Quantifying Hair Loss: Just How Much Hair Loss Has Occurred?

Quantifying Hair Loss:

All humans experience hair loss on a daily basis. But the key question is – “is this amount of hair loss abnormal?”  How do we evaluate whether there has been a lot of hair loss or just a little.”

It’s normal to lose between 50-100 hairs per day. This means its normal to see some hairs  in the brush, in the sink and in the shower drain. But when do we cross the boundary between normal and abnormal?? 

Most people intuitively know if the amount of hair loss they are experiencing is abnormal.   But, when I meet a patient I try to get a sense of just how much hair loss has occurred – and just how fast the hair loss has occurred.  These are extremely important to quickly get a sense of.

a)    Photos.  Comparing photos is sometimes a good way to get a sense of how much hair loss a patient has experienced.  How different does the individual look in their driver’s license photo compared to the way they look today?  Was the photo taken 6 months ago or 6 years ago?

b)   Daily Shedding. How much hair “shedding” is occurring on a daily basis? Are the drains clogged? Is their hair coming out in the food? Does the patient ever count the number of hairs shed on a daily basis?

c)    Pony tail. For women who wear their hair long, the size and thickness of the pony tail can be helpful in assessing the amount of loss. How much thinner is the pony tail than before? How many turns of an elastic band are needed now compared to before?

d)   Styling. How long does it take the individual to style their hair to cover their hair loss? An individual who once took 15 minutes but now takes 45 minutes or 1 hour has considerable loss.

e)     Spontaneous comments from family and friends.  Most of the time, a family member or friend will comment on hair loss only when it has become significant.  But I often ask patients if they have received spontaneous comments from others on their changing hair density.

f)     Patient estimates. It’s sometimes hard for patients to quantify their hair loss but I generally ask.  Specifically, I try to get a sense of the percent reduction in hair density. Has the patient loss 40 % of their hair volume in the past year? Is it 20 % ? Is it 60 %?

Quantifying the amount of hair loss is important. It helps give a sense of just how much hair loss has occurred and helps guide certain diagnoses as well. For example, consider the 26 year old woman who has lost 60 % of her hair density in the past one year and looks completely different than her driver’s license.  Although she may have been told she has female pattern hair loss, one thing is for certain- she has something else going on in addition to or besides female pattern hair loss!!! She might have female pattern hair loss, but other causes need to be explored, including a variety of hair shedding problems. Female pattern hair loss is a slow process and would not be consistent with a loss of 60 % density in one year. 

Quantifying the amount of hair loss is extremely important.

 

Hair Loss in Women: Often More than a Single Cause!

Hair Loss in Women: Often More than a Single Cause!

Hair loss among women is common. Although it's natural to think there is a single cause of an individual's hair loss, women often have more than one reason for their reduced hair density or 'hair thinning.'

Example: Consider the 32 year old woman who came into see me for her first appointment. She told me that she had been using minoxidil topical lotion for a 8 months now for a presumed diagnosis of:

Presumed diagnosis:

1. Female Pattern Hair Loss (also known as androgenetic alopecia).

However, she felt her hair was not getting better. She had some annoying scalp itching from time to time and wondered if she should stop the mionxidil as she was told the lotion could sometimes cause itching.

Is this the correct diagnosis? What should she do to stop her itching?

Join me as we pursue the necessary "detective work" to come up with the correct diagnosis for this woman and ultimately help her hair improve. First, lets take a look at her scalp up close:

Is this normal? Is it abnormal? Well, let's compare this photo to a relatively normal appearing scalp from a similarly aged woman in my practice with good hair density and extremely healthy hair. You'll note that all the hairs are fairly similar size (calibre) and the scalp itself is not red and their is no scaling or flaking:

Now that we know what is normal, let's return to the 32 year old woman with hair loss. Many things can be seen by examing this woman's scalp. First this woman has many 'thick' hairs. The light blue arrows show the thick hairs (also called terminal hairs).

