S10 MEETING PATIENTS' EXPECTATIONS: A PROPOSED ALGORITHM FOR INDICATIONS AND ALTERNATIVES
Shapiro J
Division of Dermatology, Faculty of Medicine, University of British Columbia, Vancouver, Canada

The male and female patient with pattern hair loss need appropriate counselling for the most suitable customized treatment plan. This is based on patient's age, extent of hair loss, occipital donor area density, and budget available. Realistic expectations need to be addressed with the intent of ensuring the patient understands what can be accomplished with either medical or surgical therapy or the additive effect of the combination. For most men with a Norwood-Hamilton Stage III-V, a combination of both medical and surgical approaches works best. Both the use of topical minoxidil solution or systemic finasteride in combination with follicular unit transplantation usually give a robust long lasting result. Although regrowth is attainable with both minoxidil and finasteride, the results usually are mild to moderate. Dense regrowth is possible but not frequent. Medical therapy is crucial as a means of preventing further hair loss. Follicular unit transplantation will usually give a more dramatic effect reliably. However, the surgical approach alone may not produce the long lasting results expected, as it is likely the hairs between the grafts will miniaturize over time. Surgical management is usually reserved for those men over 25 years of age. For women, androgen excess should be ruled out. An appropriate endocrine workup is indicated only if there are clinical signs. The use of topical minoxidil solution is usually first line therapy and has a 63% chance of regrowth and stabilization. The adjunctive use of anti-androgen therapy in combination with the appropriate oral contraceptive are options to be addressed particularly if there is a documented androgen excess. The female patient must have significant anterior or mid-frontal hair loss to consider follicular unit transplantation. Transplanting one thousand follicular units will only be appreciated by women of at least a Ludwig Stage II severity. Women with Ludwig Stage III, rarely have an adequate occipital donor area and both medical and surgical therapy are not strong options. Cosmetic camouflage may be the best alternative for these advanced cases.