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Filtering by Category: Inflammation


Cortisone Injections - Only for Inflammatory Conditions

What are steroid injections used for? 

Cortisone injections are commonly used for many hair loss conditions but are not effective in all conditions. The most well known use of cortisone injections is for alopecia areata followed by scarring alopecias such as lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia amd even some cases of traction alopecia. Steroid injections are not helpful in androgenetic alopecia and most cases of telogen effluvium.

 

Are steroid injections safe?


Monthly steroid injections are generally fairly safe for a few months and this is commonly done for small patches of alopecia areata with very good effect. However one needs to sit down with a physician to review all potential side effects even with short term use. Our Handout on Steroid Injections in shown in the link below

Donovan Hair Clinic - STEROID INJECTIONS

Side effects with short term use include temporary indentations in the scalp, tenderness with the injections, rarely fatigue, mood changes. Some female patients will notice that they might even miss a period. Complications such as adrenal suppression, diabetes, blood pressure changes, are rare but need to be considered. With longer term use beyong 4-5 months one needs to consider all the short term changes mentioned above plus changes in bone density, mood changes, fatigue, stretch marks, diabetes, cholesterol issues, cataracts, high blood pressure and a few other issues as well.  Alot of the real magnitude of risk depends on the concentration of the steroid that is being injected and the actual volume. If concerned, please be sure to have a discussion with your physician. Steroid injections can be highly highly effective for many conditions but need to be respected.

 


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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PSORIASIS-LIKE REACTIONS TO ANTI-TNF DRUGS

 

POSSIBLE ANTI-TNF DRUG REACTIONS

Anti-TNF.png

Anti-tumour necrosis factor (TNF) agents such as adalimumab and infliximab have been shown to have benefit in inflammatory bowel disease (IBD). It is now recognized that cutaneous reactions such as new onset psoriasis or psoriasiform-like reactions are among the most common adverse reactions. 

Researchers from Australia retrospectively reviewed cases of anti-TNF-induced psoriasis or psoriasiform manifestations in IBD patients. A total of 10 (six females) of 270 (3.7%). IBD patients treated with anti-TNF therapy developed drug-induced psoriatic or psoriasiform-like reactions: five patients were treated with infliximab and five with adalimumab; nine had Crohn disease. The duration from start of anti-TNF agent to onset of rash was about 8 months on average. The scalp was the most frequent distribution (7/10). Three patients discontinued anti-TNF treatment with resolution of the rash. Topical treatment of the lesions allowed continued use of biological agent in the majority. 


Reference

Peer FC et al. Paradoxical psoriasiform reactions of anti-tumour necrosis factor therapy in inflammatory bowel disease patients. Intern Med J. 2017.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Tofacitinib for Alopecia Areata: How long do we use it?

How long to continue Tofacitinib in Alopecia Areata?

 

A variety of treatments are available for alopecia areata. For localized (limited) AA topical steroids, steroid injections and minoxidil are still the mainstays of treatment. Treatment of advanced alopecia areata is more challenging. A variety of options are available in such cases including diphencyprone, prednisone, methotrexate and more recently tofacitinib.  

 

Tofacitinib in AA

We have been prescribing tofacitinib more frequently as an off label treatment for alopecia areata. The drug is surprisingly well tolerated for many, but does have potential side effects relating to long term immunosuppression. These include increased risks of infection, and concerns over possible long term cancer risks. The drug is expensive (1200-1400 USD per month). 

 

Lowest Dose, Shortest Time Needed

Clearly, in order to limit side effects of tofacitinib (and any drug) one should use the lowest dose possible and use it for the shortest duration possible. However, for many patients with advanced alopecia areata who are responding well tofacitinib and experiencing regrowth, any discussion of lowering the dose raises the possibility that hair loss could once again occur. The decision to taper the drug should always be carefully considered. Losing hair again can be devastating.

Some patients with advanced alopecia areata who start tofacitinib will likely need to use higher doses forever to maintain their hair density. But some patients will be able to eventually taper the dose. Some are able to taper it a bit and some are able to taper it a considerable amount and possibly even stop. However, it is less common to be in the latter group. Most patients who need to use tofacitinib in the first place have a more resistant form of hair loss that is unlikely to regrowth fully without immunosuppression.

