Omega 3 fatty acids: A potential adjuvant in hair loss treatment in women?

So what are omega 3 fatty acids?

Omega 3 fatty acids are called 'essential' fatty acids because we, as humans, can't synthesize them ourselves. We need to get them from our diet.   

While research in the role of these essential fatty acids in hair biology is still in it's early stages, and we don't really understand if they help or not, it is well known that these omega 3's have a variety of beneficial effects for human health. Evidence suggests that these omega 3's have benefits such as lowering triglycerides in the blood, decreasing inflammation, reducing the risk of heart attacks and strokes, possibly lowering blood pressure and improving brain function.  These fatty acids may also enhance the anti-inflammatory ability of certain drugs.

EPA, DHA and ALA

The 3 key omega 3 fatty acids are EPA, DHA (which are primarily found in fatty fish) and ALA (which is found in plant sources like walnuts), which stand for

• eicosapentaenoic acid (EPA)
• docosahexaenoic acid (DHA)
• alpha-linolenic acid (ALA)

How much: What dose of omega 3's do we need?

The exact amount of omega 3 fatty acids we need is not clear but 1000 mg (and maybe up to 3000 mg) seems reasonable and have been the numbers investigated in various studies. Doses more than 1000 mg should be used only in conjunction with a physician as they cause cause a variety of gastrointestinal side effects. While supplements are often recommended for standardized sources, many foods are rich in omega 3 fatty acids. These include oily fish like salmon, sardines, herring, mackerel, halibut, tuna. These are great ways to get EPA and DHA.  Many oils have ALA (canola oil, olive oil, flaxseed oil) but ALA in these have only a small benefit compared to the benefit of EPA and DHA.

Fish oils may not be right for everyone and I advise individuals to consider speaking with their physicians before starting. Omega 3's for example can theoretically reduce clotting and increase the propensity to bleed. While this may not be relevant on a day to day basis, it is relevant if someone is considering surgery. 

Omega 3s in genetic hair loss

The role of omega 3's in treating genetic hair loss (androgenetic alopecia) is still unknown. Two studies have prompted my research group to investigate whether omega 3's have a role in genetic hair loss. 

A study by Oner and colleagues from Turkey looked at hormonal changes in 45 women with polycystic ovary syndrome (PCOS) treated with 1500 mg of omega 3 fatty acids for 6 months.  Interestingly, body mass index, testosterone levels decreased and sex hormone binding globulin ( a protein which binds to and cancels testosterone) was increased.  Hair loss was not studied but these parameters certainly point to potential benefits. We've been studying omega 3's for a while now. 

A study by Nadjarzadeah and colleagues from Iran examined the effect of taking 3000 mg of omega 3's for 8 weeks in 78 women with PCOS. Interestingly, this study showed that omega 3's reduced testosterone levels; SHBG levels were not changed. 

Omega 3s in inflammatory hair diseases

The role of omega 3's in inflammatory hair diseases including autoimmune type scarring alopecias (lichen planopilaris, frontal fibrosing, folliculitis decalvans) and alopecia areata remains to be determined and is presently unknown. It's clear from a number of studies that consuming omega 3's lowers inflammatory markers in the blood (such as CRP, TNF-alpha). I've been closely following the role of omega 3's in the treatment of rheumatoid arthritis because some inflammatory hair diseases have similarities to the biological changes in rheumatoid arthritis. These studies suggest that omega 3's may have a modest benefit in the treatment of rheumatoid arthritis.  In another autoimmune condition lupus, studies suggest that EPA fish oils may help reduce symptoms. 

Conclusion

Overall, we don't yet know if omega 3's have any benefit in the treatment of hair loss. Studies are ongoing. Certainly, there is reason to believe that some benefit may occur. 

References

1. Oner et al. Efficacy of omega-3 in the treatment of polycystic ovary syndrome. J Obstet Gyncaecol 2013; 33(3) 289-91

2. Nadjarzadeh et al. The effect of omega-3 supplementation on androgen profile and menstrual status in women with polycystic ovary syndrome: A randomized clinical trial. Iran J Reprod Med 2013; 11: 665-72.

3. Miles EA et al. "Influence of marine n-3 polyunsaturated fatty acids on immune function and a systematic review of their effects on clinical outcomes in rheumatoid arthritis.". The British journal of nutrition. 107: S171–84. 

4. Li K et al. Effect of marine derived n-3 polyunsaturated fatty acids on C-reactive protein, interleukin 6 and tumor necrosis factor alpha: a meta-analysis. PLOS ONE 9 (2) : e88103.

Do I have to use my hair loss treatment "forever"?

Forever

The word ‘forever’ has a fairly clear meaning and isn’t really open to much in the way of interpretation.  Forever means continually. Forever means for always. Forever means forever.

For those with genetic hair loss, treatments must be used forever. If treatments are stopped, any benefits that a patient achieved will be lost. Surprisingly, when you pick up a bottle of a typical medication or treatment for genetic hair loss, the word forever is nowhere to be found.

Use daily.

Take 1 pill per day.

Do not use if pregnant or breastfeeding

Use three times per week

Check with your doctor before using.

Nowhere will you see forever.

