The Advantages and Disadvantages of Hair Loss Therapy

With approximately 70% of men and 40% of women affected by pattern baldness¹, a great deal of research has been invested into hair loss therapy. As a result, several options for treatment are now available from both topical and oral medication, surgical intervention and now the more futuristic sounding laser treatments. Moreover as fortunate as it is to have choice, that can sometimes make a tough decision even more difficult. Thus listed here are some considerations to keep in mind when electing for hair loss therapy.

Medications

There are two FDA-approved medications which have been shown to promote hair growth and prevent any further hair loss. Minoxidil is available as a topical solution while finasteride is an oral pill.

Minoxidil

Advantages

• Minimal side effects
• Clinical research to support its effectiveness²

Disadvantages

• Time-consuming topical applications
• More effective in earlier stages of hair loss
• Continued application is required to maintain results, hair loss resumes once treatment is stopped

Finasteride

Advantages

• Easy to use
• Clinical research to support its effectiveness³ and may provide some of the best non-surgical results

Disadvantages

• Not recommended for women
• A prescription is required
• More effective in earlier stages of hair loss
• Currently under investigation for some serious sexual side-effects that have been reported in a small percentage of patients⁴
• Continued application is required to maintain results, hair loss resumes once treatment is stopped

Hair Transplant

Advantages

• Effective and long lasting
• Natural hair growth

Disadvantages

• More than one treatment may be necessary
• Surgical procedure
• Success depends on the skill of the surgeon
• Price limiting

Low Level Laser Therapy

Advantages

• Easy to use
• Absence of side effects

Disadvantages

• Efficacy may vary between individuals
• Believed to stimulate present hair follicles but not bring back those which have been lost

Taken together, the best plan of action for hair loss treatment will vary with each individual. In many cases, a combination of treatments may be the most beneficial. Most importantly, talk with your physician or hair restoration expert prior to starting any of these treatments.

Article by: Dr. J.L. Carviel, PhD, Mediprobe Research Inc.

References

1. Santos Z, Avci P, Hamblin MR. Drug discovery for alopecia: gone today, hair tomorrow. Expert Opin Drug Discov 2015;10:269–92.
2. Gupta AK, Charrette A. Topical Minoxidil: Systematic Review and Meta-Analysis of Its Efficacy in Androgenetic Alopecia. Skinmed 2015;13:185–9.
3. Gupta AK, Charrette A. The efficacy and safety of 5α-reductase inhibitors in androgenetic alopecia: a network meta-analysis and benefit-risk assessment of finasteride and dutasteride. J Dermatol Treat 2014;25:156–61.
4. Perez-Mora N, Velasco C, Bermüdez F. Oral Finasteride Presents With Sexual-Unrelated Withdrawal in Long-Term Treated Androgenic Alopecia in Men. Skinmed 2015;13:179–83.

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Scarring alopecias Pt. 1: Frontal fibrosing alopecia

Frontal fibrosing alopecia (FFA) is a rare condition that mostly affects post-menopausal women. The average age of onset is about 56 years, with cases occurring as young as 21 years.(1) FFA was first described in 1994 as a type of scarring alopecia, which destroys hair follicles and subsequently replaces them with scar tissue.(2) FFA is considered a type of lichen planopilaris (an inflammatory condition that causes patchy hair loss on the scalp) but others consider it as a new disease.(3) FFA presents as a receding hairline at the front and sides of the scalp that may progress above and beyond the ears.(4) The hair loss can be sudden and proceed rapidly or can occur slowly and subtly.(4) FFA has also been reported to stabilize spontaneously over time.(5) One of the most typical and earliest signs of FFA is a loss of eyebrow hair;(3) however, it may also be associated with a loss of body hair.(4)

The cause of FFA is currently unknown. There may be complex factors influencing whether or not someone develops FFA, such as genetics, immune response, and hormones. There are some studies showing familial cases of FFA.(3) Other studies have found that FFA is associated with autoimmune conditions such as lupus erythematous, vitiligo, and rheumatoid arthritis.(4) Another possibility is that FFA is caused by a decrease in estrogen levels after menopause or after a hysterectomy.(1)

