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Hair Loss in Men and Women

Introduction 

Hair loss, or alopecia, is a common dermatological condition that affects both men and women across all age groups. While not life-threatening, it has profound psychological, emotional, and social impacts, particularly in cultures where hair is tied to identity, youth, and attractiveness.

Hair loss can be diffuse, localized, or patterned, and results from a wide array of factors—ranging from genetic predisposition and hormonal imbalances to autoimmune disease, nutritional deficiencies, and external insults (e.g., medications, stress, or trauma). The underlying pathology often involves disruption of the hair cycle, which includes the anagen (growth), catagen (regression), and telogen (resting) phases.

Although more visibly stigmatized in women, hair loss is more prevalent and earlier in onset in men. Both sexes may suffer from diminished self-esteem, anxiety, or depression as a result.

Men:

  • By age 35, ~40% of men experience noticeable hair loss.
  • By age 50, over 50% of men show signs of androgenetic alopecia (male-pattern baldness).
  • The highest rates are observed in Caucasian men, followed by Asian and African populations.

Women:

  • Female-pattern hair loss (FPHL) affects ~40% of women by age 50, often underdiagnosed or misattributed to aging.
  • Telogen effluvium, a reversible shedding disorder, is more common in women, especially postpartum and during hormonal shifts.

Global trends show:

  • An increase in early-onset alopecia in both sexes due to stress, pollution, and lifestyle.
  • A rise in cosmetic dermatology visits related to hair issues, especially among urban and professional populations.
  • Hair loss is now one of the top 5 concerns in cosmetic and dermatologic clinics worldwide.

Androgenetic Alopecia (AGA)

  • Most common cause of hair loss in both men and women.
  • Genetically determined sensitivity to dihydrotestosterone (DHT) → miniaturization of hair follicles.

In Men:

  • Recession at temples and thinning at crown
  • Progression to full baldness (Hamilton-Norwood scale)

In Women:

  • Diffuse thinning over the crown
  • Frontal hairline typically preserved (Ludwig or Sinclair scale)

Telogen Effluvium (TE)

  • Temporary, diffuse hair shedding 2–3 months after a triggering event:
    • High fever
    • Surgery or trauma
    • Childbirth (postpartum hair loss)
    • Crash diets or malnutrition
    • Emotional stress
    • Medications (retinoids, beta blockers, anticoagulants)

Alopecia Areata (AA)

  • Autoimmune disorder where immune cells attack hair follicles.
  • Sudden, round patches of complete hair loss; may involve scalp, eyebrows, or eyelashes.
  • In severe forms:
    • Alopecia totalis (entire scalp)
    • Alopecia universalis (entire body)

Traction Alopecia

  • Hair loss from prolonged tension on hair follicles (tight ponytails, braids, weaves).
  • Common in African descent women and individuals in professions with tight headgear.

Scarring (Cicatricial) Alopecias

  • Inflammatory destruction of hair follicles leads to permanent hair loss.
  • Includes lichen planopilaris, discoid lupus, folliculitis decalvans.

Hormonal and Metabolic Causes

  • Seen in:
    • Polycystic ovary syndrome (PCOS)
    • Thyroid dysfunction
    • Menopause
    • Insulin resistance or diabetes
  • Often overlaps with other forms (e.g., androgenetic alopecia with PCOS)

Category

Contributing Factors

Genetic

Family history, AR gene polymorphisms

Hormonal

High DHT, estrogen decline, thyroid dysfunction

Nutritional

Iron deficiency, zinc, vitamin D, B12, protein

Stress/Trauma

Surgery, bereavement, chronic stress

Medications

Chemotherapy, retinoids, beta-blockers

Autoimmunity

Alopecia areata, lupus

Lifestyle

Crash dieting, smoking, poor scalp hygiene

Cosmetic Practices

Heat styling, bleaching, tight hairstyles

 

Initial work-up includes:

  • Detailed history: onset, triggers, family history, shedding pattern
  • Scalp examination: presence of scaling, inflammation, follicle status
  • Hair pull test, tug test, and trichoscopy (dermatoscope)
  • Blood tests:
    • TSH, free T4
    • Ferritin and iron levels
    • Vitamin D, B12
    • Hormonal panel (testosterone, DHEA, LH/FSH)
    • ANA or ESR if autoimmune suspected
  • Scalp biopsy: In uncertain cases or scarring alopecias

Topical Treatments

  • Minoxidil (2% or 5%): FDA-approved for both sexes; prolongs anagen phase
    • Women: Often 2%
    • Men: 5% foam or solution
  • Side effects: scalp irritation, initial shedding (“shedding phase”), unwanted facial hair (in women)

Oral Medications

  • Finasteride (1 mg/day): Inhibits 5α-reductase, reduces DHT
    • Approved for men only
    • Teratogenic → contraindicated in women of childbearing age
  • Dutasteride: More potent DHT blocker, off-label
  • Spironolactone: Anti-androgen used in women with PCOS-related AGA
  • Oral minoxidil (low dose): Emerging option for resistant hair loss

Nutritional Support

  • Treat iron, zinc, vitamin D, B12 deficiencies
  • Biotin: Popular, but evidence is weak unless deficient
  • High-protein diet essential for hair shaft synthesis

Advanced Therapies

  • Platelet-rich plasma (PRP): Growth factors from the patient’s own blood injected into scalp
  • Low-level laser therapy (LLLT): Stimulates follicles
  • Microneedling: Improves topical absorption and blood flow
  • Stem cell therapy and exosome therapy (experimental)

Hair Transplantation

  • Reserved for stable, non-inflammatory AGA
  • FUE (follicular unit extraction) or FUT (strip method)

Psychological Support

  • CBT and counseling in patients with trichotillomania, body dysmorphia, or depression
  • Camouflage techniques: wigs, hair fibers, scalp pigmentation
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