What is alopecia?
The average person sheds more than a hundred hairs per day. This is no real cause for concern, as long as your body is replenishing these losses. When hair loss begins to exceed these thresholds, then it is time to worry.
Alopecia is a chronic inflammatory condition affecting hair follicles, resulting in discrete areas of hair loss. The separate areas may coalesce to form larger areas. The most commonly affected site is the scalp, but in rare cases the whole body, including pubic hair, may be affected. This is called alopecia universalis.
Alopecia occurs in approximately one per 1000 persons, affecting men and women equally. Most patients are below the age of 30 at the outset. The majority of cases resolve spontaneously, though recurrence is common.
Male pattern baldness, the most common form of alopecia, has been the source of emotional distress for men over the centuries.
Man's obsession with hair dates back to 3500 BC. From ancient biblical times to the Roman period, the specter of male pattern baldness has reared its ugly head. Julius Caesar was preoccupied with his hair loss and grew his hair long in the back and combed it all forward. He also wore laurel wreaths to camouflage his baldness.
Hippocrates, the father of Medicine made a potion for hair loss consisting of opium, horseradish, pigeon droppings, beetroot; spices and many other exotic ingredients (it didn’t work).
He observed that eunuchs (sexually immature men) never became bald. 2400 years later, researchers at Duke's University showed the association between the male hormone testosterone and male pattern baldness.
Baldness affects the scalp in a "horse shoe" pattern on the top of the head. In the majority of cases, the sides of the head is never lost. In approximately 1-2% of cases, the condition is spread to the entire scalp (called alopecia totalis).
What causes baldness?
There is no single definite-known cause for alopecia, but the most accepted explanation is that it is an auto-immune condition. Antibodies to hair follicles are frequently present in affected persons: these attack and temporarily damage the follicles, preventing further hair growth.
There is an association with other auto-immune diseases, such as thryoiditis, vitiligo and pernicious anaemia.
Up to 20% of patients have a family history of alopecia, which suggests a genetic predisposition. You may even have this tendency despite the fact that your parents have full heads of hair - this is due to a process known as spontaneous mutation, whereby the genetic information changes at conception.
Regardless of the genetic or auto-immune status, it is possible that a triggering event is required to initiate the episode of alopecia. Trigger factors which have been proposed include:
How is it diagnosed?
The diagnosis is primarily clinical, that is, based on findings at examining the patient. The hairless patches are typically painless, smooth and circular, with short broken hairs around the edges. The nails may also be involved, with roughening and pitting. Rarely, the eye may be affected. Biopsy of affected sites is rarely needed. Blood tests may be done to establish whether there are any underlying auto-immune conditions that may have precipitated alopecia and which might need to be treated.
How is it treated?
Most patients do not require treatment, as up to 80 percent who have limited alopecia will have spontaneous hair regrowth over several months. A minority may take several years to return to normal, and in some patients the hair never regrows. The prognosis is worse for patients with large areas of hair loss. Many patients will also experience relapses.
Myths regarding male pattern balding such as a decrease in blood flow, or a tight scalp, clogged or blocked pores, protein build-up, wearing of caps and hats no longer hold any truth.
Because male pattern baldness is not due to a decrease in blood flow, advertising claiming to increase blood flow in the scalp by expensive laser therapy cannot be effective.
Products that claim to stop hair loss have been around almost as long as concern about hair loss. Only two medical treatments have FDA-approval:
Finasteride 1mg oral tablet (brand name Finpecia)
Finasteride is an oral tablet, available only with a prescription, and is taken once daily. Its mode of action is well understood thanks to research that documented the hormonal cause of hair loss in androgenetic alopecia. Finasteride inhibits the enzyme that converts testosterone to dihydrotestosterone (DHT) in the follicle.
Finasteride has proven to be highly effective in clinical trials and in medical practice for slowing hair loss in almost all men and for reversing hair miniturisation in some men. It can be used alone or in conjunction with other hair loss treatments, including surgery.
Convenient pill form administration - one pill taken once a day.
Effective in most men - the vast majority of men using finasteride experience some benefit from its use.
