My hair was ripped off: Will it grow back?

Traumatic Hair Pulling:  Full Regrowth May or May Not Occur

I am often asked if hair that is pulled out forcefully will regrow. Examples of this are the pulling of hair by children on the playground, hair getting caught in doors, machines etc or cases of hair pulling during assault or abuse-related situations (for example domestic abuse).

Without actually seeing the scalp, and knowing details of the patient's story, it is impossible to determine if hair will or will not grow back in any particular case. This requires an in person examination so that the scalp can be properly examined.

Hair regrowth is not a guarantee

There is no guarantee that hair regrowth will occur. One will know in 6-9 months if they will acheive full regrowth or not because that is how long it takes for hair to grow back following any type of injury.

It is certainly possible for repeated pulling to give permanent hair loss. However, in the vast majority of cases where hair is pulled from the scalp, hair grows back.  If you or I were to reach up a pluck a hair, it will grow back. However, if pulling is repeated many times or is excessive with bleeding a greater chance exists for scarring to develop. Hair pulling that is accompanied by injury to the skin layers (i.e. that creates an actual wound) has a markedly increased chance of being associated with permanent scarring.  It is such scarring that blocks the regrowth of hair.  Scar tissue is permanent and, if present,  generally destroys stems cells. 

Anyone with concerns about incomplete growth after episodes of hair pulling should see a physician who specializes in hair loss for consideration of a scalp biopsy.

Hair Loss at the Nape of the Neck: What are the main causes?

Losing Hair at the Nape: What are the main Causes?

Hair loss can either be localized (meaning one area of the scalp) or diffuse (meaning all over the scalp). There are many causes of hair loss at nape of the neck and the back of the scalp. 

1. Traction alopecia (photo 1)

Traction alopecia refers to a type of hair loss due to the tight pulling of hair. The back of the scalp is particularly susceptible to loss of hair.  Hair styling practices can frequently lead to traction including braids and weaves and pony tail.  If traction alopecia is of recent onset, hair regrowth can occur even without treatment. If traction is longer standing, the hair loss can often be permanent.  Some women with hair loss that looks like traction actually have a scarring alopecia known as cicatricial marginal alopecia. 

PHOTO 1: Traction alopecia presenting as hair loss in the nape

2. Alopecia Areata (photo 2)

Alopecia areata is an autoimmune disease that affects about 2 % of the world. Hair loss can occur anywhere. Alopecia areata can frequently cause hair loss specifically at the nape in some patients. The particular form that causes loss at a the back of the scalp is the 'ophiasis' form. The ophiasis form is frequently resistant to standard treatments although topical steroids, steroid injections and diphencyprone are typically first line. 

PHOTO 2: Alopecia areata presenting as hair loss in the nape

 3. Androgenetic Alopecia (photo 3)

Androgenetic alopecia (male and female thinning) typically causes hair loss at the top of the scalp. In men, the temples and crown are most often affected. In women, the mid-scalp region is generally affect first. The back of the scalp can also be affected although this is not typically thought of. Hair thinking along the nape is not uncommon in advancing balding in men and women. 

PHOTO 3: Androgenetic alopecia (AGA) presenting as thinning in the nape

 

4. Frontal Fibrosing Alopecia (photo 4)

Frontal fibrosing alopecia (FFA) is a type of scarring alopecia. FFA typically affects women between 45-70. Most often hair is lost along the frontal hairline and eyebrow. However the back of the scalp (at the nape) and frequently be affected. The hair loss in the nape typically starts at the sides (left side and right side) just behind the ears. Treatments for FFA include topical steroids steroid injections, topical calcineurin inhibitors. Oral drugs include finasteride, doxycycline and hydroxychloroquine at the top of the list.

PHOTO 4: Frontal fibrosing alopecia (FFA) presenting as hair loss in the nape

5.  Heat and Chemicals

Heat and chemical treatments can lead to hair shaft damage and hair loss at the nape. Frequently, heat and chemical overuse leads to an increased tendency to develop traction alopecia which si discussed above. 

6. Acne keloidalis nuchae

Acne keloidalis nuchae (AKN) is a condition that can affect both men and women. Small papule or bumps develop along the posterior scalp and are accompanied by hair loss in the region as well.  The hair loss in AKN is often permanent and can lead to thicken and thicker scars some of which are disfiguring. 

