On the Use of Scalp Magnification by the Public and Untrained

Warnings on the Use of Scalp Magnification

Magnified Scalp Examination

Looking at the scalp up close is interesting and fascinating. Nowadays, for relatively inexpensive prices (under $50 USD), anyone can purchase a handheld microscope to look at the scalp up close. Some clinics have fancier devices.

For simplicity, I’m just going to refer to the various forms of scalp examination using some type of magnified lens as Magnified Scalp Examination (MSE). For those who wish to be precise, there is some difference between a magnifying glass, a magnified device and a polarizing dermatoscope. But for the sake of discussion, I will refer to all as MSE.

The Misuse of MSE by Professionals

Let me be the first to say that MSE is frequently misused both knowingly and unknowingly. It’s a topic not talked about often, (and in fact I’m really not sure it’s ever been talked about).  There are certainly a proportion of salons, clinics, offices, establishments that use MSE with a client in a somewhat deceptive manner. Generally the client or patient is examined with the MSE device and told and even shown that follicles that are “plugged” or follicles that are “dying.”  The purpose of course of giving this assessment is often to encourage clients to do something on an urgent or semi-urgent basis to “unplug” hairs or prevent more hairs from “dying.” Frankly, it usually means encouraging the patient to buy something that the establishment offers for sale. Sadly, all too often what is seen is not really a plugged follicle and the concept of hair death is exaggerated.

Worse yet,  many clinics not only sell patients a variety of treatments but then use MSE at various follow up appointments to convince a patient that they see “new hairs sprouting” and may even use a MSE device to show the patient or client the new hairs. (In case readers did not know, the human scalp is ALWAYS full of some new hair growth and one can always find a new hair or two).

Training in MSE

I’m not against professionals using various forms of MSE, but sadly many have very limited training and really have limited understanding of the hundreds and hundreds of patterns and findings that can be seen. I’m sorry to say that MSE frequently becomes simply a marketing tool.

But I would like to add that patients like it when their professionals use MSE. Patients even expect it and in many cases state how pleased they are that “someone took the time to really look up close.” The quality of the advice is often overlooked. But the entire show is too often deceiving and the script is too often the same. (“look at your plugged pores and dying hairs”).

MSE is appropriate of course in many situations and when used appropriately can be a great teaching tool for patients. Patients with genetic hair loss looking at a camera image can appreciate that their follicles are getting thinner and thinner. They may be redness and inflammation.  When two areas of the scalp are compared 'before' and 'after' it can become very clear that an improvement or worsening has occurred. This is how MSE is best used. 

The Misuse of MSE by the Public

There is a huge increase in the number of people in the general public buying various forms of MSE equipment on the internet and using it in their homes home for the purpose of self-diagnosis. There’s nothing wrong with this provided it is only used for general interest. Using MSE for self diagnosis has its problems.

See previous article: The Self Diagnosis of Hair Loss: A DIY Project to Avoid.

Too often, patients who buy MSE devices for personal use use these devices in a manner that only increases their anxiety and confusion. There is nothing wrong with being inquisitive and taking charge of one’s own health. However, when it comes at the expense of one’s emotional health, it’s dangerous.

Ten years ago, I don’t think there was even one patient who ever emailed or brought in photos of the scalp they obtained with MSE. Now it happens at  least weekly. Patients see things “up close” with their MSE devices and convince themselves they have a particular condition when they do not. 

The examples are numerous. The patient who sees a single skinny hair on the scalp and convinces herself she has female balding (when in fact it’s a normal finding). Or how about the patient who sees scale around a hair and convinces himself he has scarring alopecia (when in fact the finding represents simple dandruff). Consider too the patient who sees a strange hair and convinces herself she has alopecia areata (when in fact the hair has no significance in this case). Today I received further emails from patients who had performed MSE at home only to encounter confusion. 

It’s okay to be curious. But what often happens in these cases is that the patient’s emotional health is jeopardized by their use of MSE. One can not underestimate the stress that patients feel when they think they have a particular condition.

Conclusion

MSE is wonderful. Let me be the first to say that without my dermatoscope, I would not be able to practice hair dermatology in the same way.  Patients also love MSE - which makes them vulnerable to its misuse.

If one attends clinics, salons, offices that use various MSE devices, that is wonderful.  But one needs to be weary of any clinic offering extensive advice based on the findings of MSE, especially when using terminology that involves discussion about 'plugged follicles' and 'dying' hairs. Such terms are too often meant to scare and confuse.  When discussion is focused on hair density changes, inflammation, miniaturization, hair follicle calibre measurements (in micrometers), the likelihood that a valid assessment is being performed goes up considerably. Of course, it's still no guarantee and all patients must be aware of the basics of the "buyer beware" concepts.

