Patient Decision Making and the Acute Stress Reaction: What does the hair specialst need to know?

Decision Making by Patients is Impaired During the Acute Stress Reaction:

The practice of medicine is different nowadays. We advise patients on their options and help them figure out what’s best for them. Physicians no longer tell patients to “do this or that.” 

The old saying “take 2 aspirins and call me in the morning” no longer applies. Nowadays, we say something closer to “you might consider taking 1 or 2 aspirins if you are comfortable with the side effects we reviewed together or you might consider pursuing one or more of the other options we discussed.”

There is one important exception - and that is the acutely frightened, scared and terrified patient who has what we can an “acute stress reaction (ASR).” An example a patient experiencing an ASR is a patient with rapid hair loss. Many such patients have lost the ability to think clearly due to fear. These patients need more guidance than simply leaving all decisions up to them. Asking the patient “what do you think?” about certain recommendations the hair specialist gives has many challenges when the person sitting across from them cannot think clearly due to fear.

Medical research has focused on how people make decisions under stress. We don't talk about it all that much but evidence is pretty clear - many of us don't make good decisions under stress. We make mistakes. We buy things our non stressed self would not buy. We don't buy things that our non stressed self would buy. We say things our non stressed self would not say. We don't say things that our non stressed self would shout out. Stress hormones and other neurotransmitters affect how the brain makes decisions. Elegant animal studies back up this simple concept. When we are stressed we behave differently and make decisions that we otherwise would not make.

The entire issue is open to lengthy and complex discussions about ethics and informed consent. Is the acute stressed patient really making informed consent? Many patients suffering acute stress reactions (ASR) are left to figure things out on their own and some are taken advantage of by aggressive marketing. Many patients experiencing ASR’s will choose any option that they are presented. Internet marketing has preyed on many of my own patients experiencing ASRs.

In my view, there are times when we need to hold on to the steering wheel of the driver and there are times when we can offer suggestions from the passenger seat. We need to help our patients in the same manner that we someday would want to be helped when put in a similar situation. We need to help our patients who are experiencing ASR's to make decisions that really reflect what their non stressed self would make. It's certainly not easy but it certainly is how things should be done.

Does stress accelerate balding?

There is not a lot of great medical evidence to support the notion that stress directly impacts MPB.  However, it probably has a minor role and only in some men and women with the right genetic background. Of course, we don't understand yet what that genetic background is at present.

When one examines studies of identical twins, one sees that 92% actually still look identical (same level of hair loss) years and years down the road. If stress, diet, and environmental factors played a huge role, one would not expect this number to be so high.

But for some males and females, it is likely that stress accelerates balding to a minor degree. A study by Gatherwright in 2013 suggested that higher stress could lead to worsening hair loss in the crown in men.  For women, a 2012 study suggested that higher stress was correlated with worse hair loss in the frontal area and divorce and separation were correlated with worsening hair loss in the temples.

Conclusion

Stress probably accelerates the rate of progression of balding in some individuals who have the right genetic predisposition.   We know that stress can cause an increased amount of daily shedding and such shedding can accelerate follicular miniaturization. It makes sense that stress can accelerate the balding process in some individuals. However, it's not likely to be a consistent phenomenon amongst all individuals.  

Reference

The contribution of endogenous and exogenous factors to male alopecia: a study of identical twins.

Gatherwright J, et al. Plast Reconstr Surg. 2013.

The contribution of endogenous and exogenous factors to female alopecia: a study of identical twins.

Gatherwright J, et al. Plast Reconstr Surg. 2012.

Grieving and Hair Loss

Dr. Elisabeth Kubler-Ross was a pioneer in understanding how humans grieve. Further studies and observations over the years has shown that the way we grieve is similar regardless of what it is we are actually grieving.

As Dr. Kubler-Ross first described nearly 50 years ago, grieving commonly occurs through 5 stages that include:

1. denial and isolation
2. anger
3. bargaining
4. depression and
5. acceptance.

Not all stages have the same length and don't necessarily occur one after the other like the chapters in a book. Not all patients reach the end - acceptance. There is tremendous variation in how people grieve but Kubler-Ross's model has served as a valuable model for decades.

