Do I have Frontal Fibrosing Alopecia?

Do I have FFA or not?

FFA of the frontal hairline. 

Frontal fibrosing alopecia is increasingly common. It's still a relatively rare condition overall but there is no doubt that the number of women being diagnosed is increasing. On account of the increase individuals in the general public are much more aware of this otherwise uncommon diagnosis. Patients often want to know if they have this condition. The short answer is that anyone wondering if they have FFA really should see a dermatologist for a comprehensive review and examination of the scalp. 

I enjoy helping patients understand why they do or do not have FFA. Many patients are convinced they have FFA when they clearly do not.  The following are some pieces of information that patients frequently feel points to a diagnosis of FFA when it fact it does not. Following this, I have outlined 5 pieces of information that actually is helpful (and increases the odds somewhat that a true diagnosis of FFA could be present). Exceptions of course exist and nothing replaces an in person review for an up close examination.

5 PATIENT COMMENTS THAT ARE NOT HELPFUL IN DIAGNOSING FFA

In my experience with countless numbers of patients who think they have FFA (but don't).... the following pieces of information are not helpful to making the diagnosis even though patients may think that it is!

Comment 1: "My hairline is changing"

Why is it not helpful? Hairlines change for many reasons including androgenetic alopecia, traction alopecia, alopecia areata and telogen effluvium. Frontal fibrosing alopecia is certainly on that list but there are too many reasons for frontal hairloss to make the observation of hairline changes a key feature for diagnosing FFA. A patient with hairline changes could have FFA but could have other conditions too.

Comment 2: "I see 'lonely' hairs"

Not everyone knows what a lonely hair is. But a patient who understand what is meant by a "lonely hair" has generally done a lot of reading and are extremely knowledgeable about hair loss! The reality however is that most "lonely hairs" that most people find in the scalp are not what really constitutes the gist of what these hairs are all about. My feeling is that the presence of more than 6 hairs across the frontal hairline at a distance of greater than 1.5 cm from the main hairline probably does in fact raise suspicion for true 'lonely hair' phenomenon.

Comment 3: "I have redness and scarring in my scalp" 

Redness alone does not constitute a diagnosis of FFA. In fact, FFA tends to be more pinkish and subtly red than overtly red. There are simply too many scalp conditions that cause redness to give this observation any significance.

I'm always concerned when patients feel they can "see scarring" because one can't truly see scar tissue as it is mostly under the scalp. In advanced scarring alopecia, one certainly can see evidence of scarring but these cases are usually fairly advanced. In all fairness, one can however see scalp color changes (mostly to a white color) that would suggest the presence of scarring. However, one can't actually see scarring.

Comment 4: "I now have so many baby hairs"

Baby hairs are not really a feature of FFA. In fact, the presence of baby hairs probably argues against the diagnosis of FFA for most patients than actually favours the diagnosis. This is because FFA tends to be a destructive process that involves the preferential destruction of baby hairs (medically termed vellus hairs). The presence of abundant baby hairs is not a feature of progressive FFA.

Comment 5: "I have no family history of balding so it only makes sense something else is going on"

The argument that an individual must have some other diagnosis other than genetic hair loss on account of the lack of genetic hair loss in the family is never a valid argument. There are women who come to be diagnosed with androgenetic alopecia despite a family history of men and women with thick hair. The patient's account of her family history is not very relevant to most diagnoses of hair loss. Sounds strange but this is true: I frequently diagnose androgenetic alopecia in women who stated their family is comprised of individuals with 'good hair.'

TOP 5 FINDINGS AND COMMENTS THAT ARE HELPFUL IN DIAGNOSING FFA

Nothing can substitute for a careful review of one's story and examination of their scalp with dermoscopy. The following pieces of information are helpful when considering a diagnosis. Not all patients have the following features, but they greatly increase the odds that what we are dealing with is FFA.

FINDING 1. Both sideburns are lost (above the ears). Not thinned but lost. The regions below where the spectacle of the glasses sit has been depleted of hairs.

Loss of the hair frim both sideburns is actually quite an important piece of information when it comes to diagnosing FFA.  This finding is mot present in everyone with FFA but is quite common if one looks.

FINDING 2. Baby hairs are not seen in the frontal hairline but rather many single long hairs are seen. Not all the hairs have redness around them but many do have a faint redness

FFA is a process that destroys fine vellus hairs - but it does so with inflammation. The presence of small amount of inflammation (usually without symptoms) is a key finding.

