Hair Transplantation

Hair transplantation is a surgical technique that moves hair follicles from the stable area of of the scalp (typically posterior portion) to the thinning or balding portion of the scalp (typically crown, temples, or frontal portion). It can be used for management of pattern alopecia, traction alopecia, and  in special cases burned out scarring alopecia in men and women. The basic procedure was started in the 1930s.  Over the last  century the procedure has been refined and now individual follicular units are transferred with less invasive incisions made on the balding scalp.

The strip harvesting technique is the most common type of hair transplantation procedure.  It involves excision of a strip of skin from the stable portion of the scalp.  Individual 1-4 follicular units are then dissected from this strip and transferred to tiny slits on the balding scalp.

Follicular unit extraction is a newer technique that is growing in popularity.  It involves removal and dissection of individual 1-4  follicular units (FU) directly from the stable portion of the scalp. The FUs are transferred to tiny slits on the balding scalp.  Smaller scars can be expected from this procedure.  Recently, robotic devices have been able to automate the process.

With any technique, more than one procedure may be necessary to obtain the desired result. It is important to make sure medical therapy is continued in order to obtain maximal results.

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Platelet Rich Plasma for Hair Loss

Platelet Rich Plasma (PRP), the use of a person’s own blood platelets,  has been used in many areas of medicine including orthopedics, ophthalmology and cardiology to improve wound healing and tissue repair. PRP can be used to enhance hair growth as a stand-alone treatment or to improve the recovery and results of hair transplant surgery. PRP has been studied in pattern baldness and alopecia areata.  Although there has been no randomized controlled long term study on the efficacy of PRP in alopecia, there are many studies with positive results.

During the procedure, a small sample of your  blood is taken.  This sample is processed in an FDA-cleared device to separate the platelets from other components of the blood. Under local anesthesia, activated platelets containing a powerful cocktail of growth factors, cytokines and other proteins are injected into the area of scalp where weak hair follicles exist.  Microneedling of the skin is also performed prior to PRP injection for enhanced effect  One to three treatments many be required over the course of a year. Treatment may need to be repeated depending on the patient’s response to therapy, hair loss condition and goals. In order to determine if you are a good candidate for PRP,  schedule an appointment for a consultation.

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Hair Loss Consultation Now Available

SOMA Skin & Laser is now offering consultations for hair loss for men and women.  In addition to a medical evaluation includes assessment for hair transplantation and innovative procedures such as platelet rich plasma (PRP) and Acell Hair Regrowth Therapy (Please note that these procedures are not covered by insurance).

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Androgenetic Alopecia (common baldness)

About Androgenetic Alopecia

Androgenetic alopecia, or common baldness, is a genetically determined sensitivity of the hair follicle to androgens. It occurs post-pubertally in both males and females and is manifest by the non-scarring loss of hair in the vertex and frontotemporal areas. Terminal hairs are first replaced by thin, small vellus hairs. Eventually the follicles become completely atrophic. Hair loss can begin at any age after puberty and exposure to increased levels of androgens, but onset is highly variable.

With what can androgenetic alopecia be confused?

In men, the diagnosis of androgenetic alopecia is usually obvious. In women, a hormonal abnormality, especiallypolycystic ovary syndrome (PCOS) should be considered, especially if accompanied by irregular periods, infertility, hirsutism, or acne. Hypothyroidism can also be a cause of thin brittle hair. Other conditions that can cause non-scarring alopecia include: alopecia areata, telogen effluvium, secondary syphilis, hyperthyroidism, anemia, and trichotillomania. Seborrheic dermatitis and tinea infection of the scalp can also cause hair loss.

How is androgenetic alopecia diagnosed?

