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Hair Loss: How to Prevent It and How to Get It Back
- 1. Hair Loss: How can I prevent it and how can I get it back? Angela Sturm, MD, FACS www.drangelasturm.com Greater Houston Women’s Chamber of Commerce Kelsey-Seybold
- 3. Hair cycle Elaine Fuchs Scratching the surface of skin development Nature 445, 834-842(22 February 2007) Growth (Anagen) • 90% of follicles • 3-10 years • Longer in women Transition (Catagen) • <1% • <2 weeks Rest (Telogen) • 3-4 months • No growth • Hair shaft sheds • 50-100 hairs/day
- 4. Male Pattern Baldness (Androgenic Alopecia) • Most common in both genders • Corresponds with decade 50% of males at age 50 50% of women • Male pattern, female pattern, diffuse • Incidence varies with ethnicity Caucasian > African American > Japanese > Chinese Bienova, et al 2005
- 5. Misconceptions in hair loss Misconception • Genetics • Decade of onset • Incidence • Hair care Fact • From multiple genes from both sides • Teens, 20s, 30s or 40s • 50% of women <50yrs, >50% of men over 50 • Use of hair styling, teasing, hair spray, coloring, permanents or washing doesn’t change hair loss Price, 1999 • Mother’s side • 50-70s • 15-20% • Use of teasing, hair spray, hair color, straightening, permanent treatments or frequent washing worsens loss
- 6. Androgenic effects on hair follicles
- 7. Other Common Causes of Hair Loss • Thyroid disease • Hormone changes Postpartum Postmenopause • Medications Chemotherapy, anticoagulants, anticonvulsants, thyroid replacement, beta blockers, tricyclic antidepressants, OCPs • Scarring – eyebrow plucking, trauma • Tension on the hair– traction alopecia • Autoimmune disorders • Malnutrition Zinc/iron deficiency
- 8. How do I prevent it?
- 9. Diet • Vitamins Biotin No proven benefit • Diet Omega 3, protein and zinc Green leafy vegetables
- 10. Natural Therapies - Oils • Olive, Castor, Coconut • Onion Oil • Essential oils - Thyme, rosemary, lavender, cedarwood, Chamaecyparis obtusa Increases growth factors • Electromagnetic pulses Lee et al 2010, Hay et al 1998, Bureau 2003, Sharquie KE, et al 2002
- 11. Medical Therapy • Minoxidil (Rogaine) • Finasteride (Propecia) • Low level laser light therapy • All advantageous compared to placebo • Anti-androgens Spironolactone, Cyproterone acetate, 17 beta estradiaol
- 12. Finasteride (Propecia) • Developed for treatment of enlarged prostate • 5-alpha reductase inhibitor • blocks Testosterone effect • Most effective medical treatment • Esp in crown • Can take up to 1 year • Reversible depression • Can have persistent sexual dysfunction • Not for women of childbearing age birth defects • Some effectiveness in post- menopausal women • off-label and controversial Gupta, 2017
- 13. Minoxidil (Rogaine) • Effective in men and women • Increases blood flow Unknown exactly how • Longer growth phase • Enlarges miniaturized follicles • Over the counter 2% and 5% both FDA approved • Works best for men and on back of the scalp • Can have increased facial hair, shedding initially or worsening of hair loss when stop
- 14. Light therapy • At home or in office treatments • Red or near infrared LED lights at 650nm Heat Release of growth factors Stimulate into growth phase Makes growth phase longer • Not laser or radiation Very safe • Minimal to no downtime • Can increase hair count up to 50% • Capillus cap Igrow, HairMax Laser Comb
- 15. Platelet rich plasma • In office injections • Your own platelets, cytokines, and growth factors. • Promotes hair follicle growth and increased blood flow • Series of injections 30 days apart 3 sessions • Increased hair count and density
- 16. How do I get it back? Hair Restoration Surgery • Follicular Unit Transplantation “strip method” • Follicular Unit Extraction • Optimal candidate Minimal contrast Curly hair Blond, red, gray, salt-and-pepper Dark skin with dark, curly hair • Most noticeable Dark straight hair with pale skin • Dense hair elsewhere