FINDING 3. If the eyebrows are lost, they are significantly changed

Eyebrow loss is common in FFA and in a large number of individuals with FFA, they are the first finding. Eyebrow loss of course does not happen in all women with FFA and loss of eyebrows may even come after the loss of the frontal hair. However, significant eyebrow loss requiring tattooing, microblading does raise the odds a bit that the presentation fits with possible FFA.  Still, one needs a careful examination before concluding that anyone's eyebrow loss is FFA. Nevertheless, changes in the eyebrows are common to FFA.

FINDING 4. The patient is between 46 and 66

FFA is rare in the 20s and 30s. That's not to say it can't occur as we have patients in their teenage years affected. However, from a statistical point of view, women under 40 who come in with worries that they have FFA actually rarely end up having FFA. There are exceptions of course but it is not a common occurrence. In our clinic, 98 % of patients who receive a diagnosis of FFA are older than 46.

FINDING 5. Veins are seen much easier on the scalp than before and the skin itself just does not look quite normal.

FFA is a complex condition and is probably more than just a 'hair disease'.  It's likely a complex autoimmune disease that affects hair predominantly but also affects the skin as well The skin itself changes in FFA - and does so by thinning. We call this "atrophy." Some women with FFA have minimal to no atrophy but many have significant atrophy which leads to the veins becoming much more visible. Generally, the skin in the area of the hairline does not look the same as the skin of the forehead - the affected area in FFA is lighter in color and smooth.

CONCLUSION

Frontal fibrosing alopecia is a complex condition. There is no 'one way' that it appears. There are 100s of different combinations. Navigating the diagnosis oneself is frequently met with challenging. I've summarized here 5 points that patients place a great deal of emphasis on when looking at their hair - but actually don't carry all that much weight when making the diagnosis. 

Hair loss without Shedding: Where did it go?

Hair loss without shedding 

Hair loss that occurs slowly over time without the patient noticing an increase in daily shedding is a special situation. 

Some hair loss conditions are associated with significant and sometimes rapid reduction in hair density without a noticeable increase in shedding. Examples include female pattern hair loss, many scarring alopecias (pseudopelade, lichen planopilaris, frontal fibrosing alopecia, as well as subclinical shedding disorders. Trichotillomania should also be included on this list. However, the list expands greatly if the individual shampoos frequently (ie daily). In that case the list of causes also includes many of the effluviums (ie telogen effluvium), as well as alopecia areata. 

The Card Test For Darker Hair Colours.

Card Test For Darker Hair Colours.

The contrasting hair card tests for darker hair colors. The use of a piece of paper of contrasting color to the hair is an excellent means to evaluate recent changes in hair growth. Here, a white paper is placed behind dark brown hair. In this patient we can see thay signficant growth has occured in the last 3-4 months. This immediately informs me that either a massive telogen shed occured 4 months ago or a growth promoting agent was started 4 months ago. In this case it helped pinpoint regrowth from use of minoxidil.

See Also "The Card Test for Lighter Hair Colors"

The Card Test For lighter hair colours.

Card Test For Lighter Hair Colours.

The contrasting hair card tests for lighter hair colors. The use of a piece of paper of contrasting color to the hair is an excellent means to evaluate recent changes in hair growth. For example, in this patient with blond hair we can see thay signficant growth has occured in the last 3-4 months. This immediately informs me that either a massive telogen shed occured 4 months ago or a growth promoting agent was started 4 months ago. In this case it helped pinpoint the precise timing of a telogen effluvium due to surgery.

See Also "The Card Test for Darker Hair Colors"
 

Things to Consider when Latisse won't work

When Latisse Won't Work

Latisse is an FDA approved and Health Canada approved treatment for improving eyelash length, thickness and darkness in patients with eyelash hypotrichosis (not enough eyelashes). Latisse contains the ingredient bimatoprost.

Clinical studies have shown that Latisse is very effective for many user. Many notice changes as early as 4 weeks and 50 % have changes by the second month.  By 16 weeks, 80 % will have an improvement.

Latisse Non-Responders: When Latisse just doesn't work

Latisse is effective for many individuals. However, about 1 out of every 5 users is not going to find that the medication worked all that well for them.  A large proportion of the patients I see in my office come to see me wanting to know why Latisse did not work as good as the advertising stated it should.  Let's review some of the reasons for poor results.

1. The patient is simply in the "20 % group."

Latisse does not help everyone. By 16 weeks, 80 % will be pleased with the money they spent. 20 % won't. I tell my patients that someone has to be in the "80 % group" and someone has to be in the "20 % group." Not everyone responds to Latisse.

