Minoxidil Use in Children

Can minoxidil be used in Children?

Minoxidil is formally approved for adults with genetic hair loss. Minoxidil can be used as an 'off label' indication in children with several types of hair loss including alopecia areata and early onset androgenetic alopecia.  Its use should generally be monitored by a specialist. Children can be sensitive to minoxidil and side effects such as headaches, dizziness, poor concentration, swelling in the feet can occur. Rarely some children develop excess hair on the back or arms. 

 

Minoxidil Dosing

There is no standard dosing schedule for children and much of the dosing recommendations rely on the experience of the physician and the type of hair loss being treated.  Our typical dosing schedule for children who are prescribed minoxidil is shown below. Generally speaking, any child starting minoxidil should be followed by a physician.  These doses may be altered depending on a variety of factors such as the weight of the child, height, previous treatments used and extend of hair loss. These doses are generally regarded as maximal doses. 

Finasteride Use in Women: Yes or No?

Finasteride & Women

Finasteride is FDA and Health Canada approved for men with hair loss. Although it's not formally FDA approved for use in women, the medication has been prescribed to women with androgenetic alopecia for nearly two decades.  When a physician prescribes finasteride for androgenetic alopecia in women, they are said to be using these medications in an 'off label' manner.  The following is the key point about using finasterde for women : it's only prescribed on a case by case basis. 

Polar Views on Finasteride Use

The public needs to understand there are many views among physicians  on finasteride. There are some physicians that will never prescribe this medication to women -  period.  There are some physicians who will prescribe it only to post-menopausal women. There are some who will prescribe to some pre-menopausal and some post-menopausal women - but only on a case by case basis - and only with full counselling of risks and benefits.   

Much of the concern around use of finasteride in pre-menopausal women stems from the significant harm that would come to any fetus that was born to to a mother who used finasteride during pregnancy. These risks and real - and serious. Finasteride is given the highest category of risk during pregnancy - so called "category X." Women who are pregnant or who could become pregnant must never use finasteride.

The other concern that some physicians have pertains to cancer risk. To date, we actually don't have any good evidence to suggest that finasteride increases a woman's risk of cancer. In fact, reasonably well conducted studies in men would suggest that breast cancer risk is not increased. Good studies have not been done in women. However, women with strong histories of estrogen dependent cancers (breast, ovarian, gynaecological cancers) should also review use of finasteride with their doctors.  In some cases, use may not be appropriate.  I'll discuss other side effects below. 

 

Does Finasteride Help Genetic Hair Loss in Women?

So does it help women with genetic hair loss? Studies from nearly two decades ago said no. A study by Dr vera Price and colleagues in 2000 suggested a 1 mg dose in post menopausal women did not help androgenetic alopecia.  But just 2 years later, in 2002, Shum and colleagues presented 4 women (2 pre and 2 post menopausal) who did respond to a higher dose of finasteride - this time 2.5 mg finasteride. All 4 women had hyperandrogenism (one or more of elevated hormones, hair on the face, infertility issues). This refueled interest in the role of finasteride for women. 

In 2006, Dr Iorizzo and colleagues from Bologna, Italy published a study which further renewed interest in the use of finasteride for the treatment of female pattern hair loss. Iorizzo and colleagues looked at the benefit of finasteride at a dose of 2.5 mg in 37 women diagnosed with female pattern hair loss. All women in the study were also using a birth control pill to prevent pregnancy.  After 12 months of follow up, 62 % of women using finasteride had an improvement in hair density. 13 patients (30 %) hair loss had stabilized -   it did not get worse but  did not improve. Only 1 of 37 patients experienced a worsening of their hair density.
 

What are the side effects of finasteride in women?

I'm often asked about the range of side effects that are possible for women who use finasteride. Side effects of finasteride in women include, but are not limited to: harm to a fetus (finasteride can not be used in pregnancy), fatigue, weight gain, depression, anxiety, decreased libido, sexual dysfunction, hair shedding, breast tenderness, breast enlargement.  Other side effects can occur but are less common. These include changes in platelet counts and muscle injury (myopathy).

Reference

Iorizzo M1, Vincenzi C, Voudouris S, Piraccini BM, Tosti A. Finasteride treatment of female pattern hair loss. Arch Dermatol. 2006.

Shum et al. Hair loss in women with hyperandrogenism: Four cases responding to finasteride. Journal of the American Academy of Dermatology 2002; 47: 733-9

Bird ST et al. Male breast cancer and 5 alpha reductase inhibitors finasteride and dustasteride. J Urology; 190:1811-4

Minoxidil: Does age really matter?

Minoxidil and age-related hair loss

Minoxidil is a topical medication used to treat many forms of hair loss including androgenetic alopecia (for which it is FDA approved). Minoxidil can be helpful for treating androgenetic alopecia at any age but becomes even more important to consider with advancing age. 

