Is there an Increased Risk of Diabetes in Patients with Central Centrifugal Cicatricial Alopecia?

Central Centrifugal Cicatricial Alopecia: Risk of Diabetes

Hair Loss in Patient with CCCA Central centrifugal cicatricial alopecia or "CCCA" is the most common cause of scarring alopecia. Scarring alopecia refers to hair loss conditions where scarring develops around the hair follicles and leads to permanent hair loss. "CCCA" predominantly affects black women where up to 30 percent of women are affected.

Last year, an interesting paper was published in the journal Archives of Dermatology by researchers at the Cleveland Clinic. The authors handed out a survey to African American women at 2 churches as well to African American women attending a health fair. The survey allowed the collection of information about basic medical history as well as information about hair styling practices. In total, 326 women participated in the study.

8% of Women with CCCA Had Diabetes

About 8 percent of women in the study had type 2 diabetes. However, the researchers found an increased prevalance of diabetes in women with centrifugal cicatricial alopecia. Women with CCCA were more likely to used braids and weaves than women without CCCA.  The vast majority of women who participated in the study used releaxers. However it did not appear that the use of relaxers was associated with the development of CCCA in this particular study.

Although there are many limitations to this study, I particularly like the study. First, it reminds us the CCCA is a common reason for hair loss in black women. Second, this study provides new information that CCCA may be asociated with an increased risk of diabetes. Although more research is needed to confirm this, these findings open many new avenues for research.

Reference

Kyei et al. Medical and Environmental Risk Factors For the Development of Central Centrifugal Cicatricial Alopecia. Arch Dermatol 2011; 147: 909-14

 

EGFR Inhibitory Cancer Drugs: Increasing Reports of Scarring Alopecia

EGFR Inhibitory Cancer Drugs: Do they cause hair loss?

"Epidermal growth factor" is a growth factor that not only plays a role in the normal healthy growth of skin but also other tissues in the body as well. In certain types of cancers, EGF signals inside cells have been shown to be harmful and sometimes promotes the growth of those cancers.

"EGFR Inhibitors"

These are a group of drugs that block the actions of EGF. These drugs have been approved for treatment of some types of lung cancer, pancreatic cancer, colon cancer and some types of head and neck cancers. These include drugs with names like erlotinib, cetuximab and gefitinib.

These drugs can sometimes have side effects on the skin, nails and the hair. As a hair specialist, I see patients with the hair related side effects of these drugs. EGFR inhibitors can sometimes cause excessive eyebrow and eyelash growth and can cause changes in the texture of the hair. EGFR inhibitors can also cause hair loss (both scarring and non-scarring kinds). It's important to note that these hair-related side effects are not common.

Back in 2008, my colleagues and I published a report in the journal Archives of Dermatology of a patient with lung cancer who developed a scarring alopecia following use of the drug gefitinib. Now Korean researchers reported a 61 year old woman with metastatic lung cancer who reported a scarring alopecia following use of another EGFR inhibitor drug (erlotinib). This hair loss developed 9 months after starting the drug. It started out as painful pustules. A biopsy was done which proved that the patient had a scarring alopecia.

This study is interesting and provides further evidence that scarring alopecia may be a side effect of this class of cancer drugs.  More research is needed to determine just how frequently this side effect occurs.

Reference

Yang Bo Hee et al. A case of circatricial alopecia associated with erlotinib. Ann Dermatol 2011; 23:350-353.

Donovan JC et al. Scarring Alopecia Associated with the Use of Gefitinib. Archives of Dermatology 2008.144: 1524-5

 

Pioglitazone for Treatment of Lichen Planopilaris: New study of 24 Patients

Pioglitazone for  Lichen Planopilaris

Lichen planopilaris or "LPP" is a type of scarring alopecia. Patients with LPP first develop symptoms like itching, burning or pain in the scalp and sometimes notice increased hair shedding. The hair loss in the rare disorder is permanent.

Current treatments for LPP include topical steroids and steroid injections as well as an array of oral medications (hydroxychloroquine, doxycyline, prednisone, cyclosporine, isotretinoin).

Drs Baibergenova and Walsh from the University of Toronto published a nice study looking at the use of the oral medication pioglitazone in the treatment of LPP.  It's one of the largest studies exploring the use of this drug in LPP. This drug first caught the attention of dermatologists and hair specialists back in 2009 when US dermatologist Dr. Paradi Mirmirani and her colleague Dr Karnik showed that one patient with LPP had a remarkable improvement in his disease following the use of pioglitazone. Piolgitazone is an oral medication which is used in the treatment of type 2 diabetes.  After publication of this report, many dermatologists starting prescribing the medication to treat LPP.

