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Hair Loss in Women: Irregular periods = Blood tests

Irregular periods = Blood tests

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When speaking with patients about their hair loss, there are many pieces of information that a patient may share that should trigger the clinician to look deeper into the particular issue.

Irregular menstrual cycles in women are one such example especially when they occur in females age 16 to 43. Of course, there are many reasons for irregular periods and some of these reasons may have nothing to do with hair loss.

However, a variety of medical issues associated with hair loss may cause irregular periods. These include polycystic ovarian syndrome, congenital adrenal hyperplasia, hyperprolactinemia, Cushings, adrenal and ovarian tumors and cysts, stress, excessive dieting, thyroid disease.

The evaluation of women with irregular periods is best done on a case by case basis after review of all the facts. Blood tests shown here are frequently helpful especially in the third to fifth day of the menstrual cycle and especially in the morning. Patients with abnormalities may sometimes undergo further testing or referral, depending on the suspected cause.


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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Stopping Birth Control: Will My Hair Come Back?

Will My Hair Come Back?

Stopping birth control can be associated with hair shedding. For many individuals the shedding occurs with 4-8 weeks after stopping birth control and eventually shedding returns to normal within 9-12 months and hair density returns to normal as well.

One of the most misunderstood topics when it comes to hair loss and birth control, is the array of considerations when hair density and shedding do not return to normal as one would anticipate. 
Situation “A” and “B” are common when birth control is stopped. In “A”, there is an initial shed followed by a cessation of shedding at month 7-10 and hair density returns to normal by month 12. In situation “B” there is no real perceived increased in shedding at all and the patient notices no real change in her hair at all. These situations typically occur in a patient with no underlying androgenetic alopecia and no strong predisposition to it as well.

Situation “C” and “D” are different. In situation “C” the patient starts out with good hair density but notices at 9-12 month later that her hair density has not returned and is a bit thinner. In situation “D” the patient notices the hair density is quite a bit thinner. In these two situations, the patient often has an underlying predisposition to androgenetic hair loss. In “C” there may have not been any degree of androgenetic hair loss to begin with but the shedding has accelerated the arrival of the patient’s genetic hair loss. In situation “D” there was some genetic hair loss to begin with but it was so mild it was unnoticed by the patient. The birth control pill in this situation was often helping as a treatment to stop the balding process even though the patient was not using it for this reason. By stopping the birth control pill, a helpful treatment actually gets stopped without the patient knowing and the patient’s hair loss is accelerated to a greater degree than in “C”

Patients and physicians should be aware of the array of different possibilities that exist when birth control is stopped.


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

Hair loss is among the top distressing symptoms

Nearly 30,000 kidney transplants are performed every year in North America. Patients receiving kidney transplants require lifelong immunosuppressive medications to help them avoid graft rejection and loss of the transplanted kidney.  The symptoms that patients experience after their transplant have the potential to affect quality of life. These include excess hair loss on the scalp, hair growth on the face (hirsutism), gingival hyperplasia, weight gain, cushingoid facies, hand tremors, and skin disorders. These are consistently among the most bothersome to patients and may have serious psychosocial implications.

Several studies have examined factors affecting quality of life in patients receiving kidney transplants. Hair loss In a recent study of 231 kidney transplant patients, high blood pressure, tiredness and hair loss were the three most distressing symptoms in both men and women. For women, hair loss was the most distressing symptoms.  A 2010 study in adolescents showed that hair loss was among the most distressing of the symptoms in adolescent kidney transplant patients.  


Conclusion

Hair loss can occur for a variety of reasons in patients with organ transplants. This study, as well as others, indicate that patients experiencing side effects are most likely to be non adherent to various aspects of their immunosuppressive treatment recommendations. This can result in more serious complications, such as acute rejection, graft loss, rehospitalization, and even mortality. Strategies for minimizing side effects of immunosuppressive therapy and improving medication adherence are key to the long-term management of kidney transplant recipients. It is important to properly diagnose and treat hair loss in organ transplant patients to limit the effects on quality of life. 

 

Reference

Teng S, et al. Symptom Experience Associated With Immunosuppressive Medications in Chinese Kidney Transplant Recipients.  J Nurs Scholarsh. 2015.

Dobbels F, et al. Health-related quality of life, treatment adherence, symptom experience and depression in adolescent renal transplant patients. Pediatr Transplant. 2010.

 


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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Scalp Psoriasis: Many Variations

Many Variations

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Dermoscopy of Scalp psoriasis. There are many variations in how scalp psoriasis appear. It can be red to pink and scaly white to scaly silver. Psoriasis needs to be differentiated from a range of inflammatory conditions such as seborrheic dermatitis, dandruff, scarring alopecia and various infectious causes.


