•MEETING UM60 - 2016

FEMALE HAIR LOSSFEMALE HAIR LOSS
The diagnosis & managementThe diagnosis & management
is easier than you think!is easier than you think!
Bernard Cohen, MDBernard Cohen, MD
VOLUNTARY CLINICAL PROFESSORVOLUNTARY CLINICAL PROFESSOR
UNIVERSITY OF MIAMI SCHOOL OF MEDICINEUNIVERSITY OF MIAMI SCHOOL OF MEDICINE
JANUARY 16, 2016JANUARY 16, 2016
MIAMI BEACH, FLMIAMI BEACH, FL

DISCLOSUREDISCLOSURE
Dr. Cohen owns the patents, and receives royaltiesDr. Cohen owns the patents, and receives royalties
on hair mass measuring technologies.on hair mass measuring technologies.

In a general dermatology practice...In a general dermatology practice...
90% of women presenting with hair loss have:90% of women presenting with hair loss have:
ThinningThinning REDUCTION IN DIAMETERREDUCTION IN DIAMETER
SheddingShedding REDUCTION IN DENSITYREDUCTION IN DENSITY
BreakageBreakage RARELY A COMPLAINTRARELY A COMPLAINT
AND A SCALP BIOPSY IS NOT REQUIREDAND A SCALP BIOPSY IS NOT REQUIRED
TO MAKE THE DIAGNOSISTO MAKE THE DIAGNOSIS

FOUR STEPSFOUR STEPS
1. Make the diagnosis1. Make the diagnosis
Combinations frequently existCombinations frequently exist
2. Establish baselines2. Establish baselines
““How much hair” is present before treatmentHow much hair” is present before treatment
3. Choose a treatment3. Choose a treatment
4. Manage with measureable feedback4. Manage with measureable feedback
““MEASUREABLEMEASUREABLE”” FEEDBACK =FEEDBACK = ““EVIDENCE-BASEDEVIDENCE-BASED””

1. MAKE DIAGNOSIS1. MAKE DIAGNOSIS
HistoryHistory
Physical examPhysical exam
Smart phone micro-imageSmart phone micro-image
Lab studiesLab studies
2. ESTABLISH BASELINES2. ESTABLISH BASELINES
Smart phone clinical photographSmart phone clinical photograph
Hair mass measurementHair mass measurement
3. CHOOSE TREATMENT3. CHOOSE TREATMENT
4. MANAGE TREATMENT4. MANAGE TREATMENT

HISTORY– ThinningHISTORY– Thinning
Ask about:Ask about:
Family historyFamily history
Irregular mensesIrregular menses
Facial hairFacial hair
Hormone therapyHormone therapy
MenopauseMenopause
Inability to conceiveInability to conceive
PCOPCO

HISTORY– SheddingHISTORY– Shedding
Delivery -- BCP discontinuationDelivery -- BCP discontinuation
Change in hormone therapyChange in hormone therapy
MedicationsMedications
Thyroid abnormalityThyroid abnormality
Iron deficiencyIron deficiency
SLESLE
Weight lossWeight loss
General anesthesiaGeneral anesthesia
Vitamin DVitamin D

HISTORY– BreakageHISTORY– Breakage
Long hairLong hair
Curly hairCurly hair
Fine hairFine hair
Hair styleHair style
Chemical processingChemical processing
Pony tail appliancesPony tail appliances
Hot dryers, irons & rollersHot dryers, irons & rollers

PHYSICAL EXAMPHYSICAL EXAM RULE OUT THE “UNCOMMON 10%”RULE OUT THE “UNCOMMON 10%”
Frontal fibrosing alopeciaFrontal fibrosing alopecia
Diffuse and patchy AADiffuse and patchy AA
SLE, infection, inflammationSLE, infection, inflammation
Scarring alopecias, etc.Scarring alopecias, etc.
BIOPSY MIGHT BE REQUIREDBIOPSY MIGHT BE REQUIRED

PHYSICAL EXAM– ThinningPHYSICAL EXAM– Thinning
PART - Xmas treePART - Xmas tree
DISTRIBUTION - Horseshoe retentionDISTRIBUTION - Horseshoe retention

PHYSICAL EXAM– SheddingPHYSICAL EXAM– Shedding
PART -- Widened but no Xmas treePART -- Widened but no Xmas tree
DISTRIBUTION -- Generalized, no horseshoeDISTRIBUTION -- Generalized, no horseshoe
PULL TEST -- PositivePULL TEST -- Positive

