Blood test and Hair Loss: Necessary but Often Normal

Blood tests in Patients with Hair Loss

Hair loss for most is due to changes happening within the tiny hair follicles deep under the scalp. There may be a difference in the expression of certain genes or their may be different levels of inflammation surrounding hairs. It comes as a surprise to many patients that blood tests are often normal. 

Why do we need blood tests if they are likely to be normal?

We require blood tests because there are many mimickers of hair loss and many conditions associated with abnormal blood tests are asymptomatic. If we could tell with 100% certainty that a given patient had low iron or had a thyroid problem just by listening to their story or examining their scalp, we would not need blood tests. The reality is that we can't. Many systemic conditions that can contribute to hair loss are asymptomatic.  Low iron, thyroid abnormalities, zinc abnormalities, autoimmune markers, hormonal changes - these can frequently be asymptomatic. 

Does it make sense that blood tests can be normal and still have hair loss?

It makes a lot of sense when one pauses and reflects on what is happening for most people. As mentioned earlier, hair loss for most patients is due to changes happening within the tiny hair follicles deep under the scalp. There may be a difference in the expression of certain genes or their may be different levels of inflammation surrounding hairs. The key tests that we need are therefore 'hair tests' not blood tests. In the present day and age, we don't have very sophisticated "hair tests."

I often use several analogies with my patients. If your arm was hurting and your doctor sent you for a chest x-ray, you wouldn't be surprised if your chest x-ray results came back normal. it is certainly possible that something in the chest is causing arm pain, but not very likely for most. What you need are tests on the arm - not tests of the chest. If you have chronic headaches and your physician sends you for an MRI of the foot, you won't be surprised if the MRI results of the foot come back normal. Blood tests may also be important in patients with chronic headaches - and sometimes these blood tests do reveal a cause of the headaches. But more often than not what is needed is tests specifically targeting to the brain - such as an MRI, CT or other related tests. 

Conclusion

Every patient with hair loss needs blood tests to rule out a range of conditions that can cause hair loss and be asymptomatic.  The typical blood tests that I recommend as a starting option are found in the following link. 

Blood test for Hair Loss

One should always be prepared for the possibility (and likelihood that blood tests will come back normal for many patients.  We have only a limited number of "hair tests" in the present day. These include punch biopsies, clinical examinations, trichoscopy, pull tests, pluck tests, hair collections. and hair mineral analyses (which are not useful for most), and hair toxicology screens (which are not relevant for most).  We do not have an ability to easily tests the thousands and thousand of different genes expressed deep down inside the hair follicle and therefore rely on the above ancillary tests to get a sense of what might be happening inside of a tiny hair follicle. 

Obtaining information from patients

What information is most important?

When it comes to obtaining information from patients about their hair loss, every piece of information is potentially important. However, certain pieces of information are generally the most important. I refer to these as the “4 S’s.” Each letter S stands for distinct things that are important to know about including 1) the SPEED of the patients hair loss (ie fast or slow), 2) the SITES that are involved with hair loss (ie crown, frontal scalp, or even diffuse loss as well as information on eyebrows, eyelashes and body hair, etc), 3) the SYMPTOMS the patient might have (including itching, burning, tenderness, tingling) and 4) the degree of daily hair SHEDDING the patient feels they are having (normal shedding vs slightly increased vs markedly increased). These 4 S’s are among the most important of the questions a hair specialist can ask. It does not mean other questions are not important or relevant but simply these are key areas that must always be asked about as one thinks about the precise diagnosis.
 

Trichotillomania: Scalp Health & Emotional Health

Scalp Health & Emotional Health

Trichotillomania is an impulse control disorder whereby patients pull out their own hair. Many have underlying psychological or emotional issues including stress, anxiety, depression and obsessive compulsive disorders.

Treating or addressing the underlying psychological component is often most helpful in treating more chronic cases of trichotillomania. However, reatment of the inflammation, papules and pimples (ie acneiform eruptions and pseudofolliculitis) that accompany trichotillomania can also be important and helpful to patients. Chronic plucking and pulling of hairs leads to damage to hairs, inflammation and a resultant “itch-scratch-itch” cycle which is tough to stop.

In 2011, Oon and Lee published an interesting study showing that managing the actual dermatological issues can help a bit - irrespective of any focus on the underling psychological issues. The authors showed that use of topical steroids, topical and oral antibiotics reduced symptoms of itching and assisted with hair regrowth. Treatments included topical clobetasol, topical clindamycin, erythromycin, topical betamethasone, selenium sulphide shampoos, coal tar shampoos, oral doxycycline. These patients were not on antidepressants or antipsychotics.

