Hair Blogs


Tofacitinib for Alopecia Areata: A look at changes in Inflammatory Markers

CXCL10 Levels drop quickly in a patient successfully treated

You've probably never heard of CXCL10. It's a small protein that gets secreted into the blood when there is inflammation around. Many cells make CXCL10 including blood vessel cells (endothelial cell), fibroblasts, monocytes. The CXCL10 helps attract a variety of inflammatory cells such as T cells, NK cells. 

A new study looked at levels of CXCL10 in a patient successfully treated with tofacitinib. The patient was a 40 year old female with severe alopecia areata treated with 5 mg twice daily of tofacitinib. She regrew hair rapidly on treatment. This was associated with a decrease in the blood levels of CXCL10 within 1 month.  Other inflammatory markers were also altered. 

Conclusion and Comment

We are now entering a new era where blood levels of certain proteins may soon be used to predict responses to treatments as well as monitor the possible chances of relapse. CXCL10 could be an important protein to evaluate in predicting response to treatment. 

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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Minoxidil plus finasteride: better than either one alone

Minoxidil + Finasteride : How do they add up?

Patients who use minoxidil and finasteride together get better results than those who use just minoxidil or those who use just finasteride. There have been a few studies that have shown this. 

A recently designed study examined the benefits of monoxidil, finasteride and the combination in 450 males with genetic hair loss. The men in the study were randomly assigned to receive:

            finasteride (n = 160 patients), 

            minoxidil (n = 130 patients) 

            combined medication (n = 160 patients) 

In this study, the participants returned to the clinic every 12 weeks for re evaluation.  At the one year mark, 80.5 % of men treated with finasteride, 59% of of men treated with minoxidil, and 94.1% men treated with the combination of both have a benefit, respectively.  

 

CONCLUSION

The conclusion of the study was that the combination is better than either alone

 

REFERENCE

Combined treatment with oral finasteride and topical minoxidil in male androgenetic alopecia: a randomized and comparative study in Chinese patients.Hu R, et al. Dermatol Ther. 2015 Sep-Oct.

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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What's new in Alopecia Areata Research ?

AA Research Moving Ahead at Great Speed

I had the great privilege of joining the Canadian Alopecia Areata Foundation this past weekend at their Spring session. I reviewed the latest research in alopecia areata. There are many interested new studies, but I chose to focus on five including:

1. a review of the benefits of cholesterol medications for alopecia areata treatment

2. The role of platelet rich plasma in treating alopecia areata

3. New evidence that patients with AA have a  reduced risk of skin cancer

4. Evidence confirming that steroid injections are better than topical steroids for treating localized alopecia areata

5. New data on the benefits of tofacitinib and ruxolitinib in treating alopecia areata including new exciting topical formulations that have been studied. 

You can review my slides below:


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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Is there a reduced risk of skin cancer in patients with alopecia areata?

Decreased risk of skin cancer in patients with AA

Alopecia areata is an autoimmune condition. Recent studies have suggested that a closely related autoimmune condition called vitiligo (whereby skin cells lose pigment) may be associated with a decreased risk of skin cancer.

In a new study, researchers from Harvard looked at the the risk of skin cancer in patents with alopecia areata compared to patients who did not have alopecia areata. A incidence of skin cancer in 1414 patients with alopecia areata was compared to the risk of skin cancer in 4242 patients who did not have alopecia areata.

Overall, there were fewer patients with alopecia areata who were diagnosed with basal cell and squamous cell skin cancers compared to patients who did not have alopecia areata. Interestingly, there was a slightly decreased risk of melanoma as well.

CONCLUSION

Patients with alopecia areata appear to have a 37 % reduction in the risk of squamous cell and basal cell carcinomas. 

