Hairloss Information

Unless you are one of the 20 million women or 40 million men in the U.S. who are currently experiencing hair loss, it is difficult to comprehend the emotions these individuals experience. Since most individuals many people view their hair as an important part of their identity, even modest amounts of hair loss can represent a source of anxiety and depression. Studies indicate that losing one's hair can take a heavy psychological toll. One particular study revealed that both women and men, with or without hair, view bald men as "less physically attractive, less socially skilled and less socially successful than their counterparts." Interestingly, the same study found that bald men are assumed to be more intelligent. Fortunately, for those follically challenged men not all women agree with the studies. "Bald men demonstrate confidence and self-assuredness, all that, coupled with a nicely shaped head is quite appealing," states Casandra Bronson, a 40 year old teacher consultant from flint Michigan. The distress felt by these individuals is also evident by the estimated two billion dollars men and women spend each year on hair loss products and treatments.

Normally, individuals will lose on average between 40-100 hairs per day of the 100,000 hairs present on the scalp. During any given time, 85-90 percent of an individuals hair is in the growing phase advancing in length by ½ -1 inch per month. Hair can continue to grow from 2-6 years, when the growth phase ends the hair follicle starts a 2-6 month phase of resting and then shedding. Usually, only 10-15 percent of an individual's hair is in the resting or shedding phase at any given time. Randomly, new hair follicles begin to replace the shedding follicles producing a healthy cycle. However, in cases of androgenetic allopecia this natural cycle is disrupted.

Ninety-five percent of hair loss is attributable to androgenetic alopecia, more commonly known as hereditary hair loss or in men male pattern baldness. In men, the condition frequently progresses to the horseshoe fringe of hair. While in women it manifests itself as a generalized thinning of the hair over the entire scalp. Several hypothesis for this condition exist, however, most research of late has focused on a genetic predisposition and the presence of dihydrotestosterone (DHT). Every hair has a genetic predisposition, the gene that determines whether an individual will be susceptible to androgenetic alopecia is located on non-sex chromosomes that determine the genetic makeup of all cells. Contrary to the popular myths concerning these genes they can be inherited from either parent's relatives. Researchers believe that DNA is somehow responsible for the increased sensitivity of hair follicles to the hormone DHT. This hormone results from the breakdown of testosterone by an enzyme called alpha-5 reductase.

DHT causes the hair follicle to atrophy, reducing in size until only vellus hair is produced. Vellus hairs are short fine non-pigmented hairs which are difficult to see. As the diameter of the hair shaft continues to decrease in size the sebaceous glands continue to secrete the same volume of sebum (fats and oils which lubricate the hair). This results in an oily scalp and subsequently flatter hair. The process continues until the vellus hair is no longer produced and individuals develop the characteristic hair loss pattern.

Although the majority of hair loss is secondary to androgenetic alopecia there are other significant causes of hair loss that should be addressed including the following:

• Alopecia areata is an immune system disorder that effects the hair follicles ability to produce hair. A sudden loss of hair from a small area is a common presenting symptom. Advanced forms of the disorder include alopecia totalis, where all hair on the head is lost and alopecia universlis, which results in the absence of all body hair.
• Pregnancy is a period when hormones can fluctuate considerably in women. While pregnant women are not especially prone to lose hair. However, two to three months post-partum, a significant number of hair follicles will enter the resting phase. Some women will experience considerable hair loss during this time for approximately one to six months. This condition is self-limiting and reverses in most cases.
• High fever is another cause of alopecia. Four to six weeks following a high fever or significant infection individuals may notice a significant amount hair loss. This condition is self-limiting and reverses in most cases.
• Nutritional deficiencies can be a rare cause of hair loss. Some vegetarians, individuals on fad diets, etc. who severely limit their intake of proteins may lose a significant amount of hair. In protein deficiencies the body will strive to save protein by shifting the hair follicles into the resting phase. Extensive hair loss is then demonstrated several months later. Iron deficiency is also a rare cause of hair loss. The process is reversed with the proper diet.
• Thyroid disease is another disorder associated with hair loss. Individuals with hyperthyroidism or hypothyroidism may experience hair loss. The diagnosis is usually established by a patient's history combined with laboratory results. Hair loss associated with a thyroid disorder is usually reversible with the proper medication.
• Prescription medications are another source for hair loss. Some examples of medications that are known to cause hair loss include: blood thinners, gout medications, anti-depressants, arthritic medications, hypertension medications, birth control pills, high doses of vitamin A, chemotherapy/radiation, etc.
• Major surgery may present excessive stress on the system that can result in hair loss. Hair loss is generally noticed one to three months following the surgery. The condition will usually reverse itself unless the individual has a chronic illness.
• Ringworm of the scalp, actually caused by fungus, begins with small patches of scaling that subsequently spread resulting in broken hair. This condition is contagious and is common in school aged children. The condition is resolved with oral or topical medication.
• Chemical products such as dyes, bleaches, tints, straighteners, perms, chlorine, etc. can all damage hair. These products when used excessively can dry hair out causing it to break at the roots.
• Traction alopecia is the loss of hair secondary to constant pulling as seen in tight ponytails, hair weaves, braids, etc.

With at least forty treatments for thinning hair patented last year and 200 million dollars budgeted for clinical trials in the near future, there is no mystery why there is so much confusion regarding the treatment of hair loss. However, of all the hundreds of shampoos, ointments, herbal supplements, gimmicks, etc. there are only two medications that meet the strict standards set forth by the FDA. Only Rogaine (minoxidil) and Propecia (finasteride) may state in their advertising and/or labeling that their product promotes hair growth or prevents the loss of hair. All the rest of the products many of whose effectiveness are exposed to minimal, if any, clinical trials should be purchased judicially.

Propecia is the latest medication to be approved by the FDA. Researchers have recently discovered that men who suffer from male pattern hair loss have increased levels of dihydrotestosterone (DHT). DHT is produced from testosterone through the activity of 5-alpha-reductase enzyme. Propecia inhibits 5-alpha-reductase, thus blocking the formation of DHT. This appears to interrupt a key element in the development of male pattern hair loss.

Clinical studies were conducted in men aged 18 to 41 with mild to moderate degrees of androgenic alopecia. All individuals treated with Propecia received a tar-based shampoo (Neutrogena T/Gel shampoo) and were instructed to wash their hair at least once per day. Clinical improvements were seen as early as three months into the treatment with Propecia. In men with vertex hair loss, global photographs revealed hair re-growth in 66 percent of the men. Furthermore, hair counts with these men indicated that 83 percent of the recipients had no further hair loss over the two-year clinical period.

Similar to all prescription medications, Propecia may cause some side effects. In clinical studies, side effects associated with Propecia were uncommon and did not affect most men. In fact, more individuals discontinued the placebo as compared to Propecia secondary to adverse experiences. A very small number of men, less than two percent, experienced certain sexual side effects including a decrease in libido and erectile dysfunction. Resolution occurred in all men who discontinued therapy with Propecia due to these side effects. The side effects also disappeared in most men, 58 percent, who continued taking Propecia.

Propecia is for the treatment of male pattern hair loss in men only. Women who are or may potentially be pregnant must not use Propecia and should not handle crushed or broken tablets of Propecia because it may cause potential risk to the development of the male sex organs. Propecia tablets are coated and will prevent contact with the active ingredient during normal handling, provided that the tablet has not been broken or crushed.

Minoxidil was first approved by the FDA in 1979 has hypertensive medication. However, some individuals began to develop hair everywhere. So Upjohn went back to the lab and developed a topical version of the medication. Ten years later minoxidil was re-introduced has Rogaine. The mechanism of action of Rogaine is basically unknown. The medication is known to be vasodilator, however, other medications that dilate the blood vessels do not stimulate hair growth. Rogaine is believed to work in part by partially enlarging miniaturized follicles and reversing the miniaturization process. This supposedly prolongs the growth phase of the hair cycle, allowing the hair to become thicker and longer.

Clinical trials have shown with the 2% solution that 26 percent of men ages 18-49 reported moderate to dense hair re-growth following four months of treatment. An additional 33 percent had minimal hair re-growth. Approximately 20 percent of women between the ages of 18-45 had moderate re-growth, while an additional 40 percent minimal re-growth. The new extra strength 5% Rogaine solution has demonstrated slightly improved results as compared to the 2% solution in men. Currently, the extra strength 5% solution is not recommended for women.

Side effects associated with Rogaine are minimal. The most common side effects reported during clinical trials were itching of the scalp and other skin irritations in the treated areas. These side effects are not serious and will cease upon discontinuation of the medication. Well-controlled clinical studies have not been conducted in pregnant or nursing women, therefore, the medication should not be used during these conditions.

There are some other topical treatment options that warrant some discussion at this time. Please keep in mind before you rush out to purchase any of the following products that there has been limited clinical testing concerning hair loss on these treatments.

Retinoic Acid was first FDA approved for acne under the trade name RETIN-A. Since then it has been discovered that retinoic acid can be used for several medical conditions, including hair loss. Retinoic acid is known to increase the absorption of other medications through the skin, therefore it is hypothesized that the retinoic when used in conjunction with minoxidil should increase the amount of minoxidil reaching the hair follicles. There is also some experimental evidence that indicates that retinoic acid may play a role in hair growth by presently unknown mechanisms. There have been case reports where the use of retinoic acid alone induced a significant amount of hair growth.

However, retinoic acid, does have some unwanted side effects associated with its use including: itchiness and flaking of the scalp (further contributing to dandruff), increased sensitivity to the sun, and similar to the use of minoxidil, a small percentage of patients may experience an initial increase of hair loss at the onset of treatment. However, usually this resolves with time. When first starting the formulation, start using it every other night for one week, then increase to ever night for one week, and finally increase to twice a day. This method of use will decrease the unwanted side effects.

Azelaic acid is a naturally occurring dicarboxylic acid found in whole grain cereals and animal products. The medication is FDA approved as a topical preparation to treat acne vulgaris. It is also used by dermatologist to lighten hyperpigmented skin. However, there is some scientific evidence that azelaic acid is a competitive inhibitor of Alpha-5 Reductase. Inhibiting Alpha-5 Reductase decreases the levels of DHT (dihydrotestosterone) in the scalp. Side effects associated with azelaic acid include: itchiness, tingling, or stinging sensation occurring in 1-5% of patients, redness, dryness and peeling of the skin seen in less than 1% of patients, some patients have noted a lightening of the skin.

Spironolactone is a "Potassium Sparing Diuretic" that has been used for decades to treat high blood pressure and fluid retention. However, there is also some scientific data suggesting a beneficial effect of spironolactone on hair loss. Spironolactone has been noted to have anti-androgen activity. Androgenetic alopecia (male and female patterned baldness) is heavily influenced by androgens (most specifically- DHT). Spironolactone binds to the receptor sites on the hair follicles which blocks DHT from having its deleterious affect on the hair follicle. Side effects associated with spironolactone are minimal now that spironolactone has been made into a topical solution, instead of a pill. Rarely, a patient will develop a rash from the spironolactone solution, which resolves upon dicontinuation of the lotion. The product also has a malodorous scent which is increased if spironolactone is combined in the same container with other chemicals (i.e.- minoxidil, retinoic acid). Sprironolactone solution is be applied to the balding scalp twice a day. It should be applied and allowed to dry (few minutes) before placing on the minoxidil solution.

For individuals who have not benefited from the pharmaceutical approach there are hairpieces. Interestingly, over a million men in the U.S. sport a hairpiece, spending some 350 million annually on the purchases and maintenance of these products. "You would think with all his money he would have a decent hair piece," is the quite frequently stated remark concerning men with ill-fitting hairpieces. However, cost has less to do with a good-looking hairpiece than does the selection of the manufacturer combined with the grooming and care given it by the wearer. An attractive hairpiece requires careful color matching, fitting, as well as subsequent styling and replacement. Unfortunately, many individuals fail to properly care for their hairpieces as time progresses. Hairpieces can be made from synthetic materials such as nylon or actual real human hair. Prices can vary considerably, small filler pieces may cost from $250.00 up, full wig $1000.00 up. The average hairpiece of good quality, synthetic or real will usually cost between $1000.00-$3,500.00.

