Did minoxidil (Rogaine) stop working?

Minoxidil for androgenetic hair loss

Consider the following scenario. An individual has been using minoxidil for one year and feels that it was working but not it seems it's not. What's happening? Did it stop working? Is something else going on?

Mininoxidil losing effect: What are the possible reasons?

There are several reasons for such a phenomenon. All in all, a hair loss expert can help sort this out.

POSSIBILITY ONE

Rogaine helped but the genetic hair loss simply is progressing faster than Rogaine can stop. Genetic hair loss for example does not move at a constant speed. Let's say for the sake of argument that I am "strong enough" to stop a small car from progressing forward down the street if it is moving at 1 mile per hour. However, if that same car moves at 30 miles per hour I can't stop it at all. Rogaine use for hair loss is like that - it might be able to stop hair loss for some individuals if the rate of progression is slow. But if new genes start being expressed a year or two later that accelerate the hair loss further - one might suddenly feel the Rigaine has stopped working. In such cases, it may not be that the Rogaine has stopped working rather the genetic hair loss has started progressing faster. A hair loss expert can help sort this out.

POSSIBILITY TWO

The patient has genetic hair loss and Rogaine is helping but that patient now has another condition. For example, if a patient has genetic hair loss but now lost 50 pounds over 5 months or developed a thyroid abnormality, it may "appear" that Rogaine stopped working whrn in actual fact they simply developed another reason for hair loss. A hair loss expert can help sort this out.

POSSIBILITY THREE

The patient doesn't even have genetic hair loss and it was simply a coincidence that they got an improvement on minoxidil (Rogaine).  For example, let's say a patient has hair loss from certain deficiencies like low iron. Correct the iron and hair improves. If the iron levels drop hair worsens. Now add use of Rogaine to this scenario, it might just be a coincidence the hair improves. A hair loss expert can help sort this out.

POSSIBILITY FOUR

Rogaine stopped working. Rogaine does not help everyone, and it's possible that it no benefits for some people. A hair loss expert can help sort this out.

POSSIBILITY FIVE

The brand of minoxidil was switched and is now made up at the pharmacy. This rarely has an effect but needs to be considered. The preparation of minoxidil is tricky and while most companies know how to make up minoxidil, it's not as easy as it sounds. A pharmacist who compounds minoxidil and does not have experience in the proper preparation could theoretically make an inferior batch. A hair loss expert can help sort this out.

The Many Causes of Scalp Itching

Scalp itching (Scalp pruritus)

Every new patient I see gets asked about scalp itching. It's a useful question because it leads me down a pathway of additional questions, especially to determine if there is also scalp burning and scalp pain.

There are a very large number of causes of scalp itching, sometimes referred to as scalp pruritus. Most of the time, the causes are not associated with hair loss but rather a coincidence. However, one needs to quickly work through a series of questions to get to the final answer - "You're scalp itching is nothing to worry about"

Causes of Scalp Itching

In general there are about 100 reasons to have scalp itching. The top 20 or so include (in no particular order):

Seborrheic dermatitis

dandruff (pityriasis capitis)

psorasisis

eczema

sebopsoriasis

fungal infections

allergic contact dermatitis

irritant contact dermatitis

stress and anxiety

head lice

lichen planopilaris

pseudopelade

discoid lupus

folliculitis decalvans

alopecia areata

telogen effluvium

malignancies

injury and trauma

autoimmune conditions

bacterial folliculitis

shingles / zoster

systemic illness

In fact, the list doesn't stop there, just this blog. If one has scalp itching, a careful examination of the scalp is needed and a series of fairly detailed questions. 

Prognosis of Folliculitis Decalvans: Pustules and Younger Age Associated with More Severe Disease

What Clinical Factors are Associated with More Severe Disease in Folliculitis Decalvans?

Vañó-Galván and colleagues recently retrospectively reviewed their data of 82 folliculitis decalvans patient in order to better understand associated clinical features and response to treatment.

Their study included patients from 12 dermatology centers across Spain. There were 82 patients (52 males and 30 females) with a mean age of 35 years. The vertex was the most common site. There were no significant comorbidities. A family history was present in three males. Itching, trichodynia, tufted hairs and pustules were part of the disease although they were not all consistently present. The table below (modified from the authors’ paper summarizes this data).

Comparisons of Males and Females Shows important Findings

What I liked about the authors’ paper was the fact they had a good number of female patients which allowed them to compare data from males and females. Males were more likely to be younger at the time of diagnosis, have pustules and have associated androgenetic alopecia. They were also more likely to have a family history.

