Hair Loss: The 8 Most Common Mistakes
There is advice about hair care and hair loss everywhere you turn. Magazines, TV, the internet. I see it. You see it. Some of the advice is quite good actually. Some of it is not.
I hear countless stories everyday of how an individual tried a particular supplement or shampoo because a friend, family member or hairstylist recommended it. Or how an individuals asked for certain blood tests because they read it's critical to have that test done. Most of the time, (fortunately), the things people do by acting on the advice of others is not harmful - except perhaps the time or money it consumes. But exceptions do exist, of course.
Today I'd like to share my views on the 8 most common mistakes people make when it comes to the way they deal with their hair loss.
1. They don't know their diagnosis.
Anyone with hair loss needs to know their diagnosis. First and foremost. If an individual has hair loss, he or she needs to be able to say it in one sentence (not two): "My hair loss is due to ....."
Too few people know the diagnosis or reason for their hair loss before they venture into their search for treatment. It is not possible for me to recommend treatment to any person with hair loss without knowing their diagnosis so how is it possible for anyone else to recommend treatment?
Most of the time, trying something out is usually a fairly safe experiment. But one must always be aware that this is not always the case. Even a simple hair supplement can cause worsening shedding, weight gain, rash etc. Some shampoos in the mainstream have recently hit the news for possibly causing hair loss in some users. Nothing is without potential side effects. One must first and foremost know their diagnosis before venturing down a treatment path.
2. They doubt the possibility of genetic hair loss
Receiving news that one's hair loss is due to "genetic" hair loss is not typically met with a welcoming tone. Some patients are surprised. Some are angry. Some are angry at me.
"Dr Donovan, I find it a hard piece of information to swallow when you consider that nobody in my family has hair loss."
If I diagnose genetic hair loss in a person, male or female, it is because I believe beyond a doubt that they have genetic hair loss. What is unfortunate is that many individuals delay treatment on account of the doubt about a diagnosis of genetic hair loss. 40 % of women and 50-60 % of men will have evidence of androgenetic hair loss by age 50. It is more common than many realize, including physicians. A family history is not always present.
3. They overemphasize the role of 'deficiencies' (iron, biotin & vitamin D) in hair loss.
Diagnosing hair loss is a lot like detective work. We know that the patient's story is important (which we call the "history"). Everyone knows that examining the scalp is also important. And everyone knows that blood tests are important for some patients too.
What often gets missed in all this detective work is the relative importance of all these steps. Years ago, I would have told you that the story was important but the actual examination of the scalp was the most important part of the detective work and blood tests were a close second. I might have said 50 % of the detective work comes from the scalp examination; 30 % from blood tests and 20 % from the history. For many patients with hair loss, there is a feeling amongst the general public that the split is more like 10 % history, 20 % examination and 70 % blood tests.
After many years of diagnosing hair loss, I can tell you that the patient's "history" is more important than I ever realized years ago. I would now rate all the components as 65 % history, 25 % examination and 10 % blood tests. In other words, blood tests are important but not everything. If I listen carefully to a patient's story, I can gain information that I sometimes can not get from the most detailed of scalp examinations or blood tests.
But it is easy to understand why we place so much emphasis on blood tests. We want something tangible. We want something we can monitor and prove we are changing through therapy. We so much want to say to patients "Aha. Your iron is low. See here your results. You need iron!" Any of the following can be substituted for the word iron : Vitamin D, B12, zinc, biotin, selenium. It feels that we have done something of value when one of our tests show turned up something that is "abnormal" - we can guide the patient to correct it and hopefully improve their hair. It is often not this simple - and one of the biggest mistakes we make is thinking that these deficiencies are a simple fix.
Let's look at iron, vitamin D and biotin as examples.
Iron is important in hair growth. I'll be the first to say that and in fact we have been studying this issue and have published in various journal (see reference 1). Iron deficiency certainly can contribute to hair loss. But one must keep in mind a more important fact: so much of the time it does not. There are countless numbers of women with ferritin levels of 29, 36 and 44 who believe (or who are told) that once their ferritin levels rise to 70 their hair will finally start to grow. This is simply not true for most people. I wish it was so. It's not the most popular answer nor the answer people would like to hear. But it is, in fact, the correct answer.
Iron is far more complicated. It is important to ensure that anyone with a ferritin less than 40 supplement with iron. But this is mainly "just in case" the person shows growth response with iron. A large proportion of healthy female patients with ferritin levels 25-40 with concerns about their hair have androgenetic alopecia. Some have telogen effluvium. Some have alopecia areata.
