Biotin and False Test Results: Stopping Before Blood Tests is Essential

Stopping Before Blood Tests is Essential

Many supplements contain biotin at levels well above the recommended daily intake of 30 micrograms. It is now recognized that high doses of biotin can interfere with some laboratory tests (specifically immunoassays using biotinylated antibodies). Many supplements contain 2 500, 5 000  or even 10 000 micrograms of biotin.

Both falsely low and falsely high results are possible in users of biotin supplements. The concern is that some patients might undergo unnecessary testing or start unnecessary medications after being told their blood test results are abnormal.

The issue is therefore potentially quite serious. In November 2017, the US Food and Drug Administration recently issued a safety communication regarding biotin interference with laboratory tests.

A recent report in the Journal of the Endocrine Society reported a patient with abnormal thyroid results, as well as elevated cortisol and testosterone. These abnormal results prompted the patient to undergo numerous consultations and radiographic and laboratory tests.

It was ultimately discovered in this patient that her abnormal results were due to the biotin supplement she was using. The patient was taking a biotin supplement at a dose of 5 000 micrograms per day regularly.  Once she stopped biotin, her lab parameters returned to normal although TSH tests (thyroid testing) did take more than 2 weeks before any normalization was seen.

This reports highlights the potential for patients using biotin to have false results. What is more concerning is the potential for such patients to undergo potentially invasive testing or start potentially harmful medications on account of these results.

Education as well as communication between health care teams, laboratories, and patients is vital to ensure patients stop biotin well ahead of any testing.

Reference

Stieglitz HM, et al. Suspected Testosterone-Producing Tumor in a Patient Taking Biotin Supplements.
J Endocr Soc. 2018.

Androgenetic Alopecia: Variation in Hair Caliber (Anisotrichosis)

Variation in Hair Caliber (Anisotrichosis)

Individuals with androgenetic alopecia (male balding and female pattern hair loss) may lose hair at different sites of the scalp (some front, some crown, some diffusely) but all show a variation in the caliber of hairs when the scalp is examined up close. That feature is known as “anisotrichosis.” This photo shows the scalp of a patient with androgenetic alopecia. Some hairs are thick (well above 60 micrometers) and a known as terminal hairs. The arrow on the right points to one fairly thick 77 micrometer hair.

Other hairs on the scalp are thin including many that are showing “miniaturization” or the progressive reduction in calibers. Hairs that are thin, small and less than 30 micrometers are traditionally called “vellus hairs.” One very thin 21 micrometer hair is shown in the photo.

The conversion of terminal hairs to vellus hairs is the hallmark of androgenetic alopecia.

Lichen planopilaris: Shedding, Itching, Burning, Tenderness

Shedding, Itching, Burning, Tenderness

Lichen planopilaris (“LPP” for short) is a type of hair loss that is categorized as a type of so called scarring alopecia.

There is no single way that LPP first announces its presence. Some people have only scalp itching. Some have burning. Some have itching and burning along with a bruised-like tenderness in the scalp. Surprisingly, a small proportion of patients with LPP have no symptoms at all.

Many patients notice they are shedding more hairs on a daily basis than they once did.

Eventually, some patients develop an area of hair loss on the scalp that concerns them and brings them to the doctor.

In many cases the diagnosis can be determined by simply looking at the scalp but often a biopsy is performed to confirm the diagnosis. A biopsy shows the presence of both inflammation beneath the scalp (in a specfic pattern) as well as scar tissue (fibrosis). Treatments include topical steroids, topical calcineurin inhibitors, steroid injections, and a variety of oral medications (doxycycline, hydroxychloroquine, methotrexate, cyclosporine, mycophenolate, isotretinoin, low level laser, excimer laser, tofacitinib).

Using Alcohol while taking Methotrexate: Is their a risk of liver injury?

Consuming Alcohol while on Methotrexate

Methotrexate is an immunosuppressive type pill that is used in the treatment of several autoimmune hair loss conditions including alopecia areata, lichen planopilaris, frontal fibrosing alopecia, and discoid lupus. A variety of side effects are possible with methotrexate including the risk of liver toxicity. 

