Hair Fall

Overview

Hair loss is a common concern affecting millions of people worldwide.

While losing some hair daily is normal, excessive shedding or thinning can be distressing. This article aims to provide a comprehensive overview of hair fall, exploring its various causes, preventive measures, and available treatment options. 

Understanding Hair Fall

• The hair growth cycle and normal shedding patterns  
• Differentiating between normal hair loss and excessive shedding
• Psychological impact of hair loss on individuals

Hair Anatomy

It can be categorized as either vellus (fine, soft, and not pigmented) or terminal (long, coarse, and pigmented). The number of hair follicles does not change over an individual’s lifetime, but the follicle size and type of hair can change in response to numerous factors, particularly androgens. Androgens are necessary for terminal hair and sebaceous gland development and mediate differentiation of pilosebaceous units (PSUs) into either a terminal hair follicle or a sebaceous gland. In the former case, androgens transform the vellus hair into a terminal hair; in the latter case, the sebaceous component proliferates and the hair remains vellus.[1]

Hair Structure.

The hair shaft is dead protein. It form by compact cells that are covered by a delicate cuticle composed of platelike scales. The living cells in the matrix multiply more rapidly than those in any other normal human tissue. They push up into the follicular canal, undergo dehydration, and form the hair shaft, which consists of a dense, hard mass of keratinized cells. Normal Hairs have a pointed tip. The Hair in the follicular canal forms a cylinder of uniform diameter. Short hairs with tapered tips either have short growth cycles or have experienced the recent onset of anagen.

The Growing shaft surround by several concentric layers. The outermost glycogen-rich layer is called the outer root sheath. It is static and continuous with the epidermis.

Inner root sheath

The Inner root sheath (Henle’s layer, Huxley’s layer, and cuticle) is visible as a gelatinous mass when the hair pluck. It Protects and molds the growing hair but disintegrates before reaching the surface at the infundibulum. The hair shaft that emerges has three layers—an outer cuticle, a cortex, and sometimes an inner medulla—all of which compose of dead protein. The cuticle protects and holds the cortex cells together. Split ends result if the cuticle damage by brushing or chemical cosmetic treatments. The cortex cells in the growing hair shaft rapidly synthesize and accumulate proteins while in the lower regions of the hair follicle. Systemic diseases and drugs may interfere with the metabolism of these cells and reduce the hair shaft diameter. Pigment-containing melanosomes acquire deep in the bulb matrix and are deposited in the cortical and medullary cells.[1]

 Hair Follicle.

Humans have about 5 million hair follicles at birth. No follicles form after birth, but their size changes under the influence of androgens. The hair follicle form in the embryo by a club-shaped epidermal down-growth—the primary epithelial germ that invaginate from below by a flame-shaped, capillary- containing dermal structure called the papilla of the hair follicle. The central cells of the down-growth form the hair matrix, the cells of which form the hair shaft and its surrounding structures. The matrix lies deep within the subcutaneous fat. The mature follicle contains a hair shaft, two surrounding sheaths, and a germinative bulb.

Division of Follicles

The follicle divide into three sections. The infundibulum extends from the surface to the sebaceous gland duct. The isthmus extends from the duct down to the insertion of the erector muscle. The inferior segment, which exists only during the growing (anagen) phase, extends from the muscle insertion to the base of the matrix. The matrix contains the cells that proliferate to form the hair shaft. The mitotic rate of the hair matrix is greater than that of any other organ.

The cells begin to differentiate at the top of the bulb. The inner and outer root sheaths protect and mold the growing hair. The Inner root sheath disintegrates at the duct of the sebaceous gland.

Hair Growth greatly influence by any stress or disease process that can alter mitotic activity.[1]

Hormonal regulation

Depending on the body site, hormonal regulation may play an important role in the hair growth cycle. For example, the eyebrows, eyelashes, and vellus hairs are androgen-insensitive, whereas the axillary and pubic areas are sensitive to low levels of androgens. Hair Growth on the face, chest, upper abdomen, and back requires higher levels of androgens and is therefore more characteristic of the pattern typically seen in men.

Androgen excess in women leads to increased hair growth in most androgen-sensitive sites except in the scalp region, where hair loss occurs because androgens cause scalp hairs to spend less time in the anagen phase.

Although androgen excess underlies most cases of hirsutism, there is only a modest correlation between androgen levels and the quantity of hair growth. This is due to the fact that hair growth from the follicle also depends on local growth factors, and there is variability in end organ (PSU) sensitivity.

Genetic factors and ethnic background also influence hair growth. In general, dark-haired individuals tend to be more hirsute than blond or fair individuals. Asians and Native Americans have relatively sparse hair in regions sensitive to high androgen levels, whereas people of Mediterranean descent are more hirsute.[1]

Hair Physiology

Cycling of hair follicles depends on the interaction of the follicular epithelium with the dermal papilla. The dermal papilla induces hair-follicle formation from the overlying epithelium at the onset of each new follicular cycle. The bulge consists of cells in the outer root sheath, which is located near the insertion of the arrector pili muscle. The dermal papilla interacts with germ cells in the hair-follicle bulge to regenerate the lower follicle. Stem cells in the bulge portion of the outer root migrate out of the follicle and regenerate the epidermis after injury.

Rapidly proliferating matrix cells in the hair bulb produce the hair shaft. The Matrix cells differentiate, move upward, and compress and funnel into their final shape by the rigid inner root sheath. The Shape (curvature) Of the inner root sheath determines the shape of the hair. The Bulk of the hair shaft call the cortex. Pigment In the hair shaft produce by melanocytes interspersed among the matrix cells. The Volume of the dermal papilla determines the diameter of the hair shaft.

Hair Growth Cycle

The average scalp has more than 100,000 hairs. The growth phase of scalp hair is approximately 1000 days (range, 2 to 6 years). Hair in other areas, such as the eyebrows and eyelashes, has a shorter growth phase (1 To 6 months). Scalp Hair grows 0.3 To 0.4 mm/day, or approximately 6 inches a year. Humans have a mosaic growth pattern; hair growth and loss are not cyclic or seasonal, as in some mammals, but occur at random, so that hair loss is continuous (see Figure 24-3).

