Nothing is more frightening than seeing few tufts of hair going down the drain after shampooing or combing, or hair scattered over pillow when one wakes up. Its important to note that hair fall of up to 100 hairs is natural. This is natural shedding and the hair will grow again. When there is consistent hair fall of over 150 hair per day, it is called hair loss. Hair loss is different from hair fall, in that the hair fall isn’t compensated by new hair growth.
Understanding the Hair growth and hair loss.
Normal scalp contains about 100,000 strands of hair. No new hair follicles develop after birth.
Normal hair growth pattern involves replacement of all hair in a cycle of three phases. Anagen is a phase of active hair growth. This phase lasts for 2-6 years. In this phase the hair has very good thickness and is dark colored. The follicle extends deep under skin and is long.
After this phase the hair follicle passes in to Catagen phase. This phase lasts for 1-3 weeks. The hair follicle shrinks, and hair does not grow. This phase is followed by Telogen phase. It lasts for 3-4 months. It is a resting period. The hair follicle is detached from the hair but the hair remnant fiber is still inside. After this round of Telogen, the Anagen phase begins again. The new hair grows and old hair fiber is gradually pushed out.
Alopecia is a medical term for hair loss.
What are the causes of Alopecia?
- Hereditary: This is the most common cause of alopecia. It is also known as Male Pattern Baldness or Androgenetic Alopecia. It is affects, the front, the center and the crown areas of scalp in varying degrees. It is caused by genetic sensitivity of hair follicle in these areas, to a hormone called dihydrotestosterone, DHT.
- What is DHT? Testosterone is a male hormone that is produced in gonads. About 10% of testosterone is converted into DHT. DHT is more powerful than testosterone.
- How DHT is responsible for baldness? Men who are genetically prone to baldness have a very high concentration of DHT receptors in hair follicles. Such hair follicles also have higher sensitivity to circulating normal DHT. When DHT binds to these receptors, it causes shortening of anagen phase. This means, the phase of active growth shortens. DHT also causes miniaturization of hair follicles. Scalp hair can be single or in the tufts of 2,3 or even 4 strands of hair. Miniaturization is a process where the number of hair in a tuft decreases. Eventually all hair in a tuft dies, leading to appearance of bald scalp.
- How common is Androgenetic Alopecia or hereditary alopecia? It is believed that as many as 50% of men develop hereditary alopecia. It means it runs in the family. It can be inherited from either the father’s side of the family or the mother’s side of the family. It affects people of 18-50 years of age. The degree of severity and the pattern of hair loss may also follow the pattern running in the family.
- Hormonal Causes: Hormonal diseases like thyroid abnormality can cause hair loss. Hormonal changes in body of women during pregnancy, after childbirth or around menopause can also cause hair loss. Women may also loose hair because of Polycystic Ovarian Syndrome (PCOS).
- Medical Conditions: There are certain medical conditions which can cause alopecia.
- Alopecia areata: This is a condition where patches of hair loss develop on scalp. It may be of the size of a coin. There may be many such patches. In most cases it is a treatable condition.
- Scalp infection: Recurrent fungal and bacterial infection can lead to hair loss. This can also cause scarring which may lead to permanent hair loss.
- Iron Deficiency Anemia: Iron deficiency anemia and deficiency of Vitamin D3 can cause hair loss. This is a reversible hair loss.
- Trichotilomania: It is a psychological issue where a person pulls his/her hair.
- Medications: Certain medicines used for treatment of cancers, high blood pressure, heart problems, depression and arthritis can cause hair loss. Some oral contraceptive pills also cause hair loss.
- Radiation Treatment to scalp can cause hair loss which may not be reversible.
- Temporary hair loss or thinning of scalp hair can occur after major illness or a major operation. It can also occur after massive weight loss or emotional stress like death of a beloved one. This condition is also known as telogen effluvium.
- Hair Treatments: Hair loss is often caused by the way we treat our hair. Following hair treatments can increase the hair loss. Following practices/ Traditions can damage the hair.
