All About Balding

Alopecia (another word for hair loss) is when someone is going bald. Alopeca normally occurs in males who have a genetic history of baldness or this can simply apply to general hair loss.

Where the word “bald” comes from

“Alopecia” comes from the Greek term meaning “fox”, since animals shed their coats a couple of times a year and foxes lose hair due of mange. The word “bald” is most likely a derivative of the English word “balde”, which means something is pale, white, blaze, or a white patch.

Different factors that lead to someone losing their hair (also called hypotrichosis) include:

The range and severity of hair loss can be anywhere from losing all of the hair on the head (alopecia totalis) to complete loss of hair on the head and body (alopecia universalis).

Baldness refers to partial or total lack of the growth of hair and leads into the bigger topic of hair thinning. Although the pattern and rigorousness for baldness differs, the most standard causes are alopecia androgenetica, androgenic alopecia, or alopecia seborrheica (mainly found in Europe populations).


Signs of baldingbaldman

Some signs of balding include the loss of hair in a round pattern on top of the head, skin lacerations, dandruff, and/or scarring. Mild to medium level alopecia areata normally occurs in unusual areas like losing hair in the eyebrows, back of the head or above the ears.

Normally men who experience hair loss see a pattern in the mid-frontal area, like when balding begins at the temples and at the crown of the head and then falls out. An example of mid-frontal balding is like what you see on the tennis player Andre Agassi. A standard pattern for women experiencing hair loss is usually in the parietal and frontal areas.

Humans have around 100,000-150,000 hairs on the head. Although the number of hairs that a person sheds per day varies, normally it is around 100. To keep a full head of hair, one must grow/replace the hair that is lost. When you start to notice more hair in your brush or in the shower after washing it, then that is usually one of the first signs of balding. Hair loss can also be emphasized in how one styles their hair- combing it in a way that shows a wider part or a balding crown.

Other circumstances can lead to hair loss as well, like cystic acne or a psychological condition.

shutterstock_373413967Cystic acne, which refers to someone who has blemishes on their body, can also experience hair loss since acne and balding are forms of a hormonal imbalance connected with the production of dihydrotestosterone. Other hormonal imbalances apply to hair loss like when the body creates too much sebum, which can be seen stacking up on the scalp of the head like a hat (called seborrheic dermatitis). If hair is too oily or too dry, that can also lead to hair thinning.

Hair loss is connected to increased stress since society places such a high emphasis on appearance. Due to the perceived stigma that appearance leads to happiness, power, and success, a whole branch of psychology was created in the 1960’s to address these issues.shutterstock_421939312

Especially for females, hair is believed to be an integral part of one’s overall identity and has a lot to do with their femininity and attractiveness. Since balding occurs in later years for men, people associate a full head of hair with endurance and youth. Although men may see or know of a pattern of baldness affecting their relatives, it’s an uncomfortable topic to bring up.

shutterstock_414350152Therefore, baldness is a sensitive issue for both men and women. Victims of baldness can feel a loss of control or isolation. People who are suffering from hair thinning may worry that they appear older or less attractive, which can be psychologically devastating.

Hair loss is also a common occurrence for cancer patients who undergo chemotherapy, but studies show that experiencing hair loss as a result of chemo can also cause variations in self-consciousness and body image. Sadly, when a person undergoes chemotherapy and their hair grows back, a lot of times their confidence and previous ideas about their body image does not return. A lot of patients go through alexithymia (where they have trouble expressing their feelings about the hair loss) and avoid any conversation about it.


Circling back to the causes of hair loss

Male pattern baldness (MPB) explains a majority of hair loss in men. MPB is defined as the hair receding from the sides of the forehead, commonly known as a “receding hairline”, or a thinning of hair in the crown, at the “vertex”. When both types of hair loss join together, it can leave a horseshoe-like ring around the back of the head.


Male pattern baldness

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MPB is mainly caused via a person’s genetic background. A person’s environment does not necessarily affect hair growth, but it does seem to vary between different societies. A large scale study conducted in Victoria, Australia, came back with results of mid-frontal baldness increasing with age. In people aged 80-plus, the survey showed that almost three-quarters of men and 57 percent of women experienced hair thinning.

Generally, when men start to go bald, it seems to correspond with their age. According to the Medem Medical Library, male pattern balding affects around 40 million American men. By the time they are 30, one in four men will have evident hair loss. Two out of three men will have obvious hair loss by the time they are 60. In unique cases, hair loss can occur in boys as early as 12 years old.

