Answers

Q: What is your opinion of the companies that advertise hair loss solutions like Hims and Keeps?

In searching the web and riding the subway I’ve seen many ads for a company called Hims that offers hair loss medicine and other medical solutions for men’s problems. What are the medications used for hair loss and how do they compare to Propecia and Rogaine? — V.T., Long Island, NY

A: Hims and Keeps are digital wellness companies that are geared toward men. They prescribe the same hair loss products that you can receive from a doctor or from online stores like Amazon, such as minoxidil, finasteride, biotin, salicylic acid shampoos and other topical and oral medications. The patents on the most commonly used prescription medications have expired within the last few years, opening the door for companies to distribute their own generic versions. The online system that Hims uses allows people to get prescriptions without seeing a doctor. Although this might be convenient, receiving an in-person evaluation from an experienced physician is important to ensure that you receive the proper treatment. Medical treatments for hair loss are most effective when started early. Therefore, making sure the diagnosis is correct and that the medications are optimized, will give you the best chance of re-growing your hair and preventing future thinning.

• Schedule a Consultation at Bernstein Medical
• Read more Medical Treatment Options at Bernstein Medical

Q: Is it ill-advised to comb one’s hair more than twice a day, especially hair that has been transplanted? Will frequent combing induce hair loss? — G.K. ~ Paramus, N.J.

A: Combing or brushing one’s hair does not cause hair loss – no matter how many times a day you do it. However, constant traction with braids or hair extensions can cause hair loss and this loss can be permanent.

• Discover the causes of hair loss
• Read about how grafts become permanent at 10 days after a hair transplant

Q: My hair is starting to thin in the front, but it is not yet bald. I have been going back and forth about whether to get a hair transplant or use Propecia. I’m not sure what my first step should be. What do you think? — N.K. ~ Pleasantville, N.Y.

A: In general, patients who are thinning, but not actually bald, should begin with combined medical therapy (finasteride and minoxidil) for at least a year prior to considering surgery. In many cases, with this regiment, surgery can be postponed or even avoided completely. Unfortunately, some patients cannot tolerate finasteride or choose not to take it due to concern about potential side effects. Minoxidil, although useful, does not significantly alter the long-term course of hair loss when used alone.

Q: I have read several articles on the internet which suggest that resistance training can accelerate male pattern baldness. Is there any truth in this? –B.F., Altherton, CA

A: Anything that raises androgen levels in your body can potentially accelerate hair loss. That said, I suggest that you should exercise as you normally would. As long as you don’t take drugs to enhance your workout, the effects should be minimal.

• Read about Hair Loss in Men
• Read about the Treatment of Hair Loss in Men

Q: Hi Dr. Bernstein, I am a 30 year old man with a balding crown. I’m 99.9% sure its male pattern baldness (I’m currently on Propecia and Rogaine). I recently read about how people going bald are getting tested for LPP (lichen planopilaris). Do you perform this test? — F.L., Scarsdale, NY

A: Lichen Planopilaris (believed to be a type of autoimmune disease) occurs more frequently in women than in men and more commonly in African-Americans than in Caucasians. The variation that could be confused with androgenic alopecia in men is central centrifugal cicatricial alopecia (or CCCA). While definitive testing would involve a scalp biopsy, this is rarely necessary as the doctor can easily tell by just examining you with the naked eye using magnification (densitometry).

Q: How common is hair loss in adult men and women? — N.F., Bronxville, NY

A: The incidence of androgenetic alopecia (common baldness) is quite high for both men and women. By age 50, 50% of men and 30% of women are affected. By age 70, that increases to 80% of men and 60% of women. Fortunately, in spite of significant thinning, women often preserve their hairline and have a diffuse pattern, so their hair loss can be camouflaged for many years.

Q: What is Lichen planopilaris? — G.S., Pleasantville, NY

LPP in Male Pattern Alopecia

A: Lichen planopilaris (LPP) is a distinct variant of cicatricial (scarring) alopecia, a group of uncommon disorders which destroy the hair follicles and replace them with scar tissue. LPP is considered to have an autoimmune cause. In this condition, the body’s immune system attacks the hair follicles causing scarring and permanent hair loss. Clinically, LPP is characterized by the increased spacing of full thickness terminal hairs (due to follicular destruction) with associated redness around the follicles, scaling and areas of scarred scalp. In contrast, in androgenetic alopecia (AGA) or common baldness, one sees smaller, finer hairs (miniaturization) and non-inflamed, non-scarred scalp. Complicating the picture is that LPP and AGA can occur at the same time – particularly since the latter condition (common baldness) is so prevalent in the population (see photo). And LPP can involve the frontal area of the scalp, mimicking the pattern of common genetic hair loss. Interestingly, the condition is more common in women than in men.

