Lattise for Eyebrows: Does it help?

Eyebrow Loss: Latisse can help many

Latisse (generic name: bimatoprost) is FDA approved for eyelash growth. Anytime a physician prescribes a medication outside of it's intended use, it's called an 'off label' use.

Latisse for the eyebrows is an "off label" use of the drug. 

That said, Latisse can certainly work well to stimulate eyebrow growth in some patients. It has helped hundreds of my own patients improve their eyebrow density. Even in small amounts (i.e. whatever small amount is left over after applying to the eyelid) can help. It appears that Latisse works better for hereditary or age related thinning than for traumatic related loss (such as from over plucking, tweezing or trichotillomania).

Other options for Brow Loss: Minoxidil and Hair Transplants

Other options for eyebrow loss include minoxidil (Rogaine) and hair restoration. Not everyone is a candidate for these treatments.

More studies of Latisse needed

Formal studies are needed but for now Latisse is a good option for eyebrow thinning. There is no formally approved treatment on the planet for eyebrows  - but there needs to be ..... as eyebrow thinning is a common and distressing problem. 
 

No such thing as scarless hair transplant surgery - International Society issues Alert

 ISHRS clamps down on false advertising

In an effort to stop false advertising in the field of hair restoration, the world's largest hair restoration society - The International Society of Hair Restoration Surgery (ISHRS) - has issued clear guidance to the public on the topic of scarless surgery:

"THE FACT IS THAT ANY INCISION WHETHER BY MACHINE OR HAND THAT ENTERS THE SKIN BEYOND THE MOST SUPERFICIAL OF DEPTHS CAUSES A SCAR TO FORM"

(ISHRS website, Sept 2014)

 

International Society Issues Hair Transplant Consumer Alert

Hair Transplant Consumer Alert

Many hair transplant surgeons, including myself, are members of the International Society of Hair Restoration Surgery (ISHRS). It is the largest international body of hair transplant surgeons in the world. Our society is extremely concerned about the growing risk to patients of unlicensed technicians performing substantial aspects of hair restoration surgery. 

The ISHRS has recently issued a consumer alert to warn patients of potential harm that can come about when unlicensed technicians perform critical parts of the pre op or the surgery or the post op. 

In a new statement, the ISHRS has stated quite clearly that it "believes the following aspects of hair restoration surgery should only be performed by a licensed physician or licensed allied health professional practicing within the scope of his or her license:                                                                                                                                  

1. Preoperative diagnostic evaluation and consultation           

2. Surgery planning

3. Surgery execution including:

• Donor hair harvesting
• Hairline design
• Recipient site creation

4. Management of other patient medical issues and possible adverse reactions

What to read the full consumer alert?

Please click here to read the full consumer alert

Can we pre-determine who minoxidil is going to help?

Will minoxidil help?

Minoxidil is FDA approved for the treatment of androgenetic alopecia. In fact, it was the first treatment formally approved by the FDA for hair loss. The drug does not help everyone with hair loss. In fact, studies suggest it helps only 30 % - 40% of users.

Is it possible to predict if minoxidil will help me?

At present, the only way to determine if minoxidil will help is to try it out. And that phase of "trying it" phase needs to last about 6 months in order to determine if minoxidil will help or not.

The sulfotransferase enzyme

Recent research has turned to focusing on whether the activity of an enzyme in hair follicles called the sulfotransferase enzyme can predict who minoxidil will and will not help. 

In order for minoxidil to do it’s job, it needs to be converted to minoxidil sulphate. Hair follicles have the machinery to help with this but some people’s hair follicles are not really that good at it. Scientifically, we say that some people’s hair follicles lack high levels of an enzyme known as “sulfotransferase” and so they cannot convert minoxidil into the active form that actually does all the work.  (The public does not yet have minoxidil sulfotransferase testing kits available to them but this technology may be coming at some point in the near future.)

Two studies have previously reported that sulfotransferase enzyme activity in plucked hair follicles predicts a patient's response to topical minoxidil therapy. In a new study, researchers confirmed the clinical utility of a sulfotransferase enzyme test in successfully ruling out 95.9% of nonresponders to topical minoxidil for the treatment of AGA.

