Hair Restoration 01-18,21-22 Flashcards
Which of the following is a CONTRAINDICATION to the use of finasteride as a treatment for premenopausal women with hair loss?
A) Amenorrhea
B) Galactorrhea
C) Hirsutism
D) Masculinization of facial features
E) Pregnancy
The correct response is Option E.
Although FDA-approved for male-pattern hair loss, finasteride is not approved by the FDA for use in women. It is classified as Pregnancy Category X (highest risk) and should not be taken or handled by pregnant women, women who may become pregnant, or those who are breast-feeding. Finasteride has been linked to abnormalities of the external genitalia of a male fetus of a pregnant woman who receives finasteride.
The other choices are not common problems with finasteride, although breast tenderness has been reported.
European studies have selectively used the drug in women for cases of hair loss associated with hyperandrogenism.
A 37-year-old man presents to the office for evaluation and treatment of an area of localized hair loss. Physical examination shows a 2 × 4-cm ovoid-shaped area of baldness on the temporal scalp. The rest of the scalp examination is normal. On the basis of the clinical findings, which of the following is the most appropriate treatment for hair restoration?
A) Hair transplantation
B) Rotational scalp flap
C) Serial excision
D) Topical ketoconazole
E) Triamcinolone injection
The correct response is Option E.
The most likely diagnosis in this clinical scenario is alopecia areata (AA). AA is different from other forms of alopecia since it is a T-cell–mediated autoimmune disease affecting the regional hair follicles. The exact cause is not fully understood, but it is estimated to affect about 2% of the population. Severity can be limited to a singular lesion or extend to multiple confluent lesions with severe impact on a patient’s mental health. While any given lesion can spontaneously resolve, the first-line treatment is injection of triamcinolone combined with minoxidil topical therapy. The injections usually have to be repeated. Systemic therapy with Janus kinase inhibitors is reserved for severe cases of AA. Clinical examination of a fungal infection with tinea capitis differs from the patient presentation in this case. Findings may include scaly skin, brittle hair, and broken hair shafts (black dots). Treatment includes oral and topical antifungal medication such as ketoconazole.
Hair transplantation is not a treatment for AA since the underlying pathology would also affect the transplanted hair follicles.
While a rotational scalp flap may be an option for a bald spot of this size, it would not be indicated in the setting of AA. The main reason is that hair can regrow spontaneously or in response to other therapy modalities. Further, the transferred flap can also become affected by AA in the future. A rotational flap would be indicated for closure of primary defects or other causes (e.g., burn scar, previous skin graft).
Serial excision is useful for a variety of pathologies such as scars, melanocytic nevi, or skin grafts. It would not be advised in the setting of AA.
Male pattern baldness is characterized by which of the following growth phase disturbances?
The correct response is Option A.
Male pattern baldness follows an X-linked dominant inheritance pattern. The anagen phase of hair growth is the active growth phase and lasts approximately 1000 days in men. In the anagen phase, follicular cells are actively multiplying and becoming keratinized. In men with normal hair growth, 85 to 90% of hairs are in this phase, with hair growing 1 cm per month. The catagen phase is known as the transitional or degradation phase and typically lasts 2 to 3 weeks and is characterized by atrophy of the bulb, with keratinization of the hair base, and separation of the hair base from the dermal papilla. The telogen phase of hair growth usually lasts 3 to 4 months and is also known as the resting phase and is characterized by the inactivation of the hair follicle, cessation of hair growth and hair shedding.
In men with normal hair growth, 10% of hair follicles are in the telogen phase, causing approximately 50 to 100 hairs to be shed on average per day. In male pattern baldness there is an increased percentage of hairs in the telogen phase and a decreased percentage of hairs in the anagen phase.
An otherwise healthy 26-year-old man with a receding hairline presents for hair restoration of the frontal scalp. Which of the following phenomena most accurately describes features associated with this patient’s condition?
A) Absence of vellus hairs
B) Decreased duration of telogen
C) Eosinophilic perifolliculitis
D) Increased duration of anagen
E) Miniaturization of hair follicles
The correct response is Option E.
