April is Rosacea Awareness Month. Rosacea is a skin condition that causes redness, dilated capillaries, red papules and pustules on the face. When it affects the eyes, the eyes can feel dry, irritated and red. There may be a sensation of sand in the eyes as well. Rosacea usually starts with easy flushing or blushing and may or may not progress to other lesions like pustules and papules.

Eye manifestations are usually diagnosed when the patient is seen for redness of the face.  However, ocular rosacea may occur before skin involvement or even by itself.  In 20% of patients, ocular rosacea develops before skin symptoms.

If left untreated ocular rosacea may cause serious eye problems.  Eye involvement can range from dryness, burning, irritation and blurry vision to chalazia (styes), inflammation of the cornea (keratitis), corneal erosions, ulceration and scarring,  Keratitis can lead to perforation of the cornea. Ocular rosacea needs to be treated quickly.

What causes rosacea?

Our skin normally regulates body temperature by opening and closing blood vessels at the skin surface. When the body is hot, more blood vessels open to allow the circulating blood to cool at the skin surface and therefore cool the internal structures as well. When it is cold, the surface blood vessels constrict keeping the heat inside.

One of the problems with rosacea is that the facial capillaries open readily but don’t constrict back to normal very well. Over time, more and more of these capillaries stay open producing chronic redness and even visible blood vessels.

Factors to consider when treating rosacea:

1. Anything that warms up the face can flare rosacea. Examples include hot showers/sauna/steam rooms, hot drinks, spicy foods, direct sunlight, wind exposure, alcohol, exercise, stress and others. Scrubbing the face with abrasive cleansers, getting facials or using topical preparations containing alcohol, salicylic acid or other irritating substances can also flare rosacea. What I recommend after exercise is applying a paper towel or wash cloth with cool water to the face for 2-3 minutes to help shrink the blood vessels. Scrubbing the face with abrasive cleansers, getting facials or using topical preparations containing alcohol, salicylic acid, retinols or other irritating substances can also flare rosacea.
2. Patients with rosacea may have burning or stinging of the facial skin especially when they apply lotions or medicines.
3. There are good over the counter face washes and moisturizer/sunscreen combinations that usually do not inflame rosacea, such as Eucerin Redness Relief and Aveeno Ultra Calming. For sunscreens, there are also chemical-free sunscreens from Aveeno and COTZ.
4. Rosacea is a chronic condition and some form of treatment/long term maintenance is usually needed.
5. Topical and oral medications that treat rosacea usually work for the papular/pustular/inflammatory components, but are not very effective for the dilated blood vessels.
6. Topical prescription medications for rosacea include:

• Metrogel
  (topical metronidazole). This also contains some niacinamide which
  acts and a calming and anti-inflammatory medication.
• Sulfur/sulfacetamide combinations like Rosula, Clarifoam, and others
• Aczone gel (topical dapsone)
• Finacea

6. Oral medications include:

• Tetracycline class antibiotics. These work very well for ocular rosacea, where we cannot use any topical medications.
• For very resistant cases, isotretinoin (generic of Accutane)

Ocular rosacea usually requires oral medications and, possibly, topical anti-inflammatory ophthalmic drops.  Topical and ophthalmic steroids should be avoided as they can lead to worsening of rosacea long-term.

For persistent redness and/or dilated blood vessels, laser or intense pulsed light treatments are the most effective. Laser treatments help shrink the blood vessels and improve the redness and sensitivity of the skin.

There are some medications that can be applied in a pinch to shrink broken capillaries for a few hours, such as for an important event, but those are usually not part of the regular treatment of rosacea.

Papulopustular and Ocular Rosacea

Pustulonodular Rosacea

Telangiectatic Rosacea: Dilated blood vessels and persistent redness

Photos courtesy of Dermquest.com

http://www.advancedskinwisdom.com/rosacearedness.htm

Spring is here, days are getting longer, and once again it’s time to talk about sun exposure and skin cancer. There is a strong link between exposure to ultraviolet light from sun exposure or indoor tanning equipment and the risk of developing a skin cancer, such as basal cell carcinoma, squamous cell carcinoma, or the most dangerous skin cancer, melanoma.

The incidence of melanoma is growing faster than any other cancer in the United States. Melanoma is now the sixth most common cancer in the United States and is the leading cause of cancer deaths in women between the ages of 20 and 35. Every hour one person dies from melanoma in the United States.

World Health Organization map showing deaths from melanoma and other skin cancers. Areas in red have the highest mortality.

