Today, I am delighted to connect with Dr. Omer Ibrahim, a board-certified, fellowship-trained dermatologist and the Co-director of Research at Chicago Cosmetics Surgery and Dermatology. Dr. Ibrahim completed his residency at the Cleveland Clinic.
In our discussion today, we dive into the concept of hair loss in women, exploring how our hair follicles change during perimenopause and menopause, the prevalence of hair loss and hair thinning, and the many factors that contribute to it, including nutritional deficiencies, chronic stress, heat damage, weight loss (especially with GLP-1 medications), alcohol, and smoking. We discuss the benefits of hormone replacement therapy, essential supplements, red light therapy, PRP, exosomes, and topical and oral medications, and we also cover specific lab tests to request, the impact of endocrine-mimicking chemicals, and how to find qualified hair specialists or dermatologists in your area.
You will not want to miss this conversation with Dr. Omer Ibrahim, and I look forward to having him back on the podcast in the future.
IN THIS EPISODE YOU WILL LEARN:
The two most common reasons for hair thinning and hair loss
How pattern hair loss, or TE, is linked to hormonal changes in perimenopause and menopause
How hair loss patterns are not inherited directly, and how they can vary, even within the same family
Why early treatment for hair loss is essential
How weight loss and GLP-1 agonists can impact hair loss
Vitamin deficiencies that could contribute to hair loss
Why it’s important to avoid harsh hair care practices to prevent hair damage
How stress could lead to hair loss and thinning
How alcohol and smoking impact hair loss
Various prescription medications available for hair loss
Bio: Dr. Omer Ibrahim
Omer Ibrahim, MD FAAD, is a board-certified, fellowship-trained dermatologist and co-director of research at Chicago Cosmetic Surgery and Dermatology. He completed his residency at Cleveland Clinic, followed by an ASDS-accredited fellowship in cosmetic, laser, and dermatologic surgery at SkinCare Physicians in Boston. Dr. Ibrahim serves as adjunct faculty at Cleveland Clinic and Rush University, where he teaches residents the fundamentals of cosmetic and surgical dermatology.
“Vitamin D deficiencies can lead to hair thinning and hair shedding.”
-Dr. Omer Ibrahim
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Connect with Dr. Omer Ibrahim
Transcript:
Cynthia Thurlow: [00:00:01] Welcome to Everyday Wellness Podcast. I'm your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
[00:00:29] Today, I had the honor of connecting with Dr. Omer Ibrahim. He's a board certified, fellowship trained dermatologist and Co-Director of Research at Chicago Cosmetic Surgery and Dermatology. He also completed his residency at Cleveland Clinic.
[00:00:44] Today, we spoke about what is the most understood concept around hair loss in women, what actually is changing about our hair follicles in perimenopause and menopause, the prevalence of hair loss and hair thinning, what contributes to hair loss including nutritional deficiencies, mechanical and heat damage, chronic stress, weight loss and especially the GLP-1s, the role of alcohol as well as smoking, and the impact of hormone replacement therapy, strategies for assistance including key supplements, red light therapy, PRP, exosomes, and topical and oral medications. Lastly, we spoke about specific labs to ask for and the impact of endocrine-mimicking chemicals and how to find a provider in your area that is a hair specialist and also a dermatologist. I know you will love this conversation and I look forward to having Dr. Ibrahim back in the future.
[00:01:46] Well Dr. Ibrahim, I'm so excited to have you on the podcast this morning, largely because we field hundreds and hundreds of questions around hair loss and I know this is one of your areas and zones of genius. What do you think is one of the most misunderstood concepts around hair loss in women, especially as they're aging?
Dr. Omer Ibrahim: [00:02:07] Cynthia, thank you for having me. So, I do see a lot of hair loss and hair thinning and the two most common reasons for which people experience hair thinning or hair loss are either telogen effluvium or pattern hair loss. So, telogen effluvium or TE for sure, it's a hair loss condition in which there is an abnormal amount of hair shedding, so that's usually periodic and it's usually in response to something. So, it could be caused by different medications. It could be caused by changes in someone's health, illnesses, surgeries, but also changes in hormones and hormone fluctuations.
[00:02:52] So, TE can sometimes be the signal or the harbinger of changes in hormones and the beginnings of what we call pattern hair loss. So, in this case it would be female pattern hair loss, formerly known as androgenetic alopecia. I kind of like the older name, the androgenetic alopecia, because andro is like androgens. And genetic, really sort of buys genetics because there are hormonal and genetic components to pattern hair loss, especially around perimenopause and menopause. This is caused by changes in hormones, genetics, drops in estrogen, imbalance in progesterone, testosterone, and estrogen. And in this type of hair thinning, it's not usually an abnormal amount of shedding. It's actual hair follicle shrinkage.
[00:03:42] So, what's happening over time is the hair follicles, usually in women, it's on the top of the scalp. It could start on the frontal area and spread back, the way we learned it in residency, they call it the Christmas tree pattern, I don't know why they call it that, maybe because it looks like a Christmas tree later down the line, but basically, the hair follicles are shrinking. Blood circulation to the scalp is decreasing. Nutrient delivery to the scalp is decreasing, so the hair follicles shrink up top of the scalp, and that's why you see hair thinning, you see more of the scalp. And so, our treatment goals are one, to arrest the process as much as we can and to reverse the process as much as we can, so we can get those hair follicles to plump right back up.
Cynthia Thurlow: [00:04:23] Is there any truth to the fact that we, “inherit” hair pattern thinning as we get older? Because I have all boys, they're all teenagers, and they are all very fixated on, did they inherit my side of the family, where my father went prematurely bald, or did they inherit their father's genetics, where he and his dad have full heads of hair even in their middle age and older? And so, I'm curious, is there any truth to this or is it kind of like a wives tale?
