Dissecting cellulitis (DSC) is a rare scarring hair loss condition. It is characterized by deep inflammation and leads to the formation of draining sinus tracts (especially tunnels that allow pus and inflammation to escape - see number 1 and 4 in the picture). The diagnosis of DSC in advanced stages is easy as these openings (sinus tracts) can be seen all over the scalp. In the early stages an up close exam and use of a dermatoscope can prove extremely helpful.
Early DSC is characterized on dermoscopy by large yellow dots, thin vellus hairs within the area, broken hairs and healing (covered) or open sinus tracts. The early stages of the nodule can mimic alopecia areata (see top right, number 3 and 5). A swiss cheese like appearance is common as scarring progresses (number 2). Biopsies of DSC often show deep inflammation but in more advanced cases show inflammation higher up in the skin which can easily be mistaken for another scarring alopecia known as "folliculitis decalvans." Therefore, it is not uncommon for patients to be referred with a diagnosis of biopsy "proven" folliculitis decalvans only to need to explain to them after examining their scalp that what they actually have is DSC.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
I frequently get asked whether minoxidil has any benefit in treating frontal fibrosing alopecia (FFA). It seems that it could provide some benefit but it's not completely clear yet if it is truly helping the patient's FFA or their underlying androgenetic alopecia that many patients with FFA also have. Large scale studies are needed.
I generally add minoxidil once I have some evidence that a patient is stabilizing with their main anti-inflammatory treatment. This typically includes one or more of topical steroids, steroid injections, doxycycline, hydroxychloroquine and anti-androgens such as finasteride or dutasteride.
It’s interesting that 32 % of patients in one study had an improvement in their FFA with use of anti-androgens. When one looks at a larger group of 111 FFA patients of which 74.8 % were using minoxidil, one notes that 47 % of patients had an improvement with anti-androgens. So it does seem that patients using minoxidil had better outcomes. There is at least some suggestion here that minoxidil might help.
Conclusion
Up to 40 % of patients with FFA have androgenetic alopecia so it’s difficult sometimes to decipher whether minoxidil is truly helping the patient’s FFA or whether it is helping their underlying androgenetic alopecia. More good studies are needed.
Reference
Vano-Galvan S et al. Frontal fibrosing alopecia: a multicentre review of 355 patients. J Am Acad Dermatol 2014; 70: 670-678
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
This is a controversial topic but this study (as well as a study of FFA in women) has caught the attention of many. A study by Kidambi et al compared how 17 men with FFA and 73 men without FFA responded to a lengthy survey. FFA is relatively rare in men but information on a link to sunscreen use was important to investigate given the possible role among women.
A much greater proportion of men with FFA reported using sunscreens (as well as facial moisturizers) at least twice weekly compared to men without FFA. Specifically, 35 % of FFA patients reported such sunscreen use compared to just 4 % of men without FFA.
Conclusion
We have a long way to go to definitely prove sunscreens have a role. But two studies now (one in men and one in women) have described potentially the first environmental factor implicated in the way FFA develops. An environmental factor is certainly thought to be responsible given that FFA was relatively unheard of 20 years ago. There are more good studies that are needed.
Reference
Aldoori N et al. Frontal fibrosing alopecia: possible association with leave-on facial skin care products and sunscreens; a questionnaire study. Br J Dermatol 2016.
Kidambi AD et al. Frontal fibrosing alopecia in men: an association with facial moisturizers and sunscreen. Br J Dermatol 2017.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
This is a controversial question, there has been one study that has caught the attention of physicians and patients around the world. A study by Aldoori et al compared how 105 women with FFA and 100 women without FFA responded to a lengthy survey.
Surprisingly, a much greater proportion of women with FFA reported using sunscreens (at least twice weekly) compared to women without FFA. Specifically, 48 % of FFA patients reported such sunscreen use compared to just 24 % of women without FFA.
Conclusion
We still have a long way to go to definitely prove sunscreens have a role. It is potentially the first environmental factor implicated in the way FFA develops. An environmental factor is certainly thought to be responsible given that FFA was relatively unheard of 20 years ago. More good studies are needed.
Reference
Aldoori N et al. Frontal fibrosing alopecia: possible association with leave-on facial skin care products and sunscreens; a questionnaire study. Br J Dermatol 2016.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
The short answer is that we do not know. A 2017 study by Fonda-Pascual suggested that smoking was somehow protective against the development of FFA and that non-smokers had more severe disease. Other studies, including a study by Dr Messenger's group from the UK did not show this link.
