The other day I was reading the story of Rapunzel to my granddaughter, and I started to wonder what would have happened if Rapunzel had a hair loss disorder. The plot of the story hinges on the prince being able to climb up Rapunzel’s hair to meet her since she was locked in a castle tower with only one window and no door. “Rapunzel, Rapunzel, let down your hair so that I may climb the golden stair.”
We often take the amount of hair on our heads for granted, that is until we start losing it. One of the most common complaints I hear from patients of any age, almost as an afterthought, is “Doctor, I seem to be losing my hair.” Normal hair loss is anywhere from 50-100 hairs per day. Hair grows in cycles, and typically lasts 2-6 years. At any given time, 90% of hair is in a growth phase, growing at one-half inch a month, and 10% of the time it’s in resting phase. After 3-4 months the hair in the resting phase falls out, and new hair grows to replace it. The glitch can be when more hair falls out than grows back in. As I was reading the story, I wondered how exceptional was Rapunzel’s hair? Let’s presume that she lived in castle five stories high (50 feet), and her hair grew at the normal rate of one-half inch a month, (or one-half foot a year), and that her hair was always in a growth phase. A quick calculation indicates that in order for Rapunzel’s hair to reach the prince on the ground, she would have to be 100 years old! She clearly lived in a fairy tale.
When patients ask about unusual hair loss, I inspect the scalp. Men sustain hair loss in two places – a pattern of receding hair line, and balding at the top of the head or crown. When women lose hair, typically the frontal hairline is preserved, and there is diffuse hair thinning of the top of the head. (If a woman sustains male pattern baldness, this leads me to suspect a medical condition where there is an excess of male hormones such as in polycystic ovary syndrome.) Around two-thirds of men develop some balding during their lifetime, but women’s hair loss is common too. Over 50% of women over the age of 80 have hair loss. Hair loss in women can be particularly devastating since it can result in low self-esteem. Perhaps the one thing that helped Rapunzel’s confidence despite her lonely imprisonment was her bountiful head of hair.
The other thing I do to evaluate hair loss is the “hair pull test.” (Unlike many medical tests which are named after obscure medical scientists, this test has an easy name to remember!) I learned this test from a dermatologist colleague, and it’s performed by grasping a lock of hair and pulling gently. As mentioned earlier, normally no more than 10% of hairs are in a resting phase at a given time, so if I pull on 20 hairs on the scalp, I should not expect more than 2 hairs to be removed. For this test to be done accurately, it’s important that the patient be instructed to not wash his/her hair for at least 24 hours before the visit, and the test should be performed over various places of the scalp.
What Are Some Of The Causes Of Hair Loss?
Other than hereditary hair loss triggered by the interplay of genes and hormones, sudden hair loss has many causes. Stress from a major illness, surgery, or fever can result in hair loss 3-4 months later, but fortunately this is temporary. Overactive or underactive thyroid disease can result in hair loss, and improves with proper treatment. “Traction alopecia” can result in hair being pulled too tightly from wearing braids or ponytails. Hair can be damaged with other manipulations such as from bad brushes, blow dryers, and brushing aggressively when the hair is wet. In most of these cases, hair grows back after the offending behavior is stopped.
It is common for women to lose significant hair three months after childbirth due to changes in hormones – one would hope that Rapunzel’s obstetrician would warn her of this possibility. Imagine Rapunzel’s surprise if she awakens from sleep three months after a pregnancy and discovers a huge pile of hair on her pillow!
Lack of iron, inadequate protein in the diet, or eating disorders such as anorexia or bulimia may result in hair loss. Fad diets or ingesting large doses of Vitamin A may also cause a problem.
Most people are aware that radiation and chemotherapy can result in hair loss, but many common medications can cause hair loss as well. The long list of medicines that can result in hair loss include anti-clotting drugs, antidepressants, birth control pills, anticonvulsants, nonsteroidal anti-inflammatory drugs, cholesterol lowering drugs, and blood pressure medications. (If you don’t do so already, read the prescription information enclosure when you get medication to see about potential side effects.) The most common medication hair loss culprit that I have seen has been due to a beta-blocker called atenolol. When hair loss does occur from a medicine, it usually starts within a few weeks of taking the medicine, and hair typically grows back on its own after the medicine is stopped.
