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Updates in Clinical Dermatology
Series Editors: John Berth-Jones · Chee Leok Goh · Howard I. Maibach
Shari R. Lipner
PeterJ. Panagotacos
HowardMaibachEditors
Hair Loss
Advances and Treatments
Updates in Clinical Dermatology
Series Editors
JohnBerth-Jones, University Hospitals Coventry & Warwickshire, NHS
Trust, Coventry,UK
CheeLeokGoh, National Skin Centre, Singapore,Singapore
HowardI.Maibach, Department of Dermatology, University of California
San Francisco Department of Dermatology, ALAMEDA,CA,USA
ShariR.Lipner, Dermatology, Weill Cornell Medicine, New York,NY,USA
Updates in Clinical Dermatology aims to promote the rapid and ecient
transfer of medical research into clinical practice. It is published in four
volumes per year. Covering new developments and innovations in all elds of
clinical dermatology, it provides the clinician with a review and summary of
recent research and its implications for clinical practice. Each volume is
focused on a clinically relevant topic and explains how research results impact
diagnostics, treatment options and procedures as well as patient management.
e reader-friendly volumes are highly structured with core messages,
summaries, tables, diagrams and illustrat ions and are written by internationally
well-known experts in the eld. A volume editor supervises the authors in
his/her eld of expertise in order to ensure that each volume provides cuttingedge information most relevant and useful for clinical dermatologists.
Contributions to the series are peer reviewed by an editorial board.
Peter J. Panagotacos • Howard Maibach
Editors
Hair Loss
Advances andTreatments
Editors
Peter J. Panagotacos
University of California San Francisco
San Francisco, CA, USA
Howard Maibach
University of California, San Francisco
San Francisco, CA, USA
ISSN 2523-8884 ISSN 2523-8892 (electronic)
Updates in Clinical Dermatology
ISBN 978-3-031-74313-9 ISBN 978-3-031-74314-6 (eBook)
https://doi.org/10.1007/978-3-031-74314-6
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
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Preface
When Dr. Howard Maibach, a senior editor of this series “Updates in
Dermatology”, asked me to write a volume on hair covering what might be
new to the subject in the past few decades, I immediately responded in the
afrmative. Dermatology became my choice of specialty after having completed a rotation at UCSF Dermatology Clinic during my internship because
of Dr. Maibach as a role model. He also steered me to a residency program
at Charity Hospital in New Orleans which was well suited for my clinical
interests. It was there that Dr. James Burks became a mentor in hair transplantation. In 1980, Dr. Maibach asked me if I would give a lecture at an
international meeting in his place. Again, I consented, but only if I could
give the lecture on hair transplantation rather than Mycosis Fungoides. That
led to over 40years of lecturing at international meetings and the publication
of a book on hair loss meant for patients. My subspecialty in medical and
surgical hair restoration, therefore, is in large part due to his guidance early
in my career.
In deciding what should be included in this volume, I wanted to include
what was new in the diagnosis and treatment of general medical dermatology
as well as for androgenetic alopecia. The treatment of the most common form
of alopecia, androgenetic alopecia, is covered in Chap. 2 by Dr. Marc Avram
and the surgical treatment in Chap. 3 by Dr. Konstantinos Anastassakis.
Frontal brosing alopecia needed to be covered as it is a new entity that rst
appeared only a few decades ago. Trichoscopy also needed to be included as
it is a new technique for diagnosis in dermatology. Low level laser light therapy became a popular treatment for androgenetic alopecia in the past two
decades and is covered in Chaps. 4 and 5.
The next most common form of alopecia we see is alopecia areata which
is covered in Chap. 6 with a discussion of JAK inhibitors, PRP and exosomes.
To conclude the subject matter covered, I included a chapter on what research
is being done today in hair genetics and lastly a chapter on what we may see
in the near future in hair cloning.
