Hair breakage is very common in individuals with the autoimmune condition alopecia areata.
Broken hairs can either be a few mm in length or broken hairs can break at the level of the scalp (in which case the hairs are termed black dots).
TE is a from of hair loss whereby the affected individual experiences higher than normal levels of hair shedding day to day. For example, instead of losing 40, 50 or 90 hairs in a given day (i.e. what is considered normal shedding) individuals experiencing telogen effluvium lose well in excess of 100 hairs on any given day.
Telogen effluvium occurs when some "trigger" causes hair follicles to leave the growing phase of the hair cycle and enter the resting phase. So, what exactly are the triggers that "send" a hair follicle out of the actively cycling (growing) phase and into the undesired shedding phase? I teach health professionals the easy to remember memory cue "SEND"
There are quite a few causes of a red, itchy and bleeding scalp. Anyone with such a trio best see a dermatologist to guide them.
Conditions such as psoriasis and seborrheic dermatitis are common in the population and must be placed at the top of the list of possibilities. Other causes include folliculitis decalvans and other scarring alopecias, infections, bites, infestations, allergy and irritation.
Pinpoint bleeding in this photo tells me right away that the patient I am examining may be quite itchy. As it turned out, they were!
I often prescribe a topical steroid to help reduce itching.
Recognizing new growth is critically important to understanding hair cycles and how a patient is responding to treatment. New hairs are short and have pointed ends.
Watermelon:
I buy watermelon after watermelon 🍉during the Summertime. Based on "Dr Google", watermelon consumption seems pretty good for hair too👍. But I don't buy it 👎.
"Dr Google" is a phrase that my own patients taught me. The term refers to the vast amount of medical information that can be easily obtained from the internet.
The world loves Dr Google.🏅❤️ I love Dr Google. ❤️ I am frequently looking to see just what Dr Google thinks about countless numbers of topics in hair loss.
Does consuming watermelon help stop hair loss?🍉
Does drinking a lot of water 💦help my hair?
Is waking up early in the morning 🕓good for hair?
Can the odour 👃of a new car 🚗 result in hair loss?
No matter what question you raise, Dr Google has probably written something on it. However, it does not mean that "something" is correct.
Let's return to the subject of watermelons and hair loss 🍉. Those who write about the benefits of watermelon for hair loss claim that watermelon is loaded with the amino acid citrulline which gets converted in the human body to another amino acid called arginine. Arginine is a vasodilator and proponent of its benefits for hair claim this helps increase blood flow to the scalp which in turn is good for helping hair loss.
The claim that watermelon is good for hair loss has no evidence. Vasodilation itself does not help as a treatment for hair loss. Increasing blood flow as a means of treating hair loss is a myth. Massaging the scalp and standing on one's head upside down - and eating watermelon 🍉 does not help treat hair loss.
The myths prevail.
Does watermelon 🍉 help as a treatment for hair loss? I don't buy it. However, I'm still sticking with Dr Google🏅 and I'm still sticking with watermelon. Stay cool this summer 😎⛱
The first Saturday in August marks International Alopecia Day! Alopecia areata is an autoimmune condition affecting 2 % of the world's population. Hair loss can occur anywhere on the body but typically affects the scalp.
Children and adults can both be affected and a high proportion of individuals experience their first episode of hair loss before age 20.
Lichen planopilaris (LPP) is a type of scarring hair loss condition. The cause is unknown although several treatments are possible to try to stop the condition from progressively destroying hair follicles.
Recognizing whether a patient has genetic hair loss or telogen effluvium ... or both .... often requires listening to the patient's story about their hair loss in addition to examining the scalp and looking at the blood test results.
Many women have both.
AGA often shows hair loss in regions rather than all over although it can certainly be all over. AGA is fundamentally characterized by hair follicle "miniaturization." The hair follicles get skinnier - this is not a feature of TE. Telogen effluvium is characterized by diffuse loss and waves of regrowth. Empty tracts where a hair once was found and upright regrowing hairs characterize TE. Patients with TE often have a trigger such as low iron, thyroid problems, nutritional issues, crash diets, stress or medications that lead to the shedding. Shedding in TE is more pronounced than in AGA.
Psoriasis is an inflammatory condition affecting about 3 % of the world. The skin, hair, nails and joints are affected. We are also now learning that individuals may also have increased risks of cardiovascular disease. About 50 % of patients with psoriasis have scalp involvement so psoriasis is a common issue in the hair clinic. For the majority of those with scalp psoriasis, psoriasis does not cause hair loss.
Even though most individuals with scalp psoriasis do not experience hair loss as a direct result of their psoriasis, severe psoriasis can cause shedding (telogen effluvium) and rarely even a scarring type of hair loss. Some individuals with psoriasis have scalp itching - and repeated itching can cause hair breakage and subsequent hair loss.
The photo to the right shows the typical white powdery scale of psoriasis. It is easily mistaken for the scale of seborrheic dermatitis. The scale of seborrheic dermatitis, however, tends to be more yellow and greasy rather than white and powdery.
