Are there lunchtime eyebrow transplants?

Eyebrow transplants: delicate & meticulous

Lately, I've been hearing about so called "lunch time" hair transplants. You come in get a few grafts over lunch and head back to work. While theoretically this could apply to individuals who want a small number of grafts added to the scalp, this does not apply to eyebrow transplants.

It's pretty hard to have an eyebrow transplant without someone noticing. This is most certainly not a lunch time procedure. While many patients do amazing with little swelling and bruising, everyone considering a transplant needs to be aware that this is certainly possible. There is redness, swelling and bruising for 3-8 days. The bigger the session the more bruising there is. 'Black eyes' are certainly possible. My advice for patients with eyebrow transplants is to prepare to have at least 10-18 days away from work and social activities. After that some minor redness can persist. This redness usually goes away but can last a few months in some patients. 

An eyebrow transplant is an intricate and delicate process done on delicate tissues in a delicate area. It is meticulous work and bruising, redness and swelling are all part of the post op healing phase. This is not a lunch time procedure.

Topical Ruxolitinib Promotes Eyebrow Regrowth in Alopecia Universalis

More evidence the JAK inhibitors help alopecia areata

For the past 2 years, the excitement has mounting about the role of two medications – tofacitinib and ruxolitinib – as new treatments to add to the list for alopecia areata. All this came about when the news broke in the summer of 2014 that a young man with extensive alopecia areata grew back his hair following treatment with tofacitinib (Xeljanz). Then, just a few months later, another group of researchers reported patients who benefitted from the drug ruxolitinib (Jakavi, Jakavi).

New study shows benefit of topical ruxolitinib

In a brand new study, the medication ruxolitinib was found to trigger eyebrow regrowth in a woman with alopecia universalis. What was particularly interesting and novel about this report was that the investigators formulated the drug in a topical formulation - rather than as a tablet. Within 3 months of using the drug twice daily in the form of a cream, the eyebrows had regrown. The topical formulation of ruxolitinib was very well tolerated. With the exception of a very slight reduction in the patient’s white blood cell counts, there were no other reported negative side effects.

Conclusion

This is a very interesting study and gives hope that topical formulations of these new JAK inhibitors may indeed be on the horizon. Topical medications generally have fewer side effects and are better tolerated compared to oral medications.  I have no doubt we'll be hearing more about the role of  JAK inhibitors in a topical formulation.

REFERENCE

Craiglow BG and colleagues. Topical Ruxolitinib for the Treatmentof Alopecia Universalis. JAMA Dermatology Published online December 9, 2015

Seborrheic dermatitis - a side effect of the "no poo" movement

Shampooing or not

In previous blogs, I've discussed the merits of shampooing and the lack of evidence that those who don't use shampoos have healthier or better hair. The so called 'no poo' movement is popular among a small number of people.

 

Seborrheic dermatitis: a side effect for some of not shampooing

One problem that some encounter when they don't use shampoo is seborrheic dermatitis - which is a close cousin of "dandruff." Individuals with seborrheic dermatitis develop a red flaky scalp (see photo). When you look up close, many yellow and white scales are seen. 

The treatment for seborrheic dermatitis does not sit well with those who adhere to the principles of the 'no poo' movement. The treatment of seborrheic dermatitis involves anti-dandruff shampoos! These include shampoos with ingredients such as zinc pyrithione (Head and Shoudlers, etc), ketoconazole (Nizoral etc), selenium sulphide (Selsun Blue), and Ciclopirox (Stieprox etc). 

I see a lot of different shampooing practices - and seborrheic dermatitis is quite common amongst those who don't shampoo often. Seborrheic dermatitis does not usually cause significant hair loss. But in some individuals, it can cause itching. Rarely though, ti can lead to hair loss as the scalp inflammation that accompanies this condition pulls out hair. 

Hair loss in young women: Which one to start vs which one to use?

Combination therapies often best in young women with genetic hair loss

As many know, I'm a big believer in starting treatments one at a time in order to get a sense of how well a given treatment works. if one starts treatment A, B, C and D all at the same time and finds they have better hair in one year, it will be difficult to determine which one really is the one helping. 