As editor of this book, I have not attempted to have my biases in treatment
affect the other contributors’ viewpoints. For example, I do not prescribe lowdose oral Minoxidil because I do not believe the risk vs benet ratio warrants
it. I also do not use most of the popular nutraceuticals which are popular
today. These are individual preferences of relatively new treatments, and the
reader should be aware of the therapies that are currently being used by hair
restoration specialists.
v
vi
I wrote the introductory chapter of this book on the history of hair loss
treatments, a subject I thought I was well versed. However, in doing the
research on what’s new in the eld, I discovered something new about what
was old and overlooked. In 1941, Dr. Rattner wrote an excellent article
“Ordinary Baldness”, in the Archives of Dermatology and Syphilology. In
this article, he mentions Dr. Okuda as having done transplants in the 1930s,
who only recently has been acknowledged in most publications. He also mentions Dr. Tauber as having “good results from full thickness grafts from the
back and sides for the head”. It took many months of requesting reprints of
the article published by Dr. Tauber before I nally found a librarian in
New York City who was able to send me a copy. In the British Medical
Journal of Ceylon, Dr. Tauber in describing his method of a rotation ap from
the temporal-occipital area to the frontal scalp states “… the ap method is
the rst and real treatment of choice in alopecia praematura gen. Incipiens”
(now known as androgenetic alopecia). This was news to me, and when I read
further I found he had given lectures on the subject in Cairo in 1937. So, I’m
hoping others in the eld will start to recognize Dr. Tauber as the father of
hair restoration surgery.
As I nish writing this book, I am closing my 50-year private practice in
San Francisco. It is with mixed feelings that I leave the active practice of seeing patients and giving lectures, and I hope I have made a positive contribution in a eld I enjoyed so much.
The editor welcomes suggestions for the next edition.
Preface
San Francisco, CA, USA PeterJ.Panagotacos
Contents
1 The History of Hair Loss Treatments . . . . . . . . . . . . . . . . . . . . . . 1
Peter J. Panagotacos
2 Hair Loss: Advances and Treatments . . . . . . . . . . . . . . . . . . . . . . 19
Marc Avram
3 Hair Transplantation—From the “Ancient”
4 mm Plugs to the Latest Follicular Unit Excision
Technique: 8 Decades of Painful Progress . . . . . . . . . . . . . . . . . . 25
Anastasakis Konstantinos
4 Photobiomodulation for Alopecia: Mechanisms of Action . . . . . 53
Michael R. Hamblin
5 The Evolution of Photobiomodulation for the Treatment
of Hair Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Robert Haber
6 Alopecia Areata: JAK Inhibitors—PRP and Exosomes . . . . . . . 71
Doris Day
7 Nutraceuticals in the Treatment of Hair Loss . . . . . . . . . . . . . . . 77
Nicole Rogers
8 Frontal Fibrosing Alopecia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Aaron Chen and Peter J. Panagotacos
9 Trichoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Lily Park, Aaron Chen, and Martin Zaiac
10 The Transcriptomics and Epigenomics of Hair Follicles . . . . . . . 113
Raquel Cuevas-Diaz Duran, Emmanuel Martinez- Ledesma,
Melissa Garcia-Garcia, Andrea Sarro- Ramírez,
Carolina Gonzalez-Carrillo, Denise Rodríguez-Sardin,
and Alejandro Cardenas-Lopez
11 Hair Follicle Cloning and Stem Cells . . . . . . . . . . . . . . . . . . . . . . 129
Anastasakis Konstantinos
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
vii
The History ofHair Loss
Treatments
PeterJ.Panagotacos
1
The History ofMedical Hair Loss
Treatments
Since the beginning of recorded history, men and
women have searched out cures for hair loss. The
oldest known prescription is 5000years old and
was for hair loss. Written in the Ebers Papyrus,
about 1500BC, is a prescription for Queen Ses,
mother of the Egyptian King Teta, 2000 years
earlier. It is not known whether she had
Androgenetic Alopecia or Alopecia Areata. There
are several prescriptions for hair loss in the
Papyrus. The one for Queen Ses was a mixture of
“Toes-of-a dog, refuse-of-dates (and) hoof-of-anass” (Fig.1.1) [1, 2].
