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What Ages Hair?

  • MedClinConsulting, LLC
What ages hair?
Assaf Monselise, MD
, David E. Cohen, MD, MPH
, Rita Wanser
, Jerry Shapiro, MD
Department of Dermatology and Skin Science, University of British Columbia, BC, Canada
The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, NY, USA
Cicatricial Alopecia Research Foundation, Chairman of the Board, IL, USA
Private practice, Tel Aviv, Israel
Hair has always played an important role in the history of mankind.
Egyptian hieroglyphics are testimony of the paramount importance of
hair for this ancient civilization, not only because of the visual effect,
but also because of the erotic symbolism connected with hair. For the
ancient Romans hair was not only a question of fashion but was used
as a symbol of beauty, virility, class and intellect. In modern western
culture having a full head of hair is of ten associated with desirable
qualities such as youthfulness and vitality. Most pe ople experience
changes in hair and scalp health as they age. Subsequent hair loss may
cause signicant distress that deeply affects peoples life causing social
anxiety and interfering with their well being. Genetic and hormonal
changes are important factors in hair loss, but weathering and grooming
habits take a toll on our hair as well.
A recent advisory board comprising twelve experts in hair bers
and hair loss was formed to review hair loss in relation to heredity,
agin g and environmental factors emphasizing measures that m ay
slow alopecia. The following information is a summary of their discus-
sions on these topics.
Denition of a healthy scalp and hair
Although healthy scalp and hair are of prime importance, the general
public is no t kno wledgeable about these issues. Most people have little
awareness about how to appropriately care for their hair and scalp. Healthy
hair and healthy scalp typically complement each other, so a healthy scalp
is needed to give the appearance of healthy hair and vice versa. A healthy
scalp is generally dened by a lack of disease or abnormalities; however a
person could be bald and perceived as having a healthy scalp.
Experts in the eld of dermatology (Rogaine®ScienticRoundtable,
2009) agree that the characteristics of healthy hair include thickness,
volume, lus ter and resilience of the ber. The majority have agreed
that a healthy scalp would have normal follicular densi ty with no
scaling, itching, burning or erythema.
Many patients experiencing hair loss assume the problem is related
to the scalp if inammation or aking is present at the time of hair loss.
They believe that treatment of the scalp would promote future hair
growth, although th is is frequently not the case.
Chronic scalp inammation likely dim inishes hair health via a variety
of mechanisms that are not fully understood. Although research on the
effects of chronic scalp inammation on hair health is limited, a plausible
mechanism involves cytokine-driven decrease in the anagen phase hair
lengthening as well as miniaturization of the hair follicle. The ideal envi-
ronment required for a healthy growth of hair still has to be identied,
yet changes in the environment surrounding the follicle like sebum
excretion, debris, and chronic inammation could signicantly impact
the growth and health of hair. On the other hand, treatments targeted
at reducing inammatory scalp conditions, such as dandruff and infec-
tion are harsh on the hair shaft and decrease shine and manageability.
Pattern Hair Loss or Age-related thinning
Pattern hair loss (PHL) has a multi-genetic background with half the
male population affected by the age of 50 years. Different patterns for hair
loss have been identied, including the Norwood-Hamilton pattern
(Figure 1), the Ludwig pattern (Figure 2) and the Christmas tree or frontal
accentuation pattern (Figure 3) Although the Norwood-Hamilton is tradi-
tionally used to describe PHL in men and th e Ludwig and Christmas tree
pattern for women, the different patterns are not gender restricted and
can be used interchangeably. According to available data 38% of women
over the age of 50 experience signicant hair thinning (Rogaine®Scientic
Roundtable, 2009). Women often regard hair loss a problem related to
men exclusively and do not recognize this problem until signicant hair
loss has occurred, thus delaying treatment with minoxidil.
In men, hormonal factors, namely dihydrotestosterone (DHT) levels,
play an important factor in the pathophysiology of PHL, with increased
5-alpha-reductase an d androgen receptors in the frontal scalp com-
pared to the occiput (Pri ce, 2003). High scalp DHT levels are associated
with follicu lar mi niaturization which is characteristic for PHL (Whiting,
2001), however follicular downsizing has been described for senescent
alopecia as well (Table 1)(Hordinsky et al., 2002). The pathophysiology
of follicular downsizing is not fully understood. It is described as an
alteration of the anagen (growth) and telogen (resting) phases of hair
growth with a diminished scalp vasculature as an adjustment for the
needs of the decrease in size follicles. In fact, the telogen phase during
which hair is shed changes as a person ages. In a child, the number of
hairs that are shed during this phase is much less compared with an
average adult, who typically loses 100 hairs each day. As a person
continues to age, the number of hairs that are shed increases, resulting
in thinning, which is common in the senior population. Conversely,
the anagen phase of hair growth is likely inuenced by age and race
and appears to shorten as a person ages, however it is unclear when
International Journal of Women's Dermatology 1 (2015) 161166
Corresponding Author.
E-mail address: (A. Monselise).
2352-6475/© 2015 The Authors. Published by Elsevier Inc. on behalf of Women's Dermatologic Society. This is an open access article under th e CC BY-NC-ND license
Contents lists available at ScienceDirect
International Journal of Women's Dermatology
or what triggers a shortening of this phase. Additionally, people from
some ethnic backgrounds, such as African American women, appear to be
more susceptible to shortening of the anagen phase, as they often experi-
ence difculty in growing and maintaining long hair as they get older.
A direct relationship appears to exist between the degree of scalp
inammation and pattern hair loss especially in men (Jaworsky et al.,
1992), and treating this inammation can reduce the loss of hair. In this
regard, minoxidil may exert anti-inammatory/immunomodulatory
effects in the follicle environment (Fiedler and Buys, 1987, 1988). In
contrast, research in the area of female PHL suggests that sebum excre-
tion is unchanged in these patients (Birch et al., 2006). Most women
with PHL have normal serum androgen levels, suggesting genetic and
environmental factors are likely playing a role in alopecia.
