TrichoCare 2020 Comes to an End

TrichoCare Education together with the Association of Registered Trichologists put on Excellent 3 Day Program

I had the privilege of being the keynote speaker these past three days at TrichoCare Education’s 2020 conference. The conference was sponsored by the Association of Registered trichologists.

On Monday, June 1 , 2020 I spoke about the training of the hair specialist and the key educational foundations as well as key attitudes that go into producing outstanding hair professionals. On Tuesday, June 2, 2020 I spoke about thee medial treatments for hair loss including medical treatments for endogenetic alopecia, telogen effluvium and alopecia areata. On the day 3 finale, I spoke about scalp trichoscopy or the use of hand held devices to image the scalp with greater detail and precision. I reviewed a 3 step approach to performing trichoscopy.

It was a wonderful meeting and I was honoured to be invited.  Trichocare Education is committed to helping raise standards in the hair and beauty profession through the provision of education and innovation in hair science and technology. The Association of Registered Trichologists (ART) is a membership organization for qualified trichologists and those studying trichology.

Can I Use Minoxidil When My Lichen Planopilaris (LPP) is Active?

Using Minoxidil in Cases of Active Lichen Planopilaris (LPP)

I’m often asked if minoxidil can be used for patients who have active scarring alopecia. The answer really depends on the patient and other specific details. Before we tackle the question, we need to take a look at what constitutes ‘active’ scarring alopecia.

What is active scarring alopecia?

Active scarring alopecia refers to hair loss caused by an overactive immune system process. The patient may have scalp itching, have increased scalp burning and may be shedding more and more hair. All of these things point to active scarring alopecia. What do we do when scarring alopecia is deemed active? Well, we increased the amount of immunosuppressive and immunomodulatory treatments we are using.

Here are just come examples of how we change treatment is we feel LPP is active

Example 1: instead of using steroid injections, we might use steroid injections AND topical steroids.

Example 2: Instead of using topical steroids, we might ADD oral doxycycline.

Example 3: Instead of using oral doxycycline, and topical steroids, a patient might be started on oral doxycycline PLUS oral hydroxychoroquine

In other words, once the LPP is determined to be active (or still active) we are going to make some pretty important decisions about increasing treatment. These are indeed big decisions because treatments have potential side effects, cost money

What is are the potential side effects of minoxidil?

Now , let’s focus on minoxidil and the potential side effects. In addition to side effects like headaches, dizziness and heart palpitations and hair growth on the face, minoxidil can cause two important side effects for patients with scarring alopecia: 1) Minoxidil can cause increased hair shedding and 2) Minoxidil can cause scalp itching for some people. These two side effects can make it difficult to figure out if the itching and shedding are coming from the active LPP or coming from the minoxidil.

So can I use minoxidil if I have LPP or not?

I always advise that patients review use of any medication with their dermatologist. In general, if a patient was using minoxidil for a very long time (without any problem) before the LPP even started, it’s usually fine to continue. In these situations, it’s unlikely any increased shedding or scalp symptoms the patient experiences is going to be attributable to the minoxidil. But starting up or initiating the use of minoxidil when one has active LPP is active is not usually a good idea. If the patient gets more shedding or more scalp symptoms, it will impossible to tell if they are coming from active LPP or coming from the minoxidil. In the worse case scenario, one can imagine a situation where the doctor increases the dose of medications thinking that the change in clinical symptoms or signs was due to increased activity of the LPP when really it was just the minoxidil. Imagine if the patient developed a side effect of the new mediation - and it never needed to be started in the first place.

Higher Minoxidil Concentrations: Is More Always Better?

10 % Topical Minoxidil vs 5 % Topical Minoxidil: Which is better?

Minoxidil is FDA approved for treating androgenetic alopecia (male pattern balding and female pattern hair loss). It would seem logical to propose that if the drug minoxidil helps in the treatment of males and females with androgenetic alopecia that more minoxidil should help even more.

Researchers from Egypt set out to compare the efficacy and safety of 5% topical minoxidil with 10% topical minoxidil and placebo in 90 males with balding.  The study was a double-blind placebo controlled randomized trial over 36 weeks. The study comprised three treatment groups: 1) study participants receiving 5 % minoxidil 2) study participants receiving 10 % minoxidil and 3) study participants receiving placebo.

Surprisingly, after the 9 months, partipcants in the 5 % minoxidil group had higher vertex and frontal hair counts compared to study participants in the 10 % minoxidil group and the placebo group.

