Androgenetic Alopecia - Dermatologue spécialiste du cuir chevelu à

Androgenetic Alopecia: Combining Médical and
Surgical Treatments
PIERRE
BouHANNA,
Center Sabourand, Hôpital
M D
St. Louis, Paris,
France
BACKGROUND. Médical treatment or surgical reconstruction is
used separately to treat androgenetic alopecia. Two drug molécules
(5% minoxidil solution and oral finasteride 1 mg) have proven
efficacy to stabilize hair loss and promote hair regrowth.
Microtransplant of one to three hair foUicuIar unit grafts can
provide a définitive hair restoration with a natural appearance.
OBJECTIVES. Aesthetic results can be optimized with a combination of drugs and transplantation of follicular unit grafts. The
Dynaniic Multifactorial Classification is used to select suitable
candidates for this combined approach and also to assess
follow-up results.
P. BOUHANNA,
MD HAS JNDICATED
NO SIGNIFICANT
A N D R O G E N E T I C A L O P E C I A is a spécifie type of
alopecia that is characterized by progressive miiiiaturization of hair scalp follicles. Maies, females, and
monkeys are more comnionly affected. Hair follicle
sensitivity to circiilating androgens is genetically
predetermined.
Hair loss of androgenetic origin is a fréquent
symptom but is sometimes deceptive because of its
chronicity and the resulting thinning process.
Now^adays, t w o drug molécules ( 5 % m i n o x i d i l
solution and finasteride orally) were used to stabilize
hair loss and promote hair regrowth. Thèse molécules
stimulate, through varions mechanisms, increase in
diameter and length of preexisting fine hairs.
Microtransplant of follicular units and of minigrafts
and micrografts is a mere technical progress by itself.
In fact, i t does not only give a définitive hair
restoration of maie and female baidness, but also
brings hairs that naturally émerge f r o m a single orifice
in a group of one to three hairs. H a i r implantation is
made i n a simple and painless way. Therefore, it is
logical to combine the stabilizing and trichogenous
effects of both molécules to a surgical technique that
brings about natural and définitive hairs.
Address correspondence and reprint requesrs to: Pierre Bouhann.^, M D ,
14 rue Théodore de Banville, 75017 Paris, France, or e-mail: info®
bouhanna.com.
RESULTS. Dynamic Multifactorial Classification assists the
évaluation of the natural history of androgenetic alopecia
évolution and also the effects of treatment. Régression of maie
androgenetic alopecia from Hamilton type V to type 111 can be
achieved by combining drugs with hair grafts.
CONCLUSION. Improvement of investigative methods and
especially the Dynamic Multifactorial Classification makes it
easier for a patient to foUow the results of treatment adapted to
their case.
INTEREST
WITH COMMERCIAL
SUPPORTERS.
Pathophysiology of Androgenetic Alopecia
Androgenetic alopecia is an androgen-induced hairloss phenomenon i n genetically predetermined individuals.' I t affects persons between 18 and 40 years and
is of multigenic inheritance.^
M a i e hormone dihydrotestosterone acts on androgenetic receptors of hair follicles to activate gènes
responsible for the progressive transformation of
terminal hairs into intermédiare then vellus hairs.
This miniaturizarion process affecting hair length
and hair diameter characterizes androgenetic alopecia.'' However, w e should k n o w that the number of
hair follicles per unit area on bald scalp remains
unchanged.
The androgenetic enzyme 5a-reductase converts the
maie hormone testosterone into a more potent one
called dihydrotestosterone. The 5a-reductase enzyme
is of t w o types (type I and type II) at the level of scalp.
