THE YEAR AMERICA’S HAIR FELL OUT

The pandemic has been a near-perfect mass hair-loss event.
By Amanda Mul

When i first suspected that I was losing my hair, I felt like maybe I was also losing my grip on reality. This was the summer of 2020, and although the previous three months had been difficult for virtually everyone, I had managed to escape relatively unscathed. I hadn’t gotten sick in New York City’s terrifying first wave of the pandemic. My loved ones were safe. I still had a job. I wasn’t okay, necessarily, but I was fine. Now my hair was falling out for no appreciable reason. Or at least I thought it was—how much hair in the shower drain is enough to be sure that you’re not imagining things?

The second time it happened, a little more than a year later, I was sure—not because of what was in the shower drain, but because of what was obviously no longer on my head. One day, after washing and drying my hair, I looked at my hairline in the mirror and it was thin enough that I could make out the curvature of my scalp beneath it. I still had enough hair, but notably less than I’d had before the pandemic. Feeling a sense of dull panic at the no-longer-refutable idea that something might be wrong, I tipped my head forward to take a picture of my scalp with my phone’s front-facing camera. When I looked at it, the panic became sharp.

I did what everyone does: I Googled my symptoms. At the very top of the search results, a colorful carousel of vitamins, serums, shampoos, and direct-to-consumer prescription services appeared; a so-small-you-could-miss-it disclosure in one corner signaled that these products weren’t real search results, but advertising. Well below them, the real results weren’t much better—WebMD, a bundle of Reddit threads, medical journals whose articles would cost me $50 a pop, factually thin blog posts, natural-health grifters touting hair-growth secrets that doctors didn’t want me to know, product reviews that weren’t labeled as ads but for which someone had almost certainly been paid. I pressed on to gather whatever reliable-looking information I could find, itself full of terms I didn’t fully understand--effluvium, minoxidil, androgenic.

What I didn’t know at the time was that I had just started a quest for answers that many, many others had also undertaken in the previous year. Only a few months into the pandemic, around the same time when I first thought I might be losing either my hair or my mind, people whose hair was indeed falling out by the handful started to come forward. They showed up in Facebook groups about hair loss, in subreddits dedicated to regrowth, and in the waiting rooms of dermatologists and hair-restoration clinics. First there were a few, but then there were thousands. Some of them had had COVID-19, but others, like me, had not.

At first, the fire hose of products I’d been sprayed with felt like a very American type of reassurance—not only was my problem apparently common, but it was also widespread enough to be profitable, and therefore maybe it had a solution. In hindsight, the products feel more like a warning.

This story isn’t about a medical mystery. The pandemic was a near-perfect mass hair-loss event, and anyone with the most basic understanding of why people lose their hair could have spotted it from a mile away. The actual mystery, instead, is why almost no one has that understanding in the first place.

Hair loss, I eventually learned from my diligent Googling, can be temporary or permanent, and it has many causes—heredity, chronic illness, nutritional deficiency, daily too-tight ponytails. But one type of loss is responsible for the pandemic hair-loss spike: telogen effluvium. TE, as it’s often called, is sudden and can be dramatic. It’s caused by the ordinary traumas of human existence in all of their hideous variety. Any kind of intense physical or emotional stress can push as much as 70 percent of your hair into the “telogen” phase of its growth cycle, which halts those strands’ growth and disconnects them from their blood supply in order to conserve resources for more essential bodily processes. That, in time, knocks them straight off your head.

The pandemic has manufactured trauma at an astonishing clip. Many cases of TE have been caused by COVID-19 infection itself, according to Esther Freeman, a dermatologist and an epidemiologist at Harvard Medical School and the principal investigator for the COVID-19 Dermatology Registry, which collects reports of COVID-19’s effects on skin, nails, and hair. That doesn’t necessarily have anything to do with something unique about the disease, she told me—any illness that comes with a high fever can cause a round of TE, including common illnesses such as the flu. Among the millions of Americans who have been infected by the coronavirus, hair loss has been a common consequence, she said, both for patients whose symptoms resolve in a couple of weeks and for those who develop long COVID. Researchers do not yet know exactly how prevalent hair loss is among COVID-19 patients, but one study found that among those hospitalized, 22 percent were still dealing with hair loss months later.

