Hair Blogs


New data on why hairs thin? A look at the Collagen 17 A1 Protein

Why the Collagen 17 A1 protein could be important for those with hair loss?

A new study published in the prestigious journal Science provides new information into the process of hair thinning.

 

Collagen 17 A1 (COL17A1)

Researchers from Tokyo showed that stem cells in hair follicles become damaged over time as a process of normal aging. Such damage leads to a reduction in the levels of a protein called collagen 17A1, abbreviated COL17A1. Without this protein, hairs become thinner over time.

The study included important observations in mice and in humans. Researchers studied mice that lacked the COL17A1 gene to try to figure out the precise importance of this protein: The scientists found that without this protein, the mice had hair loss.  When mice were engineered to make extra amounts of COL17A1, they did not have hair loss and hairs did not thin. Turning to human based studies, the researchers analyzed hair samples of women age 22-70. They found that aging leads to a reduction in the levels of Collagen 17 A1 and this reduction seemed to correlate with thinner caliber hairs

 

Conclusion and Comment

These are interesting observations. At present, it's much too simple to say that adding back collagen 17 A1 to the scalp will promote hair growth.  The Collagen 17 A 1 protein is a complex protein that integrates in the cell membrane of cells and so simply injecting it is unlikely to do much. However, this study reminds us that understanding stem cell aging is likely to yield some of the most important findings to better understand hair loss.

 

REFERENCE

Matsumura H et al. Hair follicle aging is driven by transepidermal elimination of stem cells via COL17A1 proteolysis. Science 05 Feb 2016: Vol. 351, Issue 6273,  

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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Increased risk of stroke identified in individuals with alopecia areata

A Taiwanese research study set out to evaluate if the risk of stroke is increased in individuals with alopecia areata. Using a large research database, investigators compared 3231 patients with alopecia areata to 16,155 matched controls. Patients were tracked for 3 years.  The incidence rate of stroke was 5.44 per 1000-person years (95% confidence interval (CI) = 4.03~7.20) for those with alopecia areata compared to 2.75 per 1000-person years (95% CI = 2.30 ~ 3.27) for those without alopecia areata. Overall, investigators found the risks of stroke was increased 1.61 times compared to controls.

Comment: Many autoimmune inflammatory conditions are associated with an increased risks of stroke (such as lupus, psoriasis, rheumatoid arthritis).  This study suggests that alopecia areata may also be on this list. Further studies are needed to verify these findings in other patient populations.

 

 

REFERENCE

Kang JH et al. Alopecia areata increases the risk of stroke: a 3 year follow up study. Sci Rep 2015;5:11718.

  


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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Is the treatment really for me? The “ME” in TREAT-"ME"-NT

Do I really want to start this treatment?

 

When it comes to treating hair loss, the final decision on whether or not to use a treatment is left up to the patient.  This is true for many parts of the medicine of course, but it’s very applicable to treating hair loss. A patient with high blood pressure, really should take their blood pressure pills and change their lifestyle and diet. A patient with diabetes really should use their diabetes medications.  But there is no ‘should’ when it comes to deciding on using a hair loss treatment or not.  With no exception at all, it’s a personal decision.

 

The ME in Treat"ME"nt

In my practice, I see the whole spectrum of "ME" in Treatment.  And one must never assume that all patients want treatment for their hair loss.  The rationalization that an individual would not make an appointment, take time out of their day visit the clinicif they did not want treatment – is simply not correct.  Hundreds of stories in my professional career back this up.

 

So what is the spectrum?  There are some patients who simply want to know that their hair loss does not indicate anything more sinester.  Every now and then I meet a patient with hair loss who is so over the moon with excitement that their hair loss is “just” hereditary hair loss.  They don’t want treatment – they simply wanted to know that their health was not in jeopardy.  And then on the other side of the spectrum is the patient who has tried nearly all treatments for their hair loss.  When I mention one last one with the most remote of chances it can help, they want to try.  Side effects are possible and close monitoring will be needed to make sure none of those side effects occur. They want to try.  For them, the benefits of treatment, the benefits of growing hair greatly outweigh any such risks.  In their mind, they are saying – this is for ME!

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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Stress and Hair Loss: A closer look at the 5 D's of Stress

Does stress cause hair loss?

A common question I'm asked is whether stress can actually cause hair loss. The answer is maybe. Typical day to day stress probably is not a big culprit. 

However,  stresses that are high enough in magnitude can sometimes trigger increased hair shedding, especially stresses that fall into categories of what I call the “5 D’s” :

 

1. death of a loved one

2. divorce and relationship problems

3. debt and financial problems

4. new diagnosis for the patient or a loved one

5. dismissal from a job.

