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QUESTION OF THE WEEK

Dr. Donovan's Articles

QUESTION OF HAIR BLOGS



Hair Loss and The Use of Relaxers

Relaxers May be Associated with Many Kinds of Hair Loss

I just posted a new answer to our “Question of the Week.” I was asked to outline how best to treat hair loss from relaxers.

The full answer to this week’s question can be read here:

Hair Loss from Use of Relaxers

To submit a new question for consideration of our Question of the Week, simply visit complete our online form


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Is Hydroxychloroquine (Plaquenil) an Immunosuppressant?

Hydroxychloroquine (Plaquenil) Increases the Risk of Shingles.


Hydroxychloroquine (Plaquenil) is an oral medication that is commonly used in the treatment of many types of autoimmune conditions including lichen planopilairs, frontal fibrosing alopecia, discoid lupus and pseudopelade. I’m often asked if hydroxychloroquine is an immunosuppressant or best classified as an immunomodulatory drug.


Hydroxychloroquine (Plaquenil) Is an Immunosuppressant.

In my opinion, Plaquenil is best considered an immunosuppressant. It’s true that it’s different than other immunosuppressants like methotrexate or cyclosporine. It does not seem to predispose to cancer development but does predispose to some infections. Two studies have shown that shingles (herpes zoster) is increased in hydroxychloroquine users. That’s where we’ll turn to today.


Liao TL et al, 2017

In 2017, Liao and colleagues set out to determine the risk factors and outcomes of herpes zoster (shingles) among patients with RA. The researchers found that exposure to Plaquenil was associated with a two fold increased risk of developing shingles (aOR=1.95, 95% CI 1.39 to 2.73, p<0.001)). Other immunosuppressants were also associated with an increased risk including corticosteroids (≥10 mg/day adjusted OR (aOR)=2.30, 95% CI 1.25 to 4.22, p=0.01), anti-tumour necrosis factor biologicals (aOR=2.07, 95% CI 1.34 to 3.19, p=0.001) and conventional synthetic disease-modifying anti-rheumatic drugs (methotrexate (aOR=1.98, 95% CI 1.43 to 2.76, p<0.001). To read the paper yourself, simply click on the link below.


Hu SC et al, 2016

In 2016 another study by Hu and colleagues published in the Journal of the American academy of Dermatology set out to address a similar question. Rather than studying rheumatoid arthritis patients, the researchers evaluated the risk of zoster (shingles) in patients with lupus (SLE) treated with different immunosuppressants. The authors found that hydroxychloroquine use did increase the risk of shingles. In fact, the risk was dependent on dose with patients using higher doses having slightly higher risk of shingles. Other medications associated with greater herpes zoster (shingles) risk in patients with SLE included oral corticosteroids, intravenous methylprednisolone, oral cyclophosphamide, intravenous cyclophosphamide, azathioprine, methotrexate, and mycophenolate mofetil.


Conclusion

Hydroxychloroquine (Plaquenil) appears to increase the risk of shingles in patients with Rheumatoid arthritis and patients with lupus. Whether it increases the risk in patients with scarring alopecia has not been studied but there is no reason to believe it should not. By virtue of affecting the risk of shingles, it would seem quite reasonable to classify hydroxychloroquine as a true immunosuppressant.



REFERENCE


Liao TL, et al. Risk and severity of herpes zoster in patients with rheumatoid arthritis receiving different immunosuppressive medications: a case-control study in Asia. BMJ Open. 2017.

Hu SC, et al. Immunosuppressive medication use and risk of herpes zoster (HZ) in patients with systemic lupus erythematosus (SLE): A nationwide case-control study. J Am Acad Dermatol. 2016.




This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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TNF inhibitor induced AA: Adalimumab Infliximab Etanercept

Adalimumab Infliximab Etanercept

TNF in AA.png

Recent research in the past decade has shown the TNF inhibitors can rarely contribute to the development of alopecia areata as well as other types of hair loss as well (ie psoriatic alopecia and scarring alopecias). Alopecia areata has been reported with all three anti-TNF agents including adalimumab, etanercept and infliximab. To date, the most common TNF-inhibitor implicated is adalimumab followed by infliximab and etanercept.

