“I’d be bald by now if it weren’t for the hair loss treatment regimens I tried and the medications Dr. Mehrabi prescribed me.”
Reflecting on this, these are the words of my long-time patient, BK, who kindly shared his story about his ongoing struggle against male-pattern hair loss. Many people ignore hair loss, thinking it naturally comes with aging and must be accepted without question. However, hair loss can make people feel old and less attractive, and these thoughts can affect their relationships even though they are far from the truth.
Furthermore, this article talks about the possible causes of hair loss in men and the various hair regrowth treatments available. We also relate BK’s experience with what science knows so far about this condition.
What Is the Cause of Hair Loss in Men?
BK recalls, “I was around 25 when I first experienced losing hair. I was under a lot of stress when I noticed my hair thinning progressively within weeks, particularly at the top.
“My skin is sensitive to stress. I’ve experienced psoriasis when I’m stressed. My experience with hair loss is similar. Stress makes me lose more hair, and it gets worse with time. I don’t like it aesthetically, and I don’t like its association with stress.”
”I know I have the genes that make me vulnerable to male-pattern hair loss. My dad and grandpa have thin hair.”
Importantly, hair loss in men is multifactorial. While heredity plays a huge role in its development, other factors like stress, illness, and malnutrition can trigger or aggravate the condition. Knowledge of the mechanisms of male-pattern hair thinning can help you understand how current male hair loss treatments work for this condition.
What Are the Stages of Hair Growth?
To clarify, hair growth is divided into four stages: anagen, catagen, telogen, and exogen.
Anagen involves new hair follicle formation and growth. Hair color also darkens during this time. The duration of this stage determines the final hair length. About 90-93% of your scalp hair follicles are in the anagen phase.
Catagen is essentially when hair growth and pigmentation stop. Telogen is the resting phase, when catagen is complete, and the hair follicles prepare to fall from the scalp. Hair follicles not in anagen are in this stage.
Exogen is when hairs are shed. Some authors consider this phase still part of telogen. Around 1% of telogen hair is shed daily. Medication use and light-dark cycles can affect the speed of hair shedding.
Crucially, the major role-players in male-pattern hair thinning influence the length of the hair growth stages. Long anagen periods are associated with lush hair growth, while a lengthy telogen is linked to excessive hair loss.
What Is Androgenetic Alopecia?
Male-pattern hair loss is a manifestation of a hair growth disorder known as “androgenetic alopecia.” The condition used to be attributed solely to the genetic components of testosterone metabolism. However, studies have so far identified 12 genes that contribute to its development.
Testosterone and testosterone-like hormones called “androgens” regulate hair growth. Testosterone is metabolized into the more potent androgen 5ɑ-dihydrotestosterone (5ɑ-DHT) in the hair follicles. Genetically influenced traits, such as higher 5ɑ-DHT levels and increased androgen sensitivity, shrink the hair follicles. Consequently, the anagen phase diminishes, resulting in the hair shaft becoming shorter and thinner.
Other genes implicated in the development of androgenetic alopecia, such as the ones regulating the molecules histone deacetylase and WNT, control anagen duration by their effect on hair follicle growth.
How Do You Know If You Have Androgenetic Alopecia?
In men, androgenetic alopecia initially presents with frontal hairline recession followed by hair thinning at the top of the scalp. Without treatment, a bald patch may develop, spanning the front and top of the head. The back and sides of the scalp are spared because these areas are less sensitive to androgens.
Similarly, women may also develop androgenetic alopecia. Female-pattern hair thinning affects the top of the scalp more than the front, back, or sides.
Androgenetic alopecia may start as early as adolescence and progress with age. Disease, poor nutrition, and stress may aggravate this condition.
What Can Cause Thinning Hair in Men Besides Androgenetic Alopecia?
In addition to common hair loss issues, there are other hair growth disorders that can affect both men and women, such as:
- Telogen effluvium: This condition is the most frequent cause of >25% hair loss throughout the body. Increased telogen shedding typically occurs 2-4 months after a triggering event, such as an infection, malnutrition, use of some cancer treatment drugs, and surgery.