Pityriasis amiantacea is not a diagnosis. Rather it is a phenomenon that sometimes happens to the skin and hairs during the process of inflammation.
The finding of pityriasis amiantacea is often seen in patients with psoriasis, seborrheic dermatitis and various eczemas.
The photo to the right is a magnified photo of the scalp of a patient with "pityriasis amiantacea" from psoriasis.
Treatment includes identifying the root cause. Treatment such as topical steroids, steroid injections, anti dandruff shampoos, salicylic acid, tar all play a role in treatment.
Thanks to the many requests for my slides for the recent lecture on scarring alopecia, I've uploaded the audio to my presentation. I hope it's helpful and thanks for your interest.
Dutasteride is approved in Korea for the treatment of male pattern balding. It is used "off label" in many other countries. Whereas finasteride (Propecia) inhibits 5 alpha reductase type 2, dutasteride inhibits 5 alpha reductase types 1 and 2.
Finasteride has received press on account of its side effect profile (especially sexual side effects) and possibilities of long lasting, possibly permanent side effects in a low proportion of users.
Dutasteride is known to have a similar array of overall side effects, and given the greater inhibition of 5 alpha reductase that dutasteride has, one might expect a similar if not greater number of side effects. Interestingly, this has not been the case in all studies to date. In fact, most studies support the efficacy and tolerability of dutasteride at 0.5 mg with relatively low incidence of side effects.
New study
A new study published by Choi et al looked at over 700 men ranging in age from 18-41. These men were using dutasteride at 0.5 mg. The frequency of side effects were low. 1.3 % of patients experienced decreased libido, impotence in 1 %, fatigue in 0.7 %, breast enlargement was seen in 0.3 %. Over 79 % of men reported improvement with their hair.
This study was not set up to compare dutasteride to placebo. This was simply an observational study as part of routine "post marketing" surveillance. Overall, the findings are encouraging and expected- pointing to a low risk of adverse events with this dual inhibitor of 5 alpha reductase.
REFERENCE
Choi GS et al. Ann Dermatol. 2016 Aug;28(4):444-5
Authors from the Netherlands recently reported a very interesting case of 25-year-old man was admitted to his local medical center with fever, severe ulceration of the oral and pharyngeal mucosa, and pustules on his skin. These pathergy-like lesions developed after placement of orthodontic braces and laser hair removal therapy.
The patient was born in Iraq but moved to the Netherlands when he was 5 years old. For 4 weeks prior to the hospital admission, the patient experienced high fevers without any clear source of infection. His general practitioner prescribed empiric antibiotic treatment but these did not affect the fever. It was noted that during this period, he had received orthodontic braces for teeth straightening. Within days after placement, painful oral ulcerations occurred. One week prior to the hospital admission, the patient had also undergone laser hair removal on the arms and torso. Within days after the procedure, pustules occurred at the specific sites of laser treatment, but later also at distant sites such as the face.
The patient’s blood tests showed increased erythrocyte sedimentation rate (36 mm/h) and mildly elevated C reactive protein level (42 mg/L). A chest X-ray was normal. A PCR for herpetic viruses on an oral swab was negative. Bacterial culture of the content of a skin pustule was negative.
Van der Ree-Pellikaan Cet al. Oral ulcerations after placement of orthodontic braces and skin pustules after laser hair removal: novel inducers of pathergy reactions in new-onset Behçet's disease. BMJ Case Rep. 2016 Mar 7;2016:bcr2014209208. doi: 10.1136/bcr-2014-209208.
Coenzyme Q 10 is an interesting supplement with anti inflammatory and anti oxidant activity. I've been investigating whether it has any benefits in hair loss ... but the evidence is certainly not in yet.
Coenzyme Q 10 may have some benefits - under certain conditions. The best studies conditions include heart failure, various neurological problems (especially a condition known as multisystem atrophy) and in blood sugar control. It can lower inflammatory markers in the blood, including C reactive protein (CRP). Coenzyme Q 10 may have a variety of helpful effects on obesity too. Patients on cholesterol reducing medications (i.e. statins) may be at increased risk for coQ10 deficiency so that warrants further study.
In the autoimmune condition rheumatoid arthritis, a randomized study showed 100 mg per day of coQ10 reduced several inflammatory markers in the blood (such as tutor necrosis factor alpha). It's still too soon for those with various types of hair loss to start taking coQ10. But I am reminded of a 1995 study published in the Lancet that showed an improvement in hair loss in 2 patients who used coQ10 to treat hair loss caused by a blood thinner known as warfarin. The reference to this study is below.
Oxidative stress occurs from a variety of sources including normal cellular functions in the body but also from irritants, ultraviolet radiation, smoking, and microbes on the skin surface. Even bad dandruff and seborrheic dermatitis generate significant oxidative stress. The abnormal scalp lipids in some scarring alopecias are a particular source of potential oxidative stress and a key research interest of mine.
Overall more research is needed to better understand the uses and benefits of coenzyme Q 10.
