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Shampoo Allergy: Top Allergens

#4 Formaldehyde Releasers

Allergy 4.png

Formaldehyde-releasers (FDRs) are the fourth most common allergen in shampoos. Studies by Zirwas and colleagues showed that 48.6 % of shampoos contained FDRs. 
FDRs are used as antimicrobial and antifungal preservatives in a wide variety of cosmetics and hair care products. They are called “releasers” because these chemicals slowly release the chemical formaldehyde as they break down and such release can cause irritation or allergic contact dermatitis.

In the right circumstances these FDRs can release formaldehyde in concentrations exceeding 200 ppm.

There are well over 40 FDRs but the 7 most common are: 
DMDM hydantoin
Imidazolidinyl urea
Diazolidinyl urea
Quaternium-15
Bronopol
5-Bromo-5-nitro-1,3-dioxane
Sodium hydroxymethylglycinate
 

Reference

de Groot A, et al. Contact Dermatitis. 2010.

Zirwas et al. Dermatitis 2009.
 


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

Prednisone in Paediatric Alopecia areata

The decision to use prednisone for children with alopecia areata is always an important one. Generally, this decision comes at an important time where parents and their physician have found that topical steroids, and other more localized treatments have not worked well or in some cases have not worked at all. 

Oral steroids are an option for short term use but generally not an option for long term use. Long-term corticosteroid therapy can lead to growth retardation, metabolic dysregulation and reduced bone mineral density, and other side effects. But short term used is possible and reserved for patients with rapid onset or rapidly progressive extensive, active AA.

 

Options for Corticosteroids in Children

There are two main options for corticosteroids in children - prednisone and dexamethasone. Each has their unique benefits. Prednisone has a short half life (quickly metabolized in the body) and so one needs to take daily whereas dexamethasone has a longer half life and use is generally twice weekly. 

 

Dosing Algorithms

There are many ways that steroids can be used. Common ways include the following 

1. Daily Prednisone

Daily prednisone is among the most common ways of prescribing steroids. While older children will generally take Prednisone pills, younger children can use prednisolone liquid which comes at a strength of 15 mg for every 5 mL of the syrup.  Typically a physician will prescribe 0.5 to 0.8 mg of the prednisone for every kilogram of body weight initially and then taper the dose over a period of time. This taper is generally for 3-12 weeks - with the shorter periods being generally safer but less effective. Most uses of oral steroids perform a slow taper over 12 weeks. 

 

2. Dexamethasone

Twice weekly use of dexamethasone is another way of prescribing steroids to children with alopecia areata. Dexamethasone dosing is different than prednisone and generally 1 mg of dexamethasone equates to 6.25 mg of prednisone. In 1999, Sharma and colleagues performed a study of twice weekly dexamethasone and included children in that study. Children under 12 received 2.5 to 3.5 oral biweekly dexamethasone whereas older individuals received 5 mg.

 

3. Monthly therapy

Monthly pulsed therapy with intravenous corticosteroid therapy or oral therapy is also an option. Doses tend to be larger on the one day that they are given and therefore concerns about safety do exist. Generally studies to date support good safety for this methodology but the protocol tends to be less commonly used. Lalosevic J, et al performed a study of monthy dexamethasone pulse therapy along with topical steroids in children with alopecia areata. Outcomes were quite good with nearly two thirds having complete regrowth. 

 

Side effects

One needs to carefully review all the side effects of oral steroids with their physician. For each side effect, one needs to really ask the prescriber  "okay - is that side effect common or uncommon?" The reality is that most children do very well on steroids. Weight gain, poor sleep, poor concentration, hyperactivity, heart burn, nausea are among the more common side effects.  Suppression of the adrenal glands ability to make prednisone itself is always a discussion but this is uncommon and  if it does occur it is generally temporary.  Within the 12 week period that they are generally used, many of the long term side effects are not typically seen. With every side effect, parents need to ask, "Is that a short term side effect you are mentioning or is that one that develops with long term use?"

 

Conclusion

It's a big decision as to wether or not to use oral steroids in alopecia. However, it's certainly an option to help reset the immune system and when done for appropriate times and appropriate doses the changes of side effects are low. 