The debate goes on, human hair verses synthetic hair. Human hair tends to react more to the sun and other elements such as chlorine. The most significant problem is the color of the hair fades with time. Human hair also requires more maintenance including monthly visits to the hair stylist for styling and cleaning, at a cost of $40-$60; periodic dyeing can cost another $75-$100. Additionally, hairpieces made from human hair rarely look appropriate longer one year. Manufacturers of synthetic hair claim their products look more natural, are water resistant, hold their shape better and last longer than human hair. However, individuals must still bring their hairpiece in for maintenance every four to six weeks, at a cost of $35-$50. Synthetic hair generally looks natural for up to two years. The decision human verses synthetic is primarily one of preference. Reputable hairpiece companies will encourage individuals to research both types of hair prior to purchasing.

For many men hairpieces for one reason or another is just not an option. Many of these individuals turn to hair transplants. According to the American Academy of Cosmetic Surgery, some 244,500 hair transplants were performed in the U.S. last year. The popularity of hair transplants combined with frustration of managed care has pushed all types of physicians into the field, which has historically consisted of dermatologist and plastic surgeons. The influx of new hair-transplant physicians has subsequently brought transplant prices down significantly from as high as $30.00 to as low as $4.00 per graft. This reduction in price is not necessarily favorable news for all patients. Some of the more reputable hair transplant centers have suggested that a third or more of their clientele result from patients looking for someone to repair the inadequacies of previous transplants.

During recent years, physicians have developed and refined new transplant techniques that represent the way hair grows naturally. Physicians now transplant hair using the mini/micro-graft procedure. Rather than creating rows or clumps of conspicuous hair the mini-graft transplant consist of much smaller grafts containing 3-6 hairs, approximately the size of a pinhead. Micro-grafts contain only 1-2 hairs and are used on the periphery to create a soft and natural hairline.

Donor sites are usually obtained from the posterior aspect of an individual's head. Usually a ½ to 1 x 3 to 5 inch donor strip of hair is surgically removed. The scalp is very elastic so the incision is simply pulled together and closed with sutures. The small suture line remains concealed by the existing hair.

The surgery team then delicately divides the donor graft into mini/micro grafts for transplant. The grafts are then implanted into the appropriate donor sites. The correct selection, placement and angle of the grafts remain the critical element in obtaining a positive result. Physicians must posses a unique artistic flare combined with surgical skill to create a natural appearance of the hair. Hair transplants have evolved to the point where they are done on an outpatient basis. Most surgeries last 3-4 hours and patients may return home a couple of hours following the procedure. A bandage is usually applied to keep the area clean and free from infection, patients are usually asked to return the next day for a follow-up appointment. Many patients return to work within 24 hours although strenuous activity is discouraged.

Fortunately the scalp is very vascular, so the healing process is relatively short. However, as with any surgery there is always risk of infection. Individuals may also experience some swelling of the forehead in the week following the surgery, some areas may also scab over. Patients should also realize that transplanted hair shaft often go into a resting phase shedding the existing hair. Usually within 3-6 months the transplanted hair follicles will begin to produce noticeable hair. There is a new FDA approved product developed by ProCyte called GraftCyte that helps prevent transplanted follicles from going into the resting phase so the transplanted hair does not shed as often.

The number of procedures required is dependent on the surface area that needs to be covered and the expectations of the patient. The human scalp averages one follicular unit per 1mm and each unit represents approximately 2.2 hairs. So a section of healthy scalp measuring 1cm by 10 cm would represent some 1000 follicular units or around 2,200 hairs. Normally two or three sessions are sufficient to get a natural appearance. Natural appearance does not necessarily dictate natural density. Hair loss remains a dynamic process and donor sites are limited, therefore, individuals are encouraged to be realistic about the density of their transplants.

For those individuals who desire more expedient or dramatic results there are several other surgical procedures:

• Scalp reductions involve surgically excising a section of bald scalp from the vertex of the head. Then the adjacent skin is extensively undermined so the surgeon can close the incision. Following a recover period, mini/micro grafts are later transplanted into the appropriate regions. Scalp reductions can cost between $2,000-$3,500 depending on the extent of the surgery.
  