There is little written about grieving and hair loss. You'll never hear about the topic at any hair meeting. It has become increasingly clear to me over the years that some forms of hair loss lead to such profound changes in a person's appearance that they trigger the same grieving responses as one might have with any illness or cosmetic alteration in appearance. Patients with rapid alopecia areata, scarring alopecias, hair shedding disorders as well as androgenetic alopecia often grieve the loss of an appearance they once had. For many, hair loss brings profound changes in one's self-identify and overall self confidence. Many affected patients also progress through the grieving stages of denial, anger, bargaining, depression and acceptance.

Reference

1. www.donovanmedical.com/hair-blog/grieving

2. Kubler-Ross. On Grief and Grieving. 2007.

Recognizing Grief

Recogizing Grieiving in Patients with Advanced Hair Loss

Dr. Elisabeth Kubler-Ross was a pioneer in understanding how we grieve. Further studies and observations over the years has shown that the way we grieve is similar regardless of what it is we are actually grieving. 

As Dr. Kubler-Ross first described nearly 50 years ago, grieving commonly occurs through 5 stages that include 1) denial and isolation 2) anger 3) bargaining 4) depression and finally 5) acceptance.  Not all stages have the same length and don't necessarily occur one after the other like the chapters in a book. Of course, there is tremendousvariation in how people grieve but Kubler-Ross's model has served as a valuable model for decades.

Grieving in the World of Hair Medicine

There is not a lot written about grieving and hair loss. You'll never hear about the topic at any meeting. It has become increasingly clear to me over the years that some forms of hair loss lead to such profound changes in a person's appearance that they trigger the same grieving responses as one might have with any illness or cosmetic alteration in appearance. Patients with rapid alopecia areata, scarring alopecias, hair shedding disorders as well as androgenetic alopecia often grieve the loss of an appearance they once had. For many, hair loss brings profound changes in one's self-identify and overall self confidence. Many affected patients also progress through the grieving stages of denial, anger, bargaining, depression and acceptance. The difference with grieving hair loss and other types of grieving is that the potential exists for some types of hair loss to improve with treatment - and therefore the loss might not be permanent. This too affects how a patient might grieve loss of something that might only be temporarily lost (but might not be).

As a physician my goal is not only to help diagnose and treat a patient's hair loss but also to support them in their loss. We don't often talk about it in our profession but I am well aware that patients with hair loss do grieve. Some patients are angry,  some have come to accept their hair loss, some deny that it is much of an issue, some are depressed and just aren't themselves. In other words, all the stages of grieving are present if we care to ever take a look.  Often as physicians we are focuses on the diagnosis and prognosis and what treatment plan is best that we forget about the human sitting in front of us who wishes they had the hair of their youth.

Recognizing Patterns in the Clinic

I am interested in better understanding the emotional and psychological responses that people have when they lose hair. As part of the earliest stages of grieving (denial and anger) I frequently see several patterns of grief expressed bypatients. I believe we must learn to recognize these patterns so that we can better help our patients cope.

Examples

Let me share some examples of the subtleties of these patterns of grieving. These are helpful reminders to physicians of what signs we should be watching for in patients who need support.

1. Order Lab Tests

An example of one of these patterns starts out with a simple request by a current patient to have a few lab tests ordered. The request usually comes unexpectedly and the patient asks for a new blood test requisition "lab form" to be mailed out to them in hopes that something else shows up on the next set of results. The patient usually feels that a particular test they have heard about from a friend or read about online will provide valuable information to aid in their diagnosis or treatment. 

Comments from patients might include:

I would like all my hormones checked. Can you order for me?

I want all my labs checked again. Is that okay?

I have read that additional thyroid tests may be helpful?

You did not order test X, and my research suggests it is important, can you order for me?

Could this simply be a patient who has done their research rather than a patient who is expressing any degree of grief? Sure. But the pattern is common among those who are grieving loss of their hair.

