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- [00:03]
A
Welcome to chasing life. What if I told you that our hair is more than what we see in the mirror? It's something that can actually tell us a lot about our health. You see, hair loss and hair changes aren't just cosmetic. They can reflect real shifts in hormones and stress and nutrition and even other underlying health conditions. Here's the thing, most people naturally shed about 50 to 100 hairs a day. But sudden thinning, brittleness, graying, that can feel really alarming. And yet sometimes it's just completely normal. So the question then is, how do you know what hair changes are? Red flags, what's part of normal life? And what really does work if you want healthier hair, hair that is thicker and darker. What does healthy hair really mean? Today I'm talking with Dr. Maryanne Makridis Sena. She's a board certified dermatologist and associate professor at Harvard Medical School who specializes in hair and scalp health. Today we're going to talk about the different types of hair changes. Share some practical tips for keeping your hair and scalp healthy. And my personal favorite, we're going to bust some pretty big hair myths that you have probably heard. I'm Dr. Sanjay Gupta, CNN's chief medical correspondent and this is Chasing Life.
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A
I've been looking forward to this. I've been telling people that I was gonna be interviewing you. Everyone is interested in hair loss and I think some of it is, you know, frankly, just aesthetics and appearance. But a lot of it has to do with this idea that it may be a window into our health overall, which I just, I find really, really how did you become interested in this? What is your background?
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B
So, early on, in my dermatology residency training, we were seeing patients with all different types of skin conditions. And what stood out to me was how deeply affected the hair loss patients were. And I learned very quickly and early that while hair loss might not be life threatening, it's incredibly life altering for the people who experience it. And it sort of makes sense, right, because hair is so core to our identity. It's part of how we see ourselves. It's how we present ourselves to the world. And in evolutionary biology, hair is a sign of vitality, of health, of fitness. Right. And it can be very scary as a resident. Interestingly enough, I developed alopecia areata myself. And going through that experience was really important for me because I basically experienced what many of my patients were experiencing firsthand. Right. Feeling all of these things. And that really deepened sort of my empathy and my commitment to this space.
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A
So you had alopecia yourself?
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B
I did.
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A
What was the term you used specifically and what happened?
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B
So I was in residency, and I developed patches of alopecia areata on my scalp.
- [04:08]
A
Patches of baldness?
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B
Yes, exactly. So alopecia areata usually makes these round areas of hair loss where you basically have a complete bald patch. And one of mine was up towards the front. And so I had to become, right, really skilled at sort of, you know, combing it and doing it. And while I was fortunate in that it didn't progress to some of the more severe forms of alopecia areata, it still was tough to deal with.
- [04:36]
A
Your hair obviously looks great now. So do you know what was causing those bald patches for you and what did you do about it?
- [04:44]
B
Yeah. So, you know, this is a bit controversial, but in my case, I was a resident, right, Working, you know, at least 40 hours a week. I was pregnant with my first child, and I was having some pregnancy complications. There was a lot of stress that occurred at the time, and it was shortly after that that I noticed these bald patches occurring. And while, you know, there's varied evidence about how much stress impacts this type of hair loss, there are a good subset of patients of mine where I think stress does play a big role. You know, maybe there's a genetic predisposition where you might be a little bit more prone to autoimmune conditions like alopecia areata, but then you get sort of a second hit that makes it occur.
- [05:29]
A
The idea that it is so emotional for people. I mean, you know, one of the things that struck me as I was getting Ready to talk to you is close to 10% of patients with breast cancer may not undergo chemotherapy because of fear of hair loss. And I didn't really know what to do with that number. On one hand, I realized that hair loss is so significant. But the idea that people may not get their appropriate cancer treatments, I mean, that was really striking to me.
- [05:57]
B
Yeah, it's a very profound statistic and really highlights what we see in patients who struggle with various hair loss conditions. Say you have diabetes or you have a heart condition. These are all very stressful, potentially difficult conditions to deal with. But you don't have to share that with the public unless you choose to. When you deal with a hair loss condition, it's incredibly visible. People can see it right away. And having to share that and wear that on your sleeve and share your personal medical things with the public is very difficult for people.