Senescent alopecia: A type of hair loss often forgotten

Hair thinning as one approaches the 60s and 70s is often less truly androgen driven. The diagnosis of senescent alopecia (SA) needs to be considered in these particular age groups and it can often respond to minoxidil. Senescent or age related alopecia is often forgotten by physicians. It mimics genetic hair loss almost perfectly so is easily misdiagnosed as genetic hair loss. The genes driving it are very different. The key point is that if one recognizes senescent alopecia could be a possibility - the use of treatments like minoxidil become more important rather than other traditional AGA-type treatments like finasteride.

Androgenetic alopecia tends to start somewhere between age 8 and age 50. Hair thinning that occurs later has a high likelihood of representing senescent alopecia. (Of course other types of hair loss may also occur after age 60 and genetic hair loss and senescent alopecia can overlap). A study by Karnik and colleagues in 2013 confirmed that these two conditions (AGA and SA) are truly unique. The authors studies 1200 genes in AGA and 1360 in SA and compared these to controls. Of these, 442 genes were unique to AGA, 602 genes were unique to SA and 758 genes were common to both AGA and SA. The genes that were unique to AGA included those that contribute to hair follicle development, morphology and cycling. In contrast to androgenetic alopecia, many of the genes expressed in senescent alopecia have a role in skin and epidermal development, keratinocyte proliferation, differentiation and cell cycle regulation. In addition, the authors showed that a number of transcription factors and growth factors are significantly decreased in SA. The concept of senescent alopecia is still open to some debate amongst experts. The studies by Karnik give credence to the unique position of these two conditions. But studies by Whiting suggested that it is not so simple as to say anyone with new thinning after age 60 has SA - many of these are also more in keeping with androgenetic alopecia. As one ages into the 70's, 80's and 90's - hair loss in the form of true senescent alopecia becomes more likely.

Reference

Karnik et al. Microarray analysis of androgenetic and senescent alopecia: comparison of gene expression shows two distinct profiles. J Dermatol Sci. 2013.

AGE 50: An Important Cut off for Diagnosing Hair Loss

The Cut off of 50: Why it matters in the diagnosis of hair loss in Older Individuals ?

Any birthday is special. The 50th birthday is an important cut off in the diagnosis of many hair diseases.  An important principle of diagnosing hair loss in men and women over 60 comes from understanding what density of hair a patient had at age 50.

 A true or false question

For anyone over 60, I always ask patients to help me with a true or false question.  I generally ask it in the following way

“Is this statement true or false: My hair density at age 50 was about the same as it was at age 30.”

This is such an important question - especially if the patient replies “TRUE”. Men and women who develop hair loss in their 60s and 70s but who report that their density age 50 was quite good have a high likelihood of having another diagnosis besides simply genetic hair loss. Of course genetic hair loss is a possibility and it’s possible the patient does not really have a good recall of their hair density at age 50. Nevertheless, there are several conditions that need to be considered in somwone with good thick hair at age 50 and hair loss in the 60s”

1.     Scarring Alopecia (especially Lichen Planopilaris)

2.     Senescent Hair Loss

3.     Diffuse Alopecia Areata

4.     Hair Shedding Disorders

Final Comment:

Patients in their 60s and 70s who tell me they had thick hair at age 50 and that it was the same thickness as age 30 often have an interesting array of hair loss conditions. One should not default to diagnosing genetic hair loss in these situations because that diagnosis may be relatively unlikely in this unique situation.

Elevated testosterone Levels in Women with Hair Loss

Testosterone Levels in Women with Hair Loss

There are many causes of elevated testosterone levels in women. Slightly elevated levels can sometimes be considered 'normal' with no underlying issues to be concerned about. Many patients with increased androgen levels have polycystic ovarian syndrome (PCOS) or underlying endocrine issues such as Cushing syndrome. However, elevated but can sometimes be associated with serious underlying conditions, including cancer. Patients with rapid onset of symptoms and signs along with hormone levels that are well above normal need rapid medical attention for proper diagnosis.

What is the 'cut off' for normal?

There are no hard and fast rules when it comes to cut off numbers. A full story is needed from the patient including how fast the symptoms appeared and how many symptoms are present. Is it hair loss? Is acne present? How about increased hair growth on the face (i.e. hirsutism)? Is the patient menopausal or post menopausal? Are menstrual cycles regular? Has there been weight loss or gain? Does the patient have increasing pain anywhere ? How about fatigue levels?

Causes of elevated testosterone levels in women

There are many causes of elevated testosterone levels in women. Patients with high testosterone levels should be sure to make an appointment with their doctor to review causes. A full history and full examination will be needed and more blood tests may be needed as well. Repeating the testosterone is often advisable too given that it can vary quite a bit day to day. A measurement in the morning is advised.

The top 10 causes of elevated testosterone include

1. Just a normal level for the patient

2. Polycystic ovarian syndrome (one of most common causes)

3. Ovarian hyperthecosis

4. medication induced (androgen replacement, anabolic steroids)

5. Cushing syndrome

6. Congenital adrenal hyperplasia

7. Ovarian tumors

8. Adrenal tumors

9. Hyperthyroidism

10. Prolactinomas

Cancers of the adrenal gland and ovaries are a very rare cause

Cancers of the adrenal gland are rare and about 2 new cases are diagnosed every year per 1 million people. Cancers of the ovary are more common and currently ovarian cancer is the sixth most common cancer in women. Less than 1 % of patients presenting with hirsutism and other signs of hyperandrogegism have an ovarian or adrenal tumor - but it is important to diagnose early. 

