Hair Loss: Causes, Treatment

Brief overview

Causes:Different forms of hair loss have different causes, including, for example, hormonal reasons, certain medications, diseases or malnutrition.
Treatment: Depends on the particular form and cause of hair loss.
When to see a doctor: If you notice excessive hair loss.
Diagnosis:Medical history, physical examination, blood test, epilation test (“tear-out test”), trichogram, exclusion of other diseases, etc.
Prevention:Certain types of hair loss can be prevented by, for example, avoiding malnutrition or wearing long hair loose more often.

What is hair loss?

Experts refer to these phases as the growth phase, the transition phase and the rest phase. Thus, hair loss of up to 100 hairs per day is normal. One speaks of hair loss as a disease (alopecia) only when more than 20 percent of the hair is in the final phase at the same time.

Prognosis

The prognosis for hereditary hair loss varies greatly. In general, the earlier in life the hair loss begins, the worse the prognosis.

The course of circular hair loss cannot be predicted. In many cases, there is spontaneous healing – the hair that has fallen out grows back, so that the bald patches disappear again. However, relapses are possible, i.e. that the hair falls out again.

In other patients, spontaneous healing does not occur and the bald spots remain permanently. Many of those affected then resort to a wig. Under certain circumstances, the health insurance company will contribute to the purchase of this hairpiece. It is worth asking!

In scarring alopecia, hair loss is irreversible: the hair that has fallen out will not grow back because the hair follicles are damaged.

Mechanically induced hair loss usually returns to normal if the damaging stress on the hair roots is avoided (for example, by tying a ponytail or braid tightly).

Hair loss: causes and risk factors

The various forms of hair loss have a wide variety of causes.

Hereditary hair loss

Hereditary hair loss (androgenetic alopecia) is by far the most common form of hair loss and mainly affects men: in those affected, the hair roots exhibit a genetically determined hypersensitivity to male sex hormones (androgens), especially to dihydrosterone (DHT).

In women, congenital hair loss occurs much less frequently, but it is possible. Hair loss is usually recognizable by a thinning of the hair in the crown area. Occasionally, a disease with disturbed estrogen production or increased testosterone production is behind it, such as the so-called polycystic ovary syndrome (PCO syndrome). In most affected women, however, the testosterone level is normal.

In this case, the cause is thought to be a reduced activity of the enzyme aromatase in combination with a genetically determined sensitivity of some (not all) hair roots to androgens:

For a summary of the possible causes of hair loss in women and treatment options, see the article Hair loss in women.

Circular hair loss

The exact causes of circular hair loss (alopecia areata) have not been clarified to date. There are some suspected factors that may contribute to the development of this type of hair loss:

Mostly, an autoimmune reaction is held responsible: Due to a disorder, the immune system attacks the hair roots, so that the hair eventually falls out. This assumption is supported by the fact that people with circular hair loss sometimes also suffer from autoimmune diseases such as psoriasis.

In addition, experts suspect that a genetic predisposition and psychological factors may also promote the development of alopecia areata.

You can read more about this in the article Circular hair loss.

Diffuse hair loss

Certain medications, for example cytostatics as part of chemotherapy for cancer, drugs for hyperthyroidism (thyrostatic drugs), anticoagulants, drugs for elevated blood lipid levels (lipid-lowering drugs) or the “pill” (ovulation inhibitors)
Infectious diseases such as typhoid fever, tuberculosis, syphilis, scarlet fever, severe influenza
Metabolic diseases such as hyperthyroidism and hypothyroidism
Heavy metal poisoning (such as with arsenic or thallium)
Prolonged malnutrition, such as from crash diets or fasting cures or as a result of impaired food utilization
Radiation therapy for cancers in the head region
Acute stress (e.g., emotional stress, surgery)

Diffuse hair loss may also occur in newborns.

