We have all, at one point in time, dealt with excessive hair fall that alarmed us enough to either self treat with DIY/home remedies or to seek a dermatologist’s opinion.
Let us understand the normal physiological process that our hair goes through which is called “Hair cycle”.
Hair cycle is divided into 3 main phases :
Anagen (90% of the hair are in this active growing phase ) which proceeds to:
Catagen (resting phase), which then progress to :
Telogen (regressing phase)–> the hair then eventually falls out (exogen) as the hair follicle enters a new anagen phase.
As you can see that as new hair grows, the existing hair in that particular hair follicle has to fall out. So hair fall should not necessarily alarming, and this normal hair shedding is seen to be 50-100/day and in some individuals it could be upto 150/day as well.
When to seek a dermatologist’s opinion?
When the hair fall exceeds what was mentioned above, or you start noticing recession of the hair line or thinning of hair in crown (in men), thinning of the hair and a more visible scalp along the part line (in females), or patches of hair loss.
Common causes of hair loss:
1. Telogen effluvium: Presents with a more diffuse hair loss of >150/day. Occurs 2-4 months after any systemic illness such as infections (malaria, typhoid etc), childbirth, surgeries, crash diet, thyroid disorders, psychological stress etc.
The condition is completely reversible and the hair loss starts improving in 4-6 months once the underlying factor is corrected.
2. Androgenetic alopecia ( also called male pattern baldness or female pattern baldness in men & women respectively due to the characteristic pattern of hair loss). It is genetic disorder, in which susceptible hair follicles either have a higher response to the hormone testosterone, or have a higher amount/activity of the enzyme ( 5 alpha reductase) which converts testosterone into a more active form.
This result is the normal terminal hair (thick , black scalp hair) is transformed into vellus hair (thin, fine, light coloured hair mostly found in other parts of our body).
The overall effect is gradual thinning of hair. The disorder can be inherited from either maternal or paternal side
3. Traction alopecia:
Caused by the excessive constant stretching of the hair shaft from hair styling such as tight braids/ ponytails
4. Alopecia areata: Considered an autoimmne disease normally seen in children and presenting with localised patches of hair loss, rarely it can affect adults and be of a more diffuse nature.
There are more causes of hair loss, but the ones mentioned above are the commonest ones experienced by individuals.
Treatment for the different types of hair loss may vary with some requiring no specific treatment at all such a telogen effluvium whereas others have specific therapy such as alopecia areata and androgenetic alopecia.
Continuing my hair care series, I thought this topic is definitely worth writing about. Biotin (vitamin B7) supplements has been widely popularised for the treatment of hair fall and thinning hair. It’s promised to help grow long, thick, luscious hair and for healthy nails as well.
But is there a rational scientific evidence behind this popular trend?
I’m here to discuss the science (or more like the lack of it) behind the use of biotin supplements for hair loss.
What is biotin?
Biotin is a water soluble vitamin, and functions as a co-factor for various enzymes responsible for energy production in our body. Being water soluble means it does not get stored in the body and is excreted in the urine via the kidneys. So chances of toxicity from over consumption of biotin is minimal and so far there has not been any adverse effects from biotin supplementation. This being said, biotin supplementations for general well being or for healthy nails and hair is still not justified!!
The recommended daily allowance of biotin is 30 µg per day.
And we meet this requirement adequately from our diet.
If less is good, is more better?
from my dermatology text book
My answer to this question when it comes to nutrients for our body, is NO!! More is definitely not better and more is actually un necessary.
So why is biotin heavily popularised?
Few reported cases of biotinase (an enzyme required for recycling biotin in our body) deficiency was reported in infants and children who inherited the disease due to genetic mutations. It was noted that few of these cases had alopecia (hair loss) with or without brittle nails. Biotin helped improve the hair and nail changes in these cases.
Thus stemmed the popular trend of biotin supplements for hair fall or nail disorders.There is no regulation on vitamin supplementation production, hence pharmaceutical companies take advantage of this and advertise and market biotin supplements as a saviour for hair loss.
Note: in these cases describes above, biotin was a treatment of choice because they lacked biotin in their body.
Biotin deficiency in general population is very rare as we get adequate amounts from our diet. Supplementation of high doses (500-1000 µg/ day when the required amount is only ~ 30 µg/ day) is highly unjustified.
The few rare instances when a person can develop biotin deficiency are:
So does biotin also improve hair loss in healthy individuals without its deficiency?
There has never been any scientific study on the effectiveness of biotin for the treatment of hair loss in healthy individuals.
A study on 541 women with hair loss, showed that only 38% of these individuals had biotin deficiency of which 11% had histories on being on long term medications that can cause biotin deficiency and 35% of these women also had co-existing skin condition called seborrheic dermatitis, which shows that in individuals with hair loss, majority had normal levels of biotin and supplementation was un-necessary.
