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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES Programme no. 7 - Hair
RADIO 4
TX DATE: TUESDAY 9TH SEPTEMBER 2008 2100-2130
PRESENTER: MARK PORTER
CONTRIBUTORS: VALERIE RANDALL
ANDREW MESSENGER
MARK DAVIS
EMMA MARGRAVE
PRODUCER: PAULA MCGRATH
NOT CHECKED AS BROADCAST
PORTER
Hello. Today's programme is all about hair. Like all the men in my family I'm blessed with an unruly thatch that shows little sign of thinning. But families like ours are the exception rather than the rule. Most men, and quite a few women, will have noticeable thinning by the time they reach their late 40s, a process that for many will start in their early 20s. I'll be learning more about the genetics behind going bald and reviewing the latest treatments available for both sexes. I'll also be crossing over to the States to find out what really causes dandruff. And Barbara Myers visits the Royal Marsden to learn about what can be done to prevent hair loss in patients undergoing chemotherapy.
CLIP
When you've got something like cancer and you have to have chemotherapy, which is a very nasty thing, it's important that you try and live as normal a life as possible. And having hair helps you do that.
PORTER
My guest today is Professor Val Randall, she's from the Centre for Skin Sciences at the University of Bradford. Val, let's start with the classic age related hair loss in men, so called male pattern baldness. Why is it that some men manage to hang on to their hair and others lose their hair as early as their late teens and 20s?
RANDALL
Well mainly it's their genetic background, what they've inherited from their parents.
PORTER
And we all know that hair loss tends to run in families but what are they inheriting genetically?
RANDALL
A sensitivity to the hormones which circulate in a man's body which will make the hair follicles replace the hair with a smaller, finer and less coloured one.
PORTER
You often hear of this association with the male hormone androgens or testosterone and of course the understanding amongst bald men is that they produce more testosterone than other men, they're more virile. Is that the case, are they producing an excess of these hormones?
RANDALL
I'm afraid not. The sort of classic - are bald men sexy - question isn't actually true. They do have to have normal levels of androgens to go bald, so they won't go bald if for some reason they are castrated. As long as they have normal levels of androgens they will go bald if that's their inherited tendency.
PORTER
So you need the male hormone to go bald and they're inheriting some sort of sensitivity, the hair follicles have got some sort of over sensitivity. What's actually happening at the microscopic level, what happens to the hair?
RANDALL
The thing about androgen action hormones affecting the hair follicle is it varies depending on which part of the body the hair is in. So the same hormone which takes the hair away from the head has no effect on the eyelashes but stimulates the hair on the face. So androgens are stimulating the beard, no effect on the eyelashes, and causing balding - the exact opposite to growing a beard on the scalp. And that's because the response is that which happens within the hair follicle and each hair follicle is different depending on where it is in the body. That's the basis of the treatment of hair transplanting - taking the hair from the back of the neck, which is not sensitive to androgens, and putting it on the top of the scalp where the other hair follicles aren't making smaller hairs in response to their effect of androgens.
PORTER
But unfortunately the follicles on the scalp are sensitive to those androgens, we'll be coming back to the treatment in a moment Valerie. But first, as I said earlier, it's not just men who lose their hair as they get older, women often suffer too. At least one in 20 British women will experience significant hair loss by their late 40s, rising to one in three by the age of 70. Andrew Messenger is a consultant dermatologist at the Royal Hallamshire Hospital in Sheffield and he's leading a team that's investigating the genetics of female pattern hair loss.
MESSENGER
There are some differences from male hair loss, one of them being it's usually nowhere near as severe and the pattern is rather different from what we see in men but nevertheless it's still a fairly frequent occurrence.
PORTER
The classic pattern for men is the receding hairline, the ever expanding crown, I think most people are familiar with that but what sort of pattern would you expect to see in women?
MESSENGER
Women tend to show a more diffuse pattern where there's a reduction in hair density across the scalp. Now although that tends to be most pronounced on the top and front of the scalp it's not at all unusual to see the entire scalp being involved, including the back of the scalp which is usually spared in men. And also women tend to retain their frontal hair line, so they don't show the recession that you commonly associate with male balding.
PORTER
And at what sort of age might it start to cause trouble?
MESSENGER
Female pattern hair loss can start at any age, really following puberty. I fairly frequently see women in their teens and their 20s. I would say most women probably starting somewhere between the age of 30 and 50.
PORTER
Andrew, if a woman comes to see me in the surgery and she has generalised thinning, most noticeable on top of the head, I suspect that this may be age related female type hair loss but I want to exclude some underlying cause that's easily remedied, such as a deficiency of some sort, what sort of thing should I be looking for?
