Exosome Therapy for Hair Loss

What are your thoughts on exosome therapy?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in new therapies, including exosomes.

Question

I have been suggested by my dermatologist exosome therapy, one injection per month for three months for MPB. I understand this is a novel therapy with limited studies.

I wanted to know your opinion, if you have had experience or know of results and/or side effects.

Thank you so much,

Answer

Thanks for the great question. I’m not sure what country you live in but here in North America (Canada and the United States), exosome therapy is not permitted - except under very special circumstances whereby a doctor has applied for and received a special IND application from the FDA (or equivalent in Canada).

I have yet to use it in my practice. In North America, if I wanted to use exosomes, I’d only be permitted to use it in the the context of a research study and I’d need to do all the paperwork to have my study approved. I’ll get back to that in a moment but you can already see how new and experimental exosome therapy truly is (as of the date of your question).

Exosome therapy is a potentially interesting therapy. To date, there have been very few published studies that actually show exosomes are all that helpful for treating hair loss. There was one study, however, by Chang-Hun et al back in 2019 in the Journal of the American Academy of Dermatology. That study had just 20 patients and followed the for just 12 weeks. However, the authors of that study found a 16 % increase in hair density and an 11% increase in thickness with use of exosome therapy. Not a lot - but some improvement. There were no serious side effects. That’s a nice change in hair density - but certainly not dramatic. With only 12 weeks of follow up, it’s unclear really what this means.

There have been a variety of in-vitro studies showing that exosomes can increase proliferation of dermal papillae (DP) cells, hair matrix cells, and outer root sheath cells as well as promote hair follicle stem cell proliferation and differentiation. I follow the world of exosomes closely!

Let’s dive deeper now.

What are exosomes?

Exosomes were only recently discovered - about 40 years ago. They are now being studied in various parts of medicine. Exosomes are extracellular vesicles that are produced by some type of cell. They are essentially tiny communication vesicles about 20-50 nm in size. It was first thought that exosomes were just cellular waste that got booted out of cells. Fortunately, it eventually came to be recognized that exosomes were important carriers of signaling molecules and were used for communication between cells. They contain many things including protein, nucleic acids, growth factors, lipids. It’s the growth factors in particular that are believed to be helpful in hair loss.

There are a wide range of cells that may be used to produce exosomes. However, donated human amniotic mesenchymal stem cells are one common source. Exosomes from adipose-derived stem cells are another source. There’s more yet - including exosomes from bone marrow derived mesenchymal stem cells.

Creation of exosomes. FROM: Graça Raposo and Willem Stoorvogel. Extracellular vesicles: exosomes, microvesicles, and friends. J Cell Biol . 2013 Feb 18;200(4):373-83. USED WITH CREATIVE COMMONS LICENSE. All credit to original source

The FDA Regulates Exosomes in the USA; Health Canada does the Same in Canada

The US Food and Drug Administration (FDA) has authority to regulate regenerative medicine products, including stem cell products and exosome products. The FDA has not given the green light to exosome therapy. It can only be used in a research setting by clinics that have a defined research study in place. The same is true in Canada. In Canada, exosomes fall under the jurisdiction of the Food and Drugs Act.

A US or Canadian physician who uses exosome therapy without having all the documents in place to show that they are conducting a research study could be subject to fines, and a variety of other penalties. It’s a serious issue and so exosome therapy is more common in other countries outside North America. In North America, a clinic needs to have applied for and received approval for an ‘investigational new drug” (IND) application before doing anything with exosomes.

I don’t do exosome therapy in my office. I’ve certainly had lots of conversations and phone calls with various regulatory bodies about these therapies. The message is always the same: A doctor can’t use these therapies unless they have been approved to do a clinical trial. Obviously in these kind of trials, the patient would sign a lot of forms indicating they know they are part of a clinical trial and the patient would be provided with proof that the clinic is part of such a trial. In other words, it would be pretty clear if a clinic in North America has an IND to study exosomes.

At the present time, there are no FDA or Health Canada approved exosome products for treating hair loss of any kind. Clinics can’t offer them (unless the patient receiving them is a research study patient).

The US FDA and Health Canada are very very worried about these types of therapies getting to the public without first doing the proper study. That’s why they want to study them ! In 2019, the FDA published a document for the public to warn of their concerns.

FDA’s Public Safety Message on Exosome Therapy

FDA’s Safety Alert for Exosome Therapy

CDC Warning About Exosomes

Health Canada Warnings on Autologous Therapies

Investigational New Drug Applications (IND Applications)

An “IND” is a submission to the FDA to request permission to study a drug. The goal of the entire IND process to help collect information that a given drug is indeed safe to use in humans. An ‘investigator IND’ is a special type of IND submission whereby the IND is submitted by a doctor who then initiates and conducts the clinical study. In order for a doctor in North America to conduct any kind of study with exosomes, they need an investigator IND.

Exosomes are considered “drugs” by many regulatory organizations including the FDA and Health Canada because they are used to treat some sort of medical issue. Here, in our discussion today, that medical issue we are speaking about here is hair loss. That’s the first point that makes an IND needed for anyone wanting to use or study exosomes for hair loss. The second issue is that the drug is used in human beings. Studies on human beings using drugs that have not been approved in the past need an IND. There are no exceptions for exosomes: all users need an IND application. Exosomes are not an approved ‘drug’.

A clinic or researcher with an approved IND application has permission to ship across the country and then to use exosomes in a formal study. It does not give physicians permission to use exosomes in any way they wish - only in a pre-approved research study.

Summary

In summary, exosomes are a potential new therapy. The data to date on effectiveness is promising (although not super exciting). The concept sure is exciting. We don’t really know much about exosome therapy but more information is going to emerge in the next few years. Stay tuned. It seems safe in small studies but these studies are extremely small. We have no idea how often treatments will be needed and no idea if 5 treatments is safe but 55 treatments is unsafe. We have no idea if 1 year of treatment poses different risk than 10 years of continuous treatment. Exosomes are completely new.

Exosome therapy is not FDA approved and not Health Canada approved. Here in North America, clinics can’t offer them without first formally registering and being approved to conduct a clinical trial with the US of Canadian government. A patient in North America can’t receive these therapies yet without being part of a clinical trial. In other words, exosome therapy not just another therapy option like PRP. It’s completely different. It’s not possible to walk into a clinic and choose exosome therapy like one would choose PRP or a hair transplant. Exosomes can only be offered to North American patients in the context of a clinical trial. That’s important for North American readers of this article to be aware of.

Thanks again for the great question.

REFERENCE

Chang-Hun et al. Exosome for hair regeneration: From bench to bedside. J Am Acad Dermatol. VOLUME 81, ISSUE 4, SUPPLEMENT 1, OCTOBER 01, 2019

Graça Raposo and Willem Stoorvogel. Extracellular vesicles: exosomes, microvesicles, and friends. J Cell Biol . 2013 Feb 18;200(4):373-83.

Does inflammation in the scalp help minoxidil work better or worse?

How does inflammation affect how minoxidil helps over time?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in treatment of androgenetic alopecia with minoxidil and the relationship to inflammation.

Question

I have androgenetic alopecia and my scalp is red at time as I have seborrheic dermatitis or some say psoriasis. I have heard that inflammation in the scalp may mean minoxidil works less well and other say it will work better.

What is the correct answer?

Answer

This is such a great question. The full answer as to whether inflammation causes minoxidil to work better or worse really comes down to what is causing the inflammation. There are 100 causes of inflammation in the scalp!!!! Some causes might make it work better and some might cause it to work less well.

As we tackle this subject, it’s important to keep in mind that few studies have actually been done.

Inflammation and fibrosis are known to affect responses to minoxidil. In 1993, Dr Whiting showed that patients with significant perifollicular inflammation and fibrosis have poorer responses to topical minoxidil. We don’t routinely evaluate inflammation in the scalp with males and females with androgenetic alopecia in deciding whether minoxidil will work or not. However, this 1993 study reminds us that it’s relevant.

There are other situations whereby inflammation probably makes the minoxidil work better. We sometimes add retinoic acid to minoxidil for example to make it more irritating and therefore get into the scalp better. Here is an example where we think inflammation helps minoxidil work better rather than worse. It’s not entirely clear if inflammatory states like seborrheic dermatitis, psoriasis, lupus, contact dermatitis are associated with better responses to minoxidil or not. The companies that make minoxidil warn users not to use if they have these sorts of inflammatory conditions. That is due to concern it might get into the scalp better.

All in all, there may be some inflammatory states where minoxidil works better and gets into the scalp more efficiently. This may also be associated with a greater chance of side effects like hair on the face or body, palpitations, headaches, etc. Be sure to discuss your specific situation with your dermatologist or hair specialist. If may not be a strict contraindication to use minoxidil if there is inflammation on the scalp but you will likely need a bit closer monitoring to ensure you are not developing worsening inflammation and not getting side effects from the treatment.

I have FPHL and have used everything imaginable. What else is there?

What are the other options for female pattern hair loss?

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

Question

I am 41 and have been diagnosed with FPHL and have used Rogaine, laser, PRP and spironolactone. Nothing works! What else is there? Have I exhausted all the options?

Answer

Thanks for the question. Let me being by saying that you’ll want to make sure that you have the right diagnosis. That’s always the first key step. My question when I see patients with a story like this is:

1) Is androgenetic alopecia the correct diagnosis ?

2) Are there other diagnoses here in addition to androgenetic alopecia ?

If there is any uncertainty, a biopsy may be needed. If you and your doctors are indeed confident it’s AGA then there are alternatives but what to use really depends on a person’s age, medical history, plans for pregnancy, emotional and psychiatric health, cardiovascular health and liver and kidney health. I’ll also assume that you have given each of these 6 months because that’s how long it takes to figure out if it’s working or not. I see patients every day who use Rogaine or spironolactone for 1-2 months and conclude it’s not working and stop. It takes a long time to evaluate effectiveness.

There are options for oral minoxidil, oral finasteride, oral dutasteride, topical finasteride, bicalutamide and hair transplantation. Be sure to give each and every treatment you try 9 months before you evaluate if it worked or not. I’ve included a list of first line, second line and third line treatments for premenopausal women. These may be a starting point for further discussions with your doctors. Some of these may not be options in young women on childbearing potential so you’ll want to discuss these in great detail. Often in a situation like you’ve described oral minoxidil or topical antiandrogens would be a next step with consideration given to a scalp biopsy to rule out any mimicking conditions.

Switching from Oral to Topical Minoxidil

How easy is it to switch from Oral Minoxidil to Topical Minoxidil?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in switching from oral to topical minoxidil.

Question

I am using 2.5 mg of oral minoxidil with success. Unfortunately, there is a shortage of oral minoxidil in my area so I’m going to need to switch to topical minoxidil until we get the supply back. Will I experience shedding when I start topical minoxidil? I hear that many people do!

Thank you.

Answer

Thanks for the question. You are likely to experience shedding but for a different reason than you ask about and perhaps a different reason than you think.

You are not likely to get shedding simply because you are “starting” topical minoxidil. No. However, you are likely to experience shedding because you are not able to supply your scalp with the equivalent amount of minoxidil by using the topical compared to the oral minoxidil. 5 % foam is NOT equivalent to 2.5 mg so you hair and scalp will likely say “where is my minoxidil?” “why am I suddenly being deprived?”

If you have been using oral minoxidil for a very short time, it may not be a big issue. But if you have been using oral minoxidil at 2.5 mg for some time it could be an issue. Be sure to discuss fully with your dermatologist.
The key point here is that 2.5 mg of oral minoxidil is not equivalent to topical minoxidil so you are now likely underdosing. There are options to have a compounding pharmacy in your area make up minoxidil pills for you. Not all pharmacies have this experience but many do. That is a far better option for most than switching to topical. But be sure to discuss with your health care providers.

Thank you again for the question!

Should I get another biopsy?

Should I get another biopsy?

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

Question

I’m a 34 year old female with previously beautiful hair. My biopsy came back showing “non-scarring alopecia with features consistent with androgenetic alopecia.” I’m wondering if I should get another biopsy? Could it be wrong?

Answer

Thanks for the question.

Without knowing more about your medical history, and seeing your scalp (or photos), it’s difficult for me to say.

There are a number of possibilities here:

a) Your story and examination confirm you have androgenetic alopecia and doing a biopsy was not needed but simply served to confirm the diagnosis. Doing another biopsy would not be advised.

b) Your story and examination confirm you have androgenetic alopecia but there is a suggestion in the story or examination that a second diagnosis is also present. In this case, doing another biopsy could be a good idea if one is not 100% confident about this second diagnosis. If one is 100% confident in the second diagnosis, then another biopsy is not needed.

c) Your story and examination do not suggest androgenetic alopecia and there is a suggestion in the story or examination that a different diagnosis is present. In this case, doing another biopsy could be a good idea if one is not 100% confident about this diagnosis. If one is 100% confident in the diagnosis, then another biopsy is not needed.

I hope this helps. I don’t know your diagnosis because I haven’t seen your scalp and I don’t know your story. Certainly, if your practitioner is highly experienced in diagnosing women’s hair loss and says “This can’t be androgenetic alopecia” then I’m more likely to feel something is strange here and more likely to feel that a re-evlauation of things is needed. Early androgenetic alopecia is tricky to diagnose so many women have AGA even though it might not look like it.

If the practitioner is less experienced in diagnosing women’s hair loss, I’m less bothered by him or her saying “This can’t be AGA.” it’s tricky to diagnose some of the early forms of AGA. The reality is that if the terminal to vellus hair ratio on biopsy is dipping down below 4:1 and sebaceous glands are present in the biopsy there’s a good chance we’re dealing with AGA. The key question is whether this is the only diagnosis or the correct diagnosis.

Finally, I’d like to point out that we don’t diagnose hair loss just with biopsy results alone. One needs to take the biopsy finding and see if it ties in with the history of hair loss and the clinical examination findings. I would never every commit to saying a person has a certain diagnosis without the chance to see their hair and know their story. Even with the biopsy sitting in front of me, I need to know the story and see the scalp.

What treatments for Androgenetic Alopecia Regrow Hair and Which just Stop it from Getting Worse?

Treatments for Androgenetic Hair Loss in Women

I’ve selected this question below for this week’s question of the week. It allows us to review treatments for androgenetic alopecia.

Question

I know there are many treatments for female androgenetic hair loss. I would like to know which treatments come with the chance that it will regrow hair and which just stop it from getting worse? How are these divided

Thank you

Answer

Thanks for the great question.

Every single recognized treatment for androgenetic hair loss comes with the potential to 'regrow hair.' That does not mean that it actually will regrow hair for any given person, but all come with some chance.

Again, it might not do that for every single user, but every treatment has this chance. If it does not, it doesn't work at all! There is no treatment in the world that "just maintains" hair. We do not categorize treatments in terms of “this group is a group that grows hair” and “this group is a group that just maintains it.”

Every single treatment has a certain percent of patients that will regrow some hair, a certain percent that will regrow a lot of hair, a certain percentage that will not regrow all that much but will maintain, and a certain percentage that the product won't help at all and hair loss will occur.

