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Treatment Options

How is Alopecia Areata Treated?

While there is neither a cure for alopecia universalis nor drugs approved for its treatment, some people find that medications approved for other purposes can help hair grow back, at least temporarily. The following are some treatments for alopecia universalis. Keep in mind that while these treatments may promote hair growth, none of them prevent new patches or actually cure the underlying disease. Consult your health care professional about the best option for you.

  • Corticosteroids: Corticosteroids are powerful anti-inflammatory drugs similar to a hormone called cortisol produced in the body. Because these drugs suppress the immune system if given orally, they are often used in the treatment of various autoimmune diseases, including alopecia universalis. Corticosteroids may be administered in three ways for alopecia universalis:
    • Local injections: Injections of steroids directly into hairless patches on the scalp and sometimes the brow and beard areas are effective in increasing hair growth in most people. It usually takes about 4 weeks for new hair growth to become visible. Injections deliver small amounts of cortisone to affected areas, avoiding the more serious side effects encountered with long-term oral use. The main side effects of injections are transient pain, mild swelling, and sometimes changes in pigmentation, as well as small indentations in the skin that go away when injections are stopped. Because injections can be painful, they may not be the preferred treatment for children. After 1 or 2 months, new hair growth usually becomes visible, and the injections usually have to be repeated monthly. The cortisone removes the confused immune cells and allows the hair to grow. Large areas cannot be treated, however, because the discomfort and the amount of medicine become too great and can result in side effects similar to those of the oral regimen.
    • Oral corticosteroids: Corticosteroids taken by mouth are a mainstay of treatment for many autoimmune diseases and may be used in more extensive alopecia areata. But because of the risk of side effects of oral corticosteroids, such as hypertension and cataracts, they are used only occasionally for alopecia areata and for shorter periods of time.
    • Topical ointments: Ointments or creams containing steroids rubbed directly onto the affected area are less traumatic than injections and, therefore, are sometimes preferred for children. However, corticosteroid ointments and creams alone are less effective than injections; they work best when combined with other topical treatments, such as minoxidil or anthralin.
  • Minoxidil (5%): Rogaine: Topical minoxidil solution promotes hair growth in several conditions in which the hair follicle is small and not growing to its full potential. Minoxidil is FDA-approved for treating male and female pattern hair loss. It may also be useful in promoting hair growth in alopecia areata. The solution, applied twice daily, has been shown to promote hair growth in both adults and children, and may be used on the scalp, brow, and beard areas. With regular and proper use of the solution, new hair growth appears in about 12 weeks.
  • Anthralin: Psoriatec: Anthralin, a synthetic tar-like substance that alters immune function in the affected skin, is an approved treatment for psoriasis. Anthralin is also commonly used to treat alopecia areata. Anthralin is applied for 20 to 60 minutes (“short contact therapy”) to avoid skin irritation, which is not needed for the drug to work. When it works, new hair growth is usually evident in 8 to 12 weeks. Anthralin is often used in combination with other treatments, such as corticosteroid injections or minoxidil, for improved results.
  • Sulfasalazine: A sulfa drug, sulfasalazine has been used as a treatment for different autoimmune disorders, including psoriasis. It acts on the immune system and has been used to some effect in patients with severe alopecia areata.
  • Topical sensitizers: Topical sensitizers are medications that, when applied to the scalp, provoke an allergic reaction that leads to itching, scaling, and eventually hair growth. If the medication works, new hair growth is usually established in 3 to 12 months. Two topical sensitizers are used in alopecia areata: squaric acid dibutyl ester (SADBE) and diphenylcyclopropenone (DPCP). Their safety and consistency of formula are currently under review.
  • Oral cyclosporine: Originally developed to keep people’s immune systems from rejecting transplanted organs, oral cyclosporine is sometimes used to suppress the immune system response in psoriasis and other immune-mediated skin conditions. But suppressing the immune system can also cause problems, including an increased risk of serious infection and possibly skin cancer. Although oral cyclosporine may regrow hair in alopecia areata, it does not turn the disease off. Most doctors feel the dangers of the drug outweigh its benefits for alopecia areata.
  • Photochemotherapy: In photochemotherapy, a treatment used most commonly for psoriasis, a person is given a light-sensitive drug called a psoralen either orally or topically and then exposed to an ultraviolet light source. This combined treatment is called PUVA. In clinical trials, approximately 55 percent of people achieve cosmetically acceptable hair growth using photochemotherapy. However, the relapse rate is high, and patients must go to a treatment center where the equipment is available at least two to three times per week. Furthermore, the treatment carries the risk of developing skin cancer.
  • Alternative therapies: When drug treatments fail to bring sufficient hair regrowth, some people turn to alternative therapies. Alternatives purported to help alopecia areata include acupuncture, aroma therapy, evening primrose oil, zinc and vitamin supplements, and Chinese herbs. Because many alternative therapies are not backed by clinical trials, they may or may not be effective for regrowing hair. In fact, some may actually make hair loss worse. Furthermore, just because these therapies are natural does not mean that they are safe. As with any therapy, it is best to discuss these treatments with your doctor before you try them.

