SINGAPORE – Ms Evelyn Ng began losing clumps of hair in 2024, after two corrective knee operations that led her to use a wheelchair or walking aid for six months.
“The hair fell from everywhere,” recalls the 53-year-old, who works in administration at a plant nursery. “No matter how I combed my hair, I couldn’t hide the bald spots.”
Ms Ng’s hair has begun to grow out after treatment at Singapore General Hospital (SGH). She says her doctor also ordered blood tests to check whether the hair loss was related to another medical condition.
It was later determined that the hair loss was associated with the shocks to her system from ongoing knee inflammation, and then prolonged hospitalisation and rehabilitation after surgery.
Doctors say that hair issues may arise from stress, injury or illness, but may also signal other underlying health problems. The most common hair issue that drives people to doctors is hair loss, though premature greying might also be a warning sign.
When Dr Evelyn Tay of private practice Lumine Dermatology & Laser Clinic sees patients with sudden or inexplicable hair loss, she asks for their most recent health screening results or may order lab tests.
Thyroid dysfunction can affect hair growth and loss, as can nutritional deficiencies, she says.
Deficiencies in iron or vitamin B12 can also lead to premature greying, she adds.
Dr Eileen Tan, of private practice Eileen Tan Skin Clinic & Associates, recommends seeking professional help from a doctor or dermatologist in case of sudden or unusual hair loss.
Some patients who came to her for help with hair loss turned out to be in the second stage of syphilis, a sexually transmitted infection.
Patients are at risk of severe organ damage if this stage of the disease is left untreated. They are also infectious and pose a risk to their sexual partners.
Such cases underscore the importance of taking a clinical approach to hair loss or other hair issues, she adds.
“The state of your hair is a reflection of what’s happening in your body.”
What is normal hair loss?
What is seen and thought of as hair are lengths of protein that arise from living cells.
Every strand of hair goes through a natural cycle of growth, resting and shedding, dermatologists say, and a person may lose up to 100 strands of hair a day, on average.
Dr Seow Chew Swee, senior consultant dermatologist at private practice DAS Skin Clinic, says there are about 150,000 strands of hair on the head. Balding, or alopecia, happens when the shed hairs are not replaced, leading to hair thinning or areas without hair.
The most common type of alopecia is related to genes, hormones and ageing, and is called androgenetic alopecia, adds Dr Seow.
It is commonly referred to as male- or female-pattern baldness.
Dr Laura Hui, a consultant at SGH’s department of dermatology, says hair problems, mostly alopecia, are among the most common complaints she sees.
Men with androgenetic alopecia often lose hair in an “M” pattern, and have a receding hairline. Women often have hair thinning at the vertex of the head.
Male pattern baldness led Mr Peter Lim to open hair replacement business Aremyhair. He is pictured here in 2007.PHOTO: COURTESY OF PETER LIM
Mr Peter Lim, founder of hair replacement business Aremyhair, inherited androgenetic alopecia from his father. The 55-year-old recalls the shock he felt at age 17 when a classmate pointed out his thinning hair.
From that time, he began spending hundreds of dollars a month on products that purported to regrow hair.
“I was very disturbed. I felt so inferior,” Mr Lim says, recalling how he was often teased for his lack of hair.
A classmate in university even called him “Peter the bald”. Before his first job interview, he went for hair replacement treatment.
Mr Peter Lim, who founded hair replacement business Aremyhair, inherited androgenetic alopecia from his father. PHOTO: COURTESY OF PETER LIM
Dermatologists and patients say that hair loss can devastate self-image and negatively affect mental health as people feel unattractive and ashamed of themselves.
Dr Tan says: “We have to be mindful of the potential psychological impact of hair loss and take care of this aspect while managing hair woes.”
Hormones and nutritional deficiencies affect hair loss and colour
The length and colour of one’s hair depend on the living cells of the hair follicle.
Dr Tay says: “Hair is very metabolically active. When the body is under stress, that can affect the hair.”
Vitamin or iron deficiencies can increase hair loss or restrict hair growth by interrupting normal cellular activity, she says.
