Doctor Isaac Wong > Blog > Hair Loss > Hair Loss & Effective Medically-Proven Treatments (A money-saving hack from a doctor)

Hair Loss & Effective Medically-Proven Treatments (A money-saving hack from a doctor)

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Hair loss has always intrigued me. I’ve always been fascinated by the aesthetic impact of one’s hair, ever since I became an aesthetic doctor. Pursuing this specific passion in hair loss, I’ve spoken in hair loss conventions in places like Singapore as well as Jakarta, penned several articles pertaining to the topic of hair loss and how it is treated in a variety of health magazines.

To me, the most important aspect of this is the profound effects that hair loss can have on a person’s psychological health. It pains me when I see a patient come to me that has spent thousands of dollars on speculative and non-evidence based treatments. Many of these patients paint the same story; they wished that they had went to doctors who had actual training in preventing and managing hair loss and not those who offered treatments without any medical basis. Hence, I decided to pen this article to dispel all myths and misinformation surrounding hair loss once and for all!

Firstly, what is hair loss?

Hair loss is an extremely complex condition and cannot be summed up in one simple paragraph. Firstly, lets touch on how hair loss, especially male pattern hair loss (androgenetic alopecia) can be so potentially damaging to one’s mental health. The next part of this article will focus on the common factors that contribute to female hair loss and various ways to treat and manage it.

My training stint with Maxwell Hair Clinic of Seoul (one of the top 3 hair clinics in South Korea)


After a hair transplant masters course by the American Academy of Aesthetic Medicine (AAAM) taught by Dr Akaki Tsilosani of Georgia


My first hair loss public forum in 2012

Let me guide you in discerning the false treatments from the real ones and hopefully save you a lot of your precious time and money!

Why are hair loss treatments so immensely popular?

Hair loss is perhaps one of the most tough to deal with conditions as it can affect someone in both their medical health as well as their overall aesthetics. This means that both one’s psychological well-being and one’s social standing can be deeply affected by this (evidence can be found in the studies listed below). Many of the predatory non-medical entities that claim to be hair loss treatment experts prey on this particular fear in order to siphon away your hard earned money.

So, how do we spot these misleading advertisements? They usually tend to fall into a few easily identifiable patterns – usually having a famous celebrity endorsing their business (this will easily cost a hefty 5 to 6 figure sum!), with before-after photos that show the miraculous results they’ve achieved with the photos taken from multiple different angles. Finally, when you do look closer at the fine print, there will inevitably be a statement that says “no medical studies or evidence that point to these methods working except for evidence based medical treatments”.

I truly cannot back this point up any more strongly – we don’t visit a “sinseh” or “witch doctor” to treat medical conditions such as diabetes or hypertension, so why would we visit a non-medically trained person to treat our hair loss condition?

All I am saying is: choose your hair loss treatment personnel wisely.

Is it just a myth that hair loss can ruin us psychologically and socially?

In determining whether something is a myth or not, we should always look for scientific studies that either back up or dispute the hypothesis. These statements I’ve outlined below all have strong evidence backing them up:

  1. Men who suffer from Androgenetic Alopecia (Male Pattern Hair Loss) are 75% less confident, especially when interacting with the opposite sex1.
  2. Young men with hair loss have reported loss of self-esteem, introversion, and feeling unattractive to a higher degree than older men with hair loss1.
  3. Women are more likely, than men, to have a lowered quality of life2, and to restrict social contacts as a result of hair loss3.

Does it still seem to you that hair loss is a matter that should be trivialized?

It is a well known fact that women tend to place a higher premium on their physical appearance and attractiveness as compared to men. This is further exacerbated by the norms of our society which peg hairstyles as an essential part of a woman’s attractiveness. Any form of hair loss suffered by a woman is immediately paired with a drop in self-esteem as well as heightens their anxiety.

Natalie Portman with a crew cut vs long hair – who do you think is more feminine and attractive?

