How can we differentiate trichotillomania from alopecia areata in children?

Differentiating trichotillomania from alopecia areata 

It can be challenging in some children to distinguish alopecia areata (an autoimmune condition) from trichotillomania (an impulse control disorder whereby individuals pull out their own hair). Sometimes even both coexist in the same patient! 

Exclamation mark hairs are frequently seen in both alopecia areata and trichotillomania and are therefore not specific (arrow). Several dermatoscopic signs, however, are more common in trichotillomania than alopecia areata including flame hairs, split ends, hairs of different lengths, v-sign (shown here with yellow circle), hair powder.

Topical Tofacitinib for Alopecia Areata: How much does it really help?

2% Ointment Helped 1 of 10 Patients 

Oral tofacifitinb belongs to a group of medications known as JAK inhibitors and represents an off-label treatment for alopecia areata.  Its use is limited by cost but also by potential side effects associated with its immunosuppressive effects. An increasing interest is mounting regarding the potential use of topical JAK inhibitors in treating alopecia areata.

The optimal formulation (liposomal vs ointment) has yet to be definitively proven. Previous studies have suggested a benefit of both topical ruxolitinib and topical tofacitinib in at least some patients with alopecia areata. 

New Study Examines Topical Tofacitinib

Researchers from Yale set out to examine the benefit of tofacitinib ointment in adults with alopecia areata. In their report, the authors described the results of a 24-week, open-label, single-center pilot study of 10 patients with AA treated with tofacitinib 2% ointment applied twice daily.  Patents were eligible for the study if they were 18-years-old or older, had at least 2 patches of alopecia areata, had  stable or worsening disease for 6 months, and have received no treatment for AA for at least 1 month prior enrolment. Tofacitinib was applied to half of the involved scalp and, if and when evidence of hair regrowth was observed, tofacitinib was subsequently applied to the entire involved scalp. 

 

What were the results?

The authors showed that 3 of 10 subjects experienced hair regrowth with topical tofacitinib with a mean decrease of 34.6% in SALT score (standard deviation 23.2%).  Of these three patients, only one had excellent regrowth. 2 others had partial growth. Skin irritation was reported by 40 % of patient and folliculitis in 10 %. Both of theses side effects resolved even without treatment. 40 % of patients had a minor increase in cholesterol levels. Despite these minor side effects there were no serious side effects. 

Conclusion and Summary

This is an interesting study by these Yale researchers who are leaders in this area of JAK inhibitors. It was disappointing that only 1 of 10 patients had significant improvement.  Whether a differential topical vehicle (such as a liposomal vehicle) could have different results awaits further study.  The main message of all of the topical JAK inhibitors studies to date is that they could help some patients with alopecia areata, but for many they do not. 

REFERENCE

1. Liu L et al. Tofacitinib 2% ointment, a topical janus kinase inhibitor, for the treatment of alopecia areata: a pilot study of 10 patients. Journal of the American Academy of Dermatology.

DOI: http://dx.doi.org/10.1016/j.jaad.2017.10.043

2. Topical Ruxolitinib Promotes Eyebrow Regrowth in Alopecia Universalis  

3. Topical JAK inhibitors for Children and Adolescents with AA  

Tofacitinib for Alopecia Areata: How long do we use it?

How long to continue Tofacitinib in Alopecia Areata?

 

A variety of treatments are available for alopecia areata. For localized (limited) AA topical steroids, steroid injections and minoxidil are still the mainstays of treatment. Treatment of advanced alopecia areata is more challenging. A variety of options are available in such cases including diphencyprone, prednisone, methotrexate and more recently tofacitinib.  

Tofacitinib in AA

We have been prescribing tofacitinib more frequently as an off label treatment for alopecia areata. The drug is surprisingly well tolerated for many, but does have potential side effects relating to long term immunosuppression. These include increased risks of infection, and concerns over possible long term cancer risks. The drug is expensive (1200-1400 USD per month). 

Lowest Dose, Shortest Time Needed

Clearly, in order to limit side effects of tofacitinib (and any drug) one should use the lowest dose possible and use it for the shortest duration possible. However, for many patients with advanced alopecia areata who are responding well tofacitinib and experiencing regrowth, any discussion of lowering the dose raises the possibility that hair loss could once again occur. The decision to taper the drug should always be carefully considered. Losing hair again can be devastating.

