The Mirror Moment That Changed Her Thinking

Eleojo first noticed thinning around the edges of her hair. Life was busy and stressful, and the pandemic was underway, so she initially thought stress might explain what she was seeing. During that period, she was working from home, an unusual arrangement for a surgeon.

One day she walked past a mirror and realized she could see through her hair. “That really disturbed me,” she recalls. She could also see her scalp shining. For Eleojo, the change suggested something beyond ordinary shedding. “This might be a scarring alopecia,” she remembers thinking.

Symptoms She Had Previously Dismissed

Looking back, Eleojo recognized that she had also experienced itching and a burning sensation. At times, she says, cold air or wind made her scalp and even the roots of her hair hurt. She had not initially connected those sensations with the changes in her hair.

The combination of visible thinning and an itchy scalp with hair loss made the situation harder to dismiss. Her description is personal: it explains what she experienced, rather than establishing that every person with similar symptoms has the same condition.

Why Hair Restoration Training Mattered

Eleojo says she questioned herself and felt that her general practitioner did not understand what she was describing. In her view, basic medical training in England offered limited exposure to hair conditions. Her own training in hair restoration gave her the confidence to insist on a referral to a dermatologist, which she received.

Dr. Umar responds to her account by observing that, in the language of hair loss, a shiny scalp is concerning. Eleojo agrees. Their exchange highlights the moment she moved from attributing the changes to stress toward seeking a specialist assessment, without claiming a diagnosis can be made from appearance alone.

Eleojo’s account ends here with the referral and the discussion of what she noticed. The next chapter of her story remains for the series to tell.

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Condition or treatment page: [[ADD CONDITION PAGE URL]].

Medical Disclaimer

This article describes one person’s experience and is for educational purposes only. It is not a diagnosis or a substitute for individualized medical advice. Symptoms and treatment needs vary; consult a qualified clinician for assessment.

Further Reading

1. https://dru.com/eleojo-lichen-planopilaris-pattern-baldcast/
2. Umar S, Kan P, Carter MJ, Shitabata P, Novosilska M. Lichen Planopilaris Responsive to a Novel Phytoactive Botanical Treatment: A Case Series. Dermatol Ther (Heidelb). 2022 Jul;12(7):1697-1710. doi: 10.1007/s13555-022-00749-3. Epub 2022 Jun 8. PMID: 35674981; PMCID: PMC9276860.
   https://pmc.ncbi.nlm.nih.gov/articles/PMC9276860/

The post Video: Lichen Planopilaris: Eleojo’s Moment of Recognition appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

One Family’s Experience Is Not a Prediction

In The Bumpinator, Episode 5, Chapter 26, Dr. U puts Mia’s experience into perspective. He explains that what one family encounters may not be what another family experiences. That distinction matters whenever a parent is considering pediatric alopecia treatment for a child.

“Results do vary,” Dr. Umar says. His point is not to dismiss the value of Mia’s story. It is to make clear that a personal experience should not be treated as a promise about another child’s outcome.

Children Deserve Tolerable, Realistic Options

Dr. Umar moves beyond the question of whether a particular result can be repeated. He emphasizes a principle that applies to conversations about care for children: the available choices should be realistic for the child and tolerable in practice.

“Kids deserve … options that are tolerable and realistic,” he says. He then adds that this is what Mia had at that point in her experience. The chapter does not identify a specific treatment regimen or establish that another child would have the same experience.

For parents searching for the best hair loss treatment, the message is therefore more careful than a universal recommendation. The conversation needs to consider the individual child rather than assume that one approach or one family’s results will apply to everyone.

What Parents Can Take From Mia’s Story

Mia’s chapter highlights two ideas that belong together. Families can listen to another child’s experience and find it meaningful, while still recognizing that their own circumstances and results may differ. A responsible discussion of care should leave room for both perspectives.

Dr. Umar’s emphasis is on options, expectations, and the needs of the individual child. Mia’s story continues in the full episode, but this chapter stands on its own as a reminder that realistic, tolerable choices matter as much as the hope families bring to a consultation.

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Medical Disclaimer

This article is for general educational purposes and does not replace individualized medical advice. Treatment suitability and results vary. A qualified clinician should evaluate each child’s circumstances.

Further Reading

1. https://dru.com/mia-growing-confidence-alopecia/
2. Umar S, Kan P, Carter MJ, Shitabata P. Treatment-Refractory Central Centrifugal Cicatricial Alopecia Responsive to a Novel Botanical Treatment. Clin Cosmet Investig Dermatol. 2022;15:609-619 https://doi.org/10.2147/CCID.S358618

The post Video: Mia’s Hair Loss Story: Why Realistic Options Matter appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

The First Observation Came From Her Hairdresser

Speaking with Dr. Sanusi Umar, the guest explains that she had always had very full hair. She grew up in a large family with many sisters, each with slightly different hair. That familiar fullness was part of why a small change did not immediately stand out to her.

