What can Dr. Santos Stahl do about hair loss?

    “Autologous blood injection twice is equally safe and effective in men and women.” [1].

    “Autologous blood is a safe and simple method of treating hair loss and has few adverse effects.” [2].

    Autologous blood treatment shows high efficacy in the treatment of hormonal hereditary hair loss (androgenetic alopecia) in women.” [3].

    The satisfaction of our patients is underlined by the results of scientific publications. During the initial consultation, Dr. Santos Stahl will create a treatment plan according to the type and severity of the hair loss. For an autologous blood treatment, we recommend three sessions at intervals of about four weeks.

    The use of autologous blood in the form of concentrated platelets has played an increasingly important role in regenerative medicine for many years. Among the many areas of application (support of wound healing, improvement of scar formation, skin rejuvenation), scientific evidence for the effect of autologous blood treatment in the treatment of hair loss is particularly increasing.

    The cell renewal effect of autologous blood is based on the release of messenger substances from the body’s own platelets. These messengers include platelet-derived growth factor (PDGF), transforming growth factor (TGF), new blood vessel formation growth factor (VEGF), insulin-like growth factor (IGF), and interleukin 1 (IL-1) [4]. Messengers influence cell migration, cell proliferation, and new blood vessel formation [5].

    What can I do against hair loss?

    Treatment of hair loss should begin with avoiding harmful effects on hair growth. Key measures include:

    • Stop smoking cigarettes. Smokers have been shown to have thinner hair than non-smokers [6]. Smoking reduces the blood supply to the hair root, damages the genetic material of the hair root, promotes the release of pro-inflammatory messenger substances and alters the hormone balance [7].
    • Regular exercise is beneficial to health and prevents hair loss [8]. There are several explanations for this. On the one hand, toxins and waste products are excreted through sweating [9]. Sporting activity promotes stress reduction and increases blood circulation to the skin. Exercise regulates hormone balance, improves sugar metabolism and blood pressure [10].
    • Eat raw vegetables (lettuce, raw carrots and tomatoes) and fresh herbs (rosemary, sage, parsley, basil) at least three times a week. A Mediterranean diet protects against hair loss [11]. The observation is explained by the antioxidant and anti-inflammatory effects of secondary plant compounds. The abundant evidence for the health-promoting influence of the Mediterranean diet underscores this observation [12].
    • Watch your body weight. Being overweight leads to thinner hair. This can be explained by the fact that high-fat diet leads to the release of inflammatory signals in the stem cells of hair roots [13].
    • Avoid stress and make sure you get enough sleep. A part of the diencephalon (hypothalamus) releases more of a certain hormone (corticotropin-releasing hormone) during stress. This hormone causes the release of histamine from defense cells at the base of the hair follicles. Histamine eventually initiates the regression phase (catagen phase) of hair follicles [14].
    • Protect your hair from excessive sun exposure. Sun exposure (UV-A radiation) causes a decrease in stem cells and pigment cells in hair roots [15]. Certain degradation products of normal skin germs (propionibacteria) can be cell-damaging (light-activated porphyrin) when exposed to sunlight [16]. Free radicals generated by the sun lead to a reduction of hair pigments. Lighter hair provides less protection from UV light [17].
    • Take targeted action against dandruff. Various microorganisms colonize the scalp and form a natural protective shield (propionibacteria, staphylococcus bacteria and malassezia yeasts). The yeast fungus Malassezia accounts for 45 percent of skin germs in healthy people. Oily skin can cause yeast to proliferate more, trigger an inflammatory response, and promote hair loss [18]. In people with dandruff, the proportion of yeast in the skin flora increases to 75 percent [19]. Both in seborrheic dermatitis, psoriasis and atopic dermatitis, the yeast Malassezia is involved in the disease process. Shampoos containing the active ingredients zinc pyrithione (for example Head & Shoulders®), ciclopirox olamine (for example Stieproxal®) or ketoconazole (for example Ketozolin®) reduce Malassezia colonization [20].

    Does a treatment with processed own blood help against hair loss?

    Treatment with your own blood stops hair loss and stimulates hair growth. There are numerous scientific studies that support the benefits of the treatment [21] [22] [23] [24]. As a rule, the treatment should be repeated three times. The effect of the patient’s own blood has been used successfully for many years as a support after hair transplantation [25].

    Platelets contain numerous growth factors and stimulating mediators. Growth factors such as insulin-like growth factor (IGF-1), hepatocyte growth factor (HGF), keratinocyte growth factor and vascular endothelial growth factor (VEGF) promote the growth phase of the hair cycle [26]. The positive effect of many of these growth factors on hair growth has been scientifically proven [27].

    Does microneedling help against hair loss?

    Microneedling is a safe procedure for treating acne scars, mouth wrinkles, crow’s feet, burn scars, and pregnancy marks, either alone or in combination with other procedures [28]. In studies, it is found that hair density and thickness increases more and faster with the combination treatment of own blood and microneedling than with own blood alone [29] or with microneedling alone [30]. Microneedling is a minimally invasive procedure that uses multiple fine needles to create micropunctures in the skin. The treatment lasts about 30 to 45 minutes and is repeated three to six times at intervals of two to four weeks.

    Do muscle relaxants help with hair loss?

    Muscle relaxants are offered for the treatment of constitutional hair loss under the idea that relaxation of the scalp muscles, improves blood flow and oxygen supply to the tissues. However, good robust studies demonstrating an effect of muscle relaxation are not available [31].

    Hair loss treatment health insurance

    Health insurance companies do not usually cover the cost of hair loss treatments. There are two reasons here:

    Your health insurance will pay for services that are urgently required for medical reasons. A recommendation of the Federal Joint Committee (G-BA) must be available for cost coverage.

    What are the causes of hair loss?

    Among the most commonly discussed causes are:

    • Hereditary hair loss due to male hormones (androgenetic alopecia)
    • Hormone fluctuations due to pregnancy, childbirth or menopause
    • hyperthyroidism or hypothyroidism
    • Stress [32]
    • Obesity [33]
    • Extreme diets [34]
    • Cigarette smoking [35]
    • Deficiencies in vitamins and trace elements (detailed information on the respective food supplements can be found enclosed)
    • Air or water pollution (see this page for more information).
    • Harmful hair care products
    • Certain hairstyles (boxer braids, rasta braids)
    • Severe life-threatening illness [36].
    • Severe liver or kidney dysfunction
    • Various medications (detailed information can be found enclosed)

    For some influences, the cause-effect relationship has not been proven beyond doubt. The multitude of discussed causes and the delay with which hair loss occurs make scientific proof difficult. You can read more about this in our encyclopedia of cosmetic surgery under Cause.

    Hair loss after COVID-19 infection?

    COVID-19 infection is associated with considerable stress, even in a mild course, usually due to reduced social contacts. It is believed that stress can trigger acute diffuse hair loss [37]. In principle, however, the drugs taken during an infection can also trigger hair loss. On average, ten percent of COVID-19 infected patients exhibit diffuse hair loss. Hair loss occurs 50 to 60 days after a positive COVID-19 test. Possible treatments include minoxidil solution or minoxidil tablets and autologous blood injection [38].

    Hair loss due to environmental pollutants

    Pollutants and environmental toxins are becoming more common. Pollutants can be absorbed in very different concentrations through the air we breathe or through food. Sudden (acute) poisoning is usually accompanied by severe, sometimes life-threatening symptoms shortly after ingestion of a large quantity of a pollutant. Long-term (chronic) poisoning is often difficult to diagnose. Non-specific and mild symptoms long after the onset of toxin ingestion over a long period of time complicate the suspicion. Hair loss can, in very rare cases, be a sign of chronic poisoning. In justified cases of suspicion, traces can be detected in the blood, urine or hair, depending on the toxin.

