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QUESTION OF THE WEEK

Dr. Donovan's Articles

QUESTION OF HAIR BLOGS

Filtering by Category: Male pattern balding


Hair loss in the Frontal Hairline.

Cause of Frontal Hairline Loss

I enjoyed giving a lecture yesterday to our brilliant University of British Columbia dermatology resident physicians. We discussed the common and uncommon scarring and non-scarring hair loss conditions that affect the frontal hairline of males and females.

frontal hairline

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Delivering More Minoxidil to Hair Follicles: What's possible and what possibly helps?

How can I deliver more minoxidil to my hair follicles?

Topical 2 and 5 % Minoxidil are FDA approved and Health Canada approved for treating androgenetic alopecia. The drug does not help everyone but certainly helps a proportion of users. Given the benefits of minoxidil, there is a tremendous interest in understanding how best to delivery the minoxidil down into the scalp so that hair follicles can use it to stimulate their growth.

In this article, we’ll take a look at 5 methods to deliver more minoxidil to follicles as well as the challenges and limitations associated with these methods.

1. Use the same amount and same concentration of minoxidil and use it with the same frequency…. but apply it properly. 

There’s a bit of a learning curve to applying minoxidil and some people just don’t apply it correctly. Minoxidil probably absorbs better when applied after the scalp is washed and is still a bit warm. But clearly this is impractical for everyone as many do not shampoo daily and many who do like to apply minoxidil at night and shampoo the hair clean in the morning.  Despite this, it’s probably more important to remember to apply the minoxidil every day that fuss about when to apply it and how clean the hair is.

Regardless of how it’s applied, the minoxidil needs to get on the skin of the scalp so it can begin its journey into the scalp. Getting minoxidil on the hair shafts does not help. Similarly, if there is a great deal of gunk blocking the scalp surface, it becomes more difficult for minoxidil to penetrate the scalp. Gunk includes excessive amounts of gel, oils and hair fibers.

2. Use the same concentration of minoxidil, but use more of it... or use it more often.

For some patients, using more minoxidil allows more to get into the scalp. This is especially true for males using minoxidil and may be true for some women as well. It’s clear that using 5 % minoxidil twice daily is better when treating male pattern balding than using 5 % minoxidil once daily. For some women - but not all - this may be true too. The downside of using more minoxidil is a greater chance of side effects. The chance of headaches, dizziness, and hair on the face all increase as the amount of minoxidil increases.

3. Expose the hairs to higher concentrations of topical minoxidil

Theoretically, using higher concentrations of minoxidil may help more get into the scalp. Studies that support the ideal minoxidil concentration are few and far between. In fact, one study suggested surprisingly that 5 % minoxidil was more effective than 10 %. Researchers from Egypt set out to compare the efficacy and safety of 5% topical minoxidil with 10% topical minoxidil and placebo in 90 males with balding. Surprisingly, after the 9 months, partipcants in the 5 % minoxidil group had higher vertex and frontal hair counts compared to study participants in the 10 % minoxidil group and the placebo group. Clearly, we still have a lot to learn and a long way to go. Higher concentrations of minoxidil are not necessarily better.

minoxidil

4. Compound the minoxidil with different topical agents or via other drug delivery strategies to allow minoxidil to penetrate the scalp better.

There is a major interest in the hair research community to figure out how best to get minoxidil into the scalp. Different vehicles, use of so called nanoparticles as well as other techniques are the focus of many studies. 

It’s also clear that use of adjuvants like retinoids can help make minoxidil more effective. Before we look at this concept further, it’s important to understand a few concepts. In order for minoxidil to do it’s job, it needs to be converted to minoxidil sulphate. Hair follicles have the machinery to help with this but some people’s hair follicles are not really that good at it. Scientifically, we say that some people’s hair follicles lack high levels of an enzyme known as “sulfotransferase” and so they cannot convert minoxidil into the active form that actually does all the work.  (The public does not yet have minoxidil sulfotransferase testing kits available to them but this technology may be coming at some point in the near future.) For year now, it has been known that mixing retinoids with minoxidil makes minoxidil work better. It has long been thought that retinoids irritate the scalp and somehow by doing so allow minoxidil to get into the scalp. Now, based on interesting work published by Sharma and colleagues in 2019 it’s realized that retinoids upregulate the minoxidil sulfotransferase enzyme and by doing so help generate greater amounts of active minoxidil sulphate in the scalp.

