Causes of Hairloss

There are many causes of hair loss in men and women, including disease, nutritional deficiency, hormone imbalance, and stress. However, by far the most common cause is what is called adrogenetic alopecia or male pattern baldness (MPB). The underlying reasons for MPB is both a genetic predisposition to balding, and the influence of male hormones. These factors, combined with the passage of time results in MBP.

The genetic pathway is not always a clear and simple deduction when it comes to Androgenetic alopecia. The presence or absence of balding in a parent or grandparent on either the mother or father’s side, is not necessarily predictive of one’s likelihood of balding. Certainly, if a man’s father is completely bald, and this man begins to rapidly lose hair in his early twenties, it’s a safe bet that he will develop extensive balding at some point. In short, it’s very hard to accurately predict who will go bald and how rapidly.

This inherent uncertainly about the progression of balding is of utmost importance in planning surgical hair restoration. We therefore always have to plan for a "worst case scenario" in order to give our patients the best possible results in the long run, as well as the short term.

The enzyme 5-alpha reductase is responsible for converting testosterone to DiHidrotestosterone (DHT). DHT is the form of testosterone that binds with specific receptors in susceptible individuals in the hair follicle and this is the main cause of male pattern baldness (the complete mechanism is not fully understood at this stage). Initially the hair follicle becomes smaller and less vital because of relative oxygen starvation. The devitalized hair follicle results in a shorter anagen (growth phase of hair) and a longer telogen (resting phase of hair) phase of the hair follicle which causes  miniaturization of affected hairs, which manifests as loss of hair shaft diameter, length and colour.  Small and miniaturized hairs create the impression of baldness because less “cover” is provided by these types of hairs. In certain cells of the hair follicle, and in the sebaceous glands, there are high levels of the enzyme called 5-alpha-reductase.  The mechanism described above is the same process which gets inhibited by the use of hair growth stimulating medication, such as Propecia (finasteride). Propecia is one of the mainstays in medical treatment of male pattern baldness. Propecia (finasteride) inhibits, or limits the activity of, this 5-alpha-reductase enzyme. Therefore, there is less conversion of testosterone to DHT, and lower levels of DHT are found in the follicle, resulting in more vital hair follicles and stronger (larger calibre) terminal hairs.

There is no set age at which balding occurs. It is a process, and this is a simple, but often ignored fact. Like any process, it can be rapid or slow, it can begin toward the end of life or in the late teens, and it can progress in a predictably inexorable fashion, or it can stop and start, seemingly stabilize, and then begin again. Once we understand and accept this as a dynamic process, then we can better plan for the present and for the future in terms of how we treat it.

The three most common factors that play a role in baling are: Ageing; Hormones and Genetics.
The familiar horseshoe-shaped wreath of hair around the back and sides, is unaffected by these changes. The telogen hairs are easily dislodged during washing, drying, or combing, and this is the second sign of balding: in addition to the apparent thinning seen with miniaturization, we begin to see larger numbers of hairs on the comb, the towel, the pillowcase, or in the bathroom drain.
Other patterns of hair loss – other than male and female pattern baldness)

 

TYPES AND CAUSES OF HAIR LOSS:

1. MPB  (Male Pattern Baldness) – Norwood / Hamilton – STAGING: Type I; II; IIIa; III vertex with fringe; IVa; IV; Va; V; VI; VII
2. Diffuse Alopecias
   
   • Patterned
   • Unpatterned
3. FPHL (Female Pattern Hair Loss)
   
   • Androgenetic – Hamilton; STAGING: Type II, III, IV, V, VI, VII, VIII
   • Centrifugal – Ludwig; STAGING: Type I, II, III
   • Christmas Tree – Olsen
4. Cicatrical or Scarring Alopecias
   
   • Following tissue destruction and inflammation
5. Other types of hair loss
   
   • Alopecia Areata – patches of complete hair loss on scalp
   • Alopecia Universalis – no hair on body
   • Triangular Alopecia – occurs in triangular pattern over the temporal areas
   • Post pregnancy – Telogen Effluvium
   • Severe emotional stress – Telogen Effluvium
   • Toxic Alopecias
     
     • a) Following severe illness
     • b) Following high fever
     • c) Hypothyroidism
     • d) Hypopituitarism
     • e) Post Chemotherapy

TELOGEN EFFLUVIUM

Telogen effluvium (TE) is a term that refers to a pronounced shedding of normal club hairs, which occurs after actively growing anagen follicles are shifted into the resting or telogen state after a brief passage through the transitional catagen phase.