For those considering a hair transplant, ruling out a diagnosis of LPP is particularly important as transplanted hair will often be rejected in patients with LPP. In common baldness, the disease resides in the follicles (i.e., a genetic sensitivity of the follicles to DHT). Since the donor hair follicles remain healthy, even when transplanted to a new location, we call common baldness donor dominant. It is the reason why hair transplantation works in persons with common baldness. In contrast, LPP is a recipient dominant condition. This means that the problem is in the recipient area skin, so if healthy hair is transplanted into an area affected by LPP the hair may be lost.

Because it is so important to rule out suspected LPP when considering a hair transplant and because it is often hard to make a definitive diagnosis on the physical exam alone, a scalp biopsy is often recommended when the diagnosis of LPP is being considered by your doctor. A scalp biopsy is a simple five minute office procedure, performed under local anesthesia. Generally one suture is used for the biopsy site and it heals with a barely detectable mark. It takes about a week to get the results. The biopsy can usually give the doctor a definitive answer on the presence or absence of LPP and guide further therapy. If the biopsy is negative, a hair transplant may be considered. If the biopsy shows lichen planopilaris, then medical therapy would be indicated.

Q: What is the Origin of the Term DUPA? — Z.Z., Darien, CT

A: The terms DPA and DUPA were first described by O’tar Norwood in his seminal 1975 publication: Male Pattern Baldness: Classification and Incidence. ((Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975;68:1359-1365. Download)) In the paper, Dr. Norwood defined the two terms as:

Diffuse, Unpatterned Alopecia (DUPA). In this type there is a general decrease in the density of hair without any definite pattern, although it is usually more marked over the top and front. This type is common in women.

Diffuse, Patterned Alopecia (DPA). The patterns in this type of hair loss are essentially the same as in more common male pattern baldness, but the areas involved do not become totally bald; the hair only decreases in density. This also occurs in women.

Dr. Norwood’s realization that all hair loss did NOT follow his own Norwood patterns was a great insight, as well as his observation that DUPA was a common pattern in women and uncommon in men. The terms went relatively unnoticed and were not seen again in the medical literature until Drs. Bernstein and Rassman wrote about them again when they were developing Follicular Unit Transplantation. ((Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84. Download)) The importance of identifying these conditions is that that DUPA (either in men or women) is a relative contra-indication for hair transplantation and, with densitometry, can be readily detected in individuals at a relatively young age. Patients with DPA can be transplanted as if they were early Norwood Class 6’s.

Q: What is Saw Palmetto? — R.P., White Plains, NY

A: Saw Palmetto is a dwarf palm plant native to North America. The active ingredients can be found in the plant’s brown-black berries. It is proposed that it blocks the enzyme 5-alpha-reductase that converts testosterone to dihydrotestosterone (DHT). There is little scientific evidence that Saw Palmetto is actually effective for hair loss.

Read about the treatment of hair loss in men

Q: I have been on finasteride for about 7 months. After my latest haircut I can see that my scalp is shiny. I read that is from sebum buildup and it can cause a layer that clogs the growth of hair. I was wondering if this is true and, if so, how can it be treated? — T.C., Philadelphia, PA

A: It is not true. Hair loss is caused by the miniaturizing effects of DHT on the hair follicle, not by blocked pores.

For more on this topic, view our pages on the causes of hair loss in men or the causes of hair loss in women.

Q: What happens to hair diameter when you age? — K.L., Greenville NY

A: From infancy to puberty, hair gets progressively thicker. From adulthood to old age the hair becomes thinner again and this is exacerbated by the effects of DHT in susceptible persons. The later process is called androgenetic alopecia (common baldness) and is characterized by miniaturization – the progressive decrease in hair diameter and lengths as a result of DHT.

However, even without the effects of DHT, hair gradually thins over time in many people.

Read more about hair growth and hair loss in men and women.

Q: It seems like my hair is thicker in the summer. Can this be true? –R.B., West University Place, TX

A: Hair will increase in diameter when there is more humidity, as it absorbs moisture, and will actually be thicker in the more humid summer environment.

