Psychotrichology: the relationship between stress and hair loss

Anna Khaldeeva , dermatologist, trichologist, cosmetologist, member of EHRS, UHRS, EADV, ATU, UADVK, president of the Association of Children with Alopecia Areata "Together in Harmony", founder of the dermatological space Derm Space (Ukraine)

Ekaterina Chaikovskaya , psychiatrist, narcologist, head of a healthcare institution, member of EPA, ISSUP, EDA, AUU, APPU (Ukraine)

Stress is a set of non-specific reactions of the body in response to the action of factors that violate its integrity (homeostasis) and can be life-threatening.

Depending on the type of stimulus (stressor), stress can be conditionally divided into physical and psychological. However, it is important to understand that, regardless of the type of stressor, the changes that occur in the body during its action occur in all systems and organs, since they are the result of cascade neurohormonal reactions aimed at the survival of the body in rapidly changing conditions.

"Fight or Flight"

For the first time the term "stress" was introduced by an American researcher, psychophysiologist Walter Bradford Cannon at the beginning of the 20th century. It was he who described the response to stress in the form of a “fight or flight” reaction, which quite accurately demonstrates what happens to the body when it encounters threatening stimuli [1].

The essence of this reaction is that in case of danger the body is mobilized as much as possible in order to either resist its influence (fight) or avoid it as soon as possible (flight).

The mechanism of this phenomenon is as follows: from the sense organs, information about the stimulus is transmitted to the central nervous system, as a result of which the hypothalamic-pituitary-adrenal system is activated: the hypothalamus produces releasing hormones that excite the pituitary gland, which, in turn, secretes tropic hormones that regulate activity from endocrine glands, namely the thyroid, adrenal glands and gonads. As a result, a large number of hormones are released, among which catecholamines are adrenaline and noradrenaline, their action is associated with most instantaneous reactions to stress. The main biological purpose of these hormones is the redistribution of blood circulation and the general stimulation of the body to resist stress factors. So, there is an acceleration of the heartbeat and an increase in blood pressure, spasm of peripheral vessels and vasodilation of skeletal muscles, hyperglycemia (increased blood sugar levels). These changes are aimed at improving the blood circulation of the muscles and providing them with energy for the upcoming struggle. At the same time, blood circulation and the functional activity of other systems and organs are inhibited and go into an energy-saving mode (inhibition of the peristalsis of the gastrointestinal tract and exocrine function of the digestive glands, tear and salivation, inhibition of the function of the gonads, etc.).

The central nervous system also responds to characteristic changes by suppressing hearing, smell, and other senses, while raising the pain threshold and narrowing visual perception (“tunnel vision”). All these changes are aimed at quick adaptation of the body and response to a threatening factor by one of the two available methods - fight or escape - and are effective in confronting life-threatening situations [2].

However, such reactions require a significant mobilization of resources and are quite exhausting for an organism that needs restoration and accumulation of energy after the elimination of the threat to existence. Therefore, if the action of the stimulus does not stop or the stressful situation is repeated at a rate exceeding the time spent by the body on recovery, this will inevitably lead to disorders associated with the exhaustion of its systems. At the same time, the spectrum of deterioration varies from mental disorders associated with stress to somatic diseases caused by immune and hormonal disorders.

In a situation of martial law, the population of Ukraine is affected by both acute stress caused by catastrophic events due to unprovoked Russian aggression, and chronic stress as a result of the long duration of the situation, forced movement within the territory of Ukraine and beyond its borders, separation from socially significant groups (family, community), loss of jobs, connections and confidence in the future. Therefore, the priority for doctors is to control the mental and physical condition, paying special attention to the first manifestations of diseases associated with stress.

Interaction of the nervous system and hair

How does stress affect the quality, growth and loss of hair? Clinically, stress can be a trigger in such trichological conditions as trichotilomania, trichoteiromania, alopecia areata, telogen, anagen, cicatricial alopecia and be a powerful impetus for inflammatory processes of the scalp skin: psoriasis, seborrheic dermatitis, folliculitis.

Let us mention embryology (derived from three embryolists) and note that the nervous tissue and the epidermis, namely the upper part of the hair follicle, originate from the neuroectoderm. This is an important point in the interaction of these two systems. Of the three main phases of hair growth (anagen, catagen and telogen), we will dwell on the anagen phase in more detail, because it is she who is of interest to our topic.

The anagen phase lasts from three to seven years and is characterized by active cell division in the hair follicle. The growth rate reaches 1.0-1.5 cm per month.

