Here is an answer that I posted to a new question on realself.com
Here is an answer I posted to a new question on realself.com
I posted an answer to a new question on realself.com
I posted an answer to a new question on realself.com
I am often asked why some patients with TE shed hairs of many different lengths - EVEN WHEN THE "TRIGGER" HAS RESOLVED.
I often explain this TE situation with an analogy. The story is fictional and meant to explain important points. (No disrespect should be interpreted to anyone who experiences such devastation in real life).
Imagine a factory that produces a wooden picnic tables. The factory normally produce 100 tables per day. But now the city where the factory is located has been hit by a storm which causes massive flooding and damage.
Fortunately, the storm ends quickly and the city mayor officially declares the storm "over." People are relieved and go about fixing things up.
The next day no picnic tables are made. People don't show up to work because they are busy fixing things at home and around the neighbourhood.
After a few days, a few people go back to work and 9 picnic tables get made - still under the normal production level of 100.
And then a massive shipment of trees comes in because of all the trees that have fallen down. The company foreman wants these trees used up quickly and offers 8 times the wage for anyone who comes into work. Now many people show up to work (even those who weren't scheduled). 120 picnic tables are made that day.
But then a pipe bursts as the flooding had damaged an area in the factory that was not fully noticed. People are ready to work but only 12 picnic tables can be made the next day.
The pipe is fixed and people go back to work. 98 picnic tables are made that particular day and the next day an all time record of 135 tables is achieved.
But then fighting breaks out. There are just too many people for the factory. Not enough washrooms, no room in the lunchrooms. The refrigerator is overflowing with workers trying to store their lunch.
Picnic table production drops to 18.
The foreman builds more washrooms and buys more refrigerators. People are happy again and picnic table production climbs to 89.
And then there is a realization the illness has struck many in the city on account of the previous flooding conditions. Some fall ill. A limited number show up to work and production falls to 2 picnic tables per day.
Eventually, the illness resolves. Everyone is healthy. The factory is ready to go. 100 picnic tables are produced everyday.
Now back to TE. For some patients with TE, the "factory" gets back up and running quickly with full efficiency. For these patients, shedding stops quickly and regrowth and shedding patterns are fairly normal after 3-5 months.
For other individuals with TE, there are a few glitches in the programming - even though the main "trigger" has long gone. These glitches can last a few months or even a few years. Some hairs that are produces get shed too early because the hair cycle in that follicle is not fully functioning normally. We are not so lucky (yet) to know the reason for these glitches. (It is not so simple as a broken pipe or an overflowing refrigerator).
Most will find that the hair factory is fully operational by 12 months.
Alopecia areata (AA) is an autoimmune condition affecting 2 % of the world.
The condition is well known to be challenging to predict what will happen in the future. In fact, AA tends to be one of the most unpredictable hair loss conditions. It can grow and fall at any time.
Even though AA is said to be unpredictable - it is not completely unpredictable. We have come to understand over the years certain scalp "dermatoscopic" features that suggest a patient's condition is active.
This includes:
These features all suggest ongoing inflammation in the scalp and a high likelihood of further hair loss.
SMP continues to trend as a popular method to camouflage hair loss.
SMP involves placing pigment in the skin in a manner to mimic the appearance of a hair cut in cross section.
There is an art to SMP. The SMP specialist needs to properly choose the color of the pigment to match the patient's original hair color- otherwise it looks strange. The pigments need to be placed in the right depth- if placed too deep they appear bluish color and if placed too high in the skin they simply fade quickly. The size of the dot needs to also be accurate.
Overall, SMP is extremely helpful. It has helped many of my patients camouflage hair loss. Some of these patients have diagnosis including genetic hair loss, alopecia areata, scars, donor area scars from hair transplant surgery and more.
LPP is a type of scarring alopecia where hair loss is permanent. This makes it all the more important to secure the correct diagnosis with minimal delay.
Sometimes that is easier said than done. This picture shows an image of a female patient's scalp. At first look one could easily conclude this female patient has genetic hair loss. However, looking closer it reveals subtle scale around hair follicles (called perifollicular scale, PFS. Most of the hairs that are remaining (and shown in the photo) are the same diameter. There is not much in the way of miniaturization that is expected in pure androgenetic alopecia.
Treatments for LPP include: topical steroids, steroid injections, calcineurin inhibitors, oral pills including prednisone, hydroxychloroquine, doxycycline, methotrexate and others.
One of the main features of a scarring alopecia is the disappearance of the follicular openings or "pores." Pseudopelade is a scarring alopecia and can look very similar to alopecia areata. But, when viewed up close using a dermatoscope one can clearly see that the follicular openings start scarring over and disappearing in a scarring alopecia.
The clinical hallmark of a scarring alopecia is the loss of the follicular openings or pore markings.
The decision on whether or not to do a scalp biopsy is a big decision. A scalp biopsy is a short procedure whereby a cylindrical core of tissue is taken from the scalp. The size of the core is typically 4 mm in diameter. When the core is removed from the scalp, the area left behind is stitched up with sutures to assist in healing.
It does not matter how careful the biopsy or how beautiful the stitching the result is a small scar. Because scars are permanent, the patient will have a small scar in the area for life.
Sometimes a biopsy is essential. Differentiating complex diagnoses from one another sometimes requires a biopsy. Some forms of genetic hair loss are challenging to distinguish from telogen effluvium (especially early stages) and a biopsy may be helpful. Some forms of scarring alopecia are similar in some cases (discoid lupus vs lichen planopilaris). Some hair loss conditions need a biopsy because there are no other choices (for example ruling out breast cancer metastases to the scalp that perfectly mimic a single patch of alopecia areata). Overall, the use of a handheld dermatoscope in the clinic has greatly reduced the need for scalp biopsies. By carefully examining the scalp with a dermatoscope, features can he seen that can't be seen with the naked eye. Overall, I perform scalp biopsies on a very small minority of patients.
