Robert M. Bernstein, M.D., New York, NY
Hair Transplant Forum Intl. 1997; 7(2):14-15.
The itching that occasionally follows a hair transplant is most commonly caused by post-operative crusting. Less often, it is due to excessive drying of the scalp from aggressive shampooing, an infection (infectious eczematoid dermatitis), an allergic reaction to topically applied agents, or a previously existing skin condition (such as psoriasis).
As we all know, itching is the sensation that causes one to “scratch.” In the “evolutionary sense” scratching was the means by which we removed different foreign objects (such as bugs) from the surface of our skin. Unfortunately, man has not evolved so far as to be able to differentiate the “useful” itch, produced by various “critters,” from the problematic itch, caused by the crusts or scabs that form when the serum that exudes from all skin wounds (surgical or otherwise) subsequently dries.
Itching should always be prevented after a hair transplant because, in addition to being a nuisance for the patient, it is invariably associated with scratching (conscious or unconscious), and this increases the chance of dislodging grafts, opening donor incisions, and bacterial infection.
We markedly decrease the incidence of itching after a hair transplant by using a strict post-operative protocol whose primary objective was to promote wound healing. This includes using an antibacterial ointment along the suture line to keep it greasy for 2 weeks after the surgery. With this technique, patients sometimes complain of the greasiness, but rarely the itch. In the recipient area, we decrease the formation of crusts by the irrigation and gentle washing of the recipient area twice a day following surgery and each day thereafter. A mild shampoo is used to facilitate the removal of the crusts. If the crusts are not removed in the first two days, they will generally persist until the hairs that they are adherent to are shed.
We perform all of our hair restoration procedures using Follicular Transplantation where the follicular unit grafts fit snugly in a very small site. We do not recommend showering the day after hair transplant surgery with other techniques if there is a chance that the grafts may become dislodged.
For the occasional patient that does itch in spite of these measures, after infection and contact dermatitis have been ruled out, we prescribe hydrocortisone ointment 1% (OTC) or 2.5% applied as needed to the suture line and/or the recipient area. If patients complain about the greasiness, they can either put less on or use it only at night (but this will decrease the efficacy). The key is to keep this scalp greasy after the hair restoration! In fact in a recent publication, the authors showed that white petrolatum was as effective as Bacitracin ointment in promoting wound healing and was also less expensive and had no risk of contact dermatitis. With proper patient education, the “greasiness” of ointments can be easily managed for the two weeks following the hair transplant procedure.