Objectives: Page 1. Female Patterned Hair Loss (FPHL) A Surgeon s Approach to Female Hair Loss

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Edmund Osborne
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1 A Surgeon s Approach to Female Hair Loss CARLOS PUIG DO ABHRS TOMA 2016 Objectives: Describe Ludwig Female Pattern Hair Loss (FPHL). Explain why hair restoration surgery is now a viable treatment option for FPHL patients. Contrast and compare the evolutionary epidemiology of male and female patterned hair loss. Describe the risk-benefit ratios Of HRS for the FPHL patient. Outline the key components of the differential diagnosis in suspected FPHL. List the current treatment options for patients with FPHL. Female Patterned Hair Loss (FPHL) Centripetal hair loss that runs in families characterized by progressive miniaturization of the hair Loss of density, never lose all the hair in any region Seldom is the hairline affected lost. Page 1

2 Devastating Emotional Experience Males: Allowed to be bald or balding, Acceptable Appearance Females: Considered defective when bald or balding, Unacceptable Appearance EPIDEMIOLOGY of FPHL FPHL is the most common cause of Hair loss in women. Affecting 25% by age 49 Affecting 50% by age 80 FPHL is the Dx in about 40% of women with Hair Loss FPHL has no age predictor Reported as early as puberty Most often peri-menopausal The peaks of onset : 3 rd - 5 th decade. Seldom Have Endocrine Abnormalities FPHL is a Different Dx from MPB Not Androgenetic Most Often a Peri-MenapausalOnset Ludwig Patterns Retained Hair Line Generalized Thinning Miniaturization Hall Mark Donor Threatened 20% of L II s Become L III s Page 2

3 Females with Male Pattern Loss Women with Norwood Patterns Epidemiology: Pre Menopausal vs. Post Menopausal Male Pattern Loss in Temples & Crown Frontal Hair Loss Norwood 2,3,& 4 Isolated Crown Baldness No Good Studies of the Patient Population May Affect 10% of the Female Population Miniaturization present Look for Testosterone Problem T secreting tumors Responds Well to Hair Restoration Surgery Mix & Match Males with Female Pattern (DUPA?) Females with Male Pattern Both with Both 60% of FHL Patients Have Alternative Etiology for Hair Loss Inflammatory-Scaring Alopecia Diffuse Pattern Alopecia Areata Surgical Trauma Traction Alopecia Vitamin D, Fe ++ PCOS Thyroid Dx Telogen Effluvium Pregnancy Fever Emotional Stress Page 3

4 Increased Suspicion of Alternative Cause No family history of FPHL No or minimal miniaturization Youthful onset, under 35 Atypical loss distribution, not Ludwig Loss of epidermal architecture Pores, topical morphology Hair loss comes and goes Work Up Strategy For FPHL Fm HX (2) Ludwig Pattern Miniaturization Extended H&P, and Blood Work Up HRS Biopsy Medical Therapy (Referral) Dx Medical Therapy (Referral) Dx HRS Blood Work Up Nutritional Endocrine Immune Page 4

5 Scarring Alopecias Trauma Surgical Burn Avulsion Discoid Lupus Erythematosus Lichen Planopilaris Frontal Fibrosing Alopecia CCCA Pseusopelade of Brocq Follicular degeneration syndrome Folliculitis Decalvans Alopecia Mucinosa Dissecting Cellulitis Acne Keloidalis Tinea Capitis/Kerion/Favus Secondary Scaring En coup de sabre Aplasia cutis congenita Amyloidosis FFA (LPP) Biopsy: Quantify Inflammatory Activity How many inflammatory cells are surrounding the hair follicle? Measure of the activity of the disease. Compare this activity in serial biopsies Biopsy & Experienced Scalp dermatopathologist Serial biopsies 1 year a part Reactivation by surgery always possible Inflammatory Scaring Identify Disease Qualify Inflammation Neutrophilic vs. Lymphocytic Quantify Lymphocytic Inflammation LPP, D Whiting Inactive Process Cautious Surgery Very Careful Post OP Active Process Observe 12 months Re-Biopsy, Quantify & Compare Page 5

6 Great Imposters of FPHL Lichen Planopilaris & Diffuse Pattern Alopecia Areata Rare to see FPHL without a family history of the disease. Female Hair Loss Treatment 1) Topical treatment Minoxidil Low Level Light Treatment 2) Systemic treatment 3) Surgical Treatment 6) Camouflage Evidence Based Medical Therapies Topical Minoxidil Hard data male & female Low Level Laser Hard data male & female FU Transplantation Hard data both Page 6

7 Lasercomb FDA Cleared: Both MPHL & FPHL Wound Healing & Hair Growth 63% Retention 33% Re-growth Hairs/cm 2 Safe, no side effects Rogaine (minoxidil) Available OTC 2% & 5% 35% Retention 12 to 15% Re-growth Side effects : 1% local skin irritation Only FDA approved treatment for women Other Topical Therapeutics: 1% to 5% tincture of progesterone 3% spironolactone (and it s metabolite: 2% carenone) 0,03% estradiol valerate in menopausal women; improvement of anagen/telogen ratio and decrease loss (used during 12 and 24 weeks) of hair 0,05% topical finasteride 40% decrease of DHT serum levels, no effect on hair growth No Home Runs Page 7

8 Camouflage Hair Systems Hair Building Fibers Tattoo: Micro-pigmentation FUT Makes Women Candidates Punch grafting of little value in females Removing 7 hairs adding 15 FUT Only Adds Hair Grafts integrated with in existing hair No loss of hair FPHL Surgical Risk-Benefits Considerations 20% L II s become L III s in their late 60 s Graft retention cannot be guaranteed Re-distribution in female hair line Careful not to shave surrounding hair Increase risk of Post-Operative T. Effluvium Maybe as high as 20% Limit procedures to grafts Page 8

9 Before Before Before Page 9

10 Before At 4 months early growth Before Before Page 10

11 Summary Describe Ludwig Female Pattern Hair Loss (FPHL). Explain why hair restoration surgery is now a viable treatment option for FPHL patients. Contrast and compare the evolutionary epidemiology of male and female patterned hair loss. Describe the risk-benefit ratios for the FPHL patient. Outline the key components of the differential diagnosis in suspected FPHL. List the current treatment options for patients with FPHL. Contemporary HRS technologies allow for the treatment of FPHL and provide reliable, aesthetically pleasing results. Thank You Carlos J Puig DO FISHRS cpuig@hairdochouston.com Page 11

STOP HAIR LOSS DR JOYCE LIM DERMATOLOGIST PARAGON MEDICAL CENTRE #11-16/20

STOP HAIR LOSS DR JOYCE LIM DERMATOLOGIST PARAGON MEDICAL CENTRE #11-16/20 HAIR LOSS Types of Hair loss What causes them What are the solutions HAIR LOSS PATCHY HAIR LOSS PATCHY HAIR LOSS Single/ Multiple