Generally speaking a plasma testosterone concentration three times above the normal level (i.e. above 8.7 nmol/L or 200 ng/dL) with a normal DHEAS level raises the suspicion that the patient could have an underlying benign or malignant ovarian cause of their symptoms. Furthermore, a plasma testosterone concentration three times above the normal level (i.e. above 8.7 nmol/L or 200 ng/dL) with an elevated DHEAS level (above 16.3 umol/L or 600 ug/dL) raises the suspicion that the patient could have an underlying benign or malignant adrenal cause of their symptoms.It could of course be normal, but when levels are in this range - a full work up is mandatory. 

Further testing with elevated androgens 

Further testing may be advised depending on the degree of hormone elevation and associated signs and symptoms. As mentioned, a full history and physical examination are needed for all patients with elevated androgens. Generally a full hormonal panel with free and total testosterone, DHEAS, LH, FSH, estradiol, SHBG, prolactin, 17 hydroxyprogesterone and TSH are ordered. Other tests include AFP (alpha feto protein) and B-hCG may be ordered. A pelvic ultrasound or CT scan may be ordered for women with markedly elevated levels. Further stimulation and suppression testing (i.e a dexamethasone suppression test for a potential androgen secreting adrenal tumor) may be ordered upon referral to an endocrinologist. 

Conclusion

There are many causes of increased androgens in women. When associated with increased hair growth on the face, irregular periods, acne or hair loss, androgen hormone levels are frequently elevated. Conditions such as polycystic ovarian syndrome (PCOS) or ovarian hyperthecosis are common and frequently responsible. However, women with markedly evaluated androgen levels (especially three times above normal) require a full work up including referral to endocrinology, radiology and gynaecology specialists.

Reference

Pugeat M et al. Androgen secreting adrenal and ovarian neoplasms. Contemporary Endocrinology: Androgen Excess Disorders of Women: Polycystic Ovarian syndrome and other disorders. Second Edition. Humana Press.

Topical JAK inhibitors for Children and Adolescents with AA

Topical JAK inhibitors for Children and Adolescents with AA

The JAK inhibitors include drugs such as tofacitinib (Xeljanz) and ruxolitinib (Jakafi, Jakavi). At least 7 studies in the last 2 years have shown benefit for the oral JAK inhibitors in treating alopecia areata.  However, one must keep in mind that these drugs are not without potential side effects. A risk of infection, including serious infectious must always be kept mind with this particular immunosuppressant. Other side effects need to also be considered.

What are topical formulations? Do they work?

Topical JAK inhibitors refer to specific formulations whereby the drug is mixed into a cream or other base and applied to the surface of area of hair loss rather than taken orally. These topical formulations have the potential to be safer than the oral formulations. However, it’s not clear exactly how well the topical JAK inhibitors truly work. There have been a few published reports in the medical literature regarding the potential benefits of topical JAK inhibitors. Last year, I shared information of a study showing eyebrow regrowth in a patient with alopecia universalis treated with 0.6 % ruxolitinib cream. Now, a new study reports the outcome of 6 individuals ranging in age from 4-17 who were treated with topical JAK inhibitors. 6 of the 7 individuals had advanced forms of alopecia areata (totalis and universalis) and one had alopecia areata.

TOPICAL TOFACITINIB

Four patients (age 3, 5, 13 and 15) were treated with topical 2 % tofacitinib. 2 of the 4 patients had significant improvement of their scalp alopecia and 1 other had just a slight 20% improvement of his eyebrows

TOPICAL RUXOLITINIB

Two patients (age 4 and 17) were treated with topical 1 % ruxolitinib to the eyebrows.  Neither one experienced eyebrow regrowth although one did experience eyelash growth when the medication was prescribed to the upper eyelid skin.  The four year old had blood tests performed and all were normal.

CONCLUSION

This study suggests that about one half of children with alopecia areata treated with topical JAK inhibitors may have some degree of benefit.  This study is small and certainly a larger study is needed to confirm this. However, this study is encouraging given that these individuals had severe forms of alopecia areata to start with and treatment outcomes would therefore have been predicted to be worse.

Reference

Bayarat et al. Topical Janus kinase inhbitors for the treatment of pediatric alopecia areata. J Am Acad Dermatol 2017; 77(1):167-169

Eyebrow Hair Loss: What things do we need to consider?

Eyebrow loss: Knowing the cause allows one to plan the treatment

There are many causes of eyebrow hair loss and each has it's own treatment. Too often patients rush to treat their eyebrow loss without pausing to ask "What exactly is my diagnosis?" Here are a few common reasons for eyebrow loss and their treatment.