 

REFERENCE:

Mostaghimi et al. Reduced incidence of skin cancer in patients with alopecia areata: A retrospective cohort study. Cancer Epidemiology 2016


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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PCOS related hair loss - more than one treatment needed

Multimodal treatments are usually necessary for PCOS. The ideal is usually a combination of minoxidil, oral contraceptives, spironolactone and low level laser. I always advise that patients see their dermatologist or endocrinologist for advice. Certainly, these treatments aren't appropriate for everyone. inoxidil helps 30 % of women with genetic hair loss, but not everyone. It helps halt loss and may improve hair density a bit. It can thicken hair a little bit and promote growth of dormant hair. As many are aware,  shedding is common in months 1 and 2. 

PCOS related thinning usually requires more than 1 treatment for most effective results. I like to add zinc (periodically) and selenium to my general recommendations as well. 

Razavi et al studied the effect of receiving either 200 μg selenium daily (n=32) or placebo (n=32) for 8 weeks. Jamilian et al studied the effect of  220 mg zinc sulfate (containing 50 mg zinc) (n = 24) or placebo (n = 24) for 8 weeks.  Although the short in duration, both studies showed an improvement in various clinical parameters and improved hair growth.

 

REFERENCES

Razavi M, Jamilian M, Kashan ZF et al. Selenium supplementation and the effects on reproductive outcomes, biomarkers of inflammation and oxidative stress in women with polycystic ovarian syndrome.  Horm Metab Res. 2015 Aug 12. [Epub ahead of print]

Jamilian M, Foroozanfard F, Bahmani F et al. Effects of zinc sypplementation on endocrine outcomes in women with polcystic ovarian syndrome: a randomized, double-blind placebo controlled trial. Biol Trace Elem Res. 2015 Aug 28. 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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Chronic telogen effluvium vs Genetic hair loss - Easily confused !

CTE vs AGA - easily confused but different conditions

CTE and AGA are often easily confused. Labs normal in both. Family history of hair loss similar in both. Hair check similar in both. Biopsy often unhelpful unless done properly (meaning transverse sections and measurement of terminal to vellus ratios).

CTE takes time to figure out. Info on family history of AGA is not useful at all in diagnosing AGA in women.  AGA doesn't start in the 50s in women. All in all, you'd need a careful examination. CTE is the most challenging of diagnoses.

FEATURES OF CTE

 

1. CTE leads to fluctuations in shedding with shorter breaks

2. Women often once had thick hair (very thick)

3. Miniaturization not typical

4. Onset is sudden

5. Scalp sensations (tingling, burning) often present

6. Pretty normal looking scalp exam or maybe significant temple recession in some

7. Labs normal

8. Some days 50 hairs lost; some days 350-400

9. After 6-8 months, tends to reach a balance between shedding and growing and patients look similar month after month (despite massive shedding!!!)

10.           Biopsy done with horizontal sections show terminal to vellus ratios above 8:1 (whereas less than 4:1 for AGA)

11.           Central part width not typically widened in CTE

 

CONCLUSION

I understand how tough it is to get a diagnosis of CTE vs AGA. But they are very different conditions.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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What are the most effective and best researched treatments for lichen planopilaris?

LPP treatments: Where does the research point to?

Lichen planopilairis (LPP) is an autoimmune scarring hair loss condition that affected adults between 35 and 60. Patients develop hair loss but also symptoms of itching, burning and pain. The early stages of LPP are accompanied by increased shedding as well. Aggressive and early treatment of LPP is required to stop the hair loss. 

 

What treatments are most effective?

Treatment that block inflammation are most effective. But not any anti-inflammatory can be used. For example, aspirin and ibuprofen don't help. Rather anti-inflammatories belonging to a group of medications known as immunosuppressive and immunomodulatory drugs work best. This includes:

1. Topical steroids (mid to strong potency) and steroid injections

2. Topical tacrolimus (Protopic) and topical pimecrolimus (Elidel)

3. Oral hydroxychloroquine (Plaquenil and generics)

4. Oral tetracyclines (doxycycline, tetracyline, minocycline)

5. Oral cyclosporine (Neoral, prograft, Sandimmune)

6. Oral mycophenolate mofetil (Cellcept, Myfortic)

7. Oral predisone (mainly for flares and early bridging treatment, not long term)

 

These 7 treatments have the best published evidence for assistance with lichen planopilaris. Any other treatment has less evidence. 

