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.
Question: I have been using Rogaine for 6 months and I have recently noticed several deep wrinkles forming under my eyes, specifically the side I sleep on. I know there are some testimonies on the internet and on Wikipedia about minoxidil causing collagen depletion so I’m wondering if this is true or just an internet rumor?
Answer: So, I dug down to the research for your answer. Minoxidil has been shown in cell culture (outside of the body, also called, in vitro) studies to have range of inhibitory effects on skin fibroblasts (a type of cell that produces collagen). It has also been reported that minoxidil hinders collagen synthesis and inhibits the effects of specific growth factors, substances that are capable of stimulating cellular growth, in cultured hair dermal papilla of rats (yes, rats, not humans!) But applying these results obtained in cell culture studies or rats to the use of minoxidil in humans is uncertain.
There are no human studies demonstrating that minoxidil causes collagen depletion or wrinkles as a side effect (and there are many studies of minoxidil effects on humans). Even though there are anecdotal reports online stating this, minoxidil has been used for over 25 years and there are no real complaints or published reports in clinical practice (with patients).
You are smart to ask a professional when faced with internet rumors, especially when it comes health issues, because side effects of medications and even over-the-counter products are largely personal. Also, facial wrinkles are known to form in response to repetitive muscle movements such as facial expressions and patterns over time, such as the side you sleep on. A good idea would be to schedule an appointment with a dermatological practitioner to review your age, medical history, lifestyle (such as sun exposure) and skin and hair loss condition as well as your usage of minoxidil to see if any alterations (a weaker percentage or foam instead of liquid) or additions to your treatment plan need to made.
Question: My hair has been thinning considerably for several years now, and my hairdresser recently found some strange spots on my scalp. What are they?
Answer: Watch out for basal cell carcinoma (BCC), the most common, treatable form of skin cancer, on your scalp, especially if you are balding or your hair is noticeably thinning.
Think about it: The top of your head, forehead (and also your nose) is exposed to the sun's harmful rays more than any other part of the body. Once you lose the cover of your thicker hair, your scalp is highly vulnerable.
The tricky thing about BCCs is that those who have had one BCC are at an increased risk for developing more tumors later in the same area or elsewhere on the body and you may also be at risk for other types of skin cancer. And the recurrence of scalp BCCs is even higher within the first two years after surgery because of the constant sun exposure.
No matter where you (or someone else) notices any type of strange lesion (there are 5 warning signs of a BCC), check in with a dermatologic practitioner regularly so your entire skin surface can be examined, especially in places like the top of your head that you cannot easily see yourself...and wear a hat!
Has anyone else ever found strange spots on you? What did they turn out to be?
Question: I recently went out for a day on a boat with friends and even though I used SPF 50 sunscreen all day, I still got burned. What did I do wrong? Answer: There's a lot of news in sunscreen ingredients and thinking these days so lets update how you buy, use and apply sunscreen so you don't get burned again (or needlessly exposed to the rays that cause aging, wrinkles and skin cancer): Mistake: Not applying enough sunscreen The current guideline is to apply a shot glass-worth, one full ounce, of sunscreen to your body when spending the day in the dun. And, the most important part, you should reapply this amount of sunscreen every two hours regardless of the SPF noted on the bottle, so you could go through half of an eight-ounce bottle in one day in the sun! Mistake: Believing that sunscreens are "water-proof" The FDA, in its new labeling guidelines, has declared that the use of the term "water-proof" misleading and banned brands from using it. The word will need to be removed from labels by December 2012. Now, the guideline is that sunscreen is "water-resistant" and only for a tested time limit of 40 or 80 minutes when spending time in the water, after which the product will need to be re-applied. Mistake: Applying the sunscreen when you get there The best way to allow sunscreen to do it's work is to apply it a full 30 minutes before going into the sun, so it has time to bond to skin, instead of getting immediately rubbed off by a towel you lay on or washed off by jumping directly into the water. Mistake: Not protecting your skin from UVA rays It used to be that sunscreens only protected against UVB (the burning rays) but now a slew of new chemicals can absorb UVA rays (the ones that penetrate deeper to cause aging, wrinkles and skin cancer). Choose a sunscreen with the new designation "broad spectrum" because these have been tested by the FDA to provide protection against both UVB and UVA rays. Consumer Reports recently tested and rated sunscreens according to the new FDA labeling requirements and found these three top-rated choices:
- All Terrain AquaSport SPF 30 (for athletes and outdoor workers)
- Coppertone Sport High Performance Ultra Sweatproof SPF 30 (for athletes and outdoor workers)
- No-Ad with Aloe and Vitamin E SPF 45 (for the budget minded, every-day body user)
