In 2002, the FDA approved Avodart (dutasteride 0.5mg) for the treatment of prostate enlargement in men (the medical term is symptomatic benign prostatic hyperplasia or BPH). Dutasteride is not approved for the treatment of male pattern hair loss.
Like finasteride, dutasteride is an inhibitor of the enzyme 5 alpha-reductase responsible for the conversion of testosterone to DHT (dihydrotestosterone). However, unlike finasteride, which only inhibits the Type II form of the enzyme, dutasteride inhibits both the Type I and Typ
e II forms of the 5 alpha-reductase enzyme. This dual effect makes the drug more potent but also increases the incidence of adverse reactions.
The Type II form of the enzyme is found predominantly in the hair follicle. The Type I form of the enzyme has been found in the scalp and sebaceous glands, but its exact role in hair growth has not been determined. Type I is responsible for 1/3rd circulating DHT and type IIfor 2//3rd circulating DHT.
Effects on Hair GrowthDutasteride 0.5mg/day decreases serum DHT 91% and scalp DHT 54%. Finasteride 5mg/day decreases serum DHT 71% and scalp DHT 38%. Based on these results, dutasteride should be significantly more effective in the treatment of androgenetic alopecia than finasteride. However, since the Type I form of the 5 alpha-reductase that dutasteride blocks is not present in significant quantities in the hair follicle, these effects may not be as significant as one might expect. The increased efficacy of Dutasteride is felt to be due, in part, to its effects on lowering serum DHT.
Side EffectsDutasteride was investigated in controlled multi-center studies involving 4,325 men aged 50 and above with prostate enlargement. Drug-related side effects during the first six months were as follows: impotence (4.7 percent vs. 1.7 percent for placebo), decreased libido (3 percent vs. 1.4 percent), breast tenderness and breast enlargement (gynecomastia; 0.5 percent vs. 0.2 percent) and ejaculation disorders (1.4 percent vs. 0.5 percent).
The incidence of most drug-related sexual adverse events decreased with duration of treatment. The incidence of drug-related breast tenderness and breast enlargement remained constant over the treatment period. Ejaculate volume may be decreased in some patients with continued treatment. This decrease did not appear to interfere with normal sexual function.
Effects on PSADutasteride will reduce the amount of PSA measured in the blood and this must be taken into account when PSA is used in the detection of prostate cancer.
Precautions
The precautions when using dutasteride for prostate enlargement are more significant than for finasteride and include:
Women who are pregnant or may become pregnant should not handle dutasteride because of possibility of absorption of dutasteride and subsequent potential risk to a male fetus.
Men treated with dutasteride should not donate blood until at least six months after their final dose to prevent giving dutasteride to a pregnant woman through a blood transfusion.
Men with an allergic reaction to dutasteride or its ingredients should not take it.
Men with liver disease should talk to their doctor before taking dutasteride.
Because of the potential for drug-drug interactions, care should be taken when administering dutasteride to patients taking potent, chronic CYP3A4 enzyme inhibitors (e.g., ritonavir).
Additional Points
Unlike finasteride, were families that had a deficiency of the Type II 5-alpha reductase enzyme were followed for years without any adverse effects, there is no natural biologic model for dutasteride.
The half life of dutasteride is 5 weeks compared to 6-8 hours for finasteride and serum concentrations of dutasteride are detectable up to 4-6 months after discontinuation of treatment.
for minoxidil, was the first FDA approved medication for the treatment of hair loss. Minoxidil is a topical solution that is applied directly to the scalp. It can now be purchased without a prescription and in generic formulations in concentrations of 5% (for men) and 2% (for women).
Minoxidil was developed from the oral blood pressure medication minoxidil (Loniten). Minoxidil taken orally has potential serious side effects on the heart and circulatory system and is used only when other blood pressure medications have been unsuccessful. It was observed that patients who were taking minoxidil began growing body hair and it was reasoned that applying minoxidil directly to a bald scalp might cause hair to grow in this area as well. Studies showed that this was indeed the case, although the growth was generally modest.
The original studies on Minoxidil were performed on the crown, so there is a misconception that it only works in this area. Although minoxidil usually works best in the crown, it also works to a lesser degree in other areas, such as the front of the scalp, as long as there is some fine (miniaturized) hair in the area. It does not work when the area is totally bald. The greatest benefit from the medication is seen from 5 months to 2 years, with a gradual decrease in effectiveness after that. Those using minoxidil long-term will continue to lose hair, but at a somewhat slower rate.
The exact mechanism by which minoxidil works is not known, but the drug is felt to increase the duration of the hair follicle growth cycle (called anagen). This improves the quality of the hair by increasing the diameter and length of fine (miniaturized) hair. The simultaneous use of minoxidil and Finasteride, which directly inhibits the formation of DHT, may have some synergistic benefit in the treatment of hair loss, although the latter medication is significantly more effective.