The use of derma rolling may be yet another strategy to get more minoxidil into the scalp. Scalp Micro-needling" (dermrolling) is a technique whereby a controlled injury is created in the scalp. Skin injury (at least in some situations) can stimulate the production of growth factors and inflammatory cytokines that promote skin healing and possibly hair growth. A "dermaroller" is one such device to cause controlled injury. A dermaroller consists of teeth of different lengths that are attached to a wheel. Dermarollers of 0.5 mm, 1 mm, 1.5 mm are common. These are "rolled" back and forth across the skin to create redness. A 2013 study of 100 patients supports benefit of dermarolling. The study set out to determine in patients who use topical minoxidil (Rogaine, etc) could achieve even further benefit by dermarolling. In the study, half the patients received daily minoxidil and the other half of the patients received weekly dermarolling sessions (using a 1.5 mm dermaroller) in addition to minoxidil treatment. Results showed that patients using a dermaroller achieved greater benefits than those using minoxidil alone. Specifically, 82 % of patients receiving dermarolling felt they achieved greater than a 50 % benefit in their hair compared to just 4.5 % receiving minoxidil alone. Physicians rated the improvements similarly. Hair counts (at an up close level) were increased in the dermarolling group compared to the minoxidil alone group (91.4 vs 22.2 respectively). These studies support the potential benefit of dermarolling - especially to increase the efficacy of minoxidil. More studies need to be done to verify or refute these results as well as to determine the optimal parameters for dermarolling. These include comparisons of daily vs weekly vs monthly treatment and comparisons of 0.5 mm needles, 1 mm or 1.5 mm needles. Studies are also needed to determine if any proportion of patient actually worsen with dermarolling.

5. Eat the minoxidil (or eat more).

If someone has androgenetic alopecia but is not able to achieve high enough concentrations of minoxidil deep under the scalp with use of topical minoxidil, switching from topical minoxidil to oral minoxidil could make sense.  As reviewed above, in order for minoxidil to do it’s job, it needs to be converted to minoxidil sulphate. Hair follicles have the machinery to help with this but some people’s hair follicles are not really that good at it. Scientifically, we say that some people’s hair follicles lack high levels of an enzyme known as “sulfotransferase” and so they cannot convert minoxidil into the active form that actually does all the work. When oral minoxidil is ingested, the liver does the job of converting the minoxidil to minoxidil sulphate - bypassing the need for the hair follicle to do this job.

Patients who don’t respond to topical minoxidil may respond to oral minoxdil. Similarly, patients who don’t respond to very low doses (like 0.25 mg to 0.5 mg) may respond to moderate doses (like 1-2-5 mg). Of course, increasing the dose may increase side effects like headaches, swelling, fluid retention, hives and excessive hair growth on the body.


References


Dhurat R, et al. A randomized evaluator blinded study of effect of microneedling in androgenetic alopecia: a pilot study. Int J Trichology. 2013.

Ghonemy S et al. Efficacy and safety of a new 10% topical minoxidil versus 5% topicalminoxidil and placebo in the treatment of male androgenetic alopecia: a trichoscopic evaluation. J Dermatolog Treat. 2019 Oct 21:1-6. doi: 10.1080/09546634.2019.1654070. [Epub ahead of print]

Jeong WY et al. Transdermal delivery of Minoxidil using HA-PLGA nanoparticles for the treatment in alopecia. Biomater Res. 2019 Oct 31;23:16. doi: 10.1186/s40824-019-0164-z. eCollection 2019.

Sharma A et al. Tretinoin enhances minoxidil response in androgenetic alopecia patients by upregulating follicular sulfotransferase enzymes. Dermatol Ther. 2019 May;32(3):e12915. doi: 10.1111/dth.12915. Epub 2019 Apr 23.





This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Higher Minoxidil Concentrations: Is More Always Better?

10 % Topical Minoxidil vs 5 % Topical Minoxidil: Which is better?

Minoxidil is FDA approved for treating androgenetic alopecia (male pattern balding and female pattern hair loss). It would seem logical to propose that if the drug minoxidil helps in the treatment of males and females with androgenetic alopecia that more minoxidil should help even more.

Researchers from Egypt set out to compare the efficacy and safety of 5% topical minoxidil with 10% topical minoxidil and placebo in 90 males with balding.  The study was a double-blind placebo controlled randomized trial over 36 weeks. The study comprised three treatment groups: 1) study participants receiving 5 % minoxidil 2) study participants receiving 10 % minoxidil and 3) study participants receiving placebo.

Surprisingly, after the 9 months, partipcants in the 5 % minoxidil group had higher vertex and frontal hair counts compared to study participants in the 10 % minoxidil group and the placebo group.

Conclusion

This was a nice study showing us that even after 40 years of studying minoxidil, we still have a lot to learn and a long way to go. Higher concentrations of minoxidil are not necessarily better - although more studies are clearly needed.

Reference

Ghonemy S et al. Efficacy and safety of a new 10% topical minoxidil versus 5% topicalminoxidil and placebo in the treatment of male androgenetic alopecia: a trichoscopic evaluation. J Dermatolog Treat. 2019 Oct 21:1-6. doi: 10.1080/09546634.2019.1654070. [Epub ahead of print]


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Is Androgenetic Alopecia (AGA) Caused Only by the Effects of DHT ?

