Hair loss is a widespread issue affecting individuals of all ages and genders. With so many possible causes and treatments, it can be overwhelming to sift through all the information available online. Unfortunately, the internet is full of misleading claims and ineffective remedies that promise quick fixes but often fail to deliver. While many commercial sources advertise miracle solutions to reverse hair loss, the truth is that no treatment is 100 % effective, and understanding the condition requires a deeper look. Rather than focusing only on symptomatic relief or causes like vitamin deficiencies, we believe the approach to treating hair loss should emphasize overall health optimization.
In this article, we will discuss the different types of hair loss, their root causes, and potential treatments, mainly focusing on patterned hair loss. We will also discuss senescent alopecia (hair loss typical for people over 60),and compare it to patterned hair loss, as that may provide clues for the underlying causes of hair loss. By discussing recent research that analyses the underlying factors behind these conditions, we aim to challenge the conventional approach to treating patterned hair loss and offer fresh perspectives on understanding hair loss at its core.
NEM and hair loss – Why is it relevant?
Before diving into the topic, let’s explain its relevance to NEM. While we primarily focus on optimizing physical health and preventing chronic diseases, addressing hair loss may seem more like a cosmetic concern. However, hair loss can be viewed from two angles – aesthetic and biological (1). The aesthetic angle is about the age-related effects of hair color, quantity, and quality, while the biological focuses on macroscopic, biochemical, and molecular changes in the aging process. While many cosmetic companies and hair loss clinics focus on appearance, we at NEM approach hair aging holistically. Our approach combines lifestyle and medical interventions to address aging hair’s appearance and underlying biology.
Introduction
Hair loss of the scalp is normal, and we usually lose 100-200 scalp hairs a day. But when we start losing a lot more hair that can be a distressing event and cause concern.
Types of hair loss
Hair loss, or alopecia, comes in various types, and understanding the specific type is crucial as different types of hair loss have distinct causes and treatments.
Non-scarring hair loss
The most common type of hair loss is non-scarring hair loss (3).
Non-scarring hair loss (noncicatricial alopecia) involves significant hair loss that does not permanently destroy the hair follicles, and there is usually minimal inflammation and irritation to them. Hair loss may occur suddenly or gradually, often associated with stress and aging.
The non-scarring hair loss can be further divided into:
- Patterned Hair Loss (androgenetic alopecia): This involves progressive symmetric thinning of hair, particularly at the front, top, and sides of the scalp. Hair thinning can occur in both sexes but pronounced hairline thinning is more common in men. This type of hair loss is the type of hair loss commonly seen in middle-aged men.
- Diffuse hair loss (telogen effluvium): This type of hair loss involves even hair loss across the scalp, usually more than 200 scalp hairs per day.
- Focal hair loss (alopecia areata): presents as patches of hair loss on the scalp, face, or body.
Scarring hair loss
In contrast to non-scarring alopecia, in scarring alopecia inflammation leads to the replacement of hair follicles with scar tissue.
Common causes for hair loss
While there are numerous factors contributing to hair loss, the primary culprits often involve androgens and stress. Other causes include nutritional issues, hormonal imbalances, medications, infections, certain medical conditions, malignancies, immune system disorders, environmental influences, age, and genetic predisposition(4).
Looking more specifically into the causes of non-scaring hair loss, different types of hair loss have different causes:
- Patterned Hair Loss (androgenetic alopecia): hereditary and caused by exposure to dihydrotestosterone (3).
- Diffuse hair loss (telogen effluvium): Can occur after acute events or stressors including severe illness, major surgery, thyroid disease, pregnancy, iron-deficiency anemia, rapid weight loss, and certain medications (3).
- Focal hair loss (alopecia areata): This type of hair loss is due to an autoimmune disorder that often develops in childhood, and it can affect people of any age, sex, and race (3).