Her hairdresser, however, noticed something different. The guest remembers a casual comment about a spot that “just wasn’t quite right.” She did not treat the remark as urgent. As she puts it, “I didn’t pay that much attention to it because life’s busy.”

Why a Change at the Back Can Be Missed

The guest explains that the area was toward the back of her scalp, where she could not easily see it herself. With her hair remaining full, she did not notice what her hairdresser had observed. Her account illustrates a simple difficulty: people do not always have a clear view of every part of their own scalp.

Dr. Umar responds with a light remark about hairstylists and barbers being the ones to deliver unwelcome news. She pushes back affectionately, calling her own hairdresser brilliant and acknowledging that she was the one who noticed the difference.

A Conversation She Wishes Had Gone Further

Looking back, the guest does not criticize her hairdresser for noticing the spot. Instead, she wishes the observation had led to a more direct conversation. “I wish she had felt empowered enough to speak more,” she says, referring to what her hairdresser saw.

That distinction matters to the story. The hairdresser was not being asked to diagnose a scalp disease or decide on hair restoration. She had simply noticed something unfamiliar in an area the guest rarely examined. The guest now sees value in having those observations voiced clearly.

The Value of Speaking Up

This chapter focuses on the moment before the guest fully understood the change: a brief comment, a busy life, and a spot she could not readily see. It does not establish when her lichen planopilaris began or what treatment followed. Instead, it captures her retrospective wish that the first observation had prompted more discussion.

The Baldcast conversation continues beyond this early moment in her story, with Dr. Umar guiding the discussion of her experience.

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Medical Disclaimer

This article is for educational purposes only and describes one person’s experience. It is not a diagnosis or a substitute for individualized medical advice.

Further Reading

1. https://dru.com/eleojo-lichen-planopilaris-pattern-baldcast/
2. Umar S, Kan P, Carter MJ, Shitabata P, Novosilska M. Lichen Planopilaris Responsive to a Novel Phytoactive Botanical Treatment: A Case Series. Dermatol Ther (Heidelb). 2022 Jul;12(7):1697-1710. doi: 10.1007/s13555-022-00749-3. Epub 2022 Jun 8. PMID: 35674981; PMCID: PMC9276860.
   https://pmc.ncbi.nlm.nih.gov/articles/PMC9276860/

The post Video: Lichen Planopilaris: When a Hairdresser Notices First appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

A Message to Other Parents

Asked what he would tell other fathers watching their children go through hair loss, Mia’s father urges them to look for more options. His answer centers on continuing the search rather than feeling limited to a single approach.

He makes his central point plainly: “Not everything is medication.” The statement is a personal reflection on his family’s experience, not a claim that medical treatment should be avoided or replaced.

The Importance of Finding the Right Person

Mia’s father also speaks about the outcome he sees in his daughter and the importance of their search for help. He says, “We search and find the right person,” and describes the work as excellent. His comments express his assessment of the care his family received, without identifying a specific treatment or establishing that the same result can be expected for others.

The conversation takes place within The Baldcast, where Dr. Sanusi Umar gives families a platform to discuss the realities of scalp and hair conditions. In this chapter, the father’s perspective is the focus: asking questions, considering appropriate care, and finding a professional whose approach fits the child’s needs.

Beyond a Single Treatment Option

For families exploring hair regrowth treatment or searching for hair loss treatments that work, this chapter offers a parent’s perspective rather than a treatment comparison. The video does not specify which interventions Mia received, how they worked, or what results another child might experience.

What remains clear is the father’s encouragement to other parents: do not stop asking questions. His family’s story is an invitation to continue seeking informed, individualized medical guidance.

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Medical Disclaimer

This article shares one family’s experience for informational purposes. It is not medical advice or a recommendation to stop or replace prescribed treatment. Treatment decisions should be made with a qualified healthcare professional.

Further Reading

1. https://dru.com/mia-growing-confidence-alopecia/
2. Umar S, Kan P, Carter MJ, Shitabata P. Treatment-Refractory Central Centrifugal Cicatricial Alopecia Responsive to a Novel Botanical Treatment. Clin Cosmet Investig Dermatol. 2022;15:609-619
   https://doi.org/10.2147/CCID.S358618

The post Video: Mia’s Father on Alopecia: Keep Looking for Answers appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

A Hands-On Exchange in Hair Transplant Practice

The visit brought accomplished hair transplant surgeons from Argentina to Manhattan Beach for practical training with Dr. Sanusi Umar. The visiting physicians already brought extensive surgical experience and leadership within an established clinic network across Latin America and Spain. The purpose of the session was not introductory education. It was an exchange among experienced clinicians centered on hands-on use of a newer FUE technology.

The training combined direct practice with advanced technical discussion. According to the approved video context, the session was designed to work across the full range of FUE scenarios, giving the visiting surgeons an opportunity to engage with the technology in a practical setting while exchanging expertise with Dr. Umar.