    • Mercury (heavy metal): Pollutant sources in the environment: coal-fired power plants, gold washing, smelting furnaces, cement production. The use in batteries, lamps or thermometers is no longer permitted. Sources of pollutants for humans: Dental amalgam, contaminated fish, exposure to pollutants in the workplace. An amalgam dental filling releases 2 to 28 micrograms of mercury per day [39]. Limit values: According to WHO, two micrograms of mercury per kilogram of body weight per day (IPCS (2003) Concise International Chemical Assessment Document, World Health Organization). Signs of intoxication: fatigue, depression, insomnia, irritability, memory loss, hair loss [40].
    • Cadmium (heavy metal): Pollutant sources in the environment: alloys, paints, solder. Sources of contaminants to humans: Cigarette smoke, use of contaminated fertilizers, shellfish, crustaceans, offal, sunflower seeds, peanuts, and flaxseed [41]. Limits: According to the European Food Safety Authority, the tolerable weekly intake of cadmium is 2.5 micrograms per kilogram of body weight. Signs of poisoning: cadmium damages the kidneys, bones, blood formation, hormone balance and can lead to hair loss [42]. Cadmium accumulates in the liver and kidneys over decades.
    • Arsenic: Pollutant sources in the environment: fossil fuel combustion, lead alloys, light-emitting diodes, pest control, wood preservatives, glass manufacture. Sources of contaminants for humans: contaminated grain, rice, beer and drinking water. Limits: The European Food Safety Authority has established a health hazard limit range of 0.3 to 8 micrograms per kilogram of body weight per day (Data Collection Reports – EFSA – 2015). Signs of poisoning: Acute poisoning is accompanied by fatigue, nausea, vomiting and diarrhea. Chronic arsenic poisoning is characterized by weight loss, hair loss from the scalp, eyebrows and eyelashes, thickening of the finger end links and enlargement of the nail bed.
    • Thallium (heavy metal): Pollutant sources in the environment: pest control against rodents, ants and cockroaches, production of semiconductors and alloys. Limit values: The U.S. Environmental Protection Agency assumes a harmful limit value of 0.01 milligrams per kilogram of body weight per day. Signs of poisoning: it is tasteless, odorless, colorless. In small amounts, thallium causes hair loss; larger amounts cause sensory disturbances, diarrhea, nausea, and vomiting. Hair loss sets in two to three weeks after thallium poisoning [43]. Often there is a loss of eyebrow hair [44].
    • Selenium: The trace element selenium is an important component of many of the body’s proteins, especially enzymes involved in thyroid hormone metabolism, free radical defense enzymes, and white blood cells. Sources of pollutants for humans: Sea salt, offal, yeast, bread, mushrooms, asparagus, rapeseed, broccoli, cabbage, garlic, onion and leek [45]. As selenium is enriched in animal feed eggs and dairy products can also contain a lot of selenium. Brazil nuts are particularly high in selenium – up to 400 micrograms of selenium depending on the region of cultivation [46]. Certain anti-dandruff hair shampoos also contain selenium. Poisoning also results from overdose of dietary supplements containing selenium [47]. Limits: an intake of 15 micrograms of selenium per day is recommended for young children and 70 micrograms per day for adults. The Federal Institute for Risk Assessment recommends a maximum limit of 300 micrograms per day. Signs of poisoning: heart palpitations, chills, concentration disorders, gastrointestinal complaints as well as hair loss and nail growth disorders.

    What drugs can cause hair loss?

    Medications can cause hair loss. For many drugs, the mechanism that leads to hair loss is not yet understood. In order to avoid liability due to violation of the duty to inform according to § 84 AMG, drug manufacturers list all even remotely possible and unspecific side effects. Therefore, “hair loss” is listed on many package inserts as a possible side effect. More common relevant medications include heparin injections and the pill. Hair loss often becomes noticeable two to four months after the start of treatment. Enclosed you will find examples of some active substances for which increased hair loss has been observed.

    Fields of application of the active substancesWirkstoff
    Attention Deficit DisorderAmphetamines
    Treatment of malariaChloroquine
    HypertensionPropranolol (beta-blocker)
    Blood ThinningHeparin
    Blood ThinningPhenprocoumon
    Breast CancerTamoxifen
    Cardiac arrhythmiasAmiodoron
    Hormonal contraceptivePill
    Parkinson’s diseaseLevadopa
    Testosterone deficiencyTestosterone
    Unterdrückung der AbwehrkräfteTacrolimus
    Unterdrückung der AbwehrkräfteAzathioprine
    Unterdrückung der AbwehrkräfteMethotrexat
    Viruses, cancer or autoimmune diseasesInterferon
    Vitamin A deficiencyRetinol
    Vitamin E deficiencyTocopherol
    Prevention of malariaProguanil
    Water retentionSpironolacton
    Sources: Sinclair R., 1999, International Journal of Dermatology and Piraccini B.M., Iorizzo M., et al, Current Drug Safety, 2006.

    No two hairs are alike

    Head hair is as diverse as the human being. That is why the hair is often an expression of our personality. Hair is a part of our body, and its condition reflects our overall health. Hair has an important role in thermoregulation, the sense of touch, protection from the sun’s ultraviolet (UV) radiation, and wound healing. Beyond the length or color of the hair, hair can have many different characteristics:

    • Structure of the hair: The shape of the hair can be divided into categories: completely straight, almost straight, wavy, large curls, Afro curls, very small Afro curls. Curly or straight hair is usually hereditary. In rare cases, curling can be the side effect of certain medications (indinavir, retinoids) [48].
    • Number of hairs: blondes have an average of 140,000 hairs, dark haired have 105,000 hairs and redheads have 90,000 hairs [49].
    • The density of hair is measured in hair fibers per square centimeter. The density is approximately 170 hairs per square centimeter in Americans of Hispanic descent, 155 hairs per square centimeter in persons of African descent, and 220 hairs per square centimeter in Europeans [50].
    • Thickness of the hair: The diameter of a hair is about 65 micrometers in Europeans, 90 micrometers in Asians and 75 micrometers in Africans [51].
    • Shape of the cross section: The cross section of a hair is oval in European and African hair and round in Asian hair [52].
    • Surface roughness: The roughness of a hair is measured, among other things, as the difference in height between a peak and a valley on the surface of the hair. In European and African hair the height difference is 12 nanometers, in Asian hair 10 nanometers [53].
    • Tensile strength: Scientists talk about the tensile strength of the hair. On average, a hair can withstand a maximum tension of 80 grams per millimeter before it breaks.
    • Elasticity describes the extent to which a hair can return to its original shape after stress. A hair can be stretched by 20 to 30 percent of its length (modulus of elasticity 4.2 gigapascals) [54].
    • Hair growth: In the scalp, each hair grows evenly, around 0.3 millimetres per day or one centimetre per month continuously over two to seven years.
    • Hair loss: The proportion of growing hair compared to falling hair is called the anagen-telogen ratio. In healthy young people, about 90 percent of the hair is in the growth phase (anagen phase) and five to ten percent is in the resting phase (telogen phase).
    • Vellus hair (downy hair): Vellus hairs are hairs with a diameter smaller than 30 micrometers. The percentage of vellus hairs varies by 15 percent depending on age, sex, ethnicity, and scalp region [55].

    Structure of a hair and a hair organ

    The follicle (hair follicle) is the cell structure in which a hair is formed and grows. Follicles extend from the hair funnel to the hair root. In the center of the follicle lies the hair, which is enveloped by the hair root sheath. The base of the follicle, also called the hair bulb or bulb lies four millimeters below the surface of the skin. The stem cells of the hair bulb give rise to the horn cells of the hair. In addition, the stem cells of a hair follicle support wound healing. Each hair follicle is associated with a hair erector muscle, a sebaceous gland, and often a sweat gland [56]. Hairs can grow singly or in groups of two to three or even four to five hair follicles.

