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QUESTION OF HAIR BLOGS


New Treatment for Hair Loss

What’s new and emerging in the field of hair loss?

In this 30 minute video from 2017, Dr. Donovan discusses some emerging treatments for various types of hair loss. This includes new treatments for androgenetic alopecia, alopecia areata and chemotherapy-induced alopecia


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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New Hair Loss Video for Physicians: Approach to the Patient History

Video on Taking a Hair Loss History

I posted a new video on our YouTUBE page which outlines the importance of the patient history in diagnosing hair loss. In the 1 hour or so secure, I emphasize to physician audience members that too often the information that the patient wishes to tell the physician about his or her hair loss is pushed aside in favour of the physician examining the scalp or performing various tests. I outline here 10 questions that must be asked of every patient with hair loss.




Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Spironolactone and Fibroadenomas

Spironolactone and Breast Fibroadenomas

Spironolactone is a medication which functions in part as an anti androgen. It is used in the treatment of female pattern hair loss. Spironolactone has several uncommon breast related side effects including rare beast tenderness and rarely breast enlargement.. As I reviewed last year, there is no good evidence that spironolactone causes breast cancer.

ARTICLE: No Evidence for Increased Breast Cancer Risk From Spironolactone

Spironolactone Benign Fibroadenomas of the Breast

A question I am often asked is whether spironolactone could be implicated in causing being breast fibroadenomas. This has not been carefully studied in women to any extent. There was, however, a study dating back to 1990 in which a suggestion was made that spironolactone might be implicated in causing fibroadenomas. The study was a report of a 69-year-old man with congestive heart failure who had been treated with digoxin for 27 years and spironolactone for 4 years developed bilateral breast enlargement (gynecomastia). The excess tissue was removed and was shown to contain multiple nodules. Under the microscope (i.e. histologically), the nodules showed a pattern corresponding to fibroadenoma of the female breast. The author concluded that this so called "fibroadenomatoid hyperplasia," was probably caused by treatment with spironolactone.

This study was of course in a male and the role of the dioxin in the patent’s development of fibroadenomas is not clear. Digoxin also has an effect on causing gynecomastia and one must consider whether an interaction between dioxin and spironolactone could somehow be relevant.

Conclusion

More studies are needed whether there is any true relationship between fibroadenomas and spironolactone use. Mechanistically, and pathophysiologically, it certainly is possible. That however is a big leap between possible and actual causing the disease.

Reference

Nielsen BB. Fibroadenomatoid hyperplasia of the male breast. Am J Surg Pathol. 1990.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Hairline maturation in males

A topic which causes great confusion and anxiety for some patients and physicians is the natural changes in the hairline that all humans experience between ages 17-28. This has been called “hairline maturation” and the phenomenon occurs in both males and females. The precise changes have been better described in males (....mainly becuse female hairlines are far far more complex). I would like to add that the concept of hairline maturation does not cause confusion and anxiety in some people because they have never even heard of it.

Diagram of Hairline Changes in Males

Diagram of Hairline Changes in Males



The hairline we get as adults is called a “mature hairline” and is not the same hairline we get as children (called a juvenile hairline). It’s challenging sometimes to determine if a patient has hairline maturation (HLM) or actually has male balding (AGA) ... or has both (HLM + AGA)! In general, hairline maturation moves the hairline just a little bit back. One can figure out if a male has HLM or AGA by performing the forehead wrinkle test.If one wrinkles their forehead upward, the normal hairline in young males attached to the upper wrinkles. Hairline maturation moves it back further (about one finger breadth) and male balding moves it even further. The changes for HLM are about two finger breadths in the temple area and anything more is likely suggestive of AGA.

This picture here shows a cartoon I created over decade ago. It shows a “bird’s eye” view of the scalp. One can see a normal juvenile hairline on the left, a mature hairline in the middle and hairline with balding on the right.



Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Trichotemnomania vs Trichoteiromania

Trichotemnomania vs Trichoteiromania as Causes of Apparent Hair Loss

trichotemnomania


Every now and then, the reason for a patient’s hair loss is the actions the patient himself or herself is taking. These situations can be challenging sometimes to diagnose and can be met with a variety of emotions when the diagnosis is finally made. “Trichotillomania” refers to the self indiced pulling of hair. This is a familiar concept to many. “Trichotemnomania” refers to the appearance of hair loss created from shaving the hair on account of an underlying impulse control disorder that prompts the need to shave hair to create the appearance of missing hair. “Trichoteiromania” refers to hair loss (or the appearance of hair loss due to breakage) from repeated rubbing. Again, this type of rubbing is not just an occasional rubbing of the scalp but rather a repeated rubbing associated with an impulse control disorder. Patients may rub the scalp or affected area hundreds if not thousands of times daily. Advanced cases of trichotemnomania can sometimes mimic alopecia areata. A careful history and careful examination can often help sort things out. sometimes a repeat examination is needed 3-5 weeks later to gain an understanding of whether or not there are any changes.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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On the SPEED of Hair Loss

Various Types of Hair Loss Have Different Average Rates of Loss

There are over 100 reasons to lose hair. Some of these reasons cause the hair density to be reduced extremely rapidly and other cause changes only slowly. It is extremely important when diagnosing hair loss to get a sense from the patient exactly how fast the hair is being loss. For example a patient with long standing androgenetic alopecia who was doing well in the past but now suddently starts losing more hair may have a second diagnosis that has entered the picture (such as a telogen effluvium). The chart here shows the most common of the hair loss conditions and the speed that they “typically” cause hair loss. There are of course exceptions.

Different types of hair loss have different average rates of progression.

Different types of hair loss have different average rates of progression.

Alopecia areata among the most rapid of hair loss types

The most rapid of all the forms of hair loss are alopecia areata and chemotherapy induced hair loss. These can cause complete hair loss in a matter of weeks in some people. Telogen effluvium never ever causes complete hair loss (and never in a matter of weeks) nor does androgenetic alopecia or scarring alopecia. The speed of hair loss is important. Some forms of male balding and some forms of scarring alopecia can be fast. In general though, they cause changes over many months (not weeks).


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Listening to your Patient: The Wise Words of Sir William Osler

Dermatology is an Auditory Specialty

One of the appeals of dermatology for the medical student is that it is such a visual specialty. So many so called ‘spot diagnoses’ can be made simply by looking at the rash. Medical students around the world applying to dermatology programs can be heard saying “I like that it’s such a visual specialty.” The dermatologist comes to the rescue in so many unusual and bizarre rashes because of their ability to immediately recognize certain patterns.


Medicine & Dermatology are auditory specialties too

We rarely hear it said - but dermatology is an auditory specialty too. We can make diagnoses by listening to what our patients actually say. We can sort out many challenging diagnoses by sorting out the actually story of the patient’s medical issues.

How can I differentiate between a challenging case in which the biopsy suggests lichen planopilaris but yet the clinical examination suggests it is not? By carefully listening to the patient’s story!

How can I differentiate between a challenging case of a 34 year old female in which one clinician feels the diagnosis is chronic telogen effluvium and another clinician feels it’s diffuse alopecia areata? Certainly the scalp examination will be important but so will the patient’s story!

How can I differentiate between a challenging case in a 4 year old boy in which one clinician feels the diagnosis is alopecia areata and another clinician feels it’s trichotillomania? Certainly the scalp examination will be important but so will the patient’s story!


Sir William Osler (1849-1919)

William Osler was a Canadian physician and one of the 4 founding professors of John Hopkins Hospital . He was not only a physician but an educator, philosopher (and apparently a wonderful practical joker too). He is often honoured with the title as the “Father of Modern Medicine.” Hs teachings and words have influenced the practice and careers of countless physicians around the world.

