Hair Blogs


How can we differentiate trichotillomania from alopecia areata in children?

Differentiating trichotillomania from alopecia areata 

trich vs AA.jpg

It can be challenging in some children to distinguish alopecia areata (an autoimmune condition) from trichotillomania (an impulse control disorder whereby individuals pull out their own hair). Sometimes even both coexist in the same patient! 


Exclamation mark hairs are frequently seen in both alopecia areata and trichotillomania and are therefore not specific (arrow). Several dermatoscopic signs, however, are more common in trichotillomania than alopecia areata including flame hairs, split ends, hairs of different lengths, v-sign (shown here with yellow circle), hair powder.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Is it okay to use more minoxidil?

Using more minoxidil is not advised

The dosings of medications have been carefully worked out to balance efficacy with safety. If a patient feels he or she needs more, they should speak to their physician or pharmacist regarding how to apply minoxidil efficiently. If one feels this dose does not work, they might consider a variety of off label means... but only under supervision. This could include using a bit more than 1 mL, or using oral minoxidil at low doses.

 

Side effects of using too much minoxidil

The side effects of overdosing on minoxidil include worsening headaches, dizzininess, low blood pressure, heart palpitations, heart rhythm disturbances, ankle swelling, hair growth on the body. Rarely patients end up in the emergency department every year because they feel so unwell after using too much minoxidil. 

Minoxidil is a drug and use must be respected.

 


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

Minoxidil and age-related hair loss

Minoxidil is a topical medication used to treat many forms of hair loss including androgenetic alopecia (for which it is FDA approved). Minoxidil can be helpful for treating androgenetic alopecia at any age but becomes even more important to consider with advancing age. 

 

Senescent alopecia: A type of hair loss often forgotten

Hair thinning as one approaches the 60s and 70s is often less truly androgen driven. The diagnosis of senescent alopecia (SA) needs to be considered in these particular age groups and it can often respond to minoxidil. Senescent or age related alopecia is often forgotten by physicians. It mimics genetic hair loss almost perfectly so is easily misdiagnosed as genetic hair loss. The genes driving it are very different. The key point is that if one recognizes senescent alopecia could be a possibility - the use of treatments like minoxidil become more important rather than other traditional AGA-type treatments like finasteride.

Androgenetic alopecia tends to start somewhere between age 8 and age 50. Hair thinning that occurs later has a high likelihood of representing senescent alopecia. (Of course other types of hair loss may also occur after age 60 and genetic hair loss and senescent alopecia can overlap). A study by Karnik and colleagues in 2013 confirmed that these two conditions (AGA and SA) are truly unique. The authors studies 1200 genes in AGA and 1360 in SA and compared these to controls. Of these, 442 genes were unique to AGA, 602 genes were unique to SA and 758 genes were common to both AGA and SA. The genes that were unique to AGA included those that contribute to hair follicle development, morphology and cycling. In contrast to androgenetic alopecia, many of the genes expressed in senescent alopecia have a role in skin and epidermal development, keratinocyte proliferation, differentiation and cell cycle regulation. In addition, the authors showed that a number of transcription factors and growth factors are significantly decreased in SA. The concept of senescent alopecia is still open to some debate amongst experts. The studies by Karnik give credence to the unique position of these two conditions. But studies by Whiting suggested that it is not so simple as to say anyone with new thinning after age 60 has SA - many of these are also more in keeping with androgenetic alopecia. As one ages into the 70's, 80's and 90's - hair loss in the form of true senescent alopecia becomes more likely.

 

Reference

Karnik et al. Microarray analysis of androgenetic and senescent alopecia: comparison of gene expression shows two distinct profiles. J Dermatol Sci. 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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Differentiating DUPA from CTE

How do we distinguish DUPA from CTE?

Diffuse unpatterned alopecia (DUPA) can generally be differentiated from chronic telogen effluvium (CTE) by careful review of the patient's history, and examination of the scalp using dermoscopy. Rarely a biopsy can be confirmatory but usually this is not needed.

