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QUESTION OF THE WEEK

Dr. Donovan's Articles

QUESTION OF HAIR BLOGS

Filtering by Category: Alopecia Areata


Alopecia Areata in Children under 4: Does the amount of hair loss at the time of the appointment predict future loss

Alopecia Areata in Children Under 4: Mild Degrees of Loss Likely to Stay Mild; Moderate/Severe Likely to Worsen

Alopecia areata occurring in young children is known to be associated with lower chances for spontaneous regrowth and recovery compared to alopecia areata in older children and adults. In fact, alopecia areata starting at young ages is known to be one of the recognized poorer prognostic factors.

Castelo-Soccio’s group from Children’s Hospital Philadelphia published an helpful paper in 2019 showing that although young age of onset is generally a poorer prognostic factor, we can provide even more helpful information to parents based on the amount of hair loss the child has at the time of the appointment.

The authors performed a retrospective chart review of 125 pediatric patients who presented to clinic under the age of 4 with Alopecia Areata. Most children under 4 had mild disease severity at the time of their first visit and and for these children it was quite unlikely that progression was going to occur over the next 2 years to a more severe type of disease. In other words, mild AA stayed mild.

In contrast, children with more than 50 % loss at the time of their first visit were more likely to go on to develop more severe disease and worsening hair loss. In other words, moderate/severe AA got worse.


Comments/ Summary

This is a helpful study because it equips hair specialists with information to better counsel patients. Children presenting to clinic with Alopecia Areata generally have poorer prognosis compared to adults. However, children with mild disease are not likely to progress to severe hair loss states - especially over the periods of short term follow up.

Reference

Rangu et al. Understanding Alopecia Areata Characteristics in Children Under the Age of 4 Years. Pediatr Dermatol 2019 Nov;36(6):854-858.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Prognostic Factors for Alopecia Areata

Age of Onset, and Extent of Hair Loss are Among Most Important Prognostic Factors

Alopecia Areata is an autoimmune disease that affects about 2% of the world. About 1/3 of patients with limited alopecia will regrow hair in 6 months and about 1/3 will regrow by the end of 1 year. However, for about one third of patients, a more chronic form of alopecia areata is likely to develop. This includes 18 % of patients who will develop a relapsing remitting alopecia Areata, 10 % who will develop alopecia totalis and 5 % who will develop alopecia universalis.

AA+natural+course

Prognostic Factors for Alopecia Areata

Over the past 30 years, several factors have been found to be associated with poorer prognosis for regrowth of hair. These factors are not absolute but do enable clinicians to be able to better predict the ilkelihood of whether patients will regrow hair.

The most important prognostic factors for alopecia areata are:

1] Extensive loss (especially alopecia totalis and universalis)

2] Early age of onset (especially under 5)

3] Ophiasis variant (hair loss at the back regions of the scalp)

4] Nail changes suggestive of alopecia areata

5] History of alopecia areata in a family member

6] Presence of other autoimmune diseases in the patient (eg, atopy, Hashimoto thyroiditis)

Reference

1. Tosti A, Bellavista S, Iorizzo M. Alopecia areata: a long term follow-up study of 191 patients. J Am Acad Dermatol. 2006;55(3):438–41. Epub 2006 Jun 27.

2. Tan E, Tay YK, Goh CL, Chin Giam Y. The pattern and profile of alopecia areata in Singapore—a study of 219 Asians. Int J Dermatol. 2002;41(11):748–53. 

3. De Waard-van der Spek FB, Oranje AP, De Raeymaecker DM, Peereboom-Wynia JD. Juvenile versus maturity-onset alopecia areata—a comparative retrospective clinical study. Clin Exp Dermatol. 1989;14(6):429–33.

4. Yang S, Yang J, Liu JB, Wang HY, Yang Q, Gao M, et al. The genetic epidemiology of alopecia areata in China. Br J Dermatol. 2004;151(1):16–23. 

5. Goh C, Finkel M, Christos PJ, Sinha AA. Profile of 513 patients with alopecia areata: associations of disease subtypes with atopy, autoimmune disease and positive family history. J Eur Acad Dermatol Venereol. 2006;20(9):1055–60.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Cicatricial Marginal Alopecia: Your traction alopecia patients will thank you!

Not all ‘Traction Alopecia’ is Actually Traction Alopecia

Traction alopecia is a form of hair loss that occurs due to pulling of hair. Diagnosing traction alopecia sounds easy but surprisingly there are a great number of mimicking conditions that can fool the hair specialist.

Frontal traction alopecia refers to hair loss in the frontal hairline that is due to traction. Often the temples are affected but any part of the frontal hairline, temples and area around the ears can be affected. Often the hairs in the very frontal hairline are unaffected leading to the appearance of a so called “fringe” sign:

Classic ‘fringe’ sign in a patient with traction alopecia. The fringe refers to the fringe of hair in the frontal hairline.

Classic ‘fringe’ sign in a patient with traction alopecia. The fringe refers to the fringe of hair in the frontal hairline.

Cicatricial Marginal Alopecia (CMA)

There are times when patients who present with what seems to be traction alopecia tell us that they couldn’t possibly have traction alopecia. These are the patients who tell us that they have worn their hair fairly natural for years and that a diagnosis of traction alopecia just makes no sense to them. These are the patients that politely stare at us when we tell them to be careful how they style their hair and to be carefully to avoid heat or chemicals. When a hair specialist wants to make a diagnosis of traction alopecia but realizes the patient’s story just does not add up to give a convincing story of traction alopecia - the diagnosis of cicatricial marginal alopecia (CMA) must be considered.

The Differential Diagnosis of Frontal Hair Loss: What’s a specialist to consider anyways?

