Dr. Smith Discusses Alopecia on “ENT in a Nutshell” Podcast
Ronit Malka: [00:00:00] And welcome back to another episode of ENT In a Nutshell, my name is Ronit Malka. And today I’m joined by Dr. Jesse Smith to talk about alopecia. Thanks for being with us, Dr. Smith.
Dr. Smith: [00:00:14] Thanks for having me.
Ronit Malka: [00:00:16] We’ll deviate from our standard format a bit here and start with the discussion on our differential while I think we all hear and think about male pattern baldness as the front runner on our differential.
What other things should we be including?
Dr. Smith: [00:00:29] So the most common type of alopecia is androgenic alopecia. As we’ve spoken about previously, this happens in male pattern baldness. There’s also female androgenetic, alopecia, and there’s traction alopecia, which commonly occurs after multiple, multiple braids for long periods of time.
And we see this a lot in females or males that were braided hair quite a bit. After that we think about your modifieds demon X for like your Loram for Lakey Litas secondary and tertiary syphilis, which cause patchy, LLP, seborrheic dermatitis, psoriasis, and pityriasis.
Ronit Malka: [00:01:08] And how do these patients usually present in clinic?
Dr. Smith: [00:01:11] We frequently see males with male pattern baldness. This is the most common presentation. The incense usually occurs with increasing age, uh, 30% at 30 years old, 50 to 60% at 50 years of age. And a lot, lot of times I’m Caucasian and Hispanic man as well. Asians that usually starts with I temporal recession and then begins with balding in the Vertex as well.
Female androgenic. Alopecia is fairly common in my practices. Well, and I do see quite a bit of it. It doesn’t always need an operation and this is where lab workout and good history physical come in. Did they start to lose hair recently? Did they lose hair as a child? Uh, do they have intermittent hair loss and does it swing back and forth to where it’s full?
And then again, these are all things that you can look at for systemic disease, but the angiogenic LPC for women comes a lot of the times by looking at their mother or their sisters, if their mother and sister had hair loss. And a lot of times this has to do with androgenic alopecia. This can commonly be fixed with 50 to 100 milligrams to spare in a lactone and it is an easy fix.
And usually within 12 to 16 weeks, these guys are coming in and they’re extremely happy. For traction, alopecia. This is common in people who like to wear tight braids and it can be male, female ethnic non-ethnic it just is exactly what it says. It is. It’s attraction problem. So the bar braids or the braided hair gets kind of pulled so tight or it has so much.
Wait on it from a braided lock that it actually pulls the hair out slowly and works it out. It is the equivalent to plucking the hair, uh, over a slow period. These are really hard to fix because as traction alopecia occurs, it leaves scarring behind. And one thing that’s really, really hard to get a good result in hair transplant surgery.
He was trying to place a follicle in a scar. It just doesn’t work as well because the college in there is not the same. And the blood flow is definitely not the same. For infectious causes that are related to syphilis. Usually we see redness scaling irritation. It almost looks like and infection would on any other area.
But we, we, we can also see quite a bit of, uh, skin excess in that area where you get a lot of epidermal sloughing. And so if you do see that it’s a common sign with a little bit of redness and . This is a possible infectious agent.
Ronit Malka: [00:04:00] And since it’s key to our further discussion, can we briefly review the pathophysiology behind normal hair growth?
Dr. Smith: [00:04:07] We usually have about 100,000 to 150,000 follicles in the scalp. Each follicle contains on average 2.3 hairs per follicle. The follicle is in the reticular dermis, which is below the papillary dermis. A bulb of hair equals the papilla. Plus the surrounding epidermal cells that begin to make the hair and a full for a unit is usually one to four hairs.
Plus it’s neurovascular plexus, the erector Pillay muscle. As well as a sebaceous gland, Villa’s hairs are different from terminal hairs. Fellas are very fine hairs, and you usually see these on, uh, children, uh, in the sideburn area. They’re very fun. And they only grow to a finite length. There are three phases of hair growth.
There’s antigen, which is the growth phase. It lasts about two to five years. 90% of our follicles are in this phase at any given time there’s catagen, which is involute national phase. This lasts about three weeks and, and less than 1% of our hair faults or in this phase at any given time Tila, Jen is arresting phase and this lasts about three months.
