Lichen Planopilaris vs Seborrheic Dermatitis

Does Improvement with Corticosteroids or Dandruff Shampoos Help in Diagnosis?

I just posted a new answer to this week’s “Question of the Week.” I was asked whether improvement with topical steroid shampoos or improvement with dandruff shampoos helped in deciding whether a patient might have seborrheic dermatitis or lichen planopilaris.

The full answer to this week’s question can be read here:

Seborrheic Dermatitis vs Lichen Planopilaris: Which do I have?

Lichen planopilaris: What works and when do the treatments start helping?

Lichen Planopilaris: Treatment Options

Lichen planopilaris (LPP) is a type of scarring alopecia that affects both men and women. It can affect any region of the scalp although the central areas of the scalp tend to be most affected. There are a variety of different ways that LPP can announce its arrival and so there is no standard way.

Typically, patients with LPP first develop hair shedding accompanied by some degree of scalp discomfort. Scalp itching, burning and pain are often experienced by patients with LPP. Some patients however are quite asymptomatic.

The Clinical Evaluation: What is needed when evaluating a patient with LPP?

Evaluation of the patient with suspected LPP requires collecting information from the patient on a variety of different things including: the precise locations they feel the hair is being lost from (scalp, eyebrows, lashes, body hair), symptoms, actions they feel help improve symptoms. Overall health should be ascertained as should a family history of autoimmune diseases. The scalp should be examined to document the areas of hair loss. Up close examination using dermoscopy is important to document the presence or absence of perifollicular erythema, scaling and confirm the the type of hair loss is truly scarring and that follicular openings are lost.

The Scalp Biopsy: Is it needed?

In typical and classic cases of lichen planopilaris, a biopsy may or may not be needed. Many physicians do choose to biopsy to confirm the disease. However, in classic cases, a biopsy does not usually add any additional benefit. If performed, a biopsy must be taken from a hair containing region of the scalp and ideally an area which has the features of LPP.

The biopsy will show loss of sebaceous glands and lymphocytic infiltration in the hair follicle sheath in a very specific manner known as lichenoid infiltration. Hair follicle cells will show evidence of death (necrosis, apoptosis). The loss of sebaceous glands and hair follicle cell death are the two most important features of the biopsy to search for in the report. The presence of lymphocytic infiltration in the upper part of the hair follicle and the presence of concentric fibrosis (scarring) alone are suggestive of LPP but by no means proof. These findings may be present in non scarring alopecias such as androgenetic alopecia as well.

Blood tests: Which ones?

The exact blood tests that are needed depends on the patient’s story and the findings on examination. In other words, the blood tests required for one patient with LPP may differ slightly from another patient.

Standard blood tests in the setting of suspected LPP include:

CBC - complete blood counts

TSH - thyroid stimulating hormone

Ferritin - iron stage levels

ESR - erythrocyte sedimentation rate

ANA - antinuclear antibodies

Cholesterol profiles - including LDL, HDL and non LDL

Vitamin D - 25 hydroxy-vitamin D levels

Treatment Options for Lichen Planopilaris

There are a variety of treatment options available for LPP. In fact, taken together there are well over 25. However, several options would be considered standard options and have the best medical evidence. These options include topical steroids, topical calcineurin inhibitors, steroid injections, and oral medications such as hydroxychlorqouine, doxycycline, methotrexate, cyclosporine and mycophenolate. Other options that can be considered (especially if these options do not work) include low level laser, low dose naltrexone, pioglitazone, excimer laser, anti-androgens, azathioprine, tofacitinib, and isotretinoin,

These treatment options do not help everyone. In discussing treatment options with one’s physician, side effects, ease of use, and cost must be taken into account. The proportion of patients who achieve partial of complete disease control with various agents is shown in the table below. Some treatments like topical steroids and steroid injections have a fairly good side effects profile if used correctly. However, they are unlikely to stop the disease completely if used alone. Nevertheless they may provide some degree of benefit. Other options such as the oral immunomodulating medications are superior to topical steroids and steroid injections but have greater potential side effects that must be weighed.

Treatment duration: How long do I need to be on these medications?

A common question from patients pertains to the length of treatment. Treatment duration ranges from 9 months to many decades or even forever. In other words, there is a great variation. Some patients require treatment for a short period of time and some patients require treatment for many years. There is no cure at present for LPP and treatment is geared towards stopping the inflammation which in term stops scarring. In cases of successfully treated LPP, the inflammation will be reduced from the scalp. However, the scarring remains.