Using Minoxidil
Minoxidil should be applied to the scalp twice a day. The medication only works if it is in direct contact with the scalp (not the hair) and only works in areas where it is applied. Therefore, it is important to use the medication in the front part of the scalp if this is an area of thinning.
The 5% formulation is twice as effective as the 2% solution, but contains propylene glycol, a compound that can irritate the scalp and can make the hair feel sticky and difficult to manage. If this is a problem, one should consider using the 5% solution at bedtime and the 2% solution (which is alcohol based and less sticky) in the morning. When using minoxidil, it may take 6-12 months before any results are seen. The majority of patients who see an effect from minoxidil experience a delay, or decrease, in the rate of hair loss. The drug also serves to thicken already existing hair, but most patients who do have results, grow only short, thin fuzz. It will not grow any new hair on a bald scalp.
Rogaine or Tugain Foam is a new form of 5% Minoxidil in a glycerin and alcohol base. The foam technology is a convenient way of delivering minoxidil to the scalp without the sticky and often irritating effects of propylene glycol, the delivery compound used in the original 5% solution. When released from the canister, the new product seems like a shaving foam, but it rapidly “melts” when it reaches skin temperature. Applying Rogaine as a foam allows convenient application to the scalp without dripping or running down the forehead or neck, and without leaving a sticky residue in the hair.
Once a day topical use of Rogaine (topical minoxidil 2% and 5%) seems to be almost as effective as using it twice a day. The reason is, that although minoxidil has a relatively short half-life of several hours when given orally,when topically applied, it has a half-life of 22 hours in the skin. This suggests that once a day dosing is a reasonable option. It is important to realize that Pfizer, the company that now makes Rogaine, specifically states that it will be less effective if used only once a day.
If minoxidil is discontinued, the effects of the drug wear off within three months and the previous pattern of hair loss resumes. When minoxidil is restarted, one generally does not regain the hair that was lost, so it is best not to stop and start the mediation, but to use it regularly.
Minoxidil has been prescribed (off-label) in conjunction with other medications, such as topical retinoic acid (Retin-A), to enhance its penetration into the skin and thus increase its effectiveness. This combination of medications, however, can greatly increase the absorption of minoxidil into the bloodstream and may increase the risk of potential side effects, including changes in blood pressure and severe scalp irritation that has led to scarring.
Use in Women
Only the 2% concentration of minoxidil is approved for use in women. Women are generally more sensitive to the side effects of minoxidil in decreasing blood pressure (hypotension) and may get light-headed from the medication. Women also have an increased risk of developing allergic skin reactions (contact dermatitis).
An annoying local reaction that women sometimes get from topical minoxidil is the development of facial hair. Although the facial hair slowly resolves when the medication is discontinued, at times the hair may need to be removed. Carefully trying to avoid the medication dripping down onto the temples and forehead seems to reduce, but not totally prevent, this problem. There is a significantly greater incidence of these side effects if the 5% solution is used.
Tips on Using Minoxidil (Rogaine / Mintop) – Men
Minoxidil solution comes in a generic formulation and can be purchased over the counter. The foam is available in brand only (Rogaine / Trigain Foam).
Minoxidil only works where you apply it. Apply it to all areas that are thinning.
Minoxidil can work anywhere there is miniaturized hair (where the area is not totally bald)
Minoxidil will work in the front part of the scalp and temples if these areas are just starting to thin – so it is important to apply it to the front part of your scalp and hairline if you are thinning in these areas.
Minoxidil must be applied to the scalp to work – it doesn’t work on the hair per se.
Minoxidil 5% solution is the most effective if you have some hair, as the solution will be easier to apply to the scalp.
If the 5% solution is irritating to your scalp, try the 5% Foam which does not contain propylene glycol, the most common irritant.
If the 5% solution is too greasy and you find you are not using it, switch to the foam.
Although the Minoxidil works best when used twice a day, using it once a day will also be effective (and better than not using it at all).
Many patients find applying the medication once a day at bedtime to be the most convenient way to use it.
When using minoxidil once a day, use at least double the recommended dose, so that it will be applied to the entire area of thinning.
Minoxidil can be applied to damp scalp when you first get out of the shower and this can make grooming easier.
For minoxidil to be effective it must be used continually and regularly. Do not stop and start it. You may experience shedding during the first 3-6 months of treatment. This generally is an indication that the medication is working, so unless you are having side effects, do not stop the medication. If you do stop the medication, you will lose all of its benefits (although you will not be any worse off than if you had never used it).
Minoxidil works best when used with finasteride. Of the two medications, finasteride is more effective.
