Ep 38: Why Is My Hair Falling Out And How Do I Stop It?
Dr. Teo: Hi guys, welcome to today’s episode of Dermatologist Talks: Science of Beauty. I’m Dr. Teo Wan Lin of TWL Specialist Skin & Laser Centre, and we’re going to talk about hair loss treatment and causes today. As you may know, I am the author of a book on hair, Haircare Bible: Dermatologists Tips on Haircare and Hair Loss, which is available on amazon books, Apple books, as well as Google.
Chelsea: There’s no denying the link between hair and our personal identity and self-confidence. While we can try on clothes, dress them up or down, or discard them; our hair is part of our bodies. Unlike other physical attributes, it can modify easily. However, we still attach to certain styles, thinking our short bob or long ponytail is as fundamental to who we are as our eye colour or height.
If hair can be a signifier of personal identity, it can also function as a group identity or belonging. Choosing to cover or wear your hair in a particular manner can demonstrate religious and ethnic affiliation. Hair is important in many religions and considered sacred in many cultures. Most practicing Muslim women believe that their hair should not be visible to public, similar with Sikh men. Native Americans protect their hair as they believe it gives them power, connects them to nature, and is sacred.
As all of these examples indicate, hair is enormously symbolic. So it is unsurprising that hair thinning or hair loss can enormously affect one’s confidence. However, there are hair loss treatment options available. Before we go into that, we should first understand:
What are the causes of hair loss?
Dr. Teo: Both men and women can suffer from a genetically-induced hair loss condition known as androgenetic alopecia (AGA). This also refers to as male pattern or female pattern hair loss. It is primarily driven by personal genetics, which results in increased sensitivity of certain scalp receptors to the circulating male hormone, testosterone. It is not due to a hormonal imbalance, but the fact that both men and women have testosterone in their bodies post-puberty. An individual who suffers from androgenetic alopecia develops hair fall because of the reaction of scalp receptors in response to circulating amounts of testosterone. This is different from that of an individual who doesn’t have the genetic tendency to develop AGA.
Hair growth cycle
It’s also important and relevant for us to touch on how the hair grows. The majority of hair on your head is in a growing phase (anagen). When it falls out, it is in the catagen phase. Then telogen, which is the final resting phase of the hair cycle. If you’ve heard of the term telogen effluvium, it’s the medical term for individuals who suffer from hair fall related to a disruption in the hair cycle.
The commonest cause of telogen effluvium is related to postpartum hair loss, a reaction to major illnesses. For example, if you are in the hospital for pneumonia, dengue. In the case of the current ongoing pandemic, there have been increasing numbers of individuals who suffer from hair fall after contracting COVID-19. This is a reversible process. The body responds to this stressful event in the individual’s life by shedding hair. However, it will grow back, so it’s a 100% reversible process.
Dr. Teo: Other causes of hair loss can be related to the scalp itself. If you have symptoms of scalp sensitivity, pimples, flaking, colloquially known as dandruff, you may actually have a true disorder of the scalp known as seborrheic dermatitis. It is due to overgrowth of yeast present on your scalp, or even scalp folliculitis, which is when you present with a lot of pimple-like lesions on the scalp. This can be due to an imbalance of the scalp bacteria, yeast and other microorganisms. Having an oily scalp for example, may also predispose you to having a disturbed scalp microbiome.
Chelsea: It’s so interesting to know that so many different factors can go into hair loss! I do get strands of stray hair fall say when I’m washing my hair, or combing it.
How can I tell if my hair fall is a sign of something more serious?
Dr. Teo: What I find is a useful screening tool, called the hair pull test. It’s a test that we perform during examination of the patient as well. Just conduct a quick check on your own. If you run your hands through your hair and find that more than five strands of hair coming out with each tug, it’s likely that you have a case of acute hair loss. This is quite worrying because it can progress rapidly in certain types of hair fall conditions such as alopecia areata.
Autoimmune diseases can also present with the positive hair pull test localized areas called non-scarring hair loss. They can be circular patches in alopecia areata. If it’s rapidly progressive, it can go on to alopecia totalis where you lose all the hair on your scalp. Or, even alopecia universalis which is when you shed all the hair on your body.
Chelsea: That’s a pretty easy test that I can do myself at home!
At what stage would I need to see a dermatologist for my hair loss problem?
Dr. Teo: It’s important that you visit an accredited dermatologist who can correctly diagnose your problem. You can treat medical causes of hair fall effectively with oral medications. In this case for alopecia areata, oral steroids with intralesional injection of steroids helps to arrest an aggressive disease process. It’s also very important to rule out any underlying scalp disease. If you have any of the symptoms of scalp sensitivity, pain, pimples in your scalp or dandruff, these symptoms of possible scalp inflammation can be due to seborrheic dermatitis, scalp folliculitis. As we were discussing it earlier, it is very important to diagnose and treat it.
