243: Functional Approach to Alopecia Areata w/ Dr. Julie Greenberg

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Alopecia has been a hot topic in the media lately, but for others who have been dealing with hair loss for some time, it can be triggering and even devastating.

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My guest today, Dr. Julie Greenberg, is a licensed ND who specializes in integrative dermatology and works with hair loss in her practice.

She is the founder of the Center for Integrative Dermatology, a holistic dermatology clinic that approaches skin problems by finding and treating the root cause.

Dr. Greenberg holds degrees from Northwestern University, Stanford University and Bastyr University, and received advanced clinical training at the Dermatology Clinic at the University of Washington Medical School and at the Pediatric Dermatology Center at Seattle Children’s Hospital.

She is also the Program Chair of the Naturopathic & Integrative Dermatology series on LearnSkin.com, a learning platform for integrative health care professionals.

Join us as we discuss what a functional approach to alopecia areata is and learn about the many types of alopecia there are.

I'd love to know if you have tried any of the tips that Dr. Greenberg has shared in this episode — Let me know in the comments!

In this episode:

  • Different types of alopecia
  • Patterns in stool testing that Dr. Greenberg tends to see in hair loss cases
  • What vitamins are actually important for hair health (hint – it's not biotin!)
  • Why autoimmunity is more than just gut dysbiosis
  • Are biologics or topical minoxidil worth trying if you want to deal with alopecia holistically?
  • Why it's important to catch hair thinning early rather than waiting it out


“Biotin always comes up and it's another one of those things where, absolutely, if someone is deficient in biotin, it can cause hair loss and we would supplement, but biotin's got a really great PR person and it's out there in every supplement, and every patient who's losing their hair comes to me just taking tons of biotin. And there's no evidence to prove, unfortunately, that if you're not deficient in biotin, that biotin supplementation is going to help, and it can throw off a lot of labs, so a lot of my patients, I have to take off of biotin.” [14:51]

“When we think about an autoimmune disease, we have to stop for a minute and think like, wow, things have really gone awry in the body when the body can't identify self, right, because that's its number one job, is we have to know, what's self and what's an invader? We don't want to be attacking self. That's a self-defeating purpose. And so, for the body to get that far off, it usually takes both the microbiome gut dysfunction, leaky gut picture, and a toxic element where it's just so overwhelmed, it's under so much attack, it's just so confused that it's just firing at everything.” [17:10]


Find Dr. Greenberg online and on Instagram

Healthy Skin Show ep. 173: Malassezia: The Bug Behind Many Fungal Skin Problems w/ Dr. Julie Greenberg

Healthy Skin Show ep. 149: How Staph Aureus Wrecks Your Skin w/ Dr. Julie Greenberg

220: The Gut Microbiome Of Acne [NEW RESEARCH] w/ Dr. Julie Greenberg

225: Topical Steroid Withdrawal (TSW)- Is It Just A Waiting Game? w/ Dr. Julie Greenberg

LearnSkin Naturopathic and Integrative Dermatology Series


243: Functional Approach to Alopecia Areata w/ Dr. Julie Greenberg FULL TRANSCRIPT

Jennifer: Dr. Greenberg, I'm so excited to have you back on the show today, especially because we are going to be talking about a topic that you and I have never talked about before. And in fact, it's a little different than what we usually talk about because usually, we're talking about skin. Today, we're going to be talking about hair loss. Thank you so much for coming back.

Dr. Greenberg: Thanks so much for having me. It's a joy for me to be here, as always.

Jennifer: So let's talk a little bit about alopecia. I've covered, maybe, hair loss twice on The Healthy Skin Show so far and I know that hair loss can be a big factor for people who are going through skin issues, or maybe it's just hair loss on its own. So you had mentioned something really interesting to me. First, there are different types of alopecia, and we're going to talk about a very specific type today. So let's talk about, what is alopecia, what are the different types of hair loss that are associated with it, and then we'll go into what alopecia areata is and whatnot because I think you guys are going to love everything that Dr. Greenberg has to share.

Dr. Greenberg: Yeah, so that's a really good point. A lot of people will say, “Well, I have alopecia,” which is… It's really nonspecific because the definition of alopecia is partial or complete hair loss from an area of the body that is supposed to, or formerly had hair. So all it means is that you're losing your hair from somewhere, but it doesn't tell us, really, which disease you have or why. So we kind of create buckets for hair loss, and one of the buckets is called scarring, one is called non scarring, and one is called mixed. So I'll go through those three and then we can talk a little bit about what's in each bucket and then we'll drill down into alopecia areata.

