Hair Blogs


Tapered and Exclamation Mark Hairs in Alopecia Areata

Tapered & Exclamation Hairs in AA indicate Activity

tapped

Tapered Hairs

Tapered hairs are frequently seen in patients with small circular patches of alopecia areata. In contrast to 4-5 mm exclamation mark hairs (see next post), tapered hairs are long and typically as long as neighboring hairs. As the hair enters into the skin it becomes much thinner. At the bottom of the tapered hair (deep under the skin) is inflammation.

Tapered are important findings in patients with patchy stage alopecia areata as they tell us that the condition is active and that anti-inflammatory type treatments (such as cortisone injections) are likely to help. The above photo shows several tapered hairs (TH).

 

Exclamation Hairs

exclamation

Exclamation mark hairs are frequently seen in patients with small circular patches of alopecia areata. These hairs a short 4-5 mm hairs and represent broken hairs. The top is thick and the end is often frayed. As the hair enters into the skin it becomes much thinner. At the bottom of the exclamation mark hair (deep under the skin) is inflammation. Exclamation mark hairs are important findings in patients with patchy stage alopecia areata as they tell us that the condition is active and that anti-inflammatory type treatments (such as cortisone injections) are likely to help. The photo shows several exclamation mark hairs (EMH).


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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Chronic Telogen Effluvium (CTE)

Misdiagnoses common with CTE

CTE

Chronic telogen effluvium (CTE) is an interesting and frequently misdiagnosed hair shedding condition. Many patients with androgenetic alopecia, acute telogen effluvium and even alopecia areata are diagnosed as having chronic telogen effluvium.

 

How does CTE present?


Most patients with true CTE are 40-65 and present with sudden onset of increased hair shedding that fluctuates in intensity. Some days there is alot of shedding. Some days very little. Many patients have scalp pain (trichodynia) which may correlate with the shedding episodes. Patients with CTE often appear to have good hair density to an outsider which makes the condition frustrating for the patient. A careful history and exam can confirm the diagnosis in many cases. Follicular miniaturization is not a feature unless genetic hair loss is present too. A hair collection or scalp biopsy is useful in more challenging cases.
 


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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Androgen Blockade For FPHL: Can I use more than I medication?

Androgen blockade has the potential to be help female pattern hair loss. Caution is needed with any hormone blocker due to significant harm that can come to a developing baby were a woman to become pregnant on any hormone blocker. For this reason they are frequently used with various strict contraceptive methods.

Hormone Blocking Medications for FPHL

Female Pattern Hair Loss (also called female androgenetic alopecia) affects 40 % of women by age 50. There are a variety of treatment options including minxodil, anti-androgens, laser and PRP. 

Anti-androgens can help some women with female pattern hair loss. A long list of anti-androgens exist including spironolactone, finasteride, cyproterone acetate, flutamide, dutasteride. The combination of anti-androgens can sometimes work even better than one alone provided the patient actually has a truly androgen responsive hair loss condition. Most men do. But not all women have a form of FPHL that is truly responsive to anti-androgens.

 

Anti-androgen Side Effects

The decision to use two or more anti-androgens must always be weighed against potential side effects. The combination of androgen blocking pills has the potential to be associated with side effects such as depression, worsening fatigue, breast tenderness, breast enlargement, weight gain, decreased libido.

 

 

 

 


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 Female Pattern Hair Loss: Options for Women Over 60

Treatments for AGA in Women over 60

I'm often asked about treatment options for women over 60 who present with a diagnosis of androgenetic alopecia (female pattern hair loss). There is some degree of confusion as well as misconceptions which exist in this subject area.

My approach in this situation is to first confirm the diagnosis and then base treatment decisions according to the patient's medical history. The importance of the first step can not be overemphasized.

 

1: Confirming the Diagnosis

It is extremely important to confirm the diagnosis and ensure that a) another diagnosis is not more appropriate and b) to determine whether other diagnoses are also present. A patient need not have only one diagnosis.

A. Senescent Alopecia

Women who present with hair thinning in their 60s and 70s with no evidence whatsoever of thinning in the 30s, 40s or 50s may have senescent alopecia (age related hair loss) rather than true androgenetic alopecia. This distinction is important as senescent alopecia is less likely to be androgen-driven and therefore responds less to antiandrogens such as finasteride. The main treatment for senescent alopecia is minoxidil although agents such as low level laser and less commonly finasteride can be considered.

I typically ask patients if their hair density on their 50th birthday was more or less the same as their 30th birthday. If that answer is yes one should at least consider the possibility that senescent alopecia or even another diagnosis other than androgenetic alopecia is present.

 

B. Scarring Alopecia

Scarring alopecias are far more common than we currently diagnose. They range from subtle asymptomatic scarring alopecia to fibrosing alopecia in a pattern distribution to markedly symptomatic lichen planopilaris. Scarring alopecias are easy to miss but need to be considered in all patients with sudden onset of itchy hair loss or a more rapid decline in density from what they may have experienced in the past. A biopsy can help better evaluate these conditions. 

 

C. Hair shedding issues

Both acute and chronic telogen effluvium (CTE) need to be considered in women with hair concerns. Stress, thyroid problems, new illnesses and newly prescribed medications can all contribute to increased hair shedding and hair loss. Anyone with new shedding needs a very detailed examination and workup not only by the dermatologist but by the family physician. Blood tests are especially as is a full medical examination. One must also ensure that routine mammograms and colonoscopies are up to date.

Chronic telogen effluvium (CTE) is among the more challenging to diagnose conditions. Patients present with increased shedding that waxes and wanes. To an outsider it generally appears that the person has fairly good density. A hair collection or biopsy can help with the diagnosis.

 

Treatment Options

The main treatment options for patients with confirmed androgenetic alopecia is minoxidil, finasteride and low level laser. If the pattern of hair loss is localized frontal loss, and donor density in the occipital scalp is good, a hair transplant can be considered as well.

