How long does it take for shedding to stop once you've corrected the trigger?

How long does it take for hair shedding to stop ?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in telogen effluvium.

Question

I think I have telogen effluvium from a drug I took. I have now stopped the drug and so it’s going out of my system. How long does it take shedding to stop once a person has found the right trigger and stopped it? I’ve heard it takes 9-12 months. Is that true?

Answer

Thanks for the question.

Shedding stops far sooner that this if truly you’ve found the right trigger. In fact, shedding should start really slowing down in 1-2 months and be quite back to normal rates of shedding by month 6 at the latest (but probably month 3-5 for most patients). There are many many patients that note that shedding seems to “shut off like a tap” when a person has really found the right trigger.

It’s important not to confuse two things:

1) The timeline for the hair shedding to slow.

2) The timeline for the hair density and thickness to come back.

These two timelines are not the same!

It takes a matter of months for the shedding to slow but it takes about 6-9 months from the time of stopping the trigger for hair density to really be growing in nicely. In other words, there will be many months where a patient will say “Ok, my shedding stopped but my hair is still so thin.” This is followed by a period where the patient notes that not only is shedding remaining low but hair thickness and volume is coming back.

I have outlined some of this timing below:

Summary

To summarize. it will take up to 6 months for shedding to return to normal once the trigger is fixed. For many patients, the shedding stops much sooner than this. It’s usually just a matter of a few months before shedding is back to the normal expected rates and for some it’s a matter of weeks rather than months. If shedding is not stopping after 6 months, one really should ask themselves?

a) do I really have the correct diagnosis?

b) do I have the correct diagnosis - but have I missed another diagnosis that is also present?

What is More Accurate for Diagnosing Early Stages of Hair Loss : A Scalp Biopsy or Clinical (Trichoscopic) Examination?

Biopsy or Up Close (Trichoscopic) Examination: What’s better for diagnosing the early stages of hair loss?

I’ve selected this question below for this week’s question of the week. It allows us to the review some key concepts in diagnosing hair loss via clinical scalp examination and through a biopsy.

QUESTION

What is more accurate - a scalp biopsy or a scalp exam with a dermatoscope? My biopsy results said telogen effluvium and androgenic alopecia with the diagnosis of androgenetic alopecia being favored.

As for me, I’m a 30 year old female. My scalp is itchy, likely from seborrheic dermatitis which was diagnosed by a dermatologist. I’ve suffered from alopecia areata in the past (1 small bald patch at a time and treated with cortisone injections) . I have a lot of food and environmental allergies that I’m treating naturally. My hair started shedding excessively at the end of February 2021 after a very traumatic event in December 2020. I’m not on any prescription medications but I do take supplements (iron, vitamin D and C, coQ10, quercetin, probiotic, l-lysine, caprylic acid, and a multivitamin for hair). The shedding has been diffuse and I have lost density. My family members insist that no one would know I’m having issues with my hair. In the past few weeks I have had days with minimal shedding. I have been treating the seborrheic dermatitis with medicated shampoos. I have been treating the hair loss naturally, through dietary changes, lowering stress levels with meditation, etc; I have not used any medications.

The dermatologist that performed the biopsy said it’s “age related” (I’m a 30 year old female) and therefore not even considered an early stage AGA. The second dermatologist I saw (for a second opinion) did a scalp exam with a dermatoscope and said there was “maybe one” miniaturized follicle at the biopsy site on my crown. Throughout the rest of the top of my scalp she said about 1 in 100 follicles are miniaturized. She gave me a diagnosis of just telogen effluvium. So far all of my test results (iron, ferritin, vitamin D, vitamin B12, thyroid panel, and hormone panel) have been normal. I’m very confused and not sure if and what treatment would be best for me. Thank you!

ANSWER

Thank you for the question. In order for me to advise you on what treatment would be best for you, we need a diagnosis.

So what is your diagnosis then?

Well, in order for me to give you a diagnosis, I would need to know a bit more about your story from birth until today, and see your scalp up close myself and review your blood tests. Those are the three key steps in order to make a diagnosis for anyone!. Because I don’t have any of these pieces of information in your case, I can’t actually say what your diagnosis is.

However, there are still some very important points to be aware of and that’s why I’ve selected your question for this week’s question. It’s such a good one with so many things for us to review.

So let’s get to it.

You have what I call early hair loss. You yourself know there is a change, but your friends and family think everything is just fine. Even one of the dermatologists thinks it’s simply a telogen effluvium. This is early hair loss.

As you have correctly outlined, this can often be due to androgenetic alopecia or telogen effluvium …. or both.

As I review all your information about what your biopsy showed and what your doctors actually said, I need to know how reliable each of these three pieces of information are. If dermatologist 2 is a world expert in hair loss and doesn’t think its AGA - does this carry more “influence” as I think about your case than if dermatologist 1 thinks it’s AGA but really has only seen a handful of hair loss patients in his or her career?

Yes it most certainly does.

Your question is really all about the reliability of these three pieces of information - the 2 doctors and the 1 biopsy.

And what if the biopsy was taken from an area on the scalp that is really not so useful for making a diagnosis (like the temples) - am I to trust this result? Well, no.

So, let’s take a look at these four scenarios below in order for us to better understand when a biopsy is better than a clinician’s interpretation and when a clinician’s interpretation is to be trusted more than a biopsy report.

In general, the very early stages of hair loss can be challenging to decipher from one another. The more experience and expertise the clinician has in treating hair loss … the more reliable his or her view will be on the cause of hair loss. The less experience the clinician has, the less reliable his or her view is and the more a biopsy result is to be trusted. However, biopsies are not all the same. The only biopsy result that I really trust is one taken from the correct area of the scalp and interpreted properly by expert dermatopatholgist.

Let’s take a look at the following chart and then we’ll break it down some more.

SCENARIO 1. The practitioner evaluating the scalp is a VERY EXPERIENCED hair loss expert and a 4 mm punch biopsy was taken from a correct area of the scalp and interpretations were done by a VERY EXPERIENCED dermatopathologist.

In this case, both the dermatologist’s opinion and the dermatopathologist’s opinion are fairly reliable. In fact, in most cases, they are fairly equivalent. A highly experienced clinician can examine all areas of the scalp and can determine just how much variation in the caliber of hair follicles (ie “miniaturization”) is seen in the various regions including the front, middle, top and back. If the clinician appreciates that density is slightly different in one area compared to another it’s like their is some androgenetic alopecia going on - especially if the thinner area show a greater degree of miniaturization.

A clinician can also evaluate density in the frontal area and compare this to the back. If there is a subtle increase in “part width” in the frontal and mid scalp compared to the back, this gives a suggestion there could be some androgenetic alopecia going on.

So an astute clinician can look at the scalp, look at the part width, look a the density in various regions of the scalp and look at what the trichsocopy shows and come up with a conclusion.

Clinical examinations of the early stages of hair loss are tricky to interpret. It takes expertise to appreciate subtle changes in hair follicle caliber. It’s not something that is learned overnight. It’s not a result that pops up on any sort of screen when one places a dermatoscope one the scalp. Of course, it one’s dermatoscope its connected to a computer and the caliber of follicles can actually be measured in various areas, this really increases the reliability of the interpretation for less experienced practitioners.

But if a practitioner is less experienced with hair and scalp issues, simply placing a dermatoscope on the scalp and concluding “I don’t see any miniaturization” does not give me a great amount of confidence in diagnosing early hair loss issues.

What about a biopsy? Biopsies in early hair loss can be wonderful! A biopsy taken from the area of androgenetic alopecia can also show a DECREASING terminal to vellus ratio from a normal low 7:1 or 8:1 down to 4:1 or less. In true telogen effluvium, the terminal to vellus ratio stays well above 6 or 7 to 1. An experienced dermatopathologist who interprets a biopsy from a patient with early hair loss and says ‘the T:V ratio is 3.5:1 and sebaceous glands appear enlarged and there is no real shift in catagen to telogen ratios and there is no peribular inflammation” is telling me this is likely androgenetic alopecia. I trust that report if I know the dermatopathologist is experienced.

To summarize, a very experienced practitioner can often make a diagnosis of androgenetic alopecia fairly reliably even without a scalp biopsy. However, if a scalp biopsy is done, the results should be similar trusted as the findings of a very experienced practitioner provided the biopsy is interpreted by an expert pathologist.

SCENARIO 2. The practitioner evaluating the scalp is an INEXPERIENCED practitioner and a 4 mm punch biopsy was taken from a correct area of the scalp and interpretations were done by a VERY EXPERIENCED dermatopathologist.

In this case, the biopsy report is MORE reliable than the view of the clinician. We need to remember here that early hair loss stages are really difficult to diagnose! There is no harm in saying that and I’ll be the first to point that out.

It can take anywhere from 6 months to 5 years from the time some types of hair loss first start before a patient themselves figure out that something is changing on their scalp. So, the early stages of hair loss are tricky to spot. The early stages of hair loss can sometimes look normal. The less experience the practitioner has …. the more the scalp will look normal to them ! That’s just a fact. Any practitioner who takes a quick 5-10 second glance at the scalp and says to their patient ‘your scalp looks fine to me… don't worry” is by definition an inexperienced practitioner. This is pretty much a rule. The early stages of hair loss are hard to spot sometimes and take a bit of poking and prodding in the scalp to see what all the 100,000 hairs are doing and a bit of sleuthing to gather information from the patient as to exactly what’s been happening over the past months.

If a very experienced clinician says ‘This scalp is normal” then it’s pretty unlikely there is any androgenetic alopecia. Not 100% guarantee of course….. but pretty unlikely. If an inexperienced clinician says ‘This scalp is normal” then it carries less meaning. Of course, it could be normal, but I’m a bit more skeptical. I am sent referrals every day of the year that say “ Normal scalp exam. Patient thinks they have hair loss. Please see in consultation.”

What do many of these patients end up having as a diagnosis ? Well, many have androgenetic alopecia !

Suppose I’m meeting up with a friend for dinner and I tell my friend that I have been getting some pretty bad headaches lately. If my friend tells me everything sounds fine, do I believe it? Well, if my friend is a neurologist I’m a bit more likely to trust this information than if my friend is an accountant. The quality of the information makes a difference.

So to summarize, if a clinician is less experienced with diagnosing hair loss but takes a biopsy from a correct area of the scalp (ie where the hair loss is most affected) and the biopsy lands in the hands of an expert dermatopatholgist …. then I would usually trust the dermatopathoglist report over the clinician’s interpretation of what’s causing the early hair loss.

So what’s a good biopsy in your case? Well, in your case this likely means that biopsy was taken from somewhere in the yellow area shown below. I would prefer if the biopsy was 4 mm in size. I would also like if the biopsy was processed with horizontal sections as personally that increases my confidence in these early stages of hair loss. It’s only with horizontal sections that the pathologist can give a measurement of the terminal to vellus ratio. This can’t be done with vertical sections. If your T:V ratio is less than 4:1, we might begin to think there is some androgenetic alopecia present as a diagnosis.

SCENARIO 3. The practitioner evaluating the scalp is an EXPERIENCED hair loss expert and a suboptimal biopsy was taken from an incorrect area of the scalp and/or interpretations were done by an INEXPERIENCED pathologist.

This would be an unusual situation whereby an experienced clinician took a biopsy from a wrong spot. But this situation could be an experienced clinician is trying to decide what diagnosis a patient has and the patient brings in a biopsy report they had at another clinic showing a certain result.

In this case, I trust the result from the clinician any day over the biopsy report. Every day, I see biopsy reports that are taken form the back of the scalp or the sides of the scalp or the temples. These are not the ideal areas to be taking biopsies from if we want determine whether or not the patient has androgenetic alopecia!!!

Sometimes, the doctor does not want to cause a scar…. and so takes it from the sides of the scalp so as to hide any scar. Sometimes, a patient asks the doctor to take it from the temples because that’s where they are most worried and where they see the changes every day of their life when they look in the mirror. These are not where we should be taking biopsies to confidently assess androgenetic alopecia !

If a biopsy returns showing “no evidence of androgenetic alopecia” but was taken from the sides fo the scalp does it mean the patient does not have androgenetic alopecia? No! Not at all,. That biopsy was not helping in making the proper diagnosis.

If a biopsy returns showing “no evidence of androgenetic alopecia” but was taken from the main area of hair loss in the central scalp zone, does it mean the patient does not have androgenetic alopecia? Probably that is the correct interpretation.

SCENARIO 4. The practitioner evaluating the scalp is an INEXPERIENCED practitioner and a suboptimal biopsy was taken from an incorrect area of the scalp and interpretations were done by an INEXPERIENCED pathologist.

A particularly challenging situation is when a less experienced practitioner is not sure what the diagnosis is but proceed to take the biopsy from an area of the scalp which is less than ideal. Typically this is a well meaning practitioner who wishes to take the biopsy from an area that will best be hidden in the future should the area form a small scar. So the biopsy is taken from the sides of back of thee scalp and typically returns showing no evidence of androgenetic alopecia. The only thing that can be interpreted in this situation is that the patient does not have androgenetic alopecia down the sides of their scalp. However, we can’t conclude anything at all about what might be happening in the middle of the scalp - the area where the patient is most concerned about the hair!

I often use the following analogy when I explain the concept to doctors that I teach.

Suppose you have a mold of some kind in your home. The house smells like mold! Terrible, right?

And so you call a mold specialist for help. Unfortunately, all the mold specialists in town are away at a convention so you decide to call a plumber. After all, mold grows in water and damp conditions, and you figure that a plumber knows a lot about water and damp conditions in homes.

The plumber answers the call and says he or she knows how to take mold samples because they learned how to do so in a course they took.

Voila!

You are happy with the answer and invite the plumber to your home to get some help.

The plumber finds a bit of water in the basement and takes some mold samples. It all comes back negative.

You are all relieved there is no mold!

The problem is that the smell continues.

When the mold specialist in town returns from the convention, you invite him or her now into your home. Within a few minutes the source of the mold is located in the attic of the house. Their is a leak in the roof and this is causing the roof to leak and the attic to grow mold !!!! Samples are taken and the mold is finally proven.

Did it matter where the samples were taken? You bet it did!

An experienced specialist is more likely to know where to take the sample .

Conclusion

Your question is really a great one. Thanks again for submitting. It’s difficult, if not impossible for patients to know if their biopsy was taken from the correct spot or whether their clinician really has a lot of experience or not. It’s tough to navigate the medical world sometimes.

The short answer to your question , however, is that a very experienced clinician can often diagnose hair loss with a similar degree of accuracy to a biopsy interpreted by an expert dermatopathlogist. If the skills of the clinician change or the skills of the dermatopathologist now change, this no longer holds true and you’ll need to see the chart about as to which is better.

It is quite likely with your story that at least one of your diagnoses was telogen effluvium that was triggered by the stress of December 2020. With your story, I think it’s really important that someone make sure that your seborrheic dermatitis is under good control and someone keep an eye on the possibility that a diffuse alopecia areata is not part of the reason for your shedding. I think that would be unlikely given that shedding has settled now and that the biopsy did not capture this.

With this one biopsy that you do have I can’t exclude that there is not some degree of androgenetic alopecia present. There certainly is a possibility with this information you’ve given. oOf course, I would need to see the scalp or a photo of your scalp myself to know for sure one way or another.

Please keep taking photos of your scalp to show your doctors. If you feel that your hair returns to full by September 2021 and you are really pleased with the way your hair looks and feels at that time, then it’s pretty unlikely there is any AGA. However, if your hair does not return to full by September, I would encourage you to further explore ways to confirm this diagnosis with certainty one way or another so that you might get connected with the correct treatment in the event you do have androgenic alopecia.

Thank you again for your question.

Do I just need patience or is my hair density not going to fully return?

Is my hair density going to return?

I’ve selected this question below for this week’s question of the week. It allows us to the review some key concepts in the diagnosis of hair loss in the early stages.

QUESTION

I am a 40 year old female. I have always had a lot of hair, and coarse hair. I have always been a shedder, but it never made a difference on how dense my hair was. Until now. I had my "normal to me" hair up until August/September 2020. But, in September/October, I started to see a lot more hair coming out in the shower/brushing afterwards/when blowdrying.

Handfuls would come out in the shower when in the shower. It was definitely the worst/at it's peak in November 2020.

I remember after one shower the entire wall was covered with the hair I collected. By this time I started to freak out a bit. It was definitely making a difference on my head now as far as density. I went to my family doc, and he did blood work. My ferritin came back at 21, but my hemoglobin was ok. I started taking iron supplements at the end of November. At the end of Jan 2021 I went to see a dermatologist. She only had a physical look at my scalp, did not do a biopsy and did not look at my scalp with any sort of magnifying tool or anything. She said based on my story she thought it was either Androgenetic Alopecia or Telogen Effluvium. She had my vitamin D tested. It was a bit low, so I started taking 2000IU of vitamin D daily. The hair shedding continued like this until end of February-ish/beginning of March. (The lost hair was mostly long hairs, some medium length, barely any short hairs)

In March/April 2021 the hair fall slowed down a lot, and now I would say it is back to a normal amount with each wash.

But, I can definitely see a difference on my head. It is most noticeable on the top/sides of my head, and down the back of my head (I have weird parts all along the back of my head). It also sort of looks like I lost hair at the nape of my neck. My part has not gotten wider at all, but sparser. I do have a lot of new growth at the top and back of my head, but it doesn't seem like enough to make a difference in terms of overall thickness, even when it grows longer.

My scalp hurts often, as if it has been in a super tight ponytail, even though it has not. Sort of hurts to move it around. My scalp can be quite dry/itchy at time (always has been like this, even before hair loss)

I am still taking iron supplements, as when I was re-tested in February my ferritin had only gone up to 30. I am also still taking the vitamin D daily. I should mention I take 2.5 or Ramipril daily.

My question is … would Androgenetic Alopecia happen that quickly and then taper off that quickly? And, if it is Telogen Effluvium would I expect to have more re-growth by now? Or, is there any chance I could have some sort of diffuse Alopecia Areata, based on what is happening at the nape of my neck and the weird parts down the back of my head? I have attached some photos. I am trying to be patient, as I know hair takes a long time to grow.

Thank you for your input!!

Image 1. Hair density in the central part.

Image 2: Hair density in the crown.

Image 3: Hair regrowth.

Image 4: Hair regrowth.

ANSWER

Thanks for the great question. The short answer is that many diagnoses are possible for you. I’ll get into these in just a moment.

