•meeting um60 - 2016
TRANSCRIPT
FEMALE HAIR LOSSFEMALE HAIR LOSS
The diagnosis & management The diagnosis & management is easier than you think!is easier than you think!
Bernard Cohen, MDBernard Cohen, MD VOLUNTARY CLINICAL PROFESSORVOLUNTARY CLINICAL PROFESSOR
UNIVERSITY OF MIAMI SCHOOL OF MEDICINE UNIVERSITY OF MIAMI SCHOOL OF MEDICINE
JANUARY 16, 2016JANUARY 16, 2016MIAMI BEACH, FLMIAMI BEACH, FL
DISCLOSUREDISCLOSUREDr. Cohen owns the patents, and receives royalties Dr. Cohen owns the patents, and receives royalties on hair mass measuring technologies.on hair mass measuring technologies.
In a general dermatology practice...In a general dermatology practice...90% of women presenting with hair loss have:90% of women presenting with hair loss have:
ThinningThinning REDUCTION IN DIAMETERREDUCTION IN DIAMETER Shedding Shedding REDUCTION IN DENSITYREDUCTION IN DENSITY
Breakage Breakage RARELY A COMPLAINTRARELY A COMPLAINT
AND A SCALP BIOPSY IS NOT REQUIREDAND A SCALP BIOPSY IS NOT REQUIRED TO MAKE THE DIAGNOSISTO MAKE THE DIAGNOSIS
FOUR STEPSFOUR STEPS
1. Make the diagnosis1. Make the diagnosis Combinations frequently existCombinations frequently exist
2. Establish baselines2. Establish baselines ““How much hair” is present before treatmentHow much hair” is present before treatment
3. Choose a treatment3. Choose a treatment 4. Manage with measureable feedback4. Manage with measureable feedback
“ “MEASUREABLE” FEEDBACK = “EVIDENCE-BASED” MEASUREABLE” FEEDBACK = “EVIDENCE-BASED”
1. MAKE DIAGNOSIS 1. MAKE DIAGNOSIS HistoryHistory Physical examPhysical exam Smart phone micro-imageSmart phone micro-image Lab studiesLab studies
2. ESTABLISH BASELINES2. ESTABLISH BASELINES Smart phone clinical photographSmart phone clinical photograph Hair mass measurement Hair mass measurement
3. CHOOSE TREATMENT 3. CHOOSE TREATMENT
4. MANAGE TREATMENT 4. MANAGE TREATMENT
HISTORY– ThinningHISTORY– Thinning
Ask about:Ask about:Family historyFamily historyIrregular mensesIrregular mensesFacial hairFacial hairHormone therapyHormone therapyMenopauseMenopauseInability to conceiveInability to conceivePCOPCO
HISTORY– SheddingHISTORY– Shedding
Ask about:Ask about:Delivery -- BCP discontinuationDelivery -- BCP discontinuationChange in hormone therapyChange in hormone therapyMedicationsMedicationsThyroid abnormalityThyroid abnormalityIron deficiencyIron deficiencySLESLEWeight lossWeight lossGeneral anesthesiaGeneral anesthesiaVitamin DVitamin D
HISTORY– BreakageHISTORY– Breakage
Ask about:Ask about:Long hairLong hairCurly hairCurly hairFine hairFine hair
Hair styleHair styleChemical processingChemical processingPony tail appliancesPony tail appliancesHot dryers, irons & rollersHot dryers, irons & rollers
1. MAKE DIAGNOSIS 1. MAKE DIAGNOSIS HistoryHistory Physical examPhysical exam Smart phone micro-imageSmart phone micro-image Lab studiesLab studies
2. ESTABLISH BASELINES2. ESTABLISH BASELINES Smart phone clinical photographSmart phone clinical photograph Hair mass measurement Hair mass measurement
3. CHOOSE TREATMENT 3. CHOOSE TREATMENT
4. MANAGE TREATMENT 4. MANAGE TREATMENT
PHYSICAL EXAM PHYSICAL EXAM RULE OUT THE “UNCOMMON 10%”RULE OUT THE “UNCOMMON 10%”
Frontal fibrosing alopeciaFrontal fibrosing alopecia Diffuse and patchy AADiffuse and patchy AA SLE, infection, inflammationSLE, infection, inflammation Scarring alopecias, etc.Scarring alopecias, etc.
