hair loss

Definition of hair loss

There are basically two types of hair loss:

  • Effluvium describes the loss of hair, which causes more than 100 hairs lost per day.
  • Alopecia describes the condition of hairlessness. This manifests itself in the form of bald spots or a bald spot. If hairlessness is innate, it is called hypotrichy (partial) or atrichia (total).

Effluvia and alopecia may be diffuse or circumscribed, scarring or nonscary.

General / Introduction

Daily hair loss is a physiological rejection reaction of the scalp of older hair.

Thus, a loss of about 100 hairs per day, which get stuck in the brush when brushing or simply fail, is completely normal. However, if the hair fails in significantly larger numbers, this may be responsible for various causes, such as congenital diseases, hormonal influences or drugs.


A sparse hair growth or hair loss is not rare.
Overall, however, significantly more men are affected than women. In Germany, about 1.5 million men and 500, 000 women suffer from hair loss.
Hormonal hereditary hair loss ( Alopezia androgenetica ) is the most common form of hair loss, at around 95%. About every second man suffers from this form of hair loss.

The circular hair loss ( Alopezia areata ) is much rarer. Approximately 1-2% of all people develop a circular hair loss during their lifetime. As a rule, however, this begins as early as childhood or youth.

The hair cycle

Daily hair loss in the range of about 100 hairs is completely physiological.

The physiological hair cycle consists of 3 phases:

  1. In the growth phase ( anagen phase ), a new hair root forms and the production of the hair begins. Depending on age and gender, the growth phase lasts two to six years. 85-90% of the scalp hairs are in this phase and are also referred to as "papillary hairs".
  2. In the transition phase ( catagen phase ), the hair matrix stops its cell production and the hair follicle narrows in the lower area. As a result, the hair separates from the papilla and stunted. In this 2 to 3 weeks lasting phase is about 1% of all hair, which are then called "Beethaare".
  3. The rejection phase ( telogen phase ) represents the final phase of the hair cycle. The stunted hair falls out and hair papilla and hair follicle regenerate. The matrix re-emerges and begins cell division. This is how a new hair can be created. In this phase are about 18% of all hair and it takes about 2 to 4 months. The hair is referred to as "butt hair" in this phase.

Symptoms of hair loss

The symptoms depend on the type of hair loss.

Anageneffluvien: The usually complete hair loss begins after about 14-20 days and is reversible in most cases. The hair roots of the unusual hair are noticeably thin.

Telogenefluvien: There are more than 100 hairs per day. When combing and washing your hair you can easily take off your hair.

Androgeneffluvien begin with puberty, in the man first in the form of so-called "receding hairline" and at the apex, which gradually spread. Often you feel an itch. In women, the front hair parts are preserved, only the hair on the part of the head fall out.

Circular hair loss usually begins suddenly, with circular bald spots on the head or beard. Rarely can also lashes and eyebrows fail.

Causes of hair loss

  1. Hormonal-hereditary hair loss ( Alopezia androgenetica )

The cause of this form of hair loss is a hereditary sensitivity to the male sex hormone testosterone. Sensitivity shortens the growth phase of hair and shrinks hair follicles.
The shrinking follicles initially produce only short and thin hair ( vellus hair ). These can persist or fail. New hair can then no longer be formed. Due to the sensitivity to the male sex hormone, especially men are affected by this form of hair loss.
Although women also produce small amounts of testosterone, but suffer much less common this form of hair loss.
In menopause, which are accompanied by strong hormonal changes, the risk of hair loss in women is significantly increased.
In this form of hair loss, hair first clears on the temples and forehead. This creates receding hairlines and a balding head. Afterwards, the hair on the back of the head thins out, resulting in a tonsure. In young adult men, slow hair loss often starts between the ages of 20 and 25 years.

  1. Circular hair loss ( Alopezia areata )

To date, the exact causes of this form of hair loss are not explained in detail.
It is believed that the hair loss is caused by disorders of the immune system. This would mean that the body's own immune cells (immune cells), falsely attack the hair roots. These are responsible for hair growth. The immune cells stop the hair production and the hair falls out.

It is believed that the hair roots are not completely destroyed, but only inactivated. So it is possible that they suddenly become active again and produce new hair. The fact that many sufferers have other autoimmune diseases, such as atopic dermatitis or hay fever, prove this thesis.
Also a genetic predisposition as a cause is discussed, since in approximately 20% of the patients the circular hair loss occurs family-piled.
In this form of hair loss can be found in various places coin-sized, round to oval bald spots. In the marginal zone, so-called exclamation point hair becomes visible when viewed under magnification. These are thin, short, broken off hairs that become thinner towards the scalp. The bald spots are preferably visible at the back of the head or the sides, but can also occur on the entire head.

