Topical steroids for Pain from Telogen Effluvium

Topical steroids for telogen effluvium related pain

 
I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in treating scalp pain in the setting of telogen effluvium.

Question

What is the best topical steroid for TE pain?

Answer

This is a great question and really requires me to see the scalp up close and know more about the story. I would want to make sure first of all that the pain is truly coming the TE and not something else. There are many many conditions that mimic TE that give scalp pain. However those are not TE and a completely different approach is going to me needed.

Some common examples of conditions that look like TE but are not TE and give pain are: lichen planopilaris, psoriasis, seborrheic dermatitis, dermatomyositis, allergic contact dermatitis,

So what is the best steroids for TE related pain in general?
Well probably none unless clearly there are inflammatory issues going on too. Corticosteroids don’t do much for this in most cases. A steroid like betamethasone valerate 0.1 % is safe to try for a few days of course (under supervision from a physician). But if it takes away pain, I’d be wondering actually if there is an underlying issue like seborrheic dermatitis that is actually being treated.

If a patient gets lots of relief from steroids and they think they have TE, a careful exam should be done to confirm if another diagnosis is present (or biopsy).

No, steroids are not really a solid option for TE pain.

The best treatment is to treat the cause of the TE.

Pain and tenderness and ‘trichodynia’ can absolutely be a part of telogen effluvium symptoms. The issue however is that we typically don’t use steroids all that often. they can be tried of course if other causes have confidently been ruled out.

Other options include low dose naltrexone, topical gabapentin, topical TKAL, oral gabapentin, Lyrica, hypoallergenic shampoos, apple cider vinegar.

All in all, if a lot of relief comes from topical steroids, I would be asking myself “Are we missing another diagnosis?”

Blood Thinners Around the Time of A Hair Transplant

Prescribing Blood Thinners are Not a Part of Usual Care.

 
I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in starting a new prescription for blood thinners before a hair transplant.

Question

I have heard that blood thinners can be used around the time of a hair transplant to improve blood flow. Is this correct?

Answer

No. Blood thinners are not part of standard practice. Perhaps you are referring to something else?

A hair transplant is nothing more than a giant wound healing phenomenon. The surgeon wounds the scalp and take hairs from here to there and then the whole thing is allowed to heal. Does one try to find a doctor to prescribe blood thinners after one cuts their arm or leg or scrapes their knee? No. Blood thinners should be left out of the plan for healthy people without underlying medical conditions that require them.

Blood thinners are needed by some patients for certain diseases. That is a bit of a different situation and not what is being asked here. In these cases, consultation with the surgeon is needed to decide on the best course. Sometimes, blood thinners are stopped and sometimes changed to other blood thinners around the time of surgery. All in all, prescribing traditional blood thinners for the purpose of improving blood flow in a hair transplant is not advised.

Topical minoxidil vs Oral Minoxidil: which works better?

Should I use topical or oral minoxidil?

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

Question

Does oral minoxidil work better than topical minoxidil?

Answer

Thanks for the question. Super duper high dose oral minoxdiil works better than super mini low concentration minoxidil. Everything else lies somewhere in the middle.

For males, 5 mg oral minoxidil is much more likely to help than once daily application of 5 % minoxidil. It also has way way more side effects. This is not a yes or no answer.

For females, 2.5 mg oral minoxidil is much more likely to help than once daily application of 2 % minoxidil. It also has way way more side effects. This is not a yes or no answer.

In general, 5 % minoxidil once daily in women seems to be fairly similar to 1 mg oral minoxidil. This is based on some very nice work by Ramos and colleagues in 2020. In males, it’s not so clear, although 5 % minoxidil twice daily is probably somewhat similar to 1.25 mg. 2.5 mg dosing in males is probably superior to 5 % twice daily but good studies have yet to really be done.

All in all, topical minoxidil can be similarly effective compared to oral minoxidil in some patients. But this is assuming we are talking about standard dosing. If we increase the dose of oral minoxidil, we increase the chances that oral minoxidil works better than topical minoxidil for the patient we are talking about and we also increase the chances of side effects.

0.000000000000001 % minoxidil is not as effective as 5 % oral minoxidil.

5 % minoxidil is more effective than 0.00000000001 mg oral minoxidil.

Context is everything in these discussions.

REFERENCE

Ramos PM et al. Minoxidil 1 mg oral versus minoxidil 5% topical solution for the treatment of female-pattern hair loss: A randomized clinical trial. .J Am Acad Dermatol. 2020 Jan;82(1):252-253.

Hair loss from Kenalog: Is it going to grow back?

Hair loss after steroid injections

 
I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in hair loss from steroid injections.

Question

I have hair loss from kenalog injections. Is it gonna grow back?

Answer

Thanks for the question. The short answer is that it really depends on your full story and why you are getting steroid injections in the first place. I would need to see the scalp up close and know your full story to best answer this question.

If your hair loss patches is indeed from the kenalog injections AND THE REASON FOR THE HAIR LOSS IN THE FIRST PLACE WAS A NON SCARRING ALOPECIA it has a high chance to grow back provided you don’t keep having more and more injections in that spot. If you keep having more injections you run the risk of worsening the atrophy and affecting recovery even more profoundly. It can take 2-6 months for improvement to occur but there is a high chance of improvement (assuming that hair loss condition is being treated with some other strategy).

For example, if the patient has alopecia areata and develops worsening hair loss from steroid injections, the hair may grow back if the kenalog is stopped and some other strategy like topical minoxidil, topical JAK inhibitors, oral steroids, oral immunosuppressants are used to control the inflammation.

If your hair loss patches is indeed from the kenalog AND THE REASON FOR THE HAIR LOSS IN THE FIRST PLACE WAS A SCARRING ALOPECIA it may or may not grow back. Sometimes the scarring alopecia itself is so intense that kenalog can not stop the destruction. The patient has steroid injections and the scarring alopecia goes on to destroy more hair. The hair loss in some cases is from the scarring alopecia. Even if there is a bit of hair loss from the steroid injections, sometimes the destruction is so intense that hair growth and recovery of the shed hairs does not occur.

In summary, the original diagnosis is really important here. In a case like this, I would want to know does the patient have alopecia areata? does the patient have lichen planopilaris? frontal fibrosing alopecia? other ?

ARTICLES YOU MIGHT FIND HELPFUL:

ARTICLE 1: Atrophy from steroid injections

ARTICLE 2: Atrophy from steroid injections: Should I be stopping?

Things to Consider when Topical finasteride does not work

Topical finasteride at low doses

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

Question

I am on topical fin 0.025 %. I have been using 2 months and I am still shedding. I measured by dHT in the blood and it has not changed all that much. Do you think this is working?

Answer

Thanks for the great question.