An additional factor influencing stress is a violation of the antioxidant system of the skin, as well as neuroendocrine regulation in the body, with a subsequent effect on the hair through cell division.

It is also known that the life cycle of hair is under the control of hormones. Stress as an action can change the neuroendocrine base. The hair follicle, together with the hair, is sensitive to changes in this background.

Effects of stress on hormones

In the work of the thyroid gland, TSH, T3, T4 are important. Thyroxine increases the vital activity of hair follicle cells, TSH changes the expression of most genes in hair follicle cells.

Prolactin is often referred to as the stress hormone. In the skin, it functions as an immunomodulatory stress response agent and also stimulates the production of adrenal androgens. Prolactin inhibits cell division in the hair follicle and induces apoptosis of keratinocytes.

Active hair loss is a common problem that occurs after stress.

Classification of psychodermatological disorders in dermatotrichology

Psychophysiological disorders are dermatological disorders that are activated against the background of stress. These diseases are characterized by a close relationship in time between the influence of stress and the exacerbation of trichological pathologies. These include psoriasis, atopic dermatitis, red scalp, seborrheic dermatitis, diffuse, anagen hair loss, alopecia areata, recently noted the effect of stress on the manifestation and acceleration of cicatricial alopecia.

Primary mental disorders (dermatosoid delusions, neurotic excoriations, obsessive-compulsive disorders, in particular trichotilomania, trichoteiromania)

This group includes patients who do not have trichological or dermatological pathology. Skin manifestations of the scalp are secondary. It is very important to ensure a multidisciplinary approach, namely, counseling together with a psychiatrist.

The choice of treatment in such cases is individual and depends on the diagnosis of the underlying disease, the severity of the manifestations and the tolerance of the patient. For example, FDA-approved drugs for obsessive-compulsive disorder (OCD) are clomipramine, fluoxetine, fluvoxamine, paroxetine, and sertraline (level 1). Due to their superior safety and tolerability profile, SSRIs compared to clomipramine are considered the first-line drugs of choice for OCD (Level 1). As a method of psychotherapy, CBT has the largest evidence base [3].

Secondary mental disorders

This is a group of patients in whom skin diseases are primary, and psychological manifestations arose against the background of dermatological manifestations.

Skin-sensory syndrome

These are patients who, without visible and obvious dermatological pathology, experience discomfort in the form of soreness of the scalp, "hair" - trichodynia, itching, dysasthesia, foreclosure, a feeling of pressure, running ants on the scalp.

With psychodermatological and psychotrichological manifestations, the dominant disorders are anxiety, psychosis, depression, obsessive-compulsive disorders. While psychotic conditions are an acute psychiatric pathology, often requiring complex and urgent inpatient treatment, therefore, such patients rarely come to the attention of a trichologist, people with anxiety and depressive disorders often turn to the issue of somatic diseases. Treatment of such disorders will improve not only the quality of life of the patient, but also the prognosis for trichological pathology. For the treatment of depressive disorders, SSRIs are prescribed - fluoxetine, citalopram, sertraline as first-line drugs (level 1) and mirtazapine, venlafaxine, tricyclic AD (level 1) as second-line drugs [4].

conclusions

The relevance of psychotrichology today is gaining momentum. A dermatologist, a trichologist should have an idea about the relationship between the dermis, hair and stress conditions that can flow into a serious trichological pathology.

A trichologist should be, first of all, a good psychologist, because it is the patients of the trichological sphere who get hair loss after a stress agent (today - stress from military operations in Ukraine). In the future, the patient falls into a chronic vicious circle: stress - hair loss - stress - hair loss ...

A trichologist can help break this cycle while enhancing the therapeutic effects of the treatment. The tandem of a trichologist and a psychiatrist in trichological pathology gives powerful effects and results in my practice. The main thing is to offer the patient a multidisciplinary approach correctly in the process of counseling.

Literature:

1. Cannon, WB Bodily Changes in Pine, Hunger, Fear and Rage (1915). – P. 211/

2. Guidelines for the study of the course "Integrative regulation of physiological functions" Compiled by: doc. biol. sciences, prof. V. P. Leshenko. - Dnieper. – 2018.

3. Practical Guidelines for the Treatment of Patients with Obsessive-Compulsive Disorder prepared by the American Psychiatric Association Working Group http://www.psychiatryonline.com/

4. UK National Institute for Health and Clinical Excellence guidelines for the treatment of depression in adults and the elderly https://www.nice.org.uk/guidance/ng222

5. M. Jafferans. Guide to psychodermatology. Basic and clinical aspects. Edited by: prof. A. Litus, Ph.D. A. Gavrilyuk. – 2020.