Does Topical Minoxidil Help Beard hair in Males?

Many males value good facial hair growth. Despite the widespread use of topical minoxidil for androgenetic alopecia and many other off-label uses, studies specifically related to facial hair had not been conducted when the study was done.

Ingprasert et al., 2016

In 2016, authors from Thailand set out to review the benefits of topical minoxidil in facial hair growth.

The authors conducted a 16-week randomized, double-masked, placebo-controlled study of forty-eight men aged 20– 60 who wanted to improve beard hair growth. Patients were instructed to apply 0.5 mL of the topical assigned solution twice daily on the chin and jawline.

Patients’ beard photographs were taken for global photographic score as a primary efficacy assessment every four weeks. Three physicians evaluated photographs on a 7-point scale (+3 to
3). The changes in hair counts and diameter from baseline served as a secondary efficacy assessment. The measurement landmark was 3 cm lower from the vermilion border of the lower lip at the midline.

What were the results?

Forty-six of 48 patients completed the study. At week 16, the global photographic score in the minoxidil group was significantly higher than in the placebo group (P = 0.002). Patients also rated their improvement as greater in the treatment group. Hair counts increased more in the treatment group than in the placebo group (5.00 vs 0.35). There were no statistically significant changes in hair diameters.

Overall, adverse reactions were mild and not statistically significantly different between the two groups.

CONCLUSION

This study concluded that minoxidil 3% lotion is effective and safe for beard enhancement.

REFERENCE@

Ingprasert S et al. Efficacy and safety of minoxidil 3% lotion for beard enhancement: A randomized, double-masked, placebo-controlled study. J Dermatol . 2016 Aug;43(8):968-9. doi: 10.1111/1346-8138.13312. Epub 2016 Feb 19.

Late Onset Alopecia Areata: What are the Features?

Late Onset Alopecia Areata (LOAA)

Alopecia areata is an autoimmune disease that affects about 2 % of the world. About 50 % of patients who develop alopecia areata will develop their first episode of hair loss before age 20. The development of the first episode of alopecia areata after the age of 50 is uncommon.  Alopecia areata first occurring after age 50 is frequently referred to as late onset alopecia areaeta (LOAA).

What are the characteristics of patients who develop LOAA? 

In 2017, Lyakhovitsky and colleagues set out to determine the features of patients who develop LOAA. They performed a retrospective cohort study of patients visiting a tertiary centre over the 6 year period (January 2009 and April 2015).

Of 29 patients in their study who were found to have LOAA, 86.2% were female (female-to-male ratio, 6.2:1). There was a family history of alopecia areata in 17.2%, thyroid disease in 31%, atopic background in 6.9%, and 17/29 (58.6%) reported a significant stressful event. The most common disease pattern observed as the so called 'patchy' subtype. Interestingly the disease was mild in the majority of participants. Complete hair regrowth was observed in 82.8% of participants, and 37.9% relapsed.

Conclusion and Comments

This is a nice study which examines the characteristics of patients who develop their very first patch of alopecia after age 50. This group of patients appears have have less extensive disease, and frequently has complete hair regrowth. Affected patients are more likely to be  female than male.   

REFERENCE

Lyakhovitsky A, et al. Dermatology. 2017.

Mitochondria, Hair Loss and Hair Growth:

What are mitochondria and why do they matter?

If one thinks back to their earliest high school biology days, they'll likely remember learning about mitochondria. These are tiny 3 micrometer organelles that lie inside cells.  Mitochondria are essential components and play a key role in helping cell product energy. When one thinks of metabolism of muscle cells, liver cells, brain cells, one is really talking about mitochondria.  These are frequently referred to as the 'powerhouses' of the cell. 

A new study points to key role for mitochondria in hair loss

Most living (nucleated) cells have mitochondria, including many cells that make up the hair follicles. A new study from the University of Alabama at Birmingham nicely demonstrated just how important mitochondria are. When a mutation leading to mitochondrial dysfunction is induced in mice, the mouse develops visible hair loss in a matter of weeks. When the mitochondrial function is restored by turning off the gene responsible for mitochondrial dysfunction, the mouse regains thick fur, indistinguishable from a healthy mouse of the same age.

