Scalp Trichoscopy: Completely Wonderful but Complete with Its Own Set of Limitations !

Can I just buy a USB trichoscope and figure out my own diagnosis ?

Trichoscopy is a wonderful diagnostic tool. Trichoscopy refers to the use of some sort of handheld device for viewing the scalp with higher magnification. These devices are widespread - they range in price from $ 35 for a pretty reasonable USB microscopy to $ 1,500 for a hand held device to $ 15, 000 for a video dermatoscope.

There are quite a few misconceptions that the pubic has about these devices.

1. Will trichoscopy tell me the diagnosis?

That answer is no. One can buy a USB device, plug it in and see beautiful pictures on the screen. But what does it mean? That requires an expert! It takes a few weeks to become reasonably good at trichoscopy and then a few years to become an expert. The USB trichoscope device does not give a print out that reads “you have androgenetic alopecia” or “you have telogen effluvium.”

Consider a useful analogy. If my air conditioner breaks down, I can certainly get out my tool box and open up the back of the air conditioner and see inside. But unless I known what I’m looking for, the process is not that useful and I will not know what’s wrong with the air conditioner (I can assure you based on my experience with doing this exact task).

2. If the trichoscope won't tell me the diagnosis, can’t I just email the doctor the pictures and he can tell me the diagnosis ?

I don’t like really ever answering two “no” answers in a row , but this answer is also no. We’re commonly asked this question. We have many people who ask us if they can just send in photos they have obtained with their own trichscope. These photos are not helpful UNLESS I have the entire story of the patient’s hair loss and have reviewed their blood tests and know absolutely everything about them. Then these trichoscopic images are a major bonus! It’s true that I can be pretty sure what’s going on by their photos - but not 100 % sure. Doesn't one want to be 100- % sure or at least as close to 100 % sure as possible?

The mistake people make is thinking trichoscopy is “everything.” They think to themselves that all I need to do is take pictures of my scalp of find some clinic to take trichoscopy pictures of my scalp and I’ll know what’s going on! That’s wrong, wrong wrong ….and that’s where I see people run into problems time and time again. Trichsocopy is wonderful but it’s only part of the puzzle. As an aside, some people also make the similar mistake of thinking that their blood test results are “everything.” They think to themselves that all I need to do is get to my doctor and get some blood tests and I’ll know what’s going on! That’s also not a correct approach. One needs the entire story and the chance to see the scalp in it’s entirely.

Although I’m sure I sound like a broken record, I’d like to remind the reader that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s story

2) the findings uncovered during the process of the scalp examination (sometimes including trichoscopy, pull test, clinical exam, card test, etc)

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

In summary, I can diagnose so many conditions with trichoscopy - but there are so many situations that I can not.

Let’s take a look at some situations where trichsocopy has it’s limitations.

EXAMPLE 1: TRICHOSCOPY IN THE NON SCARRING ALOPECIAS

Trichoscopy is completely wonderful. It helps me tremendously in the diagnosis of many non scarring alopecia. Most cases of androgenetic alopecia can be diagnosed with trichoscopy but not all! In fact, unless one is very experienced with trichscopy, the early cases of AGA are going to be very challenging to diagnose by trichscopy because there is just not enough miniaturization that has developed yet. So, if a patient buys a trichoscope and sees that their is not much miniaturization, can they conclude they don’t have AGA? No.

Most cases of acute alopecia areata can be diagnosed with trichoscopy. This is certainly one area where trichoscopy is very helpful. But in cases of advanced AA and some cases of alopecia areata incognito, all that might be seen is miniaturization of hairs. It can be difficult to render the diagnosis from trichscopy alone. So how do we diagnose it? Listen to the patient’s story!

Telogen effluvium (TE) refers to a type of hair shedding and is one of the more common diagnoses in women. Guess what? Telogen effluvium has NO definitive specific diagnostic trichoscopic signs ! Yikes! it’s true that the presence of many upright regrowing hairs can be a tip off from trichoscopy that the diagnosis of TE might be present - but it’s not specific. If a person thinks they are going to diagnose their TE by buying a trichoscope, they are wrong.

EXAMPLE 2: TRICHOSCOPY IN THE SCARRING ALOPECIAS

Trichoscopy is completely wonderful. It helps me tremendously in the diagnosis of many scarring alopecia. In fact, the use of trichoscopy has massively reduced my need to perform scalp biopsies. That said, one needs to be aware that some cases of early lichen planopilaris can’t be confidently diagnosed with trichoscopy - the scalp looks just like seborrheic dermatitis! Some cases of early folliculitis decalvans look just like regular ordinary folliculitis !