The accompanying photo here shows a typical patient with trichotillomania. There are many broken and distorted hairs which has given rise to chronic inflammation - some of which has caused scarring to also occur. 
This is a nice study which reminds us that focus on both the dermatological and emotional issues are both important in treating trichotillomania.

Reference

Hazel H Oon and Joyce SS Lee. Treatment of Pseudofolliculitis in Trichotillomania improves Outcome. Int J Trichology. 2011 Jul-Dec; 3(2): 92–95.
 

Stress and Hair loss

A Study of Medical Students

An interesting study examined the effects of stress on a wide range of skin and scalp related symptoms. Study participants were medical students studying at College of Medicine, King Saud University (KSU), Riyadh, Saudi Arabia. A standard questionnaire was used to assess stress levels as well as the presence or absence of a range of health conditions - including those affecting the scalp. When compared to least stressed students, highly stressed students (ie students self reporting that they were experiencing high stress levels) were much more likely to report experiencing a range of scalp symptoms including 1) having more oily, waxy patches and flakes on the scalp, 2) having hair loss and 3) experiencing the self induced pulling-out of one’s hair (trichotillomania).

Conclusion

It’s clear that stress can impact a range of dermatological conditions including hair loss. This study supports the notion that a variety of hair-related changes are possible with higher levels of psychological stress.

Reference

Bin Saif GA et al. Association of psychological stress with skin symptoms among medical students. Saudi Med J. 2018.
 

Treatment of AKN with Long Pulsed Alexandrite Laser

AKN: Long pulsed Alexandrite as an option

Acne keloidalis nuchae is a scalp condition that commonly affects the back of the scalp. Patients develop what they frequently term 'bumps' at the back of the scalp. These frequently are associated with hair loss and the bumps themselves may stay and enlarge. In advanced cases the areas coalesce to form a large plaque. 

Treatments for AKN include topical steroids, antibiotics, retinoids, steroid injections. A variety of laser treatments may also be possible.  In previous studies the 810-nm diode laser and 1,064-nm Nd:YAG laser have been used for treating AKN with promising results.

Tafnik and colleagues set out to study the benefits of the 755-nm alexandrite laser in 16 male patients with AKN. Their study showed a significant decrease in the mean papule, pustule count, keloidal plaque size, and pliability at the fourth and sixth laser sessions when compared with baseline. The main complication was a temporary reduction in hair density in the treated area in 4 of 16 patients as a result of the laser treatment. This was accepted by the patients because of its reversible course.  No lesional recurrence was detected in the follow-up period.

STUDY CONCLUSION

This study provides evidence that the 755-nm alexandrite laser may provide options for treating AKN. The laser appears safe and effective in the condition and recurrence rates are fortunately low. 

REFERENCE

Tawfik A, et al. A Novel Treatment of Acne Keloidalis Nuchae by Long-Pulsed Alexandrite Laser. Dermatol Surg. 2018.

Pulsed Azithromycin for Folliculitis Decalvans

Pulsed therapy for Folliculitis decalvans

Folliculitis decalvans is a type of scarring alopecia and causes permanent hair loss. Affected individuals develop crops of papules, and pustules. The most effective treatment options are antibiotics and isotretinoin. 

Pulsed Therapy for FD

In an effort to reduce side effects from the daily use of a drug, "pulsed therapy" is frequently used for some medications. Pulsed therapy refers to delivery of a medication for short periods of time (i.e. the 'pulse') followed by periods of time whereby the patient does not receive any medications at all.  Pulsed therapy is common with oral steroids, oral anti-fungal medications as well as some antibiotics.

A new study has examined the possibility of using pulses of azithromycin to treat folliculitis decalvans.  The researchers studied 19 patients with mean age 27 years. Treatment was with azithromycin 500 mg per day for 3 consecutive days and repeated every 2 weeks. The severity of the disease was evaluated before treatment and after 1, 3 and 6 months.  

The study showed that azithromycin reduced the number of lesions as well as the disease activity. 

Conclusion

Pulsed azithromycin is among the antibiotic options for FD. Pulses of azithromycin are sometimes used as treatments for acne so this method of using azithromycin in a pulsed manner is not new. Side effects of azithromycin should be carefully review before starting. 

