Hair loss

Hair loss

Hair loss is a manifestation, not an illness, that is usually caused by our genes and hormones. It is the so called androgenic alopecia, which affects over 50% of adult men and 40% of women. There are other types of hair loss which distinction helps us in choosing the best treatment or surgery.

With a healthy back, the so-called donor, region on the scalp hair transplant surgery is probably possible. We always recommend a free consultation examination to assess the specific case, and determine the justification, the size and the cost of the probable FUE hair transplant intervention. If you are unable to come, you can send us photos and we can comment them over the phone together.

Causes of hair loss

Hereditary occurrence of hair loss (androgenic alopecia), an increased amount of the male hormone dihydrotestosterone (DHT) in the hair follicle and age contribute to hair loss or baldness.

Two androgen hormones play a part in the mechanism of hair loss, and they are testosterone and dihydrotestosterone. DHT is a derivative of testosterone. The enzyme 5-α reductase converts the relatively inactive testosterone in a more active form of DHT. The key enzyme in the androgenetic hair loss, 5-α reductase is located in and around the hair follicles. Once DHT is formed it has the ability to bind to androgen receptors on the hair follicle. Plain testosterone can also affect hair follicles but its influence on hair loss is significantly weaker. As a result of the interaction of these hormones and their binding to the follicles, we have a change in the quality of hair and its fallout.

Over time the hair growth cycle changes. The anagen phase (growth phase) is reduced while the catagen (transitional phase) and the telogen (resting and fallout phase) extend. The number of hairs in the resting phase and the fallout phase is increased from 10% to 20%.

Over the years, under the influence of DHT part of the affected hair follicles disappears, and most of the hair follicles are reduced. The hair that grows from these follicles over time changes so from long, thick and strong hair we get thinner, lighter and shorter hair. The sebaceous glands, which are located along the hair, continue to produce the same amount of sebum but as the hair is thinner we get the impression of an oilier scalp and hair.

Genes

The loss of hair occurs in people who have a specific genetic code in their chromosomes. This genetic code responsible for hair loss is carried on one or a group of genes and can be inherited from the mother or the father.

For the genetic code for hair loss to be active there must be a gene expression due to hormones, age, stress levels, etc. Specific hair loss genes have not yet been identified, but scientists agree that this gene or genes are responsible for the synthesis of: male hormones, the enzyme 5-α reductase and the androgen receptors in hair follicles, and these are the three main stakeholders in hair loss.

Hormones

The hormones responsible for hair loss are called androgens. Androgens like all hormones bind to specific receptors located in the cell membranes or inside the cells. Androgenic hormones may have different effects on individual hair follicles, so for example, can lead to hair loss in the scalp, but also to the growth of hair in the armpit, on the face or body.

There are three explanations of why in some people androgenic alopecia occurs, while in others does not although all have hormones and receptors that cause hair loss:

  • In the part of the scalp where hair loss occurs, the number of androgen receptors in the hair follicles is larger than usual so that the same amount of androgens in the blood has a more pronounced effect (hair loss);
  • Receptors in the follicles are more sensitive to androgens than normal;
  • Increased activity of the 5-α reductase enzyme in areas where hair is lost leading to the conversion of testosterone to DHT. The higher the value of DHT as compared to testosterone, the more pronounced is the hair loss process.

Aging

The period of time for the loss of hair varies from person to person and depends on the personal genetic expression and the amount of androgen in her or his blood. It also requires a number of years during which the hair follicles will be influenced by hormones.

When there is no predisposition for androgenic hair loss, as people get older the part of hair in the scalp will become shorter in length and width. This process is called miniaturization of hair as a result of which such hair falls out, and the number of follicular units is reduced.

Stress

In some cases hair loss is associated with stress. The most common form of hair loss is telogen effluvium. With this type of hair loss the hair stops growing and falls out after 2-3 months, and after 6-9 months it grows back.

Another form of hair loss associated with stress is alopecia areata, which occurs when white blood cells attack hair follicles and cause sudden hair loss. Most often the hair is lost in circles, but it can also affect larger parts of the scalp. In the majority of cases over time the hair re-grows while in a smaller number of cases hair transplantation is needed.

