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Ep. 3: Understanding Hair Loss and How to Fight It

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Ep. 3: Understanding Hair Loss and How to Fight It

Jun 21, 2021

Hair loss can affect all genders throughout their lifetimes, and is often genetic but sometimes even stress-related. Dr. Luke Johnson and Dr. Michelle Tarbox, both board-certified dermatologists specializing in the health of the skin, hair, and nails, explain what causes hair loss as well as how to prevent or address it.


Dr. Tarbox: Hello and welcome to Skincast, the podcast about skincare. I'm Michelle Tarbox and I'm a dermatologist. Dermatologists are medical doctors who take care of the skin, hair, and nails. And joining me is . . .

Dr. Johnson: This is Luke Johnson. I'm a dermatologist at the University of Utah in Salt Lake City.

Dr. Tarbox: I practice in beautiful sunny Lubbock, Texas, at Texas Tech University Health Sciences Center.

Dr. Johnson: We are going to be talking about various products on this episode because our goal is to keep your skin, hair, and nails as healthy as possible. And to do that, sometimes you need to use stuff. But we're not paid by any of the people who make these. We have no commercial conflicts of interest.

Dr. Tarbox: Exactly. So, speaking of hair, let's talk about hair loss. There are lots of different kinds of hair loss that can affect patients throughout their lifetime. The most common type that most people probably think of when you say ‘hair loss’ is going to be Androgenetic Alopecia, which is an inherited type of hair loss. It affects both men and women. It affects men a little bit more severely in most cases, but women can also be affected. And it's relatively common actually.

Dr. Johnson: Androgenetic alopecia is a fancy name for male-pattern hair loss, which some people call ‘female-pattern hair loss’ in women. But if you have an uncle who's balding, then that person has androgenetic alopecia in all likelihood.

Dr. Tarbox: Other people also have hair loss after stressful events. This can happen after a severe illness or a period of hospitalization or a surgery, but can also happen with severe stress. And this form of hair loss is called telogen effluvium, but you can think of it as just stress-related hair loss.

Dr. Johnson: And the classic example if you're a dermatologist is when a patient comes into you complaining that she's been losing her hair lately and she brings her 5-month-old baby in with her. Giving birth is a really stressful event on the body, and what basically happens . . . the way I explain it to my patients is that the body decides it has better things to do than put resources toward growing hair. So it stops growing hair.

Dr. Tarbox: Absolutely. There are other kinds of hair loss that are a little bit less common. Some of those include something called Alopecia Areata. That is a kind of autoimmune hair loss that causes usually small circles of hair loss to occur on the scalp. But occasionally, it can be very severe and involve the whole scalp.

Dr. Johnson: There are a few other kinds as well that dermatologists have to learn about. They have names like Trichotillomania, which is when people pull their hair out, and Anagen Effluvium, which is when people lose their hair because of chemotherapy. Those are fairly uncommon, but if you're worried you might have something like that, then obviously you should probably see a medical doctor. And then there are some potentially nutritional causes of hair loss.

Dr. Tarbox: Yeah, it actually takes a lot of nutrients to make hair. That's one of the reasons why if a person is having trouble with caloric intake, like a crash diet, your body doesn't really know the difference between that and you starving because there's a glacier and you're being chased by a tiger or something. And so it starts to shunt nutrients away from the hair.

Dr. Johnson: So you need enough protein and you need enough iron. Those are what I usually think of when I think of vitamins, for lack of a better word, or nutritional products that are related to growing hair.

Dr. Tarbox: Zinc is also helpful, as are some B vitamins. And we'll talk about that a little bit more later.

There are also kinds of hair loss that can be permanent and kinds that can be recovered from. So the ones that are permanent, these are the scarring alopecias, scarring hair loss. Now, this usually happens in association with an autoimmune disease and it can be treated, but it should be treated aggressively as soon as it's detected because once the hair has gone in a scarring alopecia, it's pretty much gone.


Dr. Johnson: So, if you have an autoimmune disease, something like lupus, and you feel like you've got areas of hair loss, please see somebody like us quickly so that we can help and hopefully stop it from getting any worse.

Dr. Tarbox: Fortunately, most kinds of hair loss are non-scarring, and that means the hair can be recovered through different treatments.

Dr. Johnson: And I want to spend most of this episode talking about the most common kind of hair loss that I think people will be wondering about, which is that male- or female-pattern hair loss. Again, the medical term is Androgenetic Alopecia.

Dr. Tarbox: It is very common and it causes a lot of problems for people both emotionally as well as sometimes socially. And so it's a good idea to treat it early if it's something that distresses you.

So the etiology of androgenetic alopecia, it's right there in the name. So our skin that makes up our scalp actually comes from the same part of the embryo that the face comes from, the skin that makes up the top part specifically. The back parts of the scalp are made from a little different part of the embryo. The reason that's important is that that skin that comes from the part that is also the part that makes the face is very, very hormonally sensitive.


