Leaving a few hair strands in your brush or experiencing mild hair loss in the shower can be normal. A healthy adult normally sheds up to 80-100 telogen hairs per day [1].
However, a sudden increase in hair shedding suggests that you may have developed a type of alopecia [1]. Hair loss disorders can be diagnosed and monitored using methods such as the hair pull test.
Although the hair pull test is unlikely to be the sole method of diagnosing the reason your hair is falling out, it can be a useful part of your clinical assessment. Here, we’ll discuss everything you need to know about the hair pull test, including:
The hair pull test is a simple hair loss investigation that takes a few minutes and is performed by trichologists, hair transplant surgeons and other hair specialists. It’s based on the idea of pulling out hair that is in the telogen phase of the growth cycle. Telogen hairs are hairs in the resting phase of their growth cycle [2]. Usually, the majority of your hair is in the anagen (growing) phase, meaning you have minimal hair loss each day. Here is the full hair growth cycle:
A hair pull test may also be called a traction test, a hair loss pull test, or Sabouraud’s sign. You will feel some scalp tension during the test as your clinician pulls a section of your hair, but you shouldn’t feel any pain.
To perform the hair pull test, the clinician selects 50-60 hairs and holds this bundle of hairs close to your scalp between their thumb, index finger, and middle finger [3]. They slowly and firmly pull on the bundle while their fingers slide down the hair shaft, making sure not to tug too fast or forcefully [1].
Hair pull tests are performed at the crown of the head, the occipital area (back of the head) and the two parietal areas (each side of the head, above the ears to the back) [1]. The pulled hairs are then counted, and any broken hairs are discarded without being included.
The hair pull test is considered positive if more than 10% of the hairs are removed from the scalp during the procedure [1]. Any less than this is considered normal hair shedding [4].
A positive test in more than one area of the scalp suggests a possible diagnosis of anagen or telogen effluvium [1]. Other hair disorders, such as alopecia areata, may only have a positive hair pull test in the affected area [1].
The hair pull test works best on people with a severe condition in the active stages of hair loss [1]. It works best to monitor hair loss conditions, including [1]:
The hair pull test is usually negative in cases of male and female pattern hair loss. However, the test may be positive in affected scalp areas when the condition is active [5].
The hair pull test is not very sensitive to hair loss conditions (meaning it can produce false negative results), and there is a big difference in measurements between clinicians [1]. Some practitioners measure by eye so the exact number of hairs may vary, and there are differences in how hard each specialist pulls on the hair bundle. Therefore, it is not recommended as a standalone test for important clinical decisions in chronic hair loss disorders.
There are a couple of similar diagnostic trichology tests your hair specialist may perform. These are the hair card test and hair tug test, often performed during the same assessment as the hair pull test.
This test is used to count the number of newly growing hair shafts and examine the health of your existing ones. The clinician creates a parting in your hair, using a small card covered in felt that contrasts with your hair colour.
New hair strands are visible against the card, even broken or very small ones. Short, hard strands with broken tips can be a sign of a hair shaft abnormality, while very thin strands are often found in people with telogen effluvium.
The hair tug test measures the fragility or brittleness of your hair. Your clinician may use it if they suspect a shaft abnormality that can cause hair thinning and hair breakage. The clinician takes a section of your hair with two hands, holding it near the root and the tip.
Then, they tug to see if any hair breaks in the middle. Hair breakage during the test indicates hair shaft abnormalities and fragile hair [8].
It can be easy to perform your own hair pull test at home, but the results may not be helpful or accurate without a professional interpretation. It can be difficult to correctly estimate the amount of hair you are pulling.
Furthermore, if you tug too hard or too gently, you can end up with incorrect results. Even if you perform this hair density test perfectly, there is a chance of misinterpreting the results in the absence of clinical knowledge of hair loss. This makes it challenging to select the right diagnosis and treatment.
When it comes to diagnosing hair loss, it is always best to leave it up to experienced professionals. That is because they have a trained eye and can corroborate the results of the hair pull test with other signs and symptoms of alopecia that you may not be aware of. Moreover, once diagnosed, trichologists can also recommend the most effective treatment for your condition. Self-diagnosis can delay this process, potentially leading to a progression of your symptoms.
