Too Much Hair with Oral Minoxidil: Should I be Stopping?

Excessive Hair with Oral Minoxidil: Is it a sign I should be stopping?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to excessive hair growth with oral minoxidil.

Question

Hi Dr Donovan,

I am a 43 year old health female. I am getting hair on my arms with oral minoxidil as well as other areas I don’t normally see hair. Is this a sign that I should I be stopping this medication? It’s helping my scalp hair amazingly but I’m worried that it’s causing more harm than good.

Answer

Well, you’ll want to speak to your doctors. It depends a little bit on the degree of excessive hair on the body and exactly how worried you are. If you are on acceptable doses of oral minoxidil (ie under 2.5 mg for females) and tolerating it well, then I’m not necessarily worried from a medical point of view. By tolerating it well, I mean no headaches, not swelling in the feet, no swelling around the eyes, no dizziness, no shortness of breath, no palpitations, no exercise intolerance, no sleeping troubles, no cough. But if you are worried about the amount of hair - then I’d be worried about the amount of hair. If you are not worried about the amount of hair, then I’m not worried.

Generally speaking, hair won’t go away unless you remove it. If you are okay with having more hair or if you are okay getting it removed, then this is not generally a problem. Of course, you don’t necessarily have to remove it. If the hair bothers you, there are ways to reduce the hair. If the hair does not bother you, then it can be left. The hair growth itself does not mean there is something harmful going on.

Hair growth on the face and body is very common with oral minoxidil. Some studies have suggested it’s even as high as 50%. Many many people get this side effect. It’s very common. Oral minoxidil grows hair - and that includes hair in places with don’t really want it to grow. You and your doctors can review together what’s best to do for you and your goals. Again, if a person does not mind the extra hair, one does not need to stop. Everyone starting oral minoxidil must be prepared for more hair on the arms, face, and body. One hopes it does not occur - but one has to be prepared for it to occur. The higher the dose of oral minoxidil, the more likely this side effect will occur. Women on 0.25 mg often don’t have much hair growth on the body as a side effect. Women on 2.5 mg often have a higher chance of hair growth on the body.

There are dozens and dozens and dozens of patients in my practice that have had really nice results with oral minoxidil but have not been happy with the hair growth that occurred somewhere else on the body. Many have chosen to have these hairs removed with various cosmetic means (laser, wax stripping, electrolysis).

Thanks again for the question.

REFERENCE

Sanabria B et al. Adverse effects of low dose oral minoxidil for androgenetic alopecia in 435 patients. JAAD 2021; 84: 1175-78

Spironolactone vs Finasteride: Which is more likely to cause weight gain? Concerns about low ALP?

Spironolactone vs Finasteride: What are the chances of weight gain?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to finasteride and spironolactone related weigth gain and important issues related to low ALP levels.

Question

I am a 53 year old female. I have progressive thinning of hair but also ongoing shedding. I have used minoxidil without success. I’m thinking about using finasteride. I am concerned about weight gain with finasteride vs spironolactone.  I am quite an inactive person.  I’d like to know your thoughts.

As far as my health goes, I have been diagnosed with osteoporosis. I have also been diagnosed with fibromyalgia and have chronic fatigue, muscle and bone pain.  I am somewhat limited in my mobility due to joint pains (feet) and difficulty walking.  My blood tests have shown low ALP all my life (around 11-17 U/L) so that is not new.  Recent tests show have low estrogen (<40)  and high FSH 56. My testosterone is low. TSH is 1.25, Ferritin is 55. ESR is 2 and CRP is 0.4. My zinc and vitamin D normal.

I am interested to know if finasteride or spironolactone is more likely to weight gain. Is low ALP associated with androgenetic alopecia?

Answer

Thanks for this question. This is a very interesting question for a reason I’ll come to in a minute.

First, the short answer is that spironolactone and finasteride can both cause weight gain in women – but overall chances are fairly low. The chances seem to be lower on spironolactone than finasteride but really good comparative studies are lack. Some estimates have suggested that 1 out of 75 users on spironolactone gain weight. We don’t have great data on finasteride, but I would guess that around 1 in 8 to 1 in 15 users have some weight gain.

We’ve compared some of the side effects of spironolactone and finasteride in the past.   I’ll link the article below.

Low ALP with Musculoskeletal Issues.

Before I leave the question, I’d like to mention a few things about your blood tests, Certainly the low estradiol,  high FSH and low testosterone are consistent with a perimenopausal transition or menopausal state. These numbers are not concerning.

What is a bit concerning is your chronically low ALP – especially in the setting of these bone and muscle issues. I do think that you should speak to your doctors about your lifelong low ALP. No, these are not associated with AGA. What’s so important here is that a condition known as hypophosphatasia at least needs to be considered by your doctors. It’s not a cause of hair loss but I thought I’d mention it as it often goes misdiagnosed and getting an accurate diagnosis could be really important. We’ve actually had a question of the week realted to low ALP in the past. The link is here: Low ALP and Hair Loss.

A variety of medical conditions can cause low ALP. I’ll direct you to a Patient Information Sheet we have for Hypophosphatasia (HPP) which outlines some of those conditions. It does not seem too likely that you have any of these other conditions on the list that cause low ALP but of course I don’t have all your story.

With your history, I think it’s important that a basic work up be done.  I have suspected HPP in several patients in the past with a simple rule “patients with persistently low ALP and bone, joint, muscle or teeth concerns often benefit from further investigation by an endocrinologist, genetics specialist or specialist in these metabolic issues.”

Your history of a fibromyalgia like presentation together with the muscle and bone pain make me wonder if HPP could be present. You should have someone review this

Here are the tests I would typically recommend to my own patients with persistently low ALP without a clear cause have done.  (I also recommend that patients stop all vitamins for 1-2 weeks before having these tests done)

1.    ALP ( in your case, not needed to repeat)

2.    AST, ALT bilirubin

3.    Ferritin and anti TTG - probably not needed for you

4.    Vitamin B6 and vitamin B12

5.    Calcium and 25 hydroxyvitamin D, Phosphate

6.    PTH, if indicated

7.    TSH - probably not needed for you.

8.    AM cortisol

9.    Glucose

10. Hemoglobin A1c

11. Ascorbic acid

12. Magnesium and Zinc

13. Creatinine

14. Urinary calcium (if needed) – not usually helpful.

15. Copper and ceruloplasmin (if appropriate)

In general, a persistently low ALP level on two or more occasions (less than 40 U/L) with the right clinical story along with confidence that other diseases have been ruled out increases the likelihood that HPP may be present.  

Diagnosis of HPP is important for several reasons.

First, proper diagnosis may help get patients connected with the right experts. I see that you have osteoporosis. I don’t know if you receive any kind of treatment for the osteoporosis but I would point out that it’s now appreciated that typical treatments for osteoporosis like bisphosphonates are not the ideal treatment if “hypophosphatasia (HPP)” is your diagnosis. This is simply because bisphosphonates use may worsen outcomes in patients with HPP.

Second, many adults with HPP have been misdiagnosed with other conditions and having a diagnosis of HPP offers validation for their symptoms. Some patients with HPP are diagnosed with depression, sleep disorders, joint problems, fibromyalgia and more. Getting an accurate diagnosis helps people heal in many aspects of the disease.

Third, HPP is thought by experts to be more common than realized. It’s possible that HPP gets passed down from one generation to another and manifestations may be different from generation to generation. In autosomal recessive forms, it’s possible that two parents with HPP who don’t know they have HPP could have a child with severe forms of perinatal, infantile or childhood HPP. Getting the diagnosis of HPP as early as possible in an adult, will help allow for appropriate genetics counseling in the event that a patient with HPP wishes to have children. In your case, it could be helpful in the event you have children and they have any bone, joint, teeth or muscle and neurological issues. If you are found to have the condition, you might discuss with your children more about the condition and if your children want to be evaluated.  Again, I’d like to make it clear that I don’t know for sure you have this but I do think someone needs to rule this out with 100% certainty. Anyone with chronically low ALP with bone and muscle issues needs to have HPP ruled out.

Thank you again for the question.

Methotrexate and Isotretinoin: Can they be used together?

Methotrexate and Isotretinoin: What concerns exist when both are used together?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to the use of methotrexate and isotretinoin.

Question

I have been prescribed isotretinoin 10 mg three times weekly and methotrexate 15 mg once weekly for severe LPP that has not responded to most treatments. A few dermatologists were nervous about this treatment and even the pharmacist phoned my doctor about it. Is this something that you prescribe?

Answer

The answer is yes - but not routinely. These two medications have been used together to treat a variety of conditions but only when prescribed by an experienced practitioner and only when prescribed alongside appropriate counselling of the patient and appropriate monitoring.

But the short answer is yes - it is possible to use these.

The main concern here is that both drugs can irritate the liver and raise liver enzymes. Methotrexate is well known to be hepatotoxic.

Methotrexate and Isotretinoin can been used in combination for psoriasis, skin cancer (mycosis fungoides), and other skin issues such as keratosis lichenoides chronic and acne. So this is not a first.

On should take special note that in June of 1999, the US Food and Drug Administration (FDA) Advisory Panel decided to go ahead and slightly modify the package insert for methotrexate, issuing a precaution regarding the potential for increased hepatotoxicity (liver toxicity) when administered concurrently with retinoids (drugs like isotretinoin and acitretin). The FDA recommended “close monitoring of patients.”

