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Knowing when not to prescribe

To prescribe or not to prescribe

Knowing when not to prescribe a medication is just as important as knowing when to prescribe it.

prescribing


Should be 24 year old male with male balding and severe depression be prescribed finasteride? What about the the 57 year old male with male pattern balding and unstable angina. Can he use minoxidil?  Should the 31 year old female with folliculitis decalvans on isotretinoin also receive doxycycline? Should the 45 year old female with lichen planopilaris and pre-existing retinopathy receive hydroxychloroquine?  The answer to all of these questions is no.

Knowing when not to prescribe a medication is just as important as knowing when to prescribe it.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Can hydroxychloroquine (Plaquenil) be prescribed in the setting of G6PD deficiency

Hydroxychloroquine in G6PD Deficiency

Hydroxychloroquine (Plaquenil) is an oral immunomodulating medication commonly used for the the treatment of autoimmune diseases. In the world of hair loss, it is commonly used for treating lichen planopilaris, frontal fibrosing alopecia, discoid lupus and pseudopelade. Some reports have emerged that it may even be useful in alopecia areata. 

For years, physicians have been taught that certain groups of patients should not be prescribed hydroxychloroquine. These include patients with psoriasis, retinal problems, certain psychiatric disorders, porphyria, anemias, neutropenias, and liver problems. In addition, patients with deficiency of an enzyme known as Glucose-6-Phosphate Dehydrogenase (G6PD) were also thought to be ineligible for the mediation given their increased risk of hemolytic anemia. 

About 400 million people have G6PD deficiency. It is more common in the Middle East, Mediterranean, and parts of Africa and Asia.  It is a genetic condition that is present from birth. Without the enzyme, patients experience hemolysis of death of their own red blood cells from triggers like infection, medications, stress and even some foods (i.e. fava beans). The actual severity of the condition varies greatly depending on the specific enzyme that is inherited at birth.

New Studies suggest Plaquenil may be safer in G6PD deficiency than once thought

I was very interested to recently read an abstract by Samya Mohammad and colleagues at Duke University presented at the 2016 meeting of the American College of Rheumatology. The abstract was titled " Hydroxychloroquine Is Not Associated with Hemolytic Anemia in Glucose-6-Phosphate Dehydrogenase (G6PD) Deficient Patients" 

The authors set out to evaluate 275 patients who were prescribed hydroxychloroquine including 11 who were G6PD deficient.   The study did not involve hair patients but rather patients with diagnoses such as lupus (32%), rheumatoid arthritis (29%), and other inflammatory joint problems (14%).  

The G6PD deficient patients had a total of 711 months of exposure to ydroxychloroquine.  In this cohort, no G6PD deficient patients developed hemolytic anemia attributable to the drug during 711 months exposure to the drug.

 

Conclusion

To date this remains the largest study to date evaluating the frequency of hemolytic anemia in  G6PD deficient patients treated with hydroxychloroquine. Although small in number, the authors felt that their data do not support routine G6PD level measurement prior to initiating HCQ therapy.

Reference

Mohammad S, Clowse MEB, Eudy A, Criscione-Schreiber L. Hydroxychloroquine Is Not Associated with Hemolytic Anemia in Glucose-6-Phosphate Dehydrogenase (G6PD) Deficient Patients [abstract]. Arthritis Rheumatol. 2016; 68 (suppl 10). https://acrabstracts.org/abstract/hydroxychloroquine-is-not-associated-with-hemolytic-anemia-in-glucose-6-phosphate-dehydrogenase-g6pd-deficient-patients/. Accessed June 23, 2018.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Focal atrichia in androgenetic alopecia

What is the significance of focal atrichia?

FA-AGA

"Focal atrichia" (FA) refers to the absence of hairs is defined areas on the scalp. It is a feature generally seen in androgenetic alopecia whereby small circular areas totally devoid of hair are seen. These areas are typically the size of a pencil eraser and sometimes a bit bigger. Biopsies of these ares in the setting of androgenetic alopecia show accumulation of tiny vellus hairs.


