July 8, 2009 -- While many men are fine with hair loss, for others baldness demands a remedy, which they seek in a variety of ways.
Over the years, the number of treatments that have been claimed to cure baldness has been exceeded, perhaps, only by the number of jokes about the condition. But since baldness -- as unappealing a prospect as it may be for many men -- is not an illness, procedures and drugs to treat it may not get the scrutiny given those for genuine medical conditions.
"Things have gotten better, so there's some of the older techniques and older treatments ... and there are newer ones, so it's a work in progress, fortunately," said Dr. Walter Unger, a clinical professor of dermatology at the Mount Sinai School of Medicine. "We're constantly doing new things and getting better in medicine; when we don't, we're all going to be in trouble."
But while treatments have come along that have not worked well, there are things available for men who are losing or have lost their hair and would like to cover their pates.
"There are a variety of medical and surgical options, as well as things that are completely noninvasive," said Dr. Nicole Rogers, a hair loss specialist with Old Metairie Dermatology in Metairie, La.
Male pattern baldness is typically associated with the conversion of testosterone to dihydrotestosterone (DHT). Over time, the presence of this hormone has been linked to the thinning or "miniaturization" of hairs.
"The new hair that grows grows thinner and less pigmented," said Dr. Amy Newburger of Dermatology Consultants of Westchester, N.Y. "It just comes back as a shadow of its former self."
For most men, noticeable hair loss begins in their 20s or 30s, but some see it even younger.
"The youngest case of male pattern hair loss I have ever seen is age 8," said Dr. Jerry Shapiro, a dermatologist affiliated with New York University's Langone Medical Center and the University of British Columbia.
However, male pattern baldness tends to start later, affecting, to some degree, 20 percent of men by the time they reach the age of 20.
But for most of these men, there are a lot of options to stop, reverse or delay hair loss.
In the ensuing pages we will look at a number of treatment options that have been tried and the pros and cons of trying them out.
Follicular Unit Transplant
Performed in two different ways, follicular unit transplantation remains the best surgical option for men seeking to counter their hair loss.
"This is an extraordinary reproducible procedure," said Dr. Robert Bernstein, a clinical professor of dermatology at Columbia University. "Hair transplant is the gold standard. It's 100 percent. The body doesn't reject its own hair."
Follicular transplant is a difficult procedure, but Bernstein noted, "[it] may not be done well, but if done well, it's "bulletproof."
As the name suggests, follicular unit transplant involves removing hair follicles from the patient's own head and transplanting them to other areas of the scalp that are losing or have lost hair.
The follicles are removed either in a strip -- which leaves a very thin but long (4-8 inch) scar -- or individually, the latter of which is a newer procedure known as follicular unit extraction.
While follicular unit extraction leaves only small scars (ideal for men who plan to possibly shave their heads) it takes longer and is more expensive.
Obviously the procedure does have some drawbacks.
"The decision to pursue actual surgery ... is not something everyone is a good candidate for," Rogers said.
Bernstein noted that it does not prevent further hair loss if areas not treated are losing hair.
Also, "we're limited by the amount of donor supply that a person has. We're redistributing hair with a transplant, we're not creating new hair," he said.
There is some recovery after the procedure.
Bernstein said he advises patients to stay home the day after the procedure and to shampoo frequently. Patients experience redness of the scalp for a week following the procedure, and it will have a crust for a few days, he said.
"As long as you can wear a hat or cover it, or if you have some hair to disguise it, you can pretty much go back to work a few days later," he said, noting the full recovery period is around 10 days.
For those willing to go under the knife and pay the cost of the operation -- which can run from $2,500 to $14,000 -- according to Bernstein, follicular unit transplant may be the way to go.
"I have to see the data on that," Shapiro said. "I've not seen anything published on the use of Botox for hair re-growth."
The theory behind why Botox might work is that it dilates blood vessels, allowing nutrients into the hair follicle.
But it does not have widespread use -- or evidence. None of the dermatologists asked about this potential treatment had heard of it being used.
"I'd like to see some studies," Shapiro said. "I don't know if that's a real mechanism of action for how this works."
"The decision to pursue actual surgery ... is not something everyone is a good candidate for," said Rogers, adding that many of her patients begin with medications.
One of those pharmaceutical interventions is the topical application of minoxidil, a foam known to many by the brand name of Rogaine.
Like many other treatments, "It's probably not going to work that well" for people who have already lost a lot of their hair, Shapiro said.
But for those early on in the process, "I would recommend ... a topical minoxidil solution," he said.
Shapiro notes that minoxidil can produce some side effects. Seven percent of men get some irritation of the scalp, while fewer than one in 10,000 can get heart palpitations.
