Manuka Honey for Treating Folliculitis Decalvans

Antibacterial Properties of Manuka Honey May Provide Benefits in Treating Folliculitis Decalvans

Folliculitis decalvans (FD) is a scarring alopecia that affects both men and women. FD is less common than some of the other  scarring alopecias like lichen  planopilaris and central centrifugal cicatricial  alopecia. The cause of FD is not completely know although a  role for bacteria has been postulated.   Bacteria such as Staphylococcus aureus frequently are found in the scalp of patients with folliculitis decalvans. Eradication  of bacteria with antibiotics, isotretinoin and other treatments frequently is associated with improvement of the disease.

A preliminary report proposes that Manuka honey may have benefits in the treatment of folliculitis decalvans

In 2019, a dermatology group in  Boston reported a patient with folliculitis decalvans whose disease improved with use of topical Manuka honey applied to the scalp. Manuka honeyis well known to wound care professionals. In fact, 17 clinical trial s involving  almost 2000 patients have suggested Manuka honey helps wounds heal.  Manuka honey has antibacterial properties – perhaps  due to its low pH, and other  plant  based and hydrogen peroxide based ingredients. A 1999 paper by Cooper and  colleagues showed that  Manuka honey killed  Staph aureus bacteria in wounds. 

The patient in the 2019 paper was a 20 year old male who had used a considerable number of  treatment before he started applying manuka honey to his scalp. These treatments included steroid injections,  clobetasol lotion, prednisone, minocycline, doxycycline and isotretinoin. Some of these treatments were actually  quite helpful for the young man – however he had to  stop because of some side effects of these treatment.  

The  patient decided to start applying Manuka honey  to his scalp after about 1 month into a course of the oral antibiotic cephalexin. As he continued on both cephalexin and topical honey and found that after an additional 4 weeks of both treatments the scalp had improved considerably. 6 months later he stopped cephalexin. His disease eventually flared again and the man used honey alone to settle down his disease. 

Summary/Conclusion

This is an interesting paper. It doesn’t definitively prove Manuka honey helps FD but it hints that it might have a role. We also can’t rule out that the patients long term use of antibiotics and other treatments (like steroids) and isotretinoin have reduced disease activity that makes Manuka honey more likely to help. Nevertheless, this is an interesting paper that hopefully fuel more research in manuka honey.

Reference

Yeh et al. Resolution of folliculitis decalvans with medical honey. Dermatology Online Journal 2019;. 25(8); 

The Widow's Peak: How does it form?

Formation of the Widow’s Peak

The widow’s peak is a triangular area of hair in the middle of the hairline. It’s common and not associated with bad luck, bad omen or bad anything...of any kind.

The term is probably 200 years old. How did the name even get started? Well, the term probably comes from a type of headdress that a woman (widow) wore after the death of her husband in the 1500’s. The headdress had a triangular peak right in the middle of the frontal hairline. And so the term.

Studies by Dr Bernie Nusbaum suggested that up to 81 % of women have a widow’s peak. This information comes from his study of hairline characteristics of 360 female volunteers performed at an informal hair salon setting. A 2013 study from Spain involved examination of hairline patterns of 103 premenopausal women. 94.17 % had a widow’s peak.

Men have widow’s peaks. Small children (3-5) do not usually have much of a widow’s peak but the widow’s peak starts to be seen in some individuals in the teenage years. The widow’s peak is not actually “created” by the body - it’s due to the body removing hairs around it on either side. What’s left over is the new adult hairline - containing a widow’s peak in some. In case you were not aware, the hairline we get as adults is not the same as the one we get as children. This is normal. 

For some - the new adult hairline has a widow’s peak.

Reference 

Bernard P Nusbaum et al. Naturally Occurring Female Hairline Patterns. Dermatol Surg. 2009 Jun.

C Ceballos et al. Study of Frontal Hairline Patterns in Spanish Caucasian Women. Actas Dermosifiliogr. 2013 May.

Delivering More Minoxidil to Hair Follicles: What's possible and what possibly helps?

How can I deliver more minoxidil to my hair follicles?

Topical 2 and 5 % Minoxidil are FDA approved and Health Canada approved for treating androgenetic alopecia. The drug does not help everyone but certainly helps a proportion of users. Given the benefits of minoxidil, there is a tremendous interest in understanding how best to delivery the minoxidil down into the scalp so that hair follicles can use it to stimulate their growth.

In this article, we’ll take a look at 5 methods to deliver more minoxidil to follicles as well as the challenges and limitations associated with these methods.