- [06:39]
A
This is your area of expertise. So are you one of these people then, who sees somebody, immediately looks at their hair and makes some determination about them? I mean, again, if hair tells us so much about our health, what are you looking for?
- [06:53]
B
Yeah, so obviously it's when a patient comes into my clinic, probably the most important thing that we do is an extensive intake where we get their history. You know, when did this start? You know, how much of your hair do you think you've lost? Do you have scalp symptoms? What are your other medical conditions? Do you have diabetes? Do you have thyroid disease? Do you have anemia? Do you have eczema? Allergies? What's your typical diet like, how much sleep do you get? Do you have a family history of hair? It's like a five to seven page intake form, and we review that really carefully. We'll also get labs to figure out, you know, is there a nutritional deficiency or something else that's going on that can be corrected from a hormonal standpoint, for example. And then, you know, we do our examination after we get that history to try to determine what might be contributing and advise the patient from there. There are red flags, of course. So if people are having persist persistent burning of the scalp, itching of the scalp, redness, scaling that's persistent loss of sideburns, loss of eyebrows, loss of the beard area, patches of hair loss, these are things that typically suggest strongly an autoimmune form for hair loss. And those things need to, you know, really be addressed more aggressively. But in the vast majority of cases, if you do a proper workup, you can often provide people reassurance and therapies and other suggestions that can help.
- [08:27]
A
One of the things you just mentioned was a nutritional deficiency could potentially be associated with hair loss. I'm just wondering if you can contextualize that for us. So I have a woman who cuts my hair. She's an 80 year old Japanese woman. Her name is Junko, by the way. She listens to this podcast. So. Hi, Junko. But she'll always tell me that, hey, I think your diet's doing well. And coming up with these ideas as to what I might be deficient in. How important, I mean, we know having good nutrition is important, but how important is it to our hair? And what are we talking specifically here? How much of a difference can it make?
- [09:03]
B
Yeah, so it's a really important question. And what's so cool about the hair follicle, especially for hair nerds like me, is, you know, it's this intricate mini organ of the body. And in order to grow hair, well, so many different things have to happen correctly, right? So we have to have proper blood flow, we have to have proper nutrition, and we have to have the right balance of hormones. Right. There's probably other things that we're still learning about, but those three major things have to go right in order to grow hair. So when you ask about nutrition, the important things here, the most important things here are, you know, iron. So even if people are not anemic, we see that iron deficiency can be associated with thinning hair or increased shedding. We know that protein, you know, hair is basically protein, right? It's keratin. So if you're deficient in protein, that's the building block for the hair. And that can impact your ability to grow hair well. And then of course, vitamin D is important. And then in rare cases, we'll also check other things like zinc or copper. Also an important thing, and we ask this of our patients in the medical history, is ensuring that patients aren't yo yo dieting, dealing with issues like anorexia, bulimia, or limiting their diet in some way. Because these things can also disrupt the proper hair follicle cycling and lead to periods of over shedding and overall thinning.
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A
I had a doctor who was a urologist actually tell me, I'm in my mid-50s now, but I guess this was probably 10 years ago. Say, taking finasteride, a type of medication, would be good for both hair and prostate health. And this is just something he recommends, I think, to all of his patients. Fundamentally. Does that sort of thing make sense to you?
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B
Yeah. So finasteride is FDA approved as a treatment for hair Loss in men, it basically works by blocking the formation of dht, which is the main hormone, particularly in male hair thinning, that binds to the hair follicle and causes miniaturization, thinning and hair loss. So if you block your body's ability to make that dht, there's less DHT around to bind to the hair follicle, so you grow thicker hair. And it is true that those medications are also used in people who have benign prostate enlargement, even prostate cancer. The one caveat that I always tell male patients is that once you're at an age where you might be undergoing screening for prostate cancer, usually with a PSA blood test or prostate specific antigen, it's very important, particularly now with these direct to patient platforms where people might just be getting finasteride, not, you know, in their medical record, but from another supplier that you inform whoever's checking your PSA that you're on finasteride or dutasteride, which is in that same family, because it can falsely reduce the PSA value. So what can happen is, you know, if you have a falsely reduced PSA value, your doctor doesn't know you're on one of these drugs. It could, it could give the impression, you know, that you have a negative blood tests, when in fact there could be something going on with the prostate. So just very important to keep that in mind.
