Bernstein Medical Center for Hair Restoration - Extensive Baldness

Extensive Baldness

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What are the chances that I will go bald? How bald will I be? Can I know for sure? These are among the most common questions we get from patients in our hair loss consultations. Despite extensive knowledge about the mechanisms and causes of androgenetic alopecia (common baldness), the answers to these questions have been a bit hazy. New research has sharpened the focus on the genetic mix that results in hair loss and has enabled more accurate predictions. A study published in February 2017 in the journal PLoS Genetics identified over 250 gene locations newly linked to hair loss. Using this information, researchers more accurately predicted severe balding compared to previous methods.

Background

We know that susceptibility to hair loss is driven by genetics. One in two men in their 50s experience some degree of balding, with that proportion increasing to over 60% of men aged 60 and over. We also know that one of the most important genes in hair loss, called the androgen receptor (AR) gene, is located on the X chromosome. Outside of that, knowledge of the precise genetic makeup resulting in baldness is sparse and there is wide variation in balding patterns. Some genetic tests, such as the HairDx test, have been developed to predict a patient’s risk of balding, but lack the ability to determine its severity. To date, the best method for predicting the extent of future hair loss is to have an experienced physician take a personal and family history and perform a physical examination that includes an assessment of miniaturization of scalp hair.

Developing a more thorough understanding of the complex genetic relationships that result in hair loss will be important in clinical practice as these relationships may help predict future hair loss and guide methods of treatment.

The Study

Researchers selected a pool of more than 52,000 men with male pattern baldness from UK Biobank. This is a massive database of over half a million people aged 40-69 years with information accumulated from 2006 to 2010. This pool was over four times the size of the previously largest hair loss study. Researchers applied a genome-wide association study (GWAS) to a cohort of about 40,000 men and identified 287 statistically important gene locations (loci) linked to varying degrees of baldness — more than 35 times the eight genetic signals found in the previous largest study.

Using this set of 247 loci on non-sex, or autosomal, chromosomes and 40 loci on the X chromosome, the researchers analyzed the remaining 12,000 men for predictive patterns. The results indicated that the predictive value of using this set of gene loci was 0.78 for severe hair loss, 0.68 for moderate hair loss, and 0.61 for slight hair loss. When the subject’s age was added, the predictive score improved to 0.79 for severe hair loss, 0.70 for moderate hair loss, and 0.61 for slight hair loss. Subjects whose individual scores, based on their genetic makeup, were below the mid-point of the range of scores were significantly more likely to have no hair loss than severe hair loss. By contrast, almost 60% of subjects whose individual scores were in the top 10% of the range of scores were moderate to severely bald.

While the predictions were not extraordinarily accurate – the authors characterized the accuracy as “still relatively crude” – they did show a distinct improvement in predictive accuracy over prior studies.

Summary

Hair loss is a serious concern for many people. Research shows that men with extensive hair loss may experience significant psychosocial impacts such as reduced self-image and reduced social interactions. Some studies have associated baldness with increased risk of prostate cancer and heart disease.

Understanding the complex factors that comprise the genetics of hair loss can help physicians potentially customize treatments based on a patient’s genetic profile and their risk of balding. Beyond that, diagnosing the potential severity of hair loss may help doctors get a head start on treating what could be related life-threatening conditions.

With large databases like UK Biobank, researchers can now drill down into this information and develop increasingly clear, highly granular data sets that can identify complex systems and potentially lead to improved treatments.

References

Hagenaars SP, Hill WD, Harris SE, Ritchie SJ, Davies G, Liewald DC, et al. (2017) Genetic prediction of male pattern baldness. PLoS Genet 13(2): e1006594. doi:10.1371/journal.pgen.1006594

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Crown Balding and Heart Disease Linked in British Medical Journal Study

A new meta-analysis of six studies, published in the British medical journal BMJ Open, has found a linkage between balding at the crown and coronary heart disease. While the top-line result of the study may be alarming, let us look first at some of the key facts.

