What I love about being involved in dermatological research is when new disease pathways are found and existing drugs can be applied to them. This is true for a new drug called Soolantra® for treating rosacea. There have been many theories about what caused the redness, large pustules, papules and broken blood vessels that characterize rosacea.
We typically treat rosacea with topical medications including drugs such as metronidazole, azelaic acid and sulfacetamide. Often, we add an oral course of antibiotics including doxycycline, tetracycline, minocycline and clarithromycin to kick start a faster response from the inside out. If that doesn't work, we moved on to topical retinoids such as Retin-A® and for really stubborn, disfiguring rosacea we try isotretinoin. We found that another topical gel formulation of the alpha2 agonist brimonidine called Mirvaso® helps decrease the facial swelling and redness, but doesn't help with the pustules and papules that are so disturbing to patients. Further, we often have to rely on lasers and light treatments to treat any broken blood vessels (we call telangiectasia) that often accompany the pimples and pustules of rosacea. After all is said and done, none of these drugs are perfect, so it is nice to have another option to add to anti-rosacea arsenal.
What can Soolantra® do that is different?
The FDA has approved a 1% cream of the anti-parasitic drug ivermectin (Soolantra®) for the topical treatment of rosacea. You may have heard of this drug as an anti-parasitic medication primarily used in the treatment of onchocerciasis (river blindness) in humans. It is also used in some epidermal parasitic skin infections, such as scabies. Researchers have now determined that Demodex, a microscopic mite that is a normal inhabitant of human facial skin is a powerful culprit in rosacea.
The results of the clinical studies may have you running to the dermatologist to try Soolantra® if you have rosacea:
Two 12-week, randomized, double-blind trials compared a once-daily application of ivermectin cream compared to a similar cream without ivermectin in a total of 1371 patients. In both trials, a complete or almost complete clearing of lesions occurred in significantly more patients treated with ivermectin cream (38.4% and 40.1%) than without the ivermectin (11.6% and 18.8%).
The ivermectin cream decreased the number of inflammatory lesions from the baseline by 76% and 75% compared to reductions of 50% using the cream without ivermectin alone.
Both trials were extended to 40 weeks of treatment with ivermectin cream which significantly boosted the percentages of patients with complete or almost complete clearing of lesions from 38.4% and 40.1% in the initial trial to 71.1% and 76% respectively in the extended trial. That's some increase.
Another 16-week randomized trial in 962 patients with moderate to severe papulopustular rosacea showed that using ivermectin 1% cream once per day was significantly more effective than metronidazole 0.75% twice a day in decreasing the number of inflammatory lesions from baseline (83% versus 73.7%) and in clearing or almost clearing lesions (84.9% versus. 75.4%).
This is such great, exciting news for those suffering rosacea
The treatment is simple, apply a pea-sized amount of prescription Soolantra® in a thin layer to any affected area of the face once a day. I would suggest my patients stay on Soolantra® until lesions have cleared which might be anywhere from 16-40 weeks (because there were virtually no side effects in the trials) depending on your specific rosacea condition.
I can't wait to see these results in my patients with rosacea...
Recently, the United States surgeon general issued a call to action to prevent skin cancer, calling it a major public health problem that requires immediate action.
Nearly 5 million people are treated for skin cancer each year. According to the American Cancer Society, more cases of skin cancer are diagnosed annually than breast, prostate, lung and colon cancer cases combined and skin cancer rates are increasing.
“We all need to take an active role to prevent skin cancer by protecting our skin outdoors and avoiding intentional sun exposure and indoor tanning,” said acting Surgeon General Boris D. Lushniak, MD, MPH.
I say this all the time, but it bears repeating as often as possible:
“Most skin cancer is 100 percent preventable.”
