Ahh the benefits of a scalp biopsy. A favourite topic of mine. A scalp biopsy refers to a short 10 minute procedures where a piece of skin and accompanying hair is taken from the scalp and sent off for analysis under the microscope. The area where the skin was removed is then stitched up with sutures.
Scalp biopsies are a big help - Sometimes!
The scalp biopsy is a BIG help when performed in the right patient and at the right time in their hair loss progression. However, the scalp biopsy is unhelpful and potentially even detrimental to reaching the proper diagnosis when they are performed "just because". As an example let's look at these two scalp photos. The patient on the left AND the patient on the right both brought in results from their scalp biopsies showing inflammation and scarring. These two features are often seen in a group of autoimmune conditions called the "scarring alopecias" . Scarring in the biopsy from the patient on the left was reported as subtle but the final report indicated possible scarring alopecia (scarring hair loss condition). The patient in the right had scarring and inflammation in the biopsy and the pathology report indicated scarring alopecia. However after closely listening to the story of hair loss from the patient on the left and examining the scalp, patient 1 leaves the office with a diagnosis of seborrehic dermatitis (a type of dandruff) and genetic hair loss and NOT a diagnosis of scarring alopecia. Powerful immune system suppressing drugs were NOT started but rather proper treatments for genetic hair loss and seborrheic dermatitis. After listening to the patient's history and examining the scalp, patient 2 (on the right) leaves the office with a diagnosis of scarring alopecia (lichen planopilaris). Powerful immune system suppressing drugs were started.
Final Point: Never Rely on a Biopsy alone!
The final point is that a scalp biopsy is not the "final answer" to why a patient is losing hair. Information from the biopsy needs to be pieced together with: 1) the patient's history of hair loss and 2) what the scalp looks like "up close" and also 3) what the blood test results show. If I'm planning to do a biopsy on my patient these other three things need to be carefully taken into consideration.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
How low can you go with shaving after FUE hair transplants?
FUE or follicular unit transplantation is a method of hair restoration whereby hairs are taken one by one from all across the back. It offers the advantage in that stitches are not used and so a linear or line type scar is not produced. It gives men the option of wearing their hair very short in the future (if desired).
So can the back of the scalp be shaved to a 0 or 1 in the future?
Although one can say for certain that patients getting FUE can wear their hair considerably shorter than men getting FUT (Strip) procedures, how low can they go?
Four points about shaving after FUE
1. The first thing to state outright is that FUE is not a scarless procedure (despite the advertising). FUE produces tiny circular scars.
2. The second thing to state is that not every person heals the same. Some people heal incredibly well and others heal with bigger scars. While some of this is influenced by size of the punch used and the post op care given, alot is determined by one's genetics. Some people "scar" worse than others.
3. Most of my patients can wear their hair very, very short following FUE. But everyone has different healing and some scars are more noticeable than others. Scarring is more noticeable with bigger sized sessions.
4. Most patients could wear a number 1 with no problem - but not all. Massive FUE sessions, especially if overharvested or the patient is a poor healer, could look noticeable with a zero.
Final points & Summary
FUE is great because if allows men to have the option of wearing their hair very short in the future. But the extreme of 'very short' is the concept of shaving down to a zero. Anyone wishing to wear a "zero" in the future should speak to their surgeon who can then advise based on the size of the planned session(s) and the patient's past healing. For patients with visible donor area harvesting, scalp micropigmentation (SMP) can be considered.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Hair transplants can be a great option in women with afro-textured hair. But my advice is to proceed cautiously with expert guidance.
Traction alopecia is a form of hair loss whereby hairs are lost from repeated strain or pulling on the hair. Many women with traction alopecia develop hair loss along the front of the scalp.
Hair transplants can be a very good option for many women with traction alopecia but expert evaluation is needed. Here are a few tips that are helpful to patients and physicians considering transplanting traction alopecia
Top 4 Tips for Patients with Traction Alopecia Considering a Hair Transplant.
1) Go slow. Don't rush the decision. Get several opinions.