Each hair follicle perpetually goes through three stages in the hair Growth cycle: catagen (transitional phase), telogen (resting phase), and anagen (growing phase). Approximately 90% to 95% of hairs are in the anagen phase, and 5% to 10% are in the telogen phase. Up To 100 Telogen hairs lost each day from the head, and about the same number of follicles enter anagen. The duration of anagen determines the length of hair, and the volume of the hair bulb determines the diameter.

Anagen (Growth)  for Hair Fall

The anagen or growth phase begins with resumption of mitotic activity in the hair bulb and dermal papilla. Interactions between the dermal papilla and the overlying follicular epithelium require for the onset of anagen. The follicle grows down and meets the dermal papilla, recapitulating the embryonic events of development of the hair follicle. A new hair shaft forms and forces the tightly held club hair out. During anagen, hair grows at an average rate of 0.35 mm/day, or 1 cm in 28 days; this rate diminishes with age.[1]

Hair follicles in different areas of the body produce hairs of different lengths. The length is proportional to the duration of the anagen cycle. Scalp hair remains in an active growing phase for an average of 2 to 6 years. The active growing phase is much shorter and the resting stage is longer for hair on the arms, legs, eyelashes, and eyebrows (30 to 45 days), which explains why these hairs remain short. Approximately 90% to 95% of scalp hairs are in an active growing phase at any one time. Continuous anagen occurs in some dogs (e.g., poodles) and in merino sheep; these animals do not lose or shed hair.

Catagen (Involution) for Hair Fall

Catagen is a process of involution that occurs with cell death in follicular keratinocytes. It is the phase of acute follicular regression that signals the end of anagen. Less than 1% of scalp hairs are in this 2- to 3-week transitional phase at any one time. Cell division in the hair matrix stops, and the resting, or catagen, stage begins. The outer root sheath degenerates and retracts around the widened lower portion of the hair shaft to become a club hair.

The Lower follicle shrinks away from the connective tissue papilla and ascends to the level of the insertion of the erector muscle. The Dermal papilla condenses and moves upward, coming to rest underneath the hair-follicle bulge. The Completion of catagen is marked by formation of the normal club hair. [1]

Telogen (Rest) for Hair Fall

All activity ceases and the structure rests during the telogen phase. The telogen phase in the scalp lasts for 2 to 3 months before the scalp follicles re-enter the anagen stage and the cycle is repeated. The percentage of follicles in the telogen stage varies according to the body region. Approximately 5% To 10% Of scalp hairs are in the telogen phase at any one time, and these follicles are randomly distributed.

The Telogen phase is much longer in eyebrow, eyelash, trunk, arm, and leg hair. Approximately 40% To 50% Of follicles on the trunk are in the telogen phase. The Inactive dead hair, or club hair, has a solid, hard, dry, white node at its proximal end; the white colour is due to a lack of pigment.

The Club hair is firmly held in place and then ejected. A New anagen hair grows and replaces the shed telogen hair. Approximately 25 To 100 telogen hairs are shed each day; possibly twice this number are lost on the days the hair is shampooed. Seasonal Shedding occurs in other animals but is random in humans.[1]

Epidemiology

A recent cross-sectional, multicenter study published in 2023 titled "Epidemiology and Treatment Aspects of Hair Loss in India – A Cross-Sectional, Multicentre, Database Study (HAILO)" provides insights into the prevalence and patterns of hair loss in India.

Key findings include:

• Telogen effluvium (TE) was the most common reason for hair fall (40.70%), followed by female pattern hair loss (FPHL) (22.09%), alopecia areata (AA) (12.81%), and male pattern hair loss (MPHL) (7.49%).  
• The majority of cases were females (74.8%), with most belonging to the 12-39 years age group. [6]

Reference:

Dogra, S., Kaur, I., De, D., & Gupta, S. (2023). Epidemiology and Treatment Aspects of Hair Loss in India – A Cross-Sectional, Multicentre, Database Study (HAILO). American Journal of Research in Dermatology & Epidemiology, 9(1), 1-11.

Causes

Genetic Causes

Individuals with pattern hair loss, certain hair follicles are genetically programmed to be more sensitive to a hormone circulating in the blood called dihydrotestosterone, commonly abbreviated as DHT. DHT is one of several hormones classified as androgens, often referred to as “male” hormones. DHT is formed from testosterone,

Other Cause of Hair Fall:

Diffuse non-scarring loss is usually androgenetic alopecia in all genders but can include telogen effluvium, and systemic diseases such as thyroid, iron deficiency, dermatitis. Patchy scarring loss can be due to follimlites (bacterial infection of the hairs), lichen planilaris and discard lupus. Patchy non-scarring alopecia can be due to ringworm, trichotillomania, traction alopecia, and syphilis. Hair loss causes that are not based on genetics are:

• Autoimmune disorders
• Diseases
• Nutritional deficiencies
• Poisons
• Prescription drugs
• Chemotherapy drugs
• Radiation exposure
• Stress
• Physical trauma to the scalp
• Hair loss following childbirth
• Psychological
• Hair styling techniques
• Hair styling products

AUTOIMMUNE DISORDERS

Autoimmune disease occurs when the body’s immune system mistakenly attacks itself. In a fairly common autoimmune disorder called alopecia areata, the white blood cells attack the deepest part of the hair follicle, commonly referred to as the bulb area, resulting in temporary hair loss. Alopecia areata is probably the second most common cause of hair loss after androgenetic alopecia (inherited predisposition for hair loss).

Most people affected by alopecia areata first develop one or two small bald patches on their scalp which persist for several months, after which they eventually re-grow hair in those areas. Some people with this condition may suffer larger and more persistent bald patches in their very first episode, and some lose all the hair on their scalp, a condition called alopecia totalis.

Even more extreme is the loss of all body hair, called alopecia universalis. In some cases the hair loss persists for long durations; nevertheless there is always the possibility of hair regrowth because the inflammation occurs in the bulb area of the hair follicle, which is regenerated with each hair follicle growth cycle.

lupus erythematosus i.e.

