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Late Onset Alopecia Areata: What are the Features?

Late Onset Alopecia Areata (LOAA)

Alopecia areata is an autoimmune disease that affects about 2 % of the world. About 50 % of patients who develop alopecia areata will develop their first episode of hair loss before age 20. The development of the first episode of alopecia areata after the age of 50 is uncommon.  Alopecia areata first occurring after age 50 is frequently referred to as late onset alopecia areaeta (LOAA).

 

What are the characteristics of patients who develop LOAA? 

In 2017, Lyakhovitsky and colleagues set out to determine the features of patients who develop LOAA. They performed a retrospective cohort study of patients visiting a tertiary centre over the 6 year period (January 2009 and April 2015).

Of 29 patients in their study who were found to have LOAA, 86.2% were female (female-to-male ratio, 6.2:1). There was a family history of alopecia areata in 17.2%, thyroid disease in 31%, atopic background in 6.9%, and 17/29 (58.6%) reported a significant stressful event. The most common disease pattern observed as the so called 'patchy' subtype. Interestingly the disease was mild in the majority of participants. Complete hair regrowth was observed in 82.8% of participants, and 37.9% relapsed.

 

Conclusion and Comments

This is a nice study which examines the characteristics of patients who develop their very first patch of alopecia after age 50. This group of patients appears have have less extensive disease, and frequently has complete hair regrowth. Affected patients are more likely to be  female than male.   

 

REFERENCE

Lyakhovitsky A, et al. Dermatology. 2017.


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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Deficiencies of iron and vitamin D in patients with alopecia areata

Deficiencies of iron and vitamin D in patients with alopecia areata

Alopecia areata is an autoimmune disease. Blood tests are important for patients with alopecia areata given that recent research has suggested that vitamin D deficiency as well as other deficiencies such as iron deficiency may be more common in alopecia areata.  

In 2017, Conic and colleagues set out to retrospectively review the clinical features of patients with alopecia areata that were seen at the Cleveland Clinic over the period 2005 to 2014.  In total, data from 504 patients was tabulated and as a comparison group 172 patients with seborrheic dermatitis were also reviewed. 

Patients with alopecia areata had more frequent vitamin D deficiency (30 % compared to 13 % in controls) and also had more frequent iron deficiency (7.3 % vs 2.9 % of controls).  Anemia was also more common being present in 17 % of those with alopecia areata and only 7.6% of control patients. 

 

Conclusion

Deficiencies of iron and vitamin D are more common in alopecia areata. Testing levels of iron nd vitamin D are important in alopecia areata.

 

REFERENCE

Conic et al. Comorbidities in patients with alopecia areata. Journal American Academy Dermatology; 754-756.


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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Vellus Hairs in Alopecia Areata: Sensitivity, Activity, Severity

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Vellus hairs are short, thin hairs are commonly seen in patients with alopecia areata. These hairs tend to be seen in patients with more severe and active disease. 
This photo shows vellus hairs in a patient with advanced alopecia areata involving 85 % of the scalp.
 


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: Broken Hairs

Hair Breakage

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Alopecia areata is an autoimmune disease that affects hairs and nails. Inflammation deep under the skin in a region of the hair follicle known as the bulb leads to the production of weak hair follicles that break easily. Hair breakage is commonly seen in active alopecia areata. The photograph here shows a hair follicle that is about to break. Within hours the hair will likely break off at the site demarcated by the arrow. Treatment of alopecia areata can reduce inflammation and lead to the production of stronger hairs that do not break. 


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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Vitiligo & Alopecia Areata: Can they occur together?

Alopecia areata and Vitiligo are Closely Related

Alopecia areata is an autoimmune disease that causes hair loss. Vitiligo is an autoimmune disease that causes loss of pigment in the skin. The prevalence of vitiligo is estimate to be between 0.5 and 2 %. The prevalence of alopecia areata is estimate between 0.1 and 0.2 % of the population. 

 

Is the risk of vitiligo increased in alopecia areata?

There are studies that have reported both outcomes. For example, a 1994 study by Schallreuter and colleagues found no increased coincidence of vitiligo and alopecia areata. Nevertheless, three studies did should that patients with alopecia areata have a higher risk of developing vitiligo  however studies by Chu et al, Narita et al and Huang et al (see references below) showed that patients with alopecia areata probably do have a higher risk for developing vitiligo compared to the general population.  Overall, about 3 to 8% of alopecia areata patients have vitiligo (compared to the general prevalence of vitiligo mentioned above of 0.5 and 2 %).

 

Similarities of AA and Vitiligo

We have come to learn that alopecia areata and vitiligo share many similarities. Both conditions are common in children and adults. In fact, about one half of patients with vitiligo develop their condition before age 20. About one-half of those with alopecia areata develop their condition before age 20. 

Both diseases are relatively asymptomatic meaning that most patients do not have itching, burning or pain. There is inflammation in both conditions, but the amount of inflammation tends to be on the lower side. Most of the inflammation in alopecia areata and vitiligo consists of T cells: CD8+ T cells are present in the epidermis of the skin in vitiligo and in the hair follicle sheath in alopecia areata; CD4+ T cells are in the dermis.   

Both are associated with other autoimmune conditions, especially thyroid disease. The prevalence of thyroid disease has been estimated to be as high as 19.4% in those with vitiligo and 28% in those with alopecia areata.

