Month: October 2021

Alopecia has been in the news recently. But what does it mean to have alopecia? Alopecia is a catch-all term that encompasses all types of hair loss. Hair loss is a common problem for many men and women, and most people will experience some type of hair loss during their lifetimes.

Alopecia areata (AA) occurs when the body’s immune system attacks hair follicles, resulting in hair loss. AA can affect the scalp, eyebrows, eyelashes, or anywhere hair grows on the body.

What causes alopecia areata?

The immune system protects the body against foreign invaders like bacteria or allergens. When the immune system isn’t working as it should, it can attack hair follicle cells, making them prematurely enter their “resting” phase (called telogen), stopping hair growth.

The exact trigger for this immune response is unknown, although environmental factors, genetics, and stress may all play a role.

AA affects patients of all ethnicities and genders. It is one of the most common hair loss disorders. Most people who develop AA are younger than 30, but AA can occur at any age.

What does alopecia areata look like?

AA usually starts as a sudden appearance of small, round patches of hair loss without redness or scarring. Rarely, this can progress to a complete absence of body and scalp hair, including eyebrows and eyelashes.

The diagnosis is often made through an examination by a doctor (usually a dermatologist), and may involve use a of a dermoscope (skin surface microscope) to help. If it’s not clear that AA is the cause of hair loss, the doctor make take a scalp biopsy (removal of a small amount of skin) to help get a clearer diagnosis.

Nail changes are found in approximately 10% to 20% of patients, and may occur more commonly in children or those with severe cases.

Because AA is an autoimmune condition, it is not surprising that it may be associated with other immune-driven conditions such as vitiligo, autoimmune hemolytic anemia, celiac disease, lupus, allergic rhinitis, asthma, atopic dermatitis, and thyroid diseases. Blood tests for thyroid dysfunction are often done to rule out thyroid conditions that affect hair loss.

AA frequently causes psychological and emotional distress and can negatively impact people’s self-esteem. People with AA have an increased risk for anxiety, depression, and obsessive-compulsive disorder.

What is the prognosis for alopecia areata?

The natural course of AA is unpredictable; however, most people with AA achieve hair regrowth within a few years. Regrowth is most likely to occur in patients with milder hair loss. The AA subtype also contributes to the prognosis: the risk of progression from limited alopecia areata to complete scalp hair loss (alopecia totalis) or whole-body hair loss (alopecia universalis) is approximately 5% to 10%.

The most important indicators for prognosis are the extent of hair loss and the age when AA starts. People who develop AA at a younger age usually have the worst outcomes. Certain subtypes of AA may also be less responsive to treatment options.

What are current treatments for alopecia areata?

Before treatment is started, it is essential to have realistic expectations, and to know that at this time there is no cure for AA and that the goals of treatment are to suppress hair loss and promote regrowth. Due to the unpredictable nature of AA, recurrence can happen, with only 30% of patients experiencing long-lasting remissions.

The first treatment choice for patients with limited, patchy AA is topical steroids (applied at home by the patient) or locally injected steroids (applied by the doctor), because of the minimal side effects, ease of application, and excellent response in most low-severity cases. Occasionally, specific topical irritating medications are applied to the scalp to try to reset the autoimmune process and regrow hair. Some of these prescriptions are squaric acid or anthralin (which may have other brand names), and they are also applied during doctor’s office visits.

For rapidly progressing or more widespread alopecia, systemic steroids or other immunosuppressants can be used. Recently, a newer class of medications called JAK inhibitors has shown promise at improving even advanced AA, but there has been a high relapse rate if treatment is stopped. Nevertheless, many clinical trials are being done for new AA treatments.

Family and patient education, as well as psychological support, are essential in the management of AA. Prosthetic and cosmetic options, like wigs, are also options in more extensive or nonresponsive cases. Support groups can be found on the National Alopecia Areata Foundation website.

Dr. Freeman: “Mr. Vargas, great news on the biopsy results: all negative. It means the workup we have done, including imaging, blood work, and endoscopies, is all normal. You’re all set.”

Mr. Vargas: “How can that be? I feel miserable!”

What are disorders of gut-brain interaction?