    The hair shaft consists of three layers: an outer cuticle, the outer cortex and the medulla. The hair fibre consists of dead horn cells, the so-called keratinocytes. These specialized cells produce the protein keratin and take up color pigments from the pigment cells of the skin [57].

    The composition and complex structure of the hair determine their properties. Hair is made up of 65 to 95 percent keratin by weight and up to 32 percent water, depending on the humidity. To a small percentage, hair is also composed of lipids [58]. The spiral-shaped α-keratin is also an important component of the skin and nails. Four keratin chains together form a protofilament. Eight protofilaments in turn form an intermediate filament. These bundle into macrofibrils that coalesce into cortex cells. Several cortex cells surrounded by an outer cuticle form a hair shaft. Each scale has an average length of 60 micrometers and a thickness of about 0.5 micrometers [59].

    Light hair and receding hairline

    Alopecia is the technical term for reduced hair density, colloquially hair loss. The word “alopecia” comes from the ancient Greek word for “fox” άλώπηξ (alōpēx). The change of hair or a loss of hair in foxes due to disease may explain the origin of the word. Age-related changes in hair start to appear from the age of 30 [60]. With age, the hair becomes thinner, the density of the hair decreases, the pigments of the hair become less and the scalp as well as the hair become drier. The first grey hairs appear in Europeans on average from the age of 35 and in Africans from the age of 44. Hormones affect the distribution, resistance and color of hair. Hereditary hair loss is often downplayed by those not affected [61]. Since hair is an expression of youthfulness, health and attractiveness, the changes have an impact on our self-image. A hereditary predisposition or diseases can lead to a reduced hair density (medical term alopecia) and thus thinning hair. The decisive factor here is the ratio of the hairs that grow back to the hairs that fall out. Light head hair is often perceived as a psychological burden and can affect quality of life [62]. In fact, bald men are rated by women as older, less attractive, less successful in the workplace and in dating [63]. It is found that both men and women with hormonal hair loss suffer from increased anxiety and depression [64].

    What is a hair cycle?

    The hair follicle goes through regular cycles of growth, regression and dormancy throughout life. In each cycle, a new hair is formed and the old hair is shed. The hair cycle consists of the following three phases:

    • Growth phase (anagen phase): This phase begins with cells that multiply in the area of the hair root to form a cell cluster (dermal papilla). Specialized horn-forming cells (keratinocytes) emerge from the stem cells. The developing horn-forming cells bring forth a new hair. A new hair root sheath also forms around the new hair. The old hair is displaced by the regrowing hair until it finally falls off. The new hair grows for two to seven years at a rate of about one centimeter per month depending on the individual and age.
    • Regression phase (catagen phase): The phase begins with the detachment of the cell cluster (dermal papilla) below the hair bulb (bulb). The hair detaches from its blood supply. The cells in the lower two-thirds of the hair follicle undergo scheduled programmed cell death. The hair bulb and the inner part of the hair root sheath regress. The cell formations shift to more superficial skin layers. The regression phase usually lasts about two weeks. During this time, the old hair remains in the channel through which the new hair will exit.
    • Resting phase (telogen phase): In this phase the hair falls out (medical term: effluvium). The renewing cell cluster (dermal papilla) and the hair bulb (bulb) approach each other. This results in the activation of stem cells and the initiation of a new cycle. With each subsequent cycle, the duration of the resting phase is prolonged, which slows down the overall hair renewal process. The resting phase lasts up to four months.

    At any given time, approximately 90 percent of the hair is in the growth phase (anagen phase), one to three percent is in the regression phase (catagen phase), and five to ten percent is in the resting phase (telogen phase). When determining the anagen-telogen ratio, the hairs in the catagen phase are added to the hairs in the telogen phase.

    What are the types of hair loss?

    About five to ten percent of the hair on the scalp is in the resting phase (telogen phase). At the hair cycle stage, hair falls out over a period of four months. About 80 hairs are lost daily, usually with each hair washing [65]. In hair loss, also called effluvium, more hair falls out than grows back. Hair loss can be described or classified according to several aspects:

    • The cause: hormones, inflammations or injuries of the hair root can lead to hair loss.
    • The duration: Hair loss can occur gradually over years (chronic) or suddenly over a few weeks (acute). If the hair loss lasts more than six months, it is called chronic hair loss.
    • The affected region: Hair loss can affect the entire scalp (alopecia totalis), the entire body (alopecia universalis) or only localized areas.
    • The affected hair cycle: If the hair is damaged in the growth phase, for example by chemotherapy, radiotherapy or repeated plucking, this is called anagen effluvium. If you notice many hairs falling out – i.e. if many hairs enter the resting phase at the same time, for example due to extreme diets (crash diets) or emotional stress, this is called telogen effluvium.
    • The recovery of the hair follicles: A distinction is made between non-scarring and scarring hair loss (scarring alopecia). In scarring alopecia, there is permanent damage to the hair follicles, for example in the course of a severe inflammation or a burn. As a result, hair no longer grows back in the affected area.

    The most common forms of hair loss are constitutional hair loss (androgenetic hair loss), followed by circular hair loss (alopecia areata) and diffuse hair loss (telogen effluvium). Rare forms of hair loss include hair loss due to pressure or traction (traumatic alopecia) and fungal disease of the scalp (tinea capitis).

    Hereditary hair loss (androgenetic alopecia)

    • This is the most common form of hair loss and is influenced by genes and hormones.
    • Cause: The activation of the hormone receptor shortens the growth phase of the hair cycle.
    • Prevalence: Among European men, thirty percent are affected by age 30, 50 percent by age 50, and 80 percent by age 70 [66]. About 15 to 20 percent of European women between the ages of 30 and 50 suffer from this form of hair loss. Up to 30 percent of post-menopausal women suffer from androgenetic alopecia [67]. Asians and Africans are less often affected than Europeans.
    • Symptoms: Hair becomes thinner and shorter and eventually barely penetrates the skin. In men, there is thinning of the hair in the temple area, which spreads to the crown area over the years. In women, diffuse hair loss occurs on the crown of the head.
    • Diagnosis: The diagnosis is made by visual inspection (clinical examination) of the hair and scalp. The patches of light and fine hair are characteristic, making it easier to identify the most common cause. The ratio of normal hair to downy hair is less than 4:1 (normal value 7:1). When the hair is pulled through (Sabouraud maneuver) or when the hair is pulled (pull test), increased hair loss (severe hair loss) is usually not observed. If diffuse hair loss, brittle hair and nails are observed and increased fatigue is complained of, a blood test of thyroid hormones may be indicated. With magnifying glass, downy hairs (vellus hairs) can be seen in the light areas during physical examination. A computer-assisted examination of the growth behaviour (TrichoScan) or the examination of the epilated hairs (trichogram) or excised hair roots (scalp biopsy) under the microscope are usually not necessary.
    • Treatment: Hereditary hair loss is usually treated with needling, a solution of the active ingredient minoxidil, processed autologous blood and finasteride tablets.
    • Prevention: Proper hair care, balanced diet, avoidance of stress, normal body weight (BMI: between 18.5 and 24.9), abstaining from tobacco consumption.
    • Prognosis: The risk of hereditary increased hair loss is significantly increased if the father, mother or grandfather have suffered from hair loss [68]. The rate of progression is unpredictable. Some men go completely bald in less than five years, but most take 15 to 25 years.