Most cases of melanoma – as many as 90 percent – are believed to be caused by cumulative exposure to UV rays. UV rays are also a major risk factor for the most common curable forms of skin cancer, basal and squamous cell skin cancers. Exposure to UV rays comes from the sun and other sources like tanning beds and sunlamps. The U.S. Food and Drug Administration (FDA) now requires that tanning beds and sunlamps carry a warning stating people under 18 should not use them. Lushniak said there is a flawed perception in the US that tanned skin looks healthy, and that needs to change. I always say,
“Tanned skin is damaged skin.”
According to the Melanoma Education Foundation, One blistering sunburn before age 20 doubles your lifetime risk of melanoma. Three or more blistering sunburns before age 20 multiplies your lifetime risk by five.
Reduce your risk of skin cancer for yourself and your children:
- Whenever spending time in the sun, always wear a sunscreen that blocks both UVA and UVB rays of SPF 30 or higher.
- Reapply sunscreen to dry skin every time you come out of the water and reapply at least every 2 hours regardless of SPF.
- Use a full 1 ounce of sunscreen (that’s a shot glass full) to cover your body. Don't forget to apply sunscreen to your neck and ears, face and tops of feet. If you have thinning hair, be sure to apply sunscreen to your scalp!
- Wear a hat to protect eyes and face by wearing sunglasses and a hat-seek shade often.
- Remember, babies under 6 months old should never spend any prolonged time in the sun.
-Jodi, proud owner of a lily white complexion.
Question: I found that during the holidays, both my acne and my rosacea flare up...at the same time. Why is that and what can I do about it?
Answer: Most people realize that rushing around fretting, shopping and baking for holiday parties and family gatherings can be stressful, but there's more going on behind the scenes that can cause skin problems to flare during the holidays. Here are some common reasons why your skin condition may flare up and what you can do to calm it down during and after the holidays.
1. You've let prescription regimens lapse. I know sometimes you feel that you just can't get to the pharmacy to pick up your prescription or you don't have time for the 3-step process of your topical skin prescription. If you suffer from acne or rosacea or any skin problem for which you have a usual regimen or you are taking or using a prescription medication, oral or topical, now is not the time to let the prescription lapse or be lax about using it exactly as recommended. Skin conditions under treatment with medication need to be used as prescribed to control flares caused by the physical, emotional and financial pressures of the holidays. Keep control of your skin conditions by paying special attention to keeping your regimen and skincare routines intact.
2. You're not protecting your skin. With the colder, windier weather this time of year, you may not be doing enough to protect skin from exposure to the elements. Always protect your face with a scarf on blustery days and switch up moisturizer at this time of year to a more emollient (thicker, soothing, smoothing) one, especially when venturing outside and to protect from the over-drying heat inside. Don't let sunscreen use lapse just because it is winter. Always wear sunscreen to safeguard your skin from ultraviolet light damage daily, especially if spending time outdoors for winter sports and activities.
3. You're keeping the house (and you're skin) too hot. Most people do not realize the effects of cooking over a hot stove and sticking your face in the hot oven, along with prolonged exposure to dry, heated indoor air during winter months on your skin. When things heat up in the kitchen, facial redness, breakouts and rosacea flares can occur. Furthermore, when the heat goes on in the house, humidity is sucked out of the air and consequently your skin. Crack a window when you sleep to prevent the bedroom from becoming overheated and use a humidifier to help replace some of your skin's moisture loss while you sleep, especially if you notice skin feels tight and looks flaky, red or cracked. If you are cooking, use a cool (clean!) wash cloth to wipe your face throughout the meal preparation and take a break when you can to a cooler part of the house or go outside.
4. You're wearing way too much makeup (and not washing it off)! Everyone tends to be a little more concerned during the holiday season with how they look for office gatherings, parties and family affairs. The temptation to wear heavier layers of primer, foundation and powder along with water-proof eye makeup and mascaras that hold up to partying to the wee hours can really block pores and cause irritation. If you do not wash it all off completely every time before going to bed, or worse, scrub too hard in trying to get it all off, your skin can become angry and inflamed; acne can flare. Never go to bed without taking off your makeup. Period.
