Permanent Chemotherapy Induced Alopecia (PCIA)

A New type of Hair loss in Patients Undergoing Chemotherapy: PCIA

Every year about 650,000 patients undergo chemotherapy in the United States. Hair loss is a common side effect of chemotherapy and occurs in about 65 % of patients who receive chemotherapy. There are two main types of hair loss that can occur in patients undergoing chemotherapy. The first is hair loss that happens within weeks of starting the chemotherapy and then lasts several months before growing back.  This is known as temporary chemotherapy induced alopecia ("TCIA"). The second type is uncommon and occurs when patients fail to regroth their hair back to the level it was before undergoing chemotherapy. If hair has not grown back after chemotherapy by the 6 month after chemotherapy, we call this permanent chemotherapy induced alopecia (PCIA) and it is sometimes also called Chemotherapy Induced Permanent Alopecia (CIPAL).

Permanent Chemotherapy Induced Alopecia (PCIA) 

The failure of the hair to grow back fully 6 months post chemotherapy raises concerns about a phenomenon known as permanent chemotherapy induced alopecia (PCIA).     In recent years a number of studies have highlighted the possibility of PCIA in women with breast cancer treated with various chemotherapeutic agents, especially drugs known as taxanes. Docetaxel and paclitaxel are part of this group of drugs. The exact mechanisms are unclear although injury to the bulb as well as follicular stem cells are thought to be relevant. Adjuvant anti-estrogen hormonal therapy may be an important cofactor in many women with PCIA. A similar PCIA presentation has been reported in patients undergoing bone marrow transplantation. The scalp is predominantly affected in women with PCIA although a minority may have eyebrow, eyelash and body hair loss as well.

Different Clinical Presentations of PCIA

PCIA doesn't appear similar in all patients. In fact, three main types appear to exist including a diffuse type, a diffuse type with vertex accentuation (mimicking androgenetic alopecia) and a patchy type mimicking alopecia areata.   

Examination under the Microscope: Biopsies of PCIA

Histopathology of biopsy specimens shows a non-scarring alopecia with preservation of sebaceous glands, miniaturization, decreased anagen hairs, increased telogen hairs and end stage avascular fibrous tracts. There may be several histological presentations and the exact features remains to be defined although a high proportion show dysmorphic telogen germinal units. Some biopsies show peribulbar type inflammation.

How do we treat PCIA?

We don't really know yet how to best treat PCIA. The most common treatments described in the medical literature are oral and topical minoxidil. Both seem to provide benefit to at least a proportion of patients.  Other treatments are not known to provide benefit. 

Dr. Donovan's Articles for Further Reading

Preventing Hair Loss from Chemotherapy

Does hair always grow back after chemotherapy?

REFERENCES

Miteva M, Misciali C, Fanti PA et al. Permanent alopecia after systemic chemotherapy: a clinicopathological study of 10 cases. Am J Dermatopathol. 2011 Jun;33(4):345-50.  

Fonia A, Cota C, Setterfield JF et al. Permanent alopecia in patients with breast cancer after taxane chemotherapy and adjuvant hormonal therapy: Clinicopathologic findings in a cohort of 10 patients. J Am Acad Dermatol. 2017 May;76(5):948-957.

Rugo HS.  Real-world use of scalp cooling to reduce chemotherapy-related hair loss.  Clin Adv Hematol Oncol. 2017

 

Risk of Fibroids Increased in Women with CCCA

Five Fold increased Risk of Fibroids in Women with CCCA  

A new study, published in JAMA Dermatology, has given evidence that women with central centrifugal cicatricial alopecia (CCCA) are at increased risk of developing benign uterine tumors known as fibroids.  The medical terms for these are uterine leiomyomas.

CCCA is a type of scarring alopecia that occurs predominantly in women with afro-textured hairs. This new data suggests that a genetic predisposition to develop excessive scar tissue in other area of the body may be central to the underlying mechanisms that cause these two diseases.  