Example with topical minoxidil

For example, consider topical minoxidil:

30%-40% of women using topical minoxidil will regrow some hair with a 15-20% of women will regrow a lot of hair

30% of women using topical minoxidil will not regrow all that much but will still benefit from using the product because it will help maintain density.

30-40 % of women using topical minoxidil won't get much help at all from using the product.

Thanks and I hope this helps.

Spironolactone and Low Blood Pressure: How much will it drop?

Spironolactone and the Risk of Hypotension

I’ve selected this question below for this week’s question of the week. It allows us to the review some key data regarding blood pressure changes with spironolactone.

Question

I have been given a prescription for spironolactone for female pattern hair loss. I am concerned it might lower my blood pressure as my blood pressure often runs on the lower side of normal. Do you have any data on the chances of patients getting low blood pressure among users of this drug. How much does blood pressure usually drop?

Answer

Thanks for the great question. We’ve talked about the side effects of spironolactone in prior posts.

As far as changes in blood pressure among healthy women, the data has not been all that clear - until recently.

Garg and colleagues recently published a retrospective case series of 403 adult women treated for acne with spironolactone between 2008 and 2019. If we look into that data a bit closer, we can gain some valuable information on how it might affect blood pressure in those with androgenetic hair loss.

Does spironolactone affect blood pressure in health individuals? A new study suggests yes, but not by very much.

The median age of women in this study was 26. For 85 % of patients, the initial dose was 100 mg. Thereafter the dose increased for 50 % of women, stayed the same for 37.5 % and decreased in the remaining women.

Data was available regarding before and after blood pressure readings in 267 patients. The mean decrease in systolic blood pressure was 3.5 mm Hg (95% CI, 2.0 to 4.9) and the mean decrease in diastolic blood pressure was 0.9 mm Hg (95% CI, -0.2 to 2.1). The data was “statistically significant” meaning that spironolactone truly does affect blood pressure - it’s just the changes are quire small. No patient in the study needed to stop spironolactone because of blood pressure problems.

Summary and Comment

This was a nice study because good data and numbers on exactly how spironolactone affects blood pressure in healthy women have been hard to come by. We know that spironolactone can lower blood pressure in those with “ high blood pressure” by as much as 16 mm Hg systolic and 6 mm Hg diastolic. This data comes from a recently meta-analysis by Liu et al. This would lead many to believe that there must be a pretty big risk of low blood pressure in all our patients who use the drug for androgenetic hair loss. However, the real data says otherwise: healthy women who use spironolactone don’t get all that big of a change in their blood pressure and if they do - it does not typically affect them all that much

This study gives us some really good numbers to go on. For most healthy individuals spironolactone doesn’t affect blood pressure enough to really make a difference. If one is concerned, then baseline blood pressure testing and periodic follow up blood pressure testing is appropriate along with a slow increases in the dose. I have prescribed spironolactone to many patients who report low blood pressure and most patients tolerate 50-100 mg doses without any issues. So, is there ever an issue? Of course there is. Fortunately, it’s not common and patients who report lower blood pressure don’t necessarily need to lose out on a potentially effective treatment for them. We need to be cautious about going up too fast or to too high of a dose. Far too many people with androgenetic hair loss have completely shut off any sort of discussion about using spironolactone out of fears about low blood pressure. This study suggests we need to be cautious but not fearful. Low blood pressure is usually not a significant problem.

Reference

Garg et al. Long-term use of spironolactone for acne in women: A case series of 403 patients. J Am Acad Dermatol. . 2021 May;84(5):1348-1355.

Lui et al. Addition of spironolactone in patients with resistant hypertension: A meta-analysis of randomized controlled trials. Clin Exp Hypertens. 2017;39(3):257-263.

Can I reduce the dose of minoxidil for treating my AGA and if so, how?

Minoxidil (Rogaine) for the treatment of Androgenetic Hair loss: How soon after starting can I go down on the dose?

I’ve selected this question below for this week’s question of the week. It allows us to the review some key concepts in the treatment of androgenetic alopecia - particularly the need for ongoing lifelong treatment.

Question

I have female pattern hair loss and I’ve been on minoxidil 1/2 cap daily for about 1 year now. It seems to be helping. I was advised this week by my provider that it’s okay to go down to 3 or 4 times weekly. What protocol do you recommend for reducing the dose and how do you taper safely so as to not lose hair?

Answer

Thanks for the question. The answer is simple: If you have androgenetic alopecia and Rogaine is helping you, then this medication probably can’t be tapered to any significant degree without you losing some hair.

If Rogaine has not been helping you all these months and you’ve actually been wasting your time in the last 12 months applying it - you can stop it without any immediate negative effects. The hair won’t mind at all that Rogaine was stopped because it wasn’t helping in the first place.

However, if Rogaine was helping (which I imagine for you it probably must be), it can NOT be tapered without losing hair. I don’t know how this concept has started permeating in this world - I’ve heard it myself. But Rogaine can’t be stopped if it was helping. You can’t go from 7 days a week to 5 without some negative effect on the hair. You can’t go 7 days to 4. You can’t go twice daily to once daily. Sure you might be able to go 7 to 6 but there’s a fine line for what its acceptable.

If all a person is able to do is apply Rogaine 5 or 6 days per week, then I say try to apply it five or 6 days per week. That’s fine. It still has a chance of helping even if it’s not perfectly daily. . But to start at a higher dose and then reduce the dose at a future time just doesn’t work well for most people.

Reducing the dose of Rogaine usually leads to hair loss (if it was helping). Consider the female patient who starts using Rogaine 5% twice daily because she really wants to try to stop her hair loss, or the patient who even uses a full cap instead of the recommended 1/2 cap. Then, imagine that the patient winds up in the clinic of a specialist 12 months later and the specialist says confidently to her“Oh, Rogaine for women only needs to be used once daily at 1/2 cap - so you can reduce your dose”

Guess what happens when the patient goes from a full cap twice daily to 1/2 cap daily?

She loses hair! !!!!!!

Hair is not pleased with a four-fold reduction in the dose.

Summary and Conclusion

All the treatments for androgenetic alopecia are lifelong. If a patient is going to use Rogain to treat their AGA, then they should plan to start it with the intention to use it lifelong. If a patient is going to use anti androgens to treat their AGA, then they should plan to start it with the intention to use it lifelong. If a patient is going to use low level laser therapy to treat their AGA, then they should plan to start it with the intention to use it lifelong. If a patient is going to use PRP therapy to treat their AGA, then they should plan to start it with the intention to use it lifelong.

We would to think that it’s possible to reduce the dose of Rogaine after some time. It sure sounds like a nice plan …. and a convenient one too! It’s just that it doesn’t really work like this and reducing the dose carries a high risk of hair loss.

Now for all the people who are using Rogaine for other types of hair loss besides androgenetic alopecia - the rules are a bit different. If one uses Rogaine for alopecia areata, one can stop Rogaine once the hair grows back. Sometimes (but not always) that’s true for other types of hair loss as well. But for androgenetic alopecia the rules are pretty straight forward. If a certain dose or amount of Rogaine has helped, then that dose or amount needs to bee continued exactly the same way to maintain results. A reduction in dose will likely lead to hair loss.

The following chart is helpful to differentiate the use of Rogaine in these conditions

What is More Accurate for Diagnosing Early Stages of Hair Loss : A Scalp Biopsy or Clinical (Trichoscopic) Examination?

Biopsy or Up Close (Trichoscopic) Examination: What’s better for diagnosing the early stages of hair loss?

I’ve selected this question below for this week’s question of the week. It allows us to the review some key concepts in diagnosing hair loss via clinical scalp examination and through a biopsy.

QUESTION

What is more accurate - a scalp biopsy or a scalp exam with a dermatoscope? My biopsy results said telogen effluvium and androgenic alopecia with the diagnosis of androgenetic alopecia being favored.

As for me, I’m a 30 year old female. My scalp is itchy, likely from seborrheic dermatitis which was diagnosed by a dermatologist. I’ve suffered from alopecia areata in the past (1 small bald patch at a time and treated with cortisone injections) . I have a lot of food and environmental allergies that I’m treating naturally. My hair started shedding excessively at the end of February 2021 after a very traumatic event in December 2020. I’m not on any prescription medications but I do take supplements (iron, vitamin D and C, coQ10, quercetin, probiotic, l-lysine, caprylic acid, and a multivitamin for hair). The shedding has been diffuse and I have lost density. My family members insist that no one would know I’m having issues with my hair. In the past few weeks I have had days with minimal shedding. I have been treating the seborrheic dermatitis with medicated shampoos. I have been treating the hair loss naturally, through dietary changes, lowering stress levels with meditation, etc; I have not used any medications.

The dermatologist that performed the biopsy said it’s “age related” (I’m a 30 year old female) and therefore not even considered an early stage AGA. The second dermatologist I saw (for a second opinion) did a scalp exam with a dermatoscope and said there was “maybe one” miniaturized follicle at the biopsy site on my crown. Throughout the rest of the top of my scalp she said about 1 in 100 follicles are miniaturized. She gave me a diagnosis of just telogen effluvium. So far all of my test results (iron, ferritin, vitamin D, vitamin B12, thyroid panel, and hormone panel) have been normal. I’m very confused and not sure if and what treatment would be best for me. Thank you!

ANSWER

Thank you for the question. In order for me to advise you on what treatment would be best for you, we need a diagnosis.

So what is your diagnosis then?

Well, in order for me to give you a diagnosis, I would need to know a bit more about your story from birth until today, and see your scalp up close myself and review your blood tests. Those are the three key steps in order to make a diagnosis for anyone!. Because I don’t have any of these pieces of information in your case, I can’t actually say what your diagnosis is.

However, there are still some very important points to be aware of and that’s why I’ve selected your question for this week’s question. It’s such a good one with so many things for us to review.

So let’s get to it.

You have what I call early hair loss. You yourself know there is a change, but your friends and family think everything is just fine. Even one of the dermatologists thinks it’s simply a telogen effluvium. This is early hair loss.

As you have correctly outlined, this can often be due to androgenetic alopecia or telogen effluvium …. or both.

As I review all your information about what your biopsy showed and what your doctors actually said, I need to know how reliable each of these three pieces of information are. If dermatologist 2 is a world expert in hair loss and doesn’t think its AGA - does this carry more “influence” as I think about your case than if dermatologist 1 thinks it’s AGA but really has only seen a handful of hair loss patients in his or her career?

Yes it most certainly does.

Your question is really all about the reliability of these three pieces of information - the 2 doctors and the 1 biopsy.

And what if the biopsy was taken from an area on the scalp that is really not so useful for making a diagnosis (like the temples) - am I to trust this result? Well, no.

So, let’s take a look at these four scenarios below in order for us to better understand when a biopsy is better than a clinician’s interpretation and when a clinician’s interpretation is to be trusted more than a biopsy report.

In general, the very early stages of hair loss can be challenging to decipher from one another. The more experience and expertise the clinician has in treating hair loss … the more reliable his or her view will be on the cause of hair loss. The less experience the clinician has, the less reliable his or her view is and the more a biopsy result is to be trusted. However, biopsies are not all the same. The only biopsy result that I really trust is one taken from the correct area of the scalp and interpreted properly by expert dermatopatholgist.

Let’s take a look at the following chart and then we’ll break it down some more.

SCENARIO 1. The practitioner evaluating the scalp is a VERY EXPERIENCED hair loss expert and a 4 mm punch biopsy was taken from a correct area of the scalp and interpretations were done by a VERY EXPERIENCED dermatopathologist.

In this case, both the dermatologist’s opinion and the dermatopathologist’s opinion are fairly reliable. In fact, in most cases, they are fairly equivalent. A highly experienced clinician can examine all areas of the scalp and can determine just how much variation in the caliber of hair follicles (ie “miniaturization”) is seen in the various regions including the front, middle, top and back. If the clinician appreciates that density is slightly different in one area compared to another it’s like their is some androgenetic alopecia going on - especially if the thinner area show a greater degree of miniaturization.

A clinician can also evaluate density in the frontal area and compare this to the back. If there is a subtle increase in “part width” in the frontal and mid scalp compared to the back, this gives a suggestion there could be some androgenetic alopecia going on.

So an astute clinician can look at the scalp, look at the part width, look a the density in various regions of the scalp and look at what the trichsocopy shows and come up with a conclusion.

Clinical examinations of the early stages of hair loss are tricky to interpret. It takes expertise to appreciate subtle changes in hair follicle caliber. It’s not something that is learned overnight. It’s not a result that pops up on any sort of screen when one places a dermatoscope one the scalp. Of course, it one’s dermatoscope its connected to a computer and the caliber of follicles can actually be measured in various areas, this really increases the reliability of the interpretation for less experienced practitioners.

But if a practitioner is less experienced with hair and scalp issues, simply placing a dermatoscope on the scalp and concluding “I don’t see any miniaturization” does not give me a great amount of confidence in diagnosing early hair loss issues.

What about a biopsy? Biopsies in early hair loss can be wonderful! A biopsy taken from the area of androgenetic alopecia can also show a DECREASING terminal to vellus ratio from a normal low 7:1 or 8:1 down to 4:1 or less. In true telogen effluvium, the terminal to vellus ratio stays well above 6 or 7 to 1. An experienced dermatopathologist who interprets a biopsy from a patient with early hair loss and says ‘the T:V ratio is 3.5:1 and sebaceous glands appear enlarged and there is no real shift in catagen to telogen ratios and there is no peribular inflammation” is telling me this is likely androgenetic alopecia. I trust that report if I know the dermatopathologist is experienced.

To summarize, a very experienced practitioner can often make a diagnosis of androgenetic alopecia fairly reliably even without a scalp biopsy. However, if a scalp biopsy is done, the results should be similar trusted as the findings of a very experienced practitioner provided the biopsy is interpreted by an expert pathologist.

SCENARIO 2. The practitioner evaluating the scalp is an INEXPERIENCED practitioner and a 4 mm punch biopsy was taken from a correct area of the scalp and interpretations were done by a VERY EXPERIENCED dermatopathologist.

In this case, the biopsy report is MORE reliable than the view of the clinician. We need to remember here that early hair loss stages are really difficult to diagnose! There is no harm in saying that and I’ll be the first to point that out.

It can take anywhere from 6 months to 5 years from the time some types of hair loss first start before a patient themselves figure out that something is changing on their scalp. So, the early stages of hair loss are tricky to spot. The early stages of hair loss can sometimes look normal. The less experience the practitioner has …. the more the scalp will look normal to them ! That’s just a fact. Any practitioner who takes a quick 5-10 second glance at the scalp and says to their patient ‘your scalp looks fine to me… don't worry” is by definition an inexperienced practitioner. This is pretty much a rule. The early stages of hair loss are hard to spot sometimes and take a bit of poking and prodding in the scalp to see what all the 100,000 hairs are doing and a bit of sleuthing to gather information from the patient as to exactly what’s been happening over the past months.

