2 how to beat hair loss third edition Antonio A. Armani, M.D. University of Toronto Redom Books Inc. 233 Carlton Street Toronto, Ontario Canada M5A 2L2 Telephone: (416) Fax: (416)
3 Copyright 1999 by Antonio Alvi Armani, M.D. All rights reserved. Printed in Canada. No part of this book may be used or reproduced in any manner whatsoever without written permission except in the case of brief quotations embodied in articles and reviews. How to Beat Hair Loss does not offer medical advice to replace the services of a physician or surgeon. The information provided here is collected from various sources and represents an effort to inform you about the options available to treat hair loss. It is intended to assist you to work with a trained medical and other hair care professionals. The author assumes no responsibility for us of information provided here or any other manner. For information address: Redom Books Inc. 233 Carlton Street Toronto, Ontario Canada M5A 2L2 Telephone : (416) Fax : (416) ISBN
4 About the Author Dr. Antonio Alvi Armani has written this book as a source of information for men and women suffering from hair loss. He is a hair transplant surgeon who graduated from the University Of Toronto. Dr. Antonio Alvi Armani is dedicated to research and development of new medical, surgical and alternative therapies for hair loss. His hair transplant practice and research centre is located in the city of Toronto, Canada, where he is the director of Cosmetic Surgery Spa. He graduated from the University of Toronto Medical Program with M.D. Honours, after which he went on to perform his residency at the Toronto Hospital. He is a member of the American Academy of Cosmetic Surgery, the International Society of Hair Restoration Surgery, member of the American Society of Hair Restoration Surgery, Italian Society of Hair Restoration Surgery, the Ontario Medical Association, the College of Physicians and Surgeons on Ontario, and the Canadian Medical Association. Dr. Antonio Alvi Armani has won numerous awards including the: J.W. Billes Admission Scholarship, University of Toronto, W.K. Mc Gillis Trophy, Gold Medallist, Yetive Heard Memorial Trophy and Steven Clarfield Trophy, Italian Society of Hair Restoration Surgery Award, Toronto Sun Readers Choice Award 2002, for Best Cosmetic Surgeon, XTRA Magazine Readers Choice Award 2002 for Best Cosmetic Surgeon. He has written articles and books on various aspects of hair loss, dieting, weight loss and fitness, and is conducting clinical research in the fields of hair transplantation and cloning of hair.
5 To my patients Who have allowed me to assist them
6 Acknowledgments I owe gratitude to many people who along the way of my career have helped in supporting and guiding my work. I cannot possibly list all those who deserve credit but I must mention the names of a few that have been most instrumental in producing this book. I owe special gratitude to my main mentor in the field of hair loss Dr. Dow B. Stough Jr. Dr. Stough trained me in hair transplantation surgery and was the major influence in my development as a hair loss surgeon. Dr. Stough has produced a masterful reference book that have been a constant source of reliance to me. I thank him for this. I must also thank the following individuals who have provided technical assistance in the production of this book: Dr. Shaheen Azmi who edited it and helped to develop its design; Fernando Andrejin who photographed the pictures and was a constant source of technical assistance; and Alex Vasolla who drew its illustrations. Last but not least I must thank my parents and family members who have nurtured me and who have always been there to support me in my every venture.
8 Table of Contents In t r o d u c t io n... 1 Se c t io n 1: Kn o w in g y o u r t y p e o f h a ir l o s s... 5 Ch a p t e r 1: Genetic h a ir l o s s... 6 Ch a p t e r 2: Ot h e r t y p e s o f a b n o r m a l h a ir l o s s a. d ie t related h a ir l o s s...25 b. d r u g related h a ir l o s s...26 c. disease related h a ir l o s s...27 s k i n diseases o f t h e s c a l p telogenic a n d a n a g e n i c a l o p e c i a s s u d d e n u n e x p l a i n e d h a i r l o s s (a l o p e c i a a r e a t a) t h y r o i d diseases p s y c h o l o g i c a l diseases c a n c e r related h a i r l o s s s a h a s y n d r o m e d. h a ir l o s s d u e to e x t e r n a l injuries to t h e s c a l p e. h a ir l o s s caused by p o o r h a ir c a r e...34 Section 2: Treatment for genetic hair loss Ch a p t e r 1: Me d ic a l t r e a t m e n t...41 a. r o g a in e...41 b. propecia...44 c. c o m p a r in g r o g a in e a n d propecia...47 d. o t h e r emerging d r u g s...52 Ch a p t e r 2: Su r g ic a l t r e a t m e n t...55 a. b a s ic q u e s t io n s a b o u t s u r g ic a l treatments...55 b. follicular u n it strip surgery (f u s s)...65 c. follicular u n it extraction (f u e)...75 d. c o m p a r in g f u s s a n d f u e m e t h o d s...83 e. g o a l s o f h a ir t r a n s p l a n t surgery...89 i
9 ii table of contents f. r i s k s associated w it h h a ir t r a n s p l a n t s g. r e p a ir cases h. c a s e studies i. t h e f u t u r e o f s u r g ic a l t r e a t m e n t Ch a p t e r 3: Al t e r n a t iv e treatments Ch a p t e r 4: Ha ir replacement t r e a t m e n t Se c t io n 3: Ab o u t y o u r h a ir...x x Ch a p t e r 1: An a t o m y o f t h e h a ir a n d h a ir follicle... x x Ch a p t e r 2: Ru l e s f o r g o o d h a ir c a r e... x x A f in a l r e c o m m e n d a t io n...xx Appendix A: Sa m p l e c o n s e n t f o r m...xx Appendix B: Sample pre-operative instructions...xx Appendix C: Sample post -operative instructions...xx Glossary...XX In d e x...xx
10 KNOWING YOUR TYPE OF HAIR LOSS 5 1 k n o w i n g y o u r t y p e o f h a i r l o s s 1. genetic h a i r l o s s other types of abnormal hair loss a. d i e t related h a i r l o s s b. d r u g related h a i r l o s s c. disease related h a i r l o s s s k i n diseases o f t h e s c a l p telogenic a n d a n a g e n i c a l o p e c i a s s u d d e n u n e x p l a i n e d h a i r l o s s (a l o p e c i a a r e a t a) t h y r o i d diseases p s y c h o l o g i c a l diseases c a n c e r related h a i r l o s s s a h a s y n d r o m e d. h a i r l o s s d u e to e x t e r n a l injuries to t h e s c a l p e. h a i r l o s s caused by p o o r h a i r c a r e... 34
