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The effect of brushing on hair loss in women



Hair loss is a common, bothersome problem among women. To evaluate the effect of different brushing frequencies on hair loss in women. This was a non-randomized crossover study. During a 4-week period, 14 women were asked to brush their hair with different frequencies during each of the 4 weeks. The amount of hairs lost during each week was counted and the average hairs lost during each week was compared with that of a week with a different brushing frequency. In all comparisons analyzed, hair loss was reduced by reducing brushing frequency. A subgroup analysis found strong association (p < 0.05) between brushing frequencies and the magnitude of hair loss. A limitation of the study was that the majority of the subgroup analyses did not find a statistically significant association between brushing frequency and amount of hair lost. Brushing is associated with hair loss. Reducing the brushing frequencies may reduce the amount of hair shed.
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Journal of Dermatological Treatment
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The effect of brushing on hair loss in women
Alexander Kiderman ab; Itzhak Gur abc; Pnina Ever-Hadani d
a Clalit Medical Services, Jerusalem, Israel b Department of Family Medicine, Hebrew University, Jerusalem,
Israel c Department of Family Medicine, University of Washington, Seattle, Washington, USA d Braun School
of Public Health, Hebrew University, Jerusalem, Israel
First Published:June2009
To cite this Article Kiderman, Alexander, Gur, Itzhak and Ever-Hadani, Pnina(2009)'The effect of brushing on hair loss in
women',Journal of Dermatological Treatment,20:3,152 — 155
To link to this Article: DOI: 10.1080/09546630802512661
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Journal of Dermatological Treatment. 2009; 20:3; 152–155
ISSN 0954-6634 print/ISSN 1471-1753 online © 2009 Informa UK Ltd.
DOI: 10.1080/09546630802512661
Journal of Dermatological Treatment. 2009; 20:3;
The effect of brushing on hair loss in women
1Clalit Medical Services, Jerusalem, Israel, 2Department of Family Medicine, Hebrew University, Jerusalem, Israel,
3Department of Family Medicine, University of Washington, Seattle, Washington, USA, and 4Braun School of Public
Health, Hebrew University, Jerusalem, Israel
Background: Hair loss is a common, bothersome problem among women. Objective: To evaluate the effect of different brushing
frequencies on hair loss in women. Methods: This was a non-randomized crossover study. During a 4-week period, 14 women
were asked to brush their hair with different frequencies during each of the 4 weeks. The amount of hairs lost during each week
was counted and the average hairs lost during each week was compared with that of a week with a different brushing frequency.
Results: In all comparisons analyzed, hair loss was reduced by reducing brushing frequency. A subgroup analysis found strong
association (p < 0.05) between brushing frequencies and the magnitude of hair loss. A limitation of the study was that the majority
of the subgroup analyses did not nd a statistically signicant association between brushing frequency and amount of hair lost.
Conclusion: Brushing is associated with hair loss. Reducing the brushing frequencies may reduce the amount of hair shed.
Key words: Hair loss, wash test
Under normal conditions, the scalp maintains a
homeostasis between hair growth and loss, resulting
in a normal hair appearance. Disruption of this
equilibrium results in hair loss (alopecia) or over-
growth (hypertrichosis). While hypertrichosis is
quite a rare symptom, hair loss is a common problem
in both sexes. As many as one-third of all women
over 40 years of age are affected by hair loss (1),
resulting in low self-esteem of the affected women
and deleterious psychological effects (2,3).
Many factors were shown to be associated with
hair loss in women, including: trauma (including
burning) to the scalp, medication usage, hair
chemicals and cosmetics usage, endocrine diseases,
hyperandrogenism, autoimmune diseases, nutri-
tional deciencies, and stressful events such as
illness or surgery (1,4). Nevertheless, the inuence
of brushing, a common behavioral manipulation of
the hair, on the process of hair loss is unknown. One
view is that brushing generates traction forces on the
hair shafts and follicles, promoting hair shedding
and alopecia, while another is that brushing may
promote hair growth. For example, brushing may
induce changes in some of the growth factors or
receptors of those factors found in the scalp and hair
follicles (5,6), inducing hair growth. Thus, the need
to evaluate the role of brushing in the process of hair
loss in women, in order to advise patients with a
proper recommendation, is indicated.