To use a MSE without appropriate training is unprofessional. To use an MSE device to deceive is unethical and possibly even illegal in some jurisdictions. More work is needed by professional organizations worldwide to establish ethical guidelines for the public in multiple areas of evaluating and treating hair loss. 

Hair Loss in Women: Irregular periods = Blood tests

Irregular periods = Blood tests

When speaking with patients about their hair loss, there are many pieces of information that a patient may share that should trigger the clinician to look deeper into the particular issue.

Irregular menstrual cycles in women are one such example especially when they occur in females age 16 to 43. Of course, there are many reasons for irregular periods and some of these reasons may have nothing to do with hair loss.

However, a variety of medical issues associated with hair loss may cause irregular periods. These include polycystic ovarian syndrome, congenital adrenal hyperplasia, hyperprolactinemia, Cushings, adrenal and ovarian tumors and cysts, stress, excessive dieting, thyroid disease.

The evaluation of women with irregular periods is best done on a case by case basis after review of all the facts. Blood tests shown here are frequently helpful especially in the third to fifth day of the menstrual cycle and especially in the morning. Patients with abnormalities may sometimes undergo further testing or referral, depending on the suspected cause.

Biotin Deficiency in Pregnancy

Biotin Deficiency in Pregnancy

Most people are not deficient in biotin. However, that said, biotin deficiency is difficult to measure. Deficiencies known to exist in a variety of situations including pregnancy, inflammatory bowel disease, Advanced age, oral antibiotics, alcoholism and certain medications (like isotretinoin, valproic acid and carbamazepine). Unlike many blood tests for testing “deficiencies”, there is no simple “biotin” blood test.

One way to determine if someone is biotin deficient or not is to evaluate for increased urinary excretion of 3-hydroxyisovaleric acid (3HIA), which likely reflects decreased activity of the biotin-dependent enzyme beta-methylcrotonyl-CoA carboxylase. A second way is to search for decreased activity of the biotin-dependent enzyme propionyl-CoA carboxylase (PCC) in peripheral blood lymphocytes.

A 2009 study by Mock and colleagues provided evidence that biotin deficiency may actually be quite common during pregnancy. In their pilot study, activity of PCC in peripheral blood lymphocytes (as a measure of biotin deficiency) was decreased in 18 of 22 (81%) pregnant women.

These studies are interesting. While they draw attention to the issue of biotin deficiency in pregnancy, it also draws attention to whether such deficiency impacts the hair during or after pregnancy. This is not known at present but deserves further study. Biotin deficiency may be more common during pregnancy than most realize.
 

Reference

Marginal biotin deficiency is common in normal human pregnancy and is highly teratogenic in mice. Mock DM. J Nutr. 2009.

Donovan Hair Clinic Among World's Top Hair Loss Blogs

Website Given Honour among Top Hair Loss Blogs

The Donovan Hair Clinic was recently given the distinction as one of the world's top 10 hair loss blogs on the internet. The distinction was given by Feedspot.com, a modern social feed reader which compiles news and feeds from online sources.   

With 50,000 visitors monthly to the website, over 5,900 twitter feeds, 1385 instagram posts, and regular updates through a variety of other social feeds, the Donovan Hair Clinic is recognized as a valued contributor to online information about hair loss.

Tofacitinib (Xeljanz) for Alopecia Areata: How fast does hair re-growth occur?

Speed of Regrowth in AA

Alopecia areata is an autoimmune condition. A number of treatments are available and these have been reviewed in previous articles. Among the newer options are the so called JAK inhibitors which includes tofacitinib (Xeljanz) and ruxolitinib (Jakafi/Jakavi). While not FDA approved yet for treating alopecia, they are increasing used off-label.  

I'm often asked how quickly regrowth can occur in alopecia areata patients treated with tofacitinib. The answer is that regrowth rates are variable but patients who respond well show regrowth by the first month and have significant regrowth by month 3. Patients who are not showing these types of regrowth patterns may be non-responders or may need higher doses.  If significant regrowth is not present by month 3, I may discuss the option to increase from 5 mg twice daily (i.e. 10 mg daily) to 15 mg or 20 mg daily.  The decision on whether to increase the dose depends on a number of factors including whether the patient has experienced any side effects to date. 

DOWNLOAD HANDOUT ON TOFACITINIB

DOWNLOAD HANDOUT ON RUXOLITINIB

Tofacitnib for Nail Alopecia Areata: What Do We Know So Far?