11 6 KNOWING YOUR TYPE OF HAIR LOSS The first thing everybody with hair loss must know is what type of hair loss they have. Some people suffer from certain types of hair loss that are temporary, which may result from a variety of causes. While these may be very stressful, many of these ailments can be corrected without resorting to major treatments. On the other hand, most men and women who suffer from hair loss are predisposed to genetic pattern hair loss. This type of hair loss is hereditary and progressive. Many people who suffer from this turn to medical, surgical and alternative treatments to combat their hair loss. In this chapter, you will learn about the different types of hair loss so that you may classify your own type and begin the task of finding proper treatment. You should, of course, have your problem confirmed by a trained professional. But you know yourself best, and only you can help your professional by providing accurate and relevant information about your hair loss based on the information that you find here. Normal hair loss Normally, each person will have around 100, 000 hairs on his or her scalp at any given time. Some of these hairs routinely take a rest from growing every few years and eventually fall out. These same hairs re-grow from their roots. As a result, the average person can expect to shed 50 to 100 hairs everyday. However, this type of normal hair loss should be spread out over the whole head and should not result in any balding or excessive thinning of hair on any particular part of the scalp. Abnormal hair loss Abnormal hair loss is the falling out of excessive hair that leads to unusual thinning or balding at specific spots on the head, which is probably the type of hair loss you are experiencing. Medical professionals call abnormal hair loss alopecia. Alopecia can be caused by many factors but the
12 KNOWING YOUR TYPE OF HAIR LOSS 7 most common factor is your own genes, meaning that you inherit the tendency to lose your hair. This type of alopecia affects over 95 per cent of all cases of balding or thinning hair for both men and women. This type of genetic hair loss is given many names, including male pattern baldness or female pattern baldness because of the consistent pattern that the hair loss tends to follow in both men and women. Its medical term is androgenic alopecia because it is believed that hereditary hair loss is associated with changes in the amount and activity of male hormones called androgens. I will be referring to this type of hair loss as genetic hair loss because it is the easiest to remember and because it does not suggest that it only applies to one sex or the other. It is important to remember that your hair loss may be the result of a combination of factors. Other factors may speed up or increase your hereditary balding. Keep this in mind because it is a major error that many people make when determining their own type of hair loss and responding to it. That being said, since hereditary balding is the most common type of hair loss, I will be discussing it first, followed by a brief discussion of the other types of abnormal hair loss. CHAPTER 1: Genetic hair loss How common is it? Genetic hair loss affects almost 50 per cent of all males and almost 40 per cent of all females as they age. This means that if people lived long enough, almost half of the population would show significant hair thinning or balding. Some ethnicities are more affected than others are. People with European origins show more hereditary tendency to hair loss than other ethnicities, though other groups are affected to a degree as well.
13 8 KNOWING YOUR TYPE OF HAIR LOSS How does it occur and can it be cured? Like so many ailments that afflict us, medical professionals are not certain as to what directly causes genetic hair loss. It is something that is programmed into your genes, but what causes the genes to act and what they cause your body to do, it not entirely known. As a result, there is no sure, full-proof cure for this kind of hair loss that we know of. Researchers have different theories about the way genetic hair loss works and they are working on various possible solutions based on these clues. The most common explanation for how genetic hair loss works suggests that it works through a complicated chemical process operating in your body. Most researchers associate it with the chemical changes that occur with the male hormone testosterone as you age. Both men and women have this male hormone but the level of testosterone is different for the sexes and changes with aging. There are also other chemicals, which react with testosterone, that change as you age and may influence hair loss. Because most researchers believe that genetic hair loss is caused by chemical reactions in your body, most of the research being done in the field has focused on finding chemicals that can reverse the chemical causes of genetic hair loss, and then forming them into medical drugs suitable for usage. Recent discoveries have found that an enzyme called 5-alpha reductase is excessively produced by the hair follicles of people with genetic hair loss. The enzyme combines with testosterone, one of the male hormones present in both men and women, to form a new chemical called dihydrotestosterone (DHT), which is known to cause hair to fall out. This chain of chemical reactions is one among many possible chemical chains that researchers are currently investigating in relation to genetic hair loss. In the last few years, researchers have been working on many different drugs for combating genetic hair loss, but so far only two have shown success in doing so. This first drug is called minoxidil, and it is currently being marketed by the
14 KNOWING YOUR TYPE OF HAIR LOSS 9 Upjohn Company under the name Rogaine as a topical solution for both men and women. The second drug is called finasteride, and it is currently being marketed by Merck & Co. under the name Propecia in a tablet form for men only. The advantages and drawbacks of both these drugs, along with other drugs that are being tested and that show promise, will be outlined later in the chapter on medical treatments for hair loss. What does it look like? Males with genetic hair loss often become at least partially bald and the hair loss follows particular patterns. The most common pattern of genetic hair loss for men is characterized by a thinning of hair at the hairline and/or the crown area. Over time, the thinning expands, receding from the hairline and in a circular fashion from the crown, until the two areas of baldness meet in the middle. The final result is a completely bald scalp except for a strip of hair along the back of the head above the nape of the neck. Though this is the most common pattern that male pattern baldness follows, there are many other variations as well. Norwood s classification describes this most common pattern but it is somewhat limited in addressing the other possibilities, including the one that applies to women. In the following section, I will outline the new patterns of genetic hair loss that have been identified, giving you a better understanding of the variety of ways in which genetic hair loss occurs. Norwood s classification has been used to classify male pattern hair loss for many decades and has been useful in many cases. However, it is not complete. Norwood s classification only describes one pattern of male genetic hair loss on a scale of seven degrees of severity. Therefore, a reclassification of genetic pattern hair loss is necessary to account for the other possible patterns of male and female genetic hair loss.
