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Seasonal Shedding of Hair: Five Studies to Know about

Seasonal Hair Shedding: A Late Summer/Fall Shed Really Does Occur

Moulting of hair is common in various animals. Moulting appears to be controlled by a variety of endogenous and exogenous factors. Both changes in air temperature and sunlight exposure likely play a role in how animals shed hair.  Overall, sunlight exposure appears to be far more important than actual changes in temperature.

Variation in daylight hours is thought to be very relevant for how mammals shed hair. Many mammals, but not all, grow a winter coat and then shed it to have a lighter coat during summer. Horses for example tend have a winter coat but some donkeys do not show such variations in coat characteristics. Understanding seasonal changes in animal coats has been important in the wool industry as promotion of better wool production has clear benefits. In cashmere goats, reducing the length of sunlight can increase anagen phase and increase cashmere production. The same is true of wool production in sheep.

In humans, seasonality of shedding was not thought to exist in some of the early medical literature. In 1969, Orentreich offered support for a seasonality of hair shedding when he reported three women in New York who experienced maximum hair fall in the month of November. Orentreich also proposed that a second lesser peak occurred in Spring. To date there have been five important studies which support seasonal shedding phenomenon in both men and women. 

 

Seasonal Shedding: 5 Key Studies to know about

 

Study 1: Randall and Ebling, 1991

Randall and Ebling studied the hair growth parameters every 28 days of 14 healthy males. 

 The study was a fascinating one whereby 14 men age 18-39 in Sheffield UK collected beard shavings, shed hair, as well as finger and toe nail clippings every 28 days for 18 months. In addition, every 28 days, hair samples were taken from the study participants from 5 areas of the scalp. The participants were also asked to record the number of hours they had spent outside. 

 Men in the Randall study reported spending more time outdoors in summer than in winter – about 30 hours per week in June and July compared to 11 hours in January and February. 

 The authors found that the proportion of hairs in anagen (by pluck tests) reached peak in March each year and then fell steadily through September. This findings was true for all areas of the scalp studied including the vertex parietal and occipital areas of the scalp. When the authors examined the bags of hair that were collected from participants, they found that shed hair was maximal in August and September and least in March. In fact, the number of hairs lost per day in August was 60 and this was about double the number of hairs loss in March. Interestingly the diameter of growing hairs did not change. 

 Beard growth had a different pattern to that of scalp hair. Beard growth was maximum in July and was lowest in January and February. Finger and toe nails did not show seasonal variations in growth. 

 

Study 2: Courtois et al, 1996

 

The Courtois study from L’Oreal Laboratories in France was a fascinating one which involved studying 10 subjects over a period of 8 to 14 years. Four of these patients did not have other forms of hair loss and 6 did. The authors used phototrichograms to document the percentage of hairs in telogen phase as well as standardized hair collection techniques to determine hair shedding rates. 

 What was remarkable in the detailed study was that the percentage of hairs in telogen varied quite significantly in all patients – but particularly among those with other forms of hair loss.

 In 9 of the 10 subjects, there was a link between sunshine hours and percentage of hairs in telogen. The authors found that late summer and early Autumn (August, September and October) were periods of the highest telogen percentages and December January and February were the periods of minimal shedding. The authors identified a smaller peak of shedding in Feb and March. The authors found that the peak hair shedding from hair collections followed the peak telogen rates by 1-2 months. 

 

 Study 3: Pieard-Franchimont and Pierard, 1999

 The authors performed trichograms of 2857 subjects over 2 consecutive years. They found an increased proportion of telogen effluvium between July and October. The lowest rates were found in January. 

 

Study 4: Kunz et al 2008

A 2008 study from Switzlerand by Kunz, Seifert and Trueb examined shedding patterns in 823 women using trichograms. The authors found that telogen rates were lowest at the beginning of February and highest in July. There was a second peak noted by the authors in April  it was less pronounced than in summer. What was remarkable about the Kunz study was just how many women were studied. Certainly, a study of 823 women is quite large. Second, the authors showed that this seasonal shedding occurred regardless of whether or not the patient had female pattern hair loss and regardless of whether or not they were using minoxidil. 

 

Study 5: Liu et al, 2014

Liu and colleagues studied seasonal changes in hair growth patterns in 41  male and female volunteers from China.  Phototrichograms were used to record the percentage of hairs in anagen and telogen. The authors showed that the highest proportion of telogen hairs were in September and lowest in January. In women, these proportions rose form approximately 8 % in January to 12 % in September. 

 

CONCLUSIONS: Why is seasonal shedding important to know about?

The five elegant studies to date support that notion that hair shedding increases in late Summer and Fall for humans. 

 We don’t really know why humans shed like this although it is proposed that climate factors are very import for humans. We know that mammals moult and patterns of moulting are quite different for different mammals. It has been proposed that delaying shedding until the end of the summer might help protect humans from ultraviolet exposure during summer. 

 These changes in growth may be related to many factors including hormones. It’s interesting that beard growth peaks in the summer in men as it has also been shown that plasma testosterone levels also rise somewhat during the summer and then fall to their lowest levels in January and February.  But a variety of factors likely contribute to these shedding patterns including melatonin, testosterone, thyroid hormones, prolactin.

 These studies are important for patients that come into the office. We need to always take into account the phenomenon of seasonal shedding when evaluating patients. Suppose a patient starts a treatment and is doing really well. In April and May she tells you that she’s so pleased with her hair. Her hairdresser is amazed with her hair. Her friends have noticed a change.  Now in September she contacts you and she is extremely upset. Her hair is shedding terribly. She has lost ground.  Of course, you need to consider all the factors. Is she using the right medications?  Is their actually another diagnosis present? But seasonal shedding needs to be considered. 

A 2017 study in the British Journal of Dermatology  also supports that people are more concerned about hair loss in the Summer and Fall than in the Winter and Spring. Specifically, a study by Hsiang and colleagues looked at the Google Trends for the search term “hair loss” in Summer, Fall, Winter and Spring.  Compared to the Spring, searches were 5.74 times more frequent in Summer and 5.05 times more frequent in Fall compared to the Spring.  Searches about hair loss in Winter were 2.63 times more frequent in Winter than Spring. Spring was a time of least entries related to hair loss.

 

 

Reference

Reinberg A et al. Circadian and circannual rhythms in plasma hormones and other variables in five healthy young males. Acta Endocrinology 1978; 88: 417-27

 Smals AGH et al. Circannual cycle in plasma testosterone levesl in man. J Clin Endocrin Metab 1976; 42: 979-82.

Orentreich N. Scalp hair replacement in man. In: Advances in Biology of Skin. Vol IX: Hair Growth. (Montagna W, Dobson RI, eds). Oxford: Pergamon. 1969. 99-108.

Courtois et al.Periodicity in the growth and shedding of hair. Br J Dermatol, 1996 Jan;134(1):47-54.

 Hsiang EY et al. Seasonality of hair loss: a time series analysis of Google Trends data 2004-2016. Br J Dermatol2018; 178(4):978-79   

Maurel D et al. Effects of photoperiod, melatonin implants and castration on molting and on plasma thyroxine, testosterone and prolactin levels in the European badger (Meles meles). Comp Biochem Phyiol A Comp Physiol. 1989;93(4):791-7.

Zhang et al. Comparative study on seasonal hair follicle cycling by analysis of the transcriptomes from cashmere and milk goats. Genomics 2019 Feb 16 

Liu et al. A Microarray-Based Analysis Reveals that a Short Photoperiod Promotes Hair Growth in the Arbas Cashmere Goat, PLoS One. 2016 Jan 27;11(1):e0147124.  

Pearson AJ et al. Inhibitory effect of increased photoperiod on wool follicle growth. J Endocrinol 1996 Jan;148(1):157-66.

 


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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Methotrexate for Treatment of Alopecia Areata: How long until results are seen?


How long does it take individuals with alopecia areata to see results with methotrexate?