Hair loss, notably temporal recession in men, is usually first noticed in the third decade of life, but can begin as early as the second decade. It progresses in a distinct pattern, hence its other designation “male pattern baldness”, involving in men the vertex and frontotemporal areas but sparing the posterior and lateral aspects of the scalp. In women, the vertex is involved but the frontotemporal aspect may be spared. Scalp examination reveals replacement of dark terminal hairs with vellus hairs or with atrophic hair follicles; the number of follicles remains unchanged, but they may be difficult to perceive. There is no scarring or inflammation. A family history of baldness is usually present. In most cases, laboratory tests and biopsy are unnecessary. In women, a thyroid stimulating hormone assay and androgen levels, including total testosterone, free testosterone, androstenedione, and DHEA-S should be ordered. If considering polycystic ovary syndrome, follicle stimulating hormone, lutenizing hormone, prolactin levels, and tests of insulin resistance may be appropriate. Iron studies and an ANA test for autoimmune disease may be warranted as well. Severity of androgenetic alopecia is classified in men by the Hamilton classification, and in women by the Ludwig classification.

How is androgenetic alopecia treated?

Topical minoxidil (Rogaine), as either a 2% or 5% solution or foam, is moderately effective in stimulating regrowth of terminal hairs on the vertex, and less so in the frontal area. However, treatment must be continued indefinitely for results to be maintained. Minoxidil can be used in women as well. Finasteride (Propecia) is a type II 5 alpha-reductase inhibitor that prevents the peripheral conversion of testosterone into the more active dihydrotestosterone. In the clinical trials for Propecia, 83% of men maintained or increased their hair counts after two years of treatment. Propecia cannot be used in women of child-bearing age since it is teratogenic. In women with androgenetic alopecia and elevated androgens, androgen-blocking agents such as spironolactone, flutamide, cimetidine, and cyproterone acetate can be used. These agent block the peripheral effects of testosterone and should not be used in men. Non-pharmaceutical approaches include various methods of hair transplantation, including punch grafts and scalp reductions, wearing a toupee or wig, or to go bald gracefully (more an option for men than for women). Recently, prostaglandin analogs, such as bimatoprost (Latisse), have come in to use to promote eyelash growth.  These drugs are now being investigated in scalp hair loss as well.

What is the prognosis for androgenetic alopecia?

The balding process is substantially complete by the age of 50, though additional thinning continues throughout life.

Other resources for androgenetic alopecia

American Hair Loss Association

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Telogen Effluvium (Stress-Induced Alopecia)

About Telogen Effluvium

Diffuse hair loss can result from physical or psychological stress such as: childbirth (most common cause), high fever, chronic illness, emotional stress, physical stress, nutritional deficiency, and various drugs. The hair loss occurs several months after the stressor. This cause of the hair loss is termed telogen effluvium, and results from the early entry of follicles into the telogen (resting) phase. Normally, 10-20% of follicles are in telogen. In stress-induced alopecia, greater than 25% of hairs are in telogen. More than 500 hairs can be lost daily, as compared with a normal value of under 100. The scalp is normal, without inflammation, erythema, or scarring.

With what can telogen effluvium be confused?

The differential diagnosis for diffuse non-scarring alopecia includes: nutritional deficiencies and toxic drugs, such as chemotherapy agents. Other causes of alopecia are either focal, have a specific pattern, or are scarring. However, occasionally androgenetic alopecia can be confused with stress-induced alopecia, especially in women. A diffuse pattern of alopecia areata is also a possibility. Other conditions that can cause non-scarring alopecia include: secondary syphilis, hyperthyroidism, hypothyroidism, anemia, loose anagen syndrome, and trichotillomania. Seborrheic dermatitis and tinea infection of the scalp can also cause hair loss. Systemic lupus erythematosus may also be a consideration.

How is telogen effluvium diagnosed?

A history of recent childbirth clinches the diagnoses in many cases. The hair may appear diffusely thin, or may not be recognized as such by the physician; sometimes the patient’s complaint of losing hair is the only guide. The “pull test” is positive if, while pulling on about two dozen hairs, more than five come free. This is characteristic of stress-induced alopecia.

It is important to determine if the condition is due to emotional stress, physiologic stress, or metabolic abnormalities. A thyroid stimulating hormone level should be drawn to screen for hypothyroidism, which can manifest with dry, brittle, thinning hair, and loss of the lateral third of the eyebrow. Iron studies to rule out anemia, ANA to rule out autoimmuine disease, and RPR to rule out syphylis may all be useful. Biopsy is not usually required. Nails should also be examined for Beau’s lines, which are transverse lines or ridges on the nail plate reflecting periods of physiologic stress.

