Scalp Pathology for the Hair Transplant Surgeon: Donor vs. Recipient Dominance:

Bernard Nusbaum, M.D.
Miami, Florida

I highly recommend as a fascinating read Dr. Orentreich’s original article (Orentreich, N. Autografts in Alopecias and Other selected Dermatologic Conditions. Ann. N.Y. Acad. ScI; 83: 463-479, 1959).

While reading this paper you feel as if you are experiencing history being made as Dr. Orentreich meticulously describes his original observations with punch autografts. Things that we take for granted, such as crusting, shedding of hairs from the hair-bearing grafts (sometimes attached to the crusts); and, finally the regrowth of hair 2 to 3 months after the procedure are described in detail as they were being observed for the first time.

Obviously, the finding of historic proportions was that androgenetic alopecia (AGA) was “donor dominant” and with regards to hair transplants, as they say; “the rest is history”.

Interestingly, the article also describes autografts in several dermatologic conditions as being “donor” or “recipient” dominant. When the grafted skin maintained its characteristics independent of the recipient site it was determined to be “donor dominant” and when the transposed grafted skin assumed the characteristics of the recipient site it was termed “recipient dominant”.

This table is taken from Dr. Orentreich’s article.

Characteristic Autograft Dominance in Dermatological Conditions Studied to Date
Alopecia prematura	Donor
Alopecia areata	Donor
Alopecia cicatrisata	Donor
Hair growth cycle	Donor
Localized amyloidosis	Donor
Vitiligo	Recipient
Allergic eczematous dermatitis	Recipient
Fixed drug eruption	Recipient
Lupus erythematosus	Recipient
Morphea	Recipient
Acrodermatitis atrophicans	Recipient
Psoriasis	Isomorphic response

The following results are of particular interest to the hair transplant surgeon.

Alopecia Areata: In 5 of 9 cases there was “partial” donor dominance. Unlike with AGA, only sparse and weak hair growth resulted in hair hearing grafts that were transplanted to alopecic areas (obviously, the inflammatory process does not discriminate between transplanted and non-transplanted hair). Classical alopecia areata is easy to recognize as a patchy, non-scarring alopecia. We must take notice, however, that this condition can rarely present in a diffuse variant that clinically mimics androgenetic alopecia. In cases of diffuse alopecia areata, the only way to make a definitive diagnosis is by performing a scalp biopsy and these patients should not be transplanted.

Scarring Alopecia: 2 cases showed “relative” donor dominance with growth of sparse hair. One case grew excellent terminal hair indicating “complete” donor dominance. (Perhaps, the cases with only sparse growth were still in an “active” inflammatory stage. Scarring alopecia should be transplanted only when the process is inactive for 12 months).

Psoriasis: In the only patient studied 4 grafts were performed and all 4 became psoriatic. It was felt that this occurred because the grafts developed an isomorphic response, also known to dermatologists as the “Koebner phenomenon”. This occurs in certain dermatologic entities (psoriasis included) whereby trauma to normal skin elicits the development of the disease process at the site of the trauma. (I have transplanted several psoriatics and have not encountered this problem. Perhaps the systemic steroids that we administer for edema have an effect in controlling the process).

As an aside, it is my opinion that the presence of scalp psoriasis should be recognized by history or physical examination at the time of the consultation and the patient should be placed on a strict treatment regimen at least 2 weeks prior to the transplant procedure to assure that the scalp is in good condition at the time of the surgery.

Vitiligo: Two patients were studied and both showed “recipient dominance”. Pigmented skin to vitiligo skin because vitiligious and vitiligo skin to pigmented skin became pigmented. (In my experience of transplanting one vitiligo patient, grafts with pigmented hairs were transferred to vitiligious recipient areas and subsequently grew depigmented hairs!) Also, dermatologic texts list vitiligo as one of the entities that exhibit the Koebner phenomenon.

I feel that knowledge of scalp pathology is an important aspect of a “well-rounded” hair restoration surgeon. It should be noted that between sessions of the ISHRS meeting in Puerto Vallarta the projection screen read: “Doctors Specializing in the Treatment of Hair Loss” and without a doubt, an increasing number of patients with different alopecias and scalp conditions are presenting to the hair transplant specialist. I hope that the readers will enjoy this column and that the information presented will make us more confident when dealing with these patients.