Biotin and Hair Loss

Why Does the World Love Biotin So Much?

Biotin is a well-known and popular supplement for treating hair loss. Let's face it - the world loves biotin. However, true deficiencies in biotin are rare given the ability of bacteria in the gastrointestinal system to produce biotin. Nevertheless, many individuals and physicians turn to biotin in the search for treatment options. 

Soleymani and colleagues from New York University School of Medicine set out to critically examine the evidence for biotin use for treating hair loss. Their findings point out that there are no randomized trials to support the use of biotin in treating hair loss and that the public’s interest in biotin over the past decades is not supported by medical evidence. 

There is really no evidence to support routine biotin supplementation for individual’s with hair loss. Exceptions do exist, of course, and true biotin deficiency may be considered in individuals who are elderly, pregnant, using anticonvulsants or chronically using alcohol. 

Reference

Soleymani T et al. J Drugs Dermatol. 2017 May 1;16(5):496-500

Is sunscreen use more common in women with FFA?

This is a controversial question, there has been one study that has caught the attention of physicians and patients around the world. A study by Aldoori et al compared how 105 women with FFA and 100 women without FFA responded to a lengthy survey.

Surprisingly, a much greater proportion of women with FFA reported using sunscreens (at least twice weekly) compared to women without FFA. Specifically, 48 % of FFA patients reported such sunscreen use compared to just 24 % of women without FFA.

Conclusion

We still have a long way to go to definitely prove sunscreens have a role. It is potentially the first environmental factor implicated in the way FFA develops. An environmental factor is certainly thought to be responsible given that FFA was relatively unheard of 20 years ago. More good studies are needed.

Reference

Aldoori N et al. Frontal fibrosing alopecia: possible association with leave-on facial skin care products and sunscreens; a questionnaire study. Br J Dermatol 2016.

Is topical Spironolactone effective for Treating Female Pattern Hair Loss?

Oral spironolactone is classified as an anti-androgen and is the most commonly prescribed oral anti-androgen in the Untied States for the treatment of female patter hair loss. IT is not FDA approved for hair loss so its use is 'off label.' Topical spironolactone is not FDA approved for androgenetic alopecia either and has not had much study.  Any use of topical spironolactone should be prescribed only in conjunction with a physician.  

Is topical spironolactone effective? 

Well, few such studies have been done but there may be some minor benefit.  A 1997 study studied 60 women using 1 % topical spironolactone. A minor degree of benefit was seen.  Side effects from topical spironolactone are potentially similar to oral spirinolactone pills (albeit at a lower incidence).  

Women should be aware of breast tenderness, mood changes, electrolyte imbalance, fatigue, dizziness, swelling, Women of child bearing age should speak to their physician about pregnancy concerns. One must never get pregnant while using spironolactone or the developing fetus could be seriously harmed.  Topical antiandrogens do get absorbed into the blood stream. It would be unwise to think otherwise. 

Overall topical spironolactone may have minor benefit in the treatment of androgenic alopecia. More studies are needed however, before its use becomes routine. 

REFERENCE

Dill-Muller D, Zaun H. Topical treatment of androgenetic alopecia with spironolactone. J Eur Acad Dermatol Venereol. 1997 Sep;9(Suppl 1):31.

Oral minoxidil for hair loss

Oral Minoxidil

Topical minoxidil was FDA approved in 1987 and we now have 30 years of experience with the drug. 

I'm increasingly asked about oral minoxidil. Does it work? Is it safe? What dose? 

Oral minoxidil is not FDA approved for treating hair loss. It was used in the 1980s for treating high blood pressure. When used at doses typical for treating blood pressure problems (5 mg twice daily), it can be associated with side effects - some quite serious. These include dizziness, low blood pressure, weight gain from fluid retention, high heart rate, heart rhythm problems. And of course hair growth can occur all over the body.

Lower doses of oral minoxidil may be safer and may still provide benefit. Doses ranging from 0.25 mg daily to up to 1 mg daily are generally well tolerated without a significantly increased risk of side effects. One does need to be closely monitored for blood pressure, weight changes, heart rate and excess hair growth on the body. For women, low dose minoxidil can be combined with spironolactone. In men low dose minoxidil can be combined with lower doses of finasteride.

