Sea of Singles (SOS): A Potential Sign of Scarring Alopecia

Lichen planopilaris (LPP) is a type of scarring hair loss condition. Patients frequently present with scalp itching, and sometimes scalp burning and tenderness. Increased hair shedding is common in the early stages. Hair loss is generally permanent and treatment helps stop the disease or at least slow down progression.

Clinically, dermoscopy (trichoscopy) of LPP often shows perifollicular erythema and perifollicular scale (follicular keratosis).

These findings are not present in all forms of LPP. A less common presentation of LPP is shown in the photo. Patients have hair loss with scalp itching. However, by dermoscopy they have many single hair follicles growing in a base of redness. This is what I have termed the "sea of singles" (SOS) appearance to describe the numerous single hairs and absence of hair follicle units containing 2 and 3 hairs. This form of LPP is similar to Abbasi's subtype described in 2016 and fibrosing aloepcia in a pattern distribution described by Zinkernagel in 2000. The "SOS" trichoscopic appearance is important to remember and provides a clue that the patient may have a scarring alopecia.

 

Reference

Zinkernagel MS et al. Arch Dermatol 2000

Abassi A et al. Dermatol Surg. 2016.

What is meant by a "clinical diagnosis?"

What is meant by a "clinical diagnosis?"

The diagnosis of most types of hair loss is achieved through what is termed a "clinical diagnosis".  Many individuals incorrectly believe that the diagnosis "shows up" in a blood test or in a hair sample sent off for fancy mineral analysis. That's not how a hair specialist achieves the diagnosis of a person's hair loss.

A "clinical" diagnosis means that a patient needs to have the scalp carefully examined in the CLINIC by a CLINICIAN and the CLINICIAN needs to listen to the patients entire story (sometimes called the CLINICAL history) of his or her hair loss. Laboratory values are not required in making the diagnosis but might be helpful in making other diagnoses.

Examples

Consider the 32 year old man who has hair loss in the crown. He is concerned that the diagnosis he was given of male balding might not be correct because his lab tests are normal and his testosterone levels and DHT levels in particular are normal. One needs to remember that the diagnosis of androgenetic alopecia is a "clinical diagnosis" and so if the CLINICIAN in the CLINIC seen miniaturization of hairs in the area of hair loss there is a good chance what we are dealing with is androgenetic alopecia.

I could give countless other examples. Many types of hair loss are diagnosed through clinical diagnosis. Lab tests might still be helpful in the work up but they are not needed to make the diagnosis. 

Consider the 23 year old female with hair loss whose labs for ferritin, thyroid (TSH) and hemoglobin come back normal. What type of hair loss does she have?  Without the opportunity for me to review the clinical history and examine the scalp clinically, I would only be guessing.

Conclusion

Most hair loss diagnoses are made through a clinical diagnosis.

What is "pityrosporum folliculitis"?

Pityrosporum folliculitis

This is a an itchy condition whereby hair follicles becomes inflamed due to overgrowth of Malassezia yeast. The condition typically occurs in areas that can support the growth and proliferation of Mallassezia - especially the upper trunk, shoulders and rarely the head and neck area. Although 92 % of the world is covered in Malassezia, most people do not develop any problems from them. Predisposing factors to develop Pityrosporum folliculitis include hot humid environments, age (rarely happens before puberty), cancer, immunocompromised states and previous use of antibiotics.

The patient develops tiny 1-3 mm inflammatory papules and pustules. These reveal the classic budding yeast when examined under the microscope with a drop of potassium hydroxide (KOH).

What conditions can look similar?

One needs to consider many other diagnoses as well before reaching the conclusion that the patient has pityrosporum folliculitis. Steroid acne, acne vulgaris, bacterial folliculitis, eosinophilic pustular folliculitis and insect bites can sometimes look similar.

How is pityrosporum folliculitis treated?

Treatment includes topical antifungal creams including ketonconazole and ciclopirox. Antifungal (antidandruff) shampoos are also frequently used with the creams. Rarely, oral antifungal agents like fluconazole and itraconazole or oral isotretinoin (to shrink the sebaceous glands altogether) are needed. 

Are newly growing hairs thinner than mature ones?