It’s clear that FA is more common in androgenetic alopecia than other types of hair loss. A 2017 study by Olsen and colleagues showed FA was seen in 44 % of patients with FPHL compared to 2 % of other diseases. Those other 2 % may include area of primary scarring alopecia, scars from trauma, and even diffuse alopecia areata. Nevertheless, focal atrichia is most commonly seen in androgenetic alopecia.

There are still a few things that are unclear about whether one sees FA atrichia only in advanced disease. That same 2017 study by Olsen suggested 67 % of women with “late onset” FPHL had FA compared to just 15 % of those with “early onset” AGA. As we continue our discussion one must keep in mind that late onset generally has better prognosis.

 

Study 1: Olsen and colleagues, 2017

The 2017 Olsen study set out to evaluate the frequency of focal atrichia in various types of hair loss and its histologic characteristics in female androgenetic alopecia. The authors reviewed 250 consecutive female patients seen with hair loss for the presence or absence of FA. Interestingly, FA was identified in 46/104 (44%) of women with female pattern hair loss, including 15 % of early onset and 67% of late onset compared to 3/146 (2%) of those with other hair disorders. The histological (biopsy) findings of FA in FPHL showed mainly a more progressive miniaturization process than that of haired areas of the scalp. Taken together Olsen and her colleagues concluded that FA wasa clinical clue to the diagnosis of FPHL, particularly late onset subtype.


 
Study 2: Hu and colleagues, 2015

Studies by both Hu and colleagues and Zhang and colleagues both independently showed FA was associated with more severe disease. Additionally, Zhang et al showed that it was also associated with longer duration of disease. These findings seem to be at odds with the Olsen study.

Hu and colleagues performed a case-control observational study to identify the trichoscopic findings of AGA and to evaluate their relationship with the overall severity of the androgenetic aloepcia. The authors performed trichoscopic examination for 750 male AGA patients and 200 female (FPHL) patients, along with 100 male and 50 female normal controls.  In this study, FA was positively related to severity of hair loss (P < 0.05). 

 

Study 3: Hu and colleagues, 2012

Zhang and colleagues set out to analyze characteristics and investigate associations and clinical and trichoscopic features of female patients with FPHL. The did so by evaluating data from 60 patients with FPHL. FA was positively correlated with the stage and duration of hair loss.
 

Taken together, it is clear that FA is frequently seen in androgenetic alopecia. At first glance, is not uncommon to wonder whether these areas in fact represent scarring alopecia (i.e. tiny patches of Pseudopelade of Brocq or lichen planopilaris) or represent small areas of alopecia areata. However, when taken in context with the miniaturization going on in other areas of the scalp nearby, one can generally be confident these are area of FA. 

The general consensus would be the FA is a negative prognostic factor. 



Reference

Olsen et al. Focal Atrichia: A Diagnostic Clue in Female Pattern Hair Loss.
J Am Acad Dermatol. 2017.

Hu R, et al. Trichoscopic findings of androgenetic alopecia and their association with disease severity. J Dermatol. 2015.

Zhang X, et al. Female pattern hair loss: clinico-laboratory findings and trichoscopy depending on disease severity.  Int J Trichology. 2012.

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Fusion Follicles: Compound Follicles = More than 6 Hairs

Compound Follicles = More than 6 Hairs

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Compound Hair Follicles are hair follicles with more than the normal number of hairs emerging from a single hair follicle opening. In this photo, we see some of the earliest signs of a condition known as folliculitis decalvans. The scalp is red and scaly and there is a clear tendency for hair follicles to fuse together. The arrow points to 9 hair follicles all grouped together and emerging from the single opening. This so called compound follicle is commonly seen in many patients with folliculitis decalvans as well as some other scarring alopecias as well.

Treatment with topical antibiotics, oral antibiotics, retinoids, topical and/or intralesional corticosteroids are the best primary options in managing the disease.
 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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The Scalp Punch Biopsy: Will anyone notice I had it done?

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Will anyone notice I had it done?

