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Happy Holidays

On behalf of the Donovan Hair Clinic, I would like to wish everyone a wonderful holiday season and the very best in 2019.

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Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Hair, Health and Differences Between Men and Women

Multiple Health Parameters Differ in Men and Women

Many health conditions announce their presence differently in men and women. Heart disease, stroke and dementias are just a few examples. Women arrive at the clinic with different stories than men. Signs and symptoms often differ. Treatments work differently in men and women.

Hair loss also presents differently in men and women. Women arrive at the clinic with different stories about their hair loss than men. Signs and symptoms may differ. Treatments work differently in men and women. Modern medicine is just starting to recognize all these important differences.






Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Miniaturization in Alopecia Areata: Why is it reversible?

Association with Arrector Pili May Determine Reversibility

Miniaturization of hairs can occur in many hair loss conditions including androgenetic alopecia as well as alopecia areata. For many years, physicians have wondered why miniaturized hairs in alopecia areata hold on to the potential to regrow back to thick hairs whereas miniaturized hairs in AGA only have the potential to thicken up slightly . and only with treatment.

In 2016, Professor Rod Sinclair’s group in Australia proposed that alot of this may be due to a muscle known as the arrector pili muscle. The arrector pili muscle (APM) is not as well known as other muscles like the biceps, triceps or quadriceps. The APM is a very small muscle that is attached to every hair. When the APM contracts, the result for the patient is “goose flesh.” In the past, it was thought that the APM did not have any active role in any type of hair loss mechanisms and more or less acted as a ‘bystander.’ However, in 2016, Sinclair and colleagues proposed a new model of balding. They proposed that the APM has a key role in the decision of a hair follicle to ultimately "miniaturize" during the course of AGA.

By observing how miniaturization occurs within follicular units – the authors proposed that by maintaining tight attachment to the APM, some hair follicles are prevented from proceeding down the pathway of permanent miniaturization. The association with the APM was thought to preserve stem cells.

APM



The authors proposed that in other conditions like alopecia areata, hair follicles maintain their close association with the APM and therefore are protected from the possibility of irreversible miniaturization.

The photo here shows strong attachment of the APM to hairs in alopecia areata (right panel) whereas some hairs in androgenetic alopecia lose their attachment and become miniaturized (left panel).

Reference


Sinclair R, Torkamani N and Jones L. Androgenetic alopecia: new insights into the pathogenesis and mechanisms of hair loss. F1000Res. 2015 Aug 19;4 (F1000 Faculty Rev):585 -


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Miniaturization in Alopecia Areata vs Androgenetic Alopecia

Miniaturization: Not Only for Androgenetic Alopecia


When most people think about the term “miniaturization”, the hair loss condition known as androgenetic alopecia “AGA” (male balding and female thinning) comes to mind. This common hair loss condition is associated wirh the progressive “miniaturization” of hairs. A biopsy from a patient with AGA or an up close dermatoscopic examination of the scalp shows this variation in the size of follicles. Some follicles are thick and some are thin and some are very thin. The variation in the size of follicles is known as “anisotrichosis” and is very much a part of what AGA is all about.

AGA is not the only hair loss condition that is associated with miniaturization. Alopecia areata for example also shows miniaturization. However, in contrast to AGA, alopecia areata often does not show the same degree of “anisotrichosis” - meaning that there is not the same degree of variation in follicle size as seen in AGA. In alopecia areata, follicles in the biopsy are generally either thick ones or thin without the dramatic variation in caliber that is seen in AGA.

  Hair follicle miniaturization can occur in AGA and AA. Hairs are similar caliber in AA when miniaturization is present.

Hair follicle miniaturization can occur in AGA and AA. Hairs are similar caliber in AA when miniaturization is present.



The schematic diagram here shows these key differences. One can see on the left side (of AGA) that miniaturized hairs are all different thickness. In contrast, in the diagram of alopecia areata on the right the miniaturized hairs are all the same size. Lymphocytes are seen in both conditions although in alopecia areata they are classically around the bulb and in fibrous tracts whereas in AGA they are higher up in the skin in the infundibulum and isthmus. Eosinophils and melanin pigment can frequently be seen in fibrous tracts in alopecia areata.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Spironolactone for FPHL: Are routine potassium blood tests needed?