One thing to note is that elaborate scalp cleansing treatments are not evidence-based for the treatment of any sort of hair loss condition. What’s important though, are prescription medications as well as medicated shampoos. You can apply them on your scalp at home on your own to treat your underlying scalp problem and you certainly do not need to visit a salon for that.
The Hair Thickening Mask, part of the Dr.TWL Pharmacy sustainability initiative now available in bulk refillable packaging, is a dermatologist-formulated hair mask designed to increase hair volume and stimulate hair growth. It contains botanically derived ingredients to thicken the hair shaft with each treatment, extend growth phase of hair cycle, and promotes hair shine.
Chelsea: That’s good to know because every time I go to cut my hair at the salon, they will recommend all sorts of scalp treatments that I supposedly need.
What can I expect at the dermatologist office? How will a dermatologist diagnose my hair condition?
Dr. Teo: When you visit a dermatologist, it’s important to note that there is a very systematic way a dermatologist will approach the problem of hair loss. The clinical examination tells us if it’s a case of scarring or non-scarring hair loss. For scarring hair loss, which is less common than non-scarring hair loss, the hair follicles permanently damaged, and the hair will not grow back again.
In the case of non-scarring hair loss, we will analyse the distribution of the hair fall. Whereas, in the case of an individual who has underlying medical conditions, such as disorders of the thyroid level, hyper or hypothyroidism and anemia, all these can cause increased shedding of the hair due to a disturbance of the hair cycle. If there has been an acute event in the preceding three to six months, it could be a case of postpartum hair loss, for example, related to telogen effluvium.
When we examine the scalp as well, there are many clues which will direct us. So, if you have symptoms or signs of scalp flaking, and increased parting of the hair at the vertex, that would tell us a few things. If you have oily scalp (seborrhea), and in conjunction with increased parting of the of the hairline, it is possible that you have early androgenetic alopecia and it can occur as early as, I’ve seen individuals in their early 20s, who have a strong family history of AGA who presented to us this way.
Chelsea: You mentioned a link between oily scalp and AGA, can you elaborate on this?
If I have an oily scalp, does that predispose me to androgenetic alopecia?
Dr. Teo: A note about how oily scalp can relate to androgenetic alopecia: on its own, it’s not causative, meaning it’s not a direct cause of androgenetic alopecia, but it’s an associated symptom. The follicles all have sebaceous glands (oil glands), which produce oil (sebum) to lubricate the hair shaft. If you have thinning hair, the hair follicles continue to produce the same amount of sebum and you have less hair now to lubricate and overall it just retains on your scalp as excess sebum. Excess sebum itself is possibly a cause for concern because it predisposes you to conditions relating to a disturbed scalp microbiome.
Chelsea: Well we also know that the progression of androgenetic alopecia tends to be very slow.
Can the process of androgenetic alopecia be reversed? Is male/female pattern hair loss curable?
Dr. Teo: Well, androgenetic alopecia is, strictly speaking, not curable because the underlying problem is in one’s genetics. However, the correct approach towards the diagnosis is early treatment and prevention. If you have family members, especially male relatives who have lost their hair, there’s a very typical pattern you can look up for called vertex thinning. This is the thinning of the hair over the top of the head. For males, the pattern is more like a recession of the hairline, or what we call the M shaped pattern. In females, we look for a widened centre parting.
So while the hair follicles in individuals who suffer from AGA are actually alive, the hair follicles over many years undergo a process which is irreversible, known as miniaturization, and over a decade even is a very slowly-progressive condition. However, once it happens, it’s not possible for you to reverse that when the hair grows and falls out, miniaturization means that every time it grows back it becomes finer and finer until it becomes what we call a vellus hair or baby hair, which after a while it’s just not very visible at all and this is the reason why individuals with AGA actually end up with this sort of very smooth, shiny scalp appearance.
Chelsea: Genetics really does play an important role in this condition, so do lookout for any signs of hair loss in your family members. Well if this condition isn’t curable, are we still able to treat it?
What are the options available for hair loss treatment? Are there any side effects?
Dr. Teo: The evidence-based approaches to enter genetic alopecia here are as follows. We are familiar with the medication minoxidil, marketed by its trade names (regaine, progaine). It is derived from a medicine previously used to treat hypertension and compounded in a topical formula for the treatment of androgenetic alopecia. However, this topical is limited by certain scalp irritation side effects. Individuals who have dandruff sensitivity may not suit to use minoxidil. What we do use in my practice is something from our pharmacy. It’s for the treatment of androgenetic alopecia, telogen effluvium and other types of hair fall or scalp inflammatory disorders. It’s essentially a scalp antioxidant consisting of copper tripeptide. It helps the overall health of the scalp and you can also use it with microneedling. This increases the absorption and penetration of the serum in terms of encouraging hair to grow.
