There are numerous nonsurgical treatments that when combined, can offer significant hair improvements. Dr. Yaker’s TCHR Volumizing Glycolic Acid Shampoo and Conditioner help restore vitality to the hair by deep cleaning the scalp and reestablishing lost moisture content and physiological pH to the scalp and hair. Dr. Yaker has also formulated his own oral supplement, which is a blend of Aminoplex hair repair vitamins. This is made up of amino acids (building blocks of protein) that produce keratin, which makes up close to 97% of our hair. In addition, Dr. Yaker’s specially compounded FDA approved topical medication, Minoxidil (brand name: Rogaine®), is clinically proven to help slow down, stop and even reverse hair loss in women. Other nonsurgical therapies offered are Low Level Laser Therapy (LLLT) using the advanced LaserCap®, and Platelet Rich Plasma (PRP) with placenta-derived extracellular matrix therapy to help restore thinning hair. Lastly, Dr. Yaker offers scalp and facial micropigmentation where permanent ink is applied to the skin, creating micro dots that replicate the natural appearance of hair. This is used for the scalp and eyebrows.
Clearly, minoxidil is not a miracle drug. While it can produce some new growth of fine hair in some — not all — women, it can't restore the full density of the lost hair. It's not a quick fix, either for hair loss in women . You won't see results until you use the drug for at least two months. The effect often peaks at around four months, but it could take longer, so plan on a trial of six to 12 months. If minoxidil works for you, you'll need to keep using it to maintain those results. If you stop, you'll start to lose hair again.
I got really sick at the age 40, 2 years after my second child was born,I started losing weight,I went from 54kg down to 47kg,my skin was splitting on the backs of my legs,both my hands,I had blisters up my arms ,on the tops of my feet,migraines that would have me vomiting none stop for ten hours,then only to sleep for 2 days to recover,no doctors were interested,I saw 8 and they all wanted me on anxiety medication because I was going through a break up that was there answer to the way I was feeling.No one wanted to listen to me.Almost feeling like
"Dr. Yaker is ABSOLUTELY AMAZING! He is innovative, highly professional, incredibly skilled and extremely passionate about hair restoration. His bedside manner is one of complete dedication and compassion with genuine care for his patients and their needs. He strives for excellence in everything he does, and it's evidenced by his loyal client following and their satisfaction with their incredible outcomes. I'd recommend him to anyone & everyone interested in hair restoration or transplantation."
Oops forgot to mention also went to Dermatologist who said it is probably just stress related but I really don’t stress ever. I am going back for a scalp biopsy just to be sure nothing going on there. I did lose 12 kg over a 15 week period last year (ending about May – hair loss started in July) but it was done properly eating well and just increasing my exercise level so not sure if this is related other than that I am totally lost as to why I am BALD.
As the name suggests, androgenetic alopecia involves the action of the hormones called androgens, which are essential for normal male sexual development and have other important functions in both sexes, including sex drive and regulation of hair growth. The condition may be inherited and involve several different genes. It can also result from an underlying endocrine condition, such as overproduction of androgen or an androgen-secreting tumor on the ovary, pituitary, or adrenal gland. In either case, the alopecia is likely related to increased androgen activity. But unlike androgenetic alopecia in men, in women the precise role of androgens is harder to determine. On the chance that an androgen-secreting tumor is involved, it's important to measure androgen levels in women with clear female pattern hair loss.
^ Martinez-Mir A, Zlotogorski A, Gordon D, Petukhova L, Mo J, Gilliam TC, Londono D, Haynes C, Ott J, Hordinsky M, Nanova K, Norris D, Price V, Duvic M, Christiano AM (February 2007). "Genomewide scan for linkage reveals evidence of several susceptibility loci for alopecia areata". American Journal of Human Genetics. 80 (2): 316–28. doi:10.1086/511442. PMC 1785354. PMID 17236136.