One must not miss the fact that this change came more than 50 years after methotrexate was approved for the treatment of cancer. As some authors have pointed out this change from the FDA came without all that great of evidence, In fact, the FDA acknowledged that no formal study was performed, only that “hepatotoxicity was reported in such cases.” interestingly, the FDA did not provide references for these mentioned cases.

Searles et al 2011

In 2011, Searles and colleagues reviewed the published medical literature regarding whether methotrexate and retinoids (such as acitretin and etretinate) in combination were a problem in patients with psoriasis. They found that few cases were reported and in the case of a patient using etretinate - it was possible that the etretinate itself rather than the combination was the problem.

The authors state that “the contraindication in the acitretin package insert is not evidence-based and may discourage appropriate use of this combination therapy for patients who require it for severe psoriasis.

Conclusion

All in all, methotrexate and isotretinoin is not a treatment one should use without careful thought. But it certainly is possible to use provided the prescriber is experienced and proper monitoring is done. In other words, if the doctor knows what he or she is doing and is the doctor is willing to order lots of blood tests to keep close watch of liver enzymes - it can be a very helpful treatment for some patients.

Now, is is not a treatment that I might use in someone with risk factors for liver disease already including risk factors for what used to be called non alcoholic steataohepatitis. These include obesity, age, and diabetes. So patients with these risk factors and patients with alcohol use and not willing to do blood tests, this might not be a good combination.

I will require baseline blood tests for CBC, creatinine, cholesterol, triglycerides, hepatitis B, hepatitis C, and liver enzymes (AST, ALT, bilirubin), urinalysis (and possibly other tests) and then after starting I will perform close monitoring of AST, ALT, bilirubin, creatinine, urinalysis, cholesterol, triglycerides according to current guidelines.

REFERENCE

Woo YR, Lee HM, Lee JS, Koo DW. Long-term follow-up of refractory mycosis fungoides which achieved remission with the addision of isotretinoin to methotrexate and psoralen plus ultraviolat a therapy. Ann Dermatol. 2013 May;25(2):259-60. doi: 10.5021/ad.2013.25.2.259. Epub 2013 May 10.

Rodríguez-Lomba E, Molina-López I, Monteagudo-Sáez I, Suárez-Fernández R, Campos-Domínguez M. A case of acne fulminans with sacroiliitis successfully treated with methotrexate and isotretinoin. Dermatol Ther. 2016 Nov;29(6):476-478. doi: 10.1111/dth.12382. Epub 2016 Jun

Alvin W Li,  William Damsky and Brett A King. Keratosis lichenoides chronica successfully treated with isotretinoin and methotrexate. JAAD Case Rep . 2017 Apr 14;3(3):205-207.

Alyssa D Searles, Andrew D Lee, Steven R Feldman. Is concomitant use of methotrexate and oral retinoids dangerous? A review of the data regarding this combination. J Am Acad Dermatol . 2011 Apr;64(4):791-3.

Can covid vaccines or COVID infection trigger scarring alopecia?

Are COVID vaccines or infection responsible for scarring alopecia?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in the connection between scarring alopecia and vaccines.

Question

I had a COVID vaccine in 2021 and developed frontal fibrosing alopecia in 2022. Do you think there is a connection? I hear you mentioning a connection between vaccines and alopecia areata for some patients. What about those of us with scarring alopecia? What’s the current thinking about all these issues?

Answer

Thanks for the great question. Yes, there has been quite a lot of questions coming in related to this subject. It’s a tricky question for reasons we will see in just a moment. I would imagine there are 5000-6000 patients with frontal fibrosing alopecia in the United States that have this very same question - their FFA started sometime in the last 1-3 years and they are wondering about the role of the vaccine or COVID infection. For most of them, it’s unlikely the vaccine or COVID was the cause - but certainly it could have flared the disease or worsened the disease for many. It’s possible that for a very small proportion it was the main trigger of the disease - that’s tougher to prove as we’ll see in a moment.

As we begin to talk about this subject, we need to distinguish two things. These distinctions are often completely forgotten about so it’s worth going over them. There is a major difference between COVID vaccines or COVID infection “flaring” or “worsening” existing scarring alopecia and COVID vaccines or COVID infection actually causing new onset (first time) scarring alopecia.

It’s fairly common for vaccines or COVID to flare existing scarring alopecia.

It’s felt to be fairly rare for vaccines or COVID infection to cause brand new scarring alopecia.

We’ll come back to this in a moment.

When a person says to me “do you think COVID vaccines can cause new onset scarring alopecia?” my responses is “I think it’s possible although I think it’s fairly uncommon and we don’t have alot of good evidence from any studies to really support this. But yes, I think it’s possible. So the answer is yes.

When a person says to me “do you think COVID vaccines can worsen someone’s existing scarring alopecia?” my responses is “I know that is possible and it happens a fair amount of the time and we’re starting to get some evidence that actually support this. So the answer is yes.

But even though the answers are yes, the odds or chances are very different. One is fairly likely and one is not so likely.

So the distinction between vaccines causing scarring alopecia and vaccines flaring or worsening scarring alopecia is very different. These distinctions are blurred by people.

Many people ask me on social media or on various public webinars if I think COVID infections or COVID vaccines cause their scarring alopecia. The reality is I can never say with 100% certainty but I can give it an approximate ranking from ‘very likely’ all the way down to very unlikely”

Let’s review the diagram below.

Consider the hypothetical patient listed as number 1 in the diagram below. She developed FFA in 2022 and had the COVID vaccine in 2021. She’s 200% convinced there is a link between her getting a vaccine and her developing FFA. Well, I can’t be 100% sure there is not a link but let me say that for this hypothetical patient I’m certainly not giving it very high odds there is a link. You see, she started losing eyebrows in 2015 and when you really sit down and review her story you realize that she probably had been misdiagnosed for 6 years or 7 years. Her FFA started a long time ago! Finally, when she got a COVID vaccine her FFA flared and someone finally made the diagnosis in 2022. Was the vaccine the cause? No way. It’s pretty common for FFA to be misdiagnosed for years and years and years. The year of a person’as diagnosis is not usually the year a person’s disease started.

And so you can go through some of the examples below. I hear stories like this every single day of my life. What it takes is some good listening to figure out - were there really any signs of scarring alopecia before the vaccine? Now, that’s not up to the patient to decide as some of the scarring alopecias are completely asymptomatic and completely hidden in the early stages. So, just because a patient says they did not have evidence of a scarring alopecia does not mean they did not have evidence of a scarring alopecia!

Scarring Alopecias Occurred Before COVID and Will Continue to Occur After COVID

Every year in the United States, there are probably 1000-2000 new cases of frontal fibrosing alopecia that get diagnosed. So that means there is going to be lots and lots of patients who get COVID infection or get a vaccine and then come to learn they have scarring alopecia. Was COVID or the vaccine responsible for their new diagnosis?

For many, it’s not related at all. But for a small number, I would estimate yes - that probably it is related in some way. For many, though - I must emphasize that it’s probably not related at all. People just develop this condition regardless of whether COVID enters the picture or not

Researchers are interested in looking at whether FFA and LPP and scarring alopecia are increasing in the pandemic or not. That’s tricky to properly study because FFA is increasing anyways year by year. So if we find that rates of FFA are higher in 2023 than 2019 (before the pandemic), that does not mean the increasing rates are due to COVID 19 or COVID vaccines. Rates of FFA are increasing and increasing and increasing long before COVID entered the picture. We expect rates of FFA to keep going up and up and up in the forseeable future (of course nobody knows why that is) !!

What will be more telling is if rates of scarring alopecia appear to sky rocket in the post COVID era or if patients with 5 or 6 vaccines are more likely to get FFA than patients with 0 or 1 vaccinations…. Or if patients with 7 COVID infections are more likely to develop scarring alopecia than those who have 1 infection. Now we’re getting somewhere!

Conclusion

Thanks for the question. I have no clue if there is a connection between your vaccine and FFA for YOU specifically as I don’t have enough information from you about your story. I need lots and lots of information !!!! I’d need to review many many things in your life and health from 1995-2022. The more and more answers from the following list below that are “yes” then I’m slowly getting less and less likely to believe your vaccine caused your FFA. (Now it could have flared it but actual causation is different). However, the fewer and fewer items on the list below that are yes, then I’m more and more likely to feel a link is possible. Again we expect 2000 people in the United States to develop FFA this year anyways so establishing a causal link is not always easy. You need to also factor in other infections as triggers (COVID, etc etc), stress, medications that may cause FFA, etc etc.

Before the year 2021…
a) did you have any loss of eyebrow hair?

b) did you have any loss of scalp hair?

c) did you have scalp itching or burning?

d) did you have loss of body hair, arm hair, pubic hair, underarm hair?

e) were you diagnosed with Hashitmoto’s thyroiditis?

f) were you diagnosed with rosacea?

g) did you feel your hairline was changing?

h) was your scalp sore?

i) did you have early menopause?

j) did you have a diagnosis of lichen sclerosus?

h) did you have skin lichen planus?

i) did you have oral lichen planus?

Where on the scalp should a scalp biopsy be done?

Poor Hair Growth After A Hair Transplant. Where on the Should A Scalp Biopsy Be Done?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in the the evaluation of poor outcomes post transplant.