2. Appointment Cancelling

Or consider the patient with an advanced form of hair loss who cancels their appointment only to rebook again several months later. This pattern too is seen from time to time. During the months between the cancelled appointment and the rebooked appointment the patient may visit other clinics, and even search online for various treatments and purchase various pills, shampoos and tonics. Of course, there can be some genuine desire on the patient's part to solve the hair loss issue themselves.  This is very normal and in some cases it can even be a healthy and appropriate response to solving one's health issues. Usually, though, it gets taken too far. Some patients who are grieving their hair fall prey to unscrupulous tactics and false promises and may spend considerable money. How do I know? Some share all these events mentioned above with me. Most of course, don't.

As Dr Kubler Ross's 5 stages of grieving remind us, there is often some degree of denial that enters into how patients think and view their experiences in the clinic ("I could not possibly have this condition my doctor is saying because nobody in my family has it" or "The condition the doctor is saying I have looks nothing like the photos I see online." There may also be some bargaining ("If I just use a better shampoo brand everything will all be okay" or "If I just start eating better and cut out the junk my hair will improve." The stages of grieving must always be considered.

3. Doubting the Diagnosis

Some patients are more open with me about sharing their doubts. Sometimes a patient will ask me if there is a possibility that the diagnosis was wrong. Sometimes they will inform me that I am wrong. This is quite normal and healthy and I encourage patients to do all the doubting they want and need.  Some patients, however, go to great efforts to cast doubt on their diagnosis. Their may be exchanges of emails, print outs of various sources of information from the internet. Various opinions from the patient's friends, colleagues and family only add to the doubt the patient feels and the time they spend in this cycle.  As a physician, I am always open to the possibility my diagnosis is wrong. 

Anger & Grief

Some patients who are grieving are angry.  They may be angry at the physician or the anger may be directed at only a single member of the physician's team.  We must always recognize this and understand that anger is not always directed in the right way. One's diagnostic skills must not be swayed by the degree of doubt or anger from the patient. I can tell you that it is quite normal for some individuals to be very angry as they grieve. That is something you don't hear much about at a hair meeting or conference but it's part of being a hair physician.

Conclusion

Patients who rebook their appointments, ask for more tests or doubt their physician's diagnosis may simply be just that. A busy parent, an inquisitive patient or a doubting skeptical person in general. Not everyone is grieving. But unless one has their mind clear and open to the possibility, it will usually be missed.

Today as I am writing this, I received a request from a patient to mail out another blood test form in a patient with a progressive scarring alopecia.  The patient's condition is refractory to many treatments. It is progressively difficult to hide the hair loss. Extensive blood tests have been ordered in the past and were normal (as they often are in these particular conditions). "Is this a patient who actually needs more blood tests? or could it be a grieving patient who simply needs our help? "

As a physician, I consider it important to be aware of my patient's response to the physical and emotional changes that come with hair loss and work hard to let go of my own emotional response in order to best help them. It is not always easy to help those patients who are angry at us (we are not hardwired as humans to want to help angry people) but that is indeed what we must do for those who are grieving. It is not easy to support those who do not believe our diagnosis but these patients often need out support as much as (and perhaps even more than) any other patient. I have learned to enjoy the challenges that come with patients who carry significant doubt as they often teach me a great deal about the diagnosis of hair loss.

We must support our patients as they grieve the loss of their hair and the changes they see in the mirror. It's easy to mistake grieving for simply an "angry patient."  or a patient who challenges their diagnosis as a "difficult" patient.  But recognizing the variety of patterns that come with grieving is important. More studies are needed to understand the emotional and psychological impact of hair loss in men and women.

Reference

Kubler Ross. On Grief and Grieving 2007.

Assumptions in the clinic : Everyone has a story to tell

Every patient has a story to tell

Over the years, I have made a few general assumptions in my clinic. I generally assume, for example, that the changes in appearance or emotion that accompany a person's hair loss really matters to any given patient who make an appointment with me. After all, why else would someone make the effort to book an appointment ?

Of course, any assumption will have it's exceptions and times where the assumption is not valid. Like the man who comes in because his wife or girlfriend asks him too make an appointment even though he is not really too bothered by his hair loss. Or the child who feels things are just fine but whose parent thinks there is something extremely wrong. Exceptions exist to any assumption and one must always be careful when making any type of assumptions.But generally speaking, most people who visit a hair physician value their hair.

