THE WASHINGTON POST – At first, I blamed the hairstylists. For several years, my hair had been flat, the cowlick too pronounced, the texture different. I kept switching salons in search of the perfect cut, the miracle product or, ideally, both. Then, as I ticked off my complaints to a new stylist, he ran his fingers through my hair and shrugged. “It happens,” he said. “We get older. The hair thins.”
Just a few months later, Ricki Lake, 51, revealed her own struggle with hair loss – an irony for the actress who found fame as the star of Hairspray. My fixation kicked into high gear, and I started searching online for answers. I learned that it’s normal to shed 50 to 100 hairs a day, and that new ones should grow in their place. But a variety of factors, including genetics, illness and poor nutrition, can disrupt that growth cycle, not just in men, but also in women of all ages. The American Hair Loss Association (AHLA) reported that 40 per cent of all hair loss sufferers are women.
“Society and medicine haven’t taken hair loss seriously because it’s not life-threatening,” said Spencer Kobren, the AHLA’s founder. “But it’s a disease of the spirit that eats away at a person’s self-esteem, and the social ramifications, especially for women, are profound.” Consider the experience of Representative Ayanna Pressley, who recently shared the story of having to attend an important impeachment vote the day after losing her last bit of hair to alopecia. (She did not specify what form of the hair-loss condition she has.) As she told the Root website, she put on a wig, voted and then hid in a bathroom stall. “I felt naked, exposed, vulnerable,” she said. “I felt embarrassed. I felt ashamed. I felt betrayed.”
Genetics is the leading cause of hair loss for both sexes, said New York dermatologist Marc Avram, who specialises in the condition. The American Academy of Dermatology reports that 30 million women in the United States (US) suffer from hereditary hair loss, compared with 50 million men, though Avram suspects the numbers are much higher.
“The clock starts ticking when puberty hits,” Avram said. “After that, there’s a spectrum when it comes to how much of the hair thins and how long it takes. For some people, it can happen very slowly over 30 to 40 years. For others, it can happen in a compressed time frame very soon after puberty.”
That genetic predisposition is more commonly known as male- or female-pattern hair loss. For men, the genetic pattern is distinct, typically an M-shaped hairline that recedes toward the temples or a thinning crown. But for women, the loss usually happens all over. The early signs can be subtle, perhaps a widening part or the need to loop a hair tie more times than usual around a pony tail.
But the word “loss” is misleading for the classic genetic pattern, said Dermatologist in Arlington, Virginia Terrence Keaney. “I spend half my time telling patients: ‘You are not losing your hair. Your hair is thinning’,” Keaney said. “That’s a big ‘aha’ moment for people. It’s really a condition of accelerated thinning – thinning in excess of your peers.”
In both sexes, the thinning visually registers as hair loss, which is why the term is widely used. But the hair is still there, it’s just “miniaturised” – thinner, shorter, unpigmented – to the point of being invisible to the naked eye. Eventually, at least some of it stops growing.
Poor nutrition, yo-yo dieting, stress, medications and certain illnesses, such as alopecia areata, an autoimmune disorder, can exacerbate a genetic predisposition to hair loss or lead to it on their own. For women, other factors include hormonal fluctuations and damage inflicted by styling tools, hair dyes and chemical treatments.
As for my stylist’s “life happens” diagnosis, that’s legitimate, too. “Most people lose elasticity in their hair as they get older,” said Dermatologist in New York Doris Day. “Like skin, the hair ages.” And, like skin, it can age more gracefully for some than others. But it’s the rare person who will have the same full head of hair at 60 that she or he had as a teenager, Day said.
What can be done about hair loss, if anything, depends on whether it’s the “scarring” or “non-scarring” type. Some rare hair disorders, or even long-term wearing of tight braids and hair extensions, can scar and destroy hair follicles, causing irreversible damage, Day said. But many of the conditions leading to chronic hair loss are non-scarring and can potentially be treated, including genetic-pattern baldness. Getting a diagnosis is a good idea – to determine what kind of hair loss you have and to rule out its connection to another condition, such as low iron or thyroid problems.