 

The Homes and Rahe Scale

The 5 D’s based on research from the late 1960s when two psychiatrists Dr Holmes and Dr Rahe conducted research into how stress and illness are linked. Based on their studies, they created the Holmes and Rahe scale. The scale ranks a variety of life events based on the stress they cause. As you guessed, the 5Ds are right at the top.  Death of a spouse was given a rating of 100, death of a close family member 63, divorce a rating of 73, a diagnosis of illness at 53, dismissal from work at 47 and financial issues (mid 20s).Hair loss and the 5Ds

When patients mention concerns about recent hair loss it is important to conduct a very thorough history which sometimes includes an assessment of stresses of the patient.

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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Causes of Sudden Hair loss in Women

What are the causes of sudden hair loss in women?

Although genetic hair loss is one of the most common causes of hair loss in women, other causes are frequently seen as well. What differentiates some of these other conditions is their speed of hair loss. Genetic hair loss tends to be a slow type of hair loss, whereas other types of hair loss can be more rapid. 

The 3 most common causes of rapid hair loss are telogen effluvium and alopecia areata and scarring alopecias. 

1. Telogen Effluvium

Telogen effluvium (TE) is not a single entity. Telogen effluvium refers to hair shedding that follows a 'trigger' such as low iron, crash diets, thyroid problems, starting mediations, massive stress. Typically TE develops 2-3 months after a trigger. Any internal illness can also trigger a telogen effluvium

2. Alopecia Areata

Alopecia areata is an autoimmune condition that affects 2 % of the world. Sudden onset of hair shedding is one way that the condition can declare itself prior to the development of circular patches of hair loss. 

3. Scarring Alopecias 

Scarring Alopecias refer to a group of autoimmune conditions that leave behind deposits of scar tissue as they move through the scalp. These pieces of scar tissue, prevent hair from regrowing in the area and therefore lead to permanent hair loss. Some scarring alopecias, especially lichen planopilaris can accounce their presence with sudden hair shedding. Affected patients often have scalp itching, burning or scalp tenderness.

4. Chemotherapy 

It is not a surprise that chemotherapy is also on the list of causes of sudden hair loss. Hair loss occurs in about 65 % of individuals receiving chemotherapy and is largely dependent on the specific drugs received. Hair loss usually starts 3-4 weeks after the chemotherapy is started.

5. Hair breakage from chemicals and styling

Recent highlighting or hair dyeing can sometimes trigger hair shedding especially if bleaching was used or their was an inappropriate mixture of chemicals or an inappropriate duration of application to the scalp. Affected patients notice breakage of small hairs sometimes within hours of leaving the salon. 

6. Allergic contact dermatitis

Application of chemicals to the scalp that cause an allergic reaction can cause sudden hair loss.  A classic example is allergy to hair dyes. What bothers patients more from hair dye allergy is not the hair loss but rather the scalp itching and scalp pain that is often present. 

7. Scalp infections

Scalp infections are not common in adults, but a variety of scalp bacterial virus and fungal infections can trigger shedding and sudden hair loss. 

8. Trichotillomania

Trichotillomania, or the self induced pulling of hair can lead to sudden hair loss. AT times of extreme emotional stress, depression and obsessive compulsive disorders hair pulling can lead to rapid hair loss within a short time. 

 

Conclusion

Women with sudden hair loss should see a dermatologist for careful review of their history, assessment of the scalp up close and review of blood tests. Further blood tests may be ordered depending on the story. 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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Choice of oral contraceptives is important for women with androgenetic hair loss

Androgenicity of 'combined' birth control pills  

First approved in 1960, there are now many different brands of oral contraceptives on the market. One common class of oral contraceptive pills are those which contain an estrogen component and a progestin component. These so called "combined OCPs" are the most popular of the birth control pills. Today, I'd like to highlight an important topic: the “androgenicity” of oral contraceptive pills or "OCPs"

The Estrogen Component. 

Significant attention has been given in recent years to making oral contraceptives safer by reducing the estrogen dose. Many modern OCPs contain 20-35 micrograms of estrogen (ethinyl estradiol) compared to 50 micrograms or higher in years past.

 

The Progestin Component.

What is sometimes forgotten in the discussion of OCPs is that the progestin component is important to consider as well, especially for women with androgenetic alopecia.  Some progestins are significantly more ‘androgenic’ than others.  

In general, all oral contraceptives are "anti-androgenic" to some degree as they function by reducing the production of androgens by the ovaries. But because the progestin that makes up the OCP differs, this translates into a scale of 'androgeneticity' for oral contraceptives with some being less androgenic than others.

