Anabolic Steroids and Hair Loss: Is one month okay?

Anabolic steroids can cause hair loss in genetically susceptible individuals

Anabolic steroids are frequently used as training aids for men and women looking to increase muscle mass. This includes body builders and athletes at various levels. Many individuals are aware of the side effects of anabolic steroids and judge in their own minds whether the risks and benefits of using the drugs are worth it to them.  These are known by a variety of names including  stackers, gym candy, Arnolds, roids, juice. They are not uncommon - and some  studies have suggested that even 4 % of high school students will have used anabolic steroids at least once. They are always on my radar. 

Hair loss from anabolic steroids

There is no doubt that anabolic steroids can trigger a worsening of hair loss in some individuals. It does not happen to everyone but happens to those with the right genetic background. It can be mild or very marked hair loss. In my experience, there can also be a worsening of seborrheic dermatitis in these individuals as well. 

How long is too long? 1 month? 2 months?

As patients weigh the risks and benefits of using anabolic steroids, I'm often asked questions such as:

How much is too much? How long is too long?

Is it 1 month? What about 2 months?

The short answer is that any amount can potentially be detrimental - but it all depends on one's underlying genetics and stage of hair loss. We can not accurately predict in the present day whether someone will experience negative hair loss related side effects. However, as I speak to patients about the duration of anabolic steroid use, I find it important to remind them that hairs don't work in months, they work in milli and microseconds. One month of steroid use is 2.5 million seconds - or as a hair would view it 2.5 Billion microseconds.

Does 2.5 Billion milliseconds of anabolic steroid use cause hair loss?

It's much easier to deal with the concept of hair loss occurring with 2.5 millions seconds of continuos exposure to anabolic steroids. While 1 month might not sound like much, 2.5 million does sound like a lot more.

Conclusion

Hair are made of proteins, which form cells. Cell don't work in months - they work in units of fractions of a second.  In my clinical experience treating many individuals using anabolic steroids, short term use of anabolic steroids is sufficient to trigger hair loss in susceptible individuals.

Caffeine and Hair loss: Where is the Research to date?

Mixed Results to date

Caffeine continues to be studied with respect to its role as a hair growth promoting agent. Studies are ongoing. To date there are only very limited studies examining the role of caffeine - with mixed results.

A 2013 study by Sisto et al from Italy showed that men using a caffeinated shampoo for 6 months were more satisfied with their outcome than men using the placebo (84.8 % vs 36.4 %, p<0.001). The study did not examine hair growth and other parameters in a rigorous manner. 

As we think about the role of caffeine in hair growth, I would like to draw your attention to 2 studies which examined coffee consumption. A study of 93 identical male twins looked at a variety of factors associated with hair loss. The survey based study suggested that increased coffee consumption was associated with increased hair thinning. In contrast a study of 98 identical female twins by the same author suggested that a lack of caffeine was associated with increased hair loss in women.

Conclusion:

Studies of the role of caffeine in hair loss and growth are still in their early stages. Limited conclusions can be made at present.

References
 

Gatherwright J, et al. The contribution of endogenous and exogenous factors to male alopecia: a study of identical twins. Plast Reconstr Surg. 2013.

Gatherwright J, et al. The contribution of endogenous and exogenous factors to female alopecia: a study of identical twins. Plast Reconstr Surg. 2012.

Efficacy of a Cosmetic Caffeine Shampoo in Androgenetic Aloepcia Management. J Appl Cosmetol 2013;

Vitamin D Levels in Alopecia Areata

Does low vitamin D levels play a role in alopecia areata?

Several previous studies have explored this topic. A new study compared vitamin D levels in 50 patients with AA compared to 35 age matched and sex matched controls. 25-hydroxy-vitamin D levels were lower in patients with AA being 16.6 in the AA group and 40.5 in the control group. 25-hydroxy-vitamin D is the best test for vitamin D status. In addition, patients with more severe AA had lower vitamin D levels than those with less severe AA. Also, those with more patches of AA had lower levels than those with fewer patches.
 

Conclusion 

This study adds to the growing body of evidence showing the vitamin D plays a role in alopecia areata. 

Reference 

Bhat YJ et al. Vitamin D Level in Alopecia Areata. Indian J Dermatol. 2017 Jul-Aug.

Alopecia areata: A close look at selenium and zinc

What are the most common abnormalities of serum trace elements in alopecia areata?

