Part 7
Dermatologic Conditions Causing Hair Loss
Interviewer: What about in the case of alopecia areata?
Dr. Bernstein: Alopecia areata is a very interesting condition. First of all, it is an autoimmune disease where the body actually attacks its own hair follicles.
In male pattern alopecia, the problem is in the genetics of the hair follicle and when the follicle is moved during hair transplantation, the genetics goes with it. This is what we call donor-dominant, since the hair maintains the characteristics of where it came from, i.e. from the donor site. So if you take healthy follicles from the back and sides and transplant them to the bald area in the top of the scalp, those healthy genes are transplanted with the graft and the hair will continue to grow in the new location.
Alopecia areata, on the other hand it is recipient dominant. This means that it is the skin in a specific location of the body that is affected by the disease process. Therefore, if you performed a hair transplant and place healthy hair into the affected area, the hair would not necessarily grow in the new location, because it could be affected by the same disease process. For this reason, we are very cautious about transplanting people with alopecia areata.
The reason why I say “cautious” but not “never” is because sometimes people have a single episode of alopecia areata and have just a couple of localized bald patches that occur once and then for years and years they have no new lesions. In those cases, it might be appropriate to consider a hair transplant, but I usually try to wait two to five years after an episode.
The risk with alopecia areata is that if you perform the hair transplant and then the transplanted hair falls out, not only is it wasted, but the donor scar can become visible. So you really want to be very cautious when transplanting people with alopecia areata.
Interviewer: Is the same true for alopecia caused by types of folliculitis and cicatricial alopecia?
Dr. Bernstein: Cicatricial alopecia is just the general medical term for scarring alopecia. It has a wide variety of causes. The most common one is referred to as Pseudopelade of Brocq which is a form of scarring alopecia of unknown cause that results in scarred bald area in the front and top of the scalp. And it is a recipient-dominant condition so that hair placed into the bald area would not be expected to grow.
The same for scarring alopecia associated with lupus and lichen planus. For these conditions, it’s not a good idea to do a hair transplant. However, if it turns out that the condition is burned out or old, because sometimes people can have, for example, an episode of discoid lupus that never reoccurs, you might want to just do a very conservative hair transplant and see if it grows. But in general, the transplantation is not successful in these conditions.
Interviewer: What if a condition such as lichen planus is not localized to the scalp, but somewhere else on the body, like the legs or the arms. Does that give you pause to give someone a hair transplant that has that condition that may affect the scalp, but it’s not affecting the area yet?
Dr. Bernstein: That is a very interesting question. From my experience, lichen planus of the body and lichen planopilaris of the scalp are usually distinct clinical conditions. So even though the pathology of the diseases seem to be similar, usually people that present with lichen planus on their body don’t generally get it in the scalp. So in that case, I would feel comfortable in transplanting somebody. But again, you have to be cautious. But I think if they have never had scalp lesions, I probably would be comfortable performing a surgical hair restoration procedure.
The other thing I just want to mention is that if when you have scarring due to burns or trauma, those patients do exceptionally well with hair transplantation. However, you must be deliberate in the surgery. You can’t overwhelm the area at once with grafts. In other words, when you have a scar, it usually has less blood supply than surrounding tissue, so you have to do the hair transplantation in a step-wise manner. But if you are methodical and don’t rush, over several hair transplant sessions, the scar can be completely filled in with hair.
In treated scarred areas, you transplant grafts into the periphery of the scar and then those grafts, since they’re living, will draw the blood supply in from the surrounding area. You then can transplant in smaller and smaller concentric circles until you have the entire area filled in with hair.
