Hair Thinning

Hair Thinning

January 03, 2021

Thinning hair is one of the most common reasons for women to see their Dermatologist and perhaps the one that causes the most worry and distress. In discussing hair loss and its causes with patients, their biggest concerns tend to be a worry that it could be a sign of something worse and worries whether they can get it to grow back.



Is thinning hair and hair loss common at a certain age? 


It is normal to experience thinning of our hair as we get older.  Aside from genetics, there is a hormonal component at play here as well.  As women go through menopause, there is less estrogen and progesterone.  This leaves our hair more susceptible to the effects of androgens.  These hormones thin the hair and slow down its growth.



It should also be noted that certain autoimmune conditions (frontal fibrosing alopecia and lichen planopilaris) that cause hair loss also become more common after the age of 40.  These conditions result in inflammation at the base of the hair follicles that can actually scar the hair follicle and has a risk of permanent hair loss.  I believe this condition is underdiagnosed as I see it quite often and find that it is best to start treatment early to prevent long term hair loss.




What types of things commonly cause women to lose hair? 


Although many people are focused on their family history for hair loss, the reality is that as many as 2/3 of women after the age of 50 will likely experience hair loss from hormonal changes that come from menopause alone.  When estrogen and progesterone levels drop, androgens in our blood stream can have more of an impact in reducing hair growth.



Autoimmune conditions are also more common in women and can result in permanent hair loss if not treated early.  To visualize autoimmune conditions I tell my patients to think of their scalp as like a farm.  If there is inflammation in the skin, then it cannot grow a good hair follicle.  We need to treat the scalp to allow the hair to grow normally.



Medications are another common source of hair loss.  Non steroidal antiflammatory medications (NSAIDs) and thyroid medications are thought to be triggers. 



Stress, any kind of stress- physical, mental, or emotional- can trigger hair loss by shedding.  Crash dieting, surgeries, family stress, new jobs, having the flu, long distance travel, etc - this one can be tough for women to identify as a trigger because there is often a delay of 3 to 6 months after the stress before shedding is noted.  Normally, without stress, 80% or so of our hair is growing while the rest is resting. When a major stress occurs, then there is a shift in the hair cycle of growth.  Suddenly less hair follicles are stimulated to grow.  Our actively growing hair is rooted pretty deep in our scalp. It can take a few months for the shut down in hair growth to show itself as actual hair loss.  Ironically in some cases the ‘loss’ phase is actually the result of a new hair follicle growing in behind the old and pushing it out. The new hair follicle is a tapered new ‘peach fuzz’ type of hair, however.  It can take months for it to coarsen and grow to catch up to where you were before.



Vitamin deficiencies such as iron deficiency and vitamin B12 deficiencies have been linked to thinning hair as well.





Tips on how to grow a fuller, thicker head of hair


The first step towards fuller, thicker hair is diagnosing the cause of thinning or loss. A thorough history and physical exam by your dermatologist will help you identify the most likely triggers to address these directly.  If there is an autoimmune component, for example, this can be partially managed by certain medications by mouth or scalp injections.  Identifying any other factors such as low thyroid, vitamin deficiencies, etc can at least take away other factors inhibiting hair from growing to its full potential.




Fuller, thicker hair can be achieved by two methods.  Trying to get more hair to grow and/or trying to make our current hair appear ‘thicker’.






To try to get more hair to grow, consider adding minoxidil topically to your daily routine.  I know many hesitate to use it, however, it truly does work.  It can widen the barrel of each hair to make them coarser.  It could trigger new growth but at the very least it will help avoid further loss. I’m honest with my patients when I tell them I have used minoxidil for years.  Most men in my family lost much of their hair early on so I decided to start using minoxidil preventatively.



If there is a strong hormonal component, more post menopausal women are starting to see some benefits from taking an oral medication.  The two used are spironolactone (a blood pressure medication) and finasteride (men have used this for years).



