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Stopping Birth Control: Will My Hair Come Back?

Will My Hair Come Back?

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

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

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

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


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

Compounding of Follicles

compound follicles.png

Compound follicles are hair follicle units that have more than 6 hairs coming out of a single pore. The tendency to form compound hair follicles is sometimes a feature of so called neutrophil mediated scarring alopecias. Folliculitis decalvans (shown here) frequently shows compounding of hairs. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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The "Positive" Pull Test: What does it mean?

A Positive Pull Test: Many Diagnoses

PULL TEST

A "pull test" is a test for excessive shedding. To perform the pull test, the clinician gently wraps his or her thumb and index finger around approximately 60 hairs and pulls gently upwards. If more than 3 hairs are removed, one should consider it a positive pull test. (the old cut off used to be 6 hairs but recent studies have suggested that number is not appropriate for most).

 

Does a positive pull test mean telogen effluvium?

It's a common error to assume that a positive pull test equates to a telogen effluvium. While the pull test is often used to give the clinician some sense if whether a telogen effluvium might be present this is not the only hair loss condition that gives a telogen effluvium.  The reality is that many conditions give a positive pull test including androgenetic alopecia, alopecia areata and scarring alopecia. In other words a positive pull test is not definitive for any given diagnosis but certainly indicates that something is not quite right with how the patient is losing hair.

Let's take a closer look at these conditions 

1. Telogen Effluvium

Telogen effluvium (TE) is the prototypical hair shedding condition. Hair shedding in a TE occurs all over the scalp which means that the pull test is positive all over the scalp. Not everyone with a TE has a positive pull test as a variety of factors can influence this, including when the patient last washed their hair.  Typical causes of TE include stress, low iron, thyroid problems, medications, diets, and illness inside the body (systemic illness).

 

2. Androgenetic alopecia

Contrary to what many patients and clinicians think, increased hair shedding does occur in the early stages of androgenetic alopecia (male and female balding). Sometimes a pull test can be weakly positive in these areas. Performing a pull test is a bit trickier int these conditions simply because the findings are subtle. But if one performs a pull test in areas of androgenetic alopecia and compares the findings to areas where there is no androgenetic alopecia, one can appreciate that a few more hairs are frequently extracted from the are of androgenetic alopecia. 

 

3. Alopecia areata

Alopecia areata is an autoimmune condition that affects about 2 % of the world's population. It causes inflammation to accumulate deep under the scalp around hair follicles. This inflammation can trigger shedding. In the earliest stages, alopecia areata can closely mimic a telogen effluvium and not surprisingly a pull test is frequently positive. The hairs that are extracted in alopecia areata are a bit different than a true TE and include a mix of telogen hairs, broken hairs and so called 'dystrophic anagen hairs."

 

4. Scarring alopecia

Patients with scarring alopecia may also have a positive pull test. Lichen planopilaris, Idiopathic Pseudopelade of Brocq, Discoid Lupus Erythematosus can all trigger increased shedding. The pull test in these situations may reveal telogen hairs as in a telogen effluvium, but may frequently also reveal anagen hairs. In fact, the extraction of normal appearing anagen hairs is a pathognomic sign of a scarring alopecia. 



Reference


McDonald et al. Hair pull test: Evidence-based update and revision of guidelines. Journal of the American Academy of Dermatology 2017; 76: 472

 

 


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

Telogen Effluvium in Young Males: Considerations

Telogen effluvium (TE) refers to a type of hair loss whereby a patient experiences increased daily shedding of hair. Instead of 30 or 40 hairs coming out of the scalp, the patient experiences 60, 70 or even hundreds of hairs shed on a daily basis. There are a  variety of causes of telogen effluvium including stress, low iron, thyroid problems, medications and crash diets. 

