“I’m losing my hair”

Introducing the most common cause of hair loss in young adults… with a silver lining.

Hair loss is a challenging issue, not for diagnostic reasons, but because our treatments lack sophistication. The current market offers primitive solutions. For hair loss that is non-scarring, meaning that it does not cause the hair follicles to lose function, patients can try Rogaine (nowadays available as generic minoxidil for ~$20 a month) or an oral pill called finasteride (that may have controversial side effects). The final effort is hair transplantation. Then we’ve basically run out of treatments.

Since no one has ever died from being bald, I imagine the National Institutes of Health (NIH) is not racing to fund research in this field, therefore any advances in curing hair loss largely falls on the shoulders of big pharma.

Fortunately one of the most common things I hear from my patients include “my hair is falling out very easily” or “the hair collecting in my shower drain is much thicker than normal.” This combined with the patient being in their early twenties to late thirties strongly suggests a diagnosis of telogen effluvium.

Hair growth cycle.

Hair has a dynamic life cycle in which it is either resting, growing, or shedding. In telogen effluvium, the hair cycles become synchronized in the resting or telogen phase, and then approximately three months later, the hairs shed in unison causing extreme worry and anxiety.

We can anticipate shedding ~100 hairs daily under “calm” circumstances. However, concern for telogen effluvium emerges when this number exceeds a few hundred hairs daily. A shedding scale is shown below that can provide a reference for what pathologic hair shedding (Grades 5 and 6) as seen in telogen effluvium would look like.

Visual shedding scale. The patient chooses the photograph that best correlates with the amount of daily hair shedding in the setting of daily washing. Grades 1–4 are considered normal while grades 5 and 6 reflect excessive shedding. Source: Dermatology by Bolognia et al.

There are numerous causes of telogen effluvium. Some of the most common are stress (e.g., pregnancy, mid-terms), infections (e.g., COVID) and drugs (e.g., discontinuing oral contraception, excess vitamin A). While there is no “cure” per se, the good news is that after the underlying cause (if identified) is removed, complete hair growth is expected in the vast majority of cases. This is because telogen effluvium does not cause scarring or permanent damage to the hair follicles. Nevertheless, hair regrowth is a slow process and we often have to remind patients that this regrowth may take at least 9–12 months.