Understanding Hair Loss due to Air Pollution and the Approach to Management

Abstract

Young patients recently shifted to metro cities are presenting with prickling in the scalp, itching, dandruff, oily scalp and pain in the hair roots. Various studies have identified this as ‘Sensitive Scalp Syndrome’ resulting from exposure to increasing levels of air pollution including particulate matter, dust, smoke, nickel, lead and arsenic, sulfur dioxide nitrogen dioxide, ammonia and polycyclic aromatic hydrocarbons (PAH) which settle on the scalp and hair. Indoor air conditioned environments cause volatile organic compounds (VOC) released from various sources to settle on the scalp. The pollutants migrate into the dermis, transepidermally and through the hair follicle conduit, leading to oxidative stress and hair loss. We have used antioxidants, regular hair wash, Ethylenediaminetetraacetic acid (EDTA) shampoo, and application of coconut oil to provide protection the hair and counter the effects of pollution. In this review, we have evaluated the causes, clinical presentation, mechanism of hair loss due to pollution and discussed the the management of hair loss due to air pollution (HDP). Hair loss due to pollution can coexist with or mimic androgenic alopecia. It requires careful history and trichoscopic evaluation to identify and advice a planned hair care program. Patients uniformly show an encouraging response within 6 - 8 weeks of following the hair care regimen.

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ISSN: 2167-0951
Hair : Therapy & Transplantation
Rajput, Hair Ther Transplant 2015, 5:1
http://dx.doi.org/10.4172/2167-0951.1000133
Open Access
Review Article
Volume 5 • Issue 1 • 1000133
Hair Ther Transplant
ISSN: 2167-0951 HTT, an open access journal
Understanding Hair Loss due to Air Pollution and the Approach to
Management
Rajput R*
Hair Transplant Surgeon and Trichologist, Mumbai, Maharashtra, India
Abstract
Young patients recently shifted to metro cities are presenting with prickling in the scalp, itching, dandruff, oily scalp
and pain in the hair roots. Various studies have identied this as ‘Sensitive Scalp Syndrome’ resulting from exposure
to increasing levels of air pollution including particulate matter, dust, smoke, nickel, lead and arsenic, sulfur dioxide
nitrogen dioxide, ammonia and polycyclic aromatic hydrocarbons (PAH) which settle on the scalp and hair. Indoor
air conditioned environments because volatile organic compounds (VOC) released from various sources to settle
on the scalp. The pollutants migrate into the dermis, transepidermally and through the hair follicle conduit, leading
to oxidative stress and hair loss. We have used antioxidants, regular hair wash, Ethylene di-amine tetra acetic acid
(EDTA) shampoo, and application of coconut oil to provide protection the hair and counter the effects of pollution. In
this review, we have evaluated the causes, clinical presentation, mechanism of hair loss due to pollution and discussed
the management of hair loss due to air pollution (HDP). Hair loss due to pollution can coexist with or mimic androgenic
alopecia. It requires careful history and trichoscopic evaluation to identify and advice a planned hair care program.
Patients uniformly show an encouraging response within 6-8 weeks of following the hair care regimen.
*Corresponding author: Rajendrasingh Rajput, M.Ch. Plastic Surgery, FISHRS,
Hair Transplant Surgeon and Trichologist, Mumbai, Maharashtra, India, Tel:
919987926463; E-mail: drrajeshrajput@gmail.com
Received January 29, 2015; Accepted March 03, 2015; Published March 06,
2015
Citation: Rajput R (2015) Understanding Hair Loss due to Air Pollution
and the Approach to Management. Hair Ther Transplant 5: 133.
doi:10.4172/21670951.1000133
Copyright: © 2015 Rajput R. This is an open-access article distributed under the
terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.
Keywords: Hair loss; Pollution; Polycyclic aromatic hydrocarbons;
Volatile organic compounds; Ethylene diamine tetra-acetic acid
shampoo; Cell phone radiation; Coconut oil
Introduction
ere is worldwide awareness on respiratory diseases, sinus
problems and allergies caused by air pollution. Now we have evidence
that this can also occur in indoor environments [1-3]. e skin and hair
form the rst barrier exposed to pollution. Large suspended particle,
small airborne particles, smoke and gaseous pollution settle on the
scalp and hair, causing irritation and damage. e fact was noticed
when Industrial Toxicology Research Center, Lucknow, published a
study with reference to eects on human hair in 1994 [4]. Hair loss due
to pollution (HDP) can coexist or mimic androgenic alopecia just like
diuse un-patterned hair loss, diuse alopecia areata, early cicetritial
alopecia or chronic telogen euvium can mimic androgenic alopecia.
We need to keep an eye for suspicion and correct the damage to deliver
a successful clinical outcome.
Aims and Objectives
e aim of this review is to understand the mechanism of hair loss
due to pollution, identify the clinical presentation and evaluate eective
modes of treatment for preventing hair damage caused by air pollution.
Material and Methods
Patients who presented with un-patterned hair loss and reveal
exposure to pollution were evaluated clinically and treated for
protection from eects of pollution. All patients had detail recording of
history, nature of work and daily commuting conditions. All patients
had clinical scalp examination, trichoscopy counts for hair density per
square centimeter (Figure 1a and 1b), hair caliber in microns (Figure 2a
and 2b) and global photographic records. e evaluation, trichoscopy
and photographs were repeated every 2 months to compare the progress.
Patient’s personal response to improvement of dandru (Figure 2a),
dryness of scalp, redness and itching (Figure 3), burning of the scalp,
pain in the hair roots was also recorded every two months. Patients
were asked to report hair fall on running ngers in the head, combing,
shampooing and hair strands seen on the pillow every morning.
Criteria for hair loss due to pollution based on patient history,
clinical scalp evaluation and trichoscopy
We have used clinical criteria from two studies to identify hair loss
due to pollution. First study by Misery et al. in 2008 [5-7] which dened
the ‘Sensitive Scalp Syndrome’ caused by the eects of pollution. e
second study by Fabio Rinaldi in 2011 [8]. e suggestive history and
clinical evaluation criteria from these two studies that describe hair loss
due to pollution are summarized below.
Criteria on patient history
History: Acute hair loss aer change of residence, moving to
another city, change of work place, added traveling distance, exposure
to wind, dust, strong sunlight, excess heat or cold, smoke, smog or
chemical fumes, construction area, mining areas, oil rigs, petroleum
products, petroleum transport, fertilizer and cement factories or sites.
Criteria on clinical examination and trichoscopy
• Diuse hair loss aecting all over the scalp
• Excessive sweating and sebum secretion
• Severe dandru, scalp irritation, itching,
• Redness in the scalp, burning, trichodynia,
• Dandru or scaling along the temporal and parietal rim where sweat
is trapped and creates prolonged contact with the irritating agent
• Dry frizzy hair
• Minimal anisotricohisis