Spironolactone (Aldactone) for Healthy Women with FPHL: Is Potassium Testing Needed?

Spironolactone is an oral antiandrogen that is sometimes used to treat female pattern hair loss. It is also used to treat acne and hirsutism.

In addition to being an antiandrogen, spironolactone is a a type of blood pressure pill and diuretic. Spironolactone acts on the kidney (in the distal convoluted renal tubule) to promote sodium and water excretion and to promote potassium retention.

   Do patients using spironolactone for hair loss needed blood tests for potassium?

Do patients using spironolactone for hair loss needed blood tests for potassium?



Previous recommendations had suggested that routine monitoring of serum potassium levels by having the patient periodically have blood tests performed was important. Recent studies have suggested this is not necessary for healthy women.

Layton and colleagues evaluated 10 randomized controlled trials (RCTs) and 21 case series pertaining to acne. The authors did not find that serum potassium was more likely to be elevated in healthy women using spironolactone for acne.

Plavanich and colleagues performed a retrospective study of healthy young women taking spironolactone for acne. The authors analyzed rates of hyperkalemia (high potassium) in 974 healthy young women taking spironolactone and also analyzed 1165 healthy young women taking and not taking spironolactone to obtain a profile for the baseline rate of hyperkalemia in this population.

The findings of the study were that young women receiving spironolactone had a hyperkalemia rate of 0.72%, equivalent to the 0.76% baseline rate of hyperkalemia in the general population. The conclusion was that the rate of hyperkalemia in healthy young women taking spironolactone for acne is equivalent to the baseline rate of hyperkalemia in this population and that potassium monitoring is unnecessary for healthy women taking spironolactone for acne.

Studies of potassium levels in women using spironolactone for hair loss have not been done but there is no reasons to believe there is any difference. Routine potassium testing in healthy women is not usually necessary. Women with cardiovascular disease, kidney disease, diabetes and women taking certain medications that affect potassium levels (ie potassium sparing diuretics), may or may not be good candidates for spironolactone but if they are candidates they will require periodic potassium measurements.



Reference


Layton AM et al. Oral Spironolactone for Acne Vulgaris in Adult Females: A Hybrid Systematic Review. Am J Clin Dermatol. 2017.

Plavanich M et al. Low Usefulness of Potassium Monitoring Among Healthy Young Women Taking Spironolactone for Acne. JAMA Dermatol. 2015.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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New Players Identified in Hair Loss Mechanisms

DKK2 Proposed to be Key Player of Blocking Growth.

It’s well known in the hair research world that a molecule known as WNT is important for hair growth. New research from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia shows that a protein known as DKK2 is responsible for blocking WNT from doing it’s job.

WNT signals are important in embryonic development and also have an important role in how cells signal with each other in adult life. WNT signals, when they are present, cause hair to grow. When they are absent, they cause hair loss stop growing or not grow at all.


DKK2

In order to study why some parts of the body don’t grow hair and to better understand what signals hairs to not grow, researchers studied the plantar skin of mice. These areas are similar to the palms of human hands in some ways. They lack hair follicles. The researchers found high levels of Dickkopf 2 (DKK2) proteins in this area. Remarkably when mice were engineered to lack the DKK2 proteins, the hair grew in these areas.


Summary

The DKK2- WNT pathway is relevant to human hair growth - and that’s of course why this study is exciting. Previous research has suggested that genes like DKK2 are plausible genes that are implicated in the pathogenesis of male balding and female thinning. More understanding of this important area is likely to be highly relevant and likely to lead us in the direction of better treatments. A DKK2 drug inhibitor for example has potential to help hair loss.

REFERENCE

Song et al. Regional Control of Hairless versus Hair-Bearing Skin by Dkk2. Cell Reports Nov 2018.

Heilmann-Heimbach S, et al. Meta-analysis identifies novel risk loci and yields systematic insights into the biology of male-pattern baldness. Nat Commun. 2017.



Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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White hypopigmented scarring with FUE

FUE is not scarless but scars can appear barely detectable

Hair transplantation involves moving hair from one area of the body to another. Most commonly, hair transplants involve moving hair from the back of the scalp to the more frontal areas of the scalp (i.e. hairline, midscalp or crown). There are two main ways that hair transplant surgery is done nowadways. One is known as follicular unit strip surgery (FUSS or FUT) and the second is known as follicular unit extraction (FUE).