The well-read patient may quote studies showing a link between low ferritin and hair loss. These studies are true and do exist. What the individual will often not quote is the numerous studies which do not show such a clear-cut link (see references 2-4).
Vitamin D deficiency is widespread in the northern hemisphere. More and more we are testing vitamin D levels in patients with hair loss because modern research tells us that some hair loss conditions are associated with low vitamin D. For example, patients with alopecia areata who have lower vitamin D levels have worse prognosis than those with normal vitamin D levels. Similarly, we now understand that changes in vitamin D signaling have a role in androgenetic alopecia as well. But what is too often forgotten in all the hype about vitamin D is that no study has convincingly shown that vitamin D supplementation directly impacts hair growth. In my opinion, supplementing vitamin D makes sense as it may help other treatments work better. But I never supplement vitamin D with the hope that it is the sole answer to the patient's hair loss. Too often, I hear patient's tell me they were very happy when they received news that their vitamin D levels were low because they felt that they finally had something they could target and a defined treatment plan they could pursue. For most patients vitamin D supplementation alone has no measurable effects on the hair. Interested readers can read a publicly available article listed in reference 7.
As for biotin, most people are not biotin deficient and supplements are not helpful (see reference 5). Exceptions to the rule exist for anything. Pregnancy, use of retinoids and anti-seizure medications, chronic alcoholism, and older age are associated with potential biotin deficiency. There is no good evidence that biotin supplements help most people with hair loss.
4. They overemphasize the role of thyroid dysfunction in the setting of normal TSH levels
The level of thyroid hormone production by the thyroid gland has an extremely important role in hair loss. Massive shedding results when the thyroid gland does not work properly. Too much thyroid hormone (hyperthyroidism) causes hair loss and so does too little thyroid hormone (hypothyroidism).
One of the more common mistakes people with hair loss make is being convinced that their thyroid gland is not working properly when there is no good evidence to support that notion. For individuals with TSH ranging from 0.5 to 3.0 there is little reason to believe thyroid issues are a cause of hair loss and there are few other thyroid related blood tests that are usually helpful in these cases. Will tests for T3, reverse T3 and thyroid antibodies be helpful in someone with TSH 0.5 to 3? Usually not. Is this a popular answer? No. Many patients with hair loss want their health care practitioners to say "these basic thyroid tests are not always accurate and you can still have thyroid problems even when these tests are normal. Let's test you with this other battery of tests"
Does the patient with a TSH of 2.1 need these fancy tests? Not usually, no.
What I spend a good proportion of my practice addressing is chronic shedding issues in patients with normal thyroid function (as measured by TSH) who were subsequently started on a low dose of various thyroid supplements because one of the supplementary tests turned up abnormal despite a normal TSH. These issues have never ever been addressed in our hair research world but are very real: Many patients get into problems for their hair by using thyroid medications in the setting of normal thyroid (TSH) profiles. Not a popular answer, I know. But the reality for most.
5. They overemphasize the role of bad hair cuts
In my experience, men are actually more likely to attribute a bad hair cut to their current hair loss state than women. Hair cuts can transmit infection and infestations and can be a source of tremendous irritation to the skin and hair follicles if cutting or shaving is done too close. Shaving can worsen folliculitis in some. For most, however, the hair cut is not the cause.
6. They attribute the cause solely to stress
Stress can cause hair loss. There is little doubt about this fact. In vitro and in vivo research and laboratory models have shown that the cytokine and hormonal changes that accompany chronic stress are not beneficial to hair growth. There are animal models that have shown stress clearly causes hair loss in animals (see reference 6). That said, the day-to-day stress that most feel is not associated with much in the way of hair loss. However some stresses are associated with hair loss and I have referred to these as the 5 D's : death of a loved one, dismissal (losing job), divorce, debt and receiving a new diagnosis of illness. These are major stresses and can give hair loss for some.
Far too many people with hair loss are told to reduce stress. This includes some children as well. For a large proportion of people I see, I'm not truly convinced that their stress caused their hair loss. Of course there are some patients where there is a link, but it's a minority.
7. They are consumed by the proper shampoo frequency
Shampoo frequency is a great topic. In fact, it's the most common topic that I receive media requests for interviews. Usually a newspaper or magazine sets out to answer the question as to whether shampooing too much is bad. They interview a salon owner or stylist who states that shampooing too often strips oils and makes the scalp produce more oil in rebound. And then they interview me. I usually recommend to shampoo every few days and that we don't really have great evidence that stopping one's shampoo habits affects oil production in the long term. And then we switch to someone who does not shampoo his or her hair at all and then I am in turn asked about my thoughts on the whole "no poo" movement. After this, the news story then ends.
