On average, a healthy person sheds between 50-100 strands of hair a day, from around 100,000 hair follicles that are usually present on the scalp. This is considered to be normal hair shedding, and accounts for part of the natural hair cycle. Hair loss refers to significantly excessive shedding over a period of time, that could arise from different causes and results in a noticeable and usually permanent change.

Hair follicles are complex tube-like structures in the dermis layer of the skin from which a single hair strand grows. It is equipped with proteins and pigment, a sebaceous gland (oil gland), blood vessels, nerves, and an arrector pili muscle, all of which support the growth and development of each hair.

Each strand of hair goes through several phases during their life cycle.

1. Anagen (growth) phase – At any given time, about 90% of our hair strands are in this phase which can last from between three to seven years. Hair growth begins at the follicle and then pushes its way out through the skin. Typically, a strand grows about 1 cm every month. An impediment of this phase leads to what we commonly call ‘hair loss’ and is referred to as anagen effluvium.
2. Catagen (transitional) phase – At any given time, about 1-2% of our hair strands are in this phase which can last from between a few weeks to a few months. Hair growth slows down during this phase and the follicle shrinks to some extent.
3. Telogen (resting) phase – At any given time, about 8-9% of our hair strands are in this phase which can last from between three to four months. The hair follicle is at rest during this phase before it detaches and falls out. The follicle, however, is believed to be very active during this phase as it prepares for the generation of a new strand of hair. If more than 10% of one’s hair is in the telogen phase at a given time, it is considered to be excessive shedding and is referred to as telogen effluvium.

Symptoms and Preliminary Diagnosis

It is normal to notice more hair shedding when bathing or brushing hair as loose strands tend to fall out when agitated. Of course, this is more obvious in people with long hair.

A simple preliminary method to determine if there is excessive shedding is to carry out a ‘pull test’. This should be done when your hair is clean and dry, and involves running your fingers through the hair and gently tugging at the end. It is normal to have 2-3 strands of hair come out when you do this. However, if 8-10 or more strands of hair come loose, it is very likely that you are experiencing excessive shedding. If this persists, it is best to see your GP or a dermatologist for advice on how to manage the condition.

Causes of Telogen effluvium

There are several reasons that could be causing excessive hair shedding, or telogen effluvium. These include:

• aging – hair often gets thinner with age, making them more susceptible to being shed
• stressful life events – stress causes androgen levels in the body to rise, which in turn could result in hair loss; e.g. separation from or loss of a loved one, job loss
• genetics – hereditary hair loss or hair thinning sometimes runs through generations
• poor nutrition – lack of a balanced diet that includes vital vitamins, proteins, iron and minerals such as zinc
• iron deficiency anaemia – this could result in blood supply, containing nutrients, to the hair being compromised
• excessive hair styling – frequently wearing hairstyles that pull tightly on the hair, or frequent use of styling chemicals could lead to increased shedding over time
• hair care products – certain products may not agree with certain skin or hair types, and may subsequently lead to hair damage or shedding
• water quality – heavily chlorinated water or frequent use of hot water can be damaging for the hair and also increase shedding
• hormonal imbalances – mostly when there is an excess of androgens such as in the case of PCOS
• hormonal medication – such as stopping or changing the birth control pill, medication used to assist conception
• medical conditions – such as thyroid disease
• biological life events – such as the menopause in women
• medical treatment – such as chemotherapy, or radiation therapy close to the head/neck
• giving birth – post-partum hair shedding may occur for a few months in some individuals
• recovering from surgery or illness – increasingly so in the case of major surgery or illness, but sometimes even with more common illnesses that cause fever
• excessive weight loss – this is often reflective on the hair as well, and so should be conducted with a healthy diet plan

In most cases, telogen effluvium is reversible or can be controlled to some extent once the causative factor is removed, or a suitable treatment is applied. As such, normal hair growth and shedding may be re-attained in about six to eight months following intervention.

