Baldness (Alopecia)

Help for those struggling with hair loss

Baldness (Alopecia) | Johns Hopkins Medicine

This article was originally published by Hopkins Medicine magazine in its Spring/Summer 2018 issue

Dermatologist Crystal Aguh studies lifestyle factors affecting hair loss in ethnic populations—an area where most dermatologists fear to tread. She speculates that's because dermatologists, the vast majority of whom were never exposed to the topic in medical school, are often “nervous on how to approach treatment.”

“Hair loss seriously impacts self-esteem and quality of life. I always make sure to bring in a box of tissues when I'm talking with my hair loss patients. It really affects their entire being.”

Crystal Aguh

Assistant professor of dermatology

This failure to communicate is particularly devastating to African-American women, as nearly 50 percent of them suffer some kind of hair loss.

Studies suggest a significant portion of middle-aged African-American women feel their hair is “unhealthy”—perhaps due to experiences involving hair care and styling—and that these concerns lead many to avoid exercising, so as to protect their existing hair.

Few of these women discuss their hair and scalp issues with their doctors, says Aguh, and those who do are often dismayed at their physicians' lack of knowledge about common African-American hair issues. These include dryness, breakage, and fragility—the result of curly hair that is farther away from the scalp's natural oils than straight hair.

“Hair loss seriously impacts self-esteem and quality of life,” says Aguh, who became the Department of Dermatology's chief resident in 2014 and is now an assistant professor. “I always make sure to bring in a box of tissues when I'm talking with my hair loss patients. It really affects their entire being.”

One common type of hair loss that almost exclusively affects African-American women is central centrifugal cicatricial alopecia, or CCCA. It's a permanent, scarring type of balding involving chronic inflammation radiating outward from the crown of the scalp.

There's no cure or effective treatment yet for CCCA—though Aguh is studying the same kind of new, platelet-rich plasma injections that other researchers are investigating for their possible use in treating inflammatory issues, including tendon injuries and arthritis.

Still, Aguh can work with patients to keep a difficult situation from getting worse.

“With CCCA, the worst hair loss comes in the middle of the scalp, but tight braids will pull out hair in other places (notably the front and sides of the scalp),” she says.

“Because there are no great CCCA treatments, I want them to max out their hair everywhere else. People who want to camouflage their hair loss want to know how styling can come into play.

So every patient I see with hair loss gets this discussion.”

As one of fewer than a dozen dermatologists nationwide specializing in hair care, Aguh treats more than 200 women a year (and some men) concerned with their hair loss and damage.

Often, they come in frustrated: They may have a dermatological scalp condition for which their specialist has prescribed a shampoo with instructions to use it every day—not knowing that daily shampooing often destroys curly hair (another effect of the lack of natural oils).

“Basic styling isn't part of any medical school dermatology curriculum, though it should be,” Aguh says.

“If someone has permanent hair loss and dreadlocks, the average dermatologist would focus on giving them steroid injections or steroid creams.

But no one will ask them how often they see their loctician and [discuss] the kind of different, looser dreads they could switch to that won't cause hair loss.”

Aguh recently co-authored Fundamentals of Ethnic Hair: The Dermatologist's Perspective (Springer, 2017) with Johns Hopkins dermatologist Ginette Okoye. The textbook covers basic science, including a comparison of the chemical and physical properties of Asian, black, and Caucasian hair—and discusses hair styling and its cultural and religious roots.

“Our book was, in part, aimed at increasing dermatologists' awareness of routine, common styling practices among our patients,” Aguh says. “That's [been] a nonstarter existing curriculums.”

Posted in Health



Diet-driven hair loss and skin damage may be reversible

Baldness (Alopecia) | Johns Hopkins Medicine

In a study conducted in mice, researchers from Johns Hopkins were able to confirm that a Western-style diet — high in fats and cholesterol — has a negative impact on hair and skin health. They went even further, however, developing a drug that is able to reverse the damage.

Share on PinterestCan an experimental compound treat hair loss and skin damage caused by diet?

In an open access paper recently published in the Nature journal Scientific Reports, Subroto Chatterjee and colleagues from Johns Hopkins Medicine in Baltimore, MD, show that a diet high in fats and cholesterol can lead to skin inflammation, as well as hair loss and hair whitening.

their initial findings, the researchers also developed an experimental drug, D-threo-1-phenyl-2-decanoylamino-3-morpholino-1-propanol (D-PDMP), hoping it would help them reverse the effects of an unhealthful diet on skin and hair.

D-PDMP regulates the production of a type of fats (lipids) known as “glycosphingolipids” (GSLs), which are part of the membranes of skin cells and other cell types.