PHYSICAL EXAM– BreakagePHYSICAL EXAM– Breakage
SLIDE DISTALLY ALONG PONYTAIL GRASP 6-10 HAIRSSLIDE DISTALLY ALONG PONYTAIL GRASP 6-10 HAIRS
Look for drop outs Try to break the bundleLook for drop outs Try to break the bundle

Handyscope deviceHandyscope device
MICRO-IMAGINGMICRO-IMAGING
Uses Iphone Lens + LED light Archival softwareUses Iphone Lens + LED light Archival software

SHEDDINGSHEDDING
HAIRS ARE THE SAME DIAMETER, BUT FEWERHAIRS ARE THE SAME DIAMETER, BUT FEWER

THINNING
WIDE RANGE OF DIAMETERSWIDE RANGE OF DIAMETERS
FOLLICULAR UNITS ARE PREDOMINATELY SINGLE HAIRFOLLICULAR UNITS ARE PREDOMINATELY SINGLE HAIR

Picture of ourPicture of our
Lab slip
STANDARDIZED “HAIR-RELATED” REQUISITION FORMSTANDARDIZED “HAIR-RELATED” REQUISITION FORM
Thinning will be diagnosed by micro-imaging.Thinning will be diagnosed by micro-imaging.
Blood tests are needed to screen for shedding, which frequently co-exists.Blood tests are needed to screen for shedding, which frequently co-exists.

LABORATORY– SheddingLABORATORY– Shedding
TSH & T4
Anti thyroid antibodies
Ferritin – must be mid range
ANA
Vitamin D3

LABORATORY- ThinningLABORATORY- Thinning
DHEAS
Free testosterone
Total testosterone

BASELINEBASELINE
Clinical photograph using same SmartphoneClinical photograph using same Smartphone

