Should I Use Finasteride for Hairline Maturation?

There are two common changes to the frontal hairline that young men can observe. One is known as hairline maturation and the second is male pattern hair loss (also known as androgenetic alopecia). Both are a cause of worry to patients and both are commonly misdiagnosed.

Hairline maturation

Hairline maturation is a normal process that occurs between age 15-27 whereby a small amount of hair recession occurs in the very frontal hairline and a slight amount of recession of the temple is observed. This is generally 1 cm above the highest forehead wrinkle in the centre and 1.5 inches in the temples. In male balding recession occurs to greater degrees.

Treatment of hairline maturation and male balding

The distinction between the two conditions (hairline maturation vs balding) is important as there are no medical treatments for hairline maturation. Male balding can be addressed with treatments such as finasteride or minoxidil as well as others too.

Finasteride (Propecia and generics) and minoxidil (Rogaine and generics) are FDA approved for male pattern balding. These treatments do not have any effect on normal male hairline maturation. One may want to check with a physician of concerns exist about signs of early male balding. The best thing that can be done in early stages of hair loss is frequent scalp photography every 4-6 months. This is extremely helpful to track changes in the hairline and get a sense of the degree of hairline maturation and balding a person might have.

Creatine and Hair Loss

There are many potential reasons for hair loss in individuals who use training supplements. Creatine is frequently used as an 'ergogenic' training aid to enhance performance. Although there is no definitive proof, I'd like to outline why it certainly might cause hair loss in those with a 'genetic susceptibility' to balding.

In a study from South Africa 20 college-aged rugby players participated in a double blind study. Subjects loaded with creatine (25 g/day) or placebo (50 g/day glucose) for 7 days followed by 14 days of maintenance (5 g/day creatine). The researchers looked at serum testosterone and DHT levels at baseline and then at 7 and 21 days. After 7 days of creatine loading, or a further 14 days of creatine maintenance dose, levels of DHT increased by 56% after 7 days of creatine loading and remained 40% above baseline after 2 weeks maintenance. Testosterone levels were unchanged.

While this data does not prove anything about hair loss, it does suggest that the higher DHT could provide a negative impact on hair loss for individuals who are predisposed to androgenetic alopecia (male balding and female thinning). Not all studies have suggested a negative impact on hormone parameters. A study completed in 2004 suggested that creatine supplementation actually decreased the free androgen index after 3 weeks of use. A 2001 study of 11 men did not find differences in serum testosterone in men receiving 10 g of creatine. However, serum cortisol levels were higher after creatine use during the resting period. 

Conclusion

We don't know if creatine supplementation promotes hair loss. One must at least consider the possibility that changes in DHT and even cortisol could have a negative impact on hair loss. 

Reference

van der Merwe J, et al. Clin J Sport Med. 2009.

Volek JS, et al. Eur J Appl Physiol. 2004.

Eijnde BO, et al. Med Sci Sports Exerc. 2001.

Minoxidil (Rogaine/Regaine): Do I really need to use forever?

I'm often asked if a patient needs to use their minoxidil (Rogaine/Regaine, etc) "forever." The answer is sometimes yes and in other cases the answer is "no." It really depends on the diagnosis and a few details specific to each patient. Here are a few examples.

Androgenetic Alopecia

Use forever?: Yes

If the patient has androgenetic alopecia (male balding and female thinning), he or she will need to use minoxidil forever. If minoxidil is stopped, the hair will return to the way it once was and progressively get worse. In fact, all treatments for androgenetic alopecia are the same - use is forever. 

Telogen Effluvium

Use forever?: Usually not

Patients with telogen effluvium or "excessive" daily shedding from a trigger such as low iron, thyroid problems or a crash diet often don't even need minoxidil. (I’m not a big fan of getting people to use minoxidil in telogen effluvium is the cause is known).

But the patient will often use to encourage more rapid resolution of the hair loss. Once the "trigger" has been addressed and treated, hair shedding usually slows down and eventually stops. Minoxidil can be used until the shedding returns back to a normal rate and them for a few months after. A patient who uses minoxidil after a crash diet will find that shedding reduces to normal once the diet is improved. If minoxidil was used it can be stopped in 6-13 months without the patient experiencing a return of the shedding. In this case minoxidil use is not forever. There are some forms of shedding which continue on and on despite fixing any known "trigger." We call this chronic idiopathic telogen effluvium and in such cases minoxidil may be needed long term for many years (1-15 years… or more!). Generally though even in such cases of chronic idiopathic telogen effluvium the minoxidil can be stopped.