My feeling here is that this is the wrong approach to evaluating hair loss.
Looking at serum DHT in this way is not really a key parameter to track to see if topical finasteride is working. No. If you could measure skin DHT (rather than blood) before and after that would be more relevant. The reality is that you can’t do this easily because it’s not available to the general public (it’s very expensive and used only in research).

For now, you can easily tell if topical finasteride is working by assessing these answers with your doctor after 6 months of treatment:

1) is the shedding less?

2) is the hair density better by photos?

Your topical finasteride concentration is pretty low so be sure to keep close follow up. Most of the time, we don’t use such low concentrations but yes, it’s an option. 0.1 % and 0.25 % are becoming more common.

Shedding can occur in the first two months of starting topical finasteride (or oral) so we can’t say for sure this is a bad sign of a sign things are not working but it’s certainly not looking favourable at the 8 week mark.

Give it a few months if you and your doctors are comfortable with that. Review the literature with your doctors for optimal dosing.

Oral Minoxidil and Pet Owners: Is there still a Concern?

Do I still need to worry if I use oral minoxidil instead of topical minoxidil?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in the use of minoxidil in cat owners.

Question

I am a cat owner and understand from your presentations how harmful topical minoxidil is to cats. My husband is thinking about starting oral minoxidil. Would it be a problem if the cats licks his skin?

Answer

Thanks for the great question. You might be referring to an important study from 2021 which highlights the toxicity of topical minoxidil in cats and dogs. A link is provided here:

The short answer is that study of cats and dogs becoming sick from licking the skin of someone using oral minoxidil have not been done. But it does not seem to be a big risk.

The body gets rid of oral minoxidil mainly by the kidneys and putting it and its metabolites into the urine. In other words, the skin does not appear to be a method of elimination of any significance although studies relating to cats have not specifically been done.

At present, one would not expect this to be a big concern in oral minoxidil users at low doses used in hair loss. Be sure to review your story in full with your dermatologist and veterinarian.

To Treat or Not To Treat Telogen Effluvium: Do I need to treat it?

To Treat or Not To Treat Telogen Effluvium

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

Question

Do I have to correct a telogen effluvium? I thought it always just runs its course and resolves.

Answer

Thanks for the question.

No. you are incorrect. Telogen effluvium does not always run its course and resolve.

An important key here is whether the trigger is removed. Unless the trigger is removed, the hair shedding does not stop.

Telogen effluvium triggered by a fever will stop on its own. A fever in February may trigger shedding in April or May and then shedding stops by September, October or November. No treatment is needed.

However, telogen effluvium that is caused by a new drug started in February will never stop until the drug is stopped.

Telogen effluvium caused by a thyroid disorder that starts up in February does not stop until the thyroid disorder is addressed.

Telogen effluvium caused by anorexia does not stop until the weight comes back up.

Some telogen effluviums need the trigger addressed before shedding stops! Some triggers resolve on their own.

But the answer to your question is no - not every telogen effluvium just resolves on its own. I have many patient with chronic nutritional issues (from cancer and other diseases), eating disorders like anorexia nervosa, chronic medication use that they just can’t stop (ie heart medications or seizure medications), high stress. This patients keep shedding because it’s challenging to fix the triggers.

Traction Alopecia vs Lichen Planopilaris: Are they easy to confuse?

 Traction alopecia vs LPP: Do they look similar?

 
I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in how traction alopecia and lichen planopilaris might differ

Question

I have one dermatologist who thinks I have traction alopecia and another who thinks I have LPP. Of course, we are going to get a biopsy soon but I’m wondering if they look similar clinically. Aren’t they normally easy to tell apart?

Answer

Thanks for the question.

LPP and traction sometimes look similar.   Most cases of LPP have more defined patches of scarring than traction alopecia and more prevalent perifollicular scaling. In the early stages however, traction and lichen planopilaris can look similar.

Usually, however, they don’t. The one exception is the perifollicular redness that can be seen in both LPP and traction.

 LPP often has scale around hairs and baby hairs (vellus hairs) missing. Traction alopecia usually does not have scale but may have tubes around the hairs higher up (called casts). Traction alopecia usually has lots and lots of baby hairs (vellus hairs) in the early stages.

Here’s a helpful summary:

I am glad to know you’ll have a scalp biopsy soon. Usually an astute pathologist can help sort through challenging cases. Most cases of traction have high numbers of hairs - it’s just many are converted to tiny vellus hairs. Sebaceous glands are present in traction alopecia but lost or reduced in LPP.

Thanks again.

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.

Is PRP an option for Alopecia Areata Treatment?

Is PRP an option for treating alopecia areata?

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

Question

I have had patches of alopecia areata for the past few months. I’d like to use something natural rather than medications and things. I am afraid to use steroid injections or topical steroids given their side effects. Is PRP an option for alopecia areata?

Answer

Thanks for your question. I would encourage you to take your time and ask lots of questions. Your views on the safety of steroid injections and topical steroids may or may not be accurate. In general, the first line treatments for ‘patchy’ alopecia areata are steroid injections, topical steroids and topical minoxidil. For small patches, the safety is quite good with these three treatments. Side effects are uncommon but of course mild temporary ones can occur.

Here are typical treatments to consider for alopecia areata in the patchy stage. You can see that PRP is a second line option rather than a first. That means that we don’t typically turn to it first as a treatment but it may be an option IF first line options don’t work or a patient does not wish to use the first line options.

Alopecia is unpredictable. I would need to know a lot more information about your story to advise what I would recommend in your specific situation. For some patients, treatment is short term and recurrences uncommon. For others treatment is lifelong. Many patients with alopecia areata regrow their hair spontaneously even without treatment within 1 year. Steroid injections is far more effective and efficient as are all the first line options. That’s why they are called first line options. Many clinics do a wonderful job scaring patients out of the first line options so that patients can start whatever the clinic offers. ( A clinic that offers laser therapy or PRP or sells other remedies may say “Oh you wouldn’t want to do injections that’s so dangerous!).

In summary, PRP is an option - yes! But it’s not usually the first step for most.

Hydroxychloroquine (Plaquenil) in Pregnancy

Is Plaquenil Safe for Pregnancy?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts about hydroxychloroquine (Plaquenil) use in pregnancy.

Question

I am a 32 year old female and have lichen planopilaris. I use Plaquenil, along with topical steroids and topical tacrolimus. I am hoping to become pregnant again soon. I am finally doing quite well on hydroxychloroquine (after resistance on my part to use it!). I wan to know if I really need to stop it or not during pregnancy.

Answer

Thank you for the question. This is an important question.

I would encourage you to review a previous article I wrote on this topic. It covers so many important points.

I would also recommend that you review a prior article on the treatment of lichen planopilaris in pregnancy as it too is likely to be helpful for you.