 

Vitiligo and AA are TH1-diseases

Vitiligo and AA are driven more by interferon gamma (IFN-γ) signalling than TNF-α which makes one consider vitiligo and AA as so called "TH1 mediated diseases". The predominant Th1 cytokine is IFN-γ.  CD8+ T cells play a key role in alopecia areata and vitiligo and interferon is abundant in affected skin of both diseases. Vitiligo and alopecia areata appear to depend primarily on IFN-γ

 

Role of TNF in AA and Vitiligo

TNF-α is inflammatory cytokine. Its levels are elevated in TH17-mediated diseases and appears to be required for the diseases to occur. Psoriasis is an example of a TH17 disease and other examples include inflammatory bowel disease, and rheumatoid arthritis. These conditions require TNF-α as well as IL-17, IL-23, and IL-22.  

TNF appears less directly relevant in alopecia areata. However, some studies have suggested that TNF-α can be elevated in vitiligo and alopecia areata. Surprisingly though, treatment of patients with vitiligo and alopecia areata with TNF blocking drugs have been largely unsuccessful and sometimes treatment even triggers, flares or worsens the conditions. 

 

Conclusion

There are many recognized similarities between alopecia areata and vitiligo and the diseases are closer related than one might otherwise have thought. Both diseases are strongly driven by IFN-γ. Treatments that reduce IFN-γ, including JAK inhibitors, are proving useful for both diseases. Further studies of alopecia areata will likely yield some benefit for how vitiligo is ultimately treatment and vice versa. 

 

 

REFERENCE
Schallreuter KU, Lemke R, Brandt O, et al. Vitiligo and other diseases: coexistence or true association? Hamburg study on 321 patients. Dermatology. 1994;188:269–275.

Chu SY, Chen YJ, Tseng WC, et al. Comorbidity profiles among patients with alopecia areata: the importance of onset age, a nationwide population-based study. J Am Acad Dermatol. 2011;65:949–956. 

Narita T, Oiso N, Fukai K, Kabashima K, Kawada A, Suzuki T. Generalized vitiligo and associated autoimmune diseases in Japanese patients and their families. Allergology international: official journal of the Japanese Society of Allergology. 2011;60:505–508.

Huang KP, Mullangi S, Guo Y, Qureshi AA. Autoimmune, atopic, and mental health comorbid conditions associated with alopecia areata in the United States. JAMA Dermatol. 2013;149:789–794.  


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 the Bowel

Increased Risk of IBS in Patients with AA

Alopecia areata is an autoimmune disease. It occurs in about 2 % of the population and in all age groups and races.  An increasing amount of data is emerging looking at the role of “gut health” in many autoimmune disease. The fact that fecal transplants was propsed to benefit AA in limited studies further highlights the role of the bowel. 

In 2017, Conic and colleagues set out to retrospectively review the clinical features of patients with alopecia areata that were seen at the Cleveland Clinic over the period 2005 to 2014.  In total, data from 504 patients was tabulated and as a comparison group 172 patients with seborrheic dermatitis were also reviewed. 

The key bowel diseases that were studied were celiac disease, inflammatory bowel disease and irritable bowel syndrome. Interestingly, the incidence of irritable bowel syndrome was increased in patients with AA but there was no increase in inflammatory bowel disease and no increase in celiac disease. 

This study is interesting as it highlights the need to inquire about bowel symptoms in those with with AA, particularly those that related to irritable bowel syndrome (IBS). Extensive testing for celiac disease in patients with normal ferritin and hemoglobin levels is probably not advisable nor cost effective in adults. 

 

REFERENCE

Conic et al. Comorbidities in patients with alopecia areata. Journal American Academy Dermatology; 754-756.


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: Is it a medical disease?

Alopecia areata has widespread health implications

aa-medical

There are several expressions that we have in the English language that point to the fact that we as humans don't always feel comfortable giving things the name that they should be called. If you have even heard someone comment how they 'call a spade a spade a  spade" or if you've ever been told to "stop beating around the bush" you know exactly what is meant by the idiom. In some ways the expression points to the need for effective communicators to "tell it as it is"  and "call it as you see it."

 

Alopecia areata

A recent article, published by Korta and colleagues in the Journal of the American Academy of Dermatology titled “Alopecia is a Medical Disease” points to the position of alopecia areata as a true medical disease. 

There is no doubt that alopecia areata fits the definition of a medical disease.  However, after many years of being involved in support groups for alopecia areata throughout the world, I can tell you that many individuals don't consider their alopecia as disease. 

 

"It's not a disease, Dr. Donovan. It's a medical condition of the hair"

"It's an autoimmune condition. It's like a disease, but not quite"

"It’s hard to describe, Dr. Donovan. I don’t have a disease like a disease disease”

"Dr. Donovan, alopecia areata is NOT a disease and even my dermatologist said so”

 

These comments are frequently similar among the 8 million people world wide who are directly affected by the condition today and the 140 million people that will become affected at some point in their lifetime.

I can tell you that many individuals with alopecia areata around the world don't like the use of the term disease. Some dislike it because they don't feel sick. Some don't like the label, stigma and stereotypes that come with having a disease.  I can feel how the room changes when I breach the subject with my support groups. There is sometime shock that I, given the privilege to be welcomed in a group of alopecia patients, would consider discussing this condition as a disease.

 

What is a disease anyways?