Other features were similar. The distribution of severity was similar in males and females as were the proportions of patients having symptoms like trichodynia and pruritus and the proportion showing clinical features liked tufted hairs.

Modified from table in Vañó-Galván S et al. Folliculitis decalvans: a multicentre review of 82 patients. J Eur Acad Dermatol Venereol. 2015 Sep;29(9):1750-7.

Distribution of Severity Found to be Similar in Males and Females

Overall, 33 patients (40%) presented grade-I FD (largest patch less than 2 cm), 32 patients (39%) had grade-II FD (largest patch 2 to less than 5 cm) and 17 patients (21%) had grade-III FD (largest patch having a diameter of 5 cm or more,

Sites of Involvement: Vertex is Most Common Site in Males and Females

The most frequently affected area was the vertex (46 patients, 56%). Other affected areas included the parietal area (nine patients), the occipital area (five patients) and the frontal area (five patients).

 In 69 patients (84%), there was just a single unique alopecic patch of hair loss that was detected. In 13 patients (16%), the patient presented with 2–5 alopecic patches. Eyebrow loss was noted in 5 patients and beard involvement was noted in one patient. Eyelashes and body hair were not involved in this study of FD.

Swab Culture Results

Bacterial cultures from the pustules of the patch of hair loss were obtained in 33 patients. A positive result was noted in 73% of cases. The isolated bacterium was S. aureus in all cases except one case (where it was E. cloacae). Nasal bacterial cultures were performed in 10 patients with a positive result in 100% of cases. S. aureus the isolated bacterium in all of the nasal swabs

Factors Associated with Severe FD

The authors explored factors that were associated with more severe FD. They found that two in particular stood out : onset of FD before 25 years of age and presence of pustules.

Onset of FD before 25 years of age was associated with a 12 fold increased risk of having severe disease (OR: 12.4; 95% CI 1.49–103.08; P = 0.020). The presence of pustules in the alopecic patch was associated with a four fold increased risk (OR: 3.94).

Treatment of FD: Oral Antibiotics, Steroid Injections, Isotretinoin Provide Options

Oral antibiotics (particularly the tetracycline family and the combination of clindamycin and rifampicin) helped 90% and 100% of the patients, respectively. The authors’ full breakdown of treatment responses according to the drug chosen is shown in the Table below.

COMMENT

This is one of the largest retrospective studies of FD to date.

the vertex is the most common site in males and females. Males a re more likely to be diagnosed at an earlier age, have pustules and have associated AGA.

Yellow+younger are the two really important words not to miss here. Yellow refers to pustules in the alopecic patch and younger refers to age less than 25. These are the two independent factors associated with more severe disease.

The authors favour the use of antibiotics such as tetracycline family members (doxycycline, minocycline) the combination of clindamycin and rifampicin and dapsone are among the top options. Isotretinoin and steroid injections are very much on the list too

.

REFERENCE

Vañó-Galván S et al. Folliculitis decalvans: a multicentre review of 82 patients. J Eur Acad Dermatol Venereol. 2015 Sep;29(9):1750-7.

Did we forget about the muscles? A new look at AGA

It’s well recognized that the “bulge” region of the hair follicle houses hair follicle stem cells and is critically important to normal hair follicle cycling. But the bulge region is also the site where the arrector pili muscle (APM) inserts. To date, it has been thought that the APM does not have any active role in any of the various mechanisms of hair loss and more or less acts as a ‘bystander.’

Now, in new model of androgenetic alopecia, Australian dermatologist Rodney Sinclair and colleagues propose a new model for understanding androgenetic alopecia.  They propose that interactions between the APM and bulge are very important and that the APM, in fact, has a key role in the decision of a hair follicle to ultimately miniaturize.

By observing precisely how miniaturization occurs within follicular units – first in so called ‘secondary’ follicles of the follicular unit that are not attached to the APM and only later in‘primary’ follicles which remain attached to the APM for longer – the authors propose that the APM actually plays a role in maintaining follicular integrity.  The authors propose that by maintaining attachment to the APM, hair follicles are prevented from proceeding down the pathway of  permanent miniaturization.

Comment: Like all models, this proposal sets the stage for further exploration. The APM has perhaps been ignored for too long and may have a more important role than we imagined. 

