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FREQUENTLY ASKED QUESTIONS
Mike A. Leake
Q - What causes hair loss?
A - There is much debate on this topic but it appears that male hormones trigger an autoimmune response that initiates an attack on the hair follicle, resulting in destructive inflammation. It may be that androgens somehow alter the follicle, causing it to be labeled as a foreign body. The follicles then gradually wither under the onslaught of the attack. Another possible complementary explanation is that androgens also trigger increased sebum production, which favors an excessive microbial population that leads to the same inflammatory autoimmune response. In any case, hair progressively miniaturizes under the autoimmune attack, so that with each growth cycle it gets shorter and thinner until it finally turns into tiny unpigmented vellus hair (peach fuzz). The story of balding is not the story of androgens alone, however. Rather pattern loss appears to have multiple causes. For instance, damage to blood vessel linings can inhibit a growth factor they ordinarily produce: endothelium-derived relaxing factor (EDRF) or nitric oxide (NO). Minoxidil probably works in part by mimicking this growth factor. Similarly it has been noted that severe baldness is strongly correlated with heart disease and even diabetes, so there appears to be some common etiology outside of the strictly androgen paradigm for pattern loss. There are likely other factors as well.
Q - What's the best hair loss treatment?
A - There is no simple answer to this. No one treatment is spectacular for the average individual. However, there are a few treatments that yield decent results for a majority of people. (Decent is defined as cessation of further hair thinning and perhaps some regrowth, ranging from a little to moderate.) Some people do respond unusually well--but then some don't respond at all. Most people fall somewhere in between. Since pattern loss is multifactorial, it is probably wisest to approach the problem from several angles to maximize results, as some treatments are complementary and address different underlying causes. A common fundamental approach is to use an "antiandrogen" of some kind, whether systemic (such as finasteride) or topical (such as azelaic acid or spironolactone), and a growth stimulant such as minoxidil. To this basic program many add a topical SOD. Other options include therapeutic shampoos, such as the antimicrobial and growth stimulant shampoos. Still other approaches that may help include dietary and nutritional considerations and even lifestyle modifications. There are many adherents to such a "kitchen sink" approach. You can also start with a single treatment, though due to the long lag time before you can actually verify efficacy, this can be very hit and miss and may bring less than optimal results by only addressing one aspect of a larger problem.
Q - How long does it take to see results from any treatment program?
A - At least 2 months, though usually significantly longer. Many do not notice any apparent improvements until well after a year. Best results are often seen after the two-year mark. This is because hair follicles undergo a relatively long dormancy period in between growth cycles (usually about 3 months). In addition, hair only grows about one inch per month in non-thinning areas and usually considerably slower in thinning areas. Since it generally takes several cycles of growth/fallout/regrowth, with the hair getting thicker and longer each time, it can take a great deal of time to see noticeable improvement. Note that best regrowth results are seen with hair that was lost within the last five years and in areas of the scalp in which there is still some fine hair.
Q - What's the difference between Propecia and Proscar?
A - Both medications contain finasteride and are made by the same company. The only difference between them is strength. Propecia has 1 mg of finasteride, while Proscar has 5 mg. Proscar has been around for awhile for the treatment of prostate enlargement, which, like pattern loss, has been linked to DHT. Because of the price disparity between the two medications, some people procure Proscar and divide the tablets into smaller dosages instead of buying Propecia.
Q - How do people divide Proscar tablets?
A - Some people section them with a pill splitter (available at any pharmacy), some crush and dissolve them in alcohol (such as Everclear, whiskey or others), and some crush and encapsulate them along with a filler to remove the air from the capsule.
Q - What if I split Proscar but don't section it perfectly. Will this slightly varied daily dosage cause a problem?
A - No. Subtle daily variations will not diminish finasteride's effectiveness. Some people even have good results by taking a larger dosage only once every few days.
Q - Where do you get Proscar? Do you need a prescription?
A - Proscar is a prescription medication in the US. Some doctors will write a prescription for Proscar for hair loss patients wishing to avoid the greater expense of Propecia; others won't. You can order Proscar from overseas from numerous sources without prescription. FDA regulations allow the importation of a 3-month supply of medication for personal use. The company selling the medication typically requires that you sign a form indicating that you are using the medication under the guidance of a physician.
Q - How come some people take less than the standard 1 mg dosage of finasteride?
A - Early dose ranging studies showed that much smaller dosages, such as 0.5 mg and even considerably less, inhibited DHT on average almost as well as much higher dosages, such as 5 mg. 1 mg was probably a compromise dosage designed to be high enough to pick up "outliers" who may not respond as well to the lower dosages. 1 mg also provides a nice round number.
Q - Is there a problem if my wife gets pregnant while I'm taking finasteride?
