Can Patients with Trichotillomania have a Hair Transplant?

Trichotillomania: Is it possible to have a Hair Transplant?

Trichotillomania is a hair loss disorder whereby individuals pull out their own hair.  About 1-2 percent of the population meet the diagnostic criteria at some point in their lives.  The condition is classified as an impulse control disorder.  A previous blog discussed the features of this condition.

In the early stages of the condition, hair regrowth is possible if the patient can be helped (either with medications or psychotherapy) to stop pulling.  If the pulling goes on long enough, the resultant hair loss may be permanent.  This is because scars develop around the damaged hair follicles and these scars block further hair growth.

Patients with trichotillomania often ask if a hair transplant is possible.  In some cases it can ben possible, but certainly not in all cases.   Generally, I look for four features to be present in order to determine if a patient with trichotillomania can have a transplant:

Candidacy for Hair Transplantation in Patients with Trichotillomania

1. The patient has not had the compulsion to pull their hair for at least 1 year

2. Patient has no ongoing scalp symptoms like itching, burning, pain or tingling

3. The area of hair loss has not enlarged over a 1-2 year period.

4. The patient is medically fit, has a good donor supply of hair, and is over 18 years of age.

These are general guidelines that I use in my practice which have been very helpful. Patients with ongoing symptoms like itching in the scalp and who have ongoing compulusion to pull, twist of pluck hairs are not good candidates because the the transplanted hair may be ultimately pulled out again.  

 

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

 

What is "trichotillomania" ?

Trichotillomania refers to hair loss due to an individual pulling out his or her hair. It was about 120 years ago that dermatologist Dr. François Henri Hallopeau introduced the term "trichotillomania" to describe a patient who pulled out his hair. 

Trichotillomania occurs in both adults and children.  My patients are often surprised when I tell them that trichotillomania is fairly common. In fact, about 3-5 % of women and 1-3 % of men will pull out hair at some point in their lives.  Many patients deny pulling out their hair at first meeting, so the diagnosis can be challenging and experience is needed to know when a patient visiting your office is likely to have trichotillomania.

What hairs are pulled out?

Individuals with trichotillomania may pull out any hair on the body.  Scalp hairs are the most common hairs to be pulled followed by the eyelashes, eyebrows and pubic hair. 

What do patients experience?

Patients with trichotillomania experience a sense of "tension" or "unease" before hair pulling occurs or while they are trying to resist the urge to pull the hair.  After the hair is pulled, individuals feel a great sense of relief or satisfaction.

How does a physician come to the diagnosis of trichotillomania?

According to the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders" (DSM-IV), there are five key features that need to be met before a patient is said to have trichotillomania.

First, the patient pulls out their hair to the point at which it causes noticeable hair loss. Second, the patient normally has some sense of tension or unease before they pull out the hair or while they are trying to resist pulling out the hair. Third, there is some pleasure or sense of relief after the hair is pulled out.  Fourth, the hair pulling has to lead to some impairment in how the patient functions in social situations or at work or at school.  Finally, if the hair pulling is better explained by some other mental disorder, then the diagnosis of trichotillomania is not given.

These are helpful guidelines, but it's possible for a patient to have trichotillomania without all five of these features present.  There is some contraversery amongst doctors as to whether these five criteria are too restrictive.

Can trichtillomania occur in children?

Yes, In addition to adults, trichtillomania can occur in children and adolesecents.  In fact, it's probably more common in chidlren than adults. In very young children (under 6) it tends to be more of a habit phenomenon.  These younger children sometimes drop the habit of pulling their hair as time goes on.  However, trichotillomania occuring in young pre-teens and teenagers tends to be more concerning.  This hair pulling is often associated with underlying depression or anxiety and may last a long time.  It may affects school and home life. These children often need psychological or psychiatric help.

How much hair can be lost?

Trichotillmania can lead to small amounts of hair loss or rarely complete loss of all hair on the scalp.

Is there are cure?

At present there is no cure.  Medications and psychotherapy provided by a psychiatrist or psychologist can be helpful in some cases. Wigs, hair pieces and other forms a scalp camouflage may be used by patients with trichotillomania. Hair Transplantation can also be performed in patients who are stable and have stopped pulling. (see article on Hair Transplantation for Trichotillomania).

