Hair Blogs


Hair Loss: Which blood tests should be ordered ?

Blood tests for Hair Loss: Some tests are simply wasteful

CW

There are literally dozens and dozens of blood tests that one could order for a patient with hair loss. Which ones should we order? Which ones are likely a "waste"? I enjoyed this article in the Medical Post about a newer organization in Canada called Choosing Wisely which serves to help clinicians become more aware of what tests are unnecessary.

In the world of hair loss, this concept is important. Is ordering a reverse T3 likely to add much in a patient with normal TSH? Probably not. What about an ANA level in a very healthy male with patterned hair loss - is that helpful? Probably not at all. What about ordering a transferrin saturation in patient with a ferritin of 76? Seems wasteful.

There are times when an ANA, reverse T3 and transferrin saturation are important and it is important to know when to order various tests and when not to! If one is not likely to change management of the patient if a test comes back, normal or abnormal then it makes little sense to order the test.



The Basic Tests

Basic tests in hair loss include CBC, TSH, ferritin, 25 hydroxyvitamin D and possibly extended to include zinc. Rarely hormonal tests and ANA are included but not routinely. Additional tests are really ordered on a case by case basis. For a list of tests I recommend see the following link

Basic Hair Loss Blood Tests

 

 


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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Treating Frontal fibrosing Alopecia (FFA): Are retinoids better than finasteride?

Retinoids in FFA Treatment

FFA 102

Frontal fibrosing alopecia ("FFA") is an autoimmune disease that mostly affects women. It is classified as a "scarring" hair loss condition and hair loss is often permanent for many women. A variety of treatments are available including topical steroids, topical calcineurin inhibitors, steroid injections as well as oral treatments like finasteride, doxycycline, hydroxychloroquine and isotretinoin.

A new study from Poland set out to compare benefits of finasteride and "retinoids" (isotretinoin and acitretin) in women with FFA. The study included 29 women who were treated with a dose of 20 mg isotretinoin, 11 women treated with 20 mg acitretin and 14 treated with oral finasteride at a dose of 5 mg/daily.  Interestingly, 76% of patients treated with isotretinoin, 73% of patients treated with acitretin, and 43% of patients treated with finasteride had their disease halted over a 12 month observation period. 

 

Comments

This study is small and should be interpreted with caution for this reason. Nevertheless it is interesting and points to a potentially valuable role for retinoids that we really don't seem to see with classic lichen planopilaris (a closely related condition). The data in this present study however do not match other much larger studies of finasteride use in FFA which have suggested that a much higher proportion of FFA benefitted from use of this drug.

For now, this study provides us with evidence that retinoids can benefit some patients and should be at considered. Many women with FFA do have a tendency for increased cholesterol levels and the use of retinoids can significantly worsen this so caution and monitoring are needed.


Reference

Rakowska A, et al. Efficacy of Isotretinoin and Acitretin in Treatment of Frontal Fibrosing Alopecia: Retrospective Analysis of 54 Cases. J Drugs 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 Vancouver office at 604.283.9299
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Do I have Frontal Fibrosing Alopecia?

Do I have FFA or not?

FFA of the frontal hairline. 

FFA of the frontal hairline. 

Frontal fibrosing alopecia is increasingly common. It's still a relatively rare condition overall but there is no doubt that the number of women being diagnosed is increasing. On account of the increase individuals in the general public are much more aware of this otherwise uncommon diagnosis. Patients often want to know if they have this condition. The short answer is that anyone wondering if they have FFA really should see a dermatologist for a comprehensive review and examination of the scalp. 

I enjoy helping patients understand why they do or do not have FFA. Many patients are convinced they have FFA when they clearly do not.  The following are some pieces of information that patients frequently feel points to a diagnosis of FFA when it fact it does not. Following this, I have outlined 5 pieces of information that actually is helpful (and increases the odds somewhat that a true diagnosis of FFA could be present). Exceptions of course exist and nothing replaces an in person review for an up close examination.