The researchers analyzed data from over 487,000 black women and examined the incidence of fibroids in women with CCCA and those without CCCA. Out of 486,000 women in the general population,  3.3 % had fibroids. However, 13.9 % of women with CCCA were found to have fibroids. Taken together, this works out to a five fold increased risk of fibroids in women with CCCA.

Conclusion

There is an increased risk of uterine fibroids in women with CCCA.  Whether there is an increased risk of other scarring related diseases of the body warrants further study.

REFERENCE

 
Dina et al. Association of Uterine Leiomyomas With Central Centrifugal Cicatricial Alopecia. JAMA Dermatology, 2017; DOI: 10.1001/jamadermatol.2017.5163

Do all women with hair loss really need blood tests?

Evaluating Hair Loss in Women: Are blood tests really needed?

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That answer, in my opinion, is a resounding - "yes." All women with concerns about hair loss need blood tests. The reason is simple: there are a great number of similar looking hair loss conditions in women and if one thinks they can confidently, with 100% certainty,  rule out any particular condition just by looking at the scalp they are wrong. One can not exclude a contribution from low iron or a thyroid disorder even in a woman presenting with classic androgenetic alopecia. Let's take a closer look why blood tests are needed.

For a review of blood tests typically recommend as part of a screening work up click on the following 

SCREENING BLOOD TESTS FOR WOMEN WITH HAIR LOSS.

1. Iron deficiency anemia is common

About 1 out of every 5 women age 18-45 have iron deficiency. It's common. Given that low iron levels may be associated with a variety of different hair loss conditions, it is important to test for it and supplement iron in women whose blood tests show low iron. Even if one were to argue that low iron levels are seldom really a true factor in hair loss, studies have also shown that supplementation with iron may allow other treatments to work better.

In 1992, Drs Rushton and Ramsay conducted a study looking at women with genetic hair loss who were being treated with an antiandrogen medication (called cyproterone acetate). The researchers showed that women with iron levels above 40 had much better results with the antiandrogen pill than women who had iron levels below 40.
 

2. Blood counts

Ordering a basic blood count (for levels of red cells, white cells) is important. It's not a very specific test, but when the levels come back abnormal, it signals something may be wrong. A common reason for low hemoglobin and a low number of red cells levels is iron deficiency. But a variety of internal illness also have as part of their presentations low blood counts. A basic screen is helpful.

My work up is very different when a female with hair loss has an abnormal blood count. A 31 year old female with low hemoglobin and low ferritin, may have this result from heavy menstrual cycles, but may also have this from celiac disease as well. Depending on the patient and specific details, I may order a so called 'celiac panel' as well. A  66 year old female with low hemoglobin and low ferritin who comes into my clinic for hair loss may need a comprehensive work up by her physician to rule out a cancer. 

3. Thyroid abnormalities are common

About 1 out of every 15-20 individuals will be diagnosed with a thyroid disorder in their lifetime. These thyroid conditions are 8 times more common among women. While it's true that many with thyroid disease will notice symptoms, about one half will not notice any problems at first. Hair loss is frequently part of the collection of symptoms that come with thyroid dysfunction. Testing for thyroid disease in women with hair loss is important.

4. Vitamin D deficiency is common

Vitamin D deficiency is common. Here in Canada, studies have shown that about two-thirds of the population is low in vitamin D and levels tend to be lower in winter than summer.  The exact role of vitamin D in hair loss is still being worked out but it's clear that individuals with alopecia areata and genetic hair loss have lower vitamin D levels than individuals without hair loss.  

5. Zinc deficiency

Zinc deficiency is not common in North America. Nevertheless, zinc deficiency does exist in a number of subgroups in the North American population and is likely more common than appreciated. About 12 % of the general population and up to 40-50 % of the elderly are at risk for zinc depletion in North America. In many parts of the world, zinc deficiency is extremely common. In North America, zinc deficiency is frequently asymptomatic - meaning that individuals with low zinc don't necessarily have symptoms. Zinc deficiency can be associated with hair loss as well as a variety of issues related to immune system function and infection. The recommended amount daily is 11 mg for men and 8 mg for women.

