What Causes Hair Loss? Ultimate Guide

Why Am I Losing My Hair?

During fetal development, hair can be found all over the body. At birth, the newborn is surrounded by vellus or very fine hair which remains as such on various parts of the body for life. As the baby gets older, various vellus hairs become what we call true hair (terminal or thicker pigmented hair), and this is what we grow on our childhood and adult scalps. Male and female pattern hair loss (or androgenetic hair loss) involves the reversion of true hairs back to the almost invisible vellus hair. This is what most of us refer to as hair loss, but this is not the only cause of hair loss, just the most common. The causes of hair loss have been categorized in more recent years and are described in detail below. Knowing which applies to you is your best chance of finding the right solution.

What Is Male Pattern Baldness?

Fifty percent of men suffer noticeable hair loss by age fifty. It characteristically appears after the onset of puberty and peaks in the twenty-one to forty-five age group. The patterns and types of loss have been charted by both Dr. James Hamilton (a full professor of anatomy at the State University of New York, Downstate Medical Center) and Dr. O’tar Norwood, a dermatologist with extensive research and publications in hair loss. It can begin in the crown (monk’s cap) or in the front and can progress to complete (not the sides or back) hair loss on top.

What Role Does Testosterone Play in Male Pattern Baldness?

There was a singing group in Italy called the Castrata. These were young males castrated prior to puberty to preserve their soprano voices. Oddly enough, none of them suffered male pattern baldness. Dr. Hamilton decided to experiment on a group of volunteer Castrata. He administered testosterone to them in various dosages to bring their male hormone levels to normal. He noticed roughly 65 percent of these men developed male pattern baldness. When he stopped the testosterone, guess what happened – the hair loss remained permanently. Dr. Hamilton was thus the first to show that male pattern baldness is caused by testosterone and the hereditary sensitivity to it of hair follicles on the top of the scalp.

Further research has shown that it is really five dihydrotestosterone (5DHT) that does the damage. This breakdown product of testosterone binds to the follicles and essentially destroys them by choking off the blood supply and nutrients. At different ages different peaks in the testosterone level will cause sensitive follicles to involute (die).

Here’s how: Testosterone circulating throughout the body has receptors to which an enzyme, 5 alpha dihydrotestosterone reductase, attaches itself. (There is a natural attraction for enzymes and receptor sites to combine in all of us.) When this happens, the enzyme allows the conversion of regular circulating testosterone to dihydrotestosterone, 5DHT.

Further experiments were performed to see if people who did not lose their hair had receptor sites for the 5 alpha dihydrotestosterone reductase. At first, investigators felt that perhaps it was the lack of sites that allowed people to keep their hair. But deeper investigation proved that all scalp hairs have sites for the enzyme. This then allowed the further conclusion that only hair follicles whose genetic code allowed the dihydrotestosterone to choke off the blood and nutrient supply would react negatively to the 5 DHT. In fact, it soon became evident that the 5DHT affected only scalp hair and no body hair at all.

Later experimentation actually showed a difference in testosterone metabolism (breakdown) between scalps destined to have hair loss and those that would keep a full head of growing hair upon it. In essence, these later results confirmed that male pattern hair loss is dependent on hair root sensitivity to various levels of 5DHT although other factors are still being investigated.

What Role Does Genetics Play in Male Pattern Baldness?

Another interesting aspect of male hair loss has to do with the inheritance of the gene for baldness. Not that many years ago we were taught that genetic hair loss was sex-linked and thereby transmitted from the mother’s side only. We have since learned that this was only the tip of the iceberg. Like a political investigation, as the research goes deeper, more and more players (in our case, chromosomes) are implicated. Although male pattern baldness is definitely transmitted on the X chromosome (XY is a male, XX is a female), there are numerous other chromosomes (humans have forty-six) that help determine the age of occurrence, rate, and degree of hair loss. So just because your maternal grandfather is bald doesn’t mean you will be also.

What Role Does Stress Play in Male Pattern Baldness?

We now know that stress can speed up the rate of hair loss. Although it usually does not cause a permanent loss in an area not meant to be bald, it can considerably move up the time frame in which genetically doomed hair dies.

Stress such as the loss of a loved one can similarly speed up hair loss. Physical stress such as heavy athletic training as well as even the simple stress of moving to a new country with a new language can push the fast-forward button on male pattern hair loss. We’ll discuss the treatments later. For now, it’s important to understand that stress can help cause hair loss other than that determined by heredity. We see this in alopecia areata (described below) as well as other more dramatic forms of baldness, such as that which occurs during chemotherapy. What is important to remember is that with the exception of hereditary and exotic causes for balding, hair will generally grow back.