2. The bottle does not contain bimatoprost and so it is not Latisse.

Latisse is available through physician's offices (and some drug stores), but there are many other ways of obtaining Latisse and products that claim to be Latisse. I encourage readers to simply enter phrases such as "buy Latisse online" in their Google search engine to see the array of possibilities. Most of these sites will ultimately lead to a box of Latisse (containing the true ingredient bimatoprost) showing up at the door.  But not all.  Patients need to keep in mind the possibility of counterfeit products. It's rare but most certainly does happen.

3. The method of application is wrong.

One needs to apply Latisse nightly to the lower eyelid margin of the upper eyelid with the brushes provided. I can't tell you how many variations of this simple sentence there actually are. Like any drug, it needs to be used according to instructions.

4. The individual has a medical condition of the hair follicle.

It comes as a surprise to many individuals that there are well over 100 reasons for eyelash loss. Not all lash loss is simply due to "aging" or a "tainted bottle of mascara" that was used in the past or improper use of a heated eyelash curler. These certainly can cause temporary or even permanent lash loss. Rather a variety of inflammatory and autoimmune conditions are associated with eyelash loss. 

Eyelash Loss: What else?
 

A careful review of one's story (called the medical history) and up close examination of the eyelashes is needed to determine the cause. One must also examine the eyebrow and scalp hair at the same time as there is no other way to confidently come to the diagnosis.

Causes of eyelash loss include

1. Inflammatory and Autoimmune Conditions. Inflammation of the hair follicle can cause it to fall out. Alopecia areata, frontal fibrosing alopecia, Scleroderma/ en coupe de sabre and lupus are all potential causes.  A variety of true dermatological conditions can also cause lash loss including various eczemas, seborrheic dermatitis and psoriasis. In such cases it is scratching and rubbing that often leads to lash loss.

2. Trichotillomania. 3-5 % of the world will purposefully pull out one or more of their hair follicles somewhere on the body during their lifetime. When repeated, the diagnosis of trichotillomania needs to be considered. Plucking of the lashes is quite common and may even be one sided. 

3. Endocrine disorders. Isolated eyelash loss is uncommon in patients presenting with endocrine disorders. However, one needs to consider thyroid, parathyroid and pituitary disorders.

4. Infections. Infections with fungus, bacteria, viruses all have the potential to cause lash loss. Isolated lash loss is uncommon but can be seen with conditions such as leprosy and syphilis. 

5. Drugs. There are many drugs now implicated in lash loss ranging from cancer drugs to antidepressants (escitalopram) to diabetes medications (sitagliptin and metformin) to methylphenidate. Other drugs include blood thinners, cholesterol meds, propranolol, valproic acid. Even cocaine vapour can cause lash loss.

6.  Infiltrative Conditions. Eyelashes can fall out when cells enter the hair loss that normally don't reside there. Lymphomas are a good example. Eyelash loss can also occur with a variety of local tumors including basal cell carcinoma, squamous cell carcinomas, sebaceous carcinomas and many others.

7.  Nutritional Issues. Poor diets and specific deficiencies can all cause lash loss. This ranges from severe illness with marasmus, to deficiencies of protein, zinc and iron.

8. Congenital and genetic conditions. Many many genetic syndromes are associated with less than normal eyelash density. Well over 50 conditions fall in this category from KID syndrome, Rothmund Thompson syndrome, Incontinentia Pigmenti, Keratosis follicularis spinulosa decalvans, Progeria, Bloom syndrome, Menke's syndrome, Monilethrix to Trichothiodystrophy. Many many others are on this list as well.

Conclusion

There are many causes of eyelash loss. Not every cause of eyelash loss responds to Latisse.

 

Treating Female Pattern Hair Loss: Options for Women Over 60

Treatments for AGA in Women over 60

I'm often asked about treatment options for women over 60 who present with a diagnosis of androgenetic alopecia (female pattern hair loss). There is some degree of confusion as well as misconceptions which exist in this subject area.

My approach in this situation is to first confirm the diagnosis and then base treatment decisions according to the patient's medical history. The importance of the first step can not be overemphasized.

1: Confirming the Diagnosis

It is extremely important to confirm the diagnosis and ensure that a) another diagnosis is not more appropriate and b) to determine whether other diagnoses are also present. A patient need not have only one diagnosis.

A. Senescent Alopecia

Women who present with hair thinning in their 60s and 70s with no evidence whatsoever of thinning in the 30s, 40s or 50s may have senescent alopecia (age related hair loss) rather than true androgenetic alopecia. This distinction is important as senescent alopecia is less likely to be androgen-driven and therefore responds less to antiandrogens such as finasteride. The main treatment for senescent alopecia is minoxidil although agents such as low level laser and less commonly finasteride can be considered.

