Alopecia Areata : Is it Genetic ?

Alopecia Areata  : Is it Genetic ?

I'm often asked if alopecia areata is "genetic." It's sometimes hard to believe that alopecia areata is so strongly tied to genetics when only 10-20 % of patients have a family history of the condition. But dozens of high quality research studies back up the statement: alopecia areata is "genetic."

Alopecia Areata is a Multifactorial Genetic Trait

There is not just one gene that is involved with the developing of alopecia areata- there are many. For this reason, alopecia areata is said to be a multifactorial genetic trait.  If one of your first degree relatives is affected by alopecia areata, you have a ten fold increased risk of developing alopecai areata.  But the inheritance patterns are complex- even if one identical twin develops alopecia areata - the other twin has only a 55 % chance of developing alopecia areata.

We're learning more and more every day about the complex genetics of alopecia areata. We've come to learn that alopecia areata is likely much more closely related to type 1 diabetes and rheumatoid arthritis than we ever imagined. The exact genes and segment of genes that increase one's risk of developing the condition are slowly being worked out.

Right now alopecia is 'genetic' but is influenced to some extent by the environment too. That's why one twin develops aloepecia and the other twin does not. The exact environmental factors that contribute to alopecia areata are still being worked out as well.

DPCP for Children and Adolescents: Is it Effective?

DPCP for Children and Adolescents

Diphencyprone or “DPCP” is frequently prescribed for individuals with alopecia areata who develop more extensive amounts of hair loss or for individuals who aren’t improving with steroid injection treatments.  As shown in the photo to the right, DPCP is a liquid and is applied to the scalp weekly, usually in a dermatology clinic setting.  It causes a mild allergic reaction in the scalp skin, which in turn promotes hair regrowth in some individuals. In adults, DPCP treatment promotes hair regrowth in approximately 30-50 % of individuals. 

What about DPCP in Children & Adolescents?

We decided to examine this question. Prior to our study, the use of DPCP in children had not been thoroughly explored is whether DPCP is effective for children with alopecia areata. In fact, the use of DPCP in children has been the focus of only a 3-4 of research studies - and these studies were quite small.  One previous research study of 26 children indicated that DPCP helped with hair regrowth in 35% of patients. A second study of 12 patients indicated hair re-growth in 67% of patients.  

We recently published our research findings in the journal Archives of Dermatology. We looked back through the medical charts of 108 children who received DPCP at Sunnybrook Hospital in the past 10 years.    Children ranged in age from 4 months to 18 years. Most children had tried other treatments, such as steroids or minoxidil, prior to starting DPCP. However, none of those treatments were helpful and so DPCP was started.

Does DPCP have side effects in Children and Adolescents?

Overall, treatment with was safe, but minor side effects did occur in about one-half of patients. These included swelling, hives, small blisters and skin breadkdown and swollen lymph nodes.  About 13 % of patients stopped treatment after 2 months owing to a variety of factors, such as these side effecsts, difficulties commuting to the treatment center, and/or the disruption caused by weekly absences from school.

Was DPCP Beneficial ?

Overall, our research data showed that about one-third of children benefitted from DPCP treatment. 25 % of children had a partial improvement and 10 % had full regrowth.   

Conclusion

Our study is one of the largest research studies looking at whether DPCP is beneficial for children and adolescents with alopecia areata. It is a valuable study because it provides us helpful information that we can share with parents who bring their child to the DPCP clinic. Overall,  DPCP will help about 1 out of every 3 children who go through treatment.  However, only 1 out of every 10 children will experience full regrowth with treatment.  Right now, it’s not possible to predict which children will benefit from DPCP and who will not.  Certainly, more research is needed to understand how to make DPCP even more effective for children.

 References of Interest

1. Salsberg, J and Donovan, J. The Safety and Efficacy of Diphencyprone for the Treatment of Alopecia Areata in Children.  Archives of Dermatology 2012; 148: 1084-5.

2. Schuttelaar ML, Hamstra JJ, Plinck EP, et al. Alopecia areata in children: treatment with diphencyprone. Br J Dermatol. 1996;135(4):581-585.

3. Hull SM, Pepall L, Cunliffe WJ. Alopecia areata in children: response to treatment with diphencyprone. Br J Dermatol. 1991;125(2):164-168.

