Even with limited impact on a person’s physical health, hair loss can have significant psychological consequences and severely impair quality of life.

Why is hair so important?

There is a lot of symbolism in scalp hair, and “healthy hair” is typically associated with a perception of good looks, charm, beauty, class and power. Moreover, hair can make a statement, both in terms of cultural origin and social affiliation. For example, monks typically shave their heads, and orthodox Jewish men wear the traditional sidelocks (Payot) to indicate status among their peers, while rockers tend to wear their hair dark, long and unkempt as a symbol of their stance against authority.

Fixing your hair for the day is an important part of getting ready to face one’s social world. So, what happens if you start losing your hair and can no longer control what social signals it conveys? As stated by Thomas Cash in an article about the psychology of hair loss, the expression “bad hair day” is a testimony to the psychological importance of hair and hair loss can turn every day into a bad hair day.

Psychosocial consequences of hair loss

Being a disfigurement that can affect a person’s sense of self and identity, hair loss is associated with a high prevalence of psychiatric comorbidities. The condition often triggers great psycho-emotional and psychosocial stress, particularly in relation to anxiety, depression, social phobia and personality disorders. Ironically, hair loss can cause these psychological disorders, but the disorders themselves can also trigger, or worsen, hair loss – leading to a vicious circle.

Common, life altering, psychosocial effects include embarrassment, humiliation, low self-esteem, altered self- and body-image, and less enjoyable social engagements. This, in turn, has been shown to result in reduced leisure and outdoor activities and decreased social engagements to avoid negative emotions, leading to self-isolation, anxiety and depression. Clinical symptoms, functional behaviour, and emotional stability in addition to anxiety and worry about hair loss all affect a person’s quality of life. These serious psychosocial consequences can cause intense emotional suffering, as well as personal, social and work-related problems.

In medical terms, hair loss can cause antisocial personality disorder, posttraumatic stress disorder, generalized anxiety disorder, major depression, adjustment disorders, obsessive-compulsive disorder, panic disorder and social phobia. Sometimes, it can even lead to suicidal intent.

Diminished quality of life

The disease burden of hair loss has, at times, been compared to the suffering caused by chronic or life-threatening diseases that, at a first glance, are of significantly higher severity. This is not due to the hair loss itself, but rather caused by the reaction to losing one’s hair.

There are several scientific studies that underline the profound implications of hair loss on a person’s quality of life. For example, an Indian study from 2019 evaluated the quality of life in 200 men experiencing moderate hair loss and found that it was significantly reduced. There results were age dependent, as younger individuals experienced a larger loss of quality of life. These findings are well in line with previous data.

The psychosocial impact of hair loss is greater for women than men

Hair loss is most common in men, in fact, it affects half of all men over the age of 50 even though it can debut at much younger ages. As a result, the efforts to reduce the stigma and psychosocial burden of hair loss in men has been going on for decades. As we have learned, there is plenty of room for improvement, but many men have come to cope with the idea of losing their hair much thanks to such activities.

However, hair loss also affects women to a large extent and about one in three women suffer from it at some point in their lives. Unlike with men, there has been no strong push to reduce the burden of hair loss experienced by women, who still need to hide their hair loss in order to preserve their femininity. Put simply, in our culture a bald man is socially acceptable, a bald woman is not.

As a natural consequence, there is scientific consensus stating that the distress caused by hair loss is larger for women compared to men. The important link between hair and identity is especially strong for women, and some studies have even reported that women have a psychologically harder time coping with hair loss than the loss of a breast through breast cancer.

Read more about female alopecia here.

Different types of hair loss

As mentioned, there are various causes of hair loss, alopecia being the most common form. Alopecia is a chronic inflammatory dermatological disorder that affects the hair follicles growth phase, resulting in hair loss – primarily on the scalp, but sometimes on the body as well.

There are several forms of alopecia, distinguished by the extent of hair loss. The most common is Androgenetic Alopecia (AGA), also referred to as Male-Pattern Alopecia (MPA). AGA is a genetically predisposed condition mediated by an increased sensitivity to testosterone in the follicle, eventually causing involution. Among men, AGA typically begins with a receding hairline, followed by loss at the vertex. If AGA progresses, the balding areas merge, leaving only a ring of hair around the scalp.

There is a specific female version to AGA called Female Pattern Hair Loss (FPHL), characterized as a non-scarring diffuse alopecia, evolving from the progressive miniaturization of hair follicles and subsequent reduction of the number of hairs on the scalp. FPHL is the most common cause of hair loss in adult women and the prevalence increases with age – peak incidence, however, is seen in ages 25-40 and 50-60, the latter group being the largest and is thought to be related to menopause.

Severe alopecia

There are also more severe versions of alopecia, like Alopecia Areata (AA), referring to a patchy loss of hair from the head rather than general thinning. The patches may vary from 1 centimetre in diameter, to relatively large areas. Loss of all hair on the head, including eyelashes and eyebrows, is referred to as Alopecia Totalis (AT), while losing all hair on both the head and body it is called Alopecia Universalis (AU).

The mechanisms behind, and the development of, the more severe versions of alopecia are not fully understood, but it is believed to be an autoimmune disorder – where immune cells attack hair follicles in the growth phase – that arises from a combination of genetic and environmental influences. The onset is typically sudden, and the disease course is unpredictable; there may be spontaneous remission but there can also be repeated episodes. AT and AU are estimated to account for between 7 and 30 per cent of cases with severe alopecia.

Moreover, chemotherapy, given as part of cancer treatment, may also cause substantial hair loss. Once the chemotherapy is stopped, the hair tends to grow back, but as with other types of alopecia (AA, AT, and AU) it may not be of the same colour or texture as before. To many cancer patients, hair loss may be the most traumatic side effect of chemotherapy.

Treatment options

For severe hair loss, the treatment options are few and with low success rates. Hence, affected individuals are often referred to hair transplant or the use of wigs.

For AGA, however, there are a few treatment options available. Minoxidil (Rogaine) is the most common topical formulation and is available for both males and females with alopecia. Among the systemic alternatives, Finasteride (Propecia) is the primary choice, although its only indicated for men. What these treatments have in common, though, is that both have limited treatment effects and come with unwanted side effects, including scalp irritation, rapid heart rate (tachycardia), and diminished sex drive.

However, Swedish biotech company Follicum is developing a new topical treatment for both male and female alopecia: FOL-005. The company has started a Phase IIa study, to be run in collaboration with the Charité Clinical Research Center for Hair and Skin Science (CRC) in Berlin and with the CRO proDERM in Hamburg. Enrolment of additional patients is temporarily halted due to the Covid-19 pandemic – listen to CEO Jan Alenfall expand on this here, in Swedish – but given the thus far rapid enrolment of patients, Follicum expect to be able to accelerate the trial once reopened. Top-line data is anticipated about three quarters after enrolment has restarted. In the meantime, the company is working on a strategic regulatory and clinical development plan to be put in place before the end of the year.

The content of BioStock’s news and analyses is independent but the work of BioStock is to a certain degree financed by life science companies. The above article concerns a company from which BioStock has received financing.