6. Hormone Testing

Most women with hair loss do not require complex and extensive hormonal work-ups that so often are seen. However women with irregular periods, acne, excessive hair growth on the face (hirsutism), difficulty conceiving/infertility, early menopause and abnormal or rapid hair loss do require hormone tests. 

Conclusion

Complete blood counts, along with tests for iron status (ferritin test) and thyroid status (TSH) are among the most important tests for all women with concerns about hair loss. Other tests may also be important for any particular individual but the exact test to order depends on the information obtained during the patient interview.  Too often I hear it said that a female patient does not need blood tests. For example, I often hear it said that a female presenting with classic androgenetic alopecia does not need blood tests because classic androgenetic alopecia is not associated with blood test abnormalities. Here, one needs to consider that classic androgenetic alopecia may be associated with low vitamin D and research has even shown that it may be associated with cholesterol abnormalities as well (low HDL, high LDL).  If one feels they can exclude with certainty that this patient does not have iron deficiency or a thyroid disorder, they are incorrect.

All women with hair loss need blood tests. 

REFERENCE

Rushton DH, et al. The importance of adequate serum ferritin levels during oral cyproterone acetate and ethinyl oestradiol treatment of diffuse androgen-dependent alopecia in women. Clinical Trial. Clin Endocrinol (Oxf). 1992.

Breast Implant Illness and Hair Loss

Hair Loss from Breast Implants: Any relationship?

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I believe that there are countless numbers of hair loss conditions that exist in the world that have not yet been described in textbooks. The reason I believe this is quite simple - I see and hear them every day in my clinic.  There are stories of hair loss from certain medications,  various unusual patterns of hair loss in otherwise common conditions. Every once in a while a new scenario arises that again causes pause - one such example is a syndrome of medical conditions that arise in women who have had breast augmentation and breast reconstruction. Readers should note that this is a very different form of hair loss than the telogen effluvium that sometimes accompanies the surgery itself (or any surgery for that matter). This has been termed 'breast implant illness.' Whether or not hair loss occurs in a small proportion of women who have undergone breast augmentation continues to be studied.  It's an area of research that we follow closely given how often these scenarios arise in our clinic. 

Breast implants and human health

Anything that triggers a systemic reaction inside the body has the potential to cause hair loss. One therefore needs to look at the data on the effects of breast implants on human health. In the last 5 years new data has emerged that breast implants may be associated with cancer - specifically the development of a type of T cell lymphoma called anaplastic large cell lymphoma. The FDA continues to study this association and the risk may be in the order of 1 in 10,000 women to as great as 1 in 1000 women.

Breast Implant Illness has many similar names in the research and medical literature. ASIA syndrome (autoimmune/inflammatory syndrome induced by adjuvants) was a name given to a specific disease that can arise with exposure to silicone. To date, it is still controversial as to whether silicone implants increase the risk of true autoimmunity in the body.  However, some studies have shown increase incdience of autoantibodies in women with silicone breast implants. 

Breast Implant Illness

There is a subset of women with breast implants who feel that their health has changed in some way followed breast implant surgery. The term 'breast implant illness' is a term that has been given to the constellation of symptoms and signs that are proposed to be attributed to breast implants. The mechanism by which this would or could occur is not yet known. Women who report symptoms consistent with breast implant illness frequently mention chronic fatigue, chronic pain, anxiety, irregular heart rate, neurological problems, body odour, rashes, endocrine problems - and hair loss.  To date, it is hard to prove an association of these symptoms of these women to their breast implant surgery and many alternative explanations are frequently given.  Many symptoms are dismissed. Many women, but not all, experience some degree of improvement in symptoms after explanation (removal of the implant).

Breast Implant Illness and Hair Loss

As mentioned in the opening paragraphs, I strongly believe that there are countless numbers of  hair loss conditions and syndromes that are unrecognized and have not yet made their way into textbooks, and classrooms of learners.  (This concept forms Principle 9 of the 20 Principles that govern my practice).