MESSENGER
Thyroid deficiency is traditionally associated with hair loss, though I have to say I don't see this very often. The other thing I would look for is evidence of excessive levels of testosterone, these may be manifested by alteration in menstruation, by increased hair growth on the face, for example.
PORTER
Now assuming you don't find any of those and the women is distressed by her hair loss is there anything that we can do to help her?
MESSENGER
I think an explanation of what's going on and what the future holds is an important part of the consultation. I think explaining that this is a natural process and it's not a manifestation of any serious underlying disorder, for some women that's all they want to know but there are some women who would like to be treated and there are some treatments available, although none of them are wonderful.
PORTER
And what would you start with?
MESSENGER
I would start with Minoxidil lotion which is at the moment the only licensed treatment for female hair loss.
PORTER
And that's used to treat male pattern loss as well.
MESSENGER
It is yes.
PORTER
And it's working how?
MESSENGER
Well we don't really know. There is some evidence that it works by opening what are called potassium channels in cell membranes but how that results in an increase in hair growth is not yet understood.
PORTER
So if I send my patients off with Minoxidil what sort of success rate can they expect?
MESSENGER
I think it depends on how severe the hair loss is. If you've got someone with severe hair loss you really cannot expect to reverse that. If you have very early hair loss then the results can be quite good and it may be possible to get back to almost normal hair density.
PORTER
What happens if you stop using it?
MESSENGER
If you stop using it within six to 12 months you will be back where you would have been if you had never used it at all.
PORTER
What if you're one of the women that doesn't respond well to Minoxidil is there anything else that we can use?
MESSENGER
Some people use drugs which block testosterone. There isn't much published clinical trial evidence to support their use but they are nevertheless quite widely used.
PORTER
And the anti-testosterone drugs - I'm thinking there's types of the pill for instance, contraceptive pill, would that be an option for use in younger women?
MESSENGER
Yes that would, the pill containing a drug called Cyproterone acetate has been used, usually with some extra cyproteronastoid [phon.], it's generally felt that there's not enough in the oral contraceptive pill.
PORTER
And what about the evidence that that works?
MESSENGER
There's really only one clinical trial which was done in Paris where they were able to show that cyrpoterone acetate stimulated hair growth in a group of women with hair loss who had menstrual abnormalities but not in those who had normal menstruation.
PORTER
And Andrew where are we in our understanding of the genetics of female hair loss, I mean is it the same set of genes that are causing problems in men?
MESSENGER
If your father is bald you have got about an 80% chance that you will go the same way by say the age of 50. Whereas if your father is non-bald you've only got a 20% chance. The role of the mother in male balding is really not at all clear at the moment. Whereas in female hair loss it's very common to see hair loss running through the female side of the family, so to see mother and her mother, sometimes sister affected.
PORTER
So Andrew what are you actually doing to investigate the genes involved?
MESSENGER
Well we've already done a fairly large study on family histories in both men and women. We've now moved on to collecting blood samples in order to extract the DNA from women with hair loss, from women and their families, with the intention of looking for the genes once we have established a sufficient bank of DNA.
PORTER
Andrew Messenger talking to me earlier from our studio in Sheffield. Andrew and his team are still recruiting women for that genetic study so if you're interested in joining it then our action line has the details on 0800 044 044.
You're listening to Case Notes, I'm Dr Mark Porter and I'm discussing hair related issues with my guest Professor Val Randall.
Val, I want to pick up on the treatments that Andrew mentioned there in a moment but first if we're going to talk about women and hair loss we should mention the impact of pregnancy shouldn't we.
RANDALL
Oh absolutely. During pregnancy they feel that their hair is beautiful and lovely and thick but after the baby is born within about three months they often complain that they've lost a lot of hair and they feel it's all coming out.
PORTER
What's actually happening?
RANDALL
Well what's happening is that the hair is regenerated and it has periods of growing to make the hair and then it may go into a period of rest where it just stays there until the next hair is produced and its shed. And what happens is during pregnancy all the hairs stay in the growing period and at the end of pregnancy the hormonal change means that a lot of them go into the shedding phase at the same time and so we notice it. And this can be particularly noticeable if the baby was born in the summer because we already have a seasonal change in the amount of hair that we shed from the scalp, so that around this time of the year - September, October - just like the leaves on the tree we are actually dropping more of our hair. Normally you would lose between 50-100 and that can increase quite a lot, just around this time.
PORTER
Let's go back to some of the treatments that Andrew was talking about there. Minoxidil, this is available over the counter, it's the most common product used. How effective do you think it is?
