Chronic telogen effluvium vs Genetic hair loss - Easily confused !

CTE vs AGA - easily confused but different conditions

CTE and AGA are often easily confused. Labs normal in both. Family history of hair loss similar in both. Hair check similar in both. Biopsy often unhelpful unless done properly (meaning transverse sections and measurement of terminal to vellus ratios).

CTE takes time to figure out. Info on family history of AGA is not useful at all in diagnosing AGA in women.  AGA doesn't start in the 50s in women. All in all, you'd need a careful examination. CTE is the most challenging of diagnoses.

FEATURES OF CTE

1. CTE leads to fluctuations in shedding with shorter breaks

2. Women often once had thick hair (very thick)

3. Miniaturization not typical

4. Onset is sudden

5. Scalp sensations (tingling, burning) often present

6. Pretty normal looking scalp exam or maybe significant temple recession in some

7. Labs normal

8. Some days 50 hairs lost; some days 350-400

9. After 6-8 months, tends to reach a balance between shedding and growing and patients look similar month after month (despite massive shedding!!!)

10.           Biopsy done with horizontal sections show terminal to vellus ratios above 8:1 (whereas less than 4:1 for AGA)

11.           Central part width not typically widened in CTE

CONCLUSION

I understand how tough it is to get a diagnosis of CTE vs AGA. But they are very different conditions.

What are the most effective and best researched treatments for lichen planopilaris?

LPP treatments: Where does the research point to?

Lichen planopilairis (LPP) is an autoimmune scarring hair loss condition that affected adults between 35 and 60. Patients develop hair loss but also symptoms of itching, burning and pain. The early stages of LPP are accompanied by increased shedding as well. Aggressive and early treatment of LPP is required to stop the hair loss. 

 

What treatments are most effective?

Treatment that block inflammation are most effective. But not any anti-inflammatory can be used. For example, aspirin and ibuprofen don't help. Rather anti-inflammatories belonging to a group of medications known as immunosuppressive and immunomodulatory drugs work best. This includes:

1. Topical steroids (mid to strong potency) and steroid injections

2. Topical tacrolimus (Protopic) and topical pimecrolimus (Elidel)

3. Oral hydroxychloroquine (Plaquenil and generics)

4. Oral tetracyclines (doxycycline, tetracyline, minocycline)

5. Oral cyclosporine (Neoral, prograft, Sandimmune)

6. Oral mycophenolate mofetil (Cellcept, Myfortic)

7. Oral predisone (mainly for flares and early bridging treatment, not long term)

These 7 treatments have the best published evidence for assistance with lichen planopilaris. Any other treatment has less evidence. 

Conclusion

Whenever a patient tells me they have tried treatments for lichen planopilaris and it didn't work, I want to know two things. First, I want to know if they truly have lichen planopilaris as there are many many mimickers. Biopsies can be wrong ... yes! and yes! Conditions like pseudopelade of Brocq can mimic LPP and so can a few other scarring alopecias (discoid lupus and folliculitis decalvans). The second thing I want to know is what treatments the patient has tried.  I've heard countless treatments - perhaps well over 60 to date. Being on treatment does not count unless it's a potentially beneficial one. 

 

References

 

Lichen planopilaris: update on pathogenesis and treatment.

Baibergenova A, Donovan J. Skinmed. 2013 May-Jun;11(3):161-5. Review

Efficacy of oral retinoids in treatment-resistant lichen planopilaris.

Spano F, Donovan JC. J Am Acad Dermatol. 2014 Nov;71(5):1016-8. doi: 10.1016/j.jaad.2014.06.013. Epub 2014 Oct 15.  

Lichen planopilaris following whole brain irradiation.

Perrin AJ, Donovan JC. Int J Dermatol. 2014 Oct;53(10):e468-70. doi: 10.1111/ijd.12576. Epub 2014 Jun 5.  

Scalp trauma: a risk factor for lichen planopilaris?

Montpellier RA, Donovan JC. J Cutan Med Surg. 2014 May-Jun;18(3):214-6.

Lichen planopilaris after hair transplantation: report of 17 cases.

