What is hair loss?
Normally, individuals will lose on average between 40-100 hairs per day of the 100,000 hairs present on the scalp. During any given time, 85-90 percent of an individual's hair is in the growing phase advancing in length by ½ -1 inch per month. Hair can continue to grow from 2-6 years, when the growth phase ends the hair follicle starts a 2-6 month phase of resting and then shedding. Usually, only 10-15 percent of an individual's hair is in the resting or shedding phase at any given time. Randomly, new hair follicles begin to replace the shedding follicles producing a healthy cycle. However, in cases of androgenetic allopecia this natural cycle is disrupted.

Ninety-five percent of hair loss is attributable to androgenetic alopecia, more commonly known as hereditary hair loss or in men male pattern baldness. In men, the condition frequently progresses to the horseshoe fringe of hair. While in women it manifests itself as a generalized thinning of the hair over the entire scalp. Several hypothesis for this condition exist, however, most research of late has focused on a genetic predisposition and the presence of dihydrotestosterone (DHT). Every hair has a genetic predisposition; the gene that determines whether an individual will be susceptible to androgenetic alopecia is located on non-sex chromosomes that determine the genetic makeup of all cells. Contrary to the popular myths concerning these genes they can be inherited from either parent's relatives. Researchers believe that DNA is somehow responsible for the increased sensitivity of hair follicles to the hormone DHT. This hormone results from the breakdown of testosterone by an enzyme called alpha-5 reductase.

DHT causes the hair follicle to atrophy, reducing in size until only vellus hair is produced. Vellus hairs are short fine non-pigmented hairs which are difficult to see. As the diameter of the hair shaft continues to decrease in size the sebaceous glands continue to secrete the same volume of sebum (fats and oils which lubricate the hair). This results in an oily scalp and subsequently flatter hair. The process continues until the vellus hair is no longer produced and individuals develop the characteristic hair loss pattern.

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Causes of Hair Loss

Although the majority of hair loss is secondary to androgenetic alopecia there are other significant causes of hair loss that should be addressed including the following:

· Alopecia areata is an immune system disorder that affects the hair follicles ability to produce hair. A sudden loss of hair from a small area is a common presenting symptom. Advanced forms of the disorder include alopecia totalis, where all hair on the head is lost and alopecia universlis, which results in the absence of all body hair.

· Pregnancy is a period when hormones can fluctuate considerably in women. While pregnant women are not especially prone to lose hair. However, two to three month's post-partum, a significant number of hair follicles will enter the resting phase. Some women will experience considerable hair loss during this time for approximately one to six months. This condition is self-limiting and reverses in most cases.

· High fever is another cause of alopecia. Four to six weeks following a high fever or significant infection individuals may notice a significant amount hair loss. This condition is self-limiting and reverses in most cases.

· Nutritional deficiencies can be a rare cause of hair loss. Some vegetarians, individuals on fad diets, etc. who severely limit their intake of proteins may lose a significant amount of hair. In protein deficiencies the body will strive to save protein by shifting the hair follicles into the resting phase. Extensive hair loss is then demonstrated several months later. Iron deficiency is also a rare cause of hair loss. The process is reversed with the proper diet.

· Thyroid disease is another disorder associated with hair loss. Individuals with hyperthyroidism or hypothyroidism may experience hair loss. The diagnosis is usually established by a patient's history combined with laboratory results. Hair loss associated with a thyroid disorder is usually reversible with the proper medication.

· Prescription medications are another source for hair loss. Some examples of medications that are known to cause hair loss include: blood thinners, gout medications, anti-depressants, arthritic medications, hypertension medications, birth control pills, high doses of vitamin A, chemotherapy/radiation, etc.

· Major surgery may present excessive stress on the system that can result in hair loss. Hair loss is generally noticed one to three months following the surgery. The condition will usually reverse itself unless the individual has a chronic illness.

· Ringworm of the scalp, actually caused by fungus, begins with small patches of scaling that subsequently spread resulting in broken hair. This condition is contagious and is common in school-aged children. The condition is resolved with oral or topical medication.

· Chemical products such as dyes, bleaches, tints, straighteners, perms, chlorine, etc. can all damage hair. These products when used excessively can dry hair out causing it to break at the roots.