7. Hair shaft disorders

Some individuals are born with abnormalities in how the hair shaft is produced. This frequently leads to hair breakage. Monilethrix is one of the hair shaft disorders that frequently leads to hair loss along the nape. 

Am I taking the right amount of hydroxychloroquine (Plaquenil)?

Hydroxychloroquine (Plaquenil): Am I taking too much?

Hydroxychloroquine is an oral medication used in a variety of autoimmune conditions. Side effects have been discussed previously but today we will focus on eye side effects. A number of side effects are possible ranging from vision changes to double vision to asymptomatic changes in various parts of the eye.

The Risk of Retinopathy with Hydroxychloroquine

"Retinopathy" is one of the more worrisome side effects of Hydroxychloroquine. At appropriate doses, studies show that the risk appears to be about 1 % of patients at 5 years of use and 2 % at 10 years. After 20 years, the risk may rise to 20 %. Once the retinal toxicity from hydroxychloroquine occurs, it is believed that the changes in the retina are permanent. Furthermore, the disease can even progress even if hydroxychloroquine is stopped.  

 

Risk Factor for Retinal Toxicity

Retinal damage can occur in anyone. However, the risk may be increased if the following risk factors are present

• Longer Duration of use (cumulative dose)
• Renal or hepatic functional impairment. Compromised kidney and/or liver function can lead to increased accumulation of hydroxychloroquine in the tissues.
• Age over 60 years.
• Preexisting retinal disease
• Concurrent tamoxifen therapy

What dose should I take?

It's clear that taking the appropriate dose reduces (but does not eliminate) the chance of side effects. The optimal dose is 6.5 mg for every kg of lean body weight (not simply what the patient weighs). "Lean body weight" is essentially the patients expected weight for their height and gender - it does not include the "extra" weight that some might carry. Instead of calculating lean body weight, some clinicians advocate simply using the patient's true body weight and multiplying by 5 (instead of 6.5).  In our clinic we typically dose hydroxychloroquine according to the following grid:

Hydroxychloroquine Dosing

Conclusion

The risk of eye related toxicity is low in the first 5-10 years of hydroxychloroquine use provided the dosing is respected. This study has had great importance as it has further helped to define risk and has encouraged changes in screening guidelines. These guidelines now include an initial examination but dedicated yearly screening to begin only after 5 years in otherwise healthy individuals deemed at low risk for eye problems.

Reference

(1) Melles & Marmor. The Risk of Toxic Retinopathy in Patients on Long-term Hydroxychloroquine Therapy. JAMA Ophthalmolol. 2014;132(12):1453–1460.

Is Lichen Planopilaris Caused By A Fungus?

Lichen planopilaris is the long name given to a type of scarring hair loss condition. It is sometimes referred to as follicular lichen planus. The name "lichen" comes from the skin lesions of lichen planus that some patients with lichen planopilaris also have. The skin lesions are flat just like lichens that one might see walking in the forest. 
Lichen planopilaris is not due to a fungus. It is an autoimmune inflammatory condition that causes permanent hair loss. Treatments include anti-inflammatory agents not antifungal agents.

Changes in Hair Texture

What causes hair to become wavier?

There are several reasons for an individual with straight hair to find their hair has become wavier or even curlier. Causes include age related genetic programming, endocrine disorders (ie hypothyroidism), scarring alopecias, hair trauma (from heat or chemicals), androgenetic alopecia, medications (ie retinoids, minoxidil) and a variety of inflammatory disorders.

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.

Elevated testosterone Levels in Women with Hair Loss

Testosterone Levels in Women with Hair Loss

There are many causes of elevated testosterone levels in women. Slightly elevated levels can sometimes be considered 'normal' with no underlying issues to be concerned about. Many patients with increased androgen levels have polycystic ovarian syndrome (PCOS) or underlying endocrine issues such as Cushing syndrome. However, elevated but can sometimes be associated with serious underlying conditions, including cancer. Patients with rapid onset of symptoms and signs along with hormone levels that are well above normal need rapid medical attention for proper diagnosis.

What is the 'cut off' for normal?

There are no hard and fast rules when it comes to cut off numbers. A full story is needed from the patient including how fast the symptoms appeared and how many symptoms are present. Is it hair loss? Is acne present? How about increased hair growth on the face (i.e. hirsutism)? Is the patient menopausal or post menopausal? Are menstrual cycles regular? Has there been weight loss or gain? Does the patient have increasing pain anywhere ? How about fatigue levels?