FUSS/FUT involves the removal of a strip of skin and hair from the back of the scalp. Sutures are used to close the wound that was created. The individual hairs are then obtained by delicately cutting up the hairs using a microscope. The result of FUSS/FUT is a linear scar that runs along the back of the scalp. 

The second type of surgery is increasingly referred to as follicular unit “excision” surgery and involves the excision of follicular units one by one from the back of the scalp using a “punch” device. One of the common and unfortunate misconceptions is that FUE is “scarless.” In fact, many advertisements list “scarless” as one the benefits of FUE over FUSS/FUT. FUE is not scarless. Anytime the skin is injured down in the deeper layers a scar has the potential to form. FUE involves removal of complete hairs - even hairs that were once rooted deep down in the fat layer.

 Circular whitish scars in a patient with a previous FUE transplant

Circular whitish scars in a patient with a previous FUE transplant

By definition, FUE is not a scarless procedure. A tiny scar forms during the procedure. Fortunately, however, the scars with FUE tend to be quite small and sometimes quite difficult to detect. That usually makes it difficult for anyone to see evidence that the patient had a procedure in the past. 

For some people, very small circular whitish scars can be seen post surgery as seen in this photo. These circular scars may be quite difficult to notice but an astute eye can sometimes make out the areas in the donor area where the FUE punch took the hairs during the surgery. Some people also develop small amounts of redness in the donor area too which makes the whitish hypopigmented circles a bit more noticeable. Over time, redness may fade to some degree leaving the whitish circles less noticeable. Some people maintain permanent faint redness


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Peripilar casts (Perifollicular scale) in LPP

Scaling in Lichen Planopilaris (LPP)

Lichen planopilaris (LPP) is a scarring alopecia that has the potential to cause permanent hair loss. Many patients first develop symptoms such as itching or burning or tenderness un the affected area. Some patients have all three. 

Clinical examination can sometimes look fairly normal. However, in more active LPP, the scalp is red to varying degrees. There is redness around the follicles (called perifollicular erythema) and there is often whitish scale around follicles too. The whitish scale is known by many names including “perifollicular scale” and “peripilar casts” and “follicular hyperkeratoses.” All these terms mean the same thing for the most part. Perifollicular erythema and perifollicular scale are signs the disease is active. 

 Perifollicular scale (white color around follicles) in a patient with LPP.

Perifollicular scale (white color around follicles) in a patient with LPP.

Treatments for LPP have been discussed in other posts but include agents such as topical steroids, steroid injections, topical calcineurin inhibitors, low level laser therapy, oral doxycycline, oral hydroxychloroquine, mycophenolate mofetil, methotrexate, cyclosporine, low dose naltrexone, oral tofacitinib. Successful treatment stops symptoms and more importantly stops hair loss.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Frontal Fibrosing Alopecia (FFA): Perifollicular Scale/Peripilar Casts

Perifollicular Scale/Peripilar Casts

IMG_3779.png

Frontal fibrosing alopecia (FFA) is a type of scarring alopecia. In some patients, eyebrow loss is one of the first signs of the disease whereas in others the frontal hairline is affected first. Many patients are asymptomatic although a bit of itching is not all that uncommon.

FFA can affect the frontal scalp as well as the sideburns and even around the back of the scalp (ie behind the ears). In fact, any body hair can be affected. The appearance of the scalp in various regions has been shown to appear differently by dermoscopy.

In 2018, Cevantes and colleagues compared the differences between the dermatoscopic appearance of the sideburns and the frontal scalp regions. The sideburn area in FFA was found to have less redness around hairs (perifollicular erythema) and less scaling (perifollicular scaling or peripilar casts) compared to the frontal scalp.

This information is helpful for physicians as we often rely on the presence or absence of perifollicular erythrma and scale as helping to decide if the FFA is active or not. This study reminds us that monitoring redness and scale makes sense when examining and monitoring the frontal scalp in patients with FFA but is of limited value when monitoring FFA of the sideburn area. 