In summary, for most patients with telogen effluvium, use of minoxidil is NOT forever. The goal of treatment is to treat the cause of the shedding (like the low iron or the thyroid problem!)

Alopecia areata

Use forever? Usually not

Alopecia areata is an autoimmune condition which can cause hairloss anywhere on the body. Most patients with alopecia areata lose hairs in circles or patches in the scalp. The hair loss in these areas can grow back on its own (we say "spontaneously") or with treatments such as corticosteroids and minoxidil. In most cases, once the hair regrowth is underway, it is possible to stop the minoxidil without the patch of hair loss coming back. 

In summary, for most patients with alopecia areata, use of minoxidil is NOT forever.

Scarring alopecia

Use forever? Sometimes 

Although scarring alopecias are commonly seen in my clinic, overall they are relatively uncommon conditions. Most have an immune basis, meaning that some sort of inflammation is generally present underneath the scalp. Treatment with minoxidil alone (as a sole treatment) is never appropriate for patients with "active" scarring alopecia. Minxodil however can be a good add on treatment (adjuvant treatment) to cheer on hairs that are trying hard to push their way through scar tissue in the scalp. I often recommend patients who decided to start minoxidil) and who show some kind of benefit) for scarring alopecias continue to use long term. Scar tissue is permanent and it is helpful if many cases to have minoxidil on board to cheer the hair growth along.

In summary, the decision to use minoxidil forever in scarring alopecias is taken on a case by case basis. For many patients long term use is advised if there is evidence it is actually helping.

Partially Treated Lichen Planopilaris

 Scale Gone, Redness Remains

Lichen planopilaris (LPP) is a scarring hair loss condition. The goal of treating LPP is to stop the condition. Successful treatment is associated with a halting of hair loss but also with an improvement in the symptoms and signs of the disease. Patients will notice a reduction in itching and burning and clinically there will be an improvement in scaling and redness around hairs. Sometimes scaling is the first to improve and improvements in redness happen later. This picture shows a patient with partially treated lichen planopilaris. The disease is still active although scaling has improved. The patient's itching has also improved.

Do I Need to See an Endocrinologist for my Hair Loss?

There are many types of hair loss. In fact, when you add them all up, there are well over 100 causes of hair.  Some of the causes impact another body system in addition to the hair and require additional focus and attention to ensure the patient's total health. For example, some of the causes are associated with an increased chance of having a thyroid disorder (alopecia areata and lichen planopilaris are example). Other causes are associated with a range of other issues including hearing issues, heart problems, kidney problems, cholesterol problems, bone abnormalities, etc.

Androgenetic alopecia is a form of hair loss that frequently affects women. It causes thinning in the central scalp area in early stages such that the scalp becomes much more "see through." Over time the hair loss pattern can be diffuse. Most women with androgenetic alopecia have no hormonal abnormalities but a small proportion do. Women with irregular periods, acne, hair growth on the face require blood tests to further evaluate for an underlying endocrine issues.

When should a referral to an endocrinologist be made?

I'm often asked by patients and physicians when I refer my patients to an endocrinologist. There are no hard and fast rules but referrals are generally made in the following situations:

1. Women with androgenetic alopecia and irregular periods, especially less than 9 menstrual cycles per year.

2. Women with androgenetic alopecia with possible evidence of late onset congenital adrenal hyperplasia evidenced by elevated day 3-4 17-hydroxyprogesterone.

3. Women with androgenetic alopecia with evidence of potential polcystic ovarian syndrome, especially elevated day 3-4 LH/FSH ratios, irregular periods and findings of acne and increased hair growth on the face.

4. Women with hair loss accompanied by regular menstrual cycles with a history of irregular cycles in the past who do not show normal surges of progesterone day 21.

5. Women with possible premature ovarian failure.

6. Women with irregular periods and elevated prolactin.

7. Women with markedly elevated DHEAS and testosterone regardless of age

8. Women with autoimmune mediated hair loss with low bone mass. Such women may require corticosteroid based therapies with the potential to further impact bone

9. Women with potential adrenal dysfunctional either concern for adrenal suppression from corticosteroid use or various causes of hyperadrenalism (especially when Cushing syndrome is a consideration).