Citation: Rajput R (2015) Understanding Hair Loss due to Air Pollution and the Approach to Management. Hair Ther Transplant 5: 133.
doi:10.4172/21670951.1000133
Page 2 of 5
Volume 5 • Issue 1 • 1000133
Hair Ther Transplant
ISSN: 2167-0951 HTT, an open access journal
• Few occasional vellous hair in the 1 sq. cm. trichoscopy eld
• Areas of excoriation on the scalp due to itching
• Peri follicular swelling
• Sebum around the hair roots
• Dry scales along with dandru
Method of Treatment
Aim of the treatment plan was oering protection from eects
of pollution and promotion of hair growth. Antioxidants were used
to neutralize free radicals created from exposure to pollution. EDTA
shampoo (less than 2% concentration) was used for chelating and
removing the pollution deposits from the hair and scalp [9] twice week
(Monday and Friday) and regular non-medicated shampoo twice a
week (Wednesday and Sunday). For both the shampoos patients were
instructed to wet the hair, massage the shampoo into the hair roots
and leave it for 3-5 minutes before washing it o which allows for good
cleansing.
Coconut oil was advised to be applied over the sha of the hair to
protect and prevent entry of pollutants into the hair [10-12]. Men used
5-10 drops of the oil applied over the outer surface of the hair, not on
the scalp (minoxidil is to be applied on the scalp). Women used 2-3 ml
coconut oil depending on length of the hair. Since eects of pollution
will slow down the hair growth cycles, we need to stimulate the hair
follicles to regrow. Stimulation of hair growth cycles was achieved with
the application of low dose 2% Minoxidil 1 ml twice a day. Finasteride
was not used in any of these patients. e care program was easily
accepted by all patients and showed results within 2-4 months.
Observations and Results
Patients reported reduction in hair fall when running ngers
through the hair, combing, shampooing and occasional to no hair
strands seen on the pillow, within 6-8 weeks of commencing the care
program. ey had reduced itching, dandru, correction of dryness
of scalp, burning and pain in the hair roots by the end of 4 months
of following the hair care program. Trichoscopy showed 9-12%
improvement in density and 5-7% improvement in hair caliber at 2
months which further improved as the hair care continued (Figures
1a, 1b, 2a and 2b). It was noted that all patients showed some degree of
improvement and none reported lack of benet or failure of response to
the hair care program. e improvement continued every two months
as the hair care continued further.
Result in a patient working on Petroleum transport ship aer
4 months of the care program can be seen in Figure 4a and 4b. An
architect girl, working in dust and cement for the supervision of
building construction sites presented with thinning of hair all over
the scalp including temporal areas as seen in Figure 5a. Improvement
achieved with 4 months of the hair care program is seen in Figure 5b.
During the study we noted that the clinical presentation of hair
loss from chlorinated swimming pool water and benet from hair care
are similar to hair loss due to air pollution. Hair loss from chlorinated
water, in a regular swimmer seen in Figure 5a, which improved aer 4
months of the care program.
Unusual case of hair loss from eects of electromagnetic radiation
from a cell phone:
Figure 1a: Trichoscopic hair counts before treatment.
Figure 1b: Trichoscopic hair counts showing 24% improvement after 4
months of care program.
Figure 2a: Trichoscopic evaluation of dandruff and hair caliber before
treatment.
Figure 2b: Trichoscopic improvement in scalp condition and hair caliber
after 2 months of hair care program.

