Plan b: Is There a Plan B to Treating Hair Loss?

The first step in determining how to help someone with hair loss is figuring out his or her diagnosis. There is no bypassing this step.  The second step is determining a treatment plan that is based on the best medical evidence. 

Plan B: What is Plan B, Doc?

After reviewing a treatment plan with my patients, I'm often asked what treatment will be considered next. "What's plan B, doc?" Well, every treatment plan needs Plan B as well as a Plan C and Plan D.

Consider the 28 year old female with androgenetic alopecia. The best treatment option for her based on all her facts, review of her blood tests and scalp exam might be topical minoxidil. Plan B might be oral spironolactone with or without minoxidil. Plan C might be the addition of a laser comb or changing the anti androgen used. Plan D for her might be a trial of PRP. A solid treatment plan has an alphabet of plans. Not guesswork and not a random pull out of a hat option. But rather options based on a delicate combination of medical science and expert consensus, and personal experience.

What about the 53 year old female with frontal fibrosing alopecia? Plan A for her might be finasteride & steroid injections with hydroxychloroquine as Plan B. Doxycycline is reserved for her as Plan C. For another patient with FFA, Plan A might start with hydroxychloroquine & steroid injections. For her, finasteride is not on the list given the past history of breast cancer the patient had. Plan B is doxycycline and plan C is methotrexate.

Conclusion

Every treatment plan should have an alphabet of plans. That does not necessarily mean one will need to move down the list but the physician should have a clear plan for how to navigate.

Oral Immunosuppressants for Lichen planopilaris: should I increase my dose?

Dosing oral immunosuppressants for Lichen planopilaris (LPP)

There are many different immunosuppressants and immune modulators that can be used for treating lichen planopilaris. Examples include doxycycline, hydroxychloroquine, methotrexate, mycophenolate, cyclosporine.  I'm often asked what dose a patient should be using? 

What dose should a patient be using? 

When it comes to immunosuppressant medications, I always try to keep patients on the lowest possible dose that controls their disease. Generally I start at fairly standard doses of immunosuppressants and observe what happens to the patient's hair loss. For example, this might be 200 or 400 mg of hydroxychloroquine (Plaquenil) daily, 15-20 mg of methotrexate weekly, 150-300 mg of cyclosporine, 500-1000 mg of mycophenolate mofetil, 100 mg of doxycycline. If the disease is vastly improved after a few months, we may consider going down on the dose or staying at the same dose for a few more months. If the disease is getting worse, we might consider going up on the dose is their is room to go up or changing the immunosuppressant altogether. 

Thermal Stability of Latisse

Heat Stability of Latisse

I've recently had an large number of questions relating to whether or not Latisse is still safe to use if it has been left in a car for brief periods during elevated temperatures.  Should the Lattise be thrown out? Is it safe to use?

What this question is really asking is what do we know about the stability of Latisse at different temperatures? The stability of a drug as a function of temperature is known as the "thermal stability." Studies to date would suggest that Latisse has remarkable "thermal stability" - at least up to 50 degrees Clecius.

A 2011 study by Johnson and colleagues looked at how the concentration of Latisse (and other prostaglandins) changed when exposed to elevated temperatures including 37 C and 50 C for 3, 6, 9,15 or 30 days. By carefully assaying the concentration of Latisse at each time point the researchers found that there was no change in the concentration of Latisse over time at any of these temperatures. 

Is Latisse safe in my hot car?

To answer this specific question, we really need to know how hot the Latisse was in the car. Of course if the Latissereaches temperatures well above 50 C we enter a grey area and don't fully know the answer based on all studies to date. However Latisse can withstand quite a bit of heat due to its remarkable thermable stability. It is likely to be unaffected to any significant degree following a short period of time at elevated temperature.

Reference 

Thermal stability of bimatoprost, latanoprost, and travoprost under simulated daily use.

Johnson TV, et al. J Ocul Pharmacol Ther. 2011.

How does a hair get its shape?

Curly? Wavy? Straight?