Some patients with advanced alopecia areata who start tofacitinib will likely need to use higher doses forever to maintain their hair density. But some patients will be able to eventually taper the dose. Some are able to taper it a bit and some are able to taper it a considerable amount and possibly even stop. However, it is less common to be in the latter group. Most patients who need to use tofacitinib in the first place have a more resistant form of hair loss that is unlikely to regrowth fully without immunosuppression.

Tapering Tofacitinib

There is no standardized formula for how to taper tofacitinib. Generally, my approach is the following.

1. Assuming a patient is using 5 mg twice daily (10 mg daily) go down to 10 mg on Monday, Wednesday and Friday and Sunday and 5 mg on Tuesday, Thursday and Saturday. This can be continued for 3 months. If there is any breakthrough hair loss, the patient returns to 10 mg daily.

2. If hair is growing fully, one can consider going down to 5 mg every day for an additional three months.

3. Thereafter, if hair growth continues to be full, we may consider 5 mg on Monday, Wednesday and Friday and no medication on the other days. A slower taper is possible if there are any concerns and this could include 5 mg daily Monday to Friday with the weekends being 'drug-free' periods.

4. Thereafter, any taper is done on a case by case basis. Many patients are not  able to taper further. However some may taper to 5 mg on Mondays and Thursdays before eventually going to one tablet weekly.

Lab Tests During a Taper

If blood tests have been stable and normal at the higher doses of tofacitinib I am generally less concerned about the patient having frequent monitoring blood tests. Nevertheless, I do feel that tests every 3-6 months is still appropriate even in a patient whose tests have been stable. I generally advise my patients to get tests for CBC, CK, cholesterol, liver function tests, creatinine, urinalysis. A repeat ECG is done every year.

Final Comments

The topic of tapering immunosuppressants is an important one in alopecia areata. Some patients are not able to taper immunosupressants at all without losing some hair. However, some patients can taper and a "go slow" approach is generally the best method. Go slow means not only taper the oral immunosuppressants slowly but given attention to how the patient's alopecia areata is treated topically. As tofacitinb is tapered, one may continue various topical (and even corticosteroid injection-based) treatments that have been performed alongside the immunosuppressive agents.  But eventually they too can be tapered in a stable patient. 

Alopecia Areata: Inflammation causes Abnormal Hairs to be Produced

Alopecia Areata: A Closer Look at Shed Hairs

Alopecia areata is a autoimmune condition that affects about 2 % of the world. The condition causes inflammation at the very bottom of the hair follicle (called the "bulb").

As a result of this inflammation, the hair does not grow well because this inflammation interferes with proper growth. Sometimes the fibers are abnormal in appearance (producing a "tapered hair" as shown in the photo). Other times the hairs that fall out are very normal looking telogen hairs (labelled 1 and 2 in photo below) that simply get shed early.

In addition, when the condition is "active" and hair loss is occuring in an accelerated manner, a variety of hairs can be easily pulled from the scalp including telogen hairs (labelled 1 and 2) and a variety of weakened hairs that break off at the root (called "dystrophic" hairs and labelled 3 in the bottom photo).

Analysis of the types of hairs that are extracted from the scalp is important as it gives information not only about the diagnosis itself but the severity of the condition and prognosis. 

Minoxidil Use in Alopecia Areata: Useful or not?

Minoxidil in Alopecia Areata

Alopecia areata ("AA" for short) is an autoimmune condition that will affect about 1.7% of the world's population at some point in their lives. Many patients with AA develop hair loss in round or oval shaped patches. The individual shown in the photos has a fairly typical presentation.

There are a variety of treatments for AA including topical steroids, steroid injections, diphencyprone, anthralin, prednisone, methotrexate, sulfasalazine, tofacitinib.

 

Minoxidil for Treating AA

I include topical minoxidil in a large proportion of the treatment plans that I recommend for my own patients. Minoxidil is a topical product that is available in both generic forms as well as popular trade names such as "Rogaine" in North America and "Regain" in part of Europe.  Studies dating back to the 1980s have shown very clearly that minoxidil is beneficial in patients with alopecia areata. My personal view is that it does not usually help on its own if one were to use it as the only treatment  (i.e. 'mono therapy) but can help when added to a treatment plan that involves any of the treatment agents listed above.  When I prescribe a plan that includes use of topical steroids or steroid injections, I frequently include minoxidil on the plan. Even with anthralin or DPCP, I frequently recommend my patients use minoxidil as well. 