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

Lack of pigment at root

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Telogen hairs are hairs that are ready to be shed from the scalp. At any time, most individuals have 9-12 % of hairs in telogen phase on the scalp.

Telogen hairs have a characteristic appearance once shed from the scalp. They look like clubs and are therefore called "club hairs". They also lack pigment at the very bottom of the hair follicle. This is due to the cessation of pigment production by the hair follicle at the end of its growing phase (called anagen).


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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From Dark to White to Dark Again: What causes transient colour changes?

Short term Hair Colour Changes

They greying of hair is common. By age 50, about 50 % of people have at least half of their hairs appearing grey/white. This type of hair colour change is permanent - and the only way most people can achieve a darker colour is through the dyeing of hair. 

A different scenario exists with individuals noticing that their hair has turned white only to notice that it turns back to the original colour again within months of noticing it.  There are a variety of causes of this phenomenon, especially when it occurs in one area compared to if it occurs all over the scalp. The most important conditions to consider in transient hair greying/whitening are the autoimmune conditions alopecia areata and vitiligo. Other issues to consider include thyroid abnormalities, pituitary problems, and deficiency of vitamin B 12.   Deficiencies of iron, calcium and vitamin D as well as pregnancy and systemic illnesses need to be considered by are uncommon causes. 

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Preventing Androgenetic Alopecia: Is it possible?

Preventing AGA in Men and Women

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

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

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

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

 

The 1992 Hayakawa Study


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

 

Limiting Genetic Hair Loss: Optimizing Environmental Factors  

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

 

1) Be a non smoker.

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

 

2) Keep a healthy weight. 

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

 

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

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

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

 

4) Limit anabolic steroid use.

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

 

5) Reduce ultraviolet radiation to the scalp.

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

 

Conclusion

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

 

Reference

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

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

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

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

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

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

 

 


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

Morgellons Disease

Morgellons

Morgellons disease (MD) is skin and scalp condition that is becoming better and better recognized. However, its cause and classification still remains open to debate.  It's important for hair specialists to recognize this condition and to understand options for patients.  Patients with Morgellons disease frequently lack insight, and are reluctant to be referred to psychiatrists regardless of the underlying psychopathology present. It's important for dermatologists and hair specialists to understand the options for managing Morgellon's disease. 

 

What are the features of Morgellons Disease?

The key features of MD is the presence of skin lesions with filaments that lie under, are embedded in, or project from skin. These filaments can be many colors including white, black, or brightly coloured. The typical patient with MD has concerns that fibers of glass/other material are coming out of the skin. They may resemble cotton. Many patients (up to 25 %) self-diagnose themselves through reading on the internet.  A vast majority of patients believe there are specific precipitating factors that explain the fibers. Patients may have burning, itching, stinging of the skin and sensations of something crawling. They may have fatigue, difficulty concentrating and difficulties with sleep.

How common is Morgellons Disease?

It's not clear how common the condition really is. Pearson and colleagues suggested rates as high as 3-4 people out of every 100,000 population. 

 

What is the cause of MD?

The exact cause of MD remains a mystery. Some sources, continue to describe this as a purely psychiatric disease having overlap with Delusions of Parasitosis. 

Recent research has suggested that MD patients display a variety of clinical manifestations that closely resemble symptoms of Lyme disease (LD). These symptoms include joint pain, nerve damage and fatigue.  In one study,  98% of patients with MD subjects had positive Lyme disease serology and/or a diagnosis of tick borne disease. IN comparison, only 6% of LD patients in an Australian study were found to have MD.

The spirochetes identified as Borrelia spp. are thought to be alive and viable in tissue from patients from Morgellon's Disease. These spirochetes are difficulty to culture in a laboratory so PCR amplification is often used to identify Borrelia.  

The exact relationship between Lyme disease and Morgellon's Disease is still open to debate. Not all experts agree with the link. A much quoted CDC study by Pearson and colleagues. did not find an infectious cause or any good proof of an environmental link in a study of 115 patients 

 

Psychiatric Disease in Patients with MD

The central debate in the Morgellons medical literature (i.e. the medical journals) is whether MD is a psychiatric disease or a infectious disease (perhaps due to Borellia) with psychiatric manifestations.  It's clear from many studies that mental illness can develop in patients affected by tick-borne disease. These include depression, mania, delusions, bipolar disorder, paranoia, schizophrenia,  sensory hallucinations, major depression, and mania. Infection by spirochetes can affect how neutrons function. 

The vast majority of patients with Morgellons disease have psychiatric disease as well. In one study by Harvey and colleagues, 23 of 25 Morgellons patients had psychiatric diagnoses including attention deficit, bipolar disorder, obsessive-compulsive disorder, and schizophrenia. The fact that MD patients may show neuropsychiatric symptoms is what makes this field so challenging. It makes the diagnosis challenging.  It also makes it difficult to distinguish from a  delusional disorder. 