ABSTRACT
Background: Hair loss affects millions worldwide. At
present, most dermatologists use simple, non-
quantitative methods to monitor hair loss progression
and response to treatment, with an emphasis on density
alone. However, the diameter of the hair fibers also
contributes greatly to the appearance of hair.
Objective: Evaluate the accuracy and sensitivity of a
cross-section trichometer (the HairCheck® device), a
simple, hand-held device that measures hair mass
influenced by both density and diameter.
Materials and Methods: Using surgical silk and cut
human hair, we analyzed the correlations between the
HairCheck® readings, the number and diameter of
strands, and the bundle dry weight.
Results: Direct correlations were observed between a
bundle’s cross-sectional area, displayed as the Hair
Mass Index (HMI), the number of strands, fiber diameter,
and bundle dry weight.
Conclusion: Cross-Section Trichometry (CST), the
HairCheck® System and its methodology to determine
the HMI, may provide a quick and accurate tool to
assess progressive alopecia and treatment response in
the clinic.
CONCLUSIONS
• Direct correlations were observed between the
bundle’s cross-sectional area, displayed as the Hair
Mass Index (HMI), the number of strands, the silk/hair
diameter, and the bundle dry weight. Therefore, HMI is a
meaningful measure of the hair mass.
• We have given the name Cross-Section Trichometry
(CST) to the trichometer system and its methodology.
CST is a simple modality that can quickly and accurately
measure the cross-sectional area of a bundle of hair, and
converts it to HMI for display.
REFERENCES
ACKNOWLEDGMENTS
• Arnold J. Hair mass index. 4th Annual Congress European
Society of Hair Restoration Surgery Barcelona 2001.
• Cohen B. The cross-section trichometer: a new device for
measuring hair quantity, hair loss, and hair growth. Dermatol
Surg 2008;34:900-10; discussion 10-1.
• Hendriks MA, Geerts PA, Dercksen MW, van den Hurk CJ ,
Breed WP. Evaluation of Cohen's Cross-Section Trichometer
for Measuring Hair Quantity. Dermatol Surg 2012. [Epub]
Cross-Section Trichometry, A Clinical Tool
for Assessing the Progression and Treatment Response of Alopecia
Joaquin J. Jimenez, Tongyu Cao Wikramanayake, Lucia M. Mauro, Irene A. Tabas,
Anne L. Chen, Isabel C. Llanes, Lawrence A. Schachner
Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL
EXPERIMENTAL PROCEDURES
TCW is the recipient
of a Career
Development Award
from NIH/NIAMS
(AR050487).
RESULTS
RESULTS
INTRODUCTION
Figure 3. Cross-Section Trichometry (CST) of surgical
silk. (a) Correlation between the number of 5-0 strands
and Hair Mass Index (HMI). (b) CST of mixed silk
strands of different types/diameters. (c) Correlation
between HMI, the number of strands, and bundle weight.
c
87
79
72
64
57
50
49
35
30
25
21
16
11
0
10
20
30
40
50
60
70
80
90
100
HMI
ba
2
11
21
29
38
51
55
63
0
10
20
30
40
50
60
70
0 20 40 60 80 100120140 160180
HMI
Number of Silk Strands
r=0.9969
31 34
40 43
50
55 58
65.3
80.282.8
88.6
97.499.4
105.3
0
20
40
60
80
100
120
80 90 100 110 120 130 140 150 160
HMI
Number of Silk Strands
Weight(0.01g)
r=0.9953
r=0.9656
Type
Number of Surgical Silk Strands
3-0 80 60 40 20
4-0 20 40 60 80 60 40 20
5-0 20 40 60 80 60 40 20
6-0 20 40 60 80
Figure 4. Cross-
Section Trichometry
of bundles of cut
human hair using the
HairCheck® device.
Shown is correlation
between the HMI, the
number of hair
strands, and bundle
weight.
23 24 25 27 28 29 30 31 32
48.2
50.9 52.3
55.2 55.8 57.4
59.1
62.0
64.7
0
10
20
30
40
50
60
70
310 320 330 340 350 360 370 380 390 400 410
HMI
Number of Hair Strands
Weight(0.01g)
r=0.9959
r=0.9874
Applications of Cross Section Trichometry:
• Early detection of non-visible hair loss.
• Progression of hair loss.
• Evaluation of response to hair loss treatments (drugs,
devices and over-the-counter products).
• For hair transplantation, CST in the donor area during
initial consultation will help develop realistic
expectations.
• Assess hair breakage.
a b
c
d
e
mm
0 1 2 3 4 5
Figure 1. For assays of hair
density, any hair with a diameter
of greater than 30µm is counted
as one hair without consideration
of the variation in hair diameter.
But for conditions such as
androgenetic alopecia, the hair
diameter varies greatly (left).
• Currently, most dermatologists use simple, non-
quantitative methods to evaluate alopecia, with an
emphasis on hair density alone.
• Small decreases in hair density are not easily detected
by the naked eye, e.g., in global photographs.
• In addition to density, the diameter of hair fibers also
contributes greatly to the appearance of hair mass.
Figure 2. The HairCheck® System consists of a locating
strip (a,b) attached to a pair of eyeglasses (a) and the
measuring device (c,d). A four-legged template is
placed on a numbered tab of the locating strip (b) to
mark the sample site, and the tab number is recorded to
allow return to the same site for future measurements.
The measuring device is hand-held and transmits a pre-
determined load to a bundle of hair (at least 2.5 cm [1
inch] in length) captured by a J-slot (c, d, e). The hair
can be of any type, from super fine to very coarse.
Obtaining the Hair Mass Index (HMI): Bundles of
surgical silk or cut human hair were placed in the J-slot
of the measuring device (c). When the lever arm is
squeezed (d), the cross sectional area of the bundle is
instantaneously displayed as the HMI on the device’s
LED screen and expressed as: mm2 of hair per cm2 of
scalp x 100, rounded up to the closest integer.
All details & published data @All details & published data @ www.howtomeasurehair.comwww.howtomeasurehair.com
SIMULTANEOUSLY MEASURE DENSITY & DIAMETERSIMULTANEOUSLY MEASURE DENSITY & DIAMETER

•
b
EXPERIMENTAL PROCEDURES
a b
c
d
e
Figure 2. The HairCheck® System consists of a locating
strip (a,b) attached to a pair of eyeglasses (a) and the
measuring device (c,d). A four-legged template is
HAIR MASS MEASUREMENT

THETHE DEVICEDEVICE MEASURES THE CROSS SECTIONALMEASURES THE CROSS SECTIONAL
AREA ON THE HAIR.AREA ON THE HAIR.
THETHE TEMPLATETEMPLATE MEASURES THE CROSS SECTIONALMEASURES THE CROSS SECTIONAL
AREA ON THE SCALPAREA ON THE SCALP
A single numeric value = mmA single numeric value = mm22
of hair per cmof hair per cm22
of scalpof scalp

So... In the treatment period... If
THE DIAMETERS GET BIGGER OR SMALLER
OR
THE DENSITY GETS HIGHER OR LOWER
The value displayed on the LED screen
will reflect those changes.
SENSITIVITY
Device can detect a change of 3 hairs in a bundle of 600 hairs.

