Undisturbed, each terminal scalp hair usually grows continuously for about approximately
three to five years. Then, the hair transitions into a resting state where the visible portion
above the skin is shed. No hair grows from the follicle for 90 days. Once this time has
passed, a new hair begins growing through the skin and continues for another three to five
years at a rate of approximately 1/2 inch per month.
Hamilton-Norwood Hair Loss Scale
For those concerned about hair loss, many myths and half-truths abound, but useful
information can be difficult to obtain. Therefore, an objective overview of pattern hair loss is
In healthy well-nourished individuals of both genders, the most common form of hair loss is
androgenetic alopecia (AGA), also known as pattern hair loss. The disorder affects
approximately 40 million American men. Perhaps surprisingly, the same disorder affects
about 20 million American women. The difference between men and women is that a
woman suffering hair loss usually retains her feminine hairline and experiences thinning
behind this leading edge. In men, a distinct "pattern" of loss manifests where the frontal
edge recedes at the same time that a thinning zone expands from the posterior crown. In
more pronounced cases, these zones meet and the person is said to be clinically bald.
Importantly, three things need to occur in order for one to be affected by AGA. First, one
must inherit the genetic predisposition. This means that the problem comes from one or
both sides of the family. Second, one needs to attain a certain age. Nine year old children
do not experience pattern hair loss. And third, one needs to have the circulating hormones
that precipitate onset and progression of the disorder.
Typically, the earliest onset of AGA occurs in late puberty or one's early 20's. As a general
rule, the earlier hair loss begins, the more pronounced it is likely to become.
Hormones, Enzymes & Other Factors
Crystallography of DHT molecule
From a susceptibility standpoint, the principle hormonal trigger linked to pattern hair loss is
5-alpha dihydrotestosterone, commonly referred to as DHT. Intriguingly, it has been shown
that in persons genetically insensitive to DHT, pattern hair loss does not occur. DHT is
synthesized from the androgen hormone testosterone and is useful early in life and during
In adults, DHT is thought to cause significant harm, but very little good. Disorders as
disparate as benign prostatic hyperplasia and pattern hair loss are both triggered by DHT.
The synthesis of DHT occurs via two closely related forms of the enzyme 5-alpha reductase.
Hair loss treatment options that efficiently interfere with the interaction between 5-alpha
reductase and androgen hormones like testosterone have been shown to offer clinical
benefit in treating pattern hair loss.
Because hair growth is regulated by multiple genes and attendant biochemical pathways,
the underlying factors are extremely complex. Another challenge to understanding hair loss
has been the fact that humans, alone among mammals, suffer from androgenetic alopecia.
Thus, no efficient animal model exists that would otherwise tend to shed light upon the key
factors at work.
Hair Loss Variations Other Than AGA
In either gender, the differential diagnosis is typically made based on the patient's history
and clinical presentation. The common differentials for AGA include alopecia areata (AA),
Trichotillomania, and telogen effluvium. Less often, the cause of hair loss may be associated
with disorders such as lupus erythematosis, scabies or other skin manifesting disease
processes. Scalp biopsy and lab assay may be useful in ascertaining a definitive diagnosis,
but, in such cases, should generally only follow an initial clinical evaluation by a qualified
Pattern Hair Loss Treatment Options
It has wryly been observed that the choices for dealing with hair loss are "rugs, plugs, or
drugs". This quip articulates three treatment options that are more kindly referred to as
non-surgical hair systems, surgical hair restoration, and pharmacotherapy. A fourth option
has recently evolved, which will also be touched on herein. This is non-drug based therapy.
Typical Hair Piece
Hair replacement systems have been in regular use at least since the time of ancient Egypt.
These products also go by the term hair integration systems, wigs, weaves, hair pieces,
toupees and many other names. All have one thing in common---they are not growing out
of one's scalp. Thus, they must somehow be attached either with the bald skin or the fringe
of hair remaining above the ears and in the back of the scalp.