I would need to see your scalp and know more about your full story to tell you which diagnosis (or diagnoses) you actually have…. but the 6 possibilities are outlined below. Each of these possibilities has different probabilities for being your actual diagnosis. If I was to see your scalp, these ‘estimated’ probabilities would change. However, with the information provided, we have six scenarios. The most likely is scenario 1 and 2 followed by scenario 3.

Six Possible Scenarios for Your Hair Loss

There are six possible scenarios for your hair loss. The most likely is scenario 1 and 2 followed by scenario 3.

Scenario 1) You have a telogen effluvium due to low iron or low vitamin D. This has now been fixed and you need to give it until October/November in order for your density is going to come back.

Scenario 2) You have a telogen effluvium for some other reason (other than simply low iron and vitamin D) and it has now somewhat resolved and you need to give it until Oct/November in order for your density is going to come back. Causes of telogen effluvium that could be relevant for you would include stress last summer 2020, low iron (which you might have), thyroid problems, medications started last summer, weight loss last summer, COVID infection last summer. Other causes are possible too.

Scenario 3) You have actually had a hint of subtle “subclinical” androgenetic alopecia for a while and this recent telogen effluvium has “unmasked” the subtle androgenetic alopecia. Your density is going to improve by the Fall 2021 now that your telogen effluvium is resolving but you might or might not get back all your density - but you may come pretty close.

Scenario 4) You have an inflammatory scalp condition that has been present for a while and is now acting up to give periods of hair shedding. The iron and vitamin D are unrelated in this particular scenario and are simply a true red herrings. Your inflammatory scalp condition has now settled again but you need to give it until November/December to see if things will fully settle. Such inflammatory condition could include seborrheic dermatitis, psoriasis, scarring alopecia or contact allergy (ie to some ingredient in a shampoo, conditioner, hairstyling product or dye). This scenario number 4 carries a risk of flare again.

Scenario 5) You have an inflammatory scalp condition that has been present for a while but it’s not enough to give hair loss. A new telogen effluvium has come along that will resolve and time will tell whether the inflammatory scalp condition also settles fully. If the inflammatory scalp condition is a low grade scarring alopecia, density won’t come back fully but still will improve to some degree when the current telogen effluvium resolves.

Scenario 6) You have an inflammatory scalp condition that has been present for a while but it’s not enough to give hair loss. You also have a subtle amount of androgenetic alopecia that has now been unmasked by the new telogen effluvium. If the inflammatory scalp condition or androgenetic alopecia is active enough it may prevent density from coming back to your full normal by Fall 2021. 

Detailed Review of the INITIAL Situation (August 2020 to Dec 2020)

Let’s go further into the situation that you describe in your question. Before we do, let me point out that there are three stages of hair loss for most people. At least that’s a helpful way that I view hair loss. These stages are important to appreciate because it impacts how I approach your question.

In “stage 1” of hair loss, the patient has hair loss but doesn’t really know it. For all practical purposes, the patient feels the hair looks the same as it always did and feels the same as it always did. Perhaps when they look at a photo from years gone by they might say something like “Wow, I can’t believe how much hair I had back then!” Otherwise stage 1 of hair loss is unrecognizable by anyone - patient, doctor, specialist or hairstylist.

In “stage 2” of hair loss, patients themselves realize they have hair loss - but others around them don’t believe it or don’t realize it. The patient feels the pony tail is smaller or the scalp is more see through or something is just not the same. A spouse, sister, parent, daughter, son, barber, hairstylist or friend usually say the same thing - “You’re exaggerating ! Everything looks fine to me! Sometimes that sentence is delivered by the doctor or other hair expert that has been asked to help.

Stage 2 is sometimes frustrating and lonely and anxiety provoking. Patients feel something is wrong but the world around them says repeatedly that everything is just fine.

Now, some patients in stage 2 resolve their hair loss and go back into stage 1 and so they do end up feeling they were exaggerating because everything resolves itself. Some patients stay in stage 2 and eventually find an answer to their hair loss issues. If specialist A does not believe them, they move on to specialist B. If specialist B does not believe them, they move on to specialist C.

Some patients in stage 2 do progress on to stage 3 of hair loss where hair loss becomes more noticeable to others. With hairstyling and camouflage a patient in stage 3 might still be able to hide their hair loss. With treatment of course, a patient may be able to return to stage 2 or even stage 1.

With these stages in mind, let’s delve a little further into this situation you have mentioned in your question.

There are two main scenarios that may have been present before you noticed hair loss in August. The first is that your hair density was completely normal and the same as it was when you were 20. You then lost hair in the August - December period and the density went down. In other words, you went from no hair loss to stage 2. This is shown below.

The second scenario is that you felt that your hair density was completely normal but it was not, in fact, completely the same as it was 20 years ago. You then lost hair in the August - December period and the density went down. In other words, you went from stage 1 of hair loss into stage 2. This is shown below

Both of these situations above would appear identical to you. In the first situation, you had normal hair to start and then you lost density. In the second situation, you had (what you thought was) normal hair to start and then you lost hair. The only difference is that in the second sitatution you actually didn’t have quite normal hair - it just seemed that way to you (and everyone else).

Detailed Review of the RECOVERY (April 2021 to Dec 2021).

Your hair loss is now in a recovery phase. Your shedding has stopped. You are sprouting hair everywhere!

Let’s spend some time looking at the recovery of your hair loss and how the hair might respond over the next few months. The most likely are the following 2 scenarios.

If you don’t have any underlying issues that are affecting how hair grows, then it’s likely that this telogen effluvium will continue to settle and a you’ll get a return to full growth by the end of the year. In other words, you’ll go from stage 2, into stage 1 and back to full hair. The chapter on hair loss will be closed

Even if you do have some kind of “subclinical” hair loss situation happening in your scalp, there is still a good chance that you’ll recover your density by the end of the year and you’ll return feeling that your hair feels ‘full’ to you. In other words, you’ll move from stage 2 into stage 1. Stage 1 of hair loss looks just as good of having no hair loss at all so for all practical purposes it does not matter.

What happens if my density does not recover by the end of the year?

The final scenario is a bit trickier to explain. If you did in fact have some sort of subclinical hair loss situation going on in the scalp before August 2020 and this condition got a little bit worse from August 2020 through summer 2021, then you might not find that you have a full recovery by the time the Fall 2021 comes around. This could be due to several situations including

a) you had some subclinical androgenetic alopecia prior to August 2020 and the androgenetic alopecia got a bit worse from August 2020 to August 2021.

b) you had some subclinical scarring alopecia prior to August 2020 and the scarring alopecia got a bit worse from August 2020 to August 2021.

c) you had some subclinical psoriasis or contact dermatitis prior to August 2020 and the inflammatory issues got a bit worse from August 2020 to August 2021.

In these situations, it’s possible you stay in stage 2.

This final scenario is the least likely but a proper scalp examination and full review of your story is going to help me decide just how likely it is in your specific situation. For now, I estimate it as unlikely (but not zero).

What you can see here in these examples above is that you really need some definite diagnoses. If you allow time to help you with a solid diagnosis then that’s one good strategy. For example, if your density comes back perfectly to normal by the end of the year, then there’s probably no real hair issues at all that need treating or need any kind of workup. In other words, if your density returns back to full by December 2020 (and you enter stage 1 or no hair loss), it’s pretty unlikely there’s any other hair loss issue going on.

But if density does not return, I strongly believe that you need to have some formal diagnoses put on paper for BOTH the hair loss and the scalp symptoms. The reason we need different diagnoses is because every hair loss condition is treated differently. Unless we have a diagnosis, we can’t formulate the right treatment plan.

My Final Comments

Thanks again for the great question.

I’m really glad you are seeing all this hair growth sprouting everywhere as it’s a really good sign. The hairs are about 5-6 cm so it seems that the telogen effluvium you had in Aug/Sept 2020 is settling down. It could be that the iron and/or vitamin D is helping or that could just be a coincidence. It’s difficult to prove.

I do feel your scalp symptoms (dry, itchy, hurts to move) needs a formal diagnosis. Your scalp symptoms need a name of some kind. Now, keep in mind that the diagnosis of that situation might not be anything concerning given how long you have had it, but it still needs a formal diagnosis. If nobody is sure of what to call your itching and soreness, then you need a scalp biopsy. That is pretty clear in my mind. There is flaking present in some of your photos so there is some kind of inflammatory issue present. I would need to see the scalp up close to give a diagnosis. Please be sure to follow up on that.

I am glad you are taking photos as that will be key over the next 6 months. If you feel by November/December 2021 that you are really happy with your hair and how the density has returned, then this chapter of your hair story is likely done: you had a telogen effluvium and it resolved. It went away. In this situation, it’s unlikely there is some subclinical androgenetic alopecia present but it does not really matter much. I wouldn’t treat hair loss if you go back to feeling good about your hair. I’d simply repeat photos in 1 year. Put the shedding episode behind you for now.

If your density does not return to normal by the end of the year, then there is a good chance that there is some androgenetic alopecia that has entered the picture. No, it’s not 100% but that becomes increasingly likely. There’s very small chance that another diagnosis besides androgenetic alopecia is responsible but that’s pretty rare. Of course, the itching and tender issues on your scalp need to be diagnosed properly. That may or may not have any role here. But someone needs to give it a name.

But if you are pleased with your density in November/December 2021 and your shedding is completely back to normal (and stays normal), and your scalp symptoms are not worrisome to you and your doctors …I would put it all to rest and simply take a photos again in 1 year. It’s helpful to have your doctors follow you closely but nobody really knows their hair better than you. If you feel your hair has not returned back to normal, then you have remained in stage 2 and need a solid convincing diagnosis.

I hope this helps.

Many thanks for the question.

Do I have AGA? Everything thinks I am Crazy!

Why am I losing hair ?

I’ve selected this question below for this week’s question of the week. It allows us to discuss the diagnosis of hair loss in the early stages and the use of the 5 day modified hair wash test.

QUESTION

Dear Doctor Donovan,

I'm a 27 year old female. I've seen a lot of dermatologists over the years but none of them could solve my problem and I'm desperate!! It's been three years that I'm losing hair. It started during a stressful period in 2018 with a significant amount of shedding (300-400 hair a day).

The shedding stopped for 4 months and then the shedding started again until now. The only thing I noticed during these years is that hair loss is focused on the side of the head and temples and hair always grows back, even if I have less. The dermatologists have all said the diagnosis is telogen effluvium or chronic telogen effluvium (CTE) because in their opinion I still have a lot of hair and no miniaturized hair (but I can see them!)

In 2019 I decided to starting using minoxidil 2% because I was losing my mind and I was scared to go bald. My mother uses it for AGA. I suffer from hypothyroidism, I have regular periods but low levels of ferritin. I'm also losing hair in different lengths (short, long, thick, thin).

I am afraid I have AGA. Nobody believes me and they think I'm crazy!.

Thank you very much for listening.

ANSWER

Thanks for submitting this very interesting question.

I’d like to discuss several important things in the question you ask and the information you have submitted.

Before we do go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s story

2) the findings uncovered during the process of the scalp examination including trichoscopy

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis. I don’t have a full story and I only have a trichoscopy photos from one area and I don’t have the opportunity to review all tests …. so I am limited to some degree in my helpfulness. Nevertheless, I do think the discussion here will be helpful.

In the early stages of hair loss, nobody can tell you have hair loss. So, when people tell you they think your hair looks normal, they are being honest. You know you hair the best.

What are the Most Likely Diagnoses in this Case?

We are deciding here between three situations:

1) Do you have androgenetic alopecia (AGA) and telogen effluvium (TE) ?

or

2) do you have telogen effluvium (TE) only ?

or

3) Do you have both of these conditions?

I think there is little doubt in your story that telogen effluvium has been present at some time in the past. Whether it is still present NOW (today) is a bit more challenging to say as we will see in a while. I will explain in a moment how we can better distinguish between the two diagnoses.

It’s fairly unlikely that other diagnoses like alopecia areata incognito are present this long and similarly the photos don’t really lead me to believe we’ve dealing with other diagnoses. Of course, a full examination can confidently exclude that. But it’s unlikely.

What do I see in the photos?

The photos seem to show less density ‘now’ compared to 2018. This simply tells me you have some type of hair loss. It’s true that the part width is wider in these photos but without a sense of the part width in the back (to compare to part width in the front) it would be a mistake to conclude that this widened part width equates to AGA. The temples have some subtle changes but we see these minor changes in AGA and TE. The changes in the temples do not allow me to determine the diagnosis.

The trichoscopic images you have included here are great quality. However, I don ’t know where on the scalp they are from. It’s really important when fully interpreting trchoscopy to know where the images are from.

Trichoscopy IMAGE 1

The top image appears pretty normal. Is it from the back of the scalp from more posterior regions on the head? Hairs in the first image are grouped in groups of 3 and 4 hairs. There are really no single hairs. There is slight variation in caliber of hairs but this is just a few percent that show this. It is nowhere near the 10-20 % variation in caliber of hairs that’s needed to make a diagnosis of AGA. There are no upright regrowing hair seen. The scalp is pretty healthy other than than some minor redness.. There is a bit of scale but that’s what a scalp looks like.

Trichoscopy IMAGE 2

The second image is different than the first which makes it important to know where exactly where it’s taken from. Whenever we interpret trichosocpy we need to know where it’s taken from or else we can’t say all that much. What stands out to me in image 2 is that it’s slightly different than image 1. This could be important but again I would need to know where on the scalp it is from. There are more single hairs seen in image 2 and the density is subtly less compared with image 1. If image 2 was from the front of the scalp and image 1 was from the back I’d be of the opinion that there was at least some good evidence for androgenetic alopecia. But I don’t know where these were taken from so I can’t say very much. However, the fact that the two images look slightly different makes me wonder about pattered hair loss - the most common being andrgoenetic hair loss.

Key Questions I Would Want to Know and Why I Would Need this Information

There is lots more to your story that I need to know if order to help determine the diagnosis in a convincing way. We need to determine if there is evidence for androgenetic alopecia and we need to determine if there is evidence for a telogen effluvium. I would want to know the answers to the following questions::

PART 1: IS THERE EVIDENCE TO SUPPORT A DIAGNOSIS OF ANDROGENETIC ALOPECIA?

Q1. Where does it feel the thinnest?

It would be helpful to know from your perspective where the hair feels the thinnest. Does it simply feel thinner “all over” (diffusely) or does one area of the scalp feel more than another? Most patients with classic TE feel that the hair is thinner all over and can’t usually point to a single area that is thinner (EXCEPT maybe the temples). In AGA, the central scalp often feels a bit thinner although some women do have a diffuse pattern or loss.

Q2. Is the part width similar in the back of the scalp as it is in the front of the scalp?

Why do I need to know? Le't’s talk now about the physical examination of the scalp and the steps your doctors would take when examining the scalp. it’s critical to know if the part width in the frontal region is the same as in the back or whether it’s different. You’ve shown a very good photo of your central part in the FRONT which allows me to see that there is more hair loss than 2018. However, what I am not able to tell now is what the part in the BACK OF THE SCALP looks like. If it’s quite similar “width” to the frontal region, that’s not really very supportive of AGA and is more supportive of TE. However, it it’s clear that you have lost more hair in the frontal region that would be more consistent with androgenetic alopecia.

Q3. What was the exact timing of starting minoxidil ?

Why do I need to know? There is evidence of regrowth on the scalp. As I see in the photos, there is considerable growth of 12-15 cm hairs which means that these hairs in the middle of the scalp started growing well about 1 to 1.5 years year ago. It would be helpful to know if this is where minoxidil was applied and if it was late 2019 rather than early 2019 that minoxidil was started.

Q4. Is that 12-15 cm regrowth seen just in the middle of the scalp or is that seen everywhere equally.

Why do I need to know? When your doctors examine the scalp, it’s going to be really important to determine if this growth of these hairs is truly everywhere or just I the central scalp where I imagine you would be applying minoxidil. If the hair regrowth is just central and these 12-15 cm hairs are not found so easily in the back of the scalp, then it’s more suggestive of an early androgenetic alopecia that is present that is responding well to minoxidil.

Q5. Is the hair density today less than 1 year ago or about the same as one year ago?

One of the most important questions in this case is whether or not you are still losing hair density. Here I am not referring to shedding but rather density and how thick your hair feels overall. Is it less thick? …. or just as thick as it used to be. I understand that you are still shedding but that is a bit different from whether you are still losing density. If you are still losing density and you feel that you have less hair on your scalp today than 1 year ago, that would be slightly more suggestive of possible AGA than TE. If you are still having problems with shedding but don’t actually feel your density is getting less and less, then TE still remains a very likely diagnosis.

Q6. Do you have acne or excessive hair growth elsewhere?

As we evaluate hair loss, it important to get a sense if there are clinical signs of hyperandrogenism (high androgens). Having hyperandrogenism does not necessarily mean the patient has AGA but does increase the odds just that much more.

Acne and hirsutism are two of the more important signs to enquire about. If there is any clinical evidence of hyperandrogenism, it will be important to have blood tests for testosterone and DHEAS. Only 10 % of women with AGA have hyperandrogenism so the finding of normal hormone levels still makes AGA possible. In addition, many women with hyperandrogenism do not have AGA at all so this is just a fact that gets considered as part of the bigger picture.

PART 2: IS THERE EVIDENCE TO SUPPORT A DIAGNOSIS OF ONGOING TELOGEN EFFLUVIUM?
It’s clear that a telogen effluvium was present in the past for you. The key question now is whether there is some kind of ongoing TE. The causes of telogen effluvium include stress, low iron, thyroid problems, medications, diets, systemic illness. So we need to understand more about these potential issues or ‘triggers’ for anyone who is shedding. In CTE, shedding can occur without a clear trigger.

Q7. Did you start and stop other medications or supplements?

Why do I need to know? Other medications and supplements can trigger shedding. Even taking some medications and herbal medications can give an ongoing shedding. I’m assuming in this scenario that minoxidil is the only product used. Clearly, if other products are used they need to be considered.

Q8. Have you had eyebrow changes, eyelashes changes, body hair changes, nail changes?