Of course, the diligent hair specialist considers many things in the differential of frontal traction alopecia like presentations including

1. Traction alopecia

2. Cicatricial Marginal Alopecia

3. Frontal fibrosing alopecia

4. Discoid lupus

5. Androgenetic alopecia

6. Telogen effluvium

7. Alopecia Areata

8. Trichotillomania

Cicatricial Marginal Alopecia: A Traction Alopecia Like Alopecia Without A Traction History

It was Dr Lynn Goldberg in Boston who put forth the notion of cicatricial marginal alopecia. She described 15 patients who presented with hair loss in a typical traction alopecia like pattern. Information pertaining to whether or not the patient relaxed or straightened the hair was available In 12 patients. 6 of the 12 patients gave a history of relaxing the hair or straightening the hair. For the other 6 other patients there was no such history. In other words, in 50 % of patients with frontal 'traction alopecia-like” hair loss a history of true traction styling practices were not present. These patients still had some degree of scarring on their biopsies indicating that this too could be a scarring type of hair loss. 

Treatment of CMA involves topical or oral minoxidil combined with topical and/or intralesional steroids. In some patients use of agents like oral doxycycline or topical tacrolimus can be helpful.

Summary and Key Lessons

As soon as we let open our mouths to pronounce the words traction alopecia, we must say in the same breath “or a traction alopecia like mimickers.” Could my patient have traction alopecia or a “traction alopecia like mimicker.”

Cicatricial Marginal Alopecia is one of these closely related mimickers. I like to refer to it as cicatrical marginal alopecia to honour my great colleague Dr Goldberg and so this is what I write in all my letters and consultation notes to other physicians. In my mind, I say the patient has a Traction Alopecia Like Alopecia Without a Traction History because it helps me remember the key elements of this presentation.

Reference

Goldberg L. Cicatricial Marginal Alopecia: Is It All Traction? Br J Dermatol 2009 Jan;160(1):62-8.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Topical tretnoin for Alopecia Areata: Is it still on the list?

Topical Tretinoin 0.05 % Cream May Help Some with Limited Alopecia Areata

Alopecia areata is an autoimmune disease that affects 2 % of patients. There are well over 2 dozen treatments available

More than Shots: The 30 Treatment Options for Alopecia Areata

Topical options are often viewed as safer than systemic options (pills) because the body gets exposed to less medication. Topical treatment options include: Topical steroids, Topical bimatoprost, Essential oils, Anthralin, Squaric acid, Diphencyprone, Minoxidil, Topical tofacitinib, Topical ruxolitinib, Onion juice, Garlic gels, Topical capsaicin and Topical retinoids

Treatments for alopecia are generally of three main types

1) those treatments that reduce inflammation around the hairs so the hairs can grow. Examples include topical steroids and topical tofacitinib.

2) those treatments that simply stimulate hair growth so that hairs can push through the skin and keep growing despite their inflammation. These options may also reduce inflammation as well. Examples include minoxidil and low level laser.

3) those treatments that cause inflammation somewhere else such as the surface of the skin layer so that inflammation gets slowly reduced from around the follicles. A variety of treatments fall into the third category include anthralin, Diphencyprone, squaric acid and tretinoin.

Use of Tretinoin in Treating AA

Today we’ll focus on the use of tretinoin in treating alopecia areata.

Tretinoin is a type of vitamin A. It is used as an acne treatment and as an anti-aging treatment and has been available to patients since the early 1970s. Several studies to date have suggested that tretinoin may have some benefit in the treatment of alopecia areata. It is not effective for everyone and is likely less effective than standard treatments like topical steroids, steroid injections and the oral immunosuppressants. But a small handful of studies suggest that it’s an option to be considered.

STUDY 1: Das and colleagues, 2010

In 2010, Das and colleagues published a study of 80 patients that sought to compare the benefits of 3 treatments, namely a strong topical steroid known as betamethasone diproprionate, tretinoin 0.05 % and anthralin paste 0.25% in the treatment of limited alopecia areata. A placebo group was also included in the study bringing the total number of study groups to four. Treatments were applied twice daily. Patients with alopecia areata in this study had more limited disease and could only be included in the study in their patches were less than 5 cm in diameter and if they had less than 5 patches in total. Results of the study showed that 70 % of patients received topical steroids had an improvement compared to 55 % with tretinoin, 35 % with anthralin and 20 % with placebo.

STUDY 2: Hussein 2020

In 2020, Hussein performed a study comparing the benefits of betamethsone diproprionate topical steroid to tretinoin 0.05% in 50 patients with limited alopecia areata. Treatments were applied twice daily. Similar to the 2010 Das study, patients could only be included in the study if they had less than 5 patches and if they had less than 25 % scalp involvement. After 12 weeks, 72 % of patients receiving the topical steroid had statistically significant clinical improvement compared to 36 % receiving tretinoin 0.05%.

STUDY 3: Kubeyinje and Mathur, 1997

A 1997 study showed that use of tretinoin in patients receiving steroid injections could have added benefit. The authors of the study evaluated the efficacy and safety of 0.05% tretinoin cream as an adjunctive therapy or ‘add on’ treatment with intralesional triamcinolone acetonide in aiopecia areata, by comparing the result of treatment with monthly intralesional triamcinolone acetone and daily application of 0.05% tretinoin cream in 28 patients with alopecia areata with 30 similar patients treated with only monthly intralesional triamcinolone acetonide as controls. Results at 4 months showed more than 90% regrowth in 85.7% of patients on triamcinolone acetonide and tretinoin cream, as compared with 66.7% of patients receiving only triamcinoione acetonide.

STUDY 4: Much, 1976

A 1976 study was among the first published studies to show benefits of tretinoin in treating alopecia areata.

Conclusion and Summary Points

With specific treatments like JAK inhibitors and others, the future of alopecia areata is bright. However, it is critically essential that we not forget our past and where we have come from over many decades of study. Physicians treating alopecia areata must appreciate that role of very simple and relatively inexpensive treatments and the large number of patients with limited alopecia areata they may potentially help. Tretinoin is on that list of simple treatments. Tretinoin is a topical treatment that certainly does not help everyone but may have a role in patients with more limited disease. In patients of mine with a few patches who can not tolerate minoxidil or who can not tolerate steroids, tretinoin remains an option.

