Want to know how much hair you're losing?

Start counting -- the hairs on your comb, not on your head.

In the June issue of Archives of Dermatology, scientists demonstrate that a so-called "60-second hair count" is a simple and reliable away to get a grip on whether you're balding and, if so, how fast.

The procedure, which can be carried out in the convenience of your own home, may reassure the adult male -- or not.

"Hair loss is fraught with emotions... Here is a hair count that allows the person to get a handle as to what's going on with their hair," said Dr. Jeffrey Miller, senior author of the study and associate professor of dermatology at Penn State College of Medicine in Hershey, Penn. "With something like the 60-second hair count, you can participate and monitor in an objective fashion what's going on with your hair."

"The reality is that hair loss is incredibly common among men and women. Fifty percent of both genders will have hair loss by the age of 50. That's a big number," added Dr. Doris Day, an attending physician in dermatology at Lenox Hill Hospital in New York City. "It affects how you're perceived, your ability to date and climb that corporate ladder."

Both the media and dermatology experts are fond of proclaiming that shedding 100 hairs a day is normal. (That's probably too high, Miller said.) But there is little scientific evidence for that number, which is based on the assumption that the average scalp holds 100,000 hairs, 10 percent of which are at any one time in the telogen, or resting, phase.

Not only do experts not know how much hair loss is normal, they also don't have any standardized way of assessing the amount of hair lost on an average day.

"We keep saying the same things over and over, that it's normal to lose 100 hairs a day," Day said. "The question is, how normal is it and what is normal in terms of hair loss."

The "wash test" involves washing one's hair over a sink five days after the last shampoo, a waiting period some might find objectionable.

A more up-to-date method is the 60-second hair count, used in this study.

Sixty healthy men aged 20 to 60 without evidence of baldness participated. All were white and all but one had straight hair. (The authors excluded, for the most part, men with curly hair and long hair "because of the difficulty of running a comb through the hair, which would lead to increased numbers of broken" hairs, which weren't counted.)

The men washed their hair three mornings in a row with Neutrogena T/Sal shampoo. On the fourth day, they were issued identical combs and instructed to comb their hair forward over a towel or pillowcase of contrasting color. They were then asked to count the hairs that had dropped out. This comb-and-count procedure was repeated on the next two days and the number of hairs was validated under a microscope.

After six months, the participants repeated the full procedure.

Based on these results, the authors concluded that losing 10 hairs is "normal." In younger men (aged 20 to 40), the shedding range was 0 to 78 hairs with a mean of 10.2 hairs. In the older men, the range was 0 to 43 hairs with a mean of 10.3 hairs.

Here are instructions on how to perform the count:

• Comb your hair for 60 seconds over a pillow or sheet of contrasting color before shampooing. Pull the comb from the back top of the scalp forward to the front of the scalp for 60 seconds. "That 60 seconds allows you to dislodge any of the resting hairs that are supposed to be shed," Miller said.
  
• Repeat the procedure before three consecutive shampooing sessions, always using the same comb.
  
• Count and record the number of hairs in the comb and on the pillow or sheet.
  
• Repeat the procedure every month and discuss results with your dermatologist.
  

The study was funded by Merck & Co. and Miller has received consulting fees from drug company Pfizer Inc.

The authors will be releasing comparable data for women in the near future, they said.

When to start panicking over hair loss? Miller counsels men who lose more than 50 hairs a day (as counted in the 60-second period) to check with their physician.

"The hair acts like a window to the inside of the body," he said. "If there's something going on inside the body that is not right, for example, low thyroid output or low iron, your hair can react by shedding more. So if you notice that you're shedding a lot of hair on the 60-second hair count, it would be worthwhile to be evaluated by physician to rule out underlying medical causes."

Sudden changes in the amount of hair you lose should also be evaluated, he said.

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Myth No. 1: The hair loss gene comes from the mothers genes
Reality: Scientific research shows that it can come from either side of the family. The best indicator of your potential for hair loss is to look at your immediate family. If members are losing their hair, you may also be at risk.

Myth No. 2: Men are the only ones that suffer hereditary hair loss
Reality: Women can suffer from hereditary hair loss. The pattern of hair loss in women, however, is slightly different. Men will lose and thin in more concentrated areas and women will lose and thin all over their heads.

Myth No. 3. Hair loss treatments cause sexual dysfunction
Reality: Hair loss treatments do not specifically cause sexual problems.

Myth No. 4 If you stop using certain hair loss treatments, your hair will fall out much faster than before
Reality: Once you discontinue a hair treatment, your hair loss may continue at the rate that you were losing hair before the treatment. It may seem faster since you were keeping the hair loss problem under control with the treatment.

Myth No. 5 Cutting your hair will make it grow
Reality: Regular trimming of the hair will take care of split and damaged ends. It does not necessarily make hair grow. Hair does, however, tend to grow slightly faster in the summer.

Myth No. 6 Oily hair and dandruff cause hair loss
Reality: Oily hair and dandruff do not cause hair loss.

Myth No. 7 Hair loss treatments don't really work
Reality: Many hair loss treatments will work if used properly. You must do your research and know the type of hair loss and amount that you are experiencing.

Myth No. 8 If you wash your hair too much, you can make your hair fall out
Reality: Frequent shampooing does not make hair fall out. Shampooing the hair regularly helps to remove residues so that hair looks fuller.

Myth No. 9 Women only experience hair loss well after menopause
Reality: Women can begin to lose hair in their twenties, after pregnancy and during and after menopause.

Myth No. 10 Stress can cause permanent hair loss
Reality: Hair can fall out during stressful times. It is not permanent hair loss. As soon as the stress goes away, the hair should grow back.

Look around a crowd, and you'll see that lots of middle-aged men are losing their hair. As Baby Boomers, they have every right to demand, What is science doing about this? Quite a bit, it turns out.

A British company, for example, says five guys are walking around with hundreds more hairs than they had before, thanks to an early test of what's been called hair cloning. An American outfit hopes to start testing a similar approach next year.

Other scientists are tracking down genes that make some men susceptible to hair loss, and struggling to understand the mysterious biology behind it. For example, how can men lose hair on the top of their heads while their beards and even eyelashes keep going strong?

Black men are far less susceptible, but about a third of 30-year-old white men have signs of what doctors call male-pattern baldness. By the time they're 50, about half of them do. The condition creeps across the head like three tiny armies bent on deforestation: one starting at the back, and two making inroads from the front.

Sure, some men say bald is beautiful. And others can smear on minoxidil (Rogaine) or take Propecia pills, or get hair transplants.

In fact, right now is "the best time in history to be going bald, because there's an awful lot of things that can be done,'' says Dr. Ken Washenik of the Aderans Research Institute in Philadelphia, which is investigating the "hair cloning'' approach.

But the drugs don't help everybody, and not everyone is interested in a transplant. So there's room for new approaches.

To understand the search for new treatments, it helps to know a little about hair and male pattern baldness. (Women can also get hormone-induced baldness like this, but it's not clear if it's really the same condition).

Everybody starts out with a lifetime supply of about 100,000 follicles on the scalp, each primed to produce a single hair shaft. Normally, any given follicle pumps out that shaft for two years to six years, then takes a break for a few weeks. Then it sheds that hair, and starts the cycle over again.

Each day, we lose about 100 hairs this way. No big deal; about an equal number of follicles enter the growth phase on the same day, and at any one time about 90 percent to 95 percent of the follicles are busy growing new hair.

But in some men, in selected places on the scalp, this orderly process goes awry.

The hair-growing phase gets progressively shorter and the resting phase gets longer. So the resulting hairs get shorter and shorter with each trip through the cycle. Eventually, they don't even poke out through the scalp.

What's more, affected follicles take longer to start growing hair again after they've shed the last one. And they shrink, so the hair they produce is finer. On your head, it's like replacing mighty trees with saplings. And the total number of remaining hairs slips by about 5 percent a year.

What causes this? The full picture isn't known, but it clearly involves a combination of genetic susceptibility and hormones, including testosterone.

Researchers are eager to identify the biochemical actors within follicles that could be manipulated to fight baldness. As for genetics, some studies have implicated a particular gene that may be necessary to get the condition but not sufficient to produce baldness on its own, said Stephen Harrap of the University of Melbourne in Australia.

In all, it might take inheriting certain versions of about five genes to get the condition, like getting a bad poker hand, suggested Rodney Sinclair of the university.

In England, meanwhile, a company called Intercytex has just begun human studies of an approach sometimes called hair cloning. It focuses on a particular kind of cell, found at the base of the follicle, that can team up with skin cells to produce new follicles.

Here's the idea: Extract some cells from the areas of a man's head that resist balding, put them in a lab dish and expand their numbers by thousands of times. Then inject these new cells back into the scalp, where they'll work with skin cells to form new follicles. So, unlike transplants, the guy actually ends up with more hairs than he started with.

The company has recently tested this on seven men with thinning hair due to male pattern baldness, and five of them gained hair, says Intercytex chief scientific officer Paul Kemp. This was just an initial study to look for side effects like inflammation, Kemp says, and no such problems appeared.

Not that this restored a full head of hair. The treated areas were just the size of a quarter, and covered places that already had hair, rather than bald spots.

"We didn't want to create these weird and wonderful patterns on their head,'' Kemp said. "It's such a small area in the hairy area anyway, I would be surprised if they really knew any difference.''

Eventually, if further studies go well, the technique could allow hair transplant surgeons to cover more of a bald head, Kemp said. The next round of human research is expected to start next summer.

Someday, men might avoid transplants altogether, just getting periodic shots of their own cells to counterbalance their hair loss. "You would be going thin, and you'd be maintained,'' Kemp said.

"Sometime in the future, I think baldness will be a choice rather than something you have to suffer,'' said Kemp. "Any bald people will have chosen to be bald.''

Within five years, Kemp says, his company may have a commercial product.

Washenik, of the Philadelphia-based Aderans institute, said his group's efforts in hair cloning have shown promise so far in mice. He hopes studies in people can begin next year.

