The Hair Loss Guide for men pt.1

INTRODUCTION

“Bald men make great lovers”, “bald men have more testosterone”, “bald men are more dominant”, “bald is sexy!” – those are some of the many stereotypes about balding men that we have all heard a thousand times. But how much truth to them is there really? Unfortunately, in most cases, not a whole lot, as we are going to explain in this article, taking a deep dive into the scientific literature, the causes, and, most importantly, the treatments of one of the most common cosmetic problems that men face.

Why is male pattern baldness most likely a problem for you?

Humans have been preoccupied with hair and the lack of it for centuries and this should come as no surprise – scalp hair plays a crucial role in framing arguably the most expressive and informative part of the body, the face. It provides us, due to its malleability, with another gift as well – the possibility to vary our appearance starkly with a simple change of hairstyle or hair color. Thus, it serves as a multifaceted social signal, providing a clue about health, age, ethnicity and social identity. On the contrary, baldness has been historically seen as a symbol of diminishing virility, old age and death. Symbolism that is most apparent in a religious context, where a shaved head denotes celibacy and dedication to God. And yet, in the modern World , baldness is mostly imposed by nature in the form of male pattern baldness a.k.a. Androgenic alopecia. In the section that follows we are going to summarize the empirical evidence of the psycho-social implications of MPB.

A study by Cash[1] makes for a good start. The portraits of 36 men, 18 with a full head of hair and 18 with aggressive hair loss, were precisely matched on several variables such as age and race. 108 university employees, half of which women, were used as raters, who were asked to assess the portraits in 6 dimensions – self-assertiveness, social attractiveness, intelligence, life success, personal likeability and physical attractiveness. The balding men were perceived as less self-assertive, less physically attractive, less socially attractive and as less likely to be successful in life. On top of that, they were rated as 2-3 older than their actual age. Cash concluded “most, albeit not all, of the deleterious social perceptual effects of MPB are mediated by its diminution of the aesthetic appeal of balding men”.

Another gloomy conclusion was reached by Muscarella and Cunningham[2] in a study with 6 males who were photographed in three conditions – full head of hair, receding hairline and bald. The subjects were rated by 204 male and female students. The results should come as no surprise to you – the lack of hair increased perceived age by as much as 9 years and significantly reduced ratings of aggressiveness and sexual attractiveness. 

Okay, this is enough bad news. By now we all understand how important hair is and it’s time to briefly go over the causes of hair loss so that we can end on a high note when we provide with you the most effective, evidence-based methods to combat MPB.

Why do we lose hair?

A first important distinction should be made here – physiologically, people lose up to 120 hairs a day and that’s not only normal, but required so that new, fresh strands can sprout on their place. So finding some on your pillow, in the shower or on your brush does not necessarily indicate that you’re going bald. But more on that later, let’s turn our attention back to the culprit(s).

  • Androgens

Endogenous androgens are steroid hormones, produced naturally in the body, that control the development and maintenance of male characteristics by binding to the androgen receptor (AR). The major example and main player in the male body is testosterone (T), with androstenedione and dihydrotestosterone (DHT), having a big importance as well. DHT is quintessential for the masculinization that occurs during puberty and, unfortunately, hair loss. It is produced by a family of enzymes, called 5-alpha-reductases, that we are going to discuss in the next section. DHT loves the androgen receptor. A lot. Three times more than testosterone. Because of that it also has the most deleterious effect on scalp hair, causing it to miniaturize through a cascade of events that is neither fully understood, nor of any practical meaning to most of us.

It is important to note that, theoretically, every androgen can trigger this cascade and this should be kept in mind when it comes to choosing therapeutic substances and the reasoning behind that choice. 

  • 5-alpha-reductase (2) – the main accomplice

As mentioned earlier, the three forms of 5-alpha-reductase, namely 5-αR-1, 5-αR-2, αR-3, catalyze the conversion of testosterone to the more potent dihydrotestosterone. Thus, they are one of the keys behind the pathogenesis of hair loss. The most important form in the context of MPB is 5-αR-2, because it is the main one found in hair follicles, followed by 5-αR-1. The same two subtypes are targeted by a class of drugs called 5-alpha-reductase inhibitors, the most popular example of which is finasteride (brand name Propecia). 

  • Everything else

There are many more molecules and pathways implicated in MPB with varying degrees of importance. Unfortunately, most are not of any particular interest for the average guy. Two worth mentioning are prostaglandins – PGD2 and PGE2. They act in a ying and yang manner, having opposing effects on hair growth, with PGD2 being the bad guy and PGE2 the good one. Prostaglandin D2 is thought to exert its deleterious effects on hair growth by binding to the GPR44 receptor.

How is male pattern baldness diagnosed?

Most of the time MPB is most often diagnosed based on clinical presentation, with the hallmark of pattern hair loss being the phenomenon known as “miniaturization”.  The typical progression starts with hairline recession in the temple region, during which one loses their “juvenile hairline” (rounded hairline, visible in females, children and adolescents) and gets a more M-shaped one. With more aggressive loss the temple recession might creep further back and, subsequently, the vertex starts to thin as well, although some people might experience thinning on their crowns while having a strong hairline. The Norwood scale has been established as a general visual guide, used by doctors for grading pattern baldness.  A practical method for monitoring and detailed evaluation is trichoscopy, which is most often performed by dermatologists or hair surgeons.