Despite the Myth, Androgenetic Alopecia is Not Simply a Story of DHT

Androgenetic alopecia is a type of hair loss that affects men and women. In males, this condition is also referred to as male balding or male pattern hair loss and eventually affects some 80 to 90 % of males. In females, the condition is referred to as female pattern hair loss or simply hair thinning and affects 40% of women by age 50. The purpose of this article is to deal with some misconceptions, wrong information, errors and myths that many people have about the role of DHT in the balding process. DHT is certainly important - but other factors must be considered too.

The Evolution of the DHT Theory of Male Balding

Some of the earliest observations about the role of hormones in male balding happened in the time of Aristotle back in 300 BC. Aristotle showed that castrated males (eunuchs) did not develop balding. JB Hamilton in 1942 did additional pioneering work to understand male balding. He showed that male hormones are relevant to the balding process. Specifically, he confirmed observations by Aristotle and others that males that were castrated before puberty did not go on to develop balding. Hamilton took this further and showed that if testosterone was given back to castrated males, the males proceeded to develop male balding. This showed that male balding was an “androgen-dependent” process.

Hamilton

Further key work in understanding male balding was done in the 1970s and ultimately published in the New England Journal of Medicine. These were studies that showed that male pseudohermaphrodite living in the Dominican Republic with a genetic deficiency known as 5 alpha reductase deficiency did not produce dihydrotestosterone (DHT) and did not develop male balding. These findings lead ultimately to the rational development of drugs such as finasteride and dutasteride which block 5 alpha reductase and lower DHT levels.

story of MPB

The Story of Male Pattern Balding has a DHT Chapter but Don't Forget to Read the Others

From 300 BC to the 1990’s, the story of male balding seemed pretty clear. Male hormones, particularly the infamous DHT, seemed to be what male balding was all about. Blocking DHT was what treatments were all about.

Many people incorrectly assume that male balding is just a DHT story. Many people incorrectly assume that this DHT chapter is the only chapter they need to read when trying to understand male balding. While it’s true that DHT has a whole lot to do with male balding - the correct way to state it is “male balding is due in part to the effects DHT on hair follicles that are genetically sensitive to this hormone.”


DHT not the only chapter in the balding story

DHT not the only chapter in the balding story. One only need to consider a few other treatments that are used for balding to very quickly realize that male balding must be much more complex than just a DHT story. Minoxidil (Rogaine), for example, has nothing to do with DHT - and yet it helps some people with male balding. Granted I agree that finasteride and dutasteride are much much better treatments than minoxidil - but if DHT was the only thing we need to think about when it comes to treating male balding then minoxidil would not be expected to have any sort of benefit. Well, it does. Low level laser therapy also has nothing to do with DHT hormone levels - and yet it helps some males with their male balding. Platelet rich plasma (PRP) also has very little to do with DHT- and yet it helps some males with their male balding.

Drug Companies are Investing Large Sums with the Knowledge that Male Balding is Far Far More than A Simply DHT Story.

At least 12 pharmaceutical companies are investing millions upon millions of dollars with the clear understanding that DHT is not the only chapter in the balding storybook. These companies are hoping to the first to market with brand new types of drugs - again drugs that have nothing really to do with DHT. A brief summary of the drugs is below.

companies in race



If Male AGA is Far More than A Simply DHT Story, Female AGA is Far Far Far More than A DHT Story

If you have now come to realize that male balding is a bit more complex than simply a story about DHT, I’d like to point out that female androgenetic alopecia (i.e. female pattern hair loss) is even more complex. If you think for even a moment that you’re going to apply the same DHT story that you used in males to explain balding to the mechanisms operating in females with androgenetic alopecia, you’re going to come up short in terms of your ability to explain hair thinning in women.

Androgenetic alopecia in females is a far more complex story - and we still don’t know all of the mechanisms that govern how hairs thin in women. Of course, there is some aspects of the DHT story that relevant to female thinning. But finasteride and spironolactone and anti-androgens are far less consistently helpful in females than in males. Other treatments such as minoxidil and laser may be far more helpful in some women than in males. In other words, there are likely several different mechanisms that are contributory to androgenetic alopecia in females besides simply a DHT story. As further information for reflection to readers who still doubt this information, one must consider that some women with a genetic condition that completely makes them insensitive to the effects of androgens (called androgen insensitivity syndrome) can still develop androgenetic alopecia. Even women with low testosterone and low DHT levels can develop androgenetic alopecia. There are even some androgen deficient women who do not develop any balding whatsoever when you give them back supplemental androgens through various means of testosterone replacement therapy.

Conclusion

Is androgenetic alopecia simply due to the sensitivity of hair follicles to DHT? Well, it’s a good story, but it’s only part of the story. The DHT chapter is an important chapter to read in the story of male balding and female thinning, but be sure to read the remaining chapters of the story book. The DHT story is not the only story - and many pharmaceutical companies are banking on this concept.