The least 'androgenic' progestins often added to OCPs include norethindrone, norethindrone actetate, desogestrel, norgestimate and drosperisone.The most 'androgenic' progestins in OCPs have names like levonorgestrel and norgestrel. However, it’s not so simple as to say that the androgenic progestins are bad and the least androgenic are better: the combination of an estrogen with the progestin to make up the combined OCP alters the pill's overall androgenic potential. For example, even the levonorgestrel is an androgenic progestin, it has such a low amount of progestin in many OCPs, that the OCP might actually itself have a low androgenicity rating.  

My preferences for starting an OCP

Overall, one should always speak to their physician before starting or changing a birth control.  My preference for women with androgenetic alopecia who decide to start a birth control pill is to choose one with 1) low androgenic activity overall and 2) a progestin with low androgenic activity.  My advice may be slightly different if someone is already on a certain type OCP. The importance of the 'androgenicity' of the OCP does not carry the same relevance if the woman does not have androgenetic alopecia. 

Low androgenicity OCPs include : ortho tri-cyclen (contains norgestimate), ortho-cept or desogen (contains desogestrel), modicon (has norethindrone), ortho cyclen has (norgestimate), demulen (has ethynodiol diacetate), and ortho 777 (has norethindrone).

Other OCPs may also have low androgenicity and all women should speak to their physicians before starting or changing any oral contraceptive. Oral contraceptive use may not be appropriate for everyone.

 

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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Diagnosing Hair Loss: Understanding The "H.A.I.R." Principle

So, what' s my diagnosis ?

I enjoy participating in a number of online forums, including those where I answer questions from individuals with hair loss. It's challenging to offer any valuable information about diagnosis with questions that offer 1 or 2 sentences about a patient's hair loss. Sometimes it's even challenging with a photo. 

Years ago in my teaching clinic, I came up with a 4 letter memory tool to teach doctors in training about the proper steps needed to diagnose hair loss. The first letter of teach of the key steps spells HAIR:

 

H = History

A= Assessment

I = Investigations

R= Repeat if necessary

 

H=History.

The history of a patient's hair loss is extremely important and can't be ignored. All aspects are important including when it first occurred, how long it's been present, symptoms that accompany the hair loss (scalp itching, burning or pain), medications used by the patient, family history of hair loss, personal history of any medical conditions. All these things could be important to a patient's hair loss and need to be uncovered. 

 

A=Assessment. 

A proper assessment of the scalp involves an "up close" exam. Sometimes this is not possible and photos need to suffice. But to be confident in what's causing a person's hair loss, the scalp needs to be examined. One can't stand across the room. One needs to look - and the closer the better!

It's important to examine exactly where the hair loss is occurring. Is it occurring in the frontal area? The top of the scalp? The middle? the back? Is there redness? Is there scarring? 

 

I= Investigations.

A variety of investigations need to be considered in anyone with hair loss. These include blood tests, biopsy and collection of shed hairs. It doesn't mean that all these are necessary - it just means they need to be considered. 

For all women with hair loss, I advise three tests: complete blood counts (CBC for hemoglobin), thyroid studies (TSH test) and iron studies (ferritin test). Other studies could also be important to order depending on what is uncovered in the steps above. For men with hair loss, such tests are not always needed.

A scalp biopsy is rarely needed. With a properly obtained history and a properly conducted scalp exam, a biopsy becomes redundant for many patients. However, a biopsy is helpful in challenging cases and helpful in some scarring alopecias to confirm the subtype.

 

R= Repeat if necessary.

It's usually possible to diagnose hair loss with the first three steps above : history, assessment and investigations. However, there are some situations where it's just not.  In such challenging cases, the only way to definitively understand the cause of the patient's hair loss is to see them back in the office and 'follow' their hair growth and hair loss over a period of time. Sometimes this is 2 months and other times it could be 6 months.  At each visit, the steps of history taking (H), assessment (A) and investigations (I) may be repeated. 

Exceptions to the HAIR Rule

There are not many exceptions. A history of hair loss and an assessment is always required. There are many mimickers of hair loss. A photo of a patient with what looks like genetic hair loss could be genetic hair loss. But without a history one can not be certain.  Investigations, as stated above, are not always needed. 

Conclusion

The "H.A.I.R." Principle is a helpful memory tool to remind both physicians and patients that diagnosing hair loss might not always be quick and easy.  A carefully obtained medical history, a thorough scalp assessment and a variety of investigations need to be part of the evaluation. In some cases where the diagnosis is elusive, these steps need to be repeated in a few months 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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Redness after a hair transplant

How long does redness last after a hair transplant ?

 

Everyone undergoing a hair transplant needs to be aware of what to expect in the first 4 weeks post op. 

One of the considerations is post op redness. For reasons that are poorly understood, some individuals have redness in the transplanted recipient area that persists. Individuals with lighter coloured skin are at higher risk. 