The dermoscopy photo shows the typical appearance of FFA of the frontal hairline. Scaling around hairs is known by many names including "perifollicular scale" and "peripilar casts."


Reference

Cervantes J, et al. Distinct Trichoscopic Features of the Sideburns in Frontal Fibrosing Alopecia Compared to the Frontotemporal Scalp.

Skin Appendage Disord. 2018.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Scalp Dysesthesias

What treatments are available for scalp dysesthesias?

I just posted a new answer to our “Question of the Week.” I was asked to outline what treatments are possible for patients who are diagnosed with ‘scalp dysesthesia.’

The full answer to this week’s question can be read here:

What treatments are available for scalp dysesthesias?

To submit a new question for consideration of our Question of the Week, simply visit complete our online form


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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What constitutes a normal appearing scalp?

normal scalp

Recognizing the Normal Scalp

In order to appreciate what is “abnormal” on the human scalp, one needs to fully understand what is normal and what are all the variations of normal that are possible.

The normal scalp is not red and not flaky. Hairs emerge in groups of 1,2 and 3 hairs. In some cases (especially younger individuals) hairs come out occassionally in groups of 4 hairs too. Most hair follicles in an area are the same diameter (caliber) but a bit of variation is normal and acceptable. The finding of an occassional thin hair carries no significance and does not mean the individual has androgenetic alopecia.









Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Diagnosis of Scarring Alopecia in the Early Stages

Early Diagnosis More Challenging that Late Stage Diagnosis

Diagnosing scarring alopecias in the earliest stages is more challenging because the appearance of the scalp may not look all that unusual.  The photo here is from a patient with lichen planopilaris. There are subtle features like scalp erythema, pili torti and single hairs that might trigger  one to think about scarring alopecia but the features are not specific. This photos could just as easily be from a patient with androgenetic alopecia and seborrheic dermatitis.

  EARLY LICHEN PLANOPILARIS: FEATURES ARE NON SPECIFIC IN THIS PHOTO

EARLY LICHEN PLANOPILARIS: FEATURES ARE NON SPECIFIC IN THIS PHOTO


However, diagnosing scarring alopecia in the early stages is made a lot easier by carrying a simple rule: if there is even the slightest possibility that what a physician is looking at could be a scarring alopecia, then a biopsy should at least be considered.


Not everyone that has scalp itching has a scarring alopecia. There are dozens of causes of itching. Not everyone with itching needs a biopsy.

Not everyone that has excessive shedding and a red scalp has a scarring alopecia. In fact, most don’t. There are many causes of shedding and a red scalp. Not everyone with a red scalp and shedding needs a biopsy.



Patients with Multiple Symptoms May Need A Biopsy

Scarring alopecias (particularly the symptomatic ones like lichen planopilaris and folliculitis decalvans) are very often associated with symptoms and signs that signal to the patient and physician that something is not right.  More times than not, these two diseases shout out clues to the patient and physician that something is not right. (In contrast frontal fibrosing alopecia can often be silent when it first develops and can go on for years without detection). For patients with lichen planopilaris and folliculitis decalvans there are often multiple clues that this is not indeed the diagnosis. The scalp sometimes itches in unusual patterns. The scalp might burn. The scalp is sometimes sore. The scalp feels bruised for some patients. The scalp is warm for many. Shedding occurs when there is otherwise no good reason.

Patients who report several symptoms (“more than itching”) often benefit tremendously from having a scalp biopsy. For example, a patient with scalp itching PLUS burning or a patient with itching PLUS scalp tenderness should at least be given consideration for a scalp biopsy.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Scarring Alopecia: Is there any chance of regrowth?

Regrowth in Early Treatment of Scarring Alopecias

 Regrowth in a patient with scarring alopecia following aggressive treatment

Regrowth in a patient with scarring alopecia following aggressive treatment

The classic teaching that physicians often learn is that the hair loss that occurs in scarring alopecias is permanent. In other words, physicians often explain to patients that “what you have lost is lost for good and the goal of treatment is to stop it from getting any worse.” We know now that this statement is not quite accurate.