Treatment takes many months to determine if it’s helping or not. The following table outlines how long it takes to first see benefits and how long it takes to know the full effects of the treatment. In general, some treatments like topical steroids may reduce inflammation and reduce itching within a very short time. However, it still takes another full 6-7 months to know how well this treatment will work. For example, if topical steroid are used as ‘monotherapy’ (the sole and only treatment), one can determine fairly quickly (1-2 months) if the treatment is having any impact. However, it would take 6-7 months to determine if the use of a topical steroid is sufficient to stop the disease.

Other treatments act much quicker. For example the oral medication cyclosporine acts quite quickly in LPP and one can generally ascertain benefits in a matter of months.

Disease Monitoring: How do we know if treatment is working?

The first signs that a treatment plan might be working is the reduction in redness, scale as well as general reduction in itching, burning or tenderness. However, the most important parameter to monitor is the clear and precise documentation that there is a halting of further hair loss. For this reason, scalp photographs are one of the most important requirements when monitoring scarring alopecia. If two photographs taken 6 months apart show that there has been more hair loss, the disease by definition is active (even if the patient feels better!). The importance of photographs can not be overstated.

Summary and Conclusion

Lichen planopilaris (LPP) is a scarring alopecia which requires immediate action to stop the disease and prevent further loss. Hair regrowth is not possible in most cases but some degree of regrowth may occur if the disease is caught in early stages. A carefully obtained history and examination but the physician are important to document the disease. A biopsy may or may not be necessary. A variety of treatment options are possible and taken several months to take effects. Some of the most effective treatment options are the oral medication and are associated with greater side effects than the topical medications. Nevertheless, many patients benefit from topical medications and these might be considered first or alongside the oral medications.

Moustaches, Men and Movember: Are Will Still Talking About Key Issues?

Are Will Still Talking About Key Issues?

The word “Movember” is derived from the month of November and the word “moustache.” Movember is an annual charity type contest event that encourages the growing of moustaches during the month of November to raise awareness of men's health issues, such as prostate cancer, testicular cancer, and men's mental health issues such as depression.

I was interested to read a 2013 study which examined 12,666 Twitter feeds to get a better sense of what people are talking about on social media during Movember. Are people talking about cancer and men’s health issues or are people talking about moustaches and selling products geared to facial hair?

To study the issue, tweets were chosen among people in Canada, United States and the UK. There were 4,222 tweets chosen in each country. 
Interestingly, only 0.7 % of 12,666 new tweets provided specific health-related information that would lead to awareness and understanding of men's health issues like cancer and depression.

If Movember tweets are not about the main issues, what are people tweeting about? According to the study, moustache growing and grooming was the most popular topic in U.S. tweets, and conversations about community engagement were most common in Canadian and U.K. tweets. Tweets from the US were often geared towards marketing products and significantly more tweets were geared to market products in the United States than Canada or the United Kingdom ( p < .05). Overall, the authors of this study felt that the findings from this study suggested that Movember campaigns are not generating as much conversation online about men’s health issues as originally intended. More work is needed to understand how best to make Movember a success in the online world.

Reference

Bravo et al. Social Media and Men's Health: A Content Analysis of Twitter Conversations During the 2013 Movember Campaigns in the United States, Canada, and the United Kingdom. Am J Mens Health. 2017.

Alopecia Areata and Thyroid Disease: Lessons from 150 Saudi Patients

Lessons from 150 Saudi Patients

It is well known that individuals with alopecia areata have an increased risk of other autoimmune diseases, including atopic dermatitis and thyroid disease.

A 2016 study from Saudi Arabia set out to determine whether there is a difference in thyroid autoimmune susceptibility between individuals with mild alopecia areata and more severe alopecia areata.

To do so, a prospective case-control study was lee formed which included 50 alopecia totalis (AT) and alopecia universalis (AU) patients, 50 age- and gender-matched patients with localized AA, and 50 age- and gender- matched healthy subjects.

Patients with advanced forms of alopecia were more likely to have thyroid disease. Thyroid autoantibodies (TAAs) were positive in AT/AU (40%), mild AA (14%), and healthy subjects (4%). The frequency of TAAs was significantly higher in patients with AT/AU than in mild AA (p=0.001) and healthy controls (p less than 0.001). The frequency of thyroid peroxidase antibody (TPO-Abs) was significantly higher in patients with AT/AU than in mild AA and healthy controls (p<0.001 for both). The frequency of TG-Abs was significantly higher in patients with AT/AU (p=0.003) and mild AA (p=0.043) than in healthy controls. Serum TSH level was significantly higher in AT/AU patients than in mild AA patients (p=0.006) and healthy controls (p=0.005). The overall conclusion was that individuals alopecia areata had a higher risk of autoimmune thyroid disease than the general population and individuals with the most severe disease were at highest risk.