 

Conclusion

Whenever a patient tells me they have tried treatments for lichen planopilaris and it didn't work, I want to know two things. First, I want to know if they truly have lichen planopilaris as there are many many mimickers. Biopsies can be wrong ... yes! and yes! Conditions like pseudopelade of Brocq can mimic LPP and so can a few other scarring alopecias (discoid lupus and folliculitis decalvans). The second thing I want to know is what treatments the patient has tried.  I've heard countless treatments - perhaps well over 60 to date. Being on treatment does not count unless it's a potentially beneficial one. 

 

References

 

Lichen planopilaris: update on pathogenesis and treatment.

Baibergenova A, Donovan J. Skinmed. 2013 May-Jun;11(3):161-5. Review

Efficacy of oral retinoids in treatment-resistant lichen planopilaris.

Spano F, Donovan JC. J Am Acad Dermatol. 2014 Nov;71(5):1016-8. doi: 10.1016/j.jaad.2014.06.013. Epub 2014 Oct 15.  

Lichen planopilaris following whole brain irradiation.

Perrin AJ, Donovan JC. Int J Dermatol. 2014 Oct;53(10):e468-70. doi: 10.1111/ijd.12576. Epub 2014 Jun 5.  

Scalp trauma: a risk factor for lichen planopilaris?

Montpellier RA, Donovan JC. J Cutan Med Surg. 2014 May-Jun;18(3):214-6.

Lichen planopilaris after hair transplantation: report of 17 cases.

Donovan J. Dermatol Surg. 2012 Dec;38(12):1998-2004.

 

 

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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Genetic hair loss in women: sides and back can be affected too

Genetic hair loss in women is different than men

Genetic hair loss in women classically affects the middle and top of the scalp. The scalp becomes more 'see through'. Hairs become miniaturized. Patterns such as the Ludwig pattern of hair loss and the Olsen pattern of hair loss are often talked about. 

What about the sides and back?

What tends to be forgotten is that the sides and back of the scalp are often affected in many women with genetic hair loss. We call this 'diffuse loss.' Diffuse thinning of hair occurs in many women. The area at the sides of the scalp just above the ear becomes noticeably thinning and the back of the scalp becomes thinner as well. 

Treatments for diffuse androgenetic thinning in women include minoxidil, spironolactone, low level laser therapy, and platelet rich plasma. Women with diffuse thinning are not candidates for hair transplant surgery because the hairs at the back of the scalp are thinning  - the donor area is poor. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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Minoxidil after hair transplantation

Minoxidil after hair transplantation: Is there a role?

 

I’m often asked whether minoxidil has any role in post operative care after a hair transplant. My general advice is that minoxidil may help reduce shedding of grafts and shedding of existing hair (ie. a post operative telogen effluvium) ...  but does not appear to influence the chance of the grafts surviving.

 

Here are some studies of note:

In 1987, Kassimir first reported that 2 of 12 patients undergoing a hair transplant showed growth of the grafts without shedding. Thereafter, Singh published a study with 40 patients showing that minoxidil did not affect the survival of grafts after a transplant but did affect the chances that the grafts would be shed. A similar finding was reported by Bouhanna in 1989.

 

Overall there is a role for minoxidil in pre and post operative care. Minoxidil may reduce shedding of grafts and may reduce the post operative telogen effluvium of existing hair as well. Whether or not one should use it, however, needs to be reviewed on a case by case basis.

