulators, Fibroblast growth factor-7 and Beta-catenin, are also increased by PRP treatment.  In the fall, the Dermatologic Surgery journal showed that mice treated with PRP have quicker transitions into the growing phase of hair than untreated mice.  When used as an adjunct to hair transplantation, hair follicles pre-treated with PRP can demonstrate better density and graft survival.  The theory is that the platelets are secreting growth factors, leading to stem cell activation from the surrounding hair follicles.  Thus, hair specialists have been trialing the therapy in patients who are balding due to androgenetic alopecia.

When I attended the International Society for Hair Restoration Surgery, several of the surgeons around the world provided anecdotal reports of using platelet-rich plasma for not only androgenetic alopecia (or balding), but also to treat alopecia areata.  However, there had been no scientific studies performed at the time.

Alopecia areata differs from androgenetic alopecia in its mechanism, as well as its clinical appearance.  Alopecia areata is an autoimmune condition, in which the person’s own immune system targets their hair follicles, causing them to fallout.  The entity may manifest as small circular patches of hair loss or may occur more diffusely.  Diffuse alopecia areata is often not only cosmetically disfiguring, but also can be recalcitrant to standard treatments, such as intralesional steroids.

A recent edition of the British Journal of Dermatology reported a pilot study successfully using platelet-rich plasma to treat alopecia areata.  In the study, 45 patients with alopecia areata were given 3 monthly injections of either PRP, intralesional steroids, or placebo and followed for a year.  The patients given PRP saw the most significant hair regrowth.

The use of PRP to treat recalcitrant alopecia areata seems promising and a great tool in our armamentarium for hair loss.  However, this advancement still has few published, large human clinical trials.  In addition, there is no consensus on optimal concentrations and dosing schedules.

Although, PRP seems to be a promising advancement in the field of hair loss, many hair specialists have not adopted its use widely because the amount of benefit is unclear and most importantly, guidelines for use have not been established.

Why Your Hair Won't Grow

I have countless patients, friends, and family members complaining about how their hair refuses to grow.  Then, the comparisons start.   “Why do (insert ethnic group) type of people always have such long hair?”  This is a troubling issue for many.  Fortunately, many studies have looked into this very issue and can give us insights into these quandaries.

Hair length is dictated by the rate of growth and the duration of the growing or anagen phase of the hair cycle.  Studies have shown that the rate of hair growth does not greatly vary amongst races.  The duration of hair growth before it enters the shedding or telogen phase of the hair cycle is dependent on many factors, mainly genetics.  Although, environmental and internal factors also contribute to the rate and duration of the hair cycle. 

The anagen phase of hair growth lasts for 2-6 years on average.  Clearly, if the rate of growth is constant; then an individual with a 6 year long anagen phase will have significantly longer hair than an individual with a 2 year long anagen phase. 

Rate and duration of hair growth really only dictates how long a hair can be potentially.  However, hair breakage can obviously shorten hairs and prevent them from appearing to grow longer.  This is the main dilemma for individuals who feel their hair is not growing.  Hair breakage is ultimately caused by structural weakness in the hair shaft.  There are genetic hair shaft abnormalities; however, most are acquired.

The differences in the burden of hair breakage vary amongst races.  Comparative studies amongst races on hair structure have shown that individuals of African descent acquire single-strand knots that act as points of weakness.  Single-strand knots are not typically seen in Caucasian or Asian hair.  Individuals with this problem are basically giving themselves a haircut everytime they comb their hair.  This explains why dreads or locks can go grow so long.  Unfortunately, relaxing the hair to prevent the knots does not seem to increase length, as the hair has now lost tensile strength due to the harsh chemicals in the relaxers.

Thus, if you are in overall good general health and your hair is not gaining length; lack of hair growth is not generally the issue.  The problem lies in acquired hair breakage, most commonly caused by everyday hairstyling practices.

Traction Alopecia: Yes…Your weave is pulled too tight!

As a dermatologist with a special interest in hair conditions, it consumes me how many Black women I see with permanent hair loss from our own styling practices!!   One of the most common forms of hair loss that plagues our population is called traction alopecia.

Traction alopecia can be a permanent, scarring form of hair loss that typically occurs around the hairline and crown.  You do not need to be a dermatologist to diagnose this.  We have all seen it on girlfriends, family members, and unfortunately, many prominent celebrities.

It is thought to be caused by hairstyling practices that pull hair tightly away from the scalp, such as braids, weaves, and locks.  Similar to trauma that happens elsewhere on the skin; the body senses the insult, sends inflammatory cells to the site of trauma, and tries to heal it with a scar.  This is exactly what occurs with traction alopecia.  The tight pulling leads to inflammation around the hair follicle and if the inflammation remains untreated, fibrosis or scar tissue forms and the hair is permanently lost.

This condition is most common in Black females but can be seen in anyone with traumatizing hairstyling practices.  For example, in India, many Sikh males that wear their hair in tight buns under their turbans can also suffer from this problem.

Luckily, there are ways to prevent traction alopecia and also ways to treat it. 