There have been several studies examining breast implant illness and one some have addressed the issue of hair loss. One such study was a 1996 study by Brawer which reported illness in 300 women who had silicone breast implants. Most women (90 %) developed their illness within 6 years of the implants.  Although rupture of the implant was present in some affected, 97 % of women did not experience rupture prior to their symptoms.  Rupture however, did worsen symptoms. 

The table below shows the most common signs and symptoms in patients with breast implant illness according to the 1996 Brawer study. Fatigue tops the list followed by arthritis and chest pain. Hair loss is number 4 on the list and experienced by 59% of patients with breast implant illness.  

from Arthur Brawer. J. Clean Technol Environ. Toxic & Occup Med Vol 5(3) 1996

Conclusion

Modern medicine is still in the early stages of understanding whether and to what degree breast implants affect health. There does appear to be an association with anapaestic large cell lymphoma and an increasing number of women are reporting concerns that can only be grouped together for now under a non specific term 'breast implant illness.'  Hair loss has been reported by many women with breast implant illness.  In my practice having seen at least a dozen cases, most end up being diagnosed with telogen effluvium, chronic telogen effluvium and/or androgenetic alopecia - which are extremely common in the population anyways. Pinpointing an exact cause is challenging. Explanation, or removal of the implant,  is helpful only in some.

For now, continued study of breast implant illness is warranted. 

Reference

1. https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239995.htm

2. Tang S et al. Breast implant illness: Symptoms, Patient Concerns, and the Power of Social Media.  Plast Reconstr Surg. 2017

3. Arthur Brawer.  Chronology of systemic disease development in 300 symptomatic recipients of silicone gel-filled breast implants. J. Clean Technol Environ. Toxic & Occup Med Vol 5(3) 1996

4. Bar-Meir E et al. Multiple autoantibodies in patients with silicone breast implants. J Autoimmune 1995

Is Low Level Laser Therapy (LLLT) Helpful For Treating Hair Loss?

Is LLLT Helpful For Treating Hair Loss?

Is low level laser therapy (LLLT) helpful for treating hair loss? To date there has been a number of studies that suggest LLLT is helpful including 5 randomized double blind studies - 2 studies with so called "laser brush/comb" devices and 3 studies with helmet/cap devices.

The photo here shows a LaserCap. This LLLT device consists of 224 ‘pure’ laser diodes (no LEDs) of 650nm/5mW each. The device is worn every second day for 30 minutes. Several hemet/cap devices now exist and are marketed as FDA cleared LLLT devices.
 

Does stress accelerate balding?

There is not a lot of great medical evidence to support the notion that stress directly impacts MPB.  However, it probably has a minor role and only in some men and women with the right genetic background. Of course, we don't understand yet what that genetic background is at present.

When one examines studies of identical twins, one sees that 92% actually still look identical (same level of hair loss) years and years down the road. If stress, diet, and environmental factors played a huge role, one would not expect this number to be so high.

But for some males and females, it is likely that stress accelerates balding to a minor degree. A study by Gatherwright in 2013 suggested that higher stress could lead to worsening hair loss in the crown in men.  For women, a 2012 study suggested that higher stress was correlated with worse hair loss in the frontal area and divorce and separation were correlated with worsening hair loss in the temples.

Conclusion

Stress probably accelerates the rate of progression of balding in some individuals who have the right genetic predisposition.   We know that stress can cause an increased amount of daily shedding and such shedding can accelerate follicular miniaturization. It makes sense that stress can accelerate the balding process in some individuals. However, it's not likely to be a consistent phenomenon amongst all individuals.  

Reference

The contribution of endogenous and exogenous factors to male alopecia: a study of identical twins.

Gatherwright J, et al. Plast Reconstr Surg. 2013.

The contribution of endogenous and exogenous factors to female alopecia: a study of identical twins.

Gatherwright J, et al. Plast Reconstr Surg. 2012.

Androgen Blockade For FPHL: Can I use more than I medication?