Studies have shown that hair growth can take 2.5-3 months before changes are seen. 2014 studies by Hammerschmidt et al showed that patients who were going to respond often showed responses by the end of the 3rd month (after approximately 180 mg of the drug, taken as 20 mg weekly). This information is important so that patients with alopecia areata don’t stop treatment with MTX too early without giving it the appropriate trial. We don’t see results in a matter of weeks.



Reference

Hammerschmidt et al. Efficacy and safety of methotrexate in alopecia areata. An Bras Dermatol 2014; 89; 729-734.


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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The Diagnostic Algorithm: How do we diagnose hair loss?

A Stepwise Approach to Diagnosing Hair Loss


Diagnosing hair loss can be challenging in some cases. Even when it seems one has figured out the diagnosis, there are many instances where one questions the diagnosis.

In this commentary, I review a formal approach to the diagnosis of hair loss. It is what I term the Diagnostic Algorithm.


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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Oral Steroids (Prednisone, Dexamethasone) for Rapidly Progressive Alopecia Areata: Still an Option

Prednisone and Dexamethasone are Still Options for Alopecia Areata

Research on alopecia areata is progressing rapidly and treatment options are changing and expanding (ie JAK inhibitors). Despite several new options, some treatments such as oral steroids are still very much a part of the management of alopecia areata as well. Oral steroids such as prednisone has been a part of medicine since 1955.

See previous articles

“ORAL STEROIDS FOR PEDIATRIC ALOPECIA AREATA”

“PULSE THERAPY FOR ALOPECIA AREATA: HOW GOOD IS IT?”

Prednisone remains an option for select patients with rapidly progressive alopecia areata

Prednisone remains an option for select patients with rapidly progressive alopecia areata



Oral steroids however come with the potential for side effects and that’s why they are cautiously used - and only in select patients. However, few treatments work as fast and are as reliable as prednisone and dexamethasone. To limit side effects, we don’t like patients on them very long and if the chances are good that the patient is going to lose hair again when we stop eventually stop the steroids, we might not even start them in the first place.

Prednisone and dexamethaonse, in my clinic, are used in one main situation. It is used if the answer to one particular question is “yes.” This question is “If we tell this patient’s immune system to settle down by using oral corticosteroids, is it reasonably likely that the immune system is going to stay quiet when we start to reduce and then ultimately stop the corticosteroids?”

The main challenge is that were are not so accurate in the present day at predicting the answer to this question. The answer is often “yes” for several groups of patients and these are groups of patients that I might sometimes consider using oral steroids including (1) patients who previously had an episode of patchy alopecia areata that grew back completely with or without treatment and are now experiencing a more severe degree of hair loss and (2) patients who are experiencing their very first episode of alopecia areata and have lost more than 30 % of their hair density in the past 3 weeks and (3) patients who have significantly more bald spots today than they did yesterday.

Other groups may also be candidates for oral steroids too but this is approached on a case by case basis.

Oral steroids have the potential to cause side effects even in the short term and this must be reviewed with the patient when deciding whether to start or not. Short term side effects include weight gain, mood changes, poor sleep, stretch marks, and less commonly issues such as frequent urination, elevated blood pressure and blood sugars. Avascular necrosis of the femoral head must be reviewed with patients as a rare side effect.


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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Videodermoscopy of Lichen Planopiliaris

LPP Videodermoscopy (Trichoscopy)

Videodermoscopy (trichoscopy) of lichen planopilaris. The patient presents with increased hair shedding thought initially to be related to a stressful life event. There is associated itching in the scalp and burning that can not seem to settle. Examination here shows redness in the scalp as well as scale around hairs (perifollicular scale). There as some hairs missing in areas which is typical of the scarring patches this disease creates. Most hair follicles are the same size (caliber) indicating the degree of miniaturization is minor and that androgenetic alopecia is not a feature here.


Treatments started with topical clobetasol daily followed by a plan to taper the dose. Steroid injections with triamcinolone acetonide were performed with 2.5 mg per mL with 10 mL and 75 injections throughout the scalp. Hydroxychloroquine was started a dose that corresponds to the patient’s weight. Doxycycline was considered but a decision was made in favour of hydroxychloroquine given the patient’s gastrointestinal issues and long hours of outdoor work that might make the photosensitizing potential of doxycycline more challenging. The patient will be seen back in 3-4 months. Blood tests will be needed monthly while on hydroxychloroquine for three months (CBC, AST, ALT). An eye examination is needed for all patients starting hydroxychloroquine and periodically thereafter. Blood tests were already done for thyroid and vitamin D status and given the associated low vitamin D the patient was started on 3,000 IU daily.



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 and Rosacea: What is the link? Who is predisposed?

Rosacea in FFA Patients Linked to Greater Scalp inflammation, Greater Body Mass and Lower progesterone Levels

Several studies to date have suggested an association between the frontal fibrosing alopecia (FFA) and the common dermatologic condition known as acne rosacea (or simply “rosacea”). How exactly the two are linked is not entirely clear.

Typical trichoscopic image of a patient with the scarring alopecia known as frontal fibrosing alopecia or “FFA.” There are most single hairs in the frontal hair line and the vellus hairs are not seen. There is scale around some hairs and also redness.

Typical trichoscopic image of a patient with the scarring alopecia known as frontal fibrosing alopecia or “FFA.” There are most single hairs in the frontal hair line and the vellus hairs are not seen. There is scale around some hairs and also redness.


Moreno-Arrones and colleagues recently conducted a multicentre case-control study and recruited 335 individuals with FFA and 329 patients who did not have FFA. Women with FFA were found to have a nearly two fold greater incidence of rosacea compared to women without FFA (OR = 1.91; 95% CI 1.07-3.39). Porriño-Bustamante and colleagues also recently performed their own cross sectional study which included 99 women with frontal fibrosing alopecia and 40 controls. 62 % of women with FFA had rosacea compares to 30% of women without FFA. Women with more advanced stages of FFA were the most likely to report having rosacea compared with women with less advanced stages.

For women with FFA, three factors were found to be associated with a higher chance of having rosacea. In order of importance, these appeared to be 1) perifollicular erythema on the scalp 2) low serum progesterone levels and 3) higher body mass index.

Women with FFA are most likely to report having a diagnosis of rosacea. However, what needs to be understood is whether FFA associated rosacea is precisely the same as rosacea in the general population. Inflammation of the small vellus hairs of the face is known to be a part of FFA but is not so much a feature of typical rosacea in the same way. Pindado-Ortega showed in 2018 that most patients who were diagnosed with rosacea (28 of 35) ended up having the so called erythematotelangiectatic subtype of rosacea and 7 of the 35 had the so called papulopustular subtype. For now, rosacea in FFA is viewed as the same as rosacea in the general population. More studies will clarify the precise etiology.



References

Moreno-Arrones OM, et al. Clin Exp Dermatol. 2019.
Pindado-Ortega C, et al. J Am Acad Dermatol. 2018.
Walker JL, et al. Skinmed. 2016.
Porriño-Bustamante ML, et al. Acta Derm Venereol. 2019.


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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On First-Line Treatments for Hair Loss

To earn the position as a first-line treatment is a privilege

When we think of treatmetns for hair loss, we typically divide them into groups accordingly to their safety and efficacy. We generally call the starting treatments “first-line” treatments, and treatments that we might consider down the road if first-line treatment do not prove helpful as “second-line” treatments followed by “third-line” treatments.

The position of first-line is earned


To earn the rank of being considered a “first-line” treatment for any given medical condition is a privilege that comes only with time and only with demonstration of the treatment being effective in repeated high-quality, independent medical studies. There is an incorrect perception among many physicians and much of the general public that new treatments automatically become first-line treatments. All new treatments start off as second-line or third- line treatments and must proceed to then earn their place at the top of the list as first-line treatments. If they are truly superstars, this upward promotion will happen rather quickly.