    Circular hair loss (alopecia areata)

    • Cause: Investigations point to an autoimmune disease in which the body’s own white blood cells (T-cells) attack the hair roots.
    • Distribution: Circular hair loss occurs in 0.2 percent of the population, regardless of gender, age and ethnic origin. About two percent of the general population suffers from this form of hair loss at some time in their lives [69]. Patients with white spot disease (vitiligo) or autoimmune thyroid disease are more often affected.
    • Symptoms: Hair may fall out in batches in circumscribed areas all over the body. Most often, the scalp or beard is affected.
    • Diagnosis: The diagnosis can be made on the basis of the pattern of hair loss. Occasionally, punctate indentations or grooves form on the nails. At the edge of the hairless areas, the hair can be easily plucked out. With magnifying glass magnification, typical signs of circular hair loss can be seen. The diameter of the hair shaft tapers near the hair exit duct. Because of the changed form, one speaks of piston-hairs or Kommahaaren. Black dots can be a sign that the hair has broken off immediately at skin level. Occasionally white hairs grow in the sparse areas. Because of the characteristic appearance, a biopsy is rarely necessary.
    • Treatment: a cortisone injection (triamcinolone, five to ten milligrams per milliliter) every two to six weeks stimulates hair regrowth in 60 to 67 percent of cases [70]. Side effects of cortisone treatment include thinning of the skin, vascular markings, and white patches [71]. Autologous blood injection is a safe and effective method with success rates of up to 76 percent [72]. Comparative studies have confirmed the efficacy and tolerability of autologous blood treatment [73].
    • Prevention: Since stress can trigger a hair loss flare-up, a balanced lifestyle should be strived for.
    • Prognosis: After an initial hair loss, the hair grows back on its own in 50 to 60 percent of cases. When there is a family history of circular hair loss, episodes of hair loss often recur [74].

    Diffuse hair loss (telogen effluvium)

    • Cause: The hair follicles enter the resting phase (telogen phase) prematurely. In about one third of the cases no trigger can be found. Known triggers include: Medications such as the contraceptive pill (birth control pills), vitamin A (retinoids), blood pressure medications (beta blockers, ACE inhibitors), antidepressants and anticoagulants (heparin), hyperthyroidism or hypothyroidism, kidney or liver failure, childbirth, Physical stress such as severe illness, inflammation, autoimmune disease, surgery, a radical diet, emotional stress.
    • Distribution: Exact figures about the frequency of diffuse hair loss are not known. Both men and women are affected.
    • Symptoms: Hair loss can occur suddenly or gradually. Hair loss usually occurs about two to three months after a triggering event. There is thinning of the hair and diffuse hair loss throughout the scalp. The loss is usually not more than 50 percent of the hair on the head.
    • Diagnosis: The diagnosis can be made on the basis of the characteristic complaints and the examination findings. Gradual diffuse hair loss and hereditary hair loss can appear very similar. In contrast to diffuse hair loss, hereditary hair loss in women mainly affects the crown region and produces more downy hair. The ratio of normal hair to downy hair is greater than 8:1 (Normally 7:1). In case of doubt, the diagnosis can be confirmed by a tissue sample of the scalp. Depending on the symptoms, further tests may be ordered, such as a blood test to determine thyroid levels, vitamin B12 and vitamin D3 levels, as well as iron levels and zinc levels.
    • Treatment: In sudden diffuse hair loss, normal hair growth resumes after the trigger is removed. If an autoimmune disease is the trigger of chronic diffuse hair loss, a local application of cortisone is useful. The treatment is safe and well tolerated and can be helpful in chronic diffuse hair loss. In chronic course, minoxidil solution can be used [75].
    • Prevention: The risk of diffuse hair loss is reduced by gentle hair care, a balanced diet and a healthy lifestyle.
    • Prognosis: If diffuse hair loss starts suddenly and a trigger can be identified, it can be assumed that the hair will grow back completely.

    What to expect during an examination

    During the consultation (anamnesis), information is already collected about the type of hair loss and the possible causes. Dr. Santos Stahl or private lecturer Dr. Stahl will discuss your individual needs during the initial consultation. Dr. Santos Stahl will therefore ask you some questions, such as:

    • When did the hair loss first occur?
    • What foods do you eat?
    • How often do you wash your hair, with what products?
    • Do family members suffer from hair loss?
    • Are you exposed to particular stressful situations?
    • Are you taking any medications or supplements? Do you smoke?

    The areas affected by hair loss are then examined. With a magnifying glass, the hair colour, hair density and hair thickness are examined. The scalp is examined for dandruff, redness and scars. Dr. Santos Stahl or private lecturer Dr. Stahl will discuss your individual needs during the initial consultation. Dr. Santos Stahl examines the tensile strength of the hair and the strength of the nails. In case of doubt, further examinations will be arranged in order to clarify the causes of hair loss. Finally, a treatment plan is created. In order to be able to assess the development, the scalp is photographed. The prospects of success and the costs of various treatment options (finasteride, minoxidil, therapy with the body’s own blood, microneedling, injections with muscle relaxants) will be discussed with you. You are welcome to make an appointment for hair loss treatment following the consultation.

    What examinations for hair loss?

    In the vast majority of cases of hair loss, the type of hair loss can be determined through conversation and physical examination. In cases of doubt, the following further tests may be ordered.

    Pluck test

    The pull test is a careful check on various parts of the scalp to see how firmly the hair is anchored. The test is considered positive if more than ten percent of the hairs detach under light traction. A positive test means that the hair follicles have entered the resting phase (telogen phase) prematurely (telogen effluvium). However, the test can only be evaluated if you have not washed your hair for at least 24 hours beforehand.

    Blood test

    Special tests of a blood sample give indications of diseases that can cause hair loss. Iron deficiency is determined by examining red blood cells, the amount of oxygen-carrying hemoglobin, and the amount of iron-storing ferritin. Thyroid hormones are determined when a disease of the thyroid gland is suspected. If there is reason to suspect a disturbance of the sex hormones, the male hormone testosterone and the hormones of the pituitary gland, the luteinizing hormone and the follicle-stimulating hormone are determined. If there is evidence that a transmissible sexually transmitted disease (syphilis/lues) has caused the hair loss, a screening test for antibodies will be arranged. In the case of unexplained hair loss in unusual places, further specific tests, such as evidence of exposure to pollutants, may be requested.

    Pathogen detection

    The appearance of circular redness, crusts, dandruff and brittle hair, especially in children, may be a sign of fungal infection. If a fungal infection of the scalp is suspected (tinea capitis), samples of skin scales or hair are examined under the microscope for traces of fungus. The differentiation from other skin diseases (psoriasis, seborrhoeic and atopic eczema) should be done by a dermatologist.

    Standard photo documentation of the scalp overview

    The aim of the documentation is to record the initial condition of the head hair and the success of the treatment. The pairwise comparison of before and after photos provides information about the hair density and changes in the hairline. For a meaningful comparison, a consistent and repeatable position of the head, camera setting and exposure must be observed. A change in hairstyle or hair color complicates the juxtaposition. The four common images include the tonsure (vertex), the middle parting, the hairline above the forehead (brow-hairline) and the hairline above the temples (receding hairline). Usually, the initial condition and the findings are photographed after three, six and 12 months.

    Examination of epilated hairs under the microscope (trichogram)

    This method is used to determine the hair diameter and growth behavior (anagen/telogen ratio) of 60 to 80 scalp hairs. Epilating the hair on the head for examination purposes is hardly ever used anymore. There are several reasons for this: the epilation process can cause hair damage and is painful. Thin downy hairs and short hairs cannot be examined with this method. Other examination methods (TrichoScan®) are simpler, faster and more accurate.