 

5 PATIENT COMMENTS THAT ARE NOT HELPFUL IN DIAGNOSING FFA

In my experience with countless numbers of patients who think they have FFA (but don't).... the following pieces of information are not helpful to making the diagnosis even though patients may think that it is!

Comment 1: "My hairline is changing"

Why is it not helpful? Hairlines change for many reasons including androgenetic alopecia, traction alopecia, alopecia areata and telogen effluvium. Frontal fibrosing alopecia is certainly on that list but there are too many reasons for frontal hairloss to make the observation of hairline changes a key feature for diagnosing FFA. A patient with hairline changes could have FFA but could have other conditions too.

 

Comment 2: "I see 'lonely' hairs"

Not everyone knows what a lonely hair is. But a patient who understand what is meant by a "lonely hair" has generally done a lot of reading and are extremely knowledgeable about hair loss! The reality however is that most "lonely hairs" that most people find in the scalp are not what really constitutes the gist of what these hairs are all about. My feeling is that the presence of more than 6 hairs across the frontal hairline at a distance of greater than 1.5 cm from the main hairline probably does in fact raise suspicion for true 'lonely hair' phenomenon.

 

Comment 3: "I have redness and scarring in my scalp" 

Redness alone does not constitute a diagnosis of FFA. In fact, FFA tends to be more pinkish and subtly red than overtly red. There are simply too many scalp conditions that cause redness to give this observation any significance.

I'm always concerned when patients feel they can "see scarring" because one can't truly see scar tissue as it is mostly under the scalp. In advanced scarring alopecia, one certainly can see evidence of scarring but these cases are usually fairly advanced. In all fairness, one can however see scalp color changes (mostly to a white color) that would suggest the presence of scarring. However, one can't actually see scarring.

 

Comment 4: "I now have so many baby hairs"

Baby hairs are not really a feature of FFA. In fact, the presence of baby hairs probably argues against the diagnosis of FFA for most patients than actually favours the diagnosis. This is because FFA tends to be a destructive process that involves the preferential destruction of baby hairs (medically termed vellus hairs). The presence of abundant baby hairs is not a feature of progressive FFA.

 

Comment 5: "I have no family history of balding so it only makes sense something else is going on"

The argument that an individual must have some other diagnosis other than genetic hair loss on account of the lack of genetic hair loss in the family is never a valid argument. There are women who come to be diagnosed with androgenetic alopecia despite a family history of men and women with thick hair. The patient's account of her family history is not very relevant to most diagnoses of hair loss. Sounds strange but this is true: I frequently diagnose androgenetic alopecia in women who stated their family is comprised of individuals with 'good hair.'

 

TOP 5 FINDINGS AND COMMENTS THAT ARE HELPFUL IN DIAGNOSING FFA

Nothing can substitute for a careful review of one's story and examination of their scalp with dermoscopy. The following pieces of information are helpful when considering a diagnosis. Not all patients have the following features, but they greatly increase the odds that what we are dealing with is FFA.

FINDING 1. Both sideburns are lost (above the ears). Not thinned but lost. The regions below where the spectacle of the glasses sit has been depleted of hairs.

Loss of the hair frim both sideburns is actually quite an important piece of information when it comes to diagnosing FFA.  This finding is mot present in everyone with FFA but is quite common if one looks.

 

FINDING 2. Baby hairs are not seen in the frontal hairline but rather many single long hairs are seen. Not all the hairs have redness around them but many do have a faint redness

FFA is a process that destroys fine vellus hairs - but it does so with inflammation. The presence of small amount of inflammation (usually without symptoms) is a key finding.

 

FINDING 3. If the eyebrows are lost, they are significantly changed

Eyebrow loss is common in FFA and in a large number of individuals with FFA, they are the first finding. Eyebrow loss of course does not happen in all women with FFA and loss of eyebrows may even come after the loss of the frontal hair. However, significant eyebrow loss requiring tattooing, microblading does raise the odds a bit that the presentation fits with possible FFA.  Still, one needs a careful examination before concluding that anyone's eyebrow loss is FFA. Nevertheless, changes in the eyebrows are common to FFA.

