By Dr.Harold Gunatillake


We are blessed with a nearly 100,000 scalp hair follicles (roots) at birth. (It is interesting to note that unborn babies, grow fine, soft, un-pigmented hair that sheds about the eighth month before birth). Some of us are lucky to retain those hair roots actively till late in life, other than thinning and graying of the hair shafts. Others are less fortunate, including both genders, gradually to lose their hair, at some stage in life, held so proud and precious earlier. In men we call this “male type of balding”, but fortunately, women may have a similar pattern, but does not lead to total baldness like the male counterparts.

Under normal circumstances hair growth in each root occurs in cycles. Three phases are described, anagen, catagen, and telogen phases.

Anagen is the active phase when the hair grows from the root at the rate of half inch per month, for two to seven years. Those ladies having a two-year growth have the hair lengthen up to the shoulder region, whilst those that extends much lower are the seven-year-old hairs. Anagen is the longest phase with up to 90% of follicles on a normal human scalp in this active hair growth state at any given time and telogen (resting stage) hair follicles comprise up to 10% on the scalp (Kligman 1988). Anagen is followed by catagen, a period of controlled regression of the hair root, lasting for about 14 – 21 days. During this phase the dermal papilla like a mound at the bottom where the hair root lies on, as in fig.1, condenses as the cells become inactive. With the lack of dermal papilla cell stimulation, the hair fiber and root sheaths stop growing. Ultimately the hair root enters telogen-the resting state. This end phase lasts just 30-90 days.

We shed under normal circumstances 50 to 100 hairs daily, and should be thought of as replaceable loss. Some people notice little hair loss on a day-to-day basis, but notice increase hair loss on shampooing and vigorous brushing. In most mammals, each of these phases mentioned affect all roots at the same time- a wave like fashion in seasonal moults. In short the hairs are shed totally synchronously.  In humans the hair follicles run through the normal cycles of growth entirely independent of neighbouring follicles (roots).

Why the human hair roots behave independently and differently from other mammals, cannot be explained. In short each human hair root has its own memory, and identity. This attribute helps when transplanting hair, and is so successful.

Let’s discuss about the hair structure, before getting on to the common causes of premature shedding.

Each hair shaft is elliptical, circular or flat in cross–section, and has three concentric layers. Asians have straight circular hair, and those that have wavy and curly hairs are elliptical. Negroid hair is flattened and ribbon like. The innermost core is the medulla, a hollow air-filled space occupying the entire length of the hair, and surrounding this- the cortex, which makes up most of the bulk of the hair, is made of a tough fibrous protein called keratin, same material present in finger and toe nails. The protein is rich in cysteine which crosslinks to form cystine as the hair moves up the follicle. Cystine provides strength to the hair shaft. Hairs have no nerve supply and can be cut without inflicting pain.

The outer layer is the cuticle composed of layers of flattened cells displayed like the flat tiles on a roof, overlapping each other at the edges. The healthy appearance, such as shininess, brightness and strength, depends how badly weathered these individual cells are.  It is akin to the damage that occurs to your roof tiles. If the edges are cracked and separated, water creeps in, weakens the hair shaft, and premature ageing occurs. If the cells are neatly tiled like on the roof, light will be reflected evenly from this smooth surface and the hair will appear glossy and smooth.

Weather beating of these tiles commonly happens on standing in the hot sun daily waiting for the bus, strong winds, and atmospheric pollution. Frequent usage of strong shampoos, hot showers, and damage caused at the salons, through waving, straightening, bleaching, colouring, etc. would lead to chemical and physical beating of these glossy tiles.

Cracks in these cell edges, unlike roof tiles can be repaired. Daily conditioning your hair will fill those cracked edges of the outer cuticle cells with silicon, found in hair conditioners. Furthermore, the silicon gives that strength, smoothness, and shine to the hair shafts. Conditioners also reduce static electricity in the hair. Both shampoo and conditioner in one is not generally recommended. It is hard to believe that both in one will perform their functions as good as when used separately.

Cucumber has sufficient silicon. Fresh slices when rubbed on the hair fills those cracks, and give that lustre to the cuticle cells (tiles). So, daily strong shampooing is damaging whilst daily conditioning is beneficial. A good shampoo should remove the build up of oil, dead skin, and atmospheric pollutants that bind to the hair shaft, and it should rinse cleanly the hair and the scalp. Acid shampoos (low pH, 4.5 to 6.0) are said to be more friendly and kind to the hair, and preserves the protective acid mantle. Soap also does the same, but in the presence of hard water may lead to build up of insoluble soap salts and may cause some discomfort. Soap does not cause premature shedding of hair or damage roots, as believed by some. You may remember the pre-shampoo era during and before the forties, men and women did use soap on the scalp, with no complains of hair loss.

Using combs
Another important factor that gradually damages your hair shafts is the type of comb you use, and the way the hair roots are stretched on combing, and the styling that maintains them stretched whole day. Ladies with long hair practice this situation.

Plastic type of brushes with soft spiky teeth well spaced fixed onto the shaft are preferable, as there is no tension on the hair roots, when brushing.

