The Skin Center

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Laguna Hills, CA 92653
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(949) 582-SKIN
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By: Nili N. Alai, MD, FAAD 8-12-10     


  • What causes hair loss?
  • What is alopecia areata?
  • What is traction alopecia?
  • What is trichotillomania?
  • What is tinea capitis (fungal infection)?
  • What is telogen effluvium?
  • What is androgenetic alopecia (“male-pattern baldness,” “female-pattern baldness”)?
  • What treatments are there for hair loss?
  • What other options do I have for hair loss?Is hair loss in women different than men?
  • What about pregnancy hair loss?
  • What treatments are there for hair loss in women?
  • What vitamins are good for hair loss?
  • Can itchy scalp cause hair loss?
  • How can I prevent hair loss?
  • Hair loss: At a Glance

What causes hair loss?

There are many causes of scalp hair loss and they do differ in men and women. This article will cover the common ones.  Studies show that losing up to 100-150 hairs per day is normal. Human hair naturally grows in 3 cycles called anagen catagen, and telogen. These cycles determine how many hairs are in the active or growing phase called anagen and how many are in the resting phase called telogen. The hairs that are shed daily are often in the resting or late phase in the hair cycle. Normally, about 10% of the scalp hairs are in the resting or telogen phase at any time. These hairs are not growing and are getting prepared for cyclic shedding.

In general, most hair loss occurs in otherwise healthy and normal people. The majority of hair loss is not associated with systemic or internal disease, nor is poor diet a frequent factor. Frequently hair may simply thin as a result of predetermined genetic factors, family history, and the overall aging process. Many men and women may notice a mild and often normal physiologic thinning of hair starting in their thirties and forties. While hair loss may be alarming for some, most people chalk up a certain amount of scalp hair loss to age. Other times, normal life variations including temporary severe stress, nutritional changes, and hormonal changes like those in pregnancy, puberty, and menopause may cause a reversible hair loss.

It is important to keep in mind that several health conditions including thyroid disease  and iron deficiency anemia can cause hair loss. While  thyroid tests and other lab tests including a complete blood count (CBC) on people who have ordinary hair loss are usually normal, it is important to exclude underlying causes in sudden or sever hair loss If you are concerned about some other underlying health issues, you may start by seeing your family physician, internist, or gynecologist for basic health screening. Dermatologists are doctors who specialize in problems of skin, hair, and nails and may provide more advanced diagnosis and treatment of hair thinning and loss.  Sometimes a scalp biopsy may be taken to help in diagnosis of severe or unexplained hair loss.

Although many medications list “hair loss” among their potential side effects, drugs are also not overall common causes of thinning or lost hair. On the other hand, with cancer treatments and immune suppression medications including chemotherapy, hair loss is very common and a known side effect. Complete hair loss often occurs after a course of chemo. Most times, hair regrows over 6-12 months after chemo.

Overall hair loss is very challenging to diagnose and difficult to treat. Studies and research are ongoing in this field.


How is hair loss classified?

There are numerous ways to describe the type of hair loss. One useful way has been  classify hair loss is by whether the loss is localized (small area) and patchy or whether it affects large areas or the whole scalp. Other medical classifications for hair loss include scarring versus non scarring hair loss and are beyond the scope of this article.

Patchy hair loss

Some conditions produce small areas of hair loss, while others affect large areas of the scalp. Common causes of patchy hair loss are

  • alopecia areata (small circular or coin size patches of scalp baldness that usually grow back within months)
  • traction alopecia (thinning from tight braids or ponytails)
  • trichotillomania (the habit of twisting or pulling hair out)
  • tinea capitis (fungal infection)


What is Alopecia areata?

A common condition, alopecia areata usually starts as a single quarter-sized circle of perfectly smooth baldness. Alopecia patches usually regrow in three to six months without treatment. Sometimes, hair grows back in white. In another variant, alopecia can produce two or three bald patches. When these grow back, they may be replaced by others. The most extensive form is called alopecia totalis, in which the entire scalp goes bald. It’s important to emphasize that patients who have localized hair loss generally don’t go on to lose hair all over the scalp. Alopecia can affect hair on other parts of the body, too — for example, the beard or eyebrow.