A - No. Originally Merck decided to err on the side of caution and warned against the possible problem of finasteride transfer in semen. This warning has since been removed. At issue is the theoretical danger that there could be genital birth defects in the male fetus. This is one reason finasteride tablets are coated, and women who are or could get pregnant should avoid finasteride ingestion and the handling of broken finasteride tablets.
Q - How effective is finasteride?
A - Finasteride is not a miracle treatment, but it works reasonably well for many people. Results tend to be slow, and it appears to be better at retaining than regrowing hair. But as treatments go, it's fairly effective. Like all treatments discussed here, it is typically best used as part of a multifaceted program.
Q - What's this I keep hearing about a dual 5AR inhibitor?
A - DHT is produced from testosterone by two 5-alpha reductase isoenzymes, called Type 1 and Type 2. Type 1 5AR is much more prominent in the scalp than Type 2, though both are present. Glaxo Wellcome is currently testing a medication that inhibits both isoenzymes to eliminate over 90% of DHT from the body, while finasteride only inhibits the Type 2 5AR and achieves roughly a two-thirds reduction in DHT. What remains to be seen is whether the incidence of side effects will increase with the dual inhibitor above the level seen with finasteride and whether results will be greater or not.
Q - What kind of side effects can you get with finasteride or other systemic DHT inhibitors?
A - Most people notice no side effects from finasteride. Some people do, however, experience a reduction in libido or notice more watery semen. Some get some noticeable hyperandrogenicity, as evidenced by increased facial oil, pimples or unusually high libido. Testicular ache is occasionally noted--probably due to increased testosterone output, which places an extra burden on the body's testosterone production. The body takes some time to adjust to this. (Increased T levels--15% on average in finasteride users--are likely in large part a compensatory response to reduced DHT.) Most often any side effects dissipate within 2 or 3 months. If they do not, things should return to normal after discontinuing finasteride, although this will probably take at least a couple of weeks, as finasteride has a relatively long biological effect, although a short serum half-life.
Q - What is DHT?
A - Dihydrotestosterone, a metabolite of the male hormone testosterone. This is the androgen thought to be most responsible for male pattern baldness. DHT has a very high affinity for the androgen receptor and is estimated to be up to ten times more potent than testosterone. Other androgens that may be significant in pattern loss include androstenedione, DHEA (especially in women) and possibly even some DHT metabolites.
Q - Is it true that the herb saw palmetto is better than finasteride (Proscar/Propecia) and has no side effects?
A - Saw palmetto has been used successfully in prostate enlargement. Accordingly it may have utility in pattern loss, though it has not been formally tested for this. Saw palmetto and finasteride are not really equivalent, since saw palmetto has a much broader range of anti- hormonal activity than finasteride. As for side effects, these are certainly possible with saw palmetto, though everyone will respond uniquely. It must be borne in mind that saw palmetto is as much a chemical concoction as finasteride; it was merely produced in Nature's laboratory instead of a conventional one. Like anything, if it's potent enough to cause a biochemical change in the body-- especially involving hormones--it's potent enough to cause side effects in some people.
Q - What's reflex hyperandrogenicity?
A - When the effects of androgens in the body are lessened, e.g. through lowering DHT or by blockading hormone receptors systemically, the body seeks equilibrium through a process called upregulation. This can take the form of increased hormone production and/or increased tissue sensitivity to the remaining hormones. The reason side effects usually gradually disappear with finasteride is probably due to such upregulation. In a small percentage of individuals, it may be that this process overshoots the mark, resulting in significant hyperandrogenicity. This is marked by such signs as greatly increased facial oil, increased pimples, and greatly elevated libido. It's possible that in certain cases such hyperandrogenicity overcomes the hair-protective effect of, say, finasteride, though this does not appear to be the case for the vast majority of people.
Q - Are there topical antiandrogens I can use instead of taking something internally such as finasteride?
A - Yes. Some things have been used topically to either bind up receptors (spironolactone or estrogens) or to diminish DHT (azelaic acid, pyridoxal B6, zinc). There is much debate about the efficacy of these agents. The problem is a lack of study data regarding their use in male pattern baldness (MPB), though there are studies suggesting why these agents should help.
Q - What's the difference between Rogaine and minoxidil and are these actually helpful for thinning hair?
A - Rogaine is just a brand name for minoxidil. Minoxidil can be purchased from numerous sources and in varying strengths from 2% to 5% liquid and even in a 12.5% micronized lotion. It also comes combined with Retin-A, which improves results by increasing the absorption of minoxidil and also by exerting some antiandrogenic effects. MiNOxidil's name betrays its relationship to nitric oxide, an important hair growing agent that appears to be diminished in balding scalp. Minoxidil can be helpful in pattern loss, but it is not a panacea. It is best used as part of an overall program that attacks the problem from different angles.
Q - Is it OK to apply minoxidil after shampooing?
