Hair loss from steroid injections: Is it possible?

Steroid injections: Is it possible to cause hair loss?

Steroid injections are frequently used for treating two conditions: alopecia areata and scarring alopecia. Medications such as triamcinolone acetonide (sometimes referred to by the popular name Kenalog) are injected into the scalp. The purpose is either to grow hair (in the case of treating alopecia areata) or to stop further hair loss (in the case of scarring alopecia). 

Steroid injections can sometimes induce hair loss (telogen effluvium) in some individuals. It's not common but some individuals actually develop small circles of hair loss around the areas injected. Some will even develop small 'indentations' in the skin in these areas as well. This hair that has been lost may grow back with time but indicates that a lower concentration of triamcinolone should be used for that patient in the future.  

Plan b: Is There a Plan B to Treating Hair Loss?

The first step in determining how to help someone with hair loss is figuring out his or her diagnosis. There is no bypassing this step.  The second step is determining a treatment plan that is based on the best medical evidence. 

Plan B: What is Plan B, Doc?

After reviewing a treatment plan with my patients, I'm often asked what treatment will be considered next. "What's plan B, doc?" Well, every treatment plan needs Plan B as well as a Plan C and Plan D.

Consider the 28 year old female with androgenetic alopecia. The best treatment option for her based on all her facts, review of her blood tests and scalp exam might be topical minoxidil. Plan B might be oral spironolactone with or without minoxidil. Plan C might be the addition of a laser comb or changing the anti androgen used. Plan D for her might be a trial of PRP. A solid treatment plan has an alphabet of plans. Not guesswork and not a random pull out of a hat option. But rather options based on a delicate combination of medical science and expert consensus, and personal experience.

What about the 53 year old female with frontal fibrosing alopecia? Plan A for her might be finasteride & steroid injections with hydroxychloroquine as Plan B. Doxycycline is reserved for her as Plan C. For another patient with FFA, Plan A might start with hydroxychloroquine & steroid injections. For her, finasteride is not on the list given the past history of breast cancer the patient had. Plan B is doxycycline and plan C is methotrexate.

Conclusion

Every treatment plan should have an alphabet of plans. That does not necessarily mean one will need to move down the list but the physician should have a clear plan for how to navigate.

Can drugs accelerate androgenetic alopecia (AGA)?

Medications can potentially accelerate androgenetic alopecia. Common examples are anabolic steroids, the use of testosterone injections and topical androgen gels (commonly used for men with "low testosterone"), androgenic progestins in birth control pills, danazol as well as many other medications.

This individual whose scalp is shown in the picture has been using anabolic steroids for body building and has experienced rapid hair loss mainly due to a conversion of his large terminal hairs (some labelled by green dot) to thinner miniaturized hairs (labelled by yellow dot). Treatment of drug accelerated AGA involves either stopping the androgen or blocking the effects of the androgen on the hair follicle using 5 alpha reductase inhibitors... or both. Less specific treatments like minoxidil may provide some benefit. Many individuals can improve with this plan but full regrowth is unlikely.

Anti-coagulants during hemodialysis: Can they cause hair loss?

Blood Thinners and Hair Loss

Dialysis is a medical procedure used to filter waste from the blood in patients with kidney disease. Close to 500,000 Americans and 25,000 Canadians are receiving dialysis. The most common reasons for dialysis is end stage kidney disease due to diabetes and high blood pressure. 

Hair loss and hair changes occur time to time in patients receiving dialysis. One needs to consider a range of nutritional issues (including protein intake, zinc deficiency, iron deficiency), thyroid abnormalities, as well as hair loss from systemic disease itself (ie. autoimmune disease). The use of medications must be considered. 

Anticoagulants are a group of blood thinning medications used during hemodialysis to prevent blood clotting when blood is filtered through machines. Several different types of anticoalgulants may be used and many can rarely cause hair loss. The mechanism by which they cause hair loss is typically a telogen effluvium although other mechanisms may occur as well. 

Apsner and colleagues, in 2001, reported 5 hemodialysis patients who had hair loss from the low molecular weight heparin blood thinner dalteparin. All patients reported that their hair loss stopped when the dalteparin was stopped and a different method of anticoagulation (regional citrate anticoagulation) was used. 4 of the 5 patients even regained hair. In 2003, Sarris and colleagues reported a hemodialysis patient who had hair loss after switching from one low molecular weight heparin (enoxaparin) to tinzaparin. Hair regrowth resumed after switching back to enoxaparin. 

Conclusion

There are many potential reasons for hair loss in patients receiving hemodialysis. Careful review of all factors is needed. Anticoagulants used during hemodialysis, including the low molecular weight heparins, need to be considered. 

Reference

Sarris E, et al. Am J Kidney Dis. 2003.