RANDALL
As Andrew Messenger said it depends on the extent and length of time that a person has had hair loss. The normal figures are about 30% of effectiveness in male pattern baldness, more effective when people are less advanced in their disorder. How it works is somewhat unclear because it was originally designed as a treatment for blood pressure.
PORTER
Yes they noticed the hair growth as a side effect didn't they.
RANDALL
Absolutely. And in my lab we have recently been working on how its worked, even though we've been using this treatment for 20 years or more, people haven't understood and we have found that they do have the channels that Andrew was referring to within the hair follicles, the human hair follicles, and in isolated culture we can make Minoxidil stimulate hair follicle growth.
PORTER
One of the other treatments - prescription only treatment - Finasteride, Propecia - we know how that works, that's working on the hormonal side that we've already alluded to, could you explain that a little bit more?
RANDALL
Yes. Androgens, male sex hormones, are carried in the blood and they can enter any cell in the body. The only cells which will respond to those are ones with the appropriate receptor, which says there's the hormone and tells the cell to do something. Testosterone is the main hormone that goes around in the male body ...
PORTER
But women have it too as well.
RANDALL
Women do have it, they have lower levels and they have levels of weaker androgens as well, these are produced by a gland called the adrenal gland and the ovaries to some extent. When the androgens - testosterone - is in the blood and enters the cell it can be metabolised to a stronger androgen, a more potent form, called dihydrotestosterone. And Finasteride blocks that step, so therefore it means that the androgens that are available to the cell are weaker ones and many of the cells are unable to respond to the weaker androgens, they need to have the more active form so that they can have that change.
PORTER
Val, I want to leave hair loss there for the moment and move on to another common complaint affecting the scalp, albeit not so serious, that of dandruff. It may seem a trivial condition but UK consumers spend millions of pounds trying to get rid of it, so what actually causes dandruff and what should you do or use to get rid of it? Mark Davis is professor of dermatology at the prestigious Mayo Clinic in Minnesota and I started by asking him where the unsightly flakes come from.
DAVIS
Well that's the excessive scale from the skin in the condition of seborrhoeic dermatitis which is the medical term for dandruff essentially. The skin becomes slightly inflamed on the scalp and when the skin is inflamed then the flakes develop.
PORTER
So it's essentially bits of excess skin that are drying and falling off.
DAVIS
That's right yeah.
PORTER
And what's gone wrong to cause that process?
DAVIS
Well what has happened is that the skin of the scalp has become inflamed. It's been demonstrated that the skin of the scalp is a little bit more oily than the other areas of skin and that provides an ideal environment for a very specific type of fungus to proliferate in the skin which actually causes inflammation and then with the inflammation the scale becomes apparent on the skin and then you see these white flecks coming off.
PORTER
So dandruff is essentially, what you're saying, a fungal infection?
DAVIS
Well yes it's in part a fungal infection which is very specific to the scalp and that's been increasingly demonstrated in some recent studies.
PORTER
Looking at the type of people that get dandruff, it's something that I tend to associate as a family doctor with teenagers in particular, is that because their scalps tend to be more greasy?
DAVIS
Yes, I mean it essentially is and that provides an ideal environment for the fungus to grow in that oil.
PORTER
So is it hygiene related, if you wash your hair more often are you removing the grease and therefore making it a less friendly environment for this fungus?
DAVIS
Well I think that that is absolutely correct and one of the main strategies for getting dandruff under control is to tell people to shampoo their scalp more often, so you're basically washing off the oil that is providing that environment for the fungus. So I always tell any patients that I have with dandruff that just simply washing their hair more frequently, for example every day or every second day, alone can vastly decrease the amount of dandruff they're experiencing.
PORTER
What do we know about the fungus?
DAVIS
Well it's a specific type of fungus that likes to live in this oily type of environment that's provided in the scalp. And it's called Malassezia species. And there was one type of subset of that that was thought to be traditionally the cause of dandruff but recently some genetic studies have demonstrated that there's seven or eight different species that can live in the scalp and there's two of them that hadn't previously been identified that are the actual cause. But I think that's more of an academic argument essentially we know that it's a Malassezia type of fungus which is a medical type of fungus that causes this problem.
PORTER
And is this a fungus that lives on our bodies normally or is it something that you catch?
DAVIS
No, no it lives on the scalp normally, it's almost universal on the scalp but it just has more of an opportunity to flourish on an oily scalp.
PORTER
And how would a professor of dermatology get rid of it - if you had dandruff yourself what would you do?