 

FINDING 4. The patient is between 46 and 66

FFA is rare in the 20s and 30s. That's not to say it can't occur as we have patients in their teenage years affected. However, from a statistical point of view, women under 40 who come in with worries that they have FFA actually rarely end up having FFA. There are exceptions of course but it is not a common occurrence. In our clinic, 98 % of patients who receive a diagnosis of FFA are older than 46.

 

FINDING 5. Veins are seen much easier on the scalp than before and the skin itself just does not look quite normal.

FFA is a complex condition and is probably more than just a 'hair disease'.  It's likely a complex autoimmune disease that affects hair predominantly but also affects the skin as well The skin itself changes in FFA - and does so by thinning. We call this "atrophy." Some women with FFA have minimal to no atrophy but many have significant atrophy which leads to the veins becoming much more visible. Generally, the skin in the area of the hairline does not look the same as the skin of the forehead - the affected area in FFA is lighter in color and smooth.

 

CONCLUSION

Frontal fibrosing alopecia is a complex condition. There is no 'one way' that it appears. There are 100s of different combinations. Navigating the diagnosis oneself is frequently met with challenging. I've summarized here 5 points that patients place a great deal of emphasis on when looking at their hair - but actually don't carry all that much weight when making the diagnosis. 

 


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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Medication induced hair loss

Does Drug Induced Hair Loss Eventually Stop ?

If a patient's hair loss is truly from a medication the hair shedding is likely to continue while the medication is present. If the hair loss does not actually have anything to do with the medication and the timing is coincidental, anything is possible... including an improvement, worsening or continued same-rate shedding.

Hair loss from medications is complex. They have different mechanisms causing the loss and not just one. Some are true telogen effluviums, some are toxic responses and some are hormonal. Some are immune-based. Growth promoters like minoxidil and low level laser therapy are often considered for hair loss due to the true effluviums but is often ineffective or results suboptimal. If hair loss is due to hormone based mechanism, then anti-hormonal treatments may help. If immune-based, then immune modulators may help.

 

Blogs on Drug Induced Hair Loss

For further review see previous blogs

Drugs and Hair Loss: Is it common?

Drug Induced Hair Color Changes

Drug Induced Hair Loss: A Closer Look at Amphetamines

Hair Loss from Chemotherapeutic Drugs: Does it always grow back fully?

 

 

 

 

 


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 without Shedding: Where did it go?

Hair loss without shedding:  

Hair loss that occurs slowly over time without the patient noticing an increase in daily shedding is a special situation. 

Some hair loss conditions are associated with significant and sometimes rapid reduction in hair density without a noticeable increase in shedding. Examples include female pattern hair loss, many scarring alopecias (pseudopelade, lichen planopilaris, frontal fibrosing alopecia, as well as subclinical shedding disorders. Trichotillomania should also be included on this list. However, the list expands greatly if the individual shampoos frequently (ie daily). In that case the list of causes also includes many of the effluviums (ie telogen effluvium), as well as alopecia areata. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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WHAT IS THE MOST EFFECTIVE TREATMENT OF ALOPECIA AREATA ?

What is the most effective treatment for a single patch of alopecia areata? 
 

Regrowth, AA inj.png

This is a common question. Corticosteroid ("Steroid") injections remain one of the most consistently effective treatment for so called "patchy" alopecia areata. This involves use of tiny 30 gauge needles connected to a syringe to adminster liquid steroid medications into the skin so that the medication can bathe the hair follicles. Despite the worry and concern, steroid injections when used in low quantity are relatively safe and side effects are uncommon. A small dimple or identation in the scalp can sometimes occur but this is temporary. Thinning of the skin does not occur with a single injection. The most commonly used corticosteroid for injection is known as triamcinolone acetonide (Kenalog) although other steroids may be used too. 
This photo shows significant hair regrowth in a patch alopecia areata about 4 months after injection. 