 

Animal Models of MD

Animal models of MD have arisen which provide some understanding of how human MD may come about. There is similarity between MD and an animal disease known as bovine digital dermatitis (BDD). Similar to MD, this particular animal disease is associated with ulcerative lesions exhibiting keratin projections and is an acknowledged spirochetal infection (just like human Lyme disease.  In this animal model, it was confirmed that there is a bona fide causal relationship between spirochetal infection and filament formation infection with pure cultured tremens lead to the clinical disease.

 

What are the fibers in Moregellon's Disease?

The fibers seen in patients with MD are often mistaken by patients and physicians to be textile fibers. However, this is not correct in most cases- the fibers are composed of keratin and collagen. They are produced by epithelial cells. They come from the patient themselves because the base of these filaments are nucleated.  A proportion of these fibers may actually be types of hairs.

 

Classification of Moregellons Disease

Middelveen and colleagues recently proposed a clinical classification system that reflects the duration and location of MD lesions:

Early localized Morgellons Disease. This is a form of MD with lesions/fibers present for less than three months and localized to ONLY ONE area of the body (head, trunk, extremities).

Early disseminated Morgellons Disease. This is a form of MD with lesions/fibers present for less than three months and involving MORE THAN ONE area of the body (head, trunk, extremities).

Late localized Morgellons Disease. This is a form of MD with lesions/fibers present for more than six months and localized to ONLY ONE area of the body (head, trunk, extremities).

Late disseminated Morgellons Disease. This is a form of MD with lesions/fibers present for more than six months and involving MORE THAN ONE area of the body (head, trunk, extremities).

 

Treatment of MD

Since the cause of MD can't be uniformly agreed upon and since the  clinical classification of MD has not been universally accepted, it is not difficult to understand why optimal treatment strategies are still open to some amount of debate.  Some view this as entirely a psychiatric disease and so much of the medical literature focuses on use of psychiatric medications. 

A few principles do seem relevant:

1. Treat it early. Morgellons Disease should be treated as early as possible to improve the ultimate outcome that a patient will achieve. 

2. Consider treatments that address Spirochetes. Although still controversial, treatment should be aimed at the Borrelia if there is evidence by serology or other studies. In such cases, treatment may involve prolonged antibiotic and/or anti-parasitic therapy.

3. Consider psychiatric medications. Psychiatric medications, particularly the antipsychotics are helpful in Morgellon's Disease patients with psychiatric symptoms. However, use of these medications as stand along treatments without addressing the tick infection often leads to incomplete clinical responses.  Psychiatric medications that have best been studies in MD include pimozide, rispidadone, olanzapine and trifluoperazine.

4. Offer support. Patients affected by Morgellons disease often feel isolated and stigmatized.  There are few resources in the medical community for patients affected by Morgellons disease. 

 

 

Conclusion and Final Thoughts

Morgellons is a fascinating condition that is still poorly understood. Some experts take a position that Morgellons Disease is a real somatic condition and yet some take the stance that it's a delusion disorder.  It's not all that easy to diagnose properly and the whole entity itself is surrounded with controversy. The literature on Morgellons is filled with a great deal of controversy. Many patients with Morgellon's have psychiatric disease and separating whether psychiatric disease is due to Lyme disease and Morgellons Disease and what component is due to pre-existing psychiatric disease is challenging.  Furthermore, countless numbers of patients I see have been given diagnoses of Lyme disease by various clinics - even using methods that are not generally agreed upon. There is still controversy as to what 'really' constitutes Lyme disease. 

Despite these controversies, I strongly believe that we need to be thinking about Lyme disease, syphilis and similar spirochetes in all patients who present to clinic with sensations of creepy crawlers, concerns about parasites, chronic itch and report of fibers emerging from their skin. If we don't think about spirochete type infections and infestations, we'll repeatedly miss this condition and the entire field of MD will remain shrouded with controversy and mystery.  It's likely that many patients with true Delusions of Parasitosis will present with a Morgellons-like presentation but the reverse needs to be considered as well.  The fact that a patient has psychiatric disease (including delusions), is not proof they don't have a Morgellon-like presentation. Moreover, the fact that a given patient responds to anti-psychotics is also not proof they have a Morgellon-like presentation. 

We certainly need to open the dialogue in this are of medicine rather than close it. For every study that suggests there is no link between infections and Morgellon's there is a study that suggests there could be. For every study that suggests the fibers that patients find are man made external fibers, there are studies that suggest these are keratin and collagen fibers from the skin itself. The true story of Morgellons will unfold as years go by. For now, patients affected by Morgellons disease need support.

