Hair Today, Gone Tomorrow? Supplements you haven't heard of, lab testing for telogen effluvium and managing folliculitis decalvans

[music] Welcome to Derms on Drugs of Video Podcast brought to you by scholars and medicine, the best educational platform in Dermatology and provided in no cost to medical providers. Derms on Drugs is where cutting-edge Derm meets Cid or Miss Comedy. A Matt Zires in each week I'm joined by my residency buddies Dr. Warf Ferris, Dr. Tim Patton, used our 60 years of combined Derm experience to discuss, debate and dissect the hottest topics in Dermatology. It's everything you need to know to be on the cutting edge of Derm and you'll actually have fun listening. New episodes drop every Friday on scholars and medicine, Apple podcasts, Spotify and any other major platform you might use. Just a reminder for everybody there is a video component that has to keep figures and tables from the articles we talk about and the episode description as a link that will take you to scholars and medicine where you can get the links to all the articles and other resources we discuss on the episode. This week we've got something super special for you. There has been such cool stuff in the area of what I would call non-invasive hair restoration. Supplements and helmets and all kinds of stuff that we're actually going to break this deep dive into two episodes. So this week we're going to talk about three articles that Dr. Patton Ferris and I thought were great. One looking at flickrlydistic calvins, one looking at lab testing in people with the Illegina Fluvium and one looking at all of the hair supplements that are out there. And then next week we're going to have a special guest, Dr. Michelle Tarbox and we are going to really go in depth into all of this stuff. So let's go ahead and get into it. Dr. Ferris, what do you got? So I picked a paper that was it published in JEDV which is management of flickrlydistic calvins, the EADV task force on hair disease position statement, waskill, burnot at all. So you know why did I pick this? Flickrlydistic calvins, are they can be challenging? I got to be honest, I also recently moved to North Carolina. I have a far more diverse patient population than I had in Pittsburgh and so it's like you know there is you know teal genofluvium, I've seen that, I see it all the time. I'm like let me brush up a little bit on flickrlydistic calvins. See what other people say. So I'd want to see like is there anything that I didn't really know? But you know, this is also the European you know perspective on it. So one of the things that I thought was kind of interesting was that you know they talked about flickrlydistic calvins existing in a spectrum with LycanPlanopilirus and they had some like long abbreviation that there are these patients who sort of have both. They have like some like some LPP and some FD. I never really thought about those two diseases together. Those two was being like oh yeah so people have over. No they used to talk about there being lymphocytic scarring alopecious and neutrophilic scarring alopecious and like this with the prototype two diseases of like the two different totally categories. I think that my theory is is that follicular is the calvins when it doesn't have the neutrophilic like postgular component to it that you may not see the neutrophils there and I think it's misdiagnosed as LPP. I think I had patients that I saw the time where they would come in and like clinically diffuse their theme a yes perifilicular scale but it wasn't that sort of very selective attack on the hair follicles that you saw on LPP and the patients came to me with the diagnosis of LPP. I was like this is not LPP. I think I think like a lot of people depended on those needs to be there and I don't know that they're always there and follicular is the calvins. Do you think a bite of the theory? Will a biopsy separate the two in that situation or do you think even the biopsy is? So the biopsy with LPP like when you have a this is totally my experience based on nothing. When you have a patient where you're like slam dunk LPP, right? Like your FFA patients. You biopsy that and the pathologist is like this is like in plain up I lures. When you biopsy flick your lice the calvins and they don't have that postgular process it's one of those weird reads in path where they're like I don't know there's a little bit of inflammation and it's kind of scarring and I don't really see neutrophils so I don't know. But in my experience slam dunk LPP from a clinical standpoint the pathologist will flat out say like in plain up Leras. Okay. Okay. Fair. All right. All right. Fairers. Let's go. All right. There's an FD PGA. There's a PGA for everything. So there's an FD PGA zero clear one mild which is perifilicular erythema and hypercarotosis. No