Donovan J. Dermatol Surg. 2012 Dec;38(12):1998-2004.

Genetic hair loss in women: sides and back can be affected too

Genetic hair loss in women is different than men

Genetic hair loss in women classically affects the middle and top of the scalp. The scalp becomes more 'see through'. Hairs become miniaturized. Patterns such as the Ludwig pattern of hair loss and the Olsen pattern of hair loss are often talked about. 

What about the sides and back?

What tends to be forgotten is that the sides and back of the scalp are often affected in many women with genetic hair loss. We call this 'diffuse loss.' Diffuse thinning of hair occurs in many women. The area at the sides of the scalp just above the ear becomes noticeably thinning and the back of the scalp becomes thinner as well. 

Treatments for diffuse androgenetic thinning in women include minoxidil, spironolactone, low level laser therapy, and platelet rich plasma. Women with diffuse thinning are not candidates for hair transplant surgery because the hairs at the back of the scalp are thinning  - the donor area is poor. 

Minoxidil after hair transplantation

Minoxidil after hair transplantation: Is there a role?

I’m often asked whether minoxidil has any role in post operative care after a hair transplant. My general advice is that minoxidil may help reduce shedding of grafts and shedding of existing hair (ie. a post operative telogen effluvium) ...  but does not appear to influence the chance of the grafts surviving.

Here are some studies of note:

In 1987, Kassimir first reported that 2 of 12 patients undergoing a hair transplant showed growth of the grafts without shedding. Thereafter, Singh published a study with 40 patients showing that minoxidil did not affect the survival of grafts after a transplant but did affect the chances that the grafts would be shed. A similar finding was reported by Bouhanna in 1989.

Overall there is a role for minoxidil in pre and post operative care. Minoxidil may reduce shedding of grafts and may reduce the post operative telogen effluvium of existing hair as well. Whether or not one should use it, however, needs to be reviewed on a case by case basis.

STUDIES:

1. Kassimir JJ. Use of topical minoxidil as a possible adjunct to hair transplant surgery. A pilot study. J Am Acad Dermatol. 1987 Mar;16(3 Pt 2):685-7.

2. Bouhanna P. Topical minoxidil used before and after hair transplantation. J Dermatol Surg Oncol. 1989 Jan;15(1):50-3.

3. Singh G. Effect of minoxidil on hair transplantation in alopecia androgenetica. Indian J Dermatol Venereol Leprol. 1998 Jan-Feb;64(1):23-4.

Monitoring blood tests in patients receiving tofacitinib (Xeljanz)

What lab tests are most important to monitor in alopecia areata patients receiving tofacitinib?

Tofacitinib is an oral medication that is used off label for the treatment of alopecia areata.  Research continues into exactly how much it helps patients with alopecia areata.  Frequent blood tests are required during the first few weeks and months of use.

Changes in four main areas are possible.

1.     Changes in blood counts. Tofacitinib can cause a reduction in neutrophils as well as lymphocytes. Patients with more severe reductions in lymphocytes appeaer to be at greatest risk for developing injections. This effect is greatest in patients receiving 10 mg compared to 5 mg.

2.     Increases in cholesterol levels. Patients experience inceases in both LDL and HDL. This effect is greatest in patients receiving 10 mg compared to 5 mg.

3.     Increase in liver enzymes. This is rather uncommon but needs to be monitored.

4.     Increase is creatine phosphokinease (CPK, CK). This occurs in a proportion of patients and is usually withouth consequence for most patients. The drug must be stopped however, when levels increase 50 % above baseline. This effect on CPK levels is greatest in patients receiving 10 mg compared to 5 mg.

Comment: 

Frequent blood tests are needed when starting tofacitinib. Slight changes are not uncommon but more significant changes may require dose reduction or even stopping of the drug. Anyone starting tofacitinib requires close monitoring. 

Predicting the rate of progression of male balding

Male balding progresses at different rates in men

I'm often asked to help patients predict their rate of balding? How different will they look in 1 year? How different in 2 years? When will they look like their father or a specific photo they bring in?