New data confirms a role for zinc and emphasizes an interesting potential role for selenium.

A study from China set out to investigate the alterations of serum level of trace elements and AA using a meta-analysis of ten published articles involving 764 subjects. Overall, lower serum levels of zinc and selenium were identified compared to healthy controls. However, there was no significant difference between the AA patients and controls in the levels of serum copper, ferritin, magnesium. and copper. 

These studies point to a potential role for selenium and zinc in alopecia areata. This warrants further study.

Reference

Jin W, et al. J Dermatol. 2017. Changes of serum trace elements level in patients with alopecia areata: A meta-analysis.

Finasteride Side Effects in Women

What are the side effects of finasteride in women?

First off, finasteride is not FDA approved for women. Any such use is therefore "off label" and any female considering finasteride will want to be guided by a knowledgeable and experienced physician if this is a route you wish to take. Depending in the patient's current age, type of hair loss and medical history and family history this may or may not be a good option.

Side effects

i'm often ask about the range of side effects that are possible for women who use finasteride. Side effects of finasteride in women include, but are not limited to: harm to a fetus (finasteride can not be used in pregnancy), fatigue, weight gain, depression, anxiety, decreased libido, sexual dysfunction, hair shedding, breast tenderness, breast enlargement.  Other side effects can occur but are less common. These include changes in platelet counts and muscle injury (myopathy).

Clobetasol for Hair Loss

Clobetasol for Hair Loss: What's that all about?

Clobetasol is the  name give to a potent topical corticosteroid. It is also known by its longer proper  name "clobetasol proprionate." Corticosteroids are medications which reduce inflammation. Clobetasol is available as a cream, ointment, lotion, foam and shampoo.

I often prescribe clobetasol for patients with hair loss conditions that are associated with inflammation. In fact, rarely does a day go by that I have not written a prescription for clobetasol. Alopecia areata, scarring alopecias, psoriasis, eczemas, dermatitis, all have the potential to benefit in some way with use of topical clobetasol. 

Clobetasol is never 'just because'

Clobetasol is not a good option for hair and scalp conditions that are not associated with inflammation. One should not use clobetasol "just because" and one should not use clobetasol or any topical steroid unless there is evidence of inflammation either clinically (the patient has symptoms) or histologically (the biopsy shows inflammation).  While the statement "my friend used clobetasol and it helped her- should I use it?" is understandable, it is simply not helpful when deciding if this medication is appropriate for a given person.

Clobetasol is a strong steroid

Clobetasol is among the most potent of topical steroids.  I can't emphasize enough the need to respect these medications. Despite what I hear everyday, these medications simply can't be dumped on the scalp and the scalp simply cannot be "soaked completely." That increases the chances of side effects. Unless you see a lot of patients with hair loss, it's challenging to appreciate the side effects that really can happen.

Long term side effects of potent topical steroids are well known but often ignored because side effects happen so infrequently. But potential side effects include: adrenal suppression, acne, hair loss, cataracts, bone loss, stretch marks, diabetes, persistent red scalp and "rebound" when trying to taper these medications.  I'll agree with anyone who says these are fairly uncommon. But I would challenge anyone who says they don't occur.

In modern medicine, we see side effects more commonly with oral steroids (like Prednisone and dexamethasone) followed by steroid injections (like triamcinone acetonide) followed by topical steroids. Even topical steroids have a range of safety with weak steroids like hydrocortisone being much safer overall than strong steroids like clobetasol.

Conclusion

Without clobetasol and similar potent topical steroids, I would not be able to fight inflammation the way I need to. These medications are extremely valuable. Nevertheless, these medications need to be respected.

The Speed of Progression of Male Balding

How fast does male pattern balding progress over time?

Today, we complete day 5 of our week long look at male balding by examining the speed at which it progresses. Male balding progresses at different rates. Most men who develop balding experience a slow and steady reduction in density starting in the front (temples) or crown. One can often detect a change in density every 1-3 years (patient 1 in diagram). There may even be long periods of time where there is no progression of the hair loss. Some men have extremely slow and almost undetectable changes in their density once hair loss starts (patient 2, green line). Some men have an extremely rapid course of hair loss, with noticeable changes in density every 6-8 months (blue line). More rapid hair loss can happen to any male who develops male balding but it is more common in men who develop balding in their teens and 20s. In summary, male balding progresses at very different rates in different individuals. However, once it does start it always moves forward.  