Hypothyroidism and Thyroid Hair Loss in Women

Claire, one of our lovely forum members, put together this incredibly informative post on hypothyroidism, TSH levels and doctors…

Just a little background. I was diagnosed with Hypothyroid in June of 2005. After over a year of fighting with doctors I finally reached a TSH level below 3.0 in August of 2006.

I am not a doctor, nor a health professional. I’ve read, experimented, and suffered through this thyroid maze. As I would say if you came to me with someone else information, please take everything I say about my treatment with a grain of salt. What works for me may not work for you, but I feel it’s important to give you an idea of what can be done.

The reason I had so much trouble with doctors is that many of them have been out of med school longer than the newest findings.

As of 2012 the AACE (American Association of Clinical Endocrinologists) published new findings on the correct thyroid levels in most individuals. No longer is the range between .5 and 5.0 but a smaller range of .3 to 3.0

AACE guidelines for correct thyroid levels in women to help find solutions to hair lossThe full AACE Guidelines can be viewed by clicking this link.

What does this mean? That many many doctors are under treating their patients. Even more frightening is that there are doctors who have not been updated on thyroid function for an even longer period of time and think that a TSH level under 10 is appropriate. Luckily those doctors are few and far between. What this teaches us is that educating oneself on ones health matters is most important. We assume that doctors are knowledgable about all health matters. The truth is, scientists and specialists come to new findings every year and general practitioners are the last to know. Doctors are well educated on health matters, unfortunately, they are well educated within the time frame in which they went to medical school. This leaves several years of updated information that they have not had access too. Even more frightening is that many of them dismiss new findings if such information is brought to them by a patient.

Synthroid tablets are a common treatment option for women who suffer from thyroid problems and hair lossIf you are hypothyroid and still suffering with symptoms and your doctor is telling you that your thyroid is functioning normally it is time to start taking control of your situation.

First, obtain a copy of your most recent lab work. Find out what your thyroid levels really are. Second approach your doctor about what issues you are having. If he is unwilling to listen, then you have a couple of options.
A. you can take in a copy of the AACE’s newest research {http://online.liebertpub.com/doi/abs/10.1089/thy.2012.0205?journalCode=thy}, a copy of a checklist of your symptoms {http://thyroid.about.com/cs/hypothyroidism/a/checklist.htm}

If you have any other symptoms that seem abnormal to you, but are not listed, please list them as well. Recently, I’ve discovered that overnight leg cramps is also a symptom of hypothyroid.

B. you can switch doctors.

You may have to do B. anyway, if your doctor is unwilling to work with you. The best thing you can do is request to be sent to an endocrinologist. If your doctor is unwilling to refer you, you are not without hope. Most insurance companies have patient outreach programs. Obtain a copy of your records, including blood tests (you have the RIGHT, by law to get copies of your medical records), a copy of the AACE’s findings, a list of ongoing symptoms and a letter requesting referral to see a specialist. It is possible to go over your doctor’s head in order to do this. You can also switch doctors and request this of your newest doctor. Be warned, even some endocrinologists go by an older TSH scale. If you find this to be so, request a second opinion.

