Can hair follicles make nerves?

Can hair follicles make nerves?

The hair follicle is an amazing structure.  Above the surface of the skin, we see only the hair fiber which is composed mostly of a non-living substance called keratin.

Nestin: A key marker for stem cells

It's only when you look below the surface of the skin, that you begin to see the complexity of the hair follicle. Just a short distance under the skin, within a part of the hair follicle called the bulge ... there exists cells that have the potential to become neurons, muscle cells and pigment producing cells. Scientists can now easily identify these cells because they contain a protein called 'nestin.'

For example, if these special hair follicle cells are transplanted (i.e. into a mouse) they can become blood vessels and neural tissue. Further research is needed to understand the full potential of the hair follicle.

Reference

Hoffman RM. The potential of nestin-expressing hair follicle stem cells in regenerative medicine. Expert Opin Biol Ther 2007

 

Options for Camouflaging Hair Loss

Camouflaging Hair Loss

Individuals with hair loss may decide to pursue medical or surgical treatment for hair loss or may decide to reduce the appearance of hair loss with a variety of scalp camouflaging agents.  Some of my patients do both.

Current camouflaging agents for hair loss include:

• wigs and hairpieces
• keratin fibers
• powder cakes
• scalp camouflaging sprays
• scalp camouflaging lotions
• hair extensions
• scalp tattooing and micropigmentation

We recently published a comprehensive article about all of these scalp camouflaging agents in the Dermatology Online Journal. Our hope is that this article will provide medical professionals with helpful information so that they may in turn counsel their own patients with hair loss.

A link to our article can be found here.

 

Hair loss and lupus: Doc, do you think my hair loss could be from lupus?

Hair loss and lupus:

Anyone who is losing hair knows how frustrating it can be to find accurate information. It is often difficult to figure answers by searching the internet. Confiding in a friend about hair loss leads to one piece of advice, while a second friend offers completely different advice. It seems daunting to pinpoint which of the 100 causes of hair loss are responsible.

In the search for answers, it's not uncommon for a patient to ask me "Do you think my hair loss could be from lupus?" Are you going to test me for it?

What is lupus?

Lupus, also known by the medical term "systemic lupus erythematosus" is an autoimmune condition. It has the potential to affect nearly every body system from the skin to heart to lungs to brain to kidney (....and that is why the word "systemic" is used). It affects approximately 50 out of every 100, 000 people. Current estimates suggest there are 500,000 individuals in the USA and 50,000 individuals in Canada affected by lupus. Women are affected nearly 9 times more commonly than men. Black women are particularly affected.

What are the signs of lupus and should I get tested?

For every patient with hair loss that I see, I run through a series of simple "screening questions. " If the answers to all these questions are "NO" then I usually don't give any further thought to the patient in front of me having lupus. If the answer to one or more of the questions is "YES" it certainly does not mean the patient has lupus, but means that I might ask more "in depth" questions.

Typically, my "screening questions" for lupus that I ask patients with hair loss include the following 13 questions:

HAIR CLINIC SCREENING QUESTIONS FOR LUPUS:

1. Have you been experiencing extreme levels of fatigue lateley?
2. Do you experience headaches... and if so...how often do you get them?
3. Have you ever experienced a seizure in your life? how many?
4. Do you see or hear things that you think other people might not hear or see?
4. Do you have joint pains ...and if so ...which joints?
5. Do you have high blood pressure? Has it been difficult to control with medications?
6. Do you have pain in the chest when you take a deep breath?
7. Do you experience dry mouth or dry eyes?
8. Do you experience ulcers in the mouth, nose (and for women in the vagina) that you are aware of?
9. Do you develop rashes on the face or skin when you go out in the sun? Do you find you burn much easier than before?
10. Have you ever been told you have abnormal blood work results? ( especially, low hemoglobin, low white blood cells, low platelets)
11. Has anyone in your family been diagnosed with lupus in the past?
12. Have you ever had a blood clot?
13.(Women) Did you ever have a miscarriage and if so, how many?

Many, many individuals will answer " YES" to a question or two from the above list. It does not mean they have lupus. But if they answer "YES" to a few questions it points me down a path of very, very detailed questioning. The formal American College of Rheumatology criteria for diagnosing lupus can be found by clicking here.


