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Losing hair is never a pleasant experience, given its visibility and the perception of thick hair as a sign of youthfulness and attractiveness in both sexes. Unfortunately, hair loss is also part of the aging process that we will all experience. However, for some hair loss can be more sudden, larger, noticeable and distressing.

Hair loss can be either diffuse and widespread or focal as one or more patches. Focal patches often result from a cause in the affected area of hair loss, such as a skin growth, fungal infection or injury.

More diffuse hair loss can result from many causes such as poor nutrition (low Zinc and Iron levels in particular), hormones (especially due to imbalances of the thyroid gland), autoimmune activity or prescription medications. It can also be due to a sudden traumatic even such as childbirth, surgery or stressful life episode- although in these cases the hair regrows as one recovers from the precipitating trauma. However, by far the most common cause is male and female pattern balding, which is also referred to as ‘androgenic alopecia.

In men it is clearly related to the production of dihydrotestosterone (DHT) from testosterone by the enzyme 5-alpha reductase, a process controlled by many inherited genes, which express themselves differently in different generations of the same family. Although the exact mechanism of how DHT causes baldness is debated, the predominant theory is that people with genetically more hair follicles sensitive to this hormone, have DHT binds to the hair follicle and shrinks it causing the current hair to stop growing untill it falls out and is not replaced.

However, in females with typical pattern balding, testosterone levels are known to remain normal and so the cause is less clear even though the phenomenon is well observed.

Diagnosis tends to be based on the history and an examination to assess the scalp and hair. Rudimentary tests such as the ‘pull test’ to see how much hair comes out on pulling are used. If the cause of hair loss is under doubt then more specific tests looking at the hair or a piece of the scalp tissue under a microscope are used.

Currently, there are only two licensed medical treatments. The first is available to both men and women in the form of Minoxidil (Regaine) at 2% strength, which works by widening the blood vessels in the scalp to increase nourishment to the hair roots. It is rubbed onto the scalp twice a day and it takes up to 6 months to manifest its full effects. However, it has to be used continuously to maintain any results. The ‘extra strength’ version of Minoxidil at 5% is currently only licensed for men.

The second treatment is for men only, in the form of a tablet called Finasteride. Taken at a 1mg dose every single day it works to block the 5-alpha reductase enzyme and decrease the levels of DHT. However, it affects the prostate gland too and so can cause problems with erections and ejaculation.

So far, there is no evidence that alternative medications and supplements make a significant improvement in hair loss and so they cannot be strongly recommended. While there is some literature in support of caffeine based shampoos, it is limited to small studies and limited improvements in hair loss, through a mechanism that is unclear.

The final and most extreme option is surgery in many different forms and techniques, including hair transplants. This should always be considered only at a reputable clinic and after consultation with a doctor.

© Syed Z Arfeen
Medical Advisor
December 2015

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