In particular, GSLs are a major component of skin cells that make up the external skin layer and of keratinocytes, a type of cell that participates in the pigmentation, or coloring, of skin, hair, and eyes.

“Further research is needed, but our findings show promise for someday using the drug we developed for skin diseases such as psoriasis and wounds resulting from diabetes or plastic surgery,” says Chatterjee.

The research team tested the effects that a fatty diet would have on the skin and hair of mice, as well as the effectiveness of the specially designed compound in offsetting the damage.

Chatterjee and team worked with a group of mice that they had first genetically modified to express symptoms of atherosclerosis, a condition in which fat deposits form inside arteries, obstructing the free flow of blood.

The researchers split the mice into two distinct groups: one of these was assigned a regular mouse diet, while the other was allocated a high-fat, high-cholesterol diet — similar to a Western-style regimen.

All the mice were 12 weeks old when they started on their respective diets, and the researchers conducted their first assessments when the mice were 20 weeks old.

The team found that the mice on a Western-style diet had begun to lose hair and displayed hair whitening and skin lesions.

At 36 weeks of age, 75 percent of the mice that had stayed on the high-fat and high-cholesterol diet had multiple skin lesions, as well as more severe hair loss.

When the mice were between the ages of 20-36 weeks, the researchers gave them all D-PDMP in varying amounts, either in liquid form or in capsule form, as they each stayed on their assigned diet.

After receiving either 1 milligram and 10 milligrams per kilogram of body weight of D-PDMP in capsule form, the mice on a fatty diet started to regain their lost hair, as well as their initial hair color. Skin damage also started to heal.

Chatterjee and team also noted that treating the rodents with 1 milligram of D-PDMP in capsule form per kilogram of body weight was as effective in reversing skin and hair damage as 10 milligrams in liquid form per kilogram of body weight.

This, the researchers explain, suggests that capsules are more effective in delivering the compound.

So, what did D-PDMP do specifically? The research team observed that the skin of mice following a Western-style diet showed numerous signs of neutrophil infiltration. Neutrophils are a type of white blood cell that plays a role in inflammation.

Encapsulated D-PDMP reduced the number of neutrophils observed, suggesting that the substance was effective in reducing skin damage and inflammation.

The researchers also noted that rodents on a fatty diet had modified levels of three important kinds of lipids — ceramides, glucosylceramides, and lactosylceramides — which normally help to maintain skin health.

While ceramides normally help to keep the skin moisturized, glucosylceramides protect skin function; lactosylceramides are involved in the inflammation response at skin level.

Chatterjee and colleagues saw that mice on a Western diet had lower-than-normal total ceramide levels. The same was true for glucosylceramide levels, while lactosylceramide levels were thrice as high as they could have been.

The researchers found that treating these animals with either 1 milligram of encapsulated D-PDMP per kilogram of body weight or with 10 milligrams of liquid D-PDMP per kilogram brought ceramide levels back to normal.

“Our findings show that a Western diet causes hair loss, hair whitening, and skin inflammation in mice, and we believe a similar process occurs in men who lose hair and experience hair whitening when they eat a diet high in fat and cholesterol,” emphasizes Chatterjee.

While the study researchers are hopeful about the promising results they obtained with D-PDMP in mice, they nevertheless point out that more animal research has to be carried out, in order to establish exactly how much of the compound is necessary to fully treat the damage caused by Western-style diets in hair and skin.

Moreover, the team also warns that the results seen in mice may not apply to people, as that is an aspect that is yet to be confirmed. D-PDMP’s safety for human ingestion has also not yet been established.

Still, the scientists think of their current findings as the first step toward better ways of maintaining or restoring hair and skin health.

“Hopefully someday in the future this can mean faster, more effective recovery from baldness, hair whitening in aging populations, and wound healing.”

Subroto Chatterjee


All hairstyles are not created equal: Scalp-pulling and hair loss

Baldness (Alopecia) | Johns Hopkins Medicine

In a review of 19 studies, researchers at Johns Hopkins say they can confirm a “strong association” between certain scalp-pulling hairstyles — many common among African-Americans — and the development of traction alopecia, gradual hair loss caused by damage to the hair follicle from prolonged or repeated tension on the hair root. An estimated one-third of African-American women suffer from traction alopecia, making it the most common form of hair loss among that group.

In a report on their analysis, published ahead of print in the Journal of the American Academy of Dermatology, the investigators urge dermatologists to better educate themselves about the damaging hairstyles — which include tight ponytails, braids, knots and buns — and advise patients of risks and alternatives.

“Hair is a cornerstone of self-esteem and identity for many people,” says Crystal Aguh, M.D.