- 17. Follicular unit transplantation • Highest density of grafts • Separate “strip” into individual follicles • Fine incision on back of scalp
- 18. Follicular Unit Extraction (FUE) • No linear scar • Each follicle harvested individually • Heals as <1mm scar • Harvest <15% of hairs in an area, have to have >50% loss to notice • More comfortable, can wear short hair, can harvest from a larger area • Can use a robot • Can take longer • Can combine FUT and FUE
- 19. Placement of Follicles • Place each follicle in incisions less than 1mm • Pattern and direction, natural angles • Re-creating natural hairline Irregular hairline Micro and macro irregularities Use single hairs at hairline • Loss continues throughout lifetime Family history 7000 donor units • Appropriate shape to face
- 20. Summary • Diet high in antioxidants, omega 3, protein, zinc and leafy greens • Some essential oils may have some benefit • Onion oil • Medical therapy Propecia Rogaine Low level laser light therapy • Hair restoration
- 21. Thank you! Angela Sturm, MD, FACS www.drangelasturm.com
Editor's Notes
- Hairs are formed in Anagen as the papilla moves up to meet the follicle so that the matrix can form a new hair. The majority of hairs on a given person’s scalp (90%) are in Anagen. It lasts the longest at -10 years and is longer in women. Catagen is the transition phase in which the hair begins to move to the skin pore and the papilla begins to separate. This is the shortest phase and only lasts 1-2 weeks. Therefore, less than 1% of hairs are in this phase. The last phase is Telogen, the resting phase, in which the papilla completely separates from the follicle and the shaft sheds. It lasts 2-4 months and 5-13% of hairs are in this phase. The cycle then starts over with anagen. It is important to understand the cycle, because the length of anagen, speed which the hairs cycle and point in the cycle that treatments are administered all effect the hair counts.
- Androgenic alopecia is the most common cause of alopecia in both genders. It can present as male pattern, female pattern or diffuse androgenic alopecia. The occurrence increases with age corresponding to the decade and varies with ethnicity.
- Circulating androgens target cells in the hair papilla and control growth. In “androgenic” alopecia, the androgen (DHT) binds the androgen receptor the hormone-receptor complex activates the genes responsible for gradual transformation of large, terminal follicles to miniaturized follicles. With successive hair cycles anagen duration shortens. The number of follicles remains the same, but hairs are shorter and finer. he intracellular signaling cascade after androgen receptor binding by DHT is poorly understood, but receptor binding leads to increased production of cytokines, such as transforming growth factor β1 (TGFβ1), which promote telogen and DP cell senescence
- Another etiology to consider is telogen effluvium. Telogen effluvium is a diffuse shedding of approximately 400 hairs/day when the follicles go through a precipitous shift from anagen to telogen. This is a physiologic response to hormonal or systemic condition. This can be from hypo/hyperthyoridism, postpartum, postmenopause, medications, or malnutrition, particularly with a zinc or iron deficiency. Since the hairs are all in telogen, they should return in 3-4 months. So the patient should be reassured during this period. This can be seen after surgery, particularly if there was some type of inflammation or irritation of the scalp. This is differentiated from post-surgical hair loss from poorly placed facelift incisions creating loss of hair tufts or posterior auricular stepoffs. Unlike telogen effluvium, these patients will benefit from micrografting.