Sir Osler once provided advice about listening to patients:

Quotation from Sir William Osler (1849-1919)

Quotation from Sir William Osler (1849-1919)

Sir Osler’s advice is too often forgotten in era of fancy diagnostic tests. The patient’s story still remains a powerful tool when tough diagnoses need to be made. If I practiced hair loss medicine without the chance to speak to the patient, I’d certainly make a great number of errors in diagnosis. That’s even with all the dermatoscopes I own, the array of tests I have at my disposal, and even with the wonderful dermatoapthologists that I’m so lucky to work with.

The patient’s story is important!



Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Itching in Patients with Lichen Planopilaris: What is the Role of Stress?

Stress Intensifies Itching Levels in Patients with Scarring Alopecia


There are many factors to consider when a patient with scarring alopecia experiences a worsening of their scalp iitching. One must always consider that the disease itself is progressing and the itch is a direct sign or worsening disease activity. Other factors like stress, heat, and scalp injury and irritation from topical products are just a few examples that also need to be considered.

stress-LPP



Many patients with lichen planopilaris notice their itching worsens during stressful times. This itch often responds well to a short term increase in medications (i.e. topical steroids). Many of my patients know to increase some of their meds for very short periods of time when the level of stress increases in their lives and the scalp starts itching more


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Itching Patterns in Patients with Seborrheic Dermatitis.

Itching in Seborrheic Dermatitis


Seborrheic dermatitis (SD) is a common scalp condition that is closely related to “dandruff.” The scalp is often itchy and appears a bit red. The yeast Malassezia is thought to play a key role in the development of SD.

The scalp in patients with SD increasingly becomes greasy as the days go by without washing the hair. Patients with seborrheic dermatitis often find their scalp and hair looks and feels great immediately after the hair is washed. If they go a day or two without washing, the itching increases and so does the greasiness and oiliness of the scalp. Many patients with seborrheic dermatitis just intuitively come to know that washing their hair daily (or at minimim every other day) keeps the itching and greasiness to a minimum.

Of course, treatment of the seborrheic dermatitis with anti dandruff shampoos (and rarely a mild topical steroid) is the optimal strategy for managing SD and can eventually allow the patient to return back to less frequent shampooing should this be their preference.

sd-itch

Does seborrheic dermatitis cause hair loss?

Seborrheic dermatitis can cause hair shedding and reduced density if it is bad enough. For most people with a diagnosis of seborrheic dermatitis though, the seb derm is NOT the reason for their hair loss. Dr Pierard- Franchimont and colleagues have done very interesting research in the area of seborrheic dermatitis and dandruff. They showed about 10 years ago that the more seborrheic dermaitits a person has, the more shedding (telogen effluvium) a person will experience. This is important information to know because it tells us that individuals with severe seborrheic dermatitis are likely to have a severe telogen effluvium. Dr Pierard Franchimont and others have also shown data that the inflammatory reaction can even accelerate male balding in some cases making it important to aggressively treat seborrheic dermatitis in patients with hair loss. 
There is no doubt about the relationship between seborrheic dermatitis and shedding. Companies that manufacture dandruff shampoos study shedding patterns to determine if their shampoo is working. Anti-dandruff shampoos can reduce shedding. In summary 1) most of thr time seb derm is not the main reason for the patient’s hair loss. 2) severe cases of SD do cause hair loss in the form of increased shedding and may actually help accelerate the speed of the main reason for the loss.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Practical Points for Dermatologists.

Lecture to Dermatology Residents

Enjoyable day in the clinic capped by lecturing in the morning and afternoon. I delivered a lecture this morning to the Family Practice Program on the diagnosis of hair loss and lectured the afternoon to our amazing UBC dermatology residents on 10 practical points that dermatologists should consider when obtaining helpful information from a patient with hair loss.

lecture




Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Variation in Follicular Caliber in the Setting of AGA


Androgenetic Alopecia and Anisotrichosis

Androgenetic alopecia in men and women looks similar when the scalp is examined up close with “trichoscopy.” (The actual pattern and areas of hair loss looks quite different when one examines the scalp from a distance because men first lose hair in the temples and crown whereas women lose hair in the mid scalp). Trichoscopy of androgenetic alopecia demonstrates a variation in the caliber or diameter of the hair follicles. This phenomenon is referred to as “anisotrichosis.” In the unaffected, non-balding scalp, most follicles in a given area are approximately the same diameter.