 

We use tretinoin with several treatment including 1) tretinoin with topical minoxidil, 2) tretinoin with topical steroids, 3) tretinoin with steroid injections and 4) tretinoin with diphenyprone or squaric acid. 

Side effects including redness and irritation and that is in fact the reason that typically use it in alopecia areata. In other words, it is a side effect but not a concerning one as that is in fact that desired effect. We ask patients to keep close follow up with our office so that we can assist them in finding the right dose that works for them. Some need use daily, some twice weekly and some just 2-3 times per week. Tretinoin must not be used during pregnancy. 

When used alone, I may prescribe tretinoin daily to start  and then increase to twice daily. When used in conjunction with other treatments, we often start tretinoin 2-3 times weekly for a few weeks and then increase to 4 times weekly and then five times weekly and then six times weekly and finally using it daily. 

REFERENCE

Baird KA. Alopecia areata. Arch Dermatol. 1971;104:562-3.

Das et al. COMPARATIVE ASSESSMENT OF TOPICAL STEROIDS, TOPICAL TRETENOIN (0.05%) AND DITHRANOL PASTE IN ALOPECIA AREATA. Indian J Dermatol. 2010 Apr-Jun; 55(2): 148–149. 

Hussein AA. A comparative study of the outcomes of potent topical steroids versus topical tretinoin in patchy alopecia areata of scalp. Int J Res Dermatol. 2020 Jan;6(1):111-114

Kubeyinje EP, C'Mathur M. Topical Tretinoin as an Adjunctive Therapy With Intralesional Triamcinolone Acetonide for Alopecia Areata. Clinical Experience in Northern Saudi Arabia. Int J DermatolJ Dermatol. 1997 Apr;36(4):320

Much T. Treatment of alopecia areata with vitamin A acid. Z Hautkr, 51 (1976), pp. 993-998

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This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Alopecia Totalis and Alopecia Universalis: How long will I be on treatment?

How long is the treatment for alopecia totalis and universalis?

Alopecia areata is an autoimmune disease that affects nearly 2 % of the world. I’m often asked by patients, as well as doctors, exactly how long patients with alopecia areata will need treatment. This question is especially relevant for patents with more advanced forms of alopecia such as alopecia totalis and alopecia universalis. How long will they need treatment? We’ll take a look together why this answer is different for different types of alopecia areata. The key point of this article is that the potential length of expected treatment must be clearly discussed with patients. Patients with advanced forms often need long term treatment for many years and many will require lifelong treatment. This is of course, until better treatments arrive.

Alopecia Totalis and Universalis: Severe Forms of AA

First, what is alopecia totalis and universalis? These are both advanced forms of alopecia areata. Alopecia totalis refers to a situation whereby the patient does not have any scalp hair, although eyebrows, eyelashes and body hair may be present to various degrees. Alopecia universalis refers to the form of alopecia areata whereby the affected individual does not have any scalp hair and does not have eyebrow, eyelash and body hair either.

The important thing to understand as we talk about alopecia totalis and universalis is that these are more severe forms of these conditions. They are very different than so called ‘patchy’ alopecia areata whereby a patient experiences several patches of hair loss. Patchy alopecia can regrow on its own and often regrows with treatment. Once hair fully regrows in patchy alopecia areeata, treatments can generally be stopped without worry that there will be an immediate loss of hair. Now of course there can be hair loss at any time in the future for any patient with alopecia areata. But chances of hair loss with the next short period is rare in alopecia areata that has grown back.

Treatment for mild AA is usually short term; Treatment for severe AA is usually long term

Treatment duration for patents with mild forms of alopecia areata is generally short term. A patient with a single patch of alopecia might use a cream or lotion for a few months or get steroid injections … but hair is likely to regrow. Once the hair regrows, treatment can be stopped without a high likelihood that the disease will come back in that area

AA AU regrowth


There is no definitive answer or prediction about whether or not long term treatment will be needed, simply a scale of how likely it will be that long term treatment is needed. For patients with alopecia areata unilocularis it is highly likely that short term treatment is all that will be needed. For patents with severe alopecia areata (alopecia totalis and alopecia universalis) it is highly likely that long term treatment will be needed.

AT AU

Counselling Patients with Alopecia Areata: What should they be told?

Regardless of what analogy or chart or graph or statistic one wants to use, the basic message is always the same. Alopecia areata in mild forms is more likely to only require short term treatments and alopecia areata in severe forms is more likely to require long term treatments. It must always be kept in mind that many patients with alopecia totalis and universalis will require lifelong treatment. Attempts to stop medications or reduce doses can sometimes be associated with hair loss. Delphine Anuset et al studied 26 patients with advanced alopecia areata who were treatment with methotrexate and oral steroids. About 60 % of patients had total regrowth. After stopping treatments, 73 % of these patients experienced loss of hair (relapse).

AA+regrowth
AU+regrowth

References

Delphine Anuset et al. Efficacy and Safety of Methotrexate Combined With Low- To Moderate-Dose Corticosteroids for Severe Alopecia Areata. Dermatology. 2016.

S C Gordon et al. Rebound Effect Associated With JAK Inhibitor Use in the Treatment of Alopecia Areata. J Eur Acad Dermatol Venereol. 2019 Apr.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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What are the types of alopecia areata?

Many Different Forms of Alopecia Areata

Alopecia areata is an autoimmune disease that causes hair loss. There are many different forms of the condition although most affected people experience ‘patchy’ alopecia areata whereby 1 or more patches develop on the scalp. When just a single patch develops, the term alopecia areata uniloculiaris is used. When 2 or more patches develop, we use the term alopecia areata multilocularis.

AA forms

Together, most patients with alopecia areata unilocularis and multilocularis are classifed as having mild disease which means that less than 25 % of hair has been lost from the scalp. Overall, about 30% of patients with alopecia area will experience moderate and severe forms and many will still experienced regrowth with treatment.

