Hair Blogs

QUESTION OF HAIR BLOGS


Botox for Reducing Scalp Sweating in Frontal Fibrosing Alopecia

Botox for Frontal Fibrosing Alopecia Scalp Sweating

Frontal fibrosing alopecia (FFA) is a scarring alopecia associated with hair loss along the frontal hairline. The eyebrows, eyelashes, body hair can also be affected. A 2017 study showed that some women with FFA experience increased sweating in the areas of hair loss. Standard treatments for frontal fibrosing alopecia including topical steroids, steroid injections, and antibiotics were found to be helpful. Interestingly, botulinum toxin treatments (Botox) were also found to be helpful.

We are seeing an increasing amount of women with scalp sweating associated with their FFA. Sweating is controlled in part by the nervous system and this raises the possibility that a specific type of inflammation known as ‘neurogenic’ inflammation may be relevant in FFA. I think we will be hearing more about this area of research in the years ahead.



Treatment of scalp Sweating with Botox in FFA

For the excessive scalp sweating that some patietns with FFA experience, Botox can certainly be considered as an off label (non FDA approved indication). There is evidence that some of the inflammation in FFA is part of what is known as ‘neurogenic inflammation’ and blockade of these nerves will block signals sent to the sweat glands eccrine glands.

 My advice for FFA patients with excessive scalp sweating is to consider Botox in the hairline starting with a conservative number of units before increasing the dose. There seems to be a great (huge) variation in the amount of Botox needed to reduce scalp sweating in FFA. There is no formal protocol for FFA, but I generally recommend starting with 40 units in the affected hairline areas and waiting several months to see how well this work to reduce the sweating. One can certainly increase up to 80-100 units - and even well beyond (100-200 units).  Many patients, but not all, require 100 Units and above. 

 

Again, even though there is no formal protocol, one might consider diluting a 50 U vial with 1.25 mL and starting with 10 injections (of a 4U / 0.1 mL concentration) spaced 10 mm apart (i.e. 40 units total).  In 4-6 months, a decision can be made as to how well this worked and either proceeding in one of three ways

 

OPTION 1. Increasing to 60-80 units instead of 40 units and increasing the size of the area injected. This would involve diluting a 100 U bottle in 2.5 mL saline and proceeding with the same technique but injections covering a larger area.

 

OPTION 2. Diluting the Botox by one half (i.e. diluting a 50 U via with 2.5 mL saline) and injecting more sites.

 

OPTION 3. Doing nothing different in the case of the patient reporting success with the first trial of Botox and simply waiting for the patient to report that sweating has returned at which point the Botox can be administered again. This is typically every 6-12 months for successfully treated patients.

Reference


Harries et al. Frontal fibrosing alopecia and increased scalp sweating: Is neuorgenetic inflammation the common link. Skin Appendage Disord May 2016; 1(4):179-84


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
Share This
No Comments

Milky Red Areas (MRA) in Lichen Planopilaris

The Milky Red Areas (MRA) in LPP



Trichoscopy (scalp dermoscopy) involves the use of a hand held dermatoscope to better assess the scalp. It has proven helpful for managing a plethora of scalp diseases. 

MRA-LPP


The field of trichoscopy is filled with bizarre terms. This photo shows the milky red areas of lichen planopilaris. These milky red areas correlate with disease activity. The more milky red areas that are seen the more activity the patient has.



Reference 


Lajevardi V, et al. Assessing the correlation between trichoscopic features in lichen planopilaris and lichen planopilaris activity index. Australas J Dermatol. 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
Share This
No Comments

Perifollicular scale in Lichen Planopilaris (LPP): Close Association with Disease Activity

The Scale in Lichen Planopilaris

Dermoscopy also called trichoscopy is extremely helpful to the proper evaluation and management of hair disorders. Hand held dermatoscopes not only help in making correct diagnoses but help in monitoring disease activity. I need my dermatoscope to properly do my job.

PFS-LPP



Perifollicular scale (scale around follicles) is one dermatoscopic feature of lichen planopilaris and frontal fibrosing alopecia. Identifying the amount of scale is important as such scaling correlates nicely with the amount of inflammation going on under the scalp as well as correlating with the so called lichen planopilaris activity index (LPPAI). The presence of perifolliclar scale in patients with LPP is not ideal as it means the patient is at significant risk to lose hair.



Reference 


Lajevardi V, et al. Assessing the correlation between trichoscopic features in lichen planopilaris and lichen planopilaris activity index. Australas J Dermatol. 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
Share This
No Comments

The Localized Telogen Effluvium

Why does everyone say I have a localized telogen effluvium?