5. You're indulging too much. Watch what you eat and drink. Certain foods and alcohol can trigger allergic reactions. When you indulge in foods and drinks you don't normally eat or drink, your body can overreact causing eczema/atopic dermatitis, itching, hives or even more severe anaphylaxis. Let's not forget the sallow, pale, splotchy and wrinkled look of a hangover. Take care to avoid the foods you know you are sensitive to. Furthermore, many foods such as red wine, steaming foods or drinks and spicy foods may trigger reddening in conditions such as rosacea. Be sure to know your personal skin triggers and take care to avoid those accordingly. Also try to maintain your body's hydration levels with lots of purified water whenever possible to flush out allergens, alcohol, stress hormones and other environmental pollutants in the body.
I know, I know - easier said than done!
Maybe you already have your goals and resolutions in place for the beginning of 2015, but none will be easier to kick off and have a greater effect than those to help improve your skin, nails and hair. Check our list and just pick one or two. You can get started right now improving your skin's health and reducing your chances of premature aging, as well as decreasing your risk of diseases of the skin and hair. Go ahead...get going...
1. I will apply sunscreen in the morning every day, whether or not it is cloudy or cold. The sun emits harmful ultraviolet (UV) rays year round and even on cloudy days, up to 80% of the sun’s harmful UV rays can penetrate your skin. Snow, sand, and water all reflect the sun’s rays and increase the need for sunscreen. One of the most valuable things you can do for your skin, is the regular, daily application of sunscreen. We know when applied every day, sunscreen use protects against photoaging-wrinkling, spotting and loss of elasticity caused by exposure to the sun's UV radiation. Furthermore, skin cancer rates are on the rise and sunscreen has been proven to decrease the risk of skin cancer. So, why not use it? Keep your sunscreen next to your toothbrush-when you brush your teeth in the morning, reach for the sunscreen. In twenty years you will be glad you did!
2. I will stop smoking. Period. Isn't it time? Beyond its known links to cancer, lung and heart disease, smoking is now known to be associated with premature skin aging, delayed wound healing, as well as other skin disorders. Moreover, we know smoking makes you look way older than you actually are and that is enough of a reason to kick the habit once and for all.
3. I will use a humidifier in my living quarters to combat winter dryness. A humidifier can be your best friend in the cold, dry winter months, helping your skin stay hydrated and supple.
4. I will increase my water intake and decrease my intake of soda, coffee and alcohol. Water is the best option to reach for when you want a drink. Being dehydrated makes your skin look more dry and wrinkled which can be improved with proper hydration. But...why water? The concept of sugary drinks and aging is really not new. Sugar can be implicated in heart disease, negative effects on brain health and can be associated with immune system suppression. Recent research has suggested that drinking even one sugary soda a day may speed up the rate at which your body ages. Our other favorite vices, coffee and alcohol can also wreck your skin. Both act like a diuretic and prevent your body from holding onto water. The result? Your skin can look dry, wrinkled, and washed out. Make a commitment to yourself, when you feel the need to indulge (and we all know we will), keep yourself hydrated. It may save your skin!
5. I will get a good night's sleep. Your lack of sleep is written all over your face. Your tired skin sags, bags and loses its luster. Lack of sleep causes blood vessels to dilate, causing dark circles under your eyes. Not enough sleep can also make you be more tense and stressed, which definitely makes you look older. When you get a good night's sleep, your body and skin go into repair mode. Skin cells grow and replace older ones...skin becomes renewed and regenerated. A good slumber helps your skin restore and rebalance after the harsh elements of the day. Skin recovers quickly, so get to bed...get that beauty sleep; everyone will notice your fresh face tomorrow.
6. I will practice head to toe monthly self exams on my skin, so I can find any new or changing lesions that may be cancerous or pre-cancerous. I will make an appointment at the dermatologist's office immediately if I notice a new skin growth or change in a mole or growth I have had for a long time. Skin cancers found and removed early are almost always curable, so look yourself over. If you spot it, you can almost always stop it.
