Bernstein Medical Center for Hair Restoration - Male Pattern Baldness

Male Pattern Baldness

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What are the chances that I will go bald? How bald will I be? Can I know for sure? These are among the most common questions we get from patients in our hair loss consultations. Despite extensive knowledge about the mechanisms and causes of androgenetic alopecia (common baldness), the answers to these questions have been a bit hazy. New research has sharpened the focus on the genetic mix that results in hair loss and has enabled more accurate predictions. A study published in February 2017 in the journal PLoS Genetics identified over 250 gene locations newly linked to hair loss. Using this information, researchers more accurately predicted severe balding compared to previous methods.

Background

We know that susceptibility to hair loss is driven by genetics. One in two men in their 50s experience some degree of balding, with that proportion increasing to over 60% of men aged 60 and over. We also know that one of the most important genes in hair loss, called the androgen receptor (AR) gene, is located on the X chromosome. Outside of that, knowledge of the precise genetic makeup resulting in baldness is sparse and there is wide variation in balding patterns. Some genetic tests, such as the HairDx test, have been developed to predict a patient’s risk of balding, but lack the ability to determine its severity. To date, the best method for predicting the extent of future hair loss is to have an experienced physician take a personal and family history and perform a physical examination that includes an assessment of miniaturization of scalp hair.

Developing a more thorough understanding of the complex genetic relationships that result in hair loss will be important in clinical practice as these relationships may help predict future hair loss and guide methods of treatment.

The Study

Researchers selected a pool of more than 52,000 men with male pattern baldness from UK Biobank. This is a massive database of over half a million people aged 40-69 years with information accumulated from 2006 to 2010. This pool was over four times the size of the previously largest hair loss study. Researchers applied a genome-wide association study (GWAS) to a cohort of about 40,000 men and identified 287 statistically important gene locations (loci) linked to varying degrees of baldness — more than 35 times the eight genetic signals found in the previous largest study.

Using this set of 247 loci on non-sex, or autosomal, chromosomes and 40 loci on the X chromosome, the researchers analyzed the remaining 12,000 men for predictive patterns. The results indicated that the predictive value of using this set of gene loci was 0.78 for severe hair loss, 0.68 for moderate hair loss, and 0.61 for slight hair loss. When the subject’s age was added, the predictive score improved to 0.79 for severe hair loss, 0.70 for moderate hair loss, and 0.61 for slight hair loss. Subjects whose individual scores, based on their genetic makeup, were below the mid-point of the range of scores were significantly more likely to have no hair loss than severe hair loss. By contrast, almost 60% of subjects whose individual scores were in the top 10% of the range of scores were moderate to severely bald.

While the predictions were not extraordinarily accurate – the authors characterized the accuracy as “still relatively crude” – they did show a distinct improvement in predictive accuracy over prior studies.

Summary

Hair loss is a serious concern for many people. Research shows that men with extensive hair loss may experience significant psychosocial impacts such as reduced self-image and reduced social interactions. Some studies have associated baldness with increased risk of prostate cancer and heart disease.

Understanding the complex factors that comprise the genetics of hair loss can help physicians potentially customize treatments based on a patient’s genetic profile and their risk of balding. Beyond that, diagnosing the potential severity of hair loss may help doctors get a head start on treating what could be related life-threatening conditions.

With large databases like UK Biobank, researchers can now drill down into this information and develop increasingly clear, highly granular data sets that can identify complex systems and potentially lead to improved treatments.

References

Hagenaars SP, Hill WD, Harris SE, Ritchie SJ, Davies G, Liewald DC, et al. (2017) Genetic prediction of male pattern baldness. PLoS Genet 13(2): e1006594. doi:10.1371/journal.pgen.1006594

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Q: I have read several articles on the internet which suggest that resistance training can accelerate male pattern baldness. Is there any truth in this? –B.F., Altherton, CA

A: Anything that raises androgen levels in your body can potentially accelerate hair loss. That said, I suggest that you should exercise as you normally would. As long as you don’t take drugs to enhance your workout, the effects should be minimal.

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According to an article published in the journal of Clinical Aesthetic, ((Rassman WR, Pak JP, Jino K, Estrin NF. Scalp Micro-Pigmentation, A Concealer for Hair and Scalp Deformities. Clinical Aesthetic, March 2015, 8(3): 35-42.)) scalp micropigmentation (SMP) is an effective cosmetic solution for millions of men and women who currently have significant scalp deformities for which there are few, if any, good medical treatment options.