Dr. Greenberg: So scarring hair loss means that the hair follicle has been attacked and killed, so there's a scar there. That hair can never come back. We can't regrow that hair. And there's a group of alopecias in that scarring bucket, and that would be things, if you've heard… They're less common, but it's frontal fibrosing alopecia, or lichen planopilaris, or there's a discoid lupus erythematosus. These are more of an autoimmune, permanent attack on the hair follicle. We can't regrow it. You need a biopsy for that. And it's important to know, do you have scarring or non-scarring, because non-scarring means the hair fell out, but the follicle is still there, the follicle is still intact. So if we can figure out what went wrong, we could regrow that. So it's really important to know which bucket you're in.

Dr. Greenberg: Then there's a mixed bucket. The mixed means that it starts off as non-scarring, which means we got a good chance of regrowing it, but if it goes too long, it can turn into scarring. And so, for those conditions, we really want to get on them as soon as possible while there's still non-scarring and we can regrow the hair, and examples of that are things like traction alopecia. Traction alopecia can be caused by hairstyles that are pulling so hard on the hair follicle for so long that it traumatizes them, and then the hair falls out. So certain professions, like ballerinas or gymnasts or ice skaters, if you look at them, sometimes you will see they've got these very tight hairstyles. Even some religions, like Sikh men, will get it. They can't cut their hair and it's so heavy and they're pulling so hard that that hair follicle gets traumatized and they lose hair from… especially around, we call it the fringe sign, around the front.

Dr. Greenberg: There's also something called trichotillomania, which is where people pull out their own hair. It's an anxiety disorder, and that also is mixed because at the beginning, it's non-scarring, but if people continue to pull out their hair, eyebrows, eyelashes, or scalp hair, for long enough, it's not going to grow back. So we need to know what bucket we're in.

Dr. Greenberg: Alopecia areata, which is the one you brought up, is a non-scarring hair loss. So the good news about that one is, really, for the most part, if we can figure out what's wrong, we can regrow the hair. The one exception is that in conventional medicine, it's thought of as, once you have lost all the hair in your head for 10 years or more, it's probably not coming back. And so, even with alopecia areata, even though it's technically a non-scarring hair loss, we do want to get in and try to get a handle on it as quickly as possible and not sit around and wait 10 years because there's not a good chance of regrowing it at that point.

Jennifer: And what exactly is alopecia areata? Is this some sort of autoimmune disease or is it something else?

Dr. Greenberg: Yes, it sure is. It is an autoimmune disease, and it's an attack on the hair follicle, and it's not fully clear to us why this happens and that's common with a lot of autoimmune diseases. We don't really understand why the body is attacking self. The most common autoimmune disease is Hashimoto's hypothyroidism, where we attack our thyroid. We don't understand why we do that, and it's the same that's happening with alopecia areata.

Dr. Greenberg: And for some reason, the hair follicle, instead of the body recognizing it as self, like, oh yeah, that's part Julie or part Jennifer and I'm going to leave it alone, it suddenly shifts and it looks at that as an invader, an intruder, and it will mount a response, kill the hair follicle, and then the hair falls out. Now, again, it's, or killing the hair follicle… It's not true because it's non-scarring, but it attacks it to the point where it shuts it down and the hair falls out until you can shut that process off. It is what we call a T cell-mediated attack. T cells are certain types of immune cells that we produce. There's lots of different types of T cells, and lots of different types of T cells are involved in alopecia areata. But yeah, it's basically where the body turns against itself, starts attacking the hair follicle with all sorts of inflammation, and then the hair falls out.

Jennifer: Hmm. And are there different types of alopecia areata, or is there just one?

Dr. Greenberg: Yeah, there's many different types of alopecia areata. So the least severe type is called patchy alopecia areata, and that's a lot of how all of it will start, and there's these coin-sized patches. They can be round or oval shaped and they can start off like a dime and then they start to grow. They often will get to be the size of a silver dollar, and it can happen all over the head, but it can happen anywhere there's hair growth. So you can see men with beards, with patchy alopecia where spots of their beard are missing. I mean, it can happen to pubic hair or other areas as well. Everything we're talking about, people are most frequently thinking about the head because that's where it tends to impact people the most in terms of their social life and psychological wellbeing, but these alopecias that I'm talking about can happen anywhere. So that's the patchy alopecia.