However, this woman also has many thinner hairs with greatly reduced calibre (skinnier hairs). These thinner hairs are known as "miniaturized hairs" and the green arrows below point to several miniaturized hairs. Miniaturization is frequently seen in individuals who have a diagnosis of "androgenetic alopecia" (also called female balding or female pattern hair loss):

So I know this woman has androgenetic alopecia as one of her diagnoses.  But the other thing that is noted is that she not only has many skinnier hairs, but she also has a significantly reduced number of hairs.  You can see that the hair density that is seen in the top of the picture is very different than in the bottom of the picture  - the blue stars show the "missing hairs." So we know that she has lost a lot of hair.  

By gently pulling on several of her hairs, I discover that many of these remaining hairs come out pretty easily. This is called a "positive pull test" and this test is a sign this woman may have excessive shedding ( a phenomenon called telogen effluvium). In fact, the orange arrows point to many of these telogen hairs - which are farily easy to spot in this photo because telogen hairs become much lighter in color as they are about to shed from the scalp. So we are gaining some good evidence that this woman has an abnormal shedding problem:

As I described in a previous  video, there are many causes of exessive or abnomal shedding. The include low iron levels, thyroid problems, crash diets and a variety of medications. Basic blood tests performed in this patient showed she had very low iron levels. Further details also revealed she had multiple cycles of crash dieting in the past one year. These are certainly two potentially important causes for her shedding.

Further examination of her scalp showed that there is redness in the scalp and some scale. The red arrows in the photo below point to this scale:

There are many causes of scale but this woman scale and the redness in her scalp is typical of a condition called seborrheic dermatitis. Scalp "dandruff" and seborrheic dermatitis are two closely related processes and are caused by a common yeast called Malasezzia. Seborrheic dermatitis is very common and causes scalp itching and redness and excess flaking. Often patients notice that their scalp feels better if they wash their hair more often as this helps reduce the annoying itch they sometimes experience. Seborrheic dermatitis may cause itching but doesn't typically cause hair loss. Additional questions showed that this woman had scalp itching long before she started using the topical minoxidil therapy - so her itching may be coming from her seborrheic dermatitis rather than the minoxidil ! However, both are possible.

So at this point, it appears this woman does in fact have female pattern hair loss, but she also has three other diagnoses:

1. Female pattern hair loss (also known as androgenetic alopecia).

2. Telogen effluvium (exess hair shedding) - from low iron levels

3. Telogen effluvium (exess hair shedding) - from crash dieting

4. Seborrheic dermatitis

But is this ALL she has?

For this patient, further questioning revealed that the cause of her low iron was very likely from heavy and sometimes irregular menstrual periods. She could go several months without a period. Additional blood work and an ultrasound of this woman's ovaries showed that she in fact had a condition known as polycystic ovarian syndrome or "PCOS."  Women with PCOS have altered hormone levels which can cause hair thinning.  The altered hormone levels are produced by the ovaries. Early diagnosis of this condition is extremely important as women with PCOS have a higher chance of developing diabetes, high blood pressure, infertility and high cholesterol.  She was referred to an endrocinologist for further evaluation of her PCOS.

Final diagnoses for this woman: 

1. Female pattern hair loss - with Polycystic Ovarian Syndrome

2. Telogen effluvium (exess hair shedding) - from low iron levels

3. Telogen effluvium (exess hair shedding) - from crash dieting

4. Seborrheic dermatitis

How was this woman ultimately treated?

This woman was continued on her topical minoxidil therapy as it was concluded this was NOT a cause of her particular symptom of itching.  On account of her diagnosis of PCOS, she was advised to start on a birth control pill to regulate her periods. Oral Spironolactone medication was also started to help her androgenetic alopecia. Iron pills were prescribed to help the low iron levels and blood work was performed every 5 months to ensure the iron levels were rising properly. The woman's diet was stabilized to ensure that no further crash dieting would occur. The seborrheic dermatitis was treated with an anti fungal shampoo and this helped stop her itching. An improvement in hair density was noted in 6 months.