Some people experience widespread thinning of their hair as they
get older. This condition is dened as senescent alopecia or age-
related thinning, and is characterized by a scalp-wide reduction in the
number of hairs rather than classic pattern hair loss. Senescent alopecia
typically occurs between the ages of 50 and 80 years in a person without
a prior history of hair thinning and any underlying scalp diseases, and
can be superimposed on PHL. Indeed the distinction between age-
related thinning and PHL is confusing since the presence of follicular
miniaturization in age-related hair loss is an inconsistent nding. The
relation between senescent hair loss and androgens has yet to be deter-
mined. A drop in estrogen levels that occur during menopause could
contribute to hair thinning, which is commonly seen in older women.
Some areas of the scalp could be dependent on androgens for either
hair growth and/or hair loss, and this may explain, for example, the
association of Hamilton PHL, which is typical for men, in some women
with age-related hair loss. If low androgen plays a major role in
senescent alopecia, Estratest® (esteried estrogens combined with
methyltestosterone) would be the hormone replacement of choice in
women. This drug could also be combined with nasteride in women
with low dihydrotestosterone (DHT) levels. However, administration
of Estratest and dehydroepiandrosterone (DHEA) supplements has
been associated with hair loss in clinical practice, so determining the
appropriate dose and product for androgen replacement could be
challenging. The ideal androgen level for hair growth must be balanced
with the negative effects of androgen administration, such as hirsutism,
acne, and osteoporosis. Since minoxidils stimulatory effect impacts
many areas of the scalp, it would indeed help manage senescence and
hair loss related to aging alopecia.
Weathering & Grooming
Weathering is dened as the cumulative effect of environmental fac-
tors on the physicochemical structure of the hair. Hair damage induced
by environmental factors including UV, humidity, wind and chemicals
in hair products and procedures, has a negative impact on the growth
and texture of the hair ber. Grooming habits and weathering interplay
in the process of hair wearing and both can compound the natural
Fig. 1. Androgenetic Alopecia in Males. Hamilton-Norwood Classication. (Reprinted with permission from Hair Loss and Hair Restoration. Authors: Shapiro J and Otberg N. CRC Press
Taylor and Francis 2015 Chapter 2 page 32.)
Fig. 2. Androgenetic Alopecia in Women. Ludwig Classication.
162 A. Monselise et al. / International Journal of Women's Dermatology 1 (2015) 161166
decrease in hair density related to age-related thinning/PHL. Typically in
Caucasians and Asians, when the inciting factor is weathering, the dam-
age occurs distally on the hair shaft. However, damage to the shaft fre-
quently occurs proximally in African Americans, caused by the harsh
chemicals applied on the scalp to relax the hair. The resilience of the
hair shaft to weathering is determined by its unique structure. Much
of the bers strength is given by the cortex and overlying cuticle that
serves as a mechanical protective barrier. The latter constitutes about
10% of the bers weight and is made of tiny scales that overlap one an-
other like shingles on a roof, with their exposed edges towards the tip of
the ber. The cortex provides strength thanks to keratin which is rich in
disulde bonds. Additionally, melanin which resides in the cortex
provides protection to the ber against UV radiation. The pathogenesis
of photo damage involves interaction between iron, wa ter, and UV
light with the formation of free radicals. The latter are partially absorbed
by melanin which acts as a scavenger of free radicals. However, when an
overwhelming amount of free radicals is formed, melanin is degraded
and UV light then generates crosslinks between proteins, melting the
cortex and making the hair very brittle. Red headed and blond people
are more prone to photo-damage since their hair is rich in pheomelanin
which is less resistant than eumelanin. Likewise white or graying hair is
less protected from UV radiation.
The frictional properties of the cuticle determine how the hair feels
to touch, how it combs and styles. When the cuticular scales are smooth
light is reected and the hair appears shiny and healthy. Typically, the
macroscopic appearance of a damaged ber is characterized by splitting
of the ends, so called trichoptilosis. This happens mostly for longer bers
that have been exposed for lo nger periods to environmental fa ctors.
Observation of the hair by scanning electron microscopy reveals pro-
gressive damage to the ber from root to tip, with slight scale lifting
proximally and gradual chipping and denudation of the cuticle, with
longitudinal ssures and transverse breakage or trichoschisis near
trichorrhexis nodosa like nodes.
Grooming habits have an important impact on the wearing of the
hair ber. Shampooing daily cleanses off the protective layer of sebum
that covers the hair, causing the shaft to dry out so it easily gets statically
charged and consequentially more prone to friction. Shampoos are am-
phiphilic molecules that have both a lipophilic side that binds sebum
and a hydrophilic part that binds water. They are divided into groups
based on their chemical structure. Those belonging to the anionic
group contain negatively charged molecules with stronger and deeper
cleansing properties, such as sodium laureth sulfate and sodium lauryl
sulfate. Sodium lauryl sulfate was used almost exclusively in shampoos
several years ago and is more irritating and damaging to the follicle com-
pared to sodium laureth sulfate. Currently, the majority of shampoos
contain sodium laureth sulfate due to its moisturizing properties
(Rogaine®Scientic Roundtab le, 2009 ). Shampoos categorized in other
chemical groups (cationic, non ionic and amphoteric) include products
that have milder cleansing properties, are less irritating and leave the
hair more manageable. Shampoos are often marketed based on the
type of hair that they are meant for. Those for oily hair have stronger
detergent properties while those for permed, permanently dyed,
bleached or dry hair, are milder in order to reduce sebum removal.
Baby shampoos are usually mild, less irritating and are suitable for
daily use.
Permanent waving or relaxing of hair involves chemicals like ammo-
nium thioglycollate, sodium hydroxide and guanidine hydroxide, which
are extremely alkaline and cause breakage of disulphide cross-links
within the keratin, inducing swelling and softening of the ber.