Newly Growing Hairs

The "miniaturization" of hairs refers to a process where hairs get thinner and thinner over time. It is frequently seen in hairs from the scalps of individuals with androgenetic alopecia (male balding and female thinning). The confirmation that a given person has miniaturized hairs frequently evokes a great amount of worry and questions about whether the individual does in fact have androgenetic alopecia. One must always keep in mind that a few conditions can produce thinner hairs - and one must not be too quick to jump to the conclusion that the patient has androgenetic alopecia.

Telogen effluvium is a hair shedding condition where hair sheds from factors such as low iron, stress, thyroid disorders or crash diets. As the hairs start growing back, they appear smaller at first until they thicken up over time. A patient with a consider number of newly regrowing hairs could be mistaken for having miniaturization due to androgenetic alopecia.

When one looks at the following picture of two trees, one can appreciate that the tree on the right is probably older than the one on the left. There is no reason to believe that with time the tree on the left won't achieve the same thickness as the tree on the right.

In cases of massive telogen effluvium, hairs thicken up to some degree over time. Re-evaluation of the patient's scalp a few months later can be helpful if one is unsure whether the patient has a TE, AGA or both.

How does a hair get its shape?

Curly? Wavy? Straight?

Why do some people have straight hair and others have curly? Why do some people have very thick hair and other people have very thin? A part of the hair follicle deep under the scalp known as the inner root sheath (IRS) is responsible for the shape of a person's hair.

Underneath the scalp, the hair fiber is surrounded by the IRS. The IRS in turn is completely surrounded by the outer root sheath. The IRS is a very rigid structure and one can imagine the IRS as being similar to the circular opening of a tube of toothpaste (see picture). The opening is rigid and as one squeezes the tube of toothpaste a cylinder of gooey toothpaste comes out. If the opening of the toothpaste container was a different shape rather than a circle, it's easy to imagine that a different shape would be created. Some people have an IRS that is very circular (...and they tend to produce straight hair!) whereas other people have an IRS that is more oval-shaped and even crescent-shaped (...and they tend to produce wavy and curly hair!). When the hair follicle is first manufactured deep under the scalp it is very soft - and the IRS helps guide the new shape of the developing follicle. Only after a few days time does the new hair follicle harden up (keratinize) and take on the qualities that we all know when it finally emerges from the scalp.

Nail Changes in Patients with Hair Loss

Nail Bed Capillaroscopy

Nails are sometimes important to examine in patients with hair loss. Some autoimmune diseases produce changes in the nail plate and some produce changes in the very tiny blood vessels of the nail fold (see arrow).

Three diseases in particular are associated with changes in the tiny vessels of the nail fold - dermatomyositis, system lupus erythematosus (sometimes just called "lupus") and scleroderma. All three of these diseases can cause hair loss and may be associated with more serious internal illnesses.

I don't perform nail capillaroscopy in all my patients. However, if the patient's story has any suggestion of autoimmune association, I often perform a nail bed capillaroscopy. 

Focal atrichia: A worrisome sign of AGA

Focal atrichia: What is it?

Focal trichina is a term which  refers to a specific observation seen on the scalp of patients with androgenetic alopecia. Those with focal atrichia have small circular areas devoid of hair.

This is a feature of advanced male balding (androgenetic alopecia) and also female pattern androgenetic alopecia. The finding is very important to recognize. Focal atrichia occurring in patients under 30 is worrisome for me as it is associated with a higher risk for progression to more extensive balding.

Excessive Daily Shedding of Hair : Telogen effluvium

Telogen effluvium (TE).

Telogen effluvium refers to a hair loss condition associated with excessive daily shedding. 

The actual amount of increased shedding experienced by the patient can vary. For some, shedding is only slightly increased. For others, shedding can be massive.

Black dots in alopecia areata

"Black dots" represent hair follicles broken off at the level of the skin surface. Black dots are also referred to as cadaverized hairs.

Black dots correlate with disease activity in alopecia areata and are a negative prognostic factor.

Black dots are seen in other conditions besides alopecia areata, including dissecting cellulitis, trichotillomania, tinea capitis and chemotherapy induced alopecia.

LPP: a type of scarring alopecia.

