You whip your hair back and forth. You can actually lose hair from constantly pulling it, whipping it, swinging it, or just having a tight hairstyle like a ponytail or cornrows. This condition, known as traction alopecia, affects only the portion of hair being tugged. Time to let down your hair and loosen up.
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Quick Consult
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Hair in a (Pill) Bottle
Many people with thinning hair or baldness can get some of their mop back with medications that promote hair growth. Of note, however, these medications only help if the hair loss is from androgenetic alopecia. In addition, the internet is full of bogus cures that will probably not thicken your mane but will definitely thin your wallet. Therefore, we always recommend you use these medications in consultation with your doctor.
For men, the best choices include a scalp cream (minoxidil, sold as Rogaine and other brands) and a pill (finasteride/Propecia). Finasteride is most effective in younger men. An extra bonus is that it shrinks the prostate and increases the force of your urine stream. Unfortunately, it can also cause sexual dysfunction in about one in one hundred men—which perhaps negates much of the purpose of regrowing your hair.
For women, the major options are minoxidil cream and spironolactone/Aldactone pills. Spironolactone is only effective before menopause. It’s also a water pill, so users may find themselves running to the toilet a bit more often. It can sometimes cause high potassium levels and breast enlargement/tenderness. Importantly, it cannot be taken during pregnancy.
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Make an Appointment
You feel tired all the time, and it’s not from staying up all night worrying about your hair. Thyroid disease and iron-deficiency anemia can both cause hair loss and decreased stamina. Low thyroid function causes constant fatigue, while anemia causes shortness of breath and decreased exercise tolerance. Simple blood tests can identify these problems and guide treatment.
You just recovered from a major stressor . . . and now you’re going bald! The intense stress associated with surgery, weight loss, childbirth, and any other emotional experience can force most of your hairs into the telogen stage. Since this stage lasts an average of three months, most of your hairs start to fall out after you’ve moved on from the stressor. This condition is called telogen effluvium, though a more appropriate name might be “insult added to injury.” Fortunately, your hair will grow back. Unfortunately, there’s nothing you can do to speed up that process, so it may be time to invest in a nice wig. It’s also reasonable to check in with your doctor to ensure you have the right diagnosis.
You need to comb through your medications. Medications that can cause hair loss include many chemotherapies, warfarin/Coumadin, steroids, birth control pills, lithium, amphetamines, and vitamin A supplements. In most cases, your hair will come back within a few months of stopping the offending medication. Please speak to your doctor before stopping any medications.
You develop small, smooth, round patches of hair loss. You may have alopecia areata, which occurs when your body’s immune system mistakenly attacks some hair follicles. This condition affects about one in fifty people, usually before age thirty. It causes smooth, coin-size patches of hair loss, surrounded by a border of short hairs. In rare cases, patients can lose all the hair on their beard (alopecia barbae), their scalp (alopecia totalis), or their entire body (alopecia universalis, which is Latin for “smooth as a baby’s bottom”). About half of patients will regrow their hair within a year, though hair loss may recur. Injecting steroids into the areas of hair loss (in order to block the immune system) may help. Thankfully, this condition isn’t a sign of a broader autoimmune problem.
You have small patches of hair loss with itching and burning. You may have cicatricial alopecia (scarring hair loss), a severe type of hair loss that involves destruction of the hair follicle. Bottom line: that hair ain’t coming back. The affected area usually has a ragged-appearing edge and may also itch and burn. The goal is to make the diagnosis early and stop it in its tracks, usually with steroid creams and/or injections. Your dermatologist will likely do a small skin biopsy (not that painful) to confirm the diagnosis. There are many different types of cicatricial alopecia; one worth mentioning is central centrifugal cicatricial alopecia (say that five times fast), which affects mostly black women. In this condition, hair loss starts on the crown of the scalp and then works its way outward. Other very common types include lichen planopilaris and frontal fibrosing alopecia.
