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Hello Dr Rassman,
I have recently been diagnosed with seborrheic derm in my right eyebrow by a dermatologist. I have read in previous Balding Blog posts that you don’t believe seb derm causes hair loss as it is primarily a skin condition, and that loss could result only if there is manipulation of the hair follicles and I agree with you! But, my case is such that I am losing anywhere from 3-6 hairs a day in my right brow (which is the only place I have this issue…white flakes that adhere to the follicle and cause weakening of the hair and then soon loss) so I was wondering if you think this means I might not have seb derm?

Afterall the doc just listened to my symptoms and as I was still speaking wrote out a prescription without even looking at my brow! I am thinking it is a condition which mimics seb derm what do you think? I am planning on eventually getting a transplant when the loss subsides but I can’t seem to control the problem first! He put me on desonide and ketoconazole cream which did nothing for the hair loss of flaking and just exacerbated the condition. Any insight you can give I would greatly appreciate. Thank you Doctor.

If you weren’t happy with your dermatologist’s review of your eyebrow (you said he didn’t even look at it before prescribing medication), you should consider seeing another dermatologist that will examine the hair loss.

As for me, I honestly do not know. It is strange that you are losing eyebrow hair on only one side. Perhaps it is temporary and the hair will grow back? Give it time. Don’t jump on the surgery solution. Follow up with your doctor. If this is of any comfort, I have yet to see someone with one good eyebrow and the other bald, unless, they are pluckers or pickers.

Can acute TE develop into chronic TE because of emotional stress?

Probably! High stress is a known cause of hair loss. In women, this usually reverses with time. In men, you have to distinguish what you see from genetic male pattern hair loss.

Snippet from the study abstract:

BACKGROUND: Few studies have extensively examined the prevalence of hair care practices and their association with scalp and hair conditions in African American girls.

OBJECTIVES: We sought to determine the prevalence of hair care practices and their association with traction alopecia, seborrheic dermatitis (SD), and tinea capitis (TC).

METHODS: A questionnaire was administered to caregivers of African American girls aged 1 to 15 years. Multivariate analyses were performed to determine the association of hair care practices with reported disorders.

Read the rest — Hair care practices and their association with scalp and hair disorders in African American girls.

201 surveys were sent out to caregivers of African American girls aged 1 to 15 years to look for links between traction alopecia, ringworm, and seborrheic dermatitis. Almost all of the respondents used oil/grease in the hair, and a substantial number used ponytails, braids, or cornrows. The results were published in the Journal of the American Academy of Dermatology.

The study concluded: “Certain hair care practices were strongly associated with development of traction alopecia and SD.” The situation of traction alopecia in women of African decent is epidemic in Western society. Many, many women have ruined their hair and developed significant balding from the various ways they went about managing their kinky hair.

Hi Doc,

i’ve been wearing a hair piece for the last year, im 22 and had a frontal hair transplant when i was 20. hair piece is my option because i dont think i will ever cover my scalp with a transplant.

however i would like to know if i can take Proscar while wearing a hair piece? i mean would i achieve the same results as other person not wearing it? and if i opt for a transplant and start from my crown, can i do it and wearing the wig for about 6 months till results are visible?

When you say Proscar, I hope you mean Propecia or are going to cut the Proscar into 4 pieces. Proscar (prostate medication) is 5x the dose of Propecia (hair loss medication). A wig/hairpiece/toupee won’t effect the benefits of Propecia (finasteride 1mg), but depending on how you attach the hair piece to the scalp, it may produce more hair loss from traction (from the glue, clips, etc). I’m not sure how you’re attaching your hairpiece.

You had a transplant to the hairline at 20 years old and are wearing a hairpiece elsewhere? I’m a little confused. You need a Master Plan with a good doctor to take a look at what you are doing to yourself. As most hair systems produce hair loss from irritation, pulling with clips, or traction, you may end up where you do not want to be — bald. A good doctor will review what you did to yourself, assess the amount of damage you have caused and determine what should be done to address your hair loss problems.