A punch biopsy of the scalp is performed if their is any uncertainty about the diagnosis of a patient’s hair loss. It involves removal of a 4 mm cylindrical core of tissue and placement of a stitch (suture). A punch biopsy should be taken from an area showing the main features of the disease in question. Provided the biopsy is taken from an area that contains a reasonable amount of hair, the stitch and healing site should be relatively unnoticeable. A dissolving suture or non dissolving suture can be placed although I tend to prefer dissolving sutures.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Scarring Alopecia: Is it inactive?

Is it inactive?

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There are many misconceptions when it comes to determining if a scarring alopecia is truly “quiet.” Scarring alopecias, are a group of hair conditions whereby the body forms scar tissue in the scalp. This scar tissue ultimately prevents hairs from growing properly.

Here are a few principles that should always be considered when one feels they want to say a scarring alopecia is “quiet” or “inactive” 1) No doctor can tell if a scarring alopecia is quiet by looking at the scalp on a first appointment visit. That sentence deserves reading twice. Some scarring alopecias look quiet but the patient continues to lose hair. You can really only say a scarring alopecia is quiet if you’ve re-examined the scalp 12-24 months after the first appointment. 2) A patient with scalp symptoms like itching, burning or pain probably does not have quiet (inactive) disease. 3) Patients with redness and scaling in the scalp probably have active disease but they may not. Redness can be a sign of active disease but some patients with prolonged use of topical steroids simply have a red scalp. 4) The most important (and too often forgotten) guide that determines if a scarring alopecia is “quiet” is a comparison of scalp photographs taken at two different time points. Provided the interval between photos is greater than 1 year, one can get some pretty good information about whether the condition is quiet.

In my opinion, if there is no change in hair density between 2 photographs taken ONE year apart, the scarring alopecia is “probably” quiet (inactive). If there is no change in hair density between 2 photographs taken TWO years apart, the scarring alopecia is “extremely likely” to be deemed quiet. Despite this inactive appearance, the scarring alopecia STILL carries a risk of reactivation.

If there is no change in hair density between 2 photographs taken THREE years apart, and the patient is OFF MEDICATION during that period of observation, the scarring alopecia is likely burnt out.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Alopecia Areata

Alopecia Areata: A Cause of Non Scarring Hair Loss

AA?.png

Alopecia areata is a form of autoimmune hair loss. Inflammation occuring deep under the scalp causes hair to fall out. The hair loss is non scarring which means the potential exists for hair to grow back. 


This photo shows the scalp of a man with advanced alopecia areata. Yellow dots represent keratin plugged openings of the hair follicles. Despite his widespead hair loss (involving 98% of this patient’s scalp), there are hairs on the scalp that appear completely unaffected by the immune reaction. Why that is remains unknown. Treatments for advanced alopecia areata include steroid injections, diphencyprone, anthralin, methotrexate, sulfasalazine, hydroxycloroquine and tofacitinib 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Lichen Planopilaris: Itching, Burning, Tenderness, Shedding

Itching, Burning, Tenderness, Shedding

LPP symptoms.png

Lichen planopilaris (LPP) is a scarring hair loss condition that leads to permanent hair loss in affected areas without treatment.

Individuals with the condition may initially develop itching, burning or pain. For some, increased amounts of shedding may be the only symptom.

Examination of LPP via up close (“dermatoscopic”) examination is shown here. The scalp is red and scaly. In particular, some of the scale is located around hair follicles (called perifollicular scale). There are distinct whitish areas seen which represent permanently scarred areas of the scalp.

Treatment of LPP includes topical steroids, topical calcineurin inhibitors, steroid injections and a variety of oral immunosuppressive medications such as doxycycline, hydroxychloroquine, mycophenolate, cyclosporine, methotrexate, isotretinoin, tofacitinib and pioglitazone. Low level laser and excimer laser could to be studied and appear to offer benefit for some.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Corticosteroid Telangiectasias

Corticosteroid Telangiectasias

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Topical steroids have an important role in the treatment of hair loss. Like any medication, they must be respected. 