 

DUPA

On history, patients with DUPA report diffuse thinning. They usually don't have all that much in terms of increased shedding. Typically, the hair loss is first noticed between age 15-24. Examination of the scalp shows variation in the sizes of follicles. We call this 'anisotrichosis'. Some hairs are thick and some are thin. The miniaturization occurs all over the scalp. A biopsy shows a terminal to vellus ratio of much less than 4:1.

 

CTE

In contrast to DUPA, patients with true CTE are usually a bit older when they first notice hair loss, often 35-60. Their stories are markes by concerns about massive shedding that comes and goes, some weeks good and some weeks bad. Patients with CTE don't usually look like they have hair loss to others whereas patients with DUPA often do look like they have hair loss. In CTE, examination shows terminal thick hairs. The temples may or may not show recession but often do in the setting of CTE. A biopsy shows T: V ratios that are high - and ratios 8:1 or higher are suggestive of CTE (compared to less than 4:1 for DUPA).

 

In summary, DUPA and CTE can usually be easily differentiated with careful examination and review of the patient's story.


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

Hydrogen peroxide inhibits hair growth in lab models

h202


This has been a question that has been discussed for some time. I have become increasingly interested in this topic as it is clear to me that at least for a small proportion of patients - hair salon visits can negatively affect their hair. Many people of course are fine and unaffected by hair dye. For others, however, the process of dyeing and bleaching can cause significant problems, including hair loss.

There are many potential reasons why someone using hair dye can raise concerns about hair loss that is potentially related to the dye. It is clear that the use of hydrogen peroxide in many dyes can induce "oxidative stress." This oxidative stress is toxic to cells.
 


A New Study Examines the Effect of H202 on Hair

Researchers from Korea set out to examine the effect of hydrogen peroxide on growing hair follicles in a laboratory setting. The researchers isolated hairs from a patient and grew them in a petrie dish. Then hydrogen peroxide at various concentrations was added. Results showed that H2O2 inhibited growth of hair follicles in a concentration dependent manner and did so by inhibiting a pathway inside cells known as the GSK3- beta pathway.

The evidence is accumulating that hydrogen peroxide has a growth inhibitory effect in vitro (in cultured and controlled conditions in a laboratory). More studies are needed to understand if and how hydrogen peroxide actually affects growing hair follicles deep under the scalp and whether the thick and someone resilient skin layer actually allows hydrogen peroxide to get under the skin to affect dermal papillae or "DP." For now, if a patient truly feels that hair dye is affecting the hair, I advise searching for alternate means to color hair which avoids hydrogen peroxide. For many patients however, hair dye use continues to be unproblematic.

 

Colouring Hair When Hair Dyes are a Problem

In general, temporary type dyes are safer/better tolerated than semi-permanent and semi-permanent are better tolerated than permanent. The richness of the colors and how pleased patients are seems to go in the opposite order: permanent dyes create some of the nicest color effects.  There are a number of dyes which are PPD free and free of ammonia, parabens, silicone, formaldehyde. There are several companies. For patients with a lot of issues, henna can be considered. Also, I find that many patients improve their tolerance with pre-shampooing with clobetasol propionate based shampoos (i.e. Clobex shampoo) the day before (or morning before). In general though, I have a pretty low threshold for recommending a patch test to rule out allergy in patients with problems to hair dyes. 



Reference


Ohn et al. Hydrogen peroxide suppresses hair growth through down regulation of beta catenin. Journal of Dermatological Science 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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Hydrogen peroxide in hair

Hydrogen peroxide inhibits pigment synthesis 

h202

Hydrogen peroxide (also known as "H2O2") is a well known bleaching agent and disinfectant. It is a household item for many people.

Hydrogen peroxide is also found in hair - and in fact accumulates in white and gray hair. It inhibits the synthesis of pigment known as melanin.

