Daily shedding: Are my numbers normal or abnormal?

Are my shedding rates normal?

I’ve selected this question below for this week’s question of the week. It allows us to discuss normal hair shedding patterns.

QUESTION

I am a 37 year old female. I have been keeping track of my shed hairs as closely as possible for 70 days.  My 30 day moving average is a steady 40 hairs per day and my 5 day moving average ranges from 38 to 42 or so.  However, my daily shed is unstable and can range from 20 to 60 with periodic days of 70.  The 60 and especially the 70 hairs a day concern me. Is it normal for your daily shed to fluctuate this much even though your averages are stable?

Hair shedding can fluctuate over the month normally in humans. A few simple questions can help screen if shedding is likely to be abnormal or normal.

ANSWER

Thanks for the question. I can’t say whether your hair changes are normal or abnormal because I haven’t examined your scalp and I don’t really know what your shedding is like today compared to 2 years ago and 10 years ago. However, I can offer a few helpful points.

First, periodic fluctuations in shedding can be quite normal. There are changes in shedding with seasons, with stress, with the amount of seborrheic dermatitis, and across the menstrual cycle.

Second, the frequency with which one shampoos the hair also makes a difference. If one shampoos the hair once per week then I’m okay with shedding numbers in the few hundreds. If one shampoos the hair every day, the daily numbers should be well below 100 that’s for sure.

There are three very helpful questions that help me figure out if the shedding in women is likely to be abnormal:

QUESTION 1

Does the amount of hair coming out in the brush, in the shower and through the day seem similar to what remembers it being like 5 years ago?

Yes or No

QUESTION 2

Does the amount of hair the patient has on the scalp (ie the overall hair coverage) seem the same as 5 years ago?

Yes or No

QUESTION 3

Does the size of the pony tail seem to be the same ?

Yes or No

If one answers yes to all three of these questions, there is a fairly high chance that shedding is quite normal. The screen is not 100 % perfect of course but pretty good. A review of your full story with your dermatologist and a thorough scalp examination can help determine with certainty if the shedding is normal or abnormal.

In summary, fluctuations of this kind described in the question can be very normal for many people.

Thank you again for the question.

Does wearing a hat cause hair loss?

Does wearing a hat cause hair loss?

I’ve selected this question below for this week’s question of the week. It allows us to discuss one of the over 25 common myths pertaining to hair loss - wearing hats.

QUESTION

Does covering your head such as wearing a hat, over the head headphone, scarf, removable wigs cause hair loss? I often wear headphones and hats so wanted to know if it can cause pressure and lack of oxygen on the hair follicles leading to hair loss.

ANSWER

Thanks for the question. It’s a great question and one that I’m asked very very often. Simply put, wearing hats, headphones and scarves do not cause hair loss.

The oxygen finds its way to hair follicles through very tiny pipes deep under the scalp called blood vessels (capillaries). The oxygen does not come in through pores on the scalp. That’s where people go wrong in their assumption. The human scalp is very different than a plant. The scalp does not need to breathe. That’s simply a myth.

Oxygen arrives to hairs in tiny pipes in the scalp known as blood vessels. Oxygen does not enter that scalp via the pores. Wearing a hat does not affect the ability of there scalp to get oxygen. Humans should rest assured that the oxygen comes in through the pipes not pores.

Provided that pressure is light - like a hat or a scarf, there is no chance of hair loss. Off course if there pressure is considerable (like leaning the back of one’s head on a surgery table to 10 hours without moving it), of course there can be other forms of pressure alopecia. Similarly, if a scarf is tied tightly such that it pulls on the hair then yes, traction alopecia can result. Also, if the clips of a wig apply pressure to the scalp, then yes, the clips can rip out hair. But that form of hair loss is different than the type you are mentioning here.

Thanks again for the great question. Today, I am sure that thousands of parents across the world will falsely tell their son’s to stop wearing hats because it will cause hair loss. I’m sure that countless numbers of barbers and stylists will tell their clients to stop wearing hats too. How do I know this? I hear it every day!

The oxygen comes in through the pipes not the pores.

Thanks again for the wonderful question.

Excessive Shedding in the 30's: Why is my hair still shedding?

Excessive hair shedding in the early 30s: What are the reasons?

I’ve selected this question below for this week’s question of the week. It allows us to discuss diagnosis of hair loss in women 30-40 years of age with chronic shedding. Here is the question….

QUESTION

Can oral vitamin + iron supplementation increase shedding the way minoxidil does?

I am a 35 years old female. I have always been under a lot of stress, especially in 2016-2017. In spring 2018 I noticed my hair got thinner (I always had rather fine hair); my scalp could be seen under direct light. I used castor oil and took spiruline tablets hoping it would improve; got the impression it did so I stopped. I was vegetarian then, too. I got preoccupied with the fear of getting bald, did a lot of research on the Internet that frightenend me even more and finally I got the courage to get an appointment with a dermatologist this summer (2020). She didn't notice hair loss (pull test); said my density was normal and scalp looked ok. She said it didn't look like AGA at all. She prescribed my iron supplementation (low ferritin (24)) and advised me to change my diet. I lack vitamin B12 too. From the end of July onwards I've been taking iron, spiruline, biotin and B12 supplementation. Since I didn't agree with the diagnosis ("no visible hair loss") I began counting the hair I'm shedding each day. The amount is horrible: it's more than 200 hair/day! The supplementation I'm taking and the changes I made to my diet don't seem to decrease the shedding at all. I've booked a appointment with anonther dermatologist for a second opinion (I'm truly terrified: my scalp feels strange; a bit of itching and burning + "crawling" sensations; my hair keeps falling out and for my dermatologist there's no problem...!) I'm surprised I still have hair left on my scalp when I see the amount that's falling every day... 
I have read that those who use Minoxidil experience shedding in the first months which is a sign that new hair is on the way (I do see regrowth but it doesn't make my hair volume look any better). So I am wondering: can oral supplementation cause a similar shedding, which proves that the treatment is working? If not, what should I do? I got no "real" dagnosis; from what I read on the internet it seems to look like TE but how can I be sure?

I would like to add that from time to time I have small pimples on my scalp that come and go. Not a lot of them though, but they can be itchy. My skin (on face) is oily, I have the same sort of sores on my face from time to time too. I don't know if this information is important.

Thank you for reading and I hope you'll be able to answer my question since my own dermatologist doesn't seem to take my problem seriously...I think the thinning is all over, but mostly noticable on the top of my scalp and at the temples. My hair become very flat, no volume at all. I wash it daily because it greases very fast (eversince I was in my early teens).

ANSWER

Thanks for the question. There’s really two very good ways to determine the cause of your hair loss - and that is to share your story with a hair specialist and have him or her

1) Evaluate your scalp up close with “trichsocopy” (magnified imaging)

or

2) Perform a 4 mm scalp biopsy

So there is a way for you to get your answer.

I’d like to discuss several important things in the question you ask and the information you have submitted. Let’s get to it.

Before we do go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s story

2) the findings uncovered during the process of the scalp examination including trichoscopy

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

AGA must be the Default Diagnosis in Women 30-40 with Increased Hair Shedding

I would need to examine your scalp to determine if you have androgenetic alopecia or telogen effluvium or both …. or some other diagnosis.

However, I strongly believe that the first diagnosis that must be ruled in or ruled out in any female patient with hair loss in the 30s is androgenetic alopecia. One must not move on until this issue has been fully settled. Once that it settled one can determine if the patient has or does not have telogen effluvium (with AGA or by itself ) and whether or not the patient has some other hair loss condition.

How does AGA present or ‘announce itself in women’? With shedding ! .. and with thinning in the top or often also diffusely!

How does telogen effluvium TE present itself or announce itself? With shedding ! …and with thinning diffusely !

It’s important to be aware that TE and AGA can look identical - at least at first glance.

What’s the most likely cause of hair loss in a 30-35 year old female with hair loss for 3 years and shedding and thinning? Androgenetic alopecia by far.

Of course, I can’t say what you have as I have not examined your scalp. But these are the principles that guide the entire discussion.

Therefore, the key question that must be asked in your story is “Does this patient have androgenetic alopecia (AGA)?” That’s the key question. That’s the number one question. The key question should not be what supplement can this patient take? ….. or what shampoo should this patient use? The key question is “does this patient have androgenetic alopecia?”

What is needed now is proof that you do have AGA or proof that you don’t have AGA. One should not rest until this question has been solved. Once we solve that question, we can move on to figuring out if any other diagnosis is present.

For now, we need to determine if AGA is present. That is what is needed now. Your doctors might be able to solve this with trichoscopy or they might need to solve it with a biopsy.

We can not always solve it with simply looking at the scalp from afar.

Only you know what your hair looked like before and your doctors do not. If you hair looks thinner to you but just fine to another person - then guess what? You still have hair loss.

The Three Stages of Hair Loss

There are 3 stages of hair loss that I describe for patient’s with androgenetic alopecia. What is so important in your case is to determine once and for all as to whether you are in stage 2 AGA or whether you don’t even have AGA at all. Here are the stages.

Stage 1 of Androgenetic Alopecia

In stage 1, hair density is slowly reducing but the patient is unaware. There may be a slight increase in hair being shed in the shower or coming out daily in the brush. However, this generally goes by unnoticed by the patient. A biopsy can sometimes (but not always) capture a T:V ratio below 4:1 and some degree of miniaturization (and anisotrichosis) may be present. Much of the time it's challenging to confidently diagnose AGA in this stage. Some stay in stage 1 for a very long time; others just a matter of months.

Stage 2 of Androgenetic Alopecia

In stage 2, the patient first becomes aware that something is not quite right. They may see a bit more scalp showing when they look in the mirror. They may feel the hair does not feels as thick when they run their fingers through the hair. Under bright lights they may feel a bit more aware of these changes. When the hair is wet, the thinning is evident.

Nevertheless, in this second stage everyone else tells the patient they look fine. Some patients are told they are "crazy". Even some physicians will tell the patient they "look fine" and need not worry. Patients often feel isolated in this stage because nobody believes them when they say they are losing hair! A biopsy definitely shows a T:V ratio less than 4:1 and miniaturization is clearly seen in more than 20 % of hairs. Many never progress to stage 3 especially those with onset of AGA later in life.

Stage 3 of Androgenetic Alopecia

In stage 3, the hair loss has progressed to a stage where hair loss may become evident not only to the patient but also to others. Of course with use of various hairstyles, products, camouflaging agents it may still be possible to hide one's hair loss from others. As stage 3 progresses it becomes more and more difficult to hide hair loss.

Understanding the Patterns of Hair Loss

Both AGA and TE can cause hair to look thinner. With AGA is typically affects the middle of the scalp whereas with TE is affects all of the scalp fairly equally. We call this a ‘diffuse’ pattern. AGA can sometimes have a diffuse pattern too but very often than not it affects the middle more than other areas. In addition, AGA often affects some areas of the middle a bit more than others.

Your photos show the hair parted in the middle. These types of photos are great for evaluating the scalp. If your part width at the back of the scalp seems smaller than the front of the scalp, the chances start to increase that you might have AGA. By part width, we simply mean the amount of scalp showing when you part your hair in the middle.

In your photos, it’s difficult to get a sense of the exact patterns because I only have photos of the middle. But when I look at these photos I do wonder whether the density towards the crown is a bit less than the density up front. In other words, it seems that even in the mid scalp the density is not reduced equally.

Summary: Putting it All Together

Thanks again for the question. Let’s review everything again.

1. You first asked if oral vitamins can increase shedding like minoxidil does. That answer is not usually. The mechanism is different.

2. You have high shedding rates so something is probably different with your hair cycles than it was 20 years ago.. One can shed 200 hairs daily in AGA and 200 hairs daily in TE so this information is not helpful to actually get to the diagnosis. You could have one, You could have both. You might have neither. Statistically speaking, a 30-35 year old female with shedding has either AGA or TE and with your history AGA is far more likely to be a diagnosis. Of course, we are not statistics and each person requires a proper examination.

3. You mention increased oiliness of the face so one needs to also consider whether you have a component of “seborrheic dermatitis”. This can increase these scalp sensations like you describe - and so can telogen effluvium. Your doctors can determine if you have SD by carefully examining your scalp.

4. Overall, it may be that you’ve had TE at some point in time - and perhaps you also have it now too. It may be that stress was a trigger before for a TE and perhaps maybe now you have different triggers that are causing a TE (such as lower iron). I suspect there was some component of TE back in 2016-2017 when your hair shedding stopped. Your doctors can evaluate these ‘triggers’ for shedding in greater detail. You may or may not need more blood tests but your doctors can review that in detail.

A full work up is needed at this point. You may need more blood tests. However, what you do need next is a thorough scalp examination with trichoscopy. If there is significant “anisotichosis” on trichoscopy then you may have AGA. I can’t tell these with your photos - it needs an up close examination. If it’s still difficult for your doctors to determine with trichsosopy, then a scalp biopsy (with use of horizontal sections) is going to be helpful. The pathologist can determine the number of large terminal hairs and tiny vellus hairs and the number of telogen hairs. A terminal to vellus hair ratio of less than 4:1 usually signals a diagnosis of AGA in women. You can review more about scalp biopsies here Scalp Biopsy Interpretation

I hope this helps and thank you again for the question.

Seasonal Shedding: Is my pattern normal ?

Is it normal to shed more in the summer months?

I’ve selected this question below for this week’s question of the week. It allows us to discuss the topic of seasonal shedding. Here is the question….