10. Women with low TSH and elevated T4 and or T3

11. Women with high TSH above 7-10 that does not improve on repeat testing or does not improve with thyroid supplementation or is associated with symptoms such as low heart rate, mood changes, constipation and/or chronic shedding. A lower threshold for referral is made in my clinic if additional underlying health issues are present (ie heart disease) or thyroid autoantibodies are positive. For an elevated TSH 2.5 to 6, I handle these situations on a case by case basis.

Conclusion

Hair loss is associated with changes in several organ systems. There are several reasons why I might ask my endocrinology colleagues to evaluate my female patients and some are listed above. Other reasons may be possible too. It is not a routine referral meaning that not all patients need such referral. In fact, it is only a small minority.

Plan b: Is There a Plan B to Treating Hair Loss?

The first step in determining how to help someone with hair loss is figuring out his or her diagnosis. There is no bypassing this step.  The second step is determining a treatment plan that is based on the best medical evidence. 

Plan B: What is Plan B, Doc?

After reviewing a treatment plan with my patients, I'm often asked what treatment will be considered next. "What's plan B, doc?" Well, every treatment plan needs Plan B as well as a Plan C and Plan D.

Consider the 28 year old female with androgenetic alopecia. The best treatment option for her based on all her facts, review of her blood tests and scalp exam might be topical minoxidil. Plan B might be oral spironolactone with or without minoxidil. Plan C might be the addition of a laser comb or changing the anti androgen used. Plan D for her might be a trial of PRP. A solid treatment plan has an alphabet of plans. Not guesswork and not a random pull out of a hat option. But rather options based on a delicate combination of medical science and expert consensus, and personal experience.

What about the 53 year old female with frontal fibrosing alopecia? Plan A for her might be finasteride & steroid injections with hydroxychloroquine as Plan B. Doxycycline is reserved for her as Plan C. For another patient with FFA, Plan A might start with hydroxychloroquine & steroid injections. For her, finasteride is not on the list given the past history of breast cancer the patient had. Plan B is doxycycline and plan C is methotrexate.

Conclusion

Every treatment plan should have an alphabet of plans. That does not necessarily mean one will need to move down the list but the physician should have a clear plan for how to navigate.

Valproate and Hair Loss: Does valproate cause hair loss through an androgen mediated mechanism?

There are many different types of drugs used as mood stabilizers is women with bipolar disorder. Many of these drugs can cause hair loss, albeit with different mechanisms. Common medications used in treating bipolar disorder include lithium, valproate, lamotrigine, topiramate, gabapentin, carbamazepine, oxcarbazepine.

Vaproate and Hyperandrogenism

There is increasing evidence suggests that valproate is associated with isolated features of polycystic ovarian syndrome (PCOS). To study this further, researchers studied three hundred women 18 to 45 years old with bipolar disorder. A comparison was made between the incidence of hyperandrogenism (including hirsutism, acne, male-pattern alopecia, elevated androgens) with oligoamenorrhea that developed while taking valproate versus other types of anticonvulsants drugs (like lamotrigine, topiramate, gabapentin, carbamazepine, oxcarbazepine) and lithium. 

What were the results?

It was interesting that among 230 women who could be evaluated, oligoamenorrhea with hyperandrogenism developed in 9 (10.5%) of 86 women on valproate compared to just 2 (1.4%) of 144 women on nonvalproate anticonvulsants or lithium. This translated into a nearly 8 fold risk of these hyperandrogenism and menstrual cycle changes with valproate. Oligomenorrhea happened within 12 months with valproic acid users.

Conclusion

Once needs to be aware of a possible PCOS like clinical phenomenon and for hair specialists - the development of hyperandrogenism and accelerated AGA in women using valproate for bipolar disorder. More studies are needed to confirm these findings.

Reference

Valproate is associated with new-onset oligoamenorrhea with hyperandrogenism in women with bipolar disorder.

Joffe H, et al. Biol Psychiatry. 2006.

Oral Immunosuppressants for Lichen planopilaris: should I increase my dose?

Dosing oral immunosuppressants for Lichen planopilaris (LPP)

There are many different immunosuppressants and immune modulators that can be used for treating lichen planopilaris. Examples include doxycycline, hydroxychloroquine, methotrexate, mycophenolate, cyclosporine.  I'm often asked what dose a patient should be using? 

