Hair loss in women: right diagnosis leads to the right treatment

 

When hair loss strikes, there seems to be nothing more important than finding a quick solution. The Internet has seemingly endless advice, as might your best friend or hair stylist. But after experimenting with supplements, shampoos and treatments, many women find the hair loss problem still remains.

“There’s a commonly held belief that there’s a one-size-fits-all solution for hair loss,” says dermatologist Dr. Jeff Donovan, director of the Hair Loss Program at Women’s College Hospital. “There are over 100 reasons to lose hair and determining the exact cause is essential in order to initiate the proper treatment. There’s a big difference between a quick solution and the right solution. Many hair loss conditions are treated differently – so getting to the specific diagnosis is critical to getting on track with the right treatment.”

Diagnosing hair loss

Dr. Donovan explains that a minimum of three things are needed to properly diagnose hair loss in women: a full medical history, examination of the hair and scalp, and blood test results. If any of these pieces are missing one can’t be 100 per cent confident of the cause.

“I can have in front of me the most complete story of someone’s hair loss, written in the most detailed manner possible. But without seeing the hair and scalp, there’s still a lot of guesswork needed for me to arrive at a diagnosis,” Dr. Donovan says. “The same is true when someone shows me a photo of someone else’s hair loss. I need the complete story of the individual’s hair loss and their blood test results and to see the pattern of hair loss – all three of these components are essential.”

A key difference in diagnosing hair loss in women compared to men is the importance of blood tests for women with hair loss.

“Without having the results of a few key tests, I can’t finalize my assessment” says Dr. Donovan. That’s why it is mandatory for patients at the Hair Clinic to arrive with results for their blood levels, iron levels and thyroid levels. Additional tests are sometimes ordered as well. 

“When the patient shows up, these test results need to show up too – blood test results are so important for diagnosing hair loss in women,” says Dr. Donovan.

In rare situations, a scalp biopsy is also needed, and adds a fourth piece to steps needed to diagnose the cause of a person’s hair loss. A biopsy involves taking a small sample of the patient’s hair and surrounding skin for further analysis under the microscope. For most patients, however, a scalp biopsy is not needed.

Genetic hair loss

Genetic hair loss (sometimes called androgenetic alopecia or female pattern hair loss) is one of the most common causes of hair loss in women. The condition usually starts in the 30s or 40s but can start as early as the teens. Overall, it affects about 40 per cent of women by age 50. Women with genetic hair loss typically notice that their scalp becomes more visible at its centre. Over time, progressive hair thinning occurs and some women develop thinning all over the scalp.

“For women, genetic hair loss causes hair thinning in different patterns than in men,” says Dr. Donovan. “Women develop hair loss in the middle of the scalp as opposed to the temples and crown as in men.”

A strong family history may or may not be present, and so it may come as a surprise to some women that they have genetic hair loss without a strong family history.

Hair shedding abnormalities

It’s normal to lose between 50 and 100 hairs per day. When the daily amount becomes excessive, a group of conditions known as ‘hair shedding problems’ may be responsible for the hair loss. The collective medical term for these hair shedding problems is telogen effluvium, and this is the second most common cause of hair loss in women. 

“Too many people get caught up in the precise numbers of hairs that one is allowed to lose on a daily basis,” Dr. Donovan says. “Women know what’s normal for them and what is abnormal. For one individual, 30 hairs might be normal, and when the daily rate goes up to 50 or 60, this could be a signal of something that needs further investigation. For other women, 50 or 60 hairs lost would be pretty normal. It’s only when there is a change in the rate of daily shedding that I become concerned.”

There are many causes of excessive daily shedding, including low iron, thyroid problems, dieting, medications and high stress levels. 

Dr. Donovan points out that for women under 40, low iron is a particularly common cause of excessive shedding. Thyroid problems become increasingly common with age. Medications that can cause hair loss include oral contraceptives, antidepressants and blood pressure medications.