Dr. Greenberg: There's patterns. There's something called alopecia areata ophiasis. Ophiasis is Greek for snake, and it's a snaking pattern where patients lose hair along the sides and where the ears are and then along the back hairline, so it's this snaking hair loss around the sides and back of the hairline.

Dr. Greenberg: Then there's alopecia areata sisaipho. Sisaipho is the opposite word of ophiasis and it's the opposite pattern of hair loss, so they are going to lose hair from the top, from the front, and middle portion of the head, kind of like a opposite skunk stripe, where that hair is missing.

Dr. Greenberg: There's alopecia totalis, which then means that you go completely bald on your head, and there's alopecia universalis, which means that you have now lost hair from all over your body, including eyelashes, eyebrows, pubic hair, arm hair. Just every hair on your body gets attacked and falls out. And it's more severe and more aggressive as we go, so the least aggressive and the easiest to treat is going to be that initial one I talked about, the patchy alopecia. Once you start getting into the other ones, particularly alopecia totalis or universalis, it's much harder to treat because it's just a much more widespread process with a lot more inflammation going on.

Jennifer: So I wanted to ask you this because your discussion about acne… I forget which specific episode number it was, but we'll link to it in the show notes, which was awesome and all about the gut microbiome. I'm sure that there is a microbiome component to this. What do you tend to see in terms of the gut microbiome in patients that you treat who are dealing with this, because I think that's an important point, everybody. It's not just about doing a diet. There's other factors here. And so, Dr. Greenberg, what do you tend to see in stool testing?

Dr. Greenberg: Yeah, it's a really good point, and if your listeners have heard me speak on any of your other episodes, they will know what I'm about to say, which is that I do do gut microbiome testing on all my patients and, absolutely, my autoimmune patients. So whether it's vitiligo, which is another dermatological condition, when instead of a attack on the hair follicle, it's an attack on the melanocyte or the pigment cells in the skin, or if it's alopecia areata or psoriasis, we need to go do that gut microbiome testing.

Dr. Greenberg: So I do a stool test and a urine test called an OAT. I want to see what's happening in the microbes in the gut, how many good guys, how many bad guys, who's missing, who do I need to get rid of? And with my alopecia areata patients, it's pretty consistent. There's usually a lot going on, a lot of overgrowth of unwanted bacteria. And in particular, some of the bad guys, that we call LPS or endotoxin producers, pseudomonas is an example, they're often present.

Dr. Greenberg: I am often seeing a leaky gut, and the way I can diagnose a leaky gut is, there's particular good bacteria like akkermansia muciniphila or faecalibacterium prausnitzii that we want to see, that contribute to a strong mucosal barrier in preventing leaky gut. They're often missing in my alopecia areata patients. A lot of times, there can be candida or mold overgrowth as well. So it usually is this microbial onslaught of pathogens combined with a leaky gut, and that really drives inflammation in the system. And once the gut is leaky and you have stuff leaking from the gut into the bloodstream, the inflammatory response that the body is producing, it's not localized to the gut. It's in the bloodstream now, and the bloodstream goes everywhere, including our hair follicles.

Dr. Greenberg: And people don't realize, but the hair follicle is a nutrient hog. We need a lot of nutrients. There's a huge amount of blood supply that goes to the hair. We think of it as dead, which is certainly true for the crown of glory that we all have, right? But at the follicle, you know if you've ever plucked out a live follicle, it hurts. You're like, “Ow.” It's certainly attached to a blood supply, and there's beautiful pictures that show just this… It's not like there's one capillary attached to the hair follicle, but through this wonderful imagery that we've done, it's basically bathed in blood and capillaries in the hair follicle root, and it's just… There's this constant supply of blood going to it and nutrients. And so, whatever's in the blood, if there's inflammation, it's going to go there as well.

Dr. Greenberg: Yeah, but people don't realize just how many nutrients hair needs, and hair is one of those things where… I mean, it's not critical to being alive. You can have alopecia universalis and lose absolutely ever hair in your body and you're going to be fine. But psychologically, it is really, really devastating to patients, and I would say even more so than a lot of my skin diseases. My alopecia patients, and particularly alopecia areata, are pretty traumatized by the hair loss, particularly when it's on the scalp, and really desperate to find a solution.