 

Reference

Schallreuter KU, et al. The redox--biochemistry of human hair pigmentation.  Pigment Cell Melanoma Res. 2011


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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Challenging Cases of Hair Loss: Practical Tips When Nothing Seems to Help

What to do when a patient's hair loss refuses to improve? 

tips


Every now and then there are some unusually challenging cases of hair loss that cause me to sit quietly at the end of the day and rethink the best means to treat me it. I'm talking about patients with alopecia unversalis who do not improve with any treatment, including the most potent of oral immunosuppressives. I'm talking about patients with scarring alopecia who continue to have symptoms and lose hair despite the most aggressive treatments. I'm talking about patients with early onset androgenetic alopecia who progress despite anti-androgens, minoxidil, laser and more. Is there anything we can do in these situations? Fortunately there usually is. Here are some practical tips.

 

Practical Tips


1. If the diagnosis is at all in question, a scalp biopsy should be done and possibly two. Blood tests should have been checked prior to the appointment but if not, basic screens are appropriate.

2. If a patient's diet is poor, one might look at ways to improve it. 


3. If stress and emotional issues are high, it might be worthwhile to address these. Stress is clearly relevant for some people.

4. Consideration needs to be given to whether a current treatment is actually causing the hair loss to worsen. Stopping treatment for a period may be useful in some situations.

5. A complete health check should be done by the patient's regular physician. Routine screening exams (mammograms, colonoscopies) should be up to date according to age appropriate screening.

6. One should always at least ask if patients are using their recommended treatment. Every now and then there are some incredible surprises.

7. If a different route of administration is possible this should be considered. Some oral drugs might be compounded topically. Some topicals may be available in oral form.
 

Conclusion

If a physician sees enough patients with hair loss, he or she will encounter cases of hair loss that don't seem to respond to anything. An organized approach in these situations is needed. Every so often some surprising improvements can finally occur!


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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Low dose Naltrexone: The Potential Uses are Many

LDN in Scalp Dermatology

LDN-uses

Low dose naltrexone (LDN) is a relatively inexpensive medication that may have benefit in many aspects of dermatology including hair dermatology. I have prescribed it to patients with lichen planopilaris, alopecia areata and even the so called scalp dysesthesias (scalp pain syndromes). It is believed that our internal opioid and endorphins have an important effect on the immune system.

It is now understood that various immune system cells also have opioid receptors on their surface. It is the ability to block opioid receptors in the body between 2 am and 4 am that is proposed to give the beneficial effects. Blockade in this manner lead to changes in the immune system and increase in the body’s endorphin and encephalin levels. These are powerful modulators of the immune system.


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 Care in The Era of the Vikings

Hair care, combs and the Vkings

combs-viking

Humans have sought to distinguish themselves through changes in their appearance for thousands of years. 


This photo shows combs used by Vikings in the 10th century. Archaeologists have come to understand that hair was important to the identity of Vikings. Comb making became a particular skill and to own a comb like the one shown was a symbol of status. Combs were made from a variety of materials including bones and antlers (especially deer antlers). Viking warriors took combs on their voyages.

Source: Royal Ontario Museum, Viking Exhibition, 2017-2018. Toronto, Canada


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 and Height

Height, AGA and Genetics

Recent research has shown that many of these genes that control balding also affect how tall an individual may become. 

height


Heilman-Heimbach and colleagues from the University of Bonn recently performed an extensive study of over 20,000 men (10,000 with hair loss compared to 10,000 without hair loss). The researchers uncovered 63 genetic changes that increase a man's risk of developing early onset balding. These same genetic changes were associated with an increased likelihood of being shorter. They concluded that many of the genes controlling male balding are also linked to being shorter in height.