Tips for Women Using Minoxidil– Women
Minoxidil solution comes in a generic formulation and can be purchased over the counter. The foam is still available in brand only.
Minoxidil is generally prescribed as a 2% solution for women to be used twice a day. If twice a day is inconvenient, then use the 5% men’s formulation just once a day.
Minoxidil can cause increased facial hair. Although the 5% is more likely than the 2% to cause this, when the 5% is used one a day, the side effects seem to be about the same.
Minoxidil only works where you apply it. Apply it to all areas that are thinning.
Minoxidil can work anywhere there is miniaturized hair (where the area is not totally bald).
Minoxidil will work in the front part of the scalp and temples if these areas are just starting to thin.
Minoxidil must be applied to the scalp to work – it doesn’t work on the hair per se
Minoxidil solution is the most effective if you have some hair, as the solution will be easier to apply to the scalp.
If the solution is irritating to your scalp, try the Foam which does not contain propylene glycol, the most common irritant.
If the solution is too greasy and you find you are not using it, switch to the foam.
Although the Minoxidil works best when used twice a day, using it once a day will also be effective (and better than not using it at all).
Many patients find applying the medication once a day at bedtime to be the most convenient way to use it.
When using minoxidil once a day, use double the recommended dose, so that it will be applied to the entire area of thinning.
Minoxidil can be applied to damp scalp when you first get out of the shower and this can make grooming easier.
For minoxidil to be effective it must be used continually and regularly. Do not stop and start it. You may experience shedding during the first 3-6 months of treatment. This generally is an indication that the medication is working, so unless you are having side effects, do not stop the medication. If you do stop the medication, you will lose all of its benefits (although you will not be any worse off than if you had never used it).
Male pattern baldness or androgenetic alopecia is caused by the effects of the male hormone dihydrotestosterone (DHT) on genetically susceptible hair follicles that are present mainly in the front, top, and crown of the scalp (rather than the back and sides). DHT causes hair loss by shortening the growth, or anagen, phase of the hair cycle, causing miniaturization (decreased size) of the follicles. The effected hair becomes progressively shorter and finer until it eventually disappears.
DHT is formed by the action of the enzyme 5-alpha reductase on testosterone. Finasteride is a synthetic 4-azasteroid compound, is a specific inhibitor of steroid Type II 5a-reductase, an intracellularenzyme that converts the androgentestosterone into 5a-dihydrotestosterone (DHT)in the hair follicle. Finastride is the only FDA approved medication for hair loss prevention.
Finasteride causes a significant drop in both scalp and blood levels of DHT and its effect is felt to be related to both of these factors. Finasteride produces a rapid reduction in serum DHT concentration, reaching 65% suppression within 24 hours of oral dosing with a 1-mg tablet Serum testosterone levels actually increased by 9%, but this is within the range of normal.
It is commonly thought that finasteride was first conceived as a prostate medication and that, only by chance, was found to prevent hair loss. In 1997, the FDA approved finasteride 1-mg/day (Propecia) for the treatment of male pattern baldness.
Studies have shown that after five years of treatment, 90% of men taking finasteride maintained their hair or increased hair growth. At five years, 48% of men treated with Propecia demonstrated an increase in hair growth, 42% were rated as having no change (no further visible progression of hair loss from baseline) and 10% were rated as having lost hair when compared to baseline.These hairs were significantly larger than the fine, miniaturized hair characteristic of balding. In the “Hair Weight Clinical Study,” a 34% increase in hair weight was observed
Using Finasteride
Finasteride should be taken once daily with or without meals. Patients must take Finasteride for one year or longer before its effects in preventing hair loss and re-growing hair can be accurately assessed. Finasteride takes up to a year or more to exert its full effects in both preventing hair loss and in re-growing hair. During the first six months you may note some thinning of your existing hair. This may be due to either progression of your hair loss before finasteride has had a chance to work or some shedding of miniaturized hair that makes way for the new healthy anagen hair to grow. It is important to be patient during this period.
Long-Term Benefits and Risks
The effects of finasteride are confined to areas of the scalp that are thinning, but where there is still some hair present. It does not grow hair in areas that are completely bald. Although it can regrow hair in thin areas, the major benefit of finasteride seems to be in its ability to slow down or halt hair loss. Results generally peak around one year and then are stable in the second year or decrease very slightly. Although the long-term ability of finasteride to maintain one’s hair is unknown, the majority of men find that after 5 years the medication is still working.
The benefits of finasteride will stop if the medication is discontinued. Over the 2-6 months following discontinuation, the hair loss pattern will generally return to the state that it would have been if the medication had never been used.
Side Effects
Side effects from finasteride at the 1-mg dose are uncommon, but reversible. The one- year drug related side effects were 1.5% greater than in the control group. The data showed that 3.8% of men taking finasteride 1mg experienced some form of sexual dysfunction verses 2.1% in men treated with a placebo. The five-year side effects profile included: decreased libido (0.3%), erectile dysfunction (0.3%), and decreased volume of ejaculate (0.0%).