Deficiencies in vitamin B12 and iron can interrupt the cellular processes in pigment-producing cells, leading to greying, she adds.
Dr Christopher Foo, a specialist in dermatology and senior consultant at Raffles Skin & Aesthetics, says the timing and extent of greying is determined by genetics, though stress and some health issues can play a part in early greying.
However, there is no well-defined threshold for premature greying in Asians. “For Caucasians, it is generally defined as greying before the age of 20,” he says.
Dr Tan says there is no evidence-based medical treatment for the natural greying of hair, which is irreversible.
She sees about one case a month of patients with hair going prematurely grey, which she defines as before the age of 30, because of thyroid issues or deficiencies in vitamins B or D.
Dr Stanley Liew, an endocrinologist at Mount Elizabeth Hospital, says hormonal disorders affect the hair cycle and manifest as hair loss or thinning.
When the thyroid produces either too much or not enough thyroid hormone, the system may be shocked into the scalp disorder telogen effluvium.
“As much as 70 per cent of scalp hair can fall out within about two months during a state of telogen effluvium,” Dr Liew says.
Treating the thyroid disorder can lead to hair regrowth, but it may take several months and regrowth may not be complete, he adds.
In people with Hashimoto’s thyroiditis, the immune system attacks the cells of the thyroid, and these people may also develop autoimmune alopecia, which results in diffuse hair loss, says Dr Liew.
Women with polycystic ovarian syndrome (PCOS) may also experience hair thinning or androgenetic alopecia, he adds.
The hair cycle is controlled by androgens, and those with PCOS may produce excessive amounts of androgens such as testosterone. The hair follicles are overstimulated and have shorter growth periods, resulting in shorter and thinner hair.
“Another hormonal disorder associated with hair loss is Cushing syndrome, which happens when the body has too much of the hormone cortisol for a long time,” adds Dr Liew.
“You should consult a doctor if you notice sudden hair loss or thinning hair.”
Stress and autoimmune disease
Ms Ana Jeremiah, 52, recalls developing three bald patches in 2010. In that year, her father was dying of heart disease and complications from a stroke, her best friend was diagnosed with a brain tumour and her marriage was falling apart.
The bald spots grew “just like the stress I had been holding inside”, she wrote on LinkedIn.
She took two courses of medications that had to be injected into the patches on her scalp. It felt as agonising as “a period cramp on the head”, she recalls. Her hair eventually grew back.
Now happily in a new relationship, the founder of counselling practice The Journey Within says she checks clients’ hair for clues to their physical health and well-being. “If it’s thinning, if I can see the scalp clearly, they may not be getting enough sleep or good nutrition. I suggest that they go for a walk, meditate or take it easier.”
Ms Jeremiah most likely experienced alopecia areata, an autoimmune condition that manifests as circular patches of baldness.
This is the most common hair-related problem seen by Dr Foo.
“The condition is often triggered by stress in genetically susceptible individuals. It can be very distressing for the individual,” he says.
Ms Ana Jeremiah developed bald spots in 2010, when her father and best friend were critically ill. Stress can show up as hair loss, experts say.ST PHOTO: SHINTARO TAY
A stressful event may also shock the system into telogen effluvium, adds Dr Foo. This includes acute illnesses such as Covid-19 or dengue fever.
Stress can also lead to greying. Dr Liew says that when the body is stressed, it releases a hormone called norepinephrine. “This can cause the pigment-producing stem cells in hair follicles to prematurely activate, depleting their reserves and leading to greying.”
Dr Hui, who treats Ms Ng, says her patient’s hair loss was due to telogen effluvium, triggered by her knee problems, the operations and long recovery.
Ms Ng also has a background of androgenetic alopecia, which increased the hair loss she experienced.
She says her hair also became greyer in 2024. It made the bald patches on her scalp more visible and added to her emotional stress.
She now sprays a topical hair growth medication, minoxidil, on her scalp daily and is delighted to see new growth cover the bare areas.
“I’m very happy now because I can comb my hair any way I like,” she says. “After all, when people look at you, the first thing they see is your hair.”
