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November 2017
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“What should I do about chronic hair shedding?” Dr Emily Altman

There are a number of causes to chronic hair shedding. Clearly not all of them will be applicable to a young, healthy man. We normally lose approximately 100 hairs a day, and they are replaced by new growing hairs. So the problem comes when either the numbers of hairs shed per day is greater than 100 or if there is hair thinning in addition to shedding.

When examining a patient with hair loss, some questions need to be answered:

  • Is the hair shedding or is it thinning?
  • Is the hair coming out with the root or is it breaking somewhere on the hair shaft? Hair shaft fragility may be from over processing the hair (blow drying, straightening, etc) or may have a genetic component.
  • If it is thinning, is there a pattern (hair line, scalp vertex, etc) or is it diffuse over the entire scalp?
  • Is there scarring of the hair follicles? Scarred areas would appear smooth and shiny and there would not be any follicular openings visible on the skin surface.
  • Is there a skin condition involving the scalp? Inflammatory conditions, such as seborrhea or psoriasis can increase hair shedding. Hair loss can also be caused by infections, such as tinea capitis, a fungal infection.
  • Is the patient on any medications? Certain medications, such as beta blockers (blood pressure pills), cholesterol lowering medications, retinoids (such as the acne medication, Accutane), chemotherapy and a number of others can cause chronic hair shedding.
  • Are there any systemic diseases? Diseases like lupus can cause chronic hair shedding, as can anemia, thyroid disease (both hypo and hyperthyroidism)
  • Has the person had any major illnesses, surgeries, blood loss in the past six months before hair loss started?
  • For women, is there a history of irregular periods or has she recently given birth? Abnormal periods may indicate hormonal abnormalities or greater than normal blood loss, which may result in low iron stores.
  • Has the person lost a significant amount of weight recently?
  • Is there a family history of hair loss, either from the mother’s or father’s side?
  • Has the person been exposed to any toxins? Lead exposure, among others, can cause hair shedding.
  • Is the person under a lot of stress? This is what is called a “waste basket diagnosis.” If everything else has been ruled out, and the person is under tremendous stress, that may be the final diagnosis.

Then, blood work should be done to figure the answers to some of these questions.

Things that I check for when doing blood work for hair loss:

  • complete blood count
  • comprehensive metabolic panel
  • iron studies
  • thyroid function tests
  • ANA (anti-nuclear antibody) that may point to lupus or other collagen vascular diseases.
  • vitamin D3 levels
  • depending on the possibility of heavy metal/toxin exposure as obtained by the history, those may be added to the test list.

Another two tests that need to be done in evaluating a person with hair shedding are:

  • gently pulling on the scalp hairs to see how many hairs come loose during the exam. The norm is 5 for the entire scalp. If there are significantly more, that may indicated a problem.
  • using a clamp, actually pulling out with the roots and all, approximately 20-30 hairs and sending the specimen to the lab for an evaluation to determine how many hairs are in which stage of growth. The ration is usually 90% in growing phase (anagen) to 10% resting phase (telogen). This type of hair pull examination also looks at any hair shaft abnormalities that may cause abnormal breakage of hair.

I also have the patient do a hair collection for me once a week over 6 weeks, to see what types and how much hair is lost. That is done once a week on a day that the person washes his/her hair. All the hair found on the brush, in the shower, on the pillow is collected into a clear plastic baggy with the date labeled. This also allows for monitoring treatment, as with treatment the amount of hairs collected should go down.

If the blood work and history are negative, a scalp biopsy may be in order to figure out if the patient may have alopecia areata, an autoimmune disease that causes hair loss. Although alopecia areata usually presents with patchy hair loss/shedding, less commonly it may be diffuse over the entire scalp.

Another condition that can cause chronic hair shedding is telogen effluvium, which may be idiopathic (no known cause) but most likely is related to one of the problems listed above. A rare condition of chronic hair shedding seen more commonly in children is loose anagen syndrome.

Any rashes on the scalp need to be treated to see if that stops hair shedding.

In any hair loss condition, I have the patients start taking a vitamin, biotin, the amounts of which are determined based on the general medical condition of the patient and any underlying illnesses.

When I have all the answers to all my questions, I can put the information together and come up with a diagnosis and treatment.

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