Too often, I hear patients tell me that they have been diagnosed with some kind of localized telogen effluvium. The story typically goes something like this:


I’m losing hair in the front and my doc thinks it’s a localized telogen effluvium 

I’m losing hair in the crown and I’ve been told it’s some kind of localized telogen effluvium.


By definition, a true telogen effluvium affects all hairs on the scalp equally. The hairs at the back feel the same pressure to leave as the hairs in the front. The hairs in the crown feel the same pressures to shed as do the hairs in the sides and back. So when someone tells me they are having a localized telogen effluvium, I know to look for another diagnosis. A localized telogen effluvium does exist. So it is not that the patient or doctor is way off in how they have come to that diagnosis. It’s simply that the main diagnosis is something else.


Here are a few examples:


1. When a patient with alopecia areata sees alot of hair coming out of one area of the scalp and someone confirms they seem to be telogen hairs that are being shed- the diagnosis is still alopecia areata. It’s true there is some kind if “localized telogen effluvium” going on - but the telogen hairs are being shed due to the alopecia areata.

2. When a patient with scarring alopecia sees alot of hair coming out of one area of the scalp and someone confirms they seem to be telogen hairs that are being shed- the diagnosis is still active scarring alopecia . It’s true there is some kind if “localized telogen effluvium” going on - but the telogen hairs are being shed due to the scarring alopecia.

3. When a patient with androgenetic alopecia sees alot of hair coming out of one area of the scalp and someone confirms they seem to be miniaturized telogen hairs that are being shed- the diagnosis is still androgenetic alopecia. It’s true there is some kind if “localized telogen effluvium” going on - but the telogen hairs are being shed due to the androgenetic alopecia.


Conclusion

A localized telogen effluvium should prompt the clinician and patient to search for an underlying diagnosis.


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
Share This
No Comments

Scalp Biopsies: Just a Piece of the Puzzle

Scalp Biopsies: Often Just a Piece of the Puzzle but Not the Whole Puzzle

Scalp biopsies are extremely helpful in some cases. When the right sized sample (4 mm) is taken from the correct spot and processed properly using the correct technique and interpreted by a dermatopathologist who understands scalp hair & scalp pathology.... a scalp biopsy can be an amazing help.

puzzle


As an analogy, take a look at the photo. I see some kind of metal object about 5 in x 2 in. It’s hard to tell what it is because it’s not representative enough of the original object. I am not so skilled in identifying electronics to know what it was when I first saw this object. I knew it was not a watch and not a toaster oven. I did not look like the insides of all the watches (or toaster ovens) that I had seen in my life.

I highly skilled electronics expert might correctly identify this as the inside of an iPhone. There are some specific design features that give clues that this is an apple iPhone and nothing else. A true iPhone expert might identify this not only as an iphone but as an iPhone5.

Biopsies of the scalp are just samples of the scalp. A good sized sample taken from the right area increases the odds that the sample will have the necessary features to make the right diagnosis. But you need an experienced pathologist too.

A good electronics technician would not just say this piece of metal is from a smartphone, they would say it’s from an iphone. A good pathologist does not just identify the patient has a scarring alopecia but helps pinpoint that the features are more consistent with lupus than lichen planopilaris. 
A biopsy is not as helpful when the principles of taking and interpreting the biopsy are not followed. A really good sample given to a less experienced pathologist can sometimes still give the right diagnosis (and usually does) and an inadequate sample given to a brilliant pathologist can also sometimes give the right diagnosis (and usually does). But really tough cases need good samples (sometimes 2 or 3), taken from carefully chosen areas and placed on the microscope stage of a pathologist who thoroughly understands hair and scalp pathology.


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
Share This
No Comments


Pityriasis Amiantacea: A Reaction Pattern Not A Diagnosis

Pityriasis amiantacea: Many Causes

Pityriasis amiantacea, also known as tinea amiantacea, is not a diagnosis. Rather it is a reactive phenomenon that sometimes happens during the process of scalp inflammation. The scalp responds by producing thick sticky (“asbestos-like) scale that wraps around hairs like shingles in a roof. The condition was first described in 1832.

The scales can be difficult to remove and often take out hairs when the scale is removed. Many different conditions can lead to the skin responding in a manner that produces the end result of pityriasis amiantacea.