1. Age related eyebrow loss and overtweezing

If the eyebrow loss is due to age related changes or over plucking/tweezing the options inlcude

a. Minoxidil
b. Bimatoprost (Latisse)
c. Hair transplantation
d. Tattoos, and microblading

2. Eyebrow loss from alopecia areata

If eyebrow hair loss is due to the autoimmune disease alopecia areata, a majority of patients will also have evidence of aloepcia areata at other areas (scalp, eyelashes). Treatments for eyebrow loss due to alopecia areata include:

a. steroid injections   b. topical steroids c. minoxidil
d. bimatoprost
e. oral immunosuppressives (Prednisone, methotrexate, tofacitinib
f. Tattoos and microblading can also be used.  

3. Frontal fibrosing alopecia (FFA)

Frontal fibrosing alopecia of the eyebrows is certainly the most underdiagnosed cause of eyebrow hair loss in women who first notice eyebrow hair loss in their late 40s and early 50s. Hair transplants are ineffective in most, if not all patients with active disease. Treatment options for FFA of the eyebrow include:

a. steroid injections and topical steroids  b.topical non steroids (pimecrolimus cream)
c. oral finasteride
d. oral hydroxychloroquine, oral tetracyclines    
e. Tattoos and microblading can also be used.                                                                                   

4. Trichotillomania

Trichotillomania is common and 3-5 % of the world pull out their own eyebrows due to underlying psychological factors. For some, the pulling is temporary and for others is a chronic condition. Treatment of the underlying psychological factors (stress, depression, anxiety, obsessive compulsive disorder) can lead to improvement. Hair transplants are not an options if the patient is actively pulling his or her eyebrows

5. Other causes

Dozens of other causes of eyebrow loss are also possible including a variety of infectious, autoimmune and inflammatory conditions. Consultation with a dermatologist or hair transplant surgeon is recommended. I strongly advise consulting a dermatologist before proceeding to hair transplantation for women over 40 with new onset eyebrow hair loss after age 40.

Hair Follicle Aging

What is Senescent Alopecia?

Hair follicle aging appears to be a real thing, like any tissue in the body. Traditionally, a form of hair loss known as senescent alopecia ("SA") has been defined as a very specific type of age related thinning that is distinct from androgenetic alopecia ("AGA"). Androgenetic alopecia tends to start somewhere between age 8 and age 50 - at least that has been the traditional view. Hair thinning that occurs after age 60, with no thinning prior to this, has a high likelihood of representing senescent alopecia. (Of course other types of hair loss may also occur after age 60). A study by Karnik and colleagues in 2013 confirmed that these two conditions (AGA and SA) are truly unique. The authors studies 1200 genes in AGA and 1360 in SA and compared these to controls. Of these, 442 genes were unique to AGA, 602 genes were unique to SA and 758 genes were common to both AGA and SA.

The genes that were unique to AGA included those that contribute to hair follicle development, morphology and cycling.

In contrast to androgenetic alopecia, many of the genes expressed in senescent alopecia have a role in skin and epidermal development, keratinocyte proliferation, differentiation and cell cycle regulation. In addition, the authors showed that a number of transcription factors and growth factors are significantly decreased in SA.

Conclusion
The concept of senescent alopecia is still open to some debate amongst experts. The studies by Karnik give credence to the unique position of these two conditions. But studies by Whiting suggested that it is not so simple as to say anyone with new thinning after age 60 has SA - many of these are also more in keeping with androgenetic alopecia. As one ages into the 70's, 80's and 90's - hair loss in the form of true senescent alopecia becomes more likely.

Reference

Karnik et al. Microarray analysis of androgenetic and senescent alopecia: comparison of gene expression shows two distinct profiles. J Dermatol Sci. 2013.

Whiting DA. How real is senescent alopecia? A histopathologic approach.
Clin Dermatol. 2011 Jan-Feb.
 

Happy International Alopecia Day

Happy IAD !

The first Saturday in August marks International Alopecia Day! Alopecia areata is an autoimmune condition affecting 2 % of the world's population. Hair loss can occur anywhere on the body but typically affects the scalp.

Children and adults can both be affected and a high proportion of individuals experience their first episode of hair loss before age 20.

Minoxidil use after ages 65: Should I just go for it?

Minoxidil (Rogaine, etc) is FDA approved for ages 18-65

I'm often asked by patients if they should just give minoxidil a 'try'. Give it a 'go'. I respond that minoxidil can certainly be helpful but minoxidil is certainly not for everyone.

Minoxidil is FDA approved for men and women 18-65 with a type of hair loss known as androgenetic hair loss. If an individual has some other hair loss condition besides androgenetic hair loss (there are actually dozens of other kinds) and if the individual is over 65, they should check with their physician if minoxidil is safe or not.

Minoxidil is not for everyone

I don't prescribe minoxidil if:

1.     the patient has heart problems, especially ischemic type heart disease or certain types of heart failure

2. the patient has heart rhythm issues (like atrial fibrillation)

3. the patient has certain internal conditions (like pheochromocytoma)

4. the individual has allergies to any of the components of minoxidil, such as propylene glycol in minoxidil solution or allergy to the minoxidil itself

 

Final Comments:

Minoxidil has a good safety profile and that has lead to its availability as an over the counter product.  But minoxidil is not for everyone. An 82 year old patient with heart failure and two previous heart attacks is not a candidate for minoxidil. A patient with hair loss due to dissecting cellulitis of the scalp (a different condition than genetic hair loss), will likely find little to no use from minoxidil application. Minoxidil is not for everyone.