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Hair loss in men

The cause of hair loss in men, in more than 95% of cases, is androgenic alopecia, i.e. the existence of hormonal receptors in the root region of hair. Receptors stimulated by the male hormone dihydrotestosterone (DHT) cause the gradual formation of an insulating layer that inhibits the passage of blood and nutrients to the roots of the hair. Usually the front and the top of the scalp are affected, and then the area of the scalp’s crown. There are no such receptors where the hair is permanent and that is the back and the side parts of the scalp.

The size of the areas where hair loss occurs is genetically determined by one or both parents. Hair loss usually begins in the front line of the scalp but often results in larger losses in all areas.

The hair is lost due to changes in the life cycle of hair caused by the DHT. The cycle of a hair consists of the anagen phase (growth phase), the catagen phase (transitional phase) and the telogen phase (resting and falling phase). Before hair loss the anagen phase lasts up to seven years, and the telogen phase 3-4 months. With time the anagen phase becomes shorter and the telogen phase extends. After falling out there is no new hair growth or the hair grows thinner and shorter.

The Norwood Hamilton Scale is used to measure the extent of hair loss in men and it is a common standard to describe hair loss.

Norwood Hamilton Scale – stage 1

Norwood Hamilton Scale - stage 1

Very minor or no recession of the hair line, therefore no need for treatment. Unless you have a family history of baldness there is no need to worry. If there is a family history of male baldness, you may want to monitor the situation closely and decide the appropriate time for treatment.

Norwood Hamilton Scale – stage 2

Norwood Hamilton Scale - stage 2

The front line of the scalp is pulled back and whiskers are formed, usually on both sides of the temporal region. Also hair thinning can occur in the central part of the front line of the scalp. The initial discrete signs of hair loss are becoming evident.

Norwood Hamilton Scale – stage 3

Norwood Hamilton Scale - stage 3

Most scalps at this stage have deep symmetrical recessions showing at the temples that are bare or only sparsely covered by hair. With stage 3 the loss of hair is primarily from the vertex with limited recession of the front temporal hairline.

Norwood Hamilton Scale – stage 4

Norwood Hamilton Scale - stage 4

The recession at the front temporal areas is more pronounced than in stage 3. There is a decisive lack of hair on the crown. The areas of hair loss, i.e. the front area and the crown, are separated by a band of moderately dense hair extending across the top of the scalp. This area also bridges between the densely hair covered areas on the side of the head, above the ears.

Norwood Hamilton Scale – stage 5

Norwood Hamilton Scale - stage 5

At stage 5 hair loss at the vertex region is still separated from the frontal region but the division is much less distinct. The band of hair extending across the crown is noticeably narrower and thinner. Hair loss at the vertex and front temporal regions are larger. When viewed from above, stages 5 to 7 show the remaining hair at the sides and back as a distinct horseshoe shape.

Norwood Hamilton Scale – stage 6

Norwood Hamilton Scale - stage 6

In stage 6 in the uppermost part of the scalp only sparse hair remains. The front area and the crown are now joined into one area. Hair loss extends sideways.

Norwood Hamilton Scale – stage 7

Norwood Hamilton Scale - stage 7

It is the most serious or advanced stage of hair loss. Only a small area in the shape of a horseshoe remains in the side and back regions of the scalp with hairs which can be thinner and sparse, and finally form just two semicircles above the ears.

Androgenic alopecia

The hormones responsible for hair loss are called androgens. Androgens like all hormones bind to specific receptors located in the cell membranes or inside the cells. Androgenic hormones may have different effects on individual hair follicles, so for example, can lead to hair loss in the scalp, but also to the growth of hair in the armpit, on the face or body.

There are three explanations of why in some people androgenic alopecia occurs, while in others does not although all have hormones and receptors that cause hair loss:

  • In the part of the scalp where hair loss occurs, the number of androgen receptors in the hair follicles is larger than usual so that the same amount of androgens in the blood has a more pronounced effect (hair loss);
  • Receptors in the follicles are more sensitive to androgens than normal;
  • Increased activity of the 5-α reductase enzyme in areas where hair is lost leading to the conversion of testosterone to DHT. The higher the value of DHT as compared to testosterone, the more pronounced is the hair loss process.