There is very little research examining possible treatments for FFA and the research that exists has many limitations. Based on a review of all treatments reportedly used for FFA, Harries and Messenger concluded that intralesional triamcinolone acetonide 20mg/mL (a corticosteroid) given every three months to the frontal hairline may be the most effective treatment available to date.(6) However, no randomized controlled trials have been conducted yet. Other treatment regimens that have been given to patients with FFA include: finasteride, dutasteride, minoxidil, corticosteroids (topical, systemic), hydroxychloroquine, tetracycline, topical retinoid, ketoconazole shampoo, and biotin.(5) Few papers have reported attempts at hair transplantation for FFA, with results suggesting that the transplanted hairs may do well initially but may disappear 2-4 years after the transplant.(7)  Treatment for FFA and scarring alopecias focus on stopping hair loss progression and alleviating disease symptoms. Treatments cannot regenerate hair from scarred areas.(7)

Article by: M.A. MacLeod, MSc., Mediprobe Research Inc.

References

1. Vañó-Galván S, Molina-Ruiz AM, Serrano-Falcón C, Arias-Santiago S, Rodrigues-Barata AR, Garnacho-Saucedo G, et al. Frontal fibrosing alopecia: A multicenter review of 355 patients. J Am Acad Dermatol. 2014 Apr;70(4):670–8.
2. Kossard S. Postmenopausal frontal fibrosing alopecia. Scarring alopecia in a pattern distribution. Arch Dermatol. 1994 Jun;130(6):770–4.
3. Navarro-Belmonte MR, Navarro-López V, Ramírez-Boscà A, Martínez-Andrés MA, Molina-Gil C, González-Nebreda M, et al. Case series of familial frontal fibrosing alopecia and a review of the literature. J Cosmet Dermatol. 2015 Mar;14(1):64–9.
4. Banka N, Mubki T, Bunagan MJK, McElwee K, Shapiro J. Frontal fibrosing alopecia: a retrospective clinical review of 62 patients with treatment outcome and long-term follow-up. Int J Dermatol. 2014 Nov;53(11):1324–30.
5. Rácz E, Gho C, Moorman PW, Noordhoek Hegt V, Neumann H a. M. Treatment of frontal fibrosing alopecia and lichen planopilaris: a systematic review. J Eur Acad Dermatol Venereol JEADV. 2013 Dec;27(12):1461–70.
6. Harries MJ, Messenger A. Treatment of frontal fibrosing alopecia and lichen planopilaris. J Eur Acad Dermatol Venereol JEADV. 2014 Oct;28(10):1404–5.
7. Jiménez F, Poblet E. Is hair transplantation indicated in frontal fibrosing alopecia? The results of test grafting in three patients. Dermatol Surg Off Publ Am Soc Dermatol Surg Al. 2013 Jul;39(7):1115–8.

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Pumpkin seed oil for treatment of androgenetic alopecia

Androgenetic alopecia (AGA) is a common form of hair loss in men, with an increased risk of hair loss for men over the age of 40 (1). With AGA, hair becomes thinner over time as hair follicles miniaturize and spend less time in the active growth phase (anagen), and more time in the resting phase (telogen) (2). Dihdrotestoderone (DHT) plays a large role in the miniaturization of hair follicles, leading to thinning and further loss of hair (3).

Currently, two United States Food and Drug Administration (US FDA) approved drugs exist for the treatment of AGA; finasteride (Propecia®) and minoxidil (Rogaine®). Finasteride works through inhibition of DHT (4), whereas minoxidil works by increasing blood flow to hair follicles (5). Both finasteride and minoxidil are effective therapeutic options for the treatment of AGA; however, they are associated with unwanted side effects (6–8). Due to the risk of adverse side effects, some patients are drawn to alternative treatments, such as natural plant oils.