This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Using Dutasteride in Male Pattern Balding.

Use of Dutasteride in Previous Finasteride users. 

Currently used 5 alpha reductase inhibitors include finasteride and dutasteride. Finasteride is FDA approved for hair loss at 1 mg. Dutasteride is not formally FDA approved for treating balding. However, the medication can can be used off label. 

Finasateride is an inhibitor of the enzyme 5 alpha reductase type 2  and dutasteride is an inhibitor of both 5 alpha reductease type 1 and type 2. Dutasteride is more potent and leads to greater reductions of dihydrotestosterone (DHT). Studies from 2004 showed that dutasteride lowers serum DHT by up to 90% whereas finasteride lowers it by about 70 %. Side effects are also potentially greater with dutasteride than finasteride.

Options for Using Dutasteride

Patients using finasteride who find that the medication has not given them the growth they hoped for or who feel that their hair loss has progressed slowly over time should speak to their physicians about options. There are several points to discuss with your health care provider. Many individuals who have a “partial” response to finasteride often wonder if they should switch to dutaseteride or add dutasteride to thr finasteride they are already taking.

1. Adding dutasteride on weekends.

Adding a very small dose of dutasteride on the weekends can often be an option for some men.  An Australian study in 2013 reported a male who was initially treated with finasteride for androgenetic alopecia (male balding). Despite good compliance with the medication, the patient noted his hair density was not as good as previous years, and low-dose dutasteride at 0.5 mg once per week was added to the finasteride therapy. Interestingly, this treatment plan resulted in a dramatic increase in his hair density, demonstrating that combined therapy with finasteride and dutasteride can improve hair density in patients already taking finasteride.

 

2. Switching to dutasteride altogether

Another option that patients may wish to discuss with their physicians is whether to stop finasteride altogether and start dutasteride.  In 2014, Jung and colleagues from South Korea studied 31 men with male balding who took dutasteride after finasteride did not help them. Well over three quarters of these men  (77 %) improved their hair density by making the switch (17 improved slightly, 6 moderately, 1 markedly).

 

Conclusion

The use of dutasteride is among the treatment options for men with incomplete responses to finasteride. 

 

 

Reference:

 

Jung et al. Effect of dutasteride 0.5 mg/d in men with androgenetic alopecia recalcitrant to finasteride. Int J Dermatol. 2014 Nov;53(11):1351-7

 

Boyapati A and Sinclair R. Combination therapy with finasteride and low-dose dutasteride in the treatment of androgenetic alopecia. Australasian J Dermatol 2013


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Classic studies from the Past: A Look at the Early Dutasteride Studies

Dutasteride vs Finasteride: Suppression of DHT

In the world of hair loss, we often quote numbers and statistics. We frequently throw around information without a good idea of where that information actually came from. An important study is a 2004 study by Dr. Clark and colleagues. It is one of the the classic studies examining how DHT changes with use of finasteride and dutasateride. 

The researchers studied 399 men with prostate enlargement (BPH) and randomized them to once-daily dosing for dutasteride (0.01, 0.05, 0.5, 2.5, or 5.0 mg), or 5 mg finasteride, or placebo for a total of 24 weeks. The percent decrease in DHT was 98% with 5.0 mg dutasteride and 95% with 0.5 mg dutasteride. This was found to be significantly lower than the 71% suppression observed with 5 mg finasteride.  Moreover there was less variability in DHT changes with dutasteride than finasteride. 

Clark et al. Marked suppression of dihydrotestosterone in men with benign prostatic hyperplasia by dutasteride, a dual 5alpha-reductase inhibitor. J Clin Endocrinol Metab. 2004

Clark et al. Marked suppression of dihydrotestosterone in men with benign prostatic hyperplasia by dutasteride, a dual 5alpha-reductase inhibitor. J Clin Endocrinol Metab. 2004

 

The other important part of their studies was the increased in DHT that follows stopping the medication. The graph above shows that DHT levels rise much more slowly when dutasteride is stopped than when finasteride is stopped. This is on account of the long half life of dutasteride compared to finasteride (6 hours for finasteride and 4-5 weeks for dutasteride).

 

 

Reference

Clark RV, et al. Marked suppression of dihydrotestosterone in men with benign prostatic hyperplasia by dutasteride, a dual 5alpha-reductase inhibitor. Randomized controlled trial. J Clin Endocrinol Metab. 2004.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Hair Transplants in Young Men

Are hair transplants an option under 25?

Hair transplantation is rarely a good option in men under 25 and it's generally never an option for men in the early 20s (i.e. before age 23). I completely understand that hair transplants are performed around the world in young men age 18-22. However, I don't think it's a good idea.

 

Why hair transplants in young men is not advisable

In an effort to look better and do something positive, many men rush into hair transplants. Not a day goes by that I don't see it or hear it.  There are a number of things that all young men should keep in mind.

