Are newly growing hairs thinner than mature ones?

Newly Growing Hairs

The "miniaturization" of hairs refers to a process where hairs get thinner and thinner over time. It is frequently seen in hairs from the scalps of individuals with androgenetic alopecia (male balding and female thinning). The confirmation that a given person has miniaturized hairs frequently evokes a great amount of worry and questions about whether the individual does in fact have androgenetic alopecia. One must always keep in mind that a few conditions can produce thinner hairs - and one must not be too quick to jump to the conclusion that the patient has androgenetic alopecia.

Telogen effluvium is a hair shedding condition where hair sheds from factors such as low iron, stress, thyroid disorders or crash diets. As the hairs start growing back, they appear smaller at first until they thicken up over time. A patient with a consider number of newly regrowing hairs could be mistaken for having miniaturization due to androgenetic alopecia.

When one looks at the following picture of two trees, one can appreciate that the tree on the right is probably older than the one on the left. There is no reason to believe that with time the tree on the left won't achieve the same thickness as the tree on the right.

In cases of massive telogen effluvium, hairs thicken up to some degree over time. Re-evaluation of the patient's scalp a few months later can be helpful if one is unsure whether the patient has a TE, AGA or both.

Finasteride for Women

Can Finasteride (Propecia) be used in women?

Finasteride is not FDA approved for women. That does not mean we never use finasteride in women - in fact, I sometimes to prescribe this medication. The fact that it is not FDA approved just alerts us that there are important reasons to consider as to why it is not approved.  

 

Does FDA approval matter?

FDA approval does matter. It directs us to consider that considerable review has been done to evaluate that safety of a given medication. However, readers must keep in mind that 99 % of the medications that a hair loss doctor uses are not FDA approved!! When a medication that is not FDA approved is used, we say that this is a so called 'off label' use. 

When I use minoxidil for alopecia areata, I'm using the medication in an 'off label' manner. Minoxidil is not FDA approved for alopecia but but sure can help many patients.  In fact - there is not a single medication on the planet that is FDA approved for alopecia areata.

When I use Plaquenil for lichen planopilaris, I'm using the medication in an 'off label' manner. Plaquenil is not FDA approved for lichen planopilaris but but sure can help many patients.  In fact - there is not a single medication on the planet that is FDA approved for lichen planopilaris.

When I use clindamycin for folliculitis decalvans, I'm using the medication in an 'off label' manner. Clindamycin is not FDA approved for folliculitis decalvans but but sure can help many patients.   In fact - there is not a single medication on the planet that is FDA approved for folliculitis decalvans.

When I use minoxidil and steroid injections for traction alopecia, I'm using these medications in an 'off label' manner. Minoxidil and steroid injections are not FDA approved for traction alopecia but but sure can help many patients. In fact - there is not a single medication on the planet that is FDA approved for traction alopecia.

Finasteride for Women - It's off label.

When I use finasteride for androgenetic alopecia in women, I'm using these medications in an 'off label' manner. Finasteride is not FDA approved for androgenetic alopecia but but sure can help many patients. 

Some medications are appropriate for a given patient others are not. One really needs to sit down with a physician and discuss. Even Rogaine is not advised for some women (heart conditions, heart rhythm problems, pregnancy, other hormone abnormalities such as pheochromocytoma). 

Some physicians never prescribe finasteride to women regardless of age. Some physicians only prescribe to post menopausal women. Some physicians will prescribe to premenopausal with appropriate counceling on the risks during pregnancy and prescription of appropriate birth control.  

Finasteride must never be used by women who may become pregnant. Women with strong histories of estrogen dependent cancers (breast, ovarian, gynaecological cancers) should also review use with their doctors. This includes breast, ovarian and other gynecological cancers. Women with depression should also have a thorough discussion as to whether this drug is appropriate for them of not.

The HAIR Principle

HAIR PRINCIPLE FOR DIAGNOSING HAIR LOSS
 

Years ago, while teaching a group of dermatology residents, I came up with a 4 letter memory tool that helps remind us all about the proper steps needed to diagnose hair loss. The first letter of teach of the key steps spells HAIR:

H = History

A= Assessment

I = Investigations

R= Repeat if necessary!