Reduced cysteine levels in relaxed hair is consistent with hair fragility
in comparison to normal unrelaxed hair Khumalo et al., nd.The
dama ged ber characteristically breaks along the shaft, leaving the
root unaffected and is more often seen on the nape area which is
treated by the stylist and is thereby exposed to the product for longer
time. Bleaching products contain hydrogen peroxide or hydrogen
persulfate. These chemicals must traverse the cuticle in order to bleach
the melanin which lays in the cortex, causing irreversible oxidation of
keratin disulde bonds with weakening the ber.
Combing and brushing, especially when done tip to root on wet hair
can be harsh on the ber with the development of trichoschisis. Wet
combing applies force on the hair close to the scalp, making it more
damaging than dry combing in which the force is pla ced on the en d
of the hair shaft (Rogaine®Scientic Roundtable, 2009). Using wide-
Fig. 3. Androgenetic Alopecia (AGA) in Women-Frontal Accentuation (Christmas Tree Pattern).
Table 1
Dening the characteristics of Senescent Alopecia
Scalp-wide reduction in the number of hairs
Occurs between the ages of 50 and 80 years
No prior history of hair thinning or underlying scalp disease
Presence of follicular miniaturization is inconsistent
Shortening of anagen
Decreased anagen/telogen ratio
Relation to androgens has yet to be determined.(low androgen levels could be a factor)
163A. Monselise et al. / International Journal of Women's Dermatology 1 (2015) 161166
toothed combs and brushes with rounded tips is a good pro tective
measure when styling the hair. (Table 2)
In African Americans, straightened hair behaves similar to Caucasian
hair, so it is less difcult to comb when it is dry compared with non-
straightened hair. The application of oil to African American hair prior
to shampooing would lubricate the hair shaft, making hair more
manageable, easier to comb, and less susceptible to damage by the
shampooing and drying process. Oils may also have antifungal proper-
ties, which could ward off scalp infe ctions. However, triglycerides in
these oils could be cleaved to free fatty acids that produce inammation
in the hair follicle (Rogaine®Scientic Roundtable, 2009).
Using hair dryers and curling irons can cook the ha ir ber. Obser-
vation with a magnier reveals the classic picture of Bubble Hair
(Mirmirani, 2008)(Figure 4) that is given by micro cavities within the
shaft, which are formed by the expansion of moisture induced by the
high temperatures of these devices. Japanese or ionic hair straightening
with ceramic irons that reach temperatures as high as 210°C has been
related to widespread breakage of the hair shaft as a result of acquired
trichorrhexis nodosa (Mirmirani, 2010). Temp orary disruption of
hydrogen bonds in the cortex involved in this procedure, imparts the
desirable softness to the hair. Interestingly, trichorrhexis nodosa is
observed where the cuticle is lost and the cortex has been damaged.
Current Treatment Concepts
Minoxidil was the rst FDA approved medication for male-pattern
baldness and has been on the market for more than 20 years. Increased
scalp blood ow resulting from local vasodilation has been proposed
as a possible mechanism of minoxidil's effect on hair growth however,
this mechanism has not been substantiated consi stently and not all
vasodilators produce hypertrichosis. Because minoxidil has stimulated
hair regrowth in several forms of alopecia, different speculations
regarding its mechanism of action have been forwarded. These include
immunomodulation (Fiedler and Buys, 1987, 1988), targeting specic
follicular p otassium channels (Davies et al., 2005 ) or induction of
PGE2 synthesis in the dermal papilla broblasts (Michelet et al., 1997).
Traditionally, topical minoxidil has shown to be efcacious for male
pattern hair loss (MPHL) involving the vertex, with an increase of 30% in
hair weight at 96 weeks of treatment compared to placebo (Price et al.,
1999). However, signicant clinical data has demonstrated minoxidils
efcacy for frontal hair loss as well, which is consistent with histologic
(Whiting et al., 1999) and photographic evidence suggesting that folli-
cles in the vertex and frontal scalp have the same morphology. Indeed
it may take up to one year of treatment before signicant changes in
hair growth are detectable by consumers. Minoxidil solution has a
high safety prole (Shapiro, 2003) with scalp irritation occurring in 7%
of patients which has been related to the vehicle (propylene glycol) or
minoxidil (Friedman et al., 2002). Minoxidil 5% foam is propylene glycol
free and is therefore recommended for patients who are suspected to be
sensitive to the vehicle. In the clinical trial of Minoxidil 5% foam (MTF) a
decrease in the incidence of irritation was observed on both the foam
vehicle a nd 5% MTF. Furthermore, the incidence of pruritus with 5%
MTF was 1.1% vs 6% seen in a separate trial of 5% Minoxidil topical solu-
tion (Olsen et al., 2007).
Many dermatologists recommend Minoxidil for age-related thinning
as this process inv olves a decrease in both hair density and the diameter
of the hair follicle (Ebling, 1988), which are successfully treated by
Non approved hair regrowth treatments
A plethora of products for hair loss is available on the market, some of
which are easily accessible through different web sites and others are
sold in salons (Table 3). Slogans and claims are provided to the public
of healthy hair seekers indicating the benecial effects of these products
as solid evidence for promoting hair growth. Hence people may be
provided with questionable information regarding their hair problem
and treatment options. Products for hair loss are sold as shampoos,
solutions, cle ansers, foams conditioners, and leave in agents. An
array of natural and non-natural occurring ingredients is mixed into
these products (i.e. vitamins, adenosine, retinoic acid, herbal extracts,
minoxidil, ketoconazole, copper peptide, amino acids) as remedies for
hair loss. It is unknown whe ther some of these hair products may
indeed have benecial effects on the follicl es. Only Rogaine®
(containing minoxidi l) has established evide nce base d sc ience to
substantiate proven efcacy.
