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Combining Oral Minoxidil and Oral Spironolactone for FPHL

New Potential Options for Female Pattern Hair Loss

Female Pattern Hair Loss (FPHL), also known as female hair thinning or female androgenetic alopecia is a common type of hair loss that affects about one-third of women. Most women affected by the condition start with slightly increased hair shedding.  Over time, the patient notices decreased hair density and a more see through appearance to the scalp.

Topical Minoxidil remains the only formally FDA and Health Canada approved treatment for FPHL. Application of minoxidil does have it's own unique set of challenges. Many patients give up after a period of time. Other options including oral anti-androgens, laser, PRP and hair transplantation (for some women).

Oral minoxidil has been around for many decades and was originally used as a blood pressure medication. It is known to increase hair growth on the body as a side effects. Recently there has been increased interest worldwide in understand the potential benefits of using low dose oral minoxidil to treat hair loss. Rather than using the 10-40 mg doses that were once used to treat blood pressure, low dose oral minoxidil for hair loss involves doses ranging from 0.25 mg to 2.5 mg. 

Rod Sinclair from Australia set out to study the potential benefits of using oral minoxidil and oral spironolactone together. The dose of minoxidil prescribed was 0.25 mg and the dose of spironolactone used was 25 mg.

100 women were included in this study. The mean age was 48.44 years and the mean duration of diagnosis was 6.5 years. Overall the drug combination reduced shedding and reduced hair loss. There was a slight reduction in mean blood pressure of 4.52 mmHg systolic and 6.48 mgHg diastolic.  8 % of patients in the study have side effects but they were deemed mild.   Only 2 of the 100 patients overall discontinued treatment and these were patients with hives (urticaria).

 

Conclusion

This is an interesting study. It has long been known that the combination of topical minoxidil and oral spirionlactone (at higher does) are beneficial to FPHL. In fact, it was Dr Sinclair who showed this many years ago as well. This study is interesting because of the safety and limited side effects that were observed. Only 2 % of patients dropped out of the study. In another study by Dr. Sinclair (of chronic telogen effluvium) which also involved study of oral minoxidil, there were no drop outs. Together, these studies speak to a relatively good safety profile of oral minoxidil. 

We have been using oral minoxidil in clinic for some time. I was first inspired to consider it by presentation by Dr SInclair a few years back. (Nobody in the world has more experience with oral minoxidil for hair loss than Dr. Sinclair). The most common side effects is the increased hair on the face (especially upper lip) and body that some patients get. Dizziness, headaches, hives, ankle swelling are among the other side effects. The most common side effect in practice is increased hair on the upper lip in 25- 35 % of women. Other less common side effects are typically headaches, ankle swelling, hives. Surprisingly, shedding does not tend to be very common when starting. The ease of taking oral minoxidil vs topical minoxidil does make it a important option for further study. 

More studies of oral minoxidil are needed but studied to date are promising.

DOWNLOAD ORAL MINOXIDIL HANDOUT

 

REFERENCE

Female pattern hair loss: a pilot study investigating combination therapy with low-dose oral minoxidil and spironolactone. Sinclair RD. Int J Dermatol. 2018.


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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Preparing for Pregnancy: Considerations for Women with Androgenetic Alopecia

Planning a Pregnancy with Female Pattern Hair Loss


Many women with genetic hair loss are worried about getting pregnant and how the pregnancy and delivery will affect their hair. It's an area that really isn't talked about very much. Some women feel it's difficult to talk opening with their partner or family about their hair when all the focus is on the pregnancy, the baby and the new or expanding family.  But these issues are important and issues that I help patients with on frequent basis. 

 

Preparing for the Pregnancy

For women who are planning when to become pregnant, there are a number of considerations that are related to the hair. I encourage all patients with hair loss who are considering pregnancy to have a good discussion with the dermatologist and of course the physician caring for the pregnancy as well.  

Most of the time, hair improves in pregnancy.  However, some women do experience hair loss during the pregnancy. A significant proportion of women experience some degree of hair shedding after delivery. Hair regrowth occurs 6-7 months later but may or may not return to pre-pregnancy densities.  