 

Conclusion

Oral minoxidil is increasingly popular as men and women look for safer options for treating hair loss. Side effects of oral minoxidil must be respected and use of the medication must only be done in conjunction with a physician experienced in the use of oral minoxidil. Close monitoring is essential.

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.

Scalp Frontal Fibrosing Alopecia (FFA)

FFA: Scaling Around Hairs

Frontal fibrosing alopecia (FFA) is a type of scarring hair loss that occurs more often in women than men. It causes hair loss along the frontal hairline as well as several other areas including the sides and back of scalp, eyebrows, eyelashes, and body hair.

This picture shows a very typical appearance of the frontal scalp in FFA. There are numerous single hairs, many with scale around those hairs (called perifollicular scaling). A few broken hairs are seen and one hair in the picture is markedly twisted (a phenomenon known as "pili torti"). This is mild scalp redness.

Many treatments are available as we have reviewed together previously. This patient was started on a 5 alpha reductase inhibitor (finasteride, 5 mg) along with pimecrolimus cream (Elidel) and steroid injections. Clobetasol proprionate shampoo (Clobex) will be used weekly and reassessment will be done in 4-6 months.
 

Hair loss after starting and stopping birth control

Hair Loss and Birth Control

Hair loss often occurs in women who start and stop birth control. This typically occurs 1-2 months after starting and stopping and can last 4-5 months. For some individuals it lasts 9-12 months. 

For the vast majority of individuals, the abnormal shedding eventually stops and returns to normal shedding patterns- even without treatment. However, some women (small minority only) develop a chronic shedding pattern for an extended period of time and some notice that density does not make it back fully on account of an acceleration of underlying androgenetic alopecia.

In summary, most women will experience additional hair shedding for a few months after starting and stopping birth control. The excessive shedding will eventually slow and return to normal for most. Consultation with a dermatologist is advised if shedding persists after 6 months.

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.

Latisse and eye color changes

Can bimatoprost (Latisse) change eye color?

Bimatoprost (Latisse) is a popular product for growing longer lashes. Users of the product are likely very familiar with the fact that the drug was originally used for glaucoma to lower eye pressures. 

The actual drug stimulates pigmentation in the iris because of  the ability of bimatoprost to  increase in pigment granulates in melanocytes. This side effect is mostly observed when individuals put the bimatoprost drops right into the eyes (as is done for those using the medication for glaucoma).

Pigmentation of the iris is not typically observed with those used bimatoprost for the eyelids or eyebrows. However, pigmentation of the surrounding skin can be observed.

What is considered "normal" hair shedding?

Normal daily shedding

Normal daily shedding is often quoted as "anything less than 100 hairs per day" but that has never been carefully studied and documented. The reality is that there is quite a range of "normal" and somewhere closer to 50-60 is probably closer to what most people experience (or at least can collect).

Of course, there is a wide variation on what is considered normal shedding.

It is incredibly challenging (and incredibly emotional) to have to count daily shedding each day. There are many methods (brushing, shampooing, collecting) to try to measure daily loss. They are helpful and I often use a variety of such methods, but they each have their limitations.

Even those with a clear "telogen effluvium" (increased shedding) sometimes return with 45 hairs collected in a particular day (rather than the magic number 100). Are they shedding excessively? Absolutely. Are they able to measure it properly and capture what is happening? No.

A key principle of shedding is if one is certain they used to lose 30 and now lose 65 hairs per day - this is likely abnormal and warrants further consideration.

Machine settings for Platelet rich plasma: A Look at Hematocrit

What is Platelet rich plasma?

Platelet rich plasma or "PRP" continues to be studied as to its precise role in the treatment algorithms for many types of hair loss.

The PRP procedure involves taking 60-120 mL of a patient's blood, spinning it down in a dedicated centrifuge machine to obtain PRP and then injecting the PRP back into the patient's scalp. The procedure takes about 1 hour. 

All PRP is not equal

One common misconception is that all PRP is equal. The reality is that different machines produce different quality of PRP. Even the settings I type into the actual PRP machine affect the characteristics of the PRP I am able to produce for the patient.

A look at the "hematocrit"

A great example of this concept of differences in PRP is the "hematocrit". Hematocrit refers to the amount of red blood cells that are allowed to enter the final PRP.

