What Combination Locks Teach us About Managing Hair Loss

Getting all the Numbers Right Opens the Lock

There are many ways people can physically lock up their personal belongings. Key locks and combination locks are popular ways of securing one’s belongings. With a key lock, one simply needs to have the right key and the lock can be unlocked. With a combination lock, one needs the right digits and enter them in the right order.

Combination Locks and Hair Loss

Combination locks remind me a lot about how we treat hair loss. Nobody ever expects to be able to open a three digit combination lock if only remember 1 or 2 of the required combination numbers can be remembered. Unless they can all be entered, the lock is simply not going to open.

Every day, I see patients with hair loss who tell me they their treatments just aren’t working. For example, they might have lichen planopilaris and tell me their topical steroids aren’t working. They might have androgenetic alopecia and tell me their minoxidil is not working. They might have alopecia areata and tell me their steroid injections aren’t working. In many cases, the patient is absolutely right - the current treatments just aren’t the right treatments and we need to change them. Sometimes, however, the treatments are actually just fine, it’s just we have not addressed the other hair loss conditions that are present. The patient and his or her physician was expecting success but several other hair loss conditions are present and have not been addressed. We can’t successfully open the lock unless we enter all the numbers and we can’t successfully treat hair loss unless all the conditions that are present are treated.

Consider the 46 year old female patient with lichen planopilaris who is using topical steroids (clobetasol). She feels the hair shedding is a bit better but she’s still losing hair and it’s still quite itchy. What I soon realize is that the patient also has seborrheic dermatitis and has low vitamin D, and low zinc. I also suspect an allergic contact dermatitis from a shampoo ingredient. After examining the patient, I recommended that she continue the topical steroids, supplement with oral vitamin D and oral zinc, add a low allergen anti dandruff shampoo (such as Free and Clear Antidandruff) and avoid her regular shampoo until patch testing is arranged by a dermatologist. Within a few weeks the patient finds her scalp feels better and looks better and hair shedding is reduced further. She’s glad she does not need stronger immunosuppressants for her particular case… and so am I.

Conclusion

With many hair loss treatments, we often expect the treatments to work. But too often we forget to ask ourselves if any other conditions are present. Many patients are surprised to leave the office with 2, 3 or 4 hair and scalp diagnoses but they should not be really too surprised. We can’t open a four number combination lock by entering just 1 number. Similarly, we can’t successfully and completely treat a scalp disorder whereby four conditions are contributing if we are just trying to deal with only one of the conditions.

Blood test and Hair Loss: Necessary but Often Normal

Blood tests in Patients with Hair Loss

Hair loss for most is due to changes happening within the tiny hair follicles deep under the scalp. There may be a difference in the expression of certain genes or their may be different levels of inflammation surrounding hairs. It comes as a surprise to many patients that blood tests are often normal. 

Why do we need blood tests if they are likely to be normal?

We require blood tests because there are many mimickers of hair loss and many conditions associated with abnormal blood tests are asymptomatic. If we could tell with 100% certainty that a given patient had low iron or had a thyroid problem just by listening to their story or examining their scalp, we would not need blood tests. The reality is that we can't. Many systemic conditions that can contribute to hair loss are asymptomatic.  Low iron, thyroid abnormalities, zinc abnormalities, autoimmune markers, hormonal changes - these can frequently be asymptomatic. 

Does it make sense that blood tests can be normal and still have hair loss?

It makes a lot of sense when one pauses and reflects on what is happening for most people. As mentioned earlier, hair loss for most patients is due to changes happening within the tiny hair follicles deep under the scalp. There may be a difference in the expression of certain genes or their may be different levels of inflammation surrounding hairs. The key tests that we need are therefore 'hair tests' not blood tests. In the present day and age, we don't have very sophisticated "hair tests."

I often use several analogies with my patients. If your arm was hurting and your doctor sent you for a chest x-ray, you wouldn't be surprised if your chest x-ray results came back normal. it is certainly possible that something in the chest is causing arm pain, but not very likely for most. What you need are tests on the arm - not tests of the chest. If you have chronic headaches and your physician sends you for an MRI of the foot, you won't be surprised if the MRI results of the foot come back normal. Blood tests may also be important in patients with chronic headaches - and sometimes these blood tests do reveal a cause of the headaches. But more often than not what is needed is tests specifically targeting to the brain - such as an MRI, CT or other related tests. 

Conclusion

Every patient with hair loss needs blood tests to rule out a range of conditions that can cause hair loss and be asymptomatic.  The typical blood tests that I recommend as a starting option are found in the following link. 

Blood test for Hair Loss

One should always be prepared for the possibility (and likelihood that blood tests will come back normal for many patients.  We have only a limited number of "hair tests" in the present day. These include punch biopsies, clinical examinations, trichoscopy, pull tests, pluck tests, hair collections. and hair mineral analyses (which are not useful for most), and hair toxicology screens (which are not relevant for most).  We do not have an ability to easily tests the thousands and thousand of different genes expressed deep down inside the hair follicle and therefore rely on the above ancillary tests to get a sense of what might be happening inside of a tiny hair follicle. 

Obtaining information from patients

What information is most important?

When it comes to obtaining information from patients about their hair loss, every piece of information is potentially important. However, certain pieces of information are generally the most important. I refer to these as the “4 S’s.” Each letter S stands for distinct things that are important to know about including 1) the SPEED of the patients hair loss (ie fast or slow), 2) the SITES that are involved with hair loss (ie crown, frontal scalp, or even diffuse loss as well as information on eyebrows, eyelashes and body hair, etc), 3) the SYMPTOMS the patient might have (including itching, burning, tenderness, tingling) and 4) the degree of daily hair SHEDDING the patient feels they are having (normal shedding vs slightly increased vs markedly increased). These 4 S’s are among the most important of the questions a hair specialist can ask. It does not mean other questions are not important or relevant but simply these are key areas that must always be asked about as one thinks about the precise diagnosis.
 

