The first step in undergoing medical hair restoration is determining what is causing the hair loss in a patient. The most common cause for hair loss in both men and women is androgenetic alopecia, which is the medical term for male and female pattern hair loss. It can affect over 50% of men as well as 40% to 50% of women.
The next most common cause after androgenetic alopecia, and probably more so for women, is telogen effluvium. Telogen Effluvium is a temporary shedding that can occur in a patient. If a woman has a baby, she can have shedding after childbirth that usually occurs three to six months after the baby is born. Telogen effluvium is also more common in women because of factors such as starting or stopping taking birth control pills, which can cause hair thinning.
Stress can also be a cause for this condition but only major physiological stress in both men and women. If everyday stress caused hair loss then everyone would be bald. And after that, alopecia areata which is an autoimmune condition that attacks the hair follicles and can cause them to shed.
Losing hair due to the aging process is known as senescent alopecia. It is a gradual age-related thinning of the caliber of the hairs. It happens all over the head as opposed to male or female pattern hair loss. Usually in male pattern hair loss, the entire hairline can move back and cause balding in the crown and the vertex. For women, the frontal hairline usually stays intact but then they have a decrease in the density in the frontal portion of the scalp. The scalp has almost a see-through appearance.
Currently, the only FDA-approved treatment is topical minoxidil AKA Rogaine. It is available in different formulations from the various companies that make it. The other one is finasteride or Propecia and that is FDA-approved only for use in men.
It is okay for women to use finasteride after menopause. Finasteride is fine as long as women are not going to get pregnant while they are taking it since it is highly teratogenic. Meaning it can disrupt the development of a fetus or embryo and might cause a birth defect.
The other medicine that is offered off-label is spironolactone and it is actually a diuretic used for people who have fluid overload such as congestive heart failure. It is used along with thiazide diuretics like hydrochlorothiazide to help take the fluid off. It also has an antiandrogen effect at the hair follicle level so it taken by women via the mouth. Spironolactone is a treatment option that also requires a woman to be careful while taking if she wants to get pregnant.
In order to achieve reliable results, a patient needs to stick with treatment options like minoxidil and finasteride that have a good success rate. There are other options available like PRP (platelet-rich plasma), which involves transferring one’s own platelets into areas of hair thinning. The idea is that platelets release growth factors which can help the hair grow in better. In general, however, there is less data to support PRP for hair loss. The success rate varies from 40-60% for PRP while finasteride has an 80%-90% success rate. Most hair loss physicians start with the things that have the best efficacy and safety data, and then work their way down the therapeutic ladder. One major advantage of PRP is that it is very safe, does not require lab testing, and has no drug contraindications. It can also be a great treatment option for patients who have failed or are not good candidates for other treatment options.
Hair transplant surgery can offer permanent and very natural looking results. The best results are achieved with a surgeon with extensive training and who is dedicated to achieving an excellent cosmetic outcome.
A hair transplant procedure involves removing donor hair from the back of the scalp and then moving it to the thinning areas. Both men and women of almost any ethnicity can benefit from the procedure.
The donor ellipse, or “strip” technique allows doctors to harvest the greatest number of hairs in the shortest amount of time from the most permanent donor zone with the least amount of trauma to the individual follicles. The strip is taken directly from the posterior rim of scalp hair. This strip may be anywhere from 10cm to 30cm long, depending on the size of the case. One disdvantage of this technique are that the patient may have a linear scar if the hair is cropped very short.
The FUE technique (follicular unit extraction) involves removing individual follicles from a large area over the back of the scalp. The advantage is that patients do not have a linear scar. One disadvantage is that there may be more trauma to the follicles as they are extracted, and it may be more difficult to harvest a large number of hairs without significantly thinning out the back. FUE is a great choice for young men who do not need a large surgery and want to be able to wear their hair cropped very short.
When comparing medical hair restoration techniques with hair surgery, the same results can be achieved in some cases. Patients with mild or early thinning may experience full regrowth with medical therapy alone such as finasteride and/or minoxidil. Also, the longer people stay on these medications the better they work. It generally takes 6-12 months to start to see a difference. Patients who stay on finasteride for 2-5years can expect continued regrowth.