The above photo shows persisting redness in a patient 4 weeks post transplant. Given the patient's longer hair, it is easy to hide. It persisted until 12 weeks. (3 months). 

It can be difficult in some cases to get ride of the redness if your skin type predisposes you to redness. However, the redness will fade with time. It can frustrating and patience is required.  Options such as mild topical corticosteroid lotions and creams can be used but are often disappointing. Camouflaging options can be reviewed as well (DermMatch, Toppik, Couvre)


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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Spironolactone for Female Pattern Hair Loss

Spironolactone (Aldactone) for Treating Genetic Hair loss in Women

Genetic hair loss in women affects the frontal scalp and may cause diffuse loss in some women. Treatments include FDA approved minoxidil (Rogaine) Spironolactone (Aldactone), low level laser and platelet rich plasma (PRP).

How well does Spironolactone work?

Previous studies examining the benefits of spironolactone are small in size, but suggested that 40 % of women experience a halting of hair loss with spironolactone and 40 % experience and increase in hair density. 

A new study from University of California Los Angeles examined the benefits of spironolactone in 19 women with genetic hair loss. A survey was given to 20 women. Follow up period was 7 to 20 months. Overall, 30 % of women experienced an improvement, deemed as either a 'mild improvement' or 'increased thickness'. Another proportion achieved stabilization (no further loss) but it's not clear in the study how many of the women in the study had follow up long enough to evaluate stabiliity. 

Conclusion

Overall, these data are similar to previous studies suggesting that 30-40 % of females with genetic hair loss will achieve a benefit using spironolactone pills for genetic hair loss

 

 

REFERENCE

    Famenini S, Slaught C, Duan L, Goh C. J Am Acad Dermatol. 2015 Oct;73(4):705-6. doi: 10.1016/j.jaad.2015.06.063. 

    Sinclair R, et al. Br J Dermatol. 2005. Treatment of female pattern hair loss with oral anti androgens. Br J Dermatol. 2005 Mar;152(3):466-73. -  

     

     


    Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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    MALE BALDING and COLON CANCER: NEW INFORMATION, NEW RISKS

    New Association Identified between Male Balding and Colon Cancer

    Previous studies have examined whether men with male pattern hair loss have an increased risk of cancer. Some studies (albeit not all) have suggested an increased risk for prostate cancer. Whether a link between male balding and other types of cancer exists is unknown. 

    Why search for links between male balding and colon cancer?

    The pathways leading to male balding and colon cancer may have similarities. Insulin, insulin growth factor type 1 (IGF -1) and androgens may have a role in both colon cancer and balding.

    In a new study, researchers examined whether there was an association between baldness and the risk of colon polyps and colon cancer.  The researchers found the men with frontal baldness and men with frontal and vertex balding had a 30 % increase risk of colon cancer compared to men without balding. In addition, men with frontal balding had a risk of polyps.
     

    Conclusion

    I found this study quite interesting as it's the first study to look at the relationship between male balding and colon cancer. Whether screening guidelines for men with balding should be different than men without balding remains to be determined.  

     Reference

    Keum N et al. Male pattern balding and risk of colorectal neoplasia. Br J Cancer 2016 12; 114: 110-7.

     


    Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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    Finasteride (Propecia) and Weight Gain: What's the evidence?

    Does Finasteride (Propecia) cause weight gain in some patients?

    As much as I specialize in how to use medicines to treat hair loss, I also specialize in understanding their side effects.  How can we deliver safe treatments - that are effective?

    Finasteride and Weight gain

    Every now and then, a patient will ask about the possibility of weight gain with finasteride.  Finasteride is an oral medication which blocks an enzyme known as 5 alpha reductase. By blocking this enzyme levels of the super potent "DHT" (dihydrotestosterone) are reduced. Levels of testosterone and estrogen may be slightly increased. 

    Weight gain with finasteride certainly is not common. I know that based on all the patients that have used the medication in my practice. However, that's the not the point of this blog. The point of the blog is - are 'some' patients at increased risk? 

    That's a very challenging question. Overall, there is not a lot of evidence. But overall, it appears that quality of evidence and the detail to which this issue has been studied in men and women with hair loss is poor. I  don't think we can say with 100% certainty that an occasional patient using finasteride might experience weight gain. However, if it does occur, it's likely rare.

    A few points to consider about weight gain and finasteride: 

    1. The product manual for finasteride (Propecia) does not mention an association with weight gain. 

    2.  Finasteride and other hormone blockers including dutasteride (men) spironolactone (in women) is known to occasional cause individuals to feel sluggish, fatigued. Mood changes rarely can occur. Could this translate into activity changes, or overall metabolic activity?  It's not clear. Certainly a very small proportion of users feel a bit 'blah' .

