Bernstein Medical - Center for Hair Restoration - Medical Treatment of Hair Loss
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An article in the New York Times discusses research surrounding a potential new hair loss treatment. The NY Times’ article “Old Transplant Drug May Have A Fringe Benefit” states that an immunosuppressant used to prevent organ rejection in those having liver, kidney or heart transplants also stimulated hair growth.

First prescribed in the 1980’s it is now used for the treatment of many diseases including rheumatoid arthritis and psoriasis. Nathan Hawkshaw, at the University of Manchester found that cyclosporine A stops the production of a protein that inhibits the growth of some tissues, one of them being hair follicles.

Old Transplant Drug May Have A Fringe Benefit

What was important to the first patients who took cyclosporine A was that it made their bone-marrow transplants work; few reported the increased luster of their hair. Now scientists think the drug may hold the key to an effective treatment for baldness.

Patients began using cyclosporine A in the Eighties and it is now prescribed for dozens of conditions, including rheumatoid arthritis. Like all immunosuppressants it has serious side-effects, so hirsutism (increased body hair) was never considered a big downside. And neither was it seriously considered an upside.

Increasing your vulnerability to infection to reverse hair loss is not a risk many would take. But a team at the University of Manchester think they have found a way to mimic the hair promoting effects without the serious consequences.

Nathan Hawkshaw, then a PhD student, found that the drug decreased production of the protein SFRPI, which acts as a brake on the growth of some tissues, among them hair follicles. He and his colleagues then learned that another compound already existed that was designed to target SFRPI – and not do much else.

In a paper in Plos Biology they wrote that the compound enhanced follicle growth better than cyclosporine A, and Dr. Hawkshaw believes that this could work as a topical hair treatment. However, since the test follicles were healthy, it is not known whether actual balding could be reversed.

If the compound turns out to be safe and effective, it will still take several years to make it onto the market.

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Cosmetic Town

Dr. Bernstein contributed to an article published on the cosmetic surgery portal “Cosmetic Town” about the benefits and usage of Rogaine® (minoxidil) hair loss medication.

The article, “Rogaine for Male Pattern Baldness,” highlights the history of minoxidil as a critical component in managing and reversing hair loss in men and women. Approval of Rogaine for topical treatment of hair loss came in 1987, followed by approval for use by women in 1992.

Rogaine works by lengthening the growth or “anagen” phase of a hair follicle. By doing so, the drug effectively halts and reverses the miniaturization of follicles, a process that, if untreated, ultimately leads to hair loss.

The article also discusses the recommended dosage of Rogaine, a comparison of Rogaine and Propecia, when a patient can expect to see results of medical treatment of hair loss, and other related topics.

Cosmetic Town provides consumers with a knowledgebase of expert doctors in the field of cosmetic surgery. It also features a “before and after” section detailing cosmetic operations by top experts and the testimonials from patients who have been under their care.

You can read the article by clicking here.

Read more about Rogaine (minoxidil)

Read Tips on Using Minoxidil

Watch videos on the medical treatment of hair loss

View Before & After Photos of patients who used Rogaine and/or Propecia to treat their hair loss

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Since 1993, minoxidil has been the most successful topical treatment for hair loss in both men and women, yet its exact mechanism of action remains unknown.

A 2004 review of minoxidil’s possible mechanisms of action ((Messenger AG, Rundegren J. Minoxidil: mechanisms of action on hair growth. Br J Dermatol. 2004;150(2):186-94.)) suggests that the best evidence supports the idea that minoxidil causes hair follicles in the later phases of their resting phase (telogen) to shift prematurely into an active growth phase (anagen) sooner than they otherwise would; this causes a rapid increase in hair growth. They also found good evidence that minoxidil works to thicken the hair by increasing hair diameter.

While minoxidil’s effects on other critical factors known to affect hair growth — such as cell proliferation, collagen synthesis, vascular endothelial growth factor and prostaglandin synthesis — remain uncertain, more recent research has found evidence that it may also suppress the androgen-androgen receptor responsible for androgenetic alopecia. ((Hsu CL, Liu JS, Lin AC, Yang CH, Chung WH, Wu WG. Minoxidil may suppress androgen receptor-related functions. Oncotarget. 2014;5(8):2187-97.))

Understanding minoxidil’s exact mechanism of action remains today an important line of research both for the development of better hair loss treatments and for a better understanding of the biology of hair growth.

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Q: I have heard that side effects from finasteride can persist even after stopping the medication. What is the most current information on this issue? — S.V., Short Hills, N.J.

A: For the past two years I have been on the International Society for Hair Restoration Surgery (ISHRS) Task Force on Finasteride Adverse Events and struggling to make sense of this issue. There seems to be a disconnect between the relatively low incidence of side effects that we, as physicians, see in our practices, what published controlled studies have shown, and what is now being reported on the internet and in some instances in the media. For example, a 2012 study by Sato of 3,177 Japanese men published the Journal of Dermatology, showed a 0.7% incidence of adverse reactions to finasteride 1mg and no persistent side effects after stopping the medication.