Scalp Micro-Pigmentation is a Permanent Hair Loss and Scar Concealer

SMP is a permanent cosmetic tattoo of carefully selected pigments applied to the scalp in a stippling pattern to mimic closely cropped hair. This technique allows a physician skilled in SMP to effectively conceal a variety of alopecias and scars.

SMP can address the following situations:

  • Female hair loss not responsive to minoxidil or cannot be treated with a hair transplant
  • Hair loss due to chemotherapy
  • Deformities from autoimmune diseases, such as refractory alopecia areata or alopecia totalis
  • Scalp scars from scarring alopecias
  • Scars from neurosurgery or head trauma
  • A visible scar from a strip harvesting procedure or punctate scars from an FUE procedure
  • Visible open donor scars from older harvesting techniques – usually those from the 1950s through the early 1990s
  • A pluggy or corn-row look from older hair restoration procedures

Scalp micro-pigmentation can also create the appearance of fullness on an otherwise thinning or bald scalp with or without a shaved head.

The Scalp Micro-Pigmentation Process

The physician skilled in SMP has a variety of tools at hand, including pigments of different colors and viscosities. The pigments can be introduced into the skin using a number of different needle types and sizes.

The physician begins by taking a needle and inserting a tiny droplet of pigment through the top layer of the skin and into the upper dermis. Because the thickness of the top layer of the skin varies across the scalp, the doctor must judge the appropriate depth at each location by both “feel” and visual cues. For example, a portion of the outer skin layer that has more fat and hair follicles will have a different look and will produce a different feel when inserting a needle compared to a scarred or bald scalp.

To place the correct amount of pigment at the correct depth at a particular location on the scalp, the operator of the tattooing instrument must take into account the following variables:

  • The angle and depth of the needle
  • The time the needle is left in the scalp (in order to place the pigment into the upper dermis)
  • The resistance of the scalp, which varies locally across the scalp
  • The particular color and viscosity of the pigment
  • The size and shape of the particular needle

In order to produce the desired shading and create the desired illusion of texture and fullness, the doctor must vary the density of the stippling across the area of application. Because every patient is unique and every area of the scalp is different, the doctor must proceed carefully in order to achieve the desired aesthetic effect and to minimize the chances of the pigment bleeding into the area surrounding the point of application.

The complete SMP process usually takes two to four sessions.

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Hair restoration physicians William R. Rassman, Jae P. Pak, and Jino Kim have outlined a practical, permanent cosmetic treatment for hair loss, called scalp micro-pigmentation (SMP) in a paper published in the journal Hair Transplant Forum International. ((Pak JP, Rassman WR, and Kim J. Scalp micro pigmentation (SMP): novel application in hair loss. Hair Transplant Forum International, Vol. 21, No. 6, Nov./Dec. 2011, p. 1, 186-87. ))

Scalp micro-pigmentation, first described in the medical literature in 2001, ((Traquina AC. Micro-Pigmentation as an adjuvant in cosmetic surgery of the scalp. Dermatologic Surgery, Vol. 27(2) 2001: 123-8)) is a cosmetic tattoo that creates the appearance of the short hairs of a closely shaved head on an otherwise bald or thinning scalp. SMP (also referred to as ‘cosmetic transdermal hair replication,’ ‘scalp pigmentation,’ ‘cosmetic hair follicle replication,’ or ‘micro hair technique’) is an option for patients who are not candidates for a hair transplant and who are willing to keep their hair cut short or shaved. It is can also serve as a “filler” for those with longer hair.

The paper discussed case studies of six hair loss patients of varying age and hair loss condition who used SMP to camouflage scalp scars or areas of hair loss:

  1. A man in his mid-30s, who was diagnosed with scarring alopecia in his teens, used SMP to camouflage his scarring.
  2. A 30-year-old male, who had worn a hat continually since being diagnosed with alopecia totalis in his teens, used SMP to frame his face and re-build his self-esteem.
  3. A 55-year-old man, who had large-graft (“hair plug”) hair transplants and several scalp reductions, used SMP to fill in plug scars and re-define his hairline.
  4. A 32-year-old man used SMP to cover donor area scars from previous FUT procedures, fill in his thinning crown, and create a smooth hairline.
  5. A 22-year-old man filled in scars from a previous FUE hair transplant using scalp micro-pigmentation.
  6. A 45-year-old man, who had always shaved his head and refused hair transplantation, used SMP to create a hairline with an overall look of a clean-shaven head.

