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On Seeing the Bigger Picture

The Bigger Picture Must Not be Forgotten When Diagnosing Hair Loss

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Emily Carr was a Canadian artist and became well know for her landscape paintings - especially of trees and the forest.I like this quote of Emily Carr. It reminds us to always consider the meaning of the the “bigger picture.”

The use of techniques like trichoscopy have really changed how physicians practice hair loss medicine. Seeing the scalp up close increases accuracy to diagnose certains hair loss conditions. But we must always remember to step back and consider the “bigger picture.”

For example, although physicians come to learn that hair follicle “miniaturization” is a feature of androgenetic alopecia (male and female balding), the finding of a small number of miniaturized hairs on the scalp does not necessarily mean that much. The advice about seeing the “bigger picture” is useful for patients too. The occasional thin hair a patient sees in the brush should not necessarily cause alarm. At least not with taken the entire scalp density into context.

Emily Carr’s words are indeed wise .... “In the forest think of the forest, not this tree and that.”

The examples for the scalp could go on and on., The finding of one hair with so called “perifollicular scale” around the hair does not necessarily mean the diagnosis is the scarring alopecia lichen planopilaris if the surrounding areas of the scalp still look normal.   

And on we go. The finding of a single scar on the scalp does not necessarily mean scarring alopecia. A single twisted hair does not necessarily mean the “pili torti” of scarring alopecia. A single pustule does not mean much either.  

Just like a forested area may have tens of thousands of trees (or more) depending on whether one is referring to a local neighbourhood forest or the forests of the deep wilderness, the scalp itself has up to 100,000-120,000 hairs. If a patient is suspected to have hormonal issue or immune based issue or genetic issue as the cause of their hair loss but yet only seems to have changes affecting one or two hairs when the scalp is examined we need to at least consider the possibility that we’re not quite barking up the right tree (as the expression goes). Perhaps we don’t quite have the diagnosis. 

It’s certainly true that many hair diseases favour certain areas of the scalp and leave other areas unaffected. So, we might not expect all the hairs to be affected. In addition, every disease has to start somewhere so one could argue that at least one hair up there on the scalp needs to be the very first hair affected in any given disease. The reality is that even when we diagnose diseases in the very earliest of stages, we generally see many hairs affected - not just one


The area that genetic hair loss affects may contain 25,000-40,000 hairs. By the time we’re confidently able to diagnose genetic hair loss clinically some 10-20 % of hairs in a given area are showing “miniaturization.” In other words many thousands of hairs on the scalp show the key diagnostic features. The area that frontal fibrosing alopecia affects may contain 5000 - 10000 hairs. Certainly more than one hair is likely to be affected by the patient’s activated immune system. Similarly the immune system in patients with lichen planopilaris may be patrolling an area containing 30,000-70,000 hairs depending on the extent. A single finding in one hair follicle does not carry much significance. After all, why would the immune system target one hair and not disturb thousands (or tens of thousands) of others nearby?

While the tools we have in trichoscopy are wonderful and have changed how hair dermatology is practiced, we need to always consider the bigger picture. Emily Carr’s quote is a nice reminder that we need to step back and consider what is happening on a bigger scale to hundreds of hairs in an area - of better yet - to tens of thousands of hairs in the area.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Why treat scarring alopecia if it can't regrow hair?

Treating Scarring Alopecia: What’ s the point?

The scarring alopecias are a group of hair loss conditions whereby patient’s lose hair in a manner that has the potential to be permanent. The reason the hair loss may be permanent is that these conditions are associated with the depositing of tiny bits of scar tissue beneath the scalp that make it difficult for hair to regrow. Treatments are often used to help stop the process, although sometimes regrowth is possible. Regrowth is more of an option when treatments are used in the earliest stages of the disease. In more advanced stages, regrowth generally does not occur.

Why treat if I’m not going to regrow anything back?

Patients often ask me why they should bother treating if they can’t grow back any hair. Sometimes this is said in frustration but other times after much thought about the whole process. Here are some important considerations as to why some patients decide to try to treat their scarring alopecia despite the fact that that hair is not going to come back for many people:

1. I want to save whatever hair I have now. Some patients choose to begin treatment to save the hair that they have. They understand that getting more hair back is not likely to occur but want to hold on to whatever they have. They want to have the ability to style the hair they have now and use the existing hair to camouflage thinning areas.

2. I want to stop my symptoms of itching and burning. Scarring alopecias can be associated iwth troublesome scalp symptoms like itching, burning and tenderness. Some patients choose to begin treatment to stop their symptoms regardless of what effect it will have on hair growth or loss. Not all patients with scarring alopecia have symptoms but for some patients the intensity of symptoms can be quite high. it’s not uncommon for itching, burning for some patients to reach levels of 6-10 out of 10 (with 10 being maximal itching and burning that one can imagine).

3. I would like to keep the hair they have now so my hairpeice, wig or system fits better on the scalp. Some patients want to hold on to their hair so that their current wig or hairpeice has something to attach to or so that it blends in better with their existing hair. Consider the middle age male with lichen planopilaris that I saw last week. He is wearing a hair system and it looks terrific. The top of the scalp is shaved and the system is attached to the top of the scalp with use of adhesive. It blends in quite unnoticeable with this hair around the sides and the back. The main issue for him is that he also has lichen planopilaris (scarring alopecia) affecting the sides and the back and this area is at great risk for being lost too. If this area were lost the current system might not camouflage as effectively. We are doing everything we can to save the hairs around the sides and back. Regrowth of hair is not a point of discussion here.