"H" stands for History.

The history of a patient's hair loss is extremely important and can not be ignored. All aspects are potentially important including when the hair loss first occurred, how many days, weeks or months it's been present, symptoms that accompany the hair loss (especially scalp itching, burning or pain), prescription and non prescription medications used by the individual, family history of hair loss, personal history of any medical conditions. All these factors could be important to a patient's hair loss and need to be fully uncovered. 

"A" stands for Assessment. 

A proper and thorough assessment of the scalp involves an "up close" exam. There are times when an up close examination is not possible and photos of the scalp need to suffice. But to be confident in what's causing a person's hair loss, the scalp needs to be examined. One can not stand across the room. One needs to look - and the closer the better!

It's important to examine exactly where the hair loss is occurring. Is it occurring in the frontal area of the scalp? The top of the scalp? The middle? the back? Is the hair loss actually occurring everywhere? Is there redness? Is there scarring? 

"I" stand for Investigations.

A variety of investigations need to be considered for an individual experiencing hair loss. These include blood tests, biopsy and collection of shed hairs. It doesn't mean that all these are necessary - but it does mean that all tests need to be considered. 

For all women with hair loss, I advise three tests: complete blood counts (CBC for hemoglobin), thyroid studies (TSH test) and iron studies (ferritin test). Other studies could also be important to order depending on what is uncovered in the steps above. For men with hair loss, such tests are not always needed.

A scalp biopsy is rarely needed. With a properly obtained history and a properly conducted scalp exam (including use of dermoscopy), a biopsy becomes redundant for many patients. However, a biopsy is helpful in challenging cases and helpful in some scarring alopecias to confirm the subtype.

 

"R" stands for Repeat if necessary.

It's usually possible to diagnose hair loss with the first three steps above : history, assessment and investigations. However, there are some situations where it's just not.  In such challenging cases, the only way to definitively understand the cause of the patient's hair loss is to see them back in the office and 'follow' their hair growth and hair loss over a period of time. Sometimes this is 2 months and other times it could be 6 months or 1 year.  At each visit, the steps of history taking (H), assessment (A) and investigations (I) may be repeated. 

 

Exceptions to the HAIR Principle

There are not many exceptions to the HAIR Principle. A history of hair loss and an assessment is always required. There are many mimickers of hair loss. A photo of a patient with what looks like genetic hair loss could be genetic hair loss. But without a history one can not be certain.  Investigations, as stated above, are not always needed.  Generally blood tests are required for every female with hair loss.

Conclusion

The "H.A.I.R." Principle is a helpful memory tool to remind both physicians and patients that diagnosing hair loss might not always be quick and easy.  A carefully obtained medical history, a thorough scalp assessment and a variety of investigations need to be part of the evaluation. In some cases where the diagnosis is elusive, these steps need to be repeated in a few months

Where should I get my scalp biopsy?

Random Biopsies are Rarely Helpful

Where on the scalp should my doctor take a biopsy sample?

This is an important question as random biopsies from "just anywhere" are generally not very helpful. First, it must be stated that biopsies are not needed in most patients with hair loss. Secondly, it must also be stated that not enough patients have scalp biopsies! A biopsy should be taken from the area that is undergoing the most change. If it is decided that a biopsy is needed to exclude androgenetic alopecia (AGA), biopsies should be taken from the front, middle or top (depending on where the most change is happening). A biopsy from the very back might show changes of AGA if present - but more significant degrees of change would always be up front rather than in the very back. In suspected scarring alopecia, a biopsy should first and foremost be taken from where the dermatologist sees evidence of the condition. This is best assessed with an instrument called a "dermatoscope." Changes of scarring alopecia include redness around hairs, scaling, scarred areas, sometimes pustules and crust. The biopsy must always contain hairs as biopsies of completely scarred areas are useless. For conditions that affect the entire scalp (like acute and chronic telogen effluvium) the biopsy should be taken from the mid scalp to better assess hair cycle characteristics (anagen and telogen ratios) and to detect conditions that mimic CTE including androgenetic alopecia and lichen planopilaris (LPP).   The three "X's" in the picture show where I would typically take a biopsy to assess for CTE. Note that these biopsies are not taken from the temples - even if the patient states this is where most of the hair loss has occurred. (A separate biopsy from the temple could be considered). This allows the dermatpathologist to best assess the terminal and vellus ratios (T:V ratios). A T:V ratio above 8:1 taken from the mid scalp is highly suggestive of a diagnosis of chronic telogen effluvium. A T:V ratio less than 4:1 is more in keeping with androgenetic alopecia.