Dr. Omer Ibrahim: [00:04:53] It is totally a wives tale and I totally feel what your sons are going through, because even when I was a teenager, I thought the exact same thing. And I'm pretty sure a bunch of young men and young boys think the same thing. And I tried to look at photos of my mom's parents and my dad's parents, and I looked at my dad's scalp, and I was like, “Okay, what's going to happen to me?” Unfortunately, it's not that simple. It's very complicated. I've seen cases in which there was minimal thinning in the family, maybe some thinning in the father himself. But then when you looked at the siblings when you look at the children, the one single girl or sister in the family would experience thinning and all the other boys would have thick manes of hair. And it's unfortunate. It's the straw that you sort of get when you're born, but there's no pattern that we've been able to decipher or discover to be able to predict who's going to experience thinning and who's not. But one good indicator is a family history of thinning. So, when I ask my patients, do you have a family history of thinning? And I say, this includes your mom, your dad, any male or female on either side of the family, that counts. And so, yeah, it is inherited, but we, as of yet, don't understand the pattern of inheritance.
Cynthia Thurlow: [00:06:16] Well, I think that my children will certainly be like very reassured because we have moments where they will see my brother, who is almost 50 years old, so he does have a little bit of thinning, but they'll look at my husband, they'll look at my brother, and they'll talk about their paternal grandfather, and they'll just go on and on and on and on. I'm like, what is it about this generation [Dr. Ibrahim laughs] of young men that they are very focused, preoccupied about hair loss? I don't know if it's just my kids because of my father's history, but I do find it fascinating and trying to reassure them that there's so many things that you can do and I'm sure we'll be talking about them.
[00:06:52] What I think is really interesting/reassuring possibly, is that when I was looking at the prevalence of hair loss, it was greater than 50% of women in menopause. So, it's like the majority of women will experience some degree. And I think from what I read and obviously this is again, your area of expertise, is that most people tend to experience the milder forms. It's less common to experience the more significant forms and I'm sure we'll touch on. But it was interesting, there was one article I read that BMI plays a factor, the number of years you've been in menopause play a factor. So maybe not as common at like 51, but you might see more of it at 60 or 70, and so I'm curious when you're doing an intake and talking to patients about this particular problem, when you're getting a gestalt or sense of the degree that the hair thinning, hair loss that they may experience, are there some risk factors other than some of the lifestyle stuff that I'm sure we'll talk about in greater detail?
Dr. Omer Ibrahim: [00:07:53] Yeah, absolutely, so there are. The statistic is totally right. So, at some point in a woman's life, especially around perimenopause or menopause, one in two women are going to experience some sort of hair thinning or hair loss. It's a sort of a jarring number because people really don't talk about it. There's a stigma, there's a taboo in admitting I have hair thinning and I have hair loss. And there's something that and it’s almost-- Especially, and we talked about men. Men are even so more concerned and more embarrassed to say something. But there is a stigma when it comes to hair thinning in both men and women.
[00:08:34] And so the key is to swoop in and start treating it early because you are totally correct. When it comes to the amount of time you've been in menopause really does affect how thin your hair will get over time and how severe it will get over time. For example, I had a patient yesterday, just yesterday, she is in her late 30s, early 40s. Due to health issues and complications, she had to have a hysterectomy with bilateral oophorectomy. So, she got her ovaries taken out as well as the uterus. And so, at 41, 42, she has the scalp really of a 50- or 60-year-old. And so, it is one of those things where, yeah, time does play a factor, so early treatment is better, genetics of course plays a factor, as we mentioned. And of course, how quickly you come in with treatment wise and how quickly you want to address it really yields you better results because you're totally right. The longer you are not treating it, the longer you're in menopause, the longer you're allowing sort of the genetic aging process take effect and take hold, the harder it will be to treat. It's almost like trying to teach an old dog a new trick. You really want to get in early when it's a puppy.
Cynthia Thurlow: [00:09:52] Well, it's reassuring. And what I find interesting, and I heard you speaking to this on another podcast, is that dermatologists are skin, hair, and nail experts. And what I find is it's been my clinical experience, even dermatologist friends that I have, is that they really just want to focus on skin. And I think that it brings it back to why finding experts or clinicians that are working specifically in the space is so essential because I think many people wait. I think it's human nature, we notice a change and we're like, “Oh, it's not that bad.” And then all of a sudden, you know, it's quite significant.
[00:10:28] And what's interesting about that young patient that you were talking about having surgical menopause at such a young age is so significant in terms of the long-term impact of that loss of sex hormones. Hopefully she's someone that's being prescribed hormone replacement therapy, if that's appropriate for her. But I think reassuring people that if you notice a change, it's time to have that conversation, not to wait six, twelve, two years later because you may be in a position where it's harder to fix or harder to remedy.
[00:11:02] Now, I think that one of the things that is very timely is the use of GLP-1s and how many of my patients have said, “I lost a bunch of weight. I was appropriately prescribed a GLP-1, Tirzepatide, etc., I lost a bunch of weight and then I had this significant hair loss.” But it's not actually the drug that's driving it's the actual mechanism related to the weight loss. For you, are you noticing it, certain amounts of weight? Is it 5, 10 pounds? Or does that to be a significant weight loss where you're starting to see disruption in the hair growth and follicles of the hair?
Dr. Omer Ibrahim: [00:11:37] I love that question because I just had that discussion with a patient yesterday. She was considering getting on either Tirzepatide or Semaglutide because you know summer's coming up, it's March, we live in Chicago, we get two months of good weather. And so, she just said, “I want to lose my last 10 pounds. I'm terrified of what they call or what they unintelligible [00:11:59] Ozempic face. And I'm terrified of losing my hair. And I think I'm going to do it sort of ‘the natural way.” And it brought up a very good discussion and it brought up your same question how much weight loss is “Too much weight loss for the hair?”
[00:12:18] Just taking a step back, the reason we shed hair during amounts of extreme weight loss or “Famine.” we don't really understand why it might be an evolutionary thing. Like one, your body senses a decrease or a drop in nutrients, it considers hair as an accessory and it's the first thing that's going to go and it's going to divert its attention and its care to your internal organs that are keeping you alive. And so, the amount of weight loss that I've seen is usually, and this is based on my clinical experience, I'm not sure, I'll have to double check, I don't know that there are any studies that show if there's a cutoff or there's a range in which the hair loss usually gets triggered.
[00:12:59] But in my experience, it's usually 15-pounds and above. When patients use the Tirz or the Semaglutide for 10 up to 15-pounds, usually I don't see any issues. It's 15 pounds and above and definitely 20 pounds and above. And it's also the time in which this occurs. With these new GLP-1s, they work beautifully. I personally think they are game changers and they are the wonder drugs and I think they're the new Botox of our generation. I think they are game changers. But the amount of time in which the weight loss happens is very important. So, if it happens quickly within and usually with these drugs, that happens within two to three months, that is very quick.
