For
thousands of years, hopeful and desperate men have fallen
prey to hucksters and salesmen hawking various potions
and ointments, with claims of miraculous balding cures.
The latest and greatest cures have never lived up to their
hype, leaving the balding victims poorer but (sometimes)
wiser. A powerful placebo effect (based on a strong desire
for the treatment to work), along with gullibility or
desperation, often resulted in a temporary sense of "improvement".
Eventually, however, the fact that there were no cures
for baldness became evident.
Even today, we have no miracle "cures" for baldness.
Even surgical hair restoration does not cure the balding
process; what it does is redistribute permanent hair to
balding areas. The same can be said of the two medical
or drug treatments that have been shown to be of use in
hair loss. Propecia, and especially Rogaine, do not so
much reverse balding, but halt or slow its progression.
Rogaine (minoxidil)
Minoxidil has been available in oral form for years. It
was originally developed as an agent for treating high
blood pressure; it had a number of significant side effects,
which limited its use to people with severe, refractory
high blood pressure, which was not completely responsive
to combinations of other medications. One of the less
dangerous, but quite obvious, side effects was "hypertrichosis",
or the growth of hair on the face or other areas of the
body.
Of course, someone had the bright idea that perhaps applying
this drug to the bald scalp might grow hair there. Thus,
Rogaine was developed by The Upjohn pharmaceutical company,
and the rest is history. Again, Rogaine does not cure
baldness; in fact, no one is quite sure how it works.
We do know that it does not grow hair on completely bald
scalp; rather, it tends to retard the loss of hair in
areas that are highly miniaturized. It may be that Rogaine
prolongs the growth phase of the hair (remember the anagen
cycle, that gets progressively shorter in the balding
process), which halts or slows the miniaturization process.
With the use of Rogaine, it may take 6 to 12 months to
notice a change; in fact, some people do not notice a
difference unless they stop using it. Within 2 to 3 months
of discontinuing the medication, any "regrowth"
or appearance of increased density will vanish. In other
words, even if Rogaine works for you, you must continue
the medication indefinitely, or any benefit will be lost.
Also, it is effective in the crown or top of the head,
but not in the frontal area. This is unfortunate, because
the front of the scalp and the hairline are the most cosmetically
important areas. (Please repeat after me! The utmost importance
of this primary rule of hair restoration will be reemphasized
over and over as we consider treatments for balding).
Rogaine also must be used twice a day; once a day application
has been clearly shown to be ineffective. In addition,
the growth may not be as great as one imagines; since
Rogaine probably works by increasing the thickness of
hairs which are already miniaturized, the most many patients
see is an apparent growth of fine, fuzzy hair which does
not tend to grow very long.
Women may also benefit from the use of Rogaine, especially
since their hair loss is often characterized by diffuse
thinning. If this is the case, a halting or reversal of
thinning may be possible with prolonged use; but as with
men, stopping the medication will result in a reversal
of the benefits.
Some hair restoration surgeons recommend that their transplant
patients use Rogaine before and then immediately after
the surgery, especially is grafts have been placed in
and around existing hair. The medication may help prevent
the temporary loss of healthy, preexisting hair due to
the shock of the procedure. Some surgeons do feel that
the medication should be stopped a week prior to the surgery,
because it dilates blood vessels, and might increase operative
bleeding.
Propecia (finasteride)
The drug finasteride (marketed as Proscar for symptoms
of prostate enlargement) has been available for years.
Only since 1998 has it been approved for use in male pattern
balding, and has been formulated as an oral, one milligram
tablet called Propecia (versus the five milligram Proscar).
This drug works by inhibiting the action of the enzyme
5-alpha-reductase, which, as you remember, is the enzyme
responsible for converting testosterone to dihydrotestosterone
(DHT). Men with pattern balding have higher levels of
this enzyme in and around the follicles that are at risk
for loss. It is the effect of DHT on the hair follicles
that leads to the miniaturization of terminal hairs. So,
if we inhibit 5-alpha-reductase, then we inhibit DHT formation,
decrease its levels in the blood stream and in the scalp,
and stop or slow the process of miniaturization that we
know as balding. Indeed, this is what was found in the
clinical studies on Propecia.
A word about hormone effects: DHT is responsible for facial
hair growth, increased incidence of acne, growth of the
prostate gland, and is integral in the development of
male pattern baldness (androgenetic alopecia). Testosterone,
on the other hand, is the classic "male" hormone,
and is responsible for the changes seen at puberty: lowering
of the voice, growth of the genitalia, an increase in
muscle mass, and increased libido or sex drive. When testosterone
is deficient, there may be decreased sex drive, erectile
dysfunction, depression, lack of normal "drive"
and ambition, and a loss of muscle mass. In other words,
most of what DHT effects, we can do without! Testosterone,
on the other hand, is extremely important. When men took
the one milligram dose of Propecia, their DHT levels dropped
by about two-thirds; on the other hand, testosterone levels
were not only maintained in the normal range, but increased
almost ten percent!
