Hair Care and Hair Growth Nancy Kleiman, BSP, MBA Date of Revision: November 2014
Humans are born with a fixed number of hair follicles. Approximately 100 000 hair follicles are on the scalp alone. Two types of hair are found on a human body; vellous and terminal. Vellous hair is fine, soft hair that is nonpigmented and covers the body. Terminal hair is generally long, course hair that is pigmented and covers the scalp, face, axillae and pubic area. Terminal hair grows on the face, chest, legs and arms in response to androgens at puberty. Decreased estrogen levels can also allow androgens to stimulate terminal hair growth in menopausal women. Hair grows at the rate of approximately 1 centimetre per month.1 Hair growth occurs in 4 stages on the scalp. 1. The active growing phase or anagen stage lasts 2–6 years and determines hair length. Normally about 80–90% of follicles are in this stage at any one time on a human scalp.1
2. The transitional phase or catagen can last 2–3 weeks at which time the follicle degenerates and growth stops. On a normal scalp approximately 1–3% of the follicles are in this stage.1 3. The 3rd stage is the resting phase or telogen stage which lasts 3–4 months. Approximately 5–10% of follicles are in this stage on a normal scalp.1 4. The last stage of hair growth is the shedding phase or exogen phase where the hair is shed and the cycle of growth begins again. Normally about 75–100 scalp hairs are shed each day or about 0.1% of scalp hair.1 Repeated chemical treatments, poor grooming habits and exposure to the environment can cause hair texture to change and result in hair breakage. This progressive degeneration of the hair shaft is called “weathering” and contributes to structural weakening of the hair, making it tangle easier and appear rough.2
Hair Loss (Alopecia)
Androgenic alopecia (AGA) is the most common type of hair loss. It is commonly referred to as male-pattern baldness or female-pattern baldness. Androgenic alopecia is a hereditary form of androgen-induced diffuse hair loss that presents as a reduction in hair size as well as hair loss.1 The exact influence of genetics on AGA is unknown but it appears that it is generally inherited by males from their mothers.1
In AGA the actual number of hair follicles remains the same and the growth cycle is constant but the anagen or growth stage is somewhat shorter producing a shorter, thinner hair shaft. This thinner hair shaft covers less scalp and the area progressively becomes larger and balding appears, particularly in men.1 In men the hair thinning starts in the crown area, gradually progressing to the mid-scalp area.
Female-pattern baldness is also referred to as AGA but it appears that androgens are of less influence than in male-pattern baldness. Hair loss in women is milder than in men and presents as central thinning or “widening of the part line.”1 Telogen effluvium is an abnormal number of hair follicles prematurely entering the telogen or resting phase.1 Excessive hair shedding and thinning occurs in the scalp, pubic and underarm areas about 3–4 months later with more than 300 hairs being lost per day (normal is 75–100 per day). Causes can include hormonal changes during pregnancy, severe psychological stress, injury or stress from
infections, serious illness or major surgery, endocrine disorders, iron deficiency and crash diets.1 In about one-third of the cases no cause can be definitely determined.1 Hair loss generally begins 1–3 months after the causative event.1
Hair loss can last up to 6 months after correcting the causative factor.1 Anagen effluvium is the loss of hair over the entire scalp. Can be caused by chemotherapy, radiation to the head, certain medications (see Table 1) and mercury toxicity.1 Hair loss is usually sudden and severe, affecting most of the anagen scalp hairs simultaneously.1 Normal hair growth is generally rapidly restored once the underlying cause is removed.
