What can we do about hair loss?

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0:51Hello, welcome to the Naked Scientist podcast. This is the program where we bring you the biggest breakthroughs and talk to the major movers and shakers from the worlds of science, technology and medicine. I'm Chris Smith and today we're looking at the science of hair loss and what we can do to put back what we've lost.

1:16Now we rarely stop to think about our hair until it starts to vanish but it is one of nature's most versatile fibres. It keeps us warm, it helps us sense the world around us, and for much of human history, it's been a powerful social and cultural symbol. But it's also fragile. And when its growth cycle falters, the change can be unsettling. In a minute, we'll find out why we lose our hair and what we can do about it. But first, what exactly is hair? Desmond Tobin is a professor of dermatological science at University College Dublin. He's also the director of the Charles Institute of Dermatology.

1:53Hair is a remarkable structure. It's a protein-rich structure made of keratin, but it is a very, very tough structure. And it's produced by a little factory in the skin called the hair follicle. And the hair follicle is an outgrowth or an appendage of the skin. It's unique to mammals and this particular follicle is a very rapidly dividing proliferative engine that can produce hair, say on the scalp of about 0.2 to 0.3 millimetres a day. And that particular follicle remains embedded in the skin and what you see growing on the surface and above the surface of the skin is dead keratinised fibre of hair.

2:34Can you just talk us through that? When the hair follicle makes a hair, is that cells that have them fused together, having been stuffed full of that protein you mentioned, keratin, and they wind together to make the hair? Or do they secrete the substance and it then plaits itself together to make hair? How does the hair actually get made? So at the very base of the follicle, during its active growth phase, the root of the follicle contains a little clump of cells called keratinocytes that form keratin in cells, and another bunch of cells called the dermal papilla, which is a kind of fibroblast structure.

3:13And that's like the, you know, grand central station really of the follicle. Without that little kind of button of fibroblast, you won't be able to make hair. And the interaction between these two different cell types, along with, of course, the pigment-forming cell called the melanocyte, that kind of triangulation of activity allows the progeny or daughter keratinocytes to not only be filled with keratin, but also hopefully be picking up some melanin granules or pigment granules as well, so that the outgrowing fiber, which is a filamentous structure, tightly wound proteins that are very, very tough, get pushed out from the follicle from below at a rate of about 0.2, 0.3 millimetres a day.

4:00But the follicle is largely permanent, but the fibre is constantly growing out until the end of the hair cycle. And then it stops for a short period of time. Just to clarify then, so the keratinocytes, they make the keratin, but do they actually die in the process? So you just get loads of keratin in what would have been a cell, and that is glued together to make the hair filament. Or is it physically cells sticking themselves together to make that filament that's then extruded? It's neither one nor the other. So we have about seven different types of keratinocyte cell in the follicle, in the lower follicle.

4:37You have about two or three of those keratinocyte subfamilies that make the fibre. So you have keratinocytes that make a central unit of the fiber called the medulla, keratinocytes that make the bulk of the hair fiber called the cortex, and keratinocytes that make the very outer kind of like shingle on the roof kind of layer called the cuticle. You know, the coordination of these three different keratinocytes form these three different parts of the hair fibre. But even if you were to take a long hair fibre and cut it at a transverse section and look under a microscope, you will see the cells that originated the keratin still there.

5:20And as you say, sitting next door to those keratinocytes are melanocytes that can almost spray paint the hair with melanin to give it its colour. How are different colours or hues achieved then? First of all, there's a very powerful geographic ancestry to pigmentation. It was one of the traits of human beings that was under very powerful evolutionary selective pressure. And as a result, you find that brown-black hair and brown-black skin and brown eyes is the preferred combination of pigment for our skin and our eyes and our hair. and that's largely to give it the best defence against ultraviolet radiation.

6:08And as humans moved out of Africa and then migrated north, where there was much less sun, the break against having any change from that pattern of colour was lifted and then we start to see the emergence of many other skin, hair and eye colours, particularly as we see in North West Europe. And lastly, I mean, us blokes, as we get older, we all know, we get hairier up our noses and out of our ears now what's that all about why on earth does that happen and is there any any way to stop it so that's a very good question and it brings into the whole question of hair aging now we're obsessed with aging generally and it's often very difficult to convince somebody that a turbocharged hair follicle that is producing much much more vigorous hair growth in the 70s than it did in the 30s is an example of an aging follicle where you'd expect things to slow down to a shuddering stop almost.

