Scarring Alopecias: What are the similarities?

What are the similarities?

The scarring alopecias are a diverse group of conditions. Taken together, there are well over 100 scarring alopecias although a group of 6 or 7 comprise the most common ones.

Lichen planopilaris (LPP), frontal fibrosing alopecia (FFA), pseudopelade (PPB), central centrifugal cicatricial alopecia (CCCA) and discoid lupus (DLE) are examples of these more common entities.

Modern research has shown there are many differences between these conditions. However they may have important similarities. For example, intense research into the basic causes of lichen planopilaris (LPP) have shown that the formation of “toxic” lipids in the hair follicle may lead to destruction of the oil glands (sebaceous glands), inflammation and ultimately destruction of the hair follicle. Certain signalling pathways inside the hair follicle, such as the PPAR gamma pathway may be important not only in LPP but other scarring hair loss conditions as well. Reduced levels of PPAR may be seen in LPP as well as FFA and CCCA and possibly others as well.

These similarities are important to explore further as they may enable many clinically distinct scarring alopecias to be treated similarly.

Psychosocial Impact of Hair Loss: Scarring vs Non-Scarring Alopecias

Scarring vs Non-Scarring Alopecias

Both scarring and non scarring hair loss have impact on the how people feel and what they ultimately do or don’t do with their social, work related and family activities. A standard measurement of the general well being and happiness of individuals is termer the “quality of life” or QoL. Measuring QoL and impact of a given disease or health condition is not easy but is an important part of medicine.

Both scarring and non-scarring hair conditions have significant psychological and psychosocial impact. Androgenetic alopecia, alopecia areata and scarring alopecias like lichen planopilaris and frontal fibrosing alopecia affect how people feel and what they do. In other words, these conditions affect QoL.

A 2015 study from Greece set out to compare and measure quality of life in women with non-scarring hair loss and scarring hair loss. Forty-four women, aged 18-70 years, including 19 with scarring alopecia and 25 with non-scarring alopecia were recruited.

All patients were evaluated by several scales including Dermatology Life Quality Index (DLQI), Hospital Anxiety and Depression Scale (HADS), Rosenberg Self-esteem Scale (RSES) and UCLA Loneliness Scale (UCLA-LS). Collectively, women with scarring alopecia were found to have higher scores in DLQI (depression scale), HADS (anxiety scale) and UCLA- LS (loneliness scale) and lower scores in self-esteem measures (RSES), compared to women with non-scarring alopecia.

This study was among the first to show that the psychological burden is heavier and quality of life is more severely impaired among women with scarring alopecia compared with non-scarring alopecia.

Reference

Quality of life and psychosocial impact of scarring and non-scarring alopecia in women.
Katoulis AC, et al. J Dtsch Dermatol Ges. 2015.

Topical JAK Inhibitors for AA: Australian Placebo Controlled Study

Australian Placebo Controlled Study

JAK inhibitors like tofacitinib and ruxolitinib have shown benefit in the treatment of alopecia areata. Over the last few years, topical JAK inhibitors have been explored as safer options to the oral JAK inhibitors. However, despite the great excitement there remains some debate as to how well the topical JAKs really work. What has desperately been needed is a placebo controlled study and a study that compares topical JAK inhibitors to topical steroids.

Dr Rod Sinclair’s group from Australia conducted a 28 week prospective, placebo-controlled, double-blind study in patients with alopecia universalis investigating hair regrowth with two topical JAK inhibitors, 2% tofacitinib ointment twice daily and 1% ruxolitinib ointment twice daily. Topical clobetasol ointment was the active comparator while vehicle was used as the placebo control. 
Sixteen patients were recruited for the study. Six patients demonstrated partial hair regrowth in scalp areas treated with 2% tofacitinib. Five patients demonstrated partial hair regrowth in the areas treated with 1% ruxolitinib. Ten patients demonstrated partial hair regrowth in the areas treated with clobetasol. No regrowth was observed in the placebo treated areas.

This preliminary study is interesting because it does lend support to potential benefits of JAK inhibitors and shows they are likely better than placebo. What is questionable in this study is whether use of an ointment truly is the best vehicle to study for alopecia trials. Dr Brett King’s study in 2018 showed that tofacitinib ointment really didn’t work very well (reference below). One wonders whether JAK topical liposomal creams in this study would have provided similar or possibly even better outcomes and whether they could have even performed better than clobetasol.

