Five clinical pearls: Hair beware

It’s a funny thing, hair. The fact that it plays a big role in our sense of self often only becomes apparent when it changes: goes grey, becomes brittle, or begins to thin or fall out. For something that has such a big impact on patients’ well-being, there are surprisingly few Canadian physicians who specialize in hair loss. Physicians should familiarize themselves with common conditions that cause hair loss and feel comfortable prescribing treatments, according to dermatologists Dr. Jeff Donovan and Dr. Thusanth Thuraisingam. Dr. Donovan is the medical director of Donovan Hair Clinic in Whistler, B.C., and clinical instructor at the University of British Columbia. Dr. Thuraisingam is an assistant professor of medicine at the University of Ottawa and McGill University and he works at a private clinic in Ottawa and in a hair loss clinic at the Jewish General Hospital in Montreal. Read: QUIZ: Have you heard the latest on hearing loss? 1. Show respect and concern The first step is to listen to patients when they come in with reports of hair loss. “I think it is really important to trust patients that if they feel they are losing hair, believe them. It sounds silly, but one of the number one complaints of patients is they really feel dismissed,” Dr. Donovan said. Complacency could lead to a delay in diagnosis and treatment or lead to inappropriate treatment. It can also impact a patient’s mental health, since hair loss affects self-esteem and selfidentity. “It is important to take these concerns seriously. Not only does hair loss have an effect cosmetically, but it has a very high psychological impact on these patients,” Dr. Thuraisingam said. How physicians react to a patient’s complaint about hair loss, especially early hair loss, is important. “The approach that the family physician takes goes a long way in helping patients come to terms with their hair loss,” Dr. Donovan said. 2. Understand the three most common conditions Drs. Donovan and Thuraisingam said there are three main conditions physicians will see in their offices. While there are many dermatological conditions that affect hair, Dr. Donovan said if a physician knows how to diagnose and treat the most common three, “you’ll be able to help 98% of patients that come through the door.” Read: Is melanoma over-diagnosed in white patients? Diagnosing before treating is essential because each condition is treated differently, Dr. Donovan said. One common complaint physicians may encounter is telogen effluvium (TE), or hair shedding. There are many causes of TE: iron deficiency, thyroid deficiency, other nutritional deficiencies, infection, medications or a major shock or stress such as losing a loved one, or blood loss during surgery. Order a blood test to help determine the underlying cause. Dr. Donovan said that every patient with concerns about shedding “should leave the office with a blood test requisition so some of these common things are not missed,” Dr. Donovan said. A good patient history is essential too, including questions about recent illness. Dr. Thuraisingam said he is seeing a lot of patients who are suffering from TE after contracting COVID. Another common condition is androgenetic alopecia, or age-related hereditary hair loss. Dr. Thuraisingam advises physicians to ask: “How long have you been losing hair?” to get clues about a possible trigger and determine if it is new onset or not. For example, if patients had COVID-19 followed by shedding, it could be TE triggered by infection; whereas if hair loss has been going on for years, it is more likely to be androgenetic alopecia. He said physicians should perform a scalp exam and check for miniaturization of hairs to see if patients are beginning to enter androgenetic alopecia. The third common complaint is alopecia areata, an autoimmune disorder that affects about 2% of patients. It often appears as coin-shaped bald patches on the scalp. The individual hairs around are thick but then thin closer to the scalp, known as an exclamation mark morphology. Some cases affect other parts of the body, such as eyelashes, eyebrows or beard hair, Dr. Thuraisingam said. Read: Many self-reported antibiotic allergies are misdiagnosed School-aged children may also present with tinea capitis, a fungal infection of the scalp. It often appears with dry scaling of the scalp and a grey patch, according to a handout from McGill University. A fungal culture is needed to confirm diagnosis. When taking a history, Dr. Donovan advises physicians to ask about the five S’s: the site of the hair loss, the speed of the hair loss, the symptoms, if they are taking supplements or medications, and how much the patient is shedding. Dr. Donovan said it is especially important to ask about the symptoms in detail to understand their severity. 