Dilatation of blood vessels (telangiectasias) can occur with prolonged topical steroid use. This is thought to occur due to stimulation of release of a chemical known as nitric oxide (NO) from dermal vessel endothelial cells which in turn leads to abnormal blood vessel dilatation. This photo shows telangiectasias occurring in a patient with alopecia areata treated with prolonged topical clobetasol. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Scarring Alopecia: Top 25 Frequently Asked Questions

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Top 25 Frequently Asked Questions

Scarring alopecia (also called cicatricial alopecia) is a form of hair loss that has the potential to cause permanent hair loss. 

These conditions are not as common as hereditary balding which gives rise to many myths, misunderstandings and miscommunications when it comes to the diagnosis and treatment of these conditions.

Our patient handout can be downloaded here

PATIENT INFORMATION - TOP 25 FAQ SCARRING ALOPECIA


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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What is scarring alopecia?

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What are scarring alopecias?

Scarring alopecias (also referred to as the cicatricial alopecias) are a broad group of hair loss conditions that are associated with inflammation and scarring. Inflammation in the upper parts of the hair follicle leads to destruction of hair loss stem cells and loss of sebaceous glands.

The slow development of fibrosis (scarring) leads to a permanent loss of hairs.
 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Caffeine and Hair: What does Caffeine do for Hair?

What does caffeine do for hair?

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This specialty coffee reminded me about the increasing attention recently on topical (not oral) caffeine for hair growth. Topical caffeine is slowly catching the attention of the hair world and general public. A small number of studies have suggested that caffeine may have positive effects on hair follicles when applied topically. Some shampoos are even including caffeine additives with “claims” it reduces shedding.

I’m reminded of a 2014 study which set out to investigate the impact of caffeine on hair growth in vitro and to better understand how caffeine modulates the effects of testosterone.

The researchers used microdissected human scalp hair follicles (both male and female) and treated them in culture with testosterone or the combination of testosterone and caffeine). Remarkably, caffeine prolonged anagen duration, enhanced hair shaft elongation and stimulated hair matrix keratinocyte proliferation. Hair follicles from men were less sensitive to caffeine than female follicles.

Caffeine had effects on TGF-β2 and IGF-1. Specifically, caffeine blocked testosterone-enhanced TGF-β2 protein expression in male HFs. In female HFs, caffeine reduced TGF-β2 expression. IGF-1 protein expression was upregulated in both male and female hair follicles.

I have read and reread this study a few times over the years. It’s quite interesting that caffeine has hair growth promoting properties.

The use topical caffeine for its effects on hair is still in its early days. There are several commercially available products that contain caffeine (mainly shampoos) and a few of these shampoos have small clinical studies that show some potential to reduce shedding and improve the look of the hair. These studies are small and preliminary in nature.

Government regulators in some countries have recently come down hard on manufacturers of “caffeine” containing hair products (especially some shampoo makers) scrutinizing claims that these products benefit hair. More rigorous studies are needed to determine definitively what role these products have.
 

Reference

Fischer TW, et al. Br J Dermatol. 2014. and Sisto et al J Appl Cosmetol 2013


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Alopecia areata and Androgens: Are we missing something?

AA and Androgens

Alopecia areata is an autoimmune disease. It occurs in about 2 % of the population and in all age groups and races. To date the role of hormones in alopecia areata is unknown – although the area is poorly studied in general.

In 2017, Conic and colleagues set out to retrospectively review the clinical features of patients with alopecia areata that were seen at the Cleveland Clinic over the period 2005 to 2014.  In total, data from 504 patients was tabulated and as a comparison group 172 patients with seborrheic dermatitis were also reviewed. 

Elevated androgens were far more common in those with alopecia areata compared to controls (13 % vs 1 %).  Ovarian cysts were also more frequent in those with AA being present in 8.6 % of patients vs just 3.2 % of controls. 

 

Conclusion

This study was interesting and certainly caught my attention. Very little is known about how hormones affect AA. The increase incidence of androgens warrants further study. If consistently found in a proportion of patients, one needs to explore whether use of anti-androgens could benefit some patients with AA as well.  In the same light, one needs to consider whether androgenic progestins in oral contraceptives could act as a trigger for AA in some patients

 

REFERENCE

Conic et al. Comorbidities in patients with alopecia areata. Journal American Academy Dermatology; 754-756.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Deficiencies of iron and vitamin D in patients with alopecia areata

Deficiencies of iron and vitamin D in patients with alopecia areata

Alopecia areata is an autoimmune disease. Blood tests are important for patients with alopecia areata given that recent research has suggested that vitamin D deficiency as well as other deficiencies such as iron deficiency may be more common in alopecia areata.  