More studies of topical JAK inhibitors are needed and comparison with a placebo should ideally be standard protocol in order to acquire a better sense of how well topical JAKs really work.

Reference 

Bokhari L, et al. Int J Dermatol. 2018.
Liu et al. J Am Acad Dermatol. 2018.

Smoking and Balding: Does smoking Impact Natural Balding?

Does smoking Impact Natural Balding?

Genetic hair loss, also known as androgenetic alopecia, male pattern balding (men), female pattern hair loss (women), is controlled to a significant degree by inherited genes.

Nevertheless, there are several environmental risk factors that influence the speed and progression of androgenetic alopecia.

Smoking is among the most influential of these. In 2017, Fortes and colleagues showed that smokers at nearly 7 times more likely to have moderate to severe balding. The effect of smoking on balding was identified in several other studies as well.

Other risk factors including obesity seem to accelerate balding. A diet rich in fresh vegetables may protect against balding to some minor degree.

References

Fortes et al. The combination of overweight and smoking increases the severity of androgenetic alopecia.
Int J Dermatol. 2017.

Schou et al. Alcohol consumption, smoking and development of visible age-related signs: a prospective cohort study. J Epidemiol Community Health. 2017.

Fortes et al. Mediterranean diet: fresh herbs and fresh vegetables decrease the risk of Androgenetic Alopecia in males. Arch Dermatol Res. 2018.

Random opinions vs Real Science: Do they carry similar weight?

Principles of Scientific Inquiry Remain Most Important

Society must continue to protect the ability of a given individual to express his or her opinion. The opinion of another person, however, must never share the same spotlight with factual information that was obtained and validated using the principles of scientific inquiry. We must continue to protect the access of the world to accurate information.

We can respect the view of a person who says that they believe the world is flat but we would never accept this view to permeate the classrooms and textbooks of our children.  Similarly we can respect the view of a person who says that they believe a certain treatment for hair loss will help. However, without proof, we must never accept this view to permeate the classrooms and textbooks of our health care providers and the magazines and media sources of the public. It is a dangerous and slippery slope when opinions of others shares similar influence as validated science.

Scalp Camouflaging Agents: A Closer Look at DermMatch

A Closer Look at DermMatch

Scalp camouflage refers to a variety of methods to reduce the appearance of hair loss. Hair camouflaging agents include hair fibers, powder cakes, lotions, sprays, hair crayons, and scalp micropigmentation.

DermMatch is a so called “powder cake” and is applied to the scalp with an applicator. The popular product colors the scalp and also binds hairs. It is available in a variety of colors. DermMatch is safe to use and provides very effective camouflage for individuals with early staged hair loss.

Male and female patients with androgenetic alopecia, telogen effluvium, alopecia areata and even some localized scarring alopecias have found these products very helpful to reduce that appearance of hair loss.

Reference

Donovan J et al. A review of scalp camouflaging agents and prostheses for individuals with hair loss. Dermatol Online J. 2012.

Dengue Infections and Hair Loss: What is the mechanism of hair loss?

What is the mechanism of 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 and even fatal illness. About 400 million infections occur per year making it a common infection.

Individuals infected with Dengue virus usually develop symptoms a few days to 2 weeks after being bitten. 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, rashes and internal bleeding problems.

Hair loss is fairly common with dengue fever. Hair loss occurs usually a few months after the illness starts and lasts a few months for most. The hair loss from Dengue can be quite dramatic in some cases.  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.

Although the hair loss that occurs from Dengue is typically though to occur via a mechanism of “telogen effluvium” (hair shedding), new research from Taiwan suggests hair loss from Dengue might be more complex. Researchers showed that human hair follicle dermal papilla cells (HFDPCs) were susceptible to Dengue virus infection and this lead ultimately to inflammation and cell death in HFDPCs.

Further research is needed to understand the long term sequelae of Dengue virus infection and to confirm whether hair regrowth is the norm for all patients.