Androgenetic hair loss is associated with cell death in a region of the hair follicle known as the dermal papilla which leads to the follicle ultimately producing a thinner hair. This photo shows the scalp of a patient with androgenetic alopecia. A reduction in the caliber (diameter) of many follicles is evident.



Reference.


Sewell L et al Anisotrichosis: A novel term to describe pattern alopecia. J Am Acad Dermatol 2007; 56: 856. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Frontal Fibrosing Alopecia in Women Under 40: The Importance of Diagnosis

Frontal Fibrosing Alopecia and Early Menopause

Frontal fibrosing alopecia (FFA) is a scarring hair loss condition that affects often affects the frontal hairline and eyebrows first but can affect many regions of the scalp as well as eyelashes, and body hair. The condition was first termed “post-menopausal frontal fibrosing alopecia” but it is now recognized that pre menopausal women can develop this condition. Men can also develop the condition less commonly as well.

FFA in Younger Women: What are the important considerations?

In 2014, Dr Vano-Galvan and colleagues performed a retrospective study looking back at some 355 patients seen in spain. 14 % of women were reported to have premature menopause (early menopause). This is an important observation that it easily overlooked in a busy practice.

We have seen many younger women with FFA in our practice some of which do have early menopause. I feel strongly that screening for premature menopause is an important part of the work up of women under 40 with FFA even if they do not plan to become pregnant in the future. There are many health consequences of early menopause that simply can not be ignored.

What is Premature menopause?

Premature menopause is defined as menopause occurring in women under 40 years of age. Overall, about 1 % of women have premature menopause making the condition not really all that rare. A variety of genetic conditions, autoimmune conditions, infections, surgeries and medications (i.e. chemotherapies) can cause premature menopause. Without appropriate treatment, some of these women may be at increased risk of premature death, neurological diseases, psychosexual dysfunction, mood disorders, osteoporosis, ischemic heart disease and infertility. It is imperative to screen for possible early menopause in women with FFA who are less than 40 years of age.

Symptoms and signs of early menopause

The signs and symptoms of premature menopause are due in part to changing estrogen levels but other hormone levels are likely important as well.

Symptoms of early menopause may include changes in menstrual cycles but may not. Symptoms may also include

1. Hot flushes/night sweats

2. Vaginal dryness and painful intercourse

3. Urinary frequency, urgency and incontinence

4. Sexual dysfunction

5. Sleep problems

6. Headaches

7. Depression and anxiety and irritability

8. Joint pains

9. Poor concentration.

Screening for Early Menopause

Blood tests for estrogen (estradiol), FSH and LH, TSH, blood sugars, blood calcium levels are important tests to order in women who may be experiencing early menopause. Early menopause is associated with reductions in estradiol levels (E2 level <20 pg/ml) and a rise in FSH (FSH level >40 Miu/ml). Other screening tests may be considered depending on the results of estradiol and FSH including AMH (anti-Mullerian hormone) and ultrasounds of the ovaries. If premature menopause is considered a bone mineral density should be considered to evaluate for possible osteopenia/osteoporosis. Referral to specialists including endocrinology and gynecology is important.

Medical Issues in Women with Early Menopause:

Some of the medical issues that need to be reviewed with each patient have been outlined above and include hot flashes, night sweats, weight gain, sexual dysfunction, vaginal dryness, psychological issues like depression and anxiety, brain fog, irritability. The longer term consequences of osteoporosis, infertility, and cardiovascular disease/stork are essential to review with appropriate medical teams on a case by case basis.

Estrogen supplementation and hormone replacement type therapy may be appropriate for many women but not all women with premature menopause. The risks and benefits should be reviewed with the physician.