A recent study was performed to test the efficacy of pumpkin seed oil for the treatment of AGA (9). Men ages 20-65 with mild to moderate AGA were enrolled to receive 400 mg of pumpkin seed oil (Octa Sabal Plus®) capsules per day. After 24 weeks of treatment, the pumpkin seed oil treatment group had a 40% average increase in hair counts from baseline, whereas the placebo treatment group had an increase of 10%. Results from investigators blinded to the treatment groups suggest pumpkin seed oil is more effective compared to placebo, as 44.1% of the pumpkin seed oil group were rated as improved, whereas only 7.7% of the placebo group improved. Although this data was statistically significant, there were no units of measurement shown (ex. hair count per mm²) so extrapolating to clinical significance is difficult. This was also a very small study, with only 37 patients receiving the pumpkin seed oil capsules and 39 receiving placebo.

Side effects were mild, and included body itching (2 participants) and abdominal discomfort (1 participant).

Always check with your physician before starting a new treatment regimen, and talk to your hair loss specialist to determine which form of treatment would work best for you.

Article by: Dr. C.D. Studholme, Mediprobe Research Inc.

1. Hoffmann R. Male androgenetic alopecia. Clin Exp Dermatol. 2002 Jul;27(5):373–82.
2. Semalty M, Semalty A, Joshi GP, Rawat MSM. Hair growth and rejuvenation: an overview. J Dermatol Treat. 2011 Jun;22(3):123–32.
3. Kaufman KD. Androgens and alopecia. Mol Cell Endocrinol. 2002 Dec 30;198(1-2):89–95.
4. Roberts JL, Fiedler V, Imperato-McGinley J, Whiting D, Olsen E, Shupack J, et al. Clinical dose ranging studies with finasteride, a type 2 5alpha-reductase inhibitor, in men with male pattern hair loss. J Am Acad Dermatol. 1999 Oct;41(4):555–63.
5. Sica DA. Minoxidil: An Underused Vasodilator for Resistant or Severe Hypertension. J Clin Hypertens. 2004 May;6(5):283–7.
6. Kaufman KD, Olsen EA, Whiting D, Savin R, DeVillez R, Bergfeld W, et al. Finasteride in the treatment of men with androgenetic alopecia. Finasteride Male Pattern Hair Loss Study Group. J Am Acad Dermatol. 1998 Oct;39(4 Pt 1):578–89.
7. Ali AK, Heran BS, Etminan M. Persistent Sexual Dysfunction and Suicidal Ideation in Young Men Treated with Low-Dose Finasteride: A Pharmacovigilance Study. Pharmacotherapy. 2015 Jul;35(7):687–95.
8. Springer K, Brown M, Stulberg DL. Common hair loss disorders. Am Fam Physician. 2003 Jul 1;68(1):93–102.
9. Cho YH, Lee SY, Jeong DW, Choi EJ, Kim YJ, Lee JG, et al. Effect of Pumpkin Seed Oil on Hair Growth in Men with Androgenetic Alopecia: A Randomized, Double-Blind, Placebo-Controlled Trial. Evid Based Complement Alternat Med. 2014;2014:1–7.

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Restoring hair in facial and scalp burns

Experiencing a facial and/or scalp burn involves a long journey of healing that can result in physical deformities that affect facial expressions and sense of identity, including self-esteem.(1) In the affected areas, the hair follicles are often destroyed and replaced with scar tissue. Hair restoration, including follicular unit transplantation (FUT) and follicular unit extraction (FUE) can be used to restore hair to burn sites. One of the first hair restoration treatments was actually performed on burn victims in 1939.(2) However, hair restoration can be complicated as some burn victims may have limited hair available in the donor area to transplant, especially if the donor area was also burned.(3) Recently, a method called partial FUE has been discussed to address this issue.(3) Although this method is not in widespread use, it is an interesting concept that we may see more of in the future.

Partial FUE works by removing a partial follicular unit from the donor area so that both the donor site and the extracted partial follicle retain follicular stem cells.(3) Previous research has found that both the distal and proximal part of the hair follicle contains stem cells that can generate hair growth.(4,5) Retaining stem cells allows two hair follicles to be generated from one. This technique would allow the donor area to continue producing hair that could then be used for future treatments. Although this technique sounds promising, it can be challenging as scar tissue behaves differently from normal skin and the procedure is labour-intensive, taking up to a full day.(3) The authors also caution that more experience with partial FUE in burn victims is needed to better understand the limitations and future potential of this technique.(3) Until then, hair restoration using FUT or FUE may be possible.