Reference

Wei KC et al. Dengue Virus Infects Primary Human Hair Follicle Dermal Papilla Cells. Front Cell Infect Microbiol. 2018.

Seborrheic Dermatitis: Do Dietary Preferences Play a Role?

Do Dietary Preferences Play a Role?

Seborrheic dermatitis is a red scaly condition that affects multiple sites including the scalp. It is thought to be closely related to dandruff. Multiple factors contribute including Malassezia yeast. Other factors such as stress, ultraviolet radiation and several others factors too also play a role.

A recent study of 4,379 participants sought to examine the relationship between dietary factors and the development of seborrheic dermatitis. 636 of the participants (14.5%) had seborrheic dermatitis. Data analysis identified specific dietary patterns such as a 'Vegetable', 'Western', 'Fat-rich' and 'Fruit' dietary pattern.

Interestingly, a fruit-rich diet was associated with a 25 % reduction in the risk for seborrheic dermatitis. A Western type diet (high in red meat and processed food) was associated with a 47 % increased risk of seborrheic dermatitis but this dietary pattern seemed to have a link only for women.

The conclusion to the interesting study was that dietary choices likely do impact the development

of seborrheic dermatitis. A fruit-rich diet in particular may reduce the risk.

Reference

Sanders MGH et al. Association between diet and seborrheic dermatitis: a cross-sectional study.
J Invest Dermatol. 2018.

Iron supplementation in Children & Adolescents with Hair Loss

Iron supplementation For Children & Adolescents with Hair Loss

Iron supplementation is a popular topic for adults with hair loss but less attention is given to iron supplementation for children/teens and what doses are appropriate. I’m often asked what doses of iron are appropriate and what level of ferritin should we be aiming for.

Iron and Pediatric Patients

A conversation with parents regarding iron never begins with a conversation about iron. The conversation must begin with a broader overview of the child’s growth and development. Consideration is needed as to whether there could be other nutrition deficiencies and whether there are other health issues present. For some children, genetic conditions also affect the ability to make blood cells and store iron (i.e. the thalasemisas). A wide variety of issues can contribute to low iron in children! A full review is needed.

Children with iron deficiency should be evaluated by the paediatrician especially when there is an anemia (hemoglobin levels less than the cut of level). The paediatrician can decide whether further blood tests are needed. This may include screening tests for hemobloginopathies as well as screening tests for other deficiencies that might be present together with the iron deficiencies. Screening for celiac disease might also be considered in some children with low hemoblogin and low ferritin levels. In addition, the paediatrician can perform and examination and get more information about the child’s dietary practices.

For children with normal hemoglobin and slightly low ferritin levels, (ferritin 10-25), one can begin by reviewing dietary means of increasing iron rich foods in the diet. This includes red meats, poultry, fish, shellfish, lentils, beans. I always encourage parents to go slow with their approach to increasing iron and start first with reviewing the diet. Dietary means are generally the best to start with and encourage life long healthy eating in the child. If dietary means are sufficient and low ferritin levels are still present, (or if it’s just not possible to raise ferritin levels with dietary changes), a multivitamin containing iron is a good first step.

Iron supplements: The Third Step in Raising Iron

For healthy children with hair loss who have normal hemoblogin levels (but persistently low ferritin in the 10-25 level range) I recommend starting with dietary means followed by a multivitamin containing iron. It’s important to keep in mind that ferritin levels in children have not been adequately researched when it comes to the relationship between ferritin levels and hair loss. Therefore, it is a big stretch to say that a child with a ferritin of 12 has an iron issue impacting his or her hair. That might in fact be incorrect for many children. Nevertheless, if hair loss issues persist, it may be appropriate to raise ferritin levels up above 30. My cut off in children is generally 30 ug/L provided there is a normal hemoglobin level and normal MCV and normal RDW

If iron supplements are needed, I recommend dosing according to the following table. The recommended dose in children is 4-6 mg/kg/day of elemental iron. There are many formulations of iron available worldwide. In Canada, typically liquid and syrups are shown in the table below. A 10 kg child might be recommended 2 mL twice daily of Fer-in-Sol drops (see table).

How should iron be taken?