Conclusion

The management of FFA in women under 40 must include screening for early menopause. These guidelines have not been formally recognized but I feel that it is imperative. Tests for estradiol, FSH are a must and test for TSH, LH, blood sugars and calcium and important to consider as well. Other tests may be necessary as well but this is quite case specific. Women with FFA believed to have premature menopause should be referred to the appropriate medical teams for additional work up an evaluation.

Whether young women with FFA who do not show show evidence of entering menopause should be monitored more frequently or whether such women should consider egg retrieval (storage) if future pregnancy is desired is something that requires more investigation and study in our field.

For now, it is important the we all be aware of the possibility of early menopause in women under 40 with FFA.

References

Van Galvan et al. Original articleFrontal fibrosing alopecia: A multicenter review of 355 patients Journal of the American Academy of Dermatology. Volume 70, Issue 4, April 2014, Pages 670-678.

Okeke TC et al. Premature Menopause. Ann Med Health Sci Res. 2013 Jan-Mar; 3(1): 90–95. 


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Men's Health Summit 2019: Jan 19 2019

Lecturing at the Men’s Health Summit

I was honoured to be invited to speak today at the Canadian Urological Association (CUA) Men’s Health Summit in Toronto, Canada. I spoke this afternoon on “The Diagnosis and Management of Male Hair Loss.”

MH2019

I reviewed the clinical features of male balding and traced how our understanding of male balding has evolved from Aristotle’s first observations of male balding in 330 BC to the present day. I reviewed the role of the dermal papillae as the master control centre of the hair follicle and how cell death and apoptosis in the dermal papillae likely contributes to the progressive miniaturization of hair follicles (so called “terminal to vellus” transformation). We discussed the role of minoxidil (topical and oral), finasteride, laser, platelet rich plasma (PRP) and hair transplantation ... and how the new era of “post finasteride syndrome” has not only changed how we counsel patients about finasteride but also changed how commonly we use other types of treatments.

The new era of male balding research is focused on understanding a variety of areas including dermal papillae biology, stem cells, PGD2 inhibitors, PGF2 agonists, Wnt activators and janus kinase inhibitors.

An exciting era awaits!


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Broadening the Educational Experiences of Physicians in Hair Loss

Education in Hair Loss: How to we expand the knowledge base?

SGPBL

I feel strongly that the optimal care of patients with hair loss will come about through broader educational efforts in the medical community.

In my opinion this includes educating family physicians, nurse practioners, physician assistants and others about hair loss. These are in addition to efforts to sustain and advance what we have in dermatology and hair restoration medicine. There is a severe shortage of medical professionals willing to rise to the challenge of caring for patients with hair loss using rigorous scientific evidence-based approaches.

In 2018, I was involved in a number of programs which sought to strengthen the objective of educating more medical professionals. In Canada, I had the honor of lecturing at the Primary Care Dermatology Society of Canada meeting back in the summer. This society seeks to educate family physicians about dermatologic care and has done an amazing job in this regard. 
I also had the opportunity in 2018 to volunteer as an expert reviewer for the continuing medical education (CME) series produced by McMaster University in Canada. The Practice Based Small Group Learning Program (PBSG) is a unique program for family doctors whereby physicians meet once or twice per month to discuss learning modules. The group has grown to include over 5000 members.

The relay of clear information backed up by medical studies is what is desparately needed in the hair loss world. A rural physician, nurse practitioner or physician assistant in the most remote areas of the country can provide care to patients with hair loss just as effectively if not better than a physician in the busiest of cities if they are equipped with the right tools.

We have a number of similar goals and objectives planned for the year ahead.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Recent Article in Journal of Cutaneous Medicine and Surgery

Working with the brightest

JCMS

I am privileged to work with many bright medical students, residents and physicians whose energy and enthusiasm can never be forgotten. One example is this wonderful manuscript recently produced by University of Toronto medical student (and soon to be physician herself) Stephanie Wan that I had the privilege of supervising.

The article was just published last month in the November/December 2018 issue of the Journal of Cutaneous Medicine and Surgery.

