Why does Hairfall?

Alopecia or hair loss can be divided into 2 main categories.

Non-scarrring alopecia is diagnosed when there is obvious hairloss and on close examination of the scalp, hair follicles are clearly visible. This form of alopecia is often reversible.

Scarring Alopecia occurs when the full thickness of the scalp is damaged from a variety of causes leading to scarring and typically scars lose their hair follicles and the skin appears smooth. Scarring alopecia is permanent and nothing can reverse the damage done.

Scarring Alopecia demonstrating smooth scalp with loss of follicles

Androgenetic alopecia occurs in both men and women. Typically the hairline may receded (at the temples) and hair loss may become obvious either as thinning of hair “on the top” or as balding of the crown (top of the head).

Androgenetic Alopecia

Telogen effuvium refers to resting hair. Severe stress (to the body) from any cause leads to cessation of growth of the hair follicles and therefore hair becomes weak and falls. Apart the causes already mentioned in the box above oral contraceptive use, cancer, high fevers due to infections can cause this kind of hairfall.

Alopecia areata is a kind of alopecia that is believed to be due to a unknown autoimmune disease process. Typically the hair is broken near the skin giving rise to the typical exclamation mark hairs. Clearly circumscribed areas of hairfall are noted on the scalp. Alopecia areata totalis is when there is complete hair loss from the head including the eyebrows and lashes.

Alopecia areata with classical exclamation mark hairs.

Trichotillomania refers to predominently unilateral (on the side of the dominant hand) hairfall due to habitual,probably absent minded pulling on the hair.

Traction alopecia is often see in girls who tie their hair tight.

Traction alopecia

Other scalp conditions such as fungal infections, dandruff etc can also cause significant hairloss.

Investigations that may be useful in people with hairfall include:

Routine screening tests: CBC, ESR, LFT, RFT-E, Lipid, Urine complete.

Specific tests: Serum Iron, Transferrin saturation, Ferritin, serum Testosterone, DHEAS,TFT,Vit D, Vit B12, Folate.

Other tests that may be done on doctors discretion: Thyroid antibodies, ANA, Fasting cortisol assays and scalp (skin) biopsy.

Usual treatment that is offered to patients who have hairfall!

Minoxidil 5% hair lotion to be applied twice daily and Tab.Finasteride 1% (for men) and upto 2.5% fo women for upto a year can lead to dense hair growth and can be tried for all forms of nonscarring alopecia.

Intralesional steroids or oral steroids is given to patient with alopecia areata. Oral JAK inhibitors like Tofacitinib and Ruxolitinib are also being used for AA.

Counselling and prescription of N-Acetyl cysteine 1200-2400mg orally every day for 3 months can be effective for Trichotillomania.

What supplements may be beneficial for hair fall?

Very many people take supplements for hairfall. I came across a recent article where the authors had screened 6000 odd citations and selected 20 articles with relevant information about use of supplements for hair fall. Here are the excerpts from the article.

Things to do before starting yourself on supplements for hairfall/loss are: Consult your doctor and discuss the pros and cons of supplementation, get some blood tests to identify deficiencies of vitamins, minerals and other nutrients accept that supplements may not have predictable effects and that they may also have some side effects.

Supplements that may be effective for hairfall.

Why do we develop Goitre?

Enlargement of the thyroid gland is called Goitre. The thyroid gland is situated in the front of the neck on or just below the thyroid cartilage (Adam’s apple). The thyroid gland is made up of lobules, each of which has 20-40 follicles. The follicles are lined by epithelial cells and contain in their centre, colloid (Thyroglobulin).

