Traction Alopecia: Yes…Your weave is pulled too tight!

As a dermatologist with a special interest in hair conditions, it consumes me how many Black women I see with permanent hair loss from our own styling practices!!   One of the most common forms of hair loss that plagues our population is called traction alopecia.

Traction alopecia can be a permanent, scarring form of hair loss that typically occurs around the hairline and crown.  You do not need to be a dermatologist to diagnose this.  We have all seen it on girlfriends, family members, and unfortunately, many prominent celebrities.

It is thought to be caused by hairstyling practices that pull hair tightly away from the scalp, such as braids, weaves, and locks.  Similar to trauma that happens elsewhere on the skin; the body senses the insult, sends inflammatory cells to the site of trauma, and tries to heal it with a scar.  This is exactly what occurs with traction alopecia.  The tight pulling leads to inflammation around the hair follicle and if the inflammation remains untreated, fibrosis or scar tissue forms and the hair is permanently lost.

This condition is most common in Black females but can be seen in anyone with traumatizing hairstyling practices.  For example, in India, many Sikh males that wear their hair in tight buns under their turbans can also suffer from this problem.

Luckily, there are ways to prevent traction alopecia and also ways to treat it. 

Most importantly, do not let allow the hair to be pulled too tight!!!! Yes, we all love to see our friends flaunt a great weave down their backs, so I will never be one to restrict wearing these types of hairstyles.  HOWEVER, I cannot stress the importance of being able to recognize signs of when the hair is being pulled too tight.  This includes any pain, tenderness, burning or itching.  These are signs of inflammation!!!

Secondly, see the previous paragraph…It’s that important.  Many of my patients will tell me that they did not notice the hair loss until months to years after wearing braids or a weave.  So it is very important to pick up on signs of inflammation as soon as possible, so that you have a possibility of being treated and holding onto the hair that you have.

As far as treatment options are concerned, the most important first step is seeing a dermatologist as soon as you notice any problem.  The longer you wait for an evaluation, the more time for scar to form and for the hair loss to become permanent.

When you are seen, likely a biopsy will be performed to determine if there is any inflammation left to treat or if scar is already present.  If there is inflammation present, treatment may include steroid injections to the scalp, topical steroids, or oral antibiotics.  Even if there is scar present and the hair loss is felt to be permanent, hair transplantation is always an option to help restore the hairline.

In summary, Black women love to experiment with myriad fabulous hair styles.  Unfortunately, many of these styling practices can lead to permanent hair loss and deflated senses of self.  Therefore, it is of the utmost importance to recognize when the hair is being traumatized to prevent traction alopecia from occurring.

Balding and Heart Disease: Does a Disappearing Hairline Reflect Heart Disease Risk?

Beauty may come from within, but a recent study out of Copenhagen, Denmark suggests that how you look externally could actually be a reflection of internal health problems.  The researchers found that visibly apparent signs of aging, regardless of actual chronologic aging, increased the participants’ risk of heart disease.

More specifically, researchers followed over 10,000, 40 and older participants from the Copenhagen Heart Study for over 35 years.  Individuals were evaluated for gray hair, balding, wrinkles, earlobe creases, and xanthelasma, or fatty growths on the eyelids.  Demonstrating balding at the crown, hairline recession at the temples, yellowish fatty growths on the eyelid, or an earlobe crease increased the risk for heart disease by 39% and increased the risk for heart attack by 57%.  The risk was independent of other more commonly cited risks for heart disease such as high cholesterol.

These findings mimic results from the Framingham Heart Study and the First National Health and Nutrition Study which also found an association between balding and heart disease.  Even in a study of over 20,000 seemingly healthier over 40 year old physicians, balding was associated with heart disease. 

All of the abovementioned studies were large cohorts that were followed over decades looking for any possible risks for heart disease.  So there are many potential confounding factors that could be playing a role in the results found.  For this reason a group of researchers from Johns Hopkins conducted a study of men with known histories of heart attacks and evaluated them for the presence of balding.  Interestingly, they could not find a significant association between balding and heart disease.