Few articles in the medical literature have explored how hair loss is portrayed in various classic works of literature. The paper draws a nice parallel between a character’s experience of hair loss with the loss of identity that patients themselves often expeirence. Honored to work with Stephanie.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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CSPA Pro-Patient Dermatologist Award

2018 CSPA Pro-Patient Dermatologist Award

I was honoured to be recognized as a 2018 Pro-Patient Dermatologist by the Canadian Skin Patient Alliance (CSPA). The CSPA is a non-profit organization that works hard to improve the quality of life of individuals with a range of dermatological issues.

CSPA

Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Vaccinations for Patients Using Immunosuppressants for Hair Loss: Which ones do I need?

Vaccinations Before and After Starting Immonsuppressants

Part 1. Vaccines BEFORE starting Immunosuppressive Agents

Immunosuppressive agents are used to treat several hair loss conditions including scarring alopecias and alopecia areata. These include drugs such as methotrexate (higher doses), cyclosporine, mycophenolate, tofacitinib, ruxolitinib, azathioprine and high dose prednisone (prolonged use of doses higher than 1 mg per kg). Individuals receiving these agents may be at higher risk for certain infections. Vaccination may help reduce rates of infection.

vaccines

The first step in deciding on what vaccines to administer comes from understanding the patient’s previous vaccination history and exposures. If there are certain childhood vaccines that the adult has never received, consideration should be given to administering these.

Vaccination should always be carefully reviewed with patients BEFORE starting immunosuppressive therapies. A number of vaccinations should be considered in patients with alopecia areata or scarring alopecias who are considering starting immunosuppressive agents. In general, one should speak to their physician about whether or not vaccination is needed for five infectious conditions: herpes zoster (Iive vaccine), HPV (recombinant vaccine), influenza (killed vaccine), hepatitis B (killed vaccine) and pneumococcus (killed vaccine). If so, these vaccines should be administered at least 4 weeks prior to starting the immunosuppressive agent.

1. Influenza vaccine (killed) - recommended for most before starting

Influenza infection can be a serious disease and sometimes fatal. The influenza vaccine can reduce morbidity and mortality from this infection. When we speak of the flu shot - we are typically referring to the inactive killed vaccine. It is important however to remember that there are two influenza vaccines: an Intranasal live attenuated influenza vaccine (LAIV) and inactive influenza vaccine (IIV)/trivalent inactivated vaccine (TIV). Patients on immunosuppressive medications should not receive live vaccine. 

The intramuscular attenuated vaccine is the vaccination is the vaccination that should be administered on a yearly basis. For patients who have demonstrated previous anaphylactic reactions to eggs in the past, there are recombinant flu vaccines available that lack ovalbumin.

These vaccinations can be re-adminsted yearly even for hair loss patients on tofacitinib, ruxolitinib and other immunosuppressive agents.

2. Pneumococcal vaccine (killed) - recommended for most before starting

The pneumococcal vaccine protected against infections with the bacteria S. pneumonia. The polysaccharide vaccine in adults protects against 23 serotypes. This is the common vaccine used in adults (i.e. Pneumovax). Conjugate vaccines are also available for adults. Normally these vaccines are given in childhood (4 vaccinations) and then repeated 5 years after the first vaccination. A lifetime revaccination dose at age 65 years or above.

3. Herpes zoster vaccine (live) - administered on a case by case basis

The zoster vaccine is a live attenuated vaccines to prevent shingles (herpes zoster) and may be appropriate for some individuals before starting immunosuppressive therapies. It is approved for individuals 50 years or older regardless of whether they have chickpox or shingles in the past. The zoster vaccine should be administered AT LEAST one month prior to receiving immunosuppressive therapy to reduce the chances of viral activation. Other live vaccines are shown in the list below.