It's surprisingly difficult to get everyone in a room to agree on the definition of disease. Yet, everyone knows intuitively what's meant by a disease. I remember the definition that I memorized in my first week of medical school. It was a definition from the World Health Organization ( WHO) which defined a health as "a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity." Others define a disease as some type of disorder of the structure or function that produces specific signs or symptoms.

For alopecia areata, there is no doubt that it impacts physical, mental and social wellbeing for affected individuals. From a pathophysiological perspective, there is little doubt that it is a disorder of the immune system that affects that structure and function of the hair.  So, from these criteria, alopecia areata is a disease.

 

So, why do some patients not consider it a disease?

Well, I’ve learned that defining a disease is not always so easy as the basic definitions allow give us permission to call something a disease.  Whether or not a person or society considers they have a disease depends on various factors including societal and cultural factors.  There has been a rapid expansion of what society calls diseases nowadays. (Ask someone 100 years ago what ‘texting thumb’ or ‘internet addiction’ was and I’m sure you’d be given some blank stares). In contrast, some conditions were viewed as diseases in the past and now have been ‘declassified’ from the list of diseases.

So classifying something as a disease is always open to some degree of interpretation. Many patients with alopecia view their hair loss as a disease. Yet, others do not.  I think we as physicians and society need to fully understand these views. 

 

The Importance of Calling Alopecia Areata a Disease. 

From the perspective of a physician, it’s clear that alopecia areata is a medical disease. In fact, it’s a complex medical disease that can affect the patient from head to toe. As a specialist who cares for patients with alopecia, one needs to not only focus on the hair, but on a range of medical issues that might be present. These need to be evaluated during a consultation. 

The following table summarizes the range of the more common medical conditions that need to be evaluated. Atopic dermatitis and thyroid disease are among the most common being present in 40 % and 20 % of patients respectively.  In addition to the medical issues, quality of life is adversely affected by alopecia areata. These include anxiety, depression and sleep disturbances.

Partial list of disease associations in alopecia areata

Partial list of disease associations in alopecia areata

 

Why we need to stop beating around the bush? 

Alopecia areata can sometimes have a significant financial impact on patients and their families as well as insurance groups that pay for various services. There is a need to make sure that alopecia maintains its position among the medical diseases and gets the appropriate recognition it deserves.  According to a recent Global Burden of Disease study which ranks the disability from having a specific disease, alopecia ranked higher than other common diseases such as psoriasis, melanoma and non melanoma skin cancer.   

Disappointedly, Korta and colleagues remind us that funding for alopecia areata remains low compared to its disease burden. It’s time to change that and perhaps the best way that one can change that is by stop beating around the bush, call a spade a spade and say it like it is: alopecia areata is a medical disease. 

It's important to position alopecia areata as a medical disease. It is important to have it recognized as medical disease in order to ensure that healthcare dollars and research resources are appropriated allocated to support this condition. Clearly, modern society has agreed that if one can't determine if something is a disease or not, it might not be worth allocating money to the area. Alopecia areata is a medical disease.

The hope is that by giving alopecia the title of a disease that it will get the recognition that it so deserves. Despite having over 25 treatments for alopecia areata on my list, it comes as a surprise to patients when I tell them that none are formally FDA approved. Making sure alopecia areata gets recognized as a disease is the first step to making sure insurance companies, drug companies, hospital, health agencies and research groups recognized alopecia areata in the way that it should be.   

Alopecia areata is a medical disease.

 

Reference

Korta DZ, et al. Alopecia areata is a medical disease.  J Am Acad Dermatol. 2018.

WHO (1946) Preamble to the Constitution of the World Health Organization. WHO, New York, USA

Karimkhani et al. JAMA Dermatol 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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Is topical clobetasol safe for the scalp?

On the Safety of Topical Clobetasol 

I've often asked if applying topical clobetsol steroid cream, lotion, foam or shampoo to the scalp is safe. Before we answer that, it's important to understand what clobetasol is and why it's used. 

 

Clobetasol is a class I steroid. Hydrocortisone is Class 7.

There are seven classes of steroid strengths. Class 1 steroids are the strongest and class 7 are the weakest. Clobetasol is a class 1 steroid and requires a prescription (in most countries). Hydrocortisone is a class 7 steroid that can often be bought 'over the counter' at the local drug store.  In simple terms, clobetasol is about 600 times stronger than hydrocortisone.  That does not simply equate to dangerous. It simply equates to stronger. A common steroid potency chart is found in the list below

TOPICAL STEROID POTENCY COMPARISON

 

Frequency, Duration, Amount

When someone tells me they are are using clobetasol, the first thing I want to know is how much are they using and how often are they using it? It comes as a surprise to some that how much steroid a patient is using is usually more important to me that the how often.  A patient who used clobetasol every day but it takes them 5 months to use up their bottle has a very different safety risk profile than someone who is using clobeetasol every day but goes through a bottle every two weeks.  Similarly, a patient who uses clobetsol twice per week could be using more than a patient using it everyday. The amount matters!

 

On the Fear of Topical steroids

There is quite a bit of inappropriate and misguided fear about topical steroids. I'm not saying topical steroids don't deserve respect, because they do. However, the fear that permeates society mainly comes form poor knowledge and also from the misuse of these products among the general population. Sadly, sometimes this misdirected fear comes from unethical practice and misguided motives. It's tough to change that but I can give at least 1000 examples from my own practice over the years of these situations:

A clinic wanting to sell product A for a child advising a parent "Oh you wouldn't want to put a steroid on your child would you?"