Download our Azithromycin Handout for Patients

REFERENCES

Andre MC et al. Effective Treatment of Folliculitis Decalvans: Azithromycin in Monotherapy. Hair Therapy and Transplantation. 

Antonio JR et al. Azithromycin pulses in the treatment of inflammatory and pustular acne: efficacy, tolerability and safety.J Dermal Treatment 2008;19(4):210-5. doi: 10.1080/09546630701881506.

Parsad D et al. Azithromycin monthly pulse vs daily doxycycline in the treatment of acne vulgaris.J Dermatol. 2001 Jan;28(1):1-4.

Female Pattern Hair Loss

Major and Minor Criteria

Female androgenetic alopecia is common. By the age of 50, well over 1/3 of women will have androgenetic alopecia (AGA)- also known as female pattern hair loss (FPHL). This type of hair loss causes thinning in the frontal and mid scalp. The sides and back may also be affected but generally to lesser degrees than the front for most women. Traditionally, the diagnosis of androgenetic alopecia has been made based on the finding of reduced density in the frontal scalp compared to the back of the scalp and the clear demonstration via dermoscopy that there is a variation in the diameter if more than 20% of hair follicles. This is known as anisotrichosis.

In 2009, Dr Rudnicka and colleagues proposed a series of major and minor criteria for diagnosing FPHL.

FPHL MAJOR CRITERIA

(1) ratio of more than four empty follicles in four images (at 70-fold magnification) in the frontal area

(2) lower average thickness in the frontal area compared to the occiput

(3) more than 10% of thin hairs (<0.03 mm in diameter) in the frontal area.

 

FPHL MINOR CRITERIA

(1) increased frontal to occipital ratio of single-hair pilosebaceous units

(2) vellus hairs

(3) peripilar signs.

Remarkably, the presence of two major criteria or of one major and two minor criteria allow diagnosis FPHL with 98% specificity.

 

Reference

Rakowska A et al. Int J Trichol. 2009;1:123–30.

Telogen Effluvium in Young Men

Telogen Effluvium in Young Males: Considerations

Telogen effluvium (TE) refers to a type of hair loss whereby a patient experiences increased daily shedding of hair. Instead of 30 or 40 hairs coming out of the scalp, the patient experiences 60, 70 or even hundreds of hairs shed on a daily basis. There are a  variety of causes of telogen effluvium including stress, low iron, thyroid problems, medications and crash diets. 

TE in Men

Telogen effluvium can occur in men and does occur in men. However, it is far less common than in women. In addition, there are many mimickers or 'lookalike' conditions that frequently lead to incorrect diagnoses of telogen effluvium in men. A good example of this is early staged androgenetic alopecia (AGA) in men. Men with early AGA experience increased hair shedding which looks very similar to a telogen effluvium. Many such men are diagnosed with TE when in fact the correct diagnosis is AGA. The most important question that should be asked in any male with a diagnosis of  suspected telogen effluvium is: does this patient actually have androgenetic alopecia instead of telogen effluvium OR does this patient ALSO have androgenetic alopecia together with telogen effluvium?

Certainly telogen effluvium can occur as a sole diagnosis in men. However, more times than not in the patients I see, this is not the only diagnosis. 

Diagnosing TE

Telogen effluvium is largely a diagnosis made on history and clinical exam. Rarely, a biopsy is needed.  For most individuals with TE, another person passing by in the street would not take notice there is hair loss even if substantial hair has been lost. TE causes diffuse loss - meaning the hair is lost all over the scalp. Such hair loss typically occurs 2-3 months after some kind of trigger.  A person with TE however can look very different to the way they know they once looked.  If I look at a photo of a patient and I say "this patient has hair loss" - it's like that another diagnosis is present other than TE or together with TE. 

Conclusion

I see many young males with early androgenetic alopecia who are misdiagnosed as having a telogen effluvium. It's true more definitely that telogen effluvium can occur in young men - but one must always keep in mind that it's not really all that common.  Most men who are shedding more than normal end up being diagnosed with androgenetic alopecia. 

I'm often asked who long of a 'window' does a patient have to treat the TE before any irreversible changes happen. The reality is that if a male has TE as their sole diagnosis, there is quite a long window actually. However, the window closes if another hair loss diagnosis is present - especially androgenetic alopecia (AGA). TE can occur in men, yes. But too often androgenetic alopecia in the early early stages is ignored and missed. Biopsies and hair collections together with a careful scalp exam and medical history can help clarify things immensely.