The other interesting consideration for the Copenhagen Study is the fact that all the patients are from a generally homogenous population in Denmark.  We all know the adage, “Black don’t crack.”  Thus, it would be intriguing to repeat the study in patients of African descent, because although we do not seem to show signs of aging as readily as our lighter skinned counterparts, we certainly do not enjoy lower rates of heart disease.  So, it would be interesting to see if the same attributes are found to increase heart disease risk amongst patients of African descent.In summary, although, the association between balding and heart disease is indeed fascinating, the main question is what we do as physicians with these possible associations.  Most patients over 40 should be seen regularly by their primary care physician and evaluated for cardiac risk factors, anyhow.  Potentially balding, earlobe creases, and xanthelasma could be used in addition to other risk factors to calculate overall risk of heart disease. 

However, as a dermatologist that specializes in hair loss, I am not so sure that I will be re- directing each one of my balding patients to their primary care physicians for a cardiac evaluation, based on the presence of balding alone.

Advances in the Cure for Balding: Platelet Rich Plasma

Most think of platelets as the component of blood that coagulates wounds.  However, the function of platelets is far more than just forming clots.  When activated, they secrete cytokines and growth factors, acting as an integral part of wound healing.  Because of platelet's important function, concentrated preparations of plasma have been used in various fields as an attractive therapy for many conditions.

Platelet Rich Plasma or PRP is a preparation taken from a patient’s own blood, in which the platelets are enriched in concentrated plasma.  The therapy was originally used for injections into damaged joints in the orthopedic field.  Now it is being used by cosmetic dermatologists and plastic surgeons for overall facial rejuvenation.

Recently, hair specialists have been trialing the therapy in patients who are balding.  Animal studies show that PRP increases dermal papilla cells, which are decreased in individuals with balding.  Potent hair growth stimulators, Fibroblast growth factor-7 and Beta-catenin, are also increased by PRP treatment.  In addition, mice treated with PRP have quicker transitions into the growing phase of hair than untreated mice.  

When used as an adjunct to hair transplantation, hair follicles pre-treated with PRP can demonstrate better density and graft survival.  The theory is that the platelets are secreting growth factors, leading to stem cell activation from the surrounding hair follicles.  

Because of the improved hair growth seen with hair transplantation and the above-mentioned animal studies, hair specialists have started using PRP as primary treatment for male and female pattern balding.  PRP treatment is particularly attractive for women who have not seen great results with minoxidil and young men who may not be suitable candidates for finasteride or hair transplantation.  

Although, PRP seems to be a promising advancement in the field of hair loss, there have not been many published, large human clinical trials for its use as a treatment in balding.  Therefore, many hair specialists have not adopted its use widely because the amount of benefit is unclear and most importantly, there is no consensus on how often the injections should be given or at what concentration.  

Thus, Platelet Rich Plasma or PRP injections are an enticing new treatment for balding.  However, widespread implementation of its use may not be seen until larger studies can demonstrate its efficacy and ideal protocol for administration.  In the future, PRP treatments may act as an adjunct to more well-studied treatments, such as minoxidil, finasteride, and hair transplantation, as opposed to primary therapy.

What Should a Doctor Look Like?

Ok, I think we all know where I’m going with this one.  As everyone can see from my profile pics; I am a young, female doctor…of color.  Brown to be exact.  Throughout my training, myself and other female doctors of color have exchanged stories of patients and other staff not realizing we were a physician or making inappropriate remarks about it.

Recently, some of my colleagues candidly shared similar, typical stories of what they continue to experience, which is what inspired me to discuss this topic on my blog.  Try to control the dismissive head shakes as you read:

“The other day a vendor came into the lab, and walked right past me, and went into supervisors' office. My hematology supervisor pointed out the woman in the lab coat and scrub standing patiently behind him and said, "Have you met Dr. ---? She's our new department head."

“Yesterday I walked into a patients room and said "Hello I am doctor ---", He then asked "are you a doctor?", I responded "I am DOCTOR ---, How can I help you?"

“I love the initial look when you walk in the room and how much they LOVE LOVE LOVE you when you walk out:)!”