Getting a sense of male balding rates of progression is challenging and certainly becomes more reliable as the patient ages. For example, predicting what someone will look like at 50 is easier to predict at 40 than 20.  However, with a series of carefully chose questions and a through evaluation of the scalp it is often possible to gain some understanding of the patient's rate of balding. 

The following questions are 'key' to ask when assessing the likelihood and degree of progression of male pattern balding:

1. What age did the hair loss start?
2. What is the current age of the patient?
3. How much progression has occurred in 6 months?
4. How much progression has occurred in 12 months
5. How much progression has occurred in 5 years (if hair loss started more than 5 years ago)?
6. What medications are used by the patient? What has been the results?
7. How much hair loss does the patent's father has?
8. What age (if any) did the patient's father start balding?
9. Does the patient's mother have hair loss?
10. What are the hair loss patterns of both grandfathers?
11. Are there any males in the extended family who have a Hamilton Norwood above level VI? If yes, how many?
12. What medications does the patient take now?
13. What mediations were used in the past ? (anabolic steroids, isotretinoin)?
14. Is the patient a smoker?
15. What is the patients' health?
16. What sun exposure has the patient had over the years?
17. Is the patient obese?
18. Does the patient have high cholesterol?
19. Does the patient have diabetes?
20. Does the patient have high stress?

The following items are key to evaluate when assessing the scalp in order to evaluate the likelihood and degree of progression of male pattern balding:

1. What is the current position of the frontal hairline? How much has it changed since age 12?
2. How much temporal recession due to balding (not hairline maturation) is there? How much has it changed since age 12?
3. What change have occurred in the crown?
4. What changes have occurred in the area in front of the ear (pre auricular area)?
5. Is there hair loss in the back of the scalp (occipital area)? Is the pattern of hair loss best described as 'diffuse unpatterned alopecia (DUPA)?
6. What percent of hairs are miniaturized in the frontal, mid scalp, crown and occipital scalp?
7. What changes in miniaturization have occurred in the past 6, 12 and 18 months?
8. Is their seborrheic dermatitis present in the scalp? What other scalp conditions are present?

Trichotillomania - is the hair loss permanent?

Trichotillomania

Trichotillomania refers to hair loss caused by a person pulling his or her own hair. Trichotillomania is common and up to 4 % of the world is affected. Some individuals pull hair when stressed. Others have underlying depression, anxiety or obsessive compulsive disorders. Both children and adults can be affected.

Does hair grow back in trichotillomania?

Trichotillomania: This patient's hair loss is caused the self induced pulling of hair. 

Some amount of hair loss may be permanent in trichotillomania, especially if it has been going on for many years. The only way to promote hair growth is to stop the pulling. Repeated pulling damages hair follicles, causes inflammation in the skin and triggers scar tissue to develop.

The photo on the right shows a patient with advanced trichotillomania. Small broken off hairs are seen all over and whitish discolouration from the presence of scar tissue is present. Hair loss in this area is likely to be permanent. 

Treatments for Trichtotillomania

The main treatment is to stop the pulling.  Assistance from a psychologist or psychiatrist is often needed to address the underlying issues that caused the pulling in the first place. Cognitive behaviour therapy, and other types of counselling are the mainstay of treatment. Treatments to promote hair growth (such as minoxidil) and treatments to stop inflammation are often used but these are less important than addressing the underlying psychological issues that led to the pulling in the first place. 

Does shaving the scalp affect hair growth?

Shaving has no effect on scalp growth 

I'm often asked if shaving affects hair growth. The answer is no. Shaving has no effect of the growth properties of the hair follicle and the decisions that are made by the dermal papillae and hair matrix which are deep under the scalp.

Men with genetic hair loss often shave the scalp to reduce the contrast between the thin miniaturizing hairs or vellus hairs and the terminal hairs. Some individuals with alopecia areata also shave for a similar reason. 

But the decision to have is purely cosmetic and has no effects whatsoever on hair growth. 