The researchers are interested to use this model to more thoroughly study mitochondrial function in a variety of states, including aging. Some treatments for hair loss are known to affect mitochondrial function - including low level laser therapy (LLLT).

Further research will elucidate if an how we can treat hair loss by affecting the function of these tiny organelles known as mitochondria.

REFERENCE

Bhupendra Singh, Trenton R. Schoeb, Prachi Bajpai, Andrzej Slominski, Keshav K. Singh. Reversing wrinkled skin and hair loss in mice by restoring mitochondrial function. Cell Death & Disease, 2018; 9 (7) DOI: 10.1038/s41419-018-0765-9

Lyme Disease and Hair Loss: What types of hair loss are possible?

What types of hair loss are possible?

Lyme disease is an infectious disease caused by bacteria known as Borrelia. These bacteria are typically spread by ticks, such as the one I photographed here.  Most people develop a rash at the site of the tick bite (often shaped like a "bull's eye" as it spreads). Not everyone develops the rash. If untreated, patients with Lyme disease can develop neurological problems, heart problems and arthritis many years later. About 300,000 people in the United states are affected yearly by Lyme disease.

Lyme disease gets transmitted to humans when a specific tick known as the Ixodes tick bites the skin. What's unique about these ticks is that the tick must be attached to the skin for 36-48 hours before the bacteria can be spread. This means that if humans can identify the tick on their skin before the 36 hour mark (and remove it gently with tweezers), it may be possible to prevent the disease.

The frequency of hair loss in patient's with Lyme disease has not been carefully studied. Lyme disease may cause a diffuse hair loss similar to a telogen effluvium. One study from 1999 suggested that telogen effluvium occurred within three months after the outbreak of disease in 13 % of patients with Lyme meningitis and in 56 % of patients with encephalitis. Lyme disease has also been implicated in one subtype of scarring alopecia (Psuedopelade of Brocq) although this remains to be verified in repeat studies. Some researchers have suggested a role for Lyme Disease in patients with Morgellons Disease (a skin disease whereby patients identify fibers within the skin, under the skin or projecting from the skin). Overall, Lyme disease may cause hair loss. A history of a tick bite and spreading bull's eye rash can be helpful early clues in the diagnosis. Antibody tests are available for Lyme disease, but they are not useful in the early stage. They are more helpful in the diagnosis of later stages.  Testing is typically a two-stage process beginning first with a test known as an “ELISA” test. Patients who test positive with the ELISA test then undergo testing using a “Western Blot.”

Reference

Cimperman J, et al.
Wien Klin Wochenschr. 1999.

Hair, Feathers and Scales: How much do they have in common?

How much do they have in common?

At first glance, it would seem like birds, mammals and reptiles are about as different as could be.

That’s of course until you speak with Dr Milinkovitch and his group in Switzerland about their landmark study in 2016. 
His data, which comes from studying specific reptile species points to the possibility that feathers and hair are in fact more closely related than ever imagined. Birds and mammals (including humans) are thought to share a common ancestor some 320 million years ago!

Scales in reptiles, feathers in birds and hair in mammals appear more closely related than once imagined.
 

Reference

Nicolas Di-Poï and Michel C. Milinkovitch. The anatomical placode in reptile scale morphogenesis indicates shared ancestry among skin appendages in amniotes. Science Advances  24 Jun 2016:Vol. 2, no. 6.
 

Gummy Vitamin Use by Hair Loss Patients

Gummy Vitamins

lI've noticed a fascinating trend in my hair clinic over the last decade: patients are increasingly consuming their multi vitamins by eating them in the form of 'gummies.' They love the taste and find them easy to take. Not a day goes by where a bottle of gummies does not emerge from a bag to be placed on my desk. 
The multivitamin industry is estimated to be a 7 billion dollar industry in the US alone; gummy multivitamins account for about 8 % of this industry. According to some estimates, there has been a 25 % increase in gummy sales in the past 3 years. Worldwide, gummy vitamin sales ares expected to increase from its present 2.7 billion dollar estimate to 4.2 billion by 2025. North Americans are chomping on the gummies at the highest rates with Europe in second place.