In addition, the hair can also fail completely in this form of hair loss. In many cases, the hair grows back after a few months. However, relapses can occur.

  1. Diffuse hair loss (Alopezia diffusa)

In general, the hair roots are damaged in a diffuse hair loss, making the hair diffuse.
The damage to the hair roots can have various causes. This includes, for example, the use of drugs in the context of chemotherapy ( cystostatic use ). But even infectious diseases such as scarlet fever, typhoid fever, thyroid dysfunction, prolonged malnutrition or hormone changes in the context of pregnancy, by taking hormone-containing drugs (eg "pill") or during menopause can lead to diffuse hair loss.
Similarly, an inflammatory scalp disease (eg psoriasis of the scalp) or a lot of stress can trigger hair loss. In many cases, it is a natural aging phenomenon. Due to the diffuse hair loss no bald visible spots, but the entire hair thins out. If a cause for the hair loss is found and treated, the hair usually grows back and the hair loss disappears.

  1. Other causes of hair loss

A fungal infection of the scalp ( tinea capitis ) can lead to hair loss in infected areas. This mostly affects children. Prolonged pressure or rubbing of the scalp can damage it and lead to hair loss at the affected areas.

Similarly, a strong pull on the hair ( tractionalopezie ), a hair loss result. The strong pull damages the hair roots. Even by a mental illness, which leads to obsessive hair, cutting or pulling on the hair, the hair clears. Affected often feel a short time a sense of pressure relief.

A congenital malfunction of the hair (anagen hair) leads to thin, brittle hair and is noticeable even in early childhood. The hair structure is changed by an inherited defect.

Another cause of hair loss can be a zinc deficiency.

Stress-related hair loss

Increased stress can also reduce hair growth.

The connection between physical stress and hair loss has long been proven. Physical stress can be eg pregnancy, surgery or high fever.

The stress causes a certain number of hair follicles (not all!) To go from the growth phase to the rejection phase, which lasts 2-4 months. After this time, the hairs of the affected follicles fall out simultaneously. It shows a hair loss, which is distributed over the entire head and only leads to a thinning (diffuse hair loss), because unaffected follicles continue to have a normal hair growth. After the failure, normal hair grows from the affected hair follicles.

A connection between psychological (psychogenic) stress and hair loss has long been considered a myth. However, today it can be considered proven that there are interactions. Only in male hormone-induced hair loss ( alopecia androgenetica ) does stress seem to have no influence.
Acute or chronic psychogenic stress can cause diffuse hair loss following a similar mechanism to physical stress. However, this is usually after checking all physical causes an exclusion diagnosis.
It should also be noted that psychogenic stress can in turn cause physical changes (physical stress), for example when weight is lost in mourning. These changes can also lead to hair loss.

In addition, psychogenic stress can aggravate hair loss caused by other factors. This includes the circular hair loss (alopecia areata), in which usually precipitate in spurts in sharply demarcated, round areas of hair. The cause is a nerve fiber-mediated inflammation of the hair roots: Each root of the hair is reached by a network of nerve fibers that release a variety of transmitter substances (transmitters), through which they are in contact with inflammatory cells. Psychic stress increases the number of nerve fibers and this causes activation of inflammatory cells, inflammation of the tissue and cell death of the hair follicle cells. As a result, it stops hair growth and hair loss. Overall, it is also important to consider the reverse context. Hair loss usually triggers psychological stress, which in turn can aggravate the hair loss.

If you suffer from stress and hair loss, you should first of all rule out physical causes at the doctor. In addition, the sources of stress should be eliminated. Sleep, relaxation techniques and time management help in terms of more space for leisure. For psychiatric disorders or very serious mental crises, psychotherapy should be used. In all cases, it helps to combat stress as the trigger or cofactor of hair loss rather than treating the hair loss itself as a symptom.


Some forms of hair loss, such as the circular hair loss and the hereditary hormone-induced hair loss can often be seen by a gaze diagnosis.
With a diffuse hair loss or ambiguity of the diagnosis, the hair, scalp and blood are examined more closely. Laboratory chemical such a chronic inflammation, a thyroid dysfunction, an anemia, iron deficiency or hormonal irregularities can be easily detected.

The exact history, especially regarding medication, other chronic diseases, family history and menopause in women are equally important.

