Nausea with Doxycycline: What strategies can help reduce nausea?

Doxycycline and Nausea

Doxycycline is an antibiotic. It's used of course in treating infections but it is commonly used for a variety of scarring alopecias including lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia, folliculitis decalvans and sometimes dissecting cellulitis.

The drugs has two important properties: it stops infection and reduces inflammation. For some conditions such as lichen planopilaris, it's the anti-inflammatory properties that are useful. For other conditions such as folliculitis decalvans, it's the anti-bacterial and anti-inflammatory properties that are key. 

The drug has a number of potential side effects even though it is generally well tolerated for most. It can cause nausea, vomitting, sun sensitivity, headaches, increased chance of yeast infections in women, rash. 

Doxycycline and Nausea

Some patients developed considerable nausea with doxycycline. Some will even vomit.  This can be a short term issue for some users which improves over time. For others it is something that continues and may even require the patient to stop the medication.  Anyone with nausea from doxycycline should speak to their prescriber for advice on how to reduce the nausea. 

Tips to reduce nausea

1.  Take doxycycline with food. Unlike tetracycline, doxycycline still gets absorbed quite well into the blood stream if the patient takes it with food. The food intake really helps to reduce nausea and this should be encouraged

2.  Avoid spicy foods with the doxycycline. Anything that upsets the stomach has the potential to makes things worse with doxycycline. I generally recommend avoiding spicy foods with doxycycline. 

3. Take Gravol.  If nausea continues despite food intake, dimenhydrate (Gravol) can be used 1 hours before the doxycycline is taken. I generally recommend starting with 25 mg Gravol and then 50 mg and then 100 to see what dose can help reduce the nausea. Gravol can make people drowsy and sleepy so this needs to be considered if one is driving or doing anything that requires focus. 

4. Use Ginger. Ginger is also a helpful anti-nausea treatment. There are a number of candies, lozenges on the market that contain ginger and can be used prior to the patient taking the doxycycline. The company that makes Gravol also has a product "Ginger-Gravol" which can be very helpful. this does not contain Gravol and therefore does not cause drowsiness.

5. Reducing the doxycycline dose. For some users, the nausea is dose related. Reducing the dose can help.

Does scalp psoriasis cause hair loss?

Scalp psoriasis and hair loss

Psoriasis is an inflammatory condition affecting about 3 % of the world. The skin, hair, nails and joints are affected. We are also now learning that individuals may also have increased risks of cardiovascular disease. About 50 % of patients with psoriasis have scalp involvement so psoriasis is a common issue in the hair clinic. For the majority of those with scalp psoriasis, psoriasis does not cause hair loss. 

 

When does hair loss occur?

Even though most individuals with scalp psoriasis do not experience hair loss as a direct result of their psoriasis, severe psoriasis can cause shedding (telogen effluvium) and rarely even a scarring type of hair loss. Some individuals with psoriasis have scalp itching - and repeated itching can cause hair breakage and subsequent hair loss.

The photo to the right shows the typical white powdery scale of psoriasis. It is easily mistaken for the scale of seborrheic dermatitis. The scale of seborrheic dermatitis, however, tends to be more yellow and greasy rather than white and powdery.

Hair loss and lupus: Doc, do you think my hair loss could be from lupus?

Hair loss and lupus:

Anyone who is losing hair knows how frustrating it can be to find accurate information. It is often difficult to figure answers by searching the internet. Confiding in a friend about hair loss leads to one piece of advice, while a second friend offers completely different advice. It seems daunting to pinpoint which of the 100 causes of hair loss are responsible.

In the search for answers, it's not uncommon for a patient to ask me "Do you think my hair loss could be from lupus?" Are you going to test me for it?

What is lupus?

Lupus, also known by the medical term "systemic lupus erythematosus" is an autoimmune condition. It has the potential to affect nearly every body system from the skin to heart to lungs to brain to kidney (....and that is why the word "systemic" is used). It affects approximately 50 out of every 100, 000 people. Current estimates suggest there are 500,000 individuals in the USA and 50,000 individuals in Canada affected by lupus. Women are affected nearly 9 times more commonly than men. Black women are particularly affected.

