The latest on baldness cures
Although it’s a phenomenon deplored and often considered abnormal, hair loss is a genetically determined, irreversible, normal event in most men with advancing years. Some balding occurs in both men and women, but the pattern and type of hair loss varies in individuals and between the sexes. Humans are not the only primates to suffer baldness – orangutans and chimpanzees also start balding once they reach maturity. Despite popular folklore, there’s no link between baldness and male potency.
The average human scalp contains 100,000 hair follicles. Blond-haired heads tend to average about 25 per cent more hairs and red-haired scalps about 25 per cent fewer hairs than brown-haired scalps. With the spurt in androgen secretion at puberty, the hairline moves back a bit in 96 per cent of boys by their late teens. Male balding or androgenic alopecia goes in waves. The loss may begin at age 20, then stop, only to start up again a few years later. By age 20-30, 30 per cent of men have bald spots; by age 35 to 40, two thirds of Caucasian men are noticeably balding; by age 40-50 it rises to 40 per cent, and by age 50-60, half the men are significantly bald.
The mechanism of balding
Male-pattern baldness usually starts with receding hair at the temples, often combined with a balding spot at the back of the head. It slowly spreads, ultimately leaving just a horse-shoe-shaped fringe. Any remaining hair in the balding areas usually manifests some miniaturization – it is thinner and grows at a below-normal rate, changing from long, thick, coarse, pigmented hair into fine, depigmented sprouts. In women, balding affects predominantly the top of the head, but sometimes spreads over the whole scalp.
The rate of hair shedding is speeded up by three forces: advancing age, an inherited tendency to bald early (genes) and an overabundance of the male hormone dihydrotestosterone within the hair follicle. The extent of hair loss in any man depends largely on the genes he inherits from mother, father or both. About 50 per cent of children with a balding parent of either sex will become bald. There is usually a relationship between the age of onset and the ultimate hair loss – the earlier the age of onset, the more extensive the baldness.
Few of the touted baldness remedies really work
The much-advertised scalp lotions, shampoos and hair products are eagerly tried by balding men who want to regrow thinning hair. But until now, hair loss in either sex has not responded well to any anti-balding stimulants, applications, injections or other promoted treatments. No over-the-counter cosmetic products consistently and significantly arrest hair loss or help regrowth. Specific foods or vitamins don’t regrow hair– although good nutrition is essential for healthy hair. A few hormonal remedies can work temporarily: certain (oral) steroids induce hair regrowth for as long as they are taken, but the associated risks preclude their use. New products being investigated hold some promise.
Minoxidil still a mixed blessing
The most effective nonsurgical baldness remedy to date is the drug minoxidil, used as a topical solution and available, by prescription only, since 1988. Interest in topical minoxidil as a baldness remedy began with the observation that oral minoxidil (Loniten), a vasodilator taken for high blood pressure, caused hair growth and partly reversed baldness in some men. The action of minoxidil is not fully understood, but it might increase bloodflow to the scalp or stimulate hair follicle growth. Minoxidil (marketed as Regaine or Rogaine) applied every night in a two per cent solution stimulates hair regrowth on some balding scalps. The manufacturer recommends applying 1 ml, twice daily, regardless of the extent of hair loss. But less than 10 per cent of men taking it achieve satisfactory results, and regrowth never exceeds an inch and a half. In about a third of the men who have tried it, minoxidil produces a soft, downy fuzz; in the rest, no hair regrowth at all! The regrown hair falls out once minoxidil use stops.
The disadvantages of minoxidil are: its high cost (not covered by health insurance schemes as it’s considered a cosmetic); it only grows hair for as long as it’s applied; its success is unpredictable – only a few men (about eight per cent of those who try it) achieve satisfying results; and it takes months of daily application to discover if one is among the lucky few whose hair will grow back. Its side effects include itching and prickling, headaches (in 40 per cent), dizzy spells and, in some, heartbeat irregularities. Although apparently safe when rubbed into the scalp – since little is absorbed into the bloodstream – it is a vasodilator and not recommended for anyone with heart trouble. Its safety in men over age 49 and its long-term safety remain unknown. Some scientists believe that minoxidil is more effective in preventing hair loss than in promoting regrowth, but no controlled trials are available.
Recently proposed nonsurgical baldness remedies
One anti-androgenic drug now being tried as a baldness remedy is oral finasteride. It inhibits the 5-alpha reductase (enzyme) that transforms testosterone into the dihydrotestosterone (DHT) form responsible for hair loss. Blocking the action of DHT seems to stimulate growth of stronger, thicker and more pigmented hair. In one multicentre study, 200 males aged 18 to 35 with distinct baldness had a one-inch circle of scalp shaved and periodically examined for hair growth. The report states that “men taking 5 mg per day of oral finasteride had significantly increased hair growth. Side effects – such as impotence, loss of libido and reduced sperm counts – were not widespread, and often decreased with time, affecting about three per cent of the sample.” Ideal candidates for finasteride treatment are men who have already fathered all the children they wish, as its use for baldness might be lifelong and it could harm any fetus conceived (while taking it). Further studies are needed to assess the drug’s efficacy, dosage and long-term safety. (One such study will begin in January 1995 at the University of Toronto and volunteers are welcomed: Call the Health News office at 416/978-5411 for details. Another dihydrotestosterone-inhibitor now being tested is a derivative of hyaluronic acid, the chemical at the tip of sperm that aids penetration of the egg’s membrane. Massaged into the scalp, this substance apparently blocks the androgenic action that causes hair loss, but more research is needed.