COVID-19 infections are only part of the picture. Throughout the pandemic, millions more Americans have suffered devastating emotional stress even if they’ve never gotten sick: watching a loved one die, losing a job, going to work in life-threatening conditions, bearing the brunt of violent political unrest. Feelings can have concrete, involuntary physical manifestations, and these traumas are exactly the kinds that leave people staring in horror at the handfuls of hair they gather while lathering up in the shower.

All of these factors have led to what Jeff Donovan, a hair-loss dermatologist in Whistler, British Columbia, described to me as a “mountain” of new hair-loss patients since the pandemic began. What exacerbates the difficulty of dealing with hair loss for many patients, he and the other doctors I spoke with told me, is just how little good, if any, information on the condition the people coming into their offices are able to assemble, even if they broached the issue with other kinds of doctors in the past. “They don’t know what’s going on, they don’t know why they’ve spent so much money, and they’re just so confused," Maryanne Makredes Senna, a co-director of Massachusetts General Hospital’s hair-loss clinic, told me. “It’s like, ‘I don’t know what to believe, and I went to this doctor and they made me feel like I was crazy.’” The doctors I spoke with said that their patients typically come to them after having seen at least a handful of other practitioners, and sometimes as many as 15.

This level of confusion—including my own—is, frankly, infuriating. Eighty percent of men and about half of women experience some form of hair loss in the course of their life. TE was first described in the 1960s, and it has long been a predictable side effect of surgery, changing medications, crash dieting, childbirth, bankruptcy, and breakups. The way TE resolves for almost everyone who doesn’t already have chronic hair-loss issues is that the hair eventually grows back—plain and simple. You would think, at some point, that someone would tell you not to panic if you lose some hair after something intense happens—that even if you shed for months, it will grow back eventually, and there’s no need to do anything but wait.

For several reasons, many people don’t get much straightforward information on any type of hair loss, TE and beyond. For one, hair loss doesn’t really lend itself to the format of the modern American doctor appointment. Finding the right diagnosis can be a detailed, time-intensive process. “You cannot do everything for a hair-loss patient in a 15-minute visit,” Senna said, and that’s all the time many doctors get to have with their patients. Seeing a dermatologist who specializes in hair loss, she said, is more likely to get patients a visit of at least 30 to 45 minutes and a more detailed, empathetic evaluation—if a patient can figure out to go to such a dermatologist in the first place.

Moreover, hair loss typically isn’t a particularly urgent problem for practitioners who may have many other types of health concerns coming into their office. Most hair loss that isn’t triggered by some kind of trauma is caused by androgenic alopecia, or AGA, often known as male or female pattern hair loss. It’s passed on genetically and has no cure, although some safe treatments are widely available. Doctors busy with other things may shrug their shoulders at patients who have incurable conditions that aren’t physically dangerous or painful. And for panicking patients who hear “Wait it out” or “Buy some Rogaine,” that recommendation may feel dismissive or inadequate, even if it is correct.

Some causes of hair loss vary along ethnic lines, so getting answers can be even harder for certain patients. Susan Taylor, a dermatologist at the University of Pennsylvania and the founder of the Skin of Color Society, told me that Black patients usually land in her office with more advanced hair loss than their non-Black counterparts, which can make treatment less effective. Black patients are more likely to have a type of hair loss called central centrifugal cicatricial alopecia, or CCCA. According to Taylor, many practitioners know little about CCCA, and their advice to patients suffering from it can be especially dismissive. “For Black women in particular, they’re told, ‘Stop your relaxers; don’t straighten your hair,’” Taylor said. “And then they say to me, ‘But Dr. Taylor, I always wear my hair natural. I don’t relax my hair.’”

What makes all of this harder is that hair loss—TE in particular—is a long game played on a wonky, counterintuitive timeline. It’s a nightmare for people trying to distinguish correlation and causation on their own. TE is temporary for almost everyone, but because of the vagaries of hair’s growth cycle, the shedding generally doesn’t start until two to four months after the stressor that triggered it occurred. By then, people are no longer thinking about the flu they had months ago—a new shampoo or medication might get the blame instead. And many people who experience TE have no idea whether their hair will ever come back; the shedding can go on for months before slowing down, and regrowth can take several more months to become visible to the naked eye. By the time people notice their hair growing back, a year may have passed since the process was set into motion. Once it starts, the only effective treatment is patience.

