Dry & Brittle Hair after Using Isotretinoin

Dry hair after Isotretinoin

I’ve selected this question below for this week’s question of the week. It allows us to review some of the reasons for post isotretinoin scalp dryness.

Answer

My  hair is  so  brittle  after stopping  isotretinoin. It’s also quite dry.  What  might  be  the  cause?  Was it the drug?

Answer

Thanks for the question.

It's possible, but there  are many  causes actually.  One  needs  to  ideally have a  proper scalp  examination  and have the story reviewed from start to  finish.  (By ‘start’  I  mean not just  the start of last month  up  until  today but a full history from birth). One  needs  to  consider  many things.  

Isotretinoin can cause dryness that takes a while to settle after stopping. In many patients it does but one might need to be a bit gentler on t he hair for 3-6 months than they might have otherwise. I like my patients to reduce chemical and fragrance and potential irritants that can worsen they way the scalp feels. sometimes we switch away from a sulphate containing shampoo for a few months to allow the scalp to return back to normal.

Other causes of scalp dryness and brittleness need to be ruled out. If they are ruled out, I often consider a corticosteroid oil for my own patients along with the sulphate free shampoo. For my patients, the steroid oil is used once or twice weekly for 2-3 weeks before going down to once every two weeks for 2-3 months. Periodic use of an oil like coconut oil can also help provided there is not a lot of seborrheic dermatitis that is also on the scalp. I don’t know if that’s appropriate for you because I don’t know your story but that is something you can speak to your dermatologist about if everything else is completely ruled out.

The main issue is to be incredibly gentle on the hair and scalp for 3-6 months.

But what other conditions need to be considered ?

1) Seborrheic Dermatitis

One needs  to consider  seborrheic dermatitis that has  now  flared after stopping Accutane.   For  some people,  Accutane  treats some coexisting seborrheic dermatitis without  the  patient even knowing  and  then the  condition  flares when stopping.  

2) Hair styling Issues

One  needs  to consider  the  possibility that  overprocessing, coloring and/or heating of hair  is leading to  the  increased dryness. In  other  words, how  has  one’s  hair styling  practices  changed recently?  

3) Shampoo and Conditioner Issues

 One  also needs to consider  irritation from shampoos and conditioners and other topical products.   Has  a shampoo  or  conditioner or styling product changed?  

4) Autoimmune and inflammatory Issues

Of  course, with dryness one  needs  to  consider  inflammatory  scalp  issues  including autoimmune  issues,  psoriasis  and scarring alopecias  that have activated  or even  flared  post  stopping  Accutane. Fortunately,  they are rare  in  a situation like this.  But a dermatologist  can properly evaluate.  

5) Hormonal and Metabolic Issues

Finally, once needs to  consider  a variety  of metabolic and/or hormonal  issues  including those related to thyroid hormones,  estrogen  hormones or  androgen  hormones.  These  can  affect dryness  in  a  dramatic way.   Other  inflammatory scalp conditions  are  possible and  can be ruled  out  following proper examination.   

Frontal Hairine Loss in a 48 Year old Black Female

Question.

I'm a black female 48 years old with what I believe is CCCA. I started loosing my hairline in 2014, however in an 18 month period I lost my entire hairline. For the last 14 months I've been treating my scalp with natural oils/home remedies. The hair loss have stopped. I think my condition could be inactive. If the e disease is in fact inactive, without any medical treatment, can my hair grow back on its own or will I need a hair transplant?

Answer

Thanks for the great question. As a physician who sees a lot of women with CCCA, your brief story shouts out to me one main message: this may or may not be CCCA that you have and if it is CCCA, one or more other hair loss conditions might be present too.

Let me begin. Central centrifugal cicatricial alopecia (CCCA) usually starts in the middle of the scalp or in the crown. CCCA does not usually start in the front like you described. However several conditions can affect the frontal hairline just like you described including traction alopecia, cicatricial marginal alopecia and frontal fibrosing alopecia. What’s a bit unexpected from your story is the complete loss of the hairline that you described. That certainly favours a diagnosis of frontal fibrosing alopecia over traction alopecia but of course I would need to see your scalp myself to answer that. An entity called cicatricial marginal alopecia is also on the list.

Your story is not a typical story of CCCA although of course you could have CCCA back in the mid-scalp too. Many black women with hair loss in the frontal hairline also have some degree of CCCA too.

What you really need now is a diagnosis. An expert dermatologist who treats a lot of patients with hair loss might be able to make the diagnosis without a biopsy but if you are thinking of hair transplants down the road a biopsy is going to be helpful to secure the diagnosis and also determine for you (and your doctors) just how active or inactive the disease truly is right now. My advice to anyone with a story like yours would be to consider a sample from the frontal hairline area and also from the crown. Remember that a biopsy always needs to have a hair in it so don’t biopsy any bare area as that is useless.

I’m suspicious about your diagnosis of CCCA but a few things about your story are more definite. First, it’s unlikely you’ll get spontaneous growth if you haven’t had growth since 2014. Depending on the exact and precise diagnosis, you still could get a bit of regrowth with treatment but likely only a bit. Second, you are probably not a candidate for surgery yet. Whether you become a candidate depends somewhat in the diagnosis but also on the activity level of your primary disease. I like to have patients take photos once they feel their disease is quiet... and if there is absolutely no change in hair loss after two years of photography then a hair transplant might be possible. If you feel your scalp has now become quiet, take a picture today and plan to compare that same picture in 2 years. If the two pictures look 100 % identical you might be a candidate for surgery. The longer answer as to whether you are a candidate for surgery actually depends on several factors.

In summary, your story suggests a diagnosis of frontal fibrosing alopecia or traction alopecia much more than it does CCCA. A biopsy could be extremely important for you and your treating physicians right now.

Hair Loss from Relaxers

Question

Can my scalp be treated after severe damage from a hair relaxer?

Answer

Thanks for the great question. This is such an important question and also a very common one. There is a lot to discuss. As you’ll see, the answer to your question is ‘maybe.’ Some patients with hair loss form relaxers will grow back their hair. Some patients do not.

Let’s begin.

When a patient says to me they have hair loss from a relaxer, it’s important to keep in mind that there is not one type of hair loss that they might have. In fact, they might have one or more of many types of hair loss, including hair breakage, inflammatory scarring alopecias, hair loss from chronic inflammation, traction alopecia, telogen effluvium or androgenetic alopecia. Some patients just have one type of hair loss. Others have two or three.

Let’s take a look.

1. Hair breakage (Trichorrhexis nodosa)

Both chemical and heat relaxing of hair can cause breakage of the hair. The hairs simply break off because of the damage to the delicate strand. The heat or chemicals cause “micro tears” in the hair shaft which we call “trichorrhexis nodosa.”

The photo below shows a picture of a hair fibre that has such a tear.

Trichorrhexis nodosa of a hair fiber. This can occur from many agents including heat and chemicals used to relax hair.

If trichorhexis nodosa is the only reason for the hair loss, the hair will grow back. The damaged sections may need to be cut off, but the long term prognosis is good. It may take 6-9 months before hair returns back to the way it once was but it will return. Unfortunately, trichorrhexis nodosa as the ONLY and sole reason for a person’s hair loss from relaxers is not common. Ofter there is another reason present as well, and these are discussed below.

2. Telogen Effluvium

Many patients who come to see me with concern about their hair after using a relaxer also have a a diagnosis of telogen effluvium or “TE.” Telogen effluvium is a type of hair loss that occurs when the body feels some type of shock. This can occur from low iron (low ferritin), thyroid problems, anemias, crash diets, weight loss, stress, medications, and illness. Some of these issues such as anemia and low iron levels may make the hair slightly weaker and slightly more susceptible to hair damage. These issues must be addressed fully. For this reason, I always order blood tests for ferritin, 25 hydroxy-vitamin D, TSH, CBC, ANA in all patients who come to see me with concerns about hair loss from a relaxer. Other causes must be fully evaluated.

3. Traction alopecia.

Traction alopecia is a type of hair loss that occurs from the chronic pulling of hair. Patients who use relaxers may be more susceptible to traction alopecia because their hair is subjected to many pulling forces during relaxers and the hair fibers may be weaker. Traction alopecia can occur anywhere on the scalp. The frontal regions near the temple are often a common site of traction.

Treatment for traction alopecia involves stopping the pulling forces that caused the traction in the first place. If traction alopecia is diagnosed and pulling is stopped immediately (within a few months of the new hair care practice), hair might grow back. However, if traction alopecia has been present many months, the hair may not fully return. Long standing traction alopecia is permanent and may even continue to progress once the hair pulling is stopped.

Traction alopecia of the frontal hairline.

4. Scarring Alopecia and Chronic Inflammation .

It’s a little known fact but chronic use of relaxers, especially chemical relaxers, can create scalp inflammation. It may not be a type of inflammation that can be seen on the surface but rather a type of inflammation that is occurring deep under the scalp. In some people using relaxers (but certainly not all people), this chronic inflammation triggers the body to also create scar tissue beneath the scalp. The exact mechanism is not clear but micro injury to the skin creates microinflammation and chronic microinflamation may induce scar tissue to form.

This pattern of hair loss from relaxers has been most carefully studied in women with afro-textured hair but likely applies to all hair types. Chronic use of relaxers in women with afro-textured hair may be linked to the development of several types of hair loss including traction alopecia and central centrifugal cicatricial alopecia (CCCA). CCCA often affects the central scalp first. The diagnosis must be caught as early as possible to prevent progress and prevent irreversible loss of hair. Too often women with CCCA are told that their hair loss is simply from a relaxer and it will grow back. CCCA is a cause of permanent hair loss. If there is any doubt, a punch biopsy should be considered to properly evaluate for scarring alopecia. Treatment with agents such as topical steroids, steroid injections, and doxycycline can help stop the disease. Hair growth does not usually occur. A photo of a woman with CCCA is shown below.

Central centrifugal cicatricial alopecia (CCCA) in a woman initially misdiagnosed as having temporary hair loss from a relaxer. The correct diagnosis for this patient was CCCA which causes permanent hair loss.

Summary and Conclusion

Thanks again for the great question. Let’s now return to the original question regarding whether or not your scalp can be treated. As we’ve seen above, it really comes down the the exact cause of the hair loss. If the relaxer caused trichorrhexis nodosa, the damaged hair simply needs to be trimmed and hair density will eventually come back. If however, the relaxers have caused traction alopecia, it may or may not come back even if the relaxers are stopped. If the cause is CCCA, the hair is less likely to return and aggressive treatment with various anti-inflammatory medications are needed to stop the inflammation. If there is a telogen effluvium (from low iron for example) that predisposed to some fragility and hair loss, there could be some improvement with iron supplementation and stopping the relaxers as well.

Be sure to see a dermatologists as relaxer related hair loss can be complex sometimes. Blood tests for ferritin, 25 hydroxy-vitamin D, TSH, CBC, ANA might be considered and if any doubt exists, a biopsy might be considered to rule out scarring alopecia.

What causes hair texture changes?

Question

QUESTION: What causes hair texture changes? I used to have very soft and glossy hair. However, now after years of hairless (androgenetic, FFA & LPP) and treatments (injections, topical clobetasol & oral medications) my hair is very dry, dull, almost straw-like. Are these texture changes due to aging, the hair loss conditions or perhaps the treatments? Conditioners do not seem to help. Thank you.

Answer

Thanks for the great question. There are many causes of hair textural changes. In your case specifically, the causes are probably "multi-factorial" rather than a single cause.  Let’s take a look at some of the more common causes of textural changes and how they apply to the question you have raised. 

Consideration 1: Scarring alopecia

Many patients with scarring alopecia notice changes in their hair texture, especially a change to a drier, more brittle and slightly curlier hair texture. As the name suggests, scarring alopecia is associated with the development of scar tissue or ‘fibrosis’ under the scalp. Such fibrosis affects how hairs emerge from the scalp. Hair frequently twist and turn as they emerge from the scalp and sometimes even rotate 180 degrees. We call this twisting and turning ‘pili torti.’ Individuals with pili torti will notice a hair textural change.

Scarring alopecias are universally associated with loss of the oil glands (sebaceous glands) in the scalp. One can not have a scarring alopecia without having a reduction in the oil glands. These oil glands lubricate the hair follicle.  The destruction of sebaceous glands during the process of scarring alopecia contributes in part to the drier texture. 

Scarring alopecia also affects the quality of the hair that is produced. Commonly there is hair breakage on account of the much weaker fibers. 

Consideration 2: Hormonal changes

A variety of hormonal changes can lead to drier, coarser hair.  About 15 % of women are affected by thyroid disease and this a common cause of textural changes. The incidence fo thyroid disease is much more common in the conditions that you mention including lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) and so thyroid status should always be carefully evaluated in patients with scarring alopecia.

With approaching menopause, the declining estrogen levels and  imbalances in the ratio of androgens to estrogens also results in drier hair. Women who are predisposed to develop androgenetic alopecia may notice that the hair becomes finer and some may notice the texture changes too. About 40 % - 50% of women with frontal fibrosing alopecia (FFA) and lichen planopilaris (LPP) have androgenetic alopecia. 

Consideration 3: Heat and chemicals

A variety of products that are applied to the scalp can lead to the hair becoming drier, and more brittle. Products containing alcohol are frequently a culprit. This includes hairsprays but many other alcohol containing cosmetic products as well. Products such as minoxidil lotion, and topical steroids may contain alcohol-based ingredients which also dry out the hair.

Consideration 4: Inflammatory scalp diseases

A variety of scalp conditions that are associated with inflammation can lead to altered hair texture over time. Conditions such as seborrheic dermatitis and psoriasis can lead to drier duller hair. Many individuals with FFA and LPP have co-existent seborrheic dermatitis and if present, this should be treated. 

Consideration 5: Androgenetic alopecia (AGA)

Androgenetiic alopecia (AGA) is also a cause of hair textural changes. Although we discussed AGA in the context of hormonal changes above (see "Consideration 2"), androgenetic alopecia can also cause textural changes irrespective of any hormonal abnormalities. In fact, 85 % of women with androgenetic alopecia have normal hormone levels. In women, androgenetic alopecia is also known as female pattern hair loss and in men, male pattern balding. 

Women with AGA often notice the hair is finer and some notice the hair becomes curlier. Others notice the hair becomes flatter and less likely to hold it's original shape, curl or wave. 

Consideration 6: Aging

Hair "aging" is a poorly researched area and poorly defined in general.  Age-related changes in hair, independent of the hormonal changes that can occur with age, can also lead to textural changes in the hair. 

Conclusion

There are a variety of reasons for hair textural changes. One can usually determine the cause of the textural changes with a full review of one's story (i.e. the medical history) along with an up close examination of the scalp. Most of the time blood tests are also needed. 

Thanks again for the great question.