INCREASED RISK OF HEART DISEASE IN MEN WITH HAIR LOSS

Do balding men have an increased risk for heart disease?

Several studies in the past have examined the relationship between balding and heart disease.   In a study published in this month's British Medical Journal, researchers from Japan carefully examined all of the research studies to date focusing on the relationship between hair loss and heart disease.

Balding and heart disease: what did the new research find?

The researchers looked at studies involving 36,690 balding men and found that men with hair loss in the top of the scalp or ‘vertex’, had an increased risk of heart disease.  Interestingly, men with more severe balding had a greater risk of heart disease compared to men with lesser degrees of balding in the vertex.  Men with hair loss in the front of the scalp did not demonstrate an increased risk of heart disease.  

The exact reasons why balding men have increased heart disease risk is not clear but may be related to common mechanisms that lead to heart disease and hair loss including high blood pressure, smoking, high cholesterol, insulin resistance and increased inflammation in blood vessels.

These findings are important for the approximately 4 million Canadian men and 40 million American men affected with male balding.

SOURCE:   Yamada et al. Male pattern baldness and its association with coronary heart disease: a meta-analysis. BMJ Open; 2013; e002537.

 

Is there an increased risk of prostate cancer in balding men?

The risk of prostate cancer in balding men

About 50 percent of men will be affected by male pattern balding throughout their lifetime. The medical term for male balding is "androgenetic alopecia."

Which men will developing balding and which will not? Well there are still some things we need to learn about balding. But in general, male balding is influenced by genetics, hormones and occurs with advancing age. Prostate cancer is one of the most common cancer in men. It  too is influenced by genetics, hormones and occurs with advancing age.

Is their any link between the male balding and prostate cancer?

Well, researchers at the Cleveland Clinic in Cleveland, Ohio recently set out to look at this question. They looked at all the high quality studies published so far which have examined the risk of prostate cancer in balding men.

In total, the researchers looked at the development of prostate cancer in 8994 patients - 4078 with prostate cancer and 4916 healthy men.

What did the researchers find?

When all of the studies were pooled together an interesting finding was confirmed - and that is that men with hair loss in the top of the scalp  or “vertex” have a small but significant increased risk of prostate cancer. It's important to note that the increased risk was quite small - but nevertheless the data pointed to an increased risk. The authors indicated that further studies in the future are needed to confirm these interesting findings.

SOURCE: Amoretti A, Laydner H and Bergfeld W. Androgenetic alopecia and risk of prostate cancer: A systematic review and meta-analysis. J Am Acad Dermatol 10.1016/j.jaad2012.11.034)

This blog has been filed into the following folders:

A New Era in the Treatment of Androgenetic Alopecia: Focus on the "Prostaglandin Pathway"

The "Prostaglandin" Pathway

Recently, we've been hearing a lot about a group of hair growth drugs that affect "prostaglandins".  Several recent blogs of mine have discussed the role of prostaglandin F2a analogues in stimulating eyelash growth (click here for article).  A few months ago a major buzz was created in the hair world when Dr. Cotsarelis at the University of Pennsylvania showed that blocking the prostaglandin D2 pathway might be relevant to the treatment of androgenetic alopecia (click here for article).

New Study Highlights Role of Prostaglandin Analogues

Latanoprost is a prostaglandin F2alpha drug that is often used in treating glaucoma (an eye disease characterized by elevated eye pressures). Recently the drug has been shown to be useful in stimulating eyelash growth. 

In yet another study, researchers from Germany examined the use of the drug latanoprost 0.1% in the treatment of men with androgenetic alopecia (male balding). 16 men participated in the study.  All men had early staged androgenetic alopecia  Men applied one drop (50 microliters) of latanoprost solution to one small area of the scalp daily and one drop of the placebo drug (mock drug) daily for 24 weeks. 

What were the results?