 

REFERENCES
 

Sharma VK, et al. Twice weekly 5 mg dexamethasone oral pulse in the treatment of extensive alopecia areata.  J Dermatol. 1999.

Lalosevic J, et al. Combined oral pulse and topical corticosteroid therapy for severe alopecia areata in children: a long-term follow-up study.  Dermatol Ther. 2015 Sep-Oct.

 

 


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

# 3 MCI/MI

Methylchloroisothiazolinone (MCI) and methylisothiazolinone (MI) are two separate ingredients but frequently used together at a ratio of 3 parts MCI to 1 part MI in preservatives. MCI/MI is commonly used in cosmetic and industrial applications.

shampoo allergy 3.png

Interestingly, MCI and MI were initially introduced in the 1980s in various occupational applications – in glues, paints, and cleaners as a mixture.  Since 2005, it has been more widely used in cosmetics, sunscreens and household products, such as moist wipes, shampoos and conditioners.  It’s also found in cleaners and liquid laundry products and household cleaners.



The world is likely become more sensitized and allergic to MCI/MI. Some reports have shown an increase in sensitization to MCI/MI and MI by itself.The global frequency of sensitization to MCI/MI remained constant at around 2.1% from 1998-2009, but increased to 3.9% in 2011. In shampoos, it represents the third most common allergen after fragrance and cocamidopropyl betaine. 51.4 % of shampoos contain MCI/MI.

Many countries have changed their regulations on how MCI/MI can be used. Interested individuals should contact local authorities as regulations differ from country to country.

The general trend is a recommendation to ban MCI/MI in leave on products and allow it in rinse off products at tightly regulated concentration levels. In Canada, an alert was issued stating that “after June 14, 2016, all products intended for use by children under the age of three that contain MI/MCI should no longer be available for purchase. All other leave-on products containing MI/MCI were longer available for purchase after December 31, 2016.

In Canada, MI is allowed as a preservative at a maximum concentration of 0.01 %. MCI is no longer permitted in leave on products but is accepted in rinse off products at a maximum concentration of 15 ppm (0.0015%) This 15 ppm is the typical threshold in most countries.

 

Increasing trend of sensitization to Methylchloroisothiazolinone/methylisothiazolinone (MCI/MI). 

REFERENCE

1. Scherrer et al. An Bras Dermatol. 2014 May-Jun; 89(3): 527. 

2.  Geier J, Lessmann H, Schnuch A, Uter W. Recent increase in allergic reactions to methylchloroisothiazolinone/methylisothiazolinone: is methylisothiazolinone the culprit? Contact Dermatitis. 2012;67:334–341.  

3.  Mowad CM. Methylchloroisothiazolinone revisited. Am J Contact Dermat. 2000;11:115–118.  3. Lundov MD, Thyssen JP, Zachariae C, Johansen JD. Prevalence and cause of methylisothiazolinone contact allergy. Contact Dermatitis. 2010;63:164–167.  

4. Urwin R, Wilkinson M. Methylchloroisothiazolinone and methylisothiazolinone contact allergy: a new epidemic. Contact Dermatitis. 2013;68:253–255. 


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

Can minoxidil lotion make an oily scalp worse?

Minoxidil is approved for use in males and females with androgenetic alopecia. A variety of different products are available including the minoxidil solution/lotion and minoxidil foam. The minoxidil foam is particularly popular because it is less greasy. There is no evidence that one product is superior to another so it's completely left up to personal preference and cost. 

Individuals with oily scalps may bind the minoxidil foam preferably to the lotion. However, one must consider that the underlying oiliness could be due to seborrheic dermatitis and treatment of the seborrheic dermatitis may be necessary in such situations. Use of shampoos with ingredients such as ketoconazole, zinc pyrithione, ciclopirox and selenium sulphide can help to reduce oils. Appropriate treatment may allow the patient to use minoxidil lotion or foam - whichever they prefer. 


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

Can minoxidil be used in Children?

Minoxidil is formally approved for adults with genetic hair loss. Minoxidil can be used as an 'off label' indication in children with several types of hair loss including alopecia areata and early onset androgenetic alopecia.  Its use should generally be monitored by a specialist. Children can be sensitive to minoxidil and side effects such as headaches, dizziness, poor concentration, swelling in the feet can occur. Rarely some children develop excess hair on the back or arms. 

