What season do humans shed more hair? A new study in the British Journal of Dermatology suggests the answer is ... Summer. In fact, the order of most likely periods to have increased shedding is Summer followed by Fall followed by Winter. Spring was a time of least shedding in this study.
This study was interesting in its design because it looked at Google Trends over time. Searches for "hair loss" were found to fluctuate according to season.
Seasonal shedding is important to remember. If one starts a treatment in Fall and notice by Spring things are better... one must ask if the treatment did it or would the hair have just gotten better anyways on account of it being Spring. The same is true if worsening is observed in Summer.
Reference
Hsiang et al. British Journal Dermatology 2017.
https://www.ncbi.nlm.nih.gov/pubmed/18505526
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Telogen effluvium or "TE" refers to a form of hair loss associated with increased daily shedding. A TE usually starts 2-3 months after some type of "trigger" such as stress, low iron levels, a crash diet or start of a new drug. However, a TE can start within a matter of days for some people. There is a form of TE known as "immediate telogen release TE" which happens very quickly. The TE that happens when starting minoxidilis one of these "immediate" shedding forms. There are other mechanisms responsible for rapid hair loss too ... so TE is not always the cause. There are forms of diffuse alopecia areata which mimic TE and also occur rapidly without delay. I always advise patients continue close follow up with a physician if things don't improve.
There are many potential mimickers of a "TE."
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
L-lysine is an amino acid, which are the building blocks of proteins. Lysine is one of the more difficult amino acids to get in foods but it is found in meat, fish and eggs.
L-lysine has an important role in iron and zinc absorption. In 2002 D.H. Rushton demonstrated the benefits of l-lysine to increase iron and zinc levels and to reduce hair shedding.
Ruston reported 14 women who were deficient in zinc and showed that 1000-1500 mg of Lysine daily led to an increase in zinc levels from 9.7 to 14.6 umol/L - even without these women consuming zinc pills.
Similarly with iron, Rushton showed that 100 mg per day of iron in 7 women with chronic telogen effluvium did not change ferritin levels at all. However, when combined with L-lysine (again at 1000-1500 mg per day), ferritin levels increased from 27.4 to 58.6 ug/L. This was associated with a decrease in the proportion of hairs in the telogen phase from 19.5 to 11.3.
L-lysine is an important amino acid and I often recommend it for my patients with chronic shedding abnormalities and those with deficiencies of iron and zinc that don't respond to routine supplementation. If I do recommend L-lysine, the dosing is typically 500 mg twice daily, and rarely three times daily for short periods.
Hairs that are shed from the scalp are known as telogen hairs. These hairs lack pigment at the very end and do not have a root sheath around the ends either. Telogen hairs are known as "club hairs."
I always encourage my patients to bring in hairs they shed if they are worried about the type of hair they are seeing. 99.9 % of the time the hairs they see are telogen hairs. About 30-70 telogen hairs are released from the scalp each day. In some hair loss conditions (such as telogen effluvium), an increased number of telogen hairs are released every day
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Does normal hair shedding occur in an even distribution?
I'm often asked if hair shedding under normal circumstances occurs equally all over the scalp. In other words, if a person's daily shedding is 60 hairs, do 30 come from the front and 30 from the back?
Normal hair shedding
Normal hair shedding does occur equally. Hairs on the scalp grow independent of each other and so shedding occurs independent of other hairs too. If 60 hairs is a person's rate of daily shedding, then 30 would come from the front half and 30 from the back.
Shedding in hair disorders
If a person has a hair disorder (hair loss condition), the shedding may or may not be equally distributed. If the person has androgenetic alopecia (male balding and female thinning), then the shedding occurs much more in the area of thinning at the front. For example, in androgenetic alopecia the rate of shedding is slightly increased and perhaps 60 hairs would be shed in the front and 30 hairs in the back half of the scalp. If the person has telogen effluvium, the shedding is equally distributed all over the scalp - but at higher rates than normal. For example, patients with telogen effluvium might experience loss of 60 hairs in the front and 60 hairs in the back. In telogen effluvium, this could even be 200 in the front and 200 in the back but the key point is that the shedding is always equal. If the individual has alopecia areata as the reason for their hair loss, shedding may not be equal. Shedding could be as high as 300 in a small section of the scalp and just 30 in another area.
Conclusion
In general, in the absence of any hair loss condition, the shedding is the same all over the scalp.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Amphetamines are a group of drugs that stimulate the central nervous system. They have been used since the 1920s. Amphetamines are used in the treatment of attention deficit hyperactivity disorder (ADHD), narcolepsy and obesity. At higher doses, amphetamines are also drugs that are frequently abused.