Scarring alopecia: Acquired Pili torti

Acquired Pili torti

Scarring alopecias are a group of diverse hair loss conditions that are associated with the presence of scar tissue in the scalp. This scar tissue can damage growing hair follicle and affect how they grow.

A common finding in many scarring alopecias is the twisting of hairs in a patient with otherwise straight hair. This “twisting” of hair is called pili torti and when it develops long after birth we call it “acquired pili torti.” This photos shows typical pili torti in a patient with frontal fibrosing alopecia. Some straight unaffected hairs can also be seen in the photo as well (bottom right). Dilated veins typical of FFA can also be seen.

Lichen planopilaris up close: A look at "perifollcular scale"

Perifollicular scale: What does this term mean?

Lichen planopilaris ("LPP") is a scarring alopecia which causes permanent hair loss.

Affected individuals frequently develop hair shedding accompanied by scalp itching and sometimes scalp burning and scalp pain.

The accompanying photo shows the typical appearance by trichoscopy of lichen planopilaris (LPP). Single hairs are seen with white scale around these hairs. This whitish scale is known as perifollicular scale and sometimes also as follicular hyperkeratosis.

Treatments for LPP include topical steroids, topical calcineurin inhibitors, steroid injections, oral tetracyclines, oral hydroxychloroquine, oral methotrexate, oral mycophenolate, oral cyclosporine, oral low dose naltrexone. Some patients also respond to oral finasteride.

Scalp Burning: Many reasons but diagnosis is essential

Scalp Burning: Before talking treatment, talk diagnosis

In our clinic, many patients present with concerns about scalp burning. There are many reasons for scalp burning and the precise treatment depends entirely on the diagnosis of the burning. A carefully obtained history, along with an examination of the scalp is needed. Some patients with burning also have itching and some have pain. 

 

Causes of Scalp Burning

1.  Diseases/Disorders of the scalp

Individuals with scalp burning needs a thorough examination to evaluate for underlying scalp disease. A variety of inflammatory scalp disorders can trigger burning including scalp psoriasis, seborrheic dermatitis, scarring alopecia, dermatomyositis, tinea capitis, sunburns, irritant and allergic contact dermatitis. Common hair loss conditions such as androgenetic alopecia, telogen effluvium and scarring alopecia are also associated with burning in some cases.

2.  Dysesthesias

The scalp dysesthesias, as described by Hoss and Segal in 1998, are a group of conditions that give physical symptoms in the scalp without any other unusual findings at the time of examination (normal scalp examination). In addition to scalp burning, many patients with scalp dysesthesias have itching and pain.

The cause of scalp dysesthesias is not clear. One study (reference below) suggested that a high proportion of women with scalp dysesthesias had cervical spine disease. It seems that patients worsen with stress and improve with anti-depressants (venlafaxine, amitrytyline). Many respond to topical or oral gabapentin.

The burning scalp syndrome (similar to burning mouth syndrome) is a variant of scalp dysesthesia. Sensitive scalp syndrome may also be as well.

3. Depression and Other Psychological Issues. 

There is a well known relationship between the brain and the skin and this has been referred to as the 'brain-skin' axis. Stressful life events are a well known trigger to scalp burning. Burning is more common in patients with a host of psychological and psychiatric diagnoses including anxiety, depression,  post traumatic stress disorder, schizophrenia.

4. Drugs

Drugs can trigger scalp burning, both topical drugs and oral medications. Topical medications containing alcohol are frequent triggers or scalp burning. Topical calcipotriol, topical steroids, and a host of anti-dandruff shampoos can trigger burning. Oral medications, including cyclophosphamide can trigger scalp burning.

5.  Damaged Nerves and Small fiber neuropathies

Scalp burning may be a result of damage to nerves. As mentioned above, cervical spine disease may be one such condition. But diabetes, multiple sclerosis, and stroke can all give scalp symptoms.

Many issues affecting the tiny nerves of the scalp can cause scalp burning. This is seen in many of the autoimmune diseases including Sjogren’s syndrome.

6. Sleep Deprivation  

Sleep deprivation has been associated with many cutaneous symptoms including scalp burning.