Question

I am a physician and enjoy your articles, videos and podcast immensely. I have a patient with a hair transplant that did not grow well. I think they have LPP or FAPD or some kind of scarring alopecia.

Do you have any tips on where on the scalp I should biopsy?

Answer

Thanks for the question and comment. This general concept of poor growth post transplant is really important to be aware of. Not everyone grows hair spectacularly after surgery. Fortunately, most patients do and hair transplants are a very reliable way of adding back density in the properly selected patient. There are a variety of patient factors, surgeon factors and scalp factors that affect the outcome of surgery. We’ve reviewed these in the past.

So where should a Scalp Biopsy Be Done?

I’m glad you are considering a biopsy as there are so few reasons not to do a biopsy when hair does not grow well post transplant.
In my opinion, the best area to biopsy would be an area that you feel has the morphological features of LPP - outside the transplanted areas. This might be an area showing perifollicular scaling outside the transplanted area. The second best is an area showing perifollicular erythema and white patches outside the transplanted area. The reason this area (outside the transplanted area) is so good is that it is not altered by the surgery. The hair transplant itself can give fibrosis and sometimes even chronic inflammation. Now a good pathologist can work through all this ‘noise’ but it makes the interpretation more challenging.

Some biopsies of scalp that has been transplanted just comes back ‘scarring” alopecia even if it’s not scarring alopecia at all. The pathologist sees some fibrosis and concludes something is wrong.

So having a biopsy from outiside the surgical field is wonderful for this reason.

The third best area to biopsy is an area showing perifollicular scaling inside the transplanted area. You’ll need to warn the pathologist that the patient had a transplant because this needs to be factored into the interpretation.

All in all, in cases like this, a few biopsies may be needed to confirm a more subtle diagnosis. I would encourage you to consider a few biopsies - including those from inside and outside the surgical field and also if there are different morphologies.

Good luck!

For Alopecia Areata, How many visits to the doctor to get hair growth?

How many doctor visits are needed in alopecia areata?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in the treatment of alopecia areata.

Question

I have alopecia areata in an area on my scalp and I am thinking about going to the dermatologist for treatment with steroid injections. How many treatments will I need?

Answer

I am glad to know that you’re considering steroid injections. This can be a very effective treatment as we’ll see in just a minute.

For most small, coin-shaped, patches of alopecia areata, 1-2 visits to the doctor are sufficient to trigger growth. Not all patients experience growth but  90 % or more of patients with such limited degrees of alopecia areata do. Patients with many patches of hair loss or patients with larger amounts of hair loss (more than just a single patch) may not benefit from steroid injections.

It’s important to keep in mind that you may even experience spontaneous regrowth too. Patients with a patch or two of hair loss can experience regrowth sometimes even without treatment. Steroid injections is a reliable and reasonably safe way to vastly improve the odds of getting hair back.

Treatment at the right concentration and the right amount is required. For example, 0.1 ml of a 1 mg per mL injected into a coin-shaped patch is unlikely to help you get growth although 0.4 or 0.5 mL of 2.5 mg per mL is quite likely to help a small patch of this size. Some doctors use 5 mg per mL and some use 10 mg / mL although the chances of atrophy increase significantly as one increases the dose.

Finally, it’s important to keep in mind that your decision to treat this area of hair loss does not prevent a new area from forming somtime in the future. In orther words, these steroid injections are a treatment for this area of hair loss but not a cure for alopecia areata.

Although hair may grow back in the patch you are treating, there is a reasonable possibility that another patch may form in that same area or at a completely different area at some point in the person’s life. Treatment of a patch does not influence whether another patch will or will not form and a high proportion of patients do experience another episode at some point in their lives.

In summary, hair regrowth following steroid injections should be seen within 4 weeks for most patients with one or two small patches of alopecia areata. It hair does not regrow, one needs to seriously reconsider if they have the right diagnosis. Tinea capitis, lichen planopilaris, pseudopelade, dissecting cellulitis, syphilis and infiltrative diseases can rarely mimic alopecia areata.

A scalp biopsy may sometimes be needed if a small patch shows absolutely no improvement.

Dose of Finasteride for Frontal Fibrosing Alopecia in Males

What is the correct dose of finasteride for treatment of male FFA?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to the correct dose of oral finasteride for treatment of male frontal fibrosing alopecia (FFA).

Question

I have a very simple question which I cannot find an answer for anywhere...maybe that means it isn't so simple! The use of finasteride and dutasteride for those with FFA is well known. Many studies refer to finasteride doses of 2.5mg or 5mg daily, but all seem to be for women. For men with FFA already using 1mg finasteride daily for androgenic alopecia, should they up their dosage to 2.5mg, or even 5mg per day? I can't find anything, any study, any reference anywhere that answers this question.

Answer

Many thanks for this question. This is a great question! You’re right - it’s not something that really gets looked at carefully in the research world. When you actually look at all the research papers on male FFA, most talk about things other than treatment! These research papers are filled with detailed information on patient age, where the hair loss occurs (eyebrows, scalp, beard), and other medical conditions affected patients have. It’s so incredibly rare to find good information about treatment (especially detailed investigations about finely tuned dosing!)

There has never ever been a good study examining 2.5 mg finasteride compared to 1 mg finasteride in males with FFA.

Now, that said, there is no good reason to believe that 1 mg is a problem. Many of my male patients are using 1 mg finasteride … and see benefit!. Would 5 mg be better? There is no reason to believe so but again studies have not been done. Petersen and colleagues (reference below) described a study of 7 male patients with FFA. 3 were put on oral finasteride and those three ended up staying on finasteride because it was part of a plan that helped.

Alegre-Sánchez and colleagues (see reference below) described 12 males with FFA. Just one was put on finasteride … and it helped.

So in most studies we have patients that are put on 1 mg finasteride stay on 1 mg finasteride.

Discussion and Conclusion.

Your question is a great one and the reality is that the studies of FFA in males are few and those that we do have show patients with a wide variety of treatments. I’m not so sure that FFA in males is so so so “antiandrogen responsive” like female FFA. It certainly is to some degree - but until that time we learn more I think it’s reasonable to cover the bases with prescribing antiandrogens PLUS other immune modulators (doxycycline, and other tetracyclines, hydroxychloroquine, steroid injections, topical calcineurin inhibitors (pimecrolimus) and/or retinoids like isotretinoin.

It really all comes down to getting on a solid plan that a person is comfortable with and then taking incredibly good photos every 3-6 months. If the photos look the same (and I mean 100% the same) then that means the disease is coming under good control.

If there is evidence of loss, that’s where I would switch a patient who is using finasteride 1 mg to dutasteride 0.5 mg (or go up to 5 mg finasteride if dutasteride is not an option for some reason).

Now that said, we don’t have any great evidence to support finasteride over dutasteride in males with FFA quite yet. In females, oral dutasteride does seem to be the favourite option for FFA. We just don’t have the data in males. So there’s nothing wrong with oral finasteride 1 mg for treating FFA in males. Lots of data supports it.

I think other things need to be considered as well. If there is evidence of ongoing beard and eyebrow and eyelash loss, then I probably would bring on board some good antinflammatories as mentioned. Hydroxychloroquine, isotretinoin, cetirizine, isotretinoin, methotrexate, and JAK inhibitors are on that list.

If I see a patient with new FFA in the clinic, I generally start 0.5 mg dutasteride rather than 1mg finasteride. This is not because there is good evidence in males but because it seems to be the preferred option in females. If I see a patient who is already on 1 mg finasteride and doing well, I may continue it for the time being and optimize other parts of the plan before thinking about a switch to dutasteride.

Good photos are key. The photos don’t need to be done weekly but rather every 3 months. If hair is continuing to be loss, then one needs to shift gears and change the plan.

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REFERENCES

Alegre-Sánchez A et al. Frontal fibrosing alopecia in male patients: a report of 12 cases. J Eur Acad Dermatol Venereol. 2017 Feb;31(2):e112-e114.

Peterson E et al. Frontal fibrosing alopecia in males: demographics, clinical profile and treatment experience. J Eur Acad Dermatol Venereol. 2020 Feb;34(2):e101-e104.

Is my hair loss coming from seborrheic dermatitis?

Seborrheic Dermatitis and Hair Loss

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to hair loss from seborrheic dermatitis.

Question

I have itchy scalp and have been told it’s seborrheic dermatitis. I have had hair loss since age 22 and I am now a 29 year old female. Is my hair loss coming from seborrheic dermatitis? I have done prp and minoxidil without help.

Answer

It’s unlikely with the information provided that seborrheic dermatitis is the main cause of hair loss. It’s possible it’s not helping the hair loss….but it’s probably not the main cause. Of course, I would need to see the scalp up close myself and review all your story to say exactly what’s going on.

Seborrheic dermatitis usually doesn’t cause all that much in the way of hair loss. Of course, it can if it’s severe but still it would not account for all the loss you describe. It’s helpful to review the 2006 Piérard-Franchimont et al paper which reminds us that severe seborrheic dermatitis may cause hair loss but minor degrees of seborrheic dermatitis are less likely to cause significant hair loss.

In order to tell you what diagnosis you have, I would need to 1) know all your medical information from birth until now, 2) examine your scalp up close with trichoscopy and review all your blood tests from the recent few years.