Another autoimmune disease that can result in hair loss is lupus erythematosus. This autoimmune disease affects the bulge area of the hair follicle rather than the bulb, and can cause permanent hair loss. A dermatologist should treat autoimmune conditions affecting the hair.

OTHER DISEASES

Fungal infections on the scalp such as ringworm (tinea capitis), kerion, and favus can result in hair loss. Bacterial infections on the scalp such as folliculitis, furuncles, and carbuncles can cause thin hair. Skin cancers—such as metastatic carcinoma and sclerosing basal cell carcinoma—can also cause hair loss.

In rare cases, certain skin diseases such as severe eczema, and lichen planus (which is called lichen planopilaris when it affects the scalp), and psoriasis can result in hair loss. Thyroid and endocrine gland disorders such as hypothyroidism and hypopituitarism can result in thin hair and brittle hair that breaks easily. Leprosy, shingles (herpes zoster infection), and advanced stages of syphilis have all been noted to cause hair loss.

NUTRITIONAL DEFICIENCIES

Nutritional deficiencies are rarely a cause of hair loss despite the marketing of a wide variety of nutritional supplements that claim to somehow enhance hair growth or hair health. Of the possible nutritional deficiencies that can cause thinning hair, iron deficiency anaemia is most common, and when it occurs it is more frequently seen in women.

Iron deficiency anaemia i.e.

Iron deficiency anaemia is a result of a decreased amount of red blood cells in the blood because of inadequate iron reserves in the body. There are several causes for this condition, including inadequate consumption of iron-containing foods, poor absorption of iron in foods or supplements, and loss of blood. The main sources of iron in a typical western diet include meat, egg yolks, poultry, fish, legumes (lentils, dried peas and beans), whole grains, iron-fortified cereal products and iron-containing multivitamin tablets.

Poor absorption of iron i.e.

Poor absorption of iron can result from disease conditions or from certain medications that interfere with iron absorption. Low red blood cell count from periodic blood loss can contribute to anaemia because the body normally recycles the iron in worn out red blood cells. If the blood is lost, the iron in those cells is lost as well.

Menstruation is the most common cause of blood loss-induced iron deficiency anaemia; however; blood loss can also result from injury, frequent donation of blood, and internal bleeding from digestive system ulcers and various disease conditions. The first step in determining if iron deficiency anaemia as a cause of a hair loss condition is a blood test for ferritin levels.

Ferritin i.e.

is an iron-storing protein that circulates in the blood and reflects the body’s iron reserve level. Just taking an iron supplement is not likely to stop hair loss. If a serum ferritin blood test indicates a deficiency, the next step is to determine the cause of the iron deficiency, and to effectively treat the condition. Many doctors and laboratories assume the normal range of serum ferritin to be 10-230 grams per liter. But in the past few years it has been found that women with levels below seventy have an increased chance of hair loss.

Inadequate dietary iron can be treated with iron supplement tablets however, iron absorption problems may require switching medications or injections of iron supplements, and blood loss treatments vary according to the cause. In addition to iron deficiency anaemia, severe “crash” diets, and psychological disorders that result in extreme nutritional imbalances such as anorexia and bulimia, can also result in hair loss. Going without food for several days, or even several weeks, will not cause hair loss. But severe swings in nutrition and body weight from “crash” diets over several months’ time may begin to affect hair condition.

Poison

• Warfarin
• Blood Thinning Drugs
• Metals: arsenic, mercury, bismuth, lithium, thallium, cadmium, and gold are poisonous,
• Consumption of 50,000 to 250,000 Units of vitamin A daily over many months can cause hair loss. Boric acid, a common household pesticide, can cause hair loss when consumed over a period of time.

PRESCRIPTION DRUGS

There are many categories of prescription drugs that present a risk of temporary hair loss as a possible side effect. Chemotherapy drug treatment almost always causes hair loss because the drugs target rapidly dividing cells typical of cancer. See Chapter 8 and Appendix 2 for a complete discussion

RADIATION EXPOSURE

With radiation treatment, only hair that is in the treatment field is affected. When the treatment field includes the scalp, hair loss generally begins about two to three weeks after the first radiation treatment. Usually the hair begins to grow back three to four months after the last treatment; however, with high doses of ra radiation, there is a risk of permanent hair loss in the treatment area

STRESS

Stress can cause a type of hair loss called telogen effluvium. This condition is not caused by the general accumulated stress of ordinary interactions with people at home and at work, but rather by sudden severe emotional or physiological incidents. Severe stressful events can cause some or most actively growing hair follicles to prematurely shift into the regression phase, and then the resting phase, during which the hairs fall out easily

In most cases of telogen effluvium, the hair follicles recover and soon shift back to the regular growth cycle. However, repeated instances of telogen effluvium can result in premature hair loss in people predisposed to lose their hair late in life. The average growth cycle of a hair follicle takes about five years, but each follicle is “genetically programmed” for only a limited number of growth cycles. For example, if a particular hair follicle were “genetically programmed” for only ten growth cycles, after about fifty years that follicle would stop producing new hairs

Risk factors

These risk factors include:

• Genetic Predisposition: Family history of hair loss, specifically androgenetic alopecia.
• Hormonal Imbalances: Conditions like thyroid disorders, polycystic ovary syndrome (PCOS), and hormonal changes during pregnancy or menopause.
• Nutritional Deficiencies: Inadequate intake of iron, vitamin D, biotin, and other essential nutrients.
• Chronic Stress: Emotional stress can trigger or exacerbate hair loss conditions.
• Medical Conditions: Autoimmune diseases (alopecia areata), scalp infections, and certain medications.
• Environmental Factors: Exposure to pollutants and harsh chemicals. [7]

Pathogenesis

Key pathogenic mechanisms include:

