Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered Podcast. I'm Dr Neha Pathak, WebMD’s Chief Physician Editor for Health and Lifestyle Medicine. Today we're talking about alopecia. Alopecia is the medical term for hair loss. It can affect the scalp, eyebrows, eyelashes, and other areas of the body, leading to patchy, partial, or complete hair loss.

There are many types of alopecia, and we'll be covering a lot of them today. For example, in alopecia areata, the immune system mistakenly attacks hair follicles, causing hair loss. Nearly 7 million people in the U.S. currently have some form of alopecia areata, but there are other, more common types of hair loss—from telogen effluvium, or stress-related hair loss, to age-related pattern hair loss.

Regardless of type, hair loss can be confusing and emotional, so we're going to take a step-by-step approach to help you understand the basics. We'll talk about the different types of alopecia and when these conditions most commonly develop. We'll discuss what to expect after diagnosis, treatment options that can help manage hair loss, and how to cope with the emotional impact that often accompanies it.

Whether you're experiencing hair loss yourself or supporting someone who is, this conversation is here to help you feel informed, empowered, and understood.

First, let me introduce my guest, Dr Carolyn Goh. Dr Goh practices general medical dermatology with a specialty in hair loss and scalp disorders. Her research and clinical interests are in all types of hair loss, including alopecia areata and scarring alopecia. She's been active with patient advocacy groups and local support groups for patients with hair loss.

Welcome to the WebMD Health Discovered Podcast, Dr Goh.

Carolyn Goh, MD: Thank you so much for having me.

Pathak: Welcome, welcome. And full disclosure, we are medical school colleagues and friends, so I'm really excited to spend this time with you.

Before we jump into our topic for today, I'd love to ask about your own personal health discovery and how that really informs the research that you do or the work that you do with your patients.

Goh: What I've noticed recently with my patients is just how much hair loss is out there. I, you know, clearly have a biased sample—I specialize in it, so people come to me with it—but it just seems like it's impacting so many people these days. And there's so much associated anxiety, both triggering the hair loss to some degree, as well as being a result of their hair loss.

And I think that sometimes what surprises even people themselves is the impact it has on them. People who don't think that they are vain people, who don't think their hair is that important to them, realize that it really is. It makes a big impact. And it's not really vanity, you know—it's more a part of who you are.

It's how you see yourself, how the world sees you. And I think that's something that I carry through with our discussion today. And just overall, something to think about: hair loss is more than just hair.

Pathak: Before we sort of get too far down our conversation, I'd love to start with some of the basics. Can you give us some general definitions around what alopecia is, and when we talk about hair loss, how do you define the different types of alopecia?

Goh: So alopecia just means hair loss of any kind. And there are a lot of different types, and usually we divide it into non-scarring and scarring. Scarring meaning permanent loss—and usually when people have scars, you can tell because it's very smooth.

Sometimes it's actually associated with kind of like a rash on the scalp. People get pimples, they have pain, itching—and those are fortunately much less common than the non-scarring types.

Another way to think about it is also diffuse versus localized. Diffuse being kind of all over, maybe in certain areas more than others. Like if you think male pattern hair loss, it's more on the top of the head, and they tend to have thicker hair still on the sides.

Women often, when they have pattern hair loss, are also a little thinner on the top—sometimes the temples—but overall, there's no smooth spots of hair loss. And sometimes you'll have patchy or very clear, coin-shaped spots where it's smooth, like your face. That's more like alopecia areata.

So those are kinds of the ways to think about it. When people sometimes come in and see me and they say, “Do I have alopecia?” I say, “Well, you told me you have hair loss, so you do have something. You have some type of alopecia—but let's figure out what kind.”

Pathak: And then tell us a little bit about how you figure out what kind.

Goh: So a lot of it is—dermatology is a very visual field—so a lot of it's just by looking and examining. But we can also get some clues from the history.

If it's something that's happened very suddenly, and a lot of times people can think of exactly when it started, and it's diffuse, and you're seeing a lot of hair coming out in clumps in your hands in the shower, that's usually something called telogen effluvium.

Telogen effluvium is often several months after some type of stress. It can be because of medications. It can be because of some major stress, like loss of a family member. Oftentimes after pregnancy, it'll happen.

But it's interesting—you have to think about there's a delay there. So then we look, we might feel, we might take a little gentle pull of the hair and see how much comes out in our hands. And then we often actually look very closely.

We have these devices called dermatoscopes, kind of like a little handheld microscope or magnifying glass. And we can look at the hairs themselves and see if there’s new growth happening, or if there are different sizes of hairs. We can see if the scalp itself is red or flaky, and that can give us a lot of different clues.

