Dr Rishika Sinha is a Consultant Dermatologist at Dr Sam Bunting + Associates, trained at the University of Cambridge and is a Member of the British Association of Dermatologists. She sees patients with eczema and other inflammatory skin conditions every week in clinic and has a particular interest in building long-term, practical management plans that actually fit around patients' lives. She is on the GMC specialist register.
Hair Loss and Thinning: Why It Happens, and What Can Actually Be Done
Hair loss is one of those things that creeps up insidiously and hits hard when you finally see it clearly. Maybe you’ve noticed clumps in the shower drain or on your pillow. Or maybe your parting looks wider than it did a year ago.
What makes it worse is the noise around it. Supplements with before-and-after photos. Shampoos claiming to stimulate growth. Advice from someone online who had a completely different kind of hair loss to yours. The most important truth about hair loss is this: the reason matters enormously. The wrong treatment for your type will do nothing. The right one, started at the right time, can stop the progression and in many cases produce meaningful regrowth.
I see patients with hair loss every week at Dr Sam Bunting + Associates. Some have been dealing with it for years without anyone explaining what’s actually happening. This blog is intended to change that.
Why Is My Hair Falling Out? The Most Common Causes
Hair loss is not one condition. It’s a presentation that can result from several different underlying processes, and identifying which one matters before any treatment is considered.
Androgenetic alopecia (AGA) is the most common cause of progressive hair loss in both men and women. It follows a recognisable pattern: in men, recession at the temples and thinning at the crown; in women, diffuse thinning across the top of the scalp with the frontal hairline usually preserved. It is driven by sensitivity to dihydrotestosterone (DHT), a hormone derived from testosterone, and progresses gradually over years. Genetics load the gun, but the timeline and severity vary widely. Critically, it does not reverse on its own, and the longer treatment is delayed, the more follicles are lost permanently.
Telogen effluvium (TE) follows a significant stressor: illness, surgery, childbirth, crash dieting, or a period of prolonged deficiency. Follicles are pushed prematurely into the resting phase, and shedding follows two to three months later. By the time the hair is coming out in handfuls, the trigger is usually long past. Acute TE typically resolves once the stressor is removed; chronic TE is more complex.
Alopecia areata is an autoimmune condition in which the immune system attacks hair follicles, producing smooth, coin-shaped patches of loss. It can affect anyone at any age and requires a different treatment approach entirely.
Other causes include thyroid dysfunction, iron deficiency, seborrhoeic dermatitis, and certain medications, all identifiable with a thorough history and blood panel.
How Do We Actually Diagnose Hair Loss?
The diagnosis of hair loss requires clinical assessment and, in some cases, laboratory investigation. Without both, you are guessing.
At a consultation, I’ll take a detailed history: how long you’ve noticed the loss, whether it’s shedding or thinning, where it’s most pronounced, any recent stressors, your menstrual and contraceptive history if relevant, your diet, and your family history. Each piece shapes the diagnostic picture.
A trichoscopy (dermoscopic examination of the scalp) gives us detail about follicle health and hair shaft calibre that the naked eye cannot see. In androgenetic alopecia, we see follicle miniaturisation: hairs progressively reducing in diameter over successive growth cycles. In alopecia areata, exclamation-mark hairs and yellow dots. In scarring alopecias, rarer but urgent to catch, follicular destruction that demands prompt intervention.
Blood tests are ordered where indicated. The key markers I check include ferritin (iron stores), thyroid function (TSH and free T4), full blood count, vitamin D, and in women with signs of androgen excess, a hormonal screen.
What Treatment Options Are Available for Hair Loss?
Early treatment produces better outcomes in androgenetic alopecia. The main options are minoxidil, anti-androgens, and DHT blockers. They are not mutually exclusive, and many patients benefit from more than one.
Minoxidil: Topical and Oral
Minoxidil prolongs the anagen (growth) phase of the hair cycle and increases blood flow to follicles. It doesn’t block DHT, so it doesn’t address the underlying driver of AGA in isolation, but it stimulates growth effectively and has a strong evidence base.
Topical minoxidil is applied to the scalp once a day. The 5% solution or foam is the standard starting point. At least six months of consistent use is needed before results can be properly judged.
Oral minoxidil (low-dose) is increasingly useful for patients who find topical application impractical or haven’t responded adequately to it. At 0.625–2.5mg daily in women and 2.5–5mg in men, it is generally well tolerated. Side effects can include fluid retention and facial hair growth, which is why we titrate carefully and review regularly.
Spironolactone (for women)
Spironolactone blocks the receptor sites that respond to DHT and other androgens. It is useful in women with signs of androgen excess (acne, hirsutism, or irregular periods) alongside hair loss. It is prescription-only, not appropriate for men, not in pregnancy, and requires contraception during use. At 50–150mg daily, it is well tolerated by most women. Results take three to six months and persist only with continued use.