QUESTION

I am a 35 year old female. For the last several years I have noticed the following shedding pattern.  In the late fall and winter, I lose around 40 hairs a day.  In the late spring the number begins to rise and I shed around 65 hairs during the summer months and into the early fall.  Shedding then drops back to around 40 hairs a day and the cycle repeats itself.  The result is, I am terrified and stressed every summer thinking “my hair is falling out”. 

My question is … is this normal or do I have a problem? 

My part is tight year round and my shedding is diffuse throughout my scalp.  If this is normal, then I can relax and enjoy my summers.

ANSWER

You certainly give a story that is highly suggestive of what is known as “seasonal shedding.” Whether or not there could be another explanation would require a review of the scalp during one of the shedding episodes but anything else would be extremely rare.

Seasonal shedding is a type of telogen effluvium (hair shedding disorder) and is much more common than we realize. Humans appear to shed less in the winter and more in the summer. Based on all the studies done to date, there actually appears to be two peaks of shedding - a main one in the late Summer/early Fall and a minor one in Spring. Your story certainly sounds like you fit this picture.

Do you need to worry ? The answer to that question is easy to figure out although I’d need you to do a bit more searching on your own. If your hair density on New Years day this past year was the same as the density on New Years day the year before, you don’t need to worry - this is likely only seasonal shedding that’s happening each spring-summer-fall. If you are experiencing seasonal shedding but find that your density is in fact getting a bit less as the years go by - then you should have a proper examination to rule out a second condition that might be present (like androgenetic alopecia). You mention your part remains tight - so it seems your story is more likely that of classic seasonal shedding.

It really is that straight forward. If you feel that your photos from every winter are identical year after year after year and your hair feels the same in winter months year after year after year …. then you can relax and enjoy your summers. That would indicate a classical seasonal shedding.

Seasonal shedding is more common than most people realize. For reasons that are not entirely clear, humans shed more hair from the scalp in late summer and early Fall.

Past Studies of Seasonal Shedding

There have been five good studies from 1991 to 2014 that all point to the same general message: humans shed more in the summer and early Fall. Some studies like those of Courtois and colleagues in 1996 and Kunz and colleagues in 2008 suggested that some humans also might shed a bit more in early Spring (a second peak). The main shed, however, is in summer/Fall.

If you’re interested in reading more about these 5 studies, I’d invite you to check out a previous article I wrote:

Seasonal Shedding of Hair: Five Studies to Know About

CONCLUSIONS:

Thanks again for the question. Good luck as you think back to your hair over the winter months in past years. This is where the answer lies for you.  

As for the” why” - why does shedding occur more in summer? Well, we don’t really know although it is proposed that climate factors and UV radiation related factors may somehow be involved.

It’s pretty common for people to worry about hair shedding in summer. A 2017 study in the British Journal of Dermatology  showed that people are punching the words “hair loss” into the Google search engine far more in the summer and Fall than they are in the sping and winter. Large numbers of people share the same concerns as you’ve raised.

References

Courtois et al.Periodicity in the growth and shedding of hair. Br J Dermatol, 1996 Jan;134(1):47-54.

Hsiang EY et al. Seasonality of hair loss: a time series analysis of Google Trends data 2004-2016. Br J Dermatol2018; 178(4):978-79   

Liu et al. A Microarray-Based Analysis Reveals that a Short Photoperiod Promotes Hair Growth in the Arbas Cashmere Goat, PLoS One. 2016 Jan 27;11(1):e0147124.  

Maurel D et al. Effects of photoperiod, melatonin implants and castration on molting and on plasma thyroxine, testosterone and prolactin levels in the European badger (Meles meles). Comp Biochem Phyiol A Comp Physiol. 1989;93(4):791-7.

Orentreich N. Scalp hair replacement in man. In: Advances in Biology of Skin. Vol IX: Hair Growth. (Montagna W, Dobson RI, eds). Oxford: Pergamon. 1969. 99-108.

Pearson AJ et al. Inhibitory effect of increased photoperiod on wool follicle growth. J Endocrinol 1996 Jan;148(1):157-66.

Piérard-Franchimont C, Peérard GE .L'effluvium télogène actinique: une facette de la chronobiologie humaine.

Int J Cosmet Sci. 1999 Feb;21(1):15-21.

Randall and Ebling. Seasonal changes in human hair growth. Br J Dermatol 1991.

Reinberg A et al. Circadian and circannual rhythms in plasma hormones and other variables in five healthy young males. Acta Endocrinology 1978; 88: 417-27

Smals AGH et al. Circannual cycle in plasma testosterone levesl in man. J Clin Endocrin Metab 1976; 42: 979-82.

Zhang et al. Comparative study on seasonal hair follicle cycling by analysis of the transcriptomes from cashmere and milk goats. Genomics 2019 Feb 16 

Androgenetic alopecia or Telogen Efflvium ? What is my diagnosis?

QUESTON

I am female and in my early 20s. I have been crash dieting for the past 2 years (most extensively over the last 1 year). I was diagnosed with subclinical hypothyroidism in February although it was normal this month. HGB was 11.2. I’ve stopped my diets in March. Since then I’m experiencing a lot of hair fall, my hair comes out in my hands whenever I touch it, and when it shower there is a whole bunch of hair. I’m experiencing new hair growth, but my concern is my new hair falls out too.

I was told I have androgentic alopecia when I was around 16 year old and I was started on finasteride. But I wasn’t regular with taking my medicines. I got regular for the last 9 months. I experience pain in the scalp (hair roots) when I move my hair, especially at the crown and temples area (more after a headache) and this pain is associated with more hair loss. My medications are finasteride, biotin and B complex vitamins.

My new hairs fall out, and I’m really worried, if this will ever stop. I had really long and thick hair as a child, but I also have done a lot of hair straightening when I was losing weight. So I didn’t realize when did all this get aggravated. My hair is really scanty compared to the past.

Please advise what can I do. I tend to believe it’s because of a diagnosis of telogen effluvium

ANSWER

Many thanks for your question. I do think that you likely have androgenetic alopecia as one of the main reasons for your hair loss. I agree you could possibly have telogen effluvium but it is likely a much more minor contributor. It would be surprising with your history if it was a major contributor to the changes you have been experiencing since 15 years of age.

Let’s review all of this further.

However, before we go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s story

2) the findings uncovered during the process of the scalp examination including trichoscopy

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

I’d like to know a lot more about your story ideally but of course the magic of the “question of the week” is that I tackle questions with limited information.

So what is your diagnosis?

Based on what I have mentioned above, I can’t be 100 % confident of what’s going on entirely without seeing your scalp up close myself and knowing more about your entire story. However, I am of the opinion that the most likely diagnosis is androgenetic alopecia (AGA). There is quite likely a component of telogen effluvium (TE) too - so I agree wth you in that regard. However, I would suspect in your case that the main diagnosis is androgenetic alopecia.

The challenge is knowing whether you have a bit of AGA and a lot of TE (like the pie chart diagram below on the left), or mostly AGA and a bit of TE (like the pie chart below on the right). I suspect you are mostly like the example on the right. Your doctors can help you figure out which diagnoses are present and whether the pie charts on the right or left are best representative of your hair.

It’s quite likely that with your history of hair loss since your mid teens and ongoing concerns that lead you to have very thin hair compared to the past that you do in fact have androgenetic alopecia. Your photos certainly suggest that anagenetic alopecia is present. Your hair loss does not appear to be completely diffuse in nature so there seems to be a component of localized “patterned” hair loss. Your reduction in central density with more preserved frontal hairline density (at the very front) is quite typical of androgenetic alopecia. It does appear there is a variation in the caliber of your hairs (or what is termed anisotrichosis) and this is very much in keeping with androgenetic alopecia.

It’s not impossible that you have telogen effluvium as well. You might possibly even have other diagnoses present as well. With your hemoglobin of 11.2 and fluctuations of thyroid hormones, and with the 2 years of dieting. it’s possible you have a telogen effluvium. Common causes of TE include stress, low iron, thyroid problems, medications, diets and illness in the body. You are your doctors can explore these and other potential triggers. It’s likely you do have a trigger but it’s unlikely you’ve had a TE for 6 or more years that just keeps going. But it may be a component of the hair loss and the TE may have made the underlying androgenetic alopecia (if present) worse. With a hemoglobin of 11.2, you will certainly want to speak to your doctors to determine what might be the cause. Low ferritin levels are one cause so you will want to speak to your doctor about these and other causes of low hemoglobin.

I do recommend that anyone with hair loss since the mid teens to have causes of hair loss thoroughly explored. You may have already had such a detailed “work up” or evaluation. It is important for adolescents and teenagers with androgenetic alopecia to have a hormone work up to evaluate for causes of increased androgens. Blood tests for testosterone and DHEAS are important and you yourself may have already had these ordered. All female adolescent patients with androgenetic alopecia and irregular periods that are still occurring at age 16, 17 and 18 years should be evaluated by their physicians to rule out polycystic ovarian syndrome (PCOS) as well as other hormonal issues like congenital adrenal hyperplasia (CAH). There are special blood tests that can be ordered.

See Article: Evaluating Patients with PCOS: What Blood Tests Should be Ordered?

Evaluation of PCOS in teenage patents can be more challenging and requires careful review of hair loss history, presence of acne, hair growth on the face, irregular periods and possibly ultrasound. Many healthy female adolescent patients who do not have a PCOS diagnosis have polycystic ovaries by ultrasound so the evaluation of possible PCOS in adolescents should involve a knowledgable specialist.

With your current mediations being finasteride, some of the hormone tests may be inaccurate by simple fact you are on these drugs but it may still be worth discussing these diagnoses with your specialists if they have not been discussed before. If your periods have been irregular, you will want to discuss whether PCOS could be a part of your diagnoses. If your periods have always been regular and you have not had increased androgens in your blood tests, and yo have no have acne and hair growth on the face then your specialists may feel that PCOS is not a consideration.

Differentiating Androgenetic Alopecia from Telogen Effluvium

I have included a comprehensive table below that compares feature of AGA and TE. In young women, TE and AGA have many features that overlap and mimic each other. Mild symptoms can be present in both although often other explanations like seborrheic dermatitis best fit with the reason for the patent to have symptoms. YOu’ll want to have all areas of your scalp carefully examined by trichoscopy to determine the specific reason.

There are several ways that your physicians can help solidify the diagnosis for you. In AGA, the story may suggest hair loss from the central scalp but sometimes if TE is also present the story appears confusing because some hair loss is also diffuse. AGA can give shedding and so can TE. Massive amounts of shedding are not seen in AGA. Trichoscopy can be performed by your doctors. In AGA, trichsocopy shows a variation in the size of hairs (as mentioned above). In TE, this variation is not present. A biopsy can be extremely helpful in your case if doubt still exists in your mind or the mind of your specialists. A terminal to vellus hair ratio of less than 4:1 on the biopsy suggests a diagnosis of AGA. This simply means the the biopsy captures a large proportion of vellus (tiny) hairs which is a feature of AGA. If a person does need a biopsy, it’s important that it be taken from the middle of the scalp as this is where the diagnosis of AGA is most accurate in women.

If you don’t wish to have a biopsy, a modified hair was test can be helpful to document the number of hairs and the proportion of small hairs. A high proportion of short 3 cm hairs by the modified wash test suggests a possible diagnosis of AGA.

Summary

I hope this helps, and thank you again for the question. I would appear that AGA is at least one of your diagnoses and TE could be too. A good history, examination of the scalp (with trichoscopy) and review of all your blood tests can help confirm the diagnosis. If there is any doubt, a scalp biopsy can be helpful.

You are right that TE may be present with your diet and low HGB. I would be surprised if TE was having the greater contribution compared to AGA with the story you have given.

If AGA is what you do have, you may wish to review all the options including minoxidil, laser, platelet rich plasma and other antiandrogens. Oral contraceptive are important considerations if PCOS is present. One must always remember that women using finasteride must never become pregnant while using this medication. Hair transplantation can be an option for some women but it may not be a good option if you hair loss is diffuse. Many females with early onset AGA are not good candidates for hair transplantation due to the diffuse nature of the hair loss.

Stress and Hair Loss: Is it real? What is the mechanism?

Stress causes hair loss through many complex mechanisms including neurogenic inflammation

I’ve selected this question below for this week’s question of the week. It allows us to discuss the relationship between stress and hair loss.

Here is the question….

QUESTION

I understand that stress can cause telogen effluvium. If that’s true what is the mechanism?

ANSWER

Thanks for the great question. The short answer is that researchers are continuing to put together all the pieces of the puzzle to explain how exactly stress causes hair loss. But yes, stress can cause hair loss.

Below, I’ll review with you some of the key medical and research evidence that helps prove that stress can cause hair loss. You and our readers will come to see that stress ultimately triggers the adrenal gland to produce cortisol which in turn triggers the release of substance P in the spinal column which in turn triggers mast cell degradation in the skin and around hairs. This is the essence of “neurogenic inflammation” and it causes hairs to fall out. When I teach medical student and dermatology trainees about the relationship between stress and hair loss and tell them simply that when they feel stressed and ready to burst - their mast cells are ready to burst as well. It helps them remember this important link.