 

1. Hair loss does not stop - it continues forever

Too many young men forget that hair loss will continue forever. If a patient is developing genetic hair loss at a young age, one thing is for sure: they will continue to slowly bald unless medication treatment is considered.  Having a hair transplant does not stop the balding process - it only delays the appearance.

 

2. Males who start balding in the early 20s are likely to develop advanced balding patterns in their 30s and 40s. 

It is critically important to understand that once genetic hair loss starts, it will continue forever. If balding starts at a young age, there is a very high chance that male will develop more significant hair loss in the 30s, 40s or 50s.  

 

3. Males who have hair transplants in the early 20s must be prepared for more surgeries throughout their lifetime

If a hair transplant is performed in the frontal hairline at too young of an age, the hairs that are moved into the frontal hairline may last a long time. However, the hairs 'behind' this frontal area could potentially disappear as normal balding continues along its course. At hair transplant performed at too young of an age often leads to placement of place hairs in an area which could look unnatural in the future. A good example would be the placement of too low of a hairline or a hairline with not enough curve to it.  In order for the patient to continue to look good and not have a 'gap' develop between the transplanted hairs and the continually receding hairline, the patient must return to the surgery centre from time to time for more transplants. In other words, if needs to be prepared for a lifetime of hair transplants. Therefore, a hair transplant is not a one time thing.

 

4. It's nearly impossible to predict prior to the mid 20s how many donor hairs a patient actually has. 

If humans had an infinite number of hairs in the “donor” area to move through hair transplants, I would be more likely to advise that more young men move forward and have hair transplants. However, hair in the donor area at the back of the scalp is present in limited supply. A young male with balding may have anywhere from 0 hairs to move (if they have diffuse unpatterned alopecia or DUPA) to up to 8000 folllicular units to move in his lifetime. It may not be clear until the mid to late 20s whether the number is closer to zero or closer to 8000.

Before the mid 20s, one needs to keep in mind that it is just a 'guess' as to how best to use hair transplant grafts from the back of the scalp.  As one ages, it becomes much clearer as to where it is best to place these grafts.  

 

Conclusion

It's rarely a good idea for a young man to have a hair transplant before the mid 20s. There are exceptions whereby a hair transplant in a 23 or 24 year old can be life altering - but these are rare exceptions. In most cases, I recommend these young patients strongly consider non surgical treatments to try to stop their hair loss before considering hair transplantation.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Hair loss is not a guessing game.

Guessing is easiest for men's hair loss

If you had to "guess" the reason for someone's hair loss, you'd likely guess correctly if the patient was male and you chose male balding (androgenetic alopecia). By far that's the most common cause of balding in men.  Dozens of other causes are possible, but they are not common. 

 

Hair loss in women is more complex.

For women, there's a very good chance you'd be wrong if you guessed androgenetic alopecia as the sole cause. Female hair loss is far more complex - and hair shedding issues and even scarring conditions are not uncommon. Hair loss of course, is not a guessing game and a diagnosis can usually be made by the patient's history, examining the scalp and sometimes examining blood test results or (rarely) performing a scalp biopsy.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Is it okay to use more minoxidil?

Using more minoxidil is not advised

The dosings of medications have been carefully worked out to balance efficacy with safety. If a patient feels he or she needs more, they should speak to their physician or pharmacist regarding how to apply minoxidil efficiently. If one feels this dose does not work, they might consider a variety of off label means... but only under supervision. This could include using a bit more than 1 mL, or using oral minoxidil at low doses.

 

Side effects of using too much minoxidil

The side effects of overdosing on minoxidil include worsening headaches, dizzininess, low blood pressure, heart palpitations, heart rhythm disturbances, ankle swelling, hair growth on the body. Rarely patients end up in the emergency department every year because they feel so unwell after using too much minoxidil. 

Minoxidil is a drug and use must be respected.

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Minoxidil: Does age really matter?

Minoxidil and age-related hair loss

Minoxidil is a topical medication used to treat many forms of hair loss including androgenetic alopecia (for which it is FDA approved). Minoxidil can be helpful for treating androgenetic alopecia at any age but becomes even more important to consider with advancing age. 

 

Senescent alopecia: A type of hair loss often forgotten

Hair thinning as one approaches the 60s and 70s is often less truly androgen driven. The diagnosis of senescent alopecia (SA) needs to be considered in these particular age groups and it can often respond to minoxidil. Senescent or age related alopecia is often forgotten by physicians. It mimics genetic hair loss almost perfectly so is easily misdiagnosed as genetic hair loss. The genes driving it are very different. The key point is that if one recognizes senescent alopecia could be a possibility - the use of treatments like minoxidil become more important rather than other traditional AGA-type treatments like finasteride.