Mistake: Thinking the higher the SPF, the better the protection… According to Consumer Report's recent ratings, top-rated sunscreens are between SPF 30-45. The new thinking is that higher SPF does not really not afford more protection. Here's why: an SPF 15 filters out approximately 93% of all incoming UVB rays, SPF 30 filters out approximately 97% and SPF 50 filters out approximately 98%. No sunscreen can block out 100% (which is why the FDA has also banned the use of the word "sunblock" on labels) of all UV rays so after an SPF 30, you can see the difference in filtering is negligible. The old thinking: If your skin starts reddening in 20 minutes when exposed unprotected to sunlight, using an SPF 15 should prevent your skin from turning red for 15 times longer (approximately 5 hours). The new thinking: No sunscreen protection lasts more than 2 hours. Choose an SPF 30-45 and reapply one ounce every two hours for real protection. Mistake: Ignoring your scalp Most people protect their eyes with sunglasses and slather on the sunscreen but completely ignore their scalp. This is very dangerous, especially if you have any hair loss or thinning issues. Apply sunscreen to any areas experiencing hair loss (a widening part-line, bald spot or receding hair line) and definitely wear a hat! Mistake: Believing that the sun does not affect your face every day I advise everybody to apply a basic "broad-spectrum" sunscreen every day to face, underneath makeup or in makeup for women, especially to protect against photo-aging and skin cancer that you cannot see happening. One that I personally recommend, that was also recommended by the Consumer Reports Ratings, is La Roche-Posey Anthelios 40 with Mexoryl SX SPF 40. Have you made any of the mistakes on this list recently? Tell us your worst sunburn story in the comments!
Wow...today is the inaugural blog...I don’t really know what to say. I guess, Welcome! Welcome to my blog! I will certainly try to give you my honest opinion, feedback and of course, answers to your skin care concerns and questions. Anything having to do with skin, hair and nails are up for grabs here...so ask away! Additionally, I will try and keep you up to date with the latest news and media reports on dermatology. I hope you enjoy it all! BTW...today is National Croissant Day! In addition to being a skin care guru, I’m also a foodie. At our office, we love to celebrate anything having to do with food. No food holiday goes unnoticed!
Answer: Well, that sounds like follicular lichen planus, also known as lichen planopilaris, attacking your hair follicles. But you need to head straight to a dermatologist for an accurate diagnosis, which could be many other things. We also call this condition you describe, scarring alopecia because unlike the smooth bald patches of alopecia areata or pattern baldness, these bald patches have raised and discolored scar tissue in them initially caused by the immune system attack on your hair follicles. We do know that lichen planus is not contagious. It can also attack the mucous membranes in the genitals or mouth (called oral or mucosal lichen planus), finger or toe nails, or anywhere on the skin especially hairy areas like eyebrows (called cutaneous lichen planus). Many times attacks are on both the head and body at the same time or several locations at once. The exact reason for this attack is unknown, but reddish or brownish raised outbreaks resembling the "lichen" shape (flat round-ish moss common on tree trunks) can be triggered by:
- Allergies to any substance or food
- A viral infection such as hepatitis
- Specific vaccines and many medications
It is also clear that lichen planus attacks 4 times more females than males and most commonly appears in middle age, between the ages of 30 and 70. How lichen planus appears on the scalp Initially you may notice some small or spiny red bumps around involved follicles which may or may not be itchy. This eventually forms scar tissue which damages hair follicles and causes hair to fall out and not grow back. You may also notice unaffected tufts of normal- hair within the scarred areas, which still may appear raised and/or discolored. Gradually hair is lost and replaced with smooth skin, with loss of follicular markings because at this point, hair loss is permanent (we call this Pseudopelade of Brocq if a cause such as lichen planus or alopecia areata is not the cause and the cause is unknown.) How we treat lichen planus If outbreaks are linked to an allergy or drug, identifying and avoiding that substance can help resolve the problem and avoid additional outbreaks. But many times oral lichen planus is a chronic auto-immune condition in which flare-ups continue to come and go over a long period of time, with lesions lasting for days, weeks or even months. Some cases may resolve in 2 years, although approximately 1 in 5 people will have a second outbreak. Since there is no known cure for lichen planus, treatment focuses on alleviating discomfort and promoting the healing of lesions before scar tissue has a chance to form and destroy hair follicles. We like to prescribe steroid medication initially to see if we can halt the reaction, which does help immediately resolve inflamed, scarring tissue. But steroid treatment is a short-term solution only, not to be continued for the long-term because oral and injected steroids increase the risk for osteoporosis, diabetes, high blood pressure and high cholesterol. The bad news: Once steroid treatment is halted, lesions may return. So, because there is no known treatment protocol that works for everybody, we alternate and try all the treatments below to see if we can mitigate the scarring and preserve hair your follicles:
- Antihistamines: Internal medication to help alleviate itching so you don't scratch and cause scars
- Topical corticosteroid: A topical medication in cream or ointment form used to reduce swelling, itching and redness.