• Androgenetic Alopecia (AGA): Miniaturization of hair follicles due to the influence of androgens (male hormones) and genetic predisposition.
• Telogen Effluvium (TE): Premature entry of hair follicles into the resting (telogen) phase, often triggered by stress, illness, or hormonal changes.
• Alopecia Areata (AA): Autoimmune attack on hair follicles, leading to patchy hair loss.
• Scarring Alopecia: Destruction of hair follicles due to inflammation or injury, resulting in permanent hair loss.
• Traction Alopecia: Hair loss caused by chronic pulling or tension on hair shafts due to tight hairstyles. [8]

Pathophysiology

Key pathophysiological aspects covered include:

• Hair Cycle Disruption: Detailed explanation of the normal hair growth cycle (anagen, catagen, telogen) and how disruptions in this cycle can lead to hair loss.
• Miniaturization of Hair Follicles: In androgenetic alopecia (male and female pattern baldness), the influence of dihydrotestosterone (DHT) causes hair follicles to shrink over time, producing progressively thinner and shorter hair shafts.
• Genetic Predisposition: Role of genetics in determining susceptibility to androgenetic alopecia and other forms of hair loss.
• Inflammation: The involvement of inflammatory processes in alopecia areata and other inflammatory hair loss conditions.
• Vascular Changes: Alterations in blood flow to the scalp and hair follicles, which can impact hair growth.
• Hormonal Factors: Influence of hormones like thyroid hormones, sex hormones, and stress hormones on hair growth and loss. [9]

Clinical Features

The following clinical features across different types of hair loss:

Androgenetic Alopecia:

• Gradual thinning of hair on the scalp.
• Receding hairline in men (M-shaped pattern).
• Widening of the hair part and diffuse thinning in women (Christmas tree pattern).

Telogen Effluvium:

• Diffuse shedding of hair all over the scalp.
• Sudden onset of hair loss, often triggered by stress or illness.
• Typically temporary and self-limiting.

Alopecia Areata:

• Round or oval patches of hair loss.
• Smooth, hairless patches on the scalp, beard, or other body areas.
• Exclamation point hairs (short, broken hairs at the edges of patches).

Scarring Alopecia:

• Patchy hair loss with scarring and inflammation.
• Permanent destruction of hair follicles.

Traction Alopecia:

• Hair loss along the hairline or areas of tension.
• Often associated with tight hairstyles like braids, ponytails, or extensions. [10]

Sign & Symptoms

Key signs and symptoms include:

• Gradual Thinning: Most common in androgenetic alopecia, a gradual decrease in hair density, often noticeable on the top of the head or at the temples.
• Circular or Patchy Bald Spots: Sudden appearance of round or oval patches of hair loss, characteristic of alopecia areata.
• Sudden Loosening of Hair: Large amounts of hair coming out when combing or washing, often associated with telogen effluvium.
• Full-Body Hair Loss: Can occur due to medical conditions or treatments like chemotherapy.
• Scalp Changes: Scaling, redness, or sores on the scalp might indicate an underlying scalp condition contributing to hair loss.

In addition to these visible signs,we must should know the importance of considering:

• Family History: Genetic predisposition to hair loss.
• Medical History: Underlying medical conditions or medications that might contribute to hair loss.
• Lifestyle Factors: Stress, diet, and hair care practices can impact hair health. [11]

Clinical Examination

1. Patient History:

   • Detailed inquiry about the onset, duration, and pattern of hair loss.
   • Questions regarding medical history, medications, family history, and lifestyle factors.

2. Physical Examination:

   • Visual inspection of the scalp for signs of inflammation, scaling, scarring, or other abnormalities.
   • Assessment of hair density, hair shaft diameter, and hair pull test (gently tugging on a group of hairs to assess shedding).
   • Examination of other body areas for hair loss (eyebrows, eyelashes, body hair).

3. Trichoscopy (Hair and Scalp Dermoscopy):

   • Examination of the scalp and hair under magnification to identify specific patterns of hair loss, such as miniaturized hairs in androgenetic alopecia or exclamation point hairs in alopecia areata.

4. Laboratory Tests:

   • Blood tests to rule out underlying medical conditions like thyroid disorders, anemia, or autoimmune diseases.
   • Scalp biopsy in select cases to confirm the diagnosis of certain types of hair loss.

5. Pull Test:

   • Gently pulling on a group of hairs (around 40-60) to assess the extent of hair shedding. More than 10% shedding may indicate active hair loss. [12]

Diagnosis

History of Hair Fall

Presenting complaint i.e.

Most adults presenting with a complaint of hair loss will complain of either gradual thinning of hair in a pattern over time or a rapid increase in the amount of hair being shed, with hair being evident in the shower, on pillows and carpets and hair coming out easily when brushed. Determining whether it is a thinning or shedding problem will help focus the history further on genetic and age‐related changes or reasons why the hair cycle may disturb. These two complaints may coexist, as both are common.

The hair cycle in genetic hair loss has a shorter growth phase and proportionally more hair will in telogen phase at any given moment, so an increase in hair shedding can be expected. Hair loss in patches is likely to point to alopecia areata. In addition to these complaints, a patient may aware of hair breakage, focal areas of hair loss that are scar‐like, recession of the hairline or loss of hair from other body sites such as the eyebrows.

Symptoms such as itch, burning and pain should note as these often associate with inflammation that can lead to scarring.

Background information i.e.

• It is common for patients with gradual thinning to have a family history affecting either parent or extended family members of premature hair loss in either a male or female pattern.
• Female patients presenting with pattern hair loss may have hormonal disturbance and therefore one should enquire as to the regularity of menstrual periods, the presence of hirsutes or any other signs of androgenization.
• A contraceptive history should record. In patients complaining of hair shedding, likely to represent a telogen effluvium,
• The history should direct to any particular life events or medications that began a few months before the onset of the shedding.

other background information i.e.

• Generally, Severe psychological stress, physical illness, new medications, dieting and weight loss may all relevant.
• Furthermore, In acute telogen effluvium a trigger may identify and the condition is usually self‐limiting.
• If the hair shedding is either more chronic or episodic it may difficult to identify a specific trigger.
• With the exception of severe diets, eating disorders, inflammatory bowel disease or bowel surgery, profound nutritional deficiencies that result in hair loss uncommon in the develop nations. Enquiries into normal diet, including whether adequate amounts of protein also iron are consumed may appropriate, but the relationship between iron stores and hair loss remains controversial [1–4].

