Alopecia is a state of not growing hair. This can occur for a number of reasons such as damage to hair follicles due to a burn or scar. It is also seen in men who had skin injuries on the scalp during pregnancy or birth (baldness can be a “birth mark” so to speak). Hair loss can also occur in areas of the body where the hair is rubbed by clothing. This can be especially true on the thighs and calves where pants, trousers, or even boots can rub against the skin causing the hair to “rub off”. The most common type of alopecia is male pattern baldness where hormones affect hair follicles on the crown of the head (click HERE to learn more about male pattern baldness).
Each day, we lose about 100 hairs. These hairs fall out, then go into a dormant or resting state, then start to regrow.[i]
One cause of hair thinning is a disorder called telogen effluvium. This can occur in both men and women. It is caused as a stress reaction in the body that forces the hair (as much as 70% of the hair on the head) to go into the rest stage of the hair growth cycle (see right). This occurs most often a month or two after a high stress event (in fact, this occurs regularly after childbirth in women where they will lose a large amount of hair shortly after delivery). It can also occur with dietary deficiencies, such as iron deficiency, or as a result of certain medication therapies. However, traumatic events or physical stress on the body can trigger acute telogen effluvium. Chronic forms of telogen effluvium tend to appear as more diffuse hair loss over longer periods of time. Unlike male pattern baldness, hair often grows back when the rest cycle of the hair ends and the regrowth cycle begins. For this reason, the first treatment is often watching and waiting. If it is due to a suspected medication side effect a trial of up to three months off the medication may reverse the telogen effluviam. Correcting dietary deficiencies can also reverse this disorder. Sometimes providers may suggest topical minoxidil to trigger hair to go into the growth cycle; however, this may not work in all men.
The onset of a new bald spot in a random location in an established field of hair is most often caused by an autoimmune disorder. In autoimmune disorders, the body attacks something as foreign when it fact it isn’t foreign. In this case, the immune system will attack certain hair follicles and stops them from functioning appropriately. Alopecia areata occurs when one or more bald spots appear, most often on the scalp.
Another, more extensive form of alopecia areata is a disorder called Persistent Patchy Alopecia Areata. In this disorder, the alopecia occurs in multiple patches over a longer period of time.
Topical (and sometimes oral) corticosteroids are often used to decrease the immune response in an effort to reverse alopecia areata. Minoxidil has been used to help stimulate more hair growth in the area, but this may not work well since the body continues to attack hair in the area.
Diffuse Alopecia Areata[iv]
Diffuse alopecia areata is a disorder where hair in a certain area is attacked by the immune system but not completely. In these cases, the hair can thin out rather than fall out. Sometimes this is mistaken for male pattern baldness thinning or telogen effluvium.
One of the more difficult types of alopecia to treat is a condition called ophiasis alopecia. This occurs when hair loss occurs in a band that runs from the temples, over and behind the ears, and behind the head at base of the scalp. This looks like reverse male pattern baldness where the hair loss is around the bottom ring of the head rather than on the crown of the head.
Alopecia Totalis & Universalis[vi]
Autoimmune areatas can spread to larger areas. Areata totalis is when hair loss spreads across the entire scalp. This affects all hair growing on the head (eyebrows, lashes, and facial hair).
An even more extensive form called alopecia universalis leads to hair loss on the entire body, including arms, legs, torso, armpits, genitals/pubic area, as well as the face and head.
INFLAMED HAIR FOLLICLES
Ingrown hair occurs most often in men who have hair shafts that are cut or damaged. This most often occurs in areas where men shave or wax. Hair can be cut or broken off at or below the surface of the skin with “lift and cut” razor blade shaving as well as hair waxing. This can cause the hair to grow inward into the skin as it regrows. This is especially true in men who have more curly body hair as the hair shaft may begin curling before it exits the pore. This creates irritation and inflammation, or folliculitis (discussed next). It also occurs in areas where the hair is shaved against the grain. Perhaps one of the most common areas for ingrown hair is the neck. This often occurs in areas where the beard/neck hair grows in a direction opposite from other hair elsewhere in the area. This causes the blade to actually shave against the grain, lifting a hair above the skin line before cutting thus allowing the hair shaft to resettle lower below the surface of the skin and become ingrown.
Ingrown hairs also occur in areas where there is tight clothing or pressure. Men who wear tight longer underwear (like sliders) or tight shorts/jeans can develop ingrown hair as the tight clothing rubs against the hair shaft forcing it into the skin or breaking it off at the skin level. Even pressure on a certain area can create ingrown hairs. For example, it’s not uncommon for men who grow hair on their buttocks to get ingrown hairs on the areas of the buttock where they sit (the sit bone area). This is caused by pressure during sitting to force hair back on itself. In addition, men who have tight curly hair are more likely to have ingrown hair as the hair can curl back into the skin.
