The Ultimate Guide to Thinning Hair

Photo Credits: Alessia Zerial / EyeEm/ Getty Images | Image Used for Illustrative Purposes Only

This article first appeared in the Fall 2019 issue of NewBeauty. Click here to subscribe.

Hair is way more than inanimate protein attached to our heads. It highlights our personal style, acts as a security blanket and boosts confidence. There’s a reason hashtag #goodhairday has been used nearly 1.5 million times on Instagram: When someone’s hair looks good, they want to show it off. But for the millions suffering from hair loss, there may be more bad hair days than good. Thanks to cutting-edge products, devices and procedures, this doesn’t have to be the case.

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WHY HAIR THINS
The average person has about 100,000 hairs on their head and loses about 100 of them every day (to the detriment of shower drains and bathroom floors everywhere). But, if those hairs don’t grow back at the same rate, or more than 100 hairs fall out, it may be a sign of thinning. And shockingly, the American Academy of Dermatology cites that a whopping 40 percent of women have visible hair loss by age 40. “The sooner you seek care, the better your chances are of successfully treating it,” says Beverly Hills, CA hair restoration specialist Dr. Craig Ziering. “But in order to prescribe a treatment, we need to determine the reason for the thinning.” These are the most common:

Genetics
Androgenic alopecia (AGA), or male and female pattern hair loss, is the most common form of hair loss and affects nearly 50 million men and 30 million women in the U.S., according to the National Institutes of Health. Chances are, if sparse strands are common on either side of your family, you will experience the same. “Female hair thinning shows up in three different ways: enlarging of the center hairline part, frontal hair line recession and a diffuse thinning pattern,” says Beverly Hills, CA hair restoration specialist Natalie H. Attenello, MD.

“Although often hereditary and occurring in healthy individuals, AGA has been associated with serious conditions such as hypertension, diabetes and polycystic ovarian syndrome, so see your doctor if you have concerns,” says Pittsburgh plastic surgeon Brian V. Heil, MD.

Diet
In addition to taking the patient’s personal and familial histories into account, doctors often suggest a blood test, which can reveal mineral and vitamin deficiencies that may be affecting hair. “Low vitamin D and iron can be culprits, and it’s common to see depleted levels of them these days,” says New York dermatologist Dhaval G. Bhanusali, MD. “In those cases, I generally prescribe a daily dose of 5,000 IU vitamin D and an iron supplement.” Beverly Hills, CA dermatologist Rhonda Rand, MD says vegetarians often have less hair because they don’t eat as much protein. “You need 40 grams a day, and most of my vegetarian and vegan patients aren’t getting that much.”

Hormones
A key hair loss offender is the DHT hormone (dihydrotestosterone), a derivative of testosterone that binds to receptors in hair follicles on the scalp and shrinks them until they can no longer function. “Blood work can disclose testosterone levels, and if they’re elevated, medication can balance them out,” says Dr. Rand.

Sharp hormone shifts after pregnancy are also commonly tied to hair thinning, although the effects are temporary. “Women have some of the thickest hair they’ll ever have right before they give birth, and then two to four months post-partum, many of them experience telogen effluvium, a dramatic, yet temporary change as the hair goes into resting phase for two to four months and thins out,” Dr. Rand explains. “Around eight months after childbirth, the hair should be back to normal.”

Menopause can stir up hair issues too, as lower estrogen levels are linked to thinning. “Many women lose substantial amounts of hair after menopause,” says Dr. Ziering. “Their hair tends to thin out all over, rather than develop a signature spot like men do at a similar age.”

Stress
Alopecia areata is a form of sudden hair loss that’s often caused by stress and shows up in circular bald patches. “It’s considered an autoimmune disease because the immune system gets stressed and attacks the hair follicles, causing them to weaken and fall out,” Dr. Bhanusali says. There’s no cure yet, but Dr. Ziering says “it can be treated successfully with injectable steroids”—typically every three to six weeks—that suppress the immune system.

Illness
“Any auto immune disorder could cause hair loss,” says Dr. Heil, “but it’s most common with lupus and thyroid disease due to the alteration of the body’s ability to function normally.” Once the disorder is treated and the body is in remission, hair growth should return to normal.


