Hair today, more hair tomorrow?
AN APPLE A DAY By Tyrone M. Reyes, M.D. Updated May 05, 2009 12:00 AM
For men and women experiencing the most common type of hair loss — androgenetic alopecia, or pattern hair loss — and pondering what, if anything, could be done about it, there’s a mix of encouraging and discouraging news. There’s still no great way to easily restore your hair to its former glory. No drug treatment has gained US FDA approval since 1997, and the most effective existing therapy — hair transplant — is expensive and unlikely to come down in price. But on a more positive note, for those who can afford them, hair transplants now offer increasingly satisfying results — thanks to improved surgical techniques. Also heartening is the news that recent biotechnology discoveries may lead to less invasive treatments.
As a teenager, the average person has about 100,000 scalp hairs. Nearly everyone experiences some hair loss with age, but for people with pattern hair loss — a genetic condition inherited from one’s parents that causes hair on top of the head to gradually fall out — the problem is more noticeable. About half of men have significant hair loss by about age 50, and 38 percent of women have it by age 70.
Pattern hair loss is caused by a gradual shrinkage of hair follicles on top of the head, so they become less effective at sprouting hair. Normally, each hair grows for two to six years, rests for several months, and falls out. Then a new hair emerges. In a healthier scalp, more than 90 percent of hair follicles are in the growth phase. But as our hair follicles shrink, the growth phase gets shorter and the resting phase, longer. The result is double trouble: Not only are the new hairs shorter, there are also fewer of them. These older, smaller follicles also produce thinner hair. Men with pattern hair loss (and a very small percentage of women) have a third problem: the follicles shrink so much they stop producing hair altogether, so the bald patch starts to take over.
Follicles become less productive because hormone levels change. An enzyme called 5-alpha-reductase converts testosterone to dihydrotestosterone(DHT), which stimulates the growth of hair follicles, but typically on the face and other parts of the body and not the scalp, where it has the opposite effect. Young men and women with androgenetic alopecia have higher levels of 5-alpha-reductase, as well as lower levels of an enzyme that converts testosterone into estrogen. Still, the cause of women’s pattern hair loss is less well understood. Researchers believe that several enzymes and hormones may combine to produce effects that are similar to DHT. Estrogen seems to be protective against hair loss, so some research suggests that the estrogen-to-testosterone ratio may be a factor. Although hair thinning can occur at any time after puberty, many women first experience it in their 50s, possibly as a result of ebbing estrogen levels.
In the early stages, you can minimize hair loss by treating your hair gently. Hair is more fragile when it’s wet, so it’s important to softly dry it with a towel — and don’t pull at it with a comb or brush. Twirling your hair can twist it off its follicle moorings. Head scratching may help you think, but it’s hard on your hair. If you’ve got an itchy scalp, the hair-friendly solution is to use some kind of an anti-itch shampoo. Hairstyles with braids — indeed, any style that pulls the hair back — can speed hair loss because they tug on the hair.
You can find plenty of treatments for hair loss on the Internet. Some are combinations of “specially formulated” shampoos and herbal supplements in capsule form that may have saw palmetto as an ingredient. But aside from paid “it really works” testimonials, there’s not much evidence that these remedies are effective. Save your money. Of course, a hairpiece of some sort is an option, but it tends to wear out or fade after a year or two of regular use because of combing, sun exposure, and routine cleaning. The less detectable ones are often expensive.
The US FDA has approved only two drugs for hair loss: over-the-counter minoxidil (Rogaine and generic) and prescription finasteride (Propecia). Minoxidil is available as a two-percent liquid solution for women and a two-percent or five-percent solution for men. In studies, between a quarter and a half of people who apply minoxidil twice a day notice a slowdown in their hair loss or even some hair regrowth. The most common side effects are itching and skin irritation, and the monthly cost is about P2,000.
Finasteride comes as a one-milligram tablet when used as a hair loss treatment. Men take it in larger doses as a treatment for an enlarged prostate gland. The drug, which blocks the conversion of testosterone to DHT, is only approved for use by men; some recent studies suggest that finasteride might be effective in women under certain circumstances, but early trials came out negative. Finasteride is more effective than minoxidil, with up to two-thirds of users reporting hair regrowth. It also costs about P 2,000 a month. Side effects are rare but may include impotence and decreased libido. A major drawback of minoxidil and finasteride is that you need to keep taking them to sustain the benefits. If you stop, your scalp will return to the balding state it was in before you started using the medicines. So year after year of treatment can start to get expensive. Doctors usually advise patients with significant pattern hair loss to try the conventional drug treatments for at least a year. If results aren’t satisfactory, a hair transplant is an option.
Splitting Hair Follicles
Hair transplants involve removing hair follicles from areas of growth on the sides of the head and implanting them in bald or thinning areas. One of the main obstacles is money: The labor-intensive surgery, which typically takes a surgical team of up to nine people five hours to perform, is expensive. One or two procedures may be needed for the best results. Hair transplant has steadily improved since its introduction in the 1950s, making for a more natural hairline and appearance. Surgeons have moved from large grafts (known as plugs) to a combination of minigrafts (three to six hair follicles) and micrografts (one or two hair follicles).
The most recent development, known as follicular unit transplantation, or FUT, continues the trend towards smaller and smaller grafts. A follicular unit is a small bundle that includes one to four follicles, oil glands, a tiny muscle, and other tissues. Once follicular units are extracted — either in a narrow strip or one unit at a time — the surgeon dissects away extra tissue before implanting the individual follicular units (see drawing on Page D-1).
This technique allows for a denser packing of transplanted hair and minimizes inadvertent damage to the follicles as they are being transplanted. FUT has improved results for women, so they’re now better candidates for hair transplantation. About 80 percent of transplanted hair falls out within three weeks, but about three months after that, the follicles start producing hair at a normal rate, and hair continues to grow from then on. Applying minoxidil can accelerate this process. Complications are rare but may include bleeding, infection, and scarring.
Several drugs that preserve the health of functioning follicles are in the pipeline. Conceptually, this is the same approach that minoxidil and finasteride take. But some companies hope to develop entirely new approaches that would involve creating hair follicles from scratch. One example started with a University of Pennsylvania researcher’s discovery that mice healing from wounds can produce new hair follicles. In a report published in 2007 in the prestigious scientific journal Nature, the researcher, Dr. George Cotsarelis, showed that when skin is damaged, the skin cells behave like stem cells and generate new hair follicles. A company he founded is working to apply the discovery to humans which, in theory, would involve using an abrasive gel to gently damage the skin and then the application of a topical cream to switch on the follicle-generating genes.
Another biotech possibility is a technique in which hair-forming cells are extracted, multiplied under controlled conditions (such as a culture), and reimplanted into the scalp.
Aside from the psychological implications, pattern hair loss has no negative health consequences. What you choose to do about it — which may be absolutely nothing — is a personal decision, best made after talking over the options with a dermatologist, family, and maybe some fairly objective friends. You’ll need to take into account your age, the extent of your hair loss, your expectations, and your bank account. There’s no right or wrong decision — just what you consider worthwhile relative to your personal appearance, inconvenience, and the cost.