A second study from the UK by Hagenaars and colleagues identified 287 genetic regions linked to male pattern baldness. This large study examined data from over 52,000 men. This study confirmed a similar finding as the Heilman-Heimbach et al. study above namely that many of the genes regulating hair loss in men also give an increased chance for shorter height.


Reference


Heilman-Heimbach et al. Meta-analysis identifies novel risk loci and yields systematic insights into the biology of male-pattern baldness. Nature Communications, 2017.

Hagenaars SP et al.  Genetic prediction of male pattern baldness. PLoS Genet 13(2): e1006594. 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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Telogen Effluvium: Is regrowth always possible ?

Is regrowth always possible with a TE?

 

Telogen effluvium refers to a type of hair loss whereby the patient experiences increased daily hair shedding. Telogen effluvium typically occurs after some sort of "trigger" disrupts the delicate balance of hair growth and loss. There are many potential "triggers" that lead to telogen effluvium including stress, low iron, scalp dermatologic issues, thyroid abnormalities, crash diets, delivery, medications and internal illnesses. If a "trigger" can be identified and shut off/dealt with shedding can often return to normal rates and hair density can return for the patient.

For example, if shedding was due to a medication and that medication has now been stopped, it's quite likely that shedding will slow and then return back to normal rates.

 

Not all TE is Self Limiting

Too often a precise "trigger" causing the hair loss can't actually be found. In fact, in up to 50% of women, it's challenging to pinpoint an exact trigger. If a trigger can't be found, there is nothing to 'fix' to stop the shed and the shedding can sometimes just continue.   In addition, even if a trigger is found, it may not be possible to easily 'fix' the trigger. For example, some patients have TE due to a drug and in some cases, it's simply not possible to stop that drug because it's critical to the patient's health. Some patients may have TE due to an underlying medical condition (internal illness). That condition may not be possible to totally eradicate and because of this, shedding may continue.

Many patients with TE eventually experience a cessation of excessive shedding and a slow return to more normal rates of shedding and improved density. However, not all patients do.  The diagnosis of telogen effluvium does not guarantee that the hair loss will be self limiting.

 

Treatment of TE when no trigger is found

The treatment of TE is geared towards addressing the specific trigger that cause the shedding in the first place. If the patient had low iron, iron supplementation is appropriate. If a thyroid abnormality was present, addressing the thyroid issue is important. In cases where not trigger can be found, a variety of options are available, including minoxidil, low level laser, platelet rich plasma, biotin, hair and nail supplements, Lysine, and cysteine.

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Topical Tofacitinib for Alopecia Areata: How much does it really help?

2% Ointment Helped 1 of 10 Patients 

Oral tofacifitinb belongs to a group of medications known as JAK inhibitors and represents an off-label treatment for alopecia areata.  Its use is limited by cost but also by potential side effects associated with its immunosuppressive effects. An increasing interest is mounting regarding the potential use of topical JAK inhibitors in treating alopecia areata.

The optimal formulation (liposomal vs ointment) has yet to be definitively proven. Previous studies have suggested a benefit of both topical ruxolitinib and topical tofacitinib in at least some patients with alopecia areata. 

 

New Study Examines Topical Tofacitinib

Researchers from Yale set out to examine the benefit of tofacitinib ointment in adults with alopecia areata. In their report, the authors described the results of a 24-week, open-label, single-center pilot study of 10 patients with AA treated with tofacitinib 2% ointment applied twice daily.  Patents were eligible for the study if they were 18-years-old or older, had at least 2 patches of alopecia areata, had  stable or worsening disease for 6 months, and have received no treatment for AA for at least 1 month prior enrolment. Tofacitinib was applied to half of the involved scalp and, if and when evidence of hair regrowth was observed, tofacitinib was subsequently applied to the entire involved scalp. 

 

What were the results?

