Hair Restoration Blog

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

Q:

Hello Dr. Mohebi,I had a hair transplant consultation with you about a week ago regarding my hair loss type and the best method that suits my need. I am still doing some more reading and researching and I came across to the Bio-Matrix Strand by Strand (non-surgical) process.  I really would like to get your input on this particular process and if this is something that you recommend for someone like me who has lost almost 90% of his hair and might not get even 80% of it if I go through the surgical process…

I would really appreciate it if you can also advise whether you perform this method or not and if so how much it will cost approximately if I decide to do the non-surgical….

Thank you so much in advance and looking forward to hear from you…

Close up image of a Biomatrix - The mesh that keeps hair attached to the scalp. Click to see enlarged picture.

A:

Turban Alopeica due to chronic use of turban and knotting hiar - Bottom: hair line design before hair transplant surgery

Turban Alopecia is a type of traction alopecia that is seen in people who wear tight turbans, such as Sikhs.  Turban Alopecia can also occur as a result of knotting and braiding long hair which results in hair being pulled continuously for long periods of time.  This can cause hair loss with the same mechanism as many other types of traction alopecia – chronic pull on hair follicles can destroy them permanently.

Prognosis of Turban Alopecia is similar to other types of traction alopecia.  It might be reversible to some degree only in some patients.  However, if re-growth is not seen after a year of stopping the use of the turban and tight hair braiding, it is unlikely that new growth will occur at all, leaving the affected areas of the scalp with permanent hair loss.

Turban Alopecia is generally seen in the frontal area of the scalp and in some cases in temple areas.  Those are the areas that are directly affected by the traction effect of the turban and hair braiding.  (This could be seen in most members of a Sikh family.)  Unlike the more common androgentic alopecia, which is a genetic predisposition to hair loss, Turban Alopecia is not genetic, but being predisposed to familial male patterned baldness is an accelerator factor and can cause occurrence of male patterned hair loss prematurely.

The risk of traction alopecia in Turban Alopecia type could be reduced by not knotting or braiding the hair and by wearing turbans more loosely. But for those who have experienced permanent hair loss due to Turban Alopecia, there is a natural and proven treatment option available through surgical hair transplantation. (It will be important to control hair braiding and tight turbans following hair transplantation to insure continued hair growth in these areas.)

Also see: Hair loss for cap

Q:

Hi doc I have a question.  I really need to get an answer towards this.

I am a propecia (finasteride 1mg) user for hairloss.  I just read an article regarding how the FDA recently(yesturday) rejected finasteride for use as a prostae cancer prevention due to the fact that finasteride sometimes increases high grade prostate cancers in  individuals who take it.  I am a bit scared since I am a healthy 25 year old who has been taking finasteride 1mg for a while and plan to to take it for hairloss.  Is it possible that finasteride can cause prostate cancer for someone who takes propecia for long term?  please help.  the article really freaked me out. I will post the link to the article below.

http://www.nytimes.com/2010/12/02/health/policy/02drug.html

A:

Finasteride is a DHT Blocker that is used both for prevention of male patterned baldness as well as prevention of prostate cancer.  There are several studies that evaluated the rate of prostate cancer in patients who take Finasteride long term.

The reported data from a recent Food and Drug Administration advisory committee evaluates available data on DHT blockers and whether or not the labels should stat that they decrease the rate of prostate cancer.

They evaluated results from two large studies of the drugs. GlaxoSmithKline’s study involved 8,000 men at risk for prostate cancer because their PSA (prostate specific antigen) tests had found elevations of PSA. The men also had prostate biopsies, but at the start of the study none had received a diagnosis of prostate cancer.

The Finasteride study, sponsored by the National Cancer Institute, was done on 18,800 healthy men over age 55 who were randomly assigned to take either the drug or a placebo.

Both above studies indicated the drugs reduced the overall prostate cancer risk by about 25 percent which is a significant improvement.  However, both studies also found small increases in the incidence of higher-grade, riskier cancers, in men taking the drugs as compared with placebos.

There are two suggested reasons for the increase in these numbers.  One is that the drugs reduced the size of a man’s prostate, making it easier to find lethal cancers on biopsies.  Also, both medications reduce the levels of PSA in blood making early diagnosis of prostate cancer in those patients difficult.

In summary we know that DHT blockers such as Finasteride (Propecia or Proscar) reduce the rate of prostate cancer, there are some reports on some slight increase in the higher stages of prostate cancer in patients who were on those medications.  Finasteride (1miligram) is still recommended for prevention of male pattern baldness.

