Committee on database of hair restoration results on patients with cicatricial alopecia and hair diseases other than androgenetic alopecia

Nina Otberg, MD Potsdam, Germany; Jerry Shapiro, MD Vancouver, British Columbia, Canada Email: ninaotberg@gmx.com

Registration Form

The ISHRS has founded a committee for the registration of hair restoration results on patients with cicatricial alopecia and hair diseases other than androgenetic alopecia. The committee consists of 6 members: Drs. Nina Otberg (chair), Valerie Callender, Jeffrey Epstein, William Parsley, Jerry Shapiro, and Ken Washenik. Together we created a registration form for the outcome of hair restoration surgery in patients with hair diseases other than androgenetic alopecia. The form is designed to collect general patient information (age, gender, ethnicity), information on the underlying cause of hair loss (primary cicatricial alopecia with subtype, secondary cicatricial alopecia, temporal triangular alopecia, aplasia cutis congenita, and alopecia areata), information on previous or ongoing medical treatment for the hair loss, histopathological reconfirmation via biopsy, disease duration, area of involvement, information on the procedure (scalp reduction, hair transplantation), information on treatment outcome, complications, and patient satisfaction.

We are asking every ISHRS member to help to create a database of hair restoration results on patients with these difficult scalp disorders. The database will help us to optimize patient selection, treatment outcome, and patient satisfaction. It will help us to create guidelines for the surgical treatment of each scalp disorder and will allow us to be more confident in managing patients with cicatricial alopecia and other rare hair diseases.

The registration form can be downloaded from the ISHRS website. Please fill out one form for each patient and send it back to the committee via mail or email at ninaotberg@gmx.com. Instructions can be found on the ISHRS website.

Scarring Alopecias

Cicatricial or scarring alopecias comprise a diverse group of scalp disorders that result in permanent hair loss. The destructive process can occur as a primary or secondary cicatricial alopecia. Primary cicatricial alopecia refers to a group of idiopathic inflammatory diseases, characterized by a folliculocentric inflammatory process that ultimately destroys the hair follicle. Secondary cicatricial alopecias can be caused by almost any cutaneous inflammatory process of the scalp skin or by physical trauma, which injures the skin and skin appendages. Regardless of whether a cicatricial alopecia is primary or secondary in nature, all scarring alopecias are characterized clinically by a loss of follicular ostia and pathologically by a replacement of hair follicles with fibrous tissue.

Cicatricial alopecias are psychosocially distressing for the affected patient and medico-surgically challenging for the treating physician. Hair regrowth cannot be achieved in areas of scarring; therefore patients depend on wigs, hairpieces, and other camouflage techniques.

Hair restoration surgery, including hair transplantation and scalp reduction, is the only available treatment to restore a natural looking hair density in patients with cicatricial alopecia. However, the treatment outcome is very difficult to predict. Any surgery may result in a reactivation of an underlying inflammatory process or difficulties with wound healing. Hair transplantation may result in a limited graft survival or in a loss of transplanted hairs months and years after the surgery due to an inflammatory scalp disease. 1-3

Temporal Triangular Alopecia (TTA)

TTA is a non-scarring, non-inflammatory alopecia on the fronto-temporal scalp. Lesions can be present at birth but mostly develop in the second to sixth year of age. TTA seems to be unresponsive to medical treatment. However, few cases are reported on successful hair restoration surgery in TTA.

Aplasia Cutis Congenita (ACC)

ACC is a non-inflammatory scalp disorder characterized by the absence of a portion of skin at birth. ACC is part of a heterogeneous group of disorders and most commonly manifests as a solitary defect on the scalp, but sometimes it may occur as multiple lesions. At birth, the lesions may have already healed with scarring or may remain superfi-cially eroded to deeply ulcerated. Very little is known on hair transplantation results in ACC. Occasionally involvement of the dura or the meninges can be found in ACC, therefore, an MRI is mandatory before surgery.

Alopecia Areata (AA)

AA is an inflammatory, non-scarring hair loss condition. AA usually presents with round patches of hair loss but can also affect the entire scalp (alopecia areata totalis) or the entire body (alopecia areata universalis). AA is usually a contraindication for hair restoration surgery since disease activity can be triggered and may result in a partial or total loss of preexisting and/or grafted hairs. However, at least one case of recalcitrant alopecia areata has been reported on successful hair transplantation6 and this is the main reason to include this disease in the current protocol.

References
1. Otberg, N., et al. Diagnosis and management of primary cicatricial alopecia: part I. Skinmed. 2008; 7:19-26.
2. Wu, W.Y., et al. Diagnosis and management of primary cicatricial alopecia: part II. Skinmed. 2008; 7:78-83.
3. Finner, A.M., N. Otberg, and J. Shapiro. Secondary cicatricial and other permanent alopecias. Dermatol Ther. 2008; 21:279-94.
4. Bargman, H. Congenital temporal triangular alopecia. Can Med Assoc. 1984; 131:1253-4.
5. Wu, W.Y., et al. Successful treatment of temporal triangular alopecia by hair restoration surgery using follicular unit transplantation. Dermatol Surg. 2009; June 2. [Epub ahead of print].
6. Unger, R., T. Dawoud, and R. Albaqami. Successful hair transplantation of recalcitrant alopecia areata of the scalp. Dermatol Surg. 2008; 34:1589-94.

Reprinted from HT Forum International, Volume 19, Number 5. September/October 2009.