Stressed out scalps
In research from the Mental Health Foundation, 82 per cent of UK adults reported experiencing increased stress due to the ongoing lockdowns and related Covid-19 issues. Inevitably, the mental health repercussions of the past year translate into physical health problems over time. Stress is understood to be the second biggest cause of hair loss, and a study by haircare brand Philip Kingsley has revealed that of 2,000 respondents, four out of five now claimed to be experiencing Covid-related scalp problems.
Adam Reed, brand ambassador for Viviscal, believes that the added stress of the past year is beginning to cause real problems for the nation’s scalps, causing excessive shedding of hair and exacerbating scalp conditions such as dandruff.
“Stress and anxiety have a huge impact on hair,” he says. “We have seen – and are seeing – a lot more hair fall and hair thinning due to the stress caused by lockdown. Hair is the last thing that the body looks after, and it’s worth noting that the effects aren’t instant. A lot of people find they have gone through a stressful time and then six weeks later, their hair starts to thin.”
Experts from Nizoral suggest that the number of people suffering from stress-related scalp conditions such as dandruff is also rising. “I personally have seen an uplift of people in clinics with dandruff and seborrhoeic dermatitis,” reports trichologist Stephanie Sey. “I usually query people’s level of stress on a scale of one to 10 and they are currently reporting very high levels.”
Ms Sey advises that pharmacy teams should also be on the lookout for other stress-related hair conditions such as trichotillomania, especially if a customer presents with hair loss. Research indicates that one or two people in every 50 people will experience this body-focused repetitive behaviour (BFRB) at some point in their lives. Hair pulling often begins in late childhood/early puberty; 80-90 per cent of reported cases are women.
The TLC Foundation for BFRB’s scientific advisory board has created resources (available here) to help improve healthcare professionals’ ability to identify and effectively treat trichotillomania, with guidance on referrals and treatment for the disorder if it’s causing distress.
Causes of hair loss
Telogen effluvium (TE) is a condition which results in a marked increase in the number of hairs shed every day. Normally, only 10 per cent of scalp hair is in the telogen phase (the resting phase in the growth cycle prior to falling out) at any one time, but with TE, this increases to 30 per cent or more.
TE usually results from a body change or shock, and occurs around three months after a trigger event such as severe trauma or illness, or a stressful or major life event. It can also be triggered by large weight loss or extreme dieting, as well as by other scalp skin conditions, using a new medication or stopping some forms of hormone treatment. However, there is no obvious cause in around a third of cases.
While medicines are not thought to help the symptoms of sudden hair loss, self care tips from the British Association of Dermatologists (website) include:
- Stopping smoking
- Eating a healthy diet including iron, protein, fresh fruit and vegetables
- Taking dietary supplements, where appropriate.
In alopecia areata (AA), hair loss is caused by inflammation. Experts believe it is triggered by the immune system attacking the new growing hair, but say complete regrowth will happen within a year or so without treatment in four out of five cases. Effective treatments are available to induce hair growth. For example, lotions containing minoxidil can be applied to bald patches.
Alopecia UK advises that although AA does not compromise the immune system or cause immune deficiency, people taking immunosuppressants should contact their dermatologist for advice, especially at the present time. AA is not a risk factor for Covid-19 – people with AA are no more likely than the general population to catch the virus or become severely affected by it. However, according to alopecia experts Dr Matthew Harries and Professor Andrew Messenger: “The exception may be anyone being treated with oral drugs that suppress the immune system. These drugs include steroid tablets, azathioprine, methotrexate, ciclosporin, mycophenolate mofetil (MMF) and JAK inhibitors.” Topical products and injections are thought unlikely to increase risk of infection.
On the scalp
Seborrhoeic dermatitis is very common, affecting around 4 per cent of the population. Dandruff, its mild form, will affect almost half of all adults at some point in their lives. The infant version, cradle cap, usually clears after a few months.
Seborrhoeic dermatitis is most effectively managed with treatments that reduce skin yeast. For mild, untroublesome cases of dandruff, creams and shampoos are most effective and can be used long term. If the scalp is irritated, a mild steroid cream can be used for a short period.
Nizoral contains the anti-fungal ketoconazole, which prevents the growth of the fungus which causes dandruff symptoms, Malassezia furfur.
Focus for self care
Ms Sey suggests that advice to customers for maintaining scalp health during stressful times should include promoting a good hair care routine, along with a healthy diet and supplementation. She says: “Lack of natural light is always a problem in winter and can contribute to a deficiency of vitamin D, which is required for immunity and also thick, strong hair. Also, a lack of B6 and B12 can lead to dry skin (and scalp). Vitamins B7 and B2 may also help with the maintenance of healthy skin.”
Mr Reed also suggests that supplementation is an effective way to support hair and scalp health, along with a balanced diet. “If a customer complains that they are suffering from dry, over oily or itchy scalp, advise on a product that targets their specific concern and suggest that they integrate this into their regular regime, along with appropriate nutrition and supplements. The scalp is a continuation of the skin and needs to be treated as such”.
Elizabeth King, pharmacist at Weleda, adds: “Skin is a reflection of internal health and how people are coping in the outer environment. Stress and anxiety can cause an inflammatory response in the skin, which then means the skin’s natural protective barrier is compromised. The result is moisture loss and exposure to irritants. Scalp health can be equally affected, leaving the scalp feeling uncomfortable, dry and itchy.”
She suggests advising customers on an appropriate shampoo and to keep styling products to a minimum, as this may help. She adds: “Daily application of a nourishing but non-oily hair tonic such as Weleda’s Revitalising Hair Tonic can help to restore and maintain a healthy scalp.”
Views of the P3pharmacy category panel
“This has become a more popular category since the pandemic, as customers want to avoid going to their GP for more minor problems. For dandruff, our best sellers are Selsun and Nizoral. For headlice, Full Marks and Hedrin sell well. The most common question we get is ‘Do I need to treat the whole family for headlice if one person has it?’ Most of these treatments are P products, so they have to be behind the counter, but you can put them at eye level so customers can see them.”
Lila Thakerar, Shaftesbury Pharmacy, Harrow
“Since our training in weight management, we now understand the issues of telogen effluvium and the necessity to explain and reassure rather than sell hair loss products. This last 12 months we have seen a massive drop off of requests for head lice treatments, likely a positive side effect of the lockdowns. If we do get requests, we use the tried and tested Hedrin range. Our small shop means we do not hold dandruff treatments OTC, but utilise our prescription stock for requests for Nizoral.”
Gareth Evans, Wansford Pharmacy, Peterborough
“The most common hair and scalp problems I see are headlice and seborrhoeic dermatitis. There is always a headlice peak at the start of each new school year, but this year we have noticed further peaks as a result of schools opening and closing more often. Ask yourself if there is anyone you know who works in your local schools. Provide leaflets or posters for them to inform parents to seek help and advice from your pharmacy if there are cases of headlice.”
Ellis Nugent, Well Pharmacy, Llantwit Major, South Wales