SMP can be applied to patients with alopecia areata, alopecia totalis, or pattern baldness. SMP can also help hide the scar tissue from several types of scarring alopecia. Finally, it can help to camouflage the scar tissue caused by large-graft “plug” transplants, scalp reduction procedures, or poorly performed or failed hair transplant procedures.

The authors note that adoption of SMP by physicians and potential patients has been slow because of the highly variable outcomes due to a lack of standardized SMP techniques and materials. However, the authors say a standardized SMP technique is being formalized that should support consistent high quality outcomes.

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According to an article published in the journal of Facial Plastic Surgery Clinics, ((Rassman W, Pak J, Kim J. Scalp micro-pigmentation: a useful treatment for hair loss. Facial Plast Surg Clin North Am. 2013;21(3):497–503.)) scalp micro-pigmentation (SMP) has been found to be a useful cosmetic treatment for hair loss and scalp scars.

SMP is a scalp tattooing technique that uses fine dots – like a stippled painting – to mimic the appearance of extremely short hairs on an otherwise bald scalp.

SMP can create the appearance of a fuller head of hair on a scalp that is losing hair by softening the contrast between the hair that remains and the color of the scalp. It can also effectively camouflage a scalp scar, like the donor scar from a strip hair transplant procedure, the scar from a scalp reduction or scars from trauma to the scalp.

Finally, SMP can help augment the results from either a Follicular Unit Hair Transplant (FUT) or a Robotic FUE Transplant (R-FUE), especially for patients who do not have enough donor hair to give the appearance of full coverage.

More Art than Science

While one might think the placement of the dots need only follow, in a straightforward fashion, the natural distribution and density of hair that occurs on a normal scalp, the application of SMP is in fact more art than science.

The effective application of SMP requires a strategy and technique custom tailored to each patient that takes into account the particular aesthetic needs of the patient and the particular characteristics of their hair and scalp.

To correctly design and execute such a tailored approach, a physician needs to have considerable expertise regarding where to place the dots, the proper needle size, the best angle of application, the depth and duration of penetration, and the best type of dye to use for a particular person’s scalp.

In addition to SMP being an art form, the article stresses that in the case of concealing pattern hair loss, a physician also needs to have a thorough medical understanding of the progressive nature of the genetic balding process.

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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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A study of Australian men between the ages of 40 and 69 suggests that men who were mostly bald by the age of 40 were more likely to develop prostate cancer in their 50s or 60s. The Melbourne Collaborative Cohort study of about 10,000 men showed that men who have high levels of testosterone may be more vulnerable to cancerous prostate tumors.

The team of scientists that conducted the long-term study, which was published in the journal Cancer Epidemiology, Biomarkers and Prevention, reported that both baldness and prostate cancer are age-related and androgen dependent conditions, so these findings are not surprising. The statement said, “We found that baldness at the age of 40 might be a marker of increased risk of prostate cancer.”

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Q: I heard that for someone who has had several strip procedures, the ARTAS robot for FUE does not work because it is programmed to work with “textbook male pattern baldness”, which I no longer have. I thought the scars from previous procedures, as well as the large amount of already transplanted hair, might throw off the robot’s programming (it wouldn’t quite know what to do). But if I am wrong about this then the robot may in fact be the best approach for me. Please advise. — N.C., Paris, France

A: When performing robotic hair transplants on patients with prior surgery, I program the robot to avoid scarred areas – just as we would do visually when performing manual FUE.

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Q: What is the Origin of the Term DUPA? — Z.Z., Darien, CT

A: The terms DPA and DUPA were first described by O’tar Norwood in his seminal 1975 publication: Male Pattern Baldness: Classification and Incidence. ((Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975;68:1359-1365. Download)) In the paper, Dr. Norwood defined the two terms as:

Diffuse, Unpatterned Alopecia (DUPA). In this type there is a general decrease in the density of hair without any definite pattern, although it is usually more marked over the top and front. This type is common in women.