I have been taking Propecia for 5 years with good results. Recently I started Avodart 0.5 MG to treat BPH. I asked my doctor if I should discontinue Proecia and he said no due to the fact that they work a little differently, at least on the prostate. But, by his own admission, he wasn’t really sure how they would affect hair loss. What is your opinion? I have not had any side affects with Propecia.

I would refer to the doctor who treats you for your BPH (benign prostatic hypertrophy) for your prostate issues, and I would refer to the doctor who prescribed you Propecia for your hair loss issues. I know there is controversy with patients taking Avodart for hair loss, but its efficacy and safety vs Propecia has still yet to be shown to my satisfaction.

Both medications are similar, but Avodart is a stronger medication than Propecia. The present thinking is that if you are taking Avodart, you will not need Propecia. I’m not your doctor though, and both of these medications are prescription drugs… so talk to your prescribing physicians, please.

I realize it will take time to figure out whether acell will stand the test of time but wouldn’t Dr Cooley and his experiments have a good idea by now. Wouldn’t they be able to provide the public with some hope

Dr. Cooley is a class act doctor that does not jump the gun. I expect that when he knows with absolute certainty if the ACell trials stand the test of time, he’ll inform the public.

This is in response to a post from earlier this week about technicians performing most or all of FUE procedures with a NeoGraft tool:

Specialty Techs are in nearly every aspect of medicine and they all are equally skilled in their own field. Phlebotomy, radiology and even hair transplant techs to name a few, all have to maintain a high level of skill and responsibility as they are dealing with the health and well being of a patient. The question is, who would you rather have working on you? A doctor with an MD behind his/her name who just took a weekend course in some new procedure or a highly skilled tech with 5 or 10 years of experience doing the same thing, day in and day out with a high level of pride and commitment.

With regard to the techs who operate NeoGraft…how is what they do any different than when they are handling, dissecting and transplanting human tissue from a strip method? If anything, NeoGraft is a “tool” which in “experienced hands” has the ability to offer fewer complications, lower rate of transaction, faster recovery times and an overall better procedural outcomes.

I would encourage those who throw around the term “surgery” when speaking about NeoGraft to exercise a little common sense because handling, dissecting and transplanting strip tissue should be considered “surgery” as well if you really think about it.

Personal Note: I have seen the techs that use the NeoGraft systems with my own eyes and every time I am extremely impressed with the level of skill, dedication and pride these individuals posses.

“FUE performed by non-physicians is a grey area and illegal in most states. Legally, a procedure where there is a cut on the skin requires an MD to do it. There are cases where a registered nurse or a PA (Physician’s Assistant) can perform certain tasks, but it has to be supervised by the physician. A surgical tech performing FUE is a dark grey area.”

One more thing…I’m not sure where you get your information but it is completely inaccurate and misleading. Please provide everyone with just ONE state that mandates what you claim along with the link to the official state website where the rule is listed. Otherwise, please stop making things up.

Thank you for your comments.

To put it simply, no matter how minor of a surgery (suturing a cut on the skin, making a cut on the skin, or even just giving a prescription pill or IV to a person) it requires some form of license issued by the state where the act is performed. You may not have to be a surgeon, but you have to have had some medical training and hold a license (nursing license, PA license, etc). A normal person off the street, no matter how talented, cannot perform FUE even if they are trained or are better than the surgeon at doing it.

The focus here should be the protection of the public. When the person who is doing the surgery has a license to do it, that means that they were officially trained and certified to do surgery in the state. I know that there are many, many doctors who perform hair transplant surgery and do not have a clue on what they are doing. Many of these doctors use technicians to perform almost every step in the surgical process (in their medical offices) and it would be clear that the technicians are more competent than the doctors they work for. But this is not an argument for allowing non-licensed people to perform surgery, but rather that we need some protection for the public when a doctor is not competent in delivering a surgical service, not in allowing non-licensed people to perform surgery. Unfortunately, an MD in almost every state in the United States can do any surgery he wishes (brain, heart, hair, etc..) and will only be held accountable when someone experiences irrevocable harm or death. It is insane that the only protection for the public against these doctors is our criminal system after the damage is done. One can look at the cardiologist who administered Propofol to Michael Jackson, who is being held accountable by the criminal justice system for manslaughter.