References

1) American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. Fourth Edition. Text Revision Washington, DC: American Psychiatric Association.

2) Woods et al. Understanding and treating trichotillomania: What we known and what we don't. Pschiatr Clin N Am 2006; 29L 487-501

Telogen Effluvium: Remembering Life's Events

Telogen effluvium is a common hair loss condition.  Patients note increased hair shedding - and hair starts collecting everywhere. There is hair around the house, hair on the floor, hair in the brush, hair in the sink, hair in the shower drain, hair in the car, hair at the office.  Spouses start to notice that there is more hair around than there used to be.  Even young children start picking up their parents hair and commenting that too much of mommy or daddy's hair is coming out. This is telogen effluvium.

Hair shedding can be caused by a wide range of 'triggers.'  These include physiologic stress, endocrine problems (including thyroid problems), nutritional problems, iron deficiency, and medications.  Other scalp diseases, including alopecia areata, and scarring alopecias can also cause hair shedding but these are different from telogen effluvium.

Sometimes it takes a bit of detective work to figure out what might be the trigger of a patient's hair shedding.  In many cases we find the cause, but in some cases we don't and just wait for the shedding to stop. 

There are many things I enjoy about being a hair doctor - but one aspect in particular I enjoy is pinpointing exactly in time when someone's hair loss 'trigger' might have occurred.  This usually occurs in a couple of classic scenarios.

Let me explain.

Suppose I see a patient who is worried about their hair shedding.   They tell me that the shedding used to be really bad a few months ago but is actually starting to get back to normal. After asking dozens of questions I proceed to examine the scalp.   I look for signs of various hair diseases, and there does not appear to be any.  Then as a final step, I lift 50-100 hairs straight up and - voila - I see a remarkable number of 3 cm hairs.  Normally, I would expect to see hairs of all different lengths - some 1 cm hairs, some 2 cm hairs, some 3 cm hairs, some 4 cm hairs and so on. But the patient in our example has many many 3 cm hairs. In fact - way too many 3 cm hairs!

What does this unusual number of 3 cm hairs tell me?

Well, it tells me the patient had some major trigger of hair shedding take place about 6 months ago. 

After a trigger like a surgery, or a crash diet, the hairs of some individuals can be rapidly shifted into a resting period called the "telogen phase". These hairs spend a mandatory period of three months in the telogen phase and then all get shed from the scalp at a similar time.   Because hairs normally grow back at a rate of about 1 cm per month - if I see alot of 3 cm hairs, I know they've been growing back for about three months and I know the trigger must have occured about 3 months before that - for a total of six months.

So when I see lots of 3 cm hairs, I know there was some major trigger about 6 months ago (3+3=6).When I see lots of 5 cm hairs, I know there was some major trigger about 8 months ago (5+3=8). When I see lots of 7 cm hairs,  I know there was some major trigger of hair shedding about 10 months ago (7+3=10). It's as simple as that.

 So for me, telogen effluvium can sometimes boil down to helping patients remember life's events.  If the patient's shedding has stopped and they are growing back their hair, I can often pinpoint when the hair loss occured.  If the shedding is ongoing and has not yet stopped, a bit of detective work especially blood tests, will be necessary.

So for the patient with 3 cm hairs, there is one simply question that can clinch the diagnosis... What happened in your life 6 months ago?  It sometimes takes patients a little bit of time and sometimes a calendar even gets pulled out from a bag, but the trigger often comes from remembering life's events:

Oh, now that you mention it, I was in the hospital, sick as a dog!

or ... That's when I started this new drug

or ... That's when my dad passed away

or ... That's when I have a bad flu and was off work for weeks

or ... That's when I had my surgery

The list goes on and on. Telogen effluvium can sometimes be challenging to diagnose. Every patient needs some basic blood work to make sure that there is no thyroid abnormality and no significant iron deficiency that caused the hair shedding. But if the hair shedding has already slowed down and is starting to grow back, one can often pinpoint exactly in time when the shedding started and then narrow down the exact cause.

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.

