One of the main difficulties facing physicians treating male and female pattern alopecia is that hair loss can progress at an unpredictable rate. Patients with mild hair loss today may have severe hair loss in the future. Physicians need to be careful to transplant hair in a pattern that will look natural not only today but also if the hair loss progresses and recedes away from the transplanted area. Areas of thinning that improved when transplanted hair was added to native hair may become thin again in the future as native hair is lost. Patients need to be educated about the possibility of needing more work in the event of progression. Physicians also have to leave enough donor hair in reserve to treat any possible progression.
The donor’s safer zone can change with age, therefore, grafts extracted on a 26-year-old may be at risk when he is 36 years old. A hair loss prevention regime is commonly recommended to stabilise future loss
Adjunctive Medical Treatment There is currently two FDA-approved medical treatments for hair loss, minoxidil (Rogaine®), and finasteride (Propecia®). In order to obtain maximum density now and in the future it is important to use adjunctive medical therapy to preserve existing native hair. Medical therapy may bring back some lost native hair but just as important is slowing down or stopping future loss. The use of medical therapy can affect surgical planning in a number of ways. On occasion, the response is so good that patients decide they don’t need surgery. On other occasions, it improves the situation so a smaller less aggressive procedure is needed. Even if medical therapy is only minimally effective a small amount of regrowth can significantly improve the appearance of density in transplanted areas.
Minoxidil (Rogaine®) is a topical application approved for both men and women. It is available in two strengths which are 2% and 5%. It has been shown to either reduce hair loss or promote hair growth in about 80% of patients. Personal experience by me, and others, suggest that approximately 50% of men have their hair loss slowed, 35% continue to lose hair (i.e. no effect), and approximately 15% show some signs of regrowth. In men, 5% minoxidil has been shown to be more effective than 2%, demonstrating a dose-dependent response. 12, 13 It appears that minoxidil acts as a direct anagen-prolonging agent. A big problem with the use of minoxidil is compliance. The original product was oily and messy and the propylene glycol additive could cause irritation in patients. Recently a new 5% foam delivery system has been released without any propylene glycol. It is much easier to use and better accepted by patients.
Finasteride (PropeciaÒ) is a 1mg oral tablet taken daily that acts as a potent 5µ-reductase type-2 inhibitor. It blocks the conversion of testosterone to Di Hydro Testosterone and decreases levels of DHT by about 65 percent. It has shown impressive effects in both blocking further hair loss, as well as producing re-growth. The effects are greatest on the crown however it has some beneficial effect on the frontal area also. Five-year results showed that by hair-count, 65% of men stabilised or improved.14, 15 There is concern that the efficacy of Finasteride may wear off with time. However, we have patients who have been on Finasteride for over 10 years with continued effects. We still don’t know what percentage of patients will continue to respond long term. Finasteride is not approved for use in women and a study by Merk on post-menopausal women over the age of 50 did not show any benefit. There are a few small independent studies and anecdotal reports that suggest Finasteride may have some beneficial effects in younger women. However, the use of Finasteride is contraindicated in women of the child-bearing potential because of possible birth abnormalities that could occur to the fetus of pregnant women taking Finasteride.
In men, Finasteride has a very low side effect profile. The most common concerns are sexual side effects, gynecomastia, and decreased sperm count. Even though the incidence of sexual side effects was low (1.8 percent with Finasteride compared to 1.6 percent in placebo) and reversible when stopped, it is still unsettling to a few men.
Dutasteride (Avodart®) is a new 5µ-reductase inhibitor that blocks both type 1 and 2 versions of the enzyme. It decreases levels of DHT greater than 90 percent and is felt to be more effective than Propecia. However, it has a very long half-life and the side effect profile is thought to be worse than that of Finasteride. It is not released for the treatment of male pattern baldness yet some hair transplant clinics use it off-label on patients that are not responsive to Propecia with warning about the potential side effect.
