Questions about Thinning Hair? We Can Help- Michele Westendorf, NP-C

Traditionally hair loss has been divided into three categories: inflammatory vs non inflammatory, genetic vs acquired, hormone driven vs not, scarring vs scarring. More recent research asserts that there is a level of “micro-inflammation” that is present across categories. Current treatment for hair loss have included: pharmaceuticals that target specific pathways, hair transplants, low-level light therapy, platelet rich plasma and nutraceuticals. Today, we will talk about the 2 most common causes of diffuse hair loss: androgenetic alopecia, and telogen effluvium.
Hair growth occurs in cycles: Anagen- active growth cycle, Catagen- transition cycle during which growth stops, Telogen- resting cycle. On a healthy scalp 80-90% of hairs are in anagen, 5% in catagen and 10-15% in telogen. Hair typically grows half an inch a month and the average anagen phase last 3-5 years. The catagen phase is much shorter and last around 10 days and the telogen phase is when hair falls out and generally lasts 3 months and then anagen begins again. It is normal to shed 50-100 hairs daily.
Telogen effluvium
Telogen effluvium occurs when there are an increased number of hairs in the telogen phase and less hairs in anagen which results increased daily hair loss and thinning of the overall hair. Telogen effluvium is most commonly seen in females is usually brought on by extreme stress on the body which can be caused by pregnancy, surgery, changing oral contraceptives, extreme dieting, significant illness or profound emotional stress. The most important thing to note is that the thinning of the hair can become pronounced balding does not occur. Telogen effluvium is self limiting and usually resolves within a year. The work up for diagnosing telogen effluvium generally includes: a hair pull test to see how many hairs are in telogen, blood work to check for iron deficiency, thyroid disease or autoimmune conditions. A trichogram can also be performed for a more definitive diagnosis. Traditionally a trichogram has involved plucking 50-100 hairs from different parts of the scalp and examining under the microscope but with Fotofinder technology in our office it can be done with high resolution photos using the Fotofinder Trichoscale. Management includes monitoring the hair loss and nutraceutical supplements such as biotin.
Nutraceuticals are supplements that are derived from food and botanicals that contain photo chemicals to promote and protect health. A key factor that patients should be aware of is that although nutritional supplements are regulated by the FDA they are not subjected to the same standards and requirements that prescription medications are. Supplements do not have to meet standard dosing requirements, prove potency or purity of ingredients or contain phytoactives that are bioavailable for the body. This is where input from your healthcare providers become invaluable. Nutrafol is a nutraceutical with standardized dosing and potency with bio available ingredients that have clinical data supporting its usage to reduce the inflammation found in hair loss. Nutrafol has 21 ingredients but the 7 most important are: Curcumin, Biotin, Ashwagandha, Saw Palmetto, Totrienols/Tocopherols, Piperine, and Marine Collagen.
Nutrafol
Curcumin Helps reduce androgen receptor and stabilize mast cells thereby reducing hair loss from stress
Biotin Helps produce amino acids which provide the building blocks for new hair growth
Ashwagandha Helps to stabilize the body and minimizes the body’s reaction to stress. Has been shown to reduce cortisol levels
Saw Palmetto Slows the progression of hair loss and increase hair regrowth in androgenetic alopecia
Totrienols/Tocepherols Powerful antioxidant and decreases inflammation
Piperine Increases the absorption of curcumin
Marine Collagen Helps increase hair growth in androgenetic alopecia and telogen effluvium

Curcumin is made from turmeric which has been used for centuries for a diverse pharmacological profile which includes: anti-inflammatory, antioxidant, anti-carcinogenic, anti-diabetic, anti-coagulant, anti-microbial, anti-aging, and liver and heart protective. Curcumin helps to reduce the aberrant androgen receptor expression found in androgenetic alopecia and has also been shown to stabilize mast cells which are key players in hair loss related to stress.
Biotin is a water soluble B vitamin also known as B7. Like curcumin, it has a diverse pharmacologic profile by supporting a healthy metabolism, improving glucose intolerance, protecting brain function, supporting a the thyroid and adrenal function and hair growth. Hair is primarily comprised of keratin which is a protein. Biotin helps to produce amino acids which are the building blocks of proteins. Biotin provides help in growing new hair, but biotin alone does not stop hair loss.
Ashwaghandha which is also known as Indian Ginseng or Wild Cherry, has been used for centuries to help stabilize the body and enhance its ability to deal with stress. Elevated stress and cortisol levels have been shown to play a key role in hair loss. Ashwaghanda has been clinically shown to reduce cortisol levels. It also helps improve blood flow to the hair follicle.
