Hair Blogs


Scarring Alopecia - LPP

Sea of single hairs in LPP

Lichen planopilaris is a scarring alopecia which destroys hair follicles. The result is permanent hair loss. Affected individuals with LPP often develop scalp symptoms like itching and burning and classical findings are often present when one examines the scalp.

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Typical findings of LPP include perifollicular scale (follicular hyperkeratosis), perifollicular erythema. and areas of scarring.  In other cases of LPP, the findings can be quite subtle. 15 % (to as high as 30 %) of patients with LPP in some studies have minimal symptoms so concerns about itching and burning are not present. 

Furthermore, in some patients with LPP, classic findings of perifollicular scale and redness may not be there. These photos shows two patients with lichen planopilaris with minimal findings except a reduction in hair density (ie hair loss), slight redness/pinkness in the scalp and a marked alteration in follicular architecture such that mostly single hairs are seen in the affected region.

s0s

While this can be seen in other conditions including genetic hair loss, it is an important finding to be aware of in (lymphocytic) scarring alopecias such as lichen planopilaris. I frequently refer to this finding as the "sea of singles".


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 Normal Blood Tests:

Can A Person Have Hair Loss Even Through Blood Tests Are Normal?

It comes as a surprise to many individuals experiencing hair loss that they could have hair loss despite normal blood tests. “I’ve had every test under the book and it all comes back normal- how can this be?”

Blood tests are important to perform in any patient with hair loss. Iron levels, thyroid abnormalities, hormonal abnormalities are all important to screen. Although abnormalities may be found, many patients have normal blood tests. And even when an abnormality is found - it does not always mean it is directly implicated in the patient’s hair loss. Examples of the later include a slightly low vitamin D level or borderline ferritin reading.

The reason blood tests do not highlight the cause of the hair loss in many patients is that an abnormality in the blood may not be the actual cause of patient’s hair loss. The abnormality lies in the scalp itself - and only a clinical examination can reveal the cause. Patients with many types of hair loss consider frequently have normal blood test results.

Some patients remain surprised that their blood tests are normal. Some have the tests repeated. Some have even more blood tests drawn. Some search for other testing to have done - perhaps a hair mineral analysis.

Further blood tests may reveal an abnormality. The problem however is that the tests that were ordered frequently have no bearing on the hair loss. Hair mineral analyses nearly always turn up some abnormality - its just that these tests are unreliable and frequently have no direct utility to hair loss.



Blood Tests and Androgenetic Alopecia (AGA)



Blood tests should typically be ordered in patients with suspected androgenetic alopecia. Testing for blood hemoglobin levels, iron, thyroid, B12, vitamin D should at least be considered in all patients. Hormone levels as well as other tests may also be considered but this is not appropriate in all patients. But many patients have normal results. However, one needs to keep in mind that results are frequently normal in patients with androgenetic alopecia.  Abnormalities in iron levels, zinc and thyroid should be corrected but such corrections do not always directly impact the hair loss. There is some evidence that correcting iron levels in patients with AGA on some types of treatments actually allows the treatments to work better.

Patients are often surprised that their hormone levels came back normal despite a diagnosis of androgenetic alopecia. 80-85 % of women with AGA have normal blood tests. Women with genetic hair loss who have irregular periods, acne, and increased hair on the face especially require hormone testing. However, even these patients have normal blood test results.



Blood Tests and Alopecia Areata (AA)


Testing for blood hemoglobin levels, iron, thyroid, B12, vitamin D should at least be considered in all patients with alopecia areata. Up to 10 -15 % of patient’s have thyroid abnormalities. Other tests may be important too - depending on the patient’s history. But many patients have normal results.

 


Blood Tests in Scarring (Cicatricial) Alopecia
 

Testing for blood hemoglobin levels, iron, thyroid, B12, vitamin D should at least be considered in all patients with scarring alopecia. For some scarring alopecias such as lichen planopilaris, it’s clear that the risk of thyroid disease is much higher than seen in the general population. Other tests may be important too - including ANA, zinc, ESR, B12, ENA but the exact tests to order depends on the patient’s history. But many patients with scarring alopecia have normal results.



