Are hair transplants possible for scarring alopecia?
I frequently perform hair transplants 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?
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:
1. The patient must not have symptoms. The patient must have no significant itching, burning or pain.
2. There must be no clinical evidence of active LPP. There must be no scalp clinical evidence of active LPP such as perifollicular erythema, perifollicular scale (follicular hyperkeratosis) and the pull test must be negative.
3. There must be no ongoing hair loss. There must be no further hair loss over a period of 24 months of monitoring. 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.
What are the differences between transplants in LPP vs other types of hair loss (genetic hair loss)?
The difference between performing hair transplants for scarring alopecia and hair transplants for genetic hair loss is that the grafts are at slight risk of being lost in those with scarring alopecia. For example, in genetic hair loss we generally say the grafts are permanent. That is not the case in scarring alopecia. There is a very small albeit definite risk of reactivation of the disease that needs to be carefully monitored and followed.
Due to the small risk of reactivation in scarring alopecia, I am a big believer in keeping patients on some type of baseline treatment to keep the condition quiet.
My general principles for transplanting scarring alopecia include:
1. Considering small test sessions when appropriate.
2. Limiting the amount of epinephrine
3. Minimizing over trimming of grafts to ensure healthy proportion of stem cells get transplanted
4. Use of minoxidil in some cases pre and post op to promote blood blow
5. Adhering to densities 20-30 FU/cm2
6. Continuing topical, injection or oral immunomodulatory medications on a patient specific protocol (depending on the specific condition, how long the patient has had it, amount of hair loss, age)
Consider reading the following articles for further information
Hair transplantation for scarring alopecia is among the most challenging types of hair transplants. In the appropriate patient, it can be a very helpful means to improve density. I generally recommend that patients have inactive disease for 2 years, meaning that there has been no hair loss and no scalp symptoms over a period of 2 years.
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