He said follicles that grow from the transplanted cells should resist balding, because they come from a part of the head that balding doesn't touch. Ordinary hair transplants show that follicles from these resistant regions stay resistant even when planted in bald regions, he said. But even if the transplanted cells do eventually succumb, "you've got years of hair on your scalp that's of benefit to you,'' said Washenik, who also works for a hair transplantation business called Bosley.

Ultimately, he said, scientists would love to accomplish the same goal with a cream that can be smeared on the scalp and deliver just the right chemical signals to stimulate new follicles to grow.

In any case, he said, it's not just about hair.

Hair follicles, after all, are organs. So what's learned from follicle research may help other scientists who are working to regenerate bigger organs like the liver and kidneys, Washenik said.

The same notion was expressed by Sinclair, who's testing a skin cream in mice that may alter follicle behavior by fiddling with genes. (He says he can't discuss the results because they are a commercial secret.)

Sinclair said follicle research allows scientists to approach not just organ regeneration, but also questions about stem cells, cell growth and gene therapy that may pay off someday in new treatments for diseases like cancer and Alzheimer's.

"The idea of growing hair on a bald scalp is only of moderate interest,'' Sinclair said in a telephone interview. "If we find the cure for baldness we're not going to stop studying hair.''

That's just great, Doc.

But if you do find the cure for baldness, lots of men would like to know.

Hair does not really serve any important function since a person can certainly live without it! Yet, our hair and how it looks is a very important part of our self-image. So when a child loses their hair, it is a disturbing event for both youngster and their parents.

The life cycle of a single hair can be divided into a period of active growth, lasting several years, and a resting stage, which last 60 to 90 days. Of the normal scalp's 100,000 hairs, as many as 15 percent are in the resting mode, soon to be lost at the rate of about 75 hairs per day (hardly noticeable to the child or parents). The rate of hair loss does increase dramatically when the growing hair follicle is subjected to different types of internal stress, such as high fever, severe flu, surgery, crash diets, and certain medications.

Almost all newborns lose some if not all of their hair. This is normal and is expected for the first six months, since the first hairs made by the infant's hair follicles are usually silky and fragile. Occasionally, an infant will lose more hair on the back of the head from constantly moving their head from side to side or spending too much time on their backs.

Most abnormal hair loss in children is caused by one of five conditions: alopecia areata, tinea capitis, traction alopecia, trichotillomania, and telogen effluvium (Dermatologists love fancy names for their diseases!)

Tinea capitis or "ringworm" is a common cause of hair loss in children. The condition is caused by a fungus (not a worm!) that invades the hair shaft and causes the hairs to break. The bare patch of hair loss is often round and the scalp takes on a black-dot stubble appearance from hair shafts broken off at the surface. There may also be mild scalp itching and scaling. The condition is transmitted by contact from one infected child to another by sharing combs, brushes, hats, barrettes, pillows and bath towels. Minor bruising of the scalp occasionally provides an entry for the microscopic fungus. Children three to ten years of are more susceptible and boys are more than girls. Ringworm of the scalp is not dangerous. Without treatment, however, the hair loss can be considerable and some children will develop a boggy tender swelling of the scalp known as a kerion.

Tinea capitis is treated with an oral antifungal medication called griseofulvin, usually taken for up to eight weeks. Selenium sulfide shampoo, used twice a week, has been shorn to shorten the course of tinea capitis. Topical antifungal creams usually do not help in killing the fungus and shaving the hair or giving the child a close haircut is unnecessary. Even though the infection is still visible, a child with tinea capitis may return to school after oral medication is started and the scalp receives at least one washing with shampoo.

Alopecia areata (alopecia means "hair loss," areata means "in patches") is another common form of patchy hair loss in children. The typical story is the sudden appearance of one or more totally bald areas in the scalp. The child with this condition loses hair in circular patches sometimes up to two inches in diameter. The hair at the borders of these patches is loose, but the peach-colored scalp looks and feels normal, without scaling or inflammation. There may be just a few patches of hair loss or a total absence of body hair. Alopecia areata is not life-threatening, and children who have it are otherwise healthy. Why the hair falls out from the roots is still a mystery. What is known is that the condition is not contagious, caused by foods, or the result of nervousness or psychological stress. In 20% of cases another family member has been affected. Some patients with this condition will also develop a grid-like pitting of the nails.

Fortunately, over 80% children with alopecia areata grow new hair back within twelve months. Oddly, the new hair may temporarily be white, but eventually the hair returns to its natural color. Because the hair loss can sometimes be psychologically devasting for the child, dermatologists have tried many different medications in an attempt to stimulate new hair growth. Treatments sometimes involve cortisone injections into the hair follicles.

Traction alopecia, or physical damage to the hair, is another common cause of hair loss, particularly in girls. The human hair is quite fragile and really does not respond well to the many physical and chemical assaults it has to endure in the name of beauty. Constant teasing, fluffing, combing, washing, curling, blow drying, hot combing, straightening and bleaching can do a number on the fragile hairs, causing them to fall out, especially those by the hair line and along the front and sides. Styles that apply tension to the hair, such as tight ponytails, braiding, barrettes, and permanent waving can also damage the hair.

Treatment is to handle the hair gently, as little as possible, and use natural hair styles. The hair will usually return, but regrowth can be slow. Injured hair follicles do not heal quickly and often take three or more months before they are back to their growing phase.

Trichotillomania is the compulsion to pull out one's own hair. It results in irregular patches of incomplete hair loss, mainly on the scalp, but may involve the eyebrows and eyelashes as well. The habit of pulling out one's hair is usually practiced in bed before falling asleep or when the child is studying or watching television. Interestingly, parents are usually not aware of the habit and frequently find it hard to believe that their child would pull out their own hair. Affected areas of hair loss often appear on the left side of right-handed children and on the right side of left-handed youngsters. Most cases of trichotillomania resolve spontaneously. The best treatment is to ignore the hair pulling and concentrate on why the child is anxious, nervous or frustrated.

Another less common form of hair loss in children is called telogen effluvium. Following a high fever, crash diet, flu, or emotional stress, hairs that were in their growth phase suddenly are converted into the resting phase. Two to four months later, when the child is otherwise fine and the stress is forgotten, these hairs begin to shed and do so for about six weeks. The hair loss is not total or in patches- the hair appears thin throughout the scalp. Unless the initial cause is repeated, all the hairs normally return (telogen effluvium explains why many mothers lose so much hair weeks after childbirth). Most parents who bring their child to the physician for this condition are worried that the youngster has cancer or another bad disease.

Remember, hair loss in children is not caused from vitamin deficiencies (at least in the United States), poor scalp circulation, headbands, hats, or helmets. When children lose their hair, parents can probably make the diagnosis themselves. If they have any doubts, they should consult with their child's physician.

The registry has been established by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the National Institutes of Health (NIH). The new registry will be located at the University of Texas M.D. Anderson Cancer Center in Houston, with affiliated centers at UCSF, the University of Colorado, University of Minnesota, and Columbia University.

Vera H. Price, MD, professor of clinical dermatology, is the UCSF collaborator for the national project.

Alopecia areata is an autoimmune disease, one in which the body's natural defense system attacks healthy cells. In alopecia areata, the target of the attack is the hair follicle, and the result is hair loss ranging from patchy baldness to complete loss of all scalp and body hair. It affects both males and females of all races, and often begins in childhood. There is no known permanent cure.

Registry scientists will seek out and classify medical and family history data for patients with three major forms of alopecia areata: alopecia areata (patchy scalp hair loss); alopecia totalis (100 percent scalp hair loss); and alopecia universalis (100 percent scalp and 100 percent body hair loss). Families with multiple affected members will be especially helpful to further research studies. The project will offer a future central information source where researchers can obtain statistical data associated with the disease. A website is currently being developed for the registry.

The registry will serve as a liaison between affected families and investigators interested in studying this disorder. Scientists hope the registry will be useful in locating the gene or genes associated with alopecia areata. It will also link patients with other researchers studying the cause or treatment of this disease.

Maui, Hawaii - While medical treatment and patient education on proper hair care practices are the mainstays of management for traction alopecia and central centrifugal scarring alopecia (CCSA) in black women, hair transplantation can have an important role as a second-line measure to correct hair loss, Valerie D. Callender, M.D., said at the annual Hawaii Dermatology Seminar, sponsored by the Skin Disease Education Foundation.

"Medical treatment and changing hair practices are critical for stabilizing disease and preventing progression of these hair loss disorders. However, existing hair loss has devastating psychosocial consequences on affected patients and is not addressed by those measures. While, historically, blacks have been shunned away from hair transplant procedures because of the challenges of hair harvesting and concern about the risks of hypertrophic and keloidal scarring, with use of proper techniques in appropriately selected patients, hair transplantation allows us to do something positive to improve appearance for these suffering women," said Dr. Callender, clinical assistant professor of dermatology, Howard University College of Medicine, Washington, and in private practice in Mitchelville, Md.

No-No's Before surgery is attempted to address areas of hair loss affected by traction alopecia or central centrifugal scarring alopecia, patients should be under medical management with stable disease for at least six months and be convinced about changing their hair styling techniques.

African-American female, age 30, with traction alopecia of temporal area of scalp.

"If, after hair transplantation is performed, patients with traction alopecia return to tight hair braiding or those with scarring alopecia begin again to use chemical relaxers or extreme heat for styling, they will jeopardize survival of the transplanted hairs and cause additional loss of non-transplanted hairs as well. Then, all the time and money spent on surgery was in vain. On the other hand, the surgical prognosis is generally good to excellent for patients who are motivated to change their grooming practices," Dr. Callender said.

The techniques used for harvesting and transplantation depend on the underlying cause of alopecia and differ in some respects from those used in white persons because of race-related differences in hair morphology. Follicular unit transplantation is performed in patients with traction alopecia while the punch graft technique is used to optimize follicle survival in patients with scarring alopecia.

In black women, donor tissue for follicular unit transplantation is harvested using a strip technique, usually taking a 1-cm x 6-cm elliptical strip, which is based on the calculated number of hairs transplanted to cover the recipient site. The strip is then cut into follicular units and micrografts that typically contain two to four hairs, and the units are placed into recipient incisions created with a 16 or18-gauge Nokor needle.