If you’ve never gone from normal hair to bald spots in a matter of weeks, you might be tempted to dismiss this as vanity. But people value their hair because the society they live in tells them it’s important. Women in particular have been told for centuries that their hair is their glory, which paraphrases a biblical edict about long hair as a demonstration of righteousness before God. A full head of hair, Donovan, the Whistler dermatologist, pointed out, is still a crude, unscientific shorthand for youth, for healthy living, for vitality. Losing it can send people into a profound depression, or make them ashamed to leave the house.

So people do what I did. They turn to the internet. Waiting for them is a booming market for nonmedical health products, ranging from the dubiously effective to the obviously scammy. Never does a new product look more promising than when you’re trying to solve a problem you don’t understand. In America, where competent medical care can be hard to access even for simple problems, hair loss—extremely common, highly emotional, absolutely confounding—is a case study in how much money there is to be made in this mixture of desperation and hope.

When I first began my own search for answers, the avalanche of hair-loss products under which Google immediately buried me was disorienting and overwhelming. It wasn’t just the beautiful, full-color photos of luxuriously packaged pills and oils that Google threw at me up front, but how the internet kept the score, using the admission that I was losing my hair to stalk me across time and platforms in a way seemingly designed to wear down my defenses. For months on end, those products and many more followed me around the internet, interrupting my friends’ Instagram stories of their latest cooking projects and slipping between my extended family’s Facebook posts about their kids’ first day of school.

At first glance, many of these products seem promising. Vegamour, a start-up that describes its shampoos and scalp serums as a “holistic approach to hair wellness,” can become practically inescapable if you use the internet to look at mainstream fashion and beauty products. It has a website and social-media presence befitting any luxury cosmetic, complete with videos of models tossing around their impossibly thick hair and promises of clinical proof that its products will grow yours. This clinical proof is not included on the site for scrutiny. (A spokesperson for Vegamour did not respond to questions about its products and website.)

Wellness products are a marketing sweet spot for a class of celebrities who are supposed to be more relatable than traditional stars, because they seem to offer a behind-the-scenes look at what it takes to be beautiful, but without really revealing anything at all. They are a simple way to assure an audience that you got hot through clean living, good nutrition, and a little self-care—that your entire deal isn’t one big, carefully stage-directed feminine farce. The catch, of course, is that the professionally beautiful absolutely do not rely on these types of products to ensure that their hair looks thick and luxurious. Celebrities, as Senna told me, generally don’t have incredible hair. Instead, they have incredibly expensive hair extensions and lace-front wigs. (SugarBearHair did not respond to multiple requests for comment.)

In the United States, cosmetics and dietary supplements occupy a separate legal category from drugs. Their efficacy claims are far less regulated, which allows the manufacturers of nonmedical hair-growth products to make enticingly vague promises that would be more heavily scrutinized and caveated when made by a pharmaceutical company. Paradoxically, this freedom from regulatory surveillance can lead potential customers to assume that these products must be superior overall. The difference can seem implicit in the distinction from pharmaceuticals—if this class of products weren’t safer, more natural, and just as effective, wouldn’t the same level of governmental caution be applied to them? Can’t we infer something from its absence?

These assumptions and their attendant fears are explicitly encouraged by many supplement and cosmetic companies as a way to more effectively market their own products. Vegamour’s website, for example, includes a list of medical-grade ingredients that its products do not include, alongside context-free lists of the most unpleasant side effects that have ever been attributed to those ingredients, even if those side effects are quite rare. The site does not mention any potential side effects of its own products. Drug manufacturers are legally required to track and disclose side effects, but cosmetic companies are not.

You can see the effect anywhere that health problems are being discussed online, especially in spaces dedicated to regrowing hair. In one Facebook group with nearly 30,000 members, the same discussion plays out again and again: A new member asks for help, alongside photos of her thinning hair. Well-meaning people post links to buy the vitamins or essential oils that they’re currently using. They suggest a megadose of biotin, which has never been linked to hair growth in those without a biotin deficiency. They recommend an iron-supplementation protocol with its own Facebook group, even though taking iron supplements can be dangerous if you’re not deficient. Suggesting minoxidil can be controversial, even though it’s one of the only effective treatments for hereditary hair loss, has been studied for decades, and is widely available over the counter in cheap generics. People express a fear of side effects without getting more specific about what scares them. The most common side effect of minoxidil is scalp irritation.