- Hair styles that tightly bind hair at the back, like braids
- Chemical treatments on hair such as chemical straightening
- Very hot drying of hair
- Hot oil and Permanents
- Repeated hair straightening and Curling
- Involutional alopecia: This means age related thinning of hair density. Scalp hair becomes thinner and reduces in number as a person grows older. This is a natural phenomenon and affects everyone.
Signs of Alopecia
As said earlier, hair fall of up to 50-100 hairs per day is normal. However, some generally agreed upon points about hair loss symptoms are:
- More than 20 hair strands in a brush in a single act of combing.
- Hairs seen on pillows after overnight sleep.
- Tufts of hairs falling off while shampooing.
Initial signs of alopecia are:
- Thinning of hair
- Receding frontal hairline
- Receding temporal peaks
- Thinning of hair and visibility of skin in the crown area
Over a period, the areas of alopecia increase leading to various stages of baldness.
Stages of Alopecia
Doctors classify alopecia according to a system of classification called “Norwood Classification” for alopecia in men. For female pattern baldness “Ludwig Classification” is followed.
Who needs treatment for baldness?
Treatment of hair loss is entirely on the individual. Usually, when alopecia affects a person psychologically leading to low self-esteem or it causes problems in career advancement etc, the individual seeks treatment.
Medical or non-surgical Treatments for Alopecia
Alopecia can be treated by Medical(non-surgical) or surgical modalities.
- Medical Treatments: Medical hair restoration remedies include use of local application and medicines. It must be done under medical supervision. Do it yourself approach may not give desired results.
- Minoxidil: It is available as Regaine, Tugain, Mintop etc in India. Minoxidil 2% or 5% solution or foam, are approved in the treatment of both Male and female pattern hair loss.
- How does Minoxidil act? Minoxidil improves blood supply to hair follicle and prolongs the anagen phase that is the phase of active growth. It is also believed that it interferes with potassium channels of follicle cells and inhibit the action of DHT. 5% Minoxidil is more effective both in men and women.
- How to apply Minoxidil? The recommended dose is 1 ml solution (or half cup foam) application morning and evening. It can be applied on mildly damp scalp after shampooing. 1 ml is approximately equal to 20 drops. Part the hair with your fingers and apply the solution drop by drop on the scalp. Wait for the solution to dry on the scalp. You may apply styling gel etc., after the solution has dried down.
- What to expect during the treatment? You may notice a slight increase in hair fall. This is a good sign of the action of the medicine as the older hair are gradually replaced. You should not discontinue the usage. It will take at least 6-8 weeks to stop the hair fall and at least 4 months for a visible hair regrowth. The hair will also start growing longer and thicker. When used continuously, approximately 52% lost hair can regrow over a period of one year. If at any point, the usage is discontinued, you will be back to the starting point over a period of 6-12 weeks.
- How long can one use Minoxidil? If you don’t see any side effects, you may use it for as long as you wish to.
- What are the side effects? The commonest side effects include dry, itchy scalp. Some may notice excess facial hair growth. This growth disappears within 4-6 weeks after the use is stopped.
- Can the routine hair care be continued? The routine hair care can be continued during minoxidil treatment. You must however, apply minoxidil first.
- Finasteride: This is the only approved oral medicine for the androgenetic alopecia. 1 mg finasteride in tablet form should be taken daily. It works by blocking conversion of testosterone to DHT. It stops hair fall in about 83% of patients and it leads to regrowth of hair in about 66% of patients.
- What are the side effects? Finasteride in 1 mg dose is a very safe and very well researched medicine. However, in 2% of users, it can lead to temporary decrease in sexual desire or poor ejaculation. In most cases, this will stop over a period of 2 months if the treatment is continued or once the treatment is stopped. Finasteride causing Prostate cancer is a myth as such incidences are very rare with 1 mg dose.
- Dutasteride: It is a medicine that works on blocking both the enzymes of DHT conversion. However, it does not offer any added advantage over finasteride and should be used only when finasteride has failed to give the results.