"It's my crowning glory, Dr. Donovan"

"It's my best feature"

"I know you might not know by looking at me but I used to have five times the amount of hair I have now"

"I used to get so many compliments about my hair"

The list could go on and on. 

And so it's fairly safe to assume that hair matters to the people who come see me. (In fact, it's a pretty safe assumption that hair matters to most humans at least for some duration of time even if just a passing thought). 

Greater degrees of hair loss doesn't necessarily mean more impact

The one assumption that is often incorrectly made by clinicians is that patients with more severe hair loss are more affected by the emotional impact of their hair loss.  It sure sounds like a good assumption... except it's just not true. Some people with a small degree of hair loss can be similarly affected and sometimes even more emotionally affected than those with more significant amounts of hair loss. Study after study has shown that physicians wrongly assume they understand the impact of a patient's hair loss. Certainly assumptions can be wrong. 

One of the reasons the assumption that "more hair loss means more impact" does not hold true is that we don't know everything about every patient. We strive of course to understand many things about the patient's medical history and all relevant related details. In fact, in my clinic I've been using a standard medical questionnaire for the past 7 years to gather all the relevant medical information from the patient. Despite this detailed medical questionnaire, we don't understand the complete picture of the patient.   The questionnaire is only a fairly complete medical picture but lacks an ability to gather information about the psychosocial factors have influenced the patient in the past and are currently influencing his or her day to day.

Why does hair actually matter to the patient? What societal pressures (if any) does the patient feel? Does youthfulness, aging, and health in general carry with it emotional significance that is hard to describe or put to paper? Why does the patient sitting in front of me motivated to do something about the changed they see in their hair?

Everyone has a story to tell

We as physicians don't always come to know all the details of everyone's story. Some stories and the details they contain are private and don't directly impact the diagnosis and treatment - and so they remain with the patient. Some issues aren't even fully understood by the patient ... and so they too remain undisclosed to the physician.

Amanda Marshall's award winning 2001 song "Everybody's got a story" reminds us that we can never assume that we have the whole story about a person. Her lyrics are a reminder not to "assume everything on the surface is what you see."

Hair loss is so closely tied in to a patient's self identity and how they feel about themselves. A key part of being a hair loss physician is understanding that there is so much more to losing hair than losing hair.  There are a tremendous number of extremely complex emotions and psychological factors at play in anyone experiencing hair loss. Some of these factors are understood by the patient and shared openly. Othertimes these issues are understood by the patient and not shared openly. And other times yet they may not even be fully understood by the patient. Both of the latter two situations create a void in the physician's full understanding of their patients. And so we can never assume we understand the impact of any given patient's hair loss. However, assuming that it does matter to them is an assumption that works well for me.

When it comes to hair loss, everybody has a story to tell.

The New Normal: Well Understood for those Living with Chronic Conditions

The New Normal: 

It was several years ago that I first heard the term "the new normal." I remember the day and where I was standing. I remember the patient. I really don't know why the day stands out so vividly among days that have so many other memories. But it does.

It was a busy clinic day. I was running a bit behind. There were a few too many patients added to my clinic list before I was to leave for a meeting abroad. A patient was describing her symptoms, and the way she was feeling and dealing with hair loss and how the world around her was equally responding to her changes and feelings.

"It's the new normal, Dr. Donovan."

The New Normal

The term "new normal" has many meanings. Those living with a chronic health conditions understand what is meant by the "new normal." There is no good definition but it refers to a resetting of some kind of internal mechanism to deal with new changes in how one looks or feels after experiencing a change in his or her health. At least that's my definition.

New Normal and Hair Loss

The new normal is often talked about in the context of patients living with cancer, heart disease or other chronic internal illness. But it equally applies to many with hair loss.  

Significant hair loss, especially if it occurs suddenly causes severe emotional distress for many patients.  For some whose hair loss is likely to be of a more permanent nature, an entirely new means of coping sets in. Such patients often tell me that they find their "new normal." To say that they accept their hair loss is not accurate for all patients. To say that they learn to deal with it is also not accurate for all patients. But they will tell me it's their new normal.