I’m all for clarity and directness. I’m all for labels saying it as it is. Use daily – forever. Use three times per week - forever. Check with your doctor before deciding to use - forever. It might not sound so swell in terms of marketing glamour but it sure would ease a lot of confusion. For example, every week, I meet with a patient with genetic hair loss who has now has developed hair loss after stopping a medication that was originally prescribed to them for their hair loss.

“You mean I was supposed to use this forever?”

Some hair loss treatments are forever

If the hair loss is due to "genetic" hair loss (sometimes called androgenetic hair loss), then the treatment needs to be used forever (provided it shows evidence of helping). One of the most common criticisms I hear regarding the use of the FDA approved treatment minoxidil is that patients dislike the fact that it needs to be used ‘forever.’ If the treatment is stopped, hair loss resumes. It is true that this medication needs to be used forever. However, the same rules apply for all the treatments for genetic hair loss. Anything that works, needs to be used continuously. Hormone blocking pills, lasers, PRP - they need to be used forever.

Some hair loss treatments are not forever

For other hair loss conditions, the rules are different. For alopecia areata, treatment is administered until hair grows back and then it is stopped. For scarring hair loss conditions, treatment is given until the disease becomes quiet, then treatments are slowly reduced. In some patients, medicines can be stopped without the disease "reactivating." For telogen effluvium (hair shedding problems), treatment is given until the shedding pattern returns to normal.

Conclusion

In the field of hair loss, it is important to understand the meaning of "forever". For some types of hair loss, medications must be used forever to maintain their beneficial effects. 

Treating Hair loss: The ‘next move’ is not a guessing game!

Treating Hair loss: Logical. Ordered. Structured.

There are over 100 reasons for hair loss. Each of the causes has different treatment.  In my mind, for every patient I see, there is one or two “best’ treatments, and then the third best treatment. If that treatment does not help, I have a next (fourth) treatment in mind.  The choice of treatment is not random.

Just like in a game of chess,  there is logic to planning each phase of treatment.  There is order. There is structure. Every treatment has a specific ‘chance’ or specific ‘odds’ that it will help.  Part of the intellectual stimulation of treating hair loss comes from understanding these odds.  I don’t leave the office each day with the false hope that I’ve helped everyone I’ve seen that day with hair loss. Not at all. For example, this week I know that 40-60 % of patients I saw will get benefit from the treatments I recommended. But I also know, that unfortunately 40 % of the patients I saw will not.  Do I know which will benefit and which will not? Not at all.  In the present day, there is no treatment that helps 100 % of patients.

How do you determine the order of treatments?

Planning the order of  treatments is not a guessing game.  Even if there are five accepted treatments for a given type of hair loss,  one should never choose their treatments by pulling one of these five treatment out of a hat. The order of treatments should be based on previous studies that have been published in medical journals. In medicine, we call this ‘evidence.’ The order of treatments should be based on published medical evidence.    

What happens when ‘medical evidence’ does not factor into decision making? Chaos.

But in the ‘real world’, most individuals do not like to speak in terms of ‘medical evidence’.  In the public’s eye, knowing that there have been over 25 well conducted studies of treatment A but none of treatment B does not necessarily make drug B less appealing than drug A.   I know that sounds strange but I have heard it nearly everyday of my professional career. Had you asked me that 10 years ago, I would have said this concept was impossible. But provided information on treatment B can be presented in a manner that sounds convincing, it can quickly find it’s way to the top of the patient’s list of preferred treatments. Sales & marketing not science & evidence frequently rule decision making in the real world.

Chaos.

Chaos is a term which refers to a state of confusion and disorder.  When medical evidence is left out of the decision making on hair loss treatments, the result is chaos. Patients with hair loss want nothing more than to have some control over a situation (i.e. hair loss) in which they deem to have little or no control. But by leaving medical evidence out of the decision making process about what hair loss treatment to choose, the result is chaos. 

This week alone, several phone calls and e-mails I received from individuals with hair loss drew attention to this chaos.

“I have scarring alopecia and was advised to start carboxytherapy.” What do you think doctor?

“I have a few patches of hair loss from  alopecia areata and was recommended to start a daily application of an oil mixture? What do you think doctor?

“I have genetic hair loss and was recommended to start treatment with scalp massage? What do you think doctor?

What I think is that in the world of hair loss treatments, there is needless confusion and disorder.  There is chaos.  

Conclusion and Final Thoughts.

In the chaos that exists out there in the real world of treating hair loss,  we need to remember that many hair loss treatments have already been carefully studied.   Statistics can readily be given on how well they ‘work.’  Clear statistics can be given on the proportion of patients that are expected to benefit from the treatment.  Newer treatments may have less evidence, but if they are truly effective, they quickly accumulate medical evidence and published studies.

It’s not practical or possible for individuals in the general public to know all the medical evidence behind various treatments. However, there are two simple questions that every patient with hair loss should ask their treating physician. If every patient asked these questions,  I believe that many treatments would never be started.

1) For the type of hair loss I have, how many scientific studies with this treatment you are suggesting have been published in the medical journals?

Is it zero? Is it one?  Two? 10 ? I encourage patients to begin with treatments that have several published studies. If a treatment is truly beneficial, why would it not be published in the medical journals?

2) What proportion of patients benefitted when they took the treatment you are suggesting?

