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Diagnosis & Treatment

Diagnosis

The pattern of male pattern baldness is quite characteristic in men, but the diagnosis may be more difficult to make in women. A positive family history, if present, may help. If necessary, the diagnosis can be confirmed by determining the anagen:telogen (A:T) ratio.

The A:T ratio is normally at least 4: 1, but in male pattern baldness, it is reduced in the areas that are affected by it. The presence of telogen hairs of different diameters also suggests male pattern baldness.

Treatment

Treatment is not necessary if male pattern baldness is mild and the person is not distressed by it. But the following treatments are available:

Minoxidil

Minoxidil is a drug used for the treatment of severehypertension (high blood pressure). One of its side effects is increased hair growth, often in unwanted places. However, its potential as a hair growth restore-r largely went unrecognized until Dr Anthony R. Zappacosta, an American cardiologist, reported in the New England]ournal of Medicine that one of his patients, a bald man of 38, had experienced hair re-growth after treatment with minoxicil. Soon, dermatologists were dissolving minoxidil and applying the lotion on bald scalps.

Upjohn Company, the manufacturer of minoxidil, also started its own trials on minoxidil. Initial studies were conducted on stumped tail macaque monkeys who also developed male pattern baldness during adolescence. The results were impressive; the animals started to grow new hair.

Subsequently, trials in human were conducted in several centers throughout the world. These more or less confirmed that 2% minoxidil lotion helps some cases of male pattern baldness affecting the crown.
However, the following points need to be emphasized about minoxidil:

1. Minoxidil lotion only helps male pattern baldness affecting the crown. It does not seem to help the receding hairline.

2. Not all patients respond to minoxidil lotion. The commonly quoted figure is 20_SO% cosmetically acceptable improvement. The term "cosmetically acceptable" means a satisfactory improvement in appearance, not complete re-growth. In my experience, minoxidil does not produce complete re-growth. Some patients show dense re-growth, but this is rare and occurs in less than 10% of cases.

3. Minoxidil works better in men below the age of 40 if the baldness is less than 10 years old, if the bald patch is less than 10 centimeters in diameter, or if there are more than 100 indeterminate hairs in a 2.S_centimetre diameter area in the centre of the bald area.

4. The minoxidil lotion has to be used for at least. four months before signs of re-growth become visible. Perseverance is necessary during this period.

5. Maximum re-growth is seen at eight to 10 months, after which there is little improvement.

6. Once regrowth is achieved, minoxidil must be continued or the re-grown hair will start to fall out. Minoxidil is expensive and the cost of treatment is considerable.

Minoxidil is no miracle drug, but it is the best treatment available for male pattern baldness. It is up to you to decide whether it is worth spending your money on it, keeping in view the above considerations.
Some studies have suggested that although minoxidil does not induce regrowth in some patients, it does appear to prevent further loss as long as it is used regularly. Minoxidil may therefore have a prophylactic (preventive) action against baldness. Again, the problem is cost.

However, minoxidil lotion appears to be safe to use on people with a normal heart. Systemic side effects such as lowered blood pressure and palpitations are uncommon because very little minoxidil is absorbed through the skin. Still, patients on it should have their blood pressure checked regularly.

Minoxidil should also not be used on scalps that are damaged by eczema or cuts because of the possibility of increased absorption through the damaged skin. Minor side effects such as itching, prickling and dryness of the skin and skin allergy may sometimes occur.

Minoxidil promotes hair growth by prolonging anagen (the growth stage). There are two possible mechanisms of action. Minoxidil reduces blood pressure by causing the blood vessels to dilate, and it has been suggested that the dilation of the small blood vessels in the papilla of the hair follicle stimulates hair growth.

Interestingly, another anti-hypertensive drug, diazozide, reduces blood pressure in the same way and also causes increased hair growth as a side effect. This theory presumes that male pattern baldness is partly due to a reduction of blood flow to the papilla, but this is unlikely because grafts of hair-bearing skin transplanted onto the bald areas do not start to lose hair, which it should do if the blood supply to the papilla is the determining factor.

The second mechanism is a direct stimulation of hair follicle cell growth. Experiments have confirmed that minoxidil can stimulate the division and prolong the survival of these cells. This, I feel, is the most likely mechanism.

Most of the published studies on minoxidil have involved men and the question on many people's minds has been: "Does minoxidil help male pattern baldness in women?"

Theoretically, at least, minoxidil should work but the question is how well. Unfortunately, this question cannot be answered at the moment because there is very little published data on the use of minoxidil in women with male pattern baldness.

There has also been a recent report that treatment with low concentration minoxidil and tretinoin is even more effective.