Blood Tests in Telogen Effluvium


When it comes to telogen effluvium, there are hundreds of tests that can be ordered. A few “screening” tests are important for everyone with suspected telogen effluvium but the remainder of the tests to order depends on the patient’s history. Screening tests often include blood hemoglobin levels, iron, thyroid testing, B12, vitamin D, and zinc levels. Numerous other tests are also possible depending on the patient’s story including ANA, ENA, ESR, creatinine, AST, ALT, bilurubin, CRP, VDRL/RPA, Hepatitis screening, HIV, rheumatoid factor, urinalysis, free and total testosterone, DHEAS, AM cortisol, prolactin, etc, etc

Despite all the tests, many patients with telogen effluvium also have normal results.
 

 

Conclusion

One need not feel confused if their blood tests return back normal. This is common in patients with many types of hair loss. One should also not be confused if they work hard to correct an abnormality (like low iron) and find their hair has not improved. Hair loss is more complicated that this. The factory that produces hair lies in the scalp - not in the blood. We have limited tools in the present day to properly assess the inner workings of the tiny hair follicle and so now blood tests and other similar tests are the best we have. 


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 Psoriasis

scalppsoriasis.png

Scalp is common site of onset

Psoriasis is a common skin disease and affects 3% or more of the world’s population. A new impressively large study from China confirmed that the scalp is a common starting site of disease for many patients. 

This was a study of over 12,000 patients from 33 cities in China. The scalp was the most common site for psoriasis to start for 52.8 % of patients. The most important aggravation factor was season change (60.2%), followed by psychological stress (34.5%). Chen K et al. Clinic characteristics of psoriasis in China: a nationwide survey in over 12000 patients. Oncotarget. 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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In defence of the scalp biopsy: Reliable or not?

Are scalp biopsies accurate and reliable?

scalpbx

I’m increasingly asked if scalp biopsies are reliable. I don’t know why or how it has happened but somewhere and somehow out there in the great and vast entity known as the internet there has come to be a pervasive view that scalp biopsies are not so helpful and not so reliable. To some degree it almost seems that this view has now overtaken the polar and equally incorrect view that scalp biopsies are the “final answer” to all hair loss problems and everyone should have a scalp biopsy. Both of these extreme views are wrong and I’d like to give some clarity to the issue.

 

Reliable scalp biopsies are generally reliable

 

Scalp biopsies have the highest chance of being helpful if they are

1. Taken from the correct area of the scalp

2. Use of both vertical and horizontal sections is considered

3. The biopsy is interpreted by an expert dermatopathologist.

 

One often runs into problems in interpreting biopsies when:

1. The sample was taken from the wrong area on the scalp

2. The sample was not the correct size (i.e. not 4 mm punch)

3. The sample was sent for vertical sectioning only

4. The sample was sent “anywhere” for analysis 

5. The sample was read by a pathologist with less familiarity in hair and scalp pathology.

 

Examples

Here are some examples. To protect privacy, these examples are all fictional but certainly match up pretty close to countless numbers of patients seen over the years. They illustrate important points. 

 

Example 1.

An 50 year old woman with classic frontal fibrosing alopecia is seen in the office. She lost her eyebrows at age 46 followed by arms, leg and pubic hair. She has now has lost her frontal hairline. The dermatologist wishes to take a biopsy but is worried about scarring and leaving a permanent scar on the scalp. On account of this a biopsy is taken 1 cm back from the hairline. The biopsy is obtained with good technique and is proper size (4 mm). It is sent off to a world expert dermatopathologist. The pathological interpretation is “androgenetic alopecia with no evidence of frontal fibrosing alopecia.”

Take a look at the (hypothetical) report if her biopsy was taken from an area of redness and scale from the frontal hairline or side temple. The dermatologist took it from this site after explaining it was the best site but also explaining it could cause a permanent scar. The final pathological interpretation is “androgenetic alopecia with evidence of frontal fibrosing alopecia.