Minoxidil is formally approved for women 18-65. It may, of course, be used off label for women over 65 with proper evaluation by a physician.  Women with heart disease, heart failure or previous heart attacks for example may or may not be good candidates for minoxidil. One is not obligated to use the full recommended dose of minoxidil. Starting with one-quarter or one-half the recommended amount is often a good way to ease in to the treatment in patients with underlying medical issues.

Finasteride may also be a good option. Studies support the notion that higher doses of 2.5 mg and 5 mg are needed for post-menopausal women and doses of 1 mg are ineffective. Finasteride is relatively contraindicated in women with previous history of breast, ovarian or gynaecological cancer. Given the rare effects of finasteride on mood, this medication is also relatively contraindicated in women with depression.

Low level laser therapies are safe but may be less effective than minoxidil or finasteride.  A number of laser devices are available in the market for use by patients in their home. None have proven superior to another and so one must balance cost with ease of use. A helmet based device may be easier for some compared to the hand-held devices.

Scalp Inflammation. Scalp inflammation must be attended to fully when caring for patients with AGA. Many women with AGA have seborrheic dermatitis and this is best controlled with periodic use of an anti-dandruff shampoo. I frequently prescribe a trial of a mild cortisone lotion if there is scalp redness if the redness does not respond to anti-dandruff 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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7 Hair Transplant Myths

7 Common Myths in Hair Transplantation

Hair transplantation is among the mostly consistently successful and  life-changing of all the hair loss therapies. Hair transplants nowadays can look extremely natural (when performed by skilled teams). However, there are a number of myths that are infrequently talked about when it comes to hair transplantation.  These can sometimes be overlooked.

 

1.     Transplanted hair lasts forever

It’s a common myth that transplanted hair moved during a hair transplant last forever. Fortunately, most hairs that are transplanted do generally remain in their new location forever. However, anyone is has followed a hair transplant patient for 10, 20 or 30 years will tell you that the same number of hairs that were put in are not always remaining over time. Most will stay - but not all

There are many reasons why hairs transplanted hairs don’t always last forever. For one, donor hair is not always completely resistant to balding in all men. In fact, it’s a spectrum, from some men who have very little to no balding in their "donor area" (at the back of the scalp) to men who have considerable thinning in the donor area over time (ie. men with DUPA are the extreme). In addition, the medical community has not rigorously studied long term the immunological and physiological changes that happen to transplanted hairs over extended periods of time.

Nevertheless, there is no arguing that transplanted hairs last forever. It holds true for a high proportion of men and women but not all. We hope they last forever are and they seem to be in many men. However, a proportion of transplanted hairs slowly disappear over decades in some men.

 

2.     Only one hair transplant surgery session is needed

From the time male balding and female thinning announces its presence in any patient, it always progresses. While it is true that androgenetic alopecia can stop or slow for periods of months to a year or two, androgenetic alopecia by definition never stops. Anyone who gets a hair transplant must assume that existing hair in an area will slowly thin over time. If a patient is under 30 years of age, he (or she) must assume that another hair transplant will likely be needed if he wishes to maintain his current look into his 50s and 60s.

 

3.     A hair transplant procedure is always a great success

Hair transplants are generally quite successful. That's why they are popular! With the right patient, and a skilled team, the chances of success are high. Unfortunately, hair transplant don’t always work out as successfully as one might hope. There is not an experienced hair transplant surgeon in the world who can state that he or she has never had a patient who did not grow as much hair as they hoped. The reasons why this occurs is quite varied - but ranges from "patient factors" (post op care, smoking, unrecognized scalp diseases), to "surgeon-related" factors (surgeon skill, skill of the technicians handling the grafts). Sometimes one never knows the exact reason why things don’t turn out. In the hair transplant field, this is called the ‘X factor.’

 

4.     A hair transplant is a one-day event

A hair transplant procedure itself is a one day event, but the actual procedure when one considers the time from the surgery to the time where the patient feels back to normal ranges from a few days to a few months.  The actual recovery time varies from patient to patient and varies based on the size of the surgery.

In general, the post op recovery period is longer for FUT procedures than FUE and longer for patients that require more grafts. Patients who don’t require shaving for FUE procedures and have limited baldness, may find that 2-3 days is sufficient to feel back to their usual self.  However, a patient whose scalp is shaved completely for a large 3000-4000 FUE procedures may find that it takes just a few days to “feel good” but takes 3-4 weeks before he feel confident to go to work. Depending on his occupation, he may or may not feel comfortable at work for an extended period. A patient who sees clients on a daily basis at work may not feel completely comfortable seeing his clients even after 2 weeks post op from a 4000 graft FUE.  This needs to be taken into account. A hair transplant is not always a ‘one day thing.’

 

5.     A hair transplant is always an option for treating hair loss

It’s a myth that a hair transplant is always an option for an individual with hair loss. Some patients may be too young, some have medical issues that preclude surgery, and some have a type of hair loss that also will not be successful if a hair transplant were performed. Hair transplants aren't for everyone.

 

6.     There are no complications to a hair transplant

Hair transplants are quite safe. But it’s a bit of a stretch to say that they are without complication. Patients may have have redness, swelling and crusting post operatively. In general, the recovery in FUE procedures is much easier than FUT procedures.  But there are rare complications in hair transplant surgery that include long lasting nerve pain (more in FUT than FUE procedures) and persistent scalp redness. Unless a physician is carefully monitoring the procedure, a patient can even get sick. The hair transplant community tends to shy away from calling hair transplant procedures a 'surgery' in order to make the procedure more patient friendly - but make no mistake a hair transplant is a surgery. 

