Mattel to Design Friend of Barbie with Alopecia

Mattel Inc, the makers of the Barbie doll, announced last week that they would be designing a doll without hair in order to support children with cancer or alopecia.

An important driving force for Mattel to create the doll comes from a Facebook group “Beautiful and Bald Barbie.” The group was founded by Jane Bingham of Sewell, New Jersey after she lost her hair during cancer chemotherapy treatment and realized how upset it made her 9 year old daughter. The group petitioned Mattel to produce a doll without hair.

The Facebook group originally declared their goals on their Facebook page long before Mattel took note:

We would like to see a Beautiful and Bald Barbie made to help young girls who suffer from hair loss due to cancer treatments, alopecia or trichotillomania. Also, for young girls who are having trouble coping with their mother’s hair loss from chemo. Many children have some difficulty accepting their mother, sister, aunt, grandparent or friend going from long-haired to bald.

The Mattel company has announced that the doll will come with wigs hats and scarves.  The doll won’t be sold in stores but rather Mattel will donate the dolls to children’s hospitals in the United States and Canada as well as the National Alopecia Areata Foundation. For now, it will be difficult for young children with parents who have alopecia from chemotherapy or parents with alopecia areata to get a doll, but that could possible change in the future. For now, the dolls are only given to children with hair loss from cancer chemotherapy, alopecia areata (areata, totalis and universalis)  or trichotillomania.

Although the news release has been met with some criticism, there are certainly many benefits of a doll for children with alopecia and for children with parents or relatives with alopecia.  Talking about hair loss can be difficult for many people and talking about it openly can sometimes be difficult. This doll has the potential to open up conversation not only between parents and young children but with other siblings and friends as well. I have many young 2-6 year old girls in my practice who love and adore their dolls with hair and use the doll as source to open conversation with their parents, grandparents or friends.  I can only image how a doll without hair will further help young children cope with their hair loss.

The dolls will likely be distributed to children in early 2013.

New Health Canada Warnings about Finasteride, Dutasteride and Prostate Cancer

Prostate cancer is one of the most commonly diagnosed cancers in men. In fact, about one in six men will be diagnosed with prostate cancer. One new case of prostate cancer occurs every 2.2 minutes and a man dies from prostate cancer every 15.6 minutes.

Health Canada released a statement last week about the possible increased risk of “high-grade” (aggressive) prostate cancer in men taking the drugs finasteride and dutasteride.  Both of these drugs are used to treat male balding but are also used to treat men with enlarged prostate glands. Large numbers of my patients have asked me about the Health Canada statement in the past weeks –  Click on the link to read more about the Health Canada statement.

READ THE HEALTH CANADA STATEMENT

In order to understand the meaning of the Health Canada warning about finasteride and dutasteride, it’s important to have some background information.  First, it’s important to know that there were TWO very large studies conducted a few years ago (one in 2003 and one in 2008) looking at whether finasteride and dutasteride could actually help prevent prostate cancer in men. 

The two reserach studies are:

STUDY 1: Prostate Cancer Prevention Trial (or ‘PCPT’ Trial)

• This was a 2003 study of 18,000 men over 55 years of age
• This study showed finasteride reduced the risk of men getting prostate cancer by 25 %
• There was a slight increased in high grade (more aggressive) prostate cancers in men who took the drug compared to those who took the placebo (sugar pill)
• The dose of finasteride in this study was  five times higher dose of finsasteride than used for hair loss (i.e. 5 mg rather than 1 mg)

STUDY 2: Reduction by Dutasteride of  Prostate Cancer Events (or REDUCE Trial)

• This was a study in 2008 of over 6700 men age 50 to 75
• Over the 4 years of the study, there as a 23 % reduction in prostate cancer in men who took the drug
• There was a slight increase in high grade (more aggressive) prostate cancers  in year 3 and 4 in men who received the drug compared to men who received the placebo (sugar pill) but overall the raw data showed there was no increase risk of high grade cancers throughout all years of the study.
• The dose of dutasteride was the same as used for hair loss (i.e. 0.5 mg)

THINGS THE PUBLIC SHOULD BE AWARE OF:

• The data from these two studies is complicated to interpret
• There is no question whatsoever that finasteride and dutasteride both reduce the risk of men getting prostate cancer.
• What is not entirely clear is if these two drugs increase the chance of men getting a "high grade" cancer.  It’s possible that for every four low-grade (non aggressive cancers) that these drugs prevent, there is one high grade cancer that gets detected while on the drug.

But do these drugs make it "easier" to detect a cancer that would have otherwise escaped detection?

OR

Do these drugs actually contribute to the development of the prostate cancer?

The answer to these questions is not known with complete certainly.  There are several explanations as to why more high grade prostate cancers were detected in men who took the drug.  For the most part, most authorities in prostate cancer do not believe there is a cause for alarm. In fact, the number of world authorities on prostate cancer who believes there could be a link between finasteride and prostate cancer is greatly outnumber by authorities who feel there is no link whatsover.  This includes Dr Otis Brawley, Chief Medical Officer of the American Cancer Society and Dr Neil Flesher, Head Division of Urology at the University Health Network and Professor of Surgery at the University of Toronto. The public needs to know this information is not cut and dry.