BIOPSY MIGHT BE REQUIREDBIOPSY MIGHT BE REQUIRED
PHYSICAL EXAM– ThinningPHYSICAL EXAM– ThinningPART - Xmas treePART - Xmas tree
DISTRIBUTION - Horseshoe retentionDISTRIBUTION - Horseshoe retention
PHYSICAL EXAM– SheddingPHYSICAL EXAM– Shedding PART -- Widened but no Xmas treePART -- Widened but no Xmas tree DISTRIBUTION -- Generalized, no horseshoeDISTRIBUTION -- Generalized, no horseshoe
PULL TEST -- PositivePULL TEST -- Positive
PHYSICAL EXAM– BreakagePHYSICAL EXAM– Breakage
SLIDE DISTALLY ALONG PONYTAIL GRASP 6-10 HAIRSSLIDE DISTALLY ALONG PONYTAIL GRASP 6-10 HAIRS Look for drop outs Try to break the bundleLook for drop outs Try to break the bundle
1. MAKE DIAGNOSIS 1. MAKE DIAGNOSIS HistoryHistory Physical examPhysical exam Smart phone micro-imageSmart phone micro-image Lab studiesLab studies
2. ESTABLISH BASELINES2. ESTABLISH BASELINES Smart phone clinical photograph Smart phone clinical photograph Hair mass measurement Hair mass measurement
3. CHOOSE TREATMENT 3. CHOOSE TREATMENT
4. MANAGE TREATMENT 4. MANAGE TREATMENT
Handyscope deviceHandyscope device
MICRO-IMAGINGMICRO-IMAGING
Uses Iphone Lens + LED light Archival softwareUses Iphone Lens + LED light Archival software
NORMAL ZOOMNORMAL ZOOM
SHEDDINGSHEDDING
HAIRS ARE THE SAME DIAMETER, BUT FEWERHAIRS ARE THE SAME DIAMETER, BUT FEWER
THINNING
WIDE RANGE OF DIAMETERSWIDE RANGE OF DIAMETERSFOLLICULAR UNITS ARE PREDOMINATELY SINGLE HAIRFOLLICULAR UNITS ARE PREDOMINATELY SINGLE HAIR
1. MAKE DIAGNOSIS 1. MAKE DIAGNOSIS HistoryHistory Physical examPhysical exam Smart phone micro-imageSmart phone micro-image Lab studiesLab studies
2. ESTABLISH BASELINES2. ESTABLISH BASELINES Smart phone clinical photographSmart phone clinical photograph Hair mass measurement Hair mass measurement
3. CHOOSE TREATMENT 3. CHOOSE TREATMENT
4. MANAGE TREATMENT 4. MANAGE TREATMENT
Picture of ourPicture of ourLab slip
STANDARDIZED “HAIR-RELATED” REQUISITION FORMSTANDARDIZED “HAIR-RELATED” REQUISITION FORM Thinning will be diagnosed by micro-imaging.Thinning will be diagnosed by micro-imaging.
Blood tests are needed to screen for shedding, which frequently co-exists. Blood tests are needed to screen for shedding, which frequently co-exists.