Minoxidil in AA: Clearing up the Many Myths and Misconceptions. 

There are certain many myths, confusions and inaccurate information when it comes to using minoxidil for alopecia areata. Here I will review a few common myths.

Confusion 1: Do I need to use it forever? Everyone tells me I do!

The 'rule' that minoxidil needs to be used forever and that one will lose hair if they stop applies to the use of minoxidil for men and women with a hair loss condition known as andoagenetic alopecia (i.e. male and female balding). These so called rules do not necessary apply to alopecia areata. Once hair starts growing really well again in those with alopecia areata, it is frequently possible for many to stop the use of minoxidil and still keep their hair. OF course, minoxidil may be needed again in the future were a patch of hair loss to occur again. However, the purchase of one bottle of minoxidil does not necessarily commit one to a lifetime of use. 

Confusion 2: The bottle says not to use it if I have patches of hair loss! What am I to do?

It is important to understand that minoxidil is only FDA approved for treating genetic hair loss. It has not gone through the million dollar rigours of the FDA approval process to have it formally approved for treating alopecia areata. However, we know from very good studies one the last 30-40 years that minoxidil does help patients with alopecia areata. Therefore, any such use in alopecia areata is said to be 'off label.' Because minoxidil is formally approved only for androgenetic alopecia the companies can not advertise that it helps other hair loss conditions. It is illegal for companies to write on their packaging that this product can be used in alopecia areata, traction alopecia, some forms of scarring alopecia. As a physician however, I can recommend it to certain patients with these conditions if I feel it will be helpful. However, the only thing that can be advertised by the companies is that it can be used in androgenetic alopecia. 

Confusion 3: I've heard minoxidil can cause hair loss. I'm terrified to start.

It is very well known that men and women who use minoxidil for treating 'androgenetic alopecia' (male and female balding) can developed hair loss in the first two months of use. This is because minoxidil triggers hairs in the telogen phase to exist fairly quickly over a span of a few weeks. This phenomenon can also happen in alopecia areata but one must remember that what is actually happening in most individuals is that minoxidil is triggering older injured hairs to exist and helping to facilitate new stronger hairs to reemerge. Most of the time a patient with alopecia areata who says their hair is worsening and worries that it is the minoxidil that is causing the worsening is actually just experiencing a worsening of their disease. For these individuals the minoxidil is not causing the hair to fall out more - it is the disease itself that is causing this. This individual needs more aggressive treatment. 

Confusion 4: Should I use 2 % or 5 %? Should I use minoxidil drops or the foam?

There is no 'one answer' for all patients. The decision on what type of minoxidil to use should be reviewed on a case by case basis. In general, if one is going to use minoxidil, they should just get the product on the scalp consistency. There are situations where I recommend the 2 % lotion and there are situations where the  5 % foam is perfect. The benefit of the older lotion is that a patient can more carefully control the dosing. Instead of using 1/2 cap of the foam, a patient using the lotion is allowed to use up to 1 mL (25 drops). This frequently allows more of the product to be spread all around the scalp. In addition, if a patient is very sensitive to the effects of minoxidil and develops headaches or dizziness and there are worries about the effects of minoxidil on the heart, I may recommend 2 % minoxidil and start with 4-6 drops and slowly work up to 25. The key is to get the product on the scalp.

 

Conclusion

Minoxidil has been used as therapy for treating alopecia areata for over 3 decades. Its use is off label but given its generally good safety profile, it its an important consideration. I frequently combine it with many treatments I recommend for AA.

 

REFERENCE

Price VH. Double-blind, placebo-controlled evaluation of topical minoxidil in extensive alopecia areata. Clinical Trial. J Am Acad Dermatol. 1987.

