What are the Most Recent Trends in Hair Transplantation?

Hair transplantation is becoming an increasingly popular option for patients with hair loss. Each year approximately 280,000 hair transplants are performed worldwide.

The interest in hair transplantation is increasing around the world, especially outside of North America. Recent statistics released by the International Society of Hair Restoration Surgery (ISHRS) showed that while hair transplant procedures increased 15 % in the US over the years 2004 to 2010, they increased 345 % in Asia and 454 % in the Middle East over the same period.

Exclamation Mark Hairs

4 mm "exclamation mark" hairs in a patient with alopecia areata

The cause of a patient’s hair loss can sometimes be diagnosed within 2-3 seconds of meeting the patient.  On other occasions, it can only be diagnosed by carefully listening to the patient’s history, performing a biopsy or blood work, or by sleuthing through evidence on the scalp with a special magnifying glass (dermatoscope). I often tell my patients that diagnosing hair loss is like “detective work”. 

Take the photo on the right for example. It shows a remarkable feature – the so called “exclamation mark” hair.  As soon as I see this finding, I know that the patient likely has one diagnosis: alopecia areata.

What is alopecia areata?

Alopecia areata is an autoimmune disease affecting about 2 % of the population.  Men and women are equally affected.  The disease starts before the age of 18 in about one-half of patients. The disease can cause hair loss in coin-shaped circular patches of hair loss, or it can lead to total loss of scalp hair (alopecia totalis) or total loss of all hair on the body (alopecia universalis). Other patterns of hair loss are also possible in patients with the condition.

What do exclamation mark hairs look like?

Exclamation mark hairs receive their name because they resemble an exclamation mark used in punctuating a sentence. They appear as very small 3-4 mm hairs and are typically wider at the top and then taper to a progressively thinner hair as the hair meets the scalp. Exclamation mark hairs typically appear pale at the bottom and darker at the top.

Why do exclamation mark hairs occur?

It’s not entirely clear why exclamation mark hairs are produced. However, it seems that the main reason is because of inflammation. In alopecia areata, inflammation occurs at the very bottom of the hair fiber deep under the skin. Because of this inflammation, the hair becomes progressively thinned and accumulates many weak spots all along the hair shaft. These weak spots lead to the hair breaking or fracturing easily.  Because of this breakage, only short hair fibers (less than 3-4 mm) are produced.

Why do I consider exclamation mark hairs to be so important?

1)     If a patient has exclamation mark hairs, I can be extremely confident that the diagnosis is alopecia areata. These hairs tend to be present in the early stages of alopecia areata and occur at the edges of an area of hair loss. Exclamation mark hairs very rarely occur in other situations, (such as poisoning with thallium), but those situations are very rare.

2)     The presence of these hairs tells me that the patient’s disease is active and that it is quite likely that the patient’s area of hair loss will increase in size over the next few weeks.

Not every patient with alopecia areata has exclamation mark hairs. However, when this finding is present, I am confident that my detective work is complete and a diagnosis of alopecia areata can be rendered.

More Women getting Hair Transplants

Every year, more and more women are asking about options for hair transplantation and about one-quarter of my hair transplant patients are women.  Last month, I posted a blog outling the hair characteristics that would make a woman a good candidate for the procedure.

What are the latest trends around the world in hair transplantation among women?

A recent study, released by the International Society of Hair Restoration Surgeons, indicates that the number of female hair transplant patients increased 24 % since 2004. In 2010, 14.1 % of all hair transplant patients worldwide were female and 85.1 % of patients were male.

Can patients with alopecia areata ever have a hair transplant?

Alopecia areata is an autoimmune disease which attacks hair follicles.  There is a strong genetic susceptibility to the condition and each year we learn more and more about the genes implicated int he condition.  In fact, just last year Dr. Angela Christiano and her research group at Columbia University uncovered eight genes that are strongly implicated in the condition. We now understand that the tendancy to develop alopecia areata may be present at birth, but what actually causes it to "come out" in some people but not in others remains poorly understood.

Patients with alopecia areata are rarely ever candidates for hair transplantation.  Hair follicles moved from a normal appearing area of the scalp into a bald area remain susceptible to being attacked by the patient’s immune system. This autoimmune attack can occur 2 months after the transplant or 50 years after a transplant. A previous post reviews hair loss conditions which typically can and can not be treated by hair transplantation

Patients with a small stubborn spots of alopecia areata are advised to seek the advice of a physician knowledgable about hair loss. Patients are typically treated with topical steroids and/or steroids injections. Other treatments such as minoxidil, diphencyprone, anthralin or squaric acid dibutyl ester may be discussed. Oral treatment options may also be discussed in some situations, including use of prednisone, sulfasalazine, methotrexate and cycosporine.