15 10 KNOWING YOUR TYPE OF HAIR LOSS Genetic Pattern Hair Loss. Progression of hair loss for men according to Norwood s classification 1 Alternative male patterns 2 2A 3 3A 3v 4 5A 5 6 6A 7
16 KNOWING YOUR TYPE OF HAIR LOSS 11 Another depiction of the progression of genetic pattern hair loss according to Norwood s classification Vertex
17 12 KNOWING YOUR TYPE OF HAIR LOSS Another depiction of genetic patterns of hair loss according to Norwood s classification 3A 4A 5A 6A 7A
18 KNOWING YOUR TYPE OF HAIR LOSS 13 Progression of hair loss for women according to Ludwig s classification
19 14 KNOWING YOUR TYPE OF HAIR LOSS Drug-related hair loss Many prescription drugs can cause varying degrees of hair loss for some people. It is likely that you have seen cancer patients who have lost hair after undergoing chemotherapy. In fact, most cancer-fighting drugs Class 1 no hair loss Class 1 mild hair loss Class 3 mild to moderate hair loss Pattern 1 Pattern 2 Pattern 3 Pattern 4 Pattern 5
20 KNOWING YOUR TYPE OF HAIR LOSS 15 cause hair loss. In addition, close to 300 more commonly employed drugs are known to be associated with hair loss. Drugs commonly associated with hair loss Class 4 mild to moderate hair loss Class5 mild to large hair loss Class 6 large hair loss Class7 complete hair loss
21 16 KNOWING YOUR TYPE OF HAIR LOSS New classification of genetic hair loss: Pattern 1 Examples of pattern 1 genetic hair loss Norwood s traditional pattern where hair loss progresses from the back and the front, and meets in the middle.
22 KNOWING YOUR TYPE OF HAIR LOSS 17 New classification of genetic hair loss: Pattern 2 Examples of pattern 2 genetic hair loss Hair loss progresses only from the front hairline and recedes backwards while maintaining the crown area. Hair loss occurs mainly in the crown area and moves forward.
23 18 KNOWING YOUR TYPE OF HAIR LOSS New classification of genetic hair loss: Pattern 3 Examples of pattern 3 genetic hair loss The frontal hairline remains intact. Ludwig s Pattern of Hair Loss Commonly seen in female
24 KNOWING YOUR TYPE OF HAIR LOSS 19 New classification of genetic hair loss: Pattern 4 pattern hair loss, though it occurs in men as well. Hair loss starts in the center and moves sideways towards the ears. This type of hair loss rarely results in total baldness. Crescent-shaped Hair Loss This pattern is common in men
25 20 KNOWING YOUR TYPE OF HAIR LOSS Examples of pattern 4 genetic hair loss in a female Examples of pattern 4 genetic hair loss in a male
26 KNOWING YOUR TYPE OF HAIR LOSS 21 New classification of genetic hair loss: Pattern 5 Examples of pattern 5 genetic hair loss from the Mediterranean and the Middle East, although it does occur in other ethnic groups as well. Hair loss begins at the two temples and moves in a circular pattern backwards, leaving a small forelock of hair at the frontal hairline.
27 22 KNOWING YOUR TYPE OF HAIR LOSS Tom K.: Male Pattern Baldness Age: 38 Occupation: Construction Worker Medications: None Medical History: No significant illness Family History: Father and two brothers all have significant hair loss It was one year ago that Tom went to see a surgeon concerning his hair loss. He had tried a number of herbal products with no change in hair growth. Based on his family history and on detailed examination of his scalp, it was clear that Tom had male pattern baldness. His surgeon discussed his options with him, including medications like Rogaine and Propecia and hair grafting surgery. Tom and his surgeon decided that hair grafting surgery was his best option to replace his lost hair. In addition, after surgery his surgeon suggested that he employ medications to slow further hair loss and help retain his new full head of hair. The hair grafting surgery went well, and Tom feels rejuvenated with his restored hair.