If a very experienced clinician says ‘This scalp is normal” then it’s pretty unlikely there is any androgenetic alopecia. Not 100% guarantee of course….. but pretty unlikely. If an inexperienced clinician says ‘This scalp is normal” then it carries less meaning. Of course, it could be normal, but I’m a bit more skeptical. I am sent referrals every day of the year that say “ Normal scalp exam. Patient thinks they have hair loss. Please see in consultation.”

What do many of these patients end up having as a diagnosis ? Well, many have androgenetic alopecia !

Suppose I’m meeting up with a friend for dinner and I tell my friend that I have been getting some pretty bad headaches lately. If my friend tells me everything sounds fine, do I believe it? Well, if my friend is a neurologist I’m a bit more likely to trust this information than if my friend is an accountant. The quality of the information makes a difference.

So to summarize, if a clinician is less experienced with diagnosing hair loss but takes a biopsy from a correct area of the scalp (ie where the hair loss is most affected) and the biopsy lands in the hands of an expert dermatopatholgist …. then I would usually trust the dermatopathoglist report over the clinician’s interpretation of what’s causing the early hair loss.

So what’s a good biopsy in your case? Well, in your case this likely means that biopsy was taken from somewhere in the yellow area shown below. I would prefer if the biopsy was 4 mm in size. I would also like if the biopsy was processed with horizontal sections as personally that increases my confidence in these early stages of hair loss. It’s only with horizontal sections that the pathologist can give a measurement of the terminal to vellus ratio. This can’t be done with vertical sections. If your T:V ratio is less than 4:1, we might begin to think there is some androgenetic alopecia present as a diagnosis.

SCENARIO 3. The practitioner evaluating the scalp is an EXPERIENCED hair loss expert and a suboptimal biopsy was taken from an incorrect area of the scalp and/or interpretations were done by an INEXPERIENCED pathologist.

This would be an unusual situation whereby an experienced clinician took a biopsy from a wrong spot. But this situation could be an experienced clinician is trying to decide what diagnosis a patient has and the patient brings in a biopsy report they had at another clinic showing a certain result.

In this case, I trust the result from the clinician any day over the biopsy report. Every day, I see biopsy reports that are taken form the back of the scalp or the sides of the scalp or the temples. These are not the ideal areas to be taking biopsies from if we want determine whether or not the patient has androgenetic alopecia!!!

Sometimes, the doctor does not want to cause a scar…. and so takes it from the sides of the scalp so as to hide any scar. Sometimes, a patient asks the doctor to take it from the temples because that’s where they are most worried and where they see the changes every day of their life when they look in the mirror. These are not where we should be taking biopsies to confidently assess androgenetic alopecia !

If a biopsy returns showing “no evidence of androgenetic alopecia” but was taken from the sides fo the scalp does it mean the patient does not have androgenetic alopecia? No! Not at all,. That biopsy was not helping in making the proper diagnosis.

If a biopsy returns showing “no evidence of androgenetic alopecia” but was taken from the main area of hair loss in the central scalp zone, does it mean the patient does not have androgenetic alopecia? Probably that is the correct interpretation.

SCENARIO 4. The practitioner evaluating the scalp is an INEXPERIENCED practitioner and a suboptimal biopsy was taken from an incorrect area of the scalp and interpretations were done by an INEXPERIENCED pathologist.

A particularly challenging situation is when a less experienced practitioner is not sure what the diagnosis is but proceed to take the biopsy from an area of the scalp which is less than ideal. Typically this is a well meaning practitioner who wishes to take the biopsy from an area that will best be hidden in the future should the area form a small scar. So the biopsy is taken from the sides of back of thee scalp and typically returns showing no evidence of androgenetic alopecia. The only thing that can be interpreted in this situation is that the patient does not have androgenetic alopecia down the sides of their scalp. However, we can’t conclude anything at all about what might be happening in the middle of the scalp - the area where the patient is most concerned about the hair!

I often use the following analogy when I explain the concept to doctors that I teach.

Suppose you have a mold of some kind in your home. The house smells like mold! Terrible, right?

And so you call a mold specialist for help. Unfortunately, all the mold specialists in town are away at a convention so you decide to call a plumber. After all, mold grows in water and damp conditions, and you figure that a plumber knows a lot about water and damp conditions in homes.

The plumber answers the call and says he or she knows how to take mold samples because they learned how to do so in a course they took.

Voila!

You are happy with the answer and invite the plumber to your home to get some help.

The plumber finds a bit of water in the basement and takes some mold samples. It all comes back negative.

You are all relieved there is no mold!

The problem is that the smell continues.

When the mold specialist in town returns from the convention, you invite him or her now into your home. Within a few minutes the source of the mold is located in the attic of the house. Their is a leak in the roof and this is causing the roof to leak and the attic to grow mold !!!! Samples are taken and the mold is finally proven.

Did it matter where the samples were taken? You bet it did!

An experienced specialist is more likely to know where to take the sample .

Conclusion

Your question is really a great one. Thanks again for submitting. It’s difficult, if not impossible for patients to know if their biopsy was taken from the correct spot or whether their clinician really has a lot of experience or not. It’s tough to navigate the medical world sometimes.

The short answer to your question , however, is that a very experienced clinician can often diagnose hair loss with a similar degree of accuracy to a biopsy interpreted by an expert dermatopathlogist. If the skills of the clinician change or the skills of the dermatopathologist now change, this no longer holds true and you’ll need to see the chart about as to which is better.

It is quite likely with your story that at least one of your diagnoses was telogen effluvium that was triggered by the stress of December 2020. With your story, I think it’s really important that someone make sure that your seborrheic dermatitis is under good control and someone keep an eye on the possibility that a diffuse alopecia areata is not part of the reason for your shedding. I think that would be unlikely given that shedding has settled now and that the biopsy did not capture this.

With this one biopsy that you do have I can’t exclude that there is not some degree of androgenetic alopecia present. There certainly is a possibility with this information you’ve given. oOf course, I would need to see the scalp or a photo of your scalp myself to know for sure one way or another.

Please keep taking photos of your scalp to show your doctors. If you feel that your hair returns to full by September 2021 and you are really pleased with the way your hair looks and feels at that time, then it’s pretty unlikely there is any AGA. However, if your hair does not return to full by September, I would encourage you to further explore ways to confirm this diagnosis with certainty one way or another so that you might get connected with the correct treatment in the event you do have androgenic alopecia.

Thank you again for your question.

Do I just need patience or is my hair density not going to fully return?

Is my hair density going to return?

I’ve selected this question below for this week’s question of the week. It allows us to the review some key concepts in the diagnosis of hair loss in the early stages.

QUESTION

I am a 40 year old female. I have always had a lot of hair, and coarse hair. I have always been a shedder, but it never made a difference on how dense my hair was. Until now. I had my "normal to me" hair up until August/September 2020. But, in September/October, I started to see a lot more hair coming out in the shower/brushing afterwards/when blowdrying.

Handfuls would come out in the shower when in the shower. It was definitely the worst/at it's peak in November 2020.

I remember after one shower the entire wall was covered with the hair I collected. By this time I started to freak out a bit. It was definitely making a difference on my head now as far as density. I went to my family doc, and he did blood work. My ferritin came back at 21, but my hemoglobin was ok. I started taking iron supplements at the end of November. At the end of Jan 2021 I went to see a dermatologist. She only had a physical look at my scalp, did not do a biopsy and did not look at my scalp with any sort of magnifying tool or anything. She said based on my story she thought it was either Androgenetic Alopecia or Telogen Effluvium. She had my vitamin D tested. It was a bit low, so I started taking 2000IU of vitamin D daily. The hair shedding continued like this until end of February-ish/beginning of March. (The lost hair was mostly long hairs, some medium length, barely any short hairs)

In March/April 2021 the hair fall slowed down a lot, and now I would say it is back to a normal amount with each wash.

But, I can definitely see a difference on my head. It is most noticeable on the top/sides of my head, and down the back of my head (I have weird parts all along the back of my head). It also sort of looks like I lost hair at the nape of my neck. My part has not gotten wider at all, but sparser. I do have a lot of new growth at the top and back of my head, but it doesn't seem like enough to make a difference in terms of overall thickness, even when it grows longer.

My scalp hurts often, as if it has been in a super tight ponytail, even though it has not. Sort of hurts to move it around. My scalp can be quite dry/itchy at time (always has been like this, even before hair loss)

I am still taking iron supplements, as when I was re-tested in February my ferritin had only gone up to 30. I am also still taking the vitamin D daily. I should mention I take 2.5 or Ramipril daily.

My question is … would Androgenetic Alopecia happen that quickly and then taper off that quickly? And, if it is Telogen Effluvium would I expect to have more re-growth by now? Or, is there any chance I could have some sort of diffuse Alopecia Areata, based on what is happening at the nape of my neck and the weird parts down the back of my head? I have attached some photos. I am trying to be patient, as I know hair takes a long time to grow.

Thank you for your input!!

Image 1. Hair density in the central part.

Image 2: Hair density in the crown.

Image 3: Hair regrowth.

Image 4: Hair regrowth.

ANSWER

Thanks for the great question. The short answer is that many diagnoses are possible for you. I’ll get into these in just a moment.

I would need to see your scalp and know more about your full story to tell you which diagnosis (or diagnoses) you actually have…. but the 6 possibilities are outlined below. Each of these possibilities has different probabilities for being your actual diagnosis. If I was to see your scalp, these ‘estimated’ probabilities would change. However, with the information provided, we have six scenarios. The most likely is scenario 1 and 2 followed by scenario 3.

Six Possible Scenarios for Your Hair Loss

There are six possible scenarios for your hair loss. The most likely is scenario 1 and 2 followed by scenario 3.

Scenario 1) You have a telogen effluvium due to low iron or low vitamin D. This has now been fixed and you need to give it until October/November in order for your density is going to come back.

Scenario 2) You have a telogen effluvium for some other reason (other than simply low iron and vitamin D) and it has now somewhat resolved and you need to give it until Oct/November in order for your density is going to come back. Causes of telogen effluvium that could be relevant for you would include stress last summer 2020, low iron (which you might have), thyroid problems, medications started last summer, weight loss last summer, COVID infection last summer. Other causes are possible too.

Scenario 3) You have actually had a hint of subtle “subclinical” androgenetic alopecia for a while and this recent telogen effluvium has “unmasked” the subtle androgenetic alopecia. Your density is going to improve by the Fall 2021 now that your telogen effluvium is resolving but you might or might not get back all your density - but you may come pretty close.

Scenario 4) You have an inflammatory scalp condition that has been present for a while and is now acting up to give periods of hair shedding. The iron and vitamin D are unrelated in this particular scenario and are simply a true red herrings. Your inflammatory scalp condition has now settled again but you need to give it until November/December to see if things will fully settle. Such inflammatory condition could include seborrheic dermatitis, psoriasis, scarring alopecia or contact allergy (ie to some ingredient in a shampoo, conditioner, hairstyling product or dye). This scenario number 4 carries a risk of flare again.

Scenario 5) You have an inflammatory scalp condition that has been present for a while but it’s not enough to give hair loss. A new telogen effluvium has come along that will resolve and time will tell whether the inflammatory scalp condition also settles fully. If the inflammatory scalp condition is a low grade scarring alopecia, density won’t come back fully but still will improve to some degree when the current telogen effluvium resolves.

Scenario 6) You have an inflammatory scalp condition that has been present for a while but it’s not enough to give hair loss. You also have a subtle amount of androgenetic alopecia that has now been unmasked by the new telogen effluvium. If the inflammatory scalp condition or androgenetic alopecia is active enough it may prevent density from coming back to your full normal by Fall 2021. 

Detailed Review of the INITIAL Situation (August 2020 to Dec 2020)

Let’s go further into the situation that you describe in your question. Before we do, let me point out that there are three stages of hair loss for most people. At least that’s a helpful way that I view hair loss. These stages are important to appreciate because it impacts how I approach your question.

In “stage 1” of hair loss, the patient has hair loss but doesn’t really know it. For all practical purposes, the patient feels the hair looks the same as it always did and feels the same as it always did. Perhaps when they look at a photo from years gone by they might say something like “Wow, I can’t believe how much hair I had back then!” Otherwise stage 1 of hair loss is unrecognizable by anyone - patient, doctor, specialist or hairstylist.

In “stage 2” of hair loss, patients themselves realize they have hair loss - but others around them don’t believe it or don’t realize it. The patient feels the pony tail is smaller or the scalp is more see through or something is just not the same. A spouse, sister, parent, daughter, son, barber, hairstylist or friend usually say the same thing - “You’re exaggerating ! Everything looks fine to me! Sometimes that sentence is delivered by the doctor or other hair expert that has been asked to help.

Stage 2 is sometimes frustrating and lonely and anxiety provoking. Patients feel something is wrong but the world around them says repeatedly that everything is just fine.

Now, some patients in stage 2 resolve their hair loss and go back into stage 1 and so they do end up feeling they were exaggerating because everything resolves itself. Some patients stay in stage 2 and eventually find an answer to their hair loss issues. If specialist A does not believe them, they move on to specialist B. If specialist B does not believe them, they move on to specialist C.

Some patients in stage 2 do progress on to stage 3 of hair loss where hair loss becomes more noticeable to others. With hairstyling and camouflage a patient in stage 3 might still be able to hide their hair loss. With treatment of course, a patient may be able to return to stage 2 or even stage 1.

With these stages in mind, let’s delve a little further into this situation you have mentioned in your question.

There are two main scenarios that may have been present before you noticed hair loss in August. The first is that your hair density was completely normal and the same as it was when you were 20. You then lost hair in the August - December period and the density went down. In other words, you went from no hair loss to stage 2. This is shown below.

The second scenario is that you felt that your hair density was completely normal but it was not, in fact, completely the same as it was 20 years ago. You then lost hair in the August - December period and the density went down. In other words, you went from stage 1 of hair loss into stage 2. This is shown below

Both of these situations above would appear identical to you. In the first situation, you had normal hair to start and then you lost density. In the second situation, you had (what you thought was) normal hair to start and then you lost hair. The only difference is that in the second sitatution you actually didn’t have quite normal hair - it just seemed that way to you (and everyone else).

Detailed Review of the RECOVERY (April 2021 to Dec 2021).

Your hair loss is now in a recovery phase. Your shedding has stopped. You are sprouting hair everywhere!

Let’s spend some time looking at the recovery of your hair loss and how the hair might respond over the next few months. The most likely are the following 2 scenarios.

If you don’t have any underlying issues that are affecting how hair grows, then it’s likely that this telogen effluvium will continue to settle and a you’ll get a return to full growth by the end of the year. In other words, you’ll go from stage 2, into stage 1 and back to full hair. The chapter on hair loss will be closed

Even if you do have some kind of “subclinical” hair loss situation happening in your scalp, there is still a good chance that you’ll recover your density by the end of the year and you’ll return feeling that your hair feels ‘full’ to you. In other words, you’ll move from stage 2 into stage 1. Stage 1 of hair loss looks just as good of having no hair loss at all so for all practical purposes it does not matter.