Finasteride
Finasteride blocks 5-alpha reductase, the enzyme that converts testosterone into DHT, directly targeting the hormonal driver of AGA. It is licensed at 1mg for men and used off-label in post-menopausal women where anti-androgen therapy is appropriate. In men it is among the most effective treatments available, with good evidence for stabilising loss and producing regrowth at the crown. Potential side effects include sexual dysfunction in a minority of patients, something I discuss in full at consultation, with the actual evidence rather than what the forums say.
Androgenetic Alopecia vs Telogen Effluvium: How Do You Tell Them Apart?
This is one of the most common points of confusion, and getting it wrong leads to the wrong treatment.
| Feature | Androgenetic Alopecia | Telogen Effluvium |
|---|---|---|
| Pattern | Progressive thinning at crown (women) or temples/crown (men) | Diffuse shedding across the whole scalp |
| Onset | Gradual, over months to years | Acute, 2–3 months after a trigger |
| Visible trigger | None | Usually identifiable: illness, stress, childbirth, rapid weight loss |
| Hair loss type | Miniaturisation and follicle reduction | Excessive shedding of normal-calibre hairs |
| Spontaneous recovery | Does not recover without treatment | Acute TE typically resolves in 6–12 months |
| Treatment | Minoxidil, anti-androgens, DHT blockers | Address underlying cause; minoxidil can support recovery |
Both conditions can coexist. TE can unmask an underlying AGA that was previously not noticeable, which is exactly the kind of complexity that gets missed without a proper assessment.
Signs You Might Be Missing the Right Diagnosis
- You’ve been shedding for more than twelve months without regrowth. Acute TE should settle within a year. If it hasn’t, either the trigger is ongoing, there’s a coexisting condition, or the diagnosis isn’t TE.
- Your parting has widened without a dramatic increase in shedding. Classic AGA: progressive miniaturisation reducing density quietly, without the alarm of heavy loss.
- You’ve tried biotin, switched shampoo, added a supplement, and nothing has changed. These are not treatments for androgenetic alopecia. They cannot reverse follicle miniaturisation.
- Your bloods came back “normal” but no one checked ferritin specifically. A normal iron level doesn’t tell us about stores. Ferritin below 40–70 mcg/L can worsen hair loss even when haemoglobin is within range.
- You’ve had a baby in the last six to twelve months. Postpartum TE is almost universal to some degree and is not a sign of permanent loss in most cases, but it does warrant an assessment.
Frequently Asked Questions
Will my hair grow back after telogen effluvium?
In most cases triggered by a single identifiable event, such as illness, surgery, childbirth, or significant emotional stress, yes. Shedding typically peaks three to four months after the trigger and settles over the following six to nine months, with density returning to baseline by twelve months in the majority of patients. The key reassurance is that the follicle itself is not damaged in TE, which is what distinguishes it from AGA. That said, the trigger should be identified and corrected where possible. If shedding continues beyond twelve months, further investigation is needed: chronic TE, nutritional deficiency, or an underlying AGA may be contributing.
Is hair loss in women the same as in men?
The biology is similar (DHT-mediated follicle miniaturisation in genetically susceptible individuals), but the pattern, hormonal context, and treatment options differ meaningfully. Women rarely develop the dramatic recession seen in men; thinning is typically diffuse across the crown with hairline preservation. Women are also more likely to have a contributing systemic factor such as iron deficiency or thyroid dysfunction, which is why investigation is often broader. Treatment differs too: spironolactone is an option in women that doesn’t apply to men, and finasteride requires careful reproductive consideration pre-menopause.
How long do I need to use minoxidil?
Minoxidil is a maintenance treatment, not a cure. It works while you use it. Stop, and the benefit is gradually lost over six to twelve months as follicles return to their pre-treatment cycle. This reflects the nature of AGA as a chronic, progressive condition, not a flaw in the treatment. It’s a conversation I have clearly at the first consultation, because starting treatment is a commitment to ongoing use.
Can I get prescription hair loss treatments at Dr Sam Bunting + Associates?
Yes. A consultation includes a full clinical assessment, trichoscopy where appropriate, and a personalised treatment plan. Where prescription treatment is indicated, whether that’s oral minoxidil, spironolactone, finasteride, or a combination, we issue prescriptions following consultation and review progress over time. We don’t prescribe without a proper assessment, and we don’t follow a one-size approach.
When to See a Dermatologist
If you’re noticing hair that isn’t growing back, a parting that’s widening, or shedding that’s lasted longer than six months, it’s worth a proper clinical assessment. The investigation itself isn’t complicated, but matching what we find on trichoscopy with your blood results, history, and pattern of loss is where clinical experience matters.
A consultation is also worth having if you’ve already been prescribed something by a GP or ordered something online and aren’t sure it’s working. Not all hair loss is the same, and not all treatment paths are equivalent.
At Dr Sam Bunting + Associates, we take the time to establish the diagnosis before recommending anything, and we review regularly because hair loss management is rarely a one-appointment story. To book an assessment with our team, contact us at info@drsambunting.com or visit our Book an Appointment page.