LABORATORY– SheddingLABORATORY– Shedding
TSH & T4 Anti thyroid antibodies Ferritin – must be mid range ANA Vitamin D3
LABORATORY- ThinningLABORATORY- Thinning
DHEAS Free testosterone
Total testosterone
1. MAKE DIAGNOSIS 1. MAKE DIAGNOSIS HistoryHistory Physical examPhysical exam Smart phone micro-imageSmart phone micro-image Lab studiesLab studies
2. ESTABLISH BASELINES2. ESTABLISH BASELINES Smart phone clinical photographSmart phone clinical photograph Hair mass measurement Hair mass measurement
3. CHOOSE TREATMENT 3. CHOOSE TREATMENT
4. MANAGE TREATMENT 4. MANAGE TREATMENT
BASELINE BASELINE Clinical photograph using same Smartphone Clinical photograph using same Smartphone
1. MAKE DIAGNOSIS 1. MAKE DIAGNOSIS HistoryHistory Physical examPhysical exam Smart phone micro-imageSmart phone micro-image Lab studiesLab studies
2. ESTABLISH BASELINES2. ESTABLISH BASELINES Smart phone clinical photographSmart phone clinical photograph Hair mass measurement Hair mass measurement
3. CHOOSE TREATMENT 3. CHOOSE TREATMENT
4. MANAGE TREATMENT 4. MANAGE TREATMENT
All details & published data @ All details & published data @ www.howtomeasurehair.comwww.howtomeasurehair.com
SIMULTANEOUSLY MEASURE DENSITY & DIAMETERSIMULTANEOUSLY MEASURE DENSITY & DIAMETER
HAIR MASS MEASUREMENT
THE THE DEVICE DEVICE MEASURES THE CROSS SECTIONALMEASURES THE CROSS SECTIONALAREA ON THE HAIR.AREA ON THE HAIR.
THE THE TEMPLATETEMPLATE MEASURES THE CROSS SECTIONALMEASURES THE CROSS SECTIONALAREA ON THE SCALP AREA ON THE SCALP
A single numeric value = mmA single numeric value = mm22 of hair per cm of hair per cm22 of scalp of scalp
So... In the treatment period... If
THE DIAMETERS GET BIGGER OR SMALLEROR
THE DENSITY GETS HIGHER OR LOWER
The value displayed on the LED screenwill reflect those changes.
SENSITIVITY Device can detect a change of 3 hairs in a bundle of 600 hairs.
1. MAKE DIAGNOSIS 1. MAKE DIAGNOSIS HistoryHistory Physical examPhysical exam Smart phone micro-imageSmart phone micro-image Lab studiesLab studies
2. ESTABLISH BASELINES2. ESTABLISH BASELINES Smart phone clinical photographSmart phone clinical photograph Hair mass measurement Hair mass measurement
3. 3. CHOOSE TREATMENT CHOOSE TREATMENT
4. MANAGE TREATMENT 4. MANAGE TREATMENT
TREATMENTTREATMENT
SHEDDINGSHEDDINGReview blood test resultsReview blood test results
Correct deficiencies and abnormalitiesCorrect deficiencies and abnormalitiesRefer patient to appropriate specialistRefer patient to appropriate specialist
If physiologic, re-assure patient of If physiologic, re-assure patient of expected return to normalexpected return to normal
TREATMENT TREATMENT
THINNINGTHINNINGMINOXIDIL MINOXIDIL multiple formulationsmultiple formulations
LOW INTENSITY LASERLOW INTENSITY LASERFINASTERIDEFINASTERIDE
PRPPRPSPIRONOLACTONESPIRONOLACTONE
BIOTINBIOTIN
1. MAKE DIAGNOSIS 1. MAKE DIAGNOSIS HistoryHistory Physical examPhysical exam Smart phone micro-imageSmart phone micro-image Lab studiesLab studies
2. ESTABLISH BASELINES2. ESTABLISH BASELINES Smart phone clinical photographSmart phone clinical photograph Hair mass measurement Hair mass measurement
3. CHOOSE TREATMENT 3. CHOOSE TREATMENT
4. 4. MANAGE TREATMENT MANAGE TREATMENT
MANAGEMENTMANAGEMENTSame for shedding & thinningSame for shedding & thinning
Use Hair Mass MeasurementUse Hair Mass Measurement
(CROSS SECTION TRICHOMETRY)(CROSS SECTION TRICHOMETRY)
to guide your management decisions.to guide your management decisions.