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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Does Chronic Telogen Effluvium Cause Androgenetic Alopecia ?

CTE does not cause AGA but may Speed Up its Arrival in those Predisposed

I’m often asked if Chronic Telogen effluvium causes people to develop androgenetic alopecia. The answer is no - with the exception that CTE can speed up the arrival AGA if a person was predisposed to develop it anyways. The main point is that the person would likely have developed AGA at some point.

Chronic telogen effuvium is a hair shedding condition that typically develops in women age 35-70. Women report the condition to a much greater extent than men. Women develop increased hair shedding that can sometimes be quite profound yet at other times be quite minimal. The condition can go on for many years. In most cases, a trigger can’t be clearly found although there may be many best guesses. Patients with CTE may have a variety of symptoms including itching, tingling, burning and soreness when the hair is moved.

Sinclair Study of 2005

The Sinclair study is an important study which helps us provide patients with clearer answers as to whether or not CTE causes AGA. Professor Rodney SInclair studied five women diagnosed with chronic telogen effluvium and followed their photos for a minimum of 7 years. Four of the 5 women continued to shed year after year after year and shedding fluctuated in severity. However, serial photographs over time showed no visible reduction in hair density, and serial scalp biopsy specimen showed no follicular miniaturization. These 4 women showed no tendency toward development of female pattern hair loss or to spontaneous improvement. One woman however was diagnosed with female pattern hair loss.

Considering that 40 % of women in the general population develop AGA, this study has important implications. This study reminds us that CTE does not simply cause AGA and that CTE does not cause hair to thin and thin over time. For patients who have the correct genetics, CTE might speed up the arrival of AGA. Instead of developing AGA at age 47 a patient with CTE might, for example, develop visible AGA at 45. But it’s important to take note that this patient likely would have developed AGA anyways.

Articles on Chronic Telogen Effluvium (CTE)

Sinclair R. Chronic telogen effluvium: a study of 5 patients over 7 years. J Am Acad Dermatol. 2005 Feb;52(2 Suppl 1):12-6.

Those who are interested may wish to review these previous articles on CTE.

Differentiating CTE from DUPA

Do I have chronic telogen effluvium (CTE) ?

Chronic Telogen Effluvium 

Chronic Telogen Effluvium: Most patients don't develop AGA  

Chronic Telegen Effluvium

Acute and chronic telogen effluvium - what's the difference?  

Scalp symptoms (burning, tingling, pain) and chronic telogen effluvium  

Chronic telogen effluvium vs Genetic hair loss - Easily confused ! 

Acute vs Chronic Telogen Effluvium: A Closer Look

CTE: Misdiagnoses are Common

Oral Minoxidil for Chronic Telogen Effluvium



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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Atrophy (Indentations) from Scalp Steroid Injections: Should I be Stopping?

Scalp Indents (Atrophy) from Steroid Injections: What should I be doing?

Steroid injections are generally well tolerated and have a good safety profile for most when the correct concentration and dose are used. Atrophy or small indentations or depressions in the skin are side effects that can sometimes occur with steroid injections. They are temporary in nature but it is important that one does not continue to inject in the area if atrophy is present. Injections of the depressed area with saline (salt water) often speeds up the resolution - possibly by stimulating the scalp to make collagen, Injections need to be postponed in the area of atrophy if indentations are noted. Once the scalp improves back to normal in that area we can often continue the injections.

Atrophy can often resolve on its own but may take 2-5 months to do so. The speed and completeness of resolution depends on several factors including 1) if injections were performed in areas that already had atrophy as well as 2) how much “topical” steroid is being used while the atrophy is trying to improve as well as 3) the concentration of steroid injected and 4) intrinsic characteristics of the disease itself and the skin of the patient. Not all patients experience total resolution but most do if steroids are reduced or abandoned during the process.

The presence of atrophy does not mean that injections need to be stopped altogether only but do indicate that injections need to be stopped in the area of atrophy. If there are only 1-2 indentations, then it may be possible to simply avoid injections and continue injections in other areas that require injections (at a lower dose). If there are 3 or more indentations, I recommend waiting 6-8 weeks to have the skin improve before attempting injections again. When injections are restarted, I recommend that a lower dose be used.

ILK ALGORITHM


The Dose of Triamcinolone acetonide (Kenalog)

One must always consider the dose of steroid that was used. Some physicians use 10 mg per mL which has a higher chance of causing atrophy than 5 mg per mL. Some physicians use 2.5 mg per mL or 3.3 mg per ML which are both common doses that I use in many patients. A patient who gets atrophy from 10 mg per mL might still benefit from 2.5 mg per mL and so steroid injections need not necessarily be totally abandoned. Of course this is handled on a case by case basis.

For any patient with atrophy, one must also consider just how much topical steroid is being used. A patient who is using extremely large amounts of high potency topical steroids may be more likely to get atrophy if injections are then performed as well.

Above is my algorithm for dealing with atrophy from steroid injections.






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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Autologous Fat Transplantation for Treating Folliculitis Decalvans: Is there a role?

Fat transplants as a source of ‘Stem Cells’ in Folliculitis Decalvans

Folliculitis decalvans is an uncommon scarring alopecia. The cause is not entirely known although it is often associated with the presence of bacteria such as Staphylococcus aureus. Patients experience itching, burning and tenderness in the scalp and often have pustules. The hair loss that the patients experience is often permanent.

The mainstays of treatment to date are oral and topical antibiotics to eradicate the Staphylococcus aureus as well as treatments such as oral isotretinoin. A variety of other treatments have been reported with limited success. Fat transplantation involves the isolation of fat stem cells by liposuction type procedure form the thigh or abdomen. These procedures are not well established yet and have little in the way of good evidence. Some countries, including Canada, have banned these procedures altogether in order to protect the public until more evidence is available. Canadian physicians and other specialists face the possibility of losing their licenses were the to participate in these procedures. But the procedure continue in other countries and are flourishing - even without good evidence. I continue to follow the data and evidence on these procedures for hair growth in various types of hair loss.

I was interested in a 2018 paper citing use of autologous fat transplantation as a source of stem cell therapy for folliculitis decalvans. The patient in the study underwent two session of adipose transplantation 5 months apart. After treatments it was noted that the patient had no new pustules and no longer had pain or burning sensation in the affected area. There was some hair regrowth noted at the periphery of the area.

Conclusions

This is an interesting and potentially promising study. Many studies in scarring alopecia suffer greatly from lack of long term follow up. Folliculitis decalvans for example can undergo periods of relative quiet followed by increased activity. It is essential to know if this patient for example maintains a good response after 1, 2,3 and 4 years. In addition. a lack of pustules and reduction in symptoms is a very good sign but what matters most is the appearance of the scalp at various intervals following treatment. Nevertheless, this is an interesting paper and likely will fuel additional studies of these therapies in scarring alopecia.

Patients should be aware that these therapies for folliculitis decalvans (and other types of hair loss) are experimental at best and likely do not provide the same degree of benefits as do standard therapies. They do however offer a new means of treatment and provided these prove safe in the long run, a novel means of harvesting one’s own stem cells as anti-inflammatory and hair growth promoting agents.

REFERENCE

Tedesco M. Adipose tissue transplant in recurrent folliculitis decalvans. Int J Immunopathol Pharmacol. 2018 Mar-Dec.




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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Chronic Telogen Effluvium: Will I go bald?

Chronic Telogen Effluvium: What is it and will I go bald?

Chronic telogen effuvium is a unique condition. it’s a hair shedding condition that typically develops in women 35-70. Women report the condition to a much greater extent than men. Women develop increased hair shedding that can sometimes be quite profound yet at other times be quite minimal. The condition can go on for many years. In most cases, a trigger can’t be clearly found although there may be many best guesses. Patients with CTE may have a variety of symptoms including itching, tingling, burning and soreness when the hair is moved.