Androgen blockade has the potential to be help female pattern hair loss. Caution is needed with any hormone blocker due to significant harm that can come to a developing baby were a woman to become pregnant on any hormone blocker. For this reason they are frequently used with various strict contraceptive methods.

Hormone Blocking Medications for FPHL

Female Pattern Hair Loss (also called female androgenetic alopecia) affects 40 % of women by age 50. There are a variety of treatment options including minxodil, anti-androgens, laser and PRP. 

Anti-androgens can help some women with female pattern hair loss. A long list of anti-androgens exist including spironolactone, finasteride, cyproterone acetate, flutamide, dutasteride. The combination of anti-androgens can sometimes work even better than one alone provided the patient actually has a truly androgen responsive hair loss condition. Most men do. But not all women have a form of FPHL that is truly responsive to anti-androgens.

Anti-androgen Side Effects

The decision to use two or more anti-androgens must always be weighed against potential side effects. The combination of androgen blocking pills has the potential to be associated with side effects such as depression, worsening fatigue, breast tenderness, breast enlargement, weight gain, decreased libido.

Treating Female Pattern Hair Loss: Options for Women Over 60

Treatments for AGA in Women over 60

I'm often asked about treatment options for women over 60 who present with a diagnosis of androgenetic alopecia (female pattern hair loss). There is some degree of confusion as well as misconceptions which exist in this subject area.

My approach in this situation is to first confirm the diagnosis and then base treatment decisions according to the patient's medical history. The importance of the first step can not be overemphasized.

1: Confirming the Diagnosis

It is extremely important to confirm the diagnosis and ensure that a) another diagnosis is not more appropriate and b) to determine whether other diagnoses are also present. A patient need not have only one diagnosis.

A. Senescent Alopecia

Women who present with hair thinning in their 60s and 70s with no evidence whatsoever of thinning in the 30s, 40s or 50s may have senescent alopecia (age related hair loss) rather than true androgenetic alopecia. This distinction is important as senescent alopecia is less likely to be androgen-driven and therefore responds less to antiandrogens such as finasteride. The main treatment for senescent alopecia is minoxidil although agents such as low level laser and less commonly finasteride can be considered.

I typically ask patients if their hair density on their 50th birthday was more or less the same as their 30th birthday. If that answer is yes one should at least consider the possibility that senescent alopecia or even another diagnosis other than androgenetic alopecia is present.

B. Scarring Alopecia

Scarring alopecias are far more common than we currently diagnose. They range from subtle asymptomatic scarring alopecia to fibrosing alopecia in a pattern distribution to markedly symptomatic lichen planopilaris. Scarring alopecias are easy to miss but need to be considered in all patients with sudden onset of itchy hair loss or a more rapid decline in density from what they may have experienced in the past. A biopsy can help better evaluate these conditions. 

C. Hair shedding issues

Both acute and chronic telogen effluvium (CTE) need to be considered in women with hair concerns. Stress, thyroid problems, new illnesses and newly prescribed medications can all contribute to increased hair shedding and hair loss. Anyone with new shedding needs a very detailed examination and workup not only by the dermatologist but by the family physician. Blood tests are especially as is a full medical examination. One must also ensure that routine mammograms and colonoscopies are up to date.

Chronic telogen effluvium (CTE) is among the more challenging to diagnose conditions. Patients present with increased shedding that waxes and wanes. To an outsider it generally appears that the person has fairly good density. A hair collection or biopsy can help with the diagnosis.

Treatment Options

The main treatment options for patients with confirmed androgenetic alopecia is minoxidil, finasteride and low level laser. If the pattern of hair loss is localized frontal loss, and donor density in the occipital scalp is good, a hair transplant can be considered as well.

Minoxidil is formally approved for women 18-65. It may, of course, be used off label for women over 65 with proper evaluation by a physician.  Women with heart disease, heart failure or previous heart attacks for example may or may not be good candidates for minoxidil. One is not obligated to use the full recommended dose of minoxidil. Starting with one-quarter or one-half the recommended amount is often a good way to ease in to the treatment in patients with underlying medical issues.