FINAL THOUGHTS

• If there is any risk of high grade prostate cancer with these drugs (again, we can't say for sure there even is).... the risk is very small.
• The public should be aware that the new Health Canada warnings do not state that finasteride or dutateride causes high grade prostate cancer. Rather, the warning states that there could be a link and more studies are needed.
• The studies discussed above were conducted with five times higher dose of finsasteride than used for hair loss (i.e. 5 mg rather than 1 mg).  Therefore, Propecia (finasteride 1 mg) was not included in these studies
• The dose of dutasteride in these studies was the same as used for hair loss (0.5 mg)
• Individuals with concerns about these drugs should speak to their doctors

 

Breakthrough in Baldness? Blocking the Prostaglandin D2 Pathway May be the Answer

We know that balding in men is due to a complex interplay of genetics and hormones. But recently there has been some exciting research looking at the role of "stem cells" in male balding.  Hair follicle stem cells are cells that theoretically can give rise to massive numbers of new hairs. This stem cell research is important since male balding affects nearly 50 % of men by age 50 and 80 % of men by age 70.

A few months ago, I wrote a blog about exciting  research discoveries  by Dr. George Cotsarelis and his group at the University of Pennsylvania.   At that time, the researchers showed that "bald" scalp surprisingly contains the same number of stem cells as "non bald" areas of the scalp. What was different was that bald areas of the scalp had fewer progenitor cells (or cells derived from stem cells that actually develop into new hair follicles).

With this discovery presented to the medical world, the researchers then set out to ask the next key question:

 Why do bald areas have fewer progenitor cells?

 Is it because something inhibits them from developing?

 or is it because they can’t be properly activated?

Last week, Dr. Cotsarelis and his team published some new reserach in the journal Science Translational Medicine.  Like the previous study, this was a major breakthrough in our understanding of the balding process.

What did the researchers find?

The  researchers again compared areas of balding scalp to areas of hairy (non-balding) scalp.  They found that the bald tissue had elevated levels of a protein called “Prostaglandin D2.”  In fact, when they studied 17 men with balding, they found that PGD2 protein levels were 3 times higher in bald areas than non-bald areas. In further experiments, it was shown that prostaglandin D2 was extremely important – in fact, when PGD2 was added to hair follicles in a petrie dish, the hairs stopped growing.  Moreover, Dr. Cotsarelis’ group identified the exact receptor that Prostaglandin D2 needs to bind to in order to produce it’s effects (a receptor called GP44).

So can we block the PGD2 protein and cure male baldness?

That answer is not know but one of the real exicting aspects of Dr. Cotsarelis’ study is that drugs that block PGD2 are already in development. In fact, the Merck company has a drug to treat facial flushing called "laropiprant" that blocks the protein and Actelion has a drug called "setipiprant"  to treat allergies that also affects the protein.  

What is the next step in developing new hair loss drugs?

There is no doubt that drugs that block PGD2 (or the GP44 receptor) will now be studied more intensively. But whether such drugs will help stop or reverse the balding process is not yet known. It’s also not known if such drugs would have benefit in women with genetic hair loss because only men were studied in Dr. Cotsarelis’ study. We know that the process of genetic balding in women is more complex than in men, so it may or may not have the same benefits.

I think we’ll be seeing more and more research about the role of prostaglandins in hair loss. A drug analogue of Prostaglandin F2 alpha (marketed under the name Latisse) is known to improve eyelash growth in women and may also help some individuals with eyebrow loss too. Now we have evidence that blocking prostaglandin D2 might also help hair growth. The prostaglandin pathway may have promise for new drugs to treat hair loss!

Hair Transplantation: Not Only for Genetic Hair Loss

One of the most common reasons that I perform a hair transplant is to restore hair density in men and women with with androgenetic alopecia (genetic hair loss). In addition to androgenetic alopecia, there are many other reasons why a hair transplant can be performed.

Hair restoration is possible:

• For men and women with androgenetic alopecia
• For some types of inactive (quiet) scarring alopecias
• To treat traction alopecia (hair loss from tight pulling of hair)
• To lower a congenitally high forehead
• To improve eyebrow density
• To restore hair density in those with burns
• To restore hair density in those with hair loss from facial cosmetic surgery
• To restore hair density in those with hair loss from radiation therapy for brain tumors

Although hair transplantation can be a good option for many different types of hair loss, it is not an option for all types of hair loss. Patients with alopecia areata, telogen effluvium, chronic telogen effluvium and active scarring alopecia are not able to have a hair transplant. In these conditions, the hairs would not grow following a hair transplant.

Scarring Alopecia - Why is it Challenging to Diagnose in Early Stages?

Scarring Alopecia: Diagnosis May Be Challenging In Early Stages

It's hard to imagine that there are over 100 reasons to lose hair.

Some types of hair loss appear very distinctive - and so it's quite easy to identify the cause. Most people recognize that a man who is balding at the top of the scalp has genetic hair loss. Similarly, most people know that a woman who loses hair a few months after delivery of a baby has a temporary hair shedding problem related to hormonal changes after pregnancy.