Is your hairline 'maturing' or a 'balding'?

Is your hairline 'maturing' or a 'balding'?

It’s a little known fact among many men that the frontal hairline actually changes shape between the ages of 17 and 27 – even if that man doesn’t proceed to develop genetic balding. We refer to this normal change as ‘maturation’ of the hairline and we say that the man noticing these changes has a ‘maturing’ hairline. Eventually the hairline stops ‘maturing’ and we say that the man has a ‘mature’ hairline.  Not all men’s hairlines proceed through this normal process of ‘maturation’ but most do.

The concept of a maturing hairline is extremely important to know about so that medical treatment or surgical treatment is not recommended to patients who don’t require it. For example, a 23 year old man who notices his hairline thinning out slightly in the area just above his eyebrows may not have genetic hair loss - but rather a ‘maturing’ hairline. He doesn’t need to begin any sort of treatment whatsoever. Several studies have shown that men with maturing hairlines don’t necessarily go on to develop balding. These are two completely separate processes!

Hairline maturation diagram

The following diagram helps to explain the process by which the hairline matures and how it differs from genetic hair loss. The hairline of a boy or early adolescent is relatively flat and we refer to this as a ‘juvenile” hairline.  Between age 17 and 27, many men (but not all) start to notice that the hairline directly above the middle section of the eyebrow starts to undergo thinning (maturing).   

In fact, if you wrinkle your forehead, you’ll see a series of lines that run side to side. The highest forehead wrinkle often marks a spot where the ‘juvenile’ hairline was once located. A ‘mature’ hairline is usually about 1-1.5 cm above this. In true genetic balding (male pattern hair loss), the hairline may recede beyond this 1.5 cm point and undergo even more significant recession in temple area. 

Why is this concept important?

Understanding the concept of hairline maturation is especially important when it comes to designing natural looking hairlines during a hair transplant.  Attempting to lower a ‘maturing’ hairline is a young man is usually not a good idea. Many young men want a more ‘juvenile’ hairline when they first meet for a hair transplant consultation.  However, by proceeding down that route,  the young man runs the risk of having his new hairline take on an unnatural looking appearance when compared to other males as he approaches his 30s, 40s and 50s.

Other References of Interest

Rassman WR, Pak JP and Kim J. Phenotype of normal hairline maturation. Facial Plast Surg Clin North Am 2013; 21: 317-23

This blog has been filed into the following folders: 

Minoxidil - Does it help with hair loss ... in the front ... or top .. or both?

Accumulating evidence suggests minoxidil helps with hair loss in the crown (top) but may help hair loss in the front and temples in men as well.

Minoxidil - Does it help with hair loss in the front?

Minoxidil is a topical medication that is FDA approved for treating genetic hair loss (sometimes referred to as androgenetic alopecia). If you pick up a bottle of minoxidil it will state that it is to be used for hair loss in the crown in men and may not benefit other areas of hair loss. The original studies of minoxidil focused on the crown and did not address the benefit in the front of the scalp.

So the question that remains is:  

Does minoxidil help men with hair loss in the front of the scalp or not?

Certainly, the answer is yes.   Many hair loss specialists around the world, including myself,  have witnessed benefit to minoxidil in the front of the scalp in balding men.  However, the companies which produce minoxidil are not setting out to formally prove the benefit in the front of the scalp and are not seeking approval from health regulatory authorities to be able to change the labelling on the bottles to indicate that it "works in the front and back."

New study shows 5 % minoxidil benefits men with hair loss in the temples

Back in the month of May 2013, I attended the World Congress of Hair Research in Edinburgh Scotland. A really nice study was presented by Dr. Blume Peytavi and colleagues from Berlin, Germany. They studied 70 men with moderate genetic hair loss and studied whether minoxidil 5 % foam could help hair loss in the crown and in the front.  The German group showed that men using minoxidil 5 % foam did obtain benefit from using the medication in the front and in the crown.  This was one of the very first studies showing the minoxidil foam benefits hair loss in the front.

Conclusion: 

Minoxidil has long been known to benefit men with hair loss in the crown. Accumulating evidence suggests it also benefits men with hair loss in the front (temples). More studies are needed to determine just 'how much' it helps men with hair loss in the front. In general, minoxidil seems to work better in the earliest stages of hair loss - as hairs are thinning and miniaturizing. 

Reference

Hillman K, Bartels GN, Stroux A, Canfield D, and Blume-Peytavi U. Investigator-initiated double blind, two-armed, placebo-controlled, randomized clinical trial with an open -label extension phase, to investigate efficacy of 5 % Minoxidil topical foam twice daily in men with androgenetic alopecia in the fronto-temporal and vertex region concerning hair volume over 24/52 weeks.  Poster at: World Congress of Hair Research, Edinburgh Scotland May 2013.