Hair transplants a growing solution for baldness
Other than creative hairstyling and hairpieces, surgical hair transplants are the only realistic way to counter baldness. Hair transplantation (with or without scalp reduction) can remedy baldness in both men and women. Men who don’t have thick hair left at the donor sites (areas from which transplants are taken) are “poor” transplant prospects, while those with especially thick hair and/or small bald areas and/or lightcoloured hair are “good” candidates.
Surgical hair replacement simply redistributes scalp that is still growing hair. Hair-bearing areas are transplanted into the bald regions. “Scalp reduction” – removal of some bald scalp – is often used as an adjunct, if the bald area is large and the man wants all of it covered. When grafted or moved to another site on the skin, the parts of the scalp that still retain hair continue to produce it for as long as they would in the original site. Much like transplanted shrubs – roots and all – bits of growing hair transplanted to bald areas can grow well. The procedure does not stimulate new hair growth nor can it halt hair loss at bald sites that receive no hair transplants.
The types of graft used depend on what can realistically be done, the amount and type of hair left and the bald area to be covered. Traditional punch-graft surgery is performed in successive sessions, usually four months apart. It entails removal of 4 mm “plugs” of hair-growing scalp that are transplanted into small holes in the bald area. It takes many plugs of 10 to 15 hairs each to fill a bald spot. At each surgical session, only 75 to 100 plugs are usually transplanted, so as not to disturb the scalp’s blood supply or cause too much trauma. The plugs are planted in neat rows, according to a carefully structured plan. Within a couple of weeks, the hairs on the transplanted graft fall out and then regrow in a few months. Post-operative complications are few and minor. Pain is controlled by pain-killers (rarely needed for longer than the first 12-24 hours); bleeding is stopped by pressure and hair can be washed within a few days. It’s crucial to space the plugs carefully in the right direction, to avoid a messy or tufted look. If done incorrectly, the transplantee might end up with hair going in all directions, impossible to comb.
New advances can speed up hair transplantation
Recent advances in hair restoration include better ways of “harvesting” donor areas with less scarring, the use of tiny “slit” receptor sites (rather than punch holes), smaller (“mini”) hair grafts and “scalp extenders.” Slit grafting and mini hair grafts reduce the temporary “plugginess” or “doll’s head” look that was an unavoidable “transition” phase in older hair transplant methods. Four types of graft are now used: standard round grafts (bearing 10-15 hairs); round minigrafts (with 3-6 hairs); slit grafts (with 3-4 hairs); and micrografts (containing 1-2 hairs). “The fewer the hairs per graft,” notes one University of Toronto dermatologist, “the easier it is to obtain a nontufted, natural-looking growth.”
Scalp “extenders,” implanted after the removal of excess scalp, promise to reduce the number of scalp reductions, cut waiting time between reduction operations and lower costs. Traditionally, three-month waits were needed between scalp reductions but the process can be significantly shortened using a tissue extender, which is a sheet of elastic silicone material with titanium hooks at each end. The extender is stretched and hooked into the under-surface of the hair-bearing rim at the time of the first “reduction” procedure. As it contracts, trying to regain its original size, it pulls the hair-bearing fringes closer together, giving swifter results so that surgeons can remove more bald skin within a month or so. Summing up the benefits of hair extenders, one University of Toronto hair surgeon explains that: “With standard scalp reductions, it often takes three to nine months and four operations to remove enough bald skin, but with extenders it can take just over one month and two procedures. It is also cheaper as it requires fewer surgical operations.”
Currently debated issues in hair restoration concern the value of several grafting sessions versus fewer but longer operations; standard 10 to 15 hair grafts versus minigrafts or micrografts – or a combination of graft types. No matter what technique is used, hair transplantation is a “matter of trade-offs,” balancing the man’s wish for more hair against the “art of the possible.” For example, with a small donor area of remaining hair and a large bald area to cover, “it’s best,” suggests one expert, “to consider smaller grafts.” The same choice applies to slits and holes. While slits are easy to do and cause minimal scarring or damage to the surrounding hair, they do not provide as dense coverage as punches or holes. The larger the bald area, the greater the need for scalp-reduction. With small bald areas, “reduction” may not be needed.
Experts warn of unethical practices
The seemingly unlimited market for baldness “cures” can attract opportunists. One University of Toronto dermatologist warns that “since there are large sums involved in helping those who wish to recapture the looks of their youth, there is also a darker side to hair transplants, and a growing one at that.” One key problem is the tendency of some practitioners to do less-than-optimal surgery. “The development of minigraft techniques has revolutionized hair transplantation,” explains the dermatologist. “But as such grafts require lower levels of skill and training, some practitioners, for example, are doing a full-head hair transplant in one eight-and-a-half hour sitting – not an acceptable method in most cases.” Making the operation “sound easy” or “quick” can lure unsuspecting men into needless risks and disappointments. And as the field is not well policed, the number of distraught men turning to established professionals for “repair work” is skyrocketing.
Those considering transplantation should carefully check out the options, consult a family physician or dermatologist for initial advice about reliable specialists, become well informed about the pitfalls, pros and cons of hair grafting methods, and make sure they find someone who can help them take a wise decision. “Simply going by the newspaper, TV or other ads is not a wise idea,” concludes one dermatologist.
The hormonal link
The link between balding and male hormones is complex. While balding men don’t have higher than average circulating testosterone levels, they do possess above-average amounts of a powerful testosterone derivative, dihydrotestosterone, in the scalp follicles. Eunuchs, who produce no testosterone, never go bald – even if they carry a baldness gene. Men castrated before puberty do not get a receding hairline or become bald, and balding men castrated as adults lose no further hair. However, if castrated men with a family history of baldness are given testosterone, they lose hair in the classic pattern.
COPYRIGHT 1994 Strategic Inc. Communications Ltd.
COPYRIGHT 2008 Gale, Cengage Learning