Overall about 50% of men benefitted from the drug.  Patients who did end up benefitting from the drug showed evidence of improved growth by 16 weeks. The drug was well tolerated with the most common adverse effect being scalp redness. Interestingly, the patients who developed scalp redness also experienced hair growth.  How exactly these two are related remains to be clarified.

Comment

These results are exciting and highlights the importance of this prostaglandin pathway.  We will certainly be hearing a whole lot more about the pathway in the years ahead. Its important to note that all participants in the study were men, so we don't know if the results are generalizable to women.  Furthermore, all men in the study had early stage androgenetic alopecia so we dont know if the drug will have benefit for men with more advanced stages of balding.

Reference

Blume- Peytavi et al. A randomized double-blind placebo-controlled pilot study to assess the efficacy of a 24 week topical treatment by latanoprost 0.1 % on hair growth and pigmentation in healthy volunteers with androgenetic alopecia.  Journal od the Amaerican Academy of Dermatology 2012; 66:794-800.

Hair Loss Treatments on the Horizon

Hair Loss Treatments on the Horizon

I returned from an outstanding meeting of the 21st Annual Meeting of the European Academy of Dermatology and Venerology in Prague.  This video highlights some of the exciting hair loss treatments that may be on the horizon including the latest in hair cloning research and new topical medications produced by L'Oreal.

Hope you enjoy it!

Finasteride Use by Young Men: Not only for Baldness in the Crown !

Finasteride Use by Young Men

For years, we've largely assumed that finasteride helps men with hair loss in the crown, but does little for men with hair loss in the front of the scalp or the temples.

A new study by US researchers has nicely shown that finasteride 1 mg daily can help young men with male pattern balding regardless of where on the scalp the man has hair thinning.

The researchers studied men 18 to 60 years of age for a period of two years. Four areas of the scalp were examined: (1) vertex (crown), (2) the mid-scalp, (3) the frontal hair line and (4) the temples.

What were the results of the study?

The study showed that young men benefitted from taking finasteride - regardless of where there hair thinning occured. Young men (age 18-40) with hair loss in front, temples, mid-scalp or crown all had benefit from taking finasteride. However, the same was not true of men age 41-60. Men in this slightly older group benefitted most if their hair loss was in the crown and the mid-scalp.

Reference

Olsen EA et al. Global photographic assessment of men aged 18 to 60 with male pattern hair loss receiving finasteride 1 mg or placebo.  J Am Acad Dermatol 2012; 67: 379-86. (click for abstract)

 

Smoking and Androgenetic Alopecia: Why I ask and Why I Encourage Patients to Quit

Smoking and Androgenetic Alopecia:

For many years, researchers have been examining whether smoking speeds up the process of genetic balding (also called "androgenetic alopecia").  The studies have been somewhat inconsistent but point to the possibility that smoking accelerates the process of male balding.

An important study examing the relationship between smoking and hair loss was a 2007 study by the Taiwanese group of Dr. Su and Dr Chen.  These researchers examined 740 patients between the ages of 40 and 91 over a 2 month period.  They found that smokers generally had worse androgenetic alopecia compared to non-smokers. In fact, smokers had nearly a two-fold increased risk of having moderate or severe genetic hair loss compared to non-smokers. In addition, the early development of male balding was more likely in smokers.

Why Would Smoking Speed Up the Development of Male Balding?

No one knows for sure. It may be that smoking is damaging to the tiny blood vessels and the there are toxic substances in cigarette smoke that damage the cells in the hair follicles. It's also possible that smoking causes inflammation which speeds up the process of genetic hair loss. Certainly, more research is needed to figure out why.

Why I Encourage my Young Patients with Androgenetic Alopecia to Quit Smoking

There is yet another reason why I encourage young men and women with androgenetic alopecia to quit smoking.  We know from carefully done studies that young men with balding have an increased risk of cardiovascular disease later in life.  The same seems to be true for women as well. Furthermore, it's well know that smoking is one of the key risk factors for cardiovascular disease.  Taken together, it's of paramount importance to help patients stop smoking. (For additional articles, on the interplay between smoking, hair loss and cardiovascular disease click here).