The authors showed that 3 of 10 subjects experienced hair regrowth with topical tofacitinib with a mean decrease of 34.6% in SALT score (standard deviation 23.2%).  Of these three patients, only one had excellent regrowth. 2 others had partial growth. Skin irritation was reported by 40 % of patient and folliculitis in 10 %. Both of theses side effects resolved even without treatment. 40 % of patients had a minor increase in cholesterol levels. Despite these minor side effects there were no serious side effects. 

 

Conclusion and Summary

This is an interesting study by these Yale researchers who are leaders in this area of JAK inhibitors. It was disappointing that only 1 of 10 patients had significant improvement.  Whether a differential topical vehicle (such as a liposomal vehicle) could have different results awaits further study.  The main message of all of the topical JAK inhibitors studies to date is that they could help some patients with alopecia areata, but for many they do not. 

 

REFERENCE

1. Liu L et al. Tofacitinib 2% ointment, a topical janus kinase inhibitor, for the treatment of alopecia areata: a pilot study of 10 patients. Journal of the American Academy of Dermatology.

DOI: http://dx.doi.org/10.1016/j.jaad.2017.10.043

2. Topical Ruxolitinib Promotes Eyebrow Regrowth in Alopecia Universalis  

3. Topical JAK inhibitors for Children and Adolescents with AA  


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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Tofacitinib for Alopecia Areata: How long do we use it?

How long to continue Tofacitinib in Alopecia Areata?

 

A variety of treatments are available for alopecia areata. For localized (limited) AA topical steroids, steroid injections and minoxidil are still the mainstays of treatment. Treatment of advanced alopecia areata is more challenging. A variety of options are available in such cases including diphencyprone, prednisone, methotrexate and more recently tofacitinib.  

 

Tofacitinib in AA

We have been prescribing tofacitinib more frequently as an off label treatment for alopecia areata. The drug is surprisingly well tolerated for many, but does have potential side effects relating to long term immunosuppression. These include increased risks of infection, and concerns over possible long term cancer risks. The drug is expensive (1200-1400 USD per month). 

 

Lowest Dose, Shortest Time Needed

Clearly, in order to limit side effects of tofacitinib (and any drug) one should use the lowest dose possible and use it for the shortest duration possible. However, for many patients with advanced alopecia areata who are responding well tofacitinib and experiencing regrowth, any discussion of lowering the dose raises the possibility that hair loss could once again occur. The decision to taper the drug should always be carefully considered. Losing hair again can be devastating.

Some patients with advanced alopecia areata who start tofacitinib will likely need to use higher doses forever to maintain their hair density. But some patients will be able to eventually taper the dose. Some are able to taper it a bit and some are able to taper it a considerable amount and possibly even stop. However, it is less common to be in the latter group. Most patients who need to use tofacitinib in the first place have a more resistant form of hair loss that is unlikely to regrowth fully without immunosuppression.

 

Tapering Tofacitinib

There is no standardized formula for how to taper tofacitinib. Generally, my approach is the following.

1. Assuming a patient is using 5 mg twice daily (10 mg daily) go down to 10 mg on Monday, Wednesday and Friday and Sunday and 5 mg on Tuesday, Thursday and Saturday. This can be continued for 3 months. If there is any breakthrough hair loss, the patient returns to 10 mg daily.

2. If hair is growing fully, one can consider going down to 5 mg every day for an additional three months.

3. Thereafter, if hair growth continues to be full, we may consider 5 mg on Monday, Wednesday and Friday and no medication on the other days. A slower taper is possible if there are any concerns and this could include 5 mg daily Monday to Friday with the weekends being 'drug-free' periods.

4. Thereafter, any taper is done on a case by case basis. Many patients are not  able to taper further. However some may taper to 5 mg on Mondays and Thursdays before eventually going to one tablet weekly.

 

Lab Tests During a Taper

If blood tests have been stable and normal at the higher doses of tofacitinib I am generally less concerned about the patient having frequent monitoring blood tests. Nevertheless, I do feel that tests every 3-6 months is still appropriate even in a patient whose tests have been stable. I generally advise my patients to get tests for CBC, CK, cholesterol, liver function tests, creatinine, urinalysis. A repeat ECG is done every year.