Learning a Skin-Responsive, All-Purpose FUE Technology

The short video centers on the physicians working with UGraft and reflecting on the technology after hands-on exposure. One visiting physician describes the device as “very intuitive” and says he believes it can help move forward the quality of what a surgeon can offer.

Another perspective in the video comes from more than 30 years of hair transplantation experience. After working with Dr. Umar’s device, the physician calls it “excellent” and says he believes UGraft can make it possible to reach more types of complex cases. Those comments reflect the visiting surgeons’ own impressions during this training session and are not presented as a guarantee of clinical outcomes.

Experienced Surgeons, Advanced Technical Discussion

The exchange highlights a specific kind of professional training: experienced hair restoration surgeons evaluating a new tool through practical use and discussion with the physician behind it. Dr. Umar’s role in the session is both technical and educational, guiding hands-on work with the technology while engaging colleagues who bring substantial experience of their own.

The video closes on that exchange of expertise rather than a patient outcome. More from the physicians’ visit is expected to follow, continuing the discussion around advanced FUE practice and technology.

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Medical Disclaimer

This article is for educational and informational purposes only and does not constitute medical advice. Individual evaluation and treatment should be personalized. No specific result is guaranteed.

Further Reading

1. https://dru.com/dr-ugraft-demonstrated-in-istanbul-turkey-at-the-april-2019-ishrs-live-and-hands-on-fue-training/
2. https://dru.com/30947-2/
3. Umar S, Shitabata P, Rose P, Carter MJ, Thuangtong R, Lohlun B, Benhiba H, Oguzoglu T, Zollinger MM, Maldonado J, Gonzalez A, Novosilska M, Gómez Zubiaur A, Marti M. A New Universal Follicular Unit Excision Classification System for Hair Transplantation Difficulty and Patient Outcome. Clin Cosmet Investig Dermatol. 2022 Jun 27;15:1133-1147. doi: 10.2147/CCID.S369346. PMID: 35784270; PMCID: PMC9249093.CopyDownload .nbibFormat:
   https://www.dovepress.com/a-new-universal-follicular-unit-excision-classification-system-for-hai-peer-reviewed-fulltext-article-CCID

The post Video: Hair Transplant Training Advances With Skin-Responsive FUE Technology appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

They Kept Making the Drive

Dr. Umar describes Fernando and Blanca as fighters because they did not limit their search to what was close to home. They repeatedly drove from Arizona as they continued looking for solutions for Mia.

“They didn’t give up,” Dr. Umar says. “They wanted the best for their daughter.”

Commitment to Mia’s Happiness

The conversation also returns to a Disneyland experience that required another long drive from Arizona. Dr. Umar calls attention to the effort involved and to how committed Mia’s parents were to her happiness. He connects that persistence with the impact the hair loss had on the family.

The point is not that every family will follow the same path. It is that Mia’s parents continued asking questions and seeking help rather than simply accepting the first answer presented to them. Their actions became part of the story Dr. Umar wanted to recognize.

When Things Turned for the Better

Near the end of the chapter, Dr. Umar notes that things had turned out better and reflects on how fulfilling that must feel after the family’s effort. The chapter does not turn that observation into a promise for anyone else. Mia’s story remains one patient’s experience, and evaluation and treatment should be individualized.

For parents concerned about a child’s hair loss, Mia’s story underscores the importance her family placed on continuing to seek an appropriate evaluation. Their persistence is the focus here, along with Dr. Umar’s recognition of the commitment behind it.

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Medical Disclaimer

This article describes one patient’s experience for educational purposes. Results can vary. Evaluation and treatment should be individualized. This content is not medical advice and does not replace consultation with a qualified medical professional.

Further Reading

1. https://dru.com/mia-alopecia-hope-for-parents/
2. Umar S, Kan P, Carter MJ, Shitabata P. Treatment-Refractory Central Centrifugal Cicatricial Alopecia Responsive to a Novel Botanical Treatment. Clin Cosmet Investig Dermatol. 2022;15:609-619 https://doi.org/10.2147/CCID.S358618

The post Video: Mia’s Hair Loss and the Commitment of a Family That Kept Looking appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

From Physician to Patient With Lichen Planopilaris

Eleojo came to the conversation with extensive medical experience of her own. The chapter introduces her as a practicing pediatric surgeon from the United Kingdom, as well as a hair specialist and hair transplant surgeon. Yet her professional background did not remove the personal reality of being a patient with LPP.

Her first impression of Dr. U was direct: “Oh, what a cowboy.” The comment captures the skepticism she felt at the beginning. What followed, however, gave her a reason to look again at what she was experiencing.

A Change She Could Track

Eleojo says that within 10 days, the itching she had been experiencing “just settled down.” She also says she did not believe it herself at first. When she stopped, the symptoms started again.

That sequence became important to her because it suggested a repeatable pattern in her own experience: the itching calmed down, then returned after she stopped. The chapter does not reveal the full treatment story or final outcome. Instead, it centers on the moment when her observation began to challenge her original impression.