Biopsies always leave a small scar. One should consider performing a biopsy away from the central "part" if at all possible as many women make use of a central part to style their hair. 

Standardized Hair Collections

Identifying AGA and TE

Telogen effluvium (TE) and androgenetic alopecia (AGA) are common, especially among women. There are many ways to differentiate a shedding disorder (TE) from AGA - and some women have both. 

A clinical examination of the scalp, a biopsy and a so called "hair collection" are three methods to evaluate a patient's diagnosis. Exactly which one I use depends on the specific clinical situation. Certainly not everyone with hair loss needs a biopsy and not everyone needs to perform a hair collection.

There are many different ways to perform a hair collection. Rebora studied the use of the 5 day hair collection, where shampooed hairs are trapped on a gauze 5 days after shampooing. The collected hairs are divided into three groups: telogen vellus hairs (less than 3 cm), intermediate hairs (3-5 cm) and long hairs (more than 5 cm). The presence of more than 10 % non broken hairs 3 cm or less is suggestive of the diagnosis of androgenetic alopecia (AGA).

Reference

Distinguishing androgenetic alopecia from chronic telogen effluvium when associated in the same patient: a simple noninvasive method.
Rebora A, et al. Arch Dermatol. 2005.

Who said miniaturization only happens in AGA?

Miniaturization of Hairs

It is often said that the "miniaturization" of hairs (ie the progressive thinning of hairs) is a key feature specific to men and women with androgenetic alopecia. However, this is not accurate.

Miniaturization can be seen in many conditions including traction alopecia, alopecia areata (shown here) as well as androgenetic alopecia.

Hair Shedding and the "Exogen" Phase

Exogen Phase

There are various phases of the hair growth cycle that you may have heard of such as anagen, catagen and telogen. Anagen is the growing phase. Catagen is the transitional phase. Telogen is the resting phase where hairs stop growing. At the end of the telogen phase, hairs shed from the body- and end up in our brushes, combs, and shower drains.

So what is the "exogen phase"? Well, for years it was thought that once a hair is ready to be shed, it simply leaves that scalp when a hair underneath pushes it out. We know now that is untrue. A hair can of course leave the scalp when enough tug is given to it. However, the departure of a hair from the scalp is now recognized to be a highly regulated process which is known as "exogen." Therefore, hairs are not simply pushed out of the scalp - the process is tightly regulated.

This picture shows the scalp of a patient with a telogen effluvium (hair shedding disorder). Upright regrowing hairs (URG) are seen. In addition, a telogen hair (also called a club hair) can also be seen. This hair has officially been shed from the patient's scalp. It is nested amongst the existing hair. At the time of the next patient's next shampooing or brushing it will likely be removed completely from the scalp.
 

Miniaturized Hairs

Do they grow the same length as originial hairs?

In the early stages of androgenetic alopecia (first few years), miniaturized hairs grow almost the same length as original hairs (not quite but close). 

As time passes, and if androgenetic alopecia progresses, them miniaturized hairs grow in the scalp for shorter and shorter periods. In advanced cases, hairs affected by androgenetic alopecia grow for only a 2-3 months - and are very, very short and very, very thin. We call these "vellus-like" hairs rather than miniaturized hairs but they are a type of miniaturized hair.  Over time, vellus like hairs just don't grow any more.