Summary and conclusion

The early and aggressive treatment of scarring alopecia can sometimes lead to a bit of improvement in hair density - but not always. Many patients with scarring alopecia chose to begin treatment even though getting back hair is not one of the goals. For some the decision to start treatment centers around the hope to hold on to whatever they have. For others, it’s centered around setting or stopping troublesome scalp symptoms like itching or burning.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Risk of Alopecia areata and Lichen planopilaris increased in Patients with Hidradenitis Suppurativa

New study Identifies Increased Risk of Autoimmune Hair Loss in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a dermatological condition that is associated with painful draining lumps in the underarm area (axillae), groin area and buttocks and under the breast. The lay public often refers to such lumps as boils - and patients affected by hidradenitis often describe their disease as one of multiple draining boils in the armpits, groin and buttocks regions. The condition can be emotionally and physically disabling.

Association of HS with Several Hair Loss Conditions

For years, it has been appreciated that there is a close relationship between HS and the scarring alopecia dissecting cellulitis. A new study points out that patients with HS are also at risk to develop alopecia areata and lichen planopilaris.

Researchers at Penn Sate Milton S Hershey Medical Center in Hershey, Pennsylvania studied 3645 patients with HS and compared the findings to 36, 450 matched controls. The researcherss showed that patietn with HS were had increased risk (relative risk 2.22) to develop alopecia areata (including totalis and universalis) compared to the control group. Interestingly, there was also an increased risk (relative risk 1.54).

Comment

This was an interested study and helps us to understand that alopecia, LPP dissecting cellulitis and hidradenitis share more in common than perhaps we once realized. This data would suggest that these diseases all share in common a central role of the hair follicle as an target of the initial inciting event. These disease probably have some common inflammatory pathways shared.

This data is an important as research in hidradenitis is at an all time high and the condition is being studied and discussed by dermatologists at a rate never seen before. Advances in treatments for HS may provide some help to how we go about treating alopecia areata and lichen planopilaris. Confirmation of this awaits further studies.

Reference

Horissian M et al Increased risk of alopecia areata for people with hidradenitis suppurativa in a cross-sectional study. J Am Acad Dermatol 2019


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Topical Treatments are Safer - but Humans Generally Dislike them

Topical Treatments: Unless the Treatment is Amazing People Generally Dislike Topical Treatments

There is a major push to develop better and better and safer and safer treatments for hair loss. There is a move from using oral treatments (ie oral finasteride) to using topical ones (ie topical finasteride). At the same time, there is ongoing recognition that many patients don’t like topical treatments. Critics can relax - of course some people don’t mind topical treatments. Yes, there are countless patients the apply topical treatments every day. Yes, not a day goes by that a patient doesn’t say to me how they are using their topical product “religiously.” But most people don’t like them. The strategists and big thinkers of the hair world understand this. Most don’t.

Men, Minoxidil and the Mapar Study: Do most men use minoxidil as they should?

I’d like to introduce you to a study that is often forgotten. I think it’s as much a study of behavioural psychology as it is a study of hair loss treatment.

A 2007 study by Mapar examined the proportion of men that stopped using minoxidil. As we go about reviewing this study it’s important to keep in mind that minoxidil doesn’t do all that much for about 75 % of men. It helps 25 % to various degrees and the rest aren’t helped all that much. So, in any study looking at use and disuse of minoxidil, we expect a good amount to eventually stop using - but we also expect a good proportion to carry on!

Mapar studied 1495 men aged 20-40 years who started treatment with 5% topical minoxidil solution. Remarkably, almost all the patients gradually avoided continuing the treatment. Only in a few patients was the cessation of medication due to adverse effects. The causes of discontinuation in the majority of patients were the low effect of medication and an aversion to this topical treatment method.

Conclusion

There are flaws to any study and granted this one has them too. But this study has important lessons. Humans are more likely to apply topical treatments if the treatment works fast and has good effect. We’re less likely to commit to a topical plan if outcomes are slow and mediocre.

It would be a mistake to conclude from this study that minoxidil has no role in male balding. Not at all. The take home message form this study is that most men left to their own will - are going to stop using. It’s the role of the specialist to help manage expectations and to encourage use for the appropriate amount of time to determine if it’s working or not.



Reference

Mapar et al. Is topical minoxidil solution effective on androgenetic alopecia in routine daily practice?J Dermatolog Treat. 2007;18(5):268-70.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Lichen planopilaris: An Inflammatory Disease

Lichen planopilaris is associated with Inflammation Around Hairs

Lichen planopilaris (LPP) is a type of scarring hair loss that gives permanent hair loss. Scalp biopsies are performed if the diagnosis is still not clear after the physician has examined the scalp.


This photo shows a scalp biopsy from a patient with lichen planopilaris. The skin surface is shown at the top of the picture. Four hair follicles can be seen below that. Inflammation is seen surrounding these hairs. This inflammation promotes the progressive destruction of hair follicles.

Histopathology of lichen planopilaris: Inflammation is seen around the hairs

Histopathology of lichen planopilaris: Inflammation is seen around the hairs

Treatments for LPP

Treatments for LPP are reviewed in other articles. Treatments that stop inflammation are often helpful in LPP including topical steroids, steroid injections, topical calcineurin inhibitors, oral doxycycline, oral hydroxychloroquine (Plaquneil), methotrexate, cyclosporine, isotretinoin, mycophenolate ... and others. The goal of treatment is typically to help stop the disease rather than prompt regrowth. That said, the aggressive treatment of LPP in the early stages may help with some amount of regrowth.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Acne necrotica of the scalp: What is it?

Acne necrotica varioliformis and acne necrotica miliaris

Acne necrotica varioliformis (ANV) - DEEP SCARRING FORM

Acne necrotic varioliformis is thought to be rare but it’s probably way more common than we realize. We just don’t speak of this entity much any more. Patients with acne necrotic varioliformis develop crops of 1-2 mm papules (bumps) or pustules (“pimples” - except they don’t have pus) that end of healing over with formation of a pitted scar. (varioloform means resembling chicken pox or variola).