Finasteride may also be a good option. Studies support the notion that higher doses of 2.5 mg and 5 mg are needed for post-menopausal women and doses of 1 mg are ineffective. Finasteride is relatively contraindicated in women with previous history of breast, ovarian or gynaecological cancer. Given the rare effects of finasteride on mood, this medication is also relatively contraindicated in women with depression.

Low level laser therapies are safe but may be less effective than minoxidil or finasteride.  A number of laser devices are available in the market for use by patients in their home. None have proven superior to another and so one must balance cost with ease of use. A helmet based device may be easier for some compared to the hand-held devices.

Scalp Inflammation. Scalp inflammation must be attended to fully when caring for patients with AGA. Many women with AGA have seborrheic dermatitis and this is best controlled with periodic use of an anti-dandruff shampoo. I frequently prescribe a trial of a mild cortisone lotion if there is scalp redness if the redness does not respond to anti-dandruff therapies.

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).

Androgenetic alopecia in women: Can I still have it if my hormones are low?

AGA in Women with Low Androgens

I'm often asked on various blogs and posts how it's possible to have androgenetic alopecia if a woman's androgen levels are normal or low. Many individuals have received a diagnosis of androgenetic alopecia and once their blood tests return normal, then have questions:

Is the diagnosis wrong?

How could I possibly have AGA if my androgens (testosterone, DHEAS, etc) is normal?

AGA in Women is best called FPHL

One must always keep in mind that androgenetic hair loss in women has much less to do with male hormones than it does in men. MOST women with AGA have normal hormone levels. In fact, about 90 % have normal hormone (androgen) levels. Treatments for AGA in women can still be helpful in many despite normal or low - normal levels. For this reason, many dermatologists choose to call female androgenetic alopecia "female pattern hair loss (FPHL)" rather than ANDROgenetic alopecia to de-emphasize the role of androgens.  

Summary

There are many complex mechanisms that lead to the development of AGA in women. For many women, androgenetic alopecia has little to do with androgens. For some it has a lot to do with androgens and for some it probably has nothing to do with androgens.  

Lysine and Hair Loss

When Can Lysine be Helpful?

L-lysine is an amino acid, which are the building blocks of proteins. Lysine is one of the more difficult amino acids to get in foods but it is found in meat, fish and eggs.

L-lysine has an important role in iron and zinc absorption. In 2002 D.H. Rushton demonstrated the benefits of l-lysine to increase iron and zinc levels and to reduce hair shedding.

Ruston reported 14 women who were deficient in zinc and showed that 1000-1500 mg of Lysine daily led to an increase in zinc levels from 9.7 to 14.6 umol/L - even without these women consuming zinc pills.

Similarly with iron, Rushton showed that 100 mg per day of iron in 7 women with chronic telogen effluvium did not change ferritin levels at all. However, when combined with L-lysine (again at 1000-1500 mg per day), ferritin levels increased from 27.4 to 58.6 ug/L. This was associated with a decrease in the proportion of hairs in the telogen phase from 19.5 to 11.3.

L-lysine is an important amino acid and I often recommend it for my patients with chronic shedding abnormalities and those with deficiencies of iron and zinc that don't respond to routine supplementation. If I do recommend L-lysine, the dosing is typically 500 mg twice daily, and rarely three times daily for short periods.

Reference

DH Rushton. Nutritional factors in hair loss. Clin Exp Dermatol 2002

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

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

Vaproate and Hyperandrogenism

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

What were the results?

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

Conclusion

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

Reference

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

Joffe H, et al. Biol Psychiatry. 2006.

Is topical Spironolactone effective for Treating Female Pattern Hair Loss?

Oral spironolactone is classified as an anti-androgen and is the most commonly prescribed oral anti-androgen in the Untied States for the treatment of female patter hair loss. IT is not FDA approved for hair loss so its use is 'off label.' Topical spironolactone is not FDA approved for androgenetic alopecia either and has not had much study.  Any use of topical spironolactone should be prescribed only in conjunction with a physician.  

Is topical spironolactone effective? 

