Bernstein Medical - Center for Hair Restoration - Androgenetic Alopecia
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ISHRS Operation Restore

August was declared National Hair Loss Awareness Month by the American Academy of Dermatology (AAD) in 2001 in order to raise the public’s awareness of hair loss as a common problem affecting millions of men and women. In appreciation of this cause, Bernstein Medical – Center for Hair Restoration has launched a fundraiser for the International Society of Hair Restoration Surgery‘s (ISHRS) pro bono program, ‘Operation Restore.’ This program provides free hair transplants for those who experience localized hair loss due to trauma or illness.

Raising Awareness of Women’s Hair Loss

Now is the ideal time to bring awareness to women’s hair loss as the stigma of the topic has begun to diminish. Women’s hair loss is now frequently discussed in the media including television programs like the Dr. Oz Show and The Doctors, and in magazines such as Vogue, Cosmopolitan, The Wall Street Journal, New York Magazine, and New York Post.

Background

Androgenetic alopecia (common genetic hair loss) accounts for more than 95% of hair loss in both men and women. While some falsely believe that women do not experience hair loss, about 40 million women in the US alone are affected by hair loss, along with about 60 million men.

Other causes of hair loss include surgical and non-surgical trauma, congenital defects, auto-immune disease, and other medical illnesses. Radiation and cytostatic drugs or other forms of chemotherapy used in cancer treatments also causes hair loss. In cases where hair loss is localized, surgical hair restoration may provide benefit.

Our Cause

We understand the emotional toll hair loss can have on the individuals affected, especially when dealing with their other medical problems. Operation Restore and Bernstein Medical aim to help those who may benefit from hair transplant surgery by assisting in this process and covering expenses.

Dr. Bernstein has worked to advance the techniques of hair restoration and have helped tens of thousands of patients around the world. His pioneering work continues to make hair loss and its treatment more socially acceptable.

Click here to donate to Operation Restore! Bernstein Medical will match all donations made during this fundraising campaign. To qualify for the match, please ensure that you list “Bernstein Medical” in the “This Donation is Being Made on Behalf of:” box. Thank you for your support!

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A study published in the December 2015 issue of the Journal of Clinical and Aesthetic Dermatology suggests that Viviscal, an oral supplement designed for women with thinning hair, may promote hair growth. ((Ablon G, Dayan S. A Randomized, Double-blind, Placebo-controlled, Multi-center, Extension Trial Evaluating the Efficacy of a New Oral Supplement in Women with Self-perceived Thinning Hair. J Clin Aesthet Dermatol. 2015 Dec;8(12):15-21.)) The researchers noted a 79 percent increase in healthy, terminal hairs and an almost 12 percent increase in hair diameter in female patients who took the supplement for six months. The evidence suggests that Viviscal may be a useful supplement to current hair restoration treatments, or an alternative treatment in patients not indicated for hair transplant surgery or medical treatment with finasteride.

Background

Viviscal, produced by Lifes2good Inc., out of Chicago, Illinois, was launched in the U.S. in 2008. Its key ingredient is a proprietary mix of powders derived from sustainably-harvested shark and mollusk species. This “amino marine complex,” known as AminoMar C™, is blended with B and C vitamins, and minerals such as calcium, to make Viviscal “Professional Strength.” The active ingredients in the AminoMar complex are glycosaminoglycans (GAGs), a group of long-chain sugar molecules present in many living creatures. GAGs are especially adept at retaining water, and ingesting them may contribute to healthy hair and skin, although it is not clear if taken orally GAGs have any benefit in this regard. According to Viviscal, the beneficial effect on skin and hair of a fish- and protein-heavy diet was first observed in Inuit people in the late 1980s.

Dr. Glynis Ablon and her research team sought to determine if Viviscal “Professional Strength” tablets could successfully treat female hair loss. (The “Professional Strength” blend contains 25mg more of the AminoMar complex than the newer “Extra Strength” variety, as well as a different blend of extracts and additives.) If determined to be a viable treatment, Viviscal could be another option in an otherwise limited market of hair loss products for women. Many women with androgenetic alopecia (common genetic hair loss) are poor candidates for hair transplant surgery. Also, the use of Propecia (finasteride), the most effective hair loss medication available, is not indicated in women due to poor efficacy and the risk of potential side effects.

The Study & Findings

The study observed 40 women, aged 25-66, who self-reported some form of hair loss. An initial densitometry, to determine the progression of hair loss, was conducted on a 4cm2 target area of the frontal hairline. This was followed by the random distribution of either Viviscal or a placebo.

At 90 days on Viviscal, the researchers noted a 56% increase in terminal hairs in the target area and 10% increase in mean hair diameter. A nearly insignificant 1% rise was noted in the number of vellus hairs (non-mature or miniaturized hairs). Compared to the placebo group, the Viviscal group had 57% more terminal hairs, a 10% larger hair diameter, and 9% fewer vellus hairs.

At 180 days, compared to baseline, patients on Viviscal showed an almost 80% increase in terminal hairs, a hair diameter increase of 11.67%, and a 14% increase in vellus hairs. Compared to the placebo group at 180 days the Viviscal group had 77% more terminal hairs, an almost 10% larger hair diameter, and slightly more vellus hairs (1.5%).

Limitations of Ablon Study

The main limitation of the study lies in the potential conflict of interest between the researchers and Lifes2good. Dr. Ablon received a grant from Lifes2good as funding for the December 2015 study. In addition, no clear mechanism of action is proposed.  Finally, the cause of the volunteer’s hair loss was uncertain and probably represents several different diagnoses further confounding any explanation as to why the supplements might work.

Summary

Viviscal has the potential to supplement current treatments for hair loss or provide an alternative treatment for patients not indicated for hair transplant surgery or medical treatment. It would be especially useful for female patients who have relatively limited treatment options. It may also benefit men who are not good candidates for surgery. While the research findings are compelling, more investigation is necessary into the long-term efficacy of Viviscal and the effects of glycosaminoglycans on the hair growth cycle. Further study should be conducted by independent researchers in order to avoid the perception of a conflict of interest.

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A review of research on the efficacy of Viviscal, published in the September 2015 issue of the Journal of Drugs in Dermatology, suggests that the oral supplement may increase hair volume as well as the thickness of healthy, terminal hairs. ((Hornfeldt CS, et al. The Safety and Efficacy of a Sustainable Marine Extract for the Treatment of Thinning Hair: A Summary of New Clinical Research and Results from a Panel Discussion on the Problem of Thinning Hair and Current Treatments. J Drugs Dermatol. 2015 Sep;14(9):s15-22.)) The article presented more than two decades of research on the hair regrowth product and also included a discussion with a roundtable of dermatology and plastic surgery experts.

Both the research review and roundtable discussion point to the benefits of Viviscal, however the article’s conclusions can be questioned due to the appearance of a conflict of interest between the researchers and Lifes2good, Inc., the company that produces Viviscal. Additional independent research needs to determine if Viviscal is a viable and effective hair loss treatment.

Background

Viviscal, was launched in the U.S. in 2008 by Lifes2good Inc., Chicago, Illinois. Its key ingredient is a proprietary mix of powders derived from sustainably-harvested shark and mollusk species. The resulting “amino marine complex,” known as AminoMar C™, is blended with B and C vitamins, and minerals such as calcium to make Viviscal. The active ingredients in the AminoMar complex are called glycosaminoglycans (GAGs), a group of long chain sugar molecules present in many living creatures. GAGs hold water, and ingesting them may contribute to healthy hair and skin – although this is still speculative. According to Viviscal, the beneficial effect on skin and hair of a fish- and protein-heavy diet was first observed in Inuit people in the late 1980s. Viviscal is marketed primarily to women because of the relative dearth of effective hair loss treatments for female patients compared to men.

