197: Why Hair Loss Can Be Complicated + Devastating w/ Dr. Hope Mitchell

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Hair loss can have a huge impact on self-esteem, and it is often tricky to figure out the cause, as well as start to slow it down.

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A native of Brooklyn, New York, Dr. Hope Mitchell attended the University of Rochester and graduated with a Bachelor of Arts in Biology.

She obtained her doctorate of medicine from The Medical College of Ohio (MCO). She also completed an internship in Internal Medicine and a Pathology Fellowship while at MCO and a residency in Dermatology at Henry Ford Hospital in Detroit, Michigan.

Dr. Mitchell is certified by the American Board of Dermatology and is a fellow of the American Academy of Dermatology.

Dr. Mitchell is an Ohio and Michigan board-certified medical and cosmetic dermatologist and the founder & CEO of Mitchell Dermatology.

With over 25 years of experience in the medical field, she is an accomplished, highly qualified dermatologist and entrepreneur. She has extensive experience in general dermatologic education and treatment, acne/complexion treatment, skin cancer diagnosis, treatment and surgery, as well as cosmetic injectables.

Dr. Mitchell has subspecialty interest in hair loss, eczema, hyperpigmentation, skin cancer prevention, and skincare consultations. She is an advocate for mentorship, education and diversity in medicine and dermatology.

Dr. Mitchell is a wife and mother of four young adult children.

Join us as we talk about all things hair loss.

Has your hair loss improved as your skin rashes improved? Tell me about it in the comments!

In this episode:

  • Can rashes on the scalp affect hair loss?
  • Can genetic hair loss affect men and women?
  • How does autoimmune hair loss differ from genetic hair loss?
  • Does scratching exacerbate the issue?
  • Lifestyle factors that affect hair loss


“I tend to see hair loss in combination with rashes. I see it in combination with psoriasis, with eczema, or just dandruff, and it really is because of the inflammation around the follicles.” [2:33]

“An example of an autoimmune form of hair loss could be someone who has lupus. And so the inflammation again, that swarms around the hair follicles and the organs, it can cause havoc on the follicle and cause the hair to fall out and so the treatment for them would be to do all that we can to stop the inflammation very quickly.” [5:22]


Find Dr. Mitchell online

Healthy Skin Show ep. 168: Misdiagnosis of Chronic Skin Conditions In Skin of Color w/ Dr. Hope Mitchell

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197: Why Hair Loss Can Be Complicated + Devastating w/ Dr. Hope Mitchell FULL TRANSCRIPT

Jennifer: Thank you so much, Dr. Mitchell, for joining us back on The Healthy Skin Show. I am so appreciative that you were willing to come back and share your expertise with us.

Dr. Mitchell: I'm so happy to be back. I had a great time last time, so thanks again for inviting me back.

Jennifer: You're welcome. Well, I mean, the thing is too, you're also tackling topics that I think are incredibly important and oftentimes overlooked and today's topic is not any different.

Jennifer: So I want to just set the stage for everyone. I've never had hair loss. I do have thinner hair, and just that alone is frustrating to me because I'm always… Don't know what to do with my hair. But I've had clients that have experienced tremendous hair loss, and one client told me, she said, “I could deal with the rashes, but when my hair started to fall out, I felt like that was it. I couldn't bear that.” I honestly didn't know what to say because I could hear in her voice so much frustration and just… I asked her actually because she was so depressed that maybe she should talk to someone and I can understand that, and I could empathize with what she was going through.

Jennifer: For you, I imagine you do see a lot of patients in your practice that are dealing with hair loss, and especially as a dermatologist, it seems like an odd combo, but I would think with rashes on the top of your head, that can certainly be a factor?

Dr. Mitchell: Yeah. You bring up a few good points. I definitely see a lot of hair loss in my practice, and it can be devastating. A lot of my patients that have come in to talk about hair loss, that's the first thing that they say is I'm really worried. I'm really concerned. This is somewhat debilitating for me. Am I going to lose all of my hair? I've even had patients say, “I could have acne all over my face and I would feel better about that than losing my hair.”

Dr. Mitchell: And so for me, it's very common. Also, I tend to see hair loss in combination with rashes. I see it in combination with psoriasis, with eczema, or just dandruff, and it really is because of the inflammation around the follicles. Anytime that we have inflammation, we're susceptible to the hair follicles being hit with that inflammation and the hair falling out.

Dr. Mitchell: And fortunately, when I see patients that have rashes, if we can treat them early enough, get them under control, then we tend not to lose as much hair. But you and I both know that there are other reasons for hair loss. There are people who have genetic hair loss, and they feel like it runs in my family, there's no hope for me, but there is hope for people who have genetic hair loss. We have lots of great treatment for that.

Jennifer: Can you actually expand on that a little bit more? What does that mean, genetic hair loss, and is that just for… I'm like, okay men, I could see that, but is that the same for women?