Are all hair loss conditions so straightforward to diagnose?

Some types of hair loss conditions are more challenging to diagnose than others. Certainly this is the case for a group of hair conditions known as scarring hair loss conditions or "scarring alopecias."  In the very earliest stages of scarring alopecia, patients can have a pattern of hair loss that looks just like genetic hair loss or age-related hair loss.  It's for this reason that patients are often surprised to learn their diagnosis.

"I thought I was losing hair for the same reason my father lost hair," many patients say.

What are scarring alopecias?

Scarring alopecias are a group of hair conditions that cause the body to form scars around the hair follicles. This causes the hairs to be permanently damaged and if the process continues - it also causes the hair follicles to be permanently lost.   In the early stages of the condition, individuals may have hair shedding, as well as scalp symptoms like itching, burning or pain.  It requires a physician who is knowledgable about these conditions to 'catch' the diagnosis and this stage.  If the condition continues untreated, areas of scarring and permament hair loss may develop. It's at this stage that scarring alopecia is more easily diagnosed.

The goal of diagnosis is to try to catch these conditions at the earliest possible stages.

A New Video on Scarring Alopecia

Every week, Monica Matys of Toronto's Sunnybrook Hospital produces a video blog and posts it on the Sunnybrook Medical Centre website. These blogs provide incredible insights into various health conditions and what patients experience.  In January 2012, Monica produced a segment specifically on scarring alopecia.  As with previous videos that Monica has produced, we've been getting a lot of positive feedback.   I've posted Monica's video below and provided a link to her blog on scarring alopecia.

Bimatoprost Solution for Eyelash Loss in Alopecia Areata

Alopecia areata is an autoimmune disease which causes hair loss. The scalp hair is most commonly affected, but any hair on the body can be affected. 

Loss of eyelashes may occur in individuals with alopecia areata, especially those with alopecia universalis.   Treatment of eyelash hair loss is challenging because medications that are used for alopecia areata on the scalp can’t always be safely used around the eyes.

Bimatoprost is a topical liquid medication which is used to stimulate eyelash growth. It is commonly sold  under the trade name Latisse ® (bimatoprost 0.03 % solution) and requires a prescription.  For the past few years, many women in North America have been using bimatoprost to grow longer lashes.  The medication was originally designed to treat glaucoma, which is an eye disease that gives increased pressures in the eye.  When bimatoprost solution is prescribed by eye doctors to treat glaucoma, a prescription is given for Lumigan® rather than Latisse®. However, both medications contain the ingredient bimatoprost.

What was known in the past about bimatoprost?

In addition to stimulating eyelash growth in individuals who don’t have alopecia areata, evidence keeps accumulating that bimatoprost may also help some individuals with alopecia areata. Several small studies in the past few years showed that bimatoprost solution could help stimulate some degree of eyelash growth in patients with alopecia areata who still have most of the eyelashes.  However, it was not clear how effective it is in those with alopecia universalis when all the eyelashes were missing. A very small study in 2009 suggested that bimatoprost probably wouldn’t work well if all the eyelashes were missing.

Does bimatoprost topical solution help individuals with alopecia universalis?

Researchers from Spain set out to conduct a larger study to determine if bimatoprost solution is helpful to patients with alopecia universalis. 41 individuals (16 women and 25 men) applied the solution to the eyelids once daily for one year.  37 individuals ended up finishing the full one year study.

Here were the results of the study:

Complete growth of eyelashes was seen in about 24 % of patents.

Moderate growth in 19 %.

Only slight growth in 27 %.

No benefit in about 30 %.

It took 4-8 months for eyelash growth to be seen.

Conclusions & Perspective

All in all, this study is one of the largest studies to date examining the use of bimatoprost in the treatment of eyelash loss.  About 40 % of individuals with alopecia universalis would be expected to have improvement with use of bimatoprost solution.  Side effects need to be carefully discussed with the prescribing physician as eye irritation, pigmentation changes around the eyes, and other changes can rarely occur.

Reference

Research Study:  Vila TO, Camacho Martinez FM. Bimatoprost in the treatment of eyelash universalis alopecia areata.  Int J Trichol 2010; 2: 86-88.

Hair Transplantation Using Leg Hair

Patients in my practice often ask me if I can take hair from the chest, back or legs and add it into thinning areas on the scalp. The concept of "body-to-scalp" hair transplantation is somewhat new but slowly catching on. Generally, most hair transplant specialists would reserve this technique for very special circumstances (i.e. poor donor hair density at the back of the scalp or poor donor quality, or excessive scarring in the donor area).  Hair from other body sites isn’t quite the same as hair on the scalp – it looks and feels different. It grows at different rates too.   

Dr. Sanusi Umar, a hair transplant specialist from California, wondered if he could use these differences to his advantage. Specifically, he wondered it he could take advantage of the fact that leg hairs are small, thin and soft and use these legs hairs to improve the appearance of the frontal hairline (which is normally chalked full of soft, thin hairs).

Can hairs from the leg really be transplanted into the hairline?