Many teens increase their use of tanning beds around this time of the year: some in preparation for the summer beach season, some to “look good” for the prom.

Looks inviting, doesn't it? Who would think looking at a friendly photo like this that tanning beds were classified by the World Health Organization as an independent carcinogen. A very high price to pay for a tan.

Today’s issue of USA Today reports a Mayo Clinic study that reveals a dramatic rise in skin cancer rates among young adults is leading health officials to shed light on the risk factors, specifically tanning salons, which women are more likely to use.

The risk is higher in those exposed to ultraviolet light before age 20. More than a million people use indoor tanning equipment every day, many of them under 18 years of age.

Women under 40 are hit hardest by the escalating incidence of melanoma, according to the Mayo Clinic study published in the April issue of Mayo Clinic Proceedings, out today.  The results of the study show that from 1970 to 2009, the incidence of melanoma increased by 8-fold among young women and 4-fold among young men. Overall and disease-specific survival seemed to improve over time; hazard ratios comparing year of diagnosis with mortality were 0.92 and 0.91, respectively.

Recently England and Wales placed a ban on the use of indoor tanning equipment by persons under 18 years of age. In the United Stated, legislation to ban teen use of tanning beds is pending in a number of States. Studies find that teens whose parents use indoor tanning equipment are more likely to use it themselves.

According to the February 2012 update of the National Conference of State Legislatures, the following states have banned the use of tanning beds by minors under 14 years of age, and some under 18 years of age:

• California – under 18
• Delaware – under 14
• Illinois – under 14
• Maine – under 14
• New Hampshire – under 14
• New Jersey – under 14
• New York – under 14
• North Carolina – under 13
• North Dakota – under 14
• Texas – under 16.5
• Wisconsin – under 16

A number of other states require minors to have parental permission to use tanning beds.  The Mayo Clinic study underscores the fact that the existing age limits are too low.

In a recent position statement, the American Academy of Pediatrics joined with the World Health Organization, the American Medical Association and the American Academy of Dermatology in supporting the ban on tanning bed use for all minors.

In order to decrease the risk of skin cancer, the following steps should be taken:

1. Avoid indoor tanning equipment altogether.
2. Avoid sun exposure between the hours of 10 am and 4 pm.
3. Use a broad spectrum sunscreen with at least SPF 50 on a daily basis, and don’t forget to reapply often, especially if swimming or sweating.
4. Use sun-protective clothing when in the sun.
5. Protect children from sun exposure as ultraviolet light damage before age 20 greatly increases the risk of skin cancer.

Melanoma Detection: See your dermatologist for a full-body skin examination once a year or more often if you have risk factors for skin cancer.

Identifying malignant melanoma: ABCDE Rule

Malignant Melanoma

Asymmetry
Border Irregularity
Color Irregularity
Diameter greater than 1/4 inch (but may be smaller if detected early)
Evolving – Any changing mole is suspect. See your dermatologist.

http://www.advancedskinwisdom.com/melanoma.htm

The golden ratio, also known as the divine proportion, golden mean, or golden section, is a special number approximately equal to 1.618.  Its symbol is the Greek letter φ (phi).

It appears many times in nature, geometry, art, architecture and other areas.

Two quantities are in the golden ratio if the ratio of the sum of the quantities to the larger quantity is equal to the ratio of the larger quantity to the smaller one.

Here are some representations of the golden ratio in nature.

Golden Ratio in Nature

Diaper rash is a rash that develops in the diaper-covered area. Most commonly it’s caused by irritation from urine or stool. Diaper rash rarely involves the groin folds because those areas are not in contact with irritants.

Skin infections can either cause a diaper rash or be superimposed on it. Bacterial (Staph and Strep) and yeast/fungal (Candida) are common causes of diaper rash. These may look like pustules or erosions on an area of redness.
If a diaper rash is resistant to treatment and looks like a bright red, painful rash around the anus, a skin culture may need to be done as perianal Strep infections present that way.

Allergic reactions are a less common cause of diaper rash. Fragrances, components of the diaper, and particularly wipes are common causes of allergic contact dermatitis.

Introduction of new foods can sometimes lead to a diaper rash because it may change the consistency or frequency of the stool. If you are breast feeding, something you eat, particularly tomato-based foods, can also affect the baby’s stool.