Why the Pattern Mattered

For a physician who was also navigating her own hair loss diagnosis, noticing that pattern became a turning point in how she viewed the experience. Dr. U frames this as the beginning of a broader hair restoration story, saying that the journey is “about layering.” This chapter leaves that idea open for the next part of the conversation rather than moving ahead of the story.

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Medical Disclaimer

This article is for educational and informational purposes only and does not constitute medical advice, diagnosis, or treatment. Individual experiences and responses can vary. Consult a qualified healthcare professional for guidance about your own condition and treatment options.

Further Reading

1. https://dru.com/what-is-lpp-aka-lichen-planopilaris/
2. Umar S, Kan P, Carter MJ, Shitabata P, Novosilska M. Lichen Planopilaris Responsive to a Novel Phytoactive Botanical Treatment: A Case Series. Dermatol Ther (Heidelb). 2022 Jul;12(7):1697-1710. doi: 10.1007/s13555-022-00749-3. Epub 2022 Jun 8. PMID: 35674981; PMCID: PMC9276860.
   https://pmc.ncbi.nlm.nih.gov/articles/PMC9276860/

The post Video: Lichen Planopilaris: The Pattern That Changed Eleojo’s View appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

Why I Developed UGraft Zeus

The difficult frontiers of FUE were not theoretical to me. They emerged from problems patients brought into my practice. Some patients with severe baldness needed donor supply beyond the traditional scalp, making efficient use of beard and body hair important. Some repair patients had already depleted conventional donor resources and also needed alternative donor areas. Tightly curled hair and tougher skin created another demanding FUE scenario. High-profile patients and others seeking minimal downtime also wanted options that did not require shaving the head.

Those different needs pushed me toward a platform that could work across regular shaved FUE, Afro-textured or tightly curled hair FUE, long-hair FUE, and body-hair FUE. The goal was not a separate answer for every donor scenario, but a more adaptable system.

A Skin-Responsive Approach to FUE

UGraft Zeus uses an Intelligent Punch and a skin-responsive driver designed to navigate differences in hair angle, follicle direction, skin thickness, and skin firmness during extraction. The short video demonstrates a simple donor-region selection, after which the system calibrates for the selected donor area.

That adaptability is intended to extend across traditional scalp FUE, tightly curled hair, long-hair procedures, and body-hair FUE. My work also led to a donor assessment and classification approach intended to help physicians anticipate FUE difficulty rather than discover it only after surgery has begun.

One Platform for Different Donor Scenarios

The video presents UGraft Zeus as a patented FUE technology designed for multiple donor scenarios and describes it as the most multicenter-studied FUE device. The broader purpose of the development was to simplify a technology created for difficult cases so that other physicians could use the same platform across a wider range of patients.

FUE planning remains individual. A hair transplant before and after comparison cannot determine whether the same approach is appropriate for another person. Donor supply, hair characteristics, skin characteristics, and the planned procedure all require medical evaluation. Technology can be designed to adapt, but treatment planning still begins with the individual patient.

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Medical Disclaimer

This content is for educational purposes only and is not a substitute for individualized medical advice, diagnosis, or treatment. Suitability for FUE and treatment planning require an individual medical evaluation. Individual results vary.

Further Reading

1. https://dru.com/a-new-follicular-unit-extraction-fue-classification-system-for-hair-transplant-patientsa-new-system-to-evaluate-fue-hair-transplant-patients/
2. Umar Sanusi. Body Hair Transplant by Follicular Unit Extraction: My Experience With 122 Patients.Aesthetic Surgery Journal 2016; DOI: 10.1093/asj/sjw089. Published September 22, 2015.
   https://pubmed.ncbi.nlm.nih.gov/27241361/
3. Umar, S.et al. (2021) A novel follicular unit excision device for all-purpose hair graft harvesting, Clinical, cosmetic and investigational dermatology. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8605797/ (Accessed: 03 August 2023).
4. Umar S, Shitabata P, Rose P, Carter MJ, Thuangtong R, Lohlun B, Benhiba H, Oguzoglu T, Zollinger MM, Maldonado J, Gonzalez A, Novosilska M, Gómez Zubiaur A, Marti M. A New Universal Follicular Unit Excision Classification System for Hair Transplantation Difficulty and Patient Outcome. Clin Cosmet Investig Dermatol. 2022 Jun 27;15:1133-1147. doi: 10.2147/CCID.S369346. PMID: 35784270; PMCID: PMC9249093.CopyDownload .nbibFormat:
   https://www.dovepress.com/a-new-universal-follicular-unit-excision-classification-system-for-hai-peer-reviewed-fulltext-article-CCID
5. Umar S, Khanna R, Maldonado JC, Chouhan K, Gonzales A. Beard and Body Hair Transplantation by Follicular Unit Excision Using a Skin-Responsive Device: A Multicenter Study. Dermatol Surg. 2024 Mar 1;50(3):306-308. doi: 10.1097/DSS.0000000000004061. Epub 2023 Dec 20. PMID: 38127669; PMCID: PMC10904000.
   https://pmc.ncbi.nlm.nih.gov/articles/PMC10904000/
   

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Imagine fixing a bad hairline with leg hair. That is the premise of this short hair transplant before and after case. The patient came in with a harsh, pluggy-looking hairline from previous hair transplants, and the corrective plan used leg hair to help create a softer transition at the front of the scalp.

