Alopecia Q&A with a Consultant Dermatologist 

We have spoken to Consultant Dermatologist Dr Adam Friedmann all about alopecia. Here he answers some common questions about the causes, prevention and treatment of alopeica.

What are the signs of alopecia to look out for?

Hair loss can occur slowly over many years, or be rapidly progressive, occurring over days or weeks but the signs to look out for would be:

1. Increased hair loss
2. Patches of hair loss
3. Itching or redness in the scalp
4. Hair loss in other places – on the body such as eyebrows

What is a normal amount of hair to lose and when should you head to the doctors?

On average, it is normal to shed around 100 hairs a day from our scalp. The moment you get up to 200 you’ll start to notice an increase in hair on the brush, on the pillow and in the shower. It can be dramatically more than that if you’re losing it fast.

What are the different types of alopecia? 

Alopecia can be a diffuse process (i.e. androgenic) or occur in localised areas on the scalp or other areas of the body (i.e. alopecia areata). If there is scarring, the skin might be featureless with loss of hair follicles and pigment.

There are many causes for alopecia which can broadly be grouped into three categories: internal deficiencies, scalp disease or ‘other’ causes. The most important distinction, however, is whether scarring is a feature or not, because this will dictate the treatment and how successful treatment can be.

Types of alopecia:

NON-SCARRING

  • Androgenic or genetic alopecia is the commonest cause of hair loss in men and women – small, round patches of baldness on the scalp, although hair elsewhere such as the beard, eyebrows, eyelashes can also be affected.
  • Thyroid related hair loss might be due to over or under-active thyroid
  • Alopecia Areata is usually patches of hair loss caused by the immune system
  • Iron deficiency or low ferritin can cause hair loss
  • Telogen effluvium is stress or illness related hair loss. An increased proportion of hairs shift from the growing phase to the shedding phase. It occurs due to an interruption of the normal hair cycle which may have been brought on by a severe trauma such as a family bereavement, childbirth, extreme dieting or perhaps new medication.
  • Age related hair loss occurs in all people over time
  • Drug induced hair loss can occur as a result of some medications

SCARRING

  • Traction/Traumatic alopecia is due to scalp damage (often through excessive braiding)
  • Lichen plano-pilaris; an inflammatory scalp condition
  • Lupus; an autoimmune condition that can affect the scalp
  • Folliculitis/dissecting Cellulitis; hair follicle inflammation that can lead to scarring
  • Pseudopelade is end stage scarring alopecia of uncertain cause

In terms of knowing which form of hair loss you have, there is nobody more qualified than a consultant dermatologist, so in order to ensure you have the correct diagnosis and therefore treatment plan visit a dermatologist to discover the actual cause of your hair loss and whether it’s treatable. So, forget the wonder creams and supposed miracle shampoos, diagnosis will involve a consultation, full scalp examination and sometimes blood testing to establish if there is a deficiency or hormonal problem. If scalp disease is present or a diagnosis is not straightforward, a scalp biopsy might be undertaken to examine the process at a microscopic level.

How does alopecia start?

Alopecia will begin with hair loss, but the symptoms will vary depending on the type of alopecia and the cause of it. For example, in non-scarring alopecia it might be a gradual process of gradually losing iron levels or with genetic alopecia it’s a very slow process of hair loss, but then the more rapid ones like the auto-immune hair loss or stress related hair loss where you can lose quite a lot quite rapidly, so you just start to notice it.

With the scarring alopecia’s you might start to notice inflammation or redness and flaking in your scalp or in certain types like traction alopecia it may be through years of abuse of your scalp inadvertently such as wearing tight braiding, hot cone use, relaxants, chemicals etc which can all damage the scalp over time.

Is there a cure for alopecia?

For some alopecia yes there is a cure but for some unfortunately, there isn’t. The key to treatment is establishing if the condition is scarring or not. If it is scarring, it is important to switch off the process as quickly as possible to prevent progression, as scarred areas will NOT regrow. Non-scarring alopecia can recover fully with treatment, like Telogen effluvium (stress related) or auto immune but some may steadily progress over time and can only be slowed down like pattern alopecia.

What can you do to prevent alopecia?

You can not prevent it but treating the cause is key i.e. replacing iron if a deficiency in iron is the cause or thyroid if an underactive or overactive thyroid is the problem.

Also, stress can exacerbate any of these conditions so making lifestyle changes can also help. Stress-related hair loss is particularly common in people who suppress feelings of stress and anger – those that implode rather than explode. We never switch off and it can result in chronic stress. Our cortisol and adrenaline levels are elevated more often and for longer. Hair grows and then reaches a resting phase where it will eventually shed, and new hair will grow – that’s normal. But in the case of telogen effluvium type hair loss, stress hormones called neuropeptides push hairs out of the growing phase into the resting phase – slowing regrowth to the point thinning hair is more obvious.

What can you do if you have alopecia?

As previously stated the most important part of treatment is correct diagnosis, and no one is more qualified than a dermatologist. The general trigger for someone to see a dermatologist will be when their condition is starting to interfere with their quality of life. The psychological and social impact of hair loss in adulthood can be profound. The degree of psychological stress caused by alopecia is usually related to the extent of alopecia and the ease (or lack thereof) with which the condition can be covered or hidden. Dermatologists are expertly qualified to assess the impact of it on the patient’s quality of life, so where necessary treatment might be offered that is both medical and psychological.

The treatment will vary depending on the cause. If the common cause is a nutrient deficiency for example you would treat with replacements like thyroid or iron and if it’s genetic then you can’t stop it, but you slow it down with things like Minoxidil (Regaine) or Finasteride (Propecia). If there’s an inflammatory disease, it’s treated with immune suppression and powerful drugs which can be quite aggressive.

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AUTHOR

adam friedmann

Dr Adam Friedmann
Consultant Dermatologist

GMC: 4425665
Qualifications: MB BS 1997 University of London

Dr Friedmann is a UK-trained Dermatologist who trained at King’s College School of Medicine, London. He has worked at many of London’s teaching hospitals including King’s College, St Georges, Hammersmith, Barts and the London and the Royal Free Hospitals.

Dr Friedmann is Chief Medical Officer of The Dermatology Partnership and Clinical Director of the Harley Street Dermatology Clinic.

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