4 main options for genetic hair loss in women

There are four main options for treating genetic hair loss in women: minoxidil, hormone blocking medications (spironolactone, birth control pills, cyproterone, etc), low level laser and platelet rich plasma therapy. 

Which one to start? 

My goal is to help patients choose the treatment which best suits their lifestyle, their safety and risk tolerance, and of course recommend treatments with the highest chances of success. For some women, minoxidil might be the best starting treatment; for others it might be spironolactone. For others yet, it's the laser devices. 

For many patients with genetic hair loss, the decision is that - which one should I use? Many women can maintain results with one treatment. For young women however, it's more of a question of which one to start. Many women with early onset genetic hair loss (i.e. before 25) are at high risk for significant hair loss as they age. For these women, I strongly recommend considering 2 or 3 treatments added one after the other 6 months apart. For young women, it's more of a decision which treatment to start off with rather than a decision which treatment to pick.  

What is the youngest age a man can have a hair transplant?

Age 25 is a reasonable cut off for hair transplants for most men

I'm often asked to see males 18-23 years of age for a hair transplant consult. Sometimes, the young man comes alone. Sometimes with a parent. Sometimes with two parents.  They are surprised to learn that a hair transplant is not the right choice for them. 

If one could see 50 years into the future for the given person, it would be possible to figure out if a hair transplant theoretically could be done for a man 19 or 20 years of age. But we can't. Nobody can. No test, questionnaire, assay or measurement can determine 'exactly' how a man will bald.  But we do know that men who develop hair loss at 19, 20 or 21 are fairly likely to have more significant balding by age 50 than a man who develops hair loss at 41. That is the one thing we do know for sure. 

Humans do not have infinite hair

If humans had infinite hair, this wouldn't be an issue. This blog would not even have been written. But we don't. Humans have anywhere from 0 to 8000 follicle units to move from the back of the scalp to the front. Yes, some men have 0 and are not even candidates (i.e. men with DUPA). Others have 8000. Can we predict how many hairs a patient has? Yes! But not very well until age 30-35. At age 20, it's nearly a complete guess.  If one does a hair transplant of 2000 grafts at age 20 and it turns out the patient really is not a candidate, then the transplanted hairs thin out. Yes, some transplanted hairs can thin if not taken from the right area of the right patient.

How many hairs might I need someday?

If an individual goes very bald, they really need 10,000-20,000 follicle units to fully cover the balding area. Since there are rarely more than 5,000-6,000 follicle units available for most men, it becomes clear that one has to choose where to put these hairs. Putting them right in the frontal area is the priority for most men. If some are left over, the crown becomes a second priority. 

What is the priority for a young man age 20? Usually the frontal hairline - making it flat. making it youthful looking and the way it was age age 16. It is never a good idea to restore this look. Further balding is guaranteed to occur behind it and more and more grafts will be needed to be moved into that area (i.e. more transplants) to make the hairline continue to look good. Many men who get transplants at age 20 will simply run out of hair.

I often hear the argument that if a man at age 20 has a hairline that looks like he's 40 ... then it's okay to have a hair transplant at age 20. I disagree. If a man at age 20 has a hairline like age 40, he may never ever be a good hair transplant candidate. The more bald someone is likely to become, the more cautious we have to be!

Key decisions for the 20 year old

The most important decision for the man in his early 20s is whether to use non surgical treatments to try to save the hair  - minoxidil, finasteride, laser, PRP. In other words, e there is nothing to do now. The period between now and the mid 20s is focused on trying to figure out how to keep the hair that is on the scalp now. Discuss medical options with your physician. 

 It basically works out to this

•    Getting a transplant at age 19, 20 or 21 "might" allow one to have improved frontal hair density in the early 20s but carries with it a huge, huge  risk of having an unnatural and even strange look in the 30s, 40s and 50s. 

•    If an individual wants the best hair possible throughout his 30s, 40s and 50s and right up until he's 95, there is only one option... and that is to wait to review hair transplant options until 25. 