Alopecia Areata and Bullying in Children

Bullying, Teasing in Children with AA

There are many challenges to losing hair at any age. Children with hair loss experience teasing and bullying which may affect their self-esteem and emotional development and in turn affects many aspects of their lives. 
Bullying and teasing is a frequent topic I discuss with parents and children with hair loss, especially alopecia areata. We discuss ways to cope, educate others, and recognize that we are all different in some way or another.

Bullying in children with alopecia areata was recently studied by Christensen and colleagues. The US authors examined the prevalence of bullying and the emotional impact of AA in children. The study found that bullying was common overall. In addition, there was additional psychological impact with impairment of social and home life being common. Children with alopecia experienced bullying across all age groups studied. Boys reported increased physical bullying. I was interested to note that children and teens with more severe disease and longer duration of disease experienced less bullying than those with less severe disease.
 

Reference

Bullying and Quality of Life in Pediatric Alopecia Areata.
Christensen T, et al. Skin Appendage Disord. 2017.

Alopecia areata: The Many Forms of "Total Baldness"

Total Loss of Scalp Hair in AA: Not one Type

Alopecia areata is an autoimmune condition. The cause is not fully known but genetics play a very important role. In fact, at least 70 % of the disease can be explained by a person's genetic make up. I often tell my own patients that the tendency for them to actually develop this condition was inside them from the day they were born (technically speaking it is the day they were conceived). Alopecia areata can cause hair loss in patches on the scalp or total hair loss.

Variations in AA

There are many many different variations. Even patients who have no hair on the scalp are of two main groups: 1) patients with smooth scalps totally devoid of any visible hair follicles and 2) patients who are completely bald but have many broken hairs (called black dots) all over the surface. This second form has much better prognosis (chances for regrowth) although complete hair loss in alopecia areata is still quite challenging to treat overall. This photo shows a patient who at a distance would appear to have no hair on the scalp. A closer examination shows that the scalp actually has many hairs - it is simply that they are broken at the surface. One hair has managed to grow but inflammation beneath the scalp has caused it to break off a few millimetres above the surface. This is called an "exclamation mark" hair.

WHAT IS THE MOST EFFECTIVE TREATMENT OF ALOPECIA AREATA ?

What is the most effective treatment for a single patch of alopecia areata? 
 

This is a common question. Corticosteroid ("Steroid") injections remain one of the most consistently effective treatment for so called "patchy" alopecia areata. This involves use of tiny 30 gauge needles connected to a syringe to adminster liquid steroid medications into the skin so that the medication can bathe the hair follicles. Despite the worry and concern, steroid injections when used in low quantity are relatively safe and side effects are uncommon. A small dimple or identation in the scalp can sometimes occur but this is temporary. Thinning of the skin does not occur with a single injection. The most commonly used corticosteroid for injection is known as triamcinolone acetonide (Kenalog) although other steroids may be used too. 
This photo shows significant hair regrowth in a patch alopecia areata about 4 months after injection. 

Scalp alopecia in men with beard alopecia: What are the risks?

Scalp alopecia in men with beard alopecia

Alopecia areata is a relative common autoimmune condition affecting up to 2 % of the world. Beard and facial alopecia is particularly concerning to many men as it can be challenging to camouflage. A frequent question from patients with beard alopecia areata is "how likely is it that I will eventually develop patches on my scalp?" Another wonderful multicentre study from Spain helped answer that question. The researchers studied 55 men with beard alopecia and followed them for at least one year. In the study, 45 % of males developed scalp alopecia over the follow up period. Most who did develop AA (80%) did so in the first 12 months. The conclusion from the study was that a significant proportion of males with beard AA do in fact develop patches of scalp AA warranting long term follow up for these patients.

Reference
Saceda-Corralo D, et al. Beard alopecia areata: a multicentre review of 55 patients. J Eur Acad Dermatol Venereol. 2017.

Hair breakage in Alopecia Areata

Why do hairs break in alopecia areata?

Hair breakage is a common finding in active alopecia areata (an autoimmune hair loss condition). Inflammation occurring deep down in the scalp at the level of the bulb prevents strong hairs from being produced. The result is hair breakage. Some of hairs that are shed are of course full length hairs. But in patients with very active AA, a close examination of shed hairs will reveal that many are broken.

