August is an opportunity to raise awareness about an extremely common concern: hair loss and the different forms of alopecia.

Hair loss is often considered mainly a cosmetic problem, but it can have many different causes and may significantly affect quality of life and self-confidence.

More importantly, hair loss is a symptom, not a diagnosis. Before choosing a treatment, we first need to understand why the hair is falling out. Not all types of hair loss are the same — and they should not all be treated in the same way.

1) What is alopecia?

The term alopecia refers to a partial or complete loss of hair, regardless of the underlying cause.

Our hair naturally follows a continuous cycle of renewal. Each hair follicle passes through a growth phase (anagen), a short transition phase (catagen), and a resting phase (telogen), after which the hair is shed and a new cycle begins.

Losing some hair every day is therefore completely normal. Around 50 to 100 hairs per day is generally considered physiological, although there is considerable individual variation.

What matters more than counting individual hairs is a change from your usual pattern: noticeably increased or persistent shedding, a progressive decrease in hair density, widening of the central part, recession of the hairline, or the appearance of clearly defined areas of hair loss.

2) Why do we lose hair?

There is no single cause of alopecia. Different mechanisms can interfere with the normal activity and growth cycle of the hair follicle.

Genetic and hormonal factors

Androgenetic alopecia is the most common form of progressive hair loss.

In genetically predisposed individuals, certain hair follicles are particularly sensitive to androgens, especially dihydrotestosterone (DHT). This sensitivity leads to progressive miniaturisation of the follicles: the hairs become finer and shorter, while their growth phase gradually decreases.

In men, this typically causes recession of the frontal hairline and thinning over the vertex. In women, the loss of density is often more diffuse and particularly noticeable over the upper scalp and along the central part.

Hormonal changes throughout life can also influence the hair cycle, for example after pregnancy or around menopause.

A disruption of the hair cycle: telogen effluvium

Illness, high fever, surgery, childbirth, significant weight loss, certain nutritional deficiencies or major physiological or psychological stress can disrupt the normal hair cycle.

A larger number of follicles may enter the telogen phase prematurely. The resulting hair shedding typically becomes noticeable several weeks to a few months after the triggering event.

This is known as telogen effluvium.

It is often reversible once the underlying trigger has resolved or been corrected. Persistent shedding, however, may require further investigation to look for an ongoing cause.

Nutritional deficiencies and general health

Iron deficiency, certain nutritional deficiencies, thyroid disorders and other medical conditions can sometimes contribute to hair loss.

This does not mean that everyone experiencing hair loss needs a long list of supplements. When a deficiency or medical cause is suspected, targeted blood tests may be appropriate. Supplementation is useful when it addresses an identified deficiency rather than being used indiscriminately.

Autoimmune disease

In alopecia areata, the immune system targets the hair follicle and disrupts its normal activity.

It most commonly presents as one or more well-defined round or oval patches of hair loss on the scalp, but other hair-bearing areas such as the beard can also be affected.

Its course can vary considerably from one person to another, making correct diagnosis important when deciding whether treatment is needed.

Repeated mechanical stress

Very tight hairstyles, extensions and repeated traction on the hair can cause traction alopecia.

In its early stages, this may be reversible. If traction continues over a long period, however, the follicles can eventually become permanently damaged.

Not all alopecia is the same

Androgenetic alopecia, telogen effluvium and alopecia areata are among the causes of hair loss frequently seen in dermatology, but they are not the only ones.

There are also scarring alopecias. These are less common but particularly important to recognise because inflammation can progressively destroy the hair follicle and replace it with scar tissue.

Early diagnosis and treatment are especially important in these conditions because once a follicle has been permanently destroyed, hair regrowth may no longer be possible.

This is one of the reasons why hair loss should not simply be treated based on its appearance or with the same standard solution for everyone.

3) How do we diagnose hair loss?

The diagnosis starts with the patient’s history and a careful examination of the scalp and hair.

When did the hair loss begin? Was it sudden or progressive? Is the loss diffuse or localised? Has there recently been an illness, pregnancy, significant weight loss, medication change or another event that could have disrupted the hair cycle?

Clinical examination allows us to assess the pattern of hair loss, hair density and the condition of the scalp.

Trichoscopy, which allows the scalp, hair shafts and follicular structures to be examined under magnification, can provide additional information and help differentiate between different forms of alopecia.

Depending on the clinical situation, targeted blood tests or additional investigations may also be appropriate.

4) Can alopecia be treated?

There is no single answer to this question.

Many forms of alopecia can be treated, improved or stabilised, but the potential for regrowth and the prognosis depend on the underlying cause, how long the hair loss has been present and whether the follicles remain viable.

Some forms of shedding, such as many cases of telogen effluvium, can be temporary. In androgenetic alopecia, the goal is mainly to slow progressive follicular miniaturisation and preserve — and when possible improve — existing hair density.

In inflammatory or scarring alopecias, the priority may instead be to control the disease process and preserve the follicles that are still present.

Treatment therefore always starts with the correct diagnosis.