- Low Level Laser therapy: This is also known as LLLT. It uses infrared light. LLLT can be given by machines or Head gears.
- How does LLLT act? It is believed that LLLT acts by prolonging the anagen phase, inducing reversal of telogen hair to anagen phase and prevent induction of catagen phase.
- LLLT treatment protocol: It is generally recommended that the LLLT should be given for 8-10 minutes. The therapy should be continued for 4-8 months to see some appreciable results.
- PRP: PRP is a short form of Platelet Rich Plasma. Platelets are already present in blood. They release several useful growth factors when injected in concentrated form. It is prepared from the person’s own blood. About 8-10 ml of blood is withdrawn. It is then centrifuged to separate red cells and plasma. The PRP obtained this way is injected in scalp at the level of hair follicles.
- How does PRP act? Several growth factors released from platelets, improve the circulation around hair follicles. It also increases stem cell activity at the hair follicle level. These actions decrease miniaturization and increase the anagen phase.
- How many PRP treatments are required? Most protocols involve one treatment every month for 3 months followed by one treatment every 3-4 months.
- What are the side effects? Since PRP uses a person’s own blood, there is hardly any side effect. The sequelae after the treatment session include mild pain or heaviness and redness on the scalp which subsides over 2-3 hours.
- When is the result visible? Results are generally visible around 6 weeks. New growth can be appreciated after 3 months.
- Other adjuvant medicines
- Biotin: It is a B complex vitamin necessary for hair and nail health. It is advised as supplement in many cases.
- Saw Palmetto: Saw Palmetto is a plant with small berries which have been used as herbal remedies for many conditions. Saw Palmetto extracts in tablet or capsule form has been shown to inhibit DHT conversion and help in hair loss.
- Procapil TM-Sederma : It is a local application lotion with multiple ingredients that inhibit DHT and strengthen the hair support system. It delays the hair loss process. 4-6 months of continuous application on scalp is required to see visible results.
- Minoxidil: It is available as Regaine, Tugain, Mintop etc in India. Minoxidil 2% or 5% solution or foam, are approved in the treatment of both Male and female pattern hair loss.
Surgical Treatment of Alopecia
- Hair Transplant
- Science- basic principle: We now know that the front, top and crown portion of scalp can go bald due to effect of DHT on hair follicles in these areas. The horseshoe shaped area on the sides and back of the head, has hair follicles which are resistant to DHT. Transferring hair from these areas to bald areas will give good permanent results. Please note that the donor areas from scalp has a limited supply. Hence it is important to select the right time and right doctor for your hair transplant.
- Who is the right candidate for the hair transplant?
- Ideally any person who has a baldness of Grade III and above, and is otherwise healthy, can be considered for Hair transplant.
- Person whose hair loss is stabilized and wants to look younger.
- Hair loss due to trauma or burns.
- What will be my first visit to doctor like? During the first visit, doctor will obtain detailed medical history and history of any treatment taken so far. The hair loss will be graded. If you are the right candidate for the hair transplant, you will be explained the whole procedure. An approximate number of graft required will be told to you. When you agree for the surgery, the doctor would prescribe some blood tests.
- On the day of surgery:
- Filling up forms and signing the consent forms
- Standard views of before surgery pictures taken
- Marking of hairline in agreement with you
- Shaving of hair all over the scalp.
- Anesthesia: The procedure is done under local anesthesia. You do not have to remain fasting before or after surgery. You will have few needle pricks to numb the scalp. The effect generally lasts through the entire duration of surgery. You may be relieved for a lunch break if the session is going to last longer.
- Making slits /holes: The next step in the surgery is making the slits or holes with special instruments. Harvested grafts will be planted later in these slits or holes. Some surgeons harvest grafts first and then make the slits. Some would use special implanters to implant the hair in the recipient areas. At Nishtha, we first make the required slits to minimize the time the grafts stay outside your body.
