Hair stem cell and its role in future of hair restoration has been a hot topic in recent years. Hair multiplication also referred to as hair cloning is a process of culturing cells responsible for development of hair follicles. This is necessarily done by generating new hair in refined laboratory conditions.. The concept is that then those hairs manufactured hairs could then be transplanted for hair restoration purposes. It is easy to understand how success in the area of Hair Multiplication would be another quantum leap in hair restoration. People affected by patterned baldness could have the stem cells of hairs from their permanent zone multiplied for hair transplant.

A new article was published in e-Publication Development by Chi W. et al. This article reviews a critical stage of hair development regarding which one of the two hair stem cells is most important for size and shape of new hair.

Dermal Papilla (DP)

Dermal papilla (DP) develops a new hair. The DP is located in the hair bulb. Dermal papilla’s interaction with stem cells from the bulge area leads to generation of a new hair. Laboratory tests on mice indicates that the number of DP cells in the follicle correlates with the size and shape of the hair produced .

The study of mouse model allowed for selective ablation of DP cells in-vivo. The result of the study demonstrates that

• DP cell number dictates the size and shape of the hair.
• DP cells help develop hairs of different sizes or types.
• The number of DP cells plays a critical role in the size of hair shaft that will get developed.
• DP cells play an important role in activation of stem cells leading to the formation of new hair shafts.

These scientists also observed that when the number of DP cells fall below a critical threshold, follicles fail to develop new hairs. Based on this new development, it is easy to understand the mechanism of degeneration of hair in hair loss situations in relation to a drop in the number of DP cells.

Reference:

Chi W, Wu E, Morgan BA. Dermal papilla cell number specifies hair size, shape and cycling and its reduction causes follicular decline. Development. 2013 Mar 13, http://www.ncbi.nlm.nih.gov/pubmed/23487317

Testosterone therapy is used more commonly in recent years in women for treatment of a variety of conditions.  Based on the evidence of current studies, it is reasonable to consider testosterone therapy for a symptomatic androgen-deficient woman with Women’s Sexual Interest and Desire Disorder.

A few days ago, I have seen a patient in my office whom I did not recognize. After, reviewing his file, I remembered that he was a patient that we transplanted about a year before. He could not come to see us at his 6 months follow up after his hair transplantation. Now, after a year from the time we performed his hair transplant, he was completely transformed to the point that it was difficult for me to remember him. I reviewed my notes from the first time I met him in our Los Angeles Hair Restoration Center. I had written in his chart his first question when he saw me: “DOCTOR IS THERE ANY HOPE FOR ME?”

He was a man with advanced male patterned baldness (class VII on the Norwood scale) with not the most generous donor hair. His donor hair was very fine. Fortunately his scalp laxity and density could compensate for his fine hair shafts.  We performed a giga-session hair transplant with over 4,000 grafts in one session for him.

I was extremely pleased to see the transformation in his look and self image. And I was glad to be able to answer his question after one year:

YES, THERE IS HOPE!

Q:

Who makes a good candidate for FUE? Are the cost’s higher than with other techniques you use?

A:

An FUE transplant is best suitable for those who have not experienced a tremendous amount of hair loss and are not expected to advance any further to a higher stage of hair loss. The ideal candidate for an FUE would be someone who falls under the category of a class III on the Norwood scale. A class III patient is one who has not experienced miniaturization on a large area of scalp and has no prior family history of advanced balding. Also, an FUE patient may require several procedures in order to restore their hair, as opposed to just one.

You also asked about the price of a FUE hair transplant.  The cost of FUE transplant is twice as much of the cost of a hair transplant with the strip method per each graft.

Q:

I am to have a hair transplant surgery with you this early July. I’ve noticed increased shedding lately and thus have been researching additional pharmacological adjuncts to add to my daily regimen. I am currently taking 1.25 mg Finasteride and shampooing with Nizoral 2% a few times a week. I’ve read online that topical Spironolactone has been used by some with some results, and wanted to know your thoughts. I’ve also found other topical medications ( especially Monoxidil) that I cannot use due to my daily use of concealer. Are there any other medications, topical, shampoos etc. that you can recommend?