4. Mukherjee N, Burkhart CN, Morrell DS. Treatment of alopecia areata in children. Pediatr Ann. 2009;38(7):388-395.

 

Hair Loss in Women: Often More than a Single Cause!

Hair Loss in Women: Often More than a Single Cause!

Hair loss among women is common. Although it's natural to think there is a single cause of an individual's hair loss, women often have more than one reason for their reduced hair density or 'hair thinning.'

Example: Consider the 32 year old woman who came into see me for her first appointment. She told me that she had been using minoxidil topical lotion for a 8 months now for a presumed diagnosis of:

Presumed diagnosis:

1. Female Pattern Hair Loss (also known as androgenetic alopecia).

However, she felt her hair was not getting better. She had some annoying scalp itching from time to time and wondered if she should stop the mionxidil as she was told the lotion could sometimes cause itching.

Is this the correct diagnosis? What should she do to stop her itching?

Join me as we pursue the necessary "detective work" to come up with the correct diagnosis for this woman and ultimately help her hair improve. First, lets take a look at her scalp up close:

Is this normal? Is it abnormal? Well, let's compare this photo to a relatively normal appearing scalp from a similarly aged woman in my practice with good hair density and extremely healthy hair. You'll note that all the hairs are fairly similar size (calibre) and the scalp itself is not red and their is no scaling or flaking:

Now that we know what is normal, let's return to the 32 year old woman with hair loss. Many things can be seen by examing this woman's scalp. First this woman has many 'thick' hairs. The light blue arrows show the thick hairs (also called terminal hairs).

However, this woman also has many thinner hairs with greatly reduced calibre (skinnier hairs). These thinner hairs are known as "miniaturized hairs" and the green arrows below point to several miniaturized hairs. Miniaturization is frequently seen in individuals who have a diagnosis of "androgenetic alopecia" (also called female balding or female pattern hair loss):

So I know this woman has androgenetic alopecia as one of her diagnoses.  But the other thing that is noted is that she not only has many skinnier hairs, but she also has a significantly reduced number of hairs.  You can see that the hair density that is seen in the top of the picture is very different than in the bottom of the picture  - the blue stars show the "missing hairs." So we know that she has lost a lot of hair.  

By gently pulling on several of her hairs, I discover that many of these remaining hairs come out pretty easily. This is called a "positive pull test" and this test is a sign this woman may have excessive shedding ( a phenomenon called telogen effluvium). In fact, the orange arrows point to many of these telogen hairs - which are farily easy to spot in this photo because telogen hairs become much lighter in color as they are about to shed from the scalp. So we are gaining some good evidence that this woman has an abnormal shedding problem:

As I described in a previous  video, there are many causes of exessive or abnomal shedding. The include low iron levels, thyroid problems, crash diets and a variety of medications. Basic blood tests performed in this patient showed she had very low iron levels. Further details also revealed she had multiple cycles of crash dieting in the past one year. These are certainly two potentially important causes for her shedding.

Further examination of her scalp showed that there is redness in the scalp and some scale. The red arrows in the photo below point to this scale:

There are many causes of scale but this woman scale and the redness in her scalp is typical of a condition called seborrheic dermatitis. Scalp "dandruff" and seborrheic dermatitis are two closely related processes and are caused by a common yeast called Malasezzia. Seborrheic dermatitis is very common and causes scalp itching and redness and excess flaking. Often patients notice that their scalp feels better if they wash their hair more often as this helps reduce the annoying itch they sometimes experience. Seborrheic dermatitis may cause itching but doesn't typically cause hair loss. Additional questions showed that this woman had scalp itching long before she started using the topical minoxidil therapy - so her itching may be coming from her seborrheic dermatitis rather than the minoxidil ! However, both are possible.

So at this point, it appears this woman does in fact have female pattern hair loss, but she also has three other diagnoses:

1. Female pattern hair loss (also known as androgenetic alopecia).

2. Telogen effluvium (exess hair shedding) - from low iron levels

3. Telogen effluvium (exess hair shedding) - from crash dieting

4. Seborrheic dermatitis

But is this ALL she has?

