Topical Estrogen for Androgenetic Alopecia:

Topical Estrogen for Androgenetic Alopecia:

Topical estrogens were used many years ago for the treatment of androgenetic alopecia as well as other hair loss problems. Their use dimished when other medications, such as minoxidil, became available.

In 2004, researchers from Greece studied the benefit of estrogens in 75 post menopausal women with androgenetic alopecia

25 patients applied the medication for 12 weeks (15 drops every evening for 4 weeks and then every other night for 8 weeks),

25 patients applied the medication for 24 weeks (15 drops every evening for 4 weeks and then every other night for 8 weeks),

25 applied placebo medication for 12 weeks.

What were the results ?

Side effects included  mild itchiness, redness and scaling in the scalp. 2 women receiving the 24 week course developed uterine bleeding about 4 and 5 months into the study. Overall, about 60 % of patients receiving the estrogen had an increase in the number of growing hairs (anagen hairs) and a decrease in the number of telogen hairs (resting hairs). “Before and after” data or assessments of patients views on their treatment were not included in this particular study.

Comment:

This 2004 study is an interesting research paper.  It reminds us of the well known fact that estradiol has important benefits  for hair. Estrogen therapy is too often forgotten about in the treatment algorithms of hair specialists. More studies in how best to administer topical estrogen are needed – especially in combination with treatments such as minoxidil, prostaglandin analogues (like Latisse) and the laser comb.

REFERENCE

Georgala S et al. Topical estrogen therapy for androgenetic alopecia in menopausal females. Dermatology 2004; 208: 178-179

 

Hair Textural Changes

Hair Texture Changes

Many changes in the hair and scalp may occur as we get older. Some women notice that hair becomes thinner in the front while remaining curlier and thicker in the back. Hair tends to grow slower. Hair greying becomes particularly common.

While hair can sometimes becomes drier, coarser and more kinky as we age, it’s important to have a thorough medical examination by a dermatologist with these particular changes you describe.

Several medical conditions (such as low thyroid hormone levels) and a handful of scalp diseases (including a group of hair conditions known as the scarring alopecia’s) may also lead to coarser and kinkier hair. 

In the photo on the left, you'll see a large area of hair loss in a patient with a hair loss condition known as a "scarring alopecia."  This patient is essentially developing scar tissue in the scalp that is destroying much of their hair.  As the disease progresses (note how it is moving outward in the direction of the little arrows), more and more hair is destroyed.  As this happens, some hairs start twisting and bending - it is during this process that the patient will begin to note textural changes in their hair.  The large yellow arrow shows one of these twisting hairs. There are many causes of hair textural changes but scarring alopecia is one of them. 

Previous blogs for Reference

Scarring Alopecia and the Concept of the "Trichologic Emergency"

Lab Tests for Assessing Thyroid Disease

 

Hair Loss in Black Women: CCCA

Hair Loss in Black Women: CCCA

Central Centrifugal Ccatricial Alopecia (or 'CCCA' for short) is a common cause of hair loss in black women. Some estimates suggest that up to 30% of black women have CCCA. Unfortunately, the condition is very much underrecognized and underdiagnosed. Too often women with CCCA are misdiagnosed as having genetic hair loss - both conditions lead to hair loss in the central scalp.

CCCA causes permanent hair loss in the central scalp.  Individuals affected by the condition sometimes have scalp itching, burning or pain but very often have no symptoms.  This make it difficult to catch the diagnosis in early stages.  Hair loss gets worse over time. The cause is not known at present although hair styling practices and the use of of chemicals and relaxers continue to be explored as causes.

How can we improve our ability to diagnose CCCA?

CCCA is underrecognized in the medical community and underdiagnosed.  How can we train more physicians to recognize this common condition? Certainly training others  to recognize this condition is the first step. There is a suprisingly easy rule I teach doctors who work with me in my clinics:

Any black women with hair loss in the middle of the scalp needs evaluation (& possibly scalp biopsy) to rule out the diagnosis of CCCA.

Hair loss from CCCA is permanent. In most cases regrowth is not possible. Treatments help stop further hair loss but are not always 100 % effective. Treatment for CCCA includes topical steroid medications and steroid injections. Oral medications including tetracycline based antiinflammatory drugs can also be used. Hair transplantation can be successfully used to restore hair density once the condition becomes quiet.