As with any other physical ailment, the available treatments don’t work for everyone. Results, if they happen, come slowly because it takes the better part of a year for new hair to grow to a length that’s noticeable. And if it grows, it will fall out again if a patient stops treatment – with the exception perhaps of a hair transplant, though even that USD8,000 to USD12,000 surgery is no guarantee, and not everyone is a good candidate for it.
Here are some common treatments for non-scarring hair loss. Dermatologists often mix and match approaches for optimal results.
This US Food and Drug Administration (FDA)-approved, topical treatment is sold in liquid and foam generically and under the brand name Rogaine. At USD10 to USD15 a month, it’s one of the more affordable options. A 2016 report in the Cochrane Database of Systematic Reviews concluded that minoxidil offered “a measure of efficacy” in female-pattern hair loss, with “the quality of evidence being mainly moderate to low”. The treatment comes in two dosages: two per cent and five per cent. The most common side effects are scalp irritation and unwanted facial hair if the product seeps onto the face.
They’re everywhere with catchy names and sometimes eye-popping prices (Nutrafol and Viviscal at USD88 and USD50, respectively, for a month’s supply). Most include collagen and old-school vitamins and minerals. Nutrafol also contains saw palmetto (a botanical said to block production of a hormone that leads to hair loss) and ashwagandha (a medicinal herb believed to help reduce stress hormones and inflammation). Viviscal touts its patented deep-sea fish protein, and Lambdapil says an amino acid called taurine is among its key ingredients.
The FDA does not independently verify the claims made by hair-supplement brands, and several doctors said the scientific evidence is soft. “We have only limited clinical trials showing that some brands of supplements would be helpful for hair loss,” Avram said.
Furthermore, some of the ingredients found in supplements can be dangerous for certain populations. Saw palmetto, for example, may not be safe for pregnant women. And the FDA says large quantities of biotin can interfere with lab tests, particularly those that diagnose heart attacks.
This can be found in the form of helmets, bands, caps and combs that can be used at home. The devices emit certain wavelengths of light in an attempt to stimulate hair growth. Costs range from a few hundred dollars for a comb to USD3,000 for a helmet.
Most of the laser devices have been FDA-cleared for safety, which is unrelated to efficacy. “The biology of this is still being figured out,” said Chair of the University of Minnesota’s Dermatology Department Maria Hordinsky. “A lot of people are asking their dermatologists to recommend the best device, but there aren’t too many studies available for us to answer that question.” One 2014 study partially funded by a device manufacturer found a “statistically significant” increase in hair density after testing laser combs on men and women with genetic hair loss.
Two prescription drugs – spironolactone and finasteride – slow down production of the hormones that are linked to hair loss in men and women.
Finasteride, sold under the brand name Propecia to treat hair loss (it’s available as Proscar to treat enlarged prostates), is FDA-approved for men with thinning hair. It can be used off-label by postmenopausal women but is not prescribed to premenopausal women because it can lead to major birth defects. A 2018 review found limited research results but called it “safe and promising”.
Spironolactone, a diuretic originally developed to treat high blood pressure, is prescribed (again off-label) for female-pattern baldness, though studies supporting its efficacy are limited.
“More people are moving away from prescription medications to procedural approaches because they don’t want to be on drugs for a lifetime” or deal with the potential side effects, including impairment of sexual libido with finasteride, according to Neil Sadick, a dermatologist in New York.
PLATELET-RICH PLASMA (PRP)
This method involves drawing a patient’s blood, spinning it in a machine at high speeds to isolate the plasma and platelet proteins, and then injecting both into the areas of the scalp that are thinning.
“It’s like fertiliser for the hair,” said Hair Specialist in Sarasota, Florida Joseph Greco. Although it has been used to heal wounds and burns for decades and most of the devices used to spin the blood have been cleared for safety by the FDA, PRP is not approved for use as a hair-loss treatment by the FDA. Prices can range from USD700 to USD1,800 per session. Initially, patients go for four to six sessions at one- to three-month intervals, then less often for maintenance.
My attempts to count my shed hairs have proved futile, so I’m not sure if I’m losing more than the normal 50 to 100 strands a day. My annual physical showed no nutritional deficiencies or other medical issues, and my friends and relatives say they haven’t noticed any thinning. But I’m going to see a dermatologist anyway; I don’t want to wait until there’s an obvious problem to figure out what I can do about it.