These simple skin care resolutions are easy ways to make a big impact on the condition of your skin (and your health). To make it easier to remember to make any of these actions part of your daily habit (or to stop the the detrimental ones from being part of your daily habit), try leaving post-it notes on all your mirrors or nightstand or set up Smartphone alerts using a free calendar app or a free reminder app such as Water Your Body. Start incorporating these changes and we're sure you will see the results. Be sure to check back the whole month of January for more skin resolutions. Remember...it is never too late!
Question: I am a young woman in my twenties and I have noticed a few dark hairs sprouting along my cheek and they are definitely not part of my hairline. What could be causing this and is it normal? How can I get rid of them?
Answer: Clinically, whenever we see a woman who has any dark hair anywhere on her face or body where hair is normally not present, we call it hirsutism. Of course, Conchita Wurst (at left), who won the Eurovision Song Contest earlier this year is in drag, so her manly hormones, mainly testosterone, are the cause of that dark hair growth on her face, where most women do not want or have hair.
How hirsutism happens...
If you've noticed some hairs growing where they shouldn't be, you may have a benign (not dangerous) condition of slightly elevated levels of serum androgens (male hormones) in your body. In women, excess androgen production stimulates (fine) vellus facial hairs to develop into long, coarse, pigmented terminal hairs (like a man's) in most areas of the body except the scalp, where normal estrogen would inhibit that hair growth. That's why women do not normally have facial hair and chest hair, for example. On the scalp, the opposite happens in a woman with too much testosterone in the bloodstream, the long, dark terminal scalp hairs are converted to vellus hairs, eventually resulting in hair thinning.
Sometimes, the condition is part of a larger problem and can be associated with polycystic ovary syndrome (PCOS) which can affect a woman's hormone levels causing the abnormal hair growth. Rarely, ovarian or adrenal tumors can also cause endocrine (hormone) problems that result in excess hair growth and other unwanted signs of masculinization in women. For this reason, it is important to see both your dermatologist and your OB/GYN if you notice any abnormal, hair growth so you can get an accurate diagnosis.
A blood test will give a more clear indication of the origin of the androgens which could simply be testosterone secreted by the ovaries. If testosterone levels are normal, other androgens may be secreted by your adrenal glands. The results will give your doctors a clearer picture of the diagnosis for the unwanted hair growth and the treatment necessary to get it under control. Sometimes, you may be further referred to an endocrinologist for further hormonal testing if necessary.
How we treat simple hirsutism, or abnormal hair growth in women
While there is no cure for hirsutism, in women with mild, isolated hair growth, we can usually get the unwanted hair growth under control in a variety of ways. The first-line therapeutic approach is to decrease the rate of androgen production and secretion which can be done simply and effectively with oral contraceptives (birth control pills). We can further inhibit the androgen action with other medications such as spironolactone (Aldactone), which we use off-label to block the androgen receptors while also suppressing testosterone production. No matter how we try to control the hormones, it usually takes six months to one year for even partial clinical improvement. Once the excess hair is under control, the medications must be continued to limit hormonal production and the unwanted hair growth.
During treatment with the medications, you can physically remove the unwanted hairs by tweezing, shaving, waxing or using depilatories, but the excess male hormones should still be treated. Permanent physical methods to remove hair such as laser hair removal (electrolysis) are great options for treating hirsutism, but for best results the hormonal aspect should still be addressed simultaneously.
Bottom line for weird hairs where they don't belong? See your dermatologist and your OB/GYN ASAP!
Question: Is there such a thing as sweating too much? What can I do about it if I’m constantly soaking through my clothes? It’s so embarrassing, especially at work!
Answer: Yes, the condition definitely heats up during the summer months but can plague sufferers all year long with overly sweaty armpits, palms and even on soles of the feet. It is called hyperhidrosis which just means “excessive sweating.”