For this patient, further questioning revealed that the cause of her low iron was very likely from heavy and sometimes irregular menstrual periods. She could go several months without a period. Additional blood work and an ultrasound of this woman's ovaries showed that she in fact had a condition known as polycystic ovarian syndrome or "PCOS."  Women with PCOS have altered hormone levels which can cause hair thinning.  The altered hormone levels are produced by the ovaries. Early diagnosis of this condition is extremely important as women with PCOS have a higher chance of developing diabetes, high blood pressure, infertility and high cholesterol.  She was referred to an endrocinologist for further evaluation of her PCOS.

Final diagnoses for this woman: 

1. Female pattern hair loss - with Polycystic Ovarian Syndrome

2. Telogen effluvium (exess hair shedding) - from low iron levels

3. Telogen effluvium (exess hair shedding) - from crash dieting

4. Seborrheic dermatitis

How was this woman ultimately treated?

This woman was continued on her topical minoxidil therapy as it was concluded this was NOT a cause of her particular symptom of itching.  On account of her diagnosis of PCOS, she was advised to start on a birth control pill to regulate her periods. Oral Spironolactone medication was also started to help her androgenetic alopecia. Iron pills were prescribed to help the low iron levels and blood work was performed every 5 months to ensure the iron levels were rising properly. The woman's diet was stabilized to ensure that no further crash dieting would occur. The seborrheic dermatitis was treated with an anti fungal shampoo and this helped stop her itching. An improvement in hair density was noted in 6 months.

Conclusion

Diagnosing hair loss in woman often requires a bit more detective work than hair loss in men. Hormonal issues, and hair shedding conditions are more common in women than men. One should never assume that a patient has a single diagnosis for their hair loss -- all causes need to be explored. This can only come with a very detailed history about the patients hair loss, past health, diet, medications, family history and a very detailed examination of the scalp.

Topical Estrogen for Androgenetic Alopecia:

Topical Estrogen for Androgenetic Alopecia:

Topical estrogens were used many years ago for the treatment of androgenetic alopecia as well as other hair loss problems. Their use dimished when other medications, such as minoxidil, became available.

In 2004, researchers from Greece studied the benefit of estrogens in 75 post menopausal women with androgenetic alopecia

25 patients applied the medication for 12 weeks (15 drops every evening for 4 weeks and then every other night for 8 weeks),

25 patients applied the medication for 24 weeks (15 drops every evening for 4 weeks and then every other night for 8 weeks),

25 applied placebo medication for 12 weeks.

What were the results ?

Side effects included  mild itchiness, redness and scaling in the scalp. 2 women receiving the 24 week course developed uterine bleeding about 4 and 5 months into the study. Overall, about 60 % of patients receiving the estrogen had an increase in the number of growing hairs (anagen hairs) and a decrease in the number of telogen hairs (resting hairs). “Before and after” data or assessments of patients views on their treatment were not included in this particular study.

Comment:

This 2004 study is an interesting research paper.  It reminds us of the well known fact that estradiol has important benefits  for hair. Estrogen therapy is too often forgotten about in the treatment algorithms of hair specialists. More studies in how best to administer topical estrogen are needed – especially in combination with treatments such as minoxidil, prostaglandin analogues (like Latisse) and the laser comb.

REFERENCE

Georgala S et al. Topical estrogen therapy for androgenetic alopecia in menopausal females. Dermatology 2004; 208: 178-179

 

Perifollicular Scale in Lichen Planopilaris

Perifollicular Scale in Lichen Planopilaris

Lichen planopilaris is a "scarring hair loss condition" (also called cicatricial alopecia) that affects both men and women. Hair loss can occur anywhere in the scalp. Lichen planopilaris often causes patients to have itching, burning or pain. Patients may also report increased daily hair shedding.

Diagnosis of LPP

The diagnosis of lichen planopilaris can be confirmed with a scalp biopsy - but sometimes it's not absolutely necessary. Patients who come to the the office with hair loss accompanied by itching or burning or pain and have scale encircling their hairs like shown in the two pictures - have a diagnosis of lichen planopilaris without question.

Early detection and treatment of lichen planopilaris is important because the hair loss in this condition is permanent. The sooner treatment can be started the sooner we give patients the chance to stop (or slow down) the rate of their hair loss.

To Dense Pack or Not to Dense Pack

What is dense packing?

