Male pattern baldness affects over half of men over the age of 50, while an estimated eight million women are affected by hair loss and hair thinning at some point in their lives, according to the NHS. Hair is an intrinsic part of who we are as a person and can be a devastating condition for patients, often leading to a lack of confidence and self-esteem. Luckily, due to the latest technological advancements, there are numerous treatments available for hair loss, which are offered in many aesthetic clinics across the UK. We spoke with Dr Ingrid Wilson, director of Crewe Hair and Skin Clinic and leading UK trichologist to provide some key considerations for aesthetic practitioners.
According to Dr Wilson, “The main forms of hair loss are split into temporary and permanent, with male and female pattern hair loss, telogen effluvium and alopecia areata being the three main types. These types of hair loss are seen as temporary or potentially reversible because they do not permanently cause damage or scarring to the hair follicle, which is the pit in the skin from where the hair grows.”
Pattern hair loss primarily affects the top and front temples of the scalp; for men it typically presents itself as either a receding front hairline, loss of the hair on the crown of the scalp, or a combination of both. Male pattern hair loss (MPHL) is typically due to a combination of age, genetics and circulating androgens, particularly dihydrotestosterone (DHT). It tends to happen as hormone levels change over the course of a man’s life. Male pattern baldness in men is mostly genetic, with those who have first or second degree relatives affected by hair loss having a greater chance of losing hair themselves. But there are also differences between ethnic groups – male pattern baldness affects up to half of all Caucasian men by the age of 50 and up to 80 per cent of men in the same group by the age of 70 years. But other ethnic groups, such as Chinese and Japanese men, are apparently less affected.
In comparison, female pattern hair loss (FPHL), also known as androgenetic alopecia, usually begins with gradual thinning of the hair at the central part line, followed by increasing diffuse hair loss emanating from the top of the head. There are many potential causes of hair loss in women, including certain medications such as chemotherapy and other drugs used for conditions such as high blood pressure, arthritis and depression. The most common cause of hair loss in women is genes, but hormonal changes due to pregnancy, childbirth and menopause, as well as thyroid problems, can also cause permanent or temporary hair loss. Excessive hair styling or hairstyles that pull the hair can cause a type of hair loss called traction alopecia and if hair follicles are damaged, the loss can be permanent. Restrictive dieting, rapid weight loss, vitamin deficiency or a very stressful event or emotional shock can also all cause hair loss.
Telogen effluvium occurs when there is a change in the number of hair follicles that are growing hair. Dermatologists report that it is the second most common form of hair loss diagnosed. At any given time, about 90-95 per cent of the hairs on a person’s head are actively growing (the anagen phase) and the others are resting (the telogen phase) or preparing to go into the resting phase (catagen). A hair is typically in the anagen phase for two to four years, then enters the telogen phase before resting for around three months, and then falls out and is replaced by new, growing hair. The average person typically loses around 50- 100 hairs a day, but for those with telogen effluvium, a body change or shock can push more hairs into the telogen phase, which may result in losing an average of 300 hairs a day instead of 100. Telogen effluvium can be triggered by numerous events, including physical trauma, psychological stress, illness (including COVID-19), surgery, extreme weight loss, abrupt hormonal changes, iron deficiency and some medications.
Alopecia areata is an autoimmune disorder that causes hair to come out as the immune system attacks the body, often in clumps the size and shape of a coin. The amount of hair loss differs in every person – some lose it in only a few spots, whereas others can lose a lot. Sometimes, the hair grows back but falls out again later, and for others, hair can be lost permanently. The exact cause of alopecia areata is unclear, however it is thought that genetics and environmental factors may trigger the initiation of the disease.
When it comes to assessing and diagnosing patients, Dr Wilson says, “I assess hair loss by listening to the history of how it started and is continuing, and finding out about the patient’s health, medication, nutrition, family history and hair care practices.” She adds, “As a result of the pandemic, trichology consultations have been virtual, so instead of examining the hair and scalp in person, I have been using photographs sent by the patient of the hair and scalp from the front, top, back and side views. During in-person consultations, I am able to examine the hair and scalp more closely using a technology called TrichoLab, which provides extremely precise images of the hair and scalp using polarised light. If am then confident that the cause of the hair loss is temporary, then I offer TrichoTest, which uses the DNA profile to help personalise hair loss treatments. This does not diagnose the cause of hair loss but provides a recommendation for topical prescribed medications or specific supplementation. I then come up with a personalised plan which is most appropriate based on the diagnosis and the current evidence about the hair loss condition.”
Medication is often the first line of treatment for both men and women, with minoxidil and finasteride being the most popular treatments for hair loss. Both are available as a prescription medicine or as over the counter treatments. Minoxidil is approved for both men and women, whereas finasteride is for men only.
This treatment is when blood is drawn from a person and spun down in a centrifuge, so that the platelet rich part of the plasma with the growth factors in it separates out. That part of the plasma is injected using fine needles into the scalp. PRP contains growth factors and bioactive proteins, vitamins, nutrients, hormones and electrolytes which speed up tissue repair and regeneration. However, according to Dr Wilson, it is worth noting that many clinics are using PRP for hair loss without necessarily having had training on diagnosing hair loss conditions. She says, “I believe it is really important for people to know that results can be subtle. PRP should be used as part of a management plan and should not be the only treatment. The results can be enhanced by microneedling (evidence suggests at 0.6mm is ideal) with minoxidil.”