So does trichosopy help in all these subtle and early forms of these diseases? - no ! It gets me thinking but usually a biopsy is needed to confirm these challenging diagnoses.

Let it be heard though - a good majority of scarring alopecia cases can be diagnosed with trichosopy. Just not all!

As for central centrifugal cicatricial alopecia (CCCA), the best way to diagnose this condition is simply to look at the scalp! Trichoscopy can help but there are not a great number of classic trichscopic signs for CCCA.

FINAL SUMMARY

Many patients want to get blood tests because they think that the blood tests will provide the entire answer the diagnosis. Many patients want to buy a trichoscope (USB dermatoscope) because they feel the trichoscope will provide the answers.

We must always remember that the confident diagnosis of hair loss from from use of the diagnostic SET - all comments from the patient’s story, scalp examination,, trichoscopic examination and blood tests go into figuring out the exact cause.

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.

Managing Hair Loss During and After Pregnancy: Facts vs False Reassurance

Hair Loss During and After Pregnancy

Individuals with hair loss often ask what steps they should be taking to best help their hair during pregnancy and what steps they should take after delivery.

I have written on certain aspects of this topic before. Please consider reviewing my past articles on Hair Loss, Pregnancy & Breastfeeding:

July 23, 2019 - Stopping Medications in Pregnancy

May 6, 2018 - Pregnancy and Female Pattern Hair Loss

Mar 1, 2017 The Safety of Hair Loss medications in Pregnancy

May 19, 2012 - Which medications are safe during breastfeeding?

For many women who ask this question and are currently pregnant, I often say that there are two ways to help the hair while pregnant. The first is make sure that the individuals does not truly have any deficiencies by getting some basic blood tests if the individual or her doctor are worried about some type of deficiency. The second way to potentially help the hair is to consider reviewing the benefits of low level laser therapy (LLLT). Besides correcting a vitamin deficiency, administration of low level laser treatments is really the only treatment that can be safely used during pregnancy.

For women who were using minoxidil before pregnancy but needed to stop during the pregnancy, I strongly encourage them to see an expert to determine when minoxidil might best be restarted after delivery. Both the American Academy of Pediatrics and the American Academy of Dermatology have stated that Rogaine is reasonably safe for breastfeeding women (yes, despite the fact that all warning labels say otherwise). I can’t emphasize enough the importance of speaking to the dermatologist about this. in my opinion, we need to let years and years of medical research and years of observation help guide how we make tough decisions not simply outdated warning labels that protect companies from legal ramifications. These decisions are of course taken on a case by case basis.

False resurgence has no place in the management of any type of hair loss - and this is particularly true in managing hair loss around the time of pregnancy. It would be wonderful if I could reassure women that hair always grows back “fully” after delivery (i.e. to the same density as before pregnancy) - but this is not accurate. For most women who shed hair post partum, the shedding eventually slows down around month 6-9 post partum and shedding returns to normal and hair regrowth happens. However, hair density does not always grow back as full as it was before pregnancy if a woman has the genes for genetic hair loss instructing the hairs what to do.  For many women it does - but not all. This is far more than my professional medical opinion - it’s fact. For this reason, I encourage patients to have a solid treatment plan in place.

False reassurance that hair “always” grows back and not to worry leaves many women confused and disappointed. I sometimes advise a conservative approach and sometimes an aggressive approach to treatment after delivery. It all depends on the stage of the patient’s androgenetic alopecia, her current age and health and her family history of hair loss and other conditions. We don’t yet have tests available to set the known genes for genetic hair loss - so this is not part of the evaluation. The decision on what to use during pregnancy is easy as only laser is safe (and supplementing any deficiencies that are uncovered in the blood tests).  

Trichoscopy of Telogen Effluvium (TE) - A Closer look at Kenogen Phase and Yellow Dots

Trichoscopy of Telogen Effluvium - Kenogen Phase & Yellow Dots

For a period of time after a hair is shed from the scalp, it appears that the hair follicle opening sits empty. Of course, it is not truly empty because deep underneath the scalp follicular machinery is preparing yet again to manufacture a brand new hair. The period of time between a shed hair and the emergence of a new hair is called “kenogen”. Kenogen phase is typically quite short (1-2 months). The duration that a follicle remains in kenogen increases in patients with some types of hair loss. For example, in some cases of androgenetic alopecia, hairs have been found to remain in kenogen for up to 1 year.