Alopecia areata is characterized by a localized area of complete hair loss (Figure 5). This may extend to the entire scalp (alopecia totalis) or the entire body (alopecia universalis)12,13 (Figure 6). Alopecia areata is probably secondary to an autoimmune reaction involving antibody, T-cell, and cytokine-mediated losses.14–16 The trait appears to be polygenic, affecting 0.1 to 0.2 percent of the population, with men and women equally affected.14 On microscopic evaluation, “exclamation-point” hairs are found, in which the proximal hair shaft has thinned but the distal portion remains of normal caliber (Figure 7). Spontaneous recovery usually occurs within six to 12 months, with hair in areas of re-growth often being pigmented differently.1,13 Prognosis is not as good if the condition persists longer than one year, worsens, or begins before puberty. Persons with a family history of the disorder, atopy, or Down syndrome also have a poorer prognosis.1 The recurrence rate is 30 percent, and recurrence usually affects the initial area of involvement.12 Thyroid abnormalities, vitiligo, and pernicious anemia frequently accompany alopecia areata.1,12,14
I too have suffered from hair loss, more noticebly over the past 2 year, although it first started 10 years ago. I am 39 female and always had a full head of hair. Now, my hair has gone dry, dull and and has lost it volume. I have been to my Dr and have had test done, however everything has come back ok. i.e. my hair los was not found to be down to any internal deficiencies hormones, nutrient levels, diseases etc , so now my Dr is referring me to a dermatoligst to see if the problem is due to the skin on my scalp. However it maybe advisable if you havent already, to visit a licesend Trichologist, this is someone who specifically deals with the scientific study of the health of hair and scalp, and would have a more thorough knowledge about your hair than any GP and by conducting a hair analysis, can identify your hair loss problem. I intially visited, and it was he who suggested I go along to my GP and ask for specific types of tests. However, he also informed me for some cases there are conditions that can be cured, but with other, it could simply be that hair loss pattern is heriditary which can occur in both male and female ( this does not necessarily need to come from your parents or grandparent, it could come from family gene from generations back, that so happened to show up in you generations later!). In this case, the frank truth is little can be done. However there are different topical treatments, and people do not have to go to the extreme of hair surgery or even having to wear undignified wigs. Below is a link to a product called Toppik which I have used. Basically it small fibre which are made from the same fibres as natrual hair, which use sprink onto your hair to cover bald and thinning areas. It adds body, volume, and makes your hair ‘magically’ appear full regardless of the lenghth of your hair. Its not expensive, and also come with conditoner and shampoo to give your hair that added volume, even to the most thinnest of hair. I hope this will provide some solution and even comfort to those experiencing hair loss. The link is below – Good luck
Wow, I just started doing some research on this because I have been having problems with my hair thinning on the top of my head for several years, along with some sensitivity. I went to my internal medicine Doctor and he didn’t say much, which struck me as odd… he referred me to my women’s doctor who was slightly more sypathetic but offered no suggestions other than to see a dermatologist. I have been putting it off because I feel like I am getting the run-around. I see that I am not alone!
My scalp is pain-free but has on occasion flared again but 1/100 of the original pain. My scalp still needs frequent shampooing (I could go weeks without it before) to keep the dermatitis at bay. My hair and scalp are still fairly dry and brittle despite aloe for moisture, avocado oil to moisturize and seal in moisture and Behentrimonium Methosulfate to close cuticles, provide slip and halt hair snapping, BUT the breakage is 90% better. I’m still too afraid to go back to humectants though I know they’re amazing as moisture-retainers for dehydrated hair. I have spots of completely missing hair towards my hairline that hasn’t and will probably never regrow but I’m focusing on nursing everything else back to health.
Thank you Diana. If you find out any more information, I would appreciate it. I have a dermatologist across the street from the Skin and Cancer Institute. I’m still not sure who to start with, the dermatologist or an endocronologist. I left a message for my PCP today to see if she is comfortable working with female hair loss or if not if she could refer me to someone who specializes in it. I will let you know what I hear back. In the meantime, thanks for your support. Take care.
Next week I will go for a second opinion to the Cioa Bell Institute here in Phoenix as well. Another cosmetic surgeon who sells the cap. So far the cap is only available through phycisians. I guess I can understand why, because laser therapy has many strength settings from hair removel to hair grows, so you really need some sort of a specialist to help you along the way.
During a hair transplant procedure, a dermatologist or cosmetic surgeon removes tiny patches of skin, each containing one to several hairs, from the back or side of your scalp. Sometimes a larger strip of skin containing multiple hair groupings is taken. He or she then implants the hair follicle by follicle into the bald sections. Some doctors recommend using minoxidil after the transplant, to help minimize hair loss. And you may need more than one surgery to get the effect you want. Hereditary hair loss will eventually progress despite surgery.