Iron can be taken with water or fruit juice or tomato juice as this really helps absorption. It should not be taken with milk. The iron can be taken 1 hour before eating or 2 hours after. Taking on an empty stomach really helps with absorption. If children develop an upset stomach with iron supplements, the iron can be taken 20 minutes after eating or even with food.

Staining of the teeth is a possible side effect of iron as is constipation (and rarely looser stools too). I always advise parents to go slow and start with half the dose for 1 week to make sure the child will tolerate it well. To prevent or at least reduce the chances of staining of the teeth, the liquid can be taken with a straw. Brushing the teeth twice daily and using baking soda to remove stains while brushing can also help alot.

Iron Supplements: How long?

Iron supplements should always be prescribed with a definitive start and stopping date. For adults, I recommend supplementing for 6 months before checking levels again. For children, I recommend checking ferritin (and hemoblogin) levels again in three months. If levels have risen to the appropriate level (i.e. above 30 for children with hair loss) iron can be reduced or even stopped. Repeat monitoring may then be appropriate again 6 months to 12 months down the road to ensure that levels have not plummeted. Chronic iron supplementation without a stop date (or recheck date) is not advisable for children.

Conclusion

Iron supplementation in children must start with a full review of the child’s health and development. Consideration should be given to all the reasons as to why a child has low ferritin levels. Children with low ferritin levels PLUS low hemoblogin levels require more urgent attention than children who have only low ferritin levels. For children with hair loss, starting with attention to dietary intake of iron is the first step followed by use of a multivitamin containing iron. If ferritin levels do not raise and hair loss is still and issue … an iron supplementation strategy can then be recommended as step three.

Scalp Redness and Burning : What are the common causes?

Scalp Burning and Redness: What are the top 10 causes?

Scalp redness with an accompanying sensation of burning has many causes. Here, I briefly review the top 10 causes of this scenario.

1) Seborrheic dermatitis.

Seborrheic dermatitis (SD) is an inflammatory condition of the scalp that affects about 3-5 % of adults. Males are more commonly affected than females. SD occurs on body sites where the skin is oily such as the scalp, eyebrows, sides of nose, eyelids and chest. Individuals with SD of the scalp develop red, flaky skin that is often itchy. The scales can be yellow, white or grey colored and are often described as being "greasy." This differs from scalp psoriasis where the scales are often silver and powdery (see below). Itching is more common in seborrheic dermatitis than burning but certainly burning can be present.

2) Psoriasis

Psoriasis is complex immune-based disease which can affect not only the skin, but also the nails and joints. Scalp psoriasis occurs in about 50 % of patients with skin psoriasis. Patients have scalp redness, flaking and scaling. Patients may also have bothersome itching and seem have burning. Although the redness and flaking often cause embarrassment, scalp psoriasis does not usually cause hair loss. 

3) Scarring alopecias 

Scarring hair loss condition or the so called "cicatricial alopecias” are a group of hair loss conditions which lead to permanent hair loss. These conditions may frequently be associated with redness of the scalp as well as a variety of symptoms such as scalp itching, scalp burning and/or scalp tenderness. These include conditions with names such as lichen planopilaris, folliculitis decalvans, lupus and several others.

4) Other inflammatory diseases

A wide variety of other inflammatory scalp conditions, including dermatomyositis and rosacea can be associated with scalp redness and burning. A scalp biopsy can help differentiate these entities.

5) "Red Scalp Syndrome"

'Red scalp syndrome" is a condition which occurs in individuals who have persistent scalp redness that is not explainable by any other condition. The condition was first described by Drs Thestrup and Hjorth. Patients with the Red Scalp Syndrome may have itching and burning but typically do not have scaling or flaking.


6) Irritation

Many products that are applied to the scalp or hair can cause irritation. These include many cosmetic products, including gel, mousse, hair spray and hair dyes. Some treatments for hair loss can also be associated with irritation and redness, including minoxidil and other topical products containing irritants such propylene glycol.

7) Allergic contact dermatitis

Shampoos, hair dyes and even some cosmetic products can cause allergic reactions in the scalp. Although some individuals with allergy have itching or burning in the scalp, many do not. In such cases, a rash may be present on the neck, ears or back where the product came into contact with the skin. Patch testing, done by a dermatologist with specific interest and expertise in this area can help determine if allergies are responsible for the scalp burning.


