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Children of Women with Polycystic Ovarian Syndrome:

What is the latest research ?

Polycystic ovarian syndrome (PCOS) is a hormonal disorder in women. It is not one condition but a constellation of symptoms. Patients with PCOS typically have evidence of hyperandrogegism (excess male type hormones and irregular periods. Women with PCOS typically have cysts present in the ovaries but some do not.  The exact cause of PCOS remains unknown although a genetic component is likely for many women. The ovaries of women with PCOS are known to secrete higher levels of male hormones which contributes to irregular periods and infertility. Women with PCOS may seek medical attention for a variety of reasons including insulin resistance, diabetes, high blood pressure, acne, increased hair growth on the face, irregular periods, infertility.  Women with PCOS may also present to a hair clinic with concerns about androgenetic alopecia. It is therefore extremely important that hair specialists understand this condition. 

 

New Research on Children born to Mothers with PCOS

A great deal of research is currently being conducted into the cause of PCOS and how it affects women. Research is also being conducted into the health of babies born to mothers with PCOS. Research has suggested that the hormonal changes in utero influence the development of the fetus. 

One issue that has been studied is the risk of attention-deficit/hyperactivity disorder (ADHD) in babies born to mothers with PCOS. ADHD is the most common childhood neurodevelopment disorder. Male hormones may play a role as boys are two to three times more likely to develop ADHD.

A study by Berni and colleagues of over 16,000 women showed that women with PCOS have a slight risk of giving birth to children with attention deficity hyperactivity disorder (ADHD) and Asperger syndrome. 

Kosidou and colleagues performed a matched case-control study using health and population data registers for all children born in Sweden from 1984 to 2008.  In their study, a total of 58,912 ADHD cases (68.8% male) were identified and matched to 499,998 unaffected controls by sex and birth month and year. The results indicated that Maternal PCOS increased the odds of offspring ADHD by 42% after adjustment for confounders (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.26-1.58). The risk for ADHD was even higher among obese mothers with PCOS and was highest among obese mothers with PCOS and other features of metabolic syndrome.

 

Conclusion

Recent research suggests that differences in maternal hormones during pregnancy in women with PCOS affect the chances of having children with ADHD and possible other neurodevelopmental issues. Overall the risk is low. 

 

 

 

REFERENCES

Berni TR, et al. Polycystic ovary syndrome is associated with adverse mental health and neurodevelopmental outcomes. J Clin Endocrinol Metab. 2018.

Kosidou K, et al. Maternal Polycystic Ovary Syndrome and Risk for Attention-Deficit/Hyperactivity Disorder in the Offspring.  Biol Psychiatry. 2017.

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Late onset Congenital adrenal hyperplasia (CAH)

Late onset CAH: A mimicker of PCOS and early balding in women

 

What is late onset CAH?

Late onset on non-classic congenital adrenal hyperplasia is an uncommon genetic disorder that is frequently due to mutations in 21-hydroxylase gene leading to reduced levels of the 21 hydroxyls enzyme.  Late onset CAH from deficiencies or mutations in other genes such as  11β-hydroxylase (CYP11B1) and 3β-hydroxysteroid dehydrogenase (HSD3B2) are extremely rare.

Late onset CAH should not be confused with the more serious and early onset condition of newborns called congenital adrenal hyperplasia (CAH). Women with late onset CAH develop signs and symptoms of the condition later in life as opposed to the first few weeks and months of life. 

 

What is the cause of Late onset CAH?

One of the most common causes of late onset CAH is so called 21-hydroxylase deficiency. This is caused by mutations in the CYP21A2 gene. To date, 127 mutations have been reported in CYP21A2. This particular gene provides instructions for making an enzyme called 21-hydroxylase (located in the hormone producing adrenal glands). Mutations in CYP21A2 lead to reduced or low levels of 21-hydroxylase enzyme activity (about 50-80% of normal) which then result in low levels of hormones such as cortisol and/or aldosterone and high levels of androgens (male hormones such as testosterone and androstenedione).