When a male patient asks me how I know his hair loss is genetic, I usually tell him that there is little else that will cause a man to lose the hair from the top of his head but spare the hair on the sides and back. Although the crazy myths that we will explore later may seem logical to the male victim of balding, simple reasoning will help him get back on track.

What Are the Other Causes of Hair Loss?

Trichotillomania

This is a condition affecting both man and beast (we see it in nervous French poodles and African Grey Parrots). In the human form, a person constantly twirls his hair with one hand while talking, reading, writing, etc., causing an inflammatory reaction at the hair follicle from the constant tugging and ripping. Subsequently, this causes permanent hair loss in an uneven random pattern. This can occur in any hair-bearing area.

Animals cause the same result by biting and ripping out their fur or feathers. For example, African Grey parrots will rip out most of their feathers if they suffer separation anxiety from their owner, leaving a bald talking bird. This topic leads us to the next and somewhat related category.

Traction Hair Loss

Tight braiding or cornrowing hair over a prolonged period of time causes the same result as trichotillomania, that is, inflammation and eventual death of the hair follicle. Many African-American women present themselves after extensive hair loss (which is too often permanent), seeking a solution they wouldn’t need if they had prior knowledge of the damage they were causing.

This is also the case in various types of prosthetic hair replacements where hairpieces or tufts of hair are attached for long periods of time to the person’s own existing hair. It is especially true in hair weaving where braids of the person’s own hair are used to attach a larger hairpiece unit to it. Tightening the hairpiece to the braids causes continuous traction. Similarly, in bonding, where hairpiece systems are glued directly to the person’s remaining hair, any motion or manipulation of the system exerts traction on the living hairs of the scalp that are covered by the unit. Hair extensions where tufts of hair are added to the person’s own remaining hair by tying them together will also cause added traction stress.

Alopecia Areata and Totalis (Universalis)

Alopecia areata is thought to be an autoimmune reaction where the body actually attacks itself, destroying the hair follicles. The condition is probably stress-related and causes circular patchy areas of hair loss.

Generally, whether it is treated or not, hair growth will return in less than six months but it can be recurrent and, in some cases, if the hair hasn’t returned after a year, there is a good chance the damage is permanent.

Although various forms of medical treatment are available to aid the hair in regrowing, there is certainly no guarantee. Areas, where hair is permanently lost, can and have been successfully transplanted so the condition is not as hopeless as it may sound. Of course, transplanting hair requires areas of healthy growing hair to use as a donor and this is certainly not available in alopecia Universalis. In any case, please see a physician regarding your hair loss. Delays can be very costly.

Alopecia areata is not by any means a rare condition. There is a National Alopecia Areata Foundation that answers over ten thousand separate inquiries per year. Each year they also supply a video to over two thousand children to help them explain alopecia areata to their schoolmates. Their services do not stop here. They maintain direct contact with over five thousand people who have needed the support services that they provide.

In an effort to educate the public and those who are afflicted by the diagnosis, problems, and consequences of alopecia areata, the foundation runs an annual conference.

Scholarships and grants are awarded to needy patients and innovative researchers respectively. Grants in recent years have amounted to hundreds of thousands of dollars, all of which are the product of private fund-raising. Their active public affairs section has been successful in placing over one hundred publicity pieces in magazines, newspapers, radio, and television annually.

Alopecia totalis is the extreme version of the above where all body hair is completely lost. This is usually permanent and traumatic to the patient.

Drugs

Various drugs can cause usually temporary hair loss on the scalp. Some of these are

• amphetamines
• anticoagulants such as Coumadin and high doses of aspirin
• overactive hyperthyroid medicines slow thyroid function and thus cause hair loss
• chemotherapy for cancer
• antidepressant drugs such as lithium
• oral contraceptives, as well as some drugs treating high blood pressure such as Hydrodiuril and Captopril

Always check with your doctor and pharmacist as to the possible side effects of any medication you are about to take.

Diseases

Various imbalances such as fast or slow thyroid function (hyper or hypo thyroid) can significantly thin the hair. Medical treatment usually corrects this by returning your thyroid hormone production to its normal rate.

Infections

These can cause scalp scarring and thus permanent hair loss. They range from fungal, viral, and bacterial topical infections (i.e. ringworm) to body-affecting diseases such as syphilis.

Yes, George Washington who died of syphilis was bald and wore a hairpiece.

Miscellaneous

There are some more obscure reasons for hair loss, such as radiation or malignant tumor cells on the scalp. Whenever hair loss occurs it’s always best to have a physician examine your scalp in person.

