Hair Loss

Hair Conditions

Male Pattern Hair Loss

Male pattern hair loss usually starts either with a recession to the temples or a diffuse thinning to the crown and can be followed in some cases by a gradual thinning, then a complete denuding of the top. Very rarely is the hair lost on the sides and back although men over seventy can lose hair in the neck area. Both the Hamilton and the Norwood scales classify Androgenetic hair loss in men.

Androgenic hair loss has three causative factors: genetic predisposition, the presence of the androgen testosterone and the age of the patient.

Male pattern baldness is more commonly inherited from the maternal grandfather.

At puberty, more of the male hormone testosterone circulates around the body causing hairs that are genetically programmed (in the pattern areas) to produce finer and shorter hairs with each new cycle of hair growth. Testosterone reaches the target organ, in this case the hair follicle, where the enzyme 5α-reductase changes testosterone into the highly potent hormone di-hydro testosterone, which causes the above affects.

Female Pattern Hair Loss

Female pattern hair loss presents a diffuse thinning to the front and crown area of the scalp (Ludwig pattern) and never at the sides and back from this reason alone. Partings seem wider and the scalp seems more noticeable at the front and the top of the head.

This is a slow, gradual process and rarely does it completely denude the area.

Androgenetic hair loss in women usually begins with the hormone changes after puberty, pregnancy or menopause and is fairly common in ladies over 80 years of age. Although there is normally no increased hair shedding noticed with this type of loss, there are cases of long-term excess shedding (telogen effluvium) that precede this condition. Androgenetic hair loss has three causative factors, age, inheritance and the presence of the hormone testosterone.

Postmenopausal thinning is related to oestrogen reduction.

Telogen Effluvium (Symptomatic/Reflective Loss)

By far the most common type of excess hair shedding in women is acute telogen effluvium (ATE) but when prolonged it is termed chronic telogen effluvium (CTE).

Acute Telogen Effluvium

Acute telogen effluvium presents a sudden excess shedding of hair in a diffuse distribution throughout the scalp. A large amount of hairs will be seen in the brush and comb, particularly so when the hair has been shampooed and conditioned. On examination of the scalp many hairs will come away on minor traction. There will also be many short re-growing tapered hairs of a similar length through the scalp; the length of the hairs depends on the duration of the condition.

Chronic Telogen Effluvium

When excess hair shedding lasts longer than nine months it is termed Chronic. Chronic telogen effluvium often starts with a sudden shedding caused by trauma, but sometimes there is a gradual onset and seemingly an unspecific cause. Hair sheds relentlessly, sometimes fluctuating in the amount of loss. There is loss of hair density, particularly to the longer lengths, and there is also a diffuse thinning to partings. Hair does not reach the length it used to and there are many re-growing tapered hairs of differing lengths throughout the head.

With chronic telogen hair loss the re-growth is still present, but at differing lengths. Mostly longer hairs will fall, but shorter ones are also noticed. Because the growing length is shortened the hair will not seem to grow.

Anagen Effluvium

Anagen effluvium is a drastic hair shedding in the anagen growth phase soon after chemotherapy or ingestion of poisons due to the direct toxic effect on rapidly dividing cells in the hair bulbs. It causes most of the hair to fall out soon after chemotherapy, but happily most people re-grow their hair within a short period after stopping treatment.

Alopecia Areata

Often the most drastic type of hair loss, alopecia areata presents a number of circular completely bald patches. These can sometimes merge with other patches The hair follicles are clearly visible and the earliest patch will often be re-growing fine, often white hairs from the centre of the patch.

This condition is unpredictable and can last from six months to many years depending on the causative factors. When the hair loss covers the whole scalp it is termed alopecia totalis. When the whole body is affected it is called Alopecia universalis.

Ophiasic Areata

Ophiasic areata is a marginal presentation of alopecia areata and can affect the nape area as well as the front and sides of the scalp. This type of alopecia areata can be more persistent.