 

Treatment for Burning Scalp

The treatment of burning scalp will depend on the diagnosis. For patients with scarring alopecia, treatments such as topical steroids, steroid injections and oral anti-inflammatory mediation such as doxycycline or hydroxychloroquine will frequently help stop the scarring alopecia itself as well as the burning. For burning due to psoriasis, a variety of topical steroids, topical vitamin D analogues can help.  The scalp dysesthesias are frequently more challenging to treat but options include topical steroids, oral gabapentin, topical gabapentin, oral amitryptyline, and topical capsaicin. Avoiding harsh shampoos is important. 

Breathing, exercise and scalp exercises are also important as outlined in prior posts.

Conclusion 

In summary, there are many reasons for a patient to present with concerns about burning scalp. A careful and detailed history along with a scalp examination is important. Many times, a scalp biopsy is needed.

Mononucleosis ("Mono") and Alopecia Areata - Any link?

Is mononucleosis ("mono") a trigger for alopecia areata?

Alopecia areata is an autoimmune disease. Environmental factors play a role in many patients to trigger the disease in patients who have the correct genetic predisposition to the disease.  Studies have examined whether environmental factors like stress, as well as various infections play a role in alopecia areata.

EBV: The Cause of Mono

Epstein Barr Virus (EBV) is the virus known to cause the infectious illness mononucleosis which is sometimes just called 'mono'. A 2008 study examined whether mononucleosis could be a trigger for alopecia areata. This particular study examined 6256 individuals. 1586 patients reported an environmental trigger that was thought to cause the alopecia areata - including 12 individuals who had an EBV infection within 6 months before the onset of AA.

Conclusion

The role of EBV and mononucleosis is not proven definitively but there is some evidence that it could be a trigger for a small proportion of individuals. More studies are needed.

Reference

Rodriguez TA, et al. Onset of alopecia areata after Epstein-Barr virus infectious mononucleosis. J Am Acad Dermatol. 2008.

Hair loss from Dengue Fever

What is dengue fever? Why does it cause hair loss?

I get a lot of questions about Dengue fever and whether or not it is implicated in hair loss.  Dengue fever is an illness caused by the Dengue virus which is spread from the mosquito. It has the potential to cause a very severe illness, very similar to the 'flu' and can be fatal in some cases. About 400 million infections occur per year making it a common infection. 

Infections typically occur in the tropics and subtropics.  Most of our patients with Dengue acquire infections from travel to the Carribean, central America and and South America. However Dengue infected mosquitos are found in many areas of the world, including Africa, part of the Mediterranean, South and Southeast Asia as well as other areas. 
 
Individuals and tourists in the area get bitten by a mosquito carrying the Dengue virus. Areas which open water which facilitate breeding of mosquitos are more likely to facilate spread. Because mosquitos bite at sunrise and sunset, these times of the day are most at risk for humans to be bitten by a mosquito infected with the Dengue-virus.

What are the symptoms of Degnue virus?

Individuals infected with Dengue virus usually develop symptoms a few days after being bitten. It can be as long as 2 weeks. Symptoms are very similar to the common flu and include high fever, a very bad headache, pain behind the eyes, joint pain, muscle pain, vomitting, rash.  A small proportion of people become very sick and develop bleeding from the gums and internal bleeding problems and breathing problems. As I mentioned above, Dengue can be fatal. 

Hair loss from Dengue virus

Hair loss is fairly common with dengue fever. Hair loss occurs usually a few months after the illness starts and lasts a few months. The proper term for this type of hair loss is 'telogen effluvium'. The hair loss from Dengue can be quite dramatic. It usually grows back but can take 6-9 months unless some other type of hair loss crops up in the interim.  The hair shedding from dengue eventually stops on its own.  There is not a lot that can be done to help it ... other than for the individual to continue to get better. 

Hair loss is not a guessing game.

Guessing is easiest for men's hair loss

If you had to "guess" the reason for someone's hair loss, you'd likely guess correctly if the patient was male and you chose male balding (androgenetic alopecia). By far that's the most common cause of balding in men.  Dozens of other causes are possible, but they are not common. 

Hair loss in women is more complex.

For women, there's a very good chance you'd be wrong if you guessed androgenetic alopecia as the sole cause. Female hair loss is far more complex - and hair shedding issues and even scarring conditions are not uncommon. Hair loss of course, is not a guessing game and a diagnosis can usually be made by the patient's history, examining the scalp and sometimes examining blood test results or (rarely) performing a scalp biopsy.