Should I get a blood test for lupus?

The vast majority of patients with hair loss do NOT need to have a test for lupus. This can't be overstated enough. However, if the answers to a few of the screening questions above are " YES" then testing 'could' be at least considered. If I am even slightly suspicious, I usually order a blood test known as the ANA (anti-nuclear antibody test).   If the ANA blood test returns "positive", additional blood tests (Group 2) may be ordered. It takes alot of experience to interpret these tests and it can sometimes be challenging to diagnose someone with lupus.  Referral to a rheumatologist is often required.

Group 1 test for lupus

ANA (anti- nuclear antibodies)

• 99 percent of people with lupus will have a positive test. However, many other conditions (and even normal healthy people) can have a positive ANA test. So having a positive ANA does not necessarily mean you have lupus.  Rarely, patients with lupus can even have a negative ANA test (especially early in the disease).

Group 2 tests for lupus (ordered if the ANA test is positive)

1. CBC (complete blood count)

• Individuals with lupus may have low levels of red blood cells, white blood cells and platelets

2. Urinalysis

• To check if there is protein or blood in the urine. This can be a sign of kidney damage.

3. Creatinine

• Another measure of kidney health. Patients with kidney disease may have increased creatinine levels.

4. ESR ( erythrocyte sedimentation rate)

• A measure of inflammation in the body. Many conditions can increase ESR, not just lupus.

5. C3 and C4 (complelment levels)

• Complement levels may be lower in patients with autoimmune diseases and used to monitor activity of the disease

6. ENA (extractable nuclear antigens) which include the anti-Smith test

• The ENA test measures many antibodies, including Jo, Sm, RNP, Ro, La, Scl-70. These antibodies can be positive in many different types of immunologic conditions. Patients with lupus may have a positive anti-Smith test (and sometimes other positive results from the ENA panel of tests too).

7. Antiphosphopilid antibodies

8. Anti-ds DNA test (anti-double stranded DNA test)

In summary, is the diagnosis of lupus should only be made by a medical professional. There are well over 100 causes of hair loss and certainly lupus is on that list and therefore needs to be at least considered. Simply having a positive ANA test doesn't automatically mean an individual has lupus. Obtaining a very detailed medical history and performing a detailed physical examination is very important in the overall evaluation of a patient suspected of having lupus.  Because lupus is a disease that affects many organs in the body, patients diagnosed with lupus are often treated by rheumatologists as well as other specialists (cardiologists, respirologists, neurologists, nephrologists, dermatologists). 

 

Genetic Balding in a 6 and 8 year old?

Genetic Balding: How young does it  affect?

Androgenetic alopecia ( also known as genetic /hereditary balding) occurs in 50 % of men and 30 % of women by age 50.  Genetic balding can occur in teenagers but rarely occurs under age 11.

Italian dermatologists recently published an interesting report in the journal Pediatric Dermatology.  They described two healthy sisters aged 6 and 8 years who presented with a one year history of hair thinning which the dermatologists diagnosed as androgenetic alopecia.  Lab tests were normal in these two girls.Treatment with 2% minoxidil was successful in improving hair density.

Comment:

Although androgenetic alopecia is rare in the pre-teen years, it may rarely occur.  In these rare situations the first occurance is just before puberty during a period of hormonal change called "adrenarche." A strong genetic predisposition is often found... and the mother of the two girls in the study also had early onset of androgenetic alopecia at age 18.

Reference

Familial Androgenetic Alopecia in Siblings with Normal Endocrinologic Status. Pediatric Dermatology. Vol 29.  p 534-35.

TIPS FOR GREAT SUMMER HAIR

Recently, Monica Matys of Sunnybrook Medical Centre interviewed me about tips for great summer hair. A short 1 minute segment of the interview can be found in the new "Sunnybrook Says" website.

Certainly, I'm seeing lots of patients with sun damaged hair. I can spot sun damaged hair because it's lighter in color, more brittle, and lacks shine. 

When I speak of sun damaged hair, I'm really referring to the damage that occurs to the outermost part of the hair follicle called the "cuticle". Lots of things can damage the cuticle in the summer months, including chlorine, salt water, sand, hair dryers and over processing of the hair with chemicals

Here's a few tips I recommend to keep hair looking great in the summer.