How common are mild moderate and severe forms of AA?

Out of every 100 patients who develop alopecia areata, about 2/3 will regrow hair back spontaneously by 1 year. About 40 % of these are individuals with alopecia areata unilocularis and 27 % are multilocularis. About 33 % of patients with alopecia areata will not experience spontaneous regrowth by the end of the first year. These include patients with alopecai totals (AT), alopecia universals (AU) and patients with relapsing alopecia areata (RR).

AA natural history



This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Scalp Trichoscopy: Completely Wonderful but Complete with Its Own Set of Limitations !

Can I just buy a USB trichoscope and figure out my own diagnosis ?

Trichoscopy is a wonderful diagnostic tool. Trichoscopy refers to the use of some sort of handheld device for viewing the scalp with higher magnification. These devices are widespread - they range in price from $ 35 for a pretty reasonable USB microscopy to $ 1,500 for a hand held device to $ 15, 000 for a video dermatoscope.

There are quite a few misconceptions that the pubic has about these devices.


1. Will trichoscopy tell me the diagnosis?

That answer is no. One can buy a USB device, plug it in and see beautiful pictures on the screen. But what does it mean? That requires an expert! It takes a few weeks to become reasonably good at trichoscopy and then a few years to become an expert. The USB trichoscope device does not give a print out that reads “you have androgenetic alopecia” or “you have telogen effluvium.”

Consider a useful analogy. If my air conditioner breaks down, I can certainly get out my tool box and open up the back of the air conditioner and see inside. But unless I known what I’m looking for, the process is not that useful and I will not know what’s wrong with the air conditioner (I can assure you based on my experience with doing this exact task).



2. If the trichoscope won't tell me the diagnosis, can’t I just email the doctor the pictures and he can tell me the diagnosis ?

I don’t like really ever answering two “no” answers in a row , but this answer is also no. We’re commonly asked this question. We have many people who ask us if they can just send in photos they have obtained with their own trichscope. These photos are not helpful UNLESS I have the entire story of the patient’s hair loss and have reviewed their blood tests and know absolutely everything about them. Then these trichoscopic images are a major bonus! It’s true that I can be pretty sure what’s going on by their photos - but not 100 % sure. Doesn't one want to be 100- % sure or at least as close to 100 % sure as possible?

The mistake people make is thinking trichoscopy is “everything.” They think to themselves that all I need to do is take pictures of my scalp of find some clinic to take trichoscopy pictures of my scalp and I’ll know what’s going on! That’s wrong, wrong wrong ….and that’s where I see people run into problems time and time again. Trichsocopy is wonderful but it’s only part of the puzzle. As an aside, some people also make the similar mistake of thinking that their blood test results are “everything.” They think to themselves that all I need to do is get to my doctor and get some blood tests and I’ll know what’s going on! That’s also not a correct approach. One needs the entire story and the chance to see the scalp in it’s entirely.

Although I’m sure I sound like a broken record, I’d like to remind the reader that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s story

2) the findings uncovered during the process of the scalp examination (sometimes including trichoscopy, pull test, clinical exam, card test, etc)

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

In summary, I can diagnose so many conditions with trichoscopy - but there are so many situations that I can not.

Let’s take a look at some situations where trichsocopy has it’s limitations.


EXAMPLE 1: TRICHOSCOPY IN THE NON SCARRING ALOPECIAS

Trichoscopy is completely wonderful. It helps me tremendously in the diagnosis of many non scarring alopecia. Most cases of androgenetic alopecia can be diagnosed with trichoscopy but not all! In fact, unless one is very experienced with trichscopy, the early cases of AGA are going to be very challenging to diagnose by trichscopy because there is just not enough miniaturization that has developed yet. So, if a patient buys a trichoscope and sees that their is not much miniaturization, can they conclude they don’t have AGA? No.

Most cases of acute alopecia areata can be diagnosed with trichoscopy. This is certainly one area where trichoscopy is very helpful. But in cases of advanced AA and some cases of alopecia areata incognito, all that might be seen is miniaturization of hairs. It can be difficult to render the diagnosis from trichscopy alone. So how do we diagnose it? Listen to the patient’s story!

Telogen effluvium (TE) refers to a type of hair shedding and is one of the more common diagnoses in women. Guess what? Telogen effluvium has NO definitive specific diagnostic trichoscopic signs ! Yikes! it’s true that the presence of many upright regrowing hairs can be a tip off from trichoscopy that the diagnosis of TE might be present - but it’s not specific. If a person thinks they are going to diagnose their TE by buying a trichoscope, they are wrong.

trichoscopy in TE- limitations



EXAMPLE 2: TRICHOSCOPY IN THE SCARRING ALOPECIAS

Trichoscopy is completely wonderful. It helps me tremendously in the diagnosis of many scarring alopecia. In fact, the use of trichoscopy has massively reduced my need to perform scalp biopsies. That said, one needs to be aware that some cases of early lichen planopilaris can’t be confidently diagnosed with trichoscopy - the scalp looks just like seborrheic dermatitis! Some cases of early folliculitis decalvans look just like regular ordinary folliculitis !

So does trichosopy help in all these subtle and early forms of these diseases? - no ! It gets me thinking but usually a biopsy is needed to confirm these challenging diagnoses.

Let it be heard though - a good majority of scarring alopecia cases can be diagnosed with trichosopy. Just not all!

As for central centrifugal cicatricial alopecia (CCCA), the best way to diagnose this condition is simply to look at the scalp! Trichoscopy can help but there are not a great number of classic trichscopic signs for CCCA.

trichoscopy scarring alopecia


FINAL SUMMARY

Many patients want to get blood tests because they think that the blood tests will provide the entire answer the diagnosis. Many patients want to buy a trichoscope (USB dermatoscope) because they feel the trichoscope will provide the answers.