Tapered and Exclamation Mark Hairs in Alopecia Areata

Tapered & Exclamation Hairs in AA indicate Activity

Tapered Hairs

Tapered hairs are frequently seen in patients with small circular patches of alopecia areata. In contrast to 4-5 mm exclamation mark hairs (see next post), tapered hairs are long and typically as long as neighboring hairs. As the hair enters into the skin it becomes much thinner. At the bottom of the tapered hair (deep under the skin) is inflammation.

Tapered are important findings in patients with patchy stage alopecia areata as they tell us that the condition is active and that anti-inflammatory type treatments (such as cortisone injections) are likely to help. The above photo shows several tapered hairs (TH).

Exclamation Hairs

Exclamation mark hairs are frequently seen in patients with small circular patches of alopecia areata. These hairs a short 4-5 mm hairs and represent broken hairs. The top is thick and the end is often frayed. As the hair enters into the skin it becomes much thinner. At the bottom of the exclamation mark hair (deep under the skin) is inflammation. Exclamation mark hairs are important findings in patients with patchy stage alopecia areata as they tell us that the condition is active and that anti-inflammatory type treatments (such as cortisone injections) are likely to help. The photo shows several exclamation mark hairs (EMH).

Alopecia Areata and Oral Contraceptives: 50 Years of Wondering

Do birth control pills cause alopecia areata? Can they be used to treat alopecia areata?

Alopecia areata is an autoimmune conditions that is not uncommon in the population. In fact, about 1 in 50 women will develop alopecia areata and usually before 30.  Oral contractive use is also common in women 18-40 years of age with 15-18 % of women in this age group using birth control. Given these relatively high frequency of alopecia areata and birth control there will be individuals who will develop alopecia areata fairly close in time to the start of an oral contraceptive pill. The question then arises :

Did starting the birth control pill cause the alopecia areata?

 

50 years of wondering

The question as to whether or not oral contraceptives can trigger a patch of alopecia areata has been with us since oral contraceptives first came to market.  In fact, oral contraceptives were first FDA approved in 1960. Reports questioning whether a possible connection could exist between alopecia areata and oral contraceptives surfaced in 1965 with studies published in the British Medical Journal in an article "Alopecia areata and Oral Contraceptives".

No good evidence

For most people, there is no good evidence that alopecia areata is triggered by oral contraceptives. That does not rule out the possibility that there are a proportion of individuals who do have this as a trigger - but for the most part medical studies can't conclusively pinpoint a link. 

Oral contraceptive and Autoimmune diseases

A compressive review by Willams in 2017 examined whether there was any link between hormonal type contraceptives and any of the known autoimmune diseases. The article indicated that ere was in fact substantial evidence exists linking the use of combined oral contraceptives to an increase in multiple sclerosis, ulcerative colitis, Crohn's disease, Systemic Lupus Erythematosus, and interstitial cystitis.  Oral contraceptives were associated with a lower incidence of hyperthyroidism. Alopecia areata was not on this list.

Alopecia areata and estrogen

We do know that the inflammation that is seen in alopecia areata can be influenced in some manner by estrogen.  One study has suggested that alopecia areata can actually be treated with a combination of oral contraceptives (especially those containing norethindrone) and metformin. 

Reisz et al 2013

In 2013, Dr Colleen Reisz from Kansas City evaluated the benefits of one or a combination of birth control pills, metformin and vitamin D in treating alopecia areata. She noted in the background leading up to the study that women of reproductive age experience variation in hormones like estrogens during different phases of the menstrual cycle.  What is so relevant to this study – and alopecia areata in general is that these changes in hormone levels during the menstrual cycle are accompanied by changes in immune function.  Dr Reisz wished to better understand how medical interventions that reduce hormone production and lower aromatase behavior can help alopecia areata. The authors evaluated 14 patients with alopecia areata. 13 had recent hair loss within the past 1 year. About 50 % had moderate to severe hair loss at baseline.

The patients were then offered norethindrone containing oral contraceptive pills (1/20 or 1.5/30) or metformin (500-850mg/day) or both, along with vitamin D (1000-2000IU/day). There were four patients treated with metformin, 9 with metformin and birth control and one with birth control. Some patients (N=5) requested intralesional corticosteroids along with hormonal therapy

Seven of the 14 (50%) had complete regrowth of hair within 3 months of treatment. Another 4 patients regrew their hair fully but the time to reach that state of full regrowth was much longer (about 1 year or more). Of the four other patients, 2 continued to have hair loss, one converted from minor degrees of alopecia to complete hair loss in one week. One patient did not respond at all. 