Just as alopecia can ruin one’s self-confidence, having one’s hair loss successfully treated can just as swiftly help one regain their self-confidence and self-worth. They begin to operate more confidently in their social lives and regain their footing in their social circles.

Androgenetic Alopecia (Male Pattern Hair Loss)

How is androgenetic alopecia caused and diagnosed?

Androgenetic alopecia, which many of us know as Male Pattern Hair Loss (MPHL) is currently the most common and widespread form of alopecia seen in males. Almost 70% of men will experience some form of MPHL in their lives. MPHL can start as early as one’s teens, which begins usually at the forehead and one’s frontal hairline. As the condition worsens, one’s hairline slowly begins to recede, followed by distinctive hair loss near the top of the head. Usually, the occipital scalp (the areas around the back of the head) are spared.

This condition is largely due to a man’s hormonal pathway. Testosterone (an androgenic hormone that is responsible for many of a man’s masculine features) is converted by the enzyme 5-Alpha Reductase into Dihydrotestosterone (DHT). DHT has a huge tendency (5 times stronger!) to bind with a man’s scalp receptors, which results in the effects of one’s hair thinning or falling out by the root. Hair grafts weakening (otherwise known as miniaturization) and eventual hair loss is an eventuality of this condition.

MPHL can be diagnosed clinically by a medical doctor’s examination, through a non-scarring typical hair loss pattern and no laboratory tests are actually necessary. Only in the event that the hair loss is random (not following any of the patterns as seen below) that a medical examination is required. Most doctors will use the Norwood-Hamilton classification in order to determine the type of hair loss.

So, how is male pattern hair loss treated?

MPHL cannot be treated overnight. It is an ongoing process that requires lots of long term dedication in order to manage. These treatments cannot be abruptly stopped as the hormonal process of MPHL does not stop as well (unless one day you decide that you no longer want any hair!). The first line defense against MPHL are the oral medications Finasteride and the topical (in spray form) Minoxidil.

Oral Finasteride (Propecia) is my recommended first-line treatment to tackle male pattern hair loss. It is said to be a treatment for any areas of the scalp outside of the temples. Finasteride tends to only provide minimal effectiveness when used around the temporal or anterior hairline regions 9. I would recommend that for patients who are suffering from hair loss around the temples and anterior hairline to opt for a hair transplant instead.

The recommended dosage for oral Finasteride should not exceed 1mg daily, either with or without food. Both total and anagen hair counts should both improve with this dosage7. Propecia is used to slow down and prevent further progression of alopecia, and generally 2/3rds of the users will notice some form of improvement8.  This treatment should be continued for at least 3-6 months where the effects becomes the most noticable, and around a year will be where the treatment effects peak. A very common mistake is to pause the medication as patients are discouraged due to the lack of effects after 1-2 months of treatment.

Finasteride can be responsible for a drop in libido, inability to ejaculate, gynocomastia (puffy nipples) in around 2% of users. However, these effects are largely temporary and recovery will happen once the medication is stopped. For a small number of patients, adverse sexual effects that are linked to the ingestion of Finasteride have been said to last up to 40 months past cessation of the medication, but these studies are still largely inconclusive and the jury is still out on whether or not Finasteride can cause long term sexual side effects10.

What about Dutasteride?

Dutasteride is a non-selective 5-AR inhibitor for hair growth and is highly dependent on the dosage14. It also has a larger propensity to cause side effects. Thus, this drug is seen mainly for off-label use.

What about Minoxidil (spray form)?

Minoxidil was intially proposed as a medication to target patients with high blood pressure but was eventually discontinued due to havinga  side effect for developing a significant level of hypertrichosis (excessive hair growth) when administered in higher dosages.

This is an FDA-approved treatment when it is used to treat Male Pattern Hair Loss. I would recommend the dosage of 1ml in order to be applied onto dry scalp and not touched for at least 4 hours. It is recommended that the lotion be rubbed gently into the scalp post-application.