Someday when medical science figures out how to create infinite amount of hair, it will be okay to have a hair transplant and 19. We are not there.

New data on why hairs thin? A look at the Collagen 17 A1 Protein

Why the Collagen 17 A1 protein could be important for those with hair loss?

A new study published in the prestigious journal Science provides new information into the process of hair thinning.

Collagen 17 A1 (COL17A1)

Researchers from Tokyo showed that stem cells in hair follicles become damaged over time as a process of normal aging. Such damage leads to a reduction in the levels of a protein called collagen 17A1, abbreviated COL17A1. Without this protein, hairs become thinner over time.

The study included important observations in mice and in humans. Researchers studied mice that lacked the COL17A1 gene to try to figure out the precise importance of this protein: The scientists found that without this protein, the mice had hair loss.  When mice were engineered to make extra amounts of COL17A1, they did not have hair loss and hairs did not thin. Turning to human based studies, the researchers analyzed hair samples of women age 22-70. They found that aging leads to a reduction in the levels of Collagen 17 A1 and this reduction seemed to correlate with thinner caliber hairs

Conclusion and Comment

These are interesting observations. At present, it's much too simple to say that adding back collagen 17 A1 to the scalp will promote hair growth.  The Collagen 17 A 1 protein is a complex protein that integrates in the cell membrane of cells and so simply injecting it is unlikely to do much. However, this study reminds us that understanding stem cell aging is likely to yield some of the most important findings to better understand hair loss.

 

REFERENCE

Matsumura H et al. Hair follicle aging is driven by transepidermal elimination of stem cells via COL17A1 proteolysis. Science 05 Feb 2016: Vol. 351, Issue 6273,  

Increased risk of stroke identified in individuals with alopecia areata

A Taiwanese research study set out to evaluate if the risk of stroke is increased in individuals with alopecia areata. Using a large research database, investigators compared 3231 patients with alopecia areata to 16,155 matched controls. Patients were tracked for 3 years.  The incidence rate of stroke was 5.44 per 1000-person years (95% confidence interval (CI) = 4.03~7.20) for those with alopecia areata compared to 2.75 per 1000-person years (95% CI = 2.30 ~ 3.27) for those without alopecia areata. Overall, investigators found the risks of stroke was increased 1.61 times compared to controls.

Comment: Many autoimmune inflammatory conditions are associated with an increased risks of stroke (such as lupus, psoriasis, rheumatoid arthritis).  This study suggests that alopecia areata may also be on this list. Further studies are needed to verify these findings in other patient populations.

REFERENCE

Kang JH et al. Alopecia areata increases the risk of stroke: a 3 year follow up study. Sci Rep 2015;5:11718.

Is the treatment really for me? The “ME” in TREAT-"ME"-NT

Do I really want to start this treatment?

When it comes to treating hair loss, the final decision on whether or not to use a treatment is left up to the patient.  This is true for many parts of the medicine of course, but it’s very applicable to treating hair loss. A patient with high blood pressure, really should take their blood pressure pills and change their lifestyle and diet. A patient with diabetes really should use their diabetes medications.  But there is no ‘should’ when it comes to deciding on using a hair loss treatment or not.  With no exception at all, it’s a personal decision.

The ME in Treat"ME"nt

In my practice, I see the whole spectrum of "ME" in Treatment.  And one must never assume that all patients want treatment for their hair loss.  The rationalization that an individual would not make an appointment, take time out of their day visit the clinicif they did not want treatment – is simply not correct.  Hundreds of stories in my professional career back this up.

So what is the spectrum?  There are some patients who simply want to know that their hair loss does not indicate anything more sinester.  Every now and then I meet a patient with hair loss who is so over the moon with excitement that their hair loss is “just” hereditary hair loss.  They don’t want treatment – they simply wanted to know that their health was not in jeopardy.  And then on the other side of the spectrum is the patient who has tried nearly all treatments for their hair loss.  When I mention one last one with the most remote of chances it can help, they want to try.  Side effects are possible and close monitoring will be needed to make sure none of those side effects occur. They want to try.  For them, the benefits of treatment, the benefits of growing hair greatly outweigh any such risks.  In their mind, they are saying – this is for ME!