Treatment can include keeping the area clean dry and wearing looser clothing in the affected area. It can also include scrubbing the area with a hot washcloth during a hot shower to open the hair follicle and promote the hair shaft out of the pore. Men can also prevent ingrown hair by not shaving against the grain of the hair or by using a single blade razor rather than a double, triple, or quad blade. Using plenty of shaving cream can create smoother gliding of the razor blade and prevent irritation of the skin or nicking the skin and introducing inflammation around the hair follicle.
For some men, shaving less frequently (every other day or even once a week) can help. Not shaving or waxing the area for a period of time to allow the hair to grow out of the skin and begin growing normally – so growing a beard or allowing body hair to grow can allow ingrown hairs to finally surface. For men who desire a “less hairy look” future outbreaks can be prevented by trimming the beard or body hair with electric clippers to avoid cutting the hair shaft below the skin can prevent ingrown hairs.
Folliculitis is the inflammation of the hair follicle. Ingrown hair is perhaps one of the leading causes of folliculitis. However, hair follicles can become inflamed without a hair growing back on itself. Any opening in the hair follicles can introduce the possibility of bacteria entering which results in infection and inflammation.
Common causes of folliculitis[vii] include the following:
Waxing – Waxing can leave an empty and open hair follicle that can become inflected.
Shaving – Nicking a goose bump (cold hair follicle) can create an avenue for bacteria to infect the skin. Nicking is more common when men use older razor blades that may be dull or carry bacteria
Hot Tubs/Springs – Heat causes pores, especially hair follicles to open. A poorly maintained hot tub or natural hot spring may be a breeding ground for bacteria that can then enter the open pore/follicle and lead to infection.
Poor Hygiene – bacteria from the skin can enter the follicle causing inflammation.
Folliculitis often appears as red bumps around a hair follicle. With ingrown hair, the hair shaft may not be visible since it is under the skin. But in infectious types of folliculitis, the hair shaft typically grows out of the inflamed, red, raised bump. A good example is the picture at right.
Treatment can involve cleaning the area and in some cases, the use of topical antibiotics. In severe cases of deeper infections, oral antibiotics may be prescribed. Good hygiene and avoiding hot tubs and hot springs can also prevent future infections. As with ingrown hair, avoiding waxing as well as close shaving can prevent infections. Simply using a clean razor blade with plenty of shaving cream can prevent nicks with a dirty blade, thus reducing the chance of infected hair follicles.
Dissecting folliculitis is a rare condition that occurs more often in black men than in other ethnic groups, although it has been seen in men of nearly all ethnic groups. It most often occurs in the scalp and involves areas of pus filled bumps and lumps that lead to scarring. Hair doesn’t grow in the scarred area leaving a blotchy appearance on the scalp when multiple areas are involved. To see images of dissecting folliculitis, click HERE.
Treatment for dissecting folliculitis is best done by a dermatologist. Anti-inflammatory agents (either topical or oral) are often used. Other medications can also be used depending on the cause and severity of the disorder.
This disease occurs in the hair follicles where skin touches skin and there are a lot of sweat glands – so mostly the armpits, groin, and crack of the buttocks. Hidradenitis can often look like folliculitis but it can also look like acne or boils. It usually begins as a bump on the hair follicle that doesn’t go away. Over time, it can grow deeper and involve tissue further under the skin and become painful and rupture. Treatments may involve topical therapy such as antibiotics, oral medications, or surgery in some severe cases. Since this disorder often mimics other disorders and can create tissue damage, it’s important to see a dermatologist for any bump or cyst that becomes painful and does not go away or worsens. To see an image of hidradenitis suppurativa, click HERE.
A pilonidal cyst occurs when the hair on the buttocks grows inwards into the skin creating an ingrown “nest of hair”. This nest of hair then surfaces as a cyst. This usually occurs near the top of the crack of the buttocks over the tailbone as shown below. This is more common in men than women. Most of these cases occur in men who sit extensively (especially men who sit for work). Sitting for long periods of time can force buttocks hair to grow inward creating a cyst. However, pilonidal cysts can also occur in the natal cleft (crack of the butt). Friction from walking or running can force hair in the crack of the buttocks to grow inward causing a similar type of cyst.
Unlike an ingrown hair that grows inwards into the skin, a pilonidal cyst goes deeper into the tissues under the skin. Treatment may involve lancing and draining the cyst and removal of the nest of hair. In some cases, men who have had a pilonidal cyst may be encouraged to shave the hair over the tailbone and/or into the crack of the buttocks to prevent a future cyst.