Potential adverse side effects can include irritation of the skin, hypertrichosis (excessive hair growth) on the face and the hands, as well as tachycardia (irregular or sped up heartrate)11. Minoxidil treatment, when it is the sole treatment being used (most often recommended to paitents who suffer adverse side effects from Finasteride), may simply only slow down hair loss and will not trigger new hair growth.

This has caused many patients to label Minoxidil as “worthless” as they have only been using it alone after being convinced by flashy advertisements on various social media platforms. Here’s my tip: combine Minoxidil in the recommended dosages with Finasteride and other treatments in order to have the best visible hair thickening effects.

Besides all these oral/topical treatments, what is Low Level Laser Therapy (LLLT)?

Low Level Laser Therapy (LLLT) is another FDA approved treatment for MPHL as well as Female Pattern Hair Loss. LLLT was actually a chance discovery in the 1960s when a scientist accidentally irradiated mice with low fluence red lasers and noticed a distinct hair growth in them. Since that time, there has been more than 10 clinical studies published showing the effectiveness of LLLT in stimulating hair growth, the mechanisms being increasing metabolism and production of energy within the hair follicles as well as influencing more blood flow into the scalp whilst reducing inflammation 29-34. Specific wavelengths of lasers are used in this treatment, between 635-650nm 35. This results in far stronger and thicker hair roots which allow for renewed hair growth.

I recommend that patients opting for LLLT go for 20 minutes of treatment, up to 3 times per week.

The brands that are commonly seen in Singapore can include iGrow Hair Laser Helmet, HairMax Laser Comb and LaserBand. One important thing to note is that these medical grade LLLT devices are made available in Singapore only in medically certified clinics and not “hair growth spas”.

Hair transplant: a surgical option

Yes, hair transplants are for recreating hair density on one’s bald scalp (where there are no more follicles) as well as restoring an aesthetic proportion to the face (hence, the forehead will avoid looking larger than the rest of the face).

A hair transplant involves the manual extraction of hair follicles from the backs and sides of the head and transplanting it to the front of the head.

Hair transplants can be a good treatment to tackle:

  1. Male Pattern Hair Loss (especially early stage MPHL)
  2. Female Pattern Hair Loss
  3. Alopecia Areata (a more coin-shaped circular form of hair loss, and only once it has stabilized)
  4. Scarring Alopecia (referring to hair loss caused by external trauma like burns or surgery)

Hair follicles that are sensitive to DHT are located near the front of the scalp as well as the vertex while the androgen-independent hair follicles can be seen near the sides and the occipital region. This is the reason why even old men with advanced stages of hair loss generally still have hair around the U-shaped bend near the sides and the backs of their heads.

The main train of thought surrounding hair transplantation is centred around the fact that hair follicles that have been harvested from the occiptal (back of the head) scalp will retain this “androgen-indepdendent” behavior even after being transplanted to the front of the scalp. This interaction is known as “donor dominance”. Simply put, the hair follicles that are transplanted are resistant to the effects of DHT. Therefore, even though they are placed in the vulnerable areas, they will grow long and thick regardless.

This is not such a simple task: hair grafts that have been extracted from the donor areas have to be implanted specifically so that the direction and density of the hair appears to be natural. Hair transplant technology has advanced to the point that hair grafts can now be extracted from all sorts of areas: beard, chest, neck and even abdomen 20,21. Hair transplants can now be performed to a variety of areas that do not have scalp tissue, including even eyebrows22, eyelashes23+, moustache24, beard24, or even the pubic area25,26.

There is a medical condition known as Telogen Effluvium that can occur in the first 3 months after the operation to the newly transplanted hairs. This is when the transplanted hairs actually fall out within the first three months. These transplanted hairs will then re-grow after 3 months and achieve their peak results at around 18 months post surgery. Hence, I recommend all my patients to opt for their hair transplants at around 9 months before any important social events that might be coming up (e.g. graduation, marriage, etc).

