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The Loss of Hair and How to Deal with It

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Introduction:

Hair is a protein filament that grows from follicles found in the dermis, the innermost layer of

the skin. Hair is one of the defining characteristics of mammals. The human body, apart from

areas of glabrous skin, is covered in follicles which produce thick terminal and fine vellus hair.

Each strand of hair is made up of the medulla, cortex, and cuticle. The innermost region, the

medulla, is not always present and is an open, unstructured region. The highly structural and

organized cortex, or middle layer of the hair, is the primary source of mechanical strength and

water uptake. The cortex contains melanin, which colors the fiber based on the number,

distribution and types of melanin granules. The shape of the follicle determines the shape of

the cortex, and the shape of the fiber is related to how straight or curly the hair is. People

with straight hair have round hair fibers. Oval and other shaped fibers are generally more

wavy or curly. The cuticle is the outer covering. Its complex structure slides as the hair swells

and is covered with a single molecular layer of lipid that makes the hair repel water. The

diameter of human hair varies from 0.017 to 0.18 millimeters (0.00067 to 0.00709 in). There

are two million small, tubular glands and sweat glands that produce watery fluids that cool

the body by evaporation. The glands at the opening of the hair produce a fatty secretion that

lubricates the hair.

Figure-1: Structure of Hair

Hair growth begins inside the hair follicle. The only "living" portion of the hair is found in the

follicle. The hair that is visible is the hair shaft, which exhibits no biochemical activity and is

considered "dead". The base of a hair's root (the "bulb") contains the cells that produce the

hair shaft. Other structures of the hair follicle include the oil producing sebaceous gland which

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lubricates the hair and the erector pili muscles, which are responsible for causing hairs to

stand up. In humans with little body hair, the effect results in goose bumps.

Hair Loss

Hair loss, also known as alopecia or baldness, refers to a loss of hair from part of the head or

body. Typically at least the head is involved. The severity of hair loss can vary from a small

area to the entire body. Typically inflammation or scarring is not present. Hair loss in some

people causes psychological distress.

Common types include:

male-pattern hair loss,

female-pattern hair loss,

alopecia areata, and

a thinning of hair known as telogen effluvium. Telogen effluvium is very common

following pregnancy.

Hair loss is a very common condition and affects most people at some time in their lives. Hair

loss from breakage of the hair shaft is different than hair loss due to decreased hair growth.

Androgenic hair loss is seen in both men and women but is more dramatic in men.

Impact of Hair Loss

Hair is both natural and symbolic – it’s interwoven in the figurative fabric of nearly every

culture across the globe. And while it’s not as central to human survival as it was prior to

clothing and indoor heating, hair is a biological feature that has since adapted into a believed

notion of superior health and well-being.

Hair loss certainly has an effect on the way people look—the loss of the hairline, for example

results in a more aged appearance. This dramatically affects the way people see themselves

and often contributes to them losing confidence.

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According to the American Academy of Dermatology, the psychological impact of hair loss can

be traumatic, leading patients to go as far as isolating themselves from embarrassment or

shame. This can be even worse for women, who account for approximately 40 percent of hair

loss cases, feeling increased communal pressure to conform to a specific and standard ideal

of attractiveness.

Such emotional ordeals have negative consequences not only on healthy interpersonal and

social interactions, but also career development and drive. Consider the following examples

of how hair loss takes a toll on everyday life:

1. The end of youth: concerns about getting older: Hair loss causes both men and

women to look older. Consequently, for many the advent of hair loss, (more than with

any other physical aspect), dramatically signals the end of youth, vitality and

desirability.

2. Inability to style the hair: Many hair loss sufferers are frustrated at the time and

trouble necessary to camouflage thinning hair and the inability to style their hair as

they would like.

3. Dissatisfaction with appearance and body-image: The loss of the hairline can change

a person’s appearance substantially. Hair loss changes the appearance of the face by

shifting the balance of the face to the forehead, resulting in an aged appearance. A

study revealed that men who had more profound hair loss were more diss atisfied with

their appearance and were more concerned with their older look than those with

minimal hair loss. This effect cut across all age groups but was more prominent in the

younger individuals.

