Alopecia, Alopecia and More Alopecia: Practical Tips for Dermatology Providers with Dr. Michelle Tarbox

[MUSIC] >> Welcome to Derms on Drugs. A video podcast brought to you by scholars in medicine, the best educational platform in dermatology, and provided to no cost to medical providers. Derms on Drugs is where cutting-edge dirt meets huge or miscomedy. A medzires in each week and joined by my residency buddies, Dr. Laura Ferris and Tim Patton to use our 60 years of combined-derm experience to discuss, debate, and dissect the hottest topics in dermatology. It is everything you need to know who be on the cutting edge of dermatology and you'll actually have some fun listening. New episodes drop every Friday on scholars in medicine, Apple Podcasts, Spotify, and other major podcast platforms. Just a reminder that the video component has the key figures and tables from the articles we talk about. The episode description has a link that will get you to the links to all of the articles and other resources which live on scholars in medicine. So, for people who were listening last week, we covered some of the new interesting stuff in hair. In this week, we've got our very special guest, Dr. Michelle Tarbox, where we are really going to get into the nitty gritty and practical applications of things like red light helmets and supplements and all the other, what kind of lab testing she does, really a great episode. So, let's go ahead and get started. Dr. Tarbox, great to see you and get your expertise in hair. I don't know about patent and fares, but I try to avoid talking about hair as much as I possibly can. But what did to do this episode because as Durham's, we've got to talk about hair because that's who people come to, you know, whatever. So Dr. Tarbox, first just tell us a little bit about yourself. What institution are you at? How do you get interested in hair? That kind of stuff. Absolutely. And I want to say thank you so much for your patience because I am a little bit late to the party today because I got my time zones incorrect. And thank you also for being in this amazing group of people. I have great respect for doctors, patent, fares, and of course for you, Matt Zaris. So the fun thing about-- More for me, more for me. I'm obviously like the numbs getting wet. Yeah, I am. I am. I hold you all in equal esteem. I think you're all wonderful people and very honored to be on this podcast with each and every one of you. So I have been a heronard since I entered the dermatology world because I trained with Dr. Wilma Bergfeld, who is one of the pioneers in both the histopathology of alopecia's as well as the therapeutic approaches to it. And I knew I was always going to be a heronard as soon as my first year in derm residency. I also had the experience of having a pretty significant telogen afluvium early in my career because I had a trough needle stick. Have you ever had a trough needle stick before? That's when a needle is wedged in the trough of the sharps container. And so you have no idea whose needle it was. And so I had to take the prophylaxis medications for about a month. And that gave me a terrible telogen afluvium. And so I was compassionate, I think, in my treatment of hair loss patients before that event. But in hindsight, I'm really grateful for that experience because it gave me the lived experience of going through a telogen afluvium shed. And you really do feel like you're going bald. You really do kind of feel like you're dying because you're losing so much hair. And your experience with that representation in the media is always people lose all their hair when they have cancer or when they're very, very sick. There's also a problem with portrayal of villains in our media as bald. So you can think of many villains off the top of your head that are actually characterized as bald or have very thin hair. And it's one of those things that can create an even action. I was thinking like Sleuthore, you know, someone like Brainiac, you know, something like, along those lines. There's Professor Axe. He's a good guy. He is a good guy. And he is a handsome bald gen, Jean-Luc Picard, one of my very favorite people. I'm going through the data on this. I might publish it. I saw it on the location. I think that would be very cool. I would love that. So, you know, hair is fascinating. And hair is also a micro organ that has so many independent ways it interacts with the environment that people experience. It actually has olfactory receptors on it that reacts to things like sandalwood fragrance. There's a synthetic compound called sandalore that is made to kind of exploit that sensitivity of hair follicles to sandaldehydrase. So, your hair can smell? It kind of can. It also has cannabinoid receptors. So, I don't know if the hair can get higher or not, but it does have cannabinoid receptors on it. And it also has stem cells that can be turned into or differentiated into many of the tissues that comprise the skin. So, the hair follicle is a world unto itself. And you can probably tell that I could talk about this all day, but I'll get to the more practical business of treating hair loss. So, woman walks into your clinic. Let's start telogen afluvium. Okay. You know, you do your hair pull test, you're okay, telogen afluvium. Do you order stuff first visit? Because we were just talking about the like, none of us order stuff the patient, because there's no real evidence to support ordering it. There's no evidence that supplement, like you could just have hair loss and a vitamin deficiency, it doesn't mean they're related. But, it's evidence is hard to generate. So, it doesn't mean that it doesn't