Dr. Mitchell: Yes, definitely. We definitely can see the genetic linkage for women as well. And what we do know is that it takes on a very similar pattern, but in women, it tends to start crown and go into the temple area whereas, with men, we can see it start in the temples and have more of that receding hairline.

Dr. Mitchell: The bulk of my patients that I see that come in for genetic hair loss, they tend to start female pattern the vertex or crown, and then they go more towards the frontal and the temporal area. What we find is that the best treatment for them may be different than some of the more inflammation forms of hair loss. And so the treatment may be a little bit different and there's so many advances in treatment right now that I've had many patients that have come in for hair loss, that if we catch it early enough, we can start the proper treatment. And I think a win is just preventing it from getting worse. That's a win right there and if we can grow hair on top of that, I think that's even better.

Jennifer: Is that similar to the case for those that have a more autoimmune type of hair loss?

Dr. Mitchell: Well, autoimmune forms of hair loss are a little bit different than androgenetic or genetic hair loss. They tend to be surrounded by inflammation.

Dr. Mitchell: So an example of an autoimmune form of hair loss could be someone who has lupus. And so the inflammation again, that swarms around the hair follicles and the organs, it can cause havoc on the follicle and cause the hair to fall out and so the treatment for them would be to do all that we can to stop the inflammation very quickly. So it may be an intramuscular injection with steroid or scalp injections, oral steroids, anything that we can do to really halt the progression of the inflammation and then get those patients onto maintenance treatment.

Dr. Mitchell: What we find with genetic forms of hair loss is that the treatment tends to be different. Those are the patients that we're going to tend to prescribe Minoxidil, better known as Rogaine. We can prescribe that oral or topical Minoxidil. And we don't tend to use a lot of steroid in that population unless we have reason to believe that the scalp is also inflamed.

Dr. Mitchell: So genetic hair loss can be in combination with psoriasis or seborrheic dermatitis or eczema. And so in those patients, we're double teaming. We're treating two conditions. And so I think this is a reason why it's really important when you're experiencing hair loss, thinning, shedding, that you start an evaluation with a board-certified dermatologist so that you can get a diagnosis.

Jennifer: Yeah, I was going to say, it sounds like sooner rather than later, too, because I would imagine it's harder… I would think the well is harder to fill up the deeper it gets, the drier it gets, so to speak.

Dr. Mitchell: Absolutely. And once we have a diagnosis or diagnoses, because hair loss we can diagnose two or three problems or causes of hair loss. I just mentioned two. Someone could be experiencing genetic or androgenetic hair loss compounded by their psoriasis that's flaring or their eczema or their seborrheic dermatitis.

Jennifer: Would itching be a factor? If someone's just scratching at their scalp because of how itchy it is?

Dr. Mitchell: Yeah. Any irritation of any form on the skin is going to exacerbate or worsen the problem. So remember the scalp is just an extension of the skin on the face. And so scratching at the scalp, just like scratching at the face, we can definitely continue to irritate the follicle. And then we could leave scarring around that follicle, which would prevent future growth. And so definitely again, doing what we can to stop the itching is going to be really, really important in that patient population.

Jennifer: So with the inflammation, I know that there is a hair cycle with the hair fall, so does the inflammation basically just shut that cycle down? Is that essentially what is happening more or less?

Dr. Mitchell: I think that's a good way to put it where we go into the resting and the shedding phase a lot quicker, so it can offset the cycle. So when we think about hair growth, there are three stages.

Dr. Mitchell: There's the anagen, which is the growth phase, the catagen, and the telogen. The anagen phase, depending upon the individual, it could be three years, four years, five years. So that the bulk of hairs, I would say about 90% or more, can be in the growing phase. And then there's going to be a small percentage that's going to be in the resting phase and then a small percentage that will be in the shedding phase. And that's why we're always going to look like we have more hair until the point in which we really start losing more than we're holding onto.

Dr. Mitchell: And so what will happen is yes, there's a condition called telogen effluvium that occurs after a stressful incident. And so for example, it could be anywhere from emotional stress to physical stress. So really significant illness can throw the hair cycle into this telogen effluvium like COVID did. So people who got COVID really were more susceptible to this form of hair loss. People who had significant stress because of COVID, maybe they lost a job. Maybe they lost loved ones. They can also experience this form of stressful hair loss, where a lot of the hairs just go into this cycle where they quickly go into the resting right into the shedding phase and we lose a lot of hair.

Dr. Mitchell: Now, the good news is that people with telogen effluvium once that process stops because it can take two to four months after the [inaudible 00:10:44]. So let's just think about the pandemic and say that it occurred mid-March. Two to four months after that is when people can start to notice if they've been affected in that way, the hair loss. Then it can take anywhere from four to six months to actually stop.

Jennifer: Wow.

