Hair loss • What to do about bald spots on the head?

A person loses 70 to 100 hairs a day. It is a completely natural process, because each hair has only a certain lifespan. Only when more than 100 hairs are lost every day and grow significantly less are we talking about increased hair loss (effluvium). If there are already light spots on the scalp, this is called visible hair loss (alopecia).

An adult with full head hair has between 70,000 and 120,000 hairs on the head, which consist of 90 percent certain proteins (keratins), depending on the hair color. They are formed in the hair follicle (hair follicle) that surrounds the root and anchors the hair in the scalp. Each hair grows independently of the others and eventually detaches from the head to make room for a new hair that grows from below. The life of a hair is affected by the activity of its follicle.

A hair cycle has three phases:

• Growth phase (anagen phase; two to six years)
• Transitional phase (catagen phase; two to four weeks)
• Failure phase (telogen phase; two to four months)

With alopecia, more than 20 percent of all hair is in the telogen phase.

At a glance:

What types of hair loss are there?

Hair loss is a worldwide symptom of various hair growth disorders and diseases. Because scalp hair is of great importance in almost all cultures and is considered an indicator of health and youth, its loss is a reason for many people to seek medical advice.

The main types of alopecia are:

• hereditary hair loss, also: androgenetic alopecia (Alopecia androgenetica)
• diffuse hair loss (Alopecia diffusa)
• circular hair loss (alopecia areata)
• scarring hair loss, also: atrophic alopecia (Alopecia cicatricalis)

Androgenetic alopecia is by far the most common hair growth disorder: it is estimated that up to 40 percent of all women and up to 70 percent of all men of European origin suffer from this type of hair loss. Alopecia areata affects around 1.4 million people in Germany (one to two percent of the population). There are no reliable figures for other hair growth disorders.

How do you recognize androgenetic alopecia?

Hereditary hair loss in men usually shows up on the so-called receding hairline at a young age. Later, the hair on the forehead and the top of the head also become thinner until there is only one hair ring left (tonsure).

The course of androgenetic alopecia is divided into the following stages:

In women with androgenetic alopecia, the middle parting is thinned out and hair is generally thinning. In rare cases, a retraction of the frontal hair border to baldness is observed.

How do you recognize diffuse hair loss?

Diffuse hair loss can be recognized by the fact that the hair thins out evenly (and not in one place). The scalp often shimmers through, especially in the area of ​​the crown.

How do you recognize circular hair loss?

In the case of circular hair loss, there are individual, delimited bald spots on the head that completely recede, but can also lead to total hair loss. The disease can also affect the fingernails and toenails and can be accompanied by swollen lymph nodes behind the ears. People with alopecia areata often suffer from other autoimmune diseases and show psychiatric abnormalities above average.

How does scarring hair loss show up?

In the case of inflammation-related, scarred hair loss, the scalp is usually initially reddened, it can flake or itch. After the inflammation has healed, visible scars often remain, on which hair no longer grows because the functionality of the hair follicles has been destroyed.

What can cause hair loss?

Depending on the type of alopecia, there are different causes for hair loss:

• Genetic predisposition: If a person suffers from androgenetic hair loss, her hair follicles in certain areas of the head are inherently particularly sensitive to the male sex hormone (androgen) dihydrotestosterone (DHT). As a result, the growth phase of the affected hair is shortened, so that it becomes thinner with each cycle and finally disappears completely. It is believed that circular hair loss and certain types of scarring alopecia can also be inherited.
• hormones: While androgenetic alopecia in men is triggered by average amounts of male sex hormones, affected women generally have a disproportionately large number of androgens in the blood. This can happen, for example, if the body reduces the production of female hormones during menopause. The use of hormonal contraceptives, hormone replacement therapies, other hormone treatments and functional disorders of the thyroid gland are often the cause of female-type alopecia. Many women experience increased hair loss around three months after pregnancy (postpartum effluvium), This is due to the sudden drop in estrogen after Birth causes: Because estrogen has prolonged the growth phase of hair during pregnancy, many hairs are now falling out at the same time.
• nutrient deficiency: The growth phase of a hair with its numerous cell divisions only works smoothly if the follicle is supplied with all important nutrients. This is why people with hair loss may have a lack of iron, zinc, folic acid, vitamin B12 or vitamin D. Nutritional deficiencies are often caused by eating disorders, chronic (intestinal) diseases, heavy bleeding (iron deficiency) or one-sided diet.
• inflammation: Scarring alopecia is usually based on an inflammatory infection of the scalp, which irreversibly damages the hair follicles and can lead to permanent hair loss. It can be caused by bacteria, fungi or viruses.
• Immune system malfunction: Circular hair loss is one of the autoimmune diseases because the body's own immune system attacks the hair roots. Immunological causes are also discussed in connection with scarring hair loss.

