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Ask your hair restoration doctor: the ISHRS fellows answer your hair restoration and hair loss questions

How do you prevent and treat post-operative folliculitis?

Paul J. McAndrews, MD, FISHRS

Folliculitis is inflammation of the hair follicle from various etiologies—foreign body, bacterial, occlusive, chemical, etc.

It is my belief that the most common cause of folliculitis fol­lowing a hair transplant is that the hair (i.e., ingrown hair) acts as a foreign body. The treatment of choice for any foreign body is to “incise” the skin and drain it. I think we see more “ingrown hairs” secondary to the patient’s hair characteristics (e.g., curly causes more ingrown) and secondary to the doctor’s or techni­cian’s technique (grafts placed upside down and/or placed too deep in the incision site); therefore, try to place the transplanted grafts flush to the skin with some hair growing out of the surface.

The post-operative gel layers we place on the recipient site can cause an occlusive folliculitis, which is treated with removal of the gel layer and by incising/draining the pustules. Neosporin is the most common cause of iatrogenic-induced allergic contact dermatitis in the United States, so we need to be careful about what we are putting on wounds.

I believe bacterial folliculitis is less common. The pustule should be cultured. The treatment of choice again is to incise and drain the pustules and to possibly add on an antibiotic that treats Strep and Staph (including MRSA).

How do you perform FUE megasessions in patients with white hair?

James A. Harris, MD, FISHRS

FUE can be performed with either a full donor area shave or with something I call individual follicular trim (IFT) where only the follicular groups that will be extracted are trimmed, leaving the other hairs long. I will address the two methods separately as the way I visualize the emerging hair is different in each situation.

My preference for FUE megasessions is to shave the entire donor area to a length of 1-1.5mm. This method of donor preparation allows for easier identification of the available units, a broader working area, and the greatest procedure ef­ficiency. The white hair is a challenge to visualize with standard illumination methods, but with the entire donor area exposed, the easiest method to see the hair is to dye the shaved stubble. I typically use the “Just for Men” brand, medium brown color. The dye is applied for 10-15 minutes then checked for color. If the amount of hair coloring is adequate for visualization, the donor is area is wiped with sponges and followed by a wipe with “Roux Clean Touch” hair color stain remover to clean the skin. Because some patients may have a reaction to the dye, a small test session should be performed before the day of the procedure.

If the patient with white hair will not allow you to shave the entire donor area or if the patient has a skin sensitivity to dye, there is an alternate method of white hair visualization. Instead of the surgical light placed in the standard illuminating position, the light is placed so that the direction of the beam is in the di­rection of hair growth (see photograph). It may be a challenge to accomplish this positioning but the hairs will illuminate a bright white color and the FUE can proceed with changes in the lighting direction as needed.

What is the medical treatment for androgenetic alopecia?

Robert T. Leonard, Jr., DO, FISHRS

There are three medically sound and scientifically proven treatments for androgenetic alopecia (AGA) in men. The patient must know that they must be used forever. If their effects on the follicle are removed, the clinical benefits will reverse:

• Propecia® (finasteride 1mg) is the only oral medica­tion approved to treat AGA. It works ~83% to stabilize progression and ~66% to re-grow hair. Propecia works primarily in the vertex area of the scalp. The side effects are decreased volume of semen, decreased hardness of an erection, and decreased libido in 0.3% of men.

• Rogaine Foam (minoxidil 5%) was the first pharmaceuti­cal agent to treat AGA. It works ~70% to stabilize and ~50% to re-grow. It must be applied to the scalp two times a day—every day. Contrary to what is written, minoxidil works over the entire scalp and not only in the vertex. Common side effects are itching, redness, and scaling in ~2% of men.

• Low level laser therapy (LLLT) is an external treatment on the scalp. Energy from specific wavelengths of light is absorbed into the skin, which increases capillary blood flow to the dermis (among other mechanisms). It works ~90% to stabilize and ~50% to re-grow. There are no known side effects of LLLT.

For women, both minoxidil and low level laser therapy are safe and effective. Because finasteride can cause a birth de­fect, it is not used in women of child-bearing years. However, many physicians prescribe it (off label) for post-menopausal women.

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