 

7.     You will regain the hair density of your youth

A hair transplant is a surgical procedure which involved moving anywhere from 10 to 10,000 hairs into an area of balding. If an area of hair loss is small, it may be possible to build some very nice density in the area – but the density is generally less than it once was. For example, in a patient who is very bald, a density of 35-40 follicular units per square centimeter will typically be created.  This area likely had a density of 90 or more follicular units per square centimeter at one time years earlier. Therefore, it is generally the norm for a hair transplant to create results that are less dense than the original density. A skilled surgeon can often help make 35-40 follicular units look like the original density. However, photos and videos of patients with amazingly thick and dense hair following their procedure may not always be accurate.  


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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NAAF VANCOUVER

The NAAF Vancouver Support Group

 

Alopecia areata is an autoimmune condition that affects about 50,000 Canadians.  The condition affects males and females of all ages and can have a tremendous impact on the lives of both patients and their families. Support groups play an important role in imparting accurate information to patients and families with new diagnoses as well as those who have had the condition for many years.   These groups connect people at different stages of coping and provides a network of support.

 

The National Alopecia Areata Foundation (NAAF) was founded 25 years ago and has a number of patient support groups throughout the United States and Canada.  I’m honored to join the NAAF Vancouver Support Group in 2018 as Medical Advisor.  Four meetings are planned for the year in Spring, Summer, Fall and Winter in Vancouver. Individuals with alopecia areata interested in attending these sessions may contact the NAAF for information on dates, times and location or contact our office. 


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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AGE 50: An Important Cut off for Diagnosing Hair Loss

The Cut off of 50: Why it matters in the diagnosis of hair loss in Older Individuals ?

 

Any birthday is special. The 50th birthday is an important cut off in the diagnosis of many hair diseases.  An important principle of diagnosing hair loss in men and women over 60 comes from understanding what density of hair a patient had at age 50.

 

 A true or false question

For anyone over 60, I always ask patients to help me with a true or false question.  I generally ask it in the following way

“Is this statement true or false: My hair density at age 50 was about the same as it was at age 30.”

 

This is such an important question - especially if the patient replies “TRUE”. Men and women who develop hair loss in their 60s and 70s but who report that their density age 50 was quite good have a high likelihood of having another diagnosis besides simply genetic hair loss. Of course genetic hair loss is a possibility and it’s possible the patient does not really have a good recall of their hair density at age 50. Nevertheless, there are several conditions that need to be considered in somwone with good thick hair at age 50 and hair loss in the 60s”

 

1.     Scarring Alopecia (especially Lichen Planopilaris)

2.     Senescent Hair Loss

3.     Diffuse Alopecia Areata

4.     Hair Shedding Disorders

 

Final Comment:

Patients in their 60s and 70s who tell me they had thick hair at age 50 and that it was the same thickness as age 30 often have an interesting array of hair loss conditions. One should not default to diagnosing genetic hair loss in these situations because that diagnosis may be relatively unlikely in this unique situation.

 

 

 

 


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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Case Reports in the Research World: Are they helpful?

Case Reports in Hair Loss: Cautiously Optimistic.

 

A Case Report is a published medical study which presents a particular finding as it relates to a single patient. Common Examples of Case Reports are:

 

1.     Reports of a New Diagnostic Finding

For example, a new feature that clinicians might consider to improve their ability to diagnose a particular condition

 

2.     Reports of a New Treatment

For example,  a new treatment or revised method of using a currently available treatment that improves the way we treat hair loss

 

3.     Reports of a New Prognostic Finding

For example, a new finding either clinical or through blood tests/biopsy that helps predict the course of a patient’s hair loss

 

Interpreting the Value of Case Reports: Time is the Best Judge.

Case Reports are wonderful in many ways because they have the potential to stimulate additional research and thinking around the world on a particular subject.  Case Reports can sometimes be the key fuel that triggered additional studies in a particular subject area.

However, case reports need to be interpreted cautiously because the results only apply to a single patient. One can not conclude that the finding will be applicable to all patients. In order to conclude that a case report has widespread applicability,  further large scale studies are needed.

Take for example, the case report of sexual dysfunction from use of topical minoxidil. The study is very interesting. I can not conclude based on this study that topical minoxidil is associated with sexual dysfunction in men. However, it sets us up for further studies in this area and keep me alert to monitor these side effects in patients who use topical minoxidil. In my mind the study is extremely valuable.

 

Conclusion

Time will tell how any case report will go down in history as a valid or not valid contribution to the medical literature.  Time is ultimately the best judge of case reports.


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 you diagnose hair loss from a photo?

Photos: Can you diagnose hair loss from a photo?

With the widespread availability of smartphones, it’s remarkably easy nowadays to take photos.  It’s also remarkably easy to post these on various forums and remarkably easily to send these via email.  For these reasons, photo use is widespread among patients with hair loss. Despite this, there is a common assumption that is being made that is not correct. Many people wrongly assume that one can properly diagnose hair loss with use of a photo.

 

Photographs for Hair Loss: Helpful but not the entire story

There are many hair loss conditions that mimic each other.  For example, I can show you a photo of androgenetic alopecia, diffuse alopecia areata, and lichen planopilaris that look identical. Can one be confident from the photo alone as to what the diagnosis is? No.

Because genetic hair loss is common, one will often be correct by guessing genetic hair loss in many photographs of hair loss. Nearly 1 out of every 2 women will have genetic hair loss by age 50 compared to approximately 1 out of 7,000 who will have (0.01%) have lichen planopilaris.  Clearly, guessing that a photo is showing genetic hair loss is more likely to be the correct answer.

 

PRINCIPLES OF USING PHOTOS


Here are some important principles of photographs in the diagnosis of hair loss

1. One can never be 100 % confident of any diagnosis with a photo alone.  

2. The lighting and background must ideally be the same if photos are to be compared. 

3. The length of the hair must also be the same. 

4. With a very detailed clinical history about the patient’s hair loss and medical history, one can move from being "uncertain" about the diagnosis to "somewhat confident." But that's about the maximum one can be. One can never be 100 % certain. There are many conditions that can mimic each other.

