Hair loss

Martina Feichter studied biology with an elective subject pharmacy in Innsbruck and also immersed herself in the world of medicinal plants. From there it was not far to other medical topics that still captivate her to this day. She trained as a journalist at the Axel Springer Academy in Hamburg and has been working for since 2007 - first as an editor and since 2012 as a freelance writer.

More about the experts All content is checked by medical journalists.

Pathological hair loss (alopecia) is when more than 100 hairs fall out per day over a longer period of time. The most common form is hereditary hair loss in men. But what other types of hair loss are there? And which means help best? Read all about it now!

Hair loss: quick reference

Forms: Hereditary hair loss (with over 60% most common form), circular hair loss, diffuse hair loss, unspecific forms (e.g. due to medication, illness, mechanical stress)
Treatment: depends on the form. Some promising approaches, especially for hereditary hair loss / receding hairline (see table)
Diagnostics: detailed investigation of the previous and family history (anamnesis, family anamnesis), physical examination, blood test, epilation test ("pull-out attempt"), trichogram (determination of the growth phase distribution), hair analysis, biopsy (tissue sample of the scalp), exclusion of other diseases
Prognosis: depending on the cause, often long-term (permanent) treatment, early onset worsens the prospects of treatment. Circular hair loss sometimes heals spontaneously.

Hair Loss: Which Treatment Will Help?

"What helps against hair loss?" For most of those affected, that is the crucial question. The answer depends on the type and cause of the excessive hair loss. For example, hereditary hormonal alopecia is treated differently than circular hair loss or hair loss due to malnutrition. Overall, the following applies: The success of a drug or other hair loss treatment is difficult to estimate - the treatment works for some, but not for others.

Hair loss: start therapy early

Three questions for

Prof. Dr. med. Christoph Bamberger,
Internist and endocrinologist
1
My dad is bald, does that mean I'll lose my hair too?

Prof. Dr. med. Christoph Bamberger
Baldness in younger or middle-aged men (and thus the most common form of hair loss) is indeed genetic. However, this predisposition is inherited through the mother. So men should look at their maternal grandfather rather than their father to predict their future hair situation.
2
What else can trigger hair loss?

Prof. Dr. med. Christoph Bamberger
Hair that falls out quickly or only in certain areas on the head can indicate illnesses such as iron or zinc deficiency, hormonal disorders or circular hair loss. It is based on an immune disorder. Some chemotherapy treatments also trigger hair loss. The following applies: Anyone who finds new hair in the brush, in the shower or in the sink and / or suddenly discovers light spots on the head should have this clarified.
3
Can i prevent hair loss?

Prof. Dr. med. Christoph Bamberger
Limited. Make sure you have a sufficient intake of micronutrients (lots of fruit and vegetables, nuts and oat flakes as a source of zinc, meat for the iron intake). Vegetarians and vegans should keep an eye on their iron levels. Once hair loss has started, start medical therapy as early as possible. Especially for the hereditary form of hair loss, the following applies: once hair has fallen out, it does not grow back.
Prof. Dr. med. Christoph Bamberger,
Internist and endocrinologist
In 2006, the hormone expert founded the Medical Prevention Center Hamburg (MPCH), now Conradia Medical Prevention, of which he is the director to this day.

The following table provides an overview of the most effective drugs and other therapies that are used for the various forms of hair loss:

Type of hair loss	Means / method	Remarks
Hereditary hair loss	Finasteride	external use; only for men
	Minoxidil	external use; for women and men
	Antiandrogens	internal application; only for women
Circular hair loss	Dithranol (cignolin, anthralin)	external use
	Glucocorticoids	external or internal application
	Topical immunotherapy	external use; only with larger bald spots
	PUVA	external application of psoralen plus irradiation with UV-A light

Finasteride

Finasteride was originally only prescribed for benign prostate enlargement (benign prostatic hyperplasia). When doctors discovered that hair growth improved in some patients taking finasteride, companies developed their own preparations for hereditary hair loss (alopecia androgenetica).

Finasteride is a so-called 5α-reductase inhibitor, which means: It blocks the enzyme 5α-reductase, which normally converts the male sex hormone testosterone into its active form dihydrotestosterone (DHT). In men with hereditary hair loss, the hair roots are overly sensitive to DHT. Therefore, finasteride can stop the progression of hair loss in those affected. Sometimes the hair on the head thickens again. However, the effect usually only becomes apparent after three to six months. When the drug is stopped, the hair will fall out again.