Q: What color hair is the thickest? I thought it was brown, followed by red then blonde? But I am also reading that red is the thickest but redheads have the fewest hairs. –S.F., Cook, Illionis

A: In very general terms, the darker the hair, the thicker it is and the lower the density (hairs per area). For example, Asians have the darkest hair, the highest hair diameter and the lowest density. Scandinavian blonds have very high hair density and the fine (diameter) hair. But there are many exceptions, African Americans have black hair, but it is usually very fine and of low density. I have seen red heads in all categories.

For more relevant info on hair, visit our links on hair loss, hair anatomy, and the top myths about hair loss.

View before and after hair transplant photos organized by the patient’s hair density.

Q: I am a 47 year old woman with thinning on the top of my scalp for three years. I think I want to go for a comprehensive evaluation for hair loss and know that the doctor may want to take blood tests to help find out the cause of my hair loss. I am not sure if I need to fast before I come in? — R.B., West University Place, TX

A: Fasting is not necessary for a comprehensive evaluation.

The comprehensive diagnosis may include hair pull tests, hair pluck, hair density measurements, anagen telogen ratios, scalp biopsies and laboratory (blood) tests but no pre-test fasting or other preparation is necessary.

Q: Why did you write another book on hair loss? — K.L., Greenville NY

A: Hair Loss and Replacement for Dummies is the first book that we have written that is specifically geared for the lay public. Besides hair restoration, it covers a wide range of topics including: the diagnosis and treatment of medical conditions that can cause hair loss, tips on hair care, information on hair systems, and a number of other topics not stressed in our other books.

Our prior books, The Patient’s Guide to Hair Restoration and The Guide to Hair Restoration focused on medical treatments and surgical hair restoration. Although very easy to understand, they are most helpful for someone that already has a basic understanding of hair loss or that had a consultation.

Q: Why do some people have a full head of hair into their seventies or eighties and others start to go bald in their late teens or early twenties? — E.Z., Darien, CT

A: The difference is genetic with the inheritance coming from either side of the family.

Although a person will have the genes his/her whole life, a gene’s expression (also called phenotype) can be quite variable. The factors that cause this variability are still unknown.

Read more about the Genetics of Hair Loss

Q: I have a quite a bit of hair on my chest, back and legs. Is that an indicator of future baldness? — S.C., Short Hills, NJ

A: Although bald people joke around that they wish the hair on their body (and ears) was on their head, body hair is not an early sign of baldness.

Read about the Causes of Hair Loss in Men

Q: My son, 25 years old, is seeing hair loss around the hairline. According to your website, he is probably a stage II. He may have a little hair loss at the vertex; right now it is hard to tell. He is very muscular and loves weight lifting, but no drug enhancement. Is there a relationship between weight lifting and hair loss, since I have read that weight lifting increases testosterone levels? — G.S., Pleasantville, NY

A: Yes, weight lifting does increase testosterone, which in turn increases DHT. This can accelerate hair loss, although the effect is generally very slight.

Rather than modify his exercise program, your son may want to consider taking finasteride (Propecia). This requires a doctor’s prescription.

Q: Didn’t you do free consults in the past? — N.F., Bronxville, NY

A: Yes. It had been in response to the policy of the larger chains. Patients coming to our practice are evaluated by a board certified dermatologist, trained in diagnosing the causes of your hair loss with expertise in both medical and surgical management. Our consults are not just screens for surgery.

Read more information on becoming a new patient on the Bernstein Medical – Center for Hair Restoration website. If you are ready for a hair loss or hair transplant evaluation, click here to schedule an evaluation with the doctor.

Q: Why is the consult fee more for diffuse thinning than for a regular visit? — B.F., Altherton, CA

A: Diffuse hair loss, more common in women, can be the result of a number of underlying medical conditions and therefore it usually requires an extended medical evaluation.

If you are a male or female with obvious diffuse thinning from androgenetic alopecia (common baldness), or if you have patterned hair loss where the diagnosis is straightforward, the fee is less because an extensive evaluation is not required.

Please visit our Hair Transplant Costs & Consultation Fees page for more information.

Q: Do you use computer type imaging to create the best way to ensure you (or any hair transplant surgeon) have the same goal or target “picture” of the particular patient’s restoration as that particular patient has as his “picture?” –F.D., Laude, Missouri

A: I prefer not to do imaging since it tends to oversell the hair restoration procedure.

In addition, the technology is unable to accurately represent what the hair transplant will really look like as there are many hair characteristics that it can’t take into account.

