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By Stephen M. Schleicher, MD, Director, DermDOX Center for Dermatology
The scalp contains approximately one hundred thousand hairs. Each hair attains a maximum length and then enters a resting stage, following which, it falls out. Unlike certain animals, which shed their entire outer layers at once, human’s have hairs that act independently; normal human hair loss occurs in random fashion and is quite inconspicuous. Some one hundred scalp hairs are regularly shed on a daily basis (This may seem like a large number, but it represents only one-thousandth of the total scalp hair).
Hair grows at different rates depending on its location. Scalp hair expands at a rate of one-hundredth of an inch per day; in other words, one hundred feet of new hair is manufactured on a daily basis. Each scalp hair is capable of growing for three to ten years. This is in contrast to the hair of the armpits and eyebrows, which has a growth period of less than 1 year; these hairs grow to fixed lengths and then enter into a prolonged resting period.
The hair that we look at, fondle, and spend so much time and money on is merely dead tissue. Living hair is produced from protein under the skin within a structure called the hair follicle. The hair is no longer alive by the time it reaches the surface.
Each follicle is attached to an oil gland and is surrounded by nerves and muscles. The muscles are very sensitive to cold and contract on stimulation, pulling the hair follicle and wrinkling the skin surface. This action gives rise to the tiny raised pimples known as goose bumps.
Hair differs in both amount and consistency among the various races. Whites are the hairiest, followed by blacks, with Asians being the least hirsute. Asians have the straightest hair, while blacks have the curliest.
Hair color depends on the number of pigment cells (melanin) within the hair shaft. Blond hair contains few pigment cells, and the snow-white hair of the elderly has virtually none. Red hair is due to an iron-bearing pigment.
As we age, so does our hair. Aged hair is grey or white. To date, despite advertising claims touting melatonin, copper blockers, and vitamins, the only effective treatment is hair dye. But there is hope. Some of the aged follicles from which hair grows still contain miniscule amounts of pigment cells, and recent evidence points to a buildup of hydrogen peroxide in older follicles which prevents these cells from producing pigment (melanin). Finding a way to decrease hydrogen peroxide within the follicle may reverse the graying process.
Reports periodically surface that hair-coloring agents promote cancer. Fortunately, this does not appear to be the case, and if there is a risk, it is quite minimal. Hair dyes can however trigger allergic reactions, hence the warning on package inserts to test the skin prior to each application. Allergic reactions do appear to be on the rise as more, and younger, individuals dye their hair. The main culprit is an ingredient called paraphenylenediamine (PPD). An allergy to hair dye may result in an itchy, red rash of the scalp, ears, and face, at times accompanied by swelling.
Damaged Hair: Split Ends
Since the hair visible to us is dead, and since it is constantly growing from under the scalp, any damage that occurs to hair above the skin is fortunately temporary. Hair problems caused by the environment and improper treatment will improve, given time and correct management.
Our hair suffers from an incredible amount of physical and chemical abuse. The longer the hair, the greater the extent of this trauma. Those of us with hair two feet long have ends nearly three years old! Over this time period, just imagine the amount of brushing, combing, pulling, curling, setting, shampooing, hot-air drying and sun, salt, and chlorinated-water exposure this hair has been subjected to. Small wonder some of us have split ends!
Split ends (the frizzies) are the result of excessive trauma to hair. The problem is usually more severe in longer hair. When performed in moderation, combing, brushing, and blow-drying do not damage hair. When such activities are too frequently and vigorously undertaken, however, split ends are the inevitable result. (Researchers can manufacture split ends in clipped normal hair by utilizing a hair-rubbing apparatus.) Blow-drying is safe as long as it does not continue after the hair is dry to the touch; over-drying leads to fragile, easily damaged hair. Similarly, chemical treatments such as bleaching, waving or curling, and straightening may damage hair under certain circumstances.
Damage to hair may be lessened by use of conditioners and cream rinses. These compounds coat the hair surface and reduce combing friction. They may also guard against some of the deleterious effects on hair from blow-drying and sun exposure. The only cure for split ends once they occur is cutting them off; avoidance of excessive damage, coupled with the judicious use of conditioners and cream rinses, will minimize their occurrence.
Hair Loss: Pattern Alopecia
As we have noted, an insignificant amount of hair is lost from the scalp on a daily basis. On occasion, hair is shed at such a rapid rate that the loss does indeed become noticeable. Such hair loss may either be generalized or confined to distinct areas.
Male pattern baldness is a hereditary disorder that first becomes apparent in late adolescence or early adulthood. Progressive hair loss is noted in the front and center of the scalp and is due to the slow shrinkage and subsequent death of hair follicles.
Millions of dollars’ worth of quack tonics and megavitamin pills “guaranteed” to reverse the hair-loss process and grow hair are sold annually. Advertised in popular journals or on late-night TV shows, many of these products prey on men’s vanity and as a rule disappear following state or federal investigations. Some meld science with pseudoscience, referencing DHT (dihydrotestosterone, a known causative factor of male pattern baldness) and concoctions of poorly studied herbal remedies.