1. Use the same amount and same concentration of minoxidil and use it with the same frequency…. but apply it properly. 

There’s a bit of a learning curve to applying minoxidil and some people just don’t apply it correctly. Minoxidil probably absorbs better when applied after the scalp is washed and is still a bit warm. But clearly this is impractical for everyone as many do not shampoo daily and many who do like to apply minoxidil at night and shampoo the hair clean in the morning.  Despite this, it’s probably more important to remember to apply the minoxidil every day that fuss about when to apply it and how clean the hair is.

Regardless of how it’s applied, the minoxidil needs to get on the skin of the scalp so it can begin its journey into the scalp. Getting minoxidil on the hair shafts does not help. Similarly, if there is a great deal of gunk blocking the scalp surface, it becomes more difficult for minoxidil to penetrate the scalp. Gunk includes excessive amounts of gel, oils and hair fibers.

2. Use the same concentration of minoxidil, but use more of it... or use it more often.

For some patients, using more minoxidil allows more to get into the scalp. This is especially true for males using minoxidil and may be true for some women as well. It’s clear that using 5 % minoxidil twice daily is better when treating male pattern balding than using 5 % minoxidil once daily. For some women - but not all - this may be true too. The downside of using more minoxidil is a greater chance of side effects. The chance of headaches, dizziness, and hair on the face all increase as the amount of minoxidil increases.

3. Expose the hairs to higher concentrations of topical minoxidil

Theoretically, using higher concentrations of minoxidil may help more get into the scalp. Studies that support the ideal minoxidil concentration are few and far between. In fact, one study suggested surprisingly that 5 % minoxidil was more effective than 10 %. Researchers from Egypt set out to compare the efficacy and safety of 5% topical minoxidil with 10% topical minoxidil and placebo in 90 males with balding. Surprisingly, after the 9 months, partipcants in the 5 % minoxidil group had higher vertex and frontal hair counts compared to study participants in the 10 % minoxidil group and the placebo group. Clearly, we still have a lot to learn and a long way to go. Higher concentrations of minoxidil are not necessarily better.

4. Compound the minoxidil with different topical agents or via other drug delivery strategies to allow minoxidil to penetrate the scalp better.

There is a major interest in the hair research community to figure out how best to get minoxidil into the scalp. Different vehicles, use of so called nanoparticles as well as other techniques are the focus of many studies. 

It’s also clear that use of adjuvants like retinoids can help make minoxidil more effective. Before we look at this concept further, it’s important to understand a few concepts. In order for minoxidil to do it’s job, it needs to be converted to minoxidil sulphate. Hair follicles have the machinery to help with this but some people’s hair follicles are not really that good at it. Scientifically, we say that some people’s hair follicles lack high levels of an enzyme known as “sulfotransferase” and so they cannot convert minoxidil into the active form that actually does all the work.  (The public does not yet have minoxidil sulfotransferase testing kits available to them but this technology may be coming at some point in the near future.) For year now, it has been known that mixing retinoids with minoxidil makes minoxidil work better. It has long been thought that retinoids irritate the scalp and somehow by doing so allow minoxidil to get into the scalp. Now, based on interesting work published by Sharma and colleagues in 2019 it’s realized that retinoids upregulate the minoxidil sulfotransferase enzyme and by doing so help generate greater amounts of active minoxidil sulphate in the scalp.

The use of derma rolling may be yet another strategy to get more minoxidil into the scalp. Scalp Micro-needling" (dermrolling) is a technique whereby a controlled injury is created in the scalp. Skin injury (at least in some situations) can stimulate the production of growth factors and inflammatory cytokines that promote skin healing and possibly hair growth. A "dermaroller" is one such device to cause controlled injury. A dermaroller consists of teeth of different lengths that are attached to a wheel. Dermarollers of 0.5 mm, 1 mm, 1.5 mm are common. These are "rolled" back and forth across the skin to create redness. A 2013 study of 100 patients supports benefit of dermarolling. The study set out to determine in patients who use topical minoxidil (Rogaine, etc) could achieve even further benefit by dermarolling. In the study, half the patients received daily minoxidil and the other half of the patients received weekly dermarolling sessions (using a 1.5 mm dermaroller) in addition to minoxidil treatment. Results showed that patients using a dermaroller achieved greater benefits than those using minoxidil alone. Specifically, 82 % of patients receiving dermarolling felt they achieved greater than a 50 % benefit in their hair compared to just 4.5 % receiving minoxidil alone. Physicians rated the improvements similarly. Hair counts (at an up close level) were increased in the dermarolling group compared to the minoxidil alone group (91.4 vs 22.2 respectively). These studies support the potential benefit of dermarolling - especially to increase the efficacy of minoxidil. More studies need to be done to verify or refute these results as well as to determine the optimal parameters for dermarolling. These include comparisons of daily vs weekly vs monthly treatment and comparisons of 0.5 mm needles, 1 mm or 1.5 mm needles. Studies are also needed to determine if any proportion of patient actually worsen with dermarolling.