I typically ask patients if their hair density on their 50th birthday was more or less the same as their 30th birthday. If that answer is yes one should at least consider the possibility that senescent alopecia or even another diagnosis other than androgenetic alopecia is present.

B. Scarring Alopecia

Scarring alopecias are far more common than we currently diagnose. They range from subtle asymptomatic scarring alopecia to fibrosing alopecia in a pattern distribution to markedly symptomatic lichen planopilaris. Scarring alopecias are easy to miss but need to be considered in all patients with sudden onset of itchy hair loss or a more rapid decline in density from what they may have experienced in the past. A biopsy can help better evaluate these conditions. 

C. Hair shedding issues

Both acute and chronic telogen effluvium (CTE) need to be considered in women with hair concerns. Stress, thyroid problems, new illnesses and newly prescribed medications can all contribute to increased hair shedding and hair loss. Anyone with new shedding needs a very detailed examination and workup not only by the dermatologist but by the family physician. Blood tests are especially as is a full medical examination. One must also ensure that routine mammograms and colonoscopies are up to date.

Chronic telogen effluvium (CTE) is among the more challenging to diagnose conditions. Patients present with increased shedding that waxes and wanes. To an outsider it generally appears that the person has fairly good density. A hair collection or biopsy can help with the diagnosis.

Treatment Options

The main treatment options for patients with confirmed androgenetic alopecia is minoxidil, finasteride and low level laser. If the pattern of hair loss is localized frontal loss, and donor density in the occipital scalp is good, a hair transplant can be considered as well.

Minoxidil is formally approved for women 18-65. It may, of course, be used off label for women over 65 with proper evaluation by a physician.  Women with heart disease, heart failure or previous heart attacks for example may or may not be good candidates for minoxidil. One is not obligated to use the full recommended dose of minoxidil. Starting with one-quarter or one-half the recommended amount is often a good way to ease in to the treatment in patients with underlying medical issues.

Finasteride may also be a good option. Studies support the notion that higher doses of 2.5 mg and 5 mg are needed for post-menopausal women and doses of 1 mg are ineffective. Finasteride is relatively contraindicated in women with previous history of breast, ovarian or gynaecological cancer. Given the rare effects of finasteride on mood, this medication is also relatively contraindicated in women with depression.

Low level laser therapies are safe but may be less effective than minoxidil or finasteride.  A number of laser devices are available in the market for use by patients in their home. None have proven superior to another and so one must balance cost with ease of use. A helmet based device may be easier for some compared to the hand-held devices.

Scalp Inflammation. Scalp inflammation must be attended to fully when caring for patients with AGA. Many women with AGA have seborrheic dermatitis and this is best controlled with periodic use of an anti-dandruff shampoo. I frequently prescribe a trial of a mild cortisone lotion if there is scalp redness if the redness does not respond to anti-dandruff therapies.

7 Hair Transplant Myths

7 Common Myths in Hair Transplantation

Hair transplantation is among the mostly consistently successful and  life-changing of all the hair loss therapies. Hair transplants nowadays can look extremely natural (when performed by skilled teams). However, there are a number of myths that are infrequently talked about when it comes to hair transplantation.  These can sometimes be overlooked.

1.     Transplanted hair lasts forever

It’s a common myth that transplanted hair moved during a hair transplant last forever. Fortunately, most hairs that are transplanted do generally remain in their new location forever. However, anyone is has followed a hair transplant patient for 10, 20 or 30 years will tell you that the same number of hairs that were put in are not always remaining over time. Most will stay - but not all

There are many reasons why hairs transplanted hairs don’t always last forever. For one, donor hair is not always completely resistant to balding in all men. In fact, it’s a spectrum, from some men who have very little to no balding in their "donor area" (at the back of the scalp) to men who have considerable thinning in the donor area over time (ie. men with DUPA are the extreme). In addition, the medical community has not rigorously studied long term the immunological and physiological changes that happen to transplanted hairs over extended periods of time.

Nevertheless, there is no arguing that transplanted hairs last forever. It holds true for a high proportion of men and women but not all. We hope they last forever are and they seem to be in many men. However, a proportion of transplanted hairs slowly disappear over decades in some men.