If the baby is given antibiotics, he/she would be more likely to develop a diaper rash with a yeast infection, as antibiotics affect the balance of the intestinal flora (yeast vs. bacteria)

There are also very rare causes of diaper rash, such as metabolic and nutritional deficiencies and immunodeficiency states. Usually these present not only with a diaper rash, but rashes around the mouth and failure to thrive.

So, because diaper rash is primarily an irritant dermatitis due to contact with urine and stool, it is necessary to minimize contact with those irritants by changing diapers more frequently.

Even though diaper rash is very common between the ages of 4 and 15 months, there are steps to take before the rash develops:

• Keep the diaper area clean and dry.
• Don’t use baby wipes to clean after a bowel movement. They can irritate. Use lukewarm water to rinse, then pat dry. Unfortunately that is not always easy to do when out with the baby.
• If you must use a wipe when you are not home, use a fragrance and dye-free wipe, but try to minimize their use.
• Do not use baby powder. The baby can actually inhale the particles when you are using it. Starch-based powders make yeast infections in the diaper area worse.
• Use a barrier ointment with zinc oxide, such as Desitin, Balmex, or my favorite, Triple Paste (NFI) at every diaper change to prevent irritation from urine or stool.
• If it’s possible to have periods of time when the baby is without a diaper, that goes a long way towards keeping the area dry.

What to do if the baby does develop a diaper rash:

• Keep doing all the preventative measures as above.
• Using an antifungal cream, like the over the counter, clotrimazole, particularly mixed in with the zinc oxide cream half and half is helpful.
• If there is a lot of inflammation, adding hydrocortisone to the mixture for 2-3 days ONLY will help ease the discomfort, however anything longer than 2-3 days may lead to a worsening of the rash.

Diaper rash is usually easily treated and improves within a few
days after starting home treatment. If your baby’s skin doesn’t improve after a
few days of home treatment with over-the-counter ointment and more frequent
diaper changes, talk to your doctor. Sometimes, diaper rash leads to secondary
infections that may require prescription medications.

Call your doctor if:

• The rash gets worse or does not go away in 2-3 days despite home treatment.
• The rash spreads to the abdomen, back, arms, or face
• You notice pimples, blisters, ulcers, large bumps, or pus-filled sores
• Your baby also has a fever
• Your baby is taking an antibiotic and develops a bright red rash with spots at its edges. This might be a yeast infection
• Your baby develops a rash during the first 6 weeks of life
• If the rash is severe

References:

1. PubMed Health http://www.ncbi.nlm.nih.gov/pubm…
2. Mayo Clinic http://www.mayoclinic.com/health…
3. Medicinenet http://www.medicinenet.com/diape…

Blood sugar level regulation is complex with contributions from many different systems. These multiple controls are designed to keep a steady supply of glucose to the brain. Brain metabolism depends primarily on glucose for fuel. If the amount of glucose supplied by the blood falls, the brain is one of the first organs affected.

There are a number of mechanisms that tightly regulate (outside of a disease state) the level of glucose (sugar) in the blood stream. When there is a plentiful supply of glucose, such as after a carbohydrate-containing meal, glucose is absorbed from the intestine, and the level of blood glucose (sugar) rises.

Glucose is removed from the blood stream by uptake into virtually all cell types, but most importantly into muscle and adipose (fat) tissue. This removal requires insulin. Insulin, which is released from the pancreas, acts to decrease the level of glucose in the blood by signalling these cells to pick up and store glucose.

Insulin also inhibits breakdown of glycogen (glycogenolysis) and formation of glucose from non-carbohydrate sources (gluconeogenesis). The central nervous system can also sense glucose levels and act to affect the blood sugar levels, at least in part by regulating gluconeogenesis.

The importance of an adequate supply of glucose to the brain is apparent from the number of nervous, hormonal and metabolic responses to a falling glucose level (1).  Most of these are defensive or adaptive, tending to raise the blood sugar via

• Glycogenolysis - breaking down of glycogen, a polymer of glucose molecules, stored in the liver and muscle. If the blood sugar level falls too low the liver converts a storage of glycogen into glucose and releases it into the bloodstream, to prevent the person going into a diabetic coma, for a short period of time.
• Gluconeogenesis - a metabolic pathway that results in the generation of glucose from non-carbohydrate carbon substrates such as lactate, glycerol, and glucogenic amino acids.

Below is a diagram from the journal Nature, demonstrating the body’s regulating mechanisms for maintaining the appropriate glucose levels in the blood.