The Pull Test

What really is normal?

The Hair Pull Test: 3 is abnormal

Telogen effluvium is a form of hair loss where patients experience increased daily hair shedding. Instead of losing 40 or 50 hairs per day, patients with “TE” lose 80 to up to 600 hairs per day. A ‘pull test’ has traditionally been one of the methods that hair specialists are taught to perform when examining the scalp. To perform the test, 60 hairs are lightly grasped between the thumb and index finger and gently pulled upwards. Removal of more than 10 % of the hairs in the bundle (i.e more than 6 hairs) has been traditionally viewed as a positive pull test. 

McDonald and colleagues from Ottawa, Canada performed a study revisiting this issues of what exactly constitutes a normal pull test and what limits should be set for abnormal. They studied 181 otherwise healthy individuals. The authors showed that for the vast majority of individuals, a pull test of 60 hairs extracts 0,1 or 2 hairs (97 % or more have 2 or less). The average was 0.44 hairs indicating that many individuals have no hairs removed. Interestingly, the date the patient last washed their hair, did not influence the pull test result nor did the frequency of brushing the hair. 
This is one of my favourite studies of the year. It is simple and elegant and answers a lot important questions. I have long abandoned the “6 hair rule” for the pull test, and frequently have told the dermatology residents and trainees that work with me that even a few hairs coming out is abnormal. I’m grateful for this well conducted study and it has renewed my interest in the pull test.
 

Reference

McDonald et al. Hair pull test: Evidence-based update and revision of guidelines. Journal of the American Academy of Dermatology 2017; 76: 472

Eyebrow Hair Loss: What things do we need to consider?

Eyebrow loss: Knowing the cause allows one to plan the treatment

There are many causes of eyebrow hair loss and each has it's own treatment. Too often patients rush to treat their eyebrow loss without pausing to ask "What exactly is my diagnosis?" Here are a few common reasons for eyebrow loss and their treatment.

1. Age related eyebrow loss and overtweezing

If the eyebrow loss is due to age related changes or over plucking/tweezing the options inlcude

a. Minoxidil
b. Bimatoprost (Latisse)
c. Hair transplantation
d. Tattoos, and microblading

2. Eyebrow loss from alopecia areata

If eyebrow hair loss is due to the autoimmune disease alopecia areata, a majority of patients will also have evidence of aloepcia areata at other areas (scalp, eyelashes). Treatments for eyebrow loss due to alopecia areata include:

a. steroid injections   b. topical steroids c. minoxidil
d. bimatoprost
e. oral immunosuppressives (Prednisone, methotrexate, tofacitinib
f. Tattoos and microblading can also be used.  

3. Frontal fibrosing alopecia (FFA)

Frontal fibrosing alopecia of the eyebrows is certainly the most underdiagnosed cause of eyebrow hair loss in women who first notice eyebrow hair loss in their late 40s and early 50s. Hair transplants are ineffective in most, if not all patients with active disease. Treatment options for FFA of the eyebrow include:

a. steroid injections and topical steroids  b.topical non steroids (pimecrolimus cream)
c. oral finasteride
d. oral hydroxychloroquine, oral tetracyclines    
e. Tattoos and microblading can also be used.                                                                                   

4. Trichotillomania

Trichotillomania is common and 3-5 % of the world pull out their own eyebrows due to underlying psychological factors. For some, the pulling is temporary and for others is a chronic condition. Treatment of the underlying psychological factors (stress, depression, anxiety, obsessive compulsive disorder) can lead to improvement. Hair transplants are not an options if the patient is actively pulling his or her eyebrows

5. Other causes

Dozens of other causes of eyebrow loss are also possible including a variety of infectious, autoimmune and inflammatory conditions. Consultation with a dermatologist or hair transplant surgeon is recommended. I strongly advise consulting a dermatologist before proceeding to hair transplantation for women over 40 with new onset eyebrow hair loss after age 40.