What Do We Know So Far?

The JAK inhibitors, including tofacitinib and ruxolitinib, are known to be helpful for many patients with alopecia areata. Not only can they help hair regrowth, the patients affected by nail disease can also be helped. The accompanying photo shows a patient of mine who had excellent response to tofacitinib.

Lee and colleagues from Korea set out to evaluate the relationship between nail and hair responses in patients with alopecia areata treated with tofacitinib. They performed a retrospective study of 33 adult patients with moderate-to-severe AA treated with oral tofacitinib monotherapy for at least 4 months.

15 of the 33 patients had nail involvement. Of 15 patients with nail involvement, 11 (73.3%) showed improvement. Overall, there was some delay before improvements were seen in the nail - first improvement was observed at a median of 5 months.

Interestingly, the nail improvement was associated with neither initial severity of hair loss nor hair response to tofacitinib. Nail improvement tended to occur later than hair regrowth.

This study adds to a growing body of evidence suggesting that tofacitinib helps with the nail AA as well as scalp AA. In this small study, there was no clear link between whether tofacitinib helped the scalp and whether it helped the nail.
 

REFERENCE

Lee JS, et al. Nail involvement in patients with moderate-to-severe alopecia areata treated with oral tofacitinib. J Dermatolog Treat. 2018.
 

Side Effects of Low Dose Minoxidil (1-2.5 mg)

Side Effects of Low Dose Minoxidil (1-2.5 mg)

Oral minoxidil was a common treatment in the past for individuals with challenging to treat blood pressure. The drug is seeing increasing uses among hair specialists at low doses (0.25 to 2.5 mg). I have been using it in clinic since late 2015. The drug may have benefits in treating androgenetic alopecia, chronic telogen effluvium and alopecia areata. Other uses are increasingly studied.

Although the drug is approved for blood pressure control, any use in treating hair loss is “off label” and should only be prescribed by a physician knowledgable and experienced with its use and only on a case by case basis.

It is important to understand the differences between low dose oral minoxidil and standard dosing - especially when it comes to side effects.

The most common side effects of low dose oral minoxidil can be summarizes with the “HAIR” memory tool and include headaches, ankle edema (swelling), increased hair on the face (and body too), skin rashes and hives. A slight reduction in blood pressure can occur but is usually just a few points. As one approaches 2.5 mg a slight increase in heart rate may occur for some users.

The side effects of higher doses of oral minoxidil reflect the impact the drug has on the cardiovascular system and increases a higher chance of dizziness, lowered blood pressure, increased heart rate, swelling around the heart, and shortness of breath. Other side effects like breast tenderness can be seen. Scroll to slide 2 to see side effects of higher dosing.

Both doses are not permitted in women who wish to become pregnant.

See Article “The Top 10 Things You need to Know About Oral Minoxidil”

Combining Oral Minoxidil and Oral Spironolactone for FPHL

New Potential Options for Female Pattern Hair Loss

Female Pattern Hair Loss (FPHL), also known as female hair thinning or female androgenetic alopecia is a common type of hair loss that affects about one-third of women. Most women affected by the condition start with slightly increased hair shedding.  Over time, the patient notices decreased hair density and a more see through appearance to the scalp.

Topical Minoxidil remains the only formally FDA and Health Canada approved treatment for FPHL. Application of minoxidil does have it's own unique set of challenges. Many patients give up after a period of time. Other options including oral anti-androgens, laser, PRP and hair transplantation (for some women).

Oral minoxidil has been around for many decades and was originally used as a blood pressure medication. It is known to increase hair growth on the body as a side effects. Recently there has been increased interest worldwide in understand the potential benefits of using low dose oral minoxidil to treat hair loss. Rather than using the 10-40 mg doses that were once used to treat blood pressure, low dose oral minoxidil for hair loss involves doses ranging from 0.25 mg to 2.5 mg. 

Rod Sinclair from Australia set out to study the potential benefits of using oral minoxidil and oral spironolactone together. The dose of minoxidil prescribed was 0.25 mg and the dose of spironolactone used was 25 mg.

100 women were included in this study. The mean age was 48.44 years and the mean duration of diagnosis was 6.5 years. Overall the drug combination reduced shedding and reduced hair loss. There was a slight reduction in mean blood pressure of 4.52 mmHg systolic and 6.48 mgHg diastolic.  8 % of patients in the study have side effects but they were deemed mild.   Only 2 of the 100 patients overall discontinued treatment and these were patients with hives (urticaria).

