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U. S. Food and Drug Administration
FDA Consumer
December 1991

HAIR!

From Personal Statement to Personal Problem

by Devera Pine

From the shaved heads of medieval monks, to the long-haired hippies of the '60s, to the spiked hairdos of today's punk rockers, hair has always made a personal statement.

"It's one of the leading ways people can establish their individuality and express their style," says Jerome Shupack, M.D., professor of clinical dermatology at New York University Medical Center in New York City. "Hair has had sociological importance throughout the ages."

Because of its importance, anything that happens to our hair that we can't control--falling out or turning gray, for instance--can be the source of much anxiety.

In the United States, some 35 million men are losing or have lost their hair from male-pattern baldness, according to the American Hair Loss Council. Approximately 20 million women have experienced a similar loss of hair (from female-pattern hair loss), and an estimated 2.5 million Americans have lost their hair due to other causes.

THE BASICS

Hair is produced by hair follicles--indentations of the epidermis (outer skin layer) that contain the hair root, the muscle attached to it, and sebaceous, or oil, glands. Hair is made up of dead cells filled with proteins, most of which are known as keratins. The cells are woven together like a rope to form the hair fiber. The hair fiber, in turn, has three layers: the outer cuticle with its fish-scale-like structure; the cortex, which contains the bulk of the fiber; and the center, or medulla. Hair color is determined by melanocytes, cells that produce pigment. When these cells stop producing pigment, hair turns gray.

Although it seems as if the hair on your head is always growing, hair actually has active and rest phases. The growth phase, known as anagen, lasts for two to six years. At any given time, about 90 percent of scalp hair is in the growth stage. The remainder is in the rest phase, known as telogen; this lasts from two to three months.

Once the rest phase is over, the hair strand falls out and a new one begins to grow. As a result, it's considered normal to lose from 20 to 100 hairs a day, says Diana Bihova, M.D., a dermatologist in private practice in New York City. Only a change in your regular pattern of loss is considered abnormal--but many things, including genetic factors, diet, stress, and medications, can change that pattern.

BALDNESS: MANIFEST DESTINY?

The most common cause of hair loss in both men and women is rooted in a genetic predisposition. Called androgenic alopecia, it is known as male-pattern baldness in men and female-pattern hair loss in women (alopecia is the scientific term for baldness). According to the American Hair Loss Council, genetics accounts for 95 percent of all cases of hair loss in this country.

Baldness results from a combination of genetic factors and levels of testosterone (a hormone produced by the adrenal gland in both sexes and also by the testes in men). If hormone levels are right, then the hair follicles will express their genetic destiny by growing for shorter periods and producing finer hairs. In men, who have higher levels of testosterone than women, this eventually results in a bald scalp at the crown of the head and a horseshoe- shaped fringe of hair remaining on the sides. In women, the hair thins all over the scalp; the hairline does not recede. This type of hair loss doesn't usually show up in women until menopause; until then, estrogen tends to counteract the effects of testosterone.

ONE APPROVED DRUG

The only drug approved by the Food and Drug Administration to treat pattern baldness or hair loss is minoxidil topical solution (Rogaine), which is rubbed into the scalp. Originally approved for hereditary male-pattern baldness in 1988, it was also approved for treating female-pattern hair loss in August 1991. However, it should not be used by pregnant or nursing women.

In his dermatological practice, Arthur P. Bertolino, M.D., Ph.D., director of the hair consultation unit at New York University, says that this lotion helps hair grow in 10 to 14 percent of the people who try it. He estimates that approximately 90 percent of the time, Rogaine at least slows down hair loss. (Minoxidil is also available in tablet form to treat severe high blood pressure. Oral minoxidil has a potential for serious side effects and is not approved to treat baldness.)

No one is certain yet just how topical minoxidil works to promote hair growth. "One theory is that it dilates the blood vessels, so it may stimulate nourishment of follicles," says Bihova. Alternatively, Rogaine may convert tiny hair follicles that produce peach fuzz into large hair follicles that produce normal-size hairs. Again, no one knows for sure.

What is certain is that, at least in men, Rogaine works better on patients who fit a certain profile: they've generally been bald for less than ten years, have bald spots on top of the head that are less than four inches in diameter, and they still have fine hairs in their balding areas. "The process begins very early," says Bihova. "I see 19-, 20-year-old males who have it."

The most common side effects with this medication are itching and skin irritation. Also, according to Bertolino, once you stop using it, any hair that grew as a result will fall out. Finally, the drug is expensive: in 1990, it cost about $600 a year to use it twice a day.

TRANSPLANTS

Baldness can also be treated with hair transplants, in which plugs of "donor" follicles from the patient's scalp are used to fill the hairline. Although hair transplants work well in both men and women, the treatment tends to have a more dramatic effect on appearance in men with bald spots than it does on women with thinning hair.

"The less hair you have, the more drama in the change," says Robert Auerbach, M.D., associate professor of clinical dermatology at New York University School of Medicine. However, the American Hair Loss Council warns against attempting to replace lost hair with hair pieces sutured to the scalp. FDA has not approved any products specifically intended for this purpose, however, this does not preclude a physician from using sutures, which are approved devices, for this purpose. According to the council, although the procedure is legal, it can result in scars, infections and even brain abscesses.

Another treatment for male-pattern baldness, hair implants made of high-density artificial fibers surgically implanted in the scalp, was banned by the FDA in 1984 because it causes infection. This is the only device FDA has ever banned.

PRODUCTS THAT DON'T WORK

So-called "thinning hair supplements," "hair farming products" and "vasodilators" for the scalp will not promote hair growth, says Mike Mahoney, a spokesperson for the American Hair Loss Council.