- Alopecia areata: This disorder is the most common cause of hair loss in children, though it can occur at any age and affects both sexes equally. Patchy hair loss is the most common presentation, but severe alopecia areata may present as total scalp (alopecia areata totalis) or total body (alopecia areata universalis) hair loss.
- Cicatricial alopecias: Hair loss is usually accompanied by scalp scarring. Cicatricial alopecias may be caused by autoimmunity or an external source like severe fungal infection and trauma.
These hair disorders are less common and typically treated differently from androgenetic alopecia. Additionally, these conditions present with symptoms not found in androgenetic alopecia. A medical professional can help patients with thinning hair determine the cause of their symptoms and get the appropriate remedy.
Which Hair-Loss Treatment Options Are Best for Men?
When asked if he tried anything to alleviate his condition, BK replies, “I can’t recall the first treatment I tried. A doctor prescribed it to me, but it didn’t work.
“However, when I was 26 or 27, I started going to a private cosmetic dermatology clinic where plant-derived stem cells were injected into my scalp. Weeks later, they also injected the area with platelet-rich plasma or PRP. The treatments were painful, but this alternating regimen worked really well for me. After that, I’d be on these treatments two months in a year and wouldn’t have to do much afterward except keep my hair moisturized.
BK explains his change in hair care routine, saying, “I discontinued using harsh shampoos that were drying out my hair. Given that I spent a lot of time in dry places, especially in California and Nevada, it was crucial to prevent my hair from becoming excessively dry.
“To nourish my scalp, I began using natural ingredients like eggs and coconut oil. This was in addition to undergoing alternating treatments of stem-cell-and-PRP therapy. I also made efforts to minimize stress to avoid triggering another episode.”
“When I was 29 or 30, I found myself in another stressful period, and I lost another bunch of hair. I just maintained my PRP and stem-cell treatments, but they stopped working a few years later. It was then that I consulted Dr. Mehrabi about my condition for the first time. He prescribed me an intensive treatment consisting of low-dose oral finasteride and topical minoxidil.
“I had already been on an over-the-counter form of minoxidil previously, but I didn’t know how to combine it with other treatments, what to expect of it, or how long to stick with it. However, with finasteride, I started getting results from the medication itself while responding a lot better to the other treatments.”
Numerous male hair loss treatments are available. However, the only medications currently approved by the FDA are topical minoxidil and oral finasteride. Topical minoxidil is the first line of treatment for androgenetic alopecia. This medication prolongs the anagen phase of the hair cycle. Finasteride inhibits 5ɑ-reductase, the enzyme that converts testosterone to 5ɑ-DHT. The dose we give for androgenetic alopecia is one-fifth that for prostate enlargement.
As for dermatologic procedures, we can perform hair restoration surgery in patients with large enough hairy scalp regions. Hair follicles are taken from a lush scalp spot and transplanted into areas with thinning hair.
Neither medications nor a hair transplant can get rid of the genetic drivers of male-pattern hair loss. However, combining hair transplantation and topical minoxidil or oral finasteride can stabilize the condition.
Are There Alternative Hair Regrowth Treatments for Men?
Additionally, other male hair loss treatments have variable effects on patients and need further studies. Some work on the androgen-influenced components of the condition, while others modify the androgen-independent hair growth processes. These treatments include:
- Low-level laser therapy: Low levels of near-infrared or visible light are used to activate growth factors in the scalp and enhance blood circulation in the area.
- Topical finasteride: A form of finasteride patients can directly apply to the scalp to spare them from the oral version’s unwanted side effects. Studies show that this formulation may be as effective as the oral form but has minimal side effects.
- Oral dutasteride: This drug is a finasteride-like molecule. It is more potent but not currently FDA-approved for androgenetic alopecia treatment. The initial concern with dutasteride was that it could lead to more serious adverse effects. However, recent studies show that oral dutasteride’s side effect profile is similar to oral finasteride’s. Physicians may prescribe this medication off-label in place of oral finasteride for hair loss treatment in men.