help. It doesn't mean we don't have any evidence to show that it's like, what do you do with telogen afluvium? So, I do have a thorough examination and take a very complete history to try to determine what the cause of the telogen afluvium is. So, if it's very clear cut, the patient had a baby recently, the patient's undergone a major life stress, the patient had COVID and started having that telogen shed, which I do want to talk about that in a second, because it's different than the telogen afluvium we get from other infectious diseases. But, the clarity of the cause can help dictate whether or not it do lab work. I also check with younger women if they're menstruating or they're menstrual cycles very heavy. Have they had any surgical interventions that might have caused blood loss? Did they have a diet that's very poor in iron? Because we do know that if you don't have replete iron stores, you won't really devote resources to making the hair. So, I've had patients who've come to me with a normal hemoglobin, a normal red blood cell count, everything on the CBC looks fine, but they're ferritin, which I like to kind of categorize as your savings account for iron, was like four. You know, and the normal range, you want to aim for kind of the middle of the normal range of ferritin when you're treating patients with hair loss. And that's about 75. Now, you do need to remember ferritin is an acute phase reactant, and so it can be elevated in states of inflammation. But I have actually also found about five patients that had undiagnosed hemochromatosis, and they're presenting complaint was actually the hair loss that can occur with that. And so we were able to make those diagnoses early for those patients. So the labs, I do check when I check them. I'll check an iron level, because we know we don't make good hair if we don't have enough iron. And I have had patients that have had very, very low iron stores, and when we made those replete and supplemented those, they were able to start growing hair again. Because the patients will not respond to hair loss therapies if they have very low iron stores. How low is low? Like at what ferritin? Do you just, if it's low at all, like, I have no harm, take some iron, or like, how low is the, do you put somebody on ferritin? My goal is to have their ferritin at about 75. That's a very good number to have. It's kind of breezy high, isn't it? It's kind of the middle of the normal range if you're trying to grow hair. For adult women, the normal range for ferritin is between 15 and 150. So 150 would be the high end. For men, it's 30 to 400 nanograms per milliliter. If you're getting above those levels, especially in women, you do need to think about either inflammatory disease or hemochromatosis. Women auto-flavotomize through their menstrual cycles. So the presentation of hemochromatosis tends to be delayed in women who carry both copies of the gene mutation. But it can be something you actually pick up through a hair loss workup. But this sort of sweet spot for getting hair to grow is around 75. 50 is reasonable too. But you need them to have enough iron stores that their body is able to devote those resources to hair growth. I'll also-- Is there a good, like, article that demonstrates that? Like, basically, we gave this person Menoxidil and their ferritin, average ferritin was 30. They didn't grow hair. Whereas the average ferritin of 80 in this group with Menoxidil did grow hair. Is there something like, I can say, yes, we absolutely know this. There are some guides about serum ferritin levels and treatment of patients with hair loss. And most experts do recommend your ferritin between 50 and 75 for optimal hair growth. And I could definitely send you some of those citations if you'd like to review them. So it is something that can be beneficial. Vitamin D is also helpful to check because vitamin D levels can be important in regulating hair loss. And you do find that patients also recover more quickly if their vitamin D levels are replete. Which is not unusual. For skin conditions, urticaria is also one of the conditions that responds better to treatment with replete vitamin D levels as does Vidaligo. And so those two labs are the ones that I will check if patients have historical evidence that something might be causing deficiency states. Whether that's heavy menstrual bleeding, recent surgery, a restrictive diet for vitamin D. If it's somebody who looks like I do, where I'm so pale that I literally glow in the dark. Like, if I go to cosmic golfing, my skin glows because I have been so aggressively photo protected my entire adult life. So I take a vitamin D supplement to make sure my levels are normal. Those are really the labs that I tend to check. If a patient has a sort of crash diet type situation going on, I might have a CMP to look at their albumin and make sure that they don't have organ damage from that kind of dieting because we do also definitely see significant hair loss in patients who have crash dieted or gone through some of these very heavy weight losses. And I'm sure all of us have seen patients who've been treated with ozempic, [BLANK_AUDIO] come in with very heavy hair loss because of the rapid weight loss. I kind of described to my patients that there's a little blind caveman that lives in the back of your abdomen and regulates the processes in your body and when certain levels get low he freaks out and gets very tight-fisted with things and he's like I would hold on to all of the iron and I will not send any of it to the hair because I need it to make red blood cells and those patients I've treated that have had ferventins in the single