- Graft harvesting: There are two techniques of Hair Transplant. FUE and FUT. Each follicular unit is a structure that can have 1,2,3 or even more hairs in it. This Follicular Unit can be harvested by either of the techniques described here.
- FUE: Follicular Unit Extraction is a newer and more popular technique. Here the hair follicle units are cored with the help of motorized punch. They are then picked up with micro-forceps using no touch technique. There are no stitches given and therefore the pain is less in this method.
- FUT: Follicular Unit Transplantation is a gold standard of harvesting grafts. Here a strip of skin with hair follicles is harvested. The follicular units are then manually removed from the strip under magnification. It gives a line like scar in the scalp.
- Comparison between FUE & FUT: Advantages and disadvantages of both the techniques are compared here in a tabular format.
- Which technique is good? Both techniques give similar final results. If a large area is to be covered in single sitting, FUT is preferred. FUT is also preferred if baldness is in progressive stage and a second sitting is expected in next few years. In many cases, a combination of both is advised.
- Graft placement: Follicular units harvested by any of the above methods are then placed with the help of micro-forceps in the slits which were made previously.
- Post operative course:
- You will be discharged on the same day. Make sure you have a healthy adult companion who can drive you home.
- A course of antibiotics, painkillers and medicines to reduce swelling is generally prescribed for 5-7 days.
- Swelling will be there around forehead and above eyes. Sometimes, swelling may extend even below the eyes and all over face. This will disappear within 3-5 days.
- Shampooing is generally permitted after 7-10 days.
- In cases of FUT, stitches are removed on the 10th day.
- From 10th day, Local application of Minoxidil, Protein serum and oral Finasteride tablets are started. This is to be continued for 6-8 months. This will increase the rate of growth of the grafted hair. It will also reduce the possibility of “Shock Loss”, wherein there is a temporary fall of non-grafted normal hair.
- Follow up is generally advised after 48 hours and after 10 days. For long distance visitors, it can be arranged on video conference.
- Post-surgery – A healthy lifestyle and a high protein diet is recommended. Normal styling and grooming is permitted when the hair growth is complete. It takes about 6-9 months for the grafted hair to grow completely.
- Factors affecting the outcome:
- Quality of Donor Hair: Thick donor hair with dense growth in the donor areas will give better results compared to thin and sparse growth in donor areas.
- Source of Donor Hair: Scalp hairs give better outcome. When combination of Scalp and body hair is to be used, scalp hair are placed in the front areas.
- Number of grafts: Large bald areas need more grafts. If the team is experienced, it may be advisable to go ahead with this. Otherwise it is safer to get it done in more than one sessions.
- Camouflaging: If a person is not fit for hair transplant or is not willing for the surgery, he may opt for camouflaging.
- Hair Addition by Hair weaving is a procedure done by hair stylists. Here, natural (human hair obtained from haircuts of others) or artificial fibers are glued or taped to a net or lattice. These are temporary and need to be regularly replaced every 2-3 months, as they wear off repeatedly. When glued to the normal hair, they lead to traction alopecia. This means baldness is aggravated. It can also damage the scalp skin. This may mean, poor result with hair transplant should one consider it in future. Lifetime cost of such treatment should be compared to one-time cost of surgery.
- Scalp Micropigmenation: This is also known as SMP. Here tattoo pigments are placed in such a way that final appearance looks like a shaved head.
- Normal scalp has about 100,000 hairs.
- Loss of up to 100 hairs per day is normal.
- Proper hair care, use of supplements and a good diet can reduce hair fall.
- Hair loss in early stages can be treated by Medicines and other non-surgical procedures.
- Androgenetic alopecia or male pattern baldness will require hair transplant as it progresses.
- Hair transplant can be done by FUT (Strip Method) and FUE techniques.
- Hair transplant is done under local anesthesia, is a one day procedure.
- Both techniques are good and can give equally good results.
- Results of hair transplant are visible between 6-12 months.
- In women, conditions like PCOS can lead to hair loss.
- Hair transplant can also be done in female patients.