Rosemary Essential Oil: Rosmarinus Officinalis

Rosmarinus Officinalis

Several essential oils have received attention with regard to a potential role in hair growth.

In 2015, Panahi and colleagues published a randomized study of 100 patients - 50 who received 2 % minoxidil and 50 who received rosemary essential oil for a period of 6 months. This study showed that rosemary was fairly similar in effectiveness to 2 % minoxidil. 

Conclusion

This small study was encouraging and supports a potential role for rosemary essential oils in androgenetic alopecia. 

Reference

Panahi et al. Skinmed 2015.

Essential Oils & Hair Loss: A Closer Look at Thyme

A Closer Look at Thyme

Several essential oils have received attention with regard to a potential role in hair growth. These include rosemary, thyme, lavender and cedarwood oil among others.

To date there has been little independent and published studies of the essential oil thyme. It is frequently combined with other essential oils in a mixture and the mixture is then studied together. Treatment with such a mixture is frequently referred to as “aromatherapy.” To date there are few well conducted studies of aromatherapy or essential oils in treating hair loss. However, a particularly well conducted one is a study from 1998 by Dr Hay and colleagues.

The study involved a randomized controlled study of 84 patients with the autoimmune condition alopecia areara. 43 received treatment with aromatherapy consisting of rosemary, thyme, lavendar and cedarwood oil in a carrier oil and 41 received the placebo (carrier oil alone). Interestingly, nineteen (44%) of 43 patients in the active “aromatherapy” group showed improvement in their alopecia areata compared with 6 (15%) of 41 patients in the control group.

To date, this remains one of the best studies looking at the role of essential oils in treating alopecia areata. Whether one particular component played the key role or whether all the essential oils together had a benefit is not known.

Essential oils are relatively safe although may be irritating for some. Surprisingly, the study has not been repeated in the published medical literature since it was introduced to the world 20 years ago. More studies of the role of essential oils in hair loss is needed.
 

Reference

Hay IC et al. Randomized trial of aromatherapy. Successful treatment for alopecia areata.
Randomized controlled trial. Arch Dermatol. 1998.

Localized and Diffuse Forms of Hair Tangling

Localized and Diffuse Forms of Matting

Hair matting can either be diffuse or localized and either acute or chronic. Bogaty and Dunlap first used the term “matting of hair” in 1970 and compared the condition with “felting.”

Acute hair felting is a very rare disorder of scalp hair. Affected patients notice that their hair becomes twisted and tangled and essentially becomes a hard stony mass not too different from a 'bird's nest.' The sudden matting of hair has been reported after several types of exposures, including the use of various chemical and herbal shampoos in a vigorous manner.   Cationic surfactants may have a particular role. In 2017, Maduri reported the sudden (acute) matting of hair after use of coconut oil and castor oil following washing. The patient's long hair coupled with the high viscosity of the castor oil was believed to contribute to the sudden felting of hair.

In contrast to diffuse forms of matting, localized matting and tangling of hair also has many causes. "Plica polonica" is a localized area of hair matting that can occur either from the simple neglecting of hair or from underlying psychiatric illness. Other risk factors are summarized below.

The matting of hair has been described for over 4000 years and the Vedic scriptures of India document the wearing of dreadlocks.  More recently in history, a similar dreadlock-type appears of hair was well known in Poland in the eighteenth century. The hairstyle itself became known as ‘plica neuropathica’ or ‘dread locks’.  In 1884, Le Page first coined the term ‘plica polonica’  when he described a 17-year-old girl with a sudden onset of tangled scalp hair. He actually attributed this strange phenomenon to “nerve force” while the parents of the child considered it a ”visitation from God”.  In the 19th century, the wearing of matted thick moist hair was rather common and very much in vogue.  Due to lack of hair care, the hair became malodorous and the scalp became inflamed and often heavily infested with lice.  The Polish custom of wearing tight fur caps did not help the issue nor did the superstitious belief that a lice -infested scalp was healthy. Plica Polonica was common in Poland. To date, the term continues to be used. 

Risk factors for Matting (Plica Polonica)

To date, Plica polonica are frequently associated with neglected personal hygiene. In addition to underlying psychiatric illness, a variety of risk factors have also been suggested including chemotherapy, seborrehec dermatitis, psoriasis and use of immunosuppressants like azathioprine.

The terms Plica Neuropatica and Plica Polonica are frequently used interchangeably. However, some reserve the term plica neuropathica for situations where there is particular underlying psychological issues. 