Traumatic Alopecia

Traumatic alopecia frequently appears on the margins of the scalp and sometimes shows irregular patchy hair loss to the crown area. There will be breakage to these area and also short re-growing hairs. It is caused by excessive chemical, thermal or physical trauma as well as scratching the scalp. Traumatic alopecia is frequently seen on Afro-type hair when subjected to any or all of the above hairstyling methods over long periods.

Traumatic Hair Loss Or Breakage

Trichotillomania is a form of self-inflicted physical trauma and is a variant of obsessive-compulsive disorder. It is very common in children and they usually grow out of the habit. It is however a much more difficult habit to break in adults.

Scarring Alopecia

Scarring alopecia often presents itself as an irregular area of shiny bald skin, which can be a darker or lighter colour than that surrounding it. No hair follicles are present and the skin can be atrophied, or even raised and thickened (Keloid). A scar is formed when a wound heals itself after deep tissue damage. The structure of scar tissue differs from normal skin and does not support normal hair growth. There are three main causes of scarring: chemical, infection and autoimmune disease.

Scalp Conditions.
Scalp Conditions

Seborrhoeic Eczema

Seborrhoeic EczemaSeborrhoeic eczema is a chronic relapsing inflammatory scalp condition occurring in seborrhoeic areas (areas with more sebaceous glands). It spite of the name it is not necessarily an oily condition. It presents differing signs, varying between mild pruritic scaling and erythema, to excessive scaling and crusting formed from dried exudation over a red and moist scalp.

The whole of the scalp can be affected, particularly the margins and retro auricular area behind the ears.

Seborrhoeic eczema can be highly pruritic, which leads to excoriation and secondary infection with pustulation.

Seborrhoeic eczema occurs in infancy as cradle cap and is rarely seen throughout childhood. It returns at puberty or later and lasts throughout life. Infantile and adolescent forms are likely to be two distinct conditions.

Irritant Dermatitis (Contact Dermatitis)

Irritant DermatitisIrritant dermatitis is caused by a substance which can create cell damage when applied for the first time in strong concentrations i.e. bleach, relaxer (sodium hydroxide). It can also occur when weak concentrations of successive applications i.e. shampoo are used. That substance is called the primary irritant. The reaction caused may be inflammatory but it is not an allergic reaction.

Primary irritants that may cause non-allergic reactions include shampoos, hair cosmetics such as conditioners, setting lotions, or perm lotions, para-dyes and relaxers on black hair. Plants and metals can also create similar problems.

Allergic dermatitis

Allergic dermatitis is a potentially life-threatening reaction to a substance previously used on the skin. The reaction takes place some time later. The allergic reaction creates an intensely irritable reaction, which happens after a substance has been applied to the skin.

A few hours or even days after the application of the substance, the affected skin may become swollen, red and blistered or dry and crusted. Mostly the area in contact with the substance is affected but when the scalp is affected, the reaction can spread to the eyes and face and sometimes there can be swollen lymph nodes and secondary infection. There can be anaphylactic shock with subsequent restriction of the windpipe. Allergic dermatitis causes intense itching and burning.


Psoriasis often begins on scalp or elbows with circular areas of uniform darker/ redder skin clearly differing in colour from adjacent normal coloured skin.

These areas are covered with dry white, adherent silvery scales, which can sometimes be quite dense. These scales are not easily removed but when they are, then coarse lined skin with bleeding points can be seen underneath them.

Other areas that can be affected are the knees, elbows and shins. The fingernails and toenails can be affected with thimble pitting. Stiff and painful joints can accompany psoriasis.

The cause of psoriasis is unknown, but there would seem to be a familial trait. Two per cent of Caucasians suffer from the condition, which more commonly appears between the ages of ten and thirty.

The condition is triggered by stress, skin damage, illness and bacterial infection. Itching to an adjacent area often denotes an extension of the condition.

Pityriasis Amiantacea

Psoriasis often begins on scalp or elbows with circular areas of uniform darker/ redder skin clearly differing in colour from adjacent normal coloured skin.

These areas are covered with dry white, adherent silvery scales, which can sometimes be quite dense. These scales are not easily removed but when they are, then coarse lined skin with bleeding points can be seen underneath them.