Comments

This is a powerful step in the right direct for a safe and somewhat effective medication. I've seen countless numbers of patients helped by minoxidil, and countless more who have not been helped.  If we can now figure out who shouldn't use mionxidil - this is a huge step in the right direction. I'm excited to follow where this sulfotransferase enzyme testing will lead- I am confident we'll hear more soon. This is good science put to good work. 

This test is not yet available but I will certainly update when it becomes available.

 

Reference

Goren et al. Clinical utility and validity of minoxidil response testing in androgenetic alopecia. Dermatol Ther. 2014 Aug 12. doi: 10.1111/dth.12164. [Epub ahead of print]

 

Eyebrow transplantation: Deceivingly Simple?

Eyebrow Transplantation: Cautionary Tales

Eyebrow hair transplants are popular, especially among women.  A few weeks ago, the Toronto star had a great article on eyebrow transplants that further caught the attention of many. In parallel to the increasing number of women having eyebrow transplants there is has been an increase in the number of women having transplants who shouldn't be.

Taking a step back before having eyebrow transplant.

Many women are good candidates for eyebrow transplants - but a small proportion are definitely not. This week alone I saw 6 patients who had eyebrow transplants sometime in the past a various centers around the world- who came into my office with one question - "why didn't it grow out like I imagined it would?"

Here's a few cautions for anyone considering eyebrow transplants. If these statements sound like you, step back and pause.

1. I have complete eyebrow loss 

Women with complete eyebrow loss "might' be a candidate for a transplant but absolutely need to see a dermatologist first.  Alopecia areata and frontal fibrosing alopecia are two conditions that can lead to eyebrow hair loss - and don't respond very well to hair transplants.  Hair loss from these conditions can sometimes look similar to age related thinning.  Simple rule: if you have complete eyebrow loss, get a proper diagnosis. Don't assume you've over tweezed, or that your thyroid abnormality caused the loss - just assume you need to see a dermatologist. 

2. I lost my eyebrow quickly and need a quick solution

The ideal candidate for eyebrow transplants is someone who lost their eyebrows slowly - through years of over tweezing or slow age related thinning. Individuals who lose their eyebrows over a 6 month to 12 month period are usually not good candidates - they need to see a dermatologist to figure out what is going on.

3.  I am looking for a single procedure only. 

An eyebrow restoration is a delicate process. Transplants of the scalp can often be accomplished with one procedure - but such a statement is inaccurate for the eyebrows. There are few areas of the face so important as a properly designed eyebrow. One must expect to have at least two procedures to make the eyebrows look amazing. The first procedure is designed to build the density and create the basic framework. I nearly always recommend a small touch up to finalize the brow. 

4. I want my eyebrows to look like Cara Delevingne

I encourage patients to bring in photos of individuals whose brows they admire. This is helpful to understand the features they are looking, the density, the shape.  The most popular photo to be brought in, by far,  is that of British model Cara Delevigne.  Together with my patients, we've studied all the angles, directions and positioning of the estimated 1000 eyebrows that make up Cara's 2 eyebrows.  But is this shape and density appropriate for everyone? Not at all. The appropriate shape and structure of the eyebrow depends on an array of factors including the patients eye structure & surrounding orbital bones, their facial symmetries, their cheek bones, nose, forehead and chin. I encourage patients to bring in many photos - but the most important photo of all - is a photo from their own past.

Conclusion

Eyebrow restoration is delicate work. The first step for anyone deciding whether to have a transplant is figuring out if they are a candidate a not. 

Finasteride and Dutasteride: No Risk of Breast Cancer

New Study Suggests no Risk

 

The 5α-reductase inhibitors (5-ARI) finasteride and dutasteride are used to treat male pattern hair loss. These medications an be used alone or combined with hair transplant surgery. One of the rare risks of these drugs is enlargement of breast tissue in men - a phenomenon called gynecomastia. There has been some question in the past as to whether there could be an increased risk breast cancer in men. Recent evidence has suggested that there is no such increased risk and a new study supports this notion as well.

