Microblading for FFA Patients Using Isotretinoin

Is eyebrow microblading safe for FFA patients using isotretinoin?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts regarding isotretinoin and procedures for patients with FFA.

Question

I am a 54 year old female with frontal fibrosing alopecia. Similar to many women, I have lost a significant amount of eyebrows. My scalp FFA has improved a great deal with use of dutasteride, isotretinoin, pimecrolimus and steroid injections. My eyebrow hair loss has halted but unfortunatley it has not grow back.

I am considering microblading for my eyebrows. The lady I see won’t do the microblading if I’m on isotretinoin and says I need to be off 6 months or more. Obviously, I am terrified to stop as it’s helped my scalp and facial bumps a very significant amount.

Should I stop the isotretinoin?

Thank you for your question section of the website so that we can ask questions of this kind.

Answer

Thanks for the great great question.

Isotretinoin is a vitamin A derivative and can affect many parts of the skin including the epidermis, sebaceous gland, and even collagen formation. The diverse affects of isotretinoin on wound healing have generated a long debate about whether patients who use isotretinoin are more likely to have poor wound healing or worse yet - develop a keloid or hypertrophic scar - if they undergo surgery or a procedure on the skin.

In fact, the US FDA advises against patients having laser resurfacing procedures within 6 months of use of isotretinoin.

The general recommendations to avoid surgical procedures have been called into question by various experts around the world in the last few years.

Tattooing in the Eyebrow Region in FFA

It appears that tattooing in the eyebrow area is likely to be safe in patients with FFA who use low doses of isotretinoin (under 10 mg daily). One should be aware that large scale studies have not yet been conducted in FFA but certainly we have had many stable patients in our clinic on low doses of isotretinoin undergo various tattooing procedures without issue.

For those who question the safety, a thorough review of two articles would be advised:

Spring et al, 2017

In 2017 a panel of experts (Spring et al 2017) put forth recommendations on the safety of isotretinoin in various dermatological procedures. Thirty-two relevant publications reported outcomes of 1485 procedures. Overall, the authors concluded that “there was insufficient evidence to support delaying manual dermabrasion, superficial chemical peels, cutaneous surgery, laser hair removal, and fractional ablative and nonablative laser procedures for patients currently receiving or having recently completed isotretinoin therapy. Based on the available literature, mechanical dermabrasion and fully ablative laser are not recommended in the setting of systemic isotretinoin treatment” (Source: Spring et al 2017).

Mysore et al, 2017

In 2017, the Association of Cutaneous Surgeons of India also put forth a recommendation “that microneedling and microdermabrasion treatment can safely be performed in patients administered with isotretinoin”. The level of evidence was 2+ (backed up by well conducted case control studies or cohort studies) and the grade of the recommendation was given a C rating.

The formal view of the Association of Cutaneous Surgeons of India was that “there is insufficient evidence to support the current protocol of avoiding and delaying treatments in the patient group under consideration and recommends that the current practice should be discontinued. The task force concludes that performing procedures such as laser hair removal, fractional lasers for aging and acne scarring, lasers for pigmented skin lesions, fractional radio-frequency microneedling, superficial and medium-depth peels, microdermabrasion, dermaroller, biopsies, radio-frequency ablation, and superficial excisions is safe in patients with concurrent or recent isotretinoin administration.

Conclusion and Comment

My general feeling is that tattooing of eyebrow is likely to be pretty safe for patients with FFA who use low doses of isotretinoin. We have not had problems with patients who use 10 mg daily or less AND whose FFA is fairly stable. I am not a big fan of eyebrow tattooing in patients with super active FFA simply because I have never guided patients through tattooing unless the FFA is somewhat calm. Likely tattooing is even active FFA is safe but of course no data is widely available. We also don’t have patients on higher doses of isotretinoin.

If one is willing to accept a really low risk of problems, then eyebrow tattooing is wonderful - assuming an experienced and competent practitioner is doing the tattooing. Close follow up with the dermatologist is advised so that immediate action can be taken in the event there are problems (ie. administration of topical steroids, steroid injections, topical calcineurin inhibitors). It is fortunately very rare to have problems other than the side effects that anyone experiences with tattooing. The improvement in self confidence and feeling of well being after successful tattooing procedures is great.

If a patient with FFA is not comfortable with any risk whatsoever, then eyebrow tattooing might not be the right procedure for them. At minimum, such a patient should be off isotretinoin for 6 months if they are not comfortable with risk - but again I must emphasize that this is without evidence and one risks worsening their scalp FFA if they stop isotretinoin and the isotretinoin was helping them.