Most important, do not think that the doctor knows more than you. You, and only you truly knows how you feel. Do not worry about offending your doctor. As it is, your doctor doesn’t seem to worry about offending you. You are the boss in this situation. He works for you, if he is unwilling to do his job, then you’ve every right to hire someone else.

Once you find someone willing to work with you ( and if you already have, thank your lucky stars) do not expect your symptoms to alleviate as soon as you start a new dosage. Do not expect your symptoms to alleviate as soon as you reach a healthy TSH level. It’s going to take some time for your body to begin to heal itself. However, you will notice some changes within weeks.

Anatomy image of the thyroid gland courtesy of UpToDate.com

Anatomy image of the thyroid gland courtesy of UpToDate.com

The Thyroid also changes with time. As you begin to reach a healthier TSH level things may plateau and you may have to adjust your meds as needed. It’s not uncommon to reach a healthy TSH level and a few weeks later begin to feel bad. It’s important that within the first year of reaching a healthy TSH goal to be checked every 3 months. After that it’s important to be tested twice a year. Some doctors say only once a year is enough, this is not true. Thyroid levels change with temperature changes. One of the best ideas is to check your thyroid levels a few weeks into the first cold snap of winter and within the first few weeks of summer heat. Many thyroid patients find they need to adjust their dose with the extreme temperatures of both seasons. Cold weather slows thyroid function, hot weather tends to call for less thyroid supplement.

It is also not uncommon for a short period of time in which you have a few of the sensations associated with HypERthyroid upon starting a new dosage. I’ve found the best way to avoid this is to titer up. My doctor is willing to work with me on this. This consists of me cutting pills and slowly adding till I reach my newest dosage level. Thyroid hormone takes time to build within the system. This is why titering up works in many cases. This is also why you do not retest your thyroid till 6-8 weeks after beginning a new dose. If you decide to titer up, do not retest till the 6-8 week mark after you reach your INTENDED dosage. My pm box is always open if you have additional questions about this. It is important to discuss this with your doctor as well. Do not raise your dosage above what he recommends till you’ve had your TSH checked. Then be sure to inform him of anything you intend to do, so that you may have another test lined up.

There is no magic number. Not when it comes to TSH, not when it comes to dosage. The ideal setting is for you and your doctor to work together by using both blood work and how you feel.

When taking thyroid medications it’s important to understand a couple of things. First, any food or vitamins taken with the thyroid med will change the absorption rate of the hormone. Your best bet is to take the thyroid med first thing in the morning and an hour before and after eating. So, no food for an hour on either side of taking your med. Even more important is delaying the taking of vitamins. Especially iron and calcium. Both of those can have an effect on the way your body absorbs the thyroid hormone. It is best to take your vitamins either in the middle of the day (2-3 hours) after your hormone or at night (6-8 hours) before.

If you are the type that has to eat first thing in the morning then know that you must follow the pattern every day. If you eat less than an hour after taking your thyroid hormone then it is important to follow this habit daily. It is also important to stick to a similar breakfast food. For instance if you drink milk, it will have an effect on how your body absorbs the hormone, so it’s important to have dairy at the same time, every day as to keep the hormone absorption similar.

Hair Loss in Women

Her Hair Loss Help has an outstanding Discussion Forum specifically for women with alopecia and other forms of hair lossWomen experience hair loss because of a number of reasons, such as pregnancy, stress, genetics or an illness. Another cause is Alopecia Areata, an autoimmune disorder which results in hair loss.

Women going through any type of hair loss becomes distraught about their changing appearance. Some are comfortable leading their life as someone without hair, but many seek out hair replacement studios to give them back what they have lost.

Unless you yourself have been through sudden and unexpected hair loss, it is nearly impossible to fully understand the emotions that a person must be experiencing. The process going from someone with hair, to someone losing their hair, to someone seeking hair replacement, is a sensitive and personal journey.