    3. Studies in men using finasteride for prostate enlargement (the other key use of the drug) do not appear to experience weight gain. In fact, a proportion of users actually experience a slight weight reduction.  These were the results of a randomized controlled study of 3040 men using 5 mg finasteride.

    4. Although finasteride is not FDA approved for females and must always be used used under direction and care of a physician who is knowledgable about its use for women, studies have looked at weight changes in females using finasteride.  A 2014 study looked at benefits of 2.5 mg dose of finasteride every third day for 28 female individuals using finasteride. There was no changes in weight (as measured by the BMI) in these individuals.

    Does finasteride cause weight gain?

    The majority of evidence does not support weight gain for the majority of users of finasteride. However, whether a minority could be affected still needs to be given attention. This can ONLY be achieved by well designed and properly conducted clinical studies.   

     

    REFERENCE

    Roehrborn CG, et al.  Effects of finasteride on serum testosterone and body mass index in men with benign prostatic hyperplasia. Urology. 2003.

    Tartagni MV, et al. Intermittent low-dose finasteride administration is effective for treatment of hirsutism in adolescent girls: a pilot study. J Pediatr Adolesc Gynecol. 2014.


    Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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    Tofcitinib (Xeljanz) and response to stress

    Is the response to stress altered in those taking Tofacitinib (Xeljanz)?

    Every day, I hear new about potentially new benefit for the immunosuppressive medication Tofacitinib (Xeljanz). Studies have shown benefit in a range of conditions including rheumatoid arthritis, alopecia areata, atopic dermatitis (excema of the skin), vilitilo, inflammatory bowel disease, ankylosing spondylitis and more. 

    I've been using it for a while now for alopecia areata and seeing responses in a proportion of patients. Side effects are not common but include headaches, runny nose, diarrhea, changes in blood counts. Serious side effects don't appear to be common but issues like infection occur in about 2 % of users. 

    As we continue to introduce Tofacintib to the clinical setting, it's important to continue to monitor all side effects.

    Tofacitinib and agression

    Today, I read a study from the Eur J Pharmacol about changes in aggressive behaviour in mice treated with tofacitinib

     

    Aggression behaviour induced by oral administration of the Janus-kinase inhibitor tofacitinib, but not oclacitinib, under stressful conditions.

    Fukuyama T, et al. Eur J Pharmacol. 2015.

     

    A recent study in mice set out to determine if tofacitinib can affect itching in mice. IN the process of conducting the study,  In the process of detecting anti-itching potency, the researchers found that tofacitinib treated mice showed slightly increased aggressive behaviour after being 'stressed'. These studies showed not only that the JAK-STAT pathway (the pathway that tofacitinib acts on) may affect behaviour, but that these side effects should be further explored in humans treated with the medication. It's not always possible to draw parallels between mouse and human studies but this study leads the way to further investigation of possible behaviour changes induced by the medication.

     

    REFERENCE

    Fukuyama T, et al. Aggression behaviour induced by oral administration of the Janus-kinase inhibitor tofacitinib, but not oclacitinib, under stressful conditions. Eur J Pharmacol. 2015.


    Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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    Tofacitinib (Xeljanz) for Alopecia Areata

    Tofacitinib: Additional benefits for alopecia areata

    Tofacitinib (Xeljanz) is an oral medication that is FDA approved for the treatment of rheumatoid arthritis. Recent studies in the past 2 years have shown a benefit for some patients with alopecia areata.   Alopecia areata is an autoimmune condition, that affects all ages and all people across the world. In fact, about 2 % of the world's population is affected by alopecia areata. Patients often lose hairs in circular patches but may lose all the hair on the body as well. I’ve been using Tofacitinib (Xeljanz) in my practice for a while now.  It doesn’t help everyone but does help a proportion of patients.

    I was encouraged too by a recent study showing benefit not only for hair loss, but also for the nail problems that frequently accompany this condition.  A study in the journal JAMA Dermatology reported 3 patients with alopecia universalis (AU) whose nail abnormalities improved with treatment with Tofacitinib. Interestingly, 2 of these 3 patients had an improvement in hair growth as well.

    Tofacitinib is proving to have many potential benefits for patients with alopecia areata.

    REFERENCE

    Dhayalan and King. Tofacitinib Citrate for the Treatment of Nail Dystrophy Associated With Alopecia Universalis. JAMA Dermatology. 

     


    Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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    CANAAF - Come Together 2016 Alopecia Awareness Conference

    July 22 - 24, 2016 Patient Conference in Toronto

    I'm looking forward to participating in this year's patient conference organized by the Canadian Alopecia Areata Foundation (CANAAF). I'll be participating in a question and answer panel on July 23, 2016. 

