Increased hair shedding in early androgenetic alopecia?

Increased hair shedding in early androgenetic alopecia

During the process of genetic hair loss, hair follicles get skinnier and skinnier (miniaturize) but they also spend less and less time in the growing phase (called anagen) and more in the shedding phase (called telogen). As a consequence, the individual with genetic hair loss experiences increased hair shedding. If the hair is washed daily, individuals with genetic hair loss don't really notice the increased shedding. That is because the shed hairs get washed down the drain. 

Normal scalp has less than 10 % telogen hairs

If you perform a biopsy of non balding scalp, about 6 - 10 % of hairs are in telogen phase (and 90% are in anagen). In the course of male androgenetic alopecia the proportion of hairs in telogen goes up considerably. In addition to increased shedding, the individual with genetic hair loss notices that he or she an't grow hair quite as long because the hair doesn't stay in the growing phase as long. Because men often wear their hair short, they don't notice this as much as women. 

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

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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.

Benefits of Combining Minoxidil and Finasteride

Benefits of Combining Minoxidil and Finasteride

Minoxidil and Finasteride are two FDA approved treatments for hair loss. Minoxidil is a topical solution that is rubbed on the scalp and finasteride is an oral treatment (pills). Many men with genetic hair loss (androgenetic alopecia) consider the use of these medications and may consider hair restoration as a more permanent solution.

Both minoxidil and finasteride have their own set of side effects. Finasteride, however, is much more effective. GIven that these two agents are clinically proven to help with hair loss, I'm often asked - "Is it better to use both of these products or should I just pick one?"

Combination Minoxidil and Finasteride better than single treatment

The answer is - 'yes.' There is clinical evidence that men using finasteride for hair loss who add minoxidil to their treatment plan have a slightly better result than men who only use finasteride. The benefits, however, are small. It makes sense that the two medications act synergisticially in treating hair loss given that they act differently. Minoxidil helps hair growth by directly stimulating the hair follicle. In contrast, finasteride works by blocking the action of the potent male hormone dihydrotestosterone or "DHT". 

Conclusion

Both minoxidil and finasteride should be considered. For men with early hair loss, the use of both might help and may be considered prior to a hair transplant. Minoxidil and finasteride have less benefit for men with advanced hair loss. In these cases, a hair transplant is the primary treatment.

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Hair Transplantation in Scars - Is it Possible?

New hair follicles transplanted into a scar.

Hair Transplantation in Scars

A small number of men and women have scars in the scalp. This can be scars from an previous accident, scars from a previous surgery in the scalp, scars from a previous hair transplant surgery or scars from a scarring hair loss problem. Regardless of the cause of scars, patients visiting the office want to know:

Is it possible to transplant hairs into a scar to improve the appearance of the scar?

In many cases, the answer is "yes" and certainly we've transplanted a wide variety of scarring issues.  But the decision as to whether someone is a good candidate for repairing a scar with a hair transplant depends on a number of factors:

1.  Thickness of the scar. Sometimes scars can be very thick and this compromises the ability of hairs to grow in the scar. A number of techniques can be used to improve a thick scar and make it more receptive to receiving new hair follicles. This includes thinning the scar slightly with steroid injections and debulking the scar by removing bits of the scar before putting in new hair follicles. 

2. Thinness of the scar. As surprising as it sounds, some scars are too thin to be successfully transplanted. The medical term for such thinning is 'atrophy.'  Some scars are too atrophic to receive new hair follicles. When we do decide to proceed and transplant atrophic scars, we use a number of techniques to improve the growth and 'uptake' of transplanted hairs but some severely atrophic scars are challenging to transplant. 

3. Blood supply to the scar. Before a transplant is performed in a scar, I usually test the blood supply. Sometimes a scarring process in the scar can reduce the blood supply to area and in turn reduce the chances of having successful uptake of hair follicles. Certain techniques, such as pre-operative and post-operative use of minoxidil to improve blood flow into a scarred area may be beneficial and is something we often recommend.

In general, our experience has been that transplanting scars can be very successful and patients are really happy to have their scars less noticeable.  It does require experience and a certain degree of art to best camouflage scars with a hair transplants.  We frequently perform smaller sessions (fewer grafts), space the grafts out a bit further and wait longer between sessions if another session is required.  A few other modifications are done during the actual procedures as well. All of these considerations are important and help improve the likelihood that individuals with a scar will achieve outstanding results.