Alcohol Use in Methotrexate Users

Both alcohol and methotrexate can irritate the liver.  On account of this, individuals using methotrexate need to have their liver enzymes monitored periodically. Traditionally, physicians have advised patients using methotrexate to limit their use of alcohol while using methotrexate.  New data suggests that while these concepts are correct, the use of limited amounts of alcohol by methotrexate users does not appear to increase the risk of liver injury.

The UK based authors studied the effects of alcohol consumption in rheumatoid arthritis patients using methotrexate. It's important to note that these were note hair loss patient and therefore the results need to be extrapolated. The researchers studies 11 839 patients over the years 1987 to 2016. They observed that there were 530 episodes of liver enzyme elevation (i.e. "transaminitis"). The authors found that methotrexate users who consumed less than 14 units of alcohol per week did not seem to have an increased risk of transaminitis. Patients who consumed between 15 and 21 units seemed to have some degree of liver injury and patients who consumed more than 21 units had a significantly increased risk of transaminitis.

 

Conclusion

This is an important study. Many patients with autoimmune hair loss conditions make decisions on use of methotrexate based on the potential side effects and the information they are presented about the necessity to limit alcohol consumption while using methotrexate. This study provides evidence that occasional use of methotrexate is likely to be safe from the perspective of liver injury and that keeping under 14 units is also likely to have a good liver safety profile.  14 units of alcohol would include 6 glasses of wine (13 %, 175 mL) or 6 pints of beer.

Reference

Humphreys J et al. Quantifying the hepatotoxicity risk of alcohol consumption in patients with rheumatoid arthritis taking methotrexate. Ann Rheum Dis. 2017 Sep;76(9):1509-1514.  

Scalp Biopsies: Expert Interpretation Needed

Expert Interpretation Needed

Scalp biopsies have multiple steps but all end with a pathologist sitting at his or her microscope looking at a slide like the one shown here.

A biopsy is important but not more important than the patient’s story (ie the “medical history”) and not more important than the actual clinical scalp examination. The biopsy is merely another tool to get information about the possible cause of the patient’s hair loss.

To perform a scalp biopsy properly, one must ensure a 4 mm punch size is used an taken from the right area of the scalp. The sample must be processed properly by the pathology laboratory and ideally should be assessed by a dermatopathologist who has a good amount of experience in scalp biopsies.

It is surprisingly for some to learn that biopsies are not the gold standard in diagnosing hair loss they are simply a tool. Incorrect interpretations are possible (false positives and false negatives)

Minoxidil for Women: Am I really supposed to be using the Men's Brand?

Topical Minoxidil for Women: Which Strength ? Which Type?

Minoxidil is a topical product for treating androgenic alopecia. It was first approved in 1988 for this indication. Depending on the advice of the treating physician, minoxidil may also be used off label to treat several other types of hair loss as well, such as alopecia areata, some scarring alopecias and some forms of hair loss related to chemotherapy.

Both minoxidil 2 % and 5 % are approved for use in men.

Both minoxidil 2 % and 5 % are approved for use in women.

What are the typical types of minoxidil that I will see at the pharmacy?

There are several main types types of minoxidil that a patient will encounter when they enter the pharmacy. At first glance it seems to be a bewildering array of options. The internet is full of claims that one type is better than another. Some companies state that their spray is the way to go - and using the foam or liquid dropper is less effective. Others promote their foam, saying that anything else is less effective.

First, we’ll take a look at the types of minoxidil products that are commonly seen and then return to some practical tips.

MINOXIDIL PRODUCTS MARKETED TO WOMEN

1) 2% Minoxidil Lotion (Dropper) for Women.

2) 2% Minoxidil Spray for Women.