 

STUDIES:

1. Kassimir JJ. Use of topical minoxidil as a possible adjunct to hair transplant surgery. A pilot study. J Am Acad Dermatol. 1987 Mar;16(3 Pt 2):685-7.

 

2. Bouhanna P. Topical minoxidil used before and after hair transplantation. J Dermatol Surg Oncol. 1989 Jan;15(1):50-3.

 

3. Singh G. Effect of minoxidil on hair transplantation in alopecia androgenetica. Indian J Dermatol Venereol Leprol. 1998 Jan-Feb;64(1):23-4.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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Monitoring blood tests in patients receiving tofacitinib (Xeljanz)

What lab tests are most important to monitor in alopecia areata patients receiving tofacitinib?

Tofacitinib is an oral medication that is used off label for the treatment of alopecia areata.  Research continues into exactly how much it helps patients with alopecia areata.  Frequent blood tests are required during the first few weeks and months of use.

 

Changes in four main areas are possible.

1.     Changes in blood counts. Tofacitinib can cause a reduction in neutrophils as well as lymphocytes. Patients with more severe reductions in lymphocytes appeaer to be at greatest risk for developing injections. This effect is greatest in patients receiving 10 mg compared to 5 mg.

2.     Increases in cholesterol levels. Patients experience inceases in both LDL and HDL. This effect is greatest in patients receiving 10 mg compared to 5 mg.

3.     Increase in liver enzymes. This is rather uncommon but needs to be monitored.

4.     Increase is creatine phosphokinease (CPK, CK). This occurs in a proportion of patients and is usually withouth consequence for most patients. The drug must be stopped however, when levels increase 50 % above baseline. This effect on CPK levels is greatest in patients receiving 10 mg compared to 5 mg.

 

Comment: 

Frequent blood tests are needed when starting tofacitinib. Slight changes are not uncommon but more significant changes may require dose reduction or even stopping of the drug. Anyone starting tofacitinib requires close monitoring. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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Predicting the rate of progression of male balding

Male balding progresses at different rates in men

I'm often asked to help patients predict their rate of balding? How different will they look in 1 year? How different in 2 years? When will they look like their father or a specific photo they bring in?

Getting a sense of male balding rates of progression is challenging and certainly becomes more reliable as the patient ages. For example, predicting what someone will look like at 50 is easier to predict at 40 than 20.  However, with a series of carefully chose questions and a through evaluation of the scalp it is often possible to gain some understanding of the patient's rate of balding. 

 

The following questions are 'key' to ask when assessing the likelihood and degree of progression of male pattern balding:

 

  1. What age did the hair loss start?
  2. What is the current age of the patient?
  3. How much progression has occurred in 6 months?
  4. How much progression has occurred in 12 months
  5. How much progression has occurred in 5 years (if hair loss started more than 5 years ago)?
  6. What medications are used by the patient? What has been the results?
  7. How much hair loss does the patent's father has?
  8. What age (if any) did the patient's father start balding?
  9. Does the patient's mother have hair loss?
  10. What are the hair loss patterns of both grandfathers?
  11. Are there any males in the extended family who have a Hamilton Norwood above level VI? If yes, how many?
  12. What medications does the patient take now?
  13. What mediations were used in the past ? (anabolic steroids, isotretinoin)?
  14. Is the patient a smoker?
  15. What is the patients' health?
  16. What sun exposure has the patient had over the years?
  17. Is the patient obese?
  18. Does the patient have high cholesterol?
  19. Does the patient have diabetes?
  20. Does the patient have high stress?


The following items are key to evaluate when assessing the scalp in order to evaluate the likelihood and degree of progression of male pattern balding:

 

  1. What is the current position of the frontal hairline? How much has it changed since age 12?
  2. How much temporal recession due to balding (not hairline maturation) is there? How much has it changed since age 12?
  3. What change have occurred in the crown?
  4. What changes have occurred in the area in front of the ear (pre auricular area)?
  5. Is there hair loss in the back of the scalp (occipital area)? Is the pattern of hair loss best described as 'diffuse unpatterned alopecia (DUPA)?
  6. What percent of hairs are miniaturized in the frontal, mid scalp, crown and occipital scalp?
  7. What changes in miniaturization have occurred in the past 6, 12 and 18 months?
  8. Is their seborrheic dermatitis present in the scalp? What other scalp conditions are present?