REFERENCE

Sinclair R, Torkamani N and Jones L. Androgenetic alopecia: new insights into the pathogenesis and mechanisms of hair loss.  F1000Res. 2015 Aug 19;4 (F1000 Faculty Rev):585

The Man Bun -

Man bun may cause hair loss in some men

I was interviewed yesterday on Global News on a new hair style in men - the so called 'man bun' also known as the top knot.

GLOBAL NEWS- THE MAN BUN

The man bun refers to the tying of hair back (generally long hair) with placement of an elastic at the top of the scalp. Started in 2013, the man bun has caught on as a popular hairstyle in Hollywood and among the fashion elite. Leonardo DiCaprio, David Beckham and Brad Pitt have all chosen to wear a man bun.

 

The Man Bun is a Potential Cause of Traction Alopecia

The Man Bun has drawn attention recently as a potential cause of a specific type of hair loss called traction alopecia. Traction alopecia refers to hair loss from constant pulling forces - forces higher than the hair was designed to withstand.  Short term traction alopecia is often not a problem as hair can regrow. Left for months, traction alopecia can cause scarring in the skin and lead to permanent hair loss. 

 

Conclusion

The man bun is a great hairstyle that simply needs to be respected. Whether a man bun or ponytail, any hair that is tied up needs to be periodically relieved so that long term traction alopecia does not develop. 

Lecture on Scarring Alopecia

Interested to learn more about scarring alopecia? I'll be giving a public lecture Monday Sept 28 at 6:00 pm at the Fall meeting of the Canadian Association of Scarring Alopecias. See casafiredup.com for more information.

Hair transplantation and Psoriasis - Things to Consider

Psoriasis & Hair transplants

Hair transplants are usually fine for patients with limited scalp psoriasis. 

Theoretically, psoriasis can 'flare' with any surgery. It's quite rare but any trauma to the skin can cause psoriasis to worsen. This is called the 'koebner phenomenon.' For this reason, it's a good idea for an individual with psoriasis to get his or her psoriasis under good control before surgery. A dermatologist can guide with this, but treatments commonly include topical steroids, topical vitamin D agents or both. Other treatments are also possible. 

After surgery, it's a good idea to monitor for flaking and itching. Significant 'flares' of psoriasis are quite uncommon after hair transplantation in my experience but it's always a good idea to have a plan in a place should it occur. 

Dry Shampoos

Dry Shampoos: What are the benefits?

I often recommend dry shampoos. They are helpful for those situations where my patients want more volume and want to remove oils but don’t want to shampoo with water. There’s no specific number as to how often they can be used but once or twice weekly is fairly normal for many of my patients. Dry shampoos have many benefits. I recommend them to some patients who are looking for ways to hide greys or even add colour to their hair. Some patients can get a similar hold to the hair without needing to use hairsprays. They are great for use after a workout. It takes a bit of time to get use to dry shampoos but many of my patients use twice weekly between shampoo days. 

Recent Article in Elle Canada

I was recently interviewed by Victoria DiPlacido from Elle Canada on dry shampoos. For a link to the article, click here:

Could dry shampoo be ruining your hair?

Steroid injections - an essential part of the hair loss toolbox

Steroid injections are a key part of the hair loss physician's toolbox. Without steroid injections, I am severely limited in treating certain types of hair loss - especially those associated with inflammation.

The conditions shown here are associated with some degree of inflammation and steroid injections can help.

Side Effects

Few hair loss treatments cause the amount of fear that steroid injections cause. When used appropriately, steroid injections can be very helpful and safe. Anyone thinking about steroid injections must speak to their physician about all the risks and benefits. Steroid injections can cause slight discomfort when injected and can cause a temporary dimpling of the skin. Very little gets absorbed into tue body, but nevertheless can be important in those with diabetes, high blood pressure and a few other medical issues. All in all steroid injections can be extremely helpful in the treatment of many hair loss conditions. There are several different compounds used for such injections including triamcinolone acetonide shown here. A physician will choose a variety of concentrations ranging from 2.5 to 10 mg per mL.

Minoxidil helps the top AND front in men

Does minoxidil only help the back?

Minoxidil is FDA approved for treating genetic hair loss in men? Early studies showed that it helps the top of the scalp in men which created confusion regarding its role in the front of the scalp. 

Minoxidil can help the frontal hairline. It may not restore it to the 'original' density. But it certainly can help. Two studies in the past year really helped clear up the myth that minoxidil doesn't help the frontal hairline. 