Reference 

Bin Saif GA. Severe subtype of alopecia areata is highly associated with thyroid autoimmunity. Saudi Med J. 2016.

Scalp Symptoms: The 6 D's

The 6 D’s of Scalp Symptoms.

Scalp symptoms are common in many different types of hair and scalp disorders. A broad approach is needed by the physicians in order to properly diagnose the condition. Here is a list of some of the most common reasons for individuals to have scalp symptoms.

1. Diseases/Disorders of the scalp 

A variety of inflammatory scalp disorders can trigger symptoms including scalp psoriasis, seborrheic dermatitis, scarring alopecia, dermatomyositis, tinea capitis, sunburns, irritant and allergic contact dermatitis. Common hair loss conditions such as androgenetic alopecia, telogen effluvium and scarring alopecia are also associated with burning in some cases.

2. "Dysesthesias" 

As mentioned above, the scalp dysesthesias are a group of conditions that give physical symptoms in the scalp without any other unusual findings at the time of examination.  The cause of scalp dysesthesias is not clear. One study suggested that a high proportion of women with scalp dysesthesias had cervical spine disease. It seems that patients worsen with stress and improve with anti-depressants (venlafaxine, amitriptyline). Many respond to gabapentin.  The burning scalp syndrome (similar to burning mouth syndrome) is a variant of scalp dysesthesia. Sensitive scalp syndrome may also be as well.

3. Depression and Other Psychological Issues.

·     There is a well-known relationship between the brain and the skin. Stressful life events are a well-known trigger to scalp itching, burning and other symptoms. Scalp symptoms are more common in patients with a host of psychological and psychiatric diagnoses including depression, anxiety, post-traumatic stress disorder and schizophrenia.

4. Drugs 

Drugs can trigger scalp symptoms including itching, burning, and pain. This includes both topical drugs and oral medications. Topical medications containing alcohol are frequent triggers or scalp burning. Topical calcipotriol, minoxidil topical steroids, and a host of anti-dandruff shampoos can trigger symptoms. Oral medications, including cyclophosphamide can trigger scalp symptoms like burning. 

5. Damaged Nerves  

Scalp symptoms may be a result of damage to nerves. As mentioned above, cervical spine disease may be one such condition. But diabetes, multiple sclerosis, and stroke can all give scalp symptoms.  

6. Deprivation of Sleep 

Sleep deprivation has been associated with a range of cutaneous symptoms including scalp itching, burning and pain

Hair Greying and Heart Disease: Lessons from 545 Egyptian Men

Lessons from 545 Egyptian Men

Cardiovascular disease is a top cause of death around the world. Many of the risk factors for cardiovascular disease have come to be well known including smoking, hypertension, high cholesterol and aging.

Researchers from Egypt set out to test the hypothesis that hair graying is associated with an increased risk of coronary artery disease (CAD) independent of chronological age.

Their study included 545 males with suspected coronary artery disease who underwent a computed tomography coronary angiography (CTCA). Patients were divided into subgroups according to the percentage of gray/white hairs (Hair Whitening Score, HWS) and to the absence or presence of coronary artery disease.

Overall, coronary artery disease was prevalent in 80% of study patients. Patients with coronary artery disease had statistically significant higher “hair whitening score” (32.1% vs 60.1%, p < 0.001) and significant coronary artery calcification (<0.001). Multivariate regression analysis showed that age, hair whitening score, hypertension and dyslipidemia were independent predictors of the presence of atherosclerosis.

The conclusion of the study was that a higher degree of white hairs (hair whitening score) was associated with increased coronary artery calcification and risk of coronary artery disease independent of chronological age and other established cardiovascular risk factors.

Reference

ElFaramawy AAA, et al. The degree of hair graying as an independent risk marker for coronary artery disease, a CT coronary angiography study. Egypt Heart J. 2018.

Treatment of Male Balding: Lessons from 18,918 Japanese Males

Lessons from 18,918 Japanese Males

One of the biggest weakness in so many hair loss studies is the small sample sizes and limited number of patients studied.

A new study from Japan examined the treatment outcomes and side effects in 18,918 male patients who underwent a specific “AGA combination therapy” between 2011 and 2017.

