Suitability for FUE hair transplantation by hair loss cause
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When deciding on whether someone is a good candidate for hair transplantation, all of the following questions should be answered affirmatively:
- Is there a predictable, stable, non hormone-dependent donor site from which to take the hair?
- Is the recipient site free of conditions that might either limit the collection of follicular units (e.g. scars) or threaten their survival (e.g. ongoing disease activity)?
For instance, alopecia areata may affect a potential donor site as well as the recipient site’s ability to accept or maintain a transplanted follicular unit. This is also the case for scarring alopecias. The following table outlines some of the most common conditions causing hair loss and their suitability for hair transplantation.
Causes of hair loss and suitability for hair transplantation
|Diagnosis (cause of hair loss)||Predictable donor site (with stable hair growth)?||Normal recipient site (for follicular unit survival)?||Is hair transplantation a good choice?|
|Androgenetic alopecia (men)||Yes||Yes||In the majority of cases|
|Androgenetic alopecia (women)||Often||Yes||Sometimes|
|Active inflammatory alopecia (e.g. discoid lupus)||No||No||No|
|Burnt-out scarring alopecia||Sometimes||Survival may be reduced because of scar or disease recurrence||In selected cases|
|Burn or other scar||Sometimes||Survival may be reduced because of scar||In selected cases|
In people with a history of scarring alopecia that has been inactive for at least 2 years it may be possible to consider hair transplantation. However the patient should be informed that scarring may decrease follicular unit yield and that the disease may recur and destroy the transplanted follicular units. If the appropriate counselling is provided, it is possible to achieve successful outcomes even in certain unusual conditions, such as “en coupe de sabre”.
Androgenetic alopecia in men
Usually it is easy to diagnose androgenetic alopecia or more simply male-pattern hair loss in men based on its typical clinical presentation and lack of findings suggesting other possible causes. The natural progression in men has been classified according to Hamilton and Norwood classification scale. Hair miniaturisation is a common finding in areas affected by androgenetic alopecia and its progession is evidenced through a stage of fine vellus hair prior to the appearance of baldness.
Hamilton & Norwood Classification
Androgenetic alopecia in women
Androgenetic alopecia in women, also called female-pattern hair loss, affects up to 50% of women by the time they become 40 years old, while after the age of 40 years old thinning is established in 50% of women. Due to greater societal expectations for women to have a nice hairstyle irrespectively of their age, psychological studies have demonstrated that women are much more severely affected by hair loss compared to men. The difficulty both for the diagnosis and for the treatment of androgenetic alopecia in women is that due to the more diffuse nature of hair loss, without the total balding which is usually seen in men, there may be other medical conditions that either mimic or present concurrently with androgenetic alopecia, masking its early appearance, such as diffuse alopecia areata, acute and/or chronic telogen effluvium.
All the above mentioned factors may result in much greater difficulty in terms of both diagnosis and treatment. Therefore it is important as a first step to perform trichoscopy, a valuable diagnostic tool that can help in the exclusion of other conditions. For example, it is very important to rule out and try to treat significant telogen effluvium if hair transplantation is considered. Especially in cases of chronic telogen effluvium this condition may lead to ongoing unstable hair loss in both the donor and the recipient area – a recipe for an unhappy patient.
Usually the clinical presentation of androgenetic alopecia in women involves the maintenance of the frontal hair line, with diffuse hair thinning posteriorly, which is illustrated in the Ludwig’s scale for women’s hair loss.
In women trichoscopy is important in order to rule out underlying causes of telogen effluvium, androgen excess or other conditions mimicking androgenetic alopecia in women. At the same time trichoscopy is performed together with an evaluation of the patient’s overall health status, including the following:
- Physical examination to rule out the possibility of androgen excess: hirtruism, acne, menstrual irregularities, galactorrhea and rapid thinning of frontotemporal recessions. If androgen excess is observed, the female patient should be referred to a gynaecologist/endocrinologist for further examination.
- Assessment of possible causes of telogen effluvium, such as rapid weight loss, high fever, certain pharmaceutical products, recent childbirth.
- Laboratory examination to confirm whether telogen effluvium is caused by something treatable.
- Biopsy to exclude and help differentiate from chronic telogen effluvium, diffuse alopecia areata and scarring alopecia.