The "Positive" Pull Test: What does it mean?

A Positive Pull Test: Many Diagnoses

A "pull test" is a test for excessive shedding. To perform the pull test, the clinician gently wraps his or her thumb and index finger around approximately 60 hairs and pulls gently upwards. If more than 3 hairs are removed, one should consider it a positive pull test. (the old cut off used to be 6 hairs but recent studies have suggested that number is not appropriate for most).

Does a positive pull test mean telogen effluvium?

It's a common error to assume that a positive pull test equates to a telogen effluvium. While the pull test is often used to give the clinician some sense if whether a telogen effluvium might be present this is not the only hair loss condition that gives a telogen effluvium.  The reality is that many conditions give a positive pull test including androgenetic alopecia, alopecia areata and scarring alopecia. In other words a positive pull test is not definitive for any given diagnosis but certainly indicates that something is not quite right with how the patient is losing hair.

Let's take a closer look at these conditions 

1. Telogen Effluvium

Telogen effluvium (TE) is the prototypical hair shedding condition. Hair shedding in a TE occurs all over the scalp which means that the pull test is positive all over the scalp. Not everyone with a TE has a positive pull test as a variety of factors can influence this, including when the patient last washed their hair.  Typical causes of TE include stress, low iron, thyroid problems, medications, diets, and illness inside the body (systemic illness).

2. Androgenetic alopecia

Contrary to what many patients and clinicians think, increased hair shedding does occur in the early stages of androgenetic alopecia (male and female balding). Sometimes a pull test can be weakly positive in these areas. Performing a pull test is a bit trickier int these conditions simply because the findings are subtle. But if one performs a pull test in areas of androgenetic alopecia and compares the findings to areas where there is no androgenetic alopecia, one can appreciate that a few more hairs are frequently extracted from the are of androgenetic alopecia. 

3. Alopecia areata

Alopecia areata is an autoimmune condition that affects about 2 % of the world's population. It causes inflammation to accumulate deep under the scalp around hair follicles. This inflammation can trigger shedding. In the earliest stages, alopecia areata can closely mimic a telogen effluvium and not surprisingly a pull test is frequently positive. The hairs that are extracted in alopecia areata are a bit different than a true TE and include a mix of telogen hairs, broken hairs and so called 'dystrophic anagen hairs."

4. Scarring alopecia

Patients with scarring alopecia may also have a positive pull test. Lichen planopilaris, Idiopathic Pseudopelade of Brocq, Discoid Lupus Erythematosus can all trigger increased shedding. The pull test in these situations may reveal telogen hairs as in a telogen effluvium, but may frequently also reveal anagen hairs. In fact, the extraction of normal appearing anagen hairs is a pathognomic sign of a scarring alopecia. 

Reference

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

Mononucleosis ("Mono") and Alopecia Areata - Any link?

Is mononucleosis ("mono") a trigger for alopecia areata?

Alopecia areata is an autoimmune disease. Environmental factors play a role in many patients to trigger the disease in patients who have the correct genetic predisposition to the disease.  Studies have examined whether environmental factors like stress, as well as various infections play a role in alopecia areata.

EBV: The Cause of Mono

Epstein Barr Virus (EBV) is the virus known to cause the infectious illness mononucleosis which is sometimes just called 'mono'. A 2008 study examined whether mononucleosis could be a trigger for alopecia areata. This particular study examined 6256 individuals. 1586 patients reported an environmental trigger that was thought to cause the alopecia areata - including 12 individuals who had an EBV infection within 6 months before the onset of AA.

Conclusion

The role of EBV and mononucleosis is not proven definitively but there is some evidence that it could be a trigger for a small proportion of individuals. More studies are needed.

Reference

Rodriguez TA, et al. Onset of alopecia areata after Epstein-Barr virus infectious mononucleosis. J Am Acad Dermatol. 2008.

Does Elevated ESR cause Hair Loss?

The ESR Test

The erythrocyte sedimentation rate (ESR) is a very sensitive but non specific test for inflammation. An increased ESR does not directly cause hair loss but can sometimes indicate that the patient has underlying inflammation in the body that could be giving hair loss. Determining the cause of an elevated ESR is detective work.

The upper limit for ESR is slightly greater for women than men but a normal ESR is usually less than 20-30 mm/hr.

There are some conditions associated with a high ESR that are associated with hair loss and there are some conditions associated with high ESR that have nothing to do with hair loss. However, conditions such as various infections, and especially the autoimmune diseases (lupus, rheumatoid arthritis, vasculitis, inflammatory bowel disease), as well as anemias, pregnancy, some thyroid diseases, inflammatory diseases of the gastrointestinal tract and advanced kidney failure can be associated with hair loss. Other conditions including some cancers (especially blood cancers and various metastatic cancers) are associated with increased ESR but usually are not associated with hair loss. 

Very high ESR values over 100 mm/hr represent a special group. The group includes those that can be associated with hair loss include systemic lupus erythematosus, rheumatoid arthritis, and sometimes a few types of blood cancers (ie lymphomas, leukemias). Some drug hypersensitivity reactions can give very high ESR values and can also trigger hair loss. Polymyalgia rheumatica is in this group of conditions giving very high ESR values and can also sometimes give hair loss. Conditions in this group that usually don't give hair loss are infectious diseases such as abscesses, bacterial endocarditis and osteomyelitis.