The very early stages of scarring alopecia are associated with inflammation which causes hairs to shed.  It’s not so easy for hairs to grow in a soup of inflammation. However, if the inflammation can be stopped some of these hairs can regrow because there are still stem cells left inside the original hair follicle tract. The early and aggressive treatment of lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia, discoid lupus and dissecting cellulitis can all be associated with some degree of regrowth. Of course the regrowth is not always 100 % but it can be quite signficant.


The above photo shows massive amounts of regrowing hair in a patient with lichen planopilaris who started hydroxychloroquine, topical steroids and steroid injections about 6 months prior. 





Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Androgenetic Alopecia: The Brown Peripilar Sign

BPPS: Brown peripilar sign in AGA

 Dermatoscopic image showing the brown peripilar sign.

Dermatoscopic image showing the brown peripilar sign.

It is increasingly clear that androgenetic alopecia (ie male and female genetic hair loss or “balding) is an inflammatory condition. Even though the scalp typically looks non-inflamed, scalp biopsies show that there is inflammation present just a few millimeters beneath the scalp in an area known as the isthmus and infundibulum. Studies have shown that inflammation occurs quite early in the course of androgenetic alopecia. This inflammation is believed to facilitate the progressive miniaturization of hair follicles.


Although the scalp usually looks fairly normal and non-inflammatory in patients with androgenetic alopecia, evaluation of the scalp via dermoscopy techniques may also show features that suggest there is inflammation under the scalp.


The 2004 Deloche Study

In 2004, Deloche and colleagues from France performed a nice study of 40 patients with androgenetic alopecia. The researchers showed that the brown discolouration around hairs that is seen with dermoscopy correlated nicely with inflammation under the scalp when evaluated by biopsy. They called this the peripilar sign (PPS). “Peri” means around and pilar means hair. The peripilar sign is known by many names as well including the “brown peripilar sign (BPPS)” and “peripilar halo.” Included here is a patient with androgenetic alopecia whose scalp hairs show the BPPS (photo below).


Treating Inflammation in AGA: Yes or No?

It’s almost a certainty that the inflammation needs to be treated in order to best stop hair loss. Modern medicine does not quite know how to best do this yet. There are many different types of anti-inflammatory treatment including corticosteroids, doxycycline, tacrolimus, TNF-inhibitors, immunomodulatory and immunosuppressants. It’s a bit of a guess as to how best to address the inflammation in AGA and more research is needed. It’s extremely likely this will play a beneficial role, particularly the earlier such anti-inflammatory treatment is started. Whether current treatments like antiandrogens or laser actually help with reducing inflammation is not known yet.


Reference

Deloche C et al. Histological features of peripilar signs associated with androgenetic alopecia. Arch Dermatol Res. 2004.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Lichen planopilaris: Is cyclosporine among the most effective?

Cyclosporine for Treating Lichen Planopilaris

LPP

Lichen planopilaris is one of the subtypes of scarring alopecia. A variety of treatments are available including topical steroids, steroid injections, topical calcineurin inhibitors and low level laser.  These four treatments are fairly safe and may help some patients with mild LPP. They do not help all. Numerous oral anti inflammatory pills are available to help patients with more resistant disease or those with more active LPP. Such drugs include hydroxychloroquine, doxycycline, mycophenolate mofetil, methotrexate, cyclosporine, prednisone, isotretinoin, and tofacitinib. These eight drugs all have evidence in their ability to reduce inflammation and slow of halt disease. Their remains debate as to which agents are truly most effective.

A recent study from Tehran which compared the effectiveness of three oral agents: cyclosporine, methotrexate and mycophenolate mofetil. Cyclosporine proved to be the most effective and most rapid in its response followed by methotrexate. Mycophenolate mofetil was third place but was the safest of all the three options.

Cyclosporine has long been known to help LPP. Mirmirani and colleagues showed back in 2003 that cyclosporine had benefits in LPP. In some countries, particularly some European counties, cyclosporine is frequently used in treating LPP. Dermatologists here in North America certainly use cyclosporine but use it less frequently than other drugs like doxycycline and hydroxychloroquine (Plaquenil).  The potential side effects of cyclosporine, of course, are the main reason for more limited use.

See Patient Handout - Cyclosporine

Side effects of cyclosporine include high blood pressure, headaches, stomach upset (nausea, vomiting, diarrhea), kidney disease, changes in blood counts, cholesterol problems, tremor, increased facial/body hair, acne, low magnesium levels, and thickening of the gums (gingival hyperplasia).