3. Learn how to prescribe and deliver common treatments Dr. Donovan advises that physicians get familiar with prescribing minoxidil because it can help a number of hair conditions. “We often use it off label for a number of hair conditions, including alopecia areata,” he said. Patients should be aware that it takes up to six months for minoxidil to take effect and that there may be increased shedding for the first month of treatment. Dr. Thuraisingam tells his patient that the minoxidil “is getting rid of all the bad hairs to make room for the good hairs.” This way patients do not stop the medication. Physicians need to counsel patients about the possible side-effects of minoxidil, such as hair on the face, headaches or dizziness. “These are fortunately not very common,” Dr. Donovan said. Patients who plan to become pregnant should avoid oral or topical minoxidil. First-line treatment for androgenetic alopecia is topical minoxidil and, in men, oral finasteride. A large randomized clinical trial found that finasteride was not effective in women with androgenetic alopecia. Patients expecting to become pregnant should not take finasteride or touch broken pills. Physicians may want to consider starting patients on lower doses. While 1 mg is the recommended dose for finasteride, physicians may want to consider starting patients on a lower dose, such as 0.5 mg, Dr. Donovan said in a webinar. First-line therapy for alopecia areata involves topical steroids, intralesion steroid treatments or minoxidil. For the injections, triamcinolone acetonide can be injected at concentrations of 2.5 mg/mL to 10 mg/mL. Treatments are repeated every four to six weeks and patients may wish to apply a numbing cream beforehand, according to a clinical review of alopecia areata treatments published in Canadian Family Physician. Although some treatments are more successful than others, all include the potential of having a relapse once treatment is stopped. Dr. Donovan said one of his goals for the next few years is to train family physicians to feel comfortable giving steroid injections so patients don’t need to wait for a dermatology appointment. “It is not a difficult technique,” he said. Within a month it can get the hair growing back and “it can dramatically change the way patients feel about themselves. Physicians can monitor treatment success using simple photos. Equipment to measure hair density and other factors don’t always capture the benefit of a treatment from a patient’s point of view. “If your photos don’t show an improvement, there’s probably not an improvement,” Dr. Donovan explained. Patients are often drawn to new treatments to restore hair, but physicians should discuss with patients if the treatments are safe, affordable, feasible and effective, Dr. Donovan said. 4. Watch for red flags Physicians should be on the watch for worrisome symptoms that merit a referral to a dermatologist. The main red flags are significant scalp itching, burning, bruising, tenderness or pain, Dr. Donovan said. Massive shedding is another red flag. This is shedding where hair is found around the house, not just on their hairbrush. Some patients have itching due to hairstyling treatments, but tremendous itching or burning, “where people come in with an ice pack on their scalp,” is when patients often need a scalp biopsy, Dr. Donovan said. Scalp biopsies are needed to rule in or rule out conditions such as scarring alopecia, Dr. Thuraisingam said. Physicians who practice in remote areas, or where access to a dermatology consult is limited, might consider learning how to perform a scalp biopsy. “It is not a difficult technique to do,” Dr. Donovan said. 5. Recognize that different people have different patterns of hair loss Physicians should learn to recognize hair loss patterns in different populations. For example, androgenetic alopecia may look different in women than in men. In women, it often begins in the middle of the scalp. “For genetic hair loss, it is easy to recognize in men because you’re used to seeing it in the general population,” Dr. Donovan said. “One of the reasons that we don’t have a lot of good examples of female balding in our society is that women go to great lengths to hide it,” he added. Read: QUIZ: Test your knowledge of alopecia areata Hairstyling practices could cause hair loss, such as traction alopecia from pulling forces on the hair. Styles such as braids, twists, weaves or cornrows may cause traction alopecia. Physicians should also consider haircare practices of different populations before recommending treatment. For example, Black hair needs less washing, and a shampoo treatment may not be appropriate for these patients. The American Academy of Dermatology has resources available for patients with Black hair.

Five clinical pearls: Hair beware

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