Why do some people have straight hair and others have curly? Why do some people have very thick hair and other people have very thin? A part of the hair follicle deep under the scalp known as the inner root sheath (IRS) is responsible for the shape of a person's hair.

Underneath the scalp, the hair fiber is surrounded by the IRS. The IRS in turn is completely surrounded by the outer root sheath. The IRS is a very rigid structure and one can imagine the IRS as being similar to the circular opening of a tube of toothpaste (see picture). The opening is rigid and as one squeezes the tube of toothpaste a cylinder of gooey toothpaste comes out. If the opening of the toothpaste container was a different shape rather than a circle, it's easy to imagine that a different shape would be created. Some people have an IRS that is very circular (...and they tend to produce straight hair!) whereas other people have an IRS that is more oval-shaped and even crescent-shaped (...and they tend to produce wavy and curly hair!). When the hair follicle is first manufactured deep under the scalp it is very soft - and the IRS helps guide the new shape of the developing follicle. Only after a few days time does the new hair follicle harden up (keratinize) and take on the qualities that we all know when it finally emerges from the scalp.

Does the immune system control hair growth?

The Immune System and Hair Growth

Every now and then, I share a landmark study which has the potential to change the way we think about the hair follicle, and how it grows. Today is one of those days.

Researchers at the University of California San Francisco reported last week an important new finding: without specific immune system cells called T regulatory cells (T regs), hair follicles do not grow properly. The study was performed in mice, but likely has relevance to humans.

T regulatory cells are important immune cells. Mice have them and so do humans. These immune system cells act as sort of peacekeepers of our immune system. In scientific terms, we say that these cells play a key role in ‘immune tolerance.’ They tell other immune cells of our body to stay quiet when the time is right to stay quiet and this helps prevent unnecessary allergies and autoimmune diseases. To study the role of T regulatory cells, the researchers developed a clever mouse model whereby T regulatory cells could be removed from the mouse whenever desired. In these studies, mice were shaved of hair and hair regrowth patterns were observed. Surprisingly, hair did not regrow after shaving.

There has now been a shift in thinking. Hair follicle stem cells, at least in mice, appear to listen to the commands of T regulatory cells to know when to grow – and when to stay quiet. Tregs are now understood to accumulate around hairs at the end of the hair growth cycle (in the telogen phase) and help direct hair follicle stem cells to make a new hair. Without Tregs, the growth phase (anagen phase) does not begin. This information could have direct relevance to humans and our understanding of a variety of hair loss conditions. It is well known from previous studies for example, that many of these genes that contribute to the condition alopecia areata are in fact genes that regulate T regulatory cells. In addition, other studies have shown that by supporting T regulatory cells in their functioning, it is possible to can help regrowhair in alopecia areata.

Reference
Ali et al. Regulatory T Cells in Skin Facilitate Epithelial Stem Cell Differentiation. Cell 2017.

Lecture on Alopecia Areata: A New Update

Alopecia Areata Research Update

I've given several research updates on the autoimmune condition alopecia areata. Great progress has been made in the last few years. For those who asked me for the lecture audio, I'm pleased to include it here.

What's new in male balding research?

NEW DRUGS MAY BE IN THE PIPELINE FOR MALE BALDING

According to a news release, Kythera Holdings has acquired licensing rights to setipiprant - potential drug for hair loss. Setipiprant is a selective oral antagonist to the prostaglandin D2 (PGD2) receptor.  

Why is blocking the PGD2 pathway important?

About three years ago, I shared a blog 

Breakthrough in Baldness? Blocking the Prostaglandin D2 Pathway May be the Answer 

In that blog, I described research showing that PGD2 levels were higher in bald areas of the scalp than non bald areas. Theoretically, blocking this pathway could have important roles for baldness. 

And so here we are three years later. Kythera Holdings, a subsidiary of Kythera Pharmaceuticals, announced that it has acquired  licensing rights to setipiprant, in the agreement with Actelion. Apparently, human studies are next for the company. What is so interesting about this drug is that it's already been studied for other uses. Setipiprant has previously been studied as a type of alley treatment, including a phase 3 study in patients with seasonal allergic rhinitis and a phase 2 study in patients with asthma. There were no serious side effects in these studies and treatment was well tolerated. According to the news release, Actelion suspended the development of setipiprant due to lack of efficacy seen in the allergy and asthma studies. So we haven't heard more about the drug. 