STUDY 1: Drs Hillman and colleagues

Hillman K et al published a study in 2015 evaluated the efficacy of twice daily 5% minoxidil foam in the frontotemporal region of male patients with genetic hair loss after 24 weeks of treatment compared to placebo treatment and to the vertex region.  Study results indicated that hair counts and hair caliber increased significantly compared to baseline in both the frontotemporal and vertex scalp.   Furthermore, patients actually using 5% minoxidil foam rated a significant improvement in scalp coverage for both the front  and top areas.

  
 
STUDY 2 - Drs Mirmirani and colleagues

In another study, Mirmirani et al  performed a double-blinded, placebo controlled research study of minoxidil topical foam 5% (MTF) vs placebo in sixteen healthy men ages 18-49 years with genetic hair loss. Study participants applied treatment (active drug or placebo) to the scalp twice daily for eight weeks. Again, similar to the previous study, results showed that minoxidil improved frontal and vertex scalp hair growth of AGA patients.

Conclusion

There is little doubt now that minoxidil can help some men with frontal hair loss. It does not help everyone, and doesn't return the hair back to the original density. But it certainly can help. 

STUDIES REFERENCED

Hillman K et al. A Single-Centre, Randomized, Double-Blind, Placebo-Controlled Clinical Trial to Investigate the Efficacy and Safety of Minoxidil Topical Foam in Frontotemporal and Vertex Androgenetic Alopecia in Men. Skin Pharmacol Physiol. 2015;28:236-244.  

Mirmirani et al. Similar Response Patterns to 5%Topical Minoxidil Foam in Frontal and Vertex Scalp of Men with Androgenetic Alopecia: A Microarray Analysis. Br J Dermatol. 2014 Sep 10. 

Frontal Hairline Changes in Women with Afro-texture hair.

Traction alopecia in young women

I posted a new video about the traction alopecia as a cause of hair loss in young women with afro textured hair.

PRP for treating alopecia areata

Our new manuscript to be published in September

In addition to genetic hair loss, platelet rich plasma also an option for treating alopecia areata.

A 2013 study in the British Journal of Dermatology showed the PRP may be as effective as low dose triamcinolone acetonide in treating patchy alopecia areata

I have an interest in understanding the role of PRP in a number of hair loss conditions. In the September 2015 issue of the Journal of the American Academy of Dermatology Case Reports, I described a patient with alopecia areata who did not regrow with traditional treatments (steroid injections). The use of platelet tich plasma (PRP) ultimately prompted regrowth of hair. 

REFERENCE
JAAD Case Reports 2015; 1:305-7

Minoxidil for the Eyebrows.

Minoxidil use in the eyebrows

Minoxidil is not formally approved for the eyebrows but many physicians have different ways of using it. There's no specific way that minoxidil must be used in the eyebrows.  For anyone considering using minoxidil for the eyebrows, I recommend to speak to a physician first to review all the risks and benefits. A 2014 study (referenced below) did show that 2 % minoxidil was helpful in stimulating eyebrow growth for some individuals.

Methods of Minoxidil use for the brows

1. 5 % minoxidil twice a day

2. 5 % minoxidil once a day

3. 2 % minoxidiil twice a day

4. 2 % minoxidil once a day

5. Minoxidil 5 times per week

6. Minoxidil alternating with bimatoprost (Latisse)

There are many causes of eyebrow loss. Without seeing a given person's eyebrows and knowing more about his or her medical history and history of eyebrow loss exactly, it's hard to know if minoxidil could work and which of these protocols might work best.  Minoxidil side effects include headaches, dizziness, heart palpitations, shedding in the first 8 weeks. The medication must never be used by women who are pregnant or breastfeeding. 

Reference of Interest

Lee S et al. Minoxidil 2% lotion for eyebrow enhancement: a randomized, double-blind, placebo-controlled, spilt-face comparative study. J Dermatol. 2014 Feb;41(2):149-52. 

Twins and Hair loss

Two types of twins

There are two types of twins: identical twins and fraternal twins. There are two types of twins. In identical twins, the DNA is the same. In fraternal twins, the DNA is different just like any other siblings. 

Identical twins' hair may look different with age

The hair of identical twins look similar at young ages and may look different when older. Genetic hair loss has a lot do to genetics, but not everything. Smoking, ultraviolet radiation, medical conditions (ie. thyroid disease), obesity, and stress all affect the process of genetic hair loss.  

PRP for Genetic Hair Loss: What is the evidence?

TREATMENT OPTIONS FOR GENETIC HAIR LOSS

Minoxidil and Finasteride are two FDA approved treatments for genetic hair loss. Other treatments like low level laser therapy (LLLT) and platelet rich plasma (PRP) are also possibilities. 