A picture-based analysis of your current hair status is included in our facial reports.

What are the therapeutic possibilities?

Okay, enough bad news and dry theory, let’s get to the actionable advice. Having gotten to know the mechanisms of male pattern baldness, you might already have some ideas in mind on how one might go about treating it. We are going to divide the treatments into two big categories – medications and surgical procedures.

1.1. 5-alpha-reductase inhibitors

                    Probably the most popular class of drugs when it comes to hair loss, consisting of the FDA approved finasteride (aka Propecia) and Dutasteride, which is commonly prescribed off-label. Their mechanism of action is rather simple – blocking the 5-alpha-reductase enzymes and thus preventing them from converting testosterone to the more powerful DHT. They have proven effectiveness  – finasteride provides an increase in hair count of around 30% long-term and dutasteride has been shown to be even more effective. The downside here is that these drugs should be taken indefinitely in order to maintain results.

1.2. Androgen receptor antagonists

                    Another important, and frankly under researched in the context of MPB, class of drugs are substances that directly compete with androgens for the androgen receptor, thus preventing androgens from triggering the cascade. There are two main classes of AR antagonists, namely the steroidal antiandrogens (SAAs) and non-steroidal antiandrogens (NSAAs). Generally, SAAs, e.g. Spironolactone, are out of the picture for men, because they have off-target hormonal activities and shut down gonadal production of hormones. NSAAs, on the other hand, have some therapeutic potential. The most popular of them is RU-58841, but since it has not been FDA approved, it’s a topic for another article. The same goes for CB-03-01, more commonly known as Breezula, which is currently undergoing trials, and Fluridil (Eucapil), a substance that is available OTC but lacks extensive data due to its hydrophobic structure.   

 1.3. Growth stimulants 

                     This is a broad category that comprises not only pharmaceuticals but also microneedling. The most important growth stimulator is undoubtedly Minoxidil. It is FDA approved and has proven itself time after time to be very efficacious[study] and virtually without side effects when applied topically.*It is available over the counter pretty much worldwide, is relatively cheap and easy to apply. It’s only weakness is that it doesn’t completely address the androgen-dependent pathway of balding and because of that results are often transient in the absence of an antiandrogen. This is the same reason why we don’t think it is suitable as a first line, standalone treatment, but more on that in part 2. 

*The suspicions of collagen degradation are going to be covered in part 2.

         

There are a lot of under-researched molecules that could work as growth stimulants as well like castor oil, valproic acid, peppermint and rosemary oil. Due to the lack of robust evidence, we have let them out of this article, but they are going to get included in an upcoming discussion on the topic.

2.1. Hair transplantation

As most of you might know, hair transplantation (HT) is a surgical technique that moves hair follicles from the back (occipital part) of the head, the so called donor zone, to the balding areas. The occipital hair follicles are generally considered to be more resistant to the deleterious effects of androgens, which makes them “permanent” when transferred to the recipient zone. HTs come with their own set of positives and negatives. For one, they are preferred by people who are averse to medication that impact their hormones. Another advantage is that a slick bald area can be returned to an almost pre-baldness state and such regrowth is rarely seen with the aforementioned substances. A commonly addressed concern with transplants is that they aren’t capable of achieving the natural density of the patient and thus rely on the “illusion of density”. This is especially true the bigger the covered area. Another downside is the cost, ranging anywhere from 3-8$ per graft, making the cost of the procedure skyrocket into the 5 figures. Hair transplantation is a very broad topic and worthy of an article of its own so we are not going to delve any deeper.

2.2. Microneedling

Another way to give your hair the much needed growth boost is microneedling. The basics are explained in our article on the topic, where we also provide you with evidence on the effectiveness of this rather novel treatment. Perhaps the biggest advantage of this method is the virtual absence of side effects when performed with attention to hygiene. It is just as easily accessible as Minoxidil and the two can mutually potentiate their effects, but it also shares the same weakness of not targeting the AR pathway.

Conclusion

Male pattern baldness could very well be the cause of a drop in your physical attractiveness as pointed out by many studies. Fortunately, modern medicine has provided us with several effective methods to combat the condition, getting the control back in our hands. In the upcoming part 2 we are going to discuss the side effects of the aforementioned therapeutic methods in more detail, as well as take a deeper dive into the more obscure and unorthodox substances that could be employed against MPB. 

1. Cash TF: Losing hair, losing points?: The effects of
male pattern baldness on social impression formation. J Applied Soc Psychol 1990;20:154–167.

2. Cash TF: The psychological consequences of androgenetic alopecia: A review of the research literature. Br J Dermatol 1999;141:398–405.

3. Muscarella F, Cunningham MR: The evolutionary
significance and social perception of male pattern
baldness and facial hair. Ethol Sociobiol 1996;17:
99–117.

4. Olsen EA, Whiting D, Bergfeld W, et al. A multicenter, randomized, placebo-controlled, double-blind clinical trial of a
novel formulation of 5% minoxidil topical foam versus placebo
in the treatment of androgenetic alopecia in men. J Am Acad
Dermatol. 2007;57:767–74.

5. Olsen EA, Hordinsky M, Whiting D, et al. The importance of
dual 5alpha-reductase inhibition in the treatment of male pattern
hair loss: results of a randomized placebo-controlled study of
dutasteride versus finasteride. J Am Acad Dermatol.
2006;55:1014–23.

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