Dutasteride (Avodart) and My Current Position Statement on It

Dutasteride (Avodart) is marketed exclusively for benign prostatic hyperplasia, i.e., to reduce an enlarged prostate to improve urinary flow.  However, that does not mean that it is unsafe or not recommended for hair loss since the company (GlaxoSmithKline) that manufacturers it has never sought the indication for hair loss from the Food & Drug Administration (FDA), which can be an expensive endeavor.

Avodart (Dutasteride)

Like finasteride (Propecia), dutasteride is a dihydrotestosterone (DHT) blocker, i.e., it blocks the conversion of testosterone to DHT, which in turn limits hair loss since the presence of DHT impacts male pattern baldness.  However, unlike finasteride, dutasteride not only blocks DHT2 but also DHT1 so it is a more universal blockade of DHT.  Some initial studies have shown great efficacy with dutasteride than with finasteride.  Although dutasteride can be potentially more efficacious than finasteride, the question is at what cost, especially to the younger male.  It is unclear whether side effects are worse but some studies report more severe sexual side effects than with finasteride and there is the potential for dutasteride to cross the blood-brain barrier unlike finasteride.  For all of these reasons, I do not routinely prescribe dutasteride and only do so in the younger male patient who is willing to accept the risks because he is desperate for a solution and has not been successful with a course of finasteride.  In general, I rarely prescribe the medication not because I believe it is unsafe but because I do not believe we have sufficient data at this time to know the long-term consequences of dutasteride.

Samuel M. Lam, MD, FACS, a board certified hair transplant surgeon in Dallas, Texas. To learn more about hair loss, or to schedule a consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair loss forum.

Scarring Alopecias:  What You Need to Know for Hair Transplantation

There are many types of scarring alopecias (scarring hair loss) like lichen planopilaris, discoid lupus erythematosis, etc.  This article will not try to review all the many types of histologic (tissue) diagnoses but to explain what goes through my head as a hair-transplant surgeon when encountering various scarring alopecias for possible hair restoration.

When I am evaluating a person for possible hair restoration, I am always concerned with the possibility of a scarring alopecia that could negatively impact my transplant result now or in the future.  I carefully evaluate the scalp for any signs of abnormalities that may hint at this likelihood.  If the scalp looks particularly shiny without pores this can be a telltale sign.  Also, redness and inflammation in the area may indicate something as mild as psoriasis or hint at something more ominous like a scarring alopecia.  Since I am not a dermatologist if I have even a remote suspicion of a possible scarring alopecia, I will send it to a qualified dermatologist for a scalp biopsy.  Without a biopsy, even the most experienced dermatologist can be wrong if a scarring alopecia is suspected.

Scarring Alopecia

It is important that if a surgery is planned that the patient’s condition be completely burned out.  My minimum criterion is at least 2 years of biopsy-proven time that there is not active disease.  However, this still does not guarantee that the disease will not come back.  In cases of just tissue scarring from trauma for example, this is obviously not a concern.  However, a case of lichen planopilaris for example may flare up again in the future causing transplanted grafts to fall out over time.

There are two principal concerns that I have if someone has been diagnosed with a scarring alopecia.  The first concern is will the transplanted grafts take and grow.  If there is any concern a surgeon can transplant a few “test grafts” to see if the grafts will grow in the scarred bed of tissue.  However, even if they do grow, this is no guarantee that the rest will grow.  The second biggest concern, as mentioned before, is whether the disease that caused the scarring alopecia will reactivate in the future causing all of the transplanted hairs to fall out again.  This is why the minimum of a 2-year period of burn out is typically advisable if still not longer.  Sometimes a transplant can look good for a few years then fall completely out when the condition of scarring alopecia returns.  For an experienced hair transplant surgeon, teamwork with an equally qualified dermatologist is a must when treating patients with scarring alopecia.

Samuel M. Lam, MD, FACS, a board certified hair transplant surgeon in Dallas, Texas. To learn more about scarring alopecias, hair loss disorders, or to schedule a consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair loss forum.

Trichotillomania and Hair Restoration

Trichotillomania describes a condition in which an individual repeatedly pulls his or her hair out of one’s head or other body parts due to an obsessive-compulsive disorder (OCD).  Sometimes trichotillomania is accompanied by ingesting the hair causing a condition of indigestible hair products in the stomach known as a trichobezoar that may require surgical extraction.  Patterns of hair loss are typically unusual and follow the center of the scalp more where there is less pain with extraction than the periphery of the hair, where nerve sensation is greater.