How is telogen effluvium treated?

If the stressor is in the past, as it usually is, only reassurance is required. The condition will reverse itself over several months.

What is the prognosis for telogen effluvium?

Stress-induced alopecia usually resolves over several months, once the stressor has been eliminated. With an ongoing stressor, metabolic disturbance, or nutritional deficiency, the course may be prolonged. In some cases, the course may be protracted without an identifiable stressor.

Other resources for telogen effluvium

American Hair Loss Association

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Alopecia Areata

About Alopecia Areata

Alopecia areata is characterized by the acute development of round or oval patches of hair loss, typically 2-3 cm in diamater, without scarring of the scalp. Alopecia areata is presumed to be an autoimmune disorder in with T lymphocytes react with antigens aberrantly expressed by hair follicle keratinocytes. It is estimated to affect 0.1 to 0.2% of the population at any time. Onset is usually in early adulthood. Patients are otherwise healthy. A family history is present in about 25% of cases. Hair elsewhere on the body may also be affected, including beard, eyelashes, and eyebrows. Nail pitting may be present, as well as other nail abnormalities. Several autoimmune diseases are associated with alopecia areata, including: atopic diathesis, thyroid disease, vitiligo, and inflammatory bowel disease.

Specific patterns of alopecia areata include:

Alopecia totalis. Complete loss of all scalp hair

Alopecia universalis. Complete loss of all body hair.

Ophiasis. A band of hair loss about the periphery of the temporal and occipital scalp.

Reticular. Recurrent disease, which may have areas of hair loss concurrent with areas where hair is beginning to regrow.

Diffuse. Widespread thinning, or limited to the vertex.  Non-pigmented hair may be spared, leading to premature graying.

What looks like alopecia areata?

Alopecia areata can sometimes be confused with other forms of non-scarring alopecia, of which the main differentials are trichotillomania and tinea capitis (fungus infection of the scalp). In trichotillomania the patches of hair loss have ill-defined margins. A KOH preparation and fungal culture can distinguish alopecia areata from tinea capitis. Diffuse alopecia areata may resemble telogen effluvium or androgenetic alopeia.

How is alopecia areata diagnosed?

The acute onset of well-circumscribed round or oval patches of hair loss is consistent with a diagnosis of alopecia areata. Scarring is absent, though there may be some tenderness and erythema. A diagnostic finding is “exclamation point” hairs, which are short broken-off hairs that are narrower toward the scalp. Hairs can be removed with a hair pull test (6 or more hairs).  If necessary a biopsy will reveal characteristic findings.

How is alopecia areata treated?

Steroids are the mainstay of treatment, either topical, intralesional, or systemic. Immunotherapy is also used, including psoralens plus ultraviolet light A (PUVA), induction of allergic contact dermatitis with squaric acid or other contactants, and cyclosporine. Topical or oral minoxidil is also used. Wigs are helpful for cosmetic reasons if hair loss is extensive.

What is the prognosis for alopecia areata?

A small percentage of patients may experience complete loss of all scalp (alopecia totalis) or body (alopecia universalis) hair; few patients with these conditions will exhibit hair regrowth. For more confined disease, the prognosis is unpredictable. The majority of patients will have spontaneous hair regrowth, but the condition may recur.  Poor prognostic factors are duration of hair loss of greater than one year, extensive areas of involvement, and an ophiasis pattern.

Other resources for alopecia areata Alopecia Areata | American Hair Loss Association | Alopecia Areata Registry | National Alopecia Areata Foundation

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Alopecia (Hair Loss)

Hair loss, or alopecia, is divided into non-scarring causes and scarring (cicatricial) causes.

Please search for one of the more specific entries below for the non-scarring alopecias.:

Alopecia areata

Alopecia, stress-induced

Alopecia, androgenetic

Anagen Effluvium


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