Causes of Anagen Effluvium

Reasons that could contribute to hair loss, or anagen effluvium, include:

• aging – apart from thinning, hair growth from follicles may also subside with age
• androgenic alopecia – more commonly referred to as hereditary hair loss, where inherited genes may cause hair follicles to shrink and stop generating hair at some point of time in life. This may be differentiated as:

1. male pattern hair loss – this may begin with a receding hairline or a bald spot at the centre of the head and then spread further
2.  female pattern hair loss – this may begin with thinning hair or a widening part (i.e. hair partition gets noticeably wider)

While anagen effluvium may not be as easily reversible as telogen effluvium, at least partial reversal of the condition is not entirely impossible in certain cases. In fact, alopecia areata is often self-reversing after about twelve months of onset.

Prevention

There are a few general measures that can be taken to avoid or minimise telogen effluvium and, perhaps to some extent, anagen effluvium. These include:

• maintaining a healthy, balanced diet that has sufficient protein
• maintaining good hygiene of the scalp
• regularly taking essential vitamins and supplements that include iron, zinc, vitamin D
• avoiding frequent hair styling, particularly if it involves pulling tightly on the hair and application of heat
• using reputed hair care or styling products that are low on chemicals (preferably ammonia-free)
• using cool, room temperature or lukewarm water (instead of hot water) when washing your hair, and fitting a shower filter if your water supply is heavily chlorinated
• avoiding drastic diets and mindfully controlling any weight loss programs
• avoiding stressful situations, where possible, and engaging in frequent relaxation while maintaining a healthy sleep pattern
• seeking prompt medical help if you notice any changes or conditions on the scalp such as psoriasis
• seeking prompt medical attention for any other inherent or incidental medical conditions or illnesses

Treatment

It is best to consult your GP or a dermatologist if you observe persistent excessive hair fall, or notice a receding hairline or balding of any sort. Treatment would depend on the nature of the hair fall and the likely cause/s behind it. As such:

• If poor nutrition or a deficiency seems to be contributing towards excessive hair fall, your doctor would likely introduce you to a more balanced diet that has the necessary nutrients incorporated into it.
• Your doctor may also prescribe the use of specific supplements that are known to stimulate hair growth, such as the amino-acid L-tyrosine which helps protein synthesis.
• If other medical conditions such as hormonal imbalances, thyroid issues, etc. have been detected, treatment of these conditions may reduce hair fall that occurs as a side effect.
• In the case of chemotherapy recipients, using a cooling/ice bag on the scalp before, during and after treatment has been shown to reduce hair fall to some extent as the low temperature reduces the flow of blood containing chemicals to the head region.
• If stress is found to be a causative factor, relaxation techniques such as meditation and yoga might help in milder cases, while more serious cases might require assistance from a mental health specialist to tackle and overcome the cause of stress.
• If certain medications are found to cause hair fall, your doctor might be able to prescribe alternative options, e.g. a different formula of medicine, non-hormonal contraceptive pills.
• While conditions like alopecia areata are usually self-healing, implementing treatment such as medicinal injections in the affected area soon after onset would almost certainly make the reversal process commence more quickly.
• Hair transplants are a more tedious and expensive option that could be used in cases of irreversible hair loss. It involves removing hair from another part of the body and introducing them to follicles on the scalp from which hair has been lost. Ideally, this should stimulate the follicles and cause the regeneration of new, healthier hair after a period of a few months. However, there still is a possibility of the new hair experiencing thinning and falling after some time.

If the condition is mild and seems to be due to a temporary reason of some sort (such as a stressful life event), a more cosmetic than medical approach could be to have electric pulse treatment that stimulates the hair follicles to regenerate. However, such a treatment should only be done at reputed salons, and preferably by someone who has handled your hair before.

Wigs and hair weaves or extensions are a few other cosmetic solutions that may be available. Of course, these are more temporary solutions, and extensions and weaves, in particular, need to be chosen and attached carefully in order to avoid damaging existing hair. Wigs should ideally be removed daily while, extensions and weaves may last for up to 6-8 weeks.

Cover illustration from Freepik