Let’s delve deeper into this great question

A. CORTISOL

To understand the relationship between stress and hair loss, one needs to understand the hormone cortisol. In 1936, Dr Reichstein identified the structure of cortisol. It was in that exact same year (1936), the concept of stress was first introduced by Dr Hans Selye.  Dr Seyle is largely regarded as the ‘father’ of stress research. His experiments on rats in 1936 showed that a stressor often alters many parts of the rat including the adrenal cortex, the immune system, and the gut. Specifically, his studies showed that rats exposed to various nocuous chemical or physical stimuli developed enlarged adrenal glands (a phenomenon called hypertrophy). These rats also had a reduction in the size of their lymph nodes and developed gastric erosions.

In 1950, Reichstein along with two others (Hench and Kendall) were awarded the Nobel Prize in Physiology and Medicine for these discoveries relating to the hormones of the adrenal cortex, their structure and biological effects.

B. THE HPA AXIS

By the mid 1950’s physicians and researchers had developed a very basic understanding of stress. Remarkably the model proposed in the 1950s has stood that test of time right up to the present day. We call this the Hypothalamus- Pituitary – Adrenal axis (HPA axis)

In the presence of stress, a part of the brain known as the hypothalamus triggers to release a hormone called CORTICOTROPIN RELEASING HORMONE or CRH. CRH in turn tells the pituitary gland to synthesize and release a chemical known as Adrenocorticotropin hormone (ACTH). ACTH then enters the blood stream and stimulates the adrenal glands to make cortisol.

B. THE HPA AXIS and Beyond: A New Model of the Skin Endocrine System

For many years after the HPA axis was proposed, the hypothalamus was truly thought to be the ‘ boss’. After all, it made hormones that told other parts of the body what to do. It not only made CRH, but may other hormones too. Soon it was discovered that the skin was able to produce many of its own hormones too including CRH, ACTH and others.

The skin is an endocrine organ unto itself and can produce many different hormones.

From there a whole new model of understanding stress flourished where it was proposed that stress causes an upreegulation of a chemical known as substance P (SP) and calcitonin gene-related peptide (CGRP) in the dorsal root ganglia of the spinal column along with epinephrine and norephineoprhine. This in turn leads to change in the hormone production in the skin and the degranulation of cells in the skin known as mast cells.

It’s this degaulation of mast cells that sets off in the skin a whole new type of inflammation called “neurogenic inflammation.”

C. Is this modern model of stress and the skin really relevant?

It appears that this model linking stress to hair loss is accurate. Studies have shown that when mice and rats are stressed in the lab, there is in increase in cortisol levels and hairs leave the growing phase. This is all associated with an increase in substance P in nerves and degranulation of mast cells. What’s quite remarkable is that effects of stress on the skin and hair of mice and rats can be blocked by administering antibodies to substance P to block the effects of substance P. It appears substance P in nerves is really important to how stress affects the skin and hair.

The modern model relating stress and hair loss is therefore :

D. Stress and Humans: What research suggests stress causes or contributes to hair loss in humans

A number of studies in human have linked stress to hair loss.

Study 1: Bin Saif et al 2018

A 2018 study by bin Saif evaluated 529 medical students to evaluate how dermatologic conditions differ among students who are the least stressed, moderately stressed and highly stressed. Compared to the least stressed students, highly stressed medical students reported:

a) More hair loss

b) More flakes on the scalp 

c) More itchy skin

d) More trichotillomania

d) More warts

Study 2: Rebora et al 2017

Rebora published a nice study in 2017 showing thee development of shedding in a patient every time the patient was stressed. When stress went down, the shedding went down. When stress increased again, shedding increased again.

E. Stress in other hair loss conditions

Your question relates to telogen effluvium so I’ll limit the discussion to TE. However, it should be noted that stress probably has a role in several hair conditions including alopecia Areata, lichen planopilaris, and others. It may not be the direct cause of course, but neurogenic inflammation appears to contribute to immune system dysregulation.

Summary and Conclusion

Thank you again for the great question. I hope you can see that the question is mighty complex but we’re developing remarkable new understand as the years go by. It appears that neurogenic inflammation is a key mechanism by which stress causes hair loss. Furthermore, it appears that mast cells are important in this whole process.

References

Arck PC et al. Indications for a 'brain-hair follicle axis (BHA)': inhibition of keratinocyte proliferation and up-regulation of keratinocyte apoptosis in telogen hair follicles by stress and substance P. FASEB J. 2001 Nov;15(13):2536-8. Epub2001 Sep 17.

Bin Saif GA et al. Association of psychological stress with skin symptoms among medical students.LSaudi Med J. 2018 Jan;39(1):59-66. doi: 10.15537/smj.2018.1.21231.

Liu et al. Chronic Restraint Stress Inhibits Hair Growth via Substance P Mediated by Reactive Oxygen Species in Mice PLoS One. 2013 Apr 26;8(4):e61574. doi: 10.1371/journal.pone.0061574. Print 2013.

Rebora A. Intermittent Chronic Telogen Effluvium.Skin Appendage Disord. 2017 Mar;3(1):36-38. doi: 10.1159/000455882. Epub2017 Jan 28.

If I have alopecia areata, what are the chances my child will have alopecia areata?

The Inheritance of Alopecia Areata

I’ve selected this question below for this week’s question of the week. It allows us to discuss the chances of children developing alopecia areata if their parents are affected.

Here is the question….

QUESTION

Our son is 19 and he has alopecia totalis for about 16 years. Now that he has reached a marriageable age, we would appreciate professional advice on an important matter. Can alopecia pass from a parent to the kids ? If he marries a girl with alopecia are the chances for the children to develop alopecia greater?

ANSWER

Thank you for the question. I’ll explain the answer to the question in greater depth in just a moment. The short answer to your question is the following:

1) Yes, alopecia areata can pass from parents to children - but it is not common. About 6 % of your son’s children would be predicated to have alopecia areata and 94 % would not. In other words, it’ s possible for your son to have a child with alopecia areata but most likely he will not.

2) Yes, if your son marries an individual who also has alopecia areata the chances their children will develop alopecia areata is greater.

Alopecia areata is an autoimmune condition. Both genetics as well as environmental factors are important. It’s not so simple as to say that if a person has the genes they develop the condition. Not at all. Even if one identical twin has the condition, there is only a 55 % chance the other twin will develop the condition. So the inheritance is complex.

There are many genes for alopecia areata, not just one. The inheritance is polygenic not autosomal dominant like some conditions. It’s not so straight ward to say that if a parent has the condition, the child will develop the condition. In fact, if a parent has the condition, there is only a small chance a child will ever develop the condition.

Let’s look further.

The Blaumeiser et al Study of 2006

In 2006, Blaumeiser and colleagues performed an incredibly detailed study. They set out to study how alopecia areata is inherited by assessing how commonly patients with alopecia areata will have other family members affected. The study included 206 patients with alopecia areata. Permission was granted from these 206 patients to contact other members of the family to enquire about alopecia areata. A total of 1029 first-degree relatives as well as 2625 second-degree relatives were assessed.

Here are the key findings of this study as it applies to your question:

1] The estimated lifetime risks for having a child with alopecia areata if a parent has alopecia was 5.7 %.

2] It does not appear that having an earlier age of onset of alopecia increases the risk that a patient will have children with alopecia areata. However, if the patient does have a child with alopecia areata, the child is also more likely to have an earlier age of onset. Age at onset in index patients and first-degree relatives was significantly correlated in the study.

3] If a patient has alopecia totals or universalis, this does not indicate that there is a higher chance his or her children will have alopecia totalis or universalis if they do develop alopecia. In fact, in the rare event that your son has a child with alopecia areata, it is more likely that it will be a more mild form than a severe form. In other words, if a patient has alopecia totalis or universalis, there is still about a 6 % chance that his or her children will have alopecia area.

REFERENCE

Blaumeiser et al. Familial Aggregation of Alopecia Areata. Journal of the American Academy of Dermatology. 2006 Apr;54(4):627-32.

What is causing my beard, body and scalp hair loss?

What’s causing my beard hair loss?

I’ve selected this question below for this week’s question of the week. It allows us to discuss the importance of the speed of hair loss in the diagnosis of hair loss.

Here is the question….

QUESTION

I have diffuse thinning across my entire body. I am male, under 30. The hair loss initially started as rapid thinning on the entire scalp, soon spread across facial hair and body hair. Some distinguishable features of my hair loss are that my beard and body hair only have one hair per follicle, a lot of hairs remain as very short stubble and do not grow, eyebrows experience pain during periods of shedding. I've been to 4 dermatologists and had one scalp biopsy which was inconclusive. Hair loss has been very rapid, from initial onset I lost well over 50% of my hair density within 4 months. My beard presented with patches of hair loss which have grown in.

Beard photos, before (left) and right (after) hair loss

Scalp does not itch and I do not feel any burning. However I feel tenderness and itching in my eyebrows which are constantly shedding. I've been on finasteride ( discontinued ), oral minoxidil for 9 weeks, and steroid injections in the eyebrows which have helped with regrowth. Hair loss started 3 months after I experienced a very traumatic event and has continued well over 1 year now.. After the traumatic event I broke out with very severe cystic acne across my back, scalp neck and face and hair loss soon followed. The way I look today is completely indistinguishable from what I looked like 1 year ago.

What is the likely cause ?

ANSWER

Thanks for submitting your question. There are several possible hair loss conditions that could be causing this, but the most likely cause, by far, is alopecia areata. But it’s certainly not 100%.

To help definitively figure out what’s going on, I would need to (1) ideally see photos of the scalp and eyebrows, (2) know the answers to a lot more questions I have, (3) review your biopsy and (4) review all your blood tests. I’d like to know if you’ve had patches of alopecia areata in the past, whether you have a family history of alopecia areata, how thin the eyebrows were, whether their was redness in the eyebrows too, whether the eyelashes were lost, whether you’ve had changes in your nails, weight loss, or abnormalities in your blood tests. I’d want to know if you’ve started or stopped any prescription medications and supplements in the last 12-16 months, started or stopped any anabolic steroids, and whether you’ve had any skin rashes of any sort in the last 2 years. Fevers, night sweats are important to know about as well. Of course, your entire medical history will be important.

The full list of possibilities for the hair loss includes:

1. Alopecia areata alone

2. Alopecia areata with a telogen effluvium

3. Alopecia areata with seborrheic dermatitis

4. Alopecia area with a telogen effluvium with seborrheic dermatitis

5. Alopecia Areata with a telogen effluvium with seborrheic dermatitis with male balding of the scalp.

6. Telogen effluvium with seborrheic dermatitis

7. Frontal fibrosing alopecia/lichen planopilaris

8. Rare mimickers - syphilis, cutaneous T cell lymphoma

There are many features of the story here which fit well with alopecia areata. First, the speed of hair loss is fast. The loss of 50 % density in 4 months is seen in alopecia areata and sometimes telogen effluvium but this kind of rapid hair loss is more typical of alopecia areata. it’s far too fast for androgenetic alopecia but of course this may be a part of the hair loss that is happening as well (more chronically). It’s too fast for most scarring alopecias too (and I would not expect regrowth to occur in the manner you described if this were the case). It’s not impossible for FFA, but it is an uncommon story for FFA.

I’ve written about the importance of the speed of hair loss in the past. Alopecia areata is classically quite fast and has the potential to cause more rapid hair loss than telogen effluvium if the alopecia areata is active.

It’s possible of course, that a person has a telogen effluvium and alopecia areata too. A person can have two diagnoses or three or even four or five. The intense stress you had from the traumatic event can cause a telogen effluvium and if you are genetically predisposed, it could precipitate alopecia areata too.

The regrowth of your eyebrows with steroid injections is best in keeping with alopecia areata. I would need more information to know it it’s a little or a lot of regrowth. It would be helpful to know what the brows actually looked like before. If the regrowth has been really significant with the steroid injections, alopecia areata remains at the top of the list. That said, any inflammatory condition of the eyebrows can cause hair loss and steroid injections can help with regrowth. Seborrheic dermatitis of the eyebrow can cause a little bit of loss but it’s usually mild and steroid injections can settle down the redness and help get brows regrowing. Even frontal fibrosing alopecia can show some regrowth so the simple fact there was regrowth does not prove it is AA. Eyebrows can improve with steroid injections in quite a few conditions so this feature alone does not prove it’s alopecia areata.

The beard photos you’ve submitted are most in keeping with a diagnosis of alopecia areata. Are there mimicking conditions that can look 100% the same ? Yes, there certainly are. Rarely, a seborrheic dermatitis can cause beard loss but that’s quite unusual to be patchy in this manner. Rarely, an immune based issue can cause beard loss too (lichen planopilaris/frontal fibrosing alopecia) but regrowth is less likely in these types of situations. Frontal fibrosing alopecia really is one of the key conditions that you and your doctors need to rule out confidently. Beard hair loss or beard thinning happens in about 30-40 % of patients with FFA. Telogen effluvium affecting the beard in a patchy manner like shown in the photos is not typical so telogen effluvium would not explain the beard loss but could, of course, still be involved. Syphilis is not common cause of the hair loss pattern you are describing but this diagnosis needs to be considered by your doctors in a presentation like this. It is a great mimicker of alopecia areata. A rare condition of the blood cells (mycosis fungoides/cutaneous T cell lymphoma) needs to be considered if things don’t improve. I would not expect these latter two conditions to have spontaneous improvement you have described without treatment so they probably don’t fit well in your particular case. Alopecia areata is still at the top of the list of causes but your dermatologists can review these entities and perform a full skin examination.

