Scalp Skin Disorders
One of the goals of the hair transplantation consultation is to identify any concurrent scalp pathology that might influence the outcome of the surgery.Considering this matter, the most common conditions of the human scalp encountered are Seborrheic Dermatitis (SD) and Psoriasis. These conditions usually begin while a person still has a full head of hair, and they persist as hair begins to be lost due to androgenetic alopecia (male or female-pattern hair loss).
Seborrheic Dermatitis
SD is a chronic, recurrent condition that ranges from mild involvement, called Dandruff and Seborrhea, to moderate and severe forms.The prevalence of SD (excluding Dandruff) is 2% to 5% of the population. After including Dandruff cases, the prevalence would probably be much higher.
In all of these conditions, a normal yeast colonizer of the scalp, Pityrosporum, is thought to play an important role in the pathogenesis of the disease by causing the formation of free fatty acids acting as irritants, causing hyperprolifration of the epidermis.These conditions are not, however, contagious from comb or brush borrowing from someone else. Emotional stresses often flare up these problems.
A) Dandruff
The condition popularly known as Dandruff is, in its most common and mild form, little more than a normal shedding of dead skin cells from the scalp. When the white flakes land on the collar or shoulders of one’s clothing they become an unattractive cosmetic nuisance. Some people experience a heavier accumulation of flakes that adhere to the scalp and fall in a literal blizzard onto clothing, bedding and furniture. When a person has excessive oiliness of the scalp, a heavy accumulation of flakes can be pasted to the scalp in oily mounds and adhere to hair in whitish globs. This condition is most likely when production of skin oils (sebum) is at its peak in puberty and adolescence, or when the production of androgenetic (male) hormones is out of balance. “Oily dandruff” that is not accompanied by inflammation or itching may be a mild form of seborrheic dermatitis that is discussed below.
Pathologically, Dandruff is characterized by involvement of the upper layers of the epidermis.
Treatment is mostly aimed at keeping the condition under control rather than curing it.Common, mildly shedding dandruff is usually managed successfully by regular use of a mild, anti-dandruff shampoo once or twice a week. Over-the-counter (OTC) shampoos containing Zinc pyrithione, Tar, Salicylic acid, and Selenium sulfide often work well to manage mild dandruff. Prescription Ketoconazole and Ciclopirox Shampoos are also highly effective due to their antifungal effect. It is a condition of no medical consequence. More severe dandruff with excessive oiliness, crusting and itching may be a form of Seborrheic Dermatitis and should be managed under the care of a Dermatologist.
The topical hair restoration medication minoxidil (Rogaine) can cause or worsen Dandruff in some patients. Dandruff due to this cause varies from mild to severe forms. In some cases minoxidil can cause scalp irritation, dryness and itching that can progress to broken and bleeding scalp skin. The condition may be worse in winter when humidity is low. When a side effect of this severity occurs, the patient should contact his or her physician. Dandruff and dry, irritated skin associated with minoxidil can be treated with anti-dandruff shampoos, decrease of the drug dose from twice to once a day, or discontinuation of the medication.
B) Seborrhea—Oily Skin, Scalp and Hair
The sensation of “oiliness” or “greasiness” of skin, scalp and hair is one that most people dislike and believe to be unattractive to other people as well. To some extent, the perception of “oiliness” or “greasiness” is highly personal and may or may not be objectively identified with excess skin oil (sebum) production. A feeling of oiliness in hair may also be associated with accumulation or degradation of hair cosmetic products, or with accumulation of by-products of heavy scalp perspiration. Excess sebum production frequently occurs during adolescence—a peak period from which sebum production usually declines as a person ages.
Excess sebum production is a clinically important feature in many cases of acne, and treatment of acne may include treatment to reduce sebum production. While acne is commonly believed to be a teen-age disease it persists into adulthood for millions of people. Seborrhea can cause scalp and hair to feel oily or greasy. Unlike seborrheic dermatitis, however, the oiliness is not associated with crusting, inflammation and intense itching. The cause of severe seborrhea should be diagnosed by a dermatologist in order to rule out other conditions and determine the best treatment.
C) Seborrheic Dermatitis
Seborrheic dermatitis (SD) is a common, chronic condition that affects people at all ages from infancy through middle age; however, the two peak periods of occurrence are in the first 3 months of life when seborrheic dermatitis is known as “cradle cap”, and from approximately ages 30 to 70 years.From viewpoint of pathology, SD involves epidermis and dermis and is associated with much greater degree of inflammation than Dandruff.
The most prominent features of seborrheic dermatitis are (1) excessive oiliness of scalp and hair, (2) greasy, yellowish scales that grow into crusts covering red, inflamed, moist scalp skin, and (3) intense itching. In more severe cases the condition involves the eyebrows, cheeks, and folds of the nose. The intense itchiness may encourage hard scratching that will enhance inflammation and open the way to secondary infection by bacteria, yeasts or fungi. The more severe forms of seborrheic dermatitis can closely resemble psoriasis, and may even overlap in a condition called sebopsoriasis.