A new study suggests no risk

A UK study of  men aged 45 years and older was done to retrospectively evaluate men with breast cancer compared to men without breast cancer over the 20 year period 1992 to 2011. 398 cases were identified and matched to 3,930 controls. In this study, there was no evidence of an association between short-term or long-term use of finasteride or dutasteride and the risk for breast cancer in men.

Comment:

Last year, I wrote a blog describing a study from the Journal of Urology which suggested that there was no increased risk of breast cancer. This study is in line with these previous studies. Overall, the overwhelming data to date suggest that use of these medications for hair loss does not increase the risk of breast cancer.

Reference

Duijnhoven et al. Long-term use of 5α-reductase inhibitors and the risk of male breast cancer.

Cancer Causes Control. 2014 Aug 19.  

 

Eyebrow Transplants: The Latest Trend in Hair Restoration

Eyebrow Transplants:  Interview in Toronto Star

Today, I was interviewed in the Toronto Star about a trend we're seeing in hair transplantation: eyebrow transplants.

For a full link to the article click here.

Eyebrows have an extremely important role in facial aesthetics. They frame the face. They draw attention to (or away) from the eyes.

 

What is an eyebrow transplant?

An eyebrow transplant is a short (3-4 hour) cosmetic procedure whereby hair follicles are removed from the back of the scalp and moved into the eyebrow. 

Briefly, hairs are generally chosen from the back of the scalp just behind the ears because these hairs are the "finest" calibre hairs and most closely match the hairs of the eyebrow. Hairs can also be taken from the nape of the neck in some patients as well as leg and arm. The choice of hair depends on the patient's hair characteristics.  99 % of the time it comes from the back of the scalp. 

In order to take hairs from the back of the scalp, the area must first be frozen with "freezing medications" like lidocaine. These are usually the same freezing medications as a dentist might use to freeze a tooth. Once the area is frozen, hairs can be removed as a large piece of skin (called strip excision) or one by one (called follicular unit extraction).  There are distinct advantages of each.

Once hairs are obtained from the back, they are prepared for placement into the eyebrow. In order to do this, the eyebrow is frozen with the same freezing medications and then tiny tiny incisions (tunnels) are made in the eyebrow at very precise angles and directions.  Once the incisions are made, the new tiny hairs from the back of the scalp are placed down into those holes.  

It is critical that patients are aware of what to expect next - I.e. the so called "post-op" period.  This must be thoroughly discussed with the physician who plans to do the procedure.  In general, a partial list of side effects include swelling and redness and crusting for a few days. Redness may persist in some patients many weeks. However, fortunately not all.  The area must be bathed twice daily as the area at the back of the scalp must also be kept meticulously clean. 

Eyebrows, once they grow out in 2-3 months must be trimmed regularly.  These hairs grow like the hairs did when they were located in the back of the scalp - i.e. they grow long.  It takes 7-12 months to see results. 
 

Cancer Drug May Offer new Treatment for Alopecia Areata

Preliminary Study in 3 Patients

Alopecia areata is an autoimmune hair loss condition that affects about 2% of the population. Treatments include a variety of immunosuppressive treatments. Hair transplantation is not an option for this type of hair loss condition.

Researchers from Columbia University in New York have uncovered a potentially new treatment for alopecia areata: an oral cancer drug known as ruxolitinib.

In a well designed study, the investigators first showed first that the drug was effective in a mouse model of alopecia areata. After showing it worked it mice, the researchers then tested the drug in three patients with alopecia areata.  All three patients experienced hair growth in just a matter of a few months. Although the study was performed in only a small number of patients, it opens the door for further study of this medication.

What is Ruxolitinib?

Ruxolitib is a type of cancer drug. It is not a new drug and in fact is already on the market to treat an uncommon bone marrow cancer called myelofibrosis as well as a few other conditions. The drug belongs to a group of medications that inhibits signals within immune cells called the JAK kinase.

Ruxolitinib is currently prescribed by cancer physicians and patients who use the drug need to be carefully monitored. It can cause a drop in blood counts, and can increase the chance of bleeding and bruising. Some patients are more prone to infections while on the medication. Rarely other side effects such as irritation of the heart and liver, weight gain and elevated cholesterol levels can occur.