Hyperhidrosis is simply abnormally heavy perspiration. Sweating is a normal bodily function, but some people may have overactive sweat glands that produce more sweat beyond what is required for regulation of body temperature. It can be most noticeable at the armpits because sweat can soak through clothing and become obviously embarrassing. Or you may also be aware your palms are often sweaty so you avoid shaking hands with others. Hyperhidrosis can occur in many parts of the body whether exposed to triggers such as heat, physical activity or exertion, embarrassment, stress or not.
How do we treat excessive sweating?
First, we’ll evaluate your excessive sweating for any potential causes of secondary hyperhidrosis (for example, an underlying disease that causes excessive sweating such as hyperthyroidism).
To gauge your sweating problem, we will try you on stronger prescription-grade antiperspirants which can also help block sweat glands to reduce sweating. Typical over-the-counter antiperspirants are 1-2% aluminum chloride but prescription products can contain up to a 20% solution of aluminum chloride hexahydrate or similar aluminum salts. While these can be irritating in those with sensitive skin and sweat glands, they do reduce perspiration, however they require continuous usage.
After a few weeks of trial, if the prescription products do not reduce your sweating problem well enough, we can now use Botox® (onabotulinumtoxinA), which is FDA approved for the treatment of excessive sweating of armpits. We also use Myobloc® (rimabotulinumtoxinB) or Dysport® (abobotulinumtoxinA) off-label as an alternative, especially for those who have excessive sweating on palms and soles of feet.
These injections work to temporarily de-nerve the sweat gland and results in a local reduction in sweating where injections have been administered for up 5 months. Injections must be repeated at regular intervals to keep excessive sweating at bay and you may still need to use an antiperspirant.
Question: I’ve seen plenty of products in the drug store skincare aisle that contain retinol and say they reduce the appearance of fine lines while balancing an uneven complexion. Is this the same as the Retin-A products I can get by prescription?
Answer: While they are both derivatives of Vitamin A, called “retinoids,” and used to promote faster skin cell turnover, they are not the same.
All retinoids have been well-studied, tested and been proven effective and powerful for treating skin issues ranging from acne to many signs of aging, including sun damage.But there is a marked difference between retinoid products you get only by prescription and the retinol products you see on drug-store shelves.
Retinoid products are prescription-only skincare products containing the most commonly-known natural vitamin A derivative, tretinoin which comes in name brands such as Atralin, Retin-A (and Micro) among others. These proven prescription products increase the rate of cell turnover to uncover healthier skin-whether it’s reducing fine lines or evening out the texture or color of your skin. Common side effects include dryness, redness, cracking, irritation and skin peeling. There are two other prescription strength (lesser known) prescription retinoids-tazarotene (Tazorac) and adapalene (Differin).
If you find, during the dead of winter, that dryness, peeling, redness and cracking are more pronounced, simply reduce the usage of your prescription retinoid to just once per day, or every other day or even every two or three days until side effects are diminished. By the way, winter weather and drier indoor heat may be exacerbating your already winter-dry skin, if you need to use them less don’t worry, the powerful retinoids still do their job!
Retinol products don’t require a prescription so you can buy them over-the-counter at the drug store or grocery store, without a prescription. Retinols are simply a synthetic, weaker version of a retionid and as such, they act more slowly than a retinoid. However, these products can be useful if you find prescription retinoid products too strong for your skin. They are also a good beginning step to starting your skin on a topical retinoid.
When choosing a drug store retinol product, check the ingredients list to make sure vitamin A is listed toward the top of the ingredients list. Also, in terms of packaging, look for an air-tight bottle that keeps the light out (exposure to light makes the products less stable and effective and more susceptible to bacteria growth.)
Other skin tips:
- Reduce your skin’s exposure to hot-hot water.
- Add a humidifier to rooms where you spend a lot of time.
- Use an emollient (thick) cream to counter peeling and cracking skin.
- Always wear sunscreen.
Question: Help – what is this bluish, clear very noticeable round lump on my lower lip?