We must always remember that the confident diagnosis of hair loss from from use of the diagnostic SET - all comments from the patient’s story, scalp examination,, trichoscopic examination and blood tests go into figuring out the exact cause.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Steroid Injections for Hair Loss - A Look at Triamcinolone Acetonide

Steroid Injections with Triamcinolone Acetonide

Steroid injections are extremely helpful for many hair loss conditions - particularly some forms of localized alopecia areata (AA) some patients with lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), central centrifugal cicatricial alopecia (CCCA) and folliculitis decalvans. I sometimes even use in the early stages of traction alopecia when I feel the condition is in its earliest stages.

Triacminolone acetonide is a common medication used for steroid injections for inflammatory related causes of hair loss. Kenalog is a popular brand name and available in 10 mg and 40 mg bottles. The final dose the physician uses is typically 2.5 to …

Triacminolone acetonide is a common medication used for steroid injections for inflammatory related causes of hair loss. Kenalog is a popular brand name and available in 10 mg and 40 mg bottles. The final dose the physician uses is typically 2.5 to 5 mg per mL.



There are two common doses of triamcinolone acetonide that one orders from the manufacturer - 10 mg per mL and 40 mg per mL. Either is fine to order provided one keeps in mind that when using the 40 mg per mL dose one is going to need to use 4 times less than if using the 10 mg per mL dose. Every few months I get calls from physicians who call me in a panic because they have prepared their injections using a 40 mg per mL bottle but they thought it was a 10 mg per mL bottle. (the correct way to deal with this is to 1) admit one’s error to the patient, and then 2) flood the scalp generously with saline injections to dilute out the steroid and see the patient back in 4 weeks and 8 weeks to see if any atrophy developed). There are many brands of triamcinolone acetonide one can order. Kenalog is one brand (shown here) but there are others. I have used many over the years and find some do get clogged up when using tiny 30 gauge needles. I don’t find this happens with Kenalog.

As reviewed in other posts, I believe in starting steroid injections at 2.5 mg per mL and only going to 5 mg per mL if needed. The low dose can be helpful and allows more injections to be performed as the maximum dose is 4 mL if one uses a 5 mg/mL concentration or 8 mL if one uses a 2.5 mg per mL concentration.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Cetirizine (Zyrtec) in Lichen Planopilaris: Best Viewed as an Adjunct not Main Treatment

Cetirizine (Zyrtec) for Treating Lichen Planopilaris: Where does it fit in?

Antihistamines are increasingly being studied for the treatment for various types of hair loss. For the autoimmune disease known as alopecia areata for example, use of antihistamines like fexofenadine (Allegra) as well as others (i.e. ebastine) may have some treatment related benefits. In scarring alopecia. the use of antihistamines has only received a limited amount of study. Today, we will discuss the use of the antihistamine cetirizine for treating lichen planopilaris.

Lichen planopilaris is an immune medicated disease. There are a number of proposed mechanisms that lead ultimately to the disease. Cetirizine is an antihistamine medication and widely used for various types of allergy related symptoms. However, the medication may have a number of general and wide reaching effects on the immune system.


How does cetirizine work and how does it affect the immune response ?

Cetirizine is an H1 receptor antagonist. The drug minimally crosses the so called ‘blood brain barrier’ and so limited amounts actually get into the brain. This results in less sedation with cetirizine compared to any other traditional antihistamines. The 5 mg and 10 mg doses are unlikely to give sedation for most people. However, the 20 mg and 30 mg doses are much more likely to give sedation. There has been concern in recent years among long term chronic use of high doses of antihistamines on cognitive decline in patients so this needs to be taken into account when discussing high dose cetirizine as chronic therapy with patients with any medical condition.


Cetirizine has a number of potential effects to modify the immune response. These include

1. Inhibit DNA binding activity of NF-kappa B,

2. Inhibit the expression of adhesion molecules on immunocytes and endothelial cells

3. Inhibit the production of IL-8 and LTB4, two potent chemoattractants, by immune cells.

4. Induce the release of PGE2, a suppressor of antigen presentation and MHC class II expression, from monocyte/macrophages

5. Reduces the number of tryptase positive mast cells in inflammation sites.


The 2010 d’Ovidio Lichen Planopilaris Study

In 2010, d’Ovidio and colleagues studied the use of cetirizine at high doses. Rather than using 5 mg to 10 mg daily that is commonly use over the counter, the authors studied the benefits of 30 mg/daily. Twenty-one patients with lichen planopilaris (LPP) were treated with cetirizine as well as their topical steroids. in 18 or 21 patients (85.7 %) there was a reduction in redness, scaling and a reduction in extractable anagen hairs by the pull test. The authors reported that one patient developed cardiac arrhythmia after 3 months of successful treatment and dropped out of the study.

Cetirizine is an antihistamine and functions as an H1 receptor antagonist. In 2010, d’Ovidio showed that cetirizine at high doses (30 mg) could benefit some patients with lichen planopilaris. Over the counter antihistamine dosing like shown in the p…

Cetirizine is an antihistamine and functions as an H1 receptor antagonist. In 2010, d’Ovidio showed that cetirizine at high doses (30 mg) could benefit some patients with lichen planopilaris. Over the counter antihistamine dosing like shown in the phone is 10 mg.



What are the side effects of cetirizine?

Side effects of cetirizine and other information can be found in our Handout.

Cetirizine Handout for LPP

Rare side effects including heart failure, angioedema and tachycardia. These side effects are rare at low doses such as the 5 mg and 10 mg (over the counter doses). Side effects increase as one increased the dose. The 30 mg dose used in the d’OIividio study would be expected to have a greater degree of side effects than the lower doses.