Same patient. Same dermatologist. Same pathologist. Different site. Different diagnosis. 

Surprised? 

Don’t be. Biopsies are important but they need to be taken from the right spot.  Are biospies accurate? Yes, fairly accurate if the right steps are taken from start to finish. Reliable biopsies are, in fact, fairly reliable. The above is a common scenario. Does this first biopsy mean the patient does not have FFA? Of course not. The biopsy means that the area where the biopsy was taken from does not contain FFA. 

As physicians we wish to limit side effects where possible. In fact, one of the oaths of our profession itself is to “do no harm.” We often want to take a biopsy from an area that will be hidden and from an area where a long term scar will be less visible. This is important to consider but if the site of the biopsy jeopardizes receiving proper interpretation of the patient’s condition, another spot should be chosen (or one should not do the biopsy).

 

Example 2.

A 33 year old male with classic male balding and seborrheic dermatitis comes to the office. His history includes anxiety and severe depression. His scalp is burning and he has itching from time to time. It sometimes even feels sore. The patient has read alot and wonders about the possibility of having a scarring alopecia. “Doctor, I have researched everything and I am certain I have lichen planopilaris.” The patient really wants a biopsy. The dermatologist says that he does not think it is a scarring alopecia but agrees to do a biopsy. The biopsy is taken from two areas - one for horizontal sections and one for vertical sections. It is sent off to a local clinic that knows where to send the result for pathology. It is read by a pathologist who is well respected for general knowledge in pathology. The biopsy report appears as follows:

4 mm samples submitted by Dr Carver with a note to “rule out scarring alopecia in this patient with severe itching burning and pain.” The biopsies are excellent. There is some miniaturization of hairs noted. There is a lymphocytic infiltrate in the upper dermis with perifollicular fibrosis noted. The findings are consistent with possible lichen planopilaris with coexistent androgenetic alopecia.”

This example above is all too common. The man in the example leaves the clinic with a diagnosis of scarring alopecia when in fact he does not have scarring alopecia. The man in the example now must cope with the diagnosis which further adds to his anxiety. Does he have lichen planopilaris? Well not in this example.

Take a look at the (hypothetical) report if his biopsy was sent to an expert dermatopathologist. This pathologist reads and interprets alot of scalp biopsies.

4 mm samples submitted by Dr Carver with a note to “rule out scarring alopecia in this patient with severe itching burning and pain.” The biopsies are excellent. There is some miniaturization of hairs noted. The terminal to vellus ratio is 2.8 to 1. There are 12 % telogen hairs noted. There is a lymphocytic infiltrate in the upper dermis with perifollicular fibrosis noted. However, there is no lichenoid change of the follicular epithelium and no necrosis. The epidermis is normal. Sebaceous glands are preserved and appear enlarged. The findings are consistent with androgenetic alopecia with no evidence of lichen planopilaris or scarring alopecia.”

Surprised?

Same patient. Same biopsy. Different pathologist. Different result. Are biospies accurate? Yes, fairly accurate if performed properly. Again, reliable biopsies are fairly reliable.

 

Example 3.

A 65 year old female with chronic shedding due to chronic telogen effluvium (CTE) comes in for an evaluation. In this example, her dermatologist suspects CTE but is not sure if it’s androgenetic alopecia. He’s confident it’s not a scarring alopecia but does a biopsy and submits it to the pathology lab for vertical sectioning. The pathologist’s report returns as follows.

The biopsy is an excellent biopsy extending to the subcutis. There is a decreased number of hairs. Sebaceous glands and preserved but not overly prominent. There is no inflammation around the bulb to suggest alopecia areata and no evidence of scarring alopecia. The epidermis is normal. The findings are consistent with a non scarring alopecia and clinic correlation is needed to distinguish entities such as androgenetic alopecia and chronic telogen effluvium. 

Here, the clinician and patient remain confused. The biopsy did not help.