Blood Tests to Have Done First for Diagnosing Hair Loss Causes

These are simple blood tests that you should have done if you think that your hair loss may be caused by a chemical deficiencyIt’s easy to get lost in the maze of tests and blood panels that your doctor should require to diagnose the cause of your hair loss. Here is a complete list of blood tests to talk to your physician or dermatologist about at the beginning of your hair loss journey, along with it’s corresponding recommended normal range/level.

Many dermatologists will recommend Rogaine (minoxidil) immediately without spending time reviewing bloodwork and ordering blood panels. It’s okay to remain assertive with your doctor and request a full series of blood tests to rule out any underlying conditions that could be causing your hair loss. Often times, a simple hormonal imbalance or vitamin deficiency can be discovered early with a blood test and you will be well on your way to restoring your hair.

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Vitamin Deficiency:

Simple blood tests to be ordered if you think your hair loss may be caused by a lack of nutrients in your diet.

CBC:
This test will show if you are anemic. Even mild anemia can often cause hair shedding. Look for lower than norm values for Red Cell Count, Hemoglobin.

RBC (Red Blood Count): normal levels: 4.2 to 5.4 mil cell/mcL
WBC (White Blood Count): normal levels: 4500 to 10000 cells/mcL
Hematocrit: normal levels: 36.1 to 44.3%
Hemoglobin: normal levels: 12.1 to 15.1 gm/dl
MCV: normal levels: 80 to 95 femtoliter
MCH: normal levels: 27 to 31 pg/cell
MCHC: normal levels: 32 to 36 gm/dL

Vitamin B12 and B6:
The lack of these vitamins can cause hairloss.
B6: optimum level: 2 to 26 ng/ml
B12: optimum level: 200 to 900 pg/ml

Zinc:
The lack of zinc is a known cause of hairloss. Be careful though, too much of zinc could cause hairloss as well. 😕

Iron:
Serum Iron: optimum level: 60 to 170 mcg/dl
Serum Ferritin: optimum level: 12 to 150 ng/ml
TIBC (Total Iron Binding Capacity): optimum level: 240 to 450 mcg/dl

A lot of hairloss specialists believe that one needs a level of ferritin higher than 40 in order to maintain hair and ferritin above 70 to regrow lost hair. There’s also a lot of opposing points of view, however in general it’s probably a good idea to get your ferritin stores at a proper level. One thing to notice is that TIBC above the norm (above 400) means the lack of iron in the iron stores. TIBC above 400 often corresponds to lower serum ferritin numbers. As ferritin increases, TIBC should drop.

ESR:
ESR: optimum level: >20mm/hr
There’s an article stating that if your ESR is less than 10 you need to considerably increase your serum ferritin level to stop/reverse hairloss.

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Electrolyte Panel:

Blood tests that you should have done prior to and during the administration of anti-androgenic medications such as spirolactone. These tests can also aid in diagnosing adrenal problems.

Sodium: normal levels: 15 to 250 mEq/L/day
Chloride: normal levels: 20 to 25 mEq/day
Potassium: normal levels: 25 to 120 mEq/L/day
CO2: normal levels: 20 to 29 mEq/L

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Thyroid Panel:

Rapid hair loss can be the worst symptom of a thyroid problem

Your thyroid gland is one of the largest endocrine glands in your body. [Image courtesy of SutterHealth.org]

Blood tests that are recommended to diagnose hyperthyroid, hypothyroid and other thyroid related problems.
TSH and T3/T4:
Thyroid conditions often cause hairloss as well. The best TSH value is between 1 and 2. Values above 3 are still considered normal by many labs (the upper level of normal is 5) however it usually indicates an overactive thyroid and should prompt for future evaluation.