Seeing lots of actual photos of hair transplant patients is much more instructive – and more honest (if the photos are taken correctly). At the time of the consult I design the hairline and photograph it.

Q: Can stress produce diffuse unpatterned hair loss (DUPA), or was it bound to happen anyway? — D.D., Park Slope, Brooklyn

A: Both DPA (diffuse patterned hair loss) and DUPA (diffuse unpatterned hair loss) are genetic conditions, unrelated to stress and would have happened anyway. These types of hair loss are characterized by a high percentage of mininiaturized hair in broad areas of the scalp. See the Classification of Hair Loss in Men and Classification of Hair Loss in Women pages on the Bernstein Medical – Center for Hair Restoration website for more information on this topic.

In contrast, stress generally presents as increased hair shedding, a reversible condition referred to as telogen effluvium. It is called this because the normal growing hair is shifted to a resting (telogen) phase before it temporarily falls out. Increased miniaturization is not associated with telogen effluvium.

Q: I’ve been dealing with daily mental stress for the past few months. I’ve noticed that during that time, I’ve experienced a lot of frontal hair loss and thinning. I thought stress was a myth for causing hair loss. — R.P., Upper East Side, Manhattan

A: Stress may cause temporary shedding, but it generally does not affect the long-term course of genetic hair loss.

It seems that women’s hair is affected by stress more commonly than men’s hair, but the reason is not clear.

Q: Dr. Bernstein, why have you not had a hair transplant? I’m sure this question gets asked a lot. Thanks. — I.L., Kentfield, CA

A: Yes, all the time.

My donor area is very thin (so I am not a good candidate) and I have gotten used to being bald. It has been years.

Q: I have read that in the evaluation of a patient for hair restoration surgery some doctors use a densitometer to measure miniaturization – the decrease in size of hair diameters. I read that miniaturization is a sign of genetic hair loss, but when there is miniaturization of greater than 20% in the donor area, a person may not be a good candidate for hair transplants. Is this correct and does 20% miniaturization mean that 20% of the population of terminal hairs have become fine vellus-like hairs or that there is a 20% decrease in the actual diameter of each of the terminal hairs? — B.A., New Albany, Ohio

A: Miniaturization is the decrease in hair shaft length and diameter that results from the action of DHT on healthy, full thickness terminal hairs. The hairs eventually become so small that they resemble the fine, vellus hair normally present in small numbers on the scalp and body. Miniaturized hairs have little cosmetic value. Eventually miniaturized hairs will totally disappear. Twenty percent miniaturization refers to the observation, under densitometry, that 20% of the hairs in an area show some degree of decreased diameter.

In the evaluation of candidates for hair transplantation, we use the 20% as a rough guide to include all hairs that are not full thickness terminal hairs. Of course we are most interested in the presence of intermediate diameter hairs — i.e. those whose diameters are somewhere between terminal and vellus and are clearly the result of DHT. I don’t know if one can tell the difference on densitometry between vellus hairs, fully miniaturized hairs and senile alopecia. The partially miniaturized population is most revealing.

Miniaturization in the recipient scalp (i.e. the balding areas on the front top and crown that we perform hair transplants into) is present in everyone with androgenetic hair loss. Miniaturization in the donor area, however, is less common (in men). It means that the donor area is not stable and will not be permanent. Men with more than 20% of the hair in the donor area showing miniaturization are generally not good candidates for hair transplant surgery.

Read about Miniaturization
Read about Candidacy for Hair Transplant Surgery

Q: Dr. Bernstein, I saw you on TV where you explained why you haven’t had a hair transplant. If you had better donor hair and you could do the surgery on yourself, then would you consider having a hair transplant? — M.U., Westport, CT

A: Yes.

Q: Will cutting my hair short – skin level – adversely affect it? — M.H., Larchmont, NY

A: Hair shafts are not alive (only the follicle is), so cutting the hair will not affect its growth. Read about the Causes of Hair Loss in Men.

Q: I seem to be thinning, but I never shed hair as such in the shower. I cannot see my hair falling out. Can it be androgenetic hair loss? — R.C., Cambridge, MA

A: In androgenetic hair loss one rarely sees hair falling out in mass, but rather the thinning is due to the hair decreasing in diameter and length (a process called “miniaturization”).

Q: I am suffering from Pseudopelade for four years now. I have lost a lot of hair & there are big bald patches on the top of my scalp that are difficult to hide. Is there any hair transplant surgery or follicle transplant surgery possible in my case, or anything else I can do? — T.L., Boston, MA

A: In general, hair transplantation does not work for Pseudopelade (a localized area of scarring hair loss on the top of the scalp) since the condition is recipient dominant rather than donor dominant.