Reference

Su LH and Chen T H-H. Association of Androgenetic Alopecia with Smoking and Its Prevalance Among Asian Men. Archives of Dermatology 2007 143; 1401-1406.

Mosley JG and Gibbs AC. Premature grey hair and hair loss among smokers: a new opportunity for heatlh education? British Medical Journal 1996; 313: 1616.

Severi G et al Androgenetic alopecia in men 40-69 years: prevalence and risk factors.British Journal of Dermatology 2003; 149: 1207-1213

 

Does Sunlight Worsen Androgenetic Alopecia? Lessons from the Police

Sunlight Worsens Androgenetic Alopecia

Androgenetic alopecia, or male pattern balding, is common.  In fact, about 50 % of men will have androgenetic alopecia by age 50. It is well known that genetics and hormonal influences play an important role in men.                                      

But what about other factors?                                                                                                                         

The role of ultraviolet radiation in male balding has been debated for many years and we still don't know all the answers.  However, many scalp diseases are made worse by ultraviolet radiation.  For example, my patients with seborrheic dermatitis will often report flares following sun exposure.  In addition, patients with discoid lupus or dermatomyositis  may note worsening after sun exposure.

The exact role of ultraviolet radiation in male balding is not clear.  We know that inflammation is present under the scalp in many men with genetic hair loss and so the question arises... How did that inflammation get there? ...  and is their any possibility that sun exposure contributes to the inflammation that is found under the scalp in men with balding?

An interesting study from researchers in Taiwan offers further clues that sunlight just 'might' contribute in some way to male balding.  The researchers compared balding patterns in 758 policemen  and 740 men in the general polulation.  Interestingly, policemen aged 40 to 59 had a two fold increased risk of having male balding. In addition, there was a statistically significant association between male balding and sunlight exposure.

More research is needed understand if and how ultraviolet radiation affects the process of male balding. If a link is found, it will be important to determine if men who reduce sun exposure (with hats, etc) will slow down the natural progression of the male balding process.

Su et al. Androgenetic alopecia in policemen: Higher prevalence and different risk factors compared to the general population.  Arch Dermatol Res 3: 753-61.

 

New Health Canada Warnings about Finasteride, Dutasteride and Prostate Cancer

Prostate cancer is one of the most commonly diagnosed cancers in men. In fact, about one in six men will be diagnosed with prostate cancer. One new case of prostate cancer occurs every 2.2 minutes and a man dies from prostate cancer every 15.6 minutes.

Health Canada released a statement last week about the possible increased risk of “high-grade” (aggressive) prostate cancer in men taking the drugs finasteride and dutasteride.  Both of these drugs are used to treat male balding but are also used to treat men with enlarged prostate glands. Large numbers of my patients have asked me about the Health Canada statement in the past weeks –  Click on the link to read more about the Health Canada statement.

READ THE HEALTH CANADA STATEMENT

In order to understand the meaning of the Health Canada warning about finasteride and dutasteride, it’s important to have some background information.  First, it’s important to know that there were TWO very large studies conducted a few years ago (one in 2003 and one in 2008) looking at whether finasteride and dutasteride could actually help prevent prostate cancer in men. 

The two reserach studies are:

STUDY 1: Prostate Cancer Prevention Trial (or ‘PCPT’ Trial)

• This was a 2003 study of 18,000 men over 55 years of age
• This study showed finasteride reduced the risk of men getting prostate cancer by 25 %
• There was a slight increased in high grade (more aggressive) prostate cancers in men who took the drug compared to those who took the placebo (sugar pill)
• The dose of finasteride in this study was  five times higher dose of finsasteride than used for hair loss (i.e. 5 mg rather than 1 mg)

STUDY 2: Reduction by Dutasteride of  Prostate Cancer Events (or REDUCE Trial)