Diffuse, Patterned Alopecia (DPA). The patterns in this type of hair loss are essentially the same as in more common male pattern baldness, but the areas involved do not become totally bald; the hair only decreases in density. This also occurs in women.

Dr. Norwood’s realization that all hair loss did NOT follow his own Norwood patterns was a great insight, as well as his observation that DUPA was a common pattern in women and uncommon in men. The terms went relatively unnoticed and were not seen again in the medical literature until Drs. Bernstein and Rassman wrote about them again when they were developing Follicular Unit Transplantation. ((Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84. Download)) The importance of identifying these conditions is that that DUPA (either in men or women) is a relative contra-indication for hair transplantation and, with densitometry, can be readily detected in individuals at a relatively young age. Patients with DPA can be transplanted as if they were early Norwood Class 6’s.

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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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Latisse, the brand name for the drug bimatoprost, is commonly used to promote eyelash growth in women who want their eyelashes to be longer, thicker, and darker, typically for cosmetic reasons. It is also used to promote growth of eyebrow hair.

In a publication on ClinicalTrials.gov titled, “Safety and Pharmacokinetics Study of New Formulation of Bimatoprost in Patients With Alopecia,” Allergan, the pharmaceutical company that produces Latisse, has announced a new study on the safety and efficacy of a new formulation of bimatoprost for use as a topical hair loss treatment for general baldness.

The study, based out of Tempe, Arizona, will test two different formulations of bimatoprost in men who suffer from moderate male pattern baldness and women who have moderate female patterned alopecia.

According to the details of the study, the test involves, “One mL dose applied evenly onto pre-specified balding area on scalp – single dose in the am followed by multiple doses daily in the am for 14 days.” The goal of the testing is to measure the results of a single dose of bimatoprost, as well as multiple doses over time. The completion date of the study is February 2011, so we will look for the results and share them with you when they are available.

Update:

The results of the study have been published and it did not result in the FDA approving Latisse for hair loss on the scalp. Latisse was found to be not nearly as effective in treating hair loss as the control group that used minoxidil 5% solution. See the results of the study on ClinicalTrials.gov.

Visit our page on Latisse/Bimatoprost for more information on the drug and its off-label use. View the publication on ClinicalTrials.gov for more specifics on the study. Read about other medical hair loss treatments on our page on medications.

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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: I am currently 28. I have been taking Propecia for 6 years and recently began to grow sparse chest hair for the first time in my life. Is the Propecia causing these effects? — H.L., Gowanus, Brooklyn, NY

A: DHT causes male pattern baldness and stimulates the growth of body hair. The use of Finasteride, a DHT blocker, will permit scalp hair to grown and inhibit the growth of body hair, not stimulate it.

However, the effects on body hair are quite small, so your natural tendency to grow chest hair over time is probably not being blocked by the treatment.

Read more about propecia and the effects and effectiveness of the medication.

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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: What are the genes that cause male pattern baldness?

A: At this time the genes that actually cause hair loss are still unknown. However, there are two gene loci, recently identified, that appear to be associated with common baldness. The first is on the Androgen Receptor (AR) gene carried on the x-chromosome and the second is a non-sex chromosome 20p11.

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It has long been thought that the genes for common baldness come from the mother side of the family – explaining why a male whose maternal grandfather is bald is more likely to lose his hair than if his own father were bald. This observation was recently supported by the discovery of the androgen receptor (AR) gene which resides on the X-chromosome.

Remember, there are two sex chromosomes; X and Y. Females have two X chromosomes (XX), while males have one X and one Y chromosome (XY). This means that a male must get his X chromosome from the mother.

But we all have seen that some bald sons have bald fathers, even when no one on the mother’s side of the family has any hair loss. This suggests that the genetics of male pattern alopecia is more complicated, with multiple genes influencing hair growth. And it is likely that the inheritance of baldness is polygenetic, with relevant genes coming from both the x-chromosome of the mother and non-sex chromosomes of either parent. So where are the other genes?