The “sudden” appearance of hair follicle openings that are empty and lack follicles must also prompt one to consider a diagnosis of telogen effluvium.

Yellow dots in telogen effluvium signify hairs in kenogen phase. This finding is a non specific finding of telogen effluvium.

Sometimes we see upright regrowing hairs by dermoscopy as a sign of telogen effluvium but sometimes the dermatoscopic findings are extremely non specific and the only finding by trichoscopy is empty pores. It’s possible to have large numbers of hairs in kenogen in advanced stages of androgenetic alopecia but this is uncommon in the early stages. The finding of many empty pores is atypical of the early stages of androgenetic alopecia. The patient in this trichoscopic image androgenetic alopecia as one of the diagnoses. Variation in the caliber of hairs is easy to spot. However the large number of empty follicles is unexpected prompting one to consider that hairs have recently shed - as in a telogen effluvium. Causes include stress, low ferritin levels, thyroid dysfunction, crash diets, medications and internal illness. In this patient, a 49 pound weight loss over 2 months together with low ferritin levels and extremely intense and sudden stressful life events caused the patient’s androgenetic alopecia to suddenly “appear worse.

Serum Magnesium Levels in Women with Diffuse Hair Loss

Should we be checking blood levels of magnesium ?

There are many causes of hair shedding or telogen effluvium. Common causes include intense stress, thyroid problems, crash diets with sudden weight loss, and medications. However, a wide variety of other ‘triggers’ have the potential to cause hair loss. Deficiencies in various minerals are also potential causes of telogen effluvium. Deficiencies in zinc, iron, magnesium, selenium, for example, all have the potential to trigger hair loss.

A 2004 study reminded us that testing for magnesium deficiency (“or hypomagnesemia”) may be reasonable in women presenting with concerns about diffuse hair loss and diffuse hair shedding. The normal adult value for magnesium is 1.6-2.5 mEq/L and hypomagnesemia is generally defined as a level of serum magnesium under 1.6  mEq/L or 1.5 mEq/L.

Tataru and Nicoara studied three groups of women age 16 to 40. Group A was made up of 26 women with diffuse hair loss for which the cause was unknown. Group B consisted of 14 women with diffuse hair loss for which the cause was known (seborrhoea, hormonal issues, thyroid disease). Group C consisted of 24 women without hair loss.

The authors found in the first group (group A), there were 12 cases (46.1%) with hypomagnesemia and the average magnesium level was 1.80 mEq/L. In the second group (group B), there were 3 cases (21.4%) and the average magnesium level was 1.99 mEq/L. Finally, in the control group (group C) the authors found 2 cases (8.3%) hypomagnesemia and the average level was 2.23 mEq/L These data suggested that low magnesium levels were indeed more likely to be found in women with diffuse shedding.

Check serum magnesium levels may be important to consider for some women with diffuse hair loss according to a 2004 study. Supplementation with magnesium may help some women with diffuse hair loss if levels are found to be low.

Magnesium supplementation may reduce hair shedding in some women

In the second part of the study, the authors evaluated the effect of providing magnesium supplementation to women in Group A and Group B. The dose was equivalent to 96 mg  (8 mEq or 4 mmol) daily for 2 months. The authors observed a noticeable decrease of hair loss in 69.1% of the patients from group A (18 from 24 cases) in comparison with 35.7% (5 from 14 cases) in the group B.

Conclusion

This study was among the first large scale studies to document the incidence of low magnesium in women with diffuse hair loss and to show that women with diffuse loss are more likely to have low magnesium levels than women without diffuse loss. Moreover, these studies showed that supplementation magnesium may help some women reduce hair loss and shedding.

Finding the precise cause of hair loss in women with diffuse loss and hair shedding can be challenging. Ordering every single blood test is not practical and not cost effective. Sometimes the medical history can guide us, but not always.

Supplementing with magnesium is reasonable if blood tests prove that there is low magnesium. Supplements with 100-250 mg of elemental magnesium are quite reasonable for 2-3 months but I often start with every other day for 2 weeks to ensure that the patient does not experience diarrhea. Supplements with higher levels of magnesium are not typically recommended. After 3 months, I typically reduce the dose quite significant and recheck levels. Depending on the patient, the old magnesium levels, the new magnesium levels at the end of month 3 and the original suspected reason for the low magnesium, I might either continue at low doses or stop the magnesium altogether.

