Patchy Hair Loss (Alopecia Areata)

Alopecia areata is a disease that affects hair follicles, resulting in patchy areas of hair loss.  In rare cases, the disease causes total loss of hair on the head and other areas of the body.  In general, alopecia areata is a benign condition, although it may cause significant emotional or psychological distress.

Who Gets alopecia areata?  Alopecia areata is most common in adults 30 to 60 years of age, however, it may also begin during childhood. It affects men and women equally. In some cases, the onset of alopecia occurs after a major life event such as an illness, pregnancy, or trauma.

What Causes alopecia areata?  A definite cause for the development of alopecia areata is not known.  It is considered to be an autoimmune disease in which the body’s immune system mistakenly attacks the hair follicles. In some cases, genetics appears to play a role since there is a higher likelihood of developing alopecia in someone with a family history of the condition.

What symptoms are associated with this condition?  In general, there are no symptoms connected with the hair loss of alopecia areata.  The condition typically begins with one or two small patches of hair loss. These areas are smooth and round in shape with no scarring.  Occasionally, the hair loss may affect the beard area, eyebrows or rarely, the entire body.

How is alopecia areata diagnosed? A well-defined area of hairless skin in an area of normal hair growth is the classic finding in alopecia areata. Often, this appearance alone is adequate to make the diagnosis. If the diagnosis is in question, a skin biopsy may be necessary to confirm the condition. On microscopic examination, inflammation of the hair follicles is typically present if the hair loss is due to alopecia areata.

What other conditions cause patchy hair loss? Tinea capitis (ringworm), a fungal infection of the scalp, is the most common condition that mimics the hair loss seen in alopecia areata. This infection is most common in children and is associated with scaling and redness of the scalp, findings not seen in alopecia areata. Traction alopecia, seen primarily in women, is caused by a pulling force being applied to the hair. This can occur as a result of wearing tight braids, wigs or using hair curlers. A psychological condition known as trichotillomania is also associated with patchy hair loss. This disorder is associated with compulsive urge to pull out one's hair, leading to hair loss and balding.

Does the hair ever grow back on its own?  In many instances the hair does grow back without specific treatment. It is not uncommon, however, for there to be several cycles of hair loss and regrowth before the condition resolves. The more extensive the hair loss and the longer the period of time of hair loss, the less likely it is that the hair will regrow on its own.

How Is Alopecia Areata Treated?  There is no cure for alopecia areata although certain treatments may help the hair to grow back more quickly. These treatments include:

• Corticosteroids (e.g. prednisone), administered via topical agents (applied to the skin), injections into the area or hair loss, or less commonly with oral tablets. This medication works by suppressing the body’s immune system so that it does not attack the hair follicles.
   
• Minoxidil, the same medicine used for male-pattern baldness, may help some people to re-grow hair.  Minoxidil 5% lotion is applied topically to the areas of hair loss.
   
• Photochemotherapy (PUVA) combines the use of a medicine called psoralen with exposure to ultraviolet A (UVA) light.
   
• Anthralin is a tar-like substance that is applied to the skin which alters the skin’s immune function.
   
• Sulfasalazine and cyclosporine are drugs that suppress the immune system. They are in a class of medications known as Disease-Modifying Anti-Rheumatic Drugs (DMARDs) and are also used in the treatment of other autoimmune diseases such as Lupus and Rheumatoid arthritis.

How does someone cope with this disease? As mentioned, the hair loss in alopecia areata can be embarrassing or the cause of emotional distress.  Men as well as women with this condition sometimes chose to shave their heads rather that endure the patchy areas of hair loss. Others wear a wig, cap or hat to cover the bald spots. It can be helpful for someone with this condition to talk with others who are dealing with the disease or to a counsellor if the hair loss is causing a loss in self-esteem. Support groups are organized all over the world by the National Alopecia Areata Foundation. It should be reassuring to someone with this condition to know that alopecia areata will not make them feel sick and is not associated with a serious underlying medical condition.
 