2) I would first recommend starting with expert evaluation to ensure that the patient has no evidence of central centrifugal cicatricial alopecia (also called CCCA, a type of scarring hair loss condition) in the scalp. Our own studies have shown hair transplants for frontal traction are less effective if there is coexistent CCCA.
3) I often recommend waiting 6-12 months if the hair loss from traction alopecia has been recent. I perform steroid injections and advise use of minoxidil and see the patient back in 6-12 months. If traction alopecia has been around many years, I may not do this step.
4) Even though I do both FUE and FUT (strip) in my practice, I would not recommend FUE for black women with traction (unless small size case less than 400 grafts). I would advise strip (FUT) without any hesitation in traction alopecia for women with afrotextured hair to ensure we get the best grafts and best outcome.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
It certainly is possible to perform FUE hair transplants for women. And from time to time we do them. 99% of our hair transplants for women are FUT.
In my opinion, FUT (strip) is a better choice for women. Most women choose FUT when presented with an unbiased view of both procedures. Shaving the back of the scalp is not something most women wish to do either at the time of a hair transplant - or ever in their lives.
Role of FUE different for men
FUE is a great option for many men as it gives the option to wear hair very short in the future if desired. Most women do not care about this as an option. FUT gives nicer grafts and allows the surgeon to more efficiently get more grafts.In summary. I am never apprehensive to do FUE to help a 20 yr old female patient. But I am apprehensive if she chooses this method without carefully considering FUT (strip method) or feels (as many incorrectly do) that FUE is somehow a better method than FUT.I advise all female patients considering hair transplant surgery to speak with surgeons who do both and can offer an unbiased view.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Latisse is a topical agent that is FDA and Health Canada approved for helping grow longer eyelashes. It is important to wait 16 weeks (4 months) to figure out if Latisse is helping or not. Some women notice changes as soon as 4-6 weeks but waiting 16 weeks is strongly advised.
What proportion of women show beneficial responses to Latisse?
For women with thin eyelashes - the chances that Latisse will prove ultimately beneficial is very high - around 80 % of women benefit.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Recently, I was asked if there are any pills that can help make the hair kinkier or more curled.
In short, there is no internal method to change follicle shape in the present day. Follicle shape is complex. It can be altered temporarily with chemical and thermal (heat) relaxers and other chemicals (see below). The shape itself is largely determined by one's genetics and the proteins that are produced by the internal root sheath. Is it easy to change one's genetics or the proteins in the internal root sheath? No.Someday there could be a pill to make hair curler. But it should not be assumed that a pill, tablet or oral medication that would alter hair follicle shape could not have side effects on other systems in the body. Changing follicle shape permanently is not easy!
Making hair curlier: Chemcials vs Heat
Fortunateley if one wants to make their hair curlier or make their hair straighter they can with use of chemicals or heat. To curl hair, one can use alkali (high pH) or acid (low pH) solutions. Alkali perms give a firmer hold. In a traditional alkaline 'cold' perm, the hair is put in curlers or in the shape one wishes. Then "reducing" agents like ammonium thioglycate (pH between 9 and 10) are added to break disulphide bonds in the strands. This allows the hair to finally be free to take on a new shape. If the hair is kept in curls during this time, it will more easily adopt the shape of the curls. The final step involves adding a "neutralizing" agent (like hydrogen peroxide) to stop the reaction and keep the new curls in place. Cold waves with ammonium thyioglycate are great for course or thick hair as well as hair that has never been curled before.
There is another way of perming hair which is more gentle - and that's called an acid perm. These types of perms use a different ingredient typically glyceryl monothioglycate and the pH is much lower (4.5-7) and closer to the pH of hair (which is around 5). Because the pH is lower it's a bit less damaging to hair and is great for those with fine hair or those whose hair has been really badly damaged by previous chemicals and over processing of hair. These acidic perms do require heat of a dryer to speed up the rate of processing. The curl that gets produced with acidic perms is not as firm as with alkaline waves.
If one wants to keep their curlier or kinkier hair, they need to keep repeating this, because the new hair that grows out has not been treated.