"When dissecting follicular units from donor material of black patients, there is an increased risk of follicle transection because of the curly nature of the follicle. Therefore, the grafts are generally larger than those used in Caucasians, and thus, larger recipient sites are needed as well," Dr. Callender said.

When performing the punch graft technique in black women, Dr. Callender uses older methodology that is based on obtaining donor material with either a 3-mm or 4- mm punch size, and creating a smaller, 2.5-mm or 3.5-mm, recipient site plug.

African-American female, age 36, with central centrifugal scarring alopecia of vertex scalp.

"Since hair is being transplanted into scar tissue, this approach is preferred over follicular unit transplantation in order to improve graft survival and optimize the cosmetic outcome," Dr. Callender said.

She added that usual objections about poor aesthetic result with use of the punch graft technique are not relevant when treating central centrifugal scarring alopecia since the transplantation site is at the vertex, not the anterior hair line, and because the curly nature of the black woman's hair helps to further camouflage the plugs.

However, before proceeding with hair transplantation to treat this scarring alopecia, Dr. Callender will do a test area, transplanting around five round punch grafts and waiting three months to evaluate survival and growth.

Scarring Concerns The potential for abnormal scarring reactions remains a concern in black patients, but seems to be addressed well with prophylactic use of a high potency topical corticosteroid, such as clobetasol propionate foam (Olux).

"Surgeons should not let fear of keloid or hypertrophic scarring stop them from performing hair transplantation in black women. Rather, they should anticipate the problem and use preventive measures to decrease the risk," Dr. Callender said.

Corticosteroid prophylaxis is initiated at the donor site immediately after suture removal, regardless of the technique used for harvesting, and is instituted at the recipient sites when punch graft hair transplantation is performed in patients with CCSA if cobblestoning appears. Keloidal and hypertrophic scarring is less likely to occur at the recipient site for follicular unit/micrograft hair transplants in patients with traction alopecia, Dr. Callender said.

African-American male, age 40, with keloid formation of occipital scalp secondary to strip donor harvesting technique for hair transplantation. (Photographs courtesy of Valerie D. Callender, M.D.)

The duration of use of the topical corticosteroid ranges from one to three months and is determined based on whether the patient has a history of hypertrophic or keloidal scarring.

Typical cases of trichotillomania, due to repeated pulling out of hairs: the new hairs grow at different rates and therefore different lengths, as can be felt when the scalp is touched

 The condition is common but not severe in children between the ages of two and six. In teenagers it is twice as common in girls as in boys, and can indicate the presence of a serious emotional difficulty.

Traction and trauma

So-called traction alopecia is seen in people whose hair is regularly subjected to strong traction (pulling). This can occur with ponytails or from backcombing or heavy-handed brushing. The braided styles and hair
weaves often worn by Afro-Caribbean people put considerable tension on the hair, and can give rise to the condition.

The effect of braiding, leading to traction hair loss

Hair loss due to traction and cosmetic abuse

Unlike the receding hair line creeping over a man's scalp, hair loss sneaks up on a woman.

Maybe she sees a few more hairs in her favorite brush. Her ponytail feels skinnier. Her part widens. Eventually she notices she can see her scalp peeking through in a photograph.

Whatever the telling sign, female pattern hair loss can be traumatic. But women today are less likely to suffer in silence than a decade ago; doctors report that women increasingly are coming forward to seek remedies.

Locks we love

In some cases, pinpointing the cause is the first step to a cure, though the source of hair loss in women is not always as clear as it is in men.

The hormone fluctuations of puberty, pregnancy and menopause can cause hair to shed. So can the stress of general anesthesia, illness, anemia, crash diets and thyroid abnormalities. Some women -- and a few men, too -- suffer a compulsion to tug at the hair, damaging the follicles.

Stress on the hair itself, whether from chemical treatments, extensions or tight hairstyles that tug at the scalp, can also break the hair or scar the follicle. Black women are particularly vulnerable due to the hair relaxing treatments and braiding often begun at a young age.

"Half of our hair loss visits are African-American women," said Dr. Marianne O'Donoghue, a dermatologist in Oak Brook and associate professor at Rush University Medical Center. "They have a terrible time keeping their hair in."

The most common cause of female hair loss is androgenetic allopecia, or female pattern baldness. Thought to be influenced by levels of sex hormones, this type of hair loss usually begins after menopause, but it can start as early as puberty. Instead of a woman losing 100 to 125 hairs a day, which is normal, she'll lose so many that her scalp will show through.

Help is available. The topical medicines, laser treatments and hair transplants designed for men can help women, too.

Stopping the loss

One of the oldest treatments for hair loss in men and women is Rogaine, the brand name of the drug minoxidil. Spread over the scalp twice a day, Rogaine works by increasing the growth phase of the hair follicles. It also helps hair grow thicker, stronger and with more pigmentation.

Women's Rogaine is less potent than men's -- a 2 percent strength rather than 5 percent -- though some doctors recommend the 5 percent strength for women, too.

"If you're going to fill your tank up with gas, you may as well fill it up," said Dr. Alan Bauman, a hair loss specialist in Florida.

A new foam version of Rogaine is less irritating to the scalp, Bauman said.

The mistake many women make with Rogaine is quitting too early, Bauman said. Many women quit after six weeks. But it will take six to 12 months to see the results in the mirror, Bauman said. As soon as you quit you'll start losing hair again.

"About 70 percent of women are going to get a response from it, but it's a long-term commitment," he said.

Since it has not been studied in pregnant women, women who are nursing or pregnant are usually advised against using Rogaine.

Propecia is an oral medication that stops hair loss in 90 percent of men, but it's not FDA-approved for use in women and poses risks to a developing male fetus. But some doctors prescribe Propecia to women who are not of childbearing age. While the evidence is not conclusive, a few studies show it works in women whose hormones are controlled with birth control pills or hormone therapy, Bauman said.

Other medications are available for specific types of hair loss. Women with alopecia areata, an autoimmune disorder signaled by circular bald patches, may get cortisone shots in the scalp or a topical cream. Low iron levels or thyroid disorders can be treated and the patient usually will regrow her hair, O'Donoghue said.

Laser therapy

A newer -- and less proven -- treatment involves beaming low-level lasers over the scalp, usually in a series of treatments lasting several months. The FDA recently approved a laser comb as a cosmetic device that can be used at home, though doctors said the laser hoods available in offices are more effective.

The lasers increase blood flow to the scalp and boost cell metabolism, said Dr. Stephen Dayan, a Chicago plastic surgeon who is testing a laser hair restoration device in his office.

"By increasing cell metabolism, you're creating more energy for the hair follicles, and the hair follicles are creating thicker hairs," he said.

The laser treatments work best on men and women with thinning -- not absent -- hair. They have to have functioning follicles.

"If they've been bald for a long time, it's probably not going to do a lot for them," Dayan said.

Jessica Hinkle of Streamwood is completing a series of laser treatments for thinning hair she first noticed five years ago. She didn't have a receding hair line, just more scalp where her bangs should be.

"My husband shaves his head on purpose," Hinkle said. "But a woman being bald is not OK."

Because she's planning to have more children, the 31-year-old didn't want to use Rogaine or other medications that pose any risk to a developing baby. So she entered a contest sponsored by a radio station and won a series of free laser treatments at Deerfield-based Natural Hair Growth Institute.

Once a week, Hinkle sits under a device shaped like a salon hair dryer while lasers glow on her scalp. Since she began treatments in May, Hinkle said her hair is thicker and her scalp less visible.

"I was skeptical, but it's noticeably different," she said. "A lot of people have noticed my hair has changed."

Not everyone can win a contest, and such treatments don't come cheap. Steve Bennis, a former engineer who launched Natural Hair Growth Institute after lasers helped with his own hair loss, says clients spend between $6,800 and $12,800 for a six-month series of treatments.

Bennis is not a doctor, so he requires clients visit one first to rule out medical conditions that could cause hair loss. He says clients start to see new hair growth within four weeks.

"When I started my business, I thought it was only for men," Bennis said. "Now I have 70 percent women. They like it because it's non-invasive, and it solves the problem."

You can also buy a variety of laser combs or brushes that range from $399 to $2,499. Newer versions cover wider areas in less time, Bauman said.

"The lasers are not a miracle cure, but I have noticed in my patients that laser therapy can certainly enhance hair quality and produce thicker, fuller, healthier, shinier hair," Bauman said. "It's not going to give you a teenager's head of hair, but you can see improvements over time."

Transplants

The growing awareness among the public about what cosmetic surgery offers has spread to include hair transplants, even for women, said Dr. Arthur Kaplan of Medical Hair Restoration in Oak Brook.

"Women are the fastest growing percentage of patients," he said.

Part of that is due to more refined technique. A surgeon can implant follicles taken from the back of the head one, two or three at a time, rather than plugs.

"For women, plugs were unacceptable from day one, whereas with men there was a time that was acceptable," Kaplan said. "The aesthetics women required were much higher. As the field has evolved, that has opened up the opportunity."

Micrografts are essential for women, who often have diffuse thinning in a part of the scalp. A surgeon must take care to preserve existing follicles, Bauman said.

"You can't put large grafts into diffuse areas or you're going to cause trauma," he said. "You can't go into a tomato garden with a backhoe. You have to use a small instrument to plant those seeds."

The cost depends on the number of follicles transplanted. Women are usually less expensive than men because a smaller area is involved. Most women spend between $4,500 and $6,000 for transplants at Medical Hair Restoration in Oak Brook.

The procedure takes two to four hours. Women start to notice new hair growth in three to five months, with full results taking a year to appear.

1. Scalp exam for any scars, erythema, scaling, or inflammation Density and distribution of hair Hair shaft exam for caliber, length, shape, and fragility Thyroid palpation to determine thyroid size, nodularity, or vascularity

If a patient demonstrates positive hair-pull tests all over the scalp, he/she may be warned he/she will most likely lose all of their hair. Next, provide anticipatory guidance during the period of extensive hair loss as the cycle reestablishes and regrowth begins.