More Benefits of Checking Iron Levels in Women with Hair Loss

Checking Iron Levels in Women with Hair Loss

As many of my patients know, iron metabolism is one of my favourite subjects. It also forms one of the components of the hair loss research that I do. 

I generally recommend that all women with concerns about hair loss have their iron levels checked using the simple blood tests called ferritin. Other blood tests may also be ordered for women with hair loss, such as thyroid tests and a complete blood test to measure the hemoglobin level.

Although it is somewhat contraversial among hair experts around the world, the iron level I like my patients to aim for is a ferritin level above 40-50 ug/L.  If the blood test shows less than this, then I recommend supplementation with iron pills.

New research outlines additional benefits of checking iron levels in women

In a recently published study, Swiss researchers studied 198 premenopausal women who had ferritin levels less than 50 ug/L and symptoms of fatigue. A proportion of women in the study received ferrous sulphate pills and another proprotion of women received placebo pills.

 

What were the results of the study?

At the end of the 12 week study, women who received iron noted a significant improvement in their overall level of fatigue compared to women receiving the placebo pills.  The ferritin level in women recieiving the iron pills increased by approximately 12 ug/L over the 12 weeks of the study.

 

Comment

Many premenopausal women have low iron levels. This study reminds us that there are many improtant benefits of iron, including helping improve the overall feeling of fatigue (if levels are low). Although I routinely follow iron levels in  my patients, this study reminds us that asking about improvement in fatigue levels may also be an important parameter to assess in making a decision about continuing iron supplements for the longer term.


Reference

Vaucher P et al. Effect of iron supplementation on fatigue in nonanemic 
menstruating women with low ferritin: A randomized controlled trial. CMAJ 
2012 Aug 7; 184:1247. (Click link for article)

 

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

Hair loss and lupus:

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

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

What is lupus?

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

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

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

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

HAIR CLINIC SCREENING QUESTIONS FOR LUPUS:

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

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


Should I get a blood test for lupus?

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

Group 1 test for lupus

ANA (anti- nuclear antibodies)

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

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

1. CBC (complete blood count)

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

2. Urinalysis

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

3. Creatinine

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

4. ESR ( erythrocyte sedimentation rate)

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

5. C3 and C4 (complelment levels)

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

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

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

7. Antiphosphopilid antibodies

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

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

 

TIPS FOR GREAT SUMMER HAIR

Recently, Monica Matys of Sunnybrook Medical Centre interviewed me about tips for great summer hair. A short 1 minute segment of the interview can be found in the new "Sunnybrook Says" website.

Certainly, I'm seeing lots of patients with sun damaged hair. I can spot sun damaged hair because it's lighter in color, more brittle, and lacks shine. 

When I speak of sun damaged hair, I'm really referring to the damage that occurs to the outermost part of the hair follicle called the "cuticle". Lots of things can damage the cuticle in the summer months, including chlorine, salt water, sand, hair dryers and over processing of the hair with chemicals

Here's a few tips I recommend to keep hair looking great in the summer.

1. Limit the amount of sun on the scalp by wearing a hat or scarf. This can make a big difference by the time the end of the summer rolls around.

2. Don't worry about how often you shampoo in the summer but focus on conditioning regularly. I ask some of my patients to condition every day. Conditioners protect the cuticle!

3. If an individual has a lot of damaged hair, I may ask them to use a deep conditioner once weekly.

4. Limit the amount of heat on the scalp. If a hair blower is going to be used to style the hair, then towel dry or air dry the hair about 80 % before using the hair blower to style the hair.

5. Limit the dyeing of the hair to every 8 weeks in the summer. There is good scientific evidence that chemicals make the hair even more susceptible to being damaged by the sun.

6. Get a trim often in the summer. There is only one way to deal with split ends from sun damage and that is to cut them off. Removing split ends can immediately improve the look of the hair.

These simple tips can make a big difference in what the hair looks like by the time September or October rolls around.

Do physicians understand how much hair loss affects their patients?

Do physicians understand emotions of hair loss?

Some patients are extremely distressed by hair loss, even if the amount of hair loss is minimal.  Are doctors very good at picking up how a patient's hair loss affects their quality of life?

Researchers from Chicago examined set out to determine if dermatologists can predict how much their patients' quality of life is affected by their hair loss. The researchers examined 104 women with three hair loss disorders (androgenetic alopecia, telogen effluvium and alopecia areata).