I am relieved to find out that I am not the only female going through this problem. Don’t get me wrong. I am sorry that you are all going through this, but I was beginning to think I was the only female with this problem. I am 22 years old and I have been experiencing hair loss for the last two years. At first, it didn’t really bother me and I imagined it wouldn’t last. Then, it progressively got worse and has continued for the last two years. I have seen my PCP, GYN as well as various Endocrinologists and ENT’s to try and get to the source of my hair loss. They have all laughed at me and told me not to worry about it. I feel like they’ve all blown me off because I’m so young; However, no one understands how emotionally and physically destructive this is! I used to have tons of hair! I was even named “Best Hair” my senior year in high school and now I am ashamed to go out in public or even look at myself. I have very little hair left and it’s ruining my life, my relationship with my boyfriend, and my ability to maintain other relationships. I am now suffering from a lot of anxiety, depression and low self esteem. I’m all out of ideas and hope! My mother suggested that I go see a dermatologist, but I wouldn’t even know who to trust with this issue. The last thing I need is another doctor looking at me like I’m crazy and thinking that because I’m so young I should just ignore it. I can’t ignore it! It has been going on for far too long and all I want is someone who will listen to me and try to help me. I live in Arizona. Do any of you know of a good dermatologist that I can go see? I hate that this is happening to me and the negative impact it has been having and will continue to have on my life. I’m afraid that it’s only going to get worse and I will wake up one day completely bald! If any of you have advice or suggestions, I would be glad to hear them!
I am on Arava and my hair has become extremely coarse, frizzy, and tight tight curls in the back. The sides of my hair are pure frizz and the top is straight, with frizz. It used to be smooth and so easy to manage. Now it takes so long and it looks awful. Anyone find the same thing and anything that helps? I have tried so very many hair products, so has my beautician. She says it is like I have 3 completely different textures on my head.
Alopecia areata is not contagious. It occurs more frequently in people who have affected family members, suggesting heredity may be a factor. Strong evidence of genetic association with increased risk for alopecia areata was found by studying families with two or more affected members. This study identified at least four regions in the genome that are likely to contain these genes. In addition, alopecia areata shares genetic risk factors with other autoimmune diseases, including rheumatoid arthritis, type 1 diabetes, and celiac disease. It may be the only manifestation of celiac disease.
Central centrifugal cicatricial (scarring) alopecia: This type of hair loss occurs most often in women of African descent. It begins in the center of the scalp. As it progresses, the hair loss radiates out from the center of the scalp. The affected scalp becomes smooth and shiny. The hair loss can be very slow or rapid. When hair loss occurs quickly, the person may have tingling, burning, pain, or itching on the scalp. Treatment may help the hair re-grow if scarring has not occurred.
THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. It is intended for general informational purposes only and does not address individual circumstances. It is not a substitute for professional medical advice, diagnosis or treatment and should not be relied on to make decisions about your health. Never ignore professional medical advice in seeking treatment because of something you have read on the WebMD Site. If you think you may have a medical emergency, immediately call your doctor or dial 911.
Alopecia areata is an autoimmune disease, where a person's immune system attacks the body, in this case, the hair follicles. When this happens, the person's hair begins to fall out, often in clumps the size and shape of a quarter. The extent of the hair loss varies; in some cases, it is only in a few spots. In others, the hair loss can be greater. On rare occasions, the person loses all of the hair on his or her head (alopecia areata totalis) or entire body (alopecia areata universalis).
Thank you all for sharing, For the pass years I have been having hair loss on and off. I have tried several natural treatment, example : hot oil , moist heat, acupuncture. Have seen several doctors and specialists which cost me thousands of dollars. I have insurance, but they will not accept, because they will not get pay, it is experimental my insurance paid for my lab tests. at this time my diagnosis is hypothyroidism. I am using organic foods, juicing; sunflowers seeds , pumpkin seed to make smoothie and oils from doTerra to massage my scalp. trying vitamins etc. etc. I cannot pinpoint what makes the improvement because I have used
The loss of hair can be sudden, developing in just a few days or over a period of a few weeks. There may be itching or burning in the area before hair loss. The hair follicles are not destroyed and so hair can re-grow if the inflammation of the follicles subsides. People who experience just a few patches of hair loss often have a spontaneous, full recovery without any form of treatment.