 

Minoxidil Dosing

There is no standard dosing schedule for children and much of the dosing recommendations rely on the experience of the physician and the type of hair loss being treated.  Our typical dosing schedule for children who are prescribed minoxidil is shown below. Generally speaking, any child starting minoxidil should be followed by a physician.  These doses may be altered depending on a variety of factors such as the weight of the child, height, previous treatments used and extend of hair loss. These doses are generally regarded as maximal doses. 

minoxidil in children

 

 


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

Does minoxidil help the temples?

Minoxidil is a topical medication that is FDA approved for treating androgenetic hair loss (male balding) in men. The initial studies that lead to its approval were performed in men with hair loss in the crown (top of the scalp) and this lead to labeling on packaging indicating that it helped the crown. The early studies were not conducted on the front of the scalp and temples and so manufacturers were therefore not permitted to label the product as helping the frontal scalp and temples.

 

Minoxidil can help temples and frontal hairline

Minoxidil can most certainly help the frontal hairline and temples - especially in younger men and especially in the earliest stages of balding. It may not restore it to the 'original' density. But it certainly can help a proportion of males.  Two studies in the past played a key role to nicely demonstrate that minoxidil helps the frontal hairline. 

 

STUDY 1:   Hillman and colleagues

IN 2015, Hillman K et al published a study that evaluated the efficacy of twice daily 5% minoxidil foam in the temples of male patients with genetic hair loss. The study was a 24 week study and compared outcomes to placebo treatment and to the vertex region.  Study results indicated that hair counts and hair caliber increased significantly compared to baseline in both the temples and vertex scalp.   Furthermore, patients actually using 5% minoxidil foam rated a significant improvement in scalp coverage for both the front  and top areas.

   

STUDY 2 -  Mirmirani and colleagues

In 2014, Mirmirani et al conducted  a double-blinded, placebo controlled study of minoxidil topical foam 5% (MTF) vs placebo in  16 men ages 18-49 years with androgenetic hair loss. Study participants applied treatment (active drug or placebo) to the scalp twice daily for eight weeks. Again, similar to the previous study, results showed that minoxidil improved frontal and vertex scalp hair growth of AGA patients.

 

Conclusion

There is no doubt now that minoxidil can help some men with hair loss in the frontal scalp and temples. It does not help everyone, and doesn't bring the hair back to the original density - but it certainly can help. 

 

REFERENCES

Hillman K et al. A Single-Centre, Randomized, Double-Blind, Placebo-Controlled Clinical Trial to Investigate the Efficacy and Safety of Minoxidil Topical Foam in Frontotemporal and Vertex Androgenetic Alopecia in Men. Skin Pharmacol Physiol. 2015;28:236-244.  

 

Mirmirani et al. Similar Response Patterns to 5%Topical Minoxidil Foam in Frontal and Vertex Scalp of Men with Androgenetic Alopecia: A Microarray Analysis. Br J Dermatol. 2014 Sep 10. 

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Hair Loss with Weight Loss Surgery: Is it common?

How common is hair loss with weight loss surgery?

Hair growth is a finely regulated process. The right balance of nutrients and hormones needs to bathe the hair follicle or else the hair follicle will shed. This shedding process is known as telogen effluvium. It's well known that a variety of triggers can cause hairs to shed including low iron, thyroid problems, nutritional issues, illnesses inside the body, crash diets and stress. 

 

Telogen Effluvium from Weight Loss Surgery. 

It's well recognized that hair loss can come from weight loss surgery. Studies looking at home common hair loss is after these types of surgery have given varied results but anywhere from 45-80 % of patients can be expected to have hair loss after weight loss surgery. This hair loss worsens in month 2 and 3 compared to month 1. 

Part of the hair loss comes from the stress on the body, and the restriction of calories Part of the hair loss comes from nutritional deficiencies that occur in patients undergoing weight loss surgery. Some studies have suggested that hair loss as well as nail changes are both predictive of a patient having underlyign nutritional issues. 