Dr. Umar studied two of patients, each of whom had 1000 leg hairs transplanted into their frontal hairlines.   In both patients, Dr. Umar reported that about 75-80 % of the hairs survived. Interestingly, the transplant legs hairs were a bit longer than the original leg hairs and were less curly.   Dr. Umar  followed the first patient for a total of 4 years and followed the second patient for 3 years. The transplanted legs hairs remained and grew well in the frontal hairline. Moreover, the areas on the leg where the hairs were taken healed without visible scars.

Dr. Umar's study, which is published in the journal Archives of Dermatology is an interesting and unique study.  It shows promise in the use of leg hairs to soften the hairline.  As body-to-scalp hair transplants move forward, it seems that both chest hair and leg hair may be a possible source of transplantable hair for some patients.

Reference

Umar S. The Transplanted Hairline: Leg Room for Improvement. Archives of Dermatology 2012; 148: 239-242

Scalp Discoloration ... from a Shampoo?

When children Selenium sulfide (left) and zinc pyrithione (right) shampoosdevelop red-brown discoloration in the scalp, every pediatrician and pediatric dermatologist takes note. This is because red-brown scalps in children can sometimes be a worrisome sign of certain internal diseases. So you can imagine how puzzling it would for a group of four doctors in St. Louis, Missouri when six children in their practice appeared with red-brown scalps. 

What was the cause of the scalp discoloration?

Selenium sulfide anti- dandruff shampoos!

The doctors' discovery was very simple but very clever: and they published their findings in the journal Pediatric Dermatology.  It’s hard to say just how common this orange discoloration is from selenium sulfide shampoo, but it’s probably more common than we currently think.  There is nothing harmful about the red-orange discoloration from these shampoos, and the pediatricians showed the discoloration could  be removed with an ordinary alcohol swab and the scalp discoloration disappeared once the shampoos were stopped.

But it took clever minds to piece this all together!

Reference

Gilbertson K et al. Scalp Discoloration from Selenium Sulphide Shampoo: A Case Series and Review of the Literature. Pediatric Dermatology 2012. 29; 84-88.

CANAAF: Celebrating Two Years as Canada’s National Organization for Individuals with Alopecia Areata

Every now and then, a YouTube video go ‘viral’ and highlights the exceptional accomplishments of a young child.  A few weeks ago, I recall watching a 6 year old gymnast performing and endless number of back flips that would even make an Olympic gynmast take note.  And not too long before that a video was posted of a 4 year old girl performing a piano solo as though she was ready to step onto the stages of Carnegie Hall.  Last year, the music world went crazy when a YouTube video by Maria Aragon went 'viral' as she performed music by Lady Gaga. We call them gifted kids. We call them talented kids. We call them prodigies. Young people doing absolutely incredible things.

Today, I won't be telling you about another young child doing something amazing, but rather a young organization doing something incredible. The focus is on the Canadian Alopecia Areata Foundation, or CANAAF - and it's only two years old!

CANAAF is a non-profit organization that represents everything and anything to do with alopecia areata areata in Canada.  Although the National Alopecia Areata Foundation (NAAF) in the United States has been around for over 25 years, CANAAF formally celebrated its second birthday a short time ago.  Although just a toddler, CANAAF is achieving great things. 

Why was CANAAF created?

CANAAF was created with four main goals:

1. To support research to find a cure for alopecia areata

2. To support research to find effective treatment for alopecia areata

3. To support those affected by the disease

4. To educate the public at large, the school systems, and the private sector

In just two short years as a charitable non-profit organization, CANAAF has developed the essential framework to allow them to acheive these four goals.  CANAAF has developed a formal network of support groups across Canada for individuals and their families with alopecia areata.  It has brought individuals with alopecia areata together by hosting picnics, weekend outings, and fundraisers to support their cause.  On Saturday February 11, 2012, CANAAF hosted a incredible fundraiser for over 200 people – the first annual "Heart and Soul" Semi Formal Dinner and Dance.  The monies raised go to supporting researching into new treatments for alopecia areata.  The organizers say next year's fundraiser might be even bigger.

How can a 'two-year-old' achieve such great things?

The answer is sweat, determination and hard work. CANAAF is led by a remarkable group of 6 people who volunteer their time as members of the board of directors.  None of the members of CANAAF are paid. The hours and hours these individuals dedicate have made it a reality for the 500,000 Canadians with alopecia areata to have a national organization to represent them.

Congratulations CANAAF on all your incredible accomplishments --- and Happy Anniversary !

If you'd like to learn more about the Canadian Alopecia Areata Foundation, learn about upcoming meetings or make a donation, visit the CANAAF website :

February is Heart Health Month: What does your hair tell about your heart?

Heart disease is one of the leading causes of death in Canada and the United States. In fact, about one out of every three deaths is due to heart disease and stroke. February is designated heart health month - a great time for us all to think about risk factors for heart disease and all the things we candue to reduce our risk of heart disease. It’s also a great time to discuss the relationship between male and female balding and heart disease.

About 50 % of men and 30 % of women will develop genetic balding by age 50. The medical term for genetic balding is “androgenetic alopecia”. In men, androgenetic alopecia causes hair loss in the front, temples and the crown and may even involve the entire frontal scalp. In women, androgenetic hair loss causes hair loss in the centre of the scalp. 