 

Conclusion

Photographs are wonderful to document the degree and pattern of hair loss. However, one must not assume that one can confidently determine the diagnosis of hair loss with photographs alone.

 


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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Side Effects from Hair Loss Medications:

Side Effects from Hair Loss Medications: What is the Chance?

Today, I’d like to review my personal view on medication and treatment-related side effects.

 

1.     Every single treatment has ‘potential’ adverse effects. (No treatment is risk-free).

Every treatment for hair loss has potential side effects. There is no treatment on the planet that is side effect free. How do I know that? Well, studies have shown that even patients using “placebo” treatments for their hair loss report side effects. This teaches us that any time a patient uses a treatment they have a chance to experience a side effect. Whether it’s a true side effect or not is sometimes challenging to decipher but a topic for another article.

 

2.     No medication or treatment for hair loss should ever be prescribed or used without patients understanding the “most common" adverse events

It is critically important for patients to understand the "most common" side effects of a treatment. The purpose of delivering such information to patients is to help them with informed consent.  A patient should only use a mediation if they feel that the benefits of using the medication are greater than the potential risks. It is the responsibility of the physician to transfer information about both the benefits and the risks to the patient so that the patient can offer their informed consent.

 

3.     It is not possible to explain all the potential side effects of a medication.

Despite the important role that we as physicians have in telling our patients about the side effects of medications, it is important for patients to be aware that a given presciber can not communicate the entire list of side effects that have ever been reported. However, it is imperative for the prescriber to advice on the most common ones. 

Take for example, the oral medication doxycycline. In the hair clinic, doxycycline is used for the treatment of scarring alopecia, folliculitis and a variety of other inflammatory and infectious conditions. A patient who is deciding on whether to use doxycycline or not should be made aware of the most common side effects including gastrointestinal upset, nausea, headaches, increased chance of yeast infections in women.

However, rare side effects are possible as well. For example, every year a small number of users of doxycycline around the world develop serious allergic skin reactions. It would be highly unusual for any prescriber or pharmacist to counsel a patient on this particular side effect.

 

4.     There may be side effects that are discovered years down the road.


One must also be aware that some side effects of a medication may not be apparent during clinical trials or even during the first few years that the medication is on the market. In some cases it may take 10, 15 or even 20 years to come to understand that rarest of side effects.  “Post marketing surveillance” is a term used to describe the monitoring that goes on after a medication is released on to the market. Post marketing surveillance has lead to some medications being removed from the market. One must always be aware that additional side effects of a medication may be revealed in the future through such post marketing surveillance.

 

5.     For any potential adverse effect, one must ask “how common” that side effect is.

 

For some medications, the chance of adverse effects may be very low, whereas for other medications, the chance of an adverse effect may be quite high. Let’s take topical minoxidil as an example. The most common side effects and headaches, dizziness, hair shedding (in the first few months), hair growth on the face and heart palpitations. However, in deciding whether to use the medication or not, patients need to understand the overall chance of these side effects.  For example, many women are extremely concerned to learn that hair growth on the face (hypertrichosis) is a potential side effect of minoxidil.  it is very important from women to note that 19 out of 20 women who use minoxidil will not have any problems with hair growth on face. However, 1 out of 20 users will. This information is helpful as it encourages many women to move forward with considering the medication with knowledge that their chance of hair growth on the face is quiet low.

 

Conclusion 

Hair loss medications have the potential to dramatically improve hair density or stop hair loss and may improve quality of life. However, anyone using a treatment, no matter what the treatment actually is, needs to be aware that every treatment has potential side effects. It is imperative that patients, together with their doctors, spend time understand how common the various side effects actually are.

 

 


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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Androgenetic Alopecia: Should I start two treatments at once?

 Androgenetic Alopecia: Should I start two treatments at once?

 

There are many treatments available for any particular hair loss condition. Let’s take androgenetic alopecia as an example. Individuals with androgenetic alopecia might consider topical minoxidil, oral hormone blocking medications, low level laser or even platelet rich plasma.  For some types of hair loss there may be an even greater array of choices.   

I’m often asked if patients should start more than one treatment at the same time. My personal view is not necessarily the right answer or the only view on the subject. However, my personal view is my view. My personal view is that whenever possible medications should not be started at the same times but rather staggered.  The intervals of staggering the treatments will depend on the specific situation and the urgency of treatment.

 

Example

Consider the 34 year old female patient with androgenetic alopecia who is considering topical minoxidil and oral spironolactone.  After a careful review of the patient’s medical history, blood tests, and examining the scalp, it is determined that both are good options for the patient.  I am faced with two options: Start both or start one at a time (stagger the treatments). Let’s look at the implications of both.

 

Treatment Option 1: Start Minoxidil and Spironolactone at the Same Time

Both Spironolactone and Minoxidil are recommended for the patient in this situation. What needs to be considered is that minoxidil has about a  30 % chance of helping the patient. It has a 70 % chance of not being all that helpful. Spironolactone has a 40 % chance of improving hair growth. If both are started at the same time and the patient experiences and improvement it will be difficult if not impossible to know which treatment was responsible for the improvement.

Was it the minoxidil?

Was it the spironolactone?

Was it both?

 

Treatment Option 2: Start Minoxidil First and Introduce Spironolactone in 6-9 months.

My personal preference in this situation was to start minoxidil first. After 6-9 months of treatment (once I determine if the minoxidil is working or not), I can make a decision to add spironolactone. In this case I can have a clear sense for the entire lifetime of the patient what helps and what does not.

 

 

Comment and Conclusions  

Treatments for some hair loss conditions (such as androgenetic alopecia) are life-long. A 33 year old woman who lives to 93 could potentially have 60 years of use of a given medication.   From a cost perspective alone, once can potentially save a patient $ 36,000 over their lifetime by confirming that a medication does not work and should be abandoned.