    The conference is July 22-24 at the Delta East 2035 Kennedy Road. 

    More details can be found on the CANAAF website. 

    See you there!

    Jeff.

     

     

     

     

     

    T


    Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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    Is there such thing as normal scalp hair density?

    The key to being human is that we're all different. The same is true for hair density. In fact, there's really no such thing as normal density. Men and women have have different hair densities.  Caucasian individuals have different density than those of African/ Afro-carribean background, and different than those of Asian background.

    Normal hair density if one was forced to quote a normal value is somewhere   between 165-220 hairs per sq cm ( ... or roughly 87 follicular units to 120- follicular units per sq cm). The back of the scalp is thicker than the temples.  he highest density occurs at birth (when the head is very small) and then slow reduces as the individual gets older.


    Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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    Bald spots in the beard: What are the possibilities?

    Hair loss in the beard area: bald spots

    Hair loss can occur anywhere on the body. Certainly most people are familiar with hair loss occurring on the scalp. But what about the beard area?

    For men with hair loss in patchy spots in the beard, there are two different scenarios that are commonly encountered

    1. the individual once had much thicker and more uniform facial hair but now has bald spots
    2. the individual never achieved even growth and areas of the beard are missing or 'patchy'

    Scenario 1

    Patients with previous thick hair and new onset bald spots need expert advice to determine the diagnosis. Conditions such as alopecia areata, lichen planopilaris are at the top of the list for possibilities. Such individuals CAN NOT be treated with a hair transplant as a first step.
     


    Situation 2

    Patients who never achieved thick hair find that some areas are patchy frequently have thin beards on account of their genetics. These individuals CAN be treated with a hair transplant. Topical agents such as minoxidil (Rogaine) can also frequently be administered (under monitoring of a physician).


    Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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    Omega 3 fatty acids: A potential adjuvant in hair loss treatment in women?

    So what are omega 3 fatty acids?

    Omega 3 fatty acids are called 'essential' fatty acids because we, as humans, can't synthesize them ourselves. We need to get them from our diet.   

    While research in the role of these essential fatty acids in hair biology is still in it's early stages, and we don't really understand if they help or not, it is well known that these omega 3's have a variety of beneficial effects for human health. Evidence suggests that these omega 3's have benefits such as lowering triglycerides in the blood, decreasing inflammation, reducing the risk of heart attacks and strokes, possibly lowering blood pressure and improving brain function.  These fatty acids may also enhance the anti-inflammatory ability of certain drugs.

    EPA, DHA and ALA

    The 3 key omega 3 fatty acids are EPA, DHA (which are primarily found in fatty fish) and ALA (which is found in plant sources like walnuts), which stand for

    • eicosapentaenoic acid (EPA)
    • docosahexaenoic acid (DHA)
    • alpha-linolenic acid (ALA)

     

    How much: What dose of omega 3's do we need?

    The exact amount of omega 3 fatty acids we need is not clear but 1000 mg (and maybe up to 3000 mg) seems reasonable and have been the numbers investigated in various studies. Doses more than 1000 mg should be used only in conjunction with a physician as they cause cause a variety of gastrointestinal side effects. While supplements are often recommended for standardized sources, many foods are rich in omega 3 fatty acids. These include oily fish like salmon, sardines, herring, mackerel, halibut, tuna. These are great ways to get EPA and DHA.  Many oils have ALA (canola oil, olive oil, flaxseed oil) but ALA in these have only a small benefit compared to the benefit of EPA and DHA.

    Fish oils may not be right for everyone and I advise individuals to consider speaking with their physicians before starting. Omega 3's for example can theoretically reduce clotting and increase the propensity to bleed. While this may not be relevant on a day to day basis, it is relevant if someone is considering surgery. 

     

    Omega 3s in genetic hair loss

    The role of omega 3's in treating genetic hair loss (androgenetic alopecia) is still unknown. Two studies have prompted my research group to investigate whether omega 3's have a role in genetic hair loss. 

    A study by Oner and colleagues from Turkey looked at hormonal changes in 45 women with polycystic ovary syndrome (PCOS) treated with 1500 mg of omega 3 fatty acids for 6 months.  Interestingly, body mass index, testosterone levels decreased and sex hormone binding globulin ( a protein which binds to and cancels testosterone) was increased.  Hair loss was not studied but these parameters certainly point to potential benefits. We've been studying omega 3's for a while now. 

    A study by Nadjarzadeah and colleagues from Iran examined the effect of taking 3000 mg of omega 3's for 8 weeks in 78 women with PCOS. Interestingly, this study showed that omega 3's reduced testosterone levels; SHBG levels were not changed. 