In 2017, Conic and colleagues set out to retrospectively review the clinical features of patients with alopecia areata that were seen at the Cleveland Clinic over the period 2005 to 2014.  In total, data from 504 patients was tabulated and as a comparison group 172 patients with seborrheic dermatitis were also reviewed. 

Patients with alopecia areata had more frequent vitamin D deficiency (30 % compared to 13 % in controls) and also had more frequent iron deficiency (7.3 % vs 2.9 % of controls).  Anemia was also more common being present in 17 % of those with alopecia areata and only 7.6% of control patients. 

 

Conclusion

Deficiencies of iron and vitamin D are more common in alopecia areata. Testing levels of iron nd vitamin D are important in alopecia areata.

 

REFERENCE

Conic et al. Comorbidities in patients with alopecia areata. Journal American Academy Dermatology; 754-756.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Autoimmunity in Patients with Alopecia areata: 

What conditions are more common and which ones are less common?

Alopecia areata is an autoimmune disease. It is well known that the risk of developing a second autoimmune condition is increased once a person is diagnosied with their first autoimmune disease. 

In 2017, Conic and colleagues set out to retrospectively review the clinical features of patients with alopecia areata that were seen at the Cleveland Clinic over the period 2005 to 2014.  In total, data from 504 patients was tabulated and as a comparison group 172 patients with seborrheic dermatitis were also reviewed. 

Interestingly, atopic dermatitis (eczema) and thyroid disease were found to be more common in patients with alopecia areata compared to controls.  The incidence of diabetes mellitus was found to be less common. 

 

REFERENCE

Conic et al. Comorbidities in patients with alopecia areata. Journal American Academy Dermatology; 754-756.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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PRP for Hair Loss: Why I'm cautious with actinic keratoses

Could PRP Accelerate Actinic Keratosis Progression?

Actinic keratoses (AKs) are red scaly lesions. They are typically found in patients with lighter skin types, especially those who have had previous sun exposure in their past. Actinic keratoses are not cancers, but they do have a very small risk of becoming cancers. For that reasons, most AKs get treated.

I'm often asked if there are any concerns with performing platelet rich plasma (PRP) on the scalp in a patient with multiple AKs. Nobody really knows this answer because studies have not been done. I think one should always be aware that many of the growth factors in PRP could theoretically favour progression of actinic keratoses en route to cancer. These include Vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), and fibroblast growth factor (FGF). This topic needs study. 

FGF for example may promote progression. In 2011, Cuevas Sánchez P, et al showed that an FGF blocking cream was able to actually treat AKs. Similarly VEGF is known to drive AKs and VEGF levels reduce as AKs are successfully treated.  EGF is overexposed in a variety of tumors.

 

Conclusions/Comments

In the present day, we have no evidence that use of PRP in patients with preexisting actinic keratoses is safe.  While we have no evidence it is harmful, the overwhelming evidence would suggest that growth factors in PRP have the potential to drive progression of AKs towards cancer.

 

Reference

Cuevas Sánchez P, et al. Topical treatment of actinic keratoses with potassium dobesilate 5% cream. a preliminary open-label study. Eur J Med Res. 2011.

Bobyr I, et al. Ingenol mebutate in actinic keratosis: a clinical, videodermoscopic and immunohistochemical study. J Eur Acad Dermatol Venereol. 2017.

Groves RW, et al. Abnormal expression of epidermal growth factor receptor in cutaneous epithelial tumours. J Cutan Pathol. 1992

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Frontal Fibrosing Alopecia: The Early Stages

When FFA First Begins 

FFA-early

Frontal fibrosing alopecia (FFA) is a scarring alopecia that affects women to a greater extent than men. The cause remains unknown although hormonal and immune-based mechanisms are clearly relevant.