4. Low self-esteem: Physical beauty is one of the cornerstones of self-esteem and it is

one of the most vulnerable. The self-esteem levels and other measures of self-worth

drop significantly when hair loss occurs.

5. Loss of personal attractiveness and fear of not looking attractive to others: Hair is an

important determinant of physical attractiveness and a mean of expressing

individuality. Hair loss affects the individual’s feelings of attractiveness. For balding

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women it is especially hard to live in a society that places great value on youthful

appearance and attractiveness.

Because women are famous for spending a lot of time and money grooming, dying,

curling, drying, and styling their hair to make it look its best, when they begin to lose

their hair, it is extremely traumatic. This cosmetic setback is quite intense when a

woman is used to having hair and suddenly finds herself losing it. They can have a lot

of trouble dealing with the reality of hair loss.

6. Embarrassment, Loss of confidence, Shyness: Although full head of hair cannot

guarantee instant confidence, studies have shown that in men who suffer from hair

loss, nearly 75% of them feel less confident since the onset of the hair loss, especially

in dealing with the opposite sex. And it isn’t just men. Statistics regarding female hair

loss are so difficult to compile mainly because of a tendency on the part of women

with hair loss to camouflage and hide a condition that they feel stigmatized by.

7. Social teasing and humiliation: When hair loss reaches a stage of visible condition it

can make the person the object of teasing or scorn. Studies show, that 60 percent of

all bald men are teased at some point in their lives.

8. Feelings of depression and introversion: In extreme circumstances, some people

really take hair loss badly and get highly distressed about it, up to the point of getting

into depression. Some people make assumptions that they are losing something about

their control of their life, things they really can't reverse when they start losing their

hair. Most of the research shows that people with alopecia have higher levels of

anxiety and depression.

9. Subconscious emotions of envy and jealousy: Those suffering from hair loss often

experience feeling of jealousy of men with full, healthy heads of hair, because they

desperately covet what non-bald people have.

10. Work-related problems: Hair loss may affect someone who is in front of the camera

or who needs to be in the public in a very devastating way professionally.

11. Negative effects on social life: Hair plays an important role in our social lives. Upon

meeting someone, one of the first things you notice is their hair. Before a social

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engagement, it is very important for us to look good, and a good lock of hair is what

completes our appearance. Those affected by hair loss become aware of how

important hair is in our social lives quickly.Hair loss may cause the person to limit social

activities. Some people avoid seeing friends and stop going out except to work.

Hair Growth Phases:

There are four phases in process of growing of hair:

Anagen (Growing Phase): The anagen phase usually lasts 2-7 years, and the length of

this phase determines our hair length.

Catagen (Transition Phase): This is the transitional phase that lasts about ten days.

During this stage, the hair follicle decreases in size and detaches from the dermal

papilla.

Telogen (Resting Phase): Telogen phase generally lasts around 3 months. Around 10-

15% of the hair on your head is in this phase at any given time. While the old hair is

resting, a new hair begins the growing phase.

Exogen (Shedding Phase): This is a part of the resting phase where the old hair

detaches and sheds, and new hair continues to grow. Approximately 50 to 150 of our

hairs may fall out daily. That is considered a normal rate of hair shedding.

Figure-2: Different phases of hair growth

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Hair loss can appear in many different ways,depending on what's causing it. It can come on

suddenly or gradually and affect just your scalp or your whole body. Some types of hair loss

are temporary, and others are permanent.

Signs and Symptoms of Hair Loss:

The signs and symptoms of hair loss include:

Gradual thinning on top of head: This is the most common type of hair loss, affecting

both men and women as they age. In men, hair often begins to recede from the

forehead in a line that resembles the letter ‘M’. Women typically retain the hairline

on the forehead but have a broadening of the part in their hair.

Circular or patchy bald spots: Some people experience smooth, coin-sized bald spots.

This type of hair loss usually affects just the scalp, but it sometimes also occurs in

beards or eyebrows. In some cases, our skin may become itchy or painful before the

hair falls out.

Sudden loosening of hair: A physical or emotional shock can cause hair to loosen.

