Hair Restoration Blog

Cicatricial alopecia refers to a group of rare skin diseases in which hair follicle get destroyed and replaced by scar tissue. It is one of the rare causes of hair loss. Hair loss could be gradual or sudden. Hair loss could be without any symptoms or it could present with sever itching, burning and pain. There is usually no visible scar, because the inflammation is below the level of skin. Cicatricial alopecia could occur in otherwise healthy men and women of all ages.

Cicatricial alopecias could be primary or secondary. This discussion is confined to the primary cicatricial alopecias in which the hair follicle is the target of the destructive inflammatory process. In secondary cicatricial alopecias, a non-follicle-directed process or external injury, such as severe infections, burns, radiation, or tumors could cause destruction of the hair follicle.

The causes of the cicatricial alopecias are not completely known. However, all cicatricial alopecias involve inflammation directed at the hair follicle, the upper part of the follicle where the stem cells and sebaceous gland are located are generally involved. Permanent hair loss occurs when the stem cells and the sebaceous glands are destroyed. This type of hair loss is usually irreversible.

Cicatricial alopecias can affect both men and women. The majority of patients with cicatricial alopecia have no family history of a similar condition. Central centrifugal cicatricial alopecia is a type of cicatricial alopecia that is more prevalent among black woman. Frontal fibrosing alopecia on the other hand is seen most commonly in post-menopausal women.

could be seen in association with chronic skin conditions such as lupus erythematosus and in people with personal or family history of autoimmune disorder. A scalp biopsy is necessary for diagnosis of cicatricial alopecia. Presence of inflammatory cells and scarring could be diagnostic and essential for determining the type of treatment.

Treatment of the lymphocytic group of cicatricial alopecias involves use of anti-inflammatory medications such as steroids, cyclosporine, hydroxychloroquine. When hair follicle destroyed, hair will not grow back. However in some cases using minoxidil solution can help to stimulate growth of some of the remaining hair. Hair transplant could only be used in the patients who have normal healthy hair in donor area. If hair multiplication becomes a reality in the future that might potentially be an option for patients who lost their scalp hair extensively as result of this condition.

I just received the last issue of the Hair Transplant Forum International, the Journal of International Society of Hair Restoration Surgery (ISHRS). Our article, Psychology of Hair Transplant‚ is published as the cover article on this issue of the journal. I also have a copy of the article in our hair loss library in our website. Here is the abstract:

Psychology of Hair Transplant

Parsa Mohebi, M.D., William Rassman, M.D.

Balding and its psychological impacts has been the subject of many studies in the past. The relationship between hair loss and stress is clear to all clinicians who practice in this field. Negative psychosocial impacts of hair loss in male patterned baldness and in women with generalized thinning have also been seen. Many of us (hair transplant surgeons) have seen the negative effects of hair loss on self esteem and self-image.

We know that hair loss impacts some men sex life and their stability with regard to career choices in men of different ages. Despite the solid evidences and published literature on psychological impact of hair loss, the corrective effect of medical and surgical hair restoration has never been studied. After observing the drastic changes in patient behavior and the high level of patient satisfaction in those who had hair transplant procedure, we were motivated to look into the psychological impact of hair restoration on different aspects of a patient’s life.

We came up with a series of criteria that could have been modified by having a hair restoration procedure; we used some indexes that were previously studied comparing bald and non bald men on different psychological variables. We initially performed a pilot study and asked patients about different aspects of their lives during their post op visits. We gave our patients open ended questionnaires and probed their psychological state after their hair restoration procedure was complete. Eventually we focused in on eight major criteria that have been reported and documented as variables associated with hair loss in the literature. We collected a subset of them in our pilot study. Included were questions on the general level of happiness, energy level, feeling of youthfulness, anxiety levels, self confidence, outlook on their future and impact on their sex life.

We have chosen the patients who had their first hair transplant surgery between one to three years from the time of our study, so they had seen the final result of their hair restoration procedure. We limited the study to male patients with male pattern baldness and the ones who had surgeries less than three years ago so they still had a fresh memory of the changes they experienced. Each patient had exclusively follicular unit transplants that reflected our standard of care for that period. We sent a questionnaire with a brief description on the nature of this scientific study. We did not collect any patient identifiers and the response was totally voluntary. We sent the two hundred questionnaires with stamped return envelope.

