Manuka Honey for Treating Folliculitis Decalvans

Antibacterial Properties of Manuka Honey May Provide Benefits in Treating Folliculitis Decalvans

Folliculitis decalvans (FD) is a scarring alopecia that affects both men and women. FD is less common than some of the other  scarring alopecias like lichen  planopilaris and central centrifugal cicatricial  alopecia. The cause of FD is not completely know although a  role for bacteria has been postulated.   Bacteria such as Staphylococcus aureus frequently are found in the scalp of patients with folliculitis decalvans. Eradication  of bacteria with antibiotics, isotretinoin and other treatments frequently is associated with improvement of the disease.

A preliminary report proposes that Manuka honey may have benefits in the treatment of folliculitis decalvans

In 2019, a dermatology group in  Boston reported a patient with folliculitis decalvans whose disease improved with use of topical Manuka honey applied to the scalp. Manuka honeyis well known to wound care professionals. In fact, 17 clinical trial s involving  almost 2000 patients have suggested Manuka honey helps wounds heal.  Manuka honey has antibacterial properties – perhaps  due to its low pH, and other  plant  based and hydrogen peroxide based ingredients. A 1999 paper by Cooper and  colleagues showed that  Manuka honey killed  Staph aureus bacteria in wounds. 

The patient in the 2019 paper was a 20 year old male who had used a considerable number of  treatment before he started applying manuka honey to his scalp. These treatments included steroid injections,  clobetasol lotion, prednisone, minocycline, doxycycline and isotretinoin. Some of these treatments were actually  quite helpful for the young man – however he had to  stop because of some side effects of these treatment.  

The  patient decided to start applying Manuka honey  to his scalp after about 1 month into a course of the oral antibiotic cephalexin. As he continued on both cephalexin and topical honey and found that after an additional 4 weeks of both treatments the scalp had improved considerably. 6 months later he stopped cephalexin. His disease eventually flared again and the man used honey alone to settle down his disease. 

Summary/Conclusion

This is an interesting paper. It doesn’t definitively prove Manuka honey helps FD but it hints that it might have a role. We also can’t rule out that the patients long term use of antibiotics and other treatments (like steroids) and isotretinoin have reduced disease activity that makes Manuka honey more likely to help. Nevertheless, this is an interesting paper that hopefully fuel more research in manuka honey.

Reference

Yeh et al. Resolution of folliculitis decalvans with medical honey. Dermatology Online Journal 2019;. 25(8); 

Cetirizine (Zyrtec) in Lichen Planopilaris: Best Viewed as an Adjunct not Main Treatment

Cetirizine (Zyrtec) for Treating Lichen Planopilaris: Where does it fit in?

Antihistamines are increasingly being studied for the treatment for various types of hair loss. For the autoimmune disease known as alopecia areata for example, use of antihistamines like fexofenadine (Allegra) as well as others (i.e. ebastine) may have some treatment related benefits. In scarring alopecia. the use of antihistamines has only received a limited amount of study. Today, we will discuss the use of the antihistamine cetirizine for treating lichen planopilaris.

Lichen planopilaris is an immune medicated disease. There are a number of proposed mechanisms that lead ultimately to the disease. Cetirizine is an antihistamine medication and widely used for various types of allergy related symptoms. However, the medication may have a number of general and wide reaching effects on the immune system.

How does cetirizine work and how does it affect the immune response ?

Cetirizine is an H1 receptor antagonist. The drug minimally crosses the so called ‘blood brain barrier’ and so limited amounts actually get into the brain. This results in less sedation with cetirizine compared to any other traditional antihistamines. The 5 mg and 10 mg doses are unlikely to give sedation for most people. However, the 20 mg and 30 mg doses are much more likely to give sedation. There has been concern in recent years among long term chronic use of high doses of antihistamines on cognitive decline in patients so this needs to be taken into account when discussing high dose cetirizine as chronic therapy with patients with any medical condition.