Examples of amphetamines
Most amphetamines are prescription based and include drugs such as:
1. Dextroamphetamine
2. Levoamphetamine
3. Lisdexamfetamine
4. Methamphetamine
5. Adderall and Adderall XR
6. Dexedrine
7. ProCentra
8. Ritalin
9. Concerta
10. Dextrostat
11. Vyvanse
12. Focalin
13. Strattera
14. Zenzedi
15. Evekeo
Hair loss with amphetamines
Hair loss is a possible side effect of amphetamines. It does not happen to everyone but a proportion are affected. Hair loss typically occurs 4-7 weeks after starting. Daily shedding increases from well under 70 to above 100. Hair loss occurs all over the scalp rather than in any given area. Hair loss from amphetamines can also occur on the body hair.
Hair loss can be from the drug itself or the caloric and nutritional deficiencies that come from the appetite suppressing effect of these drugs.
Evaluation of the patient with suspected amphetamine induced hair loss
It is important for anyone with suspected amphetamine induced hair loss to see a physician. The first step is to determine if the timing of the hair loss and the type of hair loss pattern fit with a diagnosis of amphetamine induced hair loss. On some occasions, the hair loss and amphetamine use is simply a coincidence. If the amphetamine use is thought to be contributory, it is important to determine if the patient has a telogen effluvium from the actual drug, or from a nutritional deficiency that the drug has brought about or from another cause such as androgenetic alopecia. Blood tests are necessary for anyone with amphetamine induced hair loss to look for underlying nutritional deficiencies. Sometimes a hair collection or biopsy is also performed.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
It is normal to develop increased hair shedding within days of starting minoxidil. Hairs that are dormant and resting ( called "telogen hairs") are given a strong signal to leave the scalp immediately. This specific mechanism is called immediate telogen release.
Some people start minoxidil and then stop after a few days because they are either too worried about a side effect or they actually experience a side effect. They are surprised to find that they shed into week 2, 3,4 and sometimes even months - with just a few days of minoxidil use. The question they have is "how can this be possible."
The process has started and can't be stopped. Let's look at a few analogies I often share with my own patients.
If you started pushing a huge stone down a hill and then suddenly stopped pushing, you would see the stone keep rolling and rolling and rolling down the hill. You would not ask "Why is it still rolling? I stopped pushing." It makes sense to you that the process has been started and won't easily stop.
Or imagine a group of people at a party and suddenly someone pulls the fire alarm. Everyone gets up and starts running out of the building. It is soon realized that it is a false alarm and someone shouts "sorry false alarm - go back to enjoying the party!" Nobody can hear that it was a false alarm because of all the commotion. The process has started and can't be stopped.
It's the same with minoxidil. The dormant follicles are triggered to shed. The process has started. Some shedding will happen and may last a few months. It could be less than a few months for some people but for many it does last much longer than one might imagine. Eventually it will stop just like eventually the stone will stop (if the hill was not too steep) and eventually someone will realize it was a false alarm and come back to rejoin the party.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in 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.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
There are various phases of the hair growth cycle that you may have heard of such as anagen, catagen and telogen. Anagen is the growing phase. Catagen is the transitional phase. Telogen is the resting phase where hairs stop growing. At the end of the telogen phase, hairs shed from the body- and end up in our brushes, combs, and shower drains.
So what is the "exogen phase"? Well, for years it was thought that once a hair is ready to be shed, it simply leaves that scalp when a hair underneath pushes it out. We know now that is untrue. A hair can of course leave the scalp when enough tug is given to it. However, the departure of a hair from the scalp is now recognized to be a highly regulated process which is known as "exogen." Therefore, hairs are not simply pushed out of the scalp - the process is tightly regulated.
This picture shows the scalp of a patient with a telogen effluvium (hair shedding disorder). Upright regrowing hairs (URG) are seen. In addition, a telogen hair (also called a club hair) can also be seen. This hair has officially been shed from the patient's scalp. It is nested amongst the existing hair. At the time of the next patient's next shampooing or brushing it will likely be removed completely from the scalp.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
What kind of hairs typically go down the drain after shampooing one's scalp? Well, in nearly everyone these are hairs known as "telogen hairs."
Telogen hairs are hairs that have a long history. They were previously tightly rooted in the scalp and had spent many years growing (at which point they were called anagen hairs). But after years of growing without even a moment of rest, anagen hairs retire and become known as telogen hairs - and then drop out of the scalp. Telogen hairs lack a root sheath around the ends.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Telogen effluvium ("TE") is a type of hair loss where individuals experience increased daily hair shedding. Instead of losing 30-40 or 50 hairs per day, the individual experiences loss of 60, 70, 80 or more hairs in any given day. The numbers can exceed 500 depending on the cause of the shedding.
