Balding

Introduction

Alopecia is loss of hair and sometimes baldness.

In some cases, hair loss is a side effect of cancer treatment drugs, in which case it is usually only temporary.

However, any type of hair loss can lead to problems with confidence and self-esteem. The main types of hair loss are summarised below.

Male-pattern baldness

The commonest form of hair loss is male-pattern baldness, called androgenic alopecia. This can affect both men and women. 

Alopecia areata

Alopecia areata is another type of hair loss, involving patches of baldness that may come and go. It affects about one in 100 people, mostly teenagers and young adults, and it runs in the family in one in five cases.

Alopecia areata is thought to be caused by a problem with the immune system. There is no proven effective treatment, but in most cases the hair grows back after about a year.

One in five people with alopecia areata may go on to develop a more severe form of hair loss – alopecia totalis (no scalp hair) or alopecia universalis (no hair on the scalp and body).

Telogen effluvium

Telogen effluvium is a common type of alopecia where there is widespread thinning of the hair, rather than specific bald patches. Hair is shed from the scalp and from other areas of the body, usually as a reaction to stress or medication. Telogen effluvium tends to go away on its own after several months.

Last updated: 04 October 2011

Symptoms of hair loss

The symptoms of the different types of hair loss are outlined below.

Male-pattern baldness

Male-pattern baldness is hereditary, which means it runs in families. It usually starts around the late twenties and thirties. By the late thirties, most men have some degree of hair loss.

Male-pattern baldness is so called because it generally follows a set pattern. The first stage is usually a receding hairline, followed by thinning of the hair on the crown and temples. This can leave a horseshoe shape of hair around the back and sides of the head. It can progress to complete baldness, but this is rare.

Women's hair gradually thins with age, but women generally lose hair from the top of the head only. This usually gets more noticeable after the menopause.

Alopecia areata

Alopecia areata causes patches of baldness that are about the size of a large coin. They usually appear on the scalp but can occur anywhere on the body, including the beard, eyebrows and eyelashes. There are usually no other symptoms.

Hair often grows back with alopecia areata, but it appears fine and white before it regains its original colour. This hair can be dyed, if necessary.

Last updated: 04 October 2011

Causes of hair loss

The human head has on average 100,000 hairs. Hair is made in hair follicles, the roots of the hair. Each hair grows for about three years, then it drops out and a new one grows. We lose 40-120 hairs a day.

DHT

Male-pattern and female-pattern baldness is caused by oversensitive hair follicles. This is linked to the hormone dihydrotestosterone (DHT), which is made from the male hormone testosterone. If there is too much DHT, the follicles react to it and the hair becomes thinner and grows for less time than normal. The balding process is gradual because different follicles are affected at different times.

Immune system imbalance

Alopecia areata is linked to an imbalance in the immune system. The hair follicles are not permanently damaged, and in many cases the hair grows back in a few months. It runs in the family in one in five cases.

Other causes

Some conditions such as anaemia (disorder of the blood), illness, stress (including bereavement), fungal infections and thyroid problems can make you lose some of your hair, as well as drug treatment for cancer. Women who are pregnant or have recently given birth may also experience some hair loss.

Glossary

Testosterone
Testosterone is a male sex hormone, which is involved in making sperm and sexual characteristics such as the voice getting deeper. Testosterone is also found in small amounts in women.
Immune system
The immune system is the body's defence system, which helps to protect it from disease, bacteria and viruses.
Blood
Blood supplies oxygen to the body and removes carbon dioxide. It is pumped around the body by the heart.
Thyroid
The thyroid is a jointed piece or cartilage that encloses the vocal cords and forms the laryngeal prominence (Adam’s apple) in men.
Last updated: 04 October 2011

Diagnosing hair loss

Male-pattern baldness is usually easy to identify because of the pattern it follows. It usually begins with a receding hairline in the late twenties or thirties, but can start earlier. At first, you may notice that your hair is starting to get thinner, particularly over the crown.

Female-pattern baldness usually becomes noticeable after the menopause. The hair on top tends to thin first.

If your hair loss does not follow the typical pattern as above, you should see your GP to find out what is causing it. It could be linked to an illness such as anaemia or a fungal scalp infection. Your GP may refer you for more tests or suggest that you see a dermatologist.

With alopecia areata, there are no obvious symptoms other than patches of baldness, so your partner or hairdresser may notice it before you do.

Last updated: 04 October 2011

Treating hair loss

If hair loss is caused by an infection or a condition such as anaemia, treating the infection or condition may prevent further hair loss. In some cases, including after cancer treatment, your hair may start to grow again.

Male-pattern baldness

There are two medicines that are known to be effective in treating male-pattern baldness: finasteride and minoxidil.

Finasteride

Finasteride works by preventing the hormone testosterone being converted to the hormone dihydrotestosterone (DHT). DHT causes the hair follicles to shrink, so blocking its production allows the hair follicles to regain their normal size.

Although more research is needed, studies suggest that two-thirds of men who take finasteride, experience some hair regrowth. In the remaining third, there is no hair regrowth, but most do not experience any further hair loss. It normally takes at least four months of using finasteride before any effect is seen, and the balding process will normally resume if treatment is stopped.

Finasteride is not available on the NHS, but is available on private prescription from your GP. It comes as a tablet that you take every day. Side effects are uncommon, although about two in 100 men who use it experience a loss of sex drive.

Minoxidil

Minoxidil is available as a lotion that you rub on your scalp every day. It is available from pharmacies without prescription. It is not clear how minoxidil works, but studies suggest that the balding process will slow in about half of those men who use it, and that about 15% of those who use it will experience hair regrowth. However, about a third of men who use minoxidil will not see any change in their hair loss.