Although TE is clinically recognized more commonly in women, it is common in men as well. Generally, TE occurs one to three months after the acute onset of any serious disease (especially if it was associated with a high fever) or significant emotional or physical stress, or after commencement of drug therapy. Frequently more than 100 hairs are shed each day, and this period of hair loss can extend over a period of three months or occasionally longer.
A chronic idiopathic form of TE has been described more commonly in middle-aged women. Clinically, there is often a telogen shedding over the entire scalp, resulting in diffuse thinning but also often associated with bitemporal recession.

Generally, Chronic TE is self-limiting. Ultimately, there is retention of a cosmetically acceptable amount of scalp hair, as long as there are no other coincidental causes of hair loss, such as androgenetic alopecia. A patient who manifests this pattern of hair loss in the absence of significant lab findings should be reassured that there is a good prognosis for regrowth.

Common causes of Telogen Effluvium:

1. Early stage of androgenetic alopecia
2. Prolonged and high fever
3. Acute blood loss
4. Childbirth
5. Acute psychiatric illness
6. Drug therapy
7. “Crash” dieting
8. Significant emotional or physical illness
9. Widespread skin disease
10. Discontinuation of the birth control pill
11. General anaesthesia
12. Hypothyroidism
13. Surgical interventions

 

MORE CAUSES OF HAIRLOSS:

Infectious Diseases:

Folliculitis decalvans  and Tufted Follliculitis, are persistent and progressive inflammatory disorders associated with an expanding, irregularly shaped, central scarring alopecia.
Kerion formation – severe inflammation: Hair loss may be focal, caused  by Herpes Simplex; Herpes Zoster; severe Staphylococcal or other bacterial infections that result in local abcesses.

Inflammatory Diseases:
Lichen planopilaris
Discoid lupus erythromatosis
Coup de sabre morphea
Sarcoidosis
Frontal Fibrosing alopecia (Fibrosing alopecia)
Alopecia areata
Pilar (trichilemmal) cyst

Benign tumours:
Sebaceous and Epidermal Nevi
Hemangiomas

Malignant tumours:
Basal cell carcinoma
Metastatic squamous cell carcinoma< br />Actinic keratosis with squamous cell carcinoma

Traumatic Alopecia:
Traction alopecia
Turban induced traction alopecia
Trichotillomania (compulsive hair pulling secondary to anxiety state)

Radiation of the scalp for the treatment of cutaneous neoplasms or brain tumors can result in permanent hair loss.

Idiopathic scarring alopecia:
Inflammatory prurigo nodularis with secondary alopecia
Pseudopelade of Brocq
Central centrifugal scarring alopecia

Uncommon causes of alopecia and special considerations:
Triangular alopecia
Aplasia Cutis Congenita
Ehlers Danlos Syndrome
Psoriasis
Aplasia cutis congenital

Drugs associated with Hair Loss:
Anticoagulants, eg Heparin and Warfarin
Anticonvulsants, eg Carbamasepine and Valproic acid
Antifungals eg Ketoconazole and Terbinafine
Anti-gout agents, eg. Allopurinol and Colchicine
Antineoplastic / immunosuppressant agents, eg, Cyclophosphamide; Cyclosporine; Methotrexate
Antipsychotics and antidepressants, eg. Fluoxetine; Lithium
Beta Blockers, eg, Atenolol, Propranolol
Cholesterol lowering agents eg. Atorvastatin; Clofibrate; Gemfibrozil
Gold-based agents, eg Auranofin; Aurothioglucose
NSAIDS, eg. Indomethacin; Naproxen
Oral Contraceptives
Retinoids, eg, Isotretinoin; Acitretin
Captopril
Cimetidine
Levodopa
Loratidine
Propylthiouracil
Stanozolol (in women)
Vitamin A

Treatment Options

1. FUT vs FUE comparison
   
   • Pictures - FUT (Follicle Unit Transplant) procedure
   • Pictures - Post-op progress, FUT procedure
2. Carboxitherapy
3. Hair loss medications

 

1.FUT vs FUE comparison

Comparison between FUE (follicle unit extraction) and FUT/S (follicle unit strip harvesting):

What is FUT (FUS)? This refers to follical unit transplanting via strip harvesting. In this instance a strip of hair is removed from the safe donor area under local anaesthetic. The size of the strip is determined by the density of hair in the safe donor area, the size of the reci pient area and the planned density in the recipient area. Based on this, a calculation is made and the strip is removed, e.g. 1cm x 15vm strip, which is then cut into smaller slivers from which individual hair follicles are dissected. The individual follicle units are then transplanted into reciptient sites in the recipient area. With this method, large amounts of hair follicles can be transplanted in one session.