The heredities of MPB are not yet fully implicit, but there are most likely a few genes that contribute towards hair loss. It was formerly believed that baldness was passed down from the maternal grandfather, the Androgen Receptor gene X chromosome. While there is some research to coincide with this belief, MPB is most likely inherited from both parents’ chromosomes.

How DHT affects hair loss220px-Androstanolone.svg

Dihydrotestosterone (DHT) is a strong form of testosterone that can trigger hair loss. The androgenic hormone’s function is to grow body and facial hair. DHT not only affects hair growth, but the body’s prostate as well. Although the complete process of how DHT affects baldness is not fully known, it has been noticed that people who are affected by genetically-prone hair loss experience DHT follicular miniaturization as well, where the hair strands start to break down.

When this happens, the anagen hair growth period becomes shorter and the new unpigmented vellus hair cannot grow or mature into the fully pigmented terminal hair, the type of hair that is found on the majority of one’s head.

As time goes on and the hair breaks down and thins out, its overall voluptuousness subsiding until it looks like peach fuzz (a.k.a. vellus hair). Finally, the hair follicle becomes inactive and stops producing hair at all.


ThePortrait of attractive man with hair concern many causes of hair loss


Research has shown that lack of nutrition and small food ingestion can lead to hair thinning, like having a deficit of biotin, zinc, protein, and iron metabolism. Here are other connections to hair loss:



  • Hypervitaminosis A
  • Dissecting cellulitis
  • Tinea capitis and other fungal infections
  • Folliculitis
  • Infection
  • Secondary syphilis
  • Drug use
  • Demodex folliculorum (a tiny mite that feeds on sebum, which keeps hair from receiving the nutrients hair needs to grow- mostly seen in oily scalps)
  • Medications, like those to treat diabetes, cholesterol, heart disease, and blood pressure.
  • Hormone balance medicines such as steroids, hormone replacement therapy, the birth control pill, and medicines to treat acne.
  • Mycotic infection treatments
  • Side effects from medications for drug rehabilitation treatments, chemotherapy, contraceptives, and anabolic steroids. In chemotherapy, the treatment targets splitting cells but also causes a majority of one’s hair to fall out in the process.
  • Radiation to the head area- when applied to the head for treating certain cancers, the patient can experience baldness in the irritated areas.
  • Traumas- surgery, childbirth, stress and poisoning. Also called telogen effluvium, a lot of hair strands can go into a dormant phase, noticeable through the shedding of hair.
  • Styling of hair that lessens the complete volume (called traction alopecia). People with ponytails or cornrows, those who brush their hair rigorously, or apply heat treatments to their hair are more susceptible to damaging their hair follicles. It’s easier for the protective outer casing of the strand of hair to break down and break off, causing flat and thin hair.
  • Compulsive stretching and pulling out of hair (called trichotillomania). This type of behavior usually starts at puberty and continues through to adulthood. Since hair roots are constantly being yanked, it can lead to permanent balding.
  • Pregnancy- although not a direct cause of hair loss, during pregnancy a woman may experience thicker and more hair due to increased estrogen levels. After the baby is born, estrogen levels go back to normal and any excess hair falls out. This can also happen if a woman took clomiphene, the fertility-inducing drug.
  • Autoimmune disorder alopecia areata or “spot baldness”- this type of disorder can range from monolocularis (losing hair in only one area) to alopecia areata universalis (losing hair all over the place). What actually causes alopecia areata is not certain, but it is believed that it happens when hair follicles become inactive. In a lot of cases the body’s immunity fixes the condition itself, but it can also spread to the whole head (alopecia totalis) or body.
  • Cicatricial alopecia may diffuse or limit hair loss in someone suffering from lichen plano pilaris, central centrifugal cicatricial alopecia, folliculitis decalvans, lupus erythematosus, postmenopausal frontal fibrosing alopecia, and more. Tumors and skin growths like in basal/squamous cell carcinoma and sebaceous nevus can also create localized baldness, which can be noticeable for one to a few weeks.
  • An under-active thyroid problem (hypothyroidism) and medications used to treat it can also lead to balding usually in the frontal area. This can lead to hair loss in the eyebrows, also seen in those affected with syphilis. An over-active thyroid (hyperthyroidism) can cause parietal hair loss.
  • Congenital triangular alopecia- this condition is usually related to hair loss in young children. The oval shaped patch in the temple area can normally be related back to having vellus “peach fuzz” hair follicles or none at all, but it usually stays limited to that one area. The cause of congenital triangular alopecia is unknown, although it does not seem to spread to other areas.

