Psoriasis and hair transplants

[Dr_Arvind]

Dear forum readers,
A question asked sometimes by prospective patients is
— Can they undergo a hair transplant if they have Psoriasis?
Will the surgery lead to a spread of the psoriatic lesions?
If body hair grafts are used, will the cuts lead to flaring up of psoariasis in that area?

We have performed hair transplants for quite a few patients, who also happened to be suffering from Psoriasis.

However, I recently had an ocassion to meet and talk at quite some length to a past patient when he came for his repeat HT.

Talking to him, I felt that there must be countless other readers who may benefit from a recounting of this patient’s experiences and an in depth discussion.

I would request readers to post their queries in regards to psoriasis and hair transplants and fellow doctors to share their thoughts/experience.

Regards,
Dr. A

P. S. - Some informative resources about Psoariasis.

The National Psoriasis Foundation

Psoriasis | Psoriatic Arthritis | MedlinePlus

[Dr_Arvind]

Dear forum readers,
Psoriasis is a fairly common skin disorder.
The commonest form of Psoriasis (Plaque psoriasis) is characterized by patches of red skin covered with silvery scales and inflammation.
The most frequent areas where these patches are found are the knees and elbows.
However, they may also be found on the arms, legs, trunk, or scalp. In fact almost any part of the skin.

Psoriasis are more common in the Caucasian population. However, they are known to occur in all races. In fact, the patient I refer to on this post is of Indian descent.

The true cause of Psoriasis is not known. Autoimmune influences are suspected. There seems to be a genetic predisposition and often many members of the same family are afflicted by it.

However, Psoriasis is not contagious.

Physical injury is said to be one of the factors that may cause a flaring up of the psoriatic lesions, and for purpose of hair transplants, including body hair transplants, that is the relevant concern.
Below are 2 pictures that shows what typical Psoriatic patches look like.

The first is the trunk (chest and abdomen).

The second is the knee and shin area.

While Psoriatic attacks are not difficult to control (topical sterois, UV exposure etc.), most patients prefer to limit the areas of these patches.

The patient’s concern was with what we, in medical terms, refer to as Koebner reaction.
Psoriasis patients commonly notice that new areas of psoriasis occur within 7-10 days after the skin has been injured. This has been called the Koebner reaction.

While performing hair transplants, therefore, the patient had the following concerns -

1. In the first stage, the patient had gone for a strip FUHT procedure. Will the strip incision flare up the psoriasis in scalp donor?
   Will the needle incisions in the recipient area lead to new psoriatic patches in that area (where none were before)?

2. In the 2nd stage, the patient went for a test BHT session. His concern was whether the needle cuts used for extracting body hair grafts lead to any escalation of psoriatic patches?
   Regards,
   Dr. A

[Dr_Arvind]

Dear forum readers,

Please remember scalp Psoriasis does not cause permanent balding.

It may lead to a temporary hair shedding in the psoriatic patches. However, upon remission, the hair grow back in those plaques.

When planning a scalp to scalp HT, its prudent to first treat any Psoriatic patches.

Psoriatic patches, most commonly, develop in the back of the scalp (donor area), though may occur as discrete patches in almost any part of the scalp.

Treatment of psoriasis in the scalp presents its own unique problems.

1. The hair covering the psoriatic plaques, prevent adequate sun exposure. Sunlight exposure, in form of UV light, is a known treatment for Psoriasis.

2. The presence of hair make application of many topicals difficult and messy.

3. Scalp psoriasis may be overlapped by seborrhoeic dermatitis.

Scalp care -
Keeping the above things in mind, the following is a suggested scalp care regimen.

1. Go for a buzz cut, if possible. That will help by more UV exposure to the affected area and will make application of topicals easier.

2. Coal tar and Ketoconazole shampoos. Remember that medicated shampoos need to be massaged into the scalp and left in for a longer time. We recommend that you wet your hair first, apply the shampoo and leave it on for 10 minutes before rinsing it off.

Coal tar shampoos are sufficient starting treatment for most scalp psoriasis patients. Ketoconazole can be added if the psoriasis is accompanied with seborrhoeic dermatitis (also called sebo-psoriasis) and/or fungal infections.

Use these shampoos twice a week. For people who do not like the smell of these medicated shampoos, post bath, they can shampoo again with a non medicated shampoo of their choice, followed by a conditioner. That should take care of the smell issue.