Young men or women w i t h androgenetic alopecia
show levels of 5ot-reducrase and androgenic receptors
and decreased cytochroine P450 aroinatase more in
the frontal bald area than in the n o r m a l occipital
area."* The permanent g r o w t h of implanted hairs is
explained by the différence i n receptors between the
occipital area and the other remaining areas of scalp
(Figure l a , b ) . M a i e or female androgenetic alopecia
can be classified according either to a static classification such as those of Hamilton'^ and Ludwig^ or to a
more précise one called Dynamic M u l t i f a c t o r i a l
& 200S> bv the .Ameiican Socieh/ for Dermatologie Surgtny, Inc. • Pubiis-ked hi BlackiiH'I! Piihlifhing, Inc.
liSN: 1076-0512.'03m5.00/0 •Dermatd Siirg 2003:29:1130-1134
Dermatol Surg
29:11 :November 2003
BOUHANNA: A N D R O G E N E T I C ALOPECIA
1131
a
b
Figure 2. (a) Drawing of the four axis In the Multifactorial Classification of androgenetic alopecia. (b) Evaluation of maximal baidness
stage for maie androgenetic aiopecia using three axis,
Figure 1. (a) Levels of antiandrogenic enzymes on frontal and
occipital région of maie scalp (courtesy of Sawaya ME and Price VH).
(b) Sketch of donor area in maie.
Classification^''^ (Figure 2a,b). Therefore, i t is c o m m o n
sensé to integrate the multiple-hair parameters of
every patient into a dynamic classification. Thèse
parameters include size of bald and hairy areas i n
relationship to fixed landmarks of the face, scalp
la.xity, and scalp thickness as well as hair coverage
according to density, diameter or caliber, shape, length,
growth rate, and color of hair. Thèse data can be
processeti in order to characterize each patient alone.
The goal of this multifactorial classification is to give a
better understanding of maie or female androgenetic
alopecia évolution either spontaneously or under
treatment.
androgenetic alopecia and as a first choice treatment
for maies.
Trichogenous effect of thèse drug molécules varies
according to single individuals. G o o d candidates to
this therapy are those w h o have a great aiTiount of
miniaturized hairs. For patients w h o respond well to
5 % m i n o x i d i l solution, hair loss stabilization occurs
around the 3rd or 4 t h week after ail telogen hairs have
fallen out. H a i r regrowth occurs after 2 n d or 3 r d
month of treatment. Finasteride poteiitiates b o t h
stabilizing and hair regrowth effects induced by
minoxidil.
H a i r coverage generally occurs after 6 to 12 months
of treatment. Benefit obtained can be maintained i f
treatment is continued. I f treatment is interrupted,
thinning process starts back in 6 to 12 months. N o
effect can be expected on completely bald areas.
Newest Médical Treatments
Specificity of Female Treatments
The goal of médical treatment for androgenetic
alopecia is to increase hair coverage and to retard
thinning. The use of oral finasteride at a dose of 1 mg/
day''* and of 5% m i n o x i d i l solution'*^'" has proven
efficacy on maie androgenetic alopecia. Two-percent
minoxidil solution should be prescribed for female
I n moderate androgenetic alopecia, m i n o x i d i l 2 %
solution and certain types of antiandrogens can be
prescribed either alone or in association. Finasteride is
contraindicated in women.'"'^'^
In severe androgenetic alopecia, the same médical
treatinents can be prescribed as mentioned previousiy
1132
Dermatol Surg
BOUHANNA: ANDROGENETIC ALOPECIA
here, except i n very severe cases, where they have very
little effect.
Most of the time, the choice o f therapy w i l l be
guided by the patient's o w n esthetic wish going f r o m
the covering abihty o f a hair prosthetic or o f masking
products to the définitive solution given by m i n i m i c r o grafts transplantation.
Newest Micrografting Techniques
Minimicrografts or follicular units transplantation has
greatly improved over the past décade and is widely
used by the entire international hair societies.