What is the best lab test to see if thyroid problems are causing hair loss?

Are thyroid problems causing hair loss?

Thyroid hormones are produced by the  thyroid gland, which is a small gland located in the midline of the neck. Precise levels of thyroid hormones are important for normal hair growth. 

The TSH test

The release of thyroid hormones from the thyroid gland is an intricate process. A region of the brain known as the hypothalamus releases a hormone known as "TRH" or thyrotropin releasing hormone, which in turn triggers the tiny pituitary gland to release "TSH" or thyroid stimulating hormone.  In response to the release of TSH, the thyroid gland produces thyroid hormones, namely thyroxine (T4) and triiodothyronine (T3).

When the body produces too much or too little thyroid hormone this may lead to hair shedding. The single best test for thyroid problems is a blood test for “TSH” or thyroid stimulating hormone.  If the TSH is abnormal, several additional thyroid tests can be ordered, including a "free T4".

Hypothyroidism occurs in about 3 % of the population. Hypothyroidism occurs when the thyroid gland does not release enough thyroid hormone. Most patients who are hypothyroid have an abnormally high TSH level and a low free T4 level. This is known as "primary hypothyroidism"  Most patients who are hyperthyroid have the opposite pattern – a low TSH level and high free T4 levels.

 

Hair Loss Terms Explained: Scalp Pustules

Pustules are collections of pus. Scalp PustuleThey are 1-4 mm in size and appear as yellow, white or red in color. Pustules may or may not contain bacteria. However, some pustules are completely free of bacteria and called “sterile pustules”.  If pustules are seen on the scalp, a swab is often performed to see if the pustules contain bacteria.  If bacteria are present and it is concluded that there is a true infection in the scalp, a topical or oral antibiotic medication might be prescribed.  In some cases, pustules are indicative of a scalp disease and persistent pustules should be evaluated by a physician.

Miniaturization: The Clue to the Early Diagnosis of Androgenetic Alopecia

One of the most common causes of hair thinning is androgenetic alopecia.  Men with androgenetic alopecia may notice hair loss at the top of the scalp as well progressive receding in the temples. Women with androgenetic alopecia notice thinning in the middle of the scalp.  The central hair part may become wider over time.  As hair thinning occurs the scalp becomes progressively more visible.   

I treat androgenetic alopecia with either 1) topical medications such minoxidil, 2) oral hormone blocking medications or 3) with hair transplantation. For some patients, I may recommend all three treatments. I encourage patients to consider using medical treatments in the early stages in order help maintain or improve the present hair density and prevent further loss over time.

Patients considering treatment for the very early stages of androgenetic alopecia often ask how I can absolutely sure they have androgenetic alopecia. Some of the doctors I teach ask the same question. How do you tell androgenetic alopecia is present if the patient does not actually have hair loss yet?What are the clues to the early diagnosis of androgenetic alopecia?

Androgenetic alopecia can be diagnosed based on the pattern of hair loss and by observing a process known as hair follicle “miniaturization.” When I lecture about androgenetic alopecia, I refer to miniaturization as the process by which hair follicles get skinnier over time.   It takes time for doctors to learn to identify hair follicle miniaturization, but I teach the following analogy to help others master this skill. 

Pretend that hair follicles are like tree trunks in the forest.  This analogy is kept in mind as the scalp is examined. If the size of the tree trunks is all the same – the patient does not have androgenetic alopecia.  If some of the tree trunks are fat and some of the tree trunks are skinny, the phenomenon of miniaturization is being observed. This is shown in the picture above. The most likely cause, by far, is androgenetic alopecia.

There are rarely other conditions that can be associated with miniaturized hairs besides androgenetic alopecia.  But this analogy is extremely important.  Many patients with concerns about hair loss end up receiving a diagnosis of androgenetic alopecia.  If there is no miniaturization, the diagnosis is wrong, and there is another reason for hair loss.

Telogen Phase: Exit Strategies for Hair

When I teach doctors about hair loss, I often begin by telling them that hair loss from the scalp is a normal phenomenon.  From the time a hair follicle first surfaces above the scalp, it is programmed to eventually be lost or "shed" from the scalp.  All hair follicles come programmed with an exit strategy. In fact, hair follicles have a meticulously regulated mechanism for every aspect of their growth.