When gradual balding seems to increase with age it is referred to as involutional alopecia, which happens when the hair follicles move from the growing phase (anagen) into a dormant phase (telogen).

Having an unhealthy scalp due to damage or miniaturization, environmental toxins such as air/water pollutants, certain hair styling products, and too much sebum buildup can also cause hair loss. Oil and debris can block hair strands from materializing and cause deterioration. The cuticles that are restricted or damaged weakens the hair follicles, causing them to break and disappear before they are ready to naturally fall out.

Causes of alopecia can be attributed back to: biotinidase deficiency, diabetes, chronic inflammation, alopecia mucinosa, pseudopelade of brocq, tufted follucluitis, lupus erythematosus, and telogen effluvium.

The pathophysiology of hair

Hair tends to grow in cycles, consisting of the anagen phase (the long growing strands), the catagen phase (short transitional term), and telogen phase (the resting/dormant process). When the hair has completed the telogen phase, it falls out (exogen) and new hair grows in its place, repeating the cycle.

An average of 40 hairs go through this cycle of falling out and re-growing every day (zero to 78 hairs go through this process in a normal male). Clinical hair loss (telogen effluvium) is generally diagnosed when someone loses 100 hair strands a day. This is usually a sign of a unique disruption of the growing phase of hair (anagen effluvium).

Symptoms of pattern hair loss in men and women can usually be determined without testing. If a young man experiences balding that cannot be attributed back to family genetics, it may be a sign of drug use.

However, the pull and pluck tests are examples of determining hair loss patterns. With the pull test, gentle extraction is applied to 40-60 hairs on several different areas on the scalp. The number of hairs that come out are counted under a microscope. In a pull test, less than three hairs should come out and if more than 10 hairs are released, the test is determined positive.

The pluck test is when hair is pulled out by the roots. The root of a hair not attached to the head can help determine which phase of growth the hair was in and a medical professional may be able to tell if it is related to telogen, anagen, or systemic disease.

The difference between the types of hairs is that telogen hairs have little bulbs at the ends of the roots without covers around them. Telogen effluvium shows a higher number of hairs resulting from the pluck test. Anagen hair roots have protective sheaths around the roots, so anagen effluvium is the result of less telogen hairs and more broken strands.

A biopsy of the scalp is conducted when a diagnosis cannot be determined via other methods. Samples of hair are taken from the infected area, normal along the border of the bare patch.

Testing for hair counts should be performed daily when the hair is first brushed out or when washed. The number of strands are recorded and placed in a clear plastic bag and kept for 14 days. The results are considered unusual if there are more than 100 hair strands per day, unless it is washed with shampoo (then losing up to 250 strands is still normal).

A medical tool called a handheld or video dermoscope offers a noninvasive way of checking the scalp and hair. For women who experience pattern baldness, the Savin Scale and the Ludwig Scale can help diagnose the problem. Both effectively monitor hair thinning, which normally starts on the crown behind the hairline and progressively becomes more visible. For those affected with MPB, the Hamilton-Norwood Scale can measure a thinning crown all the way to complete baldness.

In most cases of hair thinning or severe hair loss, it is best to seek the advice of a doctor or physician. Be assured that most hair loss issues have an underlying hereditary cause.

How hair loss can be cured

Although there are not very many proven treatments that stop the loss of hair, there are medications out there that can stop the hair that is left from further falling out. Here are three examples:

  1. Minoxidil (the main ingredient in Rogaine): this is an over-the-counter medicine to treat MPB and alopecia areata. Available in a foam or liquid form, it is buffed into the scalp two times a day. Since some people have experienced an allergy to propylene glycol, another ingredient in the minoxidil liquid, a foam version without propylene glycol is now available.

The longer the hair goes without growing though, the less likely the minoxidil solution will help to regenerate hair. Minoxidil can only really help with MPB and not with other types of hair loss. People who use Rogaine can start to see results anywhere from one to six months when it is used regularly. Once a person discontinues use of minoxidil, hair loss starts to occur again.

Plus, any hair that grew back during treatment can be lost again. Side effects may include allergic contact dermatitis, minor scalp irritation, and hair growing on other areas of the body.