Why do I need to know? Eyebrow and eyelash changes and body hair changes don’t occur as part of AGA but can occur in TE. They can also occur in other immune based conditions. I am not suspecting any immune based issues but certainly it would be quite unexpected if you were experiencing a lot of body hair loss. If there was any eyebrow or eyelash loss, the key is to figure out if it affects both the right and left side symmetrically or whether one side is affected more. Eyebrows and eyelashes can reduce in density from telogen effluvium, alopecia areata, trichotillomania, seborrheic dermatitis as well as cicatricial alopecia (and other conditions). It would not be surprising if you have some minor eyebrow changes over the last 3 years but it should be quite symmetrical. If you do have eyebrow changes, some of the eyebrow changes could be due to the hypothyroidism.

Similarly, if there was an increase in body hair this too would be unexpected here and a possible sign of increased androgens. Increased hair on the thighs, abdomen and nipples can be a sign of hyperandrogenism and raise suspicions for PCOS (even if periods are regular). I would think that it issei's quite unlikely you would report this to be the case. This would be information that your doctors should confirm.

Q9. Have you had weight loss or weight gain? What is the current weight?

In the setting of a likely telogen effluvium, it’s important to know whether there has been weight loss that could be triggering a telogen effluvium. In addition, we need to make sure that your current weight is high enough (i.e. BMI is above 18) otherwise the result can be an ongoing TE from poor nutritional status.

In addition, weight loss and weight gain can be reflective of underlying medical conditions. So, if weight has fluctuated either way, it could be important.

Q10. Do you have any scalp itching, burning or tenderness?

Scalp symptoms are important to know for every single patient. Your scalp looks quite healthy so I would be surprised to learn there is any itching or burning or tenderness. I’m usually not too worried about a slight among of itching from time to time, but if there was burning or tenderness in the scalp, that would be worrisome. I don’t think this is very likely to be relevant here for your case but we need to always keep in mind that there are conditions that mimic telogen effluvium.

Q11. Do you feel you are getting hair breakage?

I am not appreciating much in the way of hair breakage, but it’s important to inquire about. Some patients confuse hair breakage with actual new growth so what you are seeing on the top of the scalp appears to be new growth. It’s not uncommon for patients to exclaim - “look at all my hair breakage!” In your case, this is not breakage from what I can see. However, if you felt there truly was increased breakage that would need further exploration. Breakage can come from heat and chemicals and can give the feeling of ongoing shedding and loss. A proper examination can completely exclude breakage, but I would be surprised if that’s even an issue here. your scalp and hair are healthy.

Q12. How low your ferritin dropped over this period ?

I understand that you have a history of low ferritin. It will be important to know what your ferritin level is right NOW. That is what will be relevant to ongoing shedding. A ferritin of 10 is likely associated with hair loss. A ferritin of 40 is probably not. Therefore, it will be important to know what the ferritin level is now and how it’s been changing over the last few years.

is it possible you’ve had a ferritin of 22 and it’s been responsible for your shedding for three years? Perhaps. The higher your ferritin level - the less likely it is that your iron is the culprit in your hair loss. But you have not given me the number so I don’t know the current level.

Certainly, if you have a ferritin less than 15, it’s probably a problem and probably one of the reasons why your hair is shedding. Taking iron supplements in these situations has a high likelihood of helping. However if your ferritin is currently 40, 50 or 60, it’s less likely that you currently have an iron problem.

Most women need ferritin levels in the 30-40 range for healthy hair. However, some women definitely need those levels to be higher than that and into the 50 - 70 range. If you have a history of low ferritin, it will be important for your doctors to review why you have low ferritin and how the levels have been changing over time and what they are now. Many women have low ferritin levels. However, when low ferritin is combined with low hemoglobin (which we call iron deficiency anemia) I’m much more concerned. Excessive bleeding from menstrual cycles, poor diet, celiac disease, gastrointestinal issues all need to be explored.

The following table gives an estimate of how likely it is that taking iron supplements will help your hair according to the ferritin levels.

Q13. When did you start thyroid medications? Have your thyroid levels (TSH) changed during this time? What is the exact reason for the thyroid disease (Is it autoimmune Hashimoto’s?)

It would be helpful to understand when your thyroid disease was diagnosed and whether the TSH has been changing over this period. Some patients occasionally have fluctuation TSH levels which give shedding. Also, it would be important to know if you are on thyroid medications NOW and when this started and whether the dose has been changing over time. It is important to know the exact causes of the thyroid disease.

Q14. Were your periods always regular?

It’s always reassuring to know that your periods are regular at the present time. It would be important to know if they have always been regular of whether they have become regular just recently. It would be important to know exactly what each patient means by regular periods. Are some cycles considerably longer and some shorter than others? Having regular periods does not make it impossible to have an endocrine issue but does make it less likely. Having regular periods does not necessary mean these are ovulatory cycles but for most women they, of course, are. ovoluatory cycles.

Q15. Has your density ever come back to normal or has it just become less and less?

It would be important to know whether you feel your density and thickness ever came back to normal. When the shedding stopped for four months, did density return? Do you know the reasons why the shedding stopped for those 4 months? Was it that your iron levels finally came up? Was it that that your thyroid levels were brought back to normal? Was it that stress was reduced? Was that the period that minoxidil was started?

If your density did return completely to normal, this makes AGA much less likely during those times. It does not mean that it could not have happened or developed later but we would not expect your density to come back to 100 % normal in the setting of AGA.

Q16. Do you have other symptoms like joint pains, headaches, fatigue or rashes?

In situations like this, it’s helpful to know if the patient has any other symptoms that could suggest a systemic cause for a telogen effluvium. Issues like going pains, chronic headache, unusual fatigue or rashes on the body could prompt further work up and evaluation.

Q17. What other conditions run in the family?

it’s helpful to know what conditions run in your family. I understand your mom uses minoxidil so that tells me there is a family history of AGA. It’s helpful to know what the hair density is like in other males and females in your family. It’s also helpful to know what other diseases or medical conditions run in the family. These would include issues like psoriasis, lupus, inflammatory bowel diseases, arthritis, alopecia areata, diabetes, multiple sclerosis, early menopause, infertility and polycystic ovarian syndrome.

What Would I Recommend Next?

1. The answers to these questions above are going to be helpful and so is an evaluation of the frontal part width and back part width. That could be really informative in this case. If the part is wider in the frontal regions than the back, this suggests a possible diagnosis of AGA. If not, it still could be but TE becomes more likely.

2. Comparative trichoscopy of the middle of your scalp compared to the back of your scalp is going to be very very helpful in reaching the proper diagnosis. If the two are really different with more single hairs in the frontal and more variation in caliber noted in the frontal regions, then AGA becomes a likely diagnosis.

3. Current blood tests from ferritin and TSH and CBC are going to be important. I suspect you’ve had these tests done many times. If your ferritin is not high enough, it could be that you are shedding chronically in part from iron deficiency. The history will guide if other blood tests are helpful.

4. Finally, 5 day modified hair wash test (MHWT) is likely going to be the most helpful and least invasive next steps. Of course, a scalp biopsy can also be done but I think a modified hair wash test is probably going to be better in this case. The five day MHWT is fairly easy to do and you can do it yourself at home if you are so motivated to do so. The hair must not be washed for five days before doing the test. A 5 day modified hair wash test (MHWT) is a standardized means of assessing and quantifying hair shedding and provides information on the type of hairs being shed. It is a non-invasive method to measure hair loss by counting and identifying rinsed out (shampooed) hairs. To begin the test, a gauze is placed in the sink and hair is shampooed normally and the hair is rinsed in order to collect and trap all shed hairs on the gauze. The hair can be shampooed and rinsed repeatedly in order to remove all hairs that need to come out.

The following is helpful diagram illustrating the key steps in the 5 day hair collection.

After gently lifting the gauze from the sink, the gauze is then dried for 3 days and then counted. In our clinic, patients who do this test mail the hairs to us, but patients can also go about counting hair. It is important that the gauze not be disturbed while drying or mailing as this gauze has dozens of small fine barely detectable hairs that must be included in the analysis. The final number of hairs as well as the proportions of 3 cm or less hairs, provides information on the relative proportions of androgenetic alopecia as well as telogen effluvium.  The proportion of broken hairs and the proportion of abnormal hair gives us a sense of the possibility of an autoimmune issue such as diffuse alopecia areata. 

The number of hairs collected in the MHWT can give a good sense of excessive shedding. Ideally, results need to be interpreted by a dermatologist who is familiar with the performance and interpretation of this test but as mentioned patients can count hairs.

a) Patients with 10% or more of hairs 3 cm or shorter and who shed fewer than 100 hairs are diagnosed as having androgenetic alopecia (AGA).

b) Patients with fewer than 10% of hairs that were 3 cm or shorter and who shed at least 100 hairs are diagnosed as having chronic telogen effluvium (CTE).

c) Patients with 10% or more of hairs that were 3 cm or shorter and who shed at least 100 hairs are diagnosed as having AGA + CTE

d) Finally patients with fewer than 10% of hairs that were 3 cm or shorter and who shed fewer than 100 hairs are diagnosed as having CTE ‘in remission.’

Final Summary

Thanks again for sending in your question. I hope this was helpful. A few more details in this history together with a good scalp examination is going to go a long long way here in getting to the correct diagnosis (or diagnoses in the event there are two).

IFor you, I think that a 5 day modified hair wash test is going to really help give the evidence that you need to move forward with the right diagnosis. If there is any doubt, then a biopsy could further clarify but I doubt it will be needed.

The use of minoxidil could complicate things a bit in this case but only slightly. If one were to stop minoxidil and find that significantly worse shedding happens 4-6 weeks later I do think this would also be proof of some component of AGA being present.

Post COVID 19 Hair Shedding (Sars-CoV-2 Telogen Effluvium)

How common is hair loss after COVID 19 infection? 

I’ve selected this question below for this week’s question of the week. It allows us to discuss the issue of hair loss after COVID 19 infection.

QUESTION

Hi Dr. Donovan !

I have recently recovered from COVID 19 and was pretty sick. I have read about hair loss in people who had COVID 19 and I am terrified that I might experience hair loss. I would like to know my chances of getting hair loss.

Can you please offer some guidance as to the likelihood of all this happening?  How likely am I to get hair loss?

Thank you very much.

ANSWER

Thank you for your question. I hope you are feeling well. Let’s look at this in a bit more detail. 

There are a variety of symptoms and signs that can persist or develop long after the SARS-COV-2 virus has left the body. When symptoms or complications are present more than 4 weeks after the onset of symptoms of COVID 19 this is revered to as “Post-acute COVID 19 syndrome.” Many people who have such long lasting symptoms after COVID 19 refer to themselves as “long haulers.” Other names such as “long COVID” and post-acute COVID syndrome (PACS) have been applied to this situation as well.

It is common to have symptoms in the weeks and months after being diagnosed with COVID 19. Carfi and colleagues showed in their publication in JAMA that most people still have one or more symptoms at day 60 of recovery. specifically, the authors of this study showed that 87.4 % of patients had at least one symptom and fatigue and shortness of breath were the top symptoms. 

Patients with post-acute COVID 19 syndrome can experience a wide array of persisting symptoms. These include fatigue, chest pain, shortness of breath, heart rhythm problems, brain fog, headaches, poor sleep, loss of smell, anxiety, depression, joint pains. Quality of life is reduced in many people even after the infection has cleared the body. Patients with post-acute COVID 19 syndrome may have lung issues, kidney issues, hematologic issues, blood clotting issues, cardiovascular issues, endocrine, psychiatric and neurological issues and therefore may be referred to a variety of different medical specialists. 

Hair Loss in COVID Survivors

Hair loss is one of the most common dermatologic issues that develops in patients who recover from COVID 19. It has been estimated that about 1 in 5 patients (20 %) of hospitalized who survive COVID 19 will have hair loss. We don’t know exactly what the numbers are patients with milder forms but it could be slightly less. Hair loss typically happens 8-12 weeks after infection and can even happen in those without any symptoms of COVID 19 at all. Let’s take a look at some of the important studies. 

The Huang Study, 2021

Huang and colleagues studied patients with confirmed COVID-19 who had been discharged from a hospital in China between Jan 7, 2020, and May 29, 2020. In total, 1733 patients completed questionnaires about their health status after leaving the hospital. Hair loss was reported in approximately 22 % of patients. Interestingly, the incidence of hair loss did not seem to differ in patients with greater degrees of illness compared to patients with less degrees of illness. For example, 22- 24 % of patients who required oxygen or mechanical ventilation during their hospital stay had hair loss compared to 22 % of patients that did not require oxygen.

The Garrigues Study, 2020

Garrigues and colleagues from Paris France examined health status of patients with COVID 19 after being discharged from hospital. They included 120 patients in their study, of which 96 were admitted to a hospital ward and 24 were more ill and needed to be admitted to the intensive care unit. Hair loss was reported in 20 % of patients overall. Further analysis showed that hair loss occurred in 25 % of ICU patients and 18.8 % of hospital ward patients. In this small study, these differences did not meet statistical significance indicating that hair loss is not seem to matter much according to how ill the patient was. 

The Akama-Garren Study, 2021

Akama-Garren and colleagues used the electronic health records from Mayo Clinic to examine whether certain terms were more common in patients before they were diagnosed with COVID 19 or more common after they were diagnosed with COVID 19. The authors showed that the term “hair loss” was much more commonly found in charts in patients after diagnosis with COVID 19 than before COVID 19 (OR 2.44, 95% CI 2.15-2.76, p=8.45x10-3). Other terms that also appeared more frequently were those related to kidney disease and coagulopathies. Hair loss seemed to be much more of a concern unique to females in this study rather than males. In addition, concerned about hair loss spiked dramatically at around day 100 after a diagnosis of COVID 19 which is what we would expect in a telogen effluvium.

The Miyazato Study, 2020

Miyazato and colleagues from Japan interviewed patients following discharge from hospital. 58 patients were asked about hair loss. Fourteen (24.1%) of 58 patients reported hair loss. . Of the 14 patients, 5 were women and 9 were men. Hair loss developed approximately 58.6 days ( 8 weeks) on average after symptoms of COVID 19 firsts began. Of the 14 patients, there were only 5 patients who had been studied long enough to get a good sense of how long hair loss lasted. Nevertheless, of these 5 patients, hair loss lasted on average 76.4 days ( 10 weeks). 

The Morenes-Arrones Study, 2020

I’ve talked about the Morenes-Arrones study before. This was a study of 214 patients with proven SarsCOV2 infection. 13. 6% were asymptomatic, 77% needed medical treatment and 21 % needed hospitalization. Hair shedding occurred after an average of 57.1 days ( 8 weeks) similar to the results from the Miyazato study reviewed above. 

Conclusion and Summary 

Thanks again for the great question. If you were hospitalized for your COVID 19 infection, we can say that there is approximately a 20 % chance you’ll get hair loss. we don’t know with great confidence that chances of hair loss in patients with more mild symptoms of COVID19 but there is a chance that the chances of hair loss are under 20 %. The only good data we have so far is in patients who were released hospitalized. 

Overall, the data together indicate that there is a much better chance that you won’t get hair loss than you will get hair loss. But if you do get hair loss, it will occur most likely around week 8 to week 12 after your COVID symptoms first started. Shedding will last about 10 weeks before the stopping. Complete hair regrowth would be expected in a large proportion of patients. 

I hope you recover well and feel back to yourself soon if you are not already.

REFERENCE

Akama-Garren et al. Hair loss in females and thromboembolism in males are significantly enriched in post-acute sequelae of COVID (PASC) relative to recent medical history. medrxiv.https://doi.org/10.1101/2021.01.03.20248997

Carfì, A., Bernabei, R., Landi, F. & Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA 324, 603–605 (2020).
Huang, C. et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet 397, 220–232 (2021).

Garrigues, E. et al. Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19. J. Infect. 81, e4–e6 (2020).

Miyazato et al. Prolonged and Late-Onset Symptoms of Coronavirus Disease 2019. Open Forum Infect Dis 2020 Oct 21;7(11):ofaa507.

Moreno-Arronnes OM et al. SARS-CoV-2-induced telogen effluvium: a multicentric study. J Eur Acad Dermatol Venereol. 2021 Mar;35(3):e181-e183. doi: 10.1111/jdv.17045. Epub 2020 Dec 9.

 Nalbandian et al. Post-acute COVID-19 syndrome. Nature medicine 2021; 27: 601-614.

What is the reason for my hair loss?

Why am I shedding ?

I’ve selected this question below for this week’s question of the week. It allows us to discuss shedding issues in women with hair loss.

QUESTION

Hi!

I am a 42 year old women and have been shedding about 200 hairs a day since March, 2020. I have seen 4 dermatologists and my General Practitioner and they have different diagnoses from TE to FPHL or a combination of both. Prior to March, 2020 I was under extreme stress which started in November 2019. In March 2020 my hair loss was sudden and I have had diffuse shedding since then for the past 10 months. I have always had full, thick and healthy hair and no issues with my hair until the past 10 months. There is no family history of hair loss and my bloodwork came out normal.

Increased hair shedding.

I have been taking vitamins, biotin and Lysine (since June 2020) daily. I am washing my hair every other day, air dry my hair and do not use styling or heating products and eat healthy. I am also taking spirolactone since December 2020 (one month as of today). My dermatologist suggested I take spirolactone (50 mg twice a day) because I have irregular periods. My hair loss slowed down in September 2020 to about 100 hairs a day and went back up to 200 plus in November 2020. I am experiencing itchiness, pins and needles sensation on my scalp and my hair texture changed from straight to wavy for the past 10 months. My hair is also now flat, dull and I have some dandruff that comes and goes. My middle part is widening (compared to pre-March 2020 before the shedding) and with the ongoing shed the part has somewhat looked the same since March.

I lost about 30% of my hair and cannot style it the way I used to because of the thinning in the front. The last two dermatologists I saw performed a pull test and scalp examination and one of them said it is CTE and that there is nothing I can do but wait it out. The other doctor said it's FPHL and that she can tell just by looking at the front of my hair because of the way its thinning. I do see hair growth and my hair is full of static with short hairs coming out but I am also losing a lot of hair in all different lengths including short ones every day. I am frustrated because it has been 10 months and my shedding is not stopping. I do not know which diagnosis is right and what treatment I should start. Also It would be great for the itching and "pins and needle" feeling on my scalp to go away...

Thank you for reading and I'm so happy to find this website.

ANSWER

Thanks for the question.

I’d like to discuss several important things in the question you ask and the information you have submitted.