 

 


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 Ladder for Hair Loss: Logical and Evidence based

Treatment Ladders: What is a treatment ladder?

 

ladders

For any type of hair loss, there are many potential treatments.  Some types of hair loss may actually have 10-15 different treatments available. How does one choose which to start with? How does once decide which treatment to use if the first treatment does not work? In short, decisions on treatment are often make with use of a ‘treatment ladder.”  A treatment ladder is a term that describes a logical approach to how one should progress onto different treatments if a previous one proves ineffective.  In essence, a treatment ladder refers to a guide to how one should move “step by step” to additional treatments. If one treatment does not work one moves up to the next treatment on the treatment ladder. Treatment ladders helps clinicians balance effectiveness of treatment with safety.


Treatment Ladders for All Hair Loss

In my view, every hair loss condition has a treatment ladder. If there are 15 treatments for hair loss, one does not simply reach into a hat and decide on treatment based on the name that is pulled out of the hat. Also, one does not decide on treatment based on what was reported on the news, or what  a neighbour or friend had benefit from.  If there are 15 treatments available for a given hair loss condition, one arranges those 15 treatments on a treatment ladder for the given condition and severity of condition and moves forward with decisions on treatments based on that treatment ladder. 

 

Treatment Ladders: Alopecia Areata as an Example.

 

Let’s consider a 33 year old female with 5-6 patches of alopecia areata. She comes in with a clip from the newspaper on the oral medication “tofacitinib”  and wants to start it. It is true that oral tofacitinib can help alopecia areata, but is this a good option?

Well, an appropriate ladder for a 27 year old with 5-6 patches with alopecia areata could include:

 

TIER 1: Topical steroids and/or steroid Injections (with minoxidil)

TIER 2: Topical Immunotherapy (DPCP or Anthralin) or Prednisone Taper (with minoxidil)

TIER 3: Oral Methotrexate or Sulfasalazine or Platelet Rich Plasma (PRP)

TIER 4: Oral Tofacitinib

 

This is an example. The order of the ladder (or choices for treatment) will differ from physician to physician. But this would be ‘my’ ladder for a 33 year old female with alopecia areata totalling 5-6 patches. You can see that oral tofacitinib is on the list but not at the top of the list.  

 

Conclusion

Without a treatment ladder one needs to guess if a treatment should be used or not. Treatment ladders are important in any practice and essential in my practice to ensure that evidence based principles are used wherever possible in the treatment of hair loss. 


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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My hair was ripped off: Will it grow back?

Traumatic Hair Pulling:  Full Regrowth May or May Not Occur

I am often asked if hair that is pulled out forcefully will regrow. Examples of this are the pulling of hair by children on the playground, hair getting caught in doors, machines etc or cases of hair pulling during assault or abuse-related situations (for example domestic abuse).

Without actually seeing the scalp, and knowing details of the patient's story, it is impossible to determine if hair will or will not grow back in any particular case. This requires an in person examination so that the scalp can be properly examined.

 

Hair regrowth is not a guarantee

There is no guarantee that hair regrowth will occur. One will know in 6-9 months if they will acheive full regrowth or not because that is how long it takes for hair to grow back following any type of injury.

It is certainly possible for repeated pulling to give permanent hair loss. However, in the vast majority of cases where hair is pulled from the scalp, hair grows back.  If you or I were to reach up a pluck a hair, it will grow back. However, if pulling is repeated many times or is excessive with bleeding a greater chance exists for scarring to develop. Hair pulling that is accompanied by injury to the skin layers (i.e. that creates an actual wound) has a markedly increased chance of being associated with permanent scarring.  It is such scarring that blocks the regrowth of hair.  Scar tissue is permanent and, if present,  generally destroys stems cells. 

Anyone with concerns about incomplete growth after episodes of hair pulling should see a physician who specializes in hair loss for consideration of a scalp biopsy.


 


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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Up and Coming Treatments in the World of Hair

Hair Loss Treatments: What's around the corner?

In this video, I review the latest in emerging treatments for hair loss.


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 at the Nape of the Neck: What are the main causes?

Losing Hair at the Nape: What are the main Causes?

Hair loss can either be localized (meaning one area of the scalp) or diffuse (meaning all over the scalp). There are many causes of hair loss at nape of the neck and the back of the scalp. 

 

1. Traction alopecia

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Traction alopecia refers to a type of hair loss due to the tight pulling of hair. The back of the scalp is particularly susceptible to loss of hair.  Hair styling practices can frequently lead to traction including braids and weaves and pony tail.  If traction alopecia is of recent onset, hair regrowth can occur even without treatment. If traction is longer standing, the hair loss can often be permanent.  Some women with hair loss that looks like traction actually have a scarring alopecia known as cicatricial marginal alopecia. 

 

 

2. Alopecia Areata

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Alopecia areata is an autoimmune disease that affects about 2 % of the world. Hair loss can occur anywhere. Alopecia areata can frequently cause hair loss specifically at the nape in some patients. The particular form that causes loss at a the back of the scalp is the 'ophiasis' form. The ophiasis form is frequently resistant to standard treatments although topical steroids, steroid injections and diphencyprone are typically first line. 

 

 

3. Androgenetic Alopecia

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Androgenetic alopecia (male and female thinning) typically causes hair loss at the top of the scalp. In men, the temples and crown are most often affected. In women, the mid-scalp region is generally affect first. The back of the scalp can also be affected although this is not typically thought of. Hair thinking along the nape is not uncommon in advancing balding in men and women. 

 

 

4. Frontal Fibrosing Alopecia

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Frontal fibrosing alopecia (FFA) is a type of scarring alopecia. FFA typically affects women between 45-70. Most often hair is lost along the frontal hairline and eyebrow. However the back of the scalp (at the nape) and frequently be affected. The hair loss in the nape typically starts at the sides (left side and right side) just behind the ears. Treatments for FFA include topical steroids steroid injections, topical calcineurin inhibitors. Oral drugs include finasteride, doxycycline and hydroxychloroquine at the top of the list.