The clinical scenario above (names altered for privacy) is surprisingly common for gastroenterologists. These doctors of the esophagus, stomach, small intestines, colon, pancreas, and liver are well trained to identify and treat conditions of the gastrointestinal (GI) tract that occur from diseases caused by inflammation, infection, or cancer.

While some of these conditions can be devastating, they are usually easy to diagnose on standard testing. But there are other illnesses that can impact the GI tract that do not have a clear laboratory test or finding on endoscopy to identify them. One such class of these is called disorders of gut-brain interaction, or DGBIs. Some people (including doctors) may be familiar with the older term used to describe these conditions — functional GI diseases — but it is no longer used.

DGBIs can include irritable bowel syndrome, reflux hypersensitivity, or functional dyspepsia. They are called disorders of gut-brain interaction because it is believed the most critical abnormality is impaired communication between the gut and the brain via the nervous system in both directions (from gut to brain and brain to gut).

What can cause a DGBI?

Some things are associated with the development of DGBIs, including having suffered from prior infections, particularly those that have symptoms like nausea or diarrhea. DGBIs are more prevalent in certain populations, including women. Depression and anxiety are independent illnesses that can be associated with DGBIs as well. Unfortunately, the mechanisms of why DGBIs happen are still not well defined, which can be frustrating for patients and their providers.

From the perspective of specialists like me, DGBI management is not given a lot of attention in clinical training. This can lead to unnecessary testing that has risks, including perforation from endoscopy or radiation from imaging. Even more confusing is that DGBIs can overlap with other GI diseases. As an example, functional dyspepsia (a type of chronic indigestion) can overlap with gastroparesis (slow stomach emptying). Irritable bowel syndrome can overlap with inflammatory bowel diseases (like ulcerative colitis and Crohn’s disease).

What are the treatments for DGBIs?

DGBIs can be treated with multiple primary approaches, and these can also be combined: lifestyle, including dietary approaches; medications; complementary/alternative medicine approaches; and behavioral therapy. Lifestyle and complementary and alternative medicine approaches can be attractive options for some patients.

While eliminating very fatty and processed foods may improve GI symptoms when you have a DGBI, it is hard to sustain such severe changes in diet to control symptoms, and when done too strictly can lead to other conditions, such as feeding difficulties from avoidant restrictive food intake disorder.

Some people might try a low-FODMAP diet (this should be avoided if you’ve had an eating disorder). You can try to avoid FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols)-containing foods for one month (ideally guided by a doctor and/or a dietitian), and completely return to a normal diet if there is no improvement. If there is improvement, then add back foods systematically to make sure your diet is varied and provides all necessary nutrients.

Sometimes people consider acupuncture, ginger, turmeric, or herbal supplements, which you should always discuss with your doctor to prevent side effects or serious health issues, including liver problems.

Medication-based approaches typically use medications that have been used to treat conditions like depression, neuropathy, and fibromyalgia. Sometimes doctors do not clearly explain the rationale for using such medications; however, they are meant to improve the gut-brain interaction by improving pain sensation pathways in the brain, and perhaps even stimulating improved nerve function.

Finally, GI-directed behavioral therapies use cognitive behavioral approaches to improve GI symptom-specific anxiety with the help of a psychologist or therapist.

How can I talk about managing a DGBI with my doctor?

If your doctor has identified that you have a DGBI, make sure to emphasize how much it is negatively impacting your quality of life. For a condition like irritable bowel syndrome, the change in bowel movements and the associated pain can really cause daily distress. Many DGBIs can affect your ability to do certain types of work that may not allow you easy access to a bathroom. DGBIs also affect sexual health.

Make sure your provider understands that managing your DGBI is important, and you want to work together to find the right treatment approaches (or a combination of approaches), as discussed above.

Beyond this, it is important to recognize that DGBIs are established diagnoses, and are just as valid as any other gastrointestinal disease. When you have symptoms of a DGBI, it is not because of an issue of willpower or weakness, or ” just in your head.” These are disorders for which good treatments exist, and they can improve your symptoms and quality of life.