Citation: Rajput R (2015) Understanding Hair Loss due to Air Pollution and the Approach to Management. Hair Ther Transplant 5: 133.
doi:10.4172/21670951.1000133
Page 3 of 5
Volume 5 • Issue 1 • 1000133
Hair Ther Transplant
ISSN: 2167-0951 HTT, an open access journal
We encountered a patient with unusual hair thinning on the le
temporal and parietal area, around the le ear. e patient had developed
a hair less patch which did not show exclamation mark hair or signs of
alopecia areata on trichoscopy. Patient had history of prolonged cell
phone talk with continuous long conversations holding the phone by
pressing it between the le shoulder and the ear. Patient could recall at
least 18-20 business conversations of more than 20 minutes duration
every day for past 9-10 months. is was 6-7 hours of cell phone usage
per day. On review of literature we found an interesting study showing
single-strand DNA breakage in human hair root cells exposed to
mobile phone radiation [13]. According to the study these changes are
temporary and normal healthy cells are capable of complete recovery
from such eects [13]. e patient was advised to reduce cell phone
conversation time, use hands free option instead of holding the phone
to the ear and follow the hair care program for protection of hair and
stimulation of hair growth. Patient reported good benet beginning
to show improvement within 2 months. e regrowth of hair with
improved density and hair caliber can be appreciated. e additional
response all over the scalp is due to application of minoxidil all over
and generalized benet of antioxidants on hair roots all over the scalp.
Discussion
Misery [5-7], noted that exposure to pollution causes redness,
irritation (Figure 1), faster exfoliation of outer layers of the scalp,
exposing sensitive inner layers, causing more sensitivity, leading
to further scaling and even psoriasis on prolonged exposure [8].
Patients complain of dandru (Figure 2a) not responding to standard
treatments. Irritation due to pollution which on continued exposure,
perpetuates excessive seborrhea and oily scalp (Figure 2a). With
continued exposure to pollutants, hair follicles suer unabated low
grade inammation leading to brosis and permanent hair loss.
Microscopic changes of signs of inammation and accumulation of
phagocytes are reported to be seen on scalp biopsy from eects of
pollution [8].
Fabio Rinaldi, held public campaign in the city of Milan, to study and
document the eects of pollution on human hair, entitled ‘What your
hair breaths’ [8]. He conducted a scalp analysis of 300 volunteers from
July 2007 to April 2008, to have a yearly average. e concentration and
deposition of particulate matter and heavy metals on the hair was one
and half times more than levels in the air and deposition on the scalp
was double the levels in the air [5]. e pollution in Mumbai, Delhi
[14,15] and in most Indian metros is many times higher than the levels
in Milan. Trac pollution has been a known cause for respiratory and
skin ailments [16] the same inammatory process aects hair follicles
as well.
WHO criteria for pollution levels
WHO recommended highest PM should be 100 ng/m3. e average
particle matter (PM) in Mumbai varies from 238 ng/m3 to 643 ng/m3
[14]. Delhi levels of PM vary 398 ng/m3 to 760 ng/m3, being highest
during Diwali reworks and winter smog [15]. Rising levels of sulfur
dioxide (SO2), nitrogen dioxide (NO2), ammonia (NH3) and other
gases are between 11-48%, these can adhere to the hair shas causing
damage, the levels can be 3-5 times higher during winter smog and
Diwali [14,15].
Mechanism of hair loss caused by pollution
Vierkötter et al. studied the eects of airborne particles on skin
aging using a SCINEXA score to catalogue external skin aging [17].
e study describes that the nano-size of suspended air particle matter
(PM) itself causes oxidative stress apart from the biological interaction
with the cells. It has been postulated that these particles can serve as
carriers for organic chemicals and metals capable of localizing in the
mitochondria and generating reactive oxygen species. e highest
concern is polycyclic aromatic hydrocarbons (PAHs). e PAHs are
released from vehicle exhaust, asphalt roads, burning wood, industrial
smoke and industrial waste. PAHs can remain active in air, soil and
ground water. PAHs get adsorbed on the surface of suspended PM in
the air of urban areas. PAHs can activate xenobiotic metabolism, which
converts PAHs to quinones. Quinones are redox-cycling chemicals,
which produce reactive oxygen species, acting as the key compounds in
PM toxicity [17]. Repeated exposure to increased levels of PM itself can
lead to skin penetration, transepidermally or through the hair follicles [17].
Philpott demonstrated in his experiments that pollution levels
increase oxidative stress on the hair follicle cells, leading to increased
hair shedding, similar to the mechanism seen in persons suering from
androgenic alopecia (AA) [18]. Which implies that pollution induced
Figure 3: Redness from scalp irritation and itching caused by pollution.
Figure 4a: Hair loss in a person working on Petroleum transport ship.
Figure 4b: Improved hair growth in 4 months with antioxidant therapy
and hair care program.