Male androgenic alopecia is determined by a genetic predisposition. The normal anagen-catagen-telogen cycle is disturbed, and the anagen:telogen ratio is altered. This is due to the lengthening of the telogen denominator in this ratio. Additional aspects include gradual replacement of the normal hair shafts with vellus hair, miniaturization of the hair follicle, and an activated T-cell lymphohistiocytic perifollicular inflammation.
A 13-year-old girl is brought to the office by her mother who is concerned about the child’s patchy hair loss. The mother began to notice the hair loss shortly after she separated from the patient’s father. The patient states she often plays with her hair throughout the day. Which of the following is the best course of treatment for this patient’s hair loss?
A) Administration of topical minoxidil 5% daily for six months
B) Injections of platelet-rich plasma to areas of baldness
C) Injections of triamcinolone to areas of baldness
D) Referral to a psychiatrist
E) Transplantation of follicular units
The correct response is Option D.
This patient most likely has trichotillomania, an impulse-control disorder. This is likely associated with a change in the patient’s social situation, namely the loss of involvement of her father in her life.
The other treatment options do have proven benefits in restoring hair loss, but the best course of treatment is first addressing the underlying cause, and referral to a psychiatrist would be the most appropriate step.
This patient has signs of telogen effluvium, alopecia caused by emotional stress. With appropriate psychiatric or psychological therapy, she should be expected to stop traumatizing her hair, and its growth would return.
The other options can improve thinning hair for various other causes, but they would not be the first course of treatment for this patient.
A 25-year-old woman comes to the clinic to discuss eyebrow reconstruction. She reports that she tweezed her eyebrows several times a day because of perceived asymmetry, and she now has complete loss of eyebrows. She insists on receiving hair transplants and says that she is depressed because of her lack of eyebrows. Which of the following is the most likely DSM-5 diagnosis?
A) Body dysmorphic disorder
B) Borderline personality disorder
C) Excoriation (skin-picking) disorder
D) Major depressive disorder
E) Trichotillomania
The correct response is Option A.
Body dysmorphic disorder is considered an obsessive compulsive and related disorder in the DSM-5. Criteria include preoccupation with perceived appearance flaws for at least an hour a day, repetitive behaviors related to the preoccupation, clinically significant distress as a result of the preoccupation, and exclusion of an eating disorder.
The differential diagnosis includes major depressive disorder, trichotillomania, excoriation disorder, agoraphobia, eating disorders, and dysmorphic concerns. What differentiates body dysmorphic disorder from excoriation disorder and trichotillomania is the underlying preoccupation with symmetry and appearance seen in body dysmorphic disorder. In some cases, patients report a pleasurable sensation during hair pulling in trichotillomania. Thus, patients with body dysmorphic disorder can engage in skin picking and hair pulling, but the underlying motivation is different. Excoriation disorder is a body-focused repetitive behavior, on the obsessive compulsive spectrum, but it is not motivated by perceived asymmetry or appearance as is body dysmorphic disorder.
Depression can coexist with body dysmorphic disorder, but it does not have a preoccupation with appearance as a criterion.
Borderline personality disorder is a Cluster B personality disorder, characterized by unstable emotional responses to stimuli and relationships.
An otherwise healthy 45-year-old man presents for evaluation of progressive frontal hair loss. He reports his grandfather went bald early in life. He is interested in surgical hair restoration methods but would prefer to avoid long, unsightly scars and prolonged recovery. Which of the following is the most appropriate method for hair restoration in this patient?
A) Follicular unit transplantation
B) Hair-bearing scalp flaps
C) Micrograft unit transplantation
D) Minigraft unit transplantation
E) Tissue expansion
The correct response is Option A.