Gummy multivitamins are now produced in a variety of shapes and flavours. Gummy bears and gummy fruits are popular. For those who don't want the extra sugar that many gummy multivitamins contain, there are now sugar free versions.

My views on multivitamins are simple: if one is deficient in a particular vitamin or mineral, it makes sense to replenish it.  Getting vitamins through foods (i.e. fruits and vegetables) remains a far better option that through vitamins.  If this is not an option, or foods do not seem to restore levels, one can consider multivitamins.  Multivitamins may be particular important for certain subpopulations - including the elderly, alcoholics, patients undergoing bariatric surgery and women taking oral contraceptives. Many patients however require a different mix of vitamins and minerals and a one fits all approach may not work.

I am willing to admit that there may be some evidence that supplementation of certain compounds could be beneficial for some patients even if one is not deficient. Examples of this later category include amino acids like L-lysine and cysteine although more research is needed.  Overdosing on vitamins is common and could have negative effects on the body and hair.  High levels of vitamin A are well understood to cause hair loss.

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Diphencyprone for Alopecia Areata: Can one apply DPCP at home?

Can one apply DPCP at home?

Diphencyprone (“DPCP”) is a unique treatment for alopecia areata that has been used for over 25 years.

What’s unique about DPCP is the fact that it causes an allergic reaction on the scalp which in turn alters the type of inflammation present in the skin and around hair follicles. By doing so, hair has the potential to grow because the immune system is no longer attacking it.

For years, DPCP treatments were exclusively done in highly specialized dermatology clinics. Fewer clinics are offering DPCP nowadways because of staffing issues (lots of nurses and physicians are needed!) and because many of the staff frequently becomes allergic themselves to the DPCP over time.

For many years, clinics have started offering patients the option of having the DPCP applied at home. Often a spouse, parent or friend will be trained to properly and safely apply the DPCP for the patient. This is frequently termed “outpatient” DPCP. Many clinics around the world, including ours have been supporting patients with “outpatient” DPCP for many years.

A recent study by Lee and colleagues showed that outpatient DPCP is just as safe as DPCP application in a dermatology clinic setting. This is great reassurance for the large numbers of patients who could potentially benefit from this much underused and often forgotten about treatment. DPCP can be safety applied at home provided patients and family members receive proper training on application techniques and safety principles.
 

Reference

Lee S et al. Home-based contact immunotherapy with diphenylcyclopropenone for alopecia areata is as effective and safe as clinic-based treatment in patients with stable disease: A retrospective study of 40 patients. J Am Acad Dermatol. 2018

Examining Hair Samples: Anagen vs Telogen Hairs

Anagen vs Telogen Hairs

How do we differentiate anagen hairs from telogen hairs? This photo shows both an anagen hair (bottom) and a telogen hair (top). Anagen hairs are darkly pigmented throughout the shaft. The characteristic feature is the massive number of cells known as “keratinocytes” that can be found in the area surrounding the bottom of the hair shaft. This is termed the root sheath. Anagen hairs have a root sheath.

Telogen hairs, on the other hand, lack pigment at the base and lack a root sheath. Most hairs, if not all the hairs, from a typical collection of hairs from a patient’s scalp are telogen hairs.

Examining Hair Samples: 4 Quick Things to Evaluate

4 Quick Things to Evaluate

Many patients bring in hairs in bags. These have been collected in a variety of ways including when combing, after shampooing (while blow drying) and sometimes in the shower or from a drain. I don’t typically need hair collection performed as a starting point in any evaluation but when hairs are brought in, I always look at them.

There are several things I want to know when I examine the bag of hair. Typically, I am less interested in the number of hairs when the “hair collection” is performed in a non-standard manner (ie not done via a five day modifed hair wash test protocol or not a 60 second comb test). However, the key information I do seek to gather includes:

1. How was the sample collected? (...was it pulled from the drain or from a brush)
2. When was the last shampoo or hair wash? (...does the hair in the bag represent 1 day of not washing or 1 week?)
3. Do I see any anagen hairs in the sample? (... anagen hairs are suggestive of a scarring hair loss condition and are extremely rare to be seen to see but easily confused by patients).
4. Do I see many broken hairs ? (... broken hairs can suggest damage from heat or chemicals, traumatic brushing, alopecia areata and rarely scarring alopecias). With these 4 questions, I can sometimes get a sense of whether something unusual might be happening in the scalp. If it is necessary to get a more quantitative evaluation of the numbers and types of hairs shed, I may ask patients to perform a “five day” modified hair wash test. This involves not shampooing for five days and then collecting all hairs on a gauze during a shampooing and rinse.
 