Handfuls of hair may come out when combing or washing your hair or even after

gentle tugging. This type of hair loss usually causes overall hair thinning and not bald

patches.

Full-body hair loss: Some conditions and medical treatments, such as chemotherapy

for cancer, can result in the loss of hair all over your body. The hair usually grows back.

Patches of scaling that spread over the scalp: This is a sign of ringworm. It may be

accompanied by broken hair, redness, swelling and, at times, oozing.

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Types of Hair Loss:

There are many types of hair loss, also called alopecia:

Involutional alopecia is a natural condition in which the hair gradually thins with age.

More hair follicles go into the resting phase, and the remaining hairs become shorter

and fewer in number.

Androgenic alopecia is a genetic condition that can affect both men and women. Men

with this condition, called male pattern baldness, can begin suffering hair loss as early

as their teens or early 20s. It's characterized by a receding hairline and gradual

disappearance of hair from the crown and frontal scalp. Women with this condition,

called female pattern baldness, don't experience noticeable thinning until their 40s or

later. Women experience a general thinning over the entire scalp, with the most

extensive hair loss at the crown.

Alopecia areata often starts suddenly and causes patchy hair loss in children and

young adults. This condition may result in complete baldness (alopecia totalis).But in

about 90% of people with the condition, the hair returns within a few years.

Alopecia universalis causes all body hair to fall out, including the eyebrows, eyelashes,

and pubic hair.

Trichotillomania is seen most frequently in children, it is a psychological disorder in

which a person pulls out one's own hair.

Telogen effluvium is temporary hair thinning over the scalp that occurs because of

changes in the growth cycle of hair. A large number of hairs enter the resting phase at

the same time, causing hair shedding and subsequent thinning.

Scarring alopecias result in permanent loss of hair. Inflammatory skin conditions

(cellulitis, folliculitis, acne),and other skin disorders (such as some forms of lupus and

lichen planus) often result in scars that destroy the ability of the hair to regenerate.

Hot combs and hair too tightly woven and pulled can also result in permanent hair

loss.

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Mechanism of Hair Loss:

Male hair loss: Mechanism (Pattern Baldness):

Dihydrotestosterone (DHT) is a steroid hormone that plays an influential role in hair

loss even though, DHT is a hair growth stimulator. DHT is formed from Testosterone

with the conversion from testosterone to DHT being mediated by “5-alpha reductase”

where Testosterone is synthesized from “pregnalone” which is formed from

cholesterol.

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Figure-3: Mechanism of hair fall in men

DHT inhibits and reduces the proper growth of hair in the follicles in a process called

‘miniaturisation’. ‘Miniaturisation’ affects genetically-susceptible hair follicles

resulting in lighter, finer hairs. DHT attaches itself to receptor cells of the part of these

follicles called dermal papillas (the root), preventing the necessary nourishment for

the hair getting through for proper growth. Also, DHT causes the hair follicles to shrink.

The growing ‘anagen’ stage of the hair is shortened and the resting ‘telogen’ stage is

extended. And eventually these hairs stop growing.

Female hair loss: Mechanism (Pattern Baldness)

In female, hair loss can be very complicated and tends to result in thinning rather than

complete balding which is less common. DHT could be just one of the possible causes.

Other causes includes: nutrients/diet, illness, stress, medication & hormonal

changes/Imbalances.

DHT is influenced by decrease in “oestrogen” and the hair’s growing phase slows

down. Also takes longer for new hair to begin growing. Hair follicles shrink, leading the

hair that does grow to be thinner and finer. This can results in hair that easily breaks.

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It’s normal for women to lose 50 to 100 hairs each day, but those with female pattern

baldness can lose many more.

Hair loss is being classified on the Ludwig scale I-III.

Stage1: Thinning around parting.

Stage 2: Increased thinning of the parting resulting in a wider parting appearance.

Stage 3: Thinning throughout the head of hear with a noticeable see-through area around the

crown of the head.

Reasons of Losing Hair

It's true that men are more likely to lose their hair than women, mostly due to male pattern

baldness. But thinning hair and hair loss are also common in women, and no less demoralizing.