The thyroid gland produces two thyroid hormones, T4 which is converted to the active T3. These are mostly bound to carrier proteins that transport them to every corner of the body. These proteins maintain an constant blood level of free hormones for use by the cells of the body. The hypothalamus senses the amount of thyroxine in circulation and adjust the dose of TRH (Thyrotropin releasing hormone) secreted. TRH stimulates the anterior pituitary gland to produce TSH (Thyroid stimulating hormone) which sits on the receptor on the thyroid cells and stimulate the production of T4 and T3 from Thyroglobulin in the colloid centres of the follicles. These hormones by a negative feed back mechanism inhibit the TRH production. In this way, the levels of thyroid hormones are closely controlled by the Pituitary gland (the master gland of the body).

Thyroid hormones play a very important role of contolling the body’s metabolism and energy generation. It stimulates the breakdown of carbohydrates and fats and increases protein synthesis in all the cells of the body. Thyroxine plays a critical role in the development of a baby’s brain.

The thyroid gland is controlled and maintained by the TSH hormone. If for any reason, the production of T4 is affected, the increased TSH released, stimulates the growth of the thyroid gland in order to increase hormone production resulting in the development of a goitre.

Initially under the influence of TSH, the follicles start to grow (hyperplastic phase)where the goitre is diffusely and symmetrically enlarged (with a smooth surface) and later on they start involuting and get filled up with colloid. With continued stimulation by TSH, certain follicles enlarge excessively (due to relative increased sensitivity to TSH) to produce a large irregular (bumpy) gland called a multinodular goitre. The rapid growth of the follicles can lead to rupture,scarring, calcification and haemorrhage (with a sudden increase in size).

Goitres of this size are pretty common in a doctors practice!
A large multinodular goitre!
Common causes for Goitre

Large goitres apart from looking unsightly, may press on neighbouring structures in the neck to produce a variety of symptoms. Often a spontaneous bleed into the goitre can lead to a sudden increase in size and provoke discomfort in a hitherto asymptomatic person. I myself developed a thyroid lump overnight after being elbowed by my son, about 10 yrs ago when I was playfully wrestling with him. This was aspirated (bloody fluid was removed with a syringe) with complete resolution of the swelling. Compression of the esophagus could cause diffculty in swallowing. I had a patient recently who had a mass pressing the esophagus from the side. After extensive evaluation it was confirmed that it was of thyroidal origin and she was recommended surgery. Her neck was completely normal looking without any swelling whatsoever. But the goitre had grown downwards into the chest.

Compression of the wind pipe (trachea) could cause difficulty in breathing and stridor (noisy breathing). Thyroidal swellings could also cause hoarseness of voice due to compression of the nerve supplying the vocal cords (usually due to a malignant thyroid). The superior vena cava (the largest vein in the neck) could be compressed causing Superior Vena Caval syndrome with symptoms of congestion of the face, distension of the veins of the neck and a “bursting” headache on bending down! Large goitres could also harbour cancer.

How do you know if the neck swelling that you have is a Goitre? All thyroid masses move upwards on swallowing as the thyroid gland is enveloped by the deep fascia of the neck and is connected to which the thyroid cartilage of the larynx which moves upwards during swallowing.

An overactive thyroid may present with the following symptoms: increased appetite, increased sweating, heat intolerence, diarrhoea, palpitations, weight loss, reduced menstrual flow.

An underactive thyroid may present with reduced appetite, weight gain, cold intolerence, constipation, slowed heart rate and mental activity, increased body weight and increased menstrual blood loss.

Ofcourse, you may have no symptoms if your thyroid levels are normal (Euthyroid state).

What are the indications for surgery for someone with a thyroid mass?

The following are indications for surgery:

1.Large goitre with pressure symptoms.

2.Cosmetic reasons and if patient wishes for surgery.

3.Hyperthyroidism due to toxic adenoma.

4.When an FNAC is done and if cancer is suspected or proven – surgery is indicated if the patient is elderly, male, with a hard thyroid mass which is fixed to the neck structures, with a hoarse voice or with enlarged lymph nodes in the neck.

So if you have a thyroid swelling, see your doctor who may arrange some tests and the have a discussion with him/ her as to what you must do further.