Causes of elevated testosterone levels in women

There are many causes of elevated testosterone levels in women. Patients with high testosterone levels should be sure to make an appointment with their doctor to review causes. A full history and full examination will be needed and more blood tests may be needed as well. Repeating the testosterone is often advisable too given that it can vary quite a bit day to day. A measurement in the morning is advised.

The top 10 causes of elevated testosterone include

1. Just a normal level for the patient

2. Polycystic ovarian syndrome (one of most common causes)

3. Ovarian hyperthecosis

4. medication induced (androgen replacement, anabolic steroids)

5. Cushing syndrome

6. Congenital adrenal hyperplasia

7. Ovarian tumors

8. Adrenal tumors

9. Hyperthyroidism

10. Prolactinomas

Cancers of the adrenal gland and ovaries are a very rare cause

Cancers of the adrenal gland are rare and about 2 new cases are diagnosed every year per 1 million people. Cancers of the ovary are more common and currently ovarian cancer is the sixth most common cancer in women. Less than 1 % of patients presenting with hirsutism and other signs of hyperandrogegism have an ovarian or adrenal tumor - but it is important to diagnose early. 

Generally speaking a plasma testosterone concentration three times above the normal level (i.e. above 8.7 nmol/L or 200 ng/dL) with a normal DHEAS level raises the suspicion that the patient could have an underlying benign or malignant ovarian cause of their symptoms. Furthermore, a plasma testosterone concentration three times above the normal level (i.e. above 8.7 nmol/L or 200 ng/dL) with an elevated DHEAS level (above 16.3 umol/L or 600 ug/dL) raises the suspicion that the patient could have an underlying benign or malignant adrenal cause of their symptoms.It could of course be normal, but when levels are in this range - a full work up is mandatory. 

Further testing with elevated androgens 

Further testing may be advised depending on the degree of hormone elevation and associated signs and symptoms. As mentioned, a full history and physical examination are needed for all patients with elevated androgens. Generally a full hormonal panel with free and total testosterone, DHEAS, LH, FSH, estradiol, SHBG, prolactin, 17 hydroxyprogesterone and TSH are ordered. Other tests include AFP (alpha feto protein) and B-hCG may be ordered. A pelvic ultrasound or CT scan may be ordered for women with markedly elevated levels. Further stimulation and suppression testing (i.e a dexamethasone suppression test for a potential androgen secreting adrenal tumor) may be ordered upon referral to an endocrinologist. 

Conclusion

There are many causes of increased androgens in women. When associated with increased hair growth on the face, irregular periods, acne or hair loss, androgen hormone levels are frequently elevated. Conditions such as polycystic ovarian syndrome (PCOS) or ovarian hyperthecosis are common and frequently responsible. However, women with markedly evaluated androgen levels (especially three times above normal) require a full work up including referral to endocrinology, radiology and gynaecology specialists.

Reference

Pugeat M et al. Androgen secreting adrenal and ovarian neoplasms. Contemporary Endocrinology: Androgen Excess Disorders of Women: Polycystic Ovarian syndrome and other disorders. Second Edition. Humana Press.

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. 

If hair extensions are causing hair loss, do they need to be removed?

Hair extensions can sometimes cause hair loss. Whether to remove the extensions or change the type of extension is a decision made on a case by case basis. This is not always a simple answer. Sometimes the improvements that come with the patient using the extensions supercedes a small amount of hair loss that might come with wearing them. This makes removing the extensions less relevant - especially if this is a more permanent type of camouflaging option for the patient. If, however, the hair extensions are causing significant hair loss and the use of the extension is only temporary (and the long term goal is to improve the patient's hair), then the extensions should likely be removed or changed to reduce the chance of long term damage to the hair follicle and the scalp.

What kind of hairs are going down my drain after shampooing?

Hair Shedding: What am I seeing?

What kind of hairs typically go down the drain after shampooing one's scalp? Well, in nearly everyone these are hairs known as "telogen hairs."

Telogen hairs are hairs that have a long history. They were previously tightly rooted in the scalp and had spent many years growing (at which point they were called anagen hairs). But after years of growing without even a moment of rest, anagen hairs retire and become known as telogen hairs - and then drop out of the scalp. Telogen hairs lack a root sheath around the ends.

