Issues That Affect Loss, Regrowth

A holistic or integrative approach to hair loss considers the hair growth cycle and hair loss from a nutritional, psychosocial, and physiological perspective, according to dermatologists who spoke at the most recent annual Integrative Dermatology Symposium.

“There are many things that can cause the hair to go into telogen and many things that can bump it into anagen,” said Raja Sivamani, MD, of the Pacific Skin Care Institute, Sacramento, California, during an interactive session on hair health at the meeting, held last fall. This is why, he added, “a holistic approach is best for hair loss.” For instance, inflammation, hormones/hormonal imbalances, stress, nutritional deficiencies, and poor sleep quality each have been shown to promote anagen-to-telogen transition. On the flip side, increased blood flow, direct stimulation of the hair follicle, and growth factors each can promote telogen-to-anagen transition, he said.

“Novel topicals, supplements, and devices can be part of your standard regimen in addition to pharmaceuticals,” advised Sivamani, who co-authored a 2023 review of an “integrative and mechanistic” approach to hair growth and hair loss. “Find your favorites and have a chart or schematic” to review with patients, he said. “Sometimes I’ll draw out a diagram as we talk” that illustrates various factors contributing to hair loss and hair growth.

In another presentation on holistic care of hair loss, Michelle Tarbox, MD, chair of Dermatology and associate professor of dermatology and dermatopathology at Texas Tech University Health Sciences Center, Lubbock, Texas, stressed the value of discussing with patients the hair cycle and the importance of daily health habits for hair growth.

Addressing inflammation, nutritional deficiencies, and detrimental diet and lifestyle issues — and improving the estrogen-to-testosterone ratio in women — are important parts of holistic care, she said. So is the use of various physical modalities such as scalp massage, low-level laser therapy (LLLT), and microneedling. Platelet-rich plasma (PRP) treatments are also part of her armamentarium.

PRP and other natural treatments can be effective, but in general, “natural treatments need time,” Tarbox said. “Pharmacology is the nuclear option — it works. But some patients aren’t desiring that, and some patients aren’t appropriate candidates.”

Hormones, Nutrition, Stress Management

For male pattern androgenetic alopecia driven at least in part by the 5-alpha-reductase–fueled conversion of testosterone to dihydrotestosterone (DHT), pumpkin seed oil and saw palmetto oil have been shown to reduce DHT levels and slow hair loss and are viable alternatives to finasteride, an oral 5-alpha-reductase inhibitor, Tarbox and Sivamani both said in their presentations.

“You can offer these treatment approaches that are natural…and you can also [counsel] that a lot of plant-based foods are DHT inhibitors naturally and that a plant-based diet writ large has been found to be inhibitory of DHT signaling and premature follicular miniaturization,” Tarbox said.

Sivamani shared a study from 2014 that randomized 76 men with mild to moderate androgenetic alopecia to 400 mg/d of oral pumpkin seed oil or placebo for 24 weeks. Per subjective measures, the treatment group saw significant improvements. But strikingly, he said, analysis with phototrichography showed a mean 40% increase in hair counts over 24 weeks.

In women, the estrogen-to-testosterone ratio may be more relevant than absolute hormone levels in female pattern hair loss, and treatments targeting this balance, rather than individual hormones, may be more effective for managing female pattern hair loss, Tarbox and Sivamani both said.

Here, a well-balanced diet that is lower in fat and higher in fiber, with little or no added sugar, with organic hormone-free meats and dairy, and with whole foods over processed foods, is advisable. “We also want patients [with female pattern hair loss] to limit alcohol close to bedtime and to consume things like legumes, nuts, and seeds, which can support healthy estrogen production,” Tarbox said.

Additionally, exercise, particularly high-intensity exercise, can help improve estrogen-testosterone balance, as can stress management, according to Tarbox. Long-term stress can increase levels of cortisol, which affects hormone levels, and in both sexes, “elevated cortisol [itself] can cause disruption to the hair cycle and can induce premature anagen-to-telogen transition,” she said. Stress management and cortisol-inhibiting treatments may help combat stress-induced hair loss, she added.

B vitamins, vitamin D, omega-3 fatty acids, and magnesium play important roles in hormonal health and the estrogen-to-testosterone ratio, she noted, and supplementation in appropriate amounts can be useful. (Assessment of thyroid hormones and correction of thyroid dysfunction is part of the standard hair loss workup and treatment, Tarbox and Sivamani both said.)

The possibility of nutritional deficiencies and their impact on hair loss should always be considered, Tarbox said. “I really want to hit upon the protein issue. About 40% of women don’t consume enough protein on a daily basis, and protein is essential for appropriate hair growth,” she said. “We also want to optimize mineral intake, such as iron, zinc, and selenium as these deficiencies are associated with difficulty with hair growth.”

Tarbox also emphasized the impact of a high-fat diet on hair follicle stem cells. “You can’t recover from a telogen without hair follicle stem cells. But a high-fat diet depletes them,” she said. “It inhibits Sonic Hedgehog (Shh) signaling…and it induces inflammation and things like IL [interleukin] beta and IL-6, which in turn will inhibit Sonic Hedgehog signaling and make hair shed.”