2.     Only one hair transplant surgery session is needed

From the time male balding and female thinning announces its presence in any patient, it always progresses. While it is true that androgenetic alopecia can stop or slow for periods of months to a year or two, androgenetic alopecia by definition never stops. Anyone who gets a hair transplant must assume that existing hair in an area will slowly thin over time. If a patient is under 30 years of age, he (or she) must assume that another hair transplant will likely be needed if he wishes to maintain his current look into his 50s and 60s.

3.     A hair transplant procedure is always a great success

Hair transplants are generally quite successful. That's why they are popular! With the right patient, and a skilled team, the chances of success are high. Unfortunately, hair transplant don’t always work out as successfully as one might hope. There is not an experienced hair transplant surgeon in the world who can state that he or she has never had a patient who did not grow as much hair as they hoped. The reasons why this occurs is quite varied - but ranges from "patient factors" (post op care, smoking, unrecognized scalp diseases), to "surgeon-related" factors (surgeon skill, skill of the technicians handling the grafts). Sometimes one never knows the exact reason why things don’t turn out. In the hair transplant field, this is called the ‘X factor.’

4.     A hair transplant is a one-day event

A hair transplant procedure itself is a one day event, but the actual procedure when one considers the time from the surgery to the time where the patient feels back to normal ranges from a few days to a few months.  The actual recovery time varies from patient to patient and varies based on the size of the surgery.

In general, the post op recovery period is longer for FUT procedures than FUE and longer for patients that require more grafts. Patients who don’t require shaving for FUE procedures and have limited baldness, may find that 2-3 days is sufficient to feel back to their usual self.  However, a patient whose scalp is shaved completely for a large 3000-4000 FUE procedures may find that it takes just a few days to “feel good” but takes 3-4 weeks before he feel confident to go to work. Depending on his occupation, he may or may not feel comfortable at work for an extended period. A patient who sees clients on a daily basis at work may not feel completely comfortable seeing his clients even after 2 weeks post op from a 4000 graft FUE.  This needs to be taken into account. A hair transplant is not always a ‘one day thing.’

5.     A hair transplant is always an option for treating hair loss

It’s a myth that a hair transplant is always an option for an individual with hair loss. Some patients may be too young, some have medical issues that preclude surgery, and some have a type of hair loss that also will not be successful if a hair transplant were performed. Hair transplants aren't for everyone.

6.     There are no complications to a hair transplant

Hair transplants are quite safe. But it’s a bit of a stretch to say that they are without complication. Patients may have have redness, swelling and crusting post operatively. In general, the recovery in FUE procedures is much easier than FUT procedures.  But there are rare complications in hair transplant surgery that include long lasting nerve pain (more in FUT than FUE procedures) and persistent scalp redness. Unless a physician is carefully monitoring the procedure, a patient can even get sick. The hair transplant community tends to shy away from calling hair transplant procedures a 'surgery' in order to make the procedure more patient friendly - but make no mistake a hair transplant is a surgery. 

7.     You will regain the hair density of your youth

A hair transplant is a surgical procedure which involved moving anywhere from 10 to 10,000 hairs into an area of balding. If an area of hair loss is small, it may be possible to build some very nice density in the area – but the density is generally less than it once was. For example, in a patient who is very bald, a density of 35-40 follicular units per square centimeter will typically be created.  This area likely had a density of 90 or more follicular units per square centimeter at one time years earlier. Therefore, it is generally the norm for a hair transplant to create results that are less dense than the original density. A skilled surgeon can often help make 35-40 follicular units look like the original density. However, photos and videos of patients with amazingly thick and dense hair following their procedure may not always be accurate.  

My hair was ripped off: Will it grow back?

Traumatic Hair Pulling:  Full Regrowth May or May Not Occur

I am often asked if hair that is pulled out forcefully will regrow. Examples of this are the pulling of hair by children on the playground, hair getting caught in doors, machines etc or cases of hair pulling during assault or abuse-related situations (for example domestic abuse).

Without actually seeing the scalp, and knowing details of the patient's story, it is impossible to determine if hair will or will not grow back in any particular case. This requires an in person examination so that the scalp can be properly examined.

Hair regrowth is not a guarantee

There is no guarantee that hair regrowth will occur. One will know in 6-9 months if they will acheive full regrowth or not because that is how long it takes for hair to grow back following any type of injury.

It is certainly possible for repeated pulling to give permanent hair loss. However, in the vast majority of cases where hair is pulled from the scalp, hair grows back.  If you or I were to reach up a pluck a hair, it will grow back. However, if pulling is repeated many times or is excessive with bleeding a greater chance exists for scarring to develop. Hair pulling that is accompanied by injury to the skin layers (i.e. that creates an actual wound) has a markedly increased chance of being associated with permanent scarring.  It is such scarring that blocks the regrowth of hair.  Scar tissue is permanent and, if present,  generally destroys stems cells. 