postgules are crusts. Maybe that's what you're talking about. It is stage one. And then and then stay and then mild and then they skip right to moderate in this figure which is a little bit weird. Interest three but they call it three. Interfilicular erythema and/or hypercarotosis beyond the hair follicles possible presence of several postgules and/or thin crust and then three is interfilicular erythema and/or hypercarotosis beyond hair follicles many postgules and/or thin crust. Okay. All right. So they talk about topical therapy not much that was new here. Ultra potent topicals stare ideally for one to five weeks can also consider adding topical antibiotics. They talk about using topical tachyrolitis BID. Topical depth zone gel 5% 3 times per week to decrease flares. I was kind of like if you're going to use it wouldn't you just use it every day. Topical washes with hibiklens. Intrelational therapy, TAC 2.5 to 20. Intrelational Q1 to 3 months decrease. Concentration frequency is erythema decreases. There's some small studies with PDT as well. I've never done PDT for this. What do you guys think about those? Yeah. Don't think they do much. Topical parents. Maybe some clubbing is also my okay. Yeah. I okay. I tend to do. Oral antibiotics touch cycling not totally shocking. I think that's kind of one of our standbys and then clindamycin clindarifampin 300 BID of each for 10 weeks. They said is one of the most effective treatments in one study 55% of patients had good response, no recurrence and two to 22 months to follow up. And then they also said there's some small studies to support azithromycin or chlorotherymicin. Clindarifampin I think is something that is like a reasonable go to if people have pretty active disease thoughts. Yeah, great completely. I think 100%. Yeah. 100%. H.S. as well. I think it's I think it's uniquely uniquely effective in H.S. as well. I think the penetration of the refampin is is into the follicles is important. Right. Now agree. And then Oral steroids. They said like prednis prednisone or prednisolone 0.5 to one makes per cake per day or dexamethasone 0.5 to 0.75 make per cake per day twice a week are recommended for highly active folliculitis to calivins usually in combination with oral antibiotics. The duration should be limited to approximately three weeks. I got to be honest. I don't do a lot of oral steroids for this. Do you guys? No. If somebody, no, but if somebody Jerry Shapiro likes to use the term a trikeologic emergency where if you if you don't shut down the inflammation immediately, you're literally losing follicles by the day. Okay. That's that's the terminology like she was a trikeologic. Like CPR for the hair follicles. Yeah. We're clear. And then the other thing they talked about was isotretnoin, which I think makes sense, like 0.1 to 1 make per cake for 1 to 8 months. And so they said complete response. It observed an 82% of cases in one study. You know, they're very big on isotretnoin in this paper. So they actually have a like a one figure in here where they're like do you have mild moderate or severe disease. All of them go on isotretnoin. The only difference is moderate should get some oral antibiotics to calm them down. Then go to isotret where a severe should get apparently in the trikeologic emergency phase oral antibiotics and glucocorticoids then go on to isotretnoin. Then they're like then you go into all your other you know potential things meaning hydroxychloroquine oral dapsoin, you know your TNF inhibitors preferably adolimimab, your jack inhibitors, pdt surgical excision blah blah blah. But basically like their take home was everybody who has this shigalon isotretnoin. It's just a matter of like do they go on do they need something first like an antibiotic and/or a steroid? You guys have all like I didn't think of isotretnoin is like that's the be all end all of everybody with foliculitis to cow. Yeah. Meaning there. 10 weeks when do I famp in and I mean, that works really well. Maybe they're just seeing more severe disease. I don't know if I've ever -- -I don't know how to help you pee. Maybe that's what it is. No, I -- -That's a good -- No, I thought that that was -- and I thought it was interesting, too, because I'm like -- it's sort of like all my, you know, my therapeutic ladder, but I'm not like, "Okay, it's just a matter of when we start your eyes, so try to -- -Yeah, right. -- I have not looked at this disease in that way, so I thought that was interesting. Adjuvants are the topical, interleasional glucocorticides, as for -- glucocorticides is first line. Second line is tachyrolyma, topical tachyrolymas, or dapzone. So interesting, sort of a little difference, but, you know, maybe it'll make me think about going a little bit earlier. Think about isotretino, more often. -That's my reason. Yeah, when