Finally, determine if eyebrow, eyelash, axillary, or body hair is affected. Examine hair density in other areas such as the face and extremities. A female patient who presents with thinning scalp hair and demonstrates increased facial, thigh, chin, or chest hair may have an androgen excess.

Laboratory Studies

Once other causes such as malnutrition, androgenetic, hereditary conditions (by history, progression, and presentation), trauma (trichotillomania, traction alopecia), and drugs (telogen effluvium) have been ruled out, consider labs for secondary conditions:

• For female alopecia with symptoms of hyperandrogenism (such as menstrual irregularities, infertility, cystic acne, virilization, or galactorrhea), check total testosterone, free testosterone, dehydroepiandrosterone sulfate (DHEA-S), or prolactin levels. For male and female alopecia without symptoms of hyperandrogenism, consider measurement of serum thyroid stimulating hormone concentration to rule out thyroid disease; venereal disease research laboratory (VDRL) technique to rule out syphilis; serum ferritin to rule out anemia; antinuclear antibody test (ANA), RF (rheumatoid factor) to rule out autoimmune disease; potassium hydroxide (KOH) examination to rule out tinea capitis; swab a wound culture to rule out infections; and scalp biopsy as needed to rule out neoplasm.

Disorders Causing Hair Loss in Adults

• Androgenetic alopecia
  • Male: Hereditary. Dihydrotestosterone compels follicles into perpetual telogen phase. The earlier oral or topical treatment is started, the better results one may expect. Female: Female androgenetic pattern incidence increases with age. Incidence is approximately 6% in women under 50, but increases to 38% in women over 70. Female pattern hair loss typically demonstrates a lower density of hair but maintains a relatively even distribution, known as "Ludwig" distribution. Even thinning across the crown is typical, while the frontal line maintains position.
  Telogen effluvium
  • Telogen effluvium is the most common form of diffuse alopecia. It is often diagnosed from a history of an initiating event 3 months before the onset of shedding. Causes include childbirth, sustained high fever, surgery, systemic disease exacerbation, crash low protein diets, severe emotional stress, and drug reactions. Pull tests are positive all over the scalp. Bitemporal recession is a useful diagnostic sign in women. The acute form normally subsides in 3 to 6 months. In true telogen effluvium, the hair invariably regrows within a short time.
  Postpartum telogen effluvium
  • This condition is associated with postpartum hormone-related changes that temporarily prolong hair resting phase. It is most commonly seen 2 to 4 months postpartum.
  Anagen effluvium
  • Anagen effluvium is drug or toxin-induced and may mimic diffuse alopecia areata. Chemotherapy is the most common cause.
  Trichotillomania
  • Trichotillomania is the manifestation of a psychogenic behavioral pattern of frequent hair-pulling by the patient. It is frequently related to obsessive-compulsive disorder and can be seen in males and females of all ages, but most commonly in preadolescent and early adolescent girls. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The bald area manifests as a distinct, unnatural geometric shape. Hair may be pulled from a secondary site, such as the eyelashes, eyebrows, underarms, body, or pubis. Assess for other psychosocial factors and disorders and refer for counseling as indicated. Diagnostic and Statistical Manual-IV (DSM-IV) Criteria for Trichotillomania:
    • Recurrent pulling out of one's hair, resulting in untreatable hair loss Increasing sense of tension immediately before pulling out the hair or when attempting to resist behavior Pleasure, gratification, or relief when pulling out the hair The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatologic condition).
  Alopecia areata
  • Alopecia areata is an inherited autoimmune condition of varying severity. In some patients, hair loss is confined to one or more small oval patches; in others, the scalp is essentially denuded except for a few tufts of hair. It may involve the entire scalp (alopecia totalis) or the surface of the whole body (alopecia universalis). The condition is marked by exacerbation and recovery with high variability among individuals.
  Tinea capitis
  • Tinea capitis is a contagious fungal infection of the scalp mostly seen in ages 4 to 14 years. There are fine, scaly, circumscribed areas that are frequently itchy and inflamed. Hair is dull and brittle, breaking off at scalp. In more extensive cases, there may be fever and cervical lymphadenopathy. In the United States, over 90% of cases are from the nonfluorescent Trichophyton fungus. Potassium hydroxide (KOH) examination shows hyphae. Antifungals such as terbinafine, fluconazole, itraconazole, or griseofulvin are used for treatment.
  Systemic lupus erythematosus (SLE)
  • SLE is a chronic autoimmune inflammatory disease affecting collagen. It involves multiple systems of the body including hair loss.
  Secondary syphilis
  • Secondary syphilis usually begins 2 to 8 weeks after chancre type lesions appear. It can present with patchy hair loss, mostly on the scalp and often elsewhere on the body. This hair loss is often described as having a moth-eaten appearance. High-risk clients should also be questioned regarding past rashes, especially on the palms, soles, and any chancroid lesions or condyloma. Diagnosis is serologic (VDRL or rapid plasma regain [RPR]), and hair regrowth occurs after penicillin therapy. Penicillin remains the first choice, but if an allergy exists, intramuscular Rocephin (x 10 days), tetracycline, or doxycycline may be tried for 2 weeks.
  Side effects of medications
  • Medications such as cytotoxic agents, colchicine, heparin, oral anticoagulants, hydroxyurea therapy, vitamin A, captopril, protease inhibitors such as indinavir and nelfinavir, amphetamines, anticancer agents, gout medication, isotretinoin (Accutane), lithium, male hormones, propranolol hydrochloride (Inderal), and valproic acid (Depacon, Depakene, Depakote), can all induce nonscarring hair loss.
  Birth control pills
  • Women who lose hair while taking birth control pills may have an inherited tendency for hair thinning. If hair thinning occurs, a woman can consult her gynecologist about switching to another birth control pill. When a woman stops using oral contraceptives, she may notice that her hair begins shedding two or three months later. This may continue for six months when it usually stops. This is similar to hair loss after the birth of a child.
  Caustic chemicals
  • Anyone who curls, straightens, colors, or dyes their hair may cause hair loss. Repeated exposure to these substances can injury hair follicles, weaken hair, or even damage the scalp. It is most often seen in African women, and inflammation is not always obvious.
  High fever or severe infection
  • Acute and some chronic illnesses may cause hairs to enter a prolonged resting telogen phase (also known as telogen effluvium). It is not uncommon to experience a higher incidence of hair loss up to three months after high fever, severe illness, or infection. This resting phase typically resolves after several months and normal hair growth rebounds when the growth cycle returns.
  Other causes of hair loss
  • Other causes of hair loss include anemia, hypoalbuminemia, malnutrition, Lichen planus, Staphylococcal folliculitis, scleroderma, psoriasis, seborrhoeic dermatitis, menopause, hypothyroidism, herpes zoster, and others.

Treatment Recommendations

The choice of therapeutic intervention for alopecia depends on several factors:

• The underlying cause The goals of therapy The long-term risks, benefits, costs

The evaluation and treatment of alopecia should begin as early as possible after the onset of symptoms. Many conditions causing alopecia or reduced hair density may be reversed or minimized with prompt intervention.

Pharmacologic – Treatment of the Underlying Illness

• Hypothyroidism
  • Thyroid replacement or adjustment as indicated
  Fungal infection
  • Ketoconazole, oral antifungal agents such as griseofulvin (Grifulvin), itraconazole (Sporanox), terbinafine (Lamisil), and fluconazole (Diflucan) may be used. Oral steroids may be necessary to decrease inflammation and scarring.
  Hormone imbalance
  • If female androgen excess is suspected (hirsutism, acne) or menses is irregular, check DHEA-S and free testosterone levels first to rule out adrenal or ovarian cancer. Once ruled out, consider spironolactone, flutamide, or finasteride. Spironolactone competes with testosterone and dihydrotestosterone at the androgen receptor level. Spironolactone 100 mg per day can be given in divided doses; this dose may be increased to 200 mg. Flutamide (Eulexin), an antiandrogen that blocks androgen uptake and nuclear binding, is a very effective drug in treating hyperandrogenism. Give 250 mg daily and monitor hepatotoxicity. Finasteride (Propecia) blocks the conversion of testosterone to dihydrotestosterone. The plasma levels of testosterone may increase during treatment, whereas the dihydrotestosterone level decreases. Of utmost importance, the patient should be aware that she must avoid pregnancy during treatment with finasteride because of the potential for causing ambiguous genitalia in a male fetus.
  Drug-induced hair loss (effluvium)
  • Drugs that induce hair loss include antihypertensive agents, anti-gout medications, etc. Consider tapering or discontinuing the medication if untoward risks are low.
  Chemotherapy
  • Recommend nonpharmacologic therapy (wig, hairpiece).
  Psychological causes of hair loss (Trichotillomania)
  • Consider behavioral therapy, antianxiety or antidepressant medication, or any combination of the two.
  Physical stress from surgery/acute illness
  • Reassure patient hair regrowth once stress removed.
  Lupus and diabetes
  • Treat underlying diseases.
  Traction alopecia
  • Hair loss that is secondary to grooming such as tight braids, "cornrows," pony tail: Change hair styling technique.
  Drug therapy for alopecia (alopecia with no underlying disease)
  • Minoxidil (Rogaine 2% for women, Rogaine 5% for men): Apply 1 mL twice a day (BID) regardless of the extent of the affected area; one year of use may be needed before obvious efficacy. Minoxidil is mainly for hair loss at vertex, not for frontal baldness. Propecia (finasteride 1 mg): Food and Drug Administration (FDA) approved; for MEN ONLY Monotherapy or synergistic use:
    • For women - May add estrogen to any therapy For men/women - May add tretinoin (Retin-A) topical as an adjunct/synergistically with minoxidil

Nonpharmacologic Treatment

• Cosmetic measures (hairstyle adjustments, wigs, extensions, hair pieces, hats, scarves) Cessation of wearing tight braids, buns, pins In chemical/allergic causes, avoidance of the identified sources

Monitoring Treatment/Discontinuation of Treatment

Patients with Hypothyroidism

Initiate thyroid hormone replacement therapy to obtain thyroid-stimulating hormone (TSH), triiodothyronine (T3), and thyroxine (T4) in the normal range. Treatment will be long term, even as hair regrowth occurs. Monitor hair regrowth in each follow up with hypothyroidism.