    Computer-aided examination of growth behaviour (TrichoScan®)

    The examination is performed with a high magnification camera (20x magnification) and automatic image analysis. The TrichoScan® examination is quick and uncomplicated. However, the accuracy and error-proneness of the software are critically discussed in scientific publications [76]. For examination, a spot of one square centimeter on the scalp is marked and shaved. To improve the reliability of the automatic image analysis, the hair is dyed dark and photographed after 48 to 72 hours. It is used to evaluate treatment methods, usually in the context of clinical trials. The following parameters are determined with the TrichoScan®:

    • the hair density (number of hairs per square centimetre, standard value for Europeans: 220 hairs per square centimetre),
    • the thickness of the hair (micrometer, standard value for Europeans about 65 micrometers),
    • the growth rate (millimetres per day, standard value 0.3 millimetres per day),
    • the number of downy hairs (hairs with a diameter of less than 30 micrometers, ratio of normal hairs to vellus hairs usually 7:1),
    • the growth phases (cycles) of the hair follicles (anagen-telogen ratio: 9:1).

    Tissue sample of the scalp (biopsy)

    The tissue sample is primarily used to evaluate the hair follicles but also the sebaceous glands. Viewed under a microscope, a distinction can be made between scarring and non-scarring and hair loss. Under local anaesthesia, four millimetre samples of the scalp are punched out. In order to detect the hair follicles, the sample must have a layer thickness of at least four millimetres. A sample usually contains 35 to 40 hair follicles. The tissue is examined in several layers. The preparation and evaluation of tissue samples requires a lot of experience and is time-consuming. The following sizes can be determined from a tissue sample:

    • the number of hairs,
    • the thickness of the hair (micrometer, standard value for Europeans about 65 micrometers),
    • the growth phases (cycles) of the hair follicles (anagen-telogen ratio: 9:1).
    • the number of downy hairs (hairs with a diameter of less than 30 micrometers, ratio of normal hairs to vellus hairs usually 7:1),
    • Signs of inflammation of the hair follicles.

    Hair analysis (hair mineral analysis)

    Hair analysis is usually used for criminal investigations (forensic examinations), the detection of poisoning or the detection of doping substances. Examinations of the blood or urine provide information about short-term current changes in the metabolism. Hair analysis allows conclusions to be drawn about changes that took place weeks or months ago. Foreign substances accumulate in the hair only after a long period of time. The detection limits vary depending on the substance and hair metabolism. For naturally occurring substances (for example, trace elements), the normal values (reference ranges) vary widely [77]. Therefore, the interpretation of the concentrations of naturally occurring substances is difficult. Detectable substances include:

    • Pollutants (nicotine mercury, arsenic, lead)
    • Narcotics (cannabionoids, cocaine, amphetamines)
    • doping agents (male sex hormone testosterone, nandrolone).

    Pattern of hair loss

    Hormonal hereditary hair loss (androgenetic alopecia) affects both men and women. As the name suggests, hair loss in this case is related to hormonal changes and genes. However, the regions of hair loss differ between the two sexes. In men, hair loss occurs on the temples and forehead, while in women, hair thinning occurs on the crown of the head. Various classifications provide guidance on the pattern and severity of hair loss. Simple classifications are often imprecise, while complex classifications include transitional forms and gradations. However, complex classifications are less reliable. This means that when applying the same classification to the same case, different users may arrive at different classifications. Due to their user-friendliness, the Norwood-Hamilton classification is widely used for male pattern hair loss and the Ludwig classification for female pattern hair loss. Classifications are of practical use when a consistent treatment recommendation can be derived from the stage of hair loss. However, scientific evidence for the benefits of a stage-specific treatment concept is currently still lacking.

    Scheme of male hair loss (Hamilton-Norwood classification)

    James B. Hamilton in 1951 classified the hair loss of 300 men into eight stages [78]. The American physician O’Tar Norwood added to Hamilton’s classification in 1975 rare patterns in which hair loss on the temples and forehead progresses simultaneously [79]. In the classic pattern of hair loss, the temples are affected first and later the crown of the head, until the bald area covers the entire top of the skull, leaving hair only at the back of the head. This pattern of hair loss can rarely occur in women.

    • Type 1: The hairline at the temples has receded minimally.
    • Type 2: The hair thins above the temples. The so-called receding hairline develops.
    • Type 3: Laterally equal depressions develop at the temples. In vertex type III vertex, a bald spot develops early on the back of the head, also called the crown of the head or tonsure (“plate”).
    • Type 4: The depressions are pronounced. There are only a few hairs in the crown area. The hairy zone in the vertex is wider than in stage V.
    • Type 5: The hairy zone in the crown area becomes narrower and the hair density has further decreased. The hairline of the temples and forehead has shifted further towards the back of the head.
    • Type 6: The bald area spans the temporal regions and the crown.
    • Type 7: This is the most severe form of hair loss. All that remains is a narrow, horseshoe-shaped hair band on the sides and back of the scalp. The hair at the back of the head is also thin and the hair density is low.

    Scheme of hair loss in women (Ludwig and Sinclair classification)

    In women, hormonal hereditary hair loss (androgenetic alopecia) leads to a reduction in the volume of hair on the top of the head. The thinning starts at the crown and spreads to all sides over time. As with men, the hair in the affected areas becomes thinner and shorter until finally downy hair (vellus hair) develops. The scheme of hair loss in women was first divided into three stages in 1977 by the physician Erich Ludwig from Hamburg [80].

    • Grade 1: The hair is thinner on the top of the head. The affected area is located one to three centimeters behind the hairline of the forehead.
    • Grade 2: The hair density is significantly reduced on the top of the head and allows the scalp to show through.
    • Grade 3: In this most severe manifestation, the top of the head is bald.

    Australian physician Rodney Sinclair has divided the severity and pattern of hair loss into four stages [81].

    • Grade 1: Hair density and diameter in healthy women.
    • Grade 2: The crown widens slightly.
    • Grade 3: Beyond the crown, the hair lightens and becomes thinner.
    • Grade 4: On the entire top of the head, the density and diameter of the hair is reduced.
    • Grade 5: The hair loss is far advanced and lets the scalp shine through clearly.

    Hair care tips that will make your hair look younger

    Thin hair:

    Avoid long hairstyles. Long hair is straightened by its own weight. Perms can make hair look thicker and give it more volume.

    Gray hair:

    Gray hair that has thinned feels thicker with hair color. Another technique is a step cut. In this technique, the hair on the top of the head is cut shorter than the hair on the bottom of the head. For women, this can give the appearance of long hair, even though the top part of the hair is quite short.

    Brittle hair:

    Use shampoos and conditioners that contain natural oils (coconut oil, olive oil, jojoba oil) to smooth the hair. Avoid damaging your hair with straightening treatments, hot tools, and frequent coloring. Conditioners form a protective layer around the hair. However, broken hair or split ends cannot be repaired. Panthenol is absorbed into the hair shaft and has a moisturizing effect. Conditioners and shampoos can add moisture and body to hair [82].

    Choosing the right shampoos

    The cosmetics industry recommends a suitable shampoo for every need. A distinction must be made here as to whether the manufacturer promises an effect on the hair root or on the hair shaft. A shampoo that is supposed to stimulate hair growth with caffeine claims to have an effect at the hair root. There is no independent scientific evidence for a hair growth promoting effect of shampoos. Apart from the effectiveness of the active ingredients, it is doubtful that the substances can act in sufficient concentration and for a sufficiently long time when washing the hair. Nevertheless, high quality shampoos can improve hair resistance and the appearance of damaged hair by forming a protective layer [83].