MIRACLE GROW: The three stages of the hair growth cycle

1. The Anagen Phase (lasts 2–6 years)
Also known as the growing stage, this is when the cells in the root of each hair divide, pushing the previous strand out to make room for a new one. “Hair that’s in anagen for less than two years is usually thinning,” says Dr. Rand, “and the length of a person’s anagen phase is genetically predetermined.” 

2. The Catagen Phase (lasts 2–3 weeks)
Hair takes a break from growing and prepares to shed so it can eventually renew. This is referred to as the transitional phase, during which club hair (hair that has stopped growing) begins to form. 

3. The Telogen Phase (lasts 3 months)
This is the resting phase, during which club hair is fully formed—if one is pulled from the root, you’ll see a hard, white substance on its tip. Dr. Rand says about 10 percent of hair is usually in the telogen stage.


HOW TO TREAT IT
Thinning hair isn’t a quick-fix condition— oftentimes a multipronged approach with changes to diet, products and treatments delivers the best results. “Some nonsurgical solutions are both preventive and effective, providing reasonable improvements," says Dr. Ziering, “but it’s important to have realistic expectations, as results can take months to manifest.”

Essential Oils
Whether they’re applied solo or infused into hair-care products, essential oils are praised for their stimulating, balancing and calming properties that have been shown to spur healthy hair growth. “Tea tree and cypress are proven to improve micro-circulation deep in the scalp and increase blood flow to each follicle,” says François Hourcastagnou, CEO of hair-care brand PHYTO and Alès Group, USA. “Rosemary can gently but effectively exfoliate the scalp, sage can help calm irritation and lemon oil can balance sebum production so follicles don’t get clogged.” According to integrative medicine specialist Dr. Elizabeth Trattner, one study on 84 alopecia areata patients revealed that massaging a mix of cedarwood, lavender, thyme and rosemary oils with either jojoba or grape seed carrier oils into the scalp for seven months produced significant hair growth improvement in 44 percent of the group, compared to 15 percent of patients who used jojoba or grape seed alone. “Another study showed 3 percent peppermint oil applied topically helped facilitate hair growth by promoting circulation in the hair dermal papilla [cells at the base of hair follicles],” she adds. (Note: Applying essential oils directly to the scalp could be too strong and cause irritation, which is why most are mixed with carrier oils. Doing a patch test at the nape of the neck to check their compatibility with your skin is recommended.)

Diet + Nutraceuticals
To strengthen brittle hair, Dr. Attenello says its best to follow a balanced diet that includes protein and foods such as eggs, fish and nuts that contain omega-3 fatty acids. “We also recommend zinc, iron and biotin supplements, all of which have been shown to improve hair texture and caliber,” she adds. Dr. Ziering likes Viviscal, a daily supplement that contains a marine complex called AminoMar “that helps promote existing healthy hair growth from within, but is not an option for patients with shellfish allergies.” Another expert favorite is Nutrafol, which New York plastic surgeon Jennifer Levine, MD says is good for both thinning hair and anti-aging. “It neutralizes free radicals, rebalances stress-producing hormones and contains botanicals that promote the absorption of hair-boosting nutrients,” she adds. With the majority of hair supplements, some users can see results after one month, but experts say three months is standard.

Acupuncture
In Chinese medicine, acupuncture is often used as a remedy. “Needles are placed on the face, body and scalp to promote blood and energy circulation to the scalp, stimulating hair growth,” says Dr. Trattner. “Studies show it can help treat female thinning better than male, although reasons for this are undetermined.” A series of treatments need to be done weekly or biweekly to restore balance, and then maintenance depending on individual results. “Some people get better outcomes than others, but when combined with Chinese herbal medicine, results are synergistic and almost always better,” Dr. Trattner adds. “It is also important to find a licensed practitioner who is familiar with hair loss.”

Hair Care
Thinning hair demands extra TLC, so any products used on it should have scalp health and hair growth properties. Some brands tout biotin as a strand booster, but Dr. Rand says “minoxidil—known over-the-counter as Rogaine—is the only FDA-approved OTC ingredient that has been clinically proven to increase the diameter of the hair follicle, producing thicker hair.” Results may take months to exhibit, and side effects associated with topical minoxidil can include scalp itching and flaking, so it's not an option for everyone. For those going the natural route, botanical-based topicals can also be effective: French hair-care brand René Furterer formulates with follicle-energizing pfaffia extract (aka Brazilian ginseng) and sebumreducing curbicia (a patented extract from squash seeds) to promote growth. No matter the product used, Dr. Rand notes: “If you stop using it, the results will stop too.”