Associated symptoms i.e.

Most hair loss is asymptomatic. The presence of itch, burning or pain may point to inflammation which can a feature of scarring hair loss. Pediculosis capitis and tinea capitis may both present with an itchy scalp.

Clinical examination

Clinical evaluation should include a visual assessment of the pattern also extent of hair loss. Does the patient have clinically evident hair loss? Is hair loss diffuse or patchy? Is it occurring in a distinctive distribution (such as seen in pattern hair loss or frontal history fibrosing alopecia)? Hair colour, shine, texture and ‘hair behaviour’ may alter by conditions affecting hair growth or the hair fibre characteristics. When dealing with patchy hair loss it is important to assess whether there are patent follicular ostia or whether these are lost – a key feature in scarring conditions [5].

Moreover, The presence of scalp inflammation should sought, which may include perifollicular erythema, follicular hyperkeratosis, plugged hair follicles, pustules or swellings.

All in all, Close inspection using magnification with a light source is often helpful to appreciate variation in hair fibre diameter, exclamation mark hairs, cadaverized hairs (black dots visible beneath the surface, representing hair remnants), either abnormal scalp vessels or hair shaft abnormalities.

Daily Counts.

The patient collects hair lost in the first

morning combing and includes those lost during washing for 14 days, saving them in clear plastic bags. The patient counts the hairs and records the number on the bags. Examine the hairs under the microscope to determine if the bulbs are anagen or telogen.

Daily Hair shed

counts are not necessary if the pull test is positive. It is normal to lose up to 100 hairs daily and 200 to 250 hairs on the day of shampooing. If the hair shampooed daily, the counts should less than 100.[1]

Part Width.

Make a coronal part with a comb over the vertex. Note the part width. Make a series of parallel parts over the vertex and visually compare the part diameter. Do the same over the occipital and temporal scalp. Visually Compare the part diameters in the different anatomic scalp areas. Hair Density is greatest in childhood and decreases progressively with age. The Hair is less dense in the vertex in all genders, and thinning increases with age.

Hair Shaft Examination (Clip Tests).

Grasp 25 to 30 hairs between the thumb and forefinger just at the scalp surface. Cut the hair between the fingers and the scalp. Hair just above the fingers cut and discarded. Float the hairs onto a wet microscope slide and cover with another slide. Evaluate hair shaft diameter and structure.

There are many rare diseases that produce shaft structural abnormalities, such as pili torti in which the hair twist on its axis. Hair Growth Window. Select an area where the hair fails to grow and an area that can cover by the remaining hair. Cut the hair short; then shave a 2.0-cm 1 Week and 1 Cm in 1 month. This Test proves to the patient that the hair is growing.

Hair Pluck—Trichogram.

This is a painful technique but still use by some clinicians. Abruptly extract hairs from the scalp with a rubber-tipped needle holder. Cut the excess hair 1 cm from the roots, float the hairs onto a wet microscope slide or Petri dish, and examine with a hand lens. Telogen hairs have small, unpigmented, ovoid bulbs and do not contain an internal root sheath. Anagen hairs have larger, elongated, pigmented (if hair pigmented) bulbs shaped like the end of a broom, surrounded by a gelatinous internal root sheath.

There are diseases in which hair fragments with absent bulbs obtain during a hair pull. Processes that interfere with cell division cause the shaft to poorly formed and therefore apt to break under tension. Alopecia areata, antimetabolite therapy, and small doses of ionizing radiation interrupt the mitotic activity in the cells that normally contribute to the growing hair.[1]

Differential Diagnosis

• Androgenetic Alopecia (Male and Female Pattern Hair Loss): Gradual thinning of hair, often with a specific pattern.
• Telogen Effluvium: Diffuse hair shedding often triggered by stress, illness, or medications.
• Alopecia Areata: Patchy hair loss, sometimes with exclamation point hairs.
• Scarring Alopecia: Permanent hair loss due to destruction of hair follicles by inflammation or injury.
• Traction Alopecia: Hair loss caused by tension from tight hairstyles.
• Anagen Effluvium: Sudden hair loss caused by chemotherapy or other medications that affect rapidly dividing cells.
• Trichotillomania: Hair loss caused by compulsive hair pulling.
• Tinea Capitis (Ringworm of the Scalp): Scaly patches of hair loss caused by a fungal infection.
• Other Medical Conditions: Thyroid disorders, iron deficiency anemia, and other systemic illnesses can also cause hair loss. [12] 

Complications

• Psychological Impact: Hair loss can significantly affect self-esteem, body image, and emotional well-being, leading to anxiety, depression, and social isolation.
• Sunburn and Skin Cancer: Loss of hair on the scalp increases the risk of sunburn and, consequently, skin cancer.
• Social Stigma: In some cultures, hair loss is associated with negative stereotypes, leading to discrimination and social exclusion.
• Secondary Infections: In certain types of hair loss, such as scarring alopecia, damaged hair follicles can become infected, leading to further complications.
• Permanent Hair Loss: Some forms of hair loss, especially if left untreated, can progress to irreversible hair loss. [13]

Investigation

Hormone Test for Hair Fall:

There are several hormones which you can screen in case of having massive hair loss. They are Prolactin, Testosterone, DHEA, luteinizing hormone and follicular stimulating hormone.[5]

Thyroid Level Test Hair Fall:

This is another most important test which you can go for; they are T3, T4, and TSH. You should check the levels of these hormones.

Serum Iron, Serum Ferritin for Hair Fall:

These tests can help you to detect the exact levels of the components like serum iron and serum ferritin. Abnormalities of the above can lead to hair fall.

CBC test for Hair Fall:

This test generally gives you the result of the complete blood count of your body.

VDL for Hair Fall:

Getting affected by Syphilis can lead you to the condition of hair loss. The VDL test can be therefore important in case of the diagnosis.