What Will Not Cause Hair Loss?

I could write a book just talking about the excuses patients have given me for losing their hair.

• No, hats do not cause hair loss even if they are football helmets.
• Going into the military and having your head shaved doesn’t do it either.
• Deceased blood flow to the scalp will not cause it. (You have more than you need.)
• Neither does a poor diet.
• Nor does lack vitamins or minerals.
• No, your hair follicles are not getting clogged, causing your hair to continue growing under the scalp until you use some miracle drug to release them.
• Losing your hair is not an allergic reaction to your pet.
• Working in a dusty environment will not cause hair loss.
• Smoking may be linked to lung cancer, but it is not linked to baldness.
• Baldness is not a punishment for not leading a righteous life.
• It is not a result of brushing your hair with a stiff hairbrush too often.

Why Me?
The Psychology of Hair Loss

How Do Men Suffer Psychologically?

Most men have similar hair loss experiences. An otherwise healthy young male is suddenly faced with a gradual yet dramatic change in his appearance for, he believes, the worse. This change is progressive and permanent. The dilemma is compounded by the fact that socially and historically it is unmanly for a male to be concerned about his appearance.

Thus conflicted, many men suffer tremendous anxiety about their hair loss. They are on one hand depressed about the appearance and stigma of baldness and on the other hand, they are often ashamed to admit that the condition bothers them for fear they would be considered vain. So many men try to compensate physically, psychologically, and socially. They often manage by secretly trying to cover up their bald spots.

Many patients today confirm that they too could spend upwards of one or two hours per day trying to cover what nature was removing. Others seek hope in the opposite route. They shave everything. But nothing can help escape the fact that they are losing their hair.

How Do Women Suffer Psychologically?

In the past women often avoided discussing hair loss with anyone but their hairdressers. Because they most often suffer from diffuse thinning, it was generally easy to disguise the problem. But women were nonetheless disturbed by it. Some women say that they feared detection because, although it was normal for men to lose hair, female hair thinning was considered unnatural, a sign of some disease process. However, women are becoming much more open about this perfectly ordinary problem.

What Are the Psychological Phases Men and Women Experience?

When their hair begins to thin, both men and women go through the same psychological phases that follow the loss of anything or anyone dear to us (hair is certainly up there on the list). These are as follows:

• Denial
• Panic
• Anger
• Withdrawal and depression
• Acceptance and resolution

Denial
Can This Really Be Happening to Me?

No one wants to believe that this is really happening to them. The early hair loss sufferer sees a change in his hair, the temples are receding, or the crown seems a bit thin, but he denies the obvious. He checks the shower drain, comb, or hairbrush and then looks at his scalp under the brightest and dimmest of lights. He or she carefully listens for comments from others and then reviews all available photos of themselves from second grade onward to see if it’s really true. The new sufferer studies his relatives and carefully asks questions about their hair loss, looking for discreet differences between himself and his genetics. This strategy only works for so long. Sooner or later the thinning increases or a “sensitive” friend points out his increasingly visible scalp at a social gathering. Every time he talks to someone their eyes seem to travel to his vanishing hairline.

When you begin to realize the inevitable, it’s time to go on to phase two.

Panic
Oh My God, Does This Mean I’m Old Now?

After denial, there is usually panic. All the social implications of baldness start running through the sufferer’s head. To be bald you are older, boring, unmanly or unwomanly, possibly diseased, and deficient in sex appeal. There are no positive characteristics associated with baldness. The fact that more victims in our society do not go into a severe state of depression from hair loss is a great demonstration of the resiliency of the human species. But panic can cause its own set of problems.

Anger
Are You Looking at Me? Then Who Are You Looking At?

You wash your hair every day and you’re very careful about blow-drying, brushing, or otherwise damaging it – you haven’t done anything wrong. So someone else, the victim at this stage reasons, must be to blame.

No matter how angry you get, remember one thing – it’s the fault of genetics in most cases, and pointing blame does not cure the problem. Although you know you want to do something about it (or you wouldn’t be angry) you will still suffer through phase three in some form before you can proceed to phase four.

Withdrawal and Depression
Will I Ever Get Another Date?

Depression often does occur at the onset of hair loss and in some cases never goes away. The image we see in the mirror can certainly affect our conduct in society. Someone has made a comment! Now you wear hats and avoid photographs. You avoid social situations because they may lead to embarrassment. So it’s time to hibernate. You find reasons not to go to the beach or swim or play active sports where you can’t wear a hat. Sometimes you just stay home.

In other words, you are letting your hair rule – and maybe ruin – your life.

