Minoxidil / Rogaine
Rogaine (Upjohn) will slow down hair loss in both men and women, but is reported to stimulate hair growth in less than 25% of patients who use it. When applied as directed, twice daily, it stops hair from falling in about 75% of patients with pattern hair loss. The mechanism by which it works is a vasodilatation or opening of the blood vessels of the scalp. Interestingly, there are many preparations that will cause vasodilatation, but minoxidil is the only one that reportedly grows hair.

If you are one of the fortunate individuals to grow hair with minoxidil, you must continue using it indefinitely; otherwise the newly grown hair will fall out. In addition, hair that didn't fall because of minoxidil, will also fall out within a short period of time when the preparation is discontinued.

According to the manufacturer, minoxidil less is likely to grow hair on the front part of the scalp than it is on the crown or vertex. When new growth does occur, the density is modest. We've found a logical approach to be: Replace lost hair with transplants, and use minoxidil to preserve what remains of the original hair. Rogaine is available in 2% and 5% solutions. The 5% solution gives results that are 45% better than the 2%. Both preparations are available without prescription, and in generic varieties. A new foam version of Rogaine 5% is available and is less messy to use than the liquid equivalents.

Finasteride / Propecia
Propecia (Merck) is a prescription pill used for the treatment of hair loss. It is a low potency form of Proscar (Merck), a drug used for the treatment of enlarged prostates. Finasteride exerts its influence by blocking the enzyme 5 alpha-reductase 2 (5 AR-2), and therefore the chemical conversion of testoterone to dihydrotestosterone (DHT). In doing so, it reduces the blood level of DHT ...and the size of the prostate. Its effect was first discovered when it was noted that patients with a genetic 5AR-2 deficiency had no baldness. Finasteride is not a hormone and has no feminizing properties. Because it works via a pathway different than minoxidil, the effect of using both might be additive.

A preliminary double blind study showed that its effect on hair growth begins about three months after commencement. In patients with vertex (top of the head) hair loss, a one square inch site was observed. The average density in normal males was 2000. In balding patients, the average density was 800. After one year of treatment, the balding patients had an average density of 900 in the one-inch observation site. Although this increase in hair count is only about 10%, the patients looked much more than 10% improved. Reason: In spite of minimal increase in density, the miniaturized hairs become larger and larger in diameter.

When interviewed, 65% of Propecia patients thought they were “better” ... 30% of the placebo patients thought they were “better.” When Propecia is stopped, the serum level of DHT returns to normal level and the newly grown hair is lost slowly over the period of a year. In addition, hair that didn’t fall because of Propecia, will then fall over a short period of time. A logical approach is: Replace lost hair with transplants, and use Propecia (and/or minoxidil) to preserve what remains of the original hair.

The following details about Propecia are worth noting:

1. The PSA blood test for prostate cancer is artificially lowered and patients on
   Propecia should notify their examining physician that they are taking this medication. Men over 35 should have a baseline PSA before starting Propecia.
2. Women should not take Propecia or handle broken tablets, it can cause birth defects in male fetuses.
3. Less than one percent of patients on Propecia report decreased libido and/or impotence. This returns to normal when the drug is discontinued.
4. Long term side effects have not been determined.

Dutasteride
Dutasteride is a pill for prostate gland reduction manufactured by Glaxo Smith Kline.. Although it is available, it has not been FDA-approved as a treatment for hair loss. Dutasteride is not a hormone and has no feminizing properties. Unlike finasteride which inhibits 5 AR-2 alone --- dutasteride inhibits both 5AR-2 and 5AR-1. In FDA studies, dutasteride grew 92 new hairs in a one-inch square of thinning scalp. Finasteride grew 72. Dutastride’s sexual side effects were in the range of 5-11% versus 1-2% for finasteride. The half-life of dutasteride is >240 hours vs. 6-8 hours for finasteride. Dutasteride’s concentration in semen is 13x that of finasteride (sounds like a lot, but it takes three liters of semen from patients on finasteride to deposit a harmful dose in women who are pregnant with male fetuses.)

But most importantly, finasteride has a biologic model and dutasteride does not. Patients with genetic 5AR-2 deficiencies have no life-threatening disorders and there is no 5AR-2 present in their brain tissue. On the other hand, there is no biological model for 5AR-1 deficiencies and there are measurable levels of 5AR-1 in the human brain! Conclusion -- the blockage of 5AR-1 has unknown neurologic implications.

Camouflage
One of the oldest methods of dealing with baldness is camouflage. Wigs, toupees, or hair “systems” have been traditionally chosen as alternatives to hair loss, but ever since hair transplantation became technically sophisticated, hair “pieces” seem to be less popular. That’s because they often look unnatural, they require careful attachment, they’re uncomfortable in hot weather, they’re difficult to keep clean, they must be serviced regularly, and they must be replaced every one or two years.

Hair systems may be made of real hair or synthetic hair -- attached to bald skin with adhesive, attached to existing hair by clips, or attached to existing hair by “weaving” the system hair into the living hair. Unfortunately, hair weaves must be re-attached every 3-4 weeks, because the system loosens as the hair grows. A less popular, but more reliable form of attachment is the surgical creation of skin tunnels in the skin of the bald scalp. Large smooth hooks on the underside of the system are slid into the tunnels; much like a large earring would be passed through a pierced ear.

Several products are designed to “cover-up” the light colored skin in the area of loss. These are coloring agents of one sort or another, and they usuallly have a tendency to rub off, or run or smear when wet. Some agents coat the existing hair with a tiny colored fiber, and in that way color the scalp skin and make the hair look thicker. In some parts of the world, patients choose to have their scalp tattooed with pigment to obscure the area of loss.

Hair growth promoting preparations
Since time in memoriam, desperate patients have tried one or another magic potion that promises to actually “grow hair.” The sad but simple fact is that minoxidil and finasteride are the only hair growing preparations that are recognized as effective by the medical and scientific community. Estrogen treatments or surgical castration will prevent the further loss of hair in men, but both result in feminization. Vitamins, dietary supplements, exotic herbs, organic extracts, irritating scalp lotions, and various mechanical gadgets have all proven to be disappointments.

Low intensity laser light
In the past year, the FDA has cleared a consumer product with battery operated laser light for the stimulation of hair, and the prevention of future loss. Although several of these products are on the market, only HairMax has received FDA clearance. This device has been shown in a multi-center study to increase the number of hairs per square inch by a factor of 17% over baseline. It is still unclear whether or not the laser must be used continuously throughout one's life time to maintain the results. Furthermore, there is no data to suggest whether or not the hair continues to grow even when the device is used continuously for years. Several other lasers with the same power intensity as the HairMax are now available and are less expensive. But in general, the efficacy of all these hand-held products has yet to be published in a medical journal and conclusively proven.