Alopecia areata is considered by many to be an autoimmune condition, in which the body attacks itself (in this case its own hair follicles). Most alopecia patients, however, do not have systemic problems and need no medical tests. While alopecia areata has frequently  been  blamed on “stress,”  in fact, it may be  the other way around: Having alopecia may cause stress.

Treatments for alopecia areata include injecting small amounts of steroids like triamcinolone into affected patches to stimulate hair growth. Although localized injections  may  not be practical for large areas, often this is a very effective treatment in helping the hairs return sooner. Other treatments such as oral steroids, immunosuppressives, or ultraviolet light therapy are available for more widespread or severe cases, but may be impractical for some because of potential side effects or risks. In most mild cases, patients can easily cover up or comb over the affected areas. In more severe and chronic cases, some patients wear hairpieces; nowadays, some men shave their whole scalp now that this look has become fashionable.

What is traction alopecia?

This is a small or localized hair loss area caused by repetitive or persistent pulling or force on hair roots. Tight braids and ponytails can pull hard enough on hairs to make them fall out. If this happens, it’s best to choose hairstyles that put less pressure on hair roots. The sooner this is done the better, to avoid permanent damage.

What is trichotillomania?

This refers to the habit of someone voluntarily pulling at their own hairs or twisting them, sometimes without realizing it. The scalp and eyelashes are often affected. Unlike alopecia areata patches, which are perfectly smooth, hair patches in trichotillomania show broken-off hairs. Treatment is often entirely behavioral: You have to notice that you’re doing it and then stop, Severe or resistant cases may require stress counseling with a therapist or psychologist, or medical treatment with a psychiatrist. Several antidepressant or anxiety medications have been shown to potentially help with this condition.

What is tinea capitis?

Tinea is the medical word for fungal infection and capitis means head, fungal infection of the scalp for the most part affects school-age children. Tinea capitis is more common in black African or African American scalps. This condition is rare in healthy adults. Bald spots usually show broken-off hairs. Oral antifungals are needed to penetrate the hair roots and cure the infection after which hair grows back. It is contagious from sharing hats or combs and brushes.


What is generalized (diffuse) hair loss?

This is an overall hair thinning without specific bald spots or patterns. While this type of hair loss may not be noticeable to others, often the individual will feel their hair is not as thick or full as it previously was. Common conditions in this category are

  • telogen effluvium (rapid shedding after childbirth, fever, or sudden weight loss);
  • Androgenetic or androgenic hair loss (“male-pattern baldness,” “female-pattern baldness”).

What is telogen effluvium?

Under normal conditions, scalp hairs live for about three years (the anagen, or growing, phase); they then enter the telogen, or resting, phase. During the three-month telogen period, the hair root shrivels up into a small white “club,” then the hair falls out. It is therefore normal to lose about 100 hairs every day, more of them on days when shampooing loosens the hairs that are ready to fall out. The hairs are then replaced by the body.

Sometimes people worried about losing their hair start noticing hairs on their pillow or in the sink, not realizing that they’ve always been there. A close look at these will usually reveal the white “club” at the end, showing that these hairs were already dead. Normally, about 10% of scalp hairs are in the telogen phase.

There are several circumstances that produce a “shock to the system” that alters the hair growth rhythm. As a result, as much as 30%-40% of the hairs can cycle into telogen. Three months later, hairs come out in a massive shedding (effluvium), especially near the front of the scalp. These include

  • childbirth
  • high fever
  • sudden weight loss (crash dieting)
  • surgery
  • severe illness
  • severe stress or loss ( death in family, announcing change in sexual preference “coming out of the closet”, divorce, etc)

None of these has to be life-threatening, nor does hair loss always follow them. (It can happen after one pregnancy but not the next.) But when the hair falls out, it’s all over the place — covering the pillow, clogging the drain, and so forth. Paradoxically, the more dramatic the hair loss, the better the prognosis, because when the body gets back into normal rhythm, most if not all of that hair comes back. No special treatment is needed. Normal shampooing can continue, because this only loosens hairs that were going to come out anyway.

What is androgenetic or androgenic alopecia?

 (“male-pattern baldness,” “female-pattern baldness”)

This type of alopecia is often attributed to genetic predisposition and family history. Traditionally this was originally described only in men, but we now know it is seen in both men and women.  The hair loss in men  is often faster, earlier onset, and more extensive.