 

Deficiencies of Zinc, iron and selenium  

Deficiencies of zinc and iron are the most commonly studied but deficiencies of selenium have also been suggested. Rojas and colleagues compared the nutritional status of women who reported high degrees of hair loss after bariatric surgery and compared this to the nutritional status of women who reported mild hair loss. Patients with significant degrees of hair loss reported lower intake or zinc and iron and blood tests showed lower iron and zinc levels. Interestingly, patients with higher degrees of hair loss had less copper in their diets. 

Ruiz-Tovar and colleagues performed a prospective observational study in 42 obese women who had sleeve gastrectomy. This was one of the few studies to follow the level of various micronutrients after surgery - at 3 6, and 12 months. 41 % of patients reported hair loss. There was an association between iron and zinc levels and hair loss.  All patients who had low iron levels had hair loss. The authors indicated that zinc supplements did help with hair loss in most cases. 

 

Conclusion

Hair loss is common after bariatric surgery and generally occurs within 4-8 weeks. A variety of factors contribute to the hair loss, but nutritional deficiencies are important to evaluate. In my clinic I recommend a full panel in patients have hair loss after bariatric surgery including tests for CBC, TSH, ferritin, ESR, zinc, copper, selenium albumin. Premenopausal women should have a variety of hormones checked if menstrual cycles have not returned. 

 

References

Trindade EM, et al. NUTRITIONAL ASPECTS AND THE USE OF NUTRITIONAL SUPPLEMENTS BY WOMEN WHO UNDERWENT GASTRIC BYPASS. Arq Bras Cir Dig. 2017 Jan-Mar.

Ribeiro de Moraes M, et al. Clinical-nutritional evolution of older women submitted to Roux-en-Y gastric bypass. Nutr Hosp. 2014.

Rojas P, et al. [Alopecia in women with severe and morbid obesity who undergo bariatric surgery]. Nutr Hosp. 2011 Jul-Aug.

Goldenshluger M, et al. Postoperative Outcomes, Weight Loss Predictors, and Late Gastrointestinal Symptoms Following Laparoscopic Sleeve Gastrectomy.  J Gastrointest Surg. 2017.

dos Santos TD, et al. CLINICAL AND NUTRITIONAL ASPECTS IN OBESE WOMEN DURING THE FIRST YEAR AFTER ROUX-EN-Y GASTRIC BYPASS. Arq Bras Cir Dig. 2015.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Cocamidopropyl Betaine (CAPB): #2 Allergen in Shampoos

#2 Allergen in Shampoos

Cocamidopropyl betaine (CAPB) is an organic compound derived from two ingredients: coconut oil and dimethylaminopropylamine. It was the Johnson & Johnson company that introduced the first cocamidopropyl betaine (CAPB) detergent shampoo in the 1950s using coconut oil. This shampoo ultimately gained extreme popularity as the well known “no more tears” baby shampoo.

shampoo allergy 2.png

 

Cocamidopropyl betaine is a wonderful surfactant and creates a thick lather.  Surfactants are products that have both lipophilic (oil loving) - and hydrophilic (water loving) properties. These dual properties is what enables them to remove dirt and oil from the hair when used in a shampoo. Cocamidopropyl betaine typically doesn't cause much in the way of irritation which makes it a good choice.  For this reason it’s acommon ingredient in many liquid skin cleansers. When used in conditioners, it helps function as an anti-static agent.

Studies by Zirwas in 2004 showed that CAPB was present in 53 % of 197 shampoos that were studied. This made it the second most common allergen in shampoos, second only to fragrance. Tomorrow, we’ll review the third most common shampoo allergen.

REFERENCE

Zirwas M, et al. Shampoos. Dermatitis. 2009


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

Use of Dutasteride in Previous Finasteride users. 

Currently used 5 alpha reductase inhibitors include finasteride and dutasteride. Finasteride is FDA approved for hair loss at 1 mg. Dutasteride is not formally FDA approved for treating balding. However, the medication can can be used off label. 