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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Trichotillomania - is the hair loss permanent?

Trichotillomania

Trichotillomania refers to hair loss caused by a person pulling his or her own hair. Trichotillomania is common and up to 4 % of the world is affected. Some individuals pull hair when stressed. Others have underlying depression, anxiety or obsessive compulsive disorders. Both children and adults can be affected.

Does hair grow back in trichotillomania?

Trichotillomania: This patient's hair loss is caused the self induced pulling of hair. 

Trichotillomania: This patient's hair loss is caused the self induced pulling of hair. 

Some amount of hair loss may be permanent in trichotillomania, especially if it has been going on for many years. The only way to promote hair growth is to stop the pulling. Repeated pulling damages hair follicles, causes inflammation in the skin and triggers scar tissue to develop.

The photo on the right shows a patient with advanced trichotillomania. Small broken off hairs are seen all over and whitish discolouration from the presence of scar tissue is present. Hair loss in this area is likely to be permanent. 

Treatments for Trichtotillomania

The main treatment is to stop the pulling.  Assistance from a psychologist or psychiatrist is often needed to address the underlying issues that caused the pulling in the first place. Cognitive behaviour therapy, and other types of counselling are the mainstay of treatment. Treatments to promote hair growth (such as minoxidil) and treatments to stop inflammation are often used but these are less important than addressing the underlying psychological issues that led to the pulling in the first place. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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Does shaving the scalp affect hair growth?

Shaving has no effect on scalp growth 

I'm often asked if shaving affects hair growth. The answer is no. Shaving has no effect of the growth properties of the hair follicle and the decisions that are made by the dermal papillae and hair matrix which are deep under the scalp.

Men with genetic hair loss often shave the scalp to reduce the contrast between the thin miniaturizing hairs or vellus hairs and the terminal hairs. Some individuals with alopecia areata also shave for a similar reason. 

But the decision to have is purely cosmetic and has no effects whatsoever on hair growth. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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International Hair Course: Another Cycle begins

Biannual Hair Course starts in Toronto 

Yesterday, I had the honor of welcoming physicians into my practice for the Spring session of the International Hair course. Twice per year - in the spring and fall - I conduct a course for physicians interested in learning more about hair loss and hair transplantation.

I enjoy the course a lot and have had the opportunity to meet physicians around the world who are interested in treating hair loss. Some come equipped with great skills already and are hoping to fine tune their skills even more. Some come as relative novices in the field of hair loss and are hoping to develop a solid framework. 

The week is an intensive week of training. Through a series of clinics, surgeries, lectures, workshops, and quizzes, participants have the opportunity to learn about hair loss. 6 clinics, held on Monday, Wednesday and Thursday offer participants the opportunity to see some of the most challenging cases of hair loss.  Two surgeries held on Tuesday and Friday allow participants to observe both modern methods of hair transplantation - FUSS (follicular unit strip surgery) and FUE (follicular unit extraction).  A session is also provided on the use of platelet rich plasma (PRP) in treating hair loss and demonstrations of the technique are provided.

Looking forward to another great week.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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Hair Loss from Methotrexate

Methotrexate: Several Mechanisms of Hair Loss

Methotrexate is a medication which is widely used in to areas - as a cancer treatment and as a treatment for a wide variety of autoimmune conditions. 

Hair loss from methotrexate can occur but is not common. This side effect is estimated to occur in 1-4 % of users. There are two means by which hair loss can occur: hair shedding and hair breakage. 

Hair breakage from methotrexate. Trichorrhexis nodosa is shown in one hair. 