This patient has androgenetic alopecia. Androgenetic alopecia, or patterned alopecia, is the most common form of hair loss in both men and women and is characterized by a progressive loss of hair diameter, length, and pigmentation. The genetic inheritance of androgenetic alopecia is well known, although the causative genes have yet to be elucidated. In genetically predisposed males and females, androgenetic alopecia is caused by progressive shortening of the anagen stage and an increase in the number of hair follicles in telogen. Follicular unit hair transplantation is the gold standard, because it preserves the natural architecture of the hair units and gives natural results. The follicular unit (FU) was first described by Headington in 1984 and was shown to include 1 to 4 terminal follicles, 1 or 2 vellus follicles, and perifollicular vascular and neural plexi, all surrounded by concentric layers of collagen fibers. Seager later showed that when single-hair micrografts were generated by breaking up larger FUs, their growth was less than when the FUs were kept intact, supporting the concept of the FU as a physiologic entity, rather than just an anatomic one. This gave rise to the FU transplant era, in which grafts are single FU or multi FU (2–3 FU). It was found that peripheral areas such as the hairline naturally have 1- and 2-hair FUs, whereas the more central regions have more 3- and 4-hair FUs.
“Micrografts” (1–2 hairs) and “minigrafts” (3–6 hairs) have been used in the past for hair transplantation but are not quite as effective as follicular unit transplantion and produce less natural appearing results.
Tissue expansion and scalp flaps are generally reserved for scalp burn wounds or wounds of traumatic nature with significant hair loss. They generally leave long scars and may require multiple stages and prolonged recovery which would likely not be acceptable for this patient.
A 34-year-old man comes to the office for a routine follow-up examination 1 month after undergoing extensive micrograft hair transplantation. He is extremely upset, complaining that “all the grafts have fallen out and are gone.” Which of the following is the most appropriate response to this patient’s concerns?
A) Loss of hair shaft is expected and part of the normal healing process
B) Loss of the grafts is a potential complication that was explained preoperatively
C) More grafts will be performed without additional surgical fees
D) The patient should wait and see what happens and return to the office in several months
E) The patient will be started on finasteride immediately
The correct response is Option A.
Hair shaft loss is to be expected after the first month following implantation as the hair follicles enter into the telogen phase. Initially, hair grafts enter the catagen phase of hair growth, which is a transitional phase. Implanted hair can grow 3 to 4 mm at this time. Following this stage, implanted hair grafts enter the telogen phase or the “resting” phase, which lasts for 3 to 4 months. During this phase, the attachment of the hair at the base of the follicle becomes weaker until the hair finally sheds, and the hair follicle is inactive and hair growth ceases. Almost every implanted hair falls out during this time, and patients must be prepared for this preoperatively. This phase can last up to 6 to 9 weeks, and this is when patients worry most about whether the surgery was indeed a success. Following this time, the anagen phase begins, generating new hair growth, which is initially quite thin. This hair then grows thicker with time. Final results of hair transplantation are not evident until 6 to 8 months in men and 10 to 12 months in women.
A 55-year-old woman presents with androgenic alopecia. Her husband had a hair transplant 5 years ago. Which of the following characteristics of androgenic alopecia is more common in women than men?
A) More rapidly progressive
B) Not induced by dihydrotestosterone
C) Thinning tends to be frontoparietal
D) Topical minoxidil is ineffective
The correct response is Option C.
Unlike in men, androgenic alopecia in women tends to spare the frontal hairline and tends to affect the frontoparietal scalp. Like in men, it is a chronically progressive disease and causes miniaturization of scalp follicles through exposure of endogenous dihydrotestosterone in patients with increased scalp androgen receptors and 5-reductase concentrations. Topical minoxidil has been shown to increase scalp blood supply and slow hair loss in both males and females.
A 45-year-old man comes to the office for consultation regarding hair loss concerns. He reports that he has a friend who underwent a hair transplantation procedure that looks unnatural, especially at the front hairline. Using the minigraft and micrograft strategy, how many follicles should be in a minigraft?
A) 1 to 2
B) 3 to 4
C) 5 to 6
D) 7 to 8
E) 9 to 10
The correct response is Option B.
Minigrafts consist of 3 to 4 follicular units and are commonly used in concert with micrografts which contain 1 to 2 follicular units. Larger numbers of follicular units have been associated with artificial appearing outcomes (plug look).
A 27-year-old man comes to the office for hair restoration to correct alopecia of the scalp. He sustained a burn injury to the scalp when he was a child and underwent split-thickness skin grafting to treat the burn. Micrograft hair transplantion to restore the hairline is planned. Which of the following is the most likely percentage of micrograft survival and ultimate hair growth in this patient?