Cetirizine has a number of potential effects to modify the immune response. These include

1. Inhibit DNA binding activity of NF-kappa B,

2. Inhibit the expression of adhesion molecules on immunocytes and endothelial cells

3. Inhibit the production of IL-8 and LTB4, two potent chemoattractants, by immune cells.

4. Induce the release of PGE2, a suppressor of antigen presentation and MHC class II expression, from monocyte/macrophages

5. Reduces the number of tryptase positive mast cells in inflammation sites.

The 2010 d’Ovidio Lichen Planopilaris Study

In 2010, d’Ovidio and colleagues studied the use of cetirizine at high doses. Rather than using 5 mg to 10 mg daily that is commonly use over the counter, the authors studied the benefits of 30 mg/daily. Twenty-one patients with lichen planopilaris (LPP) were treated with cetirizine as well as their topical steroids. in 18 or 21 patients (85.7 %) there was a reduction in redness, scaling and a reduction in extractable anagen hairs by the pull test. The authors reported that one patient developed cardiac arrhythmia after 3 months of successful treatment and dropped out of the study.

Cetirizine is an antihistamine and functions as an H1 receptor antagonist. In 2010, d’Ovidio showed that cetirizine at high doses (30 mg) could benefit some patients with lichen planopilaris. Over the counter antihistamine dosing like shown in the phone is 10 mg.

What are the side effects of cetirizine?

Side effects of cetirizine and other information can be found in our Handout.

Cetirizine Handout for LPP

Rare side effects including heart failure, angioedema and tachycardia. These side effects are rare at low doses such as the 5 mg and 10 mg (over the counter doses). Side effects increase as one increased the dose. The 30 mg dose used in the d’OIividio study would be expected to have a greater degree of side effects than the lower doses.

Conclusion

Cetirizine may have some benefit in treating lichen planopilaris. I sometimes prescribe cetirizine as an adjective treatment in patients with persistent itching and burning who are not fully responding to mainstay topical, intralesional and oral treatments. Generally I use 5 mg or 10 mg and only rarely do I prescribe 15-20 mg. I do not typically prescribe 30 mg doses as I find side effects increase greatly. One must respect the drug interactions and contraindications for the drug (as outlined in the handout). In many ways, I view cetirizine as a helpful add on - much the same way as I view the use of low level laser therapy in this disease. I do not think in the present day that cetirizine should find itself at the top of the therapeutic ladder but certainly has a place.

Reference

d’Ovidio R et al Therapeutic hotline. Effectiveness of the association of cetirizine and topical steroids in lichen planus pilaris--an open-label clinical trial. Dermatol Ther. 2010 Sep-Oct;23(5):547-52.

Namazi MR et al. Cetirizine and allopurinol as novel weapons against cellular autoimmune disorders.Int Immunopharmacol. 2004 Mar;4(3):349-53.

Treating Frontal fibrosing Alopecia (FFA): Are retinoids better than finasteride?

Retinoids in FFA Treatment

Frontal fibrosing alopecia ("FFA") is an autoimmune disease that mostly affects women. It is classified as a "scarring" hair loss condition and hair loss is often permanent for many women. A variety of treatments are available including topical steroids, topical calcineurin inhibitors, steroid injections as well as oral treatments like finasteride, doxycycline, hydroxychloroquine and isotretinoin.

A new study from Poland set out to compare benefits of finasteride and "retinoids" (isotretinoin and acitretin) in women with FFA. The study included 29 women who were treated with a dose of 20 mg isotretinoin, 11 women treated with 20 mg acitretin and 14 treated with oral finasteride at a dose of 5 mg/daily.  Interestingly, 76% of patients treated with isotretinoin, 73% of patients treated with acitretin, and 43% of patients treated with finasteride had their disease halted over a 12 month observation period. 