Hair breakage from methotrexate. Trichorrhexis nodosa is shown in one hair. 

Hair shedding occurs within the first 4-7 weeks and hair comes out by the root. This type of hair loss can range from mild to marked and depends on the dose of the drug used. 

Hair breakage occurs within the first 2-3 months. Rather than breaking off at the root, affected patients notice pieces of hair falling everywhere. A close up examination of hairs shows a phenomenon known as trichorrhexis nodosa. This is shown in the photo to the right. 

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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Robotic Hair Restoration with ARTAS

The ARTAS Robot

Yesterday we did a video segment on the ARTAS and so today I'll review with you the ARTAS machine. 

The ARTAS is a robotic method of performing follicular unit extraction hair restoration. ARTAS received FDA approved in 2011. The device consists of a computer connected to a mechanical arm which in turn connects to two things - a video imaging interface (with multiple cameras) and a punch device. The entire system is controlled by the surgeon - either with a remote control device or with the computer.  

The ARTAS Punch

The punch is a circular device which removes the grafts from the skin. There are two aspects to the punch - one inner sharp punch and one outer dull punch.  The first inner sharp punch scores the skin to a depth of about 1/16th of an inch. The is followed by the outer dull punch with extracts the grafts. 

Advantages of ARTAS

The ARTAS has three main advantages in my opinion

1. Accuracy

One important limitation of manual follicular unit extraction is surgeon fatigue.  After 2500-3000 grafts fatigue sets in. Is the quality of graft 3000 the same as graft 1? We hope so! But the ARTAS does not fatigue. To the robot, graft 3000 is just the same as graft 1. The accuracy and precision of the robot are unparalleled.

2. Graft quality

For the right patient, the quality of grafts can be very high because the robot helps limit damage to the grafts (what we call transection). With better grafts, the survival is likely higher. With higher survival of grafts, the result for the patient is better density. 

3. Speed.

At top speeds the robot can extract up to 600 follicular units per hours. Faster speed means shorter procedures for the patient, and less time for the grafts to be out of the body... which in turn means better graft survival.

 

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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Hair transplants for Lichen planopilaris and scarring alopecia

Are hair transplants possible for scarring alopecia?

I frequently perform hair transplants for a group of conditions known as scarring alopecias. These conditions are frequently autoimmune in nature and have names like lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia. 

he difference between performing hair transplants for scarring alopecia and hair transplants for genetic hair loss is that the grafts are at slight risk of being lost in those with scarring alopecia. For example, in genetic hair loss we generally say the grafts are permanent. That is not the case in scarring alopecia. There is a very small albeit definite risk of reactivation of the disease that needs to be carefully monitored and followed. 

Due to the small risk of reactivation in scarring alopecia, I am a big believer in keeping patients on some type of baseline treatment to keep the condition quiet.

My general principles for transplanting scarring alopecia include:

1. considering small test sessions when appropriate.

2. limiting the amount of epinephrine

3. Minimizing over trimming of grafts to ensure healthy proportion of stem cells get transplanted

4. Use of minoxidil in some cases pre and post op to promote blood blow

5. Adhering to densities 20-30 FU/cm2

6. Continuing  topical, injection or oral immunomodulatory medications on a patient specific protocol (depending on the specific condition, how long the patient has had it, amount of hair loss, age) 

Conclusion

Hair transplantation for scarring alopecia is among the most challenging types of hair transplants. In the appropriate patient, it can be a very helpful means to improve density. I generally recommend that patients have inactive disease for 2 years, meaning that there has been no hair loss and no scalp symptoms over a period of 2 years. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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Why aren't hair transplants commonly done before 25?

Hair transplants are rarely done before 25 in men

Hair transplants are rarely done before 25 because it's in the best interest of the patient to wait. 