 

Final Comments

The topic of tapering immunosuppressants is an important one in alopecia areata. Some patients are not able to taper immunosupressants at all without losing some hair. However, some patients can taper and a "go slow" approach is generally the best method. Go slow means not only taper the oral immunosuppressants slowly but given attention to how the patient's alopecia areata is treated topically. As tofacitinb is tapered, one may continue various topical (and even corticosteroid injection-based) treatments that have been performed alongside the immunosuppressive agents.  But eventually they too can be tapered in a stable patient. 

 

 


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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2017 in Review: 20 Research Papers that Made a Difference

Hair Research in 2017

2017 was an exciting year in hair loss research. As the new year unfolds, I consider it important to pause and reflect on some of the most influential research articles of the 2017.  The article can be accessed through the link below

2017: A YEAR IN REVIEW

Download PDF version 

 


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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Happy Holidays!

On behalf of everyone at Donovan Medical, we wish you a happy and safe holiday season.  

 

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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Are hair transplants possible for individuals with scarring alopecia?

Are hair transplants a good option for scarring alopecia?

LPP-HT

The answer to that questions is sometimes "yes" and sometimes "no". For many individuals who step into the office, the answer is frequently "no". A hair transplant is not a good option for them - at least right now. Not because we can't perform hair transplants in individuals with scarring alopecia but rather because the person sitting in front of me has a scarring alopecia that is currently active. They have ongoing hair loss and they report they have less hair than one year ago. Some have persistent itching, burning or tenderness in the scalp. These individuals are not candidates for a hair transplant any time soon.



A Balanced View of Hair Transplantation

It might sound surprisingly to have such a negative view of hair restoration for scarring alopecia. I would say that my view is balanced. The positive side of this topic is that a hair transplant can be a good option once the disease becomes quiet ... and stays quiet for a few years (ideally off medication). On previous blogs,  I have shared my personal views on the criteria we use when considering whether an individual is a good candidate for a hair transplant. These are mainly centered around lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) as these have been studied most extensively in our center.

CRITERIA FOR TRANSPLANTATION OF LPP

CRITERIA FOR TRANSPLANTATION OF FFA

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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Do all women with hair loss really need blood tests?

Evaluating Hair Loss in Women: Are blood tests really needed?

Click here for PDF of Article

That answer, in my opinion, is a resounding - "yes." All women with concerns about hair loss need blood tests. The reason is simple: there are a great number of similar looking hair loss conditions in women and if one thinks they can confidently, with 100% certainty,  rule out any particular condition just by looking at the scalp they are wrong. One can not exclude a contribution from low iron or a thyroid disorder even in a woman presenting with classic androgenetic alopecia. Let's take a closer look why blood tests are needed.

For a review of blood tests typically recommend as part of a screening work up click on the following 

SCREENING BLOOD TESTS FOR WOMEN WITH HAIR LOSS.

 

1. Iron deficiency anemia is common

About 1 out of every 5 women age 18-45 have iron deficiency. It's common. Given that low iron levels may be associated with a variety of different hair loss conditions, it is important to test for it and supplement iron in women whose blood tests show low iron. Even if one were to argue that low iron levels are seldom really a true factor in hair loss, studies have also shown that supplementation with iron may allow other treatments to work better.

In 1992, Drs Rushton and Ramsay conducted a study looking at women with genetic hair loss who were being treated with an antiandrogen medication (called cyproterone acetate). The researchers showed that women with iron levels above 40 had much better results with the antiandrogen pill than women who had iron levels below 40.
 

2. Blood counts

Ordering a basic blood count (for levels of red cells, white cells) is important. It's not a very specific test, but when the levels come back abnormal, it signals something may be wrong. A common reason for low hemoglobin and a low number of red cells levels is iron deficiency. But a variety of internal illness also have as part of their presentations low blood counts. A basic screen is helpful.