Comments

This study is small and should be interpreted with caution for this reason. Nevertheless it is interesting and points to a potentially valuable role for retinoids that we really don't seem to see with classic lichen planopilaris (a closely related condition). The data in this present study however do not match other much larger studies of finasteride use in FFA which have suggested that a much higher proportion of FFA benefitted from use of this drug.

For now, this study provides us with evidence that retinoids can benefit some patients and should be at considered. Many women with FFA do have a tendency for increased cholesterol levels and the use of retinoids can significantly worsen this so caution and monitoring are needed.

Reference

Rakowska A, et al. Efficacy of Isotretinoin and Acitretin in Treatment of Frontal Fibrosing Alopecia: Retrospective Analysis of 54 Cases. J Drugs Dermatol. 2017.

Saw Palmetto: What are the side effects?

Saw Palmetto Side Effects

Saw palmetto (serenoa repens) is a natural herbal-based product commonly used for prostate problems in men and hair loss in men and women. 

A number of studies have suggested that saw palmetto can help hair loss. These studies are small and few in number. Nevertheless, countless numbers of patients turn to these natural products. Furthermore, because they are natural, most assume they are without side effects. The side effect profile of saw palmetto is not entirely clear. It is however known that saw palmetto affects hormones in the body, and risks of mood changes like depression and sexual dysfunction may be real (albeit low) risk.

A recent report provided additional evidence that this natural product might best be classified among chemicals and molecules that affect the hormone and endocrine system of the body (so called "endocrine disruptors"). A 2015 paper from Italy reported development of hot flashes in a 10-year-old girl using saw palmetto. When she stopped treatment, the hot flashes stopped. When she started back up again ("ie a rechallenge'), the hot flashes returned. However, 4 months after starting saw palmetto, the 10 year old got her first menstrual cycle. 

This report reminds us that use of saw palmetto requires counselling of at least the low possibility of side effects. I advise my own patients of the generally well tolerated nature of saw palmetto but remind them of possible risks of mood changes and even the rare possibilities of sexual side effects. More studies are needed to not only document the successes of saw palmetto in medicine but the incidence of side effects.
 

Reference

Morabito et al. Pharmacology 2015.
 

Bimatoprost for Androgenetic Alopecia: An intensely researched area

Bimatoprost for Male Balding

Bimatoprost is a prostaglandin F2 alpha analogue that stimulates hair growth. Bimatoprost at 0.03 % is a well known eyelash growth stimulatory compound and marketed under the name Latisse. 

Bimatoprost has been studied for use in androgenetic alopecia. At low concentrations, it is not particularly effective. Allergan is currently studying higher concentrations (1 and 3%). Data released by Allergan and available to the public online suggest that these higher concentrations may be beneficial in treating hair loss. This is an exciting area to watch out for in the near future.

The graph shows how bimatoprost compares to minoxidil in these Allergan led studies. In their preliminary results, higher concentrations of bimatoprost was similarly or even slightly more effective that minoxidil (the gold standard FDA approved topical treatment for androgenetic alopecia).

Treatment Ladder for Hair Loss: Logical and Evidence based

Treatment Ladders: What is a treatment ladder?

For any type of hair loss, there are many potential treatments.  Some types of hair loss may actually have 10-15 different treatments available. How does one choose which to start with? How does once decide which treatment to use if the first treatment does not work? In short, decisions on treatment are often make with use of a ‘treatment ladder.”  A treatment ladder is a term that describes a logical approach to how one should progress onto different treatments if a previous one proves ineffective.  In essence, a treatment ladder refers to a guide to how one should move “step by step” to additional treatments. If one treatment does not work one moves up to the next treatment on the treatment ladder. Treatment ladders helps clinicians balance effectiveness of treatment with safety.

Treatment Ladders for All Hair Loss

In my view, every hair loss condition has a treatment ladder. If there are 15 treatments for hair loss, one does not simply reach into a hat and decide on treatment based on the name that is pulled out of the hat. Also, one does not decide on treatment based on what was reported on the news, or what  a neighbour or friend had benefit from.  If there are 15 treatments available for a given hair loss condition, one arranges those 15 treatments on a treatment ladder for the given condition and severity of condition and moves forward with decisions on treatments based on that treatment ladder. 

