How does alopecia start? — Spotting the first signs of baldness
Alopecia is a general medical term that is used to refer to all forms of hair loss. It’s an old Greek word and originally meant a fox suffering from mange, a canid skin disease that among other things causes hair loss. A mangy fox — certainly not a very flattering term to describe baldness.
The causes of alopecia are manifold, including a bad diet, lack of iron or certain vitamins, severe stress shocks that triggers autoimmune disorders, medications, and external factors such as radiation and chemical pollution. However, in 95 percent of cases, alopecia is a genetic condition, i.e., it’s inherited from one’s ancestors. This is called androgenic alopecia and in plain English is referred to as “pattern hair loss.”
Male pattern hair loss affects around 50 percent of men; for Caucasian men the prevalence of androgenic alopecia even is 80 percent. The age of 40 plus minus 3 years is considered as the threshold for the onset of male pattern hair loss, but for some men it can be much earlier than that. While androgenic alopecia is a genetic condition, research is still trying to figure out how exactly and when it is inherited. Having bald fathers and grandfathers doesn’t imply a man will inevitably end up in the 50+ percent category of men with inherited baldness.
Even around 50 percent of women will experience hair loss at old age (>65 years), but that is typically limited to hair thinning. Women very rarely go completely bald.
Pattern hair loss is a gradual process that you may not noticed at first. It usually starts from the forehead and over the course of many years slowly advances across the vertex, the top of your head, until it’s entirely bald. The earlier you notice abnormal hair loss and get it diagnosed, the faster you can do something about protecting your remaining hair.
For men, baldness proceeds in a V-shaped pattern, which means that the formerly straight hairline that starts above the forehead is thinning at the temples while leaving the middle part intact. It increasingly looks like the letter V. If you are concerned about hair loss and want to look for early signs, take a picture of your hairline just after you had a haircut and repeat that every 3-6 months with the exact same angle and lighting. You best take the picture at the same location of your home at a similar daytime hour. This will allow you to monitor your hairline for early indications of baldness.
Counting the hairs you lose in the shower every morning or when brushing your hair would be a tedious exercise. Hair counts are difficult and not very reliable. Humans on average lose 100-150 hairs per day and there can be large fluctuations that are caused by stress or illness. Of course, it also is simply impossible to keep track of every hair you lose. Regularly comparing photographs is still the best option.
That said, if you think that for a period of longer than two weeks you have lost more hair than normal, you best talk to a dermatologist. The same goes for hair loss that is concentrated in one particular area of the scalp (focal hair loss) and is circular in shape. This could be an autoimmune disorder called area hair loss (alopecia areata).
How is alopecia diagnosed?
A dermatologist (dermatology is responsible not just for the skin but also hair and nails) can help you confirm whether you have androgenic alopecia or another condition that causes hair loss. Again, 95 percent of hair loss problems are the hereditary type, androgenic alopecia.
Doctors will first establish whether the hair loss is focal (which is a strong indicator for alopecia areata) or diffuse, as is typical in pattern hair loss. The next check will be to see whether the hair is thinning or shedding. The latter often indicates short-term stress related hair loss (telogen effluvium), such as due to malnutrition, illness or medication.
For further examination, a hair pull test can be done. In the event of pattern hair loss, when pulling hairs in different places of the scalp the hairs at the very front of the hairline will come off most easily. Their follicles are already damaged and these hairs would fall out naturally very soon anyway. In contrast, hair in the back of the scalp is much for difficult to pull. If hair loss is stress-related, all hair pulled in different parts of the scalp will come off equally well.
If the hair loss is focal and your doctor suspects alopecia areata, a skin cell biopsy can provide more clarity.
Causes of baldness — a quick summary
- Your genes: hereditary androgenic alopecia
- Stress-related (telogen effluvium): lack of carbs and/or nutrients, bereavement, illness, medication, radiation and chemicals, during or post-pregnancy
- Autoimmune disorder: such as alopecia areata which often is triggered in response to acute shocks (bereavement, severe illness, etc.)
- Hair-pulling: Called trichotillomania, this is a condition where people pull their own hair due to anxiety, depression, and other stress-induced trauma
How to treat alopecia?
For androgenic alopecia there are medications than can effectively stop the progress of balding and in many cases even stimulate new hair growth. In United States, the only two U.S. FDA approved drugs are finasteride, which is an orally taken pill, and minoxidil, a topical medication available as spray and liquid.
Finasteride stops baldness in about 85 percent of men and spurs new hair growth in 65 percent, but only for as long as you take the drug. Clinical research of up to 10 years has shown that finasteride generally is well tolerated and only rarely has more than mild side effects.
Minoxidil doesn’t stop the process of balding but it accelerates hair growth by widening the blood vessels on your scalp and thus triggers new hair growth. Minoxidil can be taken in combination with finasteride.
Talk to your doctor to learn more about finasteride and minoxidil and whether they could be the right choices for treating your baldness. If you live outside the United States and in a country where dutasteride is approved as a pattern hair loss treatment, ask your doctor about whether it could be an alternative option.
For alopecia areata no effective remedy has been found so far, but 34–50 percent of people with alopecia areata experience spontaneous and full recovery of their hair.
If your hair loss is because of stress, you’ll need to lower your stress levels. Eat better, sleep better, exercise better and try yoga and meditation to improve the body’s general health and to become more stress resilient. Vitamin supplements can also be helpful. Discuss with your doctor or nutrition specialist what steps can be taken.
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- Chandrashekar, BS, et al. “Topical Minoxidil Fortified with Finasteride: An Account of Maintenance of Hair Density after Replacing Oral Finasteride.” Indian Dermatology Online Journal, vol. 6, no. 1, 2015, p. 17, www.ncbi.nlm.nih.gov/pmc/articles/PMC4314881/, https://doi.org/10.4103/2229-5178.148925. Accessed 29 Nov. 2019.
- Pratt, C. Herbert, et al. “Alopecia Areata.” Nature Reviews Disease Primers, vol. 3, no. 1, 16 Mar. 2017, www.ncbi.nlm.nih.gov/pmc/articles/PMC5573125/, https://doi.org/10.1038/nrdp.2017.11.
- Cranwell, William, and Rodney Sinclair. “Male Androgenetic Alopecia.” Nih.Gov, MDText.com, Inc., 29 Feb. 2016, www.ncbi.nlm.nih.gov/books/NBK278957/.
- Price, Vera H. “Androgenetic Alopecia in Women.” Journal of Investigative Dermatology Symposium Proceedings, vol. 8, no. 1, June 2003, pp. 24–27, www.sciencedirect.com/science/article/pii/S0022202X15529369, https://doi.org/10.1046/j.1523-1747.2003.12168.x. Accessed 29 Nov. 2019.