HistoryHistory
3.3. CHOOSE TREATMENTCHOOSE TREATMENT
4. MANAGE TREATMENT4. MANAGE TREATMENT

TREATMENTTREATMENT
SHEDDINGSHEDDING
Review blood test resultsReview blood test results
Correct deficiencies and abnormalitiesCorrect deficiencies and abnormalities
Refer patient to appropriate specialistRefer patient to appropriate specialist
If physiologic, re-assure patient ofIf physiologic, re-assure patient of
expected return to normalexpected return to normal

TREATMENTTREATMENT
THINNINGTHINNING
MINOXIDILMINOXIDIL multiple formulationsmultiple formulations
LOW INTENSITY LASERLOW INTENSITY LASER
FINASTERIDEFINASTERIDE
PRPPRP
SPIRONOLACTONESPIRONOLACTONE
BIOTINBIOTIN

HistoryHistory
3. CHOOSE TREATMENT3. CHOOSE TREATMENT
4.4. MANAGE TREATMENTMANAGE TREATMENT

MANAGEMENTMANAGEMENT
Same for shedding & thinningSame for shedding & thinning
Use Hair Mass MeasurementUse Hair Mass Measurement
(CROSS SECTION TRICHOMETRY)(CROSS SECTION TRICHOMETRY)
to guide your management decisions.to guide your management decisions.
Casual photography is of value, but is not evidence-based.Casual photography is of value, but is not evidence-based.
It is too imprecise and does not generate measureable data.It is too imprecise and does not generate measureable data.
If less than 50% of the hair has been lost -If less than 50% of the hair has been lost -
the underlying skin will not be visible to the eye (or camera).the underlying skin will not be visible to the eye (or camera).

EXAMPLESEXAMPLES
HAIR LOSSHAIR LOSS
MANAGEMENTMANAGEMENT

DOCTOR, I THINK I’M LOSING MY HAIRDOCTOR, I THINK I’M LOSING MY HAIR
92-72/92 = 22%92-72/92 = 22%
SHE HAS A 22% LOSS (THINNING) WHICH CANNOTSHE HAS A 22% LOSS (THINNING) WHICH CANNOT
BE SEEN VISUALLY, OR ON CAMERABE SEEN VISUALLY, OR ON CAMERA
7272
9292

BASELINEBASELINE
She chooses toShe chooses to
postpone treatmentpostpone treatment
49497272 6767
12 MONTHS LATER12 MONTHS LATER
She is 7% worseShe is 7% worse

BASELINEBASELINE
She chooses to startShe chooses to start
laser therapylaser therapy
49496767 7575
She’s only 10% improvedShe’s only 10% improved

BASELINEBASELINE
She’s dissatisfied and agreesShe’s dissatisfied and agrees
to add MNX to her laser therapyto add MNX to her laser therapy
49497575 8181
She has a 7% improvementShe has a 7% improvement
with combination therapywith combination therapy

BASELINEBASELINE
But the MNX is too difficult to applyBut the MNX is too difficult to apply
bid, she wants to apply qd.bid, she wants to apply qd.
49498383 8282
Surprisingly she isSurprisingly she is
no worseno worse

5 MONTHS AFTER5 MONTHS AFTER
CHILDBIRTHCHILDBIRTH
Patient is actively shedding and frantic.Patient is actively shedding and frantic.
She is re-assured and not treated.She is re-assured and not treated.
49495555 7777
12 MONTHS AFTER12 MONTHS AFTER
CHILDBIRTHCHILDBIRTH
She is 30% improvedShe is 30% improved
And almost back to normalAnd almost back to normal

BASELINEBASELINE
A low ferritin and Vitamin DA low ferritin and Vitamin D
are picked up on blood screening.are picked up on blood screening.
Treatment is commenced.Treatment is commenced.
49497979 8686
She is 9% improved afterShe is 9% improved after
one year.one year.

IS IT DIFFUSEIS IT DIFFUSE OROR PATTERN HAIR LOSS?PATTERN HAIR LOSS?
(occiput & mid scalp essentially equal)(occiput & mid scalp essentially equal)
CONCLUSION = Hair Loss is DIFFUSE not PATTERNCONCLUSION = Hair Loss is DIFFUSE not PATTERN
6262
6464

BASELINEBASELINE
Patient reluctantly startsPatient reluctantly starts
minoxidil for thinning.minoxidil for thinning.
49496565 7979
““Doc, I don’t think theDoc, I don’t think the
minoxidil is working.”minoxidil is working.”

www.howtomeasurehair.comwww.howtomeasurehair.com

IS IT DIFFUSEIS IT DIFFUSE OROR PATTERN HAIRPATTERN HAIR
LOSS?LOSS?
(occiput & mid scalp essentially equal)(occiput & mid scalp essentially equal)
6868 6767

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