What is FUE? This refers to follicle unit extraction. In this instance individual follicle units are harvested, one-by-one under local anaesthetic from the safe donor area and transplanted one by one into the recipient sites in the recipient area. With this method less follicles can be transplanted in one session, but there are other advantages.

Read below for a comparison beween FUT (FUS) and FUE techniques.

 

Advantages of FUE compared to strip harvesting :

• No linear scar, making a short haircut possible
• "Minimal invasive surgery"
• Very short and almost pain-free recovery period 
• No visible scarring, scars shrink to an average of 0.5mm
• FUE can be performed on a tight scalp. 
• Maximum donor yield is higher than with strip harvesting
• FU's can be removed outside the ‘strip donor' zone so the yield can be increased
• FU's can be taken where strip harvesting is not possible
• FUE could be executed to reconstruct a (wide) linear scar, even after a final FUT treatment
• Possibility of expanding the donor area through Body Hair Transplantation

Disadvantages of FUE compared strip harvesting :

• Higher transection percentage than strip harvesting
• The FU's have more chance of sustaining damage than with ‘strip harvesting'
• Often, microscopic dissection is still required
• Smaller transplant numbers per FUE session
• More time-consuming and precision work (‘fine trimming')
• The treatment costs are relatively higher than for strip harvesting
• Risk of buried grafts 
• Risk of ‘moth-eaten' effect when donor area is exhausted, only if more than 12 FU/cm² are removed or when a punch needle with a diameter of >1mm is used for extraction
• FU's harvested outside the ‘safety' donor area may not be permanent
• Growth process might be relatively slower than strip harvesting (~1,5 year)

Advantages of strip harvesting compared to FUE :

• Higher transplant numbers per treatment than FUE
• Transection rate lower than with FUE
• FU's of strip harvesting are of better quality and less delicate than FU's of FUE
• Less expensive than FUE

Disadvantages of strip harvesting compared to FUE :

• The linear scar makes a short hair cut difficult or even impossible
• Longer recovery period than FUE  
• Donor area is limited 
• A larger team of special trained medical assistants is required to prepare and insert high-quality FU's

Indications for FUE :

• (Young) patients with a minor hair loss pattern (NW I,II)
• "Good candidates" Type Norwood III with a maximum of 3000 FU 
• Small treatment areas such as the temporal peaks, eyebrows, mustache, beard or pubic hair 
• Reconstruction of scars after trauma, hair transplant or other surgical operation 
• Patients with insufficient or low yield of donor material (after multiple strip procedures)
• Anxious patients, ‘bad experience‘ with strip harvesting 
• Patients who risk severe scarring 
• Patients with excessively tight scalp
• Patients with a short hairstyle 
• In combination with strip harvesting, to guarantee the highest yield of donor material (NW V, VI)

Indications for strip harvesting :

• Patients with a linear scar as a result of former strip harvesting procedure(s)
• Patients with a respectable or major hair loss pattern (NW: IV, V, VI)
•  Eyelash transplantation
• (Patients with a limited budget)

Comparison of both Techniques :

1. Training, skills of the medical team and team size;
2. Working time;
3. Amount of FU's per treatment;
4. Patient preparation;
5. Density; 
6. Transection rate;
7. Follicular unit quality;
8. Scarring and healing time of the donor area;
9. Growing rate

Patient preparation :
FUE :
In order to perform a Follicular unit Extraction to the highest standard the donor area requires total
shaving. Except for small procedures such as 100-600 follicular units, when micro strips could be
shaved and hidden by surrounding hair or when patients limit their sessions to a maximum of 1000 to 1200 follicular units per session. We are able to provide most of them with the opportunity to leave their hair long, as we extract the follicular units only in macro strips without having to shave the entire scalp.
3 possible options of shaving the donor area are:

•  A full short hair cut : allows us to perform FUE procedures up to 3000 FU in a 1-2 days session [Include picture]

• Macro strips : allow us to perform FUE procedures up to 1000-1200 FU per session [Include picture]
• Micro strips : allow us to perform FUE procedures up to 600 FU per session [Include picture ]

Density :
Similar density rates can be obtained with FUE and FUT :

• FUE: 30 up to 60 FU/cm2
• FUT: 30 up to 60 FU/cm2

Transection rate :

