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Welcome to Skinside Out Where Science Meets Beauty. In this episode, Dr. Zain, Courtney, and Heather dive deep into the multifaceted world of hair loss. The trio explores various types of alopecia, including nonscarring forms like androgenetic alopecia, telogen effluvium, and alopecia areata, as well as scarring alopecia such as CCCA, acne keloidalis nuchae, and dissecting cellulitis. They highlight the crucial phases of hair growth and the importance of a proper diagnosis through patient history, physical examination, hair pull tests, dermatoscopy, biopsies, and lab tests to identify deficiencies and hormonal imbalances. Understanding the intricacies of alopecia will prepare you for the next episode, where they cover treatment options. Don't forget to subscribe and click the notification bell to stay updated!
00:00 Introduction to Hair Loss
01:09 Understanding Hair Shedding
02:18 Types of Non-Scarring Alopecia
02:56 Stress-Related Hair Loss: Telogen Effluvium
04:42 Autoimmune Hair Loss: Alopecia Areata
06:21 Other Non-Scarring Alopecia Types
11:05 Scarring Alopecia: An Overview
17:35 Diagnosing Hair Loss
21:53 Conclusion and Next Steps
Creators and Guests
Host
Host
What is Skinside Out?
Welcome to Skinside Out, where science meets beauty, the ultimate dermatology podcast! Dive deep into the fascinating world of skin health with expert insights, evidence-based discussions, and myth-busting truths. Each episode explores the medical, cosmetic, and surgical aspects of dermatology, while keeping you informed about trending skincare topics. Whether you’re a skincare enthusiast, medical professional, or just curious about how to achieve your best skin, Skinside Out is your go-to resource for staying informed and inspired.
13 Skinside Out Hair Loss
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Dr. Zain Husain, MD: Welcome to Skin Side Out Where Science Meets Beauty. I'm your host, Dr. Zane with Courtney and Heather. So today we're talking about hair loss. So this is an important topic we see in our clinic all the time and it is distressing for a lot of patients and understandably so. Um, hair is tied to our identity and how we view ourselves and how others view us as well.
So I can understand how it can affect confidence and why people seek treatment when they're noticing hair loss. So today we're gonna talk about the different types of [00:01:00] hair loss, um, how to diagnose them. And then, since it's such a big topic, we're gonna break up, um, into two episodes and we'll talk about treatment in the next episode.
I.
Courtney Carroll, LE: Everyone does shed from day to day. Um, typically you are seeing about 50 to a hundred strands per day, that also can vary based on how often you brush your hair. That's. Something I always tell patients too, because sometimes if they're brushing less, all of those hairs will come out at one time.
you know, If you're seeing more than than that influx, that's when you think, okay, maybe we, we have a problem. Um, we have over a hundred thousand follicles on the scalp, so each follicle does go through its, um, growth phase, its resting phase, and its shedding phase, so it tends to cycle through. Otherwise, we would lose all of our hair at one time.
Dr. Zain Husain, MD: Those three phases, the antigen phase is the growth phase. Catagen phase is that, you know, transient intermediate stage where it's getting ready to shed.
And then the actual shedding phase is the telogen phase.
Heather Murray, PA-C: Yeah. And hair loss is very [00:02:00] common. I mean, if you haven't experienced it yourself, I think you've, you probably know somebody who has, there's, um, studies show one in five women deal with hair loss, one in 10 men deal with hair loss and. Of those people, half of them are either undiagnosed or poorly treated.
And so I think it's a, a very important topic. We'll get into the different types of hair loss. We'll start out with, um, nons scarring Alopecia. So alopecia is the medical term for hair loss. Um, I'll start off with probably the most common type of nons scarring hair loss. So androgenetic or androgenic alopecia.
Um, it's listed both ways is the same thing. So typically for males, it is like a temporal recession on both sides as well as. Losing a little bit in the crown. And then for females it's typically, um, most people consider like their part is widening.
So it's really that that upper half of the hair is kind of thinning out.
Dr. Zain Husain, MD: Another common type of hair loss that we encounter is telogen [00:03:00] Flum. So I kind of think of this as more of a stress related hair loss due to hormonal shifts due to a stressful event or, um, something that, you know, you've gone through such as surgery, um, childbirth,
rapid weight loss, , you know, certain medications. Um, so that is a stressor on the body. And I think as a mechanism to preserve vital functions, the body, you know, thinks of hair as an accessory, not as vital, so at least to a shedding effect. Due to some of those hormonal shifts that we see,
Courtney Carroll, LE: and with Telogen, you can lose up to 50% of your hair.