Review Article

The summary article by Hornfeldt, et al., ((Hornfeldt CS, et al. The Safety and Efficacy of a Sustainable Marine Extract for the Treatment of Thinning Hair: A Summary of New Clinical Research and Results from a Panel Discussion on the Problem of Thinning Hair and Current Treatments. J Drugs Dermatol. 2015 Sep;14(9):s15-22.)) notes that studies dating back to 1992 have suggested that Viviscal may treat hair loss to some degree. ((Lassus A, Eskelinen E, et al. A Comparative Study of a New Food Supplement, ViviScal®, with Fish Extract for the Treatment of Hereditary Androgenic Alopecia in Young Males. J Int Med Res. 1992 Nov;20(6):445-53.)) However, the more recent pivot to testing the supplement in women with thinning hair was pioneered by Dr. Glynis Ablon of the Ablon Skin Institute Research Center, Manhattan Beach, California. In a 2012 pilot study, Dr. Ablon found that Viviscal increased the number of terminal hairs by 211% and 225% after three months and six months, respectively. ((Ablon G. A Double-blind, Placebo-controlled Study Evaluating the Efficacy of an Oral Supplement in Women with Self-perceived Thinning Hair. J Clin Aesthet Dermatol. 2012 Nov;5(11):28-34.)) This was followed by a three month clinical study of women with self-perceived thinning hair; which the author attributed to poor diet, stress, hormones, or abnormal menstruation. In this study, published in early 2015, the mean number of terminal hairs increased by 32%, the count of shed hairs decreased by 39%, and subjects reported a significant increase in quality of life. ((Ablon G. A 3-Month, Randomized, Double-Blind, Placebo-Controlled Study Evaluating the Ability of an Extra-Strength Marine Protein Supplement to Promote Hair Growth and Decrease Shedding in Women with Self-Perceived Thinning Hair. Dermatol Res Pract. 2015; 841570.)) A similar randomized, placebo-controlled study, also led by Dr. Ablon and published in December 2015, found that female patients on Viviscal showed an almost 80% increase in terminal hairs and increase of 11.67% in hair diameter. ((Ablon G, Dayan S. A Randomized, Double-blind, Placebo-controlled, Multi-center, Extension Trial Evaluating the Efficacy of a New Oral Supplement in Women with Self-perceived Thinning Hair. J Clin Aesthet Dermatol. 2015 Dec;8(12):15-21.))

Some additional publications, such as Bloch’s 2014 study, ((Bloch L. Demonstrating the efficacy of a nutraceutical for promoting hair growth using a digital photography technique with posterior image analysis. Submitted for poster presentation at the 2015 World Hair Congress, Miami.)) suggest that Viviscal is effective in increasing patients’ hair volume and thickness. Another study published in 2014 suggests that Viviscal may improve scalp coverage and hair fullness in men with common baldness. ((Pinski KS. Patient satisfaction following the use of a hair fiber filler product to temporarily increase the thickness and fullness of thinning hair. Skinmed. 2014;12(5):278-281.))

In the roundtable discussion, which took place in August 2014, dermatology and plastic surgery physicians discussed findings of several clinical studies and reported a positive inclination to offer Viviscal as a treatment option. ((Hornfeldt CS, et al. The Safety and Efficacy of a Sustainable Marine Extract for the Treatment of Thinning Hair: A Summary of New Clinical Research and Results from a Panel Discussion on the Problem of Thinning Hair and Current Treatments. J Drugs Dermatol. 2015 Sep;14(9):s15-22.))

Limitations of Hornfeldt Review

The main limitation of the Hornfeldt article lies in the potential conflict of interest with the researchers and Lifes2good. Dr. Carl S. Hornfeldt received honoraria fees as a consultant for Lifes2good and his co-author of the review article, Mark Holland, is an employee of Lifes2good. Members of the expert roundtable advised Lifes2good on Viviscal or received an honorarium for their participation.

Summary

Viviscal has the potential to offer a new avenue of treatment for treating hair loss or supplementing current therapies. The review article provides a review of research and presents compelling findings over a span of two decades. However, more research is necessary into the long-term efficacy of Viviscal and the effects of glycosaminoglycans on the hair growth cycle. Also, given the appearance of a conflict of interest between the researchers and Lifes2good, it is particularly important that further research be conducted by independent investigators.

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Currently, only two FDA approved medical treatments exist for androgenic alopeciaminoxidil (Rogaine) and finasteride (Propecia) — but these drugs are not effective in all individuals, and to remain effective, both require consistent, daily, life-long use. Additionally, finasteride is not FDA approved for use in women.

Because of the need for additional hair loss treatment options, researchers have begun to look at low-level light laser therapy (LLLT), specifically red and near-infrared LLLT, due to its ability to promote hair growth by stimulating hair follicle cells ((Mester E, Szende B, Tota JG. Effect of laser on hair growth in mice. Kiserl Orvostud 1967;19:628–631.)) — a process called cellular photo-biostimulatiostimulation.

While many studies have investigated the effects of red and near-infrared LLLT on hair loss, specifically in the ranges of 635 to 780nm, there’s been no comprehensive survey of these studies to see if this treatment option has a consistent, positive effect on androgenic alopecia (genetic balding) for men and women.

To answer this question, researchers from the Harvard Medical School surveyed ((Avci P, Gupta GK, Clark J, Wikonkal N, Hamblin MR. Low-level laser (light) therapy (LLLT) for treatment of hair loss. Lasers Surg Med. 2014 Feb; 46(2):144-51.)) five clinical studies designed to measure the effects of LLLT on androgenic alopecia in both men and women. In each case, they found that red and near-infrared LLLT was a safe and effective treatment option for both men and women with genetic balding.

The authors propose that LLLT may work by supporting the anagen (growth) phase of the hair follicles affected by androgenic alopecia while also protecting them from alopecia’s inflammatory effects.

While the results in the studies were positive overall, the authors did note that the most therapeutic light wavelength and dosing remain to be determined.

Read more about Laser Therapy for Hair Loss

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Androgenetic Alopecia and Limited Medicated Treatment Options

Androgenetic alopecia (AGA) is the most common cause of hair loss in men and women. Over half of all men by the age of 50, and the same proportion of women by the age of 80, will experience some degree of permanent hair loss due to AGA.

Much is known about how AGA causes hair loss. Normally, hair follicles repeatedly cycle through growth (anagen) and rest (telogen) stages, but in individuals with AGA, hair follicles in genetically predetermined areas of the scalp gradually spend more and more time in the resting stage. Additionally, each growth stage produces a smaller and smaller hair shaft caused by a progressive miniaturization of the hair follicle. Eventually, the follicle stops producing hair ((Alonso L and Fuchs E. “The Hair Cycle,” February 1, 2006 J Cell Sci 119, 391-393.)).

Hair loss caused by AGA can be stopped by existing medications, but to date, only two FDA-approved drugs are available for treatment of AGA: finasteride (Proscar ®) and topical minoxidil (Rogaine®). Unfortunately, up to 3 out of 10 individuals will not respond to one or more of these drugs ((Fischer TW, Hipler UC, Elsner P. “Effect of Caffeine and Testosterone on the Proliferation of Human Hair Follicles in vitro.” Int J Dermatol 2007; 46: 27-35.)). Because of this, researchers have searched for alternate treatments, especially for women since finasteride is not approved for use in female patients.

Caffeine: A Possible Alternative Treatment?

One possible alternative substance is caffeine. This is because as a phosphodiesterase-inhibitor, caffeine increases cellular metabolic activity ((Green H. “Cyclic AMP in relation to proliferation of the epidermal cell: a new view.” Cell 1978;15: 801-11.)). Researchers theorize that this could counteract the miniaturization of the hair follicle ((Fischer TW, Hipler UC, Elsner P. “Effect of Caffeine and Testosterone on the Proliferation of Human Hair Follicles in vitro.” Int J Dermatol 2007; 46: 27-35.)).

Indeed, using cell-cultured (i.e., in vitro or “test tube”) male human hair follicles, researchers have demonstrated that caffeine reverses testosterone’s inhibitory effect on keratinocyte proliferation, which could lead to increased hair shaft cell production. Researchers have also demonstrated that caffeine normalizes testosterone’s inhibition of hair shaft elongation ((Fischer TW, Hipler UC, Elsner P. “Effect of Caffeine and Testosterone on the Proliferation of Human Hair Follicles in vitro.” Int J Dermatol 2007; 46: 27-35.)).