Acceptance and Resolution
Actually, Don’t You Think It Looks a Bit Sexy?

Next comes acceptance. Many men simply accept hair loss as part of the passage of life. After all, hair loss is a normal genetic trait passed on from generation to generation. There are certainly many handsome masculine individuals who have chosen to accept or simply ignore their hair loss. This is certainly the best and healthiest attitude one can take. Whether we are destined to be short or tall, handsome or homely, athletic or awkward, hairy or bald, these are all part of the genetic cards we are dealt and we should accept them.

Some men go so far as to embrace baldness. They wear it as a badge of honor, proudly proclaiming I am Bald and Proud. The Bald-Headed Men’s Club of America, in Moorehead, N.C. has members from around the world who correspond and get together to support hair loss as a mature, sexy, virile appearance that society should look upon with admiration. Most men deal with hair loss as inevitable and natural and move on with their lives and careers. Appearance is comprised of many aspects, not the least of which is our personality and intelligence. A good personality and an interesting mind have more of an influence on our attractiveness than any physical characteristic.

Unfortunately, not all men are created entirely equal and acceptance of the inevitable is a characteristic that varies dramatically from person to person. Hair loss is not something we are born with; it happens later in life after we have gotten used to seeing ourselves a certain way. Our hairline is the frame of our face, and just as an attractive frame and matting complement a picture, our hair compliments the features of our face. As with a picture, if we take away the frame, the face appears more ordinary and far less attractive.

The feeling that their appearance has suffered is a significant reason why men often do not accept baldness. Although generally, a young man suffers when going bald more than a mature male in his fifties or sixties, I often meet with older men who feel their hair loss has unfairly aged them. They do not want to change their appearance but rather want to restore it to a fairer picture of who they are.

Just as hair loss is not the cause of all your problems, it is also not the cure. For individuals to succeed socially and professionally it is much more important to have personality, intelligence, and strong character than a fuller hairline. Hair can improve our appearance and self-image but only strong character and motivation can help us to succeed in life. It is important that when we look into the mirror for answers to our problems we should look deeper than the surface for the solutions.

You now know it’s true and it’s time to either accept it or do something about it.

• You can shave your head as many sports figures do
• You can begin to look into various treatments

But first, you do what most of my patients and I have done. You consult your hairstylist.

What Can My Hairstylist Do?
“The Illusion of Hair”

Your hair has thinned. You may either have a bald spot or simply “see-through” hair. In any case, it’s time for that first consultation with the person who you feel knows you best; for most people, it’s their hairstylist.

What Hair Styles Can Hide Hair Loss?

A good hairstylist knows how to cut and shape thinning hair to help maximize its covering power. Privacy is important and I often tell people to ask for your hairstyling consultation “behind closed doors” (neighbors in the salon and barber shop love to listen to others’ problems). Your professional may recommend a “body wave” to thicken limp or fine-thinning hair, or he/she might layer it to give the look of significant thickness. The hairstylist may also cut portions of the thinning areas shorter because short, not long hair, covers better. This is because the weight of long strands of hair tends to cause them to separate. Thinning hair becomes less noticeable when the hair is shorter because it is acceptable to see some scalp through shorter hair (think of military recruits who even with full heads of hair exhibit a thinning appearance after the short haircuts given in basic training). Combine this with slightly longer hair elsewhere and a lower part, and you’ve effectively camouflaged the problem.

Hair color helps as well. When hair is thinning, the less the contrast in color between the hair and scalp, the less noticeable the problem. Thus blond-haired Caucasians look less bald than their dark-haired counterparts with the same degree and pattern of hair loss.

What Should I Not Do?

• Don’t braid or use rollers to give your hair extra body – they will cause breakage and further thinning.
• Don’t try to dye your hair because the chemicals (as mentioned) can permanently damage the scalp.
• Don’t keep your hair too long because the weight of long hair tends to make it separate and thereby expose thinning areas of the scalp.
• Don’t blow-dry your hair constantly and too closely with hot air as this will also cause hair breakage.
• Don’t brush your hair constantly because this too will cause breakage and thus thinning of your hair.

What Hair Care Products Help Conceal Hair Loss?

Hair care products can often help your assault on thinning hair. Your hairstylist can help you choose those that are best suited for you.

Shampoo

Shampoos advertise all sorts of claims. These are the most important things to remember.