3) 5% Minoxidil Lotion (Dropper) for Women

4) 5% Minoxidil Spray for Women

5) 5% Minoxidil Foam for Women

MINOXIDIL PRODUCTS MARKETED TO MEN

1) 2 % Minoxidil Lotion (Dropper) for Men

2) 2 % Minoxidil Spray for Men

3) 5% Minoxidil Lotion (Dropper) for Men

4) 5% Minoxidil Spray for Men

5) 5% Minoxidil Foam for Men

Practical Tips for Minoxidil Use and Application

As we can see from the above lists, there are many types of minoxidil. This is only a partial list as other types can also be made through compounding pharmacies. For example, the less common off label use of 7.5 % or 10 % minoxidil, or liposomal minoxidil compounded with anti androgens like finasateride.

Here are some practical pointers about use of minoxidil:

1) The men’s and women’s products are usually identical so go with whatever is less expensive and use according to your doctor’s recommendations.

A bottle of 2 % men’s minoxidil is generally identical to a bottle of 2 % women’s minoxidil. One might be a different color. One might say clearly on the packaging that it is “for men only” and the other for women only, but the products are identical. Understandably it’s creates some confusion and anxiety when a woman starts to use a bottle of 2% minoxidil liquid that states on the packaging “for men only.” However, the product is the same as the 2 % minoxidil lotion for women. If a patient has any questions about which minoxidil to use, they should take a photo of the product they have found and simply send it to their own treating physician for confirmation that it is the right product.

A bottle of 2 % minoxidil lotion is used at 1 mL twice daily regardless of whether the female is using the version marketed to men or the version marketed to women.

Minoxidil 5 % foam for men is generally the same identical product as minoxidil 5% foam for women. The men’s foam is usually less expensive so a physician may recommend that some of their female patients simply use the men’s minoxidil foam. Understandably it’s creates some confusion and anxiety when a woman starts to use a bottle of minoxidil foam that states on the packaging “for men only.” However, the product is the same as the 5 % minoxidil foam for women.

A bottle of 5 % minoxidil foam is used at a dose of 1/2 cap once daily regardless of whether the female is using the version marketed to men or the version marketed to women. If the female choses to use the version marketed to men, it will of course indicate that use is twice daily on the packaging - but those are the instructions for men. All users should use the product according to the specific recommendations given by their health care providers.

2) Experiment with Different Formulations

Most patients with hair loss prefer the foams over the liquid (dropper or spray) formulations of minoxidil. They tend to be less greasy and less irritating. However, not everyone prefers the foam and some clearly prefer the lotion for the easy of getting small amounts all over the scalp. Patients with thicker or curlier hair may prefer the lotion in some cases. Patients with widespread areas of hair loss may also prefer the liquid (dropper) formulations as it is easier to spread 1 mL (25 drops) all over the scalp as opposed to spreading 1/2 cap all over the scalp.

CONCLUSION

If there is any doubt about which minoxidil one should buy, an individual should simply check with the treating physician. One simply needs to be aware that men’s minoxidil formulations are identical. 2 % minoxidil for men is identical to 2 % minoxidil for women. 5 % minoxidil for men is the same as 5 % minoxidil for women. The packaging might be different and the cautions in fine print might be different. The use is generally the same.

Late Onset Alopecia Areata: What are the Features?

Late Onset Alopecia Areata (LOAA)

Alopecia areata is an autoimmune disease that affects about 2 % of the world. About 50 % of patients who develop alopecia areata will develop their first episode of hair loss before age 20. The development of the first episode of alopecia areata after the age of 50 is uncommon.  Alopecia areata first occurring after age 50 is frequently referred to as late onset alopecia areaeta (LOAA).

What are the characteristics of patients who develop LOAA? 

In 2017, Lyakhovitsky and colleagues set out to determine the features of patients who develop LOAA. They performed a retrospective cohort study of patients visiting a tertiary centre over the 6 year period (January 2009 and April 2015).

Of 29 patients in their study who were found to have LOAA, 86.2% were female (female-to-male ratio, 6.2:1). There was a family history of alopecia areata in 17.2%, thyroid disease in 31%, atopic background in 6.9%, and 17/29 (58.6%) reported a significant stressful event. The most common disease pattern observed as the so called 'patchy' subtype. Interestingly the disease was mild in the majority of participants. Complete hair regrowth was observed in 82.8% of participants, and 37.9% relapsed.