In affected patients, hair loss can occurs with a matter of months to many years after the TNF agent is started. Of all the reports in the medical literature to date, onset in affected patients may occur fastest with adalimumab (6.8 months average) compared to over 1 year with the other 2 agents. The degree of hair loss varies greatly from patchy type AA to alopecia totalis and universalis.

Optimal treatment for TNF inhibitor induced AA is not clear. Some patients have improved their hair by stopping the TNF inhibitor although a smaller proportion may improve even with continued use of the TNF inhibitor. The option with the highest chance of success in terms of stopping hair loss and regrowing hair appears to be stopping the anti-TNF agent.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Sebhorrheic Dermatitis in LPP: Is it more common than we think?

Is it more common than we think?

sd in lpp.png

Current evidence would suggest that a greater proportion of patients with lichen planopilaris (LPP) have seborrheic dermatitis compared to people in the general population. For example, about 5% of people in the general population have seborrheic dermatitis compared to about 50% of patients with LPP.

In 2016, Berfeld’s group at the Cleveland clinic studied the incidence of seborrheic dermatitis in patients with lichen planopilaris. This study is important to understand as it was one of the few studies to date which really documented the increased incidence of seborrheic dermatitis in patients with LPP.

The study was a retrospective review of 246 patients seen over the period 2004-2015. Interestingly seborrheic dermatitis (SD) was present in 46.2 % of LPP cases. In 27.4 % of cases the SD was found outside the area affected by the LPP. On average the SD was diagnosed 7.8 months prior to the LPP diagnosis.

Having SD seemed to delay an actual diagnosis of LPP. Patients with both SD and LPP diagnosis (LPP-SD) received their diagnosis with significantly more delay than patients with LPP who did not have SD (ie LPP). For example, patients with LPP-SD received their diagnosis in 7.6 months on average compared to 2.3 months for LPP alone.

Whether SD actually plays a role in the scarring process as well remains to be determined. It is interesting that there was a greater prevalence of late stage scarring alopecia in ptient with LPP-SD than LPP alone (41.5 % vs 15.7%). On account of seborrheic dermatitis being so common in LPP, it makes sense that many people with LPP will feel better and gain at least some relief of their itching with use of antidandruff shampoos.

Reference


Ratnaparkhi et al. Association of lichen planopilaris with seborrheic dermatitis l: A retrospective case-control study. Poster 3727. JAAD May 2016.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Early Alopecia Areata: Subtle Findings

AA subtle signs.png

Subtle Findings

Alopecia areata is an autoimmune disease that affects 2 % of the world. Most people develop small round or oval patches of hair loss when the disease first occurs. In the very earliest stages however, the clinical findings may be more subtle until sufficient time has elapsed for the actual circles of hair loss to form.

The earliest stages of alopecia areata may be associated with increased shedding of hair compared to the normal rate of shedding. Some shed hairs may be broken as well. Many patients with alopecia areata are asymptomatic although a proportion will note the presence of burning or itching prior to the hair loss.

Up close dermatoscopic examination, as shown here, may reveal reduced density as well as exclamation mark hairs (blue arrows), tapered hairs or black dots. Over time, the more classic findings typically emerge making the diagnosis much easier. 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Scarring (Cicatricial) Alopecia: Signs of Follicular Injury

Signs of Follicular Injury

Scarring alopecias are a group of hair conditions associated with the formation of scar tissue beneath the scalp. This scar tissue damages the hair follicle and affects how it emerges from the scalp. Minor degrees of follicular injury can give twisting of hairs known as pili torti. Severe injury to hairs such as shown here leads to highly curled hairs. This type of coiling is seen in scarring alopecias as well as in some post op hair transplants in which hairs were subjected to extreme injury during the procedure (especially FUE procedures).

SA -follicular injury.png

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

Ingrown hair

ingrown hair.png

Ingrown hairs occur when the distal or end portion of a hair follicle curves back into the scalp. Ingrown hairs can occur for a variety of reasons the most common being seen in individuals with coarser and curlier hair. Ingriwn hairs are seen in some individuals after shaving, and may also be seen in the context of some localized infections and folliculitis. Scarring alopecias such as dissecting cellulitis are more commonly associated with ingrown hairs than other scarring alopecias. Here an ingrown hair is seen in a patient with lichen planopilaris (LPP). Treatment includes removal of the hair from under the skin and treament of the associated inflammation or infection.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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MTHFR Polymorphisms (677T allele, etc) and Hair Loss

MTHFR Mutations, Polymorphisms and Hair Loss

I just posted a new answer to our “Question of the Week.” I was asked to explain what is currently understood about MTHFR gene mutations and hair loss.