Jennifer: Yeah. I will add to that, that every client that I've spoken to, especially those… because I don't tend to get the hair loss piece in most clients, with the exception of those who have TSW or topical steroid withdrawal, where they've also started to lose their hair. And the very common comment is, “I could relatively deal with the skin being a mess, but when I started to lose my hair was when I just lost it, and that was the tipping point where I just felt like everything was over.” And it's so hard to hear someone say that, to realize that they're at such a point of devastation and depression because of hair loss, so I can certainly echo that sentiment as well, from what I've heard from people.

Jennifer: With alopecia areata, a lot of times, they'll say, “Okay, if you start losing hair or you start noticing thinning hair, the first thing you do want to look at and assess is nutrients,” and you did mention that hair is a nutrient hog. Iron is a big deal. Do you feel like iron is a factor with this or not so much?

Dr. Greenberg: It certainly can be. There's plenty of case studies that show patients who have alopecia areata, and if they're iron deficient, then supplementing can absolutely help, and in some cases, will regrow hair, and that's true for all the nutrients. So you made a good point. When we start off looking at hair loss, we want to certainly make it a correct diagnosis. When it's generalized thinning, that's generally not alopecia areata. Alopecia areata tends to start presenting in this patchy hair loss fashion. But whatever the hair loss, if I have a patient coming, complaining of hair loss, I'm initially going to start with a workup thinking about, first of all, thyroid. Is there thyroid okay? Let's check that, because you get hair loss with thyroid problems. Absolutely, you can lose the outer portion of your eyebrows, your hair can thin, turn brittle, you can lose your hair. So we want to make sure that's not a thyroid problem and we want to make sure it's not a nutrient deficiency.

Dr. Greenberg: So for iron in particular, are they vegetarian or vegan? Are they getting only plant sources of iron, which are not as well absorbed? Do you have a menstruating female who's losing a lot of blood, maybe due to fibroids or something? She can certainly be anemic, or for other reasons. There's just so many nutrients that go into hair health, including zinc and vitamin D and vitamin A, I mean, all of them. We want to make sure that we're not deficient on vitamins. Biotin always comes up and it's another one of those things where, absolutely, if someone is deficient in biotin, it can cause hair loss and we would supplement, but biotin's got a really great PR person and it's out there in every supplement, and every patient who's losing their hair comes to me just taking tons of biotin.

Dr. Greenberg: And there's no evidence to prove, unfortunately, that if you're not deficient in biotin, that biotin supplementation is going to help, and it can throw off a lot of labs, so a lot of my patients, I have to take off of biotin. But that being said, if you really are deficient in biotin, absolutely, supplementation can help. And there was an interesting mouse study where they put the mice on antibiotics, and then they took a portion of those mice and they also deprived them of biotin, and they were able to induce alopecia areata in the mice that were both on antibiotics and deprived of biotin. Yeah, so it took both. It took both. If they were just deprived to biotin or if they were just on antibiotics, the mice did not develop alopecia areata. It took both conditions.

Dr. Greenberg: So again, the antibiotics are going in, they're creating changes in the gut microbiome of these mice, right, they're killing off good guys, along with whatever pathogens they're meant to target. And those two that I mentioned at the beginning, faecalibacterium and akkermansia muciniphila, they're susceptible to a lot of antibiotics. So we don't know exactly what happened in those mice, but we do know that antibiotics, combined with a biotin deficiency, can cause an alopecia areata, but you'll see… I mean, for most of the patients, I'm putting them on a multi… It's got biotin, or if we test the iron in the ferritin, they're totally fine. So most of the time, it's not just as simple as a nutrient deficiency. You do have to go to the gut, fix the gut microbiome. And I also find with my autoimmune patients, again, whatever type of autoimmune condition they have, there's a secondary piece of a toxic element that we need to address, and that can be a wide variety.

Jennifer: I was going to ask you about that because you made a mention of that earlier, so tell us a little bit more about this toxic piece to this hair issue.

Dr. Greenberg: Yeah, so when we think about an autoimmune disease, we have to stop for a minute and think like, wow, things have really gone awry in the body when the body can't identify self, right, because that's its number one job, is we have to know, what's self and what's an invader? We don't want to be attacking self. That's a self-defeating purpose. And so, for the body to get that far off, it usually takes both the microbiome gut dysfunction, leaky gut picture, and a toxic element where it's just so overwhelmed, it's under so much attack, it's just so confused that it's just firing at everything. And a lot of the toxins that I end up seeing, well, there's kind of different buckets, but sometimes we'll do heavy metal testing to see if that's a component, that can absolutely contribute to hair loss or alopecia areata, mycotoxins.