Five to 10% of our follicles are in this phase. And then you give them time as hair loss progresses, more and more hairs go into telogen phase and stay in that phase over time. If we look at scalp anatomy, S C a L P is an excellent acronym for this, it stands for skin dense connective tissue. Epic cranial app and Rosis, which is continuous with a smash in the face and the loose connective tissue, as well as the periosteum, the loose connective tissue and the periosteum together make up a pair of cranium.
There are five main arteries that supply the scalp, the super trochlear arterial system, the super orbital artery, the superficial temporal artery, the acceptable arterial system and the post your regular system. We really start to notice hair loss at about 50 graphs or 50 follicles per square centimeter.
The back of the hair usually has a constant of about 80 to 100 follicles per square centimeter. When we really start to notice hair loss is 50 and below when
you’re examining these patients, what things are you making sure to assess?
We often assess age skin to hair, color match, hair curl, and the pair density.
Ronit Malka: [00:06:53] Are there any criteria or grading systems that you use for bolding patients?
Dr. Smith: [00:06:58] The most common grading criteria and grading systems are the Norwood grading system. This is common for men. It’s classified as a Roman numeral one through seven and Roman numeral two, three, four, and five. Also have an, a category.
And Roman numeral three has a Vertex category as well for women, the female angiogenic LP show. We look at a lug with classification system and those are numeric values. One through three.
Ronit Malka: [00:07:33] Is there any other workup like labs or imaging you routinely get when assessing a patient with alopecia?
Dr. Smith: [00:07:39] I also in females, strongly encourage people.to look at our iron levels, ferritin levels, thyroid levels, including free T three free T four and TSH. I think you need to ask about PCLs B vitamin levels. Vitamin D vitamin K. Total iron binding capacity, hemoglobin content and DHA. All of these come into play, not only in females, but all individuals. And I think that these things need to be assessed with a full history and physical exam prior to going on to any other treatment.
Ronit Malka: [00:08:16] Moving on to treatment options, what are nonsurgical options for treating alopecia? And when would you want to use these.
Dr. Smith: [00:08:24] This has come a long way with the last 10 years. And it’s extremely exciting. Um, we’ve come so far with medications as well as non surgical therapies. We started off with minoxidil, which is Rogaine, which has a really interesting history.
Minoxidil was originally used as an oral medication. And it dilates blood vessels. It’s a potassium channel opener, sorry, increases blood flow by dilation of blood vessels. That medication didn’t work so well for hypertension. So it kind of went off the market for awhile. Then it came back as minoxidil because somebody thought we should use this topically in the scalp.
And it really does work well. It has to have content spent use, but it really does term some of these villas finer hairs that are in those later phases of Tila gen and brings them back as a terminal hair by increasing blood flow, increasing nutrients include increasing oxygen to these areas. The number of follicles in antigen increases, then we started using Propecia or finesse ride and Finasteride inhibits five alpha reductase type two.
It blocks the conversion of testosterone into DHT, and it is contraindicated in women of reproductive age because at risk of birth defects in the male fetus, but with recent and advances in benign prosthetic. Hypertrophy Avodart or do test drive became available now Avodart and do test ride do a better job at blocking the conversion of five DHT.
So in several countries, Avodart is actually used for male pattern baldness, including South Korea and Japan. That dose is 0.5 milligrams per day, and it was found in several studies to improve hair growth in men, more rapidly. And to a greater extent than even 2.5 milligrams per day of Finasteride. And we usually only only prescribe one milligram per day of Finasteride for these gentlemen.
The other things that are exciting is the matter process, which is Latiece the matter process was first used as a medication within the eye as an eye drop for open angle glaucoma. Interestingly enough, yes. These people that were using the medication reported fabulous growth of their eyelashes and they loved it.
So that became Latisse, which was put out by our, again, that worked really well for our lashes, for women that was placed on topically and not in the eye. So we got the idea of let’s put this on brows that are diminishing as well as scalps and it does work. So here’s another topical solution that we can put on the hair to assist with hair growth.
There’s now a laser hair therapy with a 655 millimeter diode. And these are diode laser with low level laser photo modulation therapy. And these are warm on the scalp as a, almost like a ball cap. And they’re done for three times per week at about 15 minutes per session. This is really exciting for guys because even before or after hair transplant, we’re increasing blood flow to the scout.
We’re decreasing inflammation. And this has been great adjunct procedure for both before and after surgery or. Some people I’ve used it and not needed surgery. It hasn’t some case has been shown to increase the number of follicles per square centimeter by as much as 19 follicles per square centimeter.