My work up is very different when a female with hair loss has an abnormal blood count. A 31 year old female with low hemoglobin and low ferritin, may have this result from heavy menstrual cycles, but may also have this from celiac disease as well. Depending on the patient and specific details, I may order a so called 'celiac panel' as well. A  66 year old female with low hemoglobin and low ferritin who comes into my clinic for hair loss may need a comprehensive work up by her physician to rule out a cancer. 

 

3. Thyroid abnormalities are common

About 1 out of every 15-20 individuals will be diagnosed with a thyroid disorder in their lifetime. These thyroid conditions are 8 times more common among women. While it's true that many with thyroid disease will notice symptoms, about one half will not notice any problems at first. Hair loss is frequently part of the collection of symptoms that come with thyroid dysfunction. Testing for thyroid disease in women with hair loss is important.

 

4. Vitamin D deficiency is common

Vitamin D deficiency is common. Here in Canada, studies have shown that about two-thirds of the population is low in vitamin D and levels tend to be lower in winter than summer.  The exact role of vitamin D in hair loss is still being worked out but it's clear that individuals with alopecia areata and genetic hair loss have lower vitamin D levels than individuals without hair loss.  

 

5. Zinc deficiency

Zinc deficiency is not common in North America. Nevertheless, zinc deficiency does exist in a number of subgroups in the North American population and is likely more common than appreciated. About 12 % of the general population and up to 40-50 % of the elderly are at risk for zinc depletion in North America. In many parts of the world, zinc deficiency is extremely common. In North America, zinc deficiency is frequently asymptomatic - meaning that individuals with low zinc don't necessarily have symptoms. Zinc deficiency can be associated with hair loss as well as a variety of issues related to immune system function and infection. The recommended amount daily is 11 mg for men and 8 mg for women.

 

6. Hormone Testing

Most women with hair loss do not require complex and extensive hormonal work-ups that so often are seen. However women with irregular periods, acne, excessive hair growth on the face (hirsutism), difficulty conceiving/infertility, early menopause and abnormal or rapid hair loss do require hormone tests. 

 

Conclusion

Complete blood counts, along with tests for iron status (ferritin test) and thyroid status (TSH) are among the most important tests for all women with concerns about hair loss. Other tests may also be important for any particular individual but the exact test to order depends on the information obtained during the patient interview.  Too often I hear it said that a female patient does not need blood tests. For example, I often hear it said that a female presenting with classic androgenetic alopecia does not need blood tests because classic androgenetic alopecia is not associated with blood test abnormalities. Here, one needs to consider that classic androgenetic alopecia may be associated with low vitamin D and research has even shown that it may be associated with cholesterol abnormalities as well (low HDL, high LDL).  If one feels they can exclude with certainty that this patient does not have iron deficiency or a thyroid disorder, they are incorrect.

All women with hair loss need blood tests. 

 

REFERENCE

Rushton DH, et al. The importance of adequate serum ferritin levels during oral cyproterone acetate and ethinyl oestradiol treatment of diffuse androgen-dependent alopecia in women. Clinical Trial. Clin Endocrinol (Oxf). 1992.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
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The Modified Hair Wash Test (MHWT)

A closer look at the MHWT for Differentiating CTE and AGA

The modified hair wash test (MHWT) is an extremely helpful non-invasive test. It is underutilized by dermatologist mainly because of lack of familiarity and exposure. It is an extremely powerful technique to differentiate challenging cases of CTE from AGA. The patient may perform this test at home. 

 

Performing the MHWT

To perform the MHWT, a patient is instructed to avoid shampooing the hair for 5 days before the date of set test date. On the day of the test, the sink is covered with a gauze. The hair is then shampooed thoroughly and rinsed. The hairs trapped in the gauze are collected counted and divided into hairs less than 3 cm and more than 5 cm.