 

1. Deciding to Stop Medications

Many of the medication used for treating female pattern hair loss (androgenetic alopecia) can't be used during pregnancy. This includes minoxidil, Rogaine, platelet rich plasma, anti-androgens. The only treatment that can be used are vitamins and low level laser therapies. 

Minoxidil should ideally be stopped two weeks before the time that a women decides to start trying. However, there are many women world-wide who become pregnant while using minoxidil and simply stop minoxidil once they miss their period. There is no evidence that this method has any harm for the pregnancy or the baby.  However, minoxidil must not be used during the pregnancy and anytime after the first period is missed. Many physicians will strictly recommend that their patients stop minoxidil if they are trying to conceive. However, there is no good evidence to support this recommendation. 

Anti androgens, however, need to be stopped several months before the pregnancy. The most common anti-androgen used in women of child bearing age is Spironolactone (Aldactone) and this must be stopped ideally 2 months before any planned pregnancy. Spironolactone can not be used during pregnancy as it could cause harm to a developing baby. Other anti-androgens, including saw palmetto, and finasteride need to be stopped long before as well. Dutasteride is not typically be used in women of child bearing ages. However due to it's very long half life, any woman who is using dutasteride and considering pregnancy should speak to their physician and dermatologist about how long they need to be off the medication before trying to get pregnant. 

 

2. Blood tests

For some women, pregnancy can lead to changes in the levels of many key mineral and vitamins relevant to hair growth. Blood tests can help identify these deficiencies. Deficiencies of vitamin D and iron are among the most common during pregnancy and levels may need to be followed during the pregnancy. Other deficiencies are less common but can include biotin and zinc. If there are concerns about thyroid stratus or diabetes these will also need to be monitored.

 

3. Supplements

All women considering pregnancy should speak to their physicians about appropriate supplements. These will generally include appropriate folic acid. However, other supplements may be very relevant depending on the patient's history. As mentioned above, these may include vitamin D, iron, biotin and zinc.

 

4. Scalp Inflammation

I am a strong believer that scalp inflammation needs to be addressed at any time during the course of hair loss. This is also true during pregnancy. Prolonged scalp inflammation from various sources has the potential to accelerate androgenetic alopecia (AGA). Inflammation can come from many potential sources including seborrheic dermatitis, psoriasis and various eczemas. 

We don't have much information on the safety of anti-dandruff shampoos in pregnancy. The data would suggest that periodic use of zinc pyrithione and ciclospirox have reasonable safety and these are frequently my top choices for many of my own patients.  If dandruff (or seborrheic dermatitis) is troublesome, I generally advise use once every 2 weeks and to be left on the scalp for 60 seconds before rinsing off. Small amounts of betamethasone valerate scalp lotion can be used once weekly if itching persists.  

Ketoconazole shampoos don't have much in the way of data. Patients interested in using should check with their OB or the physician caring for the pregnancy. There is no good data to really suggest a problem with periodic use of topical shampoos containing ketoconazole. It's not the top choice for my practice as they have the potential to affect testosterone synthesis.  Oral ketoconaole is certainly not advised. It increased the risk of cardiovascular, skeletal, craniofacial and neurological problems in many studies.  I don't recommend coal tar shampoos during pregnancy. Animal studies show that high doses are associated with perinatal mortality, cleft palate, small lungs and other developmental issues. I avoid them in my practice. 

 

Conclusion

Patients with androgenetic alopecia (female pattern hair loss) who are considering pregnancy should review their general health and scalp heath with their physicians. Blood tests may be recommended and periodic monitoring of the scalp may be appropriate during the pregnancy.

 

 


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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Preventing Androgenetic Alopecia: Is it possible?

Preventing AGA in Men and Women

I'm often asked if one can prevent genetic hair loss. The typical scenario is a patient whose parent or sibling is bald or balding and wants to know if they can reduce their chances of developing a similar pattern of hair loss. Can one prevent balding outright? In the present day, that answer is no. However, there are things that can be done to reduce the magnitude and speed of progression of the hair loss.

Genetic Hair Loss is strongly ... genetic. It's the genes inside the hair follicles that influence how the hair loss will or will not unfold. We'll take a look at factors that can affect genetic hair loss to a slight degree in a moment, but first let's turn our attention to studies of identical twins. 