With a donor dominant condition, such as androgenetic hair loss, the tendency to have the condition, or be resistant to it, is located in the hair follicle and moves with the hair follicle when the follicle is transplanted to a new area. Therefore, in androgenetic alopecia, healthy permanent hair taken from the donor area in the back of the scalp will continue to grow in the a new location in the balding part of the scalp.

In a recipient dominant condition, such as Pseudopelade, the problem is in the skin, so if you perform a hair transplant into an affected area of skin, the transplanted hair will become affected by the same process and be lost.

The disease process can often be slowed down with anti-inflammatory agents, such as corticosteriods, applied or injected locally and the bald area can be camouflaged with cosmetics specially made for use on the scalp. See the Cosmetic Camouflage Products page on the Bernstein Medical – Center for Hair Restoration website.

Q: I am a Caucasian female that has experienced hair loss on the sides of my head from the height of the eyebrow to the ear due to traction. The hair loss has been present since my teen years. My job requires me to wear my hair up most of the time. Although I don’t wear it nearly as tight, I seem to continue to lose my hair in the front and on the top of my head. My hair also used to be very thick as a child and is now quite thin. I’m not sure if this is normal or something else is going on, but I am definitely interested in a hair transplant. — M.H., Larchmont, NY

A: It sounds like you are experiencing continued traction alopecia. Unless the underlying cause is corrected (the traction), you can expect to continue to lose your hair. People that have traction alopecia can have thinning even from mild pulling that might not be a problem for others. Once you stop the pulling, it can take up to two years for the hair to return, although there may be permanent hair loss.

Surgical hair restoration is the treatment of choice for permanent hair loss from traction. If you have significant thinning on the sides, you may not be a candidate for hair transplantation since in this procedure we often need to harvest hair from the permanent area in the sides of the scalp as well as the back.

An additional problem (that you allude to) is that you may have underlying female pattern hair loss. This would further complicate the surgical treatment.

A careful examination (including densitometry) can sort these problems out and allow for more specific recommendations.

Q: I am a 45 year old woman and I am beginning to thin on the top of my scalp. I don’t want to use medications and I don’t think that I am quite ready for surgery. Is there anything else I can do? — E.H., Rye, NY

A: There are a number of things that you can do that can make you hair look more full and help disguise the thinning. Lightening ones hair will allow the hair to reflect more light and appear thicker. In lighter-skinned races it will have the additional advantage of decreasing the contrast between the hair and skin and thus the skin will essentially act as a filler between the strands of hair.

Streaking the hair is also helpful to make the hair look thicker. Waving or perming will help as well, as it will give the appearance of more volume. Normally, the hair tends to fall into a natural part where it is the thinnest. If you part your hair in the thickest area (usually the side opposite from where you are used to, or slightly lower on the same side) this will make the hair appear fuller and less see-through.

Finally, there are a number of cosmetic products that can make you look like you have more hair.

Visit the Cosmetics for Hair Loss page on the Bernstein Medical – Center for Hair Restoration website.

Q: I was at a party the other day and some women were talking about their boyfriend’s hair. I heard one refer to her ex-boyfriend as having a “bar code.” What is that? — B.A., New Albany, Ohio

A: A “bar code” is slang term used in Japan for a comb over.

Q: I am 22 and losing my hair all across the top of my head. How can I thicken my hair to its level a few years previously? — I.L., Kentfield, CA

A: If medication, such as finasteride, is successful it can thicken hair by increasing the diameter of the existing hair shafts. Although the cosmetic benefits can be dramatic in a person with significant hair loss, a hair transplant can not restore hair to its original density, since it only moves the existing hair around and does create new hair.

When hair cloning technology is available, this will change as a person’s donor supply will be increased.

Q: My hair loss resembles the grade I female hair loss scale, but none of the male hair loss patterns. It has been relatively stable for the past five years and only recently has it begun to progress further. I began both Propecia and Rogaine two months ago, but the hair loss still continues at the same pace. I’m really worried. Does a hair transplant work in such a diffuse hair loss? — D.D., Park Slope, Brooklyn

A: If your hair loss is diffuse only on top, then a hair transplant will be effective. This condition is called Diffuse Patterned Alopecia or DPA.