FUE: 5% up to 20%

FUT: <5% up to 9%  - using 0,8mm and 0,9mm punches

 

Follicular unit quality :

FUE :
Follicular units of FUE are often of medium quality and have more
chance of sustaining damage because of the torsion and traction
movement when extracting the FU's and because of the lack on
connective tissue

FUT :
Follicular units of strip harvesting are of high quality and show no
damage thanks to the accurate microscopic preparation and thanks to
the presence of sufficient connective tissue

 

Scarring and healing of the donor area:

FUE: Micro scarring' nearly invisible scarring. Not necessary to stitch the small incisions of the donor area; they usually heal already after one week (by using ≤1,0 mm punches, scars shrink to an average diameter of 0.5mm)

 FUT: Very often undetectable scars with trichophytic closure

 

Growing rate:

FUE: empirical observation and clinical studies necessary
personal experience shows a slight difference in growing rate

FUT: computer imaging controlled : >80% up to 95%

How FUE and FUT can complement each other :
FUE can be used to remove FU's in places that are not accessible via strip harvesting
a by combining FUE and FUT, a much higher yield can be obtained than with each treatment method individually.
Sometimes a wider linear scar can be the result of various strip treatments
a FUE treatment could be carried out to eliminate a wider linear scar

 

The key points of performing "state of the art" hair restoration surgery are:
1. planning
2. aesthetic hairline-design
3. sufficient density

 

2.Carboxitherapy

Carboxytherapy is a revolutionary advance in dermatology

Carboxitherapy: This is an example of chemical hyperoxigenation. It is done by infusing CO2 (Carbondioxide) gas into the sub-dermal space (just below the second layer of the skin) using a very small 30 gauge needle attached to the CO2 supply to areas of hair loss on the scalp, it causes a powerful stimulus for vasodilatation that allows for significantly increased blood flow to the scalp. This process, combined with the application of Minoxidil 2% solution to the scalp twice daily as well as daily micro-needling (using a dermaroller device) has proved to reverse hair loss or androgenetic alopecia as long as the treatment process is continued.

 

 

3. Hair loss medication

MEDICATIONS USED IN FEMALE HAIRLOSS

1. Keranique - FDA approved for female hairloss - See www
2. Pentosteen (Pentostenedione) - Estradiol base - usually required for six months as topical application to the scalp twice daily by most female patients before starting hair restoration surgery
3. Finasteride (Propecia; Proscar) - Give 2.5mg od; can be given to women also if hormonal studies show there is increased Testosterone levels (these patients usually present with MBP). Finasteride inhibits 5-alpha reductase, the enzyme that converts Testosterone to DHT
4. Ciproheptadine (ANDROCUR) = Anti-androgen - can also be given to women with high testosterone levels, also given in combination with Diane (BCP)
5. Minoxidil (Rogaine; or Regaine), also given in combination with Diane (BCP)
6. Spironolactone (Aldactone) also in combination with Cimetidine (Tagamet); Or, Spironolactone in combination with Minoxidil (Rogaine; Regaine)
7. Crescina lotion
8. Nizoral Shampoo in combination with Minoxidil, two to three times per week. Nizoral (Ketoconazole) has a weak anti-DHT effect

MEDICATIONS USED IN MALE HAIRLOSS:

1. Finasteride (Proscar; Propecia) 1mg OD - Finasteride inhibits 5-alpha reductase, the enzyme that converts Testosterone to DHT
2. Dutesteride (Avodart). Also a 5-alpha reductase inhibitor, but supposedly more effective than procpecia, but more side effects
3. Minoxidil (Rogaine; Regaine) Gel or lotion
4. Crescina lotion
5. Nizoral Shampoo in combination with Minoxidil, two to three times per week. Nizoral (Ketoconazole) has a weak anti-DHT effect

OTHERS MEDICAL METHODS

1. Noricren; Fishoil; Q10 (MALE PATIENTS USE THIS)
2. Saw Palmetto (Serenoa Serrulata) - Helps for prostate, not for hair
3. Nutragrain - some vitamins or Nutragen or Nutramigen (FEMALE PATIENTS USE THIS)
4. Nizoral shampoo, can be used for scalp dandruft, but Nizoral also stimulates hair growth
5. Cialis postop (Tadalafil) - traditionally used for erectile dysfunction - if there is any concern regarding necrosis of the scalp

OTHER MODALITIES:

1. Lasercomb - Red light laser - scalp stimulation - The underlying principle is that light energy gets absorbed into the hair follicle and this energy contributes to generating more ATP's (the basic chemical energy form used for fuelling metabolic processes in cells). This method still needs hard scientific control studies to confirm its efficacy.