Tretinoin is a vitamin-A derivative originally developed for the treatment of acne (pimples). It is known to stimulate the division of epithelial cells and also promotes the formation of new blood vessels in the skin.
Tretinoin has aroused great interest recently because it was reported to delay skin ageing and reverse early wrinkles. There has been a report by Dr Gail Bazzano and her colleagues in New Orleans which suggests that tretinoin lotion also stimulates hair growth. The investigators treated patients with 0.5% minoxidil, 0.025% tretinoin, a combination of both drugs, and placebo (dummy drug). No hair growth was observed with minoxidil (however, note that this is lower than the 2 % concentration recommended for male pattern baldness) or placebo, but 58% of the patients treated with tretinoin showed signs of re-growth.

Re-growth was even more impressive with the combination of minoxidil and tretinoin-66% responded positively. This study suggests that tretinoin has potential as a hair-growth restorer and is particularly effective when combined with a low concentration of minoxidil. This is certainly interesting but needs further confirmation.

Cyclical anti-androgen therapy

Oestrogen, you may remember, protects against male pattern baldness whereas androgens encourage it. It has been combined with anti-androgens to block the effects of androgens on the hair follicle to treat male pattern baldness.

The anti-acne drug, Diane, combines ethinyl oestradiol (an oestrogen) with cyproterone acetate (an anti-androgen) and has been reported to induce hair growth in some women With male pattern baldness. It cannot be used in men because of the risk of feminization.

Some dermatologists feel that the dose of cyproterone acetate in Diane is too low and usually give patients an extra tablet of cyproterone acetate.

Steroid-oestrogen therapy

This involves the use of a steroid like prednisolone and an oestrogen. Prednisolone suppresses the production of androgens by the adrenal glands and oestrogen counteracts the effects of androgens on the hair follicle. This form of treatment has been reported to help some women. Unfortunately, it is also unsuitable for men because of the risk of feminization.

Topical (applied) oestrogen and progesterone

Oestrogen and progesterone are female sex hormones. Topical oestrogen works by inhibiting androgen production, but this may have undesirable effects in men.

Topical progesterone has been advocated on the basis that application to the pubic skin of normal males inhibited the conversion of testosterone to DHT (a potent androgen). It may retard the progression of male pattern baldness.

ToPical ant-androgens

Anti-androgens block the effect of androgens on the hair follicle. However, they cause feminization when taken orally. Topical (applied) anti-androgens have been used instead in men, but the results have not been encouraging.

One topical anti-androgen, 11 alpha-hydroxypro gesterone, has been reported to have an effect, but this was based on very fine measurements such as the diameter of the hair shaft rather than observable re-growth (which is important when dealing with a cosmetic problem). Nonetheless, this is a very promising area for research and it is possible that an effective topical anti-androgen will eventually be found.

Spironolactone

This is an oral drug used for treating water retention or oedema. It also has anti-androgenic properties and has been reported to help women with male pattern baldness.

However, spironolactone commonly causes menstrual irregularities in women if taken on its own. This can be avoided by taking a combined birth control pill during. the first 21 days of a 28_day menstrual cycle. Spironolactone cannot be used in men because it causes gynaecomastia (breast enlargement).

Cimetidine

This is an oral, anti-ulcer drug which also has anti_ androgenic properties. It has been reported to help a few women with male pattern baldness. However, cimetidine is also known to cause hair loss as a side effect. This seems strange for a drug that is supposed to help hair grow. Other side effects include diarrhoea, rashes and dizziness.

Cyclosporin

It suppresses the body's immune system and is used to prevent the rejection of transplanted organs. It promotes hair growth as a side effect and has been reported to induce re-growth in some patients with alopecia areata.

There has also been a report of a male patient re-growing hair while taking cyclosporin. It may work by directly stimulating hair follicle cell growth. Unfortunately, cyclosporin is rather toxic (especially to the kidneys) when taken orally, so doctors have tried to overcome this by applying it externally instead. Unfortunately, the results have been disappointing, probably because topical cyclosporin has difficulty penetrating the skin and cannot reach the follicles. Doctors are still trying out different formulations of topical cyclosporin to overcome this.

Diazozide

This is another drug used for treating hypertension. Like minoxidil, it too causes the blood vessels to dilate (thus lowering blood pressure) and hair growth as a side effect.

Trials are already in progress to determine the effectiveness of topical diazozide in the treatment of male pattern baldness. Its manufacturer, Schering USA, is rather tight lipped about the results and any information apart from the fact that trials were in progress could not be obtained. It remains to be seen whether topical diazozide will eventually prove to be effective.

Cosmetic therapy

This includes creative hair styles, wigs and surgery to disguise hair loss.

People suffering from hair loss often worry that frequent shampooing aggravates the loss. This is not true. Indeed, the reverse may be correct in male pattern baldness. Dr Ronald Rizer and colleagues at the New York University Medical Center have found that the scalp sebum contains androgens and claimed that these may re-enter the scalp and aggravate male pattern baldness if the scalp is not regularly shampooed.

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