Citation: Rajput R (2015) Understanding Hair Loss due to Air Pollution and the Approach to Management. Hair Ther Transplant 5: 133.
doi:10.4172/21670951.1000133
Page 4 of 5
Volume 5 • Issue 1 • 1000133
Hair Ther Transplant
ISSN: 2167-0951 HTT, an open access journal
hair loss mimics AA and may be dicult to distinguish clinically unless
suspected and conrmed by the treating doctor.
Hair as a marker of pollution
Human hair has long been used as a biological marker for
assessment of environmental pollutants, toxins, drug abuse and
exposure to pesticides in farmers [19-21]. Renewed interest in the
common man was triggered from an article by Jasper Coppings in the
Telegraph [22]. Areas of mining and construction activity show higher
concentration of PM. Concentration of mercury, zinc, lead, heavy
metals can be determined from the air, dust and hair of the residents
living around mining areas, indicating these as a cause of hair damage
[23,24].
Hair loss from Indoor pollution in closed building
environments
You need not be exposed to open air pollution to get scalp irritation
and hair loss. Several household goods we use release Volatile Organic
Compounds (VOCs) into the air. Today we spend 90% of our time in
closed buildings with articially controlled air environments. Cooling
& Heating systems also release VOCs [1,2]. e compounds are carried
and recirculated in closed environments nally getting deposited
over the scalp and hair causing irritation and hair loss [3]. Continued
exposure to VOCs can cause skin inammation [25].
Benet from antioxidants
Since formation of reactive oxygen species is one of the main
mechanisms of hair damage due to pollutants, use of oral vitamins,
mineral and antioxidants provides good relief and results in hair
regrowth. e author has earlier reported better hair growth with
combined use of antioxidants, vitamins and minerals along with the
use of minoxidil and nasteride for the treatment of hair loss [26,27].
Role of coconut oil
Use of coconut oil can protect the hair from damage [10-12].
Coconut oil is a triglyseride of lauric acid which has high anity for
keratin protein in the hair. Coconut oil can help in repair of hair sha
lipids and also, act as mechanical barrier over the hair. Due to linear
polymer chain structure and low molecular weight, the coconut oil
can penetrate inside the hair sha. e oil soaks into the hair. e oil
thus occupies the internal spaces in the hair and prevents entry of dust,
dirt, pollutants, chemicals, into the hair sha, thus preventing the hair
damage [10-12]. Oiling the hair well is also recommended before the
festival of colors, Holi and celebration with reworks during Dussera
and Diwali. e same is true for protection from winter smog. If
coconut oil is not available, a good leave on conditioner could help in
coating the hair sha and preventing damage.
Conclusion
Pollution is on the rise all over the world and more so in Indian
metros. Air pollution can contribute to scalp irritation, redness,
itching, excessive sebum secretion, dandru, pain in the hair roots and
hair loss. e combination is dened as sensitive scalp syndrome. e
condition can mimic or overlap androgenic alopecia. e possibility
should be suspected to be discovered. Use of antioxidants, frequent
scalp wash with mild shampoos, use of special EDTA shampoos and
use of coconut oil or hair serum, are the remedies that can protect the
hair from environmental damage.
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Figure 5b: Improved hair growth in 4 months with antioxidant therapy
and hair care program.
Figure 5a: Hair loss in a female architect working in dust and cement.

Citation: Rajput R (2015) Understanding Hair Loss due to Air Pollution and the Approach to Management. Hair Ther Transplant 5: 133.
doi:10.4172/21670951.1000133
Page 5 of 5
Volume 5 • Issue 1 • 1000133
Hair Ther Transplant
ISSN: 2167-0951 HTT, an open access journal
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Citation: Rajput R (2015) Understanding Hair Loss due to Air Pollution
and the Approach to Management. Hair Ther Transplant 5: 133.
doi:10.4172/21670951.1000133