If I set the PRP machine at a hematocrit setting of 7 % (high hematocrit), I produce a more red colored PRP (like shown on the left). This contains more platelets per liter and also contains more neutrophils (inflammatory cells). It also contains higher concentrations of growth factors like TGF beta and platelet derived growth factor (PDGF).

If I set the machine at a hematocrit of 2 % (low hematocrit), we produce a more yellow colored PRP (like shown on the right). This contains fewer platelets per mL and also contains fewer inflammatory cells, lower concentrations of growth factors like TGF beta and platelet derived growth factor (PDGF).

I generally like a higher hematocrit setting (7%) for treating genetic hair loss and a lower hematocrit setting (2%) for treating alopecia areata. Studies are ongoing to determine which is best and if these settings really make a difference.

REFERENCE

Sandman et al. Growth factor and catabolic cytokine concentrations are influenced by the cellular composition of platelet rich plasma. American Journal of Sports Medicine 2011.
 

To Poo or Not to Poo: A closer look at the “no poo” (no shampoo) movement

Should you give up shampoos?

If you’re like most people, you have a bottle or two of shampoo in your shower and you use it to clean your scalp and hair. Perhaps you’re a daily user, perhaps you use shampoos a few times week. If you have coarse and curly hair, you might use shampoo even less frequently.   But you use it. If my own practice is representative of the world out there I know some of you even change your shampoo brands frequently.

However, a small number of women (and an even smaller number of men) have decided to forgo shampooing the scalp altogether. This defines the so called “no poo” movement (i.e. ‘poo’ is short for shampoo).

 1. We are a shampoo loving society

As a society, we have grown to love shampoo and love shampooing. Walk into any drug store and you’ll see just how much real estate is devoted to shampoos. We love the smells of shampoos and the feel of shampoos. We love the look and feel of shampoo bottles. We like the shampoo aisles, shampoo ads and shampoo commercials.  We are a shampoo loving society.

Shampoos were first synthesized in the 1930s, as an alternative to bar types soaps which left a heavy film or “soap scum” on the hair.  Such deposition leaves the hair dull and more difficult to manage.  In years gone by, women  would shampoo their hair at the salon and then have it set. Shampooing every 2-4 weeks was normal. Shampooing wasn’t typically a home-based procedure. It wasn’t until the 1970s and 1980s that shampoos became standard for household daily use. In North America, many women have changed to shampoo their hair very frequently. Moreover, we seem to enjoy squeezing our shampoo bottles and in general use far too much shampoo with each use than we really need to. It’s not really harmful to do so – except to our bank. It’s too often forgotten, that shampoos are meant for cleaning the scalp and conditioners are meant for the hair. A small dab of shampoo is usually sufficient to clean the scalp.

2. If people don’t poo (shampoo), what do they do?

For those who are participants in the ‘no poo” movement and don’t use shampoos, common substitutes include simply using water alone, using apple cider vinegar, baby powder, dry shampoos or using baking soda.  I believe that many of such practices are well tolerated for most people. However, those with color treated or relaxed hair may find that that high pH of baking soda (up to 10-12) to be particular harsh on their hair and increase the chance of damage and hair breakage.  

 

3. Does frequent shampooing trigger your scalp to make more oil?

It’s true that the use of shampoo removes oils from the scalp. These oils are helpful to condition the hair – and might be regarded as nature’s best conditioners. At present, however, there is no scientific proof that the scalp compensates for frequent shampooing by in turn producing more oil. The amount of oil that our scalp produces is genetically determined, and to a much lesser degree by the foods we eat, hormones, seasons and the environment. Changing your shampoo practices won’t reset your oil production. That factory is deep under the scalp (in glands known as sebaceous glands) and not influenced by how you shampoo. It would be nice to think otherwise – but there’s simply no proof.

4. How often should you shampoo?

There is no magic number for how often we should shampoo. In fact, the number is different for everyone.  Those with fine, oily hair are going to benefit from daily shampooing as the oils tend to weigh down the hair. Those with coarse and curly hair can go much longer as the hair will actually look better when not washed so often.   The same is true for those with color treated or relaxed hair – washing less frequently is preferred to further limit damage to already slightly damaged treated hair.  Once or twice a week is likely just fine. Although we certainly shampoo our hair too often, washing the scalp daily is unlikely to cause harm. Furthermore, there is no evidence that avoiding shampoo altogether offers a health benefit. In other words, the no poo movement is a personal choice, not a health choice.