If you want to know what’s causing your hair loss, see and expert. And consider a biopsy if you’re still not sure.

With this information provided, and a 7 year history of ongoing concerns about your hair androgenetic alopecia needs to be confidently ruled in or ruled out. This is the most likely reason for ongoing concerns with your hair. Telogen effluvoum may be present, of course, to some degree but young women in their 20s rarely have a 7 year history of worries about their hair without there being some degree of androgenetic alopecia present.

Is my scarring alopecia "burnt out"?

Do you think my scarring alopecia is burnt out?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to inactive and burnt out scarring alopecia.

Question

I’m 45 year old female with lichen planopilaris. I have been using hydroxychloroquine, topical steroids, topical tacrolimus and cetirizine for 9 months… with good effect! I am happy to say that I no longer have itching or burning and shedding has returned to normal. Do you think it’s possible that I am burnt out now?!!! Hoping!

Answer

Thanks for the question. It’s certainly a really good sign that itching and burning are so much better and an equally good sign that shedding has improved. This is great!

However, I can not say with the information provided whether or not the scarring alopecia is inactive. It’s unlikely that it’s “burnt out” but I would need more information. it usually takes a bit longer for scarring alopecia to be truly “burnt out.” You and your doctors might wish to use this flow chart below to assess if your scarring alopecia is burnt out.

Proper assessment for scarring alopecia starts with evaluating symptoms and signs. Itching, burning and pain and shedding are possible signs of active scarring alopecia. But it’s not so simple. Someone can have itching and burning from seborrheic dermatitis instead of scarring alopecia so the simple fact someone has itching does not mean a person has active scarring alopecia. Similarly, someone can be shedding from COVID 19 or low iron instead of scarring alopecia…. so the findings of increased daily hair shedding also does not mean a scarring alopecia is necessarily active!

Similarly, someone can have no symptoms and no shedding but can have active scarring alopecia !!!

Tricky, isn’t it?

Just follow the flow chart below and you’ll see how this is possible.

So to review again, there are several things that happen has LPP becomes quiet. Itching and burning reduce (for those that actually have these symptoms to begin with). Redness reduces. Shedding reduces. Scale and redness around hairs also reduces (that may require an up close examination by your doctors). 

But the one thing that must not be forgotten is that hair loss also stops when disease is inactive. That’s the key!

As a next step to determining if your disease is inactive, you’ll want to have proof that scale and redness have reduced (your doctor will help with that as you yourself can’t fully determine that). And you’ll want to prove that there has been no further hair loss. That’s trickier! You’ll need a good one year and ideally even two years to be really really confident of this. This means taking lots and lots of photos now and comparing an identical set in 1-2 years. If there is truly no change in any of the photos then there is a pretty good chance the disease is inactive.

If you put photos from 2024 out on the table and compare them to 2022 and they look identical in all ways… then it’s probably inactive! If the photo from 2024 shows a bit more eyebrow loss or a bit more loss in the crown … then we may be dealing with ongoing scarring alopecia. Of course, one can have hair loss from other reasons (androgenetic alopecia, etc) so it needs professional evaluation.

One of the problems with determining a disease is inactive, is that patients and doctors don’t wait long enough before assessing that.  In some forms of scarring alopecia that are mildly active it can take 12 months and rarely even 18 months before enough hair is destroyed by the immune system to see a difference on a photograph.

Not everyone with active scarring alopecia has redness, itching, burning and shedding. But everyone with active scarring alopecia will “eventually” lose some amount of hair. That timeline for what constitutes “eventually” ranges from 1 months to 4 years.

So photos are key!

To summarize, it’s possible your scarring alopecia is inactive. Again, I can’t say as I only have been given a small fraction of the total amount of information I would need to render an opinion. But if it is inactive, it’s not likely that it is burnt out. That’s a very special term that is frequently misused. Burnt out means that all medications can be stopped and the disease still stays quiet. I don’t think it’s very likely that you would be able to stop all medications tomorrow and be guaranteed that you would never had hair loss from scarring alopecia again. 

Do keep in mind that there are two types of inactive scarring alopecia. One is medication induced inactive scarring alopecia (also called treatment induced inactive scarring alopecia). This is a situation whereby the scarring alopecia goes to sleep due to the medications that are used. Once medications are stopped the disease wakes up. That’s the most likely type you would have if indeed someone can prove your scaring alopecia is inactive.

The other type of inactive scarring alopecia is “burnt out” scarring alopecia. This is a very special form of inactive scarring alopecia and means that the disease is 100 % quiet - regardless of whether or not medications are being used. In burnt out scarring alopecia, medications can be stopped and the disease stays quiet. Medications have absolutely no effect on burnt out scarring alopecia because the disease is quiet.

Will finasteride compensate for minoxidil?

Will finasteride take over where minoxidil ?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to minoxidil and finasteride for AGA.

Question

I have male balding and am using topical minoxidil. I want to start finasteride and stop my minoxidil.
Will finasteride just take over given DHT is root cause of problem?

Answer

Most likely finasteride will help more than minoxidil. But it’s no guarantee!. That’s important to be aware of!
Absolutely you run the risk of loss if minoxidil was helping and finasteride does not help ‘as much.’

Key analyses by Gupta et al in 2022 showed the finasteride is more effective than minoxidil. So the most likely scenario is a person can switch no problem. However, 10 % of males don’t respond to finasteride! So you if you WERE responding to minoxidil and now are one of the few that DOES NOT respond to finasteride… you lose hair!

DHT is important but there is a multimillion dollar pharmaceutical industry that is banking on the fact there is more than just DHT. If minoxidil helps, it’s lifelong. Could something substitute perfectly for it (like finasteride) - well maybe. Recent data suggests that 5 mg oral minoxidil is more effective than 1 mg finasteride - so how can one say DHT is champion. No.

It’s important but way more complex than the simplistic view of the lay public and thousands and thousands of males who think this is entirely a nice tightly bound story of DHT. No. Of course DHT is important. If one wants to start finasteride and stop minoxidil I advise my own patients to do one at a time. If a person is one of the 10-15 % who don’t respond at all to finasteride then disaster and chaos breaks out when finasteride is started and minoxidil stopped.

Be sure to review all this with your dermatologist.

Can I use Short Term PRP to Kick Start My Androgenetic Alopecia Treatment Plan?

Kick starting AGA with PRP Injections

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to the short term vs long term use of platelet rich plasma (PRP) therapies to treat androgenetic alopecia.

Question

I’m a 38 year old female and have androgenetic alopecia. I  went away to Europe in August and half of September and forgot to take my minoxidil with me and didn’t end up buying more while away as I though it would be okay. . (Well, it was not okay!). In total, I was six weeks off minoxidil. Now, I am shedding crazy amounts. I have now started back on minoxidil but I’m still shedding. I realize it’s only been one month since I restarted and it will take some time. I’m thinking I’d like to do PRP in October and November to help kick start this process again. PRP is a bit over budget for me to continue long term but I can afford a few treatments. Is this worth doing?

I am desperate for something to work !

Answer

Thanks for the question. Be sure to review the full and complete story with your practitioners as there are pieces here of your story that are missing and ideally I need to know more about.

In my opinion starting short term PRP for 2 months is not worth doing. There is no evidence at all that this short term strategy that you have outlined is useful - although I completely understand that it sure sounds good at first glance.

Current treatments for androgenetic alopecia don’t work like this. They don’t work “on and off” and they don’t work “start and stop.”

We can’t apply the logic of every day to the world of hair loss. If you’ve been up all night, you might have an extra cup of coffee in the morning to give yourself a bit of a boost to get through the day.

These sorts of concepts don’t apply in the world of hair follicles.

If you stopped minoxidil the first step is to get back on minoxidil as you have said.

The next step is to figure out how well the minoxidil was actually working for you before you left for your trip. If it was working really well and you were very pleased, then getting back on minoxidil may be all that is needed.

If topical minoxidil was working “just okay”, but not as good as you really would have hoped from a therapy then adding a second treatment to the plan right now would make sense. However, this second treatment must be started with the intention to use it long term. There are no short term treatments. There are no short term vitamins and no short term supplements and no short term lasers and no short term PRP and no short term pills. It’s long term only.

I can’t say what’s right for you as I have only a fraction of the information about you that I need. So let’s talk in general terms about what might be done. Possible options include adding minoxidil a second time of the day, using “more” minoxidil during the one application session you do, using oral minoxidil with the topical minoxidil, using topical minoxidil-finasteride, oral finasteride, oral spironolactone, PRP and laser.

Now keep in mind this is not a “pick and choose” list. It’s a discussion point for you and your doctors. Some of these treatments on the list may not be appropriate for a given patient at all. Only minoxidil is FDA approved and the rest are what we call off label. Some are contraindicated in women who plan to become pregnant or who might become pregnant. So these options are not right for everyone.

But any treatment you decide to add must be used long term. There are no short term kick starts or adding a bit of fuel to the plan or any of the words we like to use when describing other things we do in life.

If you start PRP, then the use should be intended lifelong. If you stop, the hair will likely protest and complain as to why it was stopped (assuming of course it was actually doing anything at all).

Now, it’s important not to wear blinders when evaluating hair loss. It’s important to always be open to a full range of possibilities as to what might be happening with the hair.