What dose should a patient be using? 

When it comes to immunosuppressant medications, I always try to keep patients on the lowest possible dose that controls their disease. Generally I start at fairly standard doses of immunosuppressants and observe what happens to the patient's hair loss. For example, this might be 200 or 400 mg of hydroxychloroquine (Plaquenil) daily, 15-20 mg of methotrexate weekly, 150-300 mg of cyclosporine, 500-1000 mg of mycophenolate mofetil, 100 mg of doxycycline. If the disease is vastly improved after a few months, we may consider going down on the dose or staying at the same dose for a few more months. If the disease is getting worse, we might consider going up on the dose is their is room to go up or changing the immunosuppressant altogether. 

Can drugs accelerate androgenetic alopecia (AGA)?

Medications can potentially accelerate androgenetic alopecia. Common examples are anabolic steroids, the use of testosterone injections and topical androgen gels (commonly used for men with "low testosterone"), androgenic progestins in birth control pills, danazol as well as many other medications.

This individual whose scalp is shown in the picture has been using anabolic steroids for body building and has experienced rapid hair loss mainly due to a conversion of his large terminal hairs (some labelled by green dot) to thinner miniaturized hairs (labelled by yellow dot). Treatment of drug accelerated AGA involves either stopping the androgen or blocking the effects of the androgen on the hair follicle using 5 alpha reductase inhibitors... or both. Less specific treatments like minoxidil may provide some benefit. Many individuals can improve with this plan but full regrowth is unlikely.

Nausea with Doxycycline: What strategies can help reduce nausea?

Doxycycline and Nausea

Doxycycline is an antibiotic. It's used of course in treating infections but it is commonly used for a variety of scarring alopecias including lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia, folliculitis decalvans and sometimes dissecting cellulitis.

The drugs has two important properties: it stops infection and reduces inflammation. For some conditions such as lichen planopilaris, it's the anti-inflammatory properties that are useful. For other conditions such as folliculitis decalvans, it's the anti-bacterial and anti-inflammatory properties that are key. 

The drug has a number of potential side effects even though it is generally well tolerated for most. It can cause nausea, vomitting, sun sensitivity, headaches, increased chance of yeast infections in women, rash. 

Doxycycline and Nausea

Some patients developed considerable nausea with doxycycline. Some will even vomit.  This can be a short term issue for some users which improves over time. For others it is something that continues and may even require the patient to stop the medication.  Anyone with nausea from doxycycline should speak to their prescriber for advice on how to reduce the nausea. 

Tips to reduce nausea

1.  Take doxycycline with food. Unlike tetracycline, doxycycline still gets absorbed quite well into the blood stream if the patient takes it with food. The food intake really helps to reduce nausea and this should be encouraged

2.  Avoid spicy foods with the doxycycline. Anything that upsets the stomach has the potential to makes things worse with doxycycline. I generally recommend avoiding spicy foods with doxycycline. 

3. Take Gravol.  If nausea continues despite food intake, dimenhydrate (Gravol) can be used 1 hours before the doxycycline is taken. I generally recommend starting with 25 mg Gravol and then 50 mg and then 100 to see what dose can help reduce the nausea. Gravol can make people drowsy and sleepy so this needs to be considered if one is driving or doing anything that requires focus. 

4. Use Ginger. Ginger is also a helpful anti-nausea treatment. There are a number of candies, lozenges on the market that contain ginger and can be used prior to the patient taking the doxycycline. The company that makes Gravol also has a product "Ginger-Gravol" which can be very helpful. this does not contain Gravol and therefore does not cause drowsiness.

5. Reducing the doxycycline dose. For some users, the nausea is dose related. Reducing the dose can help.

Tetracyclines for Scarring Alopecia: Which one should I use?

Tetracycline Antibiotics for Scarring Alopecia

Tetracycline, Doxycyline and Minocycline are members of the tetracycline family of antibiotics. These drugs are commonly used to fight infection but are also frequently used for their anti-inflammatory effects and are therefore used in a variety of scarring alopecias including lichen planopilaris, frontal fibrosing alopecia, and pseudopelade. 

These medications have several well known mechanisms for halting inflammation: they inhibit matrix metalloproteinases, they inhibit angiogenesis, they have antioxidant effects and they block the production of various pro-inflammatory cytokines. 