Saw Palmetto is a botanical that has been evaluated for treatment of erectile dysfunction and benign prostate hyperplasia. During that evaluation it was found that saw palmetto is a natural inhibitor of 5-alpha reductive thereby preventing the conversion of testosterone to the active for of DHT. This slows the progress of hair loss and stimulates regrowth in patient with androgenetic alopecia.
Tocotrienols/Tocepherols are the components of the vitamin E family which are 8 lipid soluble vitamins which act as natural antioxidants. Vitamin E helps pick up lips peroxide free radicals which can break down cell walls. Patients with alopecia have been shown to have low levels of antioxidants that prevent lipid breakdown.
Black Pepper Fruit, which is also known as piperine, is used to enhance the bioavailability of curcumin. Although the biological activity of curcumin is well known its use has been limited by poor bio availability but when combined Piperine it can increase the amount the body is able to utilize by up to 700%.
Marine Collagen: Collagen is an essential component of the extra cellular matrix and they are commonly extracted from from marine sources. Collagen fragments serve as building blocks and stimulate new cellular growth. Nutraceuticals that contain collagen hydrolysates have been shown to improve hair growth in patients with androgenetic alopecia and telogen effluvium.
Androgenetic Alopecia
The most common type of hair loss is androgenetic alopecia, more commonly known as female or male patterned hair loss. Androgenetic alopecia affects at least 40% of women and 50% of men and is a progressive without active intervention. This disorder is characterized by a gradual conversion of terminal hairs into indeterminate and vellum hairs. The disorder has a gradual onset with transition areas from large thick terminal hairs to thinner shorter hairs and then to short wispy nonpigmented vellum hairs. Men usually note a gradual recession of the frontal hairline with gradual thinning in the temporal areas. Females generally lose hair diffusely over the crown causing gradual thinning rather than marked baldness and the frontal hairline is often preserved in women. For diagnosis the history and physical exam are the most important aspects but lab test may be done to assess DHEA and testosterone level in the women, thyroid levels, and iron level.
Currently, there are two drugs approved by the FDA: topical minoxidil oral propecia. Both medication are supported by clinical studies but have limitations. Topical minoxidils application process is a barrier for many patients as is needs to be administered twice a day and allergic contact dermatitis can occur. Some women experience facial hair growth at the higher dosage. Oral finasteride is limited to men and can be used off label in post-menopausal women. Finasteride can cause feminization of a male fetus if ingested while pregnant and concern about sexual side effects in male patients. The sexual side effects and increased depression, although extremely rare, has been shown to persist in some men even when they discontinue the medication. Both minoxidil and finasteride are used indefinitely because discontinuation results in regression and progression of the hair loss.
Alternative treatment options such hair transplants are beneficial but expensive. There is research that support the use of low-level laser light therapy to help restore hair growth. There are several lasers that are approved by the FDA but they were classified as moderate risk medical device and is therefore only screened for safety and not efficacy. Only devices that are classified as high risk are screened for safety and efficacy.
Platelet-rich plasma (PRP) applications started in sports medicine and dentistry. Although the exact science behind the success of PRP is still unfolding, it’s efficacy and diverse applications have been growing rapidly. Platelets contains a variety of growth factors such as platelet derived growth factor (PDGF), transforming growth factor &TGF), vascular endothelial growth factor (VEGF), insulin like growth factor (IGF), epidermal growth factor (EGF) and interleukin. It is hypothesized that the growth factors released form the platelets act on the stem cells in the follicles which stimulates the develop of new follicles and promotes vascularization of the area.
The blood is obtained in our office by our license phlebotomist into a special PRP collection tube. The blood is then placed in a centrifuge to separate the red blood cells and the platelet plasma. The PRP is then injected into the scalp. We use a cooling machine (Zimmer cooler) to minimize any pain associated with injection. With our PRP package we also perform a Trichoscale instead of the traditional trichogram which requires pulling 50-100 from different areas of the scalp. The Fotofinder Trichoscale allows to diagnose the cause of the hair loss along with calculating the number of hairs, hair density, anagen-telogen rate, number and density of vellum and terminal hairs. The Trichoscale allows quantification of the improvement from the PRP treatments. This technique allows for a safe, comfortable, quantifiable improvement in hair growth. On average patients experience 20-30% improvement in hair quantity. The PRP process consists of 4 sessions, with each session 4 weeks apart. PRP is always most successful in combination with other hair loss treatments such as Nutrafol, minoxidil and finasteride. Further, PRP booster treatments every 6 to 12 months will give further benefit.
When experiencing diffuse hair loss, we always recommend a full assessment by one of our providers for proper diagnosis and etiology. Then, treatment plans can be discussed and created.