Conclusion
To date, there is no solid information available to suggest that smoking either causes FFA or prevents the development of FFA. Large scale studies will help answer the question for good.
References
Aldoori et al. Br J Dermatol 2017. Fonda-Pascual et al. JEADV 2017.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Hair extensions can sometimes cause hair loss. Whether to remove the extensions or change the type of extension is a decision made on a case by case basis. This is not always a simple answer. Sometimes the improvements that come with the patient using the extensions supercedes a small amount of hair loss that might come with wearing them. This makes removing the extensions less relevant - especially if this is a more permanent type of camouflaging option for the patient. If, however, the hair extensions are causing significant hair loss and the use of the extension is only temporary (and the long term goal is to improve the patient's hair), then the extensions should likely be removed or changed to reduce the chance of long term damage to the hair follicle and the scalp.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Frontal fibrosing alopecia (FFA) is a type of scarring hair loss that occurs more often in women than men. It causes hair loss along the frontal hairline as well as several other areas including the sides and back of scalp, eyebrows, eyelashes, and body hair.
This picture shows a very typical appearance of the frontal scalp in FFA. There are numerous single hairs, many with scale around those hairs (called perifollicular scaling). A few broken hairs are seen and one hair in the picture is markedly twisted (a phenomenon known as "pili torti"). This is mild scalp redness.
Many treatments are available as we have reviewed together previously. This patient was started on a 5 alpha reductase inhibitor (finasteride, 5 mg) along with pimecrolimus cream (Elidel) and steroid injections. Clobetasol proprionate shampoo (Clobex) will be used weekly and reassessment will be done in 4-6 months.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
The appearance of white colored scale around hair follicles is common. This can either be concerning - or not concerning. The white scale in the right picture is not concerning and represents a mild scale from normal epidermal turnover. The patient also has androgenetic alopecia. There is only one follicle affected and the scale is not tightly adherent to the hair follicle. When I see this, it catches my attention for just a second and then I move on to assess other scalp features.
The picture on the left shows a pattern of scale which is concerning. When I see hair follicles that look like this I am immediately concerned. This scale is tightly adherent to the follicle and forms a circular shape all around the follicle. It is important to note the underlying redness and it is also important to note that all of the follicles in the photo are just single hairs. Scale that tightly encircles the hair follicle in this manner is known as "perifollicular scale." In this left sided picture, the patient has an underlying scarring alopecia known as lichen planopilaris. Perifollicular scale and perifollicular redness are common in lichen planopilaris (as well as frontal fibrosing alopecia). Scale patterns can change if a patient washes his or her hair within 12 hours of their appointment. Sometimes, in order to better appreciate scaling in patients with challenging diagnoses - I will ask them to refrain from washing the scalp for 24-72 hours. I don't commonly do this but it can be helpful.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
There are many different forms of hair loss. We broadly classify hair loss into the "scarring" forms and the "non-scarring" forms. Patients with scarring forms (also called scarring alopecia) may experience hair loss accompanied by symptoms such as itching, burning or even scalp tenderness/bruising. Some patients, however are completely asymptomatic.
The hallmark of all scarring alopecias is the loss of the follicular openings or "pores" when examined up close. Rather these areas are replaced by scar tissue - as shown here in this photo of a patient with a scarring alopecia known as lichen planopilaris (LPP).
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
The Clevland clinic performed a new study that showed that hormone abnormalities can be common in lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA).
A proportion of patients with LPP were found to have "androgen excess" (increased levels of the male hormones). However there was a portion of patients with FFA that were shown to have "androgen deficiency." This did not prove to be true of everyone - but was a trend seen in a large proportion.
This study is surprising, especially when considering that antiandrogens are helpful in FFA. It may however provide insight into differences between LPP and FFA. More studies are needed. For now, I agree with the authors conclusions that hormone levels are important to order in women with these scarring alopecias.
Reference Ranasinghe GC, et al.Prevalence of hormonal and endocrine dysfunction in patients with lichen planopilaris (LPP): A retrospective data analysis of 168 patients. J Am Acad Dermatol. 2017.
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
Pohl Pinkus constructions or monikethrix-like constrictions are characterized by thinner areas of the hair shaft due to reduced matrix activity. This dermatoscopic finding is common is alopecia areata, and can also be seen in scarring alopecia (shown here), congenital hypotrichosis, and with some chemotherapies
This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