When the lesions on ANM first start they look like a red bump but soon form an umbilicated lesions that then goes on to form a pustules and then a crust and then scar. Patients affected by ANV are typically middle aged women (although men can be affected as well) and develop these lesions most often on the face (frontal hairline), scalp, nape but also can develop them on the chest and nose, eyebrows (interestingly in a seborrheic distribution). They can however be more widespead in the scalp, face and trunk. The condition can come and go for years (ie. a recurrent process) with outbreaks of just a few such bumps or several hundreds. Some of the literature (mainly a 1988 article by Dr David Fisher) cites that affected patients are more likely to be anxious, or under great pressure - but this has not be firmly established.

Confirming the diagnosis of Acne necrotica varioliformis (ANV)

The diagnosis of ANV is usually made clinically - meaning that an experienced physician can make this diagnosis by looking carefully at the frontal hairline, scalp, forehead/face and nose and chest and eyebrows.Pitted scars is the key finding that I look for. This an often be found on the back of the scalp but really anywhere where the disease has affected including the lateral eybrow. A biopsy can be helpful if there is uncertainty. Biopsy of an umbilicated papule typically shows a lymphocytic infiltrate around the hair follicle and this results in massive death (necrosis) of the keratinocytes in the follicular sheath. Rather than the focal inflammation in the outer portion of the follicle in lichen planopilaris, the inflammation in ANV is widespread throughout the keratinocytes in the sheath. The inflammation may spread into the epidermis with so called lymphocytic exocytosis and there may be necrosis of the epidermis too. In addition to what is happening in the follicle itself, there is also surrounding fluid accumulation (subepidermal edema) and lymphocytic inflammation as well.

In recent years, there has been a trend to call the condition lymphocytic necrotizing folliculitis. Terms such as acne frontalis are still used.

Treatment of Acne Necrotica Varioliformis

The treatment of ANV generally begins once the lesions have been cultured. I generally recommend starting with cultures before any type of antibiotic is given. If the culture comes back with an organisms, one can determine the appopriate antibiotic as this information is typically provided by the microbiology lab. If the cultures come back negative, one can begin emperical therapy with topical options like topical clindamycin lotion, topical erythromycin gel and possibly a steroid as well. If ineffective, the dermatologist will generally prescribe an oral agent such as doxycycline (50-100 mg twice daily) or isotretinoin (at a dose of 0.5 mg per kg). Options such as cephalexin or trimethoprin-sulfamethoxasole can be considered as well. I do believe, as do others, that it is imperative to stop the itch scratch itch cycle in this condition. Antihistamines can be considered as can low dose SSRI or SNRI antidepressants. If these antidepressants do not help, doxepin or tricylic antidpressants (amitriptyline 10-25 mg at night can be considered).

In order to reduce the bacterial load on the body and scalp, topical antibiotics (mupirocin) can be applied to the nares, axillae, and groin. The nails should be trimmed very short. The use of an antibacterial wash can also be considered in resistant cases.

Acne necrotica miliaris (ANM) - SUPERFICIAL FORM

The diagnosis of acne necrotica “miliaris” must also be considered in all patients with acne necrotica “varioliformis”. However, patients with ANM usually ONLY have a few lesions on the scalp at any one time -although frontal hairline, face and chest can be affected in some patients). By ‘few’ I mean 8-10. The back of the scalp can particularly be affected. The scalp is the main site compared to ANV where the chest and face, eyebrows are also affected. The lesions appear as superficial exocoriated crusts and papules that are extremely itchy. They can resemble pimples although it’s difficult to actually squeeze anything out of them. In fact, it’s usually difficult to find the actual pimple lesions because they have crusted over. The lesions in ANM do NOT heal with scars - and that’s the key differentiating factor from ANV. A link between bacteria such as Propionibacterium acnes or Staphylococcus aureus and ANM has been proposed. Many researchers feel that ANM is simply a form of P acnes folliculitis of the scalp

Treatment of Acne necrotica miliaris (ANM)

Treatment of ANM is similar to ANV with topical steroids, topical antibiotics, and oral tetracyclines being helpful.

FINAL COMMENTS

ANV is more common than we all realize. We just don’t talk about this condition anymore. The dermatologists Plewig and Kligman summarized it best in their 1993 textbook when the stated "Awareness of
this bizarre disease is a prerequisite for an accurate diagnosis."

Reference

Fisher DA. Acne necroticans (varioliformis) and Staphylococcus aureus. J Am Acad Dermatol. 1988;18:1136-1138.

Kossard S, Collins A, McCrossin I (1987) Necrotizing lymphocytic folliculitis: the early lesion of acne necrotica (varioliformis). J Am Acad Dermatol 16:1007–1014.

Pitney et al. Acne necrotica (necrotizing lymphocytic folliculitis): An enigmatic and under-recognised dermatosis. Australas J Dermatol. 2018 Feb;59(1):e53-e58.

Plewig G and Kligman AM, eds. Acne and Rosacea. 2nd ed. New York,NY: Springer Verlag NY Inc; 1993:500-505.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Aclaris Shares Some New Research Data on ATI-502 in Androgenetic Alopecia

Small Study of ATI-502 Shows Three Times the Benefits in Women than Men

Aclaris is a US pharmaceutical company that has an interest in determining if their JAK inhibitor technologies can help grow hair in various types of hair loss conditions. They have been studying the use of their JAK inhibitors in various hair loss conditions such as alopecia areata and andrognetic alopecia. Recent studies of the Aclaris topical JAK inhibitor was disappointing for those with alopecia areata. Interestingy, the companies 6 month data with the same drug for treating androgenetic alopecia has shown some positive results. Equally surprising as well was the finding that women seem to have repsonded to the treatment much better than men.

This data comes from a press release that the company has shared on their website.