READ MORE  

New Roles for the Hair Loss Drug Finasteride: Treating Heart Failure

A Drug for Hair Loss, Prostate Enlargement ... and Maybe Heart Failure!
 

It is well known that androgen hormones like dihydrotestosterone (DHT) have an important role in hair loss in those who are genetically predisposed. Recent scientific evidence also indicates that androgen hormones like testosterone or the more potent dihydrotestosterone (DHT) contribute to the development of heart failure. About 700,000 individuals die of heart disease in the USA and Canada every year.

Does blocking male hormones help improve heart failure?

Researchers from Germany recently set out to design a study to determine whether anti-androgenic therapy with the drug finasteride improves the ability of the heart to function under states of heart failure. Instead of studying humans, the researchers studied mice with heart failure.

What did the researchers find?

The researchers found the heart function was markedly improved in response to treatment with finasteride in mice. In addition, finasteride treatment also allowed mice with heart failure to live longer.  

Final Conclusions

The researchers concluded that finasteride has the potential to reverse heart failure in mice and could be a potential therapy for human trials in the future 

Reference

Zwadio C et al. Anti-Androgenic Therapy with Finasteride Attenuates Cardiac Hypertrophy and Left Ventricular Dysfunction. Circulation. 2015 Jan 28. 

Health, Obesity and Hair Loss:

Does unhealthy eating contribute to hair loss?

I'm often asked if healthy eating helps slow genetic hair loss. In other words, does an apple a day keep the hair doctor away? We don’t really  know how healthy eating slows hair low. However, what we do know is that unhealthy eating that leads to obesity does seem to accelerate hair loss.

Two studies support a relationship between obesity and hair loss

A 2011 study looked at the risk factors for male balding in policeman in Taiwan. Interestingly, young male policemen who were obese had much higher rates of male balding than thinner policemen.

In 2014, researchers from Taiwan explored whether there was a relationship between obesity the severity of male balding. They studied 142 men (average at 31 years) with male balding who were not using medicines for hair loss.   The study showed that men with more severe  hair loss tended to be more overweight than men with less severe hair loss.  In fact, men who were overweight or obese had an approximately 3.5 fold greater risk for severe hair loss than men with more normal weights. In addition, young overweight or obese men had a nearly 5 fold increased risk of severe hair loss.

 

Does an apple a day keep the hair doctor away?

We don't really know the role of healthy eating - does it slow hair loss? That's unknown. What we do know is that the flip side appears true - that extremes of unhealthy eating leading to obesity do seem to be associated with accelerated hair loss. Overall, these two studies mentioned above do support the notion that being overweight might contribute in a negative manner to balding in men. 

Further studies are needed to determine whether encouraging weight loss in obese patients could impact the rate of balding or the effectiveness of treatments for male balding.

Reference

Chao-Chun Y et al. Higher body mass index is associated with greater severity of alopecia in men with male-pattern androgenetic alopecia in Taiwan: A cross-sectional study.  J Am Acad Dermatol 2014; 70; 297-302.

Su LH et al. Androgenetic alopecia in policemen: higher prevalence and different risk factors relative to the general population (KCIS no. 23). Arch Dermatol Res. 2011 Dec;303(10):753-61

Cholesterol Lowering Drugs for Treating Alopecia Areata? A New Study says Yes

STATIN DRUGS FOR HAIR LOSS? 

Alopecia areata is considered an autoimmune condition. Medications that reduce or modify the effects of the immune system are traditionally used to treat alopecia areata. You may be familiar with treatments such as steroid injections, topical steroids, diphencyprone (DPCP), anthralin, or  immunosuppressive pills such as methotrexate, sulfasalazine and prednisone.  These all affect the immune system in some way or another.

New research now suggests that cholesterol lowering medications may also be helpful. Interestingly, in addition to the ability of these medications to lower cholesterol levels, these drugs also reduce inflammation. The reduction of inflammation is a key step in treating alopecia areata.

