Accepted Article

Accepted Date : 01-Apr-2015 Article type

: Research Letter

Hair Shedding In Women: How much is too much? R. Sinclair Professor of Medicine, University of Melbourne Director of Dermatology Epworth Hospital Director, Sinclair Dermatology, Investigational Research, Education & Clinical Trials Centre Address for correspondence:

Professor Rod Sinclair Sinclair Dermatology Level 2, 2 Wellington Parade East Melbourne Victoria 3002 Australia [email protected] Phone: +61396542426

Running Title: Hair shedding in women

Key words: Female pattern hair loss, androgenetic alopecia, telogen effluvium

Sir, Human hair growth is cyclical but asynchronous.

Women normally shed 50-150 hairs over a 24

hour period [1]. Most shedding goes unnoticed. Women who complain of excessive hair shedding, especially after washing their hair may have either an increase in the actual amount of hair falling or an increased awareness of their hair fall. Changes in actual amount of hair fall occur in anagen

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/bjd.13873 This article is protected by copyright. All rights reserved.

Accepted Article

effluvium, acute and chronic telogen effluvium, alopecia areata, cicatricial alopecia and female pattern hair loss (FPHL) [1]. A change in perception of hair loss may occur with a change in hair length, a change in bathroom lighting or flooring, or a concern about hair loss. Women anxious about hair loss may start to notice, collect and count shed hairs. FPHL is the most common cause of hair loss encountered in clinical practice [2, 3] and has a negative impact on quality of life [4]. FPHL is a complex polygenic disorder [5,6 ] characterised clinically by diffuse hair thinning over the mid frontal scalp [7] on dermoscopy by >20% variation in hair fibre diameter [8] and fewer hair fibres emerging from each pore over the affected scalp [9] and histologically hair follicle miniaturization with fewer terminal hairs per follicular unit [10]. Some women present with increased hair shedding without thinning. Approximately 60% of these women will have androgenetic alopecia on scalp biopsy [11]. Hair Follicle miniaturiazation is reversible initially, but becomes irreversible [12]. Treatment success is most likely in early FPHL [13, 14]. A tool to identify increased hair shedding would facilitate early diagnosis of FPHL. The hair pull test while widely used], does not reliably discriminate normal from excessive hair shedding. Furthermore, women may be better able to assess hair shedding than hair volume [15]. To measure hair shedding we developed a visual analogue scale by dividing a bundle of 900 shoulder length hairs into 6 piles of various sizes that were each counted, photographed and arranged in order of size. (Figure 1) To assess observer reliability, we piloted the hair shedding scale in 50 women attending a hair loss clinic for scalp biopsy. The women looked at an A4 page containing the 6 photos of hair bundles and were asked were asked to point to the photograph that best correlates with the amount of hair shed on a wash day, and the photo that correlates best with the amount shed on a non-wash day. The frequency of hair washing was also recorded. The results were scored 1-6. Their shedding was rescored on return 1 or 2 weeks later for removal of their sutures. Fifty women with FPHL were enrolled in the pilot study. Hair length was recorded as short, shoulder length or long. Scores at weeks 2 and week 0 agreed in 46 out of 50 women. Scores disagreed by 1 grade in 4 women. All 4 women had short hair. In all 4 cases where there was disagreement with the original score, the difference was only and 1 grade. Two women increased their score and 2 women decreased their score. The correlation coefficient (r) was 0.98 and the coefficient of determination (r2) was 0.96 indicating strong correlation (Table 1). As the photographs were bundles of long hair, and women with short hair had greater difficulty using the chart to score their hair shedding (and due to current fashion trends very few schoolgirls were found with short or shoulder length in the control group), FPHL patients with short or shoulder length hair were excluded from further analysis. We then asked women newly diagnosed with FPHL to score their hair shedding using the visual analogue hair shedding scale. Women already on oral antiandrogen treatment or topical minoxidil were excluded. Over a 52 week period scores were obtained from 209 consecutive women with previously untreated female pattern hair loss and with long hair. The mean age was 46.3 years. Shedding was scored as: grade 6 in 93; grade 5 in 49; grade 4in 40; grade 3 in 20; grade 2 in 6 and grade 1 in 1woman. The mean shedding score was 4.96. Results are shown in Table 1.

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Accepted Article

Twenty-three women (9.1%) with FPHL who denied increased hair shedding on history were found to have increased hair shedding when scored with the hair shedding scale, demonstrating that some women with FPHL accept excessive hair shedding as normal. This is consistent with our earlier findings that women with FPHL underestimate the severity of their hair loss. [15] Finally, as part of a school science project, 100 girls aged 11-15 years (mean 13.51), with straight long hair (below shoulder length) scored their hair shedding using the visual analogue scale. Scores are shown in Table 1. While androgenetic hair loss is reported in this age group [22], it is rare and these girls were used as normal control. 99 girls had less than or equal to grade 4 shedding. Only 1 girl had grade 5 shedding. No girl had grade 6 shedding. The mean hair shedding score was 2.68, which is considerably less than the mean shedding score seen in FPHL (p

Hair shedding in women: how much is too much?

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