 

There are two androgen hormones involved in the hair loss mechanism, i.e. testosterone and dihydrotestosterone. DHT is a derivative of testosterone. The enzyme 5-α reductase converts the relatively inactive testosterone into a more active form DHT. The key enzyme in androgenic hair loss, 5-α reductase, is located in and around the hair follicle. Once DHT is formed it has the ability to bind to androgen receptors on the hair follicle. Normal testosterone can also affect the hair follicles but his influence on hair loss is significantly weaker. The interaction of these hormones and their binding to the follicles results in changes in the quality of hair and its fallout.

Over time the hair growth cycle changes. The anagen phase (growth phase) is reduced while the catagen (transitional phase) and telogen (resting phase and fallout) are extended. The number of hairs in the resting phase and the fallout is increased from 10% to 20%.

Telogen effluvium

Hair loss due to the increased number of follicles in the resting and the fallout phase. The most common causes are: thyroid abnormalities, anemia, high doses of vitamin A, medications for lowering blood pressure, medications for gout, diet, and physical and emotional stress.

The diet can cause hair loss. Diet programs have strictly regulated dietary supplements, vitamins and meals however they cannot prevent hair loss in rapid weight loss.

Surgery, serious illnesses and stress can also cause hair loss. At such moments the body stops or slows down the hair growth cycle, and redirects the energy to vital body structures. In most cases, only 3 months after the physical or emotional stress, hair loss occurs, and it takes 3-4 months to begin regrowth.

 Scars due to surgical procedures

In various surgical procedures on the scalp, such as removing moles or atheroma, taking of old STRIP transplant hairs, and often after a face-lifting surgery, there is the possibility of hair loss along the scar or the area around it. The transplantation procedure is possible.

 Alopecia areata (hair loss in circles)

It is an autoimmune condition where the body produces antibodies against its own hair. The change usually occurs in one or more isolated areas in the form of circles, and the loss of scalp can be complete (alopecia totales). In extreme cases the loss all the body hair can occur (alopecia universalis). Only in limited and permanent cases hair transplantation is justified.

Chemotherapy and radiotherapy

Most drugs used in chemotherapy act in a way to attack malignant cells, i.e. inhibit their growth. A side effect of this is the effect on healthy cells in the body including the hair follicles. Fortunately in most cases after the end of chemotherapy hair grows back again.

In the treatment of tumors with radiation hair loss occurs only in areas exposed to radiation. After completing radiation, hair does not always re-grow but hair transplantation is possible.

Scars from burns or chemicals

Chemicals used for dyeing, bleaching, fixing or softening hair can cause hair damage or hair loss that is not permanent. If used improperly these chemicals can damage the skin and thus the root of the hair which may result in permanent loss of hair. Likewise burns can affect only the surface of the skin or also the hair roots, and thus cause temporary or permanent hair loss. Hair transplantation in most cases is possible, depending on the thickness of the remaining skin, i.e. on the thickness of the “fertile soil”.

Traction alopecia

Traction alopecia is hair loss as a result of strong and long-term pulling or tightening of hair, usually with wearing the “ponytail”. In shorter wearing hair growth can recover while with the long-term wearing hair loss may be permanent. The deficiency is most commonly seen (in both women and men) as a loss or thinning of hair in the frontal region of the scalp. Hair transplantation is possible.

Skin changes

Localized skin problems such as eczema, scars and infections can cause temporary or permanent loss of hair. The procedure of hair transplantation may be considered only when the skin is calm (dormant).

Trichotillomania

Trichotillomania is a compulsive disorder when a person uncontrollably pulls his/her hair, eyebrows or eyelashes. It is a psychological disorder, and the person is unable to stop in the above action. Such pulling of hair can result in areas with no hair. Before the potential transplantation, the patient should definitely undergo a psychological therapy.

Medicines

Over one hundred different medicines cause hair loss, for example, drugs against blood clotting, thyroid medications, chemotherapy for malignant diseases, birth control pills.

Hair loss in women

Female hair loss is less evident, but is also advancing. Normal hair loss is from 100 to 130 hairs a day. Loss of hair occurs when hair replacement is absent or daily losses rise.

Unfortunately women only after a prolonged time have the courage to seek medical advice or intervention because the customary, but wrong, attitude is that women do not lose hair. Most often occurs the thinning of hair at the top of the head or the crown. Even though the appearance of hair loss in women is often similar, causes may vary. In some cases, prior to consulting a surgeon it is recommended to consult a dermatologist, endocrinologist and gynecologist.