The active ingredient requires a prescription and is taken in the form of tablets (1 mg). Higher dose tablets (5 mg) are only approved for the treatment of benign prostate enlargement.

Side effects: Finasteride can, among other things, impair sexual desire (libido) and sexual responsiveness. Some men also report tenderness and / or chest pain.

This remedy for hair loss is not suitable for women, as damage to the fetus cannot be ruled out in pregnant women and women of childbearing age.

Minoxidil

Like finasteride, minoxidil was originally intended to treat a completely different condition - high blood pressure. Here, too, increased hair growth was observed as a side effect. As a result, researchers developed a hair tincture containing minoxidil, which is approved for external use in the case of hereditary hair loss. In female patients, minoxidil is currently the most effective therapy.

Occasionally, attempts are also made to alleviate circular hair loss (alopecia areata) with minoxidil, but this is not successful.

The exact mechanism of action of minoxidil is unknown, but could include increased blood flow to the scalp. The active ingredient-containing hair tincture is available without a prescription - there is a 5% solution for men and a 2% solution for women. In tablet form, the active ingredient is only used as a blood pressure lowering agent.

Side effects: The hair tincture can cause local skin reactions such as itching, reddening and inflammation of the skin. Sometimes the hair growth on the face increases. Changes in blood pressure rarely occur. Nevertheless, people with cardiovascular diseases should watch out for side effects such as accelerated heartbeat (tachycardia), water retention in the tissue (edema) and weight gain: If the scalp barrier is not intact (e.g. small cracks), the active ingredient can get into the bloodstream and possibly such cause undesirable effects.

Minoxidil must not be used during pregnancy and breastfeeding.

After stopping minoxidil, androgenetic hair loss usually progresses again.

Antiandrogens

Antiandrogens (such as cyproterone acetate or dienogest) are substances that prevent the action of testosterone or the more powerful dihydrotestosterone (DHT) by occupying their docking points (receptors). Some antiandrogens such as chlormadinone acetate also inhibit the enzyme 5α-reductase (such as finasteride), so that less DHT is produced in the cells. Based on these mechanisms of action, antiandrogens are said to help against hereditary hair loss in women.

After menopause, antiandrogens can be prescribed on their own. In pre-menopausal women, they must be used in combination with estrogens as a contraceptive. Pregnancy must be avoided during treatment: antiandrogens would disrupt the genital development of a male fetus and lead to "feminization".

The estrogen in the contraceptive can also strengthen the effect against hair loss: It increases the amount of so-called sex hormone-binding globulin (SHBG). As a result, more testosterone is bound in the blood. However, only free testosterone can get into the hair follicle cells.

Side effects: Antiandrogens can, among other things, reduce sexual desire.

Smokers are generally not advised to take sex hormone preparations because they have an increased risk of blood clots (thrombosis, embolism). The hormones increase this even more.

Men with hereditary alopecia are not allowed to take antiandrogens because they would "feminize" (for example growth of the male breast = gynecomastia).

Dithranol (cignolin, anthralin)

The active ingredient dithranol is mainly used in the treatment of psoriasis. The skin-irritating substance is sometimes also applied to bald areas in the case of circular hair loss: the skin irritation is said to stimulate new hair growth.

Side effects: Possible side effects are reddening of the skin, brown discolouration of the skin, hair discoloration (with blond and gray hair) and allergic reactions of the skin to contact with dithranol (contact dermatitis).

Glucocorticoids ("cortisone")

Circular hair loss is usually treated externally with cortisone creams or solutions. They are designed to alleviate the inflammatory immune response in the affected areas. In some patients, this can actually stop the hair loss and sprout new hair, but not in others. If the treatment is successful, it is generally only for as long as it lasts: When the cortisone therapy is ended, the hair often falls out again.

In certain cases, the doctor may also give cortisone injections into the bald areas. Severe hair loss can also be treated with cortisone in tablet form. However, the risk of side effects is particularly high.

Side effects: The external use of cortisone can cause allergic reactions, for example. Especially when used internally, there is a long-term risk of systemic (affecting the whole body) side effects. These include, for example, a weakening of the immune system (with wound healing disorders, increased susceptibility to infection, etc.), weight gain, water retention in the tissue (edema), menstrual disorders and Cushing's syndrome.