 

Reference

Harvey WT, Bransfield RC, Mercer DE, Wright AJ, Ricchi RM, Leitao MM. Morgellons disease, illuminating an undefined illness: a case series. J Med Case Rep. 2009;3:8243. [PMC free article][PubMed]

Kellett CE. Sir Thomas Browne and the disease called Morgellons. Ann Med Hist, n.s., VII. 1935;7:467–479.

Mayne PJ. Clinical determinants of Lyme borreliosis, babesiosis, bartonellosis, anaplasmosis, and ehrlichiosis in an Australian cohort. Int J Gen Med. 2015;8:15–26. [PMC free article] [PubMed]

Middelveen MJ, et al. History of Morgellons disease: from delusion to definition. Clin Cosmet Investig Dermatol. 2018.

Middelveen MJ, Bandoski C, Burke J, et al. Exploring the association between Morgellons disease and Lyme disease: identification of Borrelia burgdorferi in Morgellons disease patients. BMC Dermatol. 2015;15:1. [PMC free article] [PubMed]

Middelveen MJ, Stricker RB. Filament formation associated with spirochetal infection: a comparative approach to Morgellons disease. Clin Cosmet Investig Dermatol. 2011;4:167–177. [PMC free article][PubMed]

Mohandas P, et al. Morgellons disease: experiences of an integrated multidisciplinary dermatology team to achieve positive outcomes. J Dermatolog Treat. 2018.

Pearson ML, Selby JV, Katz KA, Cantrell V, Braden CR, Parise ME, et al. Clinical, epidemiologic, histopathologic and molecular features of an unexplained dermopathy. PLoS One. 2012;7:e29908.[PMC free article] [PubMed]

Savely VR, Stricker RB. Morgellons disease: analysis of a population with clinically confirmed microscopic subcutaneous fibers of unknown etiology. Clin Cosmet Investig Dermatol. 2010;3:67–78.[PMC free article] [PubMed]

Savely G, Leitao MM. Skin lesions and crawling sensation: disease or delusion? Adv Nurse Pract. 2005;13(5):16–17. [PubMed]

Savely VR, Leitao MM, Stricker RB. The mystery of Morgellons disease: infection or delusion? Am J Clin Dermatol. 2006;7(1):1–5. [PubMed]

Savely VR, Stricker RB. Morgellons disease: the mystery unfolds. Expert Rev Dermatol. 2007;2(5):585–591.

 

 

 

 


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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Pumpkins, Squash and Hair Loss: A bitter tale

A Bitter Tale

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Pumpkins and squash, together with zucchini and some gourds are members of the cucurbita family (formally Cucurbitaceae). A new interesting report suggests that “cucurbit poisoning” is something all hair loss physicians need to know a thing or two about. Fortunately, it’s not common and provided we never eat “bitter” pumpkin or squash we’ll all be fine and can continue to enjoy these foods.

Dr Assouly (Paris) reported two women who developed severe illness and hair loss after eating members of this cucurbit family. The first patient developed nausea, vomiting and diarrhea within hours of eating some “bitter tasting” pumpkin soup. Although her stomach issues quickly cleared up, one week later she developed hair loss. Her family (who also ate the soup) also got sick but didn’t lose hair - presumably because they ate less pumpkin soup.

The second patient also developed severe vomiting within 1 hour of eating “bitter tasting” squash. Three weeks later she developed hair loss.

This case is interesting as the type of hair loss found to be present was best in keeping with a true “anagen effluvium” - similar to what one might experience after chemotherapy. Numerous broken hairs and hair breakage characterized the loss. The toxic compound in this case is known as “cucurbitacin” and this is what gave these otherwise delicious foods the bitter taste. It’s thought to be rare that squash and pumpkins would have high levels of these toxins. However, cross pollination with wild growing cucurbita can cause occasional ones to have high cucurbitacin and a bitter taste. One should never eat squash and pumpkin that tastes bitter. Fortunately, both patients experienced regrowth of their hair.

Reference

Assouly P et al. Hair Loss Associated With Cucurbit Poisoning. JAMA Dermatol. 2018
 


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

Considerations when the scalp feels bruised and tender

There are many reasons why a scalp can feel tender or bruised. One needs a careful evaluation by a dermatologist if this symptom persists. Below the common causes of a tender scalp are reviewed. This list is by no means exhaustive but provides a useful overview.

 

1) Seborrheic dermatitis.

Seborrheic dermatitis (SD) is an inflammatory condition of the scalp that affects up to 5 % -10 % of adults. Males are more commonly affected than females. SD occurs on body sites where the skin is oily such as the scalp, eyebrows, sides of nose, eyelids and chest. Individuals with SD of the scalp develop red, flaky skin that is often itchy. It’s not uncommon for the scalp to be tender as well. Tenderness is SD frequently becomes more of an issue the longer and longer it has been since the individual last shampooed their hair. The scales in SD can be yellow, white or grey colored and are often described as being "greasy." This differs from scalp psoriasis where the scales are often silver and powdery (see below). 