5. Eat the minoxidil (or eat more).

If someone has androgenetic alopecia but is not able to achieve high enough concentrations of minoxidil deep under the scalp with use of topical minoxidil, switching from topical minoxidil to oral minoxidil could make sense.  As reviewed above, in order for minoxidil to do it’s job, it needs to be converted to minoxidil sulphate. Hair follicles have the machinery to help with this but some people’s hair follicles are not really that good at it. Scientifically, we say that some people’s hair follicles lack high levels of an enzyme known as “sulfotransferase” and so they cannot convert minoxidil into the active form that actually does all the work. When oral minoxidil is ingested, the liver does the job of converting the minoxidil to minoxidil sulphate - bypassing the need for the hair follicle to do this job.

Patients who don’t respond to topical minoxidil may respond to oral minoxdil. Similarly, patients who don’t respond to very low doses (like 0.25 mg to 0.5 mg) may respond to moderate doses (like 1-2-5 mg). Of course, increasing the dose may increase side effects like headaches, swelling, fluid retention, hives and excessive hair growth on the body.

References

Dhurat R, et al. A randomized evaluator blinded study of effect of microneedling in androgenetic alopecia: a pilot study. Int J Trichology. 2013.

Ghonemy S et al. Efficacy and safety of a new 10% topical minoxidil versus 5% topicalminoxidil and placebo in the treatment of male androgenetic alopecia: a trichoscopic evaluation. J Dermatolog Treat. 2019 Oct 21:1-6. doi: 10.1080/09546634.2019.1654070. [Epub ahead of print]

Jeong WY et al. Transdermal delivery of Minoxidil using HA-PLGA nanoparticles for the treatment in alopecia. Biomater Res. 2019 Oct 31;23:16. doi: 10.1186/s40824-019-0164-z. eCollection 2019.

Sharma A et al. Tretinoin enhances minoxidil response in androgenetic alopecia patients by upregulating follicular sulfotransferase enzymes. Dermatol Ther. 2019 May;32(3):e12915. doi: 10.1111/dth.12915. Epub 2019 Apr 23.

Higher Minoxidil Concentrations: Is More Always Better?

10 % Topical Minoxidil vs 5 % Topical Minoxidil: Which is better?

Minoxidil is FDA approved for treating androgenetic alopecia (male pattern balding and female pattern hair loss). It would seem logical to propose that if the drug minoxidil helps in the treatment of males and females with androgenetic alopecia that more minoxidil should help even more.

Researchers from Egypt set out to compare the efficacy and safety of 5% topical minoxidil with 10% topical minoxidil and placebo in 90 males with balding.  The study was a double-blind placebo controlled randomized trial over 36 weeks. The study comprised three treatment groups: 1) study participants receiving 5 % minoxidil 2) study participants receiving 10 % minoxidil and 3) study participants receiving placebo.

Surprisingly, after the 9 months, partipcants in the 5 % minoxidil group had higher vertex and frontal hair counts compared to study participants in the 10 % minoxidil group and the placebo group.

Conclusion

This was a nice study showing us that even after 40 years of studying minoxidil, we still have a lot to learn and a long way to go. Higher concentrations of minoxidil are not necessarily better - although more studies are clearly needed.

Reference

Ghonemy S et al. Efficacy and safety of a new 10% topical minoxidil versus 5% topicalminoxidil and placebo in the treatment of male androgenetic alopecia: a trichoscopic evaluation. J Dermatolog Treat. 2019 Oct 21:1-6. doi: 10.1080/09546634.2019.1654070. [Epub ahead of print]

Is Androgenetic Alopecia (AGA) Caused Only by the Effects of DHT ?

Despite the Myth, Androgenetic Alopecia is Not Simply a Story of DHT

Androgenetic alopecia is a type of hair loss that affects men and women. In males, this condition is also referred to as male balding or male pattern hair loss and eventually affects some 80 to 90 % of males. In females, the condition is referred to as female pattern hair loss or simply hair thinning and affects 40% of women by age 50. The purpose of this article is to deal with some misconceptions, wrong information, errors and myths that many people have about the role of DHT in the balding process. DHT is certainly important - but other factors must be considered too.

The Evolution of the DHT Theory of Male Balding

Some of the earliest observations about the role of hormones in male balding happened in the time of Aristotle back in 300 BC. Aristotle showed that castrated males (eunuchs) did not develop balding. JB Hamilton in 1942 did additional pioneering work to understand male balding. He showed that male hormones are relevant to the balding process. Specifically, he confirmed observations by Aristotle and others that males that were castrated before puberty did not go on to develop balding. Hamilton took this further and showed that if testosterone was given back to castrated males, the males proceeded to develop male balding. This showed that male balding was an “androgen-dependent” process.

