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Scalp Skin Disorders
1) Seborrheic
Dermatitis
A)
Dandruff
B)
Seborrhea
C)
Seborrheic
Dermatitis
D)
Relevance to Hair
Transplantation
2) Psoriasis
Relevance
to Hair
Transplantation
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).
1) 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.
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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.
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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.
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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.
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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.
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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.
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2) 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.
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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.
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