The Resistance of Hair in the Back to Balding

Why are hairs in the back of the scalp so resistant to balding?

Males with balding (androgenetic alopecia) frequently maintain a thick density at the back of the scalp whereas the front or top of the scalp may experience thinning. There are many reasons for these differences. Hair follicles in the back of the scalp have different androgen metabolism. There are fewer androgen receptors in these hairs. There is a reduced level of 5 alpha reductase activity. Furthermore, there are reduced DHT levels in the scalp.

On account of these differences between the back and front, a hair transplant becomes possible. Hairs moved from the back of the scalp to the front of the scalp maintain their characteristics and continue to be resistant to balding.

Hair loss from steroid injections: Is it possible?

Steroid injections: Is it possible to cause hair loss?

Steroid injections are frequently used for treating two conditions: alopecia areata and scarring alopecia. Medications such as triamcinolone acetonide (sometimes referred to by the popular name Kenalog) are injected into the scalp. The purpose is either to grow hair (in the case of treating alopecia areata) or to stop further hair loss (in the case of scarring alopecia). 

Steroid injections can sometimes induce hair loss (telogen effluvium) in some individuals. It's not common but some individuals actually develop small circles of hair loss around the areas injected. Some will even develop small 'indentations' in the skin in these areas as well. This hair that has been lost may grow back with time but indicates that a lower concentration of triamcinolone should be used for that patient in the future.  

The 2-3 month delay in Telogen Effluvium: Does it always occur?

Does a TE always require a 2-3 month delay?

Telogen effluvium or "TE" refers to a form of hair loss associated with increased daily shedding.
A TE usually starts 2-3 months after some type of "trigger" such as stress, low iron levels, a crash diet or start of a new drug. However, a TE can start within a matter of days for some people. There is a form of TE known as "immediate telogen release TE" which happens very quickly. The TE that happens when starting minoxidilis one of these "immediate" shedding forms. There are other mechanisms responsible for rapid hair loss too ... so TE is not always the cause. There are forms of diffuse alopecia areata which mimic TE and also occur rapidly without delay. I always advise patients continue close follow up with a physician if things don't improve.

There are many potential mimickers of a "TE."

Does stress, diet and smoking have a key role in male balding?

Today we continue the third of our week long look at male balding. I am often asked how much of a role does diet, stress and the environment have in male balding?

We currently believe that factors such as smoking, alcohol, stress, and sun exposure and obesity do have role in accelerating hair loss but the key question is "how much" of a role do they have? To look at this question in more detail, we need to look back at some brilliant studies of identical twins.

Identical twins carry the same genetic profile. By studying the appearance of identical twins at various points throughout their lives, we can get a sense of how important factors like genetics and the environment actually are. If genes are the key important factor in balding progress then, identical twins should look ‘identical’ in terms of their hair density. In contrast, if environmental factors like smoking, stress and ultraviolet radiation are important, identical twins might not have the same hair density because their environment is different. 

The Hayakawa Study 1992

Studies in 1992 revealed that genetics is by far the most important factor and the environment only has a minor role. 92 % of identical twins have "no significant" differences in their hair density. 8% of identical twins have a slight difference. Interestingly , no twin had a striking difference!
There studies support the notion that one’s genetics is by far the most important factor in the balding process. 

Is there any role for 'non genetic' factors?

That answer is certainly yes, but at least in men it appears much more minor in terms of the magnitude of involvement in the balding process. Other studies have suggested that "epigenetic" factors like stress, smoking and diet and sun exposure do have a role - but it is likely a minor role.

Reference

Hayakawa K, et al. Intrapair differences of physical aging and longevity in identical twins. Acta Genet Med Gemellol (Roma). 1992.

What’s new in androgenetic alopecia research ?

What’s new in AGA based research ? 

It is indeed an exciting time in biomedical research! Several companies are actively researching new treatments with the hopes to bring to market new options for androgenetic alopecia. Here are just a few of the nearly two dozen companies actively pursuing new treatments for men with balding. Some of course may apply to female androgenetic alopecia too.

 

Who are some of the key companies?