     

    Omega 3s in inflammatory hair diseases

    The role of omega 3's in inflammatory hair diseases including autoimmune type scarring alopecias (lichen planopilaris, frontal fibrosing, folliculitis decalvans) and alopecia areata remains to be determined and is presently unknown. It's clear from a number of studies that consuming omega 3's lowers inflammatory markers in the blood (such as CRP, TNF-alpha). I've been closely following the role of omega 3's in the treatment of rheumatoid arthritis because some inflammatory hair diseases have similarities to the biological changes in rheumatoid arthritis. These studies suggest that omega 3's may have a modest benefit in the treatment of rheumatoid arthritis.  In another autoimmune condition lupus, studies suggest that EPA fish oils may help reduce symptoms. 

    Conclusion

    Overall, we don't yet know if omega 3's have any benefit in the treatment of hair loss. Studies are ongoing. Certainly, there is reason to believe that some benefit may occur. 

    References

    1. Oner et al. Efficacy of omega-3 in the treatment of polycystic ovary syndrome. J Obstet Gyncaecol 2013; 33(3) 289-91

    2. Nadjarzadeh et al. The effect of omega-3 supplementation on androgen profile and menstrual status in women with polycystic ovary syndrome: A randomized clinical trial. Iran J Reprod Med 2013; 11: 665-72.

    3. Miles EA et al. "Influence of marine n-3 polyunsaturated fatty acids on immune function and a systematic review of their effects on clinical outcomes in rheumatoid arthritis.". The British journal of nutrition. 107: S171–84. 

    4. Li K et al. Effect of marine derived n-3 polyunsaturated fatty acids on C-reactive protein, interleukin 6 and tumor necrosis factor alpha: a meta-analysis. PLOS ONE 9 (2) : e88103.


    Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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    Do I have to use my hair loss treatment "forever"?

    Forever

    The word ‘forever’ has a fairly clear meaning and isn’t really open to much in the way of interpretation.  Forever means continually. Forever means for always. Forever means forever.

    For those with genetic hair loss, treatments must be used forever. If treatments are stopped, any benefits that a patient achieved will be lost. Surprisingly, when you pick up a bottle of a typical medication or treatment for genetic hair loss, the word forever is nowhere to be found.


    Use daily.

    Take 1 pill per day.

    Do not use if pregnant or breastfeeding

    Use three times per week

    Check with your doctor before using.


    Nowhere will you see forever.


    I’m all for clarity and directness. I’m all for labels saying it as it is. Use daily – forever. Use three times per week - forever. Check with your doctor before deciding to use - forever. It might not sound so swell in terms of marketing glamour but it sure would ease a lot of confusion. For example, every week, I meet with a patient with genetic hair loss who has now has developed hair loss after stopping a medication that was originally prescribed to them for their hair loss.

    You mean I was supposed to use this forever?”

     

    Some hair loss treatments are forever

    If the hair loss is due to "genetic" hair loss (sometimes called androgenetic hair loss), then the treatment needs to be used forever (provided it shows evidence of helping). One of the most common criticisms I hear regarding the use of the FDA approved treatment minoxidil is that patients dislike the fact that it needs to be used ‘forever.’ If the treatment is stopped, hair loss resumes. It is true that this medication needs to be used forever. However, the same rules apply for all the treatments for genetic hair loss. Anything that works, needs to be used continuously. Hormone blocking pills, lasers, PRP - they need to be used forever.


    Some hair loss treatments are not forever

    For other hair loss conditions, the rules are different. For alopecia areata, treatment is administered until hair grows back and then it is stopped. For scarring hair loss conditions, treatment is given until the disease becomes quiet, then treatments are slowly reduced. In some patients, medicines can be stopped without the disease "reactivating." For telogen effluvium (hair shedding problems), treatment is given until the shedding pattern returns to normal.


    Conclusion

    In the field of hair loss, it is important to understand the meaning of "forever". For some types of hair loss, medications must be used forever to maintain their beneficial effects. 



    Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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    Treating Hair loss: The ‘next move’ is not a guessing game!

    Treating Hair loss: Logical. Ordered. Structured.

    There are over 100 reasons for hair loss. Each of the causes has different treatment.  In my mind, for every patient I see, there is one or two “best’ treatments, and then the third best treatment. If that treatment does not help, I have a next (fourth) treatment in mind.  The choice of treatment is not random.

    Just like in a game of chess,  there is logic to planning each phase of treatment.  There is order. There is structure. Every treatment has a specific ‘chance’ or specific ‘odds’ that it will help.  Part of the intellectual stimulation of treating hair loss comes from understanding these odds.  I don’t leave the office each day with the false hope that I’ve helped everyone I’ve seen that day with hair loss. Not at all. For example, this week I know that 40-60 % of patients I saw will get benefit from the treatments I recommended. But I also know, that unfortunately 40 % of the patients I saw will not.  Do I know which will benefit and which will not? Not at all.  In the present day, there is no treatment that helps 100 % of patients.