Eyebrow microblading has its own inherent risks (even without isotretinoin!!) so all risks need to be reviewed with the practitioners performing the procedure. Persistent redness, tattoo reactions, bumps, poor uptake of pigment, rapid fading of pigment, allergic reactions are all part of the side effects for anyone with or without FFA. One should never undergo tattooing without first reviewing what sorts of rare side effects occur in anyone.

Finally, one must be aware that pigments don’t always taken up quite as well in FFA. The skin is different in some patients and takes of pigments differently - so multiple procedures may be needed. One must never ever assume that the microblading outcome they will have will necessarily be the same as anyone else who does not have FFA. The skin is different and it’s possible for variations in outcomes.

Fortunately, most patients have really nice results and the vast majority of patients are really pleased with the decision to have microblading and other pigmentation procedures. One should carefully review the risks and benefits with the dermatologist overseeing care as well as the tattoo expert performing the procedure. A full understanding of risks and benefits is needed.

REFERENCE

Mysore V et al. Standard Guidelines of Care: Performing Procedures in Patients on or Recently Administered with Isotretinoin J Cutan Aesthet Surg. 2017 Oct-Dec; 10(4): 186–194.

Spring L et al. Isotretinoin and Timing of Procedural Interventions: A Systematic Review With Consensus Recommendations. JAMA Dermatol . 2017 Aug 1;153(8):802-809.

How long do I need treatment for my FFA?

How long do I need treatment for my FFA?

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

Question

I was diagnosed with frontal fibrosing alopecia last month. I’ve started on hydroxychloroquine and steroid injections. How long am I going to need to do this treatment?

Answer

Thanks for your question. Some patients with FFA need treatment for 1-2 years and some patients with FFA need treatment for 10-20 years. Some never can stop treatment without losing hair. It’s difficult to say for any given person how long they will need treatment but over time you’ll come to know the answer for yourself and your specific case.

The first step in treatment is to stop the disease so that it does not keep getting worse and worse. Once your doctor stops the disease, he or she will want to continue medications a bit longer and see if it stays quiet for many years or starting acting up again and causing more hair loss. If the conditions stays quiet, it may be possible to starting slowly ‘tapering” medications or reducing the dose bit by bit. If the disease stays quiet and you don’t start losing hair again when the dose is tapered then it means that things are truly quiet.

Step 1 therefore is to stop the disease

Step 2 is to keep the disease stopped

Step 3 is to slowly taper some medications (if possible)

There is a view out there in the internet that scarring alopecia simply burn out after a year or two. This is not correct. Some patients of course do have a form that goes inactive rather quickly. But not all do. Some patients need to try many different medications before they find a combination that finally stops the disease. some get the treatment right on the first try.

How do we prevent progression from eyebrow FFA to scalp FFA?

How do I stop by scalp from developing FFA?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in the management of frontal fibrosing alopecia (FFA).

Question

I am 47 years old and have eyebrow loss that my dermatologist feels is FFA. My mother has FFA and so we think my recent loss is also FFA. I have menopause at 41 which seems to fit well with the condition.

I want to know if there is anything I can do right now to stop the stop from becoming involved. My dermatologist does not see any signs whatsoever of FFA in the scalp.

My eyebrows are doing okay with Latisse and Rogaine as well as steroid injections every few months.

Answer

Thank you for this question.

The immune system has a plan for each person and we do not know what exactly that plan is for any given person and it's different for different people. If one wants to reduce the chances of scalp involvement then systemic medications may be needed.

Eyebrow loss can be treated with the options in the following chart. You are already on a solid plan with many of these. I often start with ONE OR MORE of minoxidil, bimatoproast, pimecrolimus and steroid injections and then see how the eyebrows respond. If we are successful then these are the options.

Reducing the chances of scalp involvement in the future may require one or more of the systemic agents (pills) shown in the list below. You may want to have a good discussion with your dermatologist about these various options as there are some reasons why some women can not use these medications at all. The key decisions in my mind would be for you and your dermatologist to figure out where dutasteride, finasteride, isotretinoin or hydroxychloroquine fit in. For many patients, it could be that getting on dutasteride is among the best steps and then waiting to see if any FFA develops.

Preventive Measures in FFA Have Not Been Studied

Your question is such a great one. The best way to prevent FFA of the scalp in someone with eyebrow FFA has not been well studied. For now, most physicians treat and address hair loss as it happens. This is probably not the best plan but most things we do in modern medicine are reactive rather than proactive.