I have always found this to be an interesting study. I have not found a high proportion of women with hair shedding to have magnesium deficiency but am always on the look out.

Women with high intake of vitamin D may have low magnesium levels as well as other medication users. Low magnesium can give symptoms of muscle pain, fatigue, high blood pressure, irregular heart beats, osteoporosis and mood disorders so certainly we need to be particularly thinking about the possibility of low magnesium levels when this issues are present.

Im general, basic tests for women with hair shedding include:

CBC, TSH, ferritin, 25 hydroxy vitamin D, DHEAS testosterone, AM cortisol, ESR

zinc, magnesium, ANA, creatinine, AST, AST.

Consideration can given to ordering a variety of other tests depending on the exact patient history including syphilis screening, HIV, selenium, mercury and others.

Reference

A Tataru and E Nicoara. Idiopathic diffuse alopecias in young women correlated with hypomagnesemia. J Eur Acad Dermatol Venereol. 2004 May;18(3):393-4.

Hydroxychloroquine (Plaquenil) and Hair Loss: Is my Plaquenil causing me to lose hair?

Losing Hair on Plaquenil: The 5 Possibilities

Hydroxychloroquine (also known by its popular brand name Plaquenil) is an oral medication that is commonly used to treat a variety of autoimmune diseases including systemic lupus, dermatomyositis, rheumatoid arthritis, Sjogren’s and many other conditions as well. In the field of hair loss, conditions such as lichen planopilaris, frontal fibrosing alopecia and discoid lupus are frequently treated with hydroxychloroquine.

Can hydroxychloroquine cause hair loss?

It’s possible for any medication to cause hair loss, but for some medications it’s quite rare and for others it’s much more common. Whenever a patient using hydroxychloroquine reports hair loss there are 5 possibilities to consider.

1. The Plaquenil is Causing Hair Loss

One needs to always consider the possibility that Plaquenil is causing the hair loss. Usually Plaquenil related hair loss starts 2-6 months after the Plaquenil was started. We call this a drug induced telogen effluvium. If the Plaquenil was started 10 years ago and a patient reports hair loss last month, it’s not very likely that the Plaquenil is the culprit. That is often forgotten.

2. The Autoimmune Disease the Plaquenil is Used for is Causing Hair loss

Autoimmune disease can cause inflammation in the body and this type of inflammation itself can trigger hair loss in the form of a hair shedding or ‘telogen effluvium.’ When rheumatoid arthritis flares patients can shed hair. When lupus flares, patients can lose hair. If it’s not clear if the disease itself is contributing to hair loss, the specialist (ie rheumatologist) can help chart the activity of the patient’s disease over the past 1-2 years. It this correlates with hair shedding episodes experienced by the patient, then disease activity is likely involved in the patient’s hair loss.

3. A New Autoimmune Disease is Causing Hair Loss

It's well known that once a patient develops one autoimmune disease that he or she is more likely to develop a second autoimmune disease. One must always keep this in mind. Autoimmune scarring alopecias and autoimmune alopecia areata must always be considered when a patient with one autoimmune disease reports hair loss.

4. A New and Unrelated Hair Loss Condition has Developed

Hair loss is common and other conditions can develop. A 37 year old female with systemic lupus who uses Plaquenil for many years and now reports hair loss may have a number of possible hair loss conditions including telogen effluvium, female pattern (androgenetic alopecia), traction alopecia, or scarring alopecia. 40 % of women by age 50 will develop female pattern hair loss. This means that 40 % of female patients who use Plaquenil will develop female genetic hair loss - not from the drug itself but because that is the expected frequency in the population.

5. A New Treatment that was Introduced is Causing the Hair loss

For any patient who is currently using Plaquenil and develops new hair loss one must keep a very open mind as to the possibilities for the hair loss. In addition to the discussion points above, one must review whether new medication have been started. Was another medication introduced to treat the autoimmune disease? Was another mediation introduced to treat some other health condition. I recently saw patient with lupus who developed hair loss from an antacid type medication. We reviewed the precise course of the hair loss, pinpointed that it must have been the antacid medication and changed the medication. 2 months later the shedding had slowly considerably and 8 months later the patient’s hair has returned.

