By Dan Gwartney, MD
Once upon a time, men were afraid to reveal the relatively spherical shape of their heads, thinking they could disguise the fact that they did not actually have mushroom-shaped crania by growing a thick, disguising pad of hair atop their skulls. The 1970s and 1980s represented the pinnacle of hair absurdity, as evidenced by the 1976 movie “Car Wash” starring the late Richard Pryor and later spoofed by actor/comedian Will Ferrell in the 2008 movie “Semi-Pro.” In the late 1980s and through the 1990s, the on-court heroics of NBA superstar Michael Jordan popularized the pendulum swing to baldness.
Baldness remains popular, as it provides a clean and regular appearance; athletes, laborers and soldiers enjoy the cooling effect of losing the insulating effect of hair; and reportedly, many women find the look sexy. Yet, for many men, particularly those who are facing hair loss involuntarily, a thick head of hair remains the often-elusive goal. Hair loss is a distressing fact-of-life for many men and a surprisingly high percentage of women. The prevalence of hair loss (50 percent of men by age 50; 30 percent of women by age 70) has supported a burgeoning industry ranging from the worst examples of snake oil to proven but certainly not universally effective pharmaceutical products.1 Toupees resembling sleeping badgers are being replaced by hair transplant surgery that sometimes works, sometimes doesn’t – just like any other plastic surgery.
Hollywood makes fun of hair transplants and toupees; women and teenagers mock hair loss. Scripted as some of the testimonials in hair restoration commercials sound, the emotion expressed when the hair-impaired describe people staring at the bald spot is very real. In discussing hair loss and possible solutions, it is important to differentiate the problem causing the hair loss. This will often require a visit with a dermatologist who can often recommend or prescribe the appropriate treatment.
Estimates suggest that a “normal” person has approximately 100,000 hairs on his head.1 As we all know, hair grows and does so at an average rate of about a half-inch per month for three to five years.2 Of course, hair is not eternal, as strands (sometimes clumps) are found in sinks, brushes and combs daily – unfortunately, sometimes in food. Normal hair loss occurs continuously (50-100 hairs daily, according to those who have counted) as the pattern of hair growth allows for growth (anagen), followed by a dormant period that may last several months (telogen), then falling out and eventually being replaced by a new follicle (hair). At least, this is what is supposed to happen. If hair did not have a built-in “lifespan,” we would all be tripping over Rapunzel-length locks.
Hair loss can occur for a number of reasons. Stressed out editors may find themselves pulling their hair out as writing deadlines approach and assignments are late coming in. In fact, stress can be a cause of hair loss, but it is not the most common. Stress-related hair loss is called telogen effluvium.3 It is a temporary condition, linked both to physical stress (i.e., traumatic injury, serious illness) and psychological stress (i.e., loss of a loved one, financial crisis, divorce).4,5 The pattern of hair loss in telogen effluvium is an all-over thinning that can range from barely noticeable to very evident. If this pattern of hair loss is experienced, it is important to see a physician. If it is stress-related, obviously the care of a doctor or counselor is indicated, as the level of physical or emotional/mental stress is sufficient to affect one’s health. Importantly, telogen effluvium can also be due to underlying conditions or drug reactions that need to be diagnosed and treated promptly, and examples include: iron deficiency, malnourishment (especially protein deficiency), medications (i.e., ACE-inhibitors for high blood pressure, certain antidepressants, valproic acid – an anti-seizure medication).6,7 Fortunately, once the cause of telogen effluvium is discovered and treated, accelerated net hair loss stops and regrowth returns to normal over time.
Types of Hair Loss
Sometimes, hair falls out in patches for no apparent reason. This is not a thinning, but complete hair loss in areas ranging in size from smaller than a cm2 (square centimeter) to complete hair loss, including eyebrows, beard and even pubic hair. This pattern is seen in alopecia areata.8 The hair loss is often recurrent (meaning it will go away, then reappear) and can persist. The lifetime risk of alopecia areata is said to be 2 percent, meaning two out of every 100 people may experience this type of hair loss at some point in their life. If the condition results in complete hair loss, it is may be referred to as alopecia universalis.
Alopecia areata is an autoimmune condition, meaning an affected person is generating antibodies against his own hair follicles.9 Autoimmune conditions are unfortunately common (i.e., rheumatoid arthritis, lupus, certain thyroid conditions, etc.); people who have relatives who have developed an autoimmune condition appear to have a greater predisposition to developing alopecia areata. There is good news, though. As autoimmune disorders are relatively common, some progressing into serious or fatal threats, and with the continued growth in transplant medicine (implanted organs need to be protected from rejection, which is similar to the autoimmune process), a number of medical treatments have been developed to reduce the inflammation that damages/destroys the affected hair follicles. Topical anti-inflammatory steroid creams and direct injections of prednisose-like drugs are said to be successful in treating 75-80 percent of cases.2 This claim is controversial, as a systemic review concluded that most treatments are ineffective.8 In cases that do not respond to steroid treatment, more potent immune-suppressing drugs may be considered, but the use of such drugs carries a higher risk of adverse side effects.8,10 If a case of alopecia areata does not respond to conservative steroid treatment, referral to a dermatologist who specializes in hair loss is highly recommended.
While it is not uncommon to see a person pass by shedding hair due to telogen effluvium or suffering patchy hair loss as seen in alopecia areata, the prevalence of these conditions pale in comparison to the most common cause of hair loss, androgenetic alopecia. Commonly known as “male-pattern baldness,” androgenetic alopecia can affect women as well as men, though the age of onset is usually much later (typically after menopause has been established).11 Most men know a former classmate or neighbor who began to lose hair in his 20s or even teens. By age 50, more than 50 percent of men have some degree of male-pattern hair loss, according to some surveys.12
“Male-pattern” refers to the pattern of hair loss seen in androgenetic alopecia. Typically, the hairline recedes back with more extensive loss above the eyebrows than above the nose, resulting in an easily recognized appearance. Hair loss occurs at the vertex (top) of the head as well, which moves forward to meet the advancing line of baldness from the forehead. Hair along the temples and at the back of the head is not affected at the same rate, often leaving a “ring” of hair around the skull.
Unlike telogen effluvium and alopecia areata, male-pattern baldness is not considered a medical problem, but a cosmetic issue. As a result, many insurance policies do not cover clinic visits or treatments for the condition. However, the issue can be raised during a clinic visit for other purposes that are covered. It is certainly appropriate to ask about male-pattern baldness treatment options during a physical or a skin cancer screening.
Treatment options target one factor involved in androgenetic alopecia, that being a relative excess of the potent androgen dihydrotestosterone (DHT).13 DHT is a metabolite of testosterone that actually stimulates certain cell processes more so than testosterone. DHT is produced when the enzyme 5-alpha reductase converts testosterone to the androgenic metabolite. Many cells do not express 5-alpha reductase, such as skeletal muscle; while others have a high activity of the enzyme, such as the prostate and skin cells.14,15 The most commonly prescribed treatment for androgenetic alopecia, finasteride (Propecia) inhibits the actions of 5-alpha reductase.16 It is the same drug as is used in Proscar, which is prescribed for prostate enlargement. However, Propecia contains a lower dose of the drug finasteride. Propecia works in slowing hair loss for some men, but does not promise hair regrowth. In fact, the manufacturer’s website (www.propecia.com) suggests starting treatment as soon as hair loss is suspected. Be aware, finasteride and related drugs carry the risk of side effects, including a loss of libido, gynecomastia (breast development in men) and reduced sexual performance.16
Thanks, Mom and Dad
DHT is only one component of male-pattern balding. Genetics play a strong role in determining who will be afflicted with the condition, hence the term androgenetic.17 Since technology does not exist allowing one to choose his parents, the greatest value in this knowledge is awareness. Men who have a strong family history of baldness may benefit by monitoring for hair loss as they enter adulthood, as treatments work best early in the course of the condition.
Minoxidil was originally developed as a drug to treat high blood pressure. Doctors noticed patients were seeing hair growth and baldness reversal, prompting Upjohn to produce a topical product designed specifically to treat hair loss.18,19 Though it was originally available only by prescription, minoxidil is now marketed as an over-the-counter product (Rogaine) at two different strengths. Generally well-tolerated, minoxidil can be associated with side effects: acne, headaches, low blood pressure, fast heart rate, impotence, chest pain, etc. Many physicians feel Rogaine use carries greater risk in men with a history of heart problems. Most side effects are indicative of minoxidil’s effects on blood pressure and are a sign of toxic overuse; clinicians generally recommend starting with the lower strength product. Minoxidil produces better results if used by younger men (ages 18-41) before extensive hair loss has occurred. It has also been suggested that minoxidil works best on hair loss on the top of the head, rather than a receding hairline.
A final option that many men consider is hair restoration. Many clinics may advertise hair regrowth procedures, but as with any cosmetic procedure, results and patient satisfaction are very dependent upon the surgeon’s skill and experience. Interested parties should seek out a dermatologist or plastic surgeon specializing in this area. The specific procedure may vary somewhat, but generally involves taking healthy hair follicles from one part of a person’s head and implanting them into the thinning/balding region.1,2 Usually, the surgeon will prescribe supportive products such as minoxidil and finasteride; some may also recommend vitamin or protein supplementation. The process may not be successful, requiring additional treatments; some people fail in gaining a satisfactory outcome despite multiple implantations; hair restoration procedures are rarely covered by insurance. Out-of-pocket expenses are not insignificant and may easily exceed $10,000.
It is a much better world for men facing hair loss today compared to the “hairy” days of the 1960s through the 1980s. Not only is hair excess no longer in vogue, but baldness is even considered attractive by some. Yet, partial hair loss remains out of favor. Failed attempts such as spray-on hair, toupees, and the dreaded comb-over emphasize rather than disguise the perceived flaw, resulting in greater ridicule and scorn. This is particularly sad, as most cases of hair loss are unavoidable. Fortunately, physicians and even cosmetologists are more aware of the various hair-loss patterns, encouraging affected individuals to seek treatment at an earlier stage. Two common forms of hair loss are generally considered medical conditions. Thus, diagnosis and treatment are typically covered by insurance. Advances in immunosuppression offer hope to men and women suffering from alopecia areata; improved access to better nutrition and the lessened stigmata against mental health care allow for a more rapid resolution of telogen effluvium. For a man facing the challenge of androgenetic alopecia, the burden of treatment falls directly on his pocketbook. Yet, many men seek resolution to male-pattern balding, even at great expense, as it can dramatically impact a person’s self-esteem.20,21 Image is an individual matter; some are fine with the natural progression of their appearance as they age, while others hold a different standard. Finding comfort with oneself is not a frivolous matter and those concerned by unexplained or undesired hair loss should discuss their case with a qualified professional, as help may be available.
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