Reference
Nagao et al. Treatment of warfarin induced hair loss with ubidecarenone. Lancet. 1995; 21: 346:1104
I've given several research updates on the autoimmune condition alopecia areata. Great progress has been made in the last few years. For those who asked me for the lecture audio, I'm pleased to include it here.
Platelet rich plasma or "PRP" continues to be studied as to its precise role in the treatment algorithms for many types of hair loss.
The PRP procedure involves taking 60-120 mL of a patient's blood, spinning it down in a dedicated centrifuge machine to obtain PRP and then injecting the PRP back into the patient's scalp. The procedure takes about 1 hour.
All PRP is not equal
One common misconception is that all PRP is equal. The reality is that different machines produce different quality of PRP. Even the settings I type into the actual PRP machine affect the characteristics of the PRP I am able to produce for the patient.
A look at the "hematocrit"
A great example of this concept of differences in PRP is the "hematocrit". Hematocrit refers to the amount of red blood cells that are allowed to enter the final PRP.
If I set the PRP machine at a hematocrit setting of 7 % (high hematocrit), I produce a more red colored PRP (like shown on the left). This contains more platelets per liter and also contains more neutrophils (inflammatory cells). It also contains higher concentrations of growth factors like TGF beta and platelet derived growth factor (PDGF).
If I set the machine at a hematocrit of 2 % (low hematocrit), we produce a more yellow colored PRP (like shown on the right). This contains fewer platelets per mL and also contains fewer inflammatory cells, lower concentrations of growth factors like TGF beta and platelet derived growth factor (PDGF).
I generally like a higher hematocrit setting (7%) for treating genetic hair loss and a lower hematocrit setting (2%) for treating alopecia areata. Studies are ongoing to determine which is best and if these settings really make a difference.
REFERENCE
Sandman et al. Growth factor and catabolic cytokine concentrations are influenced by the cellular composition of platelet rich plasma. American Journal of Sports Medicine 2011.
By age 50 about 50 % of the population has a good amount of grey hair. But what about those who develop grey hair in the 20s and 30s?
The term "premature greying" refers to greying of hair that happens before the age of 20 in Caucasians, before 25 in Asian individuals and before age 30 in black men and women. From time to time, I evaluate patients in my hair loss clinic who start greying in the teens or twenties.
Many, many factors influence hair greying - especially genetics. Some individuals simply have the genetic predisposition to develop grey hair. Other causes also need to be considered including thyroid abnormalities, pituitary problems, and deficiency of vitamin B 12.
Smoking too can cause early greying of hair. In fact, 20 years ago, a study in the British Medical Journal showed that smokers are about two to four times more likely to have grey hair. A recent study supports a possible link between low iron, calcium and vitamin D but that needs to be further investigated.
Autoimmune conditions like alopecia areata, vitiligo as well as premature aging syndromes (like a condition called Werner's) can cause affected individuals to develop early greying.
Overall, early greying of hair is fairly common and not usually associated with any underlying problem. That said, a full workup is needed for greying that fits the definition of premature greying.
I'm often asked by patients if they should just give minoxidil a 'try'. Give it a 'go'. I respond that minoxidil can certainly be helpful but minoxidil is certainly not for everyone.
Minoxidil is FDA approved for men and women 18-65 with a type of hair loss known as androgenetic hair loss. If an individual has some other hair loss condition besides androgenetic hair loss (there are actually dozens of other kinds) and if the individual is over 65, they should check with their physician if minoxidil is safe or not.
I don't prescribe minoxidil if:
1. the patient has heart problems, especially ischemic type heart disease or certain types of heart failure
2. the patient has heart rhythm issues (like atrial fibrillation)
3. the patient has certain internal conditions (like pheochromocytoma)
4. the individual has allergies to any of the components of minoxidil, such as propylene glycol in minoxidil solution or allergy to the minoxidil itself
Minoxidil has a good safety profile and that has lead to its availability as an over the counter product. But minoxidil is not for everyone. An 82 year old patient with heart failure and two previous heart attacks is not a candidate for minoxidil. A patient with hair loss due to dissecting cellulitis of the scalp (a different condition than genetic hair loss), will likely find little to no use from minoxidil application. Minoxidil is not for everyone.
Scalp micro pigmentation or "SMP" is a method of camouflaging hair loss. Dots are tattooed to mimic the appearance of hairs cut in cross section. In this photo, small black dots can be seen in between the hairs. For this particular patient, these dots camouflage scars from a previous hair transplant
Lichen planopilaris is a type of scarring hair loss (sometimes called cicatricial alopecia) which has the potential to lead to permanent hair loss. Patients receiving treatment have a scalp appearance that looks different than patients not yet on treatment.
The classic features of LPP are difficult to notice in this photo from a patient currently on treatment. Features are much easier to see if a patient has not yet started treatment.
What features are still present? Well, there are many single isolated hairs (rather than hairs in groups of 2 and 3). The hair follicle openings are difficult to make out with certainty which is often a clue to the presence of scarring. In addition, there is a degree of redness around hair follicles.