For patients having a hair transplant, dense packing refers to the placement of hair follicle grafts close together such that the final density is high (i.e. dense) - greater than 30-35 follicular units per square cm.  Dense packing may lead to densities as high as 50 follicular units per square cm in some cases. The diagram on the right illustrates these different densities.

Some surgeons have argued that dense packing is preferable in some cases because a better cosmetic result can be achieved. Other surgeons have argued that very good results can still be achieved wtih densities of 30 -35 FU/cm2 without risking the chance of getting poor survival of the grafts.   Poor survival is a theoretical possibility because grafts have to be trimmed thinner and thinner in order to be able to pack them close together.

Over the past 5-10 years, we have slowly gained more information about the survival of grafts and particularly how to improve the survival of densely packed grafts. But certainly more research needs to be done. A 2005 study showed that graft survival with dense packing at 50 FU/cm2 was 84 % (i.e. 16 % died) compared to 98 % (only 2 % died) at a density of 30 FU/cm2.   Compare this to a 2008 study by Drs Nakatsui, Wong and Groot which showed that survival was as high as 98.6 % in  a patient transplanted with a density of 72 FU per cm squared in on small test area. The technique used to tranpslant hairs in this study was slightly different than used in the 2005 study mentioned above.

To dense pack or not to dense pack?

The decision on packing density depends on many factors - including their age, the quality of their hair (i.e. hair color, curl, coarseness), the available donor hair and the likelihood of future balding.

Dense packing of 50 FU/cm2 in a 45 year old man with coarse curly salt and peppery colored hair probably won't give much of a cosmetically different result than a 30 FU/cm2 density. In fact, doing so runs the risk of using up more hair and possibly limiting the number of hairs that might be possible to transplant when the man is 55 or 65.

The decision on dense packing needs careful consideration. 

References 

Mayer M, Keen se S, Perez-Meza D. Graft Density Production Curve with Dense Packing. International Society of Hair Restoration Surgery Annual Meeting. Sydney Australia 2005

Nakatsui et al. Survival of Densely Packed Follicular Unit Grafts Using the Lateral Slit Technique. Dermatol Surger 2008; 34: 1016-25.

 

Nail Pitting in Individuals with Alopecia Areata

Nail Pitting in Individuals with Alopecia 

Most patients with hair loss who come to see me are surprised when I examine their nails.  But it should come as no surprise because hair and nails are closely related.  The proteins found in the nails are also found in the nails!  In fact, I tell my patients that hair and nails are like cousins.

Nail Pitting in Alopecia Areata

For example, 10 to 40 % of individuals with the hair loss condition "alopecia areata" develop small holes in the nails that we call 'pitting.'  A picture of nail pitting is shown in the photo on the right. Individuals who have pitting usually have a more stubborn form of alopecia that is much more challenging to treat. Believe it or not, there are yet another 10 nail changes that can occur in individuals with alopecia areata; nail pitting however is the most common.  Pitting is also seen in other conditions as well (including conditions known as eczema and psoriasis) - so simply having pitting in the nails doesn't mean you have alopecia areata.

The Importance of Examing the Nails

Nails are important for all hair physicians to examine. Sometimes I glance at them when meeting a patient, sometimes I look at them quickly, sometimes I spend 2-3 mintues looking at them. But one things is for certain - the examination of the nails shouldn't be ignored.   Readers may recall a blog I wrote back in early 2011.

Take for example the young man who came to see me for a hair transplant. He was convinced he had male balding and so were his family, friends and even other doctors. He had a bit of itching in the scalp and had been losing his hair fairly quickly. His hair loss bothered him tremendously and he wanted me to transplant him.  But by examining his nails, I quickly learned that he had pits in the nails. A small scalp biopsy done that same day showed that the man didn't have male pattern balding but rather alopecia areata. If I were to transplant him - he would not have grown any hair. (Alopecia areata is one hair loss condition that can not be transplanted - see previous blog).

Nail changes occur in many hair conditions.  If we are hoping to learn as much as we can about a patient's hair loss, then the opportunity to examine the nails should not be missed.

Hair Textural Changes

Hair Texture Changes

Many changes in the hair and scalp may occur as we get older. Some women notice that hair becomes thinner in the front while remaining curlier and thicker in the back. Hair tends to grow slower. Hair greying becomes particularly common.