For (temporary) alopecia, psychological reasons (e.g. stressful life events), mechanical causes (such as tightly bound hair, constant hair pulling), medication (e.g. chemotherapy drugs, blood pressure and blood lipid lowering agents, blood thinners and psychotropic drugs) as well as serious infectious diseases (such as influenza, Scarlet fever or typhoid).

If you lose more hair in spring and autumn than usual, you usually don't have to worry: This is due to evolution. In summer, our ancestors needed fuller hair to shield UV radiation, and in winter it provided warmth.

How does the doctor make the exact diagnosis?

The right contact person for excessive hair loss is the dermatologist (dermatologist): He asks about the duration and intensity of the hair loss, other symptoms, previous illnesses, taking medication, lifestyle and family history. When considering hormonal causes, cycle fluctuations, contraceptives, hormone treatments, pregnancies, births and menopause are also of interest to women.

After the medical history, the specialist examines the scalp and hair and clarifies whether there is a specific hair clearing pattern or inflammation. If necessary, he uses a special magnifying glass (dermatoscope) or a microscope. A plucking test (epilation test) provides information about the proportion of loose hair.

Blood and hair analyzes and a microscopic hair root analysis (trichogram) can also be used as additional diagnostic methods. The colonization of the scalp with fungi or bacteria can be demonstrated by smears.

Specialized dermatologists may perform a so-called trichoscan, for which in an inconspicuous place a small square of hair is shaved off, colored and photographed. Software can draw important conclusions from the color and length of the regrown hair.

In rare cases, a scalp biopsy is necessary: ​​a tissue sample is taken from the scalp under local anesthesia and examined in the laboratory.

Therapy: what to do in case of hair loss?

Depending on the exact diagnosis, different therapeutic approaches can be considered. In the case of infections in particular, the causes of a hair growth disorder should be treated as quickly as possible, because hair follicles can be irretrievably destroyed by scarring.

Alopecia is generally not advisable to treat yourself: Although there are many over-the-counter remedies for hair loss, their effectiveness has largely not been proven.

Treatment of androgenetic alopecia

The active substance minoxidil is available under different trade names as a solution or foam in different dosages for women and men without a prescription in the pharmacy. In early stage alopecia, it can stop hair loss and stimulate hair growth. The application is external (topical). Side effects of minoxidil can include allergic reactions, itching, dandruff, inflammation, cardiovascular reactions, water retention on the hands and feet, fatigue, weight gain and headache.

The prescription drug Finasteride lowers the DHT concentration in the blood and is used in higher doses against benign prostate enlargement. It is approved for the treatment of androgenetic alopecia for men between the ages of 18 and 41. According to studies, finasteride (with continuous use) stops hair loss in around 85 percent of users and helps 50 percent to fuller hair.

At two percent, however, finasteride causes side effects so severe that the manufacturers of finasteride-containing drugs, in consultation with the Federal Institute for Drugs and Medical Devices (BfAM), issued a red hand letter to doctors in July 2018. It says: “Patients should be aware of the risk of sexual dysfunction (including erectile dysfunction, ejaculation disorder and decreased libido) while on finasteride therapy. Patients should also be informed that sexual dysfunction – based on individual patient case reports – can persist for more than ten years after therapy is discontinued. ”

Because finasteride can cause birth defects in male unborn babies and has no effect after menopause, it is not approved for women. If a patient with androgenetic alopecia suffers from an excess of male hormones, the specialist can prescribe, for example, antiandrogenic progestogens.