I looked through the -- through the text of the article, they seemed to -- the implication was the isotretino and it's kind of like acne, where you're given the isotretino and for a full course, and then puts them into long-term remission, which, if that works, yeah, I couldn't -- I can get it if -- I get it, if it puts them into remission. Sure. All right, Pat, what do you got? -All right, my deep dive is from the Journal of Cosmetic Dermatology is titled Retrospective Review of 2,851 Female Patients with Tealogen Ofluvium, a single center experienced by Caracoyan at Al, available online, February 2025. This was a retrospective study from Dichlay University. I think that's how you pronounce it in Turkey, involving 2,851 female patients that presented with hair loss between 2010, 2004, and had lab work done. Ages of the patients ranged from 8 to 79. Most of the patients, 83.5%, were between the ages of 18, 14, and 45. Table 1 looks at the population overall. Table 2 breaks down the groups into less than 18, 18, 45 greater than 45. But most of the patients were in that 18, 45 group, so I think Table 1 is sufficient. So just going down the table, 11.1% of females with Te had low hemoglobin. 46.5 had low ferritin, 29.5 had low iron. 5.8 had low B12 and 0.6 had low folic acid. 2.4 had high TSH. That would represent hypothyroidism, at least most cases of it. And 1.3 had low T3. But without a comparison group of women without Te, I don't know what this all of that data and paper means, ferritin numbers. I texted you guys over the weekend. There was driving me crazy. Like the 300-- Like, get a life patent. Get a life patent. Get a life patent. So yeah, units that I just was like, this is not what we use. It was like when Homer Simpson was buying a car in the salesman, it was like, show both 300 hectares on a single tank of carousine. I didn't know what that meant. So we usually talk about ferritin in terms of micrograms per liter. And so that's the concept I have, what's deficient, what's not. But when I tried to convert their values, the value of 18 nanocurrents per deciliter would be converted to 0.18 micrograms per liter, which would be your ferritin level if you died from blood loss after which you start to lose significant amounts of hair. So does this information help us at all? I don't know that it does. I really didn't get the point of table two. They broke down the ages, but percentages were similar enough. So I don't know that that really-- About that 18 to 45 is like menstruating women. They are probably the most dynamic group, right? Maybe that was part of it. Yeah, so statistically speaking, they had the lower ferritin. But it was like 47% of the 18 to 45 versus 40% versus 43. I mean, it's like in the same neighborhood. So it wasn't anything jumped out at me. I don't think performing blood tests on patients with hair loss, like TEAGA, absent any symptoms, or honestly, even with symptoms. I don't think that that makes any sense. This paper really didn't change my belief in that. The iron deficiency thing in hair loss kind of drives me crazy. Like I remember reading a paper. It was from 2006. Like Ferris was still in high school. And I remember reading a paper in the Jad. Like Wilma Bergfeld is one of the authors. And it was like this 20 page paper. And in the abstract that said, currently, there was insufficient evidence to recommend universal screening for iron deficiency in patients with hair loss. And then one sentence later, it was like, we check iron studies on everybody. And I like 20 years later, we're in the same exact place, insufficient evidence. And it's recommended that we do it in all patients. And I thought this paper would kind of tease out. Does that make sense? Does it not make sense? And it really didn't answer that question. So I don't know. I always like the So Jerry Shapiro wrote an article like three, four, five years ago, Journal of Drugs and Durham. Yeah, JDD, 2021. Yeah. So just like did the people that they did they tested people and then they supplemented with they were deficient. And his takeaway was it didn't do any good. Like people might have hair loss and they might have a vitamin deficiency. But like an iron deficiency in particular low vitamin D, but the two aren't related. It's just a random like nobody's ever done. Never seen a good study because it'd be easy of just women who have tealogy and a fluvia versus a matched control. Like I haven't seen anybody do that. Yeah, it's amazing, right? Because how common is TE iron study that's an easy thing to do. And even if you wanted to do the study where you supplement versus non supplement and placebo, I mean, the placebo heart, that would cost a lot of money and be hard. But it's a low cost intervention. I feel bad for our hair loss patients at how poorly dermatologists, like