Hair restoration can be particularly important for people who have experienced burns in order to improve their well-being and quality of life. If you are considering hair restoration to address hair loss from burns, please contact a hair transplant surgeon.

Article by: M.A. MacLeod, MSc., Mediprobe Research Inc.

References

1. Rivlin E, Faragher EB. The psychological effects of sex, age at burn, stage of adolescence, intelligence, position and degree of burn in thermally injured adolescents: Part 2. Dev Neurorehabilitation. 2007 Jun;10(2):173–82.
2. Jimenez F, Shiell RC. The Okuda papers: an extraordinary–but unfortunately unrecognized–piece of work that could have changed the history of hair transplantation. Exp Dermatol. 2015 Mar;24(3):185–6.
3. Gho CG, Neumann HAM. Improved hair restoration method for burns. Burns J Int Soc Burn Inj. 2011 May;37(3):427–33.
4. Kim JC, Choi YC. Regrowth of grafted human scalp hair after removal of the bulb. Dermatol Surg Off Publ Am Soc Dermatol Surg Al. 1995 Apr;21(4):312–3.
5. Reynolds AJ, Lawrence C, Cserhalmi-Friedman PB, Christiano AM, Jahoda CAB. Trans-gender induction of hair follicles. Nature. 1999 Nov 4;402(6757):33–4.

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Extreme Shedding Part 2: Triggers and Catalysts

In my last post I described the relatively common phenomenon of telogen effluvium, where growth cycles of the hair follicles synchronize, resulting in extreme shedding and an abundance of clogged shower drains. The sheer volume of hair loss can be frightening and upsetting, as well as tough on your vacuum cleaner. Fortunately, as difficult as the process is, the hair does grow back.

So what causes telogen effluvium and how do we avoid it completely? As mentioned last time, pregnancy hormones are a known instigator, but there are also many other suspected triggers. Stress, illness, pharmaceuticals, our own hair growth patterns and seasonal changes can all impact shedding.

Stress, illness and pharmaceuticals have all been suspected causes of “immediate anagen release”¹. What happens is a large number of hair follicles which had been actively growing suddenly revert to a resting phase. It takes about 2 or 3 months, but all of that hair falls out at once.

Pharmaceuticals can also cause “immediate telogen release”². Almost the reverse of immediate anagen release, starting a new medication such as minoxidil can encourage new hair growth. Non-growing hairs originating from follicles in a resting phase are released to make way for new hair growth as the follicles switch to an active growing phase.

Chronic telogen effluvium combined with an inability to grow longer hair is normally caused by “short anagen syndrome”³. In this case, for whatever reason, the growth phase of the hair cycle is consistently short. That means the hair follicles are entering the resting and shedding phases relatively more often than usual, therefore shedding is happening more often than usual.

Although it’s most often associated with animals, there are also reports of seasonal shedding in people¹. If you have ever shed your winter or summer hairstyle, it may have been a result of “delayed telogen release”. The hair follicles remain in the resting phase for extended periods of time before returning to the growing phase.

As mentioned above, as frustrating (or scary) as it is at the time of shedding, in the case of telogen effluvium, the hair does grow back. A disruption in the hair cycle occurs but it does not result in permanent hair loss as is the case for pattern hair loss and similar conditions. Additionally, see your hair loss specialist for any further questions.

Article by: Dr. J.L. Carviel PhD, Mediprobe Research Inc.

References

1. Headington JT. Telogen Effluvium: New Concepts and Review. Arch Dermatol 1993;129:356.
2. Grover C, Khurana A. Telogen effluvium. Indian J Dermatol Venereol Leprol 2013;79:591–603.
3. Gilmore S, Sinclair R. Chronic telogen effluvium is due to a reduction in the variance of anagen duration. Australas J Dermatol 2010;51:163–7.