So the mechanism by which Propecia acts, unlike that of
Rogaine, is well understood. Let’s look at what
the studies and clinical trials showed about its effectiveness.
1,553 men, ages 18 to 41, with Norwood Class II Vertex,
III Vertex, IV or V balding patterns (which are mild to
moderate; the Class VI and VII are the most severe patterns)
were given Propecia. At two years, 83% of those taking
Propecia either grew more hair or at least lost no more.
However, this effect was much more noticeable in the crown
area than in the frontal or hairline zone. Also, the hairs
that did grow in were longer and thicker, or more like
terminal hairs, in contrast to the finer, shorter hair
seen with the use of
Rogaine.
Side effects seen were minimal in number. They included
different types of sexual dysfunction (decreased sex drive,
erectile dysfunction, decreased semen volume) at a total
incidence of 3.8%. However, the group that received the
placebo (sugar pill) had an incidence of 2.1%, which is
not a large difference at all. Furthermore, these sexual
side effects went away in all the men who stopped the
medication, and in almost two-thirds of those who continued
the medication!
6 to 12 months are required before any increase in hair
is apparent; any sexual side effects would have occurred
well before that time, so there is not a problem of losing
hair that was gained on the medication when one stops
taking it. Also, remember that if a person stops either
Propecia or Rogaine, any hair lost will be only that which
was gained or maintained while on the drug, and not any
other; in short, one returns to the state of balding one
would have experienced had one never taken the drug at
all.
Another interesting finding in patients on Propecia is
that it causes an approximately one-third reduction in
the level of prostate-specific antigen (PSA). PSA is used
as a screening test for prostate cancer; it also may be
elevated in men with enlargement of the prostate. There
has been some concern that this might compromise prostate
cancer screening, even though the decrease in PSA in fairly
predictable. To be safe, however, men should let their
primary physician know if they are taking Propecia, so
that this blunting effect on PSA can be taken into account.
Propecia does not seem to grow hair in areas that are
completely bald. Its effects are apparent only in areas
of the scalp that are thinning, but where there is still
some hair present. Therefore, the major benefit of the
drug seems to be in its ability to slow down or halt hair
loss, or regrow hair in parts of the scalp that are miniaturized.
The long-term ability of Propecia to maintain one's hair
is unknown. Effects usually peak around one year and then
are stable in the second year or decrease very slightly.
As previously stated, the benefits will stop if the medication
is discontinued. Over the 3-6 months following discontinuation
of Propecia, the hair loss pattern will generally return
its native state (that is, as if no medication had ever
been used).
Although both Propecia and Rogaine are FDA approved as
being safe and effective, this does not mean that all
the long term effects are known. Even though the side
effects are rare, we can see that the drugs’ actions
are not entirely confined to the scalp. We now have three
to four years of experience with Propecia; only over time
will the full ramifications of either of these agents
be fully evident.
Many hair transplant surgeons find Propecia to be an excellent
adjunctive medication, for several reasons: 1) Propecia
works best in younger men; some of them may not be hair
transplant candidates yet. 2) the medication works better
in the crown area, and often the crown requires more surgically
harvested donor hair than may be available. 3) Propecia
is less effective in the front. Hair transplantation has
its greatest impact on the hairline and in the frontal
area. 4) If Propecia continues to slow or halt hair loss
in the crown area, surgeons may be able to create greater
density in areas such as the front, which will have a
greater cosmetic effect, while sparing the all-important
donor hair for the future.
While not an actual hair growth or maintenance product,
there is a newer post-operative product that we will mention,
known as GraftCyte, which is manufactured by the ProCyte
Corporation. This line of products contains copper peptides,
which have been shown to help with wound healing. The
company makes a shampoo and conditioner, that are often
recommended after transplant surgery, as well as a spray
for hydrating the graft sites, and prepared, foil-wrapped
sets of copper peptide saturated gauzes designed to be
used for the first three post-operative days. In addition,
there is a gel to be placed on the donor incision in the
back of the head. All of these interventions may lead
to improved, more rapid healing.
There are also claims that using the GraftCyte products
promotes the more rapid growth of the transplanted hair.
This has yet to be proven in controlled trials, but many
people chose to use these products for their healing properties,
and hope that these unproven claims are true as well.
