Hair Blogs


Is my Alopecia Areata active?

Will I lose more hair?

Alopecia areata (AA) is an autoimmune condition affecting 2 % of the world.

 
The condition is well known to be challenging to predict what will happen in the future. In fact, AA tends to be one of the most unpredictable hair loss conditions. It can grow and fall at any time.

Even though AA is said to be unpredictable - it is not completely unpredictable. We have come to understand over the years certain scalp "dermatoscopic" features that suggest a patient's condition is active.

This includes:

  • black dots (which are hairs broken right at the surface),
  • tapered hairs and exclamation hairs,
  • short vellus hairs and
  • broken hairs.

These features all suggest ongoing inflammation in the scalp and a high likelihood of further hair loss.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Scalp Micropigmentation (SMP)

Scalp Micropigmentation (SMP)

SMP continues to trend as a popular method to camouflage hair loss.

SMP involves placing pigment in the skin in a manner to mimic the appearance of a hair cut in cross section.

There is an art to SMP. The SMP specialist needs to properly choose the color of the pigment to match the patient's original hair color- otherwise it looks strange. The pigments need to be placed in the right depth- if placed too deep they appear bluish color and if placed too high in the skin they simply fade quickly. The size of the dot needs to also be accurate. 


Overall, SMP is extremely helpful. It has helped many of my patients camouflage hair loss. Some of these patients have diagnosis including genetic hair loss, alopecia areata, scars, donor area scars from hair transplant surgery and more.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Lichen planopilaris (LPP)

Lichen Planopilaris

LPP is a type of scarring alopecia where hair loss is permanent. This makes it all the more important to secure the correct diagnosis with minimal delay.

Sometimes that is easier said than done. This picture shows an image of a female patient's scalp. At first look one could easily conclude this female patient has genetic hair loss. However, looking closer it reveals subtle scale around hair follicles (called perifollicular scale, PFS. Most of the hairs that are remaining (and shown in the photo) are the same diameter. There is not much in the way of miniaturization that is expected in pure androgenetic alopecia.

Treatments for LPP include: topical steroids, steroid injections, calcineurin inhibitors, oral pills including prednisone, hydroxychloroquine, doxycycline, methotrexate and others.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Pseudopelade Vs Alopecia Areata

Pseudopelade Vs Alopecia Areata

 

 

One of the main features of a scarring alopecia is the disappearance of the follicular openings or "pores." Pseudopelade is a scarring alopecia and can look very similar to alopecia areata. But, when viewed up close using a dermatoscope one can clearly see that the follicular openings start scarring over and disappearing in a scarring alopecia.

The clinical hallmark of a scarring alopecia is the loss of the follicular openings or pore markings.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Scalp Biopsies

Do Scalp Biopsies leave a scar?

The decision on whether or not to do a scalp biopsy is a big decision. A scalp biopsy is a short procedure whereby a cylindrical core of tissue is taken from the scalp. The size of the core is typically 4 mm in diameter. When the core is removed from the scalp, the area left behind is stitched up with sutures to assist in healing.

It does not matter how careful the biopsy or how beautiful the stitching the result is a small scar. Because scars are permanent, the patient will have a small scar in the area for life.

Sometimes a biopsy is essential. Differentiating complex diagnoses from one another sometimes requires a biopsy. Some forms of genetic hair loss are challenging to distinguish from telogen effluvium (especially early stages) and a biopsy may be helpful. Some forms of scarring alopecia are similar in some cases (discoid lupus vs lichen planopilaris). Some hair loss conditions need a biopsy because there are no other choices (for example ruling out breast cancer metastases to the scalp that perfectly mimic a single patch of alopecia areata). Overall, the use of a handheld dermatoscope in the clinic has greatly reduced the need for scalp biopsies. By carefully examining the scalp with a dermatoscope, features can he seen that can't be seen with the naked eye. Overall, I perform scalp biopsies on a very small minority of patients.

Unless it is absolutely critical to achieving the diagnosis, a scalp biopsy is not necessary.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Pseudopelade of Brocq

A scarring alopecia mimicking AA

A lot hair loss conditions look alike. This makes the diagnosis very challenging. If every type of hair loss was treated the same way, with the same medications, it really wouldn't matter what the diagnosis is. But different hair loss conditions are treated differently.

Pseudopelade of Brocq is a scarring hair loss condition that causes permanent hair loss. It causes hair loss is circular patches and often shows no signs of inflammation. It can be a great mimicker of alopecia areata, another hair loss condition causing hair loss in patches.

Treatments for pseudopelade are designed to help stop further hair loss. Regrowth is not possible. In contrast, treatments for alopecia areata are administered with the hope of regrowing hair.

Treaments include: Topical steroids, steroid injections, calcineurin inhibitors, methotrexate, cyclosporine, hydroxychloroquine.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Alopecia Areata

Yellow Dots and Short Vellus Hairs

Yellow dots and short vellus hairs are the most commonly seen dermatoscopic features of alopecia areata. Both are related with severity of disease being more common in advanced alopecia areata.