So it does feel very scary for patients who are experiencing that because it goes essentially from no shed to this rapid shed. And that can be really concerning.
Dr. Zain Husain, MD: Yeah, and I mean, during the pandemic especially, there was like an epidemic mm-hmm. Of telogen effluvium from Covid. We saw [00:04:00] so much hair loss and people were freaking out, and obviously like in the beginning, we really didn't know much about Covid and its dermatologic manifestations including hair loss.
Now we know it is a very common cause of hair loss, and we see that in a lot of patients. Yeah.
Courtney Carroll, LE: And the nice part is that typically with this type of hair loss, the hair will return over time, um, once the underlying root is treated. So, yeah.
Dr. Zain Husain, MD: But sometimes it's kind of tricky because there's usually a lag like few months.
Mm-hmm. Up to even six months after that initial trigger. Um, then you can start noticing the shedding. So sometimes people can't really correlate it to that trigger 'cause oh, it was in the distant past, but mm-hmm. That's usually what happens. 'cause the hair cycle takes so long.
Courtney Carroll, LE: Yeah. Alopecia Areata is another type of hair loss that we do see a lot in our clinic.
So this is actually gonna be, um, an autoimmune condition where the immune system is attacking the hair follicles mistakenly. So it typically presents as like a round. Smooth, bald patch essentially. [00:05:00] Um, and it can be either on the scalp, sometimes we see it on the beard distribution for men. Um, so it can be a little unpredictable.
Um, some patients can regrow that hair completely, but for some patients they may experience cycles of loss in that area.
Heather Murray, PA-C: Yeah, and you might get a patch here or there. I mean, there are some people that have one little patch. It goes away and then a couple years down the line they get another patch. But then you can actually have.
Alopecia areata involved the entire scalp could even affect your eyebrows. And then that becomes alopecia totalis, which you, you pretty much have no hair anywhere.
Dr. Zain Husain, MD: It can actually affect the entire body as well. So alopecia universalis can affect hair follicles on your body hair in addition to the head and neck area.
And that can be particularly devastating because, I mean, I've seen patients with this condition, it is psychologically very difficult, um, when patients, um, are in public. People are staring at you, they're thinking that you're, either you're [00:06:00] sick or something's wrong with you, you're going through chemotherapy.
Um, so psychologically, um, I can see how, you know, especially young children, but even adults, um, they are really distressed about, , losing all their hair. And, um, you know, until recently we really didn't have that many great treatment options that were sustainable.
Heather Murray, PA-C: Yeah, there are some other types of nons, scarring, alopecia, um, another, I guess not as common one is trichotillomania.
So that is pretty much where the patient is kind of pulling their hair out. Mm-hmm. They may not, you know, recognize that I actually had a patient. Who had trichotillomania right around the crown where her ponytail sat, but she was so anxious. She was in college, it was around finals time and, um, you know, kind of involving that mental health.
Mm-hmm. Care can make a huge difference and, and really incorporating therapy or psychiatry.
Dr. Zain Husain, MD: Yeah. I've seen a lot of kids and [00:07:00] adolescents deal with this. And you can see actually the broken hairs and different lengths within that patch of hair loss. So that's kind of gives it away. And also the strange geometric patterns that you sometimes see with the hair loss.
Um, so it's common, we see it, especially with these, um, anxiety patients. Mm-hmm. OCD tendencies. Um, so it is very common.
Courtney Carroll, LE: Pressure induced alopecia is another thing we, we do see. So, um, typically things like, um, traction on, um, on the hair, like braids, for example, or, um, hat like prolonged use of hats.
We see that with men especially who might be wearing their hats all the time. , that can create hair loss in that area. And
Dr. Zain Husain, MD: then also, um, babies. Mm-hmm. Um, my baby has it right now on the back of her, um, on her occiput of her scalp. Um, she has this patch of hair loss that's starting to fill in, but it's because they're, you know, constantly on their backs.
Lying on that causes pressure induced, um, alopecia.
Heather Murray, PA-C: You can also have, um, I [00:08:00] guess it would technically be classified as a. Either pressure induced or like maybe a mini telogen effluvium, but, um, hair loss after a surgery on the scalp. I've seen that a lot. Mm-hmm. With moose. So, um, what happens is if you have like a, a skin cancer or a cyst or something removed on your scalp, you're, that area around that scar mm-hmm.
Can kind of freak out for a little bit and fall out. But it, it grows right back. You just. Fantastic. Take time.