What are statins?

The ‘statins’ are a well-known group of medications used to treat high cholesterol.  In fact,  it is estimated that about 3 millions Canadians and 30 millions Americans use statins to control their cholesterol.  Ezetimibe is a second type of cholesterol lowering medication and works by blocking the absorption of cholesterol.

In a new study, 19 patients with advanced alopecia areata were treated with two cholesterol medications – simvastatin and ezetimibe for 24 weeks.  Remarkably, after 24 weeks, 14 of 19 patients (nearly 75% of patients) were found to regrow hair so some extent. The majority of those who continued the drug after then 24 week period maintained their hair and the majority of stopped the drug after then 24 week period lost their hair again.

Comment

This is a tremendously exciting study, opening the doors to even larger studies of the use of these cholesterol lowering drugs in the treatment of alopecia areata. These drugs are well known in the population as cholesterol lowering drugs and so we have many years of experience with these drugs. Although side effects such as muscle pains, muscle damage, diarrhea, irritation of the liver, and a rise in blood sugars can occur with these medications – these are relatively infrequent. 

Study: Lattouf C and colleagues. Treatment of alopecia areata with simvastatin/ezetimibe. J Am Acad Dermatol 2015; 72: 359

Hair transplantation for central centrifugal cicatricial alopecia (CCCA)

Scarring Hair Loss Conditions in Black Women : Is hair transplantation an option?

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**CLICK TO ENLARGE ** Photo of top of scalp in woman with CCCA

Diagnosing hair loss in women with afro-textured hair requires special expertise. Many hair loss conditions are possible and they tend to look similar. Central centrifugal cicatricial alopecia (CCCA) can look similar to genetic hair loss and so can some types of traction alopecia. Our program for women with afro-textured hair addresses some of the unique aspects of hair loss and hair care in black women. 

Hair transplantation in CCCA

Central centrifugal cicatricial alopecia (or "CCCA" for short) is a type of scarring hair loss condition in black women. Hair loss starts in the centre of the scalp and spreads outwards over time. If treated early, the condition may be halted - at least for some women. Hair transplants are possible in CCCA once the condition becomes “quiet.” By quiet, we mean that there has been no further hair loss for a period of 1-2 years. 

Are hair transplants possible for CCCA?

Surgery is sometimes an option for a group of conditions known as scarring alopecias. These conditions are frequently autoimmune in nature and have names like lichen planopilaris, frontal fibrosing alopecia, central centrifugal cicatricial alopecia. 

When can a hair transplant be done in CCCA ?

A hair transplant is not possible for many patients with these conditions because the condition is "active." However, once the condition becomes "quiet" - a hair transplant can be considered. 

By 'quiet', several conditions must be met. These are summarized in the CCCA Hair Transplant Criteria.

DONOVAN CCCA HAIR TRANSPLANT CANDIDACY CRITERIA 

In order for patients with CCCA to be a candidate for hair transplant surgery ,  ALL FIVE of the following criteria must be met:

1.  The PATIENT should be off medications.

Ideally the patient should be off all topical,  oral and injection medications to truly know that the disease is "burned out (burnt out)". However, in some cases, it may be possible to perform a transplant in someone with CCCA who is using medications AND who meets criteria 2, 3 and 4 below.  This should only be done on a case by case basis and in rare circumstances. It is a last resort in a very well-informed patient. 

2. The PATIENT must not report symptoms related to the CCCA in the past 12 months, (and ideally 24 months) .

The patient must have no significant itching, burning or pain. One must always keep in mind that the absence of symptoms does NOT prove the disease is quiet but the presence of symptoms certainly raises suspicion the disease could be active.  Even the periodic development of itching or burning from time to time could indicate the disease has triggers that cause a flare and that the patient is not a candidate for surgery. The patient who dabs a bit of clobetasol now and then on the scalp to control a bit of itching may also have disease that is not completely quiet. 