Small Study of AT-502 Indicates Potential Benfits for Women’s Hair Loss

The Aclaris company is just getting going with its look at the use of JAK inhibitors in androgenetic alopecia. The interest in using the JAK inhibitors to treat androgenetic alopecia dates back to findings by Columbia University researcher Dr. Angela Christiano.

Although Dr. Christiano’s hypothesis has been that inhibiting JAK pathways could help the balding process by blocking inflammation that otherwise keeps hairs dormant, this has not always seemed to be the case so far. Patients with alopecia areata and androgenetic aloepcia who are treated with JAK inhibitors often grow back their hair from the alopecia areata component but don’t really grow back the androgenetic alopecia component. In other words, much of the information we have to date would seem to suggest that JAK inhibitors like tofacitinib and ruxolitinib don’t help the balding process. So, to consider treating androgenetic alopecia with a JAK inhibitor might seem like a bit of a stretch.

The Aclaris study shared in this press release was a very small study of AT 502 in about 23 participants. The study subjects applied the topical JAK inhibitor twice daily for 26 weeks. 14 men and 6 women with androgenetic aloepcia were able to complete the study in a manner that allowed hairs to be counted “before and after”. 22 participants were able to give their opinions on the treatment and also have have their study doctors evaluate the benefits.

What came out as interesting to me in this preliminary study was just how much better the topical drug was in helping women with androgenetic alopecia than men. In fact, it appears the topical JAK had three times the growth promoting benefits in women than men. It is important to keep in mind that the study is small and further evaluation will be needed. Nevertheless, in women using the AT 502 there was an increase in the number of thick hairs (so called non vellus target hairs) by 15.3 hairs per square cm in women and 5.6 hairs per sq cm in men. 82 % of study subjects felt that they actually had some kind of improvement with the drug. According to the study doctors, about 73 % of patients in the study improved with AT 502.

Comment

This is interesting preliminary data. It’s pretty clear now that inflammation has a role in androgenetic alopecia, ‘Microinflammation’ is now the buzz word in the field and we’re slowly coming to all realize that the inflammation hiding under the scalps in patients with androgenetic alopecia is probably not a good thing.

See previous article: Inflammation in AGA:

It’s intriguing that these JAK inhibitors would have so much better of an effect in women than men. The improvements in 15 hairs per sq cm is quite significant and we’ll need to wait to see if the women in the study can hold on to this improvement through the 1 year time point and whether this can be confirmed in bigger studies (there were only 6 women in this particular study!)

Whether getting rid of this scalp “microinflammation” is best done with a JAK inhibitor or best done with some other type of treatment will await further studies. For now, we’ll all await the 1 year update on results from Aclaris.



Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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The Oral JAK Inhibitor Race

The JAK Inhibitors in Alopecia Areata: A Look at Pfizer and Concert Pharmaceuticals

The last 5 years have witnessed some exiting progress in the field of alopecia areata research. Although not yet FDA approved, we now have several JAK inhibitors that are used “off label” in treating this disease - tofacitinib, ruxolitinib and baricitinib. These continue to be studied and they have become an important part of my practice is resistant forms of alopecia areata.

SEE PREVIOUS ARTICLES:

How long do we use tofacitinib for? Can we taper?

Tofacitinib for Alopecia Areata: How soon does regrowth occur?

New Clinical Trials For JAK Inhibitors Underway

A number of clinical trials have been completed and additional ones are in progress.

Furthermore, we are now seeing several clinical trials underway with new drugs. Companies like Pfizer, Aclaris and Concert Pharmaeuticals are studying various new JAK inhibitors.

Pfizer: PF-06651600 And PF-06700841

Pfizer has taken interest in understanding the potential benefits of its JAK inhibitors. Centers in the US, Canada, and Australia are involved in studies of Pfizer created JAK inhibitors:

Pfizer Trials: PF 06651600

Concert Pharmaceuticals: CTP-543

Concert Pharmaceuticals has recently expanded it’s clinical trials. The company studies a specific form of ruxolitinib known as “deuterated ruxolitinib.” The JAK inhibitor is also known as CTP-543. Clincial trials are now underway comparing the tolerability of once-daily versus twice-daily dosing of CTP-543, in adult patients with chronic, moderate to severe alopecia areata.

Concert Pharmaeutics: trials with CTP-543

Comments

It’s an exciting time in the clinical and research world of alopecia areata. The JAK inhibitors have brought to the clinic what we have long hoped for - treatments that specifically target pathways that are abnormal in alopecia areata. The ongoing studies of topical JAK inhibitors have been somewhat disappointing to date - but the studies of the oral JAK inhibitors continue to show promise. Of course, additional studies in both area are important as this field moves foward.

Patients interested in understanding what clinical trials may be available in their area should visit the clinical trials website of the US National Library of Medicine:

Is there a clinical trial in my geographical area?


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Results of Topical JAK Inhibitor Study for Alopecia Areata Does not Show Benefit

ATI-502 Topical JAK Inhibitor for Alopecia Areata Did Not Show Benefit

The JAK inhibitors are a group of medications that have been shown to benefit patients with alopecia areata when taking in the oral form. Tofacitinib, Ruxolitinib and Baricitinib are pills that have shown benefit in alopecia areata and are frequently used ‘off label’ in more advanced forms of the disease. By off label, we simply mean that the drugs have not yet received formal FDA or Health Canada approval.

There has been a massive surge in interest in studying whether topical JAK inhibitors could provide benefit. Companies such as Aclaris are studying various JAK inhibitors for alopecia areata. I was interested to note this week the final results that were published by Aclaris Therapeutrics regarding their Phase 2 clinical trial of ATI-502 (also known as AA-201) a ‘topical’ JAK inhibitor for alopecia areata. The study showed that the topical JAK inhibitor treatment did not prove more effective than the placebo.