28 KNOWING YOUR TYPE OF HAIR LOSS 23 Female Androgenic Alopecia (FAGA) As has already been discussed, women can suffer from genetic pattern hair loss just like men do and both forms of genetic hair loss are caused by similar chemical factors. The difference is that it is much less common for women than it is for men, and the hair loss follows a different pattern. Women with female genetic hair loss tend to experience a progressive thinning of the scalp hair only around the crown area. It is also usually more diffuse and central than male genetic hair loss; and it is often referred to as a widened part. Less commonly, women may have a receding hairline similar to that seen in balding men. It is unlikely that female genetic hair loss will result in total baldness, though it does occur. Aside from female genetic hair loss, there are other ways that women may suffer from hair loss that will be discussed in the next chapter. Female pattern baldness frontal view Female pattern baldness top view
29 24 KNOWING YOUR TYPE OF HAIR LOSS Mary L: Female Pattern Baldness Age: 42 Occupation: Marketing Consultant Medications: None Medical History: No significant illness It was two years ago that Mary L. went to see a surgeon regarding hair loss. She was anxious that she was losing too much hair too quickly. She was afraid that all her hair would fall out and felt desperate that something had to be done. On examination, it was clear that Mary was losing hair diffusely in the centre widened part of her scalp. This type of hair loss is a typical form of female pattern baldness. Her surgeon reviewed her medical and family history and performed a physical examination and laboratory testing. After this detailed review, it became clear that Mary was losing hair as a result of her genetic makeup. Weighing all factors it was decided to start her on Rogaine treatment. Shortly thereafter Mary s hair loss slowed down.
30 KNOWING YOUR TYPE OF HAIR LOSS 25 Chapter 2: Other types of abnormal hair loss Hair loss can be triggered by many factors other than genetic predisposition. While these other types of hair loss only make up five per cent of abnormal hair loss cases, they can be more severe in their effects. However, the good news is that these other types outlined below are almost always temporary or are often treatable. I will briefly discuss each of these common types of hair loss as well as the main treatments usually given for them. Diet-related hair loss Protein: There are a number of nutritional deficiencies that can cause hair loss by altering your hair s structure or hair cycles. Among these, protein deficiency is one of the most common. Your hair is composed mostly of proteins, the same materials that your nails are composed of. If your food does not provide you with enough protein then both your nails and your hair may be negatively affected. Protein is found in common foods like meats, poultry, fish, beans and dairy products. If a protein-deficient diet persists then your hair will go into a premature resting stage and will start to fall out within a few months. Unfortunately, many people simply do not eat well, or they become caught up in some fad diet. The kinds of things to watch out for are poor eating habits that lack in protein, vegetarian diets, or fad diets that restrict the amount of protein you consume. Iron: Another possible cause of diet-related hair loss is a low level of iron in your blood, which might result from an inadequate amount of iron in your diet. Foods that are common sources of iron include potatoes, dried beans, liver, beef, fortified cereals, raisins, spinach and broccoli. An inadequate amount of iron in your blood may also result from some difficulty your body has in absorbing iron, which is commonly linked with the condition anemia.
31 26 KNOWING YOUR TYPE OF HAIR LOSS Vitamin A: Another nutrient that can affect your hair is vitamin A, which can be found in whole eggs, milk and liver. Both an inadequate and an excessive amount of vitamin A can cause hair loss. Too little of this vitamin can result in a condition called hyperkeratosis. It occurs in your hair follicles and in the sebaceous glands (the small glands in your skin that secrete oil into your hair) and it can complicate hair growth. Conversely, too much vitamin A can prevent proper keratinisation (the process by which a protein called keratin builds your hair and nails), resulting in a kind of hair loss referred to as toxic alopecia. Other nutritional deficiencies that can affect your hair growth include deficiencies of: essential fatty acids, zinc, copper and vitamin C. Fortunately, the damage done to hair by this type of diet-related hair loss is only temporary and can be corrected by simply improving your diet. Your dietary history is one of the first things a medical doctor who specializes in skin and hair would ask when assessing your hair loss problem. Before considering anything else, you should assess your own diet in relation to any hair loss problems you may be experiencing. Drug-related hair loss Many prescription drugs can cause varying degrees of hair loss for some people. It is likely that you have seen cancer patients who have lost hair after undergoing chemotherapy. In fact, most cancer-fighting drugs cause hair loss. In addition, close to 300 more commonly employed drugs are known to be associated with hair loss. Drugs commonly associated with hair loss : Birth control pills Heart disease and high blood pressure pills, especially beta blockers and ace inhibitors, like captopril Blood thinners, like heparin Drugs for gout and arthritis, like allopurinol
32 KNOWING YOUR TYPE OF HAIR LOSS 27 Antidepressants, like lithium carbonate Diet drugs, like phentermine Cancer-fighting drugs Hormone replacement therapy Drugs used to treat Parkinson s Disease, like Levadopa Performance-enhancing steroids Acne medications derived from vitamin A, like isotretinoin Anti-inflammatories, like naproxen Cholesterol-lowering drugs Anti-convulsants Anti-fungals Drugs used to treat thyroid disorders Ulcer medications, like Pepcid Dermatologists always ask about drug histories, in addition to your dietary history, before diagnosing hair loss problems. Even drugs that are not currently associated with hair loss may cause you to lose hair, so you should take your drug consumption history into consideration no matter what. Fortunately, drug-related hair loss is easily treated by simply discontinuing use of the drug causing the hair loss. There are usually several drug options to treat every condition, so you should be able to find an alternative that does not cause you to lose your hair. Disease-related hair loss There are dozens of diseases and conditions that can result in some type of hair loss. In this section, I will outline the major classes of diseases that cause hair loss, the kind of hair loss that they cause and possible treatments that are available. Since so many common ailments and conditions can cause you to lose hair, your recent and long-term health