We always recommend a free consultation examination to assess the specific case, and estimate the justification, the size and the cost of a possible FUE hair transplantation. If you are unable to come to us, you can send us photos and we can comment them together over the phone. With a healthy back, the so-called “giving”, region of the scalp hair transplant surgery is probably possible.

Ludwig’s scale of female hair loss

Ludwig's scale of female hair loss

Ludwig’s scale – stage 1

At this stage, most women do not notice hair loss because the frontal part remains relatively unchanged. Hair loss can occur at the top and in the front of the scalp. The loss is visible in the front area and the area of the parting.

Ludwig’s scale – stage 2

At this stage women notice the following: thinning, falling and a general lack in the amount of hair in the central part which continues to expand over time. At this stage, the hair transplantation is usually performed.

Ludwig’s scale – stage 3

This is the most extreme form of female hair loss. At this stage the hair is extremely thin and hair loss is pronounced so that it is difficult to hide the skin that is clearly visible to the naked eye.

Androgenic alopecia

The female pattern hair loss is a hereditary incidence, not a disease that is hormonally more complex than the male pattern. The sensitivity to the effects of androgens (hormones responsible for hair loss) in the scalp and hair follicles causes the thinning and fallout of the hair. It usually occurs when male hormones rise which occurs when levels of female hormones decline as during menopause.

Women do not develop the same way of hair loss nor complete hair loss as in men. In women rarely there is the withdrawal of the front line of the scalp.

One in three women develop androgenic alopecia. It is common in women after menopause, but can occur any time after puberty. It affects 15% of women before menopause, and 75% of women after 65 years.

Both in women and in men the hormone testosterone, under the influence of the enzyme 5-α reductase, converts into dihydrotestosterone (DHT). Under the influence of DHT hair thins or falls.

Hair transplantation in some cases is possible and is justified.

Traction alopecia

Traction alopecia is hair loss as a result of strong and long-term pulling or tightening of the hair, usually in wearing the “ponytail” and is much more common in women than in men. Most commonly it affects the front part and the front line of the scalp. The often use of electric curlers can also lead to traction alopecia.

Pregnancy and childbirth

Many women testify hair loss several months after birth. This is due to the cessation of normal hair loss during pregnancy when due to increased amounts of estrogen hair is in the anagen phase (growth phase). In other words, hair becomes more luxuriant during pregnancy and postpartum the hair returns to a normal state. Usually the process lasts 6-12 months after birth during which half of the hair is in the telogen phase (resting phase and fallout).

Polycystic ovary syndrome

One in five women may have this syndrome that results in increased values of androgens (testosterone and DHT) for which we know that cause hair loss.

Menopause

Menopause has a number of effects on our bodies and thus also on the hair due to reduced levels of estrogen. Estrogen keeps the hair in the anagen phase and due to its lack the growth cycle of the hair is shorter and the hair falls before reaching its normal length. With hot flashes, mood swings and appearance of hair on the face, we can expect hair thinning, pulling of the scalp line and hair loss.

Anemia

Anemia is a blood disorder caused by lack of iron. The cause of anemia can be a diet low in iron or insufficient absorption of iron. Iron contains ferritin that helps create protein in the cells of the hair, prolongs the anagen phase and hair growth in the appropriate length.

Telogen effluvium

Hair loss due to the increased number of follicles in the resting and the fallout phase. The most common causes are: thyroid abnormalities, anemia, high doses of vitamin A, medications for lowering blood pressure, medications for gout, diet, and physical and emotional stress.

The diet can cause hair loss. Diet programs have strictly regulated dietary supplements, vitamins and meals however they cannot prevent hair loss in rapid weight loss.

Surgery, serious illnesses and stress can also cause hair loss. At such moments the body stops or slows down the hair growth cycle, and redirects the energy to vital body structures. In most cases, only 3 months after the physical or emotional stress, hair loss occurs, and it takes 3-4 months to begin regrowth.

Hormonal changes are a common cause of hair loss. Many women do not know that hair loss can occur after pregnancy or after taking birth control pills. It is important to emphasize that the loss of hair may occur 3 months after hormonal changes, and it can take up to six months for hair to re-grow.

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