In short, we don’t have any research studies of women with lichen planopilaris who used hydroxychloroquine (Plaquenil) during pregnancy. All the information that we do have comes from studies of women with the autoimmune disease known as systemic lupus. For women with lupus, it appears that hydoxychloroquine use at quite low doses does not seem to increase the risk of babies being born with deformities or congenital anomalies of any kind. It’s controversial whether using hydroxychloquine at 400 mg per day might be associated with risk. A 2021 study of 2045 women who took hydroxychloroquine during their pregnancy found a slight increase risk in congenital anomalies among women who used the highest doses. Fortunately, women using doses under 400 mg daily did not have an increased risk.

All in all, hydroxychloroquine at low doses can be used by some women but it’s not 100% clear if it is truly without risk to the baby or not. Please have a read of these two links and be sure to have thorough discussions with your dermatologist, and obstetrician about these issues.

Generally speaking LPP remains somewhat stable in pregnancy for many women. The periodic use of betamethasone lotion and zinc pyrithione shampoos can help keep inflammation to low levels and have good safety. Low level laser, clobetasol, tacrolimus and cetirizine can be used if needed.

Thank you again for your question

Stopping Doxycycline Before Sunny Travel

Doxycycline, Scarring Alopecia …. and Vacation

I’ve selected this question below for this week’s question of the week. It allows us to review the concept of photosensitivity with doxycycline.

Question

I use doxycycline and clobetasol for my scarring alopecia (lichen planopilaris). I am going on a trip with friends to a very sunny destination and I will need to be outside a lot!!!!!! I know that doxycycline can cause burns. Do you have any advice on what you recommend to patients?

Answer

Thanks for the great question. It’s difficult to give an exact answer for your situation as I don’t know all your story (or your skin type) but let me give you some important general points that I hope will help you.

Patients who use doxycycline for scarring alopecia have an importance difference compared to patients who use doxycycline for malaria prophylaxis or for treatment of an infection: they can stop it!

Stopping doxycycline for a week before leaving is often (though not always) the advice I give. It depends a bit on the skin type of the patient (light skin vs dark skin), the activity level of the scarring alopecia and how detrimental I think stopping doxycycline will be to a possible new flare of disease activity. For patients with light skin types, with stable scarring alopecia…stopping the doxycycline for short periods of time will be important to do.

Photosensitive Rashes from Doxycycline

Sun induced rashes can occur in 8-22 % of patients who use doxycycline. It is the UVA spectrum rather than UVB that seems responsible for the rash. The exact chances of a reaction depends a bit on dose. Patients who use 100 mg twice daily have a greater risk of rashes compared to those who use 100 mg once daily. This was nicely shown in a 1993 study by Layton and colleagues where the authors showed that 6 of 30 patients (20%) treated with 150 mg doxycycline per day and 32 of 76 subjects (42%) taking 200 mg per day developed a phototoxic reaction.

The rash happens within 12-24 hours of sun exposure. The patient develops redness and burning on the sun exposed areas like the nose, cheeks, lips, hands, forearms. Thicker red plaques can form as well. There is often pain and itching and it can be quite intense in severity for some patients. This is known as a photo-toxic reaction. Doxycycline-induced phototoxic reactions are more common in those with lighter skin types than darker skin types.

A completely different phototoxic reaction that can occur with doxycycline is photo-onycholysis. This refers to separation of the nail plate from the nail bed.

In some studies, there is no relation between severity of phototoxic reactions and sex, age and duration of therapy,

Treatment

I generally advise patients to stop doxycycline one week before leaving - if possible. If there is a history of severe reactions already, then 10-14 days may make more sense. Sunscreens that block the broad spectrum of UVA radiation will be helpful. Hats, long sleeve shirts, long pants are all part of the plan to consider as well as sun avoidance. In intensely hot places with a great deal of sun, wearing long sleeve shirts and long pants may not always be practical or easy. The same is true with avoiding sun while on vacation with friends.

In some cases, I may advise that patients increase the use of other supportive treatments while away including topical steroids, tacrolimus etc. For example, I may advise a patients who normally uses clobetasol three times per week to use it 4 or 5 times times week.

Conclusion

All in all, up to 1 out of 5 people can have photosensitive reactions with doxycycline when exposure to intense sun occurs. We do need to counsel patients about it and do everything we can to prepare and prevent these reactions. Stopping the medication before travel makes a lot of sense for those that are using doxycycline for its anti-inflammatory benefits. Clearly, those that use doxycycline for its anti-infective benefits such as a patient using doxycycline for malaria prevention, can not stop this medication when they head to a sunny marlaria endemic area

REFERENCE

Steven Goetze S et al. Phototoxicity of Doxycycline: A Systematic Review on Clinical Manifestations, Frequency, Cofactors, and Prevention. Skin Pharmacol Physiol. 2017;30(2):76-80.

Layton AM, Cunliffe WJ: Phototoxic eruptions due to doxycycline - a dose-related phenomenon. Clin Exp Dermatol 1993;18:425-427.

Non-Immunosuppressant options for Advanced Alopecia Areata

I’m afraid to start JAK inhibitors. What options are available?

I’ve selected this question below for this week’s question of the week. It allows us to review options for advanced alopecia areata.

Question

I am 25 year old and have alopecia universalis. I have used methotrexate and cylosporine and had steroid injections and nothing much has worked. I’m not sure I want to use JAK inhibitors yet.

Can you provide me with some options that one can at least consider in this kind of scenario?

I realize that everyone is just throwing their hands up and telling me to take the JAK inhibitor or give up - what else if anything might there be?

Answer

Thanks for the great question. You are correct that the traditional immunosuppressants are first line for patients with more advanced types of alopecia areata.

There are several non immunosuppressant options that are helpful sometimes. These include dupilumab (if there is evidence of ezecma), oral minoxidil and statin cholesterol medications (simvastatin/ezetimibe). These may be all combined with antihistamines like fexofenadine and cetirizine. I would like to point out that these tend to be less effective that the immunosuppressants you mentioned earlier. Diphenyprone and squaric acid are options but they only help the scalp and not eyebrows and eyelashes. They help 10 % of those with very advanced alopecia areata compared to 30 % with the JAK inhibitors.

You'll want to discuss these options with a dermatologist who specializes in hair loss as these are all more advanced options.

COVID-19 Vaccine Induced Hair Loss

Can the Sars-COV-2 (COVID 19) Vaccines Can Hair Loss?

I’ve selected this question below for this week’s question of the week. It allows us to review the concept of hair loss from vaccines.

Question

I had my first vaccine in April 2021 and my second in June 2021. My booster was in Jan 2022. I have had problems with hair shedding throughout 2021 and it has become particularly a problem in 2022. I feel that the vaccines probably contributed in some way because in March 2022 I developed scalp inflammation too along with muscle pains, fatigue and periodic headaches.