Telogen Effluvium and the URH

Upright Regrowing Hairs

Telogen effluvium ("TE") is a type of hair loss where individuals experience increased daily hair shedding. Instead of losing 30-40 or 50 hairs per day, the individual experiences loss of 60, 70, 80 or more hairs in any given day. The numbers can exceed 500 depending on the cause of the shedding.

Common causes of TE include low iron (low ferritin), anemias, thyroid problems, crash diets, weight loss, stress, surgery, medications (ie lithium, some blood pressure pills, retinoids (vitamin A pills)). Any significant illness inside the body (ie flu, autoimmune disease) or on the scalp surface (ie severe scalp psoriasis or severe seborrheic dermatitis) can cause a telogen effluvium.

This picture shows a typical trichoscopic appearance of someone with a "TE." Numerous short pointy hairs, known as "upright regrowing hairs (URH)" can be seen.
 

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.

Eyebrow Hair Loss: What things do we need to consider?

Eyebrow loss: Knowing the cause allows one to plan the treatment

There are many causes of eyebrow hair loss and each has it's own treatment. Too often patients rush to treat their eyebrow loss without pausing to ask "What exactly is my diagnosis?" Here are a few common reasons for eyebrow loss and their treatment.

1. Age related eyebrow loss and overtweezing

If the eyebrow loss is due to age related changes or over plucking/tweezing the options inlcude

a. Minoxidil
b. Bimatoprost (Latisse)
c. Hair transplantation
d. Tattoos, and microblading

2. Eyebrow loss from alopecia areata

If eyebrow hair loss is due to the autoimmune disease alopecia areata, a majority of patients will also have evidence of aloepcia areata at other areas (scalp, eyelashes). Treatments for eyebrow loss due to alopecia areata include:

a. steroid injections   b. topical steroids c. minoxidil
d. bimatoprost
e. oral immunosuppressives (Prednisone, methotrexate, tofacitinib
f. Tattoos and microblading can also be used.  

3. Frontal fibrosing alopecia (FFA)

Frontal fibrosing alopecia of the eyebrows is certainly the most underdiagnosed cause of eyebrow hair loss in women who first notice eyebrow hair loss in their late 40s and early 50s. Hair transplants are ineffective in most, if not all patients with active disease. Treatment options for FFA of the eyebrow include:

a. steroid injections and topical steroids  b.topical non steroids (pimecrolimus cream)
c. oral finasteride
d. oral hydroxychloroquine, oral tetracyclines    
e. Tattoos and microblading can also be used.                                                                                   

4. Trichotillomania

Trichotillomania is common and 3-5 % of the world pull out their own eyebrows due to underlying psychological factors. For some, the pulling is temporary and for others is a chronic condition. Treatment of the underlying psychological factors (stress, depression, anxiety, obsessive compulsive disorder) can lead to improvement. Hair transplants are not an options if the patient is actively pulling his or her eyebrows

5. Other causes

Dozens of other causes of eyebrow loss are also possible including a variety of infectious, autoimmune and inflammatory conditions. Consultation with a dermatologist or hair transplant surgeon is recommended. I strongly advise consulting a dermatologist before proceeding to hair transplantation for women over 40 with new onset eyebrow hair loss after age 40.

Hair Follicle Aging

What is Senescent Alopecia?

Hair follicle aging appears to be a real thing, like any tissue in the body. Traditionally, a form of hair loss known as senescent alopecia ("SA") has been defined as a very specific type of age related thinning that is distinct from androgenetic alopecia ("AGA"). Androgenetic alopecia tends to start somewhere between age 8 and age 50 - at least that has been the traditional view. Hair thinning that occurs after age 60, with no thinning prior to this, has a high likelihood of representing senescent alopecia. (Of course other types of hair loss may also occur after age 60). A study by Karnik and colleagues in 2013 confirmed that these two conditions (AGA and SA) are truly unique. The authors studies 1200 genes in AGA and 1360 in SA and compared these to controls. Of these, 442 genes were unique to AGA, 602 genes were unique to SA and 758 genes were common to both AGA and SA.

The genes that were unique to AGA included those that contribute to hair follicle development, morphology and cycling.

In contrast to androgenetic alopecia, many of the genes expressed in senescent alopecia have a role in skin and epidermal development, keratinocyte proliferation, differentiation and cell cycle regulation. In addition, the authors showed that a number of transcription factors and growth factors are significantly decreased in SA.