Your point is a very good one and we do need to be thinking about the potential for future scalp hair loss. My feeling is that confirmed eyebrow FFA requires at least one systemic treatment and very very very close follow up. I would advise that a patient take photos every 4-6 months of the eyebrows, eyelashes, frontal hairline, crown, back of the scalp and sideburns.

If there is any evidence that FFA of the frontal hairline develops, then oral isotretinoin together with pimecrolimus cream and steroid injections can be started. Again, close follow up every 3-5 months will be needed to determine if this treatment plan is effective. If not, adding an antihistamine like cetirizine together with hydroxychloroquine would be the way I’d go in the present day (date of this post!)

Thanks again for the question

Combination Treatments for Frontal Fibrosing Alopecia

Can acitretin and finasteride be combined for the treatment of FFA ?

I’ve selected this question below for this week’s question of the week. It allows us to the concept of combination treatments for frontal fibrosing alopecia and specifically address whether finasteride and acitretin can be combined.

QUESTION

I am 49 years old (female) and the clinical diagnosis was initially FFA, but the biopsy was ‘inconclusive’. It is thought that I probably have a combination of telogen effluvium and FFA.  I am still losing hair and the front hairline has receded more than half an inch. So far I've only taken a mild topical steroid for 4 months and then Dermovate for 4 months. I am on HRT and on Lipitor {statin} for high cholesterol, and on cod liver oil.

My doctor suggests either Acitretin or finasteride. It is up to me to decide which I will take.

My question: could I combine both medications?

You have always suggested combination treatments, but I don’t actually recall having read about the combination of Acetrin and Finasteride. 

Also, my doctor suggests 1mg Finasteride – however, some medical articles mention a dose of 2.5mg.

Would you suggest I start with a higher dose and if necessary, decrease it in case of side effects? 

QUESTION

Thanks for the question.

Yes, finasteride and acitretin can be used together by a great number of post-menopausal patients with FFA - but I am not usually a big fan of starting a large number of treatments together on day 1. I generally like starting one treatment and then adding another in the near or distant if at all possible. In other words, if I can “stagger” the start dates, I prefer that for my patients. I’ll go more into that in just a minute. Sometimes we do need to be more aggressive with treatment than other times and need to combine drugs from the start. That’s a clinical judgment. Even when we do start drugs together, I still like to stagger by 2-4 weeks in the event one causes any sort of rare side effect (i.e. rash, nausea, etc) when starting.

But the short answer to your question is that provided you don’t have any contraindication to using finasteride and provided you don’t have any sort of contraindication to using acitretin, you can use them together.   These two treatments are amongst the most effective treatments for FFA and I’m glad you have been considering them. I refer to these as the gold medal or first line treatments for FFA.

You and your doctor can review all the contraindications to these drugs and confirm whether or not you have any contraindications. Women with past or present depression, or past or current breast cancer may not be good candidates for finasteride and similarly women with high cholesterol or any sort of issue related to dryness  (dry lips, dry eyes, vaginal dryness) may not tolerate high doses or acitretin. You have high cholesterol treated with statins. It does not mean you can’t start acitretin but it does mean you are susceptible to cholesterol numbers bumping up. You’ll simply need to follow the numbers with repeat lab tests if you do start. Most are fine.

It always needs to be emphasized for readers that both of these drugs cannot be used in pregnancy and strict attention to contraception is needed in women who still have menstrual cycles.

You are correct that I combine treatments very often when treating scarring alopecia. But I’m not usually one to just pile on the drugs and send someone out the door with 37 prescriptions. If my patient needs only one drug to control the disease, then why use two drugs? If one can get some good control of the disease with one oral medication along with a course of steroid injections or topical calcineurin inhibitors there is no need to use 2 oral medications.  As mentioned above, it’s not always so simple and sometimes clinical judgment tells us that we need to hit the emergency button and pull out all the stops.   Sometimes we don’t even need pills at all and use of topical finasteride, steroid injections and topical minoxidil might be a good plan. Again it comes down to clinical judgment and of course - shared decision making with the patient.

In FFA, we can get a good sense of how well any newly initiated treatment is working in about 3-6 months. So periodic re-evaluation is key and often more important than the first appointment. (A second appointment is often more involved than the first and decisions can become trickier). Remember though that we might be looking for at the follow up appointment might simply be stopping hair loss as our main goal or we might be looking for some hair regrowth as our main goal. It just depends on the specific patient and the exact details of their FFA so far. Not everyone with FFA regrows any hair back - but some of course do. However, stopping the disease from getting worse is the main goal for everyone. 