Apsner R, et al. Blood. 2001

Nausea with Doxycycline: What strategies can help reduce nausea?

Doxycycline and Nausea

Doxycycline is an antibiotic. It's used of course in treating infections but it is commonly used for a variety of scarring alopecias including lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia, folliculitis decalvans and sometimes dissecting cellulitis.

The drugs has two important properties: it stops infection and reduces inflammation. For some conditions such as lichen planopilaris, it's the anti-inflammatory properties that are useful. For other conditions such as folliculitis decalvans, it's the anti-bacterial and anti-inflammatory properties that are key. 

The drug has a number of potential side effects even though it is generally well tolerated for most. It can cause nausea, vomitting, sun sensitivity, headaches, increased chance of yeast infections in women, rash. 

Doxycycline and Nausea

Some patients developed considerable nausea with doxycycline. Some will even vomit.  This can be a short term issue for some users which improves over time. For others it is something that continues and may even require the patient to stop the medication.  Anyone with nausea from doxycycline should speak to their prescriber for advice on how to reduce the nausea. 

Tips to reduce nausea

1.  Take doxycycline with food. Unlike tetracycline, doxycycline still gets absorbed quite well into the blood stream if the patient takes it with food. The food intake really helps to reduce nausea and this should be encouraged

2.  Avoid spicy foods with the doxycycline. Anything that upsets the stomach has the potential to makes things worse with doxycycline. I generally recommend avoiding spicy foods with doxycycline. 

3. Take Gravol.  If nausea continues despite food intake, dimenhydrate (Gravol) can be used 1 hours before the doxycycline is taken. I generally recommend starting with 25 mg Gravol and then 50 mg and then 100 to see what dose can help reduce the nausea. Gravol can make people drowsy and sleepy so this needs to be considered if one is driving or doing anything that requires focus. 

4. Use Ginger. Ginger is also a helpful anti-nausea treatment. There are a number of candies, lozenges on the market that contain ginger and can be used prior to the patient taking the doxycycline. The company that makes Gravol also has a product "Ginger-Gravol" which can be very helpful. this does not contain Gravol and therefore does not cause drowsiness.

5. Reducing the doxycycline dose. For some users, the nausea is dose related. Reducing the dose can help.

Amphetamines and Hair Loss

Amphetamines are a group of drugs that stimulate the central nervous system. They have been used since the 1920s. Amphetamines are used in the treatment of attention deficit hyperactivity disorder (ADHD), narcolepsy and obesity. At higher doses, amphetamines are also drugs that are frequently abused.

Examples of amphetamines

Most amphetamines are prescription based and include drugs such as:

1.    Dextroamphetamine

2.    Levoamphetamine

3.    Lisdexamfetamine

4.    Methamphetamine

5.    Adderall and Adderall XR

6.    Dexedrine

7.    ProCentra

8.    Ritalin

9.    Concerta

10. Dextrostat

11. Vyvanse

12. Focalin

13. Strattera

14. Zenzedi

15. Evekeo

Hair loss with amphetamines

Hair loss is a possible side effect of amphetamines. It does not happen to everyone but a proportion are affected.  Hair loss typically occurs 4-7 weeks after starting. Daily shedding increases from well under 70 to above 100. Hair loss occurs all over the scalp rather than in any given area. Hair loss from amphetamines can also occur on the body hair.

Hair loss can be from the drug itself or the caloric and nutritional deficiencies that come from the appetite suppressing effect of these drugs.

Evaluation of the patient with suspected amphetamine induced hair loss

It is important for anyone with suspected amphetamine induced hair loss to see a physician. The first step is to determine if the timing of the hair loss and the type of hair loss pattern fit with a diagnosis of amphetamine induced hair loss. On some occasions, the hair loss and amphetamine use is simply a coincidence.  If the amphetamine use is thought to be contributory, it is important to determine if the patient has a telogen effluvium from the actual drug, or from a nutritional deficiency that the drug has brought about or from another cause such as androgenetic alopecia.  Blood tests are necessary for anyone with amphetamine induced hair loss to look for underlying nutritional deficiencies. Sometimes a hair collection or biopsy is also performed.  

Is sunscreen use more common in men with FFA?

This is a controversial topic but this study (as well as a study of FFA in women) has caught the attention of many. A study by Kidambi et al compared how 17 men with FFA and 73 men without FFA responded to a lengthy survey. FFA is relatively rare in men but information on a link to sunscreen use was important to investigate given the possible role among women.

A much greater proportion of men with FFA reported using sunscreens (as well as facial moisturizers) at least twice weekly compared to men without FFA. Specifically, 35 % of FFA patients reported such sunscreen use compared to just 4 % of men without FFA.
 

Conclusion

We have a long way to go to definitely prove sunscreens have a role. But two studies now (one in men and one in women) have described 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. There are more good studies that 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.

