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Rapunzel, Rapunzel, where is your hair?

Mother Gothel, from the Walt Disney Classic, Tangled, went to extreme lengths to get the hair that she wanted. She secretly discovered the anti-aging capability found in a magic flower that was transferred to the long, gorgeous locks of Princess Rapunzel. Gothel tried to take a piece of Rapunzel’s hair to steal the magic and remain young forever. Cutting Rapunzel’s beautiful blond hair was not the answer, because the magical anti-aging power disappeared when her hair was cut. Gothel was selfish and desperate. She abducted the newborn, brainwashed Rapunzel, and eventually locked her in a tower to “protect” her.

The story depicts how Rapunzel eventually escaped, used the magic properties in her hair to heal a friend, and then discovered the truth….that she was the lost princess of the kingdom. Even though our hair doesn’t have magical anti-aging and healing properties like Rapunzel, our hair is significant. It represents our personality, adds to our style, and is part of our identity. Hair thinning, loss, or balding is very distressing. And it doesn’t just happen to men.

Alopecia, or hair loss, has many causative factors. It may have genetic roots or be the result of certain hair products or styling practices. It may be caused by a systemic health condition, be a reaction to stress, or stem from an autoimmune disorder. Hair loss can be diffuse or patchy, temporary, or permanent. The treatment is dependent upon the precipitating cause. Addressing the reason for hair loss more quickly tends to help decrease personal anguish, improve quality of life, and facilitate treatment outcomes.

Abrupt onset of overall hair loss and thinning can often stem from a specific, traumatic event. Telogen effluvium occurs when the hair’s growth phase is prematurely cut short and more hair than usual is forced into the telogen or “resting” phase. Hair is typically in the resting period two to four months before it falls out and is replaced by new hair. This means hair loss may not be very noticeable until two to four months after the precipitating event occurs. Telogen effluvium is characterized by clumps of hair that comes out in the shower or with brushing. It is usually self-limiting, and hair regrowth should be visible within two to six months. Since hair growth on the scalp is slow, hair may feel or look thinner for a while, but as the new hair comes in, fullness should be restored. Common causes of this type of loss include:

· Surgery

· Significant weight loss

· High fever or severe infection

· Emotional stress

· Extreme physical trauma

· Dietary changes, including iron deficiency

· Certain medications

· Abrupt hormonal changes

Classic telogen effluvium is noticeable in the postpartum period, about three to four months after giving birth. The trauma of delivery and significant hormonal changes sometimes leaves a woman wondering if she is going bald. Proper nutrition and time are typically all that is needed to recover from this situation. Most women will notice fullness returning within six to 12 months. Perimenopause is another classic time that women may see drastic thinning or loss. The decline in estrogen and progesterone at this time may slow hair growth and make shedding more pronounced. Increased androgens that may occur at this time also cause hair follicles to shrink and accentuate hair loss. This, too, should stabilize with time.

Telogen effluvium that occurs with hormonal changes should be differentiated from a familial condition called androgenic alopecia. This type of hair loss is gradual and progressive. Men have a classic balding pattern, which includes a receding hairline at the forehead and temporal regions on both sides. They also experience hair loss on the crown of the head. Women can experience similar progressive loss, which may start in their 20’s or 30’s. It is called female pattern hair loss and typically caused by elevated levels of DHEAS (indicating a high testosterone level). The pattern of loss is different compared to men. Women may see their part widening and notice a feeling of thinning at the top of the head. Minoxidil cream can be used by men and women to improve hair growth; however, hair loss recurs when treatment is discontinued.  

Women are vulnerable to over-processing their hair with heat, styling products, or tight hairstyles. Pulling, bleaching, or chemicals may cause trichorrhexis nodosa. This is when the hair suddenly breaks from trauma and can happen at the root or anywhere along the hair shaft. Once the offending agent or practice is stopped, hair should recover and regrow.

Alopecia areata is hair loss that typically results in bald patches and stems from a problem with the immune system. It only affects a small percent of the population but is not limited to age or gender. A skin biopsy may be required to help diagnose this condition, and loss can be temporary or permanent. A high rate of spontaneous remission and hair growth can often be seen within one to three months; however, loss at this site may recur. Local steroid injections may be beneficial in suppressing inflammation and allow for regrowth.

Local skin infections, systemic conditions (i.e., thyroid disease), or metabolic disorders may contribute to hair loss. Psychiatric disorders, such as hair-pulling or trichotillomania, can also cause bald patches or diffuse thinning.

Chemotherapy is classically known to cause significant loss (called anagen effluvium). Regrowth typically begins within three to six weeks of finishing treatment; however, color or texture changes may occur in the new hair.

Rapunzel is a fairy tale. Even though our hair doesn’t magically heal our wounds or keep us young forever, we may feel or look older if we experience significant or early hair loss. Many causes of hair loss are self-limiting and reversible. It is essential to have an examination done, discuss your personal and family history with your provider, and do further testing to address hair loss adequately. Talk to your provider if you are concerned about your hair.

More information may be found at:

American Family Physician, Hair Loss: Common Causes and Treatment

Haley Pledger, PA
Women’s Care
Matthew Walton, DO
Austin Bills, DO
Family Medicine
Aaron Fausett, PA
Family Medicine
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