However, some follicles become so miniaturized that they require hair transplant surgery. If they do not even have any little whisker (vellus) hairs left, there is a good chance they need to do the surgery. However even patients who undergo surgery should still do medical therapy. While hair can be successfully moved, surgery alone cannot prevent ongoing thinning of the surrounding hairs. Think of hair loss as having a leaky bathtub. More water can be poured into the tub to raise the level of the tub, like a hair transplant. However the leak cannot be stopped without some kind of additional medical therapy.
For patients who want to buy the generic topical versions, they could probably pay as little as $15 to $50 a month for minoxidil. The price depends on if they do the generic or the brand. Finasteride is now available in a generic and costs as little as $5 to $60 dollars a month depending on how it is written.
The hair surgery cost varies based on the part of the country where the surgery is performed. In New York City, it costs about $10,000-$20,000. In the South, the cost may run from $5,000-$10,000 per session.
Researchers are looking at different plant-based 5-alpha-reductase inhibitors. For example, palmetto historically has been used for benign prostatic hypertrophy, which is what finasteride was originally approved for. It has been found that it may have some role in regrowing hair although it is less effective than finasteride. Also, a recent study showed that pumpkin seed oil was also able to help regrow hair. That is a plant-based 5-alpha-reductase inhibitor, like finasteride. While palmetto might not replace finasteride, it is a possible future treatment option.
Another interesting therapy for hair loss is dutasteride. Dutasteride is Proscar, which is another drug that is approved for benign prostatic hypertrophy. It has been found to be helpful to men who do not respond to finasteride. The benefit is that it blocks both type 1 and type 2 5-alpha-reductase inhibitors, whereas finasteride only blocks type 2. The downside is that it has a longer half-life so any potential side effects would be in the system longer. This is one of the reasons it has not been approved yet.
There are a few risks associated with minoxidil. For one thing, it is a vasodilator, which can cause dizziness and headaches. The other thing that can happen with minoxidil is unwanted facial hair growth. Historically a 2% was only available for women to use twice daily. But now the 5% minoxidil has been approved for women to use once a day in order to increase compliance. Now they do not have to do the 2% twice a day anymore, they can just do the 5% once a day. The problem is some women get confused and start using the 5% twice a day and begin to get a darkening or thickening of hair on their face. To reverse this side effect, they have to stop taking the medicine, decrease the frequency of the application, or change to the 2%. Finally, the other thing that can happen with minoxidil is patients can start to have itching with the solution. The reason most people have itching is because they are allergic to the propylene glycol which is a preservative in the solution. If anyone finds they are having itching with the solution then they should switch over to the 5% foam, which cuts out the propylene glycol.
Some of the side effects of finasteride include mood changes, breast enlargement, and a decrease in the libido including performance, sperm volume, and sperm count. All of these side effects are reversible if the patient stops taking the finasteride.
Also, men cannot donate blood while they are on finasteride. If their blood were to reach a pregnant female, there is a risk of teratogenicity.
People who have a history of keloid formation should undergo hair transplant very cautiously. Keloids are extra scar tissue that grows after an injury has healed. This condition is seen more frequently in darker skinned patients but can occur in all ethnicities or genders.
The results from using Rogaine and finasteride take about 6 months before they start to become noticeable. The actual time period is between 6-12 months. The longer a patient stays on the medical therapy, the greater the chance the hairs will cycle back into thicker and fuller versions of themselves.
The nice thing about these surgeries is that they are done under local anesthesia. The recovery time is pretty quick and people can go outside their house as early as the next day with either procedure without any wrappings.
There might be some discomfort in the donor area with the strip because that section of the scalp has been completely removed. The stitches and the stretching pull the skin edges together. It generally takes 5-10 days for the back to heal altogether. With FUE, small scabs will be located over the donor hairs and should fall off by the 1 week follow-up.
Between the two choices, a patient may have slightly more discomfort with the strip simply because the strip is more invasive.
It is important for those suffering from hair loss to remember this point: If they are not ready to undergo a hair transplant there is a chance they will be pleased with the results by just starting with medical therapy. There are commercials that make it sound like there are no hair restoration options besides a hair transplant. Medications can be very helpful when it comes to hair restoration.
Written by Cosmetic Town Editorial Team - MA
Based on an exclusive interview with Nicole Rogers, MD in Metairie, LA