Is it 2%?  Is it 50%  I encourage patients to begin with treatments that are likely to benefit 30 % or more patients.  It’s rare in the present day to have treatments that lead to an improvement in hair density in more than 50 % of patients. So, if a treatment is offered that helps 100 % of patients, be cautious!

There is logic to treating hair loss. What I hope for many patients entering my office or reading my blogs is that they find some calmness and clarity amongst the chaos.  Treating hair loss is not a guessing game.  For most types of hair loss, there is a best first step, a second step and third step. 

Does seborrheic dermatitis get worse in winter?

Flares of seborrheic dermatitis common in winter

Seborrheic dermatitis (SD) is a close cousin of 'dandruff' and is due to a yeast known as Malassezia that is extremely common in the scalp.

Triggers of SD

There are many triggers of SD 'flares' including stress, dry and cold weather, certain medications. 

Flares of seborrheic dermatitis are very common in winter. For 5 % of individuals who experience seborrheic dermatitis and the occasional scalp dryness, itchiness and redness that accompanies the condition, the winter months can problematic. 

Treatments for SD

I advise the vast majority of my patient to reach for shampoos containing zinc pyrithione (i.e. Head & Shoulders), selenium sulphide (Selsun Blue), ketoconazole (Nizoral), or ciclopirox (prescription Stieprox) at least once per week in the winter months. There are many myths surrounding these shampoos and they are undoubtedly one of the best kept secrets for great hair.

What causes a red scalp? A review of the most common causes

Scalp Redness: Top 13 Causes

Scalp redness has many causes. Here, I briefly review the top causes of scalp redness.

1) Seborrheic dermatitis.
Seborrheic dermatitis (SD) is an inflammatory condition of the scalp that affects about 3-5 % of adults. Males are more commonly affected than females. SD occurs on body sites where the skin is oily such as the scalp, eyebrows, sides of nose, eyelids and chest. Individuals with SD of the scalp develop red, flaky skin that is often itchy. The scales can be yellow, white or grey colored and are often described as being "greasy." This differs from scalp psoriasis where the scales are often silver and powdery (see below).

2) Psoriasis
Psoriasis is complex immune-based disease which can affect not only the skin, but also the nails and joints. Scalp psoriasis occurs in about 50 % of patients with skin psoriasis. Patients have scalp redness, flaking and scaling. Patients may also have bothersome itching. Although the redness and flaking often cause embarrassment, scalp psoriasis does not usually cause hair loss. 

3) Scarring alopecias
Scarring hair loss condition or "cicatricial alopecias” are a group of hair loss conditions which lead to permanent hair loss. These conditions may frequently be associated with redness of the scalp as well as scalp itching, burning and/or pain. These include conditions with names such as lichen planopilaris, folliculitis decalvans, lupus and several others.

4) Other inflammatory diseases
A wide variety of other inflammatory scalp conditions, including dermatomyositis and rosacea can be associated with scalp redness. A scalp biopsy can help differentiate these entities.
 

5) "Red Scalp Syndrome"
'Red scalp syndrome" is a condition which occurs in individuals who have persistent scalp redness that is not explainable by any other condition. The condition was first described  by Drs Thestrup and Hjorth Patients with the Red Scalp Syndrome may have itching and burning but typically do not have scaling or flaking.

6) Irritation

Many products that are applied to the scalp or hair can cause irritation. These include many cosmetic products, including gel, mousse, hair spray and hair dyes. Some treatments for hair loss can also be associated with irritation and redness, including minoxidil and other topical products containing irritants such propylene glycol.

7) Allergy
Shampoos, hair dyes and even some cosmetic products can cause allergic reactions in the scalp. Although some individuals with allergy have itching in the scalp, many do not. In such cases, a rash may be present on the neck, ears or back where the product came into contact with the skin.

8) Infection
Infections are a possible causes of redness. Bacterial, viral and fungal infections may cause redness in the scalp. Determining the specific cause may come from a careful history and scalp examination and sometimes submission of a swab or piece of scalp tissue to the microbiology laboratory. 

Bacteria, such as staphylococci, may cause infections of the scalp. Bacteria may also cause infection of the hair follicle, which is a condition called " bacterial folliculitis." A variety of viral infections cause scalp redness. Chicken pox and shingles are two such examples. Scalp ringworm or “tinea capitis” refers to infection of the scalp by certain types of fungi. Scalp redness and scaling may be seen in these cases.

9) Alopecia areata
Alopecia areata is an autoimmune condition affecting about 2 % of the population. IT is not typically a cause of scalp redness. The scalp in patients with alopecia areata is usually normal in color but may be pink or peach colored in some cases. 

10) Scalp Injury and Trauma
Patients with scalp injuries, either due to previous accidents or surgeries, may have persistent scalp redness. Burns from fire, chemicals or radiation can cause redness in the scalp. Burns from ultraviolet radiation, such as might occur on a sunny day, can cause scalp redness. Patients receiving radiation for head and neck cancers and brain tumors can also develop scalp redness. 

11) Sun damage
Patients with extensive sun damage, from years of sun expose, may frequently have a red scalp.

12) Cancers
A variety of pre cancers and cancers of the skin, including non melanoma skin cancers, can cause redness in localized areas of the scalp. A biopsy may be obtained to reach the diagnosis.