Benefits of Combining Minoxidil and Finasteride

Benefits of Combining Minoxidil and Finasteride

Minoxidil and Finasteride are two FDA approved treatments for hair loss. Minoxidil is a topical solution that is rubbed on the scalp and finasteride is an oral treatment (pills). Many men with genetic hair loss (androgenetic alopecia) consider the use of these medications and may consider hair restoration as a more permanent solution.

Both minoxidil and finasteride have their own set of side effects. Finasteride, however, is much more effective. GIven that these two agents are clinically proven to help with hair loss, I'm often asked - "Is it better to use both of these products or should I just pick one?"

Combination Minoxidil and Finasteride better than single treatment

The answer is - 'yes.' There is clinical evidence that men using finasteride for hair loss who add minoxidil to their treatment plan have a slightly better result than men who only use finasteride. The benefits, however, are small. It makes sense that the two medications act synergisticially in treating hair loss given that they act differently. Minoxidil helps hair growth by directly stimulating the hair follicle. In contrast, finasteride works by blocking the action of the potent male hormone dihydrotestosterone or "DHT". 

Conclusion

Both minoxidil and finasteride should be considered. For men with early hair loss, the use of both might help and may be considered prior to a hair transplant. Minoxidil and finasteride have less benefit for men with advanced hair loss. In these cases, a hair transplant is the primary treatment.

This blog has been filed into the following folders:

The Hair Whorl: Importance in Transplanting the Crown

Transplanting the Crown

In the top of the scalp or crown, there is usually one or two areas where the hair changes direction from forward pointing to backward pointing. We call this area the “hair whorl.”

When I perform a hair transplant, I view the reconstruction of the hair whorl as being incredibly important in order to create a natural look.  For most individuals, the hair whorl is positioned in a clockwise direction.   About 2-5 % of the world has a double whorl.

Hair Whorl Research

Interestingly, recent research has focused on whether there is a relationship between the direction of the hair whorl and an individual’s tendency to be left handed or right handed.  There is some thought that genes controlling handedness also might control our hair whorl.  Research by Dr Klar showed that right-handed individuals are more likely to have a clockwise whorl pattern; for left- handed individuals there is a similar proportion of clockwise and counter-clockwise patterns.  Specifically, 8.4 % of right-handed individuals have a counterclockwise whorl compared to 45 % of left handed people.  Despite these interesting findings, the exact science of the relationship between hair whorl direction and ‘handedness’ remains a subject of controversy.

All in all, the hair whorl is something I pay particular attention to when transplanting the crown.  The rotations and directions of the hair need to be followed carefully in order for a hair transplant to look natural.

REFERENCES OF INTEREST

Beaton AA and Mellor G. Direction of hair whole and handedness.Laterality 2007; 12: 295-301

Klar, A.J.S., 2003. Human handedness and scalp hair-whorl direction develop from a common genetic mechanism. Genetics 165, 269–276

 

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How many hair transplants can a patient have?

Hair transplants: how many can a patient have?

The number of hair follicles available to move from the back of the scalp (the 'donor area') to the front or top of the scalp (the 'recipient area') is limited.  Someday, hair research may allow us to expand the number of hairs available, but for now there is a limited number. The number of grafts available to move depends on a number of factors, espeically how bald a person is destined to become.  It is generally estimated that between 4,000-10,000 follicular units are available in men. Men who are destined to have advanced balding patterns have less hair available to move than men destined to have minimal balding.

New study from Mount Sinai

A new research study by Dr Walter Unger and colleagues from the Department of Dermatology at Mount Sinai School of Medicine set out to refine these estimates even further. A group of 39 hair transplant surgeons were asked to estimate the number of 'permanent' follicular units available for surgery in a hypothetical 30 year old man destined to develop advanced balding (i.e. Hamilton Norwood Scale V or VI)

What were the results of the survey?

Respondents indicated that men destined to have Hamilton Norwood Stage V balding had between 5,000 - 8,000 follicular units available for surgery and men destined to have Hamilton Norwood Stage VI balding had between 4,000 - 6,600 follicular units available for hair transplant surgery.Man with 4000 follicular units max in lifetime

Why are these results important?

This study reminds hair transplant surgeons (and patients) that there are a finite number of follicular units available for surgery. A middle aged man destined to have advanced balding in his  lifetime has two (and maybe three) surgeries maximum in their lifetime.   It is exteremely important to discuss with patients how grafts will be placed so that the appearance of bald areas of the scalp can be minimized throughout life.

Source

Unger WP, Unger RH, Wesley CK. Estimating the number of lifetime follicular units: A survey and comments of experienced hair tranpslant surgeons. Dermatol Surg 2013;

This blog has been filed into the following folders:

INCREASED RISK OF HEART DISEASE IN MEN WITH HAIR LOSS

Do balding men have an increased risk for heart disease?

Several studies in the past have examined the relationship between balding and heart disease.   In a study published in this month's British Medical Journal, researchers from Japan carefully examined all of the research studies to date focusing on the relationship between hair loss and heart disease.