· Traction alopecia is the loss of hair secondary to constant pulling as seen in tight ponytails, hair weaves, braids, etc.

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Hair Loss Treatments

With at least forty treatments for thinning hair patented last year and 200 million dollars budgeted for clinical trials in the near future, there is no mystery why there is so much confusion regarding the treatment of hair loss. However, of all the hundreds of shampoos, ointments, herbal supplements, gimmicks, etc. there are only two medications that meet the strict standards set forth by the FDA. Only Rogaine (minoxidil) and Propecia (finasteride) may state in their advertising and/or labeling that their product promotes hair growth or prevents the loss of hair. All the rest of the products many of whose effectiveness are exposed to minimal, if any, clinical trials should be purchased judicially.

Propecia is the latest medication to be approved by the FDA. Researchers have recently discovered that men who suffer from male pattern hair loss have increased levels of dihydrotestosterone (DHT). DHT is produced from testosterone through the activity of 5-alpha-reductase enzyme. Propecia inhibits 5-alpha-reductase, thus blocking the formation of DHT. This appears to interrupt a key element in the development of male pattern hair loss.

Clinical studies were conducted in men aged 18 to 41 with mild to moderate degrees of androgenic alopecia. All individuals treated with Propecia received a tar-based shampoo (Neutrogena T/Gel shampoo) and were instructed to wash their hair at least once per day. Clinical improvements were seen as early as three months into the treatment with Propecia. In men with vertex hair loss, global photographs revealed hair re-growth in 66 percent of the men. Furthermore, hair counts with these men indicated that 83 percent of the recipients had no further hair loss over the two-year clinical period.

Similar to all prescription medications, Propecia may cause some side effects. In clinical studies, side effects associated with Propecia were uncommon and did not affect most men. In fact, more individuals discontinued the placebo as compared to Propecia secondary to adverse experiences. A very small number of men, less than two percent, experienced certain sexual side effects including a decrease in libido and erectile dysfunction. Resolution occurred in all men who discontinued therapy with Propecia due to these side effects. The side effects also disappeared in most men, 58 percent, who continued taking Propecia.

Propecia is for the treatment of male pattern hair loss in men only. Women who are or may potentially be pregnant must not use Propecia and should not handle crushed or broken tablets of Propecia because it may cause potential risk to the development of the male sex organs. Propecia tablets are coated and will prevent contact with the active ingredient during normal handling, provided that the tablet has not been broken or crushed.

Minoxidil was first approved by the FDA in 1979 has hypertensive medication. However, some individuals began to develop hair everywhere. So Upjohn went back to the lab and developed a topical version of the medication. Ten years later minoxidil was re-introduced has Rogaine. The mechanism of action of Rogaine is basically unknown. The medication is known to be vasodilator, however, other medications that dilate the blood vessels do not stimulate hair growth. Rogaine is believed to work in part by partially enlarging miniaturized follicles and reversing the miniaturization process. This supposedly prolongs the growth phase of the hair cycle, allowing the hair to become thicker and longer.

Clinical trials have shown with the 2% solution that 26 percent of men ages 18-49 reported moderate to dense hair re-growth following four months of treatment. An additional 33 percent had minimal hair re-growth. Approximately 20 percent of women between the ages of 18-45 had moderate re-growth, while an additional 40 percent minimal re-growth. The new extra strength 5% Rogaine solution has demonstrated slightly improved results as compared to the 2% solution in men. Currently, the extra strength 5% solution is not recommended for women.

Side effects associated with Rogaine are minimal. The most common side effects reported during clinical trials were itching of the scalp and other skin irritations in the treated areas. These side effects are not serious and will cease upon discontinuation of the medication. Well-controlled clinical studies have not been conducted in pregnant or nursing women, therefore, the medication should not be used during these conditions.

There are some other topical treatment options that warrant some discussion at this time. Please keep in mind before you rush out to purchase any of the following products that there has been limited clinical testing concerning hair loss on these treatments.