Conclusion

This was a nice study showing us that even after 40 years of studying minoxidil, we still have a lot to learn and a long way to go. Higher concentrations of minoxidil are not necessarily better - although more studies are clearly needed.

Reference

Ghonemy S et al. Efficacy and safety of a new 10% topical minoxidil versus 5% topicalminoxidil and placebo in the treatment of male androgenetic alopecia: a trichoscopic evaluation. J Dermatolog Treat. 2019 Oct 21:1-6. doi: 10.1080/09546634.2019.1654070. [Epub ahead of print]

Recognizing Hair Regrowth

Recognizing Hair Regrowth

Every patient with hair loss has the same question after starting treatment - is my treatment working?

For some types of hair loss, it can take 9-12 months to really appreciate if there has been an increase in density and improved scalp coverage. However, even before the actual change in density occurs, it is often possible to detect regrowth by looking at the lengths of newly regrowing hairs through the so called “card test.” This female patient in her mid 20s started minoxidil 4 months ago and had added spironolactone to her birth control pill about 12 months ago. Her diagnosis was androgenetic alopecia (AGA). Because hair grows 1 cm per month, I can conclude that these layers of regrowth measuring 4 cm and 12 cm correspond to a positive treatment response. 

Poor growth after hair transplants: Why?

Poor growth after hair transplants:  

By 8 months, a hair transplant patient should have a fairly good idea of the growth. While it's true that it can take longer (.... even up to 18 months), the vast vast majority of patients experience some nice growth by 8 months. There is no harm in waiting a bit longer - but improvement is (statistically speaking) quickly unlikely.  


Fortunately, poor hair growth following hair transplantation is not something that happens all that often. But when it occurs the surgeon will need to explore many, many possibilities, including patient factors, physician factors and scalp factors. All in all, anyone with poor growth needs to sit down with their physician to review things in detail. 

PATIENT FACTORS

There are a few patient factors to consider - and many are centred around post op care of the grafts. The other patient factor that is important is smoking. Occasionally, smokers have poor growth for reasons that are not completely understood. Other factors one might think about under patient factors are medications that impair hair growth or cause excessive bleeding. There are a few other factors as well that a surgeon will review with a patient with poor growth. 

PHYSICIAN FACTORS

Physician factors also include the physician and his or her hair transplant team. These factors  include overly tight packing of the grafts (too tight, too packed can lead to poor growth) improper depth of grafts, rough handling of grafts by technicians, harvesting of grafts, temperature of grafts and poor hydration of the grafts. All these things are important. Sometimes the density is too high to begin with in certain areas. But these are the things to think about in the "Physician Factors"
 

SCALP FACTORS

This is also an important categories. Some scalps (because of excessive sun damage or other factors) may take up grafts less efficiently and this leads to poor growth. Some scalps bleed more than others are this can rarely impact growth due to post operative "popping" of grafts. Infection post surgery can impair growth as well. And finally some patients have scalp diseases that are either present before the surgery (but could not be detected) or some patients develop new scalp diseases after the surgery that impairs the growth of the grafts. This is rare. For example some individuals rarely develop alopecia areata or rarely develop scarring hair loss problems after their hair transplant. These scalp issues can impair growth partially or completely. A scalp biopsy is sometimes needed to diagnose these problems.

 

CONCLUSION
 

As you can see there are many, many possible reasons and only with a careful evaluation and a bit of "detective work" can a few possibilities be uncovered. That said, sometimes hair transplants don't generate the results that were expected and the next time they do. Any surgeon will tell you in a busy practice, there are occasionally patient's the have less than expected growth. Hair transplant is a fascinating science - but not an exact science.  Far from it. 

Permanent Chemotherapy Induced Alopecia (PCIA)

A New type of Hair loss in Patients Undergoing Chemotherapy: PCIA

Every year about 650,000 patients undergo chemotherapy in the United States. Hair loss is a common side effect of chemotherapy and occurs in about 65 % of patients who receive chemotherapy. There are two main types of hair loss that can occur in patients undergoing chemotherapy. The first is hair loss that happens within weeks of starting the chemotherapy and then lasts several months before growing back.  This is known as temporary chemotherapy induced alopecia ("TCIA"). The second type is uncommon and occurs when patients fail to regroth their hair back to the level it was before undergoing chemotherapy. If hair has not grown back after chemotherapy by the 6 month after chemotherapy, we call this permanent chemotherapy induced alopecia (PCIA) and it is sometimes also called Chemotherapy Induced Permanent Alopecia (CIPAL).