Anyone with concerns about incomplete growth after episodes of hair pulling should see a physician who specializes in hair loss for consideration of a scalp biopsy.

Hair Loss at the Nape of the Neck: What are the main causes?

Losing Hair at the Nape: What are the main Causes?

Hair loss can either be localized (meaning one area of the scalp) or diffuse (meaning all over the scalp). There are many causes of hair loss at nape of the neck and the back of the scalp. 

1. Traction alopecia (photo 1)

Traction alopecia refers to a type of hair loss due to the tight pulling of hair. The back of the scalp is particularly susceptible to loss of hair.  Hair styling practices can frequently lead to traction including braids and weaves and pony tail.  If traction alopecia is of recent onset, hair regrowth can occur even without treatment. If traction is longer standing, the hair loss can often be permanent.  Some women with hair loss that looks like traction actually have a scarring alopecia known as cicatricial marginal alopecia. 

PHOTO 1: Traction alopecia presenting as hair loss in the nape

2. Alopecia Areata (photo 2)

Alopecia areata is an autoimmune disease that affects about 2 % of the world. Hair loss can occur anywhere. Alopecia areata can frequently cause hair loss specifically at the nape in some patients. The particular form that causes loss at a the back of the scalp is the 'ophiasis' form. The ophiasis form is frequently resistant to standard treatments although topical steroids, steroid injections and diphencyprone are typically first line. 

PHOTO 2: Alopecia areata presenting as hair loss in the nape

 3. Androgenetic Alopecia (photo 3)

Androgenetic alopecia (male and female thinning) typically causes hair loss at the top of the scalp. In men, the temples and crown are most often affected. In women, the mid-scalp region is generally affect first. The back of the scalp can also be affected although this is not typically thought of. Hair thinking along the nape is not uncommon in advancing balding in men and women. 

PHOTO 3: Androgenetic alopecia (AGA) presenting as thinning in the nape

 

4. Frontal Fibrosing Alopecia (photo 4)

Frontal fibrosing alopecia (FFA) is a type of scarring alopecia. FFA typically affects women between 45-70. Most often hair is lost along the frontal hairline and eyebrow. However the back of the scalp (at the nape) and frequently be affected. The hair loss in the nape typically starts at the sides (left side and right side) just behind the ears. Treatments for FFA include topical steroids steroid injections, topical calcineurin inhibitors. Oral drugs include finasteride, doxycycline and hydroxychloroquine at the top of the list.

PHOTO 4: Frontal fibrosing alopecia (FFA) presenting as hair loss in the nape

5.  Heat and Chemicals

Heat and chemical treatments can lead to hair shaft damage and hair loss at the nape. Frequently, heat and chemical overuse leads to an increased tendency to develop traction alopecia which si discussed above. 

6. Acne keloidalis nuchae

Acne keloidalis nuchae (AKN) is a condition that can affect both men and women. Small papule or bumps develop along the posterior scalp and are accompanied by hair loss in the region as well.  The hair loss in AKN is often permanent and can lead to thicken and thicker scars some of which are disfiguring. 

7. Hair shaft disorders

Some individuals are born with abnormalities in how the hair shaft is produced. This frequently leads to hair breakage. Monilethrix is one of the hair shaft disorders that frequently leads to hair loss along the nape. 

Am I taking the right amount of hydroxychloroquine (Plaquenil)?

Hydroxychloroquine (Plaquenil): Am I taking too much?

Hydroxychloroquine is an oral medication used in a variety of autoimmune conditions. Side effects have been discussed previously but today we will focus on eye side effects. A number of side effects are possible ranging from vision changes to double vision to asymptomatic changes in various parts of the eye.

The Risk of Retinopathy with Hydroxychloroquine

"Retinopathy" is one of the more worrisome side effects of Hydroxychloroquine. At appropriate doses, studies show that the risk appears to be about 1 % of patients at 5 years of use and 2 % at 10 years. After 20 years, the risk may rise to 20 %. Once the retinal toxicity from hydroxychloroquine occurs, it is believed that the changes in the retina are permanent. Furthermore, the disease can even progress even if hydroxychloroquine is stopped.  