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Lessons for a Long (and Healthy) Life

Scientists have studied populations of humans whose life expectancy fails to meet the norm.  Major factors related to a decreased life expectancy include: 1) poor genetics, 2) a weak immune system, 3) genetic mutations and 4) unhealthy lifestyle habits.  Lifestyle issues that are correlated with increased risk of disease and premature death include cigarette smoking, excessive alcohol intake, obesity, and inadequate amounts of exercise.
 
There may not be much that you can do about a family predisposition for either long or short life expectancy, but there are ways of strengthening the immune system, preventing certain genetic mutations and most importantly, improving one’s lifestyle habits.

Access to medical care and the availability of vaccines and antibiotics to prevent and treat infectious diseases offers Americans a huge advantage in terms of promoting longevity.  The fact that Americans have the lowest life expectancy among the industrialized nations (Canada, the United Kingdom, France, Sweden, Germany, Italy, and Japan), however, indicates that access to the most technologically advanced medical system in the world does not insure long life.

Certain cultures in the world are known for living longer and healthier. Let’s look at some of their habits and see what we can learn.

Residents of the Okinawa Islands in Japan traditionally rank at the top in health and life expectancy and at the bottom in socioeconomic indicators.  The average life expectancy is 78 years for men and 86 years for women.  They have a fifth of the heart disease, a fourth of the breast and prostate cancer and a third less dementia than Americans. Their reduced heart disease risk is thought to be due to their lifestyle---a plant-based diet, regular exercise, moderate alcohol use, avoidance of smoking, blood pressure control, and a stress-minimizing psychospiritual outlook.  They characteristically eat a fairly low calorie diet and follow a Confucian-inspired adage---“eat until your stomach is 80 percent full”.  Habits that contribute to cancer avoidance include a low caloric intake, high vegetables/fruits consumption, higher intake of good fats (omega-3, mono-unsaturated fat), high fiber diet, high flavonoid intake, low body fat level, and high level of physical activity.

Sardinians, living on an island off the coast of western Italy, are another group renowned for their longevity.  While there does appear to be a significant genetic predisposition toward living longer in this culture, they also demonstrate very healthy habits.  Sardinians are known for their hard-working nature, often continuing to perform manual labor into their 80s. Their version of the “Mediterranean Diet”, thought to contribute to their longevity, is characterized by the consumption of:

• large amounts of fruits, vegetables, bread and other cereals, potatoes, beans, nuts and seeds
• olive oil as their most important source of fat
• moderate amounts of dairy products, fish and poultry
• low quantities of red meat
• wine in low to moderate amounts 

A third group who has been found to have impressive longevity statistics are members of the Seventh-Day Adventist Church in California.  California Adventists live approximately 7 years longer than the average Californian. Those who strictly follow Church practices are vegetarians who do not smoke, drink alcohol or use “stimulant” beverages containing caffeine.  A study funded by the National Institutes of Health found Adventists had significantly lower rates of heart disease and cancer. Their diet, rich in soy products, tomatoes, beans and fruits was thought to provide protection against cancer. Avoidance of red meat, consuming whole grains and surprisingly eating four servings of nuts per day was thought to provide protection against heart disease.   Another study compared mortality rates between vegetarian Seventh Day Adventists and a group of Adventists who included meat in their diets.  The researchers found that vegetarians were 12% less likely to die from all causes combined compared to non-vegetarians.

The common denominator among all of these groups appears to be a healthy lifestyle.  They are all active; primarily non-smokers and their diet is based on fruits, vegetables and whole grains.  Other important factors thought to be related to longevity in these groups include regular social interaction, spiritual awareness and having a purpose in life---all good practices to incorporate into our own lives.

If you have any questions about increased longevity, please log into your account and send us your question. We are here to help.

Medical Reversal, Treatments that go from Boom to Bust

While writing an article on the various components of over-the-counter (OTC) cold medications, I learned that zinc, the active ingredient in a popular nasal spray marketed to shorten the duration of the common cold, had been removed from the product. This was requested by the Federal Drug Administration (FDA) because of numerous reports of loss of the ability to smell (anosmia) related to the zinc in this product. I found this interesting because not too long ago, zinc (given as an oral supplement), was considered to be an effective treatment for anosmia.