Therapy for diffuse hair loss

Diffuse hair loss can be a symptom of infection, hormonal imbalance, or nutritional deficiency, for example. It is important to clearly determine and treat the cause. With Alopecia diffusa for no apparent reason, consistent protection of the hair has proven itself. Reducing stress can also help.

Treatment of circular hair loss

Up to 80 percent of patients with alopecia areata are symptom-free after one year even without therapy. Many doctors recommend taking zinc as a support. In some cases, the use of certain cortisone preparations helps. Also effective is an external application of strongly allergy-causing substances (for example diphenylcyclopropenone), which give the immune system another goal so that it no longer attacks the hair roots (irritation therapy). In some cases, laser and UVA therapies against circular hair loss are also used.

Ttherapy approaches for scarring alopecia

Bacterial inflammation of the scalp can be combated by using antibacterial care products. If fungi are the problem, antifungal agents help accordingly. Because autoimmune diseases are behind many forms of atrophic alopecia, cortisone supplements, immunosuppressants and other specific drugs are often also a treatment option.

Due to the high psychological importance of scalp hair, any type of alopecia can lead to depressive reactions. Here, among other things, psychodynamic and behavioral psychotherapy are recommended.

Aesthetic hair surgery: What are the benefits of hair transplantation and scalp extension?

If alopecia is clearly advanced or if scarring has resulted in hairless areas, many of those affected opt for surgery (aesthetic hair surgery). There are two main surgical techniques: hair transplantation and skin extraction. The procedures are usually performed under local anesthesia.

For a hair transplant hairs with their follicles from the non-androgen-sensitive area (hair ring) are transplanted onto the bald areas. The removal is usually from the back of the head. Since a maximum of about 12,000 hairs can be transplanted, this method is not expected to produce an optimal result for large bald heads.

During skin extraction (scalp extension), the hairy scalp is expanded by a flat extender made of biological material stretched under the skin. At the same time, a piece of bald head is removed. The procedure can be repeated several times. The expander technique with balloon (volume enlargement) works similarly: Here, a balloon is transplanted under the scalp, which is gradually filled with more and more saline. The disadvantage here is that the patient's head is deformed for the time of stretching.

How can you prevent hair loss?

In general, dermatologists advise a balanced lifestyle and gentle treatment of the scalp hair. If a lot of hair falls out or the scalp is red, itchy or flaky, a dermatologist should be consulted as soon as possible: An effective, hair-preserving therapy can only be initiated promptly with an accurate diagnosis.

In general, the following rules of conduct increase the chances of healthy, full hair:

• Do not smoke: Nicotine constricts the blood vessels and limits the nutrient supply to the hair follicles. In addition, smoking can have a negative effect on the hormone balance (for example, inhibit estrogen production in women).

• Eat balanced and iron-rich: A varied diet prevents nutrient deficiencies; Women with a heavy menstrual period should have their ferritin levels analyzed in the event of complaints because hair loss can occur due to iron deficiency.

• Get enough sleep and exercise: The body cells regenerate during sleep, sport boosts metabolism and blood circulation and reduces stress hormones.

• Take care of your hair: Those who use hair care products sparingly, do without heat applications (curling irons, straightening irons, hot blow-drying), chemical procedures (perm, dyeing, tinting, bleaching) as well as scalp-wearing hairstyles do everything right. In the warm season, headgear protects hair and scalp from UV damage.

• Keep and care for the scalp: Regular hair washing with a mild (pH-neutral) shampoo, tailored to the respective hair type, protects against infections of the scalp. Circular massages with the fingertips stimulate the blood circulation in the scalp and also prevent hair loss: