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Balding and Hair Loss

Pharmacology

Traditional Approaches

A biopsy may be required to determine baldness type. A biopsy ascertains if hair follicles are normal.

Conventional choices can be used to treat hair loss: take better care of the scalp, use minoxidil (Rogaine®) and/or Proscar®, have hair transplants or a scalp reduction, or have hair replaced non-surgically.

Successful prevention and treatment of accelerated hair loss necessitates treating factors that are involved in contributing to the hair-loss process (excluding the genetic component).

Anti-Androgens

DHT (the male hormone dihydrotestosterone) is associated with premature hair loss. A wide variety of anti-androgens are used to prevent or reverse premature hair loss: progesterone, spironolactone (Aldactone®), flutamide (Eulexin®), finasteride (Proscar®), cimetidine (Tagamet®), Serenoa repens (Permixon®) and cyproterone acetate (Androcur/Diane®). The most effective anti-androgens are oral finasteride (Propecia®, Proscar®).

In hair-loss, an immune reaction caused by male hormones (e.g., DHT) has perhaps the most significant role. Stimulated by androgens, the immune system targets hair follicles in genetically susceptible areas and causes premature hair loss characteristic of male pattern baldness.25

Growth Stimulators

Topical oxygen free-radical scavengers such as superoxide dismutases (SODs) (enzymes that counter excessive free-radical activity) are potent hair-growth stimulators. SOD inhibits oxygen radicals, may inhibit a localized immune response implicated in hair loss, and offsets damage and inflammation.26 Unless immunologic factors involved in the hair loss process are effectively treated, potential for significant hair re-growth may be very limited.

Available agents (e.g., Rogaine®) stimulate some degree of hair growth in some individuals, but cannot by themselves produce healthy hair and cosmetic benefits. A multi-modal approach is required that combines anti-androgens, autoimmune system protective agents, oxygen free-radical inhibitors, and other hair-growth stimulators to halt hair loss and generate hair regrowth.

Finasteride

Finasteride (Proscar®) was originally developed to treat benign prostatic hyperplasia (BPH). It is available by prescription in 5 mg tablets. Finasteride (Propecia®) is FDA-approved for hair loss treatment. It is available by prescription in 1 mg tablets for men. Propecia® cannot be taken by women. Finasteride was once thought to be useless for androgenic alopecia treatment because it primarily affected 5-alpha-reductase, the type 2 DHT-producing enzyme. However, finasteride in doses as low as 0.2 mg daily maximally decrease scalp, skin, and serum DHT levels.27

Finasteride can produce visible hair growth in most men with mild-to-moderate alopecia and can stop hair loss in a majority of patients. Finasteride (1 mg daily over 5 years) was well-tolerated, produced durable improvement in scalp hair growth, and slowed further hair loss progression that occurred with no treatment.28 The most common side effect is decreased sexual desire or lowered amount of ejaculate (less than 2%, although men receiving placebo experienced the same side effects). Initial results of the Prostate Cancer Prevention Trial produced concerns that finasteride might promote prostate cancer. Finasteride was thought to reduce incidence of prostate cancer in men over 55 by one researcher; trial participants who developed prostate cancer had slightly more high-grade tumors.29

Dutasteride

Dutasteride (GG745), similar to Propecia®, blocks enzymatic conversion of testosterone to DHT. Unlike finasteride, dutasteride blocks two enzymes that create DHT rather than one and may be a more potent treatment for hair loss.30

Azulfidine

Azulfidine is an anti-inflammatory sulfa drug used to treat autoimmune disorders (e.g., rheumatoid arthritis and Crohn's disease). It is used in alopecia areata. In a clinical trial, azulfidine completely reversed alopecia areata in 23% of participants. Although some re-growth occurred in other participants, the majority had no effect.31

Minoxidil

Originally used to treat high blood pressure, minoxidil is now widely used as a topical solution applied twice daily to treat male pattern baldness. It may improve hair growth in 10 to 20% and slow hair loss in 90% of users. How minoxidil acts is unclear, but when effective, it appears to prolong the growing phase in the hair growth cycle, enlarge follicles, and cause dormant follicles to grow. Minoxidil may take 4 months or longer to produce results. Treatment is relatively expensive and must be continued indefinitely. When minoxidil is stopped, re-grown hair falls out. Newly grown hair may not be as long or thick as normal hair. Minoxidil is more effective in young men and men with recent-onset hair loss.32

Hair Transplantation

Early hair grafting techniques were somewhat crude, often leaving a “patchwork” appearance. Newer techniques transplant productive hair follicles from a donor area on the scalp to a balding area. Hair follicles are commonly taken in plugs of one or two hairs (micrografts) from the sides or back of the head and moved to the front and/or top, slowly reconstructing a hairline. Larger plugs of up to 10 hairs can be used. Donor sites with full hair produce more successful transplants. The flap technique transplants larger areas of hair from the sides and back of the scalp to the top of the head. Some scarring at the donor site may result. Transplanted follicles can be permanent or last only a few years.

Scalp Reduction

Balding scalp areas can be surgically removed to decrease an appearance of baldness. Scalp reduction is usually used in conjunction with grafts or flaps. Prior to reduction, the scalp may be stretched to expand areas of hair growth. Effectiveness of scalp reduction depends upon degree of hair loss and scalp elasticity.