So what are some of the causes of pityriasis amiantacea? Well, the finding of pityriasis amiantacea is often seen in patients with psoriasis, seborrheic dermatitis, fungal infections, various eczemas and many scarring alopecias.

pityriasis-amiantacea



The photo here is a magnified photo of the scalp of a patient with "pityriasis amiantacea" from seborrheic dermatitis.

Treatment includes identifying the root cause and treating that scalp condition or disease. Treatment such as topical steroids, steroid injections, anti dandruff shampoos, salicylic acid, tar all play a role in treatment.  I view the treatment of pityriasis amiantacea as being somewhat urgent because this type of scale can lead to removal of hair and sometimes even chronic permanent hair loss if secondary infection and scarring are present. #pityriasisamiantacea #hair #scale#inflammation #hairclinic #trichoscopy


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
Share This
No Comments

Air Travel and Immunosuppression: What is the effect of flying on the immune system?

Air Travel May be Slightly Immunosuppressive

Of the 2 billion people who fly on commercial airplanes every year about 1 in 5 of them report that they develop a “cold” within the first week of arriving back home. 


Is there any logic to this? Could it really be true? 


Well, the world of aviation medicine has an interest in understanding what happens to the human body in a variety of in flight situations (...let alone what happens when we all start traveling off to Mars). In 2012, a group of researchers hypothesized that hypobaric low oxygen (hypoxic) conditions associated with air travel may actually contribute to impairment of the immune system.

To test this, the researchers studied the effects of hypobaric hypoxic conditions during a simulated flight at 8000 ft cruising altitude on immune and stress markers in 52 healthy volunteers before the simulated flight and on days 1, 4, and 7 after the flight. 

flight


The findings showed that the hypobaric hypoxic conditions of a 10-h overnight simulation flight are not associated with severe immune impairment or abnormal IgA or cortisol levels. However, there were associated with short term impairment in some measurements including transient decrease in lymphocyte proliferative responses combined with an upregulation in CD69 and CD14 cells and a decrease in HLA-DR in the immediate days following the simulated flight. 


All these immune system abnormalities normalized by day 7 in most instances.

The conclusion of the study is that the 400,000 or so travellers who feel they have some kind of respiratory infection or cold after air travel could in fact be correct. A short term suppression of some immune responses could be responsible.

Reference 
Wilder-Smith A, et al. Transient immune impairment after a simulated long-haul flight. Aviat Space Environ Med. 2012.


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
Share This
No Comments

Baby Hairs: Good or Bad?

The Three Categories of Baby Hairs

There are many type of hairs that constitute “baby hairs.” Some of these are positive signs (good signs) as they indicate that this hair has a high chance of growing longer and contributing in a few months to the overall density that a patient feels. The call these group 1 baby hairs. The upright regrowing hairs of telogen effluvium are one such example and so are the normal regrowing scalp hairs that everyone has (new anagen hair). The regrowth that is seen about 2-3 months after starting a new treatment is also an example of Group 1 baby hairs.

Some baby hairs including the vellus-like hairs of androgenetic alopecia, the sick dying vellus-like hairs of scarring alopecias and the vellus hairs of alopecia areata do not mean that baby hairs will turn into something substantial. I call these group 2 baby hairs.


baby hairs

Some baby hairs that people see can also be broken hairs. These are far less common. I call these Group 3 baby hairs. Hair breakage from excessive heat or hair breakage from trichotillomania are all examples of phenomena that can give broken hairs and in turn give the appearance of baby hairs. The exclamation mark hairs of alopecia areata are also an example. Broken hairs are important to identify but these types of hairs are often misdiagnosed. In fact, most people who think they have broken hairs are wrong. They don’t, of course, usually think they are wrong, but they are often wrong about that too. Most people with baby hairs have Group 1 of Group 2 baby hairs. Group 3 hairs are blunt at the top like a freshly cut blade of grass cut by a lawnmower. Group 1 and 2 hairs are pointy with tapered ends pointing up to the sky.

It’s always better to see one hair growing than to see none. So when a patient says “I’m seeing baby hairs but I’m not sure my hair is getting better” my concerns is that this patient may in fact have one of the hair loss conditions giving the so called Group 2 or Group 3 conditions.


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
Share This
No Comments

Upright regrowing Hairs in Telogen Effluvium

URH Start Thinner and Thicken Up over Time

A true upright regrowing hair (URH) in the setting of a hair shedding disorder (telogen effluvium) starts out thinner than the original thickness it once. As it continues to sprout up and up and up it thickens up. As an analogy, I often explain that new trees are never massive diameter little trees. That would be strange. A new tree is quite thin and then thickens up over time. A 500 800 year old tree may reach several meters in diameter. Nobody has ever seen a fledgling tree that is several meters in diameter as it first emerges from the ground.