In cases where I am a bit more worried or situations where past experience tells me one drug is not going to be enough, I might add 2 drugs. So unfortunately there are no definitive rules to treatment of scarring alopecias. I might start finasteride 2.5 mg at a frequency of 3-7 times per week with isotretinoin or acitretin 10 mg daily or isotretinoin or acitretin every other day. In other situations, I will prefer to start one drug and review how the skin and hair is doing in 3-6 months and adjust accordingly.

At the follow up appointment in 3-6 months, we might go up on finasteride if we started 3 times weekly or stay the course with the dosing we used. Similarly, once I review the mandatory blood tests I like to see for anyone with FFA on acitretin , we may similarly go up or down on the dose of this drug. If we just started finasteride at a past appointment, we might add isotretinoin or acitretin at the follow up if we did not start the drug at the first appointment. But if things are going well on finasteride and the other treatments we started (topicals, injections) .. I might not add acitretin at all. 

Finasteride should be at 2.5 mg rather than 1 mg and use of the drug is 3-7 times per week.  Now, before we leave the topic of finasteride it’s probably worth noting that the related drug dutasteride may be slightly more effective than finasteride in treating FFA. More good studies are needed to definitely prove how different each drug is bit that is important to keep in mind. Sometimes I start a patient on 2.5 mg finasteride daily and depending on how things go I might alternate finasteride 2.5 mg daily with dutasteride 0.5 mg daily in the future or switch completely from finasteride to dutasteride. Dutasteride has a very long half-life so if I have any worry about side effects or potential side effects I might start finasteride rather than dutasteride. However the reality is that for most women with FFA these two drugs are very well tolerated.  

As another example, some women find dutasteride and finasteride worsen hot flashes and so if I am worried about this as a side effect in someone already dealing with hot flashes, I might start finasteride 2.5 mg 3 times weekly not dutasteride daily. Of course, depending on the clinical situation, I might not even start it at all - or might prescribe topical finasteride instead.

Sometimes we need to go higher on acitretin or isotretinoin dosing than 10 mg daily. Whether we do depends on how the patient is tolerating the drug and whether they have side effects. A patient with the side effect of unbearable dry lips or dry eyes is not a patient that we are going to want to increase the dose of acitretin or isotretinoin. In fact, we may even go down on the dose or stop and bring on board a silver medal (second line treatment) like hydroxychloroquine.   Similarly, if cholesterols is jumping up (ie LDL cholesterol or triglycerides), we may want to go down one the dose and bring on board another treatment that won’t impact cholesterol.

 

The Treatment of FFA: Combination Examples

The treatment or scarring alopecia requires a lot of decisions based on what the patient sitting in front of me feels about these treatments and the past health of the patient and the activity of the disease currently. If you dig through the charts of patients with FFA in my practice you’ll see a lot of different treatment plans:

a) some use no pills only creams (steroid or calcineurin inhibitors) and/or steroid injections 

b) some use dutasteride or finasteride and creams +/- steroid injections 

c) some use dutasteride or finasteride with doxycycline and/or hydroxychloroquine plus creams +/- steroid injections 

d) some use oral doxycycline +/- oral hydroxychloroquine alone and creams +/- steroid injections 

e) some use dutasteride or finasteride with creams and isotretinoin or acitretin +/-steroid injections 

f) some use dutasteride or finasteride with acitretin or isotretinoin with creams  +/- steroid injections   +/- hydroxychloroquine 

g) some use acitretin or isotretinoin with creams  +/- steroid injections   

h) some use acitretin or isotretinoin with creams  +/- steroid injections   +/- oral hydroxychloroquine 

i) some use topical finasteride in place or oral finasteride or dutasteride in the above

j) some also have oral minoxidil, topical minoxidil, laser therapy, mycophenolate mofetil, methotrexate, cyclosporine, apremilast, tofacitinib added into various patterns of the above examples

Variations on the Same Theme.

It is important to note that within each example there can be hundreds of variations.  Consider two patients who say, “I take dutasteride, hydroxychloroquine and isotretinoin.” 

One  patient might be on dutasteride 4 times each week PLUS at 10 mg isotretinoin 2 times per week PLUS hydroxychloroquine 200 mg daily.

The other patient might be on dutasteride 7 times per week PLUS at 10 mg isotretinoin 3 times per week PLUS hydroxychloroquine 200 mg 4 times per week.

Combinations that Are Not Permitted.

 I have reviewed a lot of the common combinations above in how we manage FFA. Some treatments cannot be used together due to side effects. Common examples are doxycycline with isotretinoin or hydroxychloroquine with cyclosporine. 

I hope this helps. Thanks for submitting the question.

REFERENCE

[1] Acitretin Handout for Patients with Scarring Alopecia

[2] Finasteride Handout for Women

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.