- In androgenic alopecia, the ideal patient for medical therapy is one that has definite thinning and many miniaturized hairs. Despite evidence that biotin deficiency causes hair loss, usually due to parenteral nutrition. However, there is no evidence that AGA is due to biotin deficiency or that biotin supplementation reverses AGA in any clinical trials. The substance 2,4-DPO has been marketed to inhibit the progression of AGA. On open study, non-blinded, non-randomized, was performed finding halting of progression. However the study was only for 3 months and was applied more frequently than the instructions indicate. Spironolactone is usually used as a diuretic and antihypertensive. It also causes androgen-receptor blockade and direct inhibition of testosterone by the adrenal gland. It is used to treat hirsutism in women. There is some interest in a topical application for men, but data has not been collected to show effectiveness. Spironolactone is a weak competitive inhibitor of androgen receptor and reduces testosterone synthesis. It has some efficacy in treatment of hirsutism. However it has little efifcacy in treatment of androgenic alopecia. Cyproterone acetate is a steroidal anti-androgen that blocks testosterone and DHT binding to receptors, but has significant side effects. Estrogens have been used, such as 17 beta estradiol that is thought to block 5 alpha reductase activity. Gomez-Vasquez, et al described using estrogens for hirsutism in patients with and without hormonal imbalances (PCOS, etc) They have side effects of gynecomastia, erectile dysfunction or impairment of spermatogenesis. Therefore they are not indicated for treatment in men. Weissmann A, Bowden J, Frank BL, Horwitz SN, Frost P. Antiandrogenic effects of topically applied spironolactone on the hamster flank organ. Arch Dermatol 1985; 121: 57-62. There are two FDA approved products minoxidil (Rogaine) and finasteride (propecia).
- Finasteride is a 5 alpha reductase inhibitor, interrupting the conversion of testosterone into DHT. It was developed for the treatment of BPH. Therefore, it should not be used in women who may be or become pregnant due to the risk of undervirilization of a male fetus. The placebo controlled, randomized multicenter trial of 137 women age41-60 did not find significant differences in the hair count, patient and investigator assessment, global photographs by a blinded expert panel and histologic analysis of scalp. Assessing finasteride-associated sexual dysfunction using the FAERS database. Gupta AK, Carviel J, MacLeod MA, Shear N. J Eur Acad Dermatol Venereol. 2017 Mar 16. 29. Kaufman KD, Olsen EA, Whiting DA, et al. Finasteride in the treatment of men with androgenetic alopecia. J Am Acad Dermatol 1998;39: 578-89. 30. Leyden J, Dunlap F, Miller B, et al. Finasteride in the treatment of men with frontal male pattern hair loss. J Am Acad Dermatol 1999;40:930-7. 31. Physicians circular for Propecia. West Point, Pa.: Merck, December 1997 Finasteride Male Pattern Hair Loss Study Group. Long term (5 year) multinational experience with finasteride 1 mg in the treatment of androgenetic alopecia. Eur J Dermatol 2002; 12: 38-49. 19. Kaufman KD, Olsen EA, Whiting D, Savin R, DeVillez R, Bergfeld W, Price VH, Van-Neste D, Roberts JL, Hordinsky M, Shapiro J, Binkowitz B, Gormley GJ. Finasteride in the treatment of men with androgenetic alopecia. J Am Acad Dermatol 1998; 39: 578-88. 20. Leyden J, Dunlap F, Miller B, Winters P, Lebwohl M, Hecker D, Kraus S, Baldwin H, Shalita A, Draelos Z, Markou M, Thiboutot D, Rapaport M, Kang S, Kelly T, Pariser D, Webster G, Hordinsky M, Rietschel R, Katz I, Terranella L, Best S, Round E, Waldstreicher J. Finasteride in the treatment of men with frontal male pattern hair loss. J Am Acad Dermatol 1999; 40: 930-7. 21. US product circular for PROPECIA® (finasteride 1 mg tablets). In: Physicians' Desk Reference. 55th ed. Montvale, NJ: Medical Economics Company, Inc., 2001: 2009-12. Price VH, Roberts JL, Hordinsky M, Olsen EA, Savin R, Bergfeld W, Fiedler V, Lucky A, Whiting DA, Pappas F, Culbertson J, Kotey P, Meehan A, Waldstreicher W. Lack of efficacy of finasteride in postmenopausal women with androgenetic alopecia. J Am Acad Dermatol 2000; 43: 768-76 Price VH, Roberts JL, Hordinsky M, Olsen EA, Savin R, Bergfeld W, Fiedler V, Lucky A, Whiting DA, Pappas F, Culbertson J, Kotey P, Meehan A, Waldstreicher J. Lack of efficacy of finasteride in postmenopausal women with androgenetic alopecia. J Am Acad Dermatol. 2000 Nov;43(5 Pt 1):768-76.