Conclusion

There are many reasons for hair loss in patients who use Plaquenil. One must always consider the possibility that the drug itself is triggering the hair loss but at the same time keep an open mind to other possibilities.

The Five Day Modified Hair Wash Test (MWHT)

THE 5 DAY MODIFIED HAIR WASH TEST

The modified hair wash test (MHWT) is an extremely helpful non-invasive test. It is underutilized (or even rarely utilized) by dermatologists mainly because of lack of familiarity, lack of exposure along with the time it takes to interpret the test. It is an extremely powerful technique to differentiate challenging cases of CTE from AGA. The MHWT involves 3 parts: 1) Collecting the Hairs 2) Analyzing the Hairs 3) Interpreting the Results

The patient may perform the first part of the test at home. 

Step 1: Collecting the Hairs

The steps in the MHWT are shown in the diagram below. To perform the MHWT, a patient is instructed to avoid shampooing the hair for 5 days before the date of set test date. On the day of the test, the sink is covered with a gauze. The hair is then shampooed thoroughly and rinsed and rinsed and rinsed again. The hairs trapped in the gauze are collected, dried for 3-4 days and then mailed to the office in the same gauze they were trapped on without moving them off the gauze.

Step 2: Analyzing the Hairs

Step 2 begins when the sample arrives back at the office. Most patients simply mail the gauze and hair back to the office in an envelope. The hairs are then divided according to length into hairs less than 3 cm, hairs 3-5 cm and hairs more than 5 cm. We use the following form to count hairs.

FORM FOR ANALYZING RESULTS OF THE MODIFIED HAIR WASH TEST (MHWT)

Step 3: Interpreting the Results

The number of hairs collected in the MHWT can give a good sense of excessive shedding. Results need to be interpreted by a dermatologist who is familiar with the performance and interpretation of this test.

a) Patients with 10% or more of hairs 3 cm or shorter and who shed fewer than 100 hairs are diagnosed as having androgenetic alopecia (AGA).

b) Patients with fewer than 10% of hairs that were 3 cm or shorter and who shed at least 100 hairs are diagnosed as having chronic telogen effluvium (CTE).

c) Patients with 10% or more of hairs that were 3 cm or shorter and who shed at least 100 hairs are diagnosed as having AGA + CTE

d) Finally patients with fewer than 10% of hairs that were 3 cm or shorter and who shed fewer than 100 hairs are diagnosed as having CTE ‘in remission.’

L-lysine: It's role in iron and zinc absorption

It's Role in Iron and Zinc Absorption

L-lysine is an amino acid and is found in eggs, meat, fish and eggs. Generally speaking, lysine is one of the more challenging amino acids to get through normal food intake. This is especially true for those who do not consume these products.

There are very few studies looking at the role of L-lysine and hair. However, there is one in particular that one should be aware of. These are studies focusing on the role of L-lysine in iron and zinc absorption. In 2002, D.H. Rushton showed benefits of l-lysine in increasing iron and zinc levels and in reducing hair shedding.

Among 14 zinc deficient women, L-lysine at doses 1000-1500 mg daily led to an increase in zinc levels from 9.7 to 14.6 umol/L even without these women consuming actual zinc pills.

Similarly, Rushton showed L-lysine may help iron absorption. In his study, iron pills (100 mg per day) in 7 women with chronic telogen effluvium did not change ferritin levels at all. However, when combined with L-lysine (again at 1000-1500 mg per day), ferritin levels increased from 27.4 to 58.6 ug/L. This reduced hair shedding causing the proportion of hairs in the telogen phase to decrease from 19.5 to 11.3.

L-lysine is a key amino acid and I often add it to the overall plan for patients with chronic shedding abnormalities and those with deficiencies of iron and zinc that don't respond to standard treatments. If I do ultimately recommend patients use L-lysine, the dosing in our clinic is typically 500 mg twice daily, and rarely three times daily for short periods.
 

Reference

DH Rushton. Nutritional factors in hair loss. Clin Exp Dermatol 2002
 

Shedding, Shedding, Shedding: Why Won't it Stop?

Why Won't it Stop?

Being a hair specialist is as much about trying to get hair back on the scalp as it is trying to figure out why it’s leaving the scalp in the first place. There are dozens and dozens of reasons to lose hair. Some diagnoses are easy. Some are challenging. Some look easy but can fool you as they are a close mimicker of another condition.