Although some hair transplant surgeons will never perform hair transplantation in a patient with "long standing" alopecia areata, some surgeons have very occasionally had successful outcomes transplanting alopecia areata in such situations. One such study is given below by Dr. Robin Unger's team in New York.

Unger R, Dawoud T and Albaqami R. Successful hair transplantation of recalcitrant alopecia areata of the scalp. Dermatol Surg. 2008 Nov;34(11):1589-94.

If the area affected by alopecia areata is small, and has remained unchanged for several years, and if a scalp biopsy shows no inflammation below the scalp, hair transplantation 'could' be considered. But this would require very thorough discussion which an experienced physician. However, patients need to be aware and accept the risk that that the transplanted hair is susceptible to falling out again -  at any time.  For these reasons, patients with alopecia areata are rarely ever candidates for hair transplantation.

 

What does a elevated "ferritin" blood test mean for someone with hair loss?

Iron metabolism is one of my favorite subjects.  Iron has an important role in hair growth and it’s important to understand the intricacies of the many iron tests available. I like all of my patients, whether seeing me for medical treatment of hair loss or hair transplantation, to have iron levels in the normal range.

The “ferritin” blood test is a traditionally a measure of iron stores in the body. When I give lectures on hair loss, I often refer to ferritin as the ‘bank’ of iron – a measure of the amount of iron that is stored away in the body.  Hair follicles seem to be able to sense these iron stores – and if they are not high enough, the result can sometimes be hair shedding. Normally, I aim for patients, especially women, to have a ferritin of at least 50 ug/L.  If ferritin is lower than this I may perform additional blood tests to determine if there are any concerning reasons for the patient to have low iron. In most situations with a low ferritin, I will prescribe iron supplements.

If a low ferritin can sometimes be associated with hair loss, what does a high ferritin mean?

Although the upper range of normal for ferritin is 250-300, it's actually not very common to have a ferritin above 90.  If someone has hair loss, an elevated ferritin should always be thought of as a "caution sign." It might simply be a normal result, or a result of taking iron pills, but a bit more detective work needs to be done before coming to that conclusion. It is important to understand that the ferritin test can rise to levels above 90 ug/L for dozens and dozens of different reasons.  Sometimes it's completely normal finding, but other causes include inflammation, infections, cancers, liver disease, and certain other diseases. The disease known as hemochromatosis leads to markedly elevated ferritin levels.  Patients with various inflammatory scalp diseases (i.e. scarring alopecia, alopecia areata) can also sometimes have a high ferritin. These are just a few examples of conditions which are sometimes associated with a high ferritin.  The list is actually quite long and the cause can sometimes only be diagnosed with further detective work by the doctor. Therefore, the ferritin test is not the most specific test for figuring out iron problems, but it is certainly the best test to start with. 

If a patient has a low ferritin level, I can be pretty sure that the patient has iron deficiency.

However, if the ferritin is high (say, over 90), and the patient does not take iron supplements, I can't assume the patient simply has a normal iron status. In most of these situations, I ask many additional questions focusing on all the causes of the slightly high ferritin test.

In cases where the ferritin is high, but the patient is not taking iron, it’s important to look for other clues to determine if the patient (and the patient’s hair) might benefit from an iron supplement. All of the following tests need to be carefully interpreted together to make sure that iron is not given if the patients does not need it:

Hemoglobin (HGB).  Patients with significant iron deficiency can sometimes develop a low hemoglobin level or “anemia.”  However, in the “early” stages of iron deficiency, the body makes a normal number of red blood cells. The hemoglobin in such situations is normal.  However, hair shedding can still occur if the iron stores are low.

Red cell distribution width (RDW). The RDW gives a rough estimate of the size of the red blood cells that are being produced by the body. In cases of iron deficiency, the patient’s body may produce some normal size cells but also some very small cells. This leads to a greater variation in cell size.  Therefore, the RDW may be elevated in patients with iron deficiency.

Mean corpuscular volume (MCV). The MCV also gives another measure of the size of red blood cells. In cases of iron deficiency, the MCV is reduced because smaller red blood cells are produced.   This tests needs to be carefully interpreted by a physician as many other conditions can cause a lower MCV.