While hair can sometimes becomes drier, coarser and more kinky as we age, it’s important to have a thorough medical examination by a dermatologist with these particular changes you describe.

Several medical conditions (such as low thyroid hormone levels) and a handful of scalp diseases (including a group of hair conditions known as the scarring alopecia’s) may also lead to coarser and kinkier hair. 

In the photo on the left, you'll see a large area of hair loss in a patient with a hair loss condition known as a "scarring alopecia."  This patient is essentially developing scar tissue in the scalp that is destroying much of their hair.  As the disease progresses (note how it is moving outward in the direction of the little arrows), more and more hair is destroyed.  As this happens, some hairs start twisting and bending - it is during this process that the patient will begin to note textural changes in their hair.  The large yellow arrow shows one of these twisting hairs. There are many causes of hair textural changes but scarring alopecia is one of them. 

Previous blogs for Reference

Scarring Alopecia and the Concept of the "Trichologic Emergency"

Lab Tests for Assessing Thyroid Disease

 

Question from Website Visitors: H1N1 Vaccine and Hair Loss

H1N1 Vaccines: Do they cause Hair Loss/

QUESTION FROM READER 

I have had hair shedding for about 2 and a half years now.  Been told I have telogen effluvium, but I also have burning, itching and scalp pain.  The burning comes and goes and sometimes my scalp is so red. Recently I also had a blood test showing elevated DHT levels. This all started about 4 months after I received the H1N1 vaccine in November of 2009, but is now getting worse. Could there be a relation between this vaccine and hair loss?  Also could the burning be a sign of scarring alopecia?

ANSWER FROM DR. DONOVAN

Thanks for this interesting question.  My main recommendation would be to ask your dermatologist for a biopsy.

You are absolutely correct that individuals with itching, burning and pain in the scalp may have an increased chance of having a scarring alopecia. However, many other conditions are possible too (inclduing conditions called chronic telogen effluvium and alopecia areata) and a thorough scalp evaluation and detailed medical history are required before reaching a diagnosis. If you haven't already, a basic blood work profile for hemoglobin levels, thyroid tests, lupus, and iron studies should be done. Other blood tests might be helpful too depending on the answers to a range of medical questions your doctor will ask you.

The elevated DHT levels may be normal, but a thorough work up for free testosterone and total testosterone and possibly other hormones could be considered to get a better sense of whether or not your elevated DHT levels are concerning or not.  

It would be anyone's guess as to whether your vaccination had any contribution to your hair loss. We do know that in a very, very small proportion of individuals vaccinations and infections can trigger various autoimmune conditions. In terms of autoimmune hair loss conditions, a very small number of individuals note that a hair loss condition known as "alopecia areata" is worsened by vaccinations. However, this proportion is very small and the vast majority of individuals recieve vaccinations without any hair loss.

At present, there is no evidence that the H1N1 vaccine causes hair loss. It is intriguing that a Japanese study from 2012 reported 7 patients who developed the hair loss condition alopecia areata within 1-4 months of getting an infection with the H1N1 virus. These patients had an actual infection with the virus not the vaccine. It's really difficult to know if this was coincidence or not because 2 % of the world will develop the hair loss condition alopecia areata at some point in their lives (it's that common).  Whether the H1N1 vaccination could cause hair loss is not known.

You might find the previous blog I wrote on scalp redness helpful as well.

What are the Causes of Scalp Redness? 

I hope this information offers you help.

- Dr. Jeff Donovan  

Reference

Ito T. Alopecia areata triggered or exacerbated by swine flu virus infection. J Dermatol 2012; Oct 39:863-4

 

Dr. Donovan Interviewed by CityNews Toronto

Dr. Donovan Interviewed by CityNews Toronto

Dr. Donovan was interviewed today by Andrea Piunno of CityNews Toronto on a new research study which showed that men and women with signs of aging (such as hair loss) have an increased risk of heart disease.

Heart attacks more likely the older you look:

Click for a link to the CityTV video

 

Follicular Units: The Building Blocks of Modern Hair Tranplantation

Building Blocks of Modern Hair Tranplants

The figure on the right shows that hair follicles normally emerge from the scalp in groups of one, two or three hairs.  These groupings of hairs are called "follicular units".