As a result of low cortisol, patients may experience changes in energy levels, blood pressure, blood sugar levels, as well as impaired ability of the body to respond to stress, illness, and injury. Aldosterone plays a key role in helping the body maintain the proper level of sodium and water and helps maintain blood pressure.  The amount of functional 21-hydroxylase enzyme determines the severity of the disorder. Patients with late onset CAH have CYP21A2 mutations that lead to reduce levels on the enzyme but not a complete absence. 

 

How is late onset CAH inherited?

Late onset CAH is usually inherited in an autosomal recessive (AR) manner. What this essentially means is that for a patient to be affected by the condition they need to have both copies of the affected gene - one gene  from mom and one gene from dad.  The parents of a person with late onset CAH are said to be 'carriers' and typically have only one mutated copy of the gene. The parents usually don't have any symptoms or signs of the disease themselves.   

 

How is late onset CAH diagnosed?

The patient's signs and symptoms may point to a possible diagnosis.  Generally speaking, the clinical features of late onset CAH reflect an excess of male hormones (androgens) rather than adrenal insufficiency.

Children with late onset CAH may present with premature pubarche (i.e. the development of pubic hair, axillary hair, and/or increased apocrine odor prior to age 8 years in girls and age 9 years in boys). Affected children may be tall and have accelerated linear growth velocity, and advanced skeletal maturation.

About 2-9 % of all women with hyperandrogenism may have late onset CAH. Women with  late onset CAH may develop a variety of symptoms including frontal baldness, hirsutism, acne,  irregular periods, a delay in the timing of the very first period, early onset of pubic hair, accelerated growth, reduced final height and infertility.  

In a multicenter study by Moran and colleagues, the most common symptoms among adolescent and adult women were hirsutism (59%), oligomenorrhea (54%), and acne (33%). Studies by Bidet and colleagues suggested that the initial presenting symptoms in 161 women with late onset CAH were hirsutism (78%), menstrual dysfunction (54.7%), and decreased fertility (12%). Therefore, presentation to a hair specialist regarding hair loss may not occur until later. 

 

Generally, additional testing is ordered to help confirm the diagnosis.  These tests may include a blood test to measure the concentration of 17-hydroxyprogesterone (17-OHP) on day 3-5 of the menstrual cycle. Levels of 170–300 ng/dL have been found to be useful as a screening tool. These should be obtained in the morning and during the follicular (preovulatory) phase of the menstrual cycle.

The clinical features of  late onset CAH in postpubertal adults may be difficult to differentiate from those of the polycystic ovary syndrome (PCOS). Even 17 OHP concentrations may be within the normal range for individuals with late onset CAH.  An adrenocorticotropic hormone (ACTH) stimulation test may also be ordered which involves measuring the concentration of 17-OHP in the blood before ACTH is administered and 60 min after ACTH is given. This test is typically conducted through an endocrinologist.  The acute ACTH stimulation test remains the gold standard to confirm decreased 21-hydroxylase activity.  

To perform the ACTH stimulation test, a blood sample is first collected to measure baseline hormone concentrations. Then, synthetic ACTH (Cortrosyn, 0.25 mg) is administered. A second blood sample is collected 30–60 minutes later.  When the ACTH-stimulated 17-OHP value exceeds 1500 ng/dL a mutation is likely. In few late onset CAH patients ACTH-stimulated 17-OHP levels will be between between 1000 and 1500 ng/dL.

A common error in investigating CAH is having the patient perform the blood test on any day of the menstrual cycle. 17-OHP levels normally rise in the second part of the menstruate cycle and if the test is done during this phase of the menstrual cycle falsely high levels will be recorded. the 17OHP test must be done on day 3-5. 

 

Other tests

In addition to 17 OHP, other tests may be recommended by the physician caring for the patient. These  are normally done in the MORNING and on day 3-5 of the menstrual cycle. They include cortisol, androstenedione, testosterone, free testosterone, DHEAS, progesterone, sodium, potassium, creatinine, glucose, hemoglobin A1C. LH and FSH may also be measured. Aldosterone may be tested. Blood pressure measurements will also be obtained. 