Table 2
Good grooming habits
Shampoo daily with mild shampoo which is less irritating to the shaft
Apply shampoo to soaked hair with ngertips and rub gently
Avoid frequent perming
Avoid frequent application of permanent dyes
Avoid frequent bleaching
Comb hair root to tip when dry
Use wide-toothed combs and brushes with rounded tips
Avoid frequent use of hair dryers
Fig. 4. Bubble Hair-Deformed hair shafts due to heat exposure cau sed by dryers and
curling irons.
Table 3
Efcacy proven by clinical trials:
Minoxidil 5% solution (or minoxidil 5% foam if allergy occurs with the solution)
Finasteride (Propecia®) 1mg Tab Once daily (for MPHL)Price et al., 2006
Dutasteride (Avodart®) 2.5mg Tab Once daily (for FPHL)
Dutasteride (Avodart®) 0.5mg Tab Once daily (for MPHL) Stough, 2007; Eun et al.,
nd; Olsen et al., 2006
Non approved products with limited clinical data :
Finasteride 2.5mg Tab Once daily (for FPHL) Iorizzo et al., 2006
Hair products with Ketoconazole
Hair products with copper peptide
Hair products combining minoxidil and retinoic acid
Hair products with various vitamins, adenosine and herbal extracts
Estratest +/- nasteride (for senescent hair loss)
164 A. Monselise et al. / International Journal of Women's Dermatology 1 (2015) 161166
Combinations of minoxidil and retinoic acid probably enhance
the penetration of the former but are unlikely benecial due to the
neutralizing effect of the latter on m inoxidil. Products that co ntain
both of these components are denitely not recommended by most
hair experts due to potential irritation and unproven efcacy. Further-
more, application of enhancing products in combination with minoxidil
should be separated by at least 2 hours to permit the abso rption of
minoxidil in to the epidermis and prevent its potential deactivation.
The concept of opening hair follicles was developed as a marketing
strategy for so me hair care products with allegedly enha nced hair
growth capabilities. However hair follicles are not necessarily closed
therefore it is unclear what are the benets of such products. Nanosome
technology has been used to enhance th e penetration of some hair
products into the epidermis, but whether it is of benet for growing
hair is questionable (Rogaine®Scientic Roundtable, 2009). Claims
regarding acceleration of metabolism in the follicle or surrounding
circulation by topically applied vitamins and herbal extracts, as well as
their nourishing effects on the hair follicle and scalp by direct applica-
tion are unknown. Many patients take mega doses of vitamins, which
could cause more harm than benet. Indeed, consumption of Vitamin
A at doses higher than 5000IU per day may be a risk factor for hair loss.
Hair Fiber Protection
Limited data s upports that replaceme nt of amino acids via a
shampoo increases the tensile of the hair ber, however this benetre-
mains unproven (Rogaine®Sci enticRoundtable,2009). Hair products
with sun-screeners are useful as they provide protection to the scalp
and hair form UV ra diation and slow the weathering process. When
sun-screens are compounded as leave-in conditioners this can provide
moisture to the ber and improve the manageability of the hair. DHT
likely exists on the scalp surface as a component of sebum. It has been
suggested that removal of DHT with clea nsing products containing
ketaconazole can improve hair growth. Literature suggests that ketoco-
nazole has anti-DHT properties, and not only improves seborrhea but
also androgenetic thinning (Pierard-Franchimont et al., 1998; Inui and
Itami, 2007). While the anti-DHT properties has not been proven to
help pattern hair loss, nevertheless the a ssociation of ketoconazole
may contribute to a healthier scalp. Copper peptide is compounded in
some hair products and scientic evidence suggests its benecial effects
on hair grow th th rough stimulation of human dermal papilla cells
(Pyo et al., 2007), and as a potent activator of both telogen and anagen
follicles in mice (Trachy et al., 1991).
Overcoming the denial of hair loss and encouraging people to seek
medical attention earlier rather than later would be valuable in the
overall management of hair thinning/hair loss. When evident alopecia
has ensued, at least 50% of the scalp hair has already been lost. Certain
patient populations are more prone to aging and thinning of their hair,
particularly those who practice certain grooming procedures, whose
hair is grayi ng or fair colored and are inadvertent ly exposed to
weathering factors. Most peo ple do not realize that UV exposure has
negative effects not only on the skin but on the hair as well, especially
when it is devoid of melanin.