Reference

Babahosseini H, et al. Lichen planopilaris: Retrospective study on the characteristics and treatment of 291 patients. J Dermatolog Treat. 2018.

Mirmirani P, et al. Short course of oral cyclosporine in lichen planopilaris. J Am Acad Dermatol. 2003


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Scalp pain, itching and burning: What are the drug-free options?

Practical non drug options for treating scalp symptoms

Scalp symptoms such as itching, burning and tenderness are common in a variety of conditions. Patients with seborrheic dermatitis, psorasis, scarring alopecia and telogen effluvium all can experience scalp symptoms. A variety of conditions (totalling well over 100) can cause patients to experience higher than normal levels of various scalp symptoms:

see The 6 D’s of Scalp Symptoms

Non drug options for scalp symptoms.

Treatments for scalp symptoms depend on the cause. If a patient has itching from psoriasis, the best option for the patient involves specific treatment for psoriasis. If the itching is due to an allergy, the best treatment is avoiding the suspected allergen altogether.

In some cases, the precise reason either can not be found and strategies are needed to reduce scalp symptoms. In other cases, the cause is known but treatments are not possible for the patient on account of side effects, cost, or ineffectiveness. A variety of non-specific drug-free treatment options can also be considered in such situations.

1. Ice packs or Cool water

Ice packs, frozen peas and cool towels are useful for many individuals with challenging scalp syndromes. These are safe to use provided they are not too cold and not left on too long.

2. Apple cider vinegar

Apple cider vinegar rinses are helpful for individuals with many different scalp syndromes including itching, burning and pain. Most often the apple cider vinegar is diluted 1:4 in water and applied to the scalp for 5-10 minutes before rinsing off.

3. Witch hazel

Several herbal ingredients are proposed to have an anti-irritant tendency and can be helpful in scalp pain syndromes. These include chamomile (Marticaria chamomilla), heart seed (Cardiospermum halicacabum), peony (Paeonia lactiflora), and the virginian witch hazel (Hamamelis virginiana). Witch hazel in particular has received great attention. We generally recommend application of pure witch hazel with a cotton ball for periods of 5-10 minutes before rinsing off. Many patients find relief from these agents.

See previous “Witch Hazel for Scalp Symptoms”

4. Allergen free shampoos

Although contact allergy must be considered in patients with scalp symptoms, a variety of allergen free shampoos can be considered even in the absence of any evidence of a true scalp allergy. A list of helpful low allergen shampoos is provided in the link below

LOW ALLERGEN SHAMPOOS

5. Vitamin C

Vitamin C or ascorbic acid occasionally helps some individuals with scalp nerve and pain syndromes. The dose is 500 mg daily.

6. Low level laser therapy.

Low level laser therapy (LLLT) involves the application of red light therapy to the scalp. The treatments were originally designed for use in androgneetic alopecia but have helped many patients with scalp dysesthesia. Some patients, however, find that the warmth of these devices makes their scalps feel worse. Therefore LLLT is not helpful for everyone.

Reference

Carr AC, et al. The role of vitamin C in the treatment of pain: new insights. Review article J Transl Med. 2017.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Witch hazel for Scalp symptoms.

Witch hazel is commonly used to treat minor skin irritations such as insect bites. However, it has other potential uses in skin medicine including the treatment of various eczemas, acne, and blistered skin. Recent evidence would suggest that witch hazel may have benefits for red scalp.

Witch hazel (Hamamelis virginiana)  has been used for hundreds of years to treat superficial skin wounds and inflammatory skin conditions. Interestingly, history teaches us that native Americans produced witch hazel extract by boiling the stems of the shrubs. These extracts were then used to treat inflammatory conditions.

In 2014, Dr Trueb and colleagues reported outcomes of a witch hazel shampoo (Erol shampoo) in 1,373 patients. The shampoo is composed of extracts of H. virginiana and a shampoo base that is devoid of cocamidopropyl betaine and parabens.After a period of application of 4 weeks, the majority of patients reported an improvement of subjective manifestations of irritation, and rated the tolerance of both products as good to excellent. Overall, the majority of the patients were satisfied with the products.