Hair transplant surgery nowadays relies on the use of these "follicular units". 

In individuals with genetic hair loss, hairs from the back of the scalp can be removed and processed into "follicular units" and then inserted into the front or middle of the scalp.

The second photos shows some freshly prepared "follicular units" from a patient undergoing a hair transplant. "Follicular units" containing single hairs are normally placed into the frontal hairline and "follicular units" containing two or three hairs are normally placed behind this area.  This strategy of placing follicular units mimics what we see in the normal scalp and when placed at precise angles and directions - allows a hair transplant to look natural.

Hair Loss in Black Women: CCCA

Hair Loss in Black Women: CCCA

Central Centrifugal Ccatricial Alopecia (or 'CCCA' for short) is a common cause of hair loss in black women. Some estimates suggest that up to 30% of black women have CCCA. Unfortunately, the condition is very much underrecognized and underdiagnosed. Too often women with CCCA are misdiagnosed as having genetic hair loss - both conditions lead to hair loss in the central scalp.

CCCA causes permanent hair loss in the central scalp.  Individuals affected by the condition sometimes have scalp itching, burning or pain but very often have no symptoms.  This make it difficult to catch the diagnosis in early stages.  Hair loss gets worse over time. The cause is not known at present although hair styling practices and the use of of chemicals and relaxers continue to be explored as causes.

How can we improve our ability to diagnose CCCA?

CCCA is underrecognized in the medical community and underdiagnosed.  How can we train more physicians to recognize this common condition? Certainly training others  to recognize this condition is the first step. There is a suprisingly easy rule I teach doctors who work with me in my clinics:

Any black women with hair loss in the middle of the scalp needs evaluation (& possibly scalp biopsy) to rule out the diagnosis of CCCA.

Hair loss from CCCA is permanent. In most cases regrowth is not possible. Treatments help stop further hair loss but are not always 100 % effective. Treatment for CCCA includes topical steroid medications and steroid injections. Oral medications including tetracycline based antiinflammatory drugs can also be used. Hair transplantation can be successfully used to restore hair density once the condition becomes quiet.

A New Era in the Treatment of Androgenetic Alopecia: Focus on the "Prostaglandin Pathway"

The "Prostaglandin" Pathway

Recently, we've been hearing a lot about a group of hair growth drugs that affect "prostaglandins".  Several recent blogs of mine have discussed the role of prostaglandin F2a analogues in stimulating eyelash growth (click here for article).  A few months ago a major buzz was created in the hair world when Dr. Cotsarelis at the University of Pennsylvania showed that blocking the prostaglandin D2 pathway might be relevant to the treatment of androgenetic alopecia (click here for article).

New Study Highlights Role of Prostaglandin Analogues

Latanoprost is a prostaglandin F2alpha drug that is often used in treating glaucoma (an eye disease characterized by elevated eye pressures). Recently the drug has been shown to be useful in stimulating eyelash growth. 

In yet another study, researchers from Germany examined the use of the drug latanoprost 0.1% in the treatment of men with androgenetic alopecia (male balding). 16 men participated in the study.  All men had early staged androgenetic alopecia  Men applied one drop (50 microliters) of latanoprost solution to one small area of the scalp daily and one drop of the placebo drug (mock drug) daily for 24 weeks. 

What were the results?

Overall about 50% of men benefitted from the drug.  Patients who did end up benefitting from the drug showed evidence of improved growth by 16 weeks. The drug was well tolerated with the most common adverse effect being scalp redness. Interestingly, the patients who developed scalp redness also experienced hair growth.  How exactly these two are related remains to be clarified.

Comment

These results are exciting and highlights the importance of this prostaglandin pathway.  We will certainly be hearing a whole lot more about the pathway in the years ahead. Its important to note that all participants in the study were men, so we don't know if the results are generalizable to women.  Furthermore, all men in the study had early stage androgenetic alopecia so we dont know if the drug will have benefit for men with more advanced stages of balding.

Reference

Blume- Peytavi et al. A randomized double-blind placebo-controlled pilot study to assess the efficacy of a 24 week topical treatment by latanoprost 0.1 % on hair growth and pigmentation in healthy volunteers with androgenetic alopecia.  Journal od the Amaerican Academy of Dermatology 2012; 66:794-800.