Your Consultation

The following factors will be taken into consideration during your interview:
Your age.  With younger patient’s the strategy is always to be more conservative in order not to deplete the safe donor area. It is always wise to keep one or two transplants “in the bank” for later in life, in the event it were required to fill in areas of later balding, should the patient request this. With older patients (this is a relative term), generally considered in hair transplantation around 35 to 45 years and older, the approach can be more aggressive, because a much better idea can be formed about the already established balding pattern and how far it has progressed. Your future donor area vs recipient area ratio is therefore very important, especially relative to your age. Within the context of the above considerations and your personal preferences and goals, your personal hair restoration plan will be designed.

Planning the Hairline Zone:
This is a very important aspect of hair restoration, simply because the hairline frames the face and is the single biggest contributor in making a difference with hair restoration.Factors that need to be considered include,
The Height – at what height should the hairline be placed?
Graft types – Which grafts should be used to create the most anterior aspect of the frontal hairline zone?
Depth / Width of the Frontal zone – How deep or wide should the frontal hairline zone be?
Shape – What shape or contour should the airline have?
Micro-contoured periphery – How will the periphery of the frontal hairline zone be micro-contoured?

Construction of the hairline zone  and the characteristics of a natural appearing hairline:
A  natural hairline has a somewhat wavy anterior border. There are random hairs, singly or in groups, protruding anterior to the general mass of hairs in the hairline zone. Fine textured hairs are positioned more anteriorly, gradually becoming progressively coarser as one moves more posteriorly. There is also low density hair anteriorly, and it gradually becomies denser as one moves more posteriorly. Irregular hair density within the general change noted as described above. The hairline zone is also often wider laterally than anteriorly.

Other important factors include: Your medical health status? What is your psychological health status? Your hair characteristics will be taken into consideration, e.g.,  What is the color, caliber (hair shaft thickness) of your hair? An increase of hair shaft caliber by a mere 0.01 increases hair bulk by an astounding 36%. Hair caliber is finest in the temporal areas and the inferior occipital (lower back of head) area.  Hair caliber is greatest in the mid section back and sides of the occipital (back of head) area.  The finer the hair caliber (diameter), the more natural a single session looks.  Therefore, the final outcome will be affected whether you have curly, wavy or straight hair? What type of hair loss are we dealing with? What stage of male or female pattern hair loss are we dealing with? Male pattern baldness stages include: Norwood I; II; IIa; III; III vertex; IIIa; IV; IVa; V; Va; VI; VII. And female pattern balndess has three basic distinct types of hairloss: Hamilton’s grading for androgenetic alopecia: II: II/III; IV; V; VI; VII; VIII; Olsen “Christmas tree pattern”; and Ludwig Grade I; Grade II; Grade III

What is the size of your safe donor area? How dense are the hairs in the three areas of the donor area where hair density is measured? How significant is the contrast between your hair color and scalp color? How many terminal hairs (existing hairs with a healthy normal caliber / shaft diameter) are present in the recipient area? How many velous hairs (miniaturized hairs) are present in the recipient area? If the miniaturized hairs exceed 35% of all the hairs in the recipient area, then we are dealing with a definite balding pattern.  This means that the resting (telogen) phase of the patient’s hairs on the scalp has increased (and the growth phase – anagen – is becoming shorter) and a larger percentage of hairs are remaining in the resting phase, which results in progressively larger visible areas of balding.
Other factors that are important include: Assessing the quality of your fringe? Assessing the thickness of your scalp? What is the quality of your temporal hairs? We may also want to establish if you are you a potential candidate for Alopecia Reduction surgery or not? Determining  the morphology (shape and size) of your head is also important.

We need to determine how sensitive you are regarding the visibility of hair restoration surgical procedures and going through the various phases of hair restoration. Also, what means of camouflage do you currently use or what is available to you for managing your baldness? Your scalp laxity and flexibility needs to be determined. This is important in order to establish how large or small a donor strip can safely be harvested without compromising wound healing, in order to ensure adequate wound knitting and a thin scar.

The presence of whisker hairs may be a sign of future potential for significant balding up to a Norwood VI or VII stage. We will want to know what current methods of hair loss treatment you may be using? Also, what is your current hair styling preference? Ultimately a decision will be made regarding the best approach for your personal hair restoration procedure.