 

TE in Men

Telogen effluvium can occur in men and does occur in men. However, it is far less common than in women. In addition, there are many mimickers or 'lookalike' conditions that frequently lead to incorrect diagnoses of telogen effluvium in men. A good example of this is early staged androgenetic alopecia (AGA) in men. Men with early AGA experience increased hair shedding which looks very similar to a telogen effluvium. Many such men are diagnosed with TE when in fact the correct diagnosis is AGA. The most important question that should be asked in any male with a diagnosis of  suspected telogen effluvium is: does this patient actually have androgenetic alopecia instead of telogen effluvium OR does this patient ALSO have androgenetic alopecia together with telogen effluvium?

Certainly telogen effluvium can occur as a sole diagnosis in men. However, more times than not in the patients I see, this is not the only diagnosis. 

 

Diagnosing TE

Telogen effluvium is largely a diagnosis made on history and clinical exam. Rarely, a biopsy is needed.  For most individuals with TE, another person passing by in the street would not take notice there is hair loss even if substantial hair has been lost. TE causes diffuse loss - meaning the hair is lost all over the scalp. Such hair loss typically occurs 2-3 months after some kind of trigger.  A person with TE however can look very different to the way they know they once looked.  If I look at a photo of a patient and I say "this patient has hair loss" - it's like that another diagnosis is present other than TE or together with TE. 

 

Conclusion

I see many young males with early androgenetic alopecia who are misdiagnosed as having a telogen effluvium. It's true more definitely that telogen effluvium can occur in young men - but one must always keep in mind that it's not really all that common.  Most men who are shedding more than normal end up being diagnosed with androgenetic alopecia. 

I'm often asked who long of a 'window' does a patient have to treat the TE before any irreversible changes happen. The reality is that if a male has TE as their sole diagnosis, there is quite a long window actually. However, the window closes if another hair loss diagnosis is present - especially androgenetic alopecia (AGA). TE can occur in men, yes. But too often androgenetic alopecia in the early early stages is ignored and missed. Biopsies and hair collections together with a careful scalp exam and medical history can help clarify things immensely.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Telogen Effluvium: What are upright regrowing hairs (URH)?

URH in TE

urh

Telogen effluvium refers to a type of hair loss whereby the patient experiences increased daily shedding. Shedding typically occurs 2-3 months after a "trigger" such as weight loss, surgery, illness, low iron, crash diet, medication initiation or development of some internal illness.

Dermoscopy (shown here) does not have many specific findings in patients with telogen effluvium although many upright regrowing hairs (URH) may be seem along with hair follicles containing only a single hair follicle.  


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Telogen hairs: Not only in Telogen Effluvium

What are telogen hairs? When does one find them?
 


Telogen hairs are hairs that are shed from the scalp because they are done their growing. If you reach up and run your hands gently through your own hair, you’ll likely remove a telogen hair. (If you forcefully pluck hairs from the scalp you’ll remove a completely different type of hair called an anagen hair). Between 30-70 telogen hairs normally fall out of the scalp every day. On shampooing days (days that one shampoos the scalp), even more wiggle out so the number can reach well over 100 for some individuals. If one shampoos the scalp everyday, they remove telogen hairs on a consistent basis and so the loss each time remains much lower than if one shampoos once per week.


Telogen Hairs can be a Normal Finding

telogen

The finding of telogen hairs can be completely normal but an increased number of telogen hairs lost from the scalp compared to what one usually loses, is not normal. If one normally loses 40 hairs per day and now loses 80, this is not normal provided the frequency of shampooing remains the same. A common mistake that individuals make is assuming that the finding of increased shedding of telogen hairs confirms a diagnosis of “telogen effluvium.” This is not accurate. Individuals with a range of hair loss conditions will shed more telogen hairs than they normally do including the following: telogen effluvium, chronic telogen effluvium, androgenetic aloepcia, alopecia areata, as well as the many scarring alopecias and the inflammatory scalp diseases (such as seborrheich dermatitis). The finding of increased numbers of telogen hairs coming out from the scalp could mean the patient has a diagnosis of telogen effluvium - but does not necessarily mean this is the only diagnosis to consider.