If the diffuse pattern of hair loss affects the back and sides as well, then surgical hair restoration should be avoided. In this case (called Diffuse Unpatterned Alopecia or DUPA) the donor area is not permanent and the transplanted hair will continue to thin over time.

Q: I underwent hair transplant surgery several years ago and was pleased with the results. However, over the last 2-3 years I’ve lost hair in the donor area with subsequent loss of hair in the transplanted area. Is this type of hair loss especially difficult to treat? What accounts for hair loss from the back of the head that is typically considered “permanent”? — F.D., Laude, Missouri

A: Less than 5% of patients have unstable donor areas, i.e. where the back and sides thin along with the front and top. We call this condition Diffuse Unpatterned Alopecia or DUPA. It is best to identify this condition before hair transplant surgery is contemplated as people with DUPA are not good candidates for hair transplantation. The diagnosis is made using densitometry by noting high degrees of miniaturized hair in the donor area.

At this point, I would use medications such as finasteride. I would not do further hair restoration surgery.

Q: I am a 36 year old female who has been diagnosed with Chronic Telogen Effluvium. Although I do not have any bald spots yet my hair is much thinner on both of my temples as well as in the back of my head. Is a hair transplant an option for me or am I just going to shed the new hair as I am shedding my current hair? — R.K., Providence, R.I.

A: Since Chronic Telogen Effluvium is a generalized condition, it is not amenable to correction by a hair transplant. The reason is that there is no stable area to take donor hair from. Chronic TE is generally self-limited, so try to be patient.

Q: Can stress accelerate hair loss? I am 25 and there is balding on my dad’s side of the family. I never had any thinning or hair loss till this year. I guess you can say I’ve been under a lot of stress. When I did notice shortly after my 25th birthday I started stressing even more, which led to more hair loss. It is thinner up front and it is thin on top. I have heard of some hair docs mapping your head for miniaturization, do you do this too? — E.W., Miami, FL

A: Yes. The presence of miniaturization (decreased hair diameter) in the areas of thinning allows us to distinguish between hair loss due to heredity (i.e. androgenetic alopecia) — in which hair progressively decreases in diameter under the influence of DHT — and other causes. The degree of miniaturization can be assessed using a hand-held instrument called a densitometer.

The pattern of hair loss and the family history are also important in the diagnosis.

Stress more commonly produces telogen effluvium, a generalized shedding that is not associated with miniaturization and is often reversible without treatment.

• Read more about the Diagnosis of Hair Loss in Men
• Read more about the Treatment of Hair Loss in Men

Q: Over the past three months, my hair seems to be thinning more on one side. Is it common in male pattern hair loss for it to be more on one side? I had a lot of stress about three months ago and have heard that this could be the cause. Is this possible? Should I use Rogaine to treat it? — B.R., Landover, MD

A: Regardless of the cause, hair loss is usually not perfectly symmetric. This applies to male pattern hair loss as well.

In your case, it is important to distinguish between telogen effluvium (shedding that can be due to stress) and hereditary or common baldness. The three month interval from the stressful period to the onset of hair loss is characteristic telogen effluvium, but you may have androgenetic alopecia as an underlying problem.

The two conditions are differentiated by identifying club hairs in telogen effluvium and miniaturized hair in androgenetic alopecia. In addition, a hair pull will be positive in telogen effluvium (when a clump of hair is grasped with the fingers, more than five hairs pull out of the scalp at one time) and will be negative in common baldness. The hair loss diagnosis can be made by a dermatologist.

Hair cuts do not affect either condition.

Rogaine (Minoxidil) is only effective in androgenetic hair loss and only marginally so. Finasteride is the preferred treatment if your hair loss is genetic when it is early and a hair transplant may be indicated if the hair loss progresses.

Shedding from telogen effluvium is reversible and does not require specific treatment.

Q: I am a 34 year woman with a patch of hair loss by my temple. I went to the salon to have my hair done and to my surprise my hairdresser told me that I have Alopecia? First time I’d heard of it, my G.P is not very concerned about it but having read so much about it on this site I am becoming a bit concerned. The rest of my hair is healthy any suggestions and diagnosis? — M.V., Williamsburg, Brooklyn

A: “Alopecia” is just a generic term for any kind of hair loss.

It sounds like you have a specific condition called alopecia areata. Alopecia areata is an autoimmune disease that presents with the sudden appearance of well localized bald spot(s) on the scalp or other parts of the body. The underlying skin is always normal.

The treatment is injections with cortisone. Hair transplant surgery is not indicated for this condition.

You should see a dermatologist to confirm the diagnosis and treat.