Topical immunotherapy

If circular hair loss has led to larger bald areas, topical immunotherapy may help. By applying the active ingredient diphencyprone (diphenylcyclopropenone, DCP), an allergic contact dermatitis is specifically triggered and maintained through repeated treatment. This is supposed to "distract" the immune cells from attacking the hair roots. Experts suspect an autoimmune reaction in the case of circular hair loss - i.e. an attack by immune cells on the hair roots due to a malfunction of the immune system.

Side effects: The complex therapy can, among other things, trigger the formation of excessive eczema on the treated skin areas. It should therefore only be carried out by specially trained doctors.

If the treatment works and the hair grows back, it can still relapse later.

PUVA

The treatment of circular hair loss with PUVA includes the application of a photoxic substance (psoralen), followed by irradiation of the bald areas with UV-A light. This is supposed to stop the immune cells from attacking the hair roots. In general, the psoralen is applied externally (e.g. as a cream). The treatment method is considered to be as successful as topical immunotherapy. However, the risk of relapse is higher.

Side effects: In general, the psoralen is applied externally as a cream (topical PUVA). If the concentration is too high, undesirable reactions such as a kind of sunburn can appear on the treated area of the skin after UV-A radiation.

You could also apply psoralen internally (as a tablet) before irradiating the skin. However, this systemic PUVA is no more promising than a topical one. It also carries a higher risk of side effects such as a higher risk of skin cancer.

Points of attack of various remedies for hair loss

More treatment options for hair loss

In addition to hereditary and circular hair loss, there are other forms of hair loss. If someone loses hair more or less evenly over the whole head, doctors speak of diffuse hair loss. It can have a wide variety of reasons: It is often caused by certain medications, for example agents against increased blood lipid levels (lipid-lowering agents), anti-cancer drugs (cytostatics) or agents against hyperthyroidism (anti-thyroid drugs). After the therapy has ended, the hair loss usually subsides again. Depending on the medication, it may also be possible to reduce the dose or switch to an alternative preparation that is less damaging to the hair.

Sometimes diffuse hair loss is caused by infections or other conditions (such as thyroid disease) that need treatment. If protein or iron deficiency is behind the excessive hair loss, the deficit must be compensated for through diet or substitute preparations.

Even in the case of scarring hair loss (scarred alopecia), the treatment of the underlying disease (lupus erythematosus, nodular lichen, etc.) is the best strategy against hair loss.

Mechanically induced hair loss can be stopped by avoiding excessive pulling on the hair roots. This means, for example, not having a tightly tied ponytail and often wearing your hair open.

Hair loss: start therapy early

Three questions for

Prof. Dr. med. Christoph Bamberger,
Internist and endocrinologist
1
My dad is bald, does that mean I'll lose my hair too?

Prof. Dr. med. Christoph Bamberger
Baldness in younger or middle-aged men (and thus the most common form of hair loss) is indeed genetic. However, this predisposition is inherited through the mother. So men should look at their maternal grandfather rather than their father to predict their future hair situation.
2
What else can trigger hair loss?

Prof. Dr. med. Christoph Bamberger
Hair that falls out quickly or only in certain areas on the head can indicate illnesses such as iron or zinc deficiency, hormonal disorders or circular hair loss. It is based on an immune disorder. Some chemotherapy treatments also trigger hair loss. The following applies: Anyone who finds new hair in the brush, in the shower or in the sink and / or suddenly discovers light spots on the head should have this clarified.
3
Can i prevent hair loss?

Prof. Dr. med. Christoph Bamberger
Limited. Make sure you have a sufficient intake of micronutrients (lots of fruit and vegetables, nuts and oat flakes as a source of zinc, meat for the iron intake). Vegetarians and vegans should keep an eye on their iron levels. Once hair loss has started, start medical therapy as early as possible. Especially for the hereditary form of hair loss, the following applies: once hair has fallen out, it does not grow back.
Prof. Dr. med. Christoph Bamberger,
Internist and endocrinologist
In 2006, the hormone expert founded the Medical Prevention Center Hamburg (MPCH), now Conradia Medical Prevention, of which he is the director to this day.