Transferrin saturation (Tr sat).  The transferrin saturation is calculated by taking into account two blood test results: the serum iron measurement (Fe) and the total iron binding capacity (TIBC) measurement. The Fe divided by the TIBC gives the transferrin saturation. The transferrin saturation can sometimes be reduced in individuals with iron deficiency.

Soluble transferring receptor (STfR). This can be an accurate measurement of iron deficiency and the test is completely independent of whether or not the patient has inflammation.  This is a very expensive test, and is usually not needed when all of the above tests are taken into account. It is rarely ordered. The soluble transfer receptor level is elevated in individuals with iron deficiency.

Taken together, a patient with elevated ferritin but low MCV, low hemoglobin, high RDW and high transferrin saturation has iron deficiency.  Further investigations would be needed to figure out why the patient is iron deficiency. But the investigations don't stop there - further tests would be needed to figure out why the patient has an elevated ferritin.

Robotics in Hair Transplantation: Coming Soon to a Clinic Near You?

Robotic assisted devices and computers are now used in many different types of surgerical procedures. It is likely that the same trend may be seen in hair restoration over the next decade.

Restoration Robotics, a privately held medical device company in the United States, created a robotic device to assist hair transplant surgeons.  The so called ARTAS system consists of a chair where a patient having a hair transplant would sit and a robotic arm that a hair transplant surgeon would control using a computer interface.  The robotic arm would dissect hair follicles from the back and sides of the scalp. The hope is that the quality of hair follicle harvesting may be enhanced by the ARTAS system. The device received FDA clearance in April 2011 for men with brown or black straight hair.

The company announced last week that they have raised 41 million dollars in venture capitalist funding and will begin now to focus on how the technology can be marketed in the United States.

Finasteride: Does it Increase the Risk of Breast Cancer in Men?

Health Canada issued a news release August 4, 2011 advising doctors and the public of the possibility of breast cancer in men using the oral medication finasteride. Finasteride at 1 mg is used approved for the treatment of hereditary hair loss in men and is marketed under the name Propecia. Finasteride at a 5 mg dose is used for the treatment of enlarged prostate in men and is marketed under the name Proscar. Although the drug is sometimes prescribed off-label to treat women with androgenetic alopecia, it is not FDA approved for women.

Reports of a possible association between finasteride and male breast cancer are not new.  The possibility of this association was raised over 10 years ago.  There are now at least 50 previous reports in the medical literature about men who developed breast cancer while taking finasteride at the 5 mg dose. There are at least 3 reports in the literature of men who developed breast cancer taking the 1 mg dose. 

Overall, breast cancer in men is rare. 99 % of breast cancers are diagnosed in women and 1 % are diagnosed in men.  Each year about 2000 new cases of male breast cancer are diagnosed in the United States and 200 cases are diagnosed in Canada. 

The public needs to be aware that these studies do not prove that finasteride causes breast cancer in men. This relationship is not known at the present time and more research is needed.  However, it remains a possibility.    The Health Canada report states:

Based on the currently available evidence, it is not known with certainty whether finasteride can cause breast cancer, nor can this possibility be ruled out at this point in time.

All men starting finasteride should be aware of the possibility that reports of breast cancer have rarely occurred in men taking finasteride.  The risks in women are unknown at the present time. Health Canada has advised individuals who take finasteride to report changes in their breasts to their doctors. These changes would include:

• Enlargement of the breasts
• Lumps in the breasts
• Tenderness or pain in the breasts
• Discharge from the breasts

 The Health Canada report is found in the following link:

Finasteride (Propecia, Proscar): Potential rare risk of breast cancer in men

 

August is National Hair Loss Awareness Month in the US

This year marks the 11^th year of the US National Hair Loss Awareness Month.  Hair loss is common with 60 % of men and 40 % of women affected by hereditary forms of hair loss by age 50. This translates into 90 million men and women in the US and Canada alone.

In addition to hereditary hair loss, there are over 100 additional reasons to lose hair. These reasons range from autoimmune and infectious causes to scarring hair diseases and hair loss from hair styling practices. It is important raise awareness of hair loss among the general population and encourage individuals to seek advice about hair loss at early stages.  For the vast majority of hair loss conditions I treat, a better long term outcome is achieved when treatment is initiated in early stages. 