Once you recreate the fronto-temporal hairline, the patient’s aesthetics is restored and their hairline is now lowered, restoring a youthful look to the patient’s face. The difference can be staggering and a successful hair transplant surgery can bring great satisfaction to both patient and doctor.

Hair transplants are performed under local anaesthesia and is considered to be a safe and effective treatment, which has resulted in it rising greatly in popularity over the last few years.

Me in action implanting the hair follicles using Choi Implanters


Me performing motorized FUE (follicular unit extraction)

What about topical growth factors, do they work?

There has been some buzz recently about cytokine and other growth factor serums which can be infused into the scalp. Common ones include SGF-57 and PDRN (extracted from Salmon DNA), with some smaller scale studies published about the efficacy of these treatments. SGF-57 treatments boast a 98.5% increase in overall hair density as well as a 9.11% increase in hair thickness as seen in patients who have MPHL 37. PDRN treatments do have some positive looking study results but is mainly used for female hair loss and I’ll definitely try to touch on this in a future article.

So, to sum it all up…

  1. Male Pattern Hair Loss (Androgenetic Alopecia) is a genetically-predisposed medical condition. Only visit medical doctors who have expertise in hair loss treamtents in order to manage this condition.
  2. The hormone that causes all this is is DiHydroTestosterone (DHT), which has the mechanism of miniaturizing hair follicles.
  3. Therapies with medical-basis for their efficacy include Finasteride (Propecia), Minoxidil spray, Low Level Laser Therapy (LLLT), Hair Transplants, SGF-57.

Got questions? Feel free to contact me through these various methods:

 

References

  1. Banka, Kristine Bunagen, Jerry Shapiro  Pattern hair Loss in men : Diagnosis and medical Treatment Dermatol Clin 31(2013) 129-140
  2. Cash TF, Price VH, Savin RC  Psychological effects of androgenetic alopecia on women : Comparisons with balding men and with female control subjects J Am Acad Dermatol 29:568-75
  3. Van Neste, Rushton  Hair Problems in Women Clincal Dermatol 1997;15:113-115
  4. Rajendrasingh J Rajput  Is there a role for adjuvants in the management of male pattern hair loss? J Cutan Aesthetic Surg. 2010 May-Aug; 3(2): 82-86
  5. McElwee, Jerry Shapiro Promising therapies for treating and/or preventing androgenic alopecia Skin Therapy Letter 2012;17(6)
  6. Drake L, Hordinsky M, Fiedler V, et al. The effects of finasteride on scalp skin and serum androgen lvels in men with androgenetic alopecia. J Am Acad Dermatol 1999;41:550-4
  7. Van Neste D, Fuh V, Sanchez-Pedreno P, et al. Finasteride increases anagen hair in men with androgenetic alopecia. Br J Dermatol 2000;143:804-810
  8. Kaufman KD, Olsen EA, Whiting D, et al. Finasteride in the treatment of men with androgenetic alopecia. Male Pattern Hair Loss Study Grop. J Am Dermatol 1998;39:578-89
  9. Leyden J, Dunlap F, Miller B et al. Finasteride in the treatment of men with frontal male pattern hair loss. J Am Acad Dermatol 1999;40”930-937
  10. Stough DB, Rao NA, Kaufman KD, et al. Finasteride improves male pattern hair loss in a randomized study in identical twins. Eur J Dermatol 2002;12:32-37
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  15. Hugo Perez BS. Ketoconazole as an adjunct to finasteride in the treatment of androgenetic alopecia in men. Med Hypotheses 2004;62:112-5
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  29. Eells JT, Wong-Riley MT, VerHoeve J, Henry M, Buchman EV, Kane MP, Gould LJ, Das R, Jett M, Hodgson BD, Margolis D, Whelan HT. Mitochondrial signal transduction in accelerated wound and retinal healing by near-infrared light therapy. Mitochondrion. 2004; 4(5–6):559–567. [PubMed: 16120414] 32. Chung H, Dai T, Sharma
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