- The first pharmaceutical to be approved was minoxidil in the early 1990s. Minoxidil is a piperidinopyrinidine derivative that acts as a vasodilator that works by opening K+ channels. It was initially used for hypertension. A side effect of hypertrichosis was noted in 70% of patients. It acts to increase the duration of anagen and enlarge miniaturized follicles converting vellus into terminal hairs, regardless of the cause. However, how it does this is unknown. Given this highly desirable effect, the topical preparation of 2% minoxidil (Rogaine) was derived and sold over the counter. It was found to be effective by a number of multicenter large, double blind trials that compared 2 or3% minoxidil to its vehicle for 12 -24 months. Further studies found that treatment with 5% stimulates up to 45% more growth. However, minoxidil’s effects are limited to the back half of the scalp, where less than 50% of patients have a slowing down or stopping of hair loss and in women, the efficacy is even lower. Hair growth is seen with continuous use in 4-6 mo. Discontinuing minoxidil will result in loss of the gained hair over 3-4 months. So the patient should give it a one year trial. It increases the duration of anagen and enlarges miniaturized suboptimal follicles, irrespective of underlying cause. Koperski JA, Orenberg EK, Wilkinson DI. Topical minoxidil therapy for androgenetic alopecia. A 30-month study. Arch Dermatol 1987; 123: 1483-7. Savin RC. Use of topical minoxidil in the treatment of male pattern baldness. J Am Acad Dermatol 1987; 16: 696-704. Olsen EA, Weiner MS, Delong ER, Pinnell S. Topical minoxidil in early male pattern baldness. J Am Acad Dermatol 1985; 113: 185-92. . DeVillez RL. Topical minoxidil for androgenetic alopecia: optimizing the chance for success by appropriate patient selection. Dermatologica 1987; 175 (suppl. 2): 50-3. Civatte J, Laux B, Simpson NB, Vickers CF. Two percent topical minoxidil solution in male-pattern baldness: preliminary European results. Dermatologica 1987; 175 (suppl. 2): 42-9. 29. Connors TJ, Cooke DE, De Launey WE, Downie M, Knudsen RG, Shumack S, Eggleston AS. Australian trial of topical minoxidil and placebo in early male pattern baldness. Australas J Dermatol 1990; 31: 17-25. 30. Koperski JA, Orenberg EK, Wilkinson DI. Topical minoxidil therapy for androgenetic alopecia. A 30-month study. Arch Dermatol 1987; 123: 1483-7. 31. Rietschel RL, Duncan SH. Safety and efficacy of topical minoxidil in the management of androgenetic alopecia. J Am Acad Dermatol 1987; 16: 677-85. 32. Savin RC. Use of topical minoxidil in the treatment of male pattern baldness. J Am Acad Dermatol 1987; 16: 696-704.
- Dermatol Surg. 2017 Mar 21. doi: 10.1097/DSS.0000000000001114. [Epub ahead of print] Novel Approach to Treating Androgenetic Alopecia in Females With Photobiomodulation (Low-Level Laser Therapy). Friedman S1, Schnoor P. In the late 1960s, Endre Mester, a Hungarian physician, began a series of experiments on the carcinogenic potential of lasers by using a low-power ruby laser (694 nm) on mice. Mice were shaved as a part of the experimental protocol. To Mester's surprise, the laser did not cause cancer but instead improved hair growth around the shaved region on the animal's back [23]. This was the first demonstration of “photobiostimulation” with LLLT, and it opened a new path in the field of medicine [24].