The ESR test is a non specific test and many times a cause can't be found despite the patient having a full examination. Very high ESR levels may warrant additional testing. This may included other blood tests such as CRP, ANA, rheumatoid factor, LDH and possibly various imaging tests (depending on the precise history and precise level of ESR). There are hundreds of causes of increased ESR.

The Self-Diagnosis of Hair Loss: A DIY Project to Avoid

ON SELF-DIAGNOSIS  

Nowadays, do-it-yourself (DIY) projects are very popular. A "DIY" Project is an activity that one undertakes without directly seeking the help of an expert.  You're probably well aware that DIY is particularly popular among individuals interested in home renovation. There are countless numbers number of books and videos to guide the lay person to renovate their home from top to bottom, inside and out. DIY need not be limited to home decor; the concept of DIY extends broadly into so many aspects of our lives nowadays.  The internet is full of DIY projects.

On account of the internet, DIY also extends into medicine. The public is increasingly looking to take control of their health and in the same light to have more autonomy to decide how they receive advice on their health. We are all familiar with the power of modern search engines. My patients often joke about what they learned form "Dr. Google". However, the reality is clear: patients are spending more and more time looking for reliable information from the internet.  We know that a vast majority of patients search for health information online. Various studies have suggested that 25-50 % of individuals seek the internet for self diagnosis.

I'm not a great fan of self diagnosis (i.e. DIY diagnosis) when it comes to hair loss. In my opinion, attempting to self diagnose the cause of one's own hair loss is rarely wise.  Unless an individual has had a comprehensive review of their medical history, a full examination of their scalp (including use of dermoscopy) and had blood tests, they have not yet begun to properly investigate their hair loss. 

.

Why are we self-diagnosing anyways?

There are many reasons why individuals want to diagnose their own medical health, including hair loss. It's certainly much faster and more convenient to look on the internet than take the time to go to a doctor.  For many, it may also present a considerable cost savings as well. For others, there is a tremendous amount of fear that surfaces when one needs to face their own health issues with a doctor. It's easier for a person with hair loss to avoid this by trying to solve one's health issues themselves.  For others, looking at information on the internet provides a much needed sense of autonomy over health-related decision making. The public increasingly wants control over their health and how decisions get made and who makes them.  When it comes to hair loss, however, it's often a false sense of control.

Why I don't encourage self-diagnosis   

I realize that patients generally want to try to figure out the cause of their own hair loss by themselves. Fundamentally, this is good.  Most of us are naturally interested to understand our own health. What concerns me is when individuals attempt to diagnosis their hair loss without the help of an expert (by definition, a DIY Project). There are several considerations I'd like patients to think about as they consider going down one of these paths to self diagnosis. 

DIY Consideration 1. All Humans have Bias

'Bias' is a term that means that we have a tendency to make certain decisions based on our previous life experiences. Essentially, the way our brains are wired based on all our collective life experiences and previous knowledge makes it more likely for us to make certain decisions than others. For example, when you see your child fall to the ground crying while playing with a group of children, your instinct may gear you up to look for the exact child that could have pushed your child. This is bias. The reality could be that your child could have tripped on an untied shoelace. We are wired to think certain ways.

When it comes to thinking about the causes of our hair loss, we have biases. For example, most of us really don't want to be diagnosed with genetic hair loss, so our bias could easily cause some of us to consider other diagnoses as the top choice.  For example, you remember a family member with balding or someone you saw in the grocery store with hair loss, and your own emotions tell you that this is not what you want to have as a diagnosis.  You have a natural bias to think you might have another diagnosis than genetic hair loss.

"There is absolutely no one in my family with balding, so my hair loss must be from stress"

This is bias.  Bias is all around us.   We are all humans and we are all filled with bias. But as a physician, I am likely filled with less bias when examining a patient's hair loss than the patient is

Bias often leads to Forgotten Information

It's normal to be biased because after all, we're human. Bias can sometimes be a good thing, and certainly the instinctive reactions that come with bias sometimes do help us. In the example above, the bias we have when we hear our children cry helps us protect our children. But time and time again, I have witnessed how bias leads to some components of information to be forgotten. 

The the past few years, I have made it a priority to have patients in my clinic complete a very detailed questionnaire about their hair loss long before meeting me. Most of my patients complete this questionnaire in the comfort of their own home, days or weeks before their appointment date. My hope in doing so is to reduce the bias that comes from face-to-face meetings with a physician. Although it's true that 'white coat syndrome' itself can influence what patients remember about their health, there many other aspects of the visit to the clinic introduce bias.

Since introducing the questionnaire some years ago, there has been a  significant reduction in phone calls and emails after the appointment from patient's that 'forgot' to tell me certain pieces of information.  My hope is that, by using this questionnaire, we're cutting down on bias that exists in standard patient-doctor interviews.

Physicians Have Bias Too

I too am filled with bias. When a close friend asks me about their hair loss, my 'gut reaction' is that I don't want them to have some systemic illness that is contributing to their hair loss. I don't want the strands of hair they pull from their scalp to be due to some serious disease. I need to recognize that I have bias and do my best to remove this from the decision making algorithms.

In fact, when discussing hair loss with friends and family, it's really best that I remove myself from the situation altogether. Legally and ethically, most physicians are not permitted to offer diagnostic or treatment advice to their closest friends and family. Medicine has recognized that physicians have bias and they are not able to properly evaluate an individual who close to the physician. If one of my family of friends has hair loss, I'm supposed to ask them to see a colleague. Sounds strange, but real bias is real!