SD should usually be diagnosed and treated by a Dermatologist. For treatment of SD, topical corticosteroid lotions, foams and shampoos are usually required plus previous treatment modalities under heading of Dandruff. In refractory cases, oral antibiotics, orar antifungals, and systemic corticosteroids are other options. Although not curable, seborrheic dermatitis is very treatable and can usually be cleared with regular use of prescribed treatments.
A typical sequential treatment approach is to use a topical lotion containing corticosteroid, salicylic acid, and antifungal at bed time and a suitable shampoo in the morning during the initial treatment phase. Once the condition is somewhat improwed, the frequency of topical lotion application is tapered while the daily use of shampoo is maintained. After control of the condition, the lotion is eliminated and the shampoo is continued for maintenance.If a flare-up occures, the sequence is repeated from the first phase.
It is generally accepted that, to maintain efficacy, patients should rotate between different medicated shampoo ingredients.This is probably due to the fact that different active ingredients treat various parts of the disease and OTC shampoos contain only one active ingredient.
D) Relevance to Hair Transplantation
The presence of SD is relevant for several reasons. Generally, one would like to avoid incising affected skin in the donor or recipient areas. Also, SD is associated with compromised skin barrier function and a possible increased incidence of staphylococcus infection. Although some physicians believe that the underlying inflammation of SD may be a factor in hair loss, patients should be reassured that in general it does not. However,frequent scratching can disrupt the hair shaft cuticle and result in hair breakage.
SD should be treated aggressively and cleared as much as possible prior to surgery. We recommend patients to be on topical therapy during the 2 weeks prior to the transplant procedure.If, on the operative day, severe SD is identified in the proposed donor zone, it may be prudent to avoid the affected area if possible.
Psoriasis
Psoriasis and SD have overlapping clinical features. In contrast to SD, however, Psoriasis is characterized by sharply defined, raised, erythematous scaly plaques,rather than the diffuse erythema and scaling seen in SD.Involvement of the nails and plaques on the elbows and knees are commonly present although psoriasis may be confined to the scalp.
`Sebo-Psoriasis` is a term used to describe the patient`s condition when it has features of SD and Psoriasis is difficult to differentiate between the two entities. Psoriasis of the scalp is a commom condition affecting about 2% of the population.It occurs in a genetically predisposed person under effect of environmental triggers. These triggers include tobacco use, medications such as beta-blockers, and infections (e.g., Streptococcal pharyngitis). Any injury to the skin can result in the appearance of psoriatic lesions, the so-called Isomorphic response, or `Koebnerization`.
Psoriasis of the scalp can be effectively treated with topical agents including corticosteroids, anthralin, vit. D3 analogues, and salicylic acid (for removal of thick scales). Persistent scalp plaques can be injected with intralesional triamcinolone acetonide (e.g., 2.5 mg/ml). Shampoos containing tar or salicylic acid are important components of topical therapy.
A typical sequential treatment approach is to use a topical lotion containing corticosteroid , and salicylic acid at bed time and a tar shampoo in the morning during the initial treatment phase. Once the condition is somewhat improwed, the frequency of topical lotion application is tapered while the daily use of shampoo is maintained. After control of the condition, the lotion is eliminated and the shampoo is continued for maintenance.If a flare-up occures, the sequence is repeated from the first phase.It must be told that prolonged topical steroid application can result in tachyphylaxis or decreased efficacy, and so intermittent approach is much better effective.
Relevance to Hair Transplantation
The presence of psoriasis is relevant for several reasons. Generally, one would like to avoid incising affected skin in the donor or recipient areas. Also, psoriasis is associated with compromised skin barrier function and a possible increased incidence of staphylococcus infection. Of particular concern in psoriasis is Koebner phenomenon, which describes the appearance of psoriasis lesions in normal skin that has been subjected to even minor injury. Of course, the incidence of the koebner phenomenon as a result of hair transplantation is uncommon. The reason is probably that we not only administer corticosteroid to prevent post-operative edema as a routine but also we add triamcinolone acetonide to the recipient area anesthesia.
Although some physicians believe that the underlying inflammation of psoriasis may be a factor in hair loss, patients should be reassured that in general it does not. However,frequent scratching can disrupt the hair shaft cuticle and result in hair breakage. In scalp psoriasis, hair loss is rare and usually associated with vigorous attempts at removing scales.
psoriasis should be treated aggressively and cleared as much as possible prior to surgery. We recommend patients to be on topical therapy during the 2 weeks prior to the transplant procedure. Although the occurrence of the koebner phenomenon is probably uncommon, the possibility of it in the donor or recipient area should be discussed with psoriasis patients at the time of the consultation. If, on the operative day, psoriasis is identified in the proposed donor zone, it may be prudent to avoid the affected area if possible.