  • While the study showed a modest link between crown balding and heart disease, the link was not as strong as for other heart disease indicators such as smoking, obesity, cholesterol levels and blood pressure.
  • There was no link established for men with a receding hair line.
  • Key indicators of heart disease — high blood pressure, high LDL cholesterol, and smoking — are present in about half of Americans, according to the Center for Disease Control in America. So this is a health issue faced by many Americans, hair loss or not.
  • Importantly, the most appropriate response if you have balding at the crown (and particularly crown balding at an early age), is not to worry first and foremost about your hair, but to concentrate on basic heart health and maintaining a healthy lifestyle. Discuss these issues and any concerns with your primary care physician.

Researchers at the University of Tokyo in Japan compiled information from six different studies with a combined total of almost 37,000 male participants. The studies were published between 1993 and 2008. Although one of the six studies did not find a link between baldness and coronary heart disease, the other five studies did find a link with the strength of the association differing in each study. In general, the more severe the balding at the crown, the more likely there was an association with heart disease. In addition, early onset of vertex balding — i.e. early balding at the crown — was found to be associated with the early development of more significant heart disease.

More research needs to be done to investigate the actual medical causes of the linkages shown.

An article on the BBC News website quotes a cardiac nurse from the British Heart Foundation discussing the findings:

“Although these findings are interesting, men who’ve lost their hair should not be alarmed by this analysis. Much more research is needed to confirm any link between male pattern baldness and an increased risk of coronary heart disease. In the meantime, it’s more important to pay attention to your waistline than your hairline.”

Image c/o BBC online

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Q: What is the most common cause of necrosis (death of tissue) in the recipient area? — A.Q., Los Altos Hills, C.A.

A: Recipient site necrosis is one of the worst complications of a hair transplant and results in skin ulceration and scarring. Usually it is caused by a combination of a few or many of the factors listed below. Each by itself should not present a risk.

Pre-existing conditions in the patient such as:

  1. smoking (the big one)
  2. diabetes (juvenile more than adult onset)
  3. photo-damage (alters the collagen and vasculature)
  4. long-standing baldness (less blood supply when there are no follicles)

Poor surgical techniques:

  1. recipient sites that are too large
  2. recipient sites that are placed too closely (too dense)
  3. too many grafts placed at one time
  4. too much epinephrine used in the procedure
  5. multiple procedures in one session — i.e. FUE and FUE in same session, or large FUT and Graft excision, scalp reduction, etc.
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Q: Is it recommended to wait for 1 year after starting Propecia, when the effect of the medication kicks in and improves density of donor area, and then perform the surgery? — Z.B., Bergen County, New Jersey

A: Propecia will not affect the donor area, as this area is generally not impacted by the miniaturizing (thinning) effects of DHT –- the hormone that Propecia blocks. The purpose of waiting the year is to possibly regrow hair in the recipient area. If regrowth is significant, a hair transplant may not be necessary. If a person’s hair loss is extensive and there is little chance that Propecia will grow a significant amount of hair back to give a satisfactory improvement, then waiting the year is unnecessary.

Read more about Propecia or read a summary of a study on the effect of Propecia on a hair transplant.

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Q: I am in my early 20’s and I was told my hair loss pattern is a Norwood Class 6, on its way to becoming a Class 7. My hair is brown in color and medium to coarse and I was told I have high density in my donor area. Although I was told I could have hair transplants, do you think that I should based upon what I have told you? — D.W., Pleasantville, N.Y.

A: The main concern I would have is that when someone is already a Class 6 by their early 20’s, he may eventually be left with only a very thin see-through fringe as he ages. A high donor density now does not ensure that this will not occur – and coarse donor hair at age 22 does not ensure that it will not become fine over time. In fact, there is a significant chance that it will.