8) Infection

Infections are a possible causes of redness. Bacterial, viral and fungal infections may cause redness in the scalp. Determining the specific cause may come from a careful history and scalp examination and sometimes submission of a swab or piece of scalp tissue to the microbiology laboratory. 

Bacteria, such as staphylococci, may cause infections of the scalp. Bacteria may also cause infection of the hair follicle, which is a condition called " bacterial folliculitis." A variety of viral infections cause scalp redness. Chicken pox and shingles are two such examples. Scalp ringworm or “tinea capitis” refers to infection of the scalp by certain types of fungi. Scalp redness and scaling may be seen in these cases.

9) Alopecia areata

Alopecia areata is an autoimmune condition affecting about 2 % of the population. It is not typically a cause of scalp redness. The scalp in patients with alopecia areata is usually normal in color but may be pink or peach colored in some cases. Burning or itching can barely occur in the patches. Most however, are asymptomatic.


10) Scalp Dysesthesias 

Patients with scalp dysesesthesias typically have scalp symptoms like itching or burning in the absence of redness. In some cases there may be some minor redness. Scalp dysestheias occur for a variety of reasons rather than a single one. Depression, anxiety, spine disease, multiple sclerosis, fibromyalgia can all contribute.

Conclusion

There are many causes of scalp redness with burning type symptoms. Fortunately, the cause of the redness and burning can often be diagnosed from a thorough examination of the scalp along with a full review of the patent’s story. In complex or challenging situations, a scalp biopsy should be performed to confirm the diagnosis.

On the Meaning and Significance of Hair

Everyone has a Different View on Hair

The way two people think about their hair or their hair loss is not only unlikely to be the same - it’s also practically impossible. Our cumulative experiences from birth to the present influence how we come to view many things in our lives, including our hair.

Every part of the life journey matters. The way that a patient’s hair was brushed, washed or styled at age 3 influences, beyond any morsel of doubt, the way they think about their hair at age 23 or 63. The way the individual feels their hair looked like in the class photo from middle school affects how the high school student feels about their hair and ultimately how the same adult now thinks about his or her hair.

Comments and actions from family, friends, and teachers in childhood impact on how our emotions and thinking ultimately develop and influence exactly how we come to view our hair.

Our schooling, our jobs, our relationships, our hobbies - they all matter. What we choose to read, what we choose to watch and what we chose to listen to - it all matters to the meaning and significance each of us attaches to our hair. Every glance we have ever given our reflective self in the mirror, and every selfie we have ever taken further shapes these views.

Despite the world population of nearly 8 billion people, and countless generations of people in the past, there has yet to be two people who think about their hair or about their hair loss in a completely identical way.

No two people have ever shared an identical life journey and no two people have ever yet come to think about their hair in an identical way.

Black Dots: Hair dye as an example

Hair dye as an example

Magnified and dermatoscopic images of the scalp have an important role in making proper diagnoses. Black dots (as shown here) are a dermatosocpic sign that is encountered from time to time.

There are many causes of black dots that must be considered. Black dots are seen in alopecia areata, tinea capitis, traction alopecia and rarely some scarring alopecias too. Other causes are possible too and this list is not complete. Black dots generally represent hair follicles that have broken off at the level of the scalp. Black dots can also be caused by a variety of different “dyes” that dye the hair follicle opening and therefore do not actually represent broken hairs.

In this photo, the black dot represent recent use of hair dye that has colored the hair follicle opening or “pore.” Other types of dyes, such as anthralin used in alopecia areata treatment, also color the opening.

Lichen Planopilaris (LPP): Scalp Symptoms: none to severe

Scalp symptoms: none to severe

Lichen planopilaris (LPP) is a scarring alopecia that has the potential to cause progressive and permanent hair loss.

Affected individuals typically first notice increased daily hair shedding and this is often accompanied by scalp symptoms such as itching, burning, tingling, tenderness or pain. Some patients, however, do not have symptoms.

This photo shows the scalp of a patient with LPP who has marked scalp symptoms. Repeated itching of the area has triggered skin excoriations and localized bleeding. This is one indication that the disease is active.