 

New study of LPP Treatment

Now, Drs. Bairbergenova and Walsh studied 24 patients with lichen planopilaris who were treated with this drug.  Five of 24 patients had complete remission of their disease and some improvement was noted in over one half of patients.  13 % of patients had no benefit and another 17 % had to stop on account of side effects.

This drug highlights the benefit of this class of drugs in the treatment of lichen planopilaris and possibly other types of scarring alopecia. The challenge now is to figure out exactly how (and if) to prescribe the drug for lichen planopilaris now that pioglitazone has been shown to increase the risk of bladder cancer, and the Food and Drug Administration (FDA) has placed a warning on prescriptions of this drug.   It remains unclear how we might intergrate pioglitazone into our current treatment protocols for LPP.

Reference

Baibergenova A and Walsh S. Use of pioglitazone in patients with lichen planopilaris. Journal of Cutaneous Medicine and Surgery 2012; March- April; 97-

Preparing the Mind to Recognize the Many Forms of Hair Loss

In addition to being a hair transplant specialist and specialist in hair disorders, I do research in hair loss and devote time to teaching and lecturing medical students, interns, residents and physicians about hair loss. In fact, part of my time away from the office is spent teaching other doctors about hair loss and about hair transplant surgery. I’m lucky that my profession is not only my job but also a real joy.

I enjoy teaching others about the approximately 100 reasons for humans to have hair loss.

Androgentic alopecia, alopecia areata, telogen effluvium, lichen planopilaris, folliculitis decalvans, dissecting cellulitis, pseudopelade, morphea, ectodermal dysplasia. The list goes on and on.

Today, I gave a lecture about hair loss to medical students at the University of Toronto.  Hair loss is rarely covered in medical schools so it's a real privilege to have the chance to speak to a room full of bright students.  What I hope for after each lecture I give is that the learner goes home with an open mind to consider the many different kinds of hair loss that exist.

Folliculitis decalvans affecting crown If someday they see a young 34 year old man with a bald crown that itches them like crazy will they instinctively think this is another case of “male balding” or is that doctor now open to consider that this man may instead have an unusual scarring hair loss condition called “folliculitis decalvans” ?

Alopecia areata diffusa mimicking genetic hair lossor....When the young doctor finds themselves evaluating a 25 year old woman with hair loss in the centre of her scalp, low vitamin B12 blood levels and dozens of little dots in her nails will that doctor instinctively think this is an young woman with early “female balding” or will the doctor remember the lecture and consider that this could be an unusual form of alopecia areata (called “alopecia areata diffusa”)?

The French philosopher and Nobel Prize winner Henri Bergson once said that the human mind sees only what it’s prepared to understand. I consider it a great privilege to teach about hair loss and help others open their minds to the many different types of hair loss that they will likely encounter in their patients in the years to come.

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.

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.

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.

 

Perifollicular Scale: A Clue to the Diagnosis of Lichen Planopilaris

The photo on the left is from a patient with a normal healthy scalp. The hair follicles are all similar size and spacing between them is similar. There is no redness, and no flaking in the scalp.

The patient on the right has redness in the scalp. The hair density is decreased.  Another striking feature is also present - the white “scale” around many of the hair follicles. The medical term for this scale hugging each of the hair follicles is known as ‘perifollicular scale.’  Perifollicular scale is a potentially important clue to the diagnosis of a certain scarring hair loss conditions, especially a condition known as lichen planopilaris (LPP).

When I see perifollicular scale in a patient with a red itchy scalp, I suspect that the patient has a scarring hair loss condition and usually do a scalp biopsy to confirm the diagnosis. Lichen planopilaris is a cause of permanent hair loss.  When the condition first starts, patients may have itching, burning or pain in the scalp and possibly increased hair shedding too. It is important to diagnose this condition in the early stages in order to try to prevent further hair loss.

 

Hair Transplantation in Frontal Fibrosing Alopecia

Hair transplants for FFA

Frontal  Fibrosing Alopecia is a cause of permanent scarring hair loss fibrosing alopecia is a  rare scarring hair loss condition that affects the frontal scalp. The condition occurs mostly in women although men can very rarely be affected. Frontal fibrosing alopecia causes permanent hair loss. Treatments for the condition include topical steroids and non-steroid medicines, steroid injections, as well as oral medications such as tetracyclines, hydroxychloroquine, mycophenolate mofetil and cyclosporine.

Patients with frontal fibrosing alopecia often ask me  - Is it possible to have a hair transplant?

To answer this question,  I remind myself of a interesting research study from Drs. Nusbaum and Nusbaum in Miami, Florida which was published in the journal Dermatologic Surgery.

Nusbaum BP and Nusbaum AG. Frontal fibrosing alopecia in a man: results of follicular unit test grafting. Dermatol Surg 2010; 36: 959-62.

