Hair Restoration Blog

Q:

Hello,

Have been diagnosed with Alopecia Universalis, not a problem from a cosmetic point of view as I’m over 65, comfortable with myself as a person, and have a positive outlook on life and a strong faith.  The only thing that is bugging me is my finger and toenails.  The pitting and destruction of the nail bed is a problem.  Wondered what the best thing I can do at this point.  I have had the nails covered with an acrylic at a nail studio and for the most part, this seems to work until they get long and snap off.  Should I be taking a special vitamin such as Biotin or Zinc?
Thanks,

A:

This is a good question and I personally could not find your answer myself anywhere. I discussed it with some of my dermatologist colleagues (when it comes to nails, they are more involved with this condition and have probably seen or treated more similar cases of nail changes with Alopecia Areata or Alopecia Universalis.

Here are two of the answers I received from other doctors who see this condition more than me:

1.    Um…I see a fair number of patients with significant deformities of their nails including clubbing, rippled nails, flaking, dents in the names and the distal phalanges with granulation tissue and fullness all starting after they started getting those acrylic manicures. They are pretty rough and they often get damaged nail beds.

2.    Hey Parsa, Unfortunately there isn’t much you can do for the nail pitting that you see with Alopecia Areata or Alopecia Universalis. You can cover it with acrylics - that would be fine, but would damage the nail further over time. Nail polish and manicuring would be preferred treatments. Using Biotin would be fine to promote healthier nails but wouldn’t get rid of the underlying problem. You can also try potent topical steroids to see if that would make a difference.  Hope this helps.

Q:

Dear Dr. Mohebi,

Thank you for taking the time to see me on Saturday! Your correspondence providing a summary of our discussion was very comprehensive and is much appreciated!

Since our meeting on Saturday, I have done some research and would like to trouble you with a few more questions:

1) Is Alopecia the correct term to describe my hair loss pattern?

2) Would you consider cortizon shot treatment for me?

3) Would you consider laser therapy?

4) If I were to use monoxidil, does it have to be 2% or a higher percentage would yield more and faster hair growth?

5) you recommended a complete medical evaluation, could you please recommend someone that you trust?

I wish to thank you again for all your time and patience!

Best regards,

A:

Hi,

Here are your answers in the order you asked:

1) Is Alopecia the correct term to describe my hair loss pattern?

Alopecia is a general term that means hair loss. We have many different patterns of hair loss or alopecia, like male pattern or female patterned alopecia or alopecia cicatricial. Your pattern is similar to a male pattern because you lost your hair on the frontal area while you kept your hair on the donor area intact, which is why you might be a good candidate for a hair transplant procedure considering that your medical evaluation is negative for any medically treatable cause of hair loss.

2) Would you consider cortizon shot treatment for me?

No, steroid shots are sometimes used for Alopecia Areata (AA), which is an autoimmune disorder. Alopeica Areata is a hair loss condition with patchy hair loss spots. Your condition does not seem to be Alopecia Areata.

3) Would you consider laser therapy?

I do not recommend laser therapy for hair loss in the form of laser comb or laser machines because of the lack of solid medical evidence that support their effectiveness at this time.

4) If I were to use Monoxidil, does it have to be 2% or a higher percentage would yield more and faster hair growth?

You can start with 2% and then you need to be re-evaluated in six to 12 months and a treatment plan might need to be adjusted at that time.

5) you recommended a complete medical evaluation, could you please recommend someone that you trust?

Any good internist or endocrinologist could follow through with the lab works that you need.  Our letter includes the list of medical conditions that should be considered and lab works to rule out those women like you who have hair loss. You can share my letter with any good internist or endocrinologist and he or she should be able to follow through with your lab result and treat any treatable conditions that could possibly be found.

Have a great day,

Dear Dr. Mohebi,

I am 21 years old and I have the beginnings of a small bald spot on the back of my head - one of my friends first noticed the spot about a year ago. My hair is thick and curly and I did not expect to have hair loss this soon, especially because I don’t really have a family history of hair loss (except for my paternal grandfather). My hair type is very similar to my mother’s family, and in her family most people keep their hair into their 80s, though it becomes very white. I currently live in Watertown, NY.

I have had widespread eczema since I was little, and when I was younger they classified it has icthyosis. At one point, when I was about 5, I suffered pretty bad eczema on my scalp and started losing some hair. I used prescription shampoos for a while and that seemed to take care of it. The only other medication I take on a regular basis is Zyrtec. I work in a very high stress field, and sometimes work 16 hour days - could that have contributed?

Do you have any suggestions as to what I can do to control my hair loss?

Thanks!

