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The Five S's of Diagnosing Hair Loss

The Five S's of Diagnosing Hair Loss

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When it comes to diagnosing hair loss, nearly “everything” is potentially important. That you travelled to far off lands on vacation 3 summers ago can rarely have relevance. But usually it does not. That you rennovated your kitchen last year can rarely have relevance. Usually, however, it does not.

Over the years, I have come to appreciate that there are five pieces of information that are absolutely critical to obtain from a patient’s story , or what physicians call the “history.” These nicely fit into what I term the five “S’s” and include obtaining detailed information on the Speed of hair loss (fast or slow), associated symptoms (like itching, burning or tenderness), degree of shedding (normal, increased or excessive), a catalogue of supplements or drugs used by the patient in the last 3-4 years (including over the counter and prescription based). The final “S” refers to the sites of hair loss (is it front vs middle?, top vs back? one area vs diffuse? scalp only or eyebrows and lashes too?). The 5 “S’s” of hair loss is a remarkably powerful tool that I use each and every day with each and every patient.
 


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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The Self-Diagnosis of Hair Loss: A DIY Project to Avoid

ON SELF-DIAGNOSIS  

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Nowadays, do-it-yourself (DIY) projects are very popular. A "DIY" Project is an activity that one undertakes without directly seeking the help of an expert.  You're probably well aware that DIY is particularly popular among individuals interested in home renovation. There are countless numbers number of books and videos to guide the lay person to renovate their home from top to bottom, inside and out. DIY need not be limited to home decor; the concept of DIY extends broadly into so many aspects of our lives nowadays.  The internet is full of DIY projects.

On account of the internet, DIY also extends into medicine. The public is increasingly looking to take control of their health and in the same light to have more autonomy to decide how they receive advice on their health. We are all familiar with the power of modern search engines. My patients often joke about what they learned form "Dr. Google". However, the reality is clear: patients are spending more and more time looking for reliable information from the internet.  We know that a vast majority of patients search for health information online. Various studies have suggested that 25-50 % of individuals seek the internet for self diagnosis.

I'm not a great fan of self diagnosis (i.e. DIY diagnosis) when it comes to hair loss. In my opinion, attempting to self diagnose the cause of one's own hair loss is rarely wise.  Unless an individual has had a comprehensive review of their medical history, a full examination of their scalp (including use of dermoscopy) and had blood tests, they have not yet begun to properly investigate their hair loss. 

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Why are we self-diagnosing anyways?

There are many reasons why individuals want to diagnose their own medical health, including hair loss. It's certainly much faster and more convenient to look on the internet than take the time to go to a doctor.  For many, it may also present a considerable cost savings as well. For others, there is a tremendous amount of fear that surfaces when one needs to face their own health issues with a doctor. It's easier for a person with hair loss to avoid this by trying to solve one's health issues themselves.  For others, looking at information on the internet provides a much needed sense of autonomy over health-related decision making. The public increasingly wants control over their health and how decisions get made and who makes them.  When it comes to hair loss, however, it's often a false sense of control.

 

Why I don't encourage self-diagnosis   

I realize that patients generally want to try to figure out the cause of their own hair loss by themselves. Fundamentally, this is good.  Most of us are naturally interested to understand our own health. What concerns me is when individuals attempt to diagnosis their hair loss without the help of an expert (by definition, a DIY Project). There are several considerations I'd like patients to think about as they consider going down one of these paths to self diagnosis. 

 

DIY Consideration 1. All Humans have Bias

'Bias' is a term that means that we have a tendency to make certain decisions based on our previous life experiences. Essentially, the way our brains are wired based on all our collective life experiences and previous knowledge makes it more likely for us to make certain decisions than others. For example, when you see your child fall to the ground crying while playing with a group of children, your instinct may gear you up to look for the exact child that could have pushed your child. This is bias. The reality could be that your child could have tripped on an untied shoelace. We are wired to think certain ways.

When it comes to thinking about the causes of our hair loss, we have biases. For example, most of us really don't want to be diagnosed with genetic hair loss, so our bias could easily cause some of us to consider other diagnoses as the top choice.  For example, you remember a family member with balding or someone you saw in the grocery store with hair loss, and your own emotions tell you that this is not what you want to have as a diagnosis.  You have a natural bias to think you might have another diagnosis than genetic hair loss.


"There is absolutely no one in my family with balding, so my hair loss must be from stress"

This is bias.  Bias is all around us.   We are all humans and we are all filled with bias. But as a physician, I am likely filled with less bias when examining a patient's hair loss than the patient is

 

Bias often leads to Forgotten Information

It's normal to be biased because after all, we're human. Bias can sometimes be a good thing, and certainly the instinctive reactions that come with bias sometimes do help us. In the example above, the bias we have when we hear our children cry helps us protect our children. But time and time again, I have witnessed how bias leads to some components of information to be forgotten. 