For individuals without hair issues, washing makes very little difference for the most part. But it is true that individuals with curlier hair have more difficulty distributing their natural oils along the hair shaft and should therefore wash once every 5-14 days. As the hair gets finer and finer and finer (especially with genetic hair loss) washing more often removes the heavy oils that weigh it down and makes it look better.
The frequency of shampooing does not impact hair loss to any significant degree. It's a far better idea to get a diagnosis about one's hair loss (see point one above) than spending time figuring out if shampooing less or more or with a different shampoo will resolve one's hair loss problems. It is true that more hair comes out on the days we shampoo (could be over 100) than on the days we do not shampoo. But overall we lose about 200-500 hairs per week. You can coax those hairs out bit by bit by shampooing daily or coax them all out at once (in alarming levels) by shampooing just once per week. And as an extreme, if one were to be very gentle with their hair and wash just once per month, it's conceivable for over 1000 hairs to come out during the monthly wash. This would be completely normal and very alarming to experience.
I'm a big fan of shampoo chemistry. The formulations for different hair types. I would much rather a person ask "What could be causing my hair loss?" than asking "What shampoo should I use?" Both are really good questions but one will take the patient much further with addressing their hair loss.
8. They think that "topical" equals safe
It's a strange world but we are seeing a trend that I never would have predicted 10 years ago. We are seeing FDA approved medications that are oral medications (i.e. oral finasteride) increasingly prescribed as topical compounded formulations. At the same time we are seeing FDA approved medications that have long been topical (i.e. topical minoxidil and "Rogaine") increasingly prescribed as oral medications. The reason is simple: We want our medications to work better but we don't like the side effects. Oral medications work better than most topical medications.
A big mistake I see people making is assuming topical medications are completely safe and without side effects. Nothing could be further from reality. The scalp is a wonderful bloody tissue - and by that I mean well-vascularized. Application of medications to the scalp leads to absorption. Some more than others. Topical steroids are absorbed if too much is applied for too long. Topical minoxidil is absorbed if too much is applied - and some is absorbed even if the proper amount is applied. These medications are relatively safe mind you and numerous health agencies have declared them safe for over the counter use. But it would be wrong to assume they are without issue.
And so are topical antiandrogens safer than oral anti-androgens? Probably. Are they without side effect? Probably not. Should the male who has experienced life altering changes in mood or sexual issues switch to topical finasteride? Or should he just stop this class of drugs altogether? We do not have those answers yet. One answer we do have is that it would be a mistake to assume topical medications are free of side effects.
It's not always easy to get hair follicles to stay in the scalp and keep them growing well. We are bombarded with information and advice from a variety of sources including the internet, media and TV. I have come to know over the years what answers are "popular" and what patients (even well read patients) expect to hear from their physicians. It's not always easy (and some firm followers of the benefits of biotin/thyroid/shampoos/vitamin D are apt to be upset). There are many common mistakes that are made when addressing hair loss. Many of these mistakes fundamentally come from not recognizing the diagnosis in the first place.
1. St Pierre SA1, Vercellotti GM, Donovan JC, Hordinsky MK. Iron deficiency and diffuse nonscarring scalp alopecia in women: more pieces to the puzzle. J Am Acad Dermatol. 2010 Dec;63(6):1070-6.
2. Olsen EA, Reed KB, Cacchio PB, Caudill L. Iron deficiency in female pattern hair loss, chronic telogen effluvium, and control groups.J Am Acad Dermatol. 2010 Dec;63(6):991-9. doi: 10.1016/j.jaad.2009.12.006. Epub 2010 Oct 13.
3. Bregy A, Trueb RM. No association between serum ferritin levels <10 microg/l and hair loss activity in women.Dermatology. 2008;217(1):1-6. doi: 10.1159/000118505. Epub 2008 Feb
4. Olsen EA. Iron deficiency and hair loss: the jury is still out. J Am Acad Dermatol. 2006 May;54(5):903-6. No abstract available.
5. Soleymani et al. The Infatuation With Biotin Supplementation: Is There Truth Behind Its Rising Popularity? A Comparative Analysis of Clinical Efficacy versus Social Popularity J Drugs Dermatol. 2017 May 1;16(5):496-500.
6. Peters EM et al. Hair growth inhibition by psychoemotional stress: a mouse model for neural mechanisms in hair growth control. Exp Dermatol. 2006 Jan;15(1):1-13.
7. Amor KT et al. Does D matter? The role of vitamin D in hair disorders and hair follicle cycling. Review article. Dermatol Online J. 2010