International Hair Course: Another Cycle begins

Biannual Hair Course starts in Toronto 

Yesterday, I had the honor of welcoming physicians into my practice for the Spring session of the International Hair course. Twice per year - in the spring and fall - I conduct a course for physicians interested in learning more about hair loss and hair transplantation.

I enjoy the course a lot and have had the opportunity to meet physicians around the world who are interested in treating hair loss. Some come equipped with great skills already and are hoping to fine tune their skills even more. Some come as relative novices in the field of hair loss and are hoping to develop a solid framework. 

The week is an intensive week of training. Through a series of clinics, surgeries, lectures, workshops, and quizzes, participants have the opportunity to learn about hair loss. 6 clinics, held on Monday, Wednesday and Thursday offer participants the opportunity to see some of the most challenging cases of hair loss.  Two surgeries held on Tuesday and Friday allow participants to observe both modern methods of hair transplantation - FUSS (follicular unit strip surgery) and FUE (follicular unit extraction).  A session is also provided on the use of platelet rich plasma (PRP) in treating hair loss and demonstrations of the technique are provided.

Looking forward to another great week.

Hair Loss from Methotrexate

Methotrexate: Several Mechanisms of Hair Loss

Methotrexate is a medication which is widely used in to areas - as a cancer treatment and as a treatment for a wide variety of autoimmune conditions. 

Hair loss from methotrexate can occur but is not common. This side effect is estimated to occur in 5-10 % of users. There are two means by which hair loss can occur: hair shedding and hair breakage. 

Hair breakage from methotrexate. Trichorrhexis nodosa is shown in one hair. 

Hair shedding occurs within the first 4-7 weeks and hair comes out by the root. This type of hair loss can range from mild to marked and depends on the dose of the drug used. 

Hair breakage occurs within the first 2-3 months. Rather than breaking off at the root, affected patients notice pieces of hair falling everywhere. A close up examination of hairs shows a phenomenon known as trichorrhexis nodosa. This is shown in the photo to the right. 

Robotic Hair Restoration with ARTAS

The ARTAS Robot

Yesterday we did a video segment on the ARTAS and so today I'll review with you the ARTAS machine. 

The ARTAS is a robotic method of performing follicular unit extraction hair restoration. ARTAS received FDA approved in 2011. The device consists of a computer connected to a mechanical arm which in turn connects to two things - a video imaging interface (with multiple cameras) and a punch device. The entire system is controlled by the surgeon - either with a remote control device or with the computer.  

The ARTAS Punch

The punch is a circular device which removes the grafts from the skin. There are two aspects to the punch - one inner sharp punch and one outer dull punch.  The first inner sharp punch scores the skin to a depth of about 1/16th of an inch. The is followed by the outer dull punch with extracts the grafts. 

Advantages of ARTAS

The ARTAS has three main advantages in my opinion

1. Accuracy

One important limitation of manual follicular unit extraction is surgeon fatigue.  After 2500-3000 grafts fatigue sets in. Is the quality of graft 3000 the same as graft 1? We hope so! But the ARTAS does not fatigue. To the robot, graft 3000 is just the same as graft 1. The accuracy and precision of the robot are unparalleled.

2. Graft quality

For the right patient, the quality of grafts can be very high because the robot helps limit damage to the grafts (what we call transection). With better grafts, the survival is likely higher. With higher survival of grafts, the result for the patient is better density. 

3. Speed.

At top speeds the robot can extract up to 600 follicular units per hours. Faster speed means shorter procedures for the patient, and less time for the grafts to be out of the body... which in turn means better graft survival.

Hair transplants for Lichen planopilaris

Are hair transplants possible for LPP?

I frequently perform hair transplants for a group of conditions known as scarring alopecias. These conditions are frequently autoimmune in nature and have names like lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia. 

When can a hair transplant be done in LPP?

A hair transplant is not possible for many patients with these conditions because the condition is "active." However, once the condition becomes "quiet" - a hair transplant can be considered. 

By 'quiet', several conditions must be met. These are summarized in the LPP Hair Transplant Criteria.