Further key work in understanding male balding was done in the 1970s and ultimately published in the New England Journal of Medicine. These were studies that showed that male pseudohermaphrodite living in the Dominican Republic with a genetic deficiency known as 5 alpha reductase deficiency did not produce dihydrotestosterone (DHT) and did not develop male balding. These findings lead ultimately to the rational development of drugs such as finasteride and dutasteride which block 5 alpha reductase and lower DHT levels.

The Story of Male Pattern Balding has a DHT Chapter but Don't Forget to Read the Others

From 300 BC to the 1990’s, the story of male balding seemed pretty clear. Male hormones, particularly the infamous DHT, seemed to be what male balding was all about. Blocking DHT was what treatments were all about.

Many people incorrectly assume that male balding is just a DHT story. Many people incorrectly assume that this DHT chapter is the only chapter they need to read when trying to understand male balding. While it’s true that DHT has a whole lot to do with male balding - the correct way to state it is “male balding is due in part to the effects DHT on hair follicles that are genetically sensitive to this hormone.”

DHT not the only chapter in the balding story

DHT not the only chapter in the balding story. One only need to consider a few other treatments that are used for balding to very quickly realize that male balding must be much more complex than just a DHT story. Minoxidil (Rogaine), for example, has nothing to do with DHT - and yet it helps some people with male balding. Granted I agree that finasteride and dutasteride are much much better treatments than minoxidil - but if DHT was the only thing we need to think about when it comes to treating male balding then minoxidil would not be expected to have any sort of benefit. Well, it does. Low level laser therapy also has nothing to do with DHT hormone levels - and yet it helps some males with their male balding. Platelet rich plasma (PRP) also has very little to do with DHT- and yet it helps some males with their male balding.

Drug Companies are Investing Large Sums with the Knowledge that Male Balding is Far Far More than A Simply DHT Story.

At least 12 pharmaceutical companies are investing millions upon millions of dollars with the clear understanding that DHT is not the only chapter in the balding storybook. These companies are hoping to the first to market with brand new types of drugs - again drugs that have nothing really to do with DHT. A brief summary of the drugs is below.

If Male AGA is Far More than A Simply DHT Story, Female AGA is Far Far Far More than A DHT Story

If you have now come to realize that male balding is a bit more complex than simply a story about DHT, I’d like to point out that female androgenetic alopecia (i.e. female pattern hair loss) is even more complex. If you think for even a moment that you’re going to apply the same DHT story that you used in males to explain balding to the mechanisms operating in females with androgenetic alopecia, you’re going to come up short in terms of your ability to explain hair thinning in women.

Androgenetic alopecia in females is a far more complex story - and we still don’t know all of the mechanisms that govern how hairs thin in women. Of course, there is some aspects of the DHT story that relevant to female thinning. But finasteride and spironolactone and anti-androgens are far less consistently helpful in females than in males. Other treatments such as minoxidil and laser may be far more helpful in some women than in males. In other words, there are likely several different mechanisms that are contributory to androgenetic alopecia in females besides simply a DHT story. As further information for reflection to readers who still doubt this information, one must consider that some women with a genetic condition that completely makes them insensitive to the effects of androgens (called androgen insensitivity syndrome) can still develop androgenetic alopecia. Even women with low testosterone and low DHT levels can develop androgenetic alopecia. There are even some androgen deficient women who do not develop any balding whatsoever when you give them back supplemental androgens through various means of testosterone replacement therapy.

Conclusion

Is androgenetic alopecia simply due to the sensitivity of hair follicles to DHT? Well, it’s a good story, but it’s only part of the story. The DHT chapter is an important chapter to read in the story of male balding and female thinning, but be sure to read the remaining chapters of the story book. The DHT story is not the only story - and many pharmaceutical companies are banking on this concept.

Prescribing Dutasteride in Males with Balding: Are there any criteria ? Should there be any criteria?

Prescribing Dutasteride in Males

The most effective medical treatments for male balding (at the time of this article being written) are oral finasteride and oral dutasteride. There is no debate about this particular comment. In the present day, as the world grapples with the meaning of “post finasteride syndrome”, dutasteride is increasingly a choice for many physicians where it never might have been a choice before. I see it - and I see more now than I did 2 years ago. I see dutasteride being used and 0.5 mg three times weekly. I see dutasteride used at 2.5 mg once weekly or twice weekly. I see dutasteride being used at 0.5 mg daily. I see dutasteride being used more often - and I too prescribe it more now than I did 10 years ago.

Dutasteride is not formally FDA approved for treating male balding but is still widely used. It’s used “off label” though and certainly has a large number of studies to back up its effectiveness. In some countries, dutasteride does have formal approval.