The “AGA combination therapy” consisted of 1 mg oral finasteride once daily, 2.5 mg oral minoxidil and 5% topical minoxidil twice daily, and an injection once monthly for more than six months with a mesotherapy mixture containing minoxidil, arginine, aspartic acid, caffeine, copper tripeptide, lysine, niacin, panthenol, propanediol, propylen glycol, retinyl palmitate, pyridoxine, sodium hyaluronate, and ubiquinone.

Overall, 80 percent of patients reported satisfaction with the results of the treatment after 12 months post-treatment.

What is particularly important to note in this study was the rate and type of complications. Minor complications were observed in a total of 802 (4.2%) patients out of 18,918. Slight pain due to injection was found in 651 patients (3.4%), and slight bleeding was found in 56 patients (0.3%). Swelling due to oral minoxidil was found in 42 patients (0.22%), and dizziness in 28 patients (0.15%). Itching of the scalp from topical minoxidil was present in 7 patients (0.04%), and redness in 4 patients (0.02%). Sexual dysfunction (erectile dysfunction and low libido) were observed in 14 patients (0.07%). These minor complications resolved spontaneously.

In contrast to other studies which indicated an incidence of sexual dysfunction as high as 2 % of finasteride users, this large study from Japan suggested a much lower rate of sexual side effects. These low rates are noted even in the presence of 2.5 mg daily of oral minoxidil which too has the potential to cause erectile dysfunction. This study also pointed to the possibility of combining topical and oral minoxidil with low rates of dizziness and edema.

Overall, this study pointed to a benefit and relatively low incidence of side effects with an “AGA combination therapy” with topical and oral minoxidil, oral finasteride and mesotherapy.

Reference

Tanaka Y et al. J Clin Aesthet Dermatol 2018

Scarring Alopecias: Lead to formation of scars

Lead to formation of scars

Scarring alopecias are a group of hair loss conditions that lead to permanent hair loss on account of scar formation within the skin. In the early stages of disease, this scar tissue can not be easily seen because it is under the scalp forming around hair follicles.

Over time, more and more scar tissue forms around hairs, causing the hairs to fall out. As more and more hairs fall out these patches of scar tissue can be seen.

The photo shows a typical appearance of a scarring alopecia. Whitish scar tissue is present in some areas. Other areas are slightly red – which is usually a sign of ongoing activity in that area.

Scarring Alopecias: What are the similarities?

What are the similarities?

The scarring alopecias are a diverse group of conditions. Taken together, there are well over 100 scarring alopecias although a group of 6 or 7 comprise the most common ones.

Lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), pseudopelade (PPB), central centrifugal cicatricial alopecia (CCCA) and discoid lupus (DLE) are examples of these more common entities.

Modern research has shown there are many differences between these conditions. However they may have important similarities. For example, intense research into the basic causes of lichen planopilaris (LPP) have shown that the formation of “toxic” lipids in the hair follicle may lead to destruction of the oil glands (sebaceous glands), inflammation and ultimately destruction of the hair follicle. Certain signalling pathways inside the hair follicle, such as the PPAR gamma pathway may be important not only in LPP but other scarring hair loss conditions as well. Reduced levels of PPAR may be seen in LPP as well as FFA and CCCA and possibly others as well.

These similarities are important to explore further as they may enable many clinically distinct scarring alopecias to be treated similarly.

Psychosocial Impact of Hair Loss: Scarring vs Non-Scarring Alopecias

Scarring vs Non-Scarring Alopecias

Both scarring and non scarring hair loss have impact on the how people feel and what they ultimately do or don’t do with their social, work related and family activities. A standard measurement of the general well being and happiness of individuals is termer the “quality of life” or QoL. Measuring QoL and impact of a given disease or health condition is not easy but is an important part of medicine.

Both scarring and non-scarring hair conditions have significant psychological and psychosocial impact. Androgenetic alopecia, alopecia areata and scarring alopecias like lichen planopilaris and frontal fibrosing alopecia affect how people feel and what they do. In other words, these conditions affect QoL.

A 2015 study from Greece set out to compare and measure quality of life in women with non-scarring hair loss and scarring hair loss. Forty-four women, aged 18-70 years, including 19 with scarring alopecia and 25 with non-scarring alopecia were recruited.

All patients were evaluated by several scales including Dermatology Life Quality Index (DLQI), Hospital Anxiety and Depression Scale (HADS), Rosenberg Self-esteem Scale (RSES) and UCLA Loneliness Scale (UCLA-LS). Collectively, women with scarring alopecia were found to have higher scores in DLQI (depression scale), HADS (anxiety scale) and UCLA- LS (loneliness scale) and lower scores in self-esteem measures (RSES), compared to women with non-scarring alopecia.