13) Polycythemia

Polycythemia is a rare condition that leads to an abnormal increase in red blood cell production. A 2003 study indicated the polycythemia is on the list of causes of a red scalp.


Conclusion
There are many causes of scalp redness. Fortunately, the cause of the redness can often be diagnosed from a thorough examination of the scalp. In complex or challenging situations, a scalp biopsy should be performed to confirm the diagnosis.

Do I have chronic telogen effluvium (CTE) ?

What is CTE?

Hair shedding problems are among the most challenging of the hair disorders. They can be challenging to diagnose. Patients with shedding problems are the most frustrated of all patients with hair loss looking for a diagnosis because they receive so many different opinions. 

Both my friend and mom think it's stress.

One dermatologist said it's genetic hair loss another said low iron

My naturopath said it's a thyroid problem even though my TSH is normal

Chronic telogen effluvium (CTE) is a real and true hair shedding problem

CTE is a true hair loss problem. IT's not a diagnosis that women get when all other diagnoses have been exhausted. Patients with CTE often look like they have tremendous amounts of hair.  Patients with CTE who tell their friends they are going to see a hair specialist, will immediately hear "why would you do that ? .... your hair is great." Patients with CTE often start out with tremendous amounts of hair (and often joke that hair stylists once complained that they had too much hair). Patients with CTE have good days and bad. Good weeks and bad weeks. Some weeks they lose 50 hairs a day and some days 400 hairs per day. Surprisingly (despite this loss), these patients never go bald. They reach a new plateau of hair density and maintain that for years.  Patients with CTE are usually 35-70. They may have scalp symptoms like scalp "pins and needles" or "burning" or "tingling" - this often confuses things tremendously! It's unusual to have TE at younger ages. 

Do I have CTE or AGA?

A common question form patients is "Do I have CTE or AGA?" Of course the only way to confidently figure that out is to have a full examination. But patients who walk into the office with 1) concerns about tremendously increased daily shedding all over the scalp AND 2) look like they have a lot of hair and 3) have normal blood test results are the typical patient with CTE. Usually the scalp is NOT showing in patients with CTE.  The patient who walks into the office with hair thinning to a degree that the scalp IS showing is more likely to have AGA. Usually women with AGA have hair loss more concentrated in the front and middle of the scalp. Patients with CTE have hair loss all over. 

Treatments for CTE

Treating CTE requires patience. There is no cure but there are treatments than can help. These include 

1. Minoxidil (Rogaine)

2. Low level laser therapy (LLLT)

3. Platelet rich plasma (PRP)

4. Supplements (vitamins, biotin, VIVISCAL, Priorin)

5. Lysine

The precise 'starting treatment' depends on a number of factors. 

Hair growth after starting a treatment: new growth or breakage?

New growth has pointy ends

Picture the following situation.  A patient has started a new treatment a few months ago. Now, they see many hairs on the scalp that are short and the question arises "Are these new hairs or broken hairs?"

I hear this all that time. I can say confidently that the vast majority of times, it's new hairs!  To have so many hairs on the scalp with broken ends requires a lot of damage (from heat, chemical, etc).  That's not common. 

Sometimes, I can sit across the room from a patient who just started treatment a few months ago and see many many hairs standing straight up. Are they broken? Never! To have that many broken  hairs would be odd. Without even looking at the scalp, I know the treatments is working?

The above photos shows the difference between new hairs and broken hairs. New hairs are pointy and broken hairs are ... broken! ... and have blunt ends. 

What is the risk of alopecia areata in my children?

If a parent has alopecia areata, what is risk of alopecia areata in their children?

Alopecia areata is an autoimmune condition. About 2 % of the population will develop alopecia areata at some point in the lives. 

About 70 % of the condition can be explained by genetics or 'genes' that get passed down from generation to generation. But 30 % of the condition is environmental. This means that it's possible for alopecia areata to develop in one identical twin but not in the other. The condition is not entirely explained by genetics. 

Passing the condition along to children

If one parent has alopecia areata, there is a slight increased risk that a child will develop the condition. The exact risk depends on a number of factors:

1. At what age did the parent develop alopecia?
2. Does the parent have alopecia areata, totalis or universalis
3. Are there other autoimmune diseases in the family ? (vitiligo, autoimmune thyroid disease, rheumatoid arthritis, type 1 diabetes, multiple sclerosis, atopic dermatitis)
4. How many other family members have alopecia areata? 

The risk for ANY child to develop alopecia areata is 2%. When one more more of the above factors are present the risks goes up above 2 %. IN general, only about 20 % of patients with alopecia areata have a family history of the condition.

No genetic tests at present

At present there is no genetic test whatsoever to predict the risk of a child developing alopecia areata if a parent has alopecia areata. I generally tell parents that there is a much much better chance their child will NOT develop alopecia areata

Does hair always start growing 3 months after a hair transplant ?

Hair regrowth is variable

Hair growth starts about 3 months after the surgery. But keep in mind it's highly variable - for some it's 2 months and some it's 5. 

But regrowth time also depends on the type of surgery. We see some delay in patients with scarring alopecias (cicatricial alopecia), compared to those with genetic hair loss. 

But overall, three months is a safe bet. 

Ferritin levels: Frantic or Factual?