5. Are there any adverse effects of not shampooing ?

Individuals with existing scalp problems could develop a ‘flare’ of their scalp disease with cessation of shampooing. For example, I’ve seen many patients who forgo shampoos that develop worsening dandruff and seborrheic dermatitis ( which is a close cousin of dandruff). It’s usually mild and tolerable. To understand why this occurs, it’s important to understand that dandruff and seborrheic dermatitis are caused by yeast that lives on our scalps.  These yeast feed off scalp oils. Excessive oiliness from not shampooing provides this yeast with an abundance of food and in turn further exacerbates the patient’s scalp problem.  The no poo decision might not be for everyone.

6. If you’re going to shampoo, should you go sulfate free?

For those who decide that the no poo movement might not be for them, a common question then arises – what about joining the sulfate free movement? Certainly, sulfate free shampoos are popular. If you’ve used a sulfate free shampoo you immediately notice they don’t lather up quite as well as a shampoo containing sodium lauryl sulfate or ‘SLS‘. The main downside of these shampoos is not their lathering ability but the fact that SLS shampoos are a bit more drying and are more likely to lift the cuticle and cause damage for those with color treated or relaxed hair. The can also cause irritation for those with scalp problems, including eczema.  The vast majority of people in the popular will notice little difference to their hair from using a sulfate free or SLS containing shampoo.  Decisions on whether to use SLS shampoos for other reasons (including environmental) are still being researched. However, from the perspective of the hair – the vast majority of people will not achieve better hair care from sulfate free shampoos.

Conclusion: Are you giving up shampoo?

Hair is personal. Hair helps define who it is we are and how we present ourselves to the world. Our hair is central to our self identify. If you don’t want to shampoo your hair – don’t shampoo your hair. There are a small number (but manageable number) of risks. Similarly if you want to shampoo your hair frequently, shampoo it. Change up your brands.  Enjoy all that shampoos offer in further defining what is personal, individualistic and what defines our feelings of self identity and self-expression.  There are risks to many things and it simply comes down to being well informed.  Humans quickly learn what shampooing frequency is right for them.

The No Poo movement - Dr. Donovan interviewed on CHCH News

More Women going without shampoos

The 'no-poo' movement refers to a trend whereby shampoos are not used. Instead various non shampoo alternatives are used (water, apple cider vinegar, baking soda).

Dr. Donovan was recently interviewed on CHCH News 

See the interview here:

http://www.chch.com/the-no-poo-movement/

Capturing the very earliest changes of Genetic Hair Loss

Recognizing genetic hair loss in the earliest stages

Genetic hair loss is common. By age 50, about 60 % of men and 35 % of women will develop genetic hair loss.  Hair loss typically starts in certain areas of the scalp - such as the temples and crown in men and central scalp in women.

 

 

Alteration in follicular counts may precede miniaturization 

Miniaturization refers to the progressive reduction in hair follicle diameter during the course of genetic hair loss. In other words, hair follicles get skinnier and skinnier over time. This is a very typical feature of genetic hair loss. One other feature that is frequently seen is the alteration of hair follicle counts. Rather than hair follicles appearing in bundles of two hairs or three hairs, they are frequently seen as single isolated hairs. 

The photo above nicely illustrates this concept. Both photos were taken from the same patient. The photo on the left shows hair follicles grouped together in groups of two three and even four hairs. This area of the scalp is unaffected by genetic hair changes. The photo on the right shows very typical genetic hair loss. Hair follicles are still similar in size (thickness), but what is seen is mostly single hairs - the groupings of two and three hair bundles are no longer present. This is very typical of the earliest features of genetic hair loss. 

Hair transplantation for central centrifugal cicatricial alopecia (CCCA)

Scarring Hair Loss Conditions in Black Women : Is hair transplantation an option?

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**CLICK TO ENLARGE ** Photo of top of scalp in woman with CCCA

Diagnosing hair loss in women with afro-textured hair requires special expertise. Many hair loss conditions are possible and they tend to look similar. Central centrifugal cicatricial alopecia (CCCA) can look similar to genetic hair loss and so can some types of traction alopecia. Our program for women with afro-textured hair addresses some of the unique aspects of hair loss and hair care in black women. 