For those suffering from more severe psoriasis, use of topicals may be required.
Topicals may be in form of steroids (Diprovate lotion is is easier to apply as it is alcohol based instead of cream/oil base) can be used to alleviate the itching. Prolonged use of steroids should, however, be avoided. Its best to use them intermittently.

Coal tar creams, salicylic acid creams and Coconut oil compound ointment are more effective (though messy). Apply these creams by rubbing them into the plaques. Wait for 1 hour and then shampoo them out. Or, apply them before bedtime and leave them overnight. Wash the next day.

Resistant or difficult to treat psoriatic patches may require Dithranol,
Calcipotriol, phototherapy and oral medications.

Please remember that all treatments mentioned above must be taken under proper medical supervision.

Its best to go for a hair transplant procedure once the psoriasis is under control.

Regards,
Dr. A

[Dr_Arvind]

Dear forum readers,

Returning to the present patient’s particular case. Patient AM.

This patient’s brother (also suffering from scalp psoriasis), had successfully undergone 2 FUHT procedures (totalling over 5000 grafts)from our clinic.

Encouraged by his results, the patient underwent a strip FUHT procedure in the first stage of his hair restoration.

Patient -
Norwood 6, has fine, straight, thin calibre hair and low scalp laxity.

Pictures Sept 2006 (Pre op)

The patient visited us 1 week after his HT.
There was no koebner’s reaction in either the donor or the recipient areas.

The following pictures show these areas 7 days after his HT.
Donor area - 7 days post HT

Recipient area - 7 days post HT

The cuts during the procedure did not lead to a flaring up of psoriasis.

Regards,
Dr. A

[Dr_Arvind]

The patient underwent a test BHT session in Dec 2006.
He was undergoing treatment for psoriatic patches at the time. The aim was to see whether his psoriasis will get aggravated by harvesting from the body donor areas.

The body hair grafts were extracted from the chest and legs. They were transplanted in a bare, identifiable area of the scalp.

4 grafts were also extracted from the facial, chin area.

Recipient area for the BH test session

Facial donor area before extraction (Dec 2006)

Facial donor area immediately after extraction (Dec 2006)

Meanwhile, the scalp donor area from Sept 2006 had been healing uneventfully.
The picture below shows the scalp donor area strip scar of the patient in Dec 2006.

The following picture shows where the grafts were placed, in Dec 2006.

[Dr_Arvind]

Dear forum readers,
The patient revisited us in June 2007.

6 months after his test bht session, and 9 months after his strip FUHT session, he was happy with the progress and confident that the different hair transplant procedures (BHT, strip , FHT) were not effecting his psoriasis in a negative way.

He also did not notice any scarring in the facial donor areas.

This time, he underwent a 751 graft procedure. The grafts were extracted from facial/beard area, the chest, the scalp and the thighs. All the grafts were extracted using the FUSE techniques.

We hope to be able to follow up this case and post the future updates of his hair restoration journey.

This picture shows the comparative improvement from the first HT that the patient underwent in Sep 2006. It also shows that there has been no psoriatic invasion of the frontal scalp areas, even though they are now populated by the transplanted hair follicles.

The following picture is a close up of the donor strip scar, from his Sept 2006 procedure. We had a hard time locating it. This picture of the strip scar was taken in June 2007. If you look carefully, you can make out the scar’s location by the different angles of the hair in a line. For all practical purposes, the patient, nor his friends, can make out the location of the strip scar in everyday life even when the patient cuts his hair very short.
This picture also shows, once again, how the strip incision did not lead to a cropping up of psoriatic lesions.

The following picture shows the growth of the hair from the 1st and 2nd stage HTs ofthe patient, as well as the location of the grafts this time, in June 2007. Since, it is not yet 12 months post op, we expect further improvement in all the transplanted areas.

The following picture shows a forceps pointing out the transplanted body hair grafts from the Dec 2006 procedure.

The following is a comparative picture. You can see the difference in the calibre of the various donor hair.
For the June 2006 procedure, 1/3rd ofthe donor hair were derived from the beard areas.

The following 2 pictures show the facial donor area in June 2007.
The first picture shows the lack of scarring in the underchin area, from where 4 grafts were extracted in Dec 2006. The second picture shows the same area, and also shows the areas, on both sides of the face, from where the facial hair grafts were extracted this time, in June 2007.

Regards,
Dr. A

[Dr_Arvind]

Dear forum readers,

For sake of ease in reference, we shall allot the nickname AM to this patient.

