Alopecia refers to hairlessness on parts of the body that are normally hairy. The special thing about diffuse hair loss (alopecia diffusa) is that the loss of hair is not limited to a specific area of the head, but that the entire head of hair becomes thinner. The process in which the hair falls out is called effluvium in Latin.
In the majority of cases of diffuse hair loss, neither a causative disease nor another triggering circumstance (e.g. medication) can be found. 90% of cases of diffuse hair loss are caused by androgenetic alopecia (hair loss due to male hormones).
Hair loss is often suspected by patients, although the hair loss is not yet relevant to the disease. People with thick, full hair can lose over 100 hairs a day without a reduction in hair volume (alopecia). In medical terms, alopecia is present when more than 60 % of the human hair is no longer present in a certain area of the body.
In general, our hair goes through a specific cycle in several phases.
Anagen phase | Catagen phase | Telogen phase |
In the growth phase (i.e. anagen phase), new hair roots are formed and the hair grows. This phase lasts around three to five years in humans, with around 80 % of scalp hair being in this phase. | In the overhang phase (i.e. catagen phase), cell production ceases and the hair detaches from part of the hair root. Around 1 to 2 % of scalp hair is in this phase. | In the subsequent final phase/resting phase (i.e. telogen phase), the hair root renews itself. During these 2 to 4 months, hair can fall out more easily as it is no longer firmly attached to the hair root. Around 20 % of scalp hair is in the telogen phase |
Various metabolic diseases (e.g. hyperthyroidism) and nutrient deficiencies (e.g. iron deficiency, calcium deficiency) cause hair loss, a slowdown in hair growth or a reduction in hair quality as the first or only symptom. Hair loss is also common in malignant diseases and autoimmune diseases. Other diseases that are often accompanied by diffuse hair loss include AIDS, anorexia and some forms of encephalitis.
The different forms of diffuse hair loss are
Androgenetic alopecia
Progressive acquired kinking
Diffuse symptomatic hair loss of the late type
Diffuse symptomatic hair loss of the early type
Diffuse telogen hair loss with accelerated hair cycle
Diffuse anagen hair loss
Diffuse alopecia areata
Physico-chemical damage to the hair
Diffuse hair loss due to mineral, coenzyme, protein or energy deficiency
Diffuse hair loss when taking medication
Diffuse hair loss due to various types of poisoning
Diffuse hair loss due to psychological strain (stress) or neurological/psychiatric illnesses
The most common form of hair loss in humans is androgenetic alopecia. Around 50 % of men and 25 % of women suffer from this form of hair loss, with the telogen effluvium showing a specific pattern. This results in hair loss in the occipital and temporal regions.
This rare, probably genetic disorder leads to the development of numerous curled scalp hairs. Many of those affected do not notice the change in hair growth, which is why a high number of unreported cases can be assumed. In men, the change often occurs at the beginning of androgenetic alopecia.
After minor damage to the hair roots, the hair that has prematurely entered the telogen falls out within a few weeks. The hair loss most severely affects the crown of the head. Causes of diffuse symptomatic hair loss of the late type include diabetes mellitus, liver cirrhosis, infectious diseases or certain types of poisoning (e.g. thallium, boron).
This type of hair loss is caused by massive damage to the hair roots, for example due to AIDS, syphilis or cytostatic therapy (chemotherapeutic agents). The hair falls out in clumps. Once the cause has been remedied, the hair usually grows back. Mental stress such as stress or operations or starvation cures can also cause this form of hair loss.
A genetically determined, accelerated hair cycle can lead to an increased loss of telogen hair without a noticeable reduction in hair growth.
Diffuse anagen hair loss is characterized by increased hair regrowth after a damaging noxious agent (e.g. chemotherapy). This results in an increase in hair growth, but for those affected it appears as if hair has been lost.
Alopecia areata diffusa is a special and spontaneously reversible form of diffuse hair loss. In most cases, no trigger is found. The disease mainly occurs in women and manifests itself with an initial diffuse hair loss, which leads to a complete loss of scalp hair over a period of several weeks.
Harmful chemical or physical influences can cause the hair to break off. Depending on how strong the damaging influence is, either individual areas of the scalp or the entire head can be affected. The trichorrhizogram shows numerous, smoothly broken-off hairs. This form of hair loss is often triggered by the incorrect use of bleaching agents.
Hair loss can occur from a dose of 3.8 Gy (i.e. Gray - unit of measurement for ionized radiation). Hair growth can recover after a few months. A radiation dose of more than 8 Gy can lead to permanent hair loss.
A deficiency of various micro- and macronutrients (e.g. iron, zinc, calcium, fatty acids and protein) can cause diffuse hair loss in children and adults. Iron deficiency often manifests itself at the beginning with a disturbance of hair growth, as iron is an essential component of hair growth. Other deficiencies that can be associated with hair loss are vitamin C deficiency, biotin deficiency and copper deficiency. Starvation and crash diets can also cause diffuse hair loss.
If hair loss occurs as a result of taking medication, it should be evaluated whether the medication can be stopped or the therapy switched to another active ingredient. In some cases (e.g. chemotherapy), hair loss must be accepted by patients due to the serious indication.
