Hair Loss in Men & Women

     Normal Hair cycle
The reason for hair loss is the most debated topic around the world for many decades.

Causes of Baldness:

     Androg genetic Alopecia is commonly known as Male Patterned Baldness. The 3 main reasons for baldness are heredity, hormones and time.

Heredity:
Genes play an important role in the establishment of baldness. A person must have the inherited tendency to go bald early and hormones play a vital role.


Normal hair fall per day is 50 to 100

Approximately more than 150 genes control hair growth. So, the pattern of inheritance may vary.

For ex: Within the same family, even though the parents are bald, the children may never go bald but the grand children may be affected.

MALE PATTERN BALDNESS or ANDROGENETIC ALOPESIA is a gradual balding of the scalp which occurs commonly in men, occasionly in women also. The gradual transformation of terminal hair follicles to smaller vellous ones with a much shorter growth period occurs in well defined patterns and is believed to require both ANDROGENS and GENETIC tendency.

No permanent treatment is currently available for Androgenic alopesia except for corrective hair transplants.

It is non scarring alopesia and results from genetically determined end organ sensitivity to Androgens.

Change in the Terminal to Velous hair ratio from 6:1-8:1 to 4:1 or less will be seen.

There is interaction of several Genes with Environmental factors. Usually 25% of men aged 25-30 yrs, 50% of men aged 50 yrs are affected by MPB.

HEREDITY—Inheritance may be MATERNAL, PATERNAL or both, but the penetrance of genes may vary.

So it is POLYGENIC inheritance with VARIABLE PENETRANCE.

Genetically no definite treatment is available till now.

HAIR LOSS INDEX ,PROFILE AND SEVERITY SCALE.

It was specially designed to describe an individual patients hair distribution and density. PROFILE is a graphic display of the loss in each 10 zones. INDEX is score for the cumulative loss in all 10 zones.

Surface map is a 3 view graphic scalp with 10 zones that corresponds to sequence of MPHL[NORWOOD].

Hair loss severity is visual ratio of hair to skin. It has 6 categories.

SCALP LAXITY CLASSIFICATIONS:

It is used to estimate the maximum donor strip width that can be safely removed during HT.

BOSLEYS TECHNIQUE AND MAYER & PAUL TECHNIQUE.

HORMONES-ANDROGENS

In normal hair growth the PAPILLA nurtures MATRIX CELLS with growth factors such as INSULIN LIKE GROWTH FACTOR.The matrix cells secrete growth factors which stimulate the papilla. The dermal papilla is mesenchyme derived structure which play major role in induction and maintenance of hair growth.

The scalp hair follicles takeup the circularing TESTOSTERONE and with the help of 5-ALPHA-REDUCTASE type 2-enzyme converts it into DIHYDRO TESTOSTERONE [DHT] . This DHT binds with AR and activates ANDROGEN RECEPTOR GENES.

Due to 5 alpha – DHT in the hair follicles there is decreased conc. Of "C AMP" which causes the shortening of hair cycle, finally this leads to transition of Anagen hairs to Telogen hairs with total loss of hair and baldness.

In addition balding scalp contains less AROMATASE which converts testosterone to estradiol. In women this enzyme maintains the frontal hairlines.

Male Hormones:
The 2 androgens namely, testosterone and dihydro testosterone (DHT) are directly responsible for hair loss. The hair growth on the face and body, acne, Prostrate enlargement and Male Pattern Baldness (MPB) are all under the control of DHT. DHT is directly responsible for MPB. But it has to be produced from testosterone only.

The enzyme 5-alpha reductase converts the testosterone to DHT.


Time:
Baldness is a progressive phenomenon with the advancing age. It takes time for the genetically inherited balding tendency to establish itself.

 


FPHL (Female Pattern Hair Loss)

FPHL—Female pattern hair loss is probably a multifactorial genetically determined trait and itis possible that both Androgen dependent and Androgen independent mechanisms contribute to the phenomenon.