The the past few years, I have made it a priority to have patients in my clinic complete a very detailed questionnaire about their hair loss long before meeting me. Most of my patients complete this questionnaire in the comfort of their own home, days or weeks before their appointment date. My hope in doing so is to reduce the bias that comes from face-to-face meetings with a physician. Although it's true that 'white coat syndrome' itself can influence what patients remember about their health, there many other aspects of the visit to the clinic introduce bias.

Since introducing the questionnaire some years ago, there has been a  significant reduction in phone calls and emails after the appointment from patient's that 'forgot' to tell me certain pieces of information.  My hope is that, by using this questionnaire, we're cutting down on bias that exists in standard patient-doctor interviews.

 

Physicians Have Bias Too

I too am filled with bias. When a close friend asks me about their hair loss, my 'gut reaction' is that I don't want them to have some systemic illness that is contributing to their hair loss. I don't want the strands of hair they pull from their scalp to be due to some serious disease. I need to recognize that I have bias and do my best to remove this from the decision making algorithms.

In fact, when discussing hair loss with friends and family, it's really best that I remove myself from the situation altogether. Legally and ethically, most physicians are not permitted to offer diagnostic or treatment advice to their closest friends and family. Medicine has recognized that physicians have bias and they are not able to properly evaluate an individual who close to the physician. If one of my family of friends has hair loss, I'm supposed to ask them to see a colleague. Sounds strange, but real bias is real!

 

DIY Consideration 2: Not everyone knows about the 'zebras'   

Self diagnosis (hair loss DIY diagnosis) is also dangerous because there is often an assumption by the individual that they appreciate all the various causes of hair loss that exist and simply need to choose which one fits best. To the individual, they mistakenly feel that all the cards are on the table and they just need to pick the right one. The reality is that most patients considering their own diagnosis do not in fact appreciate all the 100 causes of hair loss. Instead of choosing from a list of 100 causes, many individuals with hair loss are trying to choose from a short list of common causes of hair loss. Fortunately, many patients will get their diagnosis right (because common hair loss conditions are common), but unfortunately too many patients get it wrong.

if you've never seen a zebra before, you'll be quite likely to call it some type of horse.  Perhaps a striped horse. Dog owners with more exotic breeds will tell you that few people ever get their dog's breed correct. If you've never seen or heard of the hair loss condition 'pseudopelade', you're likely to incorrectly call a circular patch of hair loss 'alopecia areata'.  If a patient has never seen folliculitis decalvans, then they are likely to go on battling what they think is stubborn folliculitis for a long time. If a patient has never heard of the condition lichen planopilaris, they may be continually searching for newer strategies for treating their stubborn dandruff or eczema.

Attempting to self diagnosis one's hair loss can be challenging if one does not know all the potential entities on the list. 

 

DIY Consideration 3:  Most are On the Lookout for Only 'One' Diagnosis

In my experience, everyone with hair loss is on the lookout for the cause of their hair loss.  However, very few people take the time to consider that they could have more than one cause for their hair loss.   For many patients, it's not so much of a decision as to whether they have androgenetic alopecia or telogen effluvium but rather what proportion of the patient's hair loss is from androgenetic alopecia and what proportion if from telogen effluvium. Many patients have both! It's possible to have one, two three, four or even five causes contributing to one's hair loss. 

 

DIY Consideration 4:  The Hair Follicle is More Complex Than Your Car and Few of us Venture to Fix our Own Cars

The hair follicle is incredible.  It's also incredibly complex.  There are 20 different cell types in the hair follicle and 100,000 hairs on the scalp (2-4 million on the entire body). Added together there are trillions and trillions of cells working together in the scalp.  Can one really try to sort through the actions (or inactions) of trillions and trillions of cells themselves?

It's difficult to think in terms of such large numbers, so let's go smaller. A car, they say, has over 30,000 parts when you consider all the tiny components. Few of us venture to even guess what's gone wrong when our car breaks down. We (hopefully) seek an expert.  I often say to patients that if my car was making strange, strange noises and blowing black smoke out the back and front, I would likely be told to get an automobile mechanic to check things over. Any attempt at self-diagnosis and fixing the car oneself would not be wise, at least for most people. It certainly would not be wise for me. When my car breaks down, I need someone who works with cars and  knows exactly how things go wrong. I need an expert.

 

DIY Consideration 5: Some diagnoses can only come from advanced tests meaning that an individual in such cases will never determine their diagnosis themselves.

It is important to keep in mind that some diagnoses can only come from a biopsy and some diagnoses can only come from blood tests. Individuals attempting to diagnose the cause of their own hair loss may never reach their diagnosis unless they have these specific tests performed. A patient with hair shedding may think they have a vitamin deficiency or some other cause of telogen effluvium. However, a biopsy could reveal that the hair loss was actually from a scarring alopecia. Similarly, a patient with hair shedding may think their hair loss is simply from stress when the reality is that they have low iron levels from a life-threatening bleeding stomach ulcer. 