7:03So again, they happen in sites where there can be an influence of sex hormones and shifting levels of sex hormones. And we even see it in menopausal women, for example, where after a very significant drop in estrogen, their underlying androgens then have a more dramatic influence on their hair. And so they may get hair on their chin and mustache, for example, in a way that they didn't when they were younger, when the estrogen levels were higher and balanced the androgens for those individuals. So much of these changes are reflecting changes in hormonal levels as we age. There are certain ethnicities or people in certain countries, like in India, for example, they may have more exaggerated ear hair with age.

7:51So there will be some geographic ancestry aspects to it but there will also be an underlying shift of gear in our hormones and remember we don't have in male ageing the kind of cliff edge effect that women have for their oestrogens in terms of male testosterone which only very gradually shifts gear over time. Really interesting thanks very much to Desmond Tobin for starting the ball rolling. Now the loss of hair is extremely common by age 50, 85 % of men and 40 % of women will experience some form of pattern baldness. But why and what other ways can we end up losing hair? I've been speaking with consultant dermatologist Justine Hextall.

8:33If you've lost hair then that means that something's changing about the hair follicle. Now it might be for example one of the most common cause of hair loss is what we call androgenetic alopecia or male or female pattern baldness and what happens is over time the hair follicle becomes miniaturized becomes smaller so the hair that it produced is no longer this thick what we call terminal hair but it's very fine vellus hair follicle eventually becomes dormant and you get some loss of hair in those areas and that's what we call male pattern or female pattern broadness but there can be other causes you know of hair loss so for example your body might produce an immune response against the follicle as an alopecia areata or you might have inflammation around the follicles so there might be an inflammatory process which is effectively destroying the follicle so you get this scarring alopecia and this may be caused by infection or inflammation and that's where the follicle is actually destroyed and that hair is very hard to get back.

9:32On the first of those that you just mentioned androgenic alopecia the clue's sort of in the name isn't it androgen male hormones because it tends to affect men mostly but And exclusively, do women get this as well? They certainly do. And I think people don't realise that. So two thirds of women at the age of 50 will have experienced some hair loss. So it's obviously we see much more in men, but women will have it. But to a lesser extent, maybe less obvious. So, yes, androgenetic alopecia in men. And that's to do with the hair follicles becoming smaller. And that's through a hormone called dihydrotestosterone.

10:11and that's an active form of testosterone. Now we have these angioreceptors in men specifically at the front of the scalp, mostly concentrated, and also on the back and on the centre of the crown of the scalp. And that is why we tend to see hair loss in the front of the scalp. So you start to get some regression of the hair at the front, but also on the crown, because dihydrotestosterone focuses on those anrogen receptors and it causes them to shrink them until they get smaller and the hair starts to disappear in those areas. Do we know why that should happen? Why should a ubiquitous in the body hormone cause a pattern of hair loss like that?

10:52Heritability is quite high. The genetics in men is probably about 90%. So it depends which genes you've inherited. And it's not about one gene, it's polygenetic. So there's one important gene called the androgen receptor gene, which we inherit on the X chromosome. So men will get that from their mothers. And because men only have one X chromosome, it's kind of like sitting there, all the cells then will have that gene. And if that's a gene which is going towards hair loss, then it's going to be expressed more in men, for example, than it is in women. But it's not just that X chromosome, there are other inheritances from the father and the mother.