DIY Consideration 2: Not everyone knows about the 'zebras'   

Self diagnosis (hair loss DIY diagnosis) is also dangerous because there is often an assumption by the individual that they appreciate all the various causes of hair loss that exist and simply need to choose which one fits best. To the individual, they mistakenly feel that all the cards are on the table and they just need to pick the right one. The reality is that most patients considering their own diagnosis do not in fact appreciate all the 100 causes of hair loss. Instead of choosing from a list of 100 causes, many individuals with hair loss are trying to choose from a short list of common causes of hair loss. Fortunately, many patients will get their diagnosis right (because common hair loss conditions are common), but unfortunately too many patients get it wrong.

if you've never seen a zebra before, you'll be quite likely to call it some type of horse.  Perhaps a striped horse. Dog owners with more exotic breeds will tell you that few people ever get their dog's breed correct. If you've never seen or heard of the hair loss condition 'pseudopelade', you're likely to incorrectly call a circular patch of hair loss 'alopecia areata'.  If a patient has never seen folliculitis decalvans, then they are likely to go on battling what they think is stubborn folliculitis for a long time. If a patient has never heard of the condition lichen planopilaris, they may be continually searching for newer strategies for treating their stubborn dandruff or eczema.

Attempting to self diagnosis one's hair loss can be challenging if one does not know all the potential entities on the list. 

DIY Consideration 3:  Most are On the Lookout for Only 'One' Diagnosis

In my experience, everyone with hair loss is on the lookout for the cause of their hair loss.  However, very few people take the time to consider that they could have more than one cause for their hair loss.   For many patients, it's not so much of a decision as to whether they have androgenetic alopecia or telogen effluvium but rather what proportion of the patient's hair loss is from androgenetic alopecia and what proportion if from telogen effluvium. Many patients have both! It's possible to have one, two three, four or even five causes contributing to one's hair loss. 

DIY Consideration 4:  The Hair Follicle is More Complex Than Your Car and Few of us Venture to Fix our Own Cars

The hair follicle is incredible.  It's also incredibly complex.  There are 20 different cell types in the hair follicle and 100,000 hairs on the scalp (2-4 million on the entire body). Added together there are trillions and trillions of cells working together in the scalp.  Can one really try to sort through the actions (or inactions) of trillions and trillions of cells themselves?

It's difficult to think in terms of such large numbers, so let's go smaller. A car, they say, has over 30,000 parts when you consider all the tiny components. Few of us venture to even guess what's gone wrong when our car breaks down. We (hopefully) seek an expert.  I often say to patients that if my car was making strange, strange noises and blowing black smoke out the back and front, I would likely be told to get an automobile mechanic to check things over. Any attempt at self-diagnosis and fixing the car oneself would not be wise, at least for most people. It certainly would not be wise for me. When my car breaks down, I need someone who works with cars and  knows exactly how things go wrong. I need an expert.

DIY Consideration 5: Some diagnoses can only come from advanced tests meaning that an individual in such cases will never determine their diagnosis themselves.

It is important to keep in mind that some diagnoses can only come from a biopsy and some diagnoses can only come from blood tests. Individuals attempting to diagnose the cause of their own hair loss may never reach their diagnosis unless they have these specific tests performed. A patient with hair shedding may think they have a vitamin deficiency or some other cause of telogen effluvium. However, a biopsy could reveal that the hair loss was actually from a scarring alopecia. Similarly, a patient with hair shedding may think their hair loss is simply from stress when the reality is that they have low iron levels from a life-threatening bleeding stomach ulcer. 

In these cases, any attempt to try to self diagnose one's hair loss simply leads to a delay in getting the appropriate medical attention that is needed.  Rarely, this delay in diagnosis can have serious consequences.

DIY Consideration 6. Patients who self diagnosis often fall prey to online marketing

Finally, a high proportion of individuals who attempt self diagnosis end up spending hundreds and sometimes thousands of dollars on products and supplements they have seen online. The patient's vulnerable state makes them very susceptible to consider buying anything that could help. Online marketing is remarkably powerful. Supplements, pills, shampoos, vitamins, tonics can all be bought with a click of a button. And often are. 

 

Conclusion

I've read many Do-it-Yourself books on various topics and I'm all for liberating people to take on new challenges.    DIY self diagnosis, however, is rarely a good idea. 

I'm not one to judge how patients want to access their health care. Certainly patients are spending more and more time looking for reliable information from the internet and there are many reasons why individuals want to self diagnose the reasons for their own hair loss.  However,  properly diagnose hair loss one needs the full story, not the abbreviated version. And to properly diagnosis hair loss one needs the story told with as little bias as possible. Second, a full examination of their scalp (including use of dermoscopy) is needed. There are many mimickers of hair loss and one needs to know all the potential mimickers to make a proper diagnosis. Finally, one needs to have blood tests to complete the basic work up.  

Reference

1; Danielle Ofri, MD What Patients Say, What Doctors Hear (Beacon Press, 2017). Reprinted with permission from Beacon Press.

2. Jerome Groopman. How Doctors Think. Houghton Mifflin 2007

Do all women with hair loss really need blood tests?

Evaluating Hair Loss in Women: Are blood tests really needed?

Click here for PDF of Article

That answer, in my opinion, is a resounding - "yes." All women with concerns about hair loss need blood tests. The reason is simple: there are a great number of similar looking hair loss conditions in women and if one thinks they can confidently, with 100% certainty,  rule out any particular condition just by looking at the scalp they are wrong. One can not exclude a contribution from low iron or a thyroid disorder even in a woman presenting with classic androgenetic alopecia. Let's take a closer look why blood tests are needed.

For a review of blood tests typically recommend as part of a screening work up click on the following 

SCREENING BLOOD TESTS FOR WOMEN WITH HAIR LOSS.