digits have had normal hemoglobin and normal red blood cell counts so he has to be a blind well because he's sensing things you know he doesn't have the full picture so we also you know notice that he freaks out when you freak out so if you're super stressed out and you're doing a cortical like hormones or super elevated all the time he's like obviously it's an ISA to tigers come into kill me and we have no food so I need to not devote any resources to anything that's not essential so I'm not spending anything on the hair that I don't have to which is often why we shift into that telogen afluveum now the telogen afluveum with COVID is different it happens earlier and it's more acute and severe I've experienced that also so I'm apparently very telogen afluveum vulnerable I had I had COVID in January of 2022 is the Omacron variant I know exactly the patient I got it from it was a hospital patient that was following up he'd been hospitalized for pneumonia he came in for his follow-up and he was still coughing we all had masks on he took his off because he had a vagal from the biopsy procedure and we were in the room for a while even though I was masked that Omacron variant was very contagious and so I had a telogen shed one month to the day that started one month to the day after I had been infected with COVID and I've seen that over and over in my practice when patients have a bad COVID infection the shedding starts at about a month it's it's much faster than a traditional telogen afluveum and there's some thought that it's because of micro thrombi in the circulation that actually supplies the hair follicle there've been a couple of papers about that but it is still something that they're trying to kind of whittle down on the science with so that's one of the things that I think we need to take a really good clear history with for patients I like to of course do a complete skin exam and I use tricoscopy because you can pick up a lot of subtle mimics of telogen afluveum with your dermatoscope so you can pick up subtle signs of generalized alopecia ariata which can mimic the telogen afluveum shed you can also pick up signs of syphilis and I've had two patients that had syphilis they didn't have telogen afluveum their hair loss was infectious not environmental or nutritional what is syphilis look like on tricoscopy it makes the hairs have this little zigzag configuration and the scalp is scaly so if your histopathologist is a dermatopathologist when you look at a scalp biopsy where there is syphilitic alopecia it has many of the same findings that alopecia ariata has so you can see also those catavorized hairs that break right off at the surface and make a little black dot you can see yellow follicular orfuses with keratin plugging in them because the hair shaft isn't growing but very frequently the trepidemes are also in the epidermis and epidermis is scaly because of the inflammatory reaction to their presence and so it looks like scaly alopecia ariata and so you definitely want to think about checking a syphilis test whatever your institution offers in that setting so those those would be some other lab tests that I might I might check but I like the discussion you were having as they came on about the nutritional supplements the viscale is one of my gochus for patients who are having significant shedding because it is affordable it has the most data behind it in terms of studies and it also has not got an astronomical amount of biotin in it it does have some biotin but it also has some other nutritional support that's very helpful for patients and it's relatively easy for patients to get they are like what your theory on why it works why does a marine complex is it the amino acids is it kind of the same idea is carrot like why would it work you know I think it's similar to what you were talking about with the keratin we're learning more and more the importance of peptides and how they can regulate processes in our body and keratin is it's a protein you know it is one of those things that our body can sometimes react to and I think that that's one of the reasons I also think that as humans our sort of food sourcing has become a lot more artificial and getting some of the micronutrients that you get from the amino-mar complex I do not sell viviscal in my office I don't work for the company I have no conflicts of interest here except that I buy it as a patient and it is one of the supplements I take myself because I've proven that I am vulnerable to television flu games and I am under a little bit of stress from time to time as a department chair so I do take my viviscal I will say the one thing I don't like about viviscal is just that it's like a sweet tart that's fish flavored so you just have to swallow it fast not that's not popular the convenience stores you know I mean that you just flavored sweet tart would you like some some little fish flavored sweet tart then you could put the flakes just getting but it's it's they do they do make a keratin powder that's I able to cover the you know palette fetches of all the fish of that's just keratin there's no fish flakes in there so they they lost that on that marketing opportunity I tell them every single time you could have held it fish flakes you gave that up but I really like the viviscal lots of patients are looking for a natural supplements to be helpful for their hair growth I couple the viviscal and patients who have androgenetic pattern with a natural inhibitor of DHT if they want to stay natural so pumpkin seed oil does have a natural inhibitor of DHT synthesis of five alpha reductase inhibitor it's not as powerful as finasteride but that