Even lab studies found that the differentiation and proliferation (growth) of the follicular keratinocytes (cells in the hair follicle) was unaffected by the level of biotin.
Biotin supplementation is not the treatment for hair loss/ hair thinning nor does its intake help aid other scientifically proven treatments for hair loss
Can biotin supplements do any harm?
Like I’ve mentioned earlier, there are no known toxicities reported so far as a result of biotin supplementation.
However, excessive amount of biotin in the blood can interfere with many of the laboratory investigations such as thyroid function tests, other hormonal profiles as well as levels of troponin in the blood (which is an indicator of a heart attack).
Many lab tests rely on a biotin-streptavidin reaction as part of the test procedure. The low amount of biotin we obtain from our diet does not affect these tests however biotin level > 1 mg/ day (Biotin supplements available in the market contains around 10mg of biotin) can result in false positive or false negative test results.
FDA issued a warning to help educate about the possible interaction between high biotin levels in the blood and troponin level ( a biomarker which helps physicians diagnose a heart attack for patients presenting with chest pain). This could be dangerous as a heart attack requires immediate treatment and an early diagnosis could potentially be missed.
My take on this topic
Biotin supplements are not required for the treatment of hair loss.
If you are on long term supplements, remember to mention it to your treating physician especially if you are getting evaluated for hormonal issues, thyroid function or for a chest pain.
Follow the general hair grooming measures available on a post on my instagram feed.
Get the hair loss evaluated by a dermatologist to get to the cause of it as different types of hair loss requires different form of treatment.
Instead of wasting your money on buying these vitamin supplements, spend it on products that have actually proven to work such as minoxidil, or well formulated shampoos and conditioners instead.
Hair oil application has been the basic hair care remedy for beautiful, black, luscious hair especially in Indian females (and for some males who groom their beard religiously :P). We’ve been taught at a very early age about hair grooming, mothers would be seen applying and massaging layers of oil into their daughters scalp while enjoying the afternoon sun.
I remember during my time living in Kerala (southern tropical state in India, where the inhabitants use coconut il for everything, from cooking to hair grooming). Girls there has long thick hair touching their knees, but it was always covered in coconut oil so I could never appreciate the overall health status of their hair. I couldn’t tell if the shine was natural or because of the layer of oil, the split ends were beautifully hidden as well. But this was the norm there, they love having oil on their hair day and night and it seems to work for them.
Personally for me, as someone with fine hair, which can get oily pretty quick even just after a day post hair wash, hair oiling never played an important part in my hair grooming process.
Individuals with thin fine hair do experience oiliness of the hair quicker than those with thicker hair, as the sebum produced in our scalp can be transmitted to the hair shaft easily.
As a dermatologist, I often get question on which oil is best to use, how frequently is it to be used, is pre or post shower hair oiling better and so on and so forth.
Honestly, there is no right answer to these questions, as there are very few scientific studies done to compare between the various hair oils or their methods of application.
Lets see which hair oil actually have science backing up its claim
Studies have found that coconut oil is able to penetrate the hair shaft and this can be enhanced by application of warm oil. The oil coats the hair, prevents absorption of moisture into the hair and thus prevent the recurrent swelling and shrinking up of hair cortex which is responsible for hair fragility and breakage.
Coconut oil has been found to be the only oil to prevent protein loss from the hair shaft, thus providing more stability to the hair.
Though this oil also provides hydration to the hair similar to coconut oil by forming a film coat on the hair . It however cannot prevent protein loss from the hair shaft due to its bulky nature and presence of double bonds that prevent penetration into the hair fibre.
Articles that claims its beneficial effect on hair are based on the study of the effect of Vitamin E on hair growth. A study of 39 patients (note- small sample size) showed that oral vitamin E supplementation for a period of 8 months had positive outcome on patients suffering from hair loss. Sunflower oil is also rich in Vitamin E, but it doesn’t necessarily mean that topical application of a vitamin E rich oil will also achieve the same result as daily oral supplementation.
Moroccon argan oil
Another oil rich in vitamin E, the argan tree is endemic to Morocco, has emerged as the most expensive essential oil and as a popular hair cosmetic from shampoos, to conditioners to hair oils.
Is it worth the hype?
There are no scientific evidence for its use in hair care so far, the only reason for its popularity is that its rich in Vitamin E (a potent anti-oxidant) and the study mentioned above, of Vitamin E positive effect on hair growth.
Again rich in Vitamin E, though it has lots of health benefits when consumed. The effects of almond oil in hair, except for its emollient action i.e coats an oily film on the hair and prevents breakage, no other scientific data available for stimulating hair growth.
Unlike other oils which lacks strong scientific evidence backing up their claims in promoting hair growth, rosemary oil actually helps improve microcirculation ( improves blood flow to skin). It has been compared to be equally effective to 2% minoxidil in the treatment of androgenetic alopecia (male pattern hair loss). Increase in hair count were seen only after 6 months of daily application.
