Treatment

60% of cases in this disease are self limited. The most common treatment is with steroids (cortisone is one form) either topically or by injection. The outcome of treatment is good when the alopecia areata process is present less than one year and poor, especially in adults, if the disease has been present for longer periods of time. Minoxidil (Rogaine) can help to regrow hair. Surgical treatment of this disorder is not recommended if the disease is active.

Other causes of hair loss

Alopecia AreataAlopecia areata (AA) is a recurrent disease, which can cause hair loss in any hair-bearing area. The most common type of alopecia areata presents as round or oval patches of hair loss most noticeably on the scalp or in the eyebrows. The hair usually grows back within 6 months to one year. Most patients will suffer episodes of hair loss in the same area in the future. Those who develop round or oval areas of hair loss can progress to loss of all scalp hair (alopecia totalis). The cause of alopecia areata is unknown but commonly thought to be an autoimmune disorder (the body does not recognize the hair follicles and attacks them). Stress and anxiety are frequently blamed by patients as the cause of their hair loss.

Anesthesia (Painless Hair Transplantation)

How we minimize discomfort of local anesthetic injection?Buffering the Lidocaine by adding 7.5% sodium bicarbonate to Lidocaine neutralizes the acidic pH and decreases the pain of injection. Warming the solution to body temperature lessens discomfort as well.Cold compress with vibration before injection We use smallest needle (30G) for infiltrationSlow injectionHand holding, Talkanesthesia (talking while injecting) and Thai massage for pain distraction Many people think of anesthesia as being "put to sleep". However, there are other ways of achieving anesthesia, which just means rendering one insensitive to pain impulses. In hair transplantation we use local anesthesia, which, as the name implies, locally deadens (temporarily) the nerves, rather than the whole central nervous system (unconsciousness). This is most desirable because, when using local anesthesia, no pain is felt, the procedure can be done in the office, we avoid the expense and hazards of the hospital operating room and general anesthesia, and the patient is awake throughout the process, and can remain an active participant in decision making and respond to instruction from the physician during surgery.There is better understanding of the relationship between effective anesthesia and limitation of bleeding or "oozing" during surgery. An inadequately anesthetized, anxious patient may have increases in heart rate and blood pressure that increase risk for bleeding; thus, anesthesia level and physical signs such as heart rate and blood pressure are carefully monitored during surgery. Local anesthetics are injected into the skin and subcutaneous layers, and/or around larger nerves in the form of nerve blocks.

Sedation and pain relief

Tylenol 1 gram and Ibruprofen 400 mg are given orally one hour prior the procedure starts to minimize discomfort during local anesthetic injection. Valium 20 mg is also given orally half an hour before you get in the operating theater to make you relaxed, relieve anxiousness and prevent the potential side effects of the local anesthetics we use (Xylocaine). There are many good reasons for using mild sedation for this procedure, not the least of which is the patient’s comfort during what may be a long procedure. Much of the time spent in the surgical chair can be quite boring. The only part during hair transplant that is remotely painful is the injection of the numbing medications, or local anesthetics. So often, if a little sedation and pain killers are used at the beginning of the procedure, this potential for pain and anxiousness is relieved before it even occurs. Another reason for using the type of sedation we prefer is that it can prevent or relieve the potential side effects of the local anesthetics we use (Xylocaine). Generally, we choose a class of drugs known collectively as the benzodiazepines, specifically diazepam (Valium), midazolam (Dormicum). These are considered sedatives and anti-anxiety agents. They be given orally, the oral route has the longest time to onset of effect, they are quite safe, and we seldom see complications associated with their use. These medications render the patient relaxed, maybe slightly drowsy, and usually with a noticeable sense of wellbeing. The local anesthetic injections may become unnoticeable, or just a slight annoyance. We have found this method of sedation to be safe, effective and well accepted and tolerated by our patients.

Follicular Unit Transplantation

Insuring the Integrity of Follicular UnitsLet’s consider for a moment the other techniques that we think are integral to the follicular unit transplantation process. One is single strip harvesting, and the other is stereo-microscopic dissection. Without these companion techniques, the procedure may be called follicular unit transplantation, but it is a pale, inefficient imitation. As its name implies, single strip harvesting is the method by which a single strip of hair-bearing scalp is carefully, indeed, painstakingly, excised from the donor area; the strip is then broken down into its smallest functional units, or follicular units. Before single strip harvesting came to the fore in recent years, older, infinitely more wasteful methods were employed. The first of these was the circular, punch grafts of yore, which have little to recommend them save their simplicity (they are essentially biopsy punches), and the ease with which they were directly placed into correspondingly circular holes in the recipient area. Next, ingenious surgeons devised multi-bladed scalpels; three or more (sometimes many more) blades, attached to a handle, were oriented parallel to one another, and many thin, narrow, long strips could be excised with one pass of the scalpel. These strips could then be placed flat on their sides and sliced into small mini- and micro-grafts, with little or no concern for follicular unit integrity. This, however, was not the only drawback; transection rates were generally rather high, and were even higher when more blades were used. So time was saved, but lots of valuable follicles were wasted. What we know as single strip harvesting overcomes many of these disadvantages. Using a single blade with genuine open technique, it is possible, with experience and well training, the transection rates of several follicles is achieved. It is estimated that transection rates as high as 37% occur with the use of multi-bladed scalpels. Let’s do the math. If the patient needs 1000 grafts, then an area containing 1370 grafts would need to be removed just to account for wastage and still produce 1000 intact FU’s. If 2000 grafts were needed, 740 would need to be wasted! This is of serious import when we deal with a limited, finite amount of donor hair. This leads us to a discussion of graft dissection. One of the reasons many surgeons have used multiple strip harvesting with multi-bladed scalpels, is that an intact, single strip presents a number of difficulties in dissection. It is too thick to place on its side or to shine light through (transilluminate) in order to visualize the individual FU’s. Therefore, thin, multiple strips lend themselves to rapid, albeit inefficient, slicing of grafts. We feel, however, that the degree of wastage is unacceptably high, both during the strip harvest, and during graft preparation.