Dandruff appears as white flakes in the hair. This most often occurs on the scalp but can also occur in other areas of the body where there is a significant amount of hair – the eyebrows, eyelashes, chest, or other areas extensively covered in body hair. Dandruff can be itchy, which causes an individual to scratch, thus knocking loose more skin cells and creating more flaking.
Dandruff can be caused by a variety of issues. Stress and hormone changes can cause dandruff, thus a reason why young men going through puberty often have dandruff from time to time. For mild forms of dandruff, shampooing with a selenium sulfide shampoo (shampoos like Head and Shoulders®), can help treat the flaky, itchy skin. Also keeping the area moist by using conditioners on the scalp and lotions in other areas can be helpful.
However, some cases of dandruff are caused by a fungal infection and require a prescription antifungal shampoo in order to resolve the dandruff.
This is a fungal infection of the scalp that is caused by the same fungus as jock itch (to learn more about jock itch, click HERE). It is sometimes called ringworm because the fungus often grows in rings; however, it is caused by fungus, not a worm. On the head, there can be patches of skin that are itchy, red, and raw. In some cases, the infection may cause the shaft of the hair to break off, creating bald patches that sometimes look like alopecia areata.
These fungal infections can occur in people with thicker hair, especially if the hair is not dried sufficiently and pulled back into a ponytail or “man bun” or a hat is worn on wet hair. These can trap moisture against the scalp and create an area of darkness. Since fungus grow best in warm, dark, moist areas, not drying the hair and trapping moisture against the skin can increase the chances of getting tinea capitis.
Treatment often involves the use of an antifungal shampoo and keeping the hair and scalp well dried and open to the air.
This is a bacterial infection that actually affects the hair shaft itself. This occurs in hairy areas with a lot of sweat glands, such as the armpits and groin. The infection almost looks like a waxy coating on the hair and is usually yellow in color, but can also be black or red. To see an example of trichomycosis on armpit hair, click HERE. The infection typically has a fairly foul odor and can be mistaken as having bad body odor.
It is best to see a healthcare provider for treatment as other infections, including lice infestations can sometimes appear on the hair shaft and look similar.
Treatment for trichomycosis often includes shaving the affected hair off, then using prescription anti-infective agents to prevent growth of bacteria on the hair shaft as it regrows.
Lice are tiny insects that can infect individuals by laying their eggs on the hair shaft and feeding off the blood at the base of the hair. The eggs are called “nits” and often take 7 days to hatch. Lice most often infects the head and is called head lice. However, lice can also infect the body hair and pubic hair. Lice typically don’t carry diseases, but the lice infestation can be extremely itchy.
Head lice is the most common type of lice infection. It typically occurs in children as adult lice are passed from one individual to the next. This can occur by sharing hats, combs, brushes, pillows, headphones, or simply by touching someone else’s hair then touching their own scalp. These adult lice lay eggs on the hair shaft which hatch in about 7 days, creating an outbreak of lice in the hair (see picture below). These lice then lay eggs and another infestion hatches a week later. Treatments often require a two step process. In the first step, medication is applied (often over the counter medication like permethrin), which kills the adult lice. This medication is often left on the scalp and hair for a certain number of minutes to ensure the adult lice are killed. Unfortunately, this medication doesn’t kill the nits/eggs so reapplication in seven days is necessary to kill the newly hatched lice. Eggs can be removed from the shaft of the hair using a very fine tooth comb called a nit comb. This can reduce the number of eggs that are left to hatch.
Pubic lice (sometimes called “crabs”) is often passed from one individual to the next through sexual contact, but may also be through sharing bedding or towels. Pubic lice can also transfer to other hairy areas including the chest, armpits, beard, or buttocks. Treatment is similar to that for head lice.
Body lice is rare and usually occurs in individuals with very poor hygiene – often occuring most often in the homeless population. In cases of body lice, the entire body has to be treated and clothing has to be discarded.
In some cases, especially in children, lice can infect the eyelashes. Rather than using medications close to the eyes, petroleum jelly is often used to suffocate the adult lice for 8 to 10 days. The nits/eggs are removed from the eyelashes with tweezers.
Good grooming and hygiene can go a long way to preventing many disorders of the hair and hair follicle. However, despite an individual’s best efforts, infections and inflammation can occur – especially in men with more body hair. Treatments for most mild conditions are available over the counter as well as through a medical provider.
[i] https://www.aocd.org/page/telogeneffluviumha (2/16/19)
[iii] https://www.naaf.org/alopecia-areata/types-of-alopecia-areata (2/18/19)
[viii] https://www.dermcoll.edu.au/atoz/dissecting-cellulitis-scalp/ (2/18/19)
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