Product Picks: René Furterer Triphasic Strengthening Shampoo ($32); PHYTO Phytopolléine Botanical Scalp Treatment ($40); Nutrafol Core for Women ($79); Viviscal Advanced Hair Health Supplements ($50).

Prescription Medication
Many doctors recommend using ketoconazole, an antifungal ingredient created to treat conditions like ringworm that’s now used in shampoos such as Nirozal to boost hair growth. Two other Rx options—finasteride and spironolactone—are also used topically to prevent the conversion of testosterone to DHT in the body, but are more frequently taken as oral medications (more on that below).

However, a new platform called HairStim is now being offered by dermatologists around the country, who can customize products to include a mix of prescription-strength ingredients such as topical finasteride and spironolactone, depending on the patient’s concerns. “We’ve seen impressive results so far on both men and women,” Dr. Bhanusali says.

Oral finasteride (you may know it by its brand name Propecia) is commonly prescribed in a 1 milligram dosage for men, and sometimes for post-menopausal women as well—"it’s not advised for childbearing women because of its hormone interference,” says Dr. Attenello. “This also applies to oral spironolactone.” A double-blind study in 2014 revealed that 400-milligram capsules of pumpkin seed oil could mimic the effects of oral finasteride in men, but there hasn’t been much research since, and no studies that included women.

Light Therapy
Low-Level Laser Therapy (LLLT) technologies—usually in the form of laser headbands and hats that can be worn at home or in a doctor’s office—are designed to improve follicle function and reverse the effects of thinning hair and hereditary hair loss. “LLLT is a noninvasive, pain-free and FDA-cleared solution that uses diodes that emit infrared or red light,” says Dr. Ziering. “It increases blood circulation to the scalp and helps the follicles produce thicker, longer, healthier hairs with improved pigment.”

Dr. Rand says there are many doctors who use LLLT, and while the devices can grow some hair in carefully selected patients, they tend to work better on those who are balding (or quite thin) rather than those with moderate thinning. “The issue is that the lights can’t penetrate down to the scalp tissue if there’s hair in the way, which is why I prefer combs rather than caps for women because they separate the hair,” she explains. “In general, these devices tend to work better on men; however, as technology evolves and more hair loss studies are done on women, this may change.

Product Pick: The most high-tech headband we’ve ever seen, HairMax LaserBand 41 ($549) delivers follicle-stimulating energy to the scalp via 41 medical-grade lasers and is super easy to use. Just put it on your head, press the button and voila. Wearing it three times a week for just three minutes treats the entire scalp.

Platelet-Rich Plasma (PRP)
Platelet-rich plasma (PRP) is a newer biotechnology used to treat early androgenic alopecia or thinning hair and involves drawing a small sample of the patient’s blood from the arm before putting it through a centrifugation process to extract the blood plasma—rich in proteins and growth factors—and eliminate the red blood cells. “The plasma is then injected into the hair follicles in thinning regions of the scalp, and the platelets bond to receptors in the stem cells of the scalp tissue," says Las Vegas plastic surgeon Julio L. Garcia, MD, an early adopter of PRP treatments. "This activates the active hair growth phase and allows hair to grow back where it has been lost.”

Dr. Attenello says the treatments are best served for patients with hair thinning, where the hair bulbs still exist for the PRP to nourish them, rather than those with hair loss that has been present for more than a year, where the hair bulb is likely not intact anymore. “Preliminary studies have shown favorable results in terms of hair count and density, but larger-scale trials are warranted,” she adds.

Most PRP protocols involve treatment once a month for three months, and then a waiting period of an additional three months before results are visible; maintenance treatments every three to six months following may be necessary depending on the needs of the patient.

There is also a next-generation form of PRP called PRF, or platelet-rich fibrin, which is extracted similarly to PRP, but contains more growth factors. Dr. Levine prefers PRF because “it allows the platelets to remain viable while releasing growth factors in a controlled manner that can last hours to days; PRP growth factors only last a few minutes to hours.” The benefits of longer-lasting growth factors, she explains, are that they promote more hair growth.