, assistant professor of dermatology at the Johns Hopkins University School of Medicine, “but ironically, some hairstyles meant to improve our self-confidence actually lead to hair and scalp damage.

” Traction alopecia, she adds, is entirely preventable, and early intervention can stop or reverse it. “We have to do better as care providers to offer our patients proper guidance to keep them healthy from head to toe,” she says.

In their research review, Aguh and her colleagues categorize hair practices into low-, moderate- and high-risk styles the degree to which follicles are exposed to tension, weight, heat and hair-altering chemicals, such as straighteners.

Moderate-risk styles, the authors say, include some of the same styles noted to be high risk, but because they are performed on natural, unprocessed hair, they are less ly to result in hair loss.

Low-risk styles generally included low-tension styles, such as loose buns, and loose-hanging styles, such as wearing the hair down, as well as practices that decrease the amount of friction on the hair and scalp and avoid chemical relaxers.

Aguh and her colleagues say the highest-risk styles include braids, dreadlocks, weaves and extensions, especially when applied to chemically straightened hair.

These styles are popular among African-Americans, she says, because they are low maintenance and chemical-free, but the constant pulling of the hair in one direction, the tight-locking patterns and added weight can result in significant breakage and eventually traction alopecia.

Damage can also be done if extensions are affixed with adhesive glue put directly on the scalp, especially when the glued-on hair is removed. Chemical straightening weakens the hair shaft, causing breakage.

In the more moderate risk category are thermal straightening, permanent waving and use of wigs.

Temporary thermal or heat-related straightening of the hair, such as the use of flat irons and blow drying the hair — while not by itself significantly associated with traction alopecia — can weaken shafts, leading to “significant” hair loss when traction is applied, the researchers conclude.

Permanent waves made with ammonium thioglycolate to create or alter curl pattern, together with added tension from chemical treatment, do the same. And wigs attached with clips and adhesives to keep them in place can cause significant breakage.

Aguh also noted that cotton and nylon wig caps that rub the hairline may also weaken hair shafts, while satin ones are less ly to do so.

Observations among clinic patients reported in the reviewed studies, Aguh says, found that loose, low-hanging styles or even updos are low risk for traction alopecia.

So are natural styles that avoid chemicals and the use of frequent moisturization with conditioning agents.

Untreated and unprocessed hair, she says, can withstand greater traction, pulling and brushing, and overall decreases the risk of traction alopecia, regardless of styling.

In their review, the investigators also offered guidelines for dermatologists and other care providers to prevent and manage hair loss from traction alopecia.

The first line of therapy, they say, is to loosen braids and other high-tension styles, as well as weight on the follicle permanently or periodically.

Braided hairstyles should be in place no longer than two to three months, they say, and weaves and extensions should also be removed for a period of time after six to eight weeks.

The investigators also recommend people alternate styles, mainly reducing or avoiding updos, to allow follicles to recover from stress.

“Dermatologists need to be conscious of the fact that many high- and moderate-risk hairstyles greatly improve hair manageability, and simply telling patients to abandon them won't work for everyone,” says Aguh. “Instead, physicians can educate themselves to speak with patients about making the best hairstyling choices to minimize preventable hair loss.”

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Hair Loss Specialist

Baldness (Alopecia) | Johns Hopkins Medicine

Most people shed 50 to 100 hairs every day. This normal process doesn’t cause a noticeable thinning of scalp hair because new hair is always growing in to replace the hair that falls out. Hair loss occurs when this normal cycle of growth and shedding is disrupted.

The most common cause of hair loss among both genders is, by far, having a genetic predisposition. Male-pattern baldness, which is typified by a bald spot or a receding hairline and is highly influenced by heredity, can begin as early as puberty. Female-pattern baldness generally takes the form of thinning hair, but may also include a receding hairline.

Women may also experience hair loss caused by certain lifestyle factors, including childbirth, extreme stress, and poor nutrition.

Medical causes that contribute to hair loss in women include:

Thyroid problems: Hair loss can occur when too much or too little of the thyroid hormone is produced.

Polycystic ovary syndrome: PCOS is caused by a chronic hormonal imbalance and has numerous potential side effects, including hair loss.

Alopecia areata: With this condition, the body’s own immune system mistakenly attacks healthy hair follicles and causes hair to fall out in patches.

How is hair loss treated?

Unless the cause of your hair loss is already known, your doctor will start by testing for thyroid problems and hormone imbalances. If you do have some kind of imbalance or dysfunction, addressing the hormone or thyroid issue that’s causing your hair loss will usually result in regrowth.