Whether minoxidil can be completely replaced by rosemary oil, the answer is still “NO”. Because though it was seen to be as effective as 2% minoxidil, we normally prescribe a 5%-10% strength of minoxidil in dermatology.
An animal study concluded that extracts from the leaves of hibiscus plant does promote terminal hair growth. No new hair follicles were formed.
Crude onion juice extract was used in a study of patients with alopecia areata (auto-immune condition causing patchy hair loss) which is different from diffuse hair loss from other causes. Daily topical application of onion juice to the area of hair loss showed significant improvement in the form of new terminal hair (dark, thick hair) at the end of 6 weeks.
How it works is thought to be by “antigenic competition” ( my fellow dermatologist will understand this term.:P
Hair oils (all types; from coconut, almond, olive, vegetable oil etc) are beneficial in a way that they form an oily film on the hair shaft and prevents excess moisture absorption from the environment and prevents water loss from the hair cortex. This is important because the recurrent swelling (from absorbing water) & shrinking (from losing water) of the hair cortex is responsible for the fragility, split ends and eventually breaking off of the hair from its weakest point (which can be seen as hair fall).
Oiling hair can prevent split ends, strengthen the hair (coconut oil) and reduces the friction that arises when combing the hair. Thus, helps manage frizzy hair, gives the hair shine and tames the fly aways.
With regards to stimulating hair growth, only rosemary oil has scientific data backing up its claim.
Olive oil could have potential based on the studies available. Still no conclusive data yet as a topical application.
Heat i.e warm oil application helps the oil to penetrate into the hair fibre and leaving just a thin film on the hair shaft, giving a less oily appearance.
Regarding how to use hair oils, frequency, duration, sadly I do not have the right foolproof answer for this. My personal advice based on my understanding of the research on this topic is :
Coconut oil is definitely the hero here, its the best, safest & cheapest option, especially if you have dry, frizzy, splits ends, apply it on you hair from root to tip. It has the additional advantage of preventing protein loss from the hair. There is actually no need to apply to the scalp, as your skin produces sebum naturally. But go ahead if you have dry scalp or if you enjoy the head massages.
Since we all do not like walking around with oily hair, and since we have products like conditioners & hair serums to use post showers, to make our hair more soft, shiny and manageable, reserve hair oil application for pre-showers. Applying too much & leaving the hair oil for too long will only attract more dirt to your hair which will make it difficult washing the oil out from the hair. Extra manual effort of massaging the shampoo will only cause more friction which can lead to increase falling of hair in the shower.
You can use hair oils as frequent as you like, all the studies reporting positive effects is based on daily hair oil application. I know its impossible to keep up with this in real life, so be flexible, go with your flow. ( I know, not a very scientific advise, but there is no clear cut science behind it yet!! )
Do not depend on hair oils to fix all your hair issues. It should only be a complimentary step to your already existing hair care (shampooing, conditioning, serums, or hair treatment such as minoxidil).
And lastly, if you have straight, non frizzy hair and you’re not in the habit to apply hair oil, then thats also okay. You do not need to follow the crowd.
Dandruff is part of a common dermatological condition called “Seborrhoeic dermatitis” with dandruff being the most common & mildest form of the disease. It is said that 50% of the adult population worldwide are affected by it.
The title of an article published in the Indian journal of dermatology read: “Dandruff: The most commercially exploited skin diseases” which is aptly put. We’ve all seen the amount of commercially available anti-dandruff shampoos out there in the market. Their marketing strategies, using celebrities to endorse products with the labels such as “get rid of dandruff”, “100% dandruff free forever” etc. What they fail to mention is that, one will only be dandruff free, if one uses the product forever as well.
That being said there is still no clear explanation of why it occurs nor is there is cure for it yet. ( Yes, its frustrating that most dermatological conditions still don’t have any cure, but science is evolving, and so far dandruff is completely manageable)
So what causes dandruff?
How does it present?
Seborrhoeic dermatitis can present in infancy, and is thought to be due to the maternal androgens (male hormones) that stimulate the sebaceous glands (oil producing glands) to produce more sebum. This commonly presents as “cradle cap” in infants. The condition is self limiting, which usually resolves with just regular bathing and with application of moisturisers. Medicated shampoos containing 2% ketoconazole may be required for persistent cases.
In adults, it usually starts at puberty. In it mildest form i.e dandruff one may experience itchy oily scalp, with easily removable dry white flakes. These flakes are the upper layers of the skin (stratum corneum) that are being shed off and not dirt. It has been observed that patients with dandruff do experience an increase amount of hair loss as well.
