Baldness

Hair Loss (= Alopecia)

Introduction

Some families have more members than others who develop baldness of the scalp. Baldness is common and the quest for a permanent baldness cure is also common. There is a baldness pattern in certain families and the baldness genetics that is inherited has been identified. There are also hormonal reasons for this. When all of the bad inherited factors come together, complete baldness will develop on top of the head in an early age (around 30 to 40), particularly with male baldness.

Most hair loss cases fall into the “androgenetic alopecia” where male hormones and inherited factors come together. By the age of 50 years about 50% of men and at the time of menopause 40% of women have significant hair loss. 5-alpha-reductase is an enzyme within prostatic tissue and in the hair follicle. In the prostate it metabolizes testosterone into dihydrotestosterone (=DHT). DHT is the “culprit” that is responsible in stimulating the prostate to grow 2-3 times the normal size after the male menopause, which occurs at about the age of 50.

This condition of prostate enlargement is called benign prostate hyperplasia or benign prostate hypertrophy (see details under this link). The same enzyme (5-alpha-reductase) is present in androgen susceptible hair follicles on the scalp and it converts testosterone to DHT. Too much of this leads to premature hair loss, but fortunately this can now be remedied. Here is an illustration what happens to the hair follicles under the influence of DHT in a sensitive male. Finasteride (Propecia) is a DHT inhibitor and this normalizes the hair growth in a large percentage of males treated with it (see below).

Symptoms:

In men hair loss presents in the frontotemporal and the top of the head (=vertex) regions. In women hair loss is more diffuse and occurs mainly in the center area of the top of the scalp and the adjacent parts on each side (high temporal areas). Men’s hair loss is classified according to the Norwood/Hamilton scale, women’s hair loss according to the Ludwig scale. The above links will connect you to a site where pictures of these patterns are shown.

Treatment:

The good news is that there are newer medications available that can in the case of male baldness be taken orally and in the case of female baldness it can be applied topically. Formale baldness where the problem is a genetic overabundance of the enzyme 5-alpha-reductase in the hair follicle, as explained above, this can be treated with finasteride, which inhibits this enzyme. 1 mg per day of this (brand name: Propecia) is sufficient and should show a response over a period of 2 years. Only, when this long trial does not work can it be called a “treatment failure”. 60 % of men respond and and about 80% stabilize after 2 years. This dosage of finasteride is about 1/5-th of that , which is used for most men with prostate hypertrophy. Female baldness is treated with topical minoxidil (brand name: Rogaine), which will show a 50% minimal regrowth response rate in women (using 2% minoxidil).

In women systemic androgen modulation using spironolactone (brand name: Aldactone) can be added, which is also marginally active. However, this has been largely replaced in 2007 by topical 2 % or 5% minoxidil for women according to Dr. Jerry Shapiro (Vancouver and New York) who spoke at a conference in Vancouver about this (Ref. 13). Minoxidil is available as a 5% solution without a prescription at Costco in the US. In Canada there is still a prescription needed for 5% and it has to be made up by the pharmacist, while the 2% solution is available without a prescription in drug stores in Canada. Ludwig type I and II has a 63% response rate in women and is safe to use the 5% Minoxidil solution daily once or twice (depending on how severe the hair loss is) for the rest of your life (according to Dr. Shapiro).

Those who do not respond to any of these therapies have to consider a permanent hair transplant procedure where small pieces of hair are taken from high densitiy growth areas and transplanted to the scalp, which has no or little hair. Lately mini- and micrografts, containing only 2 or 3 hairfollicles, have revolutionized this area of plastic surgical or dermatological surgical specialties. For Ludwig stage III in women and Norwood/Hamilton stage V to VII (see pictures under these links) these cosmetic surgical methods would be advisable.

Hair transplantation performed by professionals is the only safe and effective way to regain your hair; fully grown and with a natural appearance. To find qualified practitioners you could use the link above or google Medical Hair Restauration (American Board of Hair Restoration Surgery certified) to find an expert who could explain this procedure in more detail. When all else fails and the costs of surgical methods is not affordable, a simple hair piece wig would be a more economical solution (Ref. 8).

However, before this is contemplated, it would be wise to do a battery of hormone tests as outlined under this link to see whether bioidentical hormone replacement is indicated.