 

2) Psoriasis

Psoriasis is complex immunological disease which can affect not only the skin, but also affects the nails and joints. Scalp psoriasis occurs in about 50 % of patients with skin psoriasis and is very often the first site involved. Patients have scalp redness, flaking and scaling. Patients may also have bothersome itching and not uncommonly the scalp is tender. Tenderness in scalp psoriasis may accompany areas of scalp bleeding. Although the redness and flaking often cause embarrassment, scalp psoriasis does not usually cause hair loss. 

 

3) Scarring alopecias

Scalp tenderness may be a sign of scarring alopecia. Scarring hair loss conditions or "cicatricial alopecias” are a group of hair loss conditions which lead to permanent hair loss. These conditions may frequently be associated with redness of the scalp as well as scalp itching, burning and/or pain. Tenderness and a bruise-like feeling are not uncommon. These feelings may not be present all the time but rather may come and go. Occasionally it may even hurt to move the hair or the patient may feel as though their hair has been kept in a tight ponytail despite wearing it down. The scarring alopecias include conditions with names such as lichen planopilaris, folliculitis decalvans, lupus and several others. 

 

4) Other inflammatory diseases

A wide variety of other inflammatory scalp conditions, including dermatomyositis, morphea, scleroderma and scalp rosacea can be associated with scalp redness. A scalp biopsy can help differentiate these entities.

 

5) "Red Scalp Syndrome"

'Red scalp syndrome" is a condition which occurs in individuals who have persistent scalp redness that is not explainable by any other condition. The condition was first described by Drs Thestrup and Hjorth Patients with the Red Scalp Syndrome may have itching and burning but typically do not have scaling or flaking. Occasionally tenderness can be a predominant feature.

 

6) Irritation

Many products that are applied to the scalp or hair can cause irritation. This is often due to an irritant contact dermatitis that the product elicits. Such products include many cosmetic products, including gel, mousse, hair spray and hair dyes. Some treatments for hair loss can also be associated with irritation, itching and tenderness, including minoxidil and other topical products containing irritants such propylene glycol.

 

7) Allergy

Shampoos, hair dyes and even some cosmetic products can cause allergic reactions in the scalp. Although some individuals with allergy have itching in the scalp, many have only slight tenderness. In such cases, a rash may be present on the neck, ears or back where the product came into contact with the skin. The five most common allergens in shampoos include fragrance, cocamidopropyl betaine, MCI/MI, formaldehyde releasers and propylene glycol.

 

 

8) Infection

Infections are a possible causes of a tender scalp. Bacterial, viral and fungal infections may cause redness and pain in the scalp. Determining the specific cause may come from a careful history and scalp examination and sometimes submission of a swab or piece of scalp tissue to the microbiology laboratory. 

Bacteria, such as staphylococci, may cause infections of the scalp. Bacteria may also cause infection of the hair follicle, which is a condition called " bacterial folliculitis." A variety of viral infections cause scalp redness and pain. Chicken pox and shingles are two such examples. Scalp ringworm or “tinea capitis” refers to infection of the scalp by certain types of fungi. Scalp redness, tenderness and scaling may be seen in these cases.

 

9) Alopecia areata

Alopecia areata is an autoimmune condition affecting about 2 % of the population. It is not typically a cause of scalp tenderness. However, scalp tenderness is occasionally reported by patients. A specific form of alopecia areata known as cephalagic alopecia areata is associated with pain. It is hypothesized that factors secreted from nerves play a role in the pain.

 

10) Scalp Injury and Trauma

Patients with scalp injuries, either due to previous accidents or surgeries, may have persistent scalp tenderness. Burns from fire, chemicals or radiation can cause temporary or persistent tenderness in the scalp. 

 

11) Sun damage

Patients with extensive sun damage, from years of sun expose, may frequently have scalp tenderness.

 

12) Cancers

A variety of pre cancers and cancers of the skin, including non melanoma and melanoma skin cancers, can cause tenderness in localized areas of the scalp. A biopsy may be obtained to reach the precise diagnosis.

 

13) Headaches

Headaches, especially tension headaches, can be a cause of scalp pain and tenderness. For some individuals, stress, anxiety and depression can cause or worsen the tenderness on account of making muscles tense.

 

14) Temporal arteritis

Temporal arteritis is a potentially worrisome cause of scalp pain amd tenderness. Temporal arteritis is a condition in which the temporal artery becomes inflamed and quite tender to touch. Patients with temporal arteritis may develop jaw pain, headaches, and visual disturbances. Most affected individuals are older adults. 