The study was a double blinded placebo controlled trial which evaluated two concentrations of AT-502, namely 0.12 % and 0.46 %. Participants applied the treatment twice daily for 24 weeks.

READ ACLARIS NEWS RELEASE SHOWS NO BENEFITS FOR ATI-502

COMMENT

These studies of topical JAK inhibitors are very important (and so are the studies with the oral JAK inhibitors). While it would seem that topical JAK inhibitors should help if the oral forms help, that needs to be proven in well conducted trials. The way that a topical JAK inhibitor is made up by the pharmacist is clearly important as previous studies showed the some formulations - like ointments - are quite ineffective for treating alopecia areata. For example, a 2018 study by Liu, Craiglow and King did not find the 2 % ointment to be all that helpful.

TOPICAL TOFACITINIB OINTMENT NOT VERY HELPFUL FOR ALOPECIA AREATA

It will be interesting to see if other topical JAK inhibitors have positive results in ongoing studies.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Twice daily use of bimatoprost 0.03 % for eyebrow frontal fibrosing alopecia

Bimatoprost (Lumigan, Latisse) for Eyebrow FFA

Bimatroprost is a prostaglandin F2 alpha analogue that is helpful in stimulating hair growth for some types of hairs. It is FDA approved for treating poor eyelash brow (eyelash hypotrichosis) with a once daily application. A recent report supports the use of bimatoprost twice daily in the treatment of eyebrow frontal fibrosing alopecia.

Murad and Bergfeld from the Cleveland Clinic reported a 48 year old female with eyebrow FFA along with scalp FFA. She was intiially treated wtih hydroxychloroqine (200 mg twice daily), clobetasol scalp lotion and tacrolimus 0.01% ointment. Although her scalp FFA improved somewhat, her eyebrow FFA did not improve with the hydroxychlorouqine and the patient was therefore started on an off label use of bimatoprost 0.03 % twice daily. Within 6 months the patient reported improved eyebrows. She did not experience any side effects.

Comment

This is a nice study to have on hand. There are only three things that can really the used on the eyebrows topically in FFA - minoxidil, topical steroids and bimatoprost. We’ve been using bimatoprost (as Latisse) for many eyebrow hair loss conditions - including alopecia areata, frontal fibrosing alopecia, trichotillomania, and other hypotrichotic disorders. While growth does not occur in all patients and the chances of growth depend on the specific condition being treated and its activity, bimatoprost is one of the tools in the toolbox for getting eyebrows to grow.

Reference

Murad A et al. Prostaglandin analogue for eyebrow loss in frontal fibrosing alopecia: a case report.J Eur Acad Dermatol Venereol. 2019 May 22. doi: 10.1111/jdv.15704. [Epub ahead of print]




Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Changes in the Scalp Microbiome in Alopecia Areata

Different Organisms Found on the Skin in Alopecia Areata

It has been estimated that every square centimeter of human skin normally has about 1 billion organisms. This includes bacteria, viruses and fungi. There is nothing abnormal about this - it’s simply part of being human. We share our skin with many microorganisms in the world around us. We call this normal population of organisms the “skin microbiome.” When the constitution of these organisms change, we say that there has been ‘microbial dysbiosis.

Microbial Dysbiosis in Alopecia Areata

The topic of microbial dysbiosis has become increasingly popular. In many fields of medicine, experts are examining changes in bacteria as a means to explain disease pathophysiology. The two most common areas of exploration are the gut and skin. Changes in the normal populations of organisms in the gut and skin are believed to play a role in certain diseases.

Whether or not “microbial dysbiosis” plays a role in scalp disease is actively being researched. A recent study from Milan showed that patients with alopecia areata indeed had a change in their scalp microbiome. The study showed an increase in Propionibacterium, a decrease in Staphylococcus epidermidis and no change in Staphylococcus aureus. The analysis specifically showed an increase of Propionibacterium from 45.6% to 55.1% in AA subjects. Alongside data showed a general decrease of Staphylococcus epidermidis from 32.6% to 27.4% .

Conclusion

This is one of the first studies to now focus on changes in the skin microbiome and how this relates to skin disease. The precise significance of the information is not clear. However, it should be noted that Pacnes is able to synthesize many enzymes involved in the metabolism of porphyrins that, once activated, may contribute to oxidation and follicular inflammation.


Reference

Pinto D et al. Scalp bacterial shift in Alopecia areata. PLoS One. 2019 Apr 11;14(4):e0215206. doi: 10.1371/journal.pone.0215206. eCollection 2019.






Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Are we seeing more young males with balding ?

Is Early Onset Androgenetic Alopecia Increasing in Males?

Early onset balding is important to recognize and important to understand all the health issues surrounding it. I define early onset male balding as a form of androgenetic alopecia happening before age 30. Men with early balding have an increased risk of high blood pressure, high cholesterol, and metabolic syndrome later in life - so proper counselling is essential for these males.

Is the incidence of male balding increasing?

I am often asked if more young men are balding nowadays. I was interested to read results of a survey of 41 dermatologists whereby 88% felt there indeed was an increase in incidence of AGA in men younger than 30 years.

I was also interested to read a theory by Goren and colleagues as to why more and more young men might be experiencing balding. The argument was that there are increasing social pressures for women to conceive later in life and women who are actually able to conceive in their late 30s and 40s may have genetics that leads them to have a lower risk for premature ovarian failure, higher antral follicle counts in the ovary and ovulation at a later age. These same genetics (ie the length of the CAG repeat on the androgen receptor gene) is associated with increased balding in their male children.

More study is needed of this interesting hypothesis.

Reference

Goren A et al. Social selection favours offspring prone to the development of androgenetic alopecia. J Biol Regul Homeost Agents. 2017 Oct-Dec;31(4):1013-1016.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Antidepressants in alopecia areata: Could they help the hair if depression is also present?

Is there a role for antidepressants in alopecia areata patients?