Donovan LPP Hair Transplant Candidacy Criteria

In order to be a candidate for hair transplant surgery,  ALL FIVE of the following criteria must be met:

1.  The PATIENT should be off medications.

Ideally the patient should be off all topical,  oral and injection medications to truly know that the disease is "burned out (burnt out)". However, in RARE cases, it may be possible to perform a transplant in someone using medications AND who meets criteria 2, 3 and 4 below.  This should only be done on a case by case basis and in rare circumstances. It is a last resort in a well-informed patient. 

2. The PATIENT must not report symptoms related to the LPP in the past 12 months, (and ideally 24 months) .

The patient must have no significant itching, burning or pain. One must always keep in mind that the absence of symptoms does not prove the disease is quiet but the presence of symptoms certainly raises suspicion the disease could be active.  Even the periodic development of itching or burning from time to time could indicate the disease has triggers that cause a flare and that the patient is not a candidate for surgery. The patient who dabs a bit of clobetasol now and then on the scalp to control a bit of itching may also have disease that is not completely quiet. 

3. The PHYSICIAN must make note of no clinical evidence of active LPP in the past 12 months, (and ideally 24 months).

There must be no scalp clinical evidence of active LPP such as perifollicular erythema, perifollicular scale (follicular hyperkeratosis). This assessment is best done with a patient who has not washed his or her hair for 48 hours. Some scalp redness may be persistent in patients with scarring alopecia even when the disease is quiet. Therefore scalp redness alone does not necessarily equate to a concerning finding. Perifollicular redness however is more concerning for disease activity.  In addition, the pull test must be completely negative for anagen hairs and less than 4 for telogen hairs.  A positive pull test for anagen hairs indicates an active scarring alopecia regardless of any other criteria.

4. Both the PATIENT and PHYSICIAN must show no evidence of ongoing hair loss over the past 12 months (and ideally 24 months). 

There must be no further hair loss over a period of 24 months of monitoring off the previous hair loss treatment medications. This general includes the patient and physician's perception that there has been no further loss as well as serial photographs every 6-12 months showing no changes. 

5. The patient must have sufficient donor hair for the transplant.

Not all patients with LPP maintain sufficient donor hair even if the disease has become quiet. 

 

The Chance of Disease Reactivation Following Surgery

It is important to be aware that any patient with LPP is at risk for reactivation or a 'flare' of their LPP after surgery.  The risk, I estimate based on all the patients I follow, is as follows:

LPP Reactivation Risk (Donovan, J, unpublished data)

i)               A patient with active LPP before their transplant is nearly guaranteed to have a flare of his or her LPP if a hair transplant is done. (estimate 90-100 % chance of flare within 2 years post transplant)

ii)             A patient with partially active LPP before their transplant is very likely to have a flare if a hair transplant is done. (estimate 70-90 % chance of flare within 2 years post transplant)

iii)            A patient with medication induced inactive LPP before their transplant has a moderate chance of a flare if a hair transplant is done (estimate 50-70 % chance of flare within 2 years post transplant)

iv)            A patient with inactive LPP off all medications for 1 year before their transplant has a low chance of a flare if a hair transplant is done (estimate 10-25 % chance of flare within 2 years post transplant)

v)             A patient with inactive LPP off all medications for 2 years before their transplant has a low but definite chance of a flare if a hair transplant is done (estimate less than 10% chance of flare within 2 years post transplant)

 

 

What are the differences between transplants in LPP vs other types of hair loss (genetic hair loss)?

The difference between performing hair transplants for scarring alopecia and hair transplants for genetic hair loss is that the grafts are at slight risk of being lost in those with scarring alopecia. For example, in genetic hair loss we generally say the grafts are permanent. That is not the case in scarring alopecia. There is a very small albeit definite risk of reactivation of the disease that needs to be carefully monitored and followed. 

Due to the small risk of reactivation in scarring alopecia, I am a big believer in keeping patients on some type of baseline treatment to keep the condition quiet.