Alopecia areata (AA) is an autoimmune inflammatory disorder that affects the hair follicles and nail matrix.1 Occurs at any age but commonly affects children and younger adults.1
Can be associated with pre-existing autoimmune disorders such as thyroid conditions, systemic lupus erythematosus and vitiligo.1
There is also a family history connection as those with early onset often have a close family member with the condition.1 Physical stress, emotional stress and some types of infections can also cause this condition.1
AA typically presents as smooth round or oval patches on the scalp but also can appear on any other hairy areas of the body.1 There is no evidence of inflammation or scarring in the affected area.1
Nail pitting or ridging can also occur and may be a function of the disease itself.1
AA is generally self-limiting and hair can spontaneously re-grow. Chronic, extensive forms are often associated with a family history of hair loss that may not re-grow. This chronic hair loss can occur in children with an onset prior to 5 years of age.1
Excessive Hair Growth
Hirsutism is the production of excessive terminal hair in a male-pattern distribution in women. It is usually a consequence of increased androgen activity in women caused by an underlying medical problem such as polycystic ovary syndrome, androgen-secreting tumors, Cushing syndrome, acromegaly or thyroid dysfunction. Androgenic medications (danazol, testosterone) may also be a cause of hirsutism and must be considered when diagnosing this condition.3 Hypertrichosis is excessive hair growth that is either hereditary or caused by medications such as glucocorticoids, phenytoins, minoxidil or cyclosporine. Hypertrichosis is not a result of increased androgen activity but can be aggravated by an increase in androgen activity.3 Table 1: Drugs Associated with Hair Loss
Specific drugs listed are given as examples only; other medications in the same class may have similar effects.
Goals of Therapy
Maintain healthy-appearing scalp hair
Treat any underlying medical conditions that may be causing the hair loss Consider changing medications if causative factor
Manage psychological factors such as self-esteem and mood changes Control unwanted body hair
In androgenic alopecia, retard hair thinning and increase scalp coverage
The assessment process is an opportunity to educate patients about the various factors that contribute to hair growth changes and effective treatment methods to either reverse or cosmetically cover the condition. Always refer patients to a physician for further investigation when they present with unusual changes in hair growth and/or significant concerns about their hair changes. An approach to the patient with hair-related concerns is presented in Figure 1. Figure 1: Assessment of Patients with Hair Loss/Hair Growth
Hair colour, texture, body and curliness is genetically determined. Shiny hair that has a smooth texture, clean cut ends and has not been damaged by chemically altering the hair is considered “healthy hair.”4 When the cuticle is damaged, hair can appear dull, feel rough and brittle and have split ends. To maintain healthy hair and minimize damage:
Have hair cut by a professional to remove ends that are damaged.
Use appropriate shampoos designed for the type of hair (dry, damaged or chemically treated hair) and condition hair regularly according to type of conditioner used. Minimize exposure to harsh chemical treatments such as permanents, dyes, bleaches and straighteners.4
Avoid excessive brushing. Use a brush with natural, round-ended bristles, and brush gently. Use a wide-toothed comb to detangle or comb wet hair. Minimize use of blow dryers, curling and straightening irons.4 Use a lower setting on a blow dryer, and use a diffuser to blow dry chemical-treated hair.
The frequency of hair washing may be influenced by length of hair, culture, sex, social pressures and economics, as well as individual preference. Daily washing is not harmful and is dependent on lifestyle and personal preference. Various hair care products can be used to cosmetically enhance the hair's appearance (Table 2). Nonpharmacologic options for patients with hair loss include cosmetic hair products such as sprays, foams and lotions that make the hair look thicker. Hair extensions can be attached permanently or clipped on daily to add length or volume to the existing hair.6 Excess hair can be routinely controlled with physical removal by shaving, waxing, plucking or the application of depilatory creams, or camouflaged by bleaching. These forms of physical removal are all associated with the re-growth of the hair and will often be used in combination with more permanent hair removal methods. Hair does not grow back any faster, thicker or denser than normal.7 Shaving removes hair at the skin level and is suitable for most areas, but the hair grows back quickly. This method does not affect the rate of hair growth and is a safe and inexpensive way to control regular hair growth.8 Cold waxing involves application of wax-impregnated strips that are