Is there a link between balding and heart disease?

The answer is yes. Several large research studies have confirmed an association between androgenetic hair loss and heart disease.  It seems that men who develop early balding have a higher risk to develop coronary artery disease.  This may be especially true in younger men who develop rapid balding.   New research is showing that the same relationship is true for women.

This doesn’t mean that hair loss causes heart disease or heart disease causes hair loss. Rather it tells us that the two are linked somehow through a similar process: men and women who develop early hair thinning also tend to have a higher chance to get heart disease.

Why is this information important?

The research is important for a number of reasons. If you are young and have androgenetic alopecia, do what you can to minimize your risk factors for heart disease.

If you are young and have androgenetic alopecia, do what you can to minimize your risk factors for heart disease. Eat well, excercise, get your blood pressure checked to make sure you don't have high blood pressure (hypertension).  Ask your physician about checking cholesterol and blood sugar levels. If you smoke, get help to stop.

I often encourage young men and women with early balding to get tested for all the heart disease risk factors. This involves getting a blood pressure measurement, checking cholesterol and fat levels, checking for diabetes or pre-diabetes and making sure that these individuals are getting enough exercise.  Although I encourage all smokers to stop smoking (as smoking negatively impacts hair), I advise those with early balding to quit smoking and smoking is a top risk factor for heart disease.

Happy Heart Month!

References

Lotufo, PA Chae CU, Ajani UA, Hennekens CH, et al. Male pattern baldness and coronary heart disease: the Physicians Health Study. Arch Intern Med 2000; 160 (2): 165 - 71.

Lesko SM, Rosenberg L, Shapiro S. A case-control study of baldness in relation to myocardial infarction in men. J Am Med Assoc 1993; 269: 998 - 1003.

Trevisan M, Farinaro E , Krogh V, et al. Baldness and coronary heart disease risk factors. J Clin Epidemiol 1993; 46 (10): 1213-8.

Cotton SG, Nixon JM, Carpenter RG, et al. Factors discriminating men with coronary heart disease from healthy controls. Br Heart J 1972; 34: 458-64.

Ford ES, Freedman DS, Byers T. Baldness and ischemic heart disease in a national sample of men. Am J Epidemiol 1996; 143 (7): 651 - 7.

Herrera CR, DAgostino RB, Gerstman BB,et al. Baldness and coronary heart disease rates in men from the Framingham Study. AM J Epidemiol 1995; 142(8): 828 - 33.

Persson B, Johansson BW. The Kockum study: twenty two - year follow - up coronary heart disease in a population in the south of Sweden. Acta Med Scand 1984; 216(5): 485-93.

Hair Lessons from Rapunzel

We all know the story of Rapunzel, the 1812 Grimms Brother fairy tale of the beautiful young woman trapped in a tower. Using her long hair, she pulls the witch up into the tower whenever the witch calls out:

"Rapunzel, Rapunzel let down your hair so I can climb the golden stair"

A few weeks ago, I found myself writing about Rapunzel's hair, an unusual event in my day to day activities.  But the story of Rapunzel has a few important lessons for anyone interested in learning more about the magic of hair.

1. Hair is remarkably strong. The Grimms brothers were correct in creating this fictional character who could help pull up another human being with her own hair.  Our hair is incredibly strong. In fact, a single hair fiber has about the same tensile strength as a copper wire of the same caliber. If a hair is stretched very slowly it will support about 70 grams. Of course, if a hair is tugged quickly it will break. Hair is so strong that Rapunzel could have supported 50 people climbing up her hair - at once!

2. Blondes have more hair. Rapunzel had blond hair.  Although most people don't know it, blondes have more hair than those with brown hair. Those with red hair have the least.  The more hair you have the more weight you can support, so it's no wonder Rapunzel was created a blonde. 

3. Most people can not grow hair as long as Rapunzel. The maximum length our hair will grow is determined by the length of the growing phase (also called the anagen phase). For most humans, the anagen phase of scalp hair varies from 2 to 6 years. Because hair grows about 15cm per year, most people can only grown hair down to their mid back and rarely to their waist. It is only a rare person who is able to grow hair down to their feet (or beyond). At my last check, the world record for the longest hair belongs to Xie Quiping in China. Her hair length was once measured at 6.627 m (18 ft 5.54 inches). It is not true that Xie's hair grows fast rather her anagen growth phase is very, very long.

Scarring Alopecia - An Overview

Scarring alopecias are a group of hair disoders that cause permanent hair loss in the scalp. Although these conditions are common in my practice at Sunnybrook, they are actually quite rare in the general population. With topical and oral medications, we can help stop the hair loss in many patients. New research is leading to better treatment options for patients.  The following video was prepared by Monica Matys of Sunnybrook Hospital in conjunction with the Sunnybrook Media department. I hope you will find it educational and informative.

Cortisone Injections- What are they? Why are they used?

What are "cortisone injections"?

Cortisone is an anti-inflammatory medication which helps reduce inflammation. Cortisone injections are an important part of the treatment for many types of hair loss.