Treatment of Hair Matting

Regardless of whether matting is localized or diffuse, there is only one consistently helpful treatment - and that is to cut off the hair.  If matting is in the earliest of stages, a knitting needle together with use of olive oil has been described as helpful. However, usually cutting the hair is the only good option.

Plica neuropathica (polonica) is a rare acquired disorder of the hair shafts in which groups of hair are matted together forming a malodorous, encrusted and sticky, moist mass.[1] First records of dreadlocks go back to 2500 BC with the dreadlocked Hindu deity Shiva and his followers reported in the Vedic scriptures of India as “JaTaa”, meaning twisted locks of hair. The term is probably derived from the Dravidian word “CaTai”, which means ‘to twist or to wrap’. Later, it was also described in Poland in the eighteenth century.[2] It is also known as ‘plica neuropathica’[3] or ‘dread locks’.[2] Le Page coined the term ‘plica polonica’ in 1884 when he described a 17-year-old girl with a sudden onset of tangled scalp hair.[1] Le Page attributed this strange phenomenon to “nerve force” while the parents of the child considered it a ”visitation from God”.[4] This phenomenon was historically linked to a common condition of scalp hair in Poland during the 19thcentury. It was characterized by fitting malodorous inflamed scalp usually heavily infested with lice.[5] The hair was matted into a thick, moist mass, due to deficit hair care. The Polish custom of wearing tight fur caps and the superstitious belief that a lousy scalp was healthy contributed to the frequency of plica polonica in Poland.

Some of the risk factors reported for this condition are psychological disturbances, secondary scalp infection or infestation of scalp or use of shampoos containing cationic detergents.[6] There are sporadic reports of this condition in various dermatology journals from India[1,7–10] and abroad.[6,11] Surprisingly despite the role of psychological disturbance as risk factors for this condition only few cases are reported in psychiatry journals.[1] This is perhaps the second case report from psychiatric point of view.

Reference

Maduri VR, et al. "Castor Oil" - The Culprit of Acute Hair Felting. Int J Trichology. 2017 Jul-Sep.

Suresh Kumar PN and Rammohan V.  Plica neuropathica (polonica) in schizophrenia Indian J Psychiatry. 2012 Jul-Sep; 54(3): 288–289. 

 

Steroid Injections: A Closer Look at Triamcinolone Acetonide (Kenalog)

A Closer Look at Triamcinolone Acetonide

Steroid injections are commonly used in dermatology and essential treatments offered by the hair specialist. Triamcinolone acetonide (TAC) remains one of the most common steroids used for treatment of alopecia areata, traction alopecia as well as scarring alopecias. Doses of TAC range from 2.5 to 40 mg per mL although doses of 2.5 mg/mL to 10 mg/mL are by far the most common. I frequently use 2.5, 3.3 and 5 mg/mL in my practice and limit steroids to no more than 20 mg total dose every 4-6 weeks.

Triamcinolone acetonide is a “suspension” meaning that it does not actually dissolve. In the photo, particles of TAC can be seen on the bottom of the syringe rather than dissolved in the solution. TAC particles range in size from 0.5 to 1000 micrometers. About 1/3 of particles are between 0 and 10 um, another 1/3 are between 10-20 um and the remaining 1/3 are greater than 20 um. Rarely particles can be as large as 1000 um but this occurs in less than 1% of all particles.

When preparing TAC solutions, one should ensure the steroid is well mixed before injection. If there is any difficulty injecting through a 30 G needle one should stop and ensure the solution is mixed well.

Reference

Benzon HT et al. Comparison of the particle sizes of different steroids and the effect of dilution: a review of the relative neurotoxicities of the steroids.
Benzon HT, et al. Anesthesiology. 2007.
 

Uterine Fibroids and CCCA

Uterine Fibroids and CCCA

I was interviewed for the March edition of The Chronical of Skin & Allergy about a new study showing that women with central centrifugal cicatricial alopecia (CCCA) are at increased risk of developing benign uterine tumors known as fibroids (uterine leiomyomas). The study was published in JAMA Dermatology. CCCA is one of the cicatricial (scarring) alopecias 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 fundamental to the underlying mechanisms that cause these two diseases.

The study researchers reviewed data from nearly 500,000 black women in the general population and examined the incidence of fibroids in women with CCCA and those without CCCA. In the general population,  3.3 % of women had fibroids. However, among women with CCCA 13.9 % were found to have fibroids.

