The first Saturday in August marks International Alopecia Day! Alopecia areata is an autoimmune condition affecting 2 % of the world's population. Hair loss can occur anywhere on the body but typically affects the scalp.
Children and adults can both be affected and a high proportion of individuals experience their first episode of hair loss before age 20.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Lichen planopilaris (LPP) is a type of scarring hair loss condition. The cause is unknown although several treatments are possible to try to stop the condition from progressively destroying hair follicles.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Recognizing whether a patient has genetic hair loss or telogen effluvium ... or both .... often requires listening to the patient's story about their hair loss in addition to examining the scalp and looking at the blood test results.
Many women have both.
Differentiating between AGA & TE
AGA often shows hair loss in regions rather than all over although it can certainly be all over. AGA is fundamentally characterized by hair follicle "miniaturization." The hair follicles get skinnier - this is not a feature of TE. Telogen effluvium is characterized by diffuse loss and waves of regrowth. Empty tracts where a hair once was found and upright regrowing hairs characterize TE. Patients with TE often have a trigger such as low iron, thyroid problems, nutritional issues, crash diets, stress or medications that lead to the shedding. Shedding in TE is more pronounced than in AGA.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Psoriasis is an inflammatory condition affecting about 3 % of the world. The skin, hair, nails and joints are affected. We are also now learning that individuals may also have increased risks of cardiovascular disease. About 50 % of patients with psoriasis have scalp involvement so psoriasis is a common issue in the hair clinic. For the majority of those with scalp psoriasis, psoriasis does not cause hair loss.
When does hair loss occur?
Even though most individuals with scalp psoriasis do not experience hair loss as a direct result of their psoriasis, severe psoriasis can cause shedding (telogen effluvium) and rarely even a scarring type of hair loss. Some individuals with psoriasis have scalp itching - and repeated itching can cause hair breakage and subsequent hair loss.
The photo to the right shows the typical white powdery scale of psoriasis. It is easily mistaken for the scale of seborrheic dermatitis. The scale of seborrheic dermatitis, however, tends to be more yellow and greasy rather than white and powdery.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Pityriasis amiantacea is not a diagnosis. Rather it is a phenomenon that sometimes happens to the skin and hairs during the process of inflammation.
The finding of pityriasis amiantacea is often seen in patients with psoriasis, seborrheic dermatitis and various eczemas.
The photo to the right is a magnified photo of the scalp of a patient with "pityriasis amiantacea" from psoriasis.
Treatment includes identifying the root cause. Treatment such as topical steroids, steroid injections, anti dandruff shampoos, salicylic acid, tar all play a role in treatment.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Thanks to the many requests for my slides for the recent lecture on scarring alopecia, I've uploaded the audio to my presentation. I hope it's helpful and thanks for your interest.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Dutasteride, a dual inhibitor or 5 alpha reductase type 1 and 2
Dutasteride is approved in Korea for the treatment of male pattern balding. It is used "off label" in many other countries. Whereas finasteride (Propecia) inhibits 5 alpha reductase type 2, dutasteride inhibits 5 alpha reductase types 1 and 2.
Finasteride has received press on account of its side effect profile (especially sexual side effects) and possibilities of long lasting, possibly permanent side effects in a low proportion of users.
Dutasteride is known to have a similar array of overall side effects, and given the greater inhibition of 5 alpha reductase that dutasteride has, one might expect a similar if not greater number of side effects. Interestingly, this has not been the case in all studies to date. In fact, most studies support the efficacy and tolerability of dutasteride at 0.5 mg with relatively low incidence of side effects.
New study
A new study published by Choi et al looked at over 700 men ranging in age from 18-41. These men were using dutasteride at 0.5 mg. The frequency of side effects were low. 1.3 % of patients experienced decreased libido, impotence in 1 %, fatigue in 0.7 %, breast enlargement was seen in 0.3 %. Over 79 % of men reported improvement with their hair.
FINAL COMMENT
This study was not set up to compare dutasteride to placebo. This was simply an observational study as part of routine "post marketing" surveillance. Overall, the findings are encouraging and expected- pointing to a low risk of adverse events with this dual inhibitor of 5 alpha reductase.
REFERENCE
Choi GS et al. Ann Dermatol. 2016 Aug;28(4):444-5
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Report Highlights Laser Hair Removal Procedures as a Trigger of “Pathergy” for Patients with Behcet’s Disease
Van der Ree-Pellikaan C et al, 2016
Authors from the Netherlands recently reported a very interesting case of 25-year-old man was admitted to his local medical center with fever, severe ulceration of the oral and pharyngeal mucosa, and pustules on his skin. These pathergy-like lesions developed after placement of orthodontic braces and laser hair removal therapy.