A:

Bald spots or patchy hair loss on scalp can have many different causes.  The most common cause of patchy hair loss is known as alopecia areata (AA).  We’ve discussed and described this issue on our site and in this blog on many posts before.  If AA is causing patchy hair loss, hair transplant will not be the answer.

You need to find and maintain a good relationship with a good dermatologist who can make your diagnosis and start a treatment plan for your hair loss condition.  You may also need a skin biopsy to confirm your hair loss condition.  Many of the diseases that present themselves with patchy hair loss are chronic conditions and require consistency in treatment.  Some inflammatory skin conditions may also be seen along with scalp hair loss.

Ichthyosis is a family of generalized and mostly genetic skin disorders.  All types of ichthyosis have dry, thickened, scaly or flaky skin. Ichthyosis has been reported along with patchy hair loss condition.  That combination is known as The tay syndrome (congenital ichthyosis with trichothiodystrophy).

Single balding spot of alopecia areata

Alopecia areata (AA) is an autoimmune hair loss condition that presents itself in the form of patchy hair loss in scalp and other hair bearing areas.  The role of emotional stress in alopecia areata has been discussed before in medical literature, however, the exact mechanism of it has never been explored.  I just found a new article on the relationship of the stress response to the pathogenesis of alopecia areata that was investigated by subjecting normal and skin graft-induced AA-affected mice to light ether anesthesia or stress due to restraining the animal.

Plasma corticosterone, adrenocorticotropic hormone, and estradiol levels were determined in this study as indicator or stress level, whereas gene expression in brains, lymphoid organs, and skin was measured by quantitative RT-PCR for corticotropin-releasing hormone, arginine vasopressin, proopiomelanocortin, glucocorticoid receptor, mineralocorticoid receptor, corticotropin-releasing hormone receptor types 1 and 2, interleukin-12, tumor necrosis factor-alpha, and estrogen receptors type-1 and type-2. The mice with alopecia areata had a marked increase in hypothalamic-pituitary-adrenal tone and activity centrally and peripherally in the skin and lymph nodes.

There was also altered interaction between the adrenal and gonadal axis compared with that in normal mice which proved that the stress level has been higher in those animals. Stress further exacerbated changes in the activity of hypothalamus pituitary axis in mice with alopecia areata.

Alopecia areata animals had significantly blunted corticosteroid and ACTH responses to acute ether stress (physiological stressor) and a deficit in habituation to repeated restraint stress (psychological stressor). All the findings in the study suggests that altered brain responses during stress may be associated with the occurrence of alopecia areata, which prove the hypothesis that the stress is an important factor in occurrence of alopecia areata.

As we said before, treatment of alopecia areata is through observation of the patient and in some cases injections of steroid could be useful.  More experimental studies have shown some improvements in extensive types of alopecia areata such as alopecia totalis.  Hair transplant should not be done in patients with active alopecia areata since patients may lose transplanted hair through the same mechanism.

I am a 26 year old female and felt like the world was mine, and then this happened and now I would rather hide, so I understand about feeling like a freak. But I think we all have to remember that we have nothing to be ashamed of This disease is more widespread than we think and people are more understanding than we give them credit for. We can all still live long and happy, if a little self consciously. Since getting AU, I have heard of so many people who have friends or family with this disease - there are a lot of us, and we are still lovable, attractive, successful and admired. We may look different but if we can overcome the self-imposed stigma of it, I think it will just serve to make us stronger.

Speaking as a woman, let’s give our daughters, sisters and mothers a good example for self-respect, and show them how to be fearless, how to overcome obstacles and show them that women are more than long shiny hair and a media approved image.

I know I am young and have not yet suffered with this disease as long as any of you, so it is likely easier for me to say these things. I just hope to remain this optimistic and not let it get the better of me. We are all more than our hair. And if being bald and shapely or hairy and fat is the choice, I choose to keep my body healthy on the inside instead of just looking it on the outside.

Thanks to all of you, I wish you all the best and just remember, you are more than your hair and do not accept feeling like a freak! Remember the people that love you when you are at home and hairless for all to see, what they see in you is what you truly are, not the you that has to wear a wig so people don’t stare or the one who has come to hate the wind.

A:

I like your attitude.  Treatment of Alopecia Universalis (AU) could be difficult or impossible in some cases.  You have to come to my office and talk to some of my patients who think the world has come to an end because they are losing their hair.

This is what I always say to my patients: It is important to try to look your best.  If you have the option to change your appearance for the better, do it as much as possible, but for the part that you cannot change, accept it.  Learn to use it to your advantage and learn to love it.

