Dr. Jeff Donovan is a Canadian and US board certified dermatologist specializing exclusively in hair loss. To schedule a consultation, please call the Vancouver office at 604.283.9299
This is an in important question and one that needs good data. I serve as the chair of a committee of the International Society of Hair Restoration Surgery. On Friday we sent out a survey to hair transplant surgeons around the world with the hopes of gathering more information on the successes and failures surgeons have had when transplanting scarring alopecias.
There is no doubt that hair transplantation works wonderfully in some patients with scarring alopecia and does not work well in others. One must always have quiet (inactive) disease for at least 1-2 years before a transplant is attempted.
In general, a scarring alopecia must be quiet for 1-2 years before a transplant can be even considered. Several years ago I put forth criteria for determining if an individual with lichen planopilaris is a hair transplant candidate:
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 burnt out and ‘inactive’. However, in RARE cases, it may be possible to perform a transplant in someone 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 as the risk for disease reactivation is high. A patient using medications to suppress disease activity is at high risk for reactivation following hair transplant surgery. It is a last resort in a well-informed patient.
2. The PATIENT must not report symptoms related to the LPP 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 LPP in the past 12 months, (and ideally 24 months).
There must be no scalp clinical evidence of active LPP such as perifollicular erythema, perifollicular scale (follicular hyperkeratosis). In addition, the pull test must be negative.
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. As discussed above, the 12 month waiting time is the standard of care as an accepted definition for hair transplant candidacy.
5. The patient must have sufficient donor hair for the transplant.
Not all patients with LPP maintain sufficient donor hair even if the disease has become quiet.
My research has focused on the chances of reactivation of LPP after surgery. It is important to be aware that ANY patient with LPP is at risk for reactivation or a 'flare' of their LPP after surgery. The risk, I estimate, is as follows:
i) A patient with active LPP before their transplant is nearly guaranteed to have a flare of his or her LPP if a hair transplant is done. (estimate 90-100 % chance of flare within 2 years post transplant)
ii) A patient with partially active LPP before their transplant is very likely to have a flare if a hair transplant is done. (estimate 70-90 % chance of flare within 2 years post transplant)
iii) A patient with medication induced inactive LPP before their transplant has a moderate chance of a flare if a hair transplant is done (estimate 50-70 % chance of flare within 2 years post transplant)
iv) A patient with inactive LPP off all medications for 1 year before their transplant has a low chance of a flare if a hair transplant is done (estimate 10-25 % chance of flare within 2 years post transplant)
v) A patient with inactive LPP off all medications for 2 years before their transplant has a low but definite chance of a flare if a hair transplant is done (estimate less than 10% chance of flare within 2 years post transplant)
A common concern from patients with FFA is that their steroids caused atrophy. By atrophy we mean thinning of the skin. Patients with atrophy have thin skin, visible veins. In FFA atrophy leads to blue veins becoming easy to see throughout the frontal scalp and especially at the temples. Patients want new options for treating the disease because they are worried about the atrophy.
There is one assumption that is often wrong here - and that is that steroids are the sole cause of atrophy in FFA. MOST of the time the steroids are not the main cause of the atrophy ! It is very important to keep in mind that the disease itself causes atrophy and visible veins. It is certainly very true that the steroids can cause atrophy too. But FFA itself is usually the leading cause of atrophy in patients with FFA. Many many patients with FFA who have never used steroids can have atrophy - some severe. In fact, severe atrophy is one of the so called poor prognosis signs in FFA.
When patients show a considerable amount of atrophy, I usually try to limit this by using non steroids instead of steroid. Non steroids such as pimecrolimus (Elidel) and tacrolimus (Protopic) do not cause atrophy. They seem equivalent although no comparison studies have been done. My previous research has also shown that finasteride and dutasteride may actually reverse atrophy in a proportion of patients.
Vellus hairs are tiny, short non-pigmented hairs. They are fine hairs with a caliber less than 30 micrometers by definition. It is not common to find vellus hairs on the scalp in an individual without hair loss. On a normal scalp only about 1 of every 25 hairs are vellus hairs. Most hairs on the scalp are large pigmented terminal hairs. During the course of male and female androgenetic alopecia, vellus hairs become more prevalent and may even become the dominant hair type (outnumbering terminal hairs) in advanced balding cases.
Ko JH et al. Hair counts from normal scalp biopsy in Taiwan. Dermatol Surg. 2012