Bernstein Medical Center for Hair Restoration - Thinning Hair

Thinning Hair

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Q: My hair is starting to thin in the front, but it is not yet bald. I have been going back and forth about whether to get a hair transplant or use Propecia. I’m not sure what my first step should be. What do you think? — N.K. ~ Pleasantville, N.Y.

A: In general, patients who are thinning, but not actually bald, should begin with combined medical therapy (finasteride and minoxidil) for at least a year prior to considering surgery. In many cases, with this regiment, surgery can be postponed or even avoided completely. Unfortunately, some patients cannot tolerate finasteride or choose not to take it due to concern about potential side effects. Minoxidil, although useful, does not significantly alter the long-term course of hair loss when used alone.

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Q: Hi. I am 52 years old and wish to know if Propecia will work for people my age. I have started losing some hair a couple of years ago and it’s thinning out. Thank you very much for your help. — K.E., Boca Raton, FL

A: Propecia (Finasteride 1 mg) can hold on to hair at any age, but works best to re-grow hair in those who are younger.

The reason is that finasteride works to reverse miniaturization (the thinning and shortening of hairs due to DHT). Younger patients, with early hair loss, generally have more hair in the early stages of miniaturization where the changes are readily reversible.

Older patients are more likely have more advanced miniaturization or areas that are totally bald and will thus not regrow with medical therapy.

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Dr. Angela Christiano of Columbia University in New York and a team of scientific researchers have identified a new gene involved in hair growth. Their discovery may affect the direction of future research for hair loss and the diagnosis and ultimate prevention of male pattern baldness.

The condition which leads to thinning hair is called hereditary hypotrichosis simplex. Through the study of families in Pakistan and Italy who suffer from this condition, the team was able to identify a mutation of the APCDD1 gene located in chromosome 18. This chromosome has been linked to other causes of hair loss.

According to Dr. Christiano, “The identification of this gene underlying hereditary hypotrichosis simplex has afforded us an opportunity to gain insight into the process of hair follicle miniaturization, which is most commonly observed in male pattern hair loss or androgenetic alopecia.”

The mutation of the APCDD1 gene inhibits the Wnt signaling pathway. Although this recently discovered gene does not explain the complex process of male pattern baldness, the importance of this discovery lies in the Wnt signaling that the gene directs, has now been shown to control hair growth in humans, as well as in mice.

Reference: Nature 464, 1043-1047 (15 April 2010) | doi:10.1038/nature08875;

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O, The Oprah Magazine - March 2010O, The Oprah Magazine featured hair loss in women in the beauty section of their March 2010 issue.

Dr. Bernstein was consulted for the article:

Hair transplant: A possibility if your hair loss is concentrated in specific areas. Hair follicles (in groups of up to four) are surgically removed from an area on your scalp where growth is dense and then implanted in the thinning patches. Since female hair loss is often diffuse, only about 20 percent of female patients with thinning hair are candidates, says Robert Bernstein, MD, a New York City dermatologist who specializes in these surgeries. (The price tag can run from $3,000 to $15,000.)

In October 2008 Dr. Bernstein appeared on the Oprah Winfrey Show, where he spoke with Oprah and Dr. Mehmet Oz about hair transplantation and gave a live demonstration featuring the hair transplant results of one of his patients.

Watch a video clip of Dr. Bernstein and Oprah discussion hair transplantation.

Read the full article at Oprah.com.

Reference:
“The Truth About Hair Loss,” “O” – Oprah Magazine, March 2010; p90.

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Q: Will Propecia and Minoxidil reverse some of the miniaturization going on with someone with thinning hair? If I do need a hair transplant will I have to stay on these medications? — C.C., — Fairfield County, Connecticut

A: Yes, both minoxidil (Rogaine) and finasteride (Propecia, Proscar) affect the miniaturization of the hair follicles and help restore the shrunken follicles to cosmetically viable hair.

Minoxidil works by directly simulating miniaturized follicles to grow, whereas finasteride blocks DHT, the hormone that causes hair to miniaturize and eventually fall out.

Finasteride is much more effective than minoxidil in preventing or reversing the miniaturization process and it is so much more convenient to use that we generally suggest finasteride after a hair transplant procedure, but rarely recommend minoxidil.

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Q: I am a 45 year old woman and I am beginning to thin on the top of my scalp. I don’t want to use medications and I don’t think that I am quite ready for surgery. Is there anything else I can do? — E.H., Rye, NY

A: There are a number of things that you can do that can make you hair look more full and help disguise the thinning. Lightening ones hair will allow the hair to reflect more light and appear thicker. In lighter-skinned races it will have the additional advantage of decreasing the contrast between the hair and skin and thus the skin will essentially act as a filler between the strands of hair.