• This was a study in 2008 of over 6700 men age 50 to 75
• Over the 4 years of the study, there as a 23 % reduction in prostate cancer in men who took the drug
• There was a slight increase in high grade (more aggressive) prostate cancers  in year 3 and 4 in men who received the drug compared to men who received the placebo (sugar pill) but overall the raw data showed there was no increase risk of high grade cancers throughout all years of the study.
• The dose of dutasteride was the same as used for hair loss (i.e. 0.5 mg)

THINGS THE PUBLIC SHOULD BE AWARE OF:

• The data from these two studies is complicated to interpret
• There is no question whatsoever that finasteride and dutasteride both reduce the risk of men getting prostate cancer.
• What is not entirely clear is if these two drugs increase the chance of men getting a "high grade" cancer.  It’s possible that for every four low-grade (non aggressive cancers) that these drugs prevent, there is one high grade cancer that gets detected while on the drug.

But do these drugs make it "easier" to detect a cancer that would have otherwise escaped detection?

OR

Do these drugs actually contribute to the development of the prostate cancer?

The answer to these questions is not known with complete certainly.  There are several explanations as to why more high grade prostate cancers were detected in men who took the drug.  For the most part, most authorities in prostate cancer do not believe there is a cause for alarm. In fact, the number of world authorities on prostate cancer who believes there could be a link between finasteride and prostate cancer is greatly outnumber by authorities who feel there is no link whatsover.  This includes Dr Otis Brawley, Chief Medical Officer of the American Cancer Society and Dr Neil Flesher, Head Division of Urology at the University Health Network and Professor of Surgery at the University of Toronto. The public needs to know this information is not cut and dry.

FINAL THOUGHTS

• If there is any risk of high grade prostate cancer with these drugs (again, we can't say for sure there even is).... the risk is very small.
• The public should be aware that the new Health Canada warnings do not state that finasteride or dutateride causes high grade prostate cancer. Rather, the warning states that there could be a link and more studies are needed.
• The studies discussed above were conducted with five times higher dose of finsasteride than used for hair loss (i.e. 5 mg rather than 1 mg).  Therefore, Propecia (finasteride 1 mg) was not included in these studies
• The dose of dutasteride in these studies was the same as used for hair loss (0.5 mg)
• Individuals with concerns about these drugs should speak to their doctors

 

Breakthrough in Baldness? Blocking the Prostaglandin D2 Pathway May be the Answer

We know that balding in men is due to a complex interplay of genetics and hormones. But recently there has been some exciting research looking at the role of "stem cells" in male balding.  Hair follicle stem cells are cells that theoretically can give rise to massive numbers of new hairs. This stem cell research is important since male balding affects nearly 50 % of men by age 50 and 80 % of men by age 70.

A few months ago, I wrote a blog about exciting  research discoveries  by Dr. George Cotsarelis and his group at the University of Pennsylvania.   At that time, the researchers showed that "bald" scalp surprisingly contains the same number of stem cells as "non bald" areas of the scalp. What was different was that bald areas of the scalp had fewer progenitor cells (or cells derived from stem cells that actually develop into new hair follicles).

With this discovery presented to the medical world, the researchers then set out to ask the next key question:

 Why do bald areas have fewer progenitor cells?

 Is it because something inhibits them from developing?

 or is it because they can’t be properly activated?

Last week, Dr. Cotsarelis and his team published some new reserach in the journal Science Translational Medicine.  Like the previous study, this was a major breakthrough in our understanding of the balding process.

What did the researchers find?

The  researchers again compared areas of balding scalp to areas of hairy (non-balding) scalp.  They found that the bald tissue had elevated levels of a protein called “Prostaglandin D2.”  In fact, when they studied 17 men with balding, they found that PGD2 protein levels were 3 times higher in bald areas than non-bald areas. In further experiments, it was shown that prostaglandin D2 was extremely important – in fact, when PGD2 was added to hair follicles in a petrie dish, the hairs stopped growing.  Moreover, Dr. Cotsarelis’ group identified the exact receptor that Prostaglandin D2 needs to bind to in order to produce it’s effects (a receptor called GP44).