Conclusion

This is an interesting study. It has long been known that the combination of topical minoxidil and oral spirionlactone (at higher does) are beneficial to FPHL. In fact, it was Dr Sinclair who showed this many years ago as well. This study is interesting because of the safety and limited side effects that were observed. Only 2 % of patients dropped out of the study. In another study by Dr. Sinclair (of chronic telogen effluvium) which also involved study of oral minoxidil, there were no drop outs. Together, these studies speak to a relatively good safety profile of oral minoxidil. 

We have been using oral minoxidil in clinic for some time. I was first inspired to consider it by presentation by Dr SInclair a few years back. (Nobody in the world has more experience with oral minoxidil for hair loss than Dr. Sinclair). The most common side effects is the increased hair on the face (especially upper lip) and body that some patients get. Dizziness, headaches, hives, ankle swelling are among the other side effects. The most common side effect in practice is increased hair on the upper lip in 25- 35 % of women. Other less common side effects are typically headaches, ankle swelling, hives. Surprisingly, shedding does not tend to be very common when starting. The ease of taking oral minoxidil vs topical minoxidil does make it a important option for further study. 

More studies of oral minoxidil are needed but studied to date are promising.

See Article “The Top 10 Things You need to Know About Oral Minoxidil” 

REFERENCE

Female pattern hair loss: a pilot study investigating combination therapy with low-dose oral minoxidil and spironolactone. Sinclair RD. Int J Dermatol. 2018.

Oral Minoxidil for Chronic Telogen Effluvium (CTE)

Oral Minoxidil For Chronic Shedding 

Chronic telogen effluvium is a type of hair shedding condition. Patients report high levels of daily hair shedding that seems to wax and wane. Some days and weeks are associated with high levels of shedding whereas other weeks seem less. This is extremely frustrating for patients as there seems to be no clear reason for any of the shedding patterns.  Most patients with true CTE are between 30-60 and have normal blood tests. A proportion of patients not only have shedding but unusual scalp symptoms, which collectively fit under the umbrella term of trichodynia. 

The treatments for CTE are limited. A number of things can be tried but none are consistently effective,  Common treatments including topical minoxidil, laser, vitamins, supplements, and platelet rich plasma. 

In 2017, Dr Rod Sinclair and colleague Dr Perera set out to examine the benefits of oral minoxidil in the treatment of CTE.  In total , 36 female patients (mean age 46.9) with CTE were treated with oral minoxidil (range, 0.25-2.5 mg) daily for 6 months.   Oral minoxidil was found to reduce shedding. 5 of the 36 women who noted trichodynia (scalp pain) at baseline had improvement at 3 months. 

Although oral minoxidil is a blood pressure medication, mean blood pressure change was only 0.5 mmHg systolic and 2.1 mmHg diastolic. 2 patients had dizziness that improved over time even with continuation of treatment.  13 (36 %) women developed increased hair on the face. 1 patient developed swelling of the ankles.  Interestingly, all 36 women completed the 12 months study. 

 Conclusion

This is an interesting study. The treatment of CTE tends to be frustrating for doctors and patients alike. Some patients respond to standard treatments but certainly not all. This study offers hope that oral minoxidil could also be added to the list of treatments for this frustrating shedding condition. Oral minoxidil does appear safe and we have been using it in clinic for some time. The most common side effects is the increased hair on the face (especially upper lip) and body that some patients get. Dizziness, headaches, hives, ankle swelling are among the other side effects. 

The most common side effect in practice is increased hair on the upper lip in 25- 35 % of women. Other less common side effects are typically headaches, ankle swelling, hives. Surprisingly, shedding does not tend to be very common when starting

See Article “The Top 10 Things You need to Know About Oral Minoxidil”

REFERENCE

Perera E and Sinclair R. Treatment of chronic telogen effluvium with oral minoxidil: A retrospective study.  F1000Res. 2017.

 

On the Reporting of Infinitely Amazing Discoveries

 When the media makes things infinitely amazing

The media frequently lives on a level of excitement and adrenaline that few humans can sustain for very long. In a world filled with much negative news, it is interesting that this does not seem to be the case when it comes to reporting about new hair research.

I have noticed three emerging trends when it comes to the reporting of new research in the world of hair loss.

Observation 1: Hair research findings that are not really all that interesting and not really all that promising get reported as “breakthroughs” and the ultimate “cure.”

Observation 2: Hair research findings that are somewhat interesting and somewhat promising get reported as “breakthroughs” and the ultimate “cure.”