Evidence that Caffeine can Stimulate Hair Follicle Growth in Cell-Cultures and Protect those Hair Follicles from the Effects of AGA

A 2014 paper in the British Journal of Dermatology ((Fischer TW, Herczeg-Lisztes E, Funk W, Zillikens D, Bíró T, Paus R. “Differential effects of caffeine on hair shaft elongation, matrix and outer root sheath keratinocyte proliferation, and TGF-β2-/IGF-1-mediated regulation of hair cycle in male and female human hair follicles in vitro.” Br J Dermatol. 2014 May 16)). reported that caffeine stimulated hair growth in cell-cultured follicles in three ways:

  1. It enhanced hair shaft elongation in both male and female cell-cultured follicles.
  2. It increased the number of hair matrix keratinocytes, i.e., cells that create the hair shaft and its surrounding protective structure (the inner and outer root sheath), in both male and female cell-cultured hair follicles.
  3. It increased the stimulation of a hair growth factor called IGF-1 in both male and female cell-cultured hair follicles.

The paper also reported that caffeine may protect cell-cultured hair follicles against the effects of AGA in two ways:

  1. It reversed testosterone’s suppressive effects on the anagen (growth) stage of both male and female cell-cultured hair follicles, one of the primary mechanisms of hair loss in AGA.
  2. It protected both male and female cell-cultured hair follicle against apoptosis, a process that leads to the end of the anagen (growth) stage of hair follicles. This is significant because premature exit from anagen is another mechanism of hair loss in AGA.

In sum, this 2014 research not only replicates a past finding that caffeine counteracts some of the hair growth suppression mechanisms of AGA but also, for the first time, shows that caffeine stimulates hair growth in both male and female cell-cultured hair follicles. Its beneficial effects have yet to be shown in humans.

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In a study ((Shin JW, Kwon SH, Kim SA, Kim JY, Na JI, Chan Park K, Huh CH. Characteristics of robotically harvested hair follicles in Koreans. J Am Acad Dermatol, 2014 Sep 13. pii: S0190-9622(14)01789-7.)) published in the January 2014 issue of the journal ‘Dermatologic Surgery,’ researchers from the Republic of Korea collected and analyzed robotically harvested follicular units in a clinical setting using the ARTAS® Robotic System. This is the first time such data has been collected from Korean patients.

Specifically, they looked at the yield of follicular units, the ratio of successfully extracted follicular units to the total number of attempted extractions, and the rate at which hair follicles were transected, or damaged, during the procedure.

They found that the ARTAS system was able to harvest multiple hairs with high yields and low transection rates.

The Study: Characteristics of Robotically Harvested Hair Follicles in Koreans

The researchers collected data on robotically harvested follicular units from 22 Korean patients in a clinical setting using the ARTAS system. To reduce variation due to differences in patients, they collected follicular units from the same scalp location on each patient.

On average, the researchers found that 95% of extraction attempts were successful in producing a follicular unit, while the remaining 5% of attempts resulted in follicular units either being lost inside the robot’s suction system or becoming attached to the robot’s dissection instrument.

Of the successfully extracted follicular units, the average transection rate was 4.9%. This is 16% to 38% lower than has been reported elsewhere ((Wasserbauer S. Robotic assisted harvest of follicular units: Abstract book of 19th annual scientific meeting of International Society of Hair Restoration Surgery; September 14-18, 2011; Anchorage, AK. pp. 252-6.)), ((Kasai K, Haruyama I, Aikawa Y, Saito K. Advantages and disadvantages of FUE using ARTAS system form Japanese: Abstract book of 21st annual scientific meeting of International Society of Hair Restoration Surgery; October 23-26, 2013; San Francisco (CA). pp. 387-8.)). The researchers hypothesized that this lower transection rate could be due attribute these differences to the variability of a patient’s hair profile (e.g., waviness, thickness, color) and the surgeon’s minute control of the depth of punches.

Finally, they found that the robot was able to harvest follicular units that contained multiple hair follicles, anywhere from 2 to 5 follicles with the average being 2.4; However, they also found that as the number of hair follicles inside a follicular unit increased, the likelihood of transecting one or more follicles also increased.

The researchers concluded that the robot efficiently harvests not only follicular units with single hairs but also follicular units with multiple hairs. A limitation of the study was not comparing the characteristics of robotically harvested follicular units to manually harvested follicular units within the same group of patients.

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Q: How common is hair loss in adult men and women? — N.F., Bronxville, NY

A: The incidence of androgenetic alopecia (common baldness) is quite high for both men and women. By age 50, 50% of men and 30% of women are affected. By age 70, that increases to 80% of men and 60% of women. Fortunately, in spite of significant thinning, women often preserve their hairline and have a diffuse pattern, so their hair loss can be camouflaged for many years.

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Q: What is female androgenetic alopecia?

A: Female androgenetic alopecia, also called female pattern hair loss, is caused by the shrinking of susceptible hair follicles in response to normal levels of hormones (androgens). It is the most common type of hair loss in women, affecting perhaps 1/3 of the adult female population. It is seen as a general thinning over the entire scalp, but can also present in a more localized pattern i.e. just limited to the front and top. The condition is characterized by a gradual thinning and shortening (miniaturization) of individual hair follicles, rather than their complete loss and, although the condition tends to be progressive, it rarely leads to complete baldness.

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Q: What is Lichen planopilaris? — G.S., Pleasantville, NY

A: Lichen planopilaris (LPP) is a distinct variant of cicatricial (scarring) alopecia, a group of uncommon disorders which destroy the hair follicles and replace them with scar tissue. LPP is considered to have an autoimmune cause. In this condition, the body’s immune system attacks the hair follicles causing scarring and permanent hair loss. Clinically, LPP is characterized by the increased spacing of full thickness terminal hairs (due to follicular destruction) with associated redness around the follicles, scaling and areas of scarred scalp. In contrast, in androgenetic alopecia (AGA) or common baldness, one sees smaller, finer hairs (miniaturization) and non-inflamed, non-scarred scalp. Complicating the picture is that LPP and AGA can occur at the same time – particularly since the latter condition (common baldness) is so prevalent in the population (see photo). And LPP can involve the frontal area of the scalp, mimicking the pattern of common genetic hair loss. Interestingly, the condition is more common in women than in men.

For those considering a hair transplant, ruling out a diagnosis of LPP is particularly important as transplanted hair will often be rejected in patients with LPP. In common baldness, the disease resides in the follicles (i.e., a genetic sensitivity of the follicles to DHT). Since the donor hair follicles remain healthy, even when transplanted to a new location, we call common baldness donor dominant. It is the reason why hair transplantation works in persons with common baldness. In contrast, LPP is a recipient dominant condition. This means that the problem is in the recipient area skin, so if healthy hair is transplanted into an area affected by LPP the hair may be lost.

Because it is so important to rule out suspected LPP when considering a hair transplant and because it is often hard to make a definitive diagnosis on the physical exam alone, a scalp biopsy is often recommended when the diagnosis of LPP is being considered by your doctor. A scalp biopsy is a simple five minute office procedure, performed under local anesthesia. Generally one suture is used for the biopsy site and it heals with a barely detectable mark. It takes about a week to get the results. The biopsy can usually give the doctor a definitive answer on the presence or absence of LPP and guide further therapy. If the biopsy is negative, a hair transplant may be considered. If the biopsy shows lichen planopilaris, then medical therapy would be indicated.

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Q: Dr. Bernstein, I am an attending at Mass General Hospital in Boston and would like to ask you regarding your experiences using finasteride for male androgenetic alopecia. While I have not noticed any side effects in the patients that I have been treating, I increasingly get questions regarding side effects based on the recent media attention to reports of potentially permanent problems regarding libido or erectile dysfunction. I know that in the literature there is a slight increase of reversible sexual dysfunction (~4% vs. ~2% in placebo) with Propecia, and no convincing evidence to date in the medical literature that have used controlled studies regarding permanent problems even after discontinuing Propecia. — S.Z., Boston, Massachusetts

A: That is correct.

Q: I know that you have treated many patients over a long period of time, and I was thus wondering what your take is on potentially permanent sexual dysfunction after taking finasteride. Have you seen any convincing reports/patients or do you have any concerns regarding irreversible side effects?