Dermatologists downplay hair loss severity

The researchers found women rated their hair loss as more severe than their dermatologists rated the hair loss. Moreover, the degree of a patient's hair loss did not correlate with how much patient's quality of life was affected. For example, some with minor amounts of hair loss were quite distressed by their hair loss whereas some patients with more extensive loss were minimally affected.  Interestingly, the amount of hair loss a patient perceived they had experienced did correlate with how much it impacted their quality of life.

Implications of hair loss study

This study has important implications for physicians who see patients with hair loss. If physicians want to understand how a patient is affected by their hair loss, they need to ask patients just how much hair loss they perceive to have occurred.  I generally try to get a sense of this by asking patients "how much hair loss do you think you've had - ....a little bit? ... a moderate amount? ... or a lot?"



Reid EE et al.  Clinical severity does not reliably predict quality of life in women with alopecia areata, telogen effluvium and androgenetic alopecia. J Am Acad Dermatol 2012; 66:e97-102

 

Preparing the Mind to Recognize the Many Forms of Hair Loss

In addition to being a hair transplant specialist and specialist in hair disorders, I do research in hair loss and devote time to teaching and lecturing medical students, interns, residents and physicians about hair loss. In fact, part of my time away from the office is spent teaching other doctors about hair loss and about hair transplant surgery. I’m lucky that my profession is not only my job but also a real joy.

I enjoy teaching others about the approximately 100 reasons for humans to have hair loss.

Androgentic alopecia, alopecia areata, telogen effluvium, lichen planopilaris, folliculitis decalvans, dissecting cellulitis, pseudopelade, morphea, ectodermal dysplasia. The list goes on and on.

Today, I gave a lecture about hair loss to medical students at the University of Toronto.  Hair loss is rarely covered in medical schools so it's a real privilege to have the chance to speak to a room full of bright students.  What I hope for after each lecture I give is that the learner goes home with an open mind to consider the many different kinds of hair loss that exist.

Folliculitis decalvans affecting crown If someday they see a young 34 year old man with a bald crown that itches them like crazy will they instinctively think this is another case of “male balding” or is that doctor now open to consider that this man may instead have an unusual scarring hair loss condition called “folliculitis decalvans” ?

Alopecia areata diffusa mimicking genetic hair lossor....When the young doctor finds themselves evaluating a 25 year old woman with hair loss in the centre of her scalp, low vitamin B12 blood levels and dozens of little dots in her nails will that doctor instinctively think this is an young woman with early “female balding” or will the doctor remember the lecture and consider that this could be an unusual form of alopecia areata (called “alopecia areata diffusa”)?

The French philosopher and Nobel Prize winner Henri Bergson once said that the human mind sees only what it’s prepared to understand. I consider it a great privilege to teach about hair loss and help others open their minds to the many different types of hair loss that they will likely encounter in their patients in the years to come.

Hair Loss Drugs and Breastfeeding: Which Medications are Safe?

The following situations are a commonly encountered in a busy hair loss practice:

A 32 year old woman with genetic hair loss (androgenetic alopecia) was using topical minoxidil solution before her pregnancy. She stopped it during her pregnancy and now is wondering if she should start it up again after her delivery. She is breastfeeding. Is it safe to use this medication?

A 28 year old woman with genetic hair loss (androgenetic alopecia) was using the oral drug Spironolactone  before her pregnancy. She stopped it during her pregnancy and now is wondering if she should start it up again after her delivery. She is breastfeeding. Is it safe to use this medication?

 A 34 year old woman with discoid lupus of the scalp (a scarring alopecia) was using the oral drug Hydroxychloroquine before her pregnancy. She stopped it during her pregnancy and now is wondering if she should start it up again after her delivery. She is breastfeeding. Is it safe to use this medication?

 A 27 year old woman with folliculitis decalvans of the scalp (a scarring alopecia) was using the oral drug clindamycin along with the drug rifampin before her pregnancy. She stopped it during her pregnancy and now is wondering if she should start it up again after her delivery. She is breastfeeding. Is it safe to use this medication?

WHICH HAIR LOSS MEDICATIONS ARE SAFE TO USE WHILE BREASTFEEDING?