 

Tapering Tofacitinib

There is no standardized formula for how to taper tofacitinib. Generally, my approach is the following.

1. Assuming a patient is using 5 mg twice daily (10 mg daily) go down to 10 mg on Monday, Wednesday and Friday and Sunday and 5 mg on Tuesday, Thursday and Saturday. This can be continued for 3 months. If there is any breakthrough hair loss, the patient returns to 10 mg daily.

2. If hair is growing fully, one can consider going down to 5 mg every day for an additional three months.

3. Thereafter, if hair growth continues to be full, we may consider 5 mg on Monday, Wednesday and Friday and no medication on the other days. A slower taper is possible if there are any concerns and this could include 5 mg daily Monday to Friday with the weekends being 'drug-free' periods.

4. Thereafter, any taper is done on a case by case basis. Many patients are not  able to taper further. However some may taper to 5 mg on Mondays and Thursdays before eventually going to one tablet weekly.

 

Lab Tests During a Taper

If blood tests have been stable and normal at the higher doses of tofacitinib I am generally less concerned about the patient having frequent monitoring blood tests. Nevertheless, I do feel that tests every 3-6 months is still appropriate even in a patient whose tests have been stable. I generally advise my patients to get tests for CBC, CK, cholesterol, liver function tests, creatinine, urinalysis. A repeat ECG is done every year.

 

Final Comments

The topic of tapering immunosuppressants is an important one in alopecia areata. Some patients are not able to taper immunosupressants at all without losing some hair. However, some patients can taper and a "go slow" approach is generally the best method. Go slow means not only taper the oral immunosuppressants slowly but given attention to how the patient's alopecia areata is treated topically. As tofacitinb is tapered, one may continue various topical (and even corticosteroid injection-based) treatments that have been performed alongside the immunosuppressive agents.  But eventually they too can be tapered in a stable 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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Zinc and Inflammation: A Complex Link

What is a special about zinc and inflammation?

zinc-CRP

 
Zinc is a so called "negative" acute phase reactant. When inflammation is present, zinc levels are often found to be low. In other words zinc levels and inflammatory parameters often trend in opposite directions. A variety of studies have suggested low zinc may even promote inflammation as well creating a spiral effect.

Inflammatory conditions often trigger a rapid reduction in plasma zinc concentration as a result of the redistribution of zinc into cellular compartments. In turn, zinc deficiency influences the generation of cytokines, including IL-1β, IL-2, IL-6, and TNF-α.

A patient with an inflammatory disorder who has low zinc levels on a lab test may not be as low as the test might lead them to believe. It's not entirely clear what the true zinc lab result would be in someone with inflammation and how one should "correct" the result. In other words, there is no current consensus on how to control for the effect of inflammation on serum zinc levels.



Inflammation, Zinc and Hair Loss

A variety of inflammatory hair loss conditions may be associated with low zinc levels including alopecia. Studies in 2009 by Park et al showed that zinc supplementation in patients with alopecia areata who were low in zinc helped with hair regrowth. Other hair conditions like androgenetic alopecia are now understood to be associated with "micro inflammation" and seem to also be associated with low zinc levels.



Conclusion


Zinc levels may change in the setting of inflammation and levels appear to be lower in many hair loss conditions. How best to supplement zinc is not clear nor is it clear what levels we should be aiming for in patients with inflammatory hair disorders. We are in the early stages of fully understanding zinc.



Reference
 

1. Aiempanakit K, et al. Low plasma zinc levels in androgenetic alopecia.  Indian J Dermatol Venereol Leprol. 2017 Nov-Dec.

2. Jin W, et al. Changes of serum trace elements level in patients with alopecia areata: A meta-analysis. J Dermatol. 2017.

3. Jamilian M, et al. Effects of Zinc Supplementation on Endocrine Outcomes in Women with Polycystic Ovary Syndrome: a Randomized, Double-Blind, Placebo-Controlled Trial. Randomized controlled trial Biol Trace Elem Res. 2016.

4. Park H, et al.The therapeutic effect and the changed serum zinc level after zinc supplementation in alopecia areata patients who had a low serum zinc level.  Ann Dermatol. 2009.


