Cicatricial Marginal Alopecia: Your traction alopecia patients will thank you!

Not all ‘Traction Alopecia’ is Actually Traction Alopecia

Traction alopecia is a form of hair loss that occurs due to pulling of hair. Diagnosing traction alopecia sounds easy but surprisingly there are a great number of mimicking conditions that can fool the hair specialist.

Frontal traction alopecia refers to hair loss in the frontal hairline that is due to traction. Often the temples are affected but any part of the frontal hairline, temples and area around the ears can be affected. Often the hairs in the very frontal hairline are unaffected leading to the appearance of a so called “fringe” sign:

Classic ‘fringe’ sign in a patient with traction alopecia. The fringe refers to the fringe of hair in the frontal hairline.

Cicatricial Marginal Alopecia (CMA)

There are times when patients who present with what seems to be traction alopecia tell us that they couldn’t possibly have traction alopecia. These are the patients who tell us that they have worn their hair fairly natural for years and that a diagnosis of traction alopecia just makes no sense to them. These are the patients that politely stare at us when we tell them to be careful how they style their hair and to be carefully to avoid heat or chemicals. When a hair specialist wants to make a diagnosis of traction alopecia but realizes the patient’s story just does not add up to give a convincing story of traction alopecia - the diagnosis of cicatricial marginal alopecia (CMA) must be considered.

The Differential Diagnosis of Frontal Hair Loss: What’s a specialist to consider anyways?

Of course, the diligent hair specialist considers many things in the differential of frontal traction alopecia like presentations including

1. Traction alopecia

2. Cicatricial Marginal Alopecia

3. Frontal fibrosing alopecia

4. Discoid lupus

5. Androgenetic alopecia

6. Telogen effluvium

7. Alopecia Areata

8. Trichotillomania

Cicatricial Marginal Alopecia: A Traction Alopecia Like Alopecia Without A Traction History

It was Dr Lynn Goldberg in Boston who put forth the notion of cicatricial marginal alopecia. She described 15 patients who presented with hair loss in a typical traction alopecia like pattern. Information pertaining to whether or not the patient relaxed or straightened the hair was available In 12 patients. 6 of the 12 patients gave a history of relaxing the hair or straightening the hair. For the other 6 other patients there was no such history. In other words, in 50 % of patients with frontal 'traction alopecia-like” hair loss a history of true traction styling practices were not present. These patients still had some degree of scarring on their biopsies indicating that this too could be a scarring type of hair loss. 

Treatment of CMA involves topical or oral minoxidil combined with topical and/or intralesional steroids. In some patients use of agents like oral doxycycline or topical tacrolimus can be helpful.

Summary and Key Lessons

As soon as we let open our mouths to pronounce the words traction alopecia, we must say in the same breath “or a traction alopecia like mimickers.” Could my patient have traction alopecia or a “traction alopecia like mimicker.”

Cicatricial Marginal Alopecia is one of these closely related mimickers. I like to refer to it as cicatrical marginal alopecia to honour my great colleague Dr Goldberg and so this is what I write in all my letters and consultation notes to other physicians. In my mind, I say the patient has a Traction Alopecia Like Alopecia Without a Traction History because it helps me remember the key elements of this presentation.

Reference

Goldberg L. Cicatricial Marginal Alopecia: Is It All Traction? Br J Dermatol 2009 Jan;160(1):62-8.

Hair loss in the Frontal Hairline.

Cause of Frontal Hairline Loss

I enjoyed giving a lecture yesterday to our brilliant University of British Columbia dermatology resident physicians. We discussed the common and uncommon scarring and non-scarring hair loss conditions that affect the frontal hairline of males and females.

Treating Frontal fibrosing Alopecia (FFA): Are retinoids better than finasteride?

Retinoids in FFA Treatment

Frontal fibrosing alopecia ("FFA") is an autoimmune disease that mostly affects women. It is classified as a "scarring" hair loss condition and hair loss is often permanent for many women. A variety of treatments are available including topical steroids, topical calcineurin inhibitors, steroid injections as well as oral treatments like finasteride, doxycycline, hydroxychloroquine and isotretinoin.