There are several treatments that can help slow it down or stop it but regrowth does not happen to a significant degree for most. Treatments include topical steroids, steroid injections and a range of oral medications such as doxycycline, hydroxychloroquine, methotrexate, mycophenolate, cyclosporine and low level laser. Options like low dose naltrexone, and tofacitinib may also be options.

The Patient in the Room is an Expert

The Patient as Expert

The patient is an expert in his or her hair loss. Nobody really knows more about all the facts surrounding their hair loss than they do. Of course, the patient might not even know they are an expert, but they are an expert. The patient knows when their hair loss started, which parts of the scalp are more affected by the hair loss than others, which parts itch and what seems to help the hair to grow. The patient can explain more about the ins and outs of their hair loss than anyone.

It’s true that the physician in the room is also an expert. He or she knows how to piece all the patient’s information together and what features on the patient’s examination or blood tests are relevant and which are not. The physician knows what the diagnosis is likely to be and what it simply can not be. But none of this is possible without the expertise of the patient.

I have come to realize that the patient’s story about his or her hair loss is actually more important than most give credit to. Of course, examining the scalp is important but in challenging diagnoses, it’s the patient’s story that often pushes the referral from a ‘long time mystery’ to an interesting or challenging diagnosis that finally gets solved. The patent’s story helps rule out hair loss conditions that simply don’t fit and rule in conditions that have not been thoroughly considered in the past.

The patient and physician both have expertise. However, nobody in the room will have more cumulative days and years of experience of experience with the hair issues in question than the patient in the room

Biotin and False Test Results: Stopping Before Blood Tests is Essential

Stopping Before Blood Tests is Essential

Many supplements contain biotin at levels well above the recommended daily intake of 30 micrograms. It is now recognized that high doses of biotin can interfere with some laboratory tests (specifically immunoassays using biotinylated antibodies). Many supplements contain 2 500, 5 000  or even 10 000 micrograms of biotin.

Both falsely low and falsely high results are possible in users of biotin supplements. The concern is that some patients might undergo unnecessary testing or start unnecessary medications after being told their blood test results are abnormal.

The issue is therefore potentially quite serious. In November 2017, the US Food and Drug Administration recently issued a safety communication regarding biotin interference with laboratory tests.

A recent report in the Journal of the Endocrine Society reported a patient with abnormal thyroid results, as well as elevated cortisol and testosterone. These abnormal results prompted the patient to undergo numerous consultations and radiographic and laboratory tests.

It was ultimately discovered in this patient that her abnormal results were due to the biotin supplement she was using. The patient was taking a biotin supplement at a dose of 5 000 micrograms per day regularly.  Once she stopped biotin, her lab parameters returned to normal although TSH tests (thyroid testing) did take more than 2 weeks before any normalization was seen.

This reports highlights the potential for patients using biotin to have false results. What is more concerning is the potential for such patients to undergo potentially invasive testing or start potentially harmful medications on account of these results.

Education as well as communication between health care teams, laboratories, and patients is vital to ensure patients stop biotin well ahead of any testing.

Reference

Stieglitz HM, et al. Suspected Testosterone-Producing Tumor in a Patient Taking Biotin Supplements.
J Endocr Soc. 2018.

Androgenetic Alopecia: Variation in Hair Caliber (Anisotrichosis)

Variation in Hair Caliber (Anisotrichosis)

Individuals with androgenetic alopecia (male balding and female pattern hair loss) may lose hair at different sites of the scalp (some front, some crown, some diffusely) but all show a variation in the caliber of hairs when the scalp is examined up close. That feature is known as “anisotrichosis.” This photo shows the scalp of a patient with androgenetic alopecia. Some hairs are thick (well above 60 micrometers) and a known as terminal hairs. The arrow on the right points to one fairly thick 77 micrometer hair.

Other hairs on the scalp are thin including many that are showing “miniaturization” or the progressive reduction in calibers. Hairs that are thin, small and less than 30 micrometers are traditionally called “vellus hairs.” One very thin 21 micrometer hair is shown in the photo.

The conversion of terminal hairs to vellus hairs is the hallmark of androgenetic alopecia.