3. The PHYSICIAN must make note of no clinical evidence of active CCCA in the past 12 months, (and ideally 24 months).

There must be no scalp clinical evidence of active CCCA such as hair fragility or scalp erythema. . This assessment is best done with a patient who has not washed his or her hair for 48 hours. Some scalp redness may be persistent in patients with scarring alopecia even when the disease is quiet. Therefore scalp redness alone does not necessarily equate to a concerning finding. Perifollicular redness however is more concerning for disease activity.  In addition, the pull test must be completely negative for anagen hairs and less than 4 for telogen hairs.  A positive pull test for anagen hairs indicates an active scarring alopecia regardless of any other criteria.

4. Both the PATIENT and PHYSICIAN must show no evidence of ongoing hair loss over the past 12 months (and ideally 24 months). 

There must be no further hair loss over a period of 24 months of monitoring OFF the previous hair loss treatment medications. This general includes the patient and physician's perception that there has been no further loss as well as serial photographs every 6-12 months showing no changes. 

5. The patient must have sufficient donor hair for the transplant. 

Not all patients with CCCA maintain sufficient donor hair even if the disease has become quiet. But this is an important and final criteria.

 

Dutasteride and Finasteride: New data suggests no Link with breast cancer in men

Dutasteride and Finasteride: Do they cause breast cancer?

Finasteride (Propecia) and dutasteride (Avodart) are prescribed for the treatment of male pattern baldness. Many of my male hair transplant patients receive finasteride or dutasteride in order to help reduce the progression of balding in existing hairs.  

Finasteride and dustasteride belong to a group of drugs called "5 alpha reductase inhibitors." They block the enzyme 5 alpha reductase and decrease the levels of the potent androgen hormone DHT (dihidrotestosterone). In addition to reducing DHT, the drugs increase the levels of estrogen slightly which has raised questions from physician and researchers around the world as to whether these drugs increase the risk of breast cancer in men.

US researchers set out to examine the relationship between the use of 5 alpha reductase inhibitors and male breast cancer. They studied men using the higher 5 mg dose of finasteride used in prostate enlargement (rather than the 1 mg dose used in hair loss) and the 0.5 mg dose of dutasteride.  They looked at the use of these drugs in 339 men with breast cancer and 6,780 men without breast cancer.

What were the findings and conclusions from the study?

The authors did not find an association between using 5 alpha reductase inhibitors and the development of breast cancer in men. Overall, the authors concluded that the "development of breast cancer should not influence the prescribing of 5 alpha reductase inhibitor therapy."

Reference

Bird ST et al. Male breast cancer and 5 alpha reductase inhibitors finasteride and dustasteride. J Urology; 190:1811-4

Is your hairline 'maturing' or a 'balding'?

Is your hairline 'maturing' or a 'balding'?

It’s a little known fact among many men that the frontal hairline actually changes shape between the ages of 17 and 27 – even if that man doesn’t proceed to develop genetic balding. We refer to this normal change as ‘maturation’ of the hairline and we say that the man noticing these changes has a ‘maturing’ hairline. Eventually the hairline stops ‘maturing’ and we say that the man has a ‘mature’ hairline.  Not all men’s hairlines proceed through this normal process of ‘maturation’ but most do.

The concept of a maturing hairline is extremely important to know about so that medical treatment or surgical treatment is not recommended to patients who don’t require it. For example, a 23 year old man who notices his hairline thinning out slightly in the area just above his eyebrows may not have genetic hair loss - but rather a ‘maturing’ hairline. He doesn’t need to begin any sort of treatment whatsoever. Several studies have shown that men with maturing hairlines don’t necessarily go on to develop balding. These are two completely separate processes!

Hairline maturation diagram

The following diagram helps to explain the process by which the hairline matures and how it differs from genetic hair loss. The hairline of a boy or early adolescent is relatively flat and we refer to this as a ‘juvenile” hairline.  Between age 17 and 27, many men (but not all) start to notice that the hairline directly above the middle section of the eyebrow starts to undergo thinning (maturing).   