Taken together, this works out to a five fold increased risk of fibroids in women with CCCA.
 

COCLUSION
 

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 2018; 154; 213-214.
 

Stopping Birth Control: Will My Hair Come Back?

Will My Hair Come Back?

Stopping birth control can be associated with hair shedding. For many individuals the shedding occurs with 4-8 weeks after stopping birth control and eventually shedding returns to normal within 9-12 months and hair density returns to normal as well.

One of the most misunderstood topics when it comes to hair loss and birth control, is the array of considerations when hair density and shedding do not return to normal as one would anticipate. 
Situation “A” and “B” are common when birth control is stopped. In “A”, there is an initial shed followed by a cessation of shedding at month 7-10 and hair density returns to normal by month 12. In situation “B” there is no real perceived increased in shedding at all and the patient notices no real change in her hair at all. These situations typically occur in a patient with no underlying androgenetic alopecia and no strong predisposition to it as well.

Situation “C” and “D” are different. In situation “C” the patient starts out with good hair density but notices at 9-12 month later that her hair density has not returned and is a bit thinner. In situation “D” the patient notices the hair density is quite a bit thinner. In these two situations, the patient often has an underlying predisposition to androgenetic hair loss. In “C” there may have not been any degree of androgenetic hair loss to begin with but the shedding has accelerated the arrival of the patient’s genetic hair loss. In situation “D” there was some genetic hair loss to begin with but it was so mild it was unnoticed by the patient. The birth control pill in this situation was often helping as a treatment to stop the balding process even though the patient was not using it for this reason. By stopping the birth control pill, a helpful treatment actually gets stopped without the patient knowing and the patient’s hair loss is accelerated to a greater degree than in “C”

Patients and physicians should be aware of the array of different possibilities that exist when birth control is stopped.

Why is my scarring alopecia flaring again?

Consideration when scarring alopecias become worse

Scarring alopecias are hair loss conditions which are associated with both inflammation and scarring. A variety of treatments can be used to reduce inflammation and help halt the disease. The precise choice of treatment depends on the exact diagnosis. Generally speaking, treatments include topical steroids, steroid injections, and systemic immunosuppressive medications. For some scarring alopecias, antibiotics are also used. 

Scarring alopecias may respond well to treatment are the patient will experience a halting of their hair loss and symptoms (if symptoms are present).

In some cases, relatively “inactive” scarring alopecias may become “active” again and cause further symptoms and hair loss. We call such unexpected reactivation a “flare.”

Reasons for a Flare of Scarring Alopecia

Here we review considerations that must be given for any patient with scarring alopecia who experiences a flare.  When I work with doctors or give lectures, I frequently use the teaching tool or mnemonic "I'M WORSE" to review causes of a flare. Each letters stands for considerations that must be evaluated.

I = Injury to the Scalp

Scalp injury can worsen many scarring alopecias and trigger a 'flare' in patients who had otherwise quiet disease. There can be many potential sources of such injury including a direct blow (i.e. something strikes the scalp), a massive sunburn or scalp surgery. In the latter category, a hair transplant is an example of a surgical procedure that can potentially trigger a flare in a patient with a scarring alopecia. For this reason, a hair transplant is never an option for patients with scarring alopecia that is not completed quiet.

M = Medications are making it Worse

In some patients who are experiencing “flares” of their scarring alopecia, it is sometimes the medication itself that is causing things to worsen. Occasionally patients prescribed steroids injections, steroid shampoos, hydroxychloroquine, methotrexate, minoxidil, or retinoids find their hair loss has worsened on account of a specific drug or topical product. 

This is a challenging category to evaluate but does need careful consideration.  Occasionally for example a patient with relatively stable disease who adds minoxidil in hopes to stimulate more hair growth finds that minoxidil triggers worsening shedding and dryness that seems to flare things overall. Similarly, there are some patients who find that steroid injections similarly trigger a flare.

W = Wrong Medication or Dose

It is not common for medication dosing errors to be the main reason for a flare. Nevertheless it needs to be considered. A patient who changes their dose after getting a prescription refill could find that this change triggers a flare. For topical medications that are compounded, one must consider that the method use to compound the drug may changed.