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

 

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Follicular Unit Extraction in Black Men and Women

Follicular Unit Extraction in Black Men and Women

I few weeks ago I wrote a blog about considerations when performing follicular unit extraction (FUE) in black men and women.  Because hair in black men and women tends to be curlier than caucasian hair, there are several considerations that need to be carefully addressed before performing surgery.  Unless such care is taken, precious follicular units may be cut or 'transected.' Today, I read a great article in the journal Dermatologic Surgery by New York hair transplant surgeons Drs Singh and Avram. They outlined some practical points when performing FUE.

Key Aspects of Follicular Unit Extraction

The authors outlined four points, which I have summarized here:

1. Maximal sized punch. It's important to choose a big enough punch to accomodate hairs. 1.3 mm sized punch may be acceptable depending on the patient. 

2. Minimal depth. It's important not to go to deep to limit the chance of transection

3. Manual punches instead of motorized. The authors proposed that manual punches give better control for some patients. 

4. Meticulous attention to following the angle the hairs emerge from the scalp. This ensures that transection is limited. 

On account of the greater curl, follicular unit extraction is black men and women presents several differences compared to caucasian or asian hair. However, with carefully attention to fundamental principles outstanding results can be acheived. 

Reference

Singh MK and Avram MR. Technical Considerations for Follicular Unit Extraction in African American Hair. Dermatol Surg 2013; May 13

 

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

 

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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;

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Follicular Unit Extraction (FUE) in Black Men and Women

Follicular Unit Extraction (FUE) in Black Men and Women

In a hair transplant, there are two main ways of removing hairs from the back of the scalp or 'donor area' :

1. Follicular unit extraction (FUE) 

2. Follicular unit strip harvesting (FUSS)

Both methods can give great results and there are advantages and disadvantages of each. Men who plan to shave their scalp in the future (or wear their hair very short) prefer the FUE method because the linear scar is not seen.  

FUE Techniques in Black Men and Women

There are several factors that influence whether someone is a candidate for FUE.  One of these is the shape and curl of the patient's hair follicles.  It is much easier to extract hairs by FUE in men and women with straight hair than men and women with curly hair.   The structure of hair in black men and women is such that it is curlier than caucasian and asian hair.  The curlier the hair, the more difficult it is to predict the path that the hair follows under the scalp and the more likley these hairs are to be damaged by FUE.  We call this damaged 'transection.' Curlier hair is much more likely to be transected during FUE. It's for this reason that a proportion of black men and women are not good candidates for FUE.  

Compare the photos below of follicular units in a caucasian hair (above):

 with photos of follicular units from a black hair (below):

You'll note the hairs are much curlier in black hair.

Conclusion 

I often recommend performing a short 'test session' prior to hair transplant surgery to ensure 100 % that hair follicles will be easy to harvest on the day of surgery and to ensure that the follicles will not be subjected to excessive damage.  Indeed a 30 minute test procedure for the patient in photo 2 peformed 4 weeks before a scheduled hair transplant confirmed that it was still possible to extract follicle by FUE with minimal damage (transection).  

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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.

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Minimizing the Appearance of Scars in Hair Transplant Surgery: The Trichophytic Closure

The Trichophytic Closure

Patients undergoing hair transplant surgery using the strip method not only want a natural looking transplant but also a maximally camouflaged scar. 

The trichophytic closure is a technique for stitching up the donor area which helps to minimize the appearance of donor scars.  It's use in hair tranpslant surgery is credited to three physicians: Dr Paul Rose (USA), Dr Patrick Frechet (France) and Dr Mario Marzola (Australia).  Nowadays the technique is widely used by many hair transplant physicians, including myself.

How is the trichophytic closure done?

The trichophytic closure involves clipping hairs from the edges of the donor area so that they are more likely to grow back through the scar when it heals. When hairs grow back through the scar, the appearance of the scar is greatly minimized.  A photograph of hairs growing through a scar in a patient who had a trichophytic closure is shown in the attached image.

In select individuals, (such as those with minimal tension in the donor area), the trichophytic closure is a great technique to minimize scar appearance.

 

Hair Transplantation for Early Hair Thinning: Things to Think About

Hair Transplantation for Early Hair Thinning:

It comes as a surprise to some patients who come to see me that they are not candidates for hair transplant surgery. Some patients are too young, some have hair loss diseases for which a transplant won't ever 'work,' some have too little hair (or are destined to be too bald to make a transplant a good idea).  Finally, some individuals have too much hair.