- [12:38]
A
Other downsides to doing this, I mean, the impression I was left with was basically he was saying that if you're a guy around that age, you should do this.
- [12:48]
B
Yeah. There are also some reports of it affecting mood, so leading to increased depression. This tends to be more common in people who have a personal or family history of depression. And then also there's something called gynecomastia that can occur in a small percentage of men where there can be increased volume to basically the breast tissue in men.
- [13:12]
A
And alopecia, you've used alopecia, sort of these patches of baldness. Telogen effluvium, is that a natural process? Is this something that we all go through?
- [13:21]
B
So alopecia is just synonymous with hair loss. Alopecia areata is the autoimmune form of hair loss. There are many things that can cause many reasons why people experience alopecia or hair loss. Telogen effluvium is one of them and the most common. So what happens in telogen effluvium is there is a trigger. The most common triggers are weight loss, thyroid dysfunction, or when patients have to have their thyroid dose, medication adjusted, stopping or Switching a hormonal medication that includes hormone replacement therapy, birth control pills, hormone eluding IUDs, entering menopause, pregnancy and delivery or miscarriage. And then finally a major physiologic or psychological stress. So a prolonged hospitalization. We saw a lot of hair loss from telogen effluvium with COVID 19, where everyone was losing their hair after getting sick. Or a major psychological stress rate. Not our day to day sort of stress, but something that really takes your breath away. Loss of a loved one, bad divorce, loss of a job. Three months later, your hair can go through a major shed. Basically those triggers that stress on the body causes the hair follicle to throw a bunch of hairs that should stay in the growth phase prematurely into the resting artillage phase. Three months later, you're shedding all of this hair that should have been staying on your head. And this is really upsetting for patients. It's happened to me several times. I know what's happening. And it's still devastating because you're just losing clumps of hair in the shower and you really believe you're going to go bald. After two or three months of shedding, though, your shedding goes back to normal and the hair regrows without any treatment at a centimeter a month. And for women who wear their hair long, it can take years to sort of have your ponytail back. People who wear their hair shorter will notice that they have their hair back to the way they like it sooner. But this is so distressing. And unfortunately, people with commercial interests know that it's distressing and will advertise all sorts of serums and potions and supplements and things to treat this type of hair loss, when in fact patients don't have to do anything at all. And so if there's one thing that I could shout from the rooftops to try to educate people, it's about telogen effluvium so that they're not sort of bamboozled by these things that they don't need.
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A
After the break, much more with Dr. Maryanne Macretta Senna. Stay with us. Get business done with the new American Express Graphite Business Cash unlimited card with unlimited 2% cash back on all eligible purchases. Unlimited 5% cash back on flights and prepaid hotels booked through American Express Travel online. And a flexible spending capacity that can grow with your business. You'll have the confidence to keep building. Apply today and earn a welcome offer of $1,500 cash back after you spend $50,000 in qualifying purchases on your new card within the first six months of card membership terms apply. Learn more at GOMX Graphite have you
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- [17:17]
A
What do you, you, you got your hair looks great. I'm looking at you. I'm seeing it beyond the obvious things, good diet and trying to reduce your stress, things like that. Are you taking supplements? Are you doing other things?
- [17:30]
B
I do not take supplements. I make sure that I have good iron, I make sure that I have a good diet, exercise, try to reduce stress when I can. But you know, there are medications that you can take. Oral low dose minoxidil has really been great and something that I myself started myself on as I'm approaching 50 now. And it's a great way to sort of reduce shedding and keep hairs in the growth phase. There's other medications that we can prescribe for patients in addition to low dose oral minoxidil that can also be helpful. So it depends on, you know, the degree of hair loss, what a patient's goals are, what's, what's contributing to the hair loss.
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A
You talked about the downsides of finasteride earlier. What about low dose minoxidil? You're taking it. Is that something people should consider taking if they're worried about this?
