MD NEWS: Clinical Update
Treatment of Androgenic Alopecia
(Male and Female Pattern Hair Loss)
By Alan J. Bauman, M.D.
Since the dawn of recorded history, humans have attempted to "cure" hair loss. Preparations for the treatment of hair loss have been found recorded in the earliest medical texts. A recipe for an ancient Egyptian salve for hair loss was found on a papyrus scroll written over 5,000 years ago. It contained, among other things, hippo fat, crocodile fat and goat fat. Cleopatra was said to have concocted her own topical preparation for her balding lover, Caesar, whose name ironically means "head of hair." Hippocrates, the father of modern medicine, prepared different ointments (circa 400 BC) to treat baldness, some of which contained such ingredients as pigeon droppings. A long list of attempted lotions, potions, etc. goes on and on through the ages. Through the industrial era and the present, millions upon millions of dollars have been spent by companies looking to dupe unsuspecting consumers into spending their hard-earned money on supposedly miraculous, yet ineffective "baldness cures." It is only recently that medical science has finally been able to provide those with thinning hair safe, proven and effective treatment through medicine and surgeryfinally catapulting us beyond the age of "snake oil" remedies.
Medically tested and F.D.A. approved medications in pill and spray form are now available to slow, stop and even reverse hair loss. State-of-the-art surgical treatment can redistribute a patients own hair, recreating a permanent natural-looking hairline where before there was only shiny bald skin. New microsurgical techniques have replaced the old-style "plugs," making unsightly "dolls hair" a thing of the past. Typical surgical hairlines today are subtle and look completely natural when seen at a social distance.
Hair loss can actually be caused by many factors, including thyroid disease, genetic makeup, high fever, diet and medications. But, by far the most common type of hair loss, called hereditary androgenic alopecia, or male and female pattern hair loss, accounts for 99% of all cases of premature thinning or balding scalps. According to conservative estimates, male and female pattern baldness affects over 60 million Americans, two-thirds of which are men (40 million) and the remainder women (20 million). Approximately 50% of all men over the age of forty are experiencing this type of hair loss. Despite popular belief--and some late-night infomercials--this type of hair loss is not caused by poor circulation, clogged hair follicles, hair mites, minor stress, frequent shampooing or the use of hats or helmets.
The extent by which someone is affected by male pattern baldness is determined by a combination of genetic factors and androgens, specifically, the circulating male hormones testosterone and dihydrotestosterone (DHT). The tendency for male or female pattern hair loss can be inherited genetically from either side of the family. Affected individuals within a family may express hair loss differently in terms of age of onset and quantity of loss. For example, just as several brothers may vary in height, so too could they experience baldness in varying degrees.
In males, thinning can begin in the late teen years and commonly becomes evident during the early 20s. Genetically sensitive follicles (the tiny organs that produce hair) on the scalp begin to miniaturize in the presence of normal levels of circulating DHT (dihydrotestosterone). These follicles found in the frontal hairline and extending to the top and crown of the head, become smaller and produce hair that is progressively thinner and less pigmented. DHT also affects these follicles growth cycle causing them to produce a shorter and shorter hair until the follicle finally "dies." It is at this point that hair production ceases irreversibly in that follicle and scarring occurs. The hair found in the sides and back of the head is relatively permanent because the follicles in that area are not sensitive to the effects of DHT; this is why male pattern baldness typically ends in the familiar undisturbed "monks ring" of hair.
Through history, artificial hair replacement in the form of a hairpiece might have been a balding persons only option. Hannibal, the great Carthaginian military leader, wore one into battle in 200 B.C. A myriad of cosmetic creams, sprays and powders are also currently available to those who would like to try to camouflage their hair loss. However this year, Hair Club for Mens artificial "hair systems" and the infamous Spray-on-Hair both made Time Magazines Top 100 Worst Ideas of the Century list. Patients who once might have chosen to cover their hair loss with attached artificial "systems" of wigs, weaves or toupees now have truly viable medical and surgical options available to restore and maintain their hair. Revolutionary techniques in hair restoration surgery now offer patients a viable living and growing solution to hair loss. In addition, truly effective and safe medical treatments like the once-a-day pill, Propecia® (Finasteride 1mg), or twice-a-day Rogaine® (Minoxidil 2% or 5%) spray, are also suitable options that can be used alone, or in conjunction with surgery.
Propecia® (Finasteride 1mg) manufactured by Merck & Co., Inc. is available by prescription only, and was introduced to the market with great excitement in December of 1997 as the first oral treatment for androgenic alopecia. Through four years of rigorous scientific studies, it has been shown to regrow natural hair in 2 out of 3 men and actually stop hair loss in 5 out of 6 men. On a technical level, Propecia® (finasteride 1mg) works by decreasing the formation of DHT from testosterone by blocking the enzyme 5-alpha reductase in the body. By decreasing the amount of DHT, affected follicles that were producing thin wispy hair under the influence of DHT, tend to "bounce back" producing a thicker caliber, more pigmented, longer hair. It tends to be this effect that eventually gives men who are thinning in the crown visible coverage. It should be noted that it could take 6-12 months before results are noticed with treatment with Propecia® (Finasteride 1mg).