If you were using minoxidil for 10 months before leaving for Europe and you feel it really was doing nothing helpful then certainly one needs to ask why your hair is now protesting so much with all this shedding once it was stopped. Hair should not protest if a useless treatment is stopped! So if it is protesting then either minoxidil was not as useless as the patient thought - or another condition or reason for the hair loss is present now.

I would like to add that what I really need with this question is more information about the story. The full story!

We always need to be open to the possibility of stress, low iron, thyroid conditions, COVID infections, nutritional issues, weight loss and other drugs contributing to hair loss!

If a patient has been caring for a sick relative for many months from afar and then that family member passes away requiring the patient to fly from North America to Europe to attend the funeral, is it not possible that it’s the stress and trauma of this experience that is setting off the hair shedding? Of course.

What about a patient who developed COVID after they arrived in Europe and was sick most of their vacation? or developed a febrile diarrheal illness while away ..or had been dieting for 3 months before leaving for Europe and lost 13 pounds in the month before leaving or who had started a new drug for blood pressure or depression or cholesterol before leaving for Europe. Don’t you think this could also be contributing to shedding? 

Yes, yes … it absolutely could be a cause.

So, what is needed is a full story!

So all in all, I think getting back on the minoxidil has been a great plan. What needs to be decided now with your doctors is whether any other triggers might have contributed to this shedding. Blood tests may or may not be needed depending on your story. If you have been unwell while away, then that increases the likelihood that blood tests may be useful.

Next, you and your doctors need to figure out if you want to add a second treatment to the plan or not. However, this must be started with the intention to use it long term. If PRP is out of budget, then don’t use it. It often does more harm than good if used inappropriately - such as short term. There are no short term kick starts.

Triamcinolone Acetonide Scalp Steroid Injections for Hair Loss and Influenza Vaccines

Influenza and COVID Vaccines and Steroid Injections

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to the administration of the influenza vaccine in patients receiving scalp steroid injections.

Question

My treatment for scarring alopecia includes monthly injections of triamcinolone. Now that the fall covid and flu vaccines are available, do you have a recommendation on the timing of the injections with the timing of the vaccines so I get maximum benefit from the vaccines?

Answer

For patients receiving steroid injections into the scalp, there is not sufficient immunosuppression in the body caused by the steroid injections to alter the intramuscular flu or COVID vaccination recommendations. One should check with his or her doctor about whether these vaccines are important to have. If so, the use of scalp steroid injections does not alter the decision about having the vaccine.

Generally speaking, evidence showed that even with doses of prednisone up to 20 mg/day, patients can safety receive flu vaccines and COVID vaccines because the response to inactivated intramuscular vaccines is not suppressed.

REFERENCE

Rubin LG, Levin MJ, Ljungman P, et al. IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2013; 58(3): e44–e100.

CAN MY SCALP BIOPSY BE WRONG?

Can scalp biopsies be wrong?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to accuracy of scalp biopsies.

Question

My biopsy says that I have a non-scarring alopecia but I’m terrified that I actually have a scarring alopecia. Is it possible that my biopsy could be wrong?

Answer

Sure, it’s possible for a biopsy to be wrong but pretty unlikely in a scenario like this. Of course, I would need to see your scalp up close and know more about your story and then I could answer if you have a scarring alopecia or not.

Please note that it’s more common for a patient to receive a biopsy report saying they have scarring alopecia when they do not really have scarring alopecia than for a patient to receive a biopsy report suggesting they have non-scarring alopecia when they actually have a scarring alopecia. So, if there is going to be an error, it “usually” tends to go in the other direction.

But please keep in mind some key points. If you have scarring alopecia in the crown area of the scalp and your doctor took the biopsy somewhere else than the crown area …. well then a scarring alopecia probably won’t show up in that biopsy.

Lots of poeple worry they have scarring alopecia when they have a red scalp and/or an itchy scalp. Please don’t assume for one minute that the only thing that can cause redness, itching, burning, pain, shedding is scarring alopecia. Lots and lots of other conditions can too. If you are skeptical or doubtful just have another doctor review your biopsy or case. Another review of the biopsy can always be done or another repeat biopsy can be performed.

Does HRT Use Affect FFA?

HRT Use for Women with FFA

 
I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in the use of hormone replacement therapy for women with FFA.

QUESTION

Hello Dr Donovan

I was diagnosed very recently with FFA. It’s clear to me now that I have had it for at least 6 years. I started treatment for FFA and at the same time started treatment with HRT. I have been thinking that HRT has accelerated my hair loss. Is this even possible? My dermatologist feels that HRT should help everything!

Answer

Many women with FFA take HRT. That does not mean that HRT causes FFA nor helps FFA. We know a few things about HRT in women with FFA. First, it seems that women with FFA use HRT quite often. In 2018, Imhof et al showed that 63.3% of women with FFA had a history of hormone replacement therapy.

The use of HRT varies dramatically across the world. Women in the US use HRT more often followed by UK and Scandanavia. HRT is dramatically less women among women living in central Euopean countries. In the US, HRT use by post menopausal women has declined from 22 % in 1999 to 5 % in 2010.

In 2019, Moreno-Arrones et al showed that women with FFA were almost two times more likely to use HRT than women who were similar age. (OR = 1.76; 95% CI 1.11-2.8). Again, it’s important not to conclude here that HRT causes FFA. For example, the same study showed that women with FFA were 2 times more likely to have hypothyroidism (OR = 1.73; 95% CI 1.11-2.69). We wouldn’t dare conclude that hypothyroidism causes FFA only that they are possibly somehow linked or connected.

We also know from studies by Meinhard et al that women with FFA are more likely to use HRT than women with LPP. That’s not surprising given that women with FFA tend to be older than women with FFA. But again, there could be something specific about the changes in FFA that prompt HRT.

We know that women with FFA are more likely to expereince early menopause. In 2014, Vano-Galvan showed that 14 % of women with FFA experienced early menopause. This is much higher than the 1 % risk of early menopause in the general population. A 2018 case control study by Buendia-Castrano and colleagues also showed that menopause occured earlier in women with FFA. This data came from examining records of 104 female FFA patients and 208 controls.

Does HRT use Affect the Course of FFA?

All in all, most believe that HRT does not impact the course of FFA (Kossard et al, 1997).

REFERENCE

Kossard S et al. Postmenopausal frontal fibrosing alopecia: a frontal variant of lichen planopilaris.

J Am Acad Dermatol. 1997 Jan;36(1):59-66.

Meinhard et al. Lichen planopilaris: Epidemiology and prevalence of subtypes - a retrospective analysis in 104 patients. Dtsch Dermatol Ges . 2014 Mar;12(3):229-35, 229-36.

O M Moreno-Arrones et al. Risk factors associated with frontal fibrosing alopecia: a multicentre case-control study. Clin Exp Dermatol . 2019 Jun;44(4):404-410.

Imhof RL et al. Frontal Fibrosing Alopecia in Women: The Mayo Clinic Experience With 148 Patients, 1992-2016 Mayo Clin Proc. 2018 Nov;93(11):1581-1588.

Vañó-Galván S et al. Frontal fibrosing alopecia: a multicenter review of 355 patients. J Am Acad Dermatol 2014 Apr;70(4):670-678.

Buendia-Castrano D et al. Hormonal and Gynecological Risk Factors in Frontal Fibrosing Alopecia: A Case-Control Study. Skin Appendage Disord. 2018 Oct;4(4):274-276. doi: 10.1159/000484210. Epub 2017 Dec 8.

Topical Tofacitinib vs Topical Ruxolitinib in Frontal Fibrosing Alopecia (FFA)

Topical JAK Inhibitors for Treating FFA

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to the use of topical JAK inhibitors in treating frontal fibrosing alopecia.

Question

Hi Dr Donovan.

What's better for treating frontal fibrosing alopecia - topical ruxolitinib or topical tofacitinib?

Thank you.

Answer

We don't have a good sense yet of exactly how well the topical JAKs work in FFA. I know with confidence that they do help - we just don't know how much they help and if a certain JAK inhibitor helps more than others. The problem with many topical JAKs is that they may differ if they need to be compounded. For example, topical 2 % tofacitinib made by a compounding pharmacy up the street may differ from topical tofacitinib made by a pharmacy down the street. There are a lot of things we still don't know.

Topical ruxolitinib now has a standard product in the United States for treating vitiligo and atopic dermatitis. It’s called Opzelura and it comes as a 1.5 % cream. This is a nice option becuase it’s premade so patients are guaranteed to get the same product every time. It’s expensive and off label and not generally covered my insurance.

But it’s a good option too.

Overall, I put the topical JAKs as a solid second line option.

I'm not convinced that topical JAKs are absolutely amazing in FFA but I am convinced that they do have a role to help. So if we have a pretty good plan in place and the patient’s FFA needs more help to settle - topical JAKs are an option. Good studies precisely evaluating these agents and comparing topical ruxolitinib and topical tofacitinib are needed.

There are good studies emerging showing that the JAK pathway is probably a lot more relevant in FFA than we ever realized. We’ve reviewed these studies in the past. The link is below:

Thanks again for the question.

REFERENCE

Dubin C et al. Scalp and serum profiling of frontal fibrosing alopecia reveals scalp immune and fibrosis dysregulation with no systemic involvement. J Am Acad Dermatol. 2022 Mar;86(3):551-562. doi: 10.1016/j.jaad.2021.05.016 -

Can I stop my minoxidil for alopecia areata ... or is it lifelong?