- [18:23]
B
Yeah. So low dose oral minoxidil has been great because it is not a hormonal medication. So the most common side effect that we see is about 10% or so of increased facial hair or body hair. Men tend to not really care or worry about this. And the small percentage of women who are affected, they either are so happy with what's going on in their scalp that they just manage the other stuff somehow, or we sometimes have to reduce or stop the medication if it's quite bothersome. Other serious cardiovascular side effects are incredibly rare at the low doses that we use. And there have been a number of papers, you know, showing the safety and efficacy of this.
- [19:05]
A
I mean, that's pretty interesting though, doctor, to hear that from you. The idea of low dose oral minoxidil, who shouldn't do this?
- [19:14]
B
I mean, certainly someone who has like heart Failure or a really, you know, strange or difficult to control arrhythmia, you know, but even in patients who have, like, mild atrial fibrillation or things like that, cardiologists feel pretty comfortable with giving it to them. It doesn't tend to reduce blood pressure at the doses that we give at 1.25, 2.5, but people whose blood pressure runs really low, or people who might be on other blood pressure medications, I'll usually tell them, you know, for the first week or two, you know, slowly go up to your goal dose and also monitor your blood pressure at home to make sure that, you know, it's staying within a good range. And then people who have that rare condition called pheochromocytoma, this is a very rare condition, also shouldn't take low dose oral minoxide. Finally, women who have polycystic ovary syndrome or maybe another sort of endocrine issue where they have at baseline, problems with increased body hair, increased facial hair, because minoxidil kind of boosts hair growth everywhere. You might want to, you know, just be mindful of using it in that patient population.
- [20:24]
A
What would people experience then if they took low dose? Obviously we're talking about hair growth, but how much and how quickly, what would they feel and see?
- [20:34]
B
Yep. So I've used this in patients of all ages, from teens all the way up to people in their 80s. And most people will notice a reduced shedding at around two months. Importantly at two months, that's when people, if they're worried about the hair in other places, in unwanted places, that's when they know where they're sort of going to land with that. And it tends to plateau unless you increase the dose. Ok, so by two months, you sort of know where the unwanted hair issue is going to be, if it's gonna be there at all. You notice reduction in shedding. And then usually I'll bring patients back at six months or eight months, and at that point we'll start to see some considerable regrowth. And we usually will compare before and after photos that are standardized. And it can be really impressive.
- [21:25]
A
And if people have, they don't have alopecia, they don't have areas that are specific of hair loss, and they just start taking low doses oral minoxidil. Would it just make their hair thicker or what would it do for them?
- [21:37]
B
Yeah, it probably would make their hair grow in thicker, maybe a little bit faster. And also a lot of people, even with mild hair thinning or strong family history of hair thinning, will use it in sort of a preventative manner. It doesn't halt completely the progression of hair thinning, but it can sort of slow it for people.
- [21:58]
A
It's fascinating. I truly learned something from you.
- [22:02]
B
Oh, that's great. That makes me happy.
- [22:04]
A
Just a couple minutes of myth busting, if you don't mind. And I think I know, based on what you've already said, how you're going to answer some of these questions. But supplements, you already said you don't take any. But just talk about biotin for a second. It gets a lot of attention. I think a lot of people, even within salons, talk about biotin. It's in a lot of products. Yay. Or nay? What's your feeling on it?
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B
If I could figure out where the biotin and hair story came from, I would be very happy. I don't know where it came from. I mean, biotin. So if you don't have a deficiency and you're taking all these supplements, you're basically just making expensive urine. The concern with biotin is, number one, there are no biotin monotherapy studies that have shown any impact on hair, number one. And number two, the concern is that patients, if they're just dying to take it, even if there's no evidence, they need to be aware that it can interfere with a number of laboratory tests. And these are important tests. So your thyroid function test, it can falsely lower those results. It can even falsely alter HIV in pregnancy testing or labs that you get in the emergency room if they're worried about you having heart attack or heart strain known as cardiac troponins. So the important thing is if you still just want to take biotin, even though it doesn't really work, you need to know that you need to stop it at least several days before any type of blood testing so that it doesn't interfere with the lab and give you results that you cannot rely on.