The conclusion of the study was that this particular witch hazel shampoo should at least be considered in patients presenting with sensitive scalp and related conditions, such as the red scalp syndrome, and scalp burn-out.

Reference

Trueb et al. North American Virginian Witch Hazel (Hamamelis virginiana): Based Scalp Care and Protection for Sensitive Scalp, Red Scalp, and Scalp Burn-Out. Int J Trichology. 2014 Jul-Sep; 6(3): 100–103. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Scalp Dysesthesia, Neurogenic Inflammation and Fibromyalgia

Fibromyalgia as a Cause of Scalp Dysesethesia

 

The “scalp dysesthesias” are a group of conditions whereby the patient has various types of symptoms in the scalp despite the scalp looking fairly normal. In other words, these are a group of disorders characterized by chronic cutaneous symptoms without objective findings. Patients complain of burning, stinging, or itching, which is often triggered or exacerbated by psychological or physical stress.

SEE: Scalp Dysesthesia: Misunderstood, Misdiagnosed and Poorly Managed.

Fibromyalgia and the Scalp

There are many causes to consider in patients with underlying scalp dysesthesia. Cervicaal spine disease and underlying depression/anxiety have received some attention in the research world. However, there are many causes to consider.

Today, we’ll spend time talking a bit about fibromyalgia as a potential cause of scalp dysesethesia. Fibromyalgia is a chronic pain disorder with a well-defined clinical phenotype which affects about 2-4 % of people in the United States. The condition has several key features including widespread pain and tenderness, high levels of sleep disturbance, fatigue, cognitive dysfunction and emotional distress. Research over the past decade has shown that abnormal processing of pain and other sensory input occurs in the brain, spinal cord and periphery and is related to the processes of central and peripheral sensitization. As such, fibromyalgia is deemed to be one of the central sensitivity syndromes.

Neurogenic Inflammation in Fibromyalgia

The method by which nerve signals communicate appear to be disturbed in fibromyalgia. We now know that the brain and spinal cord don’t process information about pain sensations in a normal manner. Patients with fibromyalgia often feel pain. Stimuli that might not be painful to most people are interpreted by the brain of someone with fibromyalgia as painful. For example, a scalp massage might be considered painful by someone with fibromyalgia.

A special type of inflammation known as “neurogenic inflammation” may contribute to the symptoms that patients with fibromyalgia experience. For example, there is now evidence of neurogenically-derived inflammatory mechanisms occurring in the peripheral tissues, spinal cord and brain in fibromyalgia. Neuropeptides, chemokines and cytokines are proposed to be the chemicals that drive this inflammation and are postulated to be the activators of both the innate and adaptive immune systems.  This contributes to the clinical features of fibromyalgia, such as swelling and dysesthesia, and may influence central symptoms, such as fatigue and changes in cognition. In turn, emotional and stress-related physiological mechanisms are seen as upstream drivers of ‘neurogenic inflammation’ in fibromyalgia.

Scalp Dysesthesia in Fibromyalgia 

Individuals with fibromyalgia commonly experience a variety of scalp symptoms including itching, burning, pain, throbbing, shooting pains. For some it hurts to lay down on a pillow, brush the hair or even shampoo the scalp. These types of symptoms are much more common in fibromyalgia than we realized. Unfortunately, the symptoms are often ignored by the medical community or incorrectly diagnosed as dandruff, seborrheic dermatitis. All too common the sytmposm are attributed to anxiety or depression.

Despite being so common, scalp findings and symptoms in patients with fibromyalgia have not received much attention or study in the medical literatre. We don’t really have a good understanding of the types of symptoms patients with fibromyalgia experience. Some of the pain has been attributed to the tightening of scalp muscles, but I think this is far too simplistic of a view. Now that we understand more about neurogenic inflammation in fibromyalgia it becomes clear that these cytokines, chemokine and neuropeptides are likely to be directly responsible for creating the pain, itching, and burning in fibromyalgia. A variety of other pain syndromes may be associated with the same neurogenic inflammation - including such entities as chronic fatigue syndrome. Many such entities have associated scalp conditions but have been poorly studied and documented.