Advances i n minimicrografts techniques have been
specially obtained via the foUowing:^"*'
a
29:11 :November 2003
1. Preoperative physical examination w i t h the déterm i n a t i o n o f scalp parameters and o f possible
contraindications
2. Local anesthesia w i t h topical anesthetizing cream
and nerve block (this rendered hair transplant
quite painless)
3. M i n i m i c r o g r a f t harvesting from o c c i p i t a l donor
area (a fine linear, horizontal, and almost invisible
scar is obtained after closure w i t h sutures or
Staples)
4. The minute préparation o f minimicrografts ancf of
one to three hair follicular units under stereomicroscope (this fine graft eut contributes t o
avoiding the unaesthetic "doll's hair appearance")
(Figure 3a,b)
5. The fine implantation of micrografts o n bald areas
w i t h microsurgical needles and forceps (this is
obtained through the adéquate choice o f hair
émergence, hair orientation, a n d angling, e s p e cially i n the anterior frontal line a n d the c r o w n
hair w h i r l )
b
Figure 3. (a) Micrografts eut under stereomicroscope. (b) Micrograft
aspect before implantation.
Figure 4. (a) Anterior frontal line reconstruction with micrografts and
persistence of few intermediate hairs. (b) Reconstrurtion of anterior
frontal line with micrografts alone.
Dermatoi Surg
29:11 .November 2003
6. The fine and irregular reconstruction of the anterior
frontal line with one hair grafts (Figure 4a,b)
7. The high amount of approximately 1000 to 3000
transplanted hairs i n one session, performed by a
well-trained team of three to five assistants
8. K homogeneous distribution of minimicrografts
and of follicular units on large bald areas
9. Good postoperative results (superficial implantation of minimicrografts gives a rapid and painless
wound-healing process and patient résumes w o r k
24 to 48 hours later)
10. Implanted hairs that w i l l fall out around day 15 to
grow again between m o n t h 2 to 4.
H o w do you optimize quality of results treatment?
BOUHANNA: A N D R O G E N E T I C ALOPECIA
1133
probable loss of preexisting hairs in between grafts,
to decrease the transient hair loss of grafted hairs
that may occur at day 15, to increase regrowth of
grafted hairs and of preexisting hairs that may have
transiently fallen out after surgery.
4. A surgeon must provide a good quality control of
minimicrografts cleansing w i t h an antiseptic shampoo during the 8 days after surgery.
5. A surgeon must adapt instruments and transplant
techniques to the individual scalp and hair according to ethnie background (Blacks, Asians, etc.) and
to w o m e n (Figure 6a,b).
a
1. A surgeon must select candidates w i t h respect to
their psychological profile and surgical limitations
and in accordance w i t h their aesthetic wishes,
particularly for young men or w o m e n under the
âge of 30.
2. A surgeon must w a r n patients less than 30 years o l d
about the possible évolution of androgenetic
alopecia.
3. A surgeon must k n o w h o w to combine m i n i m i c r o grafts w i t h local 5 % m i n o x i d i l solution and oral
finasteride 1 mg for men or local application of 2 %
minoxidil alone, in order (Figure 5a,b)^^"'^ to slow
down the évolutive thinning process, to stop
a
b
Figure 5. (a and b) Maie androgenetic alopecia treated with
combination of Minoxidil 5%, Finasteride, and one session of
micrografts.
Figure 6. (a and b) Female androgenetic aiopecia treated with one
session of minimicrografts and Minoxidil 2%.
1134
BOUHANNA: ANDROGENETIC ALOPECtA
We should point out that ail attempts made so far
w i t h automatic implanters or w i t h laser implantation
have not shown better results than w i t h conventional
hair transplant technique.
Conclusion
It is henceforth possible to raise efficient médical
treatment and surgical therapy w i t h définitive and
natural aesthetic results. Evaluation of différent hair
and scalp parameters helps to establish a patient's
profile and a long- and short-term plan of treatment.
Nowadays, patients can be fully informed about the
most suitable treatment adapted to them. Therefore,
they w i l l be able to follow more effectively the positive
effects given by their o w n individual treatment.
Acknowledgment The author thanks D . Bakhos, M D , for the
translation of this article.
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