Shisedo, Replicel and Tsuji-Rekin are studying cell based therapies for balding. Follica is studying how specific therapies in conjunction with microwounding can stimulate hair growth. Specific molecular pathways are being targeted by companies such as Samumed (WNT pathway), Allergan (prostaglandins), Aclaris (JAK inhibitors). Cassopia is studying novel topical antiandrogens. Histogen is studying how factors produced by neonatal cells grown under embryonic-like conditions can stimulate hair growth.

New treatments for male balding could be around the corner!

Can a biopsy showing AGA be wrong?

Can a biopsy of AGA be wrong?

I'm often asked if a biopsy can be 'wrong.' The short answer is that yes, a biopsy can potentially be wrong. Biopsies are simply "samples" and used to represent a larger area. However,  the long answer is that if a biopsy is done properly and from the right area, and read by a good pathologist, them no, it is very likely that if a biopsy returns showing that androgenetic alopecia is one of the diagnoses that this is correct. The identification of vellus hairs and a terminal to vellus hair ratio of less than 4:1 with telogen hairs less than 15% is typical of androgenetic alopecia. Many individuals (especially women) with androgenetic alopecia do not have a family history so this fact should not be given too much emphasis.

A biopsy can "sometimes" be wrong in these situations:

1. Diagnoses of Scarring Alopecia (Lichen planopilaris, Folliculitis Decalvans)

2. Some diagnoses of Telogen Effluvium

3. Some diagnoses of Alopecia Areata

Most of the time, of course, a biopsy is correct in these situations. However, there are many cases alopecia areata, telogen effluvium and scarring alopecia that are challenging. A biopsy is just a piece of the puzzle and one must put together all the facts from the clinical history. examination, blood test results to come up with the diagnosis. 

A biopsy is less likely to be 'wrong' in these situations

1. Androgenetic alopecia (especially with use of horizontal sections)

2. Tinea Capitis

3. Trichotillomania

4. Skin Cancers and Metastases

AGA in men

Vellus Hairs in AGA

This week, we'll start a five day look at androgenetic alopecia in men (also called male pattern balding). The identification of so called "vellus" hairs is important in understanding male balding. Vellus hairs are tiny hairs less than 30 micrometers in diameter. They are present on the normal nonbalding scalp but only in low proportions. In male balding, the proportion of vellus hairs rises considerably as large "terminal" hairs are converted to tiny "vellus" hairs. In advanced balding, the vellus hairs disappear leaving a completely bald scalp in the affected areas. 
 

Does Hair Dye Allergy mean I might react to other things ?

PPD allergy and "Cross Reactions"

Paraphenylenediamine (“PPD”) is the major allergen contained in hair dye. Allergy to PPD is increasing around the world and many are dyeing their hair at younger and younger ages. Individuals who are allergic to their hair dye may develop scalp swelling and blistering. However, many do not and only develop reash on the eyelids, ears, neck, forehead or face.  Reactions to PPD can be serious and life threatening and one must take these issues very seriously to avoid progression from a mild hair dye allergy to a severe life threatening reaction. Patch testing is a type of testing that can identify potential allergens  that a person is reacting to.

Allergy to PPD means one must educate themselves …. and others!

Individuals who an allergy to PPD also frequently react to other compounds as well. These include parabens, black rubber mix, sunscreens (ie PABA sunscreens), various dyes (especially yellow and ornage azo dyes and analine), benzocaine/procaine anesthetics. Many patients with PPD allergy react to henna tattoos because these also contain some amount of PPD. In addition, there are certain medications that patients with PPD allergy best avoid. Individuals with PPD allergy may develop severe generalized reactions followed use of thiazide diuretics (hydrochlorothiazide), sulfonylureas (diabetes medications), celocoxib, and sulfonamide antibiotics.

Alopecia areata in Patients with Chronic GVHD

Alopecia areata is more common in GVHD

Allogeneic hematopoetic stem cell transplants (HCT) is a procedure that is frequently performed for patients with blood cancers and other diseases of the bone marrow. The patient's blood cells are replaced by the blood from a donor.

One of the complications of stem cell transplants is the development of an immune based reaction known as graft vs host disease or "GVHD". When the phenomenon by definition occurs more than 100 days after the HCT procedure it is referred to as "chronic" graft vs host disease. It is a serious and potentially life threatening reaction whereby the donor immune cells react against the patient's own cells. Patients with cGVHD can experience a range of skin, gastrointestinal and other issues.