So if you’re just at that tipping point, right at that 50 follicles per square centimeter, we’re starting to notice hair loss, or if you’re a younger man who. We don’t really want to do surgery on because we don’t know how much hair loss is going to have. These are all really exciting therapies that we can use and avoid surgery.
Also a PRP, which is platelet rich plasma with or without, uh, AC or dermal grafting applied to the PRP has been done in sessions as few as two. And as many as six over about a four to six week break between each session, this has been found to increase hair density as well.
Ronit Malka: [00:12:55] And what are your indications for proceeding to surgical options?
And what are your main goals and considerations when thinking about surgery?
Dr. Smith: [00:13:04] The main thing you want to do is make sure that you’ve got a patient that’s old enough to know when their hair loss is, you know, at a point where you can help them younger men, 1825, 26 years old. Very hard to predict what’s going to happen.
So the last thing you want to do is do a hair transplant, put hair forward or in them, and then they go on to lose all the remainder of their hair. And now you’ve got permanent hair up there that you’ve, you’ve taken from the back of their scalp and placed. On top and it’s just not enough to cover it. So they wound up either shaving their head or, or trying to get some type of therapy to remove the hair that they’ve already put on them.
So age and predictability is a really important thing. We also, I make a natural appearing here line. We want to increase scalp coverage. We like to do that funnel hairline as the most important, and then work our way back. And really, I want to know, do we have enough density in the back of the scalp where we take the hair from to get enough grasps per square centimeter in the area that has hair loss to make sure that it looks good and that looks natural and it doesn’t look patchy.
Most of the donor hair in the post, your scalp has a graft density or a follicle density of about 80 to 100 follicles per square centimeter. Our ideal patients are dark skin patients with dark curly hair. The reason we like the dark curly hair is because if it’s curly, it can usually be in three planes all at one time.
So it’s one hair, but it’s in three different places. One time, the hardest is our light-skinned patients that have straight hair. Those tend to have the least fullness per look, even though they can have great density, they don’t have the same. Look as someone, one with an equal density that has curly or dark hair.
Ronit Malka: [00:15:10] So you’ve decided you want to proceed to surgical management of patients. Alopecia. What are your general approaches here?
Dr. Smith: [00:15:20] Two main approaches today, and those are for LeClair unit transplantation or strip grafting. There are others that have been done in the past. And those are punch graphs as well as scalp reduction surgery and, uh, jury flaps.
Those other three have been done as well, but I’ve personally never seen a punch for AFT a scalp reduction surgery or Zuri flap in the 20 years that I’ve been doing this. We have done strip procedures for a long period of time. And then along came the follicular unit transplantation. Which has also revolutionized quite a bit of what we do in hair transplants.
There are times and places where you choose one over the other. The strip graft is where we actually go to the back of the head and we look at what kind of mobility we have in the scalp. And you can take anywhere from a one to a two. Centimeter width of strip out. And my strips are usually about anywhere between 18 to 22 centimeters long, depending on the density, which you have, you take that out.
And then we cut each individual follicle out of that strip. You close this with a small advancement flap in the back of the scout and you close it with either PDs or Vicryl sutures and our proline. And you leave those sutures in place for about two weeks. And it is really, really hard to find that incision line once they field up for littler unit transplantation is where we shave the back of the head.
And then we have a very fancy what I like to call a drill press with a suction on it. So there is a one millimeter or 1.2 millimeter drill bit, basically that sharpened. And you. Basically come in at the exact angulation of the hair, go through the scalp, go through to the papillary. Dermer some to the reticular dermis and loosen that hair up.
And then there’s a gentle suction on that drill press and it sucks each individual follicle up and you do that. How many ever terms that you need to equal the number of graphs that you need. Those put pinpoint small, skinny, ours. They’re hard to see in the scab, but you get each individual follicle at a time and then you go under the microscope.
You sort, those two individuals as in singles and multiples. And then you go and place your sites in, at the scout and then you place each individual graft back into its particular side.
Ronit Malka: [00:17:57] And what considerations are you taking into account when deciding timing, positioning, and sizing of grafts?
Dr. Smith: [00:18:05] So your hairline needs to be age appropriate.
You definitely don’t want to bring a hairline down a really low on an elderly man, and you don’t want to place one too high on a youthful person. So we set our hairlines age appropriate. We also measure the hairline from Brown to Brown and make sure that when we do draw a hairline in that we make sure that it is even on both sides.