One serious cause of hair loss is alopecia areata meaning “area baldness.” Hair is lost in patches, but may proceed to complete baldness. It can be diagnosed by inspection and positive “pull test.” This is thought to be an autoimmune disorder and affects around five million people in the United States. Anyone who has this should see a dermatologist, but fortunately the condition resolves by itself in many cases.
In children, tinea capitis, or ringworm presents with a round patch of hair loss due to a fungal infection. Careful examination reveals scaling and redness around the rim of the patch, and localized enlarged lymph nodes. If the diagnosis is obscure, a skin scraping from the border of the patch can be looked at under the microscope.
Trichotillomania is a compulsive disorder involving repetitive plucking and pulling of hair in children, but may progress into adulthood. This condition results in patchy hair loss which may become permanent due to scarring.
Medical Treatment For Hair Loss
It’s virtually impossible to prevent hereditary baldness. However, there are two medicines that have been approved by the FDA to treat hair loss. Topical minoxidil (brand name Rogaine) can be purchased over the counter for use in women and men; it should be massaged into the scalp twice a day, and has to be applied indefinitely to maintain its benefits. Minoxidil helps only the crown of the head, and the new hair is like baby hair, thin and light. In one study, 20% of women reported moderate hair growth after using it for 32 weeks. Side effects may include unwanted hair growth on the adjacent skin of the face and rapid heart rate.
The other treatment is finasteride (Propecia), a prescription medicine for men only. It is a pill taken once a day, works best on men who are starting to lose hair, acts better for the crown of the head than receding hairline, and may take at least six months to see results. Side effects may include loss of sex drive and sexual function. It needs to be taken indefinitely to maintain its benefits, and there is concern how it affects the risk of developing prostate cancer.
A novel treatment for preventing hair loss in patients undergoing chemotherapy is using scalp hypothermia, or “cold caps.” The theory behind this is by cooling the scalp, blood vessels become constricted, hair follicles receive less chemo, and hair loss is prevented. The downside may be that stray cancer cells lurking in the scalp could survive so the long term safety of this technique is unknown.
A laser device called HairMax Laser Comb has been approved by the FDA for use in men, but published research on the effectiveness is lacking. Don’t waste your money since it’s too early to tell if it actually helps.
Common Sense Things To Do For Your Hair
Choose a gentle shampoo. “Revitalizing” shampoos which promise to restore hair do not regrow hair. If you use a hair dryer, use the low setting. Use a comb rather than a brush, particularly if your hair is thinning. If you do use a brush, do so when hair is dry. Avoid any brush or comb that pulls your hair, and preferably find one that has rounded edges or natural bristles. Avoid bleaching, straightening, excessive sun exposure, or anything else that can damage your hair. Consult with a hair stylist to camouflage or hide thinning hair. Perms and hair coloring are thought to be safe as long as no bleach is used. Hair transplantation surgery is an option for both men and women after thorough pre-operative assessment and discussion of realistic expectations.
It is extremely unlikely that any of us will ever have hair like Rapunzel. However, with better understanding of some of the conditions which can result in hair loss, and knowledge of how to care for our hair properly, it’s possible to enjoy the way we look for many years.
Jerry Saliman, MD is a volunteer internist at Samaritan House Medical Clinic in San Mateo. He retired from Kaiser South San Francisco after working there more than 30 years. While at Kaiser SSF, Dr. Saliman was also Chief of Patient Education. He received the 2012 “Lifetime Achievement Award” given by the Kaiser SSF Medical Staff.
Editing acknowledgement: Ellen Saliman
Neither the PJCC or our guest columnists provide medical advice, diagnosis, or treatment. Please make your health care decisions in partnership with your health care provider.