High levels of stress can also cause hair loss. However, Dr. Donovan says it may be blamed for hair loss more frequently than it should be.

“Stress can certainly cause hair loss, but I find that it’s too often implicated as a key cause when in fact other factors are responsible,” he says.

High levels of stress resulting from the loss of a loved one, job loss or financial stress can certainly trigger excessive shedding.

Alopecia areata

Alopecia areata is an autoimmune condition that affects two per cent of the world’s population. Most patients who develop alopecia areata lose hair in small circular patches. Some individuals lose all the scalp hair – a condition called alopecia totalis. In more rare situations, individuals can lose all the hair on the body – a condition known as alopecia universalis.

The cause of alopecia areata has yet to be fully worked out. Although the condition appears to have a strong genetic basis, most individuals with the condition do not have a family history.

“A family history of alopecia areata is present in only 20 per cent of patients. So it takes a bit of explaining to help patients understand the proposed genetic basis of the condition,” Dr. Donovan says.  “What is inherited seems to be the increased tendency to develop an autoimmune condition. Although family members might not have alopecia areata, there may be members with other autoimmune conditions like autoimmune thyroid conditions, vitiligo or ulcerative colitis.”

Scarring hair loss conditions

Scarring hair loss conditions comprise a group of a dozen or so conditions that cause permanent hair loss and are sometimes accompanied by scalp symptoms such as itching, burning and pain. These conditions are not common, but might appear common were you to visit the Women’s College Hair Loss Clinic. As a tertiary referral centre for hair loss from around the country, the Hair Loss Clinic sees many patients with scarring hair loss conditions.

The cause of these conditions is not fully understood but they are thought to be immunological in nature. Some of the scarring hair loss conditions are classified as autoimmune conditions.

Dr. Donovan points out that because these conditions are not common, many patients have never heard of them.

“When a patient learns that they have a condition with a name like lichen planopilaris, frontal fibrosing alopecia, or folliculitis decalvans, there’s often a degree of surprise or shock,” Dr. Donovan says. While genetic hair loss and hair shedding problems might be terms they have read about or heard about, that’s probably not true for these scarring hair loss conditions.

Treatment

The proper treatment for a patient’s hair loss rests entirely on their diagnosis. 

“If you were to spend a day in the Hair Clinic, you might hear me discuss 15 to 20 different treatments,” Dr. Donovan says. “But the treatment I discuss in one room could be completely different from the treatment I discuss in the next room. The proper diagnosis guides selection of the proper treatment.”

For genetic hair loss in women, treatments include topical minoxidil, hormone-blocking pills, low-level laser treatment and platelet rich-plasma. Hair transplantation is also an option for some women, depending on the degree of hair loss.

“While 80 to 90 per cent of men are candidates for hair transplantation, this is not the case for women,” says Dr. Donovan. “Less than 50 per cent of women are candidates, and this can only be determined with a detailed evaluation.”

For hair shedding problems, the treatment is based on the root cause. For example, women whose hair shedding is found to be from low iron may be started on iron pills. Hair regrowth occurs in six to nine months after the root cause is addressed.

For alopecia areata and scarring alopecias, treatment is focused on quieting down the overactive immune system that is thought to be central to these conditions. Steroid lotions, steroid injections and an array of immunosuppressive pills are prescribed to help these conditions. Hair transplants may be an option for restoring hair in some patients with scarring alopecias provided the condition has been successfully treated and converted to an inactive state.

The Hair Loss Clinic at Women’s College Hospital has an important role for patients who are experiencing some of the most challenging types of hair loss diagnoses.  It sees patients in whom the diagnosis is unknown and sees patients in whom the diagnosis is known but standard medical treatments have proven ineffective.  While most patients come from Ontario, the clinic sees patients who travel from across Canada and even the United States. As a teaching hospital affiliated with the University of Toronto, the clinic trains medical students, dermatologist residents and physicians around the world in the proper diagnosis and treatment of hair loss.