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QUESTION OF THE WEEK

Dr. Donovan's Articles

QUESTION OF HAIR BLOGS

Filtering by Category: Myths (Hair Loss Myths)


Managing Hair Loss During and After Pregnancy: Facts vs False Reassurance

Hair Loss During and After Pregnancy

Individuals with hair loss often ask what steps they should be taking to best help their hair during pregnancy and what steps they should take after delivery.

I have written on certain aspects of this topic before. Please consider reviewing my past articles on Hair Loss, Pregnancy & Breastfeeding:

July 23, 2019 - Stopping Medications in Pregnancy

May 6, 2018 - Pregnancy and Female Pattern Hair Loss

Mar 1, 2017 The Safety of Hair Loss medications in Pregnancy

May 19, 2012 - Which medications are safe during breastfeeding?

For many women who ask this question and are currently pregnant, I often say that there are two ways to help the hair while pregnant. The first is make sure that the individuals does not truly have any deficiencies by getting some basic blood tests if the individual or her doctor are worried about some type of deficiency. The second way to potentially help the hair is to consider reviewing the benefits of low level laser therapy (LLLT). Besides correcting a vitamin deficiency, administration of low level laser treatments is really the only treatment that can be safely used during pregnancy.

For women who were using minoxidil before pregnancy but needed to stop during the pregnancy, I strongly encourage them to see an expert to determine when minoxidil might best be restarted after delivery. Both the American Academy of Pediatrics and the American Academy of Dermatology have stated that Rogaine is reasonably safe for breastfeeding women (yes, despite the fact that all warning labels say otherwise). I can’t emphasize enough the importance of speaking to the dermatologist about this. in my opinion, we need to let years and years of medical research and years of observation help guide how we make tough decisions not simply outdated warning labels that protect companies from legal ramifications. These decisions are of course taken on a case by case basis.

False resurgence has no place in the management of any type of hair loss - and this is particularly true in managing hair loss around the time of pregnancy. It would be wonderful if I could reassure women that hair always grows back “fully” after delivery (i.e. to the same density as before pregnancy) - but this is not accurate. For most women who shed hair post partum, the shedding eventually slows down around month 6-9 post partum and shedding returns to normal and hair regrowth happens. However, hair density does not always grow back as full as it was before pregnancy if a woman has the genes for genetic hair loss instructing the hairs what to do.  For many women it does - but not all. This is far more than my professional medical opinion - it’s fact. For this reason, I encourage patients to have a solid treatment plan in place.

False reassurance that hair “always” grows back and not to worry leaves many women confused and disappointed. I sometimes advise a conservative approach and sometimes an aggressive approach to treatment after delivery. It all depends on the stage of the patient’s androgenetic alopecia, her current age and health and her family history of hair loss and other conditions. We don’t yet have tests available to set the known genes for genetic hair loss - so this is not part of the evaluation. The decision on what to use during pregnancy is easy as only laser is safe (and supplementing any deficiencies that are uncovered in the blood tests).  


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

Hamilton

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.

story of MPB

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.

companies in race



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.





This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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To Poo or Not to Poo: A closer look at the “no poo” (no shampoo) movement

Should you give up shampoos?

If you’re like most people, you have a bottle or two of shampoo in your shower and you use it to clean your scalp and hair. Perhaps you’re a daily user, perhaps you use shampoos a few times week. If you have coarse and curly hair, you might use shampoo even less frequently.   But you use it. If my own practice is representative of the world out there I know some of you even change your shampoo brands frequently.

However, a small number of women (and an even smaller number of men) have decided to forgo shampooing the scalp altogether. This defines the so called “no poo” movement (i.e. ‘poo’ is short for shampoo).

  

 1. We are a shampoo loving society

As a society, we have grown to love shampoo and love shampooing. Walk into any drug store and you’ll see just how much real estate is devoted to shampoos. We love the smells of shampoos and the feel of shampoos. We love the look and feel of shampoo bottles. We like the shampoo aisles, shampoo ads and shampoo commercials.  We are a shampoo loving society.

Shampoos were first synthesized in the 1930s, as an alternative to bar types soaps which left a heavy film or “soap scum” on the hair.  Such deposition leaves the hair dull and more difficult to manage.  In years gone by, women  would shampoo their hair at the salon and then have it set. Shampooing every 2-4 weeks was normal. Shampooing wasn’t typically a home-based procedure. It wasn’t until the 1970s and 1980s that shampoos became standard for household daily use. In North America, many women have changed to shampoo their hair very frequently. Moreover, we seem to enjoy squeezing our shampoo bottles and in general use far too much shampoo with each use than we really need to. It’s not really harmful to do so – except to our bank. It’s too often forgotten, that shampoos are meant for cleaning the scalp and conditioners are meant for the hair. A small dab of shampoo is usually sufficient to clean the scalp.

