Thoroughly evaluating patients with hair loss requires considering everything from family history to the patient's dietary and drug regimens, said experts at The Cosmetic Bootcamp. Do not underestimate the impact of microinflammation, they added.
Along with aging, said Wendy E. Roberts, M.D., factors that attack hair include stress, dihydrotestosterone (DHT) and other hormones, free radicals and oxidative stress, styling, pollution, inflammation and compromised circulation and nutrition. "So when we lay out our hair-growth strategies, we want to target all these items, not only with our nutraceuticals, but also with procedures." (See related article, Nonsurgical treatments for hair loss). She is a Rancho Mirage, Calif.-based dermatologist at Generational and Cosmetic Dermatology.
Microinflammation of the Hair Follicle
The microenvironment of the hair follicle includes a complex system of pathways that physicians must target to treat hair loss, according to a Sadick et al. publication in the November 2017 Journal of Drugs in Dermatology. Key ingredients out of balance include androgens, cortisol and corticotropin-releasing hormone.
Jeanine B. Downie, M.D., said, "I tell patients all the time, if you're totally stressed and you don't exercise, that cortisol is bathing your whole body." Sequela can include diabetes, heart disease and hair loss. "The bottom line is, you have to take down the stress by exercising and doing other things — that's absolutely critical." She is director of image Dermatology PC in Montclair, NJ, and assistant attending physician at Mountainside and Overlook Hospitals in Summit and Montclair, NJ, respectively.
Overproduction of proinflammatory cytokines such as interleukin (IL)-1 and TNFa induces premature catagen, liberate reactive oxygen species (ROS) and spur apoptosis and further inflammation, according to Sadick et al. Additional harm comes from particulate pollutants, hair-product buildup, ultraviolet radiation and smoke from cigarettes, marijuana and vaping, said Dr. Downie. "So make sure you're asking all those questions." Patients who use marijuana may not admit it unless asked specifically, she explained, even when she can smell it on them.
All the above factors stimulate the inflammatory response, which can cause release of reactive oxygen species (ROS). The result is microinflammation within the hair follicle — even in forms of hair loss previously thought to be noninflammatory in origin, such as androgenetic alopecia, according to Sadick et al.
Microscopically, hallmarks of follicular microinflammation include perifollicular lymphocytic infiltrate, immunoglobulin deposits, fibroblast activation and mast cell degranulation. Clinically, said Dr. Downie, signs can include the early phases of follicular degeneration syndrome (FDS), during which women complain that their scalp is itchy or boggy. "It's more common in women with skin of color than in Caucasian women, but it affects both. I see it in Latina women. I don't see it that much in Asian-American women. But you see it in all the other races. You cannot ignore that microinflammation, because it's just going to get worse, and it can wind up taking their hair out."
Dr. Downie has been a researcher, consultant or advisory board member for Nutraceutical Wellness Inc. (Nutrafol), Restorsea, Lifes2Good (Viviscal), and Regimen MD.
Dr. Roberts has been a speaker, consultant or researcher for Allergan, Eclipse, Lifes2Good (Viviscal), Restorsea and Vitalize.
Wendy E Roberts MD. "Noninvasive Approaches to Hair Loss," The Cosmetic Bootcamp. June 23, 2018.
Jeanine B Downie, MD. "Clinical Assessment of Hair Loss," The Cosmetic Bootcamp. June 23, 2018.
Sadick, N; Callender, V; Kircik, L; Kogan, S. New Insight Into the Pathophysiology of Hair Loss Trigger a Paradigm Shift in the Treatment Approach. J Drugs Dermatol. 2017;16(11 Suppl):s135-140.
Cheung, EJ; Sink, JR; English, JC. Vitamin and Mineral Deficiencies in Patients With Telogen Effluvium: A Retrospective Cross-Sectional Study. J Drugs Dermatol. 2016;15(10):1235-1237.