Before we do go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s story

2) the findings uncovered during the process of the scalp examination including trichoscopy

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

There is lots more to your story that I need. I would want to know exactly what your lab tests showed and which ones were tested. In about 20 % of patients who tell me they had blood tests and all came out normal, the labs are either insufficient (more are needed based on their story and examination) or the labs are not in fact really normal. I always like to see the labs. I would want to know about other symptoms like joint pains, headaches, fatigue, weight loss, eyebrow changes, eyelashes changes, body hair changes, nail changes, and rashes.

I strongly suspect that androgenetic alopecia with seborrheic dermatitis are part of the diagnoses. The 2 key questions here in your case are:

1. Do you have really have telogen effluvium as well ?

2. What really is the reason for the ‘pins and needles’ sensation ?

Let’s look at a few key points.

POINT 1. Androgenetic alopecia (female pattern hair loss) appears to be at least one of the diagnoses.

I do think that at least one of the diagnoses here is androgenetic alopecia (also called female pattern hair loss, FPHL). The widening of the part does not itself mean the diagnosis is AGA. however, the pattern of the part widening is not the same front to back. There is a slight increase in thinning noted in the mid scalp and crown compared to the frontal one third of the scalp. This leads me to believe there is a patterned nature of the hair loss. I’m open to the possibility that some of the hair loss is diffuse in nature (ie all over) but some is likely not. In other words, I don’t think this is entirely a diffuse type of hair loss.

Also, when I look up close at the images, it’s clear that some follicles are thinner than others. This is a phenomenon called anisotrichosis and is a feature of AGA. Some hair follicles are miniaturization (getting thinner).

Women with AGA often experience shedding of hair in the early stages and shedding can fluctuate in intensity. Other hair loss conditions can cause shedding as well so we’ll address that in just a moment. Women with AGA often notice that the texture of hair changes. There are many such patterns of texture change and a change from straighter to curlier is quite common as you too have described.

The fact that you note increasing numbers of short hairs is not confirmatory for a diagnosis of AGA but certainly is supportive of this diagnosis.

POINT 2: Seborrheic dermatitis/dandruff is likely another diagnosis.

I agree with you that dandruff (or its close cousin called seborrheic dermatitis) is likely present. Flakes are noted in some of the photos. I’d need to perform trichoscopy to confirm this diagnosis but it appears to be a component of the issues present. Mild dandruff is not usually a cause of hair loss but it certainly can cause all sorts of scalp symptoms. To eliminate the possibility that dandruff or seborrheic dermatitis is contributing to symptoms, I often encourage my own patients to aggressively treat their seborrheic dermatitis so we can remove this as a factor. Shampoos with zinc pyrithione, ketoconazole, selenium sulphide or ciclopirox can be used 2 times per week and left on 90 to 120 seconds before being rinsed off. The duration that these shampoos are left on the scalp can certainly be increased but I don’t recommend that to start with as many antidandruff shampoos can be drying and then the dryness starts causing itching and symptoms. I often recommend to my own patients that 5-10 drops of betamethasone valerate lotion 0.1 % can be applied in the scalp after their hair is shampooed and dried. This is a weak steroid and can be safely used for 2 week periods to help settle itching. If the use of shampoos settles the itching, tingling and pins and needles, then it’s not needed.

POINT 3: Telogen effluvium could be present.

Telogen effluvium is one of those conditions that can come and go. Sometimes it’s easy to prove a TE is present and sometimes it’s a bit more challenging. It could be that a TE was present when your AGA first started. You were under extreme stress in November 2019 and yes this could most definitively give shedding in March 2020. Telogen effluvium usually follows 2-3 month after some kind of trigger and can last 3-6 months or more. Other causes of telogen effluvium are low ferritin levels, thyroid issues, medications, diets, weight loss and internal illness. I don’t really have enough information to evaluate these other issues so I’ll go with your assessment that your blood tests were normal. Hopefully you had a reasonable set of tests including TSH, ferritin, CBC. With your irregular periods you describe it would make sense to have FSH, DHEAS, testosterone. One needs to consider whether you are entering a perimenopausal transition and how this could contribute to hair shedding and AGA. With any pins and needles sensation, it’s nice to know that liver enzymes (AST, ALT) are normal and that kidney function is normal (creatinine).

Telogen effluvium can sometimes precipitate or accelerate an underlying AGA. This is a well accepted phenomenon. it does not happen to all women with AGA. However, women with shedding who have AGA that is about to begin (ie very early onset AGA) often find that the AGA component of the hair loss gets sent into a more rapid speed of development if a TE is present. This could be a feature here.

With your normal blood tests, it’s unlikely that a TE is still driving hair loss all this time. Not impossible of course, but unlikely. What is more likely is that AGA is not fully being treated. Spironolactone helps but does not fully suppress AGA in all women at 50 mg twice daily. Sometimes higher doses are needed OR other treatments for AGA are needed (other anti androgens, laser, minoxidil, etc)

POINT 4: If you want to assess the degree to which AGA and TE are present, you could have a biopsy or 5 day modified hair wash test (or a proper trichoscopic examination). I don’t think these are really needed.

For your physicians/specialists who think that AGA is not a diagnosis here for you, a biopsy or 5 day modified hair wash test could help prove them wrong (… or prove them right!). This is a wonderful test but adds to the stress of collecting hairs so I’m not always in favour of it. Biopsies leave scars but if interpretted by a knowledgable dermatapathologist, they can be very helpful.

But, let’s be clear. A biopsy showing a terminal to vellus hair ratio of less than 4:1 taken from your mid scalp area puts to rest any argument about whether AGA its present of not. End of discussion. A 5 day modified hair wash test (done properly !) showing less than 100 hairs and more than 10% hairs being tiny 3 cm hairs also points to an underlying AGA.

Of course, simply examining the scalp with trichoscopy can also confirm this diagnosis but not all specialists are skilled with trichoscopy. If a specialist knows how to use a handheld dermatoscope, we don’t even need biopsies or hair collections to diagnose AGA. If they don’t then yes, we need to go to the extra effort to prove it.

POINT 5: The ‘pins and needles’ is a bit trickier given how many conditions can cause this.

There are a very large number of conditions that can cause pins and needles in the scalp. Stress can cause it. AGA can cause it. TE can cause it. Alopecia areata can cause it. Dandruff can cause it. Scarring alopecias cn cause it. The list is long and includes issues even outside the scalp like cervical spine disease.

I would need to know more about your story and carefully examine the scalp and eyebrows and eyelashes and nails to get a sense of what is causing this.

For pins and needles sensations, I usually advise treating any dandruff or seborrheic dermatitis and using a few drop of betamethasone lotion as outlined above. If it’s still there and the patient has AGA, I usually recommend treating the AGA more aggressively. This often help stop pins and needles. Low level laser, minoxidil and other antiandrogens can be considered.

Conclusion/Summary

Thanks for the question. I hope this helps you in your search for answers and helps with further discussion with your doctors. I think it’s really important for you and your doctors to feel confident with the diagnosis and not proceed with any sort of “maybe.” It would appear that AGA is a component of the issues here but if there is any doubt, a trichoscopic examination, biopsy or 5 day modified hair wash test can help confirm this.

Photos are really important moving forward to document changes - hopefully for the better.

if spironolactone is not fully helping then you and your dermatologists might discuss together whether or not to increase the dose or whether other treatments need to be considered. These include topical minoxidil, oral minoxidil other topical or oral antiandrogens and low level laser. PRP can be considered too. The important thing to note about minoxidil, laser and PRP is that if there is any amount of chronic shedding issue present these treatments can help promote more normal shedding patterns. This is assuming all your blood tests are normal. If any of your blood tests are abnormal and if, in fact, you have not had a proper work up then those issues need to be addressed first. it sounds like you’ve had a good set of blood tests through all the doctors you have seen.

Thank you.

Losing short hairs: is it normal or should I be concerned?

Should I be concerned if I find I am losing short hair?

I’ve selected this question below for this week’s question of the week. It allows us to the review some key concepts in evaluating shed hairs - particularly the relevance of short hairs.

Question

I noticed that I a few of the hairs that I find in my brush are short hairs - less than 3 cm. Is this evidence that I am progressing to androgenetic alopecia?

Answer

Thanks for the question.

It all depends on the proportion of short hairs you find.

If you find a low proportion of small hairs, that’s completely normal. Everyone sheds a few short hairs.

If you collect all your shed hair over a week and find that more than 10 % are tiny hairs less than 3 cm, that might suggest there is some androgenetic hair loss happening. You’d certainly want to review things with your dermatologist carefully if that were the case and have him or her performing a careful scalp examination including trichoscsopy.

But finding one hair has very little meaning otherwise.

Telogen Effluvium or Androgenetic Alopecia ... Or Both?

Biopsy Suggested AGA and a bit of TE: Which one is causing my hair loss?

I’ve selected this question below for this week’s question of the week. It allows us to the review some key concepts related to the diagnosis of hair loss

QUESTION

My biopsy came back showing that I have androgenetic alopecia with bit of telogen effluvium. My terminal to vellus ratio was 1.8: 1 and there were 16 % telogen hairs. I’m wondering if I have both diagnoses, which one is causing my hair loss.

ANSWER

Thanks for the question.

It’s likely that they both are. However, most of your hair loss is from the AGA. I would need to see your scalp to give you a precise breakdown but it’s likely the AGA is the main cause given that the T:V is well under 4:1.

But both of these contribute!

Suppose you ran a 20 mile run and also carried groceries up 40 flights of stairs because the elevator was broken. Why are your legs sore? Well mostly from the 20 mile run but some of your leg soreness is due to the climb up the stairs. If you didn’t have to do the stairs you might be 6 % less sore but you’d still be sore.

If someone has a little bit of telogen effluvium and mostly androgenetic hair loss they’ll get a bit of hair back if they address their telogen effluvium but really they need to address the androgenetic component.

Hope this helps.

Daily shedding: Are my numbers normal or abnormal?

Are my shedding rates normal?

I’ve selected this question below for this week’s question of the week. It allows us to discuss normal hair shedding patterns.

QUESTION

I am a 37 year old female. I have been keeping track of my shed hairs as closely as possible for 70 days.  My 30 day moving average is a steady 40 hairs per day and my 5 day moving average ranges from 38 to 42 or so.  However, my daily shed is unstable and can range from 20 to 60 with periodic days of 70.  The 60 and especially the 70 hairs a day concern me. Is it normal for your daily shed to fluctuate this much even though your averages are stable?

Hair shedding can fluctuate over the month normally in humans. A few simple questions can help screen if shedding is likely to be abnormal or normal.

ANSWER

Thanks for the question. I can’t say whether your hair changes are normal or abnormal because I haven’t examined your scalp and I don’t really know what your shedding is like today compared to 2 years ago and 10 years ago. However, I can offer a few helpful points.

First, periodic fluctuations in shedding can be quite normal. There are changes in shedding with seasons, with stress, with the amount of seborrheic dermatitis, and across the menstrual cycle.

Second, the frequency with which one shampoos the hair also makes a difference. If one shampoos the hair once per week then I’m okay with shedding numbers in the few hundreds. If one shampoos the hair every day, the daily numbers should be well below 100 that’s for sure.

There are three very helpful questions that help me figure out if the shedding in women is likely to be abnormal:

QUESTION 1

Does the amount of hair coming out in the brush, in the shower and through the day seem similar to what remembers it being like 5 years ago?

Yes or No

QUESTION 2

Does the amount of hair the patient has on the scalp (ie the overall hair coverage) seem the same as 5 years ago?

Yes or No

QUESTION 3

Does the size of the pony tail seem to be the same ?

Yes or No

If one answers yes to all three of these questions, there is a fairly high chance that shedding is quite normal. The screen is not 100 % perfect of course but pretty good. A review of your full story with your dermatologist and a thorough scalp examination can help determine with certainty if the shedding is normal or abnormal.

In summary, fluctuations of this kind described in the question can be very normal for many people.

Thank you again for the question.

Seasonal Shedding: Is my pattern normal ?

Is it normal to shed more in the summer months?

I’ve selected this question below for this week’s question of the week. It allows us to discuss the topic of seasonal shedding. Here is the question….

QUESTION

I am a 35 year old female. For the last several years I have noticed the following shedding pattern.  In the late fall and winter, I lose around 40 hairs a day.  In the late spring the number begins to rise and I shed around 65 hairs during the summer months and into the early fall.  Shedding then drops back to around 40 hairs a day and the cycle repeats itself.  The result is, I am terrified and stressed every summer thinking “my hair is falling out”. 

My question is … is this normal or do I have a problem? 

My part is tight year round and my shedding is diffuse throughout my scalp.  If this is normal, then I can relax and enjoy my summers.

ANSWER

You certainly give a story that is highly suggestive of what is known as “seasonal shedding.” Whether or not there could be another explanation would require a review of the scalp during one of the shedding episodes but anything else would be extremely rare.

Seasonal shedding is a type of telogen effluvium (hair shedding disorder) and is much more common than we realize. Humans appear to shed less in the winter and more in the summer. Based on all the studies done to date, there actually appears to be two peaks of shedding - a main one in the late Summer/early Fall and a minor one in Spring. Your story certainly sounds like you fit this picture.

Do you need to worry ? The answer to that question is easy to figure out although I’d need you to do a bit more searching on your own. If your hair density on New Years day this past year was the same as the density on New Years day the year before, you don’t need to worry - this is likely only seasonal shedding that’s happening each spring-summer-fall. If you are experiencing seasonal shedding but find that your density is in fact getting a bit less as the years go by - then you should have a proper examination to rule out a second condition that might be present (like androgenetic alopecia). You mention your part remains tight - so it seems your story is more likely that of classic seasonal shedding.

It really is that straight forward. If you feel that your photos from every winter are identical year after year after year and your hair feels the same in winter months year after year after year …. then you can relax and enjoy your summers. That would indicate a classical seasonal shedding.

Seasonal shedding is more common than most people realize. For reasons that are not entirely clear, humans shed more hair from the scalp in late summer and early Fall.

Past Studies of Seasonal Shedding

There have been five good studies from 1991 to 2014 that all point to the same general message: humans shed more in the summer and early Fall. Some studies like those of Courtois and colleagues in 1996 and Kunz and colleagues in 2008 suggested that some humans also might shed a bit more in early Spring (a second peak). The main shed, however, is in summer/Fall.

If you’re interested in reading more about these 5 studies, I’d invite you to check out a previous article I wrote:

Seasonal Shedding of Hair: Five Studies to Know About

CONCLUSIONS:

Thanks again for the question. Good luck as you think back to your hair over the winter months in past years. This is where the answer lies for you.  

As for the” why” - why does shedding occur more in summer? Well, we don’t really know although it is proposed that climate factors and UV radiation related factors may somehow be involved.

It’s pretty common for people to worry about hair shedding in summer. A 2017 study in the British Journal of Dermatology  showed that people are punching the words “hair loss” into the Google search engine far more in the summer and Fall than they are in the sping and winter. Large numbers of people share the same concerns as you’ve raised.

References

Courtois et al.Periodicity in the growth and shedding of hair. Br J Dermatol, 1996 Jan;134(1):47-54.

Hsiang EY et al. Seasonality of hair loss: a time series analysis of Google Trends data 2004-2016. Br J Dermatol2018; 178(4):978-79   

Liu et al. A Microarray-Based Analysis Reveals that a Short Photoperiod Promotes Hair Growth in the Arbas Cashmere Goat, PLoS One. 2016 Jan 27;11(1):e0147124.  

Maurel D et al. Effects of photoperiod, melatonin implants and castration on molting and on plasma thyroxine, testosterone and prolactin levels in the European badger (Meles meles). Comp Biochem Phyiol A Comp Physiol. 1989;93(4):791-7.

Orentreich N. Scalp hair replacement in man. In: Advances in Biology of Skin. Vol IX: Hair Growth. (Montagna W, Dobson RI, eds). Oxford: Pergamon. 1969. 99-108.

Pearson AJ et al. Inhibitory effect of increased photoperiod on wool follicle growth. J Endocrinol 1996 Jan;148(1):157-66.

Piérard-Franchimont C, Peérard GE .L'effluvium télogène actinique: une facette de la chronobiologie humaine.

Int J Cosmet Sci. 1999 Feb;21(1):15-21.

Randall and Ebling. Seasonal changes in human hair growth. Br J Dermatol 1991.

Reinberg A et al. Circadian and circannual rhythms in plasma hormones and other variables in five healthy young males. Acta Endocrinology 1978; 88: 417-27

Smals AGH et al. Circannual cycle in plasma testosterone levesl in man. J Clin Endocrin Metab 1976; 42: 979-82.

Zhang et al. Comparative study on seasonal hair follicle cycling by analysis of the transcriptomes from cashmere and milk goats. Genomics 2019 Feb 16 

What options are left for my hair loss?

What should I do about my hair loss?

I’ve selected this question below for this week’s question of the week. It allows us to discuss the advanced management of non scarring alopecia.

Here is the question….

QUESTION

Dr. Donovan I have been following your blogs and articles for quite some time and decided to tell my hair loss story and hopefully get some answers. I am a 58 year old very healthy female with no nutritional issues and an avid runner for many years. At 48 my hair started thin but underneath and at the mid back scalp in a diffuse pattern. I was put on Yaz birth control and finasteride which helped tremendously for 3 yrs. At 51 my gynecologist took me off birth control at which time I started to see similar issues recur. I started topical minoxidil, traditional HRT but nothing worked. I saw a dermatologist and she diagnosed me with AGA and started me on Climen, HRT in addition to finasteride and topical minoxidil. Within a few months I saw another dermatologist who added spironolactone 100 mg. This combo seemed to bring back my hair growth and density within 6-9 months. After a year or so my creatinine levels were in the high range and my gynecologist advised me to stop the spiro. Within a year or so after stopping I noticed significant shedding, less density mid scalp to bottom of my hair and dry hair that looked like a broom. I had numerous PRP sessions, laser cap and started various combos of low dose oral minoxidil, topical and the Climen.

I have no visible scalp anywhere but a lot of different layers and short pieces of fine hair and no bottom to my hair.  Dry hair of varying lengths mostly underneath hair. The hair has changed from long straight to short and curly with no density. Cutting has not made any difference in the fullness. From the ear down the hair is thin fine and basically see through. I do not know why there is no improvement in my condition. I have no itching or burning.

I am currently on oral minoxidil 2.5 mg once daily, Avodart, topical minoxidil, spironolactone 100 mg daily in addition to HRT estrogen patches and micronized progesterone 15 days every 3 months. I am still shedding enough to create concern and my hair won’t grow longer. The top of my hair is much fuller than the bottom which is wispy and thin. I have included my biopsy and photos for your review.