Other diagnoses to consider are triangular alopecia (which would have been present since childhood) and traction alopecia (that is cased by constant tugging on the hair).

Q: I was told that if men have a lot of testosterone that that’s when they lose hair. Is this true? — Y.B., Lake Forest, Illinois

A: Although androgenetic hair loss is dependent upon normal levels of testosterone, it is not due to increased testosterone. It is caused by a sensitivity of the follicles to normal levels of testosterone.

So someone that is bald doesn’t have extra levels of male hormones and is not necessarily over-sexed.

Q: Dr. Bernstein, I was reading about a densitometer on your website. What is it and what is it actually used for? — Z.A., Westchester, NY

A: The hair densitometer was introduced to hair restoration surgeons by Dr. Rassman in 1993. It is a small, portable, instrument that has a magnifying lens and an opening of 10mm2.

To use it, the doctor clips the hair short (~ 1-mm) and the instrument is then placed on the scalp. The doctor counts the total number of hairs in the field, looks at the number of hairs per follicular unit and assesses the diameter of the hair, looking in particular for abnormal levels of miniaturization (decreased hair shaft diameter caused by the effects of DHT).

The densitometer can increase the accuracy of the diagnosis of genetic hair loss by picking up early miniaturization.

It can also better assess a person’s donor hair supply, thus helping to determine which patients are candidates for a hair transplant.

Densitometry has helped us define the conditions of diffuse patterned and unpatterned hair loss (DPA and DUPA) and help to refine the diagnosis of hair loss in women.

Q: One of the things that I have noticed as a person who has needed to take thyroid medication for a long, long time, is that when my thyroid gets a little bit out of balance – when I’m not getting quite enough, I begin to notice is that my hair starts falling out. What about the role of thyroid for hair loss? — T.K., Mineola, NY

A: Both increases and decreases in thyroid levels can cause hair loss and changes in the levels of thyroid hormone can change the consistency of one’s hair. Elevated hormone levels cause scalp hair to be fine and soft, with diffuse thinning being relatively characteristic.

When thyroid hormone levels are low, the hair becomes dry, coarse, and brittle. Hair loss can be either patchy or diffuse (involving the entire scalp).

Low levels of thyroid hormone are associated with the loss of the outer 1/3 of the eyebrows and a decrease in body hair. When changes in thyroid hormone levels are abrupt, there can be dramatic shedding (telogen effluvium).

The most important thing to do if you have thyroid disease is to try to keep the levels within a normal range and keep them as steady as possible. If you are taking thyroid medications, try to use them on a regular basis, because alterations of ones in hair can be caused by large fluctuations in the levels, as much as by the absolute values.

Q: I know that I am going to be bald because my father is bald and I am losing my hair just like him. What actually causes this kind of hair loss? — J.P., Paradise Valley, Arizona

A: Although there are many different causes, the overwhelming number of people that have hair loss have what is referred to as “patterned hair loss” or “androgenetic alopecia.”

In men, it is due to a hormone called DHT, which is a by-product of testosterone produced by the action of the enzyme 5-alpha reductase. This enzyme is inhibited by the hair loss medication Propecia. See the causes of hair loss in men page on the Bernstein Medical – Center for Hair Restoration website for more information.

In women, the mechanism is a little bit more complex as another enzyme, aromatase, is involved in the metabolic pathway. See the causes of hair loss in women page on the Bernstein Medical – Center for Hair Restoration website for more information.

We know that the inheritance comes from both the mother’s and father’s side, although the actual genes causing hair loss in men and women have not yet been identified. Statistically, the inheritance from the maternal side appears to be a bit stronger, but the reason for this is unknown.

Q: I am 19 years old and seem to be thinning all over, including the sides. My father has all of his hair but my grandfather is totally bald. Should I have a hair transplant now or wait until I am older? — T.K., Garden City, NY

A: Most likely you have a type of androgenetic alopecia called Diffuse Unpatterned Alopecia (DUPA). In this hereditary condition, hair thins all over rather than just on the front, top and back as in the more common male pattern baldness. The fact that the back and sides of your scalp are thinning (the donor area) precludes you from being a candidate for surgery. The diagnosis can be made by observing a high degree of miniaturization (fine hair) in the donor area under a magnifier. This instrument is called a densitometer.

For further information, please read the article:

Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning, published in the journal Dermatologic Surgery in 1997. Specifically, read the last part of the article.