Coming to the more serious form called seborrheic dermatitis, here,inflammation (red inflamed skin) is marked and the condition is not limited to the scalp. Areas with high amount of sebaceous glands may be involved as well such as behind the ears, around the nose and mouth, forehead, chest. Patient will present with recurrent flares of such red itchy skin with greasy yellow scales. These flares are usually precipitated by emotional stress.
Now lets see how it can be managed.
Firstly its important to remember that there is no one time cure for dandruff or seborrheic dermatitis.
Dandruff may occur in individuals who have never experienced it before, if the conditions mentioned as the causes find a favourable environment and it may also resolve once such conditions are removed.
Avoid hair oil application, this can favour the over growth of the yeast Malassezia (or if that’s something you’re used to doing and do not want to give that up, then strictly avoid applying to the scalp & apply the oil only to the hair)
Use shampoos specially labelled “anti-dandruff”, but remember not to blindly trust labels, and look for ingredients such as anti-fungals (active against the yeast) like 2% ketoconazole, selenium sulfide, ciclopirox olamine, and 1% zinc pyrithione (helps regulate sebum production). Salicylic acid helps remove the excess sebum and helps exfoliate the flakes better.
Use 2-3 times per week for at least a month.
Massage gently into the scalp, leave for ~ 2-3 mins and rinse it off. Continue using such shampoos once a week for maintenance even when the dandruff has cleared. This will help prevent recurrence.
Conditioners can be used as usual, which is to be applied only to the hair shaft avoiding the scalp.
Bioderma Nodé DSantidandruff shampoo contains Zinc pyrithione, & salicylic acid as active ingredients. It also contains sodium shale oil sulfonate (extract from fine grained sedimentary rocks), which is approved in Europe for its anti inflammatory properties. This shampoo helps remove the flakes from the scalp, helps those with the oily sclap and also acts on the yeast. Advantage: Effectively controls dandruff, does not dry the hair out and has a neutral smell. Disadvantage– Expensive ~ Rs 1400, some people may actually prefer some scent to their shampoo.
Neutrogena T/Sal shampoo : Also conatins salicyclic acid as active ingredient. Ideal for oily scalp. Price – ~1300
Over the counter affordable anti dandruff shampoos containing zinc pyrithione.
Loreal professional anti dandruff shampoo contains zinc pyrithione with salicyclic acid. MRP – Rs 590
Scalpe + shampoocontains both ketoconazole and zinc pyrithione. Also does not dry out the hair.
Dove anti-dandruff shampoocontains zinc pyrithione but also ingredients that helps with hydrating the hair.
When to see a dermatologist?
When the skin on your scalp, face etc is red, itchy with yellowish greasy scales which in this case the seborrheic dermatitis may require a course of topical steroids to bring the inflammation down.
When the redness extends beyond the hairline and the scales are firmly adherent to your scalp,this could be a form of psoriasis instead.
Here are some questions I’ve received on this topic.
1. Could you suggest shampoos for dandruff that does not cause hairfall?
The shampoos are not the cause of the hair loss but its rather the dandruff that causes it. And list of shampoos are given above.
2. Does dandruff cause hair fall? And how to promote thick hair growth?
Yes, individuals with dandruff do experience from more hair fall. Its been noticed that they have 100-200 hair fall per day compared to the normal 50-100 per day
Hair thickness is determined by your genetics, there is nothing that can change that. However for a person with male or female pattern hair loss, the terminal hair (the thick black hair on the scalp) is turned to vellus hair (thin, fine hair normally seen in other other parts) which gives the impression of thinning of hair. Its always best to get this examined by a dermatologists, since the treatment for this is completely different.
3. Does dandruff worsen in pregnancy?
Yes, it can. As you can see from the explanation on the causes of dandruff, increase activity of the sebaceous glands (which in turn produce more oil, and facilitates overgrowth of the yeast) is one of the main factors in causing dandruff. Sebaceous glands activity also increases during pregnancy especially during the 3rd trimester due to increase level of the hormones -progesterone and androgens. But fear not!! This is completely reversible post delivery. And the anti-dandruff shampoos are completely safe to be used during pregnancy.
4. Solution for oily scalp and dandruff that is not getting controlled?
Check out the shampoos I mentioned earlier containing salicyclic acid (available ay nykaa, amazon) . This should help control the excess sebum production in your scalp. Use a combination of shampoo, for example, one containing salicylic acid on one day and one containing anti-fungals on the other hair wash day. You could also increase the frequency of shampooing, like 3 times times a week with these medicated shampoos and 2 times a week for maintainence.
5. I also have a very oily scalp, and I get too many DIY suggestions from people and I don’t know which one to believe.
Management of oily scalp, check answer on question no 4. As for the DIY lemon juice, onion juice, daily hair washes etc, its all time consuming, messy, requires a lot of effort and all un-necessary for something that is not even scientifically proven. Just stick to the advises that is known to work, follow the instructions as mentioned above and you’ll be able to manage your condition in no time.