When a hormonal imbalance isn’t part of the problem, you may be able to slow hair loss and stimulate regrowth with medications such as topical minoxidil, oral finasteride (for men only), or cortisone medications. For hair loss that can’t be addressed medically, hair transplants are an option.

What conditions do hair loss medications treat?

Hair loss medications are designed to treat hair loss stemming from specific conditions. The most common hair loss medications and their uses are:

Topical minoxidil: This medication, which stops hair from thinning and stimulates new growth, is used to address male and female pattern baldness, alopecia, and rapid hair loss resulting from medical treatment. The foam or liquid is applied directly to your scalp twice a day, and it may take several months before your hair is noticeably thicker. 

Oral finasteride: This prescription medication addresses male pattern baldness by slowing hair loss and stimulating regrowth. It works by inhibiting the production of a hormone that destroys hair follicles. It’s taken once daily by mouth and works best if it’s taken at the same time each day.

Corticosteroids: These prescription medications are used to treat hair loss caused by alopecia areata and other autoimmune conditions. They counteract the effects of an autoimmune disease to allow hair regrowth. They’re available in both topical and injectable form.


Baldness (Alopecia) | Johns Hopkins Medicine
The idea of thinning hair may conjure images of balding men with awkward comb-overs, but approximately 40 percent of sufferers are female.

Losing around 100 strands daily is normal; if your hair is coming out by the handful or your scalp is showing through, it's time to get help. And there is help. Female pattern hair loss (FPHL), called androgenetic alopecia, is the most ly cause.

Your derm will probably recommend a topical product with minoxidil, typically the first line of defense.

Other treatments include spironolactone, finasteride, platelet-rich plasma injections, and hair transplantation, when your doctor moves hair-producing follicles from the back of the head to sparse areas. If FPHL has been ruled out, however, your age can help pinpoint the culprit.


Possible cause: Pregnancy. As many as half of postpartum women notice “a massive loss of hair around two or three months after giving birth,” says Lisa Ishii, MD, a hair restoration expert at Johns Hopkins Medicine in Baltimore.

During pregnancy, an increased number of hair follicles shift to a resting cycle and stop shedding, “so for nine months, you're holding on to hair you otherwise would have lost,” Ishii explains. After you have the baby and your hormone levels return to normal, that extra hair can drop all at once.

Another cause could be an underactive thyroid, though additional symptoms, constipation and weight gain, are also usually present.

Treatment: Postpartum? You just have to ride it out. But your hair should grow back to its normal fullness. If you suspect you have a thyroid problem, see an endocrinologist to address the underlying condition.


Possible cause: Major psychological stress (the death of a loved one, divorce, job change) or physical stress (a major surgery) may be at the root. “Your body is redirecting energy to give extra support to overworked vital organs rather than to growing your hair,” says Ishii. Stopping birth control can also cause temporary hair loss in some women.

Treatment: If the loss stems from stress, you'll have to wait for hair to begin to fill out again (don't worry, it will). In the meantime, it may be helpful to discuss the cause of your anxiety with a therapist—and consider practicing known destressors yoga and meditation.

IN YOUR 50s AND 60s

Possible cause: Frontal fibrosing alopecia (FFA), a disease associated with inflammation of hair follicles, is rare but on the rise, says Lynne Goldberg, MD, director of the hair clinic at Boston Medical Center. It commonly takes out your frontal hairline and eyebrows.

Treatment: If you suspect FFA, see a doctor as soon as possible: “The earlier you address the condition with topical and systemic anti-inflammatory medications, the more hair you can save,” Goldberg says. Now…get growing.


Baldness (Alopecia)

Baldness (Alopecia) | Johns Hopkins Medicine

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Baldness is hair loss, or absence of hair. It’s also called alopecia. Baldness is usually most noticeable on the scalp, but can happen anywhere on the body where hair grows. The condition is more common in men than in women.

What causes baldness?

Hair loss is believed to be caused by a combination of the following:

  • Aging

  • Change in hormones

  • Illness leading to shedding of hair (called telogen effluvium)

  • Family history of baldness

  • Burns

  • Injury

  • Untreated ringworm of the scalp

  • Iron or protein deficiency

  • Excess vitamin A intake

  • Rapid weight loss

  • Certain medicines, such as cancer chemotherapy

  • Certain medical conditions, such as lupus

However, hair loss is not caused by the following:

  • Poor circulation to the scalp

  • Dandruff

  • Wearing hats

Generally, the earlier hair loss begins, the more severe the baldness will become.

What are the symptoms of baldness?

Depending on the type, the symptoms of baldness will vary. There are several types of baldness including:

  • Female-pattern baldness. Although less common, female-pattern baldness differs from that of male-pattern baldness in that the hair generally thins all over the head. The hairline is maintained. Female-pattern baldness rarely results in total hair loss.