  
  
• Transpositional flaps involve a series of procedures were a surgeon partially dissects a horseshoe section of skin containing healthy hair from the donor area. The free end is positioned over the follicular challenged area where a section of skin has been excised. The surgeon then closes the donor and recipient sites with sutures. Transplanted micro-grafts are then inserted to promote a natural look. Transpositional flaps can cost between $3,000-$9,000 depending upon the extent of the surgery.
  
  
  
• Free flaps represent an extensive surgery, first all or a portion of the bald area is excised. A section of micro vascular surgery, the blood vessels that supply nourishment to the donor flap are connected to the vessels in the new area. Sutures are then used to close both donor and recipient areas and transplanted micro-grafts are inserted to promote a natural look. There are some disadvantages to the flap procedures. Sometimes the resulting frontal hair does not appear natural and a scar along the hairline can be detected. Additionally, the hair of the flap may grow in a direction different from the natural hairs, giving an artificial look. Free flaps also cost between $3,000-$9,000 depending on the extent of the surgery.
  
• Tissue expanders are procedures involving two surgical sessions spaced approximately 8-12 weeks apart. Expanders are balloon-like devices, which are surgically inserted under the scalp during the first surgery. The expanders are then gradually filled with saline solution over a period of weeks. As the balloons expand, the skin supporting the healthy follicles is stretched. During the second surgery the expanders are removed, all or a portion of the bald area is excised and then the adjacent sections of healthy scalp are sutured together. The major disadvantage to this procedure is that individuals have to tolerate the strange appearance of balloons underneath their scalp for several weeks. Though men can find ways to camouflage this, most find it embarrassing. Average cost between $4,000-$6,000.
  
  
  
• Extender procedures involve two surgical sessions approximately four weeks apart. Extenders are elastic straps with small hooks attached at both ends. Initially, an extender is stretched and placed under the scalp with the hooks protruding up into the underside of the scalp. Over a period of weeks the extender draws together the healthy scalp from the periphery and extends the skin to the area where the bald spot was. During the second surgery, the extender is removed, all or part of the bald spot is excised, and then the adjacent sections of healthy scalp are sutured together. The disadvantages of this procedure are quite similar to the flap procedures. Average cost is between $4,000-$6,000.

The above mentioned procedures may be performed using local or general anesthesia depending upon the extent of the surgery. Surgical risk is similar to the mini/micro transplant procedures, there is always a risk of infection. In the US any licensed physician may perform hair surgery, many individuals end up with unsatisfactory results i.e. excessive scarring, patches of thin transplanted hair partially covering areas that continue to lose hair, loss of hair leaves the scars from previous surgeries visible, etc. Carefully and cautiously select a surgeon, beware of seductive marketing brochures showing after photos of men thick, full heads of hair. Ask for referrals, actually talk with individuals who the surgeon has treated. Check the credentials of the surgeon, individuals may contact The American Hair Loss Council phone 1-312-321-5128).

What about all the other products that are so cleverly marketed including mousses, volumizers , hair sprays, shampoos, conditioners, hot oils, etc? The first thing to remember is that many unethical companies are going to play on the emotions of individuals with hair loss. Companies will claim that their products have "secret constituents" that make an individual's hair "thicker and fuller" in hopes that sub-consciously the individual will believe that the product does actually grow hair. One thing is for certain, there will never be a "secret constituent" that actually works for hair loss. When the cure is discovered it is going to be huge. The news will be the first thing Peter Jennings mumbles on the evening news. An individual is not going to need an expert to explain to them the name of the medication, it will be common knowledge.

The following is a list of some common hair loss myths that companies exploit to sell their concoctions:

• Decreased electrical stimulation in the scalp as a cause for hair loss. Some companies will try to sell individuals "sessions" were they massage and electrically stimulate the scalp. Sorry, no clinical studies have ever shown electrical stimulation increases hair growth.
• Poor circulation in the scalp produces hair loss. This is false, clinical studies have shown repeatedly that the blood supply to an individual's scalp with hair loss is not compromised.
• Vitamin deficiencies are a cause of hair loss. Hair loss secondary to vitamin deficiencies is very rare in the US. In fact, vitamin toxicity (vitamin A) is responsible for more cases of hair loss than deficiencies in vitamins.
• Blocked follicles contributing to hair loss. Although individuals with hair loss may have an increase in the amount of sebum associated with their scalp. No study has ever indicated that the sebum could block a hair follicle from actually growing.
• Parasite such as ringworm is responsible for hair loss. Ringworm is actually a fungus. Although it does cause hair loss, it usually effects children. In addition, the hair loss associated with the fungus does not have the characteristic male pattern.
• Toweling off your head lightly rather than vigorously. This technique will postpone the inevitable around two or three days.