What are normal ferritin levels? What do they mean?

Blood tests are associated with great confusion. In other blogs, I've discussed the uselessness of DHT measurements for most patients, yet everyday patients show me results. A lot of confusion exists with TSH levels, T3, T4 measurements (all for thyroid). I'll comment on these soon too. 

For now, let's discuss ferritin. 

Iron levels are important but low iron should not cause immediate panic

Many females have ferritin levels 20-40 without hair loss. That sentence needs to be repeated over and over. And then repeated again. It's far too simple to say that ferritin levels must be above 40 for healthy hair growth. We often "AIM" for that but it is completely wrong to say that anytime ferritin is less than 40 there is a problem. The correct answer is there may be

If you were to measure iron levels (i.e. the ferritin test) in all women between ages 20-40, you'd find many with ferritin 28, 32. 44. You'd find very few with ferritin levels above 50.  You'd find a number with ferritin levels 6, 12, 19.

Misconceptions around iron levels. 

I think too often I hear women state that because their iron levels are under 40 (ie let's say 26) they MUST have a diagnosis of telogen effluvium. This is wrong. When I learn that a individual has an iron level of 26, I can only say they have an iron level of 26. They may have normal hair. They may have androgenetic alopecia (female pattern hair loss) and they may have a host of other conditions as well including alopecia areata and telogen effluvium.  Low iron levels have been associated with many hair loss conditions. 

The level of iron tells me very little. 

Ferritin levels below 15

Once the iron levels start going low enough, it is true that there is a high likelihood now that the patient will experience some hair loss an account of those low iron levels. It's quite unusual for  patient to have normal hair growth with a ferritin of 2. In general, once ferritin levels drop below 15 AND the patient has hair loss concerns, it's no longer a debate as to whether to replace iron. It's a general consensus that supplementing iron is necessary. 

Key 10 summary points about iron levels and hair loss

Here's some key 'take home' messages about iron and hair loss

1. Aiming for a ferritin level above 40 is a good idea for anyone with hair loss.

2. Aiming for a ferritin above 70 is not my recommendation and is very hard to achieve and generally has little benefit for the hair. 

3. If one's ferritin is between 20-40, it must always be remembered that the ferritin levels may be just fine for that person. I'd still recommend supplementing with iron tablets, but there is not a lot of good evidence 

4. Ferritin levels under 15 are usually associated with changes in hair cycling.  If ferritin is less than 15, I recommend speaking to one's physician about iron pills

5. If ferritin levels are low and hemoglobin levels are low (something we call an anemia), a full workup by a doctor should be booked.  

6. Vitamin C helps iron absorption and taking a vitamin C rich sources with iron pills is often helpful to increase iron. 

7. Many females have ferritin levels 20-40 without hair loss. The ferritin level alone does not mean much without taking everything into perspective. 

8. Many females have ferritin levels 20-40 without hair loss. The ferritin level alone does not mean much without taking everything into perspective. 

9. Many females have ferritin levels 20-40 without hair loss. The ferritin level alone does not mean much without taking everything into perspective. 

10. Many females have ferritin levels 20-40 without hair loss. The ferritin level alone does not mean much without taking everything into perspective. 

Immediate hair loss after bleach and dyes: What I recommend

Hair loss after leaving the salon.

It's not so uncommon nowadays to get calls to our office from patients who have lost hair or have scalp symptoms after having their hair highlighted, bleached and dyed. I don't know why these calls are increasing in recent years, but they are increasing.  

I can't emphasize enough the importance of seeing a dermatologist when this occurs. A full exam is needed. For the most part, what has been done has been done (and all that's needed now is time) EXCEPT if there is inflammation remaining in the scalp.  The whole reason for seeing a dermatologist is to evaluate if there is inflammation still remaining and if anti-inflammatory treatments would be necessary. These treatments include:

topical steroids

steroid injections

oral prednisone

Only an experienced hair specialist can gauge whether inflammation is present.  Vitamins won't help that much, nor will hair supplements. 

Washing the hair after injury

Touching and washing are fine, and please don't be worried to do that. Nothing in that regard can affect your final outcome. 

What's the normal course or "story" for the vast majority of individuals? 

For most people with hair loss after leaving the salon, this hair loss is usually temporary. The hair falls out for the next many weeks (up to 6)  and 2-4 months later starts growing in and one year later you're back to where you started. It's quite unlikely (albeit not impossible) that a patient will have permanent hair loss.

Losing eyebrows? Diagnosis comes first.

For anyone losing eyebrows, there is only one thing to do - get an expert opinion. Too often individuals bypass this step and look for the latest treatments they've heard about.

A full review of the individual's medical history and careful examination of the hair in the eyebrows AND scalp is needed along with review of blood test results. 

WHAT ARE THE COMMON CAUSES OF EYEBROW LOSS?

In general causes of eyebrow loss and treatment include:

OVER TWEEZING AND PLUCKING. Overstyling of the brows is very common. Options include minoxidil, bimatoprost and hair restoration surgery.

HYPOTHYROIDISM. Reduced thyroid levels can cause brow loss especially at the sides. A visit to the blood lab for a blood test can diagnose low thyroid levels. The treatment is thyroid replacement


ALOPECIA AREATA. This is an autoimmune condition. Hair loss can occur solely on the eyebrows albeit that is not common. For most individuals,  there are other signs of hair loss on the scalp. Treatment for AA includes steroid injections and topical corticosteroids, minoxidil. Other treatments are available too.