When wading through the sludge of the internet’s hair-loss advice, if you’re lucky, you come across someone like Tala, whose last name I’m not using in order to protect her privacy. She’s a 39-year-old moderator of the Reddit forum r/FemaleHairLoss, which has grown from about 3,000 subscribers to more than 14,000 during the pandemic. The subreddit is a relative rarity on the internet: a place to crowdsource information about a tricky health problem where discussions tend to stay based in reality. People post lots of pictures of their head, either to ask whether it looks like they’re losing more hair than they should be or to show before-and-after photos of treatment plans that really work. They talk about minoxidil and finasteride. They trade hair-war stories about scalp injections and laser helmets, and tell newbies how to find a specialist who can actually help them.

Tala has AGA, the hereditary kind of hair loss, and has been losing hair since she was 30, but she considers herself lucky—she lives in an area with lots of good doctors and she can afford to see them, which means she has access to quality information. Passing on as much of it as possible feels important to her and the subreddit’s other moderators because of how vulnerable many of the group’s new members are. “I can’t tell you how many suicidal people come to this group,” Tala told me. “To know that somebody is suffering that much because they lost their hair, it breaks my heart.”

Maintaining a safe, truthful environment is an uphill battle. “To keep this group running and to keep it free from shills and people who are trying to take advantage of it and spammers, it’s a lot of work,” Tala said. She and the other mods walk a difficult line: For the group to be helpful to as many people as possible, it has to feel welcoming and nonjudgmental, and it has to be free of people who might be trying to sell something. For the group to actually help, the moderators and regular commenters have to find ways to tell people who have spent so much money on “natural” cures that they maybe have been duped, without making them feel stupid or defensive. They teach people the basics of hair’s growth cycle, what to look out for when evaluating a scientific study, and which treatments are known to be effective for the type of hair loss they suspect they have.

Several of the doctors I spoke with think that communities like r/FemaleHairLoss, which encourage rigor and evidence-based treatment options, provide a useful port in the storm of internet health marketing and misinformation. Nonmedical products, the doctors said, are basically all useless for expediting the growth of existing hair—which is not possible in already healthy individuals—or reviving dormant follicles. Dietary supplements themselves can be useful, Senna said, but only for patients whose hair loss is caused by a nutritional deficiency, which is rarely the case for people eating a standard American diet. If you’re not medically deficient, more isn’t better—and it can certainly be worse. Senna mentioned biotin, large doses of which are extremely common in hair-growth supplements. Too much biotin can lead to an incorrect thyroid-disease diagnosis, she said. Thyroid disease can also cause hair loss, so the misdiagnosis can send doctors on a wild-goose chase. The whole problem becomes bigger than if you never took the supplements in the first place.

The myths commonly passed on as facts in some online hair-loss groups are a constant impediment to getting patients on treatment regimens that actually have some chance of helping their hair. “It can be very, very challenging to convince the patient that the diagnosis that she came up with from the internet is not the correct one,” Taylor, the University of Pennsylvania dermatologist, told me. With some types of chronic hair loss, the time that people spend trying things that don’t work is precious—the longer someone goes without effective treatment, the less effective they can expect that treatment to ultimately be.

In the case of TE, hair loss’s timeline is on the side of the wellness industry. Think about how all of this feels to the average person, who has no idea what’s happening to them or why, and who may not even realize that dermatologists treat hair loss—I didn’t. After a couple of months of shedding, they may get worried enough to start looking for remedies as their scalp becomes more visible. They pick up a bottle of hair vitamins and a vial of scalp oil, with the understanding that results will take a few months to see. Down the line, when they spot short little hairs filling back in around their hairline, they’ll attribute that regrowth to the things they bought, not their natural hair-growth cycle. Suddenly, they’re evangelists for their vitamins and oils, which seem like a miracle cure but did nothing at all.

The pandemic likely put this process into motion thousands—if not millions—of times. It’s a challenge that the supplement and cosmetic industries were well positioned to meet; beauty supplements and topical cosmetics are now often sold alongside each other, not just in luxury department stores and beauty emporiums such as Sephora and Ulta, but at Target or via Amazon’s recommendation algorithm. That these products don’t work matters very little to their profitability. In that way, this is a story that predates the pandemic by at least a century. When real, reliable information is hard to come by—in this case, when it is cut off from the general public by the structural limitations of the American health-care system—there will always be a market for new products with hollow promises.

From The Atlantic