By the plucking test ( epilation test ) the doctor can determine how severe the hair loss is. To do this, the doctor gently pulls on a small bundle of hair to see how easy they can be removed from the scalp.
The hair roots can be examined more closely with the aid of a trichogram. The different growth phases of some hairs are examined microscopically.
For the creation of a trichogram, the patient is torn 20-50 hairs in the direction of growth. The phase of the hair cycle can then be determined under the microscope. Since each hair passes through different phases, it is thus possible to estimate the proportion of hair in the individual phases. In healthy hair, more than 80% of the hair should be in the growth phase and less than 20% in the rejection phase.

The remaining approx. 1-3% are usually in the transition phase. The plucking of the hair is essential for the investigation, as previously failed hair was obviously in the rejection phase, and thus no statement can be made to the vital hairs of the scalp.
With the help of a TrichoScans further parameters of the hair can be determined.
This is a special computer software, which makes a statement about the hair density per square centimeter, the hair diameter and the growth rate of the hair possible over time through digital photography.
This not only allows the current hair loss to be assessed in its intensity, but also allows a follow-up examination to assess the success of therapy. Although the hair does not have to be ripped out in this examination method, small areas have to be shaved off at one or two places on the scalp.
The regrowing hair is stained after three days and then photographed in high magnification. Based on the growth rate, a special software calculates the proportion of each hair in the growth phases.
If the clinical picture is no longer sufficient to make a diagnosis, small tissue samples (biopsies) must be taken. The tissue samples are taken deep enough that the entire hair follicle is visible in the microscope.

Therapy of hair loss

After an analysis of the hair growth an individual therapy plan is created.

The diagnostic procedure should be individually adjusted according to the specific medical history and trend-setting findings. For this purpose, an investigation of hair growth and hair loss is made on the entire body. After diagnosis and finding analysis, an individual treatment concept should be developed.

The elimination of the causative factors, such as the replacement of the triggering drugs or harmful substances may be followed by a spontaneous recovery.

It can also help to try out measures that stimulate or accelerate hair growth.

The androgen crucial for the development of androgenetic hair loss is the Dehydrotestosteron (DHT). It is metabolized by two enzymes from testosterone. Therapeutic starting point is the hormonal follicle interaction. Selective enzyme inhibitors reduce DHT (5-alpha reductase inhibitor, finasteride, trade name: Propecia®).

Hair loss therapy

However, finasteride should not be used in women as there is a risk of harm to the unborn male in case of pregnancy!

An alternative is a local therapy of a 2 or 5% minoxidil solution. Applying it causes an increase in local circulation and hair growth stimulation.

In women, the use of oral contraceptives ("pill") may also be effective.

For permanent head hair reconstruction state-of-the-art surgical procedures achieve excellent esthetic results. Hair restoration can be accomplished by hair transplantation and plastic-surgical reconstruction options.

Homeopathic medicines can also positively influence hair loss. Here, the cause of hair loss is considered. For more on homeopathy and hair loss, see the topic: Homeopathy for hair loss.

Hair loss is a widespread problem in the population and primarily affects men.
There are basically three different types of hair loss:

Hormonal hereditary hair loss ( alopecia androgenetica ), circular hair loss ( alopecia areata ), and diffuse alopecia ( alopecia diffusa ).
The causes of these forms of hair loss are not fully explained and thus the therapy is sometimes difficult. The diagnosis is made by a close look at the hair loss pattern, the history of other underlying diseases and medication, as well as blood tests and other specific tests.
With the help of these diagnostic options hair cycle and hair follicle can be closely examined and thus possibly be diagnostic leading.

The therapy consists in many cases in a lifelong medication intake. The form of the hormonal-induced hair loss is relatively easy to treat, because the exact cause and thus a therapeutic starting point was found here.
The treatment of diffuse hair loss consists in the treatment of the triggering underlying disease. The circular hair loss, however, is relatively difficult to treat, since the exact cause has not yet been found. Basically, the therapy often takes a long time, and must be taken lifelong especially in the context of hormonal hair loss. According to the different causes and types of hair loss, the prognosis is very different.

Hair loss in the man

Male pattern baldness (male alopecia androgenetica) accounts for 95% of all hair loss in men. It is both genetically determined and influenced by age. It is based on increased sensitivity to male sex hormones (androgens). With 60-80% in Europe, over half of men suffer from this more or less pronounced hair loss, it is not considered as a disease as such. The health insurance companies therefore do not cover the costs of treatment. Clinically, four characteristics can be distinguished: At grade I, the typical receding hairline corners can be recognized, to which, in the further course, a tonsure (hairstyle) (grade II) on the back of the head is added. Hair loss on the crown joins these areas (Grade III), leaving a horseshoe-shaped hair ring from the sides of the skull to the lower back of the head. The hair growth in the hairy areas is normal and sharply demarcated from the bald areas, which shine through the still intact sebum production.