Stops hair loss from progressing.
Beneficial side effects such as the shrinking of the prostate gland in men susceptible to an enlarged prostate.
Finasteride is not a cure for hair loss. It will only work over the long term if you continue taking it. If you stop taking finasteride, you will likely lose any hair you have gained within 12 months of stopping treatments.
Finasteride is not approved for use by women.
May cause sexual side effects such as decreased sexual desire(less than 0.5% decrease).
Finasteride is only available by prescription.
Minoxidil (brand name Regaine®)
Minoxidil is available over-the-counter and applied topically to the scalp skin in areas of hair loss. Minoxidil is available in SA in only the 2% strength. The 5% strength, which is only available when made up by a pharmacist to a doctor’s prescription, has been shown to be more effective in both men and women in slowing hair loss and promoting new hair growth.... unfortunately the 5% solution also has a significantly higher incidence of side-effects(such as contact dermatitus and other allergic reactions). Results of minoxidil's effectiveness in slowing or halting hair loss to some degree in men have ranged from 50% to 80% of men treated.
Only about 20% of patients have reported new hair growth. Minoxidil is ineffective for some men and women who continue to lose hair.
While it is available without prescription it is used most effectively in a physician-guided program of hair restoration, after the cause of hair loss has been diagnosed. Minoxidil's mode of action is not completely understood. It appears to prolong the anagen (growth) phase of the hair follicle.
Hair transplantation surgery involves the relocation of individual micro and mini follicular units from the sides of the head (donor area), which are not affected by the hair-loss process, into the area of bald skin (the recipient site).
The hair taken from the donor area will continue to grow and not fall out as a result of pattern baldness because this hair in this area is not sensitive to the male hormone DHT.
Today's hair transplantation owes its success to the fact that the transplanted hair follicles (roots moved from their original location to another area) behave in the same way as they did in their original site. For example, even in the most advanced cases of male pattern baldness, a horseshoe-shaped fringe of hair persists. Hair follicles moved from this hairy fringe to the bald area on your scalp will take root and grow.
“Lateral” slit technology
To best understand this concept one needs to look at the way in which hair grows in nature. It can be seen that rather than being arranged in random fashion, the follicular units are arranged in one of several patterns. Similarly the individual follicles within a follicular unit frequently are in set patterns. The follicles appear to be lined up alongside of one another in a plane perpendicular to the direction of hair growth.
This arrangement enhances the area of scalp covered by the follicles as opposed to being arranged in random fashion or one follicle behind the other. In practice there are many other advantages to the Lateral Slit technique.
The follicular units often grow in lines perpendicular to the direction of hair growth. This optimises scalp coverage and avoids redundancy of coverage, which will occur if the follicular units were arranged randomly or in a plane parallel to the direction of hair growth. Other advantages of the Lateral Slit Technique include precise control of graft angulations relative to underlying scalp tissue. It also only requires local anaesthesia.
The incisions made by the Lateral Slit Technique are shallower than other incisions, thereby reducing trauma to the critical blood vessels deeper in the scalp. When grafts are placed in recipient sites in a sagital fashion, the outward pressure exerted by each follicular unit and the pressures exerted by neighbouring follicular units are cumulative. This build-up of pressure within the scalp limits the number of follicular units that can be safely placed in a given area without risking compression or popping.
When the grafts are placed in lateral slits, there is free transmission of pressure to the outer surface of the scalp and the pressures of neighbouring follicular units is not cumulative.
Through extensive research and state-of-the-art developments in technique and instrumentation, hair transplantation has become a highly sophisticated, yet relatively simple procedure. Three to four months later the transplanted follicles begin to grow. This hair will need to be cut, washed and styled. It will never fall out since it originates from the donor area on the sides of the scalp.
Bear in mind that hair loss is a lifelong process and further procedures may be necessary to fill in ongoing hair loss. The transplanted hair, however, will never fall out. (February, 2010)
Dr Craig Ress and Dr Larry Gershowitz at Medical Hair Restoration (021) 425 7755 or www.medhair.co.za, South African Hair Foundation.