 

What is the treatment for late onset CAH?

For some patients affected with late onset CAH, treatment is not needed. Most endocrinologists agree that treatment is geared towards treating symptoms rather than simply helping bring lab tests into more normal ranges. 

Symptoms of late onset CAH may develop at various points in life, including puberty, after puberty, post part and during times of illness or increased stress.  If symptoms are present, a physician may prescribe a glucocorticoid, often dexamethasone. Dexamethasone is commonly used to treat irregular menstruation, acne, and excess body hair (hirsutism). Anti-androgens are also frequently used, especially by the hair specialist. Oral contraceptives are sometimes used as treatment for adult women or adolescents with irregular periods, acne or hirsutism who are not seeking to become pregnant

 

If identified early, treatment of children is geared towards helping with a normal linear growth velocity and a normal timing and progression of puberty. For adolescent and adult women, the goals of treatment goals are to help regulate menstrual periods, prevent excess hair growth on the face, and help with fertility. 

 

REFERENCE

Witchel et al. Nonclassic Congenital Adrenal Hyperplasia Int J Pediatr Endocrinol. 2010; 2010: 625105. 

Moran C, Azziz R, Carmina E, et al. 21-hydroxylase-deficient nonclassic adrenal hyperplasia is a progressive disorder: a multicenter study. American Journal of Obstetrics and Gynecology. 2000;183(6):1468–1474.

Bidet M, Bellanné-Chantelot C, Galand-Portier M-B, et al. Clinical and molecular characterization of a cohort of 161 unrelated women with nonclassical congenital adrenal hyperplasia due to 21-hydroxylase deficiency and 330 family members. Journal of Clinical Endocrinology and Metabolism. 2009;94(5):1570–1578.  

 

 


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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Female Pattern Hair Loss

 

Major and Minor Criteria

fphl.png

Female androgenetic alopecia is common. By the age of 50, well over 1/3 of women will have androgenetic alopecia (AGA)- also known as female pattern hair loss (FPHL). This type of hair loss causes thinning in the frontal and mid scalp. The sides and back may also be affected but generally to lesser degrees than the front for most women. Traditionally, the diagnosis of androgenetic alopecia has been made based on the finding of reduced density in the frontal scalp compared to the back of the scalp and the clear demonstration via dermoscopy that there is a variation in the diameter if more than 20% of hair follicles. This is known as anisotrichosis.

In 2009, Dr Rudnicka and colleagues proposed a series of major and minor criteria for diagnosing FPHL.

 

FPHL MAJOR CRITERIA

(1) ratio of more than four empty follicles in four images (at 70-fold magnification) in the frontal area

(2) lower average thickness in the frontal area compared to the occiput

(3) more than 10% of thin hairs (<0.03 mm in diameter) in the frontal area.

 

FPHL MINOR CRITERIA

(1) increased frontal to occipital ratio of single-hair pilosebaceous units

(2) vellus hairs

(3) peripilar signs.

 

Remarkably, the presence of two major criteria or of one major and two minor criteria allow diagnosis FPHL with 98% specificity.

 

Reference

Rakowska A et al. Int J Trichol. 2009;1:123–30.


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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Trichoscopy of Central Centrifugal Cicatricial Alopecia

CCCA: Trichoscopy

ccca

Central centrifugal cicatricial alopecia (CCCA) is a scarring alopecia that commonly affects women with afrotextured hair.  It has a genetic basis in some women. The condition starts with central hair loss in most affected women and this is followed by expansion of the hair loss outwards. There may be symptoms such as itching, or pins and needles, but many women are asymptomatic. 

In an article earlier this year, I discussed some very interesting studies which showed a five fold increased risk of uterine fibroids among women diagnosed with CCCA.   

