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  • FEMALE HAIR LOSS

    The diagnosis & management is easier than you think! Bernard Cohen, MD VOLUNTARY CLINICAL PROFESSOR UNIVERSITY OF MIAMI SCHOOL OF MEDICINE

    JANUARY 16, 2016MIAMI BEACH, FL

    *

  • DISCLOSURE

    Dr. Cohen owns the patents, and receives royalties on hair mass measuring technologies.

    *

  • In a general dermatology practice...90% of women presenting with hair loss have:

    Thinning REDUCTION IN DIAMETER Shedding REDUCTION IN DENSITY Breakage RARELY A COMPLAINT

    AND A SCALP BIOPSY IS NOT REQUIRED TO MAKE THE DIAGNOSIS

    *In a general dermatology practice 90% of women with hair loss have one of three diagnosesOr a combination of 2 or 3A scalp biopsy is not required

  • FOUR STEPS

    1. Make the diagnosis Combinations frequently exist

    2. Establish baselines How much hair is present before treatment

    3. Choose a treatment 4. Manage with measureable feedback

    MEASUREABLE FEEDBACK = EVIDENCE-BASED

    *I will attempt to show you how to makethe diagnosis remembering that (combinations do exist)Then establish your treatment starting point or baselinesAnd thenhow to manage the treatment using modalities that give you evidence-based feedback

  • 1. MAKE DIAGNOSIS History Physical exam Smart phone micro-image Lab studies

    2. ESTABLISH BASELINES Smart phone clinical photograph Hair mass measurement

    3. CHOOSE TREATMENT

    4. MANAGE TREATMENT

    *So make thte diagnosis establish the baselines then treat and manage

  • HISTORY Thinning

    Ask about:Family historyIrregular mensesFacial hairHormone therapyMenopauseInability to conceivePCO

    *Youll want to ask these questions in your medical history. They all point to thinning

  • HISTORY Shedding

    Ask about:Delivery -- BCP discontinuationChange in hormone therapyMedicationsThyroid abnormalityIron deficiencySLEWeight lossGeneral anesthesiaVitamin D

    *Hit these items in your medical history. They point to shedding

  • HISTORY Breakage

    Ask about:Long hairCurly hairFine hairHair styleChemical processingPony tail appliancesHot dryers, irons & rollers

    *Hit these items in your medical history. They point to thinning

  • 1. MAKE DIAGNOSIS History Physical exam Smart phone micro-image Lab studies

    2. ESTABLISH BASELINES Smart phone clinical photograph Hair mass measurement

    3. CHOOSE TREATMENT

    4. MANAGE TREATMENT

    *So make thte diagnosis establish the baselines then treat and manage

  • PHYSICAL EXAM RULE OUT THE UNCOMMON 10% Frontal fibrosing alopecia Diffuse and patchy AA SLE, infection, inflammation Scarring alopecias, etc.

    BIOPSY MIGHT BE REQUIRED

    *On physical exam, try to identify the less common 10%In these cases a biopsy might be required

  • PHYSICAL EXAM ThinningPART - Xmas treeDISTRIBUTION - Horseshoe retention

    *Part the hair down the midline. A Xmas tree distribution is highly suggestive sign of thinningRetention of hair in the horseshoe fringe is a sign of thinning as well

  • PHYSICAL EXAM Shedding PART -- Widened but no Xmas tree DISTRIBUTION -- Generalized, no horseshoe PULL TEST -- Positive

    *When the hair is parted look for general widening with no Xmas tree that suggests sheddingThe distribution of loss is diffuse . Then Grasp 20 or 30 hairs and give them a tug. If more than 3 come out its a positive pull test.Because theres a high proportion of telogen hairs in states of effluvium

  • PHYSICAL EXAM Breakage

    SLIDE DISTALLY ALONG PONYTAIL GRASP 6-10 HAIRS Look for drop outs Try to break the bundle

    *To check for breakage put together a pony tail and examine with a contrasting background.The short broken hairs fall out of the bundle.The take 5 or six hair, wrap around your fingers and try to break them. Brittle hair with break easily.