Hi everyone, I’m so encouraged by reading all of the stories and different ideas. I too am suffering from thinning hair, it has been going on for years, but it’s very noticeable now. I guess I’ve been trying to ignore the problem hoping that it goes away, but of course it hasn’t. I have several things that could attribute the hair loss; I take a high blood pressure medication call Diovan, I’m starting to get hot flashes, so I’m pre menopause, I’ve had two years of terrible stress and divorce and subsequent finance problems. My father is 84 and only has hair on the side of his head, my Mom is 81 and has thinning hair (though takes many medications for different ailments). My hair has always been thick and I’m had to use relaxers most of my life (which I stopped about 1 yr ago). So it could be a number of these things causing the loss and thinning of hair. I’m stress most of time now, when I stand in front of a mirror, when I run my fingers through my hair, or simply see people’s eyes look at the top of my head as they are talking to me. I live in Fort Lauderdale Florida and work in Miami if anyone can refer a Dermatologist or maybe an Endocrinologist I would greatly appreciate it.
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My hair was healthy. No split ends and thick and tame – I could not break it. The healthy condition of my hair may be the reason that I didn’t loose all of it. My hair loss was due to a “HAIR DESTROYER” causing chemical damage, burning my scalp and my hair ( I think she used a product banned in Australia). I had bald spots on my crown the size of 50 cent pieces and the rest of my hair was singed. I lost my hair gloss, I was left with hair that was as thin a rice paper and breaking everywhere. I had severe itching on my scalp for two years. Not pleasant. I cursed her every day and still do. I bought myself a pair of hairdressing scissors and cut as much hair off as I could; and chipped into it everywhere. I do this every two weeks. Hence I will never go to a hair dresser again and have not colored my hair since December 2012 – I asked for Brown on Brown 10 vol – how could an idiot of a hair destroyer (dresser) get it so wrong.
I am 31; as a child I had beautiful brown smooth hair with a hint of a wave. As soon as I hit puberty at 13 (1st period on my 13th b-day), my hair turned wavier. Same year, I remember looking down on my legs horrified at the hair I had developed. Only 1 thought came to me: “NOT NORMAL!” Body hair on women is a tricky subject, though, with media heavily influencing what’s considered ‘normal’. My mom, similarly hairy, just told me it’s genetic and normal.
In-office laser light treatments or at-home handheld devices, such as the HairMax LaserComb, supposedly grow new hair by stimulating blood flow to the area (think: an amped-up version of a scalp-stimulating shampoo). Just don’t expect the device to make your noggin go from looking like George Costanza’s to Jerry Seinfeld’s. “These lasers won’t grow any new hair. If anything, they may just help you hang on to some of the hair that you already have a bit longer,” says Dr. Joyce.
One hard truth: Hair loss is mostly out of your control. “Baldness comes down to your genes,” says Frederick Joyce, M.D., founder of Rejuvenate! Med Spa and a member of the International Society for Hair Restoration Surgery. “If you have the baldness gene, there are some natural remedies that may make your hair stronger and healthier to slow your hair loss slightly—but they won’t prevent you from going bald. Still, maintaining hair health by eating well and using the right products—combined with medical-grade treatments—can really work all together to help you have a fuller, thicker head of hair.”
This blog is great in all the support and understanding it provides, but I had a pretty hard time finding any suggestions for treatments that have actually helped anyone. I’m 22 and my hair has been rapidly shedding over the past 5 months. It’s also gotten thin and brittle. After 2 blood screenings, a dermatologist visit, and a visit to my general practitioner, nothing has improved. The doctor’s told me to wait it out, and that sometimes this “just happens”. They tested my hairs and saw that most of them were in the “resting” telogen phase, and decided I had Telogen Effluvium (TE) for undetermined causes.
The condition affects 0.1%–0.2% of the population, and occurs equally in both males and females. Alopecia areata occurs in people who are otherwise healthy and have no other skin disorders. Initial presentation most commonly occurs in the late teenage years, early childhood, or young adulthood, but can happen at any ages. Patients also tend to have a slightly higher incidence of conditions related to the immune system, such as asthma, allergies, atopic dermatitis, and hypothyroidism.