 

Dermatoscopic Features of CCCA
 

It is critically important to identify CCCA in the early stages in order to try to stop hair loss. Today I'd like to focus on the up close features of CCCA using a handheld dermatoscope.  We refer to this as trichoscopy. 

The trichoscopic features of CCCA are few. Miteva and Tosti in 2014 published the first real compressive overview of the trichoscopic features of CCCA. They retrospectively images obtained from 51 women with histologically proven CCCA and  compared to controls (which included 30 dermatoscopic images from histologically proven cases of scarring traction alopecia and discoid lupus erythematous).   

 

The Peripilar White Gray Halo

ccca

The so called "peripilar white gray halo" was found in 94% of patients and was highly specific and sensitive for CCCA. This halo was seen around the emergence of hair follicles.

The halo was shown to correspond on pathology to the lamellar fibrosis surrounding the hair follicle outer root sheath.

 

Reference

Miteva and Tosti. Dermatoscopic features of central centrifugal cicatricial alopecia. J Am Acad Dermatol. 2014.

 

  
 


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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Treatment of Androgenetic Alopecia During Pregnancy

Treating AGA in Pregnancy:

Most treatments for AGA are either not safe or not recommended during pregnancy. This includes minoxidil, anti androgens, various supplements, over the counter products and topical agents. The cardinal rule of treating any conditions during pregnancy or using any treatment during pregnancy is simple: ask a physician. 

 

Low Level Laser: Generally Safe for Most

 Low level laser treatments (LLLT) are the only safe treatments during pregnancy for women with AGA. This applies to most of the standard at home devices. Everything else needs stopping and some treatments need stopping well in advance. For some women, treatments during pregnancy are not necessary because it is possible due to hormonal surges during pregnancy stopping treatment may potentially not have a huge effect while pregnant and one can start many treatment again after giving birth. However, it should be noted that some women do experience hair loss during pregnancy as well.

 

WHICH HAIR LOSS MEDICATIONS ARE SAFE TO USE WHILE BREASTFEEDING?

Although I often ask my patients to discontinue most hair loss medications during pregnancy, the question frequently arises as to whether some medications can be restarted while moms are breastfeeding.  Breastfeeding has many benefits for babies.  For some drugs, the answer is yes. For others, the answer is no.

In 2001, the American Academy of Pediatrics published a helpful guide as to the safety of medications during breastfeeding. It's important to always check with your physician before starting any medication during breastfeeding. However, the following medications (used in hair loss) are felt to be safe for women who are breastfeeding.  For a full list of medications which are safe during breastfeeding, click here.

I generally do not recommend restarting treatments until month 1 after delivery if the baby is breastfed although many studies and reports show no harm in use if minoxidil and antiandrogens by women who are breastfeeding.

 


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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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.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Do all women with hair loss really need blood tests?

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

Click here for PDF of Article

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

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

SCREENING BLOOD TESTS FOR WOMEN WITH HAIR LOSS.

 

1. Iron deficiency anemia is common

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

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

2. Blood counts

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

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

 

3. Thyroid abnormalities are common

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

 

4. Vitamin D deficiency is common

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

 

5. Zinc deficiency

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

 

6. Hormone Testing

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

 

Conclusion

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

All women with hair loss need blood tests. 

 

REFERENCE

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


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

Hair Loss from Breast Implants: Any relationship?

BII.jpg

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I believe that there are countless numbers of hair loss conditions that exist in the world that have not yet been described in textbooks. The reason I believe this is quite simple - I see and hear them every day in my clinic.  There are stories of hair loss from certain medications,  various unusual patterns of hair loss in otherwise common conditions. Every once in a while a new scenario arises that again causes pause - one such example is a syndrome of medical conditions that arise in women who have had breast augmentation and breast reconstruction. Readers should note that this is a very different form of hair loss than the telogen effluvium that sometimes accompanies the surgery itself (or any surgery for that matter). This has been termed 'breast implant illness.' Whether or not hair loss occurs in a small proportion of women who have undergone breast augmentation continues to be studied.  It's an area of research that we follow closely given how often these scenarios arise in our clinic. 