Those of us who have practiced medicine for longer than we care to mention have seen a fair number of treatments, which at one time were considered to be effective, end up either not working or in some cases, causing harm. The term “medical reversal” was coined to describe the process where evidence from newly conducted research contradicts existing practice standards. An analysis titled, “A Decade of Reversal: An Analysis of 146 Contradicted Medical Practices” published in the Mayo Clinic Proceedings reported on a number of these medical reversals.  Their study looked back at 10 years (2001-2010) of medical research that included 1344 studies involving various medical practices.  In their analysis, they found 146 examples of medical reversal, where a newer practice was found to be no better than an older practice.

Here are just a few examples of medical reversals, some of which you may have heard about already:

Coronary artery angioplasty - In the U.S., more than half a million Americans undergo a heart procedure known as angioplasty. During this procedure, a balloon is inflated at the site of a narrowed coronary artery in order to widen the vessel and restore blood flow.  Balloon dilation is usually accompanied by the placement of a stent, a small metal mesh tube used to prop the artery open. For someone who is experiencing a serious heart attack, this procedure can be life-saving.  It appears, however, that this procedure may be overused in many patients who have what is known as “stable” coronary artery disease. These people do have narrowing of a coronary artery, but they typically do not experience symptoms such as chest pain (angina) except during physical exertion. A major clinical trial known as COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) showed that in people with stable coronary artery disease, artery-opening angioplasty was no better than medications and lifestyle changes at preventing future heart attacks or strokes, nor did it extend life.

Taking vitamin E - As an antioxidant, it was thought that vitamin E could play an important role in preventing a number of diseases including certain types of cancer, Alzheimer’s, and heart disease. Recent research, however, has found no evidence that vitamin E is effective in preventing any of these illnesses and in fact, taking vitamin E at certain dosages could even be harmful.  One study found that taking vitamin E increased the risk of a having a type of stroke related to bleeding (hemorrhagic stroke) by 22 percent. Other researchers have reported that the use of high-dose vitamin E supplements, in excess of 400 IU (international units), is associated with a higher overall risk of dying.  Vitamin E supplements in this dosage continue to be one of the most popular available, in spite of the Recommended Dietary Allowances (RDAs) for Vitamin E for adults being 22.4 IU.

Vertebroplasty for spinal fractures - An estimated 750,000 vertebral compression fractures, primarily due to bone thinning (osteoporosis), occur each year in the United States.  A treatment for this that is still being used is called vertebroplasty.  In this procedure, bone cement is injected into the area of the fracture in order to help stabilize and support the fractured vertebra. Recent studies, however, have shown that the clinical outcome is virtually the same in patients with this type of fracture whether they have vertebroplasty or not. In 2010, the American Academy of Orthopaedic Surgeons issued a clinic practice guideline recommending against the use of vertebroplasty for patients with a vertebral compression fracture due to osteoporosis as long as there was no evidence of the unusual complication of nerves being compressed.

Tight control of Type 2 Diabetes - Conventional treatment of Type 2 diabetes has aimed for “tight” control of blood sugars, with levels approximating those of someone without diabetes.  This treatment includes measures such as weight loss, regular exercise, and a variety of glucose-lowering medications. Tight control, however, usually requires intensive treatment measures that can be difficult for patients to follow and runs the risk of causing severe low blood sugar (hypoglycemia).  Recently, the need for tight control of blood sugars in Type 2 diabetes has been brought into question. In an analysis of 13 separate studies, intensive control of blood sugars was not found to extend life expectancy. Moreover, intensive control of blood sugars appeared to double the risk of developing hypoglycemia.  A second study looking at intensive treatment in a group of Type 2 diabetics with existing heart disease found that tight control increased their risk of dying prematurely without significantly reducing heart attacks or strokes. While these studies may not yet warrant a “reversal” in standard treatment, they certainly bring into question whether tight control is appropriate for everyone with Type 2 diabetes.