1. Iron deficiency anemia is common

About 1 out of every 5 women age 18-45 have iron deficiency. It's common. Given that low iron levels may be associated with a variety of different hair loss conditions, it is important to test for it and supplement iron in women whose blood tests show low iron. Even if one were to argue that low iron levels are seldom really a true factor in hair loss, studies have also shown that supplementation with iron may allow other treatments to work better.

In 1992, Drs Rushton and Ramsay conducted a study looking at women with genetic hair loss who were being treated with an antiandrogen medication (called cyproterone acetate). The researchers showed that women with iron levels above 40 had much better results with the antiandrogen pill than women who had iron levels below 40.
 

2. Blood counts

Ordering a basic blood count (for levels of red cells, white cells) is important. It's not a very specific test, but when the levels come back abnormal, it signals something may be wrong. A common reason for low hemoglobin and a low number of red cells levels is iron deficiency. But a variety of internal illness also have as part of their presentations low blood counts. A basic screen is helpful.

My work up is very different when a female with hair loss has an abnormal blood count. A 31 year old female with low hemoglobin and low ferritin, may have this result from heavy menstrual cycles, but may also have this from celiac disease as well. Depending on the patient and specific details, I may order a so called 'celiac panel' as well. A  66 year old female with low hemoglobin and low ferritin who comes into my clinic for hair loss may need a comprehensive work up by her physician to rule out a cancer. 

3. Thyroid abnormalities are common

About 1 out of every 15-20 individuals will be diagnosed with a thyroid disorder in their lifetime. These thyroid conditions are 8 times more common among women. While it's true that many with thyroid disease will notice symptoms, about one half will not notice any problems at first. Hair loss is frequently part of the collection of symptoms that come with thyroid dysfunction. Testing for thyroid disease in women with hair loss is important.

4. Vitamin D deficiency is common

Vitamin D deficiency is common. Here in Canada, studies have shown that about two-thirds of the population is low in vitamin D and levels tend to be lower in winter than summer.  The exact role of vitamin D in hair loss is still being worked out but it's clear that individuals with alopecia areata and genetic hair loss have lower vitamin D levels than individuals without hair loss.  

5. Zinc deficiency

Zinc deficiency is not common in North America. Nevertheless, zinc deficiency does exist in a number of subgroups in the North American population and is likely more common than appreciated. About 12 % of the general population and up to 40-50 % of the elderly are at risk for zinc depletion in North America. In many parts of the world, zinc deficiency is extremely common. In North America, zinc deficiency is frequently asymptomatic - meaning that individuals with low zinc don't necessarily have symptoms. Zinc deficiency can be associated with hair loss as well as a variety of issues related to immune system function and infection. The recommended amount daily is 11 mg for men and 8 mg for women.

6. Hormone Testing

Most women with hair loss do not require complex and extensive hormonal work-ups that so often are seen. However women with irregular periods, acne, excessive hair growth on the face (hirsutism), difficulty conceiving/infertility, early menopause and abnormal or rapid hair loss do require hormone tests. 

Conclusion

Complete blood counts, along with tests for iron status (ferritin test) and thyroid status (TSH) are among the most important tests for all women with concerns about hair loss. Other tests may also be important for any particular individual but the exact test to order depends on the information obtained during the patient interview.  Too often I hear it said that a female patient does not need blood tests. For example, I often hear it said that a female presenting with classic androgenetic alopecia does not need blood tests because classic androgenetic alopecia is not associated with blood test abnormalities. Here, one needs to consider that classic androgenetic alopecia may be associated with low vitamin D and research has even shown that it may be associated with cholesterol abnormalities as well (low HDL, high LDL).  If one feels they can exclude with certainty that this patient does not have iron deficiency or a thyroid disorder, they are incorrect.

All women with hair loss need blood tests. 

REFERENCE

Rushton DH, et al. The importance of adequate serum ferritin levels during oral cyproterone acetate and ethinyl oestradiol treatment of diffuse androgen-dependent alopecia in women. Clinical Trial. Clin Endocrinol (Oxf). 1992.

The Modified Hair Wash Test (MHWT)

A closer look at the MHWT for Differentiating CTE and AGA

The modified hair wash test (MHWT) is an extremely helpful non-invasive test. It is underutilized by dermatologist mainly because of lack of familiarity and exposure. It is an extremely powerful technique to differentiate challenging cases of CTE from AGA. The patient may perform this test at home. 

Performing the MHWT

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. The hairs trapped in the gauze are collected counted and divided into hairs less than 3 cm and more than 5 cm.

Interpreting the MHWT

Patients with 10% or more of hairs 3 cm or shorter and who shed fewer than 100 hairs are diagnosed as having AGA; Patients with fewer than 10% of hairs that were 3 cm or shorter and who shed at least 100 hairs were diagnosed as having CTE; Patients with 10% or more of hairs that were 3 cm or shorter and who shed at least 100 hairs were diagnosed as having AGA + CTE; Finally patients with fewer than 10% of hairs that were 3 cm or shorter and who shed fewer than 100 hairs were diagnosed as having CTE in remission.

"Miniaturization" and "Anisotrichosis" in Androgenetic Alopecia

Terms in AGA: Miniaturization and Anisotrichosis

Androgenetic alopecia is common in men and women. By 50 years, about 50 % of men and 30 % of women have some evidence of androgenetic alopecia. The early features of AGA include hair shedding in some and hair loss in specific areas (temples and crown in men and central scalp in women).

When examined up close as in this photo, one can see "miniaturization" of hairs whereby some thicker hairs undergo a change to thinner hairs. Most hairs we have on our scalp as teenagers range in around 70-90 micrometers in diameter. During the process of androgenetic alopecia, the follicles become thinner and thinner and over time reduce slowly to 50 micrometers then 20 then 10 etc. Finally the fibers are so thin and short that they fail to reemerge from the scalp.