The response rate to our questionnaire was 37 (18%). Each patient was used as his own control since we asked about the changes that they experienced after surgery in comparison to those variables before the surgery. We used T-test to compare patient’s responses. Table 1 shows the mean and standard error in eight different criteria that were asked. Patients had significant improvements in all eight criteria regardless of their stage of baldness and their ages.

In another attempt to compare psychological changes that patients experienced in different stages of baldness, we divided patients into two groups: (1) those who had Norwood IV patterns or less and (2) the ones with Norwood V patterns and above. We observed the most significant difference in two categories, (a) sex life and (b) career experience. Patients with less balding had a greater impact on their sex life and career when compared to patients who had more advanced stages of hair loss. These changes were not age related.

Hair restoration surgery can affect many aspects of a patient’s life. Hair transplant can potentially reverse psycho-social problems associated with hair loss. The positive impact of hair restoration surgery is more visible among patients who suffer from those undesirable effects the most. In early stages of hair loss, patients may have more awareness of their condition and they might be more affected than men in the later stages of hair loss.

Patients who experienced hair loss at an early age while involved in an active social life were more prone to the negative side effects of balding. That could explain why younger people with hair loss appeared more benefited by hair restoration procedures. Also it could be assumed that hair loss can have a negative impact on a patient’s outlook which seems to reverse after receiving a hair restoration procedure which improved their outlook.

Low response rate from a blind mailing has always been a drawback in questionnaire studies. We received 37 out of 200 of the questionnaires that we sent out (response rate was 18.5%). Giving incentives to responders may be a good way of increasing the participation rate of any questionnaire studies. We presented the result of this study at the annual scientific meeting of ISHRS and have been contacted by many of our colleagues who expressed interest in collaborating in a larger scale study. We are currently trying to rise funding for repeating this study to optimize our response rate and the statistical value of the study.

If you have any questions on the content of this article you can contact US Hair Restoration office at Los Angeles through email at info@ushairrestoration or phone.

Question:

Dear Dr. Mohebi,

Dr., I had a question: say I would use proscar now and took it for a while, after how long based on studies is it possible to see adverse side effects, if any? The reason why I ask is because when I went and read the messages on the forums, I saw positive and negative feedbacks. One person used proscar for 7 years and saw nothing but great results. I would like to give it a shot and see if I am lucky, hopefully. Thank you! Have a great weekend,

Best,

Patient’s name

Answer:
The side effects of finasteride (Propecia/Proscar) could be seen anytime from right after starting it to months after starting finasteride. If you read the articles on adverse effects of finasteride you can clearly see that there is a small difference between the rates of side effects from the people who took placebos to the ones taking finasteride.

Let’s face it; you are prescribing a drug to a patient telling him that it works through altering your male hormones. What do you think the chances are that the patient will have problems with his sex drive?

The good news is that the side effects of finasteride are few and the most problematic one (decreased sex drive) is only seen in one out of a hundred patients. The other good news is that even if you are in that one percent category and you decide to continue using finasteride anyway, after one year of using finasteride the rate of side effects decreases to about the rate that was shown in people who only took a placebo.

I saw an 18 year old patient today who was worried about the recession of his hairline. We mapped his scalp hair to analyze the degree of miniaturization using a digital microscope. Here are pictures from the microscopic of his donor hair (left) vs. very frontal hairline (right).

Healthy donor hair (left) vs. significant miniaturization in hairline (right)

You can see significant miniaturization in the frontal area. When we examined a few centimeters behind his frontal hairline the miniaturization rate dropped sharply to less than 20% which was consistent throughout the top and crown area of the scalp. The patient’s father lost his hair at an early age. Patient started taking finasteride a month before his visit with us and topical Rogaine about a week before this visit.

What we observed was the maturation of his hair line, which occurs between the ages of 16-25 in most men. Hair line maturation is when the hair line migrates 1 to 2 cm higher than its normal position as when we are child (kiddy hairline). It is more significant in the corners but could be seen in the midline too. As Caucasian men go through the maturation process, the hairline rises, but many non-Caucasian men never experience hair line maturation and the hairline stays flat and low.

The best way to distinguish the maturation of the hairline from the early stages of baldness is by comparing miniaturization in different scalp areas. If you are experiencing early hair loss, your miniaturization could be seen behind the first centimeter of the frontal hairline, but if the rate of miniaturization drops sharply it could indicate that the hair line is going through maturation and the hair loss may stop shortly after maturation is complete.

We stopped all anti hair loss medications that the patient recently started, and we recommended another miniaturization study in 6 months to a year to follow his hair loss progression.

