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.

Latisse for Hair Loss

A recent article in the New York Times featured the use of Latisse (bimatoprost 0.03%) for the treatment of baldness.  As many of you may know, this Allergan-produced product is indicated for use for thinning eyelashes.

With the overwhelming response from my staff and patients, the product does work well.  I myself just started using it for thinning eyebrow hairs on the outer quadrants of my eyebrows.  By virtue of the prostaglandin effect on hair growth, this product was discovered in patients being treated at a higher percentage for glaucoma who were found to have secondary hair growth in the eyelash region.

The major limitation of this product at this time is cost, approximately $150 per month’s supply, for the eyelashes.  Obviously, potentially proportionately more when we are talking about a whole head of lost hair.  Nothing substitutes for a hair transplant in significant baldness, but Latisse may prove to be a good secondary option, especially if the price can be controlled.  Hopefully, Allergan will drop pricing when it finishes its initial FDA clinical trials.   A colleague of mine in New Jersey actually uses Latisse as his primary weapon against his own male pattern baldness.

At this time, I think Latisse is more of a novelty for extensive hair loss but can be beneficial for limited areas like eyebrows (my own) and eyelashes.

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

Designing a Temporal Point in Hair Restoration: Why, In Whom, and How?

The temporal point has become a much-vaulted point of discussion in many of the recent International Society of Hair Restoration Surgery (ISHRS) meetings.  When discussing the temporal point, the conversation is reserved here for men, as women typically do not have a pronounced temporal point (but still have one to a lesser effect).  A strong temporal point can be a very aesthetically pleasing and strongly masculinizing feature for men who choose to undergo a male hair restoration procedure.  It also allows a more aggressive anterior hairline design since the temporal point matches the hairline design and keeps it natural.  We talk about the concept of the “lid effect” which in short means if the anterior hairline is designed aggressively but the temples are not adequately rebuilt the result looks like a toupee, or hair system, because the two lines do not resemble a natural hairline.  Said another way:  no person has a very low hairline and a very receded temple except someone who is wearing a hairpiece, a typically bad one at that.  Therefore, understanding how, why and in whom to build a temporal point is an important undertaking.

Temporal Point Reconstruction

Let’s begin with the very strong word of caution that anyone in his first 5 years in practice performing hair restoration should probably not be creating temporal points.  They are the hardest areas to do right and to create a natural result.  It is one of the most telltale signs of a bad hair transplant, and a novice hair-transplant surgeon will almost invariably make a bad one.  When I teach surgeons how to do temporal points, I reserve this only for advanced students who have mastered the art of basic hair-transplant procedures first.  Why is the temporal point so difficult to do right?  In one word, angles.  The angles of the recipient sites have to be very very very low and flush flat with the surrounding skin.  This also makes it much harder for inexperienced graft placers to place into without problems.  Therefore, to create good temporal points, you have to have both an experienced surgeon and an experienced team of assistants.

Besides the angle of the recipient sites, their direction is also important.  In addition to having very low and flat angles, the sweep of the hair (the direction) must match that of a temporal point.  It tends to run at about a 30 degree angle backward and downward except at the peak of the point itself where it runs straight back and along the bottom portion that tends to run almost straight down.  These directional changes are subtle but must be maintained as well besides the low angle vis-à-vis the scalp to ensure a natural result.

Besides technique, a surgeon must find the right candidate.  The temporal points can require very few hair grafts or can expend quite a few of hair grafts depending on the degree of hair loss and the degree of desired restoration.  That being said, there must be correct judgment of who gets a temporal point and who should not get one.  A very young individual such as perhaps early 30s with significant hair loss would be the worst candidate.  The reason is that someone young and who has a lot of hair loss may run out of donor hair to cover the temporal loss that can ensue in other parts of the head that would later suffer hair loss.  Although a result can look natural today, it must be able to be maintained over a person’s lifetime.  That is something that a surgeon must always be mindful of when deciding to perform a hair transplant on a prospective patient. Oftentimes surgeries are done on patients who are not good candidates either due to unethical business practice or lack of knowledge on the part of the surgeon.  My goal in these articles is to shed light to a patient on these critical judgment issues that inform every good hair-transplant result.

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

Persistent Sexual Dysfunction with Finasteride: A New Study

What has been making rounds on the Internet this past week is a shocking report in the Journal of Sexual Medicine that states that finasteride (marketed as Propecia) for hair loss can cause permanent impotence and related sexual problems.  Merck, the manufacturer of the product, has reported between 3 to 8% incidence of sexual side effects; whereas the Journal of Sexual Medicine reported up to 38% in a study in 2008.  These numbers however have always been thought to be temporary in nature.

Michael Irwig, a medical researcher at the George Washington University in Washington D.C., the lead author of the study, argues that sexual side effects may not be temporary.  His team at George Washington University studied 71 men who reported these side effects including erectile dysfunction (ED), low libido and orgasmic issues, with average duration of ongoing symptoms being 40 months after stopping finasteride.  20% of these men reported ongoing symptoms for greater than 6 years after cessation of the medication.

I have had an email exchange with my hair-transplant colleagues from across the world regarding this matter to arrive at a collective understanding of how to educate our patients regarding these findings.  At this time, the International Society of Hair Restoration Surgery (ISHRS) is coming up with a position statement on this matter, which I will update you on as soon as it is pusblished.