The patient was born in Iraq but moved to the Netherlands when he was 5 years old. For 4 weeks prior to the hospital admission, the patient experienced high fevers without any clear source of infection. His general practitioner prescribed empiric antibiotic treatment but these did not affect the fever. It was noted that during this period, he had received orthodontic braces for teeth straightening. Within days after placement, painful oral ulcerations occurred. One week prior to the hospital admission, the patient had also undergone laser hair removal on the arms and torso. Within days after the procedure, pustules occurred at the specific sites of laser treatment, but later also at distant sites such as the face.
The patient’s blood tests showed increased erythrocyte sedimentation rate (36 mm/h) and mildly elevated C reactive protein level (42 mg/L). A chest X-ray was normal. A PCR for herpetic viruses on an oral swab was negative. Bacterial culture of the content of a skin pustule was negative.
REFERENCE
Van der Ree-Pellikaan Cet al. Oral ulcerations after placement of orthodontic braces and skin pustules after laser hair removal: novel inducers of pathergy reactions in new-onset Behçet's disease. BMJ Case Rep. 2016 Mar 7;2016:bcr2014209208. doi: 10.1136/bcr-2014-209208.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Coenzyme Q 10 is an interesting supplement with anti inflammatory and anti oxidant activity. I've been investigating whether it has any benefits in hair loss ... but the evidence is certainly not in yet.
Coenzyme Q 10 may have some benefits - under certain conditions. The best studies conditions include heart failure, various neurological problems (especially a condition known as multisystem atrophy) and in blood sugar control. It can lower inflammatory markers in the blood, including C reactive protein (CRP). Coenzyme Q 10 may have a variety of helpful effects on obesity too. Patients on cholesterol reducing medications (i.e. statins) may be at increased risk for coQ10 deficiency so that warrants further study.
In the autoimmune condition rheumatoid arthritis, a randomized study showed 100 mg per day of coQ10 reduced several inflammatory markers in the blood (such as tutor necrosis factor alpha). It's still too soon for those with various types of hair loss to start taking coQ10. But I am reminded of a 1995 study published in the Lancet that showed an improvement in hair loss in 2 patients who used coQ10 to treat hair loss caused by a blood thinner known as warfarin. The reference to this study is below.
Oxidative stress occurs from a variety of sources including normal cellular functions in the body but also from irritants, ultraviolet radiation, smoking, and microbes on the skin surface. Even bad dandruff and seborrheic dermatitis generate significant oxidative stress. The abnormal scalp lipids in some scarring alopecias are a particular source of potential oxidative stress and a key research interest of mine.
Overall more research is needed to better understand the uses and benefits of coenzyme Q 10.
Reference Nagao et al. Treatment of warfarin induced hair loss with ubidecarenone. Lancet. 1995; 21: 346:1104
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
I've given several research updates on the autoimmune condition alopecia areata. Great progress has been made in the last few years. For those who asked me for the lecture audio, I'm pleased to include it here.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Platelet rich plasma or "PRP" continues to be studied as to its precise role in the treatment algorithms for many types of hair loss.
The PRP procedure involves taking 60-120 mL of a patient's blood, spinning it down in a dedicated centrifuge machine to obtain PRP and then injecting the PRP back into the patient's scalp. The procedure takes about 1 hour.
All PRP is not equal
One common misconception is that all PRP is equal. The reality is that different machines produce different quality of PRP. Even the settings I type into the actual PRP machine affect the characteristics of the PRP I am able to produce for the patient.
A look at the "hematocrit"
A great example of this concept of differences in PRP is the "hematocrit". Hematocrit refers to the amount of red blood cells that are allowed to enter the final PRP.
If I set the PRP machine at a hematocrit setting of 7 % (high hematocrit), I produce a more red colored PRP (like shown on the left). This contains more platelets per liter and also contains more neutrophils (inflammatory cells). It also contains higher concentrations of growth factors like TGF beta and platelet derived growth factor (PDGF).
If I set the machine at a hematocrit of 2 % (low hematocrit), we produce a more yellow colored PRP (like shown on the right). This contains fewer platelets per mL and also contains fewer inflammatory cells, lower concentrations of growth factors like TGF beta and platelet derived growth factor (PDGF).
I generally like a higher hematocrit setting (7%) for treating genetic hair loss and a lower hematocrit setting (2%) for treating alopecia areata. Studies are ongoing to determine which is best and if these settings really make a difference.