Now consider the same 65 year old female but now when the dermatologist does a biopsy he does 2 samples of 4 mm size and submits it to the pathology lab for horizontal sectioning with the comment “please assess for CTE.” The pathologist’s report returns as follows.

"The biopsies are excellent biopsies and both extend to the subcutis. There are 37 hair follicles seen in the first biopsy with 17 % telogen hairs. 33 are terminal and 4 are vellus hairs. The terminal to vellus ratio is 8.25:1. Sebaceous glands and preserved but not overly prominent. There is no inflammation around the bulb to suggest alopecia areata and no evidence of scarring alopecia. The epidermis is normal. The second biopsy is similar with T:V ratios of 8.7:1. The findings are consistent with chronic telogen effluvium"

Surprised?

Same patient. Same pathologist. Different method of processing the sample. Different result. Are biospies accurate? Yes, fairly accurate if performed properly from A to Z. Reliable biopsies are fairly reliable.

 

Conclusion and Answers

The correct answer to the quiz is c. Option “a” is not correct. Scalp biopsies are not needed in everyone and really one needed if the diagnosis is in question or one os trying to decided between two diagnoses. Option “b” is also not correct. As we have seen in the post, reliable biopsies are actual fairly reliable. One can distinguish easily scarring from non scarring and determine of androgenetic alopecia is present much of the time if horizontal sections are used. One can often get a sense of telogen effluvium but the actual cause can’t be determined by biopsy (low iron, thyroid problem etc). That’s a clinical diagnosis- not a pathological one. 

The scalp biopsy can be very helpful but only if all the proper steps are taken including proper site, proper technique. It should never be forgotten that the dermatopathologist can also make a difference especially in more challenging cases. Hair and scalp dermatology can be challenging- and hair and scalp pathology can also be challenging. If all the proper steps are taken, the chances increase greatly that challenging cases can be ... solved.


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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Latisse and Benzalkonium Chloride

Can one be allergic?

Irritation happens from time to time in users of Latisse. It's not all that common but redness of the eyelid and even the eye can occur. Rarely a patient develops itching or rashes on the skin and asks "Could this be related?"

This is a complex question. Latisse contains bimatoprost as well as the preservative benzaalkonium chloride (BAC) at a concentration of 0.05 mg/mL. This preservative has been around since 1935. It is quite common in many products, especially those used around the eye. BAC is more likely to cause irritation than true allergy but certainly cases of allergic reactions can occur with BAC even serious ones. Studies at the Mayo clinic published in 2016 (see reference below) suggested that allergies to BAC might be increasing in the population. In fact, the allergen climbed up the list to now be one of their top 10 allergens they see in their clinic.

If a patient has a skin rash, it is far more likely that an allergy exists if the eyelids show some redness. If the eyelids look perfectly fine, it is much less common that the cause if the skin rash is related to Latisse use. But even without redness a systemic allergic response is still "possible". It's just much less likely. With these sorts of situations, I like to know the whole story (and see the rashes if they are present). I like to know if the patient uses products containing BAC in the past and if so, what types of reactions they had. It's a good idea to review the whole story with your physician. If it was only itching, one might (on the advice of the doctor) wait for the itching to go away completely and either try again or have a specialized physician test the product's allergic potential on the skin as a prick or patch test. However, if there was any runny nose, cough, chest tightness, wheezing, shortness of breath, dizziness, throat tightness, swollen tongue or eyelid swelling...one should should seek the advice of an allergist physician.

Overall, irritation from Latisse is much much more common than allergy. Nevertheless, if one is experiencing new or unusual type skin, mucosal or respiratory issues one must consider whether a true allergic response could be responsible

Reference

Wentworth, A et al. Benzalkonium Chloride: A Known Irritant and Novel Allergen. Dermatitis 2016.