Not all hairs become thin and not all hairs thin at the same speed (rate). There is great variation in the thickness of hairs. We call this variation in hair shaft thickness "anisotrichosis." Two finding of miniaturization and anisotrichosis is a typical feature of androgenetic alopecia in both men and women. 

Scalp Biopsies: Always 4 mm in size

Scalp Biopsies

Scalp biopsies are performed when the diagnosis of an individual's hair loss is not clear from their story and from examination of the scalp.

A biopsy is performed under local freezing and involves removal of a tiny sample 4 mm in diameter.

The sample is sent off the the dermatopathologist for review under the microscope

Hair Loss: Which blood tests should be ordered ?

Blood tests for Hair Loss: Some tests are simply wasteful

There are literally dozens and dozens of blood tests that one could order for a patient with hair loss. Which ones should we order? Which ones are likely a "waste"? I enjoyed this article in the Medical Post about a newer organization in Canada called Choosing Wisely which serves to help clinicians become more aware of what tests are unnecessary.

In the world of hair loss, this concept is important. Is ordering a reverse T3 likely to add much in a patient with normal TSH? Probably not. What about an ANA level in a very healthy male with patterned hair loss - is that helpful? Probably not at all. What about ordering a transferrin saturation in patient with a ferritin of 76? Seems wasteful.

There are times when an ANA, reverse T3 and transferrin saturation are important and it is important to know when to order various tests and when not to! If one is not likely to change management of the patient if a test comes back, normal or abnormal then it makes little sense to order the test.

The Basic Tests

Basic tests in hair loss include CBC, TSH, ferritin, 25 hydroxyvitamin D and possibly extended to include zinc. Rarely hormonal tests and ANA are included but not routinely. Additional tests are really ordered on a case by case basis. For a list of tests I recommend see the following link

Basic Hair Loss Blood Tests

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.

Assumptions in the clinic : Everyone has a story to tell

Every patient has a story to tell

Over the years, I have made a few general assumptions in my clinic. I generally assume, for example, that the changes in appearance or emotion that accompany a person's hair loss really matters to any given patient who make an appointment with me. After all, why else would someone make the effort to book an appointment ?

Of course, any assumption will have it's exceptions and times where the assumption is not valid. Like the man who comes in because his wife or girlfriend asks him too make an appointment even though he is not really too bothered by his hair loss. Or the child who feels things are just fine but whose parent thinks there is something extremely wrong. Exceptions exist to any assumption and one must always be careful when making any type of assumptions.But generally speaking, most people who visit a hair physician value their hair.

"It's my crowning glory, Dr. Donovan"

"It's my best feature"

"I know you might not know by looking at me but I used to have five times the amount of hair I have now"

"I used to get so many compliments about my hair"

The list could go on and on. 

And so it's fairly safe to assume that hair matters to the people who come see me. (In fact, it's a pretty safe assumption that hair matters to most humans at least for some duration of time even if just a passing thought). 

Greater degrees of hair loss doesn't necessarily mean more impact

The one assumption that is often incorrectly made by clinicians is that patients with more severe hair loss are more affected by the emotional impact of their hair loss.  It sure sounds like a good assumption... except it's just not true. Some people with a small degree of hair loss can be similarly affected and sometimes even more emotionally affected than those with more significant amounts of hair loss. Study after study has shown that physicians wrongly assume they understand the impact of a patient's hair loss. Certainly assumptions can be wrong. 

One of the reasons the assumption that "more hair loss means more impact" does not hold true is that we don't know everything about every patient. We strive of course to understand many things about the patient's medical history and all relevant related details. In fact, in my clinic I've been using a standard medical questionnaire for the past 7 years to gather all the relevant medical information from the patient. Despite this detailed medical questionnaire, we don't understand the complete picture of the patient.   The questionnaire is only a fairly complete medical picture but lacks an ability to gather information about the psychosocial factors have influenced the patient in the past and are currently influencing his or her day to day.

Why does hair actually matter to the patient? What societal pressures (if any) does the patient feel? Does youthfulness, aging, and health in general carry with it emotional significance that is hard to describe or put to paper? Why does the patient sitting in front of me motivated to do something about the changed they see in their hair?

Everyone has a story to tell

We as physicians don't always come to know all the details of everyone's story. Some stories and the details they contain are private and don't directly impact the diagnosis and treatment - and so they remain with the patient. Some issues aren't even fully understood by the patient ... and so they too remain undisclosed to the physician.

Amanda Marshall's award winning 2001 song "Everybody's got a story" reminds us that we can never assume that we have the whole story about a person. Her lyrics are a reminder not to "assume everything on the surface is what you see."

Hair loss is so closely tied in to a patient's self identity and how they feel about themselves. A key part of being a hair loss physician is understanding that there is so much more to losing hair than losing hair.  There are a tremendous number of extremely complex emotions and psychological factors at play in anyone experiencing hair loss. Some of these factors are understood by the patient and shared openly. Othertimes these issues are understood by the patient and not shared openly. And other times yet they may not even be fully understood by the patient. Both of the latter two situations create a void in the physician's full understanding of their patients. And so we can never assume we understand the impact of any given patient's hair loss. However, assuming that it does matter to them is an assumption that works well for me.

When it comes to hair loss, everybody has a story to tell.

Trichotillomania in Children

Always on the Lookout

"Trichotillomania" refers to a form of hair loss where an individual pulls their own hair. It can sometimes be simply a habit - especially in very young children. In adolescents, the diagnosis of trichotillomania may signify underlying psychological illness including depression, anxiety, and eating disorders.