Do Patients Receiving DPCP for Alopecia Areata Treatment Get Absorption into the Bloodsteam?

Do Patients Receiving DPCP Get Absorption into the Bloodsteam?

DPCP is a liquid chemical which is used as a topical treatment for alopecia areata. It's used in both children and adults with alopecia areata. One question that I’m often asked is whether DPCP gets absorbed into the body.

Does DPCP get absorbed?

In 1994, researchers from the UK set out to determine if DPCP is absorbed following topical application.  The researchers analyzed the blood and urine of 18 patients with alopecia areata who received approximately 0.5 mL of a 1 % DPCP solution. DPCP was not detected in any of the blood or urine samples.  These data suggest that DPCP is not absorbed following topical application onto the scalp.

Reference

Berth-Jones et al. Diphencyprone is not detectable in serum or urine following topical application. Acta Derm Venerol 1994; 74: 312-3.

 

What is the best test to do if I think I have celiac disease?

What is celiac disease?

Celiac disease is an autoimmune disease of the bowel. When individuals with celiac disease eat foods containing "gluten" (such as barley, rye, wheat), inflammation develops in the small bowel. This leads to damage to the small bowel which prevents it from properly absorbing food.  Celiac disease can develop at any age. It’s more common in Caucasians and those of European ancestry. Women are affected to a greater extent than men.

Patients with celiac disease may have many symptoms.  The most common symptom is diarrhea that lasts many weeks or months (termed "chronic diarrhea") as well as weight loss.   But a range of symptoms are possible, including abdominal pain, weight loss, bloating, gas, and constipation. In fact, celiac disease can sometime be challening to diagnose because it has many different ways of presenting.

Should patients with hair loss be tested for celiac disease?

Many patients with hair loss wonder if they should stop gluten or if they should be tested for celiac disease.  In most cases, the answer is "no."  However, testing for celiac disease may be recommended f the patient has abdominal symptoms or long standing weight loss. Sometimes I also check for celiac disease if a pateint has low iron levels that just don't seem to raise despite use of iron pills.  A very small percent of patients with autoimmune hair loss conditions (i.e. alopecia areata) do have celiac disease.  

The most common tests that are ordered to SCREEN if someone has celiac disease are:

1. Tissue transglutaminase Antibodies (tTG)

2. Endomysial Antibodies (EMA) 

3. Other tests "may" be ordered by the physician as well including IgA antibodies and specific genetic tests such as HLA-DQ2 and HLA-DQ8.

Overall, the tTG test is the best screening test. It's inexpensive, quantitative and a highly reproducible test.

What is done once a patient is diagnosed with celiac disease? 

Once diagnosed with celiac disease, a gluten free diet will be recommended. In some cases, a referral to a gastroenterologist may be recommended. Follow up blood tests may be ordered to assess how well an individual is doing with their gluten free diet.

 

Hair Loss Treatments on the Horizon

Hair Loss Treatments on the Horizon

I returned from an outstanding meeting of the 21st Annual Meeting of the European Academy of Dermatology and Venerology in Prague.  This video highlights some of the exciting hair loss treatments that may be on the horizon including the latest in hair cloning research and new topical medications produced by L'Oreal.

Hope you enjoy it!

More Pieces to the Vitamin D Puzzle

More Pieces to the Vitamin D Puzzle

At least once a day, I’m asked about the role of vitamin D in hair loss. Back in July, I wrote a blog article about the role of vitamin D in hair loss.   Vitamin D does its job inside cells by binding to the vitamin D receptor or VDR.

How important is vitamin D in helping prevent hair loss in humans?

Modern science still doesn’t have all the answers. But by turning to research in mice, we have learned a lot or valuable lessons.  About 10 years ago, we learned that hair loss develops in mice that lack the vitamin D receptor (VDR). Researchers in San Francisco recently discovered a molecule called MED1 which helps the action of the vitamin D receptor. In fact, the researchers found that if they blocked the actions of MED in mice those mice grew less hair. The research findings were recently discussed on the NBC today's show:

Visit NBCNews.com for breaking news, world news, and news about the economy

These data suggest that defects in MED1 or defects in vitamin D signaling could potentially be involved in the development of certain types of hair loss – but more research is needed.