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 hair density always come back in a telogen effluvium?

Does hair density always come back after a telogen effluvium?

te-sequelae


One of my favorite hair loss topics centers around what happens to a person’s hair density 9 months after a telogen effluvium. Broadly speaking, this is topic is called the “sequelae of telogen effluvium.”

Before we begin, I will remind you that Telogen effluvium (TE) is a hair shedding condition whereby a patient notices more hair coming out of the scalp than normal on a daily basis.

Most would say that 6-9 months after a TE, the hair density improves back to normal. This is true only if all the correct “triggers” of the TE can be found. Many times a trigger can’t be found and many times even if a patient or physician think they know the trigger, it’s not actually the trigger. For example, many patients who think their low vitamin D or low iron levels are the sole cause of their TE may find the shedding does not improve simply by supplementing vitamin D and iron. The reality is that unless the exact trigger or triggers can be found it is likely the shedding will not stop. Typical triggers include thyroid problems, dietary issues, low iron (sometimes), stress, medications, scalp diseases (seborrheic dermatitis) and over 700 internal conditions (infection, joint disease, lupus, cancer).

But two other “sequelae” can occur including the development of chronic shedding and coming to be diagnosed with another completely separate hair loss condition.


 
Sequelae 1: Chronic Shedding

For some patients, despite fixing all the suspected triggers, the shedding persists for more than 6-9 months and enters what we call “chronic shedding.” For some patients, the shedding eventually just stops and density returns to normal. This can happen without any particularly good reason and is very exciting for patients when it does occur. For other patients with chronic shedding, a trigger is eventually found and addressing that trigger causes the shedding to improve. This might be a patient who discovers a chronic underlying medical condition and addresses it. Hundreds of such examples exist. But some patients continue to shed for many many years despite their being NO obvious trigger and despite their health being very good. We call this chronic idiopathic telogen effluvium or simple chronic telogen effluvium (CTE). In my mind CTE is a specific condition when no obvious ongoing trigger is present.
 

Sequelae 2: Development of a Second Condition

Finally, one additional sequelae needs to be considered - and that is the possibility that hair density does not return to normal because a second hair loss condition develops. It's not that the shedding condition caused the second condition but rather that the second condition was there all along. This is more common than appreciated. For some individuals with a genetic predisposition to androgenetic alopecia, chronic shedding can speed up the development of balding. This is often referred to by a bizarre phrase whereby you might hear it said that chronic shedding “precipitates” androgenetic alopecia. I prefer to refer to the phenomenon in our clinic as “AFMPS” or accelerated follicular miniaturization from prolonged shedding because it makes more sense than using the word “precipitation.” But the concepts are the same: patient with chronic shedding who are destined to develop male and female balding in the more distant future may find that they develop androgenetic balding a bit sooner. We see this commonly after various effluviums. Why do some women after months and months of shedding find their density does not return despite fixing the suspected trigger? AFMPS or the unexpected arrival of genetic hair loss. This concept is too often forgotten or not understood.

One must also keep in mind that in addition to genetic hair loss, other conditions can rarely also declare themselves after a patient develop shedding. Chronic shedding diagnosed as a TE may rarely be the earliest stages of a scarring alopecia or the earliest stages of alopecia areata (diffuse alopecia areata or alopecia areata incognito). A physician must always keep these entities in the back of his or her mind when evaluating a patient with chronic shedding.

 

Summary

In summary, telogen effluvium can either be uncomplicated or complicated. We can’t tell patients that their shedding will stop in a few months and everything will return to normal. We can of course hope for it. Fortunately most patients do follow an uncomplicated story of shedding. Shedding —-> fix trigger(s) ——> shedding stops ——> hair grows back. But this is not the case for all.

 


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 one go bald in telogen effluvium?