Dr. Zain Husain, MD: Yeah. Certain infectious, um, causes include syphilis that can lead to that moth eaten alopecia. It's kinda like this kind of like these spare like little areas of hair loss that's kind of scattered throughout the scalp.
So it's very interesting. I've seen. A few patients with that when I was in residency and it's, it's very interesting, um, you know how that description is so fitting
Courtney Carroll, LE: Yeah. Psoriatic, um, alopecia, which I sometimes wonder if that's from just the inflammation on the scalp. Mm-hmm. With those plaques, it's creating that hair loss.
Mm-hmm. It's not giving the hair that. [00:09:00] Proper environment to really grow. Mm-hmm. Um, but psoriasis is an autoimmune condition as well, so, um, you know, over time it can create that hair loss.
Dr. Zain Husain, MD: Yeah. And similarly, a lot of people mistake in psoriasis, um, with seborrheic dermatitis, and a lot of these patients have seic dermatitis due to inflammation from yeast and.
The good thing about that is that can be easily treated, you know, using some medicated shampoos to reduce yeast and reducing the inflammation. So it is always important to evaluate the scalp and see if something may be contributing to the hair loss that, um, can be an easy fix.
Courtney Carroll, LE: Separate dermatitis is just a fancy word for dandruff.
Yes. For those who don't know. Sorry.
Dr. Zain Husain, MD: Part of my jargon.
Heather Murray, PA-C: There are also, um, nutritional deficiencies that I think we have to keep in mind. So most commonly, vitamin D deficiency, iron deficiency. Um, protein could play a role too. So I think it's definitely worth checking. some labs possibly see if there are any [00:10:00] hormonal abnormal abnormalities as well.
Um, because speaking of hormones like
Dr. Zain Husain, MD: thyroid disorder mm-hmm. We see a lot of hair loss associated with hypothyroidism. especially like with Hashimoto's thyroiditis that can lead to, um, hypothyroidism. And if it's not treated, it can lead to hair shedding.
Courtney Carroll, LE: And PCOS is another, um, big hormonal condition that can happen that can really affect hair growth.
I mean, some people will get hair growth on the, you know, face where they don't want it, but then lack that hair growth in the scalp area where they do wanna keep it.
Heather Murray, PA-C: Yeah. I think PCOS is really interesting because the, the. Polycystic ovaries don't necessarily directly cause the hair loss. It's actually that simultaneous insulin resistance that we see with people who have PCOS and that insulin resistance can actually drive that, um, activity of.
DHT and that can kind of correlate with the hormonal side [00:11:00] of the hair loss, which I think is really interesting.
Dr. Zain Husain, MD: That was a good summary of the nons scarring alopecia. So let's move on to the scarring alopecia, also known as sick nutritional alopecia. These types of alopecia, we see scarring.
So we actually see hair follicles being replaced with scar tissue and it is very difficult to treat often. You know, it's almost like hard to get back to its natural state again and with regular hair growth. So let's start off with talking about CCCA central centrifugal psychiatrical alopecia say that seven times fast. CCCA is a type of hair loss, um, that is marked by scarring. And often we see this in response to damage done to the scalp and the hair follicles from an outside source such as. Chemical relaxants, um, hot combs, other types of damage that are [00:12:00] physically harming the skin and the hair follicles.
We often see this in, um, skin of color, specifically African American patients because some of these practices, um, for treating hair are common in this population. , but I have seen in other races as well and, um, it is very difficult to treat and, you know, many patients, um, are looking for solutions and sometimes it's very hard to see regrowth after that.
Scarring is very prominent. I.
Courtney Carroll, LE: like implant of PIIs is again, almost kind of like, um, an attack on your own immune system. Essentially, about 30% of people who experience this also have like planus, which presents as more of a rash. Sometimes people will have sores in the mouth and.
Um, typically it's best diagnosed through something like a biopsy, which I know we've talked in the past, um, about. So that is an unfortunate condition, um, because it can be hard to manage, especially once you've gotten to that scarring point. [00:13:00]
Dr. Zain Husain, MD: Yeah. And with LPP, um, we see these really inflamed bumps around the hair follicles and surrounding scarring and.
You know, that can lead to other areas also being involved, but sometimes it just dies out and goes into remission. But sometimes it can go become active again. So you constantly have to monitor these patients and you know, unfortunately, after the scarring happens, it's difficult to treat. But if you can prevent.
The hair follicles from getting inflamed, , cooling down the lichen plan of Polaris, you can at least save areas that haven't been affected yet, and that's really important. Um, so it is something that, you know, we do see clinically in patients and there's a variant of it. Um, we think of frontal fibrosing alopecia, another type of alopecia as a subset of.