Treatment of androgenetic alopecia

Androgenetic alopecia is a chronic and progressive condition. The aim of treatment is to slow down follicular miniaturisation, preserve existing hair and, when possible, improve hair density.

• Minoxidil

Topical minoxidil remains one of the established treatments for androgenetic alopecia. It needs to be applied regularly to the scalp, and several months are usually required before its effect can be properly assessed.

For some patients, however, applying a topical product every day can be inconvenient. Depending on the formulation, it can also leave the hair feeling sticky or affect hairstyling.

Low-dose oral minoxidil is another option and may sometimes be used instead of, or in combination with, topical treatment.

Its use for hair loss is off-label, meaning that hair loss is not its officially registered indication. Nevertheless, low-dose oral minoxidil is used in dermatological practice in appropriately selected patients. Because it is a systemic medication, medical assessment and consideration of possible contraindications and side effects are important.

• Anti-androgen therapies

In men with androgenetic alopecia, oral finasteride can be used to reduce the conversion of testosterone into DHT, thereby helping to slow follicular miniaturisation. In selected cases, other 5-alpha-reductase inhibitors such as dutasteride may also be considered.

In addition, topical finasteride is increasingly used in men as an alternative or adjunct to oral therapy. It aims to reduce scalp DHT exposure while potentially limiting systemic absorption, and can be particularly useful in patients who prefer a localised treatment approach.

In women with androgenetic alopecia, particularly in premenopausal patients with signs of hyperandrogenism, anti-androgen approaches may be considered:

Spironolactone (oral) is widely used in dermatology practice. It acts as an androgen receptor antagonist and may help reduce hair follicle sensitivity to androgens. It is generally used in premenopausal women under appropriate medical supervision.

Treatment is always individualised, and different approaches can be combined when appropriate.

• PRP as an additional treatment

PRP (Platelet-Rich Plasma) may be offered as an adjunct to medical treatment.

A small amount of the patient’s own blood is collected and processed to obtain plasma with a higher concentration of platelets, which is then injected into the scalp. The growth factors released by these platelets may help stimulate follicular activity.

It is important to be realistic about the results. Response to PRP varies considerably between individuals. Some patients are very satisfied and notice an improvement in hair density or quality, while others experience little or no visible benefit.

For this reason, we consider PRP an adjunctive treatment rather than a replacement for medical therapy.

• Mesotherapy (hair filler)

In some patients, mesotherapy of the scalp can be proposed as an additional or alternative supportive treatment.

This involves micro-injections of active compounds into the dermis of the scalp to support the follicular environment and improve hair quality.

It is generally considered a second-line option, particularly when PRP is insufficient or not suitable.

• Adjunctive energy-based treatments

Photobiomodulation, also known as Low-Level Light Therapy (LLLT) uses specific wavelengths of red or near-infrared light to influence cellular activity and support hair density and quality.

In clinical practice, this category includes in-office LED and laser platforms such as LaseMD Ultra laser and Mosaic 3D fractional laser, which are sometimes used as part of a broader regenerative strategy for scalp health. 

These devices are not primary treatments for androgenetic alopecia, but may contribute to improving the scalp environment and supporting other therapies in selected patients.

• Hair transplantation

When hair loss is more advanced, hair transplantation can be considered in appropriately selected patients.

It restores density in targeted areas but does not stop the progression of androgenetic alopecia in non-transplanted hair, so long-term medical management may still be required.

Treatment of telogen effluvium

The approach to telogen effluvium is quite different.

Here, the priority is to identify the possible trigger: recent illness or fever, surgery, childbirth, significant weight loss, major physiological or psychological stress, medication changes or a possible nutritional deficiency.

When clinically indicated, targeted blood tests can be performed, particularly to look for iron deficiency or thyroid dysfunction.

Once the triggering factor has resolved or an underlying problem has been corrected, hair shedding will generally improve progressively.

It is important to remember that hair grows slowly. Even after the cause has been addressed, it takes time for the hair cycle to normalise and considerably longer before recovery of density becomes visibly apparent.

Treatment of alopecia areata

Alopecia areata is an autoimmune condition with a highly variable course.

One or a few limited patches may sometimes regrow spontaneously, and in these situations reassurance and observation can be appropriate.

When localised alopecia areata is still active or progressing, intralesional corticosteroid injections can be used to suppress the local inflammatory process and encourage regrowth.

Rapidly progressive, extensive or severe forms require more specialised management and may warrant referral to a hospital-based dermatology department to discuss appropriate systemic treatment options.

5) The most important message

When someone experiences hair loss, the first question should not be:

“What is the best treatment to make my hair grow back?”

The first question should be:

“Why am I losing my hair?”

Only once we understand the cause can we build a logical treatment strategy. Sometimes that means reassurance and time. Sometimes it means correcting an identifiable trigger. Sometimes it requires long-term medical treatment, and sometimes several approaches are combined.

For some patients with more advanced androgenetic hair loss, hair transplantation may ultimately be the most appropriate option.

In hair loss, as in dermatology in general, treatment comes after diagnosis.