Stress and Hair Loss: A closer look at the 5 D's of Stress

Does stress cause hair loss?

A common question I'm asked is whether stress can actually cause hair loss. The answer is maybe. Typical day to day stress probably is not a big culprit. 

However,  stresses that are high enough in magnitude can sometimes trigger increased hair shedding, especially stresses that fall into categories of what I call the “5 D’s” :

1. death of a loved one

2. divorce and relationship problems

3. debt and financial problems

4. new diagnosis for the patient or a loved one

5. dismissal from a job.

The Homes and Rahe Scale

The 5 D’s based on research from the late 1960s when two psychiatrists Dr Holmes and Dr Rahe conducted research into how stress and illness are linked. Based on their studies, they created the Holmes and Rahe scale. The scale ranks a variety of life events based on the stress they cause. As you guessed, the 5Ds are right at the top.  Death of a spouse was given a rating of 100, death of a close family member 63, divorce a rating of 73, a diagnosis of illness at 53, dismissal from work at 47 and financial issues (mid 20s). 

When patients mention concerns about recent hair loss it is important to conduct a very thorough history which sometimes includes an assessment of stresses of the patient.

Causes of Sudden Hair loss in Women

What are the causes of sudden hair loss in women?

Although genetic hair loss is one of the most common causes of hair loss in women, other causes are frequently seen as well. What differentiates some of these other conditions is their speed of hair loss. Genetic hair loss tends to be a slow type of hair loss, whereas other types of hair loss can be more rapid. 

The 3 most common causes of rapid hair loss are telogen effluvium and alopecia areata and scarring alopecias. 

1. Telogen Effluvium

Telogen effluvium (TE) is not a single entity. Telogen effluvium refers to hair shedding that follows a 'trigger' such as low iron, crash diets, thyroid problems, starting mediations, massive stress. Typically TE develops 2-3 months after a trigger. Any internal illness can also trigger a telogen effluvium

2. Alopecia Areata

Alopecia areata is an autoimmune condition that affects 2 % of the world. Sudden onset of hair shedding is one way that the condition can declare itself prior to the development of circular patches of hair loss. 

3. Scarring Alopecias 

Scarring Alopecias refer to a group of autoimmune conditions that leave behind deposits of scar tissue as they move through the scalp. These pieces of scar tissue, prevent hair from regrowing in the area and therefore lead to permanent hair loss. Some scarring alopecias, especially lichen planopilaris can accounce their presence with sudden hair shedding. Affected patients often have scalp itching, burning or scalp tenderness.

4. Chemotherapy 

It is not a surprise that chemotherapy is also on the list of causes of sudden hair loss. Hair loss occurs in about 65 % of individuals receiving chemotherapy and is largely dependent on the specific drugs received. Hair loss usually starts 3-4 weeks after the chemotherapy is started.

5. Hair breakage from chemicals and styling

Recent highlighting or hair dyeing can sometimes trigger hair shedding especially if bleaching was used or their was an inappropriate mixture of chemicals or an inappropriate duration of application to the scalp. Affected patients notice breakage of small hairs sometimes within hours of leaving the salon. 

6. Allergic contact dermatitis

Application of chemicals to the scalp that cause an allergic reaction can cause sudden hair loss.  A classic example is allergy to hair dyes. What bothers patients more from hair dye allergy is not the hair loss but rather the scalp itching and scalp pain that is often present. 

7. Scalp infections

Scalp infections are not common in adults, but a variety of scalp bacterial virus and fungal infections can trigger shedding and sudden hair loss. 

8. Trichotillomania

Trichotillomania, or the self induced pulling of hair can lead to sudden hair loss. AT times of extreme emotional stress, depression and obsessive compulsive disorders hair pulling can lead to rapid hair loss within a short time. 

Conclusion

Women with sudden hair loss should see a dermatologist for careful review of their history, assessment of the scalp up close and review of blood tests. Further blood tests may be ordered depending on the story. 