My colleagues and I agree on one thing:  there are very few to none of our patients who experience permanent effects.  I personally have encountered only one patient who has reported this side effect, and I have probably prescribed over a thousand prescriptions for finasteride.  The data in this article is not controlled and only pulls from individuals who have experienced this problem.  In the general population there already is an incidence of 5 to 10% of ED in younger men with some reported incidences of 40% after the age of 40 years of age.  There are a host of physical and psychological effects that impact ED that may or may not be related to finasteride usage.

One thing is for certain, finasteride is a very effective, if not the most effective medication, for male pattern baldness and at this time is the major salvation for very young men (in their early to mid 20s) who are losing their hair and in whom surgical hair restoration may not be a safe option given the risk of ongoing hair loss and need for further hair transplants.  For those who have not experienced any sexual side effects from this medication, I would encourage you to consider continuing because I truly believe the data in this report is very soft and with the overwhelming percentage of my patients doing well on this medication I am a firm believer in its efficacy and safety.  In addition, I have found that those men who suffer sexual side effects from the medication have either had the symptoms dissipate with ongoing usage or improve just with taking the medication every other day.

I hope this blog provides a more balanced appraisal of the recent study than may be portrayed in the media and does not frighten patients who continue to do well on this medication or who are interested in starting it.

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

What Hair Loss Products Actually Work?

Fortunately, today there are medical solutions to manage male pattern baldness, which if started earlier can afford better results. The Internet is filled with hawkers of miracle cures, but there are only two FDA-approved products, finasteride (marketed as Propecia) and minoxidil (marketed as Rogaine) that have proven efficacy.

First, we must understand how we lose hair in order to understand how these products work effectively to combat hair loss. Male pattern baldness involves the slow but progressive transformation from thick, terminal hairs of youth to baby, short, wispy vellus hairs, and then finally to complete absence of hair. When 50% of hair is lost, noticeable thinning begins to be apparent. Finasteride and Minoxidil both work toward returning vellus hairs back toward thicker, terminal hairs but they cannot work in the absence of discernible hair, i.e., so-called “slick baldness.”

Accordingly, the earlier in the process of hair loss that these medications are started, the more effective they will be to help slow down and reverse to a certain extent the existing hair loss. If started late in the process of hair loss, they are less effective in managing/reversing the hair loss condition.

The mechanism by which minoxidil works is not entirely clear but it is thought to act as a cellular proliferator or to keep hairs in their growth phase (known as anagen) for a longer period of time. Minoxidil, which is over the counter now, is a topical preparation meant to be applied to the scalp twice daily. Anecdotally, it is thought that the half life of minoxidil in the scalp may be close to 20 hours, meaning that even once a day application can be substantially better than not at all. The package insert reads that minoxidil is only indicated for the crown/vertex region. However, this information is outdated and reflects only the original FDA studies performed over a decade ago. Although new FDA trials were not financed, subsequent studies have shown almost the same benefit in all regions of the scalp.

Minoxidil can lead to temporary increased shedding 3 to 4 weeks after starting the product and that must be known in advance to limit fear on the patient’s part. This temporary effluvium correlates with hairs cycling into the growth or anagen phase, which is a good indicator. In addition over 20% of individuals can experience a delayed (less than 72 hours) or immediate allergic skin reaction to minoxidil, which is significantly more common with the generic or brand named liquid version. The foam version that only comes as brand name Rogaine and only in the 5% male strength has virtually eliminated this problem by removing the propylene glycol component. Minoxidil typically starts to show effect rather quickly within 6 weeks to 3 months. As a reminder, hair loss will continue to occur. Minoxidil will simply slow down the hair loss as well as re-thicken some miniaturized vellus hairs.

Finasteride, an oral pill taken once daily at a 1 mg dosage, is prescription only and helps to slow down and reverse some vellus hairs. It is a medication that takes typically 4 to 6 months to start showing benefit and unlike minoxidil is only indicated for men, as it can cause birth defects in women of childbearing age who take it and has shown little benefit in women who are postmenopausal. Of note, there is no negative effect on children for men who take the medication and impregnate a woman. Finasteride is a dihydrotestosterone (DHT) blocker, that inhibits the conversion of testosterone to DHT via the pathway of the 5-alpha reductase enzyme. The presence of DHT in the scalp causes hairs that are sensitized to possible loss of hair to lose that hair. Because DHT receptors are partly located within the blood vessels that reach the hair follicle, topical finasteride has not shown to be of commensurate benefit as oral medication.

The major side effect with finasteride is sexual, including erectile dysfunction, loss of libido, and possible breast tenderness and/or growth. The incidence of this side effect profile is 1% when compared against placebo and only shows statistical significance when all side effects are aggregated. Side effects are reversible with cessation of the medication, and 57% of men who continue to take the medication show a resolution of their side effects. The individual who takes finasteride should also know that the prostate specific antigen (PSA) value is reduced by half and should therefore be doubled during calculation for men who are being screened for prostate cancer. In addition, because finasteride is metabolized by the liver, liver function tests should be undertaken before starting the medicine and should be followed by a physician as directed. The most recent study in 2008 showed that there is a potential 25% reduction in long-term prostate cancer risk for those who take finasteride.

Finasteride and minoxidil work synergistically to combat hair loss even better than if they were taken in isolation. Those who are willing to take both products and who have been guided by a physician for proper understanding of the risks, benefits, and limitations, should consider doing so. However, one major limitation with both products is that if one should in the future decide to stop taking either product, all the hair that was gained or maintained by that product will be quickly lost over a period of several months. This limitation should always be clearly understood.

Understanding the medical nature of hair loss in men is a prerequisite step before entertaining the desire for possible hair restoration surgery.

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