At that point, once we have our grass obtained and we start making our sites. We usually make our finer sites for those singles upfront for that first half at 1.5 centimeters on the frontal hairline. If you look at a natural hairline, it’s not just straight across, you want to make it just slightly wavy.
And we also like to put singles in that first one, half to 1.5 centimeters, because that’s the way the natural hairline is. As you fade back into that one to 1.5 centimeter region, then we start to introduce multiples as graphs that have two or three hairs per graft. And then as we get even further back, you can start to put your multiples in, or those are the three and four hairs per graft.
And we mixed singles with that. So there’s not singles up front and it looks less dense. And then all of a sudden you get into this really dense hair in the back. So there’s really an artwork to working in singles and multiples, but certainly singles come in that fertile hairline, especially in the temporal, Tufts and the temporal area.
And what is the expected duration of the results of these different treatments and what defines a good outcome?
This is what you really have to talk to your patients about. And you have to tell them several times I’ve learned. So when we first placed the graphs that are going to be fine stubble, and they’re going to look great, and the patient’s going to be real excited about 10 to 21 days after those graphs, many of them will fall out and the patients get really upset about that because they’ve spent a lot of time and energy to get these graphs.
But you have to understand, this is exactly like transplanting a tree until that root really gets enough blood supply and enough oxygen to grow the hair. It’s all about survival. So the graft wants to live. And it’s just taking its time to get enough blood supply and enough nutrients to then start growing those hairs back out that usually happens at about four to six months.
You really start to see those hairs come through. No, there’ll be fun and there’ll be almost, and they may only grow a certain height and then fall out. Okay. Can, but usually by that 12, 18 month, Mark, you’ve really got your final result. And this is when hair is really thick and lush. The hair follicle goes back to the exact same density and fullness and length that it always has as it came from in the back of the scale.
And this is when your patients are really excited about their results.
Ronit Malka: [00:21:08] Are there any complications you counsel patients about before hair transplantation?
Dr. Smith: [00:21:13] I think you really have to talk to patients about the fact that scarring can happen, uh, especially with strict procedures and even with the follicular unit extraction or follicular unit transfer, even with the small one millimeter drill press or the small one millimeter extraction technique.
Some people get little dots in the back of their scalp, and those can last for a prolonged period of time. As with the strip procedure, you are creating a scar, that’s a horizontal scar in the back of your scalp. I calmly counsel patients and tell them, look, if you’ve ever planned on shaving your head, there’s a chance that this thing is going to be seen.
And so we need to make sure that if that’s in your future, that we might consider doing a fully clear unit transfer. Or for liquor unit extraction instead of a strip procedure, you can also have fair to grow hair. It’s a rare, but I have seen it in a couple of people. And if the graphs are placed too low, they can turn into ingrown hairs and we have to go through and kind of pick out.
And unroof each one of those. And that can be a real chore for the patient and the physician.
Ronit Malka: [00:22:25] And what do you do to prevent or treat these complications?
Dr. Smith: [00:22:30] I can’t express enough. One is a good history and physical. If you’ve got a patient that has as horrible scarring on their body from cuts and bruises and scratches and other surgeries, they’re probably not going to be a good candidate because no matter what method you use, you are making small wounds scalp.
So I look at that primarily. I also. I asked them, do you have any other medical problems, uh, patients with uncontrolled diabetes and hypertension? Are they a good candidate for hair transplant? I think you have to look at all those things and you have to listen to the patient about their hair loss pattern.
You can’t just assume that it’s male pattern baldness. And that’s where we got into the differential diagnosis of what male pattern baldness is. Also our complications can occur with placement of graphs. If the graft is set too high or too low, when the scalp, when it’s placed them, if it’s set too low, you’re going to get ingrown hairs.
If it’s set too high, then it’ll never get the blood supply that needs. We always set these graphs just about a half millimeter out of the skin from whence. It came to scarring as contract all force, and it will pull that hair graph down into the scalp. If it’s set dead, even with the scalp, then it will pull it down.
And that’s where you get your ingrown hairs from.
Ronit Malka: [00:23:52] Is there any other kind of aftercare or precautions, postoperatively that you would recommend for these patients?
Dr. Smith: [00:24:00] We also are very meticulous about our aftercare. We don’t let her, it’s a shower with shower, water, or any water hitting the head immediately for at least three to five days afterwards.