Conclusion

Diagnosing hair loss in woman often requires a bit more detective work than hair loss in men. Hormonal issues, and hair shedding conditions are more common in women than men. One should never assume that a patient has a single diagnosis for their hair loss -- all causes need to be explored. This can only come with a very detailed history about the patients hair loss, past health, diet, medications, family history and a very detailed examination of the scalp.

More Benefits of Checking Iron Levels in Women with Hair Loss

Checking Iron Levels in Women with Hair Loss

As many of my patients know, iron metabolism is one of my favourite subjects. It also forms one of the components of the hair loss research that I do. 

I generally recommend that all women with concerns about hair loss have their iron levels checked using the simple blood tests called ferritin. Other blood tests may also be ordered for women with hair loss, such as thyroid tests and a complete blood test to measure the hemoglobin level.

Although it is somewhat contraversial among hair experts around the world, the iron level I like my patients to aim for is a ferritin level above 40-50 ug/L.  If the blood test shows less than this, then I recommend supplementation with iron pills.

New research outlines additional benefits of checking iron levels in women

In a recently published study, Swiss researchers studied 198 premenopausal women who had ferritin levels less than 50 ug/L and symptoms of fatigue. A proportion of women in the study received ferrous sulphate pills and another proprotion of women received placebo pills.

 

What were the results of the study?

At the end of the 12 week study, women who received iron noted a significant improvement in their overall level of fatigue compared to women receiving the placebo pills.  The ferritin level in women recieiving the iron pills increased by approximately 12 ug/L over the 12 weeks of the study.

 

Comment

Many premenopausal women have low iron levels. This study reminds us that there are many improtant benefits of iron, including helping improve the overall feeling of fatigue (if levels are low). Although I routinely follow iron levels in  my patients, this study reminds us that asking about improvement in fatigue levels may also be an important parameter to assess in making a decision about continuing iron supplements for the longer term.


Reference

Vaucher P et al. Effect of iron supplementation on fatigue in nonanemic 
menstruating women with low ferritin: A randomized controlled trial. CMAJ 
2012 Aug 7; 184:1247. (Click link for article)

 

What are the Causes of Hair Shedding?

It's normal to shed between 50-100 hairs per day. When more than 100 are lost, it may be abnormal. Abnormal or excessive hair shedding is known by the medical term "telogen effluvium."

There are many reasons to have hair shedding.  These include physiological stresses on the body (like having a surgery), thyroid problems, crash diets, low iron levels and certain medications. These can all cause hair shedding.

The following video on hair shedding was prepared by Monica Matys of Sunnybrook Hospital in conjunction with the Sunnybrook Media department. I hope you will find it educational and informative.

Telogen Effluvium: Remembering Life's Events

Telogen effluvium is a common hair loss condition.  Patients note increased hair shedding - and hair starts collecting everywhere. There is hair around the house, hair on the floor, hair in the brush, hair in the sink, hair in the shower drain, hair in the car, hair at the office.  Spouses start to notice that there is more hair around than there used to be.  Even young children start picking up their parents hair and commenting that too much of mommy or daddy's hair is coming out. This is telogen effluvium.

Hair shedding can be caused by a wide range of 'triggers.'  These include physiologic stress, endocrine problems (including thyroid problems), nutritional problems, iron deficiency, and medications.  Other scalp diseases, including alopecia areata, and scarring alopecias can also cause hair shedding but these are different from telogen effluvium.

Sometimes it takes a bit of detective work to figure out what might be the trigger of a patient's hair shedding.  In many cases we find the cause, but in some cases we don't and just wait for the shedding to stop. 

There are many things I enjoy about being a hair doctor - but one aspect in particular I enjoy is pinpointing exactly in time when someone's hair loss 'trigger' might have occurred.  This usually occurs in a couple of classic scenarios.

Let me explain.