also means it doesn't come with the side effects and the drama finasteride can come with and they're also micronutrients and pumpkin seed oil that can be beneficial for hair growth as well and so patients can benefit from that in more than one way and it's a pretty darn harmless supplement it's very easy to get it isn't likely to have contamination in it so I like the pumpkin seed oil I like sawpal meadow as well of course you want to avoid anything that messes with hormones and pregnant ladies we spoke about neutrophil earlier and they do have a formula for people who've had babies recently I don't think any company is going to say take this while you're pregnant see what happens but they make one for postpartum that has no sawpal meadow in it to allow for women who are breast feeding to take that supplement so I think that those are all good quality supplements I'm glad you brought up the sort of hepatic enzyme changes that have been reported in some of the patients who take neutrophil there rare but they aren't non-existent and it is also harder to take the neutrophil it's a great supplement but it's four big capsules and for some reason the two you know sweet tart that are fish flavored tablets are easier to get down than the four capsules that are full of turmeric it's a very nice turmeric and there's you know good health benefits to that as well but how do you all feel about the red light helmets? I think they sound ridiculous but the data says they were like there are multiple studies now 630 nanometer range it just sounds dumb it's a nice thing along with the supplements because it's like you you're on your own go if the here's the data I do think it's decent data and if you want it you don't need me they're expensive so I don't know at what point you would tell somebody like if they said well you know what I'm gonna start working a second job so I have no money to get this helmet I think at that point be like yeah you really want to do that like is that really something you want to do so I do like them if people can afford them what I tell patients also and if you look on eBay you can probably find these a lot of people resell the hair max laser comb because you have to hold it and move it through your hair and so a lot of people just don't use it and so they'll resell it on eBay and stuff like that it's a little bit less expensive than the caps are and it's actually a better device if you have a lot of hair because you can't really count on the caps to get that much light to your scalp if they're just sitting there on top of a big hair mass so the comb can work a little bit better but you're absolutely right what's your light the light what is your favorite one direct so patient who's not destitute what's your favorite one I like this question because I've tried all of them because I am a hair nerd and so I've tried the comb the comb I've tried the two that look like helmets from Tron which is the ira store and the Theradome those two look like the Tron helmet in fact I think I have one of them here I was gonna say will you please put one on yes all right I am to please so this is the ira store so this one has the disadvantage of having to be plugged in so does the capillus and the Theradome has a battery pack on it but it's very heavy so the Theradome doesn't have to be plugged in the Revion in my personal opinion is the most elegant one that one has a rechargeable battery that's tiny in it it looks like a riding helmet like one of those equestrian riding helmets it's very lightweight there's no plug to kind of plug you into the wall or to a battery pack and it has the better wavelengths for improving absorption into the scalp we believe that the mechanisms that low-level laser therapy works through in the scalp is that it actually improves mitochondrial function and improves the metabolism by sort of photodysecting the carbon dioxide off of the end step of the oxidative the oxidative pattern in mitochondria and allowing them to sort of reboot their engines a little bit so it kind of jump starts the mitochondria there's some evidence it decreases DHT levels in the scalp and decreases inflammation as well as improving circulation so I personally do use my my Revion cap I also have as you saw the ira store my Theradome I had two of those and they both died on me so I don't recommend Theradome because I haven't found them to be reliable devices and I gave my sister my hair max laser cone because I don't have time to like go through the scalp with it because you have to put it in one place and you hold it for nine seconds and then it beeps at you and you move it a couple of inches and it beeps at you and you go through your whole scalp that way so how long how long and how often. So the one study I saw was like 20 minutes once a week was enough. But is it like the more if you use it for three hours every day, it's going to work, you know, you're going to have a big bushy head of hair in like two weeks, like how obviously I'm making that. But like, did they have to use it every day? Like, what's the, what do you tell people? So the recommendations actually vary by manufacturer. So for the I restore in the TheraDome, the instruction to use it three times a week for the capillaries. It's a similar recommendation pattern, but I think that the treatment interval could be two days per week as well. And then the revion is actually daily. The other thing I like about the revion is that there's an app for it. That's actually how you activate the device. Superb right there. Nobody's going to do it every day. That is ten minutes. I don't know that that's true. No, how long every day? It's ten