[00:13:39] So, if you're losing 15 to 20 pounds in like three months, you really want to make sure you're intaking your protein, you're intaking your iron. I had one of my other hair loss patients yesterday, who was shedding like crazy because she was on a health kick. She was intaking 100 g of protein a day. I was like, girl, give me your suggestions. I can't get past 40, but she had neglected her leafy green vegetables, so her iron was in the gutter and so her hair just fell. So, if you're on a weight loss journey or a health journey, with or without these GLP-1s, make sure you're intaking your protein, make sure you're intaking your leafy green vegetables, your vitamin D3, your iron, of course, and just making sure your nutrients are up to par can help mitigate those effects of the medications.
[00:14:27] But also, one other thing about these drugs, just to throw it out there, I read a report, I think it was a couple of weeks ago, that they're showing that these drugs themselves might actually induce hair loss on their own. And some might be worse than others. I read that Tirzepatide may be actually inducing hair loss on its own as a drug itself. And so, this is preliminary thoughts, preliminary ideas. Maybe because Tirzepatide causes more weight loss than Semaglutide, who knows, but it's yet to be decided, but it's most likely caused due to the weight loss itself.
Cynthia Thurlow: [00:15:03] It's so interesting because I think that for many of us, especially if we've birthed children and we notice-- We have this beautiful mane of hair while we're pregnant and then three, four, five months later we have a lot of this hair loss. What's interesting to me is there is definitely this stigma about hair loss for women. It is our mane. My ponytail is certainly--
Dr. Omer Ibrahim: [00:15:26] It’s your crown.
Cynthia Thurlow: [00:15:27] Right. It's not as thick as it was in my 30s, but I still have a good amount of hair. But about six years ago I was hospitalized, I was in the hospital for 13 days. I lost 15 pounds. And I remember when I hit that three-month mark after I left the hospital, my hairstylist, who is incredibly, just incredibly sensitive person, said “I think we may need to talk about doing extensions.” And I was like, I don't want to-- I was like, “I'm high maintenance enough, I don't need to have extensions.” And so, really getting clear about that nutritional piece really can make a big difference because that was what I really focused in on and then obviously gaining back the healthy weight that I'd lost. But I think for anyone that's listening, nutrition really does play a huge role and I think it's not focused on enough. So, I appreciate that you mentioned iron. What other vitamin deficiencies do you think contribute to hair loss or are part of the conversation when you're talking to patients?
Dr. Omer Ibrahim: [00:16:22] Great question. So sometimes fluctuations, which is rare, sometimes fluctuations in vitamin A, so decreases in vitamin A. And vitamin A deficiency is fairly rare in the US. But again, restrictive diets, who knows with these GLP-1s what's happening to people's vitamin levels. But vitamin A, of course vitamin Bs, those could cause deficiencies. Those can cause hair thinning and shedding. So, B12 deficiency, biotin deficiency, extremely rare in the US. That's why biotin, fun fact as a supplement on its own for hair thinning is almost always useless. So, stop spending money on all these biotin-only supplements because they don't do much at all. They, they're great for nails, not great for hair on their own.
[00:17:06] There’s vitamin D deficiencies they can lead to-- which are especially in places like Chicago, pretty common. They can lead to hair thinning-- worsening of hair thinning, but also hair shedding. And they can actually exacerbate other kinds of autoimmune hair losses like alopecia areata. We talked about vitamin D, vitamin B, vitamin A, iron, of course, iron levels. These can definitely decrease. They can increase hair shedding and also worsen hair thinning, I should say. And finally, zinc deficiency. Zinc is one of those. I've seen, I would say a handful of zinc deficiencies. Again, zinc deficiency is rare in the US, but I see it more common than biotin. And zinc deficiency can lead to hair shedding and worsening of hair thinning. So, these are all the types of vitamins that I check when someone comes in for an initial hair loss visit.
Cynthia Thurlow: [00:17:57] I think it's important to have this conversation because some of these values are not necessarily checked with all that frequency in internal medicine and primary care. And so, if you're someone that's experiencing this, please ask your provider to draw some of these labs. These are not unusual functional or integrative medicine labs. These are straightforward labs, certainly very important.
Dr. Omer Ibrahim: [00:18:19] Exactly.
Cynthia Thurlow: [00:18:20] And this is something that I had to learn the hard way. What about mechanical or heat damage to the hair follicles that can happen. I'm one of those people, I'm of Italian origin and my hair loves to be frizzy in the summer and between products to get rid of the frizz or using flat irons, what is the cumulative net impact of using these types of styling tools or even traction on the hair itself? You know, people that have got extensions or weaves or other types of modalities that they're using to kind of augment their hair texture.
Dr. Omer Ibrahim: [00:18:56] I love that question. So, because that's something that people don't always talk about are like hair care practices and how are they affecting your hair and your scalp long term? And so not all practices are created equal and not all have the same overall and long-term impact. So, when it comes to heat, so flat ironing and blow drying, the heat itself to the hair shaft or the hair follicle itself, I would say low to medium heat and try to maximize as much as you can the amount of time in between each treatment. So, each flat iron or blow dry. And so, if you can do it once to twice a week that would be ideal. And if you can extend it even better, I would highly recommend against daily treatment that-- in terms of frequency, that's most important.
[00:19:44] In terms of the intensity of the heat, low to medium heat and you said traction, the amount of pressure that you're putting, you can actually get traction from being too aggressive with pulling the hair down when you’re using the flat iron. I've actually seen that. Even when I was in residency, I wasn't a true believer that that could happen, but I've seen it quite enough that now I am. So that's when it comes to heat.
[00:20:12] Now let's talk about traction. So, traction is very common, especially in people that hail from cultures that use weaves, cornrows, braids. These tight hairstyles actually start killing your hair follicles as soon as you're a young girl. And so, when I'm walking down the street and I see these young girls with their hair pulled back and there are sometimes I even hear them like, I even see them like tapping or scratching or saying, “Mommy, it hurts.” That is your sign. Take those hair, take those braids, take that ponytail out immediately when there's pain, inflammation, when you get those bumps, when you get scale, that's your scalp screaming for help, that means it's too tight, remove the braid.