The disease causes loss of hairs in the frontal hairline, sides and back of scalp, eyelashes, eyebrows and body hair. What is interesting about FFA is that the very earliest stages are associated with destruction of the tiny “vellus” hairs. This destruction leaves behind the thicker terminal hairs. 


In the earliest stages of FFA, the hair loss can be completely unnoticeable. There are frequently no symptoms and there is simply a subtle thinning in the area rather than complete loss. 

This photo of a patient with FFA shows a relatively normal looking scalp that is easily mistaken for androgenetic alopecia. (In fact this photo could easily be a picture of androgenetic alopecia were it not for the loss of all vellus hairs in this area over a 3 month period). In androgenetic alopecia, there is a gradual (slow!) conversion of thick hairs to thin hairs (a process called miniaturization). In FFA, we often do not see the miniaturized and vellus hairs as they are preferentially destroyed by the immune system. We see mainly single terminal hairs in FFA. Over time (without treatment) there may be some redness that develops in this area and even some scaling. About 40 % of women with FFA have androgenetic alopecia as well, so the two conditions frequently co-exist.

It is often not a decision “is this FFA or AGA ...but rather is it FFA, AGA or both.” The goal of treatment however is to stop that from occurring and the patient was started on topical fluocinonide gel, pimecrolimus cream, steroid injections and oral finasteride.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Characteristics of FFA in Men

 Characteristics of FFA in Men

Frontal fibrosing alopecia is a type of scarring alopecia that causes hair loss along the frontal hairline and sideburns but can also affect the back of the scalp, eyebrows, eyelashes and body hair.  For every 100 patients I see with a diagnosis of FFA, 99 patients are women and 1 patent is   male.

Tolkachjov and colleagues performed a study of 7 male patients with frontal fibrosing alopecia to gain a better understanding of how these patients present and what type of hormonal or endocrine abnormalities might be present. 

Of the 7 patients, 4 showed loss of the sideburns, 3 showed loss of eyebrows, 2 showed loss of  hair in the occipital scalp.  1 patient had hair loss on the legs, 1 had hair loss on the arms and 1 had loss of hair from the upper lip. None of the 7 patients had facial papules and only 1 had androgenetic alopecia.  Interestingly, none have evidence of thyroid disease and none had low total testosterone levels (although  2 had evidence of low free testosterone).  All patients were ANA negative or only weakly positive. 

Of the 7 patients, 4 started systemic therapy with oral hydroxychloroquine and 3 of these patients were able to achieve disease stabilization with use of this drug.  

 

Comment

FFA is rare in men but we are seeing an increasing number of males affected. This study is small and so it’s difficult to get a good sense about how FFA in men differs from women.  Hypothyroid disease occurs  in 15-23 % of female patients with FFA. Although the data in this study would suggest that hypothyroidism is uncommon in men with FFA, the study is too small to really get a sense of that information.

 

Reference

Tolkachjov et al. Frontal fibrosing alopecia among men: A clinicopathologic study of 7 cases. Journal of the American Academy of Dermatology 2017; 77:683-90 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Evaluating Hair Loss in Males vs Females

Hair Loss is Different in Men and Women

Generally speaking, the evaluation of hair loss in women is more involved than the evaluation of hair loss in men. The vast majority of men with concerns about hair loss who walk through the door of a hair clinic have androgenetic alopecia. Of course, men can have scarring alopecia, alopecia areata and (rarely) true effluviums just like women and some days we see more men with scarring alopecia and alopecia areata than male balding. 

MALES-VS-FEMALES


For women, the reasons are consistently much more varied. Many women with concerns about their hair have androgenetic alopecia but telogen effluvium and scarring alopecias are commonly seen on a daily basis. Many women have more than one reason for their hair loss.
ere…


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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4000 Patient Questions: Lessons Learned

What I Learn Answering Patient Questions 

I enjoy answering patent questions on a variety of forums  - including our many social media platforms (Instagram, Facebook), Realself.com, Drugs.com, as well as  our website. Today, marks the 4,000 th question I've answered about hair loss on Realself.com.