To date, only two products are FDA approved to retard or reverse male pattern alopecia: minoxidil (Rogaine) and finasteride (Propecia).
Minoxidil (in pill form) was first marketed as an oral treatment for high blood pressure. Problems soon became evident when the drug was administered to women and children: they began to sprout beards and mustaches!
A true genius got the bright idea of rubbing the stuff on the shiny scalps of bald men, and—lo and behold—new hairs indeed began to grow. This was indeed a monumental accomplishment, the first time in history that something grew new hairs. It is known that minoxidil dilates blood vessels, but the mechanism of action on scalp hairs is still unclear.
Minoxidil does not work on everyone. People with the least hair loss, and those balding for the shortest time period, appear to do best. For many of these individuals, minoxidil really does produce cosmetically acceptable hair. For the majority, minoxidil will help prevent or delay further thinning of the hair. By starting minoxidil treatment early, male pattern baldness may be placed on hold. The trade name for minoxidil is Rogaine, now available in an elegant foam formulation.
Finasteride (Propecia) is used in higher doses to treat an enlarged prostate. This oral medication was approved in 1997 as a treatment for male pattern baldness. The drug inhibits the breakdown of the male hormone, testosterone, to DHT. Clinical studies demonstrate that finasteride can induce new hair growth in about 50 percent of men and can also increase the weight and diameter of existing hair. As is the case with minoxidil, therapy with finasteride is for life; once discontinued, the natural process of hair loss will proceed. Finasteride’s long-term effect on general health is unknown; however, data indicates that chronic use may actually decrease the risk of prostate cancer, a very significant finding.
Dutasteride (Avodart) acts in a similar manner to finasteride but has a longer half-life. In other words, one or two pills per week may well keep a guy’s hair intact. And, on another positive note, a study published in 2009 concluded that Avodart lowered the risk of prostate cancer by 23 percent.
For those unaided by, or deciding against use of either minoxidil or oral agents, depleted hair may be covered up by a toupee or hair weave, or partially rectified by hair transplantation.
Hair transplant traditionally involved the transfer of quarter-inch round plugs from the back of the scalp to thinned areas in the front of the scalp. The technique was analogous to placing sod down on a depleted lawn and results in permanent replacement. The cosmetic endpoint varied from natural to comical, with many individual heads resembling cobblestone roads. Nowadays, follicular unit transplantation has supplanted plugs; it involves removing thin strips of hair from the posterior scalp, which are then dissected into thousands of micro-grafts prior to transplantation. The results are much more natural and, in many people, virtually imperceptible.
Some physicians are utilizing lasers in attempts to slow down hair loss and stimulate new hair growth. Indeed, units are now available for home use. Until adequate clinical studies are published, laser and light use for baldness should be viewed with a healthy degree of skepticism.
Generalized hair loss in women may occur as a result of certain stressful situations. For example, increased hair shedding frequently follows pregnancy. The loss of hair may be mild or quite marked and can occur from the first to twelfth week after delivery. No treatment is necessary as the hair completely grows back. Such hair loss is called telogen effluvium.
Women taking birth control pills may experience diffuse hair thinning, either while on these pills or shortly following their discontinuation. Again, this hair loss is only temporary and fully corrects itself within a few months.
Classic female pattern hair loss is also called androgenetic alopecia. The condition most commonly occurs around menopause and characteristically involves the front and top of the scalp. Treatment with minoxidil may stabilize the condition. Rogaine for women is a 2 percent concentration as opposed to the 5 percent foam marketed to men. Women can safely use the higher concentration, which is clinically superior but not FDA approved for this purpose. Users should take care to apply minoxidil only to the scalp and let it thoroughly dry before resting the head on a pillow to avoid unwanted facial hair. Minoxidil should not be used by pregnant or nursing females. The medication Aldactone (spironolactone) helps to block male hormone uptake by the hair follicle, although clinical response is slow. Minigraft hair transplantation is another option for women and may yield excellent cosmetic result.Want fuller eyelashes? In 2009 the prescription eyelash-enhancer Latisse became available. Applied like eyeliner, Latisse enters eyelash hair follicles and results in longer, thicker, and darker eyelashes. As the drug can mask glaucoma, and induce eye irritation, initial consultation with an ophthalmologist may be recommended. And eyelash enhancement isn’t cheap: a month’s supply will set you back over fifty dollars.
Hair Loss: Alopecia Areata
A common form of localized hair loss that occurs in males and females, and in children as well as adults, is alopecia areata. In this condition a circular zone of complete hair loss rapidly develops, leaving the scalp smooth and shiny. The affected area may range from dime-sized to larger than a silver dollar. Multiple patches may occur.
The cause of alopecia areata is unknown, although an abnormality of the immune system is suspected. Some cases follow emotional stress and tension. Most of the hairless patches spontaneously grow hair in two to three months. Very rarely, the hair loss may become generalized leading to severe cosmetic disability, especially in women. Dermatologists treat localized forms of this disorder with steroid creams and/or injections.
