Hair Restoration Blog

Q:

Hi Doctor,

My mother is obsessed with my hair loss and gives me a whole bunch of vitamins and mineral tablets everyday to help regrow my hair.
Do you think they work? Or should I stop them.

A:

Although lack of certain vitamins and minerals could cause hair loss in their sever form, living in north America and having a normal and balanced diet; it is unlikely that you are suffering from vitamin or mineral deficiency. On the contrary, if you look at your family pattern of hair loss, you probably can find other male members of the family who has similar male pattern hair loss. As I always say, you need to have the triangle of baldness, which is “Gene, Male gender, and time” to become bald. Vitamins deficiency is not to blame as part of triangle of male patterned hair loss. You can continue taking vitamins to please your mom, but don’t overdo it since vitamins are not going to bring your hair back. Instead you need to see a good hair specialist or dermatologist and undergo a good hair loss evaluation with miniaturization study and start taking one of the effective medications to prevent further hair loss or to use hair transplant to restore your lost hair.

Q:

I have heard high estrogen in males can contribute to hair loss. Is that true? I am a 40 year old man with low sex drive and female patterned hair loss.

A:

High levels of estrogen in men could be seen in many other conditions such as estrogen-producing tumors, congenital adrenal hyperplasia, chronic alcoholism and advanced liver disorders. Elevation of estrogen in men can cause sexual dysfunction, change in body fat distribution in a female pattern and breast enlargement and secretion.

Balding is not a typical sign of excess estrogen. In fact one of the signs of estrogen deficiency could be hair loss in female patients. A common type of this kind of hair loss is seen in telogen effluvium that women lose hair due to sudden drop of estrogen and progesterone levels. Although excess estrogen is generally not the trigger for hair loss, it can affect the balance of other hormones and indirectly cause hair loss. The latter is not a common cause of hair loss in men or women though.

Q:

Hi Doctor,

Some doctors prescribe Dutasteride (Avodart) for hair loss prevention. I know you do not recommend Dutasteride for hair loss for obvious reasons, but based on available research findings on this medication, what do you think are the most likely possible side effects from using Dutasteride if worse come to worse. Would it be like multitude of finasteride side effects? Again, I know your view of non-FDA approved drugs.

A:

Dutasteride (Avodart) is one of the selective inhibitors of the type I and II of the enzyme 5-alpha-reductase, the enzyme that converts the male hormone testosterone to 5-alpha-dihydroxytestosterone (DHT). In comparison with dutasteride, finasteride (Propecia) acts as an inhibitor of just type II of the enzyme 5-alpha-reductase, which is more specific. Studies around dutasteride mechanism of action shows that, blocking both type I and type II enzyme can be more potent that only one in reducing the levels of DHT in the body.

If you are taking dutasteride for other indications, you may get some hair growth as a good side effect. As you may guess cannot recommend dutasteride solely for prevention of male patterned hair loss; not until it is approved for hair loss treatment by FDA. Other than not being FDA approved my other reasons are:

1. The optimum dose of dutasteride for hair loss prevention is not determined.
2. The side effects of dutasteride are much more prominent comparing to finasteride.  That include the negative effect of the medication on sex drive in men.
3. If you are considering the cost effectiveness of dutasteride, with new price reduction of finasteride that should not be in the picture any more.

Q:

How are you doing? All I have to say is TGIF.

I was doing a little bit research on hair loss, and I stumbled over retinoic acid. I read about it and have a basic understanding. Have you heard any claims that it could possible revive hair loss?

Have a great weekend!

A:

This is a good question. There are several claims on therapeutic effect of all-trans-retinoic acid (tretinoin) alone and in combination with 0.5% minoxidil for hair loss based on limited studies.

In one study the combination of tretinoin and minoxidil was used for 56 patients who had androgenic alopecia (male pattern baldness) and hair growth was followed. The growth of terminal hair was studied after one year of treating balding scalp with combination of topical tretinoin with 0.5% minoxidil. Increase in hair growth was reported in 58% of the patients who could complete the study.

Although tretinoin has been stated as a promoter of cell proliferation and vascular creation, which are both important in hair growth, there is still not enough scientific evidence from large studies to prove these effects. Also double blind studies on the efficiency and adverse effects of the product is lacking.

Q:

Dear Dr. Mohebi,

I hope all is well with you and the family. I wanted to see your opinion about something. Along with proscar, I use Murad shampoo (i dont know if you have heard of it) but it supposedly strengthens your hair and brings nourishment to the hair, therefore promoting hair regrowth. Remember how short my hair was when we first met, well now its relatively longer. Do you think i should keep it short for several reasons: easier to clean my scalp, exposure to vitamin d (sunlight). When my hair is long, I can see it shed, but when its really short it doesn’t seem that way. However, the downside to cutting my hair that short is that it will become pretty apparent that im experiencing hair loss. Thanks doc! take care!