 

5.  Heat and Chemicals

Heat and chemical treatments can lead to hair shaft damage and hair loss at the nape. Frequently, heat and chemical overuse leads to an increased tendency to develop traction alopecia which si discussed above. 

 

6. Acne keloidalis nuchae

Acne keloidalis nuchae (AKN) is a condition that can affect both men and women. Small papule or bumps develop along the posterior scalp and are accompanied by hair loss in the region as well.  The hair loss in AKN is often permanent and can lead to thicken and thicker scars some of which are disfiguring. 

 

7. Hair shaft disorders

Some individuals are born with abnormalities in how the hair shaft is produced. This frequently leads to hair breakage. Monilethrix is one of the hair shaft disorders that frequently leads to hair loss along the nape. 

 


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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DPCP for alopecia areata: Why do we use acetone to make it up?

Dissolving DPCP in Acetone

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Diphencyprone or "DPCP" is a chemical that causes allergic reactions. It is used as an off-label (non FDA approved) treatment for patients with alopecia areata whereby the DPCP is applied directly to the scalp and left on for 24-48 hours. After 48 hours the DPCP is washed off.

DPCP is not soluble in water so it is typically made up in acetone. Acetone is an organic solvent best known as the ingredient in nail polish remover. DPCP may also be soluble in other ingredients such as isopropanol.

What is often forgotten is that DPCP degrades in light and at room temperature. DPCP should be ideally stored at 4 degrees ceclius and protected from light. Usually DPCP is dispensed in brown light proof bottles but I recommend wrapping in aluminum foil to further protect from light.


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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Erectile dysfunction in Minoxidil Users: What's the Naranjo Score?

Erectile dysfunction in minoxidil users

Anyone who reads online will see that there are reported links between topical minoxidil use and erectile dysfunction. But is it accurate ?  My opinion is that it's not impossible - but very unlikely for most users. Let's take a look at the data. 

One one study to date supports an association

To date, there are no really good clinical studies that support an associated between topical minoxidil use an worsening erectile dysfunction.  The original studies from the 1980s did not raise this issue. However a recent study did suggest that topical minoxidil was the cause of erectile dysfunction. 

MINOXIDIL ASSOCIATED WITH ERECTILE DYSFUNCTION

 

Blood pressure medications can cause impotence

Minoxidil is a blood pressure medication and was used orally in the 1980s as Loneten. It's certainly not out of the question for blood pressure medications to cause erectile dysfunction. Drugs like beta-blockers and diuretics like hydrochlorothiazide can sometimes cause erectile dysfunction. Blood pressure medications like ACE inhibitors, Angiotensin receptor blockers are less likely.  Minoxidil was FDA approved in 1979 as an oral medication to treat blood pressure problems. Topical minoxidil however, does not impact blood pressure to any significant degree in most users. Erectile dysfunction is not a side effect that has been raised in clinical trials to date.

 

The Naranjo Adverse Drug Reaction Probability Scale

When a patient asks me whether their minoxidil could be causing sexual dysfunction, my answer is first that it is possible and that we really need to consider something know as the Naranjo Adverse Drug Reaction Probability Score.

Anything applied to the skin or taken by mouth has the potential to cause a side effect. Some medications rarely cause side effects and others tend to cause frequent side effects. Occasionally a patient will report a side effect that perhaps has never been reported before. The question then becomes - is this a real side effect from the drug or is it happening from something else?

 

A Closer Look at the Naranjo Adverse Drug Probability Scale

The Naranjo Scale was created nearly 40 years ago to help standardize how clinicians to about assessing whether or not a drug could be implicated in an adverse drug reaction. It is used in controlled clinical trials. The scale is quite easy to use - and involves asking the patient 10 questions. Answers to the question are recorded as "yes", "no" or "don't know" and different points are assigned to each answer (-1, 0, +1, +2). 

Typical Questions in the Naranjo Scale (using minoxidil associated erectile dysfunction ("ED") as an example)

  1. Are there previous "conclusive" reports of minoxidil causing ED? (yes) 
  2. Did the ED (or worsening ED) appear after the drug was given or were their such issues before the patient started minoxidil?
  3. Did the ED improve when the drug was discontinued or a specific antagonist was given?
  4. Did the ED reappear upon readministering the minoxidil?
  5. Were there other possible causes for the ED that were explored by the family doctor?
  6. Did the ED occur again with administration of placebo?
  7. Was the minoxidil detected in the blood or other fluids in toxic concentrations?
  8. Was the ED worsened upon increasing the dose of minoxidil (from once to twice daily)? Or, was the reaction lessened upon decreasing the dose? (ie. does going to once daily minoxidil make sexual performance better?)
  9. Did the patient have a similar reaction to  minoxidil or a related  blood pressure drug in the past?
  10. Was the ED confirmed by any other objective evidence?

 

Determining the Naranjo Score

Scores can range from -4 to + 13. A score of 0 or less means the likelihood of the drug causing the side effect is doubtful, a score 1 to 4 indicates it is 'possible', a score 5 to 8 means it is 'probable' and a score 9 to 13 means it is 'definite'

 

 

Reference

Tanglertsampan C. Efficacy and safety of 3% minoxidil versus combined 3% minoxidil / 0.1% finasteride in male pattern hair loss: a randomized, double-blind, comparative study. J Med Assoc Thai. 2012.

Cecchi M, et al. Vacuum constriction device and topical minoxidil for management of impotence. Arch Esp Urol. 1995.

Radomski SB, et al. Topical minoxidil in the treatment of male erectile dysfunction. J Urol. 1994

 

 


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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Iron Supplements: How can I raise my ferritin levels?