    A shampoo contains washing-active substances (surfactants), water, care substances and additives (preservatives, fragrances, dyes, thickeners). On average, a hair shampoo is composed of 10 to 30 ingredients [84]. The surfactants dissolve the fats in the water and form the foam. Washing-active substances are divided into four groups according to their water-binding charged portion:

    1. Non-charged nonionic surfactants
      Representatives: Fatty alcohol alkoxylates, sorbitan esters, alkyl polyglucosides.
      Properties: Good cleaning properties, but foams poorly.
    2. Negatively charged anionic surfactants
      Representatives: Sodium lauryl sulfate, alkyl ether sulfates, alkyl ether carboxylates, sulfosuccinates, olefin sulfonates, vegetable soaps.
      Properties: Good cleaning power, produce a rich foam.
    3. Positively charged cationic surfactants
      Representatives: Stearalkonium chloride, Behentrimonium methosulfate, Cetrimonium chloride.
      Properties: Acts as an antistatic, cleans poorly and does not foam well. Use therefore rather in hair conditioners and hair treatments.
    4. Negatively and positively charged amphoteric surfactants (zwitterionic surfactants)
      Representatives: Betaine, amphoteric acetate and diacetate.
      Properties: Good skin compatibility.

    On average, three different surfactants are used in a shampoo. Sodium lauryl ether sulfate, coco betaine (cocamidopropyl betaine) and glycol distearate are the most common. So-called “baby shampoos” and normal shampoos do not differ in this respect [85].

    Coco betaine (Cocamidopropyl Betaine) is well tolerated by the skin and is made from coconut oil and dimethylaminopropylamine. Skin allergies that may occur with the use of coconut betaine are due to contamination with reaction intermediates (amidopropylamines) [86].

    Shampoo ingredients you should avoid

    The detergent active substances ammonium lauryl sulfate and sodium lauryl sulfate (sodium laureth sulfate) are considered skin irritants and should be avoided [87].

    Certain additives in shampoos can trigger hypersensitivity reactions. These substances are also called allergens. Particularly frequently used allergens are the fragrances linalool, limonene, citronellol, hexyl cinnamaldehyde, benzyl salicylate and benzyl alcohol. The most common preservatives in shampoos include sodium benzoate, phenoxyethanol and benzoic acid. Interestingly, most “baby shampoos” and normal shampoos also do not differ in terms of preservatives used [88].

    Additives from the group of ethanolamines are used in shampoos to adjust the pH value. This group of substances includes monoethanolamines (MEA), diethanolamines (DEA) and triethanolamines (TEA). The substances can cause allergies, skin irritations and asthma-like symptoms and are suspected of having a carcinogenic effect [89]. Minor but measurable side effects can be detected at concentrations hundreds of times higher than use in cosmetics (Lim D.S., Roh T.H., Kim M.K., et al., 2018, J Toxicol Environ Health A.). Nevertheless, we recommend to avoid shampoos with MEA, DEA or TEA.

    Phthalates are used in hair care products to make hair more supple. Representatives of this group include: Benzyl Butyl Phthalates (BBP), Diethylhexyl Phthalates (DEHP), Diethylhexyl Terephthalates (DEHTP), Dimethyl Phthalates (DMP), Di-Isobutyl Phthalates (DiBP), Di-n-Butyl Phthalates (DBP), Di-Isononyl Phthalates (DiNP). Phthalates are considered to be toxic for reproduction and can cause allergies and asthma in children [90].

    Bisphenols especially Bisphenol A (BPA) is used in the manufacture of plastics and can transfer from the packaging to the contents of the packaging [91]. Bisphenol A has hormone-like effects in the human body. Exposure to bisphenol A can affect fertility in males, disrupt thyroid function, cause hypertension, diabetes mellitus, and obesity and breast cancer [92].

    The sustainability of shampoos should also be a selection criterion, given that a European uses on average 2kg of shampoo per year. Beyond ingredients, packaging, manufacturing and transport have an impact on CO2 emissions and water pollution [93]. The active washing substances (surfactants) in conventional shampoos are usually petroleum-based (ammonium lauryl sulfate and sodium lauryl sulfate). Better biodegradable are soaps on vegetable basis.

    Silicones make the hair smooth, supple and easier to comb. Silicones include dimethicone, dimethiconol, cyclomethicone, phenyltrimethicone, octamethylcyclotetrasiloxane (D4), decamethylcyclopentasiloxane (D5) and dodecamethylcyclohexasiloxane (D6) and amidomethicone. Silicones are long-lasting and can accumulate in the environment. Alternative ingredients include coco caprylate, lauryl glucoside, coco glucoside, glyceryl oleate and PEG (polyethylene glycol) derivatives.

    Rumors about hair, true or false?

    1. Washing your hair too often leads to hair loss.
      There is no scientific evidence to support this statement. However, there is a lot to consider when choosing the right shampoo. You can read more about this under “Choosing the right hair care products”.
    2. Frequent cutting will make your hair grow faster.
      When cutting the ends of the hair is eliminated split ends. High temperatures when blow drying or using a curling iron, as well as chemical hair straightening, can cause brittle hair shafts and split ends. Hair growth takes place in the hair roots and is not affected by cutting the ends of the hair.
    3. Frequent hair washing causes greasy hair.
      Fats are produced in the sebaceous glands of the hair and secreted onto the surface of the skin. The sebum production of the glands is controlled by hormones, among other things. A tendency to dry or oily skin is often genetically predisposed. Washing the hair removes dander and oil from the scalp, which protects the skin pores from clogging and thus inflammation. Sebum production is neither increased nor decreased by hair washing.
    4. Frequent brushing stimulates the blood circulation of the scalp and promotes hair growth.
      There is no evidence to support this claim. Brushing or combing too quickly can cause knots in your hair. Combing too tightly can cause the hair to pull out or damage the hair shaft. Straight European hair is fluffy when dry. Wet hair takes on a compact shape, with the individual hairs clinging strongly together over much of their length. Disentangling through the moving comb is difficult due to the lower stiffness of the fibers. The increased friction between the fibers and the comb makes combing even more difficult. Unlike straight European hair, which is more difficult to comb wet than dry, wet combing African hair is easier than dry combing [94].
    5. Caffeine shampoos make hair grow back.
      A growth-promoting effect of shampoos containing caffeine has not been proven. The dilution with water and the short exposure time during hair washing underline the doubts about the advertising promises.
    6. Chemical straightening or heat cause hair loss.
      The extent of the damage depends on the type and frequency of hair treatment. Sensitivity also depends on age and hair type. The use of chemical hair straighteners can cause frizzy hair, dandruff, hair loss, gray hair, hair breakage and split ends [95].
    7. Men prefer women with longer hair.
      According to studies, women with long hair are considered more feminine, younger, healthier and more attractive than women with short or pinned-up hairstyles [96]. Another study concludes that men rate women with long hair more feminine, determined, intelligent, independent and healthy. Women with short hair were perceived as more honest, caring and emotional [97]. There is one more study result that we do not want to withhold from you:
      The hairstyle of women has an influence on the helpfulness of men. A woman who drops a glove on the ground in a pedestrian zone is more likely to get it picked up by male passers-by if she wears her hair down than if she ties her hair into a pony or a chignon [98].
    8. Men prefer blonde women.
      Several studies reported that men, but not women, rated a woman with blond hair more attractive [99] [100]. Other studies fade out that drivers are more likely to think of blonde hitchhikers than dark-haired ones [101], and that blonde waitresses get more tips than dark-haired ones [102].

    Hair Antiageing

    Certain preparations, especially in combination, can counteract hereditary hair loss (androgenetic alopecia). Whether medication and which medication is suitable will be discussed with you during the examination. As with any treatment, the pros and cons must be carefully weighed.

    Non-prescription drug

    Minoxidil was patented in 1971 by the Upjohn company for the treatment of hypertension. What was initially a side effect led to its approval in 1988 by the U.S. Food and Drug Administration as a hair-growing agent in men and women over the age of 18.