It is entirely appropriate for medical science to question existing practices.  Medical replacement---when a new practice surpasses the standard of care---is a desirable outcome of ongoing research.  Medical reversal, on the other hand, is something that medical science tries its best to avoid. In some cases, reversals could be minimized by more careful attention to the design and analysis of studies as well as making sure that treatments are not rushed into use. Failure to do this not only runs the risk of harm to patients, it undermines faith in the medical system for patients as well as for physicians.

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Sound Levels and Hearing Loss

The World Health Organization (WHO) recently released a report on the effect of unsafe listening practices on hearing. They estimate that up to one billion young people worldwide could be at risk of hearing loss due to exposure to excessive sound levels.  According to WHO, teenagers and young adults in middle- and high-income countries are at particular risk due to: 

• Nearly half being exposed to unsafe levels of sound from the use of personal audio devices.
  
• Around 40% being exposed to potentially damaging sound levels at clubs, discotheques and bars.

An estimated 5.2 million children and adolescents aged 6–19 years have suffered permanent damage to their hearing from unsafe levels of sound.  The fact that people are losing their hearing at much younger ages than they did just 30 years ago, along with the surge in sales of personal listening devices, suggests that loud music may be playing a role.
 
How does loud music affect the ears? Exposure to loud music, whether live or recorded, can damage sensitive structures in the inner ear, resulting in noise-induced hearing loss (NIHL).  Once damaged, the sensitive structures, called hair cells, cannot repair themselves. NIHL is related both to the decibel level of a sound and how long someone is exposed to it.  Additionally, the risk of developing NIHL from exposure to loud sounds is cumulative, adding up over a lifetime of exposure.

At what sound level can damage to the ears occur? Sound level (or more correctly sound pressure) is measured in decibels (dB).  The lower limit of hearing is defined as 0 dB and a normal conservational level is around 60 dB.  Sound reaching 85 dB or stronger, particularly if the exposure is prolonged, can result in permanent hearing damage. Many personal listening devices generate sound levels as high as 105 dB at maximum level, more than enough to cause permanent hearing loss.

 What about the effects of prolonged listening?  As mentioned, it’s not just the sound level that is a concern regarding potential hearing damage. The length of exposure is also a critical issue. Hearing damage can occur with as little of 15 minutes of exposure to music at 100 decibels. With newer digital music players being capable of storing several hours of music, prolonged listening times increase listener’s risk of cumulative damage to their ears.

What can be done to minimize the risk of hearing loss?  Fortunately, NIHL related to listening to loud music, whether live or recorded, is almost completely preventable. Here are some tips for minimizing the risk of developing NIHL from loud music:

1. Follow the 60 percent/60 minute rule.  Researchers have determined that listening to music, a movie, or a video game a portable music player at 60 percent of its potential volume for one hour a day is relatively safe. This 60 percent for 60 minutes rule is a good guideline for everyone to follow.
    
2. If noise levels reach the point that you have to raise your voice to be heard more than an arms length away, remove yourself from the situation or wear earplugs.
    
3. In situations in which live music is consistently louder than 85 dB, consider the use of sound attenuating ear plugs. If inserted properly, earplugs can reduce the exposure by 5 to 45 dB, depending on the type of earplugs. The ones used by professional musicians can be quite expensive, however, “consumer” models are available for as little as $12 (e.g.  ETY•Plugs® High Fidelity Earplugs).
    
4. Certain newer listening devices (e.g. iPod Shuffle) allow the listener to limit the maximum volume of the device.
    
5. Consider using noise-canceling earphone or ear buds.  These allow the listener to reduce the volume of the music by blocking the majority of external sounds.
    
6. Take listening breaks.  When going to nightclubs, sporting events or other noisy places, move to a quieter spot intermittently to help reduce the overall duration of noise exposure.

You know that you have abused your ears if you have ringing in the ears, a feeling of fullness in the ears, or if speech sounds muffled.  Avoid loud noises long enough to allow your hearing to return to normal. After that, avoid repeating the exposure to excessive loud sound.  If features suggestive of damage to the ears persist, have your hearing checked by a medical professional.
 