A:

I hope you are doing well. Last time we met, we decided that you wait on doing a hair transplant procedure until your pattern of hair loss becomes more obvious. Here are the answer to your questions in the order you asked them:

• Murad shampoo has following active ingredients: Pomegranate extract, artemia extract, alpha hydroxy acids, phytantriol and Saw Palmetto. From all these only the last one or Saw Palmetto is proven for its anti hair loss properties through blocking DHT. However, the rate of penetration of this ingredient on deeper layers of skin where follicles reside is not completely clear. I don‚Äôt think it hurts to use it in general, but for someone like you who takes systemic form of DHT blockers (finasteride), I am not sure it can add anything in slowing your hair loss process.
• On whether or not keeping your hair short, it is up to you, you have to try them both and decide, long hair should not create any problem with cleaning hair. Do whatever you are more comfortable with. Neither of the two can affect the speed of your hair loss. If I wanted to choose, I would kept my hair long so layering can help covering the thin areas.
• Vitamin D could be absorbed from everywhere, especially in the sunny State of California.

Again, thanks for good questions,

Good Luck and have a great weekend
Dr. Mohebi

Toppik hair loss scam, does it really work? The fibers used by Toppik are made of the same material that hair shafts are made of and that is Keratin. The fibers of Toppik bond with hair and it’s nearly impossible with the naked eye to see that there is anything on your hair. It gives the appearance of fullness that you have a natural, thick looking head of hair. This is temporary because it does not grow hair but conceals it in the short term for a special meeting, date or party. Toppik is natural and safe and can eliminate the appearance of balding or thinning in only a certain group of patients.

The people who can get the most of Toppik are the ones who have hair with some degrees of miniaturization or thinning. If the hair is totally gone like in higher classes of baldness, Toppik does not help. Toppik needs some hair to be bond with to create the appearance of fullness.

Toppik - Scalp microscopic view

A scam is only realistic if you want to believe in it. We all know that hair loss is a bitter truth that affects many men. Men do anything to improve their appearance and hid their baldness. There are many methods that can help someone with hair loss to improve the appearance of his hair including hair transplant surgery and medical treatment for hair loss. Cosmetics like Toppik offer another way to deal with the hair loss problem.

Toppik for hair loss is a scam or not, does not really matter. The fact is that you should do whatever makes you feel better about yourself. Hair restoration is a proven treatment for psycho-social adverse effects of baldness. If you can use any other method such as Toppik to look better and feel better, why not trying it?

hey doctor!

As I read through forums and articles, people mention that propecia works better in conjunction with something else, such as rogaine for exmaple. At the moment, the vertex area of my scalp seems emptier than than the crown and minoxidil works well with the vertex. Do you recommend me go back on minoxidil for the vertex, or should I just focus on propecia?

Answer:
I generally prescribe finasteride to most of my patients who have significant miniaturization whether they are getting hair transplants or not. There are several studies on using Rogaine (minoxidil) and Propecia (finasteride) as single therapy and in combination with each other or with other medications.

Comparing minoxidil and finasteride for treatment of male pattern baldness clearly shows that treatment with only finasteride is more effective than treatment with only minoxidil. Combination of finasteride with minoxidil and with some other medications shows improved outcome, but the rate of improvement is not significant enough that I can convince myself to prescribe combination therapy to all my patients for the rest of their lives, considering difficulty of using topical minoxidil (topical spreading of medication twice a day on the balding area of scalp).

If you want to do everything possible to prevent or slow down further hair loss and maybe grow some, you can consider combination therapy, but remember when you start minoxidil you are committed to continue it for the rest of your life or until there are better alternatives.

I just received the last issue of the Hair Transplant Forum International, the Journal of International Society of Hair Restoration Surgery (ISHRS). Our article, Psychology of Hair Transplant‚ is published as the cover article on this issue of the journal. I also have a copy of the article in our hair loss library in our website. Here is the abstract:

Psychology of Hair Transplant

Parsa Mohebi, M.D., William Rassman, M.D.

Balding and its psychological impacts has been the subject of many studies in the past. The relationship between hair loss and stress is clear to all clinicians who practice in this field. Negative psychosocial impacts of hair loss in male patterned baldness and in women with generalized thinning have also been seen. Many of us (hair transplant surgeons) have seen the negative effects of hair loss on self esteem and self-image.

We know that hair loss impacts some men sex life and their stability with regard to career choices in men of different ages. Despite the solid evidences and published literature on psychological impact of hair loss, the corrective effect of medical and surgical hair restoration has never been studied. After observing the drastic changes in patient behavior and the high level of patient satisfaction in those who had hair transplant procedure, we were motivated to look into the psychological impact of hair restoration on different aspects of a patient’s life.

We came up with a series of criteria that could have been modified by having a hair restoration procedure; we used some indexes that were previously studied comparing bald and non bald men on different psychological variables. We initially performed a pilot study and asked patients about different aspects of their lives during their post op visits. We gave our patients open ended questionnaires and probed their psychological state after their hair restoration procedure was complete. Eventually we focused in on eight major criteria that have been reported and documented as variables associated with hair loss in the literature. We collected a subset of them in our pilot study. Included were questions on the general level of happiness, energy level, feeling of youthfulness, anxiety levels, self confidence, outlook on their future and impact on their sex life.