- [23:36]
A
Okay, let me pause here for a second because I think this is important. You need to remember that supplements are not regulated by the FDA in the same way drugs are. So what that means is those fancy multi ingredient hair loss supplements, I'm talking about some of the really expensive ones that you think probably are going to work or at a minimum, are safe to take. Well, number one, they might not work at all. And number two, they might not even contain what they claim. And in some cases, they can include additional ingredients or contaminants, and those can be dangerous.
- [24:12]
B
When we started off in medical school, right, we took a Hippocratic oath. First, do no harm and there's two ways that you can harm people with supplements potentially. The first is their wallet. Right. And the second is with their health. And so many of these multi ingredient supplements have very high doses of things like green tea extract, ashwagandha curcumin, turmeric that have been linked in rare cases, but have been linked in healthy people with elevation in the liver, blood tests, and even drug induced liver injury. And this is really important because not only have studies shown in men, right. That there was no difference between those who took a supplement or took placebo, a sugar pill, in hair growth. Okay. So the supplement didn't work. And then in women, they grew like seven little hairs in an area. Right. Topical minoxidil does three times that amount in the same amount of time. They're costly. And these are not regulated. They have low quality evidence at best and potentially could impact your health. And, you know, these drug induced liver injury cases have tripled since 2004 from like 7% to like 20%. And 20% of those cases have been linked to supplements. Not all hair supplements. But it's important that, you know, consumers are aware that not only is there not good evidence for the use of these in hair loss, but there are also potential risks. While rare, it's not like you can just take it and like nothing happens.
- [25:55]
A
Certainly doesn't have the evidence behind it. Like some of these FDA approved therapies like minoxidil as a low oral dose, for example. What about things like red light therapy? I've seen people wear these caps now with red light who are worried about their hair loss.
- [26:10]
B
Yeah. So there is actually data for red light therapies. So they did six month studies both in men and women. They tattooed a spot on the scalp and did hair counts. So they take a camera and they take hair counts and they look to see how many new hairs do you get after the treatment. And they had half the patients on these trials use the actual red light they use. They had the other half using a light device, but it was a sham device. Right. So it wasn't the actual light device. And at the end of the six months of using the light device or the sham, three times a week, they saw that the active light group actually had about 20 new hairs in a centimeter squared, which is pretty good. And that was much more than the sham light device. So there is data that it works. The important thing though is that the light reaches the scalp. So if you have really dense hair, particularly dark and dense hair, the light may be getting absorbed by your hair and not reaching the scalp where it needs to be. But there is data that these can be helpful.
- [27:14]
A
Your hair routine. I'm just curious. Shampoo it every day. How often do you shampoo? How often do you condition?
- [27:22]
B
So this is a question that gets asked all the time and it really depends upon the texture of your hair. So people who have really curly hair, that hair tends to run drier than people who have straight hair like mine. So the texture of the hair is really important. Washing your hair more frequently, if your scalp runs oily, could potentially dry out your hair a little bit. But if you're using a good conditioner, it's probably fine. But now people who have curlier hair or sort of like more afro textured hair, they tend to not have to wash their hair as frequently. So people with thick or curly hair, it can be very drying if you're washing your hair with that frequency. So sometimes they only have to wash their hair once a week. So it's sort of dependent on the texture of your hair and how oily your scalp is. But at least once a week and up to three times a week tends to be the range that most people fall in.
- [28:19]
A
Do you think it's just always going to be a part of our human existence to, as we age, have our hair become thinner and grayer? Is that just the human story?
- [28:30]
B
I don't think that's what we want the human story to be. I think, you know, the more that we learn about our bodies and the more we look to take care of ourselves and be more preventative than reactive with our health, you know, and the more science moves forward, you know, my hope is that we'll be able to avoid some of these things, but in a safe and meaningful way. We're not right there right now. We do have treatments that can help and certainly starting treatment earlier rather than later is always a good idea. But you know, so much has happened in just like my 15 years of being involved in this space that I can only imagine the next 15 years.
- [29:13]
A
That was Dr. Maryanne Makrida Senna, a board certified dermatologist and assistant professor at Harvard Medical School. Thanks so much for listening.
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B
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