Thanks ,

A:

Minoxidil and finasteride are the only two FDA approved medications for hair loss treatment.  Nizoral (ketoconazole 5%) is an antifungal and anti dandruff medication that can also affect hair loss in male patterned baldness.  Nizoral is not one of the FDA approved medications for hair loss treatment.  Spironolactone or Aldactone is primarily a medication for treatment of hypertension, but it has some anti-androgenic effects.  Systemic administration of spironolactone has been shown effective in some forms of female hair loss. Spironolactone in its systemic form is not recommended in men due to its side effects such as sexual dysfunction.  There have been limited studies on the topical spironolactone for treatment of acne and hair loss so we don’t recommend topical spironolactone for treatment of hair loss for androgenetic alopecia in men.

If you want to do everything possible to minimize the hair loss, you can add minoxidil to your daily regimen of finasteride.  Minoxidil is recommended to be used twice a day, but once a day could be used as well.  You can use it in the morning before you put on the concealer or at night after you wash them off.  Minoxidil does not double up the effect of finasteride but can add to it as an adjunct treatment.

 Also See:

Finansteride, Minoxidil Or Both and  Ketoconazole for Male Patterned Hair Loss

Male Patterned Hair Loss Treatment – Webinar by Dr. Mohebi

The most common type of hair transplantation surgery procedures performed are for men suffering from Male Patterned Baldness (MPB). Dr. Mohebi discusses the effects balding has on men and the solutions available to restore their lost hair.

When attempting to determine a person’s level of hair miniaturization and future patterns of balding, a miniaturization study is critical. This method reveals the rate of hair thinning in comparison with the surrounding normal healthy hair. The hair found on the back and sides of the head in most cases lasts a lifetime since these hairs are not affected by the hormone DHT, which is what is normally responsible for thinning.  The thickness of these hairs is used to determine the proper size for the hairs on a person’s head.

When hair loss is active, it is due to the fact the hair follicles are going through a growth cycle and resting intervals where the hairs progressively get thinner. Eventually the hairs will become so fine they are undetectable to the naked eye. It is when a hair shaft loses its original thickness and continues thinning that miniaturization occurs.

At any particular time, hair can go through a cycling phase. This is when a hair shaft falls and another begins to grow from the same follicle only after a few weeks of the resting period. Since this cycle is not synchronized, only a small percentage of hairs will be put into the resting phase during any particular cycle. It is uncommon for this cycle to surpass 20% of the given hair shafts in any area.

Healthy scalp hair in permanent zone with zero-to-minimal miniaturization

When doing a microscopic evaluation, the percentage of miniaturized hairs are determined by area. This is to say, when looking at a particular area on the head (top, crown, corners, etc.) the amount of thinning can be estimated when seen under the microscope. Anything seen to be above the 20% miniaturization rate is considered abnormal and needs to be further evaluated and treated.

When a microscopic evaluation is performed, the pattern of hair loss will show the surgeon which areas the patient will eventually lose their hair, in order to take preventative measures to avoid future hair loss.

There are many other reasons for acute and extreme hair loss such as emotional trauma, seasons of high stress levels, or pregnancy (for women), which only last for a time and the hair eventually restores itself. These situations can be seen by repeating the study a few months after the events which caused the hair loss, have ended.

Q:

I went to a couple different hair transplant doctors for evaluations when I was 24/25 and was told I have a juvenile hairline and that i have a good donor area and scalp laxity. The doctors recommended around 2000 grafts to fill in the diffused area at the time.

One of the doctors I visited told me to give propecia another try which I did for an additional six more months, but stopped because it seemed to have no effect and from my understanding it doesn’t really help with hair in the frontal area which was my main problem. I also did not want to risk getting any more health side effects from taking propecia.

During this time I was also taking biotin supplements which I had read are good for hair but they didn’t have any noticeable effects. I decided against getting a hair transplant because of my age and I wanted to see if the hair might grow back naturally (some people who have lost hair from accutane reported regrowing their hair several years after taking the medication).

I have a history of MPB in my family but it seems to be hit or miss. My grandfathers both had full heads of hair, my dad and 1 of his brothers are completely bald but another brother has a full head of hair. My mom has 1 brother who is bald and another with very thick hair and a low hairline (which my hair most closely resembled before taking accutane). I also have a brother who is 21 and has extremely thick hair like I used to with no signs of hair loss whatsoever.