[00:20:54] Because at one point how traction alopecia works, and people don't say this enough, it's the harsh truth. Over time, traction alopecia becomes permanent. So those bumps are temporary. We can get some regrowth back, but with longer periods of time, with traction alopecia, the inflammation eventually obliterates the hair follicle and replaces it with scar. And we as a society have not been able to figure out how to regrow hair through scars.
[00:21:25] Other specific hair care practices, relaxers. Especially in the black and African American community, relaxers have a wide range of negative effects, including possibly hormone disruptors, possibly increasing your risk of breast and endometrial and ovarian cancer, possibly inducing or unmasking inflammatory autoimmune alopecia’s like CCCA or LPP, lichen planopilaris. What other hair care practices am I missing? We talked about relaxers, heat, traction.
Cynthia Thurlow: [00:21:57] Keratin treatments, Brazilian blowouts.
Dr. Omer Ibrahim: [00:21:59] Yeah, exactly, those are included. So, I include those in the salon-based treatments as much time in between as possible. Even something like keratin treatments and blowouts, even those can stress the hair, can stress the scalp. So, extending those as much time in between as possible one other thing. Oh yeah, this is the one I wanted to mention. Hair bleaching for the love of God, [Cynthia laughs] please, please. I don't know. Yeah, if you have a way to help me convince someone to stop bleaching their hair. And it's not just like, bleach is bad for everybody, everyone should stop it. But if you are experiencing shedding hair, breakage, thinning, or if you're seeing a dermatologist for hair thinning, but you're still going to get your hair bleached, it's an oxymoron. It's a paradox. It's like me going to the gym and then eating Burger King every day and then being like, why am I not getting abs? [Cynthia laughs] The hair bleaching, studies have shown it not just damages the hair, it actually leads to significant inflammation in the scalp. It leads to hair follicle shrinkage. So many bad things can happen that can really stand in the way of getting your proper treatment for your hair thinning.
Cynthia Thurlow: [00:23:09] This is where social media is so fascinating because you'll see people who unknowingly are coloring their hair at home and they leave the product on their hair, and all of a sudden, their hair is just falling off in clumps because there's been so much damage. And what's interesting for me is that I'm like a two times a week-- I wash my hair. So, it's like twice a week I wash my hair and blow it dry, and that is it. And the rest of the time, I always say, dry shampoo, argan oil, and a ponytail. I'm like, I can squeak out a blowout for five days. And I think for a lot of people, just hearing that validation that washing your hair less frequently is certainly beneficial, being conscientious about the products you use on your hair.
[00:23:54] It was funny. I went through a period of time where my hair was more blonde than it is now. And I remember saying “It was always.” I mean, I was always having to do these treatments to add moisture to my hair. And it was so clear my hair was so unhappy. So, I can only imagine when people get to the point where their hair is falling out because of the damage incurred from these types of treatments. What about the role of stress? Now, it goes without saying, five years ago, we’re in the midst of a pandemic. But I think most women are dealing with a degree of stress. Maybe they're not even aware of it. Maybe they've subjugated that stress response so much that they don't even register that they are dealing with chronic stress. But when you're talking to your patients, they're probably stressed that they're losing their hair and their hair is thinning on top of chronic stress that they're experiencing?
Dr. Omer Ibrahim: [00:24:41] Absolutely. So, stress is a definitely a trigger for TE, telogen effluvium for worsening of hair, of actual thinning over time. And it actually can trigger autoimmune types of hair losses like alopecia areata and LPP can actually exacerbate them. Psoriasis of the scalp, eczema in the scalp can be exacerbated by stress. The reason why that happens, we're not fully aware, but stress, we know increases cortisol as well as other hormones which are pro-inflammatory and which will eventually lead to some sort of-- Not in everybody, but can lead to some sort of hair shedding or hair thinning or hair loss.
[00:25:21] And so why is one person responds to stress one way and why one person responds to stress the other way? We're not talking, “Oh, you're really good in stressful situations.” No, we're talking about physiological response is very, very genetically dependent and it's not fully understood. But stress certainly does play a response, and that's why stress reduction. And when we are counseling patients on hair thinning, yeah, we talk about medication and hair care practices and nutrition, but we also talk about meditation and yoga. And I have some patients that say, “I went to psychiatrists, I'm seeing a therapist. I feel so much better. I feel my hair is thicker.” I just feel better about myself? Is it really helping the hair or is it both? Usually in science and medicine, it's usually the answer is both. It's all the above. It's very multifactorial. And so, yeah, certainly stress does play a significant role and stress mitigation.
[00:26:18] But I completely agree with you, and this is sort of an existential sort of comment, is we are-- Look at the times we're living in. We are living in chronic stress and we don't even realize it. So I have patients, when I ask them, “So how's your stress levels?” They're like, “Oh, I'm not stressed. I haven't been stressed.” And I'm like, “Okay, girl, what are you taking? How are you not? Who's your therapist?” And so, I think we have been so accustomed and trained to live under this blanket level of stress and treat it like it's normal. It is not physiologically normal for us to be walking around hyper vigilant like this all the time. And we are, whether we want to admit it or not.
Cynthia Thurlow: [00:26:56] Yeah, I think half the battle is just acknowledging that we need to do more to balance that autonomic nervous system, find ways that rest and repose and it can make our hair healthy and our scalp healthier too, which I think is significant. What about alcohol and smoking?
Dr. Omer Ibrahim: [00:27:13] Yeah, so alcohol no. As of my latest sort of research and knowledge, alcohol directly does not cause hair thinning or hair loss, but it can be a sign as like too much alcohol intake means that, you know, what we see in medicine is if there's too much alcohol intake, there's not enough nutrient intake, so that, yeah, inadvertently can cause hair thinning and hair loss. But smoking for sure, smoking constricts blood vessels, nicotine, as well as the ingredients in smoke itself is tobacco, actually do cause vascular sort of shrinkage and constriction. And that is one of the biggest reasons why we have a hair thinning and hair loss is decreased circulation to the scalp. And so, yeah, smoking directly does worsen hair loss and other skin conditions, including eczema and psoriasis, so for sure.