pressed on the skin then pulled off in the direction opposite to hair growth. Warm waxing involves wax that is heated to 37°C and then spread over the area in the direction of hair growth. The waxed area is covered with strips and allowed to cool. The strips are then pulled off against the direction of hair growth. Hot waxing consists of melted wax spread over the desired area against the direction of hair growth and allowed to cool. It is then quickly pulled off.9 Waxing allows the area to be free of hair for several days but is painful when performed by someone not trained in the field. Plucking can be effective for small areas (eyebrows, upper lip and chin), but is time consuming, painful and temporary.9,10 Bleaching lightens hair so that it is not as noticeable. Several products are available, all containing hydrogen peroxide as well as many containing ammonia (accelerates the bleaching action). Bleaching is fast, generally painless and is reserved for small areas. Results can last up to 4 weeks. Side effects include skin irritation and hair discoloration.10 Depilatory creams act by separating the hair from the follicles. Hair re-growth can begin within a few days of treatment. These methods are best used for weekly hair removal or in combination with laser treatment. Contact dermatitis (allergic and irritant) can occur with the use of these products because of the alkaline nature as well as the added fragrances. Some find the products messy and the odour offensive which limits their use.10 Laser systems and intense pulsed light sources (IPL) work on the same principle, selectively targeting specific areas without affecting the surrounding tissue. Melanin pigment in the hair follicles absorbs the wavelength selected, effectively destroying the hair follicle by thermal damage and impairing future hair growth.10 A Cochrane review discusses studies of laser and IPL procedures and concludes that permanent hair removal is not realistic.11 More realistically, long-term stable reduction in hair re-growth lasting for 4–12 months can be accomplished with these procedures.10,11 Side effects can include mild to moderate pain, skin redness, pigment changes and burned hairs. These side effects are dependent on the type of laser used for treatment.10 Topical anesthetics containing lidocaine and prilocaine are commonly used prior to laser treatment to decrease pain from the procedure. Consumers may apply these products in larger amounts and to a larger area than is recommended, increasing the risk of serious side effects.12 These side effects can include central nervous system toxicity, methemoglobinemia and cardiovascular collapse. Systemic effects may appear as headache, drowsiness, respiratory depression, confusion, convulsions, hypotension and cardiac arrhythmias.12 Laser and IPL treatments must be administered by a trained professional on a regular basis to maintain hair removal, and are expensive.3
Electrolysis is an option for the removal of unwanted hair. A small needle or metal probe is inserted into the hair follicle and low-level electrical current is used to destroy the follicle. It is important that the procedure be performed by a trained and certified professional. The designations C.P.E. (Certified Professional Electrologist) and C.C.E. (Certified Canadian Electrologist) indicate the electrologist has satisfied a board of examiners and is a member in good standing. Table 2: Hair Care Products
Detergent component helps remove oil, dirt, sweat, fungal elements and hair care products (styling gels, hair spray).
Routine use as part of a personal hygiene regimen to maintain healthy hair.
Shampoos are formulated for hair that is considered to be normal, greasy, dry or chemically treated. Daily use is not harmful provided the product is well formulated.
Contains cationic polymers (balance the negativity of damaged hair), film formers (fill hair shaft defects) or proteins (thought to restore protein to damaged hair). Lubricates and moisturizes hair leaving the hair soft, smooth and hydrated which decreases static in the hair.
Restores appearance, softness and manageability of hair.
Instant conditioners are applied immediately after shampooing and left on for a short period of time. Deep conditioners, used for very dry hair are creams that are left on for 20–30 minutes and may or may not require heat to increase penetration.
Styling sprays, mousses, gels and waxes
Contain large molecular weight polymers, proteins, and/or resins to hold hair in place or coat hair, adding thickness and texture. Silicone-containing products provide sheen, lubricate and increase resistance to humidity, making hair more manageable.
Creates changes in hair volume or style.
Wide variety of products available. Mousses aid in styling, are soft to touch and can be easily removed. Styling lotions are applied to wet hair and hold style when blow drying.
Hair colouring agents
Dyes that cause a gradual hair colouring use metallic dyes that cause a chemical reaction on the hair shaft.
Alter the colour of hair through various methods.