Treatment Ladders: Alopecia Areata as an Example.

Let’s consider a 33 year old female with 5-6 patches of alopecia areata. She comes in with a clip from the newspaper on the oral medication “tofacitinib”  and wants to start it. It is true that oral tofacitinib can help alopecia areata, but is this a good option?

Well, an appropriate ladder for a 27 year old with 5-6 patches with alopecia areata could include:

TIER 1: Topical steroids and/or steroid Injections (with minoxidil)

TIER 2: Topical Immunotherapy (DPCP or Anthralin) or Prednisone Taper (with minoxidil)

TIER 3: Oral Methotrexate or Sulfasalazine or Platelet Rich Plasma (PRP)

TIER 4: Oral Tofacitinib

This is an example. The order of the ladder (or choices for treatment) will differ from physician to physician. But this would be ‘my’ ladder for a 33 year old female with alopecia areata totalling 5-6 patches. You can see that oral tofacitinib is on the list but not at the top of the list.  

Conclusion

Without a treatment ladder one needs to guess if a treatment should be used or not. Treatment ladders are important in any practice and essential in my practice to ensure that evidence based principles are used wherever possible in the treatment of hair loss. 

Emerging Hair Loss Therapies.

What's new in hair loss research?

I'm honoured to speak this weekend at the 2017 "Dermatology Update" conference in Vancouver. I'll be speaking about "Emerging Therapies for Hair Loss." In the last 5 years we have witnessed a remarkable increase in new options for treating various types of hair loss - and I'll have an opportunity to summarize these for the attendees.

Concerns about long-term side effects of some medications and a demand for more effective therapies are driving the development of new treatments for androgenetic alopecia. Topical anti-androgens (particularly topical finasteride) are increasingly used for treating male patterned hair loss. Topical bimatoprost (ie higher concentrations of Latisse) is actively being studied. Drugs which inhibit PGD2 (Setipiprant) are being studied and are among the exciting therapies to watch for. Low dose oral minoxidil (0.25 mg to 1 mg) is increasingly being considered as an option. Platelet rich plasma therapy has evidence now to support a therapuetic benefit in some patients.

One of the biggest breakthroughs in the last 5 years has been the recognition that inhibition of the Janus kinase (JAK) pathway can facilitate hair growth in many patients with alopecia areata. Both ruxolitinib and tofacitinib, in both topical and oral formulations, have shown benefit in treating alopecia areata and I will review these studies at the conference.

Cold caps have been popular in Europe for well over a decade but were banned in the US in 1990 on account of a lack of data on safety and efficacy. The recent FDA clearance of the Dignicap in 2015 and the Paxman cooling system this year offer new options for preventing hair loss from chemotherapy.

Plan b: Is There a Plan B to Treating Hair Loss?

The first step in determining how to help someone with hair loss is figuring out his or her diagnosis. There is no bypassing this step.  The second step is determining a treatment plan that is based on the best medical evidence. 

Plan B: What is Plan B, Doc?

After reviewing a treatment plan with my patients, I'm often asked what treatment will be considered next. "What's plan B, doc?" Well, every treatment plan needs Plan B as well as a Plan C and Plan D.

Consider the 28 year old female with androgenetic alopecia. The best treatment option for her based on all her facts, review of her blood tests and scalp exam might be topical minoxidil. Plan B might be oral spironolactone with or without minoxidil. Plan C might be the addition of a laser comb or changing the anti androgen used. Plan D for her might be a trial of PRP. A solid treatment plan has an alphabet of plans. Not guesswork and not a random pull out of a hat option. But rather options based on a delicate combination of medical science and expert consensus, and personal experience.