Cynthia Thurlow: [00:28:09] Yeah. I mean, if you need another reason not to smoke, here are many more reasons. Now, when you're doing an intake on patients, if you have women that are in perimenopause or menopause, people that are taking hormonal therapy, appropriately hormone replacement therapy, depending on the delivery method, do you see an improvement in their hair? Well, a reduction is what I mean to say, a reduction in thinning and hair loss patterns than someone who is of the same age and not taking hormone replacement therapy.
Dr. Omer Ibrahim: [00:28:40] Great question. I certainly do. I certainly do see a difference in between a patient that is on HRT and not in terms of hair thinning and hair thickness, but also in terms of skin and skin quality and skin texture. However, my big caveat is HRT is not part of the treatment of hair thinning and hair loss and menopausal hair loss, at least in the dermatologic world. In Dermatology residency, I went to Cleveland Clinic where it's one of the top hair loss centers in the country, if not the world. HRT is not standard treatment when it comes to hair thinning and hair loss, why?
[00:28:40] Because even though we can see improvements, the correlation and the correlation is not directly there and it's not still fully understood and there are other treatments including Minoxidil, Spirinolactone, Dutasteride. We can talk about all of those, including in the office treatments that have been shown to be very beneficial while trying to avoid the risks of sort of HRT if you don't need to incur them just for the hair.
Cynthia Thurlow: [00:29:43] It makes a great deal of sense. It's interesting, I think when I'm doing intakes with patients and clients, what I notice if they're taking HRT is the sleep piece. That is the consistent barometer with which of you know, I can tell if someone's on HRT or not because their sleep quality tends to better. Now, in terms of things that we can do to improve, let's start with non-prescription options because we got a ton of questions around therapies that are probably in some ways, maybe a few of these are not FDA-approved yet, but before we get to drug therapy, let's talk about supplements and red-light therapy and things like that maybe clinically you've seen to beneficial.
[00:30:24] And when I use the term supplements, there are a lot of supplements out there that were even recommended to my son who was preoccupied with hair loss by his dermatologist that we won't name. But they're very, very popular for hair loss specifically.
Dr. Omer Ibrahim: [00:30:39] I probably guessed.
Cynthia Thurlow: [00:30:40] Yes, exactly. And I'll be happy to share with listeners separately. But let's talk about some of the evolving therapies that you're getting excited about, things that you don't think are particularly beneficial before we talk about medications.
Dr. Omer Ibrahim: [00:30:52] Things that are not medications but over the counter that are out there in the zeitgeist or stratosphere that may or may work. I like that. So, let's talk supplements. So, we had mentioned earlier biotin on its own, toss it, doesn't do much for hair. There are supplements that combine biotin with other things. So when it comes to these hair loss vitamins and supplements, I have seen them really be helpful if you're experiencing telogen effluvium or TE like three-to-six-month shedding phase in response to surgery, hospitalization, as in your case, whatever it may be, those supplements I've seen really do help in mitigating and lessening the hair shedding, slowing down the hair shedding quicker, but also maximizing the hair regrowth as “naturally” and least side effect possible way, and so it works. In my experience, that's when I usually use those supplements.
[00:31:49] I use those supplements also in cases in which there's very mild, mild thinning. So, if you really don't see much and you don't want to-- And it's a young man or woman in their like early 20s, mid 20s, even late 20s and there's barely any thinning and they want to do something over the counter, I'll tell them, “Hey, use this supplement. It has nature's version of Minoxidil, nature's version of finasteride, and it's pretty much side effect free. And pair that with Minoxidil, for example.”
[00:32:21] So, supplements that contain saw palmetto. Saw palmetto does help with hair thinning. Ashwagandha helps indirectly with hair loss because it helps sort of naturally reduce cortisol levels-- stress-induced cortisol levels, horsetail extract, there are pumpkin seeds extract, there are gummies out there that contain these. So, the issue with supplements is a lot of them are not FDA controlled or regulated. So, you don't really know what you're getting.
[00:32:51] And so this is why I do-- In these companies that you had mentioned, these firms that make these very popular hair supplements, I do give them a lot of credit for one-- And these are things that people should look for when looking for supplements is one, do they have studies and data to back up their claims? Go to their website. If there's nothing listed, you could send them emails, ask them for do you have any white papers? So white papers are these published papers that they were never published but they have in their keeping and they could send you the results, they could send you the data if need be. So, is there data? Is it FDA monitored, cleared, approved? Usually, it's not FDA approved. At least is it FDA cleared or monitored? Because you don't know with these supplements, you don't know if what they claim is in the capsule is actually in the capsule and if what they claim is in the capsule is actually being absorbed and if it's the right ingredient. So not all ashwagandha is created the same. Some comes from a root, some comes from, I think I forget where else, and some is not bioavailable and some form is. So, you want to make sure you ask all these questions.
[00:33:54] So the supplements, the companies that have been vetted are the ones that I usually tend to gravitate towards to and they're great for very mild early thinning while you're waiting to see your doctor, while you're waiting to see your primary doctor, your dermatologist, keep in mind if you're taking anything, a lot of these things, a lot of these supplements throw biotin in, so if there is biotin in it and your doctor says, “Hey, let's order a panel of labs.” Even if it has nothing to do with hair thinning or hair loss, if you've been taking the supplement that has biotin for years and you have your annual checkup coming, make sure to stop the biotin for at least a week before because it can mess with your lab numbers. So, supplements, they do work, they have their place, a small place in sort of the whole tool belt, but they do exist.
[00:34:38] Other over-the-counter treatments. I'm sure the R word, Rogaine. Rogaine. Rogaine or Minoxidil, which is the active ingredient in Rogaine. It's an oldie but goodie. It tends to be the gold standard of treatment. I prescribe Minoxidil all the time. We'll get to prescription but I rarely ever use Rogaine anymore because my patients, they want results and I want results, so we tend to go prescription. But if someone doesn't have access to a physician quickly, or doesn’t feel like going to physician and just wants to treat it at home for the first few months to a year, Rogaine is fantastic 5%, don't even go to the 2%-- 5% is for both men and women. Once to twice a day. If you use the foam formulation, you can use it once a day. Foam is usually better tolerated. Less reactions in terms of itching and flaking because it has less alcohol content, so it's much better tolerated.
