Stages of Hair Loss

It is a common knowledge that baldness occurs in degrees and is a gradual phenomenon. Since it is not possible to convey the extent of baldness in words, a classification system was developed by Dr. Norwood. This is the most commonly used sytem today, although other more complicated systems are also available.

Broadly speaking, Norwood classification attempts to divide baldness in seven stages with stage I  being normal adult hairline and stage VII being total possible baldness. Although, there are many flaws in this system, it still gives a basic idea regarding the extent of baldness in an individual.

Stage I

Essentially normal adult male hairline (not to be confused with 'juvenile hairline'). Temporal recessions are well defined   with frontal hairline in normal position. No miniaturisation in crown region.

Stage II

The frontal hairline shows slight recession(< 2 cm), with more pronounced recession in temporal area.
The "A" variant implies that hair line is receding uniformly and that frontal forelock is not spared. This means
exaggerated appearance of baldness and larger requirement of hair during transplant.

In this stage hair transplant should be done if the baldness is stable. Usually a single session is adequate.

Many surgeons defer operating in such patients, especially if they are young.

Stage III

This stage can be considered as watershed for transplant, because now the baldness is very obvious
and most transplant surgeons would consider performing a procedure in such patients. There is definite recession
in frontal hairline combined with deep temporal areas and usually thinned out look in most of frontal area.
Crown may also show miniaturisation and/or actual hair loss (Stage III Vertex)

State IV

This is a more advanced state of baldness, in which frontal and frontotemporal recession is deeper than in State III
and the density of hair in these areas is noticeably reduced. As the baldness moves from front to back,
and circumferentially in crown area; a bridge of healthy hair remains in the mid section of scalp.
This area called the 'bridge' is characteristic of stage IV.  Loss of bridge, is seen is considered a feature of
advanced baldness.

Stage V

Area of baldness keeps increasing and thinning of bridge segment is present.

Stage VI

In this stage there is total disappearance of the bridge segment that separates the two main areas of baldness.
The depth of the frontal and crown areas has expanded sideward and backwards.
In some individuals, frontal forelock may be spared to become 'isolated forelock'.

Stage VII

This is the most advanced stage of hair loss. In this stage only the universal safe zone remains.
Hair transplant is useful only in those individuals of stage VII who have good hair characteristics.

Hair transplant is possible from stage II through VII. Advanced stages of baldness usually require more than
one session to achieve maximum benefit.
In selected individuals mega sessions can be planned to cover large areas in one go.

Cause of Hair Loss

There are many myths in the society regarding hair loss. Reasons from diet to dandruff and change of water to  family stress have been cited as the cause for hair loss. There also have been a lot of research on the cause of baldness. In this post I would like to tell you about real cause of hair loss. It is always an advantage to know your enemy if you want to defeat him. I hope, with this working knowledge you would be able to plan your fight against hair loss in a better way.

 On the basis of cause hair loss or alopecia can be divided into three basic groups

1. Male Pattern or Androgenic alopecia, by far the common balding.
2. Diffuse pattern alopecia usually caused by disease
3. Scarring alopecia where injury to scalp causes hair loss.
   
   
   More than 95% of hair loss in men is due to androgenic alopecia. For androgenic alopecia to occur, three conditions must be met,
   
   
   1.Genetic predisposition to balding:This is not as simple as it sounds. You may have a father with full head and brothers with some baldness but you have a clean pate. The inheritance is usually polygenic, meaning multiple genes and their expressions play a role in development of baldness.
   However, if every man in your family loses hair by thirty, there is a stronger possibility that you will follow suit. Genetic factors are non modifiable. You must live with them.

2. Androgens or Male Hormones: All men and all women (YES!) produce male hormones. These hormones are generated in different quantities in men and women and typically the levels are much higher in males. This is also the reason why patterned baldness is much much more common in males than in females.
The male sex hormone, Testosterone is converted to another product called Di Hydro Testosterone (DHT) which is presently considered the main reason for hair fall. The conversion of Testosterone to DHT is mediated by an enzyme called 5 alpha reductase. DHT progressively destroys the hair root in genetically susceptible hair by a process called “miniaturisation” which leads to baldness.

         3.Time: Time or ageing is the third factor that plays arole in balding process. Nobody           loses hair before puberty (because DHT is not present in the body) but after that, everybody loses some hair. The pace of hair fall vary amongst individuals but it takes approximately 10 hair cycles for a strong anagen hair to become velus hair.

          Although much less important let me discuss other causes of baldness as well. Diffuse thinning of hair may be caused by anemia, thyroid or other hormonal disorder, severe physical stress etc. A rare type of diffuse thinning called diffuse unpatterned alopecia may even involve permanent hair zone.

On the other hand scarring alopecia could be due to injury, burn or skin conditions. Alopecia areata is a rare autoimmune disease in which hair are lost in bunches and body hair may also be involved.I hope it is now clear that change of water, tension and helmets are not the cause of your hair loss. And repeated shaving or oiling is not going to save them either.