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Topical rosemary oil for treatment of androgenetic alopecia

There are currently only two drugs with United States Food and Drug Administration (US FDA) approval for the treatment of androgenetic alopecia; topical minoxidil (Rogaine®), and oral finasteride (Propecia®). Although these drugs have proven to be effective at reversing hair loss, they are associated with a variety of side effects (mentioned in previous blogs on finasteride and minoxidil) (1–3). Because of the risk of side effects with current medications, investigation of other therapies for androgenetic alopecia have been a popular area of interest.

A recent clinical trial was conducted comparing the efficacy of rosemary oil versus minoxidil 2% in the treatment of androgenetic alopecia (4). Participants were males aged 18-49 years, with androgenetic alopecia. Participants applied one milliliter of solution (minoxidil 2% or rosemary oil lotion containing 3.7 mg 1,8-cineole per mL) to the frontoparietal and crown areas of the scalp twice daily for six months.

Results were measured at 3 months and 6 months after the onset of treatment. Results indicate a significant increase in hair count after 6 months in both the rosemary oil and minoxidil 2% treatment groups. Although the numerical increases in hair count were statistically significant, this may not relate back to clinical significance. Baseline hair counts for rosemary and minoxidil 2% were 122.8 and 138.4, respectively (size of area not indicated). After 6 months there was an increase of 6.8 hairs for the rosemary group, and 2.3 for the minoxidil 2% group. Keep in mind that even though there was only a small increase in hair count number, it was not a decrease. This study suggests that both rosemary oil and minoxidil 2% solution are effective at inhibiting/slowing hair loss.

Side effects were mild and included dry hair, greasy hair, dandruff, and scalp itching.

Always make sure to consult your hair loss specialist before trying a new treatment option, and make sure to discuss potential treatment outcomes and side effects.

Article by: Dr. C.D. Studholme PhD,  Mediprobe Research Inc.

1. Kaufman KD, Olsen EA, Whiting D, Savin R, DeVillez R, Bergfeld W, et al. Finasteride in the treatment of men with androgenetic alopecia. Finasteride Male Pattern Hair Loss Study Group. J Am Acad Dermatol. 1998 Oct;39(4 Pt 1):578–89.
2. Ali AK, Heran BS, Etminan M. Persistent Sexual Dysfunction and Suicidal Ideation in Young Men Treated with Low-Dose Finasteride: A Pharmacovigilance Study. Pharmacotherapy. 2015 Jul;35(7):687–95.
3. Springer K, Brown M, Stulberg DL. Common hair loss disorders. Am Fam Physician. 2003 Jul 1;68(1):93–102.
4. Panahi Y, Taghizadeh M, Marzony ET, Sahebkar A. Rosemary oil vs minoxidil 2% for the treatment of androgenetic alopecia: a randomized comparative trial. Skinmed. 2015 Feb;13(1):15–21.

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Trichotillomania (hair pulling disorder)

Trichotillomania (TTM) is a behavioural (impulse control) disorder that involves repetitive hair pulling, resulting in hair loss.(1) TTM most often begins in the preadolescent-adolescent years with the mean age of onset being 9-13 years.(2) In this age group, it is more common among females (70-93%).(2) However, TTM can also occur in preschool age children where it may appear similar to other habits such as nail biting or thumb sucking. These young children are often unaware that they are pulling out their hair, which can be triggered by stressful situations such as a new sibling, lack of affection, or infections.(2) In preschool age children, TTM can usually be seen equally in males and females with most children growing out of it.(2) When TTM onset occurs in adulthood, it may be secondary to an underlying psychiatric condition and is generally a more chronic condition.(3) Interestingly, alopecia areata can also lead to TTM as a result of itchiness and pain that causes scratching of the scalp and hair pulling.(2) People with TTM may also pull out hair from their eyebrows, eyelashes, face, arms, legs, and pubic area (3) and demonstrate other habits such as nail biting, skin picking, and lip biting.(2)