URH





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
Share This
No Comments

Alopecia Areata: 3 week old Regrowing Hairs

Alopecia areata: Regrowth Can Occur Quickly

Alopecia areata is an autoimmune hair loss disease. It often shows remarkable speed - both remarkable speed for hair to fall out quickly and (sometimes) remarkable speed for hair to grow back quickly. “Patchy” alopecia areata (ie the form of alopecia areata showing just a few bald patches) has the greatest potential for rapid regrowth. Patients with one patch have a higher probability for regrowth compared to patients with two patches but overall many patients with a up to several patches of alopecia areata related hair loss do very well with treatments such as topic steroids, steroid injections and minoxidil.

aa-regrowth



This photo, taken from the scalp of a male patient with a small patch of alopecia areata, shows a few rapidly regrowing hairs just 3 weeks after the patient received steroid injections. Hairs start out thin and thicken up over time. Within another few weeks these hairs will be as thick as their neighbors and the patient will have no evidence of alopecia areata. This patient wears his hair short which allows the thickness of unaffected hairs to be easily compared to the thickness of newly regrowing hairs. #alopeciaareata #alopecia#hairloss #hairclinic


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
Share This
No Comments

Frontal Fibrosing Alopecia: More than Simply Frontal Hair Loss

The Varied Clinical Presentation of Frontal Fibrosing Alopecia (FFA)

Frontal fibrosing alopecia (FFA) is an uncommon autoimmune condition that generally starts between 44-57 years of age and affects women much more commonly than men. The cause is still not fully understood although 4 genes were recently discovered which may have a role.

Although FFA is still uncommon, the number of women diagnosed with FFA is increasing. The age of the internet has greatly increased the number of women who worry they might have FFA. Rarely, does a day go by that a patient of mine says to me “Are you sure I don’t have that FFA condition that have read about?”

FFA- presentation

FFA is more than simply frontal hair loss. It is a scarring condition that affects the frontal hairline, back of the ears, back of the neck, eyebrows, eyelashes and body hair. It sometimes causes the face to become rough and pebbled looking and may mimic rosacea in some cases due to the redness it can create. The skin may thin are veins may be more visible on the frontal scalp. In some women, the frontal scalp hair loss is the first thing noticed; in others it’s the loss of the eyebrows. For others yet, it may be something completely different such as loss of body hair. Some women with FFA have associated other autoimmune diseases, especially autoimmune thyroid disease.

Treatment has been discussed elsewhere but includes anti-inflammatory agents (topical steroids, steroid injections, hydroxychloroquine, doxycycline, methotrexate), retinoids and hormone blocking agents (antiandrogens).


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
Share This
No Comments

Minoxidil Toxicity in Cats

Minoxidil has Specific Toxicity to Cats

Minoxidil is a commonly used topical treatment for men and women with hair loss. It is not well known that minoxidil may have a unique toxicity to cats. Cats lack an enzyme to break down minoxidil. Given that 30% of households in the United States have cats and some 200 million or more cats are kept as pets worldwide, it’s important for cat owners to know a thing or two about minoxidil. Especially cat owners who live in a household where someone uses minoxidil. 

cats-minoxidil

In 2004, DeClementini and colleagues reported 2 cats who died after cat owners applied minoxidil to areas of hair loss on their pets. The first cat was a 3 year old cat had only one drop applied to an area of hair loss. That cat had trouble breathing, high heart rate, water in the lungs (pulmonary edema and pleural effusion) and showed increased liver enzymes. The cat died 15 hours later.

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

Several other cases of minoxidil toxicity have been reported to various animal poison control centers. The stories are similar with affected cats showing lethargy followed by fluid in the lungs and heart failure. Intensive veterinary care saves the lives of some but not all cats. 


Cat owners can use minoxidil but not without common sense and appropriate precautions. Minoxidil must not be applied directly to cats and cats should not have the opportunity to play with or lick the hair (or pillows) of owners who have applied minoxidil to their scalps as a treatment for their own hair loss. Cats must never come into contact with the actual minoxidil bottle or canister.



Reference

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


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
Share This
No Comments

Frontal fibrosing alopecia: How long until treatment results start happening for me?

What is the timeline to see results in FFA?

I just posted a new answer to our “Question of the Week.” I was asked to explain when patients with frontal fibrosing alopecia might start seeing results if their treatment is going to help

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

When do treatments for FFA start to take effect?