TABLE 1 Drug-Related Adverse Experiences for PROPECIA (finasteride 1 mg) in Year 1 (%) MALE PATTERN HAIR LOSS
Discontinuation due to drug-related sexual adverse experiences
1.2
0.9
Most reported cases of sexual dysfunction occurred soon after starting the medication, but there have been reports of sexual dysfunction that have occurred at later points in time. The sexual side effects were reversed in all men who discontinued therapy, and in 58% of those who continued treatment. After the medication was stopped, side effects generally disappeared within a few weeks. When finasteride is discontinued, only the hair that had been gained or preserved by the medication is lost. In effect, the patient returns to the level of balding where he would have been had he never used the drug in the first place. No drug interactions of clinical importance have been identified.
Side Effects:
Adverse reactions related to the breast, including breast tenderness or breast enlargement (gynecomastia), occurred in 1 in 4000 ( 0.4%) of men taking finasteride 1-mg (Propecia), but this was no greater than in the control group. Other side effects that were not statistically significant included hypersensitivity reactions including rash, pruritus, urticaria, swelling of the lips and face, and testicular pain. Contrary to the common belief it does not grow body hair thicker.
Effects on PSA
Finasteride causes a decrease in serum PSA (prostate specific antigen) by approximately 50% in normal men. Since PSA levels are used to screen for prostate enlargement and prostate cancer, it is important that your personal physician is aware that you are taking Propecia (finasteride) so that he/she may take this into account when interpreting your PSA results.
Finasteride and Prostate Disease
A study in The New England Journal of Medicine, in 2003, on finasteride 5-mg PROSCAR (not finasteride 1-mg, Propecia) reported that in the Prostate Cancer Prevention Trial (PCPT), men treated with finasteride 5mg for seven years had a 25 percent relative risk reduction for prostate cancer compared to the men treated with placebo. The authors also reported that high grade prostate cancers were found in 6.4 percent of the men treated with finasteride 5mg, compared to 5.1 percent of the men in the placebo group.
The authors were concerned that finasteride 5mg prevents or delays the appearance of prostate cancer and that this possible benefit and a reduced risk of urinary problems must be weighed against sexual side effects and the increased risk of high-grade prostate cancer. With new information, it is now felt that the increased incidence of a higher grade cancer was due to the fact that the finasteride shrunk the non-cancerous part of the enlarged prostate, making the cancerous part easier to detect on biopsy.
In fact, in 2009, the American Society of Clinical Oncology and the American Urological Association issued guidelines that recommend that healthy men consider finasteride to lower their level of the hormone dihydrotestosterone (DHT) with the goal of preventing the development of prostate cancer.
Caution during PregnancyFinasteride use is contraindicated in women when they are, or may be, pregnant. Women should not handle crushed or broken Finasteride tablets when they are pregnant, or may potentially be pregnant, because of the possibilities of absorption of finasteride and the subsequent potential risk to a male fetus. Finasteride tablets are coated and will prevent contact with the active ingredient during normal handling, provided that the tablets have not been broken or crushed.
Exposure of pregnant women to semen from men treated with Finasteride poses no risk to the fetus.Semen levels have been measured in 35 men taking finasteride 1 mg/day for 6 weeks. In 60% (21 of 35) of the samples, finasteride levels were undetectable (<0.2>mg) that had no effect on circulating DHT levels in men (see
Use in Post-Menopausal Women
Merck recently carried out a study to evaluate the efficacy of finasteride in post-menopausal women. After one year there was no significant hair growth and, as a result, the study was terminated. An explanation is that hair loss in women is related more to the action of the enzyme aromatase (which is unaffected by finasteride) rather than DHT. It is also possible that the low DHT levels observed in postmenopausal women are responsible for the lack of significant response to finasteride.
Finasterideand Hair Transplantation
Finasteride has shown to be useful in complementing a hair transplant for several reasons:
Finasteride works best in the younger patient who may not yet be a candidate for hair transplantation.
Finasteride is less effective in the front part of the scalp, the area where surgical hair restoration can offer the greatest cosmetic improvement.
Finasteride can re-grow hair, or stabilize hair loss, in the crown part of the scalp where hair transplantation may not always be indicated.
For those who choose not to take Finasteride, or who cannot take it due to its side effects, the surgical hair restoration is just as effective. The only difference is that medications can prevent further hair loss whereas surgery cannot. Medications are not needed for a hair transplant to be successful or the transplanted hair to grow and be permanent.