Subconscious pulling vs. conscious pulling

About 75% of adults with TTM had times when they did not realize they were pulling out their hair.(2) Subconscious hair pulling may occur (especially in children) when reading, studying, or watching television. Conscious hair pulling usually occurs with a specific ritual (e.g. pulling out white hairs or hairs with different textures).(2) People with conscious TTM may pull the hair until it “feels right” or in response to a sensation in the area (e.g. feels like there is tension that is relieved once the hair is pulled).(2) There may also be rituals with the hair after it is pulled such as chewing, licking, rubbing along the lips, biting the hair bulb, and eating the hair.(2)

Clinical signs

Diagnosis of TTM is generally done using trichoscopy, a handheld microscope to examine the scalp.(3) Some signs of TTM include unusual patterns of patchy hair loss with broken hairs of different lengths and reduced hair density.(1,3) A typical pattern called the Friar Tuck sign often occurs when hair pulling involves the crown of the head with the periphery of the hair left unaffected. Diagnosis can also be made using a microscope if there are findings of increased catagen and telogen hairs without inflammation. The chronic hair pulling induces catagen phase and as the hair growth cycle continues, there are more telogen hairs.(2)

Treatment

Most people with TTM have tried to stop at one point or another. Treatment may require addressing an underlying psychological issue, which may also include the use of pharmacological interventions such as anti-depressants.(2) However, the most successful form of treatment is cognitive behavioural therapy (CBT), or behaviour modification, including habit reversal therapy.(2) This includes awareness training to become alert to the triggers and then modifying the behaviour.

For more information and access to support groups, please visit the Trichotillomania Learning Center website.

Article by: M.A. MacLeod, MSc., Mediprobe Research Inc.

References

1. Yorulmaz A, Artuz F, Erden O. A case of trichotillomania with recently defined trichoscopic findings. Int J Trichology. 2014 Apr;6(2):77–9.
2. Sah DE, Koo J, Price VH. Trichotillomania. Dermatol Ther. 2008 Feb;21(1):13–21.
3. Rakowska A, Slowinska M, Olszewska M, Rudnicka L. New trichoscopy findings in trichotillomania: flame hairs, V-sign, hook hairs, hair powder, tulip hairs. Acta Derm Venereol. 2014 May;94(3):303–6.

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Which non-surgical treatment for androgenetic alopecia is the best?

Androgenetic alopecia is also known as male pattern baldness or female pattern hair loss. This is the most common type of hair loss in both men and women. Any hair loss can be a difficult situation to handle and navigating the treatment landscape can be confusing. An internet search for “treatment for hair loss” returns over 50 million entries! This post is a brief introduction to the approved and safe non-surgical methods for treating hair loss in men and women.

Rogaine® (generic name: minoxidil) is the only FDA- and Health Canada approved medication for female hair loss, while finasteride (Propecia®) and minoxidil are approved for use in men. Low level laser therapy is cleared by the FDA and Health Canada as hair loss treatment for both men and women.

Minoxidil is a topical medication that comes as a solution or foam. The 2% solution is applied twice daily and the 5% foam is applied once daily. While both show similar results, using the foam may be easier, with less disruption to daily grooming routines, and less itching and dandruff as compared to solution.¹ In clinical trials, both formulations, 2% solution and 5% foam, resulted in significantly higher hair counts after 3-6 months.

Finasteride is a well-known treatment for male pattern baldness and has been used for nearly 25 years. It is only approved for men, as it is works by decreasing the levels of androgen hormones (dihydrotestosterone). In clinical trials, patients reported improvement in hair loss and hair appearance. Significant increases in hair counts were seen after 1 and 2 years of treatment with finasteride, while those patients in the control group continued to experience hair loss.^2,3

Low level laser therapy (LLLT) is non-invasive, with devices in the shape of helmets and combs. LLLT is safe and can be used in-office or in the privacy of your home. This treatment option can be attractive to people who do not wish to take medications. Clinical trials have shown that LLLT is effective, with increases in hair counts after 6 months of use similar to that seen with medications.^4–6

Research has shown that the medications discussed above and laser therapy all show benefits to patients with hair loss, with an increase in hair count occurring with at least 3 months of minoxidil use and at least 6 months of finasteride or laser therapy. Individual results may vary, and some patients in clinical studies did not experience very much hair growth. To answer the question posed in the title is going to depend on the extent of your hair loss and what your treatment goals are. In all cases, consultation with a hair loss specialist will be necessary to determine the most appropriate treatment option for you.