The public is also increasing asking about dutasteride - and increasingly requesting it. After all, we don’t have a great deal of data implicating dutasteride in the same set of issues that finasteride has. Furthermore, it’s more effective than finasteride. These two points lead many to turn to the drug. Some data suggests side effects like sexual dysfunction are greater with dutasteride than finasteride but certainly not all studies show this. Some in fact, show that side effects of dutasteride are similar to placebo.

We don’t yet fully understand everything behind post finasteride syndrome to even begin to dig into what might be called a post dutasteride syndrome or a general 5 alpha reductase syndrome. More studies are needed.

So, will you prescribe me dutasteride or not?

Many patients come in the clinic wanting to know if I’ll prescribe them dutasteride. Some have been on finasteride and haven’t found that it works - and they want dutasteride. Some don’t want to try finasteride at all - they want dutasteride. Some want both. Some know the dose they want.

it all comes down to understanding the medical evidence and the 20 years of science that comes before. There is not a “yes” or “no” answer to whether I will prescribe dutasteride. I don’t know when a patient walks in the door if these medications are right for them - but I do know before the patient walks out the door if these medications are right for them.

The following are the criteria I use in the clinic for determine if the patient is a candidate for dutasteride. These are my criteria and may not necessary be the guideline principles for everyone.

Top 10 Criteria for Prescribing Dutasteride (Donovan)

1. The patient understands the treatment is life-long if he wishes to maintain active medical treatment of his androgenetic alopecia.

2. The patient is aware of the array of possible side effects that have been reported with use of 5 alpha reductase inhibitors including mood changes, depression, anxiety, sexual dysfunction, enlargement of breast tissue (gynecomastia), penile shrinkage, loss of penile sensation, weight gain, muscle weakness and others. The potential effects of dutasteride on males wishing to father are not completely understood. The patient accepts the risk of these side effects if he chooses to use dutasteride.

3. The patient does not currently have severe depression or currently have severe anxiety that might otherwise present a contraindication to using dutasteride. The patient has not been suicidal in the past or been hospitalized for depression and mental illness within the past 5 years.

4. The patient is aware of reports that some patients have experienced persistent (long lasting) problems even when the drug has been stopped. These are mainly studied in the context of finasteride but should be assumed for now to be relevant to the use of dutasteride. The patient accepts the risk of these side effects if he chooses to use dutasteride.

5. The patient is aware that class action lawsuits have been launched regarding the persistent side effects related to finasteride use.

6. The patient is aware of alternatives for treatment including topical minoxidil, oral minoxidil, topical anti androgens (topical finasteride), low level laser, platelet rich plasma and hair transplantation.

7. The patient has no known issues currently related to male inferility or infertility in a female partner.

8. The patient understands the possibility of dutasteride causing a reduction in sperm count and the rare possibility that these reductions may be permanent or long lasting (even when the drug is stopped). The original dutasteride studies showed that after 6 months of stopping the drug, sperm counts had not returned to normal in all study participants and that the total sperm count in the dutasteride group remained 23% lower than baseline.

   Males who are concerned about the possibility of lower sperm count or fertility issues may consider having baseline semen analysis or baseline FSH, LH, Free T4 and testosterone measurements before starting. These lab tests may provide some guidance about baseline fertility. These issues in point 5 are relevant to males who may wish to father children in the future.

9. The patient does not wish to donate blood and understands that blood donation is not possible for at least 6 months after stopping the drug.

10. The patient understands that dutasteride may affect future prostate cancer screening by affecting the PSA value. These issues need to be discussed at the time of such screen and consideration might be given to baseline screening depending on the age of the patient when starting dutasteride.

Conclusion

I can’t say if a patient is a candidate for starting dutasteride when they walk in the office but after 20-30 minutes I can determine if they are likely to be a good candidate for the drug or not. The answers to the questions and issues above help guide the decision making that goes into figuring out if a patient is a candidate for dutasteride or not. It’s not something that can be ascertained in a matter of a few minutes.

References

Meeker JD, Godfrey-Bailey L, Hauser R. Relationships between serum hormone levels and semen quality among men from an infertility clinic. J Androl 2007;28:397–406.

Characteristics of FFA in Men

 Characteristics of FFA in Men

Frontal fibrosing alopecia is a type of scarring alopecia that causes hair loss along the frontal hairline and sideburns but can also affect the back of the scalp, eyebrows, eyelashes and body hair.  For every 100 patients I see with a diagnosis of FFA, 99 patients are women and 1 patent is   male.

Tolkachjov and colleagues performed a study of 7 male patients with frontal fibrosing alopecia to gain a better understanding of how these patients present and what type of hormonal or endocrine abnormalities might be present. 

