Hair Loss in Women: More than Meets the Eye

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At least half of women in the U.S. will experience some form of hair loss by the time they are 50 years old. The most common types often occur with greatest frequency at a time in life when women are experiencing other life stressors such as menopause, empty nest syndrome and the aging of their parents.

Hair loss can be frightening for women since it is often unclear how much hair will be lost when it begins. Hair may cease being a “crowning glory” for the affected woman and may require an adjustment in how she perceives herself and how she presents herself. Fortunately, help is available through an appointment with a dermatologist, a physician trained in the diagnosis and treatment of hair loss.

Speaking today at the 64th Annual Meeting of the American Academy of Dermatology, dermatologist Elise A. Olsen, M.D., professor of medicine/dermatology at Duke University in Durham, N.C., discussed the three most common types of hair loss in women.

"Women are generally unclear as to why they are experiencing hair loss and often go to the Internet searching for remedies, most of which are ineffective and unnecessarily expensive,” stated Dr. Olsen. “Women need to see a dermatologist when they develop hair loss to make sure that it is not coming from an undiagnosed medical problem and a dermatologist can educate them on ways to minimize or reverse hair loss.”

Hair Loss in Caucasian Women
Different ethnic groups experience different types of hair loss. One of the most common types of hair loss in Caucasian women is telogen effluvium, which is characterized by increased shedding of hair over the entire scalp. Hair is lost when combing, brushing and washing the hair. This type of hair loss may be caused by thyroid, hormonal, nutritional or age-related factors, as well as medications being taken or underlying disease. This also is the type of hair loss that pregnant women experience following the birth of their baby. “The treatment and cure for telogen effluvium is to find the underlying problem which initiated the hair loss,” said Dr. Olsen.

Another common type of hair loss experienced by Caucasian women is female pattern hair loss. This condition can begin early (teenage years to the early 20s) or late (early 40s to 50s) and is characterized by the loss of hair on the top of the scalp, but not the back of the scalp. The hair becomes finer because the individual hairs are smaller or “miniaturized.” The overall density may decrease so dramatically that women may notice that their ponytail is smaller or that they can now easily see their scalp when they style their hair. Some women with female pattern hair loss also have hirsutism, which is the growth of hair in the beard or moustache area, or persistent acne or irregular menstrual cycles.

Some women with female pattern hair loss, particularly those with other medical conditions, may have androgen -a male hormone such as testosterone- sensitivity causing these problems. Women with this pattern of hair loss should be evaluated with special blood tests to determine their androgen levels. In some cases, female pattern hair loss may be the first sign of an underlying type of diabetes that is more frequent in women with elevated androgens in the blood. “Women with female pattern hair loss should see a dermatologist to determine if their hair loss is associated with underlying hormonal or endocrine problems,” said Dr. Olsen. “If these are present, then the hair loss will require addressing these problems first.”

Topical minoxidil is one treatment for women with female pattern hair loss, but it must be applied to the scalp twice a day for at least four months before the patient will see results. “Minoxidil actually works by stimulating hairs that are not functioning well or actively growing to have more robust active growth,” described Dr. Olsen. Topical minoxidil is currently the only hair regrowth treatment for women approved by the U.S. Food and Drug Administration (FDA).

“In general, female pattern hair loss is a potentially reversible problem, but in a small population of women, it can proceed to irreversible hair loss, or cicatricial pattern hair loss,” said Dr. Olsen. “Early diagnosis by a dermatologist and treatment are the keys to successful results when dealing with female pattern hair loss.”

Hair Loss in African-American Women
Women of African descent have a different, but just as common, type of hair loss called central centrifugal cicatricial alopecia (CCCA). This type of hair loss also results in loss on the top of the scalp, while sparing the back of the scalp. It is different than female pattern hair loss as the hair follicles have a tendency to be destroyed, not just miniaturized. Once a hair follicle is destroyed, regrowth is not possible. Thus, women with this type of hair loss are at risk for, and frequently develop, cicatricial or permanent hair loss and should seek evaluation by a dermatologist as soon as possible.

Patients with CCCA will usually need a biopsy of their scalp, a simple office procedure done in a dermatologist’s office, to make the diagnosis.

Treatment for CCCA usually begins with treating any infection and using anti-inflammatory medications to decrease or eliminate the inflammatory cells that are attacking and destroying the hair follicle. Topical minoxidil also may be used to stimulate the growth in any unscarred hair follicles.

It is currently unknown what causes this type of hair loss, but there is current research being conducted to determine if hair care practices may be involved. African-American women use relaxers, hot combs, heat and ointments on their scalps and frequently wear tight braids or use heavy extensions that Caucasian women do not. Whether these hair care practices cause or merely contribute to the process is uncertain. Other causes that are being researched are different types of infection or hereditary factors that may be more common in African-American women.

“A dermatologist is the expert to best diagnose the underlying cause when hair loss occurs and will perform a thorough history, examine the scalp and may in some cases do blood work or a scalp biopsy in order to determine the treatment options that will maximize results for the patient,” said Dr. Olsen. “I encourage anyone with concerns about hair loss to schedule an appointment with a dermatologist.”

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