In the journal, the doctors report a 44 year old man with frontal fibrosing alopecia who underwent a hair transplant.  Prior to the hair transplant he was treated with topical steroids and steroid injections. He also used the oral medicine hydroxychloroquine for 6 months.  His disease appeared to be ‘quiet.’

With the disease quiet, the man stopped the medications and underwent a very small ‘test’ hair transplant with 82 follicular units placed into the scalp.  Three months after the transplant, the hair started to grow and after 15 months after the transplant the hair had grown in normally. This would have been tremendously exciting for both the patient and surgeon.  Four years later, however, only 6 hairs remained – the remaining hairs were destroyed by the scarring alopecia. 

Comment: This report is very important. It reminds us of just how complex the disease frontal fibrosing alopecia can be. The disease can appear quiet for extended periods and then can reactivate.  It is challenging for doctors to monitor because patients often have no symptoms. 

We still can’t predict with certainty if a hair transplant will be successful in a patient with frontal fibrosing alopecia. Sometimes it can be - but sometimes it won't. The above study reminds us that hairs can grow in nicely, only to be lost in future years.  Further studies are needed to determine if patients who receive treatment with topical and oral medicines are less likely to lose their hair.

Is destruction of the oil glands a key step in the development of scarring alopecia?

Scarring Scarring Alopecia: Oil gland destruction may be a key early stepalopecias are a group of hair loss conditions that lead to permanent  hair loss. An example of a scarring alopecia is shown in the photos. Although we know how to recognize these conditions, and we understand how to treat them, we understand very little about their cause.

For years it has be thought that abnormalities developing in the sebaceous glands or "oil glands" of the hair follicle can lead to scarring alopecias.  Dr Stephen Lyle and colleages at the University of Massachusetts Medical School set out to determine if the oil glands are affected in patients with various types of scarring alopecias.

Al-Zaid T et al. Sebaceous gland loss and inflammation in scarring alopecia: A potential role in pathogenesis. Journal of the American Academy of Dermatology 2011; 65: 597-603

The researchers showed that scarring alopecias frequently showed loss of the sebaceous gland. For example, a reduction in sebaceous glands was seen in:

84 % of biopsy specimens from patients with the scarring alopecia lichen planopilaris

77% of biopsy specimens from patients with central centrifugal cicatricial alopecia

100 % of biopsy specimens from patients with follicultis decalvans

In many cases, the sebecaous glands were not only reduced but inflamed as well. For example, inflammation occurring in the sebaceous glands was seen in:

55 % of biopsy specimens from patients with lichen planopilaris

25 % of biopsy specimens from patients with central centrifugal cicatricial alopecia

50 % of biopsy specimens from patients with folliculitis decalvans

Conclusion: These data give further support to the current thinking that inflammation affects the sebaceous gland may be one of the "earliest steps" in the development of scaring alopecia.

 

Cicatricial (Scarring) Alopecia and the "Trichologic Emergency"

The word cicatricial is derived from the Latin term ‘cicatrix’ meaning scar.  Cicatricial alopecias are a group of hair loss conditions that lead to permanent scarring in the scalp.  The cause of most of these conditions is not known. There are many different types of cicatricial alopecias that I see commonly in my practice, including lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia, discoid lupus, pseudopelade, folliculitis decalvans and dissecting cellulitis. There are dozens of other types of scarring alopecias as well.  Regardless of the type of scarring alopecia, all are characterized by one common entity – a disease process that leads to irreversible destruction of the hair follicle.  For patients, this means that these diseases lead to permanent hair loss – the patient will never regrow hair in areas where hair has been lost.

It was renowned dermatologist Dr. Jerry Shapiro who coined the term “trichologic emergency.”  This is an important term because it reminds us that we need to act quickly in diagnosing and treating patients with cicatricial alopecia.    Once a patient loses hair, it will not grow back.

The photo on the right shows the scalp of a patient with a scarring alopecia known as pseudopelade. The dotted border shows an area of permanent scarring. I know this patient has a scarring alopecia because the follicular openings (i.e. holes in the scalp where the hairs come out) are missing. This area appears very smooth, similar to a ice skating rink. There were once hairs underneath this area. However, these hairs have now been permanently loss and will not regrow in this area. A biopsy was done later and also confirmed the diagnosis of scarring alopecia.

But the diagnosis is only the first step in helping patients with scarring alopecia. The next step is to stop the process.  This border of hair follicle destruction will continue to move outward unless the patient is started on treatment. The small arrows show the direction of the scarring process. In fact, some of the healthy hairs at the outer border of the process are already starting to be affected by the disease.  You can see one hair follicle with the yellow arrow is starting to look very irregular with many twists and turns.  Within a few months this hair follicle will likely be permanently destroyed and fall out of the scalp. Treatment is needed to help slow or halt the process of hair follicle destruction.