Finally, I'll leave you with another important tip regarding perming of hair. And that is that one should never chemically alter their hair (straighten or relax) and then dye hair the same day. This can be extremely damaging. There should be many weeks in between.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
At present there is no cure for alopecia areata. However, many of the treatments for alopecia areata are extremely effective. Be sure to see a dermatologist who specializes in hair loss. I can't emphasize enough the importance of getting connected with treatments that have good evidence and staying clear of those that don't.
It can sometimes be difficult for patients to navigate through all the marketing and hype that surrounds hair loss treatments.
Although there are no FDA approved treatments for alopecia areata there are over a dozen off label treatments that can help. Be sure to see a dermatologist who has experience with many many patients with alopecia areata. Alopecia areata can be challenging to treat and is unpredictable.
Treatments for alopecia areata include:
steroid injections
topical steroids
minoxidil
anthralin
squaric acid
diphencyprone
prednisone
methotrexate
sulfasalazine
cyclosporine
azathioprine
tofacitinib
essential oils like rosemary, thyme and lavender
simvastatin and ezetimbe
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
I'm often asked about hair shedding and what it signifies. How many hairs Is normal to lose everyday? What does it mean if I see lots of short hairs?
In general, when someone feels they are shedding more each day than they used to, I say that it is abnormal. Granted this is probably more than 70-100 hairs, but the cut offs are different for different people.
Individuals can shed long hairs or short hairs. How short should shed hairs be to raise suspicion for a person having genetic hair loss? It is important to keep in mind there is no exact number but 3 cm would be a fair answer. Shed hairs less than 3 cm are called "telogen vellus hairs" and these are commonly seen in androgenetic alopecia (AGA). In fact, in AGA about 60 % of shed hairs are telogen vellus hairs compared to just 4 % in the hair loss condition called chronic telogen effluvium. So you can see that if a person identifies short hairs it does not mean they have AGA. However, the likelihood they have AGA increases significantly if they shed alot of these short 3 cm hairs.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Topical minoxidil helps men and women with genetic hair loss (also called androgenetic alopecia) and is formally FDA approved for treating hair loss. If you have another kind of hair loss, it might not work or not as well. Minoxidil must be used forever if individuals are using for genetic hair loss.
Side effects can not all be listed here, but include:
headaches
dizziness
heart palpitations
hair growth on the face (in 5% of users)
shedding in months 1-2
irritation
allergy (rare)
swelling in the feet
Other side effects are possible but rare. Minoxidil must never be used by women during pregnancy.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
1. Meet with a number of surgeons, not just one. Listen to their plan for your hair for the next 20 years. Listen to their advice on how many grafts to take now and where to put them. Opinions vary.
2. Hear they thoughts about not doing surgery at all. What choices do they bring to the table? Do they advise scalp micropigmentation (SMP) as an option? What are their thoughts about using minoxidil, finasteride or other treatments after surgery? Do they mention it at all?
3. Find a surgeon you trust and can work with. Decide if you view this as a short term or long term relationship. Figure out if your surgeon views this as a short term or long term.
4. Make sure you have time away from work, social and other obligations. 5-10 days is very nice but be sure to get a good understanding of what to expect during your recovery.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
It's possible to predict future balding fairly accurately for men in their 40s. Prior to that, it is not possible to predict accurately, However, it is possible to speak in terms of one's chances, odds or probabilities.
For example, I might tell a patient:
"Based on your history and current progress there is a HIGH chance you'll bald to a Hamilton Norwood stage 5"
"Based on your history and current progress there is a LOW chance you will bald beyond Hamilton Norwood stage 3"
Family history is complicated and is not a definite guide. But yes, men with a father who is HN6 have an increased risk of balding. In a study of 572 men ages 16-91, young men with a balding father had a 5.5 times increased risk of balding thanyoung men who did not have a balding father. In another study, only 1 of the sons of 50 non balding men had Hamilton Norwood type III balding or worse. In contrast, 32 of 54 (60 %) of sons whose fathers were bald had Hamilton Norwood scale type III baldness or greater.