Confusion exists around the denition of senescent alopecia
(Kligman, 1988; Ebling, 1988). In-ofce measurement of age-related
changes in hair density is problematic since an ef
cient instrument or
rating scale has not been identied to measure and monitor diffuse
thinning of th e hair. The scales used for alopecia, such as the SALT
(severity of alopecia tool) score, are not highly applicable to the situa-
tion of senescent thinning. Establishing a norm volume of hair for a
patient would be important, as the differences of hair shafts prevents
comparisons between patients. Furthermore, normal hair density
should be den ed for each age bracket, so the severity of h air loss
could be determine d. Scalp biopsies with horizontal follicular counts
are the gold standard for conrming a reduction in hair number
(Whiting, 1993) but are problematic in everyday practice. Weathering
and grooming habits pose a signicant problem in aging patients. Dif-
ferences between declines in hair quality due to weathering v ersus
aging should be clearly characterized to help guide treatment in these
two situations. Grey or chemically/physically treated hair is drier and
more easily weathered, so conditioning is n ecessary to reinforce the
cuticular sheath and protect it from damage. A distinction should be
made between scalp care and care of the hair shaft and proper educa-
tion of the pu blic should be instituted. The former requires regular
cleaning to remove debris and build-up that can negatively impact
hair growth. Before shampooing, untangling the hair is important and
emphasis should be directed at lathering the scalp rather than the hair
shaft in order to remove debris and build-up that can negatively impact
hair growth. The hair ber is adequately cleaned as the shampoo is
rinsed off the scalp and out of the hair (Rogaine®ScienticRoundtable,
2009). The frequency of shampooing should be tailored according to the
oiliness of the scalp, as very oily scalps require daily shampooing. Some
experts a dvocate applying oil to the hair prior to sham pooing as a
protective measure. The oil would lubricate the hair, making it more
manageable and e asier to comb. In addition, the oil contains tri-
glycerides that are converted in the scalp epidermis to monoglycerides
and diglycerides, which have antifungal properties. However, some of
the triglycerides could be clea ved to free fatty acids that have a pro-
inammatory effect on the hair follicle (Rogaine®ScienticRoundtable,
2009). Drying the hair should be done gently by patting with a towel,
rather than wrapping the hair. Comb ing done slowly when the hair
has dried out using a wide-tooth comb with rounded tips will eliminate
unnecessary tension and breakage of the hair. African American
patients compared to Caucasians and Asians, pose a particular challenge
for treatment of hair loss having unique hair density, texture, scalp
conditions, and styling techniques that could inuence treatment
response. Additionally, African American women are more susceptible
to age-related thinning. This patient population, infrequently shampoo
their hair hence promoting the buildup of products on the scalp which
may negatively affect hair growth. Shampooing th e scalp more
frequently could help eliminate unwanted debris but would also wash
out the sebum and enhance dryness and irritation. Layering of condi-
tioning products may reduce hair breakage and dryness but on the
other hand impair the absorption of hair growth promoting agents
like minoxidil. Additiona lly, Minoxidil may aggravate sc alp and hair
dryness in these patients making compliance and adherence with treat-
ment difcult. Application of Minoxidil foam over several days could
produce a slight scalp residue, which does not affect its efcacy there-
fore avoiding the need of shampooing daily. Furthermore, this residue
could actually have a moisturizing effect since the Minoxidil foam con-
tains long-chain fatty acids found in conditioners. Rogaine®Scientic
Roundtable, 2009 Other measures t hat could improve ut ilization of
minoxidil and compliance of these patients would b e an over-the-
counter shampoo cont aining a low-l evel steroid that targets the
mild inammation and i rritation of the scalp associated with mi-
noxidil. A combination of a mild shampoo and conditioner that is
rinsed out followed by a leave-in conditioner that is applied while
the hair is still wet could help as well. Indeed daily application of
conditioners to dry hair between shampoos would not interfere
with minoxidil (Rogaine®ScienticRoundtable,2009). The prevalence
and pathophysiology behind follicula r miniaturiz ation in senescent
alopecia merits further investigation to better understand the potential
benets of minoxidil for this type of hair loss. Identifying the threshold
of hair thinning at which minoxidil would be benecial for senescent
alopecia is important. Minoxidil has proven efcacy for AGA in men
165A. Monselise et al. / International Journal of Women's Dermatology 1 (2015) 161166
with frontal (Olsen, 1999). The public should be educated about
grooming habits and weathering factors tha t may aggravate AGA or
senescent hair loss. Recommendations for UV protection with a hat or
by application of a sunscreen pr oduct specic for the hair should
be reinforced.
The advisors agreed that aging of hair is an inevitable process that is
determined by an interplay of many f actors including weathering,
grooming habi ts, UV exposure, hair color, androgenetic alopecia and
other age-related thining. Choice of hair care products is important to
the overall health of scalp and hair. Currently, there is no evidence
based data to suggest that hair care products are efcacious for more
than healthier hair bers. Further study should be done to determine
if use of these products can provide healthier scalp con ditions, slow
the PHL process, due to androgenetic alopecia and/or age-related
thinning. Minoxidil foam and solution has proven efcacy for AGA and
advisors agreed that their clinical evidence suggests this is a useful
treatment option for age-related thinning as well.
Birch MP, Lashen H, Agarwal S, Messenger AG. Female pattern hair loss, sebum excretion
and the end-organ response to androgens. Br J Dermatol 2006;154:859.
Davies GC, Thornton MJ, Jenner TJ, et al. Novel and established potassium channel openers
stimulate hair growth in vitro: implications for their modes of action in hair follicles.
J Invest Dermatol 2005;124:68694.
Ebling FJ. The hair cycle and its regulation. Clin Dermatol 1988;6:6773.
Eun HC, Kwon OS, Yeon JH, et al. Efcacy, safety, and tolerability of dutasteride 0.5 mg
once daily in male patients with male pattern hair loss: a randomized, double-
blind, placebo-controlled, phase III study. J Am Acad Dermatol;63:252-8.
Fiedler VC, Buys CM. Immunohistochemical characterization of the cellular inltrate in
severe alopecia areata before and after minoxidil treatment. Dermatologica 1987;
175(Suppl. 2):2935.
Fiedler VC, Buys CM. Direct T-cell effects of minoxidil. Clin Dermatol 1988;6:14851.
Friedman ES, Friedman PM, Cohen DE, Washenik K. Allergic contact dermatitis to topical
minoxidil solution: etiology and treatment. J Am Acad Dermatol 2002;46:30912.
Hordinsky M, Sawaya M, Roberts JL. Hair loss and hirsutism in the elderly. Clin Geriatr
Med 2002;18:12133 vii.
Inui S, Itami S. Reversal of androgenetic alopecia by topical ketoconzole: relevance of anti-
androgenic activity. J Dermatol Sci 2007;45:668.
Iorizzo M, Vincenzi C, Voudouris S, Piraccini BM, Tosti A. Finasteride treatment of female
pattern hair loss. Arch Dermatol 2006;142:298302.
Jaworsky C, Kligman AM, Murphy GF. Characterization of inammatory in ltrates in male
pattern alopecia: implications for pathogenesis. Br J Dermatol 1992;127:23946.
Khumalo NP, Stone J, Gumedze F, M cGrath E, Ngwanya MR, de Berker D. 'Relaxers '
damage hair: evidence from amino acid analysis. J Am Acad Dermatol;62:402-8.
Kligman AM. The comparative histopathology of male-pattern baldness and senescent
baldness. Clin Dermatol 1988;6:10818.