If you have any questions about sound levels and hearing loss, please log into your account and send us your question. We are here to help.

Navigating through the Cold Medication Jungle

A trip to the pharmacy or grocery store to pick up an over-the-counter medicine to help with cold symptoms can be a confusing affair.  A host of manufacturers, each vying for your business, claim to be better than the others.  The use of different letters behind the name of the  same medication---AC, DM, LR, XP, NX, PD, and so on---just confuse things even further.

In reality, most cold medicines are made from just a few types of drugs.  These drugs fall into just a few categories, designated by the symptoms that they treat.  By learning these categories and a few names of the drugs in these categories can help direct you toward the most appropriate medications for your cold symptoms.
 
Oral Decongestants are some of the most commonly used medications for cold symptoms. They help to open congested nasal passages and improve air flow through the nose. Decongestants work by shrinking blood vessels in the nasal region which reduces the leakage of fluid into the tissues. Two of the most common decongestants are pseudoephedrine (e.g. Sudafed) and phenylephrine (e.g. Sudafed PE).  Cold medications containing phenylephrine are available over-the-counter. Pseudoephedrine-containing cold medicines can be obtained without a prescription but have to be signed for at the Pharmacist’s counter.

Intranasal decongestants work in a similar manner as oral decongestants but are delivered to the nasal tissue via drops or sprays.  Examples include oxymetazolin (Afrin, Nasin, and others) and phenylephrine (Neo-Synephrine). In general, one or the other type of decongestant (oral or intranasal) should be used at a time.  A major concern with the nasal decongestants is using them for too long a period of time which can result in “rebound” congestion.

Antihistamines help primarily with allergy-related symptoms. In general, they are not as helpful as decongestants for stuffy nose associated with a cold. Histamine is a chemical released by the immune system when the body is challenged by infection or allergens.  Histamine causes small blood vessels to expand resulting in typical allergy symptoms such as runny nose, watery eyes, and itching.   Antihistamines work by blocking histamine receptors on the cells to prevent histamine from being released.  There are a number of antihistamines on the market, including diphenhydramine (e.g. Benadryl), brompheniramine (e.g. Dimetapp), and loratadine (e.g. Claritin).

Expectorants, also known as mucolytics, are medications that thin mucus in the bronchial passages making it easier to cough up phlegm from the lungs.  The most common  active ingredient in expectorants is guaifenesin which is contained in the brand name medications, Mucinex and Robitussin Chest Congestion.

Cough Suppressants (antitussives) work in an entirely different manner than expectorants. Instead of helping to remove phlegm from the lungs, suppressants, such as dextromethorphan or codeine, actually block the cough reflex.  The most appropriate use of cough suppressants is for a severe cough that is keeping someone up at night or interfering with activities. Otherwise, the removal of phlegm from the lungs should be encouraged.  If a cold medication’s name if followed by the letters, DM, CF, or AC, it most likely contains a cough suppressant. In some cases, cough suppressants and expectorants will appear in the same medication. This combination seems to be more of a marketing gimmick than a useful treatment.
 
Pain medications including NSAIDs and acetaminophen appear in many combination cold medications.  NSAIDs (non-steroidal anti-inflammatory medications) include ibuprofen (e.g. Advil) and naproxyn (e.g. Aleve). Acetaminophen is the active ingredients in Tylenol. While both can be effective for pain and fever associated with colds, it is important to note whether the cold medications that you are taking contains one of these medications so that you avoid taking the same medication from multiple sources.

Multisystem Cold Medications typically contain some combination of pain medication, decongestant, antihistamine, and/or cough suppressant. Examples of these include Delsym Multi-Symptom, Tylenol Cold Multi-Symptom, Theraflu Multi-Symptom, and others.  The active ingredients in these products vary depending on the symptoms they are designed to treat; however, most of them contain a decongestant. As mentioned previously, with so many different medicines containing acetaminophen, care must be taken to avoid overdosing.  Multisystem cold medications can simplify treatment of a cold, but in many cases it is better to direct treatment toward specific symptoms, for example gargling with salt water for sore throat or using a nasal decongestant for stuffy nose.