Retinoic Acid was first FDA approved for acne under the trade name RETIN-A. Since then it has been discovered that retinoic acid can be used for several medical conditions, including hair loss. Retinoic acid is known to increase the absorption of other medications through the skin, therefore it is hypothesized that the retinoic when used in conjunction with minoxidil should increase the amount of minoxidil reaching the hair follicles. There is also some experimental evidence that indicates that retinoic acid may play a role in hair growth by presently unknown mechanisms. There have been case reports where the use of retinoic acid alone induced a significant amount of hair growth.

However, retinoic acid, does have some unwanted side effects associated with its use including: itchiness and flaking of the scalp (further contributing to dandruff), increased sensitivity to the sun, and similar to the use of minoxidil, a small percentage of patients may experience an initial increase of hair loss at the onset of treatment. However, usually this resolves with time. When first starting the formulation, start using it every other night for one week, then increase to ever night for one week, and finally increase to twice a day. This method of use will decrease the unwanted side effects.

Azelaic acid is a naturally occurring dicarboxylic acid found in whole grain cereals and animal products. The medication is FDA approved as a topical preparation to treat acne vulgaris. It is also used by dermatologist to lighten hyperpigmented skin. However, there is some scientific evidence that azelaic acid is a competitive inhibitor of Alpha-5 Reductase. Inhibiting Alpha-5 Reductase decreases the levels of DHT (dihydrotestosterone) in the scalp. Side effects associated with azelaic acid include: itchiness, tingling, or stinging sensation occurring in 1-5% of patients, redness, dryness and peeling of the skin seen in less than 1% of patients, some patients have noted a lightening of the skin.

Spironolactone is a "Potassium Sparing Diuretic" that has been used for decades to treat high blood pressure and fluid retention. However, there is also some scientific data suggesting a beneficial effect of spironolactone on hair loss. Spironolactone has been noted to have anti-androgen activity. Androgenetic alopecia (male and female patterned baldness) is heavily influenced by androgens (most specifically- DHT). Spironolactone binds to the receptor sites on the hair follicles which blocks DHT from having its deleterious affect on the hair follicle. Side effects associated with spironolactone are minimal now that spironolactone has been made into a topical solution, instead of a pill. Rarely, a patient will develop a rash from the spironolactone solution, which resolves upon dicontinuation of the lotion. The product also has a malodorous scent which is increased if spironolactone is combined in the same container with other chemicals (i.e.- minoxidil, retinoic acid). Sprironolactone solution is be applied to the balding scalp twice a day. It should be applied and allowed to dry (few minutes) before placing on the minoxidil solution.

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Hair Pieces

For individuals who have not benefited from the pharmaceutical approach there are hairpieces. Interestingly, over a million men in the U.S. sport a hairpiece, spending some 350 million annually on the purchases and maintenance of these products. "You would think with all his money he would have a decent hair piece," is the quite frequently stated remark concerning men with ill-fitting hairpieces. However, cost has less to do with a good-looking hairpiece than does the selection of the manufacturer combined with the grooming and care given it by the wearer. An attractive hairpiece requires careful color matching, fitting, as well as subsequent styling and replacement. Unfortunately, many individuals fail to properly care for their hairpieces as time progresses. Hairpieces can be made from synthetic materials such as nylon or actual real human hair. Prices can vary considerably, small filler pieces may cost from $250.00 up, full wig $1000.00 up. The average hairpiece of good quality, synthetic or real will usually cost between $1000.00-$3,500.00.

The debate goes on, human hair verses synthetic hair. Human hair tends to react more to the sun and other elements such as chlorine. The most significant problem is the color of the hair fades with time. Human hair also requires more maintenance including monthly visits to the hair stylist for styling and cleaning, at a cost of $40-$60; periodic dyeing can cost another $75-$100. Additionally, hairpieces made from human hair rarely look appropriate longer one year. Manufacturers of synthetic hair claim their products look more natural, are water resistant, hold their shape better and last longer than human hair. However, individuals must still bring their hairpiece in for maintenance every four to six weeks, at a cost of $35-$50. Synthetic hair generally looks natural for up to two years. The decision human verses synthetic is primarily one of preference. Reputable hairpiece companies will encourage individuals to research both types of hair prior to purchasing.

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