TE can cause significant thinning 

Telogen effluvium is a hair shedding conditions whereby affected individuals lose more hair on a daily basis than they once did. It's important to understand that one's hair can go very thin but one NEVER loses all hair.

 

Why does one never lose all hair in TE?

Patients with telogen effluvium never go completely bald because not all the hairs on the scalp are converted to telogen hairs. A biopsy of TE will often show an increase in the proportion of telogen follicles above the typically expected level of 6-13 %. If the proportion of telogen follicles above 15% this suggests TE. However, if it's above 25%, this is a more definitive feature. One must keep in mind that a biopsy showed 25 % telogen hairs means that 75 % of hairs are anagen and growing well rooted in the scalp. There are never 100 % of the hairs in telogen phase in a patient with telogen effluvium and never 100 % of hairs in telogen phase in a biopsy from telogen effluvium. Therefore, one never loses all their hair.  However, that said, an individual with TE can have significant thinning and may even feel that they have lost 70 % or more of their hair. some telogen effluviums are mild but others are severe. In more severe cases, a wig or scarf may be used short term by the patient. 

 

What if a patient does bald in TE?

If one loses all hair and is absolutely certain they have a telogen effluvium, it is likely that is also something else going on as well. In other words, another diagnosis is present in addition to the TE. For example, if one ALREADY has genetic hair loss (or some other hair loss condition) to start with the thinning with a TE can be very, very noticeable sometimes.  In such a situation, it is both conditions that are contributing to thinning not just the TE.


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

How do we distinguish DUPA from CTE?

Diffuse unpatterned alopecia (DUPA) can generally be differentiated from chronic telogen effluvium (CTE) by careful review of the patient's history, and examination of the scalp using dermoscopy. Rarely a biopsy can be confirmatory but usually this is not needed.

 

DUPA

On history, patients with DUPA report diffuse thinning. They usually don't have all that much in terms of increased shedding. Typically, the hair loss is first noticed between age 15-24. Examination of the scalp shows variation in the sizes of follicles. We call this 'anisotrichosis'. Some hairs are thick and some are thin. The miniaturization occurs all over the scalp. A biopsy shows a terminal to vellus ratio of much less than 4:1.

 

CTE

In contrast to DUPA, patients with true CTE are usually a bit older when they first notice hair loss, often 35-60. Their stories are markes by concerns about massive shedding that comes and goes, some weeks good and some weeks bad. Patients with CTE don't usually look like they have hair loss to others whereas patients with DUPA often do look like they have hair loss. In CTE, examination shows terminal thick hairs. The temples may or may not show recession but often do in the setting of CTE. A biopsy shows T: V ratios that are high - and ratios 8:1 or higher are suggestive of CTE (compared to less than 4:1 for DUPA).

 

In summary, DUPA and CTE can usually be easily differentiated with careful examination and review of the patient's story.


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

Is regrowth always possible with a TE?

 

Telogen effluvium refers to a type of hair loss whereby the patient experiences increased daily hair shedding. Telogen effluvium typically occurs after some sort of "trigger" disrupts the delicate balance of hair growth and loss. There are many potential "triggers" that lead to telogen effluvium including stress, low iron, scalp dermatologic issues, thyroid abnormalities, crash diets, delivery, medications and internal illnesses. If a "trigger" can be identified and shut off/dealt with shedding can often return to normal rates and hair density can return for the patient.

For example, if shedding was due to a medication and that medication has now been stopped, it's quite likely that shedding will slow and then return back to normal rates.

 

Not all TE is Self Limiting

Too often a precise "trigger" causing the hair loss can't actually be found. In fact, in up to 50% of women, it's challenging to pinpoint an exact trigger. If a trigger can't be found, there is nothing to 'fix' to stop the shed and the shedding can sometimes just continue.   In addition, even if a trigger is found, it may not be possible to easily 'fix' the trigger. For example, some patients have TE due to a drug and in some cases, it's simply not possible to stop that drug because it's critical to the patient's health. Some patients may have TE due to an underlying medical condition (internal illness). That condition may not be possible to totally eradicate and because of this, shedding may continue.