A: I have seen 5 cases in over 10,000 patients on finasteride that complained of this but, of course, there is no way to know for sure if there is a cause and effect relationship. As you know, real side effects may be followed by psychological ones and if the sexual dysfunction has another cause, then stopping finasteride would have no effect on the symptoms. The incidence of intermittent or persistent sexual dysfunction in the general population of men is about 30%, so one would expect these numbers to be much higher just due to the normal incidence. It is really a difficult situation to understand. The experience that my colleagues and I have in our practices is much different than one would expect after reading the numerous anecdotal reports on the internet.

Q: Would you think it is safe to say that any potential sexual dysfunction is reversible after discontinuing the use of finasteride?

A: I don’t think that anyone knows at this point. The FDA is coming down on the side of caution and saying that it is possible, although it is not based on any new studies. If the phenomenon is real, the possible mechanism is not yet known.

Q: In the relatively few patients that I have treated with Propecia, they did not even report temporary problems regarding libido or erectile dysfunction. Do you think they are real or rather attributed to Propecia simply because the patient is made aware of these potential side effects?

A: I think that psychological effects may account for many cases. At this time, it is still not clear if a physiologic “post-finasteride syndrome” is real. A lot more work needs to be done before we have a definitive answer to this question.

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Q: I recently visited my dermatologist regarding my hair loss, and after checking my hair he said I am showing signs of Androgenetic Alopecia (common baldness), and said if I don’t treat it, it will progress. From my research on the net, I figured he will put me on Propecia. In fact he put me on Avodart. When I told him it is not FDA-approved for hair loss, and Propecia is, he said Avodart is better and brings DHT down more, and Propecia is nothing next to Avodart. He told me to take it every day for 2 weeks, then every other day from then on as it has a long half life. From researching on the net, many hair restoration doctors rarely prescribe Avodart for hair loss due to some dangers. What is your opinion on this? — T.G., Darien, Connecticut

A: Although dutasteride (Avodart) can be more effective for male pattern hair loss, I would start with finasteride (Propecia) as many patients do great with it and the safety profile is better. The following are things I would consider before starting dutasteride:

  1. As you point out, dutasteride is not FDA-approved for hair loss.
  2. There is no data on its safety when used for hair loss. This is important since dutasteride has been only tested on an older population of patients (with prostate disease) rather than a younger population of patients needing medical treatment for androgenetic alopecia.
  3. These is no natural model for dutasteride’s combined blockage of both type 1 and 2 5-alpha reductase (finasteride blocks only type 2 5-AR and there are families that have this deficiency and have no long-term problems. This, by the way, is how the drug was discovered).
  4. The type 1 enzyme which dutasteride blocks is present in many more tissues of the body (including the brain) compared to type 2 (which is more localized to the skin).
  5. Although so far unproven, there is a concern that finasteride may produce side effects than can be persistent after stopping the medication (post-finasteride syndrome). It this does turn out to be true, the effects from dutasteride would most likely be significantly more persistent.
  6. If you start with finasteride and do have side effects, you will most surely have side effects from dutasteride; therefore, by taking finasteride first you will have avoided the potentially more problematic side effects from dutasteride
  7. You may respond well to finasteride, and so do not need to consider dutasteride
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Journal of the American Academy of DermatologyA double-blind scientific study published in the May 2012 issue of the Journal of the American Academy of Dermatology has found that latanoprost, a drug that mimics naturally-derived compound molecules called prostaglandins, significantly increases hair density on the scalp after 24 weeks of treatment in young men with mild hair loss.

Latanoprost, like the eyelash restoration drug bimatoprost (better-known by its brand name Latisse), has been used to treat glaucoma. And like bimatoprost, latanoprost has been used to treat eyelash alopecia. The scientists who conducted the study sought to determine if latanoprost could stimulate hair growth when applied topically on the scalp.

While the sample size of the study was small (only 16 subjects), the researchers found that 50% of the subjects had statistically significant differences in hair density associated with increased hair pigmentation and thickness. Overall, at 24 weeks into the study, hair density had increased 22% in the entire study population. Another interesting finding is that the proportion of hairs in the anagen phase versus the telogen phase — referred to as the anagen/telogen ratio — remained stable. The authors of the study describe the significance of this finding:

“The stabile anagen/telogen ratio might indicate that latanoprost does not modify the length of anagen and telogen phases of individual hair follicles. However, as the absolute number of both anagen and telogen hair increased, it seems latanoprost recruits new hairs into the growth phase.”

In conclusion, the authors suggest that the study shows the possibilities of using prostaglandin analogues, like latanoprost, to treat androgenetic alopecia, or common hair loss on the scalp. More research is needed on latanoprost, or other prostaglandin analogues, to determine the ideal dosage and duration of treatment for hair loss.

Latisse, the brand owned by American pharmaceutical company Allergan, is currently being studied as a topical hair loss medication. The study will conclude in September 2012.

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Q: I am interested in trying home laser therapy for my androgenic alopecia? Which handheld laser device do you recommend? — N.M., Northfield, NJ

A: There are several handheld lasers currently marketed as a home use treatments for androgenic alopecia. To my knowledge there has never been a clinical study comparing different laser devices. Most of the devices use diodes to emit a narrow band red light. This wavelength of light is actually similar to those that are used in hair removal lasers, except they are at a much lower intensity. The theory is that high intensity laser damage hair follicles causing hair loss, but low level laser energy can have a bio-stimulation effect and actually induce hair growth.

If you would like to try laser therapy for hair loss, I suggest using a HairMax laser comb. This is the only device that is FDA approved. They sell a few different “strengths” of lasers for different costs. They have not shown any clinical evidence supporting one laser comb versus another. The more expensive ones have more diode lights so it would be reasonable to conclude that they are “stronger” and require less frequent use. I have patients who have used the “mid tier” laser comb, the Premium Lux 9 successfully, so that is the one I recommend to other patients.

Read more about Laser Therapy.

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Q: Have there been any lab studies proving that Saw Palmetto works to prevent hair loss? — A.B., Yonkers, NY

A: There have been no verifiable clinical studies that show saw palmetto can stop hair loss or cause hair to re-grow. There have been some preliminary tests showing that saw palmetto may be able to inhibit 5-alpha-reductase, but its usefulness for androgenetic hair loss has not been documented in controlled studies.

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Q: When was the ARTAS robot for FUE approved for use in hair transplantation? — J.B., Jersey City, NJ

A: Restoration Robotics’ ARTAS System for robotic follicular unit harvesting, received 510K clearance by the Food and Drug Administration (FDA) on April 14, 2011. The indication is for “harvesting hair follicles from the scalp in men diagnosed with androgenetic alopecia (male pattern hair loss) with black or brown straight hair.”

Read about robotic FUE hair transplantation

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Robert M. Bernstein M.D.

Q: I heard that the sexual side effects of Propecia are irreversible. Is this true? — L.R., Parsippany, NJ

A: The sexual side effects of finasteride (Propecia) begin to subside soon after the medication is discontinued. This would make sense since the drug finasteride is a reversible inhibitor of DHT. Although it is possible for side effects to be persistent after stopping the medication, this situation seems to be very uncommon and a cause and effect relationship is still in question.

One should consider that sexual dysfunction is relatively common in the adult male population and millions of patients take finasteride. Thus, there is a likely probability that some patients on finasteride may experience sexual dysfunction unrelated to the medication and, therefore, when the medication is stopped, the side effects would not be expected to go away.

Another thing to consider is that once a patient experiences sexual dysfunction (from a medication or another reason) psychological factors may come into play that make the side effects persist, even though they are unrelated to the medication or other underlying cause that may now be gone.

It is important to keep in mind that medication plays an important role in the prevention and treatment of androgenetic alopecia and decisions to use medications should be done thoughtfully and in an informed way. Blog postings can offer some subjective information, but they do not constitute true research and should be used in conjunction with the information provided by your physician and other informed sources.

Learn more about Propecia (finasteride) and other hair loss medication.