Other causes of hair loss

In addition to the three main forms of hair loss, there are other causes of sparse hair growth or increased hair loss. These include:

Persistent traction on the hair roots, for example due to frequent wearing of a tightly tied braid or ponytail (this traction alopecia mainly affects the forehead and temple area)
Scarring or tissue loss (atrophy) in the head area, such as due to infections caused by fungi or bacteria, lupus erythematosus, nodular lichen (lichen ruber planus), psoriasis, scleroderma (scarring alopecia)
Compulsive pulling or plucking of hair (trichotillomania), often in neurotic children
Genetic defect that causes hair to grow sparsely or not at all (congenital alopecia)
Hair loss due to stress (mental or physical)

Hair loss: treatment

Overall, the success of a drug or other hair loss treatment is difficult to assess – for some the treatment works, for others it does not.

The following table provides an overview of the most effective active drug ingredients and other therapies that doctors use for the various forms of hair loss:

Type of hair loss	Means/Method	Notes
Hereditary hair loss	internal use; for men only
external use; for women and men
Antiandrogens	internal use; for women only
Dithranol (Cignolin, Anthralin)	external use
Glucocorticoids	external or internal use
Topical immunotherapy	external application; only for larger bald spots
PUVA	external application of psoralen plus irradiation with UV-A light
Diffuse hair loss	B vitamins/amino acids	internal use, for women and men

Finasteride

Finasteride is a so-called 5α-reductase inhibitor, which means that it blocks the enzyme 5α-reductase, which normally converts the male sex hormone testosterone into its active form dihydrotestosterone (DHT). In men with hereditary hair loss, the hair roots are hypersensitive to DHT. Therefore, finasteride is able to stop the progression of hair loss in those affected.

Sometimes the hair on the head thickens again. However, the effect usually only becomes apparent after three to six months. If the drug is discontinued, the hair falls out again.

The active ingredient requires a prescription and is taken in the form of tablets (1 milligram). Higher-dose tablets (5 milligrams) are only approved for the treatment of benign prostate enlargement.

For women, this hair loss remedy is not suitable, because in pregnant women and women of childbearing age damage to the fetus can not be ruled out.

Minoxidil

Minoxidil, like finasteride, was originally intended for the treatment of a completely different condition – namely high blood pressure. Here, too, increased hair growth was observed as a side effect. Researchers then developed a hair tincture containing minoxidil, which is approved for external use in hereditary hair loss.

In female patients, minoxidil is currently considered the most effective therapy.

Occasionally, attempts are also made to alleviate circular hair loss (alopecia areata) with minoxidil, but no significant success is achieved.

Side effects: If necessary, local redness and inflammation of the skin occur or the scalp itches in patients who use the hair loss remedy. Sometimes hair growth on the face increases. Rarely, changes in blood pressure occur.

Nevertheless, it is advisable that people with cardiovascular diseases pay attention to side effects such as accelerated heartbeat (tachycardia), water retention in the tissues (edema) and weight gain: If the scalp barrier is not intact (for example, if there are small tears), the active ingredient may enter the bloodstream and possibly cause such adverse effects.

Initially, there may be increased hair loss. This is explained by the fact that the active ingredient pushes certain loose hairs (telogen hairs) out of the follicles by other hairs.

Minoxidil must not be used during pregnancy and breastfeeding.

Antiandrogens

Antiandrogens (such as cyproterone acetate or dienogest) are substances that prevent the action of testosterone or the more potent dihydrotestosterone (DHT) by occupying their docking sites (receptors).

Some antiandrogens such as chlormadinone acetate also inhibit the enzyme 5α-reductase (such as finasteride), so that less DHT is produced in the cells. Because of these mechanisms of action, antiandrogens are thought to help against hereditary hair loss in women.

After menopause, physicians may prescribe antiandrogens alone. For pre-menopausal women, it is important to take them in combination with estrogens as contraceptives. The reason: Pregnancy must be avoided at all costs during treatment. This is because antiandrogens would disrupt genital development in a male fetus and lead to “feminization”.