I have found two interesting situations where non-physicians have performed surgery (one good and one bad).

• Example 1: The incredible story of African American lab tech that wasn’t formally educated beyond high school, but became a pioneer in heart surgery and actually operated on white Americans in the 1940s: Vivien Thomas
• Example 2: Title of the post is self-explanatory: Non-Doctors Doing Hair Transplants?

Now to the issue where you insist that I’m making things up, here’s the Medical Board of California’s Business and Professions code #2051: “The physician’s and surgeon’s certificate authorizes the holder to use drugs or devices in or upon human beings and to sever or penetrate the tissues of human beings and to use any and all other methods in the treatment of diseases, injuries, deformities, and other physical and mental conditions.” Emphasis mine. That’s just one of many examples that I found, but that should be satisfactory.

So to cut into your scalp, no matter how minor and safe it seems, the issues are one of license (legitimacy) and competence. Both, in my opinion, need to be considered as you make the decisions on who is going to do your hair transplant. I am sure that the NeoGraft system works in the hands of competent operators and that most doctors who now do surgery (with or without that tool) are probably less competent when compared to the standard of care that we perform in our office on a daily basis. I know that this is true, because I see the results of less-than-competent hair transplant surgery on a near daily basis as patients come to see me for repair advice, to address the failures of their surgery or the next step in their hair restoration process that was started elsewhere.

Is my beard suffering from traction alopecia?

Hello Dr,

For as long as I could grow a beard - about 10 years now - I’ve been something of a beard scratcher or more appropriately a massager. You know the type, a man in contemplation, rubbing his beard growth - an image you’ve surely seen a thousand times. I keep the beard at various lengths - short and stubble like or a medium length groomed style. To achieve various looks I use a remington beard clipper. Now recently I’ve noticed that a few areas of the beard look less dense, particularly the left chin to bottom lip portion. Don’t get me wrong, there is still hair in those areas it just seems a little thinned out as if somehow it lost some density but kept its overall growth pattern. This left me confused!

I wondered if my beard massaging or perhaps even clipper could have caused this? Almost all the men I know use a clipper on their faces and most can be seen stroking their beards from time to time. I mean the hair follicles are so thick in the beard area I imagine even tweezing them out would be difficult! Any insights would be greatly appreciated.

I doubt that “massaging” your beard would cause traction alopecia. You would have to be constantly pulling on the beard to the point that it sags your face. As people age their body hairs change in general.

I do not know the cause of your beard thinning. As much as we treat scalp hair loss, we rarely treat beard hair loss. I do at times see men with spotty beard hair loss and that often comes from alopecia areata. You may want to see if there are any other areas on your body and scalp where you notice this type of thinning.

Bad timing? Bad Physiology?
Hi Doc,

I am almost 10 months into my second Hair Transplant. It is taking a long time to see any results - I have hardly any new hairs yet. I’m not going to stress out though, not unless I still have no grafts at 12 months.

My question is whether or not you have come across any cases where a patient has had more then one transplant, where the first transplant took a long time to show results, and where the second transplant that was quicker to produce results. If so what could cause that, could hair cycle at time of transplant play a role?

I sometimes wonder if there is something about me that means HT isn’t a good option.

Generally, the delay time between the actual hair transplant and the growth is 4-7 months. I always tell the patient to wait until 8 months or so when fully 80-90% of the hair has grown, mostly to a length of at least 2 inches by the eight month. If you have had no growth in 10 months, I would start to worry, but waiting out another 2 months is reasonable.

I don’t know that any studies have been done on this, but just based on observation over the years, there is little difference between growth time of the first and the second transplant in most patients.

Is it better to take finasteride Propecia in the morning? I have read mixed answers, but what time approximately in the morning should I take the pill? Is testosterone levels highest in the morning because we sleep? In case I take the pill in the morning and go to sleep afterwards will it be less effective or will testosterone increase even more?

I hope you can help, I’m quite worried..

It probably does not matter when you take the Propecia (finasteride 1mg) each day, but I can rationalize and then suggest a morning dose will hit the testosterone and DHT when blood levels are highest. I don’t know why we produce more testosterone in the morning.