The aim of this study was to evaluate the
association between brushing frequency and hair
loss in women.
Women of Jewish origin were enrolled in a non-
randomized crossover study to evaluate the association
between brushing and hair loss in women. Non-
pregnant women aged 18–60 years old, who were
used to brushing their hair an even number of times
every day, were recruited from two family medicine
Correspondence: Itzhak Gur, Chemdat, 60695, Israel. Fax: 972 2 9944206. E-mail:
Alexander Kiderman and Itzhak Gur contributed equally to this publication.
(Recevied 18 September 2008; accepted 25 September 2008)
Downloaded By: [Gur, Itzhak] At: 06:23 28 May 2009
Effect of brushing on hair loss in women 153
primary care clinics (A. K. and I. G.) in the
Jerusalem district, Israel. After providing written
informed consent, all volunteers were thoroughly
interviewed, had a complete physical examination by
one of the two principal investigators (A. K., I. G.),
and underwent blood testing. Individuals were
excluded if they gave birth during the 6 months
prior to enrollment, were pregnant during the study
period, declared using any medication or having any
illness known to be associated with hair loss,
changed medications or hair-related cosmetic prod-
ucts (shampoo, conditioner) during the 2-week
period prior to enrollment, were found (by interview
or physical examination) to have signs of a condition
known to be associated with hair loss, or found to
have any of the following in blood tests: the presence
of antinuclear antibody (ANA), low ferritin levels
(dened as < 20 ng/dl), evidence for thyroid hor-
mone disturbances (dened as thyroid stimulating
hormone (TSH) < 0.35 or > 5.5 mU/l) or low
hemoglobin (Hb) levels (Hb < 12.0 mg/dl).
Women enrolled in the study were asked not to
change their brush or comb, shampoo or conditioner
and not to curl or color their hair during the study
period. Enrollees were asked to brush their hair at
the same frequency (dened as: no. of brushings/day)
that they were used to prior to enrollment during
the second and fourth weeks of the study period,
and at half that frequency during the rst and
third weeks of the study period. Enrollees had to
count the number of hairs they found on their brush
or comb after each brushing (brush test). They were
also requested to take a shower with the draining
hole covered by a gauze, and then to count the
number of hairs trapped by the gauze (wash test).
Table I. Differences in mean hair loss (with 95% CI) and p-values of different measurement methods of compared weeks.
Brush test Wash test Total
week 1 vs week 2 –89.64286
(–179.909, 0.624130)
p < 0.0514
(–28.21993, 20.21993)
p < 0.7231
(–224.2301, 27.89672)
p < 0.1145
week 1 vs week 4 84.14286
(–178.1312, 9.845487)
p < 0.0752
(–25.51069, 16.17736)
p < 0.6319
(–220.8427, 28.84268)
p < 0.1187
week 3 vs week 2 –95.21429
(–171.5032, –18.92537)
p < 0.0183*
(–21.37241, 12.37241)
p < 0.569
(–195.3578, 6.691113)
p < 0.0644
week 3 vs week 4 –89.71429
(–172.8224, –6.6061)
p < 0.0364*
(–19.5888, 9.255559)
p < 0.4471
(–196.6377, 12.30439)
p < 0.0782
weeks 1 + 3 vs weeks 2 + 4 –179.3571
(–346.8972, –11.81713)
p < 0.0378*
(–38.14377, 19.81044)
p < 0.5
(–413.808, 33.14137)
p < 0.0876
* = Statistically signicant difference
These methods have been found to be valid in
evaluating hair shedding in previous studies (7,8).
All the women received an information sheet and a
log book in which they had to write their counting
results. Results were collected at the end of the
4-week study period.