Treatment Options for hair loss
A range of treatments for hair loss have been evaluated in randomized clinical trials. There are different treatment options including medication, surgical options (hair transplant), low-level laser therapy, and alternative treatments such as natural products and mind-body practices. While the efficacy of some of these treatments has been long studied, the evidence for complementary and alternative treatments, including natural products and mind-body practices, is limited and requires further investigation (6).
It is important to keep in mind that no treatment is 100 % effective.
Topical Treatments (Minoxidil)
Minoxidil is a medication used to treat high blood pressure. When used topically, Minoxidil is effective in promoting hair regrowth in women with female pattern hair loss and it is used for both sexes (7). It works by stimulating hair growth. It is readily available in Sweden and over-the-counter formulations can be found in pharmacies.
Oral Medications (Finasteride)
Finasteride is effective in treating hair loss in both men and women. It works by targeting hormonal factors. In a study on male identical twins, finasteride significantly improved hair growth and reduced hair loss progression (8). Similarly, in men with frontal scalp hair thinning, finasteride increased hair count and improved hair growth (9). While evidence for its use in women is limited, it may be considered for those who do not respond to topical minoxidil treatment (10). However, the potential teratogenic effects of finasteride must be considered, particularly in women of childbearing potential.
Surgical Options (Hair Transplant)
A hair transplant is a surgical procedure that involves moving hair follicles from one part of the body (usually the back or sides of the scalp) to the bald or thinning areas. Hair transplantation is an effective and permanent treatment for androgenetic alopecia, particularly in patients with stabilized hair loss (11). The procedure can significantly increase hair density and scalp coverage. While more research is needed to evaluate the efficacy of specific hair transplant techniques, the overall success of hair transplantation is well-documented (11).
Low-level laser therapy
Low-level laser therapy (LLLT) involves the use of low-level lasers or light-emitting diodes to stimulate hair follicles and promote hair growth. The light energy penetrates the scalp, encouraging cellular activity and stimulating circulation resulting in the growth of hair follicles. LLLT can be delivered through devices such as laser caps or helmets. It can be used alone or in conjunction with other treatments for conditions like androgenetic alopecia.
The majority of studies indicate the effectiveness of LLLT but additional evidence is needed. Furthermore, there is a recognized need for standardization within the field of LLLT.
A recent literature review found that LLLT is effective in treating pattern hair loss in both men and women, with a good safety profile (12). The study included 10 randomized controlled trials with 3 of them including only women. Similarly, others reported a positive effect of LLLT in treating male and female pattern hair loss, with no side effects (13). Another review also concluded that LLLT is safe and effective for male and female pattern hair loss, but highlighted the need for more randomized controlled trials and standardized protocols (14).
This need for standardized protocols and visual evidence in LLLT trials was echoed by other researchers (15). Nine trials were identified concerning comb and helmet/cap devices, with five being randomized controlled trials (15). The comparison of data across low-level laser therapy (LLLT) trials and traditional hair loss therapies (minoxidil, finasteride) proved challenging due to the absence of visual evidence, small sample sizes, and significant variations in study duration and efficacy measurements (15). Numerous uncertainties exist regarding the optimal treatment regimen, including maintenance treatment and the long-term effects of LLLT usage. To address these issues, it is advised that protocols be standardized across trials. Additionally, future trials should incorporate visual evidence, and the trial duration should be extended to 12 months for a more comprehensive evaluation.
These reviews and meta-analyses provide evidence for the effectiveness of LLLT in hair loss, but also emphasize the need for further research and standardization in the field.
Supplements
The use of supplements is one of the most controversial areas for hair loss. Often marketed as “natural” remedies there is some evidence that certain supplements may be effective for hair loss, but more randomized clinical studies are needed.
