Alopecia of various origins

It is at a cosmetology appointment that a doctor can note significant hair loss in a patient, removing his cap after a particular procedure. In such situations, having basic clinical knowledge, a cosmetologist can prescribe a set of tests necessary to carry out further diagnostics, identify concomitant pathologies and make a trichological diagnosis.

The most common forms of alopecia for which people consult a trichologist/cosmetologist are:

• androgenetic (AGA);
• diffuse telogen effluvium (DTA);
• nested (focal).

At the same time, the vast majority of requests are related to AGA and DTA.

Androgenetic alopecia

The etiopathogenesis of this form of baldness has a direct connection with male sex hormones, but develops not only due to an increase in their levels above the normal limit. Significant factors are:

• increased enzymatic activity of 5-alpha reductase during the metabolism of sex hormones;
• increased sensitivity of the receptors of the cells of the dermal papilla of the hair follicles to dihydrotestosterone;
• increased density of androgen receptors.

Along with androgen-dependent processes, the presence of perifollicular inflammatory infiltrate (microinflammation) and the further formation of perifollicular fibrosis have an additional negative effect on hair follicles, which also contributes to the miniaturization of hair follicles.

AGA is diagnosed in both men and women. According to research, 12% of women under 30 years of age experience androgenetic alopecia, by the age of 50 the percentage increases to 25% and by the age of 70 the figure is 40%.

Diffuse telogen effluvium

It is known that the stages of hair growth have a certain cyclicity and duration:

• anagen - 1-6 years;
• catagen - 1-2 weeks;
• telogen - 5-6 weeks.

As a percentage, about 85-90% of follicles are in the anagen stage (growth phase), 10-15% are in telogen (resting phase), and about 2-3% are in the transition stage (catagen). This correspondence and the uneven change of stages make the process of physiological hair loss invisible. With the development of trichological pathology, the stage balance is disrupted. There is a shortening of the anagen phase and a rapid transition of hair follicles into the resting phase, as a result, patients note obvious hair loss and thinning.

DTA triggers can be:

• endocrine diseases;
• autonomic and neuropsychic disorders, frequent stress;
• pancreas and liver disease;
• diseases of the digestive tract;
• lack of vitamins, minerals, fatty acids in food products and impaired absorption of them;
• inflammatory scalp diseases;
• taking medications (antidepressants, steroid hormones, hormonal contraceptives, antibiotics, etc.).

Hair condition and COVID

Over the past year, the list of etiological factors has increased. The COVID-19 pandemic has made its own adjustments, and many patients who suffered coronavirus infection had a number of complications from various organs and systems, including the problem of significant hair loss.

One of the symptoms of COVID-19 is an increase in body temperature above subfibrile levels. Fever is a normal protective reaction of the body in response to the action of various pyrogens (substances that provoke fever). There are exopyrogens (primary) and endopyrogens (secondary).

• Based on their origin, exopyrogens are classified into infectious (viruses, bacteria, fungi, single- and multicellular parasites, rickettsia) and non-infectious (exogenous proteins).
• Exopyrogens cause the release of endopyrogens (IL-1, IL-6, TNF-a - pro-inflammatory cytokines) in the body.

During the acute phase of the disease, the level of cytokines in the blood increases sharply, which provokes an attack by the immune system on the body’s own cells and tissues. The consequence of a “cytokine storm” can be the destruction of organs and tissues. Thus, hair follicle cells are no exception.

When the body temperature is above subfibrile, the process of proliferation of hair follicle cells is affected and, on average, 2 months after the fever, patients begin to notice a significant increase in hair loss. Such hypotrichosis can be temporary and end spontaneously after the body has fully recovered from the disease. But taking into account the fact that the majority of patients who suffered from SARS-CoV infection had multiple organ failure, it is not possible to do without corrective therapy (exogenous, endogenous) in order to restore hair growth and structure.

Another catalyst for the sharp deterioration in hair condition after COVID-19 was long-term use of high doses of broad-spectrum antibiotics. These substances can lead to disruption of matrix cell division and premature detachment of the hair follicle from the hair papilla. Thus, there is a significant shortening of the anagen phase, a rapid transition to catagen and telogen. There is an increase in hair loss when taking anticoagulants, and a situation may occur when hair follicles fall out in the anagen stage, without moving into subsequent ones (anagen loss). It is possible to accurately determine at what stage a violation occurred in the hair life cycle using instrumental diagnostic methods.

Diffuse alopecia associated with drug treatment does not develop immediately, on average, several weeks after taking medications. During this period, a gradual decrease in the diameter of the hair follicle, dystrophic changes in the hair shaft, disruptions in protein synthesis, and slower hair growth occur.

Despite the fact that hair loss associated with taking medications is reversible, it is important to promptly prescribe maintenance therapy in order to increase the proliferative activity of hair follicle cells and restore microcirculation of the scalp.

Any illness is stress for the body. During the COVID-19 pandemic, everyone has experienced some level of stress. Fear of getting sick, fear for the health of loved ones, fear of social and financial instability - all this served as another trigger for the development of alopecia. During periods of strong emotional stress, biologically active substances (adrenaline, norepinephrine, cortisol, acetylcholine, substance P) are released, which have a vasoconstrictor effect, leading to deterioration of microcirculation. As a consequence, changes occur in cellular metabolism with the possibility of further structural changes in the hair follicles.

