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    The Medical Science of Hair Loss

    Nov 11, 2005/by William Rassman, M.D./12 /Favorites, Hair Transplantation, Training

    What constitutes a good way to follow genetic balding? So far it seems to be a vague art that varies between doctors, and not something that will give an intelligent person an understanding of what is happening to them.

    Miniaturization occurs in men and women who are balding. Miniaturization is the process where a normal thickness hair shaft becomes thinner and thinner over time due to the genetically determined effects of aging and/or androgenic hormones on the terminal (normal) hair follicle. The process of miniaturization is a slow process in genetic balding. Hair shafts may lose 10% of their diameter, then 20%, then 30% and so on. Each degree of increased miniaturization reflects further progression of the genetic balding process. The instruments that measure miniaturization were invented (and patented) by me in the early 1990s and they are in wide spread use today. Socially detectable hair loss is not evident until more than 60% of the hair has been lost and as a result, many men do not seek out expert help until they see some evidence of balding (which they too often deny).

    When a doctor views the scalp hair with high magnification, the degree of miniaturization and the location of the miniaturization are both critical to establishing (1) the diagnosis and (2) the rate of the process, which progresses over time. Because miniaturization is a relative measurement at any one time (comparing finer hair to the thickest hair), it takes substantial experience before this measurement can be useful to the individual clinician. In our experience, from examining and following thousands of patients with the Hair Densitometer, we have found that assessing the degree of miniaturization has useful predictive value when evaluating the risks of hair loss and in establishing hair loss patterns. The amount of miniaturization in each section of the scalp tells the physician just how far the balding is progressing or has progressed. In men who show more and more areas of miniaturization over time, the genetic balding can be considered active.

    A high degree of miniaturization in the upper portion of the fringe area in a Norwood Class 6 pattern (see below in red) suggests that the donor fringe will lower over time so a person who may be a Class 6 pattern balding pattern may become a Class 7 pattern, reducing the fring around the sides and back to a 3 1/3 inch band. A high degree of miniaturization throughout the donor area indicates that all of the patient’s hair may be unstable for hair transplantation and that he may be at risk to have diffuse unpatterned alopecia with extensive balding, even on the sides and in the back of the head (an area normally not affected by any balding or miniaturization in most men). The unpatterned alopecia is characteristic of women’s genetic balding pattern which is often found all over the head including the back and sides.

    Miniaturization in the recipient area (front, top and crown) can often delineate which areas of the scalp are most likely to bald and which are stable, anticipating the patient’s future Norwood hair loss classification. If a man has 90% miniaturization in the crown (back of the head) and only 30% in the mid scalp, the physician may assume that the crown is at a higher risk of earlier hair loss than the mid-scalp, giving him an eventual Class 4 or 5 balding pattern.

    We feel that in predicting the short-term loss, the extent of miniaturization in the recipient area, as well as the rapidity of the loss, is critical in establishing the guidelines for treatment, whether it is a hair transplant or drug intervention. In the very early stages of hair loss (the many in his early-mid twenties), increased miniaturization can anticipate future balding even before any loss can be seen to the naked eye. Often the reason a person seeks a consultation for hair restoration expert is that there is some change in the “rate” of his hair loss (often more hair seen on the pillow or in the shower). A patient who is very gradually losing his hair is less likely to seek help than a patient who suddenly has acceleration in the rate that he is losing hair. Usually large numbers of hairs undergo miniaturization before any are actually lost and the time the drugs are most effective is in this early phase. In men, DHT is the hormone responsible for these changes.

    For the most reliable prediction of the final hair loss pattern, the patient should be over the age of 25 (above 30 is better) and have some visual evidence that the process has started. A base measurement and subsequent follow up measurements are essential to the proper management of hair loss by any doctor considered to be an expert in the field. By understanding these measurements over time, the doctor will understand just what this all means and better yet, the patient now has a way to follow what is happening to him/her. Many young men worry about following their father’s or mother’s male family balding history and come to the office to find out what their future has in store for them. The microscopic assessment for miniaturization is the best way to determine this.