Do you see patients with vaccines causing hair loss issues and other more widespread issues?

Answer

Thanks for the great question. It’s possible for vaccines to cause hair loss as well as systemic issues. There can be both short term temporary issues which are somewhat well characterized and then long term persistent issues which are not so well studied yet.

Short term, we know that vaccines can cause fever, chills, headaches, fatigue, short pains, muscle pains. We know the frequency of these fairly well because they have been documented fairly well in trials

Longer term term issues and persistent issues are less common and not as well studied.

Hair Loss and COVID Vaccines

A proper evaluation is needed for everyone with hair loss associated with COVID vaccines. These can be pretty complex issues. Sometimes the hair loss issues are unrelated and the vaccine timing is a coincidence and sometimes the vaccines is very much related. For those situations where the vaccine is felt to be related it’s important for the hair specialist to figure out if the vaccine likely caused the issue or simply made an existing issue worse.

In the clinic, we deal with a variety of clinical scenario after COVID vaccines. These include telogen effluvium, , alopecia areata, lichen planopilaris, dermatomyositis and lupus. Vaccines can cause shedding with weeks to months after vaccination. Vaccines can rarely cause new onset alopecia areata and a flare of existing alopecia areata. Flares of lichen planopilaris, a type of scarring alopecia, have been reported.

See Articles

Flare of Lichen Planopilaris After COVID Vaccines

Alopecia Areata: COVID Vaccines and Infections Can Both Act as Triggers

9 Cases of Alopecia Areata After COVID Vaccination

COVID Vaccines and Alopecia Areata

COVID Vaccines and Autoimmunity in General

It’s also recognized that vaccines can affect a variety of other autoimmune diseases. I don’t see these all that much in my hair loss clinic but they include rheumatoid arthritis, scleroderma flares, idiopathic thrombocytopenic purpusa, Sjogren’s sydrome

Final Comments

Thanks for the question. I would encourage you to first get a formal diagnosis for what’s going on. Then, your hair specialist can help determine whether it’s a coincidence or a contributor. Treatments are similar regardless of whether it’s a concidence or contributor. The key is whether to have the same type of vaccine again. There’s no right answer.

With at least 7 million deaths so far from COVID 19 (and estimates likely suggest closer to 20 million), it’s important that we reduce morbidity and mortality from COVID 19. Vaccines help do that so it’s by no means a simple topic when it comes to what to do with vaccine related side effects. The risks and benefits need to be weighed for everyone.

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.

Should I increase my oral minoxidil?

Should I increase my oral minoxidil ?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in use of oral minoxidil in LPP and the timing of adding it to the plan .

Question

I was diagnosed with LPP in early January 2022. I am receiving monthly injections and take Doxycycline twice a day.   My LPP is still active.   In early April, I started taking 0.625mg of Minoxidil, increased shedding began three weeks after starting the minoxidil and it doesn't seem to be slowing down.

The shed is extreme and now terrifying.

I am supposed to be increasing my dose soon to 1.25 mg but am concerned. Is this normal to be going on this long and if so, when will it stop or will this continue at this rate?

Answer

Thank you for this question. In order to fully answer all parts of this question, I would need to know more of the story and see the scalp up close. I don’t have all the information but hopefully my answer will help. The short answer is the it’s normal to get shedding and likely it will last 1-2 months.

I will assume here that LPP is the diagnosis. What I do not know is whether issues like frontal fibrosing alopecia (FFA), androgenetic alopecia (AGA) or seborrheic dermatitis (SD) are also present.

That is important to know in fully answering this question.

It’s quite likely that the cause of shedding here is the oral minoxidil. This is quite typical and usually lasts 2 months.

What I don’t know there is whether you also have other issues which can contribute to shedding like androgenetic alopecia and telogen effluvium.  You and your doctor will want to make sure no other issues that cause shedding are present.

If you haven’t done it already, you’ll want to get blood tests for iron studies (ferritin), thyroid studies (TSH), zinc, and vitamin D. Other labs might be important to get but that will depend on your story and what the scalp examination shows.

You and your doctors can review if other issues that cause shedding might also be present. These include stress, low iron, thyroid problems, COVID 19 infections, other infections,  other medications and weight loss. Of course, a sudden increase in the shedding can always be due to the LPP activity suddenly increasing. Whether that’s an issue needs exploration.

My personal preference when treating LPP is to get the LPP under control and then add growth stimulators like oral minoxidil, laser, PRP later on. There’s nothing wrong with adding them right now as you have – but my preference is to wait until the LPP disease activity has really been reduced to minimal levels.

So I add growth stimulators like minoxidil, PRP, laser only when the LPP has been brought under really good control.

Now back to your question.  I think it makes sense for someone with your story to continue doxycycline and the steroid injections. You might back down on the steroid injections to every 6-8 weeks and add topical clobetasol. That’s just my preference but there’s nothing wrong with monthly injections. You’ll want to make sure you don’t have atrophy (indents) forming in the scalp.

I think the oral minoxidil must continue as you may get hair loss if you stop right now and you may get hair loss if you increase right now. For my own patients with similar stories as yours, I generally advise to continue oral minoxidil for now at 0.625 mg and consider increasing the dose in the future.

I would not increase right now. But that’s my opinion.

I think the key question here is whether or not doxycycline and steroid injections are doing the job fully to shut down the LPP. If not, you might want to speak to your doctors about adding clobetasol or hydroxychloroquine (Plaquenil) or oral cetirizine (Zyrtec, Reactine, etc.) or low dose naltrexone.

You’ll want to make sure that someone checks if you have seborrheic dermatitis. If it’s present, you’ll want to add a dandruff shampoo to your plan. Zinc pyrithione, Selsun blue, ketoconazole and ciclopirox are all common options.

You’ve probably had many labs done, but you’ll want to make sure ferritin, TSH, CBC and vitamin D were done. You and your doctors can discuss others like cholesterol, glucose, hemoglobin A1c.

If there is any evidence of frontal fibrosing alopecia, dutasteride can be considered. Isotretinoin can also be considered in the future -  but we don’t use this with doxycycline because of an interaction.

Once the shedding comes under better control (hopefully in a few months), it may be possible to increase the oral minoxidil dose to 1.25 mg. I would not do that now (yet) but that’s just my view.

Overall, my thoughts in a clinical situation (with limited clinical information) like this are to 

1)    Continue doxycycline

2)    Continue steroid injections (reduce to every 6-8 weeks)

3)    Continue 0.625 mg Oral minoxidil)

4)    Considering adding one or more of the following: clobetasol, hydroxychloroquine, cetirizine

5)    Treat any seborrheic dermatitis with anti-dandruff shampoos

6)    Make sure labs are done for  CBC,TSH, ferritin, zinc, ESR, cholesterol, glucose, hemoglobin A1c, vit D

7)    Treat frontal fibrosing alopecia if it is also present (dutasteride may be used).