minutes. It's exactly ten minutes. And you know, just pop it on your head and you take it off. Can you do it in the car? You could if you don't mind having a question and writing cap on in your car. It's fairly chic. So long as you put the charging port down, otherwise it looks like a beanie with a little like round thing on the top. But so it could look a little bit dorky. There is, there is a sort of sweet spot. So if you overdo it, you can potentially kind of overheat the scalp. That might not be the most ideal circumstance. That's actually why I didn't like the original version of the capitalist because the cap was very occlusive. And I felt like it generated a little bit too much heat on the scalp. But there is a good therapeutic window. You don't want to overuse it. You just want to be consistent with its use. But the revion's the one I like the best. And is laser is low level laser better than LED? Or is it not matter? That's a very good question. The really important thing is to get the therapeutic wavelengths somewhere between 630 and 660. There's also some that have near infrared with 810 or 850 nanometer radiation. You want to make sure that the light sources are high quality. And you want to make sure that the device is sturdy. Like I said, I had trouble with two theratomes in a row. And that's a very expensive device to have malfunction twice in the same way. So you want to be cognizant of what your good investment value is. The revion that I use now I've had for two years with not a single glitch. So you're saying don't buy them off of Timo or shine? Oh yes. Yes. Well, that's how they get your thoughts. Come on. That's how they access your secret thoughts. China would be destroyed if they stole Matt's thoughts. So I think that's a good idea. It could be a good national security movement. Where do you buy them? Do they like go to the dealer website or like I'd never recommended one of these ever. You know, seriously? No. The thing that I always do. So I always like to examine the device, learn about them at conferences. I actually learned about the Revianate Fall clinical. I got to meet with the people who, you know, talk about the company, see and handle the device. But of course our patients don't go to our conferences, right? So there are. Yeah. So there are a lot of the conference right there. You know, it would be it would be interesting. It would be it would be intriguing. So the best way to to purchase them is to go straight to the website of the device manufacturer. That's where usually the best opportunities are for discounts. They always have sales around, you know, the big sale holidays. So President's Day Memorial Day. Once coming up now, actually Memorial, could you go you could go on their Memorial Day website sale? They get them for like the, you know, Black Friday, that kind of stuff. And that is usually the best time of year to buy them is Black Friday. They usually run deals at that time to, you know, Christmas gifts for the whole family. Exactly. And you can, if you get the ones that look like a drawn helmet, you can like also use them for costumes. So that's perfect. All right. So do you put everybody do you recommend Manoxa Dill as like a reflexive? So we did one article like a few months ago that was that hair consensus statement, the Manoxa Dill consensus statement where they said just everything. Everybody with any hair loss for any reason should all be a Manoxa Dill. Like do you? I offer it so long as the patients and appropriate candidate from Manoxa Dill, I offer that therapy to the people who aren't or people who have an intensive cardiac condition. So the first question I ask is do you have a cardiologist? If they have a cardiologist, we'll confer with the cardiologist. If the cardiologist is cool with it and some of them have been like, oh, that's great because I've had trouble with their blood pressure anyway and this will help. You know, so some of them have been really happy about putting the patients on Manoxa Dill. Some of them have been a little bit more cautious just depending on the patient's condition. So that's one set of persons that I wouldn't put on Manoxa Dill. I do treat children with low level oral Manoxa Dill dosing and they do your laundry. Like children, how old are we to a library? Like 16 or like nine? The youngest one I've treated with that was nine and it's compounded with a much lower dose. severe alopecia areaada, they were also one of their therapeutics but it was really impacting their ability to participate in school activities and things like that. And so the parents really wanted to try all of the potential therapeutic options and so we gave the trial of the low dose oral Manoxa Dill. She did beautifully on it, tolerated it very well. If I have a patient that is extremely anxious, I'm a little bit more cautious because one of the things that can happen as a normal side effects kind of the wrong word but reaction to Manoxa Dill is you get a reflex tachycardia when it takes action because it is a potent phasor diolator. And if you have a patient that has really bad anxiety and they get that heart pounding feeling in their chest, that can set off like a panic attack for them. So if I have patients that have to take alprasolam for the panic attacks, that's not a patient I would start off with Manoxa Dill with. But it does work for basically all types of hair loss. We feel that even with some of the scarring alopeces, it moves some of the hairs out of the category of most vulnerable hairs which are the transitional kind like with FFA. Yeah, our more vulnerable hairs for FFA are sort of our transitional hairs between terminal