The acne eruption you describe may or may not be related to the hair loss. I suspect it is related in some manner. Acne eruptions of this kind can be seen in alopecia areata. (See previous article alopecia areata and acne). In order to understand how hair could have a role in acne development, it is important to understand the function of hair. During the process of normal skin turnover, the shed skin cells from the hair follicle epithelium are carried upward in the follicular canal towards the skin surface. It is thought that the sebum that is secreted by the sebaceous glands helps in this process but helping the shed cells efficiency move out of the hair follicle canal.

Ringrose and colleagues first reported the relationship between acne and alopecia areata back in 1952. They described a male patient who developed acne, milia and cystic type eruptions only in the areas of alopecia. The authors proposed that the hair helps keep the follicular orfice open to allow sebaceous contents to be properly removed. They described the hair follicle as a “natural drain” to the removal of sebum.

These same authors performed some interesting histological studies by examining biopsies of these acne lesions. They found that acne lesions were not seen in areas that contained hair and were not seen in areas where the pilosebaceous unit was completely degenerated. The proposal here was the acne lesions of alopecia areata represented a transition period - between normal growth patterns and complete loss.

in 2007, Sergeant and colleagues proposed that the hair follicle acts as a type of ‘wick’ and acts to draw sebum up towards the skin surface. They stated that the hairs on the scalp may do this more efficiently that hairs on the face and therefore the hairs on the face may be predisposed to the formation of “micocomedones” and the typical lesions of acne. Microcomedones are a prerequisite for the ultimate acne lesion.

So in your case, there is a high likelihood a diagnosis of alopecia areata is present. It is certainly not 100 % but the likelihood is quite high. It will be really helpful to follow all hair bearing areas - as definitive signs of alopecia areata (or scarring alopecia or another condition) may show up over time. In my opinion, frontal fibrosing alopecia is the mimicker that really needs to be ruled out.

FINAL COMMENTS

At this point, the evidence would suggest alopecia areata but I would need more information to confirm or refute that. I would recommend that you speak to your doctors about these issues as they will know your case best. I would suggest you considering asking them about blood tests for CBC, TSH, ferritin, testosterone, B12, ESR, ANA, zinc, vitamin D, RPR, creatinine, AST, ALT, urinalysis if you have not already. if any of these are missing you might get them done. If the diagnosis is not clear, a repeat scalp biopsy can be considered. It may be that with trichoscopy a dermatologist can evaluate whether alopecia areata is present although I certainly do appreciate that your story is complex and you’ve probably had many evaluations (with trichoscopy too). Biopsies of the arm hair, leg hair and eyebrows are trickier and often given less information. If a repeat biopsy is needed, it should come from the scalp. The main thing we are trying to distuish in the biopsy is alopecia areata vs scarring alopecia (ie frontal fibrosing alopecia) .

If it is alopecia areata that you have, I suspect that over time, a patch of typical alopecia areata hair loss will occur that will allow your doctor to definitively tell you if that’s what it is. There are ways to explore the diagnostic possibilities further. Certainly, the blood tests above are important. You’ll want to make sure there are no systemic issues that increase the chances for cystic acne and hair loss. We’ve spoken about the possibility of having a repeat biopsy. This should be done on the scalp and be 4 mm and be done with horizontal sections and read by an expert dermatopathologist. Alopecia areata can be tricky to diagnose in some cases. However, an increased proportion of catagen and telogen hairs and eosinophils in the tracts and peribulbar inflammation can all point to the diagnosis. A biopsy will pick up immune based issues, lymphomas, and if the percent of telogen hairs is high the biopsies will give an idea of how high it really is.

Sometimes in a situation like this, we consider a "therapeutic challenge.” A therapeutic challenge means we give certain medications to observe what happens when those medications are given. If the response to the medications is exactly what we predicted, it suggests we are probably correct with our diagnosis. I would need to know more about your story to describe exactly what might be appropriate but you and your doctor could consider therapeutic challenges like steroid injections to the entire scalp, or a 4-6 week course of oral steroids is an approach therapeutic challenge if alopecia areata is considered. If you get significant regrowth during these types of therapies, it’s a pretty good indication that there is an inflammatory issue that was blocking the growth of hair. Alopecia areata would be the most likely diagnosis in such as case.

If alopecia areata is the final diagnosis, then continued beard injections together with other systemic options would be possible including dexamethasone, methotrexate, cyclosporine, tofacitinib. A return to oral minoxidil could be reconsidered depending on exactly what your story was when you stopped it

Thanks again for submitting your case. I hope this was helpful.

The significance of early onset hair loss in evaluating alopecia areata

Will my daughter’s alopecia Areata recover?

I’ve selected this question below for this week’s question of the week. It allows us to discuss the importance of the prognostic factors in evaluating alopecia Areata.

Here is the question….

QUESTION

What is your opinion on 'the younger a patient is diagnosed with alopecia,the less likely there is a chance of recovery/reversal?'

My daughter was officially diagnosed at 18 months with alopecia (she has complete hair loss). We were told that unfortunately the younger a patient is diagnosed with it, the less chance she will recover/have hair. I would like too know your thoughts on this and why this seems to be the case. 

She is 3 now, has had total hairloss since 18 months and prior to that had a lot of large bald patches/irregular hair growth. She currently has a few lashes and little bit of brows (these don’t seem to have any pigment/look clear- she was born with quite dark hair). Her lashes and brows dont usually stay very long when they do manage to come in. 

ANSWER

Thanks for this question. I would generally agree with the statement you have quoted, namely that the younger a child is diagnosed with AA, the lower the chances of regrowth/recovery. The way that I would word it even more accurately would be to say the following: “the younger a child is diagnosed with alopecia, the lower the chances of regrowth/recovery especially if the child is under 5 and has more advanced hair loss at the time of their visit or has other negative prognostic factors from the list of negative prognostic factors”

Over the last many 30 years, researchers have identified several prognostic factors that help hair specialists predict the likelihood of regrowth.

Over the past 30 years, several factors have been found to be associated with poorer prognosis for regrowth of hair. These factors are not absolute but do enable clinicians to be able to better predict the ilkelihood of whether patients will regrow hair. These are by no means definite but nevertheless provide a helpful guide.

The most important prognostic factors for alopecia areata are:

1] Extensive loss (especially alopecia totalis and universalis)

2] Early age of onset (especially under 5)

3] Ophiasis variant (hair loss at the back regions of the scalp)

4] Nail changes suggestive of alopecia areata

5] History of alopecia areata in a family member

6] Presence of other autoimmune diseases in the patient (eg, atopy, Hashimoto thyroiditis)

The above prognostic factors teach us that for your daughter, the diagnosis of Alopecia Areata at 18 months and especially a more severe form (complete hair loss), indicates she is less likely to regrow hair. Factors such as a family history and whether she has nail disease or other autoimmune diseases also are helpful to review but it would not alter the general opinion that chances for regrowth are lower. The chances are never zero, but regrowth is unlikely.

Good treatment options for Alopecia Areata increasing rapidly as years go by and so more and more good options are certainly on the way in years ahead as we understand more about the condition. There’s no doubt about that. You’ll want to keep close contact with the paediatric dermatologist. Organizations like the National Alopecia Arteata Foundation in the US and Canadian Alopecia Areata Foundation here in Canada can provide helpful updates on progress - and so can our website too.

Children with Alopecia Areata often have low vitamin D and other factors can be evaluated based on the full information you share with the doctor (ie. evaluation for iron issues, thyroid disease, anemias, other deficiencies). Some young children with alopecia areata have eczema (itchy patches of skin) and some have asthma and allergies so all these need to be carefully reviewed with the doctor.

Why is regrowth less likely?

We don’t understand all the factors involved in alopecia areata yet. We do know that the patient’s genetics is very relevant. In other words, the genes they are born with have a major influence over whether they will develop alopecia areata or not. Factors in the environment definitely have some role and these include things like infections, stress, and diet.

For children with alopecia areata occurring by 18 months, it’s the genetics that is guiding the development of the Alopecia Areata. There are likely strong genes for alopecia areata that are present (and were present from birth) which are providing signals for the hair to be lost from the scalp. We don’t know how to easily test these genes yet but someday it will be possible. These strong genes provide the hair follicles with messages to ‘fall’ and even with the currently available treatments we have, these messages can not be easily overcome. Someday it will be.

Thank you again for the question. I do hope this will be helpful to you and your daughter.

What is the cause of my alopecia?

What could have possibly caused my alopecia areata?

I’ve selected this question below for this week’s question of the week. It allows us to discuss what causes alopecia areata and the relationship between genetics and the environment.

Here is the question….

QUESTION

What could be the likely cause for my alopecia areata if the following conditions are true: 

1) I realized that I had insufficient vitamin D
2) I have been experiencing too much stress for the last 5 years resulting in poor sleep
3) I suffered from chickenpox when I was about 8 years old

How do I know if one of the above is the likely cause of alopecia areata?

ANSWER

Thanks for this question. Let’s get right to it and we’ll see that these three things you mention (stress, infections and vitamin D) might have contributed a very small amount but the chance for you to develop alopecia areata was present even on the day your were born. That’s the key message here - you were actually born with the chance to develop alopecia areata.

Alopecia areata is an autoimmune condition. There is a good amount that we still don’t understand but there is a vast amount now that we do understand in the present day and our knowledge is growing constantly. We know that fundamentally the condition is caused by inflammation that accumulates around the hairs that are trying to grow deep under the scalp. The condition is therefore an autoimmune condition meaning that the person’s immune system has become activated in such a way that the immune system generates inflammation around hairs.

In order for a person to develop alopecia areata someday, most probably need be born with the correct set of genes. Some people have the correct genes and some don’t. We know now that this is not just one gene but many genes.  As I wrote about back in 2011, there are actually eight genes that really increase a person’s chance of developing alopecia areata and then other genes that might influence it a a bit too.

READ: The Eight Genes that Markedly Affect A Person’s Risk of Alopecia Areata

We now know that most of a person’s chance to develop alopecia areata comes from their genes. Some people have these various genes and are at risk to develop alopecia later in life. Some people don’t have these genes.

In other words, it’s possible to predict to some degree if a person will develop alopecia areata from the day they are born. We may have been able to predict on the day you were born that you were at higher chance to develop it later in life. That said, we don’t test the genetics of newborn babies for their risk of alopecia areata. But we do test newborn babies for the risk of many diseases within the first hours of life. In fact, some counties test babies for their risk of dozens of health conditions by evaluating the genetics of the baby.

But someday it will be possible for parents to ask - what’s my baby’s chance of developing alopecia areata? Someday, after evaluating the baby’s genetics, we would be able to reply back to the new parents “the risk of your baby developing alopecia areata in their lifetime is very low, or we might say that the risk is medium or high or very high.” This kind of information is not routinely part of our world yet. The expense is still enormous to implement this sort of testing and we still don’t understand everything about the disease yet.

But my point is this - the risk to develop alopecia areata is in a person from the day they were born. That doesn’t necessarily mean a person with alopecia must have a family history of alopecia areata. Not at all. But there are genes that have been passed down from parents and grandparents and great grandparents that are present in the patient to give them the increased risk.

Genetics vs Environment: Genetics is important but not enough.

Now that we have reviewed the importance of a person’s genetics, we can move on to discuss what we refer to as a person’s “environment.“ By using the term environment, we are referring to all the things that happen in their life after they are born. This includes the stress the experience, the food they eat, how much sunshine they get, what types of infections they get.

Are these sorts of things relevant to alopecia areata? Yes, they are! But not nearly as much as the person’s genetics.

Both genetic and environmental factors have a role in alopecia areata - but genetic factors have the biggest and most important role

The sorts of things a person is exposed to can “tip” them from being a person who is unlikely to develop alopecia areata at any time in their life to a person is actually develops it. In this case, we would say that the person’s environment had a major effect on their alopecia areata. Similarly, a person’s environment can also tip them from being the sort of person that has a high chance to develop alopecia areata to a person who never every develops it. Those factors of course need to all be worked out completely but that’s how we have come to understand this disease.

This pie chart above is a helpful reminder to us all that when it comes to alopecia areata the genetic factors are much more important than the environmental ones - but everything has a role.

A Helpful Model of Alopecia Areata

So when I think of alopecia areata, I think in terms of the diagram you’ll see below. Hair follicles respond to signals that tell them to grow and signals that tell them to fall. For most people the “grow” signals are what predominate - and so that’s what hair follicles do. Even for people who are born with the chance to develop alopecia areata - most of what is heard by the hair follicle are the grow signals. Day in and day out the grow signals are what is heard. Not surprisingly, even if a person has the right genetics to develop alopecia areata - most won’t develop it any time soon because the grow signals far outweigh the fall signals. There might be few voices whispering “fall, fall fall” but there is a massive choir singing “grow, grow, grow” - and so the hair decides to grow.

Environmental factors like stress, infections, and some medications and low vitamin D like you said have the potential to tip the balance in some people and lead to the hair follicle receiving more fall signals. This probably only happens in people that have the underlying genetics to develop the condition in the first place. If the underlying genetics is not present in the person at birth, these sorts of environmental factors usually don’t cause alopecia areata.