Studies of identical twins are very important in answering questions like "does what I eat affect my rate of balding?" or ,,,, "does being stressed affect how fast I bald?"

Identical twins carry the same genetic profile. By studying the appearance of identical twins at various points throughout their lives, we can get a better sense of how important factors like genetics and the environment actually are. If genes are the "key factor" in how balding progresses then, identical twins should look ‘identical’ in terms of their hair density at various points in their lives. In contrast, if environmental factors like smoking, drinking, stress, weight loss and ultraviolet radiation are important, identical twins might not have the same hair density because their environment is different. 

 

The 1992 Hayakawa Study


Interesting research studies in 1992 showed that genetics is by far the most important factor and the environment only has a minor role. 92 % of identical twins were found to have "no significant" differences in their hair density at later points in their lives. However,  8% of identical twins had a slight difference. Interestingly, no twin had a striking difference! In other words, there was never a situation where one identical twin was bald and another had full hair. These studies support the notion that one’s genetics is by far the most important factor in the balding process - but there is a slight role for how outside 'environmental factors' shape genetic hair loss.

 

Limiting Genetic Hair Loss: Optimizing Environmental Factors  

The Hayakawa studies taught us that there is a bit of room to optimize how fast genetic hair loss occurs. Overall, these factors have a minor role but still have some role. These factors include the following.

 

1) Be a non smoker.

It's clear that smoking can influence genetic hair loss by speeding up how fast it progresses. An important study examing the relationship between smoking and hair loss was a 2007 study by the Taiwanese group of Dr. Su and Dr Chen.  These researchers examined 740 patients between the ages of 40 and 91 over a 2 month period.  They found that smokers generally had worse androgenetic alopecia compared to non-smokers. In fact, smokers had nearly a two-fold increased risk of having moderate or severe genetic hair loss compared to non-smokers. In addition, the early development of male balding was more likely in smokers. The exact reasons is not clear but it has been proposed that smoking is damaging to the tiny blood vessels and the there are toxic substances in cigarette smoke that damage the cells in the hair follicles. It's also possible that smoking causes inflammation which speeds up the process of genetic hair loss. 

 

2) Keep a healthy weight. 

It does appear that obesity increases one's risk of developing worsening androgenetic alopecia. A 2011 study looked at the risk factors for male balding in policeman in Taiwan. Interestingly, young male policemen who were obese had much higher rates of male balding than thinner policemen. In 2014, researchers from Taiwan explored whether there was a relationship between obesity the severity of male balding. They studied 142 men (average at 31 years) with male balding who were not using hair loss medications.   The study showed that men with more severe  hair loss tended to be more overweight than men with less severe hair loss.  In fact, men who were overweight or obese had an approximately 3.5 fold greater risk for severe hair loss than men with more normal weights. In addition, young overweight or obese men had a nearly 5 fold increased risk of severe hair loss. The exact reasons are unclear. However, obesity leads to altered metabolism, insulin resistance and worsening inflammation that could affect balding. 

 

3) Limit excess triggers that cause shedding (weight loss, stress, some medications).

Individuals with genetic hair loss are well advised to limit triggers of shedding. This is not always easy to do, but shedding can trigger worsening of hair loss in some people. Repeated cycles of shedding speeds up the arrival of genetic hair loss in patients who are genetically predisposed to develop genetic hair loss. In my hair clinic, I use the term AFMPS - or Accelerated Follicular Miniaturization from Prolonged Shedding. It's a phenomenon that happens only in those who are predisposed to develop androgenetic alopecia.  It's a phenomenon that is frequently seen but rarely is it fully appreciated.

The concept of AFMPS is very important. It is critically important to limit hair shedding in those predisposed to genetic hair loss.  Everything that causes shedding - iron, thyroid issues, dieting, medications, stress, seborrheic dermatitis - must be properly managed. 

 

4) Limit anabolic steroid use.

Anabolic steroids can worsen genetic hair loss in those that are predisposed. These steroids increase the pool of androgens that all act to facilitate miniaturization.

 

5) Reduce ultraviolet radiation to the scalp.