Conclusion and Comments

This is a nice study which examines the characteristics of patients who develop their very first patch of alopecia after age 50. This group of patients appears have have less extensive disease, and frequently has complete hair regrowth. Affected patients are more likely to be  female than male.   

REFERENCE

Lyakhovitsky A, et al. Dermatology. 2017.

Mitochondria, Hair Loss and Hair Growth:

What are mitochondria and why do they matter?

If one thinks back to their earliest high school biology days, they'll likely remember learning about mitochondria. These are tiny 3 micrometer organelles that lie inside cells.  Mitochondria are essential components and play a key role in helping cell product energy. When one thinks of metabolism of muscle cells, liver cells, brain cells, one is really talking about mitochondria.  These are frequently referred to as the 'powerhouses' of the cell. 

A new study points to key role for mitochondria in hair loss

Most living (nucleated) cells have mitochondria, including many cells that make up the hair follicles. A new study from the University of Alabama at Birmingham nicely demonstrated just how important mitochondria are. When a mutation leading to mitochondrial dysfunction is induced in mice, the mouse develops visible hair loss in a matter of weeks. When the mitochondrial function is restored by turning off the gene responsible for mitochondrial dysfunction, the mouse regains thick fur, indistinguishable from a healthy mouse of the same age.

The researchers are interested to use this model to more thoroughly study mitochondrial function in a variety of states, including aging. Some treatments for hair loss are known to affect mitochondrial function - including low level laser therapy (LLLT).

Further research will elucidate if an how we can treat hair loss by affecting the function of these tiny organelles known as mitochondria.

REFERENCE

Bhupendra Singh, Trenton R. Schoeb, Prachi Bajpai, Andrzej Slominski, Keshav K. Singh. Reversing wrinkled skin and hair loss in mice by restoring mitochondrial function. Cell Death & Disease, 2018; 9 (7) DOI: 10.1038/s41419-018-0765-9

Lyme Disease and Hair Loss: What types of hair loss are possible?

What types of hair loss are possible?

Lyme disease is an infectious disease caused by bacteria known as Borrelia. These bacteria are typically spread by ticks, such as the one I photographed here.  Most people develop a rash at the site of the tick bite (often shaped like a "bull's eye" as it spreads). Not everyone develops the rash. If untreated, patients with Lyme disease can develop neurological problems, heart problems and arthritis many years later. About 300,000 people in the United states are affected yearly by Lyme disease.

Lyme disease gets transmitted to humans when a specific tick known as the Ixodes tick bites the skin. What's unique about these ticks is that the tick must be attached to the skin for 36-48 hours before the bacteria can be spread. This means that if humans can identify the tick on their skin before the 36 hour mark (and remove it gently with tweezers), it may be possible to prevent the disease.

The frequency of hair loss in patient's with Lyme disease has not been carefully studied. Lyme disease may cause a diffuse hair loss similar to a telogen effluvium. One study from 1999 suggested that telogen effluvium occurred within three months after the outbreak of disease in 13 % of patients with Lyme meningitis and in 56 % of patients with encephalitis. Lyme disease has also been implicated in one subtype of scarring alopecia (Psuedopelade of Brocq) although this remains to be verified in repeat studies. Some researchers have suggested a role for Lyme Disease in patients with Morgellons Disease (a skin disease whereby patients identify fibers within the skin, under the skin or projecting from the skin). Overall, Lyme disease may cause hair loss. A history of a tick bite and spreading bull's eye rash can be helpful early clues in the diagnosis. Antibody tests are available for Lyme disease, but they are not useful in the early stage. They are more helpful in the diagnosis of later stages.  Testing is typically a two-stage process beginning first with a test known as an “ELISA” test. Patients who test positive with the ELISA test then undergo testing using a “Western Blot.”

Reference

Cimperman J, et al.
Wien Klin Wochenschr. 1999.

Hair, Feathers and Scales: How much do they have in common?

How much do they have in common?

At first glance, it would seem like birds, mammals and reptiles are about as different as could be.

