Medical Treatments For Hair Loss
By John P. Cole, MD & Paul Rose, MD & Truett Bridges, MD

For thousands of years, hopeful and desperate men have fallen prey to hucksters and salesmen hawking various potions and ointments, with claims of miraculous balding cures. The latest and greatest cures have never lived up to their hype, leaving the balding victims poorer but (sometimes) wiser. A powerful placebo effect (based on a strong desire for the treatment to work), along with gullibility or desperation, often resulted in a temporary sense of "improvement". Eventually, however, the fact that there were no cures for baldness became evident.

Even today, we have no miracle "cures" for baldness. Even surgical hair restoration does not cure the balding process; what it does is redistribute permanent hair to balding areas. The same can be said of the two medical or drug treatments that have been shown to be of use in hair loss. Propecia, and especially Rogaine, do not so much reverse balding, but halt or slow its progression.

Rogaine (minoxidil)

Minoxidil has been available in oral form for years. It was originally developed as an agent for treating high blood pressure; it had a number of significant side effects, which limited its use to people with severe, refractory high blood pressure, which was not completely responsive to combinations of other medications. One of the less dangerous, but quite obvious, side effects was "hypertrichosis", or the growth of hair on the face or other areas of the body.
Of course, someone had the bright idea that perhaps applying this drug to the bald scalp might grow hair there. Thus, Rogaine was developed by The Upjohn pharmaceutical company, and the rest is history. Again, Rogaine does not cure baldness; in fact, no one is quite sure how it works. We do know that it does not grow hair on completely bald scalp; rather, it tends to retard the loss of hair in areas that are highly miniaturized. It may be that Rogaine prolongs the growth phase of the hair (remember the anagen cycle, that gets progressively shorter in the balding process), which halts or slows the miniaturization process.

With the use of Rogaine, it may take 6 to 12 months to notice a change; in fact, some people do not notice a difference unless they stop using it. Within 2 to 3 months of discontinuing the medication, any "regrowth" or appearance of increased density will vanish. In other words, even if Rogaine works for you, you must continue the medication indefinitely, or any benefit will be lost. Also, it is effective in the crown or top of the head, but not in the frontal area. This is unfortunate, because the front of the scalp and the hairline are the most cosmetically important areas. (Please repeat after me! The utmost importance of this primary rule of hair restoration will be reemphasized over and over as we consider treatments for balding).

Rogaine also must be used twice a day; once a day application has been clearly shown to be ineffective. In addition, the growth may not be as great as one imagines; since Rogaine probably works by increasing the thickness of hairs which are already miniaturized, the most many patients see is an apparent growth of fine, fuzzy hair which does not tend to grow very long.
Women may also benefit from the use of Rogaine, especially since their hair loss is often characterized by diffuse thinning. If this is the case, a halting or reversal of thinning may be possible with prolonged use; but as with men, stopping the medication will result in a reversal of the benefits.

Some hair restoration surgeons recommend that their transplant patients use Rogaine before and then immediately after the surgery, especially is grafts have been placed in and around existing hair. The medication may help prevent the temporary loss of healthy, preexisting hair due to the shock of the procedure. Some surgeons do feel that the medication should be stopped a week prior to the surgery, because it dilates blood vessels, and might increase operative bleeding.

Propecia (finasteride)

The drug finasteride (marketed as Proscar for symptoms of prostate enlargement) has been available for years. Only since 1998 has it been approved for use in male pattern balding, and has been formulated as an oral, one milligram tablet called Propecia (versus the five milligram Proscar).
This drug works by inhibiting the action of the enzyme 5-alpha-reductase, which, as you remember, is the enzyme responsible for converting testosterone to dihydrotestosterone (DHT). Men with pattern balding have higher levels of this enzyme in and around the follicles that are at risk for loss. It is the effect of DHT on the hair follicles that leads to the miniaturization of terminal hairs. So, if we inhibit 5-alpha-reductase, then we inhibit DHT formation, decrease its levels in the blood stream and in the scalp, and stop or slow the process of miniaturization that we know as balding. Indeed, this is what was found in the clinical studies on Propecia.