Increasing the Dose
We are often asked if one should increase the dose of Finasteride. Although we do increase the dose under certain circumstances, there is no scientific evidence that increasing the dose will have any additional effects. There are published data demonstrating that 5 mg is no better than 1 mg from controlled clinical trials.
Patient Monitoring
It is recommended that men aged 50, or over, should inform their regular physicians or urologists that they are taking Finasteride 1mg. It is also recommended that all men aged 50 or over have a routine annual evaluation for prostate disease, regardless of whether or not Finasteride is used. For those patients who are black and/or who have a family history of prostate disease, these recommendations would apply beginning at age 40. An evaluation may include a rectal examination, a baseline PSA, and other tests that your examining physician feels are appropriate.The above are general guidelines recommended for all men of appropriate age, regardless of whether they use Finasteride or not. Specific recommendations for each Patient should be based upon the judgment of his own physician.
Common Misconceptions about Finasteride
Myth: Women can’t touch the medication.
Fact: Pregnant women should not handle crushed or broken tablets.
Myth: It only works in the crown.
Fact: It potentially works any where on the scalp where there is some hair, even in the front of the scalp.
Myth: Once you start it you must take it for ever.
Fact: You can stop the medication any time you want – you just lose its benefits when one stops.
Myth: Finasteride lowers testosterone
Fact: The medication, on average, causes a rise in serum testosterone levels by 9%.
Myth: The sexual side effects are frequent and irreversible.
Fact: The sexual side effects occur in 2% and are reversible when the medication is stopped.
Myth: Finasteride causes birth defects if a man takes it when his wife is pregnant.
Fact: Exposure of pregnant women to semen from men treated with Propecia poses no risk to the fetus.
Myth: Propecia was originally a prostate medication that was found to prevent hair loss.
Fact: Propecia is not a prostate medication that was by chance noted to have a side effect of hair growth, it is a medication that was known since its discovery that it could grow hair.
Tips on Using Finasteride (Propecia/ Finax)
Finasteride is a prescription oral medication that is now generic (Proscar in the 5mg dose). This formulation is just as effective as the brand name Propecia and is about 1/3 the cost.
The general starting dose of finasteride for hair loss is 1mg a day. For this dose, you can either take one 1mg Propecia tablet or ¼ of a 5mg tablet of generic finasteride each day. Finasteride does not have to be cut into equal parts to be effective. Just cut it into the recommended of pieces and take one piece each day.
Finasteride can be taken any time of the day without regard to food or other medications.
You may experience shedding during the first 3-6 months of treatment. This generally is an indication that the medication is working. Do not stop the medication if you see shedding. It takes up to a full year to see the effects of Finasteride, so be patient.
In addition to the regular Norwood Classes (I to VII) and the Norwood Class A’s (Ia to Va), there are two other types of male baldness that O’tar Norwood has termed “Diffuse Patterned Alopecia” and “Diffuse Unpatterned Alopecia.” Although these patterns receive little attention, they appear to be quite common and present special problems for the transplant surgeon. We have attempted to further define and stage these two types of balding in order to gain insight into their appropriate management. DUPA (Diffuse Unpatterned Alopecia) will not appear in a month. If and when it hits, it will develop over a long period of time (months to years). Chemical damage, on the other hand, will have a short cycle. We do not understand a great deal about DUPA, but we are aware that the zone of hair around the sides and back of the head may not be permanent in everyone throughout their lifetime. If you go to an old age home and look at many of the men there, about 1/3rd to a half of the men over 80 have a see-through look on the sides and back of the head. When this is evaluated by mapping out the scalp for miniaturization you will see many thin hairs in this ‘donor rim’ that should not be there. This diffuse alopecia may extend throughout the head, even in men who have no balding. These are the people withs of DUPA. I believe that a condition, which the dermatologists have labelled ‘senile alopecia’, is something that hits men in all decades of life and a few men develop this condition when they are in their 20s or 30s. The use of Finasteride (Propecia) has benefits to about half of these men. Many of the poor transplant results that are seen occurs when the patient has DUPA and the surgeon does not check for it. The transplants become thin and the donor area, which was see through prior to the procedure, gets more see through after. I strongly warn every one of those patients I see with DUPA against having hair transplants and consider this condition a contra-indication for hair transplant surgery. Diffuse Patterned Alopecia (DPA) is an androgenetic alopecia characterized by diffuse thinning in the front, top, and vertex of the scalp in conjunction with a stable permanent zone. Diffuse Patterned Alopecia is usually associated with the persistence of the frontal hairline represented by the hairline position of the Norwood Class II or Class III patient. Especially in the earlier stages, the thinning generally extends to the vertex without significant hair loss in the