Be sure to keep close follow up with your dermatologist. I thank you for your question and hope this was helpful to you.

Why am I shedding?

What are the reasons for my shedding?

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

Question

I am in my mid 50s, healthy and fit and not taking any medications except hormone replacement therapy started last year.

2 years ago I had a dramatic increase in hair shedding, more than 300 hairs a day. My temple area was always a bit thinner and so that area had shown the most visible loss, but the loss is all over my head, top, sides, back. The hairs that fall are almost all long hairs with a white bulb attached. I had started experiencing my first menopausal symptoms a few months prior to this increase in shedding.

The excessive shedding lasted 6 months or so and then slowed down and things seemed to return back close to normal shedding and hair density improved. It was during this time of normalization that I started hormone replacement therapy. After about 5 months on hrt, I cut my hormone dose in half. Less than 2 months later, the massive shedding started again.

Other considerations may be that 4 months prior to this second shedding, I was sick with a fever (not covid) and I also had the covid vaccine around that time, which triggered another fever that lasted for a couple days.

I have had blood tests done and everything is within range, except my ferritin is at 15. Vitamin D and thyroid are normal.

My scalp is itchy at times, but not constant and not sore or red or sensitive. There is a visible difference is how thick my hair looks now. It feels like I have lost 50% of my hair. I should note that I am always under chronic stress which has increased significantly since menopausal symptoms began 2 years ago.

Could this be AGA, TE, both? And depending on the diagnosis, would Minoxidil work (topical or oral) or Finasteride or something else?

PHOTO 1: FRONT OF THE SCALP

PHOTO 2: BACK OF THE SCALP

PHOTO 3: HAIRLINE

PHOTO 4: TEMPLE AREA

Answer

Thanks for the question. It’s pretty clear that telogen effluvium is a component of the loss and I also suspect some degree of androgenetic alopecia here - as well as seborrheic dermatitis. Without seeing the scalp up close myself with trichoscopy and knowing a great deal more of your story, it’s difficult to say whether any other cause of redness is contributing here (such as scarring alopecia, psoriasis, allergic contact dermatitis, or other immune based scalp disease). Overall, I don’t think it’s very likely especially when there have been periods where shedding really improved a great deal. (We don’t usually see shedding just settle so dramatically if an immune based issues is present).

TELOGEN EFFLUVIUM

Your story fits well with a telogen effluvium - and likely two episodes at least of telogen effluvium. Telogen effluvium is a hair shedding disorder and happens following a trigger in cases of the classic ‘acute telogen effluvium’. Triggers include stress, low iron, thyroid disease, medications, crash diets, scalp inflammatory disease, fevers and internal illness. Shedding happens 1-3 months after the trigger and improves once the trigger is resolved.

TELOGEN EFFLUVIUM FROM LOW FERRITIN

I’m a bit concerned about your ferritin of 15 and certainly that needs to be looked into further. Most women age 55-60 have ferritin levels in the 75 range. Some women age 55-60 have a ferritin of 50 and some have 150. But 15 is actually abnormally low. You and your doctor need to discuss this and look up old ferritin levels in past blood tests. If you have had a ferritin level of 15 for the past 40 years it’s less of an issue from the hair perspective. If it was much higher in the past and now it is lower, then that’s a concern. Other tests need to be measured including CBC, RDW, MCV, MCHC, MCH. These are standard parameters but give key information. B12 levels, folate, ESR, creatinine, zinc, AST, ALT and also helpful in a situation like this. If you have low hemoglobin (less than 12.0 in the USA and less than 120 in International units), the necessary tests may expand a bit further than these.

THE “OTHER BLOOD TESTS”

Other tests may be useful too but it all depends on what information is found when a thorough history is done and when the scalp and skin and nails are examined. I can’t go through all the possibilities as the list is enormously long. For example, if there are new joint symptoms an RF (rheumatoid factor) and ESR and anti-CCP may be advised. If there are muscle symptoms or certain skin rashes a CK and ANA may be advised. If there are significant concerns for dry eyes and dry mouth and extractable nuclear antigen blood test may be advised. If there are any nutritional concerns, a zinc level might be added. If there is any hair growth on the face, change in voice, or acne then a testosterone and DHEAS might be advised. If there are bruising, muscle weakness and fat redisribution, an AM cortisol might be ordered.

In anyone with shedding that is chronic, a really thorough history and examination is critical.

IRON SUPPLEMENTATION AND TESTING

Starting iron supplementation is likely to be part of the plan. But not first without a thorough discussion with your doctor. Colonoscopy screening is to be discussed too. The age range is dropping for who should be screened with colonoscopy. But this is something you should talk to your doctor about. The U.S. Preventive Services Task Force (Task Force) recommends that adults age 45 to 75 be screened for colorectal cancer. This is regardless of a person’s hemoglobin or ferritin level. I highly advise colonoscopy screening in my own patients with similar stories as you have given. If you’ve already had that screening then that’s great. But this is something you need to discuss with your providers. Mammography is also necessary. The U.S. Preventive Services Task Force (Task Force) recommends that all women 50-74 have mammography screening every 2 years.

Low iron comes from many reasons including poor absorption or poor intake, excessive loss and excessive demand. There are some 30 reasons why someone can have low iron. This needs to be looked into.

There’s nothing wrong with starting iron therapy provided you have a plan in place to further investigate why it is your ferritin is low.

Low ferritin can contribute to hair loss for many patients - especially a ferritin level of 15.

TELOGEN EFFLUVIUM FROM MEDICATION STARTING AND ADJUSTMENTS

It is likely that starting and adjusting HRT medications has given some shedding too. Provided levels stay the same, this particular cause of shedding will settle out and disappear from the list (usually). But every dose adjustment could give shedding again.

SEBORRHEIC DERMATITIS

I suspect in the photos that there is seborrheic dermatitis present. It’s quite possible this accounts for at least some of the redness seen in the photos and the itching. Whether it accounts for all the redness is not clear. I would need to see the scalp up close. It may make sense for you and your doctors to discuss a really solid seborrheic dermatitis treatment plan. This involves ‘dandruff’ shampoos used 2-3 times per week. Ingredients like ketoconazole shampoo, zinc pyrithione shampoo ciclopirox shampoo and selenium sulphide shampoo can help. These should be left on 2-3 minutes although sometimes we advise 3-5 minutes depending on the situation. They can be drying. Use of a mild corticosteroid lotion can help a great deal if you get itching.