Biopsy-of scalp for Hair Fall:

In this test, a small part of the scalp is examined under a microscope after removing it from your head. It helps to know the cause of your hair loss.
So, these are the test which you can go through in case of experiencing excessive hair loss.[5]

Treatment of Hair Fall

Effective treatments for some types of hair loss are available. You might be able to reverse hair loss, or at least slow it. With some conditions, such as patchy hair loss (alopecia areata), hair may regrow without treatment within a year. Treatments for hair loss include medications and surgery.

Medication for Hair Fall

If your hair loss cause by an underlying disease, treatment for that disease will necessary. If a certain medication is causing the hair loss, your doctor may advise you to stop using it for a few months.

Medications are available to treat pattern (hereditary) baldness. The most common options include:

Minoxidil (Rogaine)

Over-the-counter (non prescription) minoxidil comes in liquid, foam and shampoo forms. To most effective, apply the product to the scalp skin once daily for women and twice daily for men. Many people prefer the foam applied when the hair is wet.

Products with minoxidil help many people regrow their hair or slow the rate of hair loss or both. It’ll take at least six months of treatment to prevent further hair loss and to start hair regrowth. It may take a few more months to tell whether the treatment is working for you. If it is helping, you’ll need to continue using the medicine indefinitely to retain the benefits.

Possible side effects include scalp irritation and unwanted hair growth on the adjacent skin of the face and hands.

Finasteride (Propecia)

This is a prescription drug for men. You take it daily as a pill. Many men taking finasteride experience a slowing of hair loss, and some may show new hair growth. It may take a few months to tell whether it’s working for you. You’ll need to keep taking it to retain any benefits. Finasteride may not work as well for men over 60.

Rare side effects of finasteride include diminished sex drive and sexual function and an increased risk of prostate cancer. Women who are or may be pregnant need to avoid touching crushed or broken tablets.

Other medications.

Other oral options include spironolactone (Carospir, Aldactone) and oral dutasteride (Avodart).

Hair transplant surgery for Hair Fall

In the most common type of permanent hair loss, only the top of the head affect. Hair transplant, or restoration surgery, can make the most of the hair you have left.

During a hair transplant procedure, a dermatologist or cosmetic surgeon removes hair from a part of the head that has hair and transplants it to a bald spot. Each patch of hair has one to several hairs (micrografts and minigrafts). Sometimes a larger strip of skin containing multiple hair groupings take.

This procedure doesn’t require hospitalization, but it is painful so you’ll give a sedation medicine to ease any discomfort. Possible risks include bleeding, bruising, swelling and infection. You may need more than one surgery to get the effect you want. Hereditary hair loss will eventually progress despite surgery.

Surgical procedures to treat baldness are not usually covering by insurance.

Laser therapy for Hair Fall

The Food and Drug Administration has approved a low-level laser device as a treatment for hereditary hair loss in all genders. A few small studies have shown that it improves hair density. More studies are needed to show long-term effects.

Prevention

• Early Intervention: Identifying and addressing hair loss early can help prevent further progression and potentially reverse some types of hair loss.
• Healthy Lifestyle: Maintaining a balanced diet rich in essential nutrients, managing stress levels, and avoiding harsh hair treatments can contribute to hair health.
• Gentle Hair Care: Avoiding tight hairstyles, excessive heat styling, and harsh chemicals can minimize damage to hair follicles.
• Medications: In certain cases, medications like minoxidil or finasteride may be prescribed to help prevent further hair loss. [14]

Homeopathic Treatment of Hair Fall

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis. 

Which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions. 

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines.

Homeopathic Medicines:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.

So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).

Homeopathic Treatment for Hair Fall

Hair loss, as it is a chronic problem, requires a constitutional treatment. Homeopathy focuses on the root cause of the problem and helps in the treatment of hair loss. A well-chosen homeopathic remedy helps in controlling the amount of hair fall. However, one must understand that baldness cannot be reversed.

Homeopathic medicines which are prepared from plant, mineral, and animal sources help in reducing the quantity of hair loss.

Homeopathic medicines are individualized, selected based on the individual case history of the patient, by taking into consideration the cause like hormonal imbalance, nutritional factor, emotional stress, the nature of the patient, and other factors which may be acting as a maintaining cause in the hair loss.

Bar-c.-

Losing of hair from crown. Baldness.

Calc-c.-

Falling off hair (from sides of head). Roots of hair painfully sensitive.

Fluor-ac.-

Hair splits and breaks. (In my hand a case cure by a single dose of the remedy in the 200th potency.) Kent writes: "If examined closely under the microscope, it seen to necrose, little ragged ulcers will found along the course of the hair."

Kali-c.-

Dryness and rapidly falling off of hair with much dandruff.[2]

Nat-m.-

-Great falling off of hair, as soon touched mostly on forepart of head and temples, also beard; scalp very sensitive.

-Falling off of hair; root dry in large bunches; violent itching of scalp denuded scalp looks clear, white and smooth.

-From syphilis; sensitiveness of scalp; falling out of hair.[2]

-Great falling off of hair; scalp and roots of hair very sensitive to touch; much itching of scalp.

-Falling off of hair; great dryness of hair; scalp sore to touch; itching dandruff.

After severe acute diseases:

China, Calc-c., Carb-v., Hepar.

After confinement:

Lyco., Sulph.

During pregnancy:

Lach.

In spots:

Fluor-ac. Also, Arsen., Phos. From syphilis: Aur-m., Nit-ac.

After typhoid fever:

Fluor-ac.

Baldness:

The three great remedies in baldness are: Bar-c., Lyco., Silic.

Bar-c.

has losing of hair from crown of head. Lyco. has gained reputation from the experience of Dr. Jahr.

Silic.

indicated in premature baldness.

Zinc

develops and, therefore, cures complete baldness on vertex.

Sepia

has bald spots on scalp.

