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Hello Dr. Rassman, could you tell me what the difference between “thinning hair”, “Hair Loss”, “Miniaturization”, “Low and High Density”?

Also when people say poor nutrition, e.g. anorexia, zinc deficiency etc, causes thinned hair do they mean the shaft diameter of each hair decreases or hair falls out resulting in low density?

Thank You

“Thinning hair” means a person is losing hair (usually hair that is miniaturized - i.e. thinning of the hair shaft) and does not have as much hair bulk as they once had. “Miniaturization” of hair means that a person’s hair shaft is not as thick in one area when compared to another area as it should be in its normal/healthy state. It is normal to have around 10% of miniaturized hairs for people who are not balding that may reflect what we call vellus hairs, present in every follicular unit.

“Density of hair” describes how many hairs are in a given area of scalp. For example an average Caucasian male can have a hair density of 2 hairs per square millimeter of scalp (which translated to about 100,000 hairs on a typical head size). If it is found that the density is 3 hairs per square millimeter, than the person is said to have a high hair density (born with about 150,000 hairs on the head). Hair density is variable and may depend on the ethnicity or race of a person as much as the inheritance patterns. Caucasians are born with an average of 100,000 hair on their heads, Asians about 80,000, and Africans about 60,000. These numbers are just averages and do not necessarily apply to what you may have on your head.

I read that all persons have peach fuzz and miniaturized hairs in the beginning of their hairlines, but my question is that if it is normal to see solitary terminal hairs 1 cm before the beginning of the hairline

Most hairlines are transition zones between the bare forehead and the thick hair of the scalp. Some people have a wider transition zone than others. Some people have solitary hairs in front of the transition zone, while others have a tight frontal hairline. We are all different. When I create a hairline, I always build a wide transition zone between the forehead and the scalp hair behind it so that the point where the hairline starts does not come on strong. Some patients want a strong hairline so I often find myself negotiating with these patients on this very point as we plan the hairline for the day of surgery.

What do you make of the video below. It claims excess sebum on the scalp can cause hair loss and that the tincture of herbals and scrubbing (and brushing?) help to allow the hair follicles underneath to grow. Is there any chance that this could work? I am under the impression that shampoo eliminates sebum. Off topic regarding shampoo, should we be shampooing our scalp and our hair or just our hair?

There is hope everywhere (after all, it springs eternal). I would doubt that anything shown here will work for another person as it did for the lady demonstrating the technique in the beginning of the above video from Honolulu’s ABC affiliate. It’s obvious the news anchors have no idea about what they’re talking about when discussing hair loss, and this is quite a puff piece for this herbal maker.

As to your other question — you should shampoo your scalp and hair (the main reason for shampooing is to clean the scalp).

(female) I have been taking Hyzaar 50/12.5, a high blood pressure medication, for several years and I am experiencing balding in the top of my head and thinning around the edges; before taking this medication I had a full head of hair. Is there a high blood pressure medication that would possible not cause hair loss or thinning?

Hyzaar is known to cause hair loss in some people (”alopecia” is listed as a side effect). The pill is a combination of hydrochlorothiazide (HCTZ) and losartan, and I’ve written about HCTZ before. That being said, blood pressure medication is not generally the first thing doctors look for when evaluating hair loss in women. There are many other medical conditions that contribute to hair loss in women and these should be evaluated by your primary care physician. Some (but not all) of the causes can be anemia, thyroid conditions, menopause, genetic, lupus, etc. (see here).

Snippet from the article:

Most everyone plays mindlessly with their hair from time to time. But for some people it becomes such an uncontrollable compulsion that they end up with bald patches or eyebrows plucked bare (called Trichotillomania).

If it’s any comfort, animals too suffer from “grooming compulsions.”

Though the behavior is documented in the Bible and ancient medical texts, treatment for hair-pulling has not been studied much. But now a University of Minnesota researcher might have found an answer in a common, over-the-counter nutritional supplement that costs about $15 for 100 pills.

Read the rest — Pill could end urge to pull your hair out

If this is true, it would be a great, inexpensive way to treat this obsessive behavior. I’ll wait for the larger study to be complete, but the small 50 person study is promising.