Hi
I am 36 year old from Faridabad.  I have had Alopecia Areata (AA) since12, I took Ayurvedic treatment & after about 5 years alopecia areata appeared again since then it is continuous almost. Hairs goes in patches from all over the body including eye brow and eye lashes, but additional thing with me is that I feel itching on the place from where hairs are going to fall with pain on the itching area too, then consequently within 1-2 days hairs falls and leaves red patch behind pains also gets disappeared.  After that I start using Diprovate lotion twice daily on affected area.  Hair comes within month then I stop using Diprovate.  But normally hair length goes to only 8-10 inches and then again hair loss same process going on since 1980. One thing I observed is that places of hair loss patches are almost fixed.  One thing I also used some hormonal injections too but as usual no permanent remedy.  Do you also feel pain before falling of hair on the place of hair fall on the scalp?  Generally I felt pain on scalp only though hair loss periods.  Pain is only on scalp.

A:

It seems like you are experiencing episodes of patchy baldness.  Although hair loss in a patchy form is usually considered alopecia areata or AA, your condition is not a typical one.  Alopecia areata is usually painless and the changes in skin shape and color is not that noticeable except for the hair loss.  There are some other hair loss conditions that may present themselves as patchy hair loss such as Cicatricial Alopecia in which an inflammatory reaction causes hair loss.  A diagnosis could be established through direct examination and biopsy of the scalp from hair loss lesions.  My recommendation to you is to see a good dermatologist and confirm the diagnosis of your condition.  Hair transplant is not indicated in many types of patchy hair losses, but your hair transplant doctor can discuss it further after reviewing your scalp biopsy results.

Q:

My question is based on a hair transplant that wasn’t successful.  I received a hair transplant at [blocked hair transplant clinic name] and my hair never grew in the area and I followed all the directions carefully. Is there any other solutions to bring back my hair?
A:

The survival of transplanted hair is usually a concern among the patients who undergo hair restoration.  Transplanted hair might never grow or have suboptimal growth in several conditions.  We can categories those into two major groups:  1. Technical problem and 2. Patient factor.

• Hair Transplant Technical Problems:

  • Hair graft preparation and handling problems:  inexperienced technicians may manipulate hair grafts more than what they can tolerate.  That may damage the proliferated follicle cells during slivering, graft harvesting or implanting so the transplanted hair can never grow.
  • Graft maintenance problems:  Hair follicles should be kept in suitable physiologic solutions from the moment they are removed from body till the time that they are placed in their destination.  The temperature of the solution should always be kept between 0 - 4 degree Centigrade to lower the cell metabolism and prolong the longevity of follicular cells.
  • Problems during implantation phase:  If the sites are too tight, technicians may manipulate hair grafts too much that may affect the final potential of hair cells to grow.

• Patient Factors:

  • Many skin conditions may restrict or stop the growth of transplanted hair.  Some of those conditions are Alopecia Areata, Alopecia Cicatricial and many other medical conditions that may have caused hair loss in the first place.  Preoperative microscopic and macroscopic evaluation of hair and scalp is crucial to rule out any condition that may limit the growth of transplanted hair.  Hair transplant surgeons should raise questions for these in atypical hair loss conditions especially in patients who do not have a family history of similar hair loss condition.  The diagnosis should be confirmed by scalp biopsy.
  • Care after hair transplant play a major role in the final results of a hair transplant procedure.  Physical trauma to the transplanted hair may cause losing newly transplanted hair, including pulling hair, scratching head or psychological conditions such as trichotillomania in which patient pull hair due to an obsessive compulsive disorder.

If you experienced less than desirable results from your hair transplant surgery after one year from your hair transplant surgery, you need to see a good hair transplant surgeon to reevaluate your condition and potentially treat the disorder that has caused your less than desirable growth.

Q:

I was diagnosed with Alopecia and lost pretty much all of my hair during pregnancy. My son is now 5 months old and my hair has grown back. All but one spot. I can hide it but I would love for one day not to have to hide it.

A:

Dear Mo,

You have experienced extensive alopecia (I am assuming that you mean alopecia areata) and now only after a few months got your hair back except for a small patch. This is a pretty good recovery for a condition that could have had a much worse outcome. My suggestion to you is to hang in there. It is very likely that you can grow the rest of your hair back without any treatment. If your hair loss is due to alopecia areata, a hair transplant can not help your condition.  You need to be seen and examined by a hair specialist or a dermatologist to best confirm the diagnosis.

Best of luck to you.

Q:

Dear Dr. Mohebi,

Hello, I am really interested in doing hair transplant by you, as my friends in California highly recommended you. I wonder if you can please help me with this questions:

1. Which method would you recommend, FUT or FIT?
2. I have had Alopecia areata in the past in back part of my head. It happened several times, last time 3 years ago. I wonder how it will affect my chance for doing hair transplant. I really appreciate if you can please answer me in details.

Thank you so much for your attention and time.