Some of my patients with alopecia totalis, alopecia unversalis and some forms of advanced scarring alopecias will tell me that over time they find their new normal slowly. For some, the new normal is explaining their hair condition to family. For others it'stalking about hair with their friends, hairdressers or even complete strangers.  

For some with scarring alopecias, or hair loss from systemic illnesses like lupus, the new normal relates not only to the emotions and feelings that come with hair loss but actual physical symptoms. This might be the chronic itching or chronic fatigue they experience that comes and goes even when on the very best of medications.   

"It becomes the new normal, Dr. Donovan."

Conclusion

The "new normal" refers to something different for every one of my patients who use the term.  I have learned over the years that it does not necessarily mean that the patient is doing fine or coping well with a new emotional or physical change in the body. It simply means their internal mechanism for dealing with chronic life changing event has been reset.  

Can stress cause hair loss?

Stress and Hair Loss

It is possible that stress can cause hair loss, although it does not happen to everyone. High levels of stress can trigger an increased amount of hair shedding. The hair shedding is typically experienced 2-3 months later at its peak but is highly variable. Some shed one month later and some 3. Even the same person can experience great variability in how they shed. One stressful event triggers shedding 4 weeks later yet another stressor causes a delay of 3 months.

The diagram above shows a typical stress - shedding response. For some, a high level intense stress in February will trigger a shed sometime starting in April and peaking in May/June. For reasons that are not clear, this stress-shedding cycle does not occur in everyone.

Stress may play a role in other hair conditions. In my opinion, high stress may accelerate androgenetic alopecia a slight bit. Stress can make scarring alopecia much more itchier. I do believe stress has a major role in frontal fibrosing alopecia- with many patients reporting extremely high stress at the time of disease onset.

To Poo or Not to Poo: A closer look at the “no poo” (no shampoo) movement

Should you give up shampoos?

If you’re like most people, you have a bottle or two of shampoo in your shower and you use it to clean your scalp and hair. Perhaps you’re a daily user, perhaps you use shampoos a few times week. If you have coarse and curly hair, you might use shampoo even less frequently.   But you use it. If my own practice is representative of the world out there I know some of you even change your shampoo brands frequently.

However, a small number of women (and an even smaller number of men) have decided to forgo shampooing the scalp altogether. This defines the so called “no poo” movement (i.e. ‘poo’ is short for shampoo).

 1. We are a shampoo loving society

As a society, we have grown to love shampoo and love shampooing. Walk into any drug store and you’ll see just how much real estate is devoted to shampoos. We love the smells of shampoos and the feel of shampoos. We love the look and feel of shampoo bottles. We like the shampoo aisles, shampoo ads and shampoo commercials.  We are a shampoo loving society.

Shampoos were first synthesized in the 1930s, as an alternative to bar types soaps which left a heavy film or “soap scum” on the hair.  Such deposition leaves the hair dull and more difficult to manage.  In years gone by, women  would shampoo their hair at the salon and then have it set. Shampooing every 2-4 weeks was normal. Shampooing wasn’t typically a home-based procedure. It wasn’t until the 1970s and 1980s that shampoos became standard for household daily use. In North America, many women have changed to shampoo their hair very frequently. Moreover, we seem to enjoy squeezing our shampoo bottles and in general use far too much shampoo with each use than we really need to. It’s not really harmful to do so – except to our bank. It’s too often forgotten, that shampoos are meant for cleaning the scalp and conditioners are meant for the hair. A small dab of shampoo is usually sufficient to clean the scalp.

2. If people don’t poo (shampoo), what do they do?

For those who are participants in the ‘no poo” movement and don’t use shampoos, common substitutes include simply using water alone, using apple cider vinegar, baby powder, dry shampoos or using baking soda.  I believe that many of such practices are well tolerated for most people. However, those with color treated or relaxed hair may find that that high pH of baking soda (up to 10-12) to be particular harsh on their hair and increase the chance of damage and hair breakage.  

