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QUESTION OF THE WEEK

Dr. Donovan's Articles

QUESTION OF HAIR BLOGS

Dissecting Cellulitis

Yellow Dots

Dissecting Cellulitis is a rare scarring alopecia that affects men much more than women. Affected patients are young men in their 20s. The condition starts with discharge of pus and sometimes blood, it can be itchy. The beard, underarm (axilla) and groin can be affected. An important feature of diagnosis is the skin breakdown and presence of "sinus tracts" or tunnels under the skin. 
We'll finish our week long review of Dissecting cellulitis by looking at yellow dots. Yellow dots correspond to neutrophilc infiltrates on biopsy and may or may not contain a central black dot. Yellow structureless areas around hair follicles are highly characteristic of DSC. Yellow dots are sometimes referred to as soap bubble dots by some.

The primary treatment of dissecting cellulitis is isotretinoin although antibiotics, zinc, dapsone, colchicine, and TNF inhibitors can be used.
 

This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Early greying of hair: What conditions need to be considered?

When do people normally develop grey hair?

Typically, Caucasians begin greying in their mid-30s; Asians in the late 30s; African-Americans in the mid-40s. About one half of the world's population has some degree of greying by age 50. The term "premature greying" or early canities refers to hair greying that occurs before the age of 20-25 in Caucasians, before 25 in Asian individuals and before 30 in black men and women. 

 

Causes of grey hair

I occassionally evaluate patients in my clinic who start greying in the teens or twenties. Many, many factors influence hair greying especially genetics. Thyroid abnormalities, pituitary problems, B12 deficiency are just three examples of many conditions that cause early greying.  Smoking too can cause early greying. In fact, a 1996 study in the British Medical Journal showed that smokers are about two to four times more likely to have grey hair. A recent study supports a possible link between low iron, calcium and vitamin D but that needs to be further investigated.Autoimmune conditions like alopecia areata, vitiligo and premature aging syndromes (like a condition called Werner's) can cause early greying of hair. High stress levels may cause greying in animal models but it's not yet clear if stress contributes to greying in humans. 

 

Conclusion

Overall, early greying of hair is fairly common and not usually associated with any underlying problem. That said, a full workup is needed for greying that fits the definition of premature greying. Evaluation of cardiovascular risk factors is also important in such situations.

 

REFERENCES FOR FURTHER READING


Kocaman SA, et al. The degree of premature hair graying as an independent risk marker for coronary artery disease: a predictor of biological age rather than chronological age. Anadolu Kardiyol Derg. 2012.

 

This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Dissecting Cellulitis (DSC)

This is another example of healed sinus tract. This will likely give a permanent scar in the area.

This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Minoxidil for Telogen Effluvium: Do I need to use it forever?

Minoxidil for Treating Telogen Effluvium: Forever?

Telogen effluvium (TE) is a hair shedding condition. Individuals with telogen effluvium experience increased daily shedding than they may have normally experienced. Rather than losing 50-100 hairs per day, affected individuals lose well over 100 hairs and some lose upwards of 400-1000.  The main causes of TE are low iron levels, thyroid problems, stress, crash diets, illness within the body (i.e. systemic illness), and medications. These are all 'triggers' for TE.

 

Is minoxidil a treatment for TE?

Before addressing whether minoxidil is a trigger for TE or not, let's look at the primary treatment for TE. TE is best treated by addressing the trigger for TE. If low iron is the cause of the TE, the iron must be replaced. That is the primary treatment. If hypothyroidism (low thyroid hormone levels) is the primary cause of a TE, the affected patient needs thyroid replacement as their primary treatment. 

Minoxidil is NOT the first choice for TE, but certainly can be a choice in those individuals for which the diagnosis can't be found. This statement is important because for 50 % of individuals with TE, we can't find the cause of the TE.  For some people, despite the blood tests, and review of their history, a clear 'trigger' can't be identified.  Minoxidil can help the hair cycles return to normal and facilitate the establishment of more normal shedding patterns.  Minoxidil helps some people with such unknown shedding but not all.

 

Is the use of minoxidil life long for TE?

Minoxidil is well known for being a 'lifelong' treatment for patients with androgenetic alopecia (male and female pattern hair loss). If someone with androgenetic alopecia uses minoxidil and gets a benefit and then decides to stop the treatment, they will lose all the benefits they gained by using the treatment. Their use is lifelong. For patients with androgenetic alopecia, minoxidil can not be stopped. 

Fortunately, these same rules do not apply to all patients with TE. But they do apply to some. In many cases, however, minoxidil can be tapered and then stopped as hair follicles regain normal cycling patterns.  If an individual decides to use minoxidil to treat their TE from their crash diet, the minoxidil can be tapered and stopped once a normal diet resumes.  The use in these situations is not lifelong.

One needs to keep in mind that before starting minoxidil for a TE, they must ask themselves what they have done to figure out the cause of the TE and what they have done to treat that cause. Second they need to ask their dermatologist if they have any amount of androgenetic alopecia that goes along with their suspected TE. A patient with androgenetic alopecia who does not realize they have AGA is going to be in for a bit of a surprise when they think about stopping minoxidil after their TE has resolved - shedding is going to start up all over again and things may even get worse. The hair demands to know where the minoxidil went !

Finally, even if one has TE and no component of AGA, it’s not always easy in every case to stop minoxidil. If the cause of the TE was not known and chronic TE is a possibility, the hair may just likely have the minoxidil around. It’s worth trying to stop, but one must keep in mind that some types of TE are harder to come off minoxidil than others.

 

Conclusion

For patients with a true TE, minoxidil use is not always life long. After the trigger for the shedding is fixed, shedding will often return to normal and minoxidil can be stopped. If there is any component of androgenetic alopecia, minoxidil might either not be used in the first place, or an understanding must be present that use could be lifelong.

This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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