 

Risk Factor for Retinal Toxicity

Retinal damage can occur in anyone. However, the risk may be increased if the following risk factors are present

• Longer Duration of use (cumulative dose)
• Renal or hepatic functional impairment. Compromised kidney and/or liver function can lead to increased accumulation of hydroxychloroquine in the tissues.
• Age over 60 years.
• Preexisting retinal disease
• Concurrent tamoxifen therapy

What dose should I take?

It's clear that taking the appropriate dose reduces (but does not eliminate) the chance of side effects. The optimal dose is 6.5 mg for every kg of lean body weight (not simply what the patient weighs). "Lean body weight" is essentially the patients expected weight for their height and gender - it does not include the "extra" weight that some might carry. Instead of calculating lean body weight, some clinicians advocate simply using the patient's true body weight and multiplying by 5 (instead of 6.5).  In our clinic we typically dose hydroxychloroquine according to the following grid:

Hydroxychloroquine Dosing

Conclusion

The risk of eye related toxicity is low in the first 5-10 years of hydroxychloroquine use provided the dosing is respected. This study has had great importance as it has further helped to define risk and has encouraged changes in screening guidelines. These guidelines now include an initial examination but dedicated yearly screening to begin only after 5 years in otherwise healthy individuals deemed at low risk for eye problems.

Reference

(1) Melles & Marmor. The Risk of Toxic Retinopathy in Patients on Long-term Hydroxychloroquine Therapy. JAMA Ophthalmolol. 2014;132(12):1453–1460.

Is Lichen Planopilaris Caused By A Fungus?

Lichen planopilaris is the long name given to a type of scarring hair loss condition. It is sometimes referred to as follicular lichen planus. The name "lichen" comes from the skin lesions of lichen planus that some patients with lichen planopilaris also have. The skin lesions are flat just like lichens that one might see walking in the forest. 
Lichen planopilaris is not due to a fungus. It is an autoimmune inflammatory condition that causes permanent hair loss. Treatments include anti-inflammatory agents not antifungal agents.

Changes in Hair Texture

What causes hair to become wavier?

There are several reasons for an individual with straight hair to find their hair has become wavier or even curlier. Causes include age related genetic programming, endocrine disorders (ie hypothyroidism), scarring alopecias, hair trauma (from heat or chemicals), androgenetic alopecia, medications (ie retinoids, minoxidil) and a variety of inflammatory disorders.

Do I Need to See an Endocrinologist for my Hair Loss?

There are many types of hair loss. In fact, when you add them all up, there are well over 100 causes of hair.  Some of the causes impact another body system in addition to the hair and require additional focus and attention to ensure the patient's total health. For example, some of the causes are associated with an increased chance of having a thyroid disorder (alopecia areata and lichen planopilaris are example). Other causes are associated with a range of other issues including hearing issues, heart problems, kidney problems, cholesterol problems, bone abnormalities, etc.

Androgenetic alopecia is a form of hair loss that frequently affects women. It causes thinning in the central scalp area in early stages such that the scalp becomes much more "see through." Over time the hair loss pattern can be diffuse. Most women with androgenetic alopecia have no hormonal abnormalities but a small proportion do. Women with irregular periods, acne, hair growth on the face require blood tests to further evaluate for an underlying endocrine issues.

When should a referral to an endocrinologist be made?

I'm often asked by patients and physicians when I refer my patients to an endocrinologist. There are no hard and fast rules but referrals are generally made in the following situations:

1. Women with androgenetic alopecia and irregular periods, especially less than 9 menstrual cycles per year.

2. Women with androgenetic alopecia with possible evidence of late onset congenital adrenal hyperplasia evidenced by elevated day 3-4 17-hydroxyprogesterone.

3. Women with androgenetic alopecia with evidence of potential polcystic ovarian syndrome, especially elevated day 3-4 LH/FSH ratios, irregular periods and findings of acne and increased hair growth on the face.

4. Women with hair loss accompanied by regular menstrual cycles with a history of irregular cycles in the past who do not show normal surges of progesterone day 21.

5. Women with possible premature ovarian failure.

6. Women with irregular periods and elevated prolactin.

7. Women with markedly elevated DHEAS and testosterone regardless of age

8. Women with autoimmune mediated hair loss with low bone mass. Such women may require corticosteroid based therapies with the potential to further impact bone

9. Women with potential adrenal dysfunctional either concern for adrenal suppression from corticosteroid use or various causes of hyperadrenalism (especially when Cushing syndrome is a consideration).

10. Women with low TSH and elevated T4 and or T3

11. Women with high TSH above 7-10 that does not improve on repeat testing or does not improve with thyroid supplementation or is associated with symptoms such as low heart rate, mood changes, constipation and/or chronic shedding. A lower threshold for referral is made in my clinic if additional underlying health issues are present (ie heart disease) or thyroid autoantibodies are positive. For an elevated TSH 2.5 to 6, I handle these situations on a case by case basis.