TSH (Thyroid Stimulating Hormone): optimum level: .3 to 3.0 mlU/L
** if you are on thyroid medication already, your optimum level SHOULD be between .5 and 2.0 mlU/L
Total T3: optimum level: 100 to 200 ng/dL
Free T3: optimum level: 2.3 to 4.2
Total T4 (Total Thyroxin): optimum level: 4.5 to 12.5 mcg/dL
Free T4 (Free Thyroxin): optimum level: .7 to 2.0

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Auto Immune Testing:

These tests can also aid your physician in giving you a definitive answer as to what is causing your hair loss. They show the possibility of lupus, hashimoto’s, sjoren’s, alopecia areata and other autoimmune disorders.

ANA and Anti-DNA

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Adrenal Function Panel:

These are tests you should have done to rule out adrenal deficiencies which can cause hair loss as well as fatigue, joint and scalp pain.

Cortisol AM:
Cortisol is a stress hormone. Even though there’s no direct link to hairloss, a high cortisol value means the body is under a lot of stress and the adrenal gland is working overtime. This situation shows the ‘fight or flight’ reaction of the body as a result of which a lot of hormonal functions are interrupted. Stress significantly decreases the benefits of ALL the hormones. Moreover, high cortisol values can indicate a possibility of
adrenal tumor.

Cortisol: normal 8am levels: 6 to 23 mcg/dl

Serotonin:
Serotonin: normal levels: 101 to 283 ng/ml

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Hormone Panel:

Visit our online discussion forum to read more topics on hormone imbalances and how it affects hair loss in womenThese are ESSENTIAL blood tests to have done if you believe that you may be experiencing hair loss due to hormonal imbalances.

Estradiol:
For premenopausal woman the lowest estradiol value should be shown on the test taken on the 3rd day of her cycle (the week of her period). Values between 80-90 are preferable, values below 50 show estrogen deficiency. For the rest of the cycle the optimal range is 100-200 (closer to 200 the better). Younger women can produce significantly higher levels of this hormone.

Estradiol: normal levels:
**** Premenopause: 20 to 400 pg/ml
**** Postmenopause: 5 to 25 pg/ml

Total Testosterone:
If the value is above 50, it could potentially cause the situation of adrogen sensitivity, but the more important number is the one for free testosterone.

Total Testosterone: normal levels: 20 to 80 ng/dl

SHBG (Sex Hormone Binding Globulin):
Values around 90 are desirable. Values above 100 are considered too high. High values of SHBG decrease the availability of all the hormones in the body. Higher levels of estradiol are needed to raise SHBG.

Luteinizing Hormone (LH):
Luteininzing Hormone: normal levels: 5 to 20 IU/L

Prolactin:
Prolactin: normal levels: 0 to 20 ng/ml

Free Testosterone:
Values above 1-1.5 are considered on the higher end of normal range. Values closer to 0.5-0.6 are more desirable. Free Testosterone is the result of Total Testosterone divided by SHBG.

Progesterone:
Value above 5 means that woman is ovulating.

Progesterone: normal levels:
**** Pre-ovulation: >1 ng/ml
**** Midcycle: 5 to 20 ng/ml
**** Postmenopausal: >1 ng/ml

Follicle Stimulating Hormone (FSH):
Hormone that regulates production of female hormones. Levels above 15 indicate menopause. Levels of 3 and below usually indicate BCP use. Higher levels of FSH indicate decrease of estradiol production, while lower
levels indicate higher level of estradiol production.

FSH: normal levels:
**** Follicular: 3.5 to 12.5 IU/L
**** Midcycle: 4.7 to 21.5 IU/L
**** Postmenopausal: 25.8 to 134.8 IU/L

DHEA and DHEAS: Some doctors report finding that a high percentage of patients with autoimmune disorders are also deficient in DHEA, and should be tested.

DHEA: normal level for women by age:
18 to 29 years: 62 to 615 ug/dL
30 to 39 years: 52 to 400 ug/dL
40 to 49 years: 44 to 352 ug/dL
50 to 59 years: 39 to 183 ug/dL
60+ years: 11 to 150 ug/dL

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Illustration of glucose molecular structure

Diabetes is a common cause of hair loss due to the build-up of blood sugar in the body when it is not controlled.