A patient generally has in the back of the scalp only a limited number of hairs to move in his lifetime (i.e. hairs available to transplant). It may be 0. It may be 8000. That's a huge range I know. The older a patient gets the easier it is for his physician to tell him if the number is 0 or 8000. Only a small percent of men have 0 available - and these are men with a type of balding called diffuse unpatterned alopecia. 

By age 25-30, the patient will get a much better sense of where on this scale from 0 to 8000 he falls. If he only has 4000 available, most men want to reserve as many of these precious grafts as possible to place somewhere in the middle of the scalp, rather than use them up in a location like the temples or lowering the hairline. It's normal to want to get hair back. It's normal to want to consider a hair transplant to fix this.

My advice to young men wanting hair transplants

Let an experienced surgeon guide you and hold you back until the right time. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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How is one supposed to use topical minoxidil?

Minoxidil: how does one use it?

Topical minoxidil helps men and women with genetic hair loss (also called androgenetic alopecia) and is formally FDA approved for treating hair loss. If you have another kind of hair loss, it might not work or not as well. Minoxidil must be used forever if individuals are using for genetic hair loss. Minoxidil is not for everyone. I always  recommend individuals to follow the direction of his or her own physician and carefully review the packaging as well.

 

For men

Minoxidil 5 % foam is used 1/2 cap twice daily. 

For the minoxidil liquid the dose is 1 mL (approx 25 drops) twice daily. It is applied to the scalp and allowed to remain on for at least 6-8 hours. 

 

For women

1 mL of the 2 % lotion/solution is formally FDA approved. 

Some women opt to consider once daily application of the 5 % foam which is also now FDA approved. The 5 % lotion can also be used at a dose of 1 mL daily.

 

Regardless of the product used, minoxidil should be applied to a dry scalp and allowed to remain on the scalp at least 6-8 hours (longer is fine). Other products such as gels, sprays, mousse can be applied within 15 minutes. The goal is to get the product on the scalp, so I recommend  patients to make several parts in the hair to help ensure the minoxidil reaches the scalp. Side effects of minoxidil should be fully reviewed with a physician or pharmacist prior to starting.

 

Side effects of minoxidil

Side effects should be thoroughly reviewed by everyone before starting treatment. These include:

1. headaches

2. dizziness

3. heart palpitations

4. hair growth on the face (in 5% of users)

5. hair shedding in months 1-2

6. irritation

7. allergy (rare)

8. swelling in the feet

Other side effects are possible but rare. Minoxidil must never be used by women during pregnancy.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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Ruxolitinib (Jakafi) promotes hair regrowth in a patient with alopecia areata

More data pointing to benefits of Ruxolitinib

I've shared my thoughts as well as previous data on these new so called JAK inhibitors (Ruxolitinib and Tofacitinib) in the treatment of alopecia areata. 

I was interested to read this morning a study showing benefit of ruxolitinib at a dose of 20 mg twice daily in a 35 year old man with two autoimmune diseases - vitiligo and alopecia areata. Hair growth started after 4 weeks and was quite significant by 3 months. 

Ruxolitinib is an oral medication that is FDA approved for treatment of bone marrow cancer known as myelofibrosis.  The drug inhibits a pathway within cells known as the JANUS KINASE pathway and ruxolitinib specifically inhibits Jak 1 and Jak2. Tofacitinib, which is closely related compound and also benefits some patients with alopecia areata, is an inhibitor of Jak 1 and Jak 3.

Conclusion

I'm closely following the JAK story and ruxolitinib. I have been using tofacitinib (Xeljanz) for a while now but will continue to follow the ruxolitinib data and the clinical trials that are underway. 

 

REFERENCE

Harris JE et al. Rapid skin repigmentation on oral ruxolitinib in  a patient with coexistent vitiligo and alopecia areata (AA). Journal of the American Academy of Dermatology Feb 2016.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call 905-752-9907 (Toronto) office) or 778-960-4247 (Vancouver office).
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