 

Conclusion

There are many causes of scalp tenderness. Fortunately, the cause of the tenderness can usually be diagnosed from a thorough examination of the scalp. In complex or challenging situations, a scalp biopsy should be performed to confirm the diagnosis.


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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Seborrheic Dermatitis Risk Factors: Altitude and UV Radiation

Altitude and UV Radiation

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Seborrheic dermatitis is a common condition that can affect the scalp (where it causes an itchy, red and greasy scalp) but can also affect the eyebrows, face, chest as well as other areas too. A yeast known as Malassezia has an important role. 
There are many factors that are known to increase one’s risk of developing seborrheic dermatitis. For example, stress, age, heat, humidity, depression, Parkinson’s disease, head injury, neurological disease, HIV and UV radiation all increase the risk of SD. Other risks include acne, lighter skin, higher body fat content.

It’s clear that immunosuppression can affect SD. This is especially true in patients with HIV/AIDS. But we also see the effect of immunosuppression with ultraviolet radiation which is also a form of immunosuppression. Studies have shown that some individuals experience flares with intense UV radiation exposure.

An interesting study conducted in 2000 looked at the risk of SD in 283 mountain guides from 3 different counties who have a high occupational exposure to IV radiation. 16.3% mountain guides when examined clinically were found to have SD and these rates were similar across the 3 countries. This number is higher than the 3-5 % rate of SD in the general population. These studies suggested that UV-induced immunosuppression due to occupational sun exposure as a pathogenetic factor in SD. 

Reference

Moehrle M, et al. High prevalence of seborrhoeic dermatitis on the face and scalp in mountain guides.
Dermatology. 2000


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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Bacteria and SLE: Does bacteria have a role in Lupus?

Does bacteria have a role in Lupus?

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For the past decade, bacteria have increasingly been proposed to play a role in the autoimmune disease known as lupus. Specifically, research has shown that biofilms containing bacteria are potential triggers of this serious disease. 
A new fascinating study raises the possibility that bacteria that are commonly found on humans could trigger some of the auto-antibodies found in patients with with systemic lupus erythematosus (SLE).
About 50% of patients with SLE have anti-Ro antibodies, including anti-Ro60 antibodies. These are among the most common antinuclear antibodies that can be seen even before the disease develops. These auto-antibodies are also “pathogenic” meaning the directly cause disease.

In a new study, a research team from Yale collected microbiome samples from 8 SLE patients who were positive for anti-Ro60 autoantibodies. Controls include five SLE patients who were anti-Ro60-negative, and seven healthy controls. The researchers then took samples from the mouth, sternum, and stool. They found that commensal bacteria containing orthologs to Ro60 were found commonly in all of the patient groups.

In addition, the study investigators showed that CD4 memory T-cell clones from SLE patients that were specific to Ro60 autoantigen were stimulated by Ro60-containing bacteria. Further studies in mice showed that injection of bacteria could trigger a “lupus-like” disease. The conclusion from their study was that commensal bacterial have the potential to initiate and trigger lupus. More research is needed int his important area. This data is important and adds to a large body of research already present that infections could potentially trigger lupus. 

REFERENCE

Commensal orthologs of the human autoantigen Ro60 as triggers of autoimmunity in lupus.
Greiling TM, et al. Sci Transl Med. 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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Taxotere induced alopecia

Hair loss from Taxanes


There are two types of hair loss from taxotere and the taxanes in general. The first is a temporary one and requires time as the hair will grow back on it’s own. This is known as temporary chemotherapy induced alopecia ("TCIA"). Low level laser and minoxidil have evidence of speeding things along. The second is a type of permanent hair loss that has been described with certain taxotere dosing regimens. If hair has not grown back after chemotherapy by the 6 month after chemotherapy, we call this permanent chemotherapy induced alopecia (PCIA) and it is sometimes also called Chemotherapy Induced Permanent Alopecia (CIPAL).  The ideal treatment plan has yet to be determined. Topical and oral minoxidil do have some evidence of being helpful. There is no evidence for PRP treatments. Hormone blocking pills, which are frequently used to treat hair loss,  are generally contraindicated (not allowed) in patients with cancers treated with taxotere.

 

References

1. https://donovanmedical.com/hair-blog/pcia

2. Sibaud V, et al. Dermatological adverse events with taxane chemotherapy. Eur J Dermatol. 2016


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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Blood test and Hair Loss: Necessary but Often Normal

Blood tests in Patients with Hair Loss

Hair loss for most is due to changes happening within the tiny hair follicles deep under the scalp. There may be a difference in the expression of certain genes or their may be different levels of inflammation surrounding hairs. It comes as a surprise to many patients that blood tests are often normal. 