Fluor-ac.

useful in baldness developed from hairs which break off.[2]

Diet & Regimen

Due to environmental factors or lifestyle changes, hair tends to lose its health. In such cases, even the gifted require some help. Although, regular oiling or deep conditioning can improve the texture of your hair, but what you put into your body will make a greater difference. A good diet which will provide the essential vitamins and minerals to your hair will ensure they look happy and healthy! There are some food items that should be mandatory in your diet. They’ll not just improve the texture but also the overall health of your hair.[4]

Biotin

Biotin is responsible for hair growth and increasing the volume of hair. The nutrient is a water-soluble B vitamin also known as Vitamin B7 or H. Biotin deficiency can lead to discoloration or thinning of hair. Biotin is often an ingredient in oral hair growth supplement or even shampoos to nourish hair and prevent them from looking brittle or dull.

What to eat: Wholegrains, liver, egg yolk, soya bean, cranberries, raspberries and yeast.

Omega-3-fatty-acids

The oil that boosts the hydration for your hair and scalp is provided by Omega-3 fatty acids. This nutrient is also present in the cells that line the scalp so it’s important to add this fat to your diet.

What to eat: Oily fish like mackerel, Indian salmon, trout etc. Other options include avocados, pumpkin seeds and walnuts.

Protein

The most important component for strong healthy hair is protein. Hair majorly made up of protein so consuming an adequate amount of protein daily becomes all the more essential. If your diet consist of lower proteins, you’re likely to have hair loss or dry and brittle hair. Eat the right proteins and keep your hair strong.

What to eat: Chicken, fish, turkey, eggs and dairy products. For vegans or vegetarians, legumes and nuts are an excellent source of protein.

Iron

Another important mineral for your hair, iron ensures your hair remain healthy by providing it with oxygen. Lower levels of iron can result in anaemia which is a major cause of hair loss. The hair follicle and root is fed by a nutrient rich blood supply with the help of iron. So, make iron rich foods a staple in your diet to achieve those luscious locks.

What to eat: Seafood like clams or chicken, red meat, spinach, beetroot, apples, soybeans, broccoli etc are good sources of iron.[4]

Vitamin-C

Iron and Vitamin C are two nutrients which are best when taken in combination with each other. Eating food rich in Vitamin C will allow better absorption of iron into the body. Not only that, Vitamin C is a prime food when it comes to production of collagen. It also strengthens the capillaries that supply blood to the hair shaft.

What to eat: Strawberries, sweet potatoes, blackcurrants, blueberries, oranges and papaya.

Vitamin-E

Vitamin E is a quintessential nutrient when it comes to skin and hair care. A base ingredient included in a range of hair and skin care products, it’s a crucial nutrient for healthy hair. It helps in building and repairing hair tissue and also in protecting hair from sun damage.

What to eat: Nuts are the best source of vitamin E so include almonds, walnuts or any other nuts in your diet. Olive oil, Avocado, sunflower oil and spinach are also good options for Vitamin E. It’s also available in the form of a capsule which can purchase from your local chemist shop.

Vitamin-A

The natural conditioner produced by our body, known as Sebum, requires Vitamin A especially for its production. Additionally, The oily substance is a vital substance which conditions our scalp naturally. Sebum becomes indispensable for a healthy scalp. Besides this, It’s best to include Vitamin A to ensure adequate sebum production.

What to eat: Orange/yellow-colored vegetables with a high beta-carotene content. Beta- carotene is the substance that makes Vitamin A. Options include- carrots, sweet potatoes, dark leafy green vegetables, apricots, pumpkins also lettuce

Problem and Solution of Hair fall

There exist target hair problems as well which require special food and attention to solve, the following foods will help you with such issues.[4]

Problem: Hair growth

Solution: Either Eggs or Greek yogurt

Packed with protein, eggs also Greek yogurt are ideal for increasing the length of your hair. Additionally, They’re rich in Vitamin B and B5 respectively, ensuring hair growth and adequate blood flow to your scalp. These food items also prevent thinning also hair loss.

Problem: Excessive breakage

Solution: Guava
Vitamin C is the answer to unwanted breakage of hair. Furthermore, It protects the hair from breaking and ensures it stays strong. Guava is rich in Vitamin C also by rich we mean 377 milligrams in one cup! Perfect solution for your hair problem.

Problem: Dull locks

Solution: Sweet potatoes
Sweet potatoes are brimming with beta- carotene (responsible for production of vitamin A). In detail, Food rich in Vitamin A helps in production of the oily substance called sebum which leads to shiny locks that don’t dry out and are full of life. There is not a better option than sweet potatoes to fight dry also dull hair.

Problem: Brittle hair

Solution: Spinach
Dark green leafy vegetables like spinach or kale are full of nutrients like iron, vitamin A or folate which are essential to keep your hair moisturized. Besides this, A daily dose of this vegetable would be enough to transform your hair from brittle to nourished within no time.

Problem: Increase shine in hair

Solution: Salmon

Known for having a high content of Omega-3 fatty acids, salmon is the answer to shiny hair. These fats help the hair grow also keep them shiny and full.

Problem: Increasing blood circulation

Solution: Cinnamon
Cinnamon helps in increasing the blood circulation in your body which in turn would provide your hair follicles with ample of oxygen also nutrients. So, add some cinnamon to your food be it on oatmeal/ porridge or your coffee. Lastly, The options are endless.[4]

Do’s And Dont’s

For Hair Fall

Do’s:

• Maintain a Healthy Diet: Eat a balanced diet rich in protein, iron, zinc, and vitamins B and D. These nutrients are essential for hair growth and health.
• Manage Stress: Stress can contribute to hair loss. Practice relaxation techniques like yoga, meditation, or deep breathing exercises.
• Be Gentle with Your Hair: Avoid harsh brushing, tight hairstyles, and excessive heat styling. Use a wide-toothed comb and detangle gently.
• Choose the Right Hair Products: Opt for mild shampoos and conditioners that are free from sulfates and harsh chemicals.
• Consult a Doctor: If you experience sudden or excessive hair loss, consult a dermatologist or trichologist to determine the cause and get appropriate treatment.