Many patients with TE eventually experience a cessation of excessive shedding and a slow return to more normal rates of shedding and improved density. However, not all patients do.  The diagnosis of telogen effluvium does not guarantee that the hair loss will be self limiting.

 

Treatment of TE when no trigger is found

The treatment of TE is geared towards addressing the specific trigger that cause the shedding in the first place. If the patient had low iron, iron supplementation is appropriate. If a thyroid abnormality was present, addressing the thyroid issue is important. In cases where not trigger can be found, a variety of options are available, including minoxidil, low level laser, platelet rich plasma, biotin, hair and nail supplements, Lysine, and cysteine.

 

 


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 Dread Shed: What is meant by this?

Shedding from Minoxidil

Minoxidil lotion and foam are FDA approved for treating androgenetic alopecia (AGA) in men and women. This type of hair loss is also called male pattern balding and female pattern hair loss. A common concern among individuals who are deciding whether or not to use minoxidil is the potential for them to develop an increased amount of daily hair shedding in the first 6-8 weeks of starting minoxidil. This is known in the public as the "dread shed." Medically, the term is "immediate telogen release." This type of shedding is not to be confused with the shedding that happens when people with androgenetic alopecia incorrectly stop using minoxidil. (One must never stop treatment if they have androgenetic alopecia or else new hair growth will be shed and all benefits will be lost).

The 'dread shed' can be frightening when it occurs but is generally mild for most. Understanding why this occurs is important to help individuals decide whether this treatment is right for them to start or not.

 

Immediate telogen release: Understanding shedding with minoxidil

The increased shedding that accompanies starting minoxidil needs to occur for most people. It's not something that is really all that abnormal - it just looks abnormal. When you look closely at the scalps of men and  women with androgenetic alopecia (especially early stages of AGA), one will notice that a higher than normal proportion of cells are in the shedding phase. These hairs are waiting their turn to shed. Hairs generally need to wait in line 2-3 months before they are shed. That's just the rule of the nature. That's what it means to be human.

When minoxidil is applied to the scalp, a signal is sent to all hairs that are waiting in line to be shed. The message that is relayed is that the hairs no longer need to wait 2-2 months in that line. Rather any hair that is waiting in line to be shed is welcome to shed now.  The mandatory 2-3 month waiting period has been temporarily waived. And so what the patient then experiences is an increased amount of hairs coming out on a daily basis once they start minoxidil. What is being shed is hairs that were destined to come out anyways:

Instead of coming out tomorrow, a hair comes out today

Instead of coming out in 2 weeks, a hair comes out in tomorrow

Instead of coming out in 4 weeks, a hair comes out in 1 week

Instead of coming out in 6 weeks, a hair comes out in 2 weeks

This is what the 'dread shed' or 'immediate telogen release is all about.

 

For more information on the dread shed, readers might consider reviewing other articles. 

Immediate shedding from minoxidil: An analogy

 

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Do I have TE or androgenetic alopecia?

TE and AGA: Commonly Confused.

Many individuals with hair loss attempt to self diagnose their hair loss. This is not generally a good means to get to the bottom of why one is losing hair. Nevertheless, it is common. A frequent scenario crops up in the early stages of androgenetic hair loss where one first sees an increase in the daily shedding of hair. The patient then wonders "Is this a telogen effluvium I am experiencing or is this genetic hair loss?"

TE or AGA: Three ways to figure it out

Understanding the answer to this question really takes into account a full review of many of the hair cycle changes during telogen effluvium as well as androgenetic alopecia. In short there's three ways that one can determine if they have a TE or AGA.

 

1) Time. A TE will improve with enough time.

