Hair Loss Treatments

As previously mentioned, male pattern baldness is progressive. Once it starts, it does not stop. Whether someone ever decides to have a hair transplant or not, if his hair loss bothers him, it is silly for him not to consider a medicine that can potentially stop it. And if he decides to try these medicines, that should be his goal—to stop it. His goal should not be to regrow hair. If that happens, he should just think of that as a bonus. If his only goal is regrowth, more than likely he will be disappointed.

If a man decides to go ahead with a transplant or if he has already had one, it only makes sense for him to try to save as much of his preexisting hair as possible. Is that good for my business? No. It would be great for income generation if all patients would just keep losing hair so that I need to continue to perform more and more transplants on them as time progresses. In reality, however, I think that eliminating further hair loss is good, if not great, for business. An ethical hair transplant surgeon’s goal should be to try and make the patient look as good as possible. I can make someone look much better by performing fewer transplants and having him maintain his preexisting hair with medicines. The patient must remember that with repeated hair transplants, at some point, he will exhaust his donor supply. That is, he will run out of hair to transplant.

As mentioned above, even if a patient does not choose to have a transplant, but finds the thought of further hair loss bothersome, he needs to consider one of these medicines. I have numerous patients who had thinning hair and opted to try these medicines instead of a transplant. While most of them have not regrown significant amounts of hair, they have stabilized their hair loss and are happy where they are.

There are several other issues that must be understood about these medicines in general. The first is the need to start these medicines as soon as possible since the primary goal is to save hair. If someone decides to have a transplant, that can be done any time. There is no time pressure with a transplant, but there is for these medicines. Patients also need to decide if they even want to start the transplant process at all if they do not know whether these medicines will work for them. Frequently, I will have patients use one of these medicines for six to twelve months or longer before having them decide whether they want to go ahead with a transplant. Patients must learn to think long term. What will their scalps look like in twenty years? Forty years?

If a patient decides to try one of these medicines, one of the great difficulties is actually judging whether it is effective or not. As mentioned earlier, he should be using these medicines to save hair. Hair loss typically progresses slowly and that makes determining whether they are effective difficult. I recommend that a patient use one of these medicines for six months before he makes a judgement. If he is lucky enough to see some regrowth, or if he is simply not losing as much hair, then judging is easy. If, as frequently occurs, he cannot tell whether it is helping, it probably is, and he should stick with it. If it is obviously ineffective (he is losing just as much hair as he ever was) he should consider switching to a different medicine. Of course, if he has a transplant when he is starting one of these medicines, that makes it even more difficult to judge.

If he does find a medicine that seems to work for him, he must understand that he cannot discontinue its use. It is a long term commitment because it will only work as long as he uses it. If he stops the medicine, he must expect his hair loss to resume. In fact, some experts feel the hair loss could accelerate and catch back up to where it would have been had he not been on the medicine at all.
In regards to regrowth of hair, this typically only occurs on the top or the back of the scalp but not in the front. This actually makes these medicines very complimentary with hair transplants, because I prefer to work on the front of the scalp before I consider working on the back.

Specifically, the two I will discuss in most detail are Rogaine (minoxodil) and Propecia (finasteride). These are the only two that have currently been adequately studied and approved by the F.D.A. (Food and Drug Administration) for hair loss.

Rogaine was originally used orally for high blood pressure, but researchers later found that it could be used topically to help with hair loss although its mechanism is not certain. This solution must be applied twice a day, every day, to the areas prone to hair loss (i.e. not just the crown, but also the front of the scalp). This medication is available over the counter in two strengths, 2% and 5%. The 5% is labeled “For Men Only”, but I always recommend that women use the 5% also since it is more effective and perfectly safe. It is believed to be able to stabilize hair loss in 70% to 80% of individuals, but its regrowth abilities are limited. Even if someone gets regrowth, it is typically fuzzy, short hair like the hair on the back of a hand. For a person who does not like to use oral medicines it is a great choice. Three primary problems exist with Rogaine. The first is that some people experience a red, dandruff-like eruption in the area of application. If this occurs, that person could try the 2% solution or anti-dandruff shampoos and a topical over-the-counter steroid solution such as Scalpicin, but in some people the reaction is bothersome enough that it is intolerable. The second is that Rogaine tends to interfere with hair styling after its application. The third problem is simply one of compliance. Frankly, many users get tired of having to apply it twice a day, month after month, year after year.

Propecia is the same medication as Proscar which is used for enlargement of the prostate, but at one fifth the dose. It helps block the conversion of testosterone to 5-DHT which balding follicles are susceptible to. As opposed to Rogaine, it is taken orally once a day. I usually ask men fifty or older to make sure they obtain a baseline prostate exam with a P.S.A. (prostate specific antigen) blood study prior to starting Propecia. If someone should later develop prostate problems, as every man probably will if he lives long enough, his urologist will appreciate these baseline values( besides, he should not be worrying about balding if he has not taken the time to check for prostate cancer which kills multitudes of men annually). Studies vary, but approximately 70% to 90% of men on Propecia can stop further balding. In regards to regrowth, Propecia is superior to Rogaine. At six months of use, 50% of men will have some regrowth. This increases to 67% of men after two years of use. Although not usually dense regrowth, it does tend to be good hair (good caliber and length) as opposed to Rogaine’s regrowth. Even if the patient does not get regrowth, there is a good chance that Propecia could reverse the miniaturization of balding. In other words, it can turn those fuzzy, short hairs in someone’s balding areas back to the original, thicker, longer hairs.

Propecia’s biggest drawback is the possibility of sexual side effects. These can range from decreased libido all the way to temporary impotence. These side effects only affect about 2% of men and are reversible after stopping the medicine. They seem to be more common the older the patient is. For those who develop sexual problems, I will ask them to stop the medicine for a month and then restart it at a lower dose of a pill every other day. At this lower dose, side effects are less common and most men can eventually get back to the regular dose.

Animal studies have shown that the combination of Rogaine and Propecia can be more effective than either one alone. If someone is interested in dual therapy, I certainly feel he is improving his odds of long term success. Rather than starting both simultaneously, I usually ask the patient to start one and use it for six months. If things are going well, then I will have him add the other medicine to the regimen. If the first medicine was ineffective at six months, then I will ask him to stop that one and switch to the other. If the
patient starts both at the same time, there will be no way for him to know whether only one is helping or if they both are.
Another medicine with the potential to help is dutasteride, which is a more powerful inhibitor of 5-DHT than Propecia. Apparently, controversey exists about this medicine and it is questionable whether it will be approved by the F.D.A. for hair loss.
Fewer choices are available for women. Rogaine is the primary medicine I recommend. A medicine called Aldactone (spironolactone) is occasionally utilized in women for its anti-androgen effect, but results are questionable. Propecia has not been effective for females and is only rarely used. More information is present in the women’s chapter.

Finally, I get numerous questions about the many different shampoos, topical medications, and health supplements which are widely advertised. In general, my response is that I have not seen enough credible research that suggests that these are effective hair loss medicines. These have not been well evaluated by the F.D.A. I also explain that if these were truly effective products, I would expect that the patent owners would be scrambling to get them evaluated with good scientific studies performed by reputable dermatologists
rather than just relying on advertising. I further explain that I do not know for sure they do not work, and if that is how someone prefers to spend his money, that is O.K. with me because I do not think they would be harmful. What I do not understand is why someone would prefer these unproven remedies over ones with years of reputable research to back up their claims.