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Q: I saw your post on the clinical trials of Latisse (bimatoprost) for hair loss on the scalp. What is the status of the study? — B.V., New Providence, NJ

A: Allergan, the company that makes Latisse, conducted safety and efficacy testing of three formulations of the drug for men with androgenetic alopecia (male pattern baldness). Latisse is a drug that is approved by the FDA to help eyelash growth at a concentration of 0.03 %. The drug is applied daily to the upper eyelid.

Allergan studied the results of three formulations of Latisse (Bimatoprost .03% Opthalmic Solution) comparing them to results of a control option and also an over-the-counter minoxidil 5% solution. The drugs were applied directly to the scalp, and the progression of hair loss was measured.

This study began in June 2011 and the results were published in April 2014. The results of the study did not indicate that Latisse would be a viable alternative to use on the scalp to prevent hair loss.

It should also be noted that the cost of bimatoprost, the active ingredient in Latisse is significantly more expensive than minoxidil, the active ingredient in Rogaine. This means that even if the two treatments were equally effective, it would be cost-prohibitive to treat baldness with Latisse.

Latisee (Bimatoprost .03% Opthalmic Solution) has not been FDA approved for the treatment of scalp hair loss.

For more information, view the results and details of the study on ClinicalTrials.gov .

Read more about Latisse/Bimatoprost.

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Q: There was a retrospective study by Lotufo et al. linking male pattern baldness to heart disease. Do you think there are other links like this for androgenetic alopecia? — J.L., San Francisco, CA

A: Family studies revealed both the androgen receptor locus on the X chromosome, as well as a new locus on chromosome 3q26. Association studies performed in two independent groups revealed a locus on chromosome 20 (not near any known genes) as well as the androgen receptor on the X chromosome.

So far, the genetic studies for androgenetic alopecia (AGA) have not revealed identification of a particular gene other than the androgen receptor, as well as the two candidate regions on chromosomes 3 and 20. Inasmuch as the androgen receptor can be involved in other diseases, this might be a feasible connection. Until candidate genes are identified that underlie AGA, it is impossible to predict where the commonalities might lie.

Excerpted from Angela Christiano, Hair Transplant Forum International 2011; 21(1): 14-15.

Read more about Hair Loss Genetics, and see some other Hair Restoration Answers posts on the topic.

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After trading anecdotes with fellow hair loss physicians about how finasteride can reduce body hair in some patients, Sharon A. Keene, M.D. took the next logical step and asked whether finasteride might have a negative effect on patients who have body hair transplant (BHT) procedures.

In a review of scientific literature on whether finasteride effects body hair growth, Dr. Keene finds that current research is inconclusive.

Finasteride, the drug in the hair loss medication Propecia, works by blocking the 5-alpha-reductase type 2 enzyme (5-AR Type 2) which is needed by the body to covert testosterone to DHT. DHT causes common baldness, by making hair follicles shrink and eventually die.

In looking at DHT’s effect on body hair growth, current research strongly suggests that it does play a key role. Males born with a deficiency of 5-AR Type 2, and thus no DHT, have reduced, or absent, body hair growth (and no loss of scalp hair).

It would seem logical then, that when finasteride is used to re-grow hair on the scalp, it would also inhibit the growth of hair on the body. However, the genetic variation among people is too great to determine exactly how much of an influence it plays.

With this uncertainty of DHT’s effects on body hair, it is impossible to say, without further study, if finasteride would have the same effect on body hairs which are transplanted to the scalp. In Dr. Keene’s conclusion, she suggests:

A patient on finasteride for at least a year who undergoes BHT is probably safe to continue it, as remaining body hairs are apparently not sensitive to the effects of this drug.

You can read the full discussion and review of current research in the January/February 2011 issue of Hair Transplant Forum International, the official newsletter of the International Society of Hair Restoration Surgery (ISHRS).

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Dr. Christiano Interviewed on Alopecia, Hair Loss by New York TimesDr. Angela Christiano, a colleague of Dr. Bernstein’s at Columbia University, has been studying the causes of alopecia areata and genetic hair loss for many years. She, in fact, suffers from the disease as well.

The New York Times has published a question and answer interview with Dr. Christiano which covers her own struggle with alopecia, her research into the causes of genetic hair loss, and where she sees the field going in the future. Here is one exchange that offers a window into how her research is breaking new ground in the field of hair loss genetics:

Q. When were you able to actually do the study?

A. In 2008. We published our findings this past July. Ours was the first study of alopecia to use a genome-wide approach. By checking the DNA of 1,000 alopecia patients against a control group of 1,000 without it, we identified 139 markers for the disease across the genome.

We also found a big surprise. For years, people thought that alopecia was probably the stepchild of autoimmune skin diseases like psoriasis and vitiligo. The astonishing news is that it shares virtually no genes with those. It’s actually linked to rheumatoid arthritis, diabetes 1 and celiac disease.

Continued discovery by Dr. Christiano and others in the field of hair loss genetics will lead to clues like these, which will shape the future of hair loss treatment. The hope for hair loss sufferers around the world is that a medical treatment can be developed which will effectively cure androgenetic alopecia, or common baldness. There is a lot of ground to be covered and there are many studies yet to be conducted, but progress is being made.

You can read more about Dr. Christiano’s research on our Hair Loss Genetics News page.

Read the article and listen to a two minute audio stream of the interview at the NYT.

Photo c/o Ruth Fremson/The New York Times

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The Early Show - CBS NewsCBS News’ The Early Show has picked up the “balding buzz” that first started to grow when the National Enquirer reported that New England Patriots star quarterback Tom Brady is seeking advice on how to treat his hair loss.

Like the New York Daily News did recently, CBS turned to Dr. Bernstein for his expert medical opinion on Brady’s hair loss.

The Early Show website features the story. Here is a snippet:

Dr. Robert M. Bernstein, clinical professor of Dermatology at Columbia University, told CBS News, “It looks like Tom Brady is starting to comb his hair forward and he has some recession in his temples, so those are kinds of signs that he starting to lose his hair.”

And if Tom Brady is in fact “folically challenged,” he has plenty of company. By middle age, “Early Show” co-anchor Erica Hill reported, about 50 percent of men experience hair loss. And there are plenty of receding hair lines in Hollywood to comb through for advice. John Travolta is rumored to wear a hair piece, while Bruce Willis and tennis great Andre Agassi fully embrace their losses with clean-shaven heads. But for younger guys, like Prince William – only 28 and thinning – a bald head might not be the best bet.

Brady’s hair loss likely stems from androgenetic alopecia, or genetically inherited male pattern baldness.

If you are also “folically challenged,” then you are in good company. Check out some before and after hair transplant photos of patients at Bernstein Medical – Center for Hair Restoration or before and after hair restoration photos of our patients who are treating their hair loss exclusively with Propecia and/or Rogaine hair loss medications.

Read the report on The Early Show website.

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New England Patriots quarterback Tom Brady has a multimillion dollar contract, a supermodel wife, and not one, not two, but three Super Bowl rings.

He also has androgenetic alopecia, otherwise known as genetically inherited male pattern baldness, and future prospects of being a balding celebrity. Or does he?

An article in the New York Daily News reports that Mr. Brady has consulted with a hair transplant physician about his hair loss. The Daily News interviewed both Dr. Bernstein and a patient at Bernstein Medical – Center for Hair Restoration for the article. Here is a snippet:

“Look at me – I look awesome now,” said Bob, buttressing his claims with before-and-after pictures that show a full head of hair where once it grew only in patches.

Dr. Robert Bernstein restored Bob’s hair. The doc’s customers swear only their hairdressers know for sure they had it done.

Asked how Brady might fare, Bernstein said that judging by recent photos, it appears “he has good growth” and enough [donor] hair for a successful transplant.

When asked about why his results stand up to close scrutiny, Dr. Bernstein said:

“Hair grows in natural groupings of one to four hairs […] By following the way hair grows in nature, we can produce natural results.”

Read more about Hair Loss Genetics or some additional articles in Hair Loss Genetics News.

Read the full article at the Daily News.