My general principles for transplanting scarring alopecia include:

1. Considering small test sessions when appropriate.

2. Limiting the amount of epinephrine

3. Minimizing over trimming of grafts to ensure healthy proportion of stem cells get transplanted

4. Use of minoxidil in some cases pre and post op to promote blood blow

5. Adhering to densities 20-30 FU/cm2

6. Restarting topical, injection or oral immunomodulatory medications on a patient specific protocol (depending on the specific condition, how long the patient has had it, amount of hair loss, age). Although I frequently like to know a patient has been stable off medications for a prolonged period of time, I frequently restart periodic use of a corticosteroid or periodic use of low dose hydroxychloroquine depending on a number of factors. It must be noted that 10-25 % of patients with what would be considered quite 'inactive' disease will have flare so in our clinic we are quite aggressive in suppressing inflammation pre op and post op.

Further reading

Consider reading the following articles for further information 

How is LPP best treated?

What are the clinical signs of LPP?

Conclusion

Hair transplantation for scarring alopecia is among the most challenging types of hair transplants. In the appropriate patient, it can be a very helpful means to improve density. I generally recommend that patients have inactive disease for 2 years, meaning that there has been no hair loss and no scalp symptoms over a period of 2 years. 

Why aren't hair transplants commonly done before 25?

Hair transplants are rarely done before 25 in men

Hair transplants are rarely done before 25 because it's in the best interest of the patient to wait. 

A patient generally has in the back of the scalp only a limited number of hairs to move in his lifetime (i.e. hairs available to transplant). It may be 0. It may be 8000. That's a huge range I know. The older a patient gets the easier it is for his physician to tell him if the number is 0 or 8000. Only a small percent of men have 0 available - and these are men with a type of balding called diffuse unpatterned alopecia. 

By age 25-30, the patient will get a much better sense of where on this scale from 0 to 8000 he falls. If he only has 4000 available, most men want to reserve as many of these precious grafts as possible to place somewhere in the middle of the scalp, rather than use them up in a location like the temples or lowering the hairline. It's normal to want to get hair back. It's normal to want to consider a hair transplant to fix this.

My advice to young men wanting hair transplants

Let an experienced surgeon guide you and hold you back until the right time. 

How is one supposed to use topical minoxidil?

Minoxidil: how does one use it?

Topical minoxidil helps men and women with genetic hair loss (also called androgenetic alopecia) and is formally FDA approved for treating hair loss. If you have another kind of hair loss, it might not work or not as well. Minoxidil must be used forever if individuals are using for genetic hair loss. Minoxidil is not for everyone. I always  recommend individuals to follow the direction of his or her own physician and carefully review the packaging as well.

For men

Minoxidil 5 % foam is used 1/2 cap twice daily. 

For the minoxidil liquid the dose is 1 mL (approx 25 drops) twice daily. It is applied to the scalp and allowed to remain on for at least 6-8 hours. 

For women

1 mL of the 2 % lotion/solution is formally FDA approved. 

Some women opt to consider once daily application of the 5 % foam which is also now FDA approved. The 5 % lotion can also be used at a dose of 1 mL daily.

Regardless of the product used, minoxidil should be applied to a dry scalp and allowed to remain on the scalp at least 6-8 hours (longer is fine). Other products such as gels, sprays, mousse can be applied within 15 minutes. The goal is to get the product on the scalp, so I recommend  patients to make several parts in the hair to help ensure the minoxidil reaches the scalp. Side effects of minoxidil should be fully reviewed with a physician or pharmacist prior to starting.

Side effects of minoxidil

Side effects should be thoroughly reviewed by everyone before starting treatment. These include:

1. headaches

2. dizziness

3. heart palpitations

4. hair growth on the face (in 5% of users)

5. hair shedding in months 1-2

6. irritation

7. allergy (rare)

8. swelling in the feet

Other side effects are possible but rare. Minoxidil must never be used by women during pregnancy.

Ruxolitinib (Jakafi) promotes hair regrowth in a patient with alopecia areata

More data pointing to benefits of Ruxolitinib

I've shared my thoughts as well as previous data on these new so called JAK inhibitors (Ruxolitinib and Tofacitinib) in the treatment of alopecia areata. 