Although National Hair Loss Awareness month is targetted to the general public,  there are important messages for the medical community as well. It is critically important to train more physicians and medical speicalists about hair loss, so that patients with less common and rare hair loss conditions also receive prompt diagnosis and treatment.  

Weighing in on the Weights of Oral Medications

How does 200 mg of Spironolactone compare to 2.5 mg of Finasteride?

Oral medications which block androgens are often used in the treatment of hair loss in women. These include off-label use of medications such as spironolactone, finasteride and flutamide. Other anti-androgen medications are available in some counties as well, such as cyproterone acetate in Canada.

When given a choice between 200 mg of spironolactone, 62.5 mg of flutamide or 2.5 mg of finasteride, what sounds like a better choice? Many individuals assume that 2.5 mg of finasteride is a much lower dose and hence less likely to have side effects than 200 mg of spironolactone or 62.5 mg of flutamide.  However, this is not an accurate interpretation.  These oral medications are different, and metabolized differently by the body. They can not be directly compared simply based on a weight by weight basis. 200 mg of spironolactone is not 80 times stronger than 2.5 mg of finasteride.  Each medicine has potential benefits and potential risks that need to be discussed with a physician.

Hair Loss Terms Explained: Alopecia areata, alopecia totalis and alopecia universalis

Forms of Alopecia Areata

Alopecia areata is an autoimmune disease which causes hair loss from any part of the body. The three terms alopecia areata, alopecia totalis and alopecia universalis frequently cause confusion.  Individuals with extensive alopecia areata often wonder if they have alopecia totalis and some individuals with alopecia totalis often wonder if they really have alopecia universalis. Accurate definitions of these terms are given below: 

Alopecia areata. Alopecia areata refers to a specific autoimmune condition where there is partial hair loss on the scalp. If an individual has some scalp hair remaining, the term alopecia areata can be used. For example, if an individual has lost 60 % of his or her scalp hair, and has lost 100 % of the eyebrow and eyelash hairs, the appropriate term is still alopecia areata. About 1.7 % of the population is affected by alopecia areata.

Alopecia totalis. An individual has alopecia totalis when all of the scalp hair has been lost, but there is still body hair in other areas.  An individual with no scalp hair, and no eyebrow hair but who still retains some body hair has alopecia totalis. About 5-10 % of patients with alopecia areata will develop alopecia totalis.

Alopecia universalis. A patient is said to have alopecia universalis when all hair on the scalp and body are lost. Less than 1 % of patients with alopecia areata will develop alopecia universalis.

 

What's New in the World of Hair Research? Stem Cells.

Androgenetic alopecia: Are the stem cells still present or are they all gone?

Androgenetic alopecia is common in the population. By age 50, about 50 % of men and 30 % of women will have androgenetic alopecia.  Men often develop recession in the temples and an expanding balding area in the crown. Women with androgenetic alopecia develop hair thinning in the central scalp.

Over the last 10-15 years, research in hair diseases has focused a lot on “stem cells.” Stem cells are cells that have the ability to give rise to new cells types.  Hair follicle stems cells have the ability to give rise to “progenitor cells”, which in turn can produce a new hair follicle.

Until recently, it was unknown whether individuals with androgenetic alopecia retain stem cells in the progressively thinning hair follicles. However, researchers at the University of Pennsylvania lead by Dr. George Cotsarelis showed that hair follicles from patients with androgenetic alopecia do retain stem cells. For reasons that are still unclear, these stem cells are less able to covert into progenitor cells.

To perform the study the researchers studied 54 men aged 40-65. Hair follicles from balding areas were compared to hair follicles from non-balding areas.  The bald and non bald areas were found to contain similar levels of stem cells. However, the balding areas had fewer progenitor cells.

It is not known if the results would be similar in women, because the study population consisted only of men. However, one can speculate that they likely would be.  This study is extremely exciting. If hair follicle stem cells in androgenetic alopecia can be coaxed or convinced to convert into progenitor cells, it may be possible to reverse the balding process. More research is needed to determine how do to that.

Garza et al. Bald scalp in men with androgenetic alopecia retains hair follicle stem cells but lacks CD200-rich and CD34 positive hair follicle progenitor cells. J Clin Invest 2011; 121: 613-622.

Scalp Trauma and Hair Loss

Scalp Trauma and Hair Loss

It is well known that scalp trauma can sometimes cause certain types of hair loss. For example, individuals who were in accidents and experienced traumatic injury to the head can develop hair loss.  I also see many patients who have had facial cosmetic surgery in the form of face lifts who develop frontal hair loss from the surgery. This too is a form of scalp trauma. 