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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Is Low Level Laser Therapy (LLLT) Helpful For Treating Hair Loss?

Is LLLT Helpful For Treating Hair Loss?

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Is low level laser therapy (LLLT) helpful for treating hair loss? To date there has been a number of studies that suggest LLLT is helpful including 5 randomized double blind studies - 2 studies with so called "laser brush/comb" devices and 3 studies with helmet/cap devices.

The photo here shows a LaserCap. This LLLT device consists of 224 ‘pure’ laser diodes (no LEDs) of 650nm/5mW each. The device is worn every second day for 30 minutes. Several hemet/cap devices now exist and are marketed as FDA cleared LLLT devices.
 


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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How Many Genes Are Involved in Male Pattern Balding?

How many genes control whether an individual develops balding?

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Studies by Hagenaars et al in 2017 showed that male balding is actually more complex than we ever imagined. The researchers identified 287 genetic regions that are linked to male pattern balding (androgenetic alopecia). This data came from studies of over 52,000 men.

Reference

Hagenaars et al. PLoS Genetics 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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The Card Test For Darker Hair Colours.

Card Test For Darker Hair Colours.

Dark Card Test.png

The contrasting hair card tests for darker hair colors. The use of a piece of paper of contrasting color to the hair is an excellent means to evaluate recent changes in hair growth. Here, a white paper is placed behind dark brown hair. In this patient we can see thay signficant growth has occured in the last 3-4 months. This immediately informs me that either a massive telogen shed occured 4 months ago or a growth promoting agent was started 4 months ago. In this case it helped pinpoint regrowth from use of minoxidil.


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

Card Test For Lighter Hair Colours.

The contrasting hair card tests for lighter hair colors. The use of a piece of paper of contrasting color to the hair is an excellent means to evaluate recent changes in hair growth. For example, in this patient with blond hair we can see thay signficant growth has occured in the last 3-4 months. This immediately informs me that either a massive telogen shed occured 4 months ago or a growth promoting agent was started 4 months ago. In this case it helped pinpoint the precise timing of a telogen effluvium due to surgery.
 

Card test.jpg

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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Saw Palmetto: What are the side effects?

Saw Palmetto Side Effects

Saw palmetto (serenoa repens) is a natural herbal-based product commonly used for prostate problems in men and hair loss in men and women. 

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A number of studies have suggested that saw palmetto can help hair loss. These studies are small and few in number. Nevertheless, countless numbers of patients turn to these natural products. Furthermore, because they are natural, most assume they are without side effects. The side effect profile of saw palmetto is not entirely clear. It is however known that saw palmetto affects hormones in the body, and risks of mood changes like depression and sexual dysfunction may be real (albeit low) risk.

A recent report provided additional evidence that this natural product might best be classified among chemicals and molecules that affect the hormone and endocrine system of the body (so called "endocrine disruptors"). A 2015 paper from Italy reported development of hot flashes in a 10-year-old girl using saw palmetto. When she stopped treatment, the hot flashes stopped. When she started back up again ("ie a rechallenge'), the hot flashes returned. However, 4 months after starting saw palmetto, the 10 year old got her first menstrual cycle. 

This report reminds us that use of saw palmetto requires counselling of at least the low possibility of side effects. I advise my own patients of the generally well tolerated nature of saw palmetto but remind them of possible risks of mood changes and even the rare possibilities of sexual side effects. More studies are needed to not only document the successes of saw palmetto in medicine but the incidence of side effects.
 

Reference

Morabito et al. Pharmacology 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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Will a scalp biopsy site be immediately visible to others?

Will a scalp biopsy site be immediately visible to others?

BX Scalp.jpg

Scalp biopsies are extremely important when performed in the right patient. They can help exclude a variety of causes of hair loss - especially various inflammatory and scarring alopecias. The procedure is a brief 5-10 minute procedure done with local freezing (anesthesia). A stitch is placed in the scalp at the end. For most patients the stitch will not be noticeable to others especially if the sample is taken in an area where neighboring hair can help cover it. If a biopsy is taken from an area which is rather devoid of hair, the stitches may be visible to others for a few weeks.

