Hair loss may seem comparatively trivial medically when compared with conditions such as cancer or heart disease, but it can cause considerable distress, not least because it’s normally very hard to treat. Hence the excitement generated by the announcement that the National Institute for Health and Care Excellence (Nice) has approved its first therapy for one of the most severe types of hair loss: alopecia areata (AA).
Ritlecitinib (Litfulo) is a once-a-day capsule that works by reducing inflammation thought to be triggered by an autoimmune reaction that damages hair follicles in people with AA.
In mild cases this inflammation results in one or more bald patches in the scalp, but at the other extreme it can, rarely, lead to the loss of every hair on the body. Nice’s final guidance is due to be published next month, but ritlecitinib is likely to be available on the NHS only for the most severe cases, and after consultation with a dermatologist (your GP won’t be able to start it).
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Even though about 1 in 50 of us will develop some degree of AA during our lives — typically in our twenties or thirties, and at the milder end of the spectrum — it remains a comparatively unusual cause of hair loss seen by GPs like me.
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Much more common are androgenetic alopecia — “male pattern baldness”, which affects at least half of all men, and nearly as many women — and telogen effluvium, a disruption in the natural cycles of hair growth that can lead to dramatic but reversible thinning.
Most people will be all too familiar with androgenetic alopecia. It is caused by inherited (genetic) and hormonal factors that result in gradual and permanent hair loss. In men it often starts in early adult life, but in women it tends to become most noticeable after the menopause, and while the underlying changes to the hair follicles are the same, the results tend to look very different. Men tend to get a receding hairline and bald patch at the crown; women are prone to generalised thinning on top.
Treatments are available, but have mixed results, must be used continually to maintain any benefits, and are not available on the NHS. Men and women can use topical minoxidil (Regaine), while men have the additional option of the hormone “blocker” finasteride (Propecia).
Not everyone responds, and at best expect a slowing of progressive loss/thinning, with some regrowth if you are lucky. Prices vary but online pharmacies charge about £100 for a year’s supply of Regaine and £250 for finasteride (more if you go for the branded Propecia).
Telogen effluvium is a very different condition which, while often alarming, has a much better prognosis. The vast majority of hairs on your head (85 per cent) are in a growing phase (anagen) with the remainder resting or being shed and replaced with new ones, and the hairs we all find in the bath, shower, on our pillows etc reflect that natural cycle.
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However, in telogen effluvium as many as 70 per cent of hairs in the growing phase switch to the shedding one, causing rapid thinning and hairs everywhere (if you have a golden retriever, as we do, then you will know what I mean).
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Triggers for this sudden change include pregnancy, with most women noticing they shed lots of hairs in the first few months after giving birth. Others include illness, particularly infections associated with high fevers (eg Covid and flu), stress and crash dieting. It can also be caused by medications, including the contraceptive pill, and some antidepressants (such as sertraline) and blood pressure/heart disease treatments such as the beta-blocker bisoprolol.
Occasionally underlying hormonal problems or deficiencies can trigger or exacerbate hair loss so, even when faced with a classic case of telogen effluvium, I tend to check thyroid function and do a blood test to look for anaemia and iron deficiency. Indeed, temporary abnormalities in thyroid function are common after childbirth and often missed.
Fortunately the outlook for telogen effluvium is excellent and nearly everyone makes a full recovery, but it takes time. The abnormal shedding typically lasts three to six months, after which new hair growth should replace all that has been lost.
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Men with shorter hair should get their crowning glory back within six to nine months, but in women with longer hair it can take much longer. And, short of dealing with any treatable underlying trigger such as stress, thyroid problems, iron deficiency or medication side-effects, there is nothing your GP can do to speed up this process.
And while we are on the subject of hair, you may have noticed that, for a chap in his sixties, I have more than my fair share. Rest assured I don’t know anything you don’t. It’s down to my genes. Indeed my father had such a thick thatch in his latter years that people thought he wore a toupee.
For more information on diagnosing and treating alopecia areata, including details of the new drug, visit alopecia.org.uk
Hair raising facts
• The average scalp has about 100,000 hair follicles
• People with blond or brown hair tend to have more follicles than those with dark or red hair
• It is perfectly normal to lose anything up to about 150 hairs a day as old ones are shed and replaced by new ones
• The colour comes from melanin pigments produced by melanocytes in the scalp. When these fail the affected hairs turn grey
• Hair grows faster in warmer weather. As do nails (which are also “dead” and keratin-based)
• Ritlecitinib costs £950 for a month’s course, but the manufacturer Pfizer is understood to have offered a discount to the NHS to help gain approval by Nice. However, details are confidential