 


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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Frontal Fibrosing Alopecia

Quieter than LPP?

ffa vs lpp.png

Frontal fibrosing alopecia (FFA) is said to be a subtype of Classic Lichen planopilaris (LPP). The two conditions have many features in common but also have many differences. LPP and FFA are nearly indintinguishable by scalp biopsy although biopsies from patients with FFA generally have less inflammation than biopsies from LPP. In addition, patients with FFA are frequently much more likely to be asymptomaric compared to patients with LPP. The scalp is less likely to be itchy, and less likle to be red. Because FFA is often so “quiet”, this can frequently delay the diagnisis - sometimes by many years for affected patients.

This photo show typical feaures of FFA. A large number of single hair follicles are seen. Occassional hairs have white scale around them (perifollicular scale, see arrow) and several follicles have redness around them as well (perifollicular redness). Treatments for FFA and LPP are very similar but not identical. Finasteride for example is more effective in FFA than LPP.
 

Reference

Poblet et al. Frontal fibrosing alopecia versus lichen planopilaris: a clinicopathological study.
Int J Dermatol. 2006.


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: Up close

Dermatoscopic (Trichoscopic) Features of Alopecia Areata

AA

Typical dermatoscopic findings in alopecia areata: 1) yellow dot 2) black dot 3) exclamation mark hair and 4) tapered 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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Scalp itching and burning: A closer look at Lyrica

A closer look at Lyrica

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Scalp dysesthesias are a group of conditions whereby affected patients have symptoms in the scalp such as burning and pain. Much to the surprise of the physician and even the patient- the scalp usually looks normal in this group of scalp conditions. I frequently perform a biopsy to ensure any other condition is not being missed.

It’s not clear how exactly these conditions develop. Some studies have suggested that disease in the upper spine (cervical spine) might play a role in some patients, but it’s not a mechanism that applies to everyone with scalp dysesthesia. Some patients have underlying depression and anxiety but again this is not relevant for everyone.

Most patients with scalp dysesthesia feel they have tried nearly every to stop their burning or pain. They have used topical steroids and various shampoos including a variety of anti-dandruff shampoos too. Nothing works.

A variety of options are available to treat scalp dysesthesias including oral and topical gabapentin, Lyrica (pregabalin), amitriptyline, capsaicin and topical ketamine, amitriptyline and lidocIne (TKAL). Lyrica is an anti-seizure medication which is also FDA approved for fibromyalgia, diabetic neuropathy and post herpetic neuralgia. It can benefit some patients with scalp dysesthesia and this is an off label use. It functions by reducing neurotransmitters in nerves such as substance P, glutamate and nortriptyline. When prescribed, I generally start slow with the dose even 50-75 mg a few times per week. 
More common side effects include dizziness and drowsiness. Less common side effects includes visual problems, tremor, fatigue, dry mouth, constipation, weight gain.


Reference

Women with scalp dysesthesia treated with pregabalin.
Sarifakioglu E, et al. Int 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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Treatment of Androgenetic Alopecia During Pregnancy

Treating AGA in Pregnancy:

Most treatments for AGA are either not safe or not recommended during pregnancy. This includes minoxidil, anti androgens, various supplements, over the counter products and topical agents. The cardinal rule of treating any conditions during pregnancy or using any treatment during pregnancy is simple: ask a physician. 

 

Low Level Laser: Generally Safe for Most

 Low level laser treatments (LLLT) are the only safe treatments during pregnancy for women with AGA. This applies to most of the standard at home devices. Everything else needs stopping and some treatments need stopping well in advance. For some women, treatments during pregnancy are not necessary because it is possible due to hormonal surges during pregnancy stopping treatment may potentially not have a huge effect while pregnant and one can start many treatment again after giving birth. However, it should be noted that some women do experience hair loss during pregnancy as well.

 

WHICH HAIR LOSS MEDICATIONS ARE SAFE TO USE WHILE BREASTFEEDING?

Although I often ask my patients to discontinue most hair loss medications during pregnancy, the question frequently arises as to whether some medications can be restarted while moms are breastfeeding.  Breastfeeding has many benefits for babies.  For some drugs, the answer is yes. For others, the answer is no.