Hair transplant

The receding hairline and bald patch on the back of the head that develop in men with hereditary hair loss can be concealed with a hair transplant. Small pieces of tissue with hair follicles, which are usually not sensitive to testosterone, are cut out from the even more hairy back of the head and "transplanted" to the bald spots. The procedure should be performed by an experienced dermatologist.

A hair transplant is often unsuitable for women with hereditary hair loss because they usually do not develop any circumscribed bald areas (such as bald spots), but rather the hair generally thins out (especially on the top of the head). There is usually no complete baldness.

Even with circular hair loss, a hair transplant is not appropriate because after a few months the hair often grows back on its own (spontaneous healing).

What you can do yourself

The trade offers numerous over-the-counter products against hair loss. There are, for example, caffeine shampoo against hair loss, burdock root and saw palmetto extract, products with vitamin H, millet extract or taurine. For example, they promise to stimulate hair growth and maintain hair by stimulating the scalp and blood circulation. Most of these agents have yet to be proven to be effective.

The same applies to hair lotions with alfatradiol (17-α-estradiol). Similar to finasteride, the active ingredient can inhibit the enzyme 5α-reductase and thus the formation of highly effective dihydrotestosterone (DHT). This is why it is recommended for men with hereditary hair loss. However, the effectiveness has not been clearly scientifically proven.

Often, preparations with zinc are also taken to prevent hair loss. However, they rarely lead to success, but at least have no side effects. Biotin is also often recommended for hair loss, especially for circular hair loss, which is often accompanied by nail changes. Because biotin (like zinc) is generally important for healthy hair and nails. The effectiveness of biotin against hair loss is, however, controversial.

The right haircut or other hairstyle can hide bald spots or thinning areas of hair. Get advice from your hairdresser!

Hair replacements can also hide the affected areas. Today there are wigs and toupees made of real and synthetic hair in all shapes and colors that can be attached temporarily or permanently. With some hair replacements, you can even go swimming. In any case, seek professional advice in a second hair salon! Also ask your health insurance company whether they will contribute to the cost of a hair replacement in the event of hair loss.

Hair loss: causes

The different forms of hair loss have different causes.

Hereditary hair loss

Hereditary hair loss (androgenetic alopecia) is by far the most common form of hair loss and affects men in particular: In those affected, the hair roots show a genetic hypersensitivity to male sex hormones (androgens), especially dihydrosterone (DHT). This is the more effective variant of testosterone. In the affected men, the hair growth phase (anagen phase) becomes shorter and shorter and the follicles increasingly shrink. After all, they only produce short, thin, barely visible wool hairs (vellus hairs). These can persist or eventually fall out without new hair being reproduced.

Hereditary hair loss is much less common in women. Occasionally, a disease with impaired estrogen production or increased testosterone production is behind it, such as polycystic ovarian syndrome (PCO syndrome). Most of the women affected have normal testosterone levels. Rather, the cause is assumed to be a reduced activity of the enzyme aromatase in combination with a genetic sensitivity of some (not all) hair roots to androgens:

The enzyme aromatase converts the male sex hormones (androgens) into female sex hormones (estrogens) on the female hair follicles. This enzyme activity is reduced in women with hereditary hair loss. The result: the concentration of androgens on the sensitive hair follicles increases. At the same time, fewer estrogens are formed on site, which are said to have a beneficial effect on hair growth.

Hair growth cycle

A hair goes through three phases in the growth cycle: the growth, transition, and loss phase. The growth phase of the next hair begins in the loss phase.

Circular hair loss

The exact causes of the circular hair loss (alopecia areata) have not yet been clarified. However, there are some factors that are suspected of contributing to the development of this form of alopecia:

Mostly an autoimmune reaction is mainly blamed: Due to a disorder, the immune system attacks the hair roots, so that the hair eventually falls out. This assumption is supported by the fact that people with circular hair loss sometimes also suffer from autoimmune diseases such as psoriasis.

In addition, a genetic predisposition and psychological factors can promote the development of alopecia areata, experts believe.

You can read more about this in the article Circular hair loss.