Lichen planopilaris (LPP)

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.

Broken hairs vs new growth?

Is my hair breaking off? Or is it new growth? How can I tell?
 

Short small hairs can be confusing. So many times when short hairs are seen a conclusion is made that these hairs are short on account of breaking off.

New growth is pointy

In many situations, a careful and magnified view of the hairs will reveal that they are actually newly regrown hairs rather than broken hairs. Newly regrown hairs can be readily identified by their "pointed" ends. Broken hairs on the other hand have blunt often jagged ends.

What is considered "normal" hair shedding?

Normal daily shedding

Normal daily shedding is often quoted as "anything less than 100 hairs per day" but that has never been carefully studied and documented. The reality is that there is quite a range of "normal" and somewhere closer to 50-60 is probably closer to what most people experience (or at least can collect).

Of course, there is a wide variation on what is considered normal shedding.

It is incredibly challenging (and incredibly emotional) to have to count daily shedding each day. There are many methods (brushing, shampooing, collecting) to try to measure daily loss. They are helpful and I often use a variety of such methods, but they each have their limitations.

Even those with a clear "telogen effluvium" (increased shedding) sometimes return with 45 hairs collected in a particular day (rather than the magic number 100). Are they shedding excessively? Absolutely. Are they able to measure it properly and capture what is happening? No.

A key principle of shedding is if one is certain they used to lose 30 and now lose 65 hairs per day - this is likely abnormal and warrants further consideration.

Hair breakage in alopecia areata

Broken hairs in AA

Hair breakage is very common in individuals with the autoimmune condition alopecia areata. 

Broken hairs can either be a few mm in length or broken hairs can break at the level of the scalp (in which case the hairs are termed black dots).

Telogen Effluvium

Understanding Telogen effluvium (TE)

TE is a from of hair loss whereby the affected individual experiences higher than normal levels of hair shedding day to day.  For example, instead of losing 40, 50 or 90 hairs in a given day (i.e. what is considered normal shedding) individuals experiencing telogen effluvium lose well in excess of 100 hairs on any given day.
 

Triggers of TE

Telogen effluvium occurs when some "trigger" causes hair follicles to leave the growing phase of the hair cycle and enter the resting phase. So, what exactly are the triggers that "send" a hair follicle out of the actively cycling (growing) phase and into the undesired shedding phase? I teach health professionals the easy to remember memory cue "SEND"

 

COMMON TRIGGERS OF TE:

Stress
Endocrine problems
Nutritional issues
Drugs

New growth.

Recognizing new growth is critically important to understanding hair cycles and how a patient is responding to treatment. New hairs are short and have pointed ends.

What is "pityriasis amiantacea"?

Pityriasis amiantacea

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. 

To Poo or Not to Poo: A closer look at the “no poo” (no shampoo) movement

Should you give up shampoos?

If you’re like most people, you have a bottle or two of shampoo in your shower and you use it to clean your scalp and hair. Perhaps you’re a daily user, perhaps you use shampoos a few times week. If you have coarse and curly hair, you might use shampoo even less frequently.   But you use it. If my own practice is representative of the world out there I know some of you even change your shampoo brands frequently.

However, a small number of women (and an even smaller number of men) have decided to forgo shampooing the scalp altogether. This defines the so called “no poo” movement (i.e. ‘poo’ is short for shampoo).

 1. We are a shampoo loving society

As a society, we have grown to love shampoo and love shampooing. Walk into any drug store and you’ll see just how much real estate is devoted to shampoos. We love the smells of shampoos and the feel of shampoos. We love the look and feel of shampoo bottles. We like the shampoo aisles, shampoo ads and shampoo commercials.  We are a shampoo loving society.

Shampoos were first synthesized in the 1930s, as an alternative to bar types soaps which left a heavy film or “soap scum” on the hair.  Such deposition leaves the hair dull and more difficult to manage.  In years gone by, women  would shampoo their hair at the salon and then have it set. Shampooing every 2-4 weeks was normal. Shampooing wasn’t typically a home-based procedure. It wasn’t until the 1970s and 1980s that shampoos became standard for household daily use. In North America, many women have changed to shampoo their hair very frequently. Moreover, we seem to enjoy squeezing our shampoo bottles and in general use far too much shampoo with each use than we really need to. It’s not really harmful to do so – except to our bank. It’s too often forgotten, that shampoos are meant for cleaning the scalp and conditioners are meant for the hair. A small dab of shampoo is usually sufficient to clean the scalp.