In parts of the United States and Canada, warming temperatures driven by climate change may be contributing to a rise in tick-borne illnesses. Ticks are now thriving in a wider geographic range, and appearing earlier and sticking around later in the shoulder seasons of spring and fall. That means we need to stay vigilant about protecting ourselves against ticks that cause Lyme disease and other illnesses— even during winter months in many warmer states and provinces.

Here's a timely reminder about why preventing Lyme disease is important, and a refresher on steps you can take to avoid tick bites.

What are the symptoms of Lyme disease?

Lyme disease is best known for its classic symptom, a bull’s-eye red rash that appears after a bite from an infected tick (scroll down to see photos of classic and non-classic rashes). However, 20% to 30% of people do not develop a rash. And a rash can be easy to miss because ticks tend to bite in dark body folds such as the groin, armpit, behind the ears, or on the scalp. Some people have flulike symptoms such as a headache, fever, chills, fatigue, and aching joints. So if you notice a rash or have these symptoms, call your doctor for advice. At this stage, prompt antibiotic treatment can wipe out the bacterial infection.

When people don’t receive treatment because they didn’t see the rash or didn't have other early symptoms, the bacteria can spread to different parts of the body. Not only can the bacteria itself cause problems, but the body’s immune system can over-respond to the infection. Either process, or sometimes both, may harm joints, the heart, and/or the nervous system. And some people treated for any stage of Lyme disease develop post-Lyme disease syndrome, which can cause a range of debilitating symptoms that include fatigue, brain fog, and depression.

How to avoid getting Lyme disease

Preventing tick bites is the best way to avoid Lyme disease and other tick-borne illnesses. Blacklegged ticks (also called deer ticks) may be infected with the bacteria that causes Lyme disease. If you live in one of the areas where the incidence of Lyme disease is high, these steps can help.

Know where ticks are likely lurking. Ticks usually crawl up from leaves or blades of grass on the ground to the legs. So be extra careful when walking through fields or meadows and on hikes where you may brush up against bushes, leaves, or trees. Try to walk on well-cleared paths.

Wear protective clothing. Long pants tucked into socks is the best way to keep ticks from crawling up under the pant leg. Lighter-colored clothing can make ticks easier to see.

Use repellents. You can buy clothing that’s pretreated with the insecticide permethrin (which repels ticks). Or you can spray your own clothes and shoes; just be sure to follow the directions carefully. On all exposed skin, use a product that contains DEET, picaridin, oil of lemon eucalyptus (OLE), IR3535, para-menthane-diol (PMD), or 2-undecanone. This search tool from the EPA can help you find a product best suited for your needs. Pay attention to the concentration of active ingredients: for example, at least 20% but not more than 50% with DEET; between 5% to 20% with picaridin; and 10% to 30% with oil of lemon eucalyptus. Many products come in pump spray bottles or as sticks or wipes, which may make them easier to apply where needed.

Get a tick check. After spending time in tick-infested areas, ask a partner to check you for ticks in areas on your body that you can’t see very well. The common bite areas are the back of the knee, the groin, under the arms, under the breasts in women, behind the ears, and at the back of the neck. The tick species that transmits Lyme disease is about the size of a sesame seed. Note that a tick has to be attached to your skin for 24 to 36 hours for it to transmit enough bacteria to give you the disease.

Although inflammation serves a vital role in the body’s defense and repair systems, chronic inflammation can cause more harm than good. And that may make you wonder: what can I do about it?

In fact, there’s a lot you can do. And you may already be doing it. That’s because some of the most important ways to fight inflammation are measures you should be taking routinely.

Let’s take a look at key elements of fighting chronic inflammation: prevention, detection, and treatment.

Six ways to prevent unhealthy inflammation

Six of the most effective ways to ward off inflammation are:

• Choose a healthy diet. Individual foods have a rather small impact on bodywide inflammation, so no, eating more kale isn’t likely to help much. But making sure you eat lots of fruits and vegetables, whole grains, healthy fats, and legumes — sometimes called an anti-inflammatory diet — may reduce inflammation and lower risk for chronic illnesses like diabetes and heart disease. Not only can these diets help reduce inflammation on their own, but replacing foods that increase inflammation (such as sugary drinks and highly processed foods) benefits your body, too.
• Exercise regularly.Physical activity may help counter some types of inflammation through regulation of the immune system. For example, exercise has anti-inflammatory effects on white blood cells and chemical messengers called cytokines.
• Maintain a healthy weight. Because excess fat in cells stimulates bodywide inflammation, avoiding excess weight is an important way to prevent fat-related inflammation. Keeping your weight in check also reduces the risk of type 2 diabetes, a condition that itself causes chronic inflammation.
• Manage stress. Repeatedly triggered stress hormones contribute to chronic inflammation. Yoga, deep breathing, mindfulness practices, and other forms of relaxation can help calm your nervous system.
• Do not smoke. Toxins inhaled in cigarette smoke trigger inflammation in the airways, damage lung tissue, and increase the risk of lung cancer and other health problems.
• Try to prevent inflammatory conditions, such as
  • Infection: Take measures to avoid infections that may cause chronic inflammation. HIV, hepatitis C, and COVID-19 are examples. Practicing safer sex, not sharing needles, and getting routine vaccinations are examples of effective preventive measures.
  • Cancer: Get cancer screening on the schedule recommended by your doctors. For example, colonoscopy can detect and remove polyps that could later become cancerous.
  • Allergies: By avoiding triggers of asthma, eczema, or allergic reactions you can reduce the burden of inflammation in your body.

Do you need tests to detect inflammation?

While testing for inflammation is not routinely recommended, it can be helpful in some situations. For example, tests for inflammation can help to diagnose certain conditions (such as temporal arteritis) or monitor how well treatment is controlling an inflammatory condition (such as Crohn’s disease or rheumatoid arthritis).

However, there are no perfect tests for inflammation. And the best way to know if inflammation is present is to have routine medical care. Seeing a primary care physician, reviewing your medical history and any symptoms you have, having a physical examination, and having some basic medical tests are reasonable starting points. Such routine care does not typically include tests for inflammation.

How is inflammation treated?

At first glance, treating unhealthy, chronic inflammation may seem simple: you take anti-inflammatory medications, right? Actually, there’s much more to it than that.

Anti-inflammatory medicines can be helpful to treat an inflammatory condition. And we have numerous FDA-approved options that are widely available — many in inexpensive generic versions. What’s more, these medicines have been around for decades.

• Corticosteroids, such as prednisone, are the gold standard. These powerful anti-inflammatory medicines can be lifesaving in a variety of conditions, ranging from asthma to allergic reactions.
• Other anti-inflammatory medicines can also be quite effective for inflammatory conditions. Ibuprofen, naproxen, and aspirin — which may already be in your medicine cabinet — are among the 20 or so nonsteroidal anti-inflammatory drugs (NSAIDs) that come as pills, tablets, liquids taken by mouth, products applied to skin, injections, and even suppositories.

Yet relying on anti-inflammatory medicines alone for chronic inflammation is often not the best choice. That’s because these medicines may need to be taken for long periods of time and often cause unacceptable side effects. It’s far better to seek and treat the cause of inflammation. Taking this approach may cure or contain many types of chronic inflammation. It may also eliminate the need for other anti-inflammatory treatments.

For example, chronic liver inflammation due to hepatitis C infection can lead to liver scarring, cirrhosis, and eventually liver failure. Medicines to reduce inflammation do not solve the problem, aren’t particularly effective, and may cause intolerable side effects. However, treatments available now can cure most cases of chronic hepatitis C. Once completed, there is no need for anti-inflammatory treatment.

Similarly, among people with rheumatoid arthritis, anti-inflammatory medicines such as ibuprofen or steroids may be a short-term approach that helps ease symptoms, yet joint damage may progress unabated. Controlling the underlying condition with medicines like methotrexate or etanercept can protect the joints and eliminate the need for other anti-inflammatory drugs.

The bottom line

Even though we know that chronic inflammation is closely linked to a number of chronic diseases, quashing inflammation isn’t the only approach, or the best one, in all cases.

Fortunately, you can take measures to fight or even prevent unhealthy inflammation. Living an “anti-inflammatory life” isn’t always easy. But if you can do it, there’s an added bonus: measures considered to be anti-inflammatory are generally good for your health, with benefits that reach well beyond reducing inflammation.