In this process, which is no longer widely used, a small, circular cone of scalp -- Bernstein compared it to a pencil -- was removed from the back of the head and placed in a hole put in the front.
"It's really not done anywhere," Bernstein said of the procedure, which served as a previous generation of follicle transplant.
While follicles are able to blend into the scalp and look natural, plugs never did because of their size -- they were 30 times larger than the follicles transplanted now.
The size made the plug look completely unnatural, something that can be gotten around -- when done properly -- with the modern follicle transplant.
'"We're actually dissecting the follicular unit out from the surrounding skin," Bernstein said. "We're talking about orders of magnitude."
"Propecia is the best medication [for hair loss]. It works about 85 percent of the time, at least to prevent further hair loss," Bernstein said.
Originally designed to treat enlarged prostate, Propecia, known scientifically as finasteride, can be taken orally on a daily basis to counter hair loss.
It has been shown to be highly effective, but it is not perfect.
"It works best when the patient is younger and the hair loss is early," said Bernstein. "It doesn't grow hair on a bald scalp; it only reverses the miniaturization process."
Rogers said that despite the side effects, "Propecia has really remarkable results."
She notes that in about "one out of 50 [cases], it can cause a loss of libido. That means 98 percent of men are totally fine."
Because of the drug's origins as a prostate treatment, she said, patients need to communicate with their doctors.
"There are receptors for the medicine in the prostate," Rogers said. "For men who are on it, I always tell them to let your urologist know."
Of course, Propecia also has the drawback that it must be continuously used to enjoy its benefits.
"I always tell patients to be prepared to use it in an open manner, at least until the next best medicine comes along," Rogers said.
Flap Hair Restoration
The hair flap, also known as flap rotation, has not been done in a while.
"That's a blast from the past, that's 20-plus years ago," said Newburger. "I haven't seen that but once in my entire career."
And for good reason.
The hair flap involved isolating a flap of skin from the back of the head -- where the hair was still growing -- and rotating it to the front, maintaining the blood flow through the artery attached to the skin.
"The problem with the flap is it's much too dense and you're using up too much hair in a small area," Bernstein said.
The procedure -- which was only done by a few doctors when it was done -- had other drawbacks.
"It's very unnatural looking and the hair is in the wrong direction," Bernstein said.
But while the flap transplant is not used for male pattern baldness, it can be used for people who have lost a patch of hair.
"People who have had a traumatic injury on their head, sometimes a flap is better than a follicular unit transplant," Unger said. "It isn't done for male pattern baldness, but for traumatic injuries it's very useful."
The laser comb has drawn some attention in recent years because of its novelty, but that same newness remains one of its drawbacks in the opinion of some doctors.
"I would say basically the evidence is still forthcoming," Rogers said. "We don't really have any large, independently conducted, placebo-controlled double-blinded studies confirming that it works."
The HairMax LaserComb remains the only treatment of this type approved by the FDA. Some doctors have found encouraging results in stopping hair loss.
"We use the HairMax Laser Comb," Newburger said. "We use it in patients who have not yet completely lost their hair and get a reasonable response."
But Rogers said she favors using older methods.
"It's really something that may work for some people, but we don't have the data for that nearly that we do for these other modalities, like the minoxidil and the Propecia," she said.
"With the generics of the minoxidil, you can buy a lot of minoxidil for the $400 to $500 you might spend on one of these laser comb lamps," she added.
Needless to say, stem cells aren't used as a hair loss treatment now, but hopes are high.
"We'll have an endless supply of hair 20 years from now," said Unger. "How much sooner than that I don't know."
Doctors had differing opinions -- ranging from five to 20 years -- on how soon stem cells would be available. But the consensus was that hair treatments would change.
Bernstein, who estimates something will be available in five to 10 years, said that two barriers remain to having stem cells produce a baldness treatment.
The first, he said, was then when some stem cells multiply, they lose the ability to grow hair. The second is that it is often difficult to produce hair that is cosmetically useful.
"We can't multiply the hair well at this point or make it cosmetically oriented," Bernstein said. "Those two problems are really a big barrier."
Men who are in the process of losing their hair have several options.
Men who have already lost their hair have fewer.
"You're looking at a hair transplant, and I think they're wonderful if they're done by a skilled physician," Newburger said.
But men who want to do something about baldness but have already lost their hair and have little hair left on their head to transplant, or who for other reasons dislike medical interventions, still have an option.
"Hairpieces and wigs remain an important option for patients who either can't tolerate the medications, don't want to take something systemically, don't want the hair transplant surgery, don't have enough hair for transplantation," Bernstein said.
While he cited the maintenance costs as a strike against hairpieces, they do present a valid choice for some men.
"People who just want coverage -- wigs and hairpieces remain an excellent option for them," he said.