  • Male-pattern baldness. Male-pattern baldness is usually inherited. The condition may begin at any age. Hair loss often begins on the front, sides, or on the crown of the head. Some men may develop a bald spot or just a receding hairline. Others may lose all of their hair.

  • Alopecia areata. This hair loss disorder is characterized by sudden loss of hair in one particular area. The hair grows back after several months. However, if all body hair is suddenly lost, regrowth may not happen.

    The exact cause of this type of hair loss is unknown. There is a genetic link as well as a link with autoimmune conditions and allergies.

    If hair loss is complete on the scalp, it is called alopecia totalis, and if all body hair is lost, it is called alopecia universalis.

  • Toxic alopecia. Toxic alopecia may happen after a high fever or severe illness. Certain medicines, especially thallium, high doses of vitamin A, retinoids, and cancer medicines may also cause it. Medical conditions, such as thyroid disease, and giving birth may also trigger toxic alopecia. The condition is characterized by temporary hair loss.

  • Scarring or cicatricial alopecia. Scarred areas may prevent the hair from growing back. Scarring may happen from burns, injury, or X-ray therapy. However, other types of scarring that may cause hair loss can be caused by diseases. These include lupus, bacterial or fungal skin infections, lichen planus, sarcoidosis, tuberculosis, or skin cancer.

  • Trichotillomania (hair pulling).Hair pulling may cause hair loss. This condition is common in young children.

How is baldness diagnosed?

In addition to a medical history and physical exam, a punch biopsy of the skin may help to identify the type of baldness and/or its cause. A culture may be done if infection is suspected.

How is baldness treated?

Your healthcare provider will figure out the best treatment for you :

  • How old you are

  • Your overall health and past health

  • How sick you are

  • How well you can handle specific medicines, procedures, and therapies

  • How long the condition is expected to last

  • Your opinion or preference

Most forms of baldness have no cure. Some types of baldness will go away without treatment. Treatment may include:

  • Certain medicines to promote hair growth (such as minoxidil and finasteride)

  • Corticosteroid injections (when treating alopecia areata or other inflammatory diseases that lead to hair loss)

  • Treating any underlying condition or disease

  • Hair transplants

  • Scalp reduction

  • Skin lifts and grafts

Hair Replacement Surgery

The interest in hair replacement has gone up over the past several years. There are a number of hair replacement techniques available. But, hair replacement surgery can’t help those with total baldness.

Candidates for hair replacement must have a healthy growth of hair at the back and sides of the head. The hair on the back and sides of the head will serve as hair donor areas where grafts and flaps will be taken.

There are 4 primary different types of hair replacement methods, including the following:

  • Hair transplant. During a hair transplant, the surgeon removes small pieces of hair-bearing scalp from the back or sides of the head to be used as grafts. These grafts are then relocated to a bald or thinning area.

  • Scalp expansion. In this procedure, a device called a tissue expander is placed underneath a hair-bearing area that is located next to a bald area. After several weeks, the tissue expander causes the skin to grow new skin cells. Another operation is then needed to place the newly expanded skin over the adjacent bald spot.

  • Flap surgery. Flap surgery is ideal for covering large balding areas. During this procedure a portion of the bald area is removed and a flap of the hair-bearing skin is placed on to the bald area while still attached at one end to its original blood supply.

  • Scalp reduction. Scalp reduction is done to cover the bald areas at the top and back of the head. It involves first removing the bald scalp. Then sections of the hair-bearing scalp are pulled together filling in the bald area. This can be done alone or with hair transplantation.

What are the complications of baldness and hair transplantation procedures?

Baldness may lower cause self-esteem. There are complications associated with hair transplantation procedures that include:

  • Patchy hair growth. Sometimes, the growth of newly placed hair has a patchy look, especially if it is placed next to a thinning area. This can often be fixed with more surgery.

  • Bleeding and/or wide scars. Tension on the scalp from some of the scalp reduction techniques can cause wide scars and/or bleeding.

  • Grafts not taking. Occasionally, there is a chance that the graft may not “take.” If this is the case, surgery must be repeated.

  • Infection. As with any surgical procedure, there is the risk of infection.

Key Points about Baldness

  • Baldness, also known as alopecia, is hair loss, or absence of hair.

  • Baldness is usually most noticeable on the scalp, but can happen anywhere on the body where hair grows.

  • Treatment for baldness depends on the type of baldness and its underlying cause.

  • Most forms of baldness have no cure. Some types of baldness will disappear on their own.

  • It is important to talk with your healthcare provider about your baldness and how it can be treated.