Finasateride is an inhibitor of the enzyme 5 alpha reductase type 2  and dutasteride is an inhibitor of both 5 alpha reductease type 1 and type 2. Dutasteride is more potent and leads to greater reductions of dihydrotestosterone (DHT). Studies from 2004 showed that dutasteride lowers serum DHT by up to 90% whereas finasteride lowers it by about 70 %. Side effects are also potentially greater with dutasteride than finasteride.

Options for Using Dutasteride

Patients using finasteride who find that the medication has not given them the growth they hoped for or who feel that their hair loss has progressed slowly over time should speak to their physicians about options. There are several points to discuss with your health care provider. Many individuals who have a “partial” response to finasteride often wonder if they should switch to dutaseteride or add dutasteride to thr finasteride they are already taking.

1. Adding dutasteride on weekends.

Adding a very small dose of dutasteride on the weekends can often be an option for some men.  An Australian study in 2013 reported a male who was initially treated with finasteride for androgenetic alopecia (male balding). Despite good compliance with the medication, the patient noted his hair density was not as good as previous years, and low-dose dutasteride at 0.5 mg once per week was added to the finasteride therapy. Interestingly, this treatment plan resulted in a dramatic increase in his hair density, demonstrating that combined therapy with finasteride and dutasteride can improve hair density in patients already taking finasteride.

 

2. Switching to dutasteride altogether

Another option that patients may wish to discuss with their physicians is whether to stop finasteride altogether and start dutasteride.  In 2014, Jung and colleagues from South Korea studied 31 men with male balding who took dutasteride after finasteride did not help them. Well over three quarters of these men  (77 %) improved their hair density by making the switch (17 improved slightly, 6 moderately, 1 markedly).

 

Conclusion

The use of dutasteride is among the treatment options for men with incomplete responses to finasteride. 

 

 

Reference:

 

Jung et al. Effect of dutasteride 0.5 mg/d in men with androgenetic alopecia recalcitrant to finasteride. Int J Dermatol. 2014 Nov;53(11):1351-7

 

Boyapati A and Sinclair R. Combination therapy with finasteride and low-dose dutasteride in the treatment of androgenetic alopecia. Australasian J Dermatol 2013


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Classic studies from the Past: A Look at the Early Dutasteride Studies

Dutasteride vs Finasteride: Suppression of DHT

In the world of hair loss, we often quote numbers and statistics. We frequently throw around information without a good idea of where that information actually came from. An important study is a 2004 study by Dr. Clark and colleagues. It is one of the the classic studies examining how DHT changes with use of finasteride and dutasateride. 

The researchers studied 399 men with prostate enlargement (BPH) and randomized them to once-daily dosing for dutasteride (0.01, 0.05, 0.5, 2.5, or 5.0 mg), or 5 mg finasteride, or placebo for a total of 24 weeks. The percent decrease in DHT was 98% with 5.0 mg dutasteride and 95% with 0.5 mg dutasteride. This was found to be significantly lower than the 71% suppression observed with 5 mg finasteride.  Moreover there was less variability in DHT changes with dutasteride than finasteride. 

 Clark et al. Marked suppression of dihydrotestosterone in men with benign prostatic hyperplasia by dutasteride, a dual 5alpha-reductase inhibitor. J Clin Endocrinol Metab. 2004

Clark et al. Marked suppression of dihydrotestosterone in men with benign prostatic hyperplasia by dutasteride, a dual 5alpha-reductase inhibitor. J Clin Endocrinol Metab. 2004

 

The other important part of their studies was the increased in DHT that follows stopping the medication. The graph above shows that DHT levels rise much more slowly when dutasteride is stopped than when finasteride is stopped. This is on account of the long half life of dutasteride compared to finasteride (6 hours for finasteride and 4-5 weeks for dutasteride).

 

 

Reference

Clark RV, et al. Marked suppression of dihydrotestosterone in men with benign prostatic hyperplasia by dutasteride, a dual 5alpha-reductase inhibitor. Randomized controlled trial. J Clin Endocrinol Metab. 2004.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Children of Women with Polycystic Ovarian Syndrome:

What is the latest research ?