In these cases, any attempt to try to self diagnose one's hair loss simply leads to a delay in getting the appropriate medical attention that is needed.  Rarely, this delay in diagnosis can have serious consequences.

 

DIY Consideration 6. Patients who self diagnosis often fall prey to online marketing

Finally, a high proportion of individuals who attempt self diagnosis end up spending hundreds and sometimes thousands of dollars on products and supplements they have seen online. The patient's vulnerable state makes them very susceptible to consider buying anything that could help. Online marketing is remarkably powerful. Supplements, pills, shampoos, vitamins, tonics can all be bought with a click of a button. And often are. 

 

Conclusion

I've read many Do-it-Yourself books on various topics and I'm all for liberating people to take on new challenges.    DIY self diagnosis, however, is rarely a good idea. 

I'm not one to judge how patients want to access their health care. Certainly patients are spending more and more time looking for reliable information from the internet and there are many reasons why individuals want to self diagnose the reasons for their own hair loss.  However,  properly diagnose hair loss one needs the full story, not the abbreviated version. And to properly diagnosis hair loss one needs the story told with as little bias as possible. Second, a full examination of their scalp (including use of dermoscopy) is needed. There are many mimickers of hair loss and one needs to know all the potential mimickers to make a proper diagnosis. Finally, one needs to have blood tests to complete the basic work up.  

 

Reference

1; Danielle Ofri, MD What Patients Say, What Doctors Hear (Beacon Press, 2017). Reprinted with permission from Beacon Press.

2. Jerome Groopman. How Doctors Think. Houghton Mifflin 2007


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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Do all women with hair loss really need blood tests?

Evaluating Hair Loss in Women: Are blood tests really needed?

Click here for PDF of Article

That answer, in my opinion, is a resounding - "yes." All women with concerns about hair loss need blood tests. The reason is simple: there are a great number of similar looking hair loss conditions in women and if one thinks they can confidently, with 100% certainty,  rule out any particular condition just by looking at the scalp they are wrong. One can not exclude a contribution from low iron or a thyroid disorder even in a woman presenting with classic androgenetic alopecia. Let's take a closer look why blood tests are needed.

For a review of blood tests typically recommend as part of a screening work up click on the following 

SCREENING BLOOD TESTS FOR WOMEN WITH HAIR LOSS.

 

1. Iron deficiency anemia is common

About 1 out of every 5 women age 18-45 have iron deficiency. It's common. Given that low iron levels may be associated with a variety of different hair loss conditions, it is important to test for it and supplement iron in women whose blood tests show low iron. Even if one were to argue that low iron levels are seldom really a true factor in hair loss, studies have also shown that supplementation with iron may allow other treatments to work better.

In 1992, Drs Rushton and Ramsay conducted a study looking at women with genetic hair loss who were being treated with an antiandrogen medication (called cyproterone acetate). The researchers showed that women with iron levels above 40 had much better results with the antiandrogen pill than women who had iron levels below 40.
 

2. Blood counts

Ordering a basic blood count (for levels of red cells, white cells) is important. It's not a very specific test, but when the levels come back abnormal, it signals something may be wrong. A common reason for low hemoglobin and a low number of red cells levels is iron deficiency. But a variety of internal illness also have as part of their presentations low blood counts. A basic screen is helpful.

My work up is very different when a female with hair loss has an abnormal blood count. A 31 year old female with low hemoglobin and low ferritin, may have this result from heavy menstrual cycles, but may also have this from celiac disease as well. Depending on the patient and specific details, I may order a so called 'celiac panel' as well. A  66 year old female with low hemoglobin and low ferritin who comes into my clinic for hair loss may need a comprehensive work up by her physician to rule out a cancer. 

 

3. Thyroid abnormalities are common

About 1 out of every 15-20 individuals will be diagnosed with a thyroid disorder in their lifetime. These thyroid conditions are 8 times more common among women. While it's true that many with thyroid disease will notice symptoms, about one half will not notice any problems at first. Hair loss is frequently part of the collection of symptoms that come with thyroid dysfunction. Testing for thyroid disease in women with hair loss is important.

 

4. Vitamin D deficiency is common

Vitamin D deficiency is common. Here in Canada, studies have shown that about two-thirds of the population is low in vitamin D and levels tend to be lower in winter than summer.  The exact role of vitamin D in hair loss is still being worked out but it's clear that individuals with alopecia areata and genetic hair loss have lower vitamin D levels than individuals without hair loss.  