Dihydrotestosterone (DHT) is a byproduct of the hormone testosterone, formed primarily in the prostate gland and hair follicle cells. Hair follicles contain DHT receptors. Over time as males produce more and more DHT, the DHT molecules cause hair follicles to miniaturize and eventually fall out permanently in people who are genetically prone to baldness. In other words, some males have more hair follicles with these receptors than others.

DHT is the primary contributing factor in male pattern baldness. Unlike men with male-pattern baldness, women with female-pattern baldness are usually not characterized by increased production rates of DHT. Women with increased levels of DHT may develop certain male secondary sex characteristics, including a deepened voice and facial hair. Hair in the Crown and top of the head are usually loaded with these receptors in men with male pattern baldness. But the hair on the sides and the back, termed the permanent zone or donor area, are not affected by DHT. This allows us to transplant hair from the donor area into the frontal area without fear of it falling.

The transplanted hairs keep their resistance to DHT after hair transplant. Propecia is a drug that decrease the production of DHT by blocking the enzyme 5-alpha reductase that converts testosterone to DHT. This is how Propecia is effective in treating hair loss. Hair loss patients will decrease levels of DHT when they are on Propecia and this will help maintain and un-miniaturize hair follicles or even increase the size of hair shaft within the first year of using them.

It all has to do with the gene of male pattern baldness and being a man (having testosterone). I call it triangle of baldness. This triangle has three sides:

I visited a woman today who was suffering from female patterned baldness. She said she heard about the great work we do and she was interested in having a hair transplant procedure done at US Hair Restoration. Since her hair thinning pattern was typical of hair loss in women with female patterned baldness (also called female patterned alopecia) I decided to post this article on women’s hair loss and hair transplant to answer some of the questions many women have pertaining to female hair loss.Our hair loss patient was around 50 years old with a history of hair loss for over 6 years with more accelerated hair loss in the last 2 years. This woman has dark hair and white skin. As you can see in the picture, the thinning in the front and top was giving her the appearance of balding in front that she could not hide this with regular styling techniques.

Patients with female pattern baldness usually have significant miniaturization of hair follicles and significant widening of the spacing between hair shafts. Miniaturization occurs when hair follicles start to get smaller and smaller and they look like baby hairs that do not grow past a certain length. This miniaturization and space widening occurs in a large area of skin including their donor area. The donor area is the hair on the sides and back of the head, which remains intact in men with male patterned baldness due to male genetics.

.

We discussed different medical problems that could cause hair loss in women and the importance of discussing those with her family doctor, internist or endocrinologist. The most common causes of accelerating genetic hair loss in women are:

• Iron deficiency

• Thyroid disorders
• Female hormonal imbalance or the use of OCP ‚Äúthe contraceptive pill‚Äù
• Excess levels of male hormones
• Auto-immune disorder
• Some medications

My recommendations to this patient and other patients with this similar condition are:

1. No hair transplant as of yet
2. Visit her family doctor with our letter in hand to look for any treatable causes of hair loss
3. Rogaine 2% lotion, twice a day
4. Visit us in a year to be evaluated with another miniaturization study for the progress of her hair loss or gain
5. Coloring hair lighter to decrease the sharp contrast between hair color and skin tone to create the appearance of fullness
6. Toppik, which is a topical hair product that can give more body to hair shafts

For more information on women’s hair loss you can also visit US Hair Restoration.

I met an internist friend today and he asked me whether or not I do hair cloning for my patients. Obviously my answer was no. He mentioned that Dr. X does offer cloning to his patients and in fact plans on doing it for one of his current patients. My comment is this: The field of hair transplant surgery is a buyer beware market; just like any other fields in cosmetic surgery.

I have heard many doctors calling themselves a pioneer on this and that technique. If your doctor told you that he or she is the inventor of some popular method, make sure to ask for a published article from him or her on the topic in a peer reviewed medical journal. In medicine, we don’t keep secrets. When any inventions are formulated they are presented in scientific meetings or published in peer reviewed journals.

Hair cloning (as it is being called by people) or hair multiplication has been studied extensively in America and Europe over the past few years. There are some reports on the success of culturing hair and making new hairs from one in animals and human. There are also claims that phase 3 of clinical trials has started, but we do not know much about the success of this procedure since we don’t have any published articles as of yet. We don’t know anything about the possibility of mass production of hair through hair multiplication nor its feasibility and safety on human.

It is very likely that hair multiplication will be available in the future, but as of now we can not make any comments on the timing and quality of it.