So can we block the PGD2 protein and cure male baldness?

That answer is not know but one of the real exicting aspects of Dr. Cotsarelis’ study is that drugs that block PGD2 are already in development. In fact, the Merck company has a drug to treat facial flushing called "laropiprant" that blocks the protein and Actelion has a drug called "setipiprant"  to treat allergies that also affects the protein.  

What is the next step in developing new hair loss drugs?

There is no doubt that drugs that block PGD2 (or the GP44 receptor) will now be studied more intensively. But whether such drugs will help stop or reverse the balding process is not yet known. It’s also not known if such drugs would have benefit in women with genetic hair loss because only men were studied in Dr. Cotsarelis’ study. We know that the process of genetic balding in women is more complex than in men, so it may or may not have the same benefits.

I think we’ll be seeing more and more research about the role of prostaglandins in hair loss. A drug analogue of Prostaglandin F2 alpha (marketed under the name Latisse) is known to improve eyelash growth in women and may also help some individuals with eyebrow loss too. Now we have evidence that blocking prostaglandin D2 might also help hair growth. The prostaglandin pathway may have promise for new drugs to treat hair loss!

Hair Transplantation Using Leg Hair

Patients in my practice often ask me if I can take hair from the chest, back or legs and add it into thinning areas on the scalp. The concept of "body-to-scalp" hair transplantation is somewhat new but slowly catching on. Generally, most hair transplant specialists would reserve this technique for very special circumstances (i.e. poor donor hair density at the back of the scalp or poor donor quality, or excessive scarring in the donor area).  Hair from other body sites isn’t quite the same as hair on the scalp – it looks and feels different. It grows at different rates too.   

Dr. Sanusi Umar, a hair transplant specialist from California, wondered if he could use these differences to his advantage. Specifically, he wondered it he could take advantage of the fact that leg hairs are small, thin and soft and use these legs hairs to improve the appearance of the frontal hairline (which is normally chalked full of soft, thin hairs).

Can hairs from the leg really be transplanted into the hairline?

Dr. Umar studied two of patients, each of whom had 1000 leg hairs transplanted into their frontal hairlines.   In both patients, Dr. Umar reported that about 75-80 % of the hairs survived. Interestingly, the transplant legs hairs were a bit longer than the original leg hairs and were less curly.   Dr. Umar  followed the first patient for a total of 4 years and followed the second patient for 3 years. The transplanted legs hairs remained and grew well in the frontal hairline. Moreover, the areas on the leg where the hairs were taken healed without visible scars.

Dr. Umar's study, which is published in the journal Archives of Dermatology is an interesting and unique study.  It shows promise in the use of leg hairs to soften the hairline.  As body-to-scalp hair transplants move forward, it seems that both chest hair and leg hair may be a possible source of transplantable hair for some patients.

Reference

Umar S. The Transplanted Hairline: Leg Room for Improvement. Archives of Dermatology 2012; 148: 239-242

February is Heart Health Month: What does your hair tell about your heart?

Heart disease is one of the leading causes of death in Canada and the United States. In fact, about one out of every three deaths is due to heart disease and stroke. February is designated heart health month - a great time for us all to think about risk factors for heart disease and all the things we candue to reduce our risk of heart disease. It’s also a great time to discuss the relationship between male and female balding and heart disease.

About 50 % of men and 30 % of women will develop genetic balding by age 50. The medical term for genetic balding is “androgenetic alopecia”. In men, androgenetic alopecia causes hair loss in the front, temples and the crown and may even involve the entire frontal scalp. In women, androgenetic hair loss causes hair loss in the centre of the scalp. 

Is there a link between balding and heart disease?