Conclusion
The concept of senescent alopecia is still open to some debate amongst experts. The studies by Karnik give credence to the unique position of these two conditions. But studies by Whiting suggested that it is not so simple as to say anyone with new thinning after age 60 has SA - many of these are also more in keeping with androgenetic alopecia. As one ages into the 70's, 80's and 90's - hair loss in the form of true senescent alopecia becomes more likely.

Reference

Karnik et al. Microarray analysis of androgenetic and senescent alopecia: comparison of gene expression shows two distinct profiles. J Dermatol Sci. 2013.

Whiting DA. How real is senescent alopecia? A histopathologic approach.
Clin Dermatol. 2011 Jan-Feb.
 

Fungi

An Overview for the Hair Specialist

Living things on earth are classified as either animals, plants fungi, bacteria or protists. We are familiar with animals and plants as we see them everyday. The other groups are less familiar to most people. Certain fungi are relevant to the hair specialist. Some 6 million different species of fungi exist. Fungi survive by absorbing nutrients from the environment. They have cell walls made of a material call chitin. We are familiar with one type of fungus - mushrooms - but are less familiar with all the various yeasts and molds that exist.

There are many different fungi that can cause health problems in humans. Of the 6 million species of fungi, about 600 have the potential to cause health problems. As we have seen over the past week in various posts, fungi known as Malassezia are the cause of the common seborrheic dermatitis and dandruff. Fungi known as dermatophyte fungi are the cause of scalp tinea capitis (which is common is children). Fortunately, most people will never come to know another group of fungi known as "opportunistic fungi." These are fungi that cause serious and sometimes fatal disease in patients with a weakened immune system including cancer patients, patients with organ transplants, HIV patients, patients with low white blood cells (neutropenia). A variety of opportunistic fungi exist including Candida, Aspergillus and Mucor (3 most common).

Tinea Capitis (Scalp Fungal Infections)

In Thai Buddhist Monks

As we've seen this week, "tinea capitis" refers to infection of the scalp by various types of fungi. Tinea capitis is common among children and rare in adults. People living in close contact and sharing combs and similar type material are at higher risk for acquiring tinea capitis.

A recent study from Thailand has some important lessons about tinea capitis. In this study, 60 young male Buddhist monks with tinea capitis were studied. Many different types of fungi were uncovered from scalps included the anthropophilic fungus Trichophyton violaceum (60 %) and Trichophyton mentagrophytes (43 %). Microsporum canus (common in Europe) was less commonly found (35 %) and Trichophyton tonsurans (common in North America) was found in only 13 % of cases.

Much to my surprise, 95 % of the monks had evidence of scarring alopecia - a feared complication of tinea capitis type infections. The authors proposed that educational efforts regarding avoiding sharing personal items and improvement in personal and environmental hygiene is needed to reduce infection.

Reference
Bunyaratavej et al. Clinical and Laboratory Characteristics of a Tinea Capitis Outbreak among Novice Buddhist Monks. Pediatric Dermatology 2017; 1-3.

Tinea Capitis from dogs

Microsporum Canis is Common Culprit

Scalp fungal infections, also known as "tinea capitis", can be acquired from human to human transmission, or from animals or soil. In different areas of the world, the main agent causing tinea capitis differs. 

The family pet is one potential source. Dogs, cats, and guinea pigs can transmit infection - mostly among children. Any child with suspected tinea capitis should have a skin scraping to determine the infective agent. Is the infection coming from another child? a pet? the soil? Treatments can be differ slightly depending on the cause.

A infective dermatophyte fungus known as Microsporum canis is the most common fungal agent transmitted by dogs. Even if the dog has no signs of skin or fur problems, transmission to humans can still take place.

In some areas of Europe, Microsporum canis is the number one cause of tinea capitis. In North America, tinea capitis in children is most often caused by another fungus known as Trichophyton tonsurans. Some Microsporum canis infections in children have the potential to be highly inflammatory and can cause discomfort and pain. Rapid treatment with oral antifungal agents is needed to prevent permanent scarring in children. Topical antifungals and topical antifungal shampoos are not effective. Oral agents are mandatory.
 

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.

Which hairs should be taken during a scalp biopsy?

What is a scalp biopsy? Which hairs should be taken ?

A scalp biopsy is a 15-20 minute procedure that helps the dermatologist obtain a small piece of tissue for analysis.  The sample is processed in a history laboratory into thin sections and mounted on glass slides for review by a pathologist under the microscope.  A scalp biopsy is not required for most patients with hair loss. When the diagnosis is uncertain, it can be very helpful.