Photo c/o: NY Daily News/Townson/AP

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Q: What happens to hair diameter when you age? — K.L., Greenville NY

A: From infancy to puberty, hair gets progressively thicker. From adulthood to old age the hair becomes thinner again and this is exacerbated by the effects of DHT in susceptible persons. The later process is called androgenetic alopecia (common baldness) and is characterized by miniaturization – the progressive decrease in hair diameter and lengths as a result of DHT.

However, even without the effects of DHT, hair gradually thins over time in many people.

Read more about hair growth and hair loss in men and women.

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Dr. Angela Christiano of Columbia University in New York and a team of scientific researchers have identified a new gene involved in hair growth. Their discovery may affect the direction of future research for hair loss and the diagnosis and ultimate prevention of male pattern baldness.

The condition which leads to thinning hair is called hereditary hypotrichosis simplex. Through the study of families in Pakistan and Italy who suffer from this condition, the team was able to identify a mutation of the APCDD1 gene located in chromosome 18. This chromosome has been linked to other causes of hair loss.

According to Dr. Christiano, “The identification of this gene underlying hereditary hypotrichosis simplex has afforded us an opportunity to gain insight into the process of hair follicle miniaturization, which is most commonly observed in male pattern hair loss or androgenetic alopecia.”

The mutation of the APCDD1 gene inhibits the Wnt signaling pathway. Although this recently discovered gene does not explain the complex process of male pattern baldness, the importance of this discovery lies in the Wnt signaling that the gene directs, has now been shown to control hair growth in humans, as well as in mice.

Reference: Nature 464, 1043-1047 (15 April 2010) | doi:10.1038/nature08875;

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Q: Is it worth getting the genetic test for balding?

A: You’re referring to Hair DX (hairdx.com), which costs about $150 and came to market in January of 2008 as the first test for androgenetic alopecia, aka male pattern baldness.

The test screens for variations in the androgen receptor gene on the X chromosome, the gene that is associated with male pattern hair loss. The purpose of the test is to identify persons at increased risk of developing hair loss before it is clinically apparent – so that medical intervention can be started early, when it is most effective.

It is important to realize that, at this point, there is just an association with this gene and hair loss; the cause and effect has not been proven and the association is not anywhere near 100%. A danger is that patients may overreact to the relatively incomplete information that the test provides. It is best to have the test performed under a doctor’s supervision, so that it can be put in the context of other information that the physician gleans through a careful history, physical and a densitometry hair evaluation. As of this posting, genetic testing for hair loss is not permitted in New York State.

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Most medical conditions can best be addressed with early diagnosis. Genetic hair loss is no different. A test now has the ability to identify whether or not you may be genetically predisposed to hereditary male pattern baldness (Androgenetic Alopecia).

The HairDX genetic test offers information that can aid you and your doctor in making an informed decision about the treatment of your hair loss.

This test is not a substitute for an examination by a physician experienced in the diagnosis and treatment of hair loss. It offers one more bit of information that, in the context of other data (such as hair loss pattern, scalp miniaturization and family history) can help guide you and your doctor to formulate an appropriate treatment plan.

How does this test work?

This new genetic test examines genetic variables (SNP) which are responsible for recognizing Androgen hormones in our bodies. These specific genetic variants of the X chromosome (the Androgen Receptor or AR gene) are found in 95-98% of bald men.

These genetic differences are associated with Male Pattern Baldness (MPB) and by identifying them; the onset of MPB might be better predicted. If a person is predisposed genetically to these chromosomal variations, they may be more likely to develop male pattern baldness prior to age forty.

The test consists of a simple swab of the inside of your mouth. The skin cells are then sent to the HairDX clinical laboratory for a confidential analysis.

How accurate is the test in predicting baldness?

HairDX tests for a genetic variant of a gene (the androgen receptor gene) found on the X-chromosome that is present in more than 95% of bald men. Sixty percent of patients with this variant experience male pattern baldness before the age of 40. Therefore, if a person has this gene, they would have an increased risk of significant pattern baldness.

Another, less common genetic variant of the same gene (present in about 1 in 6 men) indicates a greater then 85% likelihood that a person will not experience early onset pattern baldness. If a person is found to have this gene, they are unlikely to become very bald.

Why is the genetic test not 100%?

The androgen receptor gene identified thus far is only one of a number of genes that affect hair loss.

How does the test compare to information obtained from a history and physical exam by your physician?

An assessment of scalp miniaturization by an experienced physician using a densitometer, combined with a history and physical, appears to be a far more reliable way of predicting future hair loss. The genetic test can complement this information, but does not replace it.

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Q: Why is the consult fee more for diffuse thinning than for a regular visit? — B.F., Altherton, CA

A: Diffuse hair loss, more common in women, can be the result of a number of underlying medical conditions and therefore it usually requires an extended medical evaluation.

If you are a male or female with obvious diffuse thinning from androgenetic alopecia (common baldness), or if you have patterned hair loss where the diagnosis is straightforward, the fee is less because an extensive evaluation is not required.

Please visit our Hair Transplant Costs & Consultation Fees page for more information.

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Q: I am a 21 yrs old male having serious hair loss over the last few years. I also have very little facial hair. Since Propecia is a DHT blocker can it inhibit beard growth? — E.M., Astoria, N.Y.

A: As you suggest, it would be reasonable to assume that since DHT stimulates beard growth, blocking DHT (with finasteride) would tend to inhibit its growth. In practice, this does not seem to be the case, i.e. we don’t find that Propecia has any effect on facial hair. The reason is not clear.

It is interesting to note that testosterone stimulates growth of axillary and pubic hair, but not scalp hair. Scalp hair growth is not androgen dependent, only scalp hair loss is.

DHT stimulates terminal hair growth of the beard, trunk and limbs, external ears and nostrils. Of course, it also is responsible for the bitemporal reshaping of hairline as one passes into adulthood and causes male patterned baldness (androgenetic alopecia).

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Q: I have read that in the evaluation of a patient for hair restoration surgery some doctors use a densitometer to measure miniaturization – the decrease in size of hair diameters. I read that miniaturization is a sign of genetic hair loss, but when there is miniaturization of greater than 20% in the donor area, a person may not be a good candidate for hair transplants. Is this correct and does 20% miniaturization mean that 20% of the population of terminal hairs have become fine vellus-like hairs or that there is a 20% decrease in the actual diameter of each of the terminal hairs? — B.A., New Albany, Ohio

A: Miniaturization is the decrease in hair shaft length and diameter that results from the action of DHT on healthy, full thickness terminal hairs. The hairs eventually become so small that they resemble the fine, vellus hair normally present in small numbers on the scalp and body. Miniaturized hairs have little cosmetic value. Eventually miniaturized hairs will totally disappear. Twenty percent miniaturization refers to the observation, under densitometry, that 20% of the hairs in an area show some degree of decreased diameter.

In the evaluation of candidates for hair transplantation, we use the 20% as a rough guide to include all hairs that are not full thickness terminal hairs. Of course we are most interested in the presence of intermediate diameter hairs — i.e. those whose diameters are somewhere between terminal and vellus and are clearly the result of DHT. I don’t know if one can tell the difference on densitometry between vellus hairs, fully miniaturized hairs and senile alopecia. The partially miniaturized population is most revealing.

Miniaturization in the recipient scalp (i.e. the balding areas on the front top and crown that we perform hair transplants into) is present in everyone with androgenetic hair loss. Miniaturization in the donor area, however, is less common (in men). It means that the donor area is not stable and will not be permanent. Men with more than 20% of the hair in the donor area showing miniaturization are generally not good candidates for hair transplant surgery.

Read about Miniaturization
Read about Candidacy for Hair Transplant Surgery

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Q: I seem to be thinning, but I never shed hair as such in the shower. I cannot see my hair falling out. Can it be androgenetic hair loss? — R.C., Cambridge, MA

A: In androgenetic hair loss one rarely sees hair falling out in mass, but rather the thinning is due to the hair decreasing in diameter and length (a process called “miniaturization”).

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Q: I am suffering from Pseudopelade for four years now. I have lost a lot of hair & there are big bald patches on the top of my scalp that are difficult to hide. Is there any hair transplant surgery or follicle transplant surgery possible in my case, or anything else I can do? — T.L., Boston, MA

A: In general, hair transplantation does not work for Pseudopelade (a localized area of scarring hair loss on the top of the scalp) since the condition is recipient dominant rather than donor dominant.