and vellus. And you get a little bit more stability of the frontal hairline with low dose oral Manoxa Dill. I usually do combine it for that condition with an antitandrogen of some type because there's some evidence that dysregulation of lipid processing is one of the potential immunologic triggers for FFA. And you can stabilize that with either finasteride or detastoride. What about spurnal actone? And I use fronal actone too and younger women that can't be on finasteride or detastoride because of child during potential. Spurnal actone is a great medication. It has been shown to be safe and efficacious, even in breast cancer survivors. There is that bad study out there that was done on rats. There were so many errors in that study. The super physiologic doses of spurnal actone was one of the issues, but they also had a pathologist looking at the slides that was unfamiliar with rent memory gland pathology and they were reading hyperplasia which we know can happen with spurnal actone as cancer. And so that's where all of that kind of Michigan shabot the safety issues around spurnal actone came from. There was a great paper in the international journal Women's Dermatology that showed that you don't really have to check potassium levels unless the patient is over 40, really 45 was their cutoff in the paper, but out of caution I do 40. Do you check it just once at baseline or do you check it regularly? Do you check it at baseline and at three months to never again? What do you do? Because I generally my screening is anybody ever told you have a kidney problem? Okay, no potassium testing for you. That's that's my potassium screening. In young patients, I do it that way. Absolutely. In patients who are 40 or over, I ask if they've had any recent lab work, we make sure their potassium levels are sitting at a normal range and then I'll usually check again in about six months and we have a big conversation about avoiding combining spurnal actone with either backdram or cipro because both backdram and cipro can act as potassium sparing diuretics and when they're taken together with spurnal actone they can cause hypercalemia that can become dangerous. So we have a conversation about that every time we start that drug. So monoxidil and spurnal actone. How do you do it? Do you? Because monoxidil, I've heard some people be like, Oh, I start them at I start men at 2.5 and I get them up to 10 and I start women at 1.25 and I get them up to five and I'm like, my God, I never go above 1.25 and anybody. Not even men you don't? No, maybe I should. I start men at 2.5. I do too. So I start women at 1.25 just because of the facial hypertrophicosis. Some women have it very quickly and you can't go above the 1.25 dose. Some women don't get it until you go over 2.5 milligrams per day. Men, I start at 2.5 milligrams per day and if they're not responding or if they need more dose response and they're asymptomatic then we'll go up to 2.5 twice a day but that's kind of my top. I did have a patient that came to my practice that somebody had in a good faith effort tried to help by starting monoxidil but they put this for a lady on 10 milligrams of monoxidil a day and she had such bad peripheral edema because of that that she was having trouble walking and when we talked to her about her hair loss and we're like we could potentially start low-dose oral monoxidil. The look on her face when I said that was like I said and I could walk into your house and shoot your dog in the face because like she was she was she was like no you know but 10 milligrams so the word has gotten out about low-dose oral monoxidil but some of our colleagues who are not dermatologists might not know what low-dose oral monoxidil means and so you may run into people being treated with inappropriately high doses like 10 milligrams per day and a non-hypertensive woman is way too much monoxidil for a patient to take. And for Spurnal Actone do you do right an acne certainly it seems to me that the higher the dose should go the better it works. Yeah. Is Spurnal Actone the same thing or do you do 25 and that's You know, in healthy young women, the tolerability of frontal actone is pretty significant. I do tend to start low and titrate up because there's some evidence that that decreases side effect incidence, but you are correct that higher doses are more efficacious and for hair loss and hair suitism usually get your best results between 100 and 200 milligrams a day. So they are higher doses of this frontal actone. You do have to talk to patients at that dose level about the potential for breast hyperplasia because they can have some changes in that tissue at that dosing range. Although I don't run into that trouble too frequently, we always discuss it so that the patients aren't concerned if that does occur for them. Pat and Ferris, I've gotten my questions answered. Pat and Ferris, you guys got anything that you're still wanting to know? I'm wanting to know what about ketoconazole shampoo as something that's just sort of like, you know, I started just recommending that. So I love, I'm not a hair nerd. I do not love hair loss, but I'm like, all right, I can, you know, go with low dose oral monoxidil for everybody. I don't check labs. I get a basic medical history, but I have started doing like ketoconazole shampoo. And, you know, a lot of people have a little underlying subderm at mind help that. I'm like, it probably, you know, I don't know. I think it maybe helps a little bit. What do you think? Do you ketoconazole shampoo you like? I do. I think it's actually a great anti hair loss medication. It has an anti-androgen property. And there's been a study