The full answer to this week’s question can be read here:

MTHFR Gene Mutations and Hair Loss: Is there a link?

To submit a question, simply visit complete our online form


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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How can I be balding if I have no family history?

The patient without a family history of AGA

fhx

Clinical studies have taught us over and over that what patients report is not always reflective of the reality. For example, patients in research studies frequently overestimate their height; other parameters like weight and family histories of a range of conditions are often inaccurate. 

Information we receive from patients about the patterns and degree of hair loss in their family must always be cautiously interpreted. Patients generally underestimate the degree of balding in the family. They may not mean to, but they often do. A patient who says “nobody in my family has balding” may be correct. I would estimate that 30 % -50 % of the time they are correct but 30 % -50 % of the time they are not.

Here are some scenarios to consider:

1) Some patients truly don’t have a strong family history and this reflects that fact that for some genetics is far more complex than we understand.

There are certainly some patients that just don’t have a strong family history. They are right on when they say “Dr. Donovan, nobody in my family is balding, so why am I balding?” This scenario arises more commonly in a female patient than a male patient and reflects that fact that genetic hair loss is pretty complex in how it develops. The genetics is not so simple for some.

2) The patient thinks they don’t have a family history (but they actually do) because they perceive balding as normal, especially in men.

There are some patients I see who truly feel they don’t have a strong family history. Some may be quite adamant about the whole thing. When I ask for any recent photos of grandparents, or uncles, they pull out their phones and show me the family.

What I often see is an elderly gentleman - let’s say the grandfather - with some pretty typical male balding. Not all that advanced mind you, but massive reduced density than he would have had at age 16. This is genetic hair loss. Careful examination of the photos off other members of the family may show similar patterns. This is androgenetic alopecia.

Patients often ask me “I know grandfather is thinning but, isn’t this just normal hair loss?”

To this I might reply “It’s certainly normal to see this pattern of hair loss in many men because genetic hair loss is so common - but there is no such thing as normal hair loss.”

Many patients perceive hair thinning in their parents and grandparents as normal and don't often attribute it to androgenetic alopecia.

3) The patient thinks they don’t have a family history (but they actually do) because they really never thought about it.

The next scenario sounds similar to the above, but it’s actually quite a bit different because the patient has never really thought carefully about the patterns of loss in their family.

When I ask for any recent photos of grandparents, or uncles, they pull out their phones and show me the family. Again, what I often see is an elderly gentleman - let’s say the grandfather - with some pretty typical male balding. Not all that advanced mind you, but massive reduced density than he would have had at age 16. This is genetic hair loss. Careful examination of the photos off other members of the family may show similar patterns. This is androgenetic alopecia.

The scenario might be even more direct. Sometimes the patient has a family member with them right then and there in the examination room. Dad or mom might be sitting right next to the patient when the patient asks me:

How can I have genetic hair loss when my dad here has good hair?

Often I will explain (with permission of the father), “Well, your father has some genetic hair loss too

Patients are often surprised to learn that members of their family have androgenetic alopecia. They never really thought about it. They might see their parents or grandparents or uncles or aunts or grandmothers countless number of times and never really clued in to the fact their their hair has thinned.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Telogen Effluvium (TE): Look for the Triggering Event (TE)

Look for the Triggering Event (TE)

TE-triggering.png

Telogen effluvium (TE) is a hair shedding disorder whereby the affected individual notices increased daily hair loss. Minor TE’s might give a few more hairs in the sink or brush than one normally sees. A massive TE is associated with loss of hundreds and hundreds or hairs.

To fully understand telogen effluvium, one must understand the concept of the triggering event (TE). In other words, anytime a health care provider makes a diagnosis of TE they need to force themselves to think of what the triggering event (TE) or events might be. TE requires a search for the TE!