Doctors refer to common baldness as “androgenetic alopecia” or androgenic alopecia which implies that a combination of hormones and heredity (genetics) is needed to develop the condition. The exact cause of this pattern is unknown. (The male hormones involved are present in both men and women.)

What is male-pattern baldness?

Even men who never “go bald” thin out somewhat over the years. Unlike those with reversible telogen shedding, those with common male-pattern hair loss don’t notice much hair coming out; they just see that it’s not there anymore. Adolescent boys notice some receding near the temples as their hairlines change from the straight-across boys’ pattern to the more “M-shaped” pattern of adult men. This normal development does not mean they are losing hair.

Some “myths” about male-pattern baldness

  • You inherit baldness through your mother’s male relatives. Actually, baldness can come from either side of the family or both. Looking at your family can give you at best an educated guess about how you’ll turn out. Studies are ongoing in this field and current research has been inconclusive about the inheritance patterns.
  • Longer hair puts a strain on roots. They don’t. And hats don’t choke off the circulation to the scalp to cause hair loss either.
  • Shampooing does not accelerate balding.
  • “Poor circulation” does not cause hair loss, and massaging doesn’t stop it.

What treatments are there for hair loss?

There are very few scientifically proven and FDA approved treatments for hair loss. There are thousands of unproven claims and products to help with hair regrowth. Many conditioners, shampoos, vitamins, and other products claim to help hair grow in some unspecified way. Nioxin has been a popular brand of shampoo for hair loss but has not definite evidence showing it is any more effective than regular shampoos. These products are usually harmless but generally not scientifically proven and thereby potentially useless. To slow down hair loss, there are at least four potentially effective, basic options. These include medications like Minoxidil, Propecia, and Avodart which are maintenance type medications and most commonly indicated for long term use. Stopping these drugs does not seem to worsen or exacerbate the prior hair loss. In other words, stopping will not leave you worse than you started out without the medications.

 Minoxidil (Rogaine): This topical medication is available over the counter and no prescription is required. It can be used in men and women. It works best on the crown, less on the frontal region. Minoxidil is available as a 2%solution, 4% solution, an extra strength 5% solution, and a new foam or mousse preparation. Rogaine may grow a little hair, but it’s better at holding onto what’s still there. There are few side effects with Rogaine. The main problem with this treatment is the need to keep applying it once or twice a day and most men get tired of it after a while. In addition, minoxidil tends to work less well on the front of the head, which is where baldness bothers most men.  Inadvertent application to the face or neck skin can cause unwanted hair growth in those areas.

  • Finasteride (Propecia): This medication id FDA approved for use in only men with androgenic hair loss. Although not FDA approved in women, it has been used “off-label” in women with androgenic hair loss who are not pregnant or planning to become pregnant while on the medication. Finasteride is in a class of medications called 5-alpha reductase inhibitors. It is thought to help reduce hair loss by blocking the action of a natural hormones in scalp hair follicles. Propecia is a lower-dose version of a commercially available drug called Proscar that helps shrink enlarged prostates in middle-aged and older men. Women, especially those who are or may become pregnant, should not handle finasteride capsules. Touching the contents of the capsules may potentially harm a male fetus and females who accidentally touch leaking capsules should wash the area to avoid side effects.  Propecia 1 mg tablets are  available by prescription and taken once daily. Propecia may grow and thicken hair to some extent for some people, but its main use is to keep (maintain) hair that’s still there. Studies have shown that this medication works well in some types of hair loss and must be used for about 6-12 months before full effects are determined. This medication does not “work” in days to weeks and its onset of visible improvement tends to be gradual. It may be  best for men who still have enough hair to retain but also can help some regrow hair. A few possible but very unlikely side effects include impotence or a decreased sex drive (libido). Studies have shown that these side effects were possibly slightly more common than seen in the general population and are reversible when the drug is stopped. Taking Propecia once a day seems to be  easier that applying minoxidil, but the prospect of taking a pill daily for years doesn’t sit well with some.. There’s also the cost, about $70-100/month which is generally not reimbursed by most health insurers.
  • ·        Dutasteride (Avodart) has recently been used as “off label” to treat hair loss in men.  It is FDA approved and primarily used to treat an enlarged prostate (benign prostatic hyperplasia, or BPH) only in men. Dutasteride is similar to finasteride (Propecia, Proscar) and is in a class of medications called 5-alpha reductase inhibitors. Dutasteride may help in hair loss by blocking the production or binding of a natural substance in the scalp hair follicles. Although not FDA approved in women, it has been used “off-label” in women with androgenic hair loss who are not pregnant or planning to become pregnant while on the medication. Women, especially those who are or may become pregnant, should not handle dutasteride capsules. Touching the contents of the capsules may potentially harm a male fetus and females who accidentally touch leaking capsules should wash the area with soap and water immediately. There is a 6 month clearance time required after taking this medication before being permitted to donate blood.
  • A group of topical medications called prostaglandin analogs have recently began undergoing testing for potential hair regrowth. They may be used in men and women, These drugs are not currently FDA approved for scalp hair loss. Most of the current market, FDA approved products are primarily used for eyelash enhancement. One of the new medications is called bimatoprost. Further testing and studies are required to assess the efficacy of these products in scalp hair loss.