Patients Considered for Treatment Related to Fungal Infection

If long-term antifungal treatment is required, monitor liver function and gastrointestinal (GI) symptoms. Obtain baseline alanine aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin before treatment. Reevaluate in 4 to 8 weeks. Discontinue if there are any GI symptoms or signs of liver dysfunction such as fatigue, nausea, anorexia, vomiting, dark urine, or pale stools. Monitor drug interactions when patients have comorbidities and are using other medications. Check safety of different antifungals on women in childbearing ages.

Patients with Androgenetic Imbalance

Monitor hepatotoxicity if the patient is treated with flutamide. Monitor irregular menses, reduced libido, mood swings, and electrolytes if treated with spironolactone.

Patients on Medications for Hair Loss

Minoxidil (Rogaine) - Topical use

Since its mechanism of action is to stimulate hair growth by vasodilation, it may exacerbate angina pectoris. Use with caution in patients with pulmonary hypertension, congestive heart failure, coronary artery disease, and significant renal failure. Topical use may also cause pruritus, and Stevens-Johnson syndrome.

Finasteride (Propecia)

Give 1 mg daily (QD) with or without food to MALE patients only. Pregnant women or women who may potentially become pregnant should not touch crushed tablets because of teratogenic effects on male fetus. Monitor hepatic function. Potential side effects include decreased libido and erectile dysfunction.

Steroids (e.g. prednisone)

Side effects of steroids include diabetes, weight gain, hypertension, electrolyte and fluid imbalance, osteoporosis, striae, acne, renal function impairment, avascular necrosis, and immunosuppression. Abrupt discontinuation may cause adrenal crisis.

Individualization of Therapy

• The Women's Androgenetic Alopecia Quality of Life Questionnaire (WAA-QOL) is useful in evaluating health-related quality of life (HRQOL) specific to women. It is self-completed in about 10 minutes and may serve both to indicate the impact on the patient (and potential indication for intervention) and evaluate therapeutic responses to therapy. Decide whether the patients want to use topical treatment or oral treatment. Patients at different ages may have preferences. The hair growth cycle is slow. Affected changes take time to notice. Once therapy is selected, stick with it for 3 to 6 months and then reevaluate. Treatment follow-up (3- to 6-month intervals). Adjust therapy and identify causes if inadequate response.

Important Considerations

Cosmetic management and psychosocial adaption

• Regrowth of new or thicker hair for larger scalp coverage Decreased rate of hair loss (i.e., slow down balding progression) Surgical reconstruction Cost and side effects of drug therapy Tolerability of therapy (patient satisfaction with care, quality of life, and adherence to treatment regimen) Final assessment and evaluation including hair density readings Assessment of patient satisfaction as measured by quality of life index

Screening and diagnosis

Routine laboratory tests help to determine the presence of underlying causes and risk factors that would affect treatment. Optional tests may be used, depending on findings obtained in the history and physical examination and previously known conditions. A greater, more inclusive assessment can be determined by referral to dermatology.

Informed guidance to treatment options

Clinicians should begin by providing the patient with a summary of information on:

• Causes of hair loss and their respective potential to respond to medical therapies Details of what therapeutic options involve, including directions for use, potential side effects, interactions, timeline for responses, follow-up visits, financial expense, and long-term outcomes

Evaluate treatment goals

The primary objective of treatment is to reach therapeutic responses as closely to patient goals within budget and expectation that is both understood and acceptable by the informed patient. To modify drug therapy and maximize response toward patient goals, clinicians should consider cost where therapeutic effect is equal. To facilitate compliance, clinicians should choose medications with simple regimens.

Therapeutic adjustment and further individualization

• Titrate drug or add another agent if there is good tolerance but poor response. Allow for several weeks to two months before drug or dosage changes are made. If the response remains less than anticipated, substitute with a drug of a different class or action. Always consider alternative explanations for poor response to drug therapy to explore secondary causes. In each patient encounter, reassess adherence, quality of life, and patient goals. Assess the long-term response to therapy. Reassess side effects that might complicate therapy or limit efficacy. Monitor the development of target organ damage. Reinforce lifestyle modification.

Evaluate the efficacy of therapy

• To assess adequacy of hair growth, use an objective measurement tool such as a scalp chart, comparison with before-treatment photos, and a subjective self-assessment of quality of life before and after treatment. Patients should be seen within 1 or 2 months after the initiation of therapy to determine therapeutic response, degree of patient adherence, and presence of adverse effects. Earlier follow-up may be necessary for patients with underlying comorbid conditions. Once the patient's response is observed, follow-up at 3- or 6-month intervals (depending on the patient status) is generally appropriate. Consider referral or consultation in unresponsive or complex comorbid cases.

by Devera Pine

"It's one of the leading ways people can establish their individuality and express their style," says Jerome Shupack, M.D., professor of clinical dermatology at New York University Medical Center in New York City. "Hair has had sociological importance throughout the ages."

Because of its importance, anything that happens to our hair that we can't control--falling out or turning gray, for instance--can be the source of much anxiety.

In the United States, some 35 million men are losing or have lost their hair from male-pattern baldness, according to the American Hair Loss Council. Approximately 20 million women have experienced a similar loss of hair (from female-pattern hair loss), and an estimated 2.5 million Americans have lost their hair due to other causes.

THE BASICS

Hair is produced by hair follicles--indentations of the epidermis (outer skin layer) that contain the hair root, the muscle attached to it, and sebaceous, or oil, glands. Hair is made up of dead cells filled with proteins, most of which are known as keratins. The cells are woven together like a rope to form the hair fiber. The hair fiber, in turn, has three layers: the outer cuticle with its fish-scale-like structure; the cortex, which contains the bulk of the fiber; and the center, or medulla. Hair color is determined by melanocytes, cells that produce pigment. When these cells stop producing pigment, hair turns gray.

Although it seems as if the hair on your head is always growing, hair actually has active and rest phases. The growth phase, known as anagen, lasts for two to six years. At any given time, about 90 percent of scalp hair is in the growth stage. The remainder is in the rest phase, known as telogen; this lasts from two to three months.

Once the rest phase is over, the hair strand falls out and a new one begins to grow. As a result, it's considered normal to lose from 20 to 100 hairs a day, says Diana Bihova, M.D., a dermatologist in private practice in New York City. Only a change in your regular pattern of loss is considered abnormal--but many things, including genetic factors, diet, stress, and medications, can change that pattern.

BALDNESS: MANIFEST DESTINY?

The most common cause of hair loss in both men and women is rooted in a genetic predisposition. Called androgenic alopecia, it is known as male-pattern baldness in men and female-pattern hair loss in women (alopecia is the scientific term for baldness). According to the American Hair Loss Council, genetics accounts for 95 percent of all cases of hair loss in this country.

Baldness results from a combination of genetic factors and levels of testosterone (a hormone produced by the adrenal gland in both sexes and also by the testes in men). If hormone levels are right, then the hair follicles will express their genetic destiny by growing for shorter periods and producing finer hairs. In men, who have higher levels of testosterone than women, this eventually results in a bald scalp at the crown of the head and a horseshoe-shaped fringe of hair remaining on the sides. In women, the hair thins all over the scalp; the hairline does not recede. This type of hair loss doesn't usually show up in women until menopause; until then, estrogen tends to counteract the effects of testosterone.

TRANSPLANTS

Baldness can also be treated with hair transplants, in which plugs of "donor" follicles from the patient's scalp are used to fill the hairline. Although hair transplants work well in both men and women, the treatment tends to have a more dramatic effect on appearance in men with bald spots than it does on women with thinning hair.

"The less hair you have, the more drama in the change," says Robert Auerbach, M.D., associate professor of clinical dermatology at New York University School of Medicine. However, the American Hair Loss Council warns against attempting to replace lost hair with hair pieces sutured to the scalp. FDA has not approved any products specifically intended for this purpose, however, this does not preclude a physician from using sutures, which are approved devices, for this purpose. According to the council, although the procedure is legal, it can result in scars, infections and even brain abscesses.

Another treatment for male-pattern baldness, hair implants made of high-density artificial fibers surgically implanted in the scalp, was banned by the FDA in 1984 because it causes infection. This is the only device FDA has ever banned.

PRODUCTS THAT DON'T WORK

So-called "thinning hair supplements," "hair farming products" and "vasodilators" for the scalp will not promote hair growth, says Mike Mahoney, a spokesperson for the American Hair Loss Council.

Thinning hair supplements are nothing more than hair conditioners that temporarily make your hair feel or look a little thicker. The main ingredient in these products--polysorbate--is also found in many shampoos. Promotional materials for hair farming products claim that they will release hairs that are "trapped" in a bald scalp. Mahoney says these products, many of which are herbal preparations, can do no such thing. And so-called vasodilators do not increase the blood supply to the scalp and do not promote hair growth.

EVERYDAY HAZARDS

While male- and female-pattern baldness results in permanent hair loss, other factors can cause temporary loss of hair. For instance, the drop in the level of estrogen at the end of pregnancy can cause a woman's hair to shed more readily. Two or three months after a woman stops taking birth control pills, she may experience the same effect, since birth control pills produce hormone changes that mimic pregnancy. A major physical stress, such as surgery, or a major emotional stress--positive or negative--can cause hair loss.

"I've seen women start losing their hair before getting married," says Bihova. Even jet lag can have a similar effect.

In most of these cases, the hormonal imbalance or stressful situation will correct itself, and the scalp will soon begin growing hair again. But, says Bihova, since most women are extremely upset by even a temporary hair loss, many dermatologists treat these conditions with either topical steroid preparations or localized injections of low doses of steroids. Bihova emphasizes that these are local, not systemic, injections of steroids, therefore, the shots do not have the same risk of dangerous side effects as systemic steroids. However, only a board-certified dermatologist should administer this treatment, she says.