11:31How does it happen in the women then? Is it that they do get exactly the same mechanism, but because they have less testosterone, it just takes longer? Well, the distribution of the antigen receptors in women is more diffuse. It's not in those sort of areas, but there are other hormones in play. So for example, estrogen will protect the hair follicles from hair loss. So until someone goes through menopause, there's a protective element. Women are more susceptible to certain environmental factors as well stress is another hormone so it's just not so direct it's it's more complicated in women now you mentioned stress this is often cited as a cause of either prematurely going gray or premature balding is that just someone fantasizing saying well i got stressed and and they're sort of making a attaching a significance to a coincidence or is there a mechanism behind that as well no as i said with epigenetics certain genes could be switched on through stress so if you have a genetic propensity towards losing your hair or androgen genetic alopecia say in a man but you're also distressed from environment it can switch those genes on but also when we're stressed and that might be mental stress you know with work or it might be for example physical stress like an operation or certain medications they can create something called telogen effluvium so our hair has a growth cycle allergen and then it has a catagen cycle and then what we call telogen where it starts to rest and then drop.

12:58And what happens with telogen effluvian, which can be switched on by stress, is the hair cycle gets pushed towards telogen where there's increased drop. But because there's a gap of about three months of that being switched on to noticing the hair loss, people don't always make that association between that period of stress or illness and that sudden diffuse loss of hair. Is that form of hair loss permanent? Because if you've got the androgen related hair loss in male pattern baldness for example you're not you're probably not going to get that hair back are you but if you go through a period of extreme stress is that also irreversible or as soon as the stress subsides your hair comes back usually when that period of stress disappears then the hair cycle shifts back to a longer anogen cycle and less of a hair drop but some people can do that we call chronic telogen flevium so it can be ongoing so it's important to look at those drivers.

13:54And if I look at my mum and my mum's dad and I find oh dear it looks like the genetic legacy being handed to me is going to be one that I'm going to prematurely bald. Is there anything as a man I can do about that? Yes I think there is. I mean first of all think about your general health. As I said diet, stress, certain factors will have an influence on our hair health that's really important but also you might want to intervene sort of bit earlier on so you might want to start using something like minoxidil minoxidil is used topically and sometimes orally and this is a medication actually for blood pressure which vasodilates the vessels and they found that in their studies on blood pressure people getting hair growth and it seems that minoxidil can help with hair growth and to sort of start to stop some of that process with androgenetic alopecia you get increased hair growth so you go back more towards the anagen phase the hair becomes slightly thicker and you start to reverse some of that miniaturization of follicles um there are other medications uh people can have things like finasteride that is a drug which blocks the enzyme 5-alpha reductase 1 which pushes testosterone to that active form of dihydrotestosterone which affects the follicle so you can use that drug.

15:17That is FDA approved, but it can have side effects. Some of them get sexual dysfunction, they can get notable breast development. There's even anecdotal discussion around possible lowering of moods. So it is a drug which works, but not without side effects, so you need to be carefully monitored. Justine Hextall there. While the loss of hair is usually no cause for medical concern, the psychological impact, on the other hand, of thinning up top can be very significant. A survey by Lloyd's Pharmacy here in the UK found that only 5 % of men were still happy with their hair when they started losing it.

15:51But this wasn't always the case. If we look back through history, a great many cultures and ideologies revered baldness. That switch, though, seems to have flipped only in the last 150 years. So why did that happen? I've been speaking with Leeds Beckett University's Glenn Jankowski. Some of the earliest forms of what's known as snake oil, which is essentially products that have no efficacy, that don't work, but are sold as miracle cures, were to cure boldness. Those proliferated in the 18th and 19th centuries, and they changed how we saw boldness. They stripped it of any positive or neutral connotations.

16:29They made it into a disadvantage, a disease, something that needed cure, that needed the product to buy. and then when we later in the 20th century mid 20th century started to do research and found hormonal and genetic links to baldness this further confirmed the claim that it's this devastating disease and that hormonal and genetic treatments were necessary to solve it even though this research and these claims are flawed it's not a disease in my view was there one particular part of the world where that kicked off and then it spread like a sort of social contagion, perhaps around the British Empire, for example, or did everyone kind of begin to move in that direction everywhere roughly around that time?

17:14Yeah, you're right. No, snake oil was more prevalent in the UK, Europe, British Empire. And we know that these companies or businesses and later companies that started to produce widespread anti-boldness products like minoxidil and Rogaine were specifically selecting wealthy white men to buy the products because they had the income. What about people taking steps to avoid it or hide it? Does that become much more common as these negative connotations spring up? So as well as snake oil and people attempting chemically to reduce the rate at which they might be losing hair, what about people taking steps to make it look like they're not going bald?