Common causes of TE include low iron (low ferritin), anemias, thyroid problems, crash diets, weight loss, stress, surgery, medications (ie lithium, some blood pressure pills, retinoids (vitamin A pills)). Any significant illness inside the body (ie flu, autoimmune disease) or on the scalp surface (ie severe scalp psoriasis or severe seborrheic dermatitis) can cause a telogen effluvium.
This picture shows a typical trichoscopic appearance of someone with a "TE." Numerous short pointy hairs, known as "upright regrowing hairs (URH)" can be seen.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Hair loss often occurs in women who start and stop birth control. This typically occurs 1-2 months after starting and stopping and can last 4-5 months. For some individuals it lasts 9-12 months.
For the vast majority of individuals, the abnormal shedding eventually stops and returns to normal shedding patterns- even without treatment. However, some women (small minority only) develop a chronic shedding pattern for an extended period of time and some notice that density does not make it back fully on account of an acceleration of underlying androgenetic alopecia.
In summary, most women will experience additional hair shedding for a few months after starting and stopping birth control. The excessive shedding will eventually slow and return to normal for most. Consultation with a dermatologist is advised if shedding persists after 6 months.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
In the early stages of androgenetic alopecia (first few years), miniaturized hairs grow almost the same length as original hairs (not quite but close).
As time passes, and if androgenetic alopecia progresses, them miniaturized hairs grow in the scalp for shorter and shorter periods. In advanced cases, hairs affected by androgenetic alopecia grow for only a 2-3 months - and are very, very short and very, very thin. We call these "vellus-like" hairs rather than miniaturized hairs but they are a type of miniaturized hair. Over time, vellus like hairs just don't grow any more.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Telogen effluvium is a form of hair loss where patients experience increased daily hair shedding. Instead of losing 40 or 50 hairs per day, patients with “TE” lose 80 to up to 600 hairs per day. A ‘pull test’ has traditionally been one of the methods that hair specialists are taught to perform when examining the scalp. To perform the test, 60 hairs are lightly grasped between the thumb and index finger and gently pulled upwards. Removal of more than 10 % of the hairs in the bundle (i.e more than 6 hairs) has been traditionally viewed as a positive pull test.
McDonald and colleagues from Ottawa, Canada performed a study revisiting this issues of what exactly constitutes a normal pull test and what limits should be set for abnormal. They studied 181 otherwise healthy individuals. The authors showed that for the vast majority of individuals, a pull test of 60 hairs extracts 0,1 or 2 hairs (97 % or more have 2 or less). The average was 0.44 hairs indicating that many individuals have no hairs removed. Interestingly, the date the patient last washed their hair, did not influence the pull test result nor did the frequency of brushing the hair. This is one of my favourite studies of the year. It is simple and elegant and answers a lot important questions. I have long abandoned the “6 hair rule” for the pull test, and frequently have told the dermatology residents and trainees that work with me that even a few hairs coming out is abnormal. I’m grateful for this well conducted study and it has renewed my interest in the pull test.
Reference
McDonald et al. Hair pull test: Evidence-based update and revision of guidelines. Journal of the American Academy of Dermatology 2017; 76: 472
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Telogen effluvium refers to a hair loss condition associated with excessive daily shedding.
The actual amount of increased shedding experienced by the patient can vary. For some, shedding is only slightly increased. For others, shedding can be massive.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Normal daily shedding is often quoted as "anything less than 100 hairs per day" but that has never been carefully studied and documented. The reality is that there is quite a range of "normal" and somewhere closer to 50-60 is probably closer to what most people experience (or at least can collect).
Of course, there is a wide variation on what is considered normal shedding.
It is incredibly challenging (and incredibly emotional) to have to count daily shedding each day. There are many methods (brushing, shampooing, collecting) to try to measure daily loss. They are helpful and I often use a variety of such methods, but they each have their limitations.
Even those with a clear "telogen effluvium" (increased shedding) sometimes return with 45 hairs collected in a particular day (rather than the magic number 100). Are they shedding excessively? Absolutely. Are they able to measure it properly and capture what is happening? No.
A key principle of shedding is if one is certain they used to lose 30 and now lose 65 hairs per day - this is likely abnormal and warrants further consideration.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
TE is a from of hair loss whereby the affected individual experiences higher than normal levels of hair shedding day to day. For example, instead of losing 40, 50 or 90 hairs in a given day (i.e. what is considered normal shedding) individuals experiencing telogen effluvium lose well in excess of 100 hairs on any given day.