That said, there has been a recent increase in anecdotal reports of side effects from finasteride as well as reports of persistent side effects after the medication has been discontinued (referred to as “Post-finasteride Syndrome”).

The FDA

Based on post-marketing reports of sexual dysfunction, in April 2012, the FDA announced changes to Propecia (finasteride 1 mg) labeling to expand the list of sexual adverse events and that some of these events had been reported to continue after the drug is no longer being used. It is important to note that no new clinical studies were reviewed to evaluate these adverse events and that the FDA is not aware of any additional controlled clinical studies conducted to evaluate these adverse events or to determine their cause or duration. (see FDA Label Changes for Finasteride 2012)

The FDA states that despite the fact that clear causal links between finasteride (Propecia and Proscar) and sexual adverse events have NOT been established, the cases suggest a broader range of adverse effects than previously reported in patients taking these drugs. The FDA states that it believes that finasteride remains a safe and effective drug for its approved indications, but also advises that healthcare professionals and patients should consider this new label information when deciding the best treatment option.

The difficulty with interpreting anecdotal information is significant. The following need to be considered; first, sexual dysfunction, both temporary and persistent, is quite common in the general population and patients may have new-onset sexual dysfunction from some other, unrelated, cause and second, patients may have real (physiologic) side effects from the medication and then have psychological after effects. It is so difficult to sort these factors out.

The ISHRS

The Finasteride Symposium at the 2012 ISHRS, of which I was a panelist, explored safety issues with finasteride. Dr. Akio Sato presented his data (quoted above) suggesting that finasteride side effects are uncommon and that persistent side effects were not seen. Dr. Freedland, a urologist and featured guest speaker at the ISHRS symposium, questioned whether long-term effects of a slight elevation in estrogen levels could have adverse effects on the prostate. The panel discussed the paper of Dr. Michael Irwig at George Washington University that appeared in The Journal of Sexual Medicine this year. In his survey of 54 patients of men who had persistent sexual side effects three or more months after the discontinuation of finasteride, he reported that sexual dysfunction continued for many months or years in the majority of the patients.

Difficulties in interpreting this study are that it assumed that the patient’s sexual dysfunction were caused by finasteride when, in fact, there is no way of knowing that finasteride was the actual cause of the side effects (this would need a blinded, placebo-controlled study). A second reason that makes interpretation difficult is that, because there was selection bias in the Irwig survey, there is no way of knowing if these patients are representative of the population of men on finasteride. That said, the data presented by Dr. Irwig stresses the importance of having more clarity on the potential side effects of finasteride, since it is so widely prescribed.

It was clear from the presentations and questions asked, that many issues are still unresolved. All in attendance agreed that further research is urgently needed. In the short term, it is most important that all patients who are having problems can have easy access to doctors with expertise in this area, so that they can be diagnosed properly and treated.

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Led by Dr. A. Sato, a Japanese team of medical researchers published the largest finasteride study ever performed, “Evaluation of efficacy and safety of finasteride 1mg in 3,177 Japanese men with androgenetic alopecia.” It investigated the effects of finasteride over a 3 1/2 year period in men with androgenetic alopecia, or common baldness.

The study found that patients who had experienced hair loss for an extended period of time and were treated with finasteride exhibited notable hair growth. While a fairly small proportion of patients with a hair loss duration over 10 years exhibited “greatly increased” growth, 85% of patients with hair loss duration of more than 15 years experienced “moderate” or “slightly increased” growth. Physicians have thought that people with advanced hair loss do not respond as well as patients in the early stages of hair loss. However, in light of the results of this study, that determination should be reconsidered.

Further, the same study found that the initial age of a hair loss patient at the time of commencing treatment has little to no effect on the outcome. While the efficacy studies that are included in the Propecia package insert were conducted in men 18 to 41 years old, men over 41 appear to respond as well as the younger group. Adverse reactions occurred in only 0.7% of the study population and the Sato study found no increase in adverse safety events over time.

In summary, the Sato study showed an increased response rate to finasteride 1mg with increasing duration of treatment. In addition, it is effective in a larger portion of the male population with androgenetic alopecia than previously thought.

Reference:

Sato A, Takeda A. Evaluation of efficacy and safety of finasteride 1mg in 3,177 Japanese men with androgenetic alopecia. J Dermatol 2012; 39: 27–32.

Download the Sato study on finasteride

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Q: Are the “result” photos from taking Propecia and using Rogaine legitimate? Some of the after photos look too good to be real and a few patients looked like they combed their hair to look like they had more coverage. — T.Y., Darien, Connecticut

A: The before and after photos of patients using Propecia and Rogaine are my patients. All photos on our website are un-retouched. When patients have a good response to medical therapy, they often have more flexibility in how they can groom and style their hair. This is reflected in the photos.

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