You also have a butterfly rash (see here). Lupus is a potential cause of hair loss in young women. It also causes the classic “butterfly” red rash over the nose and cheeks. Sometimes lupus just causes thinned and/or dry hair. In more severe cases, however, it can cause permanent hair loss, turning the underlying skin pale or dark in color. Lupus can also cause serious problems with the heart, kidneys, and joints, so it’s important to get a thorough evaluation whenever it’s suspected.
You got freaky with the wrong person. Here’s one more reason to use protection: sexually transmitted infections can cause hair loss. Maybe it’s nature’s way of decreasing your sex appeal until your business is back in order. The major cause of sexually transmitted hair loss is syphilis. (Newsflash: syphilis is still around, not just something you read about in your grandfather’s diary.) Syphilis causes scattered little patches of hair loss that are usually described as being “moth-eaten” in appearance (as if a little moth nibbled at your hair). Hair loss has also been associated with HIV, both from the disease itself and some of the medications used to treat it (like lamivudine/Epivir). For unclear reasons, black people with HIV may also experience straightening of their hair.
You have itchy, scaly areas of hair loss. A common reason for itchy, scaly areas of hair loss on the scalp is the fungal infection tinea capitis. The fungus actually breaks the hair at the scalp rather than causing it to fall out altogether; thus, affected areas are usually covered with little dots, representing tiny broken hair stumps. The condition is contagious, so think about that before you borrow a hat from anyone with a bald spot. Another potential cause of itchy plaques with hair loss is psoriasis, particularly if you have this disease on other parts of your body, like your elbows or knees. A visit to a dermatologist can help clarify the diagnosis and determine the right treatment.
Get to the E.R.
You are taking a medication for hair loss and experience severe dizziness, confusion, and/or loss of consciousness. The medications that treat hair loss—including minoxidil/Rogaine, finasteride/Propecia, and spironolactone/Aldactone—can all cause dizziness, but minoxidil and spironolactone are also specifically used to treat blood pressure and could drop yours to dangerously low levels. In addition, spironolactone can cause high levels of potassium, increasing your risk of heart arrhythmias. If you take one of these medications and experience severe lightheadedness, a rapid heart rate, and/or loss of consciousness, get help right away.
Excessive Bleeding or Bruising
The average adult body contains about five liters of blood, enough to fill nearly a dozen Snapple bottles. (Do not try to prove the accuracy of this statement.)
Blood brings oxygen to your organs, fights infections, delivers waste to the kidneys and liver, and much more. Your blood doesn’t do much good, however, if it’s collecting in a pool on the ground. To prevent this scenario, your body can generate thick globs of congealed blood known as clots, which cover any holes like plaster on a wall.
In some cases, clots don’t form as quickly as they should, resulting in bleeding or bruising in response to minor injuries. The consequences can range from annoying, recurrent nosebleeds that freak out dates and coworkers to massive, life-threatening bleeds that would scare even the most jaded horror movie enthusiasts.
Fun fact: the medical term for bleeding to death is “exsanguination.” It’s pretty rare, however, for people to literally get down to their last few drops. More often, bleeding becomes life-threatening when it occurs around the brain (whi
ch gets squished from the added pressure), or when the dwindling blood supply no longer provides adequate oxygen to the heart, which calls it quits. As all medical students learn early on, all bleeding stops . . . eventually.
So perhaps your arms and legs bruise more easily than they used to. Maybe you have recurrent nosebleeds or heavy periods. Is it normal? Should you be worried about the blood loss adding up? Do you need iron pills—or an ambulance?
Take a Chill Pill
You get occasional nosebleeds. If your nose bleeds just a few times per year, stop worrying. The major causes include nose picking (especially if you gnaw your nails into sharp edges) and common colds (from frequent blowing and wiping). Nosebleeds are also more common in the winter because dry air irritates and cracks the lining of the nostrils; the solution is simply to get a humidifier for your bedroom. Despite popular belief, high blood pressure does not cause nosebleeds, though seeing blood gush from your nostrils may raise your blood pressure. Nosebleeds usually stop if the nostrils are squeezed together for at least twenty minutes. More stubborn bleeding may require an E.R. visit. If your nose bleeds several times per week, or you’ve had multiple E.R. visits for uncontrollable bleeding, ask your doctor to check for clotting disorders.