It's this last issue that I'd like to discuss today - transplanting in areas of hair loss which are undergoing thinning but not yet significantly thin. Is it a good idea to transplant hairs in this area to prevent it from ever looking thin?

Is some cases the answer is yes, in other cases - no.  Even with the most delicate and meticulous surgery, exisiting hairs on the scalp can be damaged if the density is too high. There is a critical density below which a cosmetic improvement can be achieved.

Consider the young man (photo on the right) who came to see me for advice on getting a hair transplant. Is he a good candidate for hair transplant surgery? 

Not ideal.  A hair transplant in this man is unlikely to significantly improve density. This man would be much better off considering medical treatment with minoxidil and/or finasteride before considering hair restoration. Othe treatments could also be considered, including low light laser therapy. If these (and other) medical treatments didn't help, we could certainly discuss a hair transplant. 

At slightly reduced densities, it's possible to achieve a great cosmetic change. New hairs can be placed "between" the existing hairs in order to build a new density - without damaging any of the existing hairs.

I'm a big believer in transplanting in the early stages of hair loss in order to prevent the appearance of hair loss. But there is a fine line between when this is a good idea, and when it's not likely to provide the patient any benefit.

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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

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The Surgical Map: How hairs "go in" matters more than how they "come out" !

Follicular unit strip surgery (FUSS) or follicular unit extraction (FUE)

There is a lot of attention nowadays about what's a better technique for hair transplantation - follicular unit strip surgery (FUSS) or follicular unit extraction (FUE).  I perform both and both have distinct advantages and disadvantages.

But one aspect of surgery that is all too forgotten about in amongst the discussions of how to remove hairs from the back of the scalp - is how to put them back into balding or thinning areas so the result is natural.

The end result of either strip harvesting or FUE is the same - the production of "follicular units" - either one haired grafts, two haired grafts or three haired (or more) grafts. These are shown in the photo to the right.  Every patient has a different proportion of these grafts in the back of their scalps and so the planning of how they go into the balding areas must be given very careful considered. I refer to the exact plan of how hairs go into balding areas as the 'surgical map'

The surgical map in hair transplantation

If a patient is undergoing a transplant in the frontal area of the scalp, the typical surgical map would follow a pattern something like this: The one haired grafts are placed in the frontal area and placed in an irregular manner so as to create a soft and natural look. Anywhere from 100-400 one haired grafts might be placed in the front depending on the number of grafts they have and the density we are trying to achieve.  The two haired grafts are placed behind the one haired grafts the three haired grafts follow this.

A transplant session of 2000 grafts might contain:

200-400 one haired grafts

800-1500 two haired grafts

300-800 three haired grafts

One haired grafts vs two and three haired grafts

I view the one haired grafts differently from grafts that contain two and three hairs. One haired grafts are fantastic to help create a soft and natural look in areas. The three haired grafts (and too a lesser extent the two haired grafts) are importance for one main reason - building density!  The decision on where to put three haired grafts is very important. They are placed in areas where getting high density is important. 

Final comment

The way hairs are removed from the back of the scalp (i.e. FUSS or FUE) is important - but the way they go back in is more important. Ensuring the hairs are packed with the appropriate density, ensuring the sites are made at the correct angle and direction and ensuring the the one-haired, two-haired and three-haired grafts are put into the best possible locations are some of the most important factors to help ensure a natural result for patients.

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Challenging Diagnosis in a Teenager

A recent question, submitted by a visitor to www.donovanmedical.com

I have a teenage daughter who was diagnosed with folliculitus decalvans by one dermatologist and dissecting cellulitus by another. The first time she went bald her hair grew back. This episode is much more severe with a large region that is progressively getting bald. She is very aware of the loss and obviously upset. She is on erythromycin and topical steroid.  Is it worth seeing an immunologist? Previous biopsies show negative results for staph. I don’t know what else to do.

ANSWER FROM DR. DONOVAN

Thanks for the very interesting question.  Because I don’t know much about your daughter’s specific history, and haven’t examined her scalp, I can only make a few general comments. But I hope they are helpful to you!

1. Folliculitis decalvans and dissecting cellulitis are not very common in children and teenagers.

2. Dissecting cellulitis is more common in males, especially Black or Hispanic men.  It can occur in females. It typically causes boggy tender areas on the scalp that sometimes leak pus. Hair loss occurs in these areas and can lead to permanent hair loss. Hair growth occurs if treated early, otherwise leads to permanent hair loss. Patients rarely have bad acne, and cysts under the armpits and in the groin.

