Surgical correction of cicatricial alopecia can yield exceptional results when performed in the appropriate clinical scenario. To facilitate determination of the most suitable corrective therapy, we propose two new categories of cicatricial alopecia: "unstable" and "stable." Unstable cicatricial alopecia is intermittent and results in possible subsequent scarring hair loss in either new or old areas. Stable cicatricial alopecia, on the other hand, refers to fixed permanent scarring. While surgical excision is preferred to hair transplantation for both categories of cicatricial alopecia, this preference is even stronger in cases of unstable cicatricial alopecia due to its intermittent and progressive nature. Regardless of which corrective technique is used, analysis of specific physical patient characteristics coupled with a careful view towards the possible evolution of male pattern baldness or female pattern hair loss are essential to achieve superior long-term results. Herein we also outline guidelines for identifying these physical traits as well as for performing hair transplantation and surgical excision in order to achieve optimal cosmetic outcomes and minimize postoperative complications.

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IMPORTANCE Persistent radiation-induced alopecia (pRIA) and its management have not been systematically described.OBJECTIVE To characterize pRIA in patients with primary central nervous system (CNS) tumors or head and neck sarcoma. DESIGN, SETTING, AND PARTICIPANTSA retrospective cohort study of patients from January 1, 2011, to January 30, 2019, was conducted at 2 large tertiary care hospitals and comprehensive cancer centers. Seventy-one children and adults diagnosed with primary CNS tumors or head and neck sarcomas were evaluated for pRIA. MAIN OUTCOMES AND MEASURESThe clinical and trichoscopic features, scalp radiation dose-response relationship, and response to topical minoxidil were assessed using standardized clinical photographs of the scalp, trichoscopic images, and radiotherapy treatment plans. RESULTSOf the 71 patients included (median [range] age, 27 [4-75] years; 51 female [72%]), 64 (90%) had a CNS tumor and 7 (10%) had head and neck sarcoma. Alopecia severity was grade 1 in 40 of 70 patients (56%), with localized (29 of 54 [54%]), diffuse (13 of 54 [24%]), or mixed (12 of 54 [22%]) patterns. The median (range) estimated scalp radiation dose was 39.6 (15.1-50.0) Gy; higher dose (odds ratio [OR], 1.15; 95% CI, 1.04-1.28) and proton irradiation (OR, 5.7; 95% CI, 1.05-30.8) were associated with greater alopecia severity (P < .001), and the dose at which 50% of patients were estimated to have severe (grade 2) alopecia was 36.1 Gy (95% CI, 33.7-39.6 Gy). Predominant trichoscopic features included white patches (16 of 28 [57%]); in 15 patients, hair-shaft caliber negatively correlated with scalp dose (correlation coefficient, −0.624; P = .01). The association between hair density and scalp radiation dose was not statistically significant (−0.381; P = .16). Twenty-eight of 34 patients (82%) responded to topical minoxidil, 5% (median follow-up, 61 [interquartile range, 21-105] weeks); 4 of 25 (16%) topical minoxidil recipients with clinical images improved in severity grade. Two patients responded to hair transplantation and 1 patient responded to plastic surgical reconstruction.CONCLUSIONS AND RELEVANCE Persistent radiation-induced alopecia among patients with primary CNS tumors or head and neck sarcomas represents a dose-dependent phenomenon that has distinctive clinical and trichoscopic features. The findings of this study suggest that topical minoxidil and procedural interventions may have benefit in the treatment of pRIA.

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Fluid through the epidural needle does not reduce complications of epidural catheter insertion