the doctors who really should be studying this and finding good scientific evidence. And we're just not. We're just not. So did know the other question to me. Oh, Liseko was the co-sean your author on that just pyropaper. Liseko was a former pit resident. I'm very proud. Change in no wonder they're changing the world. They got trained by you too. So I'm in Liseko, hair expert in New York. Yep. So what's the downside? Because that's part of me is always like, what's do I think it helps know? But if a patient asked, would you-- I would gladly order this stuff. But I'd be like, I don't think it's going to help at all. But I don't think it's going to hurt. Health care costs, right? You find stuff. It's like, oh, it's the-- oh, my eye are low. What about this? Why is my MCV low? Why is my RD-- whatever? Like, it just opens up Pandora's box to be doing a lot of testing for things that is not going to guide therapy. Ferris, if your hair started falling out tomorrow, you would be begging for drug tests or blood tests out the wazoo. No, I wouldn't. I don't know what you're basing that on. But what I will say is, no, I don't reflexively order anything. And then when the patients say, my hair's still shedding, shouldn't we be checking my thigh, rode my iron, my zinc, my vitamin D? Right. I'm like, of course, that's a great idea. You know, I did it with a patient. And then two weeks later, he said, my insurance said, they're not covering any of this blood work. They said it's not indicated. Wow. And I was like, I don't know what to tell you. That's why I didn't order it from the get-go. Yeah. Well, it does open up all of that stuff. It does contribute to costs. And it's the patient costs. And you have to have a good reason to do it. And then I'm like, if they really think it's vitamin deficiency, I'm like, take a flinstowns-doubable vitamin every day. That pretty much covers all those things. What do you guys-- What about an infrogenic? And women with, you know, pattern, alopecia, or angrogenic, there are some people who order the HES and testosterone and sex hormone blinding, globulin and everything. But again, I've never seen any evidence that-- like if you've got hercetism, sure. If you've got-- She has other masculine linozational-- that's not work. I use it a lot. --masculinarizing feature. Thank you. Yes. Then sure. But not just for agia. No, I agree. I don't do it for that either. I do ask women about their-- if their menstrual cycle is regular. And if it's not, I will tell them to, like, mention to their OBGYN. Hey, you know, my dermatologist said, my hair could be an indicator of PCOS. I have no idea if there's any actual rationale behind that. But I figure I'll leave it up to the OBGYN to decide if they want to test and diagnose for PCOS. Because I feel like that's got some stuff they can do for it. But-- I think they have PCOS. Like, what do you get total for your testosterone? And I have to look up when I-- like, the once every three years that I see a woman, then I'm like, she looks like-- man, this is more than just like-- it's really bad here, satism, or something that the facial shape has changed. And then I will order-- but I have to go look up the labs. I don't have it memorized anymore. Yeah. But the PCOS part-- yes, you can look at that. But it's more like bad acne plus here, satism. plus AGA. All right, we're going to move on to my, my article, which was published in 2023, but it think it was such a good one that it's, and it's, and it's about such an important topic that comes up all the time. So evaluation of the safety and effectiveness of nutritional supplements for treating hair loss, a systematic review. So the, the primary, so this is basically a review article looking at, at the evidence for all of these different things. And, right, the first thing that I would say is we've got plenty of randomized double blind placebo, patrol, trout showing that supplements help, right? If you've, if you've got thinning hair, whether you're a male or a female, supplements help. And the real question then becomes whenever you're looking at these supplements, use their, you know, one in particular, we ought to be recommending. And it's really an interesting, because there's no head to head trials, right? Of, you know, any of these against each other. So I tend to end up thinking about it in terms of cost to a significant factor that in the, in the absence of evidence, saying, use one instead of the others. So I'm going to pick kind of what's cheapest. So the, the ones that they had in here, has been some time today looking at pricing for all of these and where you could get them. And I did pick up a couple of things that I'm going to start doing a little bit differently. So we've, we've got some evidence that pumpkin seed oil works fairly well as a five alpha