By: Nikki D. Hill, MD, Board-Certified Dermatologist and Hair Loss Specialist
There is no fear like seeing numerous stands of your hair on the floor, on your clothes, in your brush, or the worse hanging on your fingers when you run your hand through your hair. First thing to do is breathe and remember that everyone loses 100 strands a day. Granted 100 hairs a day is normal but the sight of 100 collected hairs is quite alarming. We will discuss in brief some causes of hair shedding in this article. For more information, read this article to learn about different reasons for hair thinning.
When patients present with increased shedding I ask about the background story of their hair shedding. First I ask if they are seeing short hairs or long hairs, because this can help determine whether they are experiencing breakage or shedding. Next I ask about grooming habits such as the frequency of hair washing as well as the type of hair styles. Simple things such as grooming habits can lead to perceived increased shedding. If the hair is not brushed/combed or taken out of a style for weeks at a time, those 100-per-day shed hairs will find their way onto your shower floor or in your brush. This is commonly a false alarm shed. I counsel patients to wait out the shed for a week after taking down a hairstyle to see if the shedding normalizes.
The next questions are health related: medications, hormonal changes (birth control or pregnancy or menopause), stress levels, thyroid and anemia, and recent illnesses. Starting or stopping medications and the above-mentioned conditions can all lead to a stress shed called telogen effluvium (TE). This happens when more than 100 follicles (a normal day shed count) shift simultaneously to a shed or telogen phase. The result is a noticeable diffuse increase in shedding. TE typically occurs 1-3 months after the incident (starting/stopping medication, illness, surgery, etc) and can persist up to 1-3 months after the incident has resolved. Chronic TE is considered when you experience increased shedding for more than 6 months. Typically stress shedding will autocorrect itself once the trigger has resolved and the hair follicles can normalize back into their normal growth cycles.
Blood work should be checked to make sure anemia, thyroid, amongst other internal conditions are not driving the process of the TE. Correcting these conditions can lead to a dramatic improvement in the shedding. For medications that were started when the shed began, typically the shed will start to slow down. If you need to take the medication for specific reasons I tell patients to continue and likely the shed will cease. If medications are stopped a similar pattern of waning will occur within a few weeks to months.
Hair products and the length of time between chemical processes (relaxer stretching) and whether the patient is transitioning to a chemical-free state can also influence shed or long hair breakage. When transitioning from a chemical process the hair has a transition point where two textures meet — chemically straightened and the natural hair pattern intersect. The point is often referred to as the line of demarcation.
At this junction (or line of demarcation) the hair is weakest and common tension can cause the hair to break resulting in “full-length” long hairs in brushes and combs. Maintaining moisture, protein and being careful with combing and brushing when wet are important factors to maintain length while transitioning out. Additionally, the hair can go through a shed phase when a chemical break is longer than usual, almost similar to stopping a medication and having resultant shedding. The mechanical stress leading to long-hair breakage is dependent on the moisture content of the hair and the person styling the hair. The chemical transition shed will wane down with time, typically 2-3 months.
Lastly examine the scalp to make sure there isn’t any inflammatory reasons for the scalp to shed hairs. Inflammatory scalp conditions prematurely shed hairs still in their anagen or growth phase. Close analysis with trichoscopy (similar to trichology) can lead to diagnosis of premature anagen hair shedding. A biopsy should be performed to determine the cells in the inflammation, the pattern of the inflammation, and whether the follicles are becoming scarred. Once a diagnosis is given, treatment options are discussed and targeted towards the type of inflammatory scalp condition.
Nikki D. Hill, MD
Board-Certified Dermatologist and Hair Loss Specialist
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