When I took a job in industry, my boss started to notice that the immediate response to the intro was "is this your new admin?"...when I was an intern @ Grady, a drunk white dude demanded to talk to the charge nurse "someone who knows more than YOU!!!"

“ Would go to offices with one of our device reps to do meet and greets, me in a suit, they're in their scrubs...and the docs walk right by me to shake the rep's hands. Then the rep has to say..."Have you met Dr. ---?"

“Last yr I had a white male drug rep ask if I was a PA, I nearly lost it he never approached me again! This would never happen to a white MD, then when started at new job had black and Hispanic clerks and maintenance worker ask if I was a new clerk, and I have an MD on my badge.”

“When I accompany other physicians to meetings I am consistently asked, are your Dr. So and So's ARNP? Despite the fact my name is all over my scrub top. When I enter a patients room in the SNF some pts assume I'm the CNA and ask me to change their brief, give them the bed pan, fill their water cup even after I have introduced myself "Hi I'm Dr.---, I will be your physician while you are here"!

Personally, I have never had any preconceived notions of how a doctor should look, act, or speak.  My mother was one of the first African-American females to graduate from her medical school.  And since I was raised with her influence and presence, it was similar to how my kids view presidents.  They have only known Barack Obama as president.  Therefore, they have no preconceived notions of what a commander-in-chief should look like. 

Thus, the clearly racially charged experiences that I have gone through have been very hurtful because I naively never expected it.  For example, when I was in training at the Mayo Clinic, myself and the two other young black dermatologists in our program, literally had at least one patient daily express surprise when we walked in the room and then ask where we went to medical school.  Thankfully, two of us could respond---“Harvard.”  That usually abruptly ended the line of questioning.  Except for the one time, when I said “Harvard” and the patient responded, “Well my niece is having trouble getting into medical school and she’s really smart…I bet being Black helped your application.”  I guess black people can only get into medical schools like Harvard through Affirmative Action.  One of the other docs actually had a patient not believe he was a doctor, call the 'higher-ups', and demand to see his diploma.

One of the more hurtful incidents was when, the nurse (wearing maroon scrubs) roomed the patient, I walked into the room (wearing the mandatory Mayo business attire), introduced myself as “DOCTOR Singh” and then spent the next 30 minutes, taking a detailed history, examining the patient, PERFORMING A BIOPSY!!, and discussing my impression.  When I left the room, the man turned to the nurse and asked, “When is the doctor coming in?”  No words…

I have no idea what patients are expecting to see when they book an appointment with a “Dr. Meena Singh”.  However, I can safely assume that physicians who look anything like LOST characters “Jack” or his dad “Christian Shephard” cannot relate to any of the above experiences.

Thankfully, shows like Grey’s Anatomy are casting more female physician roles with black actors.  And of course, there is now Disney's Doc McStuffins which highlights a little black girl playing doctor and her actual black doctor mom.  Hopefully, with more Hollywood influence and as the number of young, black female physicians continues to increase, the stereotypical portrait of a patriarchal, white male physician fades.  After all, the Surgeon General of these United States is Dr. Regina Benjamin.  I sincerely hope that she is no longer being confused with anything but the Surgeon General.  

Is Vin Diesel the new McDreamy?

Who doesn’t love a Michael Jordan, Lamar Odom, or Vin Diesel?  Allegedly, the world perceives their look as a sign of masculinity.  The Wall Street Journal recently published a report (http://online.wsj.com/article/SB10000872396390443862604578032541863652264.html) detailing a study published online in the Social Psychological and Personality Science Journal by Dr. Albert Mann from the Wharton School.  According to the article, men who sport the “Mr. Clean” are perceived as more dominant and powerful.  This may aid them in the board room, negotiations, business deals, etc. 

A set of three experiments were performed, in order to gauge perceptions of bald individuals.  In the first experiment, men with shaved heads were perceived as more dominant than men with ‘McDreamy’-inspired hair.  For the second experiment, men’s hair was digitally removed and the bald versions of themselves were considered taller, stronger, and once again more dominant.  In the third experiment, they found that men who are actually balding or thinning might improve their status by shaving their heads.