Conclusion

Cetirizine may have some benefit in treating lichen planopilaris. I sometimes prescribe cetirizine as an adjective treatment in patients with persistent itching and burning who are not fully responding to mainstay topical, intralesional and oral treatments. Generally I use 5 mg or 10 mg and only rarely do I prescribe 15-20 mg. I do not typically prescribe 30 mg doses as I find side effects increase greatly. One must respect the drug interactions and contraindications for the drug (as outlined in the handout). In many ways, I view cetirizine as a helpful add on - much the same way as I view the use of low level laser therapy in this disease. I do not think in the present day that cetirizine should find itself at the top of the therapeutic ladder but certainly has a place.


Reference

d’Ovidio R et al Therapeutic hotline. Effectiveness of the association of cetirizine and topical steroids in lichen planus pilaris--an open-label clinical trial. Dermatol Ther. 2010 Sep-Oct;23(5):547-52.


Namazi MR et al. Cetirizine and allopurinol as novel weapons against cellular autoimmune disorders.Int Immunopharmacol. 2004 Mar;4(3):349-53.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Is Immunotherapy (DPCP, SADBE) Effective for Lichen Planopilaris or Frontal Fibrosing Alopecia ?

Immunotherapy (DPCP, SADBE) Does NOT Help Scarring Alopecia

Diphencyprone (DPCP) and Squaric Acid Dibutyl Ester (SADBE) are long standing treatments for the autoimmune hair loss condition alopecia areata. The cause itching and burning in the scalp and essentially trigger an allergic contact dermatitis. The inflammation that these chemicals create can trigger hair growth in some patients with alopecia areata. It’s quite remarkable.

FIGURE 1. Diphenycyprone (DPCP) is a liquid that is applied to the scalp to treat alopecia areata. It causes an allergic reaction but can stimulate hair growth in some users.

FIGURE 1. Diphenycyprone (DPCP) is a liquid that is applied to the scalp to treat alopecia areata. It causes an allergic reaction but can stimulate hair growth in some users.

FIGURE 2: Hair Regrowth in a patient with ‘ophiasis” type of alopecia areata who was treated with diphenyprone.

FIGURE 2: Hair Regrowth in a patient with ‘ophiasis” type of alopecia areata who was treated with diphenyprone.


Does DPCP and Squaric Acid Help Lichen Planopilaris or Frontal Fibrosing Alopecia (FFA)?

DPCP and Squaric acid are not effective in these scarring alopecias. It’s not that large studies have been done - it’s just that I’ve seen patients many patients over the years with scarring alopecias who have come to see my after having DPCP. These patients were all mistakenly diagnosed as having alopecia areata when really they had frontal fibrosing alopecia or lichen planopilaris. Hair regrowth did not occur and many experiencing a significant worsening.

FIGURE 3: Patient with frontal fibrosing alopecia who was first thought to have the ophiasis form of alopecia areata and was treated with DCPC for many months. The patient did not experience regrowth.

FIGURE 3: Patient with frontal fibrosing alopecia who was first thought to have the ophiasis form of alopecia areata and was treated with DCPC for many months. The patient did not experience regrowth.

There is absolutely no reason to believe that DPCP or squaric acid are effective in LPP or FFA. The pathogenesis of these two conditions is very different than alopecia areata. While it’s true that some treatments overlap - many do not. The following table summarizes some of these important differences. DPCP is effective for some patients with alopecia areata but is not effective in LPP. Doxycycline is effective for some patients withLPP but not helpful in treating alopecia areata.

Table 1: Treatments in Alopecia Areata vs Lichen Planopilaris

AA vs LPP

This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Patient-Doctor Conference Focused on Scarring Alopecia

CARF’s Patient-Doctor Conference All Set For Nashville, TN

I’m looking forward to another great meeting of the Cicatricial Alopecia Research Foundation (CARF). Every 2 years, CARF hosts a wonderful meeting that brings together patients and physicians. I’ve attended for several years now and always enjoy it. I’ll be speaking again at this year’s meeting and look forward to seeing everyone there. The two and a half day meeting is packed with lots of great information, support, and good fun.

Information on the meeting can be found on the CARF website and is also highlighted here:

CARF 2020 Patient Doctor Conference

CARF Prg

The conference brochure can be downloaded here:

CARF 2020 in Nashville, TN: April 24-26, 2020

carf 2020





This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Steroid Injections in Alopecia Areata: Advice for the Primary Care Practitioner and Other Physicians who Treat Alopecia

How do we inject steroids in alopecia areata?

It’s always a great privilege when I have the chance to speak with primary care physicians about the treatment of alopecia areata. Alopecia areata is common in the world - and many patients who first notice the typical patches of alopecia related hair loss are going to make an appointment with their family doctor for advice on the diagnosis and treatment. The family doctor who accepts the challenge to help the patient with alopecia areata can dramatically affect their quality of life - let alone potentially help them get their hair growing back again. It’s a privilege to have the chance to speak to family practitioners about how to perform steroid injections.

There are over 25 treatment options for alopecia areata. However, there are really three treatment options that every family physician should know about. These include 1) topical class I steroids like clobetasol propionate 2) topical minoxidil (ie. Rogaine and generics) and 3) steroid injections with triamcinolone acetonide (ie ‘Kenalog injections’). Many patients with alopecia areata will do extremely well with use of topical steroids and minoxidil. However, if patients don’t regrowth hair with these treatments, steroid injections are often a very good option. Steroid injections are among the most effective options for patients with localized alopecia areata. By localized, I am referring to the type of alopecia areata with one or more discrete patches of hair loss.

Today, I’d like to review the basics of the procedure involved with administering ‘steroid injections.’ I’ll begin with discussing what steroid injections are, what side effects we need to counsel patients, what supplies are actually needed, how these steroid injections are performed and how often they are performed.

What are steroid injections?

Steroid injections for scalp alopecia areata is a short office-based procedure that involves administering a medication known as triamcinolone acetonide into the scalp. Triamcinolone acetonide is a type of corticosteroid which is different than anabolic steroids ( a common source of confusion and fear for the patient). There are many companies that manufacture triamcinolone - and many patients will come to the physician speaking in different terms and different language. Some patients will enquire about ‘steroid injections’, others will ask about “Kenalog injections” (a popular brand name). Other patients will ask if they are going to be getting ‘needles.’ All patents in these cases are referring to the same thing - the use of medications known as corticosteroids to stop the immune reaction that is at the heart of what is causing the alopecia areata.