Trichotillomania, alopecia areata and tinea capitis are the three most common diagnoses in children followed by telogen effluvium and androgenetic alopecia. One must always at least consider this diagnosis as it is easy to miss. The presence of broken hairs, black dots, hairs of different length, and other trichoscopic features a v-sign, tulip hairs, and exclamation hairs are helpful in arriving at the diagnosis. The picture shows numerous scattered broken hairs (see green dots) in a young child with trichotillomania.

Do I Need to See an Endocrinologist for my Hair Loss?

There are many types of hair loss. In fact, when you add them all up, there are well over 100 causes of hair.  Some of the causes impact another body system in addition to the hair and require additional focus and attention to ensure the patient's total health. For example, some of the causes are associated with an increased chance of having a thyroid disorder (alopecia areata and lichen planopilaris are example). Other causes are associated with a range of other issues including hearing issues, heart problems, kidney problems, cholesterol problems, bone abnormalities, etc.

Androgenetic alopecia is a form of hair loss that frequently affects women. It causes thinning in the central scalp area in early stages such that the scalp becomes much more "see through." Over time the hair loss pattern can be diffuse. Most women with androgenetic alopecia have no hormonal abnormalities but a small proportion do. Women with irregular periods, acne, hair growth on the face require blood tests to further evaluate for an underlying endocrine issues.

When should a referral to an endocrinologist be made?

I'm often asked by patients and physicians when I refer my patients to an endocrinologist. There are no hard and fast rules but referrals are generally made in the following situations:

1. Women with androgenetic alopecia and irregular periods, especially less than 9 menstrual cycles per year.

2. Women with androgenetic alopecia with possible evidence of late onset congenital adrenal hyperplasia evidenced by elevated day 3-4 17-hydroxyprogesterone.

3. Women with androgenetic alopecia with evidence of potential polcystic ovarian syndrome, especially elevated day 3-4 LH/FSH ratios, irregular periods and findings of acne and increased hair growth on the face.

4. Women with hair loss accompanied by regular menstrual cycles with a history of irregular cycles in the past who do not show normal surges of progesterone day 21.

5. Women with possible premature ovarian failure.

6. Women with irregular periods and elevated prolactin.

7. Women with markedly elevated DHEAS and testosterone regardless of age

8. Women with autoimmune mediated hair loss with low bone mass. Such women may require corticosteroid based therapies with the potential to further impact bone

9. Women with potential adrenal dysfunctional either concern for adrenal suppression from corticosteroid use or various causes of hyperadrenalism (especially when Cushing syndrome is a consideration).

10. Women with low TSH and elevated T4 and or T3

11. Women with high TSH above 7-10 that does not improve on repeat testing or does not improve with thyroid supplementation or is associated with symptoms such as low heart rate, mood changes, constipation and/or chronic shedding. A lower threshold for referral is made in my clinic if additional underlying health issues are present (ie heart disease) or thyroid autoantibodies are positive. For an elevated TSH 2.5 to 6, I handle these situations on a case by case basis.

Conclusion

Hair loss is associated with changes in several organ systems. There are several reasons why I might ask my endocrinology colleagues to evaluate my female patients and some are listed above. Other reasons may be possible too. It is not a routine referral meaning that not all patients need such referral. In fact, it is only a small minority.

Plan b: Is There a Plan B to Treating Hair Loss?

The first step in determining how to help someone with hair loss is figuring out his or her diagnosis. There is no bypassing this step.  The second step is determining a treatment plan that is based on the best medical evidence. 

Plan B: What is Plan B, Doc?

After reviewing a treatment plan with my patients, I'm often asked what treatment will be considered next. "What's plan B, doc?" Well, every treatment plan needs Plan B as well as a Plan C and Plan D.

Consider the 28 year old female with androgenetic alopecia. The best treatment option for her based on all her facts, review of her blood tests and scalp exam might be topical minoxidil. Plan B might be oral spironolactone with or without minoxidil. Plan C might be the addition of a laser comb or changing the anti androgen used. Plan D for her might be a trial of PRP. A solid treatment plan has an alphabet of plans. Not guesswork and not a random pull out of a hat option. But rather options based on a delicate combination of medical science and expert consensus, and personal experience.

What about the 53 year old female with frontal fibrosing alopecia? Plan A for her might be finasteride & steroid injections with hydroxychloroquine as Plan B. Doxycycline is reserved for her as Plan C. For another patient with FFA, Plan A might start with hydroxychloroquine & steroid injections. For her, finasteride is not on the list given the past history of breast cancer the patient had. Plan B is doxycycline and plan C is methotrexate.

Conclusion

Every treatment plan should have an alphabet of plans. That does not necessarily mean one will need to move down the list but the physician should have a clear plan for how to navigate.

What is meant by a "clinical diagnosis?"

What is meant by a "clinical diagnosis?"

The diagnosis of most types of hair loss is achieved through what is termed a "clinical diagnosis".  Many individuals incorrectly believe that the diagnosis "shows up" in a blood test or in a hair sample sent off for fancy mineral analysis. That's not how a hair specialist achieves the diagnosis of a person's hair loss.

A "clinical" diagnosis means that a patient needs to have the scalp carefully examined in the CLINIC by a CLINICIAN and the CLINICIAN needs to listen to the patients entire story (sometimes called the CLINICAL history) of his or her hair loss. Laboratory values are not required in making the diagnosis but might be helpful in making other diagnoses.