Kidambi AD et al. Frontal fibrosing alopecia in men: an association with facial moisturizers and sunscreen. Br J Dermatol 2017.

Gynecomastia (Enlargement of Breast Tissue) in Men using Finasteride and Dutasteride

Gynecomastia in Men using Finasteride and Dutasteride

It is well known that finasteride and dutasteride can cause enlargement of breast tissue in men. This phenomenon is known as ‘gynecomastia’. It is postulated that hormonal changes that accompany the reduction in DHT (particularly a small 13 % increase in estrogen) may be partly responsible.

New study shows risks greatest with dutasteride

A new study looked at the risk of gynecomastia in men using finasteride for prostate enlargement. The authors used the UK’s Clinical Practice Research Datalink (CPRD) to perform a case control study examining the risk of gynecomastia in individuals using finasteride compared to those who did not use.

The researchers showed that there was a three fold increased risk of gynecomastia in men using finasteride. A 5 fold increased risk of gynecomastia was seen with dutasteride.

Conclusion

It’s clear that these medications can cause gynecomastia. Dutasteride appears to carry greater risk.

Reference

Hagberg et al. Risk of gynecomastia and breast cancer associated with the use of 5-alpha reductase inhibitors for benign prostatic hyperplasia. Clinical Epidemiology 2017; 9; 83-91.

Can stress cause hair loss?

Stress and Hair Loss

It is possible that stress can cause hair loss, although it does not happen to everyone. High levels of stress can trigger an increased amount of hair shedding. The hair shedding is typically experienced 2-3 months later at its peak but is highly variable. Some shed one month later and some 3. Even the same person can experience great variability in how they shed. One stressful event triggers shedding 4 weeks later yet another stressor causes a delay of 3 months.

The diagram above shows a typical stress - shedding response. For some, a high level intense stress in February will trigger a shed sometime starting in April and peaking in May/June. For reasons that are not clear, this stress-shedding cycle does not occur in everyone.

Stress may play a role in other hair conditions. In my opinion, high stress may accelerate androgenetic alopecia a slight bit. Stress can make scarring alopecia much more itchier. I do believe stress has a major role in frontal fibrosing alopecia- with many patients reporting extremely high stress at the time of disease onset.

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.

Minoxidil and the cat

Minoxidil is Toxic to Cats

Minoxidil is FDA approved for treating male and female androgenetic alopecia. It has been studied in humans for over 35 years. 
However, it is not well known among users of minoxidil that minoxidil may have a unique toxicity to cats. That is not to say that cat owners can not use minoxidil - but important lessons come from a 2004 study in the veterinary literature.

DeClementini and colleagues reported 2 cats who died after their owners applied minoxidil to areas of hair loss on the cat. The first cat was a 3 year old cat had just one drop applied to an area of hair loss . That cat had trouble breathing, high heart rate, water in the lungs (pulmonary edema and pleural effusion) and showed increased liver enzymes. The cat died 15 hours later.

The second cat was a 7 year old cat and the owners applied an unknown amount of 5 % minoxidil solution to an area of hair loss and left the home for three days. Upon returning to the home, the owners found the cat also having difficulty breathing. Veterinarians confirmed pulmonary edema and pleural effusions. That cat died 10 hours later despite supportive care.

These are important lessons. Minoxidil must not be applied to cats and cats should not have the opportunity to play with the hair of owners who have applied minoxidil for their own hair loss. Most of what is needed though is just common sense. It is possibly to have a cat and have minoxidil users in the home.

Minoxidil may be uniquely toxic to cats and less toxic to other pets like dogs. A 1997 study involved the application of 3 % minoxidil to hairless puppies (descendants of Mexican hairless dogs) for 31 days. Side effects were not observed. However, minoxidil should never be applied to any animal. 

Reference

Suspected toxicosis after topical administration of minoxidil in 2 cats. Journal of Veterinary Emergency and Critical Care 2004; 14:287-292

Minoxidil: Can it raise heart rate?

Minoxidil can raise heart rate in some individuals

One uncommon side effect from minoxidil is an increase in heart rate. This is not the only thing that minoxidil is doing in this situation. It's actually primary lowering blood pressure and in turn the body increases heart rate to compensate.

I'm often asked if one needs to stop. This needs to be handled on a case by case basis. Some people will say to me " my heart rate goes up when I exercise ... so what's the difference?"

During exercise both heart rate and blood pressure go up. It's a very different physiology than minoxidil. A person's heart rate also goes up (and blood pressure goes down) when hey are dehydrated and we know this is not good.  A person's heart rate can go up (and blood pressure go down) with topical minoxidil. Fortunately, this does not happen to everyone. But if there are significant heart rate changes with minoxidil, I advise checking with one's physician about whether or not to stop. This is especially important for those over 65.