Dr. Mitchell: Think about how scary that can be.

Jennifer: Oh my goodness.

Dr. Mitchell: It can take about four to six months to stop and then people will notice that their hair will grow back. But then there's a small amount of people, about 10% of those people will stay in a chronic telogen effluvium. The chronic telogen effluvium are the ones that are really, really, really hard to manage because it's almost like we can't get that cycle to stop and they may feel like they're back to normal. They may feel like I'm no longer stressed like I was, so why am I losing my hair? Why is it still coming out? Why is it still shedding? And we don't know in that small percentage of people.

Jennifer: And so I also want to touch on too, that nutrients are really important to grow hair. I think most people know that because if that wasn't the case, biotin supplements wouldn't be all the rage for people that want thicker hair. Sometimes they help. Sometimes they don't, but other nutrients like iron. Iron deficiency is a big problem. If you have that, that can cause hair loss and just nutrients in general.

Jennifer: And I know too with Hashimoto's and thyroid issues that could potentially be an issue too. I guess there's other medical things or other things that could disturb the balance of the body that can contribute to this beyond… Because I think sometimes when you hear genes, you're like, “What can I really do? It's my genes.” But there are some things that you can do on this other hand where you could look at some of the lifestyle factors. Like you were saying, stressful events is a huge piece of the puzzle.

Dr. Mitchell: Mm-hmm (affirmative). Well, it's interesting that you mentioned biotin, and some of my derm colleagues and myself, we talk about the great marketing that has been done behind biotin because we really don't have any scientific studies that have proven that biotin will grow hair like it will grow the nails. But you're right, people will reach out for supplements as opposed to really evaluating their nutrient intake, which is much more important in terms of what we're consuming, the right amount of protein, et cetera, to stimulate the hair growth.

Dr. Mitchell: But when I have patients that come in, one of the components of their evaluation is to do blood work, looking at, like you said, some of the studies that could also be a part of hair loss. We know that vitamin D deficiency can be a part of hair loss and hair thinning. I actually have many patients that are vitamin D deficient and with correction, we've seen improvement in the hair. I know that thyroid imbalances, blood count imbalances such as anemia can be an issue. And then we also screen for autoimmune conditions like we just talked about. In terms of loss, iron ferritin levels.

Dr. Mitchell: So that's another reason why it's important to see the dermatologist, because we also, in addition to the evaluation, we want to look for any underlying causes that could be contributing to hair loss because we know that hair loss is multifactorial in the majority of people. So there's not going to be one reason why we're losing our hair. Usually, we can find more than one reason, some of them correctable and some of them not. And so just because again, we may have the genetics for hair loss, all hope is not lost. All hope is not lost.

Jennifer: I think that's really important to hear. That is. And for someone… Let's just say they come into your practice, and you feel like there is a chance that with certain treatments you could actually start to see an improvement. Expectation-wise, I don't think it's realistic to proudly say, “Oh, my hair will be normal in a month.” What would be an expectation that someone who feels like they're experiencing hair loss, once you figure out those answers, what's the timeline generally?

Dr. Mitchell: That's a great question. I tell my patients because of the hair cycle, it would be three to six months. Hang in there with me for three to six months. And in that period of time, what I want them to notice is less shedding. I think that's a very reasonable time to note that if all is working well. After that, then we'll start to see the growth.

Dr. Mitchell: Most of my patients that come in, they're coming in with the shedding. They've noticed the shedding. Less of them have come in and have been like, “I woke up and I've lost hair and I didn't see it coming.” So the bulk of them, we have to get them through the point of the shedding. And they feel a lot better after the three months. So I find that after three months, the shedding decreases and then at about six months, if the treatment plan is working properly, is when we start to see the growth.

Dr. Mitchell: Now it depends on what we're dealing with. If we're dealing with a really difficult divorce or loss of a loved one, if we still have issues surrounding that, meaning we have emotional stress, loss of a job, we haven't found a job. It just depends on how significant the trauma or the stress is. It may take a little bit longer to start to see things settle down.

Jennifer: And I actually want to touch on this one last point of just the emotional component. I know we kind of started with that and I think it's important to stress that you actually know what this is like, not just in treating patients. Do you want to share a little bit? I know that you've talked about it a bit on Instagram. What was your experience? Because you're a doctor, you deal with this, and then you're like in it.

Dr. Mitchell: Yeah. My response to stress has always been hair shedding. I have colleagues where their response to stress has been breakouts and acne, and I've never really experienced that or the up and down in their weight. Mine has always been the fragility of my hair and to the point where I have had to subject myself to dermatologic care. Where I've had to remove myself from me and see a colleague consistently for scalp injections, recommendations.