Answer: I had a young patient come into the office this week with just that: A clear, bluish-tinted bump on her lower lip. It was more than just a "fat lip." I immediately suspected a mucocele because of the bluish tint, roundness and the lower lip placement, so I asked the mom if her daughter had hit or bumped her lip in some way. Yes, she had been riding her bike and fell, hitting that portion of her lip against her teeth.
But a mucocele is not just a child's occurrence…it can happen to anyone who bumps their lower lip on anything which can be common in active adults when skiing, kayaking, climbing, mountain biking or other activities.
Luckily, a mucocele is easy to treat. Usually, just one soft, round, painless lesion (lump) appears noticeably on the lower lip, which may be anywhere from 2-10 mm in diameter. It may look clear or bluish and the bluish tint represents a bruising to the mucous duct from the trauma.The exact cause of the lump is a rupture of a minor salivary (mucous) duct, which causes a leaking of mucous into cystic spaces combined with inflammation from the trauma.
As new connective tissue is formed, scarring may form. That's why I always drain the mucocele (cyst) of its excess fluid to allow the healing process to begin before any more damage to surrounding tissue occurs. A quick, tiny incision to the cyst releases the thick fluid. If scar tissue forms we may treat it using cryotherapy (freezing) or a laser resurfacing treatment.
I also recommend rinsing the mouth thoroughly with a mixture of one tablespoon of salt to one cup of warm water four to six times per day to help it heal.
A cyst like this can occur elsewhere in your mouth. Musicians who play wind instruments may develop a mucocele opposite the upper second molar on the inside of the cheek (called the buccal mucosa) from the repeated pressure on the mucous duct there.
A mucocele can also form anywhere in the mouth when there is a true blockage of a salivary duct (which may turn painful), so always see a dermatologist or dentist immediately if you see or feel a bump in your mouth.
Question: I had an injury to my shoulder earlier this year and while the wound has mostly healed and is no longer scabby, the resulting scar is still painful, raised, hard and lumpy. It's bigger and uglier than the original wound. What can I do?
There are two types of scars that resemble what you describe and there's a lot we can do in the dermatologists office to help them look and feel better.
This type of scarring is usually after local skin trauma (e.g., laceration, tattoo, burn, vaccination or surgery) or as a result of an inflammatory skin disorder (e.g., acne, bites or abscesses).
Scars are composed of new connective tissue that replaces lost tissue in the dermis or deeper parts of the skin, as a result of injury. Their size and shape are determined by the form of the previous wound. The process of scarring is characteristic of certain inflammatory processes. A resulting scar can be thin (atrophic) or thickened, fibrous and overgrown. Some individuals and some areas of the body (e.g., anterior chest) are especially prone to scarring. Scars may be smooth or rough, pliable or firm, they can be pink or violaceous or become white. They can also be hyperpigmented (darkened). Scars are persistent and normally become less noticeable in the course of time.
Keloids & Hypertrophic Scars
At times though, and in certain anatomical locations (e.g., shoulders, sternum, mandible and arms) they can grow thick, tough and corded forming a hypertrophic scar or keloid. Under normal circumstances, wound healing takes place through the rapid and repeated reproduction of fibroblasts (the most common cells of connective tissue) at the wound site. But when fibroblast activity continues unchecked and excessive collagen (protein found in connective tissue) is deposited at the site of injury, the scar gets too big and a hypertrophic scar or keloid is formed.
A Hypertrophic Scar remains confined to the borders of the original wound and most of the time, retains its shape. It is characterized by hardness, redness and irritation compared to the surrounding skin and can take the form of a firm papule or nodule.
Conversely, a Keloid is an overgrowth of dense fibrous tissue that you'll notice extending beyond the borders of the original wound. Like a hypertrophic scar, a keloid can be hardened, raised and often darkly discolored. Keloids do not regress, appear to get better or shrink over time on their own. Instead they grow in a pseudo tumor fashion and distort the size and shape of the original lesion. If you know you have a hereditary predisposition toward keloid scarring, mention that to your dermatologist because then we will not try to surgically remove them (called excision) because keloids tend to recur.