What is PRP?

Platelet rich plasma is a treatment whereby a patient's own blood is used for treating his or her hair loss. We no longer live in a world where we wonder if PRP works. We have now entered an era where we have evidence it does something and now need to figure out how well it works and who it works in.  

To date there have been approximately seven studies on the role of platelet rich plasma in treating genetic hair loss. These studies include:


1) Schiavone et al 2014

Number of patients in study: 64 patients

Design: PRP every 3 months

Results: At 6 months, 40.6% to 54.7 % had clinically significant change

2) Cervelli et al 2014

Number of patients in study: 10 patients

18 mL blood

Design: Randomized half head study

Results: Significant increase in terminal hairs at 3 months

3) Gkini MA et al

Number of patients in study: 20 patients

Design: 16 mL blood; 3 treatments q 21 days and at 6 months

Results: Hair increased; 7 out of 10 satisfaction rating

4) Park et al
Number of patients in study: 1 patient

Design: Weekly treatment x 4 week

Results: Hair grew faster

5) Kang JS et al

Number of patients in study: 13 patient

Design: One treatment

Results: Improved number of hairs and thickness

6) Khatu et al, 2014

Number of patients in study: 11 every

Design: 2 weeks x 4 treatments

Results: Improved thickness & hair counts by 22.09 FU per cm2

7) Betsi et al 2012
 

Number of patients in study: 42

Design: 16 mL blood

Results at 3 months; High patients satisfaction 7 of 10; Improvement in hair volume 

REFERENCE LIST

Cervelli et al. The effect of autologous activated platelet rich plasma (AA-PRP) injection on pattern hair loss: clinical and histomorphometric evaluation. Biomed Res Int. 2014;2014:760709. 

Gkini MA et al. Study of platelet-rich plasma injections in the treatment of androgenetic alopecia through an one-year period. J Cutan Aesthet Surg. 2014;7:213-9. 

Kang JS et al . The effect of CD34+ cell-containing autologous platelet-rich plasma injection on pattern hair loss: a preliminary study. J Eur Acad Dermatol Venereol. 2014;28:72-9. 

Khatu et al, Platelet-rich plasma in androgenic alopecia: myth or an effective tool. Cutan Aesthet Surg. 2014;7:107-10. 

Park et al. Letter: Platelet-rich plasma for treating male pattern baldness. Dermatol Surg. 2012;38:2042-4. 

Schiavone G et al. Platelet-rich plasma for androgenetic alopecia: a pilot study. Dermatol Surg. 2014;40:1010-9.

Scarring Alopecia - October Lecture

Do you have scarring alopecia? Join us Oct 5th in Toronto

If you or someone you care about has scarring alopecia, you might consider joining the Canadian Association of Scarring Alopecia for its Fall Meeting. I'm honoured to be invited to speak to the Group Oct 5th at 6 pm on the topic: What's New in Scarring Alopecia?

There's been an incredible surge of new information. I'll be sharing research from our own studies as well as studies from around the world on frontal fibrosing alopecia, lichen planopilaris, central centrifugal cicatricial alopecia, pseudopelade, discoid lupus, folliculitis decalvans, dissecting cellulitis, acne keloidalis

Contact the Canadian Association of Scarring Alopecia for more information. 

See you then,

Jeff

Hair Follicle Stem Cells: What are they?

A stem cell is a cell that has the ability to become many different types of cells depending on the conditions. In essence, it can wear many hats, take on many roles depending on the conditions. Once a stem cell changes into a new cell type there is no going back - it needs to keep its new job.

Once of the most revolutionary studies that changed the face of the field of hair medicine was Dr George Cotsarelis's study in 1990 that the hair follicle bulge area contains stem cells. Dr Cotsarelis is Professor at the University of Pennsylvania in the United States


REFERENCE
Cotsarelis G, Sun TT, Lavker RM. Label-retaining cells reside in the bulge area of pilosebaceous unit: implications for follicular stem cells, hair cycle, and skin carcinogenesis. Cell. 1990 Jun 29;61(7):1329-37.

THE NOCEBO PHENOMENON

What is the nocebo phenomenon?

Some people get side effects from a drug because they know if could be a side effects. It's simply a part of being human. And we see it with many drugs. Now imagine males being warned about a drug that can cause erectile dysfunction, decreased libido and other sexual issues. How many will develop issues simply from this advanced knowledge and warning?