What are the signs of lupus and should I get tested?

For every patient with hair loss that I see, I run through a series of simple "screening questions. " If the answers to all these questions are "NO" then I usually don't give any further thought to the patient in front of me having lupus. If the answer to one or more of the questions is "YES" it certainly does not mean the patient has lupus, but means that I might ask more "in depth" questions.

Typically, my "screening questions" for lupus that I ask patients with hair loss include the following 13 questions:

HAIR CLINIC SCREENING QUESTIONS FOR LUPUS:

1. Have you been experiencing extreme levels of fatigue lateley?
2. Do you experience headaches... and if so...how often do you get them?
3. Have you ever experienced a seizure in your life? how many?
4. Do you see or hear things that you think other people might not hear or see?
4. Do you have joint pains ...and if so ...which joints?
5. Do you have high blood pressure? Has it been difficult to control with medications?
6. Do you have pain in the chest when you take a deep breath?
7. Do you experience dry mouth or dry eyes?
8. Do you experience ulcers in the mouth, nose (and for women in the vagina) that you are aware of?
9. Do you develop rashes on the face or skin when you go out in the sun? Do you find you burn much easier than before?
10. Have you ever been told you have abnormal blood work results? ( especially, low hemoglobin, low white blood cells, low platelets)
11. Has anyone in your family been diagnosed with lupus in the past?
12. Have you ever had a blood clot?
13.(Women) Did you ever have a miscarriage and if so, how many?

Many, many individuals will answer " YES" to a question or two from the above list. It does not mean they have lupus. But if they answer "YES" to a few questions it points me down a path of very, very detailed questioning. The formal American College of Rheumatology criteria for diagnosing lupus can be found by clicking here.


Should I get a blood test for lupus?

The vast majority of patients with hair loss do NOT need to have a test for lupus. This can't be overstated enough. However, if the answers to a few of the screening questions above are " YES" then testing 'could' be at least considered. If I am even slightly suspicious, I usually order a blood test known as the ANA (anti-nuclear antibody test).   If the ANA blood test returns "positive", additional blood tests (Group 2) may be ordered. It takes alot of experience to interpret these tests and it can sometimes be challenging to diagnose someone with lupus.  Referral to a rheumatologist is often required.

Group 1 test for lupus

ANA (anti- nuclear antibodies)

• 99 percent of people with lupus will have a positive test. However, many other conditions (and even normal healthy people) can have a positive ANA test. So having a positive ANA does not necessarily mean you have lupus.  Rarely, patients with lupus can even have a negative ANA test (especially early in the disease).

Group 2 tests for lupus (ordered if the ANA test is positive)

1. CBC (complete blood count)

• Individuals with lupus may have low levels of red blood cells, white blood cells and platelets

2. Urinalysis

• To check if there is protein or blood in the urine. This can be a sign of kidney damage.

3. Creatinine

• Another measure of kidney health. Patients with kidney disease may have increased creatinine levels.

4. ESR ( erythrocyte sedimentation rate)

• A measure of inflammation in the body. Many conditions can increase ESR, not just lupus.

5. C3 and C4 (complelment levels)

• Complement levels may be lower in patients with autoimmune diseases and used to monitor activity of the disease

6. ENA (extractable nuclear antigens) which include the anti-Smith test

• The ENA test measures many antibodies, including Jo, Sm, RNP, Ro, La, Scl-70. These antibodies can be positive in many different types of immunologic conditions. Patients with lupus may have a positive anti-Smith test (and sometimes other positive results from the ENA panel of tests too).