 

Interpreting the MHWT

Patients with 10% or more of hairs 3 cm or shorter and who shed fewer than 100 hairs are diagnosed as having AGA; Patients with fewer than 10% of hairs that were 3 cm or shorter and who shed at least 100 hairs were diagnosed as having CTE; Patients with 10% or more of hairs that were 3 cm or shorter and who shed at least 100 hairs were diagnosed as having AGA + CTE; Finally patients with fewer than 10% of hairs that were 3 cm or shorter and who shed fewer than 100 hairs were diagnosed as having CTE in remission.

 


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 I eliminate the possibility of side effects from finasteride?

Eliminating a Drug is the only way to Eliminate the Possibility of Side Effects

I'm often asked how one can eliminate the side effects of a medication. "I want to take it doctor if it weren't for the side effects."  The reality is that it is possibility to eliminate the chances of side effects from any drug - and that is by not taking the drug.

 

Reducing Side Effects from Finasteride

The only way to really eliminate side effects from finasteride is not to take the drug. The chances of side effects with oral finasteride are low and in the order of 1-2 %. Nevertheless, all men need to be aware of the possibility of sexual dysfunction, mood changes, gynecomastia and other potential side effects as well.  The chances of side effects tend to be depenent on the amount of finasteride absorbed into the blood stream which in turn affects the degree of reduction in DHT.

 

1. Reducing the dose

Reducing the dose to 0.5 mg or 0.25 mg may be associated with reduced chances of side effects. DHT is still inhibited at these doses, albeit not as effectively as a 1 mg dose. Studies have suggested that DHT inhibition at 0.2 mg is about 80 % the level of 1 mg pill.

 

2. Reducing how often it is taken

Even though the drug half life is 6-8 hours, one needs to consider how long 5 alpha reductase inhibition in the scalp is actually occurring. Studies have suggested that 1 mg finasteride daily and 1 mg finasteride every other day are fairly similar in effectiveness although good studies still have yet to be done to really back this up definitely. Taking every other day can reduce side effects but may potentially alter effectiveness as well.

 

3. Using topical compounded finasteride

The other way to minimize finasteride side effects is to consider topical finasteride applied to the scalp. Absorption into the blood stream may still occur with topical finasteride (as systemic DHT levels are still reduced) but side effects are much less.

 

4. Taking time to understand the risk and benefits, long term studies

Studies also show that a broad and objective understanding of finasteride, its proper use also reduces side effects. Men who are alarmed about the drug and proceed into taking the drug without a full and balanced view of the risks and benefits also have a higher incidence of side effects. Studies have shown that risks increase in this situation from 2-5 % to above 60 % (i.e. nocebo effects).

 

Conclusion

Anyone wishing to minimize side effects of finasteride should have a thorough discussion with their physician. For more information on finasteride, download our handout. 

FINASTERIDE - 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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Differentiating between Short 1 cm Hairs by Dermoscopy: Many Possibilities !

How can we tell apart the various causes of short hairs?

short-hairs

I'm frequently asked by patients and physicians how to determine the identify of a short 1 cm or so hair that is seen on the scalp. Looking at the scalp with dermoscopy, one often want to know "Is this a vellus hair I'm seeing or is it an upright regrowing hair as part of a telogen effluvium? ... or is it simply a normal regrowing hair ?"

This chart below helps summarize the main things I think about when I see a short hair. The answer does not necessarily come immediately but rather it comes by asking 4 questions:

1) Is the hair reasonably thick (i.e. 40-50 um or more) or is it very thin (less than 30 um)?

2) Are the ends pointy or blunt?

3) Are these short hairs found all over the scalp or just one area?

4) Are there just a few of these short hairs or lots and lots of them?

 

By working through these 4 questions, I can generally determine the cause of the short hair I'm seeing on the scalp. 

shorthairs

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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