DAVIS
Well first of all I'd make sure that I was washing my scalp every day with a shampoo. In the initial stages that doesn't necessarily have to be a dandruff shampoo, just trying any shampoo. If that isn't working then I'd move to one that is a dandruff - specifically dandruff shampoo that has been shown to inhibit this fungus and that would be any of the shampoos that contain, for example, zinc, pyrithione, there's a lot of different makes that have that and you can see them in the supermarket. That works for the vast majority of people. And then finally if patients are really having a very itchy scalp in association with this flaking we'd give them a prescription for a cortical steroid to settle down the inflammation. But I think the principle thing is to increase the frequency of the scalp shampooing. And when putting in the shampoo on the scalp make sure you leave it on for a few minutes before you wash it out, there's no point in putting on shampoo and just leaving it on for a couple of seconds, you have to leave it in contact with your scalp for up to say a minute or so before washing it out.
PORTER
Professor Mark Davis talking to me earlier on the phone from the Mayo Clinic.
My studio guest today is Professor Val Randall. Val, a subject closer to my heart now, that of greying, why does our hair turn grey, indeed why is it coloured in the first place?
RANDALL
The hair is coloured because it has pigment in it, in the actual dead part of the hair, which is everything that comes out of the skin. And the pigment is the same pigment called melanin that is in your skin and is stimulated when you have sunlight on it. The pigment is put into the base of the hair bulb in the bottom of the hair follicle right deep in your skin as the cells are dividing by cells called melanocytes. When you're greying the melanocytes stop transferring the pigment into the follicle as it's being made to the same extent and therefore you get a paler hair. And eventually they stop functioning altogether and you get then a white hair.
PORTER
So it's not so much that our hair turns grey it's just that it loses its natural colour.
RANDALL
Absolutely.
PORTER
And why does that happen earlier in some people than in others?
RANDALL
I think again we're talking about genetics. I mean it happens in most people by the age - mid 30s, it starts earliest around the sides of the temples and then spreads over the top of the head and eventually gets to the back. And the normal rule of thumb is that 50% of Caucasians have 50% grey by the time they are 50.
PORTER
Thank you Val.
Now one of the most distressing forms of hair loss is the type that so often follows chemotherapy treatment for cancer. The hair follicle is particularly sensitive to chemotherapy so hair loss is a common side effect. Although not all types of chemo cause hair loss most do. But it's not inevitable, thanks to the cold cap, a device that cools the scalp while the patient receives an infusion of chemo. The cooler the scalp the lower the blood flow to the hair follicles and the less the amount of drug that reaches them. A simple but very effective solution, albeit one that doesn't work for all women or with all types of chemo.
Barbara Myers went along to the Royal Marsden Hospital in Sutton to see the cold cap in use and meet Linda Allpress who's hoping it will protect her hair for the second time.
ALLPRESS
I was first diagnosed seven years ago with breast cancer and I had a mastectomy and reconstruction at the same time which was very successful. But I had chemotherapy afterwards for almost four months, just to kill off any remaining cancer cells. I knew that the drugs they were using would cause hair loss and so I opted to have scalp cooling. What it meant was having ice cold bandages wrapped round my head and then an ice helmet put on my head and that stayed on for the duration of the treatment which was about an hour and a half.
MYERS
And did it work, did it help save your hair?
ALLPRESS
It was partly successful. I did have quite a lot of hair loss, when I was washing my hair quite a lot of hair came out in one go from the crown of my head which was a bit depressing. But thereafter I just had normal shedding, of course the hair wasn't growing so gradually the hair did get thinner but I thought it was worth it.
MYERS
Now fast forward seven years and here we are at the Royal Marsden, you're being treated for the same problem?
ALLPRESS
It's secondary breast cancer which is the name they give to cancer after you've had the main operation, if it comes back it's secondary breast cancer.
MYERS
And while the chemotherapy's going on again you've opted to have the cold cap therapy, talk me through it this time.
ALLPRESS
Well it's a lot lighter for one thing, the ice hat was very, very heavy, not surprisingly. This time round I'm having a gel filled riding hat, I mean I think that's probably how I would describe it because it does look like a riding hat. And it's put on my head about 20 minutes or so before I start the chemo and the purpose is to shrink the veins in my head so that the chemo drugs can't get through and affect the hair follicles.
NURSE
Okay then Linda. So I've got your hat here. That has been in the freezer stored between minus 28 degrees Celsius and minus 32 degrees Celsius so it will be cold when it goes on your head. Okay are you ready? Just pulling the hat on and just making sure that it's actually sitting on Linda's head, so that it's actually got contact. Does that feel like it's in contact everywhere?