Suppose I see a patient who is worried about their hair shedding.   They tell me that the shedding used to be really bad a few months ago but is actually starting to get back to normal. After asking dozens of questions I proceed to examine the scalp.   I look for signs of various hair diseases, and there does not appear to be any.  Then as a final step, I lift 50-100 hairs straight up and - voila - I see a remarkable number of 3 cm hairs.  Normally, I would expect to see hairs of all different lengths - some 1 cm hairs, some 2 cm hairs, some 3 cm hairs, some 4 cm hairs and so on. But the patient in our example has many many 3 cm hairs. In fact - way too many 3 cm hairs!

What does this unusual number of 3 cm hairs tell me?

Well, it tells me the patient had some major trigger of hair shedding take place about 6 months ago. 

After a trigger like a surgery, or a crash diet, the hairs of some individuals can be rapidly shifted into a resting period called the "telogen phase". These hairs spend a mandatory period of three months in the telogen phase and then all get shed from the scalp at a similar time.   Because hairs normally grow back at a rate of about 1 cm per month - if I see alot of 3 cm hairs, I know they've been growing back for about three months and I know the trigger must have occured about 3 months before that - for a total of six months.

So when I see lots of 3 cm hairs, I know there was some major trigger about 6 months ago (3+3=6).When I see lots of 5 cm hairs, I know there was some major trigger about 8 months ago (5+3=8). When I see lots of 7 cm hairs,  I know there was some major trigger of hair shedding about 10 months ago (7+3=10). It's as simple as that.

 So for me, telogen effluvium can sometimes boil down to helping patients remember life's events.  If the patient's shedding has stopped and they are growing back their hair, I can often pinpoint when the hair loss occured.  If the shedding is ongoing and has not yet stopped, a bit of detective work especially blood tests, will be necessary.

So for the patient with 3 cm hairs, there is one simply question that can clinch the diagnosis... What happened in your life 6 months ago?  It sometimes takes patients a little bit of time and sometimes a calendar even gets pulled out from a bag, but the trigger often comes from remembering life's events:

Oh, now that you mention it, I was in the hospital, sick as a dog!

or ... That's when I started this new drug

or ... That's when my dad passed away

or ... That's when I have a bad flu and was off work for weeks

or ... That's when I had my surgery

The list goes on and on. Telogen effluvium can sometimes be challenging to diagnose. Every patient needs some basic blood work to make sure that there is no thyroid abnormality and no significant iron deficiency that caused the hair shedding. But if the hair shedding has already slowed down and is starting to grow back, one can often pinpoint exactly in time when the shedding started and then narrow down the exact cause.

The Seasonality of Hair Shedding

The Seasonality of Hair Shedding

As the Autumn in Toronto transitions from summer to early autumn approaches, I'm reminded of a remarkable feature of human hair growth - the increased tendancy for humans to shed hair in the early Fall.

Several research studies have shown that humans living in northern regions tend to shed more during the late summer and early autumn months.   Most of the time this goes undetected, but some individuals do notice this feature. A second phase of increase shedding in human beings may occur in Spring as well.

What causes hair shedding?

Of course, anyone coming into the office with concerns about hair shedding requires a thorough evaluation to determine the causes of increased hair shedding. These many include:

Physiological stress (i.e. surgery, labour and delivery, systemic diseases of the body, infections)

Endocrine problems (i.e. thyroid abnormalities)

Nutritional deficiencies (i.e. low iron, dieting)

Medications (i.e. anti-depressants, ACE inhibitors, heparin, beta blockers, lithium)

In addition to a thorough history and scalp examination, a patient with concerns about hair shedding requires blood work for complete blood count, thyroid studies and iron studies. Other studies may be needed as well.  All in all, there is a periodicity to how humans normally shed hair. Although loss of 50-100 hairs each and every day is considered normal, slightly increased rates can be observed in the Fall.

References of Interest

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

2) Kunz M et al. Seasonality of hair shedding in healthy women complaining of hair loss. Dermatology 2009; 219: 105-10.

3) Randall CA and Ebling EJG. Seasonal changes in human hair growth.  Br J Dermatol 1991; 124: 146-51.

 

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.

Drugs and Hair Loss: Is it Common?

Many patients with hair loss tell me that they think one of the medications they take caused their hair loss. How can I tell if this is the case?      