 

Breast implants and human health

Anything that triggers a systemic reaction inside the body has the potential to cause hair loss. One therefore needs to look at the data on the effects of breast implants on human health. In the last 5 years new data has emerged that breast implants may be associated with cancer - specifically the development of a type of T cell lymphoma called anaplastic large cell lymphoma. The FDA continues to study this association and the risk may be in the order of 1 in 10,000 women to as great as 1 in 1000 women.

Breast Implant Illness has many similar names in the research and medical literature. ASIA syndrome (autoimmune/inflammatory syndrome induced by adjuvants) was a name given to a specific disease that can arise with exposure to silicone. To date, it is still controversial as to whether silicone implants increase the risk of true autoimmunity in the body.  However, some studies have shown increase incdience of autoantibodies in women with silicone breast implants. 

 

Breast Implant Illness

There is a subset of women with breast implants who feel that their health has changed in some way followed breast implant surgery. The term 'breast implant illness' is a term that has been given to the constellation of symptoms and signs that are proposed to be attributed to breast implants. The mechanism by which this would or could occur is not yet known. Women who report symptoms consistent with breast implant illness frequently mention chronic fatigue, chronic pain, anxiety, irregular heart rate, neurological problems, body odour, rashes, endocrine problems - and hair loss.  To date, it is hard to prove an association of these symptoms of these women to their breast implant surgery and many alternative explanations are frequently given.  Many symptoms are dismissed. Many women, but not all, experience some degree of improvement in symptoms after explanation (removal of the implant).

 

Breast Implant Illness and Hair Loss

As mentioned in the opening paragraphs, I strongly believe that there are countless numbers of  hair loss conditions and syndromes that are unrecognized and have not yet made their way into textbooks, and classrooms of learners.  (This concept forms Principle 9 of the 20 Principles that govern my practice).

There have been several studies examining breast implant illness and one some have addressed the issue of hair loss. One such study was a 1996 study by Brawer which reported illness in 300 women who had silicone breast implants. Most women (90 %) developed their illness within 6 years of the implants.  Although rupture of the implant was present in some affected, 97 % of women did not experience rupture prior to their symptoms.  Rupture however, did worsen symptoms. 

The table below shows the most common signs and symptoms in patients with breast implant illness according to the 1996 Brawer study. Fatigue tops the list followed by arthritis and chest pain. Hair loss is number 4 on the list and experienced by 59% of patients with breast implant illness.  

from Arthur Brawer.&nbsp;J. Clean Technol Environ. Toxic &amp; Occup Med Vol 5(3) 1996

from Arthur Brawer. J. Clean Technol Environ. Toxic & Occup Med Vol 5(3) 1996

Conclusion

Modern medicine is still in the early stages of understanding whether and to what degree breast implants affect health. There does appear to be an association with anapaestic large cell lymphoma and an increasing number of women are reporting concerns that can only be grouped together for now under a non specific term 'breast implant illness.'  Hair loss has been reported by many women with breast implant illness.  In my practice having seen at least a dozen cases, most end up being diagnosed with telogen effluvium, chronic telogen effluvium and/or androgenetic alopecia - which are extremely common in the population anyways. Pinpointing an exact cause is challenging. Explanation, or removal of the implant,  is helpful only in some.

For now, continued study of breast implant illness is warranted. 

 

 

 

Reference

1. https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239995.htm

2. Tang S et al. Breast implant illness: Symptoms, Patient Concerns, and the Power of Social Media.  Plast Reconstr Surg. 2017

3. Arthur Brawer.  Chronology of systemic disease development in 300 symptomatic recipients of silicone gel-filled breast implants. J. Clean Technol Environ. Toxic & Occup Med Vol 5(3) 1996

4. Bar-Meir E et al. Multiple autoantibodies in patients with silicone breast implants. J Autoimmune 1995

 


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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Androgen Blockade For FPHL: Can I use more than I medication?