The list of causes of temporary hair loss goes on: pressure on the scalp from wigs or hairdos that pull too tightly can cause it. A fever of 103 degrees Fahrenheit or more often causes hair loss six weeks to three months later. And some medications can cause a temporary loss. These include vitamin A derivatives such as Accutane, cough medicines with iodides, anti-ulcer drugs, some antibiotics, beta blockers, antidepressants and amphetamines, anti-arthritis drugs, blood thinners, some cholesterol-lowering agents, aspirin taken over long periods, some thyroid medications, and chemotherapy.

YOU HAIR WHAT YOU EAT?

Although nutrition does play a role in hair loss and in the overall health of your hair, only extreme nutritional deficiencies or excesses will cause hair loss. For instance, people with anorexia and bulimia may temporarily lose hair. So will others suffering from malnutrition.

"It's pretty rare in the United States," says Bertolino. "If someone was on a real strange, restrictive diet, it could happen to them."

Megadoses of some vitamins--particularly A and E--and an iron deficiency may lead to hair loss. People who claim they can determine which vitamins are lacking in your diet by analyzing your hair, however, are not speaking from a scientifically sound basis. The test used with this type of hair analysis--atomic absorption spectrophotometry--is a legitimate analytical chemistry method; however, used on hair, the results of this test do not correlate with nutritional status, says Shupack. "Because of the sociological importance of hair, a lot of people try to cash in on it," he says. "Hair analysis is all witchcraft as far as I'm concerned."

There are, however, a few legitimate hair tests for substances such as arsenic and lead.

FOR BEAUTY'S SAKE

Every time you shampoo, blow dry, perm, straighten or dye your hair, you damage it slightly, says Bertolino. For the most part, hair can withstand this type of treatment. But overzealous beautifying can damage the hair fiber, resulting in many broken strands, and a frizzy, split-end look. For instance, if you bleach your hair and then have a bunch of perms done in a short time, you're heading for trouble.

Misuse of hair cosmetics can cause the hair to break as it comes out of the scalp, says Frances Storrs, M.D., professor of dermatology at the Oregon Health Sciences University. Permanent wave solutions break the bonds that hold hair together and then reform them. But with a perm that is not diluted right or not rinsed off properly, for instance, those bonds may not re-form and the hair would soon fall out as a result. Fortunately, most professional hair dressers know how to use perms correctly, says Storrs.

Most hair dyes are not as irritating as permanent solutions, mostly because they do not break the bonds between hair fibers and are therefore not likely to cause a hair loss, she says. However, a severe allergic reaction to hair dye could cause hair loss. "The allergy is pretty common, actually," says Storrs. Permanent solutions can also cause allergic reactions, though that's a rare side effect.

Other beauty-related manipulations of the hair can cause problems, too: hot irons, corn rows and braids may bring on temporary or permanent hair loss. If the hair breaks often enough, the follicles may eventually not be able to produce normal hair, says Bihova. "If someone has a problem with thinning and excessive loss, we advise being gentle," she says. "Don't use rollers; don't use blow dryers on a hot setting; don't wear tight hair styles." Rough shampooing may accelerate any loss, though it's usually not a problem in people with healthy hair.

THE MEDICAL SIDE

Some hair loss is the result of a type of immune disorder known as alopecia areata--some 2.5 million people suffer from this condition in which antibodies attack the hair follicle, causing the hair to fall out. Alopecia areata often causes small, oval or circular areas of hair loss. However, in some forms of the condition, all the scalp hair falls out; in other forms, all body hair is lost. Although the loss is usually temporary, the condition can recur. Treatments include topical steroids or the use of chemicals to produce an allergic reaction to start the hair growing again.

Finally, chronic, systemic conditions--including one form of lupus, abnormal kidney and liver function, and hypothyroidism or hyperthyroidism--can affect the hair. If you're experiencing hair loss, see a doctor. He or she will want to order some basic blood tests to rule out any medical cause of the condition.

Devera Pine is a freelance writer in New York City who frequently writes about health and science.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service, Food and Drug Administration
Office of Public Affairs, 5600 Fishers Lane, Rockville, MD 20857

Alopecia, which means hair loss, is of epidemic proportion for many women of color. Although there have been magazine articles and television segments about alopecia, it continues to be poorly understood by many women. There are many different causes of alopecia that affect women with brown skin. However, there are two types of hair loss that women with curly or tightly coiled hair are plagued with: central centrifugal cicatricial alopecia (Figure 1 and Figure 2).

Fig 1. Mild CCCA	Fig 2. Traction alopecia

Alopecia is a devastating condition for all women, despite the cause. All women want to have their own healthy hair. Hair loss effects self-esteem, social interactions and relationships.

Central centrifugal cicatricial alopecia (CCCA) was previously called follicular degeneration syndrome or hot comb alopecia. CCCA is a form of hair loss that has the following features:

• Central (crown) portion of the scalp is were the problem begins
• Centrifugal (circular) pattern is the outward pattern in which this problem progresses
• Cicatricial (scarring) of the hair follicles occurs
• Alopecia (hair loss) is progressive

Fig 3. Moderate CCCA

With CCCA, the hair loss may appear suddenly and progress relentlessly (Figure 3). It occurs in women of all ages, from as young as 20 to as old as 60. The cause of CCCA is unknown but it is felt to be related to repeated and frequent but unnoticed damage to the hair follicles. There may be a hereditary component to CCCA and for Black and some Latina women, a combination of hair care habits and practices may cause or contribute to the condition. Some dermatologists theorize that the following factors may play a role in the cause or CCCA:

• Genetics
• Hot combing (microscopic droplets of hot hair oil drip onto and damage the hair follicles)
• Chemical relaxing (the severe tingling and burning that occurs when the application directions are not followed may produce inflammation and destruction of the hair follicles)
• Tight rollers or curlers used to set the hair (the chronic pulling or traction of the hair may produce inflammation and destruction of the follicles)
• Braids with extensions or weaves to style the hair (the chronic pulling or traction of the hair may produce inflammation and destruction of the follicles)
• Blow drying (excessive heat applied to the scalp and hot oil droplets may destroy the follicles)
• “Oiling or greasing the scalp” (may block the follicles and cause inflammation in the follicles)

Once the hair follicles become damaged or destroyed, scar tissue (cicatrix) forms and hair will never regrow. Therefore, if you suspect that you may have CCCA, it is important to see your dermatologist immediately. An evaluation by the dermatologist will include blood tests to eliminate other causes of hair loss and a scalp biopsy. A scalp biopsy is a simple procedure in which a small area of the scalp is removed after numbing medication is administered. A stitch is then placed to close the areas. When the biopsy is analyzed by the pathologist, features typical of CCCA may be seen: a decrease or absence of hair follicles, scar tissue formation and inflammatory cells surrounding the hair follicles.

Treatment
Since dermatologists do not know the exact cause of CCCA, outlining a treatment is difficult. The first step is to stop any styling practice that may be causing or contributing to the hair loss. Often that means no hot combs, no tightly applied rollers or braids, blow drying or relaxers for a period of time. If the hair follicles have not been damaged beyond repair, you may, for example, be able to resume your hair care practices but with modifications. Your dermatologist can help you determine when—and if—you can resume these styling practices. Taking a break from harsh styling and substituting gentler techniques may allow the inflammation to resolve, the scalp to heal and hair growth to resume.

Your dermatologist may prescribe medications to decrease the inflammation that is seen in the hair follicles of those affected by CCCA. Oral or topical antibiotics are sometimes prescribed because they help to reduce inflammation. Likewise, topical cortisones applied to the scalp or cortisones directly injected into the scalp may also be used to treat or reduce scalp inflammation. Finally, once the inflammation is minimized, your dermatologist may recommend over-the-counter Minoxidil (Rogaine) to stimulate grow of follicles that have not been destroyed.

Fig 4. Severe CCCA

With severe CCCA (Figure 4), the hair follicles are destroyed and neither topical or injected medications will help the condition. Hair transplantation may be a solution for some women although the severe scarring may make this procedure technically difficult.

Sometimes CCCA is confused with the hereditary form of alopecia, called androgenic alopecia. This form of alopecia is also characterized by thinning in the central portion of the scalp with extension toward the hairline. With androgenic alopecia, the underlying scalp appears normal and the follicles are not scarred. Therefore, there is a greater likelihood that hair will regrow. The over the counter medication, Minoxidil (Rogaine), may help improve the particular condition.

Bottom line
CCCA is a devastating condition for women with brown skin and the best chance of reversing the process and restoring hair is early diagnosis and prevention. Therefore, it is important to see a dermatologist who is knowledgeable in tightly coiled or curly hair at the first sign of hair loss.

  Traction Alopecia

Traction alopecia is hair loss that occurs as a result of continuous pulling of the hair. Pulling may occur from hairstyles such as tight cornrows or braids, weaves, ponytails or even hair rollers or curlers. Traction alopecia may also be due to excessive weight from long extensions or locks. Signs that the hair is being pulled too tightly are difficulty moving your forehead or temples, headache, and scalp soreness. Side effects of pulling too hard are breakage of hair strands and hair loss from the follicle. An even more serious side effect of chronically pulling the hair is an inflammation of the follicle and the appearance of small bumps (folliculitis). Inflammation can lead to destruction of the hair follicle and permanent hair loss. Over time, bald spots may develop along the hairline and in the area above the ears. Since the hair loss happens gradually, you may not even notice it until the bald spot develops or your hairline recedes significantly. If traction alopecia continues for a prolonged period of time, the follicles may become destroyed and hair loss permanent.

Treatment
It may seem obvious but it’s time to stop pulling your hair out. To save your hair, you may need to switch hairstyles altogether. However, if your hair loss is minimal and you want to continue to braid your hair or plait your child’s hair, for instance, you can make adjustments, such as wearing looser braids, plaiting the hair loosely and wearing shorter weaves or locks. Women of color often pull tightly on hair to make it look smooth or straighter in a ponytail or bun. A better solution might be to apply a hair gel or a dab of conditioner to the hair to help it to lie flatter and straighter. More manageable hair will look smooth and neat without all that pulling, so wash and deep condition regularly. To camouflage bald spots or a receding hairline you might consider brushing your hair towards the hairline or coloring the scalp with a scalp pencil. You can find scalp pencils at a local beauty supply store; apply as you would an eyebrow pencil, with short strokes in the direction of hair growth.

