Dupa and bupa, definition and treatment, an article by Dr. Jose Lorenzo

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1908
dupa e bupa

It was anatomist James Hamilton, in 1949, after studying 312 men and 104 eunuchs, who first observed the relationship between:

  • Androgens
  • Genetic predisposition and age.

In 1951 Hamilton published the article: “Patterns of hair loss in men: types and incidence” introducing the classification of the various types of male pattern baldness.

In 1975 O’Tar Norwood, after studying more than 1000 patients, published the article, “Pattern of male pattern baldness: classification and incidence.”

Norwood used Hamilton’s classification of baldness as a basis, aggregating the “type a” variant

At the end of his article Norwood says, “the possible variations of androgenetic alopecia are endless. Classification of the minor forms of it would not only be impossible but would reduce the very usefulness of classification.”

 

Diffuse unpatterned alopecia (dupa)

This type is characterized by a general decrease in hair density, which does not follow any specific pattern although many times it is more marked in the frontal and upper area. This type of alopecia is common in women.

 

Diffuse patterned alopecia (dpa)

this typology is quite similar in evolution to the classic pattern of male baldness with the only difference that the areas involved do not become totally bald and there is only a decrease in hair density.

 

Male pattern baldness with persistent central bridge

(FORELOCK): is characterized by an evolution of baldness similar to that described in the Norwood scale but with a central bridge of hair (forelock) that is not subject to fall.

SENILE ALOPECIA: Occurs in both men and women with aging. The role played by androgens in this type of alopecia is uncertain. In senile alopecia, the decrease in density involves not only the top and sides but the entire scalp.

Bernstein and Rassman covered the topic of DUPA in 2002 when they were studying the FUE technique.

 

DUPA, the studies of the two leading physicians

The presence of DUPA in men and women is a important contraindication for hair transplantation in general and for surgery using the FUE technique. A patient with DUPA will have only temporary results because the transplanted hair will succumb to the androgenetic condition and therefore fall out in the course of a short time.

Dr. Lorenzo has dedicated himself exclusively to FUE since 2003. During the first years of his activity he didn’t pay much attention to the donor area, but some unsuccessful cases led him to try to understand what the negative results were due to, not justifying them only with the famous X factor.

Dr. Lorenzo began to perform biopsies of the scalp in patients who had negative results and discovered the presence of androgenetic alopecia in the donor area.

One of the cases is that of this patient, 45 years old with diffuse baldness, who did not follow treatments. The caliber of the hair was 45 microns, the follicular units were easily transected (damaged during extraction) and the follicles were small in size.

2661 follicular units were grafted and the result was not completely satisfactory. After 1 year, the patient began to lose transplanted hair in the recipient area and also worsen in the donor area.

A biopsy was performed which confirmed the presence of androgenetic alopecia. Dr. Lorenzo decided to treat the patient with Finasteride. After 1 year, the donor area of the patient improved and it was possible to perform a new intervention whose results lasted over time.

Dr. Lorenzo began to study in detail the donor area of his patients focusing on the miniaturization, the number of single units present in the donor, the number of hairs per cm2 and the number of hairs per follicular unit, thanks to the use of the USB microscope, the Dermalite and the Hair Counter.

This allowed him to draw guidelines regarding the identification and treatment of patients with androgenetic alopecia in the donor area.

 

A patient who has DUPA has more than 15% miniaturized hair in the donor area and one or more of the following features

  • Alopecia of diffuse type in the upper part of the scalp in the majority of cases with intact hairline and frontal areas
  • Less than 2 hairs per follicular unit in the temporal and parietal areas
  • Less than 130 hairs per cm2 in the temporal and parietal areas
  • More than 20% single follicular units
  • You can clearly see the scalp in the temporal and parietal zones
  • Different hair characteristics in the temporal, occipital and sideburn areas, with these two areas showing better coverage than the rest of the donor
  • Normal follicular units mixed with miniaturized follicular units in donor area

 

Dr.Lorenzo has developed a protocol for considering a patient presenting with DUPA as a candidate for surgery.