 

5. Zinc deficiency

Zinc deficiency is not common in North America. Nevertheless, zinc deficiency does exist in a number of subgroups in the North American population and is likely more common than appreciated. About 12 % of the general population and up to 40-50 % of the elderly are at risk for zinc depletion in North America. In many parts of the world, zinc deficiency is extremely common. In North America, zinc deficiency is frequently asymptomatic - meaning that individuals with low zinc don't necessarily have symptoms. Zinc deficiency can be associated with hair loss as well as a variety of issues related to immune system function and infection. The recommended amount daily is 11 mg for men and 8 mg for women.

 

6. Hormone Testing

Most women with hair loss do not require complex and extensive hormonal work-ups that so often are seen. However women with irregular periods, acne, excessive hair growth on the face (hirsutism), difficulty conceiving/infertility, early menopause and abnormal or rapid hair loss do require hormone tests. 

 

Conclusion

Complete blood counts, along with tests for iron status (ferritin test) and thyroid status (TSH) are among the most important tests for all women with concerns about hair loss. Other tests may also be important for any particular individual but the exact test to order depends on the information obtained during the patient interview.  Too often I hear it said that a female patient does not need blood tests. For example, I often hear it said that a female presenting with classic androgenetic alopecia does not need blood tests because classic androgenetic alopecia is not associated with blood test abnormalities. Here, one needs to consider that classic androgenetic alopecia may be associated with low vitamin D and research has even shown that it may be associated with cholesterol abnormalities as well (low HDL, high LDL).  If one feels they can exclude with certainty that this patient does not have iron deficiency or a thyroid disorder, they are incorrect.

All women with hair loss need blood tests. 

 

REFERENCE

Rushton DH, et al. The importance of adequate serum ferritin levels during oral cyproterone acetate and ethinyl oestradiol treatment of diffuse androgen-dependent alopecia in women. Clinical Trial. Clin Endocrinol (Oxf). 1992.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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The Modified Hair Wash Test (MHWT)

A closer look at the MHWT for Differentiating CTE and AGA

The modified hair wash test (MHWT) is an extremely helpful non-invasive test. It is underutilized by dermatologist mainly because of lack of familiarity and exposure. It is an extremely powerful technique to differentiate challenging cases of CTE from AGA. The patient may perform this test at home. 

 

Performing the MHWT

To perform the MHWT, a patient is instructed to avoid shampooing the hair for 5 days before the date of set test date. On the day of the test, the sink is covered with a gauze. The hair is then shampooed thoroughly and rinsed. The hairs trapped in the gauze are collected counted and divided into hairs less than 3 cm and more than 5 cm.

 

Interpreting the MHWT

Patients with 10% or more of hairs 3 cm or shorter and who shed fewer than 100 hairs are diagnosed as having AGA; Patients with fewer than 10% of hairs that were 3 cm or shorter and who shed at least 100 hairs were diagnosed as having CTE; Patients with 10% or more of hairs that were 3 cm or shorter and who shed at least 100 hairs were diagnosed as having AGA + CTE; Finally patients with fewer than 10% of hairs that were 3 cm or shorter and who shed fewer than 100 hairs were diagnosed as having CTE in remission.

 


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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Differentiating between Short 1 cm Hairs by Dermoscopy: Many Possibilities !

How can we tell apart the various causes of short hairs?

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I'm frequently asked by patients and physicians how to determine the identify of a short 1 cm or so hair that is seen on the scalp. Looking at the scalp with dermoscopy, one often want to know "Is this a vellus hair I'm seeing or is it an upright regrowing hair as part of a telogen effluvium? ... or is it simply a normal regrowing hair ?"

This chart below helps summarize the main things I think about when I see a short hair. The answer does not necessarily come immediately but rather it comes by asking 4 questions:

1) Is the hair reasonably thick (i.e. 40-50 um or more) or is it very thin (less than 30 um)?

2) Are the ends pointy or blunt?

3) Are these short hairs found all over the scalp or just one area?

4) Are there just a few of these short hairs or lots and lots of them?

 

By working through these 4 questions, I can generally determine the cause of the short hair I'm seeing on the scalp. 

shorthairs

Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Alopecia Areata: Inflammation causes Abnormal Hairs to be Produced

Alopecia Areata: A Closer Look at Shed Hairs

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Alopecia areata is a autoimmune condition that affects about 2 % of the world. The condition causes inflammation at the very bottom of the hair follicle (called the "bulb").

As a result of this inflammation, the hair does not grow well because this inflammation interferes with proper growth. Sometimes the fibers are abnormal in appearance (producing a "tapered hair" as shown in the photo). Other times the hairs that fall out are very normal looking telogen hairs (labelled 1 and 2 in photo below) that simply get shed early.

dystrophicAA

In addition, when the condition is "active" and hair loss is occuring in an accelerated manner, a variety of hairs can be easily pulled from the scalp including telogen hairs (labelled 1 and 2) and a variety of weakened hairs that break off at the root (called "dystrophic" hairs and labelled 3 in the bottom photo).