A - Yes, in fact you will have enhanced absorption after shampooing, as a well-hydrated scalp is more permeable and will better absorb topical agents. Just be sure to towel dry the hair first to remove standing water. The only precaution is to be attentive to signs of excessive absorption, such as a racing heart.
Q - Is oral minoxidil safe and is it effective in MPB?
A - Some people have used oral minoxidil (Loniten), but this is a much more risky treatment than topical application. Use at your own risk. Side effects of excessive minoxidil intake (either orally or topically) include racing heart and salt and water retention. Oral minoxidil in any significant quantity ordinarily has to be taken with a loop diuretic and is best done under a physician's care.
Q - What's SOD?
A - Superoxide dismutase. This is an enzyme produced by the body to neutralize the superoxide radical. Superoxide is a messenger of inflammation and is involved in the body's autoimmune response. It exists in a yin-yang relationship with nitric oxide, a vasodilator that appears to be important for hair growth, while superoxide is a vasoconstrictor that may be part of the signaling mechanism that tells hair to stop growing. Superoxide can also interact with nitric oxide to form a highly destructive compound called peroxynitrite. A few hair products contain copper peptides, which are SOD mimetics; i.e., mimic the effects of the body's SOD enzyme. SOD-containing products have been noted a number of times by researchers to stimulate hair growth and block hair loss in mice. Recent Tricomin study data indicates increased hair growth in MPB. (Tricomin is a copper peptide SOD.) Among other beneficial things, SODs appear to help spare growth-stimulating nitric oxide and to reduce damaging inflammation. There are a few patents for SODs as hair growth stimulators and even one for an SOD inhibitor that blocks hair growth by increasing superoxide.
Q - Six weeks ago I started using X and now my hair is shedding like crazy. What's going on?
A - Sometimes treatments will cause follicles to "wake up" a few weeks early in initiating hair growth. This causes the old dormant hair that's still present to suddenly be ejected prematurely. Thus you may see a temporary wave of increased loss. It's only an apparent increase in actual loss, however, as this falling hair had stopped its growth cycle many weeks earlier and was just waiting to drop out. Increased fallout of this sort should normalize within a few weeks. If it continues over a prolonged period of time (several months) it may be that the treatment is contraindicated. Note that the majority of people do not notice any increased shedding with various treatments. Increased shedding is most often a positive sign, but its absence is not a negative sign. Note also that hair fallout is not perfectly uniform throughout the year, so sometimes increased or decreased shedding is simply coincidental with normal hair cycles. Also bear in mind that it is perfectly normal to lose hair every day. The problem with pattern loss is primarily one of having insufficient regrowth.
Q - A few days ago I began using X and now I'm losing a lot of hair. How come?
A - This week's loss has nothing to do with what you've been doing the last few days. The hair fallout you see this week is actually of hair that ended its growth cycle many weeks ago. Thus today's loss is a picture of the state of your scalp from at least 2 - 4 weeks (and probably more like 6 -12 weeks) ago. This hair was already in the loss phase, in other words, before you even started your recent treatment. Thus, short of mechanically pulling hair out and thus forcing it out prematurely, this week's falling hair is completely uninfluenced by what you're doing this week. Any loss you're seeing now is coincidental to other events. Similarly, what you're doing treatment-wise today won't be reflected in your hair fallout until several weeks from now. Many agents grow some hair in some people. The question is whether or not a given treatment will grow a significant amount of hair in a significant percentage of people. Personal experimentation will provide the only sure answer for any given individual. On the other hand, there clearly are "snake oil" treatments that only make the seller's bank account grow, so be wary.
Q - Can shampoo make a difference in MPB?
A - Sometimes. For instance, seborrheic dermatitis ("seb derm," a bad case of dandruff) is now thought to play some role in pattern loss. In the Propecia trials, researchers had test subjects use T/Gel shampoo (one of the many treatments for seb derm) as a means of leveling the field and cutting out this factor as a variable in determining results. Also, 2% prescription strength Nizoral shampoo was shown in one study to produce hair growth results comparable to 2% minoxidil when used 2 - 4 times weekly. There are almost certainly other shampoos that can positively influence hair growth, as medication can reach the hair follicle fairly easily when the scalp is in a well-hydrated state.
Q - Do any treatments work in the frontal area or are they only effective in the crown?
A - All treatments that work on the crown also work to some degree in the front--just not as well. Treatments are generally more effective the further back you go. Confusion arises because of the way some studies were conducted. With minoxidil, for instance, studies only measured vertex balding; i.e., the traditional bald spot. Accordingly, the only hair growth results that the manufacturer-- Upjohn--is allowed to claim pertain to the vertex.
This FAQ represents the views of the author and is presented for informational purposes only. The author is not a physician and this information should not be construed as medical advice. This FAQ Copyright 1999-2000 by Michael A. Leake. All rights reserved. No reproduction without written permission.