This photo shows the scalp of a patient who has just finished a biopsy. The area is quite hidden. As the patient leaves the office, nobody would know a biopsy had been performed. The patient can even return to work. Stitches here are dissolving stitches. After a few weeks the area will heal with a small scar. But that scar too should be relatively hidden by neighboring hair.
 


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 dye for patients with LPP: Any Problems?

Hair dye for patients with LPP: Any Problems?

I am frequently asked if patients with lichen planopilaris (LPP) and similar scarring alopecias can dye their hair?For most people with scarring alopecia the use of permament, semipermanent or temporary hair dyes is completely safe. I always advise that patients review with their dermatologist if they feel any change in their scalps whatsoever following the salon visit or home application. Any marked change in scalp itching, burning or even new tenderness in the scalp would cause concern but fortunately this is extremely rare. 

For my patients with minor irritation from hair dye application, I sometimes recommend use of an anti-inflammatory cortisone shampoo (ie clobetasol proprionate (Clobex) shampoo) 1-24 hours before the dye is applied. Some of my patients even bring the shampoo to the salon and have the stylist use and wash it out let the normal instructions. 

All in all, most individuals with LPP don't experience any difficulties with hair dyes and no special precautions are needed.


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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Do all males bald in the same way? 

Do all males bald in the same way? 

male balding.jpg

The answer to that is no. Most men whonare going to bald first notice changes in the temples and/or crown and then ultimately bald according to the so called "Hamilton Norwood" scale. However this male shown in the photo has a pattern of balding that does not match up to any of the Hamilton Norwood patterns. He has what is known as a "female" pattern of male balding where the central scalp is involved first and the frontal hairline is relatively unaffected. This pattern of androgenetic hair loss is common in women and affects about 10-13 % of males.
 


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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Scalp alopecia in men with beard alopecia: What are the risks?

Scalp alopecia in men with beard alopecia

AA Beard photo.jpg

Alopecia areata is a relative common autoimmune condition affecting up to 2 % of the world. Beard and facial alopecia is particularly concerning to many men as it can be challenging to camouflage. A frequent question from patients with beard alopecia areata is "how likely is it that I will eventually develop patches on my scalp?" Another wonderful multicentre study from Spain helped answer that question. The researchers studied 55 men with beard alopecia and followed them for at least one year. In the study, 45 % of males developed scalp alopecia over the follow up period. Most who did develop AA (80%) did so in the first 12 months. The conclusion from the study was that a significant proportion of males with beard AA do in fact develop patches of scalp AA warranting long term follow up for these patients.

Reference
Saceda-Corralo D, et al. Beard alopecia areata: a multicentre review of 55 patients. J Eur Acad Dermatol Venereol. 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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Does stress accelerate balding?

There is not a lot of great medical evidence to support the notion that stress directly impacts MPB.  However, it probably has a minor role and only in some men and women with the right genetic background. Of course, we don't understand yet what that genetic background is at present.

When one examines studies of identical twins, one sees that 92% actually still look identical (same level of hair loss) years and years down the road. If stress, diet, and environmental factors played a huge role, one would not expect this number to be so high.

But for some males and females, it is likely that stress accelerates balding to a minor degree. A study by Gatherwright in 2013 suggested that higher stress could lead to worsening hair loss in the crown in men.  For women, a 2012 study suggested that higher stress was correlated with worse hair loss in the frontal area and divorce and separation were correlated with worsening hair loss in the temples.

Conclusion

Stress probably accelerates the rate of progression of balding in some individuals who have the right genetic predisposition.   We know that stress can cause an increased amount of daily shedding and such shedding can accelerate follicular miniaturization. It makes sense that stress can accelerate the balding process in some individuals. However, it's not likely to be a consistent phenomenon amongst all individuals.  