I was interested to read this morning a study showing benefit of ruxolitinib at a dose of 20 mg twice daily in a 35 year old man with two autoimmune diseases - vitiligo and alopecia areata. Hair growth started after 4 weeks and was quite significant by 3 months. 

Ruxolitinib is an oral medication that is FDA approved for treatment of bone marrow cancer known as myelofibrosis.  The drug inhibits a pathway within cells known as the JANUS KINASE pathway and ruxolitinib specifically inhibits Jak 1 and Jak2. Tofacitinib, which is closely related compound and also benefits some patients with alopecia areata, is an inhibitor of Jak 1 and Jak 3.

Conclusion

I'm closely following the JAK story and ruxolitinib. I have been using tofacitinib (Xeljanz) for a while now but will continue to follow the ruxolitinib data and the clinical trials that are underway. 

REFERENCE

Harris JE et al. Rapid skin repigmentation on oral ruxolitinib in  a patient with coexistent vitiligo and alopecia areata (AA). Journal of the American Academy of Dermatology Feb 2016.

Pulse steroid therapy for alopecia areata: how good is it?

Pulse therapy helps those with recent onset hair loss

Alopecia areata is an autoimmune disease that affects children and adults. There are several possible treatments including topical steroids, steroid injections, minoxidil,  anthralin, diphencyprone, oral steroid, methotrexate, sulfasalazine, cyclosporine.

Oral steroids are often used as "pulse therapy" meaning the steroids are given for short periods of time with long breaks in between. A recent study looked at all of the published studies to date looking at the benefits of such a treatment plan in patients with alopecia areata. A total of 41 studies with 1078 were included in the researchers analyses.

Not surprisingly, the review showed that pulse therapy is effective for many patients - but not all. 

Best prognosis in those with 3 factors

These studies showed that patients with three factors seemed to respond best to pulsed steroid therapy, including those with what I call the "3 S's of steroid therapy"

1. START OF DISEASE.

• Individuals who just developed their first episode of alopecia areata respond best to steroid treatments than than those who have had previous patches in the past. 

2. SOME HAIR REMAINING. 

• Individuals who have multiple patches of alopecia rather than complete loss of hair respond best to steroid than than those who have had the condition for a long time. 

3. SHORT DURATION

• Individuals who have developed hair loss within the past 2 years respond best to steroid than than those who have been without hair for a long time. 

REFERENCE
Shreberk-Hassidim R et al. A systematic review of pulse steroid therapy for alopecia areata. J Am Acad Dermatol Feb 2016. 

Short term to moderate term use of topical steroids around the eyes: How safe is it?

Few Years of Topical Steroids not associated with Cataracts and Glaucoma

I enjoyed reading an article by Khurrum and colleagues from Saudi Arabia where the authors examined the risk of cataracts and glaucoma in patients using strong steroids around the eyes.

Many of my patients use strong steroids around the eyes - especially the eyebrows. These include patients with alopecia areata who are treating eyebrow loss and patients with frontal fibrosing alopecia as well. I'm keenly aware of the possibility of cataract and glauoma risks in patients who use ORAL (pill forms) of corticosteroids. IT's rather unknown whether use of TOPICAL steroids (i.e. creams and lotions and ointments) could carry a risks. I often refer patients for eye examinations if they've been on these products for several years.

New study in Vitiligo Patients

A new study looked at the risks in patients with vitiligo - which is an autoimmune disease causing loss of pigment in the skin. It was not carried out in patients with hair loss. The researchers examined 90 patients with vitiligo and compared to 90 patents without vitiligo. The patients with vitiligo had been using steroids for approximately 4.5 years

Overall, two patients with vitiligo had glaucoma compared to none in the control group but the difference was not thought to be statistically significant.  Overall the risk of cataracts, glaucoma or other eye problems was not found to be increased. 

Conclusion

This study is good news for patients using topical steroids around the eyes in the short term. The risk of cataracts, glaucoma and other eye problems does not seem to be increased. Further studies are needed - especially in specific patient populations with hair loss (such as alopecia areata and scarring alopecias). Above all, anyone using topical steroids around the eyes needs to be carefully followed by a physician knowledgable about the safe use of these products. 