Will I be able to stop my minoxidil?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to the use of minoxidil in alopecia areata.

Question

I am a 25 year old female and have alopecia areata. I have three patches and am getting steroid injections as well as using topical clobetasol and topical minoxidil. The protocol seems to be helping a lot and I’m happy with my progress so far. I know the steroid injections and clobetasol are not likley to be lifelong (if the hair can come back) but I’m confused if my Rogaine will be lifelong. Some say that once you start Rogaine that you can never stop?

Answer

In a patient with a few patches of alopecia areata who has no current evidence of androgenetic alopecia … topical or minoxidil can be started and stopped depending on how active the alopecia areata is. It’s simply an add on bonus. In other words, once the hairs grows back from treatment of the alopecia areata, the minoxidil can be stopped and the hair keeps growing (assuming the alopecia areata is still quiet and stays quiet).

However, if the patient also has some degree of androgenetic alopecia, the rules might be a bit different. In a patient with alopecia areata who also has any degree of androgenetic alopecia … any decision to add on minoxidil must be done with the understanding that the minoxidil use will be forever IF IT IS USED IN THE AREA OF ANDROGENETIC ALOPECIA - and stopping minoxidil at any time in the future will likely trigger shedding and possibly irreversible worsening of the AGA.

How fast does female pattern hair loss progress?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to the speed of progression of female androgenetic alopecia

Question

I want to know how fast does FPHL progress once it starts? Is it a fast thing - or a slow thing?

Answer

Thank you for your question.

The speed of hair loss varies from patient to patient. It can range from 6 month to 6 years before further changes can be detected. It is extremely variable and depends alot on a person's underlying genetics and how frequent they have episodes of telogen effluvium that may accelerate the baseline rate of the androgenetic alopecia.

Some females have a form of FPHL that really does not progress all that fast. Young women with onset 15-24 may have a higher chance of having a pattern that progresses faster (without treatment).

With treatment of course, this can all be changed. The hope with treatment is that FPHL can be slowed and even improved for many. 

I am getting palpitations on Rogaine: what do I do?

Palpitations with Rogaine: What should I do?

I’ve selected this question below for this week’s question of the week. It allows us to review the topic of minoxidil related heart palpitations in women.

QUESTION

I am a 55 year old female with female pattern hair loss. I am getting palpitations on Rogaine! I use a full cap instead of 1/2 cap as I wanted to really try do everything I can. I realize that I’ve been using too much! What should I do?

ANSWER

Thank you for your question.

Palpitations are common - even without Rogaine in the picture. One study suggested that up to 16 % of the population has palpitations.

2-4 % of Minoxidil Users Have Palpitations

Palpitations can certainly occur with Rogaine. In the original 2011 randomized controlled trial comparing 5 % minoxidil foam once daily to 2 % minoxidil solution twice daily, 1.8 % of women using the foam once daily had palpitations and 3.5 % using the minoxidil solution had palpitations.

I would recommend that anyone with palpitations speak to his or her doctor. This is really the best step to take. It’s easy enough to focus only on the Rogaine and what to do with the Rogaine - but that’s not really the ideal way to evaluation this for most patients.

ALL PATIENTS WITH HEART PALPITATIONS NEED A REVIEW!

Although the palpitations may be related to Rogaine (minoxidil) use, one needs a full history and good general examination to see if any other contributors may be relevant. Other medications, substance abuse, caffeine intake, psychological stresses and mental health issues, other heart rhythm issues (atrial fibrillation, PVCs, PACs), family history of heart issues all need to be reviewed carefully. Your doctor will want to find out when they occur (sleep or awake), how often they occur, and what provokes them and what they feel like. A review of your blood pressure, weight, general health (obesity, smoking, sleep apnea) all need to be taken into account. Your doctor needs to listen to the chest, evaluate your JVP, and look for evidence of ankle edema or other signs of heart failure. Blood tests for thyroid stimulating hormone, hemoglobin, ferritin, calcium, potassium, magnesium, creatinine, urinalysis, blood sugars, cholesterol are often appropriate. In some cases, cardiac troponins are ordered but this is generally only ordered in the case of more prolonged or frequent palpitations - and in more acute settings (like the emergency room). Women of child bearing age should have a pregnancy test in the standard evaluation of palpitations.

What are the most common causes of palpitations?

As your doctor goes about evaluating your specific situation, he or she will be thinking about all the causes of palpitations. Doctors typically divide these into two big groups - cardiac causes and non-cardiac causes. The cardiac causes include things like atrial fibrillation, premature ventricular and atrial contractions, heart failure, valvular disease, ventricular tachycardia, autonomic dysfunction, long QT syndrome, supraventricular tachycardia. Non cardiac causes include things like alcohol, anemias, stress, cocaine, smoking, pregnancy, thyroid problems, fever, medications (including withdrawal).

Your doctor will be trying to figure out where you fall in this list:

Common Causes of Palpitations and their Frequencies. From: Wexler  RK Palpitations: Evaluation in the Primary Care Setting. Am Fam Physician. 2017 Dec 15;96(12):784-789.

Reducing or Stopping Rogaine: Considerations

Reducing or stopping the Rogaine is an option. You and your doctor can review what is most appropriate in your case. If there are no major worries about the heart (such as non concerns for ischemic heart disease or cardiac issues), then reducing the dose may make sense. If there are concerns, then stopping it may be the best option.

There are situations where continuing Rogaine makes sense - even at the off label dose of 1 cap daily. For example, if palpitations occur once every 2 months, this is very different than if they occur once every 2 hours. A patient with extremely infrequent palpitations mightt continue Rogaine while the exact cause is being evaluated.

A person will possibly lose hair if Rogaine is stopped. However, the likelihood of this depends on many factors. For example, if you just started Rogaine last week, then there probably won’t be much hair loss that occurs. If you started Rogaine 8 months ago, there is likely to be hair loss. These are clearly important discussions that you and your doctors will need to have as nobody wants to lose hair.

In some cases, your family doctor or dermatologist may consider ordering an electrocardiogram (ECG or EKG) for you. This is a tracing of the heart electrical patterns and gives helpful information about whether any other issues might be present. If there are any concerns about your pattern of palpitations on your ECG tracing, then other tests like a 24 hour monitoring test (HOLTER TEST) or echocardiography may be considered before or at the same time as referral to a cardiologist. In some cases, a chest xray is also done. The more often the palpitations occur and the more accompanying signs and symptoms that are present (dizziness, chest pain, shortness of breath, leg swelling, syncope and passing out), the more likely a patient will be advised to seek urgent medical attention rather than wait for a standard cardiologist referral. Again you and your own medial team will want to carefully review your issues.

Conclusion

As far as what’s the right step for you to take, I do not know. I would need to have all the facts, review all your story. Be sure to speak to your doctor. Most of the time there are no undelrying worries. But one should not jump to that conclusion without a proper review. There may be situations where stopping the Rogaine is the right answer. There may be situations where reducing the dose is the right answer.

If Rogaine (minoxidil) is felt to be the only cause (no other issues), some patients find it helpful to divide Rogaine into two daily smaller applications rather than one without losing effect. This means using ½ the cap in the morning and ½ the cap in the evening. In the morning the frontal area can be targeted with the Rogaine. In the evening the more posterior areas of the scalp can be targeted. The results is that each area of the scalp still receives the same amount of Rogaine on a given day, it just receives it at different times. Many patients of my own report that palpitations disappeared with this strategy. Again, you’ll want to talk to your doctor if stopping, reducing or adjusting how you apply Rogaine is the best step for you.

Thank you again for your question.

REFERENCES

Blume-Peytavi U et al. A randomized, single-blind trial of 5% minoxidil foam once daily versus 2% minoxidil solution twice daily in the treatment of androgenetic alopecia in women. J Am Acad Dermatol. 2011 Dec;65(6):1126-1134.e2.

Govender I et al. Palpitations: Evaluation and management by primary care practitioners. S Afr Fam Pract (2004). 2022; 64(1): 5449.

Raviele A et al. Management of patients with palpitations: A position paper from the European Heart Rhythm Association. Europace 2011;13(7):920–34. doi: 10.1093/europace/eur13

Wexler  RK Palpitations: Evaluation in the Primary Care Setting. Am Fam Physician. 2017 Dec 15;96(12):784-789.

Did my medication cause my tinnitus?

Did my medication cause tinnitus?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to tinnitus.

Question

I am a 53 year old woman and have been prescribed dutasteride for my diagnosis of androgenetic alopecia. I have developed tinnitus recently and am wondering if it could be related to the dutasteride.

Answer

Thanks for the excellent question. The short answer is - it’s not impossible but more likely than not - it’s not related. But one needs to know all your life story from birth until now and review your medications and current health - and a whole lot more. Let’s dive in to the topic of tinnitus and then come back to this question.

Tinnitus, commonly called “ringing in the ears”, refers to sounds that patients hear despite the fact that those sounds are not present. Tinnitus is very common in the population. In fact 10-25% of the population will develop tinnitus. This means that many patients in the hair loss clinic will report tinnitus. So - from the very day you were born, there was a slight chance you were going to develop tinnitus.

What is meant by tinnitus?

