Hair loss in female patients in the vast majority of cases require a more systematic and comprehensive approach when compared to dealing with male pattern hair loss. In men we deal mostly with Androgenetic Alopecia which follows a pattern distribution. A very effective approach was shown to me by one of my colleagues, Dr. Paul McAndrews who uses the Hair Loss Algorithm. Firstly, we determine if there is any Hair Breakage. Hair Breakage can be caused via genetic mechanisms or mechanical factors that cause hair shaft abnormalities and weaknesses. Mechanical factors include physical or chemical manipulation of hair such as when using relaxers (eg formaldehyde in Brazilian type relaxers), dyes, hot combs, curlers and excessive brushing.

Once hair breakage has been excluded, we consider conditions which are called True Hair Loss. Firstly we exclude Scarring Alopecias. These are conditions where scar tissue formation results after destruction of hair follicles which can be caused by a primary mechanism, such as an auto-immune type reaction where the body’s immune system accidentally targets and destroys hair follicles or it can be of secondary origin, caused by infections, tumours, trauma, traction or inflammatory processes. In scarring alopecias the destruction of hair follicles are permanent and hair transplant surgery is less often performed as a treatment modality however it can be done in special circumstances. Clinically active primary scarring alopecias present as areas of hair loss with complete absence of follicular markings on the skin, and sometimes there are accompanying symptoms and signs such as redness of the skin, itching, burning, scaling and peri-follicular tufting. The diagnosis is mostly confirmed via a skin biopsy and histology reporting.

Once scarring alopecias have been excluded, hair loss caused by shedding of hairs is considered. This includes conditions such as Telogen Effluvium, Anagen Effluvium and Loose Anagen Syndrome. Hair grows in cycles and there is a growth cycle called the Anagen phase which lasts on average 3 years, then there is a resting cycle called the Telogen phase and this lasts on average 3 months and a short transition cycle called the Catagen phase which lasts about two weeks. On the average scalp approximately 10% of all hair follicles are in the resting or Telogen phase. This will occur in a random or mosaic pattern, meaning those follicles in the Telogen phase are scattered randomly all over the scalp and that is why we are not aware that at least 10% of our hair shafts have shed at any given moment. During stressful situations more than the average 10% of hair follicles may go into the resting phase and this will cause excess shedding of hairs which is called Telogen Effluvium. In most cases of Telogen Effluvium it recovers after about 6 to 12 months. If not, it is called Chronic Telogen Effluvium. Hairs can also be shed during the growth or Anagen cycle, but this is very rare. There are specific conditions that may cause Anagen Effluvium, such as when patients are treated with radiotherapy for cancer treatment, or with Alopecia Areata (auto-immune condition that causes patchy transient hair loss), or Scarring Alopecias, or with Loose Anagen Syndrome where there is a defective mechanism attaching the hair shaft’s outer root sheath to the epidermis. It is also seen in cases of Trichotillomania (patients who actively pull their hair out as a consequence of a chronic anxiety state), Traction Alopecia, because of long term traction on follicles due to braides, hair extensions, dreadlocks etc and also from heavy metal poisoning with Mercury, Thallium, Nickel, Arsenic and Copper.

When hair loss via shedding has been excluded, we then move on to Non-Shedding hair loss causes. Under this section causes of Focal or Patterned Hair loss and Diffuse Hair or Non Patterned hair loss are considered. Causes of Focal or Patterned hair loss include Androgenetic Alopecia (Male Pattern Baldness and Female Pattern Hair Loss), infections, trauma, Alopecia Areata, Hair breakage, Traction Alopecia, Trichotillomania and developmental conditions such as Triangular Alopecia.

Causes of Difffuse Hair loss include, Alopecia Totalis, Alopecia Universalis, Chronic Telogen Effluvium secondary to chronic illnesses, or recent surgery or the use of medication for longer than 6 months. Also, conditions such as Diffuse Alpecia Areata, Loose Anagen Syndrome and hair shaft breakage caused by genetic hair shaft disorders, physical and chemical processing can cause diffuse hair loss. Furthermore, conditions that result in low levels of Zinc, Iron, Vit D, Biotin and hyper or hypo-thyroidism can also cause diffuse hair loss.

By following a systematic clinical approach that includes a thorough history, a systemic physical examination, a scalp examination, a range of blood tests and often a scalp biopsy we are able to make a diagnosis via this process of elimination and then the underlying condition can be treated.

– Dr. Paul McAndrews lecture at ISHRS conference 2011, Anchorage, Alaska and Hair Transplant Forum International Magazine Article
– Disorders of Hair Growth, Diagnosis and Treatment, Elise A. Olsen
– Hair Transplantation, 5th Edition, Unger, Shapiro
– Cicatricial Alopecia, An approach to diagnosis and management, Price; Mirmirani

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