Over the years, hair specialists have wondered about whether scalp trauma has a role in the development of a form of hair loss called "scarring alopecia."  More research is needed to determine the exact role, but some patients with a history of injury to the scalp occassionally develop a scarring alopecia.

Recently, a  report  was published of a 26 year old man who developed a scarring alopecia on the top of the scalp (specifically the condition known as lichen planopilaris) following several years of break dancing.  Presumably the repeated head spins in breakdancing provided a source of repeated trauma. The patient’s biopsy confirmed the diagnosis of lichen planopilaris.

Whether trauma can lead to scarring hair loss remains unknown. This publication may be among the first reports of scarring hair loss in breakdancers.

Study source: Moselise A, Chan LJ and Shapiro J. Break dancing: a new risk factor for scarring hair loss. J Cutan Med Surg 2011; 15: 177-9.

 

What is the best lab test to see if thyroid problems are causing hair loss?

Are thyroid problems causing hair loss?

Thyroid hormones are produced by the  thyroid gland, which is a small gland located in the midline of the neck. Precise levels of thyroid hormones are important for normal hair growth. 

The TSH test

The release of thyroid hormones from the thyroid gland is an intricate process. A region of the brain known as the hypothalamus releases a hormone known as "TRH" or thyrotropin releasing hormone, which in turn triggers the tiny pituitary gland to release "TSH" or thyroid stimulating hormone.  In response to the release of TSH, the thyroid gland produces thyroid hormones, namely thyroxine (T4) and triiodothyronine (T3).

When the body produces too much or too little thyroid hormone this may lead to hair shedding. The single best test for thyroid problems is a blood test for “TSH” or thyroid stimulating hormone.  If the TSH is abnormal, several additional thyroid tests can be ordered, including a "free T4".

Hypothyroidism occurs in about 3 % of the population. Hypothyroidism occurs when the thyroid gland does not release enough thyroid hormone. Most patients who are hypothyroid have an abnormally high TSH level and a low free T4 level. This is known as "primary hypothyroidism"  Most patients who are hyperthyroid have the opposite pattern – a low TSH level and high free T4 levels.

 

Do I need any blood tests prior to a hair transplant?

The decision to order pre-operative blood tests depends on the hair transplant specialist. I recommend blood tests for CBC (complete blood count), PTT, INR (bleeding parameters) as well as Hepatitis B, Hepatitis C and HIV.   Patients with any previous heart problems may also be requested to obtain an electrocardiogram or “ECG.”

Does Hair Always Grow Back Fully After Chemotherapy?

Some types of chemotherapy medications can cause hair loss.  In most cases the hair grows back. In some situations, however, the hair does not regain full density even months after completion of chemotherapy. What are some reasons that hair does not grow back fully after chemotherapy?  A full assessment is needed to determine all the reasons but a few of the most common reasons are listed here.

Permanent chemotherapy induced alopecia (PCIA). Some chemotherapy drugs can cause permanent damage to the follicular stem cells of the hair follicle and lead to hair loss.  Three common examples include taxanes (used to treat breast cancer), cisplatin (used to treat lung cancer as well as other cancers), busulfan (used to treat blood cancers). There are other drugs that do this as well.

Androgenetic alopecia. Androgenetic alopecia is common in the population. 30-40 % of women and 50-60 % of men have androgenetic alopecia.  Sometimes with hair loss from chemotherapy, androgenetic alopecia can become noticeable a few years sooner.

Drug induced hair loss. Some drugs used in patients after chemotherapy can rarely lead to hair loss.  For example, anastrozole is an example of a drug that can occasionally be associated with hair loss. There are several other examples too.  It is important to know that some drugs will cause hair loss in certain people but not cause hair loss in other people. 

Telogen effluvium (hair shedding). Hair shedding can happen for a variety of reasons, including surgery, infections, thyroid abnormalities, nutritional problems and drugs.  For a variety of reasons, cancer patients may be more prone to telogen effluvium. 

Other hair diseases.   There are about 100 reasons for anyone in the population to lose hair.  Patients who received chemotherapy can develop many other hair loss conditions. It is important to have a thorough evaluation to determine the reasons for hair loss.