Of the 7 patients, 4 showed loss of the sideburns, 3 showed loss of eyebrows, 2 showed loss of  hair in the occipital scalp.  1 patient had hair loss on the legs, 1 had hair loss on the arms and 1 had loss of hair from the upper lip. None of the 7 patients had facial papules and only 1 had androgenetic alopecia.  Interestingly, none have evidence of thyroid disease and none had low total testosterone levels (although  2 had evidence of low free testosterone).  All patients were ANA negative or only weakly positive. 

Of the 7 patients, 4 started systemic therapy with oral hydroxychloroquine and 3 of these patients were able to achieve disease stabilization with use of this drug.  

Comment

FFA is rare in men but we are seeing an increasing number of males affected. This study is small and so it’s difficult to get a good sense about how FFA in men differs from women.  Hypothyroid disease occurs  in 15-23 % of female patients with FFA. Although the data in this study would suggest that hypothyroidism is uncommon in men with FFA, the study is too small to really get a sense of that information.

Reference

Tolkachjov et al. Frontal fibrosing alopecia among men: A clinicopathologic study of 7 cases. Journal of the American Academy of Dermatology 2017; 77:683-90 

Classic studies from the Past: A Look at the Early Dutasteride Studies

Dutasteride vs Finasteride: Suppression of DHT

In the world of hair loss, we often quote numbers and statistics. We frequently throw around information without a good idea of where that information actually came from. An important study is a 2004 study by Dr. Clark and colleagues. It is one of the the classic studies examining how DHT changes with use of finasteride and dutasateride. 

The researchers studied 399 men with prostate enlargement (BPH) and randomized them to once-daily dosing for dutasteride (0.01, 0.05, 0.5, 2.5, or 5.0 mg), or 5 mg finasteride, or placebo for a total of 24 weeks. The percent decrease in DHT was 98% with 5.0 mg dutasteride and 95% with 0.5 mg dutasteride. This was found to be significantly lower than the 71% suppression observed with 5 mg finasteride.  Moreover there was less variability in DHT changes with dutasteride than finasteride. 

Clark et al. Marked suppression of dihydrotestosterone in men with benign prostatic hyperplasia by dutasteride, a dual 5alpha-reductase inhibitor. J Clin Endocrinol Metab. 2004

The other important part of their studies was the increased in DHT that follows stopping the medication. The graph above shows that DHT levels rise much more slowly when dutasteride is stopped than when finasteride is stopped. This is on account of the long half life of dutasteride compared to finasteride (6 hours for finasteride and 4-5 weeks for dutasteride).

Reference

Clark RV, et al. Marked suppression of dihydrotestosterone in men with benign prostatic hyperplasia by dutasteride, a dual 5alpha-reductase inhibitor. Randomized controlled trial. J Clin Endocrinol Metab. 2004.

Hair loss is not a guessing game.

Guessing is easiest for men's hair loss

If you had to "guess" the reason for someone's hair loss, you'd likely guess correctly if the patient was male and you chose male balding (androgenetic alopecia). By far that's the most common cause of balding in men.  Dozens of other causes are possible, but they are not common. 

Hair loss in women is more complex.

For women, there's a very good chance you'd be wrong if you guessed androgenetic alopecia as the sole cause. Female hair loss is far more complex - and hair shedding issues and even scarring conditions are not uncommon. Hair loss of course, is not a guessing game and a diagnosis can usually be made by the patient's history, examining the scalp and sometimes examining blood test results or (rarely) performing a scalp biopsy.

Minoxidil: Does age really matter?

Minoxidil and age-related hair loss

Minoxidil is a topical medication used to treat many forms of hair loss including androgenetic alopecia (for which it is FDA approved). Minoxidil can be helpful for treating androgenetic alopecia at any age but becomes even more important to consider with advancing age. 

Senescent alopecia: A type of hair loss often forgotten

Hair thinning as one approaches the 60s and 70s is often less truly androgen driven. The diagnosis of senescent alopecia (SA) needs to be considered in these particular age groups and it can often respond to minoxidil. Senescent or age related alopecia is often forgotten by physicians. It mimics genetic hair loss almost perfectly so is easily misdiagnosed as genetic hair loss. The genes driving it are very different. The key point is that if one recognizes senescent alopecia could be a possibility - the use of treatments like minoxidil become more important rather than other traditional AGA-type treatments like finasteride.