crown. It differs from the regular Norwood classification in that, when the hair loss is first noted, it is already in a stage resembling a thinning Norwood Class VI, rather than having progressed through the Norwood stages III, III Vertex, IV, and V, which are characterized by continued recession at the temples, an expanding vertex/crown, and the presence of a defined bridge separating the anterior and posterior portions of the scalp. In addition, there is an absence of the residual triangular elevation in the parietal region that helps to define the typical Norwood Class VI patient. Diffuse Patterned Alopecia differs from the less common Diffuse Unpatterned Alopecia (DUPA) which is also androgenetic, but lacks a stable permanent zone. Diffuse Unpatterned Alopecia( DUPA) patients have a similar progression of balding as the DPA patient except that the progression is often more rapid and will more likely eventuate in a “horseshoe pattern” resembling the Norwood class VII, except that in contrast to the Norwood VII, the DUPA “horseshoe” can look almost “transparent” due to the low density. The differentiation between DPA and DUPA is critically important because DPA patients are often good candidates for an appropriately timed transplant, whereas DUPA patients should almost never be transplanted because they will inevitably have extensive hair loss without a stable zone in which to harvest the hair. Both Diffuse Patterned and Unpatterned alopecia also occur in women. However, in contrast to men, the DUPA in women is much more common, probably occurring 10 times as frequently as DPA. As in men, the female DUPA patients are not good candidates for a transplant (except in the instance where the donor hair is used solely to soften the frontal edge of a wig). The high incidence of Diffuse Unpatterned Alopecia in women partly explains why so few women have their hair transplanted. It is also important to emphasize that a non-androgenetic differential must be considered in all unpatterned alopecias. This is especially true in women, where a host of medical conditions can produce diffuse unpatterned hair loss including anemia, thyroid disease, connective tissue disease, gynecological conditions, and severe emotional problems. We find densitometry to be helpful in distinguishing Diffuse Patterned Alopecia from Diffuse Unpatterned Alopecia. A donor density in the range of 1.0 to 1.5 hairs/mm 2 with donor miniaturization in excess of 35% indicates an unstable permanent zone and precludes a diagnosis of DPA. As discussed in the section “Predicting Short- and Long-Term Hair-Loss,” these densitometry readings in a younger patient, even with little clinically apparent hair loss, point toward a high risk of extensive balding. The importance of densitometry is that not only will it help to distinguish between DPA and DUPA, but it can help to predict which patient will not be a good candidate for a transplant even before visible balding has begun. “
Follicular unit density is generally highest in the midline of the donor area and decreases laterally. The majority of patients have density range from 1.5 hairs/unit to 3.0 hairs/unit with an average of 2.0 hairs /Follicular unit
The density of naturally occurring follicular units is 60 to 100 follicular units ( or 120 hairs to 300 hairs) per sq.cmLower in this range in blacks and higher in this range in Caucasians.
"Cross Sectional Area." or diameter the range in terminal hair shaft diameter is approximately 60 micron to 140 micron.
It is interesting to note that compared to hair density, hair shaft diameter plays a much more significant role in the volume or "bulk" of the transplant.
Natural hair groupings in this case might be 20% 1's, 45% 2's, 30% 3's, and 5% 4's.
In our experience, the average donor density for all patients (both bald and non-bald) seeking a consultation for hair restoration surgery has an average donor density of 200 hairs/cm2. In general, for individuals with straight hair of average diameter, the donor density must be at least 100 hair/cm2 in order to adequately cover the donor area and not have it appear too thin. A density of 100 hair/cm2 is also the minimal density needed to hide an average donor scar. If a patient has wavy or thick hair the minimum density may be slightly less and in patients with very fine, straight hair the minimum density will be more.
A unit change in donor density away from the norm will produce a two-fold change in the availability of transplantable hair. For example, compared to the average person (with a donor density of 200 hairs/cm2), a balding individual with a donor density of 270hairs /cm2 (which is a 35% increase) will have 70% more hair available to transplant. Conversely, a person with a donor density of 130 hairs /cm2 will have 70% less transplantable hair, and may not be a candidate for surgery regardless of his Norwood classification. If he were to bald extensively, almost any type of hair restoration would leave him desperately short of hair and short on coverage in the donor area..
An average scalp is approximately 500 cm2. Since the normal, non-balding scalp has 100 follicular unit/cm2, and each unit contains on the average 2 hairs (yielding a density of 200 hairs/cm2), the average scalp would have 100,000 hairs in total. The permanent zone normally represents approximately 25% of this area, and half is available to be moved without the donor area appearing too thin. Thus, in theory, 12.5% of the scalp would be available for transplantation. This donor area would contain 12,500 hairs or 6,250 implants, averaging two hairs each. When a patient’s density is higher, a greater proportion of the donor hair can be used for the transplant.