Side effects: Among other things, antiandrogens are capable of reducing sexual desire.

Physicians advise smokers not to take sex hormone preparations for hair loss because they have an increased risk of blood clots (thromboses, embolisms). The hormones additionally increase this risk.

Men with hereditary alopecia must not take antiandrogens because they would “feminize” (for example, through growth of the male breast = gynecomastia).

Dithranol (Cignolin, Anthralin)

The active ingredient dithranol is used primarily in the treatment of psoriasis. However, doctors sometimes also prescribe the skin-irritating substance for bald spots caused by circular hair loss: the skin irritation stimulates new hair growth.

Glucocorticoids (“cortisone”).

Doctors usually treat circular hair loss externally with cortisone creams or solutions. They alleviate the inflammatory immune response in the affected areas. In some patients this actually stops the hair loss and new hair sprouts, but in others it does not.

If the treatment is successful, it generally lasts only as long as it lasts: if the cortisone therapy is stopped, the hair often falls out again.

In certain cases, the doctor administers cortisone injections into the bald spots. Severe hair loss can also be treated with cortisone tablets. However, the risk of side effects is particularly high in this case.

Side effects: External use of cortisone may cause allergic reactions or other side effects. Especially when used internally, there is a long-term risk of systemic side effects, i.e. side effects that affect the entire body.

Topical immunotherapy

If circular hair loss has already led to larger bald patches, topical immunotherapy may help. This involves the targeted application of the active ingredient diphencyprone (diphenylcyclopropenone, DCP) to trigger allergic contact dermatitis, which is maintained by repeated treatment.

The aim is to “distract” the immune cells from attacking the hair roots. Indeed, experts suspect an autoimmune reaction in circular hair loss – that is, an attack by immune cells on the hair roots due to a malfunction of the immune system.

Side effects: Among other things, the complex therapy possibly triggers the formation of exuberant eczema on the treated skin areas. It is therefore advisable to have it performed only by specially trained doctors.

If the treatment is effective and the hair grows back, a relapse may still occur later.

PUVA

In general, psoralen is applied externally (e.g. as a cream). The treatment method is considered to be similarly successful as topical immunotherapy. However, the risk of relapse is higher.

Side effects: In general, psoralen is applied externally as a cream (topical PUVA). Especially if the concentration is too high, undesirable reactions such as a kind of sunburn may appear on the treated skin area after UV-A irradiation.

It would be possible to apply psoralen internally (as a tablet) before irradiating the skin. However, this systemic PUVA is not more promising than a topical one. It also carries a higher risk of side effects, such as a higher risk of skin cancer.

Other treatment options for hair loss

In the case of circular hair loss, zinc is also frequently used due to its effect on the immune system.

If it is caused by certain medications, the hair loss usually subsides when you stop the therapy. Depending on the medication, it is possible to reduce the dose or switch to an alternative preparation that is less harmful to the hair.

Sometimes infections or other diseases (such as thyroid disorders) cause diffuse hair loss. These should be treated accordingly. If protein or iron deficiency is behind the excessive hair loss, it is important to compensate for the deficit through diet or substitute preparations.

Preparations from the pharmacy are also helpful for the supportive treatment of diffuse hair loss. Active ingredients such as various B vitamins and amino acids (L-cysteine) strengthen the hair roots and stimulate the formation of new hair cells.

Even in the case of scarring hair loss (cicatricial alopecia), treatment of the underlying disease (lupus erythematosus, nodular lichen et cetera) is the best strategy against hair loss.

Hair transplantation

The receding hairline and bald spot that form in men with hereditary hair loss can be concealed with an autologous hair transplant. In this procedure, doctors cut out small pieces of tissue with hair follicles from the even more hairy back of the head, which usually do not react sensitively to testosterone, and transplant them to the bald areas. It is recommended to have the procedure performed by an experienced dermatologist.