Permanent Chemotherapy Induced Alopecia (PCIA)

A New type of Hair loss in Patients Undergoing Chemotherapy: PCIA

Every year about 650,000 patients undergo chemotherapy in the United States. Hair loss is a common side effect of chemotherapy and occurs in about 65 % of patients who receive chemotherapy. There are two main types of hair loss that can occur in patients undergoing chemotherapy. The first is hair loss that happens within weeks of starting the chemotherapy and then lasts several months before growing back.  This is known as temporary chemotherapy induced alopecia ("TCIA"). The second type is uncommon and occurs when patients fail to regroth their hair back to the level it was before undergoing chemotherapy. If hair has not grown back after chemotherapy by the 6 month after chemotherapy, we call this permanent chemotherapy induced alopecia (PCIA) and it is sometimes also called Chemotherapy Induced Permanent Alopecia (CIPAL).

Permanent Chemotherapy Induced Alopecia (PCIA) 

The failure of the hair to grow back fully 6 months post chemotherapy raises concerns about a phenomenon known as permanent chemotherapy induced alopecia (PCIA).     In recent years a number of studies have highlighted the possibility of PCIA in women with breast cancer treated with various chemotherapeutic agents, especially drugs known as taxanes. Docetaxel and paclitaxel are part of this group of drugs. The exact mechanisms are unclear although injury to the bulb as well as follicular stem cells are thought to be relevant. Adjuvant anti-estrogen hormonal therapy may be an important cofactor in many women with PCIA. A similar PCIA presentation has been reported in patients undergoing bone marrow transplantation. The scalp is predominantly affected in women with PCIA although a minority may have eyebrow, eyelash and body hair loss as well.

Different Clinical Presentations of PCIA

PCIA doesn't appear similar in all patients. In fact, three main types appear to exist including a diffuse type, a diffuse type with vertex accentuation (mimicking androgenetic alopecia) and a patchy type mimicking alopecia areata.   

Examination under the Microscope: Biopsies of PCIA

Histopathology of biopsy specimens shows a non-scarring alopecia with preservation of sebaceous glands, miniaturization, decreased anagen hairs, increased telogen hairs and end stage avascular fibrous tracts. There may be several histological presentations and the exact features remains to be defined although a high proportion show dysmorphic telogen germinal units. Some biopsies show peribulbar type inflammation.

How do we treat PCIA?

We don't really know yet how to best treat PCIA. The most common treatments described in the medical literature are oral and topical minoxidil. Both seem to provide benefit to at least a proportion of patients.  Other treatments are not known to provide benefit. 

Dr. Donovan's Articles for Further Reading

Preventing Hair Loss from Chemotherapy

Does hair always grow back after chemotherapy?

REFERENCES

Miteva M, Misciali C, Fanti PA et al. Permanent alopecia after systemic chemotherapy: a clinicopathological study of 10 cases. Am J Dermatopathol. 2011 Jun;33(4):345-50.  

Fonia A, Cota C, Setterfield JF et al. Permanent alopecia in patients with breast cancer after taxane chemotherapy and adjuvant hormonal therapy: Clinicopathologic findings in a cohort of 10 patients. J Am Acad Dermatol. 2017 May;76(5):948-957.

Rugo HS.  Real-world use of scalp cooling to reduce chemotherapy-related hair loss.  Clin Adv Hematol Oncol. 2017

 

Can psoriasis also cause scarring?

Scalp Psoriasis

Can psoriasis of the scalp cause permanent hair loss? Traditionally psoriasis has been classified as a non scarring alopecia - with proper treatment allowing hair to grow back.
We now understand that that is not quite accurate. Scarring alopecia lead to atrophy of the oil glands which is a small proportion of patients appears to lead on to scarring alopecia. A handful of publications (dating back to 1972) have shown the development of scarring alopecia in patients with scalp psoriasis.

References

Shuster S et al. Br J Dermatol. 1972;87:73–77.
van de Kerkhof PC, Franssen ME. Am J Clin Dermatol. 2001;2:159–165.
van de Kerkhof PC et al. Br J Dermatol. 1992;126:524–525.
Wright AL et al. Acta Derm Venereol. 1990;70:156–159.
Bardazzi F, et al. Int J Dermatol. 1999;38:765–776.

Does Elevated ESR cause Hair Loss?

The ESR Test

The erythrocyte sedimentation rate (ESR) is a very sensitive but non specific test for inflammation. An increased ESR does not directly cause hair loss but can sometimes indicate that the patient has underlying inflammation in the body that could be giving hair loss. Determining the cause of an elevated ESR is detective work.

The upper limit for ESR is slightly greater for women than men but a normal ESR is usually less than 20-30 mm/hr.