The presence of perifollicular inflammation, which increases during stress with substance P (activates the synthesis and release of inflammatory mediators), serves as an additional factor inhibiting the proliferation of hair follicle cells, as a result - hair loss and stunted hair growth.

Thus, an important component of a successful treatment protocol for diffuse alopecia is the normalization of the patient’s psycho-emotional background. In some situations, consultation with a psychotherapist and corrective therapy is required, which will further increase the effectiveness of the appointments of a trichologist and cosmetologist.

AGA and DTA therapy

Since the problem of hair loss is primarily endogenous, it is important to determine the etiological factor and eliminate it. To do this, it is necessary to exclude the following pathologies by referring the patient to undergo basic tests:

• diabetes mellitus, dysfunction of the thyroid gland, pituitary gland - T3, T4, TSH; blood glucose; prolactin;
• imbalance of sex hormones - LH (luteinizing hormone); FSH (follicle stimulating hormone); testosterone (total and free); androstanediol glucuronide; dihydrotestosterone;
• anemia - general blood test; serum iron; ferritin;
• folate cycle disorders - serum folic acid levels; cyanocobalamin; homocysteine;
• disturbances of phosphorus-calcium metabolism - phosphorus; total calcium; ionized calcium (Ca++); parathyroid hormone; osteocalcin; vitamin D (25-OH vitamin D2-D3).

After the diagnosis has been made and the cause-and-effect relationships of a particular type of alopecia have been determined, it is important to draw up the correct treatment protocol, taking into account the individual characteristics of the patient, his social activity and the financial side of the issue.

Basic techniques in the office of a cosmetologist-trichologist are:

• mesotherapy using multicomponent preparations with different rheological characteristics and compositions (peptides, nucleotides, vitamins, minerals, amino acids, hyaluronic acid);
• PRP therapy (use of autologous plasma).

Biologically active substances in the complex treatment of AGA and DTA

Biomimetic peptides. The life cycle of the hair follicle is regulated by growth factors (GFs). Currently, protein structures are known that are directly involved in biochemical reactions:

• epidermal growth factor (EGF);
• fibroblast growth factor (FGF);
• keratinocyte growth factor (KGF);
• insulin-like growth factor (IGF);
• vascular endothelial growth factor (VEGF);
• hepatocyte growth factor (HGF).

A special feature of PR is that the entire PR molecule does not participate in the process of cellular interaction, but only its part (active center). Taking this fact into account, scientists have synthesized biomimetic peptides (BPs) - compounds that are structurally similar to the active centers of FRs, have the characteristic properties of one or another FR, but are not such.

Biomimetic peptides stimulate the proliferation of fibroblasts and vascular endothelial cells, increase the life cycle of the hair, prolonging anagen and inhibiting the onset of the telogen phase.

Currently, the following compounds are known to inhibit the formation of hair follicles:

• BMP4 (Bone morphogenetic proteins) is a signaling protein that triggers a sequence of reactions that inhibit the formation of placode cells (hair follicle precursors), shortening their life cycle. Suppresses the processes of cell growth and differentiation by inhibiting the expression of matrix cell growth factors. Accelerates the transition of hair from the active growth phase to the subsequent catagen and telogen phases;
• DKK-1 (Dickkopf-related protein) is a factor in the death of hair follicle cells, a key protein in the pathogenesis of androgenetic alopecia, since DKK-1 increases the activity of 5-α-reductase and the transition of testosterone to its hydrogenated form, dihydrotestosterone. Increased levels of DKK-1 lead to suppression of angiogenesis, activation of apoptosis, and disruptions in the WNT/β-catenin hair growth signaling pathway.

Biomimetic peptides used for injection therapy are able to restore hair growth and structure by acting on the WNT/β-catenin signaling pathway, leveling the hyperactivity of BMP4 and DKK-1. The most prominent representatives are Oligopeptide-54, decapeptide-10, decapeptide-18, oligopeptide-42, octapeptide-2, octapeptide-11, oligopeptide-71, decapeptide-28.

Amino acids, vitamins, coenzymes. It is known that hair consists of keratin protein (78%), water (15%), lipids (6%), pigment (1%). Amino acids are the building blocks for any protein, so their presence in the formulas of mesotherapy drugs is an important aspect. No less important substances for restoring hair growth and structure are B vitamins, taking part in metabolic processes and being additional sources of energy for the hair follicle. Depending on the phase of the hair life cycle, the need of hair follicles for ATP changes (anagen is the most energy-consuming stage). Therefore, in addition to amino acids and vitamins, cells require coenzymes, which, along with the above substances, contribute to the production of all types of energy molecules: ATP, NAD, NADP, FAD, FMN.

Thus, complex therapy of the scalp using multicomponent drugs makes it possible to prolong the anagen phase and stimulate the growth of new hair.

The problem of hair loss, to varying degrees, can lead to the development of psychosocial maladjustment and a significant decrease in the quality of life. Therefore, it is important to carry out timely diagnosis and prescribe comprehensive treatment, which will be aimed primarily at eliminating etiological factors, restoring biochemical processes in the hair follicles, consolidating the results obtained and preventing relapse.