•MEETING UM60 - 2016

57
FEMALE HAIR LOSS FEMALE HAIR LOSS The diagnosis & management The diagnosis & management is easier than you think! is easier than you think! Bernard Cohen, MD Bernard Cohen, MD VOLUNTARY CLINICAL PROFESSOR VOLUNTARY CLINICAL PROFESSOR UNIVERSITY OF MIAMI SCHOOL OF MEDICINE UNIVERSITY OF MIAMI SCHOOL OF MEDICINE JANUARY 16, 2016 JANUARY 16, 2016 MIAMI BEACH, FL MIAMI BEACH, FL

Transcript of •MEETING UM60 - 2016

Page 1: •MEETING UM60 - 2016

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

Page 2: •MEETING UM60 - 2016

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.

Page 3: •MEETING UM60 - 2016

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

Page 4: •MEETING UM60 - 2016

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”

Page 5: •MEETING UM60 - 2016

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

Page 6: •MEETING UM60 - 2016

HISTORY– ThinningHISTORY– Thinning

Ask about:Ask about:Family historyFamily historyIrregular mensesIrregular mensesFacial hairFacial hairHormone therapyHormone therapyMenopauseMenopauseInability to conceiveInability to conceivePCOPCO

Page 7: •MEETING UM60 - 2016

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

Page 8: •MEETING UM60 - 2016

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

Page 9: •MEETING UM60 - 2016

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

Page 10: •MEETING UM60 - 2016

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

Page 11: •MEETING UM60 - 2016

PHYSICAL EXAM– ThinningPHYSICAL EXAM– ThinningPART - Xmas treePART - Xmas tree

DISTRIBUTION - Horseshoe retentionDISTRIBUTION - Horseshoe retention

Page 12: •MEETING UM60 - 2016

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

Page 13: •MEETING UM60 - 2016

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

Page 14: •MEETING UM60 - 2016

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

Page 15: •MEETING UM60 - 2016

Handyscope deviceHandyscope device

MICRO-IMAGINGMICRO-IMAGING

Uses Iphone Lens + LED light Archival softwareUses Iphone Lens + LED light Archival software

Page 16: •MEETING UM60 - 2016

NORMAL ZOOMNORMAL ZOOM

Page 17: •MEETING UM60 - 2016

SHEDDINGSHEDDING

HAIRS ARE THE SAME DIAMETER, BUT FEWERHAIRS ARE THE SAME DIAMETER, BUT FEWER

Page 18: •MEETING UM60 - 2016
Page 19: •MEETING UM60 - 2016

THINNING

WIDE RANGE OF DIAMETERSWIDE RANGE OF DIAMETERSFOLLICULAR UNITS ARE PREDOMINATELY SINGLE HAIRFOLLICULAR UNITS ARE PREDOMINATELY SINGLE HAIR

Page 20: •MEETING UM60 - 2016

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

Page 21: •MEETING UM60 - 2016

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.

Page 22: •MEETING UM60 - 2016

LABORATORY– SheddingLABORATORY– Shedding

TSH & T4 Anti thyroid antibodies Ferritin – must be mid range ANA Vitamin D3

Page 23: •MEETING UM60 - 2016

LABORATORY- ThinningLABORATORY- Thinning

DHEAS Free testosterone

Total testosterone

Page 24: •MEETING UM60 - 2016

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

Page 25: •MEETING UM60 - 2016

BASELINE BASELINE Clinical photograph using same Smartphone Clinical photograph using same Smartphone

Page 26: •MEETING UM60 - 2016

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

Page 27: •MEETING UM60 - 2016

All details & published data @ All details & published data @ www.howtomeasurehair.comwww.howtomeasurehair.com

SIMULTANEOUSLY MEASURE DENSITY & DIAMETERSIMULTANEOUSLY MEASURE DENSITY & DIAMETER

Page 28: •MEETING UM60 - 2016

HAIR MASS MEASUREMENT

Page 29: •MEETING UM60 - 2016
Page 30: •MEETING UM60 - 2016

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

Page 31: •MEETING UM60 - 2016

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.

Page 32: •MEETING UM60 - 2016

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

Page 33: •MEETING UM60 - 2016

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

Page 34: •MEETING UM60 - 2016

TREATMENT TREATMENT

THINNINGTHINNINGMINOXIDIL MINOXIDIL multiple formulationsmultiple formulations

LOW INTENSITY LASERLOW INTENSITY LASERFINASTERIDEFINASTERIDE

PRPPRPSPIRONOLACTONESPIRONOLACTONE

BIOTINBIOTIN

Page 35: •MEETING UM60 - 2016

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

Page 36: •MEETING UM60 - 2016

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).

Page 37: •MEETING UM60 - 2016

EXAMPLESEXAMPLES

HAIR LOSSHAIR LOSSMANAGEMENTMANAGEMENT

Page 38: •MEETING UM60 - 2016

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

7272 9292

Page 39: •MEETING UM60 - 2016

BASELINEBASELINEShe chooses toShe chooses to

postpone treatmentpostpone treatment

49497272 6767

12 MONTHS LATER12 MONTHS LATERShe is 7% worseShe is 7% worse

Page 40: •MEETING UM60 - 2016

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

Page 41: •MEETING UM60 - 2016

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

Page 42: •MEETING UM60 - 2016

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

Page 43: •MEETING UM60 - 2016

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

Page 44: •MEETING UM60 - 2016

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.

49497979 8686

12 MONTHS LATER12 MONTHS LATERShe is 9% improved afterShe is 9% improved after

one year.one year.

Page 45: •MEETING UM60 - 2016

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

6262 6464

Page 46: •MEETING UM60 - 2016

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.”

Page 47: •MEETING UM60 - 2016

www.howtomeasurehair.comwww.howtomeasurehair.com

Page 48: •MEETING UM60 - 2016

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

Page 49: •MEETING UM60 - 2016
Page 50: •MEETING UM60 - 2016
Page 51: •MEETING UM60 - 2016
Page 52: •MEETING UM60 - 2016
Page 53: •MEETING UM60 - 2016
Page 54: •MEETING UM60 - 2016
Page 55: •MEETING UM60 - 2016
Page 56: •MEETING UM60 - 2016
Page 57: •MEETING UM60 - 2016