1. Limit the amount of sun on the scalp by wearing a hat or scarf. This can make a big difference by the time the end of the summer rolls around.

2. Don't worry about how often you shampoo in the summer but focus on conditioning regularly. I ask some of my patients to condition every day. Conditioners protect the cuticle!

3. If an individual has a lot of damaged hair, I may ask them to use a deep conditioner once weekly.

4. Limit the amount of heat on the scalp. If a hair blower is going to be used to style the hair, then towel dry or air dry the hair about 80 % before using the hair blower to style the hair.

5. Limit the dyeing of the hair to every 8 weeks in the summer. There is good scientific evidence that chemicals make the hair even more susceptible to being damaged by the sun.

6. Get a trim often in the summer. There is only one way to deal with split ends from sun damage and that is to cut them off. Removing split ends can immediately improve the look of the hair.

These simple tips can make a big difference in what the hair looks like by the time September or October rolls around.

Smoking and Androgenetic Alopecia: Why I ask and Why I Encourage Patients to Quit

Smoking and Androgenetic Alopecia:

For many years, researchers have been examining whether smoking speeds up the process of genetic balding (also called "androgenetic alopecia").  The studies have been somewhat inconsistent but point to the possibility that smoking accelerates the process of male balding.

An important study examing the relationship between smoking and hair loss was a 2007 study by the Taiwanese group of Dr. Su and Dr Chen.  These researchers examined 740 patients between the ages of 40 and 91 over a 2 month period.  They found that smokers generally had worse androgenetic alopecia compared to non-smokers. In fact, smokers had nearly a two-fold increased risk of having moderate or severe genetic hair loss compared to non-smokers. In addition, the early development of male balding was more likely in smokers.

Why Would Smoking Speed Up the Development of Male Balding?

No one knows for sure. It may be that smoking is damaging to the tiny blood vessels and the there are toxic substances in cigarette smoke that damage the cells in the hair follicles. It's also possible that smoking causes inflammation which speeds up the process of genetic hair loss. Certainly, more research is needed to figure out why.

Why I Encourage my Young Patients with Androgenetic Alopecia to Quit Smoking

There is yet another reason why I encourage young men and women with androgenetic alopecia to quit smoking.  We know from carefully done studies that young men with balding have an increased risk of cardiovascular disease later in life.  The same seems to be true for women as well. Furthermore, it's well know that smoking is one of the key risk factors for cardiovascular disease.  Taken together, it's of paramount importance to help patients stop smoking. (For additional articles, on the interplay between smoking, hair loss and cardiovascular disease click here).

Reference

Su LH and Chen T H-H. Association of Androgenetic Alopecia with Smoking and Its Prevalance Among Asian Men. Archives of Dermatology 2007 143; 1401-1406.

Mosley JG and Gibbs AC. Premature grey hair and hair loss among smokers: a new opportunity for heatlh education? British Medical Journal 1996; 313: 1616.

Severi G et al Androgenetic alopecia in men 40-69 years: prevalence and risk factors.British Journal of Dermatology 2003; 149: 1207-1213

 

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.  

 

Do physicians understand how much hair loss affects their patients?

Do physicians understand emotions of hair loss?

Some patients are extremely distressed by hair loss, even if the amount of hair loss is minimal.  Are doctors very good at picking up how a patient's hair loss affects their quality of life?

Researchers from Chicago examined set out to determine if dermatologists can predict how much their patients' quality of life is affected by their hair loss. The researchers examined 104 women with three hair loss disorders (androgenetic alopecia, telogen effluvium and alopecia areata).

Dermatologists downplay hair loss severity

The researchers found women rated their hair loss as more severe than their dermatologists rated the hair loss. Moreover, the degree of a patient's hair loss did not correlate with how much patient's quality of life was affected. For example, some with minor amounts of hair loss were quite distressed by their hair loss whereas some patients with more extensive loss were minimally affected.  Interestingly, the amount of hair loss a patient perceived they had experienced did correlate with how much it impacted their quality of life.