Two independent research groups, one from England and the other Germany, both published in the journal Nature Genetics, have identified a gene locus p11 on chromosome 20 that seems to be correlated with male pattern hair loss, and since the gene is on a non-sex chromosome, it offers an explanation for why the inheritance of common baldness can be from either side of the family. It is important to emphasize that like the AR gene, the chromosome 20p11 locus has only been shown to correlate with hair loss. It is not been shown that either of these genes actually cause baldness.

Unlike many genes whose expression is one or the other (i.e. blue eyes or brown), the 20p11 variations tend to be additive; therefore, men with one affected copy will have a 3.7 fold increase in the chance of having early hair loss and those with two copies a 6.1 fold increase. Men with both the chromosome 20p11 variation and the AR gene will have a seven-fold increase of developing male pattern hair loss at an early age. This gene combination occurs in about 15% of Caucasian men.

The mainstay of predicting future hair loss is with a Densitometer – an instrument used by physicians to measure changes in hair shaft diameter (miniaturization). According to Dr. Robert Bernstein, “Looking at hair shafts under a microscope can spot shrinkage years before it is apparent – we can pick it up when kid are still teenagers.” Early diagnosis is important in androgenetic alopeica because medication is useful only if the hair loss is not too advanced. The genetic studies are significant in that they supply the physician with one more piece of information when developing a master plan for treating a person’s hair loss. See the article in the Wall Street Journal titled, Hair Apparent? New Science on the Genetics of Balding.

While researchers consider these latest discoveries to be of significant merit, caution must be made since these genes are felt to be associated with hair loss, but not yet shown to be causative. More importantly, the associations are not absolute. A clinical evaluation is still the most reliable indicator of future hair loss. Finally, the ability to identify associated genes does not suggest that a “cure” for male pattern baldness is imminent.

Reference
“On the Genetics of Balding,” Wall Street Journal, Vol. 4 – October 1, 2008.

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Q: I have hair loss due to a treatment of Accutane. I have been off this medication for about a year and a half now, yet my hair has not recovered. The texture of my hair has completely changed. Given the fact that there is no family history linking me to male pattern baldness, I attribute my hair loss exclusively to Accutane. What should I do? — H.F., Eastchester, NY

A: If the texture alone has changed there is nothing you can do except to wait. The texture should improve over time even though it has already been 18 months.

If there are signs of genetic hair loss (i.e. male pattern alopecia), then finasteride should be considered.

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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: My hair loss resembles the grade I female hair loss scale, but none of the male hair loss patterns. It has been relatively stable for the past five years and only recently has it begun to progress further. I began both Propecia and Rogaine two months ago, but the hair loss still continues at the same pace. I’m really worried. Does a hair transplant work in such a diffuse hair loss? — D.D., Park Slope, Brooklyn

A: If your hair loss is diffuse only on top, then a hair transplant will be effective. This condition is called Diffuse Patterned Alopecia or DPA.

If the diffuse pattern of hair loss affects the back and sides as well, then surgical hair restoration should be avoided. In this case (called Diffuse Unpatterned Alopecia or DUPA) the donor area is not permanent and the transplanted hair will continue to thin over time.

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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: I heard that Propecia was being used originally for shrinking the prostate, is this true? — M.D., New Hyde Park, N.Y.

A: Propecia (finasteride 1mg) is not a prostate medication that was serendipitously noted to have a side effect of re-growing hair, it is a medication that was known all along that it might be able to slow hair loss and/or to grow hair.

Although finasteride was first approved for the treatment of prostate enlargement, the researchers at Merck knew, at the outset, that there were families whose members were deficient in the 5-alpha reductase Type II enzyme and that the men in these families neither developed prostate disease nor went bald. In addition they had no long-term problems from the lack of this enzyme.

Merck used this natural model to develop a medication that could block the 5-alpha reductase Type II enzyme – the result was finasteride. Because the only approved treatment for symptoms related to prostate enlargement at the time was surgery, Merck developed finasteride as a medical treatment for this condition prior to developing finasteride as a potential treatment for men with male pattern hair loss.

This also meant that Merck would understand the safety profile of finasteride, and have it approved for a medical disease (symptomatic prostate enlargement), before developing it for a cosmetic condition.

The drug was first submitted to the FDA for the treatment of prostate enlargement as Proscar (finasteride 5mg) in 1991 and it was approved for this use in 1992. The drug was submitted for the treatment of men with male pattern hair loss as Propecia (finasteride 1mg) in 1996 and was approved for this use in 1997.