All hair follicles proceed through four phases as they grow.  These phases are called anagen phase, catagen phase, telogen phase and exogen phase.  Hairs on the scalp spend about 2-6 years in the anagen phase, 3-5 weeks in catagen phase and 3 months in telogen phase.  At the end of telogen phase, hair follicles are shed in the exogen phase.  As these follicles fall out of the scalp and a new hair follicle pushes up from below.  All hair follicles come programmed with an exit strategy. It’s called exogen. This is why hair loss is a normal phenomenon.

If you reach up an grab a strand of hair on your scalp, it's likely in the anagen phase. In fact, 90 % of hairs on the scalp are in anagen phase. Less than 1 % of hairs are in catagen phase. 10 % are in telogen phase. 

Every day about 100 hairs on the scalp find themselves in the exogen phase and are shed from the scalp.  This is an important statistic to remember: the normal rate of daily shedding is about 100 hairs.   Loss of more than 100 hairs per day is abnormal and indicates excessive shedding.  A comprehensive evaluation will usually reveal the cause of a patient's excess shedding.

Do I have alopecia?

The word ‘alopecia’ sometimes causes confusion.  The Greek term “alopex” means fox. The word alopecia is thought to derive from the Greek term alopekia which literally translated means “fox disease.”  

But the term alopecia simply means “hair loss”.  There are over 100 reasons to lose hair which means that there are over 100 types of alopecia.  When most people in the general population use the word alopecia, they are referring to a specific autoimmune hair disease called alopecia areata. Alopecia areata affects about 2 % of the population.

Individuals with hair loss want to know exactly why they are losing hair and it’s not uncommon for a patient to ask – “So, does that mean I have alopecia?” By definition, nearly every patient who comes to my hair loss clinic has alopecia.  Some, of course, do end up being diagnosed with alopecia areata, but a large proportion have one of the other 99 types of hair loss. The most common type of alopecia is androgenetic alopecia – also known as common balding. Androgenetic alopecia affects about 50-60 % of men and 30-40 % of women over the age of 40.

Hair Shaft Damage: The Real Cost of a Hair Dryer

Last week, I was discussing hair dryers at a local salon. The salon had an astonishing array of models to choose from. Some models offered high heat, others a variety of speeds. Some were inexpensive, some were hundreds of dollars.  How does one choose a hair dryer? It’s an important question – especially if someone already has hair damage. 

The process by which hair dries is a complex and fascinating process.   Water doesn’t simply evaporate from the hair that way water evaporates from city streets after a rainstorm. Instead, as water is removed from hair, many chemical bonds form and reform.  As everyone knows, hair drying not only removes water from the hair, but helps style it as well. This is because of new chemical bonds that are formed.

Excessive heat can damage hair and hair damage is something that I see often among women.  When I use the term hair damage, I’m really talking about damage to the hair fiber itself.   Individuals with hair damage note that hair is easily broken.  The hair loses its shine. The hair becomes less manageable. In some cases, hair shaft damage may even lead to hair loss.

For those individuals in whom I detect damaged hair, I advise using a hair dryer on a warm setting or locking the hair blower away for a period of time and only towel drying the hair.   The use of a deep conditioner or leave in conditioner may also prove useful.

I can instantly spot hair damage.  But knowing what causes hair damage can be a bigger challenge as hair damage can come from many sources.  The way the hair is colored, dried, brushed and ultimately styled can potentially lead to hair shaft damage. An array of scalp problems and hair diseases can also cause hair shaft damage.   

It’s incredible just how many types of hair dryers there are on the market.  The biggest price we pay for using them incorrectly is hair shaft damage.  Fortunately, for most individuals this damage is completely repairable and reversible when the problem is detected early.  Many women in my hair loss practice are hesitant to change way they dry their hair.  They want their hair dried quickly, and easily styled.  If there is no hair shaft damage, I don’t advise changing anything.  But for those with hair shaft damage due to heat, the heat must be reduced.  At first it is challenging, but when they see improvements in manageability and shine and eventually hair density too – it becomes impossible to go back to previous ways.