Lichen planopilaris: Shedding, Itching, Burning, Tenderness

Shedding, Itching, Burning, Tenderness

Lichen planopilaris (“LPP” for short) is a type of hair loss that is categorized as a type of so called scarring alopecia.

There is no single way that LPP first announces its presence. Some people have only scalp itching. Some have burning. Some have itching and burning along with a bruised-like tenderness in the scalp. Surprisingly, a small proportion of patients with LPP have no symptoms at all.

Many patients notice they are shedding more hairs on a daily basis than they once did.

Eventually, some patients develop an area of hair loss on the scalp that concerns them and brings them to the doctor.

In many cases the diagnosis can be determined by simply looking at the scalp but often a biopsy is performed to confirm the diagnosis. A biopsy shows the presence of both inflammation beneath the scalp (in a specfic pattern) as well as scar tissue (fibrosis). Treatments include topical steroids, topical calcineurin inhibitors, steroid injections, and a variety of oral medications (doxycycline, hydroxychloroquine, methotrexate, cyclosporine, mycophenolate, isotretinoin, low level laser, excimer laser, tofacitinib).

Using Alcohol while taking Methotrexate: Is their a risk of liver injury?

Consuming Alcohol while on Methotrexate

Methotrexate is an immunosuppressive type pill that is used in the treatment of several autoimmune hair loss conditions including alopecia areata, lichen planopilaris, frontal fibrosing alopecia, and discoid lupus. A variety of side effects are possible with methotrexate including the risk of liver toxicity. 

Alcohol Use in Methotrexate Users

Both alcohol and methotrexate can irritate the liver.  On account of this, individuals using methotrexate need to have their liver enzymes monitored periodically. Traditionally, physicians have advised patients using methotrexate to limit their use of alcohol while using methotrexate.  New data suggests that while these concepts are correct, the use of limited amounts of alcohol by methotrexate users does not appear to increase the risk of liver injury.

The UK based authors studied the effects of alcohol consumption in rheumatoid arthritis patients using methotrexate. It's important to note that these were note hair loss patient and therefore the results need to be extrapolated. The researchers studies 11 839 patients over the years 1987 to 2016. They observed that there were 530 episodes of liver enzyme elevation (i.e. "transaminitis"). The authors found that methotrexate users who consumed less than 14 units of alcohol per week did not seem to have an increased risk of transaminitis. Patients who consumed between 15 and 21 units seemed to have some degree of liver injury and patients who consumed more than 21 units had a significantly increased risk of transaminitis.

 

Conclusion

This is an important study. Many patients with autoimmune hair loss conditions make decisions on use of methotrexate based on the potential side effects and the information they are presented about the necessity to limit alcohol consumption while using methotrexate. This study provides evidence that occasional use of methotrexate is likely to be safe from the perspective of liver injury and that keeping under 14 units is also likely to have a good liver safety profile.  14 units of alcohol would include 6 glasses of wine (13 %, 175 mL) or 6 pints of beer.

Reference

Humphreys J et al. Quantifying the hepatotoxicity risk of alcohol consumption in patients with rheumatoid arthritis taking methotrexate. Ann Rheum Dis. 2017 Sep;76(9):1509-1514.  

Scalp Biopsies: Expert Interpretation Needed

Expert Interpretation Needed

Scalp biopsies have multiple steps but all end with a pathologist sitting at his or her microscope looking at a slide like the one shown here.

A biopsy is important but not more important than the patient’s story (ie the “medical history”) and not more important than the actual clinical scalp examination. The biopsy is merely another tool to get information about the possible cause of the patient’s hair loss.

To perform a scalp biopsy properly, one must ensure a 4 mm punch size is used an taken from the right area of the scalp. The sample must be processed properly by the pathology laboratory and ideally should be assessed by a dermatopathologist who has a good amount of experience in scalp biopsies.

It is surprisingly for some to learn that biopsies are not the gold standard in diagnosing hair loss they are simply a tool. Incorrect interpretations are possible (false positives and false negatives)

Minoxidil for Women: Am I really supposed to be using the Men's Brand?

Topical Minoxidil for Women: Which Strength ? Which Type?