Alopecia areata in cGVHD

Recent studies over the last few years have shown that patients with cGVHD are are much higher risk of developing alopecia areata than previously thought. Alopecia areata is an autoimmune disease that leads to hair loss.

Studies by Ceovic et al suggested that patients with the most severe forms of cGVHD were nearly 4 times more likely to develop alopecia areata or vitiligo (another autoimmune disease affecting the skin pigment cells). Zuo et al showed in 2015 that female donor and female donor to male recipient sex mismatch, in particular, are significantly associated with the development of vitiligo and/or AA. 

Conclusion 

cGVHD is an immune-based complication in patients who have receive stem cell transplants as a treatment for blood cancers and other blood diseases. The incidence of alopecia areata is increased in patients with cGVHD.

References

Čeović R, et al. Croat Med J. 2016.High frequency of cutaneous manifestations including vitiligo and alopecia areata in a prospective cohort of patients with chronic graft-vs-host disease.

Zuo RC, et al. JAMA Dermatol. 2015. Risk factors and characterization of vitiligo and alopecia areata in patients with chronic graft-vs-host disease.

Occam's (Ockham's) razor vs Hickam's dictum: Lessons for treating hair loss

Occam and Hickam: Who are they and why do we care?

The most important aspect of treating hair loss is to first and foremost make sure that the correct diagnosis has been made. There are two interesting philosophical principles that I often remind myself of when working in my clinic - Occam's razor (sometimes written as Ockham's razor) and Hickam's dictum. I'd like to share them with you - and how they apply to the hair doctor.

Meet Friar Occam

Friar Occam (Ockham) was a Franciscan friar who wrote about logic, philosophy and ethics. He put forth some of his key principles way back in the 1300s. In the world of philosophy, "Occam's razor" is a helpful guiding principle. It states that if there are two explanations for an occurrence, one should generally consider the simpler explanation as being the correct one.

If you are wondering why the word 'razor' is used when apparently it has nothing to do with a razor, one must understand that the use of this word is a metaphor. In philosophy, a razor is a basic principle or rule of thumb. The word razor is used to describe the sraping away of the non essential information. Back in the day, a razor was used to scrape away ink from a page when people wrote with ink and quills.  A razor used in a similar manner to a pencil eraser. 

In medicine, we often speak of Occam's razor as a reminder that if a patient has two possible diagnoses, the simpler one is probably the more likely. Nearly every medical student remembers being told that "if they hear the sound of hoofs, they should consider first that they might be horses rather than zebras." These are the teachings of Occam's razor.

Although there are many exceptions of course, Occam's razor certainly applies in my day to day. When it comes to male hair loss, Friar Occam is often correct. Consider the patient who wonders if he has male balding or whether his recent life stress is causing his hair loss. Occam's razor says that male balding is more likely the cause. I hear many similar questions throughout my day. For many men, the simple explanation is that they are experiencing male balding:

Do you think my shampoo is the culprit, doctor?

What about my poor diet?

What about my use of a hard hat?

Occam's razor says that male balding is more likely the cause. Male balding is common and a very high proportion of  men with concerns about their hair are experiencing male balding. Of course exceptions do exist but common things being common - most men with hair loss are experiencing male balding. 

Meet Dr. Hickam

From Friar Occam, we turn now to John Hickam, MD. Dr Hickam was a physician and former chairman at Indiana University in the mid 1900s. Like Occam's razor, "Hickam's dictum" is also a helpful guiding principle. The principle reminds us that a person can have more than one diagnosis and one need not try to explain everything with a single diagnosis especially the simplest one. While Occam's razor reminds us to seek the simplest explanation when faced with more than once choice, Hickam's dictum reminds us that many diagnoses are possible. 

In the world of hair loss, Hickam's dictum is a more powerful guiding principle than Occam's razor. The astute hair loss physician should seek to diagnose all the reasons for a person's hair loss rather than come up with one unifying simplest explanation. Hickam's dictum most often applies to women with hair loss since women are much more likely than men to have more than one reason for hair loss. For example, it is not uncommon to diagnose androgenetic alopecia, telogen effluvium and seborrheic dermatitis all in the same patient. Yesterday, a patient had androgenetic alopecia, seborrheic dermatitis, telogen effluvium from low iron, traction alopecia from her hairpiece and trichotillomania of her eyebrows. That's five diagnoses! Clearly to best help the patient, each of the reasons must be deciphered. Hickam's dictum reminds us that there is no reason why a sixth of seventh diagnosis could not be present - so we need to look carefully.