Permanent Chemotherapy Induced Alopecia (PCIA) 

The failure of the hair to grow back fully 6 months post chemotherapy raises concerns about a phenomenon known as permanent chemotherapy induced alopecia (PCIA).     In recent years a number of studies have highlighted the possibility of PCIA in women with breast cancer treated with various chemotherapeutic agents, especially drugs known as taxanes. Docetaxel and paclitaxel are part of this group of drugs. The exact mechanisms are unclear although injury to the bulb as well as follicular stem cells are thought to be relevant. Adjuvant anti-estrogen hormonal therapy may be an important cofactor in many women with PCIA. A similar PCIA presentation has been reported in patients undergoing bone marrow transplantation. The scalp is predominantly affected in women with PCIA although a minority may have eyebrow, eyelash and body hair loss as well.

Different Clinical Presentations of PCIA

PCIA doesn't appear similar in all patients. In fact, three main types appear to exist including a diffuse type, a diffuse type with vertex accentuation (mimicking androgenetic alopecia) and a patchy type mimicking alopecia areata.   

Examination under the Microscope: Biopsies of PCIA

Histopathology of biopsy specimens shows a non-scarring alopecia with preservation of sebaceous glands, miniaturization, decreased anagen hairs, increased telogen hairs and end stage avascular fibrous tracts. There may be several histological presentations and the exact features remains to be defined although a high proportion show dysmorphic telogen germinal units. Some biopsies show peribulbar type inflammation.

How do we treat PCIA?

We don't really know yet how to best treat PCIA. The most common treatments described in the medical literature are oral and topical minoxidil. Both seem to provide benefit to at least a proportion of patients.  Other treatments are not known to provide benefit. 

Dr. Donovan's Articles for Further Reading

Preventing Hair Loss from Chemotherapy

Does hair always grow back after chemotherapy?

REFERENCES

Miteva M, Misciali C, Fanti PA et al. Permanent alopecia after systemic chemotherapy: a clinicopathological study of 10 cases. Am J Dermatopathol. 2011 Jun;33(4):345-50.  

Fonia A, Cota C, Setterfield JF et al. Permanent alopecia in patients with breast cancer after taxane chemotherapy and adjuvant hormonal therapy: Clinicopathologic findings in a cohort of 10 patients. J Am Acad Dermatol. 2017 May;76(5):948-957.

Rugo HS.  Real-world use of scalp cooling to reduce chemotherapy-related hair loss.  Clin Adv Hematol Oncol. 2017

 

HOW ARE HAIR FOLLICLES ARRANGED?

Follicle arrangements

Hair follicles normally emerge from the scalp in groups of 1, 2 or 3 haired "bundles." They don't all emerge as single strands.

During the process of genetic hair loss as well as during the process of scarring alopecias, the bundles of 2 and 3 haired follicular units start disappearing from the scalp and what is left is 1 and 2 haired follicular units.

Is it okay to use more minoxidil?

Using more minoxidil is not advised

The dosings of medications have been carefully worked out to balance efficacy with safety. If a patient feels he or she needs more, they should speak to their physician or pharmacist regarding how to apply minoxidil efficiently. If one feels this dose does not work, they might consider a variety of off label means... but only under supervision. This could include using a bit more than 1 mL, or using oral minoxidil at low doses.

Side effects of using too much minoxidil

The side effects of overdosing on minoxidil include worsening headaches, dizzininess, low blood pressure, heart palpitations, heart rhythm disturbances, ankle swelling, hair growth on the body. Rarely patients end up in the emergency department every year because they feel so unwell after using too much minoxidil. 

Minoxidil is a drug and use must be respected.

Does hydrogen peroxide affect hair growth?

Hydrogen peroxide inhibits hair growth in lab models

This has been a question that has been discussed for some time. I have become increasingly interested in this topic as it is clear to me that at least for a small proportion of patients - hair salon visits can negatively affect their hair. Many people of course are fine and unaffected by hair dye. For others, however, the process of dyeing and bleaching can cause significant problems, including hair loss.

There are many potential reasons why someone using hair dye can raise concerns about hair loss that is potentially related to the dye. It is clear that the use of hydrogen peroxide in many dyes can induce "oxidative stress." This oxidative stress is toxic to cells.
 