O = Other Condition Developed or Worsened

For a scarring alopecia may be perceived to have worsened, one must keep in mind that it could actually be a completely separate medical issue that has triggered the worsening rather than the scarring alopecia itself. A example would be the development of iron deficiency in a patient with lichen planopilaris that triggered a worsening of hair loss. The key treatment in this scenario is to treat the iron deficiency rather than more aggressively treat the scarring alopecia. Similarly, in a patient with stable LPP who develops hyperthyroidism (and hair loss from the thyroid disease) the perception to the patient is likely to be that their scarring alopecia is worse. In reality, their scarring alopecia may be stable but they have a second condition that has developed and it too is causing hair loss. 

Seborrheic dermatitis and S. aureus related infections can rarely make scarring alopecia worse as well. Seborrheic dermatitis is very common in scarring alopecia so one should always consider this entity.

R = Rejection of Prescribed Medications (Medication Compliance/Adherence)

For a patient whose scarring alopecia is flaring, one needs to consider the possibility that the patient is not using the medication in the manner that was intended. An example could be a patient who was supposed to use doxycycline for 6 months but stopped it after two months. In such situations it is important to inquire about the exact reason the medication was stopped prematurely. In some cases, it may due to side effects that prompted stopping the medication or other factors such as cost. We know that a very large proportion of patients do not take their medications in the manner prescribed. So a physician should never assume adherence to the treatment protocol

S= Stressful life events

For patients with scarring alopecia, stress is a potential trigger of a “flare” of scarring alopecia.  Many patients with scarring alopecias such as lichen planopilaris, pseudopelade, frontal fibrosing alopecia, folliculitis decalvans notice that the scalp can become considerably more itchy around times of intense stress. This may be stress related to work or family, personal relationships, finances or other issues. All have the potential to trigger a flare.

E= Enigma (NO clear reason)

The last category is the most common. Most of the time, the exact cause of a patient's “flare” is not known. The disease just wants to get worse. We see this sort of phenomenon in nearly every immune based disease known to humans. Despite all factors being reviewed, it just does not seem clear why a patient who was stable for so many months is now experiencing worsening of their disease (i.e. a flare). There is much about the immune system in the present day and age that we simply do not understand. The immune system can become active for reasons we do not understand. In this situation, additional treatment is needed to halt inflammation. 

Compounding of Follicles

Compounding of Follicles

Compound follicles are hair follicle units that have more than 6 hairs coming out of a single pore. The tendency to form compound hair follicles is sometimes a feature of so called neutrophil mediated scarring alopecias. Folliculitis decalvans (shown here) frequently shows compounding of hairs. 

Trichotillomania in Children: More than hair loss

Hair Loss In TTM

Trichotillomania (TTM) is an impulse control disorder that is associated with the pulling of one’s own hair. Usually the scalp hair is pulled but eyebrows, eyelashes and body hair can also be pulled or even represent the only area of pulling.

In children, other comorbidities need to be assessed. Nail biting, eating of one’s hair (trichophagia) and a variety of psychiatric and emotional issues may be present. These include anxiety, depression and obsessive compulsive disorders. Attention deficit hyperactivity disorder (ADHD) may also be present.

A recent study examined the clinical findings in 38 children with trichotillomania. 21 were girls and 17 boys. The activities during which the participants state that they mostly pull out hairs were the following: while doing homework and learning, working on PC, in the toilet, and watching TV. Nail biting was seen in more than a half of children. In nearly 60 % of children, one or more comorbid disorder was identified, of which ADHD (16 %) and tics (13%) were most common. Eating of hair (trichophagia) was found in 5 % of children. More than two thirds of children isolate themselves during hair pulling and half of them try to hide consequences.
 

Conclusion

The proper evaluation of TTM requires a detailed evaluation of a variety of co-occurring factors. Focus only on the hair without attention to other issues does little to help many children with TTM.

Reference

Klobučar A, et al. Clinical Characteristics and Comorbidity of Pediatric Trichotillomania: the Study of 38 Cases in Croatia. Psychiatr Danub. 2018.
 

Hair loss in Kidney Transplant Patients

Hair loss is among the top distressing symptoms

Nearly 30,000 kidney transplants are performed every year in North America. Patients receiving kidney transplants require lifelong immunosuppressive medications to help them avoid graft rejection and loss of the transplanted kidney.  The symptoms that patients experience after their transplant have the potential to affect quality of life. These include excess hair loss on the scalp, hair growth on the face (hirsutism), gingival hyperplasia, weight gain, cushingoid facies, hand tremors, and skin disorders. These are consistently among the most bothersome to patients and may have serious psychosocial implications.