A word about hormone effects: DHT is responsible for facial hair growth, increased incidence of acne, growth of the prostate gland, and is integral in the development of male pattern baldness (androgenetic alopecia). Testosterone, on the other hand, is the classic "male" hormone, and is responsible for the changes seen at puberty: lowering of the voice, growth of the genitalia, an increase in muscle mass, and increased libido or sex drive. When testosterone is deficient, there may be decreased sex drive, erectile dysfunction, depression, lack of normal "drive" and ambition, and a loss of muscle mass. In other words, most of what DHT effects, we can do without! Testosterone, on the other hand, is extremely important. When men took the one milligram dose of Propecia, their DHT levels dropped by about two-thirds; on the other hand, testosterone levels were not only maintained in the normal range, but increased almost ten percent!

So the mechanism by which Propecia acts, unlike that of Rogaine, is well understood. Let’s look at what the studies and clinical trials showed about its effectiveness. 1,553 men, ages 18 to 41, with Norwood Class II Vertex, III Vertex, IV or V balding patterns (which are mild to moderate; the Class VI and VII are the most severe patterns) were given Propecia. At two years, 83% of those taking Propecia either grew more hair or at least lost no more. However, this effect was much more noticeable in the crown area than in the frontal or hairline zone. Also, the hairs that did grow in were longer and thicker, or more like terminal hairs, in contrast to the finer, shorter hair seen with the use of Rogaine.

Side effects seen were minimal in number. They included different types of sexual dysfunction (decreased sex drive, erectile dysfunction, decreased semen volume) at a total incidence of 3.8%. However, the group that received the placebo (sugar pill) had an incidence of 2.1%, which is not a large difference at all. Furthermore, these sexual side effects went away in all the men who stopped the medication, and in almost two-thirds of those who continued the medication!

6 to 12 months are required before any increase in hair is apparent; any sexual side effects would have occurred well before that time, so there is not a problem of losing hair that was gained on the medication when one stops taking it. Also, remember that if a person stops either Propecia or Rogaine, any hair lost will be only that which was gained or maintained while on the drug, and not any other; in short, one returns to the state of balding one would have experienced had one never taken the drug at all.

Another interesting finding in patients on Propecia is that it causes an approximately one-third reduction in the level of prostate-specific antigen (PSA). PSA is used as a screening test for prostate cancer; it also may be elevated in men with enlargement of the prostate. There has been some concern that this might compromise prostate cancer screening, even though the decrease in PSA in fairly predictable. To be safe, however, men should let their primary physician know if they are taking Propecia, so that this blunting effect on PSA can be taken into account.

Propecia does not seem to grow hair in areas that are completely bald. Its effects are apparent only in areas of the scalp that are thinning, but where there is still some hair present. Therefore, the major benefit of the drug seems to be in its ability to slow down or halt hair loss, or regrow hair in parts of the scalp that are miniaturized. The long-term ability of Propecia to maintain one's hair is unknown. Effects usually peak around one year and then are stable in the second year or decrease very slightly.

As previously stated, the benefits will stop if the medication is discontinued. Over the 3-6 months following discontinuation of Propecia, the hair loss pattern will generally return its native state (that is, as if no medication had ever been used).

Although both Propecia and Rogaine are FDA approved as being safe and effective, this does not mean that all the long term effects are known. Even though the side effects are rare, we can see that the drugs’ actions are not entirely confined to the scalp. We now have three to four years of experience with Propecia; only over time will the full ramifications of either of these agents be fully evident.

Many hair transplant surgeons find Propecia to be an excellent adjunctive medication, for several reasons: 1) Propecia works best in younger men; some of them may not be hair transplant candidates yet. 2) the medication works better in the crown area, and often the crown requires more surgically harvested donor hair than may be available. 3) Propecia is less effective in the front. Hair transplantation has its greatest impact on the hairline and in the frontal area. 4) If Propecia continues to slow or halt hair loss in the crown area, surgeons may be able to create greater density in areas such as the front, which will have a greater cosmetic effect, while sparing the all-important donor hair for the future.

While not an actual hair growth or maintenance product, there is a newer post-operative product that we will mention, known as GraftCyte, which is manufactured by the ProCyte Corporation. This line of products contains copper peptides, which have been shown to help with wound healing. The company makes a shampoo and conditioner, that are often recommended after transplant surgery, as well as a spray for hydrating the graft sites, and prepared, foil-wrapped sets of copper peptide saturated gauzes designed to be used for the first three post-operative days. In addition, there is a gel to be placed on the donor incision in the back of the head. All of these interventions may lead to improved, more rapid healing.

There are also claims that using the GraftCyte products promotes the more rapid growth of the transplanted hair. This has yet to be proven in controlled trials, but many people chose to use these products for their healing properties, and hope that these unproven claims are true as well.