Conclusion

Further studies are needed to determine if the cancer drug ruxolitinib is safe and effective for patients with alopecia areata before determining if it should or should not be prescribed to larger numbers of patients. Certainly, results from the first three patients are encouraging.  

Reference

Study article: Xing et al. Alopecia areata is driven by cytotoxic T lymphocytes and is reversed by JAK inhibition. Nature Medicine. Published online Aug 17 2014

Control of Graft Depth Essential in Hair Transplantation

Many factors to create natural looking hair transplant results 

How does one great natural looking results in hair transplantation? Well there are many ways, including paying careful attention to the angle and direction that new hairs are put into the area of hair loss, controlling the density or spacing of the hairs, controlling the calibre of hairs and controlling the depth that hairs are placed.

Going deeper: Understanding Depth Control

Hair transplantation essentially involves taking follicles from the back of the scalp and moving them into areas that are thinning or bald. Small "holes" "tunnels" or incisions are created in the bald area to accommodate the new hairs. 

Creating these incisions is meticulous work. They have to be perfect. Tunnels that are too deep will cause the new hairs to sink into them creating unsightly 'pitting' (little indents around the hairs). Tunnels that are not deep enough may lead to hairs falling out or the hairs may heal as tiny mounds raise above the surface of the skin. 

 

Ensuring Proper Depth in Hair Transplant

The photo to the right shows how I ensure proper depth of a patient's grafts. The instrument on the far right is a needle attached to a blade holder. The needle must be adjusted so that it is the appropriate size.

Conclusion

A number of factors, including graft depth,  are important to ensuring natural looking results

Breast Cancer Patients on Aromatase Inhibitors: Risk of Hair loss Increased

Risk of hair loss increased two fold

Aromatase inhibitors are a group of medications used to treat breast and ovarian cancer. Common names of these drugs include Anastrozole (Arimidex), Letrozole (Femara), Exemestane (Aromasin), Vorozole (Rivizor), Formestane (Lentaron), Fadrozole (Afema). Over the past few years we've come to realize that these medications can cause hair loss in some women.

How do these medications cause hair loss?

Aromatase inhibitors cause hair loss because they reduce the levels of estrogen and increase the levels of testosterone. Both of these can contribute to hair loss.

New study quantifies risk of hair loss

A new study published in the journal Breast Cancer Research and Treatment  examined the association between aromatase inhibitor treatment and hair loss or hair thinning among female breast cancer survivors. Records were analyzed from 851 female breast cancer survivors. The results showed that 22.4 % of the breast cancer survivors reported hair loss and 31.8 % reported hair thinning. In addition,  breast cancer survivors who were within 2 years of starting aromatase inhibitor treatment at the time of survey completion were approximately two and a half times more likely to report reporting hair loss  or hair thinning  within the past 4 weeks compared to those who were never treated with these drugs. 

 This study adds to a growing body of literature showing that aromatase inhibitor use is associated with an increased risk of hair loss and hair thinning

Treatment Options: Minoxidil and Hair Transplantation.

Few studies have been done examining the optimal treatment plan. However, I have used minoxidil and hair transplantation to restore density in many patients with aromatase inhibitor induced hair loss. More studies are needed 

Reference

Gallicchio L et al. Aromatase inhibitor therapy and hair loss among breast cancer survivors. Breast Cancer Res Treat. 2013 Nov;142(2):435-43.  

 

Hair loss after brow lifts: Hair transplantation sometimes an option

Brow lifts may cause hair loss in some women

The brow lift

In this week's blog I'd like to discuss a cosmetic procedure called the "brow lift." It's not a cosmetic procedure that I do, but a cosmetic procedure that I've come to understand. I've been performing an increasing number of hair restoration procedures on for women who developed hair loss after facial plastic surgery, including brow lifts.

A browlift (also called a forehead lift) is a cosmetic surgery procedure to help minimize the sagging or drooping of the skin around the eyebrows and above the nose. According to the American Society for Aesthetic Plastic Surgery about 70,000 people have brow lifts each year.  Patients often have a brow lift to restore the appearance of a droopy eyebrow which may give the appearance of being sad, angry or tired. 