What happens if my density does not recover by the end of the year?

The final scenario is a bit trickier to explain. If you did in fact have some sort of subclinical hair loss situation going on in the scalp before August 2020 and this condition got a little bit worse from August 2020 through summer 2021, then you might not find that you have a full recovery by the time the Fall 2021 comes around. This could be due to several situations including

a) you had some subclinical androgenetic alopecia prior to August 2020 and the androgenetic alopecia got a bit worse from August 2020 to August 2021.

b) you had some subclinical scarring alopecia prior to August 2020 and the scarring alopecia got a bit worse from August 2020 to August 2021.

c) you had some subclinical psoriasis or contact dermatitis prior to August 2020 and the inflammatory issues got a bit worse from August 2020 to August 2021.

In these situations, it’s possible you stay in stage 2.

This final scenario is the least likely but a proper scalp examination and full review of your story is going to help me decide just how likely it is in your specific situation. For now, I estimate it as unlikely (but not zero).

What you can see here in these examples above is that you really need some definite diagnoses. If you allow time to help you with a solid diagnosis then that’s one good strategy. For example, if your density comes back perfectly to normal by the end of the year, then there’s probably no real hair issues at all that need treating or need any kind of workup. In other words, if your density returns back to full by December 2020 (and you enter stage 1 or no hair loss), it’s pretty unlikely there’s any other hair loss issue going on.

But if density does not return, I strongly believe that you need to have some formal diagnoses put on paper for BOTH the hair loss and the scalp symptoms. The reason we need different diagnoses is because every hair loss condition is treated differently. Unless we have a diagnosis, we can’t formulate the right treatment plan.

My Final Comments

Thanks again for the great question.

I’m really glad you are seeing all this hair growth sprouting everywhere as it’s a really good sign. The hairs are about 5-6 cm so it seems that the telogen effluvium you had in Aug/Sept 2020 is settling down. It could be that the iron and/or vitamin D is helping or that could just be a coincidence. It’s difficult to prove.

I do feel your scalp symptoms (dry, itchy, hurts to move) needs a formal diagnosis. Your scalp symptoms need a name of some kind. Now, keep in mind that the diagnosis of that situation might not be anything concerning given how long you have had it, but it still needs a formal diagnosis. If nobody is sure of what to call your itching and soreness, then you need a scalp biopsy. That is pretty clear in my mind. There is flaking present in some of your photos so there is some kind of inflammatory issue present. I would need to see the scalp up close to give a diagnosis. Please be sure to follow up on that.

I am glad you are taking photos as that will be key over the next 6 months. If you feel by November/December 2021 that you are really happy with your hair and how the density has returned, then this chapter of your hair story is likely done: you had a telogen effluvium and it resolved. It went away. In this situation, it’s unlikely there is some subclinical androgenetic alopecia present but it does not really matter much. I wouldn’t treat hair loss if you go back to feeling good about your hair. I’d simply repeat photos in 1 year. Put the shedding episode behind you for now.

If your density does not return to normal by the end of the year, then there is a good chance that there is some androgenetic alopecia that has entered the picture. No, it’s not 100% but that becomes increasingly likely. There’s very small chance that another diagnosis besides androgenetic alopecia is responsible but that’s pretty rare. Of course, the itching and tender issues on your scalp need to be diagnosed properly. That may or may not have any role here. But someone needs to give it a name.

But if you are pleased with your density in November/December 2021 and your shedding is completely back to normal (and stays normal), and your scalp symptoms are not worrisome to you and your doctors …I would put it all to rest and simply take a photos again in 1 year. It’s helpful to have your doctors follow you closely but nobody really knows their hair better than you. If you feel your hair has not returned back to normal, then you have remained in stage 2 and need a solid convincing diagnosis.

I hope this helps.

Many thanks for the question.

Increased Shedding: Should I start treatment for Male Pattern Balding?

Does increased shedding indicate that a male should start finasteride?

I’ve selected this question below for this week’s question of the week. It allows us to the review the diagnosis and work up of increased hair shedding in males.

QUESTION

I am a male, 30 years old who has been monitoring his hair for quite some time as I don't want to lose my hair to androgenetic alopecia (AGA). I have been counting the hairs that I shed in the shower since around 2016. Since I have usually midlength to long curly hair I stretch out the days I wash my hair, otherwise it gets dry. I have always shed around 210/220 hairs when showering every third day. This has increased to 280 since a few weeks now.

Since I said every third day this means the average on a day was: 210/3=70 . Now it has become 280/3=93 a day, for the last month or so. I know that 100 hairs a day is normal, but considering that the number I was shedding was consistently around 70 for years I am a little worried. The majority of the shed hairs look healthy and thick and long. My hairline, crown and density are still the same. Could this be temporary and could the shedding go down within the next few months?

When should I start finasteride? As soon as I see recession / lessening in density / thinning?

In short, is a little increase in shedding a reason to go on treatment?

ANSWER

Thanks for submitting this question.

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

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. I don’t have a full story in your case and I don’t have photos (or a chance to examine the scalp) and I don’t have the opportunity to review any tests …. so I am limited to some degree in my helpfulness. Nevertheless, I do think the discussion here will be helpful.

The main phenomenon you are describing is increase shedding. You have gone from 70 hairs per day of shedding to 93 hairs per day . Although both are considered within the realm of normal, I would agree that in your case this likely represents a true increase in shedding. This does not necessarily mean that this will be long term shedding or that it will actually translate into a loss of hair density or thickness. There are some unknowns here.

There are 3 potential considerations for why you are shedding more hair in the last month:

a) a telogen effluvium has occurred

b) the initiation of androgenetic hair loss has taken place

c) an autoimmune mimicker of telogen effluvium is present rather than telogen effluvium

d) combination of the above

Let’s take a look at these in more detail.

a) Is this a true telogen effluvium and if so what is the cause?

It’s quite possible that you are having a minor telogen effluvium. Hair shedding does not need to be over 100 hairs per day to have a telogen effluvium - it just needs to be more than one’s original shedding rates. If a person shed 38 hairs per day before and now sheds 68 - it’s abnormal. In your case, your shedding from 70 to 93 is abnormal. Of course, there is a big difference between something being abnormal and something being serious. Your hair shedding may not be serious and might only be temporary. We’ll get to that in moment. But this shedding suggests a potential diagnosis of telogen effluvium. As we’ve reviewed in the list above, a diagnosis of telogen effluvium is not the only cause of shedding. So it would be a mistake to assume otherwise.

A variety of ‘triggers’ are responsible for telogen effluvium. These triggers include stress, low ferritin levels, thyroid problems, medications, weight loss, seborrheic dermatitis, scalp psoriasis, immunizations, infections and internal illness inside the body.

You and your doctors really need to go through each of these potential triggers step by step very carefully to see if anything fits with your story. If your shedding started at the beginning of April, then you’ll want to go back to January or February (2-3 months prior) and ask yourself if something changed in your life. If this is a telogen effluvium, that’s probably when the body felt some sort of a trigger.

So, you and your doctors will want to evaluate that answers to the following

1) Did you experience higher stress levels in January or February?

Stress in January can trigger shedding 8-12 weeks later.

2) Did levels of any of your key blood test parameters change in January or February?

Clearly, blood tests are going to be needed if you really want to get to the bottom of why you are shedding more. There are over 75 blood test abnormalities that can trigger shedding. Fortunately, most of those 75 are rare and we don’t go about even ordering them. The ones we mainly check are iron (ferritin levels) and thyroid (TSH test) along with basic hemoglobin level and 25 hydroxy vitamin D level. However, your doctor will need to review your story from start to finish and examine your scalp and ideally perform aa physical examination too. If there’s anything that crops up as a concern, more blood tests besides just ferritin and TSH might be needed. For example, patient who has lost 25 pounds in 2 months and has no idea why they are losing so much weight is likely going to need an extensive work up.

3) Did you start any new medication or vitamin or supplement in January or February?

Starting medications can sometimes be a trigger - and the same is true for some supplements, herbal medications, teas, and vitamins. This all needed to be reviewed.

4) Did you stop any sort of medication or vitamin in January or February?

Stopping medications can sometimes be a trigger - and the same is true for some supplements, herbs, teas, vitamins. This all needed to be reviewed. In addition to stopping medications. sometimes even changing brands can be an issue. For some people, a change in drug A from brand name to generic is enough to trigger a shed. You can see that we’re going to need aa pretty detailed understanding of what’s been happening in your life to determine why you area shedding.

5) Did you receive any sort of immunization in January or February?

Immunizations are not common causes of shedding but that does not mean they are not on the list. Immunizations of all kinds have a slight chance to trigger some temporary shedding. COVID vaccination rarely does too. I don’t know if you received a vaccine or not, but your doctors will need to review this carefully. If you were vaccinated in January or February, it most certainly could give a shed now. Fortunately, it’s pretty rare - but we’ve seen it.

6) Did you get any kind of infection in January or February?

Infections of any kind can trigger shedding. Granted, severe infections associated with someone being quite ill are more likely overall to trigger shedding than less severe infections. But even minor infections can trigger shedding. Tooth infections, flus, COVID 19, all can trigger shedding. Many patients who have been infected with COVID 19 do not even know they had COVID 19 but some still get shedding. In fact, about 10 % of patents with hair shedding due to COVID 19 didn’t really have any COVID 19 symptoms. You and your doctors are going to want to evaluate that carefully and whether there is any possibility of an asymptomatic COVID 19 infection happened in January or February. Antibody tests can help address this question in some patients.

Other infections may also be relevant to ask about. Again, over 300 infections can cause shedding but most of the time, none are all that relevant for the patent in front of the doctor. But a variety of bacterial, viral, protozoal infections can cause shedding. In some of my patients from outside of North America, Dengue fever (spread by dense virus) is a common cause of shedding. There are estimated to be 390 million Dengue viral infections every year in the world. Sometimes we test for infections like HIV and syphilis in patients with risk factor who have chronic shedding. So depending on your story, more broad testing could be needed. For most people, we don’t need much in the way to these sorts of tests.

7) Did you develop any kind of illness inside my body in January or February?

Any illnesses inside the body can trigger shedding. Most often these are illnesses that a significant impact on the body. For example, an illness that causes diarrhea or a bad cough or an intensively sore joint that affects the motion in the joint all have the potential to cause shedding.

8) Did you have any kind of surgery or procedure in January or February?

Any proper evaluation for shedding examines whether or not the patient had any type of surgery or hospitalization in the months leading up to the shedding. Medications used in surgery, blood loss during surgery are well known triggers of telogen effluvium.

In summary, you can see that if you want to get to the bottom of what is happening with your hair, you are going to need a proper history and examination and you are going to need blood tests. Whether you get blood tests now or simply wait a month or two if things don’t improve is a clinical decision that is left to you and your doctors. But the only way right now to be sure that an abnormality in some blood test is not the reason why your shedding went from 70 to 93 is to order these blood tests.

Three Important Patterns of Telogen Effluvium

Before we leave the concept of telogen effluvium, it’s important to mention a few more points regarding the patterns of shedding that you might see. There are a few scenarios that might happen. If the diagnosis of your hair shedding is telogen effluvium and there is some well defined trigger that happened to you in January or February and then went away you will have some shedding in April through July but then the months of August September and October will be associated with less shedding and things should return to normal by November or December (assuming you don’t have genetic hair loss). If you do have genetic hair loss, that’s a bit of a different story as patients who are en route to slowly developing genetic hair loss may not find there shedding goes back completely to normal once the trigger of the telogen effluvium is fixed. We say in this case that the TE precipitated or unmasked an androgenetic hair loss.

Let’s take a look at scenario 2 now. If the diagnosis of your hair shedding is telogen effluvium and there is some well defined trigger that happened to you in January or February but is not going to end up being fixed until July then you will have a bit more prolonged shedding. This could be a scenario whereby an individual went on a diet from January to July or had intense stress from January to July or developed a thyroid problem in January and could not get into the doctor until July to get it fixed. If scenario 2 applies in your case, you will not slow your shedding quite as quickly. You will have some shedding in April through July but then the months of August September and October will be associated with less shedding and things should return to normal by November or December (assuming you don’t have genetic hair loss). If you do have genetic hair loss, that’s a bit of a different story as patients who are en route to slowly developing genetic hair loss may not find there shedding goes back completely to normal once the trigger of the telogen effluvium is fixed.

Let’s take a look at scenario 3 now. If the diagnosis of your hair shedding is telogen effluvium and there is some well defined trigger that happened to you in January or February but it simply goes unfixed then you will have a prolonged shedding and it’s not going to stop. This could be a scenario whereby an individual developed a chronic illness like inflammatory bowel disease in January and does not get connected with the right treatment because either the diagnosis has not yet been even uncovered or the medications are not working. Another example would be a patient who experience high stress starting January because they are caring for a terminal ill member of the family and the stress just continued to run high. Another example is patient who develops an unknown chronic illness in January but just can’t get the right diagnosis and shedding just goes on and on because the issue is not addressed.

If scenario 3 applies in your case, you will not slow your shedding at all until the problem is fixed. You will have some increased shedding starting in April but then it will persist. Only when the trigger actually gets fixed will you shedding resolve.

b) Is this the start of androgenetic hair loss?

You are very wise to consider the possibility that your increased shedding is actually a reflection of androgenetic alopecia arriving on the scene. Very wise. More hair specialists and patients need to get into the frame of mind that hair shedding means potentially so much more than simply a diagnosis of telogen effluvium. What’s the most likely cause of chronically increased shedding in a healthy 30 year old male with normal blood tests? Androgenetic alopecia is the answer.

Now, are you a 30 year old male with chronically increased hair shedding and normal blood tests? No, you are not. You are a 30 year old male with acutely increased shedding (just a few weeks so far) and I have no idea what your blood tests show.

So you could have the early stages of endogenetic alopecia and this diagnosis becomes more and more likely if your shedding does not reduce as time goes on and more and more likely if all your blood tests come back normal.

Is now the right time to start finasteride?

You have asked a great question - is now the right time to start finasteride? In my opinion, a male should only every consider finasteride if five conditions are met. Interested readers can read more about these in a previous article that I wrote last year.

Criteria 1: The individual has a proven (confirmed) diagnosis androgenetic alopecia

Criteria 2: The individual does not have any contraindications to finasteride

Criteria 3: The individual accepts the potential side effect profile of this drug

Criteria 4: The individual has considered the other treatment options but feels they are not better than finasteride as a starting point (topical minoxidil, oral minoxidil, laser, PRP)

Criteria 5: The individual plans to use the medication lifelong.

A little bit of shedding that is due to AGA is certainly a reason to consider starting treatment but it does not necessarily mean it has to be with oral finasteride. It could be topical minoxidil, topical finasteride, laser or PRP . There’s nothing wrong with being conservative in the early stages and seeing if the AGA can be halted with minimal coaxing.