A clinic wanting to sell treatment B to there patient saying "Steroids are not safe. This treatment I am recommending is drug-free and natural."

A clinic wanting to establish 'trust' with a client and advises them "You need to stay away from that other clinic recommending you that steroid treatment. What was recommended is very unsafe. I can't believe they wanted to give you that. They should be reported."

 

It's difficult in the short term to change how hair medicine gets practiced throughout the world and it's difficult to regulate clinics and practitioners that prey on the vulnerability of their clients and patients. However, we can first and foremost recognize these patterns and spread accurate information as a starting point. I can assure you it's not always a popular view. Topical steroids can be quite safe when used appropriately.  Of course, they are unsafe when used inappropriately.

 

Logic, Practicality and other Forgotten Issues

When it comes to topical steroids, we need to be logical and practical.  Practical thinking does us good as humans, and we should not forget these principles:

A. It's safe to walk to your across the parking lot to your car on a blazing hot summer day, but it would not be appropriate to walk for hours across the entire city on the same hot day.

B. It's safe to add a bit of hot chili pepper to dish that one is preparing for dinner, but adding the entire chili pepper bottle would just not make sense.

C. It's safe to add a dab of toothpaste to one's toothbrush, but squeezing out the whole tube onto the brush would just be bizarre. 

D. It's generally safe to use a bit of topical steroid for short periods of time to calm down an inflammatory scalp disorder that is causing a patient extreme discomfort, itching and burning. 

E. It's generally safe to use a bit of topical steroid for short periods of time to reduce scalp inflammation that is preventing hair growth.

 

Safety Monitoring

Anyone using topical steroids needs to be monitored by an expert who knows how to use these prescriptions and what side effects they carry.  

First, patients using the steroid must understand how much to use and for how long. They should carefully record the amount of steroid they are using on a monthly basis and carefully record how long it takes them to go through their tube or bottle. 

Excessive use of topical steroids does lead to thinning of the skin, and even side effects from absorption into the body. These side effects are relatively uncommon with proper doses. 

 

Use of Topical Clobetasol in Hair Loss

In hair dermatology, we use topical steroids for many reasons. Topical clobetsol is commonly used to treat alopecia areata, and scarring alopecias such as lichen planopilaris (LPP). When used, these should be used for a short of time as needed and always under supervision. Frequent breaks from the steroid use ("steroid holidays")  are frequently helpful. For children with inflammatory scalp conditions that require topical steroids, we often prescribe topical steroids for 4-6 weeks straight and then give a 2-4 week steroid-free holiday period. This cycle is often repeated.

 

Summary 

Topical steroids can be both safe and effective when used appropriately. Of course, the don't help everyone and may not be enough of an immunosuppressive type treatment for certain kinds of hair loss. For example, some patients with alopecia areata and some patients with lichen planopilaris find that topical steroids help but not enough and hair loss still occurs despite using them.  In such as case the physician needs to decide whether to continue the topical steroid and add other immunosuppressive treatments or whether to stop the topical steroids altogether in place of the new immunosuppressive treatments. 

 

 

 


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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Tofacitinib (Xeljanz) for Alopecia Areata: How fast does hair re-growth occur?

Speed of Regrowth in AA

Alopecia areata is an autoimmune condition. A number of treatments are available and these have been reviewed in previous articles. Among the newer options are the so called JAK inhibitors which includes tofacitinib (Xeljanz) and ruxolitinib (Jakafi/Jakavi). While not FDA approved yet for treating alopecia, they are increasing used off-label.  

I'm often asked how quickly regrowth can occur in alopecia areata patients treated with tofacitinib. The answer is that regrowth rates are variable but patients who respond well show regrowth by the first month and have significant regrowth by month 3. Patients who are not showing these types of regrowth patterns may be non-responders or may need higher doses.  If significant regrowth is not present by month 3, I may discuss the option to increase from 5 mg twice daily (i.e. 10 mg daily) to 15 mg or 20 mg daily.  The decision on whether to increase the dose depends on a number of factors including whether the patient has experienced any side effects to date. 

DOWNLOAD HANDOUT ON TOFACITINIB

DOWNLOAD HANDOUT ON RUXOLITINIB


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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Tofacitnib for Nail Alopecia Areata: What Do We Know So Far?

What Do We Know So Far?

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The JAK inhibitors, including tofacitinib and ruxolitinib, are known to be helpful for many patients with alopecia areata. Not only can they help hair regrowth, the patients affected by nail disease can also be helped. The accompanying photo shows a patient of mine who had excellent response to tofacitinib.

Lee and colleagues from Korea set out to evaluate the relationship between nail and hair responses in patients with alopecia areata treated with tofacitinib. They performed a retrospective study of 33 adult patients with moderate-to-severe AA treated with oral tofacitinib monotherapy for at least 4 months.

15 of the 33 patients had nail involvement. Of 15 patients with nail involvement, 11 (73.3%) showed improvement. Overall, there was some delay before improvements were seen in the nail - first improvement was observed at a median of 5 months.

Interestingly, the nail improvement was associated with neither initial severity of hair loss nor hair response to tofacitinib. Nail improvement tended to occur later than hair regrowth.

This study adds to a growing body of evidence suggesting that tofacitinib helps with the nail AA as well as scalp AA. In this small study, there was no clear link between whether tofacitinib helped the scalp and whether it helped the nail.
 