Reference

The contribution of endogenous and exogenous factors to male alopecia: a study of identical twins.

Gatherwright J, et al. Plast Reconstr Surg. 2013.

The contribution of endogenous and exogenous factors to female alopecia: a study of identical twins.

Gatherwright J, et al. Plast Reconstr Surg. 2012.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Things to Consider when Latisse won't work

Latisse is an FDA approved and Health Canada approved treatment for improving eyelash length, thickness and darkness in patients with eyelash hypotrichosis (not enough eyelashes). Latisse contains the ingredient bimatoprost.

Clinical studies have shown that Latisse is very effective for many user. Many notice changes as early as 4 weeks and 50 % have changes by the second month.  By 16 weeks, 80 % will have an improvement.

Latisse Non-Responders: When Latisse just doesn't work

Latisse is effective for many individuals. However, about 1 out of every 5 users is not going to find that the medication worked all that well for them.  A large proportion of the patients I see in my office come to see me wanting to know why Latisse did not work as good as the advertising stated it should. 

Let's review some of the reasons for poor results.

1. The patient is simply in the "20 % group."

Latisse does not help everyone. By 16 weeks, 80 % will be pleased with the money they spent. 20 % won't. I tell my patients that someone has to be in the "80 % group" and someone has to be in the "20 % group." Not everyone responds to Latisse

2. The bottle does not contain bimatoprost and so it is not Latisse

Latisse is available through physician's offices (and some drug stores), but there are many other ways of obtaining Latisse and products that claim to be Latisse. I encourage readers to simply enter phrases such as "buy Latisse online" in their Google search engine to see the array of possibilities. Most of these sites will ultimately lead to a box of Latisse (containing the true ingredient bimatoprost) showing up at the door.  But not all.  Patients need to keep in mind the possibility of counterfeit products. It's rare but most certainly does happen.

3. The method of application is wrong

One needs to apply Latisse nightly to the lower eyelid margin of the upper eyelid with the brushes provided. I can't tell you how many variations of this simple sentence there actually are. Like any drug, it needs to be used according to instructions.

4. The individual has a medical condition of the hair follicle.

It comes as a surprise to many individuals that there are well over 100 reasons for eyelash loss. Not all lash loss is simply due to "aging" or a "tainted bottle of mascara" that was used in the past or improper use of a heated eyelash curler. These certainly can cause temporary or even permanent lash loss. Rather a variety of inflammatory and autoimmune conditions are associated with eyelash loss. 

Eyelash Loss: What else?

A careful review of one's story (called the medical history) and up close examination of the eyelashes is needed to determine the cause. One must also examine the eyebrow and scalp hair at the same time as there is no other way to confidently come to the diagnosis.

Causes of eyelash loss include

1. Inflammatory and Autoimmune Conditions. Inflammation of the hair follicle can cause it to fall out. Alopecia areata, frontal fibrosing alopecia, Scleroderma/ en coupe de sabre and lupus are all potential causes.  A variety of true dermatological conditions can also cause lash loss including various eczemas, seborrheic dermatitis and psoriasis. In such cases it is scratching and rubbing that often leads to lash loss.

2. Trichotillomania. 3-5 % of the world will purposefully pull out one or more of their hair follicles somewhere on the body during their lifetime. When repeated, the diagnosis of trichotillomania needs to be considered. Plucking of the lashes is quite common and may even be one sided. 

3. Endocrine disorders. Isolated eyelash loss is uncommon in patients presenting with endocrine disorders. However, one needs to consider thyroid, parathyroid and pituitary disorders.

4. Infections. Infections with fungus, bacteria, viruses all have the potential to cause lash loss. Isolated lash loss is uncommon but can be seen with conditions such as leprosy and syphilis. 

5. Drugs. There are many drugs now implicated in lash loss ranging from cancer drugs to antidepressants (escitalopram) to diabetes medications (sitagliptin and metformin) to methylphenidate. Other drugs include blood thinners, cholesterol meds, propranolol, valproic acid. Even cocaine vapour can cause lash loss.