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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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Hair transplant surgeon Robert M. Bernstein M.D. was recently interviewed on the National Public Radio program The People’s Pharmacy. Invited to speak about hair loss, Dr. Bernstein offered insights about the causes of hereditary baldness and it’s solutions, including hair transplantation.

The show was entitled “Dealing with Hair Loss” and addressed issues such as the importance of hair to our sense of well being.

The full hour radio interview was filled with informative facts about male pattern baldness, cultural attitudes toward hair loss and surgical hair restoration. For example, Dr. Bernstein was asked about his pioneering work in follicular unit hair transplantation and host of other questions ranging from the causes of hair loss to the psychological effects of balding. Here is one exchange from the interview:

Moderator: How one can tell the difference between hair loss from hormonal imbalances and common baldness?

Dr. Bernstein: Measuring hormone levels alone, although important for medical management, does not necessarily reveal whether the cause of the hair loss is actually hormone related or is genetic. The diagnosis is made by examining the scalp and looking at the hair under close magnification using an instrument called a “Densitometer.” If the hair shafts are of different calibers, this is relatively diagnostic of female patterned genetic hair loss and in this case hormone levels are often normal. Hormonal changes or imbalances, on the other hand, may cause alterations in hair texture (such as in thyroid disease) or a generalized shedding that can occur after childbirth (called telogen effluvium). In telogen effluvium, the hair can l actually fall out in clumps – you can literally get handfuls of hair, but the hair often returns over time. In genetic hair loss, however, it is not a question of the hair falling out any faster, but the hair being replaced with thinner, finer hair in each hair cycle, until the hair gradually disappears.

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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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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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“Good Morning America” interviewed Dr. Bernstein in their two-part series on hair transplant surgery. View a clip of the video here:

Read the full transcript:

Charles Gibson: In a two-part series this week, “The Bald Facts,” we are looking at what works and what doesn’t in hair replacement.

And first up, we want you to meet Charles Teacher, a real estate executive who for 30 years has been a guinea pig for every kind of baldness remedy there was. Let’s look at his struggle through the years.

Charles Teacher: It was very restrictive. You’re always patting it down, looking in the mirror to see that it’s not sort of showing. It’s a really difficult way to live.

Charles Gibson: Charles Teacher should know. He’s been studying the latest trends in baldness for three decades. His hair started thinning when he was just 26, and back then he tried that bastion of hope, the comb-over.

Charles Teacher: I still had hair then. You couldn’t see that I was bald, but I could see I was very thin. It really is this fear of being unattractive to women. I suppose it is a certain amount of vanity in terms of how you look, but most of it is this fear of being rejected.

Charles Gibson: So even at an early age, he began wearing a toupee and bemoaning his genetic fate. His father had male pattern baldness. Would he spend the rest of his life worrying which way the wind blew on the golf course? Then came 1977 and the heralding of the hair plug. Charles Teacher was first in line for the surgery, and what a surgery it turned out to be.

Charles Teacher: Most of the plugs didn’t take and the few that did were in the front in a very bad hairline. It looked stupid.

Charles Gibson: This was the hairline of those old plugs, right across his forehead, so he went back to his toupee. He had a curly rug when styles were curly, a grayer one as he grayed, and he wore his hairpiece to bed. Even his wife never saw him without it.

Charles Teacher: She never saw me without the hairpiece for 30 years until I had the consultation with the surgeon who is doing the transplant and I removed it off like that.

Charles Gibson: The consultation was with hair transplant surgeon Robert Bernstein who recommended Teacher go bald, just a better bald, moving hair around to give him more on top. He demonstrated with before and after pictures of former patients. Teacher signed on and had the old plugs removed which would be added on with the rest.

Years ago in transplants like Charles Teacher’s, the surgeon removed small circles of tissue from the back of the head where hair growth is stable, then to transplant those clumps of up to 30 hairs, the surgeon would remove a matching circle of tissue from the top of the head and put in the graft. It worked, but it didn’t look natural.

Dr. Bernstein: That has always been the problem, that grafts that were done 25, 30 years ago are still around. So really the idea is not just to get the hair to grow. That’s the simple part. The challenge is to do it in a way that looks natural.