Minoxidil is a topical product for treating androgenic alopecia. It was first approved in 1988 for this indication. Depending on the advice of the treating physician, minoxidil may also be used off label to treat several other types of hair loss as well, such as alopecia areata, some scarring alopecias and some forms of hair loss related to chemotherapy.

Both minoxidil 2 % and 5 % are approved for use in men.

Both minoxidil 2 % and 5 % are approved for use in women.

What are the typical types of minoxidil that I will see at the pharmacy?

There are several main types types of minoxidil that a patient will encounter when they enter the pharmacy. At first glance it seems to be a bewildering array of options. The internet is full of claims that one type is better than another. Some companies state that their spray is the way to go - and using the foam or liquid dropper is less effective. Others promote their foam, saying that anything else is less effective.

First, we’ll take a look at the types of minoxidil products that are commonly seen and then return to some practical tips.

MINOXIDIL PRODUCTS MARKETED TO WOMEN

1) 2% Minoxidil Lotion (Dropper) for Women.

2) 2% Minoxidil Spray for Women.

3) 5% Minoxidil Lotion (Dropper) for Women

4) 5% Minoxidil Spray for Women

5) 5% Minoxidil Foam for Women

MINOXIDIL PRODUCTS MARKETED TO MEN

1) 2 % Minoxidil Lotion (Dropper) for Men

2) 2 % Minoxidil Spray for Men

3) 5% Minoxidil Lotion (Dropper) for Men

4) 5% Minoxidil Spray for Men

5) 5% Minoxidil Foam for Men

Practical Tips for Minoxidil Use and Application

As we can see from the above lists, there are many types of minoxidil. This is only a partial list as other types can also be made through compounding pharmacies. For example, the less common off label use of 7.5 % or 10 % minoxidil, or liposomal minoxidil compounded with anti androgens like finasateride.

Here are some practical pointers about use of minoxidil:

1) The men’s and women’s products are usually identical so go with whatever is less expensive and use according to your doctor’s recommendations.

A bottle of 2 % men’s minoxidil is generally identical to a bottle of 2 % women’s minoxidil. One might be a different color. One might say clearly on the packaging that it is “for men only” and the other for women only, but the products are identical. Understandably it’s creates some confusion and anxiety when a woman starts to use a bottle of 2% minoxidil liquid that states on the packaging “for men only.” However, the product is the same as the 2 % minoxidil lotion for women. If a patient has any questions about which minoxidil to use, they should take a photo of the product they have found and simply send it to their own treating physician for confirmation that it is the right product.

A bottle of 2 % minoxidil lotion is used at 1 mL twice daily regardless of whether the female is using the version marketed to men or the version marketed to women.

Minoxidil 5 % foam for men is generally the same identical product as minoxidil 5% foam for women. The men’s foam is usually less expensive so a physician may recommend that some of their female patients simply use the men’s minoxidil foam. Understandably it’s creates some confusion and anxiety when a woman starts to use a bottle of minoxidil foam that states on the packaging “for men only.” However, the product is the same as the 5 % minoxidil foam for women.

A bottle of 5 % minoxidil foam is used at a dose of 1/2 cap once daily regardless of whether the female is using the version marketed to men or the version marketed to women. If the female choses to use the version marketed to men, it will of course indicate that use is twice daily on the packaging - but those are the instructions for men. All users should use the product according to the specific recommendations given by their health care providers.

2) Experiment with Different Formulations

Most patients with hair loss prefer the foams over the liquid (dropper or spray) formulations of minoxidil. They tend to be less greasy and less irritating. However, not everyone prefers the foam and some clearly prefer the lotion for the easy of getting small amounts all over the scalp. Patients with thicker or curlier hair may prefer the lotion in some cases. Patients with widespread areas of hair loss may also prefer the liquid (dropper) formulations as it is easier to spread 1 mL (25 drops) all over the scalp as opposed to spreading 1/2 cap all over the scalp.

CONCLUSION

If there is any doubt about which minoxidil one should buy, an individual should simply check with the treating physician. One simply needs to be aware that men’s minoxidil formulations are identical. 2 % minoxidil for men is identical to 2 % minoxidil for women. 5 % minoxidil for men is the same as 5 % minoxidil for women. The packaging might be different and the cautions in fine print might be different. The use is generally the same.