In fact, if you wrinkle your forehead, you’ll see a series of lines that run side to side. The highest forehead wrinkle often marks a spot where the ‘juvenile’ hairline was once located. A ‘mature’ hairline is usually about 1-1.5 cm above this. In true genetic balding (male pattern hair loss), the hairline may recede beyond this 1.5 cm point and undergo even more significant recession in temple area. 

Why is this concept important?

Understanding the concept of hairline maturation is especially important when it comes to designing natural looking hairlines during a hair transplant.  Attempting to lower a ‘maturing’ hairline is a young man is usually not a good idea. Many young men want a more ‘juvenile’ hairline when they first meet for a hair transplant consultation.  However, by proceeding down that route,  the young man runs the risk of having his new hairline take on an unnatural looking appearance when compared to other males as he approaches his 30s, 40s and 50s.

Other References of Interest

Rassman WR, Pak JP and Kim J. Phenotype of normal hairline maturation. Facial Plast Surg Clin North Am 2013; 21: 317-23

This blog has been filed into the following folders: 

Minoxidil - Does it help with hair loss ... in the front ... or top .. or both?

Accumulating evidence suggests minoxidil helps with hair loss in the crown (top) but may help hair loss in the front and temples in men as well.

Minoxidil - Does it help with hair loss in the front?

Minoxidil is a topical medication that is FDA approved for treating genetic hair loss (sometimes referred to as androgenetic alopecia). If you pick up a bottle of minoxidil it will state that it is to be used for hair loss in the crown in men and may not benefit other areas of hair loss. The original studies of minoxidil focused on the crown and did not address the benefit in the front of the scalp.

So the question that remains is:  

Does minoxidil help men with hair loss in the front of the scalp or not?

Certainly, the answer is yes.   Many hair loss specialists around the world, including myself,  have witnessed benefit to minoxidil in the front of the scalp in balding men.  However, the companies which produce minoxidil are not setting out to formally prove the benefit in the front of the scalp and are not seeking approval from health regulatory authorities to be able to change the labelling on the bottles to indicate that it "works in the front and back."

New study shows 5 % minoxidil benefits men with hair loss in the temples

Back in the month of May 2013, I attended the World Congress of Hair Research in Edinburgh Scotland. A really nice study was presented by Dr. Blume Peytavi and colleagues from Berlin, Germany. They studied 70 men with moderate genetic hair loss and studied whether minoxidil 5 % foam could help hair loss in the crown and in the front.  The German group showed that men using minoxidil 5 % foam did obtain benefit from using the medication in the front and in the crown.  This was one of the very first studies showing the minoxidil foam benefits hair loss in the front.

Conclusion: 

Minoxidil has long been known to benefit men with hair loss in the crown. Accumulating evidence suggests it also benefits men with hair loss in the front (temples). More studies are needed to determine just 'how much' it helps men with hair loss in the front. In general, minoxidil seems to work better in the earliest stages of hair loss - as hairs are thinning and miniaturizing. 

Reference

Hillman K, Bartels GN, Stroux A, Canfield D, and Blume-Peytavi U. Investigator-initiated double blind, two-armed, placebo-controlled, randomized clinical trial with an open -label extension phase, to investigate efficacy of 5 % Minoxidil topical foam twice daily in men with androgenetic alopecia in the fronto-temporal and vertex region concerning hair volume over 24/52 weeks.  Poster at: World Congress of Hair Research, Edinburgh Scotland May 2013.

The Secret to Growing More Hair? Just Ask a Wounded Mouse

NEW RESEARCH UNCOVERS ONE OF IMPORTANT MISSING PIECES OF THE HAIR LOSS PUZZLE

 Researchers from the University of Pennsylvania have discovered an important scientific finding that offers good news to the 60-90 million men and women in North America affected with hair loss.

Humans are born with about 100,000 hairs on the scalp. At present, it is thought that the number of hair follicles an individual is born with is the maximum number of hair follicles that person will ever develop during their lifetime. For humans, it seems that it is not possible to produce new hair follicles beyond the number generated at birth. Hair loss conditions like genetic hair loss, reduce the number of follicles on the scalp.

