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.

Cyclosporine and Hydroxychloroquine Drug Interactions

Why is their a concern about using cyclosporine with hydroxchlorquine?

I’ve selected this question below for this week’s question of the week. It allows us to discuss an important drug interaction between cyclosporine and hydroxychlroquine (Plaquenil).

QUESTION

Dear Dr. Donovan.

I'm a 25 yr old woman with diagnosed lichen planopilaris (LPP). It's proven difficult to treat. My doc just prescribed plaquenil and cyclosporine, but I noticed on your handout that it says these drugs interact. Why do you not prescribe them together?

Thank you for your time!

ANSWER

Thanks for your excellent question. The reason is this: hydroxychloroquine (Plaquenil) can potentially Increase cyclosporine levels in the blood leading to higher cyclosporine in the blood and increase the risk of cyclosporine side effects.

Cyclosporine and hydroxychloroquine are two drugs that may have benefit the treatment of lichen planopilaris. The use of the two medications together (at the same time) carries the risk of increased side effects and elevated serum creatinine. Use of the two medications together is generally discouraged but if they are used together it should be done only under supervision of doctors who understand the proper monitoring that is necessary. Frequent blood pressure monitoring and frequent measurement of serum creatinine and frequent evaluation of side effects will be required.

Let’s take a look at what is known in the past.

The first indication of a potential interaction between cyclosporine was with “chloroquine” - a close cousin of hydroxychloroquine. In 1993, Finielz and colleagues published a study in the journal Nephron of a 28 year old kidney transplant patient who was stable on cyclosporine, prednisone and azathioprine. His creatinine level was 200 umol/L. His blood cyclosporine level was 105 ng/mL and his blood pressure was normal 130/80.

He then decided to go on vacation and started treatment with chloroquine for prevention of malaria. His blood pressure just 6 days later increased to 160/100, his creatinine level rose to 234 and his blood cyclosporine level rose more than four times to 470 ng/mL. His levels reduce again when chloroquine was stopped and levels rose yet again when the drug was given back.

An increase in cyclosporine levels has also been noted in patients using hydroxychloroquine (Plaquenil). Some rheumatologists in years gone by have studied this combination. But that’s not to say it’s not without potential risk - there are.

A 1996 study examined the benefits of combining cyclosporine to patents with rheumatoid arthritis who were not improving with hydroxychloroquine or methotrexate. We’ll focus here on the results of combining cyclosporine and hydroxychloroquine because this is what your question pertains to.

The study included 12 patients using both hydroxychloroquine and cyclosporine. During the study, the mean daily dose of CsA ranged from 2.5 to 4.2 mg/kg and at 6 months it was 3.3 mg/kg. The mean serum creatinine levels increased by 0.1 +/- 0.2 mg/dl in the patients treated with the two drugs. In 5 of 12 patients (41.6 %) there was a concerning increase in creatinine of more than 130 %. Other side effects seen in the combination were gastrointestinal side effects (41.6%), hypertrichosis (25%), gingival hyperplasia (25%), liver test abnormalities (8.3 %), and neurological problems (16.6%). This is not by any means a complete lists of side effects of cyclosporine - those will need to be reviewed with your doctor.

Conclusion

Thanks again for the great question. Yes, there most certainly is a potential drug interaction between cyclosporine and hydroxychloroquine that is very important for patients and treating physicians to be aware. Cyclosporine is notorious for drug interactions so I recommend that anyone who uses cyclosporine get in a routine of shouting out loudly “I am on cyclosporine - does this drug interact?”

Any patient started on combined hydroxychloroquine and cyclosporine treatment will need to first check that this was not an error by the prescriber. Sometimes this is what the prescriber intended - as seen above in the 1996 study I mentioned. This is not, however, all that common anymore. If it was not an error, the patient will need very, very close monitoring. Blood pressure will need to be measured daily during the starting period. Serum creatinine levels and serum cyclosporine levels will need to be measured very frequently and side effects will need to be closely monitored.

References

1] Uptodate.com

2] https://www.drugs.com/interactions-check.php?drug_list=763-0,1298-0

3] Salaffi et al. Combination therapy of cyclosporine A with methotrexate or hydroxychloroquine in refractory rheumatoid arthritis. Scand J Rheumatol. 1996;25(1):16-23.

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.