Balding and heart disease: what did the new research find?

The researchers looked at studies involving 36,690 balding men and found that men with hair loss in the top of the scalp or ‘vertex’, had an increased risk of heart disease.  Interestingly, men with more severe balding had a greater risk of heart disease compared to men with lesser degrees of balding in the vertex.  Men with hair loss in the front of the scalp did not demonstrate an increased risk of heart disease.  

The exact reasons why balding men have increased heart disease risk is not clear but may be related to common mechanisms that lead to heart disease and hair loss including high blood pressure, smoking, high cholesterol, insulin resistance and increased inflammation in blood vessels.

These findings are important for the approximately 4 million Canadian men and 40 million American men affected with male balding.

SOURCE:   Yamada et al. Male pattern baldness and its association with coronary heart disease: a meta-analysis. BMJ Open; 2013; e002537.

 

Is there a Link Between Sun Exposure and Hair Loss?

Sun Exposure and Hair Loss: Is there a Link?

This new video highlights the current evidence of the relationship between sun exposure and hair loss.

I hope you enjoy it!

- Dr Jeff Donovan

 References of Interest

Gatherwright J et al. The contribution of endogenous and exogenous factors to female alopecia: a study of identical twins. Plast Reconstr Surg 2012 130; 1219-26.

Su LH and Chen.  Androgenetic alopecia in policemen: higher prevalence and different risk factors relative to the general population. Arch Dermatol Res. 2011 Dec;303: 753-61

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Quantifying Hair Loss: Just How Much Hair Loss Has Occurred?

Quantifying Hair Loss:

All humans experience hair loss on a daily basis. But the key question is – “is this amount of hair loss abnormal?”  How do we evaluate whether there has been a lot of hair loss or just a little.”

It’s normal to lose between 50-100 hairs per day. This means its normal to see some hairs  in the brush, in the sink and in the shower drain. But when do we cross the boundary between normal and abnormal?? 

Most people intuitively know if the amount of hair loss they are experiencing is abnormal.   But, when I meet a patient I try to get a sense of just how much hair loss has occurred – and just how fast the hair loss has occurred.  These are extremely important to quickly get a sense of.

a)    Photos.  Comparing photos is sometimes a good way to get a sense of how much hair loss a patient has experienced.  How different does the individual look in their driver’s license photo compared to the way they look today?  Was the photo taken 6 months ago or 6 years ago?

b)   Daily Shedding. How much hair “shedding” is occurring on a daily basis? Are the drains clogged? Is their hair coming out in the food? Does the patient ever count the number of hairs shed on a daily basis?

c)    Pony tail. For women who wear their hair long, the size and thickness of the pony tail can be helpful in assessing the amount of loss. How much thinner is the pony tail than before? How many turns of an elastic band are needed now compared to before?

d)   Styling. How long does it take the individual to style their hair to cover their hair loss? An individual who once took 15 minutes but now takes 45 minutes or 1 hour has considerable loss.

e)     Spontaneous comments from family and friends.  Most of the time, a family member or friend will comment on hair loss only when it has become significant.  But I often ask patients if they have received spontaneous comments from others on their changing hair density.

f)     Patient estimates. It’s sometimes hard for patients to quantify their hair loss but I generally ask.  Specifically, I try to get a sense of the percent reduction in hair density. Has the patient loss 40 % of their hair volume in the past year? Is it 20 % ? Is it 60 %?

Quantifying the amount of hair loss is important. It helps give a sense of just how much hair loss has occurred and helps guide certain diagnoses as well. For example, consider the 26 year old woman who has lost 60 % of her hair density in the past one year and looks completely different than her driver’s license.  Although she may have been told she has female pattern hair loss, one thing is for certain- she has something else going on in addition to or besides female pattern hair loss!!! She might have female pattern hair loss, but other causes need to be explored, including a variety of hair shedding problems. Female pattern hair loss is a slow process and would not be consistent with a loss of 60 % density in one year. 

Quantifying the amount of hair loss is extremely important.

 

Hair Loss in Women: Often More than a Single Cause!

Hair Loss in Women: Often More than a Single Cause!

Hair loss among women is common. Although it's natural to think there is a single cause of an individual's hair loss, women often have more than one reason for their reduced hair density or 'hair thinning.'

Example: Consider the 32 year old woman who came into see me for her first appointment. She told me that she had been using minoxidil topical lotion for a 8 months now for a presumed diagnosis of:

Presumed diagnosis:

1. Female Pattern Hair Loss (also known as androgenetic alopecia).

However, she felt her hair was not getting better. She had some annoying scalp itching from time to time and wondered if she should stop the mionxidil as she was told the lotion could sometimes cause itching.

Is this the correct diagnosis? What should she do to stop her itching?