 

Why do we need blood tests if they are likely to be normal?

We require blood tests because there are many mimickers of hair loss and many conditions associated with abnormal blood tests are asymptomatic. If we could tell with 100% certainty that a given patient had low iron or had a thyroid problem just by listening to their story or examining their scalp, we would not need blood tests. The reality is that we can't. Many systemic conditions that can contribute to hair loss are asymptomatic.  Low iron, thyroid abnormalities, zinc abnormalities, autoimmune markers, hormonal changes - these can frequently be asymptomatic. 

 

Does it make sense that blood tests can be normal and still have hair loss?

It makes a lot of sense when one pauses and reflects on what is happening for most people. As mentioned earlier, hair loss for most patients is due to changes happening within the tiny hair follicles deep under the scalp. There may be a difference in the expression of certain genes or their may be different levels of inflammation surrounding hairs. The key tests that we need are therefore 'hair tests' not blood tests. In the present day and age, we don't have very sophisticated "hair tests."

I often use several analogies with my patients. If your arm was hurting and your doctor sent you for a chest x-ray, you wouldn't be surprised if your chest x-ray results came back normal. it is certainly possible that something in the chest is causing arm pain, but not very likely for most. What you need are tests on the arm - not tests of the chest. If you have chronic headaches and your physician sends you for an MRI of the foot, you won't be surprised if the MRI results of the foot come back normal. Blood tests may also be important in patients with chronic headaches - and sometimes these blood tests do reveal a cause of the headaches. But more often than not what is needed is tests specifically targeting to the brain - such as an MRI, CT or other related tests. 

 

Conclusion

Every patient with hair loss needs blood tests to rule out a range of conditions that can cause hair loss and be asymptomatic.  The typical blood tests that I recommend as a starting option are found in the following link. 

Blood test for Hair Loss

One should always be prepared for the possibility (and likelihood that blood tests will come back normal for many patients.  We have only a limited number of "hair tests" in the present day. These include punch biopsies, clinical examinations, trichoscopy, pull tests, pluck tests, hair collections. and hair mineral analyses (which are not useful for most), and hair toxicology screens (which are not relevant for most).  We do not have an ability to easily tests the thousands and thousand of different genes expressed deep down inside the hair follicle and therefore rely on the above ancillary tests to get a sense of what might be happening inside of a tiny hair follicle. 

 

 

 


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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Obtaining information from patients

What information is most important?

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When it comes to obtaining information from patients about their hair loss, every piece of information is potentially important. However, certain pieces of information are generally the most important. I refer to these as the “4 S’s.” Each letter S stands for distinct things that are important to know about including 1) the SPEED of the patients hair loss (ie fast or slow), 2) the SITES that are involved with hair loss (ie crown, frontal scalp, or even diffuse loss as well as information on eyebrows, eyelashes and body hair, etc), 3) the SYMPTOMS the patient might have (including itching, burning, tenderness, tingling) and 4) the degree of daily hair SHEDDING the patient feels they are having (normal shedding vs slightly increased vs markedly increased). These 4 S’s are among the most important of the questions a hair specialist can ask. It does not mean other questions are not important or relevant but simply these are key areas that must always be asked about as one thinks about the precise diagnosis.
 


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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Trichotillomania: Scalp Health & Emotional Health

Scalp Health & Emotional Health

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Trichotillomania is an impulse control disorder whereby patients pull out their own hair. Many have underlying psychological or emotional issues including stress, anxiety, depression and obsessive compulsive disorders.

Treating or addressing the underlying psychological component is often most helpful in treating more chronic cases of trichotillomania. However, reatment of the inflammation, papules and pimples (ie acneiform eruptions and pseudofolliculitis) that accompany trichotillomania can also be important and helpful to patients. Chronic plucking and pulling of hairs leads to damage to hairs, inflammation and a resultant “itch-scratch-itch” cycle which is tough to stop.

In 2011, Oon and Lee published an interesting study showing that managing the actual dermatological issues can help a bit - irrespective of any focus on the underling psychological issues. The authors showed that use of topical steroids, topical and oral antibiotics reduced symptoms of itching and assisted with hair regrowth. Treatments included topical clobetasol, topical clindamycin, erythromycin, topical betamethasone, selenium sulphide shampoos, coal tar shampoos, oral doxycycline. These patients were not on antidepressants or antipsychotics.

The accompanying photo here shows a typical patient with trichotillomania. There are many broken and distorted hairs which has given rise to chronic inflammation - some of which has caused scarring to also occur. 
This is a nice study which reminds us that focus on both the dermatological and emotional issues are both important in treating trichotillomania.