Other areas that can be affected are the knees, elbows and shins. The fingernails and toenails can be affected with thimble pitting. Stiff and painful joints can accompany psoriasis.

The cause of psoriasis is unknown, but there would seem to be a familial trait. Two per cent of Caucasians suffer from the condition, which more commonly appears between the ages of ten and thirty.

The condition is triggered by stress, skin damage, illness and bacterial infection. Itching to an adjacent area often denotes an extension of the condition.


Folliculitis is inflammation and infection of the hair follicle, mostly affecting young black men. The signs of folliculitis are pustules and follicular inflammation throughout the scalp, but mostly affecting the nuchael to occipital area where raised nodules and keloidal scarring can exist.

There are pustules, weeping, bleeding, erythema, crusting, and hair breakage in particular to the neck area. The condition can extend upwards towards the vertex.

Symptoms include prolonged intense itching and it can occur on any hairy position.

Acne Necrotica Miliaris

Acne necrotica miliaris presents a few minute yellow pustules that are extremely itchy. They are situated at the opening of the hair follicles. The pustules have a cone-shaped crust over a moist base and are of pinhead size. Four or five of these tiny lesions can be found scattered across the scalp. They are prone to affect the top of the scalp and when healed they form tiny scars which can occur with male pattern loss making the scarring difficult to see.


Ringworm is not caused by a worm but is a superficial fungal infection of the scalp affecting mostly children.

It is a non-scarring, patchy hair loss showing brittle hairs and broken stumps of hair with grey coloured scale and erythema. The patch or patches are circular and show dry, dull broken hairs very unlike the surrounding uninfected hairs. The hairs tend to lie at different angles to one another.

Hair shedding

Shedding is most often temporary and due to telogen effluvium (hair bulbs present), but may also be during anagen (no hair bulb) if due to alopecia areata or provoked by a drug (e.g. retinoid, hormone, anticoagulant, statin, cytotoxic).

Telogen effluvium may follow two or three months after a provoking event, most often parturition, sudden weight loss, blood loss, fever or stress. The shedding stops within a few months but it may take a couple of years for the hair bulk to appear normal.

Chronic telogen effluvium arises when the hair cycle has sped up so that the anagen phase is shorter; identify and treat iron deficiency (test ferritin) and hypothyroidism. it is rare in children; most cases are women with diffuse non-androgenic pattern balding.

Telogen effluvium


Diffuse alopecia

Diffuse hair thinning in adults is most often due to male pattern balding in men (androgen-dependent) and female pattern balding (non-androgen-dependent) in females. These rarely present in adolescents. However, diffuse hair thinning may accompany internal disease (particularly systemic lupus erythematosus and syphilis). Thin fragile hair may also accompany iron deficiency. Coarse dry hair may be due to hypothyroidism. In the absence of other symptoms, alopecia areata may be responsible.

Diffuse hair loss

Pattern balding (male)

Pattern balding (female)


Localised alopecia

Balding can be reversible, but if there is scarring it is permanent. Alopecia areata is the most common cause of one or more areas of localised baldness on the scalp and other hair-bearing areas. It is an autoimmune skin disease and is more common in those affected by, or with a family history of, vitiligo, diabetes and thyroid disease. It is also more common in Down syndrome. Although the onset may be at any age, it most often starts in childhood or young adult life.

The scalp appears normal in alopecia areata, but there may be broken-off short hairs resembling exclamation marks (!) In typical alopecia areata, there are one or several round smooth bald patches. In about 5% all hair from the head is lost (alopecia totalis) and in 1% the body hair is also lost (alopecia universalis). In 80% there is regrowth within a few months, but it may be lost elsewhere at the same time or later. Prognosis seems less good in very young children, if the initial hair loss is severe and extensive or affecting facial areas. The nails may be affected resulting in pitting and ridging.

Alopecia areata

Alopecia universalis

Loss of eyebrows

Marginal regrowth



There is a strong placebo effect of treatment because spontaneous regrowth may occur at any stage. It is therefore hard to assess the value of individual treatments. Limited localised disease in children is best managed by ultrapotent topical steroid cream or gel under occlusion. Older children may tolerate intralesional corticosteroid injections 6 to 8-weekly (maximum 20mg per visit).