The processes are not fully understood. However, hypersensitivity of the hair follicles to the active form of the hormone testosterone (dihydrotestosterone, DHT), which is formed in the hair follicles, probably plays an important role. This causes a shortening of the growth phase (anagen phase). Thus, the hair that grow from the affected hair follicles, smaller and finer and smaller until they fall out directly. The corresponding hair follicles atrophy, which is why this process is not reversible.

However, not all hair follicles become hypersensitive to DHT at the same time, which is reflected in the time course of failure (grade I-IV). The hair follicles over the ears and at the back of the head usually remain largely insensitive and the hair stops. Transplanting an insensitive hair follicle from the side in a bald spot on the forehead, so grow back there hair again. The severity of the sensitivity and thus the degree of hair loss is variable. The time course and expression are genetically predetermined on hitherto unknown genes, but they are inherited to a variable degree. To estimate the expected course, a comparison of hair density between father and son at the same age makes sense.

Environmental influences, such as wearing a headgear or frequent combing, play no role due to the strong genetic component. Also, the often suspected connection with stress is not true. The change of diet or cosmetic articles affect hair loss at most marginally. The testosterone level in the blood, for example, it is slightly increased by frequent sexual intercourse, hardly affects the hair loss. The hypersensitivity of the affected hair follicles is already so great that the normal testosterone levels for the hair loss range. A slight increase has no additional effect. Finasteride (tablet) and Minoxidil (tincture) are the only medications that are currently proven to be effective in influencing hair growth. Especially with finasteride, however, the side effects should be considered and weighed.

Hair loss in children

As with adults, many different causes in children can lead to hair loss. Almost always the hair grows completely, often without treatment.

A rare cause can be genetic diseases. However, these usually have other, more serious symptoms in the foreground, so that the hair loss is secondary.

More common is an infection of the scalp, called tinea capitis . The fungus causes the scalp to shed. Typically, the hair breaks off on reddened areas. Possible causes include close contact with animals or stay in rural areas. This type of hair loss is completely reversible with the use of antifungal ointments or tablets.

Another type of hair loss, which usually completely regresses is the circular hair loss. The most likely cause is a malfunction of the immune system, which is directed against the hair-forming cells. Most of the bald spots are formed within half a year. However, a recurrence is possible. Cortisone preparations that are applied to the bald spots, ensure a faster regression.

Stress or mental stress also affect children's hair. The phenomenon of self-inflicted hair tearing was also observed in children.

Hair loss and thyroid

The thyroid hormones act on many different tissues and cells in the human body.

Among other things, on the hair-forming cells. Normally, the hormones ensure that the hair on the one hand re-form and on the other for a certain time to survive stable. If the hormone balance is disturbed by a disorder, this can manifest itself in hair loss. It is not decisive whether an over-function or a sub-function of the thyroid tissue is present, because both too much and too little of the hormone can lead to hair loss.

For a clinical difference, the accompanying symptoms are groundbreaking. In the case of hyperthyroidism, the hair is rather greasy and thin, and tachycardia, anxiety attacks, diarrhea and many other symptoms can occur.
In contrast, hypofunction ( hypothyroidism ) is characterized by blunt, brittle hair, freezing, tiredness, depression and constipation.

A safe distinction can make the family doctor with the control of thyroid hormones in the blood. When the balance of hormone balance is restored, the symptoms, which include hair loss, are slowly and usually fully restored.

  • Hair loss through the thyroid gland
  • Hair loss due to a thyroid disorder

Hair loss in pregnancy

Hair loss during pregnancy is less common than after pregnancy.

The many estrogens make the hair more beautiful and longer. In some women, however, there is a hair loss, especially in the first third of pregnancy. This is however reversible, the hair will regrow completely. One reason for the hair loss may be iron deficiency, which can be improved with iron tablets after consulting with the doctor and after determining the iron in the blood.

In addition to iron deficiency, stress or anxiety can trigger or increase hair loss.

  • Consequences of iron deficiency .
  • Iron deficiency in pregnancy

Hair loss during breastfeeding

Breastfeeding itself has no reliable influence on increased hair loss.

That's why you should never stop nursing to minimize hair loss!
Many women suffer from hair loss after pregnancy, as the body's hormonal balance has to rearrange.
For example, by low iron or the decline in estrogen levels, the hair falls out earlier than usual. Although that seems scary, so you can rest assured that the hair will regrow again.
The duration is very different from woman to woman, but usually the hair loss within a few months after.

Abstract topic hair loss

Hair loss is a fairly common disorder with multiple causes. Different diseases have to be considered. Overall, the treatment of hair loss is individually tailored.

Managing Alopecia: Cause of Hair Loss and Treatments for Regrowth (January 2020).

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