Article written by: Dr. K.A. Foley, Mediprobe Research Inc.

References

1. Blume-Peytavi U, Hillmann K, Dietz E, Canfield D, Garcia Bartels N. A randomized, single-blind trial of 5% minoxidil foam once daily versus 2% minoxidil solution twice daily in the treatment of androgenetic alopecia in women. J Am Acad Dermatol 2011;65:1126–34.e2.
2. Kaufman KD, Olsen EA, Whiting D, Savin R, DeVillez R, Bergfeld W, et al. Finasteride in the treatment of men with androgenetic alopecia. Finasteride Male Pattern Hair Loss Study Group. J Am Acad Dermatol 1998;39:578–89.
3. Leyden J, Dunlap F, Miller B, Winters P, Lebwohl M, Hecker D, et al. Finasteride in the treatment of men with frontal male pattern hair loss. J Am Acad Dermatol 1999;40:930–7.
4. Jimenez JJ, Wikramanayake TC, Bergfeld W, Hordinsky M, Hickman JG, Hamblin MR, et al. Efficacy and Safety of a Low-level Laser Device in the Treatment of Male and Female Pattern Hair Loss: A Multicenter, Randomized, Sham Device-controlled, Double-blind Study. Am J Clin Dermatol 2014;15:115–27.
5. Lanzafame RJ, Blanche RR, Bodian AB, Chiacchierini RP, Fernandez-Obregon A, Kazmirek ER. The growth of human scalp hair mediated by visible red light laser and LED sources in males. Lasers Surg Med 2013;45:487–95.
6. Lanzafame RJ, Blanche RR, Chiacchierini RP, Kazmirek ER, Sklar JA. The growth of human scalp hair in females using visible red light laser and LED sources. Lasers Surg Med 2014;46:601–7.

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Extreme Shedding: Could I be going bald?

With the exception of the obvious excitement of the arrival of a new baby, there wasn’t much that I enjoyed about pregnancy. One symptom that I did appreciate was that my hair seemed to be getting thicker and longer. I couldn’t see my toes for months but at least I had a great pony tail. Until very suddenly one day I didn’t. It was after my princess was born and around the time that I began weening. After shampooing one evening all of my beautiful pregnancy hair fell out in clumps. All at once.

Thankfully all it took was a second pregnancy to regain my long hair. Princess number two had a much more difficult time transitioning to solid food which led to a much longer period of nursing the second time around. This time I was prepared for what was to come. Surprisingly though, I did not dramatically lose all my hair in one evening and even a more gradual hair loss was not right away. But when I did start losing enough hair to build a new pet Chihuahua every day, instead of worrying that I was very quickly going bald, I was equipped with a label for what I was experiencing.

Telogen effluvium is a condition whereby some people lose hundreds of hairs in a single day (1). Aside from the extreme shedding, people are normally in good health (1). The condition may become chronic, with periods of remission followed by relapses (1). Common symptoms sometimes include loss of 100 – 400 strands of hair per day with a noticeable reduction in pony tail size (2). Interestingly, despite the obvious hair loss, total hair density remains stable (2). So how is this possible?

Hair grows in cycles. At some points in time, hair is actively growing. At other times the hair follicle enters a resting period. Eventually the hair falls out which allows the follicle to return to its active growing phase. Unlike certain animals that shed seasonally, the hair cycle in people is asynchronized. What that means is that at any given point in time, you will find different hair follicles at a different stage in the hair cycle. Thus we are always losing some amount of hair but always actively growing hair as well. During telogen effluvium, the individual hair follicles become much more synchronized, resulting in a large loss of hair at the same time. Fortunately though, those hair follicles also return to the growing phase which is how the steady hair density is maintained.

There are several different ways in which the hair follicles can become synchronized and there are even more catalysts suspected to trigger these events. Some of these will be addressed in subsequent blogs. For pregnancy however, “delayed anagen release” has been reported. Anagen is the medical term for the growth phase of the hair cycle. Pregnancy hormones encourage the hair follicles to remain in the growing phase, leading to simultaneous heavy shedding 3-4 months postpartum when those hormones subside (3,4). A similar effect is sometimes observed after discontinuation of contraceptive pills (3,5).