Analysis of the types of hairs that are extracted from the scalp is important as it gives information not only about the diagnosis itself but the severity of the condition and prognosis. 


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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Where should a scalp biopsy be taken from?

Choosing (Wisely) A Site to Biopsy

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Scalp biopsies are a brief 10-15 minute procedure that allows the clinician to obtain a sample for analysis under the microscope.

Great care is needed to choose the spot or location to sample. Random biopsies are rarely helpful. The site should ideally be the site where the most changes representative of the potential disease in question are seen by the clinician or the most symptoms are felt by the patient (ie itching, burning and pain).

Far too often I evaluate biopsies form patients whereby a biopsy was taken from an area that is not truly representative of the disease that is believed to be present. Biopsies are often taken from an area that will be 'hidden' in the event that a scar forms. However, a biopsy should always be taken form a representative area or one should not take the biopsy at all. Too many biopsies for androgenetic alopecia are taken from the lateral (side) parts of the scalp rather than the central regions. This often yields information that is not always helpful. If a decision is made to take a biopsy, it must be taken from an area that is most likely to capture the disease in question. Otherwise my personal opinion is not to do it. 

Once the site is chosen, the area is marked with a dot (as shown in the photo). The scalp in this area is anesthetized ("frozen") with local anesthetic medications such as lidocaine. Then, a punch biopsy instrument is used to obtain a sample about 4 mm in diameter. The area where the sample was removed is then stitched with suture. The punch biopsy specimen is then sent to a dermatopathology lab for processing.  Results may take 2-6 weeks depending on the type of processing needed. 

 


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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"Miniaturization" and "Anisotrichosis" in Androgenetic Alopecia

Terms in AGA: Miniaturization and Anisotrichosis

miniaturization

Androgenetic alopecia is common in men and women. By 50 years, about 50 % of men and 30 % of women have some evidence of androgenetic alopecia. The early features of AGA include hair shedding in some and hair loss in specific areas (temples and crown in men and central scalp in women).

When examined up close as in this photo, one can see "miniaturization" of hairs whereby some thicker hairs undergo a change to thinner hairs. Most hairs we have on our scalp as teenagers range in around 70-90 micrometers in diameter. During the process of androgenetic alopecia, the follicles become thinner and thinner and over time reduce slowly to 50 micrometers then 20 then 10 etc. Finally the fibers are so thin and short that they fail to reemerge from the scalp.

Not all hairs become thin and not all hairs thin at the same speed (rate). There is great variation in the thickness of hairs. We call this variation in hair shaft thickness "anisotrichosis." Two finding of miniaturization and anisotrichosis is a typical feature of androgenetic alopecia in both men and women. 


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 Biopsies: Always 4 mm in size

Scalp Biopsies

biopsy

Scalp biopsies are performed when the diagnosis of an individual's hair loss is not clear from their story and from examination of the scalp.

A biopsy is performed under local freezing and involves removal of a tiny sample 4 mm in diameter.

The sample is sent off the the dermatopathologist for review under the microscope


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: Which blood tests should be ordered ?

Blood tests for Hair Loss: Some tests are simply wasteful

CW

There are literally dozens and dozens of blood tests that one could order for a patient with hair loss. Which ones should we order? Which ones are likely a "waste"? I enjoyed this article in the Medical Post about a newer organization in Canada called Choosing Wisely which serves to help clinicians become more aware of what tests are unnecessary.

In the world of hair loss, this concept is important. Is ordering a reverse T3 likely to add much in a patient with normal TSH? Probably not. What about an ANA level in a very healthy male with patterned hair loss - is that helpful? Probably not at all. What about ordering a transferrin saturation in patient with a ferritin of 76? Seems wasteful.

There are times when an ANA, reverse T3 and transferrin saturation are important and it is important to know when to order various tests and when not to! If one is not likely to change management of the patient if a test comes back, normal or abnormal then it makes little sense to order the test.



The Basic Tests

Basic tests in hair loss include CBC, TSH, ferritin, 25 hydroxyvitamin D and possibly extended to include zinc. Rarely hormonal tests and ANA are included but not routinely. Additional tests are really ordered on a case by case basis. For a list of tests I recommend see the following link

Basic Hair Loss Blood Tests

 

 


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

Card Test For Darker Hair Colours.

Dark Card Test.png

The contrasting hair card tests for darker hair colors. The use of a piece of paper of contrasting color to the hair is an excellent means to evaluate recent changes in hair growth. Here, a white paper is placed behind dark brown hair. In this patient we can see thay signficant growth has occured in the last 3-4 months. This immediately informs me that either a massive telogen shed occured 4 months ago or a growth promoting agent was started 4 months ago. In this case it helped pinpoint regrowth from use of minoxidil.

See Also "The Card Test for Lighter Hair Colors"


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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Will a scalp biopsy site be immediately visible to others?

Will a scalp biopsy site be immediately visible to others?