The differences… A hypertrophic scar can occur at an any age and usually stays within the borders of the original wound, whereas a keloid commonly occurs in the third decade and enlarges beyond the area of the initial wounding with web-like extensions. Keloidal growth can also be triggered by pregnancy and compared with hypertrophic scars, a keloid can often be painful and super-sensitive.
How we treat stubborn keloids and hypertrophic scarring
We often use a 3-step process in the office to attack raised, hardened scars as soon as we notice a scar is exhibiting signs of hardening, as early as one month-post op, in the case of a scar due to surgery. The earlier you treat a keloid or hypertrophic scar, the better your results will be.
We inject 5-fluorouracil "5-FU" (used primarily as an anti-cancer drug but also used for the prevention of scars in glaucoma surgery for at least 15 years) combined with a specific low-dose corticosteroid (to reduce further inflammation and any pain) along with Pulsed Dye Laser treatments.
5-FU works to reduce skin's metabolism rate and inhibits the over-production of the fibroblasts building up on and around the wound. We combine that with Kenalog (triamcinolone), the low-dose corticosteroid, and perform injections one to three times per week, at regular intervals such as Monday, Wednesday and Friday, depending on how red, hardened and inflamed the scar is. Once the scar softens, injections can be reduced to two times per week, once a week and then every other week, monthly and finally, every six months. The Pulsed Dye Laser is used to decrease any redness, to normalize the wound surface and improve skin texture at the scar and to further blend scar into surrounding skin and we perform those treatments in intervals of four to eight months apart.
While any keloid or hypertrophic scar can be treated with this technique, you'll get the best results the younger the scar is. The more inflamed and symptomatic the scar, the better the response to treatment. Older scars that have been hardened for many years and are not inflamed, red, itchy or painful, will not respond as quickly or as thoroughly. Hypertrophic scars respond better than keloids, which frequently recur, although small isolated keloids (less than 2 cm in diameter) usually completely resolve with this technique without recurrence.
No matter what, keep all scars out of the sun for best healing, at least until the “pink” of new skin is gone because exposure to the sun only makes scars darker.
Question: I've noticed more hair fall out than usual recently, so, upon looking at my scalp and feeling around more closely, I've found several different areas with around my scalp where there is no hair. Some areas of hair loss feel smooth with no hair in them and some are sensitive and painful, as if a sore is there or has healed. HELP!
Answer: Clinically, we call that cicatricial alopecia which is the medical term for hair loss due to scarring. Since scars, sores or inflammation occur due to many different causes, you should head directly to your dermatologist so you can have your scalp examined and a diagnosis made.
The sooner you figure out the the source, the sooner you can begin treatment to cure any lesions (sores) so they don't scar and cause permanent hair loss.
Once hair loss occurs, hair does not usually grow back because the scar tissue has killed the hair follicle.
How we diagnose cicatrical alopecia, or scarring alopecia
It's a process that starts with many questions. We will ask you about any recent illnesses, injuries, allergies, your lifestyle, medications and your haircare regimen. We will closely examine your scalp using a magnifying glass and a special light to determine if the lesions have bacterial or fungal causes. We will feel your entire scalp and any lesions feeling for inflammation, sores or scales to determine the exact nature of the lesions and how they appear at different stages and locations. We will also document any hair loss that has occurred and take pictures for future reference. Often, we will take a biopsy of the sore or scarred area to determine the exact cause (if bacterial or fungal) and also to examine the health of the hair follicles to ascertain the severity of the condition. (We use a 4mm punch biopsy to provide an adequate specimen from an active lesion. Sometimes we will also take another sample from an unscarred area.)