In 2001, the American Academy of Pediatrics published a helpful guide as to the safety of medications during breastfeeding. It's important to always check with your physician before starting any medication during breastfeeding. However, the following medications (used in hair loss) are felt to be safe for women who are breastfeeding.  For a full list of medications which are safe during breastfeeding, click here.

I generally do not recommend restarting treatments until month 1 after delivery if the baby is breastfed although many studies and reports show no harm in use if minoxidil and antiandrogens by women who are breastfeeding.

 


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 Effluvium: What are upright regrowing hairs (URH)?

URH in TE

urh

Telogen effluvium refers to a type of hair loss whereby the patient experiences increased daily shedding. Shedding typically occurs 2-3 months after a "trigger" such as weight loss, surgery, illness, low iron, crash diet, medication initiation or development of some internal illness.

Dermoscopy (shown here) does not have many specific findings in patients with telogen effluvium although many upright regrowing hairs (URH) may be seem along with hair follicles containing only a single hair follicle.  


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 Finasteride and Dutasteride increase the risk of muscle injury?

Is there a risk of myositis or myopathy?

MUSCLE INJURY.png

Finasteride and dutasteride are the two 5 alpha reductase inhibitors commonly used for treating androgenetic alopecia. Previous studies suggested an increase risk of muscle injury in some users of the drug. A new study examined the risk of muscle injury in 93 197 men ≥66 years of age who initiated a new prescription for finasteride or dutasteride, and they were matched to an equal number of men not prescribed a 5ARI.

Interestingly, the risk of myositis and myopathy was almost 2 times higher among users of finasteride or dutasteride (HR 1.63, 95% CI, 1.48-1.80, P < .01).

 

Conclusion


Finasteride and dutasteride can potentially cause muscle injury. The risk overall is quite low but any patient with concerns about muscle soreness, weakness, poor exercise ability should have their muscle enzymes tested.

 

Reference

Welk B et al. Risk of rhabdomyolysis from 5-α reductase inhibitors. Pharmacoepidemiol Drug Saf. 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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Lichen planopilaris: A classic example of scarring alopecia

LPP: A scarring (cicatricial) alopecia

LPP-trichoscopy

Hair loss is frequently divided into two big groups - "scarring" and "non-scarring."  The accompanying photo shows the typical 'dermatoscopic' appearance of lichen planopilaris (LPP), namely the absence of the hair follicle openings (pores), white scale around some hairs, appearance of many single hairs, and reduced overall density. 

Lichen planopilaris is an example of a scarring alopecia. The entities in this group generally are associated with permanent hair loss because the scarring alopecias are associated with death of hair follicle stem cells.

Treatment may help stop the disease but does not generally prompt new hair growth.

DOWNLOAD LPP HANDOUT


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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Hydroxychloroquine: 2 months to onset

How long does it take for hydroxychloroquine to start working?

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Hydroxychloroquine (Plaquenil) is a notoriously slow acting drug. It is frequently used for treating scarring alopecia. It can take 2 months or more before the drug really starts to have an effect and actually help a patient using the drug. Because the drug is so delayed in its onset, I usually give it 4-6 months before judging if it is working ... and sometimes even longer. Clinical symptoms (itching and burning) are reduced first in those who respond followed by clinical signs (perifollicular erythema, perifollicular scale, scalp erythema). The reduction or slowing of hair loss is last.

Hydroxychloroquine is the slowest acting of all the typical oral immunomodulators such as doxycycline, methotrexate, mycophenolate and cyclosporine (cyclosporine tends to be the most rapid). For my patients I often tell them we are going to start the “timer” in 2 months. So if I see them in July, I tell them we will actually set your zero point or start of treatment in September. I tell the patient that for the next two months they can 'consider/imagine' that they are not really even on treatment from the perspective of their scalp. (Of course blood tests need to be done because the body knows from day 1 that the drug was taken.

I may even ask patients to come in at month 2 or 3 for repeat photos (or have them take at home) as a reminder that this time point is really the starting point.


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 causes scalp pustules?