Hair Loss Vocabulary: Do We Use Words Appropriately?

Do We Use Words Appropriately?

The professional world that I live in (ie the “hair world”) loves words - all kinds of words.

Some of the words serve to make things a bit clearer. A “pustule” is a much better term than a little bump. Hair follicle “miniaturization” is a much better term than hair thinning. 
But words are not always effectively used. We seek to teach our junior doctors and students the importance of effective communication with patients. Yet, without realizing it, we continue to teach the value of miscommunication. For example, we train our physicians to use the term “erythema” instead of simply saying or writing the word “redness.” We train them to say “pruritus” instead of saying “itching.” Instead of saying “scarring” ...we often opt to use the word “cicatricial” instead. We inform our patients of options to administer “intralesional” steroids instead of simply calling them “steroid injections.” The list goes on and on.

Words must always keep the patient in mind.

It would appear that the term perifolliculitis capitis abscedens and suffodiens of Hoffman (yes, an actual disease!) to describe the scarring hair loss condition needs a bit of an overhaul. In case you didn’t know, the hair loss condition called lichen planopilaris has nothing to do with lichens.

When it comes to hair terminology, frankly we are all in a bit of a mess.

Some names are changing and not necessarily for the good of our patients nor our profession. Did you know that low level laser therapy is now known as photo biostimulation. Did you know that we no longer refer to “FUE” hair transplants by the name follicular unit extraction. It’s now called follicular unit excision. 

The dictionary of hair loss is filled with countless bizarre terms. Some terms are needed because there are simply no better terms to describe a given phenomenon. Not every term in hair medicine needs to be clear to patients and practitioners alike. But where possible, one must remember at the core of every phrase, term or word is a patient with hair loss. If we can make this alarming, confusing and perplexing world of hair loss a bit clearer by choosing our words to optimize communication.... why wouldn’t we?

Scalp Biopsies: Set Up

Set Up

A scalp biopsy is a short procedure performed under local anesthesia which allows a small 4 mm cylindrical sample of hair and skin to be obtained from the scalp.

A "punch" is a sharp circular instrument that allows a core of skin to be taken. Once the sample is removed from the scalp, it is placed in a liquid solution called formalin and then sent off to the laboratory. A suture (stitch) is generally placed in the scalp at the site where the biopsy was performed.

Scalp Rosacea: What Is It? How Do We Treat it?

What Is It? How Do We Treat it?

Rosacea is a common condition affected up to 10 % of individuals. Skin flushing, persistent redness of the face and prominent blood vessels are common.

It is increasingly recognized that "extra-facial" rosacea (rosacea at locations other than the face) is a true entity. Rosacea affecting the scalp is a diagnosis that is increasingly recognized.

Patients with scalp rosacea present with redness and burning. Up to 5 % of those with facial rosacea experience scalp rosacea. Doxycycline pills (shown here) can be effective for a proportion of patients with scalp rosacea.
 

Reference

Fortuna et al. A case of scalp rosacea treated with low dose doxycycline and probiotic therapy and literature review with therapeutic options. Derm Ther 2016; 29:249-51

Reducing Medication Dosing: Can I Reduce My Dose?

Can I Reduce My Dose?

The safest dose of any medication is no dose at all. However, that’s not usually possible, nor practical. Nevertheless, one must always ask the question “Can I reduce my overall dose?” In general, one must be careful about lowering doses of medications when treating androgenetic alopecia. Lower doses are not always as effective. Often I hear patients using minoxidil who think that going down to three times per weeks will allow them to maintain their results. The reality is that it seldom does. For oral medications (like finasteride for men) it may be possible to skip a dose once or twice per week without negative consequences. This is not possible for everyone.