What about the 53 year old female with frontal fibrosing alopecia? Plan A for her might be finasteride & steroid injections with hydroxychloroquine as Plan B. Doxycycline is reserved for her as Plan C. For another patient with FFA, Plan A might start with hydroxychloroquine & steroid injections. For her, finasteride is not on the list given the past history of breast cancer the patient had. Plan B is doxycycline and plan C is methotrexate.

Conclusion

Every treatment plan should have an alphabet of plans. That does not necessarily mean one will need to move down the list but the physician should have a clear plan for how to navigate.

Nail Changes in Patients with Hair Loss

Nail Lichen Planus

We will finish this week with a closer look at the importance of examining the nails in patients with hair loss. 

I generally ask about nail changes in most new patients I see in my office. I often describe hair and nails as "cousins" and it should therefore come as no surprise that many conditions that affect the hair also affect the nails. Patients with alopecia areata, lichen planopilaris, telogen effluvium, drug related hair loss, psoriasis may have changes in their nails.

Some patients with scalp lichen planopilaris have nail lichen planus (LP). The clinical features of nail LP depend on where in the nail the disease is attacking (i.e. whether the matrix or nail plate are involved). Longitudinal ridging and splitting are the most commons clinical signs of nail matrix LP. This is shown in the photo. The splitting often extends right to the end as shown in the picture. However, a wide range of additional nail findings are also possible.

Some forms of nail lichen planus lead to rapid scarring and loss of the nail - (very similar to what is seen in the scalp). Other forms only lead to minor changes that may be difficult to differentiate from age related changes. Some patients have resolution of nail disease even without treatment.

There are a variety of treatments are possible including topical steroids (with occlusion), steroid injections (0.5 to 0.1 mg/nail), intramuscular steroids every 30 days (0.5 mg/kg) and oral steroids for 3 weeks. Antimalarials (i.e. oral hydroxychloroquine), oral retinoids, psoralen, tacrolimus are also used. About 1/2 of patients will not improve despite any type of treatment.

Coenzyme Q 10: What are the roles in hair loss?

Co Q 10 (Ubidecareneone)

Coenzyme Q 10 is an interesting supplement with anti inflammatory and anti oxidant activity. I've been investigating whether it has any benefits in hair loss ... but the evidence is certainly not in yet.

Coenzyme Q 10 may have some benefits - under certain conditions. The best studies conditions include heart failure, various neurological problems (especially a condition known as multisystem atrophy) and in blood sugar control. It can lower inflammatory markers in the blood, including C reactive protein (CRP). Coenzyme Q 10 may have a variety of helpful effects on obesity too. Patients on cholesterol reducing medications (i.e. statins) may be at increased risk for coQ10 deficiency so that warrants further study. 

In the autoimmune condition rheumatoid arthritis, a randomized study showed 100 mg per day of coQ10 reduced several inflammatory markers in the blood (such as tutor necrosis factor alpha). It's still too soon for those with various types of hair loss to start taking coQ10. But I am reminded of a 1995 study published in the Lancet that showed an improvement in hair loss in 2 patients who used coQ10 to treat hair loss caused by a blood thinner known as warfarin. The reference to this study is below. 

Oxidative stress occurs from a variety of sources including normal cellular functions in the body but also from irritants, ultraviolet radiation, smoking, and microbes on the skin surface. Even bad dandruff and seborrheic dermatitis generate significant oxidative stress. The abnormal scalp lipids in some scarring alopecias are a particular source of potential oxidative stress and a key research interest of mine.

Overall more research is needed to better understand the uses and benefits of coenzyme Q 10.

Reference
Nagao et al. Treatment of warfarin induced hair loss with ubidecarenone. Lancet. 1995; 21: 346:1104

Scalp micro pigmentation (SMP)

Scalp micro pigmentation or "SMP" is a method of camouflaging hair loss. Dots are tattooed to mimic the appearance of hairs cut in cross section. In this photo, small black dots can be seen in between the hairs. For this particular patient, these dots camouflage scars from a previous hair transplant