A) 10%
B) 25%
C) 50%
D) 85%
E) 95%
The correct response is Option D.
Because of their small size, micrografts and minigrafts appear to have a lower metabolic requirement to thrive. They tend to grow in areas of fibrosis and burn scars and over skin grafts and flaps, including split-thickness skin grafts. The rate of survival and ultimate hair growth under these circumstances appears to be approximately 85%, compared with approximately 95% on unscarred, healthy tissue. More recently, follicular unit grafts have been used in hair transplantation.
A 41-year-old woman comes to the office for consultation regarding breast reconstruction after mastectomy. She is also embarrassed by her sudden loss of hair as a result of chemotherapy with paclitaxel. All of her hair has fallen out, and she wears a wig. Which of the following is the most likely diagnosis for this patient’s hair loss?
A) Alopecia areata
B) Anagen effluvium
C) Androgenetic alopecia
D) Telogen effluvium
E) Traction alopecia
The correct response is Option B.
Anagen effluvium occurs after an insult to the hair follicle that impairs its mitotic or metabolic activity. This hair loss is commonly associated with chemotherapy. The characteristic finding in anagen effluvium is the tapered fracture of the hair shafts. The hair shaft narrows as a result of damage to the matrix. Eventually, the shaft fractures at the site of narrowing and causes the loss of hair. Hair regrowth occurs after the cessation of chemotherapy.
Androgenetic or androgenic alopecia is caused by the action of androgens. Dihydrotestosterone (DHT) is partially to blame, as it is in men. Androgenic alopecia can be caused by a variety of factors tied to the actions of hormones, including some ovarian cysts, taking high-androgen-index birth control pills, pregnancy, and menopause.
Telogen effluvium is attributable to stress on the body, such as childbirth, malnutrition, severe infection, major surgery, or extreme mental stress. Many of the 90% or so of hairs in the growing (anagen) or transitional (catagen) phases can shift all at once into the resting (telogen) phase. A few weeks to several months after the stressful event, a shedding phenomenon called telogen effluvium begins. It is possible to lose handfuls of hair at a time. This phenomenon is usually self-limited, and hair growth returns.
Alopecia areata is an inflammatory condition thought to result from the immune system attacking the hair follicles at the root. Treatment may include steroids or minoxidil. Hair loss can be temporary or permanent.
Traction alopecia is caused by localized trauma from tight hairstyles, braids, cornrows, etc. If recognized early enough, the hair will grow back.
A 35-year-old woman with diffuse hair thinning comes to the office for evaluation of hair transplantation. Physical examination shows facial hirsutism, acne, and diffusely decreased hair density over the crown and frontal scalp, except for the frontal hairline, which is quite well preserved. The scalp skin appears normal. Which of the following is the most likely underlying cause?
A ) Alopecia totalis
B ) Polycystic ovary syndrome
C ) Psoriasis
D ) Tinea capitis
E ) Trichotillomania
The correct response is Option B.
Although all options listed can cause hair loss, psoriasis and tinea capitis would be associated with visible scalp changes, such as scaling or crusting. Trichotillomania, which is traction alopecia from compulsive hair pulling, would be unlikely to show a diffuse hair loss with sparing of the frontal hairline. Alopecia totalis, by definition, is total hair loss over the entire scalp, and does not fit the patient’s description.
This woman has female pattern hair loss (FPHL), which is the preferred term for androgenetic alopecia in females. Typically there is a reduction in hair density over the crown and frontal scalp, with relative sparing and preservation of the frontal hairline, as described for this patient. Between 10 and 40% of women with FPHL have been found to be hyperandrogenic. The presence of menstrual irregularities, marked acne, or hirsutism in this patient should prompt an investigation for polycystic ovary syndrome or other underlying causes.
A 30-year-old man with alopecia undergoes micrografting for reconstruction of the anterior hairline. The patient should be counseled to expect which of the following hair growth timelines in grafted areas postoperatively?