Triggers of TE
Telogen effluvium occurs when some "trigger" causes hair follicles to leave the growing phase of the hair cycle and enter the resting phase. So, what exactly are the triggers that "send" a hair follicle out of the actively cycling (growing) phase and into the undesired shedding phase? I teach health professionals the easy to remember memory cue "SEND"
Recognizing whether a patient has genetic hair loss or telogen effluvium ... or both .... often requires listening to the patient's story about their hair loss in addition to examining the scalp and looking at the blood test results.
Many women have both.
Differentiating between AGA & TE
AGA often shows hair loss in regions rather than all over although it can certainly be all over. AGA is fundamentally characterized by hair follicle "miniaturization." The hair follicles get skinnier - this is not a feature of TE. Telogen effluvium is characterized by diffuse loss and waves of regrowth. Empty tracts where a hair once was found and upright regrowing hairs characterize TE. Patients with TE often have a trigger such as low iron, thyroid problems, nutritional issues, crash diets, stress or medications that lead to the shedding. Shedding in TE is more pronounced than in AGA.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Many patients who come and meet with me are candidates for hair transplants - but some individuals are not. For some individuals who aren't good candidates for hair transplants, this information may come as a surprise.
Who can have a transplant and who can not?
Individuals with certain hair loss conditions like genetic hair loss (also called androgenetic alopecia), traction alopecia are good candidates for surgery. Individuals with other conditions like alopecia areata, scarring alopecia and hair shedding disorders are not candidates for surgery.
Within 1-2 minutes of meeting a patient, I can usually determine if they are good candidates for surgery or not.
Consider the following patient (pictured on the left) who came to see me with concerns about her increasing hair loss in the centre of the scalp. At close examination and after asking her a series of questions, it became clear that her reason for hair loss was genetic. This made her a good candidate for surgery.
Consider now the woman pictured on the right in the photo. She looks just like the woman on the left. However, a series of questions followed by a detailed examination of her scalp as well as a scalp biopsy allowed me to utlimately diagnose her with lichen planopilaris which is a type of scarring alopecia. I was not able to perform a hair transplant on this woman as she was was not a candidate for surgery. Scarring hair loss conditions like lichen planopilaris can not be transplanted when they are in the active phase. If she had gone for surgery without being properly diagnosed, the transplanted hairs would not have grown well and perhaps not grown at all.
Not everyone is a candidate for hair transplant surgery. Only with a careful record of questions and a detailed examination of the scalp can all the other reasons for hair loss be excluded.
This blog has been filed into the following folders:
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Here is a recent question from our website visitor:
I have been visiting a dermatologist for 2 months now. My hair was coming out from the root in clumps. Half my hair is gone (thank god I have lots of hair). He has been giving me the cortizone shots. First time i Went he advised me to wash hair every other day and the last time i went he told me to wash every day. Now sometimes when I go a day without washing my hair my scalp hurts a lot. I can say with washing my hair every day its falling out less but it still falls out. I took test for iron and thyroid and everything came back ok. I do dye my hair and he ruled my hair loss from that but something is just not right. I know its only been 2 months but I want my hair back...badly. Should I just give it more time or should i see someone else. Will a natural remedy help or maybe scalp massages?
Dr Donovan's response:
Thanks for the interesting question. The key question is: what diagnosis was given for your hair loss? There are 100 causes of hair loss and cortisone injections can be used in over 20 of them!!! Most likely you were diagnosed with alopecia areata because that's the most common reason that cortisone injections are given. But cortisone injections are also used for scarring alopecia and other conditions as well. Without a diagnosis, I can't comment much more.
Washing your hair everyday or every second day is fine. If you have some seborrheic dermatitis in the scalp ( a distant cousin of dandruff) or if you are using alot of topical medications (lotions, creams), then washing your hair every day will just make it feel better. Patients with alopecia areata and scarring alopecia often feel better washing their scalp everyday too. It just feels better.
If you were diagnosed with alopecia areata, there's a good chance your hair will improve with injections. But whether it comes back fully is hard to predict. Please note that ccortisone injections do not help everyone with alopecia areata. If you are getting injections because you were diagnosed with a scarring hair loss condition (like lichen planopilaris), you probably won't improve much at all - but hopefully the cortisone injections will prevent your hair loss condition from getting worse. That's why we use cortisone injections for lichen planopilaris.
As you can see, the cause of your hair loss is critical to know before fully answering your question. Cortisone injections help some hair loss conditions but not all.
As for scalp massages, they have no benefit in any hair loss condition. As for natural remedies, most have not been well studied. One exception would be the use of aromatherapy for patients with alopecia areata. Check out the discussion I wrote a few years ago about this subject
Treating hair loss can sometimes be challenging. If you trust your physician's opinion, stick with him or her. You will hear many answers for your hair loss if you "shop" around. Make sure you ask what your diagnosis is and make sure you ask if hair regrowth is even possible in this condition.
This blog has been filed into the following folders:
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