Reasons can range from the simple and temporary—a vitamin deficiency—to the more

complex, like an underlying health condition.

Physical stress: Any kind of physical trauma surgery, a car accident, or a severe illness,

even the flu can cause temporary hair loss. This can trigger a type of hair loss called

telogen effluvium.

Pregnancy: Pregnancy is one example of the type of physical stress that can cause hair

loss. Pregnancy-related hair loss is seen more commonly after your baby has been

delivered rather than actually during pregnancy.

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Too much vitamin A: Overdoing vitamin A-containing supplements or medications can

trigger hair loss, according to the American Academy of Dermatology. The Daily Value

for vitamin A is 5,000 International Units (IU) per day for adults and kids over age 4;

supplements can contain 2,500 to 10,000 IU.

Lack of protein: If you don't get enough protein in your diet, your body may ration

protein by shutting down hair growth.

Male pattern baldness: About two out of three men experience hair loss by age 60,

and most of the time it's due to male pattern baldness. This type of hair loss, caused

by a combo of genes and male sex hormones, usually follows a classic pattern in which

the hair recedes at the temples, leaving an M-shaped hairline.

Heredity: Female-pattern hair loss, called androgenic or androgenetic alopecia, is

basically the female version of male pattern baldness. “If you come from a family

where women started to have hair loss at a certain age, then you might be more prone

to it.

Female hormones: Just as pregnancy hormone changes can cause hair loss, so can

switching or going off birth-control pills. This can also cause telogen effluvium, and it

may be more likely if you have a family history of hair loss. The change in the hormonal

balance that occurs at menopause may also have the same result.

Emotional stress: Emotional stress is less likely to cause hair loss than physical stress,

but it can happen, for instance, in the case of divorce, after the death of a loved one,

or while caring for an aging parent. More often, though, emotional stress won't

actually precipitate the hair loss.

Anemia: Almost one in 10 women aged 20 through 49 suffers from anemia due to an

iron deficiency (the most common type of anemia), which is an easily fixable cause of

hair loss. You doctor will have to do a blood test to determine for sure if you have this

type of anemia.

Autoimmune-related hair loss: This is also called alopecia areata and basically is a

result of an overactive immune system. “The body gets confused“. The immune

system sees the hair as foreign and targets it by mistake.”

Dramatic weight loss: Sudden weight loss is a form of physical trauma that can result

in thinning hair. This could happen even if the weight loss is ultimately good for you.

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It’s possible that the weight loss itself is stressing your body or that not eating right

can result in vitamin or mineral deficiencies. Loss of hair along with noticeable weight

loss may also be a sign of an eating disorder such as anorexia or bulimia.

Chemotherapy: Some of the drugs used to beat back cancer unfortunately can also

cause your hair to fall out. “Chemotherapy is like a nuclear bomb. It destroys rapidly

dividing cells. That means cancer cells, but also rapidly dividing cells like hair.”

Antidepressants, blood thinners, and more: Certain other classes of medication may

also promote hair loss. More common among them are certain blood thinners and the

blood-pressure drugs known as beta-blockers. Other drugs that might cause hair loss

include methotrexate (used to treat rheumatic conditions and some skin conditions),

lithium (for bipolar disorder), nonsteroidal anti-inflammatory drugs (NSAIDs) including

ibuprofen, and possibly anti-depressants.

Overstyling: Vigorous styling and hair treatments over the years can cause your hair

to fall out. Examples of extreme styling include tight braids, hair weaves or corn rows

as well as chemical relaxers to straighten your hair, hot-oil treatments or any kind of

harsh chemical or high heat. Because these practices can actually affect the hair root,

your hair might not grow back.

Aging: It’s not uncommon to see hair loss or thinning of the hair in women as they

enter their 50s and 60s. Experts aren’t sure why this happens.

Anabolic steroids: If you take anabolic steroids, the type abused by some athletes to

bulk up muscle, you could lose your hair.

Hair Loss Management

Medication:

Minoxidil: Applied topically, is widely used for the treatment of hair loss. It may be

effective in helping promote hair growth in both men and women with androgenic

alopecia.

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Figure-4: Beneficial effect of topical minoxidil in a 46-year-old woman.