Bimatoprost solution (Latisse) has just been started to be used as off-label for help in selected cases of hair loss. It is currently FDA approved for cosmetic eyelash enhancement. Studies have shown it can treat hypotrichosis (short or sparse) of the eyelashes by increasing their growth, including length, thickness, and darkness. This medication is also commercially available as Lumigan which is used to treat glaucoma. It is not known exactly how this medication works in hair regrowth but it is thought to lengthen the anagen phase (active phase) of hair growth.

During routine medical use of Lumigan eye drops for glaucoma patients, it was serendipitously found that eyelashes got longer and thicker in many users. This led to clinical trials and the approval of cosmetic use of Latisse for eyelashes.

What other options do I have for hair loss?

There are many options and alternative cosmetic treatments for hair loss. Some of these are listed here and include hair fiber powders, hairpieces, synthetic wigs, human hair wigs, hair extensions, hair weaves, laser, and surgery.

  • Hair fiber powders

Colored, powdery fiber sprinkles are commercially available and may work really well to cover up thinning hair areas. These colored sprinkles have special properties that help them attach to hair and give a fuller appearance. Toppik is one manufacturer of these products and can be found online. These cosmetic products are available without a prescription, are fairly inexpensive ($20-$40 range), and quite safe with minimal risk. Often these may be used in addition to medical treatments like Rogaine, Propecia, hair transplants and are a great temporary measure to tie you over for special occasions.   

  • Hair pieces

Among the time-honored ways to add hair temporarily are hairpieces or hair weaving, in which a mesh is attached to your remaining hair and artificial or human hair of similar color and texture is woven with existing hair. Quality varies considerably with price; also, hairpieces and weaves may stretch, oxidize, and loosen.

  • Surgery or hair transplants

Surgical hair restoration approaches include various versions of hair transplantation (taking hair from the back and putting it near the front) or scalp reduction (cutting away bald areas and stitching the rest together). Transplant procedures have improved greatly in recent years. They can produce much more attractive and natural-looking results than older methods that sometimes left a “checkerboard “or hair plug look. Many transplant patients now take Propecia to maintain or keep what they’ve transplanted. When considering a hair transplant, check the surgeon’s credentials and experience carefully. Micrografts are some of the newest techniques whereby single 1-2 hair follicles are transplanted. Hair transplants may be very expensive and time consuming procedures ranging widely anywhere from $1000- $20,000 depending on the number of hair grafts transplanted. Typically 500 or more hairs may be transplanted in a session.


Is hair loss in women different than men?

Female-pattern baldness

Women lose hair on an inherited (genetic) basis, too, but the female pattern tends to be more diffuse, with less likelihood of the crown and frontal hairline being lost. Although some women may notice hair thinning as early as their 20s, the pace of hair loss tends to be gradual, often taking years to become obvious to others. There seems to be a normal physiologic thinning that comes with age and occurs in many women in their early to mid thirties.

More women have underlying causes of hair loss than men. These include treatable conditions like anemia and thyroid disease. In particular, women with a form of thyroid disease called Hashimoto’s autoimmune thyroiditis may have hair loss. These conditions are diagnosed by lab tests.

Although a few studies have suggested that  baldness may potentially be  inherited maternally through the mother’s family genes, these theories require further testing. Current studies are inconclusive.  

While  stories about hats choking off follicles or long hair pulling on the roots may be more folklore, repeat hair trauma like tightly woven hair pulled back and consistent friction can potentially worsen or cause localized hair loss in some individuals. Photos and studies have shown a localized bi-frontal hair loss that occurs in black individuals who pull their hair tightly back in a rubber band.