- PRP treatment: Growth factors derived from the patient’s own blood are injected into the scalp.
- Mesotherapy: Medications, vitamins, and growth factors are injected under the scalp skin. Some practitioners may administer dutasteride by this route.
- Botulinum toxin injection: Enhances scalp circulation and blocks 5ɑ-DHT’s suppressive effects on the hair follicle cells.
- Pulse electrotherapy: Electromagnetic or electrostatic pulses are used to activate hair follicle growth.
- Topical caffeine: Enhances hair follicle proliferation and growth.
- Melatonin: Topical melatonin prevents oxidative stress in scalp tissue.
- Retinoids: Retinol and other vitamin A-like substances promote hair follicle growth.
- Biochanin A: This red clover extract resembles steroid hormones like estrogens and androgens. The structural similarity allows biochanin A to inhibit 5ɑ-reductase from making more 5ɑ-DHT.
- Adenosine: Stimulates growth factor synthesis in the scalp.
- Latanoprost: Prolongs the anagen period.
- Nutritional supplements: Vitamins C and D, iron, folate, and selenium are some nutrients necessary for hair growth.
- Oral minoxidil: Enhances hair growth but may severely lower blood pressure and affect heart function.
- JAK inhibitors like baricitinib: Oral formulations have been shown to reduce hair follicle inflammation in patients with alopecia areata. However, JAK inhibitors have shown limited efficacy on male hair loss.
- Spironolactone, ketoconazole, and other medications with antiandrogenic activity: These drugs counter the effect of androgens on the scalp.
- Stem cell therapy: Stem cells are immature precursor cells that can become any mature cell type when activated. These cells can be induced to transform into hair follicles. Stem cell injection replaces shrunken hair follicles and reduces scalp inflammation and oxidative stress.
- Microneedling: Activates mechanisms that enhance the production of growth factors in the scalp. This procedure may be performed shortly before injecting or applying PRP, caffeine, vitamins, and other substances that don’t normally penetrate the scalp easily.
- Plant-based oils: Rosemary oil reduces scalp inflammation and oxidative stress that may injure the hair follicles. Pumpkin seed oil inhibits 5ɑ-reductase.
- Saw palmetto: Inhibits 5ɑ-reductase.
Furthermore, some procedures on this list, like microneedling, PRP, and botulinum toxin injection, are available at our clinic. We tell patients they must be under strict medical supervision and continue topical minoxidil or oral finasteride while trying these alternative treatments.
What Are the Side Effects of Men’s Hair Growth Treatment?
BK recounts his experience with oral finasteride, stating, “For over two years, I was on oral finasteride, stopping only a few weeks back. In the recent months, I had reduced the dosage to half.
“My concerns were primarily about the drug’s side effects. During the course of taking it, I felt like I lost some of my sex drive and endurance when I was taking it. Additionally, there was a noticeable dip in my overall motivation, leading me to speculate if this could be another side effect of oral finasteride.
“Nevertheless, I’ve switched to a topical finasteride prescription now. Currently, my treatment involves the topical application of both finasteride and minoxidil.”
Unfortunately, all hair loss treatments have side effects, even the FDA-recommended ones. For topical minoxidil, concentrations greater than 5% may cause skin reactions and headaches. Abnormal hair growth may occur in areas outside the scalp exposed to the solution. Patients may see some hair shedding in the first eight weeks of topical minoxidil use.
Meanwhile, oral finasteride may cause reduced sex drive, sexual dysfunction, hypersensitivity, and testicular pain. Patients vulnerable to depression and other mental health conditions may develop behavioral changes.
Intolerable side effects are reasons for stopping a treatment. Patients who report adverse events must be given safer alternatives.
The Chronic Nature of Hair Loss in Men
What does BK’s hair regrowth regimen look like now after stopping oral finasteride intake?