Polycystic ovarian syndrome (PCOS) is a hormonal disorder in women. It is not one condition but a constellation of symptoms. Patients with PCOS typically have evidence of hyperandrogegism (excess male type hormones and irregular periods. Women with PCOS typically have cysts present in the ovaries but some do not.  The exact cause of PCOS remains unknown although a genetic component is likely for many women. The ovaries of women with PCOS are known to secrete higher levels of male hormones which contributes to irregular periods and infertility. Women with PCOS may seek medical attention for a variety of reasons including insulin resistance, diabetes, high blood pressure, acne, increased hair growth on the face, irregular periods, infertility.  Women with PCOS may also present to a hair clinic with concerns about androgenetic alopecia. It is therefore extremely important that hair specialists understand this condition. 

 

New Research on Children born to Mothers with PCOS

A great deal of research is currently being conducted into the cause of PCOS and how it affects women. Research is also being conducted into the health of babies born to mothers with PCOS. Research has suggested that the hormonal changes in utero influence the development of the fetus. 

One issue that has been studied is the risk of attention-deficit/hyperactivity disorder (ADHD) in babies born to mothers with PCOS. ADHD is the most common childhood neurodevelopment disorder. Male hormones may play a role as boys are two to three times more likely to develop ADHD.

A study by Berni and colleagues of over 16,000 women showed that women with PCOS have a slight risk of giving birth to children with attention deficity hyperactivity disorder (ADHD) and Asperger syndrome. 

Kosidou and colleagues performed a matched case-control study using health and population data registers for all children born in Sweden from 1984 to 2008.  In their study, a total of 58,912 ADHD cases (68.8% male) were identified and matched to 499,998 unaffected controls by sex and birth month and year. The results indicated that Maternal PCOS increased the odds of offspring ADHD by 42% after adjustment for confounders (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.26-1.58). The risk for ADHD was even higher among obese mothers with PCOS and was highest among obese mothers with PCOS and other features of metabolic syndrome.

 

Conclusion

Recent research suggests that differences in maternal hormones during pregnancy in women with PCOS affect the chances of having children with ADHD and possible other neurodevelopmental issues. Overall the risk is low. 

 

 

 

REFERENCES

Berni TR, et al. Polycystic ovary syndrome is associated with adverse mental health and neurodevelopmental outcomes. J Clin Endocrinol Metab. 2018.

Kosidou K, et al. Maternal Polycystic Ovary Syndrome and Risk for Attention-Deficit/Hyperactivity Disorder in the Offspring.  Biol Psychiatry. 2017.

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Fragrance Allergies: #1 Allergen in Shampoos

 #1 Allergen in Shampoos

fragrance.png

It's possible to be allergic to an ingredient in shampoos. Many patients with shampoo allergies don't develop scalp reactions as their main concern - rather they develop a range of dermatologic issues such as eyelid dermatitis, neck dermatitis and facial dermatitis.

Fragrance is the most common allergen in shampoos. Of 179 shampoos analyzed in a study by Zirwas, 95 % had fragrance. About 99 % of the population comes into contact with fragrance allergens during a given week and about 1-4 % of the population has fragrance allergies. They are added to shampoos (and other cosmetic products) to increase their appeal. Overall, the expert consensus is that the incidence of fragrance allergy is increasing around the world. 
The terms 'fragrance-free' and 'unscented' are often used interchangeably but mean very different things. Unscented is a somewhat meaningless term but does indicate that the product does not have a strong odour. An unscented product could actually be full of fragrance but the fragrance dampens down some objectionable smell to create an overall neutral smelling product.  A patient with a fragrance allergy could have a serious reaction to an unscented product but not to a fragrance-free product.  Legal regulation over use of the term unscented has not yet occurred.

In the US, the terms fragrance are used to denote a product containing any one of many fragrances. In Canada, the term fragrance/parfum is used. North America is behind the times when one compares regulations in Europe. In Europe, it is now mandatory to report and disclose 26 fragrance ingredients in products.  Manufacturers can no longer simply label the product with the generic term 'fragrance.' Some North American companies are following suit and disclosing the exact fragrance allergen, but the process has been slow. 
In summary, fragrance allergens are the most common allergen in shampoos. Individuals with concerns about fragrance should look for shampoos that are fragrance free.
 


