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Male Pattern Baldness

Male pattern baldness affects over half of men to some extent over the age of 50, and most
men at some stage in their lives. Most affected men do not wish to have any treatment. If
required, treatment can usually prevent further hair loss, and often cause hair regrowth.

What is male pattern baldness?

Male pattern baldness is the common type of hair loss that develops in most men at some stage. The
condition is sometimes called androgenetic alopecia. It usually takes 15-25 years to go bald. However,
some men go bald in fewer than five years.

Typically, at first the hair begins to recede (thin) at the front. At the same time, the hair usually becomes thin
on the top of the head. A bald patch gradually develops in the middle of the scalp. The receding front, and
the bald patch on the top (the crown) gradually enlarge and join together.

A rim of hair is often left around the back and sides of the scalp. In some men, this rim of hair also thins
and goes to leave a completely bald scalp.

Who gets male pattern baldness?

Nearly all men have some baldness by the time they are in their 60s. However, the age the hair loss starts is
variable. About three in ten 30 year-olds, and half of 50 year-olds are quite bald. Some women also
develop a similar type of hair loss, mainly at the crown. Baldness in women is much more common after the
menopause. About 13 in a 100 women have some baldness before the menopause, rising to 75 in a 100
over the age of 65.

What causes male pattern baldness?

Hair is made in hair follicles which are like tiny pouches just under the skin surface. A hair normally grows
from each follicle for about three years. It is then shed, and a new hair grows from the follicle. This cycle of
hair growth, shedding, and new growth goes on throughout life. The following is thought to occur in men as
they gradually become bald:

Affected hair follicles on the scalp gradually become smaller than normal.
As the follicle shrinks, each new hair is thinner than the previous one.
Before falling out, each new hair grows for much less time than the normal three years or so.
Eventually, all that remains is a much smaller hair follicle and a thin stump of hair that does not
grow out to the skin surface.

Male hormones are involved in causing these changes. The level of testosterone, the main male hormone,
is normal in men with baldness. Hair follicles convert testosterone into another hormone called
dihydrotestosterone. For reasons that are not clear, affected hair follicles become more sensitive to
dihydrotestosterone, which causes the hair follicles to shrink. It is also not clear why different hair follicles
are affected at different times to make the balding process gradual.
The condition is genetic (hereditary); the location of the gene was identified in 2008.

It is also not clear why only scalp hairs are affected, and not other areas such as the beard or armpits.

Are there any complications from male pattern baldness?

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Although male pattern baldness is a common and harmless condition, it can be linked to heart disease. One
study compared 45 year old men who had baldness with men of the same age who had a full head of hair.
It found that men who had frontal hair loss at the crown were at a slightly increased risk of heart disease (an
extra nine for every 100 men with a full head of hair) whilst those who had severe hair loss at the crown had
a significant risk of heart disease (an extra 32 for every 100 men with a full head of hair). The risk for men
with hair loss at the crown is further increased if they have high cholesterol or a raised blood pressure.

Women with male pattern baldness should be checked for causes of raised male hormone levels, such as
polycystic ovary syndrome (a condition in which cysts develop in the ovaries).

What are the treatment options for male pattern baldness?

No treatment
To become gradually bald is a normal part of the ageing process for most men. No treatment is wanted or
needed by most affected men. For some men, baldness can be distressing, particularly if it is excessive or
occurs early in life. Treatment may then help.

Medication
Currently there are two medicines that help - finasteride (trade name Propecia®) and minoxidil (trade name
Regaine®). Neither is available on the NHS, so you need to pay the full price for them.

Finasteride was launched in the UK in 2002, although it has been available in the USA since 1997. It works
by blocking the conversion of testosterone to dihydrotestosterone. The hair follicles are then not affected
by this hormone, and can enlarge back to normal.
Some hair regrowth occurs in about 2 in 3 men who take a finasteride tablet each day. In about 1 in 3 men
there is no hair regrowth, but most do not have any further hair loss whilst taking finasteride. It has no effect
in about 1 in 100 men. So, if you take finasteride, you have a good chance that hair will regrow, or at least
stop any further hair loss.
Some points about finasteride include the following.

It takes about four months for any effect to be noticed, and up to 1-2 years for full hair growth.
The balding process returns if treatment is stopped. Therefore, if successful, you need to carry
on treatment to maintain the effect.
Side-effects are uncommon. The most common is that about 2 in 100 treated men report loss of
sex drive (libido).
It does not work in women with male pattern baldness.
It is expensive, costing around £34 per month (June 2010). You need a private prescription to get
it from a pharmacy.

Minoxidil lotion is a rub-on treatment that you can buy at pharmacies without a prescription. It is not clear
how it works. The higher-strength solution (5%) is more effective than the 2% strength.
There is debate as to how effective it is. Probably about half of men who use minoxidil delay further
balding. About 15 in 100 users have good hair regrowth. There is continued hair loss in about a third of
users. However, some reports claim much higher success rates. It seems that it is best used to prevent
further hair loss, but hair regrowth occurs in some users.
Some points about minoxidil include the following.

It needs to be rubbed on the scalp every day.

It usually takes four months or more for any effect to be noticed.
Treatment needs to be continued indefinitely. Any new hair that does regrow falls out two months
after treatment is stopped.
It is quite expensive.
It may work in some women who have male pattern baldness.
Side-effects are uncommon. For example, skin irritation or a rash sometimes occurs.
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Wigs
A wig is the traditional option for baldness.

Scalp surgery
Techniques such as hair transplantation, scalp flaps, and other procedures have been used for a number of
years. Success rates vary and a specialist opinion is needed if surgery is considered. It is expensive and
not available on the NHS.

Further reading & references

Lotufo PA, Chae CU, Ajani UA, et al; Male pattern baldness and coronary heart disease: the Physicians' Health Study. Arch Intern
Med. 2000 Jan 24;160(2):165-71.
Fenstein RP, Androgenetic Alopecia, Medscape, Mar 2012
Stough D, Stenn K, Haber R, et al; Psychological effect, pathophysiology, and management of androgenetic alopecia in Mayo
Clin Proc. 2005 Oct;80(10):1316-22.

Original Author: Dr Tim Kenny Current Version: Dr Laurence Knott

Last Checked: 27/07/2010 Document ID: 4501 Version: 38 © EMIS

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