Adipocytes as regulators of energy balance and glucose homeostasis (2)
Evan D. Rosen and Bruce M. Spiegelman
Nature 444, 847-853(14 December 2006)

Sometimes blood sugar levels fall too low. This is called hypoglycemia.  Hypoglycemia can happen when a person eats too little food, takes too much insulin or diabetes medicine, or is more physically active than usual.  Hypoglycemia is less common in non-diabetic persons, but can occur at any age.  Among the causes are excessive insulin produced in the body (hyperinsulinemia), inborn errors of metabolism, medications and poisons, alcohol, hormone deficiencies, prolonged starvation, alterations of metabolism associated with infection, and organ failure.

Often hypoglycemia happens suddenly, and sometimes there is no explanation for why it occurs. When this happens, a person may have some, or all of these symptoms (3):

• Shaking
• Fast heartbeat
• Sweating
• Dizziness
• Feeling anxious
• Hunger
• Vision problems
• Weakness or feeling very tired
• Headache
• Feeling irritable

Since hypoglycemia can be life-threatening, it must be treated immediately.

Recommendations from the NY Department of Health for treatment of hypoglycemia:
If you have any of the symptoms of hypoglycemia, check your blood glucose. If the level is 70 or below, have one of the following quick acting sources of sugar right away:

• 3 or 4 glucose tablets
• 1 serving of glucose gel (equal to 15 grams of carbohydrate)
• 1/2 cup (4 ounces) of any fruit juice
• 1 cup (8 ounces) of milk
• 1/2 cup (4 ounces) of a regular (not diet) soft drink
• 5 or 6 pieces of hard candy
• 1 tablespoon of sugar or honey

After 15 minutes, check your blood glucose again to make sure your level is 70 or above. Repeat these steps as needed. Once your blood glucose is stable, if it will be at least an hour before your next meal, have a snack.

If you take diabetes medicines that can cause hypoglycemia, always carry a quick acting source of sugar for emergencies. It’s a good idea also to wear a medical identification bracelet or necklace.

You can usually prevent hypoglycemia by eating regular meals, taking your diabetes medicine, and checking your blood glucose often. Checking will tell you whether your glucose level is going down. You can then take steps, like drinking fruit juice, to raise your blood glucose.

Most hypoglycemic reactions are mild and can be resolved within 10 to 15 minutes of receiving the treatments listed above. Sometimes, hypoglycemia can happen rapidly and may progress to a more serious stage where a person becomes unconcious, has a seizure, or is unable to swallow. If this happens, nothing should be given by mouth. This is an emergency situation and 911 should be called immediately.

There is a life-saving treatment called glucagon that can be given by injection in an emergency. Glucagon is a hormone made in the pancreas and raises glucose levels. Glucagon helps to reverse the symptoms of hypoglycemia. A glucagon emergency kit can be ordered by a doctor or health care provider and carried with the person who has diabetes in case of emergencies. Even if glucagon is given, 911 should be called. Glucagon will not harm a person, but sometimes may cause vomiting or nausea.

References:

1. Hypoglycemia.  Wikipedia. http://en.wikipedia.org/wiki/Hypoglycemia
2. Rosen ED, Spiegelman BM. Adipocytes as regulators of energy balance and glucose homeostasis. Nature 2006;444:847-853
3. The importance of controlling blood sugar http://www.health.ny.gov/diseases/conditions/diabetes/controlling_blood_sugar_importance.htm

Disclaimer: Advanced Skin Wisdom provides the content on this website solely for informational and educational purposes. Information provided on this website should not be considered medical advice and is not a substitute for consultation with a qualified medical professional. Communications to or from the Advanced Skin Wisdom website and any person will not be considered to establish a patient/doctor relationship.

Most of the time dark spots or brown spots left after trauma or a burn to the skin are not permanent, although sometimes they can last a long time.

Dark spots (post inflammatory hyperpigmentation) on the face after acne

How long they last depends on a number of factors:

• how much pigment there is in the skin initially. Post-inflammatory hyperpigmentation tends to be worse and last longer in skin types IV-VI that have higher amounts of melanin.

• how deep the injury is. Deeper injuries that go into the reticular dermis cause scars (changes in skin texture) and leave long-lasting pigmentary changes lighter or darker than normal skin tone. If there is a burn that does not cause a blister or break in the skin, it has not reached the reticular dermis. To cause a blister, the injury should have reached at least to the junction between the top two layers of the skin (epidermis and dermis).
• how much ultraviolet light gets to the skin after the injury. UV light either from the sun or tanning equipment can worsen the hyperpigmentation and make it last significantly longer.

