Hair Loss FAQ
The following are frequently asked questions regarding hair loss. For additional entries, please see the Hair Loss topic at the Hair Transplant Blog.
Q: I am 27 and have a Class 3 degree of hair loss. Should I do a hair transplant or consider non-surgical methods of hair restoration? ~ Y.G. Brooklyn, New York
A: At age 27, with early hair loss, you should consider the non-surgical options first. Propecia is the most important medication, but you need to be on it for a year at the full dose of 1mg a day to assess its benefits. If you have done this, and other parameters are OK for a hair transplant, such as adequate donor hair density & scalp laxity and you have little evidence that you will become extensively bald (i.e. no donor miniaturization and no family history of extensive baldness) then hair transplantation can be considered.
Q: I am 28 years old and was told that I have early Norwood Class 3 hair loss. I want to have a hair transplant but my doctor told me to use Propecia for 6 months and then come back to discuss surgery. I don’t want to wait that long, what should I do? ~ K.J., New York, NY
A: Actually, you should wait a full year. If you are an Early Norwood Class 3, the Propecia can work so well (in actually growing hair back) that you may not even need a hair transplant. The important point is that Propecia only starts working at 3-6 months and during this time there may actually be some shedding as the new growing hair literally pushes out the old. A hair transplant performed at 6 months may not only be unnecessary, but growth from the medication may be attributed to the hair restoration surgery. I suggest to wait and see what the medication can do before having hair restoration surgery.
Q: I had some side effects from Propecia after being on the medication for about 10 days that included decreased sex drive and difficulty in holding an erection. I would like to try to continue taking the medication. What should I do? ~ R.R., Tenafly, NJ
A: First, you should discuss this with your prescribing physician. In my practice, I generally advise patients to discontinue the Propecia until the side effects have disappeared, and then re-start at half the dose. If the side effects reoccur at the lower dose, then I would not use the medication.
Q: I am considering taking Propecia, but I went to my local pharmacy in New York City and it is so expensive. Is there a way I can get it cheaper? ~ J.M. – Brooklyn, NY
A: The website www.drugstore.com sells Propecia online at a reasonable price. A doctor’s prescription is required. The least expensive way to take Propecia is to purchase generic finasteride 5mg and a pill cutter and cut the pill into 4 parts. Take one part (1/4 of 5mg) a day. It is anticipated that Propecia will be available in generic form, as finasteride 1mg, towards the end of 2012.
Q: I have been taking Propecia for three months. Would it help to up my dose? ~ B.T – Scarsdale, New York
A: It seems that for most people (of average body weight of approx. 150 pounds) 1mg is the ideal dose. This is a statistical statement, however. There are occasional people who fall outside the bell curve. As we don’t know who these people will be, we generally increase the dose only on non-responders. It can take up to two years to see the full effects of the medication. Remember, an increased dose also increases the risk of side effects and for most people the greater dose offers no additional benefit.
Q: I’m currently 24 years old. Ever since turning 20, my hair on top began to thin little by little. I have noticeable thinning on the top part of my scalp and on my crown, but have no recession at the temples. My hairline looks amazingly young and hair on the donor areas seems quite thick. Am I in the early stages of male patterned baldness? I cannot place myself in the Norwood scale since my thinning doesn’t seem to follow the classic pattern. I just started on Propecia. Should I be considering a hair transplant? ~ E.G., Union City, New Jersey
A: From the description, it sounds like you have typical Diffuse Patterned Hair Loss (DPA). Please see Classification of Hair Loss in Men for more information. In this condition, the top of the scalp thins evenly, the donor area remains stable, and the hairline is preserved for a considerable period of time. Propecia would be the best treatment to start with. When the hair loss becomes more significant, patients with DPA are generally good candidates for surgical hair restoration. It is important, however, that before hair transplantation is considered, your donor area is checked for miniaturization to be sure that it is stable.
Q: I have early frontal thinning and was told that I am a Norwood Class 4A. I have been taking Propecia for several years. I recently went to see a doctor who told me go off Propecia and consider a hair transplant, since there is “no scientific evidence that Propecia works in the front of the scalp.” What should I do? ~ C.G., New York, NY
A: The fact that Propecia (finasteride 1mg) and Rogaine (minoxidil 5%) are not FDA approved for use in the front of the scalp relates to the fact that the drugs were not formally tested in these areas. Lack of FDA approval prevents the drug companies from making claims that go beyond the scope of the clinical trials. It does not mean, however, that the medications do not work in this area of the scalp.
We have seen many patients who have had early thinning in the frontal scalp and who have had a dramatic re-growth of hair using a combination of finasteride and minoxidil. The majority of patients with early hair loss get modest re-growth in the front of the scalp, although a good response is far from universal. The fact that DHT causes frontal hair loss and that Propecia blocks DHT, gives a logical explanation for the beneficial effects. See our page of before and after photos of treatment with hair loss medication alone.
Q: I am 19 years old and seem to be thinning all over, including the sides. My father has all of his hair but my grandfather is totally bald. Should I have a hair transplant now or wait until I am older? ~ K.C., Toms River, New Jersey
A: Most likely you have a type of androgenetic alopecia called Diffuse Unpatterned Alopecia (DUPA). In this hereditary condition, hair thins all over rather than just on the front, top and back as in the more common male pattern baldness. The fact that the back and sides of your scalp are thinning (the donor area) precludes you from being a candidate for surgery. The diagnosis can be made by observing a high degree of miniaturization (fine hair) in the donor area under magnification. For further information, please read the article “Follicular Transplantation: Patient Evaluation and Surgical Planning” that was published in 1997 in Dermatologic Surgery. Specifically look at the last part of the article.
Q: I was wondering why you chose two years as the amount of time one should wait to judge the effectiveness of Propecia. Have you had patients who only saw results after that long? Why does Merck say 3-6 months and Dr. Rassman at New Hair say 6-8 months. I know these numbers aren’t arbitrary, but I’m just wondering what the logic is behind this and how does this relate to planning a hair transplant? ~ K.L., Fort Lee, NJ
A: The Merck data showed that over 90% of patients had peak response at 1 year and this has been my experience as well. Most patients show the most dramatic response between 6 to 12 months with some getting additional benefit up to two years. Prior to 6 months, the results are quite variable and there may even be a net loss due to shedding during this period, as the Propecia stimulates a new anagen cycle.
Q: I am not yet ready for a hair transplant but am considering Propecia. What is your opinion on the “optimal dose”? I know Merck recommends 1 mg, but could I get away with taking less? Or would I get a better result by taking more (2-3 mgs)? G. H. New York, NY
A: You can probably get away with 0.5 mg a day, but there is a slightly greater incidence of non-responders at this dose than at 1mg. There is little evidence that a higher dose helps, but I often increase the dose if a patient has been on 1mg a day for 3-5 years and then stops responding.
Read more Q&A’s on Hair Loss at the Hair Transplant Blog.