Unless it is absolutely critical to achieving the diagnosis, a scalp biopsy is not necessary.
A lot hair loss conditions look alike. This makes the diagnosis very challenging. If every type of hair loss was treated the same way, with the same medications, it really wouldn't matter what the diagnosis is. But different hair loss conditions are treated differently.
Pseudopelade of Brocq is a scarring hair loss condition that causes permanent hair loss. It causes hair loss is circular patches and often shows no signs of inflammation. It can be a great mimicker of alopecia areata, another hair loss condition causing hair loss in patches.
Treatments for pseudopelade are designed to help stop further hair loss. Regrowth is not possible. In contrast, treatments for alopecia areata are administered with the hope of regrowing hair.
Treaments include: Topical steroids, steroid injections, calcineurin inhibitors, methotrexate, cyclosporine, hydroxychloroquine.
Yellow dots and short vellus hairs are the most commonly seen dermatoscopic features of alopecia areata. Both are related with severity of disease being more common in advanced alopecia areata.
Yellow dots are hair follicles that are plugged with keratin. Short vellus hairs in alopecia areata represent hairs that are trying to regrow.
There are four things that can happen when a patient receives treatment for Alopecia Areata:
1) the hair regrows fully (known as a "complete response")
2) the hair regrows partially (known as a "partial response")
3) treatment does not lead to any change. This can either be because the treatment does not work or because the treatment works a little but the rate of loss matches it.
4) hair loss gets worse. Usually this is because the patient's hair loss is active rather than the treatment itself causing hair loss. A small proportion of patients receiving steroid injections find their hair loss worsens with steroid injections. In most of these cases, the patient's alopecia is so active that the steroid injections could not overcome or stop the hair loss. The treatment itself usually does not make it worse when proper concentrations and doses are used. Of course there are exceptions.
This photos shows a partial response. Hairs are growing and many new "pointy" hairs can be seen. However, two tapered hairs are seen indicating inflammation beneath the skin. These "tapered" hairs will most likely fall out within days. The "pointy" ones likely will likely keep growing. This patient required a more aggressive treatment.
Finasteride is FDA approved for the treatment of male pattern hair loss at a dose of 1 mg and FDA approved for the treatment of male prostate enlargement (a condition called benign prostatic hypertrophy) at a dose of 5 mg.
The drug works by inhibiting an enzyme known as "5 alpha reductase type 2." This enzyme helps covert testosterone (T) to dihydrotestosterone (DHT). By blocking this pathway, DHT levels are lowered in the scalp by about 60 % and bloodstream by 70 %. Topical finasteride is also be an option to treat male pattern hair loss but good studies have yet to be done and I am not yet convinced either way.
Chronic telogen effluvium or "CTE" is one of the simplest yet most complex conditions.
Patients with CTE are usually 35-70 years old with sudden onset of hair shedding. 300, 400 or 500 hairs are lost on some days yet 40, 50 or 60 are lost on other days. A trigger most often can't be identified. Blood tests are normal. Hair density looks high to a casual observer. Individuals with CTE often had incredibly high density - so high at one time that most patients joke that they were initially glad when the shedding first happened because their hair was just much too thick. Many affected patients recall a time long ago when their hairdresser would sigh at every appointment because they knew the appointment would take soo long in account of all the hair volume and density the patient once had.
This is CTE.
CTE is not shedding that happens with low iron. CTE is not shedding after crash diets or massive stress. This is a completely different (although similarly sounding condition) called acute telogen effluvium). Great confusion exists between CTE and acute TE.
The exact cause of CTE is not known which makes treatment challenging. Options such as vitamins, biotin, hair and nail supplements, laser, PRP, anti-androgens can be tried.
The hair science world has devoted little attention to this condition and more research is needed. More research is also needed to create drugs that block a hair follicle's ability to leave anagen (the growth phase). Although this might not solve the underlying reason for this condition, such drugs would be useful for an array of conditions including CTE, acute TE, AGA, and alopecia areata.
Alopecia areata affects 1.7 % of the world's population. About 1/2 of patients with alopecia areata develop their first patch of hair loss prior to age 18. Options include treatments that block or alter the inflammatory process.
1. topical steroids
2. steroid injections (usually for children over 10)
3. Topical minoxidil
4. Anthralin
5. diphencyprone
6. Methotrexate
7. Prednisone
Other less commonly used options include oral tofacitinib (age 12 and over) and topical tofacitinib,
Exclamation mark hairs are fragile hairs commonly seen in patients with alopecia areata. They are short hairs (3-4 mm hairs) that break, snap and fall out easily. This dermatoscopic image shows a typical "frayed" exclamation mark hair.
Tapered hairs are seen in "active" alopecia areata. Unlike exclamation mark hairs, tapered hairs are long hairs rather than short hairs.
Tapered hairs are caused by massive inflammation in the bottom of the hair follicle (called the bulb). Many tapered hairs will break off and become exclamation mark hairs. Some tapered hairs will fall out of the pore and be shed.
Exclamation mark hairs are 3-4 mm hairs that are wide at the top and thin at the bottom. They are seen in individuals who have recently developed a patch of alopecia areata.
These hairs are caused by the inflammation around the hair bulb that impairs the ability of the hair matrix to make a proper hair.
Long standing alopecia areata does not have much inflammation and correspondingly exclamation mark hairs are not seen.
"Exclamation mark" hairs are 3-4 mm hair usually seen at the edges of a bald patch in individuals with alopecia areata.
Exclamation mark hairs signify the patient's disease is active and further hair loss is likely to occur without additional treatment.