Join me as we pursue the necessary "detective work" to come up with the correct diagnosis for this woman and ultimately help her hair improve. First, lets take a look at her scalp up close:

Is this normal? Is it abnormal? Well, let's compare this photo to a relatively normal appearing scalp from a similarly aged woman in my practice with good hair density and extremely healthy hair. You'll note that all the hairs are fairly similar size (calibre) and the scalp itself is not red and their is no scaling or flaking:

Now that we know what is normal, let's return to the 32 year old woman with hair loss. Many things can be seen by examing this woman's scalp. First this woman has many 'thick' hairs. The light blue arrows show the thick hairs (also called terminal hairs).

However, this woman also has many thinner hairs with greatly reduced calibre (skinnier hairs). These thinner hairs are known as "miniaturized hairs" and the green arrows below point to several miniaturized hairs. Miniaturization is frequently seen in individuals who have a diagnosis of "androgenetic alopecia" (also called female balding or female pattern hair loss):

So I know this woman has androgenetic alopecia as one of her diagnoses.  But the other thing that is noted is that she not only has many skinnier hairs, but she also has a significantly reduced number of hairs.  You can see that the hair density that is seen in the top of the picture is very different than in the bottom of the picture  - the blue stars show the "missing hairs." So we know that she has lost a lot of hair.  

By gently pulling on several of her hairs, I discover that many of these remaining hairs come out pretty easily. This is called a "positive pull test" and this test is a sign this woman may have excessive shedding ( a phenomenon called telogen effluvium). In fact, the orange arrows point to many of these telogen hairs - which are farily easy to spot in this photo because telogen hairs become much lighter in color as they are about to shed from the scalp. So we are gaining some good evidence that this woman has an abnormal shedding problem:

As I described in a previous  video, there are many causes of exessive or abnomal shedding. The include low iron levels, thyroid problems, crash diets and a variety of medications. Basic blood tests performed in this patient showed she had very low iron levels. Further details also revealed she had multiple cycles of crash dieting in the past one year. These are certainly two potentially important causes for her shedding.

Further examination of her scalp showed that there is redness in the scalp and some scale. The red arrows in the photo below point to this scale:

There are many causes of scale but this woman scale and the redness in her scalp is typical of a condition called seborrheic dermatitis. Scalp "dandruff" and seborrheic dermatitis are two closely related processes and are caused by a common yeast called Malasezzia. Seborrheic dermatitis is very common and causes scalp itching and redness and excess flaking. Often patients notice that their scalp feels better if they wash their hair more often as this helps reduce the annoying itch they sometimes experience. Seborrheic dermatitis may cause itching but doesn't typically cause hair loss. Additional questions showed that this woman had scalp itching long before she started using the topical minoxidil therapy - so her itching may be coming from her seborrheic dermatitis rather than the minoxidil ! However, both are possible.

So at this point, it appears this woman does in fact have female pattern hair loss, but she also has three other diagnoses:

1. Female pattern hair loss (also known as androgenetic alopecia).

2. Telogen effluvium (exess hair shedding) - from low iron levels

3. Telogen effluvium (exess hair shedding) - from crash dieting

4. Seborrheic dermatitis

But is this ALL she has?

For this patient, further questioning revealed that the cause of her low iron was very likely from heavy and sometimes irregular menstrual periods. She could go several months without a period. Additional blood work and an ultrasound of this woman's ovaries showed that she in fact had a condition known as polycystic ovarian syndrome or "PCOS."  Women with PCOS have altered hormone levels which can cause hair thinning.  The altered hormone levels are produced by the ovaries. Early diagnosis of this condition is extremely important as women with PCOS have a higher chance of developing diabetes, high blood pressure, infertility and high cholesterol.  She was referred to an endrocinologist for further evaluation of her PCOS.

Final diagnoses for this woman: 

1. Female pattern hair loss - with Polycystic Ovarian Syndrome

2. Telogen effluvium (exess hair shedding) - from low iron levels

3. Telogen effluvium (exess hair shedding) - from crash dieting

4. Seborrheic dermatitis

How was this woman ultimately treated?

This woman was continued on her topical minoxidil therapy as it was concluded this was NOT a cause of her particular symptom of itching.  On account of her diagnosis of PCOS, she was advised to start on a birth control pill to regulate her periods. Oral Spironolactone medication was also started to help her androgenetic alopecia. Iron pills were prescribed to help the low iron levels and blood work was performed every 5 months to ensure the iron levels were rising properly. The woman's diet was stabilized to ensure that no further crash dieting would occur. The seborrheic dermatitis was treated with an anti fungal shampoo and this helped stop her itching. An improvement in hair density was noted in 6 months.

Conclusion

Diagnosing hair loss in woman often requires a bit more detective work than hair loss in men. Hormonal issues, and hair shedding conditions are more common in women than men. One should never assume that a patient has a single diagnosis for their hair loss -- all causes need to be explored. This can only come with a very detailed history about the patients hair loss, past health, diet, medications, family history and a very detailed examination of the scalp.

Dr. Donovan Interviewed by CityNews Toronto

Dr. Donovan Interviewed by CityNews Toronto

Dr. Donovan was interviewed today by Andrea Piunno of CityNews Toronto on a new research study which showed that men and women with signs of aging (such as hair loss) have an increased risk of heart disease.

Heart attacks more likely the older you look:

Click for a link to the CityTV video