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


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
Share This
No Comments

Upright regrowing Hairs in Telogen Effluvium

Upright Regrowing Hairs (URH) in Telogen Effluvium: Many per Field of View

Seeing new pointy hairs is potentially good news as it indicates that a hair has regenerated after falling out just a few weeks prior. There are quite a few hair loss conditions associated with new hairs (what the public frequently likes to call “baby hairs”). The presence of many many new sprouts in close proximity to one another may be a sign of telogen effluvium (hair shedding).

Numerous upright regrowing hairs in a patient with telogen effluvium.

Numerous upright regrowing hairs in a patient with telogen effluvium.


Telogen effluvium can occur from over 2000 potential triggers. Triggers like stress, low iron, thyroid problems, diets, medications, scalp diseases and internal disease are among the more common categories. In the case of a telogen effluvium, these tiny pointy hairs are formally known as “upright regrowing hairs (URH).” They indicate that previously shed hairs are doing their very best to regrow. They do not however, mean that whatever caused the hair to shed in the first place is gone and that the underlying cause is solved. They just mean that some hairs are able to recover despite the trigger. 


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
Share This
1 Comment

Nobody Can Figure out the Cause of My Hair Loss

When Nobody Can Figure out the Cause of Hair Loss

There are some pretty challenging and unusual presentations of hair loss. Often I hear patients tell me that they have spent years trying to figure out the cause of their hair loss and nobody has been able to figure it out. While some of these truly are mysteries, I’d venture to say that the vast majority have simply not had a complete work up.

Mystery Causes of Hair Loss

I’m willing to say that a patient truly has a mystery cause of hair loss if four conditions are satisfied and the diagnosis is still not known:

CRITERIA 1: The patient has seen a hair specialist.

This is important. Tough cases need the expertise of someone who handles tough cases. When the heart does not seem to work right, one needs a heart specialist. When the kidneys are not doing what they should, one needs a kidney specialist. When the car breaks down, one needs an expert mechanic - the advice of the neighbours just doesn’t cut it. It only follows that when hair is not growing as it should, one needs a hair specialist. It’s simply but overlooked. One can not say that their diagnosis is a mystery case if they have not seen the right specialists.

CRITERIA 2: The patient has had blood tests for varioius contributors of hair loss.

If the cause of hair loss is unknown and blood tests have never been ordered, then one can not say that the cause is unknown. Every single patient with hair loss needs to be evaluated for what blood tests are appropriate to order. Most people with hair loss benefit from a basic hemoglobin (CBC), a thyroid study (TSH), and assessment of iron status (ferritin). But the list of potential tests that could be ordered is incredibly long. The exact tests that one needs depends on the information that the physician obtains during the visit (i.e. the so called medical history). A variety of hormonal test, autoimmune tests, minerals, and tests for sexually transmitted diseases could be appropriate.

CRITERIA 3. The patient has had a biopsy.

If a patients feels their case is a mystery case and they’ve never had a biopsy, then it can’t be called a mystery case. If a person is coughing for several months and he or she has never had even a simple chest x-ray, it’s inappropriate to say that nobody can figure out the cause of the cough. A variety of tests are available to determine the cause of the cough and unless a person has had those tests, it’s not appropriate to say it’s a medical mystery.

Let me say at the outset that not everyone needs a scalp biopsy. If the cause of hair loss can be determined after listening to the patient’s story of their hair loss, examining the scalp and examining the blood tests, they one does not usually need a biopsy. Most patients who step into my office don’t receive a biospy. i don’t need it to diagnose the reason for their hair loss.

With that said, it’s important to realize that if the cause of hair loss is still unknown after listening to the patient’s story of their hair loss, examining the scalp and examining the blood tests, then one needs a scalp biopsy. it’s that simple.

CRITERIA 4. The patient has had photographs taken one year apart.

Criteria 4 comes as a surprise to some people but to truly say the cause of hair loss is a ‘medical mystery’, (i.e. biopsies, blood tests are not helpful), I need to see photos of the scalp one year apart. These can either be photos the patient brings in or photos that I take one year apart. We need to figure out if the hair issue is contributing to ongoing loss or whether it has stabilized. Some hair loss issues like CTE do not change much over time. The patients loses massive amounts of hair first and then maintains that year after year after year. CTE can usually be diagnosed by history and if not a biopsy can usually capture it so photos are not really needed. However, there are a variety of hair loss situations whereby a photograph taken one year apart helps diagnose the condition that was once labelled a mystery. This includes some cases of scarring alopecia, some cases of androgeenetic alopecia and some psychiatric issues associated with a variety of hair issues.