Like finasteride, minoxidil normally needs at least four months of use before any effect is seen, and the balding process will normally resume if treatment is stopped. Any new hair that does regrow will fall out two months after treatment is stopped. Side effects are uncommon.

Female-pattern baldness

Currently, the only medicine available to treat female-pattern baldness is minoxidil. Minoxidil lotion may help hair to grow in 20-25% of women who use it, and in the majority it may slow or stop the loss of hair.

Other treatments for hair loss include wigs, hair transplants (taking hair from the sides and back of the head) and plastic surgery, such as scalp reduction, where the bald area is removed and the bit with hair on is stretched forward.

Alopecia areata

There is no completely effective treatment for alopecia areata.

However, in about eight out of 10 cases, the hair grows back after about a year without any treatment, so sometimes ‘watchful waiting’ is best, especially if you just have a few small patches.

When treatments are necessary, they tend to have variable results (see below). 

Steroid injections

Steroid injections appear to be the most effective treatment for small patches of alopecia. A steroid solution is injected several times into the bald areas of skin. This stops the immune system from attacking the hair follicles, and it can stimulate hair to grow again in those patches after about four weeks. Injections are repeated every few months. Alopecia may return when injections are stopped.

Topical steroids and steroid tablets

Topical steroids (creams and ointments) are widely prescribed for alopecia areata, but their long-term benefits are not known. There is some evidence that they can make hair regrow.

Steroids can also be taken as tablets, but alopecia often returns when the tablets are stopped, and after a while of taking them they can produce serious side effects, such as diabetes and stomach ulcers. Other possible side effects are itching or hair growth in other areas. 

Minoxidil lotion

Minoxidil lotion is applied to the scalp and can stimulate hair regrowth after two to three months. It is not recommended for those under the age of 16 and is not available on the NHS, but can be prescribed privately or bought over the counter. It can take up to a year for a maximum response.

Immunotherapy

Immunotherapy appears to be the most effective treatment for extensive or total hair loss. A chemical solution called diphencyprone (DPCP) is applied to a small area of bald skin. This is repeated every week, using a stronger amount each time. Eventually, the DPCP causes an allergic reaction and the skin develops mild eczema (dermatitis). With many people, after about 12 weeks, hair then starts to regrow.

A possible side effect is a severe skin reaction, although this can be avoided by increasing the DPCP concentration gradually. Less common side effects include a rash and patchy-coloured skin (vitiligo). In many cases, if treatment is stopped, the hair falls out again, therefore treatment needs to be maintained. Immunotherapy is only available in specialised centres.

Dithranol cream

Similar to immunotherapy, dithranol cream is applied regularly to the scalp and then washed off. It causes a skin reaction, followed by hair regrowth in some cases. It is not as effective as immunotherapy, it can cause itchiness and scaling of the skin, and it can stain the scalp and hair. For these reasons, dithranol is not widely used.

UV light treatment

Two to three sessions of light therapy are given every week in hospital, where the skin is exposed to UVA rays. It can take up to a year to produce maximum results. Responses vary and there is a high relapse rate. Side effects include nausea, pigment changes, and an increased risk of skin cancer, so it is often not a recommended treatment.

Tattooing

Eyebrows can be tattooed over a few hourly sessions. This is known as dermatography, and it generally produces good results.

Wigs

Synthetic wigs:

The cheapest wigs are made from acrylic, and they cost anywhere between £60 and £200.  An acrylic wig lasts for six to nine months and is easier to look after than a wig made of real hair (it does not need styling). However, it can be itchy and hot, and it needs to be replaced more often than a real-hair wig. You may be entitled to receive a free acrylic wig every six months on the NHS.

Real-hair wigs:

Some people prefer the look and feel of a real-hair wig, even though it is more expensive - it costs anywhere between £200 and £2,000.  The wig lasts for three to four years, but is harder to maintain because it may need to be set and styled by a hairdresser, and professionally cleaned. A human-hair wig is only available on the NHS if you are allergic to acrylic, or have a skin condition made worse by acrylic. You may wish to buy your wig privately.

Complementary therapy

Aromatherapy, acupuncture and massage are often used for alopecia, but there is not enough evidence to support their use as an effective treatment.

Glossary

Testosterone
Testosterone is a male sex hormone, which is involved in making sperm and sexual characteristics such as the voice getting deeper. Testosterone is also found in small amounts in women.
Last updated: 04 October 2011

Complications of hair loss

A person with alopecia areata is more likely to have or to develop other autoimmune conditions, such as thyroid disease, diabetes and vitiligo (a condition that produces white patches on the skin). These are all linked to problems with the immune system.

Glossary

Immune system
The immune system is the body's defence system, which helps protect it from disease, bacteria and viruses.
Thyroid
The thyroid is a jointed piece or cartilage that encloses the vocal cords and forms the laryngeal prominence (Adam’s apple) in men.
Last updated: 04 October 2011

Preventing hair loss

If you have inherited the genes responsible for male-pattern or female-pattern baldness, there is not a lot you can do to prevent it happening. The treatment suggestions may slow down the loss, but are not an actual cure.

It is important to remember that hair loss happens to a lot of people as they get older, and there is no need to be embarrassed or depressed about it. If hair loss is making you worried or unhappy, you can see your GP or ask to see a dermatologist. Your local pharmacist may have some useful advice for you as well. Your hairdresser may be able to suggest a flattering haircut for you.

Glossary

Genes
Genes contain information that you inherit from your parents, such as eye or hair colour. They are carried by chromosomes.
Depressed
Depression is when you have feelings of extreme sadness, despair or inadequacy that last for a long time.
Last updated: 04 October 2011