Conclusion

Hair loss is associated with changes in several organ systems. There are several reasons why I might ask my endocrinology colleagues to evaluate my female patients and some are listed above. Other reasons may be possible too. It is not a routine referral meaning that not all patients need such referral. In fact, it is only a small minority.

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.

What is "pityrosporum folliculitis"?

Pityrosporum folliculitis

This is a an itchy condition whereby hair follicles becomes inflamed due to overgrowth of Malassezia yeast. The condition typically occurs in areas that can support the growth and proliferation of Mallassezia - especially the upper trunk, shoulders and rarely the head and neck area. Although 92 % of the world is covered in Malassezia, most people do not develop any problems from them. Predisposing factors to develop Pityrosporum folliculitis include hot humid environments, age (rarely happens before puberty), cancer, immunocompromised states and previous use of antibiotics.

The patient develops tiny 1-3 mm inflammatory papules and pustules. These reveal the classic budding yeast when examined under the microscope with a drop of potassium hydroxide (KOH).

What conditions can look similar?

One needs to consider many other diagnoses as well before reaching the conclusion that the patient has pityrosporum folliculitis. Steroid acne, acne vulgaris, bacterial folliculitis, eosinophilic pustular folliculitis and insect bites can sometimes look similar.

How is pityrosporum folliculitis treated?

Treatment includes topical antifungal creams including ketonconazole and ciclopirox. Antifungal (antidandruff) shampoos are also frequently used with the creams. Rarely, oral antifungal agents like fluconazole and itraconazole or oral isotretinoin (to shrink the sebaceous glands altogether) are needed. 

If hair extensions are causing hair loss, do they need to be removed?

Hair extensions can sometimes cause hair loss. Whether to remove the extensions or change the type of extension is a decision made on a case by case basis. This is not always a simple answer. Sometimes the improvements that come with the patient using the extensions supercedes a small amount of hair loss that might come with wearing them. This makes removing the extensions less relevant - especially if this is a more permanent type of camouflaging option for the patient. If, however, the hair extensions are causing significant hair loss and the use of the extension is only temporary (and the long term goal is to improve the patient's hair), then the extensions should likely be removed or changed to reduce the chance of long term damage to the hair follicle and the scalp.

What kind of hairs are going down my drain after shampooing?

Hair Shedding: What am I seeing?

What kind of hairs typically go down the drain after shampooing one's scalp? Well, in nearly everyone these are hairs known as "telogen hairs."

Telogen hairs are hairs that have a long history. They were previously tightly rooted in the scalp and had spent many years growing (at which point they were called anagen hairs). But after years of growing without even a moment of rest, anagen hairs retire and become known as telogen hairs - and then drop out of the scalp. Telogen hairs lack a root sheath around the ends.

Telogen Effluvium and the URH

Upright Regrowing Hairs

Telogen effluvium ("TE") is a type of hair loss where individuals experience increased daily hair shedding. Instead of losing 30-40 or 50 hairs per day, the individual experiences loss of 60, 70, 80 or more hairs in any given day. The numbers can exceed 500 depending on the cause of the shedding.

Common causes of TE include low iron (low ferritin), anemias, thyroid problems, crash diets, weight loss, stress, surgery, medications (ie lithium, some blood pressure pills, retinoids (vitamin A pills)). Any significant illness inside the body (ie flu, autoimmune disease) or on the scalp surface (ie severe scalp psoriasis or severe seborrheic dermatitis) can cause a telogen effluvium.

This picture shows a typical trichoscopic appearance of someone with a "TE." Numerous short pointy hairs, known as "upright regrowing hairs (URH)" can be seen.
 

Hair loss after starting and stopping birth control

Hair Loss and Birth Control

Hair loss often occurs in women who start and stop birth control. This typically occurs 1-2 months after starting and stopping and can last 4-5 months. For some individuals it lasts 9-12 months. 

For the vast majority of individuals, the abnormal shedding eventually stops and returns to normal shedding patterns- even without treatment. However, some women (small minority only) develop a chronic shedding pattern for an extended period of time and some notice that density does not make it back fully on account of an acceleration of underlying androgenetic alopecia.

In summary, most women will experience additional hair shedding for a few months after starting and stopping birth control. The excessive shedding will eventually slow and return to normal for most. Consultation with a dermatologist is advised if shedding persists after 6 months.

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.