BLOOD TESTS

All blood results are normal and ferritin has ranged from 40-50. The only red herring is a positive ANA of 1:80 for 5 years with no symptoms. I would appreciate your opinion.

BIOPSY

Biopsy showed a non-scarring pattern with follicular miniaturization, anisotrichosis, and increase telogen hairs.

ANSWER

Many thanks for your question. Of course, I’d need the full story from A to Z , more photos and to review all your blood tests to give a complete opinion. It’s clear you have androgenetic alopecia (AGA) and a telogen effluvium (TE). In your case, I think it’s worth still looking for a trigger of your TE rather than explaining it simply by a chronic TE with no underlying cause. I think there are two important points to consider here:

1) Maximizing/Optimizing Anti-androgen Therapy

First - your hair loss has been quite responsive to anti-androgens in the past. Yaz and finasteride have helped you and Climen and spironolactone have helped you. I do think that it will be important to review with your dermatologists if there is more that can be done to maximize treatment in this big category of antiandrogens.. You are on spironolactone and dutasteride. Increasing spironolactone is not going to be a good option given your kidney (creatinine) concerns. However, brining on board other antiandrogens just might.

You and your doctors may want to carefully review if the drug bicalutamide might be considered. Bicalutamide can be used with dutasteride and spironolactone and it might even be introduced 2 or 3 times weekly if you are still going to continued on dutasteride and spironolactone. Bicalutamide is an antiandrogen (androgen receptor blocker) which is used for the treatment of male prostate cancer. It has been used off label in women for the treatment of hair loss, as well as other androgen related issues such as hirsutism (hair growth on the face). It tends to be just as well tolerated for most of my patients as dutasteride so side effects overall are low. Side effects include elevated liver enzymes, peripheral edema and gastrointestinal side effects (diarrhea, constipation, nausea). Other side effects like itching can rarely occur. General antiandrogen side effects like decreased libido, breast tenderness, breast enlargement, mood changes (depression) can occur although seem to be quite uncommon. These are the same side effects that dutasteride, finasteride and spironolactone can cause. Mood changes with bicalutamide are not common. Bicalutamide has not been associated with a decrease in bone mass (osteoporosis). An increase in liver enzymes (3 % to 11 % of patients) is quite rare although monitoring of liver enzymes for the first 2 months is recommended.

 For my patients who are on anti androgens like duasteride and spironolactone already, I generally start ¼ pill (12.5 mg) for 2-3 months and then increase to ½ pill (25 mg) after that. Sometimes I start every other day. Liver enzymes are evaluated after the 4-6 weeks and then again at week 12.

2) Evaluating the Telogen Effluvium

The increased proportion of telogen hairs in your biopsy is very interesting in my opinion. I would need to know a lot more about your story and review all your blood tests, but it would seem based on the information you have provided that this needs to be explored further to make sure that we’re not missing a potential cause of shedding. There are an enormous number of triggers of shedding.

They key to evaluating shedding is to perform a search for possible triggers and if anything comes up suggestive that it could be a trigger - then this needs to be pursued fully.

Your ANA result may or may not have any relevance. It’s low and many people in the population (5-7%) have a low level ANA like this without any consequence. However, given that you are still shedding I think that you and your doctors might consider pursuing further evaluation in this area. Because your ANA is positive, further work up might be discussed with your physicians if it has not been already. The exact tests to order depends on your history (your medical story), but might include ENA, ESR, C3, C4 and CK. If there is any suggestion of rheumatological disease, referral to a rheumatologist would be advised. With chronic shedding, I always encourage patents to make sure their age appropriate screening examinations have been done. You and your primary care doctors can review if colonoscopies, and mamograms are up to date.

The full causes of telogen effluvium including stress, low iron, thyroid problems, medications, diets, weight loss and internal diseases. I understand based on your comments above that your iron and thyroid labs are normal. I’m assuming your vitamin D levels were normal. The remainder of your TE triggers need careful evaluation. If there are any other mediations you have started, those need to be reviewed. Furthermore, if there are any other symptoms those need careful evaluation as well. The symptoms I ask about are shown in the table below. One really needs to go head to toe when dealing with chronic shedding issues. If anything comes up - it gets explored fully. The issues that I’m most interested to ask about in a patient with positive ANA and increased telogen proportion on biopsy are whether the patient has dry mouth, dry eyes, joint pains, fatigue, weight loss, and muscle weakness.

Conclusion/Summary

Thanks again for submitting your question. I hope this was helpful in some way. I think overall you need to figure out if any more detective work needs to be done as far as your shedding goes, or has it all been done. Sometimes the detective work has all been done and we’re left with AGA and shedding. In these cases, treating the AGA fully as mentioned above is going to be important. Use of a multivitamin is going to be important. In tough cases, I may add biotin 2000 -5000 micrograms daily and a good antidandruff shampooing regimen. Of course, if there are any deficiencies that were identified they need to be fixed.

If something does turn up positive on the investigations I mentioned above, it needs to be explored fully and completely. If the clinical picture does suggest an autoimmune issue, then low doses of hydroxychloroquine are used.

If anything changes in the scalp in terms of new symptoms, massively increased shedding, a repeat biopsy should also be considered.

Stress and Hair Loss: Is it real? What is the mechanism?

Stress causes hair loss through many complex mechanisms including neurogenic inflammation

I’ve selected this question below for this week’s question of the week. It allows us to discuss the relationship between stress and hair loss.

Here is the question….

QUESTION

I understand that stress can cause telogen effluvium. If that’s true what is the mechanism?

ANSWER

Thanks for the great question. The short answer is that researchers are continuing to put together all the pieces of the puzzle to explain how exactly stress causes hair loss. But yes, stress can cause hair loss.

Below, I’ll review with you some of the key medical and research evidence that helps prove that stress can cause hair loss. You and our readers will come to see that stress ultimately triggers the adrenal gland to produce cortisol which in turn triggers the release of substance P in the spinal column which in turn triggers mast cell degradation in the skin and around hairs. This is the essence of “neurogenic inflammation” and it causes hairs to fall out. When I teach medical student and dermatology trainees about the relationship between stress and hair loss and tell them simply that when they feel stressed and ready to burst - their mast cells are ready to burst as well. It helps them remember this important link.

Let’s delve deeper into this great question

A. CORTISOL

To understand the relationship between stress and hair loss, one needs to understand the hormone cortisol. In 1936, Dr Reichstein identified the structure of cortisol. It was in that exact same year (1936), the concept of stress was first introduced by Dr Hans Selye.  Dr Seyle is largely regarded as the ‘father’ of stress research. His experiments on rats in 1936 showed that a stressor often alters many parts of the rat including the adrenal cortex, the immune system, and the gut. Specifically, his studies showed that rats exposed to various nocuous chemical or physical stimuli developed enlarged adrenal glands (a phenomenon called hypertrophy). These rats also had a reduction in the size of their lymph nodes and developed gastric erosions.

In 1950, Reichstein along with two others (Hench and Kendall) were awarded the Nobel Prize in Physiology and Medicine for these discoveries relating to the hormones of the adrenal cortex, their structure and biological effects.

B. THE HPA AXIS

By the mid 1950’s physicians and researchers had developed a very basic understanding of stress. Remarkably the model proposed in the 1950s has stood that test of time right up to the present day. We call this the Hypothalamus- Pituitary – Adrenal axis (HPA axis)

In the presence of stress, a part of the brain known as the hypothalamus triggers to release a hormone called CORTICOTROPIN RELEASING HORMONE or CRH. CRH in turn tells the pituitary gland to synthesize and release a chemical known as Adrenocorticotropin hormone (ACTH). ACTH then enters the blood stream and stimulates the adrenal glands to make cortisol.

B. THE HPA AXIS and Beyond: A New Model of the Skin Endocrine System

For many years after the HPA axis was proposed, the hypothalamus was truly thought to be the ‘ boss’. After all, it made hormones that told other parts of the body what to do. It not only made CRH, but may other hormones too. Soon it was discovered that the skin was able to produce many of its own hormones too including CRH, ACTH and others.

The skin is an endocrine organ unto itself and can produce many different hormones.

From there a whole new model of understanding stress flourished where it was proposed that stress causes an upreegulation of a chemical known as substance P (SP) and calcitonin gene-related peptide (CGRP) in the dorsal root ganglia of the spinal column along with epinephrine and norephineoprhine. This in turn leads to change in the hormone production in the skin and the degranulation of cells in the skin known as mast cells.

It’s this degaulation of mast cells that sets off in the skin a whole new type of inflammation called “neurogenic inflammation.”

C. Is this modern model of stress and the skin really relevant?

It appears that this model linking stress to hair loss is accurate. Studies have shown that when mice and rats are stressed in the lab, there is in increase in cortisol levels and hairs leave the growing phase. This is all associated with an increase in substance P in nerves and degranulation of mast cells. What’s quite remarkable is that effects of stress on the skin and hair of mice and rats can be blocked by administering antibodies to substance P to block the effects of substance P. It appears substance P in nerves is really important to how stress affects the skin and hair.

The modern model relating stress and hair loss is therefore :

D. Stress and Humans: What research suggests stress causes or contributes to hair loss in humans

A number of studies in human have linked stress to hair loss.

Study 1: Bin Saif et al 2018

A 2018 study by bin Saif evaluated 529 medical students to evaluate how dermatologic conditions differ among students who are the least stressed, moderately stressed and highly stressed. Compared to the least stressed students, highly stressed medical students reported:

a) More hair loss

b) More flakes on the scalp 

c) More itchy skin

d) More trichotillomania

d) More warts

Study 2: Rebora et al 2017

Rebora published a nice study in 2017 showing thee development of shedding in a patient every time the patient was stressed. When stress went down, the shedding went down. When stress increased again, shedding increased again.

E. Stress in other hair loss conditions

Your question relates to telogen effluvium so I’ll limit the discussion to TE. However, it should be noted that stress probably has a role in several hair conditions including alopecia Areata, lichen planopilaris, and others. It may not be the direct cause of course, but neurogenic inflammation appears to contribute to immune system dysregulation.

Summary and Conclusion

Thank you again for the great question. I hope you can see that the question is mighty complex but we’re developing remarkable new understand as the years go by. It appears that neurogenic inflammation is a key mechanism by which stress causes hair loss. Furthermore, it appears that mast cells are important in this whole process.

References

Arck PC et al. Indications for a 'brain-hair follicle axis (BHA)': inhibition of keratinocyte proliferation and up-regulation of keratinocyte apoptosis in telogen hair follicles by stress and substance P. FASEB J. 2001 Nov;15(13):2536-8. Epub2001 Sep 17.

Bin Saif GA et al. Association of psychological stress with skin symptoms among medical students.LSaudi Med J. 2018 Jan;39(1):59-66. doi: 10.15537/smj.2018.1.21231.

Liu et al. Chronic Restraint Stress Inhibits Hair Growth via Substance P Mediated by Reactive Oxygen Species in Mice PLoS One. 2013 Apr 26;8(4):e61574. doi: 10.1371/journal.pone.0061574. Print 2013.

Rebora A. Intermittent Chronic Telogen Effluvium.Skin Appendage Disord. 2017 Mar;3(1):36-38. doi: 10.1159/000455882. Epub2017 Jan 28.

What is causing my beard, body and scalp hair loss?

What’s causing my beard hair loss?

I’ve selected this question below for this week’s question of the week. It allows us to discuss the importance of the speed of hair loss in the diagnosis of hair loss.

Here is the question….

QUESTION

I have diffuse thinning across my entire body. I am male, under 30. The hair loss initially started as rapid thinning on the entire scalp, soon spread across facial hair and body hair. Some distinguishable features of my hair loss are that my beard and body hair only have one hair per follicle, a lot of hairs remain as very short stubble and do not grow, eyebrows experience pain during periods of shedding. I've been to 4 dermatologists and had one scalp biopsy which was inconclusive. Hair loss has been very rapid, from initial onset I lost well over 50% of my hair density within 4 months. My beard presented with patches of hair loss which have grown in.

Beard photos, before (left) and right (after) hair loss

Scalp does not itch and I do not feel any burning. However I feel tenderness and itching in my eyebrows which are constantly shedding. I've been on finasteride ( discontinued ), oral minoxidil for 9 weeks, and steroid injections in the eyebrows which have helped with regrowth. Hair loss started 3 months after I experienced a very traumatic event and has continued well over 1 year now.. After the traumatic event I broke out with very severe cystic acne across my back, scalp neck and face and hair loss soon followed. The way I look today is completely indistinguishable from what I looked like 1 year ago.

What is the likely cause ?

ANSWER

Thanks for submitting your question. There are several possible hair loss conditions that could be causing this, but the most likely cause, by far, is alopecia areata. But it’s certainly not 100%.

To help definitively figure out what’s going on, I would need to (1) ideally see photos of the scalp and eyebrows, (2) know the answers to a lot more questions I have, (3) review your biopsy and (4) review all your blood tests. I’d like to know if you’ve had patches of alopecia areata in the past, whether you have a family history of alopecia areata, how thin the eyebrows were, whether their was redness in the eyebrows too, whether the eyelashes were lost, whether you’ve had changes in your nails, weight loss, or abnormalities in your blood tests. I’d want to know if you’ve started or stopped any prescription medications and supplements in the last 12-16 months, started or stopped any anabolic steroids, and whether you’ve had any skin rashes of any sort in the last 2 years. Fevers, night sweats are important to know about as well. Of course, your entire medical history will be important.

The full list of possibilities for the hair loss includes:

1. Alopecia areata alone

2. Alopecia areata with a telogen effluvium

3. Alopecia areata with seborrheic dermatitis

4. Alopecia area with a telogen effluvium with seborrheic dermatitis

5. Alopecia Areata with a telogen effluvium with seborrheic dermatitis with male balding of the scalp.

6. Telogen effluvium with seborrheic dermatitis

7. Frontal fibrosing alopecia/lichen planopilaris

8. Rare mimickers - syphilis, cutaneous T cell lymphoma

There are many features of the story here which fit well with alopecia areata. First, the speed of hair loss is fast. The loss of 50 % density in 4 months is seen in alopecia areata and sometimes telogen effluvium but this kind of rapid hair loss is more typical of alopecia areata. it’s far too fast for androgenetic alopecia but of course this may be a part of the hair loss that is happening as well (more chronically). It’s too fast for most scarring alopecias too (and I would not expect regrowth to occur in the manner you described if this were the case). It’s not impossible for FFA, but it is an uncommon story for FFA.

I’ve written about the importance of the speed of hair loss in the past. Alopecia areata is classically quite fast and has the potential to cause more rapid hair loss than telogen effluvium if the alopecia areata is active.

It’s possible of course, that a person has a telogen effluvium and alopecia areata too. A person can have two diagnoses or three or even four or five. The intense stress you had from the traumatic event can cause a telogen effluvium and if you are genetically predisposed, it could precipitate alopecia areata too.

The regrowth of your eyebrows with steroid injections is best in keeping with alopecia areata. I would need more information to know it it’s a little or a lot of regrowth. It would be helpful to know what the brows actually looked like before. If the regrowth has been really significant with the steroid injections, alopecia areata remains at the top of the list. That said, any inflammatory condition of the eyebrows can cause hair loss and steroid injections can help with regrowth. Seborrheic dermatitis of the eyebrow can cause a little bit of loss but it’s usually mild and steroid injections can settle down the redness and help get brows regrowing. Even frontal fibrosing alopecia can show some regrowth so the simple fact there was regrowth does not prove it is AA. Eyebrows can improve with steroid injections in quite a few conditions so this feature alone does not prove it’s alopecia areata.

The beard photos you’ve submitted are most in keeping with a diagnosis of alopecia areata. Are there mimicking conditions that can look 100% the same ? Yes, there certainly are. Rarely, a seborrheic dermatitis can cause beard loss but that’s quite unusual to be patchy in this manner. Rarely, an immune based issue can cause beard loss too (lichen planopilaris/frontal fibrosing alopecia) but regrowth is less likely in these types of situations. Frontal fibrosing alopecia really is one of the key conditions that you and your doctors need to rule out confidently. Beard hair loss or beard thinning happens in about 30-40 % of patients with FFA. Telogen effluvium affecting the beard in a patchy manner like shown in the photos is not typical so telogen effluvium would not explain the beard loss but could, of course, still be involved. Syphilis is not common cause of the hair loss pattern you are describing but this diagnosis needs to be considered by your doctors in a presentation like this. It is a great mimicker of alopecia areata. A rare condition of the blood cells (mycosis fungoides/cutaneous T cell lymphoma) needs to be considered if things don’t improve. I would not expect these latter two conditions to have spontaneous improvement you have described without treatment so they probably don’t fit well in your particular case. Alopecia areata is still at the top of the list of causes but your dermatologists can review these entities and perform a full skin examination.

The acne eruption you describe may or may not be related to the hair loss. I suspect it is related in some manner. Acne eruptions of this kind can be seen in alopecia areata. (See previous article alopecia areata and acne). In order to understand how hair could have a role in acne development, it is important to understand the function of hair. During the process of normal skin turnover, the shed skin cells from the hair follicle epithelium are carried upward in the follicular canal towards the skin surface. It is thought that the sebum that is secreted by the sebaceous glands helps in this process but helping the shed cells efficiency move out of the hair follicle canal.

Ringrose and colleagues first reported the relationship between acne and alopecia areata back in 1952. They described a male patient who developed acne, milia and cystic type eruptions only in the areas of alopecia. The authors proposed that the hair helps keep the follicular orfice open to allow sebaceous contents to be properly removed. They described the hair follicle as a “natural drain” to the removal of sebum.

These same authors performed some interesting histological studies by examining biopsies of these acne lesions. They found that acne lesions were not seen in areas that contained hair and were not seen in areas where the pilosebaceous unit was completely degenerated. The proposal here was the acne lesions of alopecia areata represented a transition period - between normal growth patterns and complete loss.

in 2007, Sergeant and colleagues proposed that the hair follicle acts as a type of ‘wick’ and acts to draw sebum up towards the skin surface. They stated that the hairs on the scalp may do this more efficiently that hairs on the face and therefore the hairs on the face may be predisposed to the formation of “micocomedones” and the typical lesions of acne. Microcomedones are a prerequisite for the ultimate acne lesion.