Well, few such studies have been done but there may be some minor benefit.  A 1997 study studied 60 women using 1 % topical spironolactone. A minor degree of benefit was seen.  Side effects from topical spironolactone are potentially similar to oral spirinolactone pills (albeit at a lower incidence).  

Women should be aware of breast tenderness, mood changes, electrolyte imbalance, fatigue, dizziness, swelling, Women of child bearing age should speak to their physician about pregnancy concerns. One must never get pregnant while using spironolactone or the developing fetus could be seriously harmed.  Topical antiandrogens do get absorbed into the blood stream. It would be unwise to think otherwise. 

Overall topical spironolactone may have minor benefit in the treatment of androgenic alopecia. More studies are needed however, before its use becomes routine. 

REFERENCE

Dill-Muller D, Zaun H. Topical treatment of androgenetic alopecia with spironolactone. J Eur Acad Dermatol Venereol. 1997 Sep;9(Suppl 1):31.

Oral minoxidil for hair loss

Oral Minoxidil

Topical minoxidil was FDA approved in 1987 and we now have 30 years of experience with the drug. 

I'm increasingly asked about oral minoxidil. Does it work? Is it safe? What dose? 

Oral minoxidil is not FDA approved for treating hair loss. It was used in the 1980s for treating high blood pressure. When used at doses typical for treating blood pressure problems (5 mg twice daily), it can be associated with side effects - some quite serious. These include dizziness, low blood pressure, weight gain from fluid retention, high heart rate, heart rhythm problems. And of course hair growth can occur all over the body.

Lower doses of oral minoxidil may be safer and may still provide benefit. Doses ranging from 0.25 mg daily to up to 1 mg daily are generally well tolerated without a significantly increased risk of side effects. One does need to be closely monitored for blood pressure, weight changes, heart rate and excess hair growth on the body. For women, low dose minoxidil can be combined with spironolactone. In men low dose minoxidil can be combined with lower doses of finasteride.

 

Conclusion

Oral minoxidil is increasingly popular as men and women look for safer options for treating hair loss. Side effects of oral minoxidil must be respected and use of the medication must only be done in conjunction with a physician experienced in the use of oral minoxidil. Close monitoring is essential.

Finasteride for Women

Can Finasteride (Propecia) be used in women?

Finasteride is not FDA approved for women. That does not mean we never use finasteride in women - in fact, I sometimes to prescribe this medication. The fact that it is not FDA approved just alerts us that there are important reasons to consider as to why it is not approved.  

 

Does FDA approval matter?

FDA approval does matter. It directs us to consider that considerable review has been done to evaluate that safety of a given medication. However, readers must keep in mind that 99 % of the medications that a hair loss doctor uses are not FDA approved!! When a medication that is not FDA approved is used, we say that this is a so called 'off label' use. 

When I use minoxidil for alopecia areata, I'm using the medication in an 'off label' manner. Minoxidil is not FDA approved for alopecia but but sure can help many patients.  In fact - there is not a single medication on the planet that is FDA approved for alopecia areata.

When I use Plaquenil for lichen planopilaris, I'm using the medication in an 'off label' manner. Plaquenil is not FDA approved for lichen planopilaris but but sure can help many patients.  In fact - there is not a single medication on the planet that is FDA approved for lichen planopilaris.

When I use clindamycin for folliculitis decalvans, I'm using the medication in an 'off label' manner. Clindamycin is not FDA approved for folliculitis decalvans but but sure can help many patients.   In fact - there is not a single medication on the planet that is FDA approved for folliculitis decalvans.

When I use minoxidil and steroid injections for traction alopecia, I'm using these medications in an 'off label' manner. Minoxidil and steroid injections are not FDA approved for traction alopecia but but sure can help many patients. In fact - there is not a single medication on the planet that is FDA approved for traction alopecia.

Finasteride for Women - It's off label.

When I use finasteride for androgenetic alopecia in women, I'm using these medications in an 'off label' manner. Finasteride is not FDA approved for androgenetic alopecia but but sure can help many patients. 