1. Change your shampoo regularly; the hair adapts to the same product if used daily. The goal of shampooing is to leave the hair clean and manageable.
2. Beware of “coating” shampoos which in actuality coat your hair with a chemical and so make it appear dirty and less manageable.
3. A detergent shampoo is meant to cleanse the scalp by removing sebum (the discharge from sebaceous glands) and dirt; however, some sebum is necessary to retain your hair’s sheen.
4. Foaming shampoos are not better than nonfoaming ones.
5. Kinky hair should be shampooed less often than straight hair as sebum is necessary for grooming kinky hair.

Conditioners

Conditioners counteract the detergent effect of shampoos. They “smooth” the hair shaft and remove static cling while attracting light reflection. Thus, they create shiny, manageable hair.

Remember, different hair types (e.g. fine vs. coarse hair) adapt differently to different agents. Coating conditioners (hair thickeners) can actually add much weight to fine hair as to make it unmanageable. This is why your stylist is your best guide to hair care products.

Gels and Mousse

In the professional hair care world, gels and mousse are known as “left-in” conditioning agents. They can vary from the pomades that African-Americans often apply to kinky hair to add luster and body, to the moisture-absorbing “gels” that add thickness and body to limp hair. Many of these products also contain silicone which helps the hair feel smooth and silky to the touch.

The primary purpose of these products in our context, though, is to give more holding power to thinner hair.

Hair Spray

Hair spray, like mousse and gels, is directed at giving increasing holding power to finer or thinner hair. The base of many hair sprays, however, is alcohol and can thus dry and dull hair. The key is to be smart and sparing. Hair should be able to blow somewhat freely in a breeze. The helmet look may be okay to some, but can be as artificial as a bad hairpiece to many others. Hairstylists have the proper training in what is best for you.

Perms and Waves

Perms and waves are chemical methods to make fine, thin, or straight hair appear thicker by making it wavier or curlier. They generally will last about four months and can be helpful to those people in various stages of hair loss. They can also be damaging, as I have mentioned before. If you decide to go ahead, make sure you go to a professional who performs these techniques regularly and will carefully monitor the application.

Haircolor

As mentioned earlier, many people do not realize that what makes thinning hair very obvious is the contrast between skin and hair color. For example, thinning black hair on a fair-skinned person is much more obvious than the same amount of blond hair thinning on the same skin type. Therefore, proper hair coloring (vs. skin) and highlighting can help hide a “multitude of thinning sins.” Once again – all chemical treatments of hair can be dangerous and should be performed only by a competent professional.

What Vitamins Promote Hair Growth?

Although vitamins are important and can affect hair sheen, a lack of them is not a cause of hair loss.

You should not confuse hair quality and hair care with hair loss. Vitamins and minerals may be partially contributing to good hair care, as well as other vital body functions, but they will not cure hereditary baldness. The person who sold Vitamins For Your Hair along with Right Places Breast Enlargement Pills served prison time for mail fraud. There is a good reason for this.

Spend your money on products that help, not ripoffs. If you take vitamins they should be for the right reason, not for some false hope.

What Are the Best Cosmetic Hair Loss Coverups Available?
What Are the Benefits and Pitfalls of Each?

1. Temporary hairpieces. They can be made to clip to existing hair for security and to prevent damaging adherence to fresh surgical sites.
2. Invisible concealer. This is inexpensive makeup with a fine applicator which works great on the scalp reduction lines as well as on small areas of scabbing. Most are hypoallergenic and I have never seen a topical reaction to them.
3. DerMatch. This is a water-resistant scalp coloring that can be safely applied over even fresh surgical sites to give the appearance of thicker hair. It can also be used in sites with existing thin hair as well. It does not run when wet nor when caught in the rain and it looks very natural. The problem is applying it. You must use your fingertip for a good application, although every package now comes with a new applicator to remedy this. It also can stain your fingers if not washed off immediately, requiring longer, harder scrubbing to completely remove the coloring.
4. Couvre. This is an excellent scalp colorant (as per DermMatch) and applies very easily. The problem with this product is that it runs in water (which can be embarrassing) and stains your pillowcase and shirt collar. Used correctly, it can be a big help because of the quick application and excellent coloring matches.
5. HairSoReal. It is a fiber that adheres to surrounding hair to give it increased fullness and thickness. It sprinkles on easily and does not run. Like all colorants, it is available in a variety of shades and colors. This is a great product with a funny name. Don’t let the package or the silly name fool you – this works well for easily and safely covering thinning spots. Although I would advise any patient to be careful and consult their physician before using any product, this physician loves the HairSoReal best for general camouflage.
6. Spray-On (shoe polish). The spray-ons can be messy and can also stain pillowcases and clothing. More importantly, in many cases, they inflame the scalp and in my opinion, are not safe for use on recent scalp surgical sites.