So in your case, there is a high likelihood a diagnosis of alopecia areata is present. It is certainly not 100 % but the likelihood is quite high. It will be really helpful to follow all hair bearing areas - as definitive signs of alopecia areata (or scarring alopecia or another condition) may show up over time. In my opinion, frontal fibrosing alopecia is the mimicker that really needs to be ruled out.

FINAL COMMENTS

At this point, the evidence would suggest alopecia areata but I would need more information to confirm or refute that. I would recommend that you speak to your doctors about these issues as they will know your case best. I would suggest you considering asking them about blood tests for CBC, TSH, ferritin, testosterone, B12, ESR, ANA, zinc, vitamin D, RPR, creatinine, AST, ALT, urinalysis if you have not already. if any of these are missing you might get them done. If the diagnosis is not clear, a repeat scalp biopsy can be considered. It may be that with trichoscopy a dermatologist can evaluate whether alopecia areata is present although I certainly do appreciate that your story is complex and you’ve probably had many evaluations (with trichoscopy too). Biopsies of the arm hair, leg hair and eyebrows are trickier and often given less information. If a repeat biopsy is needed, it should come from the scalp. The main thing we are trying to distuish in the biopsy is alopecia areata vs scarring alopecia (ie frontal fibrosing alopecia) .

If it is alopecia areata that you have, I suspect that over time, a patch of typical alopecia areata hair loss will occur that will allow your doctor to definitively tell you if that’s what it is. There are ways to explore the diagnostic possibilities further. Certainly, the blood tests above are important. You’ll want to make sure there are no systemic issues that increase the chances for cystic acne and hair loss. We’ve spoken about the possibility of having a repeat biopsy. This should be done on the scalp and be 4 mm and be done with horizontal sections and read by an expert dermatopathologist. Alopecia areata can be tricky to diagnose in some cases. However, an increased proportion of catagen and telogen hairs and eosinophils in the tracts and peribulbar inflammation can all point to the diagnosis. A biopsy will pick up immune based issues, lymphomas, and if the percent of telogen hairs is high the biopsies will give an idea of how high it really is.

Sometimes in a situation like this, we consider a "therapeutic challenge.” A therapeutic challenge means we give certain medications to observe what happens when those medications are given. If the response to the medications is exactly what we predicted, it suggests we are probably correct with our diagnosis. I would need to know more about your story to describe exactly what might be appropriate but you and your doctor could consider therapeutic challenges like steroid injections to the entire scalp, or a 4-6 week course of oral steroids is an approach therapeutic challenge if alopecia areata is considered. If you get significant regrowth during these types of therapies, it’s a pretty good indication that there is an inflammatory issue that was blocking the growth of hair. Alopecia areata would be the most likely diagnosis in such as case.

If alopecia areata is the final diagnosis, then continued beard injections together with other systemic options would be possible including dexamethasone, methotrexate, cyclosporine, tofacitinib. A return to oral minoxidil could be reconsidered depending on exactly what your story was when you stopped it

Thanks again for submitting your case. I hope this was helpful.

What's the reason for my hair loss? What does my trichoscopy show?

Why am I experiencing hair loss?

I’ve selected this question below for this week’s question of the week. It allows us to discuss some of the finer aspects of interpreting trichoscopy and how the clinical history must be interpreted together with all trichoscopic analyses.

Here is the question….

QUESTION

I really hope you can help me with the diagnosis of my hair loss that I've been experiencing for a year now without being able to get a real diagnosis, doctors can't seem to find anything else than '' light dermatitis'', yet I can' t help but notice everyday that this isn't normal and I have no clue so far. 
About a year ago I suddenly noticed that I had way less hair and I could see my scalp, which never happened before. A few weeks later I've started to notice redness in my scalp and itching that never left ever since. The itching seems to come and go without any logical pattern, and the more red and itching my scalp gets, the more hair I seem to lose. I did a trichoscopy 2 weeks ago, where you can see the results.

I'm quite desperate to get a real diagnosis because I don't think something innocuous would last that long and cause hair loss without stopping. Overall I am in good health. Blood tests were all okay 

ANSWER

This is a great question because it allows us to talk about so many things.

Before we go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s Story

2) the findings uncovered during the process of the scalp examination and

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

I’d like to know a lot more about this story ideally but of course the magic of the “question of the week” is that I tackle questions with limited information.

I can’t be sure of what’s going on entirely without seeing your scalp up close myself and knowing your entire story. Your age, and details about your scalp symptoms all matter.

In my opinion there are 4 possibilities for what you have:

1. Androgenetic alopecia with seborrheic dermatitis (AGA + SD)

2. Androgenetic alopecia with mild telogen effluvium with seborrheic dermatitis (AGA + TE+ SD)

3. Mild telogen effluvium with seborrheic dermatitis (TE + SD)

4. Seborrheic dermatitis alone (SD alone)

I’d like to make a few comments about the type of thinking that is needed in case like this.

A few comments

1. It’s true that you have very nice trichoscopy pictures - but what’s also important is just getting a sense if the frontal density is truly the same as the back. There certainly is a suggestion that your frontal density may be less than the back (occipital area) despite all the numbers that you see in your measurements. If there truly is a significant difference in the density in the frontal and back then we need to think about a patterned hair loss (ie androgenetic alopecia).

2. A physician can get a better sense of density by parting the hair down the middle from front to back and comparing the part width in the front to the back. If the part width is wider in the front than the back that means there may be more hair loss in the front compared to the back - and this might be a suggestion that there is some degree of androgenetic alopecia.

3. It does seem that your blood tests have been normal so we’ll assume that. This does not mean that a person can not have telogen effluvium or androgenetic alopecia with normal blood tests. In fact, most people with hair loss have normal blood tests. I have not seen your blood tests of course, but I would hope that you have had CBC, TSH, ferritin, 25 hydroxyvitamin D. If your periods are irregular you should have a hormonal panel. If you have other symptoms, you might need other testing too.

4. There appears to be clear differences with the photos in the frontal areas compared to the occipital (back) areas including more single hairs and less density. While this could be simply suggesting diffuse loss as in a telogen effluvium, we need to consider the possibility that this could represent a pattern to the loss (and female pattern alopecia also called androgenetic alopecia).

5. Your average hair caliber seems to be lower than expected at 60 um. This depends on your background and your type of hair but it certainly does make me wonder if there is some change happening that affect caliber especially a diffuse process like a diffuse AGA. Of course, androgenetic alopecia is one of the more common hair loss conditions that affect caliber. Your data from the trichoscopy is not definite so I can’t completely rule in or rule out this particular diagnosis.

6. If you do not have much in the way of increased shedding, I would favour a diagnosis of AGA. If there is a lot of shedding that you have, it still could be AGA but a mild effluvium (TE) certainly does not need to be considered. Your story of suddenly “noticing” that you have less hair is more typical of AGA than TE. The degree that you are shedding today and the degree that you have been shedding in the past 6-9 months would sway me someone as far as how likely a diagnosis of TE really is.

7. I do favour options 1 and 2 but it’s by no means definite based on the information you have given. It will be helpful to follow the trichsocopy measurements over time. If you have a TE like in option 3, the measurements and numbers will likely get better over time. If it’s an AGA (option 1 and 2), the numbers will not likely improve and may get slightly worse in 6-12 months. Photos will also be very helpful. If it does become clear that the density in the frontal areas is slightly less than the back of the scalp, one needs to consider androgenetic alopecia.

8. If you are concerned a scalp biopsy or a 5 day modified hair wash test might help. Sometimes in the very early stages a a biopsy only slightly helpful so I am not of the opinion that you must have a biopsy. However, if the terminal to vellus ratio of your biopsy is shown to be less than 4:1 it indicates androgenetic alopecia is likely to be present. If the terminal to vellus ratio is above 4:1 is suggests that TE alone (option 3 or 4) is more likely. A biopsy can also capture any rare mimickers of redness such as lichen planopilaris, although I do not suspect that is what is going on (the density and changes are far too similar in the 3 areas to really support early LPP - and the story I have so far and the trichoscopy does not really support that diagnosis). A modified hair wash test can give a sense of how many hairs are being shed and whether any of these are small. What’s interesting in your photos is that it does appear that there are more vellus hairs in the photos from the frontal area than the measurements state in the information you were given. I am personally a big believer not only in looking at the measurements these computers give but also in looking at the images myself and looking at the scalp myself and getting sense if the measurements the computer gives makes sense or not. The presence of thinner and thinner hairs (miniaturized hairs) and the presence of thinner and shorter hairs (vellus hairs) is what androgenetic alopecia is all about.

9. I do think that there is likely a component of seborrheic dermatitis complicating the picture here. Your dermatologist can review with you at your next appointment. The trichoscopy would suggest this as well. SD is not typically a major cause of hair loss but can give a bit of shedding if severe enough. If you do have SD, it is mild and may contribute to symptoms like itching and tingling from time to time and then there will be periods where the scalp feels good again. The involvement of the temples is quite typical of SD and your photos are noticeably most red in the temples. There are no signs of scarring alopecia in the trichoscopy images provided but again a biopsy can help further clarify.

FINAL SUMMARY

Thanks for the great question. With the information provided, I can’t say one way or another exactly what is the diagnosis. However, a scalp biopsy or 5 day modified hair wash test could take you that much closer to understanding the diagnosis if there is really debate. I am suspicious about their being androgenetic alopecia here but I can’t tell for sure and ideally would want to see the scalp in a situation like this. Once you have the proper diagnosis, you can plan treatment. In addition, it is going to become much clearer over time what the diagnosis is especially if you do repeat trichoscopy measurements in 6 and 12 months. The frontal density and caliber of the hair in the frontal area will decrease and the number of single hairs is going to increase in the frontal if AGA is truly what is present. For now, treating the seborrheic dermatitis is quite reasonable. I would normally recommend that efforts be put into confirming the diagnosis with certainty. Some of the treatments for TE overlap with AGA treatments including laser and topical minoxidil and oral minoxidil so one can certainly get started with a plan once the diagnosis is made. Certain other treatments however, like anti androgens, are only effective in AGA and will not be effective if TE is the true diagnosis.

Thank you for your question.

What is normal shedding? A Closer Look at SEVEN Key Points.

Is my shedding normal?

I’ve selected this question below for this week’s question of the week. It allows us to discuss some of the finer aspects of shedding and why 7 main considerations matter when it comes to evaluating shedding:

Here is the question….

QUESTION

I have been keeping track of my shed hairs as closely as possible for 70 days.  My 30 day moving average is a steady 40 hairs per day and my 5 day moving average ranges from 38 to 42 or so.  However, my daily shed is unstable and can range from 20 to 60 with periodic days of 70.  The 60 and especially the 70 hairs a day concern me. Is it normal for your daily shed to fluctuate this much even though your averages are stable?
I am a 37 year old female.

ANSWER

Thanks for the question. There’s a lot to discuss with your question, so let’s get to it!

Before we go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s Story

2) the findings uncovered during the process of the scalp examination and

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

I’d like to know a lot more about this story ideally but of course the magic of the “question of the week” is that I tackle questions with limited information. We’ll review 7 key questions in a moment. Other questions may also be helpful. I’d like to know what blood tests were done in your case and what the results were. I’d like to know if your menstrual cycles are now regular. I’d like to know if the person asking the question has any medical issues or takes any medications. I’d like to know about stress levels? I’d like to know her family history of hair loss. I’d like to know if the patient has lost any brows or lashes. I’d like to know if her weight has been stable? I’d like to know if the density is the same as 6 months ago or actually worse? I’d like to know if the patient has any headaches, joint pains, skin rashes, dry eyes, dry mouth, thirst, abdominal pain, fatigue, changes in libido, or ulcers the mouth. All these things matter in fully answering these questions.

With that behind us, let's return to our question of the week again!

With the information given in the question submitted, one can not get to the diagnosis. That requires a more full review of your story from A to Z …. and it requires examination of the scalp or at least photos. But let’s explore how we get to the answer.

It’s possible that the shedding here is just a variation of normal. We need to keep that in mind. Many people with your story have normal shedding. If you feel your hair density at age 37 is the same as age 25 and if you feel that your shedding rates are pretty similar now to what they were like at age 25, then it’s likely this is a variation of normal ! If not, then more work is needed for you and your doctors to get to the answer as to whether your shedding is normal or not. Hair loss conditions such as androgenetic alopecia and telogen effluvium are very much a possibility too. Conditions such as chronic telogen effluvium, alopecia areata incognito and scarring alopecia are possible with anyone with the story given in your submission, but the chances of these are pretty low overall. Statistically speaking, most likely a person with your story has either a normal variation or has androgenetic alopecia or has telogen effluvium or has BOTH androgenetic alopecia and telogen effluvium. An astute hair specialist can help you solve the mystery once they gather from you more information, examine your scalp and review some key blood tests with you.

If you really want to understand more about your shedding and what it means, you may wish to review things in detail with your dermatologist. He or she might order a 5 day modified hair wash test. This test takes time and patience to perform yourself at home, but it gives a wonderful amount of information. You can read more about it in the link above. A scalp biopsy is not advised in most cases of someone asking about shedding because the diagnosis can be determined by using the principles discussed above (the SET principles).

As well, as you think about your own shedding, you and your hair specialists can refer to the helpful table below.
Let’s take a look at this table and let’s review some key things we can learn from it.

1. First - Normal shedding ranges from 20-80 hairs per day. Of course, if once shampoos every 2 days then that means the number is 40-160. If every 3 days then up to several hundreds hairs may be quite normal to be lost in the shampoo day. We lose more hair on the days we shampoo than on the days we don’t shampoo. It’s true that some lose up to 100 hairs per day but the reality is that if you average if out over a long time, it works out to under 100 hairs for most. This is the daily rate assuming one shampoos every day. If a person shampoos once per week, then they may lose 500 hairs easily that day without me even being concerned. shedding can vary across the menstrual cycle - especially after ovulation and in the days leading up to one’s period. This is normal. Other patterns are also possible.

2. Second - shedding can occur in other hair loss conditions and that rate of shedding can range from fairly normal to quite profound. Some individuals with telogen effluvium shed a little bit more than normal. However, some with TE shed massive amounts of hair. Generally speaking the rate of daily hair shedding in androgenetic alopecia is mild - but it must never ever be forgotten that AGA is one of the most common causes of slightly increased shedding in women with hair loss. Far too often we jump to the conclusion that a person with shedding has a diagnosis of telogen effluvium - nothing could be further from the reality. AGA must be on that list for women.

3. Third - the lengths of the hairs that are shed gives helpful information. If there are a few short hairs, one can’t conclude anything all that much. Everyone loses some short hairs and some long hairs - but mostly it’s long hairs that get shed. But if 20 %, 30 % or 40 % of the hairs that are being shed from the scalp are short less than 3 cm hairs, we need to at least start thinking about a diagnosis of androgenetic alopecia. A modified hair wash test can help quantitate this.

4. Fourth - the types of hairs that are being lost is helpful. We’ve talked about short hairs and long hairs in the section above. But long hairs can be telogen hairs, broken hairs and anagen hairs. If anagen hairs are being lost that look pretty normal anagen hairs, then scarring alopecia needs to be considered. If the anagen hairs are a bit “strange looking” then this may be a dystrophic anagen hair that one is seeing and a diagnosis of alopecia areata or scarring alopecia need to be reviewed. Finally, long hairs can be broken hairs. If broken hairs are what’s coming out of the scalp then alopecia areata, scarring alopecia needs to be considered - as does other entities like trichotillomania and chemotherapy induced loss and over use of heat or chemical styling practices. Of course, one usually knows if chemotherapy induced loss is a possibility because the patient will tell you if they have recently received chemotherapy treatment for cancer or not.

5. Fifth- the patient with shedding needs to figure out if they have hair loss all over or whether it’s occurring form one area more than others. If the patient feels that the back is much much less affected than the front of the scalp, the chances go up that the patient has androgenetic alopecia (AGA) as the cause of at least one of their diagnoses. Of course, they might still have TE and they might even have a scarring alopecia - but if there is a preferential reduction in density from one main area of the scalp that the person can point to with one finger - we need to consider the possibility of AGA.

6. Six - scalp symptoms can occur in any hair loss condition, but if they are profound and disabling and interfere with life then one needs to consider a scarring alopecia as the cause of shedding. Patients with AGA can have a little bit of itching. Patients with TE can have a little bit of itching. But massive 10 out of 10 itching, burning and pain is not a feature of AGA or TE. Conditions that give marked symptoms - that prompt people to put ice bags on their scalps - include scarring alopecias, allergic contact dermatitis, and scalp burns. Others exist too but you can see that AGA and TE are not part of this list.

7. Finally, the loss of other body hair can sometimes give clues. AGA is not associated with loss of eyebrows or eyelashes or body hair. Of course, if a patient says to me “oh, I do have eyebrow loss, come to think of it” this does not mean that they can’t have AGA. Eyebrow loss is common with age and so the simple finding of eyebrow loss does not mean that we have confirmed that the patient can’t have AGA . Not at all. It’s possible the patient has eyebrow loss as part of aging or over styling and now develops AGA too. But rapid loss of eyebrows, eyelashes and body hairs often points to an immune based reaction against hair follicles (with alopecia areata and frontal fibrosing alopecia being most common).

   SUMMARY

   I hope this helps. If you want to explore your shedding more, be sure to review with a hair specialist and pursue it methodically. You can look at the sizes of hairs being lost. You can measure the density on various areas of the scalp to determine if one area is thinner in density than another. You can review your symptoms. Together you can get a sense of whether your shedding is within the realm of normal or whether it is a reflection on an underlying scalp issue like AGA, TE or something else. If you feel that you have the same amount of hair on your head as age 27 and 17, then you are most likely dealing with the normal variations of shedding patterns. That’s really the most important question here.
   
   

Constant hair shedding for 2 years: Is the diagnosis TE or something else?

2 years of constant hair shedding: Is this just a TE?

I’ve selected this question below for this week’s question of the week. It allows us to discuss some of the finer aspects of the topic of chronic hair shedding. Hair shedding is often felt by some to be synonymous with telogen effluvium. This is incorrect.

Here is the question….

QUESTON

Hello. Would I be able to ask you a question about TE? I first experienced this in July 2018 4 months after I had my son by c section. Since July 2018 my hair fall has continued at a consistent rate of 70-80 hairs a day. Mostly all falling out in the shower. I’ve had all my blood work done by my doctor and he did a hair pull test and just says it’s TE. What do I do now that it’s almost been 2 years of constant fall out? Mind you the hairs are growing back in, tapered at the ends, sticking straight up, ALL over my entire scalp. The excessive hair fall is not stopping, which makes my hair look extremely thin even though they’re growing back in when one falls out.  
Any advice would be appreciated. My doctor wants me to try rogaine 2% and I don’t know if that’s the solution or not. 