Androgenetic alopecia tends to start somewhere between age 8 and age 50. Hair thinning that occurs later has a high likelihood of representing senescent alopecia. (Of course other types of hair loss may also occur after age 60 and genetic hair loss and senescent alopecia can overlap). A study by Karnik and colleagues in 2013 confirmed that these two conditions (AGA and SA) are truly unique. The authors studies 1200 genes in AGA and 1360 in SA and compared these to controls. Of these, 442 genes were unique to AGA, 602 genes were unique to SA and 758 genes were common to both AGA and SA. The genes that were unique to AGA included those that contribute to hair follicle development, morphology and cycling. In contrast to androgenetic alopecia, many of the genes expressed in senescent alopecia have a role in skin and epidermal development, keratinocyte proliferation, differentiation and cell cycle regulation. In addition, the authors showed that a number of transcription factors and growth factors are significantly decreased in SA. The concept of senescent alopecia is still open to some debate amongst experts. The studies by Karnik give credence to the unique position of these two conditions. But studies by Whiting suggested that it is not so simple as to say anyone with new thinning after age 60 has SA - many of these are also more in keeping with androgenetic alopecia. As one ages into the 70's, 80's and 90's - hair loss in the form of true senescent alopecia becomes more likely.

Reference

Karnik et al. Microarray analysis of androgenetic and senescent alopecia: comparison of gene expression shows two distinct profiles. J Dermatol Sci. 2013.

Do all males bald in the same way?

Do all males bald in the same way? 

The answer to that is no. Most men whonare going to bald first notice changes in the temples and/or crown and then ultimately bald according to the so called "Hamilton Norwood" scale. However this male shown in the photo has a pattern of balding that does not match up to any of the Hamilton Norwood patterns. He has what is known as a "female" pattern of male balding where the central scalp is involved first and the frontal hairline is relatively unaffected. This pattern of androgenetic hair loss is common in women and affects about 10-13 % of males.
 

Scalp alopecia in men with beard alopecia: What are the risks?

Scalp alopecia in men with beard alopecia

Alopecia areata is a relative common autoimmune condition affecting up to 2 % of the world. Beard and facial alopecia is particularly concerning to many men as it can be challenging to camouflage. A frequent question from patients with beard alopecia areata is "how likely is it that I will eventually develop patches on my scalp?" Another wonderful multicentre study from Spain helped answer that question. The researchers studied 55 men with beard alopecia and followed them for at least one year. In the study, 45 % of males developed scalp alopecia over the follow up period. Most who did develop AA (80%) did so in the first 12 months. The conclusion from the study was that a significant proportion of males with beard AA do in fact develop patches of scalp AA warranting long term follow up for these patients.

Reference
Saceda-Corralo D, et al. Beard alopecia areata: a multicentre review of 55 patients. J Eur Acad Dermatol Venereol. 2017.

Does stress accelerate balding?

There is not a lot of great medical evidence to support the notion that stress directly impacts MPB.  However, it probably has a minor role and only in some men and women with the right genetic background. Of course, we don't understand yet what that genetic background is at present.

When one examines studies of identical twins, one sees that 92% actually still look identical (same level of hair loss) years and years down the road. If stress, diet, and environmental factors played a huge role, one would not expect this number to be so high.

But for some males and females, it is likely that stress accelerates balding to a minor degree. A study by Gatherwright in 2013 suggested that higher stress could lead to worsening hair loss in the crown in men.  For women, a 2012 study suggested that higher stress was correlated with worse hair loss in the frontal area and divorce and separation were correlated with worsening hair loss in the temples.

Conclusion

Stress probably accelerates the rate of progression of balding in some individuals who have the right genetic predisposition.   We know that stress can cause an increased amount of daily shedding and such shedding can accelerate follicular miniaturization. It makes sense that stress can accelerate the balding process in some individuals. However, it's not likely to be a consistent phenomenon amongst all individuals.  

Reference

The contribution of endogenous and exogenous factors to male alopecia: a study of identical twins.

Gatherwright J, et al. Plast Reconstr Surg. 2013.

The contribution of endogenous and exogenous factors to female alopecia: a study of identical twins.

Gatherwright J, et al. Plast Reconstr Surg. 2012.

Androgenetic Alopecia and Height

Baldness Associated with Shorter Height

Is there a link between the height of a man and his chances of developing androgenetic hair loss (male pattern balding)? 

Recent studies have suggested that answer is yes. Researchers at the University of Bonn performed an extensive study of over 20,000 men (10,000 with hair loss compared to 10,000 without hair loss) and concluded that many of the genes controlling male balding are also linked to being shorter in height.

The researchers discovered 63 genetic changes that increase a man’s risk of developing early onset balding. These same genetic changes were linked with a greater likelihood of being shorter.

This study confirms that hair loss is not an isolated phenomenon but rather controlled by genes that also determine one’s height and various aspects of health.

Reference

Heilman-Heimbach et al. Meta-analysis identifies novel risk loci and yields systematic insights into the biology of male-pattern baldness. Nature Communications, 2017; 8: 14694 DOI

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.

Is sunscreen use more common in men with FFA?

This is a controversial topic but this study (as well as a study of FFA in women) has caught the attention of many. A study by Kidambi et al compared how 17 men with FFA and 73 men without FFA responded to a lengthy survey. FFA is relatively rare in men but information on a link to sunscreen use was important to investigate given the possible role among women.