KEY QUESTIONS TO CONSIDER FOR DISSECTING CELLULITIS DIAGNOSIS:

Is your daughter experiencing discharge of pus (often with odor) in the areas of hair loss?

Are the areas tender?

Are the areas boggy?

(Individuals with Dissecting Cellulitis often answer yes)

3. Folliculitis decalvans also causes permanent hair loss and begins with itchy bumps often in the crown. Swabs from the scalp may grow bacteria (like the Staphylococcus you mentioned) but not always.

Folliculitis decalvans

KEY QUESTIONS TO CONSIDER FOR FOLLICULITIS DIAGNOSIS :

Does your daughter have itching red bumps in the scalp?

Does she ever wake up with blood on the pillow?

(Individuals with folliculitis decalvans often answer yes)

Why is the diagnosis important?

The diagnosis is important because treatments are different for folliculitis decalvans compared to dissecting cellulitis. For folliculitis decalvans treatment includes medications such as antibiotics, dapsone and retinoids. For dissecting cellulitis, treatments include retinoid medications, possibly antibiotics and sometimes even injectable medications known as TNF inhibitors. 

Other considerations

Episodes of hair loss in teenagers where baldness occurs and then grows back is quite typical of alopecia areata – or specifically a form known as alopecia totalis.  Of course without seeing your daughter, I can't determine the cause of her hair loss- but alopecia areata is one of the few scalp conditions that leads to complete baldness followed by regrowth. Did your daugther experience "complete" scalp baldness for a period of time? Alopecia areata is an autoimmune disease – it’s common in the population and affects about 2 % of the world.  Seeing an immunologist for alopecia areata is not necessary, nor folliculitis decalvans or dissecting cellutlis. 

Dermatologists are among the best trained physicians to address complex hair loss issues.  If you're not sure of what diagnosis your daughter has or question the diagnosis that has been given, be sure to address these issues with the dermatologist. All in all, if the diagnosis remains uncertain, a scalp biopsy might be considered and sent to a specially trained dermatopathologist with expertise in evaluating scalp biopsies.

I hope this information offer help.

- Dr Jeff Donovan

 

Is there an increased risk of prostate cancer in balding men?

The risk of prostate cancer in balding men

About 50 percent of men will be affected by male pattern balding throughout their lifetime. The medical term for male balding is "androgenetic alopecia."

Which men will developing balding and which will not? Well there are still some things we need to learn about balding. But in general, male balding is influenced by genetics, hormones and occurs with advancing age. Prostate cancer is one of the most common cancer in men. It  too is influenced by genetics, hormones and occurs with advancing age.

Is their any link between the male balding and prostate cancer?

Well, researchers at the Cleveland Clinic in Cleveland, Ohio recently set out to look at this question. They looked at all the high quality studies published so far which have examined the risk of prostate cancer in balding men.

In total, the researchers looked at the development of prostate cancer in 8994 patients - 4078 with prostate cancer and 4916 healthy men.

What did the researchers find?

When all of the studies were pooled together an interesting finding was confirmed - and that is that men with hair loss in the top of the scalp  or “vertex” have a small but significant increased risk of prostate cancer. It's important to note that the increased risk was quite small - but nevertheless the data pointed to an increased risk. The authors indicated that further studies in the future are needed to confirm these interesting findings.

SOURCE: Amoretti A, Laydner H and Bergfeld W. Androgenetic alopecia and risk of prostate cancer: A systematic review and meta-analysis. J Am Acad Dermatol 10.1016/j.jaad2012.11.034)

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Dr Donovan Answers Reader Questions: Hair Coming out in "Clumps"

Here is a recent question from our website visitor:

I have been visiting a dermatologist for 2 months now. My hair was coming out from the root in clumps. Half my hair is gone (thank god I have lots of hair). He has been giving me the cortizone shots. First time i Went he advised me to wash hair every other day and the last time i went he told me to wash every day. Now sometimes when I go a day without washing my hair my scalp hurts a lot. I can say with washing my hair every day its falling out less but it still falls out. I took test for iron and thyroid and everything came back ok. I do dye my hair and he ruled my hair loss from that but something is just not right. I know its only been 2 months but I want my hair back...badly. Should I just give it more time or should i see someone else. Will a natural remedy help or maybe scalp massages?