This study was among the first to show that the psychological burden is heavier and quality of life is more severely impaired among women with scarring alopecia compared with non-scarring alopecia.

Reference

Quality of life and psychosocial impact of scarring and non-scarring alopecia in women.
Katoulis AC, et al. J Dtsch Dermatol Ges. 2015.

Topical JAK Inhibitors for AA: Australian Placebo Controlled Study

Australian Placebo Controlled Study

JAK inhibitors like tofacitinib and ruxolitinib have shown benefit in the treatment of alopecia areata. Over the last few years, topical JAK inhibitors have been explored as safer options to the oral JAK inhibitors. However, despite the great excitement there remains some debate as to how well the topical JAKs really work. What has desperately been needed is a placebo controlled study and a study that compares topical JAK inhibitors to topical steroids.

Dr Rod Sinclair’s group from Australia conducted a 28 week prospective, placebo-controlled, double-blind study in patients with alopecia universalis investigating hair regrowth with two topical JAK inhibitors, 2% tofacitinib ointment twice daily and 1% ruxolitinib ointment twice daily. Topical clobetasol ointment was the active comparator while vehicle was used as the placebo control. 
Sixteen patients were recruited for the study. Six patients demonstrated partial hair regrowth in scalp areas treated with 2% tofacitinib. Five patients demonstrated partial hair regrowth in the areas treated with 1% ruxolitinib. Ten patients demonstrated partial hair regrowth in the areas treated with clobetasol. No regrowth was observed in the placebo treated areas.

This preliminary study is interesting because it does lend support to potential benefits of JAK inhibitors and shows they are likely better than placebo. What is questionable in this study is whether use of an ointment truly is the best vehicle to study for alopecia trials. Dr Brett King’s study in 2018 showed that tofacitinib ointment really didn’t work very well (reference below). One wonders whether JAK topical liposomal creams in this study would have provided similar or possibly even better outcomes and whether they could have even performed better than clobetasol.

More studies of topical JAK inhibitors are needed and comparison with a placebo should ideally be standard protocol in order to acquire a better sense of how well topical JAKs really work.

Reference 

Bokhari L, et al. Int J Dermatol. 2018.
Liu et al. J Am Acad Dermatol. 2018.

Smoking and Balding: Does smoking Impact Natural Balding?

Does smoking Impact Natural Balding?

Genetic hair loss, also known as androgenetic alopecia, male pattern balding (men), female pattern hair loss (women), is controlled to a significant degree by inherited genes.

Nevertheless, there are several environmental risk factors that influence the speed and progression of androgenetic alopecia.

Smoking is among the most influential of these. In 2017, Fortes and colleagues showed that smokers at nearly 7 times more likely to have moderate to severe balding. The effect of smoking on balding was identified in several other studies as well.

Other risk factors including obesity seem to accelerate balding. A diet rich in fresh vegetables may protect against balding to some minor degree.

References

Fortes et al. The combination of overweight and smoking increases the severity of androgenetic alopecia.
Int J Dermatol. 2017.

Schou et al. Alcohol consumption, smoking and development of visible age-related signs: a prospective cohort study. J Epidemiol Community Health. 2017.

Fortes et al. Mediterranean diet: fresh herbs and fresh vegetables decrease the risk of Androgenetic Alopecia in males. Arch Dermatol Res. 2018.

Random opinions vs Real Science: Do they carry similar weight?

Principles of Scientific Inquiry Remain Most Important

Society must continue to protect the ability of a given individual to express his or her opinion. The opinion of another person, however, must never share the same spotlight with factual information that was obtained and validated using the principles of scientific inquiry. We must continue to protect the access of the world to accurate information.

We can respect the view of a person who says that they believe the world is flat but we would never accept this view to permeate the classrooms and textbooks of our children.  Similarly we can respect the view of a person who says that they believe a certain treatment for hair loss will help. However, without proof, we must never accept this view to permeate the classrooms and textbooks of our health care providers and the magazines and media sources of the public. It is a dangerous and slippery slope when opinions of others shares similar influence as validated science.

Scalp Camouflaging Agents: A Closer Look at DermMatch

A Closer Look at DermMatch

Scalp camouflage refers to a variety of methods to reduce the appearance of hair loss. Hair camouflaging agents include hair fibers, powder cakes, lotions, sprays, hair crayons, and scalp micropigmentation.

DermMatch is a so called “powder cake” and is applied to the scalp with an applicator. The popular product colors the scalp and also binds hairs. It is available in a variety of colors. DermMatch is safe to use and provides very effective camouflage for individuals with early staged hair loss.