There are well over 2000 potential triggers of TE. At first it seems almost impossible to sort through all 2000 causes. Fortunatley, the most common triggering events can be classified in 7 big categories including

1) Low iron (ferritin) levels
2) Thyroid and other endocrine problems
3) Stressful life events
4) Poor diet
5) Weight loss and crash diets
6) Medications
7) Illnesses inside the body
8 Inflammatory scalp diseases like seborrheic dermatitis, lupus or psoriasis

This list is helpful as one sorts through potential triggering events. Unfortunately, in some cases one does not find the triggering event despite a methodical search through all these causes. One must in these cases either search deeper, ask more questions, order more tests or wait until the cause becomes apparent. Sometimes it never does which speaks to the limitations we have in the present day. 
Treatment of TE is centered entirely around trying to deal with the triggering event. If iron levels were low, they must be replenished. If a thyroid problem was identified, it must be addressed. If the patient’s diet is poor, it must be improved. 
In cases where we can’t find a trigger sometimes the shedding resolves on its own after some extended period of time. In other cases, treatment with non specific agents like minoxidil or laser helps reduce shedding and helps the hair stay “better glued” to the scalp.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Telogen Effluvium or Androgenetic Alopecia: Which do I have?

Do I have AGA or TE?

Androgenetic alopecia and telogen effluvium are both common diagnoses in women. They can look very similar in some cases which makes the proper differentiation just a bit more challenging. Not a day goes by the someone doesn’t say to me “Dr. Donovan, I just need your help to figure out if I have TE or AGA.” 

To this, I typically reply “What you meant to say I’m guessing is Dr. Donovan, I just need your help to figure out if I have TE or AGA or I have both of these or I have something else altogether.


Many times, in return, I just receive a stare.


What could be causing my increased shedding?

You see, there are 7 possibilities that exist when a female patient notices she’s shedding more than normal:

1) the patient’s shedding is from TE as the sole diagnosis 

2) the patient’s shedding is from AGA as the sole diagnosis 

3) the patient’s shedding is from both AGA and TE

4) the patient’s shedding is from TE plus another diagnosis besides AGA 

5) the patient’s shedding is from AGA plus another diagnosis besides TE

6 )the patient’s shedding is from AGA plus TE plus another diagnosis  

7) the patient’s shedding is from neither AGA or TE but rather has a hair loss condition like scarring alopecia or alopecia areata the looks identical sometimes to TE.

Conclusion

The question about TE vs AGA is a good one. But one does themselves a great amount of harm by being so closed minded as to think they are choosing between the two. There are seven possibilities! A careful review of the patient’s history, together with an examination of their scalp and review of blood tests will help determine which of these seven possibilities are the real answer.


 





This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Telogen Effluvium (TE): Patient Stories Teach A Great Deal

Patient Stories Teach A Great Deal

TE pts tell alot.png

Telogen effluvium (“TE”) refers to a type of hair loss whereby the affected individual notices more hair being shed from the scalp on a daily basis than he or she normally would have.

For example, an individual who might have once lost 35 hairs per day might now lose 75; an individual who once lost 50-60 hairs per day might now lose over 200. Telogen effluvium can be associated with either minor shedding or major shedding. Some more severe effluviums can give 400-700 hairs lost on a given day.

If one listens carefully to a patient’s hair loss story, it becomes clearer as to just how severe of a shed they are having. A patient who finds more hair in their brush or more hair in their hand after a shower might be having a mild TE. A patient who sees dozens of hairs on their pillow when they wake up in the morning or who sees hair in their food at dinner time, is likely having a more severe TE. 


Common causes of telogen effluvium include low ferritin (iron levels), thyroid abnormalities, poor diets, weight loss and crash diets, stress and some type of medications. A variety of illnesses in the body can also trigger shedding.


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

Side Effects of Hair Loss: The ‘Whatif’

In my clinic, a “whatif” is used as a condensation of the words “what & if”. Individuals with hair loss often spend a great deal of time & energy thinking about various “whatifs” and what they will say or do in certain situations.

whatif


Whatifs are Less Common than We Want to Believe.

The reality is “whatif” events don’t happen as often as our mind wants to believe they should and even if such events do occur they are typically far less severe than the mind first prepared itself to imagine.

