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'My hair's falling out!'



Mrs Jones is a smartly dressed middle-aged woman but today she looks close to tears. 'I've come about my hair, doctor. It's going all thin, and I think I'm going bald.' Her hair doesn't actually look that bad to you, but she shows you a small bare patch the size of a 5p piece. 'My hairdresser found it. She said you'd be able to do something about it.'

Dr Melanie Wynne-Jones discusses.

What is normal hair growth and loss?

We have around 100,000 hairs on our heads and lose up to 100 a day without really noticing. Scalp hair grows at a rate of 1 centimetre per month for three to five year (anagen phase), reaching a maximum length of around 60cm before it eventually stops growing (catagen phase).

The hair follicle then enters a dormant phase (telogen), and after about three months a new hair starts growing and pushes out the old one. As all the scalp hairs are at different stages, hair loss is usually slight and continuous.

As we get older; most of us start to lose some hair. Female-pattern baldness produces generalised thinning, although male pattern baldness (a receding hairline leading to partial or total baldness) can affect women too.

Why is Mrs Jones so upset?

'Bad hair days' genuinely upset many women and the thought of permanent problems can be devastating. An important part of this consultation is to ask Mrs Jones how her hair problems make her feel, and what her worst fears are.

She may be worried that her hair may never regain its past thickness and body, and may have underlying fears about getting older or losing her looks. These may relate to problems with relationships, work status and so on.

The hairdresser may have refused to continue dyeing or perming her hair, frightened her with warnings of severe hair loss, or alternatively have raised her expectations that the doctor can magically put it all right.

What are the medical causes of hair loss?

The telogen phase is prolonged by pregnancy and the oral contraceptive pill, so shedding is delayed. Afer childbirth or stopping the pill, the 'delayed' hairs rapidly start to fall out ­ telogen effluvium.

This looks alarming, especially if the sink is clogged after hairwashing, but sufferers should be reassured that it should stop after three to six months. Stress, acute illness and dieting can also trigger a telogen effluvium.

Cytotoxics produce an anagen effluvium with rapid and dramatic hair loss; scalp radiotherapy, high-dose colchicine and heavy metal poisoning can also trigger it. Other causes of hair loss/thinning include:

·Iron-deficiency, hypothyroidism, diabetes, lupus

·Falling hormone levels after the menopause

·Anticoagulants, antidepressants and other drugs

·Depot progesterone injections ­ check oestradiol levels

·Traction alopecia (tight hair styles such as braids or corn-rows may pull hairs out)

·Hair dyes and chemical treatments which can damage and scar hair follicles

·Skin conditions affecting the scalp, including alopecia areata, fungal infections, burns or trauma

·Trichotillomania (deliberate pulling out of hairs) ­ this may be a nervous habit or sign of more disturbed behaviour, especially when it leads to large denuded areas of scalp.

Does Mrs Jones have alopecia areata?

What does the patch look like? In alopecia areata, the bald skin looks completely normal, although there may be 'exclamation mark' (short, tapering) hairs around the edges, or fine downy regrowth of hair which gradually strengthens and regains its natural colour. There may be multiple or recurring patches and body hair may also be lost although alopecia totalis/universalis is rare.

Alopecia is an auto-immune attack on the hair follicle which recovers within a year in up to 80 per cent of cases. One in five sufferers has an affected family member; there are also links to vitiligo, diabetes and thyroid disease. It can be triggered by stress or lead to depression. Treatments include:

·Steroid creams and scalp applications which may stimulate regrowth; local steroid injections to the scalp or brows are effective for small patches.

·Contact sensitisation treatment. A strong sensitiser, for example diphencyprone, is applied to the skin; subsequent weaker applications to the bald areas produce a mild allergic dermatitis and regrowth in up to 50 per cent of patients over six months. Risks include excessive sensitivity or depigmentation.

·Dithranol cream.

·UVA radiation plus psoralen tablets or cream (PUVA) may be effective over a period of months; relapse often occurs after stopping PUVA.

·Minoxidil lotion (Regaine), normally used for male-pattern thinning and baldness, sometimes works for alopecia areata.

What other conditions damage hair growth?

·Fungal infections such as ringworm. Unlike alopecia, this patchy hair loss produces itching redness and scaling; antifungal cream should clear it.

·Psoriasis often affects the scalp and produces thick, itchy silvery scale and plaques; scratching can damage the hair follicle in this and other itchy scalp conditions such as eczema, seborrhoeic eczema and lichen planus.

·Physical trauma that causes scarring can lead to permanent local loss of hair.

Melanie Wynne-Jones is a GP in Marple, Cheshire

Key points

·Damage to hair can also damage self-esteem

·The commonest cause of hair loss is ageing

·Many medical and skin conditions can cause hair loss

·Telogen effluvium is a common but self-limiting cause

·Alopecia areata is also often self-limiting; available treatments have a variable success rate


Patient information leaflets

·British Association of Dermatologists,

4 Fitzroy Square, London W1T 5HQ. Tel: 020 7383 0266

·Hairline International (The Alopecia Patients Society) Lyons Court, 1668 High Street, Knowle, West Midlands B93 0LY (enclose an A4 stamped addressed envelope). Tel: 01564 775281

·PRODIGY Guidance on fungal infections of skin and nails


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