There are reputable products on the market that do not promote hair growth but they can help give the illusion that an individual has more hair. Regular shampooing is an important concept for individuals experiencing hair loss. The sebaceous glands continue to produce the same quantity of sebum even has hair follicles shrink. Therefore, the thinning hair shaft is subjected to more oil, which results in flat and/or dull looking hair. DHT is also found in high concentration sebum and is secreted with the oil onto the scalp. Regular shampooing prevents the scalp from reabsorbing the DHT so it cannot be recycled into the follicle, thus, preventing further damage. As a physician, patients commonly ask for a recommendation when it comes to shampoo. There are literally hundreds of shampoos currently on the market with a new product being introduced every day. The problem is each one of these products has a different marketing ploy that can be very confusing to consumers. The most inexpensive shampoo at neighborhood department store is probably the best, however, none of us would actually use that shampoo! The next choice would be the Neutrogena T/Gel shampoo. Neutrogena is a name that has become synonymous with quality products in the hospital. Merk Pharmaceuticals must also have some confidence in the Neutrogena products because that is the brand of shampoo they used in their clinical trials while testing the effectiveness of Propecia.

American men spend an estimated 60 million dollars per year on coloring their hair. Melanocytes, the cells containing the pigment, become dormant as individuals grow older. Usually Caucasian men begin to show signs of graying around age thirty-five, black individuals follow around ten years later. By age fifty, approximately 50 percent of all hairs on men are white. Many men resolve this condition by coloring their hair. Unlike women, hair coloring is not generally the primary topic of lunch for most men, they secretly color their hair. Home coloring techniques have improved significantly over the last several years. Men now have the option to accurately color their hair at home. Clairol's product, Men's Choice, provides five shades of color ranging from light brown to jet-black. The coloring process is simple, men just lather the lotion in their hair and then shampoo it out in two-five minutes depending how subtle or dramatic a change they prefer. The coloring process exhibits added benefits for those individuals with thinning hair. First, the dyes will color the thin blonde vellus hairs giving the illusion of more hair. Next, the coloring agents actually bind to the hair follicles making the follicles thicker which further contributes to the illusion.

Another product, that appears almost comical, is actually quite beneficial for those individuals who are experiencing subtle hair loss primarily on the vertex of their head. Remember the late night infomercials where the host pulls out this can of stuff, resembling spray paint, and the next thing you notice is the whole set has a haze finally surrounding it. Then when the haze finally settles, the host directs his attention to some poor follicley challenged individual whose head as been assaulted with a paint like substance. Today, this type of product has improved immensely, by matching a small area of the scalp with the hair color the illusion of more hair can be realized. For example, thinning hair in individuals with red hair is far less noticeable than in the general public. Dermatologist attribute this to how the course red hair matches or agrees the ruddy skin in these individuals.

In conclusion, if an individual is searching for an absolute truth in determining which one medication, product or surgery can reverse or prevent an individual's hair loss he or she will probably be very discourage and disheartened. There is no singular treatment that has been proven to be effective for every individual. However, most physicians agree that the best way to treat hair loss is to take the offensive, that is, begin a combined treatment with both Rogaine and Propecia prior to extensive thinning. Clinical tests have shown that both Rogaine and Propecia have significantly reduce the hair loss process as well as promote new hair growth. Studies have also shown that thinning hair shaft is subjected to more oil, which results in flat and/or dull looking hair. DHT is also found in high concentration sebum and is secreted with the oil onto the scalp. Regular shampooing prevents the scalp from reabsorbing the DHT so it cannot be recycled into the follicle, thus, preventing further damage. Frequent shampooing also prevents hair from appearing flat and dull. Probably the best shampoo on the market for men with thinning hair is the product Merk Pharmaceuticals trusted in their clinical trials with Propecia, Neutrogena T/Gel shampoo.