Tinnitus refers to the perception of sound in one ear (or both ears) in the absence of an external source of sound that would be responsible for generating that sound. Although tinnitus is commonly called ‘ringing in the ears” the sound may be more than just ringing - buzzing, hissing, sizzling and whooshing are commonly described too. About 50 % of people experience this in both ears and 50 % have tinnitus in just one side (the left side is favoured for reasons that are unclear).

How common is tinnitus anyway?

As mentioned in my introductory words, tinnitus is common. About 15 % of the adult population has experienced tinnitus. Studies across various countries including Japan, Nigeria, Egypt and the US suggest rates are similar. One study estimated that about 50 million people in the US have experienced tinnitus and about 16 million experience it frequently.

What are the common causes?

There are many causes of tinnitus. When the precise cause can not be found, a person’s tinnitus may be referred to as ‘primary’ or ‘idiopathic’ tinnitus. When an underlying cause for the tinnitus is found, the tinnitus is referred to as ‘secondary’ tinnitus.

Tinnitus can be associated with the following conditions and risk factors:

1. Hearing loss. The main risk factor for tinnitus is hearing loss. A large proportion of patients with tinnitus have some degree of hearing loss. For this reason, it is essential that everyone with tinnitus have a hearing test.

2. Noise exposure. Many people develop tinnitus after exposure to loud noises - and this can either be short term or long term noise exposure. For example, some patients may develop tinnitus after attending a rock concert. Others may develop after years of working in a loud working environment.

3. Acoustic neuromas (schwannomas).

4. Ear diseases. Various inner ear, middle ear and outer ear diseases can cause tinnitus.

5. Depression and Anxiety. A link between these conditions and tinnitus has been demonstrated in several studies.

6. Drugs. The most common drugs causing tinnitus are aspirin and NSAIDs, benzodiazepines, tricyclic antidepressants, antibiotics (gentamicin) and isotretinoin. Blood pressure pills including loop diuretics, ACE inhibitors, angiotensin receptor blockers, thiazide diuretics, potassium-sparing diuretics, and calcium channels blockers are rare causes. The antimalarial drugs chloroquine and hydroxychloroquine can also give tinnitus. anti-cancer drugs can also cause tinnitus.

7. Vascular issues. Disease of the blood vessels are sometimes associated with a ‘pulsatile’ tinnitus

8. Hypertension

9. Immune diseases - rheumatoid arthritis, lupus, multiple sclerosis

10. Endocrine issues- hypothyroidism

12 TMJ disease - diseases of the temporomandibular joint

13. Caffeine intake.

Now back to Tinnitus and Dutasteride

Tinnitus is not something that is typically reported with dutasteride. In the 2011 review by Dr Cianfrone and colleagues called “Pharmacological drugs inducing ototoxicity, vestibular symptoms and tinnitus: a reasoned and updated” dutasteride is not even listed. That does not mean it’s not a potential cause - it just means it’s pretty uncommon if there is any link.

There are of course people who develop tinnitus with dutasteride. In fact, 10-25 % of people using dutasteride are statistically expected to get tinnitus. Not because tinnitus was caused by the dutasteride but rather because 10-25 % of human beings get tinnitus. 10-25 % of adults over 50 who eat popcorn are expected to develop tinnitus. 10-25 % of adults over 50 who wear brown shoesare expected to develop tinnitus. 10-25 % of adults over 50 who own dogs are expected to develop tinnitus. 10-25% of adults over 50 who use dutasteride are expected to get tinnitus.

Good studies are really needed to know if the rates are truly increased in dutasteride users or not. We just don’t have that data.

How does a patient know if it’s related to the drug?

As reviewed above, dutasteride is not likely the culprit of tinnitus for most people. It’s not impossible - just not common.

However, one needs to know your whole story from birth until the present day and examine your ears, eyes, neck and blood pressure and heart rate and joints and TMJ and possibly more. One needs to know all the medications you take, including the key culprits listed above

Tinnitus from drugs usually happens fairly quickly after starting the drug. The drug with the most rapid onset of tinnitus are the salicylates (ie aspirin). Following oral consumption or systemic injection of the drug, tinnitus presents within minutes and subsides within 72 h of the final dose. Blood pressure medications like furosemide also cause a fairly rapid onset of tinnitus. Tinnitus occurring months after starting is not likely to be related to the drug.

Suggestions for Patients on Dutasteride with tinnitus

For patients who develop tinnitus, I recommend seeing their primary care physician for a full examination from head to toe. This should include examination of the ears (wax), basic neurological testing (cranial nerves) TMJ evaluation, lymph node evaluation, blood pressure evaluation, heart rate evaluation, thyroid examination. Your primary care doctor may send you for some blood tests (thyroid), measure your blood pressure, possibly perform and EKG and possible send you for hearing tetss. We’ll get more into this in a moment.

In many cases (for my own patients), I will recommend stopping the drug for 1 -3 weeks and seeing if the symptoms disappear and then restarting it again and seeing if the symptoms appear. A diary should be kept each day of the number of times the tinnitus occurred (or whether it was constant), the ear it was heard in and the type of tinnitus (pulsatile, etc). Whether this is an appropriate thing for you to do, I can’t say as I don’t have all your information.

What investigations could a patient considering having if they have tinnitus?

1. Patients with tinnitus should first seek the attention of their primary care physician as this physician is best positioned to assess, investigate and provide appropriate counselling. The doctor will ask whether the tinnitus affects one ear or both, when it started and how it’s changing over time. The presence of tinnitus in one ear may raise concern to the doctor that a focal lesion could be present. The evaluating doctor will ask about other symptoms like dizziness, and hearing loss. Sudden onset of tinnitus associated with hearing loss requires prompt evaluation. It may require the patient to have an MRI imaging test and may require the patient to start a course of oral steroids,.

A full history will be taken by the primary care doctor during the evaluation of tinnitus. Blood pressure will be measured by the doctor. Ears will be examined. Bedside hearing and vibration tests (with a tuning fork) will be done. Basic neurological testing will be done. Blood tests may be ordered if deemed appropriate (ie thyroid studies, etc)

2. A formal audiology assessment (hearing test) is recommended for all patients who have tinnitus. Many patients with tinnitus have hearing loss so all patients with tinnitus should be evaluated with a hearing test.

3. Referral to an ENT (ear nose and throat) surgeon may be recommended if the cause of tinnitus is not clear or if further evaluation is needed.

4. Patients with tinnitus only on one ear (one side) or who have pulsatile tinnitus or who have asymmetric hearing loss or who have a focal neurological problem will likely be given a recommendation by their primary care physician to have further imaging tests done. This may include CT or MRI depending on the specific situation.

How is tinnitus treated?

Sometimes tinnitus just goes away on its own and therefore treatment is not needed. If tinnitus lasts more than 3 months, we call it chronic tinnitus.

If there is an underlying cause of the tinnitus (as there is in cases of ‘secondary tinnitus'‘), the goal of treatment is to address the cause. If a drug is thought to be causing the tinnitus, it is stopped. If a tumor is causing the tinnitus, it is treated. If depression and anxiety are contributing to the tinnitus, these are addressed.

There are no drug treatments for tinnitus that have proven effective.

In cases of primary tinnitus, hearing aids may be ordered for the patient if there is evidence of hearing loss. Sound therapy (provided by an audiologist) or cognitive behavioural therapies (provided by the primary care physician or a psychologist) are helpful therapies. Other treatments include tinnitus retraining.

Thanks again for the great question.

Should the JAK inhibitor tofacitinib be continued in pregnancy for patients with alopecia areata?

Current Evidence Supports Stopping JAK Inhibitors in Women with Alopecia Areata Who Immediately Plan to Become Pregnant

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts related to the use of tofacitinib (Xeljanz) in pregnancy.

Question

I had alopecia areata and I took Xeljanz 5mg twice a day for 8 years now. My hair grew back and everything is fine. My question is does Xeljanz affects fertility? Does it cause birth defects? Because I am trying to get pregnant and I'm worried that Xeljanz might be the reason why I haven't conceived yet. I am in my early 30s.

I also want to know if I stopped Xeljanz, my hair will fall again?

Thank you

Answer

Thanks for the great question. The “short answer” to these questions is 1) I generally do NOT recommend that tofacitinib be used during pregnancy and 2) yes, hair could fall out again if Xeljanz is stopped but it may or may not fall out as much as it did before starting.

Let’s look at all these issues in more detail.

Tofacitinib and other JAK inhibitors like baricitinib and ruxolitinib and ritlecitinib and upadacitinib and abrocitinib are now commonly used to treating more advanced forms of alopecia areata. Baricitinib and ritlecitinib are of course FDA approved but other JAK inhibitors are used off label.

Because tofacitinib is such a small molecule, it is thought that it can easily cross the placental barrier. In other words, a mother using tofacitinib is likely to transfer the tofacitinib to the developing fetus. However, information on the effects of tofacitinib on pregnancy outcomes in humans is somewhat limited.

In some autoimmune diseases, the decision to withdraw immunosuppression during pregnancy is not taken lightly. In fact, in some diseases, many immunosuppressives are in fact continued. For example, patients with ulcerative colitis (UC) have a significantly higher risk of adverse birth outcomes compared with controls, including low birth weight, preterm delivery, and neonatal death. Many immunosuppressants (but not all of them) are continued during pregnancy for women with ulcerative colitis.

