It is an unfortunate fact of life that the majority of men will notice a decrease in the volume (thickness) of their hair as they age. In Caucasian males (the most prone to male pattern hair loss) a degree of hair loss probably occurs in 100 per cent. This can vary between a slightly receding hairline, a thinning crown, an overall reduction in apparent thickness, advanced receding from the forehead, very thin hair, and all the different stages through from being left with only a ‘horseshoe’ of hair going around the scalp from ear to ear, to baldness. The size of the horseshoe can also vary considerably, depending on genetic predisposition and the age at which thinning started.
Caucasians are the most effected. Black races less so, by probably about 50 per cent, and the extent of loss is also less. Asians are the least prone and don’t often go bald. An odd fact is that American Indians rarely, if ever, do either.
Male pattern hair loss has been mentioned historically as far back as 4000 years ago. At the time of the Roman Empire men wore their hair forward (like Julius Caesar) to hide their receding and thinning hair lines. And throughout history there have been countless baldness ‘cures’. The ancient Egyptians used snake oil extract, bird droppings and stinging nettles. Other bizarre remedies included blood from pregnant women and newborn babies, the menstrual flow of virgins, bat’s ears, rat entrails, bear’s grease, all sorts of plant mixtures and saps–and so it goes on. Although these days they are a little more sophisticated, so-called baldness cures don’t work either–at least the ones available over the counter don’t.
To start at the beginning, firstly, male pattern hair loss never starts before puberty. Perhaps in extreme cases where the genetic predisposition is strong, a small amount of hair thinning may occur pre-puberty.
There are a number of changes that take place coming up to, during and after puberty: the voice begins to change, becomes deeper and more resonant; sexual organs, testes and penis, enlarge and ejaculation becomes possible; the beard begins to become noticeable, the fluffier facial hairs get coarser leading to the necessity of shaving; hair begins to grow under the arms and the sexual parts, and hair can begin to grow on the chest and back. Every one of these changes is due to the increased production of androgens (male hormones), the most important of which is testosterone.
You may already be aware of it, but if not, look at the men on the beach or at a pool. The men with obviously thinning hair, and certainly those that are bald, have more hair on their body, particularly the chest and back, than the men with full heads of hair. An anomaly, you may think. It’s not. Body hair and beard hair are stimulated and become longer and stronger by the action of androgens. Scalp hair, on the other hand, is quite the reverse when the genetic predisposition is such that the scalp hair follicles are more sensitive to circulating androgens.
It is odd, too, that bald men are thought to be more virile, but this is only because bald men are more hairy chested, and hairy bodies give the impression of extra masculinity. These have nothing to do with vitality. It is, of course, a myth perpetuated by balding men! Simply, it’s all a matter of hair follicle sensitivity.
Asian men–Japanese and Chinese in particular–who are least prone to baldness also have least hair on their chest. Tell them they aren’t as virile!
To reiterate then, male pattern hair loss depends upon two main factors: genetics and androgens (male hormones), which is why the medical name for it is androgenetic or androgenic alopecia–alopecia is hair loss and androgenic is androgens plus genetics. You can’t have male pattern baldness without androgens; for example, there has never been a recorded case of baldness in eunuchs castrated before puberty. The proportion of androgens produced, testosterone being the main one, although playing a part in the degree of loss, does not need to be excessive. In fact, normal amounts of androgens or even sub-normal amounts can cause hair loss in genetically predisposed men. The more sensitive the hair follicles are to the presence of androgens, the greater the effect of the androgens on them.
It is commonly thought that the gene or genes responsible for hair loss are passed through the mother’s family. This is not necessarily true (see Chapter 27 on ‘Hair Myths’): it can be from either side. Sometimes there is no discernable loss in any of the family, but a quirk or some predisposition from way back shows itself. However, whatever the origin, to develop male pattern hair loss you must have hair follicles that are androgen sensitive. You may think it’s a case of chicken or egg–it’s not really. Firstly comes the predisposition or ‘sensitivity’: without it, androgens won’t effect the follicles.
Androgens restrict the growth cycle of hair. By not allowing the hair to reach its optimum growth, which is approximately three and a half years and 21 inches long, it stops at, say, three years, then two and a half years, two years and so on. A shorter growth phase results in the hair being shed sooner–hair doesn’t remain in the scalp unless it is growing. You may not always notice extra fall (although the chances are that you will), but a secondary change also occurs, i.e. the hair strands become finer, thinner in diameter. Two further things then occur. Firstly, thinner textured hairs resulting from hairs that were thicker also don’t grow as long. Additionally, they take up less space, so there is more area between the hairs. Compare 100 thumbs (as hairs) and 100 fingers on the same site. The ‘thumbs’ would have appeared to be thicker, which they were, and stronger, which they also were, compared to the fingers that are there now, giving less volume overall. The ‘fingers’ are eventually replaced by little fingers (‘pinkies’), lasting less time. And so it goes on until only fluffy hairs grow, or non-meaningful hairs as I call them–they don’t mean anything to the look of your hair because you can’t see them.