Antidepressants may not only benefit some patients with depression but may have an anti-inflammatory effects as well. inflammation is increasingly understood to have some type of role in the mechanisms that lead to depression. It has been proposed that the anti-inflammatory actions of antidepressants maybe relevant to their anti-depressive effects. Decreases in TNF -alpha levels and increases in IL-10 levels may be among the effects observed with antidepressants.

Studies of Antidepressants in Alopecia Areata

To date, there have been three controlled trials of antidepressants in pateins with alopecia and several case reports. These include studies of using the following antidepressants:

1) Imipramine 75 mg daily

2) Paroxetine 20 mg daily

3) Citalopram 20 mg daily

4) Trimipramine 100 mg daily

Three Controlled Antidepressant Trials of Note

Three controlled trials have reported beneficial effects of antidepressants in treating alopecia areata. Patients with alopecia areata that were part of these studies had either anxiety or a depressive disorder.


STUDY 1: Perini et al, 1994

Perini and colleauges conducted one of the earliest studies looking at the potential benefits of antidepressants. Here they studied the tricyclic antidepressant antidepressant imipramine. The authors conducted a placebo-controlled study with imipramine 75 mg once daily as the sole therapy for alopecia areata. At 6 months, hair regrowth was reported in 5 out of 7 patients treated with imipramine, with no regrowth noted in the placebo group of 6 patients.

STUDY 2: Cipriani et al, 2001

In 2001, a small randomized controlled study was conducted by Cipriani and colleagues. The study involved a total of 13 patients with alopecia areata who were randomized to receive either paroxetine 20 mg (8 patients) or placebo (5 patients). The authors reported a better outcome with paroxetine than placebo.

Unlike other studies this study also includes more severe and resistant types of AA: alopecia totalis in 3 patients and alopecia universalis in one patient. Paroxetine was given for 3 months, with a follow-up at 4 and 6 months after treatment was discontinued. Complete regrowth of hair was observed in 2 patients treated with paroxetine, and 4 patients showed partial regrowth.. In comparison, only one patient from the placebo group had an almost complete regrowth of hair.

STUDY 3: Abedini and colleauges, 2014

In a 2014 study by Abedini et al. 60 individuals with recent onset AA were treated with triamcinolone injections in alopecic patches, and one half of these (i.e. 30 indivdiuals) were randomized to also receive the open-label supplement of citalopram 20 mg orally once daily. At 6 months of treatment there was significantly more hair regrowth, as measured by reduced mean diameter of the alopecic patch, in the citalopram patients compared with the triamcinolone injection only patients. Citalopram was then stopped at the 6 month mark, and patients were reassessed after another 6 months. Relapse of AA was noted in 20% of patients who had previously received citalopram compared with 66.7% of patients who had only received triamcinolone injections.


Reference

Abedini H, Farshi S, Mirabzadeh A, Keshavarz S. Antidepressant effects of citalopram on treatment of alopecia areata inpatients with major depressive disorder. J Dermatol Treatm 2014; 25: 153–155.

Cipriani R, Perini GI, Rampinelli S. Paroxetine in alopecia areata. Inter J Dermatol 2001; 40: 600–601

Perini G, Zara M, Cipriani R, Carraro C, Preti A, Gava F, et al. Imipramine in alopecia areata. A double-blind, placebo-controlled study. Psychother Psychosom 1994; 61: 195–198. 56.

Ricciardi A, Ruberto A, Garcia-Hernandez MJ, Kotzalidis GD, Trevisi M, Persechino S, et al. Alopecia areata with comorbid depression: early resolution with combined paroxetine- triamcinolone treatment. J Eur Acad Dermatol Venereol 2006; 20: 1000–1001.

Ruiz-Doblado S, Carrizosa A, Garcia-Hernandez MJ, Rodrigu-ez-Pichardo A. Selective serotonin re-uptake inhibitors (SS-RIs) and alopecia areata. Int J Dermatol 1999; 38: 798–799.



Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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" When did your loss start?" - A closer look at whether people truly appreciate their own hair loss

Many people with hair loss don’t realize they have loss

I generally like to believe that my patients know their hair quite well. After all, they see if every day. It seems true that patients know their hair well once they become patients (and realize they do have hair loss). However, several studies however, support a notion that many people in the general population don’t realize they have hair loss for quite some time once it develops. Furthermore, studies suggest that when they do realize they have hair loss they tend to underestimate its severity rather than overestimate it. This is such a good lesson for many physicians who see hair loss patients who mistakingly believe that patients worry excessively and inappropriately about their hair.

Bondo et al 2004, British Journal of Dermatology

A 2004 study by Biondo and colleauges found that 44 women on the waiting list for hair loss actually tended to underestimate the severity of their hair loss rather than overesimate it.

Tosti et al 2005, British Journal of Dermatology


Tosti and colleagues found similar results to the Bondo study. The authors recruited 629 young women who were interviewed by a trained dermatologist the end of secondary school and university. Of these 629 women, 31 of those interviewed had FPHL.

Study participants completed various questionnaires investigating, among other points, the severity ratings of their AGA. Each of the 31 women who had hair loss were asked to describe her alopecia by choosing one of the following descriptions: ‘my scalp is clearly visible’ (12 subjects chose this answer); ‘my scalp is slightly visible’ (12 subjects); and ‘my scalp is not visible’ (seven subjects). Interestingly, 39 % of the women (12 of 39) denied their was a problem, and 39 % underestimated it.

Conclusion

These studies are important because they provide information that women tend to underestimate the severity of their hair thinning before seeing a physician. Although it still needs to be proven, the authors proposed that the tendency to deny hair loss may be considered as a self‐defence mechanism against the psychological stress caused by this problem. This is such a good lesson for many physicians who see hair loss patients who mistakingly believe that patients worry excessively and inappropriately about their hair.

