One of the commonest complaints I see is increased amount of hair coming out which is most often noticed at the time of washing or brushing. This usually points to a disturbance of the hair cycle or telogen effluvium. Normally 80-90% of all hair should be in the “Anagen” growth phase. Each hair has it’s own cycle and the growth phase lasts for several years before going through a short regression phase and then a two to three month resting phase (Telogen). At times of life, or following physical or psychological illness, the hair cycle can be disturbed. Hairs can synchronise together and all leave the growing phase at the same time, leading to an increased percentage of hairs reaching telogen and then coming out.
A good medical history and examination may point to the underlying cause. Sometimes blood tests can point to an underlying reason, for example low iron stores. And sometimes there is no obvious cause to be found and management turns to ways of trying to promote hair growth and decrease the amount coming out.
One can assess the percentage of hairs in the different parts of the cycle using a trichogram, either using a forced pluck or using video trichoscopy. The latter involves two appointments. Firstly, a small 10p coin size area of hair is shaved. This is usually a discrete area that can easily be covered. After 48 hours, a hair dye is applied to the shaved area for 15 mins and then wiped off. A 20x image is recorded using the Fotofinder Medicam, and the percentage of hairs that have grown in the 2 days is calculated. From this one can deduce the percentage of hairs in each part of the cycle as well as a number of other useful parameters.
Alopecia Areata is a type of hair loss that causes bald patches, usually in the scalp. It is thought to be an autoimmune condition (where the body’s immune system mistakes a part of the body as foreign). Immune (defense) cells attack the growing hair roots, causing them to become inflamed and hair to fall out. This can become more widespread and involve the entire scalp or the whole body.
“My hairdresser had noticed a couple of patches of hair loss and advised me to see my GP. She prescribed a steroid cream to use but it was pretty messy and didn’t seem to do anything. After searching on the internet I found that Dr Farrant specialised in hair conditions and booked an appointment with him. Dr Farrant diagnosed me with alopecia. He explained the nature of the condition and the latest understanding as to why patients get it. He recommended a steroid injection into the areas of hair loss and within a few weeks there was new hair growing back. I had a repeat injection after six weeks and now the area has grown completely. Having been previously dismissed, it was wonderful to see someone really interested and generous with his time.”
Both men and women can experience hair thinning with age and this may run in families. Men typically thin in the bitemporal region (either side of the head above the temples) and the crown (top of the head). These areas sometimes join to leave a horseshoe area of hair just around the sides of the head. Women often thin over the top of the head, known as the vertex, but this does not normally affect hair at the front of the head and it is unusual for them to become completely bald.
Male pattern hair loss (MPHL) is well understood and is influenced by a hormone called dihydrotestosterone, which can make the hair follicle smaller (miniaturisation) and affect the growing structure of the hair fibre. Eventually the resulting hair fibre becomes thinner and thinner until the area becomes bald.
The miniaturisation process in women is very similar but the role of hormones in this condition is less well understood.
“I had been aware of my hair thinning on the top for some time. I could see the pink of my scalp showing through and it was really affecting my confidence. I had been to a well-known clinic in London and had been using their own (rather expensive!) treatments for some time, but wanted to get an expert opinion.
Dr Farrant took a very thorough history and then examined and photographed my hair. Dr Farrant diagnosed me with female pattern hair loss and went through the different treatments that were available and the evidence behind them. It was refreshing that there was no commercial selling of products and I was shocked that I could buy a very similar product to the one that I had been using for a fraction of the cost! Dr Farrant also went through various camouflage techniques with me, which were really useful.”
Occasionally, the hair follicle structure can be destroyed by inflammation or trauma to the scalp. This results in the growing structure being replaced by scar tissue and permanent hair loss. Some inflammatory skin conditions such as discoid lupus and lichen planopilaris lead to progressive scarring hair loss. An accurate diagnosis and prompt treatment is necessary to prevent further hair loss.
“My GP had initially diagnosed me as having a fungal infection of my scalp and had given me an anti-fungal shampoo. It was clear that Dr Farrant knew something more serious was going on and he told me that some of the hairs had been destroyed. He carried out a biopsy of the scalp.
The results confirmed his initial diagnosis of a condition called lichen planopilaris. I’ve been started on a strong steroid lotion and an anti-malarial tablet and all the itching has got better and the skin is less red. I know there is no chance of the hair coming back, but I know a hair expert is looking after me and hopefully we can limit this condition so it doesn’t get any worse.”
Dr Farrant offers extensive investigations for hair loss. These will vary depending on the type of hair loss or scalp problem. They include blood tests, hair microscopy, scalp biopsies, tricholab assessment of hair thinning and video trichoscopy for hair shedding.
Scalp biopsies involve two 4 mm cores of skin and hair being removed under local anaesthetic. This test is used to diagnose inflammatory scalp and hair conditions, particularly ones that attack and destroy the hair follicles.
Tricholab assessment involves a series of magnified photos taken from the top, the side and the back to look at the hair fibre diameter and arrangement of the hairs. It is particularly useful in the diagnosis and management of pattern hair loss and response to treatments. The images are sent securely to tricholab and a printed report is available within a week. This assessment can be carried out in advance of a clinic appointment so that results are available for discussion.
Video trichoscopy involves two appointments 48 hours apart. A small area is shaved from somewhere discreet that can easily be covered by surrounding hairs. At the second appointment a hair dye is applied to the shaved area and washed off after 15 minutes. Using the Fotofinder medicam, a trichoscopic image is taken of the shaved area that calculates the percentage of hairs that have grown in the 48 hour period. This calculates the percentage of hairs in each part of the growing cycle and is really useful for hair cycling and shedding problems.
Hair treatments include steroid injections, immunosuppressive therapies, contact immunotherapy, hair growth stimulants and hormonal manipulation.
Steroid injections are used for localised alopecia areata and limited scarring hair loss conditions.
Immunosuppressive therapies vary from prednisolone to methotrexate to use of JAK inhibitors, the latest and most effective treatment for Alopecia Areata.
Contact immunotherapy is used as a treatment for alopecia areata and involves stimulating the immune system in the skin surface using either an irritant chemical applied to the skin surface, typically Dithranol or using an allergic chemical, typically Diphencyprone. Dithranol is applied to the areas of hair loss on a daily basis for a specified amount of time. Gradually the time and strength is increased until a mild scalp irritation is achieved. This needs to be continued for at least 3 months. Diphencyprone requires weekly application of a chemical that is also gradually increased in strength.
Hair growth stimulants vary from Minoxidil, a chemical that pushes hair into the growth part of the hair cycle, to low level laser light and to platelet rich plasma injections. They are used for pattern thinning, disturbances of the hair cycle and occasionally Alopecia Areata and scarring conditions.
Hormonal manipulation is predominantly used for pattern hair loss, particularly in young female patients and men.
Dr Farrant is a principle investigator in a number of clinical trials. These are conducted at the Clinical Investigation and Research Unit at the Royal Sussex County Hospital. Present studies include the use of JAK inhibitors in the treatment of alopecia areata. The current studies are aimed at patients with extensive hair loss (>50%) but a second study about to start recruiting will be including patients with 25% loss or more. There are also planned studies for patchy alopecia that had to be deferred due to the Covid 19 outbreak that may be starting in late 2020 or early 2021.