A number of surgical technique are available nowadays for performing a brow lift including endoscopic procedure and open procedures.  Some of these procedures involve incisions placed in the eyebrow, some in the forehead and some well into the hairline.

Hair loss after brow lift

Hair loss is one of the top side effects of brow lifts done by both open and endoscopic procedures. It may occur in up to 10 % of patients undergoing these procedures.  Hair loss is often temporary but may be permanent in a very small proportion. Patients with permanent hair loss from cosmetic facial plastic surgery may be candidates for hair transplant surgery.

It is important for patients undergoing cosmetic facial procedures including brow lifts to understand the potential risks of hair loss and discuss these risks with their surgeons.

Reference

Stephanie Byun et al. Complications of Browlift Techniques: A Systematic Review.  Aesthetic Surgery Journal 2013 33: 189

DANDRUFF

Scalp Dandruff:  

Scalp Dandruff: 

Nearly 50 % of the world will be affected by dandruff, the well-known flaky scalp condition. 

A number of factors contribute to dandruff including oil gland activity, a yeast known as Malassezia, the state of our immune system, stress and even some medications. 

 

What is the treatment?

Anti-dandruff shampoos are the basis of treatment - with shampoos like ketoconazole, selenium sulphide, ciclopirox and zinc pyrithione being used to treat the condition. Overall, the world spends about 2 billion dollars annually to treat this otherwise harmless condition.

Breakthrough melanoma drug causes hair loss in many

Vemurafenib causes hair loss in nearly one-half

Vemurafenib received FDA approval in 2011 for patients with metastatic or unresectable melanoma provided their melanoma cancer samples had a specific BRAF mutation. The drug has changes the way melanoma is treated with some patients now living longer on account of the drug.

Since 2011, we are now hearing abut more and more individuals who have hair loss from the drug. In fact hair loss is one of the more common side effects of this drug. Other side effects in patients treated with vemurafenib were joint pains, rash, hair loss, fatigue, photosensitivity reaction, and nausea. 

Conclusion

Hair loss is common from the new melanoma drug Vemurafenib and is likely temporary in most.  Physicians need to be aware of this side effect to counsel patients 

Reference

Kim et al. FDA Approval Summary: Vemurafenib for Treatment of Unresectable or Metastatic Melanoma with the BRAF V600E Mutation. Clin Cancer Res. 2014 Aug 5. pii: clincanres.0776.2014. 

IMAGE OF THE WEEK (Aug 3-9, 2014)

Did you check out our image of the week?

Our image of the week for this week is an up close photo of the normal process of graying hair. The "50-50 Rule of Hair Graying" says that by age 50 about 50 % of the population has 50 % of their hair gray.

Can we prevent hair loss from chemotherapy?

Hair Loss from Chemotherapy

Hair loss from chemotherapy is one of the most distressing side effects. There has been a lot of  research looking into how to prevent hair loss from chemotherapy - or what is called "chemotherapy induced alopecia." A research group for Korea recently looked at every single study that has been published so far - in order to get a better sense of what works best.

So - what works best to prevent hair loss from chemotherapy?

Scalp cooling by far. 

In order to come to this conclusion, the authors looked at nearly 700 articles, of which a total of 8 randomized controlled trials and 9 controlled clinical trials involving about 1100 participants were reviewed. Scalp cooling came out as the most effective. Other treatments like scalp compression, a combination of cooling and compression, topical minoxidil, and Panicum miliaceum didn't seem to help much (or not at all).

What is scalp cooling?

Scalp cooling (also called scalp hypothermia) is a new treatment option that is being explored. Cooling the scalp reduces the amount of chemotherapy to the scalp. The technique is used in Canada (by some hospitals) and Europe but not in the USA. It is currently undergoing study in the US and may be approved in the USA in the near future.  The two scalp cooling agents to be on the lookout for are the Penguin Cold Cap and Dignicap. 

Reference  

Shin et al. Efficacy of Interventions for Prevention of Chemotherapy-induced alopecia: A Systematic Review and Meta-Analysis. Int J Cancer. 2014 Aug 1. doi: 10.1002/ijc.29115. [Epub ahead of print]

The antifungal drug voriconazole: can it cause hair loss?