2. If people don’t poo (shampoo), what do they do?

For those who are participants in the ‘no poo” movement and don’t use shampoos, common substitutes include simply using water alone, using apple cider vinegar, baby powder, dry shampoos or using baking soda.  I believe that many of such practices are well tolerated for most people. However, those with color treated or relaxed hair may find that that high pH of baking soda (up to 10-12) to be particular harsh on their hair and increase the chance of damage and hair breakage.  

 

3. Does frequent shampooing trigger your scalp to make more oil?

It’s true that the use of shampoo removes oils from the scalp. These oils are helpful to condition the hair – and might be regarded as nature’s best conditioners. At present, however, there is no scientific proof that the scalp compensates for frequent shampooing by in turn producing more oil. The amount of oil that our scalp produces is genetically determined, and to a much lesser degree by the foods we eat, hormones, seasons and the environment. Changing your shampoo practices won’t reset your oil production. That factory is deep under the scalp (in glands known as sebaceous glands) and not influenced by how you shampoo. It would be nice to think otherwise – but there’s simply no proof.

4. How often should you shampoo?

There is no magic number for how often we should shampoo. In fact, the number is different for everyone.  Those with fine, oily hair are going to benefit from daily shampooing as the oils tend to weigh down the hair. Those with coarse and curly hair can go much longer as the hair will actually look better when not washed so often.   The same is true for those with color treated or relaxed hair – washing less frequently is preferred to further limit damage to already slightly damaged treated hair.  Once or twice a week is likely just fine. Although we certainly shampoo our hair too often, washing the scalp daily is unlikely to cause harm. Furthermore, there is no evidence that avoiding shampoo altogether offers a health benefit. In other words, the no poo movement is a personal choice, not a health choice.

5. Are there any adverse effects of not shampooing ?

Individuals with existing scalp problems could develop a ‘flare’ of their scalp disease with cessation of shampooing. For example, I’ve seen many patients who forgo shampoos that develop worsening dandruff and seborrheic dermatitis ( which is a close cousin of dandruff). It’s usually mild and tolerable. To understand why this occurs, it’s important to understand that dandruff and seborrheic dermatitis are caused by yeast that lives on our scalps.  These yeast feed off scalp oils. Excessive oiliness from not shampooing provides this yeast with an abundance of food and in turn further exacerbates the patient’s scalp problem.  The no poo decision might not be for everyone.

6. If you’re going to shampoo, should you go sulfate free?

For those who decide that the no poo movement might not be for them, a common question then arises – what about joining the sulfate free movement? Certainly, sulfate free shampoos are popular. If you’ve used a sulfate free shampoo you immediately notice they don’t lather up quite as well as a shampoo containing sodium lauryl sulfate or ‘SLS‘. The main downside of these shampoos is not their lathering ability but the fact that SLS shampoos are a bit more drying and are more likely to lift the cuticle and cause damage for those with color treated or relaxed hair. The can also cause irritation for those with scalp problems, including eczema.  The vast majority of people in the popular will notice little difference to their hair from using a sulfate free or SLS containing shampoo.  Decisions on whether to use SLS shampoos for other reasons (including environmental) are still being researched. However, from the perspective of the hair – the vast majority of people will not achieve better hair care from sulfate free shampoos.

Conclusion: Are you giving up shampoo?

Hair is personal. Hair helps define who it is we are and how we present ourselves to the world. Our hair is central to our self identify. If you don’t want to shampoo your hair – don’t shampoo your hair. There are a small number (but manageable number) of risks. Similarly if you want to shampoo your hair frequently, shampoo it. Change up your brands.  Enjoy all that shampoos offer in further defining what is personal, individualistic and what defines our feelings of self identity and self-expression.  There are risks to many things and it simply comes down to being well informed.  Humans quickly learn what shampooing frequency is right for them.