THE ‘RED SCALP’

There are many causes of ‘red scalp’ and the list is long. I’m not too suspicious of any of these being relevant in your case but no it’s not possible to say 100% because I don’t have the whole story and I don’t have the chance to see the scalp up close myself. Some conditions are great great mimickers and always need to be considered including lichen planopilaris and contact dermatitis. A proper examination with trichoscopy can exclude the condition known as lichen planopilaris with reasonably high certainty. If anyone has doubt, a biopsy of the scalp can be done and is quite safe and easy to do. I don’t think you have this condition but you do appear to have seborrheic dermatitis scale that can hide other conditions. Again, I’m not too suspicicious about any sort of scarring alopecia and I see very large numbers of patients with this rare condition.

Allergic contact dermatitis is always to be considered. Nothing really worries me in your story so far about contact dermatitis except for the fact that we need to figure out the cause of your redness. It appears to be seborrheic dermatitis for at least one of your causes. If you get rashes on the face, neck, eyelids, ears, chest, the chances of a true allergy to some topical product in your life goes up a bit. These can give itching and shedding and include shampoos, conditions, styling agents, dyes, mousse, etc. I’m not really of the opinion this is likely to be a culprit here but someone needs to give it a passing thought with proper examination and proper questions. If there is even a hint of suspicion about allergic contact dermatitis, referral for ‘patch testing’ can be done. This is done usually by a dermatologist in most countries although some allergists will also do.

ANDROGENETIC HAIR LOSS

There is likely a component of androgenetic alopecia here. I feel that it’s not the only cause as there is most certainly a telogen effluvium here as well as seborrheic dermatitis. But AGA is quite likely a part of why you are losing hair. The frontal scalp zones appear less dense than other areas although you do have diffuse loss as well. A proper examination and use of trichoscopy can confirm the diagnosis of AGA. But it seems to be a component.

TREATMENT

There are a large number of treatments that can be considered here. The exact plan will depend on the final diagnosis. Because I can’t offer a definitive diagnosis, I can’t give a definitive plan. If we assume the diagnosis is androgenetic alopecia with seborrheic dermatitis and telogen effluvium then first we need to treat the seborrheic dermatitis and investigate the cause of low iron while starting supplementation of some kind. A really thorough history and physical will determine if you need more blood tests done. If any other labs (blood tests) come back abnormal, they need to be addressed. I think that’s pretty unlikely.

In addition to iron supplementation, dandruff shampoos and possibly topical corticosteroids, you can also consider one or more of the following for treatment of the androgenetic hair loss: topical Rogaine, oral minoxidil, finasteride, low level laser and PRP. For someone with your story, I’d generally advise starting Rogaine with or without finasteride and then deciding from there whether to add laser, PRP or oral minoxidil in the future.

SUMMARY

Thanks again for the question. I hope this helps. I think seborrheic dermatitis, telogen effluvium and androgenetic alopecia are the three diagnoses. I can’t say it’s chronic telogen effluvium you have because really what it seems like we are dealing with is an acute TE that has not been fully addressed.

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!

Hair Loss: What's causing my hair loss?

What’s causing my patch of hair loss?

I’ve selected this question below for this week’s question of the week. It allows us to review some concepts regarding clinical and trichoscopic examination of acute hair loss.

Question

Hi Dr. Donovan.

I’m a 31 year old female. While giving birth I almost died, went in to septic shock and lost a massive amount of blood. 2.5 months later I lost a lot of hair, I had thinning all over but more obvious around my ears, sides of my head and on the nape of my neck. My dermatologist (and biopsy) said it was TE and gave me steroid shots and my hair is growing back normally with no thinning.

I developed seborrheic dermatitis, my head is a little itchy and I’m on ketoconazole shampoo. 5 months after birth, I had to have major surgery on my kidney, the surgery itself lasted 8 hours. On the 2nd or 3rd day at the hospital I noticed a painful bump on my parietal lobe. On the 19th day after surgery, I washed my hair and then noticed the hair loss on the same area as the swelling. Ive attached photos of the first time noticing it.

My dermatologist injected it with steroids and it isn’t growing back. It’s been 3.5 months since it fell out. There are tiny hairs in the area so my dermatologist is sure it isn’t scarred.

But there are also exclamation looking hairs so we are not sure. The area is reddish. I have no hair loss anywhere else. It hasn’t gotten bigger and I don’t have any patches elsewhere. The picture labeled February 7 is the day I noticed it.

Answer

Thanks for submitting this question. I hope that you are feeling well. At first overview, it certainly would appear that the diagnosis is alopecia areata with some overlapping findings of seborrheic dermatitis. In addition, it appears that you first had a telogen effluvium (of alopecia areata again) that settled after delivery. I still favour alopecia areata as the diagnosis in the current photos but there are a few things in your story and some of your images that cause me to pause and ask “is it possible there is anything else going on here?”

The reason I’ve chosen this question is that it allows us to review some of these features today.

There are several scalp conditions that can cause localized hair loss in this manner with possible ‘exclamation mark like hairs”. The top 4 include:

1. alopecia areata ** most likely **

2. dissecting cellulitis

3. pseudocysts (alopecic and aseptic nodules of the scalp

4. infections (syphilitic alopecia)

Other diagnoses to consider here but do not have good evidence include:

1. tinea capitis

2. pressure alopecia

3. infiltrative conditions.

4. trichotillomania

Let’s take a look first at some of the images supplied in this question and then we’ll go into these possibilities a little further and come to some conclusions.

Submitted Image 1

This image shows patchy hair loss. There are broken hairs. Inflammation is mild. The top diagnosis at this magnification would be alopecia areata. The differential diagnosis from this image might include trichotillomania, tinea capitis, and pressure induced alopecia. Alopecia areata would be the top diagnosis. Exclamation mark hairs are not clearly seen in this image but are seen in other images. There is no evidence for a scarring alopecia. Density may be reduced in the more anterior portion of the scalp (top of the photo) suggesting ongoing TE or another hair loss diagnosis happening in this area.

Submitted Image 2

This image shows a well cicumscribed area with minimal inflammation. There are vellus hairs and broken hairs. Some hairs have hair shaft changes suggestive of a pseudo-monilthrix like change (Pohl Pinkus constrictions). Exclamation mark hairs are not clearly seen in this image but are seen in other images. There is no good evidence for a scarring alopecia. Alopecia areata remains a favoured diagnosis.

Submitted Image 3

Numerous exclamation mark hairs are seen in this image. Elbow hairs are seen. Yellow dots are seen. There is an inflammatory type change with whitish scale. There is a mild pigmentation alteration which is somewhat non specific. The exclamation mark hairs make other diagnoses quite unlikely as exclamation mark hairs of this kind do not occur in pressure alopecia nor in inflammatory connective issues issues. The appearance of the scalp in this image differs quite a bit from the appearance seen in other images.