[00:35:32] The red-light therapies. So, red-light therapy masks or those helmets, they do work. There are all different kinds of companies. For the most part, most of them are pretty similar to each other. How it works is, the red light itself actually promotes circulation in the scalp and it promotes ATP or energy production and it promotes cellular turnover. There is a significant amount of research that shows that these red-light therapies do work. However, you really have to use them as prescribed as indicated. Some are every day, some are twice a week, some are once a week. So, it really depends on the product and you have to use them for at least a year diligently to get the full benefit. So it does come with a commitment. If you and I--This is what I tell my patients, “If you're motivated and you think you're going to do it. Add it on. It's like those red-light therapy masks for the face. If they're just sitting in the corner of your room like mine is, it's not going to do anything for you. [Cynthia laughs] You have to make sure you use it.”
[00:36:32] I'm not sure what else I'm missing. There are some vegetable-based or plant-based topicals out there. I won't mention any brand names, but they have serums that contain these pumpkin seed oil, rosemary oil and other sort of oils out there. Some have merit to them, some don't. So, you really want to ask yourself, is the FDA involved in this at all? Is there any data? Even if it's consumer perception or, you know, clinical trials or any data or any studies that were done and look at customer reviews, that's what I do.
Cynthia Thurlow: [00:37:07] Yeah. And I think it's helpful because as you stated, people may be waiting to get in to see the specialist and they want to feel like they're proactively doing something. What I find exciting are the concept of exosomes. And so, I know this is something that you utilize. Let's talk about what they are and how they work because this to me is really cool and like much more cutting edge. It's like, okay, this is effective and the science behind it's really interesting. And it's FDA approved, which for a lot of people that's going to be the path that they want to kind of head down towards.
Dr. Omer Ibrahim: [00:37:39] Precisely. And so, we can't talk about exosomes without talking about her predecessor PRPs. So, we'll touch base on PRP real quick because they're kind of one and the same. So PRP or platelet rich plasma. PRP facials really are vampire facials, really took hold I think seven, eight years ago when the Kardashians posted about it, I think. [Laughter] And so PRP involves a procedure in office in which you come in, we draw your blood. It's an insignificant amount of blood. It's a tiny amount of blood. We put it in like a centrifuge that spins it and it separates your red blood cells, the red part from sort of what we call the liquid gold or your plasma that contains your platelets.
[00:38:23] So, what do platelets do? So, platelets are these little things that are in your blood and they contain growth factors like PGF, PDGF, VEGF, epidermal growth factor. All these things that have potential to stimulate hair growth, stimulate cellular turnover and stimulate hair follicles and stimulate blood flow. And PRP works there are if you look at the studies, they're a little all over the place. Some studies show it helps, some studies show it helps very well. Sometimes studies show it doesn't really help all that much. The issue with PRP is it depends on the system that you're using. It depends on how good your blood is. It depends on your genetics. It depends on how hydrated you are. Your PRP might be beautiful one day. The next month you do it, not so much because you're dehydrated, you had ibuprofen that morning, so the results can be pretty inconsistent and that's where exosomes come in.
[00:39:15] So, exosomes are little packets. So, they are literally little packets of growth factors and proteins that your cells release. And once those packets pop and release these growth factors, similar to the growth factors that are in PRP but are much higher and pure concentrations, these can also induce blood flow, cellular turnover, hair growth, etc. Where are exosomes sourced? So exosomes are sourced from different sources. One plant based, you can get plant-based exosomes. Exosomes are the future. I think they're starting to put exosomes in skin care and they're starting to put exosomes in hair care. Most of those, if not all of those are usually plant derived.
[00:40:02] Exosomes can also be human derived. There are some companies that have bone marrow-derived exosomes. There's one company that I have used in the past and we still currently use here and there that get their exosomes are derived from bone marrow from healthy 18- to 24-year-old volunteers. And it sounds a little hunger games-ish, [Cynthia laughs] but these volunteers are paid and they undergo a quick sort of bone marrow procedure in which they source their growth factors and stem cells. It's purified, it's gone through a lab, all that stuff. The exosomes are put into a bottle and then these are used.
[00:40:40] They are not FDA approved for injection. I need to preface that and neither is PRP. However, they are approved for, they are cleared for FDA for topical application. So, you can use them after laser treatment, you can use them after microneedling on the scalp. There are folks out there that do inject them, and there are great results out there with both topical application and injection. I have seen that with my own eyes. However, I have to, have to go on the record by saying these are not FDA-approved treatments. Unfortunately, in the world of Dermatology, most of our treatments are not FDA approved, and so we have to get creative while also maintaining-- We want to get results, but we want to maintain the patient's safety. Safety above all, efficacy and results is second. But I'm very excited about exosomes.
[00:41:27] Other places exosomes are sourced are umbilical cord and so umbilical cord stem cells. You can get them from fat, fat stem cells. There are sometimes-- sometimes people will harvest their own fat and then extract their own growth factors and exosomes from that. So, there are different sources of exomes. There are different ways to purify them, different ways to extract them, different ways to apply them and inject them. They're the way of the future. I'm very excited about them. But still there's much more research on safety and efficacy that needs to be done.
Cynthia Thurlow: [00:41:59] Well and I appreciate that you were very transparent about that. And for any listener that the whole concept of bone marrow aspiration, I hope those healthy 18- to 22-year-olds are amply compensated because that is not a pain free procedure after watching many throughout my medical training. Okay, let's talk about the kind of oral options because there are many. And what's nice is we used to use quite a bit of Minoxidil in Cardiology and we’re noticing it was making our patients who, many of whom were thrilled that they were getting more body hair. These were oftentimes middle aged or older patients. Let's talk about Minoxidil and some of the other options that are available right now.