There are some conditions associated with a high ESR that are associated with hair loss and there are some conditions associated with high ESR that have nothing to do with hair loss. However, conditions such as various infections, and especially the autoimmune diseases (lupus, rheumatoid arthritis, vasculitis, inflammatory bowel disease), as well as anemias, pregnancy, some thyroid diseases, inflammatory diseases of the gastrointestinal tract and advanced kidney failure can be associated with hair loss. Other conditions including some cancers (especially blood cancers and various metastatic cancers) are associated with increased ESR but usually are not associated with hair loss. 

Very high ESR values over 100 mm/hr represent a special group. The group includes those that can be associated with hair loss include systemic lupus erythematosus, rheumatoid arthritis, and sometimes a few types of blood cancers (ie lymphomas, leukemias). Some drug hypersensitivity reactions can give very high ESR values and can also trigger hair loss. Polymyalgia rheumatica is in this group of conditions giving very high ESR values and can also sometimes give hair loss. Conditions in this group that usually don't give hair loss are infectious diseases such as abscesses, bacterial endocarditis and osteomyelitis.

The ESR test is a non specific test and many times a cause can't be found despite the patient having a full examination. Very high ESR levels may warrant additional testing. This may included other blood tests such as CRP, ANA, rheumatoid factor, LDH and possibly various imaging tests (depending on the precise history and precise level of ESR). There are hundreds of causes of increased ESR.

PSORIASIS-LIKE REACTIONS TO ANTI-TNF DRUGS

POSSIBLE ANTI-TNF DRUG REACTIONS

Anti-tumour necrosis factor (TNF) agents such as adalimumab and infliximab have been shown to have benefit in inflammatory bowel disease (IBD). It is now recognized that cutaneous reactions such as new onset psoriasis or psoriasiform-like reactions are among the most common adverse reactions. 

Researchers from Australia retrospectively reviewed cases of anti-TNF-induced psoriasis or psoriasiform manifestations in IBD patients. A total of 10 (six females) of 270 (3.7%). IBD patients treated with anti-TNF therapy developed drug-induced psoriatic or psoriasiform-like reactions: five patients were treated with infliximab and five with adalimumab; nine had Crohn disease. The duration from start of anti-TNF agent to onset of rash was about 8 months on average. The scalp was the most frequent distribution (7/10). Three patients discontinued anti-TNF treatment with resolution of the rash. Topical treatment of the lesions allowed continued use of biological agent in the majority. 

Reference

Peer FC et al. Paradoxical psoriasiform reactions of anti-tumour necrosis factor therapy in inflammatory bowel disease patients. Intern Med J. 2017.

Challenging Cases of Hair Loss: Practical Tips When Nothing Seems to Help

What to do when a patient's hair loss refuses to improve? 

Every now and then there are some unusually challenging cases of hair loss that cause me to sit quietly at the end of the day and rethink the best means to treat me it. I'm talking about patients with alopecia unversalis who do not improve with any treatment, including the most potent of oral immunosuppressives. I'm talking about patients with scarring alopecia who continue to have symptoms and lose hair despite the most aggressive treatments. I'm talking about patients with early onset androgenetic alopecia who progress despite anti-androgens, minoxidil, laser and more. Is there anything we can do in these situations? Fortunately there usually is. Here are some practical tips.

Practical Tips

1. If the diagnosis is at all in question, a scalp biopsy should be done and possibly two. Blood tests should have been checked prior to the appointment but if not, basic screens are appropriate.

2. If a patient's diet is poor, one might look at ways to improve it. 

3. If stress and emotional issues are high, it might be worthwhile to address these. Stress is clearly relevant for some people.

4. Consideration needs to be given to whether a current treatment is actually causing the hair loss to worsen. Stopping treatment for a period may be useful in some situations.

5. A complete health check should be done by the patient's regular physician. Routine screening exams (mammograms, colonoscopies) should be up to date according to age appropriate screening.

6. One should always at least ask if patients are using their recommended treatment. Every now and then there are some incredible surprises.

7. If a different route of administration is possible this should be considered. Some oral drugs might be compounded topically. Some topicals may be available in oral form.
 

Conclusion

If a physician sees enough patients with hair loss, he or she will encounter cases of hair loss that don't seem to respond to anything. An organized approach in these situations is needed. Every so often some surprising improvements can finally occur!

Breast Implant Illness and Hair Loss

Hair Loss from Breast Implants: Any relationship?