Critics point to the treatments’ lack of FDA-approval and regulation: Dr. Garcia says there are numerous PRP preparation systems on the market today with FDA clearance for PRP used in bone graft procedures, but not those for hair. Therefore, “the use of PRP outside this setting is considered ‘off label’ and scrutinized by the FDA,” he explains. Nevertheless, it is widely considered safe. Pasadena, CA plastic surgeon Gordon Sasaki, MD and a team of doctors are currently conducting the first randomized-controlled clinical trials to study the safety and efficacy of low versus high amounts of PRP for hair regrowth in patients with androgenetic alopecia. “By four months, an increase in both terminal [longer, darker hairs] and vellus [shorter, thinner hairs] have been documented with minimal to no side effects or complications,” Dr. Sasaki notes. Ian Sanderson, president of skin-care brand AnteAGE, is dedicating his efforts to a newer area of research—the topical application of growth factors to battle thinning hair—which, he hopes, will one day make PRP injections obsolete.

“PRP is mostly effective by deploying growth factors like VEGF—vascular endothelial growth factor—and other stem cell by-products like cytokines to restart dormant hair follicles. We’ve been able to engineer a topical treatment solution containing all those hair growth factors in precise dosages, along with several bio-signals that go beyond what’s possible with PRP alone,” he says, adding that it’s also an alternative to minoxidil. “It’s been recently understood that one of minoxidil’s key mechanisms of action is up regulation of VEGF. Using this growth factor topically—it’s a key ingredient in our hair treatments—we may make minoxidil obsolete, along with its potential side effects."

THE PRP DEBATE
Not all doctors see eye to eye when it comes to PRP.
PRO: “I advocate the use of PRP for androgenic alopecia in men and women. Excellent clinical outcomes are seen after a series of four monthly injections. Diminished hair loss and noticeable new hair growth is typical.” —Washington, D.C. dermatologist Tina Alster, MD

CON:“There is some evidence that it can benefit those with hair loss, but it’s still very controversial because there’s not a wealth of good data or research done under appropriate FDA guidelines. There have also been some issues of PRP being done in salons and spas with catastrophic outcomes such as contamination and the spread of HIV.” —La Jolla, CA plastic surgeon Robert Singer, MD


SURGICAL SOLUTION
When nonsurgical solutions have been exhausted without success, hair restoration surgery can dramatically improve one’s appearance and self-confidence. “The gold-standard surgical option for hair loss is a hair transplant, which entails surgically removing hair from the back of the head—the area that’s most resistant to DHT—and implanting it into thinning areas,” says Dr. Attenello. “It can be done on both men and women, but because women have a different pattern of hair loss and hair thinning, not all female patients are ideal candidates.”

The Two Main Types
Follicular Unit Transplantation (FUT): “A strip of hair is removed from the back of the head, and then the hairs are separated and implanted into the areas that need to be addressed,” says Dr. Levine. “The advantage to FUT is that you’re able to cover a larger surface area of baldness, but the downtime is typically five to seven days.”

Follicular Unit Excision and Extraction (FUE): The surgeon (the procedure can be performed robotically or manually) cuts around each individual hair follicle, removing and implanting it back into thinning areas. Many surgeons use handheld motorized devices to enhance the hair extraction process. “These procedures are lengthy and can take five to eight hours, depending on the size of the treatment area,” says Dr. Levine. “But, the recovery time is faster—two to five days—than with the FUT method and there is no linear scar on the head.”

Power Play
No matter how skilled the surgeon, robots can offer exactness human hands can’t— they also don’t tire after hours in an OR. “The most advanced surgical technology currently available to treat hair loss is the ARTAS robotic system, which utilizes state-of-the-art technology to assist physicians with difficult, manual placements of grafts that require repetitive and precise movements,” says Dr. Heil. “ARTAS was developed with leading hair transplant physicians and researchers, and offers a clinically proven, permanent solution that provides natural results without stitches, staples or linear scars.” Regardless of how the grafts are placed, Dr. Ziering says the hair will continue to grow and function like it normally would, although some routine maintenance may be needed. Post-procedure, patients can’t color their hair for four weeks and need to avoid direct sun exposure for at least three months to reduce risk of hyperpigmentation, therefore many patients opt to have transplant surgeries in the winter. Dr. Ziering adds, “Noticeably thicker, natural-looking hair growth begins around six months, and the final outcome is seen one year following treatment.”


Medically reviewed by La Jolla, CA plastic surgeon Robert Singer, MD, Eugene, OR plastic surgeon Mark Jewell, MD and Montclair, NJ dermatologist Jeanine B. Downie, MD