I generally ask the patients who are over 50 to be tested for PSA before they start taking Finasteride.  I also stress that their family doctor be aware of the medication they are using so any slight increases in PSA are able to be taken more seriously (as opposed to people who are not taking the Finasteride medication).

Q:

hi doc I have another question for you. I was wondering…when a person begins taking Finasteride, they go thru an accelerated shedding period that lasts roughly 3-6 months. After this initial period of shedding, just say that the Finasteride works and stabilizes the loss. Does the person end up growing back the hair that was lost during the accelerated shed? What if it doesn’t grow back? Is this the price that you must pay to halt or slow down loss with Finasteride? Do you have to take your amount of hair a step down in order maintain whatever’s left?

What if you fall into that 20-25% category of users who don’t respond to Finasteride in terms of hair stabilization? You could end up just accelerating your loss for those 6 months for no reason at all. Whether you stay on it or off, after this period, you will continue to lose. This is a big risk for people thinking about taking meds.

A:

Hair shedding is not equivalent to hair loss and shed hair will regrow as normal (especially in long and thick hair that is not miniaturized).

People who take Finasteride may have increased levels of hair shedding possibly due to increased hair cycling within the first few weeks or months of taking Finasteride, but the initial hair shedding should resolve within a month or two from the start date. Final effects of Finasteride should be assessed after at least 6 months from the time the medication was started, but can be seen as late as 12 months from when you start the medication.

For more information on this topic, please feel free to check out an earlier blog post below:

http://ushairrestoration.com/blog/2008/05/hair-shedding-after-starting-finasteride/

Q:

Dr. Mohebi,

I would like to thank you for the time you spent with me during my consultation.

You were thorough, knowledgeable and willing to spend as much time with me as was necessary in order to answer all my numerous questions.

I would also like to thank your office staff for their friendly and courteous treatment.

I have a  question regarding the prescription for Finasteride.  Am I to begin this prescription regimen immediately, just prior to surgery, or after hair transplant surgery?

I am certain you directed me at the time, but with all the info I had to digest, I somehow forgot whatever it was you said regarding the prescription.

Thanks in advance for your time in addressing my question.

A:

I am glad you had a good experience with our office.  I always enjoy having patients who present educated questions.  Below are my responses to your recent questions:

We are prescribing finasteride to you in order to prevent shock loss in the areas at the edge of your balding area following hair transplantation.  I generally recommend starting this medication about a week before surgery so it is locked in your system and shock loss could be prevented.  You should then continue this mediation for the fist 8 months following surgery, which is the time that you are most at risk for losing hair due to shock loss.

It does not matter what time of day you use Finasteride, as long as you are sure to take it once every day.
We look forward to see you soon.

Have a great weekend

Q:

Thank you for your reply to my previous e-mail Dr. Mohebi. I’m getting close to being ready for this, but I still have some concerns that I would like to address prior to booking.

I realize I won’t come out of this looking like Brad Pitt, but can I expect some decent density in the area you’re going to operate on? I’ve seen a lot of pictures of “great” results that were little more than thin whiffs of hair lying limp over shiny, conspicuous scalp. I’d like to be able to style it in the youthful way, showing off my hair line. I suppose that depends on the number of grafts?

A:

The number of transplanted grafts and extent of your balding area are two very important factors in the final thickness of your hair. However, because you have fine hair, even with using the maximum density, you may not achieve the original fullness that you once had. Some patients with the same circumstances as yourself may need more than one surgery to develop maximum density close to that of their original coverage prior to losing hair.

There are several studies that suggest ketoconazole (Nizoral Shampoo) to be beneficial for men with male patterned baldness.  Ketoconazole has been compared with minoxidil in a research in 1998 that (ketoconazole 2% vs.  minoxidil 2%  in men with typical male patterned alopecia.  The study indicated improvement of hair density and growing hair with both medications.  Both 1% and 2% solutions and shampoos reported to benefit patients with male patterned hair loss.  The shampoo however needs to stay on scalp for at least 3 to 5 minutes before it is rinsed, which is not always easy in our today’s life.  Ketoconazole shampoo is used for treatment of seborrheic dermatitis or hair dandruff.

At this time, Nizoral Shampoo is not FDA approved for the treatment of hair loss and thus is not endorsed for this purpose for public.  We recommend finasteride for most men with active male patterned hair loss which has higher potency for correcting male patterned balding in comparison to minoxidil.  For more information on this topic, please visit our page discussing minoxidil vs. finasteride for hair loss.