Telogen effluvium (TE) refers to hair shedding in excess of what is normally experienced by the patient. A variety of triggers commonly cause TE including low iron, thyroid problems, crash diets and medications. Once the trigger is properly identified and “fixed” the hair grows back. (for example once the dieting stops the hair shedding stops in 6-9 months). TE is among the most frustrating of conditions because many conditions can mimic TE. Far too many patients are told to just be patient as the shedding will stop only to find 6-9 months later that the shedding has not in fact stopped.

Why would shedding not stop?

Well, there are a number of reasons for this. First, we need to consider that we may not have found the right “trigger.” We might not realize that the patient’s supplement they started last year is actually the trigger. We not have realized that the patient’s fatigue and headaches and sore joints are actually a sign of underlying disease.

Second, we need to be humble to the fact that we may have the wrong diagnosis and were fooled into thinking this is a TE. Androgenetic alopecia (female thinning and male balding) often starts with shedding that perfectly mimics a TE. Some early scarring alopecias like lichen planopilaris can mimic TE.

Finally, we may have got the general diagnosis of telogen effluvium correct but failed to recognize that the patient’s hair shedding really fits best with chronic telogen effluvium or “CTE.” In true cases of CTE a trigger can often not be found.
 

Conclusion

Excessive hair shedding is frequently seen with TE. However, physicians need to keep a broad and open mind to other possible diagnoses if the shedding does not stop.
 

Stopping Birth Control: Will My Hair Come Back?

Will My Hair Come Back?

Stopping birth control can be associated with hair shedding. For many individuals the shedding occurs with 4-8 weeks after stopping birth control and eventually shedding returns to normal within 9-12 months and hair density returns to normal as well.

One of the most misunderstood topics when it comes to hair loss and birth control, is the array of considerations when hair density and shedding do not return to normal as one would anticipate. 
Situation “A” and “B” are common when birth control is stopped. In “A”, there is an initial shed followed by a cessation of shedding at month 7-10 and hair density returns to normal by month 12. In situation “B” there is no real perceived increased in shedding at all and the patient notices no real change in her hair at all. These situations typically occur in a patient with no underlying androgenetic alopecia and no strong predisposition to it as well.

Situation “C” and “D” are different. In situation “C” the patient starts out with good hair density but notices at 9-12 month later that her hair density has not returned and is a bit thinner. In situation “D” the patient notices the hair density is quite a bit thinner. In these two situations, the patient often has an underlying predisposition to androgenetic hair loss. In “C” there may have not been any degree of androgenetic hair loss to begin with but the shedding has accelerated the arrival of the patient’s genetic hair loss. In situation “D” there was some genetic hair loss to begin with but it was so mild it was unnoticed by the patient. The birth control pill in this situation was often helping as a treatment to stop the balding process even though the patient was not using it for this reason. By stopping the birth control pill, a helpful treatment actually gets stopped without the patient knowing and the patient’s hair loss is accelerated to a greater degree than in “C”

Patients and physicians should be aware of the array of different possibilities that exist when birth control is stopped.

Hair Loss with Weight Loss Surgery: Is it common?

How common is hair loss with weight loss surgery?

Hair growth is a finely regulated process. The right balance of nutrients and hormones needs to bathe the hair follicle or else the hair follicle will shed. This shedding process is known as telogen effluvium. It's well known that a variety of triggers can cause hairs to shed including low iron, thyroid problems, nutritional issues, illnesses inside the body, crash diets and stress. 

Telogen Effluvium from Weight Loss Surgery. 

It's well recognized that hair loss can come from weight loss surgery. Studies looking at home common hair loss is after these types of surgery have given varied results but anywhere from 45-80 % of patients can be expected to have hair loss after weight loss surgery. This hair loss worsens in month 2 and 3 compared to month 1. 

Part of the hair loss comes from the stress on the body, and the restriction of calories Part of the hair loss comes from nutritional deficiencies that occur in patients undergoing weight loss surgery. Some studies have suggested that hair loss as well as nail changes are both predictive of a patient having underlyign nutritional issues. 

Deficiencies of Zinc, iron and selenium  

Deficiencies of zinc and iron are the most commonly studied but deficiencies of selenium have also been suggested. Rojas and colleagues compared the nutritional status of women who reported high degrees of hair loss after bariatric surgery and compared this to the nutritional status of women who reported mild hair loss. Patients with significant degrees of hair loss reported lower intake or zinc and iron and blood tests showed lower iron and zinc levels. Interestingly, patients with higher degrees of hair loss had less copper in their diets. 