FRONTAL FIBROSING ALOPECIA. This is an autoimmune hair loss condition causing scarring hair loss that is permanent. Eyebrow loss in women over 60 is more likely FFA than AA. Treatment includes steroid injections, and immunosuppressive pills and hormone blockers. A dermatologist should be consulted for anyone with FFA.

TRICOTILLOMANIA (TTM). Self induced pulling of the eyebrows is not uncommon in the general population. It is often associated with anxiety, depression or obsessive compulsive disorder. The treatment for TTM includes medications and counselling.

AGE RELATED CHANGES. Some women and men develop sparse eyebrows with age. Treatment includes minoxidil, bimatoprost and hair transplantation. 
 
TELOGEN EFFLUVIUM. Hair shedding problems give hair loss in the scalp and rarely eyebrows. The precise treatment depends on the precise cause of the shedding (stress, low iron levels, weight loss, pills the patient uses)

All in all these are some of the more common reasons for brow loss but but many, many reasons are possible! A dermatologist can help guide a diagnosis and treatment plan. 

Finasteride (Propecia): Do men need to stop when fathering a child?

Do men need to stop when fathering a child?

This is an important question and I generally advise patients to review on a case by case basis with their physicians. There is no one perfect answer and this needs to be reviewed carefully with each patient. Stopping may be an option for some males and transition to a topical finasteride may be an option for others.

Finasteride is found in semen at very, very low concentrations. If it weren't found in semen, the issue would not even be an issue. But finasteride is found in semen at doses either undetectable to up to 21 ng/mL. Studies have shown these concentrations do not appear to harm a developing baby. Many men have fathered healthy children while using finasteride. At the present time, there is no evidence whatsoever that the children (either sons or daughters) of men taking finasteride have a higher risk of birth defects.
However, finasteride may lower sperm counts and cause temporary infertility in some men.  Couples having difficulty conceiving need to be aware of the possibility that the man's use of finasteride could be problematic.

The most important part of this question is that this information should be frequently reviewed with the prescribing doctor for updated information as it may change over time as new information emerges. At the present time, there is no evidence that use of finasteride by men increases the risk of birth defects in his children. 1-3 % of all children in the world are born with birth defects and this rate at present seems similar in finasteride users compared to non users. About 1 out of every 100 men who use finasteride while fathering a child will have a baby with a birth defect of some kind - but that rate is similar to men who did not use finasteride.

Several agencies currently advise that finasteride not be used by males whose partners are trying to conceive. Several agencies state that there is no reason for it to be stopped. There is no evidence at present to support either the recommendation not to take or the recommendation to take. References are stated below this page.

Finasteride: Does it affect spermatogenesis and pregnancy?

Men with a genetic deficiency of 5 alpha reductase (i.e. men with genetic mutations) may have hypospadias (abnormal opening of urethra), cryptorchidism (undescended testes) and abnormal genitalia. These side effects do not appear increased in men using finasteride based on information available today. Many of these side effects are common in the general population. For example, 3 % of all boys in the world are born with cryporchidism making it a very common abnormality in the world’s population. Similarly 1 in 200 boys are born with hypospadius making it also one of the more common birth defects. In fact, hypospadius is the second most common congenital abnormality after cryptorchidism. We do not have evidence at present to suggest that men using finasteride have a higher than 3 % risk of having a boy with cryptorchidism or higher than a 1:200 risk of hypospadius. At present, all evidence would suggest that 3% of all men who use finasteride would have a baby boy born with cryptorchidism -the same rate as the general population. Similarly, all evidence would suggest that 1 in 200 men who use finasteride would have a baby boy born with hypospadius - the same rate as the general population.

It's important to be aware that finasteride can lower semen volume in some men.  Therefore, men may wish to stop finasteride if there is any issues regarding fertility in the couple.  Women, however, must never use finasteride during pregnancy and must never touch crushed tablets.

REFERENCES

1. Amichai B, Grunwald MH, Sobel R. 5 alpha-reductase inhibitors—a new hope in dermatology? Int J Dermatol1997;36:182-4.

2. Mowszowicz I, Melanitou E, Doukani A, Wright F, Kuttenn F, Mauvais-Jarvis P. Androgen binding capac- ity and 5 alpha-reductase activity in pubic skin fibro- blasts from hirsute patients. J Clin Endocrinol Metab1983;56:1209-13.

3. Cather JC, Lane D, Heaphy MR Jr, Nelson BR. Finasteride: an update and review. Cutis 1999;64:167-72.

4. Merck Frosst Canada & Co. Propecia—discontinuation prior to/during pregnancy. Dorval, Que: Merck Frosst Canada; 2000.
5. Overstreet JW, Fuh WL, Gould J, Howards SS, Lieber

MM, Hellstrom W, et al. Chronic treatment with finasteride daily does not affect spermatogenesis or semen production in young men. J Urol 1999;162:1295-300.

6. Imperato-McGinley J, Guerrero L, Gautier T, Peterson RE. Steroid 5α-reductase deficiency in man: an inherited form of male pseudohermaphroditism. Science1974;186:1213-5.