Fasting Blood Glucose (also known as a Fasting Blood Sugar): Blood test done after fasting for 8 to 10 hours
Normal glucose tolerance: From 70 to 99 mg/dL (3.9 to 5.5 mmol/L)
Impaired fasting glucose (pre-diabetes): From 100 to 125 mg/dL (5.6 to 6.9 mmol/L)
Diabetes: 126 mg/dL (7.0 mmol/L) and above on more than one testing occasion

Glucose Tolerance Test (OGTT or GTT): Blood test done two hours after a 75-gram glucose drink
[levels below are NOT for gestational diabetes GTT testing]
Normal glucose tolerance: Less than 140 mg/dL (7.8 mmol/L)
Impaired glucose tolerance (pre-diabetes): From 140 to 200 mg/dL (7.8 to 11.1 mmol/L)
Diabetes: Over 200 mg/dL (11.1 mmol/L) on more than one testing occasion

Fasting Insulin: normal levels: 5 to 20 mcU/mL

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Tests that your Dermatologist should do:

** Pull Test
** Scalp Biopsy

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How Can I Cope With the Effects of Alopecia?

Living with hair loss can be hard, especially in a culture that views hair as a sign of youth and good health. Even so, most people with alopecia areata are well-adjusted, contented people living full lives.

The key to coping is valuing yourself for who you are, not for how much hair you have or don’t have. Many people learning to cope with alopecia universalis find it helpful to talk with other people who are dealing with the same problems. More than four million people nationwide have this disease at some point in their lives, so you are not alone. We have a number of women who live with alopecia universalis on a daily basis in our Online Community who can help through message boards and support groups. You can also find others with the disease, the National Alopecia Areata Foundation (NAAF) can help through its pen pal program, message boards, annual conference, and support groups that meet in various locations nationwide.

Wigs and hair extensions are available to help achieve a full head of hair even when you have lost all your hairAnother way to cope with the disease is to minimize its effects on your appearance. If you have total hair loss, a wig or hairpiece can look natural and stylish. For small patches of hair loss, a hair-colored powder, cream, or crayon applied to the scalp can make hair loss less obvious by eliminating the contrast between the hair and the scalp. Skillfully applied eyebrow pencil can mask missing eyebrows.

For women, attractive scarves can hide patchy hair loss; jewelry and clothing can distract attention from patchy hair; and proper makeup can camouflage the effects of lost facial hair. If you would like to learn more about camouflaging the cosmetic aspects of alopecia universalis, visit our online forum for information about your cosmetic options.

Information on Telogen Effluvium & Tips on How to Deal with Hair Loss

Her Hair Loss Help has an outstanding Discussion Forum specifically for women with telogen effluvium and other forms of hair lossTelogen effluvium (TE) is the second most common form of hair loss most dermatologists see. When a woman is actively shedding hair during an effluvium (meaning ‘outflow’), it can be exasperating, depressing, and scary.

Sometimes a TE shed, as our forum members frequently call their thinning hair loss, can last for months or even years. Occasionally, it will appear as if the shedding occurs along with your menstrual cycle (cyclical shedding). Women with TE never completely lose all their scalp hair, but the hair can be noticeably thin in severe cases. Whatever form of hair loss your telogen effluvium takes, it is fully reversible.

Things that can help minimize a telogen effluvium shed (or hair thinning):

  • Sometimes skipping a shampoo for a day will make it seem as though more hair comes out the next time you wash. Many of our forum members say it helps to shampoo your hair every day.
  • Use an apple cider vinegar hair rinse once per week.
  • Blot your hair dry with a towel instead of vigorously rubbing your hair.
  • Apply a light conditioning cream to your hair after towel drying to protect it from unnecessary breakage.