Diffuse hair loss: causes

In diffuse alopecia, the hair roots are damaged. This leads to hair loss occurring more or less evenly all over the head, as a result of which the scalp hair is increasingly thinned and the scalp shines through. The causes can be varied. The most important are:

certain drugs, for example cytostatics as part of chemotherapy for cancer, drugs against hyperthyroidism (thyreostatics), anticoagulants (anticoagulants), drugs against increased blood lipid levels (lipid-lowering agents) or the pill (ovulation inhibitors)
Infectious diseases such as typhoid, tuberculosis, syphilis, scarlet fever, severe flu
Metabolic diseases such as hyperthyroidism and hypothyroidism
Heavy metal poisoning (e.g. with arsenic or thallium)
Long-term malnutrition, for example through crash diets or fasting cures or as a result of impaired food utilization
Radiation therapy for cancers in the head region

Diffuse hair loss in women can also be related to hormonal changes after childbirth, with the result that more and more hair falls out about two to three months after childbirth. But that usually goes away on its own after two to four months.

Other causes of hair loss

In addition to the three main forms of hair loss, there are other causes for sparse hair growth or increased hair loss. This includes:

Continuous pull on the roots of the hair, for example by frequently wearing a tightly tied braid or ponytail (this traction alopecia mainly affects the forehead and temples)
Scars or tissue shrinkage (atrophy) in the head area, for example as a result of infections by fungi or bacteria, lupus erythematosus, lichen planus (lichen planus), psoriasis, scleroderma (scarring alopecia)
compulsive tearing or plucking of the hair (trichotillomancy), often in neurotic children
Gene defect that causes no or only sparse hair to grow (congenital alopecia)

Hair loss in women

When women suffer from thinning hair or even bald spots on their heads, it can have a variety of causes. The most common cause of hair loss in men - hereditary alopecia - is much less common in women, but it is possible. It can usually be recognized by a thinning of the hair in the crown area.

Round, bald spots in the coat indicate circular loss of hair. General hair loss (diffuse alopecia) is widespread in women. It can occur, for example, as part of hormonal changes (e.g. after childbirth or during the menopause), but it can also have other explanations.

A summary of the possible causes of hair loss in women and the treatment options can be found in the article Hair Loss in Women.

Hair loss: examinations and diagnosis

If you are suffering from hair loss, the first thing you should do is consult your family doctor. Sometimes he can already determine the cause, such as an iron deficiency with a blood test. If necessary, he can refer you to a specialist. This can be, for example, a dermatologist (if a skin disease is suspected) or an endocrinologist (if a hormonal cause is suspected).

Medical history survey

The first step in clarifying hair loss is the anamnesis discussion, i.e. the doctor-patient discussion to collect the medical history. The doctor asks, for example, how long the hair loss has existed, whether you suspect a certain trigger, which medication you are using and whether you are aware of any underlying diseases.

Physical examination

This is followed by a physical exam. Hereditary hair loss, for example, can often be clearly diagnosed by the pattern of thinning or balding: balding forehead, a bald spot on the back of the head (tonsure) and receding hairline are also groundbreaking:

Receding hairline

Men in particular complain about a receding hairline in the upper temples. For some, receding hairlines develop in young adulthood. They are often the first sign of hereditary alopecia. In women with this type of hair loss, however, receding hairlines develop very rarely.

The growing baldness in the upper temples is mostly "only" an aesthetic problem. In very rare cases, however, receding hairlines can also indicate an increased risk of certain diseases. These include prostate cancer and heart disease.

You can read more about receding hairlines as well as the health risks that may be associated with them in the article: receding hairlines.

Rounded, completely bald spots on the scalp with no signs of skin changes (such as inflammation or scarring) indicate circular hair loss. This is also supported by so-called exclamation mark hairs (comma hairs), which can often be found in the edge area of the bald areas: These are short broken hairs that can be pulled out painlessly and have a tapering root instead of a normal round one. In addition, people with circular hair loss often have changes in their fingernails (grooves, dimples).

The circular, bald spots sometimes also appear on other hairy parts of the body, for example in the beard, armpit or pubic hair. Occasionally, the affected person completely loses all body hair, which is known as alopecia areata universalis. Such extreme hair loss is rare. It is also only occasionally that the patient's eyelashes fall out.

Blood test

A blood test is particularly informative in the case of diffuse hair loss. Among other things, the iron values, the thyroid values and the inflammation values (such as the number of leukocytes, sedimentation rate) are determined. The results provide information on possible causes of hair loss such as iron deficiency, hyperthyroidism or inflammatory diseases.