With a donor dominant condition, such as androgenetic hair loss, the tendency to have the condition, or be resistant to it, is located in the hair follicle and moves with the hair follicle when the follicle is transplanted to a new area. Therefore, in androgenetic alopecia, healthy permanent hair taken from the donor area in the back of the scalp will continue to grow in the a new location in the balding part of the scalp.

In a recipient dominant condition, such as Pseudopelade, the problem is in the skin, so if you perform a hair transplant into an affected area of skin, the transplanted hair will become affected by the same process and be lost.

The disease process can often be slowed down with anti-inflammatory agents, such as corticosteriods, applied or injected locally and the bald area can be camouflaged with cosmetics specially made for use on the scalp. See the Cosmetic Camouflage Products page on the Bernstein Medical – Center for Hair Restoration website.

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Q: Why should a doctor measure miniaturization in the donor area before recommending a hair transplant? — E.B., Key West, F.L.

A: Normally, the donor area contains hairs of very uniform diameter (called terminal hairs). In androgenetic hair loss, the action of DHT causes some of these terminal hairs to decrease in diameter and in length until they eventually disappear (a process referred to as “miniaturization“). These changes are seen initially as thinning and eventually lead to complete baldness in the involved areas.

These changes affect the areas that normally bald in genetic hair loss, namely the front and top of the scalp and the crown. However, miniaturization can also affect the donor or permanent regions of the scalp (where the hair is taken from during a hair transplant). If the donor area shows thinning, particularly when a person is young, then a hair transplant will not be successful because the transplanted hair would continue to thin in the new area and eventually disappear. It is important to realize that just because hair is transplanted to another area, that doesn’t make it permanent – it must have been permanent in the area of the scalp it initially came from.

Unfortunately, in its early stages, miniaturization cannot be seen with the naked eye. To detect early miniaturization a doctor must use a densitometer, or an equivalent instrument, that magnifies the surface of the scalp at least 20-30 times. This enables the doctor to see early changes in the diameter of the hairs that are characteristic of miniaturization. If hairs of varying diameter are noted (besides the very fine vellous hairs that normally occur in the scalp), it means that the hair is being affected by DHT and the donor area is not truly permanent.

In this situation, a person should not be scheduled for hair transplantation. If the densitometry reading is not clear, i.e. the changes are subtle and the doctor is not sure, then the decision to have surgery should be postponed. By waiting a few years, it will be easier to tell if the donor area is stable. Having surgery when the donor area is miniaturizing can be a major problem for a patient, since not only will the transplanted hair eventually disappear, but the scar(s) in the donor may eventually become visible. This problem will occur with both follicular unit transplantation (FUT) and follicular unit extraction (FUE).

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The British government has awarded Intercytex a grant to automate the production of their new hair regeneration therapy. Intercytex is a cell therapy company that develops products to restore and regenerate skin and hair. Intercytex has partnered with a private company, The Automation Partnership (TAP), to develop an automated manufacturing process for their novel hair multiplication treatment.

The hair multiplication product, ICX-TRC, has been submitted as a hair regeneration therapy that uses cells cloned from one’s own scalp. It is intended for the treatment of male pattern baldness (androgenetic alopecia) and female pattern hair loss. The key researcher, biochemist Dr. Paul Kemp, founder of Intercytex, is developing the hair multiplication treatment at their Manchester facility. This investment in hair cloning research is spearheaded by UK Science Minister, Lord Sainsbury.

The government grant will be used mainly to develop a robotic system specifically designed to support the commercial-scale production of their hair cloning product ICX-TRC, at a scale that can handle a large number of people. The company is currently in Phase II clinical testing.

How Intercytex’s Hair Cloning Product Works

Intercytex’s method of hair regeneration involves removing a slice of the scalp, complete with hairs and follicles, from the back of the head. Hair follicles from this area are most resistant to typical hereditary baldness. The sample is taken to a laboratory where the hair producing dermal papilla (DP) cells are extracted and multiplied in flasks. After eight weeks, the DP cells should have cloned into millions of hair cells.

To complete the hair cloning process, the new cells are injected back into the patient’s scalp under a local anesthetic. These cultured cells should then develop into brand new hair follicles.

Intercytex

Intercytex is a 6-year-old company with its main office is in Cambridge, UK and has a clinical production facility and research and development laboratories in Manchester, UK. Additional laboratories are located in Boston, Massachusetts. TAP, founded in 1988, is a private company with headquarters near Cambridge, UK. Intercytex is publicly traded on the London Stock exchange (LSE: ICX).

Additional information about this hair cloning product can be found at www.intercytex.com.

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Q: Can stress accelerate hair loss? I am 25 and there is balding on my dad’s side of the family. I never had any thinning or hair loss till this year. I guess you can say I’ve been under a lot of stress. When I did notice shortly after my 25th birthday I started stressing even more, which led to more hair loss. It is thinner up front and it is thin on top. I have heard of some hair docs mapping your head for miniaturization, do you do this too? — E.W., Miami, FL

A: Yes. The presence of miniaturization (decreased hair diameter) in the areas of thinning allows us to distinguish between hair loss due to heredity (i.e. androgenetic alopecia) — in which hair progressively decreases in diameter under the influence of DHT — and other causes. The degree of miniaturization can be assessed using a hand-held instrument called a densitometer.

The pattern of hair loss and the family history are also important in the diagnosis.

Stress more commonly produces telogen effluvium, a generalized shedding that is not associated with miniaturization and is often reversible without treatment.

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Q: I have been on Propecia for a year and my hair loss has not stopped or slowed down. How much longer should I give the drug? Can Propecia speed up hair loss in some patients? — N.V., East Hills, N.Y.

A: If you have not responded to Propecia in one year, it is unlikely that you will.

Finasteride may cause shedding in the first 6 months of treatment, but should not accelerate hair loss long-term. It is most likely that you have progression of your hair loss.

In addition, be sure that you have a correct diagnosis i.e. that you actually have androgenetic alopecia.

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Q: Over the past three months, my hair seems to be thinning more on one side. Is it common in male pattern hair loss for it to be more on one side? I had a lot of stress about three months ago and have heard that this could be the cause. Is this possible? Should I use Rogaine to treat it? — B.R., Landover, MD

A: Regardless of the cause, hair loss is usually not perfectly symmetric. This applies to male pattern hair loss as well.

In your case, it is important to distinguish between telogen effluvium (shedding that can be due to stress) and hereditary or common baldness. The three month interval from the stressful period to the onset of hair loss is characteristic telogen effluvium, but you may have androgenetic alopecia as an underlying problem.

The two conditions are differentiated by identifying club hairs in telogen effluvium and miniaturized hair in androgenetic alopecia. In addition, a hair pull will be positive in telogen effluvium (when a clump of hair is grasped with the fingers, more than five hairs pull out of the scalp at one time) and will be negative in common baldness. The hair loss diagnosis can be made by a dermatologist.

Hair cuts do not affect either condition.

Rogaine (Minoxidil) is only effective in androgenetic hair loss and only marginally so. Finasteride is the preferred treatment if your hair loss is genetic when it is early and a hair transplant may be indicated if the hair loss progresses.

Shedding from telogen effluvium is reversible and does not require specific treatment.

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Q: My friend is taking Avodart, he bought it over the internet. Is it safe to take? — T.G., Denver, Colorado

A: Avodart (dutasteride 0.5mg) was approved by the FDA for the treatment of prostate enlargement in men in 2002. Avodart has not been approved for the treatment of androgenetic hair loss, although physicians can use an approved medication in ways other than for which it was specifically approved. That said, the use of dutasteride certainly requires a doctor’s supervision.

Like finasteride (the active ingredient in Proscar and Propecia), dutasteride blocks the enzyme 5-alpha reductase that converts testosterone to DHT (DHT is a key hormone that causes hair loss). However, unlike finasteride, which only inhibits the Type I form of the enzyme, dutasteride inhibits both the Type I and Type II forms. This combined effect lowers circulating DHT more with dutasteride than with finasteride, but also increases the incidence of its side effects.