Is tofacitinib harmful during pregnancy in animal studies?

Tofacitinib - when used at high doses - was shown to be teratogenic at high doses in animal models. For example, in preclinical animal studies, tofacitinib was both feticidal and teratogenic in rats when used at doses 146 times above the typical human dose and in rabbits when doses were 13 times greater than the typical human dose.

Is tofacitinib harmful in humans during pregnancy?

The Pfizer drug monograph for tofacitinib is clear that tofacitinib is contraindicated in pregnancy. The drug monograph for tofacitinib reminds us that there is a registry of tofacitinib use in pregnancy. In other words, the company is keeping track of patients who become pregnant while on tofacitinib to follow outcomes of babies and mothers. Pfizer invites patients to call the toll free number 1-877-311-8972 if they wish further information. The company is doing the same with their JAK inhibitor ritlecitinib LITFULO.

For now, the official stance of the company is that available data is insufficient to say whether or not tofacitinib “is associated with a risk of major birth defects, miscarriage or adverse maternal or fetal outcomes.”

The company reminds us that in the general U.S. population, about 2-4 % of pregnancies are associated with babies being born with some type of major birth defect and at least 15-20 % of clinically recognized pregnancies lead to miscarriages. This is the statistics for women who do not use tofacitinib. Whether these numbers are truly different for tofacitinib users is not known. in addition, it is not know if these numbers are different for tofacitinib users with ulcerative colitis who use tofacitinib or rheumatoid arthritis who use tofacitinib or alopecia areata who use tofacitinib.

In clinical trials of tofacitinib, women of child bearing potential were required to use contraception and were required to stop tofacitinib if pregnancy did occur. Therefore, we have very limited data on tofacitinib in pregnancy.

Are other JAK Inhibitors okay to use in pregnancy?

The product monographs for baricitinib and upadacitinib are very clear that these drugs should not be used in pregnancy. The product monograph for abrocitinib advises against using the drug in pregnancy as does ruxolitinib.
The ritlecitinib (LITFULO) product monograph is perhaps the most confusing, in my opinion, with no clear and bold statement against pregnancy but rather information that risks are unknown who do contact if pregnancy does occur. In my opinion, I would not advise my patients with alopecia areata to consider pregnancy while using ritlecitinib until we have more data.

Do women with alopecia areata and active autoimmune diseases have worse pregnancy outcomes?

For some autoimmune diseases, like rheumatoid arthritis, lupus, and ulcerative colitis, the data is pretty clear that women with more active disease have a higher chance of negative outcome in pregnancy. This includes outcomes such as preterm delivery (before 37 weeks of gestation), low birth weight (less than 2500 g) infants, and small for gestational age (SGA) at birth.

A few years ago, I reviewed an important paper from South Korea. Authors used the Korean National Health Insurance claims database to investigate the association between AA and obstetric complications. They identified 4,552 patients with alopecia areata and compared data to 508,345 individuals without alopecia areata (control population). After the authors used statistical analyses to adjust data for age, comorbidities, and obstetric and gynecological diseases, they found that the total live birth rate was significantly lower in patients with alopecia areata compared to controls (73.31 % vs 76.35%), the rate of miscarriage was significantly higher in patients with alopecia areata compared to controls (17.55 % vs 16.33%), the rate of ectopic pregnancy was significantly higher in patients with alopecia areata compared to controls (5.69% vs 4.48%). There were no differences in rates of cesarean deliveries, stillbirths or infertility. All in all, it’s clear that alopecia areata can impact pregnancy outcomes.

There were two key limitations of this Cho et al 2021 paper that are relevant to the question today. First, we don’t know if patients with more severe AA have worse outcomes than patients with less severe AA. Second, we don’t know if treatment has any impact either. For example, would it at all be possible that treatment with an immunosuppressive drug would improve outcomes rather than make it worse. These are answered questions.

IMPORTANT STUDIES OF TOFACITINIB USE IN PREGNANCY

STUDY 1: Clowse and colleagues, 2016

A 2016 report by Clowse and colleagues reported outcomes of women who became pregnant while receiving tofacitinib. These were pregnancy cases identified from a variety of sources including tofacitinib randomized controlled trials (of Rheumatoid arthritis and psoriasis), other RA studies, and spontaneous adverse-event reporting.

Authors reported 47 women who became pregnant on tofacitinib. This included 33 women who received tofacitinib monotherapy and 13 who received combination therapy with methotrexate, and one patient whose therapy was still blinded. There were no fetal deaths. There was one congenital pulmonary valve stenosis (monotherapy patient), seven miscarriages (4 from monotherapy group and 3 from combination therapy group.

All in all, there were 25 reported healthy newborns among the remaining cases. 6 patients were lost to follow up.

STUDY 2: Mahadevan and colleagues, 2018

A 2018 study reported eleven cases of maternal exposure and 14 cases of paternal exposure to tofacitinib (doses of 5 mg or 10 mg twice daily) before/at the time of conception or during pregnancy. Outcomes included 15 healthy newborns, no fetal deaths, no neonatal deaths, no congenital malformations and 2 miscarriages. The tofacitinib was used for treating ulcerative colitis in this study.

SUMMARY

All in all, we don’t really know if tofacitinib is completely safe in pregnancy. That’s the reality. There is ongoing research about the safety of tofacitinib in pregnancy. At the present time, most practitioners and most physician-based organizations and societies and most product monographs for the drugs do not generally support the use of tofacitinib in pregnancy. We can’t exclude the possibility that it has some safety issues.

Some publications and writings are stronger in their opinion than others. In 2016, EULAR (Götestam Skorpen C et al, 2016) formally stated that tofacitinib be stopped during pregnancy until more information and data can be obtained. The gastrointestinal community has a similar but ever so slightly less negative stance that tofacitinib should be used with ‘extreme caution’ if it ever were to be used in pregnancy by patients with inflammatory bowel disease (Laube et al 2021). The same authors note that tofacitinib is teratogenic in animal studies and for the most part should be ‘generally avoided.”

A Mother to Baby Ask the Experts Fact Sheet highlights to readers that so very little is known about tofacitinib in pregnancy.

In my professional opinion, JAK inhibitors should not be used in pregnancy in patients with alopecia areata until we have more data. Across the board, there is so little to support the use of tofacitinib in pregnancy by patients with alopecia areata.

Before I leave the subject, I would like to mention a few things. First, you should speak with your physicians as soon as possible. That means right away if possible. If you are trying to conceive and using tofacitinib, you need to have some serious discussions right away. I can’t give you advice one way or another (because you are not my patient) but you and your doctors should review carefully all the information about what is known and what is unknown about the safety of tofacitinib in pregnancy. You should speak with your physicians as soon as possible.

Second, it’s important to speak with a gynecologist as well regarding fertility. Just like we don’t know for sure if tofacitinib increases the chance of birth defects and other issues, we don’t know for sure if tofacitinib affects the chances of becoming pregnant if a person were to use the drug. But in general, if you have decided to try to become pregnant while on tofacitinib and you’ve been trying with regular frequency for more than 1 year, you really need to see an expert for a full assessment regarding all fertility issues. All women under 35 who can not become pregnant after 1 year of trying need full evaluation by a gynecologist. Your gynecologist can evaluate if this could be due to tofacitinib or due to other factors. But this too needs evaluation.

All in all, most of my own patients with alopecia areata are recommended not to use JAK inhibitors during pregnancy until we know more information about their safety. Several professional societies have this viewpoint too. I can’t say what you should or should not do as you are not my patient but I would urge you to speak to your doctors immediately so that you can review all this information and understand what plan is best for you and your specific situation.

You had asked in your second question whether you will lose hair if you stop tofacitinib (Xeljanz). That answer is maybe but most patients who had advanced alopecia areata and regrew back their hair with a JAK inhibitor will lose some or all of the hair again if they stop. What we can’t predict is whether it will be all the hair that is lost or just some of the hair and what we can’t predict is whether pregnancy will alter this (as some patients have reduced activity of alopecia areata in pregnancy). But in general, there is a very high chance of losing at least some hair when the tofacitinib is stopped. Some women do get it back again when tofacitinib is restarted at a later date. But not every single patient who stops tofacitinib and loses hair and then restarts tofacitinib at a later date gets back all the hair again. These are tough issues but important to review in exhaustive detail with your doctors.

REFERENCE

Clowse ME, Feldman SR, Isaacs JD, et al. Pregnancy outcomes in the tofacitinib safety databases for rheumatoid arthritis and psoriasis. Drug Saf. 2016;39:755–62. 22. Sandborn WJ, Gh

Mahadevan U et al.Outcomes of Pregnancies With Maternal/Paternal Exposure in the Tofacitinib Safety Databases for Ulcerative Colitis. Inflamm Bowel Dis. 2018 Nov 29;24(12):2494-2500.

Pfizer Inc. Xeljanz prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/203214s018lbl.pdf. Accessed aug 5 2023.

Carina Götestam Skorpen et al. The EULAR points to consider for use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Ann Rheum Dis. 2016 May;75(5):795-810.

Laube R et al. Use of medications during pregnancy and breastfeeding for Crohn's disease and ulcerative colitis. Expert Opin Drug Saf. 2021 Mar;20(3):275-292.