Clearly, having a father with balding greatly increases the chance a given male with develop male pattern baldness.
Hair transplantation is not a good option for men in the late teens and early 20s. Progressive balding is highly likely and the key decision for any male with hair loss at this age is to stabilize or possibly improve the hair. Medical treatments supercede surgical treatments at this age. It is impossible to predict further balding at this age, impossible to really know where to place a hairline and impossible to really know how many donor hairs a particular man has.
Advice for young men
There are two things any male should do if the have hair loss at 20:
Stay away from a hair transplant. Hair transplants are only options (good options) once a male reaches the mid 20s
Discuss medical options with an expert including finasteride, minoxidil, laser and PRP.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Hair loss can occur at any age. In females, hair loss before 20 is not uncommon but can occur from a variety of causes. A careful examination can usually help figure out how many (1, 2, 3 or more) of the following the patient has. These include
1. Hair loss from low iron
2. hair loss from medications
3. hair loss from weight changes
4. hair loss from hair styling (heat and chemicals)
5. hair loss from early androgenetic hair loss
6. Other conditions are less common including alopecia areata.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Form someone to have full hair in the 50s and 60s and then to develop hair loss in the 70s is not common. However, hair loss is emotional and devastating at any age. Treating hair loss in individuals over 75 can be challenging because multiple diagnoses are often present (rather than a single diagnosis). I advise patients to make sure their physician has enough time set aside to do the necessary 'detective work' to give answers about your diagnosis and then time to provide treatment solutions.
Common causes of hair loss above 75 include:
hair loss from age related changes to the follicle (senescent alopecia)
hair loss from multiple medications, hair loss from surgeries (including those with general anesthetics), hair loss from dietary issues
In order to improve the hair, each of these issues needs to be addressed.
The experience of the physician is important because individuals over 75 may be more sensitive to mediations used to treat hair loss problems. Lower doses and more frequent monitoring may be needed. Some medications can't be used if there are coexistent medical problems. For example, minoxidil, a common hair loss treatment for female or age related hair loss, can't be used in individuals with heart problems or issues with blood pressure. For scarring alopecias, lower doses of medications also need to be used (i.e hydroxychloroquine). Knowing what treatment to prescribe and the proper dosing comes with experience.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
I'm often asked if Spironolactone is an option for women with genetic hair loss.
My first comment would be that anyone considering the possibility of using spironolactone - should receive a full and comprehensive evaluation by a physician experienced with the diagnosis of hair loss and of course the use of spironolactone. Often this is a dermatologist.
Spironolactone can help 30-40 % of women improve their hair and another 30 % stop hair loss. It must never be used by any female who may become pregnant, is planning a pregnancy, or is pregnant. Other side effects include irregular periods, dizziness, mood changes, depression, decreased libido, hair shedding in the first few months, beast tenderness, breast enlargement, frequent urination and rarely elevated potassium levels in the blood.
Spironolactone has been studied in only a limited number of small studies. The largest and best referenced is a study by Professor Rodney Sinclair and colleagues which as published in the 2005 British Journal of Dermatology. Among 40 women using spironolactone Dr Sinclair reported that 40 % achieved and improvement, 40 % stabilized and only a small proportion got worse.
REFERENCE Sinclair R, et al. Br J Dermatol. 2005. Treatment of female pattern hair loss with oral anti androgens. Br J Dermatol. 2005 Mar;152(3):466-73.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Do we really need more anti-androgen drugs for male balding?
There is no doubt that antiandrogens are among the most effective treatments for male balding (androgenetic alopecia, AGA) in the present year. Antiandrogens like finasteride and dutasteride stop hair loss in a high proportion of users and even improve density in a good proportion as well. However they don't help everyone and side effects (sexual dysfunction, depression, etc) limit their wide spread use. Safer anti androgens, if they worked well, would be a great addition to the treatments we currently use.
We've seen an increasing interest in topical anti androgens in recent years, including agents such as topical finasteride, topical Fluridil, topical RU 54481 and others.
To date there is no topical anti androgen approved by the FDA for use in male AGA. In theory a good topical anti androgen should have potent activity that is confined to the skin, have no systemic side effects and have good tolerability.