First, time is the most definitive way albeit the slowest.  If a patient's hair loss is from a resolving telogen effluvium, there should be a significant improvement in hair density over 6 to 9 months. For most with resolving TE, the hair density should be completely back to normal at that time. If this is actually androgenetic alopecia a worsening of hair density will likely occur over a 12 month period. At best, the hair density would probably be the same but it would be very unlikely for it to improve unless there was some components of seborrhoeic dermatitis that was adequately treated that led to a minor improvement of the overall appearance of the  androgenetic alopecia.  

 

2) Self diagnosis. A TE causes hair loss all over in a 'diffuse manner'

Another way to determine if this is a result of telogen effluvium or androgenetic alopecia is to perform self diagnosis. This is of course the most dangerous of all the options but nevertheless it's a common way. True androgenetic alopecia has less density on the top middle and front of the scalp compared to the back of the scalp. At least for males, true balding is a patterned hair loss. In telogen effluvium, the density is reduced equally all over the scalp.  I would encourage anyone with hair loss to see his or her dermatologist to review whether a resolving TE or genetic hair loss is in fact what is going on.  

 

3) Clinical Examination by a Dermatologist

A clinical examination by a physician is often a very good option to help an individual sort out if they have TE or AGA. One needs to consider the timing of the hair loss, when it occurred, factors leading up to the hair loss. But the most important is the scalp examination looking at exactly where the hair is being lost from and whether or not miniaturization of follicles is occurring. Miniaturization is a process whereby hairs get thinner and thinner in their diameter over time. This is frequently a features of androgenetic alopecia. It may be challenging to determine if miniaturization is present in the earliest stages of AGA. Nevertheless, it will become present over time in AGA whereas it will not in a true isolated telogen effluvium. If one has any concern about the diagnosis, then blood tests and a biopsy will complement the work up. Patients with a TE may have normal blood tests, so the presence of normal blood tests does not rule out TE. A biopsy performed with horizontal sections can give valuable information about the percentage of telogen hairs and the ratio of terminal to vellus hairs. A T:V ratio less than 4:1 is a feature of genetic hair loss. It is not a feature of TE. An increase in the proportion of telogen hairs above 15 % is often seen in a TE. This is not typically a feature of AGA.

 

Comment

Deciphering whether an individual has a TE or AGA can be challenging not only for patients but many clinicians as well. I would like to point out that the vast majority of males who are wondering about telogen effluvium or androgenetic alopecia generally turn out to have androgenetic alopecia.  Exceptions exist of course. The early stages of androgenetic alopecia are associated with shedding which give a confusing clinical picture.  The same is true with women as well although true effluviums are much more common in women than in men. Overall. I would encourage anyone to see a physician to review the accurate diagnosis. 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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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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Acute and Chronic Telogen Effluvium: How do they differ?

Acute and Chronic TE

There are two common types of telogen effluviums. Both lead to increased daily shedding.

Acute TE

CTE 620

Acute telogen effluvium (ATE) is associated with some type of "trigger" that then leads to massive shedding. Correction of the "trigger" can lead to resolution of the shedding and a return in density back to normal in 9-12 months. Common triggers include thyroid problems, dieting, medications, high stress, low iron and illness in the body.

Chronic TE

"Chronic" telogen effluvium (CTE) is often misdiagnosed and often mixed up with acute telogen effluvium. Chronic TE is associated with shedding too. The actual amount of hair shed is typically less than the worst possible cases of acute TE. CTE can be associated with a "trigger" but less commonly than acute TE. CTE does improve but then shedding occurs again - sometimes in a very unpredictable manner. Resolution can occur but it may take many years. 
This graph shows how density typically changes over time in patients with acute and chronic effluviums.


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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Medication induced hair loss

Does Drug Induced Hair Loss Eventually Stop ?

If a patient's hair loss is truly from a medication the hair shedding is likely to continue while the medication is present. If the hair loss does not actually have anything to do with the medication and the timing is coincidental, anything is possible... including an improvement, worsening or continued same-rate shedding.