What about the side effects? Most men who inquire about Propecia® (Finasteride 1mg) are concerned about the possible sexual side effects of the medication; "But doc, is it going to take the lead out of my pencil?" And it is of course every mans fear that now that he has attracted a beautiful woman with his new youthful locks of hair (motivation for many men seeking hair restoration), he will be unable to "perform" at his peak. What a patient needs to realize is that Propecia® (Finasteride 1mg) lowers levels of DHT, the hormone primarily responsible for male pattern hair loss, without decreasing levels of testosteronethe male hormone responsible for masculinity. The male sexual side effects (described as erectile dysfunction or loss of libido in the clinical trials) are therefore mild and rare, occurring in less than 2% of all patients. (And of course theres always Viagra®!) But seriously, any uncommon side effects that do occur have been shown to be temporary, disappearing completely when the medication is discontinued. It should also be noted that the side effects usually abate even if the patient continues the medication. Also, a stronger dose, Finasteride 5mg (Proscar®), has actually been available for over 10 years to effectively treat men with enlarged prostates, and has demonstrated an excellent safety profile over that time. It is important to remember that Propecia® (Finasteride 1mg) must be taken daily in order to sustain results. If the medication is discontinued, any hair previously gained is lost over the following 12-month period. Propecia® (Finasteride 1mg) tends to work best in the crown of patients experiencing early to moderate hair loss and is effective in slowing and/or reversing male pattern hair loss in many men.
Minoxidil 2% (Rogaine®) solution for application to the scalp has been available for over 10 years and is now available without a prescription in the US. Originally used for the treatment of high blood pressure, physicians noted that one of its side effects was promoting hair growth. Although its mechanism is not completely understood, it seems to work best to stop or slow further hair loss and works more effectively on the crown than at the frontal hairline. A more potent concentration of Rogaine® (Minoxidil 5%) is now available and has been shown to be more effective than the 2% solution. Like Propecia® (Finasteride 1mg), Minoxidil must be used continuously to sustain results. They may be used alone or concurrently but, if discontinued, the natural balding process resumes. Discontinuation of Rogaine® (Minoxidil) typically results in a rapid shedding of hair (usually within one week). Propecia® (Finasteride 1mg) or Rogaine® (Minoxidil 2% or 5%) can be successfully used by themselves or together synergistically because of their different mechanisms of action. As part of a total treatment plan to restore and maintain scalp hair, medication can be used either alone or in conjunction with a surgical procedure.
Taking advantage of the "monks ring" of relatively permanent hair on the sides and back of the head, hair transplant surgeons redistribute hair-producing follicles to thinning or balding areas of the scalp. Current techniques in surgical hair restoration involve the removal of a strip of permanent, hair-bearing skin from the donor area, which is then typically dissected into micrografts (containing 1-3 hairs) and minigrafts (3-8 hairs each). The donor area is sutured closed and the tiny grafts are then meticulously "planted" into the recipient area. Critical to the aesthetic outcome of the procedure, the tiny incisions determine the angle, orientation and position of each individual graft. The use of very small micrografts, called follicular units, and advances in surgical technique now allow the creation of highly aesthetic, feathery and natural hairlinesavoiding the "pluggy" look that was typical of old-style transplant techniques. (Older techniques utilized circular punches of skin, or "plugs," that contained 15-20 hairs each. This typically yielded a very noticeable, unnatural resultcommonly referred to as "dolls hair.")
A hair transplant specialist and his team can transplant 1500-3000 micrografts in a single session, depending on the quality of the donor area. Additional procedures may be required to achieve a greater density and as hair loss progresses. Hair transplant procedures are typically performed under local anesthesia and there is little or no pain during the procedure. The patient may or may not require a bandage overnight. On each transplanted graft, small crusts form within 24 hours, which are shed in 10-14 days. The sutures in the donor area are removed between 7-12 days after the procedure. With proper surgical technique, the minor scars that occur in the donor scalp are typically narrow, about the width of a pencil line, and are easily hidden by the surrounding hair. The graft sites in the recipient area usually heal with no visible scarring and are covered by the transplanted hair. The grafted follicles typically begin to grow hair in 6-12 weeks and will continue to grow for a lifetime.
Patients may undergo hair restoration surgery at any age. It is often wise to begin treatment before you are completely bald so that existing hair can be used to camouflage the procedures. However, because hair loss tends to be gradual and progressive and the donor area "finite," it is often unwise to begin surgical treatment in a very young patient. For men with mild to moderate hair loss, the use of medication, such as Finasteride and Minoxidil, can help preserve thinning hair in the crown area. Hair transplants can be used to fill-in or re-establish a frontal hairline as well as increase the density in the front half of the scalp. Medical treatment can be used to maintain the patients existing hair and thereby enhance the long-term results of hair restoration surgery.
Before embarking on a course of treatment, it is vital for the hair restoration physician to work closely with his patient to design an individualized plan that best fulfills their specific needs in the present, as well as the future. This usually occurs during an in-depth, one-on-one consultation. Realistic patient expectations are, of course, always essential when planning a hair restoration strategy or cosmetic procedure of any type. Typically, a combination of available medical and surgical "tools and techniques" are used in order to achieve each patients treatment goal.
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