Michelet JF , Commo S, Billoni N, Mahe YF, Bernard BA. Activa tion of cytoprotectiv e prosta-
glandin synthase-1 by minoxidil as a possible explanation for its hair growth-stimulating
effect. J Invest Dermatol 1997;108:2059.
Mirmirani P. What is your diagnosis? Bubble hair. Cutis 2008;82:176 84.
Mirmirani P. Ceramic at irons: improper use leading to acquired trichorrhexis nodosa.
J Am Acad Dermatol 2010;62:1457.
Olsen EA. The midline part: an important physical clue to the clinical diagnosis of andro-
genetic alopecia in women. J Am Acad Dermatol 1999;40:1069.
Olsen EA, Hordinsky M, Whiting D, et al. The importance of dual 5alpha-reductase inhibi-
tion in the treatment of male pattern hair loss: results of a randomized placebo-con-
trolled study of dutasteride versus n asteride. J Am A cad Dermatol 2006;55:
Olsen EA, Whiting D, Bergfeld W, et al. A multicenter, randomized, placebo-controlled, double-
blind clinical trial of a novel formulation of 5% minoxidil topical foam versus placebo in
the treatment of androgenetic alopecia in men. J Am Acad Dermatol 2007;57:76774.
Pierard-Franchimont C, De Doncker P, Cauwenbergh G, Pierard GE. Ketoconazole
shampoo: effect of long-term use in androgenic alopecia. Dermatology 1998;196:4747.
Price VH. Androgenetic alopecia in women. J Investig Dermatol Symp Proc 2003;8:247.
Price VH, Menefee E, Strauss PC. Changes in hair weight and hair count in men with
androgenetic alopecia, after application of 5% and 2% topical minoxidil, placebo, or
no treatment. J Am Acad Dermatol 1999;41:71721.
Price VH, Menefee E, Sanchez M, Kaufman KD. Changes in hair weight in men with andro-
genetic alopecia after t reatment with
nasteride (1 mg daily): three- and 4-year
results. J Am Ac ad Dermatol 2006;55:714.
Pyo HK, Yoo HG, Won CH, et al. The effect of tripeptide-copper complex on human hair
growth in vitro. Arch Pharm Res 2007;30:8349.
Rogaine®Scientic Roundtable. Short Hills NJ. April, 2009.
Shapiro J. Safety of topical minoxidil solution: a one-year, prospective, observational
study. J Cutan Med Surg 2003;7:3229.
Stough D. Dutasteride improves male pattern hair loss in a randomized study in identical
twins. J Cosmet Dermatol 2007;6:913.
Trachy RE, Fors TD, Pickart L, Uno H. The hair follicle-stimulating properties of peptide
copper complexes. Results in C3H mice. Ann N Y Acad Sci 1991;642:4689.
Whiting DA. Diagnostic and predictive value of horizontal sections of scalp biopsy speci-
mens in male pattern androgenetic alopecia. J Am Acad Dermatol 1993;28:75563.
Whiting DA. Possible mechanisms of miniaturization during androgenetic alopecia or
pattern hair loss. J Am Acad Dermatol 2001;45:S816.
Whiting DA, Waldstreicher J, Sanchez M, Kaufman KD. Measuring reversal of hair minia-
turization in androgenetic alopecia by follicular counts in horizontal sections of serial
scalp biopsies: results of nasteride 1 mg treatment of men and postmenopausal
women. J Investig Dermatol Symp Proc 1999;4:2824.
166 A. Monselise et al. / International Journal of Women's Dermatology 1 (2015) 161166
... Antifungal shampoo is used for long-term maintenance but requires daily use and may not be suitable for patients with traditional African American hairstyles. Additionally, anti-dandruff shampoos often contain sodium lauryl sulfate, a surfactant that is extremely irritating and can result in hair breakage [49]. These shampoos are particularly damaging in patients of color that utilize heat or chemical relaxers to style their hair. ...
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The US population is becoming increasingly diverse, yet patients of color remain underrepresented in dermatology. The lack of diverse images in dermatologic learning materials can lead to discomfort in treating patients of color, delayed, and missed diagnoses. In this review, we compare and contrast the clinical presentation, management, and special considerations of common skin conditions between patients of color and white patients as well as provide a visual representation of these differences.
The hair loss treatment industry is a 3.5 billion dollar industry in the United States alone, and it is poised to reach 5.5 billion dollars within the next decade. The majority of treatments for hair loss target patients suffering patterned hair loss. Platelet-rich plasma was first used as a form of hair loss treatment in the mid-2000s out of a growing interest around cell-based and regenerative medicine. PRP is thought to lengthen the life cycle of hair follicles and prevent follicle miniaturization. The preliminary studies surrounding the use of PRP in hair restoration are largely favorable. This chapter will discuss the current literature regarding the use of PRP for hair restoration.KeywordsHair lossPRP for hair growthPRP for treating baldness
Hair analysis has become a valuable tool in forensic toxicology to assess drug or alcohol abstinence. Yet, hair adulteration by cosmetic products presents a major challenge for forensic hair analysis. Oxidative treatments, e.g. bleaching, may lead to analyte loss and thereby to false negative results. Currently, the eumelanin degradation product 1H‐pyrrole‐2,3,5‐tricarboxylic acid (PTCA) serves as a marker for oxidative hair treatment, but requires the definition of cut‐off values. To investigate further eumelanin degradation products as markers for oxidative hair treatment, hair samples with and without in vitro bleaching (hydrogen peroxide (H2O2) concentrations 1.9 % up to 12 %; incubation times 15 min, 30 min, 60 min) were analyzed by liquid chromatography coupled to high‐resolution time of flight mass spectrometry (HPLC‐HRMS). The distribution of eumelanin degradation products along the hair shaft was investigated for routine applicability after segmentation of cosmetically untreated hair samples and authentically treated hair samples. The signals of the eumelanin degradation products PTCA, 1H‐pyrrole‐2,3,4‐tricarboxylic acid (isoPTCA) and 1H‐pyrrole‐2,3,4,5‐tetracarboxylic acid (PTeCA) were found to be significantly elevated after in vitro bleaching already with low H2O2 concentrations and after short incubation times. In contrast to PTCA and isoPTCA, PTeCA was not detectable in cosmetically untreated segments up to 12 cm from hair root and was only formed through the oxidation process. The results of the study show that the detection of PTeCA within the proximal 3 to 6 cm segment can be applied to reliably detect hair adulteration attempts through hair bleaching.