Streaking the hair is also helpful to make the hair look thicker. Waving or perming will help as well, as it will give the appearance of more volume. Normally, the hair tends to fall into a natural part where it is the thinnest. If you part your hair in the thickest area (usually the side opposite from where you are used to, or slightly lower on the same side) this will make the hair appear fuller and less see-through.

Finally, there are a number of cosmetic products that can make you look like you have more hair.

Visit the Cosmetics for Hair Loss page on the Bernstein Medical – Center for Hair Restoration website.

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Q: I have some early thinning in my crown and the doctor said I am too early for a hair transplant. I don’t want to take Propecia, but using Rogaine twice a day is a big nuisance. Can I use Rogaine once a day? — L.B., Cleveland, Ohio

A: The tissue half-life of minoxidil is 22 hours.

This means that 22 hours after it is applied, about 1/2 of the compound is still bound to the skin and exerting some effect. Because of this, once a day dosing is probably OK.

Please note that this is hypothetical and that there have been no controlled studies to confirm this.

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Q: I am 22 and losing my hair all across the top of my head. How can I thicken my hair to its level a few years previously? — I.L., Kentfield, CA

A: If medication, such as finasteride, is successful it can thicken hair by increasing the diameter of the existing hair shafts. Although the cosmetic benefits can be dramatic in a person with significant hair loss, a hair transplant can not restore hair to its original density, since it only moves the existing hair around and does create new hair.

When hair cloning technology is available, this will change as a person’s donor supply will be increased.

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Q: I underwent hair transplant surgery several years ago and was pleased with the results. However, over the last 2-3 years I’ve lost hair in the donor area with subsequent loss of hair in the transplanted area. Is this type of hair loss especially difficult to treat? What accounts for hair loss from the back of the head that is typically considered “permanent”? — F.D., Laude, Missouri

A: Less than 5% of patients have unstable donor areas, i.e. where the back and sides thin along with the front and top. We call this condition Diffuse Unpatterned Alopecia or DUPA. It is best to identify this condition before hair transplant surgery is contemplated as people with DUPA are not good candidates for hair transplantation. The diagnosis is made using densitometry by noting high degrees of miniaturized hair in the donor area.

At this point, I would use medications such as finasteride. I would not do further hair restoration surgery.

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Q: I have been on Propecia for a year and my hair loss has not stopped or slowed down. How much longer should I give the drug? Can Propecia speed up hair loss in some patients? — N.V., East Hills, N.Y.

A: If you have not responded to Propecia in one year, it is unlikely that you will.

Finasteride may cause shedding in the first 6 months of treatment, but should not accelerate hair loss long-term. It is most likely that you have progression of your hair loss.

In addition, be sure that you have a correct diagnosis i.e. that you actually have androgenetic alopecia.

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Q: Over the past three months, my hair seems to be thinning more on one side. Is it common in male pattern hair loss for it to be more on one side? I had a lot of stress about three months ago and have heard that this could be the cause. Is this possible? Should I use Rogaine to treat it? — B.R., Landover, MD

A: Regardless of the cause, hair loss is usually not perfectly symmetric. This applies to male pattern hair loss as well.

In your case, it is important to distinguish between telogen effluvium (shedding that can be due to stress) and hereditary or common baldness. The three month interval from the stressful period to the onset of hair loss is characteristic telogen effluvium, but you may have androgenetic alopecia as an underlying problem.

The two conditions are differentiated by identifying club hairs in telogen effluvium and miniaturized hair in androgenetic alopecia. In addition, a hair pull will be positive in telogen effluvium (when a clump of hair is grasped with the fingers, more than five hairs pull out of the scalp at one time) and will be negative in common baldness. The hair loss diagnosis can be made by a dermatologist.

Hair cuts do not affect either condition.

Rogaine (Minoxidil) is only effective in androgenetic hair loss and only marginally so. Finasteride is the preferred treatment if your hair loss is genetic when it is early and a hair transplant may be indicated if the hair loss progresses.

Shedding from telogen effluvium is reversible and does not require specific treatment.

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Q: What is the difference between Rogaine for men and Rogaine for women? — G.K., Hawthorne, N.Y.