The answer is yes. Several large research studies have confirmed an association between androgenetic hair loss and heart disease.  It seems that men who develop early balding have a higher risk to develop coronary artery disease.  This may be especially true in younger men who develop rapid balding.   New research is showing that the same relationship is true for women.

This doesn’t mean that hair loss causes heart disease or heart disease causes hair loss. Rather it tells us that the two are linked somehow through a similar process: men and women who develop early hair thinning also tend to have a higher chance to get heart disease.

Why is this information important?

The research is important for a number of reasons. If you are young and have androgenetic alopecia, do what you can to minimize your risk factors for heart disease.

If you are young and have androgenetic alopecia, do what you can to minimize your risk factors for heart disease. Eat well, excercise, get your blood pressure checked to make sure you don't have high blood pressure (hypertension).  Ask your physician about checking cholesterol and blood sugar levels. If you smoke, get help to stop.

I often encourage young men and women with early balding to get tested for all the heart disease risk factors. This involves getting a blood pressure measurement, checking cholesterol and fat levels, checking for diabetes or pre-diabetes and making sure that these individuals are getting enough exercise.  Although I encourage all smokers to stop smoking (as smoking negatively impacts hair), I advise those with early balding to quit smoking and smoking is a top risk factor for heart disease.

Happy Heart Month!

References

Lotufo, PA Chae CU, Ajani UA, Hennekens CH, et al. Male pattern baldness and coronary heart disease: the Physicians Health Study. Arch Intern Med 2000; 160 (2): 165 - 71.

Lesko SM, Rosenberg L, Shapiro S. A case-control study of baldness in relation to myocardial infarction in men. J Am Med Assoc 1993; 269: 998 - 1003.

Trevisan M, Farinaro E , Krogh V, et al. Baldness and coronary heart disease risk factors. J Clin Epidemiol 1993; 46 (10): 1213-8.

Cotton SG, Nixon JM, Carpenter RG, et al. Factors discriminating men with coronary heart disease from healthy controls. Br Heart J 1972; 34: 458-64.

Ford ES, Freedman DS, Byers T. Baldness and ischemic heart disease in a national sample of men. Am J Epidemiol 1996; 143 (7): 651 - 7.

Herrera CR, DAgostino RB, Gerstman BB,et al. Baldness and coronary heart disease rates in men from the Framingham Study. AM J Epidemiol 1995; 142(8): 828 - 33.

Persson B, Johansson BW. The Kockum study: twenty two - year follow - up coronary heart disease in a population in the south of Sweden. Acta Med Scand 1984; 216(5): 485-93.

What are the Most Recent Trends in Hair Transplantation?

Hair transplantation is becoming an increasingly popular option for patients with hair loss. Each year approximately 280,000 hair transplants are performed worldwide.

The interest in hair transplantation is increasing around the world, especially outside of North America. Recent statistics released by the International Society of Hair Restoration Surgery (ISHRS) showed that while hair transplant procedures increased 15 % in the US over the years 2004 to 2010, they increased 345 % in Asia and 454 % in the Middle East over the same period.

Finasteride: Does it Increase the Risk of Breast Cancer in Men?

Health Canada issued a news release August 4, 2011 advising doctors and the public of the possibility of breast cancer in men using the oral medication finasteride. Finasteride at 1 mg is used approved for the treatment of hereditary hair loss in men and is marketed under the name Propecia. Finasteride at a 5 mg dose is used for the treatment of enlarged prostate in men and is marketed under the name Proscar. Although the drug is sometimes prescribed off-label to treat women with androgenetic alopecia, it is not FDA approved for women.

Reports of a possible association between finasteride and male breast cancer are not new.  The possibility of this association was raised over 10 years ago.  There are now at least 50 previous reports in the medical literature about men who developed breast cancer while taking finasteride at the 5 mg dose. There are at least 3 reports in the literature of men who developed breast cancer taking the 1 mg dose. 