Hair transplantation in CCCA

Central centrifugal cicatricial alopecia (or "CCCA" for short) is a type of scarring hair loss condition in black women. Hair loss starts in the centre of the scalp and spreads outwards over time. If treated early, the condition may be halted - at least for some women. Hair transplants are possible in CCCA once the condition becomes “quiet.” By quiet, we mean that there has been no further hair loss for a period of 1-2 years. 

Are hair transplants possible for CCCA?

Surgery is sometimes an option 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 CCCA ?

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 CCCA Hair Transplant Criteria.

DONOVAN CCCA HAIR TRANSPLANT CANDIDACY CRITERIA 

In order for patients with CCCA 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 some cases, it may be possible to perform a transplant in someone with CCCA who is 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 very well-informed patient. 

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

There must be no scalp clinical evidence of active CCCA such as hair fragility or scalp erythema. . 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 CCCA maintain sufficient donor hair even if the disease has become quiet. But this is an important and final criteria.

 

Can I have a hair transplant?

Am I a candidate for a hair transplant?

Many patients who come and meet with me are candidates for hair transplants - but some individuals are not.  For some individuals who aren't good candidates for hair transplants, this information may come as a surprise.

Who can have a transplant and who can not?

Individuals with certain hair loss conditions like genetic hair loss (also called androgenetic alopecia), traction alopecia are good candidates for surgery.  Individuals with other conditions like alopecia areata, scarring alopecia and hair shedding disorders are not candidates for surgery.

Within 1-2 minutes of meeting a patient, I can usually determine if they are good candidates for surgery or not.  

Consider the following patient (pictured on the left) who came to see me with concerns about her increasing hair loss in the centre of the scalp. At close examination and after asking her a series of questions, it became clear that her reason for hair loss was genetic. This made her a good candidate for surgery.

Consider now the woman pictured on the right in the photo. She looks just like the woman on the left. However, a series of questions followed by a detailed examination of her scalp as well as a scalp biopsy allowed me to utlimately diagnose her with lichen planopilaris which is a type of scarring alopecia.  I was not able to perform a hair transplant on this woman as she was was not a candidate for surgery.  Scarring hair loss conditions like lichen planopilaris can not be transplanted when they are in the active phase.    If she had gone for surgery without being properly diagnosed, the transplanted hairs would not have grown well and  perhaps not grown at all.

Not everyone is a candidate for hair transplant surgery. Only with a careful record of questions and a detailed examination of the scalp can all the other reasons for hair loss be excluded.

This blog has been filed into the following folders:

Quantifying Hair Loss: Just How Much Hair Loss Has Occurred?

Quantifying Hair Loss:

All humans experience hair loss on a daily basis. But the key question is – “is this amount of hair loss abnormal?”  How do we evaluate whether there has been a lot of hair loss or just a little.”

It’s normal to lose between 50-100 hairs per day. This means its normal to see some hairs  in the brush, in the sink and in the shower drain. But when do we cross the boundary between normal and abnormal?? 

Most people intuitively know if the amount of hair loss they are experiencing is abnormal.   But, when I meet a patient I try to get a sense of just how much hair loss has occurred – and just how fast the hair loss has occurred.  These are extremely important to quickly get a sense of.

a)    Photos.  Comparing photos is sometimes a good way to get a sense of how much hair loss a patient has experienced.  How different does the individual look in their driver’s license photo compared to the way they look today?  Was the photo taken 6 months ago or 6 years ago?

b)   Daily Shedding. How much hair “shedding” is occurring on a daily basis? Are the drains clogged? Is their hair coming out in the food? Does the patient ever count the number of hairs shed on a daily basis?

c)    Pony tail. For women who wear their hair long, the size and thickness of the pony tail can be helpful in assessing the amount of loss. How much thinner is the pony tail than before? How many turns of an elastic band are needed now compared to before?

d)   Styling. How long does it take the individual to style their hair to cover their hair loss? An individual who once took 15 minutes but now takes 45 minutes or 1 hour has considerable loss.

e)     Spontaneous comments from family and friends.  Most of the time, a family member or friend will comment on hair loss only when it has become significant.  But I often ask patients if they have received spontaneous comments from others on their changing hair density.

f)     Patient estimates. It’s sometimes hard for patients to quantify their hair loss but I generally ask.  Specifically, I try to get a sense of the percent reduction in hair density. Has the patient loss 40 % of their hair volume in the past year? Is it 20 % ? Is it 60 %?