Several studies have examined factors affecting quality of life in patients receiving kidney transplants. Hair loss In a recent study of 231 kidney transplant patients, high blood pressure, tiredness and hair loss were the three most distressing symptoms in both men and women. For women, hair loss was the most distressing symptoms.  A 2010 study in adolescents showed that hair loss was among the most distressing of the symptoms in adolescent kidney transplant patients.  

Conclusion

Hair loss can occur for a variety of reasons in patients with organ transplants. This study, as well as others, indicate that patients experiencing side effects are most likely to be non adherent to various aspects of their immunosuppressive treatment recommendations. This can result in more serious complications, such as acute rejection, graft loss, rehospitalization, and even mortality. Strategies for minimizing side effects of immunosuppressive therapy and improving medication adherence are key to the long-term management of kidney transplant recipients. It is important to properly diagnose and treat hair loss in organ transplant patients to limit the effects on quality of life. 

Reference

Teng S, et al. Symptom Experience Associated With Immunosuppressive Medications in Chinese Kidney Transplant Recipients.  J Nurs Scholarsh. 2015.

Dobbels F, et al. Health-related quality of life, treatment adherence, symptom experience and depression in adolescent renal transplant patients. Pediatr Transplant. 2010.

Scalp Psoriasis: Many Variations

Many Variations

Dermoscopy of Scalp psoriasis. There are many variations in how scalp psoriasis appear. It can be red to pink and scaly white to scaly silver. Psoriasis needs to be differentiated from a range of inflammatory conditions such as seborrheic dermatitis, dandruff, scarring alopecia and various infectious causes.

Turmeric for Scalp Psoriasis: New Research Highlights Potential Role

New Research Highlights Potential Role

Psoriasis is an autoimmune condition that affects 3-5 % of the world. For many patients, the scalp is the very first site of involvement. Current treatments include topical steroids, vitamin D analogues, calcineurin inhibitors and a variety of biologic agents.

Turmeric (Curcuma longa L.), a spice commonly used throughout many parts of the world. Turmeric has been shown to exhibit anti-inflammatory, antioxidant, antimicrobial, and even anti-cancer properties.

T lymphocytes are a type of white blood cell that have a key role in psoriasis. Interestingly, Turmeric has been reported to exhibit inhibitory activity on potassium channels
A new study examined the effects of turmeric compared to placebo in 40 patients with mild-to-moderate scalp psoriasis. The study group received turmeric tonic twice daily for 9 weeks, whereas the other group received a placebo applied in the same manner. Patients were evaluated at baseline, as well as weeks 3, 6, and 9.

Compared to the placebo group, topical turmeric tonic significantly reduced the redness, scaling and induration of lesions (PASI score), and also improved the patients' quality of life.

This is interesting and adds to the body of research supporting a role for turmeric in psoriasis.
 

Reference

Bahraini P, et al. Turmeric tonic as a treatment in scalp psoriasis: A randomized placebo-control clinical trial. J Cosmet Dermatol. 2018.

Scalp Micropigmentation (SMP): Is it all the same?

Is it all the same?

Scalp micropigmentation (SMP) is a cosmetic technique whereby small dots are tattooed onto the surface of the scalp to mimic hairs cut in cross section. 
Some SMP results looks great and some ... less so. Some SMP results fade quickly and others look great for longer periods of time. A variety of factors affect SMP outcome and the overall results including 1) type of needles used by the specialist 2) angle of needle against the scalp, 3) depth of needle into the scalp 4) total duration of the needle contact in scalp, 5) speed of the rotor, 6) resistance of scalp, 7) color of pigment, 8) viscosity of dye, 9) needle number, 10) needle thickness, and dot placement pattern.

SMP is not all the same and one specialist can produce very different results from another.
 

Reference

Dhurat RS, et al. Standardization of SMP Procedure and Its Impact On Outcome. J Cutan Aesthet Surg. 2017 Jul-Sep.
 

Alopecia Areata and Vitamin D: Levels Lower in AA

Levels lower in Alopecia Areata

Accumulating studies have suggested that vitamin D levels are lower in patients with the autoimmune condition alopecia areata. Now, a large review of 14 studies including a total of 1,255 individuals with alopecia areata and 784 non-AA control were analyzed. Data showed clearly that mean serum 25-hydroxyvitamin D levels were significantly lower in individuals with AA. Although it had been suggested in previous studies that patients with more extensive hair loss were more likely to have the lowest vitamin D levels, it was difficult in the to find a clear correlation in this review.
 