FOR DETAILS ON THE SCALP BIOPSY, CLICK HERE
 

Which hairs should be included?
 

First, an area of the scalp containing hair follicles should always be included in a biopsy. A scalp biopsy specimen from a completely bald area is not helpful!

Second, the hair follicles obtained should be taken from an area showing the specific abnormalities thought to be in keeping with the hair loss condition in question. If no such features are present, hair follicles might be obtained from an area of the scalp where the hairs are easily extractable (positive pull test), or from an area having the most symptoms (itching, burning or pain).

The key point is that obtained a scalp biopsy from a random area on the scalp does not usually yield useful information.

Hair transplantation for central centrifugal cicatricial alopecia (CCCA)

Scarring Hair Loss Conditions in Black Women : Is hair transplantation an option?

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**CLICK TO ENLARGE ** Photo of top of scalp in woman with CCCA

Diagnosing hair loss in women with afro-textured hair requires special expertise. Many hair loss conditions are possible and they tend to look similar. Central centrifugal cicatricial alopecia (CCCA) can look similar to genetic hair loss and so can some types of traction alopecia. Our program for women with afro-textured hair addresses some of the unique aspects of hair loss and hair care in black women. 

Hair transplantation in CCCA

Central centrifugal cicatricial alopecia (or "CCCA" for short) is a type of scarring hair loss condition in black women. Hair loss starts in the centre of the scalp and spreads outwards over time. If treated early, the condition may be halted - at least for some women. Hair transplants are possible in CCCA once the condition becomes “quiet.” By quiet, we mean that there has been no further hair loss for a period of 1-2 years. 

Are hair transplants possible for CCCA?

Surgery is sometimes an option for a group of conditions known as scarring alopecias. These conditions are frequently autoimmune in nature and have names like lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia. 

When can a hair transplant be done in CCCA ?

A hair transplant is not possible for many patients with these conditions because the condition is "active." However, once the condition becomes "quiet" - a hair transplant can be considered. 

By 'quiet', several conditions must be met. These are summarized in the CCCA Hair Transplant Criteria.

DONOVAN CCCA HAIR TRANSPLANT CANDIDACY CRITERIA 

In order for patients with CCCA to be a candidate for hair transplant surgery ,  ALL FIVE of the following criteria must be met:

1.  The PATIENT should be off medications.

Ideally the patient should be off all topical,  oral and injection medications to truly know that the disease is "burned out (burnt out)". However, in some cases, it may be possible to perform a transplant in someone with CCCA who is using medications AND who meets criteria 2, 3 and 4 below.  This should only be done on a case by case basis and in rare circumstances. It is a last resort in a very well-informed patient. 

2. The PATIENT must not report symptoms related to the CCCA in the past 12 months, (and ideally 24 months) .

The patient must have no significant itching, burning or pain. One must always keep in mind that the absence of symptoms does NOT prove the disease is quiet but the presence of symptoms certainly raises suspicion the disease could be active.  Even the periodic development of itching or burning from time to time could indicate the disease has triggers that cause a flare and that the patient is not a candidate for surgery. The patient who dabs a bit of clobetasol now and then on the scalp to control a bit of itching may also have disease that is not completely quiet. 

3. The PHYSICIAN must make note of no clinical evidence of active CCCA in the past 12 months, (and ideally 24 months).

There must be no scalp clinical evidence of active CCCA such as hair fragility or scalp erythema. . This assessment is best done with a patient who has not washed his or her hair for 48 hours. Some scalp redness may be persistent in patients with scarring alopecia even when the disease is quiet. Therefore scalp redness alone does not necessarily equate to a concerning finding. Perifollicular redness however is more concerning for disease activity.  In addition, the pull test must be completely negative for anagen hairs and less than 4 for telogen hairs.  A positive pull test for anagen hairs indicates an active scarring alopecia regardless of any other criteria.

4. Both the PATIENT and PHYSICIAN must show no evidence of ongoing hair loss over the past 12 months (and ideally 24 months). 

There must be no further hair loss over a period of 24 months of monitoring OFF the previous hair loss treatment medications. This general includes the patient and physician's perception that there has been no further loss as well as serial photographs every 6-12 months showing no changes. 

5. The patient must have sufficient donor hair for the transplant. 

Not all patients with CCCA maintain sufficient donor hair even if the disease has become quiet. But this is an important and final criteria.