  • The patient must understand that consistently following a finasteride treatment is essential to undergo surgery. Finasteride treatment usually works better and allows for better stabilization in the donor area than in the recipient
  • The patient must understand that he has an unstable donor area. He must follow the finasteride treatment for at least 1 year and show signs of stabilization of alopecia to be able to operate
  • Medical treatment consists of taking finasteride although dutasteride is an option.

 

Dr.Lorenzo believes he can treat patients who present with DUPA and are happy to follow the drug treatment. Patients who follow the treatment without any problems are trustworthy and you can be assured that they will not abandon the treatment.

The doctor believes that a patient presenting with DUPA stabilized pharmacologically with the use of finasteride or dutasteride can have in the long term an evolution similar to a subject presenting only the classic evolutionary process of male pattern baldness and this constitutes a reason to be able to treat surgically patients with DUPA.

The donor area of a subject with DUPA presents 2 types of follicular units, the miniaturized ones and the almost normal ones, the latter should be the target of FUE harvesting.

90% of women present DUPA and are candidates for surgery and this is also true for men who present DUPA and follow a pharmacological treatment to stabilize it.

Dr. Lorenzo has been treating patients with DUPA since 2010 and believes that they too can have a good result in the short and long term.

Dr. Lorenzo then coined a new term HIDDEN DUPA (hidden dupa).

With HIDDEN DUPA we refer to patients with diffuse alopecia, who have miniaturization in the donor area, but who appear normal from a macroscopic point of view thanks to the medical treatment they are following (Finasteride/Dutasteride).

Great care must be taken in patients with hidden DUPA. If these patients have surgery and discontinue drug treatment they may end up losing their transplanted hair.

In 2013, Dr.Bisanga presented a paper at the ISHRS congress on donor area miniaturization, explaining how patients with a pattern of androgenetic alopecia could present this situation. Dr. Bisanga concluded his report by explaining how a patient with 25% miniaturization in the donor area could not be considered a suitable candidate for a hair transplant.

Dr. Bisanga and Dr. Lorenzo had the opportunity to discuss the subject a couple of years ago during a congress and both realized that Norwood had never described a type of male androgenetic alopecia with miniaturization of the donor area.

In fact, Dupa is a diffuse alopecia with miniaturization of the recipient area but without any bald areas and is not represented by any of the situations depicted in the Norwood scale.

Norwood in his famous article indicated how: “the possible variations of androgenetic alopecia are infinite. The classification of minor forms would not only be impossible but would reduce the very usefulness of the classification”.

However, it must be said that the number of patients with androgenetic alopecia and miniaturization of the donor area is quite high, it is not a rare type of baldness but a “well-defined variation” that deserves to be described and to be differentiated from DUPA, with which were classified all the cases that presented miniaturization of the donor area without considering the situation of the recipient area.

It should be considered that Hamilton and Norwood did not have the instruments now used to evaluate the donor area and establish the possible degree of miniaturization.

We can therefore define BUPA (Bald Unpatterned Alopecia) and differentiate it from DUPA.

 

DUPA, the conclusions

Generalized decrease in hair density in male and female patients that does not follow a specific pattern and is characterized by the presence of a degree of miniaturization of the donor area of more than 15% associated with one or more of these factors:

  • The patient retains most of the hairline
  • The patient has less than 2 hairs per follicular unit in the temporal and parietal area
  • The patient has less than 130 hairs per cm2 in the temporal and parietal areas
  • The patient has a donor area composed of more than 20% single follicular units
  • The patient has a thinning donor area in the parietal and temporal area, scalp can be seen
  • The patient has different hair quality in temporal, occipital and sideburns areas
  • The patient has normal and miniaturized follicular units in donor area with different percentages

 

BUPA, conclusions

Describes the situation of a patient suffering from androgenetic alopecia and whose type of baldness falls within the Norwood Hamilton classification but presenting more than 15% miniaturization in the donor area in addition to one or more of the following characteristics:

  • Less than 2 hairs per follicular unit in temporal and parietal area
  • Less than 130 hairs per cm2 in temporal-parietal area
  • More than 20% single follicular units in donor area
  • Thinned donor area in temporal and parietal area (scalp can be seen)
  • Different hair characteristics in temporal, occipital and sideburn area
  • Normal and miniaturized follicular units in donor area, in different percentages

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