 

Norethindrone containing oral contraceptives

The following oral contraceptives may contain norethindrone and ethinyl estradiol:  

Norethindrone & Ethinyl Estradiol Containing OCPs

 

CONCLUSION

It's clear that estrogen affect the immune system and at least for some immune based diseases (like multiple sclerosis, ulcerative colitis, Crohn's disease, Systemic Lupus Erythematosus, and interstitial cystitis) there is good evidence that oral contraceptive use increases the risk of developing these conditions. 

We don't have good evidence yet for alopecia areata and to date it would appear for the vast majority of patients there is no link. However, this does not exclude a small subset of individuals that in fact develop alopecia areata after starting a birth control pill. Detailed studies have not examined this and whether there are certain types of birth control pills that are protective against AA and some that are contributory.  The study by Reisz and colleagues discussed above would certainly cause us to give pause and consider that some oral contraceptives may actually be helpful.  For my patients who clearly feel that their OCP is a trigger, I may consider stopping if the alopecia areata is not responding to treatment as one might expect. If an oral contraceptive is restarted in the future, a different one might be considered with close monitoring of whether the OCP gives a flare of the alopecia areata.

REFERENCES

1) Williams WV.  Hormonal contraception and the development of autoimmunity: A review of the literature. Linacre Q. 2017.

2) Oral contraceptives and alopecia. 1968 Mar 9; 1(5592): 593. 

3) Oral contraceptives and alopecia areata. Br Med J. 1965 Oct 23; 2(5468): 1005. 

4) Wallace ML, et al. Estrogen and progesterone receptors in androgenic alopecia versus alopecia areata. Am J Dermatopathol. 1998.

5) Reisz, CM. “Reinstitution of Immune Privilege in Alopecia Areata: norethindrone and metformin” International Journal of Immunology 2013

 

 

NAAF VANCOUVER

The NAAF Vancouver Support Group

Alopecia areata is an autoimmune condition that affects about 50,000 Canadians.  The condition affects males and females of all ages and can have a tremendous impact on the lives of both patients and their families. Support groups play an important role in imparting accurate information to patients and families with new diagnoses as well as those who have had the condition for many years.   These groups connect people at different stages of coping and provides a network of support.

The National Alopecia Areata Foundation (NAAF) was founded 25 years ago and has a number of patient support groups throughout the United States and Canada.  I’m honored to join the NAAF Vancouver Support Group in 2018 as Medical Advisor.  Four meetings are planned for the year in Spring, Summer, Fall and Winter in Vancouver. Individuals with alopecia areata interested in attending these sessions may contact the NAAF for information on dates, times and location or contact our office. 

DPCP for alopecia areata: Why do we use acetone to make it up?

Dissolving DPCP in Acetone

Diphencyprone or "DPCP" is a chemical that causes allergic reactions. It is used as an off-label (non FDA approved) treatment for patients with alopecia areata whereby the DPCP is applied directly to the scalp and left on for 24-48 hours. After 48 hours the DPCP is washed off.

DPCP is not soluble in water so it is typically made up in acetone. Acetone is an organic solvent best known as the ingredient in nail polish remover. DPCP may also be soluble in other ingredients such as isopropanol.

What is often forgotten is that DPCP degrades in light and at room temperature. DPCP should be ideally stored at 4 degrees ceclius and protected from light. Usually DPCP is dispensed in brown light proof bottles but I recommend wrapping in aluminum foil to further protect from light.

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.

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.

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.  

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.

Partially Treated Alopecia Areata

Alopecia areata is an autoimmune condition that affects approximately 2 % of the worlds population. Many treatments are available. For patches of alopecia areata, the most effective treatment is steroid injections. When the scalp is examined a few weeks after a patient has received steroid injections a mixture of hair regrowth and hair loss is typically seen. In alopecia areata, hairs that are in the losing stage include broken hairs (arrow) and so called exclamation mark hairs (asterisk). Over time as hair growth dominates, the proportion of broken hairs and exclamation mark hairs will be reduced.