Why Leg Hair Was Used in the Hairline

For this corrective FUE hair transplant (follicular unit extraction), Sanusi Umar, MD used leg hair as part of the hairline restoration with U-Graft FUE technology. The supplied caption describes the goal as creating a softer, more natural-looking transition rather than leaving the harsh, pluggy appearance produced by the patient’s previous hair transplants.

The case was published in JAMA Dermatology for its use of leg hair in hairline restoration. The supplied material also notes that U-Graft technology, including U-Graft Zeus, has been demonstrated for body hair extraction in a multicenter study published in Dermatologic Surgery.

The Body Hair Transplant Result Shown in the Video

The short video moves directly from the earlier hairline to the later appearance. Its closing line describes the result simply: “His hairline looks natural, smooth, and soft.” The final comparison is labeled “2 years after BHT,” giving viewers the follow-up point shown in the video.

A Different Source of Hair for Corrective Restoration

This case highlights a less familiar option in hair restoration: using body hair when the treatment plan calls for it. Here, leg hair was incorporated into a corrective transplant to address the appearance of a previously transplanted hairline. The result shown in the supplied material is a softer, smoother, more natural-looking hairline.

Individual treatment planning depends on the patient and the clinical situation. The images and result in this case describe one patient’s experience and should not be taken as a guarantee of the same outcome for others.

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Medical Disclaimer

This content is for educational purposes only and is not medical advice. Individual treatment plans and results vary. A qualified physician should evaluate whether a particular treatment approach is appropriate for an individual patient.

Further Reading

1. https://dru.com/best-hair-transplant-repair-doctor-in-the-world/
2. Umar, S. and Popescu, F. (2023) Allogeneic hair transplant in a kidney transplant recipient : Dermatologic surgery, Dermatologic Surgery. Available at: https://journals.lww.com/dermatologicsurgery/Fulltext/9900/Allogeneic_Hair_Transplant_in_a_Kidney_Transplant.458.aspx (Accessed: 03 August 2023).
   https://www.ovid.com/jnls/dermatologicsurgery/fulltext/10.1097/dss.0000000000003880~allogeneic-hair-transplant-in-a-kidney-transplant-recipient

The post Video: Hair Transplant Before and After: Using Leg Hair to Soften a Hairline appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

If this sounds like you, this article is for you:

• You are consistent with treatment, but your hair loss or baldness still progresses.
• Minoxidil and/or finasteride helped at first, then results slowed or stopped.
• You have “dandruff” or scalp irritation that keeps coming back.
• A hair transplant result was disappointing, unpredictable, or did not last.

If you are doing “all the right things” for your androgenetic alopecia or pattern baldness, but results are stalling, read this.

Androgenetic alopecia (AGA), also known as male pattern baldness (MPB) or female pattern hair loss (FPHL), is common, visible, and emotionally heavy. Many patients do everything they are told: minoxidil, finasteride (or dutasteride), devices, shampoos, supplements, and still find that progress slows, stops, or becomes unpredictable.

When that happens, it is not always “bad luck,” and it is not always “you waited too long.”

The study titled “Perifollicular Inflammation and Fibrosis in Androgenetic Alopecia: Implications for Diagnosis and Treatment – A Comparative Histopathologic and Clinical Study with Normal-Appearing Scalp” was published in the peer-reviewed Clinical Cosmetic and Investigational Dermatology journal. There, we describe a specific histologic pattern that can live quietly under the surface and help explain why some AGA and pattern baldness patients stop responding as expected, progress faster, or respond unpredictably to both medical therapy and hair restoration surgery.

It is called PIILIF, short for Perifollicular Infundibulo-Isthmic Lymphocytic Infiltrates and Fibrosis.

Quick takeaways

• PIILIF is a low-grade, immune-type inflammatory and early fibrotic pattern found around the upper portion of hair follicles (infundibulo-isthmic region) that can coexist with AGA and pattern baldness.
• It can be easy to miss clinically and can be mislabeled as “seb derm” or “just dandruff.”
• It may help explain why finasteride or minoxidil alone may not be enough for some people over time.
• It supports a dual-pathway strategy: address the hormonal pathway and the immune-fibrotic pathway, not one or the other.
• This is exactly why I created the Inflammatory AGA Screen Program (PIILIF Track).
• Important classification insight: the paper proposes that what has been described as fibrosing alopecia of patterned distribution (FAPD) aligns with a later stage of AGA-PIILIF, and recommends staging AGA-PIILIF by the degree of perifollicular fibrosis to support earlier recognition and intervention.