In younger women with hereditary hair loss, it is recommended that the blood levels of androgens and estrogens be determined. This is especially necessary if the women also show signs of increased androgen levels, such as cycle irregularities and male hair type (hirsutism).

Epilation test

Suspected hair loss can be confirmed with an epilation test: the doctor grabs a small tuft of hair and pulls it. If hairs can be pulled out in this way in several parts of the scalp, there is likely to be increased hair loss.

Trichogram

The trichogram is a microscopic examination method with which pathological processes in the hair roots and hair shaft can be identified. Hair goes through different phases in the course of its life (hair cycle):

Growth or anagen phase: The active hair growth phase usually lasts four to six years, sometimes up to ten.
Transitional or catagen phase: It lasts one to two weeks, in which the functional breakdown of the hair follicle occurs and the hair is shifted towards the surface of the scalp.
Rest or telogen phase: It comprises three to four months in which there is no longer any metabolism - the hair "rests". In the end, it is repelled (it fails).

The trichogram can be used to estimate how large the proportion of hair is in the individual stages. This helps to clarify the hair loss.

To create the trichogram, a suitable scalp area is exposed using a hair clip. Then a tight row of about 20 to 50 hairs is gripped with an arterial clamp just above the scalp and pulled out with a short, powerful jerk in the direction of growth. The hair roots are examined under a microscope to determine what stage of the hair cycle they are in.

In a normal trichogram, more than 80 percent of the torn hair is in the growth stage (anagen phase) and less than 20 percent in the rejection stage (telogen phase). Only a few hairs (one to three percent) show the transition stage (catagen phase) and are therefore usually difficult to see under the microscope.

Increased hair loss occurs when the proportion of anagen hair is less than 80 percent and the proportion of telogen hair is correspondingly more. A telogen content of up to 50 percent indicates pronounced hair loss. When evaluating a trichogram, however, the anamnesis discussion and the results of the physical examination must always be taken into account.

By the way: plucking the hair is essential for this examination. Some patients bring their hair that has fallen out, hoping to save themselves plucking it. For the trichogram, however, they are worthless because they are clearly all in the rejection phase (telogen phase).

Computerized hair analysis

It is now possible to create a trichogram with the help of a digital camera and special computer software. No hair has to be pulled out of the patient for this. Instead, a small area of the scalp is shaved in an invisible area. Three days later, the area and the regrowing hair are colored with a hair dye and the whole thing is photographed at a high magnification. The result provides the doctor with information on the hair density and the activity of the hair follicles.

biopsy

Sometimes a small sample of hairy scalp (including the hair follicles) has to be cut out and examined more closely. This can be necessary in the case of scarring alopecia or unexplained diffuse hair loss. Tissue extraction should be carefully considered: it is painful, leaves a scar and hair no longer grows in the affected area.

Other investigations

If the doctor suspects a certain underlying condition as the cause of the hair loss, further tests may be necessary. For example, an ultrasound examination or a scintigraphy of the thyroid is often performed to clarify an overactive thyroid.

Hair loss: prognosis

The prognosis for hereditary hair loss is very different. In general, the earlier hair loss begins in life, the worse the prognosis.

The course of circular hair loss cannot be predicted. In many cases, spontaneous healing occurs - the hair that has fallen out grows back so that the bald spots disappear again. However, relapses are possible, meaning that the hair will fall out again.

Other patients do not heal spontaneously and the bald spots persist. Many of those affected then resort to a wig. The health insurance company may contribute to the purchase of this hairpiece. It's worth asking!

Diffuse hair loss is often temporary: if the cause (such as iron deficiency, chemotherapy, poisoning, etc.) is eliminated, the hair grows back. Hair loss after a severe infection or after giving birth will also go away on its own. Therapy is generally not necessary here.

In the case of scarring alopecia, hair loss is irreversible: the hair that has fallen out cannot grow back because the hair follicles are damaged.

Mechanically induced hair loss usually normalizes again if one avoids the damaging stress on the hair roots (for example by tying a ponytail or plait tightly).

By the way: The best way to prevent hair loss is that which is mechanical or caused by malnutrition. So wear your hair loosely or openly and regularly supply your body with all the important nutrients and minerals (protein, iron, B vitamins, etc.)!