- Uses your own platelets and growth factors and cytokines to stimulate hair growth Promotes hair follicle growth proliferation and increased blood flow and differentiation, angiogenesis, and vascular modeling opical application of activated PRP to harvested follicles prior to implantation has already been shown to increase their survival rate by 15% Moreover, patients treated with calcium gluconate-activated PRP exhibit increased hair density three months post-surgery with terminal hair density (i.e., hair with a diameter >40 μm) increasing by 19% during that time [27]. These findings were confirmed in a study following AGA patients treated with calcium-activated PRP Int. J. Mol. Sci. 2017, 18, 408 3 of 16 over the course of one year [28]. Three months after the final PRP injection, hair density peaked with a 19% increase over baseline measurements; at the one-year mark, hair density fell to 7% above baseline measurements but this value still constituted a significant increase in hair density compared to the baseline values [28]. PRP with hair opical application of activated PRP to harvested follicles prior to implantation has already been shown to increase their survival rate by 15%
- FUE was described by Rassman et al. It is also called the FOX procedure, FUSE (Follicular Unit Separation Extraction) method,Wood’s technique, FU Isolation method. It is a technique that isolates and dissects intact individual follicular units from the donor area with a 0.8-1mm sharp punch. extraction of intact follicular unit is dependent on the principle that the area of attachment of arrector muscle to the follicular unit is the tightest zone. Once this is made loose and separated from the surrounding dermis, the inferior segment can be extracted easily. Because the follicular unit is narrowest at the surface, one needs to use small micropunches of size 0.6–0.8 mm and therefore the resulting scar is too small to be recognised. Proponents claim reduced postoperative pain and recovery, expanded potential donor area, loss noticable scarring. The main anatomical limitation of the technique is that it is not possible to identify the bulge of the hair from outside and hence the procedure is blind. Also, since the hairs with intact unit splay at the lower end and diverge in different directions, the process of extraction can result in a higher transection rate. The procedure is also slow as each unit has to be pulled out slowly. FOX test, the surgeon takes out a few (about 100) grafts from the donor area and then evaluates how many complete/incomplete follicular units are extracted Complications including epithelial cysts due to unharvested punched areas, necrosis of the donor site, J Plast Reconstr Aesthet Surg. 2012 Apr;65(4):e87-9. Epub 2011 Jul 20. Necrosis of the donor site after hair restoration with follicular unit extraction (FUE): a case report. Karaçal N, Uraloğlu M, Dindar T, Livaoğlu M.
- When planning hair replacement, future loss should be taken into consideration. The surgeon should take a careful family history to make an estimation of future loss. Unlike the popular thought, alopeica can be passed from both maternal and paternal sides since it is polygenic. This is particularly important in young patients. Therefore, intervention on patients <20 years should be discouraged since loss is so unpredictable at that point. It must relfect an appropriate level of maturity rather than a perpetual recession-free appearance. This allows optimal use of donor hair and accomodates for future loss. Create irregular hairlines to mimic natural hairlines. Avoid “trendy” hairlines. For example widow’s peaks were likely transplanted in the 1960’s. The most crucial aspect of a natural result is re-creating a natural hairline. The critical anatomic regions are the frontal tuft and frontotemporal regions. The grafts should be placed in an irregular manner to appear natural. Advancing the hairline too far (10cm from the orbial rim in the forelock and 12cm from the lateral orbital rim) yields an unnatural result. The older concepts of creating a wall of hair, through several procedures of plug grafting, led to the creation of unnatural-appearing results initially that, with further hair loss, became even more unnatural. The lifetime progression of hair loss has become an appreciated fact more than ever before, replacing the mistaken concept that hair loss did not progress much further once a man reached his 60s or so. The reality is that hair loss continues for the rest of an individual’s lifetime. In no group of individuals is this concept more important than in young men with early signs of hair loss. The 25-year-old man who presents with a class 2 hair loss pattern, with minimal crown hair loss, is at a high risk for developing into a class 4 or greater pattern within 5 to 7 years, and winding up as a class 6 or 7 pattern by 50 years old. While Propecia1 can arrest with some efficacy this progression, its effects are primarily in the back half of the scalp, and it has little chance of stopping the frontal hair loss and recession of the temporal hairline. As such, any hairline work in a young man must be done with a very conservative hairline (a minimum of 9 cm cephalad to the nasion) with at least somewhat receded frontotemporal recessions, such that it will not only look ‘‘age appropriate’’ but also will be in proportion to the receded temporal hairline and the