The missing link for AGA medication non-responders

This section is for the patient who is not planning surgery (or not yet), but is frustrated because the standard plan is not delivering what it should.

If the scalp environment is immunologically active and early fibrosis is already present, “more of the same AGA routine” is not always the answer.

The answer is:

• better biology control
• better targeting
• better timing

Here is the practical point

If PIILIF is present, “DHT control only” can leave a second driver running.

Standard AGA treatment often focuses on androgen signaling and follicle cycling support (for example, finasteride and minoxidil). That can be appropriate, but in a subset of patients, there is an additional layer: a perifollicular inflammatory and early fibrotic process that may continue even when DHT is addressed.

That is why some patients report:

• good early improvement, then slow decline again
• a stable period, then sudden acceleration
• “I’m consistent, but the response does not match the effort”

What this changes in real life

For the non-responder, the best move is not to guess harder.

It is to confirm what is actually happening in the scalp environment, and then treat the relevant pathways when indicated.

That does not mean every patient needs a biopsy.

It means:

• for non-responders, ambiguous cases, or high-stakes decisions, it is worth considering early diagnostic confirmation, not late.

What is PIILIF, in plain language?

PIILIF describes a subclinical perifollicular inflammatory pattern that concentrates around the upper follicle and is associated with early perifollicular fibrosis.

Key idea: it can be present even when the scalp looks “quiet,” and it can be present even in areas that are not yet visibly thinning or bald.

This matters because once fibrosis progresses, it can reduce the predictability of regrowth and restoration. That is why early recognition is the whole game.

Seeing PIILIF makes the concept clearer.
The short video below illustrates how PIILIF can exist beneath visible pattern baldness and why scalp biology matters when treatments or hair transplants stop responding.

Where FAPD fits: why this paper matters beyond “routine AGA”

If you have heard the term FAPD (fibrosing alopecia of patterned distribution), you already know it sits at the crossroads of two worlds:

• pattern hair loss that looks like AGA or male pattern baldness, and
• fibrosing/scarring biology that behaves more like early scarring alopecia

The key contribution of the paper is that it proposes a unifying framework:

• FAPD may represent a later, more fibrosing stage within the AGA-PIILIF spectrum, rather than a completely separate diagnosis.
• The paper recommends staging AGA-PIILIF by the degree of perifollicular fibrosis, which supports earlier recognition and more informed management decisions.

For patients, the takeaway is not to panic about “scarring.”
The takeaway is precision: if inflammatory and fibrotic drivers are present, it changes what “optimal care” looks like and why durability sometimes requires more than growth stimulation alone.

Why PIILIF gets mislabeled as seb derm or “just dandruff”

Many people with PIILIF report flaking, scale, or irritation. So it is easy to default to seborrheic dermatitis (“seb derm”) or “dandruff.” Whatsmore, the trichoscopic features of PIILIF may show similar findings associated with seborrheic dermatitis

But in our cohort, true seborrheic dermatitis on biopsy was rare compared with PIILIF.

Even when anti-dandruff shampoos temporarily improve scale or redness, that does not necessarily address the deeper perifollicular inflammatory process.

If you are treating “seb derm” aggressively and hair outcomes are still slipping, it is time to consider whether the label is wrong.

Why this matters for hair transplant planning

If the scalp environment is immunologically active and early fibrosis is already present, “more grafts” is not the answer.

The answer is:

• better biology control
• better planning
• better timing

In higher-risk candidates, pre-transplant control of PIILIF and biopsy-informed planning are advisable.

That does not mean every patient needs a biopsy. It means that for non-responders and high-stakes surgical candidates, diagnostic confirmation should be considered early rather than late.

Who should consider PIILIF screening?

You should at least consider PIILIF screening if you relate to one or more of these:

• You are not responding as expected to a well-run AGA regimen (meds, topical plan, lifestyle, compliance is solid).
• You have been told you have “seb derm” for years, but hair continues to miniaturize.
• You have advanced AGA or you are a complex case (including prior surgery, donor depletion, body hair follicular unit excision (FUE) or beard hair FUE reliance).
• You are planning a transplant and you want to reduce the risk of disappointing yield, ongoing thinning, or unpredictable healing.
• You are 44 years or older.
• You have perifollicular scale, redness, itch, tenderness, or shedding that does not match the clinical look of “routine AGA.”
• You developed overt features of scarring alopecia or severe inflammation after a hair transplant.

The Inflammatory AGA Screen Program (PIILIF Track)

I created this because too many complex patients with hair loss and baldness were being managed with a one-pathway playbook.