Patients with true isolated CTE do not go bald because CTE is not a condition of hair loss. Rather, it's a condition of hair shedding. Patients with true CTE lose hair density first and then look the same year after year after year after year. Therefore, it follows that photos are an essential part of the evaluation and management of CTE! In contrast, in true “acute” telogen effluvium, patients lose density first and then once the trigger is fixed (ie the low iron or thyroid problem), the hair grows back.

This graph shows the change in hair density in Acute vs Chronic Telogen Effluvium

Comparison of Hair Density Over TIme in Patients with Chronic Telogen Effluvium vs Acute Telogen Effluvium. In CTE, the hair drops to a new density and then remains at that density for many, many years. in acute TE, the hair grow back once the trigger is identified.

Comparison of Hair Density Over TIme in Patients with Chronic Telogen Effluvium vs Acute Telogen Effluvium. In CTE, the hair drops to a new density and then remains at that density for many, many years. in acute TE, the hair grow back once the trigger is identified.


If density keeps changing over time another diagnosis might be also present with the CTE (or present instead of the CTE).


The 2005 Sinclair Study

If you are going to really come to understand a thing or two about CTE, you need to understand an important study from 2005. The study captures very nicely the essence of CTE. Professor Rodney SInclair studied five women diagnosed with chronic telogen effluvium and followed their photos for a minimum of 7 years. Four of the 5 women continued to shed year after year after year and shedding fluctuated in severity. However, serial photographs over time showed no visible reduction in hair density, and serial scalp biopsy specimen showed no follicular miniaturization. These 4 women showed no tendency toward development of female pattern hair loss or to spontaneous improvement. One woman was diagnosed with female pattern hair loss as well.

Treatment of CTE

The Treatment of CTE has been discussed in our other articles (see below) and includes a vareity of growth promoting agents to true to keep hairs in the growth phase. This includes topical and oral minoxidil, low level laser, and various supplements.

Previous Articles on Chronic Telogen Effluvium (CTE)

Those who are interested may wish to review my previous articles on CTE.

Differentiating CTE from DUPA

Do I have chronic telogen effluvium (CTE) ?

Chronic Telogen Effluvium 

Chronic Telogen Effluvium: Most patients don't develop AGA  

Chronic Telegen Effluvium

Acute and chronic telogen effluvium - what's the difference?  

Scalp symptoms (burning, tingling, pain) and chronic telogen effluvium  

Chronic telogen effluvium vs Genetic hair loss - Easily confused ! 

Acute vs Chronic Telogen Effluvium: A Closer Look

CTE: Misdiagnoses are Common

Oral Minoxidil for Chronic Telogen Effluvium

Reference

Sinclair R. Chronic telogen effluvium: a study of 5 patients over 7 years. J Am Acad Dermatol. 2005 Feb;52(2 Suppl 1):12-6.


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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Vision Changes from Topical Steroids: A Closer Look at Central Serous Chorioretinopathy (CSCR)

Central serous chorioretinopathy from Topical Steroids

Topical steroids are an important aspect of managing many scalp conditions. Many different topical steroid strengths from class I (strongest) to class VII (weakest) are available.

See Previous Articles

IS TOPICAL CLOBETASOL SAFE FOR THE SCALP?

WHAT TOPICAL STEROIDS ARE SAFE IN FFA?

TELANGIECTASIAS FROM USE OF TOPICAL STEROIDS

CLOBETASOL FOR HAIR LOSS

I was interested in a few reports from the last decade that mentioned the development of an eye condition known as central serous chrorioretinopathy (CSCR) from prolonged or even short term use of topical steroids. Central serous chrorioretinopathy is associated with visual impairment, often temporary, and usually affects a single eye. Blurry vision is often the symptom that affected patients report but it may even be asymptomatic. Other symptoms that patients with CSCR reports are a dark area in the central vision, objects appearing smaller than they really are, objects appearing further away than they really are, the change of straight lines to crooked lines or bent lines, and a duller color to objects that are white.

It is a common retinal disease that can cause loss of vision as a result of accumulation of fluid behind the retina (subretinal) leading to localized serous retinal detachments. In simple terms, CSCR causes a blister-like swelling in the retinal layers. Males aged 20 to 50 are the most commonly affected (94 % in one 2016 study) but it may also affect women. Some studies have suggested that emotional stress, smoking, hypertension, sleeping problems, heart disease, migraine headaches, medications (stimulants, erectile dysfunction medications), autoimmuen diseases and peptic ulcer disease may be among risk factors that are sometimes (but certainly not always) present.

CSCR occurring after prolonged use of topical steroids is not common. Most cases typically occurring in patients using oral or inhaled steroids.

In 2011, Ezra and colleagues in the Journal of Drugs in Dermatology reported a 25 year old male who had been using a corticosteroid ointment for 15 years. He presented to the eye clinic with vision impairment from central serous chrorioretinopathy.

In 2016, Chan et al reported 2 patients who developed CSCR in 2 patients who were using topcial steroids on limited areas of the body.

in 2018, George et al reported an interesting case where CSCR developed quite quickly. The patient was a female patient with oral lichen planus who was started on a topical steroid in the mouth (triamcinolone acetonide 0.1%). One week later, she reported with blurring of vision of both eyes. She was referred to the ophthalmologist and was diagnosed to have acute central serous retinopathy (CSR).. The topical steroid was discontinued and she was advised ketorolac eye drops (0.3%). At a follow up appointment 2-months later, there was significant improvement in her ocular condition.

Conclusion

Central serous chrorioretinopathy is not common but it is important that dermatologists are aware of this condition. It appears that steroid induced CSCR may happen in patients who have some sort of a predisposition to begin with - and can even happen with very lower doses. Treatment of CSCR involves stopping the steroid as the first step. Many cases resolve on their own in a few months and many patients regain vision fully. However, it has been suggested that patients who develop CSCR on account of steroid use may have slightly poorer prognosis than some other groups so close follow up is advisable. If symptoms persist, a variety of options are available including lasers, photodynamic therapy, oral treatments (methotrexate 5 to 10 mg, finasteride, beta blockers, aspirin), and injections (anti VEGF agents like bevacizumab). Agents like doxycycline have not been well studied in CSCR.

The main take away message here is that all patients who use topical steroids and develop vision changes should be referred for a proper eye examination.

REFERENCE

Chan et al. Localized topical steroid use and central serous retinopathy. J Dermatolog Treat. 2016 Oct;27(5):425-6. doi: 10.3109/09546634.2015.1136049. Epub 2016 Jan 29.

Ezra et al. Central serous chorioretinopathy associated with topical corticosteroids in a patient with psoriasis.J Drugs Dermatol. 2011 Aug;10(8):918-21.

Fernandez CF et al. Central serous chorioretinopathy associated with topical dermal corticosteroids.Retina. 2004 Jun;24(3):471-4.

George et al. A potential side effect of oral topical steroids: Central serous chorioretinopathy. Indian J Dent Res. 2018 Jan-Feb;29(1):107-108. doi: 10.4103/ijdr.IJDR_694_16.

Islam et al. Frequency of Systemic Risk Factors in Central Serous Chorioretinopathy.J Coll Physicians Surg Pak. 2016 Aug;26(8):692-5. doi: 2407.


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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10 Signs You Are Probably Not On Track In Treating Your Scarring Alopecia

Scarring Alopecia: Clues that You’re Off Track and How to get back On Track

Scarring alopecias are hair loss conditions that have the potential to cause permanent hair loss. Patients often have scalp itchiness and may also expeirence burning in the scalp as well. Increased shedding is common. There is a lot of misinformation about these conditions becasue all too often they are grouped in the bigger category of ‘hair loss.’ It’s too often felt that what worked for one person with hair loss should work for another person. That’s just not the case if that other person has scarring alopecia.

After treating many patients with scarring alopecia over the years, I can say that there are often signs that that tell me that a patients needs a bit of help with how they are approaching their own scarring alopecia. These may be patients who contact our office, or patients who post concerns on social media or patients who come to the office.