Tough cases can’t be truly labelled mysteries unless sufficient time has been given to follow the pattern of loss.

Conclusion

There’s so many different ways that humans can lose hair. Some hair loss conditions can present a challenge to properly diagnose. However, many people who label their hair loss as a mystery have simply not had an appropriate evaluation.


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
Share This
1 Comment

Stress and Lichen Planopilaris (LPP): Did stress cause my LPP?

Stress and LPP

Patients often ask me if stress caused their scarring alopecia. In the present day and age, it seems that stress does not cause scarring alopecia but can certainly contribute to it being more active and flaring when it might otherwise be quiet.

An Analogy

As many of my patients know, I often use analogies in the clinic. Analogies are helpful means of thinking about otherwise complex or abstract topics in simpler ways.

Does stress cause scarring alopecia? Well, let consider as an analogy two campers that are camping in the wilderness in the middle of the Summer. It’s been a dry summer and there are signs posted everywhere not to build a campfire because of the concern that it could cause a forest fire. After returning from a long hike, one of the campers decides that he wishes to have a cigarette and proceeds to light and smoke the cigarette. Twenty minutes later both campters realize that somehow the cigarette has caused the nearby underbrush to catch on fire and there is now a small forest fire happening.

The forest rangers and firefighters are called in to put on the fire. During the conversation, one of the campers makes a comment that all this dry weather caused the fire.

Did the dry weather cause the fire? No, not at all. An improperly disposed of cigarette caused the fire. The dry weather did not cause the fire but certainly the dry weather contributed to the fire developing more easily and spreading more rapidly.

Now back to the role of stress in scarring alopecia. The cigarette is like the immune system and the dry weather is like stress. It is the aberrant immune system activation that causes the LPP just like the aberrantly disposed of cigarette causes the forest fire. The dry weather makes the fire flare when it might otherwise have just extinguished itself just liek stress causes the LPP to flare when it might otherwise have just stayed quiet.

Stress can contribute to a scarring alopecia becoming more active and contribute to flares but probably is not an underlying cause. In my experience, some conditions (like frontal fibrosing alopecia) seem to have a greater contribution from stress than other conditions (like folliculitis decalvans) The exact reason for this is not clear.

Articles of Interest

Interested Readers may wish to see previous articles by Dr. Donovan

Why is My Scarring Alopecia Flaring Again?

What Causes Scarring Alopecias Like LPP to Reactivate?


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
Share This
No Comments

PRP for LPP: Perhaps Rethink the Plan

Platelet rich plasma (PRP) for LPP: Is it an option?

Does PRP help lichen planopilaris and other scarring alopecias? Maybe sometimes.. Does it help the disease alot? Rarely. Is is a good option for starting treatment for someone with LPP? No, it’s not.

That’s the jist of what really needs to be said and that’s where this article could end. But I won’t let it end there. In the present day, PRP is popular. If people are looking for a popular treatment, I say go for it. it If they are looking for a treatment that helps stop a disease and is effective, I’d say have seat and let’s chat. Popular vs effective - the choice is up to the patient.

To say that PRP is a consistently effective treatment for scarring alopecia is nonsense. In fact, even with the most potent of drugs we don’t always shut down this disease. Of course, we win a good amount of the time in treating scarring alopecia but not nearly enough.

PRP is popular nowadays because it is fairly safe (there are side effects of course that one needs to know about). Yes, it’s that patient’s own blood. Yes, it’s not a drug. Yes, it’s natural. I agree with all these points. Do I agree that it stops scarring alopecia on a consistent basis? No way. How do I know? I treat a lot of patients with scarring alopecia over the years and I have treated lot of patients with PRP over the years. But more importantly I have treated a good number of patients with scarring alopecia PLUS PRP over the years and never found it to really help that much.

The most effective treatments for lichen planopilaris are treatments that are found in the following list: hydroxychloroquine (Plaquenil), doxycycline, methotrexate, cyclosporine, topical steroids, steroid injections, tacrolimus, mycophonolate, isotretinoin, tofacitinib. Treatments like low level laser may also help a bit.

The most effective treatments for frontal fibrosing alopecia are treatments that are found in the following list: antiandrogens, isotretinoin hydroxychloroquine (Plaquenil), doxycycline, methotrexate, cyclosporine, topical steroids, steroid injections, tacrolimus, mycophonolate.

Conclusion.