 

2. If people don’t poo (shampoo), what do they do?

For those who are participants in the ‘no poo” movement and don’t use shampoos, common substitutes include simply using water alone, using apple cider vinegar, baby powder, dry shampoos or using baking soda.  I believe that many of such practices are well tolerated for most people. However, those with color treated or relaxed hair may find that that high pH of baking soda (up to 10-12) to be particular harsh on their hair and increase the chance of damage and hair breakage.  

 

3. Does frequent shampooing trigger your scalp to make more oil?

It’s true that the use of shampoo removes oils from the scalp. These oils are helpful to condition the hair – and might be regarded as nature’s best conditioners. At present, however, there is no scientific proof that the scalp compensates for frequent shampooing by in turn producing more oil. The amount of oil that our scalp produces is genetically determined, and to a much lesser degree by the foods we eat, hormones, seasons and the environment. Changing your shampoo practices won’t reset your oil production. That factory is deep under the scalp (in glands known as sebaceous glands) and not influenced by how you shampoo. It would be nice to think otherwise – but there’s simply no proof.

 

4. How often should you shampoo?

There is no magic number for how often we should shampoo. In fact, the number is different for everyone.  Those with fine, oily hair are going to benefit from daily shampooing as the oils tend to weigh down the hair. Those with coarse and curly hair can go much longer as the hair will actually look better when not washed so often.   The same is true for those with color treated or relaxed hair – washing less frequently is preferred to further limit damage to already slightly damaged treated hair.  Once or twice a week is likely just fine. Although we certainly shampoo our hair too often, washing the scalp daily is unlikely to cause harm. Furthermore, there is no evidence that avoiding shampoo altogether offers a health benefit. In other words, the no poo movement is a personal choice, not a health choice.

 

5. Are there any adverse effects of not shampooing ?

Individuals with existing scalp problems could develop a ‘flare’ of their scalp disease with cessation of shampooing. For example, I’ve seen many patients who forgo shampoos that develop worsening dandruff and seborrheic dermatitis ( which is a close cousin of dandruff). It’s usually mild and tolerable. To understand why this occurs, it’s important to understand that dandruff and seborrheic dermatitis are caused by yeast that lives on our scalps.  These yeast feed off scalp oils. Excessive oiliness from not shampooing provides this yeast with an abundance of food and in turn further exacerbates the patient’s scalp problem.  The no poo decision might not be for everyone.

 

6. If you’re going to shampoo, should you go sulfate free?

For those who decide that the no poo movement might not be for them, a common question then arises – what about joining the sulfate free movement? Certainly, sulfate free shampoos are popular. If you’ve used a sulfate free shampoo you immediately notice they don’t lather up quite as well as a shampoo containing sodium lauryl sulfate or ‘SLS‘. The main downside of these shampoos is not their lathering ability but the fact that SLS shampoos are a bit more drying and are more likely to lift the cuticle and cause damage for those with color treated or relaxed hair. The can also cause irritation for those with scalp problems, including eczema.  The vast majority of people in the popular will notice little difference to their hair from using a sulfate free or SLS containing shampoo.  Decisions on whether to use SLS shampoos for other reasons (including environmental) are still being researched. However, from the perspective of the hair – the vast majority of people will not achieve better hair care from sulfate free shampoos.

 

Conclusion: Are you giving up shampoo?

Hair is personal. Hair helps define who it is we are and how we present ourselves to the world. Our hair is central to our self identify. If you don’t want to shampoo your hair – don’t shampoo your hair. There are a small number (but manageable number) of risks. Similarly if you want to shampoo your hair frequently, shampoo it. Change up your brands.  Enjoy all that shampoos offer in further defining what is personal, individualistic and what defines our feelings of self identity and self-expression.  There are risks to many things and it simply comes down to being well informed.  Humans quickly learn what shampooing frequency is right for them.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Is your hairline 'maturing' or a 'balding'?

Is your hairline 'maturing' or a 'balding'?

It’s a little known fact among many men that the frontal hairline actually changes shape between the ages of 17 and 27 – even if that man doesn’t proceed to develop genetic balding. We refer to this normal change as ‘maturation’ of the hairline and we say that the man noticing these changes has a ‘maturing’ hairline. Eventually the hairline stops ‘maturing’ and we say that the man has a ‘mature’ hairline.  Not all men’s hairlines proceed through this normal process of ‘maturation’ but most do.

The concept of a maturing hairline is extremely important to know about so that medical treatment or surgical treatment is not recommended to patients who don’t require it. For example, a 23 year old man who notices his hairline thinning out slightly in the area just above his eyebrows may not have genetic hair loss - but rather a ‘maturing’ hairline. He doesn’t need to begin any sort of treatment whatsoever. Several studies have shown that men with maturing hairlines don’t necessarily go on to develop balding. These are two completely separate processes!