One of the many goals of the treating physician is to help reduce the number of minutes, hour and days a patient spends contemplating all the “whatifs.”


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Seasonal Hair Shedding: Which Season has Greater Shedding?

Which Season has Greater Shedding?

seasonal shedding.png

Do humans really shed different amounts of hair at different times of the year? That answer, in several studies, has been a resounding yes.

Studies to date would suggest that humans tend to shed the most in late Summer and early Fall. That's the seasonal time period whereby humans experience the greatest daily hair shedding. Seasonal shedding is one type of “telogen effluvium.”

Some studies have suggested that another important wave of increased shedding occurs in the Spring, whereas other studies have suggested Spring is distant fourth place (behind Fall and Winter). Seasonal shedding is important to remember for a few reasons.

First, if a patient with pre-existing hair loss is experiencing more shedding in the late Summer and early Fall it may or may not be that their underlying condition is getting worse. The increased shedding may simply be a result of seasonal shedding. This of course requires careful scalp examination and review of the patient’s details. Furthermore, if one starts a new treatment in Fall and notices by early Spring that shedding is less and density is better... one must ask if the treatment was responsible for the improvement or whether the hair have just gotten better anyways on account of the late Summer/Fall seasonal shedding coming to an end.

Reference

Courtois M et al. Periodicity in the growth and shedding of hair. Br J Dermatol 1996; 134;47-54.

Hsiang et al. British Journal Dermatology 2017.

Kunz M et al. Seasonality of hair shedding in healthy women complaining of hair loss. Dermatology 2009; 219: 105-10.

Randall CA and Ebling EJG. Seasonal changes in human hair growth.  Br J Dermatol 1991; 124: 146-51.

Liu C et al. Changes in Chinese hair growth along a full year. Int J Cosmet Sci . 2014 Dec;36(6):531-6.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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What are the important features of a biopsy report?

TOP 10 FEATURES IN A GOOD BIOPSY REPORT

I just posted a new answer to our “Question of the Week.” I was asked to explain the key features that I look for in a biopsy report that tells me immediately that this is a good report.

The full answer to this week’s question can be read here:

What features do you look for in a good biopsy report?

To submit a question, simply visit complete our online form


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Do I Have Frontal Fibrosing Alopecia? : Vellus hairs in hairline may mean "no"

Vellus hairs in hairline may mean "no"

ffa-hairline.png

Frontal fibrosing alopecia (FFA) is a scarring alopecia that affects women to a greater extent than men. Affected patients typical lose hair along the frontal hairline but many different areas can be involved including the back of the scalp, the eyebrows, eyelashes and body hair.

FFA is becoming more common. The incidence is increasing worldwide for reasons that are not entirely clear. Both physicians and the geineral public are coming to better recognize the condition. Nevertheless, challenges still exist with it’s early recognition as well as in differentiating it from some types of androgenetic alopecia and alopecia areata.

One of the important features of FFA when viewed using a dermatoscope is that the FFA disease process generally destroys the tiny vellus hairs that are seen readily in the frontal hairlines of women. Such tiny vellus hair becomes even more prominent in patients with androgenetic alopecia.

If ones sees an abundance of vellus hairs under dermoscopy, it is less likely that FFA is a diagnosis to consider. This photo shows the frontal hairline of a patient with androgenetic alopecia. Vellus hairs are preserved.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Alopecia Areata: How active is it?

How active is it?

Alopecia areata is an autoimmune condition that affects up to 1.7 % of the world’s population.  In the early stages (called ‘acute’ alopecia areata), inflammation is present in the skin at the bottom of hair follicles that inflammation causes these hair follicles to be lost.

There are many “trichoscopic” (dermatoscopic) features of alopecia areata, including broken hairs, yellow dots, black dots, exclamation mark hairs, tapered hairs. 
In the early stages of alopecia areata, one can often gather a great deal of information about a patient’s chance of regrowth over the next few months by careful examination of the scalp.

Consider the patient with a patch of hair loss shown in the photo. Numerous white hairs are present in color indicating that a large proportion of the hairs are trying their best to grow. The hairs are white because the immune system has affected the pigment producing cells in the hair follicles making it difficult for them to add pigment into the follicle. (The hair first tries to remember how to make a hair fiber and then tries to remember how to add pigment to it). The yellow arrow shows an exclamation mark hair indicative of active disease.