that actually did ahead to head, forgive the pun, study of topical 2% monoxidil twice daily up against ketoconazole twice a week. Ketoconazole 2% shampoo twice a week, so the prescription strength. And they actually had equal performance in terms of hair regrowth. So there is definitely something to what? 2% monoxidil applied topically twice a week. Wow. Wasn't it just in women or men and women or how do you know? That study was done in women. Just women. But I think that that's also been demonstrated in men. And it's a very useful ingredient. Now the downside to the prescription ketoconazole is it's made like a caveman made shampoo. It's like soap medicine. You know, so it's like not very cosmetically elegant. And so I'm obsessed with cavemen. I've just realized. Yeah. You're the guy in your stomach who's making you. You know, like, um, it's a different. We have patients that come to us from Carlsbad and their mascot is actually the caveman. Isn't that hilarious? Like I love that Carlsbad, New Mexico. We've got the caveman and cave women that come to CS. But the ketoconazole shampoo isn't terribly cosmetically elegant. There are a couple companies that have made a more stabilized version of the ketoconazole and you do have to also be aware that it can strip color if a person has colored hair. And so it's not my go to somebody has a lot of, you know, very complicated highlights. And they obviously spend a lot of money coloring their hair. I'll use a different agent or I'll use one of the stabilized cosmetic versions. There's a company I have no conflicts of interest with. That's called revita or EVI TA and then core COR. They make some hair loss shampoos. They even have a very interesting one that takes advantage of that cannabinoid receptor. It's a CVD shampoo, which does have that CVD smell to it in the shower. Most people don't walk around smelling like they are enjoying an alternative lifestyle when they're out of the shower. So they can use that and still go to their job, even if they're a judge or somebody who's in the legal profession. Any other shampoo you like for hair? So I can't remember the name of it now. There used to be that one. Nioxin. Nioxin. No way to ask about that. Yeah. Nioxin actually is a very interesting product. It has some activity against demodex of all things and does have some benefit. I think it's biggest benefit is that it's very, very gentle. So patients whose hair is not growing well tend to have more fragile hair and it can break more easily. It tends to also be more difficult to manage. So a shampoo that doesn't have sodium laurel sulfate and things that strip moisture can be helpful. There's a great shampoo conditioner made by a dermatologist called Cine SEEN. I have no conflicts of interest with that either. It is a very hypoallergenic product. It's great for patients that have what I like to call telogen effluvian plus where they have like an itchy scaly scalp and they're having hair shedding because it helps to decrease the number of potential irritants or allergens they're exposed to. And for our patients that do have FFA or like in planus, there's some evidence that contact dermatitis to fragrance plays a role in exacerbating those conditions, specifically to things like linolewol is one of them. But geranol is another one and those are very frequently found in fragrance shampoos and they're not in the Cine shampoo which also is very, leaves the hair very manageable and soft. It's a nice product line. As a dermatologist. I would say as a contact dermatologist and I think those studies are baloney. If you have contact dermatitis and it looks like okay, but it's hard for me to buy that there's asymptomatic contact dermatitis could be contributing to hair loss. I do find that the most of my patients that I have done patch testing on that have fragrance allergies and LPP or FFA do itch. So they may have like concomitants. Then it's reasonable. Yeah, I think that's possible. They have both. But I think the most important thing is to meet the patient where they are. Some people are really very comfortable with anything you offer them. They just want the hair loss better and they'll do everything. So I have some patients that have the helmet and they do, oh, we haven't talked about scalp massage yet. We'll talk about that in a second. They're doing scalp massage. They're doing, you know, twice weekly oiling of the scalp. They're putting on topical compounded prescriptions and taking lotus oral monoxidil and maybe an antianidrogen. And then I have other patients that don't want anything pharmaceutical and want everything natural and you have to work in that arena for the patients. I do like scalp massage. There was a very interesting article that showed that regimented scalp massage given five minutes daily with regularity changed gene expression at the level of the dermal papilla so the part of the tissue that holds the hormonal sensitivity of the scalp and grows the hair and nourishes it with the blood flow. That tissue had change in gene expression by the mechanotherapy of doing scalp massage, which is interesting. If you look at traditional care practices, many of them incorporate massage as a part of the therapeutic regimen. It doesn't matter if you massage your own or does it work better in treating that. Somebody else. I think for gentlemen, it probably works better if it's a beautiful young lady that's doing the scalp massage or something along those lines. There's some really nice information about the potential for improvement of scalp hair loss and also tissue elasticity with scalp massage. I don't know if you felt the scalps of some of your patients