Statistical analysis
The number of hairs lost in each week, established
by the comb test, wash test or both were calculated
separately for each individual. Based on the assump-
tion that the within-individual standard deviation of
the weekly hair loss is 50 hairs, and for a probability
of 80% that the study will detect an intervention
difference of at least 60 hairs, at a two-sided 5%
signicance level, a total of 13 patients were needed
to be enrolled in this crossover study. For each
method (brush test, wash test or both), the means
and standard deviations of the number of hairs lost
during each week were calculated. Paired t-test
analysis was performed in order to evaluate the differ-
ence in the means by weeks differed by brushing
frequency. We analyzed the difference of the means of
the number of hairs found by the same counting
method during: 1st week versus 2nd week, 1st week
versus 4th week, 3rd week versus 2nd week and
3rd week versus 4th week. We also examined the dif-
ference of the means during weeks of half-frequency
brushing (1st and 3rd weeks) compared to weeks
with regular brushing frequency (2nd and 4th weeks).
Differences between 2 weeks of hair loss means were
considered signicant if the paired t-test reached a
p < 0.05. All analyses were made using Stata/IC 10.0
software (Statacorp LP, College Station, TX, USA).
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154 A. Kiderman et al.
The study was approved by the Institutional Review
Board (IRB) of Hadassah Medical Organization,
Jerusalem, Israel.
Twenty women volunteered to participate in the
study. Of those, one did not complete the study
period, and ve failed to comply with the protocol.
The mean age of the 14 women eligible for analysis
was 44 years (SD: 10.122); their mean TSH level
was 1.79 mg/dl (SD: 0.69), mean ferritin level was
57.14 ng/dl (SD: 52.26097, range: 20–223), and
mean Hb level was 14.12 (SD: 0.99). All the women
were ANA negative.
Table I shows the results of t-test analysis of the
mean number of hairs lost for the weeks that differed
by brushing frequency. The brush test achieved
signicant differences for the comparison of week 3
versus week 2, and week 3 versus week 4 and the
half-frequency weeks (weeks 1 and 3) versus the
normal brushing frequency weeks (weeks 2 and 4).
For the comparison of week 1 and the weeks with
normal frequencies (2 and 4), the brush test nearly
reached t-test signicance. Other measurements did
not reach a signicant level of difference by t-test
analysis. In all of the measurements, the mean
number of hairs lost during weeks with reduced
brushing frequencies was smaller than that of a week
with regular brushing frequency.
Hair loss is a common complaint of women of all
ages. While several treatments for female hair loss
exist, the long-term efcacy, adverse effects, safety
and costs are unknown, making the utilization of
these treatment modalities unlikely by many women
(4,9). Our study showed that brushing increases the
shedding of hair, at least in the short term. With any
kind of measurement, daily hair loss was increased as
brushing frequency increased, and the brush test
found a strong association between frequency of
brushing and the amount of hair lost. Hair loss was
not found to be signicantly reduced during weeks
with reduced brushing frequency when evaluated by
the wash test alone or the total count of hairs
shed. This may be due to low overall measurements
made at the wash test, and the subjectivity by
which the counts were obtained by the enrollees.
Moreover, the exposure variability between the
two strategies (i.e. half-frequency brushing versus
normal-frequency brushing and the length of a week
for each exposure period) may have not been
sufcient to yield a signicant difference between
the two strategies. As this study was designed to
investigate the impact of brushing on hair shedding
in all women, most of the women in our study were
individuals who had not experienced hair loss or
alopecia and were young and healthy. We believe
that among older women and those who identify hair
loss as a problem, together with longer exposure
variability (i.e. a longer period for each strategy,
bigger differences in the frequency of brushing
between the two approaches), the mean number of
hairs lost will likely show a stronger association with
frequency of brushing by any means of diagnosis.
Thus, the results of this study may be underestimated.
The wash test showed low sensitivity, which may
explain why this method failed to show a signicant
association between combing and hair loss.
Although other sophisticated measures may have
produced better estimations, the methods used in
this study were implemented simply, were previously
validated (7,8), and enabled us to study this
phenomenon in the normal, healthy population.