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Previous studies have shown that physicochemical properties of hair can be impacted by internal and environmental exposures ranging from chemical stressors to weather. Besides the efects on hair, these exposures, termed “exposome”, can act on specifc organs including skin, as a synergistic damaging efect of UV exposure and pollution on human surfaces. The combination of several environmental factors such as sun exposure, temperature, relative humidity, air pollution and photooxidation caused by ground level ozone impacts hair properties such as melanin oxidation, protein content, surface quality and structural components. Therefore, exposome studies can reveal new hypotheses on how epithelia and hair could be afected by daily life environment and routine. The aim of this study was to evaluate the impact of several environmental aggressors on human surfaces, using portable and wearable devices for monitoring exposome. To better understand the underlying mechanisms associated with environmental factors, two subjects wore multiple sensors to capture the meteorological conditions biking through urban areas in summer and winter. Temperature, humidity, UV radiation and ozone concentration were recorded and hair swatches of diferent types, including natural, bleached/colored, colored and gray, were exposed on the helmets. Silicon wristbands were used on skin to identify main chemical aggressors. After exposure, hair swatches were analyzed by surface microscopy analysis, oxidation markers and more than 1,500 chemicals were evaluated on the bracelets. Correlated with GPS and monitoring data, all these results provide insights on how environmental stressors afect the quality of diferent hair types and body surface according to exposure routine. Our results suggest extreme climate conditions associated with hair damage and photo-oxidative marker linked to the environmental aggressors. Polycyclic aromatic hydrocarbons (PAH) indicate possible causes of hair damages. This is the frst meteorotropic study of its kind, combining environmental aggressors related to hair damage, opening new research hypothesis further studies on exposome.
Background: Cosmetic products are commonly marketed using dermatologic terms such as “hypoallergenic,” “non-comedogenic,” “fragrance-free,” etc. The clinical relevance of these claims can be confusing to both patients and clinicians. Methods: A systematic review was performed from via a PubMed search of published articles from January 1985 to October 2017 to further describe and elucidate the clinical utility of a predefined list of common dermatologic terms used by pharmaceutical companies to market over the counter products. Results: The terms “fragrance-free,” “hypoallergenic,” “non-comedogenic,” and “oil-free” on cosmetic product labels are not regulated by any governing body and provide varied clinical utility. Products labeled as having “natural ingredients” are not necessarily safer or less irritating to patients with atopy or a history of allergic contact dermatitis. Despite the increasing popularity of “paraben-free” cosmetics, parabens are safe for patients in the quantities used in cosmetic products and can be safely used in patients who don’t exhibit contact dermatitis to this preservative. Conclusion: A working knowledge of common cosmetic ingredients may help dermatologists counsel patients on which products to avoid for their specific dermatologic conditions.
Volles Kopfhaar wird assoziiert mit Gesundheit, Jugend und Vitalität. Die meisten Menschen erfahren allerdings im Laufe ihres Lebens Veränderungen insbesondere bei Haarfülle und Haarqualität der Kopfhaare. Hierbei handelt es sich vornehmlich um Störungen der normalen Haarphysiologie mit unverhältnismäßigem Haarverlust. Haare sind Hautanhangsgebilde; das Verständnis von Haarphysiologie, Haarpathologie, spezifischer Diagnostik und entsprechender therapeutischer Optionen und Behandlungskonzepten liegt deshalb in der ureigensten Kompetenz des Dermatologen und stehen deshalb im Fokus der dermatologischen Sprechstunde des entsprechend ausgebildeten Arztes. Ziel des vorliegenden Artikels ist es, ein Update über aktuelle Diagnostik und Therapie über die beiden in der Dermatologischen Sprechstunde häufigsten Formen des Haarausfalls, das telogene Effluvium und die androgenetische Alopezie zu geben.
Acquired trichorrhexis nodosa is a common cause of hair loss for patients of all ethnicities. It is especially prevalent in black patients with tightly curled hair types and can present unique diagnostic and therapeutic challenges due to structural differences in these hair types and the combination of various hair care and styling practices that contribute to hair damage. While scalp biopsies can help rule out other etiologies of hair loss, there is a paucity of histologic findings in acquired trichorrhexis nodosa, making this primarily a clinical diagnosis. Instead of more traditional prescription based therapies, the management of this form of hair loss emphasizes protecting the hair shaft and minimizing further damage through the development of a healthy hair care regimen. This involves appropriate selection and use of cleansing products and conditioning agents that help protect the hair from the insults of daily grooming. This paper will review the current literature on acquired trichorrhexis nodosa and will provide guidelines and recommendations for management by reviewing the different types of cleansing and conditioning products that can be used to prevent and/or halt the progression of hair breakage.
Data from the literature indicate that nonsteroidal anti-inflammatory drugs (NSAIDs), such as indomethacin, naproxen, piroxicam, or ibuprofen, induce hair loss in vivo. These NSAIDs are well-known inhibitors of both the cytoprotective isoform of prostaglandin endoperoxide synthase-1 (PGHS-1) and of the inducible form (PGHS-2). By immunohistochemical staining, we found that PGHS-1 is the main isoform present in the dermal papilla from normal human hair follicle (either anagen or catagen), whereas PGHS-2 was only faintly and exclusively expressed in anagen dermal papilla. Thus, PGHS-1 might be the primary target of the hair growth-inhibitory effects of NSAIDS. We thus speculated that activation of PGHS-1 might be a mechanism by which minoxidil (2,4-diamino-6-piperidinopyrimidine-3-oxyde) stimulates hair growth in vivo. We demonstrate here that minoxidil is a potent activator of purified PGHS-1 (AC50 = 80 μM), as assayed by oxygen consumption and PGE2 production. This activation was also evidenced by increased PGE2 production by BALB/c 3T3 fibroblasts and by human dermal papilla fibroblasts in culture. Our findings suggest that minoxidil and its derivatives may have a cytoprotective activity in vivo and that more potent second-generation hair growth-promoting drugs might be designed, based on this mechanism.