Male and female patients with androgenetic alopecia, telogen effluvium, alopecia areata and even some localized scarring alopecias have found these products very helpful to reduce that appearance of hair loss.

Reference

Donovan J et al. A review of scalp camouflaging agents and prostheses for individuals with hair loss. Dermatol Online J. 2012.

Dengue Infections and Hair Loss: What is the mechanism of hair loss?

What is the mechanism of hair loss?

Dengue fever is an illness caused by the Dengue virus which is spread from the mosquito. It has the potential to cause a very severe and even fatal illness. About 400 million infections occur per year making it a common infection.

Individuals infected with Dengue virus usually develop symptoms a few days to 2 weeks after being bitten. Symptoms are very similar to the common flu and include high fever, a very bad headache, pain behind the eyes, joint pain, muscle pain, vomitting, rashes and internal bleeding problems.

Hair loss is fairly common with dengue fever. Hair loss occurs usually a few months after the illness starts and lasts a few months for most. The hair loss from Dengue can be quite dramatic in some cases.  The hair shedding from Dengue eventually stops on its own. There is not a lot that can be done to help it ... other than for the individual to continue to get better.

Although the hair loss that occurs from Dengue is typically though to occur via a mechanism of “telogen effluvium” (hair shedding), new research from Taiwan suggests hair loss from Dengue might be more complex. Researchers showed that human hair follicle dermal papilla cells (HFDPCs) were susceptible to Dengue virus infection and this lead ultimately to inflammation and cell death in HFDPCs.

Further research is needed to understand the long term sequelae of Dengue virus infection and to confirm whether hair regrowth is the norm for all patients.

Reference

Wei KC et al. Dengue Virus Infects Primary Human Hair Follicle Dermal Papilla Cells. Front Cell Infect Microbiol. 2018.

Seborrheic Dermatitis: Do Dietary Preferences Play a Role?

Do Dietary Preferences Play a Role?

Seborrheic dermatitis is a red scaly condition that affects multiple sites including the scalp. It is thought to be closely related to dandruff. Multiple factors contribute including Malassezia yeast. Other factors such as stress, ultraviolet radiation and several others factors too also play a role.

A recent study of 4,379 participants sought to examine the relationship between dietary factors and the development of seborrheic dermatitis. 636 of the participants (14.5%) had seborrheic dermatitis. Data analysis identified specific dietary patterns such as a 'Vegetable', 'Western', 'Fat-rich' and 'Fruit' dietary pattern.

Interestingly, a fruit-rich diet was associated with a 25 % reduction in the risk for seborrheic dermatitis. A Western type diet (high in red meat and processed food) was associated with a 47 % increased risk of seborrheic dermatitis but this dietary pattern seemed to have a link only for women.

The conclusion to the interesting study was that dietary choices likely do impact the development

of seborrheic dermatitis. A fruit-rich diet in particular may reduce the risk.

Reference

Sanders MGH et al. Association between diet and seborrheic dermatitis: a cross-sectional study.
J Invest Dermatol. 2018.

Iron supplementation in Children & Adolescents with Hair Loss

Iron supplementation For Children & Adolescents with Hair Loss

Iron supplementation is a popular topic for adults with hair loss but less attention is given to iron supplementation for children/teens and what doses are appropriate. I’m often asked what doses of iron are appropriate and what level of ferritin should we be aiming for.

Iron and Pediatric Patients

A conversation with parents regarding iron never begins with a conversation about iron. The conversation must begin with a broader overview of the child’s growth and development. Consideration is needed as to whether there could be other nutrition deficiencies and whether there are other health issues present. For some children, genetic conditions also affect the ability to make blood cells and store iron (i.e. the thalasemisas). A wide variety of issues can contribute to low iron in children! A full review is needed.

Children with iron deficiency should be evaluated by the paediatrician especially when there is an anemia (hemoglobin levels less than the cut of level). The paediatrician can decide whether further blood tests are needed. This may include screening tests for hemobloginopathies as well as screening tests for other deficiencies that might be present together with the iron deficiencies. Screening for celiac disease might also be considered in some children with low hemoblogin and low ferritin levels. In addition, the paediatrician can perform and examination and get more information about the child’s dietary practices.

For children with normal hemoglobin and slightly low ferritin levels, (ferritin 10-25), one can begin by reviewing dietary means of increasing iron rich foods in the diet. This includes red meats, poultry, fish, shellfish, lentils, beans. I always encourage parents to go slow with their approach to increasing iron and start first with reviewing the diet. Dietary means are generally the best to start with and encourage life long healthy eating in the child. If dietary means are sufficient and low ferritin levels are still present, (or if it’s just not possible to raise ferritin levels with dietary changes), a multivitamin containing iron is a good first step.