Overall, breast cancer in men is rare. 99 % of breast cancers are diagnosed in women and 1 % are diagnosed in men.  Each year about 2000 new cases of male breast cancer are diagnosed in the United States and 200 cases are diagnosed in Canada. 

The public needs to be aware that these studies do not prove that finasteride causes breast cancer in men. This relationship is not known at the present time and more research is needed.  However, it remains a possibility.    The Health Canada report states:

Based on the currently available evidence, it is not known with certainty whether finasteride can cause breast cancer, nor can this possibility be ruled out at this point in time.

All men starting finasteride should be aware of the possibility that reports of breast cancer have rarely occurred in men taking finasteride.  The risks in women are unknown at the present time. Health Canada has advised individuals who take finasteride to report changes in their breasts to their doctors. These changes would include:

• Enlargement of the breasts
• Lumps in the breasts
• Tenderness or pain in the breasts
• Discharge from the breasts

 The Health Canada report is found in the following link:

Finasteride (Propecia, Proscar): Potential rare risk of breast cancer in men

 

August is National Hair Loss Awareness Month in the US

This year marks the 11^th year of the US National Hair Loss Awareness Month.  Hair loss is common with 60 % of men and 40 % of women affected by hereditary forms of hair loss by age 50. This translates into 90 million men and women in the US and Canada alone.

In addition to hereditary hair loss, there are over 100 additional reasons to lose hair. These reasons range from autoimmune and infectious causes to scarring hair diseases and hair loss from hair styling practices. It is important raise awareness of hair loss among the general population and encourage individuals to seek advice about hair loss at early stages.  For the vast majority of hair loss conditions I treat, a better long term outcome is achieved when treatment is initiated in early stages. 

Although National Hair Loss Awareness month is targetted to the general public,  there are important messages for the medical community as well. It is critically important to train more physicians and medical speicalists about hair loss, so that patients with less common and rare hair loss conditions also receive prompt diagnosis and treatment.  

Do I need any blood tests prior to a hair transplant?

The decision to order pre-operative blood tests depends on the hair transplant specialist. I recommend blood tests for CBC (complete blood count), PTT, INR (bleeding parameters) as well as Hepatitis B, Hepatitis C and HIV.   Patients with any previous heart problems may also be requested to obtain an electrocardiogram or “ECG.”

Is there a Minimum or Maximum Age for Hair Transplantation?

The minimum age for hair transplantation differs for each patient and depends on a number of factors. For patients with early onset androgenetic alopecia or with a family history of early onset or advanced androgenetic alopecia I may advise medical therapy first and delay a transplant until the mid 20s. This allows me to observe the rate of progression of hair loss over time. 

It is more challenging to predict the rate of hair loss in very young men with a family history of advanced hair loss. However, it becomes easier to predict the likely patterns of future loss by age 25-30.

There is no maximum age for men or women to have a transplant provided the patient is in good health.   

Do Androgens Cause Hair Loss?

It is well known that androgen hormones contribute to some types of hair loss.  The main culprit is the androgen hormone “DHT” or dihydrotestosterone, which is made from testosterone.  There are several pieces of evidence over the last few years that support the relationship between androgens and the development of androgenetic alopecia. This relationship is more direct in men than women.

First, it was appreciated even in ancient times that castrated young men do not go on to develop androgenetic alopecia, or male pattern balding.   Later it was understood that these men maintain low testosterone levels.  It was J.B. Hamilton in the 1940s who showed that wen testosterone was given back to castrated men later years, they developed male pattern balding.  Further evidence of the role of androgen hormones in hair loss came from study a group of men in the living in the Dominican Republic. Many of these men lacked the ability to convert testosterone to the potent androgen DHT.  Interestingly, these men did not develop male pattern baldness. Finally, we now have several medications available, such as finasteride and dutasteride, which block the ability of the body to covert testosterone to DHT. These medications can halt male pattern baldness in a significant proportion of men.