Choice of oral contraceptives is important for women with androgenetic hair loss

Androgenicity of 'combined' birth control pills  

First approved in 1960, there are now many different brands of oral contraceptives on the market. One common class of oral contraceptive pills are those which contain an estrogen component and a progestin component. These so called "combined OCPs" are the most popular of the birth control pills. Today, I'd like to highlight an important topic: the “androgenicity” of oral contraceptive pills or "OCPs"

The Estrogen Component. 

Significant attention has been given in recent years to making oral contraceptives safer by reducing the estrogen dose. Many modern OCPs contain 20-35 micrograms of estrogen (ethinyl estradiol) compared to 50 micrograms or higher in years past.

The Progestin Component.

What is sometimes forgotten in the discussion of OCPs is that the progestin component is important to consider as well, especially for women with androgenetic alopecia.  Some progestins are significantly more ‘androgenic’ than others.  

In general, all oral contraceptives are "anti-androgenic" to some degree as they function by reducing the production of androgens by the ovaries. But because the progestin that makes up the OCP differs, this translates into a scale of 'androgeneticity' for oral contraceptives with some being less androgenic than others.

The least 'androgenic' progestins often added to OCPs include norethindrone, norethindrone actetate, desogestrel, norgestimate and drosperisone.The most 'androgenic' progestins in OCPs have names like levonorgestrel and norgestrel. However, it’s not so simple as to say that the androgenic progestins are bad and the least androgenic are better: the combination of an estrogen with the progestin to make up the combined OCP alters the pill's overall androgenic potential. For example, even the levonorgestrel is an androgenic progestin, it has such a low amount of progestin in many OCPs, that the OCP might actually itself have a low androgenicity rating.  

My preferences for starting an OCP

Overall, one should always speak to their physician before starting or changing a birth control.  My preference for women with androgenetic alopecia who decide to start a birth control pill is to choose one with 1) low androgenic activity overall and 2) a progestin with low androgenic activity.  My advice may be slightly different if someone is already on a certain type OCP. The importance of the 'androgenicity' of the OCP does not carry the same relevance if the woman does not have androgenetic alopecia. 

Low androgenicity OCPs include : ortho tri-cyclen (contains norgestimate), ortho-cept or desogen (contains desogestrel), modicon (has norethindrone), ortho cyclen has (norgestimate), demulen (has ethynodiol diacetate), and ortho 777 (has norethindrone).

Other OCPs may also have low androgenicity and all women should speak to their physicians before starting or changing any oral contraceptive. Oral contraceptive use may not be appropriate for everyone.

Diagnosing Hair Loss: Understanding The "H.A.I.R." Principle

So, what' s my diagnosis ?

I enjoy participating in a number of online forums, including those where I answer questions from individuals with hair loss. It's challenging to offer any valuable information about diagnosis with questions that offer 1 or 2 sentences about a patient's hair loss. Sometimes it's even challenging with a photo. 

Years ago in my teaching clinic, I came up with a 4 letter memory tool to teach doctors in training about the proper steps needed to diagnose hair loss. The first letter of teach of the key steps spells HAIR:

H = History

A= Assessment

I = Investigations

R= Repeat if necessary

H=History.

The history of a patient's hair loss is extremely important and can't be ignored. All aspects are important including when it first occurred, how long it's been present, symptoms that accompany the hair loss (scalp itching, burning or pain), medications used by the patient, family history of hair loss, personal history of any medical conditions. All these things could be important to a patient's hair loss and need to be uncovered. 

A=Assessment. 

A proper assessment of the scalp involves an "up close" exam. Sometimes this is not possible and photos need to suffice. But to be confident in what's causing a person's hair loss, the scalp needs to be examined. One can't stand across the room. One needs to look - and the closer the better!

It's important to examine exactly where the hair loss is occurring. Is it occurring in the frontal area? The top of the scalp? The middle? the back? Is there redness? Is there scarring? 

I= Investigations.