For women with hereditary hair loss, hair transplantation is often not very suitable, because they usually do not develop circumscribed bald patches (such as bald patches on the back of the head), but the hair as a whole becomes thin or thins out (especially on the top of the head). In most cases, complete baldness does not occur.

Hair transplantation is also not advisable in cases of circular hair loss, because the hair often grows back on its own after a few months (spontaneous healing).

The trade offers numerous over-the-counter products against hair loss. For example, there are caffeine shampoo against hair loss, burdock root and saw palmetto extract, products with vitamin H, millet extract or taurine.

They promise, for example, to stimulate hair growth and maintain hair by stimulating the scalp and blood circulation. However, most of these products have not yet been proven to be effective.

The same applies to hair tonics containing alfatradiol (17-α-estradiol). Similar to finasteride, the active ingredient is able to inhibit the enzyme 5α-reductase and thus the formation of highly effective dihydrotestosterone (DHT). Therefore, it is recommended to men with hereditary hair loss. However, its efficacy has not been clearly proven scientifically.

The right haircut or a different hairstyle may hide bald spots or thinning hair sections. Seek advice from your hairdresser!

Hair replacement also conceals the affected areas. Today, there are wigs and toupees made of real and synthetic hair in all shapes and colors that can be attached temporarily or permanently.

With some hair replacements it is even possible to go swimming. Be sure to get professional advice at a second hair studio!

Ask your health insurance company whether they will contribute to the cost of hair replacement for hair loss.

Hair loss: When to see a doctor?

If you suspect you are suffering from increased hair loss, it is advisable to see a doctor. But which doctor do you go to for hair loss? It makes sense to visit your family doctor first. Sometimes he already determines the cause, such as an iron deficiency by means of a blood test.

By the way, one speaks of increased hair loss when one loses more than 100 hairs a day. Then baldness is imminent.

Hair loss: examinations and diagnosis

In order to diagnose hair loss and clarify the possible causes, the doctor performs various examinations in addition to a doctor-patient discussion (anamnesis). These include a physical examination, a blood test and, depending on the need, other procedures such as an epilation test, a trichogram or the examination of a hairy scalp sample.

Taking the medical history

The first step in the clarification of hair loss is the anamnesis, i.e. the doctor-patient consultation to obtain the medical history. The doctor asks, for example, how long the hair loss has existed, whether you suspect a particular trigger, what medications you are using and whether you have any known underlying diseases.

Physical examination

This is followed by a physical examination. Here, the doctor examines the scalp and the distribution pattern of the hair on your head. Depending on the type of hair loss you suffer from, the symptoms of alopecia differ: If necessary, the hair loss looks different depending on the cause.

Hereditary hair loss, for example, can often be clearly diagnosed by the pattern of thinning or balding: Bald forehead, a bald spot on the back of the head (tonsure) and receding hairline are also indicative:

A receding hairline in the upper temple area is mainly a complaint of men. In some cases, receding hairline already develops in young adulthood. They are often the first sign of hereditary alopecia. In women with this form of hair loss, however, receding hairline develops only very rarely.

You can read more about receding hairline and health risks that may be associated with it in the article Receding hairline.

Round, completely bald patches on the scalp without signs of skin changes (such as inflammation or scarring) indicate circular hair loss. This is also indicated by so-called exclamation mark hairs (“comma hairs”), which are often found around the edges of bald patches:

These are short broken hairs that can be pulled out painlessly and have a pointed root instead of a normal round one. In addition, people with circular hair loss often have changes in their fingernails (grooves, dimples).

Blood test

A blood test is particularly informative in the case of diffuse hair loss. Among other things, the doctor examines iron and zinc levels, thyroid levels and inflammation levels (such as leukocyte count, blood cell sedimentation rate). The blood values provide indications of possible causes of hair loss such as iron or zinc deficiency, hyperthyroidism or inflammatory diseases.