Hairline maturation diagram

The following diagram helps to explain the process by which the hairline matures and how it differs from genetic hair loss. The hairline of a boy or early adolescent is relatively flat and we refer to this as a ‘juvenile” hairline.  Between age 17 and 27, many men (but not all) start to notice that the hairline directly above the middle section of the eyebrow starts to undergo thinning (maturing).   

mature%20and%20balding[1].jpg

In fact, if you wrinkle your forehead, you’ll see a series of lines that run side to side. The highest forehead wrinkle often marks a spot where the ‘juvenile’ hairline was once located. A ‘mature’ hairline is usually about 1-1.5 cm above this. In true genetic balding (male pattern hair loss), the hairline may recede beyond this 1.5 cm point and undergo even more significant recession in temple area. 

Why is this concept important?

Understanding the concept of hairline maturation is especially important when it comes to designing natural looking hairlines during a hair transplant.  Attempting to lower a ‘maturing’ hairline is a young man is usually not a good idea. Many young men want a more ‘juvenile’ hairline when they first meet for a hair transplant consultation.  However, by proceeding down that route,  the young man runs the risk of having his new hairline take on an unnatural looking appearance when compared to other males as he approaches his 30s, 40s and 50s.

Other References of Interest

Rassman WR, Pak JP and Kim J. Phenotype of normal hairline maturation. Facial Plast Surg Clin North Am 2013; 21: 317-23

 

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This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Minoxidil - Does it help with hair loss ... in the front ... or top .. or both?

Accumulating evidence suggests minoxidil helps with hair loss in the crown (top) but may help hair loss in the front and temples in men as well.

Accumulating evidence suggests minoxidil helps with hair loss in the crown (top) but may help hair loss in the front and temples in men as well.

Minoxidil - Does it help with hair loss in the front?

Minoxidil is a topical medication that is FDA approved for treating genetic hair loss (sometimes referred to as androgenetic alopecia). If you pick up a bottle of minoxidil it will state that it is to be used for hair loss in the crown in men and may not benefit other areas of hair loss. The original studies of minoxidil focused on the crown and did not address the benefit in the front of the scalp.

So the question that remains is:  

Does minoxidil help men with hair loss in the front of the scalp or not?

Certainly, the answer is yes.   Many hair loss specialists around the world, including myself,  have witnessed benefit to minoxidil in the front of the scalp in balding men.  However, the companies which produce minoxidil are not setting out to formally prove the benefit in the front of the scalp and are not seeking approval from health regulatory authorities to be able to change the labelling on the bottles to indicate that it "works in the front and back."

New study shows 5 % minoxidil benefits men with hair loss in the temples

Back in the month of May 2013, I attended the World Congress of Hair Research in Edinburgh Scotland. A really nice study was presented by Dr. Blume Peytavi and colleagues from Berlin, Germany. They studied 70 men with moderate genetic hair loss and studied whether minoxidil 5 % foam could help hair loss in the crown and in the front.  The German group showed that men using minoxidil 5 % foam did obtain benefit from using the medication in the front and in the crown.  This was one of the very first studies showing the minoxidil foam benefits hair loss in the front.

Conclusion: 

Minoxidil has long been known to benefit men with hair loss in the crown. Accumulating evidence suggests it also benefits men with hair loss in the front (temples). More studies are needed to determine just 'how much' it helps men with hair loss in the front. In general, minoxidil seems to work better in the earliest stages of hair loss - as hairs are thinning and miniaturizing. 

Reference

Hillman K, Bartels GN, Stroux A, Canfield D, and Blume-Peytavi U. Investigator-initiated double blind, two-armed, placebo-controlled, randomized clinical trial with an open -label extension phase, to investigate efficacy of 5 % Minoxidil topical foam twice daily in men with androgenetic alopecia in the fronto-temporal and vertex region concerning hair volume over 24/52 weeks.  Poster at: World Congress of Hair Research, Edinburgh Scotland May 2013.

 

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Is there a Link Between Sun Exposure and Hair Loss?

Sun Exposure and Hair Loss: Is there a Link?

This new video highlights the current evidence of the relationship between sun exposure and hair loss.

I hope you enjoy it!

- Dr Jeff Donovan

 References of Interest

Gatherwright J et al. The contribution of endogenous and exogenous factors to female alopecia: a study of identical twins. Plast Reconstr Surg 2012 130; 1219-26.

Su LH and Chen.  Androgenetic alopecia in policemen: higher prevalence and different risk factors relative to the general population. Arch Dermatol Res. 2011 Dec;303: 753-61


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This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Dr. Donovan on Discovery Channel's Daily Planet

Back in 2010, I was interviewed by Ziya Tong, the co-host of the Discovery Channel's Daily Planet show.   Our topic was hair (and fur!). I've posted a link to the Daily Planet segment below. Enjoy!

Watch video

ziyology.jpg



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