CONCLUSIONS

1. Vitamin D has an important role in hair growth – mice that lack the vitamin D receptor (VDR) develop hair loss and mice that lack an activator of the VDR (called MED) develop hair loss

2. It’s more complicated than simply taking more vitamin D pills. Don’t think for a minute that popping more vitamin D pills is going to lead to more hair growth.

REFERENCES

Xie et al. Lack of the vitamin D receptor is associated with reduced epidermal differentiation and hair follicle growth. J Invest Dermatol 2002; 118: 11-6.

Oda Y et al. Coactivator MED1 Ablation in Keratinocytes Results in hair Cycling Defects and Epidermal Alterations. Journal of Investigative Dermatology 2012; 132: 1075-83

Finasteride Use by Young Men: Not only for Baldness in the Crown !

Finasteride Use by Young Men

For years, we've largely assumed that finasteride helps men with hair loss in the crown, but does little for men with hair loss in the front of the scalp or the temples.

A new study by US researchers has nicely shown that finasteride 1 mg daily can help young men with male pattern balding regardless of where on the scalp the man has hair thinning.

The researchers studied men 18 to 60 years of age for a period of two years. Four areas of the scalp were examined: (1) vertex (crown), (2) the mid-scalp, (3) the frontal hair line and (4) the temples.

What were the results of the study?

The study showed that young men benefitted from taking finasteride - regardless of where there hair thinning occured. Young men (age 18-40) with hair loss in front, temples, mid-scalp or crown all had benefit from taking finasteride. However, the same was not true of men age 41-60. Men in this slightly older group benefitted most if their hair loss was in the crown and the mid-scalp.

Reference

Olsen EA et al. Global photographic assessment of men aged 18 to 60 with male pattern hair loss receiving finasteride 1 mg or placebo.  J Am Acad Dermatol 2012; 67: 379-86. (click for abstract)

 

More Benefits of Checking Iron Levels in Women with Hair Loss

Checking Iron Levels in Women with Hair Loss

As many of my patients know, iron metabolism is one of my favourite subjects. It also forms one of the components of the hair loss research that I do. 

I generally recommend that all women with concerns about hair loss have their iron levels checked using the simple blood tests called ferritin. Other blood tests may also be ordered for women with hair loss, such as thyroid tests and a complete blood test to measure the hemoglobin level.

Although it is somewhat contraversial among hair experts around the world, the iron level I like my patients to aim for is a ferritin level above 40-50 ug/L.  If the blood test shows less than this, then I recommend supplementation with iron pills.

New research outlines additional benefits of checking iron levels in women

In a recently published study, Swiss researchers studied 198 premenopausal women who had ferritin levels less than 50 ug/L and symptoms of fatigue. A proportion of women in the study received ferrous sulphate pills and another proprotion of women received placebo pills.

 

What were the results of the study?

At the end of the 12 week study, women who received iron noted a significant improvement in their overall level of fatigue compared to women receiving the placebo pills.  The ferritin level in women recieiving the iron pills increased by approximately 12 ug/L over the 12 weeks of the study.

 

Comment

Many premenopausal women have low iron levels. This study reminds us that there are many improtant benefits of iron, including helping improve the overall feeling of fatigue (if levels are low). Although I routinely follow iron levels in  my patients, this study reminds us that asking about improvement in fatigue levels may also be an important parameter to assess in making a decision about continuing iron supplements for the longer term.


Reference

Vaucher P et al. Effect of iron supplementation on fatigue in nonanemic 
menstruating women with low ferritin: A randomized controlled trial. CMAJ 
2012 Aug 7; 184:1247. (Click link for article)

 

Plan to Attend the Canadian Skin Patient Conference !

The Canadian Skin Patient Alliance (CSPA) is a Canadian Organiziation created by patients for patients with a variety of skin problems – including various types of hair loss. The CSPA is planning to hold its first-ever Canadian Skin Patient Conference, October 12 to 14, 2012. The conference is being held at the Toronto Downtown Marriott Eaton Centre Hotel.  Attendees will have access to the latest information and opportunities to get to know other skin patients and how they cope.  Click on the link to learn more about this unique conference and watch the video for more information.

Hope to see you there!

Jeff.

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