Medications that can cause diffuse hair loss include
Anticoagulants (e.g. heparin, warfarin, Macoumar)
Analgesics and NSAIDs (e.g. diclofenac, naproxen, ibuprofen)
Thyreostatics
Beta-receptor blockers
Cetuximab and panitumubab
Lipid-lowering drugs (e.g. clofibrate, fenofibrate, bezafibrate)
Antiretroviral medication (e.g. indinavir, didanosine)
Methylphenidate (treatment of ADHD)
Cytostatics
Oral contraceptives
Poisoning with thallium or arsenic classically leads to hair loss. In both cases of poisoning, special so-called Meess's stripes can also be seen on the nails. Arsenic poisoning causes hair loss from the entire scalp. In contrast, with thallium poisoning, individual patches of hair remain. Smoking also damages the hair and hair roots. In this case, hair density, hair length and hair growth are reduced by around 10 to 15 years earlier, as is the case with normal ageing.
Mental illness, stress or inflammation of the brain (encephalitis) can lead to temporary or reversible hair loss. Chronic fatigue and burnout are often accompanied by slight, diffuse hair loss. In contrast to androgenetic alopecia, the loss of hair on the receding hairline in men and women is reversible.
Damage to the hair roots in diffuse hair loss leads to hair loss spread over the entire head. This results in thinning areas and the newly formed hair only grows back at a slower or weaker rate. The symptoms of hair loss vary depending on the subtype.
The extent of hair loss depends heavily on the triggers. Severely damaging substances (such as chemotherapeutic agents as part of cancer treatment) lead to such massive damage to the hair root cells that the hair can fall out within a month of the start of treatment.
When clarifying hair loss, dietary habits, existing illnesses (e.g. diabetes, hyperthyroidism, gout) and medications are asked about during the initial consultation with a doctor.
Other important aspects in the course of a hair loss diagnosis are
Diets and vitamin deficiencies
Previous blood diseases
Iron deficiency
Hormone disorders
Nicotine consumption
Circulatory disorders, sleep disorders, states of exhaustion
Headaches and neck pain
Suspicion or presence of cancer
Psychiatric disorders such as depression or burnout
Age-related complaints, premature ageing
Hair cosmetics and hair coloring
In the case of diffuse hair loss of unclear origin, a blood test with a determination of the iron metabolism parameters, blood cells and haemoglobin content is recommended.
Important laboratory parameters that should be examined in the case of diffuse hair loss are
Complete blood count (incl. red and white blood cells, platelets and haemoglobin content).
Serum iron, transferrin, ferritin, soluble transferrin receptor
Liver function parameters (incl. GOT, GPT and serum bilirubin)
Renal function parameters (incl. serum creatinine and BUN)
uric acid
Lipid metabolism parameters (incl. total lipids, triglycerides and LDL)
Serum glucose and HbA1c
Thyroid function parameters
Calcium, zinc
In women: Serum levels of oestrogen, progesterone and testosterone
In some cases, a trichogram is also carried out. This involves epilating (plucking out) around 20 to 50 hairs using a clamp, which can then be examined under a microscope. By assessing the hair roots, conclusions can be drawn about the growth behavior of the hair on the head, which also makes it possible to estimate the extent of hair loss.
Clinical tests for diffuse hair loss are
Clinical epilation test (hair plucking test, test for the firmness of the hair fit)
Phototrichogram (trichorrhizogram): Photographic documentation of hair growth in small areas
TrichoScan: Assessment of hair growth using specialized software
If the blood test indicates the presence of a disease or hormonal disorder, the treatment of this problem is a priority. This can often improve or even eliminate the hair loss. If there are indications of diffuse hair loss caused by taking medication, the medication in question should either be discontinued or replaced with another suitable active ingredient.
The treatment of diffuse hair loss can generally be divided into local external applications and local injections (mesotherapy).
Local therapy options for diffuse hair loss are
Mild, gentle, alkali-free hair washes at intervals of 5 to 7 days
Circulation-promoting measures such as scalp massages with solutions
Rubbing the scalp with various active ingredients
Local application of minoxidil (2-5%)
The benefits of mesotherapy are controversial. This form of therapy involves the subcutaneous injection of various substances such as
plant extracts
homeopathic active ingredients
vitamins
vasodilators
minoxidil and finasteride
Common side effects of mesotherapy are abscesses due to the injection, as well as irreversible hair loss and scarring.
Oral preparations that stimulate hair growth are also frequently used. These are, for example, dietary supplements that contain important nutrients for hair growth.
Recommended micronutrient levels for hair loss are
Substance | Daily amount |
Iron | 10 - 15 mg |
Zinc | 30 - 50 mg as zinc-histidine |
iodine | 200 μg |
Biotin | 60 - 90 mg |
Folic acid | 600 μg |
Protein with sulphur-containing amino acids | 1 - 1,2 g |
The prognosis for diffuse hair loss is good in most cases. If the cause of the hair loss is remedied, the hair on the head often regenerates.
If the diffuse hair loss was the result of chemotherapy or radiotherapy, the newly formed hair is often thinner and lighter than the previous head of hair. The reason for this is that cancer therapy often severely damages the hair root cells (especially the matrix and pigment cells in the hair growth zone).
Dr. med. univ. Moritz Wieser
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