Before leaving the topic, let me reiterate how important criteria one actually is. If you had some major stress in January or February and telogen effluvium is actually the cause of your shedding rather than a diagnosis of androgenetic alopecia, starting finasteride would not be the right step, If you are shedding 93 hairs because your diet is poor and you have a micronutrient deficiency, starting finasteride is not the right step, However, fixing the diet or starting a vitamin in the meantime would be .

c) Is this a mimicker of telogen effluvium ?

There are many conditions that look like telogen effluvium, sound like telogen effluvium but aren’t telogen effluvium. Unfortunately, they can be tough to spot for even clinicians. Fortunately, they are not common. Alopecia areata incognito is not common but presents with shedding. Trichoscopy is needed for the diagnosis (or a biopsy). It’s usually not so perfectly symmetrical as seen with AGA but it can be of course. It responds to topical steroids and Rogaine. Lichen planopilaris and folliculitis decalvans are scarring alopecias that can mimic AGA in some cases. They generally have associated itching, burning or scalp tenderness. Some patients have all three symptoms and some have only two and some have no symptoms at all .

The other common mimicker of classic TE is seborrheic dermatitis and scalp psoriasis. These are common in the population so every hair specialist needs to know everything there is to know about scalp seborrheic dermatitis and scalp psoriasis because these are common concerns. . About 5-10 % of people have seborrheic dermatitis and 2-3 % of all people have psoriasis. In mild cases, seborrheic dermatitis and psoriasis don’t give much in the way of shedding. In moderate to severe cases, they most certainly do. These can mimic a telogen effluvium.

Conclusion

Thanks again for your great question. I hope this helped.

In summary, it’s likely your shedding is abnormal but it could be temporary. A full exam together with review of your story and completion of some key blood tests would be part of an ideal plan. Taking photos every 3 months is probably the most helpful thing you can do for yourself. If your shedding settles but density seems to be dropping off it’s likely there is some AGA present and starting one of the treatments is a good idea if your goal is to halt hair loss. If your shedding stabilizes in the next few months and density stays high, watchful waiting is probably the way to go. This later situation probably means you had some form of telogen effluvium.

Do I have AGA? Everything thinks I am Crazy!

Why am I losing hair ?

I’ve selected this question below for this week’s question of the week. It allows us to discuss the diagnosis of hair loss in the early stages and the use of the 5 day modified hair wash test.

QUESTION

Dear Doctor Donovan,

I'm a 27 year old female. I've seen a lot of dermatologists over the years but none of them could solve my problem and I'm desperate!! It's been three years that I'm losing hair. It started during a stressful period in 2018 with a significant amount of shedding (300-400 hair a day).

The shedding stopped for 4 months and then the shedding started again until now. The only thing I noticed during these years is that hair loss is focused on the side of the head and temples and hair always grows back, even if I have less. The dermatologists have all said the diagnosis is telogen effluvium or chronic telogen effluvium (CTE) because in their opinion I still have a lot of hair and no miniaturized hair (but I can see them!)

In 2019 I decided to starting using minoxidil 2% because I was losing my mind and I was scared to go bald. My mother uses it for AGA. I suffer from hypothyroidism, I have regular periods but low levels of ferritin. I'm also losing hair in different lengths (short, long, thick, thin).

I am afraid I have AGA. Nobody believes me and they think I'm crazy!.

Thank you very much for listening.

ANSWER

Thanks for submitting this very interesting question.

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

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. I don’t have a full story and I only have a trichoscopy photos from one area and I don’t have the opportunity to review all tests …. so I am limited to some degree in my helpfulness. Nevertheless, I do think the discussion here will be helpful.

In the early stages of hair loss, nobody can tell you have hair loss. So, when people tell you they think your hair looks normal, they are being honest. You know you hair the best.

What are the Most Likely Diagnoses in this Case?

We are deciding here between three situations:

1) Do you have androgenetic alopecia (AGA) and telogen effluvium (TE) ?

or

2) do you have telogen effluvium (TE) only ?

or

3) Do you have both of these conditions?

I think there is little doubt in your story that telogen effluvium has been present at some time in the past. Whether it is still present NOW (today) is a bit more challenging to say as we will see in a while. I will explain in a moment how we can better distinguish between the two diagnoses.

It’s fairly unlikely that other diagnoses like alopecia areata incognito are present this long and similarly the photos don’t really lead me to believe we’ve dealing with other diagnoses. Of course, a full examination can confidently exclude that. But it’s unlikely.

What do I see in the photos?

The photos seem to show less density ‘now’ compared to 2018. This simply tells me you have some type of hair loss. It’s true that the part width is wider in these photos but without a sense of the part width in the back (to compare to part width in the front) it would be a mistake to conclude that this widened part width equates to AGA. The temples have some subtle changes but we see these minor changes in AGA and TE. The changes in the temples do not allow me to determine the diagnosis.

The trichoscopic images you have included here are great quality. However, I don ’t know where on the scalp they are from. It’s really important when fully interpreting trchoscopy to know where the images are from.

Trichoscopy IMAGE 1

The top image appears pretty normal. Is it from the back of the scalp from more posterior regions on the head? Hairs in the first image are grouped in groups of 3 and 4 hairs. There are really no single hairs. There is slight variation in caliber of hairs but this is just a few percent that show this. It is nowhere near the 10-20 % variation in caliber of hairs that’s needed to make a diagnosis of AGA. There are no upright regrowing hair seen. The scalp is pretty healthy other than than some minor redness.. There is a bit of scale but that’s what a scalp looks like.

Trichoscopy IMAGE 2

The second image is different than the first which makes it important to know where exactly where it’s taken from. Whenever we interpret trichosocpy we need to know where it’s taken from or else we can’t say all that much. What stands out to me in image 2 is that it’s slightly different than image 1. This could be important but again I would need to know where on the scalp it is from. There are more single hairs seen in image 2 and the density is subtly less compared with image 1. If image 2 was from the front of the scalp and image 1 was from the back I’d be of the opinion that there was at least some good evidence for androgenetic alopecia. But I don’t know where these were taken from so I can’t say very much. However, the fact that the two images look slightly different makes me wonder about pattered hair loss - the most common being andrgoenetic hair loss.

Key Questions I Would Want to Know and Why I Would Need this Information

There is lots more to your story that I need to know if order to help determine the diagnosis in a convincing way. We need to determine if there is evidence for androgenetic alopecia and we need to determine if there is evidence for a telogen effluvium. I would want to know the answers to the following questions::

PART 1: IS THERE EVIDENCE TO SUPPORT A DIAGNOSIS OF ANDROGENETIC ALOPECIA?

Q1. Where does it feel the thinnest?

It would be helpful to know from your perspective where the hair feels the thinnest. Does it simply feel thinner “all over” (diffusely) or does one area of the scalp feel more than another? Most patients with classic TE feel that the hair is thinner all over and can’t usually point to a single area that is thinner (EXCEPT maybe the temples). In AGA, the central scalp often feels a bit thinner although some women do have a diffuse pattern or loss.

Q2. Is the part width similar in the back of the scalp as it is in the front of the scalp?

Why do I need to know? Le't’s talk now about the physical examination of the scalp and the steps your doctors would take when examining the scalp. it’s critical to know if the part width in the frontal region is the same as in the back or whether it’s different. You’ve shown a very good photo of your central part in the FRONT which allows me to see that there is more hair loss than 2018. However, what I am not able to tell now is what the part in the BACK OF THE SCALP looks like. If it’s quite similar “width” to the frontal region, that’s not really very supportive of AGA and is more supportive of TE. However, it it’s clear that you have lost more hair in the frontal region that would be more consistent with androgenetic alopecia.

Q3. What was the exact timing of starting minoxidil ?

Why do I need to know? There is evidence of regrowth on the scalp. As I see in the photos, there is considerable growth of 12-15 cm hairs which means that these hairs in the middle of the scalp started growing well about 1 to 1.5 years year ago. It would be helpful to know if this is where minoxidil was applied and if it was late 2019 rather than early 2019 that minoxidil was started.

Q4. Is that 12-15 cm regrowth seen just in the middle of the scalp or is that seen everywhere equally.

Why do I need to know? When your doctors examine the scalp, it’s going to be really important to determine if this growth of these hairs is truly everywhere or just I the central scalp where I imagine you would be applying minoxidil. If the hair regrowth is just central and these 12-15 cm hairs are not found so easily in the back of the scalp, then it’s more suggestive of an early androgenetic alopecia that is present that is responding well to minoxidil.

Q5. Is the hair density today less than 1 year ago or about the same as one year ago?

One of the most important questions in this case is whether or not you are still losing hair density. Here I am not referring to shedding but rather density and how thick your hair feels overall. Is it less thick? …. or just as thick as it used to be. I understand that you are still shedding but that is a bit different from whether you are still losing density. If you are still losing density and you feel that you have less hair on your scalp today than 1 year ago, that would be slightly more suggestive of possible AGA than TE. If you are still having problems with shedding but don’t actually feel your density is getting less and less, then TE still remains a very likely diagnosis.

Q6. Do you have acne or excessive hair growth elsewhere?

As we evaluate hair loss, it important to get a sense if there are clinical signs of hyperandrogenism (high androgens). Having hyperandrogenism does not necessarily mean the patient has AGA but does increase the odds just that much more.

Acne and hirsutism are two of the more important signs to enquire about. If there is any clinical evidence of hyperandrogenism, it will be important to have blood tests for testosterone and DHEAS. Only 10 % of women with AGA have hyperandrogenism so the finding of normal hormone levels still makes AGA possible. In addition, many women with hyperandrogenism do not have AGA at all so this is just a fact that gets considered as part of the bigger picture.

PART 2: IS THERE EVIDENCE TO SUPPORT A DIAGNOSIS OF ONGOING TELOGEN EFFLUVIUM?
It’s clear that a telogen effluvium was present in the past for you. The key question now is whether there is some kind of ongoing TE. The causes of telogen effluvium include stress, low iron, thyroid problems, medications, diets, systemic illness. So we need to understand more about these potential issues or ‘triggers’ for anyone who is shedding. In CTE, shedding can occur without a clear trigger.

Q7. Did you start and stop other medications or supplements?

Why do I need to know? Other medications and supplements can trigger shedding. Even taking some medications and herbal medications can give an ongoing shedding. I’m assuming in this scenario that minoxidil is the only product used. Clearly, if other products are used they need to be considered.

Q8. Have you had eyebrow changes, eyelashes changes, body hair changes, nail changes?

Why do I need to know? Eyebrow and eyelash changes and body hair changes don’t occur as part of AGA but can occur in TE. They can also occur in other immune based conditions. I am not suspecting any immune based issues but certainly it would be quite unexpected if you were experiencing a lot of body hair loss. If there was any eyebrow or eyelash loss, the key is to figure out if it affects both the right and left side symmetrically or whether one side is affected more. Eyebrows and eyelashes can reduce in density from telogen effluvium, alopecia areata, trichotillomania, seborrheic dermatitis as well as cicatricial alopecia (and other conditions). It would not be surprising if you have some minor eyebrow changes over the last 3 years but it should be quite symmetrical. If you do have eyebrow changes, some of the eyebrow changes could be due to the hypothyroidism.

Similarly, if there was an increase in body hair this too would be unexpected here and a possible sign of increased androgens. Increased hair on the thighs, abdomen and nipples can be a sign of hyperandrogenism and raise suspicions for PCOS (even if periods are regular). I would think that it issei's quite unlikely you would report this to be the case. This would be information that your doctors should confirm.

Q9. Have you had weight loss or weight gain? What is the current weight?

In the setting of a likely telogen effluvium, it’s important to know whether there has been weight loss that could be triggering a telogen effluvium. In addition, we need to make sure that your current weight is high enough (i.e. BMI is above 18) otherwise the result can be an ongoing TE from poor nutritional status.

In addition, weight loss and weight gain can be reflective of underlying medical conditions. So, if weight has fluctuated either way, it could be important.

Q10. Do you have any scalp itching, burning or tenderness?

Scalp symptoms are important to know for every single patient. Your scalp looks quite healthy so I would be surprised to learn there is any itching or burning or tenderness. I’m usually not too worried about a slight among of itching from time to time, but if there was burning or tenderness in the scalp, that would be worrisome. I don’t think this is very likely to be relevant here for your case but we need to always keep in mind that there are conditions that mimic telogen effluvium.

Q11. Do you feel you are getting hair breakage?

I am not appreciating much in the way of hair breakage, but it’s important to inquire about. Some patients confuse hair breakage with actual new growth so what you are seeing on the top of the scalp appears to be new growth. It’s not uncommon for patients to exclaim - “look at all my hair breakage!” In your case, this is not breakage from what I can see. However, if you felt there truly was increased breakage that would need further exploration. Breakage can come from heat and chemicals and can give the feeling of ongoing shedding and loss. A proper examination can completely exclude breakage, but I would be surprised if that’s even an issue here. your scalp and hair are healthy.

Q12. How low your ferritin dropped over this period ?

I understand that you have a history of low ferritin. It will be important to know what your ferritin level is right NOW. That is what will be relevant to ongoing shedding. A ferritin of 10 is likely associated with hair loss. A ferritin of 40 is probably not. Therefore, it will be important to know what the ferritin level is now and how it’s been changing over the last few years.

is it possible you’ve had a ferritin of 22 and it’s been responsible for your shedding for three years? Perhaps. The higher your ferritin level - the less likely it is that your iron is the culprit in your hair loss. But you have not given me the number so I don’t know the current level.

Certainly, if you have a ferritin less than 15, it’s probably a problem and probably one of the reasons why your hair is shedding. Taking iron supplements in these situations has a high likelihood of helping. However if your ferritin is currently 40, 50 or 60, it’s less likely that you currently have an iron problem.

Most women need ferritin levels in the 30-40 range for healthy hair. However, some women definitely need those levels to be higher than that and into the 50 - 70 range. If you have a history of low ferritin, it will be important for your doctors to review why you have low ferritin and how the levels have been changing over time and what they are now. Many women have low ferritin levels. However, when low ferritin is combined with low hemoglobin (which we call iron deficiency anemia) I’m much more concerned. Excessive bleeding from menstrual cycles, poor diet, celiac disease, gastrointestinal issues all need to be explored.

The following table gives an estimate of how likely it is that taking iron supplements will help your hair according to the ferritin levels.

Q13. When did you start thyroid medications? Have your thyroid levels (TSH) changed during this time? What is the exact reason for the thyroid disease (Is it autoimmune Hashimoto’s?)

It would be helpful to understand when your thyroid disease was diagnosed and whether the TSH has been changing over this period. Some patients occasionally have fluctuation TSH levels which give shedding. Also, it would be important to know if you are on thyroid medications NOW and when this started and whether the dose has been changing over time. It is important to know the exact causes of the thyroid disease.

Q14. Were your periods always regular?

It’s always reassuring to know that your periods are regular at the present time. It would be important to know if they have always been regular of whether they have become regular just recently. It would be important to know exactly what each patient means by regular periods. Are some cycles considerably longer and some shorter than others? Having regular periods does not make it impossible to have an endocrine issue but does make it less likely. Having regular periods does not necessary mean these are ovulatory cycles but for most women they, of course, are. ovoluatory cycles.