  • 1. MAKE DIAGNOSIS History Physical exam Smart phone micro-image Lab studies

    2. ESTABLISH BASELINES Smart phone clinical photograph Hair mass measurement

    3. CHOOSE TREATMENT

    4. MANAGE TREATMENT

    *So make thte diagnosis establish the baselines then treat and manage

  • Handyscope deviceMICRO-IMAGINGUses Iphone Lens + LED light Archival software

    *Its a dermatoscopeThe phone slips into a shell that contains a lens and light source.The device comes with a good archival software for keeping track of the photos

  • NORMAL ZOOM

    *The image on the left is what you see.On the right is the same image zoomed in for close examination

  • SHEDDINGHAIRS ARE THE SAME DIAMETER, BUT FEWER

    *In cases of shedding expect to see hairs of essentially all the same diameter

  • *In cases of thinning, the hairs become progressively miniaturized

  • THINNINGWIDE RANGE OF DIAMETERSFOLLICULAR UNITS ARE PREDOMINATELY SINGLE HAIR

    *So on the left -- a micro-image of cut hair. Note the wide variation of diameters and the single hair follicular units.On the right is what you see using the PhotoFinder Take a look at how easily the variation can be seem there is no need to cut hair

  • 1. MAKE DIAGNOSIS History Physical exam Smart phone micro-image Lab studies

    2. ESTABLISH BASELINES Smart phone clinical photograph Hair mass measurement

    3. CHOOSE TREATMENT

    4. MANAGE TREATMENT

    *So make thte diagnosis establish the baselines then treat and manage

  • Picture of ourLab slip

    STANDARDIZED HAIR-RELATED REQUISITION FORM Thinning will be diagnosed by micro-imaging. Blood tests are needed to screen for shedding, which frequently co-exists.

    *We use a form that contains the hair-related lab test and diagnoses. Tip Dont use a hair diagnosis - use Unspecified endocrine disorder 259.9 and the tests are rarely denied the the insurance company.

  • LABORATORY Shedding TSH & T4 Anti thyroid antibodies Ferritin must be mid range ANA Vitamin D3

    *

  • LABORATORY- Thinning

    DHEAS Free testosterone Total testosterone

    *90% of women with thinning but a small percentage have an adrenal hormone imbalance identified with DHEAS and testosterone

  • 1. MAKE DIAGNOSIS History Physical exam Smart phone micro-image Lab studies

    2. ESTABLISH BASELINES Smart phone clinical photograph Hair mass measurement

    3. CHOOSE TREATMENT

    4. MANAGE TREATMENT

    *So make thte diagnosis establish the baselines then treat and manage

  • BASELINE Clinical photograph using same Smartphone

    *

  • 1. MAKE DIAGNOSIS History Physical exam Smart phone micro-image Lab studies

    2. ESTABLISH BASELINES Smart phone clinical photograph Hair mass measurement

    3. CHOOSE TREATMENT

    4. MANAGE TREATMENT

    *So make thte diagnosis establish the baselines then treat and manage

  • All details & published data @ www.howtomeasurehair.comSIMULTANEOUSLY MEASURE DENSITY & DIAMETER

    *This technology called cross section trichometry has been published by me as well as Drs. Jimenez and Cao.It is in multiple published articles and textbook chapters Used by Loreal, Proctor and Gamble, and Unilever

  • HAIR MASS MEASUREMENT

    *

  • THE DEVICE MEASURES THE CROSS SECTIONALAREA ON THE HAIR.THE TEMPLATE MEASURES THE CROSS SECTIONALAREA ON THE SCALP A single numeric value = mm2 of hair per cm2 of scalp

    *IT CONSISTS OF -- READ THE SLIDE

  • So... In the treatment period... If

    THE DIAMETERS GET BIGGER OR SMALLERORTHE 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 History Physical exam Smart phone micro-image Lab studies

    2. ESTABLISH BASELINES Smart phone clinical photograph Hair mass measurement

    3. CHOOSE TREATMENT

    4. MANAGE TREATMENT

    *So make thte diagnosis establish the baselines then treat and manage

  • TREATMENT

    SHEDDINGReview blood test resultsCorrect deficiencies and abnormalitiesRefer patient to appropriate specialist

    If physiologic, re-assure patient of expected return to normal

    *

  • TREATMENT

    THINNINGMINOXIDIL multiple formulationsLOW INTENSITY LASERFINASTERIDEPRPSPIRONOLACTONEBIOTIN

    *

  • 1. MAKE DIAGNOSIS History Physical exam Smart phone micro-image Lab studies

    2. ESTABLISH BASELINES Smart phone clinical photograph Hair mass measurement

    3. CHOOSE TREATMENT

    4. MANAGE TREATMENT

    *So make thte diagnosis establish the baselines then treat and manage

  • MANAGEMENTSame for shedding &