REFERENCE

Lee JS, et al. Nail involvement in patients with moderate-to-severe alopecia areata treated with oral tofacitinib. J Dermatolog Treat. 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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Alopecia Areata and Vitamin D: Levels Lower in AA

Levels lower in Alopecia Areata

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Accumulating studies have suggested that vitamin D levels are lower in patients with the autoimmune condition alopecia areata. Now, a large review of 14 studies including a total of 1,255 individuals with alopecia areata and 784 non-AA control were analyzed. Data showed clearly that mean serum 25-hydroxyvitamin D levels were significantly lower in individuals with AA. Although it had been suggested in previous studies that patients with more extensive hair loss were more likely to have the lowest vitamin D levels, it was difficult in the to find a clear correlation in this review.
 

Conclusion

Testing for vitamin D is an important consideration for all patients with alopecia areata. Supplementation is appropriate when levels are suboptimal.
 

Reference

Increased prevalence of vitamin D deficiency in patients with alopecia areata: A systematic review and meta-analysis.
Lee S, et al. J Eur Acad Dermatol Venereol. 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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Methotrexate for Hair Loss:

A closer look at MTX for Autoimmune Hair Loss

Methotrexate (MTX) is an immunosuppressive medication that can both be used to treat some forms of hair loss as well as cause hair loss. Methotrexate is a medication the has been used for over 60 years. It was initially developed as a cancer treatment (and continues to be used in oncology) but is also used to treat a variety of autoimmune conditions including lupus, rheumatoid arthritis, psoriasis and vasculitis.

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When treating hair loss, MTX has a role in treating both scarring and non scarring conditions. Evidence supports a role of weekly oral methotrexate in treatment of lichen planopilaris, frontal fibrosing alopecia, discoid lupus and alopecia areata. In the treatment of alopecia areata, methotrexate has been used in both children and adults, often in combination with systemic corticosteroids (like dexamethasone and prednisone).



Hair Loss as a side effect of MTX

In addition to its use in treating hair loss, methotrexate can sometimes also cause hair loss. About 2-4 % of users experience hair loss and the type of hair loss includes both increased hair breakage as well as increased shedding.  Hair color changes can also occur.



MTX side effects

Anyone considering MTX needs to speak to their physician about the risks and benefits. Side effects from methotrexate include reduced blood counts, liver damage, ulcers, cough, lung irritation (rarely fibrosis or scarring in the lung), nausea and abdominal pain, fatigue, kidney damage and memory problems. Methotrexate can not be used by women trying to become pregnant or who are pregnant. 


Because methotrexate interferes with how folic acid is metabolized, the drug needs to be taken with folic acid supplements. Generally methotrexate is given only one day per week and folic acid is given the other 6 days of the week (on the days methotrexate is not taken).

Download MTX Handout for Patients. 


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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Oral Steroids for Paediatric Alopecia Areata

Prednisone in Paediatric Alopecia areata

The decision to use prednisone for children with alopecia areata is always an important one. Generally, this decision comes at an important time where parents and their physician have found that topical steroids, and other more localized treatments have not worked well or in some cases have not worked at all. 

Oral steroids are an option for short term use but generally not an option for long term use. Long-term corticosteroid therapy can lead to growth retardation, metabolic dysregulation and reduced bone mineral density, and other side effects. But short term used is possible and reserved for patients with rapid onset or rapidly progressive extensive, active AA.

 

Options for Corticosteroids in Children

There are two main options for corticosteroids in children - prednisone and dexamethasone. Each has their unique benefits. Prednisone has a short half life (quickly metabolized in the body) and so one needs to take daily whereas dexamethasone has a longer half life and use is generally twice weekly. 

 

Dosing Algorithms

There are many ways that steroids can be used. Common ways include the following 

1. Daily Prednisone

Daily prednisone is among the most common ways of prescribing steroids. While older children will generally take Prednisone pills, younger children can use prednisolone liquid which comes at a strength of 15 mg for every 5 mL of the syrup.  Typically a physician will prescribe 0.5 to 0.8 mg of the prednisone for every kilogram of body weight initially and then taper the dose over a period of time. This taper is generally for 3-12 weeks - with the shorter periods being generally safer but less effective. Most uses of oral steroids perform a slow taper over 12 weeks. 

 

2. Dexamethasone

Twice weekly use of dexamethasone is another way of prescribing steroids to children with alopecia areata. Dexamethasone dosing is different than prednisone and generally 1 mg of dexamethasone equates to 6.25 mg of prednisone. In 1999, Sharma and colleagues performed a study of twice weekly dexamethasone and included children in that study. Children under 12 received 2.5 to 3.5 oral biweekly dexamethasone whereas older individuals received 5 mg.

 

3. Monthly therapy

Monthly pulsed therapy with intravenous corticosteroid therapy or oral therapy is also an option. Doses tend to be larger on the one day that they are given and therefore concerns about safety do exist. Generally studies to date support good safety for this methodology but the protocol tends to be less commonly used. Lalosevic J, et al performed a study of monthy dexamethasone pulse therapy along with topical steroids in children with alopecia areata. Outcomes were quite good with nearly two thirds having complete regrowth. 