Research has shown that when a hair reaches a diameter of 40 microns, it rarely grows longer than 80mm (3 1/2 inches). This appears to be a crucial stage, when often the hair loss can appear to accelerate noticeably. However, sometimes the deterioration seems to stop and the quantity remains similar for a long time.
There are numerous instances when the rate of hair fall doesn’t noticeably change yet the hair is obviously getting thinner and receding. This is a slower progression and isn’t noticed until it reaches an obvious stage, whereby the man thinks it has happened very fast and can’t understand why he hadn’t noticed more hair fall (see Chapter 2 on ‘The Rules of Hair Growth’).
Everyone loses hairs daily, even if you don’t see them fall out, particularly if the hair is short. It’s the replacement hairs that have become gradually finer; then suddenly there is an awareness to the loss of volume or the recession, again the thought being that it has happened quickly. The rate of shedding and change in diameters also fluctuate. Often for no discernable reason your hair seems to go into remission and remain the same for months or longer–or even appear to improve. However, the changes over a year or two are usually remorseless.
There is no doubt that dietary factors enter into the equation, and a look at these by reading Chapter 17 on ‘Hair Nutrition’ will certainly help. But reading the chapter is obviously not enough: you have to do what it suggests! Particularly with adequate protein intake.
Keeping the scalp clean and exercised with daily washing and gentle kneading and massage–and not abusing your hair with hard brushing to pull it out–are also factors.
However, the primary consideration is to control the effect of the androgens on the ‘target site’: your hair follicles. There are two ways of doing this, either internally or externally.
The internal method tries to control the main culprit, which is di-hydro-testosterone (DHT). The testes produce testosterone. This on its own doesn’t do the damage: it’s when the conversion into DHT occurs that can be the problem. DHT can cause many of the miniaturizing changes in the hair shaft, and takes place in the presence of 5-alpha-reductase.
The latest drug to help counter this is Propecia (Finasteride). Finasteride was originally used to treat benign prostrate enlargement. It blocks the enzyme 5-alpha-reductase and helps to reduce the conversion rate and therefore the miniaturizing effect on the hair follicles.
Theoretically, all well and good. And it sounds a wonderful way to stop (and they claim reverse) male hair thinning. ‘They’ are Merck Sharpe & Dohme, a pharmaceutical company.
I met with some of their Research and Development and Sales people in 2001 after they had sent me details of clinical trials. The trials’ results were as thick as a book and as intriguing as a good novel. The recommended dose to treat benign prostrate enlargement is 5mg a day. This dosage may reduce volume of ejaculation by 25 per cent, reduces the size of the prostrate by about 20 per cent and lowers PSA (prostate specific antigen), the measurement of which indicates the degree of the prostate problem, by approximately 50 per cent.
At a dosage of 1mg a day for the treatment of male hair loss, none of these reductions occurred, although a small percentage noticed sexually adverse signs. It is interesting to note that in large long-term studies, 3.8 per cent of men taking Finasteride at 1mg a day noticed ‘erectile dysfunction’, but 2 per cent of those on placebo did, too! This indicates the psychological effects. In addition, the men on Finasteride noticed a considerable improvement in their hair after a year: 70 per cent reported no further hair loss and 37 per cent reported extra thickness. However, those on placebo also noticed an improvement, but less so: 44 per cent no further loss and 7 per cent extra hair. This was the front hair line and behind.
The crown area showed that 83 per cent on Propecia and 28 per cent on placebo had no further loss. Extra growth in the area was noticed in the Propecia users, and less so, but still significantly, in the placebo group. This also tends to indicate the ‘mind over matter’ aspect, but it does cast a certain amount of doubt on the methodology of the researchers. It’s not possible for a placebo to help over such a long period of time.
Theoretically, Propecia should help. Yet there is a further problem: there are two types of 5-alpha-reductase–Type I and Type II. It helps to block Type II but not Type I. So men with Type I of the enzyme may be unlucky.
Because I also believe that Propecia could be helpful, I have instigated a study in my clinic along with Dr Jeremy Gilkes, a dermatologist. It has recently started and will continue for at least another year or so. It is too early to judge, but the results so far are not as good as those given by Merck.