The main strength of the current study is the use
of a crossover study design to answer the study
question. This approach eliminates most of the
potential confounders (and the need to adjust for
those), since each individual served as her own
control. Thus, the results of our study can be interpreted
with the assurance that potential confounders biased
the analysis to a minimum.
This study examines the inuence that brushing
frequency has on the amount of hairs shed in the
short term. Other studies will have to examine the
effect of reduced brushing frequency and its thera-
peutic efcacy in the long term among women who
do suffer from hair loss, and will have to evaluate the
benets and harms of the long-term pharmaceutical
and surgical treatments compared with the long-term
effect of reducing brushing frequency on overall hair
loss, hair appearance and patient satisfaction.
Source of funding
Dr Gur is a recipient of fellowship grants from the
Advancing Academic Family Medicine in Israel
(AAFMI) fellowship at the University of Washington,
Seattle, Washington, and The American Physicians
Fellowship for Medicine in Israel.
Conict of interests
The authors have no conict of interest to declare.
Prior presentations: none.
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Effect of brushing on hair loss in women 155
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Ηardy described the hair follicle as “a treasure waiting to be discovered by even more molecular biologists” [1]. And there is nothing more intriguing about hair follicle physiology than its life cycle.
Full-text available
Hair has many useful biologic functions, including protection from the elements and dispersion of sweat-gland products (e.g., pheromones). It also has psychosocial importance in our society, and patients with hair loss (alopecia) (Table 1) or excessive hair growth often suffer tremendously. Not surprisingly, the demand for drugs that alter hair growth and appearance has led to a multibillion-dollar industry, yet few drugs that are effective for these purposes are available. However, recent progress in our understanding of the biology and pathology of hair follicles should lead to more effective therapies for disorders of hair growth. Structure and Function of Hair . . .
Scalp hair loss problems and the policies of general practitioners were studied by sending questionnaires to 374 physicians, of whom 21% responded. About 50% of the patients, according to their physicians, had psychological problems which predominantly comprised low self-esteem in the male patients and fear and anxiety in the female patients. The general practitioners followed the same policy for patients with psychological problems and for those without. The findings suggest that many alopecia patients need more psychological support from their physicians.
Assessing how many hairs are actually shed by patients complaining of hair loss is a difficult task. Many methods have been proposed, but all need standardization. We examined 234 women complaining of hair loss. Alopecia areata and scarring alopecias were excluded. Eighty-nine of the patients had an apparently normal density of hair. Seventy-four were classified as Ludwig stage I, 37 as Ludwig II and 15 as Ludwig III. In 19 patients, classification had not been recorded. They were tested with the pull test (PT), daily count (DC) and wash test (WT). Telogen percentage was obtained by a trichogram in 43 patients. Dispersion of the data was very high. The medians of the PT, DC and WT were 0.6, 60.5 and 122 hairs, respectively. The telogen median of percentage was 16. In patients with normally dense hair, the PT, DC and WT means were significantly higher than in those with Ludwig stages I-III. Telogen means did not differ. WT values correlated significantly with those of the DC and PT, and DC values did so with those of the PT. By contrast, telogen percentage did not correlate with WT, DC and PT values. WT values and telogen percentage increased in autumn, the latter preceding the WT by 1 month. The methods adopted and the problem of 'normality' are critically analyzed. Subjects complaining of hair loss proved to shed a higher number of hairs than those with various degrees of baldness. The PT is a poorly sensitive method, while telogen percentage is not correlated with the severity of hair loss. As the DC is a cumbersome procedure, the WT is probably the best method to adopt. Standardization of methods and assessment of normality in prepubertal children are imperative.