Hence numbers are not as dismal as they appear. In a completel
y bald area, 17% of the patient’s original density offers a vast cosmetic improvement over having no hair, especially if the transplant is totally natural, and the patient has realistic expectations. But most importantly, the aesthetic impact of these absolute numbers can be improved upon with “artistic” adjustments in the “weighting” of the implants. In addition, if it can safely be assumed that the patient will not be extensively bald, then more hair can be committed to a more limited area. Great care must be taken so that excessive amounts of hair are not removed from the donor area to treat a limited area of recession, given the possibility that such a patient may need to reserve his donor hair to cover an almost certain evolving hair loss process over time.
The decision regarding moving hair reserves to meet patient’s goals must be a joint one between patient and doctor. The doctor has the obligation to fully inform the patient of the consequences of donor hair depletion when planning any reconstruction.
We feel that the solution to increasing recipient density should be to perform a properly planned second procedure using follicular units and not to increase the size of the implants, since this will result in a density that is either equal to or greater than (due to compression) the
density of the donor area. This density will either be unnatural for a mature patient whose density in the front and top of his scalp should be less than in the donor area, or unrealistic if future hair loss should occur (and this level of density cannot be maintained). Conversely, splitting up the follicular units would not increase the density either. This would only produce groupings smaller than occur naturally and would run the risk of having poor growth and an appearance that was too thin.
n general (assuming straight, brown hair of average hair weight, and light skin), 50% of the hair in a given area may be lost before any appreciable change is noted. For the average person, with a density of 2.0, this would result in a density of 1 hair/mm2
hese numbers are not as dismal as they appear. In a completely bald area, 17% of the patient’s original density offers a vast cosmetic improvement over having no hair, especially if the transplant is totally natural, and the patient has realistic expectations. But most importantly, the aesthetic impact of these absolute numbers can be improved upon with “artistic” adjustments in the “weighting” of the implants. In addition, if it can safely be assumed that the patient will not be extensively bald, then more hair can be committed to a more limited area. Great care must be taken so that excessive amounts of hair are not removed from the donor area to treat a limited area of recession, given the possibility that such a patient may need to reserve his donor hair to cover an almost certain evolving hair loss process over time.
The decision regarding moving hair reserves to meet patients goals must be a joint one between patient and doctor. The doctor has the obligation to fully inform the patient of the consequences of donor hair depletion when planning any reconstruction.
We feel that the solution to increasing recipient density should be to perform a properly planned second procedure using follicular units and not to increase the size of the implants, since this will result in a density that is either equal to or greater than (due to compression) the density of the donor area. This density will either be unnatural for a mature patient whose density in the front and top of his scalp should be less than in the donor area, or unrealistic if future hair loss should occur (and this level of density cannot be maintained). Conversely, splitting up the follicular units would not increase the density either. This would only produce groupings smaller than occur naturally and would run the risk of having poor growth and an appearance that was too thin.
In a patient with a density of 2.4 hairs/mm2, the yield would be:
20% 1 hair implants
35% 2 hair implants
30% 3 hair implants
15% 4 hair implants
If we see with different perspective if the donor area has say 12500 hairs or 6000 Follicular units for the coverage of 375 cm2 area of the stage 7 Norwood baldness. If this hairs are equally distributed the density per cm2 would not be more than 16 /cm2. For say class 6 baldness the area may be 270 cm2 the equal distribution of 6000 follicular units will yield density of 22 FU / cm2. In other words if you are looking for density of 60 /cm2 in the entire area you would need 270 x 60 = 16200 FU ! But for good natural look it is important that one should have higher density in the front esp. in the hair line area (front 1 to3 cm) of at least 35 to 50 FU /cm2. This will obviously reduce the density in the area behind it because the available donor hair from the back are limited ( i.e. up to 6000 FU). More over covering the crown area with high density can consume a large number of FU and still will not give a dense cover because the whorl in the crown has centrifugal direction form the centre of the whorl and there is no shingling effect as in case of the front. More over crown is not making the framework of the face like the hair line so is cosmetically not as significant as the hair line and therefore priority should be given to the frontal cover rather than the crown cover. Our looks is judged majority of time from the front (Hair line) and very occasionally from the back side (crown).
What is PRP?
Platelet rich plasma is concentrated blood plasma which contains approximately five times the number of platelets found in normal circulating blood. Human blood is comprised primarily of red blood cells (RBC), as well as white blood cells (WBC), platelets, and plasma. By initiating the first step of coagulation, platelets are the key to the body’s ability to heal wounds.
It is thought that by increasing the platelet count in a wounded area, the body’s healing to that area would be accelerated – explaining the use of PRP (platelet rich plasma) in wound healing.