For those with alopecia areata, one can lower doses when hair starts growing well. Topical steroids can be a few times per week rather than daily once hair is growing well. Steroid injections are reduced to every few months. Oral medications are reduced as well.

For scarring alopecia, medications can also be reduced once the disease comes under control. A patient using hydroxychloroquine (Plaquenil) might go from twice a day to once a day and eventually twice a week.

Medication dosing is a bit of an art and one must always consider whether they can or can not reduce their dosing. In general, once diseases like alopecia areata and scarring alopecias come under excellent control one can consider reducing the dose at some point.
 

Frontal Fibrosing Alopecia: Importance of Skin Color Changes

Importance of Skin Color Changes

Frontal fibrosing alopecia ("FFA" for short") is an autoimmune scarring hair loss condition that affects mostly peri menopausal and post menopausal women (most commonly). Individuals with

FFA experience loss of the frontal hairline and frequently eyebrow, eyelash and body hair loss as well.

The appearance of the scalp and the remaining hair follicles in the scalp are diagnostic in most cases. A biopsy is not always needed but is helpful in challenging cases.

The hair follicles are surrounded by redness (perifollicular erythema) and less commonly also scale (perifollicular scale). When one looks closely, a border can generally be seen between the unaffected skin of the forehead and the shiny, smooth atrophic skin of the area affected by FFA.

Many different types of treatments are available including topical steroids, steroid injections, topical calcineurin inhibitors, oral doxycycline, oral hydroxychloroquine, oral finasteride, oral dutasteride, oral methotrexate, oral isotretinoin, oral tofacitinib, oral mycophenolate. Benefits of lasers, including excimer and low level lasers continue to be explored.
 

Dissecting Cellulitis: Early Disease can look like Alopecia Areata

Early Disease can look like Alopecia Areata

Dissecting cellulitis (DSC) is an uncommon hair loss condition characterized by boggy draining areas on the scalp. These areas frequently leave behind permanently scarred areas.

It is not difficult to recognize "classic" or well developed areas of dissecting cellulitis. The areas are weepy, draining pus and the patient is uncomfortable (often with itching, burning or pain). In early disease, where sinus tracts and skin breakdown might not be seen (or where they have healed) it is more challenging to detect DSC.

These areas can often resemble alopecia areata and may even be skin colored in some cases rather than red.

Treatment for dissecting cellulitis includes agents such as isotretinoin, antibiotics, TNF inhibitors as well as other treatments.
 

Trichotillomania and White Hairs: Can white hairs be permanent?

Development of Permanent White Hairs from Plucking

The process by which a hair gets its pigment is very complex. Melanin needs to be transferred from the melanocytes into the developing hair follicle in the anagen phase. A variety of genetic and inflammatory processes can disrupt this process. The autoimmune disease alopecia areata is a classic example of a condition that causes white hairs to grow.

The development of white hairs is seen in patients who pull their hair. This includes trichotillomania and hair pulling conditions along this spectrum. Any white hairs that are produced typically grow back with color. However, extensive damage to the hair follicle apparatus has the potential to cause the hair to lose its ability to properly pigment hairs.

In 2010, Tan and colleagues published a study in the Journal of Cutaneous Medicine and Surgery where they reported an adolescent who developed permanent white hairs after repetitive plucking. This paper is a nice reminder of how delicate the hair follicle machinery is and how, in some cases, extensive damage to the hair follicle may impair the ability of the hair to properly pigment hairs in the future.

Reference

Permanent poliosis following repetitive plucking in an adolescent.

Tan C, et al. J Cutan Med Surg. 2010 Jul-Aug.

FOLLICULR NEOGENESIS: Humans are born with 100,000 hairs, making more is NOT possible

Humans are born with 100,000 hairs, making more is NOT possible

Follicular "neogenesis" refers to the generation of brand new follicles in areas where follicles did not exist before.

Humans are born with 100,000-120,000 follicles but no new follicles develop after birth. The only possibility is replacement of follicles that get shed. In other words, follicular neogenesis does not appear to occur in humans at the present time. Existing follicles can shed and regrow but no new ones can be produced.