Q: I am 27 years old and have a Class 3 degree of hair loss. Should I do a hair transplant or consider non-surgical methods of hair restoration? — Y.B., Lake Forest Illinois

A: At age 27 with early hair loss, you should consider non-surgical options first.

Propecia is the most important medication, but you need to be on it for one year at the full dose of 1mg a day to assess its benefits.

If you have done this and other parameters are OK for a hair transplant, such as adequate donor hair density and scalp laxity and you have little evidence that you will become extensively bald (i.e. no donor miniaturization and no family history of extensive baldness), then hair transplantation can be considered.

Q: Over the years, I have worn my hair in braids and extensions. My hair is not growing at my hairline and temples. Can the braids be the cause and can this be treated with a hair transplant? — Williamsburg, Brooklyn, NYC

A: The name for hair loss is this area is called alopecia marginalis. It is almost invariably caused by continued traction from braids or hair extensions. When this is the case, the condition is also called traction alopecia. If the problem is long-standing, the hair will rarely come back, even if the braiding is stopped, and a hair transplant would be indicated.

If there is enough hair loss on the sides of the scalp that the donor supply is significantly reduced, surgical hair transplantation may not be possible.

• Read about Traction Alopecia

Q: I’m currently 24 years old. Ever since turning 20, my hair on top began to thin little by little. I have noticeable thinning on the top part of my scalp and on my crown, but have no recession at the temples. My hairline looks amazingly young and hair on the donor areas seems quite thick. Am I in the early stages of male patterned baldness? I cannot place myself in the Norwood scale since my thinning doesn’t seem to follow the classic pattern. I just started on Propecia. Should I be considering a hair transplant? — B.R., Landover, MD

A: From the description, it sounds like you have typical Diffuse Patterned Hair Loss or Diffuse Patterned Alopecia (DPA). In this condition, the top of the scalp thins evenly, the donor area remains stable, and the hairline is preserved for a considerable period of time. Please see: Classification of Hair Loss in Men for more information.

Propecia would be the best treatment at the outset. When the hair loss becomes more significant, patients with DPA are generally good candidates for surgical hair restoration. It is important, however, that your donor area is checked for miniaturization to be sure that it is stable before a hair transplant is considered.

• Read our page on Hair Transplants in Young Patients
• Read about DPA and DUPA

Q: What are “Senior Medical Consultants”? — E.W., Miami, FL

A: These are non-medical personnel who wear white coats to give the impression that they have formal medical training. They are actually salespersons and they should immediately identify themselves as such. Although non-medical personnel can help to answer general questions, they should not be examining you and making specific recommendations about your hair transplant procedure. That is the job of your doctor.

When a physician evaluates you and makes recommendations, he or she is responsible for informing you of the risks as well as the potential benefits of your surgery, and is ultimately responsible for your care. They will also have the knowledge to provide you with a balanced view regarding your surgery as well as other treatment options. This is the practice of medicine.

A “consultant” who is being paid to convince people to have a transplant, but who is not actually performing the surgery, does not bear this responsibility and may have a natural tendency to over-sell the procedure. Beware!

Here are some resources about hair loss consultations at Bernstein Medical:

• About hair loss consults at Bernstein Medical
• How to choose a hair transplant surgeon
• About Bernstein Medical and our hair restoration services

Q: Can a hair transplant into bald areas caused by alopecia areata ever be successful? — R.K., Providence, R.I.

A: Alopecia areata is an autoimmune disease in which the body attacks its own hair follicles. It generally appears as round patches of smooth bald areas scattered in the scalp or beard. Less commonly, it can involve the entire scalp (alopecia totalis) or all facial and body hair (alopecia universalis). Unless the condition is well localized and totally stable, hair transplantation is not likely to be effective because the transplanted hair would be subject to the same problem.

We prefer that one have no new lesions for a minimum of two years before considering surgical hair restoration, although this does not ensure that the procedure will be successful.

You may find more information on this relatively common condition at the National Alopecia Areata Foundation (NAAF). For more information, visit: www.naaf.org.

• Read posts tagged with alopecia areata

Q: I am twenty and think that I am starting to thin. I am also experiencing a slight tingling in my scalp. Are these related? — T.N., Philadelphia, PA

A: Most likely. Early androgenetic alopecia can be associated with a slight tingling or slight tenderness of the scalp.

You should see a dermatologist for evaluation and, if you have early male pattern baldness, consider starting finasteride (Propecia).

• Read about early hair loss
• Read about hair loss consultations at Bernstein Medical