GENERAL PRINCIPLES OF TAKING IRON PILLS

 

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Iron supplements are commonly prescribed for individuals with low iron stores and low hemoglobin levels. I always advise patients to check with their physicians before simply taking a pill. Some causes of iron deficiency are quite serious and need a proper evaluation.  Here are some general principles.

 

1. There is no perfect choice.

I'm okay with my patients taking most supplements provided they are not having side effects and provided it’s doing a good job and helping to raise ferritin levels. There are over 100 iron supplements on the market. There is no right or wrong as a starting point for most people. If the supplement helps raise ferritin levels to the desired range and the patient feels good while taking the supplement, then it may in fact be the right choice. 

 

2. Start with the least expensive (if possible).

Iron supplements range from 5-10 cents per pill to 1.25 to 1.50 per pill. If a patient generally has a good stomach and is not prone to constipation or diarrhea, I recommend to start with the least expensive forms. They often work very well and the patient has the potential to save a lot of money. Any of the formulations listed in the attachment below are reasonable starting points. Ferrous gluconate for example is just pennies per pill.

 

3. I recommend that patients buy specific (more expensive) formulations if they have gastrointestinal issues or use antiacids.

If my patient frequently experiences an upset stomach, or is prone to constipation from previous iron supplements I recommend they consider PROFERRIN or FERRAMAX. Others may also be acceptable. These pills are particularly helpful if patients use antiacids as PROFERRIN and FERRAMAX do not require acid to be absorbed and are therefore acceptable for patients who use antacid medications. 

 

4. Go slowly!

Regardless of which pill a patient chooses, I can't overemphasize the important of the following key message: go slowly! Start with one pill every other day for 5 days and then go up to daily for 2 weeks. I may  advise patients to go higher than once daily but it depends on the exact pill they are using. 

 

5. Take the iron with a source of vitamin C.

Vitamin C (ascorbic acid) helps increase iron absorption. Taking iron pills with a glass of orange juice or with an actual vitamin C tablet can help iron absorption.  If a patient is using ferrous gluconate, fumerate or sulphate, I advise them to be sure to take their iron supplements 1 hour before a meal or 2 hours after.

 

6. Avoid milk, calcium, high fiber food and caffeine

If patients are having difficulties raising their ferritin levels, I may advise them to avoid milk, calcium, high fiber foods and caffeine containing beverages. These can  impair iron absorption. 

 

7. If more than 1 pill is recommended, spread them out throughout the day. 

Iron absorption is much better if the dose is spread out throughout the day rather than taken all at once. In addition, this may help to limit gastrointestinal side effects, such as nausea and vomiting. 

 

8. If liquid iron is chosen, be aware that it may stain teeth

Liquid forms of iron may stain the teeth. If patients are using liquid iron they may wish to combine with fruit juice or tomato juice to limiting staining. Drinking the iron with a straw may also help.

 

 

9. If necessary, oral lysine supplements at 500 mg twice daily can also help to increase iron absorption.

Lysine is an amino acid (a building block of protein). Studies have shown that L-lysine can help increase iron absorption. If patients are having difficult with raising their ferritin levels, I may advise them to include L-lysine in their plan. 

 

10. Follow your ferritin levels.

One should never ever start iron pills unless they plan to test their levels again at some point in the future. This is important. The precise time point to retest ferritin levels will differ from patient to patient but is never sooner than 3-4 months and never more than 9 months.  Testing ferritin levels weekly or monthly is pointless. However, re-testing a few months down the road is a good idea. 

 

11. If one has low hemoglobin and low ferritin, further evaluation and tests might be needed.

Anyone with low hemoglobin and low ferritin needs to speak to their doctor about a range of tests. They may not be necessary of course, but one needs to consider celiac disease, excessive menstrual bleeding (women), gastrointestinal bleeding, dietary issues, and a range of other illnesses. In my clinic, I generally screen for celiac disease (gluten sensitivity) in all patient’s with low hemoglobin and low ferritin.  Patients with persistently low levels need a full evaluation by physician. 

 

Conclusion

Taking iron is easy for many individuals but presents its challenges to some people. For some, the ferritin levels simply don't budge upwards despite taking iron. For others, any amount of iron causes gastrointestinal upset. A slow are methodical approach such as that suggested above often helps increase levels. 

 


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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Am I taking the right amount of hydroxychloroquine (Plaquenil)?

Hydroxychloroquine (Plaquenil): Am I taking too much?

Hydroxychloroquine is an oral medication used in a variety of autoimmune conditions. Side effects have been discussed previously but today we will focus on eye side effects. A number of side effects are possible ranging from vision changes to double vision to asymptomatic changes in various parts of the eye.

 

The Risk of Retinopathy with Hydroxychloroquine

"Retinopathy" is one of the more worrisome side effects of Hydroxychloroquine. At appropriate doses, studies show that the risk appears to be about 1 % of patients at 5 years of use and 2 % at 10 years. After 20 years, the risk may rise to 20 %. Once the retinal toxicity from hydroxychloroquine occurs, it is believed that the changes in the retina are permanent. Furthermore, the disease can even progress even if hydroxychloroquine is stopped.  

 

Risk Factor for Retinal Toxicity

Retinal damage can occur in anyone. However, the risk may be increased if the following risk factors are present

  • Longer Duration of use (cumulative dose)
  • Renal or hepatic functional impairment. Compromised kidney and/or liver function can lead to increased accumulation of hydroxychloroquine in the tissues.
  • Age over 60 years.
  • Preexisting retinal disease
  • Concurrent tamoxifen therapy

 

What dose should I take?