7. Walsh PC, Madden JD, Harrod MJ, Goldstein JL, MacDonald PC, Wilson JD. Familial incomplete male pseudohermaphroditism, type 2. Decreased dihydrotestosterone formation in pseudovaginal perineo- scrotal hypospadias. N Engl J Med 1974;291:944-9.

8. Katz MD, Kligman I, Cai LQ, Zhu YS, Fratianni CM, Zervoudakis I, et al. Paternity by intrauterine insemination with sperm from a man with 5 α-reductase 2 deficiency. N Engl J Med 1997;336:994-7.

9. Ivarrson SA, Nielsen MD, Lindberg T. Male pseudoher- maphroditism due to 5 alpha-reductase deficiency in a Swedish family. Eur J Pediatr 1988;147:532-5.

10. Moghetti P, Castello R, Magnani CM, Tosi F, Negri C, Armanini D, et al. Clinical and hormonal effects of 5 α-reductase inhibitor finasteride in idiopathic hirsutism. J Clin Endocrinol Metab 1994;79:1115-21.

11. Serafini P, Ablan F, Lobo RA. 5 alpha-reductase activity in the genital skin of hirsute women. J Clin Endocrinol Metab 1985;60:349-55.

Starting Two Treatments at Once: Good Idea or Not?

Starting two treatments Simultaneously for Hair Loss:

For individuals with genetic hair loss, I never recommend starting two treatments at once. Certainly the rules are sometimes a little bit different for other types of hair loss, but for genetic hair loss, I'm a big believer in one at a time. 

Wait 9 months

If one starts two treatments at once, it can be challenging to figure out what is working. If a patient has a hair specialist who can follow scalp growth parameters carefully, waiting 4-5 months is reasonable before starting another treatment. This gives times for the physician to evaluate changes in the scalp. Otherwise, if patients are figuring things out 'on their own" waiting 9 months is absolutely critical in order to evaluate if a treatment is working or not. 
 

Laser devices & blood flow: Is increasing blood flow the main mechanism of hair lasers?

Low level laser therapy (LLLT) for hair loss

I'm often asked if increasing blood flow to the scalp is the main mechanism of hair lasers?

In short the answer is no.

How do lasers help hair loss?

Although it is often explained that low level laser devices simply increase blood flow this is not really the precise mechanism. That's far too simple. Increasing blood flow via exercise, a hot towel or standing on one's head does not help hair loss.

The precise mechanism by which low level laser works has still to be fully understood. Laser acts at the cellular level to affect mitochondria inside cells to affect their production of a chemical known as ATP. Low level laser therapy also changes reactive oxygen species (ROS) inside cells and affects various transcription factors (which influences the messages that are exchanged deep inside the cell).

In short, low level laser therapy brings about a very complex array of biochemical and cellular changes. It's far more involved than simply altering blood flow.

Primum non nocere and the Modern S.A.F.E. Principle

Primum non nocere (Latin for "first, do no harm")

Choosing appropriate treatments for patients with any medical condition must always be guided by one of medicine's most basic principles: primum non nocere (Latin for "first, do no harm").  As health care providers, we must always consider the potential harm that a treatment can cause. Even the Hippocratic oath that many physicians recite at graduation emphasizes the promise to "abstain from doing harm."

 

My "S.A.F.E." Principle: A Personal view on the Modern Latin Phrase

As a hair loss physician, I'm frequently reminded of the importance of "primum non nocere" when treating any of the dozens and dozens of common and rare hair loss conditions.  Primum non nocere closely mirrors a principle that I've shared with medical interns, residents and medical students for many years, namely treating patients in a manner that is "S.A.F.E". Each of the four letters S, A, F, E in this four letter acronym reminds me of factors to consider when recommending treatment to patient -  in order to specifically avoid causing harm.  My S.A.F.E. Principle applies to any treatment in medicine, but I've adapted it here for my practice in hair loss. 

S: Safety

The first letter S stands for "Safety". Fundamentally, our patients count on us to bring them treatments have a good safety profile with side effects that are minimal. This is particularly important with treating hair loss, where our patients our often healthy and treatments have the potential to make them unhealthy. I can tell you first hand that the risks patients are willing to take to grow more hair is incredibly varied.  For some patients with hair loss,  any side effects are unacceptable. These patients often proclaim "after all, doctor, it's only hair."  For others, hair is central to their self-identity and many risks are accepted.    It seems unbelievable to an outsider when I share with them results from studies that have shown that men are willing to give up years of life for better hair.  Helping patients better understand not only the side effects of a given medication or treatment but also how commonly they occur is important in order for them to be fully informed. Initiating treatments with many potential side effects has the potential to harm the patient and is clearly not in keeping with "primum non nocere." 

A: Affordability

The second letter "A" in my S.A.F.E. Principle stands for affordability. Helping patients find affordable, safe and effective treatments is the responsibility of the physician. What is the cost of the given treatment and is it affordable?  What are the alternatives and the cost of alternatives? Are there one time costs or ongoing costs? Is the treatment covered by insurance?  I can think of many hair loss conditions where I can achieve the same result with a $ 100.00 treatment as I can with a $ 20,000 treatment. What is the best option? Fortunately, I don't have to answer that as society dictates what the correct answer is. Unfortunately, it is often forgotten what the correct answer is. Clearly, starting a treatment that is not affordable to the patient can create considerable harm and is not in keeping with "primum non nocere."