Although I often discontinue many hair loss medications during pregnancy, the question frequently arises as to whether some medications can be restarted while moms are breastfeeding.  Breastfeeding has many benefits for babies.  For some drugs, the answer is yes. For others, the answer is no.

In 2001, the American Academy of Pediatrics published a helpful guide as to the safety of medications during breastfeeding. It's important to always check with your physician before starting any medication during breastfeeding. However, the following medications (used in hair loss) are felt to be safe for women who are breastfeeding.  For a full list of medications which are safe during breastfeeding, click here.

List of Hair Loss Drugs Regarded as Safe in Breastfeeding

B12

Cefazolin

Chloroquine

Ciprofloxacin

Clindamycin

Hydroxychloroquine

Folic acid

Ketoconazole

Topical Minoxidil

Prednisone

Rifampin

Trimethoprim/sulfamethoxazole

Therefore, the four women I mentioned above were able to safely use these medications while breastfeeding.  However, women considering using any medication while breastfeeding must check with their health care provider.

Am I getting new hair growth or is it breaking off?

Whenever I examine the scalp, I methodically check for a number of different things. Essentially I have a "checklist" in my mind and all components need to be evaluated before I feel I have properly examined the scalp.

One essential part of the scalp examination is evaluating if patients have new growth - and if so - how much. I like to get a sense of how much hair the patient has grown in the last one month, the last three months and the last six months. Often when I remark to patients that they are experiencing a lot of new growth, I hear a reply such as

How do you know it's new growth?

How do you know my hair is not just breaking off?

The answer is straight forward. Newly growing hairs have 'pointy' ends whereas hairs that have broken off have 'blunt' ends. The photo on the right illustrates these differences. The yellow arrow highlights a newly growing hair with a pointy end and the green arrow identifies a broken hair with a blunt end.  The presence of broken hairs can be due to many causes, including excessive hair damage (heat damage, chemical processing, use of straightners).

Examining for newly growing and broken hairs is an important part of the scalp examination and should be done each time a thorough scalp exam is done.

What are the Causes of Hair Shedding?

It's normal to shed between 50-100 hairs per day. When more than 100 are lost, it may be abnormal. Abnormal or excessive hair shedding is known by the medical term "telogen effluvium."

There are many reasons to have hair shedding.  These include physiological stresses on the body (like having a surgery), thyroid problems, crash diets, low iron levels and certain medications. These can all cause hair shedding.

The following video on hair shedding was prepared by Monica Matys of Sunnybrook Hospital in conjunction with the Sunnybrook Media department. I hope you will find it educational and informative.

Bimatoprost Solution for Eyelash Loss in Alopecia Areata

Alopecia areata is an autoimmune disease which causes hair loss. The scalp hair is most commonly affected, but any hair on the body can be affected. 

Loss of eyelashes may occur in individuals with alopecia areata, especially those with alopecia universalis.   Treatment of eyelash hair loss is challenging because medications that are used for alopecia areata on the scalp can’t always be safely used around the eyes.

Bimatoprost is a topical liquid medication which is used to stimulate eyelash growth. It is commonly sold  under the trade name Latisse ® (bimatoprost 0.03 % solution) and requires a prescription.  For the past few years, many women in North America have been using bimatoprost to grow longer lashes.  The medication was originally designed to treat glaucoma, which is an eye disease that gives increased pressures in the eye.  When bimatoprost solution is prescribed by eye doctors to treat glaucoma, a prescription is given for Lumigan® rather than Latisse®. However, both medications contain the ingredient bimatoprost.

What was known in the past about bimatoprost?

In addition to stimulating eyelash growth in individuals who don’t have alopecia areata, evidence keeps accumulating that bimatoprost may also help some individuals with alopecia areata. Several small studies in the past few years showed that bimatoprost solution could help stimulate some degree of eyelash growth in patients with alopecia areata who still have most of the eyelashes.  However, it was not clear how effective it is in those with alopecia universalis when all the eyelashes were missing. A very small study in 2009 suggested that bimatoprost probably wouldn’t work well if all the eyelashes were missing.

Does bimatoprost topical solution help individuals with alopecia universalis?

Researchers from Spain set out to conduct a larger study to determine if bimatoprost solution is helpful to patients with alopecia universalis. 41 individuals (16 women and 25 men) applied the solution to the eyelids once daily for one year.  37 individuals ended up finishing the full one year study.