Iron supplements: The Third Step in Raising Iron

For healthy children with hair loss who have normal hemoblogin levels (but persistently low ferritin in the 10-25 level range) I recommend starting with dietary means followed by a multivitamin containing iron. It’s important to keep in mind that ferritin levels in children have not been adequately researched when it comes to the relationship between ferritin levels and hair loss. Therefore, it is a big stretch to say that a child with a ferritin of 12 has an iron issue impacting his or her hair. That might in fact be incorrect for many children. Nevertheless, if hair loss issues persist, it may be appropriate to raise ferritin levels up above 30. My cut off in children is generally 30 ug/L provided there is a normal hemoglobin level and normal MCV and normal RDW

If iron supplements are needed, I recommend dosing according to the following table. The recommended dose in children is 4-6 mg/kg/day of elemental iron. There are many formulations of iron available worldwide. In Canada, typically liquid and syrups are shown in the table below. A 10 kg child might be recommended 2 mL twice daily of Fer-in-Sol drops (see table).

How should iron be taken?

Iron can be taken with water or fruit juice or tomato juice as this really helps absorption. It should not be taken with milk. The iron can be taken 1 hour before eating or 2 hours after. Taking on an empty stomach really helps with absorption. If children develop an upset stomach with iron supplements, the iron can be taken 20 minutes after eating or even with food.

Staining of the teeth is a possible side effect of iron as is constipation (and rarely looser stools too). I always advise parents to go slow and start with half the dose for 1 week to make sure the child will tolerate it well. To prevent or at least reduce the chances of staining of the teeth, the liquid can be taken with a straw. Brushing the teeth twice daily and using baking soda to remove stains while brushing can also help alot.

Iron Supplements: How long?

Iron supplements should always be prescribed with a definitive start and stopping date. For adults, I recommend supplementing for 6 months before checking levels again. For children, I recommend checking ferritin (and hemoblogin) levels again in three months. If levels have risen to the appropriate level (i.e. above 30 for children with hair loss) iron can be reduced or even stopped. Repeat monitoring may then be appropriate again 6 months to 12 months down the road to ensure that levels have not plummeted. Chronic iron supplementation without a stop date (or recheck date) is not advisable for children.

Conclusion

Iron supplementation in children must start with a full review of the child’s health and development. Consideration should be given to all the reasons as to why a child has low ferritin levels. Children with low ferritin levels PLUS low hemoblogin levels require more urgent attention than children who have only low ferritin levels. For children with hair loss, starting with attention to dietary intake of iron is the first step followed by use of a multivitamin containing iron. If ferritin levels do not raise and hair loss is still and issue … an iron supplementation strategy can then be recommended as step three.

Scalp Redness and Burning : What are the common causes?

Scalp Burning and Redness: What are the top 10 causes?

Scalp redness with an accompanying sensation of burning has many causes. Here, I briefly review the top 10 causes of this scenario.

1) Seborrheic dermatitis.

Seborrheic dermatitis (SD) is an inflammatory condition of the scalp that affects about 3-5 % of adults. Males are more commonly affected than females. SD occurs on body sites where the skin is oily such as the scalp, eyebrows, sides of nose, eyelids and chest. Individuals with SD of the scalp develop red, flaky skin that is often itchy. The scales can be yellow, white or grey colored and are often described as being "greasy." This differs from scalp psoriasis where the scales are often silver and powdery (see below). Itching is more common in seborrheic dermatitis than burning but certainly burning can be present.

2) Psoriasis

Psoriasis is complex immune-based disease which can affect not only the skin, but also the nails and joints. Scalp psoriasis occurs in about 50 % of patients with skin psoriasis. Patients have scalp redness, flaking and scaling. Patients may also have bothersome itching and seem have burning. Although the redness and flaking often cause embarrassment, scalp psoriasis does not usually cause hair loss. 

3) Scarring alopecias 

Scarring hair loss condition or the so called "cicatricial alopecias” are a group of hair loss conditions which lead to permanent hair loss. These conditions may frequently be associated with redness of the scalp as well as a variety of symptoms such as scalp itching, scalp burning and/or scalp tenderness. These include conditions with names such as lichen planopilaris, folliculitis decalvans, lupus and several others.

4) Other inflammatory diseases

A wide variety of other inflammatory scalp conditions, including dermatomyositis and rosacea can be associated with scalp redness and burning. A scalp biopsy can help differentiate these entities.