Treating scarring alopecia is not only about connecting patients with effective treatments but also about dispelling myths and misinformation - some of it quite strongly rooted in the mind of the patient and sometimes their doctors too. Treatments can help the patient but knowledge also heals too.

Here are these 10 signs.

10 signs

CLUE 1: The patient has no idea what they should be monitoring.

Many patients with scarring alopecia tell me that they leave their doctor’s office with prescriptions but don’t know exactly what they are supposed to be monitoring until their next appointment. Alternatively (as in CLUE 3 below), they leave the office with the expectation that their hair will grow back.

Patients with scarring alopecia should be monitoring SEVEN main things at home - scalp itching, scalp burning, scalp tenderness, scalp redness, scalp pimples (pustules), hair shedding and density in various areas of the scalp. Of course, not all patients want to monitor these things and leave it up to the doctor to ask about these things at the follow up appointments. However, for those who want to actively play a role in montiroign their disease at home, we encourage them to complete the following form at home on a weekly or monthly basis

SCARRING ALOPECIA MONITORING FORM



CLUE 2: The patient knows what to monitor but does not know how soon to expect it all occur.

Some patients come to understand the basics of what sorts of things they should be monitoring at home. They know to keep track of scalp itching, scalp burning, scalp tenderness, scalp redness, scalp pimples (pustules), hair shedding and changes in density in various areas of the scalp. However, they are not sure when all this is expected to improve or when they are to notice a change.

It is import to review these sorts of things with the dermatologist as they may differ slightly with the exact type of scarring alopecia. I normally expect scalp symptoms to improve within 2-3 weeks and scalp shedding to improve within 2-3 months. Changes in hair density however, may take 2-7 months depending on the type of treatment that the patient has chosen.

For lichen planopilaris, for example, these changes might occur as follows (according to various treatment)

LPP_TIMELINE

CLUE 3: The patient is expecting hair regrowth.

Many patients with scarring alopecia tell me that they have been doing all the things that their doctor recommended but are just not seeing an improvement. These patients are essentially telling me that they have not been educated on what it is they should expect.

While it’s true that hair regrowth does occur in many scarring alopecias, especially when treated in the early stages - the expectation should be that we STOP further hair loss rather than get new growth back. I tell patients that if they look the exact same as they do today in 6 or 12 months from now - it means the treatment is working well. Of course, I also tell some patients that a bit of regrowth might occur too. But this does not happen for everyone.


CLUE 4: The patient has never taken a photo of the hair & scalp to date.

If a patient has scarring alopecia and has never every taken a photo of the scalp since their diagnosis, they are missing out on an important step. Patients simply MUST take photos at home for optimal management. Of course, the doctor should take photos in the office but not all do. In today’s busy world, patients simply must be their own advocate and must take photos themselves or get someone else to take them.

When a patient of mine emails our office and says they are doing worse, the first thing I want to see is photographs.

Photos should of course be taken of the areas of hair loss, but should also be taken of normal appearing areas in the event these are slowly changing or in the event loss occurs in the future.

A patient who has never taken photos of their scalp needs to be educated on the importance of this step in scarring alopecia.

CLUE 5: The patient is shampooing the hair less and less.

Most patients with scarring alopecia react to their hair loss by shampooing less often. Many of these patients develop worse and worse seborrheic dermatitis on account of shampooing less and less. Some even develop thick scale in areas (pityriasis amiantacea) that traps bacteria and other microorganisms and worsens inflammation. In addition, some patients who shampoo less and less start to see more and more hair coming out after showering which prompts them to shampoo the scalp even less. A vicious cycle sometimes develops. For example, a patient who shampoos the hair once per week is going to see a lot more hair loss compared to if they shampoo the scalp daily.

I recommend that patients with scarring alopecia be gentle on their scalp but generally speaking shampooing every 2-3 days is appropriate for those with fine or straight hair and shampooing every 4-6 days is appropriate for those with curly hair. If seborrheic dermatitis is present, an anti-dandruff shampoo should be added to the shampooing routines. It thick scale is present, a salicylic acid based shampoo may be needed to help lift the scale.

CLUE 6: The patient has never used a topical corticosteroid.

Corticosteroids are the mainstay of treatment for many types of scarring alopecia. That’s not to say by any means that they are the most effective treatments. Not at all. However, for most types of scarring alopecia, especially lichen planopilaris, frontal fibrosing alopecia, discoid lupus, pseudopelade, they are a an improtant treatment to consider given their relatively safety and reasonable effectiveness.

A patient who has never used a topical steroid is quite likely to be misinformed, or poorly educated about their scarring alpecia. On average. Of course, there are exceptions. Yes. But we are talking averages here. A patients who has used this supplement or that supplement in hopes it will help their scarring alopecia or done this cosmetic non sense or that cosmetic non sense but has never used a topical steroid is all too common.

The purpose of this article is to help patients and physicians recognize the clues of being off track with treating scarring alopecia - and this is certainly one of them.

CLUE 7: The patient has never had any blood tests after your diagnosis.

Many scarring alopecias are diseases of the immune system of the body. Yes, it’s true many just have effects in the scalp (and the rest of the patient is perfectly healthy. But not all. We know that many scarring alopecias are associated with an increased chance of having blood test abnormalities - including thyroid abnormalities and low vitamin D. If a patient has not had blood tests since their diagnosis, they need them. Plain and simple. The basic tests are CBC (blood counts), TSH (thyroid studies) and ferritin (iron storage) and 25 hydroxyvitmain D (vitamin D status). Yes, other tests might be needed too - but these are the four basics that everyone needs. If a patient has never had blood tests, they are not quite on track yet.

CLUE 8: You have not seen a dermatologist to date about your hair loss.

This one often prompts some to take offence, but it should not. Many physicians treat hair loss and do a great job. Many hair transplant surgeons treat hair loss and do a great job. Many endocrinologists treat hair loss and do a great job. Many trichologists treat hair loss and do a great job. But most scarring alopecias are best handled by dermatologist.

A hair transplant surgeon, general practioner, endocrinologist and trichologist are not equipped with the tools to fully battle this group of diseases. A hair transplant surgeon does not usually prescribe systemic medications. For example, it’s rare that a hair transplant surgeon prescribes hydroxychloroquine, mycophenolate, cyclosporine, isotretinoin, clindamycin, rifampin. Are these really needed sometimes? They most certainly are.

A hair transplant surgeon treats hair loss with surgery and surgery is never ever an option in the early stages of scarring alopecia. An endocrinologist may have great strategies for some cases of female pattern androgenetic alopecia and may offer minoxidil, spironolactone and other systemic hormonal based options. But no, most endocrinologists don’t prescribe systemic medications for scarring alopecia and do not have the experience to monitor these systemic medications in the setting of scarring alopecia.

I’ll leave this topic now, but it’s one I feel strongly about. The only physician group with advanced skills to battle scarring alopecias are dermatologists. The exception of course would be physicians with advanced training in the field of hair loss dermatology. It’s simple. Yes, this concept rubs some the wrong way. But it shoud not. Patients are confused with available treatments. Bold statements are needed to help patients. And my primary concern is to help patients. The vast majority of patients with scarring alopecias are best treated by a dermatologist.

CLUE 9: The patient is using treatments but you don’t know what ingredients they contain.

It’s common for a patient to tell me they are using this treatment and that treatment. This vitamin and that vitamin. Many go on to say they are using something their hairdresser gave them or something they ordered from the internet, but they are not sure what it is.

If a patient is using something that they don’t know what it is, they need to stop. The treatment of scarring alopecia is a finely tuned process. At every single step, we need to know what we are doing. Taking things that one does not know what it contains is unsafe.

The immune system however, does know what the patient is taking - and so does the rest of the body. Some treatments activate the immune system, some have no effect and some actually weaken it. This includes natural products, herbs and random supplements.