First off, sometimes it’s not possible to tell at all. Sometimes it’s only possible to give an “estimate” of how likely it is that a medication caused hair loss.  If a patient started a medication in January and notices hair loss in March or April of the same year, that increases the likelihood that that medication caused hair loss. However, there are dozens of other reasons why the patient may be losing hair and these have to be carefully explored.

Furthermore, some medications are more likely to cause hair loss than others.  These include blood pressure medications such as beta blockers or ACE-inhibitors, psychiatric medications such as lithium, SSRI antidepressants, allopurinol and vitamin A related medications.  Heparin blood thinners are also sometimes the cause of hair. These drugs typically cause a hair shedding condition known as "telogen effluvium." Cancer chemotherapy drugs also cause hair loss, and often this is a specific type of more profound hair loss called "anagen effluvium." There are over 500 medications that can cause hair loss, but these examples are some of the most likely.

Overall, hair loss due to a medication is not very common.  More times than not, another explanation for a patient’s hair loss can be found.

Iron and Healthy Hair

Iron has an important role in hair growth.  But consuming too much iron could potentially be harmful rather than helpful.  Patients often wonder if they should be consuming more iron to their help hair loss. Do you really need more iron?

Iron deficiency is the most common nutrition deficiency in North America. Iron deficiency refers to a state when the storage levels of iron in the body are reduced. When iron storage levels are reduced enough, the body can’t make enough haemoglobin and can’t make enough red blood cells to carry oxygen around the body.  When the haemoglobin levels drop below a certain level, a condition develops called "anemia."   Therefore, an individual may develop iron deficiency first and then develop anemia over time.

Iron deficiency is common and there are many causes. In fact, there are dozens of reasons to have low iron. It’s important to check with a physician to evaluate specific causes of iron deficiency.Iron deficiency is especially among pre-menopausal women on account of blood loss from menstrual cycles.    Because iron has an important role in hair growth, I routinely ask patients to get blood tests to measure haemoglobin levels as well as various iron tests.  The most common iron test is called the ‘ferritin test.’  For optimal hair health, I recommend patients take increase their daily intake of iron until ferritin levels rise above 40-50 ug/L. Levels below 20 ug/L can often be associated with hair shedding even if the patient has not yet developed an anemia.

If haemoglobin levels or ferritin levels are low, I recommend the patient be evaluated by a physician.  Sometimes an individual simply needs to consume more iron. This can come from meat, chicken, fish, grains and eggs as well as other foods.  Patients with significantly reduced iron levels, may also be advised by their doctor to take iron tablets.  

Telogen Phase: Exit Strategies for Hair

When I teach doctors about hair loss, I often begin by telling them that hair loss from the scalp is a normal phenomenon.  From the time a hair follicle first surfaces above the scalp, it is programmed to eventually be lost or "shed" from the scalp.  All hair follicles come programmed with an exit strategy. In fact, hair follicles have a meticulously regulated mechanism for every aspect of their growth.

All hair follicles proceed through four phases as they grow.  These phases are called anagen phase, catagen phase, telogen phase and exogen phase.  Hairs on the scalp spend about 2-6 years in the anagen phase, 3-5 weeks in catagen phase and 3 months in telogen phase.  At the end of telogen phase, hair follicles are shed in the exogen phase.  As these follicles fall out of the scalp and a new hair follicle pushes up from below.  All hair follicles come programmed with an exit strategy. It’s called exogen. This is why hair loss is a normal phenomenon.

If you reach up an grab a strand of hair on your scalp, it's likely in the anagen phase. In fact, 90 % of hairs on the scalp are in anagen phase. Less than 1 % of hairs are in catagen phase. 10 % are in telogen phase. 

Every day about 100 hairs on the scalp find themselves in the exogen phase and are shed from the scalp.  This is an important statistic to remember: the normal rate of daily shedding is about 100 hairs.   Loss of more than 100 hairs per day is abnormal and indicates excessive shedding.  A comprehensive evaluation will usually reveal the cause of a patient's excess shedding.