33 28 KNOWING YOUR TYPE OF HAIR LOSS history is one of the first things a medical doctor would question when assessing a case of hair loss. You should also question your own medical history to determine if disease is a factor in your own hair loss. Skin diseases of the scalp There are a number of different conditions that can affect the scalp and cause varying degrees and types of hair loss. These include: infections like syphilis and ringworm; infestations like pediculosis, which is caused by lice; inflammatory diseases like folliculitis; genetic diseases like Darier s disease and other syndromes of the skin like psoriasis. The hair loss in each case is usually only partial and can be treated. Ringworm: Ringworm is a contagious disease that is caused by the infection of fungus. It results in small, scaly patches on the skin and, when it occurs on the scalp, is also followed by a loss of hair. It can be treated effectively with a topical solution. Darier s disease: Darier s disease is a genetic disorder characterized by dark, crusty patches on the skin, sometimes containing pus, which results in the hair becoming rough and dry with patches of baldness. Psoriasis: Psoriasis is a chronic skin disease characterized by scaling and inflammation. It is a disorder of the immune system that occurs when cells in the outer layer of the skin reproduce faster than normal and pile up on the skin s surface. The hair loss is reversible with treatment. Telogenic and anagenic alopecias To understand this type of hair loss, you first need to be familiarized with the hair growth cycle. All human hairs go through a natural cycle beginning with growth, called the anagen phase, followed by a period of rest, called the
34 KNOWING YOUR TYPE OF HAIR LOSS 29 telogen phase, and ending with the hair falling out. When only the hairs that belong in a particular phase fall out, we call this either anagenic alopecia or telogenic alopecia. Dozens of factors can cause either of these alopecias, including stress, chronic diseases and nutritional deficiencies. Many of these different factors send anagen hairs prematurely into the resting stage and result in excessive shedding months after. This is called telogenic alopecia. In this section we will discuss some of the more common telogenic and anagenic syndromes. Loose anagen syndrome: This condition generally affects young, Caucasian blonde girls, although anyone is susceptible. The characterizing symptom is the ability of anagen hairs (hairs that are in the anagen, or growth, stage of the hair cycle) to be pulled out easily and painlessly. In children ages 2 to 5 years with loose anagen syndrome, the hair is usually unable to grow past the ears, though the density is otherwise unremarkable and the hair is not particularly fragile otherwise. Treatment is usually unnecessary because although loose anagen hair grows slowly, it does grow and if it is accidentally pulled out, it grows back quickly. Pregnancy and childbirth: The stress of childbirth, similar to that of a severe fever or chronic illness, can prematurely push anagen hairs into the resting stage, resulting in excessive shedding some months later. Hormonal changes that occur during pregnancy also play a part in this telogenic alopecia. The slight hair loss should fix itself within 6 to 12 months. Alopecia areata Hair loss may sometimes affect otherwise healthy people with good eating habits, no notable diseases or injuries to the scalp that can explain such a loss of hair. When this occurs, it is referred to as alopecia areata. This unpredictable but common disease affects 1.7 per cent of the world s population. Although it can affect men and women of all ages, onset most often begins in childhood. In most cases, the hair falls out in round patches all over the
35 30 KNOWING YOUR TYPE OF HAIR LOSS scalp and body. In some extreme and rare cases, the hair loss may lead to a complete loss of hair all over the head and body. Alopecia areata that causes complete hair loss of the scalp is called alopecia totalis and when it causes hair loss over the whole body it is called alopecia universalis. It is believed that alopecia areata is caused by the immune system unexpectedly, and usually temporarily, attacking the hair follicles, causing them to fall out and preventing re-growth in some cases. However, it is not known why this occurs. Cases of alopecia areata usually disappear on their own and never occur again. If this type of hair loss persists, however, medical treatment is a possibility. Various steroids, Propecia, Rogaine, and various immunogens (drugs that interfere with the immune system) have been found to be effective in combating alopecia areata. Although alopecia areata is not life threatening, it is so dramatic in its effects that it often damages the mental and emotional states of its victims. For this reason, many support groups have been established to help people cope with alopecia areata. You can find a local support group in most countries around the world by contacting the National Alopecia Areata Foundation via their website at www. alopeciaareata.com. Thyroid diseases Your thyroid gland resides in your neck and is responsible for producing hormones that are involved in many of your body s functions, your metabolism in particular, making its proper functioning vital to your overall health. Hypothyroidism occurs when your thyroid is underactive, meaning it is producing inadequate amounts of hormones. When this occurs, there is a slight shedding of the hair on the scalp, and possibly of the armpits and pubic area. An under-active thyroid gland may become enlarged due to a bombardment of thyroid-stimulating-hormones (TSH) produced by the pituitary gland, which occurs in order to
36 KNOWING YOUR TYPE OF HAIR LOSS 31 entice the thyroid to produce more hormones. The result is the creation of goiter. The most common cause of hypothyroidism is a previous (or ongoing) inflammation of the thyroid gland that leaves a large percentage of the gland s cells damaged or dead. This kind of inflammation is most likely the result of autoimmune thyroiditis, which is caused by the patient s own immune system. Hypothyroidism may also be caused by certain medical treatments that, indirectly or directly, affect the thyroid gland. The hair loss that results from thyroid disease can be reversed by treating the condition that is affecting the thyroid gland. There are many other symptoms of thyroid disease, including fatigue, weakness, weight gain, dry skin, intolerance to the cold, constipation, memory loss, muscle aches and/or depression. The proper functioning of your thyroid gland is very important and is worth seeing a medical doctor if you think you may be experiencing some or all of these symptoms. Psychiatric and psychological diseases The most common type of psychological condition that can cause hair loss is stress. Excessive stress can cause telogenic alopecia, which is described above. Anorexia nervosa: Anorexia nervosa occurs when someone restricts their diet to such a degree that there are nutritional, endocrinal and psychological impairments. The hypocaloric diet (meaning there is an insufficient amount of calories being ingested) may result in a loss of hair. This may also be accompanied by an increase in lanugo (the fine, light hairs that cover the body) on the face, trunk and arms. Cancer-related hair loss Neoplasic alopecias: This term refers to hair loss that results from cancer spreading from one area of the body to the scalp. The word neoplasic comes from the word neoplasm, which means tumor.