 

Scalp Pustules

PUSTULES.png

What causes scalp folliculitis? Folliculitis refers to a process whereby inflammation develops within the wall of a hair follicle. Individuals with folliculitis have redness around the hair follicles and may have pustules, papules and vesicles.

There are many ways to classify folliculitis but these processes are generally classified as infectious, non infectious and perifolliculitis. 
Bacteria, viruses and fungi and yeast can all cause various types of infectious folliculitis. They can cause temporary or permanent hair loss.

The list of non infectious causes is long. Certain medications like topical steroids or topical products like various hair care products can cause folliculitis. A variety of scarring alopecias are on the list of causes of scalp folliculitis including folliculitis decalvans, dissecting cellulitis, acne necrotica, and follicular mucinosis.

Perifolliculitis simply refers to inflammation that surrounds the hair follicles without penetrating through them. Lichen planopilaris is another scarring alopecia and a classic example but there are many others in this class including vitamin A deficiency and lithium toxicity.

A careful history and examination is needed for anyone with a suspected folliculitis. Swabs are essential if there are pustules and one should normally culture any pustules on the scalp. Viral swabs and scrapings for fungi may also be important depending on the situation. A scalp biopsy can sometimes be helpful and becomes mandatory if scarring is seen.


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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Permanent Chemotherapy Induced Alopecia

 

TCIA vs PCIA

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Every year well over 1/2 million patients undergo chemotherapy in the United States. About 65 % of these patients will lose hair as hair loss is a common side effect of chemotherapy. There are two main types of hair loss that occur in patients undergoing chemotherapy: TCIA AND PCIA

TCIA

The first type of hair loss that I would like to explain  is hair loss that happens within weeks of starting the chemotherapy and then lasts several months before growing back. This is known as temporary chemotherapy induced alopecia ("TCIA"). 

PCIA

The second type is uncommon and occurs when patients fail to regroth their hair back to the level it was before undergoing chemotherapy. If hair has not grown back after chemotherapy by the 6 month after chemotherapy, we call this permanent chemotherapy induced alopecia (PCIA).



PCIA in Breast Cancer Patients

A number of studies have highlighted the possibility of PCIA in women with breast cancer treated with various chemotherapeutic agents, especially drugs known as taxes (Docetaxel and paclitaxel are part of this group of drugs). The exact mechanisms by which they cause permanent hair loss are unclear although injury to the bulb as well as follicular stem cells are thought to be relevant. Adjuvant anti-estrogen hormonal therapy may be an important cofactor in many women with PCIA. A similar PCIA presentation has been reported in patients undergoing bone marrow transplantation. The scalp is predominantly affected in women with PCIA although a minority may have eyebrow, eyelash and body hair loss as well.

We don't really know yet how to best treat PCIA. However, the most common treatments described in the research literature are oral and topical minoxidil. Both seem to provide benefit to at least a proportion of patients. Other treatments are not known to provide benefit.


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: One of the many 'non-scarring' alopecias

Alopecia Areata is Non-scarring

AA-nonscarring

It's hard to believe that there are so many different reasons for hair loss. We see about a dozen causes commonly in the office each week but many more rarer entities exist.

Hair loss is frequently divided into two big groups - "scarring" and "non-scarring." Alopecia areata is an example of a non scarring alopecia. Clinically, when one looks at the scalp up close as in the accompanying dermatoscopic image, it can be seen that the hair follicle openings are present. If one were to biopsy the scalp in this condition, there would not be scar tissue present. 

The entities in this group of "non-scarring alopecias" theoretically have the potential to regrow although regrowth is more difficult for some of the non scarring alopecias compared to others. Common non scarring alopecias include alopecia areata, androgenetic alopecia, telogen effluvium, tinea, trichotillomania, and traction alopecia.


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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An Up Close Look at AGA

AGA - Magnified

What does androgenetic alopecia (male balding and female thinning) look like up close and magnified?