Such attachment to the living scalp is almost never permanent, and for good reason. Aside
from the fact that the unit itself wears out, basic hygiene dictates that the wearer regularly
remove the unit to clean the underlying hair and scalp. There are almost always three basic
elements to a hair replacement system. The first is the hair itself which may be synthetic,
natural, or a combination thereof. The second element is the base of the unit. Typically, the
hair is woven in to a fabric-like base which is then attached in some fashion to the scalp.
This brings up the third element; which is the means of attachment. Methods include sewing
the base to the fringe hair, gluing the base to the fringe hair, or gluing the base to the bald
Potential advantages to hair systems include the immediacy of achieving a full hair "look"
that can appear, to the casual observer, to approximate a full head of hair. The potential
disadvantages of hair systems are many and varied.
In persons who are actively losing hair, vs. those who are essentially bald, the hair system
itself may rapidly accelerate the process of going bald. Another disadvantage is the hard
leading edge that can give away the fact that a person is wearing a hair system. In the
past, this problem has been addressed by using delicate lace front artificial hairlines that
look quite natural but tend to be extremely fragile.
Because they are nonliving, hair systems must be serviced and eventually replaced
themselves. The costs of servicing and maintaining a hair replacement system are not
insubstantial--and such costs can dramatically exceed the initial price of acquisition.
Surgical Hair Restoration
Surgical hair restoration, commonly known as hair transplantation, exploits a phenomenon
first described in the 1950's. This phenomenon, donor dependence refers to the observation
that hair bearing tissue, when relocated to a previously balding area of the same person's
scalp, continues to produce viable, vigorously hair that persists in its new location as it
otherwise would, had it not been "relocated". In appropriately selected patients, surgical
hair restoration can constitute a positive solution to pattern hair loss.
There are important caveats to hair transplantation. The first concerns supply and demand.
At the present time, one may not transplant hair from one person to another without
causing a florid and destructive foreign body response in the recipient. Thus, both operator
and patient are relegated to whatever permanent hair bearing tissue is in place.
Accordingly, it is highly important to conserve and strategically place this precious resource
The second major caveat to hair transplantation concerns achieving clinically beneficial
endpoint results. A hair line that is spotty or too abrupt may look worse than it did before it
was restored. By the same token, hair behind the leading edge that is not restored in a
fashion that yields meaningful density (e.g. 1 hair per mm/sq) often fails to approximate a
full head of hair. Therefore, in selecting a transplant surgeon, artistic excellence is at least
equal in importance to basic surgical skill.
The third caveat to hair transplantation refers to a problem known as chasing a receding
hair line. Because hair loss is progressive and relentless, it is possible that donor hair
restored integrated into an apparently intact area of scalp hair may end up as an island of
hair because the hair behind it continues to erode. In this situation, patients are compelled
to augment hair behind the restoration zone in order to retain a full appearance. This works
reasonably well until either the hair stops thinning or one eventually runs out of donor hair.
Ideally, for persons undergoing transplant surgery, it would be helpful to incorporate a
treatment option that safely and effectively arrested the progression of hair loss, allowing
the treating surgeon to fill in the thin areas without the concern of chasing a receding hair
Minoxidil, first sold under the trade-name Rogaine(TM) was initially developed as the oral
antihypertensive drug, Loniten(TM). In some patients who used minoxidil to treat blood
pressure problems, it was observed that unusual hair growth occurred on the face and
scalp. This was somewhat colloquially referred to as the werewolf affect. >From this
observation, topical compositions containing minoxidil were successfully tested on balding
scalps. Rogaine(TM) (2% minoxidil) was the first hair loss treatment drug approved by the
FDA for use in men. Eventually, Rogaine(TM) (2% minoxidil) was approved for use in
women. Extra Strength Rogaine(TM) (5% minoxidil) was approved by the FDA for use solely
The advantages of Rogaine(TM) include the ability to arrest, and possibly reverse, pattern
hair loss. Based on Pfizer's own marketing materials, Rogaine(TM) has primarily been shown
to be effective in treating hair loss in the vertex and posterior scalp, but not the anterior
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