Once the pulling and tension have been eliminated, if there is active folliculitis, your dermatologist may prescribe an oral or topical antibiotic to reduce the inflammation. In addition, potent cortisone containing creams or cortisone injections may reduce inflammation. If severe scarring is present, hair transplantation may be an effective treatment.

Bottom Line

Traction alopecia can also be a devastating condition for women with brown skin in much the same way as CCCA. Although women may think that they look terrific with tight hair styles, they can and do lead to permanent loss of hair. The key with traction alopecia is simply to avoid tight hair styles. Also, it is important to see a dermatologist at the first sign of hair loss.

It might be strange to think of a 19 year-old female getting a hair transplant, but Kris Johnson of Atlantis Hair Transplant Clinic in Fort Lauderdale Florida says he is seeing an increase in the number of young women seeking hair transplants, most of them African-American.

The reason for the increase is Traction Alopecia, a hair loss condition caused by damage to the dermal papilla and hair follicle by constant pulling or tension over a long period. It often occurs in persons who wears tight braids, especially "cornrows" that lead to high tension, pulling and breakage of hair.

This condition is most common in African-American women and men who braid their hair too tightly. It is also common in Sikh men of India and Japanese women whose traditional hair styles also pull and damage hair. Traction alopecia occurs more frequently in children, teenagers and young adults then it does in older women and men.

Traction alopecia is reversible if diagnosed early, but may lead to permanent hair loss if it is undetected for a protracted period. Hair loss is often in the frontal and temporal regions, but also depends on the hair style.(1) With those who wear cornrows, the area most commonly affected is that adjacent to the region that is braided. (2)

Traction Alopecia can also occur due to overprocessing of the hair. Chemical treatment of hair with dyes, bleaches, or straighteners disrupts the keratin structure in a manner that reduces its tensile strength. (2) The hair can become fragile and heavy fall out can occur with brushing or combing.

The use of thermal or chemical hair straightening, and hair braiding or weaving are examples of styling techniques that place African American women at high risk for various "traumatic" alopecias.(3)

The key to stopping traction alopecia is detecting it early. Hair styles that put unnecessary strain on the hair root must be changed for "looser, more gentle hair style. Women, African-American women, who suspect they may be vulnerable to traction alopecia should take action immediately to change their hair style or treatment methods and by all means, take the time to see a dermatologist. Professional hair stylists specializing in braids, cornrows, weaving and chemical processing should warn their clients about traction alopecia.

Unfortunately, no medical treatment is available to reverse late-stage traction alopecia. Hair grafts have been identified as the only practical solution. "We're seeing an increase in the number of young women who are coming to us for a hair transplant," Kris Johnson said. "Just the other day we did a hair transplant for a 19 year-old African-American girl. It's a shame really because she didn't have to lose her hair." (4)

Johnson said he's had good success in treating traction alopecia with hair transplants. "Women and men with permanent traction alopecia make good candidates for hair transplants," he said. "Many of them are treated with hair transplant results I'd rate from Good to Excellent."

Summary Points:

• In the USA, traction alopecia is most common in African-American women due to their hair styles. Can also occur in men who use hair weaving to conceal bald areas.

• More common in children and young adults and less common in older adults.

• Traction Alopecia is reversible if detected early but can lead to permanent hair loss. Early detection is the key.

• For women, no medical treatment exists and hair grafts are their only option.

• Traction alopecia is more common in the frontal and temporal regions, but also depends on the hair style. With cornrows, hair loss is adjacent to the rows.

• Women and men who suspect they might be vulnerable to traction alopecia should change their hair style and/or reduce usage of hair chemicals, and consult their dermatologists.
  

"Corn rows" and other styles, like extensions, which pull the hair are to blame, particularly if combined with hair straightening chemicals.

The South African research, published in the British Journal of Dermatology, looked at almost 2,000 adults and children.

A UK dermatologist said that affected hair follicles may never recover.

Specialist braided hairstyles are increasingly popular in the UK, particularly among young people from the Afro-Caribbean community.

Short cuts

The Cape Town-based researchers wanted to find out if they, and other popular cuts such as short "brush-cut" haircuts could cause skin problems.

They found that nearly one in seven children and a third of women suffered from "traction alopecia", a type of hair loss directly linked to the hair being constantly under tension.

The problem was even more common if chemical "relaxers" had been used to straighten the hair, with one in five children who had used the chemicals suffering hair loss.

The research also found that very short haircuts made men much more prone to developing severe acne on the scalp, thought to be caused by the hair clippers damaging the scalp when pressed hard against the head.

They pointed out that the risk of catching a disease such as HIV or hepatitis could be increased by this type of haircut.

No growth

Dr Nonhlanhla Khumalo, who led the research, said: "Traction alopecia is common in women and girls and is significantly linked to hairstyles, particularly when relaxed hair has braids, extensions or weaves attached.

"This can cause unsightly hair loss which is distressing."

In the UK, dermatologists are reporting similar problems, both due to braiding, and to other popular hairstyles where the fringe is dragged backwards and tied.

Dr Andrew McDonagh, from the Royal Hallamshire Hospital in Sheffield, said: "The best thing is to try to identify the problem early - if this happens for a long time, the hair follicles may be permanently damaged, and hair will not grow back."

A spokesman for the British Association of Dermatologists added: "Some of these hairstyles might be fashionable, but they can lead to permanent hair loss, which is difficult to cover up and can have a huge impact on a person's confidence."

Farrell Hair Replacement creates "ultra-custom" nonsurgical hair replacement hair systems for men suffering from the devastating effects of hair loss. Farrell hair systems are virtually undetectable to both sight and touch and are produced with the highest quality human hair available. Farrell hair systems have been voted "Best in the World" by HairSiteBlog.com, the world's #1 website for hair loss.

At Farrell Hair Replacement we produce hair systems that appear as though the hair is growing right out of your scalp. With a Farrell hair system you can create any hairstyle you wish including those that allow you to comb your hair back and away from your face, exposing your entire hairline.

Chemicals like Propecia and Rogaine have not grown back a single full head of hair!

Since this is true, what is the point of paying thousands of dollars per year on chemicals that might grow peach fuzz that will fall out once you stop taking the medication? Just like the hair transplant surgeon, the pharmaceutical company has you trapped into spending more and more money on a "solution" that ultimately doesn't work. Side effects of these drugs occur in 2% of men and include sexual side effects, such as less desire for sex, difficulty in achieving an erection, and a decrease in the amount of semen produced by the body. Propecia.com reports that "In general use, the following have been reported: allergic reactions including rash, itching, hives, and swelling of the lips and face; problems with ejaculation; breast tenderness and enlargement; and testicular pain." 2% doesn't sound like a lot, but do you care about the statistic if you are one of the unfortunate 2%? Of course not. Again, let's face the facts: These chemicals are serious medications with potential serious side effects. If you are a man, you have as much of a chance growing breasts as growing hair.

"Androgenetic alopecia, a hereditary androgen-dependent disorder, is characterized by progressive thinning of the scalp hair defined by various patterns," the authors write as background information in the article. "It is the most common type of hair loss in men." Although risk for the condition is largely genetic, some environmental factors also may play a role.

Lin-Hui Su, M.D., M.Sc., of the Far Eastern Memorial Hospital, and Tony Hsiu-Hsi Chen, D.D.S., Ph.D., of National Taiwan University, Taipei, surveyed 740 Taiwanese men age 40 to 91 (average age 65) in 2005.

At an in-person interview, the men reported information about smoking, other risk factors for hair loss and if they had alopecia, the age at which they began losing their hair. Clinical classifications were used to assess their degree of hair loss, their height and weight were measured and blood samples were provided for analysis.

The men's risk for hair loss increased with advancing age, but remained lower than the average risk among white men. "After controlling for age and family history, statistically significant positive associations were noted between moderate or severe androgenetic alopecia and smoking status, current cigarette smoking of 20 cigarettes or more per day and smoking intensity," the authors write.

This association could be caused by several mechanisms, they note. Smoking may destroy hair follicles, damage the papilla that circulate blood and hormones to stimulate hair growth or increase production of the hormone estrogen, which may counter the effects of androgen.

"Patients with early-onset androgenetic alopecia should receive advice early to prevent more advanced progression," the authors conclude.

Journal reference: Arch Dermatol. 2007;143(11):1401-1406.

Adapted from materials provided by JAMA and Archives Journals, via EurekAlert!, a service of AAAS.

Asian Hair

In the past, hair restoration surgeons approached the Asian patient with hair loss with considerable hesitation. This was because of the concern that it would be difficult to produce a natural looking transplant in a patient with dark, coarse hair and relatively light skin. This fear was justified by the limitations of older hair transplant techniques.

With the advent of Follicular Unit Transplantation all this has changed. The versatility of using follicular units enables the surgeon to successfully produce a completely natural looking transplant regardless of the person's specific hair characteristics. Still, understanding the distinctive features of Asian hair is extremely important to achieve maximum cosmetic benefit from the transplant.

In general, Asian hair is characterized by being:

• Coarse
• Straight
• Black
• High skin/hair color contrast
• Smaller follicular units
• Lower density
• Emergent angle of hair is less acute

Coarse hair, which makes large grafts look even more "pluggy," is actually a benefit in Follicular Unit Transplantation. The reason is that hair shaft diameter is the major determinant of hair volume (in fact, hair shaft diameter is twice as important as the absolute number of hairs). Therefore, all things being equal, patients with coarse hair will have the greatest impact from the transplant.

The concern that coarse hair may not look natural at the frontal hairline is not an issue since only individual, one-hair follicular units are used in this area. For the occasional patient with very coarse hair and light skin, the bottoms of the hair follicles can be removed. This produces a finer textured hair that can add additional softness to the hairline if desired.