District Health Boards provide a subsidy to obtain a wig, if medically necessary.

If bald patches are accompanied by inflammation (erythema, scaling, pustules) consider other reasons for hair loss in children:

  • Tinea capitis (positive microscopy/culture of scale and extracted hair)
  • Trichotillomania (hair that has been pulled or twisted out: look for broken hairs)
  • Traction from plaits and braids

Inflammatory hair loss

Tinea capitis



These disorders may result in scarring (cicatricial alopecia) in which there is shiny pale skin and reduced or absent follicular orifices.

Hair shaft abnormalities

These are rare and diagnosed by light or electron microscopy. They present as thin, short, or unruly hair in young children. The most common abnormalities are:

  • Monilethrix: beaded hair
  • Pili torti: twisted hair

Hair shaft abnormalities

Loose anagen syndrome

Spangled hair shaft abnormality


Skin diseases affecting the scalp

Skin diseases that favour the scalp may not cause any hair loss, although when they are very severe this may occur.

The most common conditions affecting the scalp are:

Dandruff or pityriasis capitis Diffuse scaling
Seborrhoeic dermatitis Ill-defined inflammatory plaques with yellowish scale
Psoriasis Diffuse or localised well-defined erythematous plaques with silvery scale
Pityriasis amiantacea Sticky scale due to underlying psoriasis or seborrhoeic dermatitis
Head lice Adult lice, nits on hair shaft, tiny haemorrhagic spots and excoriations
Lichen simplex Well demarcated lichenified intensely itchy plaques, usually on occiput
Folliculitis Chronic scattered and irritable follicular pustules


Scalp conditions

Pityriasis amiantacea

Infantile seborrhoeic dermatitis

Scalp folliculitis


Excessive hair

Hirsutism is excessive hair growth in females in the beard area, around the nipples, in a male pattern on the abdomen (diamond-shaped pubic hair) and often elsewhere. It is more common in darker skinned Europeans or Middle-Eastern women. It causes a great deal of distress and onset may be at puberty.

Hirsutism is the result of the conversion of fine vellus hair to coarse terminal hair induced by androgens. These may be endogenous (adrenal, pituitary or ovarian origin) or exogenous (androgenic drugs). Excessive androgens will also result in virilism, amenorrhoea and infertility. Investigations should include:

  • Free testosterone and sex hormone binding globulin
  • Cortisol, FSH, LH
  • Ultrasound examination for polycystic ovaries

However, end-organ sensitivity in idiopathic hirsutism is more common, in which investigations indicate hormone status to be normal.

Idiopathic hirsutism


Physical methods of hair removal include:

  • Shaving
  • Depilating cream
  • Waxing
  • Electrolysis
  • Laser epilation

Medical treatment may be helpful: spironolactone, ethinyloestrodiol/cyproterone contraceptive pill or 50-200mg cyproterone for days 1 to 10 of the menstrual cycle.

Hypertrichosis may be congenital (hairy congenital naevi, hypertrichosis lanuginose and familial hypertrichosis) or acquired. Acquired hypertrichosis may be due to medications (ciclosporin, minoxidil, antiepileptics) or disease (hypercorticism, hypothyroidism, porphyria cutanea tarda, anorexia nervosa). Medical treatment should be directed at the underlying disease.


Congenital hypertrichosis

Becker naevus

Effect of ciclosporin


Glossary for Hair loss

A glossary of the medical terms used in this guide.



This is the name given to a loss of hair on the scalp but can also include other areas of the body. There are many different types of alopecia which include alopecia areata, traction alopecia and the more common androgenetic alopecia.


The ‘growth’ phase of the hair growth/loss cycle.

Androgenetic alopecia

Also known as male pattern baldness: this is a form of hair loss which is usually genetic in nature and accounts for the vast majority of hair loss in men.

It occurs to a lesser extent in women.