Here were the results of the study:

Complete growth of eyelashes was seen in about 24 % of patents.

Moderate growth in 19 %.

Only slight growth in 27 %.

No benefit in about 30 %.

It took 4-8 months for eyelash growth to be seen.

Conclusions & Perspective

All in all, this study is one of the largest studies to date examining the use of bimatoprost in the treatment of eyelash loss.  About 40 % of individuals with alopecia universalis would be expected to have improvement with use of bimatoprost solution.  Side effects need to be carefully discussed with the prescribing physician as eye irritation, pigmentation changes around the eyes, and other changes can rarely occur.

Reference

Research Study:  Vila TO, Camacho Martinez FM. Bimatoprost in the treatment of eyelash universalis alopecia areata.  Int J Trichol 2010; 2: 86-88.

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

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

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

Is there a link between balding and heart disease?

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

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

Why is this information important?

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

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

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

Happy Heart Month!

References

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

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

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

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

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

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

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

Hair Lessons from Rapunzel

We all know the story of Rapunzel, the 1812 Grimms Brother fairy tale of the beautiful young woman trapped in a tower. Using her long hair, she pulls the witch up into the tower whenever the witch calls out:

"Rapunzel, Rapunzel let down your hair so I can climb the golden stair"

A few weeks ago, I found myself writing about Rapunzel's hair, an unusual event in my day to day activities.  But the story of Rapunzel has a few important lessons for anyone interested in learning more about the magic of hair.

1. Hair is remarkably strong. The Grimms brothers were correct in creating this fictional character who could help pull up another human being with her own hair.  Our hair is incredibly strong. In fact, a single hair fiber has about the same tensile strength as a copper wire of the same caliber. If a hair is stretched very slowly it will support about 70 grams. Of course, if a hair is tugged quickly it will break. Hair is so strong that Rapunzel could have supported 50 people climbing up her hair - at once!

2. Blondes have more hair. Rapunzel had blond hair.  Although most people don't know it, blondes have more hair than those with brown hair. Those with red hair have the least.  The more hair you have the more weight you can support, so it's no wonder Rapunzel was created a blonde. 

3. Most people can not grow hair as long as Rapunzel. The maximum length our hair will grow is determined by the length of the growing phase (also called the anagen phase). For most humans, the anagen phase of scalp hair varies from 2 to 6 years. Because hair grows about 15cm per year, most people can only grown hair down to their mid back and rarely to their waist. It is only a rare person who is able to grow hair down to their feet (or beyond). At my last check, the world record for the longest hair belongs to Xie Quiping in China. Her hair length was once measured at 6.627 m (18 ft 5.54 inches). It is not true that Xie's hair grows fast rather her anagen growth phase is very, very long.

Improving Eyebrow Growth: Does Bimatoprost (LATISSE®) Help?

Loss of eyebrows is common. A previous article reviewed a range of treatment strategies for eyebrow loss. These include topical medicines, like minoxidil and bimatoprost, as well as hair transplantation.

Bimatoprost is an interesting medication.  It is used for the treatment of glaucoma, an eye disease which leads to elevated eye pressures. Recently, it has found a new use – in the treatment of hair loss. The product is available by prescription under the name LUMIGAN® (used to treat glaucoma)  and LATISSE® (used to stimulate eyelash growth).  Both LUMIGAN® and LATISSE® contain the ingredient bimatoprost.

Chemically, bimatoprost is classified as prostaglandin analogue. Bimatoprost binds to prostaglandin receptors in the hair follicle and stimulates hair growth.  Several hair specialists including myself, have occasionally used this medication for patients with eyebrow loss. This is known as an “off-label” use as the drug is not formally approved for this use. Bimatoprost is formally approved for eyelash regrowth.

Doctors from Miami recently published an interesting report of two patients who achieved an improvement in their eyebrow density using bimatoprost solution.

Elias MJ et al. Bimatoprost ophthalmic solution 0.03 % for eyebrow growth. Dermatol Surg 2011; 37: 1057-59

Both patients used one 2.5 mL container each month and applied the medication nightly to each eyebrow. One patient, a 52 year old man had results after 16 weeks and the second patient, a 46 year old woman had results after 12 weeks. These two patients did not experience any side effects.

This is an exciting report and calls for more studies to be done to evaluate the use of bimatoprost (LATISSE®) in the treatment of eyebrow loss.