I only had access to the abstract, so I would have liked to critically review this article to see how they arrived at their conclusions.  I could imagine that a completely bald individual may appear to be more domineering, more mature, more experienced and maybe even a more difficult negotiator.  However, multiple sociological studies have shown that individuals with a full head of hair are considered more attractive, more youthful, and with more vigor.  This study did agree with the finding that men who are balding or thinning were perceived as less dominating, powerful and attractive.

Check out the response to the WSJ article by Martin Peers, who thinks the study is nonsensical: http://blogs.wsj.com/atwork/2012/10/03/is-a-shaved-head-more-powerful-balderdash/

I have to say, I somewhat agree.  When I was growing up, the ‘Mr. Clean’ was considered sexy, especially within the African American culture.  Men with shorn heads, like R. Kelly, Michael Jordan, Boris Kodjoe (the list goes on forever) were basically sex symbols.  Now that I’ve hit the 30 and up crowd, I’ve noticed that men only really shave their heads because they have to.  Because as this study may have proven, a nice, shiny BALD head may come off as sexier and more masculine than a BALDING head.  Two words: Andre Agassi.  He went from balding mullet to a smooth dome.

In summary, if you are balding and don’t feel like treating it with Rogaine, Propecia, hair laser, or hair transplant---> it may be time to pull out the razor.

Razor Bumps: Common, Bothersome, and sometimes Difficult to Treat

Pseudofolliculitis barbae, more commonly referred to as “razor bumps”, is an extremely common condition affecting mostly the beard, neck, bikini area, posterior scalp and lower legs .  Studies have estimated that 45-83% of African American men are affected by this problem.  However, it can be seen in anyone with curlier hair that is cut short on the face, neck, lower leg and bikini region.

Pseudofolliculitis barbae is an extremely aggravating problem, not just symptomatically, but also cosmetically, leaving blemishes in the skin.

It can be caused by various different depilatory mechanisms, including shaving, tweezing, plucking, waxing, and electrolysis.  The short hairs curl back into the skin and act as a foreign body.  This leads to chronic inflammation and infection.   Shaving against the grain and pulling the skin tight while shaving can exacerbate the condition.

So, what can you do to prevent this problem?

Laser hair removal is the gold standard for treating this problem.  Permanently destroying the hair follicles resolves the problem.  Laser hair removal works in all skin types; although, we recommend the long-pulsed neodymium:Yag laser for darker skin types. It takes 5-8 treatments to permanently reduce the majority of hair in a treated area. The substantial reduction in hair greatly diminishes the pain associated with the condition and the discoloration will improve over months.

Lasers do have limitations. They work only on dark hair. The laser light is absorbed by the pigment in hair follicles.  If there is no pigment, such as gray or blond hair, the laser will not work and should not  be done. In addition, the procedure is not covered by insurance companies. Lasers are safe, but it is vital that the procedure is performed only by experienced operators.

If you cannot have lasers, what are your alternatives?

Other methods of hair removal or depilation, include chemical depilatory agents.  More commonly known products include, Nair, Neet, and Magic Suave.  They contain barium sulfide and calcium thioglycolate, which dissolve the hair follicles.  Only use these when the skin is clear.  Leave these on for less time than recommended as they can cause chemical burns.

In general, if you can stop trying to get rid of the hair, even for up to 6 months; this can lead to a cure, or at the very least, significant improvement.  Growing the beard out, typically leads to resolution.  However, for many individuals this is not a viable option. 

Therefore, the following recommendations can be trialed:

Try to avoid shaving for several weeks to one month or until all lesions have resolved, while applying a mild topical antibiotic to calm the lesions.  If it is not possible to avoid shaving for that period of time, try shaving every other day, instead of daily.

We recommend trimming the beard area with clippers or scissors to prevent a shave closer than 1 mm of hair.  However, if a blade must be used, I would suggest applying a warm compress to the face for about 5 minutes to soften the hairs.  Then, apply a shaving gel that is lubricating.  Do not stretch the skin, and shave with the grain of the hair.  Only use one stroke over each area.