6.  Infiltrative Conditions. Eyelashes can fall out when cells enter the hair loss that normally don't reside there. Lymphomas are a good example. Eyelash loss can also occur with a variety of local tumors including basal cell carcinoma, squamous cell carcinomas, sebaceous carcinomas and many others.

7.  Nutritional Issues. Poor diets and specific deficiencies can all cause lash loss. This ranges from severe illness with marasmus, to deficiencies of protein, zinc and iron.

8. Congenital and genetic conditions. Many many genetic syndromes are associated with less than normal eyelash density. Well over 50 conditions fall in this category from KID syndrome, Rothmund Thompson syndrome, Incontinentia Pigmenti, Keratosis follicularis spinulosa decalvans, Progeria, Bloom syndrome, Menke's syndrome, Monilethrix to Trichothiodystrophy. Many many others are on this list as well.

Conclusion

There are many causes of eyelash loss. Not every cause of eyelash loss responds to Latisse.

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Can drugs cause or exacerbate seborrheic dermatitis?

Can drugs cause or exacerbate seborrheic dermatitis? 

Seborrheic dermatitis is red, scaly and sometimes itchy scalp and skin condition that closely resembles dandruff. The condition is extremely common and affects 5 % or more of the population.

There are a variety of well known factors that increase the risk of seborrheic dermatitis including depression, neurological conditions, alcoholism, stress, HIV/AIDS, organ transplantation and advanced age (over 60). 

Drugs are also potential causes of either worsening or inducing seborrheic dermatitis. The anti-cancer drugs are well known causes of seborrheic dermatitis like eruptions. Examples include dasatinib, gefitinib, sorafenib, sunitinib, vemurafenib, 5-FU, Erlotinib, cetuximab, IL-2, and interferon-α. I often advise a scalp biopsy in many of these cancer drug associated seborrheic dermatitis-like presentations as many are actually forms of scarring alopecia (ie EGFR inhibitors). 

Other drugs causing a seborrheic dermatitis-like eruption include griseofulvin, cimetidine, lithium, buspirone, haloperidol, lithium, methyldopa, gold, ethionamide, methoxsalen, methyldopa, phenothiazines, psoralens, stanozolol, and thiothixene.

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Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Seborrheic Dermatitis: What causes it and how can we treat it.

Seborrheic Dermatitis: What causes it and how do we treat it?

Seborrheic dermatitis is a red, scaly, skin and scalp condition that affects both children and adults. The condition is extremely common. Estimates suggest that up to 3-5 % of the world is affected by the condition. Infants can be affected by seborrheic dermatitis, and this is typically called 'cradle cap.' During pre-pubertal years the incidence of seborrheic dermatitis reduces significantly until it spikes again in adolescence. Adults can be affected and the incidence increases again in the 60s and 70s. 

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Seborrheic dermatitis is thought to be caused by a variety of factors. However, central to all these factors is the presence of a yeast known as Malassezia and some local or systemic alteration in the immune system. Malazzesia yeast are thought to help metabolize certain types of fats in the skin from non irritating to irritating and inflammatory fatty acids that cause inflammation. It's clear that getting rid of these yeast helps control the symptoms and signs of seborrheic dermatitis. Most individuals with seborrheic dermatitis have a healthy immune system. However, it's clear that there is some alteration in the skin immune system that prevents these individuals from eradicating the Malazzesia yeast. 

 

Risk Factors for Seborrheic Dermatitis

Some patients develop seborrheic dermatitis for no clear reason. These individuals likely have an underlying predisposition to the condition. However, it is now clear that there are a number of risk factors for seborrheic dermatitis, including neurological disease (Parkinson's disease, traumatic brain injury), depression, organ transplantation, HIV/AIDS, alcoholic pancreatitis, intense stress.