An interesting study from researchers in Taiwan offers further clues that sunlight just 'might' contribute in some way to male balding.  The researchers compared balding patterns in 758 policemen  and 740 men in the general polulation.  Interestingly, policemen aged 40 to 59 had a two fold increased risk of having male balding. In addition, there was a statistically significant association between male balding and sunlight exposure. More research is needed understand if and how ultraviolet radiation affects the process of male balding. Reference

 

Conclusion

It's not always possible to prevent genetic hair loss. However, it may be possible to reduce the speed of its progression by limiting hair shedding and limiting toxic (i.e. smoking, obesity, UV radiation) and hormonal effects (i.e. anabolic steroids) on the hair follicle.

 

Reference

Hayakawa K, et al. Intrapair differences of physical aging and longevity in identical twins. Acta Genet Med Gemellol (Roma). 1992.

Su LH and Chen T H-H. Association of Androgenetic Alopecia with Smoking and Its Prevalance Among Asian Men. Archives of Dermatology 2007 143; 1401-1406.

Mosley JG and Gibbs AC. Premature grey hair and hair loss among smokers: a new opportunity for heatlh education? British Medical Journal 1996; 313: 1616.

Severi G et al Androgenetic alopecia in men 40-69 years: prevalence and risk factors.British Journal of Dermatology 2003; 149: 1207-1213

Chao-Chun Y et al. Higher body mass index is associated with greater severity of alopecia in men with male-pattern androgenetic alopecia in Taiwan: A cross-sectional study.  J Am Acad Dermatol 2014; 70; 297-302.

Su LH et al. Androgenetic alopecia in policemen: higher prevalence and different risk factors relative to the general population (KCIS no. 23). Arch Dermatol Res. 2011 Dec;303(10):753-61

 

 


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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Female Pattern Hair Loss

 

Major and Minor Criteria

fphl.png

Female androgenetic alopecia is common. By the age of 50, well over 1/3 of women will have androgenetic alopecia (AGA)- also known as female pattern hair loss (FPHL). This type of hair loss causes thinning in the frontal and mid scalp. The sides and back may also be affected but generally to lesser degrees than the front for most women. Traditionally, the diagnosis of androgenetic alopecia has been made based on the finding of reduced density in the frontal scalp compared to the back of the scalp and the clear demonstration via dermoscopy that there is a variation in the diameter if more than 20% of hair follicles. This is known as anisotrichosis.

In 2009, Dr Rudnicka and colleagues proposed a series of major and minor criteria for diagnosing FPHL.

 

FPHL MAJOR CRITERIA

(1) ratio of more than four empty follicles in four images (at 70-fold magnification) in the frontal area

(2) lower average thickness in the frontal area compared to the occiput

(3) more than 10% of thin hairs (<0.03 mm in diameter) in the frontal area.

 

FPHL MINOR CRITERIA

(1) increased frontal to occipital ratio of single-hair pilosebaceous units

(2) vellus hairs

(3) peripilar signs.

 

Remarkably, the presence of two major criteria or of one major and two minor criteria allow diagnosis FPHL with 98% specificity.

 

Reference

Rakowska A et al. Int J Trichol. 2009;1:123–30.


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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Telogen Effluvium in Young Men

Telogen Effluvium in Young Males: Considerations

Telogen effluvium (TE) refers to a type of hair loss whereby a patient experiences increased daily shedding of hair. Instead of 30 or 40 hairs coming out of the scalp, the patient experiences 60, 70 or even hundreds of hairs shed on a daily basis. There are a  variety of causes of telogen effluvium including stress, low iron, thyroid problems, medications and crash diets. 

 

TE in Men

Telogen effluvium can occur in men and does occur in men. However, it is far less common than in women. In addition, there are many mimickers or 'lookalike' conditions that frequently lead to incorrect diagnoses of telogen effluvium in men. A good example of this is early staged androgenetic alopecia (AGA) in men. Men with early AGA experience increased hair shedding which looks very similar to a telogen effluvium. Many such men are diagnosed with TE when in fact the correct diagnosis is AGA. The most important question that should be asked in any male with a diagnosis of  suspected telogen effluvium is: does this patient actually have androgenetic alopecia instead of telogen effluvium OR does this patient ALSO have androgenetic alopecia together with telogen effluvium?