Androgen blockade has the potential to be help female pattern hair loss. Caution is needed with any hormone blocker due to significant harm that can come to a developing baby were a woman to become pregnant on any hormone blocker. For this reason they are frequently used with various strict contraceptive methods.

 

Hormone Blocking Medications for FPHL

Female Pattern Hair Loss (also called female androgenetic alopecia) affects 40 % of women by age 50. There are a variety of treatment options including minxodil, anti-androgens, laser and PRP. 

Anti-androgens can help some women with female pattern hair loss. A long list of anti-androgens exist including spironolactone, finasteride, cyproterone acetate, flutamide, dutasteride. The combination of anti-androgens can sometimes work even better than one alone provided the patient actually has a truly androgen responsive hair loss condition. Most men do. But not all women have a form of FPHL that is truly responsive to anti-androgens.

 

Anti-androgen Side Effects

The decision to use two or more anti-androgens must always be weighed against potential side effects. The combination of androgen blocking pills has the potential to be associated with side effects such as depression, worsening fatigue, breast tenderness, breast enlargement, weight gain, decreased libido.

 

 

 

 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Hair Loss at the Nape of the Neck: What are the main causes?

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

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

 

1. Traction alopecia (photo 1)

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

PHOTO 1: Traction alopecia presenting as hair loss in the nape

PHOTO 1: Traction alopecia presenting as hair loss in the nape

 

2. Alopecia Areata (photo 2)

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

PHOTO 2: Alopecia areata presenting as hair loss in the nape

PHOTO 2: Alopecia areata presenting as hair loss in the nape

 3. Androgenetic Alopecia (photo 3)

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

PHOTO 3: Androgenetic alopecia (AGA) presenting as thinning in the nape

PHOTO 3: Androgenetic alopecia (AGA) presenting as thinning in the nape

 

 

4. Frontal Fibrosing Alopecia (photo 4)

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

 

PHOTO 4: Frontal fibrosing alopecia (FFA) presenting as hair loss in the nape

PHOTO 4: Frontal fibrosing alopecia (FFA) presenting as hair loss in the nape

5.  Heat and Chemicals

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

 

6. Acne keloidalis nuchae

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

 

7. Hair shaft disorders

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

 


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

What are the side effects of finasteride in women?

First off, finasteride is not FDA approved for women. Any such use is therefore "off label" and any female considering finasteride will want to be guided by a knowledgeable and experienced physician if this is a route you wish to take. Depending in the patient's current age, type of hair loss and medical history and family history this may or may not be a good option.

Side effects

i'm often ask about the range of side effects that are possible for women who use finasteride. Side effects of finasteride in women include, but are not limited to: harm to a fetus (finasteride can not be used in pregnancy), fatigue, weight gain, depression, anxiety, decreased libido, sexual dysfunction, hair shedding, breast tenderness, breast enlargement.  Other side effects can occur but are less common. These include changes in platelet counts and muscle injury (myopathy).


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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Androgenetic alopecia in women: Can I still have it if my hormones are low?

AGA in Women with Low Androgens

I'm often asked on various blogs and posts how it's possible to have androgenetic alopecia if a woman's androgen levels are normal or low. Many individuals have received a diagnosis of androgenetic alopecia and once their blood tests return normal, then have questions:

Is the diagnosis wrong?

How could I possibly have AGA if my androgens (testosterone, DHEAS, etc) is normal?

 

AGA in Women is best called FPHL

One must always keep in mind that androgenetic hair loss in women has much less to do with male hormones than it does in men. MOST women with AGA have normal hormone levels. In fact, about 90 % have normal hormone (androgen) levels. Treatments for AGA in women can still be helpful in many despite normal or low - normal levels. For this reason, many dermatologists choose to call female androgenetic alopecia "female pattern hair loss (FPHL)" rather than ANDROgenetic alopecia to de-emphasize the role of androgens.  