REFERENCE

Tosti et al. Tendency to underestimate the severity of androgenetic alopecia. Br J Dermatol. 2005 Jun;152(6):1362-3; author reply 1363.

Biondo et al. Women who present with female pattern hair loss tend to underestimate the severity of their hair loss.Br J Dermatol. 2004 Apr;150(4):750-2.






Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Alopecia areata and Sclerotherapy: Coincidence or Connection?

Alopecia Areata And Sclerotherapy for Venous Veins

Alopecia areata is an autoimmune disease that causes hair loss on all part of the body. A large proportion of the disease is felt to be due to genes the patient inherits at birth. However, a minor proporiton of the disease is due to various environmental ‘triggers.’ Dozens upon dozens of triggers exists ranging from stress, infections, medications.

In 2017, Whiteley and colleagues published a report suggesting that perhaps sodium tetradecyl sulphate foam sclerotherapy might be added to the long list of potential triggers.

The authors described a 40-year-old woman with a history of alopecia areata who underwent treatment for bilateral primary symptomatic varicose veins. Her first procedure entailed pelvic vein embolisation of three pelvic veins using 14 coils and including foam sclerotherapy of the smaller vein tributaries (using 3% sodium tetradecyl sulphate). Following this procedure, she had an exacerbation of her alopecia areata. . Seven months later, she underwent foam sclerotherapy of leg and labial varicose veins again using sodium tetradecyl sulphate. Two days following this procedure, she had a severe exacerbation of alopecia areata with gross shedding of hair.

The authors raised the possibility that two episodes of exacerbation of alopecia areata appear to be associated with sodium tetradecyl sulphate foam sclerotherapy of veins. This is an interesting article and clearly demands larger studies. A large retrospective review among vein clinics world-wide could easy answer the question as to the real magnitude of risk.

ARTICLE: SCLEROTHERAPY FOR ALOPECIA AREATA


REFERENCE


Whiteley et al. Exacerbation of alopecia areata: A possible complication of sodium tetradecyl sulphate foam sclerotherapy treatment for varicose veins SAGE Open Medical Case Reports Volume 5: 1–4


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Estrogen, Anti-estrogens and Frontal Fibrosing Alopecia: What have we learned ?

Loss of Estrogen and Use of Anti-Estrogens May have a Role

Frontal fibrosing alopecia is a type of scarring alopecia which is becoming more common around the world. The condition typically affects peri-menopausal and post menopausal women. The disease may start with reduction in eyebrow density and recession of the frontal hairline. Other areas including eyelashes, body hair and hair on other regions of the scalp may be affected.

It is increasingly clear that hormonal factors are involved in the development of frontal fibrosing alopecia. Abnormalities in androgens and estrogens are thought to be involved.

Declining estrogens may have a role in women who are predisposed to develop this condition. The peri-menopausal period is well understood to be associated with steadily declining estrogen. A 2018 case control study by Buendia-Castrano and colleagues showed that menopause occured earlier in women with FFA. This data came from examining records of 104 female FFA patients and 208 controls. The same authors found additional data that interruption of estrogen signaling may have a role - the anti-estrogen tamoxigen was found to be associated with a nearly 15 fold greater risk of developing FFA.

Other studies have also supported the notion that low estrogen environments are somehow associated with the development of FFA. Imhof and colleagues in 2018 showed that 13 % of women in their study had a history of surgically induced menopause through hysterectomy. This data has raised the question as to whether the incidence of hysterectomy is higher than we previously had considered. In the same line of thinking, studies dating back to 2014 showed the early menopause was detected in 14 % of FFA patients.

Premature menopause is defined as menopause occurring in women under 40 years of age. Overall, about 1 % of women in the general population have premature menopause making the condition not really all that rare. The fact that 14 % of women with FFA may have early menopause draws attention to this as a contributing factor.

Conclusion

It is increasingly clear that the decline of estrogen has some sort of a role in FFA. It’s too simple to say that it’s the main reason. All women enter menopause but yet only 1 in every 5000 to 10000 develop FFA. it may be that the decline in estrogen in women who have some sort of a genetic predisposition promotes the development of this autoimmune hair disease. More studies are needed.

Reference

Buendia-Castrano D et al. Hormonal and Gynecological Risk Factors in Frontal Fibrosing Alopecia: A Case-Control Study. Skin Appendage Disord. 2018 Oct;4(4):274-276. doi: 10.1159/000484210. Epub 2017 Dec 8.

Imhof et al. Frontal Fibrosing Alopecia in Women: The Mayo Clinic Experience With 148 Patients, 1992-2016. Mayo Clin Proc. 2018 Nov;93(11):1581-1588. doi: 10.1016/j.mayocp.2018.05.036.

Vano-Galvan et al. Frontal fibrosing alopecia: a multicenter review of 355 patients. J Am Acad Dermatol. 2014 Apr;70(4):670-678. doi: 10.1016/j.jaad.2013.12.003. Epub 2014 Feb 5.




Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Can I use Latisse on my Thinning Hair? Will it Help? Is it Safe?

Latisse for Thinning Hair

I’m often asked if Latisse, containing the active ingredient bimatoprost 0.03 %, can be used for women and men with androgenetic alopecia. The short answer is it just doesn’t help enough to even make it even worthwhile.

Research over the last few yeas has shown that these so called ‘prostaglandin agonists’ do help to grow hair. Latisse contains the ingredient bimatoprost and this too has been shown to grow hair. In fact, it’s FDA approved to help eyelash growth at a concentration of 0.03 %. Application is nightly to the upper eyelid.

The main issue with Latisse is that the concentation of bimatoprost is quite good for growing longer eyelashes when placed on the delicate eyelid skin. However the concentration is just much too weak to be used on the very thick scalp. Latisse has much too low of a low concentration of bimatoprost - and it simply not enough gets into the scalp.