- Corticosteroid: Internal medication (such as prednisone) or shots to alleviate a serious attack of swelling, pain or many lesions at one time.
- PUVA light therapy: A type of light treatment used for eczema and psoriasis conditions that may help clear the skin of scarring lesions.
- Retinoic acid: Topical or internal medication to help clear lesions.
- Tacrolimus ointment or pimecrolimus cream: A topical medication that is not a steroid (so it can be used for longer duration) used for severe eczema cases that may help clear lesions.
The most important thing is not to give up and keep alternating and trying the different medications to stop the scarring and the hair loss and save your hair. -Jodi
Question: Can I be causing my own hair loss problem? I have a habit of tugging and twisting on individual hairs every day and even pulling some out and I've noticed some spots where my hair seems to be thinning. What should I do?
This is actually a hair loss disease, but it is psychological in nature rather than physical. The disease is pronounced: trik- oh-till-oh-may-nee-ah. People also call it ‘Trich’ or TTM for short. I can tell if a patient is suffering from this disease rather than something physical such as pattern baldness or auto-immune such as alopecia areata because if I feel stubble in the bald spots, it tells me that hair is growing back normally, although it might have been removed. Bald patches of alopecia areata feel smooth and so do pattern baldness spots because hair is not growing back normally and the growth cycle is disrupted for a physical reason. I suggest a visit to a dermatologist to get an accurate diagnosis. It's a compulsion to pull your hair out…literally. If you feel a strong compulsion to pull out hairs, as you said, you may very well be causing your hair loss. In some patients, the compulsion to pull at hairs is so strong, they feel they can't stop, but others can learn to control it through awareness or will power. Trich does not affect everyone who suffers from it the same way or to the same degree. Some pull hair deliberately and some pull hair out unconsciously and some people pull only scalp hair while others may pull facial hair such as eyelashes and eyebrows or body hair on legs and arms. Some patients pull any and all hair. Some Trich patients just pick up hairs and roll them between fingers. Hair loss can become permanent The longer the hair pulling and twisting habit goes on, the more severe the hair loss may be. In extreme cases, hair loss can become permanent because hair follicles can become damaged to the point of death. In milder cases, hair keeps re-growing, although eyelashes and eyebrows take a notoriously long time to grow back. A dermatologist can confirm the health of hair follicles and a prognosis for hair re-growth.
- What's the prognosis and treatment for Trich? Researchers are unsure how the compulsion to pull out hair starts.
- Past statistics on the disease show that Trich can strike happy, well-adjusted people as often as emotionally disturbed or depressed people. these same statistics show that Trich behavior usually starts in early adolescence and that 90 percent of sufferers are women.
- I think that the statistics may be a little more skewed towards women because Trich is a less satisfying compulsion and less noticeable in men with short hair and male pattern baldness and maybe less men seek medical attention for such a habit. Current research on Trich shows that similar brain chemical imbalances that cause depression or bulimia can cause Trich behavior and treatment with anti-depressant medications may help curb the compulsion to pull at hairs and allow hair to grow back. A Psychologist can help you determine your best course of action once a diagnosis is made.