A New Study Examines the Effect of H202 on Hair

Researchers from Korea set out to examine the effect of hydrogen peroxide on growing hair follicles in a laboratory setting. The researchers isolated hairs from a patient and grew them in a petrie dish. Then hydrogen peroxide at various concentrations was added. Results showed that H2O2 inhibited growth of hair follicles in a concentration dependent manner and did so by inhibiting a pathway inside cells known as the GSK3- beta pathway.

The evidence is accumulating that hydrogen peroxide has a growth inhibitory effect in vitro (in cultured and controlled conditions in a laboratory). More studies are needed to understand if and how hydrogen peroxide actually affects growing hair follicles deep under the scalp and whether the thick and someone resilient skin layer actually allows hydrogen peroxide to get under the skin to affect dermal papillae or "DP." For now, if a patient truly feels that hair dye is affecting the hair, I advise searching for alternate means to color hair which avoids hydrogen peroxide. For many patients however, hair dye use continues to be unproblematic.

Colouring Hair When Hair Dyes are a Problem

In general, temporary type dyes are safer/better tolerated than semi-permanent and semi-permanent are better tolerated than permanent. The richness of the colors and how pleased patients are seems to go in the opposite order: permanent dyes create some of the nicest color effects.  There are a number of dyes which are PPD free and free of ammonia, parabens, silicone, formaldehyde. There are several companies. For patients with a lot of issues, henna can be considered. Also, I find that many patients improve their tolerance with pre-shampooing with clobetasol propionate based shampoos (i.e. Clobex shampoo) the day before (or morning before). In general though, I have a pretty low threshold for recommending a patch test to rule out allergy in patients with problems to hair dyes. 

Reference

Ohn et al. Hydrogen peroxide suppresses hair growth through down regulation of beta catenin. Journal of Dermatological Science 2018.

Hydrogen peroxide in hair

Hydrogen peroxide inhibits pigment synthesis 

Hydrogen peroxide (also known as "H2O2") is a well known bleaching agent and disinfectant. It is a household item for many people.

Hydrogen peroxide is also found in hair - and in fact accumulates in white and gray hair. It inhibits the synthesis of pigment known as melanin.

Reference

Schallreuter KU, et al. The redox--biochemistry of human hair pigmentation.  Pigment Cell Melanoma Res. 2011

Differentiating between Short 1 cm Hairs by Dermoscopy: Many Possibilities !

How can we tell apart the various causes of short hairs?

I'm frequently asked by patients and physicians how to determine the identify of a short 1 cm or so hair that is seen on the scalp. Looking at the scalp with dermoscopy, one often want to know "Is this a vellus hair I'm seeing or is it an upright regrowing hair as part of a telogen effluvium? ... or is it simply a normal regrowing hair ?"

This chart below helps summarize the main things I think about when I see a short hair. The answer does not necessarily come immediately but rather it comes by asking 4 questions:

1) Is the hair reasonably thick (i.e. 40-50 um or more) or is it very thin (less than 30 um)?

2) Are the ends pointy or blunt?

3) Are these short hairs found all over the scalp or just one area?

4) Are there just a few of these short hairs or lots and lots of them?

By working through these 4 questions, I can generally determine the cause of the short hair I'm seeing on the scalp. 

The Card Test For lighter hair colours.

Card Test For Lighter Hair Colours.

The contrasting hair card tests for lighter hair colors. The use of a piece of paper of contrasting color to the hair is an excellent means to evaluate recent changes in hair growth. For example, in this patient with blond hair we can see thay signficant growth has occured in the last 3-4 months. This immediately informs me that either a massive telogen shed occured 4 months ago or a growth promoting agent was started 4 months ago. In this case it helped pinpoint the precise timing of a telogen effluvium due to surgery.

See Also "The Card Test for Darker Hair Colors"
 

Things to Consider when Latisse won't work

When Latisse Won't Work

Latisse is an FDA approved and Health Canada approved treatment for improving eyelash length, thickness and darkness in patients with eyelash hypotrichosis (not enough eyelashes). Latisse contains the ingredient bimatoprost.

Clinical studies have shown that Latisse is very effective for many user. Many notice changes as early as 4 weeks and 50 % have changes by the second month.  By 16 weeks, 80 % will have an improvement.

Latisse Non-Responders: When Latisse just doesn't work

Latisse is effective for many individuals. However, about 1 out of every 5 users is not going to find that the medication worked all that well for them.  A large proportion of the patients I see in my office come to see me wanting to know why Latisse did not work as good as the advertising stated it should.  Let's review some of the reasons for poor results.