ALLPRESS
Yes that's okay yeah.
NURSE
And I've just got some pads to go over Linda's ears, to protect her ears from the severe cold.
ALLPRESS
Yes the ears do get very cold, you notice it when it's all over.
NURSE
Do you feel like you need any other padding on your forehead or are you okay? Right and now the elastic hat to go over the top, if you can hold that by your forehead, it's just pulled over like a swimming hat. Just to make sure that it is really nice and secure. How's that feel?
ALLPRESS
Delightful.
NURSE
You look wonderful. Okay? So in 15 minutes time we'll be able to start your paclataxel.
ALLPRESS
Okay right.
NURSE
Okay?
MYERS
Because Linda has breast cancer, which is being treated with Taxol, she's an ideal candidate for the cold cap. But it is only suitable for certain cancers being treated with certain chemo drugs and even then it doesn't always work. Senior staff nurse Emma Margrave explains.
MARGRAVE
It's a really individual thing. Anybody who's - well chemotherapy and its side effects are very individual and scalp cooling is similar in that sense, so it's very difficult to predict, you can't look at someone's hair and say you're going to be a good candidate for scalp cooling. It's - for the people it works for it can be very, very effective, in fact to the point where you might look at somebody and it will have thinned but you would and look think no that - it looks like a good head of hair. You get very clear indication at about six weeks into treatment whether somebody's going to have a successful time and if they've got beyond six weeks and they've held on to enough hair for us to continue scalp cooling then we would be optimistic that we can successfully scalp cool them for the whole of their treatment.
MYERS
How important do you get the impression it is for most women and some men to keep their hair whilst they go through this treatment for obviously a life threatening disease?
MARGRAVE
I think it's hugely important. It's one of the most external signs that somebody's having treatment, it's one of the things that people can't hide, a lot of the time people are trying to sort of keep the illusion, if nothing else, that everything's normal. There are lots of deep issues they say about people knowing, people who want to work through their treatments or who have small children who don't want to explain why mummy's got no hair or even don't want to tell their parents, you know there can be a whole myriad of things that govern why they want to keep their hair which do go much deeper than vanity.
MYERS
There are many different reasons for wanting to try to save your hair but it can be quite a struggle. Linda is having chemo once a week for six months and she'll have to have the cap fitted every single time.
ALLPRESS
After the initial shock of having the cold cap you do get used to it, it's not the pleasantist experience I've ever had but it's not too bad, it's bearable and I think you have to think about what the outcome will be and if it means that I can walk around with a reasonable head of hair then two and a bit hours discomfort is neither here nor there frankly.
PORTER
Linda Allpress talking to Barbara Myers at the Royal Marsden Hospital.
And we've had an e-mail from listener Wendy Nordiman who when she heard we were doing this item wanted us to highlight the Headstrong Service. It's organised by Breast Cancer Care and offers free advice and support for women who've lost their hair as a result of treatment and there's a link to Headstrong on our website.
Val, back to less sinister causes of hair loss. Let's turn our attention to the future and perhaps the holy grail of the hair business. Is a cure for age related male and female hair loss a real proposition?
RANDALL
That's a very difficult question. As we heard there in that extract from the Marsden there has already been changes just in that area over seven years, we are finding out a lot more about how the hair follicle works and in understanding how the disorders actually progress and as a result of that we are able to understand more how things happen within cells and that is allowing us to understand a little more and be able to develop further things. And this is of course how Finasteride came into action, because we understood how the androgens work inside the cell. We've now moved further down the system from just the receptor to things that happen after the receptor activation within the cell and being able to look at those we may be able to prevent some of those next steps occurring and that would be more selective. One of the problems with treating any hormonal disorder with an anti-hormone treatment is that it's not selective to that particular tissue, so, for example, the Finasteride was first developed for the prostate and is now used particularly for the hair follicle, therefore understanding how these things will act may well allow us to bring something which will only affect the hair follicle.
PORTER
Professor Valerie Randall thank you very much, we must leave it there.
Don't forget you can hear any part of the programme again by clicking on the listen again button on the website at bbc.co.uk/radio4 where you will also find the hair loss study and Headstrong contacts I mentioned earlier. And if you don't have access to the internet you can call the Radio 4 action line on 0800 044 044.
Next week's programme will be devoted to the human papilloma virus, HPV, responsible for everything from verrucas and genital warts to cancers of the mouth and cervix. What impact will the cervical cancer vaccine have on the smear programme and might older women benefit from the protection it offers, even if they have to pay for the jab themselves? Just two of the questions we'll be answering next week.
ENDS
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