Dr. Greenberg: So when I run the OAT, or Organic Acid Test, I like that test because it really drills down on the fungal piece, both candida, but also molds. And molds show up in a lot of my patients, and then if there's molds, there can be mycotoxins, which are secondary metabolites produced by mold. And that's a fancy word for saying, if a mold feels like it's under attack from other mold or bacteria, then it knows that its life is in danger and it has to go to war, and it starts producing these chemicals that it shoots into the air. They're called mycotoxins. Myco is another word for fungal, so fungal toxins, and it will kill oncoming bacteria or fungus. It's not trying to harm us as humans, but if we're in a living space where there's this fight for life going on behind the wall and the mold is just pumping out mycotoxins, we're going to breathe it all day long. And if it's in the gut, then of course, we're being exposed to it within our own body. So mycotoxins show up a lot.

Dr. Greenberg: There can be environmental toxins, stuff in the water, like pesticides, herbicides, runoff from the petroleum industry, from chemicals, from rubbers, plastics, stuff like that. So sometimes it can take a bit of testing to try to figure out all the pieces that are there, but I let the gut microbiome initial testing guide the way and then see how patients are responding because I've had really good success with regrowing hair in alopecia areata. Usually, within three to four months, we're starting to see some hair growth, and then we continue on an onward trend. When things are more static or it's regrowing here but losing there, that's more when I would start to suspect like, okay, is this patient in a mycotoxic environment, where it's almost like a boat that it's got a hole in it, and so you're bailing water, but then there's more water coming in, right? You're only going to make so much progress that way.

Jennifer: Can I ask you a little bit about the heavy metal piece to this? I oftentimes stress to clients like, “It's not always wise to deal with everything at the same time,” and that can also be the case with mold and mycotoxin issues, is that sometimes everyone wants to tackle everything at the same time because they want to be efficient, but your body just can't… You just cannot handle that. And at least the way that I was taught, was really that heavy metal toxicity is an issue that I still believe, frankly, should be handled by a doctor, not someone that's a health coach or even a nutritionist or dietician because it's really beyond our scope of practice. You have to be careful with what happens to these heavy metals when they're released from wherever they're being stored at, essentially.

Jennifer: So when do you recommend, or at least in your practice, when do you deal with heavy metals if you find them, and do you agree that, really, this is something that would be best handled by a physician like yourself, especially… There's chelation therapy, but then there's all these cleanses out there now that you're like, “Heavy metal detox,” and I'm like, “Is that really the appropriate thing to do on your own?”

Dr. Greenberg: Yeah, it's a good point, and a lot of it depends on what I'm actually seeing on the lab results for heavy metal. So I have an alopecia areata patient. He's in his twenties, had a good percentage of hair loss. He had a mixed alopecia areata, which I didn't say, but you can have different types. So he started out as the patchy, it turned into ophiasis, and just a lot of hair loss all… and then a frontal as well, so he had a lot, a lot of hair loss. He had, certainly, the leaky gut picture and he had some mycotoxins. But when we did heavy metal testing on him, his mercury came up high, and this was a mercury… So if you want mercury from fillings, from amalgams, you need to do a blood test. This was a heavy metal hair test, which will not give you that data. You need a blood draw for that. But his mercury was high on the hair test, which told me that it was coming from food, and he was a big sushi eater.

Dr. Greenberg: So for something like that, right, we can tackle that. That was the only thing that was high on his heavy metal hair test. A, we're going to, if possible, reduce the sushi consumption, but we can take chlorella with the sushi, and we're going to also try to reduce our consumption of top predatory fish. So you don't want to be eating things like tuna or shark because the top predators are going to bioaccumulate the heavy metals because they're eating the next fish down, and that fish that it just ate has been eating smaller fish than it. And so, as you work your way up the predatory chain, you're bioaccumulating the heavy metals in the tissue, and each bigger fish that comes along and eats it is now getting all the mercury that that fish before it had bioaccumulated, and now each time it eats one, it's bioaccumulating. So you can do things like eliminate tuna from your sushi, but… So something like that, I can certainly tackle.

Dr. Greenberg: To your point, I don't do IV chelation or anything. I don't use those types of products. So if someone was really overloaded with lead or something like that, I'm going to absolutely refer out because that's not my specialty and I don't do that type of heavy metal chelation and stuff like that.