Pathak: That's really helpful. And so you're looking at the hair visually, you're looking at the pattern visually, you're listening for a story.

In terms of types that are reversible or irreversible—you mentioned that if you see scarring, that's generally something that is going to be irreversible. So let's start with that type of alopecia. Let's dig into that a little bit more. What are some of the reasons that someone might develop scarring types of alopecia?

Goh: That's a great question, and I wish we knew. But I'm happy that we're starting with scarring alopecia because it gets a little less attention out there. And while it is less common, it is more urgent, right? Because if you are losing your hair and it's not reversible, it's something that we'd want to try to intervene on earlier.

So there are a lot of theories out there. Something I heard recently was thinking of it like there are multiple reasons usually. And sometimes I'll tell my patients it's kind of like the perfect storm.

You have maybe the right genetic tendencies. Maybe you have a tendency to get a little more inflamed or reactive to things. Maybe you've done a few more harsh haircare practices, like perms or really tight hairstyles. Maybe you were exposed to some type of illness or something.

So it's probably a couple different things that go on, and then suddenly you develop this condition. Another way to think about it really is that it's kind of like a rash, right? Why did you get a rash? Why did you get this or that? We don't always have those answers.

But we do have some tendencies. Some types of scarring alopecia tend to happen more in postmenopausal women, for example. There's a form called frontal fibrosing alopecia, which was first described in the 1990s. Since then, hundreds and thousands more cases have been seen and described, and it definitely seems to be increasing in frequency.

Interestingly, it tends to occur in postmenopausal women—not to say that it doesn't occur in younger women or men. With frontal fibrosing alopecia, the hair gets progressively lost from the front, sometimes all around the sides, edges, and back of the hair, as well as the eyebrows.

Men and women can both lose sideburns, and some men will lose beard hair too. Sometimes even body hair is lost, and sometimes it's very subtle at first. So there are a lot of reasons people might have a delay in diagnosis.

But it is something to be aware of. It can almost look like pattern hair loss because there's a recession in the front. And it does seem to affect hair that might thin in other people. So that genetic tendency to have hair loss may also contribute to developing something like frontal fibrosing alopecia.

Pathak: So let's continue then with talking about some of the other types of scarring alopecia.

Goh: So other types of scarring alopecia, very common, is something called central centrifugal cicatricial alopecia. It's a mouthful. We usually call it CCCA. But you can think about it as—it is really descriptive. So it's central—it usually starts around the top of the head—and centrifugal, meaning that it tends to start in the middle and then kind of spread outward.

And then cicatricial just means scarring, and alopecia, of course, means hair loss. That's very common, especially in Black individuals. There have been some genetic factors found there, and it mostly happens in women more than men. And so the thought there is yes, there's a little bit of a tendency—Black hair tends to be more curly, so structurally there's maybe a little more fragility there. There have been links with perming and heat, but it's not the cause, because people who've never done those things can still develop it. I think it's just that the hair itself is structurally more fragile and breaks more easily, and therefore can get inflamed more easily too. But that's a really important one to catch early.

And so anybody who's experiencing this usually has a little bit of burning or redness, maybe some pimples, like I mentioned earlier. So if you're experiencing these types of things, it's good to get seen even before hair loss is really noticed. The hairdressers can often play a big role there, right? You go see the hairdresser regularly, and if they start to notice something, referring to a dermatologist would be really helpful early.

Pathak: And then talk to us a little bit about early intervention. So somebody notices some of the things that you've talked about, and you mentioned that it's really important to intervene early to slow down, potentially stop what's happening. Can you talk to us about what interventions you would be thinking about?

Goh: So usually we're talking a lot about inflammation here, and the interventions that we start with are usually anti-inflammatory. In dermatology, we use a lot of topical steroids, and injections of steroids in order to intervene early. It may also be recognizing that you need to switch your hair care routines, and maybe there's some intervention we can do.

We can do that hopefully very simply—sometimes different shampoos. We use a lot of antifungal shampoos sometimes to help reduce the inflammation on the scalp. Also, there are oral medicines, usually when things are a little more severe—also anti-inflammatory medications. There we even use sometimes oral antibiotics for a few months, short periods of time. And a lot of times there's a medication called hydroxychloroquine that we use for some of the scarring alopecia also.

Pathak: And how effective are these treatments? I imagine that it depends on how early you intervene. But is this the good news part of the story—that if you intervene early, this can really be slowed down or stopped?