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I believe that there are countless numbers of hair loss conditions that exist in the world that have not yet been described in textbooks. The reason I believe this is quite simple - I see and hear them every day in my clinic.  There are stories of hair loss from certain medications,  various unusual patterns of hair loss in otherwise common conditions. Every once in a while a new scenario arises that again causes pause - one such example is a syndrome of medical conditions that arise in women who have had breast augmentation and breast reconstruction. Readers should note that this is a very different form of hair loss than the telogen effluvium that sometimes accompanies the surgery itself (or any surgery for that matter). This has been termed 'breast implant illness.' Whether or not hair loss occurs in a small proportion of women who have undergone breast augmentation continues to be studied.  It's an area of research that we follow closely given how often these scenarios arise in our clinic. 

Breast implants and human health

Anything that triggers a systemic reaction inside the body has the potential to cause hair loss. One therefore needs to look at the data on the effects of breast implants on human health. In the last 5 years new data has emerged that breast implants may be associated with cancer - specifically the development of a type of T cell lymphoma called anaplastic large cell lymphoma. The FDA continues to study this association and the risk may be in the order of 1 in 10,000 women to as great as 1 in 1000 women.

Breast Implant Illness has many similar names in the research and medical literature. ASIA syndrome (autoimmune/inflammatory syndrome induced by adjuvants) was a name given to a specific disease that can arise with exposure to silicone. To date, it is still controversial as to whether silicone implants increase the risk of true autoimmunity in the body.  However, some studies have shown increase incdience of autoantibodies in women with silicone breast implants. 

Breast Implant Illness

There is a subset of women with breast implants who feel that their health has changed in some way followed breast implant surgery. The term 'breast implant illness' is a term that has been given to the constellation of symptoms and signs that are proposed to be attributed to breast implants. The mechanism by which this would or could occur is not yet known. Women who report symptoms consistent with breast implant illness frequently mention chronic fatigue, chronic pain, anxiety, irregular heart rate, neurological problems, body odour, rashes, endocrine problems - and hair loss.  To date, it is hard to prove an association of these symptoms of these women to their breast implant surgery and many alternative explanations are frequently given.  Many symptoms are dismissed. Many women, but not all, experience some degree of improvement in symptoms after explanation (removal of the implant).

Breast Implant Illness and Hair Loss

As mentioned in the opening paragraphs, I strongly believe that there are countless numbers of  hair loss conditions and syndromes that are unrecognized and have not yet made their way into textbooks, and classrooms of learners.  (This concept forms Principle 9 of the 20 Principles that govern my practice).

There have been several studies examining breast implant illness and one some have addressed the issue of hair loss. One such study was a 1996 study by Brawer which reported illness in 300 women who had silicone breast implants. Most women (90 %) developed their illness within 6 years of the implants.  Although rupture of the implant was present in some affected, 97 % of women did not experience rupture prior to their symptoms.  Rupture however, did worsen symptoms. 

The table below shows the most common signs and symptoms in patients with breast implant illness according to the 1996 Brawer study. Fatigue tops the list followed by arthritis and chest pain. Hair loss is number 4 on the list and experienced by 59% of patients with breast implant illness.  

from Arthur Brawer. J. Clean Technol Environ. Toxic & Occup Med Vol 5(3) 1996

Conclusion

Modern medicine is still in the early stages of understanding whether and to what degree breast implants affect health. There does appear to be an association with anapaestic large cell lymphoma and an increasing number of women are reporting concerns that can only be grouped together for now under a non specific term 'breast implant illness.'  Hair loss has been reported by many women with breast implant illness.  In my practice having seen at least a dozen cases, most end up being diagnosed with telogen effluvium, chronic telogen effluvium and/or androgenetic alopecia - which are extremely common in the population anyways. Pinpointing an exact cause is challenging. Explanation, or removal of the implant,  is helpful only in some.

For now, continued study of breast implant illness is warranted. 

Reference

1. https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm239995.htm

2. Tang S et al. Breast implant illness: Symptoms, Patient Concerns, and the Power of Social Media.  Plast Reconstr Surg. 2017

3. Arthur Brawer.  Chronology of systemic disease development in 300 symptomatic recipients of silicone gel-filled breast implants. J. Clean Technol Environ. Toxic & Occup Med Vol 5(3) 1996

4. Bar-Meir E et al. Multiple autoantibodies in patients with silicone breast implants. J Autoimmune 1995