Androgenetic alopecia tends to start somewhere between age 8 and age 50. Hair thinning that occurs later has a high likelihood of representing senescent alopecia. (Of course other types of hair loss may also occur after age 60 and genetic hair loss and senescent alopecia can overlap). A study by Karnik and colleagues in 2013 confirmed that these two conditions (AGA and SA) are truly unique. The authors studies 1200 genes in AGA and 1360 in SA and compared these to controls. Of these, 442 genes were unique to AGA, 602 genes were unique to SA and 758 genes were common to both AGA and SA. The genes that were unique to AGA included those that contribute to hair follicle development, morphology and cycling. In contrast to androgenetic alopecia, many of the genes expressed in senescent alopecia have a role in skin and epidermal development, keratinocyte proliferation, differentiation and cell cycle regulation. In addition, the authors showed that a number of transcription factors and growth factors are significantly decreased in SA. The concept of senescent alopecia is still open to some debate amongst experts. The studies by Karnik give credence to the unique position of these two conditions. But studies by Whiting suggested that it is not so simple as to say anyone with new thinning after age 60 has SA - many of these are also more in keeping with androgenetic alopecia. As one ages into the 70's, 80's and 90's - hair loss in the form of true senescent alopecia becomes more likely.

 

Reference

Karnik et al. Microarray analysis of androgenetic and senescent alopecia: comparison of gene expression shows two distinct profiles. J Dermatol Sci. 2013.

 

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Differentiating DUPA from CTE

How do we distinguish DUPA from CTE?

Diffuse unpatterned alopecia (DUPA) can generally be differentiated from chronic telogen effluvium (CTE) by careful review of the patient's history, and examination of the scalp using dermoscopy. Rarely a biopsy can be confirmatory but usually this is not needed.

 

DUPA

On history, patients with DUPA report diffuse thinning. They usually don't have all that much in terms of increased shedding. Typically, the hair loss is first noticed between age 15-24. Examination of the scalp shows variation in the sizes of follicles. We call this 'anisotrichosis'. Some hairs are thick and some are thin. The miniaturization occurs all over the scalp. A biopsy shows a terminal to vellus ratio of much less than 4:1.

 

CTE

In contrast to DUPA, patients with true CTE are usually a bit older when they first notice hair loss, often 35-60. Their stories are markes by concerns about massive shedding that comes and goes, some weeks good and some weeks bad. Patients with CTE don't usually look like they have hair loss to others whereas patients with DUPA often do look like they have hair loss. In CTE, examination shows terminal thick hairs. The temples may or may not show recession but often do in the setting of CTE. A biopsy shows T: V ratios that are high - and ratios 8:1 or higher are suggestive of CTE (compared to less than 4:1 for DUPA).

 

In summary, DUPA and CTE can usually be easily differentiated with careful examination and review of the patient's story.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Androgenetic Alopecia and Height

Height, AGA and Genetics

Recent research has shown that many of these genes that control balding also affect how tall an individual may become. 

height


Heilman-Heimbach and colleagues from the University of Bonn recently performed an extensive study of over 20,000 men (10,000 with hair loss compared to 10,000 without hair loss). The researchers uncovered 63 genetic changes that increase a man's risk of developing early onset balding. These same genetic changes were associated with an increased likelihood of being shorter. They concluded that many of the genes controlling male balding are also linked to being shorter in height.

A second study from the UK by Hagenaars and colleagues identified 287 genetic regions linked to male pattern baldness. This large study examined data from over 52,000 men. This study confirmed a similar finding as the Heilman-Heimbach et al. study above namely that many of the genes regulating hair loss in men also give an increased chance for shorter height.


Reference


Heilman-Heimbach et al. Meta-analysis identifies novel risk loci and yields systematic insights into the biology of male-pattern baldness. Nature Communications, 2017.

Hagenaars SP et al.  Genetic prediction of male pattern baldness. PLoS Genet 13(2): e1006594. 2017.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Hair Loss in Androgenetic Alopecia: Why can't anyone notice my hair loss?

On the Three Stages of Hair Loss in Androgenetic Alopecia

Hair loss in patients with androgenetic alopecia (AGA) starts well before the affected individual actual becomes "aware" that his or her hair is thinning. I often think of AGA in three "stages" - labelled 1, 2 and 3 in the following diagram. These are not to be confused with the 3 Ludwig stages of hair loss.

threestagesAGA

 

Another way that I think about the 3 stages of hair loss is shown here.

three stages

Stage 1

In stage 1, hair density is slowly reducing but the patient is unaware. There may be a slight increase in hair being shed in the shower or coming out daily in the brush. However, this generally goes by unnoticed by the patient. A biopsy can sometimes (but not always) capture a T:V ratio below 4:1 and some degree of miniaturization (and anisotrichosis) may be present. Much of the time it's challenging to confidently diagnose AGA in this stage. Some stay in stage 1 for a very long time; others just a matter of months.

 

Stage 2

In stage 2, the patient first becomes aware that something is not quite right. They may see a bit more scalp showing when they look in the mirror. They may feel the hair does not feels as thick when they run their fingers through the hair. Under bright lights they may feel a bit more aware of these changes. When the hair is wet, the thinning is evident.