You take an antidepressant. The most popular antidepressants are selective serotonin reuptake inhibitors, or SSRIs, which alter signals in the brain that depend on the chemical serotonin. Unfortunately, your clot-forming blood cells (platelets) use this same chemical to communicate while forming a clot. As a result, some people on SSRIs may notice a very mild increase in bleeding or bruising. A more significant increase in bleeding suggests a different problem.
You take a daily aspirin or pain medication. The NSAIDs—a popular class of pain relievers that includes aspirin, ibuprofen/Advil/Motrin, and naproxen/Aleve/Naprosyn—block the normal function of blood platelets and cause a slight increase in bleeding risk. Sometimes this effect is intentional: for example, your doctor may prescribe a daily low-dose aspirin (formerly known as baby aspirin) to help prevent the blood clots that cause heart attacks and strokes. In those taking high doses of NSAIDs for pain, however, bleeding can become a bothersome side effect. If you’re taking aspirin to prevent a heart attack or stroke, speak to a doctor before stopping it. If you’re taking an NSAID for pain, try switching to acetaminophen/Tylenol.
Later in life, you started getting frequent small bruises on your arms and legs. Your skin, unlike your waistline, reliably gets thinner with age. The blood vessels become closer to the surface and more susceptible to the slings and arrows of everyday life, with minor injuries more likely to result in bruises. If you have a long history of sun exposure or steroid cream usage, these changes can occur even earlier. Unfortunately, there is no effective treatment other than wearing long-sleeved shirts and pants.
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You’re pretty sure you bleed or bruise more, and more often, than the average person. Your doctor should test you for a bleeding disorder if any of the following sounds familiar:
You frequently notice large bruises all over your body despite no recent major injuries.
You have nosebleeds several times per week or have been to the hospital multiple times for nosebleeds.
You have very heavy periods, but your gynecologist says your uterus looks normal.
Your joints swell and bruise after minor injuries.
Your dentist says you bleed a lot after tooth extractions.
If the initial tests look normal, your doctor should also check for von Willebrand disease, a bleeding condition that affects one in a hundred people but doesn’t show up on routine tests (and is often missed). People with von Willebrand disease may require special medications when they bleed or undergo surgery.
You miss school or work because of heavy periods. See here for our advice on dealing with vaginal bleeding. The bottom line is that heavy periods usually result from abnormalities in the uterine wall, like fibroids or polyps. If those aren’t present, however, it’s reasonable to consider a clotting disorder.
You take a blood thinner. What did you expect?! Blood thinners help prevent clots, but increased bleeding is an inevitable side effect. You and your doctor should have an ongoing discussion about the risks of clotting versus the risks of bleeding. The most common blood thinners are listed in the Quick Consult. Of course, you should never stop these medications without speaking to a doctor.
You’re glowing (and bleeding). See your obstetrician right away. Vaginal bleeding most likely indicates a pregnancy-related problem. Excessive bleeding or bruising elsewhere could indicate a new clotting disorder. For example, HELLP syndrome—an ominously named mash-up of “hell” and “help”—causes bleeding later in pregnancy owing to an abnormal destruction of platelets, the blood cells that produce clots. (The LP in HELLP actually stands for low platelets. The H stands for hemolysis, meaning destruction of red blood cells, while EL stands for elevated liver enzymes, meaning the liver is injured and releases high levels of certain chemicals into the blood.)