Ruiz-Tovar and colleagues performed a prospective observational study in 42 obese women who had sleeve gastrectomy. This was one of the few studies to follow the level of various micronutrients after surgery - at 3 6, and 12 months. 41 % of patients reported hair loss. There was an association between iron and zinc levels and hair loss.  All patients who had low iron levels had hair loss. The authors indicated that zinc supplements did help with hair loss in most cases. 

 

Conclusion

Hair loss is common after bariatric surgery and generally occurs within 4-8 weeks. A variety of factors contribute to the hair loss, but nutritional deficiencies are important to evaluate. In my clinic I recommend a full panel in patients have hair loss after bariatric surgery including tests for CBC, TSH, ferritin, ESR, zinc, copper, selenium albumin. Premenopausal women should have a variety of hormones checked if menstrual cycles have not returned. 

References

Trindade EM, et al. NUTRITIONAL ASPECTS AND THE USE OF NUTRITIONAL SUPPLEMENTS BY WOMEN WHO UNDERWENT GASTRIC BYPASS. Arq Bras Cir Dig. 2017 Jan-Mar.

Ribeiro de Moraes M, et al. Clinical-nutritional evolution of older women submitted to Roux-en-Y gastric bypass. Nutr Hosp. 2014.

Rojas P, et al. [Alopecia in women with severe and morbid obesity who undergo bariatric surgery]. Nutr Hosp. 2011 Jul-Aug.

Goldenshluger M, et al. Postoperative Outcomes, Weight Loss Predictors, and Late Gastrointestinal Symptoms Following Laparoscopic Sleeve Gastrectomy.  J Gastrointest Surg. 2017.

dos Santos TD, et al. CLINICAL AND NUTRITIONAL ASPECTS IN OBESE WOMEN DURING THE FIRST YEAR AFTER ROUX-EN-Y GASTRIC BYPASS. Arq Bras Cir Dig. 2015.

Telogen Hairs: Lack of pigment at root

Lack of pigment at root

Telogen hairs are hairs that are ready to be shed from the scalp. At any time, most individuals have 9-12 % of hairs in telogen phase on the scalp.

Telogen hairs have a characteristic appearance once shed from the scalp. They look like clubs and are therefore called "club hairs". They also lack pigment at the very bottom of the hair follicle. This is due to the cessation of pigment production by the hair follicle at the end of its growing phase (called anagen).

Recovery from Post Surgical Telogen Effluvium

Telogen Effluvium After Surgery

Telogen effluvium (TE) is a form of hair loss that is associated with an increased amount of daily hair shedding. Instead of losing 50-100 hairs daily, patients with TE lose a far greater amount.  There are many so called 'triggers' of TE including stress, low iron, thyroid problems, medications, diets. Many patients experience TE after hospitalizations - especially if surgery was the reason for the hospitalization.

Post Surgical Telogen Effluvium

Not everyone experiences hair loss after surgery. But if it does occur, it often occur 2-3 months after surgery. A variety of factors influence whether hair loss will or will not occur. Some are similar patient intrinsic factors that are poorly understood. These influence one's risk of developing a TE in the first place. But factors like type of surgery, length of surgery, medications and anesthetics used, blood loss, weight loss, nutrition all influence the likelihood of shedding.

Sequelae of TE: Will hair shedding stop? Will hair grow back?

There are three things that can happen to an individual who develops hair shedding after surgery:

1) The hair sheds and then grows back to the same density in 6-9 months. This would be the 'classic recovery' in TE.

2) The hair sheds and then the shedding rate slows down but shedding rate is still higher than normal and the hair density does not seem to return quite back to normal. In such a case, the patient may be developing persistent TE or chronic TE.

3) The shedding rate eventually goes back to normal but the hair density remains thinner and never quite comes back the same. In such a case, the patient may have developed worsening of another type of hair loss, such as androgenetic alopecia. The TE may have resolved but another hair loss condition has taken over as more pressing. 

Evaluation of Post Surgical TE

The key to addressing telogen effluvium from surgery is trying to determine the exact cause. If it was factors such as stress, weight loss, medications or anesthetics in hospital, those triggers are presumably gone by the time the patient develops or notices shedding. Waiting (rather than active treatment) is one very good option in this situation as hopefully the hair will grow back in 6-9 months.