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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Tapered and Exclamation Mark Hairs in Alopecia Areata

Tapered & Exclamation Hairs in AA indicate Activity

tapped

Tapered Hairs

Tapered hairs are frequently seen in patients with small circular patches of alopecia areata. In contrast to 4-5 mm exclamation mark hairs (see next post), tapered hairs are long and typically as long as neighboring hairs. As the hair enters into the skin it becomes much thinner. At the bottom of the tapered hair (deep under the skin) is inflammation.

Tapered are important findings in patients with patchy stage alopecia areata as they tell us that the condition is active and that anti-inflammatory type treatments (such as cortisone injections) are likely to help. The above photo shows several tapered hairs (TH).

 

Exclamation Hairs

exclamation

Exclamation mark hairs are frequently seen in patients with small circular patches of alopecia areata. These hairs a short 4-5 mm hairs and represent broken hairs. The top is thick and the end is often frayed. As the hair enters into the skin it becomes much thinner. At the bottom of the exclamation mark hair (deep under the skin) is inflammation. Exclamation mark hairs are important findings in patients with patchy stage alopecia areata as they tell us that the condition is active and that anti-inflammatory type treatments (such as cortisone injections) are likely to help. The photo shows several exclamation mark hairs (EMH).


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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My hair was ripped off: Will it grow back?

Traumatic Hair Pulling:  Full Regrowth May or May Not Occur

I am often asked if hair that is pulled out forcefully will regrow. Examples of this are the pulling of hair by children on the playground, hair getting caught in doors, machines etc or cases of hair pulling during assault or abuse-related situations (for example domestic abuse).

Without actually seeing the scalp, and knowing details of the patient's story, it is impossible to determine if hair will or will not grow back in any particular case. This requires an in person examination so that the scalp can be properly examined.

 

Hair regrowth is not a guarantee

There is no guarantee that hair regrowth will occur. One will know in 6-9 months if they will acheive full regrowth or not because that is how long it takes for hair to grow back following any type of injury.

It is certainly possible for repeated pulling to give permanent hair loss. However, in the vast majority of cases where hair is pulled from the scalp, hair grows back.  If you or I were to reach up a pluck a hair, it will grow back. However, if pulling is repeated many times or is excessive with bleeding a greater chance exists for scarring to develop. Hair pulling that is accompanied by injury to the skin layers (i.e. that creates an actual wound) has a markedly increased chance of being associated with permanent scarring.  It is such scarring that blocks the regrowth of hair.  Scar tissue is permanent and, if present,  generally destroys stems cells. 

Anyone with concerns about incomplete growth after episodes of hair pulling should see a physician who specializes in hair loss for consideration of a scalp biopsy.


 


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 at the Nape of the Neck: What are the main causes?

Losing Hair at the Nape: What are the main Causes?

Hair loss can either be localized (meaning one area of the scalp) or diffuse (meaning all over the scalp). There are many causes of hair loss at nape of the neck and the back of the scalp. 

 

1. Traction alopecia

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Traction alopecia refers to a type of hair loss due to the tight pulling of hair. The back of the scalp is particularly susceptible to loss of hair.  Hair styling practices can frequently lead to traction including braids and weaves and pony tail.  If traction alopecia is of recent onset, hair regrowth can occur even without treatment. If traction is longer standing, the hair loss can often be permanent.  Some women with hair loss that looks like traction actually have a scarring alopecia known as cicatricial marginal alopecia. 

 

 

2. Alopecia Areata

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Alopecia areata is an autoimmune disease that affects about 2 % of the world. Hair loss can occur anywhere. Alopecia areata can frequently cause hair loss specifically at the nape in some patients. The particular form that causes loss at a the back of the scalp is the 'ophiasis' form. The ophiasis form is frequently resistant to standard treatments although topical steroids, steroid injections and diphencyprone are typically first line. 

 

 

3. Androgenetic Alopecia

AGA NAPE.png

Androgenetic alopecia (male and female thinning) typically causes hair loss at the top of the scalp. In men, the temples and crown are most often affected. In women, the mid-scalp region is generally affect first. The back of the scalp can also be affected although this is not typically thought of. Hair thinking along the nape is not uncommon in advancing balding in men and women. 