Conclusion

Testing for vitamin D is an important consideration for all patients with alopecia areata. Supplementation is appropriate when levels are suboptimal.
 

Reference

Increased prevalence of vitamin D deficiency in patients with alopecia areata: A systematic review and meta-analysis.
Lee S, et al. J Eur Acad Dermatol Venereol. 2018.
 

Smoking and Toxic Metals: Accumulation in Hair Follicles

Accumulation in Hair Follicles

Smoking is a source of exposure to toxic heavy metals - and such exposures have many health implications to many cell types including hair follicles.

Metals have both an essential role in the body but can also be toxic. For example, iton plays a key role in many metabolic functions. Cobalt is the key metal in vitamin B12 molecules. Without certain metals, humans can not survive.

Toxic metals are metals that have the ability to accumulate in the body and affect a variety of normal functions. A variety of metals are studied with regard to effects on the human body. These include mercury, cadmium, lead and silver.

The effect of smoking on how heavy metals accumulate in the body has been studied for many years. Most studies focus on measuring the levels of these toxic metals in hair follicles. Generally speaking the level of these metals in hair follicles provides a surrogate measure of how the metal might be accumulating inside the body. One should not forget that these results also provide us with valuable information about how hair follicles themselves are affected by smoking.

A recent study by Zhu an colleagues in adults showed a positive correlation between nicotine and conitine (a metabolite of nicotine) and levels of mercury, cadmium, lead and silver in hair.

A recent study in 822 children by Li and colleagues showed that second hand smoke was associated with increase levels of cadmium and lead in their hair which correlates with the accumulation of these metals in the body.
 

Conclusion

There is little doubt that smoking is associated with an accumulation of certain toxic metals in both hair follicles as well as the body.
 

Reference

Secondhand smoke is associated with heavy metal concentrations in children. Li L, et al. Eur J Pediatr. 2018.

Association Between Chronic Exposure to Tobacco Smoke and Accumulation of Toxic Metals in Hair Among Pregnant Women.
Zhu Y, et al. Biol Trace Elem Res. 2018.

Shampoo Allergy

Reduced Allergen Shampoos

With this post, we complete our week long look at shampoo ingredient allergies. Of the 10-30 ingredients that are present in modern shampoos, it's possible to be irritated or allergic to one of the components.  Diagnosing a true shampoo allergy is not easy as patients don't necessarily present to clinic with a red scalp immediately after using a shampoo. Rather patients with sensitivities to an ingredient in shampoos may present with dermatitis of the eyelids, neck, ears, face, back ... and sometimes (but not always!) the scalp.

This week we have focused on the top five allergens in shampoos. Of 179 shampoos analyzed in a study by Zirwas and colleagues, 170 had fragrance, making it the most common allergy. CAPB was second palace allergen (53 %), MCI/CI was third place (51. 4 %), formaledye releasers were fourth (48 %) and propylene glycol was fifth (38 %). Vitamin E and parabens are sixth and seventh.

About 1-4 % of the population has fragrance allergies and the incidence of fragrance allergy is increasing.  Given the large proportion of shampoos that have fragrance it can be quite difficult to find a shampoo that does not have fragrance.

Not everyone needs to change their shampoos. The vast majority of people do not have problems with common shampoos. However, if there is any suspicion that an ingredient in a shampoos might be irritating or causing allergy, a switch to an low irritant - low allergen shampoo might be considered. Consultation with a dermatologist who specializes in contact allergy would also be appropriate in many situations.

Interested individuals may wish to review our website for our handouts on shampoos that don't contain fragrance and shampoos that are devoid of ingredients like CAPB, MCI/MI, formaldehyde releasers and propylene glycol. This information is available at www.donovanmedical.com/shampoos.

With that we end our week long look at potential allergens and irritants in shampoos!

Perifollicular erythema in FFA

Redness around hair follicles: Perifollicular eythema

Frontal fibrosing alopecia or "FFA" is a scarring alopecia (scarring hair loss condition) that most commonly develops in women 45-65. It causes permanent hair loss. The cause is not know although a mix of immune based mechanisms and hormonal mechanics are likely to contribute. The condition can be asymptomatic - and many patients have no itching, burning or pain.