Conclusion

There are many reasons to lose hair. In men, androgenetic alopecia (male balding) is by far the most common cause. From time to time, patients wish to consider an array of other possibilities for their hair loss even though the simplest explanation in these particular cases (and correct explanation) is male balding. Occam's razor reminds us to choose the simplest explanation whenever given the choice. This simple principle often applies well to men with hair loss. Hair loss in women is more complex than men and it's not uncommon for two or three diagnoses to be present. I frequently reflect on Hickam's dictum - which reminds us that many reasons can exist in the same patient and we need to consider them all!

Spironolactone Shortages in US and Canada: Update

Spironolactone Back Order Mainly Affects Canada

There is currently a shortage of spironolactone (Aldactone) in Canada. I have spoken with representatives from Pfizer Canada and USA this morning again and the following are updates.

1. Spironolactone in Canada (1 866 532 8608)

There is a shortage of both 25 mg and 100 mg supplies Canada due to a backorder. The pills are not being discontinued according to the company. These are currently being preferentially released to hospitals as the drugs are used at low doses in heart failure and other medical issues.

By the end of October 2017, the 25 mg pills should be available for shipment to pharmacies in Canada. By early November, the 100 mg pills should again be available as well. For now, it is somewhat hit and miss. Some pharmacies have abundant supplies and others have none. Trial and error can often lead one to find a pharmacy with supply. 

2. Spironolactone in the United States (1 800 438 1985)

According to Pfizer USA, the generic spironolactone is being discontinued but the trade name Aldactone pills are still being produced and are currently widely available. 

My team or I will update as any further updates become available. 

Narcolepsy in Alopecia areata: Is there an association?

Narcolepsy in AA

Narcolepsy is a sleep disorder that is characterized by excessive sleepiness, sleep attacks, sleep paralysis, hallucinations and, for some, the sudden loss of muscle control (cataplexy). It affects roughly 1 in every 2,000 people but can go undiagnosed for many years.  

Narcolepsy is poorly understood. However, it is now recognized that there are two main forms of narcolepsy depending on whether the patient has cataplexy (Ioss of muscle control): Narcolepsy with Cataplexy ("N+C" form or type 1 form) and Narcolepsy without Cataplexy ("N-C" form or type 2 form). The "N+C" form is now understood to be due to an autoimmune reaction destroys the brain’s 70,000 hypocretin 1 and hypocretin 2-producing cells. Hypocretin is a chemical (neurotransmitter) in the brain that is important for regulating wakefulness. Hypocretins 1 and 2 is also called orexin A and B. 

Narcolepsy may therefore be a true autoimmune disease. The recent discovery of a link between narcolepsy and a gene for a component of the T cell receptor supports this theory. A link to HLA allele DQB1*0602 has been proposed. 

The cause of the "N-C" form (type 2 form) is remains poorly understood.

Reports of Narcolepsy in Alopecia areata

As reported in an earlier article,  sleep quality does not appear to be different in patients with alopecia areata compared to the general population. This is based on 2014 studies by Inui and colleagues published in the International Journal of Dermatology.

Sleep Quality in Patients with AA

However, these studies of course are small (105 patients) and such studies do not have the ability to capture rare associations. One such rare association may be narcolepsy. 

Alopecia areata and Narcolepsy

Both type 1 and type 2 narcolepsy has been reported in association with AA. One of the first reports of an association between alopecia areata and narcolepsy occurred in 1992 in the Spanish language medical literature. This was a report by Dominguez Ortega in which 3 patients with alopecia areata were described to also have narcolepsy. The diagnosis in these three patients was made with a multiple sleep latency test.  In 2010, Lloyd King and colleagues from Vanderbilt University reported 2 additional cases of narcolepsy seen in association with alopecia areata.  Nigam and colleagues reported a male with type 1 narcolepsy. 

References

Nigam G, et al. Alopecia areata and narcolepsy: a tale of obscure autoimmunity. BMJ Case Rep. 2016.

Domínguez Ortega L. [Narcolepsy and alopecia areata: a new association?]. An Med Interna. 1992.

King LE Jr, et al. A potential association between alopecia areata and narcolepsy.Arch Dermatol. 2010.