The wash test is currently used to assess hair shedding, though it lacks a cut-off point of normality and any evidence of being reliable. The aim of this study is to provide data to fulfil those needs. The wash test was employed in a standardized way on 31 children aged 3-11 years. The test yielded 10.68 +/- 3.91 hairs, a figure which may be considered as 'normal' for children of that age. The chi(2) test granted the validity of the method. The number of shed hairs counted in the washing basin increased with the age of the subjects. The wash test proved to be reliable and to be a useful tool for monitoring hair shedding. The increasing trend with age may suggest a possible prepubertal onset of androgenetic alopecia.
Finasteride, an inhibitor of type 2 5alpha-reductase, decreases serum and scalp dihydrotestosterone (DHT) by inhibiting conversion of testosterone to DHT and has been shown to be effective in men with androgenetic alopecia (AGA). The effects of finasteride in women with AGA have not been evaluated. The purpose of this study was to evaluate the efficacy of finasteride in postmenopausal women with AGA. In this 1-year, double-blind, placebo-controlled, randomized, multicenter trial, 137 postmenopausal women (41-60 years of age) with AGA received finasteride 1 mg/day or placebo. Efficacy was evaluated by scalp hair counts, patient and investigator assessments, assessment of global photographs by a blinded expert panel, and histologic analysis of scalp biopsy specimens. After 1 year of therapy, there was no significant difference in the change in hair count between the finasteride and placebo groups. Both treatment groups had significant decreases in hair count in the frontal/parietal (anterior/mid) scalp during the 1-year study period. Similarly, patient, investigator, and photographic assessments as well as scalp biopsy analysis did not demonstrate any improvement in slowing hair thinning, increasing hair growth, or improving the appearance of the hair in finasteride-treated subjects compared with the placebo group. Finasteride was generally well tolerated. In postmenopausal women with AGA, finasteride 1 mg/day taken for 12 months did not not increase hair growth or slow the progression of hair thinning.
The aim of this study was to quantify the effect of hair loss on quality of life. Patients were recruited from an alopecia support group, and were assessed using the Dermatology Life Quality Index (DLQI) and an adapted version of the DLQI. Financial utility questions, an abbreviated version of the Center for Epidemiologic Studies Depression Scale and open-ended questions were also used. Seventy (90% response rate) questionnaires were returned. DLQI scores in responders with hair loss (mean score = 8.3, SD = 5.6, range 0-23, n = 70) were similar to those recorded in severe psoriasis. The hair loss continued to have a significant impact on life quality well after the initial event (median duration of hair loss = 138 months +/- 114; range 7-588, n = 70). Forty per cent of patients also felt dissatisfied with the way in which their doctor dealt with them. This study specifically identifies the feelings of loss of self-confidence, low self-esteem and heightened self-consciousness in people affected by hair loss.
Female pattern hair loss is a common condition characterized by a diffuse reduction in hair density over the crown and frontal scalp with retention of the frontal hairline. The prevalence increases with advancing age. It has been widely thought to be the female counterpart of male balding and is often referred to as female androgenetic alopecia. However, the role of androgens is not fully established. Scalp hair loss is undoubtedly a feature of hyperandrogenism in women but many women with female pattern hair loss have no other clinical or biochemical evidence of androgen excess. Female pattern hair loss is probably a multifactorial genetically determined trait and it is possible that both androgen-dependent and androgen-independent mechanisms contribute to the phenotype. In managing patients with female pattern hair loss the physician should be aware that the adverse effects on quality of life can be quite severe and do not necessarily correlate with the objective degree of hair loss. The treatment options are currently limited but modest improvements in hair density are achievable in some women.
A 45-year-old white woman presents with a 1-year history of scalp-hair loss. She was hospitalized with appendicitis 14 months ago. She has been a vegetarian for 20 years. She takes no medications. Her father was bald. On physical examination, she has diffuse, nonscarring hair thinning with a widened part over the central portion of the scalp. How should this problem be evaluated and treated?
Dialogues in Dermatology, a monthly audio program from the American Academy of Dermatology, contains discussions between dermatologists on timely topics. Commentaries from Dialogues Editor-in-Chief Warren R. Heymann, MD, are provided after each discussion as a topic summary and are provided here as a special service to readers of the Journal of the American Academy of Dermatology.