In Summary

For the properly selected patient, combined surgical and medical approached to hair restoration is likely to yield excellent results over the lifetime of the patient. Results of minoxidil and finasteride clinical trials and treatment indicate that use of a medical agent in a responsive patient will have a satisfactory response with minimal side effects that complements surgical therapy.

Combined Medical Hair Restoration Therapy and Hair transplantation Requires Planning and Commitment

While the possible benefit of combined medical hair restoration therapy and hair transplantation may be attractive, it is a choice that must be based on carefully considered factors. For example:
The patient must have an acceptable response to medical hair restoration therapy in slowing of hair loss and/or stimulation of new hair growth. Some patients respond well, some less well, some poorly.
As with all medications, the best result is obtained when the patient complies with instructions for use. Poor compliance can significantly alter benefit. A patient may become discouraged if benefit does not appear to be rapidly or consistently apparent; the patient should discuss this with the physician hair restoration specialist rather than unilaterally altering dose or timing of the hair restoration agent.Is Hair Transplantation Needed If Medical Hair restoration Therapy is Successful? Clinical trials of minoxidil and finasteride have shown patterns of benefit, or lack of benefit, for both agents. Some persons who respond well to a pharamcologicl hair restoration agent—with slowing of hair loss and/or stimulation of new hair growth—may not seek hair transplantation if the outcome of medical hair restoration therapy is satisfactory. Some of these persons may eventually consider hair transplantation if the medical hair restoration benefit is not maintained over time.

Combined Surgical and Medical Hair Restoration Therapy: A Comprehensive Approach

Medical hair restoration therapy and hair transplantation are two different approaches to the correction of hair loss due to androgenetic alopecia. Either medical or surgical hair restoration may be the best approach to hair loss for an individual, depending on variable factors such as degree of hair loss, rapidity of hair loss, pattern of hair loss, and response to medical treatment. Some persons may benefit from a carefully controlled use of both medical hair restoration therapy and hair transplantation, under the supervision of a physician hair restoration specialist.

Medical Treatments

What are the current medical treatments available?Finasteride (Propecia®, Proscar®), an oral medication available by prescription only, has been introduced to the market in the past decade. Finasteride is approved only for use by men. Through scientific studies, it has been shown to re-grow hair in a significant number of men and stop hair loss in an even higher percentage. Finasteride works by decreasing the formation of DHT, a hormone responsible in large part for male pattern hair loss, while not reducing testosterone, the overall male hormone responsible for masculinity. Therefore, any side effects that may involve male sexual function are mild and occur in less than 2% of all patients.Finasteride has been available for over 10 years and has been shown to be safe and effective. Finasteride (Propecia, Proscar) works best for early or moderate hair loss, but it may also help patients with more advanced hair loss to preserve their remaining hair, and its use is suggested by hair restoration surgeons as an effective medication to slow down or reverse male pattern hair loss in many men. It is often used as a complementary treatment for hair transplant patients. Topical minoxidil (Rogaine) has been around for over 15 years and is helpful in slowing down hair loss, but less effective in helping new hair to grow. A higher concentration (5% solution) of minoxidil is now available for men and has been shown to be more effective than the 2% solution. 5% minoxidil solution is generally not recommended for use by women because it may stimulate the growth of facial hair, and also because at least one study suggests that it is not more effective than the 2% in females.Both finasteride and minoxidil must be used on a continual basis in order to sustain results, and if discontinued, the process of balding resumes. These medications may not work for everyone, but they have a proven track record that shows a significant benefit to many people. In addition, combination treatment with minoxidil solution and finasteride may provide added benefit for men with androgenetic alopecia. A third drug, dutasteride, is in clinical trials. Similar to finasteride in action, it has been approved in Europe for use in hair restoration and is sometimes prescribed “off-label” for that purpose in the U.S. Under the brand name Avodart, dutasteride is approved in the U.S. for treatment of benign prostatic hypertrophy (prostate enlargement) in men.