Dr. Mitchell: And I have had four children and I have experienced telogen effluvium after the birth of each child. My hair has grown back. I've done and gone through all the proper steps, but I'm older now and I've experienced menopause and so it's even more challenging as you age to handle that. You have the stress. You have the predisposition almost to have that shedding or hair loss with changes and then you're dealing with maybe menopause or other things like that and it can be difficult emotionally to really accept it.

Dr. Mitchell: But for me, I've always been able to do the things that I know are right. To evaluate my diet. To get the blood work. To get my physical done every year. To make sure that all the tests that I should be doing, that I get them done. And I have to honestly say, I've been able to keep healthy hair. And in the field of dermatology, there's a lot of technology and innovation that… There's lots of new ways to treat hair loss. There are new supplements, there are new treatments, there are laser treatments. And that's another reason, we keep saying this, but see the professional because there's so many options, you'd be surprised at the numbers of treatments that we have now for hair loss.

Dr. Mitchell: And on top of that, we still have the foundational treatments for conditions like psoriasis and eczema, and seborrheic dermatitis where we can get that inflammation under control pretty quickly.

Jennifer: And it's important to understand what's going on. I think a lot of times people just want a supplement for a problem. And that's not always the best way because you don't actually know what's driving the issue.

Jennifer: A lot of times in my practice, I'm just looking mostly at nutrients and whatnot. And people say, “Well, but I eat a really healthy paleo diet and just water. I don't drink any alcohol, and I'm really active, but I can't figure this out.” Then lo and behold, under the surface, there are severe iron deficiency, severe vitamin D deficiency. There's all these crazy deficiencies that they're like, “I don't understand. Everything I eat is the best of the best. That's what I spend my budget on.” I'm like, “But if you're not able to absorb it, there's a problem. And so now we've got to dig deeper to see, do you have celiac? What's going on here?”

Jennifer: So I love that you're able to add this whole other component to it and say, look, there's so many other things it's important to understand because as you were talking, I was reminded of that concept of the canary in the coal mine almost like one's hair is this outward sign that something's wrong and it's important to look deeper.

Dr. Mitchell: Exactly. On the inside in addition to haircare practices. That's a whole other component of hair loss. How healthy is the hair because of how you're treating it, how you're taking care of it? So it's a pretty in-depth consultation or evaluation when we're talking to our patients about hair loss that we take very seriously in dermatology.

Jennifer: I have to be honest with you. I never knew that if you lost your hair or you had hair thinning, I never knew that you would go to a dermatologist because I only think of a dermatologist for dealing with skin. And actually, by following you on Instagram, I was like, oh, I didn't know. That's one other facet to your whole toolbox that you guys handle. I had no clue, so it's really good to know for anybody who's struggling that dermatology is really where you're going to go to, to take a look at that.

Dr. Mitchell: Yeah. We are the experts in hair, skin, and nails. I call us the external medicine experts. So all on the outside, we take care of that. We're trained in over 3,000 conditions. And we can't pass our boards if we don't know them.

Jennifer: Wow. It's a lot of work. I know my dad, when he went and sat for his boards exams, he was in ophthalmology, but it was a lot.

Dr. Mitchell: It's a lot.

Jennifer: And even with dermatology and hair… See, hair, skin, and nails. It's all in one. But I think this is a really good conversation for people to hear because it really is a super emotional one. I know that rashes in and of themselves can be emotional, but this for… Every single person has said, this was the thing that almost put them over the edge. It was the hair. They could live… Like you said, I could live with acne. I could live with all this stuff. It's bad but… And I really appreciate you not just coming here to share your expertise, but also your own personal story and be vulnerable and let people know that you don't get it just from the clinical side, you get it personally. You really understand.

Dr. Mitchell: Exactly. Mm-hmm (affirmative).

Jennifer: So I just want to make sure everybody can find you. You have a great Instagram account as I have mentioned multiple times. I learn a lot. She's @DrHopeMitchell, and then they can also find you at your website, MitchellDerm.com as well. And remind everyone, where is your practice located?

Dr. Mitchell: My practice is located actually in Ohio, in a community called Perrysburg, and Perrysburg sits very close to Toledo. It's about 45 minutes from Ann Arbor, 45 minutes or an hour from Detroit. And so that's where I'm at. Easy to find.

Jennifer: Great. Awesome. Well, thank you so much for joining us today. I really appreciate it. And I love having you back on the show. It's been so great to include you in the family of experts that we talk to, and I hope to have you back sometime.

Dr. Mitchell: I love, love, love talking with you so thanks for having me.

“I tend to see hair loss in combination with rashes. I see it in combination with psoriasis, with eczema, or just dandruff, and it really is because of the inflammation around the follicles.”

Jennifer Fugo, MS, CNS

Jennifer Fugo, MS, CNS is an integrative Clinical Nutritionist and the founder of Skinterrupt. She works with women who are fed up with chronic gut and skin rash issues discover the root causes and create a plan to get them back to a fuller, richer life.

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