Treatment of scalp symptoms in Fibromyalgia

A variety of treatment options are available to address the scalp symptoms that occur in patients with fibromyalgia. It’s important for the physician treating the scalp symptoms to work closely with the rheumatologist to formulate a plan for treating the scalp symptoms. When I work with patients who have scalp symptoms, I generally correspond with the main fibromyalgia treating team.

Daily exercise and improving sleep as much as possible can help many people. Meditation techniques are helpful for some. There are hundreds of different types of meditation that are possible and there is no right or wrong way. Some of my patients with scalp pain simply find that turning on the TV helps take their mind off the symptoms (other patients of mind with fibromyalgia find the noise and light of the TV bothersome altogether so their is no one type of answer). Yoga, tai chi, prayer help many others. A variety of medications can be considered including gabapentin, Lyrica, and amitriptyline. Low dose naltrexone at 1.5 to 4.5 mg helps some patients with fibromyalgia-related scalp symptoms. Topical TKAL is proving helpful for some but not all individuals with fibromyalgia as sometimes rubbing creams into the scalp causes pain.

A variety of non pharmacological options are available including apple cider vinegar rinses, use of witch hazel and use of essential oils. Ice packs and frozen peas placed on the scalp or neck provide relief to many patients. Cool water placed on scalp also helps many as well.

Summary

A variety of scalp symptoms may be experienced by patients with fibromyalgia. These include burning, pain, itching, brushing, shoot pains and throbbing. These types of symptoms are poorly understood. Unfortunately they are all too often dismissed by health care providers or attributed to other reasons. Treating is challenging but a multifaceted approach often provides some degree of help.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Good Hair Days for the Hair Specialist

The One Mandatory Requirement for Hair Specialists

Patients often comment about the quality and quantity of the hair in hair specialists they have seen in the past. I’m been storing and processing the information for a number of years now. I have a little storage closet in the back of my brain for comments and stories that patients share. The stories that patients share tend to be quite varied.


Stories and anecdotes that apply to the hair quality of the hair specialist typically go something like this:

“My doctor told me that I have way more hair than him and I just just be grateful for what I have.”

“I would never go to a bald hair specialist.”

“I prefer to go to a female specialist as they understand what hair means for a woman.”

“I don’t like going to her because her hair is perfect and she doesn’t understand what I’m going through.”

“A hair doctor should have good hair. Would you really want to go to a weight loss specialist who was overweight?”

“My hair doctor has experienced hair loss first hand. She knows what it’s like and that’s important to me.”

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Hair and the Hair Specialist

The reality, at least in my mind, is that hair specialists need not themselves have good hair or be affected by hair loss to be a hair specialists - any more than kidney specialists have good kidneys or be affected by kidney disease or a heart specialist have a strong heart or be affected by heart disease. A mandatory requirement, however is a genuine desire to help one’s follow human with their hair loss concerns.

Practicing hair loss is about understanding what a patient experiences both emotionally and physically and applying one’s knowledge and skills to remedy the situation in the best way possible. A specialist with hair loss can be just as good as a specialist with good hair. A doctor with hair loss can become what society might call “a good doctor” or they can just as easily become “a bad doctor”. A doctor with with good hair can become either a good doctor or a bad doctor. The quality of a practitioner’s hair does not dictate the quality and sincerity of the care they provide.

It all comes down to a genuine desire to help. If the health care provider sets out with the goal to achieve the best possible outcome for his or her patient - the possibilities for the patient then open up considerably. If health provider sets out with the goal to achieve the best possible outcome for himself or herself, the possibilities for the patient likely remain quite limited.

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Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Hair Loss Teaching Sessions: Hair Rounds Fall 2018

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Hair Rounds Fall 2018

Great afternoon working with our local dermatology residents and our amazing patient volunteers who gave up their time to help teach physicians about hair loss. We learned about scalp dysesthesias and the differential diagnosis of patients with marked scalp symptoms. We discussed the lymphocytic scarring alopecias including lichen planopilaris and frontal fibrosing alopecia and learned about the beneficial role of antiandrogens and retinoids in treating FFA. We finished with a discussion of female androgenetic alopecia and reviewed the definitions of miniaturized and vellus hairs. We finished the afternoon by reviewing what we know about the risk of cancer with antiandrogens such as finasteride and spironolactone.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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