And so, if you think of your stereotypical balding man, that part of the scalp that usually has the hair loss is that very hormonally sensitive area. And the hair follicles in that area in some individuals who are genetically predisposed will be extra sensitive to male-type hormone. And in response to exposure to male-type hormone, they will undergo a process called follicular miniaturization, which means that the hair follicles get smaller and smaller and smaller until you really can't see them anymore.


Dr. Johnson: I think most of us have a pretty good idea of what this looks like in men because it's more obvious in men. In women, it's more like kind of diffused thinning of the hair, especially along the central part. So, if you're a woman and you worry that that might be what's going on with you, probably you have this androgenetic alopecia thing, female-pattern hair loss.

Dr. Tarbox: So we always want to know "How bad is it going to get? What is the prognosis?" And that does vary somewhat based off of the individual and their unique genetics, but it is a progressive process. So, if you don't do anything to interfere with it, it will continue to get worse in most patients.

Dr. Johnson: But the good news is that we can do stuff to interfere with it.

Dr. Tarbox: We have the technology. We can repair it.

Dr. Johnson: Dermatologists are, again, medical doctors when it comes to the hair, so one of the things we treat is various types of hair loss. And our goal with this pattern hair loss, male or female, is mostly to slow it down or stop it. And if we can recover hair that's already been lost, that's kind of a bonus. So that's an argument in favor of getting to your dermatologist early to jump on this so that you don't lose more hair than you have to.

Dr. Tarbox: So the most common and easily accessible treatment for androgenetic alopecia and really useful in all types of alopecia is topical minoxidil. Minoxidil goes under the brand name of Rogaine, but there are a lot of generic producers of this medication as well. And it has sort of a fascinating origin story. Luke and I are both comic book nerds, so we love a good origin story, and minoxidil has a great one.

So back in the day when we didn't have a whole lot of medications that treated high blood pressure, minoxidil was one of the first and earliest developed blood pressure medications, and it was used intravenously in patients with severe high blood pressure that were in the hospital.


If you look back in the dermatology literature around the same time it was introduced, there are all of these case reports about full body hirsutism, hair growing over the entire body because people were using that IV minoxidil to treat the hypertension.


So somebody very smart thought to themselves, "Well, if you give people minoxidil by vein and they grow hair everywhere, what would happen if you just put it on the skin?" And so they actually paid medical students to take the IV infusion solution and rub it on their forearms and the hair on the forearms where they were treating it got darker and thicker, and lo, Rogaine was born.


Dr. Johnson: Interestingly, my great uncle was involved in the team that developed this drug in the first place.

Dr. Tarbox: What? I never knew that.

Dr. Johnson: Yeah, Herschel Schnapper. We called him Uncle Hershey. The only other medical doctor in the family before my brother and I. But that's an aside.

So topical minoxidil, or Rogaine, is available over the counter and is a very safe medicine. Women can use the men's strength unless they are pregnant or breastfeeding. And you apply it to wherever you want your hair to grow, which is usually the scalp, a couple of times a day and wash your hands afterward because it can grow hair wherever it's applied. And for the same reason, be careful about it running down your cheek or onto your neck or something like that.


Dr. Tarbox: Absolutely. Topical minoxidil works where it is applied. So it's been used in both liquid form as a solution, there are sprays, and there are foams. The strengths over the counter typically are 2% or 5%, but there are some manufacturers that will go up to about 8% over the counter. It's a very safe medication if it's used topically. We don't recommend it's used during pregnancy. However, if you are not pregnant, it is safe to use.

People can have an allergy to minoxidil. So, if you have irritation after using minoxidil, it might be the medication or it might be something in the solution. Usually, it's propylene glycol.


There are a few important things to know about when you're using minoxidil. Luke, do you remember what happened when you had your baby teeth and then you grew your adult teeth? What happened when your adult teeth started to come out?


Dr. Tarbox: My adult teeth did not start to come out, yikes. I still have them all. Thank you.

Dr. Johnson: Oh, I'm sorry. What happened when your adult teeth started to emerge? You shed your baby teeth, right?

Dr. Tarbox: I did. I put them under the pillow and got money from the Tooth Fairy.

Dr. Johnson: Exactly. So, when minoxidil is used in a patient who has alopecia, sometimes that will trigger a new hair shaft to just start growing out of the hair follicle. And if there is an old hair shaft in that follicle, it can get pushed out by the newly growing hair shaft. And that means that you can end up having some shedding after starting minoxidil. Some people panic when this occurs and they stop the medication. But the thing is if you have that shed, it actually means you're responding really well to the minoxidil and a whole new bumper crop of baby hairs is trying to grow. And if you continue the medication, you can continue to get that benefit.