 

Side effects

One needs to carefully review all the side effects of oral steroids with their physician. For each side effect, one needs to really ask the prescriber  "okay - is that side effect common or uncommon?" The reality is that most children do very well on steroids. Weight gain, poor sleep, poor concentration, hyperactivity, heart burn, nausea are among the more common side effects.  Suppression of the adrenal glands ability to make prednisone itself is always a discussion but this is uncommon and  if it does occur it is generally temporary.  Within the 12 week period that they are generally used, many of the long term side effects are not typically seen. With every side effect, parents need to ask, "Is that a short term side effect you are mentioning or is that one that develops with long term use?"

 

Conclusion

It's a big decision as to wether or not to use oral steroids in alopecia. However, it's certainly an option to help reset the immune system and when done for appropriate times and appropriate doses the changes of side effects are low. 

 

REFERENCES
 

Sharma VK, et al. Twice weekly 5 mg dexamethasone oral pulse in the treatment of extensive alopecia areata.  J Dermatol. 1999.

Lalosevic J, et al. Combined oral pulse and topical corticosteroid therapy for severe alopecia areata in children: a long-term follow-up study.  Dermatol Ther. 2015 Sep-Oct.

 

 


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 JAK inhibitors for Hair Loss

The Future of JAKs

The janus kinase pathway is a signaling pathway inside cells and continues to be explored in terms of its relevancy to hair disorders. Accumulating research suggests that blockade of this pathway with so called JAK inhibitors can benefit a number of hair loss conditions including alopecia areata. Both topical and oral JAK inhibitor have shown promise.  JAK inhibition may also be relevant to the treatment of androgenetic alopecia.   Another trial is evaluating the effect of two concentrations of ATI-502 on the regrowth of hair in a randomized, double-blinded, parallel-group, vehicle-controlled trial in a larger study of AA.  

Aclaris is a company which has secured the rights to study and develop the use JAK inhibitors for the treatment of alopecia areata (AA) as well as androgenetic alopecia (AGA). They have a number of JAK inhibitors they are studying and several are currently in clinical trials. This includes ATI-502 and ATI-501. Press releases from the company indicate that a number of studies are underway. This includes a trial to evaluate the effect of ATI-502 on the regrowth of scalp and eyebrow alopecia areata.  In addition to AA, it is interesting to note that trials are underway to evaluate the effect of ATI-502 on the regrowth in androgenetic alopecia (AGA). 

 

Comment

It's an exciting time for many new potential treatments in hair loss. The JAK inhibitors have already shown benefit in AA and additional studies will determine whether these agents receive approval and ultimately come to market. 


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

Shaved scalp: Exclamation mark hairs

AA shaved scalp.png

Many patients with advanced alopecia areata shave their scalp. For some, this allows a wig to fit better. For others, especially men, the shaving is done to reduce the appearance of hair loss. 
Even with a shaved scalp, it is sometimes possible to tell if a patient's alopecia areata is active or not. This is especially true if exclamation mark hairs can be seen. "Exclamation mark" (arrow) hairs are easy to identify with a magnifying device. They are 3-5 mm in size and wide at the top and narrow at the bottom. They signal disease activity and the need for more aggressive treatment if hair loss is to be stopped.

Other features can also be seen on a shaved scalp including yellow dots (and hair follicles lacking a hair follicle) and hair follicles with just a single hair coming out (rather than in groups of 2 and 3 haired follicles).


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 Paraneoplastic Syndromes

Cancer, the Immune System and Alopecia Areata 

Alopecia areata is an autoimmune disease. Approximately 1.7 % of the world's population will be affected by alopecia areata. Studies have shown that the vast majority of patients with alopecia areata are extremely healthy. A higher incidence of eczema and thyroid problems is well known to exist in patients with alopecia areata.  Other autoimmune conditions can occur less frequently. 

70-80 % of the disease has a genetic basis and 20 % or so is influenced by environmental factors or 'triggers.' Most of the time, a trigger can not be identified in patients with alopecia areata.  There are a variety of triggers that have been studied through the years. Stress, medications, vaccines have all be proposed to play a role in a small minority of patients. It is extremely rare that cancer is a trigger, but such a phenomenon whereby a cancer triggers clinical manifestations at a site far away from the cancer itself is called a 'paraneoplastic syndrome.'

 

Paraneoplastic syndromes associated with Alopecia

Álvarez Otero J in 2017 reported the case of a man who developed alopecia areata two months before being diagnosed with gastric adenocarcinoma. Of course, it is challenging to know with certainly in these cases whether the alopecia is coincidental or not and this is the challenge with all paraneoplastic syndromes. However, often the timing of the alopecia, and the improvement in the hair loss with removal of the tutor lends some support to the possibility of a link.

Cancers of the gastrointestinal system have some of the most frequent reports of being associated with alopecia areata. Other cancers which may have a paraneoplastic relationship to hair loss are thymomas and Hodgkin disease. Overall though, the link is quite rare and work up an evaluation for cancer is not appropriate for most patients with alopecia areata. Nevertheless, these paraneooplastic syndromes are reminders that there can be many potential triggers of alopecia areata. 

 

REFERENCE

Álvarez Otero J, et al. Alopecia areata as a paraneoplastic syndrome of gastric cancer.  Rev Esp Enferm Dig. 2017

Alopecia areata as a paraneoplastic syndrome of Hodgkin's lymphoma: A case report.Gong J, et al. Mol Clin Oncol. 2014

Multiple paraneoplastic syndromes: myasthenia gravis, vitiligo, alopecia areata, and oral lichen planus associated with thymoma.Qiao J, et al. J Neurol Sci. 2011

[Alopecia areata as the initial paraneoplastic presentation of gastric adenocarcinoma].Molina Infante J, et al. Gastroenterol Hepatol. 2009. Article in Spanish.