And then you have to wear a loose ball cap or a loose surgeons hat for at least three to five days until those hairs actually start taking hold and the body is sort of grown into them so that they’re not loose. We also use some copper peptide solutions in order to assist with hair growth. And the most important thing is while the hairs haven’t taken over the life of the first three to five days is we constantly spray the scalp with normal saline in order to keep those grafts hydrated.
So hydration is important to keep the grass from drying out and then not taking.
Ronit Malka: [00:24:50] What kind of followup do you usually schedule for these patients?
Dr. Smith: [00:24:53] I usually see my patients back at the first week Mark, the second week Mark. And then after that, if they’re doing well, then we start spatial their appointments out.
If they’re doing really well, I’ll see them at the one month Mark. And then I’ll do two months after that and then three months and then six months.
Ronit Malka: [00:25:11] Was there anything else that you’d like to add or go over?
Dr. Smith: [00:25:15] I would say, talk to your patients and listen to your patients. A lot of times they will give you their diagnosis and their problem.
If you’ll just ask the right questions and listen to them, it’s easy to point to everyone as common androgenic alopecia, whether that be male or female, but if you really want to catch the people that have different types of LP shirt, you really have to just ask the right questions and listen to them and do a really good history physical exam.
Thank you for having me. I’ve enjoyed it.
Ronit Malka: [00:25:50] To briefly summarize, there are a number of etiologies of alopecia. The most common of which is androgenic health patient. This most frequently presents in men as male pattern baldness, beginning with bitemporal recession and progressing to Vertex balding, but can also affect women. Other hormonal etiologies, just hypothyroidism and infectious etiology, such as dramatic and syphilis can also cause alopecia, but typically present in patchy distributions and can include skin changes.
Alopecia can be graded on the Norwood scale from one to seven for male pattern baldness or on the Ludwig scale from one to three for female androgenic alopecia. When assessing these patients, noting skin to hair, color, match, and hair curl, and density is important as, as assessing a patient’s susceptibility to scar formation.
Some labs such as TSH free T three T four iron and some vitamin levels are important in ruling out other systemic etiologies of hair loss before proceeding with treatment, many nonsurgical treatment options exist, including minoxidil Finasteride, do test dried and blend out oppressed as well as laser therapy to improve blood flow to the scalp, which promote hair growth and can improve results after surgical therapies.
When considering surgery, we should consider expected future hair loss, pattern, and creating an age appropriate. Natural appearing hairline. Surgical options can include strip grafting and follicular unit transplantation, which are most common as well as punch grafts and jury flaps, which are much less commonly used.
Stripped grafting is often used for them larger defects and to create the frontal hairline. Whereas follicular unit transplantation is more commonly used when there is limited donor hair available or in patients who might shave their head in the future. It is important to counsel patients on expected post transplantation hair loss, which can be due to initially poor blood flow to follicles as well as telogen effluvium, or the expected hair loss that occurs when transplanted hair appropriately enters the telogen phase and falls out.
Other complications can include scarring, particularly with strip grafting, ingrown hairs, failure of transplanted hairs to grow and progression of alopecia to make transplant hair undesirable. Transplanted follicles are very susceptible to mechanical injury and dehydration. I need to be sprayed with water and protected with a loose cap, the immediate postoperative period.
It typically takes about 12 to 18 months after transplantation to see the final expected result. Before we go, we’ll wrap up with a couple of review questions as always. I’ll ask the question, pause for a few moments and then say the answer. Starting off, what are the three phases of follicle growth?
The three phases of follicle growth are anagen, catagen and telogen. The anogen phase is a growth phase lasting about three years. And the majority of our follicles are in this phase. At any time. Catagen is an evolution of phase. Last name about three weeks and Tila gin is a resting phase listing up three months.
What is most common and topical medication prescribed for alopecia.
Minoxidil also known as Rogaine is the most common topical medication prescribed for alopecia minoxidil acts by lengthening the antigen phase and increasing blood supply to the follicle.
And lastly, as somewhat of a bonus question, since we didn’t go into it in depth during the episode, describe a jury flap and what it is used for.
A jury flap is a temporoporiatal rotation flap that is used to treat from a balding. Its blood supply is the superficial temporal artery, and it should be noted that this is a very uncommon procedure today, given advances in strip grafting, follicular, unit transplantation, and nonsurgical treatment options.
Thanks so much for listening. We’ll see you next time.