The name given to the male hormones.



A type of hair style in which the hair is woven into tight strands.


The base of the hair follicle (the root)



The ‘shedding’ phase of the hair growth/loss cycle.


A cream based hair product which is used after the hair is washed to help moisturise the hair.


A braiding technique in which the braids form a series of rows or tracks on the top of the head.


The top of the head.


The hard, outer layer of a hair strand which helps to protect it. Healthy cuticles give a shine to the hair.



A condition characterised by dry, flaking scalp.

Dihydrotestosterone (DHT)

A hormone derivative which is formed when testosterone combines with 5-alpha reductase. The main cause of male pattern baldness.

Donor site

The area of the head where hair follicles are removed, for grafting purposes, during hair transplant surgery.


A medication for hair loss which prevents the formation of dihydrotestosterone.


Endocrine system

The name given to a system of glands in the body, which produce hormones that help regulate the normal functions of the body.


A protein which speeds up chemical reactions in the body.


A piece of real or artificial hair which is attached to natural hair in order to increase its length.



A hair loss medication that prevents testosterone from combining with 5-alpha reductase to produce dihydrotestosterone. Marketed as the brand name Propecia.


A bulb like structure underneath the skin where hair is grown. It is comprised of a root sheath, bulb, shaft and sebaceous glands.

Each follicle contains blood vessels which transport in oxygen and nutrients to promote hair growth.


Grey hair

Hair which has lost its natural colour. Occurs as a result of the ageing process.


Hair cloning

A developmental technique which aims to create an unlimited supply of donor hair for hair transplantation.

Hair growth cycle

The normal hair growth and loss cycle in which hair passes through 3 phases on a daily basis. These phases are: anagen, telogen and catagen.


Intense pulse light

A form of treatment in which short bursts of light are emitted from a hand held device against the skin. This is aimed at the scalp to boost blood circulation and stimulate hair growth.


Jojoba oil

A type of hair product which is used to treat dry hair.



A type of protein which helps with the formation of a hair strand.



A type of hair style which results in textured, thicker hair.


Male pattern baldness

Often known as androgenetic alopecia. A type of hair loss common in men which starts at the temples then continues over the crown and finishes at the back of the head.

Usually caused by genetic factors.


A substance responsible for the colour of the hair and skin.


The smallest graft used in hair transplant surgery which only consists of one to two hairs.


A form of medication used to treat androgenetic alopecia. Marketed as the brand name Regaine.


A cream used to lubricate the skin.



Essential vitamins and other similar substances which help with the normal functions of the body.



One of two female hormones. Produced by the woman’s ovaries, it plays an important part in her monthly ovulation cycle.



A female hormone that prepares the woman’s uterus for an impending pregnancy. Progesterone levels rise and fall throughout the monthly ovulation cycle.


The brand name of the hair loss medication Finasteride.





The brand name of the medication used to treat androgenetic alopecia.

Root sheaths

Each hair strand is contained within a root sheath which consists of the cuticle, middle layer or cortex and an inner layer or medulla.


Sebaceous glands

Glands attached to the hair follicles which produce sebum to lubricate the hair.


A type of oil produced by the sebaceous glands.


The part of the hair strand which appears above the skin. It is formed from dead cells, keratin and water which have bound together to give it its cylindrical shape.

Split ends

A hair condition caused by excessive heat or use of hair products which results in hair with frizzy ends.



The ‘resting’ phase of the hair growth cycle.


A male hormone which is responsible for the development of male characteristics.

Thyroid gland

An endocrine gland, located in the neck which controls the body’s metabolism.


To apply directly onto the scalp. Usually refers to a type of hair loss medication.


A ‘hair doctor’/hair specialist.


A type of hair loss in which the patient pulls out their own hair.


UV light treatment

A type of hair loss treatment which is directed at areas of hair loss to stimulate blood flow, and encourage new hair growth.



A failure of melanin production which results in patchy coloured skin and/or hair.



A hair piece with a cap which is worn to disguise areas of hair loss. There are two choices of wigs: synthetic hair and human hair.










Leave a Reply