Some medications are appropriate for a given patient others are not. One really needs to sit down with a physician and discuss. Even Rogaine is not advised for some women (heart conditions, heart rhythm problems, pregnancy, other hormone abnormalities such as pheochromocytoma). 

Some physicians never prescribe finasteride to women regardless of age. Some physicians only prescribe to post menopausal women. Some physicians will prescribe to premenopausal with appropriate counceling on the risks during pregnancy and prescription of appropriate birth control.  

Finasteride must never be used by women who may become pregnant. Women with strong histories of estrogen dependent cancers (breast, ovarian, gynaecological cancers) should also review use with their doctors. This includes breast, ovarian and other gynecological cancers. Women with depression should also have a thorough discussion as to whether this drug is appropriate for them of not.

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.

The Pull Test

What really is normal?

The Hair Pull Test: 3 is abnormal

Telogen effluvium is a form of hair loss where patients experience increased daily hair shedding. Instead of losing 40 or 50 hairs per day, patients with “TE” lose 80 to up to 600 hairs per day. A ‘pull test’ has traditionally been one of the methods that hair specialists are taught to perform when examining the scalp. To perform the test, 60 hairs are lightly grasped between the thumb and index finger and gently pulled upwards. Removal of more than 10 % of the hairs in the bundle (i.e more than 6 hairs) has been traditionally viewed as a positive pull test. 

McDonald and colleagues from Ottawa, Canada performed a study revisiting this issues of what exactly constitutes a normal pull test and what limits should be set for abnormal. They studied 181 otherwise healthy individuals. The authors showed that for the vast majority of individuals, a pull test of 60 hairs extracts 0,1 or 2 hairs (97 % or more have 2 or less). The average was 0.44 hairs indicating that many individuals have no hairs removed. Interestingly, the date the patient last washed their hair, did not influence the pull test result nor did the frequency of brushing the hair. 
This is one of my favourite studies of the year. It is simple and elegant and answers a lot important questions. I have long abandoned the “6 hair rule” for the pull test, and frequently have told the dermatology residents and trainees that work with me that even a few hairs coming out is abnormal. I’m grateful for this well conducted study and it has renewed my interest in the pull test.
 

Reference

McDonald et al. Hair pull test: Evidence-based update and revision of guidelines. Journal of the American Academy of Dermatology 2017; 76: 472

Minoxidil and the cat

Minoxidil is Toxic to Cats

Minoxidil is FDA approved for treating male and female androgenetic alopecia. It has been studied in humans for over 35 years. 
However, it is not well known among users of minoxidil that minoxidil may have a unique toxicity to cats. That is not to say that cat owners can not use minoxidil - but important lessons come from a 2004 study in the veterinary literature.

DeClementini and colleagues reported 2 cats who died after their owners applied minoxidil to areas of hair loss on the cat. The first cat was a 3 year old cat had just one drop applied to an area of hair loss . That cat had trouble breathing, high heart rate, water in the lungs (pulmonary edema and pleural effusion) and showed increased liver enzymes. The cat died 15 hours later.

The second cat was a 7 year old cat and the owners applied an unknown amount of 5 % minoxidil solution to an area of hair loss and left the home for three days. Upon returning to the home, the owners found the cat also having difficulty breathing. Veterinarians confirmed pulmonary edema and pleural effusions. That cat died 10 hours later despite supportive care.

These are important lessons. Minoxidil must not be applied to cats and cats should not have the opportunity to play with the hair of owners who have applied minoxidil for their own hair loss. Most of what is needed though is just common sense. It is possibly to have a cat and have minoxidil users in the home.

Minoxidil may be uniquely toxic to cats and less toxic to other pets like dogs. A 1997 study involved the application of 3 % minoxidil to hairless puppies (descendants of Mexican hairless dogs) for 31 days. Side effects were not observed. However, minoxidil should never be applied to any animal. 

Reference

Suspected toxicosis after topical administration of minoxidil in 2 cats. Journal of Veterinary Emergency and Critical Care 2004; 14:287-292

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.