A: Rogaine, the brand name of generic minoxidil, comes in formulations for both men and women. The men’s versions come in a 5% solution and a 5% foam while women’s products are the 5% foam and 2% solution. Of these, the strongest and most effective is the 5% men’s solution. This is due to the inclusion of propylene glycol, which is a vehicle that helps the active ingredient, minoxidil, to more readily penetrate the scalp. As the other products do not contain propylene glycol, they may be slightly less effective.

Instructions for use also differ on the label between the men’s and women’s products. All products (5% men’s solution, 5% men’s foam, 2% women’s solution) recommend twice daily use, except for the 5% women’s foam which recommends once daily application. In reality, a thorough once daily application seems to be nearly as effective as twice daily for all version of topical minoxidil.

While the 5% solution may be stronger, it is more irritating to the scalp and more difficult for some to tolerate. Some people have a sensitivity to the added propylene glycol and will experience redness, burning, itching, and irritation. If this occurs, patients should switch to the 5% foam or 2% solution. We also recommend that patients use enough of the medication when they apply to adequately cover the treatment area of the scalp. Often, this means using 2 or 3 capfuls of foam or 2-3 droppers full of the solution (2-3mL).

It is important to understand, that contrary to the more restrictive package indications, it works in all areas of the scalp where there is thinning. It is not only for use in the crown. Many patients find that evening application allows the full 4-6 hours of contact time necessary for absorption and that the product will dry overnight and no longer look greasy in the morning. Results can appear as early as 3-6 months, but we often advise using minoxidil for a full year before judging its efficacy. As the hair is always cycling and growing, the product will need to be continued daily for ongoing benefit.

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Q: Dear Dr. Bernstein, a full head of hair averages ~100 FU/cm2. To achieve the appearance of fullness with a hair transplant 50% is required. In one of your articles you say that you recommend 25 FU / cm2 to your patients. Is that the density per one session or the final one? If that is final density, then it is far below the 50%. Please explain as I am profoundly confused. — W.N., Easton, C.T.

A: If a person is to become a Norwood Class 6, the hair that we have available for us to transplant is only about 12% of what was there originally. This, of course, will vary from patient to patient depending upon one’s donor density and scalp laxity and a host of other factors.

We make the hair restoration look good by restoring 25-50% in the front, and proportionately less in the back. Logically one cannot restore 1/2 of ones original density to an entire bald scalp with only a thin strip of donor hair – there is just not enough hair, even with multiple sessions.

I transplant 25-35 FU/mm2 in one session, but this is the density created in the front, not overall.

Due to follicular unit graft sorting (placing the larger follicular units in the forelock area) this provides even more density than the actual numbers suggest. If someone is relatively certain to have more limited hair loss, then the numbers can be increased, but it is risky if you underestimate the degree of eventual hair loss.

Please carefully read the article on Hair Transplant Aesthetics.

It will answer your excellent question in greater detail. The article is a bit old, but the principles are the same.

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Q Do Rogaine and Propecia work synergistically? — N.W., Chappaqua, N.Y.

A: They are synergistic, since the mechanisms of action are different.

Rogaine directly stimulates hair growth, while Propecia is permissive for hair growth by blocking DHT, the byproduct of testosterone that causes hair to miniaturize and eventually disappear.

The important thing to remember, however, is that for most people, Propecia is far more effective.

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Q: I have a question about one of the products referenced under the Camouflage section of your website. As you suggested, I have begun to use DermMatch as an alternative to a hair transplant as I have diffuse thinning and been told that hair restoration is not an option right now. I have been very impressed with the results of DermMatch. However, I am concerned that the product might be damaging my existing hair or impeding future growth. Should I have any concerns about this product?

A: None of the well-known cosmetic camouflage products will damage hair or inhibit its growth.

The products come in a variety of forms, including sprays, creams, powders.

A list of these products, their descriptions, and the telephone number where you can obtain them can be found on the Cosmetic Camouflage Products page of the Bernstein Medical website.

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Q: What is your opinion on having a hair transplant to restore the hairline and then wearing a hair system behind it to regain the appearance of a full head of hair? K.Y. – Hackensack, New Jersey

A: It is my personal feeling that one should not use a hair transplant to supplement a hair system, especially at a young age. We have occasionally performed this procedure in older men and women.

In my view, a main purpose of a hair transplant is for it to be low maintenance. The combination of a hair transplant and a hairpiece is extremely fussy.

In addition, hair systems cause traction alopecia (hair loss from constant tugging) and the hair loss will become permanent over time, limiting the ability to have a hair transplant in the future. If one needs to have the high density of a system — i.e. for a career — then just use the system. It will give you more long-term options.

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