Dutasteride (Avodart) is a dual inhibitor of both type I and type II 5 alpha reductases, and thus inhibits conversion of testosterone to dihydrotestosterone, a key mediator of male pattern hair loss. The aim of this randomized double-blind phase III study was to compare the efficacy, safety, and tolerability of dutasteride (0.5 mg) and placebo for 6 months of treatment in male patients with male pattern hair loss. A total of 153 men, 18 to 49 years old, were randomized to receive 0.5 mg of dutasteride or placebo daily for 6 months. Efficacy was evaluated by the change of hair counts, subject assessment, and photographic assessment by investigators and panels. Mean change of hair counts from baseline to 6 months after treatment start was an increase of 12.2/cm(2) in dutasteride group and 4.7/cm(2) in placebo group and this difference was statistically significant (P = .0319). Dutasteride showed significantly higher efficacy than placebo group by subject self-assessment and by investigator and panel photographic assessment. There was no major difference in adverse events between two groups. The study was limited to 6 months. This study clearly showed that 0.5 mg of dutasteride improved hair growth and was relatively well tolerated for the treatment of male pattern hair loss.
'Relaxers' are used by more than two thirds of African females to straighten hair, with easy grooming and increased length often cited as reasons. A recent study reported relaxed hair lengths much shorter than expected, suggesting increased fragility; the potential for scalp inflammation and scarring alopecia remains unclear. To investigate the biochemical effects of 'relaxers' on hair. With informed consent, included participants represented 3 groups: natural hair, asymptomatic relaxed hair, and symptomatic (brittle) relaxed hair. Biochemical analysis was performed by using a Biochrom 30 amino acid analyzer. Differences in amino acid levels were assessed using either Wilcoxon rank sum test or matched-pairs signed-rank test. There was a decrease in cystine, citrulline, and arginine; however, an increase in glutamine was found in all relaxed compared to natural hair. Cystine levels (milligram per gram amino acid nitrogen) were similar in natural proximal and distal hair: 14 mg/g (range, 4-15 mg/g) versus 14 mg/g (range, 12-15 mg/g); P = .139. In asymptomatic relaxed hair, cystine levels were higher in less frequently relaxed samples proximal to scalp: 7.5 mg/g (5.6-12) versus 3.3 mg/g (1.3-9.2); P = .005. Cystine levels in distal asymptomatic relaxed and symptomatic relaxed hair were similar to each other and to those in the genetic hair fragility disease trichothiodystrophy. It was not possible to analyze lye and no-lye 'relaxers' separately. 'Relaxers' are associated with reduced cystine consistent with fragile damaged hair. A decrease in citrulline and glutamine has been associated with inflammation; prospective studies are needed to investigate whether or how 'relaxers' induce inflammation.
Hair-bearing, transitional, and alopecic scalp from three males and one female with progressive pattern alopecia were examined. Ultrastructural studies disclosed measurable thickening of the follicular adventitial sheaths of transitional and alopecic zones compared with those in the non-alopecic zones. This finding was associated with mast cell degranulation and fibroblast activation within the fibrous sheaths. Immunohistochemically, control biopsies were devoid of follicular inflammation (n = 3), while transitional regions consistently showed the presence of activated T-cell infiltrates about the lower portions of follicular infundibula. These infiltrates were associated with the induction of class II antigens on the endothelial linings of venules within follicular adventitia and with apparent hyperplasia of follicular dendritic cells displaying the CD1 epitope. Inflammatory cells infiltrated the region of the follicular bulge, the putative source of stem cells in cycling follicles. The data suggest that progressive fibrosis of the perifollicular sheath occurs in lesions of pattern alopecia, and may begin with T-cell infiltration of follicular stem cell epithelium. Injury to follicular stem cell epithelium and/or thickening of adventitial sheaths may impair normal pilar cycling and result in hair loss.
The most important feature of hair growth is the cyclic activity of hair follicles in which an active phase, anagen, is succeeded by a resting phase, telogen, during which the fully formed hair remains anchored in the follicle. Between anagen and telogen there is a short transitional phase called catagen. In 1924, Trotter1 recognized that such a cycle existed in man. Two years later, Dry2 described the cycle in detail for the mouse and first used the terminology, which currently is universally accepted. A detailed account of the hair cycle in the human scalp, however, awaited the work of Kligman in 1959.3 Today, his pictures still provide classic illustrations of the sequence of events.
The mechanism of minoxidil-induced hair regrowth in alopecia areata (AA) is unknown. In vitro studies suggest that pharmacologic tissue levels of minoxidil may have both epithelial and T cell effects. Response in 36 of 47 patients with severe AA to topical minoxidil 5% b.i.d. was characterized by a return toward normal of hair follicle diameter, depth and structure, and an apparent shift in T cell populations from the skin into the peripheral blood. Nonresponders showed none of these changes. Biopsies from 34 patients subsequently treated with oral minoxidil 5 mg q. 12 h showed no further changes in perifollicular total T, helper-inducer T or suppressor-cytotoxic T cell counts; they did, however, demonstrate significant decreases in perifollicular Langerhans cell and activated T cell counts, and nearly significant decreases in perifollicular monocyte counts. It is possible that minoxidil may be altering a presumed follicular chemoattractive stimulus to a variety of cell types. Decreases in activated T cell counts suggest the possibility of direct immunomodulatory effects of minoxidil on T cells which might contribute to a hair regrowth response in AA.