A ) No growth for one month, followed by normal growth
B ) Immediate hair loss followed by new, normal growth after one month
C ) Immediate hair loss followed by new, normal growth after three months
D ) Growth for one month, followed by hair loss and then new, normal growth after three months
E ) Immediate normal growth
The correct response is Option D.
Following micrografting, the patient has hair growth for one month followed by hair loss and then normal growth after three months. Once the grafting is completed, there is an initial period of false growth lasting three to four weeks. The hair follicles then pass into the telogen phase, and this new hair growth is lost. The telogen phase lasts two to three months; following this, normal permanent growth begins at a rate of 1 cm monthly. Therefore, a total of approximately six months is required for the onset of permanent hair growth in the grafted area.
A 15-year-old boy is referred to the office for management of alopecia areata. Physical examination shows that more than 50% of the scalp is involved. Which of the following is the most appropriate management?
(A) Administration of finasteride
(B) Construction of a scalp rotation-advancement flap
(C) Injection of a corticosteroid
(D) Transplantation of follicular units
(E) Observation
The correct response is Option C.
Alopecia areata (AA) is a recurrent nonscarring type of hair loss that can affect any hair €‘bearing area. Clinically, AA can present with many different patterns. Although medically benign, AA can cause tremendous emotional and psychosocial stress in affected patients and their families. The pathophysiology of AA remains unknown. The most widely accepted hypothesis is that AA is a T €‘cell €“mediated autoimmune condition that is most likely to occur in genetically predisposed individuals.
Because AA is believed to be an autoimmune condition, corticosteroids have been used to treat this condition. Few studies are available regarding the efficacy of intralesional corticosteroids, but they are used widely in the treatment of AA. Intralesional corticosteroids are the first €‘line treatment in localized conditions. In a study including 84 patients, regrowth on treated areas was present in 92% of patients with patchy AA and 61% of patients with alopecia totalis (AT). Regrowth persisted three months after treatment in 71% of patients with patchy AA and 28% of patients with AT. Regrowth usually is seen within four to six weeks in responsive patients. Patients with rapidly progressive, extensive, or long €‘standing AA responded poorly. Another study showed regrowth in most patients (480) treated with intralesional corticosteroids, except in two patients with alopecia universalis (AU). Hair growth may persist for six to nine months after a single injection. Injections are administered intradermally using a 3 €‘cm3 syringe and a 30 €‘gauge needle. Triamcinolone acetonide (Kenalog) is used most commonly; concentrations vary from 2.5 to 10 mg/cm3. Less than 0.1 cm3 is injected per site, and injections are spread out to cover the affected areas (approximately 1 cm between injection sites). Adverse effects mostly include pain during injection and minimal transient atrophy (10%). The atrophy rarely can be severe or permanent. Injections are administered every four to six weeks.
For patients with extensive AA (>40% hair loss), little data exist on the natural evolution. The rate of spontaneous remission seems to be less than in patients with less than 40% involvement. In one review of 50 patients with extensive AA, 24% experienced spontaneous complete or nearly complete regrowth at some stage during the observation period of 3 to 3.5 years. Without therapy, the relapse rate is high in patients with severe forms of AA. Surgery does not have a role in this condition.
Finasteride (Propecia) works on alopecia secondary to male pattern baldness by affecting the 5 €‘alpha reductase enzyme.
Which of the following best characterizes male-pattern alopecia?
The correct response is Option B.
Male-pattern alopecia is characterized by a decrease in the anagen, or active, phase of the hair follicle and an increase in the telogen, or resting, phase. Patients with this condition have more of their hair follicles in the resting phase, and those in the active phase produce hair growth for a shorter time. Hair follicles can also be classified as either terminal, which produce larger, pigmented fibers, or villous, which produce finer fibers that have less pigmentation and are more difficult to visualize. Terminal fibers are found typically on the adult scalp, eyebrows, axilla, and pubic region, while villous fibers are noted on the forehead, bald scalp, and along the hairline itself. In patients with male-pattern alopecia, many follicles in the scalp are transformed from terminal to villous.
Minoxidil is the recommended treatment of male-pattern alopecia. This agent halts the hair loss and increases the number of hairs as well as the diameter of the existing hairs, but is only effective in patients with mild to moderate baldness.