that have antigenetic alopecia, but very frequently those patient's scalps are very tight, like a little timpani drum. Getting some movement back in the scalp, some suppleness improves the circulation to the scalp. There was a paper that looked at circumferential Botox for the scalp and improvement in hair growth. They thought that the changes there were attributable to the relaxation of the musculature that makes the scalp more tight. The frontalis and occipitalis muscles kind of clenching down on the scalp aphenurosis and making that tissue a little bit more tight. There's some I think very nice supportive evidence that scalp massage can be beneficial. The other thing that's nice about it is that it is a process that gets the patient to touch their scalp that they've developed maybe a little bit of an adversarial relationship with. I've found that sometimes patients have a negative set of feelings about the tissue that they're presenting with the problem for. The ritual of massage can kind of reconnect the patient to that part of their body. They're caring for that part of their body in a very intimate way. I think that there is power to that to help the patient kind of reestablish a relationship that isn't adversarial with that part of their body. They love and appreciate what their body is doing for them. Just like we work in patients who are trying to improve their lifestyle, we find that it's much more productive for them to look at their body in the mirror and talk about all the good things their body can do. I'm grateful for my body because it helped me bring my babies into the world. It helped me to run a marathon and things like that. Instead of, I hate this, I hate that. The changes can be more productive if the patient has a positive attitude about it. The other benefit, which is a little complicated, but the placebo effect with hair loss studies is often very, very high. I think taking advantage of that by giving people reasonable things to do that may help. Can be a successful strategy to get patients to the point where their hair loss isn't running their life because I think we've all met patients who have become expert connoisseurs of their own hair loss. I've even had patients that bring, I'm not kidding here, a laminated photo book with dates and then the wad of hair that they shed from the shower in the photo book, like in the photo album each day, and really have lost a lot of their life time and life quality because of sort of an obsession that has developed with the hair loss. So if you can turn that attention into action and that action has the potential benefit, I think you can really help the patient to kind of recover some positive feelings about their own body. Patent, you got any final questions before we move into trivia? No, no, no, let's just go to trivia. What is that? Let's do it. All right, Dr. Tarbox, the rules are we have to let Dr. Patent finish the question. And as soon as he finishes the question, you can shout out, first person to shout out the correct answer is the winner. Oh my goodness, this is exciting. And there's no prize. It's just all for. for the glory. For the glory. -Farris won the first like 12, but I'm on a streak of winning. -Yeah, now I'm losing. -Beater the last two. -It doesn't surprise me, Dr. Ferris is a very smart cookie as our both Dr. Rosaris and Dr. Pattinson. -All right. -All right. -So, hair trivia, ready? What song from the musical hair spent six weeks at number one on the Billboard charts? -Ooh. -Hairspray. -Is it just hair? Is it the theme song? -No. -Let the sunshine. -Oh, that's probably a good job. -Farris. -Did you look that up? -No, I did not. -Yeah. -Okay. -How shall we lose points as we speak? [laughter] -Yes, so technically the song is Aquarius/Let the Sunshine. And it was released as a single by a group called The Fifth Dimension. But that was close enough. I'm giving you the point. -Thank you, Iris. -What 2010 Disney movie was an updated take on the German fairy tale Rapunzel? -Tangled. -Tangled. -I was going to say Rapunzel. -Tangled. -Rapunzel too. -All right. We'll make it last question. A little bit of a medical. This is ostensibly a medical show. So, low-dose ormanoxidil being prescribed more and more these days for the treatment of Androgenetic alopecia. And what year was Oromanoxidil FDA approved to treat hypertension? -Is it 1981? -1992. -No. 1983. -1993. -No, so, you said '82 first as your first guy? -I said '81. -That's the closest. 1979. -Oh, I was going to say maybe, okay, yeah, because all the case reports came out in the early '80s about people with total body hairstatism with the IV. What's really interesting is in the early 2020s, there was a rash part in the fun of hairy babies in India because a infant gas formula got mislabeled ormanoxidil got switched, I guess, for the infant gas formula. And so, all these little babies that were supposed to be getting relief from their colloc just got hairy everywhere, little one, plague of werewolf babies. -Yeah, I heard about that story. That was great. That's how we knew it was like really safe. -Yeah. -They were giving this to a bunch of little kids. -And they were fine. It was an accidental experiment on babies. -Yeah. -All right, Michelle, thank you for coming on. This was so much fun. And I want to thank all of our listeners for joining us. If you got questions, comments, ideas for topics, shoot us an email, questions at termsondrugs.com. And we hope you learned a few things. We have to laugh once or twice and mostly we're hoping you're planning to join us next week. Until then, I'm Matt Zyrus. I'm Tim Pat. And I'm Laura Ferris and we are termsondrug.