37 32 KNOWING YOUR TYPE OF HAIR LOSS The susceptibility of the scalp to neoplasic alopecia is higher for women with breast cancer and for men with lung cancer in particular, as opposed to other types of cancer. It is believed that mucines, a certain kind of protein created by breast and lung carcinoma, degenerate the cells of the outer root sheath of the hair follicle. However, not all cases of breast or lung cancer will cause hair loss. Ovarian and adrenal tumors are also likely to cause hair loss. Both types of tumors can cause hyperandrogenism, which is the excessive production of androgens (male hormones). Androgens are known to play a key role in male and female pattern baldness. Once the tumor has been removed, however, the hair loss should go away. Cancer-fighting drugs: Most cancer-fighting drugs, like chemotherapy, attack the body, including the hair follicles, and cause considerable hair loss. The hair should grow back after the treatment has stopped. SAHA syndrome SAHA syndrome is a skin condition that only affects women and is caused by hyperandrogenism, which is the excessive production of male hormones (androgens) and which occurs in the whole body (cases of hyperandrogenism affecting only particular parts of the body are considered different conditions). The four main symptoms of this syndrome make up the acronym SAHA : seborrhea, acne, hirsutism and alopecia. These four manifestations appear in this order, although not all women suffer from all of them. All sufferers of SAHA syndrome do experience seborrhea, however. Seborrhea is a skin condition characterized by inflammation, dry or oily scaling, crustiness and/or itching. It is so called because of the excessive production of sebum (the oily secretion of the skin) that causes the condition. The acne associated with the syndrome is considered part of the condition because the increased sebum production that causes acne in this case is caused by androgenic action. Hirsutism, the third symptom, is the excessive growth
38 KNOWING YOUR TYPE OF HAIR LOSS 33 of male-pattern hair in women, also caused by an increase in androgens. The hair loss that accompanies SAHA syndrome is also caused by excessive amounts of androgens and results in typical female pattern baldness. A uniform clearing of the scalp of the crown occurs, though total alopecia is unlikely and the frontal hairline remains intact. Treatment of SAHA syndrome includes several drug options, including the use of antiandrogens and estrogens (female hormones). Hair loss due to external injuries to the scalp Hair loss commonly occurs as a result of something as simple as physical stress being put on the hair, the destruction of the hair follicles themselves or excessive amounts of hair being pulled out of the scalp. In these cases, we say that the hair loss is due to external injuries to the scalp as opposed to a skin disease or disorder. Cicatricial alopecias Hair loss may occur due to the destruction of the hair follicle. In this case, the skin of the scalp is somewhat like scar tissue and is therefore unable to produce hair, meaning that the hair loss is permanent and the only option is surgical treatment. This destruction of the hair follicles can result from mechanical, physical or chemical trauma (which may include the use of acids, chronic traction, electrical or thermal burns, or freezing), as well as tumors, special skin diseases or severe infections such as syphilis. The destroyed hair follicles may not necessarily cover the entire scalp, depending on the method and type of damage. Again, the only option for this kind of hair loss is surgical treatment. Trichotillomania Hair loss among children can occur as a result of
39 34 KNOWING YOUR TYPE OF HAIR LOSS a usually unrecognized behavioral disorder known as trichotillomania. It is characterized by uncontrollable hair pulling, similar to impulsive disorders such as pyromania or kleptomania. The disorder usually appears in males at the age of 8 and in females at the age of 12 and has a prevalence of about one per cent. Sufferers of trichotillomania generally spend about one hour per day pulling their hair out. This can last for a few seconds or minutes, or it may last for prolonged periods of time. Some may try to resist the urge, while some are unaware of its occurrence, pulling hair absent-mindedly while driving, reading or watching television. While the disorder itself is a stressful condition, the hair loss that results is an unfortunate additional complication that affects many children and teenagers psychologically and emotionally. The hair loss that occurs is usually focused on the scalp, but it may also occur among the eyebrows, eyelashes and pubic region. Hair loss is usually patchy, irregularlyshaped and occurs most often on the side of the body that coincides with the person s predominant hand. Most sufferers of trichotillomania are likely to feel embarrassed about the disorder and may try to hide their hair loss, prolonging diagnosis and complicating treatment. Treatment for trichotillomania involves behavioral therapy and/or medication. Possible drugs include mood stabilizers, anxiolytics (drugs that work on the central nervous system to relieve anxiety), neuroleptics (also known as antipsychotics) and topical agents including steroids. However, behavioral therapy has been found to be more effective than drug therapy, especially if the hair pulling has only been occurring for less than 6 months and because there are no clear guidelines for how drugs should be used to treat trichotillomania. With therapy, sufferers of trichotillomania can overcome this disorder and resume their normal lives without worry of uncontrollable urges or hair loss. Hair loss due to poor hair care The effects of poor hair care on hair loss are significant.