“My routine right now consists of weekly shampoo with 2% ketoconazole, topical finasteride, and topical minoxidil five days a week, and once-weekly microneedling with topical caffeine. I still go for PRP and stem cell treatments three times a year.
“I think, now, the amount of hair on my scalp has stabilized. My initial goal was just to stop losing hair, and I believe I have achieved that. I don’t have to have super-thick hair.
“Some days, I stop my routines and do nothing to give my scalp a bit of a break. But whenever I do that for a period of time, I start losing hair again.
As for my future plans, I don’t want to keep putting in the effort and money just to maintain my hair for the rest of my life. I might wait for a new form of treatment, such as autologous stem cell injection, to turn mainstream or have a hair transplant done. Another obvious and easy option would be just to accept that I’m balding. We’ll see.”
Withdrawal of minoxidil and finasteride causes patients to start losing hair again, like what BK experienced. Androgenetic alopecia has a strong genetic component, which means it’s lifelong. None of the FDA-approved and experimental therapies can be a definitive cure for this condition, though they can delay its progression.
The desire to have healthy hair and scalp must not be dismissed as sheer vanity. Male-pattern hair loss may reduce the quality of a person’s life, as it can have profound psychological and emotional effects. Therefore, managing this condition is not only about aesthetics but also about maintaining mental and emotional health.
There is no one-size-fits-all approach to dealing with male-pattern hair loss. Each person’s experience with the condition is unique, and the decision to seek treatment or embrace one’s natural appearance is a personal one. Talking to a licensed healthcare provider and seeking support can help patients cope with the challenges of hair disorders.
Effective Hair Regrowth Treatments in LA
Androgenetic alopecia is a lifelong condition. However, a highly experienced, board-certified dermatologist can help you treat the symptoms effectively.
BHSkin Dermatology’s hair regrowth specialists are some of California’s best. Visit our Glendale or Encino clinic or use our telederm platform for your initial consultation.
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- Blume-Peytavi, U. and Kanti, V. (2019). Chapter 85: Androgenetic Alopecia. Fitzpatrick’s Dermatology, 9th ed. https://accessmedicine.mhmedical.com/content.aspx?bookid=2570§ionid=210420621
- Devjani, S., et al. (2023, May 11). Androgenetic Alopecia: Therapy Update. Springer Nature. 83(8). 701-715. https://doi.org/10.1007%2Fs40265-023-01880-x
- Estill, M. C., et al. (2023, October 27). Finasteride and Dutasteride for the Treatment of Male Androgenetic Alopecia: A Review of the Efficacy and Reproductive Adverse Effects. Georgetown Medical Review. https://doi.org/10.52504/001c.88531
- Gupta, S., et al. (2019, July-August). Quality of Life Assessment in Patients with Androgenetic Alopecia. International Journal of Trichology. 11(4). 147-152. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6706984/
- Hu, X., et al. (2021, August 11). A systematic summary of survival and death signalling during the life of hair follicle stem cells. Stem Cell Research and Therapy. 12(453). https://doi.org/10.1186/s13287-021-02527-y
- Ntshingila, S., et al. (December 2023). Androgenic alopecia: An update. JAAD International. 13. 150-158. https://www.jaadinternational.org/article/S2666-3287(23)00112-8/fulltext
- Ohyama, M. (2019). Chapter 86: Telogen Effluvium. Fitzpatrick’s Dermatology, 9th ed. https://accessmedicine.mhmedical.com/content.aspx?bookid=2570§ionid=210420738
- Otberg, N. and Shapiro, J. (2019). Chapter 87: Alopecia Areata. Fitzpatrick’s Dermatology, 9th ed. https://accessmedicine.mhmedical.com/content.aspx?bookid=2570§ionid=210420857
- Otberg, N. and Shapiro, J. (2019). Chapter 88: Cicatricial Alopecias. Fitzpatrick’s Dermatology, 9th ed. https://accessmedicine.mhmedical.com/content.aspx?bookid=2570§ionid=210420920
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