Things that can help boost volume and give the illusion of thick hair:

  • Visit a professional hair salon professional in your area and request a cut that will give your hair more bounce and move lightly (generally just below the chin and lightly touching the shoulders). Highlights and lowlights using foil can also give the illusion of thicker, fuller hair.
  • Use a gentle hair care product that has thickening properties. Some of our forum members’ favorites include: Tigi Bedhead Superstar Sulfate Free Thickening Line, WEN Lavender Conditioning Cleanser, WEN Sweet Almond Conditioning Cleanser, Aquage Sulfate Free Shampoos and Conditioners, and Aquage Thickening Style Gel.
  • Loosely piling your hair up on top of your head and then piecing random pieces of hair with a good hair texturizer makes thinning hair look healthy and thick.

Supplements
Supplements can be a controversial topic in matters of hair loss. Many women who have recovered from telogen effluvium agree that you should steer clear of unnecessary supplements unless you have had blood tests to diagnose any vitamin deficiencies that can contribute to your hair loss. For example, if you are iron deficient or anemic, you should take a doctor recommended amount of iron supplements. Iron deficiency is known to cause or aggravate hair loss.

It’s important to remember that one supplement that worked for one woman may not work for you. Our bodies are unique and unnecessary supplements and medicines may do more harm than good.

Finding a Good Dermatologist (or Doctor in General)

doctorFinding a good dermatologist or doctor can prove to be one of the most difficult things to face when you are experiencing hair loss…

  • A good physician will say, “I’m sorry. This must be hard for you to understand.”
  • He/she will give you the address of the National Alopecia Foundation or other support organizations and tell you about the information they provide.
  • He/she will tell you there are others with this same condition and the medical field just doesn’t understand what’s going on.
  • He/she will understand that you have NEVER heard of this condition and that you are scared.
  • A good physician won’t scoff at your questions or minimize your concerns. He/her will appreciate your questions and will be willing to learn with you as much as possible about the condition.

SIGNS OF A BAD DERMATOLOGIST!!!

  • Inappropriate Commentaries
  • Disbelief
  • Cruelty
  • Callousness
  • Impatience

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The craft of the physician may be judged by the thoroughness of the history and physical examination. The following list provides a schematic of some of the things that a physician should do, or consider doing, when first examining a patient with alopecia. Subsequent visits may be shorter but the physician should always be vigilant to the appearance of other autoimmune conditions, of which, thyroid disease appears to be the most common.

History
The initial part of the history is aimed at providing a background to the patient’s condition and allowing the physician to focus on particular problems. Some of the initial questions include:

  1. Is the hair coming out by the roots or is it breaking off?
  2. Is the loss slowing down or getting worse?
  3. Is your hair becoming thinner or do you have totally bald spots?
  4. Do you color, bleach or straighten your hair?
  5. Do you shampoo or condition the hair?
  6. Do you blow dry your hair or use a hot comb?
  7. Is your father’s, mother’s, sister’s or brother’s hair thinning?

The physician then documents all alopecia episodes including age of onset, duration, remissions, patterns of hair loss, relieving or exacerbating factors, treatments, and associated systemic diseases (autoimmune diseases, allergic rhinitis, asthma, atopic dermatitis, connective tissue disease, bowel disorders involving malabsorption, endocrine abnormalities, chromosomal disorders, or cancer). Some of the questions include:

  1. Do you have anorexia nervosa?
  2. Do you have a thyroid disorder?
  3. Have you gained or lost weight?
  4. Are you anemic?
  5. Are your mentrual periods heavy?

The history should date any medication and events within the past 6 months before the first and subsequent episodes of alopecia. The drugs include aminosalicylic acid, amphetamines, bromocriptine, capatopril, carbamazepine, cimetidine, coumadin, danazol, enalapril, etretinate, levodopa, lithium, metoprolol, propanolol, phenytoin, pyridostigmine, and trimethadione. Other pertinent questions include:

  1. Do you take vitamins?
  2. Do you take separate vitamin A tablets?

An inventory of stressful life events and psychiatric disorders. Specific questions will include:

  1. Did you have a baby?
  2. Have you started or stopped oral contraceptives?
  3. Have you gone through menopause?
  4. Have you had a high fever, the flu, been hospitalized or had major surgery?
  5. Have you been on a crash diet? Are you a vegetarian?
  6. Have you had any major stresses during this time?