What is the name of the medication being injected?

The name of the medication used for injections is called triamcinolone acetonide although some physicians may (rarely) use other types of medications to inject as well.  Triamcinolone acetonide is marketed under the name Kenalog® (so many individuals simply remember that they received Kenalog injections). The concentration of medication varies as well but generally ranges from 2-10 mg per mL.

How many injections are performed?

2 to 50 injections may be performed depending on the size of the area that is being addressed.  For example, a small quarter-sized area of alopecia areata may be treated with 4 injections and a full eyebrow may be treated with 5-6 injections.

Are cortisone injections safe? Are there any side-effects from injections?

When it comes to cortisiones, it's important to remember that there are three main ways that cortisones can be used by doctors - 1) cortisone creams and lotions that are applied to the surface of the skin, 2) cortisone injections and 3) cortisone pills that are taken by mouth.  Cortisone pills, by far, have the most potential side effects. Cortisone creams/lotions and injections have much fewer side effects - especially when used for short periods of time and under the care and direction of a physician. This last point can't be stated enough.

The most common side effect from injections is some discomfort at the time the medication is injected. Most  patients rate this discomfort about 3 out of 10 and it lasts about 3-4 seconds.  Many  individuals with report that injections in the eyebrows are slightly more uncomfortable than injections in the scalp.

Other side effects are possible too so it's important to meet with your doctor to discuss the range of side effects with injections.  For example, a small indentation or depression in the scalp can rarely occur in the area where the medicine is injected. This is a temporary indentation and goes away over time. However, it may take a few months to completely resolve.  It's not possible to predict who will have this side effect and who will not, but it's not common and most individuals are not bothered by the side effect should it occur.

What types of hair loss conditions can cortisone injections be used for?

I frequently use cortisone injections to stop or reduce inflammation under the scalp in many hair loss conditions, including:

• alopecia areata
• lichen planopilaris and frontal fibrosing alopecia
• central centrifigal cicatricial alopecia
• pseudopelade
• folliculitis decalvans
• some types of traction alopecia

What types of hair loss conditions are cortisone injections NOT used for?

Injections are not used for hair diseases that don't have much inflammation under the scalp. Therefore, I do not use cortisone injections as part of the treatment plan for the following conditions:

• androgenetic alopecia (male and female genetic balding)
• telogen effluvium (hair shedding problems)
• tinea capitis (fungal infections)
• trichotillomania (hair pulling)

Can children receive cortisone injections too ?

Although it is safe for young children can receive cortisone injections, I rarely perform injections in children with hair loss under the age of 8-10 years.  This is simply to make sure the child is comfortable with the treatment. But it all depends on the child.  There are some young children age 8 or 9 who feel comfortable with a few injections in the scalp, especially when I used  a variety of distraction techniques. However, there are other children and adolescents who are not comfortable at all -  and we choose not to inject but rather focus on other types of treatments.

What is the most important message to give about cortisone injections?

For many types of hair loss conditions, injections are a very important part of the treatment. When performed properly with the right concentration and amount these treatments are very safe.

A Discussion about Alopecia Areata

Alopecia areata is an autoimmune disease which affect about 2 % of the population. It most often leads to hair loss in circles but can lead to complete loss of all hair on the scalp (called alopecia totalis) or all hair on the body (called alopecia universalis).

Below, I've provided a link to another video on alopecia areata produced by Monica Matys of Sunnybrook Hospital. Each week Monica posts an interesting health related segment on her Sunnyview blog.  Another one of Monica's videos on alopecia areata was highlighted in a previous blog.

In this particular video, Monica has incorporated a short segment on basic aspects of the treatment of alopecia areata. In the first part of the video, I helped answer questions on the cause of alopecia areata and how the condition is treated. In the second part of the video, Monica interviews four patients with alopecia areata.  The information and advice these individuals provide is very valuable to everyone and I encourage you to watch and learn from them.

 

Hair Greying and the 50-50-50 Rule

The process of hair greying is a fascinating process. (For my US friends, I’m talking about the “graying” of hair). I’ve lost count how many friends, family members and colleagues have commented about grey hair in the past week alone. Grey hair is common (and getting more common) so let’s talk about it.

I can’t clear up all the myths associated with grey hair in this blog. But the three most common myths are:

• Plucking a grey hair causes more new ones to appear - False!

• Individuals with grey hair are less healthy than those with darker hair - False!

• Getting grey hair is related to stress - False!

What age do we start to grey?

The age that our hair turns grey is determined by several factors. The most important factor, by far, is our genetics. If there are alot of individuals in the family with early greying, there is a very good chance you’ll go grey early too. President Obama started going grey in his late 40s and he once remarked to the media that his own grandfather was grey by his late 20s.

The normal process of hair greying starts in the temples and then the crown. Caucasians starting greying first (sometimes in the 30s) followed by Asians (in the late 30s) followed by those with African descent (in the mid 40s). In general by age 50, about half of the Caucasian population has at least 50 % grey hairs. I refer to this as the “50-50-50 Rule:"

By age 50, about 50 % of the Caucasian population will have 50 % grey hair (commonly referred to as salt and pepper hair).