There are various ways to treat the bumps.  Typically we will give a mild topical steroid to use immediately after shaving.  Active lesions can be treated with topical glycolic acid lotion, antibiotics (often combined with benzoyl peroxide), and retinoids to reduce the bumps.  In moderate to severe cases, oral antibiotics may be warranted.

In summary, pseudofolliculitis barbae is a common, painful, and often disfiguring condition. Currently we have several excellent treatment options. We recommend you discuss these options with your dermatologist to see which one will work best for you.

Biolux Hair loss Clinical Trial

Do you currently have ongoing hair loss or hair thinning?  Many patients come to us and at times can be frustrated with the multiple medical treatments available, such as minoxidil and finasteride.   Although these treatments can retard the rate of hair loss or thinning, some patients may not necessarily notice increased hair density and regrowth.  Other options include cosmetic cover ups; however, these can be frustrating to use as well. 

Our patients often ask, “What else can we do?”  “Are there any other options?”  For those patients that choose not to undergo surgical treatment, alternative treatments may be limited.  However, if you have attempted to treat your hair loss and have not achieved the desired results, there are now safe alternatives available.   

We are currently enrolling patients in a study to test the safety and efficacy of a new device used to stimulate hair growth.  It utilizes low-level-laser light therapy through an LED light source to stimulate hair growth.  It is called the Biolux laser hair brush.   As we previously blogged about (on dravram.com), our office performed a similar study on the HairMax LaserComb, which also used low-level-light therapy to stimulate hair growth.  It was recently FDA approved and found to be safe for use.  The Biolux laser hair brush works very similarly to the HairMax LaserComb; however, utilizes different wavelengths for possible greater efficacy. 

If you are interested in finding out more information and possibly enrolling in this study, you can click here and fill out the survey.

Information is also posted on our office website: www.dravram.com.

Advances in the Cure for Baldness: the Vitamin D Receptor

Recently an article in the Wall Street Journal (http://online.wsj.com/article/SB10000872396390443921504577643442954317340.html?mod=googlenews_wsj) was published describing research performed by several different teams of scientists, regarding the role of Vitamin D and its receptor in hair loss.

My mentor, Dr.  Marc Avram, recently commented on the subject on the Today Show: http://todamy.msnbc.msn.com/id/26184891/vp/49001161#49001161

So what are the facts? 

Can taking vitamin D supplements cure balding?

The answer is probably no.  The research performed on the subject does not support that Vitamin D supplementation alone will lead to hair growth.  The receptor that vitamin D acts on is likely more important to regulating hair cycling and growth than vitamin D itself. 

The vitamin D receptor can be thought of as the lock and vitamin D can be thought of as a key that fits into the lock.  Research has shown that there are many different molecules besides vitamin D that can act as keys to the vitamin D receptor’s lock.  Some of these molecules, such as MED1 and LEF-1, were recently described by researchers at Harvard Medical School and the University of California San Francisco as being critical to hair growth. 

These molecules, such as vitamin D, that bind to the vitamin D receptor are called ligands.  When they bind to the vitamin D receptor, they lead to activation of the receptor, which leads to regulation of various genes that control hair cycling and growth.  Although, according to a July 2012 report by Dr. Haussler from the University of Arizona, the vitamin D receptor can be activated without being bound by a ligand. 

Interestingly, although the actual vitamin D receptor and not necessarily vitamin D alone, seems to play a bigger role in hair growth regulation, a recent study by Dr. Yoshimura from the University of Tokyo, suggests that vitamin D may also stimulate hair growth.  They used cells taken from mouse skin, and pretreated them with vitamin D.  When the cells were transplanted back into the mouse and induced to form hair, they found that the addition of vitamin D enhanced hair follicle growth.

This is a promising finding that could potentially be useful in the future, when cloning hair for its use in hair transplantation.

So have scientists discovered the cure for baldness?  The answer is not yet.  The recent discoveries about the Vitamin D receptor’s influence on hair growth is just a small piece of this very complex puzzle.

Intro

Hi all!!!

I just created this blog for patients, friends, and the general public.  I get asked questions on skin and hair constantly.  So, I thought I would start blogging about these general "hot topics".

Hope you find this helpful, as well as, educational!

Dr. Meena Singh