Nail Changes in Patients with Hair Loss

Nail Bed Capillaroscopy

Nails are sometimes important to examine in patients with hair loss. Some autoimmune diseases produce changes in the nail plate and some produce changes in the very tiny blood vessels of the nail fold (see arrow).

Three diseases in particular are associated with changes in the tiny vessels of the nail fold - dermatomyositis, system lupus erythematosus (sometimes just called "lupus") and scleroderma. All three of these diseases can cause hair loss and may be associated with more serious internal illnesses.

I don't perform nail capillaroscopy in all my patients. However, if the patient's story has any suggestion of autoimmune association, I often perform a nail bed capillaroscopy. 

Nail Changes in Patients with Hair Loss

Nail Lichen Planus

We will finish this week with a closer look at the importance of examining the nails in patients with hair loss. 

I generally ask about nail changes in most new patients I see in my office. I often describe hair and nails as "cousins" and it should therefore come as no surprise that many conditions that affect the hair also affect the nails. Patients with alopecia areata, lichen planopilaris, telogen effluvium, drug related hair loss, psoriasis may have changes in their nails.

Some patients with scalp lichen planopilaris have nail lichen planus (LP). The clinical features of nail LP depend on where in the nail the disease is attacking (i.e. whether the matrix or nail plate are involved). Longitudinal ridging and splitting are the most commons clinical signs of nail matrix LP. This is shown in the photo. The splitting often extends right to the end as shown in the picture. However, a wide range of additional nail findings are also possible.

Some forms of nail lichen planus lead to rapid scarring and loss of the nail - (very similar to what is seen in the scalp). Other forms only lead to minor changes that may be difficult to differentiate from age related changes. Some patients have resolution of nail disease even without treatment.

There are a variety of treatments are possible including topical steroids (with occlusion), steroid injections (0.5 to 0.1 mg/nail), intramuscular steroids every 30 days (0.5 mg/kg) and oral steroids for 3 weeks. Antimalarials (i.e. oral hydroxychloroquine), oral retinoids, psoralen, tacrolimus are also used. About 1/2 of patients will not improve despite any type of treatment.

Alopecia Areata Incognito

AA Incognito

Most forms of alopecia areata are easy to diagnose, however one form is not. Alopecia areata incognito (which some pair together with so called diffuse alopecia areata) is the most difficult type of alopecia areata to diagnose.

A number of dermatoscopic features support a diagnosis including yellow dots, regrowing hairs, dystrophic hairs, exclamation hair and black dots. Unfortunately, all these features are not always present.

In my opinion, most cases of diffuse alopecia areata I see have a unique feature that I have traditionally called "wimpy hairs". These hairs are short and fine and refuse to grow straight up. They are very different than the strong thick pointy "upright regrowing hairs" seen in telogen effluvium. Rather these wimpy hairs twist and turn and flop over on the scalp. Many such hairs are seen in the photo.

Treatment includes potent topical steroids and steroid injections.

Fungi

An Overview for the Hair Specialist

Living things on earth are classified as either animals, plants fungi, bacteria or protists. We are familiar with animals and plants as we see them everyday. The other groups are less familiar to most people. Certain fungi are relevant to the hair specialist. Some 6 million different species of fungi exist. Fungi survive by absorbing nutrients from the environment. They have cell walls made of a material call chitin. We are familiar with one type of fungus - mushrooms - but are less familiar with all the various yeasts and molds that exist.

There are many different fungi that can cause health problems in humans. Of the 6 million species of fungi, about 600 have the potential to cause health problems. As we have seen over the past week in various posts, fungi known as Malassezia are the cause of the common seborrheic dermatitis and dandruff. Fungi known as dermatophyte fungi are the cause of scalp tinea capitis (which is common is children). Fortunately, most people will never come to know another group of fungi known as "opportunistic fungi." These are fungi that cause serious and sometimes fatal disease in patients with a weakened immune system including cancer patients, patients with organ transplants, HIV patients, patients with low white blood cells (neutropenia). A variety of opportunistic fungi exist including Candida, Aspergillus and Mucor (3 most common).