FFA Disease Activity: How do we know it's' active or not

How do we know whether a given patient's FFA is active? Undoubtedly, the absolute best way is with a photo. If a patient's photo changes over a period of monitoring (6 months or 12 months) the FFA is active by definition.

However, photographs don't capture subtle changes in activity. To accomplish this examination by "dermoscopy" is helpful. In this photo, slight redness around the hairs can be seen. We call this "perifollicular" erythema. (note peri means "around"). In 2013, Spanish researchers Toledo- Pastrana and colleagues published an article in the International Journal of Trichology examining dematoscopic features of FFA. Of 79 patients examined, 66 % showed perifollicular erythema. In patients with active disease, perifollicular erythema was present in 95 % of patients.

Conclusion

Perifollicular erythema is an important sign to look for in FFA. It indicates disease activity and a high likelihood of further hair loss in the patient.

Reference

Toledo- Pastrana et al. Perifollicular erythema as a trichoscopy sign of progression in frontal fibrosing alopecia. Int J Trichoscopy 2013; 5: 151-3.

Dissecting Cellulitis: Early Features

Early Stages of DSC

Dissecting Cellulitis (DSC) is a relatively rare scarring alopecia. Men are affected much more than women and affected patients are frequently young males in their 20s.

The condition beings with discharge of pus and sometimes blood from the scalp. It can also be quite itchy. The beard, underarm (axilla) and groin can be affected with similar discharge. A key feature of diagnosis is the presence of sinus tracts or "tunnels" underneath the skin. Small thin vellus hairs are also seen in the affect area.

The primary treatment of DSC is isotretinoin although antibiotics, zinc, dapsone, colchicine, and TNF inhibitors can be used.

Methotrexate for Hair Loss:

A closer look at MTX for Autoimmune Hair Loss

Methotrexate (MTX) is an immunosuppressive medication that can both be used to treat some forms of hair loss as well as cause hair loss. Methotrexate is a medication the has been used for over 60 years. It was initially developed as a cancer treatment (and continues to be used in oncology) but is also used to treat a variety of autoimmune conditions including lupus, rheumatoid arthritis, psoriasis and vasculitis.

When treating hair loss, MTX has a role in treating both scarring and non scarring conditions. Evidence supports a role of weekly oral methotrexate in treatment of lichen planopilaris, frontal fibrosing alopecia, discoid lupus and alopecia areata. In the treatment of alopecia areata, methotrexate has been used in both children and adults, often in combination with systemic corticosteroids (like dexamethasone and prednisone).

Hair Loss as a side effect of MTX

In addition to its use in treating hair loss, methotrexate can sometimes also cause hair loss. About 5-10 % of users experience hair loss and the type of hair loss includes both increased hair breakage as well as increased shedding.  Hair color changes can also occur.

MTX side effects

Anyone considering MTX needs to speak to their physician about the risks and benefits. Side effects from methotrexate include reduced blood counts, liver damage, ulcers, cough, lung irritation (rarely fibrosis or scarring in the lung), nausea and abdominal pain, fatigue, kidney damage and memory problems. Methotrexate can not be used by women trying to become pregnant or who are pregnant. 

Because methotrexate interferes with how folic acid is metabolized, the drug needs to be taken with folic acid supplements. Generally methotrexate is given only one day per week and folic acid is given the other 6 days of the week (on the days methotrexate is not taken).

Download MTX Handout for Patients. 

Shampoo Allergy: Top Allergens

#4 Formaldehyde Releasers

Formaldehyde-releasers (FDRs) are the fourth most common allergen in shampoos. Studies by Zirwas and colleagues showed that 48.6 % of shampoos contained FDRs. 
FDRs are used as antimicrobial and antifungal preservatives in a wide variety of cosmetics and hair care products. They are called “releasers” because these chemicals slowly release the chemical formaldehyde as they break down and such release can cause irritation or allergic contact dermatitis.

In the right circumstances these FDRs can release formaldehyde in concentrations exceeding 200 ppm.

There are well over 40 FDRs but the 7 most common are: 
DMDM hydantoin
Imidazolidinyl urea
Diazolidinyl urea
Quaternium-15
Bronopol
5-Bromo-5-nitro-1,3-dioxane
Sodium hydroxymethylglycinate
 

Reference

de Groot A, et al. Contact Dermatitis. 2010.

Zirwas et al. Dermatitis 2009.