Dr Donovan's response:

Thanks for the interesting question. The key question is: what diagnosis was given for your hair loss? There are 100 causes of hair loss and cortisone injections can be used in over 20 of them!!! Most likely you were diagnosed with alopecia areata because that's the most common reason that cortisone injections are given. But cortisone injections are also used for scarring alopecia and other conditions as well. Without a diagnosis, I can't comment much more.

Washing your hair everyday or every second day is fine. If you have some seborrheic dermatitis in the scalp ( a distant cousin of dandruff) or if you are using alot of topical medications (lotions, creams), then washing your hair every day will just make it feel better. Patients with alopecia areata and scarring alopecia often feel better washing their scalp everyday too. It just feels better.

If you were diagnosed with alopecia areata, there's a good chance your hair will improve with injections. But whether it comes back fully is hard to predict.  Please note that ccortisone injections do not help everyone with alopecia areata.  If you are getting injections because you were diagnosed with a scarring hair loss condition (like lichen planopilaris), you probably won't improve much at all - but hopefully the cortisone injections will prevent your hair loss condition from getting worse.  That's why we use cortisone injections for lichen planopilaris.

As you can see, the cause of your hair loss is critical to know before fully answering your question. Cortisone injections help some hair loss conditions but not all.

As for scalp massages, they have no benefit in any hair loss condition. As for natural remedies, most have not been well studied. One exception would be the use of aromatherapy for patients with alopecia areata. Check out the discussion I wrote a few years ago about this subject 

AROMATHERAPY FOR ALOPECIA AREATA

Treating hair loss can sometimes be challenging. If you trust your physician's opinion, stick with him or her. You will hear many answers for your hair loss if you "shop" around.  Make sure you ask what your diagnosis is and make sure you ask if hair regrowth is even possible in this condition.

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Quantifying Hair Loss: Just How Much Hair Loss Has Occurred?

Quantifying Hair Loss:

All humans experience hair loss on a daily basis. But the key question is – “is this amount of hair loss abnormal?”  How do we evaluate whether there has been a lot of hair loss or just a little.”

It’s normal to lose between 50-100 hairs per day. This means its normal to see some hairs  in the brush, in the sink and in the shower drain. But when do we cross the boundary between normal and abnormal?? 

Most people intuitively know if the amount of hair loss they are experiencing is abnormal.   But, when I meet a patient I try to get a sense of just how much hair loss has occurred – and just how fast the hair loss has occurred.  These are extremely important to quickly get a sense of.

a)    Photos.  Comparing photos is sometimes a good way to get a sense of how much hair loss a patient has experienced.  How different does the individual look in their driver’s license photo compared to the way they look today?  Was the photo taken 6 months ago or 6 years ago?

b)   Daily Shedding. How much hair “shedding” is occurring on a daily basis? Are the drains clogged? Is their hair coming out in the food? Does the patient ever count the number of hairs shed on a daily basis?

c)    Pony tail. For women who wear their hair long, the size and thickness of the pony tail can be helpful in assessing the amount of loss. How much thinner is the pony tail than before? How many turns of an elastic band are needed now compared to before?

d)   Styling. How long does it take the individual to style their hair to cover their hair loss? An individual who once took 15 minutes but now takes 45 minutes or 1 hour has considerable loss.

e)     Spontaneous comments from family and friends.  Most of the time, a family member or friend will comment on hair loss only when it has become significant.  But I often ask patients if they have received spontaneous comments from others on their changing hair density.

f)     Patient estimates. It’s sometimes hard for patients to quantify their hair loss but I generally ask.  Specifically, I try to get a sense of the percent reduction in hair density. Has the patient loss 40 % of their hair volume in the past year? Is it 20 % ? Is it 60 %?

Quantifying the amount of hair loss is important. It helps give a sense of just how much hair loss has occurred and helps guide certain diagnoses as well. For example, consider the 26 year old woman who has lost 60 % of her hair density in the past one year and looks completely different than her driver’s license.  Although she may have been told she has female pattern hair loss, one thing is for certain- she has something else going on in addition to or besides female pattern hair loss!!! She might have female pattern hair loss, but other causes need to be explored, including a variety of hair shedding problems. Female pattern hair loss is a slow process and would not be consistent with a loss of 60 % density in one year. 

Quantifying the amount of hair loss is extremely important.