In younger women with hereditary hair loss, experts recommend determining the blood levels of androgens and estrogens. This is particularly necessary if the women show signs of elevated androgen levels such as cycle irregularities and a male pattern of hair growth (hirsutism).

Epilation test

Trichogram

The trichogram is a microscopic examination method that can be used to detect pathological processes in the hair roots and hair shaft. Hair goes through different phases (hair cycle) in the course of its life:

Growth or anagen phase:The phase of active hair growth usually lasts four to six years, sometimes up to ten.
Transitional or catagen phase: It lasts one to two weeks, during which functional degradation of the hair follicle occurs and the hair shifts towards the scalp surface.
Resting or telogen phase: It comprises three to four months, during which no metabolism takes place anymore – the hair “rests”. At the end, it is shed (= it falls out).

The trichogram can be used to estimate the proportion of hair in the individual stages. This helps to clarify the hair loss.

In a normal trichogram, more than 80 percent of the pulled-out hairs are in the growth stage (anagen phase) and less than 20 percent are in the rejection stage (telogen phase). Only a few hairs (one to three percent) show the transitional stage (catagen phase) and are therefore usually difficult to identify under the microscope.

Increased hair loss is present when the proportion of anagen hairs is less than 80 percent and the proportion of telogen hairs is correspondingly more. A telogen proportion of up to 50 percent indicates pronounced hair loss. When evaluating a trichogram, it is always important to take into account the medical history interview and the results of the physical examination.

Computer-aided hair analysis

It is now possible to create a trichogram using a digital camera and special computer software. The patient’s hair is not pulled out for this purpose. Instead, the doctor shaves a small area of the scalp in an invisible place. Three days later, the area and the regrowing hair are dyed with a hair dye and photographed in high magnification. The result provides the doctor with information about the hair density and the activity of the hair follicles.

Biopsy

Sometimes it is necessary for the doctor to cut out a small hairy scalp sample (along with the hair follicles) and examine it more closely. This is the case, for example, with scarring alopecia or unexplained diffuse hair loss. The removal of tissue should be considered carefully: it is painful, leaves a scar and no hair will grow back in the affected area.

Hair diary

Other examinations

If the doctor suspects a certain underlying disease as the cause of hair loss, further examinations may be necessary. For example, to clarify hyperthyroidism, the doctor often performs an ultrasound examination or a scintigraphy of the thyroid gland.

Hair loss: prevention

The best way to prevent hair loss is mechanical or caused by malnutrition. So wear long hair loosely tied or open more often and supply your body regularly with all important nutrients and minerals (protein, iron, B vitamins et cetera) to prevent hair loss caused by malnutrition!

Frequently asked questions about hair loss

What helps against hair loss?

What helps women with hair loss?

Treatment for women with hair loss is generally no different from treatment for men. Hair loss in menopausal women is often hormonal, when estrogen levels decrease and androgens increase. If hormone replacement therapy is necessary, it can counteract the effects of androgens.

What vitamins for hair loss?

The vitamins that help against hair loss are vitamins A, C, D, E and B (especially B7 and B12). They support hair growth. A balanced diet and, if necessary, dietary supplements provide these vitamins.

Which doctor for hair loss?

If you have hair loss, you should see a dermatologist (skin doctor). In some cases, it may also be helpful to consult a specialist trichology practice that specializes in hair and scalp disorders.

Which shampoo helps with hair loss?

How much hair loss is normal?

It is normal to lose 50 to 100 hairs a day. If you notice that you are losing significantly more hair than usual or bald patches are forming, you should consult a doctor. Hair loss can indicate various health problems, such as hormonal imbalances, stress or malnutrition.

Why does hair loss occur?

Hair loss can have various causes, such as genetic predisposition, hormonal changes, stress, malnutrition, certain medications or diseases. In men, the most common cause is hereditary hair loss. In women, hormonal fluctuations during menopause can cause hair loss.

Which medications can cause hair loss?