Nevertheless, in this second stage everyone else tells the patient they look fine. Some patients are told they are "crazy". Even some physicians will tell the patient they "look fine" and need not worry. Patients often feel isolated in this stage because nobody believes them when they say they are losing hair! A biopsy definitely shows a T:V ratio less than 4:1 and miniaturization is clearly seen in more than 20 % of hairs. Many never progress to stage 3 especially those with onset of AGA later in life.

 

Stage 3

In stage 3, the hair loss has progressed to a stage where hair loss may become evident not only to the patient but also to others. Of course with use of various hairstyles, products, camouflaging agents it may still be possible to hide one's hair loss from others. As stage 3 progresses it becomes more and more difficult to hide hair loss.

 

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As a physician, I try to understand the goal of my patients. Some patients in stage 2 want help to simply stop their hair loss so that they can "stay" in stage 2 and not move on to stage 3. Other patients want treatment advice to get them back into stage 1 (if possible). Some patients in stage 3 want to improve their density such that they can get a bit more hair back to hide their hair thinning more easily. The patient in such an example may not be looking to move from stage 3 to stage 2 but may be looking to improve their density.

Consider the 31 year old female with early thinning who is worried about her hair. Her friends and family think she's crazy worrying about her hair. After listening to the patients story and examining her scalp, I can reassure her that even without treatment she will stay in stage 2 for 5-10 years (and her friends and family will likely keep telling her she's crazy for many more years to come). However, my concern for her is that if nothing is done she will move on to stage 3 in her 40s, 50s and 60s. The goal of treatment is to prevent this.

I find this chart helpful for many of my patients and when teaching physicians about hair loss. 

 

 

 

 

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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How Many Genes Are Involved in Male Pattern Balding?

How many genes control whether an individual develops balding?

DNA.png

Studies by Hagenaars et al in 2017 showed that male balding is actually more complex than we ever imagined. The researchers identified 287 genetic regions that are linked to male pattern balding (androgenetic alopecia). This data came from studies of over 52,000 men.

 

Reference

Hagenaars et al. PLoS Genetics 2017
 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Do all males bald in the same way? 

Do all males bald in the same way? 

male balding.jpg

The answer to that is no. Most men whonare going to bald first notice changes in the temples and/or crown and then ultimately bald according to the so called "Hamilton Norwood" scale. However this male shown in the photo has a pattern of balding that does not match up to any of the Hamilton Norwood patterns. He has what is known as a "female" pattern of male balding where the central scalp is involved first and the frontal hairline is relatively unaffected. This pattern of androgenetic hair loss is common in women and affects about 10-13 % of males.
 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Treatment of Male Balding: A closer look at the three tiers of options

Treatment of Male Balding

A variety of treatment options exist for males with balding, also known as androgenetic alopecia. I like to think of the options in terms of three tiers or categories of treatments. Tier 1 treatments have the best evidence and are consistently the most effective. Tier 3 treatments have the least evidence.

 

Tier 1 Treatments

Minoxidil and Finasteride are the two FDA approved treatments. Dutasteride is off label in North America but is also not uncommonly prescribed as well. These are among the most effective treatments and what I would term "tier 1" treatments. 

 

Tier 2 Treatments

Other treatments can also be considered including low level laser and platelet rich plasma. Meta-analyses support a benefit of these over placebo or sham treatments so they are not without at least potential benefit. These are what I term "tier 2" treatments. Other tier 2 treatments with less evidence but still reasonable likelihood of benefit include oral minoxidil and topical finasteride. These are not FDA approved and off label.

 

Tier 3 Treatments

Then we come to "tier 3" treatments. Some treatments in this group might help some males but not all and tesults may be inconsistent. Some tier 3 treatments could be helpful, it's just that not enough studies have been done. The public loves many "tier 3" treatments as they wrongly assume some are completely safe. Many tier 3 treatments simply have not been studied to any significant degree to render conclusions about safety. Lack of studies does not equate to them being safe.

This tier 3 group includes a variety of treatments purported to have a DHT blocking and anti-androgen type effect. There is biochemical evidence of this effect for some of the treatments and even a hint of clinical benefit for others. There is far less study of this group of agents which includes saw palmetto, pumpkin seed oil, ketoconazole shampoo, topical androgen receptor blockers. In the last category are many agents that can be bought on the internet and that I see in my office at least once per week. The evidence for a clinical benefit from these agents is weak at best.

This summarizes the three tiers of non surgical treatments that can be considered in males with balding. A number of exciting options are on the horizon and only careful study will determine if we ever see them in the clinical setting. This includes topical prostaglandin F2 analogues (bimatoprost), prostaglandin D2 inhibitors, Wnt pathway activators, JAK inhibitors and a variety of cell based therapies.