5) "Red Scalp Syndrome"

'Red scalp syndrome" is a condition which occurs in individuals who have persistent scalp redness that is not explainable by any other condition. The condition was first described by Drs Thestrup and Hjorth. Patients with the Red Scalp Syndrome may have itching and burning but typically do not have scaling or flaking.


6) Irritation

Many products that are applied to the scalp or hair can cause irritation. These include many cosmetic products, including gel, mousse, hair spray and hair dyes. Some treatments for hair loss can also be associated with irritation and redness, including minoxidil and other topical products containing irritants such propylene glycol.

7) Allergic contact dermatitis

Shampoos, hair dyes and even some cosmetic products can cause allergic reactions in the scalp. Although some individuals with allergy have itching or burning in the scalp, many do not. In such cases, a rash may be present on the neck, ears or back where the product came into contact with the skin. Patch testing, done by a dermatologist with specific interest and expertise in this area can help determine if allergies are responsible for the scalp burning.


8) Infection

Infections are a possible causes of redness. Bacterial, viral and fungal infections may cause redness in the scalp. Determining the specific cause may come from a careful history and scalp examination and sometimes submission of a swab or piece of scalp tissue to the microbiology laboratory. 

Bacteria, such as staphylococci, may cause infections of the scalp. Bacteria may also cause infection of the hair follicle, which is a condition called " bacterial folliculitis." A variety of viral infections cause scalp redness. Chicken pox and shingles are two such examples. Scalp ringworm or “tinea capitis” refers to infection of the scalp by certain types of fungi. Scalp redness and scaling may be seen in these cases.

9) Alopecia areata

Alopecia areata is an autoimmune condition affecting about 2 % of the population. It is not typically a cause of scalp redness. The scalp in patients with alopecia areata is usually normal in color but may be pink or peach colored in some cases. Burning or itching can barely occur in the patches. Most however, are asymptomatic.


10) Scalp Dysesthesias 

Patients with scalp dysesesthesias typically have scalp symptoms like itching or burning in the absence of redness. In some cases there may be some minor redness. Scalp dysestheias occur for a variety of reasons rather than a single one. Depression, anxiety, spine disease, multiple sclerosis, fibromyalgia can all contribute.

Conclusion

There are many causes of scalp redness with burning type symptoms. Fortunately, the cause of the redness and burning can often be diagnosed from a thorough examination of the scalp along with a full review of the patent’s story. In complex or challenging situations, a scalp biopsy should be performed to confirm the diagnosis.

On the Meaning and Significance of Hair

Everyone has a Different View on Hair

The way two people think about their hair or their hair loss is not only unlikely to be the same - it’s also practically impossible. Our cumulative experiences from birth to the present influence how we come to view many things in our lives, including our hair.

Every part of the life journey matters. The way that a patient’s hair was brushed, washed or styled at age 3 influences, beyond any morsel of doubt, the way they think about their hair at age 23 or 63. The way the individual feels their hair looked like in the class photo from middle school affects how the high school student feels about their hair and ultimately how the same adult now thinks about his or her hair.

Comments and actions from family, friends, and teachers in childhood impact on how our emotions and thinking ultimately develop and influence exactly how we come to view our hair.

Our schooling, our jobs, our relationships, our hobbies - they all matter. What we choose to read, what we choose to watch and what we chose to listen to - it all matters to the meaning and significance each of us attaches to our hair. Every glance we have ever given our reflective self in the mirror, and every selfie we have ever taken further shapes these views.

Despite the world population of nearly 8 billion people, and countless generations of people in the past, there has yet to be two people who think about their hair or about their hair loss in a completely identical way.

No two people have ever shared an identical life journey and no two people have ever yet come to think about their hair in an identical way.

Black Dots: Hair dye as an example

Hair dye as an example

Magnified and dermatoscopic images of the scalp have an important role in making proper diagnoses. Black dots (as shown here) are a dermatosocpic sign that is encountered from time to time.

There are many causes of black dots that must be considered. Black dots are seen in alopecia areata, tinea capitis, traction alopecia and rarely some scarring alopecias too. Other causes are possible too and this list is not complete. Black dots generally represent hair follicles that have broken off at the level of the scalp. Black dots can also be caused by a variety of different “dyes” that dye the hair follicle opening and therefore do not actually represent broken hairs.

In this photo, the black dot represent recent use of hair dye that has colored the hair follicle opening or “pore.” Other types of dyes, such as anthralin used in alopecia areata treatment, also color the opening.