Examples

Consider the 32 year old man who has hair loss in the crown. He is concerned that the diagnosis he was given of male balding might not be correct because his lab tests are normal and his testosterone levels and DHT levels in particular are normal. One needs to remember that the diagnosis of androgenetic alopecia is a "clinical diagnosis" and so if the CLINICIAN in the CLINIC seen miniaturization of hairs in the area of hair loss there is a good chance what we are dealing with is androgenetic alopecia.

I could give countless other examples. Many types of hair loss are diagnosed through clinical diagnosis. Lab tests might still be helpful in the work up but they are not needed to make the diagnosis. 

Consider the 23 year old female with hair loss whose labs for ferritin, thyroid (TSH) and hemoglobin come back normal. What type of hair loss does she have?  Without the opportunity for me to review the clinical history and examine the scalp clinically, I would only be guessing.

Conclusion

Most hair loss diagnoses are made through a clinical diagnosis.

Can drugs accelerate androgenetic alopecia (AGA)?

Medications can potentially accelerate androgenetic alopecia. Common examples are anabolic steroids, the use of testosterone injections and topical androgen gels (commonly used for men with "low testosterone"), androgenic progestins in birth control pills, danazol as well as many other medications.

This individual whose scalp is shown in the picture has been using anabolic steroids for body building and has experienced rapid hair loss mainly due to a conversion of his large terminal hairs (some labelled by green dot) to thinner miniaturized hairs (labelled by yellow dot). Treatment of drug accelerated AGA involves either stopping the androgen or blocking the effects of the androgen on the hair follicle using 5 alpha reductase inhibitors... or both. Less specific treatments like minoxidil may provide some benefit. Many individuals can improve with this plan but full regrowth is unlikely.

Elevated testosterone Levels in Women with Hair Loss

Testosterone Levels in Women with Hair Loss

There are many causes of elevated testosterone levels in women. Slightly elevated levels can sometimes be considered 'normal' with no underlying issues to be concerned about. Many patients with increased androgen levels have polycystic ovarian syndrome (PCOS) or underlying endocrine issues such as Cushing syndrome. However, elevated but can sometimes be associated with serious underlying conditions, including cancer. Patients with rapid onset of symptoms and signs along with hormone levels that are well above normal need rapid medical attention for proper diagnosis.

What is the 'cut off' for normal?

There are no hard and fast rules when it comes to cut off numbers. A full story is needed from the patient including how fast the symptoms appeared and how many symptoms are present. Is it hair loss? Is acne present? How about increased hair growth on the face (i.e. hirsutism)? Is the patient menopausal or post menopausal? Are menstrual cycles regular? Has there been weight loss or gain? Does the patient have increasing pain anywhere ? How about fatigue levels?

Causes of elevated testosterone levels in women

There are many causes of elevated testosterone levels in women. Patients with high testosterone levels should be sure to make an appointment with their doctor to review causes. A full history and full examination will be needed and more blood tests may be needed as well. Repeating the testosterone is often advisable too given that it can vary quite a bit day to day. A measurement in the morning is advised.

The top 10 causes of elevated testosterone include

1. Just a normal level for the patient

2. Polycystic ovarian syndrome (one of most common causes)

3. Ovarian hyperthecosis

4. medication induced (androgen replacement, anabolic steroids)

5. Cushing syndrome

6. Congenital adrenal hyperplasia

7. Ovarian tumors

8. Adrenal tumors

9. Hyperthyroidism

10. Prolactinomas

Cancers of the adrenal gland and ovaries are a very rare cause

Cancers of the adrenal gland are rare and about 2 new cases are diagnosed every year per 1 million people. Cancers of the ovary are more common and currently ovarian cancer is the sixth most common cancer in women. Less than 1 % of patients presenting with hirsutism and other signs of hyperandrogegism have an ovarian or adrenal tumor - but it is important to diagnose early. 

Generally speaking a plasma testosterone concentration three times above the normal level (i.e. above 8.7 nmol/L or 200 ng/dL) with a normal DHEAS level raises the suspicion that the patient could have an underlying benign or malignant ovarian cause of their symptoms. Furthermore, a plasma testosterone concentration three times above the normal level (i.e. above 8.7 nmol/L or 200 ng/dL) with an elevated DHEAS level (above 16.3 umol/L or 600 ug/dL) raises the suspicion that the patient could have an underlying benign or malignant adrenal cause of their symptoms.It could of course be normal, but when levels are in this range - a full work up is mandatory. 

Further testing with elevated androgens 

Further testing may be advised depending on the degree of hormone elevation and associated signs and symptoms. As mentioned, a full history and physical examination are needed for all patients with elevated androgens. Generally a full hormonal panel with free and total testosterone, DHEAS, LH, FSH, estradiol, SHBG, prolactin, 17 hydroxyprogesterone and TSH are ordered. Other tests include AFP (alpha feto protein) and B-hCG may be ordered. A pelvic ultrasound or CT scan may be ordered for women with markedly elevated levels. Further stimulation and suppression testing (i.e a dexamethasone suppression test for a potential androgen secreting adrenal tumor) may be ordered upon referral to an endocrinologist. 

Conclusion

There are many causes of increased androgens in women. When associated with increased hair growth on the face, irregular periods, acne or hair loss, androgen hormone levels are frequently elevated. Conditions such as polycystic ovarian syndrome (PCOS) or ovarian hyperthecosis are common and frequently responsible. However, women with markedly evaluated androgen levels (especially three times above normal) require a full work up including referral to endocrinology, radiology and gynaecology specialists.

Reference

Pugeat M et al. Androgen secreting adrenal and ovarian neoplasms. Contemporary Endocrinology: Androgen Excess Disorders of Women: Polycystic Ovarian syndrome and other disorders. Second Edition. Humana Press.