 

3. Does frequent shampooing trigger your scalp to make more oil?

It’s true that the use of shampoo removes oils from the scalp. These oils are helpful to condition the hair – and might be regarded as nature’s best conditioners. At present, however, there is no scientific proof that the scalp compensates for frequent shampooing by in turn producing more oil. The amount of oil that our scalp produces is genetically determined, and to a much lesser degree by the foods we eat, hormones, seasons and the environment. Changing your shampoo practices won’t reset your oil production. That factory is deep under the scalp (in glands known as sebaceous glands) and not influenced by how you shampoo. It would be nice to think otherwise – but there’s simply no proof.

4. How often should you shampoo?

There is no magic number for how often we should shampoo. In fact, the number is different for everyone.  Those with fine, oily hair are going to benefit from daily shampooing as the oils tend to weigh down the hair. Those with coarse and curly hair can go much longer as the hair will actually look better when not washed so often.   The same is true for those with color treated or relaxed hair – washing less frequently is preferred to further limit damage to already slightly damaged treated hair.  Once or twice a week is likely just fine. Although we certainly shampoo our hair too often, washing the scalp daily is unlikely to cause harm. Furthermore, there is no evidence that avoiding shampoo altogether offers a health benefit. In other words, the no poo movement is a personal choice, not a health choice.

5. Are there any adverse effects of not shampooing ?

Individuals with existing scalp problems could develop a ‘flare’ of their scalp disease with cessation of shampooing. For example, I’ve seen many patients who forgo shampoos that develop worsening dandruff and seborrheic dermatitis ( which is a close cousin of dandruff). It’s usually mild and tolerable. To understand why this occurs, it’s important to understand that dandruff and seborrheic dermatitis are caused by yeast that lives on our scalps.  These yeast feed off scalp oils. Excessive oiliness from not shampooing provides this yeast with an abundance of food and in turn further exacerbates the patient’s scalp problem.  The no poo decision might not be for everyone.

6. If you’re going to shampoo, should you go sulfate free?

For those who decide that the no poo movement might not be for them, a common question then arises – what about joining the sulfate free movement? Certainly, sulfate free shampoos are popular. If you’ve used a sulfate free shampoo you immediately notice they don’t lather up quite as well as a shampoo containing sodium lauryl sulfate or ‘SLS‘. The main downside of these shampoos is not their lathering ability but the fact that SLS shampoos are a bit more drying and are more likely to lift the cuticle and cause damage for those with color treated or relaxed hair. The can also cause irritation for those with scalp problems, including eczema.  The vast majority of people in the popular will notice little difference to their hair from using a sulfate free or SLS containing shampoo.  Decisions on whether to use SLS shampoos for other reasons (including environmental) are still being researched. However, from the perspective of the hair – the vast majority of people will not achieve better hair care from sulfate free shampoos.

Conclusion: Are you giving up shampoo?

Hair is personal. Hair helps define who it is we are and how we present ourselves to the world. Our hair is central to our self identify. If you don’t want to shampoo your hair – don’t shampoo your hair. There are a small number (but manageable number) of risks. Similarly if you want to shampoo your hair frequently, shampoo it. Change up your brands.  Enjoy all that shampoos offer in further defining what is personal, individualistic and what defines our feelings of self identity and self-expression.  There are risks to many things and it simply comes down to being well informed.  Humans quickly learn what shampooing frequency is right for them.

Do physicians understand how much hair loss affects their patients?

Do physicians understand emotions of hair loss?

Some patients are extremely distressed by hair loss, even if the amount of hair loss is minimal.  Are doctors very good at picking up how a patient's hair loss affects their quality of life?

Researchers from Chicago examined set out to determine if dermatologists can predict how much their patients' quality of life is affected by their hair loss. The researchers examined 104 women with three hair loss disorders (androgenetic alopecia, telogen effluvium and alopecia areata).

Dermatologists downplay hair loss severity

The researchers found women rated their hair loss as more severe than their dermatologists rated the hair loss. Moreover, the degree of a patient's hair loss did not correlate with how much patient's quality of life was affected. For example, some with minor amounts of hair loss were quite distressed by their hair loss whereas some patients with more extensive loss were minimally affected.  Interestingly, the amount of hair loss a patient perceived they had experienced did correlate with how much it impacted their quality of life.