LPP and it's got specific clinical features too, and we're seeing a lot more of it. Mm-hmm. In the past couple decades, like I feel [00:14:00] like before like the nineties, it was very rare to even hear about this. And now we're seeing more and more of this where we're seeing , , especially in females, um, the forehead being involved, you're getting like this recession very shiny.
Tight appearance. Um, you're getting like these little lonely hair sign where you have like these individual strand of hairs still there. Their eyebrows are being obliterated and you're losing that. , and it's, it's got a striking feature and you see some very prominent facial veins too. So it's got a very distinct look.
And we are, we do think that it is a subset of LPP, so something to look out for.
Heather Murray, PA-C: . Another type of scarring, alopecia, I think we kind of mentioned it last time, but traction alopecia, um, can kind of turn into that scarring type of hair loss. So that's the like tight ponytails, tight braids, any sort of tension on the scalp.
Um, if you catch it early and, and you make changes, you know, trying to avoid those hairdos or hairstyles, it [00:15:00] can grow back. But if you, if you, you know, keep. Doing that tight ponytail, it could mm-hmm. Turn into that permanent hair loss.
Dr. Zain Husain, MD: Yeah. Another autoimmune condition that we see hair loss with is with lupus, specifically discoid, lupus, ery the mitosis.
So with this condition we see scarring alopecia, um, specifically, um, we see it especially on the head and neck, but it can happen anywhere in the body. But when it involves a scalp, it definitely can affect the hair. , I've had numerous patients who, um, have had discoid lupus, , it can be devastating.
So. Not only is it important to treat the discoid lupus, but also making sure that they don't have systemic lupus. Many times patients who have discoid lupus don't really have active systemic lupus, but it's still important. So getting a rheumatologist involved to also assess and make sure that you know their other organs are also doing fine and not affected.
Courtney Carroll, LE: Yeah. Acne keloidal is a condition we see. Um, typically more so I would say in men we're seeing that. Mm-hmm. Especially men who tend to shave their [00:16:00] head or, you know, either at home or at a parlor. Um, it. Tends to be more in that occipital scalp in the back mm-hmm.
Where they'll get kind of these bumps, um, that turn into these like angry inflamed areas. And so that can, um, contribute to that, that hair loss. But again, I feel like it's kind of cyclical where we see these people who are doing that close shave to the scalp. Mm-hmm. And then they're presenting and getting that routine.
Dr. Zain Husain, MD: Yeah. And I think it's a combination of the physical trauma from. Those close shapes. Mm-hmm. Um, as well as bacteria that's on our skin. And then also probably a genetic predisposition. So we do often see that these are patients who, you know, are predisposed to developing keloids. Mm-hmm. So that's the second word.
Acne keloid Dallas NUAs on the neck. So it's just a common area where I think people just get, like clo do really close shaves. Ed, um, the trauma plus the bacteria. Mm-hmm. It's just this combination and [00:17:00] recipe to develop this condition. Mm-hmm.
Heather Murray, PA-C: Yeah. There's also, um, dissecting cellulitis. Mm-hmm. Which I think is a really interesting condition.
Um, it mostly presents as like, kind of like a nodular cystic acne of the scalp. Mm-hmm. Um, very inflamed. That's, you know, what cellulitis means is inflammation of the skin. It typically responds pretty well to acne treatments I have found. Yeah. Um, but can, you know, you definitely have some hair loss associated with it, so if it's treated, it can definitely be.
Um, reversed.
Dr. Zain Husain, MD: Yeah.
Courtney Carroll, LE: So lots of different types of hair loss. How do we determine which one we are seeing? So there's a few different ways. Number one, taking in your patient's history, it's gonna be the most helpful thing. I know when, um, I work as a medical assistant. First thing I'll ask patients is, when did this start?
And prior to this event, did you have anything traumatic or stressful? That might have happened about three to six months ago. You also kind of wanna ask what they're [00:18:00] experiencing as far as, is it true shedding or are you having those patches of hair loss because where they're having the hair loss will give you a little bit more intel as to what type of hair loss it is.
Again, if someone is having that receding hairline, okay. We think more of that genetic, um, you know, male pattern balding or female pattern balding, or if they are just having that shedding and it's been going on after childbirth. Okay, maybe that's telogen, but, , there are, you know. Key parts of their history that will help put the puzzle pieces together.
Dr. Zain Husain, MD: Like with anything clinically, we want to examine the patient. The physical exam is really important, um, because not only are we assessing, um, patterns of hair loss, we're also looking at the health of the skin of the scalp. As well as the hair follicles, the hair itself. , so when I am examining my patients, I am looking at the areas where we're noticing a decrease in density of hair.