That’s of course until you speak with Dr Milinkovitch and his group in Switzerland about their landmark study in 2016. 
His data, which comes from studying specific reptile species points to the possibility that feathers and hair are in fact more closely related than ever imagined. Birds and mammals (including humans) are thought to share a common ancestor some 320 million years ago!

Scales in reptiles, feathers in birds and hair in mammals appear more closely related than once imagined.
 

Reference

Nicolas Di-Poï and Michel C. Milinkovitch. The anatomical placode in reptile scale morphogenesis indicates shared ancestry among skin appendages in amniotes. Science Advances  24 Jun 2016:Vol. 2, no. 6.
 

Gummy Vitamin Use by Hair Loss Patients

Gummy Vitamins

lI've noticed a fascinating trend in my hair clinic over the last decade: patients are increasingly consuming their multi vitamins by eating them in the form of 'gummies.' They love the taste and find them easy to take. Not a day goes by where a bottle of gummies does not emerge from a bag to be placed on my desk. 
The multivitamin industry is estimated to be a 7 billion dollar industry in the US alone; gummy multivitamins account for about 8 % of this industry. According to some estimates, there has been a 25 % increase in gummy sales in the past 3 years. Worldwide, gummy vitamin sales ares expected to increase from its present 2.7 billion dollar estimate to 4.2 billion by 2025. North Americans are chomping on the gummies at the highest rates with Europe in second place.

Gummy multivitamins are now produced in a variety of shapes and flavours. Gummy bears and gummy fruits are popular. For those who don't want the extra sugar that many gummy multivitamins contain, there are now sugar free versions.

My views on multivitamins are simple: if one is deficient in a particular vitamin or mineral, it makes sense to replenish it.  Getting vitamins through foods (i.e. fruits and vegetables) remains a far better option that through vitamins.  If this is not an option, or foods do not seem to restore levels, one can consider multivitamins.  Multivitamins may be particular important for certain subpopulations - including the elderly, alcoholics, patients undergoing bariatric surgery and women taking oral contraceptives. Many patients however require a different mix of vitamins and minerals and a one fits all approach may not work.

I am willing to admit that there may be some evidence that supplementation of certain compounds could be beneficial for some patients even if one is not deficient. Examples of this later category include amino acids like L-lysine and cysteine although more research is needed.  Overdosing on vitamins is common and could have negative effects on the body and hair.  High levels of vitamin A are well understood to cause hair loss.

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Diphencyprone for Alopecia Areata: Can one apply DPCP at home?

Can one apply DPCP at home?

Diphencyprone (“DPCP”) is a unique treatment for alopecia areata that has been used for over 25 years.

What’s unique about DPCP is the fact that it causes an allergic reaction on the scalp which in turn alters the type of inflammation present in the skin and around hair follicles. By doing so, hair has the potential to grow because the immune system is no longer attacking it.

For years, DPCP treatments were exclusively done in highly specialized dermatology clinics. Fewer clinics are offering DPCP nowadways because of staffing issues (lots of nurses and physicians are needed!) and because many of the staff frequently becomes allergic themselves to the DPCP over time.

For many years, clinics have started offering patients the option of having the DPCP applied at home. Often a spouse, parent or friend will be trained to properly and safely apply the DPCP for the patient. This is frequently termed “outpatient” DPCP. Many clinics around the world, including ours have been supporting patients with “outpatient” DPCP for many years.

A recent study by Lee and colleagues showed that outpatient DPCP is just as safe as DPCP application in a dermatology clinic setting. This is great reassurance for the large numbers of patients who could potentially benefit from this much underused and often forgotten about treatment. DPCP can be safety applied at home provided patients and family members receive proper training on application techniques and safety principles.
 