When a patients says to me - “I want PRP for treating my disease” I say to them the following:

IF PRP treatment is something you want for treating your LPP, I will leave the ultimate decision to you. If you can answer the following 3 simple questions for me, you may in fact be a good candidate for considering PRP. If you answer no to any of the following, I would urge you to please rethink the plan:

QUESTION 1: Can you say out loud at least 5 types of medications that are typically used to treat your type of scarring alopecia? Yes or No.

QUESTION 2: Do you take photos of your scalp (or does somebody take photos) consistently every 3-6 months? Yes or No.

QUESTION 3: Do you understand that PRP may be required every few months for life and that it is not a one time treatment? Yes or No.

If a patient answers yes to ALL of these three questions, there is a good chance they have the background understanding that puts them in a position to make an informed decision about PRP for treating their scarring alopecia. Of course, I’d also like the patient to be able to state in question 1 how well the treatment is expected to work (i.e. percent of patients they are expeccted to help) but these 3 questions are pretty good screening questions.

IF a patient can not answer ‘yes’ to these three questions or answers no to even one of them, I would say to the patient - perhaps rethink the plan (PRP).


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
Share This
No Comments

Dexamethasone Pulsed Therapy for Alopecia Areata in Children Under 12

Oral Dexamethasone Pulsed Therapy for Alopecia Areata in Children

There are over 25 treatment options for alopecia areata. Generally speaking, topical steroids, steroid injections and minoxidil are important therapies for patchy alopecia areata (early staged disease). This is by far the most common type of alopecia areata and so these three treatments are among the most useful.

For patients with more extensive and progressive alpecia areata, a variety of treatment options can be considered including oral steroids (dexamethasone, prednisone, prednisolone), and oral immunosuppressants such as methotrexate, tofacitinib, ruxolitinib, sulfasalazine. Topical irritant and allergic therapies such as anthralin, diphencyprone and squaric acid are also important parts of the treatment ladder.

Treatment of Alopecia Areata in Children

The principles of treating alopecia areata in children is similar to treating alopecia in adults. One wants treatments that work really well and at the same time are really safe, affordable and easy to administer.

See previous article: The S.A.F.E. Principle for Treating Hair Loss

In my practice, treatment of alopecia areata in children under the age of 12 involves use of 8 main treatments. Four of them are topical and include topical steroids, minoxidil, anthralin and diphencyprone (or squaric acid). Three of them are oral treatments and include oral methotrexate, oral oral steroids, and the JAK inhibitors. The last one is neither topical nor oral - and simply involves what I call “active observation:” (or what some might call doing nothing). Many children and adults with alopecia areata regrow spontaneously so treatment is not always necessary.

Oral Dexamethasone in Alopecia Areata

Dexamethasone is an oral steroid that may be helpful in some cases of rapidly progressing alopecia areata. It has been studied in children with various medical conditions for well over 30 years. Because of the long half life of dexamethasone compared to prednisone (54 hours vs 1-2 hours), the option exists to use dexamethasone less frequently in so called “pulses” rather than daily as in the use of prednisone.

One of the important studies of dexamethasone use for treating alopecai areata was a 1999 study by Sharma and Gupta. They studied 30 patients with alopecica areata including a mix of adults and chilfren. 3 patients in the study were children under 12 and were treated with dexamethasone on two day of the week at doses of 2.5 to 3.5 mg.

Sharma’s study showed that patients who received treatment for the minimum 12 week study period had excellent growth in 63.3 % of patients. 20 % of patients had no growth. It took an average of 5 months to get to the stage of excellent regrowth indicating that the regrowth can take time in these more challenging cases. Relapse was observed in two patients after 3 and 6 months but hair did regrow with treatment. About 25 % of patients had side effects of some kind but these were generally mild.

Other studies of dexamethasone use in adults have been conducted more recently. Vano-Galvan and colleagues from Spain conducted a nice study in 2016 reviewing dexamethasone use in 31 adults with alopecia totalis (n=9) and alopecia universalis (n=22). The dose used in treatment was 0.1 mg per kg per day for the two days of the week. About 80 % of patients had some type of response and 71 % had a complete response. The mean time to see any type of hair growth happpening was about 1.5 months. Side effects were observed in 31 % of patients including weight gain, Cushing-like phenomena, striae and irritability.