[Gastrointestinal tumor (GIST) of the esophagus in a 34-year-old man: clubbed fingers and alopecia arealis as an early paraneoplastic phenomenon].Axel J, et al. Dtsch Med Wochenschr. 2005. Article in German.

Alopecia areata and multifocal bone involvement in a young adult with Hodgkin's disease.Mlczoch L, et al. Leuk Lymphoma. 2005

 


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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Onion extracts for alopecia Areata: Small study suggested benefit

Small study suggested benefit

onion.png

When it comes to treating hair loss, I’m all for anything that works. It doesn’t matter if it’s Eastern or Western medicine, Northern or Southern. It doesn’t matter if it’s allopathic, osteopathic, naturopathic or functional medicine. If it works, it works.

In the same light, I’m against using things that don’t work. I’m against using treatments with no evidence or treatments that prey on the vulnerability of patients. I’m against treatments that waste the time, money of patients and exhaust their emotions.

Onions are on the list of treatments that work in alopecia areata. That’s not to say they are at the top of the list. But the onion made it on the list.

A 2002 study compared the benefits of onion extract in 23 patients with alopecia areata and compared it to 15 patients who used placebo (tap water). Participants applied it twice daily for 2 months. At the end of 2 months, 86.9 % of participants had regrowth compared to just 13% (2 of 15) using tap water.

Onion juice is a consideration for patients looking for simple treatments for alopecia areata. This study of course is small and has not been repeated. How best to prepare the onion extract, which onions are best to use, how often and what exact dosing schedule remain to be determined. Other similar vegetables such as garlic may also benefit.

We don’t use this treatment all that often as other treatments seem more effective for most patients. Mixing with lemon juice can cut onion odour and generally my patients apply in a mixture of essential oils such as rosemary, thyme, lavendar, cedarwood, peppermint in jojoba carrier.

Handout on Onion Juice for Hair Loss
 

Reference

Sharquie KE, et al. Onion juice (Allium cepa L.), a new topical treatment for alopecia areata.
Clinical Trial J Dermatol. 2002.


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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Steroid Injections: Atrophy (dents, depressions, holes)

Atrophy (dents, depressions, holes)

inj-atrophy.png

Steroid injections are a relatively common treatment for many inflammatory and autoimmune scalp conditions. There is rarely a day in the office that I don’t perform steroid injections. These are very valuable treatments for many patients with alopecia areata, scarring alopecias and even some forms of traction alopecia.

One of the side effects of steroid injections is atrophy. Atrophy appears as an indentation in the skin at the site of injection. The patient may refer to it as a “dimple” or a “depression.” Others may call it a “dent” or even a “hole” The indentation can often be better felt than seen.

The chance of developing indentations (atrophy) depends on the concentration of steroid the doctor uses. Higher concentrations (10 mg/mL) give a greater risk of causing atrophy than lower concentrations (2.5 or 5 mg/mL). Some studies suggested that the risk may be as high as 3 in 10 patients when a dose of 10 mg/mL is used. 
The indentations occur because the steroid affects collagen and elastin underneath the skin. The steroids inhibit the growth of fibroblasts, which are the cells that collagen and elastin. Studies have shown there is less collagen made and it’s degraded more quickly. There is a reduction in diameter of collagen fibrils. The collagen bindles become atrophic snd separated. Similar to collagen, elastin fibers become thin and fragmented.

Atrophy typically is seen by 3 weeks if it’s going to occur. An important point to be made is that the atrophy is generally reversible provided more injections aren’t given to an area already showing atrophy. The skin usually returns to normal in 3-4 months. Steroid injections should not be readministered too soon to an area that has not “recovered” as further atrophy can occur - some of which can be very long lasting.

Treatment for steroid atrophy is mainly to wait for the body to start making more collagen and elastin again in a few months. If this does not happen, saline injections, dermal fillers and fat injections can be considered.


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 alopecia areata: More than shots?


Options for treating alopecia areata

ILK-AA

Alopecia areata is an autoimmune condition that affects nearly 2 % of the world's population. The condition is autoimmune in nature, which means that the patient's own immune system is attacking the hairs. Treatments that reduce inflammation can often be helpful - although spontaneous regrowth can occur in some patients even without treatment. 

 

Options for Treating AA:

Steroid injections, also known as "steroid shots" are  helpful treatment for many patients with several patches of alopecia. Steroid injections are less effective for wide spread alopecia areata - and other options need to be considered in these situation. Too often I hear patients say "Is there anything else besides shots?"