Reference

Lee S et al. Home-based contact immunotherapy with diphenylcyclopropenone for alopecia areata is as effective and safe as clinic-based treatment in patients with stable disease: A retrospective study of 40 patients. J Am Acad Dermatol. 2018

Examining Hair Samples: Anagen vs Telogen Hairs

Anagen vs Telogen Hairs

How do we differentiate anagen hairs from telogen hairs? This photo shows both an anagen hair (bottom) and a telogen hair (top). Anagen hairs are darkly pigmented throughout the shaft. The characteristic feature is the massive number of cells known as “keratinocytes” that can be found in the area surrounding the bottom of the hair shaft. This is termed the root sheath. Anagen hairs have a root sheath.

Telogen hairs, on the other hand, lack pigment at the base and lack a root sheath. Most hairs, if not all the hairs, from a typical collection of hairs from a patient’s scalp are telogen hairs.

Examining Hair Samples: 4 Quick Things to Evaluate

4 Quick Things to Evaluate

Many patients bring in hairs in bags. These have been collected in a variety of ways including when combing, after shampooing (while blow drying) and sometimes in the shower or from a drain. I don’t typically need hair collection performed as a starting point in any evaluation but when hairs are brought in, I always look at them.

There are several things I want to know when I examine the bag of hair. Typically, I am less interested in the number of hairs when the “hair collection” is performed in a non-standard manner (ie not done via a five day modifed hair wash test protocol or not a 60 second comb test). However, the key information I do seek to gather includes:

1. How was the sample collected? (...was it pulled from the drain or from a brush)
2. When was the last shampoo or hair wash? (...does the hair in the bag represent 1 day of not washing or 1 week?)
3. Do I see any anagen hairs in the sample? (... anagen hairs are suggestive of a scarring hair loss condition and are extremely rare to be seen to see but easily confused by patients).
4. Do I see many broken hairs ? (... broken hairs can suggest damage from heat or chemicals, traumatic brushing, alopecia areata and rarely scarring alopecias). With these 4 questions, I can sometimes get a sense of whether something unusual might be happening in the scalp. If it is necessary to get a more quantitative evaluation of the numbers and types of hairs shed, I may ask patients to perform a “five day” modified hair wash test. This involves not shampooing for five days and then collecting all hairs on a gauze during a shampooing and rinse.
 

Hair Loss Vocabulary: Do We Use Words Appropriately?

Do We Use Words Appropriately?

The professional world that I live in (ie the “hair world”) loves words - all kinds of words.

Some of the words serve to make things a bit clearer. A “pustule” is a much better term than a little bump. Hair follicle “miniaturization” is a much better term than hair thinning. 
But words are not always effectively used. We seek to teach our junior doctors and students the importance of effective communication with patients. Yet, without realizing it, we continue to teach the value of miscommunication. For example, we train our physicians to use the term “erythema” instead of simply saying or writing the word “redness.” We train them to say “pruritus” instead of saying “itching.” Instead of saying “scarring” ...we often opt to use the word “cicatricial” instead. We inform our patients of options to administer “intralesional” steroids instead of simply calling them “steroid injections.” The list goes on and on.

Words must always keep the patient in mind.

It would appear that the term perifolliculitis capitis abscedens and suffodiens of Hoffman (yes, an actual disease!) to describe the scarring hair loss condition needs a bit of an overhaul. In case you didn’t know, the hair loss condition called lichen planopilaris has nothing to do with lichens.

When it comes to hair terminology, frankly we are all in a bit of a mess.

Some names are changing and not necessarily for the good of our patients nor our profession. Did you know that low level laser therapy is now known as photo biostimulation. Did you know that we no longer refer to “FUE” hair transplants by the name follicular unit extraction. It’s now called follicular unit excision. 

The dictionary of hair loss is filled with countless bizarre terms. Some terms are needed because there are simply no better terms to describe a given phenomenon. Not every term in hair medicine needs to be clear to patients and practitioners alike. But where possible, one must remember at the core of every phrase, term or word is a patient with hair loss. If we can make this alarming, confusing and perplexing world of hair loss a bit clearer by choosing our words to optimize communication.... why wouldn’t we?

Scalp Biopsies: Set Up

Set Up

A scalp biopsy is a short procedure performed under local anesthesia which allows a small 4 mm cylindrical sample of hair and skin to be obtained from the scalp.