Program name: Inflammatory AGA Screen Program (PIILIF Track)
Format: Virtual first (with in-person follow up when needed)
Deposit: Required to protect quality, reduce no-shows, and allow proper time allocation

What the PIILIF Track helps us do

• Identify whether a patient’s AGA is likely “standard AGA” alone, or AGA plus PIILIF biology.
• Decide when a biopsy is appropriate and where it should be taken to improve diagnostic yield.
• Build a personalized plan aimed at:
  • controlling the inflammatory axis when indicated
  • reducing progression and improving durability
  • planning surgery only when the scalp biology is optimized

Long-Term Care Matters Long-term

Sustainable treatment matters because AGA‑PIILIF is a long game
When PIILIF is present, the goal is not a short burst of change. The goal is long-term stability of the scalp environment. PIILIF is best understood as a chronic, genetically influenced tendency toward follicle‑centered inflammation and early fibrosis that is not “cured” once and for all. It is managed. That reality changes how we choose treatments.

Control, not cure, means the plan must be livable for years
If control may need to be maintained for the long term, the foundation of care should be something a patient can realistically sustain. This argues against building the core plan around high‑burden or high‑risk approaches, especially because AGA‑PIILIF can be subtle compared with overt primary scarring alopecias. The biology may be meaningful even when the scalp looks “quiet,” but the management must remain practical and tolerable over time.

What we evaluated in our cohort
Because the working model involves long-term control, the study emphasized steroid-sparing options that may be suitable for longer-term use, with short-course therapies used selectively. Selections were informed by peer-reviewed literature on steroid-sparing management in primary cicatricial alopecias. Treatments used in the cohort, often in combination and individualized to the patient, included:

• Dutasteride and finasteride
• Oral minoxidil
• Topical calcineurin inhibitors
• Minocycline or doxycycline (typically as a time‑limited course)
• A selected phytoactive approach: Gashee topical and Gashee oral

What showed the clearest statistical signal in our analysis (and what did not)
In this retrospective cohort analysis, only some interventions showed a clear statistical association with improvement. In order of p‑value significance, the strongest signals in our dataset were observed with:

1. Topical and oral phytoactives (Gashee)
2. Topical calcineurin inhibitors
3. Minocycline
4. Dutasteride

Other treatments used in the cohort (including finasteride, oral minoxidil, and doxycycline) did not show the same level of statistical signal in this dataset. This may reflect sample size, duration, selection bias, combination regimens, dosing, or when and how an agent was deployed, rather than proving a treatment has no role.

The practical takeaway
The point is not that every patient needs every component. The point is that when AGA‑PIILIF biology may require long-term management, the strategy should prioritize approaches that are realistic to sustain, steroid‑sparing when appropriate, and matched to the level of inflammatory and fibrotic activity.

How this relates to Phytoactives
Within a long-term, steroid‑sparing framework, a phytoactive topical or oral option may be considered as supportive care as part of a broader plan, particularly when long‑term tolerability is a priority. In our cohort analysis, the use of Gashee in both topical and oral forms showed the strongest statistical signal among the steroid‑sparing measures evaluated, but this study is observational, and larger studies are needed to confirm and refine these findings. Gashee is not a substitute for diagnosis and is not positioned as a cure. It may be one tool within a clinician‑guided program when it fits the patient’s overall plan and risk profile.

Where a phytoactive product like Gashee fits (and where it does not)

Important points of clarification.

What Gashee is not

• It is not positioned as a “cure” for AGA, hair loss, or baldness.
• It is not a replacement for diagnosis.
• It is not a substitute for physician-directed therapy when stronger interventions are warranted.

Where Gashee can fit logically in the PIILIF conversation

PIILIF changes the strategy from “only push growth” to “optimize the scalp environment and protect follicle viability.”

Because AGA is a long-course condition, and because PIILIF (when present) can behave like a persistent, low-grade inflammatory process, long-term tolerability matters. That pushes smart clinicians toward steroid-sparing approaches whenever feasible.

In our PIILIF work, the practical takeaway is that some patients benefit when care includes scarring alopecia or PCA (primary cicatricial alopecia)-style anti-inflammatory and anti-fibrotic measures alongside appropriate androgen management.

In that context, phytoactive support can be part of a long-term maintenance philosophy, particularly for patients who need a plan they can sustain.

Gashee exists in both topical and oral forms. In my practice, when it is used, it is used as part of a broader plan, not as a standalone promise.

Important note: Gashee is designed to support the scalp environment as part of a broader hair loss program. It is not intended to diagnose, treat, cure, or prevent disease. Individual results vary.

The bigger point: stop guessing. Start staging.

If the biology is wrong, the plan will be wrong.

PIILIF gives us a clearer framework for:

• earlier detection
• better durability
• better surgical planning
• fewer “mystery non-responders”

If you are a patient who feels stuck, or a clinician managing difficult AGA cases, the PIILIF Track is built for you.

Next steps

Patients: Request a PIILIF Track evaluation
Start the PIILIF Track Intake

Clinicians: Refer a complex AGA case for PIILIF screening
Clinician Referral: PIILIF Track

Medical and product disclaimer

1. Gashee is designed to support the scalp environment as part of a broader hair loss program. It is not intended to diagnose, treat, cure, or prevent disease.
2. This article is for educational purposes and does not provide medical advice. Diagnosis and treatment should be individualized and guided by a qualified clinician. Product statements have not been evaluated by the FDA. Products are not intended to diagnose, treat, cure, or prevent any disease.