The green arrow in the photo points to small regions of the white hairs that do in fact contain pigment. This is a nice reminder to me that these particular hairs are not too far off from producing thicker, longer, and fully pigmented hairs. In this particular patient, the chances of hair growth with steroid injections was estimated at well above 80 %... and fortunately the patient returned back to clinic with marked growth.

Alopecia areata is an autoimmune condition that affects up to 1.7 % of the world’s population.  In the early stages (called ‘acute’ alopecia areata), inflammation is present in the skin at the bottom of hair follicles that inflammation causes these hair follicles to be lost.

There are many “trichoscopic” (dermatoscopic) features of alopecia areata, including broken hairs, yellow dots, black dots, exclamation mark hairs, tapered hairs. 
In the early stages of alopecia areata, one can often gather a great deal of information about a patient’s chance of regrowth over the next few months by careful examination of the scalp.

Consider the patient with a patch of hair loss shown in the photo. Numerous white hairs are present in color indicating that a large proportion of the hairs are trying their best to grow. The hairs are white because the immune system has affected the pigment producing cells in the hair follicles making it difficult for them to add pigment into the follicle. (The hair first tries to remember how to make a hair fiber and then tries to remember how to add pigment to it). The yellow arrow shows an exclamation mark hair indicative of active disease.

The green arrow in the photo points to small regions of the white hairs that do in fact contain pigment. This is a nice reminder to me that these particular hairs are not too far off from producing thicker, longer, and fully pigmented hairs. In this particular patient, the chances of hair growth with steroid injections was estimated at well above 80 %... and fortunately the patient returned back to clinic with marked growth.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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"I See New Hairs" What do new hairs indicate?

What do new hairs mean?

new hairs.png

New hairs are wonderful to see because they remind us of what we are often hoping for - hair regrowth!

But new hairs can mean several things. Sometimes they indicate overall regrowth and a trend towards a patient experiencing an improvement, but not always.

The appearance of new hairs can mean:

1. Regrowth with treatment. This usually meNs density will likely get better over time.
2. Regrowth of a vellus hair. In androgenetic hair loss, these hairs just stay small and the patient gets no improvement in density. In this case the new hairs seen do not signify a positive sign.
3. Regrowth in telogen effluvium. In telogen effluvium, there are more new hairs on the scalp than normal because the once shed hairs have returned. If the “trigger” for the telogen effluvium has been discovered and treated the hair density may increase. If the trigger has not been found the density won’t increase and these new little hairs may eventually fall out prematurely.
4. Regrowth of a sick struggling hair in scarring alopecia. Small hairs, similar to the one shown in the photo can be seen in scarring alopecias as well. These hairs are doing their best to grow but are too injured from all the surrounding inflammation and scar tissue to keep growing. They eventually fall out. 
5. Regrowth in alopecia areata. A large number of regrowing hairs is generally a good sign. Sparse regrowing hairs is not and may mean the disease is still active.
6. Normal regrowth. Hairs are always growing on the healthy scalp. A new hair can be found on the vast majority of people’s scalp.

New regrowth is exciting. It is important to understand that this may mean something good and positive, but it may not. Many patients see new hairs and notice over time their hair density improves. Other patients see new hairs and are surprised to discover that the hair is not improving.


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

Pohl Pinkus Constrictions in Alopecia Areata

Pohl Pinkus.png

Pohl Pinkus constrictions refer to periodic constrictions in anagen hair follicles that are seen in patients with alopecia areata. They are also called “monilethrix-like” constrictions as well because they hairs resemble the hairs seen in the genetic condition monilethrix.

The constricted areas occur because the hair follicle matrix (which produces the hair follicle) enters into a period of reduced keratin synthesis on account of the abundant inflammation present in the scalp.

Constrictions seen in the follicle remind us that the inflammatory activity was high during that particular period of time. Constricted areas are notably weaker and hair breakage often occurs at these areas.  The areas within the Pohl Pinkus constriction may also be lighter in color because of reduced melanin transfer into hair follicles as well.


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