Hair loss “myths” of special concern to women:

  • Longer hair does not necessarily put a strain on roots.
  • Shampooing does not accelerate hair loss; it just removes those that were ready to fall out anyway.
  • Coloring, perming, and conditioning the hair do not usually cause hair loss. Burns or severe processing may cause hair loss and breakage. Styles that pull tight may cause some loss, but hair coloring and “chemicals” usually don’t.

What about pregnancy hair loss?          

Pregnancy may cause many changes in the scalp hair. As the hormones fluctuate during pregnancy, a large number of women feel their hair thickens and becomes fuller. This may be related to change in the number of hairs cycling in the resting phase of hair growth but the exact reason is unknown.  Quite often, there may be a loss of hair after delivery or six months later. Prevention of this often, natural post pregnancy hair loss is unknown. It is also not known if this loss is just a return to the pre-pregnancy volume of hair.

What specific treatments are there for hair loss in women?

Female hair loss treatments include minoxidil (Rogaine), hair transplants, hair powder fibers like Toppik, wigs, hair extensions, and weaves. Non-FDA approved and off label use of Propecia may be discussed with your doctor.

  • Minoxidil (Rogaine) is available over the counter and available in 2%, 4% and 5% concentrations. It may be something of a nuisance to apply twice daily, but it has been shown to help conserve hair and may even grow some. Minoxidil tends to grow very fine small hairs wherever it is applied. It is important to avoid running the liquid onto the face or neck where it can also grow hair. It is marketed for women at the 2% concentration, but may be used in higher strengths as directed by your doctor.
  • Propecia is a drug that is currently FDA approved only in men for help in hair loss. It has undergone extensive safety testing on women and it was found to be safe in postmenopausal women. It is unsafe for women of childbearing to take this drug or even handle tablets. (It is, however, safe for their husbands to take it while they are trying to become pregnant.) Propecia may be used as an “off- label use in women who are not pregnant or planning to become pregnant while taking the medication. Studies have been inconclusive with effectiveness of Propecia in some women and not in others. Although not consistent results, it may be a good option  for post menopausal women or women who are not pregnant or considering pregnancy.   Newer studies suggest that Propecia may  be somewhat helpful and worth considering in treatment of women’s hair loss.
  • Surgical procedures like hair transplants can be useful for some women as well as men to “fill in” thinned-out areas.

What vitamins are good for hair loss?

A good daily multivitamin containing zinc, vitamin B, folate, iron, and calcium is a very reasonable choice. Newer studies suggest that vitamin D may be somewhat helpful and worth considering. Specific vitamin and mineral deficiencies like iron or vitamin B12 may be diagnosed by lab tests and treated individually.

Can itchy scalp cause hair loss?

  • Itchy scalp may cause mild, reversible hair loss. Causes may include seborrheic dermatitis (dandruff). Treatments may include medicated shampoos like ketoconazole (Nizoral) and topical cortisone creams and lotions to help decrease itching.

How do I prevent hair loss?

  • Hair loss prevention involves several factors depending on the underlying cause. Good hair hygiene with regular shampooing is a basic step. Good nutrition especially adequate levels of iron and vitamin B are helpful. Treatment of underlying medical conditions like thyroid disease, anemia, and hormonal imbalances may useful in prevention.

At a Glance

  • Hair loss is a very common condition and affects most people at some time in their lives.
  • Andorgenetic hair loss is seen in both men and women but is worse in men.
  • Health issues like thyroid disease, anemia, and low vitamin levels may cause hair loss,
  • Alopecia areata is a very common, coin shaped temporary hair loss patch that usually self resolves.
  • Medications for hair regrowth include Minoxidil (Rogaine), finasteride (Propecia), and (Dutasteride) Avodart.
  • Prevention includes good hair hygiene, regular shampooing, and good nutrition. 
  • Medical health screening for hair loss may include tests like complete blood count (CBC), iron level, vitamin B, and thyroid function tests (TFT).
  • The outlook for hair loss is improving and research is ongoing in this field.


Call to Schedule an appointment at (949) 582-SKIN 
Dr. Gary Cole and Dr. Nili Alai are Board-Certified Dermatologists.
For more information, please call (949) 582-7699 or visit the practice website at

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