Exciting research over the last few years has challenged the concept that new hairs can never be generated after birth.    For years, it has been recognized that when the skin of a mouse is wounded, new hair follicles can be created. This phenomenon of new hair creation after skin injury does not happen in humans -  a finding that has stumped researchers.  The answer may now have been uncovered.

New Research from UPenn

Researchers from the University of Pennsylvania showed that when the skin of mouse is injured, immune cells residing in the skin known as gamma delta T cells are triggered to produce a chemical known as Fgf9.  Fgf9 stimulates the wound repair machinery of the skin to produce additional chemicals that not only heal the skin but stimulate creation of brand new hair follicles.

Interestingly the skin of humans was shown to have much lower numbers of the gamma delta immune cells compared to mice. When skin injury occurs in humans, a wound is healed with creation of a scar, and no new hair follicles are created.

With the new discovery of the importance of the Fgf9 protein in creating new hairs, the race is on to better understand how to use this information to generate new hairs in humans and to design drugs that prompt creation of new hair follicles.  One might imagine the possibility that if a minor wound could be introduced on human scalp and FgF9 like drugs were applied to the skin, new hair follicles could theoretically be generate. This remains to be tested, but offers hopes to the millions of individuals across North America with hair loss.

SOURCE: Gay D et al. Fgf9 from dermal gamma delta T cells induces hair follicle neogenesis after wounding. Nature Medicine. Published Online June 2 2013

 

This blog has been filed into the following folders:

The Hair Whorl: Importance in Transplanting the Crown

Transplanting the Crown

In the top of the scalp or crown, there is usually one or two areas where the hair changes direction from forward pointing to backward pointing. We call this area the “hair whorl.”

When I perform a hair transplant, I view the reconstruction of the hair whorl as being incredibly important in order to create a natural look.  For most individuals, the hair whorl is positioned in a clockwise direction.   About 2-5 % of the world has a double whorl.

Hair Whorl Research

Interestingly, recent research has focused on whether there is a relationship between the direction of the hair whorl and an individual’s tendency to be left handed or right handed.  There is some thought that genes controlling handedness also might control our hair whorl.  Research by Dr Klar showed that right-handed individuals are more likely to have a clockwise whorl pattern; for left- handed individuals there is a similar proportion of clockwise and counter-clockwise patterns.  Specifically, 8.4 % of right-handed individuals have a counterclockwise whorl compared to 45 % of left handed people.  Despite these interesting findings, the exact science of the relationship between hair whorl direction and ‘handedness’ remains a subject of controversy.

All in all, the hair whorl is something I pay particular attention to when transplanting the crown.  The rotations and directions of the hair need to be followed carefully in order for a hair transplant to look natural.

REFERENCES OF INTEREST

Beaton AA and Mellor G. Direction of hair whole and handedness.Laterality 2007; 12: 295-301

Klar, A.J.S., 2003. Human handedness and scalp hair-whorl direction develop from a common genetic mechanism. Genetics 165, 269–276

 

This blog has been filed into the following folders:

How many hair transplants can a patient have?

Hair transplants: how many can a patient have?

The number of hair follicles available to move from the back of the scalp (the 'donor area') to the front or top of the scalp (the 'recipient area') is limited.  Someday, hair research may allow us to expand the number of hairs available, but for now there is a limited number. The number of grafts available to move depends on a number of factors, espeically how bald a person is destined to become.  It is generally estimated that between 4,000-10,000 follicular units are available in men. Men who are destined to have advanced balding patterns have less hair available to move than men destined to have minimal balding.

New study from Mount Sinai

A new research study by Dr Walter Unger and colleagues from the Department of Dermatology at Mount Sinai School of Medicine set out to refine these estimates even further. A group of 39 hair transplant surgeons were asked to estimate the number of 'permanent' follicular units available for surgery in a hypothetical 30 year old man destined to develop advanced balding (i.e. Hamilton Norwood Scale V or VI)

What were the results of the survey?

Respondents indicated that men destined to have Hamilton Norwood Stage V balding had between 5,000 - 8,000 follicular units available for surgery and men destined to have Hamilton Norwood Stage VI balding had between 4,000 - 6,600 follicular units available for hair transplant surgery.Man with 4000 follicular units max in lifetime

Why are these results important?