I have been trying to deal with thinning hair for the past several years. I am 37 yrs and used to have very thick, lock, curly hair. I am not an arrogant person, but I did love my hair and I thought it was a beautiful feature. My attempts to cover up the hair loss by using Toppik has been somewhat favorable, but it has not been a solution by any means. I tried Rogaine and as a result, I ended up looking like a warewolf with hair growth on my cheeks. (I had to laugh at that sight!) I have been to a dermatologist who recommended Rogaine and ordered expensive labs that my insurance would not cover (I did not follow through with the labs b/c I do not have the money and I did not return to him because I was disappointed in his suggestion for Rogaine with the initial visit.) My endocrinologist (I have hypothyroidism) shrugged off my report of hair loss by saying “it’s not that noticable.” I’ve been to two different nutritionalists and spent hundreds (if not close to a thousand) on supplements. I have new insurance and I’m looking for a new endocrinologist and dermatologist. I was recently diagnosed with fibromyalgia, so I am trying to control my stress level to decrease the pain. At times I feel guilty for being consumed by my insecurities and by the lack of results for my hair regrowth. So many others have much more serious conditions, and I remind myself that the situation could be much worse. I continue with the Toppik applications and I have ordered a topper in case my hair loss worsens. I am afraid that I will embarrass my son and that my boyfriend will not see me as attractive any more. But, I do continue to have faith that the Lord will see us through any trial, and in the end, we will come out stronger. Sometimes I need to vent and get things off my chest, and I don’t have anyone who can relate so this forum is very helpful for me. I thank you all for your stories and I hope that we all find peace and that we do not allow this burden to overcome us. Be encouraged and Be Blessed!
Without a doubt, poor nutrition (often caused by eating disorders and crash dieting) is a common trigger of temporary hair loss. If you don’t get enough protein in your diet, your body may respond by shutting down hair growth—resulting in hair loss. Great source of protein include red meat and dairy products, as well as quinoa, legumes, and nuts and nut butters (all great options for vegetarians). Hair loss can also be triggered by anemia, or a deficiency in iron. Getting enough iron (found in red meat) is key to treating this; often times, an iron supplement can help. If this is the cause of your hair loss, our dermatologists can do a simple blood test to confirm this.
have something to say that sounds alarming: I came to the Texas to live 10 weeks ago from the UK. Within only 2 weeks of being here my hair started falling out dramatically, I would lose around 500 to 700 hairs every time I washed my hair, this would also include hair lost through blow drying as I got to the point I would sweep it up off the floor too. Before I left the UK my hair was beautifully silky and shiny and looked so healthy. Over the following 8 weeks the hair loss worsened to the extent I started getting so dramatically thin all over the top of my head that I got myself into a panic every time I would do out as I didn’t want anyone to see me this way as I am quite an attracted woman 38 years of age. My periods are normal and my health appears good, just now I am suffering from depression because of this. The point I am making here is, I never had this in my life before, sure I have had bouts of hair fall from stress but never has it ever got to the point I can no-longer go out ever. I see so many things about this on the TV here in Dallas always advertising women’s hair loss? I also see too much of this on the net also from the US that now I am really getting worried about ever coming here and if this continues I’m going to leave the US and never come back. The people here are so lovely so please don’t get me wrong just that my health and my hair come first. I have visited the US many times and been to many States over the recent years from California to FL to Chicago and each time I come over I start to lose my hair. Bit this time is the worst ever! When I Skype my family back home they are shocked of course and we are all wondering if it is the food chain, the water, the air, pollution, I mean it’s got to be something right? I also spent years over in Brasil and also Lima Peru but never had anything like this, in fact my hair got even better over there than from when I was in the UK last. I’ve got a strong suspicion the doctor’s over here know more than they are letting on and have done for a long time but just making money out of peoples misery. I saw a doctor here who did some blood works and charged me $800 and he didn’t even do a hormone profile or (Ferritin) as checking iron is a total waste of time, Ferritin is the end response of iron absorption. Checking iron in the blood is what is floating around and not what has been absorbed. He wanted to then send me onto an Endo who wanted to charge me another $400. for a consult plus she said anything from $600. for additional blood works. I Lima Peru I can get 10 x more blood works done for no more than $120. Be cheaper for me to get a return flight and have all the tests done over there. Sorry to say this but, the US is a total rip-off when it comes to this sort of thing. Everyone back home thinks the whole thing stinks and sounds very suspect. If my hair gets any worse I’m defo going leave and most likely head on to Lima for a while and then go set my roots in Brasil. I really wanted to be here in the US as I have so many lovely friends over here and could really see a future for me here. I am gutted. Anyways I’m going to do some research to see if I can find a good Endo myself as well as a dermatologist. Maybe it is all to I do with all the nuclear testing they did years ago? they say radiation remains for a 100 years and what with weather conditions, wind, rain, crops, livestock, water supply? Now we have phytoestrogens and now we have this other thing to worry about frankenfoods. Us women have a more complex hormone system than males and this has got to wreak havoc on our endocrine system our glands and of course our hormones. I believe whatever is causing this must be doing something to us internally that is the cause. So lotions and potions working from the outside is not the answer or a permanent solution. I think something is disrupting us from the inside and screwing with our hormones be it thyroid, sex hormones or whatever. So stop sugar drinks, artificial foods and water from plastic bottles, microwave foods and start to clean up your health from the inside and perhaps try find organic meat, vegetable, fruit, fish suppliers. Maybe little more costly, but far cheaper than giving the money to a bunch of quacks? I guess thank goodness for European rules and regulations on food compared to here. Like to hear peoples thoughts.