Implications of hair loss study

This study has important implications for physicians who see patients with hair loss. If physicians want to understand how a patient is affected by their hair loss, they need to ask patients just how much hair loss they perceive to have occurred.  I generally try to get a sense of this by asking patients "how much hair loss do you think you've had - ....a little bit? ... a moderate amount? ... or a lot?"



Reid EE et al.  Clinical severity does not reliably predict quality of life in women with alopecia areata, telogen effluvium and androgenetic alopecia. J Am Acad Dermatol 2012; 66:e97-102

 

Dr. Donovan on Discovery Channel's Daily Planet

Back in 2010, I was interviewed by Ziya Tong, the co-host of the Discovery Channel's Daily Planet show.   Our topic was hair (and fur!). I've posted a link to the Daily Planet segment below. Enjoy!

Watch video

Mattel to Design Friend of Barbie with Alopecia

Mattel Inc, the makers of the Barbie doll, announced last week that they would be designing a doll without hair in order to support children with cancer or alopecia.

An important driving force for Mattel to create the doll comes from a Facebook group “Beautiful and Bald Barbie.” The group was founded by Jane Bingham of Sewell, New Jersey after she lost her hair during cancer chemotherapy treatment and realized how upset it made her 9 year old daughter. The group petitioned Mattel to produce a doll without hair.

The Facebook group originally declared their goals on their Facebook page long before Mattel took note:

We would like to see a Beautiful and Bald Barbie made to help young girls who suffer from hair loss due to cancer treatments, alopecia or trichotillomania. Also, for young girls who are having trouble coping with their mother’s hair loss from chemo. Many children have some difficulty accepting their mother, sister, aunt, grandparent or friend going from long-haired to bald.

The Mattel company has announced that the doll will come with wigs hats and scarves.  The doll won’t be sold in stores but rather Mattel will donate the dolls to children’s hospitals in the United States and Canada as well as the National Alopecia Areata Foundation. For now, it will be difficult for young children with parents who have alopecia from chemotherapy or parents with alopecia areata to get a doll, but that could possible change in the future. For now, the dolls are only given to children with hair loss from cancer chemotherapy, alopecia areata (areata, totalis and universalis)  or trichotillomania.

Although the news release has been met with some criticism, there are certainly many benefits of a doll for children with alopecia and for children with parents or relatives with alopecia.  Talking about hair loss can be difficult for many people and talking about it openly can sometimes be difficult. This doll has the potential to open up conversation not only between parents and young children but with other siblings and friends as well. I have many young 2-6 year old girls in my practice who love and adore their dolls with hair and use the doll as source to open conversation with their parents, grandparents or friends.  I can only image how a doll without hair will further help young children cope with their hair loss.

The dolls will likely be distributed to children in early 2013.

Dr. Seuss and Coping Strategies in Children

Some people are surprised to learn that children can be affected by hair loss. Conditions such as alopecia areata, tinea capitis, trichotillomania, traction aloepcia and telogen effluvium can affect children. Most of the very young patients in my practice have alopecia areata, an autoimmune condition which can lead to hair loss in circular patches, or total hair loss (alopecia totalis) or total body hair loss (alopecia universalis).

Children, like adults, develop strategies to cope with their hair loss.  These coping strategies change as the child ages.  Many children with hair loss find going back to school especially stressful. It’s a time when the coping strategies they have developed are put to the test.

Parents usually tell me if their child is having problems coping with hair loss.  When I am concerned about how a child is coping I sometimes ask the child an indirect question. In the months of August and September I frequently ask:

“What would you say to another child who had hair loss and was worried about starting back up at school?”

When most children hear this question, there is a pause. Most children smile or laugh and then look at their parents. Some start their sentence only to pause for an extended period. One child had clearly thought about this in great detail and had developed some useful coping skills. The child answered:

I would tell them ... to be who you are and say what you feel, because those who mind don't matter, and those who matter don't mind.  

I knew right away that these could not be the original thoughts of the child. Not the words of the parents, the grandparents, the teacher or a friend.  I soon learned from the child that these were the words of Dr. Seuss.  Today marks the 20th anniversary of the loss of Theodor Seuss Geisel (March 2, 1904 – September 24, 1991), better known as Dr. Seuss. The words in his 46 children’s books impacted millions of children, including at least one child who used these words as a coping strategy for hair loss. Every now and then I find myself quoting Dr. Seuss when talking to children and their parents about hair loss.