This study reminds hair transplant surgeons (and patients) that there are a finite number of follicular units available for surgery. A middle aged man destined to have advanced balding in his  lifetime has two (and maybe three) surgeries maximum in their lifetime.   It is exteremely important to discuss with patients how grafts will be placed so that the appearance of bald areas of the scalp can be minimized throughout life.

Source

Unger WP, Unger RH, Wesley CK. Estimating the number of lifetime follicular units: A survey and comments of experienced hair tranpslant surgeons. Dermatol Surg 2013;

This blog has been filed into the following folders:

INCREASED RISK OF HEART DISEASE IN MEN WITH HAIR LOSS

Do balding men have an increased risk for heart disease?

Several studies in the past have examined the relationship between balding and heart disease.   In a study published in this month's British Medical Journal, researchers from Japan carefully examined all of the research studies to date focusing on the relationship between hair loss and heart disease.

Balding and heart disease: what did the new research find?

The researchers looked at studies involving 36,690 balding men and found that men with hair loss in the top of the scalp or ‘vertex’, had an increased risk of heart disease.  Interestingly, men with more severe balding had a greater risk of heart disease compared to men with lesser degrees of balding in the vertex.  Men with hair loss in the front of the scalp did not demonstrate an increased risk of heart disease.  

The exact reasons why balding men have increased heart disease risk is not clear but may be related to common mechanisms that lead to heart disease and hair loss including high blood pressure, smoking, high cholesterol, insulin resistance and increased inflammation in blood vessels.

These findings are important for the approximately 4 million Canadian men and 40 million American men affected with male balding.

SOURCE:   Yamada et al. Male pattern baldness and its association with coronary heart disease: a meta-analysis. BMJ Open; 2013; e002537.

 

Can I have a hair transplant?

Am I a candidate for a hair transplant?

Many patients who come and meet with me are candidates for hair transplants - but some individuals are not.  For some individuals who aren't good candidates for hair transplants, this information may come as a surprise.

Who can have a transplant and who can not?

Individuals with certain hair loss conditions like genetic hair loss (also called androgenetic alopecia), traction alopecia are good candidates for surgery.  Individuals with other conditions like alopecia areata, scarring alopecia and hair shedding disorders are not candidates for surgery.

Within 1-2 minutes of meeting a patient, I can usually determine if they are good candidates for surgery or not.  

Consider the following patient (pictured on the left) who came to see me with concerns about her increasing hair loss in the centre of the scalp. At close examination and after asking her a series of questions, it became clear that her reason for hair loss was genetic. This made her a good candidate for surgery.

Consider now the woman pictured on the right in the photo. She looks just like the woman on the left. However, a series of questions followed by a detailed examination of her scalp as well as a scalp biopsy allowed me to utlimately diagnose her with lichen planopilaris which is a type of scarring alopecia.  I was not able to perform a hair transplant on this woman as she was was not a candidate for surgery.  Scarring hair loss conditions like lichen planopilaris can not be transplanted when they are in the active phase.    If she had gone for surgery without being properly diagnosed, the transplanted hairs would not have grown well and  perhaps not grown at all.

Not everyone is a candidate for hair transplant surgery. Only with a careful record of questions and a detailed examination of the scalp can all the other reasons for hair loss be excluded.

This blog has been filed into the following folders:

Is there a Link Between Sun Exposure and Hair Loss?

Sun Exposure and Hair Loss: Is there a Link?

This new video highlights the current evidence of the relationship between sun exposure and hair loss.

I hope you enjoy it!

- Dr Jeff Donovan

 References of Interest

Gatherwright J et al. The contribution of endogenous and exogenous factors to female alopecia: a study of identical twins. Plast Reconstr Surg 2012 130; 1219-26.

Su LH and Chen.  Androgenetic alopecia in policemen: higher prevalence and different risk factors relative to the general population. Arch Dermatol Res. 2011 Dec;303: 753-61

This blog has been filed into the following folders: