How does an exclamation mark hair differ from a regrowing hair?

Question

I have alopecia areata and see many short hairs on my scalp and wonder if they are exclamation mark hair or regrowing hairs. How can I tell?

Answer

It's generally quite easy to tell an exclamation mark hair from a regrowing hair. A regrowing hair is thick at the bottom and 'pointy' at the top. Regrowth gets longer and longer over time. In contrast, an exclamation mark hair is wider at the top and thinner at the bottom where it enters the scalp. The exclamation hair does not get longer and longer over time. In fact, it usually falls out of the scalp.

You may wish to review these helpful articles (below) I've written in the past. Thanks again for the question. 

Exclamation mark hairs

Pointy regrowing hairs

For alopecia areata, what treatments should I consider to boost growth?

Question:

I have alopecia areata and am currently getting steroid injections from my dermatologist. What treatments can I also be using or discussing with my doctor that could help me get back my hair faster?

Answer:

There are many treatments that are possible for alopecia areata. In fact, at last count there were 26. The so called first-line "top 3" starting points for anyone with alopecia areata are steroid injections, topical steroids and minoxidil. These should not be abandoned before they have at least been given consideration. Combining them can often help get the hair back more readily if use of one alone seems to not be giving robust regrowth. There treatments are not appropriate for everyone, but are appropriate for those with 1-8 distinct patches of alopecia that cover less than one-half the scalp. Of course, these treatments should only be considered after someone has had blood tests to check their iron (ferritin), vitamin D and thyroid levels. If these are abnormal, treatments of any kind might not work as well.

Topical steroids, steroid injections and minoxidil are helpful for many people with 'patchy' alopecia areata (which is a form of alopecia where the hair loss occurs in circles). These treatments become less helpful the more hair loss a person has. Individuals with widespread alopecia areata, alopecia totalis or alopecia universals typically require other treatments that steroid injections, topical steroids and minoxidil. Such treatments included DPCP, anthralin, methotrexate, prednisone or tofacitinib. 

You may wish to review these helpful articles (below) I've written in the past. Thanks again for the question. 

Treating alopecia areata: More than shots?

Cortisone injections: What are they and how are they used?

General articles on alopecia areata

What topical steroids are safe to use in FFA?

Question:

I was diagnosed with frontal fibrosing alopecia and prescribed a topical steroid by my dermatologist. I've been using it for 5 months. I am wondering if it's too strong because my skin seems thin in the area of the hair loss. What topical steroids are best to use for FFA?

Answer:

Topical steroids can be mildly helpful for some patients with FFA. Generally speaking they are not as effective as steroid injections, and oral medications such as finasteride, doxycycline or hydroxychloroquine. Nevertheless, topical steroids do have a role in the treatment of FFA.

There are many classes of topical steroids and they range from class I to class VII. Class I steroids are the strongest and include agents like clobetsol. Class VII steroids include weak steroids like hydrocortisone.  Clobetasol is up to 600 times strong than  hydrocortisone and so has much more potent anti-inflammatory effects.  There's no doubt about it that stronger steroids suppress inflammation better- but that does not mean that stronger steroids are better, especially for FFA. In FFA, we need to consider side effects  - in particular the thinning of the skin that both the steroids and the disease itself can cause. 

Clobetasol, however, carries a greater risk of side effects including thinning of the skin. Patients with FFA already have thin skin to begin with (on account of their disease). So, one needs to be careful when treating FFA not to thin the skin further. Monitoring is needed and photographs are essential in this regard. 

Generally speaking, when someone with FFA notices thinner skin and blue veins appearing it's typically the disease itself that caused this - not the topical steroid. Nevertheless, to limit the side effects of topical steroids, dermatologists frequently prescribe weaker steroids to use on the frontal hairline for those with FFA. Instead of using clboetasol, steroids like fluocinonide or betamethasone are often used. Rather than using daily, these are frequently used every other day to limit side effects.  In addition, a non-steroid medication like pimecrolimus might be used as well. Pimecrolimus does not cause thinning of the skin but the trade off is they are not quite as consistently effective as the topical steroids. 

If clobetasol is going to be used, that is a decision that the dermatologist and the patient must both review together and be comfortable with. Daily use of clobetasol on the frontal hairline for a prolonged period is probably not a good idea when treating FFA. Some physicians might use it a few times per week or daily for a very short period of time. However, daily use of a strong steroid increases the risk of the patient experiencing further thinning of the skin.  

You may wish to review these helpful articles (below) I've written in the past. Thanks again for the question. 

Topical steroids and FFA

General articles on frontal fibrosing alopecia

Does a sunburn cause hair shedding?

Question

I have had a few burns on the scalp from a recent trip to a sunny destination. I notice that I am shedding more than normal in the last few weeks and am wondering if a sunburn can cause hair shedding?

Answer

A sunburn can cause a hair shedding in the form of a "telogen effluvium"  which can last a few weeks. It is the ultraviolet radiation rather than the heat itself that triggers the shedding. Ultraviolet radiation is a powerful inducer of hair cycle changes. A sunburn can cause a telogen effluvium (shedding) which can last a few weeks. Burns can cause inflammation which also drives shedding. Most with sun burn induced telogen effluvium find things settle in 3-6 weeks.