 

Summary

There are many complex mechanisms that lead to the development of AGA in women. For many women, androgenetic alopecia has little to do with androgens. For some it has a lot to do with androgens and for some it probably has nothing to do with androgens.  


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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Lysine and Hair Loss

When Can Lysine be Helpful?

L-lysine is an amino acid, which are the building blocks of proteins. Lysine is one of the more difficult amino acids to get in foods but it is found in meat, fish and eggs.

L-lysine has an important role in iron and zinc absorption. In 2002 D.H. Rushton demonstrated the benefits of l-lysine to increase iron and zinc levels and to reduce hair shedding.

Ruston reported 14 women who were deficient in zinc and showed that 1000-1500 mg of Lysine daily led to an increase in zinc levels from 9.7 to 14.6 umol/L - even without these women consuming zinc pills.

Similarly with iron, Rushton showed that 100 mg per day of iron in 7 women with chronic telogen effluvium did not change ferritin levels at all. However, when combined with L-lysine (again at 1000-1500 mg per day), ferritin levels increased from 27.4 to 58.6 ug/L. This was associated with a decrease in the proportion of hairs in the telogen phase from 19.5 to 11.3.

L-lysine is an important amino acid and I often recommend it for my patients with chronic shedding abnormalities and those with deficiencies of iron and zinc that don't respond to routine supplementation. If I do recommend L-lysine, the dosing is typically 500 mg twice daily, and rarely three times daily for short periods.

Reference

DH Rushton. Nutritional factors in hair loss. Clin Exp Dermatol 2002

 


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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Biotin and Hair Loss

Why Does the World Love Biotin So Much?

Biotin is a well-known and popular supplement for treating hair loss. Let's face it - the world loves biotin. However, true deficiencies in biotin are rare given the ability of bacteria in the gastrointestinal system to produce biotin. Nevertheless, many individuals and physicians turn to biotin in the search for treatment options. 

Soleymani and colleagues from New York University School of Medicine set out to critically examine the evidence for biotin use for treating hair loss. Their findings point out that there are no randomized trials to support the use of biotin in treating hair loss and that the public’s interest in biotin over the past decades is not supported by medical evidence. 

There is really no evidence to support routine biotin supplementation for individual’s with hair loss. Exceptions do exist, of course, and true biotin deficiency may be considered in individuals who are elderly, pregnant, using anticonvulsants or chronically using alcohol. 

Reference

Soleymani T et al. J Drugs Dermatol. 2017 May 1;16(5):496-500


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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Is sunscreen use more common in women with FFA?

This is a controversial question, there has been one study that has caught the attention of physicians and patients around the world. A study by Aldoori et al compared how 105 women with FFA and 100 women without FFA responded to a lengthy survey.

Surprisingly, a much greater proportion of women with FFA reported using sunscreens (at least twice weekly) compared to women without FFA. Specifically, 48 % of FFA patients reported such sunscreen use compared to just 24 % of women without FFA.

 

Conclusion

We still have a long way to go to definitely prove sunscreens have a role. It is 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. More good studies 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.


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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Is topical Spironolactone effective for Treating Female Pattern Hair Loss?

Oral spironolactone is classified as an anti-androgen and is the most commonly prescribed oral anti-androgen in the Untied States for the treatment of female patter hair loss. IT is not FDA approved for hair loss so its use is 'off label.' Topical spironolactone is not FDA approved for androgenetic alopecia either and has not had much study.  Any use of topical spironolactone should be prescribed only in conjunction with a physician.  

 

Is topical spironolactone effective? 

Well, few such studies have been done but there may be some minor benefit.  A 1997 study studied 60 women using 1 % topical spironolactone. A minor degree of benefit was seen.  Side effects from topical spironolactone are potentially similar to oral spirinolactone pills (albeit at a lower incidence).  

Women should be aware of breast tenderness, mood changes, electrolyte imbalance, fatigue, dizziness, swelling, Women of child bearing age should speak to their physician about pregnancy concerns. One must never get pregnant while using spironolactone or the developing fetus could be seriously harmed.  Topical antiandrogens do get absorbed into the blood stream. It would be unwise to think otherwise. 