1. The patient is simply in the "20 % group."

Latisse does not help everyone. By 16 weeks, 80 % will be pleased with the money they spent. 20 % won't. I tell my patients that someone has to be in the "80 % group" and someone has to be in the "20 % group." Not everyone responds to Latisse.

2. The bottle does not contain bimatoprost and so it is not Latisse.

Latisse is available through physician's offices (and some drug stores), but there are many other ways of obtaining Latisse and products that claim to be Latisse. I encourage readers to simply enter phrases such as "buy Latisse online" in their Google search engine to see the array of possibilities. Most of these sites will ultimately lead to a box of Latisse (containing the true ingredient bimatoprost) showing up at the door.  But not all.  Patients need to keep in mind the possibility of counterfeit products. It's rare but most certainly does happen.

3. The method of application is wrong.

One needs to apply Latisse nightly to the lower eyelid margin of the upper eyelid with the brushes provided. I can't tell you how many variations of this simple sentence there actually are. Like any drug, it needs to be used according to instructions.

4. The individual has a medical condition of the hair follicle.

It comes as a surprise to many individuals that there are well over 100 reasons for eyelash loss. Not all lash loss is simply due to "aging" or a "tainted bottle of mascara" that was used in the past or improper use of a heated eyelash curler. These certainly can cause temporary or even permanent lash loss. Rather a variety of inflammatory and autoimmune conditions are associated with eyelash loss. 

Eyelash Loss: What else?
 

A careful review of one's story (called the medical history) and up close examination of the eyelashes is needed to determine the cause. One must also examine the eyebrow and scalp hair at the same time as there is no other way to confidently come to the diagnosis.

Causes of eyelash loss include

1. Inflammatory and Autoimmune Conditions. Inflammation of the hair follicle can cause it to fall out. Alopecia areata, frontal fibrosing alopecia, Scleroderma/ en coupe de sabre and lupus are all potential causes.  A variety of true dermatological conditions can also cause lash loss including various eczemas, seborrheic dermatitis and psoriasis. In such cases it is scratching and rubbing that often leads to lash loss.

2. Trichotillomania. 3-5 % of the world will purposefully pull out one or more of their hair follicles somewhere on the body during their lifetime. When repeated, the diagnosis of trichotillomania needs to be considered. Plucking of the lashes is quite common and may even be one sided. 

3. Endocrine disorders. Isolated eyelash loss is uncommon in patients presenting with endocrine disorders. However, one needs to consider thyroid, parathyroid and pituitary disorders.

4. Infections. Infections with fungus, bacteria, viruses all have the potential to cause lash loss. Isolated lash loss is uncommon but can be seen with conditions such as leprosy and syphilis. 

5. Drugs. There are many drugs now implicated in lash loss ranging from cancer drugs to antidepressants (escitalopram) to diabetes medications (sitagliptin and metformin) to methylphenidate. Other drugs include blood thinners, cholesterol meds, propranolol, valproic acid. Even cocaine vapour can cause lash loss.

6.  Infiltrative Conditions. Eyelashes can fall out when cells enter the hair loss that normally don't reside there. Lymphomas are a good example. Eyelash loss can also occur with a variety of local tumors including basal cell carcinoma, squamous cell carcinomas, sebaceous carcinomas and many others.

7.  Nutritional Issues. Poor diets and specific deficiencies can all cause lash loss. This ranges from severe illness with marasmus, to deficiencies of protein, zinc and iron.

8. Congenital and genetic conditions. Many many genetic syndromes are associated with less than normal eyelash density. Well over 50 conditions fall in this category from KID syndrome, Rothmund Thompson syndrome, Incontinentia Pigmenti, Keratosis follicularis spinulosa decalvans, Progeria, Bloom syndrome, Menke's syndrome, Monilethrix to Trichothiodystrophy. Many many others are on this list as well.

Conclusion

There are many causes of eyelash loss. Not every cause of eyelash loss responds to Latisse.

 

Bimatoprost for Androgenetic Alopecia: An intensely researched area

Bimatoprost for Male Balding

Bimatoprost is a prostaglandin F2 alpha analogue that stimulates hair growth. Bimatoprost at 0.03 % is a well known eyelash growth stimulatory compound and marketed under the name Latisse. 