Sincerely,
S T

A:

Thanks for you interest in our hair restoration services.  I will answer your questions in the order they were received:

1. Follicular Unit Transplantation (FUT) is the gold standard method in doing hair restoration. FUT is done in two methods 1. strip technique and 2. Follicular unit extraction (FUE, also called FIT).  It has to do with your goals in hair restoration and you can read more about advantages and disadvantages of FUE in my hair restoration blog.  Planning on doing one vs. the other needs to be discussed with the patient during the initial consultation.
2. Alopecia areata (AA) is an autoimmune disorder and usually a reversible condition in which a patient loses hair in a patchy fashion.  It affects transplanted hair the same as normal hair.  I generally make sure that patients don’t have active AA before proceeding with hair transplant.  A physical examination is extremely important in differentiating between male patterned baldness and diffuse alopecia areata (a rare type of alopecia areata).  In undiagnosed cases of alopecia areata, if a patient gets a transplant in the balding area that hair is lost due to AA, there is a risk that patient will lose the transplanted hair with the same mechanism.

Dear doctor,

I am a 38 old married woman from Bangalore. I have 2 children (13 years daughter and 9 years son) . I was having alopecia areata problem since I was 10 years old. But I used to get hair back in a year. Like this, hair was falling and getting back was happened 3-4 times. But hair was very lengthy and very beautiful when I got married. After that during second pregnancy I started loosing hair.

After delivery I lost all my hair and became bald including eyebrows, eyelashes and body hair.I was very lean. I took Allopathy medicines in kurnool(AP) like steroids. I got my hair back and became fat. I stopped the medicines gradually as per doctor’s advice. I lost my hair again after stopping medicines. After that I tried homeopathy(Bathra’s) and ayurvedic. No use by these. After that I have tried intra regional steriods(injections). I can see a few hair,but if I stop medicines, they started falling again.

1 year back I got affected with Chikun Gunya. I met rheumatologist in Bangalore. He again suggested some steroids(wysolone) and Azoran(immunosuppresents) for both severe leg pains and alopecia universalis. I have seen a very good progress and got hair back. But those new hairs are very soft and not strong. He reduced the dose of Wysolone(1/2 of 5 mg) and maintaining the azoran -50mg 3 tabs per day. After reducing wysolone again  I am getting so many bald patches.

I recently met my doctor and he again increased the dose of wysolone to 10 mg. I think this is neverending process. I have almost lost the hope and fed up with all these tests, treatments and side effects and unnecessary spending of money. I was very lean and my weight was 50 kgs at the time of second delivery.

Now I am 85 kgs.I am fighting with this desease  since 10 years. Presently I am using the medicines suggested by rhemotologist.I am having brittling nails and will get headache some times. Every 2 months once I will take blood and urine tests before consulting doctor. The reports are showing more ESR. No other problems for now. I have taken thyroid test and found hypothyroidism. Now taking thyroxin tablets for that.
Family background: My mother is having Diabetes and Thyroid problems.

Please suggest any permanent solution for my problem. Please help me out of this problem…..

Thanks

A:
Alopecia Areata or its more aggressive alopecia universalis, in which patients experience whole body hair loss, is an autoimmune disorder. Autoimmune reaction is an abnormal response from the immune system that attacks certain organs or cell lines and causes malfunction on that system.  In alopecia areata (AA), patients may have involvement of some other body organs such as thyroid disease or other appendages of skin such as nails and hair.

It seems like your alopecia areata was activated by pregnancy and led you to get alopecia universalis. A precipitating factor can be found in 15.1% of patients with alopecia areata and include major life events, febrile illnesses, drugs, pregnancy or trauma but no clear conclusions can be drawn. Despite these findings, most patients with alopecia areata do not report a triggering factor preceding episodes of hair loss.

Your thyroid disease could be part of the same autoimmune disorder that affected your hair and skin.  Eight percent of people with alopecia areata have thyroid disease; this is higher than the incidence of thyroid disease in the general population which is 2%. Despite the correlation between alopecia areata and thyroid disease, treating the thyroid disease does not generally remedy the alopecia areata.

The outcome of alopecia areata is unpredictable. Some people lose hair in only small patches. Others may have more extensive involvement like you. Alopecia capitis or alopecia totalis is the loss of 100% of your scalp hair and alopecia universalis is the loss of 100% of body hair. These last two conditions are rare and more difficult to treat. In the majority of patients with smaller involvements of alopecia areata, the hair will re-grow completely within about 1 year without any treatment.

More serious involvements need to be closely followed by a dermatologist or a rheumatologist. Treatment might not be permanent and complete.  If immunal-suppressive treatments are being used, close monitoring to the treatment and correcting the course of treatment based on the initial response is the key to the following treatments.

Parsa Mohebi, MD