Dr. Johnson: Minoxidil works pretty well. There's an old "Simpsons" episode where Homer uses it and gets impressive hair. I think Harvey Fierstein is a guest voice in that one. Usually, it's not that impressive in real life. Give it a good six months before you decide whether or not it's really working for you.

Dr. Tarbox: And it's really safe in most people. If you have a severe cardiac problem, a heart disease that's very bad, the heart doctor that treats you should be asked if you should start that medication, as it is, when used orally, a blood pressure altering medication.

Dr. Johnson: There are some other over-the-counter products that can be helpful for hair loss regardless of the kind. But again, usually, it's this androgenetic type of hair loss. And one of them is a vitamin called biotin. So biotin has been shown to be good for hair and nails. Don't take too much of it because that can play around with some lab results that your doctors might want to get for some reason. Just follow the instructions on the bottle and it's shown to be good for hair and nails.

Dr. Tarbox: Yeah, I've seen some supplements that have crazy mega-doses of biotin and you really don't need that much of it. Now, biotin being a B vitamin, there is some good news about that. All our B vitamins tend to be fat . . . they tend to be liquid soluble, so they dissolve in water, which means that if you take too much of them, they are excreted in your urine. So taking too much doesn't really help so much.

Speaking of taking too much, you definitely want to make sure you're balancing your diet and your supplements when you're trying to treat hair loss and ensure that you're taking proper nutrition.


Dr. Johnson: Yes, I remember a hair loss expert talking to us once how she knows a number of very fit, healthy young women who eat nothing but salads. And because they don't have enough protein intake, they can't grow their hair properly.

I've been looking forward to talking to you during this episode, Michelle, because I know you're especially good at hair loss, and I remember you had told me about a product called Viviscal.


Dr. Tarbox: So Viviscal is a different kind of oral supplement for hair loss. It has a couple of ingredients in it that are a little bit novel. So it has some marine minerals. It has actually shark cartilage, but they're not murdering sharks to make this product. It's a cultured cell line of shark chondroblasts. So it's the cells that make cartilage.

Dr. Johnson: So they don't get it actually from sharks. They get it from cells that make cartilage that is the same type of cartilage that sharks have.

Dr. Tarbox: Exactly. And there's some apple enzyme in the Viviscal. They have some pretty decent studies to show that it has some benefit. In my personal experience using it for a lot of hair loss patients, I find that it slows down the rate of shedding if somebody has one of those stress-induced moments of hair loss we talked about earlier, that telogen effluvium. And in patients who have androgenetic alopecia, it tends to help thicken the hair back up.

It does take time, like any hair loss medication. So I like to tell patients when I meet them for the first time for hair loss, "If I had a magic wand and I could fix everything that caused you to shed your hair right now today, it would still take about six months for you to start to notice it growing back."


Dr. Johnson: Do you like Viviscal or Viviscal Professional?

Dr. Tarbox: Well, I personally like Viviscal Professional. Viviscal Professional is a little bit more expensive than the regular version of Viviscal, but both are effective. Viviscal without the professional branding, that is available I think at Walgreens. The Viviscal Professional is often sold through doctor's offices. I don't sell any products in my practice because I'm at a university and it just doesn't work well to do that. But I do think that that's a good product and a lot of people use it and tolerate it well.

Other things that can be helpful . . . we talk about blood flow, right? So the reason that you bleed so much if you cut your scalp is you have a lot of blood flow to your scalp, and that's necessary to be able to grow hair. So things that improve blood flow can be helpful, including scalp massage. So I often will have my patients who present to me with alopecia do a little soothing self-scalp massage, or if they have a willing and loving partner to help them with this.


And it's important to note that you're not just rubbing the hair. You're actually moving the skin of the scalp. And what your goal is, is to get the circulation to the scalp to increase.


Dr. Johnson: So massage, this Viviscal, biotin supplements, and minoxidil that you put on your scalp, those are all over-the-counter things that can help. It's important to know that if you stop them, especially minoxidil, you will lose all the hair that it gave you. So one of my colleagues likes to talk about it like toothpaste for the scalp. You brush your teeth twice a day to keep your teeth healthy. You can put this stuff on your scalp twice a day to keep your hair healthy.

Dr. Tarbox: I think that's a great way to think about it. It's like any other cosmetic product. So I find that a lot of people's hang-ups about using it are, "Well, I'll have to keep using it." I'm like, "If it works for you, you do have to keep using it. You'll lose the benefit of it if you stop." But it's not that cumbersome of a thing to do and it's really quite effective. And if people do stop it, they would only lose what they gained from it. So you're not going to be worse off for having used it.