17:56Yeah, they exist. And to me, it's very hard to separate their own individual distress from the wider culture of advertising, especially that promotes boldness as such a negative issue. I feel adverts get inside us and change our behaviour. And I believe that's the case for many bolding people, including myself. It's very, you know, these adverts are very explicit as well. There was an award-winning campaign for a series of anti-boldness adverts that won awards that used to feature a hair follicle on the edge of a bridge or a cliff about to jump to its death. And the only thing saving it is the bottle of anti-boldness lotion.

18:38And this really promotes the claim that boldness will drive you to suicide is so depressing. and it's very hard for me as a researcher to say that that won't affect the personal experience and interpretation of boldness. Executives and company employees in the billion dollar transplant industry for instance saying we want to grow around the world, boldness affects everyone, we want to expand our markets and some of them make claims that we don't and you know we're going to make the world boldness free or that all people should get hair transplants around the world. So their agenda is quite explicit in reducing the amount of acceptance there is around the world for this.

19:18Amazing, isn't it? It wasn't an issue until someone had a product to sell and turned it into a problem in need of a treatment. A very interesting observation there from Glenn Jankowski. The Naked Scientist podcast is produced in association with Spitfire. Cost-effective voice, internet and IP engineering services for UK businesses. Find out how Spitfire can empower your company at spitfire.co.uk

20:08bras altogether. And now my life has changed, you guys. The only bras I have in my dresser right now are Aerie, and I'm not kidding. Aerie's on a mission to make you feel good, and that starts with your bra. Your bra should hold you in, not back. Visit Aerie.com to find the right bra for you. Music in the program is sponsored by Epidemic Sound, perfect music for audio and video productions. This is the Naked Scientist podcast with me, Chris Smith. And today we're looking at why we lose hair and what we can do about it if and when we do. Now apart from snake oil which obviously doesn't work what options are available to those experiencing hair loss and feeling vulnerable because of it?

20:50A bit later on we'll look at hair transplants but historically the most common way to cover up hair loss was with a wig. Wigs became a significant fashion statement and a practical solution in Europe from the 17th century onwards primarily to conceal the symptoms of diseases like syphilis and its associated hair loss, as well as skin lesions and baldness of course. Fortunately, modern medicine means we're far more able to treat the underlying diseases behind the need for those wigs, but that isn't to say though that wig advancements haven't come on in leaps and bounds too, and they're a massive part of treatment today.

21:25Indeed, gone are the days of dodgy toupees that blow away on the wind. Now we have perfectly sculpted, in fact almost undetectable synthetic specimens. I've been hearing from Maureen Reynolds. She works at Adorantrenko, a company that creates and fits bespoke wigs. So who make up the majority of her clients? Anybody that's suffering from fine thinning hair, anybody that may be going through chemotherapy, clients that suffer from alopecia, men, women and children who may be experiencing any form of hair loss. Do the medical teams refer people to you proactively as in it hasn't happened yet but it's going to because of some of the things we're going to do to you they'll say to the patient go and see Maureen or do people tend to come to you once they're already losing their hair?

22:19So the medical teams do refer to us clients from Macmillan, clients from Maggie's, anybody that may be having chemotherapy, they will be referred to Adderans, yes. And how do you approach it with them? Always, it's down to consultation. We would never put ourselves in the client's shoes, never, ever, ever. We would ask them lots of questions to gain an understanding of their journey and what they're experiencing. But do you get some people, I mean I think if I was in that position, God forbid, I would think oh I don't want to wear a wig. Do you get people who are very resistant and then actually they say in fact you know what Maureen, I've changed my mind?

23:10Absolutely, we have lots of patients who come in who have the idea that the wigs are going to look nylon, on, they're not going to look natural, they're not going to feel like hair. And once we go through the consultation with them, we try different wigs, different systems for them from the information that they give us. Many of them, Chris, they're so shocked and surprised by the results that they actually continue wearing the hair after they've completed their treatment. So if I came to see you and I was in that position. How would you consult with me? How would you come up with a solution for me?