Q15. Has your density ever come back to normal or has it just become less and less?

It would be important to know whether you feel your density and thickness ever came back to normal. When the shedding stopped for four months, did density return? Do you know the reasons why the shedding stopped for those 4 months? Was it that your iron levels finally came up? Was it that that your thyroid levels were brought back to normal? Was it that stress was reduced? Was that the period that minoxidil was started?

If your density did return completely to normal, this makes AGA much less likely during those times. It does not mean that it could not have happened or developed later but we would not expect your density to come back to 100 % normal in the setting of AGA.

Q16. Do you have other symptoms like joint pains, headaches, fatigue or rashes?

In situations like this, it’s helpful to know if the patient has any other symptoms that could suggest a systemic cause for a telogen effluvium. Issues like going pains, chronic headache, unusual fatigue or rashes on the body could prompt further work up and evaluation.

Q17. What other conditions run in the family?

it’s helpful to know what conditions run in your family. I understand your mom uses minoxidil so that tells me there is a family history of AGA. It’s helpful to know what the hair density is like in other males and females in your family. It’s also helpful to know what other diseases or medical conditions run in the family. These would include issues like psoriasis, lupus, inflammatory bowel diseases, arthritis, alopecia areata, diabetes, multiple sclerosis, early menopause, infertility and polycystic ovarian syndrome.

What Would I Recommend Next?

1. The answers to these questions above are going to be helpful and so is an evaluation of the frontal part width and back part width. That could be really informative in this case. If the part is wider in the frontal regions than the back, this suggests a possible diagnosis of AGA. If not, it still could be but TE becomes more likely.

2. Comparative trichoscopy of the middle of your scalp compared to the back of your scalp is going to be very very helpful in reaching the proper diagnosis. If the two are really different with more single hairs in the frontal and more variation in caliber noted in the frontal regions, then AGA becomes a likely diagnosis.

3. Current blood tests from ferritin and TSH and CBC are going to be important. I suspect you’ve had these tests done many times. If your ferritin is not high enough, it could be that you are shedding chronically in part from iron deficiency. The history will guide if other blood tests are helpful.

4. Finally, 5 day modified hair wash test (MHWT) is likely going to be the most helpful and least invasive next steps. Of course, a scalp biopsy can also be done but I think a modified hair wash test is probably going to be better in this case. The five day MHWT is fairly easy to do and you can do it yourself at home if you are so motivated to do so. The hair must not be washed for five days before doing the test. A 5 day modified hair wash test (MHWT) is a standardized means of assessing and quantifying hair shedding and provides information on the type of hairs being shed. It is a non-invasive method to measure hair loss by counting and identifying rinsed out (shampooed) hairs. To begin the test, a gauze is placed in the sink and hair is shampooed normally and the hair is rinsed in order to collect and trap all shed hairs on the gauze. The hair can be shampooed and rinsed repeatedly in order to remove all hairs that need to come out.

The following is helpful diagram illustrating the key steps in the 5 day hair collection.

After gently lifting the gauze from the sink, the gauze is then dried for 3 days and then counted. In our clinic, patients who do this test mail the hairs to us, but patients can also go about counting hair. It is important that the gauze not be disturbed while drying or mailing as this gauze has dozens of small fine barely detectable hairs that must be included in the analysis. The final number of hairs as well as the proportions of 3 cm or less hairs, provides information on the relative proportions of androgenetic alopecia as well as telogen effluvium.  The proportion of broken hairs and the proportion of abnormal hair gives us a sense of the possibility of an autoimmune issue such as diffuse alopecia areata. 

The number of hairs collected in the MHWT can give a good sense of excessive shedding. Ideally, results need to be interpreted by a dermatologist who is familiar with the performance and interpretation of this test but as mentioned patients can count hairs.

a) Patients with 10% or more of hairs 3 cm or shorter and who shed fewer than 100 hairs are diagnosed as having androgenetic alopecia (AGA).

b) Patients with fewer than 10% of hairs that were 3 cm or shorter and who shed at least 100 hairs are diagnosed as having chronic telogen effluvium (CTE).

c) Patients with 10% or more of hairs that were 3 cm or shorter and who shed at least 100 hairs are diagnosed as having AGA + CTE

d) Finally patients with fewer than 10% of hairs that were 3 cm or shorter and who shed fewer than 100 hairs are diagnosed as having CTE ‘in remission.’

Final Summary

Thanks again for sending in your question. I hope this was helpful. A few more details in this history together with a good scalp examination is going to go a long long way here in getting to the correct diagnosis (or diagnoses in the event there are two).

IFor you, I think that a 5 day modified hair wash test is going to really help give the evidence that you need to move forward with the right diagnosis. If there is any doubt, then a biopsy could further clarify but I doubt it will be needed.

The use of minoxidil could complicate things a bit in this case but only slightly. If one were to stop minoxidil and find that significantly worse shedding happens 4-6 weeks later I do think this would also be proof of some component of AGA being present.

What is the reason for my hair loss?

Why am I shedding ?

I’ve selected this question below for this week’s question of the week. It allows us to discuss shedding issues in women with hair loss.

QUESTION

Hi!

I am a 42 year old women and have been shedding about 200 hairs a day since March, 2020. I have seen 4 dermatologists and my General Practitioner and they have different diagnoses from TE to FPHL or a combination of both. Prior to March, 2020 I was under extreme stress which started in November 2019. In March 2020 my hair loss was sudden and I have had diffuse shedding since then for the past 10 months. I have always had full, thick and healthy hair and no issues with my hair until the past 10 months. There is no family history of hair loss and my bloodwork came out normal.

Increased hair shedding.

I have been taking vitamins, biotin and Lysine (since June 2020) daily. I am washing my hair every other day, air dry my hair and do not use styling or heating products and eat healthy. I am also taking spirolactone since December 2020 (one month as of today). My dermatologist suggested I take spirolactone (50 mg twice a day) because I have irregular periods. My hair loss slowed down in September 2020 to about 100 hairs a day and went back up to 200 plus in November 2020. I am experiencing itchiness, pins and needles sensation on my scalp and my hair texture changed from straight to wavy for the past 10 months. My hair is also now flat, dull and I have some dandruff that comes and goes. My middle part is widening (compared to pre-March 2020 before the shedding) and with the ongoing shed the part has somewhat looked the same since March.

I lost about 30% of my hair and cannot style it the way I used to because of the thinning in the front. The last two dermatologists I saw performed a pull test and scalp examination and one of them said it is CTE and that there is nothing I can do but wait it out. The other doctor said it's FPHL and that she can tell just by looking at the front of my hair because of the way its thinning. I do see hair growth and my hair is full of static with short hairs coming out but I am also losing a lot of hair in all different lengths including short ones every day. I am frustrated because it has been 10 months and my shedding is not stopping. I do not know which diagnosis is right and what treatment I should start. Also It would be great for the itching and "pins and needle" feeling on my scalp to go away...

Thank you for reading and I'm so happy to find this website.

ANSWER

Thanks for the question.

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

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.

There is lots more to your story that I need. I would want to know exactly what your lab tests showed and which ones were tested. In about 20 % of patients who tell me they had blood tests and all came out normal, the labs are either insufficient (more are needed based on their story and examination) or the labs are not in fact really normal. I always like to see the labs. I would want to know about other symptoms like joint pains, headaches, fatigue, weight loss, eyebrow changes, eyelashes changes, body hair changes, nail changes, and rashes.

I strongly suspect that androgenetic alopecia with seborrheic dermatitis are part of the diagnoses. The 2 key questions here in your case are:

1. Do you have really have telogen effluvium as well ?

2. What really is the reason for the ‘pins and needles’ sensation ?

Let’s look at a few key points.

POINT 1. Androgenetic alopecia (female pattern hair loss) appears to be at least one of the diagnoses.

I do think that at least one of the diagnoses here is androgenetic alopecia (also called female pattern hair loss, FPHL). The widening of the part does not itself mean the diagnosis is AGA. however, the pattern of the part widening is not the same front to back. There is a slight increase in thinning noted in the mid scalp and crown compared to the frontal one third of the scalp. This leads me to believe there is a patterned nature of the hair loss. I’m open to the possibility that some of the hair loss is diffuse in nature (ie all over) but some is likely not. In other words, I don’t think this is entirely a diffuse type of hair loss.

Also, when I look up close at the images, it’s clear that some follicles are thinner than others. This is a phenomenon called anisotrichosis and is a feature of AGA. Some hair follicles are miniaturization (getting thinner).

Women with AGA often experience shedding of hair in the early stages and shedding can fluctuate in intensity. Other hair loss conditions can cause shedding as well so we’ll address that in just a moment. Women with AGA often notice that the texture of hair changes. There are many such patterns of texture change and a change from straighter to curlier is quite common as you too have described.

The fact that you note increasing numbers of short hairs is not confirmatory for a diagnosis of AGA but certainly is supportive of this diagnosis.

POINT 2: Seborrheic dermatitis/dandruff is likely another diagnosis.

I agree with you that dandruff (or its close cousin called seborrheic dermatitis) is likely present. Flakes are noted in some of the photos. I’d need to perform trichoscopy to confirm this diagnosis but it appears to be a component of the issues present. Mild dandruff is not usually a cause of hair loss but it certainly can cause all sorts of scalp symptoms. To eliminate the possibility that dandruff or seborrheic dermatitis is contributing to symptoms, I often encourage my own patients to aggressively treat their seborrheic dermatitis so we can remove this as a factor. Shampoos with zinc pyrithione, ketoconazole, selenium sulphide or ciclopirox can be used 2 times per week and left on 90 to 120 seconds before being rinsed off. The duration that these shampoos are left on the scalp can certainly be increased but I don’t recommend that to start with as many antidandruff shampoos can be drying and then the dryness starts causing itching and symptoms. I often recommend to my own patients that 5-10 drops of betamethasone valerate lotion 0.1 % can be applied in the scalp after their hair is shampooed and dried. This is a weak steroid and can be safely used for 2 week periods to help settle itching. If the use of shampoos settles the itching, tingling and pins and needles, then it’s not needed.

POINT 3: Telogen effluvium could be present.

Telogen effluvium is one of those conditions that can come and go. Sometimes it’s easy to prove a TE is present and sometimes it’s a bit more challenging. It could be that a TE was present when your AGA first started. You were under extreme stress in November 2019 and yes this could most definitively give shedding in March 2020. Telogen effluvium usually follows 2-3 month after some kind of trigger and can last 3-6 months or more. Other causes of telogen effluvium are low ferritin levels, thyroid issues, medications, diets, weight loss and internal illness. I don’t really have enough information to evaluate these other issues so I’ll go with your assessment that your blood tests were normal. Hopefully you had a reasonable set of tests including TSH, ferritin, CBC. With your irregular periods you describe it would make sense to have FSH, DHEAS, testosterone. One needs to consider whether you are entering a perimenopausal transition and how this could contribute to hair shedding and AGA. With any pins and needles sensation, it’s nice to know that liver enzymes (AST, ALT) are normal and that kidney function is normal (creatinine).

Telogen effluvium can sometimes precipitate or accelerate an underlying AGA. This is a well accepted phenomenon. it does not happen to all women with AGA. However, women with shedding who have AGA that is about to begin (ie very early onset AGA) often find that the AGA component of the hair loss gets sent into a more rapid speed of development if a TE is present. This could be a feature here.

With your normal blood tests, it’s unlikely that a TE is still driving hair loss all this time. Not impossible of course, but unlikely. What is more likely is that AGA is not fully being treated. Spironolactone helps but does not fully suppress AGA in all women at 50 mg twice daily. Sometimes higher doses are needed OR other treatments for AGA are needed (other anti androgens, laser, minoxidil, etc)

POINT 4: If you want to assess the degree to which AGA and TE are present, you could have a biopsy or 5 day modified hair wash test (or a proper trichoscopic examination). I don’t think these are really needed.

For your physicians/specialists who think that AGA is not a diagnosis here for you, a biopsy or 5 day modified hair wash test could help prove them wrong (… or prove them right!). This is a wonderful test but adds to the stress of collecting hairs so I’m not always in favour of it. Biopsies leave scars but if interpretted by a knowledgable dermatapathologist, they can be very helpful.

But, let’s be clear. A biopsy showing a terminal to vellus hair ratio of less than 4:1 taken from your mid scalp area puts to rest any argument about whether AGA its present of not. End of discussion. A 5 day modified hair wash test (done properly !) showing less than 100 hairs and more than 10% hairs being tiny 3 cm hairs also points to an underlying AGA.

Of course, simply examining the scalp with trichoscopy can also confirm this diagnosis but not all specialists are skilled with trichoscopy. If a specialist knows how to use a handheld dermatoscope, we don’t even need biopsies or hair collections to diagnose AGA. If they don’t then yes, we need to go to the extra effort to prove it.

POINT 5: The ‘pins and needles’ is a bit trickier given how many conditions can cause this.

There are a very large number of conditions that can cause pins and needles in the scalp. Stress can cause it. AGA can cause it. TE can cause it. Alopecia areata can cause it. Dandruff can cause it. Scarring alopecias cn cause it. The list is long and includes issues even outside the scalp like cervical spine disease.

I would need to know more about your story and carefully examine the scalp and eyebrows and eyelashes and nails to get a sense of what is causing this.

For pins and needles sensations, I usually advise treating any dandruff or seborrheic dermatitis and using a few drop of betamethasone lotion as outlined above. If it’s still there and the patient has AGA, I usually recommend treating the AGA more aggressively. This often help stop pins and needles. Low level laser, minoxidil and other antiandrogens can be considered.

Conclusion/Summary

Thanks for the question. I hope this helps you in your search for answers and helps with further discussion with your doctors. I think it’s really important for you and your doctors to feel confident with the diagnosis and not proceed with any sort of “maybe.” It would appear that AGA is a component of the issues here but if there is any doubt, a trichoscopic examination, biopsy or 5 day modified hair wash test can help confirm this.

Photos are really important moving forward to document changes - hopefully for the better.

if spironolactone is not fully helping then you and your dermatologists might discuss together whether or not to increase the dose or whether other treatments need to be considered. These include topical minoxidil, oral minoxidil other topical or oral antiandrogens and low level laser. PRP can be considered too. The important thing to note about minoxidil, laser and PRP is that if there is any amount of chronic shedding issue present these treatments can help promote more normal shedding patterns. This is assuming all your blood tests are normal. If any of your blood tests are abnormal and if, in fact, you have not had a proper work up then those issues need to be addressed first. it sounds like you’ve had a good set of blood tests through all the doctors you have seen.

Thank you.

Daily Shedding... with high DHEAS.... What should I be doing?

Why am I still shedding ?

I’ve selected this question below for this week’s question of the week. It allows us to discuss shedding issues in young women with high DHEAS.

QUESTION.