As a form of treatment, I am certainly not against it, and those of you who wish to try it should do so–it may help and could help, but I don’t think to the extent that it’s claimed.
Minoxidil, also known as Regaine (Rogaine) was initially marketed as an orally taken drug for hypertension. It was noticed that one of its side effects was randomly spaced hair growth on the face and body and sometimes on the scalp. This effect arises from the drug’s tendency to dilate the blood capillaries. On the basis of this, a 2 per cent solution was made and applied to the scalp. Studies indicated that this helped to reverse male pattern hair loss and the mixture was marketed, after FDA approval, about fifteen years ago. It has not lived up to its clinical trial results. The initial studies were based on hair counts (not dissimilar to Propecia). Observers counted at intervals the number of hairs on a circular area of scalp whilst using Minoxidil (and placebos). The method was brought into disrepute because it was found that the more experienced the observers became on counting the number of hairs, the more hairs they counted! Even the placebo controls had considerable increases.
Since then, Pharmacia Upjohn, the pharmaceutical company that produces Minoxidil, has made 3 per cent and ‘extra strength’ 5 per cent solutions available. Even with these, the results are disappointing. At first it seems they are helping–the solution darkens the vellus (fluffy) hairs and coats the hairs near the scalp with a stiffening film, giving the impression of more hair. All well and good–I’m all for improving the cosmetic appearance of quantity. The negative, though, is that the coating dulls the hair, gives it a brittle, dry look and feel, and often causes scalp flaking. Some of it is due to the inclusion of propylene glycol in the solution, which is necessary for the Minoxidil to dissolve.
I have not seen any noticeable improvement in the many hundreds of men and women that have been using it. However, intriguingly, even though they don’t see an improvement, most want to continue using it because they think their hair may get worse if they stop. Perhaps a valid point and another example of mind over matter, since, theoretically, it would probably make no difference. Minoxidil doesn’t effect androgens, 5-alpha-reductase or change the genetic aspects. Again, I’m not against its use. If you want to try it, do so. But be prepared, as with Propecia, for long-term use and not necessarily seeing the claimed benefits. However, there may be a possibility that the hair loss is slowed down.
Taking an anti-androgen–that is, a drug that reduces or blocks testosterone and therefore di-hydro-testosterone or 5-alpha-reductase–can certainly be beneficial to your hair. The amount needed to have an effect, though, can cause side effects: tender breasts, loss of libido and lower sperm counts. And sometimes even large doses do not sufficiently reach the target of the hair follicle.
Applied topically in the correct vehicle–a solution that enables penetration to the hair follicle–they can be very effective. I have already discussed the use of anti-androgens in Chapter 8 on ‘Hair Loss in Women’. With men, an externally dilute solution including cyproperone acetate (a very potent anti-androgen) and medroxy progesterone acetate has been found to have very good results. Recently, we included in the solution 3 per cent Minoxidil for some men. Not that the Minoxidil itself is beneficial, but it does help to dilate the blood capillaries, as explained when I was discussing Minoxidil. In this way the penetration of the anti-androgens can be more effective. Their use is long-term too, but there is no doubt about the therapeutic effect, whereby the hair loss is at least slowed, very often stopped and sometimes improved in overall thickness. Also, there are no side effects.
Many men want to try everything combined–Propecia, Minoxidil and topical anti-androgens–to cover all bases. This can also be good, not only because of their combined effect, but because it gives a feeling of satisfaction–almost euphoric–that they are doing everything possible.
The number of over-the-counter and mail order baldness cures is extraordinary. You would think, if you believed them, that everything is so easy. I wish it were. There is no over-the-counter product that is going to grow your hair once it’s gone. Minoxidil may slow it down, but even that in the long-term may be debatable.
I urge you not to waste your money pursuing the promised dreams from often spurious claimants. It is difficult enough with an ethical and knowledgeable professional, so don’t believe the ‘tests’ and the ‘results’ of non-scientific, incorrectly perused and unsubstantiated claims–even if they say they have met all the criteria of proof. I assure you that they haven’t. Avoid them all.
These should be viewed similarly unless they have an experienced, qualified professional in attendance–a Member of The Institute of Trichologists. If they ask for payment in advance, and this can run into thousands of pounds, leave! That is, if you’re tempted to go in the first place. Unethical and ‘cowboy’ clinics are the bane of my life, and I have seen so many people taken for a ride that I can’t emphasize strongly enough the necessity to avoid them.