Summary

I thank you again for your question. Your stress, low vitamin D and poor sleep and the infections you had in the past are your ‘environmental triggers.” They do have some role and in the present day and age we can’t tell you exactly how much of a role they had. But they had some role. The main message I hope that you will receive from this article is that your genetics is the main factor that influenced your alopecia. It’s a pretty complex genetics and most people don’t have strong family history of alopecia. But in your family there are probably other autoimmune diseases in parent, grandparents, great grandparents, great great grandparents or great great great grandparents that have influence the complex set of genes that you were born with. Some of these genes when they come together have influenced your risk to develop alopecia areata. All the various environmental factors come together to influence whether there are really enough “fall signals” present or not to cause thee hair to fall out.

What's the reason for my hair loss? What does my trichoscopy show?

Why am I experiencing hair loss?

I’ve selected this question below for this week’s question of the week. It allows us to discuss some of the finer aspects of interpreting trichoscopy and how the clinical history must be interpreted together with all trichoscopic analyses.

Here is the question….

QUESTION

I really hope you can help me with the diagnosis of my hair loss that I've been experiencing for a year now without being able to get a real diagnosis, doctors can't seem to find anything else than '' light dermatitis'', yet I can' t help but notice everyday that this isn't normal and I have no clue so far. 
About a year ago I suddenly noticed that I had way less hair and I could see my scalp, which never happened before. A few weeks later I've started to notice redness in my scalp and itching that never left ever since. The itching seems to come and go without any logical pattern, and the more red and itching my scalp gets, the more hair I seem to lose. I did a trichoscopy 2 weeks ago, where you can see the results.

I'm quite desperate to get a real diagnosis because I don't think something innocuous would last that long and cause hair loss without stopping. Overall I am in good health. Blood tests were all okay 

ANSWER

This is a great question because it allows us to talk about so many things.

Before we go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s Story

2) the findings uncovered during the process of the scalp examination and

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

I’d like to know a lot more about this story ideally but of course the magic of the “question of the week” is that I tackle questions with limited information.

I can’t be sure of what’s going on entirely without seeing your scalp up close myself and knowing your entire story. Your age, and details about your scalp symptoms all matter.

In my opinion there are 4 possibilities for what you have:

1. Androgenetic alopecia with seborrheic dermatitis (AGA + SD)

2. Androgenetic alopecia with mild telogen effluvium with seborrheic dermatitis (AGA + TE+ SD)

3. Mild telogen effluvium with seborrheic dermatitis (TE + SD)

4. Seborrheic dermatitis alone (SD alone)

I’d like to make a few comments about the type of thinking that is needed in case like this.

A few comments

1. It’s true that you have very nice trichoscopy pictures - but what’s also important is just getting a sense if the frontal density is truly the same as the back. There certainly is a suggestion that your frontal density may be less than the back (occipital area) despite all the numbers that you see in your measurements. If there truly is a significant difference in the density in the frontal and back then we need to think about a patterned hair loss (ie androgenetic alopecia).

2. A physician can get a better sense of density by parting the hair down the middle from front to back and comparing the part width in the front to the back. If the part width is wider in the front than the back that means there may be more hair loss in the front compared to the back - and this might be a suggestion that there is some degree of androgenetic alopecia.

3. It does seem that your blood tests have been normal so we’ll assume that. This does not mean that a person can not have telogen effluvium or androgenetic alopecia with normal blood tests. In fact, most people with hair loss have normal blood tests. I have not seen your blood tests of course, but I would hope that you have had CBC, TSH, ferritin, 25 hydroxyvitamin D. If your periods are irregular you should have a hormonal panel. If you have other symptoms, you might need other testing too.

4. There appears to be clear differences with the photos in the frontal areas compared to the occipital (back) areas including more single hairs and less density. While this could be simply suggesting diffuse loss as in a telogen effluvium, we need to consider the possibility that this could represent a pattern to the loss (and female pattern alopecia also called androgenetic alopecia).

5. Your average hair caliber seems to be lower than expected at 60 um. This depends on your background and your type of hair but it certainly does make me wonder if there is some change happening that affect caliber especially a diffuse process like a diffuse AGA. Of course, androgenetic alopecia is one of the more common hair loss conditions that affect caliber. Your data from the trichoscopy is not definite so I can’t completely rule in or rule out this particular diagnosis.

6. If you do not have much in the way of increased shedding, I would favour a diagnosis of AGA. If there is a lot of shedding that you have, it still could be AGA but a mild effluvium (TE) certainly does not need to be considered. Your story of suddenly “noticing” that you have less hair is more typical of AGA than TE. The degree that you are shedding today and the degree that you have been shedding in the past 6-9 months would sway me someone as far as how likely a diagnosis of TE really is.

7. I do favour options 1 and 2 but it’s by no means definite based on the information you have given. It will be helpful to follow the trichsocopy measurements over time. If you have a TE like in option 3, the measurements and numbers will likely get better over time. If it’s an AGA (option 1 and 2), the numbers will not likely improve and may get slightly worse in 6-12 months. Photos will also be very helpful. If it does become clear that the density in the frontal areas is slightly less than the back of the scalp, one needs to consider androgenetic alopecia.

8. If you are concerned a scalp biopsy or a 5 day modified hair wash test might help. Sometimes in the very early stages a a biopsy only slightly helpful so I am not of the opinion that you must have a biopsy. However, if the terminal to vellus ratio of your biopsy is shown to be less than 4:1 it indicates androgenetic alopecia is likely to be present. If the terminal to vellus ratio is above 4:1 is suggests that TE alone (option 3 or 4) is more likely. A biopsy can also capture any rare mimickers of redness such as lichen planopilaris, although I do not suspect that is what is going on (the density and changes are far too similar in the 3 areas to really support early LPP - and the story I have so far and the trichoscopy does not really support that diagnosis). A modified hair wash test can give a sense of how many hairs are being shed and whether any of these are small. What’s interesting in your photos is that it does appear that there are more vellus hairs in the photos from the frontal area than the measurements state in the information you were given. I am personally a big believer not only in looking at the measurements these computers give but also in looking at the images myself and looking at the scalp myself and getting sense if the measurements the computer gives makes sense or not. The presence of thinner and thinner hairs (miniaturized hairs) and the presence of thinner and shorter hairs (vellus hairs) is what androgenetic alopecia is all about.

9. I do think that there is likely a component of seborrheic dermatitis complicating the picture here. Your dermatologist can review with you at your next appointment. The trichoscopy would suggest this as well. SD is not typically a major cause of hair loss but can give a bit of shedding if severe enough. If you do have SD, it is mild and may contribute to symptoms like itching and tingling from time to time and then there will be periods where the scalp feels good again. The involvement of the temples is quite typical of SD and your photos are noticeably most red in the temples. There are no signs of scarring alopecia in the trichoscopy images provided but again a biopsy can help further clarify.

FINAL SUMMARY

Thanks for the great question. With the information provided, I can’t say one way or another exactly what is the diagnosis. However, a scalp biopsy or 5 day modified hair wash test could take you that much closer to understanding the diagnosis if there is really debate. I am suspicious about their being androgenetic alopecia here but I can’t tell for sure and ideally would want to see the scalp in a situation like this. Once you have the proper diagnosis, you can plan treatment. In addition, it is going to become much clearer over time what the diagnosis is especially if you do repeat trichoscopy measurements in 6 and 12 months. The frontal density and caliber of the hair in the frontal area will decrease and the number of single hairs is going to increase in the frontal if AGA is truly what is present. For now, treating the seborrheic dermatitis is quite reasonable. I would normally recommend that efforts be put into confirming the diagnosis with certainty. Some of the treatments for TE overlap with AGA treatments including laser and topical minoxidil and oral minoxidil so one can certainly get started with a plan once the diagnosis is made. Certain other treatments however, like anti androgens, are only effective in AGA and will not be effective if TE is the true diagnosis.

Thank you for your question.

What is normal shedding? A Closer Look at SEVEN Key Points.

Is my shedding normal?

I’ve selected this question below for this week’s question of the week. It allows us to discuss some of the finer aspects of shedding and why 7 main considerations matter when it comes to evaluating shedding:

Here is the question….

QUESTION

I have been keeping track of my shed hairs as closely as possible for 70 days.  My 30 day moving average is a steady 40 hairs per day and my 5 day moving average ranges from 38 to 42 or so.  However, my daily shed is unstable and can range from 20 to 60 with periodic days of 70.  The 60 and especially the 70 hairs a day concern me. Is it normal for your daily shed to fluctuate this much even though your averages are stable?
I am a 37 year old female.

ANSWER

Thanks for the question. There’s a lot to discuss with your question, so let’s get to it!

Before we go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s Story

2) the findings uncovered during the process of the scalp examination and

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

I’d like to know a lot more about this story ideally but of course the magic of the “question of the week” is that I tackle questions with limited information. We’ll review 7 key questions in a moment. Other questions may also be helpful. I’d like to know what blood tests were done in your case and what the results were. I’d like to know if your menstrual cycles are now regular. I’d like to know if the person asking the question has any medical issues or takes any medications. I’d like to know about stress levels? I’d like to know her family history of hair loss. I’d like to know if the patient has lost any brows or lashes. I’d like to know if her weight has been stable? I’d like to know if the density is the same as 6 months ago or actually worse? I’d like to know if the patient has any headaches, joint pains, skin rashes, dry eyes, dry mouth, thirst, abdominal pain, fatigue, changes in libido, or ulcers the mouth. All these things matter in fully answering these questions.

With that behind us, let's return to our question of the week again!

With the information given in the question submitted, one can not get to the diagnosis. That requires a more full review of your story from A to Z …. and it requires examination of the scalp or at least photos. But let’s explore how we get to the answer.

It’s possible that the shedding here is just a variation of normal. We need to keep that in mind. Many people with your story have normal shedding. If you feel your hair density at age 37 is the same as age 25 and if you feel that your shedding rates are pretty similar now to what they were like at age 25, then it’s likely this is a variation of normal ! If not, then more work is needed for you and your doctors to get to the answer as to whether your shedding is normal or not. Hair loss conditions such as androgenetic alopecia and telogen effluvium are very much a possibility too. Conditions such as chronic telogen effluvium, alopecia areata incognito and scarring alopecia are possible with anyone with the story given in your submission, but the chances of these are pretty low overall. Statistically speaking, most likely a person with your story has either a normal variation or has androgenetic alopecia or has telogen effluvium or has BOTH androgenetic alopecia and telogen effluvium. An astute hair specialist can help you solve the mystery once they gather from you more information, examine your scalp and review some key blood tests with you.

If you really want to understand more about your shedding and what it means, you may wish to review things in detail with your dermatologist. He or she might order a 5 day modified hair wash test. This test takes time and patience to perform yourself at home, but it gives a wonderful amount of information. You can read more about it in the link above. A scalp biopsy is not advised in most cases of someone asking about shedding because the diagnosis can be determined by using the principles discussed above (the SET principles).

As well, as you think about your own shedding, you and your hair specialists can refer to the helpful table below.
Let’s take a look at this table and let’s review some key things we can learn from it.

1. First - Normal shedding ranges from 20-80 hairs per day. Of course, if once shampoos every 2 days then that means the number is 40-160. If every 3 days then up to several hundreds hairs may be quite normal to be lost in the shampoo day. We lose more hair on the days we shampoo than on the days we don’t shampoo. It’s true that some lose up to 100 hairs per day but the reality is that if you average if out over a long time, it works out to under 100 hairs for most. This is the daily rate assuming one shampoos every day. If a person shampoos once per week, then they may lose 500 hairs easily that day without me even being concerned. shedding can vary across the menstrual cycle - especially after ovulation and in the days leading up to one’s period. This is normal. Other patterns are also possible.

2. Second - shedding can occur in other hair loss conditions and that rate of shedding can range from fairly normal to quite profound. Some individuals with telogen effluvium shed a little bit more than normal. However, some with TE shed massive amounts of hair. Generally speaking the rate of daily hair shedding in androgenetic alopecia is mild - but it must never ever be forgotten that AGA is one of the most common causes of slightly increased shedding in women with hair loss. Far too often we jump to the conclusion that a person with shedding has a diagnosis of telogen effluvium - nothing could be further from the reality. AGA must be on that list for women.

3. Third - the lengths of the hairs that are shed gives helpful information. If there are a few short hairs, one can’t conclude anything all that much. Everyone loses some short hairs and some long hairs - but mostly it’s long hairs that get shed. But if 20 %, 30 % or 40 % of the hairs that are being shed from the scalp are short less than 3 cm hairs, we need to at least start thinking about a diagnosis of androgenetic alopecia. A modified hair wash test can help quantitate this.

4. Fourth - the types of hairs that are being lost is helpful. We’ve talked about short hairs and long hairs in the section above. But long hairs can be telogen hairs, broken hairs and anagen hairs. If anagen hairs are being lost that look pretty normal anagen hairs, then scarring alopecia needs to be considered. If the anagen hairs are a bit “strange looking” then this may be a dystrophic anagen hair that one is seeing and a diagnosis of alopecia areata or scarring alopecia need to be reviewed. Finally, long hairs can be broken hairs. If broken hairs are what’s coming out of the scalp then alopecia areata, scarring alopecia needs to be considered - as does other entities like trichotillomania and chemotherapy induced loss and over use of heat or chemical styling practices. Of course, one usually knows if chemotherapy induced loss is a possibility because the patient will tell you if they have recently received chemotherapy treatment for cancer or not.

5. Fifth- the patient with shedding needs to figure out if they have hair loss all over or whether it’s occurring form one area more than others. If the patient feels that the back is much much less affected than the front of the scalp, the chances go up that the patient has androgenetic alopecia (AGA) as the cause of at least one of their diagnoses. Of course, they might still have TE and they might even have a scarring alopecia - but if there is a preferential reduction in density from one main area of the scalp that the person can point to with one finger - we need to consider the possibility of AGA.