There are many popular home remedies found on the internet, such as petroleum jelly, lemon juice, aloe, tomato paste, among others. I would not advise using any of these methods as they all can cause additional inflammation and darkening of the skin. Using petroleum jelly (Vaseline) can lead to acne breakouts on the face, which will compound the problem.

The most important thing one can do after hyperpigmentation has already occurred is to use a broad-spectrum, oil-free non-comedogenic sunscreen with a high SPF to protect the injured areas from sun exposure.

Additionally, there are a number of topical medications that can improve the hyperpigmentation. If the injury is recent, I would just use sunscreen and give it 2-3 weeks to see if there is improvement.

If there is still inflammation and redness around the injured area, I would discuss using an anti-inflammatory topical such as a cortisone (not around the eyes) for a few days with your dermatologist.

If there is no inflammation and no improvement after 2-3 weeks, products like topical hydroquinones alone or in combination with retinoids (relatives of vitamin A) and cortisones can be tried to improve the pigmentation. Care must be taken with hydroquinones as longer use of these products can cause paradoxical hyperpigmentation.

I must add that without seeing the patient and the extent of the injury it is impossible to give correct medical advice and I am attempting to give general guidelines here. I would recommend a consultation with a board-certified dermatologist for a more definitive diagnosis and treatment.

More information on treatment of dark spots (hyperpigmentation) http://www.advancedskinwisdom.com/melasma.htm

Anal or perianal itching is a common skin condition that goes undiagnosed and untreated for years, because patients are embarrassed to bring that up to their doctors.  Many patients think,  ”They have to look down there?  No way!”  The importance of bringing this “embarrassing” topic up with your doctor cannot be overestimated.

Anal itch (pruritus ani) has a number of causes.  The right diagnosis has to be made first. Then treatment depends on the diagnosis.

Possible causes of anal itching (1):

• Fecal contamination due to either soiling (overt or occult) or inadequate cleansing. Approximately 50% of patients with pruritus ani have loose stools. Just to add (see below), hemorrhoids, growths (benign or malignant) at the anal opening or above it may increase soiling, again pointing to the need for a checkup.
• Hemorrhoids
• Trauma from overzealous wiping or cleansing
• Perianal infection with bacterial or fungal organisms. Fungal organisms, dermatophytes (those that cause athlete’s foot, ringworm and jock itch) and yeast (Candida) account for approximately 15% of pruritus ani.
• Allergic contact or irritant dermatitis, which can be caused by creams, soaps, wipes, topical medications, scent in toilet paper or laundry products, etc.
• Certain foods. This one has not been completely worked out, but citrus, tomatoes, caffeine and anything that promotes loose stools can potentially contribute to itching.
• Dermatologic conditions, like eczema, psoriasis, lichen sclerosus.
• Tumors, such as anal or colorectal cancer, perianal Paget’s disease (usually an extension of adenocarcinoma from the rectum), and Bowen’s disease (squamous cell carcinoma). HPV infections of the area may lead to development of squamous cell carcinoma in the area as well.
• Use of topical steroids, which leads to thinning and hypersensitivity of the perianal skin.
• Stress or anxiety have been implicated as well.

Here is the biggest problem. Once the perianal skin is scratched or rubbed, it becomes much more itchy, which leads to more scratching, creating a vicious cycle. The skin thickens, darkens and has accompanying neural changes leading to a condition known as lichen simplex chronicus. (2)

So treatment of anal itching very much depends on the cause.  A proper diagnosis must be made first. However, even when the cause is found and eliminated or corrected, the problem is how to deal with the itch.

Aside from prescribing medications to treat the skin condition, here is what I recommend for my patients with anal itching:

• Eliminate chlorine and all dyes and fragrances in anything that may touch the skin, including laundry detergents, fabric softeners, perfumes, etc.
• Switch to a non-soap cleanser. One of my favorites is Cetaphil cleansing bar (not the antibacterial one)
• Stop using washcloths, sponges, anything that rubs the skin in any way.
• After a bowel movement, wet a toilet tissue with warm water, wipe with the wet toilet tissue and then blot (not rub) the area with the dry one.
• Eliminate any wipes that may be used for cleansing. They are easy to use but can irritate the skin.
• When drying yourself after bathing, blot the area with the towel.

The perianal area is exquisitely sensitive to itch. The first thing in successful treatment of perianal itching is breaking the itch-scratch cycle. Even after successful treatment of perianal lichen simplex chronicus, the area is still very much prone to itching, so one should be very conscious of any rubbing or scratching as the condition will recur quickly.