Any type of scalp reaction or injury resulting in a lesion that causes a scar can cause death to the hair follicles and permanent hair loss and we call that scarring alopecia. Lesions that cause scars and hair loss can be caused by any of the following conditions and diseases:
UNKNOWN ORIGIN & AUTOIMMUNE
- Discoid lupus erythematosus (DLE): A chronic skin condition characterized by inflamed sores that begin as a red, inflamed patch with a scaly and/or crusty look and feel. The patches leave noticeably discolored, raised scars. Hair follicles are damaged first by the sores and then the resulting scar tissue causes permanent hair loss.
- Lichen planopilaris: Also called follicular lichen planus, this a rare inflammatory condition results in patchy progressive permanent hair loss. Initially you may notice some small or spiny red bumps around involved follicles which may or may not be itchy. This eventually forms larger reddish lesions (resembling a lichen pattern) and scar tissue which damages hair follicles and causes hair to fall out and not grow back. Additionally, Frontal Fibrosing
- Alopecia: appears to be a variant of lichen planopilaris. This occurs in mostly older women and appears in a band-like pattern in the frontal and temporal areas of the scalp. Often, a patient's eyebrows are also affected.
- Sarcoidosis: This disease, also with unknown origin, causes collections of mixed inflammatory cells (granulomas) which form lesions resulting in scarring at many different parts of the body, including the scalp.
- Seborrheic dermatitis: We believe this condition is an inflammatory reaction related to an over-abundance of a normal yeast species found on the scalp called M. globosa. It produces toxic substances that irritate the scalp causing a scaly rash.
- Ringworm (tinea capitis): On the scalp, this common fungal infection characterized by itchy red rings can result in scaling and hair loss in children, and can progress to folliculitis, too (see below).
- Folliculitis decalvans: Simple folliculitis is any bacterial infection of the hair follicles. But when hair loss is caused by redness, swelling and pustules surrounding hair follicles that appears to be spreading, it is called folliculitis decalvans. Another type of scarring alopecia, hairs shed as follicles are completely destroyed by the inflammation. A resulting scar is left behind where hair will no longer grow. Simple folliculitis (one sore) can stem from a bug bite or a scratch and flare-up or spread if infected with the bacteria Staphylococcus Aureus but recently we have found Methicillin Resistant Staphylococcus Aureus (MRSA) in some lesions and boils, so we always want to take a culture in any open lesions on the scalp, especially those that are spreading. In addition, a variant of folliculitis decalvans occurs in African Americans who present with ingrown hairs of the beard (pseudofolliculitis), acne keloidalis (a destructive folliculitis of the back of the scalp) and scarring alopecia.
- Central Centrifugal Cicatricial Alopecia (CCCA): Usually seen in African American women, this type of scarring alopecia usually develops on the crown and spreads peripherally to form a large oval of hair loss on the scalp. Originally, this type of hair loss was thought to be caused by hair straightening with a hot comb or due to the hot petrolatum used with the iron; however, was also found to take place in patients without the use of hot combs or straightening methods.
How we aggressively treat lesions that cause scars…
Once we know what may be causing the lesions, we can treat them to minimize spreading, scarring and any resulting hair loss, using any of the following treatments or combinations of treatments:
- Oral and intra-lesional steroids
- Topical corticosteroids
- Oral retinoids (isotretinoin)
- Antimalarials (hydroxychloroquine)
- Antibiotics (tetracycline, doxycycline, minocycline)
- Antifungals (itraconazole)
- Immunosuppressants (cyclosporine, mycophenolate mofetil)
- DHT blockers (dutasteride internally and minxoidil topically to -induce hair growth if follicles are alive.)
I have found that most patients experience hair loss very gradually (and cannot see the back and top of their head) and the prolonged course of the disease may cause a lack of necessary action. You need to know that the progressive destruction of hairs will result in ever-expanding areas of permanent hair loss. So, no matter what, go see a dermatologist as soon as you feel any sores, pimples, pustules, pain, itchiness, scaliness or inflammation on your scalp, whether or not they have already caused hair loss, because they need to be treated ASAP and aggressively as possible.