Antiandrogens: Finasteride is used to treat male pattern hair loss. Treatment provides

about 30% improvement in hair loss after six months of treatment, and effectiveness

only persists as long as the drug is taken. There is no good evidence for its use in

women. It may cause gynecomastia, erectile dysfunction and depression.

Figure-5: treatment with oral finasteride in a 31-year-old man with pattern hair loss.

Ketoconazole: Ketoconazole may help in women.

Surgical treatments

Hair transplantation: Hair transplantation is a surgical technique that moves

individual hair follicles from a part of the body called the donor site to bald or balding

part of the body known as the recipient site. It is primarily used to treat male pattern

Before After

Before After

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baldness. In this condition, grafts containing hair follicles that are genetically resistant

to balding are transplanted to bald scalp.

Scalp reduction: Scalp reduction is a surgical procedure in which the hairless region of

the scalp of a bald man is reduced. This procedure can reduce the area of the scalp

without hair.

Some other treatment procedures include:

Radiation-induced hair loss: Radiation induces hair loss through damage to hair

follicle stem cell progenitors and alteration of keratin expression. Radiation therapy

has been associated with increased mucin production in hair follicles.

Cosmeses: Certain hair shampoos and ointments visually thicken existing hair, without

affecting the growth cycle.

Laser therapy: 2008 and 2012 reviews found little evidence to support the use of

special lights or lasers to treat hair loss. Additionally none are approved by the FDA in

America for this use. Both laser and lights appear to be safe.

Figure-6: Laser treatment.

Dietary supplements: Dietary supplements are not typically recommended. There is only one

small trial of saw palmetto which shows tentative benefit in those with mild to moderate

androgenic alopecia. There is no evidence for biotin. Evidence for most other produces is also

insufficient. There was no good evidence for gingko, aloe vera, ginseng, bergamot, or hibiscus

as of 2011.While lacking both evidence and expert recommendation, there is a large market

for hair growth supplements, especially for products that contain biotin.

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Recent Researches on Hair Loss treatment

Stem Cell Therapy

According to a very recent study published in ePlasty journal, stem cell therapy has been

found to increase new hair growth in both males and females who have androgenetic

alopecia.

This retrospective analysis examined a group of male and female androgenetic alopecia

patients with stem cells derived from fat tissue, called adipose-derived stem cells.

Additionally, to see if finasteride would confer any additional benefit along with any possible

benefit of stem cell treatment, the researchers gave finasteride to half of the male patients.

After the treatment, the researchers observed a significant growth of new hair in both male

and female subjects, with no significant difference between males and females. Finasteride

conferred no significant additional hair growth benefit to males also receiving stem cell

therapy. The researchers concluded that injections of stem cells into the scalp of alopecia

patients appears to be an effective hair loss treatment and may represent a new avenue of

therapy, especially for men who do not respond well to finasteride and for women who

currently have limited medical treatment options.

Androgen Treatment

Another study published in the British Journal of Dermatology suggests that subcutaneous

placement of testosterone pellets may boost hair regrowth in some women.

Researchers treated a group of female patients who had androgen deficiency. Of the 285

patients studied, 76 had some degree of hair loss prior to beginning treatment. At one year

on testosterone replacement 63% reported an increase in hair regrowth on the scalp.

Traditionally, elevated levels of androgens, such as testosterone, are felt to be the primary

cause for common hair loss in both men and women. This is due to the seemingly adverse

effect of androgens on hair follicles. This has held true for most men with patterned hair loss

in whom DHT-blockers, such as Propecia (finasteride) and Avodart (dutasteride), have proven

to be a potent remedy.

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Given this, it was surprising that none of the 285 women in the study who had been treated

with testosterone reported any hair loss after one year. In fact, of the 76 women who initially

reported hair loss before the study, 63% reported positive hair regrowth at one year.

Viviscal Therapy

A study published in the December 2015 issue of the Journal of Clinical and Aesthetic

Dermatology suggests that Viviscal, an oral supplement designed for women with thinning

hair, may promote hair growth. The researchers noted a 79 percent increase in healthy,

terminal hairs and an almost 12 percent increase in hair diameter in female patients who took

the supplement for six months. The evidence suggests that Viviscal may be a useful

supplement to current hair restoration treatments, or an alternative treatment in patients

not indicated for hair transplant surgery or medical treatment with finasteride.