    Mechanism of action:

    Minoxidil regulates the exchange of electrically charged particles of certain body cells (potassium channel blocker). As a result, the blood vessels dilate, allowing more oxygen and nutrients to reach the hair roots. The exact mechanism of action is still unclear. The solution contains alcohol and propylene glycol to increase the uptake of minoxidil into the tissues [103].


    Minoxidil is available over the counter in two concentrations (two and five percent). Minoxidil is available as a solution (liquid form) or as a foam and should be used morning and night.

    Side effects:

    The most common adverse effects are a burning sensation, itching and flaking. The latter is mostly due to the alcohol and propylene glycol in the solution. Minoxidil causes a shortening of the resting phase (telogen phase) of the hair cycle. Therefore, temporary hair loss may occur at the beginning of treatment. Allergic skin reactions to the minoxidil or propylene glycol are possible. In case of an allergic reaction to propylene glycol, the minoxidil foam can be used without propylene glycol.

    Prescription drugs

    One drug was approved in 1992 for the treatment of benign prostatic hyperplasia at a dosage of five milligrams by the U.S. Food and Drug Administration. The occurrence of increased hair growth under the treatment, led in 1998 to the approval for the treatment of hereditary hair loss (androgenetic alopecia) in a dosage of one milligram.

    Mechanism of action:

    The active ingredient (N-tert-butyl-3-oxo-4-aza-5α-androst-1-en-17β-carbamide) inhibits a type II and III enzyme (5-alpha-reductase isoenzymes) that controls the conversion of testosterone to dihydrotestosterone (DHT). Type II enzyme is found in the hair root, outer root sheaths of hair follicles, epididymis, vas deferens, seminal vesicles, and prostate [104]. The drug increases hair growth, especially in the area of the vertex. The maximum effect is achieved after one year.


    The tablets are available only on prescription. For the treatment of hair loss, a dosage of one milligram once a day is recommended. It may take four to six months before increased hair growth is noticed.

    Side effects:

    During the first few weeks, there may be a temporary increase in hair loss. The drug should not be used in women who are pregnant, as it may interfere with the development of sex if they become pregnant. The drug may decrease the desire to have sexual intercourse and cause erectile dysfunction. Depression has also been described. As a rule, these complaints decrease with time. Isolated cases of persistent side effects after discontinuation of the tablets have been observed. The drug also decreases the PSA level, a value used for early detection of prostate cancer. There is therefore a risk that prostate cancer may be detected later while taking the tablets.

    Another drug has been approved by the U.S. Food and Drug Administration since 2001 and in Germany since 2003 for the treatment of benign prostatic hyperplasia. The drug has only been approved for the treatment of hereditary hair loss in South Korea and Japan since 2009.

    Mechanism of action:

    The drug inhibits a type I and type II enzyme (5-alpha reductase isoenzymes) that controls the conversion of testosterone to dihydrotestosterone (DHT). Type I enzyme is found in the sebaceous glands of the adult face and scalp, epidermis, sweat glands, hair follicles, hair roots of the occipital hair, liver, adrenal glands and kidneys. Several studies show that this drug increases the diameter and number of hairs more than the drug developed in 1998 [105][106][107].


    This drug is not approved for the treatment of hair loss in Germany. In South Korea and Japan, the tablets are used in a dosage of 0.5 milligrams once a day to treat hereditary hair loss.

    Side effects:

    The side effects of this enzyme inhibitor are similar to the side effects of the drug approved in 1998.

    Vitamins and dietary supplements for hair loss

    About one in two U.S. residents take dietary supplements [108]. Approximately $7 billion is spent annually on dietary supplements worldwide ((—Growth-Trends-Key-Players-Competitive-Strategies-and-Forecasts—Research-and-Markets)). Despite its popularity, it must be noted that there are no high-quality and independent studies that prove the benefits of supplements [109]. Unlike medicinal products, proof of efficacy is not required for their manufacture and marketing. There are also no laws protecting consumers from misleading advertising promises, as is the case with prescription drugs. Nevertheless, dietary supplements are not free side effects or interactions. Many providers make misleading advertising promises or misleading claims about the actual daily requirement of vitamins and trace elements [110]. Enclosed you will find an overview of dietary supplements that are often offered to strengthen hair growth:

    vitamin A

    Vitamin A describes a group of substances that has numerous functions in the body, including in the renewal of the epidermis, vision and body defenses [111]. Two forms of this vitamin are ingested with food: retinol and beta-carotene. Retinol is found in dairy products and calf’s liver, for example, and beta-carotene is found in sweet potatoes and pumpkin, among other things. Vitamin A deficiency can be ruled out with a balanced diet of fruit and dairy products. The recommended daily amount of vitamin A is expressed retinol activity equivalent (RAE), where one RAE is equivalent to 1 μg of retinol. The daily requirement varies between 400 and 1300 RAE depending on age and gender. Vitamin A poisoning can occur in the long term if more than 10,000 RAE per day are ingested [112]. Vitamin A overdose can lead to hair loss and eyelash loss [113]. Other complaints include fatigue, malaise, weight loss, nail growth disturbances, and scaly skin [114]. Concomitant administration of vitamin E increases the risk of vitamin A intoxication [115].

    vitamin B

    The vitamin B group includes diamine (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), pyridoxine (B6), biotin (B7), folic acid (B9) and cobalamin (B12). The recommended daily allowance of these vitamins is achieved through a balanced diet. Vitamin B2 is a component of important enzyme accelerators: flavin mononucleotide (FMN) and flavin adenine dinucleotide (FAD) and is therefore important for energy metabolism. Vitamin B2 is found in dairy products. Vitamin B9 is important for cell division and is abundant in green leafy vegetables, citrus fruits and animal products. Vitamin B12 is needed, among other things, for cell division and nerve metabolism. Vitamin B12 is found in meat, dairy products and eggs. Therefore, a strict vegan diet may result in B12 deficiency after several months [116]. The benefits of vitamin B supplementation have not been scientifically proven in healthy diets.

    vitamin C

    Vitamin C, also called ascorbic acid, C is found abundantly in citrus fruits, potatoes, tomatoes, green peppers and cabbage vegetables. It is an antioxidant and protects the body from free radical damage [117]. Free radicals are produced, for example, by tobacco smoking, environmental toxins and UV radiation. Vitamin C is needed for the formation of collagen, L-carnithine and messenger substances of the nerve cells [118]. Vitamin is also important for iron absorption in the intestine and iron transport and storage in the body. Women should consume 75 milligrams per day and men 90 milligrams of vitamin C [119]. The body’s vitamin C stores are depleted after about three months of a very unbalanced diet. The deficiency symptom is summarized under the name scurvy. Hair loss is not among the manifestations of vitamin C deficiency (Fleming J.D., Martin B., Card D.J., 2013, Clin Exp Dermatol.).

    vitamin D

    There are two forms of vitamin D. The vitamin D2 (ergocalciferol) is found in shiitake mushrooms and mushrooms. Vitamin D3 (cholecalciferol) is largely produced in the skin under the influence of sunlight (UVB radiation). Other foods rich in vitamin D3 are salmon, sardines and egg yolks. The metabolism of vitamin D2 and D3 are very similar. Vitamin D triggers the production of certain proteins in the cell nucleus. The main sites of action include the skin, intestines, bones, parathyroid gland and immune system. The daily requirement of vitamin D is estimated to be 400 to 1000 IU (international units) per day [120]. Vitamin D deficiency is widespread and affects over 60 percent of the adult population [121]. Many foods are therefore fortified with vitamin D, such as orange juice or milk (40 IU per 100 millilitres). The association between hair loss and vitamin D deficiency is controversial [122]. Provided there is no vitamin D deficiency, the benefits of dietary supplementation should be critically questioned.

    vitamin E

    Vitamin E refers to a group of different substances, of which α-tocopherol is the most important representative. Like vitamin A and vitamin C, vitamin E has an antioxidant effect and thus protects against free radicals. Vitamin E is found in cooking oils, nuts, seeds and whole grains. Studies do not show a benefit of vitamin E supplementation for hair growth [123].