reductase inhibitor. And we've got some evidence to support pumpkin seed oil. And it's cheap. You can get a decent pumpkin. There's a bunch of pumpkin seed oils on Amazon for 15 bucks a month. Those are reasonable to do. Next one that has some data behind it was capsaicin. And so capsaicin plus isoflavones are reasonable data, but I couldn't find any products that specifically had those that were still available on the market. There was like one being sold in Canada, but I wasn't sure if you could like get it from America and I didn't know about the Canadian dollar conversion and like whatever. So I left that one out. Carotin. I think we've got good data for two different carotens. One's called pantagar Pantigar Pantigar Pantigar. Evidence is mostly in German. So I couldn't look at it very much, but you can get it for 45 bucks a month. The one that I tend to prefer is called synateen CYNATIN E HNS. That's 18 bucks a month for the now. So one of the brands of supplements that I recommend kind of for a topic, derm stuff and other things are is this now brand. Do you get the synateen for 18 bucks a month. It's got evidence that it. Make sure hair shinier and it makes your hair stronger. So it doesn't grow any new hair, but it makes the hair that you have look better. Then you've got the Marie. So that was you can get it for about 18 bucks a month. Then you got the marine complex product. So you got two of those Viviscale in Norkin N O U R K I N. Those are about about $33 a month. So they're priced identically. It's hard to do now that I know about Norkin. Like I didn't know about it until today. I don't think one has like massively stronger evidence than the other. So either one of those 33 bucks a month. Then you got neutrophal. And neutrophal's got pretty good evidence, but it's also by far the most expensive, right? So neutrophal's 88 bucks a month. So it's not cheap. It's got a whole bunch of stuff in it. Absolutely think it works. There are some cases of liver toxicity reported with it. But you know, we're looking at 90 bucks a month as a. So we're looking at basically three times the cost of the marine complex ones. Then another one I didn't know about it goes along with the pumpkin seed oil that I hadn't heard of. So a pio can sanded in pio canad in on with that. And then you say it. But it's from a special apple that the data shows it increases how long your hair spend an antigen. The one that I would get is called apple wise, like literally the word apple W I see apple wise on Amazon at 16 bucks a month. I hadn't heard of before so lamb but lamb to pill, which is 16 saw Palmetto, which is a five alpha reductase inhibitor and then silicone to increase hair strength. And that one again was 60 bucks a month. I actually asked AI to like put together like taking like if if cost wasn't an issue and you could take as much as you wanted. Like what wouldn't overlap completely. And the takeaway I got was well if it was a guy you could do pumpkin seed oil you could do kind of all of them pumpkin seed oil, keratin, viviscale, neutrophil, pio sanded in now the lamb to pill. And then you could probably overlap a lot with the other ones. But so if you wanted to you could do like all four of those. And but if I was going to do if I personally was going to do one or if like with person in my life was asking I would I would go with the viviscale because it's the cheapest that has pretty good evidence. The pie if they wanted more than I don't know if I would add on the pie of canadin or the pumpkin seed or if I would then you know, add in the keratin or whatever. But the nice thing with the keratin so that's also your best go to when somebody complains about nails. Because we have good data that synateen makes your nails stronger and more resistant to breakage. And so that's the other keratin is good for both your hair and your nails. Now I like the idea of the keratin because like I like I hate the question like what can I do for my brittle nails. Now I can be like I'm like do terminal now I'm going to be like take synatin or I'll look at you. Synatin. Yeah. I've got something to answer. How about ketocon is all shampoo. Does anybody do that because of the was that was that wasn't I remember looking at that paper a couple of years ago. So this idea that you know ketocon is all shampoo has and is also a five alpha reductase inhibitor and so. It decrease it blocks DHT and the scalp but you say leave it on you put it on the scalp you leave it on for 10 minutes and then rinse it off. 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 terms on drugs.com. And we hope you learned a few things. We have to laugh once you're twice and mostly we're hoping you're planning to join us next week. Until then I'm Matt Cyrus. I'm Tim Patton. And I'm Laura Ferris and we are terms on drugs. [Music]