REFERENCE

Khurrum et al. Screening of glaucoma or cataract prevalence in vitiligo patients and its relationship with periorbital steroid use. Journal of Cutaneous Medicine and Surgery 2016; 20(2): 146-149

Chronic Telogen Effluvium: Most patients don't develop AGA

Chronic Telogen Effluvium and Androgenetic Alopecia are Separate Conditions

Chronic telogen effluvium ("CTE" for short) is a hair shedding condition that occurs in women age 35-60 years. Often women have extremely thick hair to begin with.  Affected patients often look like they have a lot of hair, even though they may have lost considerable amounts. 

Does CTE turn into AGA?

So does chronic telogen effluvium "turn into" AGA? This is a common concern among patients. For most patients, the answer seems to be no. It appears that many patients who shed, especially women over 50, don't go on to develop genetic hair loss. They simply shed.  

A nice study by Australian dermatologist Dr Rodney Sinclair followed 5 patients over a period of 7 years. Patients were photographed year after year after year. In 4 of the 5 patients (in other words 80 %) there was no change in the overall density between year 1 and 5. Only 1 patient developed androgenetic alopecia during this time.

Overall, it appears that for most women with CTE, the norm is not to develop androgenetic alopecia. The norm is to keep shedding.  

When can I exercise after a hair transplant?

Exercise after hair transplantation

The decision on when to exercise hard after a hair transplant really depends on whether a patient had their hair transplant via FUE or strip methods.

For my FUE patients, I like them to go easy for 7 days and then light exercise from day 7-14. For strip patients, I like them to go easy for 10 days and hit the gym or exercise hard after day 14. Widening of the donor scar is my main concern for those who exercise too early after strip surgery.

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Do I need blood tests for my hair loss? If so which ones

Blood tests for hair loss: Exactly what tests depends on many factors

 

Do all individuals with hair loss need to head to the lab for blood tests? This is such an important question and fuels much confusion. In general terms, blood tests are required for most women with hair loss. For men, they are usually not.  But each patient's hair loss needs to be reviewed on a case by case basis.

Men with hair loss

For men with male pattern balding (androgenetic alopecia), blood tests are not needed most of the time.  The one exception would be young males with male pattern balding where I often test cholesterol level as there may an increased risk of lipid abnormalities in this patient group. For men with hair loss due to various autoimmune causes (such as alopecia areata or lichen planopilaris) I often check blood tests such as basic blood counts (CBC) , thyroid (TSH), iron status (ferritin), ANA, B12, ESR. In some situations,  I'll consider a free and total testosterone.

Women with hair loss

For women, I'll not go without blood tests. Blood tests are required. Blood tests are mandatory. Simply put there are so many mimickers of female hair loss and diagnosing female hair loss is far more complex than diagnosing hair loss in men. I will order tests for basic blood counts (CBC), thyroid (TSH) and iron (ferritin) in all women with hair loss. For young women with acne or increased facial hair, a tests for DHEAS (hormones from the adrenal gland), androstenedione (hormones from the ovaries) as well as free and total testosterone and sex hormone binding globulin (SHBG) are ordered. Women with irregular menstrual cycles may require blood tests to evaluate polycystic ovarian syndrome including tests for LH, FSH, DHEAS, androstenedione, prolactin, estrogen, free and total testosterone and 17 hydroxyprogesterone (17OHP) and sex hormone binding globulin (SHBG). Blood sugars may also be checked. Women with dietary restriction may also have zinc levels checked and a few other minerals as well. Sometimes vitamin D is checked depending on where the patient lives. 

Similar to the discussion for men, women with potential autoimmune causes of hair loss require comprehensive evaluation including complete blood counts (CBC), thyroid (TSH), iron (ferritin), ESR, ANA, B12. 

Conclusion

All in all, there is no magic or standard template for ordering blood tests for a patient with hair loss. However, one must listen carefully to the patients story and examine the scalp. With this information, one can decide what blood tests to order - if they are needed at all.