References:

1. Siddiq et al. Pruritus ani Ann R Coll Surg Engl 2008;90:457-463 http://www.ncbi.nlm.nih.gov/pmc/…
2. Hogan DJ Lichen Simplex Chronicus. Medscape Reference http://emedicine.medscape.com/ar…

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There are a number of causes to chronic hair shedding. Clearly not all of them will be applicable to a young, healthy man. We normally lose approximately 100 hairs a day, and they are replaced by new growing hairs. So the problem comes when either the numbers of hairs shed per day is greater than 100 or if there is hair thinning in addition to shedding.

When examining a patient with hair loss, some questions need to be answered:

• Is the hair shedding or is it thinning?
• Is the hair coming out with the root or is it breaking somewhere on the hair shaft? Hair shaft fragility may be from over processing the hair (blow drying, straightening, etc) or may have a genetic component.
• If it is thinning, is there a pattern (hair line, scalp vertex, etc) or is it diffuse over the entire scalp?
• Is there scarring of the hair follicles? Scarred areas would appear smooth and shiny and there would not be any follicular openings visible on the skin surface.
• Is there a skin condition involving the scalp? Inflammatory conditions, such as seborrhea or psoriasis can increase hair shedding. Hair loss can also be caused by infections, such as tinea capitis, a fungal infection.
• Is the patient on any medications? Certain medications, such as beta blockers (blood pressure pills), cholesterol lowering medications, retinoids (such as the acne medication, Accutane), chemotherapy and a number of others can cause chronic hair shedding.
• Are there any systemic diseases? Diseases like lupus can cause chronic hair shedding, as can anemia, thyroid disease (both hypo and hyperthyroidism)
• Has the person had any major illnesses, surgeries, blood loss in the past six months before hair loss started?
• For women, is there a history of irregular periods or has she recently given birth? Abnormal periods may indicate hormonal abnormalities or greater than normal blood loss, which may result in low iron stores.
• Has the person lost a significant amount of weight recently?
• Is there a family history of hair loss, either from the mother’s or father’s side?
• Has the person been exposed to any toxins? Lead exposure, among others, can cause hair shedding.
• Is the person under a lot of stress? This is what is called a “waste basket diagnosis.” If everything else has been ruled out, and the person is under tremendous stress, that may be the final diagnosis.

Then, blood work should be done to figure the answers to some of these questions.

Things that I check for when doing blood work for hair loss:

• complete blood count
• comprehensive metabolic panel
• iron studies
• thyroid function tests
• ANA (anti-nuclear antibody) that may point to lupus or other collagen vascular diseases.
• vitamin D3 levels
• depending on the possibility of heavy metal/toxin exposure as obtained by the history, those may be added to the test list.

Another two tests that need to be done in evaluating a person with hair shedding are:

• gently pulling on the scalp hairs to see how many hairs come loose during the exam. The norm is 5 for the entire scalp. If there are significantly more, that may indicated a problem.
• using a clamp, actually pulling out with the roots and all, approximately 20-30 hairs and sending the specimen to the lab for an evaluation to determine how many hairs are in which stage of growth. The ration is usually 90% in growing phase (anagen) to 10% resting phase (telogen). This type of hair pull examination also looks at any hair shaft abnormalities that may cause abnormal breakage of hair.

I also have the patient do a hair collection for me once a week over 6 weeks, to see what types and how much hair is lost. That is done once a week on a day that the person washes his/her hair. All the hair found on the brush, in the shower, on the pillow is collected into a clear plastic baggy with the date labeled. This also allows for monitoring treatment, as with treatment the amount of hairs collected should go down.

If the blood work and history are negative, a scalp biopsy may be in order to figure out if the patient may have alopecia areata, an autoimmune disease that causes hair loss. Although alopecia areata usually presents with patchy hair loss/shedding, less commonly it may be diffuse over the entire scalp.

Another condition that can cause chronic hair shedding is telogen effluvium, which may be idiopathic (no known cause) but most likely is related to one of the problems listed above. A rare condition of chronic hair shedding seen more commonly in children is loose anagen syndrome.

Any rashes on the scalp need to be treated to see if that stops hair shedding.

In any hair loss condition, I have the patients start taking a vitamin, biotin, the amounts of which are determined based on the general medical condition of the patient and any underlying illnesses.

When I have all the answers to all my questions, I can put the information together and come up with a diagnosis and treatment.