40 KNOWING YOUR TYPE OF HAIR LOSS 35 Unfortunately, there are many styling habits and treatments that are bad for the overall health of your hair and that promote hair loss. Hairstyles that require unusual pulling, dying or conditioning may severely stress the natural workings of your hair and may lead to unusual balding. When a high degree of physical stress is constantly being put on the hair for styling purposes, hair loss may occur. This condition is referred to as cosmetic alopecia. It is usually caused by the constant use of curlers, brushes and other tools used to style hair as well as hairstyles that pull the hair. The alopecia appears as a slight shedding of the hair and occurs because the strain that the hair is put under leads to reduced blood flow in the capillaries at the bottom of the hair follicles. The hair s growth is stunted and eventually leads to a slight loss of hair a few months later. This usually affects the triangular areas above and in front of the ears, though it is dependant on the direction in which the hairstyle is aimed. It is also possible to damage the hair follicles and/ or the scalp itself with the constant use of chemicals used to curl or dye the hair. In most cases of cosmetic alopecia, the reduced blood flow that causes the hair loss disappears after the pressure is removed, although the shedding may take a few months to return back to normal.
41 36 KNOWING YOUR TYPE OF HAIR LOSS Anna S. : Losing Hair Due to Iron Deficiency Age: 32 Occupation: Receptionist Anna S. initially saw a surgeon three years ago, complaining of ongoing hair loss over six months. A history and medication review indicated no significant findings. No one in her family had lost significant hair before. On physical examination, it was discovered that her hair was thinning mainly on the crown area of her head. Her blood tests showed an iron deficiency, and she informed her surgeon that she had been experiencing unusually heavy periods over the last year. It was diagnosed that her hair loss could be related to this. Anna started on iron therapy and it was recommended that certain dietary changes be made to support this. Within three months Anna s hair loss had stopped. Within six months Anna s hair was back to normal, and she was much relieved. She has had no recurrence of hair loss ever since.
42 KNOWING YOUR TYPE OF HAIR LOSS 37 Julia B. : Losing hair because of Hypothyroidism Age: 27 Occupation: Homemaker Julia B. went to a clinic complaining of fatigue, increase in weight, and sparse hair on the scalp and on the eyebrows. She was not taking any medications. Julia had no family history of hair loss. Physical examination showed dry skin, diffuse hair loss, and noticeable loss of hair on both eyebrows. Lab testing revealed that Julia s TSH levels were elevated. Julia was suffering from hypothyroidism (the slowing of the thyroid gland). Often such a condition causes the unusual loss of hair not only on the scalp but on other parts of the body. Julia was started on a thyroid replacement medication. In six months not only was her hair restored to normal, but Julia found herself less fatigued and in better overall health.
43 38 KNOWING YOUR TYPE OF HAIR LOSS Peter K. : Losing Hair Because of a Medication Age: 40 Occupation: Accountant Peter came to see me after having suffered ongoing hair loss for over three years. He had no family history of hair loss, but Peter did have high blood pressure for the last five years. He had been on a drug called Propranolal, a type of beta-blocker medication, that is often used to control high blood pressure. A physical examination showed his hair to be thinning diffusely at the center. It was suspected that Peter s hair loss was caused by his blood pressure medication. The Propranolal that he was taking was replaced with another medication, and He was monitored for the effect this would have. Slowly but surely Peter s hair loss was reversed. After one year all his hair was regained.
44 KNOWING YOUR TYPE OF HAIR LOSS 39 Many people with other types of hair loss aggravate their situation by poor hair care habits. For example, there are many genetically balding people who are losing more hair than they should be and at a faster rate because of poor hair care habits. In these cases, people can forestall the appearance of baldness for years by maintaining good hair care. You can learn how to properly take care of your hair and prevent, or forestall, the appearance of balding later in this book in the section regarding rules for good hair care.
45 2 t r e a t m e n t o p t i o n s for hair loss 1. m e d i c a l t r e a t m e n t...41 a. r o g a i n e (minoxidil) b. propecia (f i n a s t e r i d e) c. c o m p a r i n g r o g a i n e a n d propecia d. o t h e r emerging d r u g s s u r g i c a l t r e a t m e n t...55 a. b a s i c q u e s t i o n s a b o u t s u r g i c a l t r e a t m e n t b. follicular u n i t strip surgery (f u s s) c. follicular u n i t extraction (f u e) d. c o m p a r i n g f u s s a n d f u e m e t h o d s e. g o a l s o f h a i r t r a n s p l a n t surgery f. r i s k s associated w i t h h a i r t r a n s p l a n t s g. r e p a i r cases h. c a s e studies i. t h e f u t u r e o f s u r g i c a l t r e a t m e n t a l t e r n a t i v e t r e a t m e n t h a i r replacement t r e a t m e n t
46 40 DRUG TREATMENTS FOR HAIR LOSS Over 90 per cent of all hair loss cases fall under the category of genetic hair loss. For this reason, all the treatment options discussed in this section, with the exception of hair replacement therapy, are meant only for the treatment of genetic hair loss. For all other types of hair loss, you should contact a qualified medical doctor to discuss treatment options. And while this section is meant to guide you in treating your hair loss, you should always contact a medical doctor before beginning any treatment program.