Gradual dyes must be used continuously for colour change to remain and are inexpensive. Hair can become stiff, dull and brittle and colour quality is often poor. Temporary dyes are safe and gentle. They are available as rinses, gels, mousses or sprays that are easily washed out.
Baby shampoos contain amphoteric detergents that are less irritating to eyes. Conditioner
Reconditions hair after chemical treatments and physical trauma such as blow drying and brushing.
Reduces static electricity and restores manageability by reducing friction on the hair shaft.
Temporary colours are watersoluble dyes consisting of large molecules that are deposited on the hair shaft. Semi-permanent dyes are mainly synthetic. They consist mainly of low molecular weight coal tar dyes that penetrate the
May be useful for those with thinning hair, low hair density or if increased volume is desired.
Gradual dyes change grey hair gradually over a few weeks to brown or black. Temporary dyes are used to cover small amounts of grey, brighten natural or coloured hair or
hair shaft easily. Permanent colour results from an oxidation process within the hair shaft and is irreversible.
remove yellow tones from grey hair.
cause contact dermatitis. These dyes last 4–6 weeks depending on the condition of the hair. Natural vegetable dyes such as henna have largely been replaced by synthetic formulations for use as semi-permanent dyes.
Semi-permanent dyes are used to cover grey, produce highlights or to change hair tones. Permanent dyes are used to cover grey or change hair colour.
Changes the chemical structure of hair shaft by altering disulfide bonds in the hair shaft. Hair straightening also involves mechanically straightening the hair once it has been treated.
Used to either curl or add wave to hair or to straighten hair that is naturally curly.
Permanent dyes are re-applied every 4–6 weeks depending on rate of hair growth. These dyes contain ammonia and/or peroxide and can damage hair. Process must be repeated every 4–6 weeks based on individual's hair. May damage hair if too strong, left on too long, used too often.
Pharmacologic Therapy Nonprescription Therapy
Information about nonprescription management of hair loss can also be found in Table 3.
Hair Loss The mechanism of action of minoxidil is unclear but it is thought to stimulate the conversion of small hair follicles to larger follicles. Minoxidil prolongs the duration of the anagen phase and increases hair count and weight.13,14 Minoxidil 2% solution is approved for male pattern hair loss only and minoxidil 5% foam is approved for both male and female pattern hair loss. Minoxidil is most effective when started early, prior to the area becoming completely bald. Hair growth is visible within 2 months or more with a maximum effect within a year.13,15 Daily application indefinitely is required to maintain hair growth.1 The most common side effect is contact dermatitis at the application site, which is possibly caused by propylene glycol.16 Compounding minoxidil using butylene glycol instead of propylene glycol may decrease this side effect.16 Minoxidil 5% foam formulation is propylene glycol-free, causes less scalp irritation and improves adherence.17 This formulation is more cosmetically pleasing as it is less greasy, and it is easier to apply to the scalp only and avoid inadvertently applying to the hair directly. Systemic absorption of minoxidil is minimal but tachycardia and decreased blood pressure have been reported. Use caution when recommending this treatment for patients with cardiovascular disease or low blood pressure.13 Although systemic absorption of topical minoxidil is minimal, safety in pregnancy has not been established and it is not recommended.18 Transfer of topically applied minoxidil into breast milk is expected to be minimal and pose low risk to the nursing infant.19 1,16
Table 3: Nonprescription Management of Hair Loss
For product selection, consult Compendium of Products for Minor Ailments. Skin Care
Leave on scalp for at least 4 hours to maximize absorption. minoxidil 5% foam for women
Leave on scalp for at least 4 hours to maximize absorption.
Systemic absorption is minimal with correct application and usual doses.
Systemic absorption is minimal with correct application and usual doses.