Hair colour
The number and type of melanosomes from melanocytes within the hair bulb matrix determine hair colour. Melanosomes are large, ellipsoid, and rich in melanin in dark hairs, spherical in red hairs, and present in low numbers in white, gray, and blond hairs. Bleaching is a lightening of hair colour. Oxidizing agents, usually hydrogen peroxide chemically changes the hair pigment melanin.

The hydrogen peroxide is mixed with an alkaline ammonium solution immediately before applying. This process damages the keratin, rendering the hair dry, porous, and more prone to tangling. The increased porosity of the hair allows bleached hair to absorb more water through cracked outer cells (tiles), resulting in longer drying times, and increased susceptibility to humidity changers.

For graying hairs a natural old remedy would be to rub boiled ‘karawila leaves’ extract on the hair frequently.

Frequent colouring and tinting of hair may also lead to weakening, thinning and loss of hair. Semi-permanent hair dyes are the most popular forms used at home and at the salons. The chemicals used in such dyes will penetrate the outer cells of the hair shaft, and cause gradual damage to the structure of the hair.

Vegetable dyes derived from plants are also semi-permanent dyes. They do not penetrate the outer layers of the hair shaft and hence less damaging to the hair.

Permanent dyes on the other hand penetrate the hair shaft and get trapped within the hair cortex, and cannot be removed by shampooing. The dye is mixed with the developer, i.e. hydrogen peroxide- 20 volumes, which generate a chemical reaction within the shaft of the hair. Unfortunately, the bleaching reaction caused by hydrogen peroxide is damaging to the keratin, leading to breakage of the hair shaft.

Hormone dependency
The distribution of hair at the time of puberty and development of other secondary sexual characteristics in both genders are totally under the influence of the hormones secreted in the sex glands. The male hormone-testosterone, the dominant one in males, is produced in the testicles during puberty and continues during once sexual life.

 It travels in the bloodstream to the hair follicles. However, testosterone does not kill off the hair follicles (roots) directly. It is converted, inside the follicle, to a much more powerful hormone called dihydro-testosterone (DHT). DHT has a great effect on the hair follicles, affecting them in different ways in different parts of the body. On the face and chest, DHT stimulates the growth of thick curly hair. This contrasts with its effect on the scalp where it makes hair thin out and eventually kill off the follicles altogether, on the hairline, sides of the frontal scalp (receding), and the crown.

Why do males go bald only to a defined line and hair loss stops at that point? This is because the DHT receptors are in the area that goes bald and not in the part that does not. Another important question is- why do hair transplants grow in the bald area if it has concentrations of DHT that kills hair follicles? It is believed that the DHT receptors are actually in the follicle itself. If they do not exist in the follicle that is transplanted then they are unaffected by the DHT levels in the surrounding tissue.

The presence of DHT in the balding hair follicles, destroys the follicles, and contrary the DHT has no sensitivity on the hair follicles on the sides and the back of the scalp. Hence the hair grows uninterruptedly.

This is referred to as male pattern baldness, or Androgenic Alopecia, or genetic hair loss in men. It is believed that those men who develop early thickening of body hair are bound to grow prematurely bald later in life.

A significant difference in the pattern of hair loss in androgenic alopecia between the genders is that women do not become completely bald. Instead, they show patterns of diffuse thinning, often worse centrally. This difference is mainly due to the influence of the female hormone- oestrogen a stimulating factor for hair growth.

Androgenic alopecia is the most common cause of hair loss in men, and women. Women too manufacture androgen- the dominant male hormone in their ovaries and adrenal glands. In most situations the dominantly present female hormone subdues this effect during the child-bearing period. Thinning and loss of hair prominently is more common during the post-menopausal period among women. Oestrogen depletion in the shrinking ovaries, and increased production of the male hormones in adrenal glands may be responsible for this change.

Women are recommended to take hormone replacement therapy (HRT) during their pre and post-menopausal period for their well-being, and prevent early loss of hair.

It is also an observation that teenage girls and young women in western countries do not complain  loss of excessive hair on the scalp, although they indulge in more salon treatments like hot stretching, permanent waving, straightening, bleaching, tinting, and what not. It is possible the hormones in their contraceptive pill may favour growth of healthy hair. Likewise, the elderly ladies too retain their hair, in spite of the processes they indulge in the hair salons regularly. Again HRT may be responsible for such continuation of having healthy strong hair. Another reason why ladies should be on HRT is that their hormones become more androgenic (male like) at menopause.

Hirsutism in teenage girls
In Sri Lanka it is quite an observable feature that many young girls suffer thick and black hair distributions, like the male counterparts, on the upper lips, chin, side burns, chest, and exposed extremities. These unfortunate teenagers may also suffer from face scars, secondary to rosacea vulgaris (acne), oily skins, black and white heads, associated with menstrual irregularity. It is a most embarrassing situation, and stressful to spend lots of money for temporary hair removing methods and creams to clean the face skin. Using home made hot wax, and threading are most popular, and cheap. Electrolysis, which is a technique to burn the roots through a fine filament by passing an electric current, is a permanent exacting method. This method has to be practiced by qualified doctors, as the technique involves local anesthesia and training to perform confidently and skillfully. Plucking facial hair with pincers is another past time. In western countries dry shaving with electric shavers specially made for ladies is quite popular, cheap and convenient.