In terms of treatments for lymphoctic scarring alopecias, all these drugs are fairly similar in terms of efficacy but good studies have yet to be published. Personally I prefer doxycycline over others. 

Doxycycline is the most commonly prescribed tetracycline family member. It can be taken with food and tends to have the least overall chances of side effects compared to minocycline and tetracycline. That is not to say of course it does not have side effects because it certainly does. Doxycycline can cause upset stomach, headaches and tends to be the most photosensitizing.  Headaches and raised intracranial pressure are a rare side effect but nevertheless must be respected. Immediate cessation of the drug and medical attention is needed in anyone with persistent headaches on doxycycline. Women using doxycycline are at increased risk for vaginal yeast infections. The dose is 100 mg once to twice daily. The medication should be taken while seated upright and with plenty of water to avoid heartburn and esophagitis. Doxycycline is safer than tetracycline (see below) for use in those with kidney disease.

Recently, the possible use of low dose sub-antimicrobial doses of doxycycline have emerged on the market. This is sometimes referred to as "SD" or sub-antimicrobial dosing." Such medications are frequently used for inflammatory conditions such as rosacea. I frequently use these drugs in patients with scarring alopecia who I want to transition off higher doses doxycycline. Doxycycline formulation Oracea was approved by the FDA in 2006. Side effects are less than 100 mg conventional doxycycline but may not be appropriate as a first line off label treatment for active scarring alopecias.

Tetracycline is less expensive than doxycycline which is great but it needs to be taken on an empty stomach.  This makes it less convenient. The dose is typically 500 mg twice daily for typical dosing in lichen planopilaris but this can sometimes be increased to three times daily. It must not be used in those with kidney disease and used only with extreme caution in those with liver disease. It must never be used during pregnancy and never in children (particularly under 8 years due to effects on teeth and bones). Tetracycline is less photosensitizing than doxycycline but caution is still needed. Tetracycline is more photosensitizing than minocycline.

Minocycline can sometimes be associated side effects that are not seen commonly with other tetracycline members including a serious lupus like phenomenon and other side effects like malaise and joint pains. Minocycline is a much more frequent cause of serious reactions like hypersensitivity reactions, serum sickness like reactions and single organ dysfunction. Pigmentation issues are also possible. It is less photosensitizing compared to doxycycline and tetracycline. The dose is 100 mg daily and doses up to twice daily may also be considered. Similar to tetracycline and doxycycline, minocycline must never be used in pregnancy.

All in all, one should speak with his or her dermatologist about other specific side effects of the tetracycline group. These medications may be taken for many months to even several years in those with scarring alopecia. Patients should not use retnoid medications while using tetracyclines. Moreover one should not consume iron, magnesium, calcium or aluminum at the same time as their tetracycline as these bind to the tetracycline and block absorption. Tetracyclines (all 3 members) must never be used during pregnancy and never by children under 8 due to teeth discoloration.

Amphetamines and Hair Loss

Amphetamines are a group of drugs that stimulate the central nervous system. They have been used since the 1920s. Amphetamines are used in the treatment of attention deficit hyperactivity disorder (ADHD), narcolepsy and obesity. At higher doses, amphetamines are also drugs that are frequently abused.

Examples of amphetamines

Most amphetamines are prescription based and include drugs such as:

1.    Dextroamphetamine

2.    Levoamphetamine

3.    Lisdexamfetamine

4.    Methamphetamine

5.    Adderall and Adderall XR

6.    Dexedrine

7.    ProCentra

8.    Ritalin

9.    Concerta

10. Dextrostat

11. Vyvanse

12. Focalin

13. Strattera

14. Zenzedi

15. Evekeo

Hair loss with amphetamines

Hair loss is a possible side effect of amphetamines. It does not happen to everyone but a proportion are affected.  Hair loss typically occurs 4-7 weeks after starting. Daily shedding increases from well under 70 to above 100. Hair loss occurs all over the scalp rather than in any given area. Hair loss from amphetamines can also occur on the body hair.

Hair loss can be from the drug itself or the caloric and nutritional deficiencies that come from the appetite suppressing effect of these drugs.