Prescription Therapy Hair Loss Finasteride effectively halts or reverses the progression of mild to moderate hair loss in men.16 Finasteride (1 mg per day for 2 years) produced visible hair growth in up to 66% of men and prevented the progression of hair loss in up to 83% of men.16 The most common side effects experienced by men using finasteride are decreased
libido, decreased semen volume and erectile dysfunction.16 These side effects may decrease with continued treatment and are reversible when treatment is discontinued.16 Evidence for use of finasteride in females is very limited, but use may be warranted in cases where minoxidil has failed. Finasteride should never be used or handled by women who are pregnant or may become pregnant.6
Excessive Hair Growth Hormonal treatments for hirsutism either suppress or block androgen activity on the skin. Combination oral contraceptives containing estrogen and a nonandrogenic progestogen can slow progression but not reverse excess hair growth and generally require 9–12 months for maximal effect.3,7 Cyproterone acetate is an antiandrogen which interferes with testosterone metabolism and is generally used in combination with oral contraceptives.3,7 Drospirenone is a derivative of spironolactone with antiandrogenic and antimineralocorticoid activity that has also been used in the treatment of hirsutism in combination with an oral contraceptive.6,7 Spironolactone has some antiandrogenic and antimineralocorticoid action, however randomized controlled trials showing efficacy are lacking. Spironolactone has been utilized when cyproterone is not an option.6 Spironolactone has the potential benefit of treating those patients who develop hypertension while on the contraceptive combinations.7 Eflornithine 15% cream reduces hair growth in some women. It can be applied twice daily with some results seen after 24 weeks. Discontinuing use of the product results in hair re-growth within 8 weeks of stopping treatment.7
Monitoring of Therapy
Monitoring plans for patients should be individualized as hair loss and the psychological results are different for each person. The degree of hair loss (mild to moderate or severe) should also be considered when determining initial treatment and monitoring treatment. Table 4 provides a monitoring plan framework. Table 4: Monitoring Therapy for Hair Conditions Symptom
Monitor for improvement for a minimum of 6–12 months after treatment started.
Reduced thinning, progression slowed and improved scalp coverage.
Continue therapy indefinitely if patient satisfied with results.
Monitor for increased shedding for 2–8 weeks after treatment started.
Normal rate of hair loss (75–100 hairs per day) within 4–6 months after treatment started.
Refer if shedding does not resolve in 4–6 months after removal of trigger or treatment began.
Monitor hair re-growth after removal.
Cosmetically acceptable appearance.
Cosmetic management of excess hair is usually required.
Excess hair shedding
Monitor for excess hair shedding (>300/day) for 1–3 months (possible diagnosis of telogen effluvium). Excess hair growth
Shaving, waxing, plucking, bleaching, depilatories: monitor daily. Laser therapy and electrolysis procedures should be monitored for 4–12 months.
Patient must weigh benefits vs cost of long-term treatment.
Topical anesthetics should be used with caution prior to laser treatment. Refer if serious reaction.
Monitor daily for skin reactions to cosmetic treatment as well as topical treatment.
Minimal to no skin irritation.
Stop using product. Treat symptomatically with topical 0.5% hydrocortisone.
Gray J. Hair care and hair care products. Clin Dermatol 2001;19:227-36. Jensen K, Sanderson D. At a loss: alopecia. Pharmacy Practice 2008 October (CE Lesson). Koulouri O, Conway GS. Management of hirsutism. BMJ 2009;338:b847.