Conclusion and Summary

Pulsed therapy with oral steroids is an option for children with alopecia areata. When one is deciding about which oral steroid to use, options for both prednisone and dexamethasone need to be considered. The long half life of dexamethasone and option for twice weekly dosing makes it a useful option. I generally prescribe dexamethasone on Saturday and Sundays to make it easy to parents to remember. The dose in children is according to weight but generally 2-4 mg of dexamethasone on Saturday and 2-4 mg of dexamethasone on Sunday is quite common. Because the dose is 0.1 mg per kg, it’s quite easy to calculate the appropriate dose - a 20 kg child would receive 2 mg each day of the weekend and a 30 kg child would receive 3 mg on each day of the weekend and a 40 kg child would receive 4 mg on each day of the weekend. Dexamethasone is given with calcium and vitamin D to protect bone mass. Side effects seen in children are generally mild but one must monitor for side effects carefully include irritability, weight gain, blood pressure changes. Long term use is generally discouraged and the goal of dexamethasone therapy is to help reset the immune system in some way so that minoxidil and topical steroids can once again become the mainstay of therapy for the child.

References

Sharma VK and Gupta S. Twice weekly 5 mg dexamethasone oral pulse in the treatment of extensive alopecia areata. J Dermatol 1999; 26: 562-5.

Vañó-Galván S et al. Pulse corticosteroid therapy with oral dexamethasone for the treatment of adult alopecia totalis and universalis. J Am Acad Dermatol. 2016 May;74(5):1005-7.

Spano F and Donovan JC. Alopecia areata: Part 1: pathogenesis, diagnosis, and prognosis. Can Fam Physician. 2015 Sep;61(9):751-5. Review.

Spano F and Donovan JC. Alopecia areata: Part 2: treatment. Can Fam Physician. 2015 Sep;61(9):757-61. Review.



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
Share This
No Comments

Taking Iron Supplements: What's the best way anyway?

Alternate Day Iron May be Most Effective

Many hair loss patients with low serum ferritin are advised to increase their iron intake. The most common means of doing so is through oral iron supplements. The ideal way of taking supplements continues to be researched. New research supports the notion that taking iron supplements every other day (alternate days) may be a better way to get iron into the body.

The whole reason why researchers began studying how best to take iron is because iron intake triggers the body’s liver to make a protein called “hepcidin” and this hepcidin protein in turn blocks iron absorption from the gut. It seems the body has a fascinating built in mechanism to help prevent too much iron getting into the body.

New research suggests that taking iron supplements on alternate days may be equally effective if not more effective way for patients with low ferritin to address their low iron stores

New research suggests that taking iron supplements on alternate days may be equally effective if not more effective way for patients with low ferritin to address their low iron stores


A recent study set out to determine if iron absorption is better when iron supplements are given on consecutive days vs giving them on alternate days as well as to determine whether iron absorption is better when pills are given as single morning doses or better when doses are split with half in the morning and half in the evening.

In order to answer these questions, researchers performed two prospective, open-label, randomised controlled trials assessing iron absorption using special isotope labelled iron in iron-depleted (defined as serum ferritin less than 25 μg/L) women aged 18–40. In the first study, women were randomly assigned to two groups. One group was given 60 mg iron in the morning on consecutive days for 14 days, and the other group was given the same doses on alternate days for twice as long - 28 days. In the second study, women were assigned to two groups. One group was given 120 mg iron in the morning and the other was given 60 mg in the morning and 60 mg in the afternoon for three consecutive days.


For study 1, 40 women were enrolled. 21 women received daily iron and 19 received iron every other day. At the end of treatment (14 days for the consecutive-day group and 28 days for the alternate-day group), cumulative total iron absorption was 131 mg in the daily group compared to 175 mg in the every other day group. Serum hepcidin levels were greater in the consecutive-day group than the alternate-day group (p=0·0031). In study 2, 20 women were enrolled. Ten women received once-daily dosing and 10 received twice-daily divided dosing. There were no significant differences seen in total iron absorption between the two dosing regimens. However twice-daily divided doses resulted in a higher serum hepcidin concentration than once-daily dosing (p=0·013).


Conclusion and Summary


The study was interesting and supports a notion that prescribing iron on an every other day basis such as Monday, Wednesday and Friday mornings might be ideal. These strategies may limit the body’s production of hepcidin and facilitate iron absorption. These strategies may also limit the gastrointestinal side effects that can happen with iron supplements.


Reference

Stoffel NU et al. Iron absorption from oral iron supplements given on consecutive versus alternate days and as single morning doses versus twice-daily split dosing in iron-depleted women: two open-label, randomised controlled trials. Randomized controlled trial. Lancet Haematol. 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
Share This
No Comments

Blogs by Topic





Share This
-->