Such an event prompts me to pause and reflect back on many questions I've answered across various sites.  How would I summarize common concerns from patients? What errors do people make in their assumptions about their hair?

Below I'll summarize the Top 10 Lessons I've Learned from Answering Questions

 

TOP 10 LESSONS

 

1. Many people underestimate the importance of an "up-close" examination and review of their story

One of the common errors I see as a participant in various online platforms is that many people underestimate what it takes to actually diagnose hair loss. One needs a full story, a full examination and often a full review of blood tests.  A sentence or two from a patient is never enough. A photo is sometimes helpful but one can never confidently diagnose hair loss with 100% confidence with a photo.  There are far too many hair loss conditions that mimic each other to rely solely on a photo.

 

2.  Many people assume blood tests hold the answer.

Blood tests are important in diagnosing hair loss, but they are only a part of the full evaluation. Many people with hair loss are disappointed that their blood tests returned 'normal' and wonder how this can be. The reality is that many patients with hair loss have normal blood tests and even when they are abnormal it does not necessarily mean the lab test is relevant to the patient's hair loss! Is a ferritin level of 31 relevant to hair loss in a female patient? Probably not even through it is true that we like the value to be above 50.  Is a low vitamin D level relevant? Probably not even through it is true that we like the value above a certain level.  Many times, blood tests can be slightly abnormal and have little or no relevance for the hair. Many patients focus excessively on these numbers while the real diagnosis goes undiscovered.

 

3.  Androgenetic alopecia is generally undiagnosed. 

In all the forums I participate in and questions I answer, there is an underrecognition of the presence of androgenetic alopecia both in men and women. Most young men between 20 and 30 who have concerns about shedding have androgenetic alopecia. Not all of course, but a much higher proportion than recognized. There is a similar failure to recognize the presence of androgenetic alopecia in women. 

 

4.  PRP treatments are overused

It would appear that platelet rich plasma (PRP) has become the panacea for all hair loss. This is unfortunate. While PRP can help certain conditions (and we used it in our clinic too) to some degree its overall value in my opinion is overstated.   PRP is a highly non-specific treatment.  What is needed in so many of the questions I read is a highly specific approach. 

 

5. Scalp biopsies are not preformed nearly enough

There is most certainly an under usage of the scalp biopsy. Countless numbers of dilemmas, confusions and conundrums that I come across can be solved through use of a scalp biopsy. 

 

6. Hair transplants are too often performed in young male patients. 

Among the most concerning situations I see frequently is the use and recommendation of hair transplantation to young patients. This is a particularly worrisome trend in those 18-22 but generally speaking in all males under 25. Hair transplantation is rarely if ever a good idea in a young male. 

 

7. There is a failure to recognize that 2 diagnoses may be present.

There is often a tendency among questions and posts from readers to want to decide between diagnosis 1 and diagnosis 2 without realizing that both diagnoses may be present. Many women have both androgenetic alopecia and telogen effluvium for example. 

 

8.  There is an over reliance on hair supplements

There is an increasing popularity with hair supplements without search for the underlying cause. What is needed for anyone with hair loss is a diagnosis. Discussions about treatment come second.  

 

9.  Family history is given too much attention

Family history is given too much attention by many patients. The genetic balding patterns of the family are clearly important but they should not be used as the main criteria to rule out a diagnosis. There are countless numbers of patients who claim that they can not have patterned hair loss because no such history exists in the family.  This reasoning rarely ever holds true. 

 

10.  Most patients lack appropriate follow up

Many types of hair loss, especially androgeneetic alopecia, are life long concerns. Far too many patients have seen a physician once or twice and been sent on their way to deal with their issues on their own. Most types of hair loss require a follow up evaluation to carefully evaluate effectiveness, and side effects. 

 

Conclusion

I've enjoyed answering thousands of questions from patients.  I'm moving on to question 4001 shortly on the website Realself.com and found this an appropriate time to reflect on commonalities from individuals across the world.  Generally speaking, it would appear that greater emphasis is needed on the thorough evaluation and follow up of hair loss. Biopsies are underused in the world of hair loss. In my opinion, hair supplements, PRP and hair transplantation are all to often inappropriately recommended. 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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