Hair loss from Voriconazole

I enjoyed reading this new study from Michigan which showed that the antifungal drug voriconazole caused hair loss in 82 % of 152 users and was rated as severe in 15 %. In most patients the hair grew back once the drug was stopped and even in some when another antifungal drug was substituted. 

This comes as a surprise given that hair loss occurred in only 2 % of users in the premarketing clinical trials. More study is needed to better define the risks but all users of voriconazole should be advised about the side effect of hair loss. 

Reference

Malani et al. Alopecia and nail changes associated with voriconazole therapy. Clin Infect Dis. 2014 Aug 1;59(3):e61-5. 

Can piggybacks cause hairgrowth?

Do "piggy-backs" cause hair growth? 

Not usually! I enjoyed this article which showed piggyback can cause hair growth if you are 9 months old & grandpa is using minoxidil (Rogaine). 

Reference

Farsani et al. Piggyback acquired hypertrichosis. Pediatr Dermatol 2014. 31(4):520

Topical Finasteride for Men

Topical Finasteride for Hair Loss

Finasteride pills (Propecia etc) are FDA approved for the treatment of male balding. The drug reduces blood DHT and stops hair loss in 90 % of men. Side effects are the main limitation.

I just read a new study about a topical formulation of finasteride for hair loss. I was interested to see that blood DHT levels were reduced by similar amounts compared to finasteride pills. Will side effects be similar? Nobody knows. It's likely that side effects will be present. The only benefit of a topical formulation would be if side effects were lower. 

Reference

A novel finasteride 0.25% topical solution for androgenetic alopecia: pharmacokinetics and effects on plasma androgen levels in healthy male volunteers. Caserini et al. Int J Clin Pharmacol Ther. 2014 Jul 30. 

Follicular "miniaturization" in Androgenetic alopecia

What is follicular "miniaturization"?

Follicular miniaturization is a key part of the diagnosis of androgenetic alopecia. In androgenetic alopecia hair follicles get thinner and thinner over time. This occurs in both male androgenetic alopecia (sometimes called male pattern balding) and female hair loss (sometimes called female pattern hair loss)

Where on the scalp does miniaturization occur?

Miniaturization doesn't just occur anywhere. It initially occurs on the top of the scalp (vertex) and temples in men and middle of the scalp in women

Can one block this miniaturization process?

Medications like finasteride and minoxidil can help slow this process of miniaturization. In many cases non miniaturized hairs can be taken from the back of the scalp and moved into the areas of hair loss. This is the basis for a hair transplant.

FUE, Strip or ARTAS Hair Transplants: At least 5 days recovery/down time please

How soon can hair transplant patients return to their "usual" activities?

I'm often asked how soon patients can return to their usual activities. The answer is 5-7 days for FUE and 2 weeks for strip. Any sooner than that is not a good idea and something I do not recommend.

It's a mistake to think that FUE procedures require a lot less downtime than strip procedures The only difference between FUE and strip is the way the hairs are removed from the back. The way they are put in the front is exactly the same!

 

Why 5 days of downtime is needed

It takes five days for a brand new hair to adapt to it's new home. If I were to take a pair of forceps and try to pull out a graft after day 1 - it would come out! The same is true for days 2-5. However after 5 days the graft is while stable and that's when normal activity is same. 

Significant increases in blood pressure, heart rate can increase one's chances of developing graft popping (and graft loss) in the days after a transplant. 5 days rest minimum is needed - no exercise, no weight lifting, sexual activity, lifting heavy objects. In strip procedures, this is extended to 2 weeks to allow the incision to heal.

Returning to work

Provided a patient feels good,  returning to light activities at work is fine in 2-3 days. Patients with smaller procedures (especially those with existing hair) find it much easier to camouflage the look of the transplant than patients with larger procedures.

Conclusion.

It's often seen and heard that hair transplantation is a short office procedure and patients can return to their usual activities in a few days. While it's true that hair transplantation is a short office procedure, returning to usual activities is not advised for at least 5-7 days.