6. Six - scalp symptoms can occur in any hair loss condition, but if they are profound and disabling and interfere with life then one needs to consider a scarring alopecia as the cause of shedding. Patients with AGA can have a little bit of itching. Patients with TE can have a little bit of itching. But massive 10 out of 10 itching, burning and pain is not a feature of AGA or TE. Conditions that give marked symptoms - that prompt people to put ice bags on their scalps - include scarring alopecias, allergic contact dermatitis, and scalp burns. Others exist too but you can see that AGA and TE are not part of this list.

7. Finally, the loss of other body hair can sometimes give clues. AGA is not associated with loss of eyebrows or eyelashes or body hair. Of course, if a patient says to me “oh, I do have eyebrow loss, come to think of it” this does not mean that they can’t have AGA. Eyebrow loss is common with age and so the simple finding of eyebrow loss does not mean that we have confirmed that the patient can’t have AGA . Not at all. It’s possible the patient has eyebrow loss as part of aging or over styling and now develops AGA too. But rapid loss of eyebrows, eyelashes and body hairs often points to an immune based reaction against hair follicles (with alopecia areata and frontal fibrosing alopecia being most common).

   SUMMARY

   I hope this helps. If you want to explore your shedding more, be sure to review with a hair specialist and pursue it methodically. You can look at the sizes of hairs being lost. You can measure the density on various areas of the scalp to determine if one area is thinner in density than another. You can review your symptoms. Together you can get a sense of whether your shedding is within the realm of normal or whether it is a reflection on an underlying scalp issue like AGA, TE or something else. If you feel that you have the same amount of hair on your head as age 27 and 17, then you are most likely dealing with the normal variations of shedding patterns. That’s really the most important question here.
   
   

Constant hair shedding for 2 years: Is the diagnosis TE or something else?

2 years of constant hair shedding: Is this just a TE?

I’ve selected this question below for this week’s question of the week. It allows us to discuss some of the finer aspects of the topic of chronic hair shedding. Hair shedding is often felt by some to be synonymous with telogen effluvium. This is incorrect.

Here is the question….

QUESTON

Hello. Would I be able to ask you a question about TE? I first experienced this in July 2018 4 months after I had my son by c section. Since July 2018 my hair fall has continued at a consistent rate of 70-80 hairs a day. Mostly all falling out in the shower. I’ve had all my blood work done by my doctor and he did a hair pull test and just says it’s TE. What do I do now that it’s almost been 2 years of constant fall out? Mind you the hairs are growing back in, tapered at the ends, sticking straight up, ALL over my entire scalp. The excessive hair fall is not stopping, which makes my hair look extremely thin even though they’re growing back in when one falls out.  
Any advice would be appreciated. My doctor wants me to try rogaine 2% and I don’t know if that’s the solution or not. 

Thank you in advance... 

ANSWER

Thanks for the question and probably one of the most common scenarios I encounter with female hair loss. There’s a lot to discuss with your question, so let’s get to it!

Before we go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s Story

2) the findings uncovered during the process of the scalp examination and

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

I’d like to know a lot more about this story ideally but of course the magic of the “question of the week” is that I tackle questions with limited information. I’d like to know what blood tests were done in your case and what the results were. I’d like to know if there is any itching, burning or pain in the scalp. I’d like to know if your menstrual cycles are now regular. I’d like to know if the person asking the question has any medical issues or takes any medications. I’d like to know about stress levels? I’d like to know her family history of hair loss. I’d like to know if the patient has lost any brows or lashes. I’d like to know if her weight has been stable? I’d like to know if the density is the same as 6 months ago or worse? I’d like to know if the patient has any headaches, joint pains, skin rashes, dry eyes, dry mouth, thirst, abdominal pain, fatigue, changes in libido, or ulcers the mouth. I’d like to know the precise age of thee patient. All these things matter in fully answering these questions.

With that behind us, let's return to our question of the week again.

You might have telogen effluvium. But the main point here and the entire reason I chose this as the question of the week, is you might not have TE as the diagnosis or a TE might not be the main reason. I feel strongly that you need another examination or a scalp biopsy.

First, let’s take a look at the reasons why your shedding is not stopping. There are several reasons why shedding does not stop in women. I don’t know anything about your story and don’t have photos of your scalp so I can’t say which of these 3 reasons (see below) it is. However, I’d encourage you to meet with an expert dermatologist as he or she might assist you in determining which of the following is applicable to you.

REASON 1: You have telogen effluvium, but you have not found the trigger

I’d possible you have telogen effluvium as the “only” diagnosis, but I doubt it. If, in fact, you do have isolated TE, then you may still be shedding because you have not found the trigger of the shedding. Causes of telogen effluvium include stress, low iron, thyroid problems, medications, crash diets, weight loss, illness inside the body. Which one is relevant to you?

I’m hoping you have had blood tests done already … but if not, you need them. A person with shedding of hair needs CBC, TSH, ferritin, vitamin D at minimum. In someone with your story, other tests like ANA, zinc, testosterone, DHEAS, ESR, VDRL may be important to consider. There could be other tests you need too! The exact tests that you need depend on your entire story. There are about 50 tests possible but most people need 5-10. It would only be possible for me to list the blood tests you need if I knew about your entire story from A to Z

it’s possible you are still shedding because there still is a trigger telling your hair to shed. If so, you are your doctor need to find it. Is there something in the blood test results? Do you need more blood tests? is there a medication causing your shedding - like birth control? like a prescription mediation? Do you have any medical issues that you do or don’t know about that are causing the shedding? Is your diet adequate to sustain hair growth?

REASON 2 You have telogen effluvium but also have another diagnosis or you don’t really have TE at all

You might have telogen effluvium but there may be a second diagnosis present that you are your doctor are not recognizing - or you might not really have TE at all. The most common scenario is a patient who has TE but also has evolving androgenetic alopecia (AGA). It’s not uncommon for AGA to start in some when after delivery of a baby and then progressively get worse. When the condition first starts up the only thing that is experienced by the patient is shedding. For many women with AGA, this shedding is all over the scalp so this fact alone does not just mean you could only have TE.

So, it could be that you have TE + AGA or it could be that you don’t really have TE but rather you have only AGA that is mimicking TE. If you feel there is less hair on your hair today compared to one year ago, then there is a reasonable high chance you have AGA as one of your diagnoses or the only diagnosis. If there is the SAME amount of hair on your scalp compared to 1 year ago, then it’s still possible that TE is the only diagnosis that you have.

Be sure to see a dermatologist who specializes in hair loss for the proper diagnosis. A skilled dermatologist might be able to determine if you have androgenetic alopecia (also known as female pattern hair loss) simply by looking at the scalp with dermosopy. If not, then a scalp biopsy can be done. If you want to get some clues yourself, then you might consider performing a test yourself known as the five day modified hair wash test.

You can read more about this in the link above, but it essentially involves collecting every single hair that exits your scalp exactly five days after not shampooing your hair. If you see mostly long hair, it’s like TE. As a person starts to see an increasing number of short hairs, the possibility of androgenetic alopecia goes up. Now, I always suggest that the 5 day wash test be explained to your properly by your dermatologist and then interpreted properly by your dermatologist. But it is an option to get further clues about what diagnosis might be going on .

We also need to keep in mind that there are many other conditions besides just AGA and TE that cause shedding. Scarring alopecias are one of them. Lichen planopialris for example can cause constant shedding. It woudl be unusual for a person with your story to have scarring alopecia but not impossible. If there is burning on the scalp or tender sore areas on the scalp or redness in the scalp, the chances that a person has scarring alopecia goes up a bit. Alopecia areata incognito (a form of alopecia aerate) is another cause of shedding that mimics TE. A consultation with an experienced dermatologist can help determine if you have any other mimickers of telogen effluvium.

REASON 3: You have chronic idiopathic telogen effluvium or what is termed “CTE”

A person with chronic shedding may have CTE. Your story is certainly not typical of CTE but you’ll probably hear that term thrown around a lot. Most women with classic CTE have thick hair that sheds and sheds and sheds. Thinning is not obvious. You are in the wrong age group for CTE. You have what sounds like progressive thinning. While you could ‘potentially’ have a TE that follows what we talked about under reason 1, you probably don't have CTE. Again, a dermatologist can assist you.

SUMMARY

In summary, you might want to see an expert dermatologist in your city for diagnosis. I’m suspicious that TE is the only diagnosis you have. It might not be. You need to make sure you’ve had a proper examination and determine if other issues like AGA, alopecia areata or scarring alopecia are at all present on your scalp. The most likely of all of these is AGA. You need to make sure that you’ve had all the blood tests ordered based on your story. There may be 5 tests you need or 25 tests -it depends on your story that you share with your doctor. If anyone is still not sure about the diagnosis or you yourself are not confident with the diagnosis being told to you, a modified hair wash test could be a first step, or a scalp biopsy. A biopsy woudl be preferred in your case. A properly done scalp biopsy with horizontal sections and determination of the so called terminal to vellus ratio (T:V ratio) is going to go a long way to helping. IF your T:V is above 4 with lots of telogen hairs in the biopsy (above 15%), then isolated TE may be what you do have. If your T:V ratio in the biopsy is less than 4:1 then you probably have AGA. The biopsy can also help determine if you do have scarring alopecia or do have alopecia areata.

I hope this helps.

Good luck,

Why am I shedding with zinc supplements?

Localized Shedding with zinc supplements

I’ve selected this question below for this week’s question of the week. It allows us to discuss some of the finer aspects of zinc on the human body and how to approach atypical or unexpected reactions in the human body.

Here is the question….

QUESTION

I shed hair when taking zinc supplements. I cannot find any information on this at all. Most suggest zinc helps the hair cycle not cut it short and shed. The shedding appears to occur in locations that already had issues. It is not global (all over the body).  Is zinc connected to the hair growth/shed cycle or is it inflammation? Thank you.

ANSWER

This is a terrific question. Not one that I encounter often - but a fascinating one. There’s a lot to review with this question, so let’s get to it!

Before we go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s Story

2) the findings uncovered during the process of the scalp Examination and

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

I’d like to know a lot more about this story ideally but of course the magic of the “question of the week” is that I tackle questions with limited information. It could be relevant if the patient takes zinc for one weekend because they heard it was good to boost their immune system or took zinc for one year to finish the bottle that they purchased one day on sale. It could matter if the patient is obese or thin, malnourished or well nourished and elderly or young. It could matter if the patients knows their actual zinc levels through blood tests or not. Finally, it could matter and probably does matter if the patient has early staged adnrogenetic alopecia, mid staged androgenetic alopecia or advanced androgenetic alopecia. All these things matter in fully answering these questions.

With that behind us, let's return to our question of the week again.

WHAT’S THE MOST LIKELY EXPLANATION FOR SHEDDING WITH ZINC?

Well, the most likely explanation (given that I don’t know anything else about you), is that:

1) you have some male pattern balding and you are not using finasteride or dutasteride to treat your male balding and that zinc has trigger a mild effluvium of hairs that are in the early balding phase. We call this phenomenon immediate telogen release and it’s common with every treatment that acts on male balding including minoxidil, laser therapy, PRP therapy, finasteride therapy …. and sometimes zinc.

2) The second explanation is that you actually do have diffuse loss of hair on the scalp and you are just noticing it more in the areas that are already thin. In this scenario, the male balding has nothing to do with the discussion, it just so happens you notice hair loss more in areas that are already thinner.

3) The third explanation is that you have something else going on that is not related at all.

It zinc related to my hair loss? A Closer Look at the Naranjo Scale

Before we go further, I’d like to introduce you and readers to a wonderful system of determining how likely it is that a person’s rare observation is linked to the drug or supplement they are taking. It’s called the Naranjo Scale. I always refer to the Naranjo scoring system when some observation a patient is experiencing is uncommon because it helps to get a better sense of just how plausible things really are. If someone tells me their new supplement is causing hair loss, I might pull up the Naranjo Scale. If someone tells me their new cat is causing them hair loss, I might pull up the Naranjo Scale. We’ll take a look at this scale in a moment.

Now, it seems pretty obvious that if you say that when you take zinc you get more shedding that I believe you that zinc is causing your hair shedding. First off, I believe you. I have seen this phenomenon before so I’m not introducing the Naranjo scale as a way to prove whether you are correct in your observation or not. Rather, the Naranjo Scale helps us look at causation with a little greater precision - something a bit more scientific.

The Naranjo scale involves use of 10 simple question. You might want to try it yourself. The questions are below and I’ve worded each questions specifically to pertain to zinc although the Naranjo scarring system itself pertains to any drug not just zinc. You answer “yes", "no" or "don't know" and different points are assigned to each answer (-1, 0, +1, +2). 