 

Hair Loss After Pregnancy

Hair loss is common after pregnancy and can be extremely distressing. It typically occurs between 3 months and 6 months and can last a further 6 months.  The medical term is “post-partum telogen effluvium.”  Current research suggests that a drop in hormones, especially estrogen, after delivery results in hairs being shed. 

Why does hair loss occur after pregnancy?

To understand why hair loss occurs after delivery, it's important to understand how hair grows normally and the changes that occur during pregnancy:

Before pregnancy

About 85-90 % of hair are in the active "growing" phase. These growing hairs lengthen in size by 1 cm each month.

About 10-15 % of hairs on the scalp in the inactive "resting" phase. These hairs are preparing to be shed.

For most women, this means that there are about 100,000 hairs on the scalp at any time and between 50 to 100 hairs are lost or "shed" every day.

During pregnancy

Due to rising estrogen levels, fewer and fewer hairs get "shed" from the scalp with each passing day. More hairs accumulate in the active growing phase.

This means that the total number of hairs on the scalp actually increases during pregnancy. Hair counts may rise from 100,000 to 110,000 hairs. The result is thicker and more dense hair. 

After delivery

A decrease in hormones, especially estrogen and progesterone, causes the balance of growing and shedding hairs to again be disrupted in an effort to return back to pre-pregnancy patterns.

More and more hairs are shifted from the growing phase into the shedding phase. The result is increased hair shedding – usually all over the scalp.

This phenomenon typically occurs around 3-4 months after delivery

Full hair re-growth should occur by 12 months. A small proportion of women will note that hair density remains less than before pregnancy.

What tests are needed?

Extensive testing is not required in most patients. The resetting of the hair shedding patterns is a completely normal phenomenon, and there is no treatment or cure for post-partum hair shedding. I sometimes order blood tests to make sure that iron and thyroid levels are normal but only if there is some indication this may be a problem. All in all, I advise women that hair density should be regained by the time of celebrating their son or daughter’s first birthday.  Very rarely, hair shedding can extend to 15 months. If hair shedding does not stop, further investigation into other causes of hair loss should be undertaken.  Hair loss during pregnancy is abnormal, and I recommend women with hair loss in pregnancy seek medical advice.

Practical Advice for Women with Hair Shedding

1. Wash and shampoo as often needed.  More hair will come out on the days that the hair is shampooed but this will not affect the long term density of hair.  The use of a volumizing or thickening shampoo may help the hair look fuller and feel thicker.

2. Use a conditioner formulated for fine hair. I recommend that women with shedding avoid heavy conditioners as these tend to weigh down the hair. A conditioner formulated specifically for "fine hair" tends not to weigh the hair down as much.  The conditioner should be applied only to the ends of the hair.   If it is applied to the scalp and the entire hair it tends to weigh the hair down.

3. Avoid hair styles that puts stress on the hair.  This includes tight braids, pigtails, cornrows, or a tight pony tail. These hair styling practices can lead to more hair being pulled out.

4. Avoid excessive combing of hair when it is wet.  This can lead to more hair breakage. The use of a large tooth comb can be helpful.

5. Eat as healthy as possible.

6. Talk openly about hair loss concerns. With so much focus on the new baby, there is often little attention given to the concerns of the new mom. It is normal to be worried about hair loss. Talking with others, especially other mothers who experienced hair loss, can be helpful.

7. Wear a wig or hairpiece for a short time if it helps cope with hair loss. Very rarely, a new mom with extensive hair shedding will ask whether wigs or hair pieces are safe or whether they weigh down the hair and prevent it from breathing. Wearing a wig or hairpiece is completely safe. This can be a helpful camouflaging option for women whose scalp can be seen.

8. Consider cutting the hair shorter. This will give more lift to the hair and weigh it down less. This can help camouflage hair loss to some degree. However, cutting hair won’t make the shedding stop faster or hair grow back quicker.  Shorter hair can also be much easier to manage.