A:

Male patterned baldness (MPB) is a progressive condition and it generally won’t get better without treatment.  The medications that are being used for the treatment of hair loss are generally for maintaining your existing hair and have preventative effects rather than restoring your hair at its full thickness like what you had in previous years.

A good hair transplant surgeon can help you realize what the best options for hair restoration are; whether it is a surgery or medication.  Using Accutane could cause hair loss as one side effect, but that is reversible within a few months after stopping it.  That is the most common case for medication related hair losses.

It is important for you to develop a good relationship with a qualified hair transplant surgeon whom you can trust.  Then let him walk you through this process.  Using medications for a while is a good idea and some patients respond well to using them.  Unfortunately the results are not permanent and most hair loss sufferers continue losing hair, but at a slower rate.

You can use medications such as Propecia or Rogaine to minimize the speed of hair loss. When it is the time for a hair transplant you can consider that as another option as well.

Alopecia areata (AA) is a type of local hair loss due to autoimmune reaction of the patient’s body against hair follicles.  Alopecia Areata generally presents as circular coin shape hair loss lesions, but it can progress to involve larger areas of the scalp (Alopecia Capitis) or even the entire body (Alopecia Universalis).

Several treatment options are recommended for inducing hair growth for treatment of alopecia areata. Some patients may recover spontaneously over a period of time; because of this patients should be evaluated and selected carefully.  It is important that the options to forgo treatment are reviewed with the patients, as well as discussing the high failure rate of all the various options available.

Most people who have hair loss on the hair line prefer to treat this condition more aggressively with a variety of medications.  The chance of spontaneous recovery appears to be more in patients who have smaller and fewer hair loss paths.

• Topical Steroids

Topical steroids for treatment of AA has been widely used with little evidence of success.  They are easy to use and more affordable to many patients. However, the current lack of evidentiary success does not make this a valuable recommendation for patients.

• Local Injection of Steroids

Infiltration of long acting corticosteroids into the AA lesions has been studied with some degree of success.  Patients with smaller lesions of alopecia areata may respond better to local steroid injections.

This type of local injections of steroids is most desirable for limited lesions of cosmetically sensitive areas like hair lines and eyebrows.  The most common used medication is Triamcinolone acetonide (5-10 mg/mL).

• Systemic Steroids

Systemic treatment with steroids may stimulate hair regrowth in a limited number of patients.   Continued use of steroids is generally needed in most of these patients to maintain the level of hair growth.  Pros and cons of long term use of steroids should be discussed with these patients before initiating systemic steroid therapy.

• Topical immunotherapy

Topical immunotherapy utilizing allergens has been studied and proven to have some success in patients. The protocol for contact immunotherapy using DPCP has been recommended. Continued use of DPCP is needed to keep the skin irritated for a long time.  The inflammation seems to be able to change the progress of immune reaction that causes hair loss in alopecia areata.

Treatment should be discontinued only after full regrowth is apparent.  This can take an indeterminate length of time, and during this period patients may have to tolerate inflammation of the skin.  A high rate of relapse after discontinuation of treatment makes this option less desirable for most hair specialists.

• Other treatments of alopecia areata

Other medical treatments such as phototherapy, photochemotherapy, minoxidil and dithranol  have shown limited improvements.  Finally patients with extensive stages of hair loss with no response to treatment options may use wigs or hair systems.  That is more desirable for many women with extensive hair loss due to alopecia areata that are having zero to minimal response from any other treatments.

At the 2011 International Society of Hair Restoration Surgery (ISHRS) Scientific Meeting, the updated statistics for the Hair Restoration industry were released. Hair Restoration continues to be a growing branch in the cosmetic surgery field for decades now.  The new data shows that it continues to be emerging exponentially and in 2010 there was an estimated 279,381 surgical hair restoration procedures, an 11% increase over the 2008 census. The United States alone reported 101,252 surgical procedures in 2010 as well.

The ratio between male to female hair transplantation patients in 2010 was 85.9% to 14.1%.  Since 2004, the number of female hair restoration patients has increased 24% which might be due to the better techniques of evaluation of female hair loss and better methods of determining the eligibility of the women with hair loss for hair transplantation.  Since 2008, eyelash, eyebrow, and face hair restorations procedures increased 14.2%. In the US alone, mustache and beard procedures nearly doubled (1,369 to 2,382).

For more information, check out the ISHRS Practice Census located at: www.ishrs.org/mediacenter/media-statistics.htm