We have chosen the patients who had their first hair transplant surgery between one to three years from the time of our study, so they had seen the final result of their hair restoration procedure. We limited the study to male patients with male pattern baldness and the ones who had surgeries less than three years ago so they still had a fresh memory of the changes they experienced. Each patient had exclusively follicular unit transplants that reflected our standard of care for that period. We sent a questionnaire with a brief description on the nature of this scientific study. We did not collect any patient identifiers and the response was totally voluntary. We sent the two hundred questionnaires with stamped return envelope.

The response rate to our questionnaire was 37 (18%). Each patient was used as his own control since we asked about the changes that they experienced after surgery in comparison to those variables before the surgery. We used T-test to compare patient’s responses. Table 1 shows the mean and standard error in eight different criteria that were asked. Patients had significant improvements in all eight criteria regardless of their stage of baldness and their ages.

In another attempt to compare psychological changes that patients experienced in different stages of baldness, we divided patients into two groups: (1) those who had Norwood IV patterns or less and (2) the ones with Norwood V patterns and above. We observed the most significant difference in two categories, (a) sex life and (b) career experience. Patients with less balding had a greater impact on their sex life and career when compared to patients who had more advanced stages of hair loss. These changes were not age related.

Hair restoration surgery can affect many aspects of a patient’s life. Hair transplant can potentially reverse psycho-social problems associated with hair loss. The positive impact of hair restoration surgery is more visible among patients who suffer from those undesirable effects the most. In early stages of hair loss, patients may have more awareness of their condition and they might be more affected than men in the later stages of hair loss.

Patients who experienced hair loss at an early age while involved in an active social life were more prone to the negative side effects of balding. That could explain why younger people with hair loss appeared more benefited by hair restoration procedures. Also it could be assumed that hair loss can have a negative impact on a patient’s outlook which seems to reverse after receiving a hair restoration procedure which improved their outlook.

Low response rate from a blind mailing has always been a drawback in questionnaire studies. We received 37 out of 200 of the questionnaires that we sent out (response rate was 18.5%). Giving incentives to responders may be a good way of increasing the participation rate of any questionnaire studies. We presented the result of this study at the annual scientific meeting of ISHRS and have been contacted by many of our colleagues who expressed interest in collaborating in a larger scale study. We are currently trying to rise funding for repeating this study to optimize our response rate and the statistical value of the study.

If you have any questions on the content of this article you can contact US Hair Restoration office at Los Angeles through email at info@ushairrestoration or phone.

Question:

Dear Dr. Mohebi,

Dr., I had a question: say I would use proscar now and took it for a while, after how long based on studies is it possible to see adverse side effects, if any? The reason why I ask is because when I went and read the messages on the forums, I saw positive and negative feedbacks. One person used proscar for 7 years and saw nothing but great results. I would like to give it a shot and see if I am lucky, hopefully. Thank you! Have a great weekend,

Answer:
The side effects of finasteride (Propecia/Proscar) could be seen anytime from right after starting it to months after starting finasteride. If you read the articles on adverse effects of finasteride you can clearly see that there is a small difference between the rates of side effects from the people who took placebos to the ones taking finasteride.

Let’s face it; you are prescribing a drug to a patient telling him that it works through altering your male hormones. What do you think the chances are that the patient will have problems with his sex drive?

The good news is that the side effects of finasteride are few and the most problematic one (decreased sex drive) is only seen in one out of a hundred patients. The other good news is that even if you are in that one percent category and you decide to continue using finasteride anyway, after one year of using finasteride the rate of side effects decreases to about the rate that was shown in people who only took a placebo.

I saw an 18 year old patient today who was worried about the recession of his hairline. We mapped his scalp hair to analyze the degree of miniaturization using a digital microscope. Here are pictures from the microscopic of his donor hair (left) vs. very frontal hairline (right).

Healthy donor hair (left) vs. significant miniaturization in hairline (right)

You can see significant miniaturization in the frontal area. When we examined a few centimeters behind his frontal hairline the miniaturization rate dropped sharply to less than 20% which was consistent throughout the top and crown area of the scalp. The patient’s father lost his hair at an early age. Patient started taking finasteride a month before his visit with us and topical Rogaine about a week before this visit.

What we observed was the maturation of his hair line, which occurs between the ages of 16-25 in most men. Hair line maturation is when the hair line migrates 1 to 2 cm higher than its normal position as when we are child (kiddy hairline). It is more significant in the corners but could be seen in the midline too. As Caucasian men go through the maturation process, the hairline rises, but many non-Caucasian men never experience hair line maturation and the hairline stays flat and low.

The best way to distinguish the maturation of the hairline from the early stages of baldness is by comparing miniaturization in different scalp areas. If you are experiencing early hair loss, your miniaturization could be seen behind the first centimeter of the frontal hairline, but if the rate of miniaturization drops sharply it could indicate that the hair line is going through maturation and the hair loss may stop shortly after maturation is complete.

We stopped all anti hair loss medications that the patient recently started, and we recommended another miniaturization study in 6 months to a year to follow his hair loss progression.