Typical Questions in the Naranjo Scale

1. Are there previous conclusive reports of zinc causing hair loss from areas that already have an issue?

Yes (+1) No (0) Do not know or not done (0)

2. Did the shedding appear after zinc was given?

Yes (+2) No (-1) Do not know or not done (0)

3. Did the shedding improve when the zinc was discontinued ?

Yes (+1) No (0) Do not know or not done (0)

4. Did the shedding appear when the zinc was readministered?

Yes (+2) No (-1) Do not know or not done (0)

5. Are there alternative causes that could have caused the shedding?

Yes (-1) No (+2) Do not know or not done (0)

6. Did the shedding reappear when a placebo was given?

Yes (-1) No (+1) Do not know or not done (0)

7. Was the zinc detected in the blood at higher levels?

Yes (+1) No (0) Do not know or not done (0)

8. Was the shedding more severe when the zinc dose was increased, or less severe when the zinc dose was decreased?

Yes (+1) No (0) Do not know or not done (0)

9. Did the patient have a similar shedding to the same or similar zinc pills in any previous exposure?

Yes (+1) No (0) Do not know or not done (0)

10. Was the adverse event confirmed by any objective evidence?

Yes (+1) No (0) Do not know or not done (0)

Determining the Naranjo Score

Scores for the Naranjo Scale can range from -4 to + 13. A score of 0 or less means the likelihood of the drug causing the side effect is doubtful, a score 1 to 4 indicates it is 'possible', a score 5 to 8 means it is 'probable' and a score 9 to 13 means it is 'definite'. The website http://www.pmidcalc.org/index.php provides a free online calculator for clinicians to calculate the Naranjo Score. It is easy to use and has been embedded below as an example. Individuals wanting to know if a specific drug caused hair loss should be sure to speak to their dermatologist. For you, I’m guessing you are somewhere between 5 and 8 and probably and 6 or 7. This just simply reinforces that what you are experiencing is probable.

What are the effects of zinc on the body and on hair ?

Zinc is well known to affect the human body in about 50 different ways. Actually, it’s best to say that there are at least these are the 50 different ways that have been studied. There are probably 250 ways that zinc affects the human body - we just haven’t studied them all. Here are some of the more common effects of zinc under different conditions. You can see that zinc has a profound effect on many hormones, inflammatory markers and immune system components.

Zinc and Hormones.

Zinc has a complex relationship with hormones. Zinc supplementation seems act as an anti androgen in most scenarios. In women with PCOS, it’s clear that zinc supplementation helps PCOS and reduces hirsutism and improves hair loss. However actually hormone levels (DHEAS) don't seem affected. In prostate cancer cells grown in the lab, it’s clear that zinc acts as an androgen receptor blocker. Zinc blocks male hormones.

Zinc containing shampoos have a positive effect on male balding. In a 2003 study, Berger et al showed a benefit for 1 % zinc pyrithione (found in Head and Shoulders and other shampoos). The researchers performed a 6 month randomized study in healthy men 18-49 with Hamilton Norwood type III vertex or type IV baldness to assess the benefits of daily use of 1 % ZP shampoo. The researchers compared growth with zinc pyrithione shampoo compared with three other groups: 1) those using minoxidil 5 % twice daily, 2) those using a placebo shampoo, and 3) those using a combination of minoxidil and the 1 % ZPC shampoo. The results of the study showed hair growth with zinc pyrithione shampoo alone was almost as good as with minoxidil. Whether these effects are due to the anti-inflammatory effects of zinc on yeast and Malassezia (the causes of dandruff and seborrheic dermatitis) or specific zinc effects on the scalp are not clear.

Depsite all the studies showing zinc has antiandrogenic effects, there are studies showing that zinc supplementation may have the effect to increase testosterone. Zinc supplementation to subfertile men increased testosterone and DHT levels and improved the chances that the female partners of these men became pregnant.

SUMMARY AND FINAL CONCLUSION

There is a lot we have learned about zinc so far and here is a lot we still need to learn when it comes to zinc.

For most people, taking zinc doesn’t have any effect on the hair in any way. However, there will be some people who experience a reduction in daily shedding - especially if they had low zinc to begin with. For a very small proportion a bit of shedding might occur for 1-4 weeks but this is not something that is seen commonly. We do see it in patients with early androgenetic balding - but again even then it’s not common. Most individuals with androgenetic hair loss who use zinc either have no effects or experience a slight improvement.

Your question suggests you have a degree of underlying androgenetic alopecia (male balding) and what you are experiencing is a telogen effluvium of the hairs in that area. Of course a dermatologist can help confirm this.

Hairs that are found in the balding areas of the scalp are notiously more loose than hairs that are found in other areas. They wiggle out of the scalp very easily. We refer to this medically by saying that the hairs are in the telogen phase. Taking zinc supplements certainly gives the hairs some 50 to 250 reasons to wiggle out (or shed) but why this happens for some people and not other is not clear.

There are many different so called genetic polymorphisms that people are born with hat affect how they process zinc and what zinc does to the body. These too have been researched over the years. Polymorphisms in IL6 (IL 6 -174) and ZIP2 Lue- (Arg43Arg) are all examples of genetic changes inside of a person’s DNA that affect how they respond to zinc and why one person might respond differently than another person.

If you have used treatments for male balding before (like laser, minoxidil, finasteride, PRP) and developed some shedding when you started these treatments, you are likely to be experiencing the same sort of phenomenon with your zinc. Although it is unusual to shed hair with zinc supplementation, I must add that it is extremely unusual for males who are currently on finasteride to shed hair with zinc supplements given that the androgens pathways inside hairs are so effectively suppressed. Not impossible but unusual in my experience.

If you shed more with higher doses of zinc and less with lower doses of zinc, and stop shedding completely when you stop the zinc pills, the Naranjo score tells us you are onto something. The fact that you shed when you start zinc does not necessarily mean you will continue to shed forever. Just like with finasteride, laser, PRP, minoxidil, most shedding when related to male balding actually settles down in 6-8 weeks. So most men who continue zinc will find their shedding eventually slows down.

I’m not a fan of my patients taking zinc forever. Zinc level should be kept above 85 µg/dL (13 mmol/L) and below 118 µg/dL (18 mmol/L). Excessive zinc causes copper deficiency which is also a rare cause of hair loss. Long term copper deficiency leads to a great number of problems in the body. Zinc should always be taken with the goal to measure zinc levels over time. If you notice shedding every time you take zinc for a few days, that’s one thing, but if you notice shedding everytime you take zinc for months at a time, that’s a different thing. If zinc is causing a pure telogen effluvium due to low copper for example, it is never going to settle down.

As mentioned in the opening it is going to matter if the zinc is taken for the weekend or for one year. The longer the zinc is used (beyond 4 months), the less likely the shedding is due to helpful actions on the balding process and more likely this zinc is detrimental (or something else entirely is going on). It could matter if the patient is obese or thin, malnourished or well nourished and elderly or young. The more obese the patient is (above a BMI of 30) the more likely the zinc supplementation is going to significantly change hormones, insulin sensitivity and lipid metabolism. Mind you, these changes are probably for the good, but there is a chance they are going to set off some shedding in these patients. It could matter if the patients knows their actual zinc levels through blood tests or not. If one is taking zinc, and the levels skyrocket above 150 ug/dl (23 mmol/L) we often see zinc issues with the hair.

Finally, I hope I’ve made the point that all of this probably does matter if the patient has early staged androgenetic alopecia, mid staged androgenetic alopecia or advanced androgenetic alopecia. The earlier the AGA the more likely that zinc is going to cause a bit of temporary shedding. It’s still an uncommon phenomenon overall - but it’s the patients with early AGA that are the most likely to report shedding with zinc supplements in our clinic.

I hope this helps. It’s an interesting question and you and your doctor may want to consider how zinc is potentially affecting the androgenetic hair loss issues on the scalp and how the levels of zinc are changing over time when you supplement. The actual levels of testosterone and DHT may or may not have any relevance because some people could have slight elevations without it actually causing hair loss (or actually inhibiting hair loss as time goes by.

Thank again for the question.

Reference

Barnett et al. Effect of Zinc Supplementation on Serum Zinc Concentration and T Cell Proliferation in Nursing Home Elderly: A Randomized, Double-Blind, Placebo-Controlled Trial. Am J Clin Nutr 2016 Mar;103(3):942-51.

Ebrahimi et al. The Effects of Magnesium and Zinc Co-Supplementation on Biomarkers of Inflammation and Oxidative Stress, and Gene Expression Related to Inflammation in Polycystic Ovary Syndrome: A Randomized Controlled Clinical Trial. Biol Trace Elem Res 2018 Aug;184(2):300-307.

Foroozanfard et al. Effects of Zinc Supplementation on Markers of Insulin Resistance and Lipid Profiles in Women With Polycystic Ovary Syndrome: A Randomized, Double-Blind, Placebo-Controlled Trial. Clin Endocrinol Diabetes. 2015 Apr;123(4):215-20.

Giacconi et al. Effect of ZIP2 Gln/Arg/Leu (rs2234632) Polymorphism on Zinc Homeostasis and Inflammatory Response Following Zinc Supplementation. Biofactors.. Nov-Dec 2015;41(6):414-23.

Hosui et al. Long-Term Zinc Supplementation Improves Liver Function and Decreases the Risk of Developing Hepatocellular Carcinoma. Nutrients. 2018 Dec 10;10(12):1955

Jamillan et al. Effects of Zinc Supplementation on Endocrine Outcomes in Women With Polycystic Ovary Syndrome: A Randomized, Double-Blind, Placebo-Controlled TrialTrace Elem Res. 2016 Apr;170(2):271-8.

Kahmann et al. Zinc Supplementation in the Elderly Reduces Spontaneous Inflammatory Cytokine Release and Restores T Cell Functions. Rejuvenation Res. . 2008 Feb;11(1):227-37.

Kim et al. Effect of Zinc Supplementation on Inflammatory Markers and Adipokines in Young Obese Women.Biological Trace Element Research 2014 Feb;157(2):101-6.

Lomagno et al. Increasing Iron and Zinc in Pre-Menopausal Women and Its Effects on Mood and Cognition: A Systematic Review. Nutrients. 2014 Nov 14;6(11):5117-41.

Mariani et al. Effect of Zinc Supplementation on Plasma IL-6 and MCP-1 Production and NK Cell Function in Healthy Elderly: Interactive Influence of +647 MT1a and -174 IL-6 Polymorphic Alleles. Exp Geront.  2008 May;43(5):462-71.

Mocchegiani et al. Zinc: Dietary Intake and Impact of Supplementation on Immune Function in Elderly. Age.  2013 Jun;35(3):839-60.

Ranasinghe et al . Zinc Supplementation in Prediabetes: A Randomized Double-Blind Placebo-Controlled Clinical Trial. J Diabetes. 2018 May;10(5):386-397.

Hair shedding after a low calorie diet

My diet is done but when is my hair shedding going to stop?

I’ve selected this question below for this week’s question of the week. It allows us to discuss some of the finer aspects of telogen effluvium from dieting.

Here is the question….

QUESTION

Hi! I have a quick question regarding my hair loss. For the past few months I have been on a very low calorie diet, and i’m now noticing a lot of my hair falling and thinning. I therefore changed my diet and am eating more calories now. But when will my hair stop falling? …. and is there anything i can do to stop it? I am a female 5’5, and weigh 123 pounds. I was consuming about 800-1,000 calories a day.. but burning about 500.

ANSWER

This is a terrific question. For most people, the answer is simple. For some, however, it’s a little more involved as we will see.

Before we go further, I’d like to point out that the ideal way to diagnose hair loss is using what I termed the ”Diagnostic S.E.T.” I refer to these as the diagnostic “set” because theses 3 aspects all go together. These 3 items include:

1) the patient’s Story

2) the findings uncovered during the process of the scalp Examination and

3) the results of relevant blood tests. 

The first letter of each of the three words 1) story, 2) examination and 3) tests spell out the word “S.E.T.” - again a helpful reminder of how the information obtained from reviewing each of these 3 aspects helps solidify a proper diagnosis.

With that behind us, let's return to our question of the week again.

WHAT’S THE MOST LIKELY EXPLANATION?

First, it’s quite likely that you are experiencing what we term a “telogen effluvium” and in your case this is occurring from dieting. Anytime a person consumes less than 1300 calories per day the chances of telogen effluvium increase.

Telogen effluvium (TE) Is a hair shedding disorder whereby the patient experiences more daily hair loss than they may have in the past. Mild effluviums may lead to 50-100 hairs loss daily whereas more severe effluvium may be associated with several hundreds. Many forms of TE occur 2-3 months after a so called triggering event. A trigger in January, for example,  causes hair loss in March. A trigger that occurs in March causes hair shedding in May.   Common triggers include low iron, such as low iron, stress, thyroid abnormality, initiation (or cessation) of a new medication, or weight loss. Hundreds of other examples of triggers exist as well. In many cases a trigger cannot be found and the TE resolves on its own. Most telogen effluviums resolve about 9-12 months after the trigger has been completely corrected. Many patients with shedding disorders have scalp symptoms of itching, burning, tenderness, and feeling of something moving in the scalp. This is referred to as trichodynia. 

Your story is quite typical for Telogen effluvium. Let’s suppose for the sake of this question that you started your diet in February. When would I expect you to start noticing shedding? The answer is April. How long will your shedding last? That answer is 6-9 months from the time that you started eating a normal 1500 calorie balanced nutritional diet AND provided your diet did not leave you with any nutritional deficiencies that keep you chronically depleted.

TYPICAL COURSE OF HAIR SHEDDING FOLLOWING A DIET

The typical course of hair shedding would follow something like this. Shedding would start 2 months after the diet and then worsen. In your case, I would not be surprised if shedding worsens in May and June and July even if the diet stopped in May. But over the course of the late summer and Fall, shedding should start reducing again and by the end of the year hair shedding should be back to ‘normal.’ It’s normal to shed 20-60 hairs per day and for some a bit more.