 

 


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Bimatoprost for Androgenetic Alopecia: An intensely researched area

Bimatoprost for Male Balding

Bimatoprost is a prostaglandin F2 alpha analogue that stimulates hair growth. Bimatoprost at 0.03 % is a well known eyelash growth stimulatory compound and marketed under the name Latisse. 

bimatoprost-aga


Bimatoprost has been studied for use in androgenetic alopecia. At low concentrations, it is not particularly effective. Allergan is currently studying higher concentrations (1 and 3%). Data released by Allergan and available to the public online suggest that these higher concentrations may be beneficial in treating hair loss. This is an exciting area to watch out for in the near future.

The graph shows how bimatoprost compares to minoxidil in these Allergan led studies. In their preliminary results, higher concentrations of bimatoprost was similarly or even slightly more effective that minoxidil (the gold standard FDA approved topical treatment for androgenetic alopecia).


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Androgenetic Alopecia and Height

Baldness Associated with Shorter Height

Is there a link between the height of a man and his chances of developing androgenetic hair loss (male pattern balding)? 

Recent studies have suggested that answer is yes. Researchers at the University of Bonn performed an extensive study of over 20,000 men (10,000 with hair loss compared to 10,000 without hair loss) and concluded that many of the genes controlling male balding are also linked to being shorter in height.

The researchers discovered 63 genetic changes that increase a man’s risk of developing early onset balding. These same genetic changes were linked with a greater likelihood of being shorter.

This study confirms that hair loss is not an isolated phenomenon but rather controlled by genes that also determine one’s height and various aspects of health.

 

Reference

Heilman-Heimbach et al. Meta-analysis identifies novel risk loci and yields systematic insights into the biology of male-pattern baldness. Nature Communications, 2017; 8: 14694 DOI


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Valproate and Hair Loss: Does valproate cause hair loss through an androgen mediated mechanism?

There are many different types of drugs used as mood stabilizers is women with bipolar disorder. Many of these drugs can cause hair loss, albeit with different mechanisms. Common medications used in treating bipolar disorder include lithium, valproate, lamotrigine, topiramate, gabapentin, carbamazepine, oxcarbazepine.

 

Vaproate and Hyperandrogenism

There is increasing evidence suggests that valproate is associated with isolated features of polycystic ovarian syndrome (PCOS). To study this further, researchers studied three hundred women 18 to 45 years old with bipolar disorder. A comparison was made between the incidence of hyperandrogenism (including hirsutism, acne, male-pattern alopecia, elevated androgens) with oligoamenorrhea that developed while taking valproate versus other types of anticonvulsants drugs (like lamotrigine, topiramate, gabapentin, carbamazepine, oxcarbazepine) and lithium. 

 

What were the results?

It was interesting that among 230 women who could be evaluated, oligoamenorrhea with hyperandrogenism developed in 9 (10.5%) of 86 women on valproate compared to just 2 (1.4%) of 144 women on nonvalproate anticonvulsants or lithium. This translated into a nearly 8 fold risk of these hyperandrogenism and menstrual cycle changes with valproate. Oligomenorrhea happened within 12 months with valproic acid users.

 

Conclusion

Once needs to be aware of a possible PCOS like clinical phenomenon and for hair specialists - the development of hyperandrogenism and accelerated AGA in women using valproate for bipolar disorder. More studies are needed to confirm these findings.

Reference

Valproate is associated with new-onset oligoamenorrhea with hyperandrogenism in women with bipolar disorder.

Joffe H, et al. Biol Psychiatry. 2006.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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Oral minoxidil for hair loss

Oral Minoxidil

Topical minoxidil was FDA approved in 1987 and we now have 30 years of experience with the drug. 

I'm increasingly asked about oral minoxidil. Does it work? Is it safe? What dose? 

Oral minoxidil is not FDA approved for treating hair loss. It was used in the 1980s for treating high blood pressure. When used at doses typical for treating blood pressure problems (5 mg twice daily), it can be associated with side effects - some quite serious. These include dizziness, low blood pressure, weight gain from fluid retention, high heart rate, heart rhythm problems. And of course hair growth can occur all over the body.

Lower doses of oral minoxidil may be safer and may still provide benefit. Doses ranging from 0.25 mg daily to up to 1 mg daily are generally well tolerated without a significantly increased risk of side effects. One does need to be closely monitored for blood pressure, weight changes, heart rate and excess hair growth on the body. For women, low dose minoxidil can be combined with spironolactone. In men low dose minoxidil can be combined with lower doses of finasteride.

 

Conclusion

Oral minoxidil is increasingly popular as men and women look for safer options for treating hair loss. Side effects of oral minoxidil must be respected and use of the medication must only be done in conjunction with a physician experienced in the use of oral minoxidil. Close monitoring is essential.


This article was written by Dr. Jeff Donovan, a Canadian and US board certified dermatologist specializing exclusively in hair loss.
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