CLUE 10: The patient is buying more and more products from the internet.

Patients who find themselves buying more and more treatments from the internet are probably not on track. This supplement, that supplement - it probably does nothing in the case of scarring alopecia. Fancy packaging and elevated prices are not associated with a great chance of helping scaring alopecia.

Do I ever recommend various supplements? Sure. Some may have benefit in non scarring alopecias, especially those associated with increased shedding (telogen effluvium). Rarely do they help scarring alopecia.

If a patient is increasing turning to amazon or various online website stores for options for their hair loss, it’s probably an indication that they should be seeing a dermatologist who treats scarring alopecia.

Conclusion and Summary: How do I get back on track?

There is a great deal of misinformation about scarring alopecias out there in the world. After treating many patients with scarring alopecia over the years, I can say that there are often signs that that tell me that a patients needs a bit of help with how they are approaching their own scarring alopecia.

I feel strongly that patients need to know what it is they should expect and how best to monitor their scarring alopecia. Not everyone follows there symptoms like our chart enables them to, but I certainly encourage patients to take photos. Everyone with primary scarring alopecia needs blood tests and there simply are no exceptions. Some types of scarring alopecia may need more tests than others, but everyone needs blood tests. Most patients with scarring alopecia benefit by a visit with a dermatologist. it’s true that future appointments and ongoing monitoring may be handled by many different types of specialists, but scarring alopecias are fundamentally dermatological diseases. I understand that it can be difficult to access a dermatologist in many parts of the world. It still does not change the view that dermatologists are the group of physicians with the skills to battle the toughest cases of scarring alopecia.

Treating scarring alopecia is not only about connecting patients with effective treatments but also helping dispel myths and misinformation. Helping the patients starts with education - long before I reach for a prescription pad.






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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Treatment Options for Lichen Planopilaris: What to consider?

Lichen planopilaris: What are the treatment options to consider?

Lichen planopilaris is a scarring alopecia with the potential to cause permanent hair loss. Treatment helps stop the disease in many but may or may not actually help the hair to grow back. Treatment, however, may help reduce symptoms such as scalp itching, burning or tenderness.

Lichen planopilaris: A variety of options are available although some are clearly better than others.

Lichen planopilaris: A variety of options are available although some are clearly better than others.

The Main Nine Treatments of LPP

There are a variety of treatment options available for LPP. In fact, taken together there are well over 25. This list in this figure is not complete by any stretch. However, several options would be considered "standard options" or “first-line options” and have the best medical evidence. These options include topical steroids, topical calcineurin inhibitors, steroid injections, and oral medications such as hydroxychlorqouine, doxycycline, methotrexate, cyclosporine and mycophenolate and isotretinoin. These are by far the most helpful nine treatments. Oral cyclosporine is probably the most helpful treatment for LPP overall but rarely we start with this due to side effects (it's viewed as a “third-line option” in my pratice). It may help up to 80 % of patients. The next best is probably methotrexate and hydroxychloroquine with up to 60 % benefiting.

LPP-options

The First Step: Where does one start?

Typically, I start with topicial steroids, (sometimes with topical calcineurin inhibitors), and steroids injections and give careful discussion to whether to start doxycycline or hydroxychloroquine. Other options that can be considered (especially if these 9 options do not work) include low level laser, low dose naltrexone, pioglitazone, excimer laser, anti-androgens, azathioprine, and tofacitinib.


These treatment options do not help everyone and it may take 4-6 months to get an idea if it’s helping stop loss. Symptoms however can go away very quickly on the right treatment (3-4 weeks). In discussing treatment options with one’s physician, side effects, ease of use, and cost must be taken into account. Some treatments like topical steroids and steroid injections have a fairly good side effects profile if used correctly. However, they rare stop the disease completely if used alone (but rarely can). Nevertheless they may provide some degree of benefit. Other options such as the oral immunomodulating medications are superior to topical steroids and steroid injections but have greater potential side effects that must be weighed.

LPP-speed

Cautionary Tales

Starting with treatments like platelet rich plasma for LPP is common but not based on solid evidence. Rarely do patients really benefit. Over the counter supplements don't shut down the disease and are not first line either. Hair transplantation for LPP can be done but only when the disease is 100 % quiet (patient has no symptoms and has not lost any hair and taken no medications) and has shown itself to be 100 % quiet over 2 years of extremely careful monitoring. If photos of a patient taken two years apart look identical, a patient with LPP may be a candidate for surgery. Even then the disease can still flare and long term dermatological monitoring is needed.


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 Hair Loss: Should we be measuring potassium levels in patients or not?

Potassium Levels and Spironolactone: Measuring May be More Relevant for Women over 45.

Spironolactone is an oral medication often used off label for treatment of androgenetic alopecia in women. Previous recommendations in patients using spironolactone for acne (not hair loss) suggested that routine monitoring of serum potassium levels was important. However, more recent studies have suggested this is not necessary for healthy women. This includes a 2017 study by Layton and colleagues that evaluated 10 randomized controlled trials (RCTs) and 21 case series pertaining to acne.

See Previous Article: Spironolactone and FPHL: Are routine measurements necessary?

Similar conclusions were found by Plavanich and colleagues in a retrospective study of healthy young women taking spironolactone for acne. 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.

Although there is increasing evidence that measuring potassium levels in young healthy women who do not use any other medications is probably not necessary, a key question is whether we should or should not be measuring potassium levels in women in the late 40s, 50s (and beyond) who are prescribed the drug.

Thiede and colleagues recently reported data on potassium levels in 124 women both before and after spironolactone initiation. 112 women were in an 18 to 45 years age group, and 12 were in a 46 to 65 years age group. All women had potassium levels within normal limits before starting the drug. Interestingly, 17 % of women in the 46 to 65 years age group had high potassium levels (hyperkalemia) after starting spironolactone compared with less than 1 % of women 18 to 45 years of age.

Routine monitoring of potassium levels is probably not necessary in young healthy women who don’t take other medications.

Routine monitoring of potassium levels is probably not necessary in young healthy women who don’t take other medications.



Conclusion

Overall, this was a very small study and there were only 12 patients in the older age group which limits how we interpret this data. Nevertheless, the study has important lessons which are likely relevant not only for women using spironolactone for acne but hair loss as well. First, routine potassium testing in young healthy women is probably not necessary. Second, 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 deemed good candidates for spironolactone in the first place but if they are they will certainly require periodic potassium measurements. Third, even healthy women over 45 could potentially be at increased risk of hyperkalemia from spironolactone and one should at least consider whether or not monitoring is warranted.


References
Thiede RM et al. Hyperkalemia in women with acne exposed to oral spironolactone: A retrospective study from the RADAR (Research on Adverse Drug Events and Reports) program. Int J Womens Dermatol. 2019 Apr 25;5(3):155-157.

Layton AM et al. Oral Spironolactone for Acne Vulgaris in Adult Females: A Hybrid Systematic Review. Am J Clin Dermatol. 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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Top 10 Things You Need to Know about Oral Minoxidil for Hair Loss

Oral Minoxidil: Top 10 Points for Prescribers and Patients.

Here are the top 10 points that prescribers and users of minoxidil need to know.

1. Oral minoxidil is not FDA approved for hair loss.

The use of oral minoxidil is FDA approved for high blood pressure. Its use in hair loss is entirely off label.

2. If you are going to use or prescribe oral minoxidil, you need to know a thing or two (or three) about it - including who should not be prescribed the drug.

If one is going to use or prescribe oral minoxidil they need to know everything about it. The same is true for any treatment - prescription, non-prescription, cosmeceutical, holistic, natural or ayurvedic. No treatment should be used without solid understanding of risks and benefits, indications and contraindications. If you can’t list 5-6 common side effects of oral minoxidil, I believe you should not be using it or should not be prescibing it. Plain and simple.