47 DRUG TREATMENTS FOR HAIR LOSS 41 chapter one : medical treatment The treatment of genetic hair loss with medication, taken either orally or applied topically on the scalp, has long been the dream of people suffering from this type of hair loss. But until recently this hope has been nothing but a dream. During the last couple of decades researchers have been developing two drugs that have proven effective in combating genetic hair loss. First the drug minoxidil, which is now marketed as Rogaine, was approved by the Food and Drug Administration and later on the drug finasteride, which is now marketed as Propecia, was also approved for use in fighting genetic hair loss. There are also many other drugs and combinations of drugs that are now being tested and which may be available in the coming few years. It should be noted, however, that there is always the risk of side effects with any medications. Also, it takes decades to completely understand the full effects of any drug and many of these drugs have not been around long enough to determine these full effects. Rogaine (minoxidil) Rogaine was introduced as a new drug for promoting hair growth by the Upjohn Company in It is sold as a topical solution, which means that it is a rubbing solution meant for the balding areas of your scalp. It comes in either a 2 per cent or a 5 per cent solution depending on how much
48 42 DRUG TREATMENTS FOR HAIR LOSS minoxidil the solution contains. Rogaine is available over the counter and should be applied on the balding area(s) twice a day, every day. How does Rogaine work? Although there is only a small percentage of minoxidil in Rogaine, it is this drug that makes it work. Minoxidil is known as a hair growth stimulator. It was originally marketed in a tablet form for the treatment of high blood pressure and unwanted hair growth was one of the common side effects. It is unclear why it is able to do this. How effective is Rogaine? While the Food and Drug Administration recognizes that Rogaine works, it is well known that it doesn t work for everyone. Recent studies show that when the 2 per cent solution is used properly, it can stimulate hair growth 30 per cent of the time, with a slightly higher rate in females. And the new 5 per cent solution has shown only slightly more success than the weaker solution. Rogaine is most effective when used at the first signs of balding and in relatively small areas of hair loss. It is also more effective in the center of the scalp than on the frontal hairline. Rogaine can inhibit further hair loss and can be used to supplement hair transplantation. It should be noted, however, that if you stop using Rogaine you will lose any hair re-grown while you were using it. This means that once you start using Rogaine, you must continue to use it for the rest of your life to enjoy its benefits. Are there any side effects to using Rogaine? Every drug has some side effects. In the case of Rogaine the drug that makes it work, minoxidil, has a dangerous effect on the body (and the heart in particular) if
49 DRUG TREATMENTS FOR HAIR LOSS 43 taken orally. When it is diluted in a solution for topical use, as it is in Rogaine, the side effects are less severe because the amount of minoxidil entering the body is much less. However, even in small doses the use of minoxidil does have some minor and major side effects that should be noted. Minor side effects: These include skin irritations on the scalp such as dry red skin, flaking and itching; nausea and vomiting; and diarrhea. These are short-term, temporary side effects that should go away when your body adjusts to the use of Rogaine. Major side effects: These include back and chest pain; cold-like symptoms; rapid heartbeat; fluid retention; difficulty breathing; weight gain; worsening of hair loss. These are very rare, extreme side effects that are similar to the effects of minoxidil taken orally. Also, Rogaine is not safe for people who: Show allergic reactions to minoxidil; have heart disease; have high or low blood pressure; have skin diseases like dermatitis; are pregnant; or who are nursing mothers. What improvements can we expect in the near future? The most likely advancements in the use of Rogaine will come from two different approaches: Increasing the amount of minoxidil: Like the addition of the 5 per cent solution to the 2 per cent solution, researchers have been trying to improve the effectiveness of Rogaine by increasing the amount of minoxidil in the solution. Increasing the ability of minoxidil to enter the skin: Researchers have also been trying to make Rogaine more effective by increasing the ability of the minoxidil in the solution to enter the skin and cause hair growth. Tests have shown that if
50 44 DRUG TREATMENTS FOR HAIR LOSS minoxidil is mixed with certain other substances it may be able to enter into the skin better and cause more effective hair growth. Final recommendations for Rogaine Only use Rogaine if your health is good, if you are willing to test how it works for more than one year while accepting the possibility of failure, if you are disciplined in taking medications and following detailed instructions, and if you are prepared and able to pay to use Rogaine for the rest of your life. Propecia (finasteride) In late 1997, the Food and Drug Administration approved Propecia for distribution in the United States as a hair-restoring drug. It is sold by the company Merck in 1 mg pill form by prescription only. It is the first pill that effectively treats genetic hair loss. The active agent in Propecia is a drug called finasteride. It was originally used in a prostate medication called Proscar that was found to grow hair. Propecia is a lower-dose form of Proscar developed specifically to fight hair loss. One of the main differences between Rogaine and Propecia is that Propecia should only be used by men. It is dangerous for women of childbearing age and can cause severe birth defects in women that have handled Propecia in any way. Possible dangers aside, Propecia does not work for any women of any age. How does Propecia work? Finasteride is the active agent in Propecia. It works by manipulating the underlying chemical causes of genetic hair loss. We know that men with genetic hair loss have increased levels of a hormone called dihydrotestosterone
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