Don’ts:

• Don’t Over-wash Your Hair: Washing your hair too frequently can strip it of natural oils, leading to dryness and breakage.
• Don’t Use Harsh Hair Treatments: Avoid chemical treatments like perming, straightening, and coloring as they can damage hair and lead to breakage.
• Don’t Smoke: Smoking can restrict blood flow to the scalp, impairing hair growth.
• Don’t Ignore Underlying Medical Conditions: If hair loss is related to an underlying medical condition, address the condition promptly.
• Don’t Self-Medicate: Avoid using over-the-counter hair loss treatments without consulting a doctor.

Terminology

• Alopecia: The general medical term for hair loss.
• Androgenetic Alopecia (AGA): The most common type of hair loss, also known as male or female pattern baldness. It is caused by a combination of genetic and hormonal factors.
• Telogen Effluvium (TE): A form of temporary hair loss that occurs due to stress, illness, hormonal changes, or medications.
• Alopecia Areata (AA): An autoimmune condition that causes patchy hair loss on the scalp, face, or other parts of the body.
• Traction Alopecia: Hair loss caused by hairstyles that pull on the hair, such as tight braids or ponytails.
• Anagen Effluvium: Hair loss that occurs during the anagen (growth) phase of the hair cycle, often caused by chemotherapy or radiation therapy.
• Trichotillomania: A psychological disorder characterized by compulsive hair pulling.

• Hair Follicle:The tiny sac in the skin from which a hair grows.

• Hair Shaft: The visible part of the hair that extends beyond the scalp.

• DHT (Dihydrotestosterone): A male hormone that plays a key role in the development of androgenetic alopecia.

• Minoxidil (Rogaine): An over-the-counter medication used to treat hair loss.
• Finasteride (Propecia): A prescription medication used to treat male pattern baldness.

Homoeopathic terms

• Miasm: A fundamental concept in homeopathy referring to a predisposition to certain types of diseases. Homeopaths consider miasmatic background when selecting remedies for hair loss.
• Constitutional Remedy: A homeopathic remedy chosen based on the individual’s overall physical, mental, and emotional characteristics, aiming to address the root cause of hair loss rather than just the symptoms.
• Repertory: A book containing a vast index of symptoms and the remedies associated with them, used by homeopaths to find suitable remedies.
• Materia Medica: A comprehensive reference book describing the properties and uses of homeopathic remedies.
• Potency: The strength or dilution of a homeopathic remedy. Higher potencies are considered more diluted and are often used for deeper-acting constitutional treatment.
• Aggravation: A temporary worsening of symptoms after taking a homeopathic remedy, often seen as a positive sign indicating that the remedy is working.
• Proving: A systematic process of testing a homeopathic remedy on healthy individuals to determine its effects and symptom picture.
• Nosode: A homeopathic remedy prepared from diseased tissue or bodily fluids, sometimes used in cases of hair loss associated with specific infections or diseases.

References

[1] Clinical Dermatology A Color guide to diagnosis and therapy 6^th edition.

[2] The Homeopathic Prescriber by K.C.Bhanja

[3] Rooks Textbook of Dermatology 4^th Volume

[4] https://timesofindia.indiatimes.com/life-style/health-fitness/diet/21-foods-for-healthy-hair/articleshow/22575168.cms

[5] https://www.trutestlab.com/blog/what-are-the-tests-to-be-done-to-diagnose-hair-loss

[6] Dogra, S., Kaur, I., De, D., & Gupta, S. (2023). Epidemiology and Treatment Aspects of Hair Loss in India – A Cross-Sectional, Multicentre, Database Study (HAILO). American Journal of Research in Dermatology & Epidemiology, 9(1), 1-11.

[7] Gentile, P. (Ed.). (2020). Alopecia: Risk Factors, Treatment and Impact on Quality of Life. Nova Science Publishers.

[8] Draelos, Z. D. (2015). Hair and Scalp Disorders (3rd ed.). Informa Healthcare.

[9] Norwood, O. T., & Rassman, W. R. (2019). Hair Loss and Restoration (4th ed.). Springer Publishing Company.

[10] Shapiro, J., & Diaz, V. H. (Eds.). (2011). Hair Loss: Principles of Diagnosis and Management (2nd ed.). Informa Healthcare.

[11] Keene, S. (2021). Hair Loss: Understanding the Causes and Finding Solutions (2nd ed.). Johns Hopkins University Press.

[12] Avram, M. R., & Donovan, J. J. (2019). Hair and Scalp Disorders: Medical, Surgical, and Cosmetic Treatments (2nd ed.). Elsevier.

[13] Price, V. (2010). Hair Loss: Causes, Treatments, and Prevention (4th ed.). Simon and Schuster.

[14] Shapiro, J., & Diaz, V. H. (Eds.). (2011). Hair Loss: Principles of Diagnosis and Management (2nd ed.). Informa Healthcare.

There are several ways to search for information about hair fall, depending on your needs and preferences:

1. Online Search Engines:

• Using keywords like "hair loss," "hair fall," "alopecia," or related terms in search engines like Google, Bing, or DuckDuckGo can yield a vast array of articles, websites, and resources on the topic.
• Be specific with your search terms to get more relevant results. For example, search for "causes of hair loss in women" or "natural remedies for hair fall."

2. Medical Websites and Databases:

• Reputable websites like Mayo Clinic, WebMD, Healthline, and the American Academy of Dermatology offer reliable information on the causes, types, treatments, and prevention of hair loss.
• Medical databases like PubMed or Google Scholar provide access to scientific research articles and studies on hair loss.

3. Consulting Healthcare Professionals:

• If you are experiencing hair loss, it’s best to consult a dermatologist or trichologist (hair specialist) for diagnosis and treatment options.
• They can provide personalized advice and recommend the most suitable treatment plan for your specific condition.

4. Books and Publications:

• Many books and publications are available on hair loss, covering various aspects from causes and treatments to psychological impact and coping strategies.
• Look for books by reputable authors and publishers, or consult your doctor for recommendations.

5. Support Groups and Online Forums:

• Online forums and support groups can connect you with others who are experiencing hair loss.