On the 'Natural Course' of Hair Loss Conditions

Giving credit where credit is due: A look at the reality of the ‘natural course’ of various hair loss conditions.

Many hair loss patients ask me if doctors give themselves too much credit when a patient has a successful outcome after a treatment. 

“My body might have done this anyways,” is often the comment I hear.

“How do you know that the natural course of my disease would not have been the same?”

Some patients who state that their body would have shut off their hair loss on its own are correct. But some are not. Let’s take a look at 5 common hair loss conditions and how likely it is for the hair to improve on its own.

EXAMPLE 1: Alopecia areata

Likelihood of improvement without treatment: low to very high

Alopecia areata is an autoimmune disease. About 2 % of the world will be affected by the condition at some point or another. What’s typical of alopecia areata is it’s potential to regrow all on its own - at least in a subset of patients. About 1/3 of patients will regrow their hair “spontaneously” in 6 months and another 1/3 will grow in back “spontaneously” within 12 months. About 1/3 of patients will develop a chronic form of alopecia areata some of whom will develop alopecia totalis and universalis.

Therefore, many patients with alopecia areata can successfully grow back hair even without treatment. Treatment helps it grow back faster and could theoretically reduce the chance of disease flares.

For patients with more advanced forms and patients with disease of longer duration - it’s less and less likely the hair will grow back on its own. If treatment is given in these cases, and the hair does grow back, it’s likely that the treatment (rather than the natural course) that is affecting the regrowth.

EXAMPLE 2: Acute telogen effluvium

Likelihood of improvement without treatment: low to very high

Acute telogen effluvium (or simple “TE”) is a type of hair loss whereby the patient experiences increased shedding. A variety of triggers can cause TE including stress, low iron, thyroid problems, medications and crash diets. In at least 50% of cases, a trigger can not be found in acute telogen effluvium and shedding continues.

In many cases of TE, the hair grows back spontaneously. A patient with a TE that was due to a general anesthetic received in the hospital often just needs time - NOT treatment. With the passage of time, the hair shedding will again slow and the patient will likely regain density (unless another condition is also present such as androgenetic alopecia). 

In this example, the natural course is towards regrowth. In fact, treatment if not needed because the body itself can do it all itself. I would even go further to say that offering treatment is completely inappropriate. To offer therapy of any kind if spontaneous regrowth is suspected is not good practice.

EXAMPLE 3: Chronic telogen effluvium

Likelihood of improvement without treatment: moderate

Chronic telogen effluvium is often mixed up with acute telogen effluvium but is a very different condition. For chronic telogen effluvium (CTE) cessation of shedding and regrowth can also occur. In fact, the classic teaching of CTE is that it is a ‘self-limiting’ condition. But what many people forget is that it can take 5, 10 or 15 or more years in some cases for a CTE to halt. Granted some are faster in their resolution. If a patient with chronic shedding for 2 years comes and sees me and we start treatment and shedding slows down in a matter of months am I to believe it was the therapy I gave or was this natural history of the condition? Odds would favour the treatment being responsible in this case.

EXAMPLE 4: Androgenetic alopecia

Likelihood of improvement without treatment: very low 

Androgenetic alopecia is a common type of hair loss. For men, it is referred to as male pattern hair loss, or male balding. When it occurs in women, it is referred to as female pattern hair loss or simply female thinning.  Without treatment, this type of hair loss is always progressive. It may, however, progress very very slowly for some affected individuals and may even stay relatively stable for some patients for long long stretches of time. It does not, however, improve spontaneously. A patient with androgenetic alopecia who says their hair is actually getting better on its own likely had another issue present as well in the past - such as a telogen effluvium. In that sort of example it’s the telogen effluvium that is getting better - not the androgenetic alopecia.

EXAMPLE 5: Scarring alopecia

Likelihood of improvement without treatment: very low

Scarring alopecias are a group of conditions that are associated with the presence of scar tissue in the scalp.  A variety of scarring alopecias exist including lichen planopilaris, frontal fibrosing alopecia, folliculitis decalvans and central centrifugal cicatricial alopecia. Without treatment all active scarring alopecias by definition will cause further hair loss. For some it can be quite slow (meaning it takes 1 -2 years before any further hair loss occurs). For others, it can be more rapid (meaning it takes just several months before any further hair loss occurs).

I occasionally meet patients with scarring alopecia who believe that there is a high chance their disease will burn out rather quickly. Many of these patients start treatment and experience an improvement in their hair shedding or symptoms and a cessation of further loss. On occasion a patient will ask me something like:

“How do you know my disease would not have just gone quiet anyways?”

or 

“How do you know the natural course would not have been to just go dormant and burn out?”

I’m not sure why it is that some patients feel that these scarring alopecias have such a high chance of spontaneous resolution. This is not accurate. For many patients, the immune response inside the body to destroy hair has been mounting for many, many years - even well ahead of the patient actually experiencing hair loss. It is not likely that that that sort of programmed immune response can simply shut off so quickly. I often say to patients that if it took 2, 5 or 10 years for the immune system to slowly reprogram itself to attack the hair, why would the disease stop in 6 months without treatment? Why would the ‘natural history’ be to stop.

Without treatment, most scarring alopecias grumble along with various levels of activity and slowly destroy hair. It’s true that scarring alopecia can eventually stop - but not for years in the vast majority of patients. Without treatment, some patients with scarring alopecia will find that every few months they are noticing they have less hair and look different. That’s considered fast progression. Other patients will find that it takes about two years for them to sustain enough cumulative hair damage to really appreciate a difference in their hair. That’s slow progression.

Conclusion and Summary

The ‘natural history’ of some hair loss conditions does favour improvement in density. In other words, even without treatment some conditions can improve. This is common for alopecia areata and some forms of acute telogen effluvium. Chronic Telogen effluvium (CTE) can most certainly improve on its own - but it usually takes a number of years. For scarring alopecias, the natural course is not one of rapid cessation of disease activity. A patient with scarring alopecia who sees improvement in the hair after starting treatment should not wonder “perhaps my scalp was going to do that anyways.” That is not the natural course of these diseases. Androgenetic alopecia is slowly progressive without treatment. The natural course (without treatment) is not one of improvement or cessation.