Thank you in advance... 

ANSWER

Thanks for the question and probably one of the most common scenarios I encounter with female hair loss. There’s a lot to discuss with your question, so let’s get to it!

Before we go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s Story

2) the findings uncovered during the process of the scalp examination and

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

I’d like to know a lot more about this story ideally but of course the magic of the “question of the week” is that I tackle questions with limited information. I’d like to know what blood tests were done in your case and what the results were. I’d like to know if there is any itching, burning or pain in the scalp. I’d like to know if your menstrual cycles are now regular. I’d like to know if the person asking the question has any medical issues or takes any medications. I’d like to know about stress levels? I’d like to know her family history of hair loss. I’d like to know if the patient has lost any brows or lashes. I’d like to know if her weight has been stable? I’d like to know if the density is the same as 6 months ago or worse? I’d like to know if the patient has any headaches, joint pains, skin rashes, dry eyes, dry mouth, thirst, abdominal pain, fatigue, changes in libido, or ulcers the mouth. I’d like to know the precise age of thee patient. All these things matter in fully answering these questions.

With that behind us, let's return to our question of the week again.

You might have telogen effluvium. But the main point here and the entire reason I chose this as the question of the week, is you might not have TE as the diagnosis or a TE might not be the main reason. I feel strongly that you need another examination or a scalp biopsy.

First, let’s take a look at the reasons why your shedding is not stopping. There are several reasons why shedding does not stop in women. I don’t know anything about your story and don’t have photos of your scalp so I can’t say which of these 3 reasons (see below) it is. However, I’d encourage you to meet with an expert dermatologist as he or she might assist you in determining which of the following is applicable to you.

REASON 1: You have telogen effluvium, but you have not found the trigger

I’d possible you have telogen effluvium as the “only” diagnosis, but I doubt it. If, in fact, you do have isolated TE, then you may still be shedding because you have not found the trigger of the shedding. Causes of telogen effluvium include stress, low iron, thyroid problems, medications, crash diets, weight loss, illness inside the body. Which one is relevant to you?

I’m hoping you have had blood tests done already … but if not, you need them. A person with shedding of hair needs CBC, TSH, ferritin, vitamin D at minimum. In someone with your story, other tests like ANA, zinc, testosterone, DHEAS, ESR, VDRL may be important to consider. There could be other tests you need too! The exact tests that you need depend on your entire story. There are about 50 tests possible but most people need 5-10. It would only be possible for me to list the blood tests you need if I knew about your entire story from A to Z

it’s possible you are still shedding because there still is a trigger telling your hair to shed. If so, you are your doctor need to find it. Is there something in the blood test results? Do you need more blood tests? is there a medication causing your shedding - like birth control? like a prescription mediation? Do you have any medical issues that you do or don’t know about that are causing the shedding? Is your diet adequate to sustain hair growth?

REASON 2 You have telogen effluvium but also have another diagnosis or you don’t really have TE at all

You might have telogen effluvium but there may be a second diagnosis present that you are your doctor are not recognizing - or you might not really have TE at all. The most common scenario is a patient who has TE but also has evolving androgenetic alopecia (AGA). It’s not uncommon for AGA to start in some when after delivery of a baby and then progressively get worse. When the condition first starts up the only thing that is experienced by the patient is shedding. For many women with AGA, this shedding is all over the scalp so this fact alone does not just mean you could only have TE.

So, it could be that you have TE + AGA or it could be that you don’t really have TE but rather you have only AGA that is mimicking TE. If you feel there is less hair on your hair today compared to one year ago, then there is a reasonable high chance you have AGA as one of your diagnoses or the only diagnosis. If there is the SAME amount of hair on your scalp compared to 1 year ago, then it’s still possible that TE is the only diagnosis that you have.

Be sure to see a dermatologist who specializes in hair loss for the proper diagnosis. A skilled dermatologist might be able to determine if you have androgenetic alopecia (also known as female pattern hair loss) simply by looking at the scalp with dermosopy. If not, then a scalp biopsy can be done. If you want to get some clues yourself, then you might consider performing a test yourself known as the five day modified hair wash test.

You can read more about this in the link above, but it essentially involves collecting every single hair that exits your scalp exactly five days after not shampooing your hair. If you see mostly long hair, it’s like TE. As a person starts to see an increasing number of short hairs, the possibility of androgenetic alopecia goes up. Now, I always suggest that the 5 day wash test be explained to your properly by your dermatologist and then interpreted properly by your dermatologist. But it is an option to get further clues about what diagnosis might be going on .

We also need to keep in mind that there are many other conditions besides just AGA and TE that cause shedding. Scarring alopecias are one of them. Lichen planopialris for example can cause constant shedding. It woudl be unusual for a person with your story to have scarring alopecia but not impossible. If there is burning on the scalp or tender sore areas on the scalp or redness in the scalp, the chances that a person has scarring alopecia goes up a bit. Alopecia areata incognito (a form of alopecia aerate) is another cause of shedding that mimics TE. A consultation with an experienced dermatologist can help determine if you have any other mimickers of telogen effluvium.

REASON 3: You have chronic idiopathic telogen effluvium or what is termed “CTE”

A person with chronic shedding may have CTE. Your story is certainly not typical of CTE but you’ll probably hear that term thrown around a lot. Most women with classic CTE have thick hair that sheds and sheds and sheds. Thinning is not obvious. You are in the wrong age group for CTE. You have what sounds like progressive thinning. While you could ‘potentially’ have a TE that follows what we talked about under reason 1, you probably don't have CTE. Again, a dermatologist can assist you.

SUMMARY

In summary, you might want to see an expert dermatologist in your city for diagnosis. I’m suspicious that TE is the only diagnosis you have. It might not be. You need to make sure you’ve had a proper examination and determine if other issues like AGA, alopecia areata or scarring alopecia are at all present on your scalp. The most likely of all of these is AGA. You need to make sure that you’ve had all the blood tests ordered based on your story. There may be 5 tests you need or 25 tests -it depends on your story that you share with your doctor. If anyone is still not sure about the diagnosis or you yourself are not confident with the diagnosis being told to you, a modified hair wash test could be a first step, or a scalp biopsy. A biopsy woudl be preferred in your case. A properly done scalp biopsy with horizontal sections and determination of the so called terminal to vellus ratio (T:V ratio) is going to go a long way to helping. IF your T:V is above 4 with lots of telogen hairs in the biopsy (above 15%), then isolated TE may be what you do have. If your T:V ratio in the biopsy is less than 4:1 then you probably have AGA. The biopsy can also help determine if you do have scarring alopecia or do have alopecia areata.

I hope this helps.

Good luck,

Why am I shedding with zinc supplements?

Localized Shedding with zinc supplements

I’ve selected this question below for this week’s question of the week. It allows us to discuss some of the finer aspects of zinc on the human body and how to approach atypical or unexpected reactions in the human body.

Here is the question….

QUESTION

I shed hair when taking zinc supplements. I cannot find any information on this at all. Most suggest zinc helps the hair cycle not cut it short and shed. The shedding appears to occur in locations that already had issues. It is not global (all over the body).  Is zinc connected to the hair growth/shed cycle or is it inflammation? Thank you.

ANSWER

This is a terrific question. Not one that I encounter often - but a fascinating one. There’s a lot to review with this question, so let’s get to it!

Before we go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s Story

2) the findings uncovered during the process of the scalp Examination and

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

I’d like to know a lot more about this story ideally but of course the magic of the “question of the week” is that I tackle questions with limited information. It could be relevant if the patient takes zinc for one weekend because they heard it was good to boost their immune system or took zinc for one year to finish the bottle that they purchased one day on sale. It could matter if the patient is obese or thin, malnourished or well nourished and elderly or young. It could matter if the patients knows their actual zinc levels through blood tests or not. Finally, it could matter and probably does matter if the patient has early staged adnrogenetic alopecia, mid staged androgenetic alopecia or advanced androgenetic alopecia. All these things matter in fully answering these questions.

With that behind us, let's return to our question of the week again.

WHAT’S THE MOST LIKELY EXPLANATION FOR SHEDDING WITH ZINC?

Well, the most likely explanation (given that I don’t know anything else about you), is that:

1) you have some male pattern balding and you are not using finasteride or dutasteride to treat your male balding and that zinc has trigger a mild effluvium of hairs that are in the early balding phase. We call this phenomenon immediate telogen release and it’s common with every treatment that acts on male balding including minoxidil, laser therapy, PRP therapy, finasteride therapy …. and sometimes zinc.

2) The second explanation is that you actually do have diffuse loss of hair on the scalp and you are just noticing it more in the areas that are already thin. In this scenario, the male balding has nothing to do with the discussion, it just so happens you notice hair loss more in areas that are already thinner.

3) The third explanation is that you have something else going on that is not related at all.

It zinc related to my hair loss? A Closer Look at the Naranjo Scale

Before we go further, I’d like to introduce you and readers to a wonderful system of determining how likely it is that a person’s rare observation is linked to the drug or supplement they are taking. It’s called the Naranjo Scale. I always refer to the Naranjo scoring system when some observation a patient is experiencing is uncommon because it helps to get a better sense of just how plausible things really are. If someone tells me their new supplement is causing hair loss, I might pull up the Naranjo Scale. If someone tells me their new cat is causing them hair loss, I might pull up the Naranjo Scale. We’ll take a look at this scale in a moment.

Now, it seems pretty obvious that if you say that when you take zinc you get more shedding that I believe you that zinc is causing your hair shedding. First off, I believe you. I have seen this phenomenon before so I’m not introducing the Naranjo scale as a way to prove whether you are correct in your observation or not. Rather, the Naranjo Scale helps us look at causation with a little greater precision - something a bit more scientific.

The Naranjo scale involves use of 10 simple question. You might want to try it yourself. The questions are below and I’ve worded each questions specifically to pertain to zinc although the Naranjo scarring system itself pertains to any drug not just zinc. You answer “yes", "no" or "don't know" and different points are assigned to each answer (-1, 0, +1, +2). 

Typical Questions in the Naranjo Scale

1. Are there previous conclusive reports of zinc causing hair loss from areas that already have an issue?

Yes (+1) No (0) Do not know or not done (0)

2. Did the shedding appear after zinc was given?

Yes (+2) No (-1) Do not know or not done (0)

3. Did the shedding improve when the zinc was discontinued ?

Yes (+1) No (0) Do not know or not done (0)

4. Did the shedding appear when the zinc was readministered?

Yes (+2) No (-1) Do not know or not done (0)

5. Are there alternative causes that could have caused the shedding?

Yes (-1) No (+2) Do not know or not done (0)

6. Did the shedding reappear when a placebo was given?

Yes (-1) No (+1) Do not know or not done (0)

7. Was the zinc detected in the blood at higher levels?

Yes (+1) No (0) Do not know or not done (0)

8. Was the shedding more severe when the zinc dose was increased, or less severe when the zinc dose was decreased?

Yes (+1) No (0) Do not know or not done (0)

9. Did the patient have a similar shedding to the same or similar zinc pills in any previous exposure?

Yes (+1) No (0) Do not know or not done (0)

10. Was the adverse event confirmed by any objective evidence?

Yes (+1) No (0) Do not know or not done (0)

Determining the Naranjo Score

Scores for the Naranjo Scale can range from -4 to + 13. A score of 0 or less means the likelihood of the drug causing the side effect is doubtful, a score 1 to 4 indicates it is 'possible', a score 5 to 8 means it is 'probable' and a score 9 to 13 means it is 'definite'. The website http://www.pmidcalc.org/index.php provides a free online calculator for clinicians to calculate the Naranjo Score. It is easy to use and has been embedded below as an example. Individuals wanting to know if a specific drug caused hair loss should be sure to speak to their dermatologist. For you, I’m guessing you are somewhere between 5 and 8 and probably and 6 or 7. This just simply reinforces that what you are experiencing is probable.

What are the effects of zinc on the body and on hair ?

Zinc is well known to affect the human body in about 50 different ways. Actually, it’s best to say that there are at least these are the 50 different ways that have been studied. There are probably 250 ways that zinc affects the human body - we just haven’t studied them all. Here are some of the more common effects of zinc under different conditions. You can see that zinc has a profound effect on many hormones, inflammatory markers and immune system components.

Zinc and Hormones.

Zinc has a complex relationship with hormones. Zinc supplementation seems act as an anti androgen in most scenarios. In women with PCOS, it’s clear that zinc supplementation helps PCOS and reduces hirsutism and improves hair loss. However actually hormone levels (DHEAS) don't seem affected. In prostate cancer cells grown in the lab, it’s clear that zinc acts as an androgen receptor blocker. Zinc blocks male hormones.

Zinc containing shampoos have a positive effect on male balding. In a 2003 study, Berger et al showed a benefit for 1 % zinc pyrithione (found in Head and Shoulders and other shampoos). The researchers performed a 6 month randomized study in healthy men 18-49 with Hamilton Norwood type III vertex or type IV baldness to assess the benefits of daily use of 1 % ZP shampoo. The researchers compared growth with zinc pyrithione shampoo compared with three other groups: 1) those using minoxidil 5 % twice daily, 2) those using a placebo shampoo, and 3) those using a combination of minoxidil and the 1 % ZPC shampoo. The results of the study showed hair growth with zinc pyrithione shampoo alone was almost as good as with minoxidil. Whether these effects are due to the anti-inflammatory effects of zinc on yeast and Malassezia (the causes of dandruff and seborrheic dermatitis) or specific zinc effects on the scalp are not clear.

Depsite all the studies showing zinc has antiandrogenic effects, there are studies showing that zinc supplementation may have the effect to increase testosterone. Zinc supplementation to subfertile men increased testosterone and DHT levels and improved the chances that the female partners of these men became pregnant.

SUMMARY AND FINAL CONCLUSION

There is a lot we have learned about zinc so far and here is a lot we still need to learn when it comes to zinc.

For most people, taking zinc doesn’t have any effect on the hair in any way. However, there will be some people who experience a reduction in daily shedding - especially if they had low zinc to begin with. For a very small proportion a bit of shedding might occur for 1-4 weeks but this is not something that is seen commonly. We do see it in patients with early androgenetic balding - but again even then it’s not common. Most individuals with androgenetic hair loss who use zinc either have no effects or experience a slight improvement.

Your question suggests you have a degree of underlying androgenetic alopecia (male balding) and what you are experiencing is a telogen effluvium of the hairs in that area. Of course a dermatologist can help confirm this.

Hairs that are found in the balding areas of the scalp are notiously more loose than hairs that are found in other areas. They wiggle out of the scalp very easily. We refer to this medically by saying that the hairs are in the telogen phase. Taking zinc supplements certainly gives the hairs some 50 to 250 reasons to wiggle out (or shed) but why this happens for some people and not other is not clear.

There are many different so called genetic polymorphisms that people are born with hat affect how they process zinc and what zinc does to the body. These too have been researched over the years. Polymorphisms in IL6 (IL 6 -174) and ZIP2 Lue- (Arg43Arg) are all examples of genetic changes inside of a person’s DNA that affect how they respond to zinc and why one person might respond differently than another person.

If you have used treatments for male balding before (like laser, minoxidil, finasteride, PRP) and developed some shedding when you started these treatments, you are likely to be experiencing the same sort of phenomenon with your zinc. Although it is unusual to shed hair with zinc supplementation, I must add that it is extremely unusual for males who are currently on finasteride to shed hair with zinc supplements given that the androgens pathways inside hairs are so effectively suppressed. Not impossible but unusual in my experience.

If you shed more with higher doses of zinc and less with lower doses of zinc, and stop shedding completely when you stop the zinc pills, the Naranjo score tells us you are onto something. The fact that you shed when you start zinc does not necessarily mean you will continue to shed forever. Just like with finasteride, laser, PRP, minoxidil, most shedding when related to male balding actually settles down in 6-8 weeks. So most men who continue zinc will find their shedding eventually slows down.

I’m not a fan of my patients taking zinc forever. Zinc level should be kept above 85 µg/dL (13 mmol/L) and below 118 µg/dL (18 mmol/L). Excessive zinc causes copper deficiency which is also a rare cause of hair loss. Long term copper deficiency leads to a great number of problems in the body. Zinc should always be taken with the goal to measure zinc levels over time. If you notice shedding every time you take zinc for a few days, that’s one thing, but if you notice shedding everytime you take zinc for months at a time, that’s a different thing. If zinc is causing a pure telogen effluvium due to low copper for example, it is never going to settle down.

As mentioned in the opening it is going to matter if the zinc is taken for the weekend or for one year. The longer the zinc is used (beyond 4 months), the less likely the shedding is due to helpful actions on the balding process and more likely this zinc is detrimental (or something else entirely is going on). It could matter if the patient is obese or thin, malnourished or well nourished and elderly or young. The more obese the patient is (above a BMI of 30) the more likely the zinc supplementation is going to significantly change hormones, insulin sensitivity and lipid metabolism. Mind you, these changes are probably for the good, but there is a chance they are going to set off some shedding in these patients. It could matter if the patients knows their actual zinc levels through blood tests or not. If one is taking zinc, and the levels skyrocket above 150 ug/dl (23 mmol/L) we often see zinc issues with the hair.

Finally, I hope I’ve made the point that all of this probably does matter if the patient has early staged androgenetic alopecia, mid staged androgenetic alopecia or advanced androgenetic alopecia. The earlier the AGA the more likely that zinc is going to cause a bit of temporary shedding. It’s still an uncommon phenomenon overall - but it’s the patients with early AGA that are the most likely to report shedding with zinc supplements in our clinic.

I hope this helps. It’s an interesting question and you and your doctor may want to consider how zinc is potentially affecting the androgenetic hair loss issues on the scalp and how the levels of zinc are changing over time when you supplement. The actual levels of testosterone and DHT may or may not have any relevance because some people could have slight elevations without it actually causing hair loss (or actually inhibiting hair loss as time goes by.

Thank again for the question.

Reference

Barnett et al. Effect of Zinc Supplementation on Serum Zinc Concentration and T Cell Proliferation in Nursing Home Elderly: A Randomized, Double-Blind, Placebo-Controlled Trial. Am J Clin Nutr 2016 Mar;103(3):942-51.