4. Human papilloma virus HPV vaccine (recombinant) - administered on a case by case basis

HPV is the most common sexually transmitted disease in the world. Cervical cancer contributes to 8 % of all cancers in women worldwide. HPV is a clear risk for for cervical cancer. One in four individuals in the United States are infected with HPV. The HPV vaccines may be appropriate for some individuals before starting immunosuppressive therapies on a case by case basis. Current recommendations in Western countries include women through age 26 and men through age 21. In general, protocols are in place to vaccinate adolescents age 11 or 12 (two vaccination 6-12 months apart). Teens older than 14 years need three vaccinations over 6 months. Also, three doses are still recommended for people with certain immunocompromising conditions aged 9 through 26 years. Other patient subgroups (men who have sex with men, transgender adults, and young patients with immocompromsing medical condition) may slo benefit.

How best to vaccinate patients on immunosuppressants is not known and is therefore done on a case by case basis. Patients who do not fall in the above risk categories should speak to their physician.

5. Hepatitis B Vaccine - administered on a case by case basis

Recommendations for Hepatitis vaccination differ from country to country according to the prevalence of Hepatitis B in the country. In general, vaccination with Hepatitis B is appropriate for those at high risk. This includes health care workers, IV drug users, and those with multiple sexual partners in the last 6 months.

Patients who May be Considered for Hepatitis B Vaccination

1) Polygamous relationship (those with more than 1 sex partner during the last 6 months)

2) Persons seek evaluation or treatment for a sexual transmitted disease

3) Current or past IV drug users

4) Men who have sex with men

5) Health care workers who are exposed to blood or potentially infectious body fluids

6) All diabetics younger than 60

7) Diabetics over 60 years (at discretion of doctor)

8) End stage kidney disease

9) Chronic liver disease in those with HIV

10) Household contract of those with BSAG positivity

11) Clients and staff members of institutions for those with developmental delay

12) International travellers to counties with high Hepatitis B infection

5. Tetanus and diphtheria - administered on a case by case basis

Tetanus and diphtheria (Td) is recommended as part of the childhood DTaP 5 series injection. Revaccination is recommended every 10 years. If a patient has not had a tetanus shot in the last 10 years, it’s a good idea to have it before starting immunosuppression.

A note on Live vaccines

The following is a helpful list of live vaccines which must not be administrated to patients on immunosuppressants. If vaccination is needed, it should be done well ahead of starting immunosuppressants.

  • MMR

  • Varicella/Zostavax

  • Oral Polio

  • Flu mist (nasal vaccine)

  • Yellow fever

  • Typhoid vaccine (1 of 3 is live)

  • Small pox

  • BCG – bladder irrigation

Part 2. Vaccines AFTER starting Immunosuppressive Agents

For patients already using immunosuppressive agents, non-live vaccines can be administered on a routine schedule.

A few helpful points:

1. THE ANNUAL FLU SHOT IS OKAY. In general, the routine administration of the seasonal influenza vaccine is recommended for hair loss patents using immunosuppressive agents.

2. MOST INACTIVE VACCINES ARE OKAY. Most inactive vaccines (recombinant, subunit, toxoid, polysaccharride, conjugated polysaccharide vaccines), conjugated pneumococcal (CPV), tetanus-diphteria-acellular pertussis- hemophilus influenza type B (Hib) -inactive polio (DTaB-Hib-IPV), inactive influenza, tetanus-diphteria-acellular pertussis-inactive polio (DTaB-IPV), Hepatitis B, Hepatitis A)] can be administered in accordance with routine vaccine schedules.

3. LIVE VACCINES SHOULD NOT BE GIVEN. Live vaccines (see list above) MUST be avoided in patients already using immunosuppressive agents. Live viruses can replicate in patients who have received immunosuppressants and this can bring about potential harm to the patient. The CDC states that oral polio virus OPV) should not be administered to any household contact of a severely immunocompromised person. Measles-mumps-rubella (MMR) vaccine is not contraindicated for the close contacts (including health-care providers) of immunocompromised persons.

Summary

Discussion about previous and future vaccinations is important for all patients about to start immunosuppressive agents. The pneumococcal and injectable (killed) influenza are the only two vaccines universally recommended in all cases of immunosuppression. The remainder are dealt with on a case by case basis. Another important principle is that live vaccines must never be given to patients who are receiving immunosuppressive medications.