The Allergan company is studying much higher concentrations (3 % instead of 0.03%) and this is showing great promise. Indivdiuals using Latisse right now at the low concentration of 0.03 % on the scalp are going to find that it does not help enough to make it worth while.

Here’s another way of looking at it

1 mL of minoxidil costs 30 cents Canadian and this helps a bit for some people

1 mL of 0.03 % bimatoprost costs about 40 Canadian dollars and this helps hardly any for hardly any people

Interested readers may wish to refer to a previous article

BIMATOPROST FOR ANDROGENETIC ALOPECIA




Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Black Seed Oil (Nigella sativa) and It's Potential Anti-Inflammatory Properties.

Black seed Oil and Its Potential as an Anti lymphocytic treatment.

Black seed oil (Nigella sativa) is a 'herb with many pharmacological properties. The active constituent ‘thymoquinone’ (TQ) is thought to have the therapeutic effects and TQ are shown to possess multiple useful effects for the treatment of patients with several diseases, such as inflammatory and auto-immune disorders. It continues to be studied in other areas of medicine due to its potential effects in the setting of metabolic syndrome, its anti-cancer effects as well as its antimicrobial, anti-nociceptive and anti-epileptic properties. There is some evidence that it reduces fibrosis (scarring) in various models of lung scarring, kidney scarring, liver scarring and wound healing.

Whether black seed oil has any benefit in autoimmune scarring alopecias is unknown but warrants further study. In patients with autoimmune and inflammatory issues who do not wish to use more evidence based treatments (which have the best evidence) typically recommend does of 500 mg daily for 2 weeks and then 1000 mg daily after if the patient is tolerating it well.

I continue to follow ongoing studies of black seed oil. It is not possible at present to say that this herb has any benefit in the treatment of any of the autoimmune hair issues I treat. However, there is good reason to continue exploring this area. As just one example, I present a nice 2016 study by Kheirouri and colleagues. The authors reported results from a randomized, double-blinded placebo-controlled, 2 months, parallel-group clinical trial of black see oil. Forty-three female patients (20-50 years) with mild to moderate rheumatoid arthritis were recruited and assigned into black seed oil groups (n = 23) and placebo groups (n = 20) groups to receive 1000 mg of black seed oil (500 mg twice daily) capsule or placebo capsule. The disease activity scores of 28 joints (DAS28) were calculated and percentages of CD4(+), CD8(+), and CD4(+)CD25(+) T cells were examined using flow cytometry.

This study showed that treatment with black seed oil resulted in a significant reduction of the serum high-sensitivity C-reactive protein (hs-CRP) level and DAS-28 score and an improved number of swollen joints compared with baseline and study subjects using only the placebo. The treatment also resulted in reduced CD8(+) T cells, and increased the CD4(+)CD25(+) T cell percentage (i.e. the so called beneficial T regulatory cells) and increased the CD4(+)/CD8(+) ratio as compared to placebo and baseline. An increased CD4 to CD8 ratio is felt to be associated with better immune function. The overall conclusion of the study was that black seed oil had the potential to benefit an inflammatory disease through modulating T lymphocytes.

Conclusion

Black seed oil continues to be studied and for good reason. There is evidence that it has potential inflammatory effects and benefits in various auto-immune disorders. Whether it has any effects in patients with autoimmune hair loss is unknown but something that warrants further study.

REFERENCE

Kheirouri et al. Immunomodulatory Effect of Nigella sativa Oil on T Lymphocytes in Patients with Rheumatoid Arthritis. Immunol Invest. 2016 May;45(4):271-83. doi: 10.3109/08820139.2016.1153649. Epub 2016 Apr 21.

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Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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The Potential Antiandrogenic Effects of Stinging Nettle

Stinging Nettle: More studies needed of this interesting herb.

Stinging nettle has been around a long time. It has been used in traditional medicine circles for it’s anti-inflammatory and diuretic effects.

There are no good studies to date pertaining to its effects in hair loss. However, there are interesting studies in other areas of medicine that support a potential antiandrogenic benefit at doses of 300-600 mg daily. In a very small 2014 study, levels of testosterone and free testosterone and DHEAS were found to be reduced by this herb and clinical parameters like acne, irregular menstrual cycles and oily skin were improved in women using the herb.

THE ANTI-ANDROGENIC EFFECTS OF STINGING NETTLE:

It’s still far to premature to say that stinging nettle might have benefits for hair loss. However, this is a first small study that will hopefully fuel additional studies.

Reference

Najafipou et al. Therapeutic effects of stinging nettle (Urtica dioica) in women with Hyperandrogenism. International Journal of Current Research and Academic Review, 2014.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Using Low Dose Naltrexone for Lichen Planopilaris (LPP)

LDN for Lichen Planopilaris: Practical Points in Home Compounding

Interest in low dose naltrexone arose in 2017 when a US group report some benefits in a small number o patients. It’s clear that LDN helps some patients but it does not appear to help all patients. What remains to be seen is whether it actually stops hair loss effectively or whether it is merely better at suppressing symptoms.

The typcial dose of LDN is 3 mg nightly at 9 pm. The medication can be made up in tablets by a compounding pharmacy or patients can make up a solution of 1 mg per mL themselves in water provided they are comfrotable doing this. We’ve had many patients dissolving 50 mg tablets in glass bottles containing 50 mL of water and using 3 mL every day.

This video is a nice video on how this can easily be done at home. All patients should review this directly with their physicians or pharmacist to ensure that they understand how this is properly done.


MAKING UP LOW DOSE NALTREXONE AT HOME


Reference

https://donovanmedical.com/hair-blog/ldn

Strazzulla LC et al. Novel Treatment Using Low-Dose Naltrexone for Lichen Planopilaris. J Drugs Dermatol. 2017 Nov 1;16(11):1140-1142.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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