Hair Loss: Traumatic
Some neurotic or psychotic persons consciously or subconsciously pull at and twist their hair until breakage occurs. This compulsive behavior is called trichotillomania and results in patchy zones of hair loss within which are found broken hairs of uneven length. Chronic cases warrant psychiatric consultation.
Various cosmetic manipulations can lead to hair loss. Traction produced by tight rollers or braids may so weaken the hair as it exits the scalp that patchy areas of reversible baldness result. The kinky hair of blacks is particularly prone to fracture. Such traction alopecia is most noticeable on the sides of the scalp.
Bleaching, setting, and permanent wave solutions will not significantly damage hair unless applied in an inappropriately high concentration or over a prolonged time. However, the frequent use of hot combs and oils to straighten hair (a cultural adaptation practiced by many African Americans) may cause marked scarring of the scalp and permanent baldness. “Hot-comb alopecia” most commonly occurs in the center of the scalp.
Several “hairy” myths must be debunked here as well. The plucking of hair does not produce permanent baldness (nor does it cause the hair to grow in thicker). Cutting, shaving, or massaging the scalp has no effect on hair growth. Frequent hair washing and shampooing also do not lead to hair loss, nor does dandruff (no matter how severe).
Excess hair growth is known as hirsutism. For most individuals, the problem is simply a cosmetic one, indicating neither the presence of hormonal nor of gender abnormalities. In fact, if one examined a group of white females, nearly one-quarter would be found to have hair on the upper lip (with the condition being very apparent in 10 percent), and over three-quarters would exhibit coarse hair on their arms and legs.
Hair distribution is in large part genetically determined; if your mother has excess facial hair, you most likely will too. In general, women of southern Mediterranean and Near Eastern origin have more facial and body hair than do North American and Asian women.
About 1 percent of women complaining of excess body hair have a significant medical problem such as overactive adrenal glands or ovaries. Such women may also experience menstrual irregularities, weight gain, and acne. Since both benign and malignant tumors must be ruled out, hirsute women with these associated disorders should visit a physician and undergo examination and laboratory studies. Some drugs, such as Depo-Provera, Dilantin, and tamoxifen, can also induce hirsutism.
Many women are quite concerned about excess body and facial hair. Several means are available for the removal of unwanted hairs, the current gold standard being lasers and intense pulsed light (IPL).
Lasers and IPL are specialized light sources. Light used for hair removal passes through the skin and is absorbed by pigment within the hair follicle. The procedure can be safely performed on virtually any part of the body with excess hair, except about the eyes. Hair that is coarse and dark responds best to laser treatment. Blond or red hair is difficult to treat. When dealing with lasers, the lighter the skin, the better. Indeed, individuals with dark skin, including those with suntans, are not ideal candidates because the light will also target pigment cells in the dermis. As the pulses of light energy are of brief duration, discomfort is momentary.
Laser and IPL hair removal usually require multiple sessions, and in most cases, the results are best referred to as reduction rather than permanent removal. Approximately 20 to 30 percent reduction will be noted after each treatment with long-term hair reduction approaching ninety percent. Treatments are repeated every four to six weeks depending on location (shorter time intervals are required for hairs above the neck). Note that the FDA allows approved manufacturers to claim “permanent reduction” but not “permanent removal” for their devices.
Side effects associated with laser and IPL hair removal are transient redness, inflammation of the hair follicles (folliculitis), activation of fever blisters, pigmentary changes, and (rarely) scarring.
Commercially available light-based hair reduction devices for home use are now available. These appear to be safe and somewhat effective, although determining just how effective they are will require larger studies. You should make sure that any light or laser device marketed for hair reduction is approved by the FDA before using it.
Unsightly hair may be removed by electrolysis. In this procedure a tiny needle is placed within each hair follicle and a short burst of current is administered. The electrical charge destroys the follicle and prevents further hair growth. Similar to lasers and IPL, multiple treatment sessions are required. Electrolysis is time-consuming, somewhat painful, and not inexpensive. Results range from acceptable to excellent. Electrolysis is a viable alternative to treat light-blond, white, and gray hairs, as these are not amenable to light-based treatment modalities.
Shaving with either a safety razor or electric shaver is a simple, temporary means of hair removal. As noted, repeated shaving or plucking with a tweezers does not lead to increased or thickened hair growth. Hair plucking pulls the hair from the root. Results last about six weeks.
Another means of hair removal consists of the application of depilatory creams. These compounds cause a transient dissolution of surface hair following a brief application time ranging from five to ten minutes. Their use on sensitive skin may produce irritation.
Objectionable hairs may be rendered inconspicuous through bleaching. Again this is a simple, albeit temporary, measure to lessen the unfavorable cosmetic impact of excess facial hair.
Vaniqa is the first FDA-approved prescription cream utilized to slow the growth of unwanted facial hair in females. About half of women who use this product, applied twice daily, experience satisfactory hair reduction after several months of therapy. Hair excess linked to ovarian dysfunction is often treated with birth control pills.