Observation 3: Hair research findings that are truly breakthroughs and truly promising get reported as “breakthroughs” and the ultimate “cure.”

In a world with much negative news, one might admire the media's tremendous positivity (and tremendous consistency) when it comes to reporting new hair research. But what must not be forgotten is the countless numbers of people that act on these reports - either emotionally, physically or financially.

It is the responsibility of the media to help people understand if new hair loss research best fits in a category of not all that promising, somewhat promising or truly a breakthrough. Every hair loss discovery adds to our body of knowledge but not every discovery needs to be reported as infinitely amazing.

Shampoo Allergy: A Closer Look at Propylene Glycol

Propylene Glycol as a Shampoo Allergen

Propylene glycol is an ingredient commonly found in shampoos and cosmetic products in general. It acts as a solvent for many other ingredients including preservatives, fragrances and chemicals. It also acts as a humectant (meaning that it attracts water), and has some antimicrobial properties.

PG can act as an irritant and sometimes a true allergen. Irritant reactions are far more common; however allergic reactions have been well appreciated for several decades.

Studies by Zirwas and colleagues showed that propylene glycol was the fifth most common allergen in shampoos - found in 38 % of surveyed shampoos.
 

Reference

Skin reactions to propylene glycol.
Hannuksela M, et al. Contact Dermatitis. 1975.

Zirwas M, et al. Shampoos. Dermatitis. 2009

Secondary Hair Casts: Psoriasis

What are hair casts?

Hair casts are thin, elongated, cylindrical concretions that encircle the hair shaft. Hair casts range in size from 2-7 mm and can be easily dislodged. The term was coined by Kligman in 1957.

Hair casts (sometimes called “pseudonits”) can be easily differentiated from true “knits" because they slide along hairs when grabbed with the fingers. They are usually asymptomatic and particularly common in young women.

Hair casts are said to be "primary" in nature when not associated with an underlying scalp disorder and "secondary" when associated with an underlying disorder. Common secondary causes include psoriasis, seborrheic dermatitis, pemphigus and traction alopecia and scarring alopecia. Many other causes are possible too including hair sprays and deodorants.

Hair casts are thought to represent material from both the internal root sheath and the external root sheath.

The photo here shows casts in a patient with psoriasis.
 

Saw Palmetto: How Does it Compare?

How Does it Compare?

For men with balding (androgenetic alopecia) there is no argument that oral antiandrogens are the most effective non-surgical treatment. However the potential side effects of antiandrogens means that for some patients (and physicians) other options can be considered. These options include topical and oral minoxidil, topical finasteride, laser, PRP, topical rosemary, ketoconazole, zinc pyrithione, and others.

Saw palmetto, known medically as sernenoa repens, is frequently added to the list of options. Unfortunately there are very few good studies of the use of saw palmetto in male balding. Rossi and colleagues performed a two year study comparing daily use of 320 mg saw palmetto to 1 mg finasteride in 100 patients with balding. Overall, saw palmetto helped 38% of patients whereas finasteride helped 68% of patients. Finasteride helped both the front and crown/vertex whereas saw palmetto tended to be mainly helpful for the crown.

Conclusion

We still have a long way to go to really understand the benefits of saw palmetto. A well conducted randomized double blind study is needed. However the Rossi study is encouraging that saw palmetto may have some benefits.

Reference

Rossi et al. Comparitive effectiveness of finasteride vs Serenoa repens in male androgenetic alopecia: a two-year study.Randomized controlled trial. Int J Immunopathol Pharmacol. 2012 Oct-Dec.
 

Finasteride, Dutasteride and Insulin Resistance

Do 5 alpha reductase inhibitors affect insulin sensitivity?

The topic of insulin resistance induced by 5 alpha reductase (5αR) inhibitors like finasteride and dutasteride is interesting.  Finasteride inhibits 5αR2 selectively, whereas dutasteride inhibits both 5αR1 and 5αR2. There is evidence that dutasteride has a more potent effect on insulin resistance than does finasteride. Finasteride may even reduce insulin resistance in some studies. 

It appears that the inhibition of 5αR1 is the relevant enzyme when discussing insulin resistance. Interestingly, Dowman and colleagues showed that increased liver fat and decreased insulin sensitivity are seen in mice with targeted disruption of 5αR1, but not 5αR2.