A much greater proportion of men with FFA reported using sunscreens (as well as facial moisturizers) at least twice weekly compared to men without FFA. Specifically, 35 % of FFA patients reported such sunscreen use compared to just 4 % of men without FFA.
 

Conclusion

We have a long way to go to definitely prove sunscreens have a role. But two studies now (one in men and one in women) have described potentially the first environmental factor implicated in the way FFA develops. An environmental factor is certainly thought to be responsible given that FFA was relatively unheard of 20 years ago. There are more good studies that are needed.
 

Reference

Aldoori N et al. Frontal fibrosing alopecia: possible association with leave-on facial skin care products and sunscreens; a questionnaire study. Br J Dermatol 2016.

Kidambi AD et al. Frontal fibrosing alopecia in men: an association with facial moisturizers and sunscreen. Br J Dermatol 2017.

Oral minoxidil for hair loss

Oral Minoxidil

Topical minoxidil was FDA approved in 1987 and we now have 30 years of experience with the drug. 

I'm increasingly asked about oral minoxidil. Does it work? Is it safe? What dose? 

Oral minoxidil is not FDA approved for treating hair loss. It was used in the 1980s for treating high blood pressure. When used at doses typical for treating blood pressure problems (5 mg twice daily), it can be associated with side effects - some quite serious. These include dizziness, low blood pressure, weight gain from fluid retention, high heart rate, heart rhythm problems. And of course hair growth can occur all over the body.

Lower doses of oral minoxidil may be safer and may still provide benefit. Doses ranging from 0.25 mg daily to up to 1 mg daily are generally well tolerated without a significantly increased risk of side effects. One does need to be closely monitored for blood pressure, weight changes, heart rate and excess hair growth on the body. For women, low dose minoxidil can be combined with spironolactone. In men low dose minoxidil can be combined with lower doses of finasteride.

 

Conclusion

Oral minoxidil is increasingly popular as men and women look for safer options for treating hair loss. Side effects of oral minoxidil must be respected and use of the medication must only be done in conjunction with a physician experienced in the use of oral minoxidil. Close monitoring is essential.

Seborrheic Dermatitis and Scarring: Seborrheic Folliculitis

Can a seborrheic dermatitis lead to a scarring alopecia-like phenomenon?

In 2015, Australian researchers reported an interesting article in the Australasian Journal of Dermatology suggesting the possibility of a low grade folliculitis which ultimately leads to development of a scarring alopecia.

The study described 56 patients (35 female and 21 male, age range late teens to late 70s) with a seborrheic dermatitis like presentation that was associated with a scarring alopecia. They termed the condition “seborrheic folliculitis.” These patients presented clinically with a red, itchy scalp (some patients) along with a diffuse or patchy dandruff like presentation. Shedding of telogen hairs was a feature.

Perifollicular parakeratotic scale was noted along with variable scalp erythema, and perifollicular prominence. Dermoscopy showed perifollicular hyperkeratosis and increased vascularity in the perifollicular areas. Pathology showed an absence of lichenoid change and there was a mild interfollicular fibrosis much like is seen in folliculitis decalvans (although too mild for typical folliculitis decalvans).  Spongiosis of the follicular epitheilium was noted along with a perivascular and perifollicular infiltrate of lymphocytes. Treatment was successful in many patients with tar shampoos and doxycycline. 

Here is one such example of a "seborrheic folliculitis" in a patient with androgenetic alopecia. Scarring is present and focal areas devoid of hair can be found on the scalp.

Reference

Pitney L et al. Is seborrhoeic dermatitis associated with a diffuse, low-grade folliculitis and progressive cicatricial alopecia? Australas J Dermatol 2016; 57(3):e105-7.

Focal atrichia: A worrisome sign of AGA

Focal atrichia: What is it?

Focal trichina is a term which  refers to a specific observation seen on the scalp of patients with androgenetic alopecia. Those with focal atrichia have small circular areas devoid of hair.

This is a feature of advanced male balding (androgenetic alopecia) and also female pattern androgenetic alopecia. The finding is very important to recognize. Focal atrichia occurring in patients under 30 is worrisome for me as it is associated with a higher risk for progression to more extensive balding.

Lichen planopilaris of the beard area

LPP of the Beard

Lichen planopilaris (LPP) can affect any area of the body that has hair. When it affects the scalp, it's often red, itchy and scaly/flaky.

When LPP affects the legs, arms facial hair, eyebrows and eyelashes, it's often completely asymptomatic and the patient simply notices hair has disappeared.  Occasionally, a bit of redness is seen in the area too as seen in this photo of the beard area in a man with lichen planopilaris of the facial hair.