Most importantly, do not let allow the hair to be pulled too tight!!!! Yes, we all love to see our friends flaunt a great weave down their backs, so I will never be one to restrict wearing these types of hairstyles.  HOWEVER, I cannot stress the importance of being able to recognize signs of when the hair is being pulled too tight.  This includes any pain, tenderness, burning or itching.  These are signs of inflammation!!!

Secondly, see the previous paragraph…It’s that important.  Many of my patients will tell me that they did not notice the hair loss until months to years after wearing braids or a weave.  So it is very important to pick up on signs of inflammation as soon as possible, so that you have a possibility of being treated and holding onto the hair that you have.

As far as treatment options are concerned, the most important first step is seeing a dermatologist as soon as you notice any problem.  The longer you wait for an evaluation, the more time for scar to form and for the hair loss to become permanent.

When you are seen, likely a biopsy will be performed to determine if there is any inflammation left to treat or if scar is already present.  If there is inflammation present, treatment may include steroid injections to the scalp, topical steroids, or oral antibiotics.  Even if there is scar present and the hair loss is felt to be permanent, hair transplantation is always an option to help restore the hairline.

In summary, Black women love to experiment with myriad fabulous hair styles.  Unfortunately, many of these styling practices can lead to permanent hair loss and deflated senses of self.  Therefore, it is of the utmost importance to recognize when the hair is being traumatized to prevent traction alopecia from occurring.

Balding and Heart Disease: Does a Disappearing Hairline Reflect Heart Disease Risk?

Beauty may come from within, but a recent study out of Copenhagen, Denmark suggests that how you look externally could actually be a reflection of internal health problems.  The researchers found that visibly apparent signs of aging, regardless of actual chronologic aging, increased the participants’ risk of heart disease.

More specifically, researchers followed over 10,000, 40 and older participants from the Copenhagen Heart Study for over 35 years.  Individuals were evaluated for gray hair, balding, wrinkles, earlobe creases, and xanthelasma, or fatty growths on the eyelids.  Demonstrating balding at the crown, hairline recession at the temples, yellowish fatty growths on the eyelid, or an earlobe crease increased the risk for heart disease by 39% and increased the risk for heart attack by 57%.  The risk was independent of other more commonly cited risks for heart disease such as high cholesterol.

These findings mimic results from the Framingham Heart Study and the First National Health and Nutrition Study which also found an association between balding and heart disease.  Even in a study of over 20,000 seemingly healthier over 40 year old physicians, balding was associated with heart disease. 

All of the abovementioned studies were large cohorts that were followed over decades looking for any possible risks for heart disease.  So there are many potential confounding factors that could be playing a role in the results found.  For this reason a group of researchers from Johns Hopkins conducted a study of men with known histories of heart attacks and evaluated them for the presence of balding.  Interestingly, they could not find a significant association between balding and heart disease.

The other interesting consideration for the Copenhagen Study is the fact that all the patients are from a generally homogenous population in Denmark.  We all know the adage, “Black don’t crack.”  Thus, it would be intriguing to repeat the study in patients of African descent, because although we do not seem to show signs of aging as readily as our lighter skinned counterparts, we certainly do not enjoy lower rates of heart disease.  So, it would be interesting to see if the same attributes are found to increase heart disease risk amongst patients of African descent.In summary, although, the association between balding and heart disease is indeed fascinating, the main question is what we do as physicians with these possible associations.  Most patients over 40 should be seen regularly by their primary care physician and evaluated for cardiac risk factors, anyhow.  Potentially balding, earlobe creases, and xanthelasma could be used in addition to other risk factors to calculate overall risk of heart disease. 

However, as a dermatologist that specializes in hair loss, I am not so sure that I will be re- directing each one of my balding patients to their primary care physicians for a cardiac evaluation, based on the presence of balding alone.

Advances in the Cure for Balding: Platelet Rich Plasma

Most think of platelets as the component of blood that coagulates wounds.  However, the function of platelets is far more than just forming clots.  When activated, they secrete cytokines and growth factors, acting as an integral part of wound healing.  Because of platelet's important function, concentrated preparations of plasma have been used in various fields as an attractive therapy for many conditions.

Platelet Rich Plasma or PRP is a preparation taken from a patient’s own blood, in which the platelets are enriched in concentrated plasma.  The therapy was originally used for injections into damaged joints in the orthopedic field.  Now it is being used by cosmetic dermatologists and plastic surgeons for overall facial rejuvenation.

Recently, hair specialists have been trialing the therapy in patients who are balding.  Animal studies show that PRP increases dermal papilla cells, which are decreased in individuals with balding.  Potent hair growth stimulators, Fibroblast growth factor-7 and Beta-catenin, are also increased by PRP treatment.  In addition, mice treated with PRP have quicker transitions into the growing phase of hair than untreated mice.  

When used as an adjunct to hair transplantation, hair follicles pre-treated with PRP can demonstrate better density and graft survival.  The theory is that the platelets are secreting growth factors, leading to stem cell activation from the surrounding hair follicles.  