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

The Benefits of Urology Research

At first glance, it would seem that the medical specialists of Urology and Dermatology and quite different.  One deals with the physiology and functioning of the urinary system and the other deals with the dermatological system which comprises skin, hair and nails. The two however, are much more closely linked that you might imagine. 

 

The Androgen Receptor

The Androgen Receptor is a protein that sits in the outer layer of cells (known as the cytoplasm). One of its jobs is to bind to androgens that diffuse into the cell and form an androgen receptor-androgen complex.  The types of androgens that bind to the androgen receptor are many but the most commonly studied ones are testosterone and dihydrotestostone. The newly formed androgen receptor-androgen complex then translocates from the cytoplasm into the deepest regions of the cell (known as the nucleus) where the complex binds to DNA and stimulates the machinery needed for the cell to make new types of proteins (called transcription and translation).

 

What's the connection?

The androgen receptor has an important role in many fields of medicine including Urology and Dermatology. It's very clear that aberrant signals from the androgen receptor help prostate cancer cells to grow and so an understanding of androgen receptor physiology drives much of the field of prostate cancer research. Some of the drugs that are used to treat prostate cancers are blockers of some kind of androgen receptor function. Common examples are non-steroidal anti androgens like bicalutamide, nilutamide, enzalutamide, apalutamide, and steroidal anti androgens like cyproterone acetate.

In dermatology, the androgens and the androgen receptor also has an important role. Conditions like acne, hair loss and even syndromes associated with increased hair growth can be driven by androgens. Androgenetic alopecia (male balding and female pattern hair loss) are androgen dependent to some degree and medications that block androgens are commonly used. This includes finasteride, dutasteride, spironolactone, cyproterone acetate, flutamide.

 

Research Research in Urology

I continue to closely follow the field of Urology. There's no doubt in my mind that advances in Urology (especially in prostate cancer research) will directly translate into benefits to dermatology.   Just this week, I was asked about the use of an experimental prostate cancer drug Darolutamide for treating male balding. Darolutamide, which is a close cousin of enzalatumide and apalutamide, is not approved for use yet even for treating prostate cancer but clearly many minds have recognized this important link between drugs in Urology and drugs that may be useful to the hair loss world. 

As yet another example of the commonality between Urology and the field of hair loss dermatology, studies continue to show that balding in the crown (vertex) in men has some link to an increased risk of prostate cancer. Clearly, there are some genes that unite the two conditions, and research into prostate cancer genes and genes for balding will continue to merge together over time. 

 

Conclusion

It makes good sense for any hair loss specialist to follow the latest happenings in the field of urology. Many urological diseases, especially prostate cancer, are affected by androgens and medications that block the function of androgens provide benefit to these diseases. 

 

REFERENCE

Liang W, et al. Possible association between androgenic alopecia and risk of prostate cancer and testicular germ cell tumor: a systematic review and meta-analysis. BMC Cancer. 2018.

 

Jin T, et al. Association between male pattern baldness and prostate disease: A meta-analysis. Urol Oncol. 2018.

 

 


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

Look Beyond the Scalp!

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It’s possible to be allergic to the shampoo one is using. This week we’ll talk about this important topic. It’s often forgotten about.

Shampoo allergy is not easy to diagnose. Patients don’t simply develop any itchy, red scalp right after they use a shampoo. Rather individuals who are allergic to an ingredient in their shampoo may develop rashes elsewhere including the eyelids, face, ears, neck and back. Of course the scalp can be involved but often not right away. 
Even patients who think of the possibility find that when they change their shampoo the problem does not go away. Often that is simply because the next shampoo also has the allergen.

This week we’ll talk about common allergens in shampoos including fragrance, cocamidopropyl betaine (main two we’ll discuss on Tuesday and Wednesday). Others include MCI/MI, propylene glycol, formaldehyde releasers and vitamin E.
 


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

Recognizing Hair Regrowth

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Every patient with hair loss has the same question after starting treatment - is my treatment working?