Implications of hair loss study

This study has important implications for physicians who see patients with hair loss. If physicians want to understand how a patient is affected by their hair loss, they need to ask patients just how much hair loss they perceive to have occurred.  I generally try to get a sense of this by asking patients "how much hair loss do you think you've had - ....a little bit? ... a moderate amount? ... or a lot?"



Reid EE et al.  Clinical severity does not reliably predict quality of life in women with alopecia areata, telogen effluvium and androgenetic alopecia. J Am Acad Dermatol 2012; 66:e97-102

 

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

 

Does Sunlight Worsen Androgenetic Alopecia? Lessons from the Police

Sunlight Worsens Androgenetic Alopecia

Androgenetic alopecia, or male pattern balding, is common.  In fact, about 50 % of men will have androgenetic alopecia by age 50. It is well known that genetics and hormonal influences play an important role in men.                                      

But what about other factors?                                                                                                                         

The role of ultraviolet radiation in male balding has been debated for many years and we still don't know all the answers.  However, many scalp diseases are made worse by ultraviolet radiation.  For example, my patients with seborrheic dermatitis will often report flares following sun exposure.  In addition, patients with discoid lupus or dermatomyositis  may note worsening after sun exposure.

The exact role of ultraviolet radiation in male balding is not clear.  We know that inflammation is present under the scalp in many men with genetic hair loss and so the question arises... How did that inflammation get there? ...  and is their any possibility that sun exposure contributes to the inflammation that is found under the scalp in men with balding?

An interesting study from researchers in Taiwan offers further clues that sunlight just 'might' contribute in some way to male balding.  The researchers compared balding patterns in 758 policemen  and 740 men in the general polulation.  Interestingly, policemen aged 40 to 59 had a two fold increased risk of having male balding. In addition, there was a statistically significant association between male balding and sunlight exposure.

More research is needed understand if and how ultraviolet radiation affects the process of male balding. If a link is found, it will be important to determine if men who reduce sun exposure (with hats, etc) will slow down the natural progression of the male balding process.

Su et al. Androgenetic alopecia in policemen: Higher prevalence and different risk factors compared to the general population.  Arch Dermatol Res 3: 753-61.

 

Treating Alopecia Areata with Antihistamines: Just a Co-incidence or a New Avenue of Study?

Alopecia Areata & Antihistamines:

It’s challenging to conduct research studies in alopecia areata. One of the reasons is that hair growth can occur spontaneously – even if no treatments are administered. For this reason, it’s important that any new drug promising benefit in alopecia areata be carefully studied.

Several studies have suggested that antihistamines might be helpful for treating alopecia areata. However, these studies were small and we still don’t know if this might be a helpful treatment.

For example, researchers from Japan recently reported a 19 year old woman patient with alopecia areata at the back of the scalp (called the ophiasis pattern of alopecia areata) who improved following treatment with fexofenadine (marketed under the trade names Allegra, Telfast, Fastofen, Tilfur, Vifas, Telfexo, Allerfexo). The young woman was initially treated with strong topical steroids but had no improvement over a four month period. After adding fexofenadine, an improvement was seen within 3 months.

Is this a co-incidence or a real effect?

The answer is - we don't know.

A previous study of 121 patients with advanced alopecia areata suggested that fexofenadine could help patients with alopecia who were receiving treatment with immunotherapy (either DPCP or squaric acid dibutyl ester). But the improvement was only seen in patients who had atopic eczema, asthma or hayfever. A handful of other studies have suggested that other types of antihistamines may be beneficial for alopecia areata.

Reference

Nonomura Y et al. Case of intractable ophiasis type alopecia areata presumably improved by fexofenadine. The Journal of Dermatology 2012; 39: 1-2.

Inui S. Fexofenadine hydrochloride enhances the efficancy of contact immunotherapy for extensive alopecia areata: Retrospective analysis of 121 cases. Journal of Dermatology 2009; 36:323-327.

 

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 Loss Drugs and Breastfeeding: Which Medications are Safe?

The following situations are a commonly encountered in a busy hair loss practice:

A 32 year old woman with genetic hair loss (androgenetic alopecia) was using topical minoxidil solution before her pregnancy. She stopped it during her pregnancy and now is wondering if she should start it up again after her delivery. She is breastfeeding. Is it safe to use this medication?