    With successful medical (drug) treatments like Propecia in men, the miniaturization may be reversed (partly or completely). The responsiveness of each patient is different, so each patient must be diligent in follow up measurements of the degree of miniaturization and the location of the miniaturization by scalp location. The same diagnostic criteria should and must be followed in women. Without good measurements for miniaturization, there is no clinical science in the treatment of hair loss, just hocus-pocus and blustering, a problem that is far too frequent today.

    Reader Comments12

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    1. Jan
      Jan says:
      May 31, 2006 at 9:39 am

      Help! My 15 year old is losing his hair fast. I find so much of it in the bathroom and on his pillow and sheets. He is becoming very self conscious of it. I took him to a general practioner and he just said that he is going bald and bald is beautiful.His only suggestion was rogaine. Baldness runs in my family, but is it normal to begin losing hair at 15? What can I do to help him?

      Reply
    2. Dallas
      Dallas says:
      May 31, 2006 at 6:37 pm

      Where would I get a “hair miniturization test”?

      I live in Calgary, Alberta, Canada

      Thanks.

      Reply
    3. morgan
      morgan says:
      Aug 4, 2006 at 10:54 am

      Comments of Accutane inducing hair loss raised my concern. I’ve been through two sessions of the drug, the first round 5 years ago and the latest last year, and have experienced recession of the hair-line. Attributing the hair loss to genetics, I began splitting Proscar (Finasteride) tablets 3 years ago. Since then, progression of hair loss at least isn’t significant, but may still be worsening. Photos from years ago are difficult to compare to the present. If the hair loss I’ve noticed is along temples in the normal MPB fashion, could the problem be a result of Accutane? If Accutane were the culprit, wouldn’t it cause an overall thinning of scalp and not be so localized at the temples? Further, if the balding is from Accutane, is Finasteride a proper treatment?

      Thanks!

      Reply
    4. MORGAN
      MORGAN says:
      Sep 3, 2006 at 7:17 am

      My son was on Accutane for two sessions and your comments make sense to me as he has a receding hairline also and his hair is very thin-that may be genetic though. Have you gotten any response to your question?

      Reply
    5. john
      john says:
      Nov 24, 2006 at 8:26 pm

      Where do i go to get my 15 year old son a miniaturization test? Many thanks.
      John

      Reply
    6. malka
      malka says:
      Apr 13, 2007 at 12:45 am

      I started losing hair when I first had General Anesthesia after D&C, then more after wrist fracture anesthesia, and then a fractured T6 vertebra which was operated on. The last time had anesthesia was in 2003, however, every two years I get a Colonoscopy because brother had Colon cancer. My mother did not have baldness. I’m 65 and my hair looks sick…I’ve been tested and other than Osteoporosis, I am well except I take Forteo injections every day to build up my bone mass. Please how can I find out what is causing this thinning of my hair and how to get my hair back if possible or stop any more hair loss. I started taking biotin 2,000 every day…HELP myra

      Reply
    7. connie
      connie says:
      Apr 19, 2007 at 8:40 pm

      Does male pattern baldness come from the mother or fathers side of the family?

      Reply
    8. Heidi
      Heidi says:
      Apr 26, 2007 at 7:29 pm

      i have the prettiest hair in the family thick dirty blond all of a sudden i find that im losing hair at im not even 15 yet help me

      Reply
    9. Michele
      Michele says:
      Sep 23, 2007 at 4:22 pm

      I have been taking Forteo injections for almost 3 months and have noticed an alarming increase in hair loss, although this is not listed as a side effect. I am on no other medications.
      I am a woman in mid 50s. Has anyone else on this medication noticed this?

      Reply
    10. Kayla
      Kayla says:
      Oct 14, 2007 at 5:57 am

      I have been taking Forteo for 22 months. I have also had hair loss, mostly when washing my hair. I have wondered if it could be from the medication, since I have experienced this for almost that long. Another thought is that it is from hair dye.

      Reply
    11. Ellen
      Ellen says:
      Oct 27, 2007 at 9:08 am

      I have been taking Forteo for a little less than 2 months. Within the last 2 weeks I noticed an excessive amount of hair loss. Has anyoone discussed this with their doctor who prescribed Forteo? I plan ot call my doctor.

      Reply
    12. chalk
      chalk says:
      Sep 30, 2010 at 12:15 pm

      yes, losing hair on forteo. lots of it. did it come back when you were finished with forteo?

      Reply

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