Putting a label on what I was experiencing helped confirm that I wasn’t imagining anything, as well as reduced my worry that all the tumble weeds rolling around my bathroom and clogging my vacuum cleaner would lead to baldness. If you are concerned, your hair loss expert can help to differentiate telogen effluvium from other common hair loss conditions such as female pattern baldness and alopecia areata.

References

1. Grover C, Khurana A. Telogen effluvium. Indian J Dermatol Venereol Leprol. 2013 Oct;79(5):591–603.
2. Sinclair R. Chronic telogen effluvium: a study of 5 patients over 7 years. J Am Acad Dermatol. 2005 Feb;52(2 Suppl 1):12–6.
3. Dawber RP, Connor BL. Pregnancy, hair loss, and the pill. Br Med J. 1971 Oct 23;4(5781):234.
4. Strumia R. Dermatologic signs in patients with eating disorders. Am J Clin Dermatol. 2005;6(3):165–73.
5. Griffiths WA. Diffuse hair loss and oral contraceptives. Br J Dermatol. 1973 Jan;88(1):31–6.

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History of hair transplantation

There are reports that the first hair transplant was performed in Germany in 1822 by a medical student named Diffenbach and their professor, Dr. Dom Unger.(1) They reportedly transplanted hair in both animals and humans from one area of the scalp to another; however, their technique did not seem to catch on. Hair transplantation is now recognized to have first developed in Japan in the 1930s through the work of Dr. Okuda.(2) Dr. Okuda used a punch technique to remove sections of hair that were then transplanted into smaller punches, where they were found to continue producing hair. Their technique was mainly performed in patients who had hair loss due to scarring from trauma. In 1943, Dr. Okuda’s technique was refined by Dr. Tamura who used smaller grafts of 1-3 hairs.(1) Because of Japan’s role in World War II, Dr. Okuda and Dr. Tamura’s progress in the field of hair restoration remained unknown outside of Japan for many years.

About 20 years later, hair transplantation was rediscovered in the United States by Dr. Orentreich.(3) The technique described in the influential 1959 paper was very similar to the technique described earlier by Dr. Okuda. However, Dr. Orentreich performed the technique mainly on patients with androgenetic alopecia. Both of these techniques used large grafts (around 4 mm) that created an unnatural look. This paper was also particularly influential because it was the first to describe the concept of donor dominance and recipient dominance. Dr. Orentreich described donor dominance as occurring when the transplanted hair maintained its characteristics regardless of the recipient site whereas recipient dominance occurred when the transplanted hair took on the characteristics of the recipient site.(3)

Over time, hair transplantation techniques were improved to create a more natural look. In 1984, mini-grafting was introduced, which used smaller grafts taken from a strip on the back of the scalp. Mini-micro grafting was also used, which involved placing smaller grafts around a larger graft in the centre to create a more natural look. This technique replaced the plug technique described earlier until the 1990s when follicular unit transplantation (FUT) was introduced. FUT uses a large number of mini-micrografts in naturally occurring groups, also known as strip harvesting. This was the main hair transplantation technique used until the 2000s, when follicular unit extraction (FUE) was introduced. These advances in technique have dramatically improved the appearance of hair transplants, creating a natural look in patients seeking to address their hair loss.

Article by: M.A. MacLeod, MSc., Mediprobe Research Inc.

References

1. International Society of Hair Restoration Surgery. History of hair restoration [Internet]. [cited 2015 Dec 1]. Available from: http://www.ishrs.org/mediacenter/media-history.htm
2. Jimenez F, Shiell RC. The Okuda papers: an extraordinary–but unfortunately unrecognized–piece of work that could have changed the history of hair transplantation. Exp Dermatol. 2015 Mar;24(3):185–6.
3. Orentreich N. Autografts in Alopecias and Other Selected Dermatological Conditions. Ann N Y Acad Sci. 1959;83(3):463–79.

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