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H air loss is a very common problem and the concern a patient shows for hair fall is usually out of proportion to the magnitude of hair loss. When the patient is convinced of hair loss, even normal loss of 50 to 100 per day causes anxiety. Therefore reassurance forms the mainstay of management of hair fall, after evaluating the patient to rule out the possible disease states.

Causes of hair loss can be broadly classified into:

Most commonly encountered hair loss is non-cicatricial and is further classified into those due to internal causes and external causes.

External causes include such common practices that damage the hair shaft - chemical treatment of hair (dying, perming, waving etc.), grooming (back combing, combing wet hair, use of dryers) etc.

Internal causes are the ones that affect the hair cycle (anagen, catagen, telogen).

• Seasonal: Hair fall is maximum in the months of August-September and minimum in March
• Nutritional: Iron deficiency anemia, Zinc deficiency, protein deficiency, essential fatty acid deficiency, biotin deficiency
• Physical stress: Surgery, accidents, unusually hectic work, medical illness (chronic renal failure, liver disease etc.)
• Emotional stress: Depression, anxiety
• Endocrinal: Hypothyroidism, hyperthyroidism, hypoparathyroidism, hyperparathyroidism, hyperandrogenism
• Post partum (after delivery), menopause, oral contraceptives
• Medications: High doses of vitamin A, retinoids (used in the treatment of acne); propranolol, captopril (used for high blood pressure); lithium carbonate; thiouracil; blood thinning agents like heparins and coumarins; cancer chemotherapeutic agents
• Chronic dandruff (See Dandruff)

Physical, emotional stress and post partum state: Hair fall following physical, emotional stress and post partum is called telogen effluvium. The hair follicles prematurely exit the anagen phase (growing phase) to enter the telogen phase (shedding phase) and are thus shed prematurely. There is a delay of about 3 months between the actual event and the onset of hair loss. Furthermore, there may be another 3-6 months delay prior to the return of noticeable hair growth. Therefore a patient should wait for about 6-9 months following such incidents to naturally gain back the lost hair.

Nutritional Deficiency: Iron deficiency (due to nutritional deficiency or blood loss) results in thinning of the hair rather than shedding and the hairs fail to enter the anagen (growing) phase. Protein calorie malnutrition, zinc deficiency, biotin deficiency and essential fatty acid deficiency result from inadequate intake (food fadism, crash dieting) or inadequate supplementation following major illnesses and lead to diffuse hair loss. Such hair loss improves on correction of nutritional deficiency.

Hypothyroidism has been found to be the cause in 10% of patients with diffuse hair loss. It is reversible on administration of Thyroxine, but if the hypothyroidism has been present over a long period, it can result in permanent miniaturization of the hair follicle.

Assessment: Assessment of a patient with hair loss should include

• Detailed medical history and physical examination
• Full blood count
• Serum iron and ferritin measurement
• Thyroid function tests
• Liver and renal function tests
• Microscopy of the hair

Treatment of diffuse hair loss involves correction of the underlying problem. When no cause is present, reassurance helps.