Trichotillomania

The question that I encounter as a hair-transplant surgeon is whether I should offer a hair-transplant procedure to someone who has this condition.  This is obviously a complicated question, as it truly depends on the person and the extent, periodicity, and current state of the problem.  Here are two extremes.  Someone that is currently suffering from the problem clearly is not a surgical candidate for two reasons.  First, sometimes the plucked hairs come back if they are not overplucked.  Second, the ongoing nature of the psychological condition must be treated with anti-OCD medications before even contemplating the possibility of surgical intervention.  The opposite extreme is someone who had this condition when he or she was a child and has now many years out from it no longer has any desire or proclivity to engage in that behavior.  Working with a psychologist or a psychiatrist can help a surgeon determine the candidacy for a suffer of trichotillomania to undergo a hair-restoration procedure.

Samuel M. Lam, MD, FACS, a board certified hair transplant surgeon in Dallas, Texas. To learn more about trichotillomania, or to schedule a consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair loss forum.

Understanding Traction Alopecia and The Role of Hair Restoration

Traction alopecia refers to hair loss that arises from hair being pulled too tightly for too long causing permanent destruction to that hair.  Most typically, this condition is caused by tight hair braiding, as seen more commonly in African-American women.  Fortunately, this kind of hair loss is known as a non-scarring type of hair loss, i.e., the damage is only to the lost follicle and not to the surrounding skin.  Therefore, hair restoration for traction alopecia is highly successful.

Traction alopecia oftentimes affects the temple hair where a woman will tie back her hair causing loss of blood supply to this temple fringe.  In men who are Sikh, the hair loss can be circumferential around their head since their religion does not permit them to cut their hair and they must tie it up to be covered by a turban.  Accordingly, the tension is greatest to the hair around the periphery of the knot causing this unusual pattern.  Obviously, this is not a problem until they want to remove their turban when they abandon their religion.

Traction Alopecia Correction through Hair Transplant in an African-American Female

However, the most common indication still remains hair restoration for African-American women in the temple region.  Although donor hair density is typically low in Africans, the hair curl covers quite a bit of surface scalp distance.  Therefore, it is not as critical to dense pack the area when transplanting for traction alopecia.  I have found that transplantation for traction alopecia works very well with a high patient satisfaction.

Samuel M. Lam, MD, FACS, a board certified hair transplant surgeon in Dallas, Texas. To learn more about Dr Lam’s African hair restoration procedures and African hair loss disorders, or to schedule a consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair transplant forum.

Hair Loss After Pregnancy: When and Why

I have encountered many patients who experience hair loss after pregnancy and wonder what is going on.  What happens during pregnancy is that the body is sustained at a high level of estrogen.  Estrogen causes the hairs to stay in a prolonged state of anagen, or growth phase.  When the estrogen is reduced at the time of delivery, the hairs cycle back toward a more normal distribution in each of the three hair phases:  anagen, catagen, and telogen.  This condition of related hair loss is known as telogen effluvium.  At the time of childbirth, the hairs appear to shed because the percentage of hairs that were intended to be in a different hair phase rapidly cycle into that phase and hairs are then shed all at once rather than in smaller waves as they do in non-pregnant individuals.

Typically, this hair loss does not make anyone bald, but noticeable thinning can occur.  It is also a self-limiting problem that tends to rectify itself in the first few months after childbirth.  It is oftentimes worse after the first child is delivered than in subsequent pregnancies.  Minoxidil, or Rogaine, can be used to help stabilize the hair loss and shorten the period of shedding.  However, two words of caution should be extended.  Sometimes additional shedding can be noted at 3 to 4 weeks after starting minoxidil because the hairs can cycle back into the growth phase again causing hairs that move into this phase to be shed.  In addition, after stopping minoxidil, hair shedding can be noted again as hairs cycle out of the growth phase. Sometimes not intervening and just waiting it out may be a preferred course of action if there is not significant and socially embarrassing hair loss related to post-pregnancy shedding.  Remember whenever you experience hair shedding it is oftentimes worth seeing a dermatologist on internist just to make sure that it is in fact a benign condition like telogen effluvium and not indicating something more serious.

Samuel M. Lam, MD, FACS is a board certified hair transplant surgeon in Dallas, Texas. To learn more about female hair loss, and Dr Lam’s female hair transplant procedures please visit our website www.HairTX.com or call 1-888-866-3388 to schedule a consultation.