Evaluation of the patient with suspected amphetamine induced hair loss

It is important for anyone with suspected amphetamine induced hair loss to see a physician. The first step is to determine if the timing of the hair loss and the type of hair loss pattern fit with a diagnosis of amphetamine induced hair loss. On some occasions, the hair loss and amphetamine use is simply a coincidence.  If the amphetamine use is thought to be contributory, it is important to determine if the patient has a telogen effluvium from the actual drug, or from a nutritional deficiency that the drug has brought about or from another cause such as androgenetic alopecia.  Blood tests are necessary for anyone with amphetamine induced hair loss to look for underlying nutritional deficiencies. Sometimes a hair collection or biopsy is also performed.  

Can topical JAK inhibitors be used for the eyelashes?

Today we will continue with a look at the use of JAK inhibitors beginning with a 4 day look at the topical JAK inhibitors for treating alopecia areata. Both oral and JAK inhibitors are not FDA approved for treating alopecia areata but are increasingly used off label. Many reports have emerged of benefits of JAK inhibitors when formulated as creams or lotions rather than pills. Given that topical compounds are likely more safer than oral ones, these studies are extremely important.

Topical treatments for eyelash alopecia areata have largely been limited to bimatoprost (Latisse). In a new study, researchers described a patient with improvement of eyelash growth with application of 1 % ruxolitinib to the upper eyelid skin.

Conclusion

This is an interesting study and clearly more such studies are needed, especially to ensure eye safety. However, topical JAK inhibitors may provide a second option to Latisse in treating eyelash alopecia. 

Reference

Bayarat et al. Topical Janus kinase inhbitors for the treatment of pediatric alopecia areata. J Am Acad Dermatol 2017; 77(1):167-169

JAK inhibitors for Alopecia areata: A closer look at the studies to date

JAK inhibitors for AA

This week we will take a look at using topical and oral JAK inhibitors for treating alopecia areata. This includes the drugs tofacitinib (Xeljanz) and ruxolitinib (Jakavi, Jakafi).

A closer look at the Oral JAK Inhibitors

Today, we will start with the oral JAK inhibitors. To date, there have been six reasonably sized studies looking at the benefits of the oral JAK inhibitors. These are summarized in the table. Most of the studies have been done with tofacitinib- the one exception is the study of 12 patients using ruxolitinib by Mackay-Wiggan and colleagues. Two of the 6 studies have been in patients under 18 years - namely the 2017 studies by Craiglow and colleagues Castelo-Soccio and colleagues.
 

Conclusion

The message of all the studies has been the same: use of oral JAK inhibitors in patients with advanced alopecia areata helps, approximately one half achieve cosmetically significant regrowth. 

Topical JAK inhibitors for Children and Adolescents with AA

Topical JAK inhibitors for Children and Adolescents with AA

The JAK inhibitors include drugs such as tofacitinib (Xeljanz) and ruxolitinib (Jakafi, Jakavi). At least 7 studies in the last 2 years have shown benefit for the oral JAK inhibitors in treating alopecia areata.  However, one must keep in mind that these drugs are not without potential side effects. A risk of infection, including serious infectious must always be kept mind with this particular immunosuppressant. Other side effects need to also be considered.

What are topical formulations? Do they work?

Topical JAK inhibitors refer to specific formulations whereby the drug is mixed into a cream or other base and applied to the surface of area of hair loss rather than taken orally. These topical formulations have the potential to be safer than the oral formulations. However, it’s not clear exactly how well the topical JAK inhibitors truly work. There have been a few published reports in the medical literature regarding the potential benefits of topical JAK inhibitors. Last year, I shared information of a study showing eyebrow regrowth in a patient with alopecia universalis treated with 0.6 % ruxolitinib cream. Now, a new study reports the outcome of 6 individuals ranging in age from 4-17 who were treated with topical JAK inhibitors. 6 of the 7 individuals had advanced forms of alopecia areata (totalis and universalis) and one had alopecia areata.

TOPICAL TOFACITINIB

Four patients (age 3, 5, 13 and 15) were treated with topical 2 % tofacitinib. 2 of the 4 patients had significant improvement of their scalp alopecia and 1 other had just a slight 20% improvement of his eyebrows

TOPICAL RUXOLITINIB

Two patients (age 4 and 17) were treated with topical 1 % ruxolitinib to the eyebrows.  Neither one experienced eyebrow regrowth although one did experience eyelash growth when the medication was prescribed to the upper eyelid skin.  The four year old had blood tests performed and all were normal.