Casual photography is of value, but is not evidence-based. Casual photography is of value, but is not evidence-based. It is too imprecise and does not generate measureable data.It is too imprecise and does not generate measureable data.
If less than 50% of the hair has been lost -If less than 50% of the hair has been lost -the underlying skin will not be visible to the eye (or camera).the underlying skin will not be visible to the eye (or camera).
EXAMPLESEXAMPLES
HAIR LOSSHAIR LOSSMANAGEMENTMANAGEMENT
DOCTOR, I THINK I’M LOSING MY HAIRDOCTOR, I THINK I’M LOSING MY HAIR92-72/92 = 22%92-72/92 = 22%
SHE HAS A 22% LOSS (THINNING) WHICH CANNOTSHE HAS A 22% LOSS (THINNING) WHICH CANNOTBE SEEN VISUALLY, OR ON CAMERABE SEEN VISUALLY, OR ON CAMERA
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BASELINEBASELINEShe chooses toShe chooses to
postpone treatmentpostpone treatment
49497272 6767
12 MONTHS LATER12 MONTHS LATERShe is 7% worseShe is 7% worse
BASELINEBASELINEShe chooses to startShe chooses to start
laser therapylaser therapy
49496767 7575
12 MONTHS LATER12 MONTHS LATERShe’s only 10% improvedShe’s only 10% improved
BASELINEBASELINEShe’s dissatisfied and agreesShe’s dissatisfied and agrees
to add MNX to her laser to add MNX to her laser therapytherapy
49497575 8181
12 MONTHS LATER12 MONTHS LATERShe has a 7% improvementShe has a 7% improvementwith combination therapywith combination therapy
BASELINEBASELINEBut the MNX is too difficult But the MNX is too difficult
to applyto applybid, she wants to apply qd.bid, she wants to apply qd.
49498383 8282
6 MONTHS LATER6 MONTHS LATERSurprisingly she isSurprisingly she is
no worseno worse
5 MONTHS AFTER5 MONTHS AFTERCHILDBIRTHCHILDBIRTH
Patient is actively shedding and Patient is actively shedding and frantic.frantic.
She is re-assured and not treated.She is re-assured and not treated.
49495555 7777
12 MONTHS AFTER12 MONTHS AFTERCHILDBIRTHCHILDBIRTH
She is 30% improvedShe is 30% improvedAnd almost back to normalAnd almost back to normal
BASELINEBASELINEA low ferritin and A low ferritin and
Vitamin DVitamin Dare picked up on blood are picked up on blood
screening.screening.Treatment is commenced.Treatment is commenced.
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12 MONTHS LATER12 MONTHS LATERShe is 9% improved afterShe is 9% improved after
one year.one year.
IS IT DIFFUSE IS IT DIFFUSE OROR PATTERN HAIR LOSS? PATTERN HAIR LOSS?(occiput & mid scalp essentially equal)(occiput & mid scalp essentially equal)
CONCLUSION = Hair Loss is DIFFUSE not PATTERNCONCLUSION = Hair Loss is DIFFUSE not PATTERN
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BASELINEBASELINE Patient Patient reluctantly starts reluctantly starts minoxidil minoxidil for thinning.for thinning.
49496565 7979
8 MONTHS LATER8 MONTHS LATER““Doc, I don’t think the Doc, I don’t think the minoxidil is working.”minoxidil is working.”
www.howtomeasurehair.comwww.howtomeasurehair.com
IS IT DIFFUSE IS IT DIFFUSE OROR PATTERN HAIR PATTERN HAIR LOSS?LOSS?
(occiput & mid scalp essentially equal)(occiput & mid scalp essentially equal) CONCLUSION = Hair Loss is DIFFUSE not PATTERNCONCLUSION = Hair Loss is DIFFUSE not PATTERN
6868 6767