Jennifer: Yeah, and I think that's an important point to stress, is that it has to be somebody that's really set up to deal with that. It's not just going to a spot on the corner and they're like, “Oh, we do heavy metal detox, IV therapy,” and you don't even have a doctor there on the premises. I think you have to be careful with that kind of things. When you start mobilizing heavy metals, sometimes things can go awry and can cause more damage in the process, so we just want to be cautious of that.

Jennifer: Okay, so that being said, it sounds like there's hope because you said, “I have a pretty good track record at dealing with this,” which I have… If I was struggling, Dr. Greenberg, I would go see you because we've had so many great conversations. You know what you're doing. Oh my goodness. Every single time you're on the show, you share so many amazing pearls with everyone. So what do you think about somebody who's just going the conventional route? Not that there's necessarily anything wrong with that, but they're just necessarily trying to stop inflammation. That's it. We're just saying, “Okay, we'll just try and stop the reaction. We'll try and arrest the process and leave it at that.”

Jennifer: If someone is doing the conventional route and they're not seeing improvements, could they transition into doing a more functional route without necessarily seeing an increase in hair loss? Or what are some… Maybe they're tough truths that you could share as we get to the end of this, that people need to know? You know what I mean? I think a lot of times, that you get there and you go, “I wish I knew that.” What do individuals struggling with this probably need to know that no one's told them before?

Dr. Greenberg: Yeah, so I have a lot of patients who come to me, having gone the conventional route, and the most popular conventional route, at least for patchy alopecia areata, is going to be corticosteroid injections into the scalp. Now, that's obviously not going to work for kids. They're not going to let you inject things into their scalp, so they'll use really potent topical steroids in kids or someone who's not able to tolerate an injection.

Dr. Greenberg: Sometimes you can do a couple corticosteroid injections and if that's it and the hair regrows… I mean, alopecia areata, like any autoimmune disease, can come and go, and so if that's it and it's gone, then great. But obviously, the patients who are coming to see me, it's not that case. And usually, it's that things are getting worse, like the 20-something-year-old patient I mentioned who started out with the patchy alopecia and then it really progressed into ophiasis. He lost all the hair around the sides and the back and it was now coming up from the front. And frontal hair loss is usually the worst for people because there's no way to hide that. That's not like, well, I got a patch on the back and I'll grow my hair out and cover it up.

Dr. Greenberg: And then the other thing is, they sometimes will use a topical minoxidil to try to save existing hair. A lot of my patients come to me already doing corticosteroid injections and/or on topical minoxidil, and I actually don't take them off because maybe it is reducing some inflammation and doing some good. And it's going to take me a while to get in there and address it, so part of what I go through with patients when I first meet with them, with hair loss, is that the hardest thing about hair loss is, you have to be patient because hair loss and hair growth, hair growth is slow. There's no way to speed it up. It's not like skin. You can see dramatic results in skin in a matter of days, right? Skin can do crazy things in just a few days, either better or worse. Hair can't do that. There's different hair cycles of growth and you're not going to see regrowth in a follicle that's not growing for at least three or four months, so it's a slow process and you have to be patient.

Dr. Greenberg: If patients are already doing topical minoxidil, a lot of times when you pull minoxidil, you're going to get hair fall out, and so I don't definitely want to make it worse until we know that things are getting better. I don't want to pull them off of things that could be helping. But all of those conventional options are suppressive medications and we don't even fully understand why minoxidil even works for hair loss. We know that it increases blood supply to the scalp, and as we talked about, hair needs blood, it needs nutrients. So we think maybe that's how it's working, but we don't even know for sure, so they're limited. It's not really getting to the root cause of anything. It's just trying to suppress inflammation. And I would say, if that's not working for patients, if it's getting worse, if the hair is not regrowing, there are alternative options for you to pursue, like seeing a naturopathic doctor or a nutritionist or people who specialize in this in a more holistic role, to try to get at some of those deeper root causes. There's more.

Dr. Greenberg: And now, very much, the way dermatology has gone is to now extend topical suppressive medication to internal. And so, there's something called JAK-STAT inhibitors that they're giving patients with alopecia areata, and again, it's a biologic. It's messing with the immune system. And so, it is an option. If people want to go that route, it's an option, but there's… From a naturopathic or a holistic approach, it's like, well, let's figure out, why is the body going wrong? And let's try to fix that instead of just suppressing all the time. So I think it also depends on what route somebody wants to take. It's a lot of work to do naturopathic medicine. It's not just like, take a pill and I'll see you in two months. It's a lot of work on the part of patients.