Being diagnosed with a hair loss condition can be a very unsettling time. For many people, hair has profound symbolic and psychosocial importance, and its loss can cause emotional distress [9]. In turn, stress and anxiety can cause further hair loss.
Fortunately, there are many treatment options available to you from the first signs of hair thinning and balding. These can include medication, therapies and hair transplants.
A hair transplant is a permanent cure for hair loss, although it is not suitable for all conditions. Androgenetic alopecia (female or male pattern baldness) is the most common condition treated with hair restoration surgery [10]. Hair transplantation tends to be a highly successful procedure– one study found that 98% of patients rated their experience as ‘excellent to good’ [11].
You can receive a hair transplant into scar tissue, including when it has been caused by scarring alopecia, although the procedure is challenging in these patients. Eyebrow, moustache, and beard transplants are also possible, and those who have had previous hair restoration surgery may be good candidates for a natural-looking hair transplant [12].
There are two main types of hair restoration surgery, both of which are available with the expert surgeons at Wimpole Clinic. These two techniques are Follicular Unit Extraction (FUE) and Follicular Unit Transplantation (FUT).
FUE involves extracting hair from a donor area of the scalp by harvesting individual hair follicles and transplanting them to a balding area. FUT follows the same principle, but, rather than individual hair follicles, a thin strip of hair skin containing hair follicles is harvested, cut up into grafts, and then transplanted. FUE is more time-consuming, but leaves minimal hair transplant scarring and offers a shorter hair transplant recovery period.
Minoxidil, finasteride, and dutasteride are some of the most effective medications that treat hair loss. Both topical Minoxidil and oral Minoxidil can treat a wide range of hair loss conditions [13].
Finasteride regrows hair in male pattern baldness and dutasteride is a more potent medication that offers an alternative to finasteride. Neither medications are recommended for premenopausal women as they may cause birth defects, and dutasteride can only be prescribed off-label as it is not yet authorised as a treatment for hair loss.
Several medications are also used to treat hair loss caused by autoimmune diseases, such as alopecia areata. These include steroid creams for hair loss, steroid injections, and JAK inhibitors, which can reduce the body’s immune response, so your white blood cells stop attacking your hair follicles.
Low-level laser therapy (also known as red light therapy) is a new treatment that has been shown to effectively treat hair loss in men and women [14]. The theory behind it is that low-dose laser treatments boost blood flow to the scalp, increase mitochondrial activity (so more energy is transported to the follicles), and stimulate hair follicles to grow new hair.
Lifestyle changes may not entirely prevent hair loss conditions like pattern baldness. However, they can reduce the severity of this and other hair loss conditions and may protect you against certain types of hair loss.
Stress is a known cause of telogen effluvium [15], a condition that causes excessive shedding of telogen hair. Stress-relieving strategies to improve hair loss may reduce your risk of developing this condition and improve symptoms if you already have it.
Many nutrients are vital for healthy hair, including biotin, iron, and protein. These nutrients are absorbed naturally from a balanced diet containing hair growth foods, but you can always consider a specific diet for healthy hair or taking vitamins for hair growth if you have a known deficiency.
Excessively tight hairstyles like tight ponytails, top knots or man buns can cause a form of hair loss called traction alopecia [16]. To prevent this, opt for hairstyles that don’t place too much pressure on your head. If you must wear tight hairstyles, change your style regularly and give your hair time to recover when you can.
If you start to notice increased hair loss in the shower or while brushing, you may wonder whether your hair is thinning or if you are being paranoid. If you are concerned your hair may be falling out, it’s a good time to book an appointment with a trichologist.
Our hair specialists will complete all the necessary tests to diagnose your symptoms, such as a hair pull test, a dermoscopy, or blood tests for hair loss. There are plenty of treatment options available to restore your hair, even if your hair is so thin you can see your scalp.
If non-surgical treatments have failed to improve your hair growth, you still have options – you may be a candidate for a hair transplant. The best hair transplant clinics in the UK produce excellent results, which you can view for yourself in our before and after hair transplant gallery.
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