Most studies have shown that men with androgenetic alopecia have similar levels of blood testosterone compared to men who are not bald.  It appears therefore that men with androgenetic alopecia inherited hair follicles that are "more sensitive" to the effects of androgens rather than simply having higher levels of testosterone.

The relationship between androgens and hair loss is more complex in women. Androgens do play a role in the development of androgenetic alopecia, but likely not to the same degree as in men. Therefore, we now appreciated that the cause of androgenetic alopecia in women is much more complex.  It is for this reason that oral anti-androgen medications are helpful in treating hair loss in women, but do not have the same profound effects as in men.

Miniaturization: The Clue to the Early Diagnosis of Androgenetic Alopecia

One of the most common causes of hair thinning is androgenetic alopecia.  Men with androgenetic alopecia may notice hair loss at the top of the scalp as well progressive receding in the temples. Women with androgenetic alopecia notice thinning in the middle of the scalp.  The central hair part may become wider over time.  As hair thinning occurs the scalp becomes progressively more visible.   

I treat androgenetic alopecia with either 1) topical medications such minoxidil, 2) oral hormone blocking medications or 3) with hair transplantation. For some patients, I may recommend all three treatments. I encourage patients to consider using medical treatments in the early stages in order help maintain or improve the present hair density and prevent further loss over time.

Patients considering treatment for the very early stages of androgenetic alopecia often ask how I can absolutely sure they have androgenetic alopecia. Some of the doctors I teach ask the same question. How do you tell androgenetic alopecia is present if the patient does not actually have hair loss yet?What are the clues to the early diagnosis of androgenetic alopecia?

Androgenetic alopecia can be diagnosed based on the pattern of hair loss and by observing a process known as hair follicle “miniaturization.” When I lecture about androgenetic alopecia, I refer to miniaturization as the process by which hair follicles get skinnier over time.   It takes time for doctors to learn to identify hair follicle miniaturization, but I teach the following analogy to help others master this skill. 

Pretend that hair follicles are like tree trunks in the forest.  This analogy is kept in mind as the scalp is examined. If the size of the tree trunks is all the same – the patient does not have androgenetic alopecia.  If some of the tree trunks are fat and some of the tree trunks are skinny, the phenomenon of miniaturization is being observed. This is shown in the picture above. The most likely cause, by far, is androgenetic alopecia.

There are rarely other conditions that can be associated with miniaturized hairs besides androgenetic alopecia.  But this analogy is extremely important.  Many patients with concerns about hair loss end up receiving a diagnosis of androgenetic alopecia.  If there is no miniaturization, the diagnosis is wrong, and there is another reason for hair loss.

The Inheritance of Androgenetic Alopecia: Father’s Father ... Mother’s Father ... or Father’s Mother?

Androgenetic alopecia is common in the general population. In fact, the condition is often called “common balding”.  Approximately 50-60 % of men and 30-40 % of women will develop androgenetic alopecia by the age of 50.  

When I meet with patients, I generally ask about the hair characteristics of his or her mother and father.  I try to get a sense of his or her parent’s hair density and the age at which the parents started losing hair.   Although men and women with androgenetic alopecia often have a family history of androgenetic alopecia, it’s not absolutely necessary for the diagnosis.   In fact, a family history is least likely to be found in women diagnosed with androgenetic alopecia.  This is because the inheritance of androgenetic alopecia is much more complicated in women than in men.

There are many myths when it comes to hair loss and patients are often surprised to hear me say that the chance to inherit hair loss comes from both sides of the family tree.  Upon hearing this I commonly hear patients reply:

I thought hair loss came from the mother’s father?

or ... I thought hair loss came from the father’s mother?

or ... I thought hair loss came from the father’s father?

The main message is that hair loss is inherited from both mother and father and their respective sides of the family tree.  It’s possible for children to have high hair densities in adulthood even if dad has androgenetic alopecia.  Furthermore, it’s possible (albeit uncommon) for children to have significant androgenetic alopecia when dad or mom have minimal hair loss in adulthood.