Overall topical spironolactone may have minor benefit in the treatment of androgenic alopecia. More studies are needed however, before its use becomes routine. 


REFERENCE


Dill-Muller D, Zaun H. Topical treatment of androgenetic alopecia with spironolactone. J Eur Acad Dermatol Venereol. 1997 Sep;9(Suppl 1):31.


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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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.

DOWNLOAD ORAL MINOXIDIL HANDOUT


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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Finasteride for Women

Can Finasteride (Propecia) be used in women?

 

Finasteride is not FDA approved for women. That does not mean we never use finasteride in women - in fact, I sometimes to prescribe this medication. The fact that it is not FDA approved just alerts us that there are important reasons to consider as to why it is not approved.  

 

Does FDA approval matter?

FDA approval does matter. It directs us to consider that considerable review has been done to evaluate that safety of a given medication. However, readers must keep in mind that 99 % of the medications that a hair loss doctor uses are not FDA approved!! When a medication that is not FDA approved is used, we say that this is a so called 'off label' use. 

When I use minoxidil for alopecia areata, I'm using the medication in an 'off label' manner. Minoxidil is not FDA approved for alopecia but but sure can help many patients.  In fact - there is not a single medication on the planet that is FDA approved for alopecia areata.

When I use Plaquenil for lichen planopilaris, I'm using the medication in an 'off label' manner. Plaquenil is not FDA approved for lichen planopilaris but but sure can help many patients.  In fact - there is not a single medication on the planet that is FDA approved for lichen planopilaris.

When I use clindamycin for folliculitis decalvans, I'm using the medication in an 'off label' manner. Clindamycin is not FDA approved for folliculitis decalvans but but sure can help many patients.   In fact - there is not a single medication on the planet that is FDA approved for folliculitis decalvans.

When I use minoxidil and steroid injections for traction alopecia, I'm using these medications in an 'off label' manner. Minoxidil and steroid injections are not FDA approved for traction alopecia but but sure can help many patients. In fact - there is not a single medication on the planet that is FDA approved for traction alopecia.

 

Finasteride for Women - It's off label.

When I use finasteride for androgenetic alopecia in women, I'm using these medications in an 'off label' manner. Finasteride is not FDA approved for androgenetic alopecia but but sure can help many patients. 

Some medications are appropriate for a given patient others are not. One really needs to sit down with a physician and discuss. Even Rogaine is not advised for some women (heart conditions, heart rhythm problems, pregnancy, other hormone abnormalities such as pheochromocytoma). 

Some physicians never prescribe finasteride to women regardless of age. Some physicians only prescribe to post menopausal women. Some physicians will prescribe to premenopausal with appropriate counceling on the risks during pregnancy and prescription of appropriate birth control.  

Finasteride must never be used by women who may become pregnant. Women with strong histories of estrogen dependent cancers (breast, ovarian, gynaecological cancers) should also review use with their doctors. This includes breast, ovarian and other gynecological cancers. Women with depression should also have a thorough discussion as to whether this drug is appropriate for them of not.


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

FFA: Scaling Around Hairs

Frontal fibrosing alopecia (FFA) is a type of scarring hair loss that occurs more often in women than men. It causes hair loss along the frontal hairline as well as several other areas including the sides and back of scalp, eyebrows, eyelashes, and body hair.

This picture shows a very typical appearance of the frontal scalp in FFA. There are numerous single hairs, many with scale around those hairs (called perifollicular scaling). A few broken hairs are seen and one hair in the picture is markedly twisted (a phenomenon known as "pili torti"). This is mild scalp redness.

Many treatments are available as we have reviewed together previously. This patient was started on a 5 alpha reductase inhibitor (finasteride, 5 mg) along with pimecrolimus cream (Elidel) and steroid injections. Clobetasol proprionate shampoo (Clobex) will be used weekly and reassessment will be done in 4-6 months.
 


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