Physical Exam of the entire cutaneous surface, oral cavity, nails, and sweating. Some of the special exam maneuvers are individualized and not done in every patient but include:

  1. Scalp examination to determine the patterns of hair loss and associated lesions. The presence or absence of hair follicles and sebaceous glands.
  2. Hair Pull Test where 50-100 hairs are pulled in several sections of the scalp. Normally 2-5 telogen hairs will be obtained in this manner, depending on when the last shampoo and styling were done. An active telogen effluvium condition will produce 3-4 times the normal amount of hair pulled; androgenetic alopecia or resolving telogen effluvium has a slight to moderate increase in the number of hairs shed.
  3. Quantitative Analysis of Hair Shedding – The patient is asked to collect ALL hairs shed daily for 7 days in individual plastic bags. The hair is then counted and averaged per day. Normal daily loss is 50-100 hairs. Patients with active telogen effluvium have a 10-40% greater loss.
  4. Density determination – By shaving a small area of the scalp, marking with a skin punch and ink pad, the hairs are counted per square centimeter (normally 150 hairs/cm). The growth rate is measured one month later (normally 1.0-1.2 cm/mo).
  5. Microscopic Hair analysis looking for telogen bulbs, broken hairs (exclamation point hairs), anagen hairs, hair diameter (a high variability in diameter of the hair shaft is evident in androgenetic alopecia), anagen-telogen ration, and sometimes potassium hydroxide is applied to an individual hair strand sample allowing visualization of fungal spores (blackdot ringworm) which causes broken hairs.
  6. Scalp Biopsy which will show them the following:
    • A normal 4-6 mm skin sample should contain 30 terminal hairs, sweat glands, and hair follicles. When alopecia appears to be scarring, the absence of these establishes the diagnosis.
    • The biopsy must go deep enough to include subcutaneous tissue in order to capture anagen hair bulbs. It is closed with suture to ensure proper healing.
    • Various stains are used to detect scarring, lupus, lichen planus, or a blistering disease.
    • Evidence of inflammation may be an indication for the use of steroids.
    • Amino acid and sulfur analysis may be done for certain rare genetic hair disorders.

Birth Control / Contraceptives and Hair Loss

BCPs contain a combination of estrogen and progestin. All BCPs now have one main source of estrogen — ethinyl estradiol. Ethinyl estradiol is a constant in the BCP equation but the part that changes is the progestin level. There are a number of different types of progestin and some of them are higher in androgenic value than others. I’ve compiled data from a number of different sources and come up with a handy chart that helps you identify which BCPs are high in androgens and which ones are lower. Remember that the higher the androgens, the more likely it will cause excessive hair loss, acne and hirsutism.

Click the image to view the full PDF file.

Click the image to view the full PDF file.

How can I cope with the effects of AGA?


Living with hair loss can be hard, especially in a culture that views hair as a sign of youth and good health. Even so, most people with alopecia areata are well-adjusted, contented people living full lives.

The key to coping is valuing yourself for who you are, not for how much hair you have or don’t have. Many people learning to cope with alopecia areata find it helpful to talk with other people who are dealing with the same problems. More than four million people nationwide have this disease at some point in their lives, so you are not alone. We have a number of women who live with alopecias of all kinds a daily basis in our Online Community who can help through message boards and support groups.

Another way to cope with the disease is to minimize its effects on your appearance. A wig or hairpiece can look natural and stylish. For small patches of hair loss, a hair-colored powder, cream, or crayon applied to the scalp can make hair loss less obvious by eliminating the contrast between the hair and the scalp. Skillfully applied eyebrow pencil can mask missing eyebrows.

For women, attractive scarves can hide patchy hair loss; jewelry and clothing can distract attention from patchy hair; and proper makeup can camouflage the effects of lost facial hair. If you would like to learn more about camouflaging the cosmetic aspects of androgenetic alopecia, ask your doctor or members of your local support group to recommend a cosmetologist who specializes in working with people whose appearance is affected by medical conditions.