The Copper Peptide Hair Regrowth Serum uniquely contains Copper tripeptide, a novel molecule that stimulates hair growth. Clinically proven to have similar efficacy to that of 5% minoxidil, stimulating growth without irritation side effects or toxicity. Studies show collagen production is increased, strengthening existing hair and thickening the hair shaft.
Laser devices for hair regrowth
Something else we want to talk about now would be, home-use devices. We’re familiar with laser diode combs, which have been cleared by the FDA for stimulating hair growth. Red and yellow lights are used in the clinic setting with large machines over a period of three to six months, at regular intervals. This can stimulate the hair follicles to grow as well. In terms of a combination of all these therapies, I find that an individual who implements all of these measures will have a better result than one who just focuses on just the topicals alone. This is because there is a limit to how well the hair regrowth process occurs via a certain pathway.
For laser devices, our pharmacy, under the biomaterials arm has a Razer Comb. The comb is the established laser diode technology combined with radio frequency, which helps to stimulate hair growth. Radiofrequency is an established technology to stimulate collagen production. It’s important for us to note that we have sufficient evidence in dermatology research that links this particular wound healing micro-environment, stimulation of collagen to the process that can also stimulate hair regrowth and this is where radiofrequency has been found to be beneficial in both situations.
The Raser Hair Regrowth Comb is a multi-functional 5 in 1 comb. It is beneficial for hair follicle stimulation, hair regrowth, scalp serum absorption, hair elasticity, anti-frizz and hair shine.
Chelsea: It does make sense that implementing and combining these treatment plans will yield better results than just focusing on one treatment alone.
Innovations in hair growth
In the same vein, on the topic of innovations in hair growth and hair loss treatment. While this may not sound relevant yet – hear me out. The nose is where, predominantly, we have olfactory (smell) receptors that play a central role in the sense of smell. These expressed olfactory receptors are not just restricted to the nasal epithelium, but also occur in various human tissues. In 2014, there was an original article published in the Journal of investigative dermatology. It showed that there was expression of olfactory receptors in keratinocytes which is the main cell type of the epidermal layer, the topmost layer of the skin, and these actually enable the skin cells to react to different types of stimulus in the environment, and subsequently processed this information as well. Can you tell us more about this?
Smell receptors on the scalp contribute to hair regrowth
Dr. Teo: Yes Chelsea, that is indeed a very interesting study. The paper identified that this synthetic sandalwood odorant (sandalore), funcitons as an agonist of the receptor OR2AT4. This is expressed in the skin and also on the scalp. Researchers found that it causes a strong production of calcium signals that directly stimulates wound healing and re-epithelialization, which is the process that causes wounded skin or injured skin to heal. This is really fascinating because the process of stimulating hair regrowth in an individual with hair loss is very similar in terms of its unique cellular microenvironment to that of wound healing. So, if we are able to stimulate the wound healing process, we can recreate the optimal environment for wound healing. Then, your chances of stimulating hair regrowth will be proportionately increased.
In 2018, in the top scientific journal ‘Nature’, we find that a group of researchers confirmed this that the olfactory receptor, which was mentioned before in the previous study, actually directly regulates human hair growth in an ex-vivo study. Conversely, when they silenced this receptor, it blocked hair growth. When the receptors are stimulated with the synthetic sandalwood odorant, it prolongs human hair growth. It also increases the growth phase of the hair cycle and reduces the chances of cell death while increasing growth factor IGF-1.
Chelsea: Wow, the mechanism behind wound healing and hair regrowth is really a fascinating one! Well good news for those suffering with hair loss. Another hair loss treatment option is the Sandalore Hair Regrowth comb. It is designed to stimulate and support rigorous, healthy hair growth when used regularly. Could you elaborate more on this?
Hair regrowth comb
Dr. Teo: Yes, Chelsea, so just to add on, we have the latest study on sandalore which was published in 2020. About 1% solution of sandalore was used in patients suffering from telogen effluvium. This can result from common states such as the postpartum pregnancies states and having a major illnesses. For example, being hospitalised with pneumonia, dengue or COVID-19. Three to four months after the major event, you can find yourself having hair fall and that’s telogen effluvium. In this study, 1% sandalore was topically applied to the scalp. Patients who suffered from telogen effluvium actually reduced the signs of the condition itself. Therefore, it supports the previous ex-vivo studies about prolonged effects of sandalore on the hair cycle which is very beneficial.
The ORZAT4 Infusion Treatment Comb is impregnated with Sandalore which has been scientifically proven to stimulate hair regrowth. Specifically designed for hair loss treatment.
Chelsea: Well that’s it for today’s podcast episode. We’ve discussed the various causes of hair loss, when to see a dermatologist for your hair condition We also covered various hair loss treatment options, and recent innovations in hair growth treatments – Sandalore, that targets olfactory receptors for hair growth. If you suffer from this condition, do consult your dermatologist for advice on hair loss treatment. You can follow Dr. Teo on instagram at @drteowanlin for more podcast updates and also head over to www.scienceofbeauty where you can find the full podcast transcript.