Upreti and colleagues performed a double-blind randomized controlled study of 46 men (20–85 years) with oral dutasteride (0.5 mg daily; n = 16), finasteride (5 mg daily; n = 16), or control (tamsulosin; 0.4 mg daily; n = 14) for 3 months. Dutasteride, but not finasteride, showed evidence of insulin resistance. There were no effects of dutasteride, finasteride or controls on BP, heart rate, body weight, BMI, or waist-to-hip ratio. However, there was an increase in body fat with dutasteride, but not finasteride. There were no differences in serum lipid profile

Hazlehurst and colleagues conducted a randomized study in 12 healthy male volunteers with detailed metabolic phenotyping performed before and after a 3-week treatment with finasteride (5 mg od) or dutasteride (0.5 mg od). Dutasteride, not finasteride, increased hepatic insulin resistance and hepatic lipid accumulation.

Clinical studies on Finasteride and Insulin Resistance

Duskova  and colleagues performed one of the most thorough studies examining the relationship between finasteride and insulin resistance. They examined 12 men with androgenetic alopecia who used finasteride for 12 months. Hormonal levels, metabolic parameters  and insulin tolerance tests performed for all individuals.  The authors observed an initial increase in total cholesterol and HDL- and LDL-cholesterol, which stabilized with prolonged treatment. However, they found a significant decrease in glycated hemoglobin HbA1c and decreased insulin resistance. The authors concluded that finasteride improves blood sugar parameters.

Conclusion

Dutasteride appears to have different effects on insulin sensitivity than finasteride likely due to its inhibitory effects on 5 alpha reductase type 1.  There are limited studies available on insulin resistance mediated by these drugs. However, the data would point to a slight insulin resistance effect with dutasteride and possibility slight improvement in insulin sensitivity with finasteride. 

References

Dowman et al. Loss of 5α-reductase type 1 accelerates the development of hepatic steatosis but protects against hepatocellular carcinoma in male mice. Endocrinology 2013; 154: 4536-4547

Duskova M, et al. Changes of metabolic profile in men treated for androgenetic alopecia with 1 mg finasteride. Endocr Regul. 2010.

Hazlehurst JM, et al. Dual-5α-Reductase Inhibition Promotes Hepatic Lipid Accumulation in Man. Randomized controlled trial. J Clin Endocrinol Metab. 2016.

Rita Upreti et al. 5α-Reductase Type 1 Modulates Insulin Sensitivity in Men. The Journal of Clinical Endocrinology & Metabolism, Volume 99, Issue 8, 1 August 2014, Pages E1397–E1406,  

New hopes from an Osteoporosis Drug: New Ways for WAY-316606

WAY-316606 Offers Promise

Male balding is common. By the age of 50, nearly one-half of all men have some degree of male balding. The most effective non-surgical treatments today focus on altering levels of DHT or dihydrotestosterone. However, potential side effects of these medications, which include finasteride and dutasteride have spurred the world of hair research to search for new avenues of treatments. Indeed, other pathways inside cells (other than DHT) seem to be relevant to hair loss. 

A new study from Professor Ralf Paus's lab in Manchester introduces us all to the potential of a drug originally designed to treat osteoporosis to help individuals with hair loss. The results are published in the May 8 edition of PLOS BIOLOGY

 In the first part of the study, the researchers re-examined the molecular mechanisms of an old immunosuppressive drug, Cyclosporine A (CsA) which is known to promote hair growth.  CsA has been in use since the 1980s and is widely used to treat autoimmune diseases as well as to prevent organ transplant rejection. One of the interesting side effects of CsA is that it can trigger hair growth in patients using the drug - often in unwanted areas. 

Cyclosporine inhibits SFRP1

Prof Paus' team ultimately uncovered a completely new understanding of how cyclosporine affects hair follicles.  The researchers carried out a full gene expression analysis of isolated human scalp hair follicles treated with CsA and found that CsA reduces the expression of SFRP1, a protein that inhibits the development and growth of many tissues, including hair follicles. Interestingly, this inhibitory mechanism is completely unrelated to CsA's immunosuppressive activities, and in turn make SFRP1 a new and very promising drug target for anti-hair loss strategies.

 

WAY-316606 also inhibits SFRP1

After some further work, the group found that a drug called WAY-316606 also antagonizes SFRP1. Surprisingly, WAY-316606 was originally developed to treat osteoporosis. Further work is needed to understand whether topical or oral compounds of WAY-316606 (or similar compounds) could actually work to help patents with hair problems in the clinical rather than laboratory setting. 

REFERENCE

Hawkshaw N et al. Identifying novel strategies for treating human hair loss disorders: Cyclosporine A suppresses the Wnt inhibitor, SFRP1, in the dermal papilla of human scalp hair follicles. PLOS Biology 2018. ARTICLE.