The hope is that someday follicular neogenesis might occur in humans someday as research in the area advances. In mice, brand new follicles can be made after birth. A landmark study was published in 2007 by Ito et al which showed that mice that are wounded can develop brand new hairs in the area surrounding the wound. These were not just hairs that replaced previous ones but were completely new. This study provided hope that follicular neogenesis might someday occur in humans.
 

Reference
 

Ito M et al, Wnt-dependent de novo hair follicle regeneration in adult mouse skin after wounding.  Nature. 2007.

Why Do T:V Ratios increase in Chronic Telogen Effluvium? (Pool Party Analogy)

Terminal to Vellus (T:V) Hair Ratios (Pool Party Analogy)

Today, we’ll talk about a slightly more advanced topic of terminal to vellus (T:V) hair ratios. Terminal hairs are thick (big hairs) and vellus hairs are tiny (thin) hairs. The normal ratio is typically between 4:1 and 7:1 in the healthy scalp. A T:V ratio of less than 4:1 is quite typical of a diagnosis of androgenetic alopecia.

But can this ratio ever rise higher? ... above 7:1? It comes as a surprise to many physicians and patients that the ratio of terminal hairs to vellus hairs increases in biopsies from patients with chronic telogen effluvium (CTE). It can rise above 8:1 in biopsies from CTE.

It’s difficult for many to understand this concept ... even the physicians I teach! The analogy I often use is a kids pool party on a hot summer day. Let’s say for the sake of argument that there are 15 children invited to the party and 3 adults supervising. That’s a children to adult ratio of 5:1, right? Let’s just call this the normal ratio of children to adults on the poolside deck. Now let’s imagine that it’s so incredibly hot outside that the only way anyone can deal with it is to periodically hop in the pool to cool off - that includes the children and the supervising adults. But not everyone wants to swim because there’s alot of fun and games on the deck as well. So kids may enter the pool at random times to cool off and the adults do too! There are periodically so many people entering and exiting the pool.

Now when we look at the deck at any given time we may see 12 children on the deck and 2 adults (a ratio of 6:1) or perhaps when it’s super hot we might even see 9 children on deck and 1 adult (a ratio of 9:1). One can easily see that the weather change has triggered an increase in the children to adult ratio on the deck (from 5:1 to 9:1). This is precisely what happens in CTE! The “trigger” of shedding leads to both terminal hairs and vellus hairs from leaving the scalp and an increase in the T:V ratio. Few people realize the power of measuring the T:V ratio. But now you do! A T: V ratio less than 4:1 is typical of androgenetic alopecia and above 8:1 is typical of pure CTE.

Female Pattern Hair Loss: Very Front Hairline Often Unaffected

Very Front Hairline Often Unaffected

Female genetic hair loss looks different than male genetic hair loss. In men, the frontal hairline progressively moves back. The crown is often affected too. In women with genetic hair loss, the very frontal hairline is usually not completely lost. A band of hair is seen in the front and more prominent hair loss occurs behind that band.

Heat and Hair: Hot Combs/Thermal Pressing

Hot Combs and Thermal Pressing

Heat has a wonderful ability to modify the structure of hair. The application of heat to hair can break hydrogen bonds (chemical bonds) that were responsible for the original shape of the hair. Unless the hair comes into contact with water, the hair will maintain the new shape. 
Hot combing involves application of temperatures 300-450 F. A pressing oil may be applied prior to the hot combing. The practice is safe for many individuals and can provide remarkable straightening effects. It is not however without side effects.

Damage to the hair shaft and scalp burns are among the potential risks. The temperate settings can be adjusted depending on a patient's specific hair qualities. This does not however completely eliminate risk.

Hair shaft damage (called trichorrhexis nodosa) is commonly seen no matter how careful one is. The combination of heat styling to “chemically relaxed” hair is more likely to lead to hair damage.

In general, limiting heat to 350 F and application once per week or less is a recommended starting routine for those who do wish to use heat. It does not eliminate risk but reduces it considerably. The safest way to treat hair is to do absolutely nothing to it. But we are only human and simply being practical goes a long way.