Whilst practicing these temporary techniques, changing the hormone distribution biochemically through the blood stream is the permanent solution for these girls. Today there are medications to suppress the androgenic effects of hormones, and enhance the female oestrogen levels. If one has these problems, one must consult a doctor for the right specific medication. Such medication should be taken at least for a year to visualize results. The doctor will also do blood tests, and other tests, to find out the causes of the problem. Vast majority of women with excessive hair in the said areas are perfectly normal in the hormone levels. It is possible that the hair follicles are overly sensitive to androgen hormones.

Most men and women at some stage in their lives seek professional services, for these problems, but it is advised that they should seek early, rather than delaying.

Alopacea Areata
This is a condition where there is total loss of scalp hair in discrete areas. This is considered as an autoimmune phenomenon caused by one’s own disease fighting white cells. Stress has been blamed for this state. The condition is reversible with medication, especially when the hair loss is confined to one discrete area.

When the whole scalp is affected the condition is called Alopacea totalis, and if body also involved, it is called alopacea universalis. The doctors prescribe cortisone injections into these areas weekly, until visible results.

Other causes
There are many other factors that cause loss of hair. Sometimes the word non-scarring alopacea is used to denote that there is no actual destruction of follicles, and no scar tissue formation. Your physician will look through a magnifying lens to detect the presence or absence of hair follicles. The presence of hair follicles is an excellent signal for remedial measures.

Some of these causes are associated with medical conditions, including infections, autoimmune diseases, thyroid and kidney diseases. In these diseases hair loss forms a minor symptom.

Many drugs and chemotherapy can cause loss of hair. Medications such as statins given to lower  cholesterol level in blood, is one such culprit.  Medications given for stomach ulcers, arthritis, heart disease, may cause hair loss.

Dandruff, diabetes, high blood pressure, and stress are contributing factors for hair loss. Once the drugs are stopped the hair follicles will recover and the hair will re-grow.

Some nutritional deficiencies can also cause non-scarring hair loss, i.e. protein deficiency, anemia, and zinc deficiency. Vegetarians can lose hair, and nutritional supplementation may be required.

When primary causes for hair loss are ruled out, Minoxidil (2% or 5%), Propecia, and Folligro, are worth given a trial, during the early stages of hair loss. These medications need to be tried long term for adequate response. Folligro was originally developed in Germany and has been slowly gaining popularity in Europe.

For male type of balding today, there are experienced surgeons who can restore hairs surgically. The techniques practiced are, hair transplants, scalp reduction, strip grafts,Yuri flaps, among others.

Hair transplant techniques are most popular in affluent countries, and our interested clients had to go abroad for such surgery. Today, this sought of surgery is available at your doorstep, performed by surgeons experienced in this field abroad for many years, and the price you pay is affordable, compared to what is paid abroad.

The key to hair transplants is the concept of donor area dominance. The men who require such restoration have sufficient hair follicles on the back and sides of their heads. These hair follicles have no genetic instructions to be sensitive to DHT, and hence are most suitable to be transferred to bald areas of the head. A strip of hair bearing skin, 9mm width, a length extending from one ear lobe to the other, is harvested under local anaethesia. The gap is approximated straight away with fine dissolving sutures. The flaps containing hair remaining above and below on either side fill the gap, and no visible scar is seen.

This harvested strip is sliced into strips, ultimately to obtain single or double hair follicle units. After the follicular units are carefully prepared under magnification, they are strategically placed into the balding scalp through minute stab incisions.

The whole procedure done under local analgesia takes five hours. A fixative solution is sprayed to the recipient site, at the end of the procedure, sent home without hospitalization, with no wrapped up dressings.

The whole process is so simplified, that you may be able to go for your usual occupation about the third day. Bleeding after this surgery is a rarity, and mild analgesics are sufficient for night pain.

This technique is mainly for males, but rarely can be done for ladies if the balding is severe. Scalp reduction may be more suitable for women who suffer from crown loss of hair.

The question is asked whether there is a connection between heart disease and hair loss? Two recent studies in USA have shown that bald men have a greater incidence of heart disease. It has also been shown that bald men have higher cholesterol levels than non-bald.

Recent studies also suggest that food choices influence the hormones that lead to hair loss, and so you may be able to postpone balding by modifying your diet.

High fat foods increase testosterone production and reduce the amount of sex hormone binding globulin that keeps it in check. As a result, there is more testosterone available to enter the hair follicles and cause hair loss. In contrast, low fat high fibre foods slow down hormone production and speed up hormone elimination.

Remember, today in this "stone age", there is a solution for your hair loss problem.


Ref: All about skin care by Annette Callan, Oxford University Press, Australia 3205.