Jennifer: That is very true. So if you're at the salon… or most of the time, I hear from ladies who are like, “I was at the salon and my hairdresser noticed that I have a patch of hair missing,” because usually either you notice it, if it's up front, but if it's further back, it's somebody else that notices it. Would you say, in your opinion, that that is the time to start digging into it, not to wait and see what happens?

Dr. Greenberg: Yes, absolutely. You're 100% correct. Getting on top of this stuff earlier is better than later because also, as we talked about, it's going to take a while to fix it anyways. You're going to be three to four months before you even start to see hair regrowth, let alone it actually growing out to a level, and that's if you found the cause and are on top of it. So whatever it is, if you feel like your hair is thinning, if there's spots missing, you're going to want to go get a diagnosis.

Dr. Greenberg: Due to COVID, I've been seeing patients exclusively via telemedicine, and also, my scope of practice here in California. I can see patients in California, Oregon, and Washington, but in California, I can't do any surgical things, so I refer all the time for hair loss to dermatologists, to do a biopsy, to get a diagnosis because as we talked about, you want to know what type of hair loss you're dealing with. Are you in a scarring, a non-scarring? What are we dealing with? Because if it's a scarring hair loss, you do need to get on top of it before it spreads. But we can't regrow that hair, and so you might be looking at other options for that, like a transplant or something like that, right? It's totally different treatment plans.

Dr. Greenberg: But yeah, do not wait. If you think you're having hair loss of any type, patches missing, thinning, whatever it is, go see someone. And patients with thinning hair loss will have the unfortunate experience, and I've heard this from many patients, where they go in and they'll tell their doctor, “I think my hair is thinning,” and the doctor will look at them and say, “Your hair looks fine to me. You have thicker hair than I do,” and the patients are left without anything because the doctor is looking at them and not believing them. And what I found is, patients know when their hair is thinning. Their ponytail is thinner, there's more falling out. They know. Whatever hairstyle they're doing, it doesn't feel the same.

Dr. Greenberg: And so, if you get a doctor who tells you, “Nah, your hair looks fine to me,” just go get a second and a third opinion until you find a doctor who will listen to you because there are plenty who understand hair loss and understand… It's not necessarily that we're looking at a person and going like, “Oh, wow, that's really thin hair.” To your point, we want to catch it early. And people know when their hair is thinning, and you want a doctor who's going to listen to you and believe you, and don't stop until you find one that you get to who understands this.

Jennifer: Well, I love your message of persistence. It's so important because it's easy to become or to feel what you're experiencing doesn't matter. It's not true.

Dr. Greenberg: You get invalidated and think, oh, well, maybe it's in my head, but it's not in their heads.

Jennifer: Exactly. No, it's not. It's not at all. So if someone is in, so you say California, Oregon, and Washington, you're able to… And I know you have a wait list, but you do see patients and you do take patients, so we'll make sure that everybody will find your website and your information so that they can contact you and reach you because you are such a wealth of knowledge, and it is just such a pleasure too. For those of you who don't know, I got to meet Dr. Greenberg a few months ago at the Integrative Dermatology Symposium, and she presented an amazing presentation on Malassezia. She just is such a wealth of knowledge, so if you're looking for a fantastic physician, hands down, I would highly suggest going to see her because she really knows her stuff. And she's incredibly compassionate as well, which I think is so, so important.

Jennifer: So yeah, Dr. Greenberg, thank you so much for coming back and sharing about this. I know this is one of your favorite topics and I look forward to having you back. Every time, it's like knowledge bombs, and I really appreciate it.

Dr. Greenberg: Thank you so much. You're so kind. I'm blushing. I really do love the podcast. I listen to every episode and it's just a pleasure to be here.

“Biotin always comes up and it's another one of those things where, absolutely, if someone is deficient in biotin, it can cause hair loss and we would supplement, but biotin's got a really great PR person and it's out there in every supplement, and every patient who's losing their hair comes to me just taking tons of biotin. And there's no evidence to prove, unfortunately, that if you're not deficient in biotin, that biotin supplementation is going to help, and it can throw off a lot of labs, so a lot of my patients, I have to take off of biotin."