F: Feasibility

The third letter "F" stands for feasibility. For any treatment we need to consider how feasible or "likely" is it for the patient to ultimately adhere to the recommended treatment. Some treatments administered by the patient "at home" and are too time consuming, too messy or too inconvenient for them. There treatments may sound okay to the patient sitting across from me at the office, but once the patient gets home it quickly becomes clear this just is not feasible. Similarly, some treatments require frequent office visits which also create challenges.   Clearly, starting a treatment that is not feasible to the patient can create harm by wasting time or creating other difficulties in the patient's life and is clearly not in keeping with "primum non nocere."

E: Effectiveness

The final letter "E" in the four letter acronym stands for effectiveness. Not all treatments for hair loss have the same effectiveness! Some are very effective, some are mildly beneficial and others don't help at all or have the potential to worsen hair loss. Using a treatment that is highly advertised but highly ineffective takes money from the patient, delays treatment for the patient and may even allow the hair loss to progress.  At present, there are very few regulations or laws to protect patents and sadly another Latin phrase often comes into effect for patents with hair loss: caveat emptor (Latin, buyer beware). The use of ineffective treatments is also not in keeping with "primum non nocere."

S.A.F.E. PRINCIPLE

Treatments must be safe, affordable, feasible and effective. The four letter "S.A.F.E." acronym reminds me of these important considerations in order to practice in a manner reflecting the principles of "primum non nocere."

Minoxidil for Telogen Effluvium: Maybe.

Minoxidil is not a simple patch for TE

I'm often asked if minoxidil can be used for a telogen effluvium which is a hair shedding condition where the amount of daily hair shedding goes up. The answer is (unfortunately) ... maybe.

Key to helping stop a shedding problem is determining the cause!

Minoxidil can sometimes help a patient with a telogen effluvium. However the key treatment is to figure out the cause of the patient's shedding including:

1. stressful events (bereavement, break up and financial problems)
2. thyroid problems
3. nutritional issues (weight loss, bowel problems)
4. crash diets
5. low iron
6. medications (antidepressants, lithium, beta blockers, heparin)
7. internal illnesses (lupus, autoimmune disease, cancers)

What tests are needed for anyone with shedding?

Blood tests and a full comprehensive examination is needed for anyone with a telogen effluvium.
 

FINAL COMMENTS

Yes, Minoxidil can help a proportion with TE but not everyone. It some it makes worse. Telogen effluvium (if truly the diagnosis) can be challenging to treat. I advise patients to get expert advice rather than self diagnose and attempt to patch the situation. 
 

Each individual with hair loss has a unique story

The Story

Each and every patient with hair loss has a unique "story" to share about his of her hair loss. No two people are the same. Even the pair of identical twins I saw this month each shared very different stories.

The Plot: Not Always Essential to My Diagnosis

For some patients, a precise and accurate story of the hair loss is extremely important to me and I need to collect all the details in order to help formulate a diagnosis. For other patients, the actual story of hair loss is interesting but it is the "up close" examination or results from some other testing that allows me to render the diagnosis.

The Plot: Always Essential to the Patient

But regardless of whether I deem the details of a patient's story as "important" or "unimportant" to my diagnostic work-up, it must always be remembered that to the patient every detail of his or her story is important. They live it!

How many days does it take for grafts to 'take'?

Day 10 is a key milestone in hair transplantation.

After about 10 days days, hairs are pretty well adapted to their new location. There is still a need to continue proper post operative washing steps but there is little that can go wrong for most patients after Day 10.  In fact, there is really only two ways that hairs can be damaged at this point

1) the patient forefully pulls them out or bumps the head

2) the patient allows thick crusting to develop on the scalp that ultimately causes the hair to come out when the crust is removed

 

Washing and post op care is key

Post operative washing is very important and we explain these steps very carefully to our patients. We like patients to wash with a gentle stream of soapy water for day 1-6 (without touching the grafts) and then gently massage the grafts from day 7-14 to loosen any crusts. We routinely ask patients to use baby oil from day 7-14 to loosen up and soften up crusts. 

Is there much that can go 'wrong' after day 10?

Provided the patient does a good job with crust removal and does not bump his or her head there is little that can do wrong at this point. Hairs are allowed to start coming out a few days after FUE. More and more hairs will be seen coming out week 2, 3 and 4. 

Are transplanted hair follicles prone to DHT or resistant to DHT?

Hair transplants 'usually' resistant to DHT - but not always!

I'm often asked if transplanted hair follicles prone to DHT or resistant to DHT? It's a good question and not as straight forward as it may look initially. Here's some facts:

1. Certainly, the "existing" hair is prone to the effects of DHT

2. If one has an FUE and hairs are removed from a part of the donor area that is not in the permanent donor zone (ie too high up on the back of the scalp), then yes these hairs may be prone to effects of DHT

3. Some males have diffuse patterned alopecia (DUPA). They are not good transplant candidates and will have their donor hair further weakened by DHT.

Conclusion:

All in all, donor hair is usually fairly resistant to DHT's action. But one can not say 100 % resistant.