The Five S's of Diagnosing Hair Loss

The Five S's of Diagnosing Hair Loss

When it comes to diagnosing hair loss, nearly “everything” is potentially important. That you travelled to far off lands on vacation 3 summers ago can rarely have relevance. But usually it does not. That you rennovated your kitchen last year can rarely have relevance. Usually, however, it does not.

Over the years, I have come to appreciate that there are five pieces of information that are absolutely critical to obtain from a patient’s story , or what physicians call the “history.” These nicely fit into what I term the five “S’s” and include obtaining detailed information on the Speed of hair loss (fast or slow), associated symptoms (like itching, burning or tenderness), degree of shedding (normal, increased or excessive), a catalogue of supplements or drugs used by the patient in the last 3-4 years (including over the counter and prescription based). The final “S” refers to the sites of hair loss (is it front vs middle?, top vs back? one area vs diffuse? scalp only or eyebrows and lashes too?). The 5 “S’s” of hair loss is a remarkably powerful tool that I use each and every day with each and every patient.
 

Shedding, Shedding, Shedding: Why Won't it Stop?

Why Won't it Stop?

Being a hair specialist is as much about trying to get hair back on the scalp as it is trying to figure out why it’s leaving the scalp in the first place. There are dozens and dozens of reasons to lose hair. Some diagnoses are easy. Some are challenging. Some look easy but can fool you as they are a close mimicker of another condition.

Telogen effluvium (TE) refers to hair shedding in excess of what is normally experienced by the patient. A variety of triggers commonly cause TE including low iron, thyroid problems, crash diets and medications. Once the trigger is properly identified and “fixed” the hair grows back. (for example once the dieting stops the hair shedding stops in 6-9 months). TE is among the most frustrating of conditions because many conditions can mimic TE. Far too many patients are told to just be patient as the shedding will stop only to find 6-9 months later that the shedding has not in fact stopped.

Why would shedding not stop?

Well, there are a number of reasons for this. First, we need to consider that we may not have found the right “trigger.” We might not realize that the patient’s supplement they started last year is actually the trigger. We not have realized that the patient’s fatigue and headaches and sore joints are actually a sign of underlying disease.

Second, we need to be humble to the fact that we may have the wrong diagnosis and were fooled into thinking this is a TE. Androgenetic alopecia (female thinning and male balding) often starts with shedding that perfectly mimics a TE. Some early scarring alopecias like lichen planopilaris can mimic TE.

Finally, we may have got the general diagnosis of telogen effluvium correct but failed to recognize that the patient’s hair shedding really fits best with chronic telogen effluvium or “CTE.” In true cases of CTE a trigger can often not be found.
 

Conclusion

Excessive hair shedding is frequently seen with TE. However, physicians need to keep a broad and open mind to other possible diagnoses if the shedding does not stop.
 

Punch Biopsies & Pencil Erasers

Scalp Punch Biopsies

Punch biopsies are performed when the diagnosis of a patient’s hair loss is not clear.

Patients frequently ask “how big of a piece are you going to take?” A punch biopsy for hair loss should normally be 4 mm in size - which is a bit smaller than the typical 5 mm pencil eraser. 

Preparing for Pregnancy: Considerations for Women with Androgenetic Alopecia

Planning a Pregnancy with Female Pattern Hair Loss

Many women with genetic hair loss are worried about getting pregnant and how the pregnancy and delivery will affect their hair. It's an area that really isn't talked about very much. Some women feel it's difficult to talk opening with their partner or family about their hair when all the focus is on the pregnancy, the baby and the new or expanding family.  But these issues are important and issues that I help patients with on frequent basis. 

 

Preparing for the Pregnancy

For women who are planning when to become pregnant, there are a number of considerations that are related to the hair. I encourage all patients with hair loss who are considering pregnancy to have a good discussion with the dermatologist and of course the physician caring for the pregnancy as well.  

Most of the time, hair improves in pregnancy.  However, some women do experience hair loss during the pregnancy. A significant proportion of women experience some degree of hair shedding after delivery. Hair regrowth occurs 6-7 months later but may or may not return to pre-pregnancy densities.  

1. Deciding to Stop Medications

Many of the medication used for treating female pattern hair loss (androgenetic alopecia) can't be used during pregnancy. This includes minoxidil, Rogaine, platelet rich plasma, anti-androgens. The only treatment that can be used are vitamins and low level laser therapies. 