For some types of hair loss, it can take 9-12 months to really appreciate if there has been an increase in density and improved scalp coverage. However, even before the actual change in density occurs, it is often possible to detect regrowth by looking at the lengths of newly regrowing hairs through the so called “card test.” This female patient in her mid 20s started minoxidil 4 months ago and had added spironolactone to her birth control pill about 12 months ago. Her diagnosis was androgenetic alopecia (AGA). Because hair grows 1 cm per month, I can conclude that these layers of regrowth measuring 4 cm and 12 cm correspond to a positive treatment response. 


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

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Pseudopelade of Brocq

Pseudopelade of Brocq (PPB) is a scarring alopecia. It causes permanent hair loss. The cause is unknown.

In contrast to lichen planopilaris, there is little to no scale around hair follicles. The areas may be pink-colored when active. Treatment is similar to lichen planopilaris including use of topical steroids, steroid injections, topical calcineurin inhibitors, oral methotrexate, oral doxycycline, oral hydroxychloroquine and others.


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

Pseudopelade of Brocq

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Pseudopelade of Brocq (PPB) is a scarring alopecia that affects both women and men. The central scalp is often affected first. This condition causes permanent hair loss - hair does not regrow. The goal of treatment is to stop further loss. The cause is unknown.

The areas of hair loss are usually pale colored in those with PPB although they may be slightly pink. When one feels these areas with a finger it is usually obvious that the area dips down below the level of the skin. We call this phenomenon "atrophy". The condition is frequently misdiagnosed as lichen planopilaris (another scarring hair loss condition). The two conditions are similar but lichen planopilaris has more redness and scaling than PPB and is generally more responsive to treatment. Treatment of PPB is similar to LPP and includes topical steroids, topical calcineurin inhibitors, doxycycline, hydroxychloroquine, steroid injections and similar anti-lymphocytic agents.


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

The Future of JAKs

The janus kinase pathway is a signaling pathway inside cells and continues to be explored in terms of its relevancy to hair disorders. Accumulating research suggests that blockade of this pathway with so called JAK inhibitors can benefit a number of hair loss conditions including alopecia areata. Both topical and oral JAK inhibitor have shown promise.  JAK inhibition may also be relevant to the treatment of androgenetic alopecia.   Another trial is evaluating the effect of two concentrations of ATI-502 on the regrowth of hair in a randomized, double-blinded, parallel-group, vehicle-controlled trial in a larger study of AA.  

Aclaris is a company which has secured the rights to study and develop the use JAK inhibitors for the treatment of alopecia areata (AA) as well as androgenetic alopecia (AGA). They have a number of JAK inhibitors they are studying and several are currently in clinical trials. This includes ATI-502 and ATI-501. Press releases from the company indicate that a number of studies are underway. This includes a trial to evaluate the effect of ATI-502 on the regrowth of scalp and eyebrow alopecia areata.  In addition to AA, it is interesting to note that trials are underway to evaluate the effect of ATI-502 on the regrowth in androgenetic alopecia (AGA). 

 

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It's an exciting time for many new potential treatments in hair loss. The JAK inhibitors have already shown benefit in AA and additional studies will determine whether these agents receive approval and ultimately come to market. 


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

Shaved scalp: Exclamation mark hairs

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Many patients with advanced alopecia areata shave their scalp. For some, this allows a wig to fit better. For others, especially men, the shaving is done to reduce the appearance of hair loss. 
Even with a shaved scalp, it is sometimes possible to tell if a patient's alopecia areata is active or not. This is especially true if exclamation mark hairs can be seen. "Exclamation mark" (arrow) hairs are easy to identify with a magnifying device. They are 3-5 mm in size and wide at the top and narrow at the bottom. They signal disease activity and the need for more aggressive treatment if hair loss is to be stopped.

Other features can also be seen on a shaved scalp including yellow dots (and hair follicles lacking a hair follicle) and hair follicles with just a single hair coming out (rather than in groups of 2 and 3 haired follicles).


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

Lack of pigment at root

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Telogen hairs are hairs that are ready to be shed from the scalp. At any time, most individuals have 9-12 % of hairs in telogen phase on the scalp.

Telogen hairs have a characteristic appearance once shed from the scalp. They look like clubs and are therefore called "club hairs". They also lack pigment at the very bottom of the hair follicle. This is due to the cessation of pigment production by the hair follicle at the end of its growing phase (called anagen).


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