Um, we're looking at any scale, any inflammation, , any areas of potential [00:19:00] scarring. Um, 'cause these all are giving us clues as to the cause of the hair loss. Um, I also do something called the hair pull test. So this is a useful test to kind of see how easy is it for hairs to come out of the scalp with some gentle pulling.
Um, most hair follicles should be pretty, um, resilient and should not kind of come out with a, a gentle pull, but when you see an excessive amount that that can point to, you know, just different certain types of hair loss. So I do think that that is useful. Um, I also use my dermatoscope, um, it's called Oscopy.
We look at the hair follicles, we look at the skin health, the hair shaft health. We sometimes even look at the hair shafts under the microscope. 'cause sometimes that can give us clues. So there's a lot on the physical exam that can help us aid in determining what. The cause is, and in addition, a biopsy in the office can be very helpful because especially for inflammatory, um, [00:20:00] you know, alopecia, it can help us determine what's the cause and how to properly treat it.
Is there scarring involved or not on the microscopic level so that we can really properly treat the patient.
Heather Murray, PA-C: Yeah, and sometimes with the biopsy we might need to take multiple, specimens because sometimes the pathologist likes to look at the. The depth of the skin and the hair follicle from like a horizontal angle as well as a vertical angle.
So, so sometimes they'll ask for two different specimens. Mm-hmm. Um, but in addition to that, we also want to rule out any nutrient deficiencies. So we're checking for, um, vitamin D, iron most commonly. And then, um, also checking hormones, making sure that there's no underlying thyroid disorder too.
Courtney Carroll, LE: So if you're noticing persistent hair loss, you definitely want to seek medical advice from a professional, um, who knows what they're talking about.
Um, because it can, again, as we've talked about, it can lead to further, , whether [00:21:00] it be scarring, hair loss, or just further hair loss in general. And I think the sooner that you're able to tackle it, the more chance you have of retaining and potentially regrowing that hair.
Heather Murray, PA-C: Yeah. And some of the types of hair loss are, um, short-lived.
You know, there are some treatments that can regrow that hair very quickly. Um, you know, especially those stressful induced hair loss types. You know, if you can manage that stress accordingly or differently, then that can really help too. Also, treating any sort of nutritional deficiencies can make a huge difference.
Dr. Zain Husain, MD: Yeah. And other types of hair loss are obviously more chronic in nature and need long-term management. Especially with our androgenetic alopecia, typically it's a lifelong condition, right? It's part of your genetics, part of your hormone profile. So we can definitely help, but this is going to be a long-term journey, um, that we're gonna be doing with our patients.
Heather Murray, PA-C: Hair loss can definitely be. Overwhelming, um, anxiety provoking and emotional and frustrating. [00:22:00] So, um, if you are experiencing this or if you know somebody who is, you're not alone, um, there is help out there and we're happy to help you.
Courtney Carroll, LE: Yeah. And if you take one thing away from today's episode, you don't wanna self-diagnose because there are so many different types of hair loss out there.
And again, seeking the right treatment will be so much better in the long run, you'll save time, money, and a lot of emotional angst.
Dr. Zain Husain, MD: Yeah. And remember, the earlier that you intervene, the better the outcomes. Um, I always say that the longer that you wait, it is going to be so much more difficult and expensive.
To regain some of that hair growth, um, and that hair loss, um, that you've encountered. And it's not guaranteed, you know, so you wanna intervene earlier when you start seeing the signs of, you know, hair loss and just seeking the attention of, you know, board certified dermatologist, um, or a dermatology clinic that can really truly assess, you know, what's causing this, rather than just kind of leaving it up to question and just potentially [00:23:00] treating you with the wrong treatment protocol.
A big discussion on hair loss. And I think that a lot of people aren't aware that there are different types of hair loss. I mean, when they hear the word alopecia a lot of different, you know, thoughts come to mind, like those brown patches of hair loss, that's not what necessarily alopecia is.
There's a lot of different types and it's complex. So I think that, you know, we hopefully have explained in general terms how to look at hair loss. How to identify it, um, how to properly diagnose it. And for the next episode, we're gonna teach you how we treat it. And I think that's gonna be really important because that is where the magic, I think, really lies in what we do.
So, um, thanks for joining us today, um, on our episode regarding hair loss. And then join us next time to learn more about treatment options. Until then, skin side out,
Heather Murray, PA-C: out.
[00:24:00]