Reference

Elias MJ et al. Bimatoprost ophthalmic solution 0.03 % for eyebrow growth. Dermatol Surg 2011; 37: 1057-59.

The Seasonality of Hair Shedding

The Seasonality of Hair Shedding

As the Autumn in Toronto transitions from summer to early autumn approaches, I'm reminded of a remarkable feature of human hair growth - the increased tendancy for humans to shed hair in the early Fall.

Several research studies have shown that humans living in northern regions tend to shed more during the late summer and early autumn months.   Most of the time this goes undetected, but some individuals do notice this feature. A second phase of increase shedding in human beings may occur in Spring as well.

What causes hair shedding?

Of course, anyone coming into the office with concerns about hair shedding requires a thorough evaluation to determine the causes of increased hair shedding. These many include:

Physiological stress (i.e. surgery, labour and delivery, systemic diseases of the body, infections)

Endocrine problems (i.e. thyroid abnormalities)

Nutritional deficiencies (i.e. low iron, dieting)

Medications (i.e. anti-depressants, ACE inhibitors, heparin, beta blockers, lithium)

In addition to a thorough history and scalp examination, a patient with concerns about hair shedding requires blood work for complete blood count, thyroid studies and iron studies. Other studies may be needed as well.  All in all, there is a periodicity to how humans normally shed hair. Although loss of 50-100 hairs each and every day is considered normal, slightly increased rates can be observed in the Fall.

References of Interest

1) Courtois M et al. Periodicity in the growth and shedding of hair. Br J Dermatol 1996; 134;47-54.

2) Kunz M et al. Seasonality of hair shedding in healthy women complaining of hair loss. Dermatology 2009; 219: 105-10.

3) Randall CA and Ebling EJG. Seasonal changes in human hair growth.  Br J Dermatol 1991; 124: 146-51.

 

Flutamide May Help Women With Androgenetic Alopecia Who Don’t Respond to Spironolactone

By age 50, about 30 % of women will develop female pattern hair loss, also known as androgenetic alopecia. Treatments for this condition include topical minoxidil, hormone blocking oral medications such as spironolactone, flutamide and cyproterone actetate as well as hair transplantation. Spironolactone is considered among the first-line oral medications to treat female pattern hair loss.  

But what is the next step when spironolactone doesn’t seem to be helping?

Australian hair loss specialist Dr. Rodney Sinclair and his colleague Dr. Anosha Yazabadi suggested that the oral medication flutamide could be a helpful next step. They report the case of a 35 year old woman with androgenetic alopecia whose hair loss did not improve despite 5 years of spironolactone treatment at a daily dose of 200 mg and a 6 month course of 5 % minoxidil. A decision was made to stop the spironolactone and start flutamide at 250 mg per day and continue minoxidil. After 6 months of use, the patient’s hair loss ceased and her hair density improved.

Yazdabadi A adn Sinclair R. Treatment of female pattern hair loss with the androgen receptor antagonist flutamide. Australasian Journal of Dermatology 2011; 52: 132-34.

Comment: Flutamide may be a helpful medication in women with androgenetic alopecia whose hair loss does not improve with minoxidil and spironolactone and who are not candidates for hair transplantation. This oral medication blocks androgen hormones in several ways, including inhibiting update and the binding of androgens to the androgen receptor. Overall, it is a more potent androgen blocking medication than spironolactone. 

Consultation with a physician is necessarily to fully discuss the side effects of flutamide. This medication can rarely cause inflammation in the liver and so blood tests to monitor the liver are needed while using this drug. Furthermore, premenopausal women must not get pregnant while on flutamide and therefore contraceptive methods need to be carefully discussed with each patient.

 

Hair Loss After Pregnancy

Hair loss is common after pregnancy and can be extremely distressing. It typically occurs between 3 months and 6 months and can last a further 6 months.  The medical term is “post-partum telogen effluvium.”  Current research suggests that a drop in hormones, especially estrogen, after delivery results in hairs being shed. 

Why does hair loss occur after pregnancy?

To understand why hair loss occurs after delivery, it's important to understand how hair grows normally and the changes that occur during pregnancy:

Before pregnancy

About 85-90 % of hair are in the active "growing" phase. These growing hairs lengthen in size by 1 cm each month.