Dr. Donovan, I'm hoping you may be able to shed some light onto my hair shedding situation. I started experiencing increased hair shedding 6 months ago. Prior to the shedding, I'd started a birth control pill (low androgen) 2.5 months before, and Spironolactone 5.5 months before (for hirsutism). I experienced mild stress but it was nothing out of the ordinary. A month into the shedding, I began to experience tingling, crawling, and pain in my scalp. 1.5 months after the hair loss started, I went off of Spironolactone, and 2.5 months into the shedding, I went off birth control. My scalp became itchy as well.

I went to 3 dermatologists, all of whom diagnosed me with telogen effluvium. I recently had a biopsy done that stated telogen effluvium as well. I was also diagnosed with seborrheic dermatitis (which I've never had before in my life). I tried ketoconazole shampoo. I've had blood work done that stated my thyroid was normal, ferritin within normal range, (was 95 in October due to brief supplementation and then 26 in January), and I was deficient in vitamin D. My vitamin B12 level was too high, I'm not sure what that means.

I have symptoms of androgen excess (acne and excess hair growth on my face / body), dating back to my teen years (17), I'm 21 now, soon to be 22. The facial hair growth appeared in November of 2019 at age 20. I have elevated DHEAs (512), and had an ultrasound ruling out PCOS (no irregular periods, no polycystic ovaries).

Photo of the patient’s scalp.

Since the hair shedding began, I experienced massive emotional stress as a result. I was diagnosed with anxiety and depression - which I'm sure I've had for years but got extremely bad once my hair started to fall out. I am thin (weighing only 104lbs) but lost 10 pounds presumably due to stress of the hair loss. I've had two episodes of what was probably telogen effluvium in the past - one was related to low iron (ferritin of 7) back when I was 15, and one episode when I was 18 most likely due to a bad case of the flu. Those episodes only lasted 3-6 months and I grew all of my hair back.

This time, I've been consistently shedding for 6 months with no sign of improvement. My scalp is very tender, sensitive, flaky and itchy still. On an average day, I used to shed maybe 5-10 hairs, now I am shedding roughly 50-150 hairs - which is not normal for me. I'm at a loss for what could be causing this and what I can do about it. Any advice would be greatly appreciated

ANSWER

Thanks for the question.

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

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.

There is lots more to your story that I need. I would want to know about other medications you have started and stopped. I would want to know about other symptoms like joint pains, headaches, fatigue, weight loss, eyebrow changes, eyelashes changes, body hair changes, nail changes, and rashes.

The 2 key questions here in your case are:

a) Is the diagnosis ONLY telogen effluvium … and …. if so what is the trigger?

b) Is this a telogen effluvium with the starting stages of androgenetic alopecia?

Let’s go further into your story.

POINT 1. Many people who take birth control pills shed for the first few months.

First, I think there’s little doubt that at least one of your diagnoses is telogen effluvium. We don’t actually need to debate that. The debate we will get into in a moment is whether anything else is going on.

You have several reasons why you could have a telogen effluvium, including starting the birth control pill and starting spironolactone. A large proportion of women shed when starting these treatments, especially birth control pills. The shedding starts 2-3 months after taking the first pill and the shedding lasts 3-6 months provided the pill is continued every day. A lot of women shed when stopping these pills too, especially the birth control pill. The shedding starts 2-3 months after stopping the pill and the shedding lasts 3-6 months provided the pill is not restarted.

So what would I expect to hear from a 21 year old woman who starts spironolactone and then starts a birth control pill? Shedding.

And what would I expect to hear from a 21 year old woman who starts spironolactone and then starts a birth control pill and then stops these pills? Shedding.

What is your story? Shedding.

So in some ways, it’s possible this is entirely consistent with your story.

POINT 2: All patients with hair loss, acne and hirsutism and androgen excess need a proper work up. A work up should be done off birth control.

You have DHEAS 512 (which is 13.9 umol/L in SI units). Any female age 21 with DHEAS 512 and acne and hirsutism and hair loss needs a thorough endocrine work up in my opinion. We need to rule out PCOS and late onset CAH.

With the limited information you have provided here, it would be false to say that you “don’t” have PCOS.

The correct way to say it is more likely “you have a low likelihood of having PCOS.”

Women with PCOS who are thin with low BMI often have regular periods and often have no cysts visualized on ultrasound examinations … but still have elevated androgens. This is a bit more advanced type of knowledge, but I think it’s important especially since you have hyperandrogenism. Anyone who claims there is zero chance you have PCOS is wrong. Anyone who thinks there is a very low chance you have PCOS is correct. I have seen many women with your story exactly who go from being thin to being heavier in their 20s and 30s and ‘develop’ PCOS. I’m not saying that is your case, but sometimes weight gain brings about insulin resistance that then promotes a fuller PCOS clinical presentation.

So what work up do you need? Well, I would advise a proper work up on day 3-5 of your cycle for my own patients that come to see me with a story like yours. The fact that you are off birth control again is a good time to do this. We can’t do these tests when women are on birth control.

The tests that I order on day 3-5 of the cycle for my patients with similar stories are: LH, FSH, estradiol, testosterone, free testosterone, SHBG, glucose, insulin, hemoglobin 1A1c, AM cortisol, prolactin, androstenedione and 17 hydroxyprogesterone, AST, ALT, and cholesterol. These should be done fasting and day 3-5 of the cycle. You have already had your DHEAS measured so there is not a lot of good reason to do this again unless someone suspected levels could be climbing. I would probably include it again for completeness.

What am I looking for in these tests?

a) a high 17 OHP level on day 3-5 that would lead us to a diagnosis of late onset congenital adrenal hyperplasia

b) a high testosterone, high fasting insulin, high LH that would point is towards a PCOS like state

c) A normal prolactin and AM cortisol that reassures us that no other issues are present

In your case, I would want more blood tests if I was your doctor. I would want to know if there is any evidence of insulin resistance that would push me towards PCOS. I would want to know if the other hormones were normal. I would want to know your free testosterone and SHBG. I would want to know your 17 OHP levels to rule out late onset congenital adrenal hyperplasia before moving on.

POINT 3: When it comes to ultrasound examinations, there is a lot that patients don’t realize.

When I hear that a patient had an ultrasound that showed no cysts, my first response is usually that I’m glad to hear that news. But there are a few points to keep in mind. First, it depends on whether the ultrasound examination was a transabdominal ultrasound or transvaginal. There is a big difference in the quality of the studies and what it all means. Transvaginal studies with modern ultrasound techniques are the most helpful. Many people don’t have these studies done. Transvaginal studies can pick up a lot of cysts that the transabdominal can not. Of course, it’s very unlikely this is even an issue with your story but it’s something that we need to keep in mind.

With your ultrasound, I would want to know where it was done (what center? what clinic?) and whether it was transabdominal or transvaginal? What was the volume of the ovaries noted in the report ? Were any ovary measurements more than 10 mL ?

POINT 4: In the early stages of hair loss, TE and AGA can look the same and have the same story. Rarely, they can have a similar biopsy too.

When I look at your photos, I immediately say to myself :

Could this person have AGA?

Could this person have TE?

Could this person have both conditions?

(Also …. whenever we use the word TE, we need to immediate shout out hey could this be diffuse alopecia areata …. but I don’t think that’s what this is. But I include this for completeness of this write up).

In the early stages TE and AGA look the same. Of course, an up close examination with use of trichoscopy is going to help in your situation. In fact, it’s critical this be done! If the back of the scalp is convincingly thicker than the front of the scalp, I am pushed more towards thinking this could be AGA (with your TE). If the back and front areas are similar density, we are more likely thinking about a sole diagnosis of isolate TE. If there is no evidence of “follicular miniaturization” or variation in the caliber of your hairs when your scalp is examined with trichoscopy, we are likely dealing with an isolated TE. If there is a convincing variation in the caliber of hairs, it could be an early AGA.

Biopsies can be tricky. There is so much more to doing a biopsy than just doing it and so much more to interpreting a biopsy than just reading the information that comes printed on report. My ability to accurately interpret a biopsy depends where on the scalp it was taken from!. It depends how it was processed (horizontal vs vertical section). It depends who read the biopsy (dermpath vs general path). If a biopsy was taken from the sides or the back or somewhere just to prevent the patient from having a visible scar, then the biopsy is often useless. Biopsies in your case need to come from the top.

Here is where I would need your biopsy to have been taken from for me to feel better about the situation:

Also, if someone is going to tell me all you have in your biopsy is a telogen effluvium, I’m going to hope that horizontal sections were used. It’s a huge stretch to diagnose a telogen effluvium confidently from vertical sections. In horizontal sections, the pathologist gets to see 20-40 hairs in order to give their best guess about what could be going on with the rest of the scalp. With vertical sectioned biopsies, they just get to see 3-6 hairs. I don’t want to leave my patient’s hair loss diagnosis to interpretations as to what is seen with 3-6 hairs.

POINT 5: TE and seborrheic dermatitis (and sometimes even AGA) give tingling and symptoms.

With the biopsy result you have in your possession, I’m much much less worried about the tingling, crawling and pain. Of course, I wish you did not have it. But I’m not suspecting anything inflammatory that would make me want to act with a much different course. This is assuming your biopsy came from an area that was tender) I’m always worried when a patient says they have scalp pain. But this worry evaporates to a large degree when the biopsy from that area shows non-scarring alopecia. If your biopsy was from a random area and not from a tender area, then it becomes more difficult to interpret what it means.

Pain and tingling in your case can come from seborrheic dermatitis. it can come from TE, It can come from depression. It can come from allergy or irritation from a current shampoo. it can come from irritation of allergy from other cosmetics.

We still need to keep an eye on this pain. I often encourage my patients to commit to treating their seborrheic dermatitis with a rotating schedule of shampoos. Zinc pyrithione one day. Ketoconazole the next regular shampooing day and selenium sulphide shampoo the next shampooing day. Shampooing must be done 2-3 times per week and left on 2 minutes. I advise my patients to not over do the time as this often just dries the hair and scalp out further. Also, putting a prescription topical steroid on the scalp like betamethasone valerate lotion 0.1 % aa few times per week right after showering is often helpful (of before bed). 10 drops to 15 drops of betamethasone valerate lotion two times per week for a few months is very safe and anyone who says otherwise has little understanding, knowledge or training in the area.

If the pain is still present in 3-5 months, this needs to be looked into further.

POINT 6: What to do next depends on the blood test results and your prior response to spironolactone.

What exactly to do next and how do help your shedding depends partly on your next set of blood test results. If you have elevated 17 OHP on your blood tests, you may want to see an endocrinologist. If you have high LH or evidence of insulin resistance you’ll want to see a really experienced endocrinologist for evaluation of PCOS. Not all women with PCOS are overweight and in fact, women with PCOS who are thinner or have low body mass index often have regular periods and no cysts on ultrasound.

If you tolerated spironolactone well (in the past) and tolerated birth control well, it may even be an option to return to these and stay on these. Did it control your acne? Did it stop hirsutism? Did you feel good on it? Anyone starting these medications has a chance to get shedding so I’m not necessarily worried by a story of shedding. You stopped too soon to really get any sense what the long term outcome was. If there is any evidence of AGA with an up close examination, this could be a good option again. If not, you might want to treat your acne and hirsutism differently - perhaps topically.. The other option is to wait longer in hopes the TE resolves. Continuing iron and vitamin D and shampooing your hair diligently with these anti dandruff shampoos is going to be important no matter what is going on up on the scalp.

Finally, with any TE, we need to always keep in mind that maybe we have not found the trigger. If your ferritin was low and your hemoglobin was low (less than 12.0), a work up could be important. I often test for example a celiac panel in patients with BOTH low HGB and low ferritin. I’m not worried about your high B12. I would want to know about other medications you have started and stopped. As mentioned above, I would want to know about other symptoms like joint pains, headaches, fatigue, weight loss, eyebrow changes, eyelashes changes, body hair changes, nail changes, and rashes. Sometimes we consider ordering autoimmune tests in women with shedding but only if the history points us to ordering these. Ordering these tests ‘just to cover all bases’ is usually not a good idea.

Summary

I can instantly tell by your question that you’ve read a lot and thought a lot about your issues and what all this information means. Congratulations for that. That is important. You need to figure out if late onset CAH is a possibility or not ….. and whether insulin resistance/PCOS its truly off the list or not. In my opinion, these blood tests on day 3-5 are important to you. I’m glad you are off the birth control pill now because it allows you to get these tests done.

If your biopsy was taken from the area I have noted above, then that’s probably very helpful provided it was analyzed in the lab with horizontal sections. . The key point now is figuring out if there is any possibility of an evolving androgenetic alopecia that just could not be picked up in the early stages with the work up you had. A biopsy with horizontal sections and a good trichoscopic examination by a specialist who understands hair loss will uncover these answers.

Regardless, photos should be taken every 3 months. Not every day and not every week. If there is any kind of evolving pattern of hair loss, a photos will also capture these changes over time.

If TE is truly what you have and there are no underlying concerns, doing minimal additional things could be the best plan. However, if your hyperandrogenism is part of a bigger endocrine issue (like PCOS or CAH), getting advice from an endocrinologist would be a good way to proceed. These blood tests will be a really important guide. Some women just have elevated DHEAS and some women with elevated DHEAS develop AGA but some don’t. I never recommend patients start treatment because of what the labs say - treatment is started because of what the skin or hair is doing.

Thanks again for sending in the question. I hope this helps you are your team of specialists.

Losing short hairs: is it normal or should I be concerned?

Should I be concerned if I find I am losing short hair?

I’ve selected this question below for this week’s question of the week. It allows us to the review some key concepts in evaluating shed hairs - particularly the relevance of short hairs.

Question

I noticed that I a few of the hairs that I find in my brush are short hairs - less than 3 cm. Is this evidence that I am progressing to androgenetic alopecia?

Answer

Thanks for the question.

It all depends on the proportion of short hairs you find.

If you find a low proportion of small hairs, that’s completely normal. Everyone sheds a few short hairs.

If you collect all your shed hair over a week and find that more than 10 % are tiny hairs less than 3 cm, that might suggest there is some androgenetic hair loss happening. You’d certainly want to review things with your dermatologist carefully if that were the case and have him or her performing a careful scalp examination including trichoscsopy.

But finding one hair has very little meaning otherwise.

Telogen Effluvium or Androgenetic Alopecia ... Or Both?

Biopsy Suggested AGA and a bit of TE: Which one is causing my hair loss?

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

QUESTION

My biopsy came back showing that I have androgenetic alopecia with bit of telogen effluvium. My terminal to vellus ratio was 1.8: 1 and there were 16 % telogen hairs. I’m wondering if I have both diagnoses, which one is causing my hair loss.

ANSWER

Thanks for the question.

It’s likely that they both are. However, most of your hair loss is from the AGA. I would need to see your scalp to give you a precise breakdown but it’s likely the AGA is the main cause given that the T:V is well under 4:1.

But both of these contribute!