Three patterns of hairloss have been described-

1. A more or less male pattern or fronto parietal pattern as described by Hamilton and Norwood.

13% of premenopausal women have type 2-4 MPB.

37% Post menopausal women had type 2-4 MPB

2. Centrifugal pattern first described by LUDWIG .It is divided into 3 degrees.

In this type we observe intact frontal fringe of hair with caudal scalp baldness.App. 87% of premenopausal women show some type 1 or 2 baldness.

3. Christmass tree pattern described by OSLEN. In this there is increasing hairloss towards frontal scalp with occasional breach of frontal hair line also.

Many women develop small 2-5 mm oval or irregular areas of total alopesia in diffuse thinning.

Usually in women there appear tobe 2 peaks of onset of hairloss at 3rd and 5th decades.

FOLLICULAR UNIT or GRAFT Hair grows in the human scalp mostly in groupings of 1-4 terminal hair follicles,sometimes vellous hairs may also present in it.[rarely 5-6 terminal hairs also present].

Normal density of FU is app. 100/sq cm.

Average FU contains 2-3 hairs. So app.230 hairs/sq.cm present.

Norwood Hamilton Classification

The Norwood classification categories are as follows;

1. Type I depicts the normal mature hairline. It pictures minimal temporal recession.
2. Type II depicts mild temporal recession with thinning along the anterior margin of the forelock. The recession is pictured as symmetrical.
3. Type III depicts the minimal amount of hair loss required of the definition of balding and demonstrates deep frontal recession with few or no remaining hairs.
4. Type III Vertex depicts hair loss confined to the vertex with deep frontal recession (no greater than the recession in Type III).
5. Type IV depicts significant frontal and temporal recession and frontal thinning together with sparse or absent hair in the vertex. The bridge between the frontal area and the vertex is still retained.
6. Type V depicts larger areas of frontotemporal and vertex alopecia than Type IV and only a narrow and sparse bridge separating both areas.
7. Type VI depicts loss of the bridge that separates the frontal and vertex areas with lateral and posterior progression of alopecia.
8. Type VII represents the most severe form of balding. The remaining horseshoe-shaped band of hair in the lower scalp in narrow. It begins anterior to the ear and extends posteriorly and bilaterally to a low point in the occiput. The preauricular hairs have receded both posteriorly and inferiorly. The remaining hair band is frequently of lower density with evidence of some miniaturization. Hair is sparse on the nape of the neck and in some cases the inferior occipital border is significantly raised.

Type A variants on the Norwood scale present two significant variations to the normal scale. First, recession involves the entire frontal border with no sparing of the mid-frontal zone. Second, there is no simultaneous vertex balding. Vertex balding develops from continuous posterior progression of the anterior recession.

Causes of Hairloss:
1. Non scarring Alopecia
i. Alopecia Areata.
ii. Anagen Effluvium
iii. Telogen Efflvium
2. Scarring Alopecia
3. Drugs
4. Self Induced hair loss
5. Hair loss in women

Alopecia Areata:
    Auto immune disease in which dermal papilla of hair follicle gets affected leading to partial or total loss of hair over the head, face and body. Spontaneous remissions and relapses are common and uncertain.

      Hair transplantation can be done under special conditions only.

Anagen Effluvium:
Loss of hair in the Anagen growth phase which occurs due to anti cancer drugs, X-ray therapy, Toxic drugs like heavy metals, arsenic, bismuth, gold, colchicines etc. After stop using the anti cancer drugs complete regrowth of hair occurs.

Telogen Effluvium:
Excessive loss of (>100) hairs in the Telogen growth phase. The common causes of TE are…
Hormonal changes – Hypothyroidism, PCOD etc.
High Fevers
Surgery
Child birth
Chronic health conditions like.. diabetis, anemia.
Stress
Crash diets
Some time after Hair transplantation

   After rectification of the above problems the regrowth of the hair always may not be full.