Bimatoprost has been studied for use in androgenetic alopecia. At low concentrations, it is not particularly effective. Allergan is currently studying higher concentrations (1 and 3%). Data released by Allergan and available to the public online suggest that these higher concentrations may be beneficial in treating hair loss. This is an exciting area to watch out for in the near future.

The graph shows how bimatoprost compares to minoxidil in these Allergan led studies. In their preliminary results, higher concentrations of bimatoprost was similarly or even slightly more effective that minoxidil (the gold standard FDA approved topical treatment for androgenetic alopecia).

AGE 50: An Important Cut off for Diagnosing Hair Loss

The Cut off of 50: Why it matters in the diagnosis of hair loss in Older Individuals ?

Any birthday is special. The 50th birthday is an important cut off in the diagnosis of many hair diseases.  An important principle of diagnosing hair loss in men and women over 60 comes from understanding what density of hair a patient had at age 50.

 A true or false question

For anyone over 60, I always ask patients to help me with a true or false question.  I generally ask it in the following way

“Is this statement true or false: My hair density at age 50 was about the same as it was at age 30.”

This is such an important question - especially if the patient replies “TRUE”. Men and women who develop hair loss in their 60s and 70s but who report that their density age 50 was quite good have a high likelihood of having another diagnosis besides simply genetic hair loss. Of course genetic hair loss is a possibility and it’s possible the patient does not really have a good recall of their hair density at age 50. Nevertheless, there are several conditions that need to be considered in somwone with good thick hair at age 50 and hair loss in the 60s”

1.     Scarring Alopecia (especially Lichen Planopilaris)

2.     Senescent Hair Loss

3.     Diffuse Alopecia Areata

4.     Hair Shedding Disorders

Final Comment:

Patients in their 60s and 70s who tell me they had thick hair at age 50 and that it was the same thickness as age 30 often have an interesting array of hair loss conditions. One should not default to diagnosing genetic hair loss in these situations because that diagnosis may be relatively unlikely in this unique situation.

What cells play key roles in hair growth?

If you've ever gone deep into the basement of a large building, factory or even a house, you will likely be amazed at how complex the machinery, wires, circuits that all work together are to make the building function optimally.

As far as the hair follicle goes, it takes a considerable amount of coordination by many cell types to finally produce a normal hair fiber. The dermal papilla (or "DP") has an important role in making it all happen.

The DP is found at the base of the hair follicle. It is made up of a group of very specialized cells known as fibroblasts.

The DP is an important control centre for the hair follicle. It tells another collection of cells known as the "hair matrix" exactly what to do in order to make a hair fiber.

The more cells the DP contains and the more active it is .... the bigger and wider the hair follicle that will be produced. 

The DP has the remarkable potential to form brand new hairs when transplanted into other areas of the skin. DP are therefore said to be "trichogenic" (hair forming). One day, it could theoretically be possible to take a patient's skin and increase the number of DP cells they have and inject them back into their scalp. This could lead to an endless supply of hairs.

Creatine and Hair Loss

There are many potential reasons for hair loss in individuals who use training supplements. Creatine is frequently used as an 'ergogenic' training aid to enhance performance. Although there is no definitive proof, I'd like to outline why it certainly might cause hair loss in those with a 'genetic susceptibility' to balding.

In a study from South Africa 20 college-aged rugby players participated in a double blind study. Subjects loaded with creatine (25 g/day) or placebo (50 g/day glucose) for 7 days followed by 14 days of maintenance (5 g/day creatine). The researchers looked at serum testosterone and DHT levels at baseline and then at 7 and 21 days. After 7 days of creatine loading, or a further 14 days of creatine maintenance dose, levels of DHT increased by 56% after 7 days of creatine loading and remained 40% above baseline after 2 weeks maintenance. Testosterone levels were unchanged.

While this data does not prove anything about hair loss, it does suggest that the higher DHT could provide a negative impact on hair loss for individuals who are predisposed to androgenetic alopecia (male balding and female thinning). Not all studies have suggested a negative impact on hormone parameters. A study completed in 2004 suggested that creatine supplementation actually decreased the free androgen index after 3 weeks of use. A 2001 study of 11 men did not find differences in serum testosterone in men receiving 10 g of creatine. However, serum cortisol levels were higher after creatine use during the resting period. 

Conclusion

We don't know if creatine supplementation promotes hair loss. One must at least consider the possibility that changes in DHT and even cortisol could have a negative impact on hair loss. 