BX Scalp.jpg

Scalp biopsies are extremely important when performed in the right patient. They can help exclude a variety of causes of hair loss - especially various inflammatory and scarring alopecias. The procedure is a brief 5-10 minute procedure done with local freezing (anesthesia). A stitch is placed in the scalp at the end. For most patients the stitch will not be noticeable to others especially if the sample is taken in an area where neighboring hair can help cover it. If a biopsy is taken from an area which is rather devoid of hair, the stitches may be visible to others for a few weeks.

This photo shows the scalp of a patient who has just finished a biopsy. The area is quite hidden. As the patient leaves the office, nobody would know a biopsy had been performed. The patient can even return to work. Stitches here are dissolving stitches. After a few weeks the area will heal with a small scar. But that scar too should be relatively hidden by neighboring hair.
 


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

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

 

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

 

 A true or false question

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

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

 

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

 

1.     Scarring Alopecia (especially Lichen Planopilaris)

2.     Senescent Hair Loss

3.     Diffuse Alopecia Areata

4.     Hair Shedding Disorders

 

Final Comment:

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

 

 

 

 


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

Photos: Can you diagnose hair loss from a photo?

With the widespread availability of smartphones, it’s remarkably easy nowadays to take photos.  It’s also remarkably easy to post these on various forums and remarkably easily to send these via email.  For these reasons, photo use is widespread among patients with hair loss. Despite this, there is a common assumption that is being made that is not correct. Many people wrongly assume that one can properly diagnose hair loss with use of a photo.

 

Photographs for Hair Loss: Helpful but not the entire story

There are many hair loss conditions that mimic each other.  For example, I can show you a photo of androgenetic alopecia, diffuse alopecia areata, and lichen planopilaris that look identical. Can one be confident from the photo alone as to what the diagnosis is? No.

Because genetic hair loss is common, one will often be correct by guessing genetic hair loss in many photographs of hair loss. Nearly 1 out of every 2 women will have genetic hair loss by age 50 compared to approximately 1 out of 7,000 who will have (0.01%) have lichen planopilaris.  Clearly, guessing that a photo is showing genetic hair loss is more likely to be the correct answer.

 

PRINCIPLES OF USING PHOTOS


Here are some important principles of photographs in the diagnosis of hair loss

1. One can never be 100 % confident of any diagnosis with a photo alone.  

2. The lighting and background must ideally be the same if photos are to be compared. 

3. The length of the hair must also be the same. 

4. With a very detailed clinical history about the patient’s hair loss and medical history, one can move from being "uncertain" about the diagnosis to "somewhat confident." But that's about the maximum one can be. One can never be 100 % certain. There are many conditions that can mimic each other.

 

Conclusion

Photographs are wonderful to document the degree and pattern of hair loss. However, one must not assume that one can confidently determine the diagnosis of hair loss with photographs alone.

 


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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Diagnosing Hair Loss in Darker Skin Types

Diagnosing hair loss in patients with darker skin types employs the same principles as for lighter skin types. However, a few features are unique including the the greater likelihood for scalp inflammation to create areas of hypopigmentation and hyperpigmemtation. In this picture of a male with androgenetic alopecia several findings are present. The redness and fine scale is consistent with seborrheic dermatitis. The patient also has folliculitis and a pustule can be seen in the upper portion of the picture. In the bottom left of the picture, areas of whitish hypopigmentation can be seen and in the bottom right areas of darker hyperpigmentation can be seen. The tiny white dots that are speckled al over the scalp represent the openings of the eccrine glands.


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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Do I Need to See an Endocrinologist for my Hair Loss?

There are many types of hair loss. In fact, when you add them all up, there are well over 100 causes of hair.  Some of the causes impact another body system in addition to the hair and require additional focus and attention to ensure the patient's total health. For example, some of the causes are associated with an increased chance of having a thyroid disorder (alopecia areata and lichen planopilaris are example). Other causes are associated with a range of other issues including hearing issues, heart problems, kidney problems, cholesterol problems, bone abnormalities, etc.

Androgenetic alopecia is a form of hair loss that frequently affects women. It causes thinning in the central scalp area in early stages such that the scalp becomes much more "see through." Over time the hair loss pattern can be diffuse. Most women with androgenetic alopecia have no hormonal abnormalities but a small proportion do. Women with irregular periods, acne, hair growth on the face require blood tests to further evaluate for an underlying endocrine issues.

 

When should a referral to an endocrinologist be made?

I'm often asked by patients and physicians when I refer my patients to an endocrinologist. There are no hard and fast rules but referrals are generally made in the following situations:

1. Women with androgenetic alopecia and irregular periods, especially less than 9 menstrual cycles per year.

2. Women with androgenetic alopecia with possible evidence of late onset congenital adrenal hyperplasia evidenced by elevated day 3-4 17-hydroxyprogesterone.