Scarring alopecia:
It may occur due to inherited abnormalities of the skin and hair follicles. Bacterial, fungal, viral infections of the scalp disorders such as lupus, lichen planus, severe scalp psoriasis, Kerion of tinea etc… also cause hair loss. Consultation by a dermatologist is mandatory.

Hair transplantation can be considered in some cases after stabilization of the disease progression. Patchy congenital hair loss can be treatable with HT.

Drugs:
Drugs such as ACE inhibitors, Beta blockers, Calcium channel blockers, Anti coagulants, Anti Convulsants etc may effect hair loss. Approximately 300 varieties of drugs may cause the hair loss.

Self Induced hair loss:
1. Traction Alopecia: Due to prolonged physical tension on the hair like wearing tight braids and using clips and gums for fixing hair additions the existing hair will be lost in patches.

2. Trichotillomania: It is a psychological condition that mainly effects children, adolescents and women. They pull out hair from their scalps in distinct patches. This condition is manageable with counseling.

Scarring alopecia:
It may occur due to acquired abnormalities of the skin and hair follicles (bacterial, fungal, viral infections). Disorders such as lupus, lichen planus, severe scalp psoriasis, Kerion of tinea etc… also cause hair loss. Consultation by a dermatologist is mandatory.

Non Scarring alopecia:
Conditions like Alopecia aereta, Anagen or Telogen effluim also cause hair loss. Regrowth of the hair depends upon the detection and evaluation of the root cause.

FPHL (Fmale Pattern Hair Loss)

FPHL—Female pattern hair loss is probably a multifactorial genetically determined trait and itis possible that both Androgen dependent and Androgen independent mechanisms contribute to the phenomenon.

Three patterns of hairloss have been described-

1. A more or less male pattern or fronto parietal pattern as described by Hamilton and Norwood.
13% of premenopausal women have type 2-4 MPB.
37% Post menopausal women had type 2-4 MPB

2. Centrifugal pattern first described by LUDWIG. It is divided into 3 degrees.
In this type we observe intact frontal fringe of hair with caudal scalp baldness. Approx. 87% of premenopausal women show some type 1 or 2 baldness.

3. Christmass tree pattern described by OSLEN. In this there is increasing hairloss towards frontal scalp with occasional breach of frontal hair line also.
Many women develop small 2-5 mm oval or irregular areas of total alopesia in diffuse thinning.
Usually in women there appear tobe 2 peaks of onset of hairloss at 3rd and 5th decades.

FOLLICULAR UNIT or GRAFT—Hair grows in the human scalp mostly in groupings of 1-4 terminal hair follicles, sometimes vellus hairs may also present in it [rarely 5-6 terminal hairs also present].
According to histologic anatomy HEADINGTON described the FU also includes Sebaceous lobules, Arrector pili muscle insertions, vascular plexus and neural network.

LIMMER done microscopic dissection, which leads to development to FU development.
Normal density of FU is approx. 100/sq cm.
Average FU contains 2-3 hairs. So approx. 230 hairs/sq.cm present.

Ludwig Classification

HAIRLOSS in women:
Usually hair loss in women is in a ‘Christmas tree’ pattern. But occasionally women also lose their hair in male pattern but retain their frontal hair. A particular enzyme called Aromataze (rich in frontal area) helps maintain the hair line.

Hair loss in women is usually very gradual and accelerates at Menopause.

It is mostly effected by hormones (PCOD, thyroid etc..), general conditions (hemorrhage, pregnancy, anemia, fever, crash diet etc..). Few medications and stress also accelerates the hair loss.

So in females always first treat the general health condition as chronic anemia is one of the common problem.

Hair transplantation can be performed on women creating undetectable and natural looking hair line.

Congenitally high hair lines and big foreheads in women can be rectified with newly created hair lines.

 
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