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Chapter: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 |17 | 18
PATIENT GUIDE TO SURGICAL & MEDICAL HAIR
RESTORATION
PAGE 6 |
Medical Hair Loss Treatments |
| 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. |
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