Goh: So we would love to believe that. And I would say we don't know for sure. I would say probably, and most likely we can get in there. And I do see some people with CCCA, for example—we get in there early and we are able to see some actual regrowth of their hair. Lupus is another disease that can sometimes present with hair loss and usually rashes, kind of plaques on the skin.

And that's another one where if you treat early enough, sometimes you do see improvement. Interestingly, another one to mention is sometimes people will get fungal infections in their hair and it'll cause hair loss. That's another one—if you recognize it and treat it, since it's an infection, the hair usually grows back and you can actually see improvement.

So those are some where we know for sure. Sometimes we don't know as much—sometimes it looks like there's inflammation, there's some itching, it looks like it might become a scarring alopecia, and then it doesn't. It actually is just a little bit of inflammation that you had. So sometimes in medicine we have a little bit of those unknowns where we don't know who's really going to get worse and who's not. And we can't—if we could clone somebody and treat one person and not treat the other, then we would know for sure if we've made an impact.

But a lot of times we don't have that information. But I think overall, there are definitely specific situations where we know we make an impact. And I think it's usually better to be safe than sorry, but we try not to be—we don't want our treatments to be worse than the actual condition either. So it's really important, and the way I practice medicine is really personalized and taking into account the patient's values and individual situation.

Pathak: I'd love to dig in a little bit more to what we know about when some of these forms are more common than others. So you mentioned some that are more common in post-menopausal women. We've talked about male pattern hair loss, that can happen over the course of a lifetime. Tell us about some forms that might be more common in childhood, adolescence, and is there something where you can say it starts happening in childhood—it's more commonly a particular type versus something that happens later in life.

Goh: Yes, definitely. So we've been talking about scarring alopecia, and those definitely tend to happen more later in life. They're less common in children. We do have some that can occur in children, much less likely. The most common thing I think people think about in children with hair loss is alopecia areata.

That's aside from, we mentioned fungal infections of the scalp—that is pretty common, more common in children. Also, as you can imagine, just like warts and other things where kids are in close contact with each other, they may get an infection more easily as well. So that's always an important one to think about because, like I said, it's easily cured.

But alopecia areata—as far as primary types of hair loss—alopecia areata is the one we usually think of with kids. With alopecia areata, that's where you get spots of hair loss. They're usually smooth, and they often just come and go. They can be one or two small lesions on the scalp or anywhere on the body really, or they can be full hair loss—total hair loss on the scalp and the body, including eyelashes and eyebrows.

But the most common time that occurs is between the twenties and forties. However, it can happen in kids—even as young as a couple months old, people may have alopecia areata. And even I've had new patients who've never had a spot of hair loss in their eighties or nineties present for the first time. So it's really something that can occur at any age. But like I said, most people are between the twenties and forties. And I want to say at least half of people will present before the age of 20. So it is something that often does affect younger people.

Pathak: How do you make that diagnosis of alopecia areata? Are there specific criteria?

Goh: So actually no, it's a clinical diagnosis. It's something that is very recognizable. There are other things that could be sometimes—people pull their hair, and that's called trichotillomania. That is a condition where people have this little habit of pulling their hair. Sometimes it presents similarly to alopecia areata in little circles, but usually the scalp is not as smooth as it is.

Fungal infections, again, sometimes will look similar, but it's usually something that we can just look at and recognize. Sometimes with any type of hair loss, the dermatologist may do a biopsy of the skin, where we take a little sample—it’s usually like a little circle of skin—and send it to the lab to look under the microscope.

There are features under the microscope that are more diagnostic of alopecia areata or other types of hair loss. That can be another way to be more certain. None of these are like a checkbox—yes, you have it or no, you don’t—but in general, dermatologists can recognize these just by looking.

Pathak: And then how does your management differ if someone has a diagnosis of alopecia?

Goh: So alopecia areata is an autoimmune disease also, and it's very well established that it's almost like an allergy to the hair that somebody develops. And so the treatment again is usually something anti-inflammatory. Oftentimes topical steroids or injections of steroids are the first-line treatment, especially if you have very localized, smaller spots—sometimes about an inch or smaller, maybe dime-sized—and then we can just inject it. A lot of times the hair will grow back pretty quickly.

Sometimes those injections have to be every month or so until it gets better. And then if it's more—and usually when we say more, it's something like 20% or more of your hair, maybe 50% or more of your hair is gone, or it's really impacting you a lot, or you have eyebrows and eyelashes lost, or maybe it's falling out really fast—then we can offer oral medicines.