What is CB-03-01 ?
CB-03-01 is a topical anti-androgen compound patented by Cosmo and investigated under the name Breezula. It is an androgen receptor antagonist rather than an inhibitor of 5 alpha reductase. It has good penetration through the skin. Studies are underway to determine if the drug has benefit in male pattern balding or not. In fact, a 26 week study by Intreprid is now underway to compare 5 % CB-03-01 to 5 % minoxidil and placebo. It will be interesting to see if CB-03-01 has any benefit and if so, how it compares to topical minoxidil.
To date, there are only two published studies in the medical literature about CB-03-01. So we have limited information on the drug. It appears that CB-03-01 is rapidly metabolized to cortexolone which does not have any anti androgen activity. Second, it appears that CB-03-01 has an anti-inflammatory effect which could be important in treating AGA which is known to be associated with inflammation in many cases. Studies in rats and rabbits showed that it is not mutagenic. Studies in humans have not shown any significant adverse events.
Does dutasteride help individuals with androgenetic alopecia (male balding) if finasteride did not? Well, for men, the answer appears to be - yes.
In fact, last year, Jung and colleagues from South Korea studied 31 men with male balding who took dutasteride after finasteride did not help them. Interestingly, 77.4 % of these men improved their hair density (17 improved slightly, 6 moderately, 1 markedly).
This study suggested that dutasteride could be a good option for men if finasteride does not help.
Side effects, especially sexual dysfunction, are possible on dutasteride and this, and other side effects, should be discussed in depth before starting.
Reference:
Jung et al. Effect of dutasteride 0.5 mg/d in men with androgenetic alopecia recalcitrant to finasteride. Int J Dermatol. 2014 Nov;53(11):1351-7
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Treating hair loss its share of incredibly inspiring stories, and patients with amazing results. But, this is balanced to some degree by patients with no response to treatment or patients who get worse despite the best available methods we know.
Beinga hair loss doctor is all about understanding "probabilities" or "odds". I'm up front and direct with my patients. I might say to one patient...
"you have a 90 % chance of seeing an improvement"
... and to the next patient I might say
"your hair loss pattern and type carries onlysmall chance that anything we do will lead to an improvement".
But despite the odds and despite the statistics, I often remind patients that anything is possible. We can never be so bold and pretend that we hold a crystal ball that sees into a patient's future. Many surprises exist when it comes to treating hair loss. Tout est possible.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
They say that time flies when you're having fun, and it's hard to believe that our another intensive hair course has come and gone. Last week I hosted 6 six physicians here in my clinics in Toronto and we had an intensive week learning about the diagnosis of scarring and non scarring hair loss. Participants saw two hair transplants - one performed via follicular unit extraction and one performed via follicular unit transplantation (FUT). Participants also observed the process of platelet rich plasma (PRP). We had 6 challenging clinics with a range of complex diagnoses including discoid lupus, frontal fibrosing alopecia, telogen effluvium, androgenetic alopecia, folliculitis decalvans, alopecia areata and trichotillomania.
International Learners
Our hair course has drawn visitors from around the world. Physicians participants in the Hair Course this session were from Brazil, Turkey and Canada. It was a great week and I enjoyed tremendously the opportunity to work with this group. Our next hair course is set for March 28 -April 1, 2016. Physicians interested in the course can contact our coordinators at training@donovanmedical.com
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Many men express concerns about facial hair, most concerns about why they don't have more. "I don't get why I don't get more facial hair!!!" is a common sigh.
Two things are important for young men to know about facial hair growth:
1. Facial hair growth is strongly genetic. Some men, especially those of Mediteranean, Middle Eastern and men of the Indian subcontinent are more likely to grow thicker facial hair and have more hair compared to men of Northern European background. There are exceptions of course.
2. Facial hair density and growth increases throughout the 20s and even into the 30s for some men. So the amount of facial hair you have at 18 is likely not the density you'll have at 28.
Hair transplantation is an option for men to increase facial hair density - a trend that is increasingly popular.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