Yellow dots are hair follicles that are plugged with keratin. Short vellus hairs in alopecia areata represent hairs that are trying to regrow.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Alopecia Areata

Partial Responses to Treatments

There are four things that can happen when a patient receives treatment for Alopecia Areata: 

1) the hair regrows fully (known as a "complete response")

2) the hair regrows partially (known as a "partial response")

3) treatment does not lead to any change. This can either be because the treatment does not work or because the treatment works a little but the rate of loss matches it.

4) hair loss gets worse. Usually this is because the patient's hair loss is active rather than the treatment itself causing hair loss. A small proportion of patients receiving steroid injections find their hair loss worsens with steroid injections. In most of these cases, the patient's alopecia is so active that the steroid injections could not overcome or stop the hair loss. The treatment itself usually does not make it worse when proper concentrations and doses are used. Of course there are exceptions. 


This photos shows a partial response. Hairs are growing and many new "pointy" hairs can be seen. However, two tapered hairs are seen indicating inflammation beneath the skin. These "tapered" hairs will most likely fall out within days. The "pointy" ones likely will likely keep growing. This patient required a more aggressive treatment.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Finasteride inhibits 5 alpha reductase

Finasteride inhibits 5 alpha reductase

Finasteride is FDA approved for the treatment of male pattern hair loss at a dose of 1 mg and FDA approved for the treatment of male prostate enlargement (a condition called benign prostatic hypertrophy) at a dose of 5 mg.

The drug works by inhibiting an enzyme known as "5 alpha reductase type 2." This enzyme helps covert testosterone (T) to dihydrotestosterone (DHT). By blocking this pathway, DHT levels are lowered in the scalp by about 60 % and bloodstream by 70 %. Topical finasteride is also be an option to treat male pattern hair loss but good studies have yet to be done and I am not yet convinced either way.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Chronic Telogen Effluvium

Chronic Telogen Effluvium

Chronic telogen effluvium or "CTE" is one of the simplest yet most complex conditions. 
Patients with CTE are usually 35-70 years old with sudden onset of hair shedding. 300, 400 or 500 hairs are lost on some days yet 40, 50 or 60 are lost on other days. A trigger most often can't be identified. Blood tests are normal. Hair density looks high to a casual observer. Individuals with CTE often had incredibly high density - so high at one time that most patients joke that they were initially glad when the shedding first happened because their hair was just much too thick. Many affected patients recall a time long ago when their hairdresser would sigh at every appointment because they knew the appointment would take soo long in account of all the hair volume and density the patient once had.

This is CTE.

CTE is not shedding that happens with low iron. CTE is not shedding after crash diets or massive stress. This is a completely different (although similarly sounding condition) called acute telogen effluvium). Great confusion exists between CTE and acute TE. 


The exact cause of CTE is not known which makes treatment challenging. Options such as vitamins, biotin, hair and nail supplements, laser, PRP, anti-androgens can be tried.

The hair science world has devoted little attention to this condition and more research is needed. More research is also needed to create drugs that block a hair follicle's ability to leave anagen (the growth phase). Although this might not solve the underlying reason for this condition, such drugs would be useful for an array of conditions including CTE, acute TE, AGA, and alopecia areata.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Exclamation Hairs=Broken Hairs

Exclamation Hairs=Broken Hairs

 

Exclamation mark hairs are fragile hairs commonly seen in patients with alopecia areata. They are short hairs (3-4 mm hairs) that break, snap and fall out easily. This dermatoscopic image shows a typical "frayed" exclamation mark hair.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Tapered hairs in AA

Tapered hairs in AA

Tapered hairs are seen in "active" alopecia areata. Unlike exclamation mark hairs, tapered hairs are long hairs rather than short hairs. 


Tapered hairs are caused by massive inflammation in the bottom of the hair follicle (called the bulb). Many tapered hairs will break off and become exclamation mark hairs. Some tapered hairs will fall out of the pore and be shed.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Exclamation mark hairs in Alopecia Areata

Exclamation mark hairs in AA

Exclamation mark hairs are 3-4 mm hairs that are wide at the top and thin at the bottom. They are seen in individuals who have recently developed a patch of alopecia areata. 


These hairs are caused by the inflammation around the hair bulb that impairs the ability of the hair matrix to make a proper hair.

 
Long standing alopecia areata does not have much  inflammation and correspondingly exclamation mark hairs are not seen.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Exclamation mark hairs in Alopecia Areata are located at the periphary

Exclamation mark hairs in Alopecia Areata are located at the periphary

"Exclamation mark" hairs are 3-4 mm hair usually seen at the edges of a bald patch in individuals with alopecia areata.

Exclamation mark hairs signify the patient's disease is active and further hair loss is likely to occur without additional treatment.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Tofacitinib for children & teens with Alopecia Areata

Tofacitinib for children & teens with Alopecia Areata

Some of the most difficult forms of alopecia areata to treat are those occurring in children. 
Treatments used for children with alopecia areata are typically similar to those used in adults with even more attention and concern placed on safety.