References 1. Disorders of hair follicles and related disorders. In: Wolff K, Johnson RA, eds. Fitzpatrick's color atlas and synopsis of clinical dermatology. 6th ed. New York: McGraw-Hill Medical; 2009. 2. Sinclair RD. Healthy hair: what is it? J Investig Dermatol Symp Proc 2007;12:2-5. 3. Rosenfield RL. Clinical practice. Hirsutism. N Engl J Med 2005;353:2578-88. 4. Gray J. Hair care and hair care products. Clin Dermatol 2001;19:227-36. 5. Bolduc C, Shapiro J. Hair care products: waving, straightening, conditioning, and coloring. Clin Dermatol 2001;19:431-6. 6. University of Texas at Austin, School of Nursing, Family Nurse Practitioner Program. Treatment of female pattern hair loss in primary care. May 2011. Available from: www.guideline.gov/content.aspx?id=34048. 7. Smith D, Tan C. Hirsutism: investigation and management. Endocrinologist 2007;17:335-40. 8. Koulouri O, Conway GS. Management of hirsutism. BMJ 2009;338:b847. 9. Kunte C, Wolff H, Gottschaller C et al. Therapy of hypertrichosis. J Dtsch Dermatol Ges 2007;5:807-10. 10. Wanitphakdeedecha R, Alster TS. Physical means of treating unwanted hair. Dermatol Ther 2008;21:392-401. 11. Haedersdal M, Gotzsche PC. Laser and photoepilation for unwanted hair growth. Cochrane Database Syst Rev 2006;(4):CD004684. 12. Health Canada. Safety information regarding topical anesthetics with serious adverse events—for health professionals. Available from: www.hc-sc.gc.ca/dhp-mps/medeff/advisories-avis/prof/_2009/emla_ametop_hpccps-eng.php. Accessed April 7, 2010. 13. Messenger AG, Rundegren J. Minoxidil: mechanisms of action on hair growth. Br J Dermatol 2004;150:186-94. 14. Herskovitz I, Tosti A. Female pattern hair loss. Int J Endocrinol Metab 2013;11:e9860. 15. Johnson & Johnson Inc. Rogaine topical 2% solution, Rogaine foam 5%, Women's Rogaine foam 5% [product monograph]. Available from: www.rogaine.ca. Accessed May 7, 2014. 16. Ross EK, Shapiro J. Management of hair loss. Dermatol Clin 2005;23:227-43. 17. Olsen EA, Whiting D, Bergfeld W et al. A multicenter, randomized, placebo-controlled, double-blind clinical trial of a novel formulation of 5% minoxidil topical foam versus placebo in the treatment of androgenetic alopecia in men. J Am Acad Dermatol 2007;57:767-74. 18. Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2014. 19. Drugs and Lactation Database (LactMed). Minoxidil. Bethesda: National Library of Medicine. Available from: toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT. Accessed September 22, 2014.
Hair Concerns — What You Need to Know 03-Mar-16 6:49 AM
Wash hair regularly to remove dirt, oil, sweat and hair care products. People with oily hair may need to shampoo daily. People who have dry hair should shampoo less often to allow the natural scalp oils to condition the hair. Have hair cut by a professional to remove ends that are damaged.
Use appropriate shampoos designed for the type of hair (dry, damaged or chemically treated hair) and condition hair regularly according to conditioner used. Minimize exposure to harsh chemical treatments such as perms, dyes, bleaches and straighteners.
Avoid excessive brushing. Use a brush with natural, round-ended bristles, and brush gently. Use a wide-toothed comb to detangle or comb wet hair. Minimize use of blow dryers, curling and straightening irons. Use a lower setting on a blow dryer, and use a diffuser to blow dry chemical-treated hair.
Tips to treat thinning hair:
The most common cause of hair thinning is male-pattern/female-pattern baldness. This type of hair loss is genetic—it runs in families. It can start any time from the teens to middle age. For women, it is more common after menopause. Nonprescription products containing minoxidil can be used to treat thinning hair. The instructions should be followed carefully to ensure optimal treatment.
Apply minoxidil directly to the area on the scalp that is affected. Hands should be washed immediately after applying the product. The scalp should remain dry for 4 hours after applying minoxidil to ensure maximum absorption. It will take at least 2 months before any results will be seen. Full results may not be seen for a year.
Patient Self-Care and Nonprescription Drugs in Health CareIntroduction The Public's Response to Illness Jeff Taylor, PhD Date of Revision: January 2013 Self-care has been common practice across centuries of human history. From perhaps the dawn of hum
Effect of soil transfer on ectomycorrhiza formation and the survival and growth of conifer seedlings on old, nonreforested clear-cuts M. P. AMARANTHUS AND D. A. PERRY Department of Forest Science, Oregon State University, Corvallis, OR, U.S.A. 97331