Speaking of a new style: Don’t choose one that’s so high maintenance that it needs to be heat styled daily—the damage you’ll do with too much hot tool usage can leave strands damaged and fried, and breaking before it can grow to a certain length. Plus, thinner hair tends to break easier, so you want to avoid any extra damage-inducing practices at all costs. Make a conscious effort, too, to brush more gently, and use a moisturizing and reparative hair mask to hydrate hair and nourish the scalp—where hair gets most of its strength.
The characteristic finding of alopecia areata is one or more well-circumscribed areas of otherwise normal, hairless skin in hair-bearing areas. Occasionally, it may be necessary to biopsy the scalp to confirm the diagnosis. Other findings that may be helpful are the appearance of short hairs that presumably represent fractured hairs, short thin hairs, and gray hair growing in a bald area. Other causes of hair loss are generally excluded from the consideration by history and clinical evaluation.
Women also may experience AGA, often with thinning in the central and frontal scalp area but usually without frontal–temporal recession (Figure 3). A history and physical examination aimed at detecting conditions of hyperandrogenism, such as hirsutism, ovarian abnormalities, menstrual irregularities, acne, and infertility are indicated. Laboratory tests are of little value in women with AGA who do not have characteristics of hyperandrogenism.5
I’m 42 and I noticed my front top and sides thinning about a year ago – a lot coming out when brushing after washing. I went to the doctor who happened to be African-American (I’m caucasion) and she actually asked me if I wore “corn rows” a lot! Needless to say, she was worthless and just prescribed me something for dandruff, which I do not have! I went to an endocrinologist to see if my thyroid or menopause was the problem – tests turned out honky dorie! Now I can see through the top of my head when the sun shines on it (scar-y) and I’m having to cover over the temple areas with sweeps of hair from the other side (interesting, the right side is much thinner). I will say that I’ve gone through hell and back with a mentally ill young adult but if it was stress, wouldn’t it have come out quicker than just in the last year (I’ve been dealing with his illness for 7 years now)?? I’ve heard that sometimes it takes 2 or 3 blood tests and doctors to finally see that one has thyroid problems. Is this the experience of others, and would I be throwing my money away by seeing my general practitioner?
Thank you for all your post. My daughter had extremely thick hair about eight years ago. It was so thick you could barely put it in a scrunchie. Her hair has been continuously thinning to the point that you can see through it. All the women in my family on both sides have extremely thick hair. We live in the north east and have seen several GP and a Dermatologist who act like there is nothing wrong. I work in the medical field and when I hear this I get so mad because I feel like they want to just brush of like no big deal. It is a big deal to all women no matter what ages. I have written done some of the post advise and will continue to look for an endocrinologist for her. Please keep me postes on any new developements.
Alopecia areata, also known as spot baldness, is a condition in which hair is lost from some or all areas of the body. Often it results in a few bald spots on the scalp, each about the size of a coin. Psychological stress may result. People are generally otherwise healthy. In a few, all the hair on the scalp or all body hair is lost and loss can be permanent.