The Ebers Papyrus is the oldest complete
medical text ever found, and it is devoted to
treatments for various skin diseases and cosmetic conditions. It includes the oldest known
written prescription for treating baldness: a
mixture of iron oxide, red lead, onions, alabaster, honey, and fat from a variety of animals,
including snakes, crocodiles, hippopotamuses,
and lions. The mixture was to be swallowed
after rst reciting a magical invocation to the
Sun God.
Another cure for baldness from the Ebers
Papyrus involved swallowing the following
P. J. Panagotacos (*)
University of California San Francisco,
San Francisco, CA, USA
“mixture of iron, red lead, onions, alabaster, and
honey” while reciting the invocation below:
“O Shining one, thou who hoverest above!
O Xare! O Disk of the Sun!
O Protector of the Divine Neb-Apt!”[3, 4]
Later in the Ebers Papyrus, there are remedies
suggested for Alopecia Areata. It was known as
“bite hair loss.” In 30 CE, Celsus described
Alopecia Areata presenting as scalp alopecia in
spots, or the “windings of a snake” and suggested
treatment with caustic compounds and scarication” [5].
Wigs and hairpieces of various sorts were
popular among upper-class Assyrians, Sumerians,
Cretans, Carthaginians, and Persians in the
Fertile Crescent area of the Middle East.” Both
sexes seem to have often worn large wigs, as in
ancient Egypt” [6].
Wigs were popular among Egyptian royalty at
this time as well, and a number of elaborate and
well-preserved hairpieces have been found in
tombs by archaeologists. Many Egyptian wigs
were ornate creations constructed of linen ber
as well as human hair, while others made of metal
were more helmet-like. As an example of the
importance hair played in certain cultures, certain
Egyptian royalty also used “facial hair wigs,”
specically fake beards, to signify power. Both
male and female royalty wore fake beards [7].
Hippocrates, about 400 BC, described
Alopecia Areata and coined the term alopecia
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
P. J. Panagotacos, H. Maibach (eds.), Hair Loss, Updates in Clinical Dermatology,
https://doi.org/10.1007/978-3-031-74314-6_1
1
2
Fig. 1.1 Ebers Papyrus
(2023, March 16). In
Wikipedia
P. J. Panagotacos
(from the Greek for fox). The term most likely
derives from a reference to a mange causing
spotty hair loss in foxes [8]. Hippocrates has been
depicted in busts and drawings as being very
bald. There has been some question as to whether
Hippocrates was in fact as bald as depicted in
most drawings and busts done of him over the
past 2000 years because there were none done
while he was alive which remain intact. Most
authors assume he was very bald, and the term
“Hippocratic baldness” used for centuries not
only refers to inherited baldness but to his personal extensive baldness with only a rim of hair
in the periphery (Fig.1.2).
A conventionalized image in a Roman “por-
trait” bust (nineteenth-century engraving).
We know he prescribed topical treatments such
as a mixture of opium, horseradish, pigeon droppings, beetroot, and various spices that were
applied to the head. Hippocrates eventually lost it
to the extent that today we refer to advanced male
pattern baldness as “Hippocratic baldness” [9, 10].
In his collection of astute observations called
the “Aphorisms of Hippocrates,” he noted that
Persian Army eunuchs guarding the king’s harem
never experienced hair loss. In Aphorism XXVIII,
he states: “Eunuchs are not affected by gout, nor
do they become bald” [11]. We now know that it is
true that castration before or shortly after puberty
reduces testosterone and Dihydrotestosterone
(DHT) levels in the blood to such a degree that
genetic hair loss is prevented [12, 13].
In ancient Rome, hair continued to be a symbol of power and virility. This presented a problem for Julius Caesar, whose hairline was
receding even as his empire was expanding. He
developed some cosmetic solutions to his hair
loss problem. First, he began growing it long in
the back and combing it straight forward over his
bald spot. Sort of a “comb forward” instead of a
“comb-over”. This didn’t seem to work all that
well, perhaps because hair gel would not be
invented for another 2000years [14]. According
to Suetonius, Cesar was awarded the Civic