REFERENCE
Sandman et al. Growth factor and catabolic cytokine concentrations are influenced by the cellular composition of platelet rich plasma. American Journal of Sports Medicine 2011.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
By age 50 about 50 % of the population has a good amount of grey hair. But what about those who develop grey hair in the 20s and 30s?
The term "premature greying" refers to greying of hair that happens before the age of 20 in Caucasians, before 25 in Asian individuals and before age 30 in black men and women. From time to time, I evaluate patients in my hair loss clinic who start greying in the teens or twenties.
What are the causes?
Many, many factors influence hair greying - especially genetics. Some individuals simply have the genetic predisposition to develop grey hair. Other causes also need to be considered including thyroid abnormalities, pituitary problems, and deficiency of vitamin B 12.
Smoking too can cause early greying of hair. In fact, 20 years ago, a study in the British Medical Journal showed that smokers are about two to four times more likely to have grey hair. A recent study supports a possible link between low iron, calcium and vitamin D but that needs to be further investigated.
Autoimmune conditions like alopecia areata, vitiligo as well as premature aging syndromes (like a condition called Werner's) can cause affected individuals to develop early greying.
Conclusion
Overall, early greying of hair is fairly common and not usually associated with any underlying problem. That said, a full workup is needed for greying that fits the definition of premature greying.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Minoxidil (Rogaine, etc) is FDA approved for ages 18-65
I'm often asked by patients if they should just give minoxidil a 'try'. Give it a 'go'. I respond that minoxidil can certainly be helpful but minoxidil is certainly not for everyone.
Minoxidil is FDA approved for men and women 18-65 with a type of hair loss known as androgenetic hair loss. If an individual has some other hair loss condition besides androgenetic hair loss (there are actually dozens of other kinds) and if the individual is over 65, they should check with their physician if minoxidil is safe or not.
Minoxidil is not for everyone
I don't prescribe minoxidil if:
1.the patient has heart problems, especially ischemic type heart disease or certain types of heart failure
2. the patient has heart rhythm issues (like atrial fibrillation)
3. the patient has certain internal conditions (like pheochromocytoma)
4. the individual has allergies to any of the components of minoxidil, such as propylene glycol in minoxidil solution or allergy to the minoxidil itself
Final Comments:
Minoxidil has a good safety profile and that has lead to its availability as an over the counter product. But minoxidil is not for everyone. An 82 year old patient with heart failure and two previous heart attacks is not a candidate for minoxidil. A patient with hair loss due to dissecting cellulitis of the scalp (a different condition than genetic hair loss), will likely find little to no use from minoxidil application. Minoxidil is not for everyone.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Scalp micro pigmentation or "SMP" is a method of camouflaging hair loss. Dots are tattooed to mimic the appearance of hairs cut in cross section. In this photo, small black dots can be seen in between the hairs. For this particular patient, these dots camouflage scars from a previous hair transplant
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Lichen planopilaris is a type of scarring hair loss (sometimes called cicatricial alopecia) which has the potential to lead to permanent hair loss. Patients receiving treatment have a scalp appearance that looks different than patients not yet on treatment.
The classic features of LPP are difficult to notice in this photo from a patient currently on treatment. Features are much easier to see if a patient has not yet started treatment.
What features are still present? Well, there are many single isolated hairs (rather than hairs in groups of 2 and 3). The hair follicle openings are difficult to make out with certainty which is often a clue to the presence of scarring. In addition, there is a degree of redness around hair follicles.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
New study supports use of bimatoprost for alopecia areata
Bimaprost is FDA approved for treating glaucoma. It's also FDA approved for treating thin eyelashes in those with sparse eyelashes, and in this case is known popularly as Latisse. The use of bimatoprost in treating alopecia areata has only recently been investigated. Studies have suggested a role in treating eyelash loss in those with alopecia areata.
Bimatoprost in Treating Scalp Loss
A new study, published in Paediatric Dermatology, supports the use of bimatoprost in treating scalp hair loss in patients with alopecia areata. The authors described a 9 year old girl with alopecia areata who had been treated with steroid injections, topical steroids and minoxidil. Despite these treatments, she did not experience regrowth. A decision was made to initiate treatment with bimatoprost solution one drop twice daily on the patches of hair loss.
Within one month the patient experienced the first signs of regrowth and by 7 months the patient had regrown her hair and was able to stop the bimatoprost.
