The Curbsiders' 'Hot Takes'

Hair Loss and Breakouts of 'Maskne'

The Curbsiders


November 30, 2020

This transcript has been edited for clarity.

Matthew Watto, MD: This is The Curbsiders.

Paul N. Williams, MD: We interviewed Dr Helena Pasieka about disorders of the scalp and face. Dr Pasieka is an amazing dermatologist and a great educator who breaks things down in a very practical way. We are going to recap some of the pearls we took away from that interview.

Watto: Starting with the scalp. I knew next to nothing about the scalp other than to use some fluconazole shampoo once in a while.

Stuart K. Brigham, MD: Can we get this off of our chests first? We are three White guys with good heads of hair talking about hair loss.

Williams: I was listening to that androgenic alopecia stuff with rapt interest. Believe me, I found it personally relevant and was very excited to hear what she had to say.

Watto: I had way less forehead for most of my life, Paul, so I'm right there with you. She had some really great tips about alopecia. The two main buckets to split it into are scarring alopecia and nonscarring alopecia.

Scarring alopecia is not subtle. You see total destruction of the follicles. It's fairly uncommon, but if you see it, send the patient right to a dermatologist.

There are a couple of different types of nonscarring alopecia. Androgenic alopecia is the one everyone's familiar with: male pattern baldness. Men get the temporal baldness and hair loss on the crown or back of the head. Women have a slightly different pattern: hair loss extending across the whole top of the head.

Apparently, patients bring in a bag of hair and say, "I'm losing so much hair." Dr Pasieka tells them it's okay. Everyone loses up to 200 hairs a day; that can be normal. During periods of high stress — such as a global pandemic — all of a person's hair can get pushed into the telogen phase, which is when the hair falls out. You can have a whole bunch of hair falling out at once. Generally it stops when the stress goes away, but it can last for a couple of months.

Williams: Given the present circumstances, I've been losing hair for a couple of years.

Watto: The other common type of nonscarring alopecia is alopecia areata, an autoimmune condition. These patients should be referred to a dermatologist. It can become generalized, with the loss of eyebrows and all other hair. It usually starts out with a coin-sized bald spot. If you look at that bald spot and the patient is starting to regrow hair, the hair will be white because the condition knocks out melanin as well.

Stuart, would you talk about treatment for alopecia?

Brigham: I thought it was interesting that minoxidil, which we've used as a mainstay of first-line treatment for alopecia, comes in a 2% formulation for women and 5% for men. I looked up the prices. Minoxidil for men is about 10%-20% more expensive. The recommendation is for women to use minoxidil for men because it's more effective, which begs the question: Why even have 2% for women?

Watto: Give everybody the good stuff, is basically what she was saying. The other great pearl about minoxidil is that you have to coach patients about two very important things. Number one is that there is an upfront period of hair loss. That freaks patients out, but they have to push through it. Let them know that for the first couple of days or weeks they might shed a little more hair than they are used to, but that will go away. They need to try for at least 16 weeks to know whether it's going to work. Unfortunately, if they stop it, they will probably lose any progress that they've made. But dermatologists have other things they can do, so send patients to them if they are really upset about their hair loss.

Paul, you have our final pearl, which is not related to hair.

Williams: This was an episode that I had a selfish interest in. I asked about "maskne" in this time of the coronavirus pandemic. Hopefully one day this video will be terribly dated, but as we are all walking around wearing masks, people have been noticing outbreaks of acne around the area of the mask. It's been called maskne — an adorable name — but the actual name of it is amazing: acne mechanica. It's caused classically in athletes by friction, heat, sweat, and moisture. An area of skin that rubs back and forth and becomes sweaty is more prone to acne. It's a papulopustular eruption.

After the episode I looked this up. There are some neat articles about it. It was also seen in soldiers in Vietnam where their backpack straps were rubbing against their skin. There are case reports of turtleneck-induced acne mechanica, and of people with a tic who rub their faces over and over, causing enough mechanical friction and heat to cause acne in that spot.

Dr Pasieka recommends sulfur washes or benzoyl peroxide (4% or higher) as well as making sure that you are washing the mask you are using frequently. Our own Beth Garbitelli, who wrote the show notes, made a personal recommendation for using 100% tea tree oil for spot treatment, which she says is "straight-up magical." Practical advice all around for those of us who have to wear masks day to day.

Click to hear our full conversation with Dr Pasieka, #232 Skinternship: Scalp & Face , or find The Curbsiders podcasts on iTunes. You can read our show notes and join our mailing list.

Thank you for watching.

The Curbsiders are a national network of students, residents, and clinician educators from across the country, representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about their contributors and follow them on Twitter.

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