 

 

4. Frontal Fibrosing Alopecia

FFA.png

Frontal fibrosing alopecia (FFA) is a type of scarring alopecia. FFA typically affects women between 45-70. Most often hair is lost along the frontal hairline and eyebrow. However the back of the scalp (at the nape) and frequently be affected. The hair loss in the nape typically starts at the sides (left side and right side) just behind the ears. Treatments for FFA include topical steroids steroid injections, topical calcineurin inhibitors. Oral drugs include finasteride, doxycycline and hydroxychloroquine at the top of the list.

 

5.  Heat and Chemicals

Heat and chemical treatments can lead to hair shaft damage and hair loss at the nape. Frequently, heat and chemical overuse leads to an increased tendency to develop traction alopecia which si discussed above. 

 

6. Acne keloidalis nuchae

Acne keloidalis nuchae (AKN) is a condition that can affect both men and women. Small papule or bumps develop along the posterior scalp and are accompanied by hair loss in the region as well.  The hair loss in AKN is often permanent and can lead to thicken and thicker scars some of which are disfiguring. 

 

7. Hair shaft disorders

Some individuals are born with abnormalities in how the hair shaft is produced. This frequently leads to hair breakage. Monilethrix is one of the hair shaft disorders that frequently leads to hair loss along the nape. 

 


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

I frequently get asked whether minoxidil has any benefit in treating frontal fibrosing alopecia (FFA). It seems that it could provide some benefit but it's not completely clear yet if it is truly helping the patient's FFA or their underlying androgenetic alopecia that many patients with FFA also have. Large scale studies are needed. 

I generally add minoxidil once I have some evidence that a patient is stabilizing with their main anti-inflammatory treatment. This typically includes one or more of topical steroids, steroid injections, doxycycline, hydroxychloroquine and anti-androgens such as finasteride or dutasteride. 

It’s interesting that 32 % of patients in one study had an improvement in their FFA with use of anti-androgens. When one looks at a larger group of 111 FFA patients of which 74.8 % were using minoxidil, one notes that 47 % of patients had an improvement with anti-androgens. So it does seem that patients using minoxidil had better outcomes. There is at least some suggestion here that minoxidil might help. 

 

Conclusion

Up to 40 % of patients with FFA have androgenetic alopecia so it’s difficult sometimes to decipher whether minoxidil is truly helping the patient’s FFA or whether it is helping their underlying androgenetic alopecia. More good studies are needed.

Reference

Vano-Galvan S et al. Frontal fibrosing alopecia: a multicentre review of 355 patients. J Am Acad Dermatol 2014; 70: 670-678


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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Does the immune system control hair growth?

The Immune System and Hair Growth

Every now and then, I share a landmark study which has the potential to change the way we think about the hair follicle, and how it grows. Today is one of those days.

Researchers at the University of California San Francisco reported last week an important new finding: without specific immune system cells called T regulatory cells (T regs), hair follicles do not grow properly. The study was performed in mice, but likely has relevance to humans.

T regulatory cells are important immune cells. Mice have them and so do humans. These immune system cells act as sort of peacekeepers of our immune system. In scientific terms, we say that these cells play a key role in ‘immune tolerance.’ They tell other immune cells of our body to stay quiet when the time is right to stay quiet and this helps prevent unnecessary allergies and autoimmune diseases. To study the role of T regulatory cells, the researchers developed a clever mouse model whereby T regulatory cells could be removed from the mouse whenever desired. In these studies, mice were shaved of hair and hair regrowth patterns were observed. Surprisingly, hair did not regrow after shaving.

There has now been a shift in thinking. Hair follicle stem cells, at least in mice, appear to listen to the commands of T regulatory cells to know when to grow – and when to stay quiet. Tregs are now understood to accumulate around hairs at the end of the hair growth cycle (in the telogen phase) and help direct hair follicle stem cells to make a new hair. Without Tregs, the growth phase (anagen phase) does not begin. This information could have direct relevance to humans and our understanding of a variety of hair loss conditions. It is well known from previous studies for example, that many of these genes that contribute to the condition alopecia areata are in fact genes that regulate T regulatory cells. In addition, other studies have shown that by supporting T regulatory cells in their functioning, it is possible to can help regrowhair in alopecia areata.

Reference
Ali et al. Regulatory T Cells in Skin Facilitate Epithelial Stem Cell Differentiation. Cell 2017.


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