Increased Shedding of Hair without Appreciable Loss of Density (ISHWALD PHENOMENON)

Can one have increased shedding without a change in pony tail diameter or density?

Hair loss is a normal part of being human. Everyday between 30-120 hairs are lost from the scalp. Hair shedding can certainly be much higher on a wash day. I’m often asked if it’s possible to have increased shedding without really having a change in the density of the hair. For example, the patient says “I’m losing more hair on a daily basis than I used to… but I feel my density looks just the same.” What could be going on?

Increased Shedding of Hair without Appreciable Loss of Density (ISHWALD Phenomenon)

Most people are experts in themselves. After all, few people really know a patient’s hair better than the patient themselves. When a patient notices that their rate of shedding is higher than normal, they are usually correct. Most people who have increased shedding feel that they’ve lost density too. They feel some part of the scalp is just not as thick as it once was. We see shedding PLUS a change in hair density in lots of different conditions such as telogen effluvium, androgenetic alopecia. lichen planopilaris, lupus, marked seborrheic dermatitis, and many others too.

But what about when someone has increased shedding but they are NOT seeing any change in their density. More hair is coming out but they hair looks just a good as it always did. This is an important exercise for hair experts to work through! When I teach doctors about hair loss, we often work through examples of why I have come to call the ISHWALD Phenomenon - or “Increased Shedding of Hair without Appreciable Loss of Density.”

MAIN CAUSES OF ISHWHALD

1) A Very Mild Acute Telogen Effluvium

Some people can have a mild acute telogen effluvium (acute TE) that does not really lead to much in the way of a noticeable change in density. These are usually individuals that have NO OTHER hair loss condition going on - especially no evidence of androgenetic alopecia. They start out with 100,000-120,000 hairs on the scalp and shed out a bit but still have 90,000-100,000 hairs remaining. Usually one can’t tell the difference between 90,000 and 100,000 hairs especially if the hair is on the thicker side or curly (or both). Individuals with fine hair might be more apt to notice a change. But a patients with healthy hair with a bit of a seasonal shedding, or a bit of a shed from stress or low iron might notice increased shedding of hair without much in the way of a change in hair density.

2) Early and Slowly Progressive Androgenetic Alopecia

The very earliest stages of androgenetic alopecia may be associated with increased daily hair shedding. There may be months that go by where all the patient notices is increased shedding but the hair still looks quite dense. It’s only one day down the road that the patient comes out of the shower or stands under a bright light and says - “Oh my, I think my hair is getting thinner.” This type of phenomenon is more likely to occur in patients with a form of genetic hair loss that is very slow in progressive. Often this is a woman 35-50 with later onset AGA.

3) Mild Seborrheic Dermatitis (SD)

Dandruff and seborrheic dermatitis are closely related. They are inflammatory conditions that are common. 5-10 % of the world has seborrheic dermatitis and up to 50 % have dandruff at some point. Seborrheic dermatitis may give a bit more shedding in some people although it usually goes completely unnoticed. Seborrheic dermatitis may be associated with increased greasiness of hair. Some patients with mild SD find they are shedding more. If the SD is mild and there are no other conditions going on (like androgenetic alopecia or other forms of acute TE), they may find their density is maintained at quite a high level.

4) Chronic Telogen Effluvium (CTE)

Chronic telogen effluvium is a very special condition that typically happens in women 35-60. Affected patients with CTE often start out with extremely thick hair and then suddenly develop high rates of hair shedding. Surprisingly, the density may decrease a bit (or alot at first) but they remains the same for year after year after year. Patients are often shocked that they could possibly have any hair left on the scalp when they have so much shedding. This is CTE. Some patients just don’t appreciate the initial drop in density to realize that their density has in fact been reduced compared to the past. But the main point is that these patients maintain the same density year and year after years despite massive amounts of shedding. CTE is said to be a hair shedding condition not a hair loss condition per se.