One should also have a clear sense who should not use this medication. The following are contraindications or reasons not to be using or prescribing minoxidil:

1. Minoxidil should not be used if women are pregnant or trying to conceive. 

2. Patients over 60 years of age can use oral minoxidil only with caution as they may be more sensitive and could potentially have underlying cardiovascular disease which can precipitate angina if blood pressure were to drop.

3, Patients with underlying chronic health issues, especially kidney, heart and liver problems should not use

4. Patients with heart disease include those with previous heart attacks but also those with angina, heart failure and rhythm problems should not use

5. Patients with pheochromocytomas should not use oral minoxidil

6. Patients with porphyria should not use oral minoxidil

7. Patients who have not used or considered other standard hair loss treatments first should not jump not necessarily jump into using oral minoxidil.

8. Patients with low blood pressure to begin with or those using other anti-hypertensives may not be ideal candidates for oral minoxidil. This needs careful review.


3. Oral minoxidil can be a very helpful second-line treatment for many conditions when used properly. This includes androgenetic alopecia, alopecia areata, chronic telogen effluvium, traction alopecia and post-chemotherapy permanent induced alopecia.

As mentioned above, oral minoxidil is not FDA approved for hair loss. Oral minoxidil can help some conditions and can have an amazing role in managing various conditions. However, it is rarely a first-line agent. Other options might be considered first for many of these conditions, including consideration given to topical 2 or 5% minoxidil. However, if various first-line treatments do not prove completely helpful or can not be used for various reasons, oral minoxidil might be considered. Oral minoxidil at doses 0.25 to 5 mg has shown benefit in treating androgenetic alopecia, alopecia areata, chronic telogen effluvium, traction alopecia and post-chemotherapy permanent induced alopecia.

4. When minoxidil pills are taken by mouth, most of the drug is quickly absorbed into the blood.

Oral minoxidil is easily absorbed from the gastrointestinal tract. The peak levels in the blood occur at around 1 hour after taking the medication and then levels slowly drop after that. Minoxidil is metabolized by the liver. The half life of oral minoxidil is around 4.2 hours. The concentration of minoxidil that appears in the blood depends on the dose used. With 5 mg pills, a concentration of of 157 ng/mL can be measured in the blood about 1 hour later before levels start to drop off. If one-half the amount of minoxidil is ingested (ie a 2.5 mg pill), the concentration in the blood at the one hour time point is actually much less than simply one half the amount. It’s about one-fifth the amount at approximately 28 ng/mL. This is important information because it reminds us that it’s not appropriate to say “Oh you did well on 2.5 mg, I’m sure you’ll do just fine if we go up to a 5 mg dose …. let’s go up on the dose.” Likely the patient will do just fine, but we need to monitor things just the same. There may be more than twice the amount of minoxidil in the blood at certain times with twice the dose.

oral-minoxidil

5. There are many ‘potential’ side effects of oral minoxidil. The most common ones are easily remembered by the mnemonic “HAIR “- (headaches, ankle edema, increased hair on the face, and rashes/urticaria). Other side effects potentially occur as well.

minoxidil-side-effects


The headaches may occur from changes in blood pressure. The ankle edema occurs from fluid retention and rarely also manifests with swelling around the eyes. Of course other side effects are also possible, and one needs to understand the range of side effects that can occur. Shortness of breath, increased heart rate and weight gain from fluid retention are all possible.

6. Topical minoxidil does not often change heart rate and blood pressure in most users - but oral minoxidil can.


Studies of topical minoxidil showed that blood pressure and heart rate don’t change significantly in healthy users who use minoxidil at the appropriate dose. That said, there is an occasional patient who does find that their heart rate goes up in the firsts hours after applying minoxidil or that they feel dizzy.

Oral minoxidil can affect heart rate and blood pressure. 0.625 mg doses and 1 mg doses rarely cause changes in blood pressure and heart rate. As we increase the dose, the more and more likely it is for the patient to experience changes. For example, the 5 mg dose is much more likely to cause changes in blood pressure and heart rate than the 2.5 mg dose. We advise our patients to monitor heart rate and blood pressure after starting. (See ORAL MINOXIDIL MONITORING FORM).

7. Although the oral minoxidil reaches peak levels in the blood about 1 hour after a single dose of the pills, the main effect on blood pressure occurs at the 2-3 hour mark and then blood pressure rises again slowly after that. For those using minoxidil daily long term, the maximal effect on blood pressure occurs at the 10-14 day mark.

We generally advise patients to monitor their heart rate and blood pressure weekly after starting. We compare this to baseline measurements to get a sense of the hemodynamic changes (if any) that occur with oral minoxidil use.

ORAL MINOXIDIL MONITORING FORM

It’s helpful to know what is happening to the blood pressure in the first few days but especially 10-14 days after any change in dose. It’s a good idea for users of oral minoxidil to get a baseline blood pressure reading before they start using the pills because one will refer back to this number in future days, weeks and months ahead. Previous studies have taught us that patients using oral minoxidil at doses 0.625 mg and 1 mg rarely have changes in their heart rate or blood pressure after using minoxidil. Changes in blood pressure and heart rate are not that common with 2.5 mg but certainly more common with 5 mg doses. I always advise measuring blood pressure and heart rate initially and then again at the end of the first week and then again at the end of the second and third week. Patients can do this at home themselves if they own a blood pressure cuff or in any local pharmacy (many pharmacies in North America have blood pressure machines that patients can use for free). For most people, there are no changes on the really low doses or oral minoxidil we use for hair growth. Blood pressure should be measured at any time a patient using oral minoxidil experiences dizziness. Fortunately, this is are.

Most studies in the past have shown that it’s once a patient starts using 5-10 mg doses of oral minoxidil that effects on heart rate and blood pressure can be seen. The early studies of oral minoxidil showed that serum concentrations of 21.7 ng/mL was the lowest concentration that resulted in significant blood pressure and heart rate changes in patients. About 1:200 to 1:300 patients using topical minoxidil will achieve this concentration but it’s a bit more common of course in users of 2.5 and 5 mg oral minoxidil.

8. Serum concentrations with oral minoxidil are about 20-30 times higher than topical minoxidil.

It is not surprising that blood levels of minoxidil are higher when you take it orally, but the key question is how much higher? First, it’s important to understand the there is some systemic absorption of minoxidil even in users of topical minoxidil. It’s just that it’s very low. About 99 % of users of topical minoxidil have blood levels less than 2-5 ng/mL. However, some patients using topical minoxidil occassionally do acheive much higher levels or minoxidil in the blood - even levels up to 21 ng/mL. Fortunately that is uncommon. Concentrations of minoxidil higher than 5 % may increase absorption. Topical medications like topical retinoids and topical cortisones can increase absorption of minoxidil for example. The serum concentration of minoxidil is about 20-30 times higher with use of oral minoxidil than topical minoxidil.

9. The higher the dose of oral minoxidil, the higher the levels in the blood.

It may seem obvious but bears mentioning that higher doses of minoxidil lead to greater levels in the blood and the potential for greater side effects. One needs to simply monitor side effects with any dose increase. The potential for side effects for those using 1 mg is greater than 0.5 mg. The chance of side effects for those using 5 mg is greater than 2.5 mg.


10. In addition to the scalp, hair growth on the body occurs in fairly predictable areas if it is to occur.

The eyebrows, hairline, temples, areas under the eyes (malar areas), back of the arms and shoulders are areas outside of the scalp which are most likely to be affected by oral minoxidil use.

About 15-20 % of women using oral minoxidil will experience an increase in body hair including hair on the face. Many users will chose to still continue the minoxidil because they are pleased with its effects on the scalp and remove the excess hair with various means (laser, electrolysis).

Conclusion

Oral minoxidil can be a very helpful second line treatment for many conditions. One must be aware to risks and benefits of this medication and how the risks and potential for side effects change with different doses. IN addition, one needs to be aware to how to monitor patients using oral minoxidil.

Reference

[1] ORAL MINOXIDIL, FDA DATA.