23:51So we would ask you about your lifestyle. We would look at any existing hair that you have at this moment in time. I'm going to look for a perfect colour match for you. I'm going to look for the density being the exact density that you're wearing, that your natural hair is at the moment. And I'm going to look at the texture and any curl formation that might be there. From that then, we can then recommend systems. And are these real human hair these wigs are made from? They are human hair, they are fibre, and there's a new product on the market that we use called Cyber V. And what's that? Is that synthetic?

24:37It is synthetic, but it's actually designed that it has a cuticle, it has a cortex and it will lie exactly the same as human hair would lie. How do you then kind of fit people? Is it a bit like going to Savile Row and people measure you up and kind of give you a sort of trim here, tuck there? Is it over a sequence of fittings then? You get something people are happy with or is it a one size fits all? it's definitely not one size fits all so depending on your lifestyle and it's very important at Adderans that we get that information from you you may be a swimmer you might be you know very athletic you might want to wear your hair when you're in bed at night you may not want to take it off.

25:26So there are systems such as a system called the CNC, which is a hair replacement system. It's non-surgical. It's very natural looking. It's very comfortable. It will last 18 months and you come back to the salon every four to six weeks to have it cleansed and refitted. But there's also things like ready to wear, which is a whole collection of wigs, hair pieces, gents systems. And you can buy those on the actual day, have them fitted and have them styled. How do you keep it in place? Because that's the thing that when I talk to people, including patients, their biggest fear is being de-wigged in public and the embarrassment of that.

26:15So how do you make sure that doesn't happen? Your adherence consultant does all the fitting for you. It's a very secure attachment. We use medical grade adhesive or specialist tape and you will come back every four to six weeks for removal, cleansing and then reapplication. The whole thing will actually last you 18 months before you need a new one. And if you're not Maureen, who has an eye for this kind of thing, can you tell that it's a prosthetic? You cannot tell. It's what we call an invisible connection. So even the client who's wearing it often forgets they're wearing a piece. They really do.

27:01Do you know, you've really opened my eyes because I thought I knew a bit about this and I had no idea it was this good or could give people that liberating sense of normality going about their daily life doing this. That must be so amazing for the patients who want that. It certainly is. It gives them their freedom back, definitely. And is that the reaction you get when you see people and you take them on this journey? And incidentally, how long does it take from first meeting you to they walk out the door a new person? How long has it taken? What is their general reaction? So if they decide that they wanted something that was ready to wear, we have over 300 wigs here over 500 different colours if it's ready to wear they could actually walk out the door with it on the same day so from the consultation through to us fitting through to us cutting styling and then explaining how they care for it they can take that home on the same day.

28:03If you decide you wanted the CNC hair replacement system, you would come back for two or three fittings because we would be doing a digital 3D render of your head. So that's basically as taking the measurements to ensure the precision with the fitting. Maureen Reynolds, and I really was blown away. I had no idea the technology had come so far and people could even do things like go swimming and then head off to the shower in their wig. Absolutely fabulous. But while cosmetic solutions can play a crucial role, some prefer to go down the route of hair transplantation, in which patients have hair follicles moved from areas of the head on which hair is still growing to those areas that need a top-up.

28:48So how's it done? I caught up with Harley Street hair transplant surgeon Asim Shamalak. Hair transplantation means that removing of the follicles from the back of the head and removing from that area to insert those hair follicles, also known as grafts, to those areas where people have lost their hair. When you move a hair follicle in that way, does it take with it its resistance to being lost? So if you put a hair from the back of your head where you haven't lost hair to a place where you have lost hair, it doesn't die off like the hair that was there before? No, it does not. The reason being, mostly of my patients are men.

29:32Ninety percent are male patients. And if you would say a quite old chap who is maybe 80, 90 year old, bless him, and he's totally lost his head. But men always keep a horseshoe area at the back of the head, which are genetically programmed that they will never lose in their life. Doesn't matter how old they are. So this is known as safe donor zone. So when you remove from that particular part, which is permanent for the rest of their lives, and then they put them back wherever they need to be, as I mentioned before, and the scalp or the eyebrows or beard, they will never go. And practically, what's actually involved in harvesting a hair follicle from that safe zone at the back of the head so it can be re-implanted somewhere else?