Hair Loss Terms Explained: Scalp Pustules

Pustules are collections of pus. Scalp PustuleThey are 1-4 mm in size and appear as yellow, white or red in color. Pustules may or may not contain bacteria. However, some pustules are completely free of bacteria and called “sterile pustules”.  If pustules are seen on the scalp, a swab is often performed to see if the pustules contain bacteria.  If bacteria are present and it is concluded that there is a true infection in the scalp, a topical or oral antibiotic medication might be prescribed.  In some cases, pustules are indicative of a scalp disease and persistent pustules should be evaluated by a physician.

Minoxidil and Itch: Am I allergic to Minoxidil?

Some individuals who use minoxidil solution develop itching in the scalp.  In most cases, this is not due to an allergy to the minoxidil but rather due to irritation from a chemical that is mixed with the minoxidil. This chemical is called propylene glycol. If patients have a lot of itching with minoxidil, a minoxidil formulation that does not contain propylene glycol can be recommended.  A common example of a proplylene glycol free product would be minoxidil 5% foam or minoxidil compounded by the pharmacist in glycerin, water and ethanol.

Very rarely, a patient can be truly allergic to minoxidil. Specialized allergy testing performed by a dermatologist (called patch testing) can help to determine if a patient is actually allergic to minoxidil.  Usually such testing is only performed in complex or challenging situations.

Is there a Minimum or Maximum Age for Hair Transplantation?

The minimum age for hair transplantation differs for each patient and depends on a number of factors. For patients with early onset androgenetic alopecia or with a family history of early onset or advanced androgenetic alopecia I may advise medical therapy first and delay a transplant until the mid 20s. This allows me to observe the rate of progression of hair loss over time. 

It is more challenging to predict the rate of hair loss in very young men with a family history of advanced hair loss. However, it becomes easier to predict the likely patterns of future loss by age 25-30.

There is no maximum age for men or women to have a transplant provided the patient is in good health.   

Do Androgens Cause Hair Loss?

It is well known that androgen hormones contribute to some types of hair loss.  The main culprit is the androgen hormone “DHT” or dihydrotestosterone, which is made from testosterone.  There are several pieces of evidence over the last few years that support the relationship between androgens and the development of androgenetic alopecia. This relationship is more direct in men than women.

First, it was appreciated even in ancient times that castrated young men do not go on to develop androgenetic alopecia, or male pattern balding.   Later it was understood that these men maintain low testosterone levels.  It was J.B. Hamilton in the 1940s who showed that wen testosterone was given back to castrated men later years, they developed male pattern balding.  Further evidence of the role of androgen hormones in hair loss came from study a group of men in the living in the Dominican Republic. Many of these men lacked the ability to convert testosterone to the potent androgen DHT.  Interestingly, these men did not develop male pattern baldness. Finally, we now have several medications available, such as finasteride and dutasteride, which block the ability of the body to covert testosterone to DHT. These medications can halt male pattern baldness in a significant proportion of men.

Most studies have shown that men with androgenetic alopecia have similar levels of blood testosterone compared to men who are not bald.  It appears therefore that men with androgenetic alopecia inherited hair follicles that are "more sensitive" to the effects of androgens rather than simply having higher levels of testosterone.

The relationship between androgens and hair loss is more complex in women. Androgens do play a role in the development of androgenetic alopecia, but likely not to the same degree as in men. Therefore, we now appreciated that the cause of androgenetic alopecia in women is much more complex.  It is for this reason that oral anti-androgen medications are helpful in treating hair loss in women, but do not have the same profound effects as in men.

What Determines if a Woman is a Good Candidate for Hair Transplantation Surgery?

By age 50, about 30-40 % of women will develop androgenetic alopecia. More and more women are asking about hair transplantation. In fact, a recent survey of members of the International Society of Hair Restoration Surgery, indicated that hair transplant procedures for women increased from 11.4 % in 2004 to 15.1 % in 2008.  What determines if a woman with androgenetic alopecia is a good candidate for hair transplantation?

1. Women with androgenetic alopecia with a good density and quality of donor hair at the back of the scalp and hair loss that is limited to the front and top of the scalp are good candidates for hair transplantation.

2. Women with androgenetic alopecia showing diffuse hair loss, whereby thinning is seen in the front, back and sides of the scalp are not good candidates for hair transplantation.

A careful evaluation of the scalp will determine the pattern of hair loss for each woman. Women who have good density in the back of the scalp and have hair thinning primarily in the front of the scalp are good candidates for hair transplantation.