A "punch" is a sharp circular instrument that allows a core of skin to be taken. Once the sample is removed from the scalp, it is placed in a liquid solution called formalin and then sent off to the laboratory. A suture (stitch) is generally placed in the scalp at the site where the biopsy was performed.

Scalp Rosacea: What Is It? How Do We Treat it?

What Is It? How Do We Treat it?

Rosacea is a common condition affected up to 10 % of individuals. Skin flushing, persistent redness of the face and prominent blood vessels are common.

It is increasingly recognized that "extra-facial" rosacea (rosacea at locations other than the face) is a true entity. Rosacea affecting the scalp is a diagnosis that is increasingly recognized.

Patients with scalp rosacea present with redness and burning. Up to 5 % of those with facial rosacea experience scalp rosacea. Doxycycline pills (shown here) can be effective for a proportion of patients with scalp rosacea.
 

Reference

Fortuna et al. A case of scalp rosacea treated with low dose doxycycline and probiotic therapy and literature review with therapeutic options. Derm Ther 2016; 29:249-51

Reducing Medication Dosing: Can I Reduce My Dose?

Can I Reduce My Dose?

The safest dose of any medication is no dose at all. However, that’s not usually possible, nor practical. Nevertheless, one must always ask the question “Can I reduce my overall dose?” In general, one must be careful about lowering doses of medications when treating androgenetic alopecia. Lower doses are not always as effective. Often I hear patients using minoxidil who think that going down to three times per weeks will allow them to maintain their results. The reality is that it seldom does. For oral medications (like finasteride for men) it may be possible to skip a dose once or twice per week without negative consequences. This is not possible for everyone.

For those with alopecia areata, one can lower doses when hair starts growing well. Topical steroids can be a few times per week rather than daily once hair is growing well. Steroid injections are reduced to every few months. Oral medications are reduced as well.

For scarring alopecia, medications can also be reduced once the disease comes under control. A patient using hydroxychloroquine (Plaquenil) might go from twice a day to once a day and eventually twice a week.

Medication dosing is a bit of an art and one must always consider whether they can or can not reduce their dosing. In general, once diseases like alopecia areata and scarring alopecias come under excellent control one can consider reducing the dose at some point.
 

Frontal Fibrosing Alopecia: Importance of Skin Color Changes

Importance of Skin Color Changes

Frontal fibrosing alopecia ("FFA" for short") is an autoimmune scarring hair loss condition that affects mostly peri menopausal and post menopausal women (most commonly). Individuals with

FFA experience loss of the frontal hairline and frequently eyebrow, eyelash and body hair loss as well.

The appearance of the scalp and the remaining hair follicles in the scalp are diagnostic in most cases. A biopsy is not always needed but is helpful in challenging cases.

The hair follicles are surrounded by redness (perifollicular erythema) and less commonly also scale (perifollicular scale). When one looks closely, a border can generally be seen between the unaffected skin of the forehead and the shiny, smooth atrophic skin of the area affected by FFA.

Many different types of treatments are available including topical steroids, steroid injections, topical calcineurin inhibitors, oral doxycycline, oral hydroxychloroquine, oral finasteride, oral dutasteride, oral methotrexate, oral isotretinoin, oral tofacitinib, oral mycophenolate. Benefits of lasers, including excimer and low level lasers continue to be explored.
 

Dissecting Cellulitis: Early Disease can look like Alopecia Areata

Early Disease can look like Alopecia Areata

Dissecting cellulitis (DSC) is an uncommon hair loss condition characterized by boggy draining areas on the scalp. These areas frequently leave behind permanently scarred areas.

It is not difficult to recognize "classic" or well developed areas of dissecting cellulitis. The areas are weepy, draining pus and the patient is uncomfortable (often with itching, burning or pain). In early disease, where sinus tracts and skin breakdown might not be seen (or where they have healed) it is more challenging to detect DSC.

These areas can often resemble alopecia areata and may even be skin colored in some cases rather than red.

Treatment for dissecting cellulitis includes agents such as isotretinoin, antibiotics, TNF inhibitors as well as other treatments.