Minoxidil should ideally be stopped two weeks before the time that a women decides to start trying. However, there are many women world-wide who become pregnant while using minoxidil and simply stop minoxidil once they miss their period. There is no evidence that this method has any harm for the pregnancy or the baby.  However, minoxidil must not be used during the pregnancy and anytime after the first period is missed. Many physicians will strictly recommend that their patients stop minoxidil if they are trying to conceive. However, there is no good evidence to support this recommendation. 

Anti androgens, however, need to be stopped several months before the pregnancy. The most common anti-androgen used in women of child bearing age is Spironolactone (Aldactone) and this must be stopped ideally 2 months before any planned pregnancy. Spironolactone can not be used during pregnancy as it could cause harm to a developing baby. Other anti-androgens, including saw palmetto, and finasteride need to be stopped long before as well. Dutasteride is not typically be used in women of child bearing ages. However due to it's very long half life, any woman who is using dutasteride and considering pregnancy should speak to their physician and dermatologist about how long they need to be off the medication before trying to get pregnant. 

 

2. Blood tests

For some women, pregnancy can lead to changes in the levels of many key mineral and vitamins relevant to hair growth. Blood tests can help identify these deficiencies. Deficiencies of vitamin D and iron are among the most common during pregnancy and levels may need to be followed during the pregnancy. Other deficiencies are less common but can include biotin and zinc. If there are concerns about thyroid stratus or diabetes these will also need to be monitored.

3. Supplements

All women considering pregnancy should speak to their physicians about appropriate supplements. These will generally include appropriate folic acid. However, other supplements may be very relevant depending on the patient's history. As mentioned above, these may include vitamin D, iron, biotin and zinc.

4. Scalp Inflammation

I am a strong believer that scalp inflammation needs to be addressed at any time during the course of hair loss. This is also true during pregnancy. Prolonged scalp inflammation from various sources has the potential to accelerate androgenetic alopecia (AGA). Inflammation can come from many potential sources including seborrheic dermatitis, psoriasis and various eczemas. 

We don't have much information on the safety of anti-dandruff shampoos in pregnancy. The data would suggest that periodic use of zinc pyrithione and ciclospirox have reasonable safety and these are frequently my top choices for many of my own patients.  If dandruff (or seborrheic dermatitis) is troublesome, I generally advise use once every 2 weeks and to be left on the scalp for 60 seconds before rinsing off. Small amounts of betamethasone valerate scalp lotion can be used once weekly if itching persists.  

Ketoconazole shampoos don't have much in the way of data. Patients interested in using should check with their OB or the physician caring for the pregnancy. There is no good data to really suggest a problem with periodic use of topical shampoos containing ketoconazole. It's not the top choice for my practice as they have the potential to affect testosterone synthesis.  Oral ketoconaole is certainly not advised. It increased the risk of cardiovascular, skeletal, craniofacial and neurological problems in many studies.  I don't recommend coal tar shampoos during pregnancy. Animal studies show that high doses are associated with perinatal mortality, cleft palate, small lungs and other developmental issues. I avoid them in my practice. 

Conclusion

Patients with androgenetic alopecia (female pattern hair loss) who are considering pregnancy should review their general health and scalp heath with their physicians. Blood tests may be recommended and periodic monitoring of the scalp may be appropriate during the pregnancy.

 

Ciprofloxacin and Stem Cells: Are Some Antibiotics Good for Hair?

Are Some Antibiotics Good for Hair?

Stem cells are cells which have the potential to give rise to many cell types. An interesting study has drawn attention to a potential role for the antibiotic ciprofloxacin in maintaining stem cells during cell culture and preventing their transformation into cells with other characteristics. 
Authors from Thailand studied a human dermal papilla cell line as well as primary dermal papilla cells as model systems and showed evidence that ciprofloxacin treatment could prevent the loss of “stemness” during the time spent in cell culture.

Without addition of ciprofloxacin to cell culture models, the researchers showed that clonogenicity and stem cell markers of dermal papilla cells gradually decreased in the culture over time. However, treatment of the cells with nontoxic concentrations of ciprofloxacin was shown to maintain both stem cell morphology and clonogenicity, as well as all stem cells markers. This ability of ciprofloxacin to maintain stemness was found to occur through a mechanism that involved that involved an ATP-dependent tyrosine kinase/glycogen synthase kinase3β dependent mechanism which in turn upregulated β-catenin.

Further studies are needed to understand if this is a unique feature of ciprofloxacin and if the finding has relevance to other cell lines. If found to be a consistent and unique feature, this study could have tremendous relevance for model systems to “clone” hairs.
 

Reference

Kiratipaiboon et al Ciprofloxacin Improves the Stemness of Human Dermal Papilla Cells. Stem Cells International Volume 2016