7. Antiphosphopilid antibodies

8. Anti-ds DNA test (anti-double stranded DNA test)

In summary, is the diagnosis of lupus should only be made by a medical professional. There are well over 100 causes of hair loss and certainly lupus is on that list and therefore needs to be at least considered. Simply having a positive ANA test doesn't automatically mean an individual has lupus. Obtaining a very detailed medical history and performing a detailed physical examination is very important in the overall evaluation of a patient suspected of having lupus.  Because lupus is a disease that affects many organs in the body, patients diagnosed with lupus are often treated by rheumatologists as well as other specialists (cardiologists, respirologists, neurologists, nephrologists, dermatologists). 

 

Smoking and Androgenetic Alopecia: Why I ask and Why I Encourage Patients to Quit

Smoking and Androgenetic Alopecia:

For many years, researchers have been examining whether smoking speeds up the process of genetic balding (also called "androgenetic alopecia").  The studies have been somewhat inconsistent but point to the possibility that smoking accelerates the process of male balding.

An important study examing the relationship between smoking and hair loss was a 2007 study by the Taiwanese group of Dr. Su and Dr Chen.  These researchers examined 740 patients between the ages of 40 and 91 over a 2 month period.  They found that smokers generally had worse androgenetic alopecia compared to non-smokers. In fact, smokers had nearly a two-fold increased risk of having moderate or severe genetic hair loss compared to non-smokers. In addition, the early development of male balding was more likely in smokers.

Why Would Smoking Speed Up the Development of Male Balding?

No one knows for sure. It may be that smoking is damaging to the tiny blood vessels and the there are toxic substances in cigarette smoke that damage the cells in the hair follicles. It's also possible that smoking causes inflammation which speeds up the process of genetic hair loss. Certainly, more research is needed to figure out why.

Why I Encourage my Young Patients with Androgenetic Alopecia to Quit Smoking

There is yet another reason why I encourage young men and women with androgenetic alopecia to quit smoking.  We know from carefully done studies that young men with balding have an increased risk of cardiovascular disease later in life.  The same seems to be true for women as well. Furthermore, it's well know that smoking is one of the key risk factors for cardiovascular disease.  Taken together, it's of paramount importance to help patients stop smoking. (For additional articles, on the interplay between smoking, hair loss and cardiovascular disease click here).

Reference

Su LH and Chen T H-H. Association of Androgenetic Alopecia with Smoking and Its Prevalance Among Asian Men. Archives of Dermatology 2007 143; 1401-1406.

Mosley JG and Gibbs AC. Premature grey hair and hair loss among smokers: a new opportunity for heatlh education? British Medical Journal 1996; 313: 1616.

Severi G et al Androgenetic alopecia in men 40-69 years: prevalence and risk factors.British Journal of Dermatology 2003; 149: 1207-1213

 

Is there an Increased Risk of Diabetes in Patients with Central Centrifugal Cicatricial Alopecia?

Central Centrifugal Cicatricial Alopecia: Risk of Diabetes

Hair Loss in Patient with CCCA Central centrifugal cicatricial alopecia or "CCCA" is the most common cause of scarring alopecia. Scarring alopecia refers to hair loss conditions where scarring develops around the hair follicles and leads to permanent hair loss. "CCCA" predominantly affects black women where up to 30 percent of women are affected.

Last year, an interesting paper was published in the journal Archives of Dermatology by researchers at the Cleveland Clinic. The authors handed out a survey to African American women at 2 churches as well to African American women attending a health fair. The survey allowed the collection of information about basic medical history as well as information about hair styling practices. In total, 326 women participated in the study.

8% of Women with CCCA Had Diabetes

About 8 percent of women in the study had type 2 diabetes. However, the researchers found an increased prevalance of diabetes in women with centrifugal cicatricial alopecia. Women with CCCA were more likely to used braids and weaves than women without CCCA.  The vast majority of women who participated in the study used releaxers. However it did not appear that the use of relaxers was associated with the development of CCCA in this particular study.

Although there are many limitations to this study, I particularly like the study. First, it reminds us the CCCA is a common reason for hair loss in black women. Second, this study provides new information that CCCA may be asociated with an increased risk of diabetes. Although more research is needed to confirm this, these findings open many new avenues for research.