CONCLUSION

This study suggests that about one half of children with alopecia areata treated with topical JAK inhibitors may have some degree of benefit.  This study is small and certainly a larger study is needed to confirm this. However, this study is encouraging given that these individuals had severe forms of alopecia areata to start with and treatment outcomes would therefore have been predicted to be worse.

Reference

Bayarat et al. Topical Janus kinase inhbitors for the treatment of pediatric alopecia areata. J Am Acad Dermatol 2017; 77(1):167-169

Topical JAK inhibitors for Alopecia areata: Are Lab Abnormalities still possible?

Are lab abnormalities still possible with topical JAK inhibitors?

Topical medications are generally viewed as 'safer' than oral medications. However, one must always study in this is, in fact, true. One must always carefully consider whether topical medications are similarly effective as the oral formulation or whether it is less effective.

Lab Abnormalities with Oral JAK Inhibitors

The oral JAK inhibitors tofacitinib and ruxolitinib have the potential to produce several lab abnormalities. These include changes in blood counts, increased creatinine kinase (CK), increased cholesterol, and changes in liver enzymes.  Prior to starting these medications I typically order a range of blood tests, along with an ECG, a TB skin test, and Hepatitis B/C and HIV testing.

The Topical JAK Inhibitors

Extensive studies of topical JAK inhibitors have not been done. A recent study of 4 patients who had blood tests while using topical JAK inhibitors showed that 50 % had lab abnormalities while using the drug.  Fortunately, none were serious. One had a slight decrease in her white blood cell count but it eventually normalized.  One other patient had a slight increase in her liver enzymes but they too returned to baseline levels. It was not clear in either patient whether the lab changes were really attributable to the JAK inhibitor or not.

CONCLUSION

Lab abnormalities can occur while using tofacitinb but tend not to be severe in studies to date. Close monitoring is needed to ensure the safety of these medications.

Reference

Bayarat et al. Topical Janus kinase inhbitors for the treatment of pediatric alopecia areata. J Am Acad Dermatol 2017; 77(1):167-169

Gynecomastia (Enlargement of Breast Tissue) in Men using Finasteride and Dutasteride

Gynecomastia in Men using Finasteride and Dutasteride

It is well known that finasteride and dutasteride can cause enlargement of breast tissue in men. This phenomenon is known as ‘gynecomastia’. It is postulated that hormonal changes that accompany the reduction in DHT (particularly a small 13 % increase in estrogen) may be partly responsible.

New study shows risks greatest with dutasteride

A new study looked at the risk of gynecomastia in men using finasteride for prostate enlargement. The authors used the UK’s Clinical Practice Research Datalink (CPRD) to perform a case control study examining the risk of gynecomastia in individuals using finasteride compared to those who did not use.

The researchers showed that there was a three fold increased risk of gynecomastia in men using finasteride. A 5 fold increased risk of gynecomastia was seen with dutasteride.

Conclusion

It’s clear that these medications can cause gynecomastia. Dutasteride appears to carry greater risk.

Reference

Hagberg et al. Risk of gynecomastia and breast cancer associated with the use of 5-alpha reductase inhibitors for benign prostatic hyperplasia. Clinical Epidemiology 2017; 9; 83-91.

Methotrexate dosing in Children: How much ?

Methotrexate in Children with Alopecia areata

Methotrexate is sometimes used as a treatment for children with alopecia areata. Generally, topical steroids, minoxidil are used first followed sometimes by diphencyprone (DPCP) and/or anthralin as second line agents. Methotrexate in my clinic tends to be a third line agent but in some situations I will use it before DPCP and anthralin. 

Methotrexate is an immunosuppressant. It inhibits the proliferating of rapidly dividing immune system cells.  Studies of children aged 8-18 years with alopecia areata have suggested that benefit is seen in about 40 % of children who use methotrexate. 

Methotrexate Dosing in Children. 

The dose of methotrexate is discussed on a case by case basis. Generally, the dose to use depends on the child's weight. Doses in the range of 0.2 to 0.7 mg of methotrexate for every kilogram of body weight are not uncommon. The medication is only given once per week, and must never be used daily.