Dr. Omer Ibrahim: [00:42:40] Perfect. So, getting into the prescription category. So Minoxidil, as we mentioned, was originally developed as a blood pressure medication. And back in the 1990s, they were giving it to a bunch of people. They were giving it as a blood pressure medication, especially in the inpatient setting. And they were noticing that everyone was growing hair. And so that's when Minoxidil or Rogaine was born. Literally for-- crudely, they take the pills, crush them, put them in a solution, and that's your Rogaine. And that's how we were using it for decades until the pendulum swung the other way. And now mostly most people are actually using Minoxidil from what I've seen, especially in my clinic, orally, why? Because we have learned how to use the medication orally at doses that don't affect your blood pressure, but we're still getting the positive side effect of hair growth
[00:43:33] And the question I always get from my female patients, “Am I going to grow hair everywhere?” [Cynthia laughs] No offense, you're handsome, I love your beard, but I don't want your beard. And so, I tell them that the hair growth, the side effects are very dose dependent. And I've used the medication enough that I know at what dose to start my female patients and how high I can take them and at what dose to start my male patients and how high I can take those patients. And so, like I said, we're getting the side effect of hair growth without the negative side effect of tanking your blood pressure, causing extreme fluid retention, palpitations, extreme headaches. All of these negative side effects can be mitigated by picking the right dose.
[00:44:16] How does Minoxidil work? We don't fully know, but there are-- The most likely way it increases blood flow to the scalp and increases nutrient development to the scalp, decreases the amount of androgens and testosterone that are in the scalp. And so that's what helps promote hair growth. So Minoxidil is pretty much the gold standard. And thanks to that New York Times article, I think that was in 2021 or 2022 that they published about oral Minoxidil, the new player in the game when hair thinning and hair loss, thanks to that, people are coming to realize that, “Oh, this is not such a scary medication.” And all my patients were already on the medication when the article came out. [Cynthia laughs] But now nationwide, which is great I think, the fear around oral Minoxidil has really lessened, which is great.
[00:45:03] Other oral medications for women, Spironolactone. Spironolactone again was the medication that is a medication that's mostly used in Cardiology. It is a medication that was originally designed as a blood pressure medication in heart failure patients. It is what we call a diuretic medication that helps you release fluids from your body. But I don't know what it is with these blood pressure medications. It also helps like Minoxidil, does block the effects of those androgens, those “bad hormones” that cause hair thinning and hair loss. We could use Spironolactone in the premenopausal as well as menopausal women. No issues with that, very well tolerated medication, Spironolactone, we hand out like candy in the world of dermatology because it has a lot of benefits. It helps with hair thinning, it helps hair growth, it helps reduce oil production. So, if you're a person that's not experiencing hair thinning, but you are a person that you're like, if I don't wash my hair every day, it is greasy, it is flaky, it is scaly, it's itchy, it is matted down. Spironolactone, that is a sign of too much oil production, and that too much oil production doesn't necessarily lead to hair thinning, but Spironolactone can reduce that oil production. And so, I have patients that are like, “Now I can wash every two or three days rather than every day.” And Spironolactone also does help with hormonal acne and acne in general. And so, there are lots of uses for it. So, all of these conditions that I listed, like oil production, acne, hair thinning, postmenopausal thinning, all of those are hormone related, so that's why Spironolactone works.
[00:46:36] And similarly to that, Finasteride or Dutasteride works similarly by blocking hormone levels, by blocking hormone interactions, those bad hormones. But the Finasteride and Dutasteride do not affect your blood pressure. All of these medications are prescription. All of these medications should be taken under the discretion, under the guidance of a medical professional. And this is why I kind of-- I'm a little nervous around these automated online systems in which you log in and you say, I have this, I have that, and then you get the medication in your mail. I just, I want-- If you go that route, fine. But just know a lot of what you're paying for is a premium for these medications that can be covered by your insurance. If not covered by your insurance, that can be pennies on the dollar. It can be a few dollars here and there. You should not be paying a premium for these medications.
[00:47:28] These medications that we are discussed, these past Minoxidil, Spironolactone, Finasteride, Dutasteride, they've been around for decades. They're not medications that these companies invented. And they're going to hate me for saying this. [laughs] These medications are available, but I hope whatever route someone takes to get these medications get on these treatments, they work. I have hundreds, if not thousands of people on these medications, but please make sure that you know what you're getting into. You know your own medical histories. People have asked about your medical history and you know your own side effect and you know what side effects to look out for.
Cynthia Thurlow: [00:47:59] Well, and I mean, that is the key is that an experienced clinician, like as an example, Spironolactone, Aldactone, yes, we used a ton of it with our heart failure patients, many of whom couldn't tolerate more than 12.5 mg or 25 mg. And because it's a potassium-sparing diuretic, you have to monitor that potassium, you got to look at renal function. So, when I hear about these online options. Yes, I understand it's convenient, but these drugs do have side effects. And you want someone that's prescribing it for you to know your unique past medical history and the things that they need to look out for in case there's a problem.
Dr. Omer Ibrahim: [00:48:36] Absolutely. Especially with Spironolactone. I know that is prescribed-- I'm pretty sure that it's prescribed on some of these online platforms. And you have no idea how many times, and I'm sure you understand this, how many times you ask a patient when you're reconciling their medications, you ask them “What medications are you on?” “Absolutely nothing. Absolutely nothing.” I'm like, “Okay, what is this? Amlodipine or what is this Carvedilol?” “That's for my blood pressure.” I'm like, “That is a medication.” They think it's a vitamin. And so, if some of these other blood pressure medications or if you don't have proper renal function and you combine it with Spironolactone, your potassium level can get to like fatal levels that you can die. And so, these are medications not to be played around with.
Cynthia Thurlow: [00:49:23] Yes, absolutely. And that's where I think the input of a medical professional is so critically important. Now, one last thing I wanted to talk about. When you're looking at labs, a lot of questions came in around, are we looking at free and total testosterone? Are we looking at DHT? Why is it important when you are kind of looking at a female patient that comes to you with some-- Maybe it's starting as mild hair thinning or maybe it's more significant. What are some of the specific hormone labs you really like to zero in on? Because I think this is important. I think that with knowledge comes power. And then patients can go to their providers and say, “Hey, I just want to make sure that these numbers are within range.” And we could make the argument that depending on who you're talking to, they may have differing opinions about where those ranges need to be optimal, but when you're talking about labs specifically, what are you looking for.