     

    How do you determine the order of treatments?

    Planning the order of  treatments is not a guessing game.  Even if there are five accepted treatments for a given type of hair loss,  one should never choose their treatments by pulling one of these five treatment out of a hat. The order of treatments should be based on previous studies that have been published in medical journals. In medicine, we call this ‘evidence.’ The order of treatments should be based on published medical evidence.    

    What happens when ‘medical evidence’ does not factor into decision making? Chaos.

    But in the ‘real world’, most individuals do not like to speak in terms of ‘medical evidence’.  In the public’s eye, knowing that there have been over 25 well conducted studies of treatment A but none of treatment B does not necessarily make drug B less appealing than drug A.   I know that sounds strange but I have heard it nearly everyday of my professional career. Had you asked me that 10 years ago, I would have said this concept was impossible. But provided information on treatment B can be presented in a manner that sounds convincing, it can quickly find it’s way to the top of the patient’s list of preferred treatments. Sales & marketing not science & evidence frequently rule decision making in the real world.

     

    Chaos.

    Chaos is a term which refers to a state of confusion and disorder.  When medical evidence is left out of the decision making on hair loss treatments, the result is chaos. Patients with hair loss want nothing more than to have some control over a situation (i.e. hair loss) in which they deem to have little or no control. But by leaving medical evidence out of the decision making process about what hair loss treatment to choose, the result is chaos. 

     

    This week alone, several phone calls and e-mails I received from individuals with hair loss drew attention to this chaos.

     

    “I have scarring alopecia and was advised to start carboxytherapy.” What do you think doctor?

    “I have a few patches of hair loss from  alopecia areata and was recommended to start a daily application of an oil mixture? What do you think doctor?

    “I have genetic hair loss and was recommended to start treatment with scalp massage? What do you think doctor?

     

    What I think is that in the world of hair loss treatments, there is needless confusion and disorder.  There is chaos.  

     

    Conclusion and Final Thoughts.

     

    In the chaos that exists out there in the real world of treating hair loss,  we need to remember that many hair loss treatments have already been carefully studied.   Statistics can readily be given on how well they ‘work.’  Clear statistics can be given on the proportion of patients that are expected to benefit from the treatment.  Newer treatments may have less evidence, but if they are truly effective, they quickly accumulate medical evidence and published studies.

    It’s not practical or possible for individuals in the general public to know all the medical evidence behind various treatments. However, there are two simple questions that every patient with hair loss should ask their treating physician. If every patient asked these questions,  I believe that many treatments would never be started.

     

    1) For the type of hair loss I have, how many scientific studies with this treatment you are suggesting have been published in the medical journals?

    Is it zero? Is it one?  Two? 10 ? I encourage patients to begin with treatments that have several published studies. If a treatment is truly beneficial, why would it not be published in the medical journals?

     

    2) What proportion of patients benefitted when they took the treatment you are suggesting?

    Is it 2%?  Is it 50%  I encourage patients to begin with treatments that are likely to benefit 30 % or more patients.  It’s rare in the present day to have treatments that lead to an improvement in hair density in more than 50 % of patients. So, if a treatment is offered that helps 100 % of patients, be cautious!

    There is logic to treating hair loss. What I hope for many patients entering my office or reading my blogs is that they find some calmness and clarity amongst the chaos.  Treating hair loss is not a guessing game.  For most types of hair loss, there is a best first step, a second step and third step. 

     


    Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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    Does seborrheic dermatitis get worse in winter?

    Flares of seborrheic dermatitis common in winter

    Seborrheic dermatitis (SD) is a close cousin of 'dandruff' and is due to a yeast known as Malassezia that is extremely common in the scalp.

    Triggers of SD

    There are many triggers of SD 'flares' including stress, dry and cold weather, certain medications. 

    Flares of seborrheic dermatitis are very common in winter. For 5 % of individuals who experience seborrheic dermatitis and the occasional scalp dryness, itchiness and redness that accompanies the condition, the winter months can problematic. 

    Treatments for SD

    I advise the vast majority of my patient to reach for shampoos containing zinc pyrithione (i.e. Head & Shoulders), selenium sulphide (Selsun Blue), ketoconazole (Nizoral), or ciclopirox (prescription Stieprox) at least once per week in the winter months. There are many myths surrounding these shampoos and they are undoubtedly one of the best kept secrets for great hair.


    Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair restoration. His research has been published in national and international medical journals and presented at scientific meetings around the world. To schedule a consultation in Toronto, please call 416-921-4247. To schedule a consultation in Vancouver, please call 778-960-4247.
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