Platelet rich plasma is concentrated blood plasma which contains approximately five times the number of platelets found in normal circulating blood. In addition, blood plasma contains the growth factors PDGF and VEGF and other bioactive proteins that aid in wound healing. To obtain PRP, a patient’s blood is spun in a centrifuge that separates the solid from liquid components. This separated “solid” portion of the blood is PRP (platelet rich plasma)
PRP is used in many areas of medicine, including the acceleration of healing of tendon injuries, the treatment of osteoarthritis, in some aspects of dental work (i.e. jaw reconstruction), and in cardiovascular medicine. The concentrated form of plasma has been shown to accelerate wound healing and tissue repair and, thus, could potentially benefit hair restoration procedures.
In hair transplantation, PRP can be injected into the recipient site area to theoretically stimulate the healing of the transplanted grafts and into the donor area to facilitate healing of the donor incision.
Mechanism of Action in Hair Transplants
Basically, a small amount (50cc) of your blood is taken before surgery. The platelets, which are part of your blood and help with healing of wounds, are separated to form a solution called platelet rich plasma. The follicular unit grafts are bathed in this PRP before being implanted. The PRP is also injected in the scar and recipient sites.
Hair follicles survive through the absorption of oxygen from surrounding tissue. It is conjectured that the introduction of platelets and white blood cells through platelet rich plasma (PRP) would amplify the body’s naturally occurring wound healing mechanism. Others propose that PRP can actually stimulate the stem cells (dermal papilla) of the newly transplanted hair follicles. Some practitioners also claim that PRP can be used to stimulate the growth of follicles, thereby reversing hair miniaturization seen in androgenetic alopecia and even preventing hair loss.
While there is much conjecture as to the benefits of using PRP during hair transplantation and its use in the medical treatment of hair loss, there is little scientific evidence to support these theories at the present time. This is an exciting new area in the field of hair restoration that awaits further scientific data.
[Graft survival and the use of platelet rich plasma in hair transplantation
Our interest was stimulated by two previous hair restoration physicians, Carlos Uebel from Brazil and Joseph Greco from Florida, who reported improved healing and graft survival with use of PRP.
Vascular factors include the immediate post-operative oxygenation and successful revascularization of each graft. Unlike organ transplants where the transplanted organ is hooked up to a new blood supply, hair transplants are “free” grafts which are surgically implanted without re-attaching a new blood supply (because that would be impossible to do with hair follicles). Until this process is complete, the graft must survive by passively absorbing oxygen from the surrounding tissue. We have been using and testing a variety of techniques to ‘prime the pump’ so to speak: topical hyperbaric oxygen, vasodilators, and angiogenesis stimulators. This is where platelet - rich plasma (PRP) comes in.
How does applying PRP help transplanted hair? Remember that platelets are key players in the body’s wound healing mechanism. Whenever there is a wound (e.g. an incision to place a hair graft during hair replacement), the platelets are trapped in the clot and are activated to release various hair growth factors that stimulate the healing process. These naturally occurring growth factors include:
PDGF (Platelet derived growth factor)
TGF-a & b (Transforming growth factor alpha & beta)
EGF (Epidermal growth factor)
FGF (Fibroblast growth factor)
Insulin-like growth factor (IGF)
PDEGF (platelet derived epidermal growth factor)
PDAF (platelet derived angiogenesis factor)
These factors stimulate new blood vessels to form (angiogenesis) and collagen to be produced. Cells are stimulated to divide and go into action surrounding the wound. In addition, white blood cells present in the area help eliminate bacteria in the area. PRP merely amplifies this naturally occurring wound healing process by providing increased numbers of platelets and white blood cells to the wound. It is important that the PRP be concentrated enough to have a therapeutic value and some techniques and devices in use by some physicians today may not accomplish this. produce at least 1.5 million platelets/1ml, well above the therapeutic threshold. This represents about a five-fold increase compared to the platelet count in circulating blood (for 10 cc of PRP).
Follicular unit transplantation outcomes may be increased by the correct application of PRP.
Donor site pre-treatment with PRP ( purpose is to provide platelet cell therapy and platelet-derived growth factors, both of which are key elements in wound healing).
Recipient site pre-treatment with PRP ( this seems to be an important factor affecting graft growth and survival rates).
Optimal use of intra-operative PRP and platelet-derived growth factors, in and around the graft
Graft emersion in PRP ( “ soaking the graft in the PRP gel”)
Following advantages are claimed by use of PRP
to enhance donor site wound healing
to decrease the incidence of infection
to reduce donor scarring
to increase donor scar tensile strength
to enhance recipient site healing (which should increase growth)
to be utilized as an effective treatment protocol in severe cases of wound dehiscence or infection.
Today, physicians and scientists demonstrate that platelet rich plasma may actually wake up dormant follicular stem cells and could quite potentially become the next major breakthrough in treating hair loss and growing hair. While some people feel this is yet another marketing attempt to rob balding men and women of their hard earned money, others are very excited by its potential.