A 28 year old woman with genetic hair loss (androgenetic alopecia) was using the oral drug Spironolactone  before her pregnancy. She stopped it during her pregnancy and now is wondering if she should start it up again after her delivery. She is breastfeeding. Is it safe to use this medication?

 A 34 year old woman with discoid lupus of the scalp (a scarring alopecia) was using the oral drug Hydroxychloroquine before her pregnancy. She stopped it during her pregnancy and now is wondering if she should start it up again after her delivery. She is breastfeeding. Is it safe to use this medication?

 A 27 year old woman with folliculitis decalvans of the scalp (a scarring alopecia) was using the oral drug clindamycin along with the drug rifampin before her pregnancy. She stopped it during her pregnancy and now is wondering if she should start it up again after her delivery. She is breastfeeding. Is it safe to use this medication?

WHICH HAIR LOSS MEDICATIONS ARE SAFE TO USE WHILE BREASTFEEDING?

Although I often discontinue many hair loss medications during pregnancy, the question frequently arises as to whether some medications can be restarted while moms are breastfeeding.  Breastfeeding has many benefits for babies.  For some drugs, the answer is yes. For others, the answer is no.

In 2001, the American Academy of Pediatrics published a helpful guide as to the safety of medications during breastfeeding. It's important to always check with your physician before starting any medication during breastfeeding. However, the following medications (used in hair loss) are felt to be safe for women who are breastfeeding.  For a full list of medications which are safe during breastfeeding, click here.

List of Hair Loss Drugs Regarded as Safe in Breastfeeding

B12

Cefazolin

Chloroquine

Ciprofloxacin

Clindamycin

Hydroxychloroquine

Folic acid

Ketoconazole

Topical Minoxidil

Prednisone

Rifampin

Trimethoprim/sulfamethoxazole

Therefore, the four women I mentioned above were able to safely use these medications while breastfeeding.  However, women considering using any medication while breastfeeding must check with their health care provider.

Am I getting new hair growth or is it breaking off?

Whenever I examine the scalp, I methodically check for a number of different things. Essentially I have a "checklist" in my mind and all components need to be evaluated before I feel I have properly examined the scalp.

One essential part of the scalp examination is evaluating if patients have new growth - and if so - how much. I like to get a sense of how much hair the patient has grown in the last one month, the last three months and the last six months. Often when I remark to patients that they are experiencing a lot of new growth, I hear a reply such as

How do you know it's new growth?

How do you know my hair is not just breaking off?

The answer is straight forward. Newly growing hairs have 'pointy' ends whereas hairs that have broken off have 'blunt' ends. The photo on the right illustrates these differences. The yellow arrow highlights a newly growing hair with a pointy end and the green arrow identifies a broken hair with a blunt end.  The presence of broken hairs can be due to many causes, including excessive hair damage (heat damage, chemical processing, use of straightners).

Examining for newly growing and broken hairs is an important part of the scalp examination and should be done each time a thorough scalp exam is done.

Alopecia Areata Occurring After Age 50

Alopecia areata affects all age groups. In fact, one-half of individuals with alopecia areata develop their first episode of hair loss before the age of 18.

Over the past 20-30 years, we have come to understand that a wide range of autoimmune diseases can occur in patients with alopecia areata. For example, previous studies have taught us that up to 20 % of patients with alopecia areata have thyroid disease and about 50 % of patients with alopecia areata have an itchy skin condition known as atopic eczema. In addition, we now know that a family history of alopecia areata occurs in about 10 to 20 % of patients.

Alopecia areata is an autoimmune disease. Many different autoimmune diseases behave differently in older individuals than younger individuals. We don’t know exactly why this occurs but it may be because the immune system changes as we get older.

But what about alopecia areata? -

Does this condition have different characteristics in those who first develop the condition after age 50?

Do older patients differ from younger patients with alopecia areata?

A New Study from Taiwan

Researchers from Taiwan set out to determine the characteristics of individuals who developed their first episode of alopecia areata after age 50.