I generally start with 2.5 - 5 mg and slowly move upwards every week until the desired dose is obtained. For example, for a 70 pound child (31.8 kg), the dose range is 6.36 mg to 22.2 mg. I would generally start 2.5 mg in the first week and then 5 mg in the second week and then 10 mg in the third week and then 15 mg in the fourth week. One can move up faster if they wish, but this is my preference, especially in children under 10 years of age. 

Side effects of Methotrexate

Many children tolerate methotrexate well. Nausea is the most common side effect and tends to occur on the particular day of the week that the medication is taken (methotrexate is not used every day). Sometimes vomiting can occur. Other side effects include lowered blood counts, irritation of the liver, and cough from irritation of the lungs. 

I try hard to reduce nausea and especially vomiting in children taking methotrexate. Sometimes when children develop vomiting from Methotrexate then become extremely fearful of taking the medication. Administration of anti-nausea medications before taking the methotrexate can really help. About 25-30 % of children will have significant nausea with their methotrexate and 10 % will experience vomiting. 

Folic acid with Methotrexate

Folic acid is a vitamin which is prescribed every day except on the day that the child takes the methotrexate pill. The use of folic acid has been shown to reduce the chances of the child having changes in his or her blood counts and reduces the chance of the medication irritating the liver. 

Reference

Royer M, et al. Efficacy and tolerability of methotrexate in severe childhood alopecia areata. Br J Dermal 2011;165(2):407-10.

Hair loss after starting and stopping birth control

Hair Loss and Birth Control

Hair loss often occurs in women who start and stop birth control. This typically occurs 1-2 months after starting and stopping and can last 4-5 months. For some individuals it lasts 9-12 months. 

For the vast majority of individuals, the abnormal shedding eventually stops and returns to normal shedding patterns- even without treatment. However, some women (small minority only) develop a chronic shedding pattern for an extended period of time and some notice that density does not make it back fully on account of an acceleration of underlying androgenetic alopecia.

In summary, most women will experience additional hair shedding for a few months after starting and stopping birth control. The excessive shedding will eventually slow and return to normal for most. Consultation with a dermatologist is advised if shedding persists after 6 months.

Low iron and hair loss - Do I need an iron transfusion?

Iron transfusions low iron and hair loss- when do I need a transfusion?

A common question that I'm asked is when are iron infusions needed for individuals with low iron levels (i.e. low ferritin level).  One key point rules the discussion - unless 3-6 months of iron pills have been used, iron infusions are not generally going to be recommended. We call this a 'trial of iron oral iron supplementation."

Unless a trial of oral iron supplementation has been done, iron infusions are pretty unlikely to happen. 

Low iron in Women

First off, it's important to know that low ferritin levels are very common in women. 30 % of premenopausal women have low iron.  Low iron with normal hemoglobin levels is also very common.  Low iron in young women is common. Low iron after an illness is not too uncommon either.

In order to fully assess if someone qualifies for iron infusions it's critical to know one's age, medications, medical history. In other words, a whole bunch of other factors matter.  The question of iron infusions is not usually just yes or no. But unless an individual tells me they have had 3-6 months or oral iron supplementation and his or her ferritin level didn't show any move upwards - they probably don't qualify for iron infusions. Exceptions do this do exist.

Improving oral iron supplementation

It takes time for iron levels to move up. Be sure to take with vitamin C to improve absorption. Be sure to take enough. If constipation happens, use lots of fiber in the diet and consider new iron pills that are less likely to cause constipation and GI upset in general.  Limit coffee and teas. Limit antacids

REASONS FOR IRON SUPPLEMENTATION

Iron supplementation is done in several cases. This list is not complete - AND it also depends on the hematologist who sits in front of you. Here are some common reasons for IV iron.

1. Individuals who have tried iron pills for several months and ferritin levels don't raise!

2. Individuals who just can't tolerate iron pills on account of GI upset.

3. Individuals who are losing iron fast - and can't keep up with levels by simply taking iron pills

4.  Individuals with nondialysis-dependent chronic kidney disease, obstetric indications, heart failure, heavy bleeding wth menstrual cycles and anemia associated with cancer and its treatment (chemotherapy induced anemias).

5. Individuals with inflammatory bowel disease - whereby oral iron can aggravate symptoms

6. Individuals who can't maintain iron levels with hemodialysis. 

7.  individuals with low iron after gastric bypass and other stomach surgeries. 

Summary 

In most people, a 'trial' of oral iron is generally needed before considering IV iron therapy.