Dr. Omer Ibrahim: [00:50:18] So let's talk about the role of hormones and we'll talk about the labs, but let's talk about androgens. So, the androgens are these “Male hormones” or I hate calling it that, but the testosterone, DHEAS, DHT. When I'm checking labs where, I was trained at how most dermatologists what they usually check is total testosterone, free testosterone, because your total testosterone, if that's elevated, that's something that you should consider as something that's remarkable and should be treated and should be looked at. Your total testosterone could be fine, but your free testosterone can be elevated, meaning your numbers are fine, but the amount of active testosterone that you have running around is elevated. So that's something that you should consider as you know a factor. And we also check DHEAS and that is another one that has a direct implication on hair thinning and hair loss. So those are really the three things that we check.
[00:51:18] When it comes to-- If we have concerns for PCOS or other hormonal imbalances, we usually refer out to Endocrinology or their primary or Gynecology. However, I want to stress that most of the time we really don't see abnormalities in hormones. And when I have patients in their 30s, 40s, 50s, 60s, and they say my hormone levels are dead normal, so, your diagnosis is wrong, the biopsy is wrong. It's not true because most people that have hair thinning or androgenetic alopecia and have normal hormone levels experience what we call androgen sensitivity or hormone sensitivity or androgen receptor sensitivity. Your hormone levels may be normal, but your hair follicles are hypersensitive to the normal levels that you have.
[00:52:12] And there are, we can-- This is a whole other topic and possibly controversial, but what we're putting in our bodies, what we're putting on our skin, what we're putting on our scalp, there are lots of things out there that are hormone disruptors, including believe it or not, changes in the climate, changes in weather. These are all hormone disruptors that can affect hormone levels. And these are things that are not caught on labs but can still mimic these androgens that attack hair follicles. And so, there are lots of ways that hormones can affect your hair without showing those elevated numbers on the labs.
Cynthia Thurlow: [00:52:47] That's such a good point because when we think about these endocrine-disrupting chemicals, they can offset the receptor for that hormone, and I think I read in a study, they can be a thousand times more potent than that hormone is. And so, is it any wonder that, yes, the labs may look normal, but someone is still experiencing symptoms? I think that validation that you do see that whether it's environmental, in the food, or personal care products, all can contribute. Are there resources that you'd like to refer patients to in terms of increasing their knowledge around this topic in particular? Because I can imagine from a traditional kind of allopathic perspective, that's oftentimes not something we discuss or we've been trained in, but yet the research is certainly emerging that these factors can impact our health quite significantly.
Dr. Omer Ibrahim: [00:53:36] Absolutely. And there are lots of, what's the word I'm looking for? People that are just sensationalists out there. There's a lot of sensationalism, especially around the media when it comes to these hormone disruptors. And then, God forbid, a civil action lawsuit comes out and there are lots of not so credible sources out there. The two sources that I tell patients that are pretty credible and will publish facts based on actual truth and data and vetted data. The American Academy of Dermatology, there are tons and tons and tons of patient resources on there. And they used to call it the North American, but I think now it's called the American Hair Society or American Hair Research Society. They have blogs on patient resources. And the NARS, North American Hair Research Society, that's what it is. But there are tons and tons and tons and tons of patient resources on there, and data, publications, and constant updates that patients that can know and feel reassured that the information that they're getting has been vetted and is science backed.
Cynthia Thurlow: [00:54:48] And if someone's listening and maybe their dermatologist, maybe that's not their area of expertise is hair loss and hair thinning. Are there places that individuals can go to locate a specialist in their area? Obviously, if you're in Chicago, you've got a great resource obviously. But if people live outside Illinois or live in other parts of the country, how do they find specialists?
Dr. Omer Ibrahim: [00:55:11] Great question. So, the official answer is, number one, the American Hair Research Society that I had mentioned, the website has a list of providers on there. The problem is they only list-- The issue is they only list providers that are part of this society. And even though I'm a hair loss specialist, I don't even think I'm part of the society anymore because my membership sort of lapsed. But another way really, and it sounds kind of weird, but Facebook, to be honest, like, the amount of patients that I get that are looking for specialized hair specialists, I get them from two sources. One, by directly asking your dermatologist, you will not offend them. In fact, they might be like, “Oh, yeah, that's fine, thank God.”
[laughter]
[00:55:55] Nothing against you. Hair is tough to treat. It takes a lot of energy. It's frustrating to treat on the part of the patient and the physician sometimes, so don't take it personally that physician will not take it personally. So, if you ask your doctor, “You know what, can we get another opinion? No offense. Is there someone that you know?” Trust me, that we all know each other. They will find you a specialist. So, you can ask your primary doctor or your dermatologist. That's number one.
[00:56:20] Number two, Facebook, the amount of patients that I get, especially with specific types of especially autoimmune hair losses that they are on blogs. My name is on these blogs and that's how I get a lot of these patients. But through Facebook, through these online communities, through these forums, as well asking your dermatologist directly, you will not offend them.
Cynthia Thurlow: [00:56:39] Yeah, no, I think that's important. And I love hearing that you mentioned Facebook because I feel like Facebook is kind of have like fallen off a cliff. I think for most of us, we get on Facebook now and it's like one ad after another. But I think for a lot of individuals that are really-- And especially we didn't really touch on the autoimmune piece, but for a lot of autoimmune disorders, that hair loss piece can really be a significant exacerbation. I've so enjoyed this conversation. I would love for you to share listeners how to find you if they're in Chicago, if they want to learn more about your work, I know that you do quite a bit of academic work as well. How can they learn more about you and work directly with you?
Dr. Omer Ibrahim: [00:57:16] So you can find me. I practice in Chicago at Chicago Cosmetic Surgery and Dermatology. And I've sort of built a hair loss team. I have two or three Pas depending on the day, that are helping me intake hair loss patients. And they are fantastic. They're wonderful. They're amazing. They actually do my hair loss treatments too, so you're in good hands. And then the more severe, complicated cases we collaborate with as a team, so we have a hair loss team at Chicago Cosmetic Surgery and Dermatology you can find us at chicagodermatology.com. And my Instagram handles at @chicagoskindoc.
Cynthia Thurlow: [00:57:54] Awesome. Thank you again for your time today. I've so enjoyed this conversation.
Dr. Omer Ibrahim: [00:57:58] My pleasure. Thank you for having me.
Cynthia Thurlow: [00:58:00] If you love this podcast episode, please leave a rating and review. Subscribe and tell a friend.
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