Rapid Greying (turning white overnight)

You may have heard stories of hair turning grey (or white) over night. These stories usually focus on the great deal of stress experienced by the person.  What is going on here?

It's not actually possible for a dark hair to suddenly become white. Rather, what is happening is that the dark hairs are falling out leaving behind the white hairs to be seen.  This pattern of sudden greying may be seen in patients with a condition called alopecia areata.

Premature Greying of Hair (PGH)

The term "premature greying" of hair refers to hair greying that occurs before the age of 20 in Caucasians, before 25 in Asian individuals and before 30 in black men and women.  I occasionally evaluate patients in my clinic who start greying in the teens or twenties. These individuals usually have an underlying genetic or systemic abnormalities. Many, many factors influence hair greying. Thyroid abnormalities, B12 deficiency are just two examples of many conditions that cause early greying.  Smoking too can cause early greying. In fact, a 1996 study in the British Medical Journal showed that smokers are about two to four times more likely to have grey hair.

Why does hair turn grey?

Hair doesn't actually 'turn' grey color, but simply loses its original color. Grey hair occurs because a pigment called melanin stops being pumped into newly manufactured hairs. It’s a specific cell called a melanocyte that is responsible for producing the melanin. The reasons why this change occurs is complex and continues to be the topic of research around the world.

Grey hair is actually different than the neighbouring darker hairs. In other words, a grey is not simply a normal hair that lacks pigment. The hair shafts seem to be different. Anyone who has grey hair will notice that the hairs are frequently wirier, coarser and less likely to hold pigment in hair dyes than the neighbouring pigmented hairs.

The Future of Grey Hair

The main treatment for greying hair, at present, is hair coloring and hair dyeing. At present, we spend over 2 billion dollars a year on hair coloring products in North America.

With an aging population, I’m sure we will soon see increasing demand for new ways to color our hair in years to come and even more focus on understanding the molecular and genetic process of greying. At present we have about 40 million individuals in the US and Canada aged 65 and over. By 2050, this number may be approaching 90 million.

What treatments will be available for grey hair in 2050?

I'll be following with you!

References of Interest

1. Premature grey hair and hair loss among smokers: A new opportunity for health eduation. British Medical Journal 1996; 313: 1616

2. Data in graph extrapolated from US Census Data. http://www.aoa.gov/agingstatsdotnet/Main_Site/Data/2010_Documents/Population.aspx

Alopecia Areata - Insights from Patients

Every week, Monica Matys of Sunnybrook Hospital produces a video blog and posts it on the Sunnybrook website. These blogs provide incredible insights into various health conditions and what patients experience.  In September 2011, Monica produced a segment on alopecia areata.  Many of my patients have commented about how much they enjoyed this video.   I've posted Monica's video below and provided a link to her blog on alopecia areata.

Scarring Alopecia - Is my treatment helping? Is it still active?

I often have medical students, interns and resident doctors join me in my clinic at the Sunnybrook Medical Centre in Toronto, a teaching hospital which is part of the University of Toronto.  I enjoy teaching others about hair loss  -  how to diagnose it and how to treat it - and how to know if the treatment is "working".  

For patients with scarring alopecias the goal of treatment is to stop the disease. The hair loss that the patient has experienced to date is permanent, and so the goal is not to grow back new hair.  It therefore takes a bit more thinking to know if the treatment is working.

So what do you think?

I often ask the doctors "So, what do you think?"   Take the patient in the photo on the right for example.  She is referred regarding a diagnosis of scarring alopecia (a condition called lichen planopilaris) and she's already on treatment (topical steroids and steroid injections).  The key question I might be asked at this point by the patient is

Is the treatment helping and is the disease still active?

Often I might ask the doctors working with me:

So what do you think?

I don't always expect the doctors to know the answers, but the question helps get the mind thinking. When I see this woman's scalp - I think one thing - the treatment that was used so far is not working. At least not as well as we need to get it. 

I can tell that this patient is itchy, even without asking. I can see that the hair follicles have some redness around them and one of them at the front has been repeatedly picked at.  This is the hair follicle with the arrow attached.  In fact, it's been picked at to the point where it is now coming out of the scalp. The white 'root sheath' or blanket of cells can be seen wrapped around the hair follicle.

And when we ask the patient, we learn that she is in fact very itchy, and  she's been scratching her head often. She scratches and scratches and that's why the hairs have been uprooted. There is also some burning in the scalp and a bit of tenderness in some areas. Morever, she feels she has lost more hair in the last 6 months.

Taken together - all these features suggest this patient has a scarring alopecia that is still "active."  She still has scalp symptoms and she's still losing hair.  

The following are questions I ask to determine if a scarring hair condition might still be "active":

1) Is the scalp still itchy?

2) Is there burning in the scalp?

3) Is there pain in the scalp?

4) Has there been further hair loss since the last visit?

When a patient has ongoing activity it means they are at risk to lose even more hair in the future.  In this case oral medications might be considered in addition to the topical steroids and injections, including such pills as doxycycline, hydroxychloroquine, mycophenolate mofetil or cyclosporine. Other strategies could also be used as well.