    Iron is an important building block of every human cell and is especially needed for oxygen transport in the bloodstream and in the muscles. Nearly two-thirds of the iron in the body is in red blood cells, 25 percent is in iron stores (liver, spleen, and bone marrow), and 15 percent is in muscle tissue [124]. Food sources of iron are meat, poultry and fish, as well as cereals, legumes, fruits and vegetables. The incidence of iron deficiency in men in industrialized countries such as the United States is five percent, and in women it is 10 percent [125]. The most common cause of iron deficiency in women is heavy menstrual bleeding. The most common symptoms of iron deficiency include fatigue, muscle weakness, shortness of breath and hair loss. However, if there is no evidence of iron ingestion, dietary iron supplementation does not confer any benefits [126].


    Zinc is an important trace element that is required by many enzymes. The Recommended Daily Allowance (RDA) of zinc is 10 milligrams (DIRECTIVE 2008/100/EC of 2008). Normal zinc levels in adults range from 70 to 250 micrograms per deciliter. The trace element is found mainly in meat, fish, shellfish and poultry. The phytic acid found in legumes, cereals and bran can inhibit the absorption of zinc. Zinc deficiency can occur with chronic intestinal disease or a strict vegetarian diet. A deficiency is compensated for by taking zinc tablets (one milligram per kilogram of body weight per day) for one to two weeks. Dietary supplementation with zinc provides benefit only when deficiency is present [127].


    Copper is a catalyst in many enzymes of cellular respiration and hormone metabolism. The Recommended Dietary Allowance (RDA) for adult men and women is 0.9 milligrams per day. In the body, copper is stored in muscle tissue and bones. Copper deficiency is rare. Causes include unbalanced artificial nutrition through infusions in critically ill people and rare hereditary copper metabolic diseases. Copper is found in foods such as meat, seafood, nuts, seeds, whole grains, legumes and cocoa. In the blood, 60 to 95 percent of copper is bound to the protein ceruloplasmin. Copper deficiency is determined by coeruloplasmin level (less than 20 milligrams per deciliter) and serum unbound copper (less than 60 micrograms per deciliter or 10 micromoles per liter). There is no evidence that supplementing the diet with copper can stop or prevent hair loss.


    Magnesium acts as a catalyst for numerous enzymes in cellular respiration and in the production of genetic building blocks. In the body, magnesium is mainly stored in the bones. The major dietary sources of magnesium are vegetables, fruits, grains, and nuts [128]. Magnesium blocks the transport of calcium of the muscle cells. Therefore, when there is a deficiency of magnesium, the calcium in the muscle cells increases. Therefore, a deficiency of magnesium can lead to muscle cramps and hypertension [129]. There is no scientific evidence for the benefits of magnesium supplementation for hair loss.


    Selenium is important for the function of many enzymes of the body and for the immune defense. Enzymes that rely on selenium, for example, protect against free radicals, metabolize thyroid hormones, make building blocks of genetic material [130]. Selenium-rich foods include seafood, meat, and grains and cereals. Brazil nuts have the highest selenium content. Both too much and too little selenium can be hazardous to your health. Ingesting too much selenium can cause hair and nail loss, nervous system and skin disorders, and paralysis [131].

    Biotin (vitamin B7)

    Biotin is important for the function of certain enzymes and for gene regulation. Foods rich in biotin include egg yolks, calf’s liver and some vegetables. The daily requirement for biotin is estimated to be 5 to 35 micrograms per day (21-143 nmol/day) [132]. A deficiency of biotin leads to skin rashes, inflammation of the conjunctiva, hair loss, impaired coordination, and seizures. Biotin deficiency can be detected by increased urinary excretion of 3-hydroxyisovaleric acid [133]. Dietary supplementation with biotin is considered safe because excess biotin is excreted in the urine. Supplementing with biotin can falsify test results in the event of a heart attack, delaying timely life-saving treatment [134]. Biotin deficiency is observed when taking certain drugs (carbamazepine, phenytoin and phenobarbital, isotretinoin), the elderly, malnutrition, excessive alcohol consumption and tobacco smoking. Unless a deficiency has been demonstrated, dietary supplementation with biotin does not produce measurable improvements in hair growth [135] [136].

    Home remedies for hair loss

    There are almost countless home remedies, natural remedies and shampoos that are offered for hair loss. Unlike prescription drugs, manufacturers are not required to prove an effect. The effects of the sleeping berry (Withania somnifera, in Sanskrit Ashwagandha), of turmeric and of capsaicin on congenital hair loss have not been scientifically proven. Also, there are no studies showing the benefits of pumpkin seed oil or saw palmetto for androgenetic alopecia [137]. There is no scientific evidence for the hair growth promoting effect of Schüssler salts and fenugreek. The reports on positive effects of horsetail (Equisetum) and the dietary supplement dimethylsulfone (methylsulfonylmethane) on hair growth are not free of conflicts of interest. The studies were conducted by employees of or were funded by the companies that manufacture and market these foods [138] [139] [140].

    Field report on hair loss treatment

    Numerous patients who suffer from hair loss and wish to have a full head of hair again have already made use of the various treatment methods at CenterPlast and shared their experiences. Patient testimonials as well as reviews can be found in the popular online portals for grading doctors. You will also find a separate category on the topic on our website. In addition, several patients who have had treatments at CenterPlast have agreed to tell interested parties about their experiences. Talk to us about this possibility during your personal consultation.

    Before and after pictures for hair loss treatment

    It is not allowed by law to publish before and after photos of hair loss treatments on the internet. However, you are welcome to view such pictures during the consultation to get an impression of the expected result. In our menu category Service you will find further information on the subject under the item Before and After Pictures.

    Costs of hair loss treatment at the CenterPlast practice in Saarbrücken

    If you would like to know the price of a hair loss treatment at the CenterPlast practice in Saarbrücken, simply try our online price calculator now.

    The author

    Dr. Adelana Santos Stahl

    “Our goal is to provide the best, most discreet and precise treatment based on our extensive expertise in plastic surgery. „

    Dr. Adelana Santos Stahl is distinguished by a unique international perspective with a feminine view of plastic surgery. Her personalized and detailed approach is key to the beautiful and natural results she achieves. Having trained in Brazil, one of the largest and most well-known countries for aesthetic and reconstructive plastic surgery, she understands her patients’ desire to look and feel their best.She completed her medical studies and her training as a specialist for plastic and aesthetic surgery in Brazil. In 2009, she also successfully passed the German equivalence examinations for the medical state examination. Two years later, in 2011 she received the German and in 2012 the EU specialist recognition (EBOPRAS) for plastic surgery.From 2009 to 2013, she deepened her knowledge of aesthetic and reconstructive facial surgery with world-renowned representatives of plastic surgery such as Professor Gubisch at the Marienhospital and Madame Firmin in Paris.A VDÄPC Fellowship (continuing fellowship for graduate students) in Switzerland, France and the USA has further enriched her professional experience.Dr. Santos Stahl is active in several prestigious professional societies. Besides the DGPRÄC and DGBT, she is also a member of the Brazilian Society of Plastic Surgery – SBCP.She is also the author of several scientific articles and, together with her husband, is dedicated to research and clinical studies in the field of plastic surgery.


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