A variety of investigations need to be considered in anyone with hair loss. These include blood tests, biopsy and collection of shed hairs. It doesn't mean that all these are necessary - it just means they need to be considered. 

For all women with hair loss, I advise three tests: complete blood counts (CBC for hemoglobin), thyroid studies (TSH test) and iron studies (ferritin test). Other studies could also be important to order depending on what is uncovered in the steps above. For men with hair loss, such tests are not always needed.

A scalp biopsy is rarely needed. With a properly obtained history and a properly conducted scalp exam, a biopsy becomes redundant for many patients. However, a biopsy is helpful in challenging cases and helpful in some scarring alopecias to confirm the subtype.

R= Repeat if necessary.

It's usually possible to diagnose hair loss with the first three steps above : history, assessment and investigations. However, there are some situations where it's just not.  In such challenging cases, the only way to definitively understand the cause of the patient's hair loss is to see them back in the office and 'follow' their hair growth and hair loss over a period of time. Sometimes this is 2 months and other times it could be 6 months.  At each visit, the steps of history taking (H), assessment (A) and investigations (I) may be repeated. 

Exceptions to the HAIR Rule

There are not many exceptions. A history of hair loss and an assessment is always required. There are many mimickers of hair loss. A photo of a patient with what looks like genetic hair loss could be genetic hair loss. But without a history one can not be certain.  Investigations, as stated above, are not always needed. 

Conclusion

The "H.A.I.R." Principle is a helpful memory tool to remind both physicians and patients that diagnosing hair loss might not always be quick and easy.  A carefully obtained medical history, a thorough scalp assessment and a variety of investigations need to be part of the evaluation. In some cases where the diagnosis is elusive, these steps need to be repeated in a few months 

Redness after a hair transplant

How long does redness last after a hair transplant ?

Everyone undergoing a hair transplant needs to be aware of what to expect in the first 4 weeks post op. 

One of the considerations is post op redness. For reasons that are poorly understood, some individuals have redness in the transplanted recipient area that persists. Individuals with lighter coloured skin are at higher risk. 

The above photo shows persisting redness in a patient 4 weeks post transplant. Given the patient's longer hair, it is easy to hide. It persisted until 12 weeks. (3 months). 

It can be difficult in some cases to get ride of the redness if your skin type predisposes you to redness. However, the redness will fade with time. It can frustrating and patience is required.  Options such as mild topical corticosteroid lotions and creams can be used but are often disappointing. Camouflaging options can be reviewed as well (DermMatch, Toppik, Couvre)

Spironolactone for Female Pattern Hair Loss

Spironolactone (Aldactone) for Treating Genetic Hair loss in Women

Genetic hair loss in women affects the frontal scalp and may cause diffuse loss in some women. Treatments include FDA approved minoxidil (Rogaine) Spironolactone (Aldactone), low level laser and platelet rich plasma (PRP).

How well does Spironolactone work?

Previous studies examining the benefits of spironolactone are small in size, but suggested that 40 % of women experience a halting of hair loss with spironolactone and 40 % experience and increase in hair density. 

A new study from University of California Los Angeles examined the benefits of spironolactone in 19 women with genetic hair loss. A survey was given to 20 women. Follow up period was 7 to 20 months. Overall, 30 % of women experienced an improvement, deemed as either a 'mild improvement' or 'increased thickness'. Another proportion achieved stabilization (no further loss) but it's not clear in the study how many of the women in the study had follow up long enough to evaluate stabiliity. 

Conclusion

Overall, these data are similar to previous studies suggesting that 30-40 % of females with genetic hair loss will achieve a benefit using spironolactone pills for genetic hair loss

REFERENCE

Famenini S, Slaught C, Duan L, Goh C. J Am Acad Dermatol. 2015 Oct;73(4):705-6. doi: 10.1016/j.jaad.2015.06.063. 

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. -  

MALE BALDING and COLON CANCER: NEW INFORMATION, NEW RISKS

New Association Identified between Male Balding and Colon Cancer

Previous studies have examined whether men with male pattern hair loss have an increased risk of cancer. Some studies (albeit not all) have suggested an increased risk for prostate cancer. Whether a link between male balding and other types of cancer exists is unknown. 