Beyond Shots

Steroid injections are extremely important for many patients and if done properly present a treatment option with reasonably good efficacy and quite good safety. I think alot of people are suprised when I say there are at least 25 different treatment options for alopecia areata other than 'shots.'  Here I've listed the treatment options for alopecia areata
 


Topical Treatments
Topical steroids
Topical bimatoprost
Essential oils
Anthralin
Squaric acid
Diphencyprone
Minoxidil
Topical tofacitinib
Topical ruxolitinib
Onion juice
Garlic gels and topicals

Topical capsaicin 



Injection Treatments
Steroid injections
Platelet rich plasma
 

Intramuscular Treatments
Intramuscular triamcinolone 


Oral Treatments
Prednisone
Dexamethasone
Antihistamines
Simvastatin & Ezitimibe
Methotrexate
Tofacitinib
Ruxolitinib
Azathioprine
Cyclosporine
Sulfasalazine
Oral minoxidil

Hydroxychloroquine

Zinc supplements

 



Light and Laser Treatments
Psoralen UVA (PUVA)
308 nm Excimer Lasers

 

Conclusion:

There are many treatments that can be considered for patients with alopecia areata.  Steroid injections are helpful for many patients and should never be discounted. But patients who find that steroid injections did not help have numerous other options available to discuss with their dermatologists.

 


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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Correcting Vitamin D Deficiency: Do we try hard enough?

Vitamin D deficiency and Dosing Regimens

vitamin D

Vitamin D deficiency is common. Given that there may be some role between hair growth and vitamin D signaling inside cells, the current view is to ensure that vitamin D levels are adequate. This remains controversial from the perspective of hair loss because simply taking vitamin D tablets is not going to promote hair growth for most. Nevertheless, having low vitamin D levels could impair hair function, at least theoretically. 

 

Vitamin D: The 30/75 Target Number

To monitor vitamin D levels, we don't actually measure vitamin D, we measure 25 hydroxy-vitamin D (sometimes simply referred to as 25 OH D). It's important to maintain 25 hydroxy-vitamin D levels above 30 ng/mL which translates to 75 mol/L. Some countries like the United States use ng/mL as their base measure and other countries (such as Canada) use mol/L. It's important to take note of these units.  These numbers of 30/75 come from recommendations of the World Health Organization and others:

Vitamin D Deficiency is 25 OH D levels less than 20 ng/mL (50 nmol/L)

Vitamin D Insufficiency is 25 OH D levels less than 30 ng/mL (75 mol/L)

 

Vitamin D2 and Vitamin D3

To complicate matters slightly, there are two common forms of vitamin D supplements that can be taken. Vitamin D3, known as cholecalciferol, is the most common and available in doses of 400, 800, 1000, 2000 IU at most pharmacies and grocery stores. It is not typically available on prescription. High doses of vitamin D are available through use of vitamin  D2, which is called ergocalciferol.  It is the only form of vitamin D typically available by prescription. Vitamin D2 is available in 50,000 IU pills which makes higher dosing easier and for this reason it's the typical form using for individuals trying to correct vitamin D deficiency.  In general, vitamin D3 (cholecalciferol) is thought to be more bioavailable than vitamin D2. 

 

Vitamin D toxicity: A Healthy Respect

We need to respect all supplements since any supplement has the potential to be toxic.  Large doses of vitamin D can cause calcium balance to go out of whack, leading to hyperalcemia. For vitamin D3, doses up to 10,000 IU daily are generally viewed to be quite safe for most individuals. For vitamin D2 mega-doses of 50,000 IU weekly (not daily), there is good safety when taken for short periods of time.  studies have shown that individuals who mistakingly take vitamin D2 daily instead of weekly or monthly, can develop serious side effects. In other words, if anyone is going to take vitamin D, they need to know if they are taking vitamin D3 or vitamin D2 and focus on whether they are supposed to be taking it daily or weekly or monthly. 

Individuals with chronic medical conditions, including osteoporosis, diabetes, kidney disease and women who are pregnant may need to follow other doses recommendations than listed here. 

 

Correcting vitamin D deficiency: Are we taking enough?

There is a great deal of focus on the dose of vitamin D we should be taking. Depending on one's age and risk for various diseases, this may range from 400 IU daily to 2000 IU daily. But these numbers are generally for individuals who have normal levels and are trying to maintain them. The question then arises: What type of dosing is appropriate is someone  is trying to simply get their levels up to a normal range?

There are a variety of different dosing schedules. For individuals with mild vitamin D insufficiency, I typically recommend 3000-4000 IU daily for a period of 6 months and retesting the 25 OH D levels down the road.  For individuals who  have more marked deficiency, I generally follow standard protocols, and prescribe vitamin D2 in many cases:

 

FOR SEVERE DEFICIENCY:

Vit D2 50,000 IU weekly for 12 weeks then once monthly for 3-5 months 

FOR MODERATE DEFICIENCY

Vit D2 50,000 IU weekly for 4-8 weeks then once monthly for 2-4 months

 

In patients who don't respond adequately to the above regime, 50,000 IU of vitamin D2 used three times weekly for 6 weeks may be advised. 

Studies have shown that for most people a total dose of 600,000 IU is needed over a 6 month period to help get vitamin D levels up high enough.  For patients with vitamin D deficiency, I generally recommend retesting at the 6 month mark. 

 

Conclusion

If one has vitamin D "deficiency" or "insufficiency", taking the standard vitamin D3 doses of 400 IU or 1000 IU that are available in pharmacies is not usually enough to correct the vitamin D deficiency. It's enough to keep levels normal once they are normal, but it's not enough to get levels up to a normal range. One needs slightly different doses for shorter periods of time to bring the vitamin D levels up. 

 

REFERENCE
Pepper KJ et al. EVALUATION OF VITAMIN D REPLETION REGIMENS TO CORRECT VITAMIN D STATUS IN ADULTS. Endocr Pract. 2009; 15(2): 95–103. 

 

 


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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