Reference

Kyei et al. Medical and Environmental Risk Factors For the Development of Central Centrifugal Cicatricial Alopecia. Arch Dermatol 2011; 147: 909-14

 

February is Heart Health Month: What does your hair tell about your heart?

Heart disease is one of the leading causes of death in Canada and the United States. In fact, about one out of every three deaths is due to heart disease and stroke. February is designated heart health month - a great time for us all to think about risk factors for heart disease and all the things we candue to reduce our risk of heart disease. It’s also a great time to discuss the relationship between male and female balding and heart disease.

About 50 % of men and 30 % of women will develop genetic balding by age 50. The medical term for genetic balding is “androgenetic alopecia”. In men, androgenetic alopecia causes hair loss in the front, temples and the crown and may even involve the entire frontal scalp. In women, androgenetic hair loss causes hair loss in the centre of the scalp. 

Is there a link between balding and heart disease?

The answer is yes. Several large research studies have confirmed an association between androgenetic hair loss and heart disease.  It seems that men who develop early balding have a higher risk to develop coronary artery disease.  This may be especially true in younger men who develop rapid balding.   New research is showing that the same relationship is true for women.

This doesn’t mean that hair loss causes heart disease or heart disease causes hair loss. Rather it tells us that the two are linked somehow through a similar process: men and women who develop early hair thinning also tend to have a higher chance to get heart disease.

Why is this information important?

The research is important for a number of reasons. If you are young and have androgenetic alopecia, do what you can to minimize your risk factors for heart disease.

If you are young and have androgenetic alopecia, do what you can to minimize your risk factors for heart disease. Eat well, excercise, get your blood pressure checked to make sure you don't have high blood pressure (hypertension).  Ask your physician about checking cholesterol and blood sugar levels. If you smoke, get help to stop.

I often encourage young men and women with early balding to get tested for all the heart disease risk factors. This involves getting a blood pressure measurement, checking cholesterol and fat levels, checking for diabetes or pre-diabetes and making sure that these individuals are getting enough exercise.  Although I encourage all smokers to stop smoking (as smoking negatively impacts hair), I advise those with early balding to quit smoking and smoking is a top risk factor for heart disease.

Happy Heart Month!

References

Lotufo, PA Chae CU, Ajani UA, Hennekens CH, et al. Male pattern baldness and coronary heart disease: the Physicians Health Study. Arch Intern Med 2000; 160 (2): 165 - 71.

Lesko SM, Rosenberg L, Shapiro S. A case-control study of baldness in relation to myocardial infarction in men. J Am Med Assoc 1993; 269: 998 - 1003.

Trevisan M, Farinaro E , Krogh V, et al. Baldness and coronary heart disease risk factors. J Clin Epidemiol 1993; 46 (10): 1213-8.

Cotton SG, Nixon JM, Carpenter RG, et al. Factors discriminating men with coronary heart disease from healthy controls. Br Heart J 1972; 34: 458-64.

Ford ES, Freedman DS, Byers T. Baldness and ischemic heart disease in a national sample of men. Am J Epidemiol 1996; 143 (7): 651 - 7.

Herrera CR, DAgostino RB, Gerstman BB,et al. Baldness and coronary heart disease rates in men from the Framingham Study. AM J Epidemiol 1995; 142(8): 828 - 33.

Persson B, Johansson BW. The Kockum study: twenty two - year follow - up coronary heart disease in a population in the south of Sweden. Acta Med Scand 1984; 216(5): 485-93.

Scarring Alopecia - An Overview

Scarring alopecias are a group of hair disoders that cause permanent hair loss in the scalp. Although these conditions are common in my practice at Sunnybrook, they are actually quite rare in the general population. With topical and oral medications, we can help stop the hair loss in many patients. New research is leading to better treatment options for patients.  The following video was prepared by Monica Matys of Sunnybrook Hospital in conjunction with the Sunnybrook Media department. I hope you will find it educational and informative.