AGA



This photo is a dermatoscopic image of early staged androgenetic alopecia. It shows a variation in the thickness of hairs that is typical of this type of hair loss. "Anisotrochosis" is a term that was introduced to the medical literature in 2007 to describe a simple phenomenon - namely the great diversity and variation in the thickness and thinness of hair follicles that is seen in individuals with genetic hair loss. This photo shows a large thick terminal hair (labelled “1”) as well as three progresively thinning hairs (labelled 2,3 and 4). In individials with androgenetic aloepcia, hairs get thinner and thinner over time. When more than 20 % of hairs are displaying this variation in size in an individual with hair loss, there is a good chance that genetic hair loss is present although the diagnosis may be possible to determine even with a 10 % variation in size using certain other strict criteria as well.

Over time, the thin “miniaturizing” hairs become thinner and thinner. Hair follicle 2 in the photo was once as thick as hair follicle 1. Hair follicle 3 in the photo was once as thick as hair follicle 2 and hair follicle 4 was once as thick as hair follicle 3. 
Treatments for androgenetic alopecia differ very slightly for men and women but include minoxidil, antiandrogens, laser, PrP, essential oils (rosemary), pumpkin seed oil, saw palmetto, ketoconazole shampoos, oral contraceptives (women), zinc. For women with AGA in the setting of PCOS resveratrol, and selenium can be considered. Hair transplants and scalp micropigmentation are treatments to also be considered.


Reference


Sewell L et al Anisotrichosis: A novel term to describe pattern alopecia. J Am Acad Dermatol 2007; 56: 856.


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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Focal Atrichia in AGA

Focal trichina: What does it mean? 

Focal atrichia refers to small circular areas on the scalp that are devoid of hair. These areas are typically slightly larger than a pencil eraser. 

fa-in-aga


Focal atrichia is seen in both male and female androgenetic alopecia and more common in more advanced stages. They may contain a few tiny vellus hairs if one looks closely but eventually these tiny hairs disappear over time. Hair regrowth does not occur in these areas.

Studies by Olsen and Whiting (see references below) showed that focal atrichia was present in 44% of women with female pattern hair loss, including 67% of late onset vs 15% of early onset, compared to 3/146 (2%) of those with other hair disorders. Hu and colleagues showed that focal atrichia in men with balding was associated with more advanced stages.
 


Reference


Olsen EA, et al. Focal Atrichia: A Diagnostic Clue in Female Pattern Hair Loss. J Am Acad Dermatol. 2017.

Hu R, et al. Trichoscopic findings of androgenetic alopecia and their association with disease severity. J Dermatol. 2015.


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

Focal atrichia (+ itching)

fa-in-lpp

Focal areas of hair loss are common in advanced stages of androgenetic alopecia. However, other conditions can often mimic this so called 'focal atrichia'.

The photo shows a patient with lichen planopilaris (a scarring alopecia) who has focal areas of complete hair loss. The slight amount of redness along with the itching and tenderness in the area is an indication that another cause besides androgenetic alopecia might be present. A biopsy confirmed the diagnosis of lichen planopilaris (LPP).  

 

Further Reading

Focal trichina: A worrisome sign of androgenetic alopecia


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Acute Telogen Effluvium: Will my hair grow back or not?

Telogen Effluvium: Hair regrowth

I'm often asked if a patient with acute telogen effluvium will regrow their hair fully in 6-9 months. The answer is neither "yes" nor "no" but rather ... maybe. Hair often regrows very well if the specific "trigger" that caused the shedding in the first place can be identified AND treated properly and fully. These triggers include low iron, thyroid problems, stress, new drugs, diets, and various internal diseases as well.

te-regrowth

 

Telogen Effluvium: Is the the only diagnosis?

But one must always keep in mind that if another hair condition develops in the interim (such as androgenetic alopecia)... the regrowth might not be full and complete after a telogen effluvium. This is especially true in patients with androgenetic alopecia where a telogen effluvium often worsens the underlying androgenetic alopecia such that even when the telogen effluvium resolves the hair does not return to the original density.


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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