Submitted Image 4

This image shows several exclamation mark hairs with regrowing vellus hairs. There is mild yellow scale which may be in keeping with seborrheic dermatitis (of psoriasis) or an artefact of the photo itself. There is no evidence for a scarring alopecia.

Further Discussion

Thanks again for submitting this case. I favour alopecia areata but of course it’s nice to have more information and see the entire scalp eyebrows eyelashes, and nails. The most accurate way to diagnosis hair loss is to collect all the information about the patient and then examine all the scalp.

The features that support alopecia areata are the exclamation mark hairs, vellus hairs, regrowing hairs and localized nature of the hair loss.

What other conditions cause exclamation mark hairs?

As we think about this question, it’s helpful to think about all that conditions that cause exclamation mark hairs. After all, one of the key features in the submitted images are the exclamation mark hairs.

Exclamation mark hairs are seen in alopecia areata, trichotillomania, thallium poisoning, dissecting cellulitis. Syphilitic alopecia has been rarely described to have a type of tapered hair closely resembling a true exclamation mark hair. This is very rare.

Trichotillomania

There does not appear to be good evidence here for trichotillomania. The story does not fit. It’s one of the famous causes of exclamation mark like hairs. Certainly extensive broken hairs can be a feature but other findings like black dots, V hairs, coiled hairs, hook hairs, hair powder just don’t appear to be a feature of this patient’s hair loss. I don’t think we’re dealing with trichotillomania.

Thallium poisoning

Of course, thallium poisoning is rare.

Dissecting Cellulitis and Alopecic and Aseptic Nodules of the Scalp

The description of the ‘painful bump’ is a bit unusual in the submitted question. It’s not typical of alopecia areata. It may be a ‘red herring’ and unrelated to the case here or it may truly be a valuable clue. Also, it would be helpful to know more about what is meant by a painful bump and how big of a bump is the individual referring to.

As we think about painful bumps, we need to think about small bumps and things like a folliculitis. As we get into larger and larger bumps we need to consider more significant inflammatory conditions of the scalp. Dissecting cellulitis can cause a larger dome shaped bump when it occurs and is famous for mimicking alopecia. Another closely related entity is “alopecic and aspetic nodules of the scalp” (AANS). AANS can resemble alopecia areata. The condition was first called “pseudocyst” but the name AANS was proposed in 2009 by Abdennader and Reygagne when it became clear that not all of these lesions show a pseudocyst morphology under the microscope.

The back of the scalp is a common area for AANS. Often patients present with just a single painful bump. Some authors feel that AANS is closely related to dissecting cellulitis.

Exclamation mark hairs have not been described in AANS but have been described in dissecting cellulitis.

Dome shaped area of hair loss on the vertex scalp, consistent with a diagnosis of alopecic and aseptic nodules of the scalp. Image from Anna Isabel Lázaro-Simó et al. Alopecic and Aseptic Nodules of the Scalp with Trichoscopic and Ultrasonographic Findings. Indian J Dermatol. Sep-Oct 2017;62(5):515-518. Image used with creative commons license.

Trichoscopic image from alopecic and aseptic nodules of the scalp (AANS), also known as pseudocysts. There are black dots, yellow dots, vellus hairs and broken hairs. Image from Anna Isabel Lázaro-Simó et al. Alopecic and Aseptic Nodules of the Scalp with Trichoscopic and Ultrasonographic Findings. Indian J Dermatol. Sep-Oct 2017;62(5):515-518. Used with creative commons license.

Trichoscopy of alopecic and aseptic nodules of the scalp. Image from Khalil I. Al-Hamdi and Anwar Qais Saadoon. Alopecic and Aseptic Nodules of the Scalp with a Chronic Relapsing Course. Int J Trichology. 2019 Nov-Dec; 11(6): 244–246. Used with creative commons license.

There are three stages of appearance to AANS lesions as described by Al-Hamdi and colleagues. It’s important to understand this - especially in this case.

Stage 1: Firm nodule. A firm and often tender nodule is present and the nodule lasts 1-3 weeks. There may be lymphadenopathy. If the nodule is punctured, it does not usually express any fluid. But if it does, the fluid is sterile and does not grow bacteria

Stage 2: Fluctuant Nodule with Hair Loss. In this stage, the nodule becomes less tender and hair loss is clearly seen. If the lesion is punctured in this stage a yellow fluid is expressed. This stage lasts 3-7 days.

Stage 3: Patchy Hair Loss Stage. In this stage, the nodule is no longer present as it has flattened either spontaneously or by puncture. This stage may last 2-3 month at which point hair growth normally occurs. It’s common in this stage for the patchy hair loss to be given a diagnosis of alopecia areata.

Was the bump described by the patient in this case actually stage 1 or stage 2 of AANS? Clearly, more information is needed. I would say it’s still quite unlikely.

Infections (Syphilitic Alopecia)

In a case like the one presented, one must never lose sight of alopecia areata as the most likely diagnosis. Most things fit well and it could be simply that this patch is more refractory and needs further steroid injections. However, we do need to consider rare mimickers (like AANS) - and another rare mimicker of syphilitic alopecia.

I don’t think that there is much in this case that makes a diagnosis of syphilitic alopecia high on the list. However, it can be a cause of patchy hair loss - especially with tapered exclamation mark like hairs, scale and redness like we see in the photos sent in by the patient.

Atypical trichoscopy of a patient with syphilitic alopecia in a 32 year old male. Exclamation mark like hairs are seen. Tapered bended hairs, erythematous background, diffuse scaling and perifollicular hyperkeratosis were present. Testing revealed a positive Venereal Disease Research Laboratory (VDRL) at a titer of 1:256 and a reactive Treponema pallidum particle hemoagglutination assay. Image from Linda Tognetti et al. Syphilitic alopecia: uncommon trichoscopic findings. Dermatol Pract Concept. 2017 Jul; 7(3): 55–59.

Other Diagnoses to Consider

There are several other diagnoses to consider here but they do not really have good evidence. These include:

1. tinea capitis

2. pressure alopecia

3. infiltrative conditions.

Tinea capitis

Tinea capitis can be a mimicker and the appearance can be altered by steroid injections. I don’t know the patient’s history well enough to know if there are predisposing factors that might make tinea capitis more likely. (In fact, I don’t have enough information in this patient’s history including information about the kidney surgery at 5 months post partum). It’s always possible that an inflammatory tinea developed and was flattened by steroid injections and persists in some manner. Of course, that’s unlikely and there do not really appear to be any trichoscopic features of tinea. There are no corkscrew hairs, comma hairs, bent hairs, i hairs, morse code hairs and no zig zag hairs. I don’t think this is tinea.