Why search for links between male balding and colon cancer?

The pathways leading to male balding and colon cancer may have similarities. Insulin, insulin growth factor type 1 (IGF -1) and androgens may have a role in both colon cancer and balding.

In a new study, researchers examined whether there was an association between baldness and the risk of colon polyps and colon cancer.  The researchers found the men with frontal baldness and men with frontal and vertex balding had a 30 % increase risk of colon cancer compared to men without balding. In addition, men with frontal balding had a risk of polyps.
 

Conclusion

I found this study quite interesting as it's the first study to look at the relationship between male balding and colon cancer. Whether screening guidelines for men with balding should be different than men without balding remains to be determined.  

 Reference

Keum N et al. Male pattern balding and risk of colorectal neoplasia. Br J Cancer 2016 12; 114: 110-7.

Finasteride (Propecia) and Weight Gain: What's the evidence?

Does Finasteride (Propecia) cause weight gain in some patients?

As much as I specialize in how to use medicines to treat hair loss, I also specialize in understanding their side effects.  How can we deliver safe treatments - that are effective?

Finasteride and Weight gain

Every now and then, a patient will ask about the possibility of weight gain with finasteride.  Finasteride is an oral medication which blocks an enzyme known as 5 alpha reductase. By blocking this enzyme levels of the super potent "DHT" (dihydrotestosterone) are reduced. Levels of testosterone and estrogen may be slightly increased. 

Weight gain with finasteride certainly is not common. I know that based on all the patients that have used the medication in my practice. However, that's the not the point of this blog. The point of the blog is to address the question- are 'some' patients at increased risk for weight gain? That' answer is likely yes.

It's a very challenging question overall. The medical literature (studies to date) do not provide us with a lot of evidence. The quality of evidence and the detail to which this issue has been studied in men and women with hair loss is poor. We don’t have good statistics about weight gain and finasteride. My belief based on a large practice of male and female patients is that it likely does cause weight gain and women are probably more likely to be affected than men.

A few points to consider about weight gain and finasteride: 

1. To date (the date of this blog -see below), the product manual for finasteride (Propecia) does not mention an association with weight gain. 

2.  Finasteride and other hormone blockers including dutasteride (men) spironolactone (in women) is known to occasional cause individuals to feel sluggish, and fatigued. Mood changes rarely can occur. Could this translate into activity changes, or overall metabolic activity?  It's not clear. Certainly a very small proportion of users feel a bit 'blah' .

3. Studies in MEN using finasteride for prostate enlargement (the other key use of the drug) do not appear to experience weight gain. In fact, a proportion of users actually experience a slight weight reduction.  These were the results of a randomized controlled study of 3040 men using 5 mg finasteride.

4. Although finasteride is not FDA approved for females and must always be used used under direction and care of a physician who is knowledgable about its use for women, studies have looked at weight changes in females using finasteride.  A 2014 study looked at benefits of 2.5 mg dose of finasteride every third day for 28 female individuals using finasteride. There was no changes in weight (as measured by the BMI) in these individuals. This is one of the few studies that have been published specifically addressing weight gain and finasteride.

Does finasteride cause weight gain?

The majority of the published medical evidence does not support weight gain for the majority of users of finasteride. However, whether a minority could be affected still needs to be given attention. This can ONLY be achieved by well designed and properly conducted clinical studies.  

I generally advise my own patients, especially my female patients, that weight gain could be a side effect of taking antiandrogens. I provide this advice to all my patients using antiandrogens in fact (finasteride, dutasteride, spironolactone).

REFERENCE

Roehrborn CG, et al.  Effects of finasteride on serum testosterone and body mass index in men with benign prostatic hyperplasia. Urology. 2003.

Tartagni MV, et al. Intermittent low-dose finasteride administration is effective for treatment of hirsutism in adolescent girls: a pilot study. J Pediatr Adolesc Gynecol. 2014.

Tofcitinib (Xeljanz) and response to stress

Is the response to stress altered in those taking Tofacitinib (Xeljanz)?