Laser is typically used for those with male or female pattern hair loss. Dr Wilson explains, “LLLT is an adjunct to hair loss treatment plans. LLLT is a non-thermal light therapy method that has a photobiomodulatory effect. The consensus seems to be that the current products are likely to give some form of benefit to the user for increasing hair health rather than hair growth.”
Mesotherapy is a non-invasive injectable treatment option for hair loss. It uses superficial microinjections, just below the epidermis, into the target tissues to nourish layers of the skin where there is cell repair and growth. The solution injected can contain a range of minerals, vitamins, amino acids, co-enzymes and nucleic acids to deliver nutrients, stimulate blood circulation, and balance hormone levels around the follicles.
“This is a cosmetic topical solution designed for people suffering hair loss, that works from the outside to support the stem cells in the follicle. It approaches hair loss by considering both increasing the length of life of hair stem cells, and also by balancing scalp nutrition,” says Dr Wilson. She adds, “Its ingredients are intended to reduce the inflammation of the hair follicle and provide a better supply of key ingredients for healthy hair growth. The programme is based on peptides which are involved in many physiological processes. Weekly treatments can be done at the clinic with microneedling, but there are also home-based products available.”
For advanced cases of hair loss, where the hair loss has stabilised, for example genetic hair loss, a hair transplant could be an option. There are two types of hair transplants – a follicular unit transplantation (FUT) and follicular unit extraction (FUE). The primary difference between FUT and FUE hair transplants is that in FUT, the surgeon excises a strip of donor skin from patients to remove individual follicular units to be moved to the areas experiencing hair loss. Whereas in FUE, the individual follicular units are extracted directly from the scalp. Dr Wilson says, “It is important to know that hair transplants are not suitable for all types of hair loss, and if the wrong type of hair loss is operated on there is a chance that the procedure could accelerate hair loss (e.g. Frontal Fibrosing Alopecia).”
Prevention is usually better than cure. But although it is not possible to completely prevent hair loss, particularly if it is caused by genetic factors, there are ways to protect the remaining hair, as well as lifestyle and dietary changes that can improve the appearance of thinning hair.
For patients experiencing hair loss, practitioners might consider taking a holistic approach, by incorporating patient wellness into the consultation to optimise patients’ overall health and wellbeing. This can help facilitate discussion around a patient’s lifestyle including nutrition, alcohol intake and stress management, which may be affecting the hair loss.
The impact of diet on health has been an area of extensive research and has been shown to influence hair loss. In particular, deficiencies in iron, zinc, vitamin D and vitamin B-12 have all been associated with hair loss, so taking supplements may help. One study showed that 91 per cent of alopecia areata sufferers were also deficient in vitamin D. Eating a diet rich in antioxidants can help combat environmental factors that contribute to oxidative stress, which in turn can cause hair loss. Sugar, processed fats and alcohol all contribute to oxidative stress so it is worth bearing this in mind and minimising consumption too.
For women experiencing hair loss or hair thinning, iron supplements can help if the hair loss is connected to anaemia or a heavy menstrual cycle, and for those who have reached menopause, hormone replacement therapy (HRT) can help.
We’ve looked at treatments for hair loss and baldness and explored how to prevent hair loss. But is there a cure for baldness? Unsurprisingly, this is a frequently asked question but of course it depends on the initial cause. If the baldness is caused by a medical condition, it may grow back following recovery and, as we have seen, there are a number of very effective treatments available and medications like finasteride and minoxidil that can help, but no treatment is 100 per cent effective. We are born with all the hair follicles we’ll ever have, so once one is taken out of action, it’s gone forever. The major challenge facing any permanent hair loss cure is restoring full functionality to the follicles, or producing new follicles. Although there are a number of products and treatments available to fight hair loss, there is currently no cure for male pattern baldness.
Hair loss treatments are still advancing, with numerous new procedures in the pipeline. For Dr Wilson, non-surgical treatments are the areas she is mostly excited about, including topical cetirizine and supplements. She says, “I have attended many webinars over the last year about the use of topical cetirizine to treat hair loss, as mast cells have been shown to play a role in stress-induced hair loss, serving as a link between the nervous system and immunologic system.”
Regarding supplements, Dr Wilson says, “The unknown safety profile of ingredients in hair supplements is being recognised as a cause for concern, however on the positive side, the field of nutraceuticals is evolving, with some evidence of benefits in using them for hair loss related to some breast cancer treatment, which leads to thinning of hair. A literature review study published in 2020 found that, although the exact mechanisms are unclear, supplements containing resveratrol, saw palmetto, maca, curcumin, tocotrienols, ashwagandha, horsetail, astaxanthin, kelp, capsicum, Annurca apple fruits, saﬄower and ginseng can have beneﬁcial eﬀects on hair growth, without adverse eﬀects on breast cancer patients. It is an exciting area.”
When it comes to offering hair loss treatments in clinic, Dr Wilson advises, “Make sure that you learn about the common causes of hair loss. Start with reputable sources of education such as good quality CPD courses, and membership of organisations such as the British Association of Hair Restoration Surgery, The British Hair and Nail Society, Primary Care Dermatology Society and International Association of Trichologists. Also check the literature to find out what has been published and ensure that you are satisfied with any safety issues.”
Dr Wilson concludes, “The main consideration is to make sure that you have the correct diagnosis. It can be tempting to just treat without understanding what is going on because there is not much general awareness about the fact that often there are several factors driving hair loss, and one issue can unmask another. If you are at all unsure, please encourage a consultation with a professional who you believe is competent in recognising the main hair loss conditions, and who will be responsible in the advice that they give.”