Dr. Johnson: There are a couple of other out-of-the-box ideas. So there are ways to disguise your hair loss rather than actually correcting it by getting hair back or slowing the hair loss. So I think there are . . . they look like markers or pens and you sort of just color in the scalp where you don't have the hair or where you have thinning hair, so it becomes less obvious.

Dr. Tarbox: That's one product to use. The ones I like better actually . . . they have these powders that are keratin fibers that are electrostatically charged, so they stick to the hair. Just like when you were a kid and you'd rub a balloon on your hair and then you could move the hair around with the balloon. So these particles of keratin are electrostatically charged and dyed to match different hair colors. You can actually spray them onto the area where the hair is thinner and they will adhere by electrostatic forces to those hairs and make them seem fuller and thicker and they help to camouflage in the areas where the scalp is showing. And then they just rinse out in the shower.

Dr. Johnson: Do you remember the name of that product?

Dr. Tarbox: There are a couple of different ones. One is called Toppik. Viviscal also makes one that are the hair fibers. There are a lot of different ones. There's another one that you can kind of buy at the salons, but most of them are well made. The ones that I've found that work the best . . . I like the Viviscal one because they actually have a little atomizer. It's kind of a squishy thing that blows little fibers out onto the areas where you have the areas of thinning. So it's very easy to use.

Dr. Johnson: So those are some over-the-counter things that can be helpful for the type of hair loss you have, mostly regardless of what kind you have, but there's lots of stuff that's not available over the counter, but that a dermatologist can help you with. So how can a dermatologist help if you have hair loss, Michelle?

Dr. Tarbox: So, if you are a person who is a gentleman, we really only have one . . . well, we have two prescription medicines that we can use kind of with some routine usage. So one of them is Finasteride. Finasteride is a medication whose first indication was actually to treat patients with prostate cancer or prostate hypertrophy. It is a medicine that inhibits an enzyme that is called 5-alpha reductase, and it basically turns testosterone into super testosterone.

So that super testosterone, which is called dihydroxytestosterone, is really active at the hair follicle. It makes acne worse. And it also causes that miniaturization of the hair follicles that we talked about earlier. So by inhibiting the enzyme that does that, that 5-alpha reductase, you can actually improve your hair growth.


There are some natural products that have natural antagonism of 5-alpha reductase as well. One of them is saw palmetto. So you might hear about people with hair loss taking saw palmetto. Another natural product that does that is nettle. So those stinging nettles that you might see when you go out in the mountains, don't go pick those up. They make this in a convenient capsule form that's much less pokey.


Dr. Johnson: So, if you wanted to go see a dermatologist for your hair loss, dermatologists can help by getting the right diagnosis so we know what kind of hair loss you have, and they can do that through numerous ways. They can look at your scalp, they can sort of tug on your hair to see if it comes loose easily, they have special magnifiers that they can use to take a really close look at the hair follicles, or we can draw labs. So sometimes we'll check iron and vitamin levels and thyroid levels and things like that. Some patients get a skin biopsy of their scalp so that we can look at some of the scalp skin tissue under the microscope to figure out what's going on.

And then after we've figured out what's going on, we can give you the right treatment, like some of the ones that we have mentioned and then there are other options as well.


Dr. Tarbox: And so finasteride can be used for men. It is also able to be used for women, but women have to be very careful that they might not be pregnant, because if you were taking finasteride and you were pregnant, it could have effects on the fetus, especially if the fetus was a boy.

We talked about topical minoxidil, but you can also use PO minoxidil. So minoxidil can be given by a physician at a known dosage by mouth to help with hair. Now, this is very important. If you take too much minoxidil by mouth, you can put yourself in the hospital. So this is not a DIY thing. Do not do this yourself at home. I don't want anyone going home and drinking Rogaine solution or something like that. People have ended up in the hospital because of doing that. But if you use the minoxidil under the supervision of a doctor at the proper doses, it can be beneficial.


It has to be taken properly. This is not the kind of medication you want to American it up with. You know the good old American way where if one is good, 10 is better? This is not a medicine to do that with because it has what we call a narrow therapeutic index. So the doses that it's prescribed for hair loss, it's very, very safe. But if people get impatient and want to see if taking more makes it work better or faster, what they're going to do is potentially worsen the side effects and not really get any extra benefit.


If you take too much, you can get peripheral edema. You can get swelling in your legs. And if you take way too much, you can have trouble maintaining your blood pressure. It is a very powerful antihypertensive.


Dr. Johnson: But very good for some people, and a dermatologist can help you with it. So come to somebody like that and we'll help you out.

Thanks a lot for listening to us today. We want to thank our institutions for supporting the podcast. Thanks to the University of Utah Department of Dermatology and Texas Tech University Department of Dermatology.


If you consider yourself a dermatology nerd, you might be interested that Michelle and I have another podcast called "Dermasphere," where we talk about some of the latest research in dermatology.