If the 'trigger' was actually due to a deficiency in some mineral or metal (iron and zinc deficiency are common after bowel surgery) or some hormonal issue (thyroid issues are common in hospitalized patients)... then the hair will only properly grow back when these specific issues are addressed. The key to treating a telogen effluvium is addressing the trigger.

 A few in depth blood tests would be appropriate before deciding to treat or wait. The specific tests to order in any given patient will differ depending on their story, but tests for CBC, TSH, ferritin, zinc, 25 hydroxy-vitamin D, calcium, ESR, ANA can be considered. Other tests may be appropriate as well including imaging tests (Chest X-ray, etc).

Treatment of TE

Sometimes the exact trigger can’t be confidently agreed upon in a post surgical patient and one needs to make a decision as to whether they want to wait and see what happens or treat with non-specific hair growth stimulators like minoxidil (Rogaine) or low level laser or vitamins. These all encourage hair growth. One must keep in mind that if the trigger has not adequately been addressed (i.e. the patient actually has an undiagnosed thyroid disorder), these growth stimulators will be less effective.

Is my shedding normal?

The actual number varies among people 

I'm often asked what constitutes normal shedding. Of course, many people have in their mind that 100 is the magical cut off and anything less is normal and anything more is abnormal. This is really too simplistic. The first principle is that anyone's normal is what they used to shed in the past. The problem is it's hard for patients to know the number of hairs they lost 3, 5 and 10 years ago because they weren't focused on their hair back then. But if a patient loss 20 hairs per day in the past, and now loses 55, that represents abnormal shedding.

Generally speaking, most people lose 25-65 hairs per day and 50-150 on a showering day. But this number depends on how often the patient shampoos his or her hair. If one shampoos their hair once per week, many hundreds of hairs lost while showering could still be within the realm of normal. If the patient shampoos once per month, the number could be very large.  

Conclusion

The key point for patients to be aware of is that if they feel something is different than the past and they believe that they never had this rate of loss before, then there is a good chance it’s abnormal.

Telogen Effluvium in Young Men

Telogen Effluvium in Young Males: Considerations

Telogen effluvium (TE) refers to a type of hair loss whereby a patient experiences increased daily shedding of hair. Instead of 30 or 40 hairs coming out of the scalp, the patient experiences 60, 70 or even hundreds of hairs shed on a daily basis. There are a  variety of causes of telogen effluvium including stress, low iron, thyroid problems, medications and crash diets. 

TE in Men

Telogen effluvium can occur in men and does occur in men. However, it is far less common than in women. In addition, there are many mimickers or 'lookalike' conditions that frequently lead to incorrect diagnoses of telogen effluvium in men. A good example of this is early staged androgenetic alopecia (AGA) in men. Men with early AGA experience increased hair shedding which looks very similar to a telogen effluvium. Many such men are diagnosed with TE when in fact the correct diagnosis is AGA. The most important question that should be asked in any male with a diagnosis of  suspected telogen effluvium is: does this patient actually have androgenetic alopecia instead of telogen effluvium OR does this patient ALSO have androgenetic alopecia together with telogen effluvium?

Certainly telogen effluvium can occur as a sole diagnosis in men. However, more times than not in the patients I see, this is not the only diagnosis. 

Diagnosing TE

Telogen effluvium is largely a diagnosis made on history and clinical exam. Rarely, a biopsy is needed.  For most individuals with TE, another person passing by in the street would not take notice there is hair loss even if substantial hair has been lost. TE causes diffuse loss - meaning the hair is lost all over the scalp. Such hair loss typically occurs 2-3 months after some kind of trigger.  A person with TE however can look very different to the way they know they once looked.  If I look at a photo of a patient and I say "this patient has hair loss" - it's like that another diagnosis is present other than TE or together with TE. 

Conclusion

I see many young males with early androgenetic alopecia who are misdiagnosed as having a telogen effluvium. It's true more definitely that telogen effluvium can occur in young men - but one must always keep in mind that it's not really all that common.  Most men who are shedding more than normal end up being diagnosed with androgenetic alopecia. 

I'm often asked who long of a 'window' does a patient have to treat the TE before any irreversible changes happen. The reality is that if a male has TE as their sole diagnosis, there is quite a long window actually. However, the window closes if another hair loss diagnosis is present - especially androgenetic alopecia (AGA). TE can occur in men, yes. But too often androgenetic alopecia in the early early stages is ignored and missed. Biopsies and hair collections together with a careful scalp exam and medical history can help clarify things immensely.