 

Alopecia areata - an autoimmune condition

Alopecia areata affects about 2 % of the world's population.  Most people with alopecia areata develop a small circular area of hair loss such as the individual in the left photo. In such patients, the hair often grows back spontaneously.  The hair growth can be helped by use of cortisone or cortisone injections. Individuals with many circular areas of hair loss or with extensive scalp hair loss (such as alopecia totalis and alopecia universalis) are less likely to experience spontaneous growth and treatment may be considered if any regrowth is to  occur.

Alopecia areata is an autoimmune disease.  The word "auto" means "self" and the word immune refers to the  "immune system". Alopecia areata is a condition whereby the individual's own immune system reacts to its own hair.

Normally, our immue system is designed to attack bacteria and viruses as our main line of defence from the outside world.  Our immune system also kills some types of cancer cells.  The immune system is complex and has dozens of other roles too. However, when a patient has an autoimmune disease, the immune system also targets a specific part of the patient's own body. 

In the case of alopecia areata, the immune system is targetting the patient's hair follicles. Inflammation develops around the hairs and this causes the hair to fall out. The photo on the right shows that the inflammation develops at the very bottom of the hair follicle - around a region called the 'bulb.'  Cortisone medications and cortisone injections help to"chase away" the inflammation around the bulb and help to get the hairs back in a growing mode.

What Everyone Needs to Know about the Hair Dye Chemical PPD

There have been recent reports in the news of women having serious reactions to a specific ingredient found in some hair dyes.  The ingredient is paraphenylenediamine or “PPD” for short.  Many patients have asked me about these articles appearing in various newspapers reports.

PPD is commonly found in permanent and semi-permanent hair dyes. It is used to help give a hair dye a dark color that doesn’t easily wash out.  PPD also gives hair dyes a natural, realistic color. My previous blog reviewed the topic of hair dye allergy.

Despite making the news recently, there is nothing new about allergic reactions to PPD.  It is well known that PPD can cause some sort of allergic reactions in about 5% of users. These allergic reactions vary from skin rashes & blisters (a phenomenon called allergic contact dermatitis)  to hives (a phenomenon called contact urticaria) to serious anaphylactic reactions and rarely even death.  Reactions can occur as a few days to a week or more after application of a hair dye.  These reactions tend to occur on the second, third or fourth application rather than on the very first. 

Health Canada has banned the use of PPD in cosmetic products that are applied directly to the skin.  For example, PPD is banned in black henna tattoos which are sometimes known as holiday tattoos because vacationers may have these dark richly pigmented tattoos applied while enjoying a vacation.  However, PPD is not banned in hair dyes.  PPD is allowed in hair dyes provided the product labelling contains a warning about possible allergic reactions. On its website, Health Canada states

PPD is an acceptable ingredient for use in hair dyes that are rinsed off after a maximum of 30 minutes. When used correctly, hair dye does not come directly into contact with skin for prolonged periods of time.

Allergic reactions to PPD include red skin rashes, itching, blisters, open sores, and scarring within 2 to 10 days following application. These allergic reactions may also lead to sensitivities to other products such as hair dye, sun block and some types of clothing dyes.

My general advice for individuals considering dyeing their hair:

1) Read the instructions on the package carefully.  If there are no instructions, don't buy the product.

2) Be sure to do a "patch test". Apply a small amount (size of a penny) to an area on the skin. An area such as behind the ear or on the forearm is a particularly good spot.

3) Let it dry.

4) If immediate redness develops, the individual may be 'irritated' by the product. This usually does not indicate an allergy. 

5) Wait 72 hours (3 days) and do another check of the area where the dye was applied.

6) If there is no reaction, then the test is said to be "negative". Individuals who have a "negative" test are unlikely to develop an allergic reaction when they use a hair dye. 

7) If the individual develops redness, scaling and/or blisters in the area where the patch test was applied, they may be truly allergic to the PPD chemical.  Use of the hair dye is not recommended. Take a picture of the reaction. Make an appointment with a physician knowledgeable about hair dye allergy to discuss further.

8) In general, semi-permanent dyes have less PPD than permanent dyes, so try to use them first to see if you can achieve your desired color.  To even further reduce your exposure to PPD, try to use  the lightest color possible. Highlights or low lights can be used too because these don't touch the scalp. Consider experimenting with natural colors, which don’t contain PPD.

 

Marilyn Denis discusses Alopecia Areata

One of the segment topics of the Nov 23 Marilyn Denis Show was alopecia areata. Alopecia areata is an autoimmune hair loss condition that affects about 2 % of the world, and causes hair loss on the scalp and sometimes the eyebrows, eyelashes and body.

The show featured Sherry, a talented University of Ottawa swimmer who has alopecia universalis. Marilyn invited me to speak about alopecia, current treatments for the condition, and the important role of the Canadian Alopecia Areata Foundation (CANAAF).  The segment also included Michael Suba of Continental Hair who disucssed wigs and Karen, a woman with alopecia areata who discussed her experience with hair loss.

 If you'd like to learn more about the Canadian Alopecia Areata Foundation, learn about upcoming meetings or make a donation, visit the CANAAF website :