Recently, we have seen adults with alopecia areata get improvement with tofacitinib (also marketed under the name Xeljanz)

The question  then arises: Would tofacitinib help children? 

A recent study now proves that it does. Craiglow and colleagues from Yale published a study looking at 13 children age 12-18 with alopecia areata. 9 of them (69%) improved confirming that this drug is beneficial in children. 

The next question that is raised is what age to we draw the cut off and tell parents that their children they are too young for this medication. If 12 years old is acceptable, what about an 10 year old with alopecia areata? What about a 6 year old? What about a 2 year old? I think it's clear that most would agree some cut off exists, but what is it? That is where careful discussion with parents are so important. There is no universal right or wrong answer. There is no universal age cut off. For some the answer is no and for others it may be yes.

REFERENCE
Craiglow BG, et al. Tofacitinib for the treatment of alopecia areata and variants in adolescents.J Am Acad Dermatol. 2016 Nov 2


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Platelet Rich Plasma (PRP)

PRP: Treating Alopecia Areata

How does PRP compare to minoxidil in the treatment of the autoimmune condition alopecia areata?

Researchers from Egypt studied the effect of PRP, minoxidil and placebo in 90 patients with alopecia areata. 
Patients with alopecia areata grew hair faster than patients receiving minoxidil. The authors conclusions were that PRP was more effective than minoxidil for patients with alopecia areata.

Reference
Platelets rich plasma versus minoxidil 5% in treatment of alopecia areata: A trichoscopic evaluation.
El Taieb MA, et al. Dermatol Ther. 2016.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Arrector Pili Muscle (APM)

Arrector Pili Muscle (APM)

The arrector pili muscle (APM) is not as well known as other muscles like the biceps, triceps or quadriceps. The APM is a small muscle attached to every hair. When it contracts, the result is goose pimples! It has been thought that the APM does not have any active role in any of the various mechanisms of hair loss and more or less acts as a ‘bystander.’ In new model of how balding develops, Australian dermatologist Rodney Sinclair and colleagues propose a model for understanding androgenetic alopecia. They propose that the APM has a key role in the decision of a hair follicle to ultimately "miniaturize" or get skinnier during the course of AGA.

By observing how miniaturization occurs within follicular units – the authors propose that by maintaining attachment to the APM, some hair follicles are prevented from proceeding down the pathway of permanent miniaturization.

Like all models, this proposal sets the stage for further exploration. The APM has perhaps been ignored for too long and may have a more important role than we ever imagined.

Reference
Sinclair R, Torkamani N and Jones L. Androgenetic alopecia: new insights into the pathogenesis and mechanisms of hair loss. F1000Res. 2015 Aug 19;4 (F1000 Faculty Rev):585


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Sebaceous Glands (SB)

Sebaceous Glands

Sebaceous Glands (SG).png

It takes a lot of coordination by many cell types to finally produce a healthy hair fiber. One particular participant is the sebaceous glands (also called the oil glands). The sebaceous glands secrete an oily substance to help lubricate the hair follicle. The substance also has anti-microbial and antibacterial properties to help prevent the hair follicle from becoming infected.

Without sebaceous glands, a hair follicle can't form properly. Mice engineered in the lab that have abnormal sebaceous glands develop a scarring alopecia (scarring hair loss condition) which teaches us just how important these structures really are.

The sebaceous glands get bigger in patients with genetic hair loss and this can often be seen in their biopsies. The sebaceous glands get smaller and then disappear altogether in patients with scarring hair loss (scarring alopecias) and this phenomenon can always be seen in their biopsies.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Dermal Papilla (DP)

Dermal Papilla

It takes a great deal of coordination by many cell types to finally produce a healthy hair fiber. Let me tell you about one participant - the dermal papilla.

The dermal papilla is found at the bottom of the hair follicle. It is composed of a group of very specialized cells known as fibroblasts.

The dermal papilla is a key control centre for the hair follicle. It tells another group of cells known as the "hair matrix" exactly what to do in order to make a hair fiber.

The more active and bigger the dermal papilla, the bigger and wider the hair follicle that will be produced. 
The dermal papilla has the potential to form new hairs when transplanted into other areas of the skin and are therefore said to be "trichogenic" (hair forming).

One day, it may be possible to take a patient's skin and expand the number of dermal papilla cells they have and inject them back into their scalp. This could lead to an endless supply of hairs.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Preparing a Scalp Biopsy

What happens when a scalp biopsy is sent to a pathologist

Typically a 4 mm diameter cylindrical core sample is obtained from the patient. The tissue is allowed to bathe in formalin to fix it before being cut into very thin slices (4-5 micrometer thick), mounted onto a microscope slide and then stained with a special pink/purple stain known as hematoxylin and eosin. Once the biopsy specimen is stained, it is presented to the pathologist for interpretation. A formal report is then sent to the dermatologist.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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