In inflammatory conditions, she noted, hair cycles from the anagen to telogen phase, and a cellular infiltrate of inflammatory cells such as substance P surrounds the hair follicles and hair follicle stem cells, mediating hair loss.

Sivamani said he routinely considers the “building blocks” for hair growth, such as protein, iron/ferritin, vitamin D, and zinc. He also routinely assesses fasting glucose levels in his patients with thinning hair — testing that “really helps with the nutrition conversation.”

A study of 45 patients with female pattern hair loss that evaluated the efficacy of topical minoxidil or minoxidil combined with oral vitamin D found greater reductions in thin hairs and single hairs with the vitamin D-minoxidil combination, Sivamani noted. “So it’s important to include vitamin D in the conversation.”

In the study, investigators evaluated serum vitamin D levels in these patients and in 15 controls (without hair loss) and divided the 45 patients into three groups to receive vitamin D 5000 International Units daily, topical minoxidil daily, or both combined for 6 months. As assessed with dermoscopy, the percent reduction in thin hairs was 5.5% in the vitamin D group, 29% in the minoxidil group, and 55% in the combination group. The reduction in single hairs was 14%, 34%, and 55%, respectively, Sivamani said. Vitamin D levels were significantly lower in the patients than in the control individuals, the investigators reported.

At the meeting, Sivamani, whose 2023 review covers lab testing (standard and functional testing), clinical evaluations, and evidence for various therapies and lifestyle changes, said that in addition to thyroid testing, he sometimes assesses mitochondrial function through organic acid profile testing. And to assess the influence of stress, diurnal cortisol slope testing can be useful, he said.

Physical/Mechanical Modalities to Promote Hair Growth

Scalp massage: Scalp massage is “a very therapeutic practice, and I hope there will be better support for it in the future,” Tarbox said. “I teach my patients how to do this when I’m treating their hair loss,” using a zigzag motion.

She shared findings from a Japanese study in which nine healthy men aged 25-46 years received daily 4-minute scalp massages for 24 weeks. Hair thickness at 24 weeks was improved, and “the stretching force on the dermal papilla cells actually influenced gene expression [of hair cycle-related genes] in a way that can be helpful to tilt the scales toward hair growth,” she said. After just several days of stretching, certain hair cycle-related genes such as BMP4 and NOGGIN were upregulated, while IL-6 was downregulated.

LLLT:  Controlled clinical trials have demonstrated that LLLT can stimulate hair growth in many types of non-scarring alopecia. LLLT acts on the mitochondria, improving cell metabolism through photodissociation of inhibitory nitric oxide off cytochrome C oxidase (in the mitochondrial respiratory chain), “allowing oxygen to replace it and allowing for more ATP synthesis and blood flow,” Tarbox said.

She referred to a 24-week randomized, double-blind, controlled trial in which 40 patients with androgenetic alopecia (20 men and 20 women) were randomized to use a helmet-type LLLT device or a sham helmet at home. At week 24, the laser helmet was significantly superior to the sham device in increasing hair density and hair diameter (P = .002 and P = .009). Laser-treated patients had a significantly greater improvement in global photographic assessment by both investigators and patients.

The device “did seem to give patients a significantly improved perception of their hair loss and was also significant in the eyes of the investigators who were blinded,” Tarbox said. What was categorized as “moderate improvement” in the study “wasn’t overwhelming, but it was helpful,” she noted.

Asked during a question-and-answer period how to choose LLLT caps, she said, “It’s all about the wavelengths.” Most studies looking at the effects of LLLT on hair growth have used wavelengths between 635 nm and 660 nm.

Microneedling: This is a “safe and promising treatment” for patients with androgenetic alopecia and alopecia areata “who are intrepid enough to do it,” Tarbox said. It is believed that microneedling stimulates blood flow to hair follicles and, through controlled micro-trauma, activates stem cells in the hair bulge area and recruits growth factors like platelet-derived growth factor and vascular endothelial growth factor.

In a 2020 case report of 50 men and women with androgenetic alopecia or alopecia areata who had three microneedling sessions at 4-week intervals over 6 months, all patients reported reduced hair loss and improved density (9.75% increase overall in the frontal area and 9.08% increase overall in the vertex area), without any serious side effects, she shared. Results were confirmed by clinical iconography and trichoscopy.

In another case report published in 2020 co-authored by Tarbox, a patient with ophiasis alopecia areata was treated with a clobetasol 0.05% solution and four treatments of microneedling with triamcinolone over 6 months. He experienced gradual improvement with nearly complete hair regrowth on his left occipital scalp, and “he had persistence of his results at 1 year post treatment,” Tarbox said.

Tarbox reported that she is a researcher for Sanofi-Regeneron and Castle Biosciences and that she has served as an advisor for Novartis, Sanofi, Boehringer Ingelheim, and UCB. Sivamani did not report any disclosures in the IDS interactive session on hair loss but in another IDS session, disclosed that he serves as an advisor for Arbonne, Codex Labs, and as a consultant/Honoria for Burt’s Bees, Novozymes, Nutrafol, AbbVie, Leo, UCB, Sun, Regeneron, Bristol Myers Squibb, Novartis, Pfizer, Sanofi, Eli Lilly and Company, Biogena, Fotona, and Image Skincare. He also disclosed being a clinical investigator for Arcutis Biotherapeutics, Dermavant, and Incyte.