Conclusion:

Because the individual experience of hair loss varies, a customized management plan is

required for each patient. The patient should be actively engaged in the development of this

plan. For the motivated patient who wants treatment, the selection of modality depends on

age, extent of alopecia, comorbid factors, expected outcomes, and patient preference. In

patients with mild to moderate pattern hair loss, effective medical and surgical approaches

are available; these can be used alone or in combination to further enhance improvement. In

patients with advanced pattern hair loss, hair transplantation and hair prostheses should be

discussed. The elimination of an identifiable trigger usually underlies the effective

management of TE, although this is not always possible. Patients with AA are particularly

challenging to manage because of the unpredictable nature of the disease and the lack of a

therapeutic cure. A flexible approach is essential, based on changing needs of the patient and

evolution of the disease. The initial use of half-head/lesion treatment will control for

spontaneous remission. Regardless of the cause of hair loss, the option to forgo treatment is

important to discuss with all patients, as is the use of cosmetic means for correction. An open-

minded and steadfast approach to management, guided by each patient’s needs and

expectations, will ensure its success.

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References: 1. https://en.wikipedia.org/wiki/Hair 2. http://www.emedexpert.com/tips/hair-loss-effects.shtml 3. http://www.miamihair.com/blog/hair-loss/psychological-impact-hair-loss/ 4. https://en.wikipedia.org/wiki/Hair_loss 5. http://www.viviscal.com/hair-growth-cycle

6. https://www.mayoclinic.org/diseases-conditions/hair-loss/basics/symptoms/con-20027666

7. https://www.webmd.com/skin-problems-and-treatments/hair-loss/understanding-hair-loss-basics#1

8. https://www.google.com/imgres?imgurl=https://www.disabled-world.com/pics/1/types-of-hair-loss.jpg&imgrefurl=https://www.disabled-

world.com/health/dermatology/hair/hair-loss.php&h=365&w=500&tbnid=LDibvVupLNzB8M:&tbnh=154&tbnw=210&usg=__L

sZsHZqDMwvIqbcasfw8f47BpAQ=&vet=10ahUKEwi33Ini9KfXAhUGv48KHVpfB5oQ9QEIKDAA..i&docid=cb4JRmLkSIBTnM&sa=X&ved=0ahUKEwi33Ini9KfXAhUGv48KHVpfB

5oQ9QEIKDAA 9. http://www.hair-loss.ro/articles/mechanism_of_male_pattern_baldness.htm

10. https://www.theprivateclinic.co.uk/blog/2013/05/17/how-dht-hormone-affects-hair-loss 11. https://www.healthline.com/health/womens-health/female-pattern-baldness#overview1 12. https://www.theprivateclinic.co.uk/blog/2017/08/25/what-you-need-to-know-about-

female-pattern-baldness 13. http://www.health.com/health/gallery/0,,20727114,00.html#why-is-my-hair-falling-out--0

14. https://en.wikipedia.org/wiki/Management_of_hair_loss

15. http://onlinelibrary.wiley.com/doi/10.1002/psb.1478/pdf 16. Fukuoka, H., & Suga, H. (2015). Hair Regeneration Treatment Using Adipose-Derived Stem

Cell Conditioned Medium: Follow-up With Trichograms. Eplasty, 15, e10

17. Glaser, R., Dimitrakakis, C., & Messenger, A. (2012). Improvement in scalp hair growth in

androgen-deficient women treated with testosterone: a questionnaire study. The British Journal

of Dermatology, 166(2), 274–278. http://doi.org/10.1111/j.1365-2133.2011.10655.x

18. Ablon, G., & Dayan, S. (2015). A Randomized, Double-blind, Placebo-controlled, Multi-center,

Extension Trial Evaluating the Efficacy of a New Oral Supplement in Women with Self-

perceived Thinning Hair. The Journal of Clinical and Aesthetic Dermatology, 8(12), 15–21.