REFERENCES

https://www.cdc.gov/mmwr/preview/mmwrhtml/00023141.htm. Accessed Jan 4 2019.

Lopez et al. Vaccination recommendations for the adult immunosuppressed patient: A systematic review and comprehensive field synopsis. Journal of Autoimmunity 2017.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Men's Health Summit (Jan 19 2019) - Toronto, Canada

University of Toronto Men’s Health Summit

I am looking forward to joining the faculty of the Division of Urology at the University of Toronto next week to speak at the Men’s Health Summit. I’ll be lecturing Saturday afternoon on the topic of Male Hair Loss


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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Post Partum Hair Loss

Hair Loss After Delivery

Post partum hair loss (hair loss after delivery) is common and nearly all women develop some degree of shedding after delivery. I was recently interview for the Huffington Post on this subject.

Postpartum Hair Loss Can Be Severe And Devastating For New Moms

Post-partum hair loss is a normal physiological process and not a sign of disease. During pregnancy, the rate of daily hair shedding decreases to extremely low levels and the result is an increased density on the scalp for most women. The result is that hair appears quite full for many women while pregnant. After delivery the changes in estrogen and progrestone trigger a resetting of the shedding rates back to what they once were - and this comes about only by increased shedding of hair initially.

Post partum hair shedding typically starts 2-3 months post partum and can last 6 months or more. By the time of the baby’s first birthday, hair shedding should be returning back to normal for the new mother. If not, careful review should be done by a dermatologist.

Practical Advice for Women with Hair Shedding

1. Wash and shampoo as often needed.  More hair will come out on the days that the hair is shampooed but this will not affect the long term density of hair.  The use of a volumizing or thickening shampoo may help the hair look fuller and feel thicker.

2. Use a conditioner formulated for fine hair. I recommend that women with shedding avoid heavy conditioners as these tend to weigh down the hair. A conditioner formulated specifically for "fine hair" tends not to weigh the hair down as much.  The conditioner should be applied only to the ends of the hair.   If it is applied to the scalp and the entire hair it tends to weigh the hair down.

3. Avoid hair styles that puts stress on the hair.  This includes tight braids, pigtails, cornrows, or a tight pony tail. These hair styling practices can lead to more hair being pulled out.

4. Avoid excessive combing of hair when it is wet.  This can lead to more hair breakage. The use of a large tooth comb can be helpful.

5. Eat as healthy as possible.

6. Talk openly about hair loss concerns. With so much focus on the new baby, there is often little attention given to the concerns of the new mom. It is normal to be worried about hair loss. Talking with others, especially other mothers who experienced hair loss, can be helpful.

7. Wear a wig or hairpiece for a short time if it helps cope with hair loss. Very rarely, a new mom with extensive hair shedding will ask whether wigs or hair pieces are safe or whether they weigh down the hair and prevent it from breathing. Wearing a wig or hairpiece is completely safe. This can be a helpful camouflaging option for women whose scalp can be seen.

8. Consider cutting the hair shorter. This will give more lift to the hair and weigh it down less. This can help camouflage hair loss to some degree. However, cutting hair won’t make the shedding stop faster or hair grow back quicker.  Shorter hair can also be much easier to manage.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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On the Chasing of Dreams

On the Chasing of Dreams…


The dreams and ambitions of humans do not live inside of hair follicles. Rather, dreams live and are nurtured inside the human mind before they are finally translated by the individual into reality.

The loss of one’s hair should never lead to loss or modifications to one’s original dreams and ambitions - unless of course one has lost their mind somewhere along the way. The chances of the latter are, of course, rather unlikely. Dreams reside entirely in the mind.

Yes, it is true that the chasing one’s dreams in the face of hair loss may take more work for some individuals and perhaps even take more time for others...but the exact same dreams are right there for the taking.

Small dreams or big dreams. Let nothing stand in the way of your ambitions. Your mind is powerfully strong.


Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Whistler office at 604.283.1887
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