Hair, and what can be done about losing it

Hair loss is distressing out of proportion to its medical significance, which is a legitimate reason to treat it and also the reason the market around it is so poorly regulated.

The main patterns

Androgenetic alopecia, male and female pattern hair loss, which is by far the most common.

In men it presents as receding temples and crown thinning; in women as diffuse thinning over the crown with preservation of the frontal hairline.

It is progressive, is driven by genetic sensitivity of follicles to androgens, and does not resolve without treatment.

Telogen effluvium: diffuse shedding two to three months after a trigger, which is the delay that makes people look for the cause in the wrong place.

Triggers include illness, surgery, childbirth, significant weight loss, severe stress, and starting or stopping certain medications.

It is self-limiting and recovers over months, provided the trigger has resolved.

Alopecia areata: autoimmune, presenting as discrete round patches, sometimes progressing further.

It can regrow spontaneously, and treatment options have expanded considerably with newer systemic agents for severe disease.

Scarring alopecias, which destroy the follicle permanently and which are the reason any hair loss with redness, scaling, pain or loss of follicular openings needs prompt specialist assessment — treatment can stop progression but cannot restore what is gone.

Traction alopecia, from sustained tension in tight styles, braids and extensions, which is preventable and becomes permanent if continued.

What to check

Reversible contributors that a blood test identifies.

Iron deficiency, where ferritin matters even with a normal haemoglobin, and where hair is one of the first things affected.

Thyroid disease, both under- and overactive.

Vitamin D deficiency, with an association that is debated.

Zinc deficiency in specific circumstances.

Very low protein or very rapid weight loss.

Coeliac disease.

And in women with hair loss plus irregular periods, acne or hirsutism, an androgen assessment for polycystic ovary syndrome.

The treatments with evidence

Topical minoxidil, which has trial evidence in both men and women, requires continuous use, and produces an initial increase in shedding that causes many people to stop just before it starts working.

Effects take three to six months to become visible.

Oral finasteride and dutasteride in men, which have strong evidence for slowing loss and producing some regrowth, and which carry a well-known discussion around sexual side effects.

They are not used in women who may become pregnant.

Low-dose oral minoxidil, increasingly used off-label with growing evidence and requiring monitoring.

Anti-androgen treatments in women, including spironolactone and certain combined contraceptives, used in appropriate cases.

Hair transplantation, which moves follicles resistant to androgens and which works, provided the underlying loss is medically stabilised first — otherwise the surrounding hair continues to thin around the transplant.

Platelet-rich plasma, which has a growing but heterogeneous evidence base and variable protocols.

Low-level laser devices, with modest supporting evidence.

What does not work

The larger part of the market.

Most shampoos, which cannot affect follicle biology in the time they are in contact with the scalp, though some contain ingredients with modest evidence for scalp conditions.

Most supplements in people who are not deficient — and biotin specifically, which is only useful in genuine deficiency and which interferes with several laboratory assays including thyroid and cardiac tests, producing misleading results.

Scalp massage, castor oil, rosemary oil and similar remedies, where evidence ranges from absent to a small number of low-quality studies.

And anything promising regrowth in weeks, since the hair cycle does not permit it.

Timing

The single most important practical point.

Treatments for androgenetic alopecia preserve what is present far more effectively than they restore what is lost.

Follicles that have miniaturised completely do not respond.

Which means that starting early makes a substantial difference to the outcome, and that the common pattern of waiting several years to see whether it stops is the most costly available decision.

The psychological part

Worth acknowledging rather than minimising.

Hair loss has documented effects on mood, self-esteem and social confidence, particularly in women, for whom it is less socially normalised.

Which makes it reasonable to treat, reasonable to seek help for, and unreasonable to be told it does not matter.

Alopecia support organisations exist and are useful, particularly for extensive autoimmune hair loss where the psychological impact is greatest.

General information only, not medical advice. Consult a qualified clinician or dermatologist about hair loss, particularly if there is scalp redness, scaling or scarring.