Every day, I hear new about potentially new benefit for the immunosuppressive medication Tofacitinib (Xeljanz). Studies have shown benefit in a range of conditions including rheumatoid arthritis, alopecia areata, atopic dermatitis (excema of the skin), vilitilo, inflammatory bowel disease, ankylosing spondylitis and more. 

I've been using it for a while now for alopecia areata and seeing responses in a proportion of patients. Side effects are not common but include headaches, runny nose, diarrhea, changes in blood counts. Serious side effects don't appear to be common but issues like infection occur in about 2 % of users. 

As we continue to introduce Tofacintib to the clinical setting, it's important to continue to monitor all side effects.

Tofacitinib and agression

Today, I read a study from the Eur J Pharmacol about changes in aggressive behaviour in mice treated with tofacitinib

Aggression behaviour induced by oral administration of the Janus-kinase inhibitor tofacitinib, but not oclacitinib, under stressful conditions.

Fukuyama T, et al. Eur J Pharmacol. 2015.

 

A recent study in mice set out to determine if tofacitinib can affect itching in mice. IN the process of conducting the study,  In the process of detecting anti-itching potency, the researchers found that tofacitinib treated mice showed slightly increased aggressive behaviour after being 'stressed'. These studies showed not only that the JAK-STAT pathway (the pathway that tofacitinib acts on) may affect behaviour, but that these side effects should be further explored in humans treated with the medication. It's not always possible to draw parallels between mouse and human studies but this study leads the way to further investigation of possible behaviour changes induced by the medication.

REFERENCE

Fukuyama T, et al. Aggression behaviour induced by oral administration of the Janus-kinase inhibitor tofacitinib, but not oclacitinib, under stressful conditions. Eur J Pharmacol. 2015.

Tofacitinib (Xeljanz) for Alopecia Areata

Tofacitinib: Additional benefits for alopecia areata

Tofacitinib (Xeljanz) is an oral medication that is FDA approved for the treatment of rheumatoid arthritis. Recent studies in the past 2 years have shown a benefit for some patients with alopecia areata.   Alopecia areata is an autoimmune condition, that affects all ages and all people across the world. In fact, about 2 % of the world's population is affected by alopecia areata. Patients often lose hairs in circular patches but may lose all the hair on the body as well. I’ve been using Tofacitinib (Xeljanz) in my practice for a while now.  It doesn’t help everyone but does help a proportion of patients.

I was encouraged too by a recent study showing benefit not only for hair loss, but also for the nail problems that frequently accompany this condition.  A study in the journal JAMA Dermatology reported 3 patients with alopecia universalis (AU) whose nail abnormalities improved with treatment with Tofacitinib. Interestingly, 2 of these 3 patients had an improvement in hair growth as well.

Tofacitinib is proving to have many potential benefits for patients with alopecia areata.

REFERENCE

Dhayalan and King. Tofacitinib Citrate for the Treatment of Nail Dystrophy Associated With Alopecia Universalis. JAMA Dermatology. 

CANAAF - Come Together 2016 Alopecia Awareness Conference

July 22 - 24, 2016 Patient Conference in Toronto

I'm looking forward to participating in this year's patient conference organized by the Canadian Alopecia Areata Foundation (CANAAF). I'll be participating in a question and answer panel on July 23, 2016. 

The conference is July 22-24 at the Delta East 2035 Kennedy Road. 

More details can be found on the CANAAF website. 

See you there!

Jeff.

T

Is there such thing as normal scalp hair density?

The key to being human is that we're all different. The same is true for hair density. In fact, there's really no such thing as normal density. Men and women have have different hair densities.  Caucasian individuals have different density than those of African/ Afro-carribean background, and different than those of Asian background.

Normal hair density if one was forced to quote a normal value is somewhere   between 165-220 hairs per sq cm ( ... or roughly 87 follicular units to 120- follicular units per sq cm). The back of the scalp is thicker than the temples.  he highest density occurs at birth (when the head is very small) and then slow reduces as the individual gets older.