Since the hair restoration would require one or more large sessions, there is a risk that the donor scar(s) will not be hidden over time. If you had a widened linear donor scar from an FUE-strip procedure, you would need to grow your hair longer on the back and sides to cover it (if that is even possible). And this look of longer hair on the back and sides would not be a good one for a young person, especially if there was not enough donor hair to fill in the crown.

On the other hand, large FUE sessions leave a very wide band of small round scars in the back and sides of the scalp that can become visible if the anticipated permanent donor zone was not truly permanent and narrowed over time.

When we are younger, our decisions are often more emotion-based and impulsive. When one is older, and our tastes change, we may change our mind about having had surgical hair restoration, but the hair transplant, once performed, is not reversible.

Read about the Candidacy for a Hair Transplant

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Q: It is my understanding that as a person loses his or her hair, the skin of the scalp undergoes a number of changes, namely there is a loss of fat, an increase in cellular atrophy, and of course the dreaded perifollicular fibrosis (now that’s a mouthful). It seems to me that these changes, in particular the fibrotic scarring, are the main obstacles in the way of regrowth, and the reason Propecia does not work for extensively bald men. What can be done about this demon we call fibrosis? Can it be slowed, stopped, prevented, reversed? If we could somehow counteract collagen formation, wouldn’t our baldness problems be solved for good? If a bald scalp is atrophic, how does it have the capacity to hold a whole new head of transplanted hair? Is there a limitation to the number of hairs we can transplant (outside of donor limitations)? — R.L., Rivington, C.T.

A: The findings that you are describing are well documented; however, it is not clear if these changes are the cause of the hair loss or are the result of having lost one’s hair. Most likely, the DHT causes the hair follicles to miniaturize and eventually disappear. This, in turn, causes the scalp to thin and lose its abundant blood supply (whose purpose is to nourish the follicles). The changes in the scalp are also affected by normal aging, which causes alterations in connective tissue including the breakdown of collagen and other components of the skin. The changes seen with aging are greatly accelerated by chronic sun exposure.

Fortunately, even with long-standing baldness there is still enough blood supply to support a hair transplant, although there are some limitations. One should perform a hair transplant with a lower density of grafts when patients have thin, bald fibrotic scalps since the blood supply is diminished.

The most important factor, however, is photo change. The sun dramatically alters the connective tissue making the grafts less secure in their sites and alters the vasculature, (blood vessels) decreasing tissue perfusion (blood flow to the tissues). When there is bald atrophic, sun damaged scalp, I generally perform two hair transplant sessions of lower density (in place of one) spaced at least a year apart to give time for the scalp to heal and blood flow to increase in the area.

I often have the patient treated with topical 5-flurouracil before the surgery to improve the quality of the skin and to treat or prevent pre-cancerous growths from the sun.

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Q: Should you perform a hair transplant on a crown that is just starting to thin? — R.R. Philadelphia, Pennsylvania

A: A “thin” crown should first be treated with Propecia, as it may thicken the hair to a cosmetically acceptable degree without the need for surgery. If Propecia is ineffective in restoring enough hair, then surgical hair restoration can be considered.

The surgeon must also factor whether or not the patient has enough donor reserves to transplant the front and top part of the scalp if the patient becomes very bald. This is hard to predict in patients who are still in their twenties.

See the paper Follicular Transplantation: Patient Evaluation and Surgical Planning for a more complete discussion.

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Q: I am 27 years old and have a Class 3 degree of hair loss. Should I do a hair transplant or consider non-surgical methods of hair restoration? — Y.B., Lake Forest Illinois

A: At age 27 with early hair loss, you should consider non-surgical options first.

Propecia is the most important medication, but you need to be on it for one year at the full dose of 1mg a day to assess its benefits.

If you have done this and other parameters are OK for a hair transplant, such as adequate donor hair density and scalp laxity and you have little evidence that you will become extensively bald (i.e. no donor miniaturization and no family history of extensive baldness), then hair transplantation can be considered.

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Hair loss has a variety of causes. Diagnosis and treatment is best determined by a board-certified dermatologist. We offer both in-person and online photo consults.

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