In case you have any queries regarding the case of AM, anytime now, or in future, please use the nickname when reffering to the patient. That will make it easy for us to understand which particular case you are talking about.
Regards,
Dr. A

[marco]

» Dear forum readers,
»
» For sake of ease in reference, we shall allot the nickname AM to this
» patient.
»
» In case you have any queries regarding the case of AM, anytime now, or in
» future, please use the nickname when reffering to the patient. That will
» make it easy for us to understand which particular case you are talking
» about.
» Regards,
» Dr. A

Thank you Dr. A for this informative post. I have often felt that psoriatic lesions are somehow stimulated by grazing or grazing around a new wound rather than by a “sharp” trauma. That is just based on looking at a few freinds of mine and some loose biochemical ideas. The idea being that things go wrong where a fully coordinated inflammatory or immune response is not initiated and resolution is not fully competent.

The pic above shows 3000 fu after about 9 months. Why was the area revisited on one side only? The results do not seem that great compared with other examples we see. Do you think this is true?

Thanks,
Marco.

[wassup]

I have plaque psoriasis and pretty much can get it anywhere (typically not too often on the scalp though). Will be interesting to see if anyone chimes in as well. I’ve been on a variety of medicines throughout the years but have been doing enbrel injections for the past couple years. I don’t believe it has interfered with any of my surgeries (all of mine have been scalp donor not body hair). Interesting thread Dr. A.

» Dear forum readers,
» A question asked sometimes by prospective patients is
» — Can they undergo a hair transplant if they have Psoriasis?
» Will the surgery lead to a spread of the psoriatic lesions?
» If body hair grafts are used, will the cuts lead to flaring up of
» psoariasis in that area?
»
»
» We have performed hair transplants for quite a few patients, who also
» happened to be suffering from Psoriasis.
»
» However, I recently had an ocassion to meet and talk at quite some length
» to a past patient when he came for his repeat HT.
»
» Talking to him, I felt that there must be countless other readers who may
» benefit from a recounting of this patient’s experiences and an in depth
» discussion.
»
» I would request readers to post their queries in regards to psoriasis and
» hair transplants and fellow doctors to share their thoughts/experience.
»
» Regards,
» Dr. A
»
» P. S. - Some informative resources about Psoariasis.
» The National Psoriasis Foundation: National Psoriasis Foundation
»
» Psoriasis | Psoriatic Arthritis | MedlinePlus

[Dr_Arvind]

» The pic above shows 3000 fu after about 9 months. Why was the area
» revisited on one side only? The results do not seem that great compared
» with other examples we see. Do you think this is true?
»
» Thanks,
» Marco.

Dear Marco,
The patient has a large surface area and the donor hair quality is thin calibre and straight.
We, (the patient as well as us), do not expect dramatic transformation, given the hair characteristics. (3000 + curly, coarse hair grafts will give more coverage). But we can only use what is available.

The area where the grafts were placed in June 2007 was not transplanted in Sept 2006 (except for a few overlapping rows).

Regards,
Dr. A

[HairSite]

» I have plaque psoriasis and pretty much can get it anywhere (typically not
» too often on the scalp though). Will be interesting to see if anyone
» chimes in as well. I’ve been on a variety of medicines throughout the
» years but have been doing enbrel injections for the past couple years. I
» don’t believe it has interfered with any of my surgeries (all of mine have
» been scalp donor not body hair). Interesting thread Dr. A.

Same here, although mine was on the scalp only. I used Temovate and then later switched to DermaSmooth, both are corticosteroids based topicals, I believe. It did help to a certain extent. Eventually I realized that the culprit is the propylene glycol in Rogaine. I stopped using Rogaine entirely and my scalp has never felt healthier.

[gillenator]

» » I have plaque psoriasis and pretty much can get it anywhere (typically
» not
» » too often on the scalp though). Will be interesting to see if anyone
» » chimes in as well. I’ve been on a variety of medicines throughout the
» » years but have been doing enbrel injections for the past couple years.
» I
» » don’t believe it has interfered with any of my surgeries (all of mine
» have
» » been scalp donor not body hair). Interesting thread Dr. A.
»
»
» Same here, although mine was on the scalp only. I used Temovate and then
» later switched to DermaSmooth, both are corticosteroids based topicals, I
» believe. It did help to a certain extent. Eventually I realized that the
» culprit is the propylene glycol in Rogaine. I stopped using Rogaine
» entirely and my scalp has never felt healthier.

I have heard the same feedback from countless patients over the years that used a PG based minoxidil product. From my understanding, the new Rogaine foam does not contain it.

[helpmeout]

The foam is great, I just started using it, no itch. Highly recommended.