3. Women with androgenetic alopecia with evidence of potential polcystic ovarian syndrome, especially elevated day 3-4 LH/FSH ratios, irregular periods and findings of acne and increased hair growth on the face.

4. Women with hair loss accompanied by regular menstrual cycles with a history of irregular cycles in the past who do not show normal surges of progesterone day 21.

5. Women with possible premature ovarian failure.

6. Women with irregular periods and elevated prolactin.

7. Women with markedly elevated DHEAS and testosterone regardless of age

8. Women with autoimmune mediated hair loss with low bone mass. Such women may require corticosteroid based therapies with the potential to further impact bone

9. Women with potential adrenal dysfunctional either concern for adrenal suppression from corticosteroid use or various causes of hyperadrenalism (especially when Cushing syndrome is a consideration).

10. Women with low TSH and elevated T4 and or T3

11. Women with high TSH above 7-10 that does not improve on repeat testing or does not improve with thyroid supplementation or is associated with symptoms such as low heart rate, mood changes, constipation and/or chronic shedding. A lower threshold for referral is made in my clinic if additional underlying health issues are present (ie heart disease) or thyroid autoantibodies are positive. For an elevated TSH 2.5 to 6, I handle these situations on a case by case basis.

 

Conclusion

Hair loss is associated with changes in several organ systems. There are several reasons why I might ask my endocrinology colleagues to evaluate my female patients and some are listed above. Other reasons may be possible too. It is not a routine referral meaning that not all patients need such referral. In fact, it is only a small minority.


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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Valproate and Hair Loss: Does valproate cause hair loss through an androgen mediated mechanism?

There are many different types of drugs used as mood stabilizers is women with bipolar disorder. Many of these drugs can cause hair loss, albeit with different mechanisms. Common medications used in treating bipolar disorder include lithium, valproate, lamotrigine, topiramate, gabapentin, carbamazepine, oxcarbazepine.

 

Vaproate and Hyperandrogenism

There is increasing evidence suggests that valproate is associated with isolated features of polycystic ovarian syndrome (PCOS). To study this further, researchers studied three hundred women 18 to 45 years old with bipolar disorder. A comparison was made between the incidence of hyperandrogenism (including hirsutism, acne, male-pattern alopecia, elevated androgens) with oligoamenorrhea that developed while taking valproate versus other types of anticonvulsants drugs (like lamotrigine, topiramate, gabapentin, carbamazepine, oxcarbazepine) and lithium. 

 

What were the results?

It was interesting that among 230 women who could be evaluated, oligoamenorrhea with hyperandrogenism developed in 9 (10.5%) of 86 women on valproate compared to just 2 (1.4%) of 144 women on nonvalproate anticonvulsants or lithium. This translated into a nearly 8 fold risk of these hyperandrogenism and menstrual cycle changes with valproate. Oligomenorrhea happened within 12 months with valproic acid users.

 

Conclusion

Once needs to be aware of a possible PCOS like clinical phenomenon and for hair specialists - the development of hyperandrogenism and accelerated AGA in women using valproate for bipolar disorder. More studies are needed to confirm these findings.

Reference

Valproate is associated with new-onset oligoamenorrhea with hyperandrogenism in women with bipolar disorder.

Joffe H, et al. Biol Psychiatry. 2006.


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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Elevated testosterone Levels in Women with Hair Loss

Testosterone Levels in Women with Hair Loss

There are many causes of elevated testosterone levels in women. Slightly elevated levels can sometimes be considered 'normal' with no underlying issues to be concerned about. Many patients with increased androgen levels have polycystic ovarian syndrome or underlying endocrine issues such as Cushing syndrome. However, elevated but can sometimes be associated with serious underlying conditions, including cancer. Patients with rapid onset of symptoms and signs along with hormone levels that are well above normal need rapid medical attention for proper diagnosis.

 

What is the 'cut off' for normal?

There are no hard and fast rules when it comes to cut off numbers. A full story is needed from the patient including how fast the symptoms appeared and how many symptoms are present. Is it hair loss? Is acne present? How about increased hair growth on the face (i.e. hirsutism)? Is the patient menopausal or post menopausal? Are menstrual cycles regular? Has there been weight loss or gain? Does the patient have increasing pain anywhere ? How about fatigue levels?

 

Cancers of the adrenal gland and ovaries

Cancers of the adrenal gland are rare and about 2 new cases are diagnosed every year per 1 million people. Cancers of the ovary are more common and currently ovarian cancer is the sixth most common cancer in women. Less than 1 % of patients presenting with hirsutism and other signs of hyperandrogegism have an ovarian or adrenal tumor - but it is important to diagnose early. 

Generally speaking a plasma testosterone concentration three times above the normal level (i.e. above 8.7 nmol/L or 200 ng/dL) with a normal DHEAS level raises the suspicion that the patient could have an underlying benign or malignant ovarian cause of their symptoms. Furthermore, a plasma testosterone concentration three times above the normal level (i.e. above 8.7 nmol/L or 200 ng/dL) with an elevated DHEAS level (above 16.3 umol/L or 600 ug/dL) raises the suspicion that the patient could have an underlying benign or malignant adrenal cause of their symptoms.It could of course be normal, but when levels are in this range - a full work up is mandatory. 

 

Further testing with elevated androgens 

Further testing may be advised depending on the degree of hormone elevation and associated signs and symptoms. Generally a full hormonal panel with free and total testosterone, DHEAS, LH, FSH, estradiol, SHBG, prolactin, 17 hydroxyprogesterone and TSH are ordered. Other tests include AFP (alpha feto protein) and B-hCG may be ordered. A pelvic ultrasound or CT scan may be ordered for women with markedly elevated levels. Further stimulation and suppression testing (i.e a dexamethasone suppression test for a potential androgen secreting adrenal tutor) may be ordered upon referral to an endocrinologist. 

 

Conclusion

There are many causes of increased androgens in women. When associated with increased hair growth on the face, irregular periods, acne or hair loss, androgen hormone levels are frequently elevated. Conditions such as polycystic ovarian syndrome (PCOS) or ovarian hyperthecosis are common and frequently responsible. However, women with markedly evaluated androgen levels (especially three times above normal) require a full work up including referral to endocrinology, radiology and gynaecology specialists.

 

Reference

Pugeat M et al. Androgen secreting adrenal and ovarian neoplasms. Contemporary Endocrinology: Androgen Excess Disorders of Women: Polycystic Ovarian syndrome and other disorders. Second Edition. Humana Press.


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

HAIR PRINCIPLE FOR DIAGNOSING HAIR LOSS
 

Years ago, while teaching a group of dermatology residents, I came up with a 4 letter memory tool that helps remind us all about the proper steps needed to diagnose hair loss. The first letter of teach of the key steps spells HAIR:

H = History

A= Assessment

I = Investigations

R= Repeat if necessary!

 

"H" stands for History.

The history of a patient's hair loss is extremely important and can not be ignored. All aspects are potentially important including when the hair loss first occurred, how many days, weeks or months it's been present, symptoms that accompany the hair loss (especially scalp itching, burning or pain), prescription and non prescription medications used by the individual, family history of hair loss, personal history of any medical conditions. All these factors could be important to a patient's hair loss and need to be fully uncovered. 

 

"A" stands for Assessment. 

A proper and thorough assessment of the scalp involves an "up close" exam. There are times when an up close examination is not possible and photos of the scalp need to suffice. But to be confident in what's causing a person's hair loss, the scalp needs to be examined. One can not stand across the room. One needs to look - and the closer the better!

It's important to examine exactly where the hair loss is occurring. Is it occurring in the frontal area of the scalp? The top of the scalp? The middle? the back? Is the hair loss actually occurring everywhere? Is there redness? Is there scarring? 

 

"I" stand for Investigations.

A variety of investigations need to be considered for an individual experiencing hair loss. These include blood tests, biopsy and collection of shed hairs. It doesn't mean that all these are necessary - but it does mean that all tests need to be considered. 

For all women with hair loss, I advise three tests: complete blood counts (CBC for hemoglobin), thyroid studies (TSH test) and iron studies (ferritin test). Other studies could also be important to order depending on what is uncovered in the steps above. For men with hair loss, such tests are not always needed.

A scalp biopsy is rarely needed. With a properly obtained history and a properly conducted scalp exam (including use of dermoscopy), a biopsy becomes redundant for many patients. However, a biopsy is helpful in challenging cases and helpful in some scarring alopecias to confirm the subtype.

 

"R" stands for Repeat if necessary.

It's usually possible to diagnose hair loss with the first three steps above : history, assessment and investigations. However, there are some situations where it's just not.  In such challenging cases, the only way to definitively understand the cause of the patient's hair loss is to see them back in the office and 'follow' their hair growth and hair loss over a period of time. Sometimes this is 2 months and other times it could be 6 months or 1 year.  At each visit, the steps of history taking (H), assessment (A) and investigations (I) may be repeated. 

 

Exceptions to the HAIR Principle

There are not many exceptions to the HAIR Principle. A history of hair loss and an assessment is always required. There are many mimickers of hair loss. A photo of a patient with what looks like genetic hair loss could be genetic hair loss. But without a history one can not be certain.  Investigations, as stated above, are not always needed.  Generally blood tests are required for every female with hair loss.

 

Conclusion

The "H.A.I.R." Principle is a helpful memory tool to remind both physicians and patients that diagnosing hair loss might not always be quick and easy.  A carefully obtained medical history, a thorough scalp assessment and a variety of investigations need to be part of the evaluation. In some cases where the diagnosis is elusive, these steps need to be repeated in a few months


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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