Platelet rich plasma (PRP) has also gained a lot of attention in the past few years.  This is where I draw blood from the patient, spin it down with a centrifuge, and then remove the plasma layer that is rich in platelets and growth factors.  This is then injected directly into the scalp to trigger hair growth.  PRP has been used in various specialties for varying purposes.  I think it best to consider PRP as “enhancing self”.  In Dermatology we use it for scalps to promote hair growth and it’s also injected into face to improve scars and improve turgor to the skin by promoting collagen production (“the vampire facial”).  I tend to quote that PRP is about 70% effective when choosing the right patients for the procedure.  It still needs to be combined with minoxidil and/or oral medications to maximize it’s effect.




Hair transplants have come a long way to have impressive results with minimal scarring.  They are not as obvious as they used to be.  The key to understanding why they work is that our hair is fascinating in that it maintains the ‘growth characteristics’ of where you take it from.  If you transplant an eyebrow hair into your scalp – it will only grow the way an eyebrow hair grows! For hair transplants, the hair from the occipital or back of the scalp are transplanted to the crown of the scalp.  The occipital hairs are actually less affected by hormonal changes (which is why men maintain this band of hair when they experience hair loss) because of where it is derived from embryologically.



The other things people often reference, such as biotin supplements, have had very little data to support their use.  I caution my patients on the use of supplements for hair loss as I worry that the anxiety that comes with thinning hair leads some to go ‘overboard’ with the supplements- either in variety or volume of supplements they take. If there is a true identifiable deficiency, iron for example, then taking a supplement if needed may be helpful.  I caution on the use of biotin in particular as the FDA issued a warning in 2017 on biotin’s ability to interfere with hundreds of laboratory tests.  This can result in false lab results when obtaining bloodwork.



I have seen some studies suggesting improvement in hair growth with Omega 3, Omega 6 and antioxidants.  This is likely why the foods generally recommended for healthy hair are fish like salmon, eggs, avocados, nuts, flax seeds- these are foods rich in biotin and omega 3 and omega 6.  I personally would prefer that my patients add these to their diet instead of taking a vitamin supplement in the case that they may be beneficial.



Aside from treating the underlying cause, the other route for volumizing effects are through products.



There are thickening shampoos.  These do give an effect of the appearance of more volume.  Some work by ‘swelling’ hair follicles to add the appearance of volume while others may leave a residue on the hair follicle to give the appearance of volume.  I like these but do caution to not use them routinely.  It helps to use a clarifying shampoo routinely to reduce the buildup on the hair.



Leave in conditioners, gels, and other styling agents are nice as they “coat” the hair.  They add moisture and help as many people with thinning hair find that it tangles easily.  Leave in conditioner can prevent the tangling and make us less likely to get further hair loss from hair breakage.  I’m actually a fan of these products as they tend to hydrate the hair giving the appearance of more volume and also makes hair breakage less likely.


Even coloring your hair can add the appearance of volume to hair. The hair shaft is actually not smooth- it’s scaly when magnified. Most hair dyes work by opening the outermost part of the hair follicle called the cuticle to deposit artificial pigment.  Once artificial pigment or color is deposited in your cuticles, it undergoes a reaction that makes the particle too large to just come out on its own.  It needs a pH change in your hair and heat to open the cuticles back up to release the pigment.  This is why the goal of a shampoo for color treated hair is to maintain a pH that allows your hair to hold onto its pigment and to avoid stripping color with harsh detergents that can strip the cuticle and the color along with it.    Many of my patients with hair loss are fearful of doing any treatment to their hair.  When we do get new hair growth, it’s often lightly colored or grey making it difficult to appreciate. Adding color can help people see the new growth. 



 Please remember:


The number of hair follicles we have is hereditary- we actually cannot get more! When it comes to thinning and loss the real question is whether each hair follicle is actually growing a hair and whether each individual hair is as coarse as it can be.

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