Charles Gibson: Now Charles Teacher’s best hope, single follicular unit transplants. The surgeon removes a strip of hair-producing tissue from the back of the head and separates it under a microscope into units of one to four hairs, the way hair grows naturally. The surgeon then makes tiny incisions exactly where and at what angle he wants each hair to grow and then implants it.

Teacher decided it was worth a try, even though it would cost thousands of dollars. Now he wants to burn his old toupee for one of the best results of all, to go swimming with his new grandchild, carefree.

Charles Teacher: I really feel that I’ve been given a new lease in life in many ways. It sounds silly, but just to be normal, just to be normal.

Charles Gibson: We’re joined by Charles Teacher, sans toupee, and the man who helped to get rid of it, Dr. Robert Bernstein, Associate Clinical Professor of Dermatology at Columbia University.

Good to have you both here. Why go through all this trouble? Why not just be bald?

Charles Teacher: I think it’s because I started with a hairpiece when I was rather young, 26, and I just didn’t have the guts to take it off. I think I felt a bit like Samson and Delilah, should we say, you know, if I lost my hair, I’d lose my strength or my personality.

Charles Gibson: And you’re pleased with this.

Charles Teacher: It’s just awesome.

Charles Gibson: Dr. Bernstein, is his hair actually growing? I had always heard that you can transplant hair, but you can’t make it grow.

Dr. Bernstein: No, actually, a transplant will continue to grow. He has to get haircuts just like it’s his normal hair.

Charles Gibson: Are there good candidates and bad candidates for this?

Dr. Bernstein: Yes. And actually people that wear hairpieces are sometimes tricky because their baseline is a full head of hair, so one of the important things that we had to discuss in the first consult was what his expectations were and whether he realized that a transplant wouldn’t give him the fullness of a hairpiece, but of course, it would look much more natural.

Charles Gibson: That’s why you lose the line, you’re still bald to some extent, but it’s a better kind of bald.

Dr. Bernstein: Yes.

Charles Gibson: Single follicular unit transplants is such a mouthful, but basically it’s saying you’re just transplanting a hair two or three at a time.

Dr. Bernstein: Right. In the old days, hair was planted in little clumps and then it was divided into small pieces but arbitrarily. Now we transplant hair exactly the way it grows in nature, and hair normally grows in little tiny bundles and they’re called follicular units.

Charles Gibson: I don’t know if it’s dirty trick, but we have a camera behind you because in the back of your head, you’re going to have a second procedure now.

Charles Teacher: Yes, we’ll have a second procedure actually this morning. I think that we’ll leave the back and probably just reinforce the front so that it –- I mean, you don’t really see the back of your head, you’re only worried about how you appear in the mirror.

Charles Gibson: Right. How much does it cost?

Charles Teacher: I haven’t told my wife. Can I give that a miss?

Charles Gibson: Well, I’m sure Dr. Bernstein, he’ll probably say something.

Dr. Bernstein: We charge about $5 a graft.

Charles Gibson: About $5 a graft, which is one, two, three, four, five hairs –-

Dr. Bernstein: That’s right.

Charles Gibson: — per time. So that gets rather expensive. I mean, we’re talking about $10,000, $15,000 for a total procedure?

Dr. Bernstein: Yes.

Charles Gibson: Which insurance does or does not cover?

Dr. Bernstein: It usually does not.

Charles Gibson: But you probably spent that much in toupees over the time.

Charles Teacher: Absolutely. You know, so $2,000 or $3,000 a year with the toupees and the hairdresser worrying every week, you know, yeah.

Charles Gibson: Gotta ask. You’re a little thin on top yourself, yet you haven’t done this.

Dr. Bernstein: Everybody asks me that. It just doesn’t bother me. And I think it’s important being a doctor that people, when they come to see me, they don’t feel compelled that they have to have the transplant, that they’re here because they want to. And that being bald is okay.

Charles Gibson: So the title, if somebody’s interested in this, is follicular unit transplant.

Dr. Bernstein: Yes.

Charles Gibson: All right. Dr. Bernstein, thanks very much. Charles Teacher, thank you very much.

Charles Teacher: Thank you.

Charles Gibson: Good to see you. Good luck with the procedure today.

Charles Teacher: Thank you.

Watch more videos on hair transplantation and hair transplant repair in our Hair Restoration Videos section

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