FREQUENTLY ASKED QUESTIONS

PIILIF, FAPD, treatment resistance, and what to do next

1) What is PIILIF?

PIILIF stands for Perifollicular Infundibulo-Isthmic Lymphocytic Infiltrates and Fibrosis. In plain terms, it describes a low-grade immune-type inflammation and early fibrotic change occurring around the upper portion of the hair follicle. It can coexist with androgenetic alopecia (AGA), also known as male pattern baldness or female pattern hair loss, and may be present even when the scalp looks “normal” on casual inspection.

2) Is PIILIF the same as FAPD?

Not exactly. FAPD (fibrosing alopecia of patterned distribution) is a term typically used when patterned hair loss shows a more advanced fibrosing or scarring-leaning biology. The key insight from this publication is that FAPD may align with a later stage within an AGA-PIILIF spectrum, rather than representing a completely separate condition.

From a practical standpoint, this means that earlier recognition of inflammatory and fibrotic drivers matters. Identifying AGA-PIILIF before extensive fibrosis develops allows clinicians to plan care with durability in mind, when the biology may still be more modifiable.

Waiting until the histologic features associated with FAPD are fully established may correspond to a more treatment-resistant stage. For this reason, the authors emphasize the value of recognizing and addressing AGA-PIILIF earlier, rather than deferring evaluation until later stages when fibrotic changes are more entrenched.

3) Do I need a biopsy to know if I have PIILIF?

Not everyone needs a biopsy. A biopsy becomes more relevant when your provider finds signs of inflammation on magnified (trichoscopic) examination of your scalp. The threshold is reduced if you are already a non-responder, your presentation is ambiguous, you have symptoms that do not fit “routine AGA” (itch, tenderness, burning, persistent scale), or you are making high-stakes decisions like hair transplant planning. The goal is not to biopsy everyone, it is to confirm scalp biology early when the stakes or uncertainty are high.

4) Why did my finasteride or minoxidil stop working?

There are several reasons treatments may stop working, and not all are about the medication itself. The main concept here is that AGA or pattern baldness is often treated as purely androgen-driven, but in a meaningful subset of patients an inflammatory and early fibrotic process may be operating in parallel. If that second driver is active, “more DHT control” alone may not fully stabilize the situation, which is why biology-aware evaluation and a dual-pathway strategy may be needed in selected cases.

5) Can PIILIF affect hair transplant outcomes?

It can. Hair transplantation is not just about graft numbers or technique, it is also about the health of the recipient scalp environment and long-term stability of surrounding native hair. If inflammatory-pattern biology and early fibrosis are active, predictability and durability can be affected, which is why scalp optimization and biopsy-informed planning can be important in higher-risk candidates.

6) What are phytoactives, and where do they fit in a long-term plan?

Phytoactives are plant-derived compounds that may support the scalp environment as part of a broader hair loss program. In a long-term maintenance context, many patients and clinicians prefer steroid-sparing approaches when appropriate, especially when scalp inflammation behaves as a chronic, low-grade process. In that framework, a phytoactive topical or oral product can be considered as supportive care, but it is not a replacement for diagnosis, and it should be used as part of a clinician-guided plan when stronger interventions are indicated.

7) Does PIILIF require lifelong treatment?
PIILIF, when present, may behave like a chronic, genetically influenced inflammatory tendency around hair follicles. The practical goal is long-term control and stability, not a one-time cure. Some patients may need ongoing maintenance for years, with the plan adjusted over time based on symptoms, exam findings, and overall risk profile under clinician guidance.

8) Do I need strong steroids or immunosuppressants to control PIILIF?
Not necessarily. AGA-PIILIF can be subtle compared with overt primary scarring alopecias, so aggressive therapy is not automatically the default. In our cohort, the emphasis was on steroid-sparing strategies that can be considered for longer-term use when clinically appropriate. Treatment choice and intensity should be individualized and supervised by a qualified clinician.

9) What kinds of long-term, steroid-sparing treatments were used in the study?
In this cohort, patients were managed with a steroid-sparing approach tailored to clinical context and often used in combination. Treatments used included dutasteride or finasteride, oral minoxidil, topical calcineurin inhibitors, and time-limited tetracyclines (such as minocycline or doxycycline). A selected phytoactive topical and oral option (Gashee) was also used as part of the broader scalp-care plan when appropriate.

In this retrospective dataset, the clearest statistical associations with improvement were observed in regimens that included: Gashee topical, Gashee oral, topical calcineurin inhibitors, minocycline, and dutasteride. Because many patients received combination regimens, these findings do not establish that any single component alone caused the observed outcomes. Observational findings do not prove cause and effect, larger studies are needed, and individual results vary. Gashee is not intended to diagnose, treat, cure, or prevent disease.

Important note: Products and supplements are not intended to diagnose, treat, cure, or prevent disease. Individual results vary, and medical decisions should be individualized with a qualified clinician.

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