 

Reference

Hazel H Oon and Joyce SS Lee. Treatment of Pseudofolliculitis in Trichotillomania improves Outcome. Int J Trichology. 2011 Jul-Dec; 3(2): 92–95.
 


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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Stress and Hair loss

A Study of Medical Students

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An interesting study examined the effects of stress on a wide range of skin and scalp related symptoms. Study participants were medical students studying at College of Medicine, King Saud University (KSU), Riyadh, Saudi Arabia. A standard questionnaire was used to assess stress levels as well as the presence or absence of a range of health conditions - including those affecting the scalp. When compared to least stressed students, highly stressed students (ie students self reporting that they were experiencing high stress levels) were much more likely to report experiencing a range of scalp symptoms including 1) having more oily, waxy patches and flakes on the scalp, 2) having hair loss and 3) experiencing the self induced pulling-out of one’s hair (trichotillomania).

Conclusion

It’s clear that stress can impact a range of dermatological conditions including hair loss. This study supports the notion that a variety of hair-related changes are possible with higher levels of psychological stress.

Reference

Bin Saif GA et al. Association of psychological stress with skin symptoms among medical students. Saudi Med J. 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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Treatment of AKN with Long Pulsed Alexandrite Laser

AKN: Long pulsed Alexandrite as an option

AKN-image

Acne keloidalis nuchae is a scalp condition that commonly affects the back of the scalp. Patients develop what they frequently term 'bumps' at the back of the scalp. These frequently are associated with hair loss and the bumps themselves may stay and enlarge. In advanced cases the areas coalesce to form a large plaque. 

Treatments for AKN include topical steroids, antibiotics, retinoids, steroid injections. A variety of laser treatments may also be possible.  In previous studies the 810-nm diode laser and 1,064-nm Nd:YAG laser have been used for treating AKN with promising results.

Tafnik and colleagues set out to study the benefits of the 755-nm alexandrite laser in 16 male patients with AKN. Their study showed a significant decrease in the mean papule, pustule count, keloidal plaque size, and pliability at the fourth and sixth laser sessions when compared with baseline. The main complication was a temporary reduction in hair density in the treated area in 4 of 16 patients as a result of the laser treatment. This was accepted by the patients because of its reversible course.  No lesional recurrence was detected in the follow-up period.

 

STUDY CONCLUSION

This study provides evidence that the 755-nm alexandrite laser may provide options for treating AKN. The laser appears safe and effective in the condition and recurrence rates are fortunately low. 

 

REFERENCE

Tawfik A, et al. A Novel Treatment of Acne Keloidalis Nuchae by Long-Pulsed Alexandrite Laser. Dermatol Surg. 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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Pulsed Azithromycin for Folliculitis Decalvans

Pulsed therapy for Folliculitis decalvans

Folliculitis decalvans is a type of scarring alopecia and causes permanent hair loss. Affected individuals develop crops of papules, and pustules. The most effective treatment options are antibiotics and isotretinoin. 

 

Pulsed Therapy for FD

In an effort to reduce side effects from the daily use of a drug, "pulsed therapy" is frequently used for some medications. Pulsed therapy refers to delivery of a medication for short periods of time (i.e. the 'pulse') followed by periods of time whereby the patient does not receive any medications at all.  Pulsed therapy is common with oral steroids, oral anti-fungal medications as well as some antibiotics.

A new study has examined the possibility of using pulses of azithromycin to treat folliculitis decalvans.  The researchers studied 19 patients with mean age 27 years. Treatment was with azithromycin 500 mg per day for 3 consecutive days and repeated every 2 weeks. The severity of the disease was evaluated before treatment and after 1, 3 and 6 months.  

The study showed that azithromycin reduced the number of lesions as well as the disease activity. 

 

Conclusion

Pulsed azithromycin is among the antibiotic options for FD. Pulses of azithromycin are sometimes used as treatments for acne so this method of using azithromycin in a pulsed manner is not new. Side effects of azithromycin should be carefully review before starting. 

Download our Azithromycin Handout for Patients

 

REFERENCES

Andre MC et al. Effective Treatment of Folliculitis Decalvans: Azithromycin in Monotherapy. Hair Therapy and Transplantation. 

Antonio JR et al. Azithromycin pulses in the treatment of inflammatory and pustular acne: efficacy, tolerability and safety.J Dermal Treatment 2008;19(4):210-5. doi: 10.1080/09546630701881506.

Parsad D et al. Azithromycin monthly pulse vs daily doxycycline in the treatment of acne vulgaris.J Dermatol. 2001 Jan;28(1):1-4.

 


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

 

Major and Minor Criteria

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

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

 

FPHL MAJOR CRITERIA

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

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

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

 

FPHL MINOR CRITERIA

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

(2) vellus hairs

(3) peripilar signs.

 

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

 

Reference

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


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