I was taking Kariva for a few years for perimenopause. I quit taking it in February and for the last month or more my hair has been shedding. It fell out while I was taking it so my doctor recommended Rogaine 2%. After 2 months my hair got so much better so I tried discontinuing the Kariva. Now my hair is shedding again and I was wondering if it will last for much longer. My doctor said to give it 6 months but I may be bald by then. Should I go to a stronger Rogaine while it’s shedding from stopping the birth control pills? Thank you

Kariva (ethinyl estradiol and desogestrel) is a birth control pill that is a powerful hormone. Listen to your doctor’s advice — he/she knows more than I do about this, as I do not treat many women for birth control. If you want, you can try the over the counter extra strength Rogaine, which is 5%.

Ive had a transplant 6 mnths ago.The hair that has been transplanted on the front top of my head has made the skin look bumpy cobble stoned appearance. I want to shave my hair short to blade 0 and not have the bumpy look. What procedures can be carried out to solve my problem. I do not wish to have another transplant so im looking on ways to make my linear scar fade away to. Is laser treatment good for the scar.

Of course, I will start by saying I want to see what your hair looks like and if you can visit California (we have two offices here) it would be best to let us examine you directly. The second option (and probably most convenient if you’re not local) is to send me good photographs of what you are referring to with good lighting. Be sure to include photos of the scar where the hair was taken from.

Cobble-stoning is usually the result of the larger grafts which have a reasonably sized skin disk with it. The skin from the graft does not align with the scalp skin around it so that it appears bumpy. If that is what you have, your doctor used an obsolete technique and these just can not be fixed by shaving down the scalp skin with dermabrasion, which only makes the visibility worse with depigmentation of the scalp skin. The only solution is to put more hair around these bumps to hide it in the ‘forest’ of normal hair (more hair transplants, but this time by a well skilled doctor using modern techniques). Laser treatments do not work either and the linear scars from the donor area can be difficult to fix, but again, I would need to see it to understand the problem.

Dr. Rassman,

I have two specific questions for you:

1) How many grafts/what would the cost be to fill in a moderately thin area about the size of a quarter?
2) Do you have any suggestions for good, reputable doctors in Rhode Island?

And I have two non-specific answers for you:

1. A quarter sized area might take a variable amount of hair, depending upon where in the scalp it is located. It may possibly take between 100-200 grafts. Cost per graft varies per doctor, and many have a minimum fee for surgery. Without having your age, history, or really much information at all, it’s difficult to make recommendations — but assuming your thinning area is in the crown, you should talk to your doctor about Propecia or even getting some minoxidil (Rogaine). You might be able to avoid surgery altogether.
2. I don’t have any physician recommendations in RI, but if you don’t mind a little drive, Dr. Robert Bernstein is in Manhattan and he’s the best doctor on the East Coast. I would recommend him if you can manage a trip to New York. He should be able to do a telephone consultation with you by looking at good digital photographs, and then you can do it in one trip all in the same day.

Hi doctor, I just have two questions. Why in the beginning of normal hairlines the existence of miniaturized hairs and vellus hairs is normal?

And the second question is that how can you distinguish them in your hairline?

The very frontal leading edge of the hairline has more vellus hairs per square centimeter than other parts of the scalp. If you get a video microscope (see here), you can then study them and maybe understand what is growing out on your head better. It’s normal, because that is the way it is. It’s genetics. It’s a transition area from nothingness to a head of hair. Vellus hairs are usually short while miniaturized hairs can grow long, so they usually can be distinguished from each other that way.

Hi doc,
I’m a 19 year old male and i’ve just started thinning. I say just because i still have a full head of hair and all my friends think i’m crazy but my dad was bald at 25 so… my mum is a pharmacist so she bought me a box of propecia even though i didn’t went to the doctor to get a prescription. i have two questions.

1) Can I take propecia if I take at the same time half a pill of 250mg of lamisil ( for my toes)? I have a liver in really good condition : I did all the tests.
2) I have very small puffy nipples. But very very small ones, my doctor told me it was nothing. can I still take propecia? I have an appointment with and endocrinologist in august for that but I want to start taking propecia as soon as possible.

Cheers from France!

Lamisil should not interact with Propecia.

It shouldn’t be a problem for you to take Propecia due to very small, puffy nipples. I’m not comfortable with you taking prescription medication without a prescription, though. If you saw a doctor about your puffy nipples, why did you not get a prescription for Propecia at that point? If you see any changes in your chest after starting the medication, discuss it with your physician.