Certainly telogen effluvium can occur as a sole diagnosis in men. However, more times than not in the patients I see, this is not the only diagnosis. 

 

Diagnosing TE

Telogen effluvium is largely a diagnosis made on history and clinical exam. Rarely, a biopsy is needed.  For most individuals with TE, another person passing by in the street would not take notice there is hair loss even if substantial hair has been lost. TE causes diffuse loss - meaning the hair is lost all over the scalp. Such hair loss typically occurs 2-3 months after some kind of trigger.  A person with TE however can look very different to the way they know they once looked.  If I look at a photo of a patient and I say "this patient has hair loss" - it's like that another diagnosis is present other than TE or together with TE. 

 

Conclusion

I see many young males with early androgenetic alopecia who are misdiagnosed as having a telogen effluvium. It's true more definitely that telogen effluvium can occur in young men - but one must always keep in mind that it's not really all that common.  Most men who are shedding more than normal end up being diagnosed with androgenetic alopecia. 

I'm often asked who long of a 'window' does a patient have to treat the TE before any irreversible changes happen. The reality is that if a male has TE as their sole diagnosis, there is quite a long window actually. However, the window closes if another hair loss diagnosis is present - especially androgenetic alopecia (AGA). TE can occur in men, yes. But too often androgenetic alopecia in the early early stages is ignored and missed. Biopsies and hair collections together with a careful scalp exam and medical history can help clarify things immensely.


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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Hair Transplants in Young Men

Are hair transplants an option under 25?

Hair transplantation is rarely a good option in men under 25 and it's generally never an option for men in the early 20s (i.e. before age 23). I completely understand that hair transplants are performed around the world in young men age 18-22. However, I don't think it's a good idea.

 

Why hair transplants in young men is not advisable

In an effort to look better and do something positive, many men rush into hair transplants. Not a day goes by that I don't see it or hear it.  There are a number of things that all young men should keep in mind.

 

1. Hair loss does not stop - it continues forever

Too many young men forget that hair loss will continue forever. If a patient is developing genetic hair loss at a young age, one thing is for sure: they will continue to slowly bald unless medication treatment is considered.  Having a hair transplant does not stop the balding process - it only delays the appearance.

 

2. Males who start balding in the early 20s are likely to develop advanced balding patterns in their 30s and 40s. 

It is critically important to understand that once genetic hair loss starts, it will continue forever. If balding starts at a young age, there is a very high chance that male will develop more significant hair loss in the 30s, 40s or 50s.  

 

3. Males who have hair transplants in the early 20s must be prepared for more surgeries throughout their lifetime

If a hair transplant is performed in the frontal hairline at too young of an age, the hairs that are moved into the frontal hairline may last a long time. However, the hairs 'behind' this frontal area could potentially disappear as normal balding continues along its course. At hair transplant performed at too young of an age often leads to placement of place hairs in an area which could look unnatural in the future. A good example would be the placement of too low of a hairline or a hairline with not enough curve to it.  In order for the patient to continue to look good and not have a 'gap' develop between the transplanted hairs and the continually receding hairline, the patient must return to the surgery centre from time to time for more transplants. In other words, if needs to be prepared for a lifetime of hair transplants. Therefore, a hair transplant is not a one time thing.

 

4. It's nearly impossible to predict prior to the mid 20s how many donor hairs a patient actually has. 

If humans had an infinite number of hairs in the “donor” area to move through hair transplants, I would be more likely to advise that more young men move forward and have hair transplants. However, hair in the donor area at the back of the scalp is present in limited supply. A young male with balding may have anywhere from 0 hairs to move (if they have diffuse unpatterned alopecia or DUPA) to up to 8000 folllicular units to move in his lifetime. It may not be clear until the mid to late 20s whether the number is closer to zero or closer to 8000.

Before the mid 20s, one needs to keep in mind that it is just a 'guess' as to how best to use hair transplant grafts from the back of the scalp.  As one ages, it becomes much clearer as to where it is best to place these grafts.  