Reference
Li and Antaya. Successful Treatment of Pediatric Alopecia Areata of the Scalp Using Topical Bimatoprost. Pediatr Dermatol. 2016
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Turmeric is a well-known spice used throughout the world. The active ingredient in Turmeric is called “curcumin.” (Curcuma longa). About 2 to 6 % of turmeric is made of curcumin and related compounds.
Turmeric has anti-inflammatory properties and may have some role in inflammatory conditions in humans. Studies suggest some benefit in osteoarthritis and other studies have indicated possible effects on inflammatory bowel syndrome, diabetes and insulin resistance states, abnormal cholesterol profiles (including the so called 'metabolic syndrome') and possibly cancer (colon cancer and leukemias being the most intensively studied).
It's not clear yet if turmeric and curcumin have benefit in hair loss. I'm keenly interested and have used in a limited number of patients with alopecia areata, and the scarring alopecias where inflammation is present.
Exactly how the compound cur cumin reduces inflammation remains to be completely worked out. Curcumin may reduce inflammatory chemicals in the blood and inside blood cells. These chemicals are known as "chemokines" and "cytokines" and are the means by which cells in the body talk to each other. Cytokines like interleukin 6 may be reduced by curcumin and this is important since these cytokines are known to stop hair from growing. Inflammatory markers like ESR are also reduced by curcumin. Similar to aspirin, curmumin has effects on the cyclooxygenase (COX) and lipo-oxygnesase (LOX) pathways .
Once should check with his or her physician before using turmeric extracts or related compounds. As mentioned above, I do occassionally use in alopecia areata (where IL-6 appears relevant) and some scarring alopecias. It's not clear yet what, if any benefit, turmeric has but I'm very interested.
When I do advise curcumin, I recommend 50 mg twice daily of the Turmeric Rhizome Extract (curcuma Longa L, 50:1) and typically start every other day for 1-2 weeks then daily for 1 month then work up to twice daily. One should always check with their physician before using turmeric or curcumin extracts. Some of my patients enjoy using the spice itself and I recommend a teaspoon daily (sprinkled over food during throughout the day). I do not advise the use of turmeric extracts during pregnancy but the spice itself has been used for thousands of years by women. In addition, turmeric can increase the tendency to bleed so patients need to be stopped before surgery.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Body hair transplants to the scalp: Are we achieving patient needs?
More and more patients with limited or depleted scalp donor hair are opting for 'body hair transplants' or "BHT". Chest, beard, and extremity body hair provide additional means of further building scalp density.
A study recently reported results of a survey of 122 patients who underwent body hair to scalp transplants. Most patients in the study had hair moved from the beard, and some had hair from the chest, arms, pubic area and axillae. Recipient sites included the hairline, previous strip scars and the crown. Using a 11 point rating scale (Likert scale scored 0 to 10), the researcher showed that patients were generally quite satisfied with the procedure, given a score of 7.8 out of a maximum 10 for healing, hair growth in the recipient area and overall satisfaction
Comment: We have a great shortage of information pertaining to body hair transplantation. The data from this study show that not only can healing and hair growth be fairly high, but so can the overall patient satisfaction.
STUDY
Umar S. Body hair transplant by follicular unit extraction: My experience with 122 patients. Aesthetic Surg J 2016
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
It's common to have a variety of surgical procedures in the scalp. Some individuals experience injury to the scalp and need stitches. This can sometimes leave permanent areas of hair loss. Some individuals have cosmetic surgery to the scalp (ie facelifts). This also can leave permanent hair loss for some patients.
Overall, anytime surgery is performed on the scalp requiring stitches, some degree of hair loss can occur and sometimes can be permanent. It's a good idea to speak with a hair restoration physician.
Options for restoration
Whenever someone comes in to see me about restoration options, there are a few options to discuss.
1.Waiting longer
It's sometimes helpful to wait a bit longer to see if some growth can occur (growth can be delayed after traumatic injury so waiting is sometimes helpful).
2.Hair transplantation
It can sometimes be beneficial to simply add a few grafts in the area through traditional hair restoration means. Hair can be moved from the back of the scalp (donor area) into the area of hair loss created by the original surgery
3. Surgical Revision
I might advise some patients to see a plastic surgeon to revise the area. This involves cutting out (excising) the original scarred area and resuturing (re-stitching) the area in a variety of creative ways to make smaller. There are many factors that go into determining whether a patient is even a candidate for surgical revision.
4.Scalp micropigmentation (SMP)
SMP is a helpful technique for small areas of scarring. It involves placing tiny dots in the area of scarring. These dots mimic the appearance of hair cut in cross section. They reduce the appearance of the scarring.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