Quantifying the amount of hair loss is important. It helps give a sense of just how much hair loss has occurred and helps guide certain diagnoses as well. For example, consider the 26 year old woman who has lost 60 % of her hair density in the past one year and looks completely different than her driver’s license.  Although she may have been told she has female pattern hair loss, one thing is for certain- she has something else going on in addition to or besides female pattern hair loss!!! She might have female pattern hair loss, but other causes need to be explored, including a variety of hair shedding problems. Female pattern hair loss is a slow process and would not be consistent with a loss of 60 % density in one year. 

Quantifying the amount of hair loss is extremely important.

 

Frontal Fibrosing Alopecia: Do we Need a New Name for the Condition?

Frontal Fibrosing Alopecia: Do we Need a New Name

Frontal fibrosing alopecia is an uncommon hair loss condition that usually affects post menopausal women. The cause is not known. 

Frontal Fibrosing Alopecia: What does it mean?

At first glance, the name seems like a good one. Women with frontal fibrosing alopecia lose hair in the front of the scalp and it occurs with scarring (fibrosing process). The women in the photo on the right has typical frontal fibrosing alopecia. 

FRONTAL: Hair from the front of the scalp is lost

FIBROSING: Occurs with scarring (fibrosing process)

ALOPECIA: Simply a medical term for hair loss

Once the hair is lost, it's lost permanently. Only with hair transplant surgery can hair density in the front be improved. But surgery can only be done when the condition is quiet or else the newly transplantedn hairs are likely to die.  An ongoing research study in our office is seeking to understand when it's best to transplant women with frontal fibrosing alopecia.

But is this a good name for the condition?

As time passes, we're learning more and more about frontal fibrosing alopecia. Many women not only lose hair in the front of the scalp (hairline), but also at the sides (above the ears) and at the back as well. The women in the photo shows a typical picture of hair loss occuring at the back. In addition, women with frontal fibrosing alopecia often lose eyebrows (in three quarters of patients) and often lose body hair as well ( in one quarter of patients).

Conclusion

The term frontal fibrosing alopecia has been with us for almost 20 years now. When hair specialists use the term, we know exactly what condition is being referred to. But the term has its limitations - and someday it might take on even a different name - one that encompasses the hair loss from the back and sides of the scalp,  body hair and eyebrows.

Hair Loss in Women: Often More than a Single Cause!

Hair Loss in Women: Often More than a Single Cause!

Hair loss among women is common. Although it's natural to think there is a single cause of an individual's hair loss, women often have more than one reason for their reduced hair density or 'hair thinning.'

Example: Consider the 32 year old woman who came into see me for her first appointment. She told me that she had been using minoxidil topical lotion for a 8 months now for a presumed diagnosis of:

Presumed diagnosis:

1. Female Pattern Hair Loss (also known as androgenetic alopecia).

However, she felt her hair was not getting better. She had some annoying scalp itching from time to time and wondered if she should stop the mionxidil as she was told the lotion could sometimes cause itching.

Is this the correct diagnosis? What should she do to stop her itching?

Join me as we pursue the necessary "detective work" to come up with the correct diagnosis for this woman and ultimately help her hair improve. First, lets take a look at her scalp up close:

Is this normal? Is it abnormal? Well, let's compare this photo to a relatively normal appearing scalp from a similarly aged woman in my practice with good hair density and extremely healthy hair. You'll note that all the hairs are fairly similar size (calibre) and the scalp itself is not red and their is no scaling or flaking:

Now that we know what is normal, let's return to the 32 year old woman with hair loss. Many things can be seen by examing this woman's scalp. First this woman has many 'thick' hairs. The light blue arrows show the thick hairs (also called terminal hairs).