Although the focus of this article is on the treatment of alopecia areata, steroid injections are useful for treating many hair loss conditions. These include scarring alopecia like lichen planopilaris, pseudopelade of Brocq, discoid lupus of the scalp, frontal fibrosing alopecia and sometimes even early forms of traction alopecia. The medication in all cases is the same - triamcinolone acetonide. Doses that can be used range from 2.5 mg per mL to up to 10 mg per mL. However, as I will mention in the sections below, I strongly believe that use of 2.5 mg per mL concentrations will reduce the chance of side effects and this concentration is definitely the starting point for dermatologists and non dermatologists alike.

Steroid injections are performed a medication known as “triamcinolone acetonide.” Kenalog is a popular brand and many patients enter the clinic asking their physicians if they will be performing “Kenalog injections.”

Steroid injections are performed a medication known as “triamcinolone acetonide.” Kenalog is a popular brand and many patients enter the clinic asking their physicians if they will be performing “Kenalog injections.”

Side effects of Steroid Injections: What side effects do we need to counsel patients?

Before one begins steroid injections, it’s important to review possible short term and long term steroid-related side effects with the patient and get their permission (consent) to do the injections. I won’t go into all the possible side effects but the main message here is that side effects are actually not common with appropriate technique.


Short term steroid injections: What do we need to counsel patients?

The main side effects of a single session of steroid injections include:

1. Minor Pain and Bleeding with injections. Steroid injections are not extremely painful but they can be uncomfortable. They are usually more uncomfortable for patients the first time they receive injections than in subsequent visits. This is likely because the effect of stress heightens pain for many patents. Many patients will say that the pain is a 3 out of 10 (with 10 being maximum). The pain is highest in the frontal hairline and especially above and around the ears compared to the middle of the scalp. The crown area is a bit more painful than the middle of the scalp. In general though pain is mild. Use of a vibration device and chatting with patients and taking many breaks during the procedure can reduce pain and discomfort a lot. Steroid injections can be performed in children over 12 using these types of basic principles. Small amounts of bleeding are possible with injections but these are easily stopped with light pressure form a gauze. Patients using blood thinners and patients who are very nervous (and have higher heart rates), may bleed a bit more - but this is seldom ever an issue that can’t be stopped with pressure from a gauze.

2. Minor soreness in the scalp after injections. In the first 24-48 hours the scalp can be a bit sore. it is usually extremely minor and relieved partially or completely with use of acetominophen or ibuprofen if necessary. Most patients, however, do not require these supplementary pain medications.

3. Headaches after the procedure (rare). Some patients can develop a minor headache after the procedure. It is not common.

4. Indentations in the area where the steroids were injected (atrophy). Indentations or depressions in the scalp can occur following injections but are much less common when low concentrations are used than when high concentrations are used. Indentations don’t occur in the first day or even in the first week. They develop over 2-4 weeks following the injections. Provided another set of injections is not performed into the area of scalp depressions (i.e. the atrophic area), the skin goes back to normal again in 2-4 months, and sometimes much sooner. If injections are performed into an area that is already atrophic, the recovery may take longer and in some cases be persistent (i.e. very long lasting or even forever).

5. Irregular periods (missed periods). Steroid injections performed in premenopausal and perimenopausal female patients can sometimes result in missed periods, irregular periods or changes in the length of the period or amount of bleeding. This too is not common but some women who receive many steroid injections for alopecia areata will note that their periods are irregular. some patents may even miss their period altogether - prompting some to wondering if they are pregnant or wondering if there is some issue for concern. Advising patients of this side effect before the steroid injections are performed can be very helpful.

Long term steroid injections: What do we need to counsel patients?

Steroid related side effects are still quite uncommon even in patients who receive many many steroid injections (i.e. such as monthly injections for 4-6 months). However, patients who are receiving steroid injections over the long term should be aware the steroid injections can be associated with a range of relatively uncommon side effects. These include acne, increased blood pressure, stretch marks (striae), bone thinning (osteopenia, osteoporosis), cataracts, blood sugar issues. and adrenal suppression and Cushing syndrome. Steroid injections in the eyebrow (i.e. for eyebrow alopecia areata) over many years may also increase the risk of cataracts. Side effects with long term steroid injections are still relatively uncommon - especially when the patient has many months of drug free holidays. The use of 2.5 mg per mL concentrations of triamcinolone acetonide (rather than 5 mg per mL of 10 mg per mL) may reduce absorption and therefore systemic side effects as well.


Setting up for steroid injections: What 9 supplies are needed?

Steroid injections are easy to perform in the office setting and don’t require a great deal of supplies. The basic supplies are shown in the diagram below and include:

1) triamcinolone acetonide 10 mg per mL bottle 2) saline used for dilution 3) 3 mL syringes 4) alcohol swabs to wipe the top of the bottles of bacteriostatic injection grade saline and triamcinolone 5) 18 gauge needle to draw up the steroid and saline 6) 30 gauge needle to administer the triamcinolone into the scalp 7) vibration device to make the injections less painful and 8) gauze and 9) gloves.

Basic supplies for steroid injections. When performing the actual injections, gauze can also be used to stop tiny amounts of bleeding.

Basic supplies for steroid injections. When performing the actual injections, gauze can also be used to stop tiny amounts of bleeding.

Performing Steroid injections: What are the actual steps?

STEP 1. Clean the top of the bottle of triamcinolone with alcohol and draw up 0.75 mL the triamcinolone into a 3 cc syringe with an 18 G needle.