Thinning hair supplements are nothing more than hair conditioners that temporarily make your hair feel or look a little thicker. The main ingredient in these products--polysorbate--is also found in many shampoos. Promotional materials for hair farming products claim that they will release hairs that are "trapped" in a bald scalp. Mahoney says these products, many of which are herbal preparations, can do no such thing. And so-called vasodilators do not increase the blood supply to the scalp and do not promote hair growth.

EVERYDAY HAZARDS

While male- and female-pattern baldness results in permanent hair loss, other factors can cause temporary loss of hair. For instance, the drop in the level of estrogen at the end of pregnancy can cause a woman's hair to shed more readily. Two or three months after a woman stops taking birth control pills, she may experience the same effect, since birth control pills produce hormone changes that mimic pregnancy. A major physical stress, such as surgery, or a major emotional stress--positive or negative--can cause hair loss.

"I've seen women start losing their hair before getting married," says Bihova. Even jet lag can have a similar effect.

In most of these cases, the hormonal imbalance or stressful situation will correct itself, and the scalp will soon begin growing hair again. But, says Bihova, since most women are extremely upset by even a temporary hair loss, many dermatologists treat these conditions with either topical steroid preparations or localized injections of low doses of steroids. Bihova emphasizes that these are local, not systemic, injections of steroids, therefore, the shots do not have the same risk of dangerous side effects as systemic steroids. However, only a board-certified dermatologist should administer this treatment, she says.

The list of causes of temporary hair loss goes on: pressure on the scalp from wigs or hairdos that pull too tightly can cause it. A fever of 103 degrees Fahrenheit or more often causes hair loss six weeks to three months later. And some medications can cause a temporary loss. These include vitamin A derivatives such as Accutane, cough medicines with iodides, anti-ulcer drugs, some antibiotics, beta blockers, antidepressants and amphetamines, anti- arthritis drugs, blood thinners, some cholesterol-lowering agents, aspirin taken over long periods, some thyroid medications, and chemotherapy.

YOU HAIR WHAT YOU EAT?

Although nutrition does play a role in hair loss and in the overall health of your hair, only extreme nutritional deficiencies or excesses will cause hair loss. For instance, people with anorexia and bulimia may temporarily lose hair. So will others suffering from malnutrition.

"It's pretty rare in the United States," says Bertolino. "If someone was on a real strange, restrictive diet, it could happen to them."

Megadoses of some vitamins--particularly A and E--and an iron deficiency may lead to hair loss. People who claim they can determine which vitamins are lacking in your diet by analyzing your hair, however, are not speaking from a scientifically sound basis. The test used with this type of hair analysis--atomic absorption spectrophotometry--is a legitimate analytical chemistry method; however, used on hair, the results of this test do not correlate with nutritional status, says Shupack. "Because of the sociological importance of hair, a lot of people try to cash in on it," he says. "Hair analysis is all witchcraft as far as I'm concerned."

There are, however, a few legitimate hair tests for substances such as arsenic and lead.

FOR BEAUTY'S SAKE

Every time you shampoo, blow dry, perm, straighten or dye your hair, you damage it slightly, says Bertolino. For the most part, hair can withstand this type of treatment. But overzealous beautifying can damage the hair fiber, resulting in many broken strands, and a frizzy, split-end look. For instance, if you bleach your hair and then have a bunch of perms done in a short time, you're heading for trouble.

Misuse of hair cosmetics can cause the hair to break as it comes out of the scalp, says Frances Storrs, M.D., professor of dermatology at the Oregon Health Sciences University. Permanent wave solutions break the bonds that hold hair together and then reform them. But with a perm that is not diluted right or not rinsed off properly, for instance, those bonds may not re-form and the hair would soon fall out as a result. Fortunately, most professional hair dressers know how to use perms correctly, says Storrs.

Most hair dyes are not as irritating as permanent solutions, mostly because they do not break the bonds between hair fibers and are therefore not likely to cause a hair loss, she says. However, a severe allergic reaction to hair dye could cause hair loss. "The allergy is pretty common, actually," says Storrs. Permanent solutions can also cause allergic reactions, though that's a rare side effect.

Other beauty-related manipulations of the hair can cause problems, too: hot irons, corn rows and braids may bring on temporary or permanent hair loss. If the hair breaks often enough, the follicles may eventually not be able to produce normal hair, says Bihova. "If someone has a problem with thinning and excessive loss, we advise being gentle," she says. "Don't use rollers; don't use blow dryers on a hot setting; don't wear tight hair styles." Rough shampooing may accelerate any loss, though it's usually not a problem in people with healthy hair.

THE MEDICAL SIDE

Some hair loss is the result of a type of immune disorder known as alopecia areata--some 2.5 million people suffer from this condition in which antibodies attack the hair follicle, causing the hair to fall out. Alopecia areata often causes small, oval or circular areas of hair loss. However, in some forms of the condition, all the scalp hair falls out; in other forms, all body hair is lost. Although the loss is usually temporary, the condition can recur. Treatments include topical steroids or the use of chemicals to produce an allergic reaction to start the hair growing again.

Finally, chronic, systemic conditions--including one form of lupus, abnormal kidney and liver function, and hypothyroidism or hyperthyroidism--can affect the hair. If you're experiencing hair loss, see a doctor. He or she will want to order some basic blood tests to rule out any medical cause of the condition.

Devera Pine is a freelance writer in New York City who frequently writes about health and science.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service, Food and Drug Administration
Office of Public Affairs, 5600 Fishers Lane, Rockville, MD 20857