A full head of hair. This is how I came away from Dr. Heather Woolery-Lloyd’s lecture on hair and scalp disorders at the 2019 Skin of Color Update. There were many aspects of her talk that challenged me to rethink how I approach the management of hair loss in my patients. In this post we will cover biotin’s role in treating alopecia, and important considerations in the treatment of central centrifugal cicatricial alopecia (CCCA)—two topics that Dr. Woolery-Lloyd took a deep dive into during her lecture. To purchase Skin of Color Update On-demand, click here.
So I have a potentially hair raising confession to make…I might start recommending biotin again to my alopecia patients! I have previously written about the use of biotin in the treatment hair loss (see article here), the gist of it being—don’t. The don’t is because most individuals are not biotin deficient, there are potential risks associated with supplementation (such as effects on the results of thyroid function and troponin testing), and scientific data supporting the use of biotin to promote hair growth are weak unless there is a proven biotin deficiency. But Dr. Woolery-Lloyd discussed the results of a recent study out of Switzerland1 that lead me to question whether I might want to rethink my previous stance on biotin—Bad hair day for me!
Biotin is a coenzyme that plays a role in protein synthesis, including the production of keratin (which explains its contribution to healthy nail and hair growth). Primary and secondary biotin deficiencies are both considered very rare. Secondary biotin deficiency is thought to be rare because our intestinal flora produce more than our daily requirement. However, there are certain risk factors that may predispose an individual to a secondary biotin deficiency, including gastrointestinal disease, certain medications (isotretinoin, antibiotics, anti-epileptics), smoking, alcoholism, advanced age, extreme athleticism, pregnancy, and lactation. Moreover, serum biotin levels can demonstrate daily fluctuations of up to 100%, which is important to keep in mind when trying to identify which patients have suboptimal or deficient levels of biotin.1
Let’s examine this study with a fine toothed comb. This retrospective study examined serum biotin levels in 503 female alopecia patients who presented to a hair loss clinic in Switzerland. It was found that 13% had optimal biotin levels (defined as >400 ng/L in this study), 49% had suboptimal levels (defined as 100-400 ng/L), and 38% were biotin deficient (defined as <100 ng/L).1 The authors of the study concluded that 5000 mcg daily of biotin should be supplemented in cases of established biotin deficiency. But Dr. Woolery-Lloyd’s take on this study was that if 87% of subjects had at least suboptimal levels of biotin, it may be reasonable to offer a trial of biotin supplementation to patients who present with a chief complaint of hair loss. And I tend to agree with her—that a 3-month trial of 5000 mcg of biotin daily could be offered to patients who are very motivated to pursue any means possible to try to regrow their hair, and who are willing to accept the possibility that it may not provide any benefit, and may even entail a few risks. Remember to counsel patients on the potential for biotin to falsely lower the results of cardiac troponin testing, and to falsely increase or decrease the results of thyroid function tests. For patients undergoing routine thyroid monitoring who wish to take biotin, counsel them to stop biotin supplementation at least 72 hours (and ideally 1 week before) testing.
Though many big wigs in alopecia have yet to reach a consensus on the use of biotin to promote hair growth, I suspect that this will continue to be a topic of discussion for some time to come, as more and more hair supplements hitting the market these days count it among their ingredients.
On to the next topic—new developments and considerations in the management of CCCA. (If you are interested in reading more about how to diagnose and manage CCCA, please check out this previous post from my Hair Apparent series.
I see a lot of CCCA in my residency clinics, which is why I found this portion of Dr. Woolery-Lloyd’s lecture to be so incredibly useful. In my own experience, two of the more challenging aspects of caring for patients with CCCA are managing expectations, and gently steering them towards altering their hair care practices to give them the best chance of regrowth. Dr. Woolery-Lloyd emphasized that it is important to let patients know that a successful treatment outcome is fundamentally cessation of hair loss. For those patients who are fortunate enough to attain this and regrow hair, 10-30% regrowth of new hair is considered clinical success.
Let us all remind ourselves to under-promise and over-deliver. Patients who are educated on realistic treatment goals early are more likely to be satisfied with the outcomes they obtain.
Then there is the matter of how to help patients reach their hair regrowth potential, which is in no small part related to the effect of styling practices on the disease itself. While styling practices are not believed to cause CCCA, Dlova and colleagues in South Africa have found that hair grooming habits nevertheless influence disease expression—“CCCA can be inherited in an autosomal dominant fashion, with partial penetrance and a strong modifying effect of hairstyling and gender.”2 In their study of 31 immediate family members, they found that 48% of CCCA patients with more severe disease practiced frequent braiding and weaving, and 29% had a history of braiding or weaving chemically processed hair. In contrast, among patients with less severe disease, 35% had natural virgin hair that had never been exposed to chemicals or traction. Although this was a small study, it is nevertheless one that may be useful to reference for CCCA patients who are reluctant to take a step back from frequent tight braiding, weaving, or chemical processing.
And finally, a bit of nerdy basic science that helped me better understand why I employ one of my workhorses for treating CCCA—tetracycline class antibiotics. PAR-2, a mediator of chronic pruritus, may have a role in the pathogenesis of CCCA.3 Not only does this explain why patients with CCCA often complain of scalp itching, but it also explains why tetracycline antibiotics often prove effective at treating it, as they are capable of attenuating the effect of PAR-2 and PAR-2 mediated downstream signaling.
So what do you tell your patients about biotin supplementation? How do you like to counsel patients with CCCA? What hair care practices do you recommend? Please share your comments at the end of this post!
Dr. Heather Woolery-Lloyd is the Director of Ethnic Skin Care and voluntary Assistant Professor at the University of Miami Miller School of Medicine Department of Dermatology and Cutaneous Surgery.
This information was presented by Dr. Heather Woolery-Lloyd at the 2019 Skin of Color Update held September 7-8 in New York City. The above highlights from her lecture were written and compiled by Dr Kimberly Huerth, Chief dermatology resident at Howard University in Washington DC.
References
- Trüeb RM. Serum biotin levels in women complaining of hair loss. Int J Trichology. 2016;8(2):73-77.
- Dlova NC, Jordaan FH, Sarig O, Sprecher E. Autosomal dominant inheritance of central centrifugal cicatricial alopecia in black south africans. J Am Acad Dermatol. 2014;70(4):67-682.e1.
- Bin Saif GA, McMichael A, Kwatra SG, Chan Y, Yosipovitch G. Central centrifugal cicatricial alopecia severity is associated with cowhage-induced itch. Br J Dermatol. 2013;168(2):253-256.
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