Once the supplies are laid out on a tray, the first step starts with cleaning the top of the bottle of 10 mg per mL bottle of triamcinolone acetonide with alcohol pads. This is to ensure that there is no bacterial contamination. While waiting the 30 seconds for the triamcinolone bottle to dry, an 18 gauge needle can be removed from its packaging can be attached to a sterile 3 mL syringe that was also removed from its own sterile packaging. The 18 G needie is then used to puncture the triamcinolone rubber top and draw up 0.75 mL of steroid.

STEP 1 ILK

STEP 2. With the 0.75 mL of triamcinolone already in the syringe, the 18 G needle is used again to puncture the saline bottle and an additional 2.25 mL is draw up into the syringe.

Drawing up the saline in this manner effectively reduces the triamcinolone concentration from 10 mg per mL to 2.5 mg per mL which is the concentration recommended for injections in most cases.

ILK STEP 2

STEP 3. A sterile 30 gauge needle is then attached to the syringe

ILK STEP 3

Once the sterile 30 gauge needle is attached to the syringe, the syringe can be labelled as “2.5 mg per mL” with either marker or tape and set aside. Additional syringes can be then made up - up to a maximum of three syringes per session. Generally speaking no more than approximately 20 mg of triamcinolone acetonide should be injected monthly - which equates to around 3 of these 2.5 mg per mL syringes. Safety is increased by performing the injections every 6 weeks, and that would be a solid recommendation for physicians new to treating alopecia with steroid injections.

ILK


STEP 4. Steroid injections are performed with 0.1 to 0.2 mL of solution injected about 1 cm apart.

With a 30 gauge (thin) 1/2 needle attached to the syringe, the physician can begin injecting. A 1/2 needle is appropriate as longer needles are much too flimsy and make it difficult to precisely control the injections. Injections are done every 1 cm and with each injection about 0.1 to 0.2 mL of the steroid is administered. This typically works out to about 15-20 injections at first. A piece of gauze can be held in the non-dominant hand to help stop any inevitable little bits of bleeding that occur during the injections. Over time, as one becomes more proficient with the injections, it’s possible to inject up to 30 individuals times with each syringe. As one injects into the scalp, the physician can help reduce pain by using one or more distraction techniques. I often ‘scratch’ the surrounding scalp with my finger as I inject. A number of battery operated vibration and massaging devices are available which help a great deal as well to distract the patient and his or her nerves.

Injections are performed every 1 cm using a total of 0.1 to 0.2 mL with each injection.

Injections are performed every 1 cm using a total of 0.1 to 0.2 mL with each injection.

STEP 5. Inject an appropriate number of times into each affected area.

The number of injections is often too few. This is often because physicians are trying to limit side effects. The use of 2.5 mg per mL rather than 5 mg per mL greatly enhances the margin of safety and gives physicians the opportunity to inject appropriate amounts of medicine. A golf ball sided area should be injected with 4-5 injections and a grapefruit sized area should be injected with 20-23 injections.

Too often when treating alopecia areata, the patient receives too few injections. The result is poor regrowth and a conclusion (eventually) by the patient and doctor that “steroid injections didn’t work.” The patient then often moves on to strong and stronger medications with more and more potential side effects. Rather than setting oneself up for failure from the beginning, my recommendation in treating limiting alopecia areata is to make sure the area is appropriately treated. One must not exceed three syringes total in a single 4-6 week interval, but if a small number of patches are being treated one should ensure the patch receives adequate medication.

The number of steroid injections is often too few. If a patient has only limited number of alopecia patches, the number of injections can be performed according to this figure.

The number of steroid injections is often too few. If a patient has only limited number of alopecia patches, the number of injections can be performed according to this figure.




STEP 6. The process can be repeated in 4-6 weeks, with a preference for 6 weeks to enhance safety.

Steroid injections can be repeated in 4-6 weeks. My advice for physicians who are newer to performing injections is to space these injections out every 6 weeks rather than every 4 weeks. This enhances safety, limits atrophy and allows one to feel more comfortable using three FULL 2.5 mg/mL syringes with each visit. Steroid injections are among the most effective treatments for localized alopecia areata. I’ll repeat that again just in case it was missed: Steroid injections are among the most effective treatments for ‘localized’ alopecia areata. By using appropriate amounts of medicine, and performing the injections every 6 weeks, one can achieve regrowth in a large proportion of patients with “localized” alopecia areata. Some patients may also elect to also use minoxidil on the patches at home on a daily basis. That is dealt with on a case by case basis and is not always necessary.

Steroid injections can be repeated in 4-6 weeks. For localized patches of alopecia, regrowth is expected to start in 1 month in 80 % to 90 % of patients. It may take several months to achieve full regrowth in the area Not all patients achieve full r…

Steroid injections can be repeated in 4-6 weeks. For localized patches of alopecia, regrowth is expected to start in 1 month in 80 % to 90 % of patients. It may take several months to achieve full regrowth in the area Not all patients achieve full regrowth but certainly a very large proportion of patients do - especially those with smaller patches of hair loss to begin with.

Conclusion

Steroid injections can be very helpful for patients with localized patches of alopecia areata. Family physicians can safely take on the task of performing these injections into areas fo the scalp affected by alopecia areata. Patients can be counselled about potential side effects but given the appropriate perspective as well that these side effects are rare. Using 2.5 mg per mL rather than 5 mg per mL is highly advised as it enhances safety a great deal. Injections should be performed every 4-6 weeks (if they are needed) and my advice is to space these injections out to every 6 weeks at first. This is to again enhance safety. Patients with localized patches of presumed alopecia areata who fail to respond to steroid injections after 4 visits may benefit from referral to a dermatologist.

To learn more about the diagnosis and treatment of alopecia areata from the perspective of the family physician, consider watching the following video




This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Vellus Hairs in Alopecia Areata: Sensitivity, Activity, Severity

AA-vellus-sensitivity.png

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.
 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Alopecia Areata: Broken Hairs

Hair Breakage

hair breakage.png

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. 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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.  


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Alopecia areata: Is it a medical disease?

Alopecia areata has widespread health implications

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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. 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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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. 

 

 

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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