 

Signs and Symptoms of Seborrheic dermatitis

Seborrheic dermatitis can affect both the scalp and the skin. Patients may be completely asymptomatic or notice varying degrees of scalp itching, redress, flaking and scaling. The scalp may become greasy with patients feeling that more frequent shampooing just makes things feel better. The eyebrows can also be affected by redness and flaking. Many patients with seborrheic dermatitis have red flaky patches arund the nose, on the mid-chest and even back.

 

Treatment of Seborrheic Dermatitis

There is no cure for seborrheic dermatitis but there are treatments that can help reduce the frequency and severity of flares. In other words, appropriate treatment, can help make it appear that patients have minor disease or no disease at all. However, periodic use of anti-fungal and anti-inflammatory agents may be needed to keep the condition under control. 

 There are a variety of treatments of Seborrheic dermatitis. Eradicating the Malasezia yeast appears to be important in the treatment. For this reason, I generally recommend use of various anti-dandruff shampoos including those containing zinc pyrithione, selenium sulphide, ketoconazole, and ciclopirox. These should be left on the scalp for 1-5 minutes depending on the specific patient's scalp. Anti-dandruff shampoos can be drying, and so careful monitoring is needed to determine how best to use these for any given patent. 

A variety of natural products can also help seborrheic dermatitis. Tea tree oil is among the most helpful of the natural products and is available in a variety of shampoo formulations. 

Corticosteroids can sometimes be used but are generally not first line agents for most with mild cases of seborrheic dermatitis. However, use of corticosteroid shampoo (such as Clobex) or mild corticosteroid lotions (including periodic use of betamethasone valerate lotion of foam) during times of flares can help many to achieve remission and feel better. 

Oral agents including retinoids (isotretinoin) and oral anti-fungal agents (itraconazole) are reserved for more challenging cases of seborrheic dermatitis that is unresponsive to conventional treatments. 


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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Treatment of Male Balding: A closer look at the three tiers of options

Treatment of Male Balding

A variety of treatment options exist for males with balding, also known as androgenetic alopecia. I like to think of the options in terms of three tiers or categories of treatments. Tier 1 treatments have the best evidence and are consistently the most effective. Tier 3 treatments have the least evidence.

 

Tier 1 Treatments

Minoxidil and Finasteride are the two FDA approved treatments. Dutasteride is off label in North America but is also not uncommonly prescribed as well. These are among the most effective treatments and what I would term "tier 1" treatments. 

 

Tier 2 Treatments

Other treatments can also be considered including low level laser and platelet rich plasma. Meta-analyses support a benefit of these over placebo or sham treatments so they are not without at least potential benefit. These are what I term "tier 2" treatments. Other tier 2 treatments with less evidence but still reasonable likelihood of benefit include oral minoxidil and topical finasteride. These are not FDA approved and off label.

 

Tier 3 Treatments

Then we come to "tier 3" treatments. Some treatments in this group might help some males but not all and tesults may be inconsistent. Some tier 3 treatments could be helpful, it's just that not enough studies have been done. The public loves many "tier 3" treatments as they wrongly assume some are completely safe. Many tier 3 treatments simply have not been studied to any significant degree to render conclusions about safety. Lack of studies does not equate to them being safe.

This tier 3 group includes a variety of treatments purported to have a DHT blocking and anti-androgen type effect. There is biochemical evidence of this effect for some of the treatments and even a hint of clinical benefit for others. There is far less study of this group of agents which includes saw palmetto, pumpkin seed oil, ketoconazole shampoo, topical androgen receptor blockers. In the last category are many agents that can be bought on the internet and that I see in my office at least once per week. The evidence for a clinical benefit from these agents is weak at best.

This summarizes the three tiers of non surgical treatments that can be considered in males with balding. A number of exciting options are on the horizon and only careful study will determine if we ever see them in the clinical setting. This includes topical prostaglandin F2 analogues (bimatoprost), prostaglandin D2 inhibitors, Wnt pathway activators, JAK inhibitors and a variety of cell based therapies.

 

 


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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