These are usually in the class of JAK inhibitors, or Janus kinase inhibitors. They're newer medications, and we actually have three of them approved for alopecia areata by the FDA. So it's very exciting—a very exciting time with alopecia areata specifically, where we have these tools, and they're pretty effective in getting people to grow their hair back.

But they do have some risks associated. So it is a discussion that we have with patients to determine if it's the right medicine for them.

Pathak: You've been so helpful in helping us understand the different types of alopecia, the different ways that you might go about identifying what type someone has, and the interventions that actually have an evidence base. Can you talk a little bit about the emotional impact of hair loss? When you're talking to your patients, how do you help them through that part of their hair loss journey?

Goh: It's a lot of empathy—seeing people where they are, and we talk about what the impact is. Sometimes people don't feel like they can open up about it, or that people don't understand what they're going through. And so just expressing that in a visit is really important.

I also provide a lot of resources for scarring alopecia. There is a group called the Scarring Alopecia Foundation. It's a patient advocacy group that provides webinars and online resources. They have a patient conference every few years. There's a lot of Facebook groups, honestly, for scarring alopecia, which are very active.

So you can kind of see what others are dealing with, what others have tried, and get some advice that way. I do encourage people to reach out to some of these resources. There's the National Alopecia Areata Foundation, one of the patient advocacy groups for alopecia areata. Now, people who have more like pattern hair loss or telogen effluvium, there tend not to be as many specific resources for them.

However, both of those groups I mentioned—the Scarring Alopecia Foundation and the National Alopecia Areata Foundation—both have support groups, and a lot of them are online now, so very easily accessible. I've had people who have very severe female pattern hair loss from a young age, and they will join us because the journey of losing hair is often very similar.

And there are a lot of similar themes that you can get regardless of the type of hair loss that you have.

Pathak: Thank you so much for all of those resources. I'd love to end our time together by really empowering someone who's listening with information about how to have this conversation with their healthcare provider when it comes to hair loss. You mentioned that there are some forms that you really want to identify early and get to a dermatologist as early as possible.

So how do you suggest a patient can be the most empowered? What kinds of questions should they be bringing to their healthcare professional if they're concerned or worried about hair loss?

Goh: That's a wonderful question, because I have people who come in and they say, "I've been trying to get a referral to dermatology for a long time," and their primary care provider just—for whatever reason—they were unable to get in.

And yet, on the other hand, sometimes we have people who just started losing their hair, and they're shedding, and all of a sudden they get in with a dermatologist. I think awareness is probably the number one thing, and then advocating for yourself—saying, "I've heard that there are some more serious types of hair loss, and I would really like to get in and see a professional, because I'm worried that maybe I do have that."

Encouraging their doctor to take a good look if they can, but I think equipping yourself with as much knowledge as possible so that you can advocate for yourself is probably the best way to go about it. Now, other things that might push you in one direction are if you are having symptoms, like itching or redness of the scalp or even other areas—that might be a little thing to highlight with your doctor in order to get a referral.

And it's always important to think about other symptoms, like if you're losing weight, if you're not feeling well overall, or having any joint pains—of course, those are more red flags.

Pathak: I just want to thank you so, so much for your time. This has been such a really informative conversation, so thank you again.

Goh: Thank you. Thank you for giving us the opportunity to highlight these diseases, and especially some of the less common ones. It's a really good way to get the awareness out.

Pathak: As we close this episode, I want to acknowledge something we said at the beginning: Hair loss is never just hair. Hair loss can impact identity, confidence, and how you move through the world. You deserve both answers and support, and we hope we've offered both in this episode.

My three key takeaways from the conversation with Dr Goh are:

First, alopecia is an umbrella term. It's important to figure out which type through careful evaluation, including looking at the pattern, timeline, other symptoms, and how the scalp itself looks. The information can make all the difference in choosing the right next step.

Second, your scalp is trying to tell you something, so don't delay. When you notice a change, especially if it's accompanied by itching, burning, tenderness, redness, or smooth, shiny patchy areas, those can be signs of inflammatory or scarring conditions where early treatment may help slow or prevent permanent hair loss. If something feels new or rapidly changing, it's worth advocating for a dermatology evaluation sooner rather than later.

And finally, a quick fix may not be the right fix for you. There's a huge market of supplements and products. It's important to focus on the evidence, as even natural supplements can have real effects and side effects.

To find out more information about Dr Goh and her work, make sure to check out our show notes. Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform. If you'd like to send me an email about topics you are interested in or questions for future guests, please send me a note at [email protected].

This is Dr Neha Pathak for the WebMD Health Discovered Podcast.