Black hair on light skin tends to look less full than light hair on light skin because the increased contrast tends to exaggerate the spacing between the hair. When hair and skin color match, the skin color acts as a "filler" between the hair shafts. When there is significant contrast, an additional transplant session may be needed to achieve the desired degree of coverage, and the patient should be made aware of this. In addition, side-to-side grooming patterns can greatly increase the appearance of fullness through the effects of layering. For the most part, the increased hair shaft diameter makes hair transplantation in Asians very successful, regardless of color contrast.

If we examine Asian hair with densitometry (30x magnification), we find that the Asian scalp contains follicular units of predominately 1- and 2-hairs, with 2-hair units being the most prevalent. This is in contrast to the typical Caucasian scalp that contains follicular units in groups of 2-, 3-, and even 4- hairs. See the following two Videoscans for comparison.

Asian Scalp

Caucasian Scalp

I addition, the total number of hairs per area is less, so Asians average about 170 hairs per cm², whereas Caucasians have around 210/cm². The following table summarizes these differences:

	Caucasians	Asians
Follicular Unit Density (mm2)	1.0	1.0
Average Hair Density (hairs/mm2)	2.1	1.7
Predominant Hair Grouping	Two	Two

We can see from the above chart that although the hair density is slightly lower in Asians, the number of follicular units are approximately the same, so comparable numbers of follicular unit grafts are available from the same sized donor strip. This, together with a greater hair shaft diameter, makes transplantation very successful in Asians.

A final aspect of Asian hair that has some bearing on the transplant is the angle that the hair emerges from the scalp. Whereas hair in most Caucasians tends to lie relatively flat (the angle that it emerges from the scalp is acute), Asian hair emerges slightly more perpendicular to the skin and thus appears to stand away from the scalp. Interestingly, hair in Asian newborns often stands "straight up."

This has two interesting consequences. First, when Asian hair is long, the heavy weight of the thick shafts tend to bend it down, creating an illusion of fullness. (Bent or "bowed" hair always looks more full than straight, flat hair and most grooming and styling techniques capitalize on this fact). On the other hand, when Asian hair is very short, it tends to appear more "see-through" since the hair points straight out and the eye looks directly at the scalp.

The implication for surgery is that the doctor must replicate this angle exactly if the Asian patient is to get the most impact form his transplant and to keep the look of his original hair. The second is a that a meticulous, low tension, closure must be performed in the donor area as any scarring in the donor area would be more visible in an Asian if he were to keep this area short.

In sum, hair restoration surgery in Asians can be extremely gratifying, when the surgeon is aware of the unique aesthetic characteristics of Asian hair.

African Hair

Patients of African descent are believed to be among the best candidates for hair restoration surgery, because of the low color contrast between their skin and hair, and the excellent coverage provided by its curl or kink. Understanding the unique hair qualities of African hair enables the surgeon to help the African/African American patient achieve the best possible results.

The hair shaft of African hair is oval on cross section (in contrast the round shafts of Caucasians and Asians). This configuration allows the hair shaft to twist on itself and form the characteristic kinky or curly hair. This hair type provides excellent local coverage since each hair covers a large area around it. However, a limitation of this hair type is that the tight curl doesn't allow the hair to be easily combed back to cover thin or bald areas that are some distance behind it. To compensate for this, the surgeon should place at least a small amount of hair in all of the areas that need coverage.

In addition, the increased visual density provided by kinked hair may create contrast with adjacent thin or bald areas and thus accentuate any hair loss. Although the increased visual density of kinky hair causes specific aesthetic problems when it is long, the low skin/hair color contrast serves to greatly improve the cosmetic impact of balding when the hair is kept short.

African hair can be divided into two distinct, but overlapping types; one that is wiry and tightly kinked and other that has a looser, more wavy kink with a softer feel. The surgery in each case must observe slight differences. The hair with the softer kink is usually fairly straight below the surface of the skin and can easily be dissected from the donor strip by trimming away a moderate amount of surrounding bald tissue. The more tightly kinked hair curves significantly below the skin surface. This requires a more deliberate dissection in which more tissue is left around the grafts, making them slightly more plump. As a result, the recipient sites have to be expanded to accommodate the slightly larger grafts.

The following video-scans illustrate two variations of hair growth patterns in Africans/African Americans.

African patient with density of 1.6 hairs/mm2 and tightly kinky hair

African patient with density of 1.6 hairs/mm2 and curly-kinky hair

African hair is also unique in that the density of naturally occurring follicular units is relatively low (they are spaced farther apart). Africans have an average density of about 0.65 follicular units/mm², in contrast to Caucasians with an average density of 1.0 follicular unit/mm². During the transplant, the surgeon must account for this by spacing the grafts in African/African American patients slightly further apart to insure that there will be adequate coverage of the areas to be treated. Technically this works well, since the slightly larger grafts cannot be placed quite so close together.

It is interesting to note that in spite of the relatively low density, the scalps of individuals of African descent generally contain a significant proportion of 3-hair follicular units. It is possible that, in Africans, the low overall density with high follicular groupings and darkly pigmented hair and skin, enhances photoprotection while at the same time minimizing heating of the skin. Curly hair in tight groups of 3 may act like a scaffolding that holds the hair away from the surface of the scalp (to cool it), and in a tight meshwork (that blocks the sun), making both the hair and skin of the African well adapted for sunny, hot climates.

The following table compares some easily measurable aspects of the follicular units in Africans/African Americans and Caucasians.

	Caucasians	Africans
Follicular Unit Density (mm2)	1.0	0.6
Average Hair Density (hairs/mm2)	2.1	1.6
Predominant Hair Grouping	Two	Three

The following chart summarizes the slightly different surgical techniques used in Caucasians and in Africans.

	Implant Density	Site Sizes
Caucasians	x	y
African, wavy/kinky	0.6x	y
African, tightly kinky	0.6x	1.2y

Another important consideration when transplanting those of African descent is the characteristics of the donor scalp. Their scalps tend to be thicker, more fibrotic and less distensible. The thick scalp may give the impression that it is mobile and that donor closure will be easy, but, in fact, the scalp tends to have little "give." In order to insure a low-tension closure, the width of the donor incision should always be conservative.

A final issue in transplanting Africans/African Americans is their increased risk of hypertrophic scarring and keloids. Although the incidence of keloid formation is rare in the back of the scalp, the formation of hypertrophic scarring is quite common. This usually presents as a thin ridge along the suture line beginning several weeks after the surgery. It is readily amenable to intralesional corticosteroids, but it can lead to local hair loss along the line of the incision and, if not totally resolved, can make wearing a short hairstyle difficult.

A superficial, low-tension closure using only cutaneous sutures that are removed early may decrease, but not eliminate the risk of this problem.

It is important to identify the common skin condition in Africans/African Americans called "Acne Keloidalis" which presents as small bumps on the back of the scalp. Although it is neither a "keloid" nor "acne," the condition can cause local hair loss and may present a problem for the hair transplant surgeon if unrecognized.

In sum, hair restoration surgery in Africans/African Americans can be very rewarding for the patient, but the surgery must be performed with the physician carefully taking into account all of the unique characteristics of their hair and skin.

Latino Hair

The hair and skin characteristics of Latinos are generally excellent for hair restoration. Thick, dark, wavy hair provides excellent coverage and the visual effect is enhanced by darker skin.

The average number of hairs/cm² appears to be slightly lower in Latinos as compared to Caucasians, but the greater hair shaft diameter more than compensates, enabling the hair transplant surgeon to produce great results.

Farrell Before Video

Farrell After Video

Watch Part 2 of  the videos and become a believer!
At Farrell Hair Replacement, you can expect to receive close to perfect duplication of the hair you used to grow naturally. Watch our client testimonial video and see for yourself! And when you visit us at one of our worldwide locations , we will prove to you in person that our hair systems are totally undetectable! But before you come in, study our website and view Richard Farrell’s performances at Live Cut-Ins , TV Appearances and Makeover Shows . All of these projects offer further proof that Farrell Hair Replacement is the Best in the World.

No other hair replacement companies have any of these events on their websites simply because they can not produce the quality and undetectability that Farrell produces on a daily basis. Other hair replacement companies only give you false hopes and promises. Farrell Hair Replacement is the only ultra custom hair replacement company in the world.

Give up the search... Nothing else works! Everybody knows that surgical transplants, laser gizmo's, pills and topical solutions won’t give you all of your hair back. Non surgical hair systems are the only answer to advanced hair loss situations. And no other hair systems compare to Farrell hair systems.

Let’s get together! Consultations are free , but are by appointment only. We will help you reach your esthetic goals and your hair loss situation will be remedied. Then you can enjoy the benefits of having all of your hair back. You will once again be able to style your hair in any manner. Swim, Shower and sky dive. Do any activity in confidence. Feel sexy again!

No one can compete with Farrell... See for yourself!

Watch the videos and become a believer!
At Farrell Hair Replacement, you can expect to receive close to perfect duplication of the hair you used to grow naturally. Watch our client testimonial video and see for yourself! And when you visit us at one of our worldwide locations , we will prove to you in person that our hair systems are totally undetectable! But before you come in, study our website and view Richard Farrell’s performances at Live Cut-Ins , TV Appearances and Makeover Shows . All of these projects offer further proof that Farrell Hair Replacement is the Best in the World.

No other hair replacement companies have any of these events on their websites simply because they can not produce the quality and undetectability that Farrell produces on a daily basis. Other hair replacement companies only give you false hopes and promises. Farrell Hair Replacement is the only ultra custom hair replacement company in the world.

Give up the search... Nothing else works! Everybody knows that surgical transplants, laser gizmo's, pills and topical solutions won’t give you all of your hair back. Non surgical hair systems are the only answer to advanced hair loss situations. And no other hair systems compare to Farrell hair systems.

Let’s get together! Consultations are free , but are by appointment only. We will help you reach your esthetic goals and your hair loss situation will be remedied. Then you can enjoy the benefits of having all of your hair back. You will once again be able to style your hair in any manner. Swim, Shower and sky dive. Do any activity in confidence. Feel sexy again!

No one can compete with Farrell... See for yourself!