However, this woman also has many thinner hairs with greatly reduced calibre (skinnier hairs). These thinner hairs are known as "miniaturized hairs" and the green arrows below point to several miniaturized hairs. Miniaturization is frequently seen in individuals who have a diagnosis of "androgenetic alopecia" (also called female balding or female pattern hair loss):

So I know this woman has androgenetic alopecia as one of her diagnoses.  But the other thing that is noted is that she not only has many skinnier hairs, but she also has a significantly reduced number of hairs.  You can see that the hair density that is seen in the top of the picture is very different than in the bottom of the picture  - the blue stars show the "missing hairs." So we know that she has lost a lot of hair.  

By gently pulling on several of her hairs, I discover that many of these remaining hairs come out pretty easily. This is called a "positive pull test" and this test is a sign this woman may have excessive shedding ( a phenomenon called telogen effluvium). In fact, the orange arrows point to many of these telogen hairs - which are farily easy to spot in this photo because telogen hairs become much lighter in color as they are about to shed from the scalp. So we are gaining some good evidence that this woman has an abnormal shedding problem:

As I described in a previous  video, there are many causes of exessive or abnomal shedding. The include low iron levels, thyroid problems, crash diets and a variety of medications. Basic blood tests performed in this patient showed she had very low iron levels. Further details also revealed she had multiple cycles of crash dieting in the past one year. These are certainly two potentially important causes for her shedding.

Further examination of her scalp showed that there is redness in the scalp and some scale. The red arrows in the photo below point to this scale:

There are many causes of scale but this woman scale and the redness in her scalp is typical of a condition called seborrheic dermatitis. Scalp "dandruff" and seborrheic dermatitis are two closely related processes and are caused by a common yeast called Malasezzia. Seborrheic dermatitis is very common and causes scalp itching and redness and excess flaking. Often patients notice that their scalp feels better if they wash their hair more often as this helps reduce the annoying itch they sometimes experience. Seborrheic dermatitis may cause itching but doesn't typically cause hair loss. Additional questions showed that this woman had scalp itching long before she started using the topical minoxidil therapy - so her itching may be coming from her seborrheic dermatitis rather than the minoxidil ! However, both are possible.

So at this point, it appears this woman does in fact have female pattern hair loss, but she also has three other diagnoses:

1. Female pattern hair loss (also known as androgenetic alopecia).

2. Telogen effluvium (exess hair shedding) - from low iron levels

3. Telogen effluvium (exess hair shedding) - from crash dieting

4. Seborrheic dermatitis

But is this ALL she has?

For this patient, further questioning revealed that the cause of her low iron was very likely from heavy and sometimes irregular menstrual periods. She could go several months without a period. Additional blood work and an ultrasound of this woman's ovaries showed that she in fact had a condition known as polycystic ovarian syndrome or "PCOS."  Women with PCOS have altered hormone levels which can cause hair thinning.  The altered hormone levels are produced by the ovaries. Early diagnosis of this condition is extremely important as women with PCOS have a higher chance of developing diabetes, high blood pressure, infertility and high cholesterol.  She was referred to an endrocinologist for further evaluation of her PCOS.

Final diagnoses for this woman: 

1. Female pattern hair loss - with Polycystic Ovarian Syndrome

2. Telogen effluvium (exess hair shedding) - from low iron levels

3. Telogen effluvium (exess hair shedding) - from crash dieting

4. Seborrheic dermatitis

How was this woman ultimately treated?

This woman was continued on her topical minoxidil therapy as it was concluded this was NOT a cause of her particular symptom of itching.  On account of her diagnosis of PCOS, she was advised to start on a birth control pill to regulate her periods. Oral Spironolactone medication was also started to help her androgenetic alopecia. Iron pills were prescribed to help the low iron levels and blood work was performed every 5 months to ensure the iron levels were rising properly. The woman's diet was stabilized to ensure that no further crash dieting would occur. The seborrheic dermatitis was treated with an anti fungal shampoo and this helped stop her itching. An improvement in hair density was noted in 6 months.

Conclusion

Diagnosing hair loss in woman often requires a bit more detective work than hair loss in men. Hormonal issues, and hair shedding conditions are more common in women than men. One should never assume that a patient has a single diagnosis for their hair loss -- all causes need to be explored. This can only come with a very detailed history about the patients hair loss, past health, diet, medications, family history and a very detailed examination of the scalp.