Because of the improved hair growth seen with hair transplantation and the above-mentioned animal studies, hair specialists have started using PRP as primary treatment for male and female pattern balding.  PRP treatment is particularly attractive for women who have not seen great results with minoxidil and young men who may not be suitable candidates for finasteride or hair transplantation.  

Although, PRP seems to be a promising advancement in the field of hair loss, there have not been many published, large human clinical trials for its use as a treatment in balding.  Therefore, many hair specialists have not adopted its use widely because the amount of benefit is unclear and most importantly, there is no consensus on how often the injections should be given or at what concentration.  

Thus, Platelet Rich Plasma or PRP injections are an enticing new treatment for balding.  However, widespread implementation of its use may not be seen until larger studies can demonstrate its efficacy and ideal protocol for administration.  In the future, PRP treatments may act as an adjunct to more well-studied treatments, such as minoxidil, finasteride, and hair transplantation, as opposed to primary therapy.

What Should a Doctor Look Like?

Ok, I think we all know where I’m going with this one.  As everyone can see from my profile pics; I am a young, female doctor…of color.  Brown to be exact.  Throughout my training, myself and other female doctors of color have exchanged stories of patients and other staff not realizing we were a physician or making inappropriate remarks about it.

Recently, some of my colleagues candidly shared similar, typical stories of what they continue to experience, which is what inspired me to discuss this topic on my blog.  Try to control the dismissive head shakes as you read:

“The other day a vendor came into the lab, and walked right past me, and went into supervisors' office. My hematology supervisor pointed out the woman in the lab coat and scrub standing patiently behind him and said, "Have you met Dr. ---? She's our new department head."

“Yesterday I walked into a patients room and said "Hello I am doctor ---", He then asked "are you a doctor?", I responded "I am DOCTOR ---, How can I help you?"

“I love the initial look when you walk in the room and how much they LOVE LOVE LOVE you when you walk out:)!”

When I took a job in industry, my boss started to notice that the immediate response to the intro was "is this your new admin?"...when I was an intern @ Grady, a drunk white dude demanded to talk to the charge nurse "someone who knows more than YOU!!!"

“ Would go to offices with one of our device reps to do meet and greets, me in a suit, they're in their scrubs...and the docs walk right by me to shake the rep's hands. Then the rep has to say..."Have you met Dr. ---?"

“Last yr I had a white male drug rep ask if I was a PA, I nearly lost it he never approached me again! This would never happen to a white MD, then when started at new job had black and Hispanic clerks and maintenance worker ask if I was a new clerk, and I have an MD on my badge.”

“When I accompany other physicians to meetings I am consistently asked, are your Dr. So and So's ARNP? Despite the fact my name is all over my scrub top. When I enter a patients room in the SNF some pts assume I'm the CNA and ask me to change their brief, give them the bed pan, fill their water cup even after I have introduced myself "Hi I'm Dr.---, I will be your physician while you are here"!

Personally, I have never had any preconceived notions of how a doctor should look, act, or speak.  My mother was one of the first African-American females to graduate from her medical school.  And since I was raised with her influence and presence, it was similar to how my kids view presidents.  They have only known Barack Obama as president.  Therefore, they have no preconceived notions of what a commander-in-chief should look like. 

Thus, the clearly racially charged experiences that I have gone through have been very hurtful because I naively never expected it.  For example, when I was in training at the Mayo Clinic, myself and the two other young black dermatologists in our program, literally had at least one patient daily express surprise when we walked in the room and then ask where we went to medical school.  Thankfully, two of us could respond---“Harvard.”  That usually abruptly ended the line of questioning.  Except for the one time, when I said “Harvard” and the patient responded, “Well my niece is having trouble getting into medical school and she’s really smart…I bet being Black helped your application.”  I guess black people can only get into medical schools like Harvard through Affirmative Action.  One of the other docs actually had a patient not believe he was a doctor, call the 'higher-ups', and demand to see his diploma.

One of the more hurtful incidents was when, the nurse (wearing maroon scrubs) roomed the patient, I walked into the room (wearing the mandatory Mayo business attire), introduced myself as “DOCTOR Singh” and then spent the next 30 minutes, taking a detailed history, examining the patient, PERFORMING A BIOPSY!!, and discussing my impression.  When I left the room, the man turned to the nurse and asked, “When is the doctor coming in?”  No words…

I have no idea what patients are expecting to see when they book an appointment with a “Dr. Meena Singh”.  However, I can safely assume that physicians who look anything like LOST characters “Jack” or his dad “Christian Shephard” cannot relate to any of the above experiences.

Thankfully, shows like Grey’s Anatomy are casting more female physician roles with black actors.  And of course, there is now Disney's Doc McStuffins which highlights a little black girl playing doctor and her actual black doctor mom.  Hopefully, with more Hollywood influence and as the number of young, black female physicians continues to increase, the stereotypical portrait of a patriarchal, white male physician fades.  After all, the Surgeon General of these United States is Dr. Regina Benjamin.  I sincerely hope that she is no longer being confused with anything but the Surgeon General.