Top 5 Hair Loss Myths

When you are suffering from hair loss, every one will offer you an advice or two. From office boy to neighborhood auntie, each can tell you cause and remedy of your hair loss. How they became so knowledgeable is anybody’s guess but here is a list to tell you when they are right and when they are not.

Myth No.1 : Shaving the Head will Prevent Hair Loss

NO! NO! NO! Shaving does not prevent hair fall. Probably the origin of this myth lies in the fact that short stubble feels coarser and is therefore considered made of better quality hair. In fact, it only feels harder because the hair is short and not because hair quality has improved overnight.  

Another contributing factor to the popularity of this myth may be that you stop “seeing” hair loss. After shaving your head, you don’t see hair in your hands or pillow like you used to. This is again because the hair is so short that you don’t notice its fall and not because hair loss has stopped.

Remember, the hair is falling due to hair root injury and shaving can not change this process. Hair fall will continue even if you shave your head hundred times.

Myth No.2 :  Dandruff causes Hair Loss

Again not true. The origin of this myth is the fact that every time you scratch your scalp you get one or two hair in your hands. These are just weak telogen hair that were about to fall any way. Dandruff on the other hand is a surface infection or colonization by a fungus. It happens in oily scalp and is medically treatable. It does not cause any damage to hair roots. Also remember that flaking of dry scalp is different from dandruff and only requires good hair conditioner.

Myth No.3 : Tension causes Hair Loss

False.  I  don’t know where this came from. Severe prolonged stress due to injury or disease can cause telogen effluvium, but day to day stress does not exacerbate hair loss.

Myth No.4 : Helmet or Hat causes Hair Loss

Wrong. Tight helmets or hats may contribute to hair fiber damage, but it does not cause root injury. On the other hand, pulling the hair too hard while wearing a turban or cornrows, can cause permanent hair loss. This is called traction alopecia and requires surgical treatment.

Myth No.5 : Oiling Prevents Hair Loss

Not true. Adequate oil is produced by your scalp to nourish hair roots. In fact, evey hair has its own oil producing gland. If you have very long hair, then putting hair oils may improve the texture, but short hairs do not require oiling. Head massage with oils can relax you but does little for hair growth.

So, what causes hair loss? I shall discuss this in my next blog.

Hair Fall and Stem Cells

There was a very interesting news item in field of hair transplant which I would like to share. This concerns cause of male pattern alopecia.
It is a known fact that in male pattern balding (Androgenetic alopecia), hair follicles don't disappear. They become so small by a process called “miniaturization” that they are not visible to naked eye. Although, we know that DHT is responsible for this process, how exactly it causes miniaturization of hair roots is still not known.

One theory of miniaturization says that DHT causes stem cell depletion in hair follicles of bald areas. A new study, published in the Journal of Clinical Investigation, tries to shed some light on this.  The research team led by Dr. Costarelis, MD collected cell samples from bald and non bald areas from the same persons and counted the number of stem cells present. They were surprised to find that bald areas had the same number of stem cells as hair bearing areas. When they looked further, they found that another cell type, which develops from stem cell, called progenitor cell was deficient in miniaturized follicle.

Dr Costarelis says that, "This implies that there is a problem in the activation of stem cells converting to progenitor cells in bald scalp." As of now, why or what causes the arrest in progression of stem cells to progenitor cells is not known. "However, the fact that there are normal numbers of stem cells in bald scalp gives us hope for reactivating those stem cells," notes Costarelis.
The logical next step would be to identify the factors that arrest this progression and to remove them. A locally applied agent or growth factors that can help stem cells to get converted to progenitor cells would also be very useful.
I have used growth factors injections in some of my patients. The results, especially when used with PRP are good but temporary. The repeated injections overcome the cost benefit. The big break will be an agent that can grow hair permanently. Till then we have hair transplants.

Hair Transplant Basics: Who is the Right Candidate?

Did you know that by the time you start noticing hair loss, approximately 50% of the hair are already gone. So, as soon as you notice hair loss, you should consult a doctor. Remember that consulting a doctor is not same as going for transplant. In early stages of baldness, medicines can help you retain your hair and may postpone the need of transplant. However, medicines can not bring back the lost hair and to grow new hair in a bald area, transplant is the only option..

You should plan a transplant if,

      You have Androgenetic alopecia stage III to stage VII.

      Your hairline is not appropriate for age or you wish to achieve younger looking hair line

      You have burn alopecia or traction alopecia.

      You have eyebrow, eyelash or facial hair loss.

You should wait if,

You are in your teens or early twenties with unstable hair line.

If you have rare genetic conditions like DUPA, extensive alopecia areata etc.

If you are medically unfit for surgery (uncontrolled blood pressure, uncontrolled diabetes, heart failure etc)

Even in these conditions, it is best to consult a qualified plastic and cosmetic surgeon; because he can help you chalk out a plan for future and may offer you alternative therapies. An honest expert advice can save you lot of grief and money.