Your current weight tell me that your body mass index is now in a healthy range. Body mass index is something that I calculate for all my patients to get a sense of whether their weight is right for them. It’s not a perfect scale but gives a sense of where things should be Your BMI is 20.5 which is a healthy weight.

Does hair shedding always stop people who go back to eating a normal amount of calories?

For most people, shedding goes back to normal in a few months of eating a healthy number of calories. For some people however, that’s not the case. There are several reasons why shedding does not slow down including.

1. There were deficiencies created by the diet which have not been corrected.

A diet can create all sorts of deficiencies in vitamins and minerals. We only need small amounts of most vitamins and minerals anyways so once a health diet resumes, most people can make up for any losses and the body will absorb what it needs. However, for some people levels of vitamins and minerals don’t get replenished like they need to be. A good vitamin and mineral supplement can help but I often recommend testing potential deficiencies like iron, zinc, selenium, magnesium, B12, vitamin A, folate, vitamin D in addition to the usual tests for anyone with hair loss (CBC and TSH).

2. There are other reasons for the shedding which were forgotten about.

It’s possible for a person to shed because of diet. But sometimes a person can think they are shedding from a diet but that’s not really the reason they are shedding at all! Shedding can happen from over 100 causes so a broad approach is needed.

See Top 10 Causes of Telogen Effluvium

Thyroid abnormalities, stress, medications, illnesses in the body can cause shedding. In addition, many conditions mimic telogen effluvium and so the patient is actually shedding from a completely different condition such as alopecia areata incognito or a type of scarring alopecia.

3. The shedding has precipitated or ‘unmasked’ an andogenetic alopecia

For some people who shed, the process of shedding uncovers their slightest tendency to develop androgenetic alopecia. If a person has the underlying predisposition to develop genetic hair loss, then a shedding episode from telogen effluvium can cause the adnrogenetic alopecia to be set in motion. Even though the person’s telogen effluvium from the diet ends - they are faced with a new hair issue - androgenetic alopecia.

See Why Won’t My Shedding Stop?

Telogen Effluvium: Why is my density not returning to normal?

4. The patient has developed a chronic shedding issue.

Finally, some patients with shedding develop chronic shedding problems even though the original trigger has been identified, corrected and is long behind them. This is known as a form of chronic telogen effluvium

FINAL SUMMARY

Thanks again for the great question. I’d encourage you to see your dermatologist if the shedding does not improve. For most with shedding problems that come after dieting, the shedding gets worse for a few months and then progressively gets better and better until shedding rates go back to normal in 6-9 months. In some people though, this is not the story, and issues like androgenetic alopecia, chronic nutritional deficiencies, and other hair issues like chronic telogen effluvium need to be explored in greater detail.

Diphencyprone (DPCP) For Patients with Breast Cancer

I’ve selected this question below for this week’s question of the week. It allows us to discuss some of the finer aspects of using a treatment for alopecia areata that some are unfamiliar with - diphencyprone .

Here is the question….

Question

I am a late 60s year old woman and I have had Alopecia Areata verging on Totalis, for 20 years. I have tried cortisone injections, minoxidil, simvastatin, etc., with varying results. Finally I used DPCP starting summer 2018 and had a good response by early Spring 2019. I even had 2 haircuts! But by mid summer 2019, some new bald patches appeared. I was diagnosed with breast cancer in the Fall of 2019, at which point DPCP was stopped. Hair shedding continued for the next 2-3 months. I had 2 surgeries to remove the cancer in the last few months of 2019, then radiation for 4 weeks in early 2020. I noticed diffuse patchy hair regrowth in January and now have approximately 70% regrowth coming in.

Question 1:
With the removal of the tumor, and associated immune stimulation, could this affect the beginning of hair regrowth?

Question 2:
I there a known link between DCPC use and my breast cancer?

Question 3:
Should I continue using DCPC in the future?

Answer

Thanks for the great question. First, I hope you are doing well after your surgery and treatments. As far as alopecia areata and breast cancer goes, we don’t have a lot of good evidence to link the removal of the breast cancer and the ability of the hair to grow back. It is certainly possible. Of course, the “how likely” this is probably depends a bit on the patient’s cancer exact histological type, size, etc. A small tumor is going to stimulate the immune system differently than a large tumor. A localized tumor is going to stimulate the immune system differently than a cancer that has spread.

We don’t have any evidence that diphenycprone enters the blood to any significant degree and we we don’t have evidence that there is no known link to DPCP and breast cancer.

See previous article : Does DPCP Get absorbed ?

DPCP is not an immunosupressing medication and has its advantages for patients with alopecia areata with a previous diagnosis of cancer. It also has advantages for patients with alopecia areata with a previous diagnosis of cancer who are going through a pandemic due to COVID 19. You’ll clearly want to speak to your dermatologist about all the facts as I don’t have all the facts in front of me with the information given in this question. But it’s quite likely that returning to DPCP is an excellent option.

Thank you again for the great question.

References

[1] Can one apply DPCP at home?

[2] DPCP for treating Alopecia areata

[3] Information for Patients on DPCP

What is the diagnosis? Trichotillomania vs Alopecia Areata

I’ve selected this question below for this week’s question of the week. It allows us to discuss some of the finer aspects of trichotillomania and alopecia areata - both of which are common diagnoses in children and teens. It can sometimes be tough to tell them apart as alopecia areata and trichotillomania both have broken hairs and black dots. Exclamation mark hairs can be found in both although one needs to be careful, in my opinion about using the term exclamation mark hair too liberally. In my opinion a true exaltation mark hair is quite a bit thinner at the bottom than it is at the top rather than “just a bit” thinner.

Here is the question….

Question

Hi! My daughter was diagnosed with alopecia areata two years ago... her first bald spot was right behind the ear...

Photo 1: Back of the scalp behind year in 2018. This is typical of alopecia areata

I took her to a dermatologist and she was given injections and the hair grew back.. soon after, the hair in the front of her head began to fall...

Photo 2: Front of the Scalp in 2020. As I will review below, features of trichotillomania are identified in this patch of hair loss. Alopecia areata can not be completely ruled out as a second diagnosis …. but features suggest trichotillomania without any doubt.

I questioned her numerous times about wether or not she was pulling the hair, but she always denied it... fast forward to the beginning of March... I took her to a dermatologist who was well versed on alopecia and she looked at her scalp thru a magnifying glass and said that she had alopecia and it was definitely AA... then with everything happening with COVID-19 we weren’t able to see see the specialist she recommended due to being on lockdown... this past week I had a heart to heart with my daughter and she admitted that she had in fact been pulling her hair out... so now I’m questioning the validity of the exclamation hair statement... I do see hair that looks like it could be so my question is can exclamation hair be present in someone suffering from Trichotillomania? Or is it only specific to alopecia? I appreciate any words of advice u can give... we have been so desperate these past two years doing anything and trying anything we could to make this stop... and now that she has admitted to pulling, maybe there’s light at the end of the tunnel... but maybe she also has alopecia... thanks again!

Answer

Thanks for submitting your question. This is a terrific one - and a challenging one too. However, I do feel that what we are seeing here is alopecia areata in the back fo the scalp (two years ago) and trichotillomania in the frontal region at the present time. I don’t see any good evidence for alopecia areata in the frontal region but it can’t be completely excluded. I just don’t feel that’s all that likely - at least as a major feature of the loss in this area.

The story is quite typical for your daughter having alopecia areata in 2018 at the back of the scalp. First, the appearance is quite typical of alopecia areata and the location is too, Second, the robust response to steroid injections is very much in keeping with alopecia areata as trichotillomania would not grow back quite so fast.

But let’s take a closer look at this region at the back of the scalp:

Photo 3: Magnified View of the Back of the Scalp Behind the Ears. This is typical of alopecia areata.

This is a pretty typical photo of alopecia areata. We see many broken hairs, black dots and vellus hairs. The other finding we see is what I term the “short long” sign. This is shown in the circle - one hair is long and a neighbour right next to it is short. This is very different than the “V sign” in trichotillomania where the fingers rip our hairs in a manner such that the hairs right next to each other are the same size:

V sign of trichotillomania compared to the short long sign of alopecia areata.

The Trichoscopic Features of Trichotillomania

So now that we are on the subject, what exactly are the trichoscopic features of trichotillomania. Well, they include broken hairs, v-sign, flame hairs, hair powder, tulip hairs, and coiled hairs among others. The most common are the irregularly broken hairs. The “v sign” represents two hairs that were pulled at the same time and snapped off at the surface. They are found in well over 50 % of patients with trichotillomania.

We’ve seen the V sign in the diagram above. Now let’s take a look at coiled hairs. Coiled and hook hairs represents hairs that recoil after being pulled out suddenly. They are found in well about one-third of patients with trichotillomania.

In fact, when we look up closer to the scalp, from the recent 2020 photos (from the frontal scalp), we see many features of trichotillomania including irregularly brown hairs, V hairs, hook hairs and tulip hairs and exclamation-mark like hairs.

Photo 4: Magnified view showing V sign

Photo 5: Magnified view showing “flame hair.”

Photo 5: Magnified view showing “tulip hair.”

Photo 6: A pseudo exclamation mark hair. This hair is tapered but not tapered to the degree we expect in a classic exclamation mark hair. The hair is only slightly thinner at the bottom than the top. True exclamation mark hairs, in my opinion, are very thin as they enter into the scalp. They are less than 1/3 the thickness at the bottom compared to the hair at the top. This hair does not fit that definition so I term it a pseudo exclamation mark hair. Both true and pseudo exclamation mark hairs, can be seen in alopecia areata and trichotillomania although extremely tapered exclamation mark hairs are more common in alopecia areata.

Photo 7: Magnified view showing “hook hair.” Hook hairs are quite specific for trichotillomania.

Conclusion and Final Comments

Thanks for the submission to our Question of the Week Program. I hope this was helpful. In summary, the area at the back of the scalp back in 2018 is typical of alopecia areata and the area at the front of the scalp in 2020 is typical of trichotillomania. I can’t completely rule out “some” alopecia areata in the frontal scalp being present but it would not be the most likely scenario. A biopsy could ultimately prove whether there is any amount of alopecia areata in the front - but I don’t think this is necessary here. I know there may be a thought these are exclamation mark hairs but in my opinion they are not classic exclamation mark hairs but rather broken hairs and pseudo exclamation mark hairs. One can have exclamation mark hairs in alopecia areata and trichotillomania and this finding alone is not enough. We need to dig deeper. Here we have features of trichotillomania as the main features. It’s possible for both alopecia areata and trichotillomania to BOTH be present. It’s more likely to occur together in children younger than 5. In an older child and teen or adult, it’s more likely that trichotillomania alone or alopecia areata alone is the sole diagnosis in a case like this. But they can occur together, yes.

Your dermatologist can guide you further. One certainly needs to be humble that alopecia can always resurface in anyone who previously had the diagnosis. Ongoing surveillance is appropriate for anyone with a past diagnosis of alopecia areata. There is nothing wrong with speaking to the dermatologist about use of topical steroids or another steroid injection as there can be quite a bit of inflammation that also occurs in trichtotillomania. However, in this case, the regrowth of hair after injection does not mean the diagnosis was alopecia areata. Repeat photos fo the scalp and repeat trichoscopy can be helpful to monitor what is happening and whether in fact any amount of alopecia areata does appear again. A biopsy can be considered if there is any doubt or confusion but I’m generally against biopsies in situations like this because a) we can make the diagnosis without a biopsy and b) biopsies only add to the stress of the child or teen.

When the diagnosis of trichotillomania is made in children and teens, we need to pause and look carefully into the the child’s stressors. There can be underlying psychological and psychiatric issues present and the sooner these can be addressed the better for the child or teen. Not all children and teens with trichotillomania have underlying psychiatric issues but it’s far more likely to be present if the patient is a teenager than if they are preschoolers. A variety of issues such as depression and anxiety and eating disorders and obsessive compulsive disorders need to be explored. The dermatologist’s office may be a good place to start but the paediatric or general practitioner may be the next step and a psychologist or psychiatrist is sometimes needed if underlying psychiatric or psychological issues are present. Sometimes there are issues in the child’s life that a parent is fully aware. Sometimes there are issues that a a parent is only partly aware. And sometimes there are issues that a parent is not aware at all. I can’t emphasize enough how important this is to examine these sorts of issues more closely. If there are underlying issues, addressing them sooner can can change a child’s life forever for the better. The fact that the individual in this case has admitted to her parent that she pulls hair is a really important finding. It certainly speaks to better prognosis. A supportive rather than blame centred approach is what is needed next. It takes a lot of courage for a child or teen to admit pulling. Some individuals can stop easily and some can not. While I agree that there may be “light at the end of the tunnel” as you have said I would encourage you to be patient as this can be much more chronic than many parents first realize when the diagnosis is made. It all depends on the exact situation of course but the diagnosis is sometimes only step 1 in a long journey. Stopping the pulling may or may not relieve the underlying psychological issues. The long term measure of success here is not whether the hair grows back but whether the child or teen has been helped with whatever issues may have triggered the pulling in the first place.

Thank you again for participating in our question of the week program.

References of Interest

The “V sign” in Trichotillomania

Coiled Hairs and Hook Hairs in Trichotillomania

Trichotillomania in Children

Trichotillomania: Addressing both scalp heath and emotional health

Tulip Hairs in Trichotillomania