It's clear that taking the appropriate dose reduces (but does not eliminate) the chance of side effects. The optimal dose is 6.5 mg for every kg of lean body weight (not simply what the patient weighs). "Lean body weight" is essentially the patients expected weight for their height and gender - it does not include the "extra" weight that some might carry. Instead of calculating lean body weight, some clinicians advocate simply using the patient's true body weight and multiplying by 5 (instead of 6.5).  In our clinic we typically dose hydroxychloroquine according to the following grid:

Hydroxychloroquine Dosing

 

Conclusion

The risk of eye related toxicity is low in the first 5-10 years of hydroxychloroquine use provided the dosing is respected. This study has had great importance as it has further helped to define risk and has encouraged changes in screening guidelines. These guidelines now include an initial examination but dedicated yearly screening to begin only after 5 years in otherwise healthy individuals deemed at low risk for eye problems.

 

Reference

(1) Melles & Marmor. The Risk of Toxic Retinopathy in Patients on Long-term Hydroxychloroquine Therapy. JAMA Ophthalmolol. 2014;132(12):1453–1460.

 


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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Prostaglandin analogues and Melanoma: What is the data?

Do we need to be concerned about melanoma when using Bimatoprost (Latisse, Lumigan)?

I was recently asked a very interesting question - and that is whether one needs to exercise caution when using prostaglandin analogues like bimatoprost (Latisse) or latanoprost (Xalatan) in patients with a history of melanoma. The short answer is that there is no good evidence to support an increased risk of melanoma in users of any of the prostaglandin analogues - which includes latanoprost (Xalatan) and bimatoporst (Latisse).  However, a number of  points are important to carefully consider here - especially for individuals who already have a history of this type of cancer. 

In general, patients with a personal or family history of melanoma (especially eye melanomas or skin melanomas around the eye) should speak with their physician if prostaglandin analogue type drugs are to be prescribed. This includes latanoprost (Xalatan) and bimatorpost (Lumigan, Lattise). 

 

1. Prostaglandin analogues increase pigmentation. 

It is well known that users of prostaglandin analogues can develop increased pigmentation. For example, users of Bimatoprost (Latisse), can sometimes develop pigmentation of the eyelid or skin around the eyelid. Bimatoprost is a drug that stimulates prostaglandin F2 alpha (PGF2a). There is a good scientific basis for the observation that PGF2a drugs can cause pigmentation. In 2005, a study by Scott and colleagues (see reference below) showed that PGF2-alpha stimulates the activity and expression of tyrosinase, the rate-limiting enzyme in melanin synthesis. The group showed that fluprostenol, a potent and specific analog of PGF2a, stimulates tyrosinase activity in normal human melanocytes, but does not affect melanocyte proliferation. They also showed that melanocytes produce PGF2a in response to UVR.

 

2. There is no solid evidence of eye melanoma with prostaglandin eye drops

Given that the prostaglandin F2 alpha drugs can stimulate melanocyte pigmentation, health authorities have asked manufacturers of these drugs to submit data and monitor if there is any increased risk of eye melanoma (ocular melanoma) in users of these drugs. In studies and discussions in 2002 examining whether latanoprost (Xalatan) increased the risk of ocular melanoma , the conclusion was that it did not. 

READ DISCUSSION

 

3. There have been cases reports of melanoma associated temporally with use of latanoprost and bimatoprost

Latanoporst (Xalatan) and bimatoprost (Latisse, Lumigan) are both drugs that target the prostaglandin F2 pathway.  Latanoprost and Bimatoprost are widely prescribed as "first-line" agents for glaucoma.

In 2009, Esteve and colleagues reported 1 case of eyelid melanoma associated with the use of latanoprost.  Two group reported two other cases of choroidal melanoma and earlobe melanoma that was associated with the use of latanoprost. 

In 2012, Sun and colleagues reported a 77 year old patient who developed eyelid melanoma. She had used bimatoprost (Lumigan) for 6 years prior. When she first presented to her physicians, the pigmented lesion she had on her lower eyelid was biopsied and felt to benign. However, it subsequently progressed to a superficial spending melanoma in situ.

 

4. To date, there is no good evidence PGF2a affects negatively affects the biology of melanoma cells

Melanocytes express receptors for prostaglandins, including PGF2-alpha and PGE2 as well. PGF2-alpha binds to the FP receptor to activates signals in melanocytes. PGF2-alpha stimulates melanocyte dendricity.  As mentioned above, PGF2α stimulates the activation of tyrosinase (the rate limiting step in melanin synthesis), and the formation of dendrites, which facilitate the transfer of melanosomes from melanocytes to keratinocytes

One study suggested that melanomas reduce their expression of the PGF2-alpha receptor (FP receptor) suggesting that the FP receptor is lost at the transcriptional level in melanoma and in nevi and melanoma in vivo. it appears the FP receptor is expressed only by melanocytes, but is lost in melanoma and in nevi. There remains some uncertainty as to whether melanomas increase their expression of PGF2 alpha on account of loss of the FP receptor.   

 

Conclusion

To date, there is no good evidence to suggest that users of prostaglandin analogues like latanoporst (Xalatan) or bitmatoprost (Latisse) are at increased risk of skin or eye melanomas. However, individuals who are already diagnosed with melanoma of the eye or skin around the eye or face should speak to their physicians as the use of the drugs would need to be considered on a case by base basis. There are no guidelines for using these drugs if a patient already has a diagnose of melanoma and current prescribing guidelines do not offer it as a contraindication.  Although previous case reports do not prove any cause, these findings simply prompt one to take pause and carefully consider the risks and benefits based on current scientific evidence.

REFERENCE

 

1. Fricke A, et al. The PGF(2alpha) receptor FP is lost in nevi and melanoma. Pigment Cell Melanoma Res. 2010.

2 Scott et al. Effects of PGF2a on human melanocytes and regulation of the FP receptor by ultraviolet radiation. Exp Cell Res 2005.

3. Esteve E et al. Melanoma during latanoprost therapy: three cases. Ann Dermal Venereol 2009; 136: 60–1.

4. Sun LL, et al. Lower eyelid melanoma during bimatoprost (Lumigan) therapy. Clin Exp Ophthalmol. 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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