Their study consisted of 73 patients with alopecia areata. All patients developed their first episode of hair loss after age 50. Two-thirds of the patients in the study were female and one-third of the patients were male. Approximately one-third were found to have thyroid abnormalities and one-quarter had a skin condition, like nail pitting or atopic eczema. None of the 73 patients had a family history of alopecia areata.

Conclusions

 
All in all, this small study suggested that older individuals who develop their first episode of alopecia areata may have slightly different characteristics compared to younger individuals. Although more studies (and larger studies) are needed to definitively prove this, but it appears that alopecia areata first occurring in older individuals:

• tends to be a milder type
• may be slightly more likely to affect women than men
• may not have as strong of an association with skin eczema or a family history of alopecia

 Reference 

Title of Study: Wu MC, Yang CC, Tsai RY and Chen WC. Late-onset alopecia areata: A retrospective study of 73 patients from Taiwan. Journal European Academy Dermatology Venereology 2012;

Dr. Donovan on Discovery Channel's Daily Planet

Back in 2010, I was interviewed by Ziya Tong, the co-host of the Discovery Channel's Daily Planet show.   Our topic was hair (and fur!). I've posted a link to the Daily Planet segment below. Enjoy!

Watch video

Antibiotics after Scalp Biopsies: Do You Need to Use Them?

There are over 100 reasons to lose hair. Sometimes the reason a person is losing hair (i.e. the diagnosis) is obvious as soon as I meet the patient. Othertimes, a small scalp biopsy is needed in order to examine the hairs under the microscope before reaching the final diagnosis.

A previous blog of mine reviewed how a scalp biopsy is performed. The procedure takes about 15 minutes and is performed using local numbing medicines. An important question patients ask is:

Should I be applying an antibiotic cream or ointment from the drug stores to my stitches after the procedure in order to help prevent infection?

The answer is straightforward for the vast majority of scalp biopsies I do: No.

Antibiotic creams or ointments are usually not required for patients undergoing a scalp biopsy. Numerous studies have shown that about 1 to 2 % of patients undergoing simple skin surgeries willl develop an infection. But more importantly, the risk is not reduced if patients use an antiobiotic cream or ointment. In fact, the unnecessary use of a topical antibiotic might increase the risk of developing an allergy to one of the ingredients (like neomycin or bacitracin).

Fortunately, the message is catching on among physicians that we don't need to use topical antibiotics for most procedures. A recent study showed that between 1993 and 2007 there were about 212 million routine skin surgery procedures in the USA. Topical antibiotics were used in about 6 % of those procedures. Fortunately, the researchers showed that the use of topical antibiotics has decreased over time (from about 7 percent back in 1992 down to about 3 percent at the present time).

Exceptions, of course, do exist. If a patient has very poorly controlled diabetes or they are immunosuppressed the use of oral antibiotics before a procedure might be recommended. Similarly, I might consider antibiotics if a patient has certain types of problems with their heart valves or recently had a hip or knee replacement.

But more often than not, patients do not need to use antibiotic creams or ointments after their scalp biopsy. Petroleum jelly might be recommended to simply keep the area moist and speed up healing.

References

1. Levender MM et al. Use of topical antibiotics as prophylaxis in clean dermatologic procedures. Journal of te American Academy of Dermatology 2012; 66:445-51.

2. Smack DP etal. Infection and allergy incidence in ambulatory surgery patients using white petrolatum vs bacitracin ointment: a randomized controlled trial. JAMA 1996; 276:972-7

3. Campbell RM et al. Gentamycin ointment vs petrolatum for management of suricular wounds. Dermatol Surg 2005; 31;664-9.

4. Dixon AJ et al. Randomized clinical trial of the effect of applying ointment to surgical wounds before occlusive dressing. Br J Surg. 2006; 93:937-43.

What are the Causes of Hair Shedding?

It's normal to shed between 50-100 hairs per day. When more than 100 are lost, it may be abnormal. Abnormal or excessive hair shedding is known by the medical term "telogen effluvium."

There are many reasons to have hair shedding.  These include physiological stresses on the body (like having a surgery), thyroid problems, crash diets, low iron levels and certain medications. These can all cause hair shedding.

The following video on hair shedding was prepared by Monica Matys of Sunnybrook Hospital in conjunction with the Sunnybrook Media department. I hope you will find it educational and informative.