The Type II form of the enzyme (blocked by finasteride) is found predominantly in the hair follicle. The Type I form of the enzyme has been found in the scalp and sebaceous glands, and many other parts of the body, but its exact role in hair growth has not been determined. It is felt that dutasteride’s ability to dramatically lower serum levels of DHT is what makes it a more potent medication in hair loss.

When considering the safety of dutasteride, one should consider the following:

  • It acts on other parts of the body besides the hair follicle.
  • Unlike finasteride, where families that had a deficiency of the Type II 5-alpha reductase enzyme were followed for years without any adverse effects, there is no natural biologic model to show the safety of dutasteride.
  • Dutasteride has been approved for prostate enlargement in an older male population. It is not approved for hair loss and, in fact, the clinical trials for hair loss were discontinued, so there is no safety data for its use in younger patients. There is a greater incidence of sexual side effects with dutasteride compared to finasteride.
  • The 1/2 life of dutasteride is 5 weeks compared to 6-8 hours for finasteride. Serum concentrations of dutasteride are detectable up to 4-6 months after discontinuation of treatment.
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Q: I was told that if men have a lot of testosterone that that’s when they lose hair. Is this true? — Y.B., Lake Forest, Illinois

A: Although androgenetic hair loss is dependent upon normal levels of testosterone, it is not due to increased testosterone. It is caused by a sensitivity of the follicles to normal levels of testosterone.

So someone that is bald doesn’t have extra levels of male hormones and is not necessarily over-sexed.

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Q: I know that I am going to be bald because my father is bald and I am losing my hair just like him. What actually causes this kind of hair loss? — J.P., Paradise Valley, Arizona

A: Although there are many different causes, the overwhelming number of people that have hair loss have what is referred to as “patterned hair loss” or “androgenetic alopecia.”

In men, it is due to a hormone called DHT, which is a by-product of testosterone produced by the action of the enzyme 5-alpha reductase. This enzyme is inhibited by the hair loss medication Propecia. See the causes of hair loss in men page on the Bernstein Medical – Center for Hair Restoration website for more information.

In women, the mechanism is a little bit more complex as another enzyme, aromatase, is involved in the metabolic pathway. See the causes of hair loss in women page on the Bernstein Medical – Center for Hair Restoration website for more information.

We know that the inheritance comes from both the mother’s and father’s side, although the actual genes causing hair loss in men and women have not yet been identified. Statistically, the inheritance from the maternal side appears to be a bit stronger, but the reason for this is unknown.

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Dr. Bernstein summarizes an article on hair cloning in The Plain Dealer:

An English based company called Intercytex has claimed some success in its research on hair cloning with its first testing in humans. This technique is similar to the one initially proposed by Dr. Colin Jahoda and published in 1999. (Download the article )

The idea is that certain cells (called fibroblasts) found at the bottom of hair follicles can be separated from the follicles after they have been removed from the scalp, and then be used to form new follicles.

The way this works is as follows: a few hair follicles at the permanent area from the back of the scalp (the area that does not bald) are removed. In a lab, the germinative cells at the base of the follicle are dissected off and placed in a Petri dish. They are then incubated in a special medium and allowed to multiply thousands of times.

These cultured cells are then injected into the balding area of the scalp where they induce complete hair follicles to form. In contrast to traditional hair transplants, where the doctor is limited by the patient’s finite donor supply and hair is literally just moved around (from the back to the front), in hair cloning, there will be an actual increase in the total number of hairs on a person’s head.

Initial testing involved seven male volunteers that were suffering from androgenetic alopecia (common baldness). After the process, five of them showed an increased amount of hair. Fortunately, there were no complications, such as skin inflammation or tissue rejection. However, the test area was small and volunteers only grew a little hair.

Towards the middle of next year, additional patients will be tested using a greater number of cloned cells, so that a larger area of the scalp could be covered. The researchers speculate that this new cloning technology may be on the market in as soon as five years.

The researchers speculate that in the distant future, traditional hair transplants may not be needed at all. Instead, as patients start to thin, they could come to the clinic on a regular basis for injections of their own cells to stimulate the growth of new follicles and stop the impending balding – a sort of hair maintenance.

Reference: The Plain Dealer, Tuesday, November 15, 2005. “Hope grows for bald baby boomers,” Malcolm Ritter, Associated Press.

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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? — T.K., Garden City, NY

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 a magnifier. This instrument is called a densitometer.

For further information, please read the article:

Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning, published in the journal Dermatologic Surgery in 1997. Specifically, read the last part of the article.

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Edwin S. Epstein, M.D.
Stuart Medical Group, Richmond, VA, USA.

SUMMARY of Dr. Epstein’s Abstract from his presentation at the International Society of Hair Restoration Surgery, 2005 – Sydney, Australia

Dihydrotestosterone (DHT) is known to be the more potent androgen in both Benign Prostatic Hyperplasia (BPH) and in Androgenetic Alopecia (AGA). Testosterone is converted to DHT by the enzyme 5-α reductase in several organs including the prostate, hair follicles, skin, liver and sebaceous glands. 5-α reductase exists in two isoforms: type 1 and type 2. Type 2 is the predominant enzyme in prostate and hair follicles. Finasteride, approved in 1992, inhibits the type 2 isoenzyme and is available in two doses: 1mg dose for AGA, and 5mg for BPH. Dutasteride, approved in January 2003 to treat BPH, is a dual inhibitor of both isoenzymes.

In current the study, men ages 21-45 received dutasteride (0.01mg, 0.1mg, 0.5mg, 2.5mg), finasteride 5mg, or placebo.

Results showed the following:

• Dutasteride seemed to have an earlier onset of effect than Finasteride
• Dutasteride 2.5mg appeared to be significantly more effective than Dutasteride 0.5mg.
• The effects of Dutasteride 0.5mg were comparable to Finasteride 5mg.

The side effect profile was difficult to interpret. All of the data is presented in such limited terms that make any interpretation difficult.

Dutasteride appears to work faster than finasteride in the treatment of androgenetic alopecia and clearly is more effective in lowering DHT levels. Because there is no human model for combined type I and II 5-α reductase inhibition (as there is with type II) long-term usage should be viewed cautiously.

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Rodney Sinclair, MBBS, FACD, MD.
University of Melbourne, Fitzroy, Australia.

SUMMARY of Dr. Sinclair’s Abstract from his presentation at the International Society of Hair Restoration Surgery, 2005 – Sidney, Australia

Twin studies have confirmed the strong heredity of androgenetic alopecia. The purpose of the present study is to explore the genetic basis of androgenetic alopecia by gene analysis. The study compared the sequence of several candidate genes between groups of individuals considered to be most and least genetically predisposed to androgenetic alopecia. Most likely are young males who already have a significant degree of baldness and least likely are those who are older and have no sign of hair loss.

The 5 alpha-reductase genes (SRD5A1 and SRD5A2), aromatase genes, Y chromosome and androgen receptor genes were analyzed. The authors found a significant difference in the frequency of a single base change in the coding region of the AR gene. These results provide good evidence for the involvement of AR in androgenetic alopecia.

Interestingly, 77% of non-bald men carry the version of the AR gene found in bald men. This suggests that the AR gene is necessary but not sufficient for causing baldness. This raises the possibility that other genes are acting in conjunction with AR. For instance, genes other than SRD5A1 and SRD5A2 that control levels of DHT production remain candidates. Given that 5 alpha-reductase is increased in balding scalp, these might include transcription factor genes which regulate the production levels of 5 alpha-reductase. Such transcription factor genes are yet to be identified. The many other genes, known and unknown, that are involved in androgen production, regulation and response may also be involved.

In addition to androgen-related genes, genes involved in patterning, signaling and hair follicle morphogenesis are other potential candidates for future research.

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Q: I am twenty and think that I am starting to thin. I am also experiencing a slight tingling in my scalp. Are these related? — T.N., Philadelphia, PA

A: Most likely. Early androgenetic alopecia can be associated with a slight tingling or slight tenderness of the scalp.

You should see a dermatologist for evaluation and, if you have early male pattern baldness, consider starting finasteride (Propecia).

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