[2] Novak et al. Topically applied minoxidil in baldness. Int J Dermatol. 1985 Mar;24(2):82-7.


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: What are the treatments?

What are the treatments for frontal fibrosing alopecia?

Frontal fibrosing alopecia (FFA) is scarring alopecia that mainly affects women. Hair loss often begins in the eyebrows or in the frontal hairline - or both. The precise cause is unknown although hormone-related and immune-related mechanisms are felt to be involved. A variety of treatments are available to stop the disease although treatments are not effective in everyone. Sometimes regrowth to a slight degree of even marked degree can occur. However, the main goal of treatment of all scarring alopecias is to stop them from getting worse.

SEE PREVIOUS ARTICLES ON FFA

The Early Stages of FFA

Do I have Frontal Fibrosing Alopecia?

Inflammation in Frontal Fibrosing Alopecia

Baby Hairs in Frontal Fibrosing Alopecia

Frontal Fibrosing Alopecia: How long until treatments start helping?

FFA vs LPP: Which is often quieter in its appearance?

Scaling around Hairs in Frontal Fibrosing Alopecia


What treatments have good evidence of helping?

The treatments with the best evidence for helping FFA are the antiandrogens (finasteride/dutasteride) and the retinoids (isotretinoin). Other oral agents like doxycycline, hydroxychloroquine (Plaquenil) and methotrexate also are helpful although likely not quite to the same degree as the retinoids and antiandrogens.


Topical calcineurin inhibitors (tacrolimus, pimecrolimus) do appear more helpful than topical steroids based on a limited number of published studies. Topical antiandrogens likely help somewhat as well but require more study. Low level laser also needs more study but may have a role too. Steroid injections with triamcinolone acetonide help some patients (not all) and are typically performed every 2-3 months.

FFA-treatments



What treatments must we be very careful of?

Treatments like platelet rich plasma (PRP) are popular but have absolutely no solid evidence of being helpful in FFA. Hair transplants are an option if the disease has been completely quiet for 2 years (without medication) and the patient has proven that no hair loss has occurred in that 2 year waiting period. Otherwise hair transplants are not a good idea and can be a disaster leading to more hair loss.

Donovan Criteria for Hair Transplantation in FFA

Most hair supplements have limited benefit for FFA and can not be routinely recommended at this time.

The exact treatment I recommend depends on many patient factors. In general, I often start with a combination of topical steroids+ topical calcineurin inhibitors (pimecrolimus) + steroid injections + one systemic agent (pills). There is no standard template as it depends on patient factors. For example, a patient with a history of severe depression or personal history of breast cancer might not be started on finasteride.


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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How rare are scarring alopecias?

Scarring Alopecias: More Common than Realized

Five leaf clovers, like scarring alopecias, are probably alot more common than people realize.

Five leaf clovers, like scarring alopecias, are probably alot more common than people realize.


Five leaf clovers are much more common than people realize. It’s just that people don’t always think about it when looking in a patch of clovers or if they are on the lookout for it, they don’t quite have the skills that allow them to be spotted.

Scarring alopecias are also much more common than clinicians realize. It’s just that clinicians don’t always think about it when looking at the scalp or .... if they are on the lookout for it, they don’t quite have the skills that allow these conditions to be spotted.


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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Some Hair Loss Conditions Look Alike - but that not mean they can not be distinguished

Look-alike does not mean alike

I’m often asked how it’s possible to distinguish different hair loss conditions if sometimes they can look so similar. How can we distinguish a challenging case of seborrheic dermatitis from lichen planopilaris? How can we be sure that a patient who is concerned about hair shedding has early androgenetic alopecia not telogen effluvium?

The answer is to dig deeper and get more clues if one is not sure. Few detectives solve a complex mystery by sitting at the coffee shop. They get out on the scene and gather necessary clues. If the detective is not sure, they ask more questions, examine things closer or in more detail …. or perform more tests.

The same is true with hair medicine. We need to ask good questions that direct us in the right direction. We need to perform a careful scalp examination (including trichoscopy). We also have available a plethora of tests that we can use if we need to. These include blood tests, biopsies, swabs, pull tests, trichograms, and hair collections. When put to use at the right time and interpretted correctly - these tests also provide important information. A good doctor puts all the pieces together.

It’s true that some hair loss conditions can look similar. But that is far from needing to express frustration that we simply can’t tell them apart. In cases of frustration, I tell my trainees “Be an expert!” A golden retriever dog can look like a yellow lab dog but an expert can easily tell them apart. A wine expert can easily distinguish a Chardonnay from a Riesling, Pinot Grigio or Pinot Blanc. There are lots of things that seem alike but people who understand the subject can tell them apart. A knowledgeable hair expert can sort through challenging hair loss diagnoses.

Many hair loss conditions can look similar. Yes, this is true! If one is not sure, they ask more questions, examine things closer or in more detail …. or perform more tests. Few detectives solve a complex mystery by sitting at the coffee shop and few hair specialists can solve complex cases by sitting back in the office chair.


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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Inflammation and Scarring Alopecia: If I get rid of my inflammation, will hair loss stop?

Do scarring alopecias halt once inflammation disappears?

Many of the so called ‘primary scarring alopecias’ are associated with inflammation under the scalp. Conditions like lichen planopilaris, frontal fibrosing alopecia, discoid lupus, central centrifugal cicatricial alopecia, pseudopelade, folliculitis decalvans are all associated with inflammation.

This inflammation is present both histologically (under the microscope) and clinically (we see it on the surface of the scalp). The clinical disappearance of inflammation is always a good sign. The disappearance or reduction of redness, scaling, pustules, are all good signs that inflammation is going away and that treatments are helping.

Reduction of inflammation in necessary but not always sufficient to stop the disease.

The first step in treating scarring alopecia is to get rid of these signs of inflammation. It’s where we start as goal number 1. We try to get rid of the inflammation and see if the hair loss will stop. However, we need to keep in mind that sometimes even when the scalp returns back to quite a normal in appearance (minus the permanent scarring), it’s possible for the disease to still continue.

Fortunately for everyone - this is not the normal scenario.

The normal and typical scenario is for the disease to halt once inflammation disappears. However, there are situations where we stop the inflammation quite well but the hair loss grumbles onwards. There are several things that must be considered when this happens.

Consideration 1: Inflammation is still present under the scalp

Sometimes in situations where clinically the disease seems pretty quiet or inactive, the patient still experiences hair loss. Granted hair loss in this scenario is usually quite slow if it occurs at all. But sometimes there is inflammation going on under the scalp at varying degrees that could, at least theoretically, be driving further hair loss. We don’t in the present day and age have a way of picking out an inflammatory cell from the scalp and asking it whether it is responsible for hair loss or not. That’s simply not possible. But we do have situations where there is a tiny bit of inflammation present and the patient has not lost a strand of hair in years and another situation where the same amount of tiny bits of inflammation are present in the scalp and the patient is still losing hair. Why these differences occur is still a mystery.

Consideration 2: Other non-inflammation based mechanisms are operative

Inflammation seems to be at the center of the mechanisms that operate in scarring alopecia. However, we need to be humble to the fact that that we really understand very little about these diseases (despite our feeling that we are getting closer). There are likely a variety of mechanisms that contribute to the progressive depletion of stem cells in scarring alopecias. Some of these may be dependent on inflammation and some others might not be.

Conclusion

In the present day, clinicians treating scarring alopecia must have as their goal number 1 the removal of inflammation from the scalp. We need to help the patient stop their itching. We need to help them stop their burning and tenderness. We need to get rid of redness from the scalp and get rid of scaling and pustules. Fortunately when we achieve all this - we stop the scarring alopecia disease. But we don’t always. Tiny bits of inflammation under the scalp can still drive progression of scarring alopecias in some cases. In addition, there may be a variety of cytokine, chemokine, and endocrine changes that drive stem cell depletion even in the absence of gross inflammation.


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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