Pressure alopecia

In anyone with patchy hair loss after surgery, we need to consider pressure alopecia. It’s thought that hypoxia and altered blood flow predisposes to hair loss. Studies of patients with pressure alopecia have not suggested that exclamation mark hairs are part of the pressure alopecia diagnosis. Therefore, a diagnosis of pressure alopecia would not be likely in this case. According to Neema et al, trichoscopic findings of pressure alopecia include comedone- like black dots, black dots and area of scarring. In 2016, Francine Papaiordanou et al proposed that black dots, broken and dystrophic hairs were main features of pressure alopecia. In 2020, Tortelly et al proposed that black dots and vellus hairs were key features.

It’s not impossible that pressure from surgery facilitated the development of alopecia areata. in fact, R L Zuehlke et al in 1981 suggested that pressure may be a risk for alopecia areata too. So it’s going to be important to review if this area on the scalp shown in the photos had pressure during surgery. I don’t think it’s likely that what we’re seeing is related to pressure alopecia.

Trichoscopy of pressure alopecia showing black dots, broken and dystrophic hairs. In Image from Papaiordanou F et al. Trichoscopy of Noncicatricial Pressure-induced Alopecia Resembling Alopecia Areata. Int J Trichology. Apr-Jun 2016;8(2):89-90. Used with creative commons license.

Infiltrative conditions.

The term “infiltrative conditions” refers to a massively long list of cells that can enter into an area of the scalp (infiltrate) and cause localized hair loss. A variety of inflammatory and neoplastic cells can trigger patchy hair loss so one needs to always keep these in mind. They don’t usually cause exclamation mark hairs. Alopecia neoplastica refers to hair loss from metastatic cancer and can mimic alopecia areata in some cases.

This would not be expected in this case but this is added to the list and discussed here for completeness as we review patchy hair loss and considerations in the setting of refractory patchy hair loss. It does seem that hair is growing back in your case which makes infiltrative type causes quite unlikely. I don’t have a good sense of the time course of the photos you’ve submitted so that too would need to be carefully reviewed.

Alopecia neoplastica due to breast cancer. Image from Efthymia Skafida et al. Secondary Alopecia Neoplastica Mimicking Alopecia Areata following Breast Cancer.Case Rep Oncol. 2020 Jun 11;13(2):627-632. Image used with creative commons license.

Alopecia neoplastica due to breast cancer. Image from Efthymia Skafida et al. Secondary Alopecia Neoplastica Mimicking Alopecia Areata following Breast Cancer.Case Rep Oncol. 2020 Jun 11;13(2):627-632. Image used with creative commons license.

Conclusion and Summary

Thank you for this question. There are a few important points here in this case as we conclude. The first is that a full history and full examination are needed. This area is the area that you have photographed but one needs to always examine the entire scalp. A full history is needed of health and medical conditions over the past 31 years. The reason for the kidney surgery is completely unknown and would need to be included in the full story. I need to know everything about patients to confirm diagnoses with absolute certainty.

That said, the photos and clinical case still fit with undertreated alopecia areata as a top diagnosis. The exclamation mark hairs here and vellus hairs and regrowing hairs support this diagnosis. There are mimickers of course and these need to be considered.

For my own patients with similar stories I would first take a full history and do a full examination of the scalp, eyebrows, eyelashes and body hair. Then I might inject with 2.5 mg per mL triamcinolone acetonide (steroid) with 2 to 3 mL injected into the area. I would not be too concerned if hair does not immediately grow back as it might take 2-3 sessions one month apart. I would not do more frequent than this. There is an option to add topical minoxidil to the plan but you’d want to review side effects with your supervising doctor.

If the area was slow to regrow I might add periodic use of clobetasol and minoxidil at home while doing these steroid injections.

Your photos would suggest you are already growing back significant hair.

If the area did not respond, I might do a biopsy. I don’t see this as necessary right now. The area needs to be properly treated and then if it does not respond to proper treatment, one can move on to step 2.

I don’t see AANS as a likely diagnosis (alopecic and aseptic nodules of the scalp), or pressure alopecia as being likely. We don’t see exclamation mark hairs in most cases of pressure alopecia. It would be helpful to know just how lumpy or raised this area was when you noticed it as this might lead one to at least consider AANS. The reality is that even if it is AANS and it’s some unusual pattern of exclamation mark hairs, it should respond to steroid injections at this point. I don’t think it’s likely we’re dealing with AANS.

Finally, anyone with this story should have blood tests for CBC, TSH, ferritin, vitamin D, creatinine. An antidandruff shampoo should continue to be used. Ketoconazole is reasonable. As mentioned, a biopsy will be needed if the area is not responding to appropriate doses of steroid injections (+/- minoxidil or clobetasol).

A full scalp examination is needed to determine if there are any other issues too. The area to the front may be thinner than prior years and that needs to be evaluated. It could be part of a resolving telogen effluvium or another diagnosis. A full examination of the scalp is needed in this case (as well as full examination of eyebrows, eyelashes and body hair as mentioned)

Thanks again

REFERENCE

Anna Isabel Lázaro-Simó et al. Alopecic and Aseptic Nodules of the Scalp with Trichoscopic and Ultrasonographic Findings. Indian J Dermatol. Sep-Oct 2017;62(5):515-518.

Khalil I. Al-Hamdi and Anwar Qais Saadoon. Alopecic and Aseptic Nodules of the Scalp with a Chronic Relapsing Course. Int J Trichology. 2019 Nov-Dec; 11(6): 244–246.

Abdennader S, Reygagne P. Alopecic and aseptic nodules of the scalp. Dermatology. 2009;218:86.

Linda Tognetti et al. Syphilitic alopecia: uncommon trichoscopic findings. Dermatol Pract Concept. 2017 Jul; 7(3): 55–59.

Neema S et al. Trichoscopy of Pressure-Induced Alopecia and Alopecia Areata: A Comparative Study. Int J Trichology. Jan-Feb 2022;14(1):17-20.

Papaiordanou F et al. Trichoscopy of Noncicatricial Pressure-induced Alopecia Resembling Alopecia Areata. Int J Trichology. Apr-Jun 2016;8(2):89-90.

Tortelly et al,Pressure-Induced Alopecia: Presence of Thin Hairs as a Trichoscopic Clue for the Diagnosis Skin Appendage Disord. 2020 Jan; 6(1): 48–51.

R L Zuehlke et al. Pressure-potential alopecia areata. Am J Orthod . 1981 Apr;79(4):437-8.

Efthymia Skafida et al. Secondary Alopecia Neoplastica Mimicking Alopecia Areata following Breast Cancer.Case Rep Oncol. 2020 Jun 11;13(2):627-632.