Hair loss from medications is complex. They have different mechanisms causing the loss and not just one. Some are true telogen effluviums, some are toxic responses and some are hormonal. Some are immune-based. Growth promoters like minoxidil and low level laser therapy are often considered for hair loss due to the true effluviums but is often ineffective or results suboptimal. If hair loss is due to hormone based mechanism, then anti-hormonal treatments may help. If immune-based, then immune modulators may help.

 

Blogs on Drug Induced Hair Loss

For further review see previous blogs

Drugs and Hair Loss: Is it common?

Drug Induced Hair Color Changes

Drug Induced Hair Loss: A Closer Look at Amphetamines

Hair Loss from Chemotherapeutic Drugs: Does it always grow back fully?

 

 

 

 

 


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 without Shedding: Where did it go?

Hair loss without shedding 

Hair loss that occurs slowly over time without the patient noticing an increase in daily shedding is a special situation. 

Some hair loss conditions are associated with significant and sometimes rapid reduction in hair density without a noticeable increase in shedding. Examples include female pattern hair loss, many scarring alopecias (pseudopelade, lichen planopilaris, frontal fibrosing alopecia, as well as subclinical shedding disorders. Trichotillomania should also be included on this list. However, the list expands greatly if the individual shampoos frequently (ie daily). In that case the list of causes also includes many of the effluviums (ie telogen effluvium), as well as alopecia areata. 


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

Card Test For Darker Hair Colours.

Dark Card Test.png

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

See Also "The Card Test for Lighter Hair Colors"


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

Chronic Telogen Effluvium: How does density change over time?

Chronic Telogen Effluvium (CTE) and Androgenetic alopecia (AGA) are both commonly encountered diagnoses in women age 40-70 years. They are however, very different conditions. 

CTE-density

AGA: Androgenetic Alopecia

AGA presents with hair thinning and sometimes increased daily shedding as well. The loss of hair is sometimes just frontal in location or the crown but can be diffuse (all over). A key to the diagnosis is recognition of the progressive reduction in the caliber (diameter) of hairs. 

 

CTE: Chronic Telogen Efflvuium


Patients with CTE can appear to have a similar story. Many have a sudden onset of shedding. The shedding is diffuse. The temples may be particularly affected with reduced density to a much more significant degree than seen in AGA. Reduced hair caliber (miniaturization) is not a feature of CTE. CTE has periods where shedding appears to slow considerably or even stop. When one follows these conditions for many years there is a realization of another important difference: Density in CTE reduces initially but then plateaus and does not reduce further. Density in AGA continues to drop off over time. These points are illustrated in the graph.


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 and ​Shedding: Why does minoxidil cause shedding?

Why does minoxidil cause shedding?

Minoxidil commonly causes increased hair shedding in the first 6-8 weeks of use (and sometimes a bit longer).  

Every human has hairs on their scalp that are destined to come out next week, the week after and the week after that. When minxodil is applied to the scalp, many of those hairs simply come out earlier than they are supposed to. This is termed "immediate telogen release" and is the main mechanism by which minoxidil causes shedding in the first 2 months of use.


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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Chronic Telogen Effluvium (CTE)

Misdiagnoses common with CTE

CTE

Chronic telogen effluvium (CTE) is an interesting and frequently misdiagnosed hair shedding condition. Many patients with androgenetic alopecia, acute telogen effluvium and even alopecia areata are diagnosed as having chronic telogen effluvium.

 

How does CTE present?


Most patients with true CTE are 40-65 and present with sudden onset of increased hair shedding that fluctuates in intensity. Some days there is alot of shedding. Some days very little. Many patients have scalp pain (trichodynia) which may correlate with the shedding episodes. Patients with CTE often appear to have good hair density to an outsider which makes the condition frustrating for the patient. A careful history and exam can confirm the diagnosis in many cases. Follicular miniaturization is not a feature unless genetic hair loss is present too. A hair collection or scalp biopsy is useful in more challenging cases.
 


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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