Suppose you ran a 20 mile run and also carried groceries up 40 flights of stairs because the elevator was broken. Why are your legs sore? Well mostly from the 20 mile run but some of your leg soreness is due to the climb up the stairs. If you didn’t have to do the stairs you might be 6 % less sore but you’d still be sore.

If someone has a little bit of telogen effluvium and mostly androgenetic hair loss they’ll get a bit of hair back if they address their telogen effluvium but really they need to address the androgenetic component.

Hope this helps.

Elevated DHEAS with Hair Shedding: What might be going on?

Persistent Shedding, Elevated DHEAS and Ongoing Hair Loss

I’ve selected this question below for this week’s question of the week. It allows us to discuss persistent shedding in young women in the setting of elevated DHEAS.

QUESTION

I am a female in my mid 20s. In March 2020, I began to notice my hair shedding more than normal. I related it to stress of moving to a new town, and possible TE following local anasthesia from a breast augmentation in late summer 2019. Fast forward to October 2020. I was still experiencing a significant amount of shedding that had not lessened or improved. Therefore, I made an appt with a Dermatologist. He did a pull test which came back as negative. I also had Blood work done which all came back as normal except for the following: ferritin of 48, DHEAS high at 404, and free T high at 4.3. When I followed up with the dermatologist in the Fall 2020, he interpreted my blood work for me. He said that it was likely that I have AGA due to the high androgens, and could possibly have an iron deficiency which is causing the thinning. At that visit, he recommended that I supplement with iron. He also suggested starting spironolactone. I inquired about the continuous shedding considering AGA is a hair loss diagnosis and not a hair shedding diagnosis, and he suggested that I could also have a CTE.

Moving forward I have decided to begin supplementing with iron once daily as recommended. However I am on the fence about spironolactone due to side effects. Also I did not get a definitive diagnosis and he did not recommend a scalp biopsy. My question for you is would you have the same recommendations? At this time in January 2021, I am continuing to experience significant amount of shedding, a density decrease in my overall hair, and thinning at my crown and middle part that is more noticeable with bright lights. Thank you!

Mid 20s Female with elevated androgens and persistent shedding

ANSWER

Thanks for the question.

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

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.

The key question here in your case is whether or not you have androgenetic alopecia. The only way I can really confidently determine that is with an up close examination (or review the results or a biopsy which you have not had). So, I cannot yet say whether you have androgenetic alopecia or not.

Let’s go further into your story.

You are correct that some of these things you mention like moving to a new town and having surgery could trigger TE, but the timing is a bit off. Having a breast augmentation in summer 2019 causes shedding in the late fall not way into March of 2020. So this is unlikely linked especially since the shedding in Oct 2020 is pretty much the same. . Furthermore you still kept shedding in October and now into January 2021. Those events of 2019 are probably not all that close related.

There are a few possibilities for what’s going on:

a) you have androgenetic alopecia

b) you have telogen effluvium and nobody has found the cause

c) you have another diagnosis altogether.

Let’s take a look at these…..

a) Do you have androgenetic alopecia ?

It’s possible you have androgenetic alopecia. I would like to point out that AGA most certainly is a ‘hair shedding’ diagnosis so don’t let that confuse you. Women with early AGA experience increased shedding. It is incorrect to link that because you have shedding you are looking for some list of hair shedding causes for which androgenetic alopecia is not on the list. It’s on the list. You have persistent shedding despite fairly normal blood tests for typical triggers of telogen effluvium. You are seeing your crown and mid scalp more visible in bright lights. What’s the most common reason for this? Androgenetic alopecia.

We don’t diagnose AGA by blood tests. Having a high DHEAS or free T does not mean you have AGA. No way. If you have a variation in the caliber of your hairs when your scalp is examined up close with trichsoscopy, that is suggestive of AGA. Or if you have a terminal to vellus ratio of less than 4:1 if you ever did a biopsy that would be suggestive of AGA. I have many patients with elevated DHEAS who don’t have AGA!!!! So that’s not the key point that its going to nail down the diagnosis. A proper scalp exam (or biopsy) is!

I do think it’s really important for anyone with elevated androgen hormones to figure out if there is any underlying condition that can give a slightly elevated DHEAS or Free T. Some women with PCOS have elevated androgens and some women with late onset congenital adrenal hyperplasia (CAH) have elevated androgens. It’s going to be very important for your physicians to understand whether or not your periods are regular or not and whether any of these diagnoses might be present. If you have irregular periods you’ll want speak with your dermatologist about having an extended panel of blood tests the 3rd to 5th day of your menstrual cycle. (These tests need to be done off all oral medications). Your DHEAS is not high enough to worry about adrenal gland tumors in case that’s something you have read about yourself. It’s only slightly elevated. But even though you think you’ve had all the blood tests you need, it’s important to keep in mind you might not have. For some women with increased DHEAS, a compressive blood test panel includes TSH, prolactin, AM cortisol and 17 hydroxprogesterone. Again this should be done on day 3-5 of the cycle.

b) Do you have telogen effluvium and nobody has found the cause?

There are hundreds of reasons to shed hair. The common causes are stress, low iron, thyroid problems, medications, diets, etc. But there are so many other causes too - and it’s going to be important for your doctors to ask you oodles of questions to make sure you don’t have another cases. I can’t go into all the questions because there are so many but it’s essentially a head to toe understanding if there are concerns. With a ferritin of 48, I don’t think it’s likely that iron is an issue here at all. A ferritin of 48 is not associated with hair shedding issues for 99 % of people.

For persistant shedding in a patient with NORMAL basic blood tests, we want to know 1) does this patient have an autoimmune disease Iike lupus ? or another autoimmune disease? 2) is there an infectious disease present (syphilis, COVID, lyme)? 3) does the person have gastrointestinal disease affecting absorption of micronutrients ? 4) is there a supplement or drug the patient is using? If there are other features present like fatigue, headaches, muscle pain, poor sleep, depression then you are your doctors may need to review the concept of breast implant illness. It’s a rare consideration for hair shedding but certainly part of a comprehensive approach to investigation of the cause of your hair loss. The answers to these questions will influence whether blood tests like ANA, RPR, zinc, Sars-COV-2 antibodies and others get ordered. The panel of blood tests can be quite large but the specific tests to order depend on the answer you give to a lot of detailed questions.

CTE is misdiagnosed often and this is not something you likely have. CTE is a condition of women 35- 70 with chronic shedding for no good reason. That’s the key to CTE. It’s not just shedding that goes on and on without figuring out common causes. If you have androgenetic alopecia in the end, then your shedding is from AGA most likely. Your story is not a typical CTE story! The diagnosis fo CTE gets thrown out way too easily in my opinion. You either have an acute telogen effluvium that nobody has found that diagnosis to, or you have androgenic alopecia or you have another diagnosis altogether that has been missed. I would favour that you have AGA.

c) Do you have another diagnosis altogether?

I don’t have all your story information … but I would imagine that a lot of other answers would be negative. I’m assuming that if you did have scalp itching or burning you’d include it in your question. I would imagine if your scalp was tender you’d include that too. But maybe not. We have to be open to the possibility that autoimmune diseases like lichen planopilaris could be present and give chronic shedding. I would highly doubt it though as LPP s not something that I see in your scalp based on the one photo I have.

Summary.

Thanks again for submitting your question. I would need to see your scalp up close to guide you further. It’s the scalp examination that is going to help figure out if you have AGA not the blood tests. We don’t diagnose hair loss from blood tests! If you have miniaturization of follicles on examination then you likely have AGA. Or if you get a biopsy and if captures the miniaturization in the biopsy (with a terminal to velds ratio less than 4:1) you likely have AGA.

Not everyone needs a scalp biopsy but it’s helpful if there s doubt from anyone - patient or doctor.

If you have AGA, minoxidil, spironolactone, laser, and PRP are options. If you have AGA with elevated androgens and have no other underlying endocrine issues spironolactone can be a good option. You are correct that spironolactone can have side effects. Fortunately, most side effects are mild and less than 4 % of users actually stop spironolactone due to side effects. But people who do not wish to use spironolactone can consider laser, PRP, topical minoxidil, oral minoxidil and other treatments too.

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.

What options are left for my hair loss?

What should I do about my hair loss?

I’ve selected this question below for this week’s question of the week. It allows us to discuss the advanced management of non scarring alopecia.

Here is the question….

QUESTION

Dr. Donovan I have been following your blogs and articles for quite some time and decided to tell my hair loss story and hopefully get some answers. I am a 58 year old very healthy female with no nutritional issues and an avid runner for many years. At 48 my hair started thin but underneath and at the mid back scalp in a diffuse pattern. I was put on Yaz birth control and finasteride which helped tremendously for 3 yrs. At 51 my gynecologist took me off birth control at which time I started to see similar issues recur. I started topical minoxidil, traditional HRT but nothing worked. I saw a dermatologist and she diagnosed me with AGA and started me on Climen, HRT in addition to finasteride and topical minoxidil. Within a few months I saw another dermatologist who added spironolactone 100 mg. This combo seemed to bring back my hair growth and density within 6-9 months. After a year or so my creatinine levels were in the high range and my gynecologist advised me to stop the spiro. Within a year or so after stopping I noticed significant shedding, less density mid scalp to bottom of my hair and dry hair that looked like a broom. I had numerous PRP sessions, laser cap and started various combos of low dose oral minoxidil, topical and the Climen.

I have no visible scalp anywhere but a lot of different layers and short pieces of fine hair and no bottom to my hair.  Dry hair of varying lengths mostly underneath hair. The hair has changed from long straight to short and curly with no density. Cutting has not made any difference in the fullness. From the ear down the hair is thin fine and basically see through. I do not know why there is no improvement in my condition. I have no itching or burning.

I am currently on oral minoxidil 2.5 mg once daily, Avodart, topical minoxidil, spironolactone 100 mg daily in addition to HRT estrogen patches and micronized progesterone 15 days every 3 months. I am still shedding enough to create concern and my hair won’t grow longer. The top of my hair is much fuller than the bottom which is wispy and thin. I have included my biopsy and photos for your review.

BLOOD TESTS

All blood results are normal and ferritin has ranged from 40-50. The only red herring is a positive ANA of 1:80 for 5 years with no symptoms. I would appreciate your opinion.

BIOPSY

Biopsy showed a non-scarring pattern with follicular miniaturization, anisotrichosis, and increase telogen hairs.

ANSWER

Many thanks for your question. Of course, I’d need the full story from A to Z , more photos and to review all your blood tests to give a complete opinion. It’s clear you have androgenetic alopecia (AGA) and a telogen effluvium (TE). In your case, I think it’s worth still looking for a trigger of your TE rather than explaining it simply by a chronic TE with no underlying cause. I think there are two important points to consider here:

1) Maximizing/Optimizing Anti-androgen Therapy

First - your hair loss has been quite responsive to anti-androgens in the past. Yaz and finasteride have helped you and Climen and spironolactone have helped you. I do think that it will be important to review with your dermatologists if there is more that can be done to maximize treatment in this big category of antiandrogens.. You are on spironolactone and dutasteride. Increasing spironolactone is not going to be a good option given your kidney (creatinine) concerns. However, brining on board other antiandrogens just might.

You and your doctors may want to carefully review if the drug bicalutamide might be considered. Bicalutamide can be used with dutasteride and spironolactone and it might even be introduced 2 or 3 times weekly if you are still going to continued on dutasteride and spironolactone. Bicalutamide is an antiandrogen (androgen receptor blocker) which is used for the treatment of male prostate cancer. It has been used off label in women for the treatment of hair loss, as well as other androgen related issues such as hirsutism (hair growth on the face). It tends to be just as well tolerated for most of my patients as dutasteride so side effects overall are low. Side effects include elevated liver enzymes, peripheral edema and gastrointestinal side effects (diarrhea, constipation, nausea). Other side effects like itching can rarely occur. General antiandrogen side effects like decreased libido, breast tenderness, breast enlargement, mood changes (depression) can occur although seem to be quite uncommon. These are the same side effects that dutasteride, finasteride and spironolactone can cause. Mood changes with bicalutamide are not common. Bicalutamide has not been associated with a decrease in bone mass (osteoporosis). An increase in liver enzymes (3 % to 11 % of patients) is quite rare although monitoring of liver enzymes for the first 2 months is recommended.

 For my patients who are on anti androgens like duasteride and spironolactone already, I generally start ¼ pill (12.5 mg) for 2-3 months and then increase to ½ pill (25 mg) after that. Sometimes I start every other day. Liver enzymes are evaluated after the 4-6 weeks and then again at week 12.

2) Evaluating the Telogen Effluvium

The increased proportion of telogen hairs in your biopsy is very interesting in my opinion. I would need to know a lot more about your story and review all your blood tests, but it would seem based on the information you have provided that this needs to be explored further to make sure that we’re not missing a potential cause of shedding. There are an enormous number of triggers of shedding.

They key to evaluating shedding is to perform a search for possible triggers and if anything comes up suggestive that it could be a trigger - then this needs to be pursued fully.

Your ANA result may or may not have any relevance. It’s low and many people in the population (5-7%) have a low level ANA like this without any consequence. However, given that you are still shedding I think that you and your doctors might consider pursuing further evaluation in this area. Because your ANA is positive, further work up might be discussed with your physicians if it has not been already. The exact tests to order depends on your history (your medical story), but might include ENA, ESR, C3, C4 and CK. If there is any suggestion of rheumatological disease, referral to a rheumatologist would be advised. With chronic shedding, I always encourage patents to make sure their age appropriate screening examinations have been done. You and your primary care doctors can review if colonoscopies, and mamograms are up to date.

The full causes of telogen effluvium including stress, low iron, thyroid problems, medications, diets, weight loss and internal diseases. I understand based on your comments above that your iron and thyroid labs are normal. I’m assuming your vitamin D levels were normal. The remainder of your TE triggers need careful evaluation. If there are any other mediations you have started, those need to be reviewed. Furthermore, if there are any other symptoms those need careful evaluation as well. The symptoms I ask about are shown in the table below. One really needs to go head to toe when dealing with chronic shedding issues. If anything comes up - it gets explored fully. The issues that I’m most interested to ask about in a patient with positive ANA and increased telogen proportion on biopsy are whether the patient has dry mouth, dry eyes, joint pains, fatigue, weight loss, and muscle weakness.

Conclusion/Summary

Thanks again for submitting your question. I hope this was helpful in some way. I think overall you need to figure out if any more detective work needs to be done as far as your shedding goes, or has it all been done. Sometimes the detective work has all been done and we’re left with AGA and shedding. In these cases, treating the AGA fully as mentioned above is going to be important. Use of a multivitamin is going to be important. In tough cases, I may add biotin 2000 -5000 micrograms daily and a good antidandruff shampooing regimen. Of course, if there are any deficiencies that were identified they need to be fixed.

If something does turn up positive on the investigations I mentioned above, it needs to be explored fully and completely. If the clinical picture does suggest an autoimmune issue, then low doses of hydroxychloroquine are used.

If anything changes in the scalp in terms of new symptoms, massively increased shedding, a repeat biopsy should also be considered.