A new study from Poland set out to compare benefits of finasteride and "retinoids" (isotretinoin and acitretin) in women with FFA. The study included 29 women who were treated with a dose of 20 mg isotretinoin, 11 women treated with 20 mg acitretin and 14 treated with oral finasteride at a dose of 5 mg/daily.  Interestingly, 76% of patients treated with isotretinoin, 73% of patients treated with acitretin, and 43% of patients treated with finasteride had their disease halted over a 12 month observation period. 

Comments

This study is small and should be interpreted with caution for this reason. Nevertheless it is interesting and points to a potentially valuable role for retinoids that we really don't seem to see with classic lichen planopilaris (a closely related condition). The data in this present study however do not match other much larger studies of finasteride use in FFA which have suggested that a much higher proportion of FFA benefitted from use of this drug.

For now, this study provides us with evidence that retinoids can benefit some patients and should be at considered. Many women with FFA do have a tendency for increased cholesterol levels and the use of retinoids can significantly worsen this so caution and monitoring are needed.

Reference

Rakowska A, et al. Efficacy of Isotretinoin and Acitretin in Treatment of Frontal Fibrosing Alopecia: Retrospective Analysis of 54 Cases. J Drugs Dermatol. 2017.

Capturing the very earliest changes of Genetic Hair Loss

Recognizing genetic hair loss in the earliest stages

Genetic hair loss is common. By age 50, about 60 % of men and 35 % of women will develop genetic hair loss.  Hair loss typically starts in certain areas of the scalp - such as the temples and crown in men and central scalp in women.

 

 

Alteration in follicular counts may precede miniaturization 

Miniaturization refers to the progressive reduction in hair follicle diameter during the course of genetic hair loss. In other words, hair follicles get skinnier and skinnier over time. This is a very typical feature of genetic hair loss. One other feature that is frequently seen is the alteration of hair follicle counts. Rather than hair follicles appearing in bundles of two hairs or three hairs, they are frequently seen as single isolated hairs. 

The photo above nicely illustrates this concept. Both photos were taken from the same patient. The photo on the left shows hair follicles grouped together in groups of two three and even four hairs. This area of the scalp is unaffected by genetic hair changes. The photo on the right shows very typical genetic hair loss. Hair follicles are still similar in size (thickness), but what is seen is mostly single hairs - the groupings of two and three hair bundles are no longer present. This is very typical of the earliest features of genetic hair loss. 

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.

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.

This blog has been filed into the following folders:

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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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)

This blog has been filed into the following folders:

Frontal Fibrosing Alopecia: Do we Need a New Name for the Condition?

Frontal Fibrosing Alopecia: Do we Need a New Name

Frontal fibrosing alopecia is an uncommon hair loss condition that usually affects post menopausal women. The cause is not known. 

Frontal Fibrosing Alopecia: What does it mean?

At first glance, the name seems like a good one. Women with frontal fibrosing alopecia lose hair in the front of the scalp and it occurs with scarring (fibrosing process). The women in the photo on the right has typical frontal fibrosing alopecia. 

FRONTAL: Hair from the front of the scalp is lost

FIBROSING: Occurs with scarring (fibrosing process)

ALOPECIA: Simply a medical term for hair loss

Once the hair is lost, it's lost permanently. Only with hair transplant surgery can hair density in the front be improved. But surgery can only be done when the condition is quiet or else the newly transplantedn hairs are likely to die.  An ongoing research study in our office is seeking to understand when it's best to transplant women with frontal fibrosing alopecia.

But is this a good name for the condition?

As time passes, we're learning more and more about frontal fibrosing alopecia. Many women not only lose hair in the front of the scalp (hairline), but also at the sides (above the ears) and at the back as well. The women in the photo shows a typical picture of hair loss occuring at the back. In addition, women with frontal fibrosing alopecia often lose eyebrows (in three quarters of patients) and often lose body hair as well ( in one quarter of patients).

Conclusion

The term frontal fibrosing alopecia has been with us for almost 20 years now. When hair specialists use the term, we know exactly what condition is being referred to. But the term has its limitations - and someday it might take on even a different name - one that encompasses the hair loss from the back and sides of the scalp,  body hair and eyebrows.