Follicular Units: The Building Blocks of Modern Hair Tranplantation

Building Blocks of Modern Hair Tranplants

The figure on the right shows that hair follicles normally emerge from the scalp in groups of one, two or three hairs.  These groupings of hairs are called "follicular units".

Hair transplant surgery nowadays relies on the use of these "follicular units". 

In individuals with genetic hair loss, hairs from the back of the scalp can be removed and processed into "follicular units" and then inserted into the front or middle of the scalp.

The second photos shows some freshly prepared "follicular units" from a patient undergoing a hair transplant. "Follicular units" containing single hairs are normally placed into the frontal hairline and "follicular units" containing two or three hairs are normally placed behind this area.  This strategy of placing follicular units mimics what we see in the normal scalp and when placed at precise angles and directions - allows a hair transplant to look natural.

Hair Loss in Black Women: CCCA

Hair Loss in Black Women: CCCA

Central Centrifugal Ccatricial Alopecia (or 'CCCA' for short) is a common cause of hair loss in black women. Some estimates suggest that up to 30% of black women have CCCA. Unfortunately, the condition is very much underrecognized and underdiagnosed. Too often women with CCCA are misdiagnosed as having genetic hair loss - both conditions lead to hair loss in the central scalp.

CCCA causes permanent hair loss in the central scalp.  Individuals affected by the condition sometimes have scalp itching, burning or pain but very often have no symptoms.  This make it difficult to catch the diagnosis in early stages.  Hair loss gets worse over time. The cause is not known at present although hair styling practices and the use of of chemicals and relaxers continue to be explored as causes.

How can we improve our ability to diagnose CCCA?

CCCA is underrecognized in the medical community and underdiagnosed.  How can we train more physicians to recognize this common condition? Certainly training others  to recognize this condition is the first step. There is a suprisingly easy rule I teach doctors who work with me in my clinics:

Any black women with hair loss in the middle of the scalp needs evaluation (& possibly scalp biopsy) to rule out the diagnosis of CCCA.

Hair loss from CCCA is permanent. In most cases regrowth is not possible. Treatments help stop further hair loss but are not always 100 % effective. Treatment for CCCA includes topical steroid medications and steroid injections. Oral medications including tetracycline based antiinflammatory drugs can also be used. Hair transplantation can be successfully used to restore hair density once the condition becomes quiet.

What is the best test to do if I think I have celiac disease?

What is celiac disease?

Celiac disease is an autoimmune disease of the bowel. When individuals with celiac disease eat foods containing "gluten" (such as barley, rye, wheat), inflammation develops in the small bowel. This leads to damage to the small bowel which prevents it from properly absorbing food.  Celiac disease can develop at any age. It’s more common in Caucasians and those of European ancestry. Women are affected to a greater extent than men.

Patients with celiac disease may have many symptoms.  The most common symptom is diarrhea that lasts many weeks or months (termed "chronic diarrhea") as well as weight loss.   But a range of symptoms are possible, including abdominal pain, weight loss, bloating, gas, and constipation. In fact, celiac disease can sometime be challening to diagnose because it has many different ways of presenting.

Should patients with hair loss be tested for celiac disease?

Many patients with hair loss wonder if they should stop gluten or if they should be tested for celiac disease.  In most cases, the answer is "no."  However, testing for celiac disease may be recommended f the patient has abdominal symptoms or long standing weight loss. Sometimes I also check for celiac disease if a pateint has low iron levels that just don't seem to raise despite use of iron pills.  A very small percent of patients with autoimmune hair loss conditions (i.e. alopecia areata) do have celiac disease.  

The most common tests that are ordered to SCREEN if someone has celiac disease are:

1. Tissue transglutaminase Antibodies (tTG)

2. Endomysial Antibodies (EMA) 

3. Other tests "may" be ordered by the physician as well including IgA antibodies and specific genetic tests such as HLA-DQ2 and HLA-DQ8.

Overall, the tTG test is the best screening test. It's inexpensive, quantitative and a highly reproducible test.

What is done once a patient is diagnosed with celiac disease? 

Once diagnosed with celiac disease, a gluten free diet will be recommended. In some cases, a referral to a gastroenterologist may be recommended. Follow up blood tests may be ordered to assess how well an individual is doing with their gluten free diet.