  1. Finasteride (the main ingredient in Propecia) is taken in a one milligram pill form to treat MPB. This type of solution is not recommended for women, especially those who are pregnant. Within six weeks of treatment one can start to see results. Finasteride is effective in retaining hairs, the volume of it, and even re-growing hair. However, side effects that a small percentage of men have experienced include erectile dysfunction, decreased sex drive, and ejaculatory dysfunction. Propecia should be consumed as long as it is visibly working, otherwise hair thinning will resume.
  1. Corticosteroid injections: Mainly used for those suffering from alopecia areata, this type of treatment isnormally performed monthly. A pill form is also available, with results noticeable in up to a month.

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  1. Immunosuppressants: Applied to the scalp, this treatment can actually reverse alopecia areata, but it comes with some bad side effects.
  1. Anthralin: Currently being tested, this may help treat alopecia areata in the future.
  1. Hormonal modulators or antiandrogens like flutamide or spironolactone are primarily made for women’s hair thinning connected to hyperandrogenemia.

Hair transplant surgery

In this type of surgery, a patient is induced under an anesthetic and the doctor relocates the head’s healthy hair to areas where it is thinning. A hair transplant can take anywhere from four to eight hours, with the option of scheduling more sessions to create thicker hair. Although transplanted hair tends to fall out in a few weeks, new strands grow back in and stay permanently.

A hair transplant is the process of taking small plugs of skin and hair and integrating the plugs into the bare sections. Plugs are normally found on the sides or the back of the head.

Other surgical options such as follicle transplants, hair loss reduction, and scalp flaps are also available. Normally people who opt for these kinds of surgeries are self-conscious about their looks, but these types of treatments can be painful and expensive with many risks involved. After surgery, it takes 6-8 months to determine whether the transplant worked.

Scalp reduction refers to lessening the bare skin on the head. Over time, the head’s skin gains flexibility and can stretch enough to where it can be surgically removed. When the bald scalp is detached, it is replaced with a hair-covered scalp. A scalp reduction surgery usually coincides with a hair transplant to create a more natural-looking hairline. A hairline lowering procedure is also available.

Or wigs are a simple, inexpensive and temporary option. Nowadays, high-quality hairpieces and wigs are sold in specialty stores.

Other ways to hide hair loss

One technique of hiding baldness is to style the hair in what is called a “comb over”, which is basically combing hair from one side of the head over the bare area to hide the bald spot. This is an effective temporary solution when the bald spots are small, but may lose its effectiveness as more hair thinning occurs.

Wigs and toupees have progressed to the point of looking very real even though a lot of times the hair is fake. High quality wigs in the United States can cost upwards of thousands of dollars. Certain non-profit organizations and hair salons collect natural hair donations to be given back to cancer patients who lost their hair due to chemotherapy.

Eyebrow hair loss

One can lose their eyebrows due to hormone imbalance, chemotherapy, and hypothyroidism. But if this happens, fake eyebrows can easily replace ones that are completely gone or cover up patchy ones. Like tattooing, eyebrow embroidery uses a blade to integrate pigment into the face, giving eyebrows a more natural look that only lasts for a couple of years. Permanent makeup tattooing (micropigmentation) is available as an option that doesn’t require any maintenance down the road.

Hypothermia caps for chemo patients

Hypothermia caps with anthracyclines or tazanes can also avert hair loss in cancer patients. But it is most useful for chemotherapy patients and should not be used in leukemia or lymphoma cases. Although there are some side effects from this option, they are minor.

Or just embrace the new look

Instead of trying to hide hair thinning, many people purposely shave their heads. In men, the head grows hair just like stubble on the face. The good news is that intentionally bald heads are more socially acceptable these days, although still not so much with females.

Alternative treatments

Alternative options such as dietary supplements or biotin do not help with hair loss, but there was one clinical trial that tested saw palmetto, which showed signs of improving mild androgenetic alopecia problems. As of 2011, aloe vera, ginseng, hibiscus, gingko, or sorphora supplements tested don’t seem to cause any reaction. In other cultures, it is believed that egg oil helps with hair loss, but this hasn’t been scientifically concluded.

The evolving research and environmental factors

Scientists are currently continuing to research connections with other health problems and hair loss. In the mid-1950’s it was believed that MPB was related to heart disease, but no conclusive evidence was found.

A study in 2007 alluded to the connection between smoking and hair loss amongst older Asian men. A survey that recorded age and family demographics showed that there were many positive results with balding Asian men who were smokers.

It has been proven that vertex baldness is connected with a high risk of coronary heart disease. Studies show that vertex baldness is a big sign of CHD depending on its seriousness and atherosclerosis, although this does not apply to frontal baldness.



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