These are precisely the low but well known uncommon side effects of the male balding drug finasteride. How common are sexual issues from finasteride simply from the warnings? Well, a study from Italy set out to test this in 2007. Patients were divided into two groups - one group which got a warning and one which did not. 

So, what were the results?

Results showed that about three times more men reported side effects when they were given advanced waring compared to me who did not receive any such warning. Erectile dysfunction and decreased libido was reported in 31 %  and 24 % of men who received the warning compared to only 10 % and 8 % of men who were not counselled about this side effect.

Conclusion

The so called Nocebo Phenomenon is powerful and needs to be remembered in interpretation of all studies and evaluation of all clinical data. 

REFERENCE

Mondaini N et al. Finasteride 5 mg and Sexual Side Effects: How many of these are related to the Nocebo Phenomenon? J Sex Med 2007; 4: 1708-12

New molecules for future research in androgenetic alopecia

New pathways for androgenetic alopecia: A look at IGF-1

We still don't fully understand the cause of genetic hair loss (aka androgenetic alopecia) and how best to treat it. Of all the cytokines & growth that have been postulated to play a role in hair follicle, insulin-like growth factor-1 (IGF-1) is known to be regulated by androgens. It's not clear if IGF-1 is altered in any way in the course of androgenetic alopecia.

Is IGF-1 altered in the balding scalp?

Prior to 2014, it wasn't well understood if IGF-1 levels are altered in the scalp's of patients who are experiencing balding.  In a recent 2014study, the  expressions of IGF-1 and its binding proteins from dermal papilla (DP) cells were compared in balding and non balding scalps. 

Interestingly,  cells from balding scalp follicles were found to secrete significantly less IGF-1, as well as the binding proteins, IGFBP-2 and IGFBP-4 (P < 0.05).

Conclusion and Comments

While this study does not prove that IGF-1 plays a direct role in androgenetic alopecia, it certainly is interesting. Further study is needed. It will be interesting to research whether PGD2 levels (which are known to be elevated in androgenetic alopecia) somehow impair IGF-1. 

REFERENCE

Panchaprateep R1, Asawanonda P. Exp Dermatol. 2014 Mar;23(3):216-8. Insulin-like growth factor-1: roles in androgenetic alopecia.

 

 

The FOUR "S's" of hair loss

SPEED, SYMPTOMS, SHEDDING AND SUPPLEMENTS

The fascinating thing about hair loss is that every single piece of information from the patient is 'potentially' relevant to their hair loss. That's a lot of 'potentially' - and potentially a great deal of frustration ..... unless one is prepared with a strategy to decipher all the information being given to them!

Is the fact that a patient's hair got worse after starting a job in the bank relevant? Maybe. Maybe not. 

Is the fact that a patient's hair got worse after starting a new vitamin relevant? Maybe. Maybe not. 

Is the fact that a patient's hair got worse after changing shampoos relevant? Maybe. Maybe not.

 

The Four S's of Hair Loss

I use the 4 S's of hair loss every day. It's an extremely important tool to keep track of what is important and what is less important when acquiring information about a patient's hair loss. The four 's stand for SPEED, SYMPTOMS, SHEDDING AND SUPPLEMENTS.

Everything piece of information about hair loss is potentially important to gather from patients.

1. SPEED.

How fast is the hair loss occurring (speed)? A patient who looks different month to month does not have genetic hair loss as the main issue!  A patient who looses massive (near total) amounts of hair in 3 days likely has alopecia areata or has had chemotherapy.  The speed of hair loss is important. 

2. SYMPTOMS

Does the patient have itching, burning or pain in your scalp (symptoms)? I never get too concerned about a bit of itching; however burning and pain raise alarm for something inflammatory and concerning. I generally perform a scalp biopsy in patients with significant itching, burning and pain.

3. SHEDDING

Is the patient shedding more than your normal? Is there hair on the pillow in the morning? Is their hair in the patient's food? Hair shedding is a normal thing but once it becomes excessive a patient notices. If shedding patterns are different for a given patient than they once were, this is abnormal shedding. plain and simple!  We get too hung up on counting hairs - Is it less than 100? Is it more than 100? This is important I agree. But the most important question is : Is the patient's daily shedding patterns different than they used to be!

4. SUPPLEMENTS

Finally, what pills or supplements does the patient take (supplements)? Many pills have the potential to cause hair loss but so do all supplements - including those for treating hair loss, blood pressure, weight loss, body building, depression.

I ask about the four S's - everytime !