About 10-15 % of hairs on the scalp in the inactive "resting" phase. These hairs are preparing to be shed.

For most women, this means that there are about 100,000 hairs on the scalp at any time and between 50 to 100 hairs are lost or "shed" every day.

During pregnancy

Due to rising estrogen levels, fewer and fewer hairs get "shed" from the scalp with each passing day. More hairs accumulate in the active growing phase.

This means that the total number of hairs on the scalp actually increases during pregnancy. Hair counts may rise from 100,000 to 110,000 hairs. The result is thicker and more dense hair. 

After delivery

A decrease in hormones, especially estrogen and progesterone, causes the balance of growing and shedding hairs to again be disrupted in an effort to return back to pre-pregnancy patterns.

More and more hairs are shifted from the growing phase into the shedding phase. The result is increased hair shedding – usually all over the scalp.

This phenomenon typically occurs around 3-4 months after delivery

Full hair re-growth should occur by 12 months. A small proportion of women will note that hair density remains less than before pregnancy.

What tests are needed?

Extensive testing is not required in most patients. The resetting of the hair shedding patterns is a completely normal phenomenon, and there is no treatment or cure for post-partum hair shedding. I sometimes order blood tests to make sure that iron and thyroid levels are normal but only if there is some indication this may be a problem. All in all, I advise women that hair density should be regained by the time of celebrating their son or daughter’s first birthday.  Very rarely, hair shedding can extend to 15 months. If hair shedding does not stop, further investigation into other causes of hair loss should be undertaken.  Hair loss during pregnancy is abnormal, and I recommend women with hair loss in pregnancy seek medical advice.

Practical Advice for Women with Hair Shedding

1. Wash and shampoo as often needed.  More hair will come out on the days that the hair is shampooed but this will not affect the long term density of hair.  The use of a volumizing or thickening shampoo may help the hair look fuller and feel thicker.

2. Use a conditioner formulated for fine hair. I recommend that women with shedding avoid heavy conditioners as these tend to weigh down the hair. A conditioner formulated specifically for "fine hair" tends not to weigh the hair down as much.  The conditioner should be applied only to the ends of the hair.   If it is applied to the scalp and the entire hair it tends to weigh the hair down.

3. Avoid hair styles that puts stress on the hair.  This includes tight braids, pigtails, cornrows, or a tight pony tail. These hair styling practices can lead to more hair being pulled out.

4. Avoid excessive combing of hair when it is wet.  This can lead to more hair breakage. The use of a large tooth comb can be helpful.

5. Eat as healthy as possible.

6. Talk openly about hair loss concerns. With so much focus on the new baby, there is often little attention given to the concerns of the new mom. It is normal to be worried about hair loss. Talking with others, especially other mothers who experienced hair loss, can be helpful.

7. Wear a wig or hairpiece for a short time if it helps cope with hair loss. Very rarely, a new mom with extensive hair shedding will ask whether wigs or hair pieces are safe or whether they weigh down the hair and prevent it from breathing. Wearing a wig or hairpiece is completely safe. This can be a helpful camouflaging option for women whose scalp can be seen.

8. Consider cutting the hair shorter. This will give more lift to the hair and weigh it down less. This can help camouflage hair loss to some degree. However, cutting hair won’t make the shedding stop faster or hair grow back quicker.  Shorter hair can also be much easier to manage.

What are the Most Recent Trends in Hair Transplantation?

Hair transplantation is becoming an increasingly popular option for patients with hair loss. Each year approximately 280,000 hair transplants are performed worldwide.

The interest in hair transplantation is increasing around the world, especially outside of North America. Recent statistics released by the International Society of Hair Restoration Surgery (ISHRS) showed that while hair transplant procedures increased 15 % in the US over the years 2004 to 2010, they increased 345 % in Asia and 454 % in the Middle East over the same period.

More Women getting Hair Transplants

Every year, more and more women are asking about options for hair transplantation and about one-quarter of my hair transplant patients are women.  Last month, I posted a blog outling the hair characteristics that would make a woman a good candidate for the procedure.

What are the latest trends around the world in hair transplantation among women?

A recent study, released by the International Society of Hair Restoration Surgeons, indicates that the number of female hair transplant patients increased 24 % since 2004. In 2010, 14.1 % of all hair transplant patients worldwide were female and 85.1 % of patients were male.