Reference

van der Merwe J, et al. Clin J Sport Med. 2009.

Volek JS, et al. Eur J Appl Physiol. 2004.

Eijnde BO, et al. Med Sci Sports Exerc. 2001.

Telogen Effluvium and the URH

Upright Regrowing Hairs

Telogen effluvium ("TE") is a type of hair loss where individuals experience increased daily hair shedding. Instead of losing 30-40 or 50 hairs per day, the individual experiences loss of 60, 70, 80 or more hairs in any given day. The numbers can exceed 500 depending on the cause of the shedding.

Common causes of TE include low iron (low ferritin), anemias, thyroid problems, crash diets, weight loss, stress, surgery, medications (ie lithium, some blood pressure pills, retinoids (vitamin A pills)). Any significant illness inside the body (ie flu, autoimmune disease) or on the scalp surface (ie severe scalp psoriasis or severe seborrheic dermatitis) can cause a telogen effluvium.

This picture shows a typical trichoscopic appearance of someone with a "TE." Numerous short pointy hairs, known as "upright regrowing hairs (URH)" can be seen.
 

The Pull Test

What really is normal?

The Hair Pull Test: 3 is abnormal

Telogen effluvium is a form of hair loss where patients experience increased daily hair shedding. Instead of losing 40 or 50 hairs per day, patients with “TE” lose 80 to up to 600 hairs per day. A ‘pull test’ has traditionally been one of the methods that hair specialists are taught to perform when examining the scalp. To perform the test, 60 hairs are lightly grasped between the thumb and index finger and gently pulled upwards. Removal of more than 10 % of the hairs in the bundle (i.e more than 6 hairs) has been traditionally viewed as a positive pull test. 

McDonald and colleagues from Ottawa, Canada performed a study revisiting this issues of what exactly constitutes a normal pull test and what limits should be set for abnormal. They studied 181 otherwise healthy individuals. The authors showed that for the vast majority of individuals, a pull test of 60 hairs extracts 0,1 or 2 hairs (97 % or more have 2 or less). The average was 0.44 hairs indicating that many individuals have no hairs removed. Interestingly, the date the patient last washed their hair, did not influence the pull test result nor did the frequency of brushing the hair. 
This is one of my favourite studies of the year. It is simple and elegant and answers a lot important questions. I have long abandoned the “6 hair rule” for the pull test, and frequently have told the dermatology residents and trainees that work with me that even a few hairs coming out is abnormal. I’m grateful for this well conducted study and it has renewed my interest in the pull test.
 

Reference

McDonald et al. Hair pull test: Evidence-based update and revision of guidelines. Journal of the American Academy of Dermatology 2017; 76: 472

Does the immune system control hair growth?

The Immune System and Hair Growth

Every now and then, I share a landmark study which has the potential to change the way we think about the hair follicle, and how it grows. Today is one of those days.

Researchers at the University of California San Francisco reported last week an important new finding: without specific immune system cells called T regulatory cells (T regs), hair follicles do not grow properly. The study was performed in mice, but likely has relevance to humans.

T regulatory cells are important immune cells. Mice have them and so do humans. These immune system cells act as sort of peacekeepers of our immune system. In scientific terms, we say that these cells play a key role in ‘immune tolerance.’ They tell other immune cells of our body to stay quiet when the time is right to stay quiet and this helps prevent unnecessary allergies and autoimmune diseases. To study the role of T regulatory cells, the researchers developed a clever mouse model whereby T regulatory cells could be removed from the mouse whenever desired. In these studies, mice were shaved of hair and hair regrowth patterns were observed. Surprisingly, hair did not regrow after shaving.

There has now been a shift in thinking. Hair follicle stem cells, at least in mice, appear to listen to the commands of T regulatory cells to know when to grow – and when to stay quiet. Tregs are now understood to accumulate around hairs at the end of the hair growth cycle (in the telogen phase) and help direct hair follicle stem cells to make a new hair. Without Tregs, the growth phase (anagen phase) does not begin. This information could have direct relevance to humans and our understanding of a variety of hair loss conditions. It is well known from previous studies for example, that many of these genes that contribute to the condition alopecia areata are in fact genes that regulate T regulatory cells. In addition, other studies have shown that by supporting T regulatory cells in their functioning, it is possible to can help regrowhair in alopecia areata.

Reference
Ali et al. Regulatory T Cells in Skin Facilitate Epithelial Stem Cell Differentiation. Cell 2017.