To Dense Pack or Not to Dense Pack

What is dense packing?

For patients having a hair transplant, dense packing refers to the placement of hair follicle grafts close together such that the final density is high (i.e. dense) - greater than 30-35 follicular units per square cm.  Dense packing may lead to densities as high as 50 follicular units per square cm in some cases. The diagram on the right illustrates these different densities.

Some surgeons have argued that dense packing is preferable in some cases because a better cosmetic result can be achieved. Other surgeons have argued that very good results can still be achieved wtih densities of 30 -35 FU/cm2 without risking the chance of getting poor survival of the grafts.   Poor survival is a theoretical possibility because grafts have to be trimmed thinner and thinner in order to be able to pack them close together.

Over the past 5-10 years, we have slowly gained more information about the survival of grafts and particularly how to improve the survival of densely packed grafts. But certainly more research needs to be done. A 2005 study showed that graft survival with dense packing at 50 FU/cm2 was 84 % (i.e. 16 % died) compared to 98 % (only 2 % died) at a density of 30 FU/cm2.   Compare this to a 2008 study by Drs Nakatsui, Wong and Groot which showed that survival was as high as 98.6 % in  a patient transplanted with a density of 72 FU per cm squared in on small test area. The technique used to tranpslant hairs in this study was slightly different than used in the 2005 study mentioned above.

To dense pack or not to dense pack?

The decision on packing density depends on many factors - including their age, the quality of their hair (i.e. hair color, curl, coarseness), the available donor hair and the likelihood of future balding.

Dense packing of 50 FU/cm2 in a 45 year old man with coarse curly salt and peppery colored hair probably won't give much of a cosmetically different result than a 30 FU/cm2 density. In fact, doing so runs the risk of using up more hair and possibly limiting the number of hairs that might be possible to transplant when the man is 55 or 65.

The decision on dense packing needs careful consideration. 

References 

Mayer M, Keen se S, Perez-Meza D. Graft Density Production Curve with Dense Packing. International Society of Hair Restoration Surgery Annual Meeting. Sydney Australia 2005

Nakatsui et al. Survival of Densely Packed Follicular Unit Grafts Using the Lateral Slit Technique. Dermatol Surger 2008; 34: 1016-25.

 

Hair Transplantation Using Leg Hair

Patients in my practice often ask me if I can take hair from the chest, back or legs and add it into thinning areas on the scalp. The concept of "body-to-scalp" hair transplantation is somewhat new but slowly catching on. Generally, most hair transplant specialists would reserve this technique for very special circumstances (i.e. poor donor hair density at the back of the scalp or poor donor quality, or excessive scarring in the donor area).  Hair from other body sites isn’t quite the same as hair on the scalp – it looks and feels different. It grows at different rates too.   

Dr. Sanusi Umar, a hair transplant specialist from California, wondered if he could use these differences to his advantage. Specifically, he wondered it he could take advantage of the fact that leg hairs are small, thin and soft and use these legs hairs to improve the appearance of the frontal hairline (which is normally chalked full of soft, thin hairs).

Can hairs from the leg really be transplanted into the hairline?

Dr. Umar studied two of patients, each of whom had 1000 leg hairs transplanted into their frontal hairlines.   In both patients, Dr. Umar reported that about 75-80 % of the hairs survived. Interestingly, the transplant legs hairs were a bit longer than the original leg hairs and were less curly.   Dr. Umar  followed the first patient for a total of 4 years and followed the second patient for 3 years. The transplanted legs hairs remained and grew well in the frontal hairline. Moreover, the areas on the leg where the hairs were taken healed without visible scars.

Dr. Umar's study, which is published in the journal Archives of Dermatology is an interesting and unique study.  It shows promise in the use of leg hairs to soften the hairline.  As body-to-scalp hair transplants move forward, it seems that both chest hair and leg hair may be a possible source of transplantable hair for some patients.

Reference

Umar S. The Transplanted Hairline: Leg Room for Improvement. Archives of Dermatology 2012; 148: 239-242