Ebrahimi et al. The Effects of Magnesium and Zinc Co-Supplementation on Biomarkers of Inflammation and Oxidative Stress, and Gene Expression Related to Inflammation in Polycystic Ovary Syndrome: A Randomized Controlled Clinical Trial. Biol Trace Elem Res 2018 Aug;184(2):300-307.

Foroozanfard et al. Effects of Zinc Supplementation on Markers of Insulin Resistance and Lipid Profiles in Women With Polycystic Ovary Syndrome: A Randomized, Double-Blind, Placebo-Controlled Trial. Clin Endocrinol Diabetes. 2015 Apr;123(4):215-20.

Giacconi et al. Effect of ZIP2 Gln/Arg/Leu (rs2234632) Polymorphism on Zinc Homeostasis and Inflammatory Response Following Zinc Supplementation. Biofactors.. Nov-Dec 2015;41(6):414-23.

Hosui et al. Long-Term Zinc Supplementation Improves Liver Function and Decreases the Risk of Developing Hepatocellular Carcinoma. Nutrients. 2018 Dec 10;10(12):1955

Jamillan et al. Effects of Zinc Supplementation on Endocrine Outcomes in Women With Polycystic Ovary Syndrome: A Randomized, Double-Blind, Placebo-Controlled TrialTrace Elem Res. 2016 Apr;170(2):271-8.

Kahmann et al. Zinc Supplementation in the Elderly Reduces Spontaneous Inflammatory Cytokine Release and Restores T Cell Functions. Rejuvenation Res. . 2008 Feb;11(1):227-37.

Kim et al. Effect of Zinc Supplementation on Inflammatory Markers and Adipokines in Young Obese Women.Biological Trace Element Research 2014 Feb;157(2):101-6.

Lomagno et al. Increasing Iron and Zinc in Pre-Menopausal Women and Its Effects on Mood and Cognition: A Systematic Review. Nutrients. 2014 Nov 14;6(11):5117-41.

Mariani et al. Effect of Zinc Supplementation on Plasma IL-6 and MCP-1 Production and NK Cell Function in Healthy Elderly: Interactive Influence of +647 MT1a and -174 IL-6 Polymorphic Alleles. Exp Geront.  2008 May;43(5):462-71.

Mocchegiani et al. Zinc: Dietary Intake and Impact of Supplementation on Immune Function in Elderly. Age.  2013 Jun;35(3):839-60.

Ranasinghe et al . Zinc Supplementation in Prediabetes: A Randomized Double-Blind Placebo-Controlled Clinical Trial. J Diabetes. 2018 May;10(5):386-397.

Hair shedding after a low calorie diet

My diet is done but when is my hair shedding going to stop?

I’ve selected this question below for this week’s question of the week. It allows us to discuss some of the finer aspects of telogen effluvium from dieting.

Here is the question….

QUESTION

Hi! I have a quick question regarding my hair loss. For the past few months I have been on a very low calorie diet, and i’m now noticing a lot of my hair falling and thinning. I therefore changed my diet and am eating more calories now. But when will my hair stop falling? …. and is there anything i can do to stop it? I am a female 5’5, and weigh 123 pounds. I was consuming about 800-1,000 calories a day.. but burning about 500.

ANSWER

This is a terrific question. For most people, the answer is simple. For some, however, it’s a little more involved as we will see.

Before we go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s Story

2) the findings uncovered during the process of the scalp Examination and

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

With that behind us, let's return to our question of the week again.

WHAT’S THE MOST LIKELY EXPLANATION?

First, it’s quite likely that you are experiencing what we term a “telogen effluvium” and in your case this is occurring from dieting. Anytime a person consumes less than 1300 calories per day the chances of telogen effluvium increase.

Telogen effluvium (TE) Is a hair shedding disorder whereby the patient experiences more daily hair loss than they may have in the past. Mild effluviums may lead to 50-100 hairs loss daily whereas more severe effluvium may be associated with several hundreds. Many forms of TE occur 2-3 months after a so called triggering event. A trigger in January, for example,  causes hair loss in March. A trigger that occurs in March causes hair shedding in May.   Common triggers include low iron, such as low iron, stress, thyroid abnormality, initiation (or cessation) of a new medication, or weight loss. Hundreds of other examples of triggers exist as well. In many cases a trigger cannot be found and the TE resolves on its own. Most telogen effluviums resolve about 9-12 months after the trigger has been completely corrected. Many patients with shedding disorders have scalp symptoms of itching, burning, tenderness, and feeling of something moving in the scalp. This is referred to as trichodynia. 

Your story is quite typical for Telogen effluvium. Let’s suppose for the sake of this question that you started your diet in February. When would I expect you to start noticing shedding? The answer is April. How long will your shedding last? That answer is 6-9 months from the time that you started eating a normal 1500 calorie balanced nutritional diet AND provided your diet did not leave you with any nutritional deficiencies that keep you chronically depleted.

TYPICAL COURSE OF HAIR SHEDDING FOLLOWING A DIET

The typical course of hair shedding would follow something like this. Shedding would start 2 months after the diet and then worsen. In your case, I would not be surprised if shedding worsens in May and June and July even if the diet stopped in May. But over the course of the late summer and Fall, shedding should start reducing again and by the end of the year hair shedding should be back to ‘normal.’ It’s normal to shed 20-60 hairs per day and for some a bit more.

Your current weight tell me that your body mass index is now in a healthy range. Body mass index is something that I calculate for all my patients to get a sense of whether their weight is right for them. It’s not a perfect scale but gives a sense of where things should be Your BMI is 20.5 which is a healthy weight.

Does hair shedding always stop people who go back to eating a normal amount of calories?

For most people, shedding goes back to normal in a few months of eating a healthy number of calories. For some people however, that’s not the case. There are several reasons why shedding does not slow down including.

1. There were deficiencies created by the diet which have not been corrected.

A diet can create all sorts of deficiencies in vitamins and minerals. We only need small amounts of most vitamins and minerals anyways so once a health diet resumes, most people can make up for any losses and the body will absorb what it needs. However, for some people levels of vitamins and minerals don’t get replenished like they need to be. A good vitamin and mineral supplement can help but I often recommend testing potential deficiencies like iron, zinc, selenium, magnesium, B12, vitamin A, folate, vitamin D in addition to the usual tests for anyone with hair loss (CBC and TSH).

2. There are other reasons for the shedding which were forgotten about.

It’s possible for a person to shed because of diet. But sometimes a person can think they are shedding from a diet but that’s not really the reason they are shedding at all! Shedding can happen from over 100 causes so a broad approach is needed.

See Top 10 Causes of Telogen Effluvium

Thyroid abnormalities, stress, medications, illnesses in the body can cause shedding. In addition, many conditions mimic telogen effluvium and so the patient is actually shedding from a completely different condition such as alopecia areata incognito or a type of scarring alopecia.

3. The shedding has precipitated or ‘unmasked’ an andogenetic alopecia

For some people who shed, the process of shedding uncovers their slightest tendency to develop androgenetic alopecia. If a person has the underlying predisposition to develop genetic hair loss, then a shedding episode from telogen effluvium can cause the adnrogenetic alopecia to be set in motion. Even though the person’s telogen effluvium from the diet ends - they are faced with a new hair issue - androgenetic alopecia.

See Why Won’t My Shedding Stop?

Telogen Effluvium: Why is my density not returning to normal?

4. The patient has developed a chronic shedding issue.

Finally, some patients with shedding develop chronic shedding problems even though the original trigger has been identified, corrected and is long behind them. This is known as a form of chronic telogen effluvium

FINAL SUMMARY

Thanks again for the great question. I’d encourage you to see your dermatologist if the shedding does not improve. For most with shedding problems that come after dieting, the shedding gets worse for a few months and then progressively gets better and better until shedding rates go back to normal in 6-9 months. In some people though, this is not the story, and issues like androgenetic alopecia, chronic nutritional deficiencies, and other hair issues like chronic telogen effluvium need to be explored in greater detail.

Aggressive telogen effluvium in males: A common misdiagnosis of androgenetic alopecia

Question

I am a 23 year old male and have been diagnosed with fairly aggressive case of telogen effluvium. It started at age 21 and does not seem to be improving. I have been using biotin supplements recently but they too don’t seem to be helping. I am healthy and take no medications or drugs. What are your recommendations to stop the shedding?

Answer

Thanks for the great question. I think the most important consideration for you is whether, in fact, you have been given the correct diagnosis. I would need to see photos and know everything about your story and recent blood test results to tell you what diagnosis you have. However, androgenetic alopecia (male balding) needs to be considered in your case. In fact, I would state it even more boldly: in a situation like this with a 2 year history of hair loss in a 23 year old male, we need to prove that you don’t have androgenetic alopecia before moving any further. Once we deal with that, we can move on.

Far too many cases I see that are diagnosed as being telogen effluvium are misdiagnoses. Does telogen effluvium exist? Of course! In fact it is a common cause of shedding in patients with hair loss. Is 2 years of telogen effluvium common in a 23 year old healthy male? No, it most certainly is not.


Telogen effluvium happens from a variety of reasons. These include low iron levels, thyroid problems, stress, medications and illness. In most cases, they are temporary and once the trigger is identified and stopped or fixed- hair grows back. In your case we need to look for a trigger but the reality is that after two years of shedding in a healthy male, there may not be one. It’s still important to search.

Most cases of aggressive telogen effluvium in young males are in fact cases of aggressive androgenetic alopecia instead. It is commonly forgotten that androgenetic alopecia in males can be associated with shedding. In young males with strong genetics that is driving the balding process, shedding can be quite significant.

A male with shedding needs of course to have a full evaluation. One needs to know your history in precise detail. Underlying health conditions, medications, recreational drugs, sexual transmitted diseases, diet, eating disorders and psychological issues all need to be considered.

Young males with shedding need blood tests for CBC, iron (ferritin), thyroid (TSH) and vitamin D (25 hydroxyvitamin D). A hormonal profile is not useful for most males. Other tests could be relevant on a case by case basis including zinc, ANA, ESR and tests for sexually transmitted diseases but usually these are unnecessary.

If there is any doubt that exists, a scalp biopsy can be helpful in proving or disproving whether a patient has androgenetic alopecia - especially when so called “horizontal sections” are used by the pathology lab. Horizontal sections allow the pathologist to determine accurately something called the terminal to vellus (T:V) ratio. A terminal to vellus ratio of less than 4:1 indicates a high likelihood of androgenetic alopecia.

In summary, for a young male a diagnosis of “aggressive telogen effluvium” one must be absolutely certain that a diagnosis of androgenetic alopecia is not being missed.

Why isn't my hair loss improving despite improving my iron?

QUESTION

I was told that my hair loss was from my low iron levels. However, after working hard for the past 6 months to bring my ferritin levels up from 23 to 55…… I am still not seeing any improvement with my hair at all. Is my hair loss related to iron or not?

Answer

Thanks for the question. It’s certainly a possibility that a person’s iron levels are related to their hair loss. It’s just that they are not implicated as often as most people think. For every one patient I meet with whose lower iron levels are truly related to their hair loss, there are 6 or 7 others where the lower iron levels don’t really seem to be playing role. It’s common to hear stories from patients that they were told their low iron is the reason for their hair loss. Many such patients spend months trying to improve their iron only to find that their hair density has not improved even after correcting their iron.

The short answer is that the lower a person’s ferritin is - the more likely it’s related to the hair loss they are experiencing. It’s a scale from “very likely related” when the ferritin is down below 15 to very like unrelated. I often think in terms of the following table:

With a ferritin of 23 you described, there is a good chance it will help. But it’s far from 100 %. In fact, as you’ll see in the studies I discuss below, almost one half of people in the general population with ferritin levels of 23 will have no hair loss problems.

Hypoferritinemia without anemia (HWA): Is it consistently implicated ?

Ferritin is a measure of iron storage levels in body. In order to get a sense of a patient’s iron status, we measure “ferritin” levels rather than iron. Males tend to have higher ferritin levels than females. Premenopausal women tend to have lower ferritin levels than post menopausal women. Extremely low ferritin levels have many potential side effect and may prevent the body from making hemoglobin - a condition which is called ‘anemia’. However, many patients have low ferritin levels without actually having an anemia. This condition is sometimes called hypoferritinemia without anemia or HWA.

Borderline ferritin levels: Evidence for direct role remains poor

The discussion of ferritin levels and hair loss comes down to how low one must go before the low ferritin levels start impacting hair loss. Many females have ferritin levels 20-40 without hair loss. In fact, if you were to measure iron levels (i.e. the ferritin test) in all women between ages 20-40, you'd find many with ferritin 28, 32. 44. You'd find very few with ferritin levels above 50.  You'd find a number with ferritin levels 6, 12, 19.

While it’s often said that one needs to have a ferritin level above 40 (or above 70) for healthy hair growth, this rule is far too simple. We often "aim" for that level in the hair clinic …. but it is completely wrong to say that anytime ferritin is less than 40 there is a problem.

Ferritin levels below 15

Once the iron levels start going low enough, it is true that there is a higher likelihood now that the patient will experience some hair loss an account of those low iron levels. However, it’s now a definite yes or no. It's quite unusual for patient to have normal hair growth with a ferritin of 2 but not completely impossible. However, it’s still within the realm of possibilities for a patient to have normal hair growth with a ferritin of 18.

The biggest challenge is knowing when a patient should be strongly encouraged to increase their iron levels. The simplest rule, as mentioned above, is to recommend to all people with ferritin less than 40. But one must keep in mind that there will be many people with ferritin levels in their 20s and and 30s who are not going to get any benefit from their efforts to increase iron.

FOUR KEY IRON STUDIES TO KNOW ABOUT

As we think about the relationship between low iron and hair loss, there are 4 key studies that everyone should be aware of.

STUDY 1

AUTHOR: Sinclair et al. British Journal of Dermatology

TITLE: There is no clear association between low serum ferritin and chronic diffuse telogen hair loss.

DATE: 2002

Sinclair and colleagues set out to evaluate the relationship between low serum ferritin (</=20 micro g L-1) and chronic diffuse telogen hair loss in women. He analyzed nearly 200 women who presented with chronic hair loss. 12 women had ferritin levels less than 20 ug/L. In 5 women with pure chronic telogen effluvium (and no evidence of androgenetic alopecia), iron supplementation was recommended to bring ferritin levels up above 20. None of these women experienced improvements in their hair with iron supplementation.

STUDY 2

AUTHOR: Deloche et al European Journal of Dermatology

TITLE: Low iron stores: a risk factor for excessive hair loss in non-menopausal women.

DATE: 2007

Deloche and colleagues assessed the relationship in a very large population of 5110 women aged between 35 and 60 years. Hair loss was evaluated using a standardized questionnaire and iron status was assessed by a serum ferritin assay. patients were categorized into three categories acceding to whether they had an "absence of hair loss" (43%), "moderate hair loss" (48%) or "excessive hair loss" (9%). While it was generally found that women affected by excessive hair loss were more often affected by low iron stores, (59 % vs 48 % in the other two groups), this study reminds us that many patients with no hair loss still have low iron levels.

11.4 % of pre-menopausal women who had concerns about ‘excessive hair loss’ had ferritin levels less than 40 ug/L and 10.2 % had ferritin levels less than 15 ug/L. This compares to just 6.8 % of women with ferritin above 70. This information certainly suggests a link between iron and hair loss. However, one must keep in mind that many patients in the study with low ferritin did not have hair loss. Of all premenopausal women with ferritin levels less than 15 ug/L, about 40 % had no concerns about hair loss at all. This is an important reminder that low ferritin levels are not related to hair loss in all patients.

STUDY 3

AUTHOR: Rasheed et al (Skin Pharmacol Physiol.)

TITLE: Serum ferritin and vitamin d in female hair loss: do they play a role?

DATE: 2013

Rasheed and colleagues set out to study the role of several blood tests including iron levels in 80 females (18 to 45 years old) with telogen effluvium (TE) or androgenetic alopecia (FPHL) and compared levels of iron to 40 age-matched females with no hair loss.

Rasheed found that serum ferritin levels were lower in patients with TE (14.7 ± 22.1 μg/l) and FPHL (23.9 ± 38.5 μg/l) compared to the controls (43.5 ± 20.4 μg/l). Interestingly, these levels seemed to decrease with increased disease severity. While these studies suggested a role of low ferritin levels in hair loss the study did not include any investigation as to whether supplementing with iron was a helpful treatment strategy. That was not part of the study.

STUDY 4

AUTHOR: Kantor et al, J Invest Dermatol.

TITLE: Decreased serum ferritin is associated with alopecia in women.

DATE: 2003

One of the earlier studies investigating the role of iron was a 2003 study in the Journal of Investigative Dermatology. The authors studied patients with telogen effluvium (n = 30), androgenetic alopecia (n = 52), alopecia areata (n = 17), and alopecia areata totalis/universalis (n = 7). The normal group consisted of 11 subjects without hair loss.

The authors found that the mean ferritin level in patients with androgenetic alopecia (37.3) and alopecia areata (24.9) were statistically significantly lower than in normals without hair loss (59.5). Interestingly, the mean ferritin levels in patients with telogen effluvium (50.1) and alopecia areata totalis/universalis (52.3) were not significantly lower than in normals. This study was a good reminder that low iron may have a role in some types of hair loss but the role in telogen effluvium remained unclear.

Key summary points about iron levels and hair loss

Here's some key 'take home' messages about iron and hair loss

1. Aiming for a ferritin level above 40 is likely good idea for anyone with hair loss.

2. Aiming for a ferritin above 70 is not my recommendation and is very hard to achieve and generally has little benefit for the hair. 

3. If one's ferritin is between 20-40 and they have hair loss, it must always be remembered that the ferritin levels may be just fine for that person. I'd still recommend supplementing with iron tablets, but there is not a lot of good evidence that doing so is going to help their hair

4. Ferritin levels under 15 are often associated with changes in hair cycling.  If ferritin is less than 15, I recommend speaking to one's physician about iron pills

5. If ferritin levels are low and hemoglobin levels are low (something we call iron deficiency anemia), a full workup by a doctor should be booked.  

6. Vitamin C helps iron absorption and taking a vitamin C rich sources with iron pills is often helpful to increase iron.  Limiting the use of caffeine may also help.

7. Many females have ferritin levels 20-40 without hair loss. The ferritin level alone does not mean much without taking everything into perspective.