You have known kidney or liver disease. In advanced kidney disease, your kidneys are unable to adequately filter your blood, leaving behind chemicals that screw with your platelets. In advanced liver disease, your liver fails to produce adequate amounts of clotting factors, the chemicals that work with your platelets to form clots. If you notice increased bruising or bleeding, speak with your doctor. There’s no easy way to jump-start your kidneys or liver, but your doctor can check for any other reversible causes of bleeding.
You have had lots of diarrhea in the last few weeks or months. First of all, why are you ignoring your diarrhea?! You should definitely check out the chapter on that topic and get that situation under control. Long-standing diarrhea of any cause can result in poor absorption of certain vitamins, like vitamin K, from your food. Vitamin K is needed for the liver to properly create clotting factors. As a result, if you’re deficient, you’ll bleed and bruise more easily. Until your intestines get back to normal, you can take vitamin K supplements under the supervision of your doctor.
You have tiny bruises all over your skin. The widespread disruption of small blood vessels can lead to lots of small bruises, each about the size of an eraser tip. In some places, the bruises can join together to form larger ones. The medical term for this phenomenon is “purpura.” The many different causes include major disruptions in the clotting system, severe infections, calcium deposition in blood vessel walls (which can occur in advanced kidney disease), and autoimmune diseases. See your doctor as soon as possible. If the lesions are painful and/or you’re spiking high fevers, go to the emergency room.
You’ve had occasional bleeding for a few days or weeks and often feel tired or winded. You’re likely anemic, meaning your body’s blood supply is becoming perilously low. Your organs and muscles aren’t getting enough oxygen, causing them to tire out at low levels of exertion. See your doctor as soon as possible to determine and control the cause of bleeding. Patients with severe anemia need blood transfusions, while others can usually get by with iron supplements. (Iron is needed for blood cell production, and levels become low after lots of blood loss.)
You’re double-jointed. You could have a rare condition known as Ehlers-Danlos syndrome, which affects connective tissue in the body (basically, the stuff that holds together joints, skin, blood vessels, and so on). People with this disorder are extra flexible—meaning, for example, that when they put a hand palm-side down on a table, they can lift up that hand’s pinky until it’s pointing straight up at the ceiling. If you move like Gumby and also have really stretchy skin and frequent bruising (from fragile blood vessels), you might have Ehlers-Danlos syndrome. (When you mention this to your doctor, be prepared for a brief, blank stare followed by some Googling.)
You have frequent nosebleeds and tiny red dots on your lips, tongue, and/or fingertips. You could have a rare condition known as Osler-Weber-Rendu syndrome, also known as hereditary hemorrhagic telangiectasia. (We hope you won a l
ot of spelling bees growing up!) In this condition, the body is full of dilated, fragile blood vessels and abnormal connections between arteries and veins. The most common symptoms are frequent (weekly or even daily) nosebleeds and/or bloody stools. Most patients also have numerous red dots on their lips, tongue, and/or fingertips, which are actually just enlarged blood vessels near the skin’s surface.
You did not put the lime in the coconut. Ahoy, matey! It’s pretty unlikely you have scurvy, but it can cause frequent bruising and is fun to talk about. This disease, which occurs if you go weeks without eating vitamin C, was once common among seafarers and explorers. Foods rich in vitamin C include lemons, limes, strawberries, brussels sprouts, broccoli, and cauliflower—not the sort of rations typically found in the cargo hull of a pirate ship. Because vitamin C is required for the creation of connective tissue (which holds together blood vessels and joints), deficiency causes frequent bruising. Nowadays, scurvy occurs primarily among those who are severely malnourished.
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Quick Consult
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Your Blood Clots Too Easily
Although blood clots are an effective plaster for damaged vessels, sometimes you end up with plaster where it doesn’t belong, and the consequences can be disastrous. For example, heart attacks occur when tiny clots form in the arteries supplying the heart muscle with blood. Likewise, strokes often occur when small blood clots block the arteries that supply the brain with blood. Finally, blood clots in the legs or pelvis can travel to the lungs and block the flow of blood back to the heart (a condition known as pulmonary embolism).
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