A recent systematic review tried to answer the question “Are nutritional supplements or dietary interventions safe and effective for patients with hair loss” (16). The analysis included 30 studies of nutritional interventions, with the highest-quality evidence suggesting the potential effectiveness of various nutritional supplements in treating hair loss, including Viviscal, Nourkrin, Nutrafol, Lamdapil, Pantogar, capsaicin and isoflavone, omegas 3 and 6 with antioxidants, apple nutraceutical, total glucosides of paeony and compound glycyrrhizin tablets, zinc, tocotrienol, and pumpkin seed oil. However, the review also highlighted the need for larger randomized clinical trials with active comparators. Others proposed a combination treatment approach, including nutritional supplements, for managing hair loss, but emphasized the need for further studies to establish efficacy (17).
In contrast, others cautioned against the use of vitamin and mineral supplements for hair growth, citing a lack of evidence and potential health risks (18).
The overall efficacy of supplements as a hair loss treatment remains inconclusive, with the need for further research and evidence.
In conclusion, while treatments like Minoxidil, Finasteride, and hair transplants have advanced, LLLT and supplements still need more research for widespread acceptance. LLLT shows promise, but we need more evidence and standardization. Supplements remain controversial, with some studies suggesting effectiveness, while others caution against them without strong proof. Overall, finding effective and safe treatments for hair loss requires ongoing research and a clear understanding of the various factors involved.
Why standard approaches may not be enough to treat or prevent further hair loss?
While standard approaches like Minoxidil and 5-alpha-reductase inhibitors have long been the go-to options for treating hair loss, emerging research suggests that they may not fully address the complex factors contributing to hair aging and loss, prompting a need to explore alternative and more comprehensive treatment strategies.
To understand the complexity of hair loss, let’s look into two types of hair loss: senescent alopecia and pattern hair loss (1). Senescent alopecia is a relatively new concept and is recognized as hair loss due to “old age” as it happens in people over 60 who don’t have a family history of baldness (we do not think age 60 is old!). Senescent alopecia leads to hair thinning without being influenced by hormones, and it also causes a reduction in the number of hair follicles and hair thickness over time. When senescent alopecia is compared to pattern hair loss using gene analysis, it was found that they have different genetic patterns, indicating that they might have different causes.
Some researchers are interested to know how oxidative stress and inflammation affect hair follicles (20). In senescent alopecia, certain genes responsible for signaling within the hair follicles and maintaining their structure and energy production are less active (downregulated), while genes linked to oxidative stress and inflammation are more active (upregulated). This suggests that both genetic factors and environmental factors like oxidative stress play a role in aging hair.
Likewise, in pattern hair loss, there are changes in gene activity related to different stages of hair growth and maintenance, with some genes becoming more active during stages where hair growth is reduced. Scientists are also investigating the effects of lipid peroxides on hair follicles (21). They discovered that applying these compounds can trigger the early onset of a phase in the hair growth cycle called catagen, and it can also cause hair follicle cells to undergo apoptosis, or cell death. These findings highlight the significance of oxidative stress in the aging of hair and offer clues about possible targets for treatment.
Furthermore, investigations into hair dermal papilla cells from both balding and non-balding scalps suggest notable variations in cell characteristics and gene activity. Dermal papilla cells from balding areas demonstrate reduced ability to multiply, heightened presence of markers linked to cell aging, and increased levels of indicators associated with oxidative stress and DNA damage. These findings indicate that cells in balding regions are especially responsive to environmental pressures, emphasizing the link between hair follicle health and the aging process.
Based on these discoveries, scientists have challenged the conventional view of pattern hair loss as solely driven by genetics and hormones. Instead, they propose a new perspective, framing it as a hair follicle-specific aging process accelerated by various internal and external factors like hormones, environment, inflammation, blood flow, and diet. This fresh outlook suggests novel treatment directions beyond the traditional use of Minoxidil and 5-alpha-reductase inhibitors. Moreover, the significance of microscopic follicular inflammation in pattern hair loss highlights its impact on treatment response. The presence of microinflammation and fibrosis correlates with a lower likelihood of regrowth in response to treatment, emphasizing the importance of addressing inflammatory processes in hair loss management (1).