 

Conclusion

It's rarely a good idea for a young man to have a hair transplant before the mid 20s. There are exceptions whereby a hair transplant in a 23 or 24 year old can be life altering - but these are rare exceptions. In most cases, I recommend these young patients strongly consider non surgical treatments to try to stop their hair loss before considering hair transplantation.


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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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 Whistler office at 604.283.1887
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Treating Female Pattern Hair Loss: Options for Women Over 60

Treatments for AGA in Women over 60

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

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

 

1: Confirming the Diagnosis

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

A. Senescent Alopecia

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

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

 

B. Scarring Alopecia

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

 

C. Hair shedding issues

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

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

 

Treatment Options

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

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

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

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

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

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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AGE 50: An Important Cut off for Diagnosing Hair Loss

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

 

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

 

 A true or false question

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

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

 

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

 

1.     Scarring Alopecia (especially Lichen Planopilaris)

2.     Senescent Hair Loss

3.     Diffuse Alopecia Areata

4.     Hair Shedding Disorders

 

Final Comment:

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

 

 

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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The early greying of hair: What are some of the causes?

Premature greying

By age 50 about 50 % of the population has a good amount of grey hair. But what about those who develop grey hair in the 20s and 30s?

The term "premature greying" refers to greying of hair that happens before the age of 25 in Caucasians and before age 30 in black men and women. From time to time, I evaluate patients in my hair loss clinic who start greying in the teens or twenties. 

 

What are the causes?

Many, many factors influence hair greying - especially genetics. Some individuals simply have the genetic predisposition to develop grey hair. Other causes also need to be considered including thyroid abnormalities, pituitary problems, and deficiency of vitamin B 12.

Smoking too can cause early greying of hair. In fact, 20 years ago, a study in the British Medical Journal showed that smokers are about two to four times more likely to have grey hair. A recent study supports a possible link between low iron, calcium and vitamin D but that needs to be further investigated.

Autoimmune conditions like alopecia areata, vitiligo as well as premature aging syndromes (like a condition called Werner's) can cause affected individuals to develop early greying.

 

Conclusion

Overall, early greying of hair is fairly common and not usually associated with any underlying problem. That said, a full workup is needed for greying that fits the definition of premature greying.


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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Minoxidil use after ages 65: Should I just go for it?

Minoxidil (Rogaine, etc) is FDA approved for ages 18-65

 

I'm often asked by patients if they should just give minoxidil a 'try'. Give it a 'go'. I respond that minoxidil can certainly be helpful but minoxidil is certainly not for everyone.

Minoxidil is FDA approved for men and women 18-65 with a type of hair loss known as androgenetic hair loss. If an individual has some other hair loss condition besides androgenetic hair loss (there are actually dozens of other kinds) and if the individual is over 65, they should check with their physician if minoxidil is safe or not.

 

Minoxidil is not for everyone

I don't prescribe minoxidil if:

1.     the patient has heart problems, especially ischemic type heart disease or certain types of heart failure

2. the patient has heart rhythm issues (like atrial fibrillation)

3. the patient has certain internal conditions (like pheochromocytoma)

4. the individual has allergies to any of the components of minoxidil, such as propylene glycol in minoxidil solution or allergy to the minoxidil itself

 

Final Comments:

Minoxidil has a good safety profile and that has lead to its availability as an over the counter product.  But minoxidil is not for everyone. An 82 year old patient with heart failure and two previous heart attacks is not a candidate for minoxidil. A patient with hair loss due to dissecting cellulitis of the scalp (a different condition than genetic hair loss), will likely find little to no use from minoxidil application. Minoxidil is not for everyone.

 


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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Is there a Minimum or Maximum Age for Hair Transplantation?

 

The minimum age for hair transplantation differs for each patient and depends on a number of factors. For patients with early onset androgenetic alopecia or with a family history of early onset or advanced androgenetic alopecia I may advise medical therapy first and delay a transplant until the mid 20s. This allows me to observe the rate of progression of hair loss over time. 

It is more challenging to predict the rate of hair loss in very young men with a family history of advanced hair loss. However, it becomes easier to predict the likely patterns of future loss by age 25-30.

There is no maximum age for men or women to have a transplant provided the patient is in good health.   

 



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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