Hair Loss

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Hair and Cosmetics

Who gets hair loss?

About 50% of men will have some hair loss by the age of 50. A smaller number of men will experience significant balding in their 20s and 30s and most people will have thinning of their hair as they age. About 30% of women will also experience hair loss; often in a different pattern to men.

What are the types of hair loss?

The most common type of hair loss in men is male pattern balding. This is also called Androgenic Alopecia. The pattern here is a receding hairline, thinning over the scalp and a bald patch on the back of the head.

Male pattern hair loss is caused by the effect of testosterone. In the scalp, testosterone is converted into a powerful form of testosterone called Dihydrotestosterone or DHT. DHT has the effect of slowing or stopping the growth of hairs on the top of the head but not the back of the head. Under a microscope, men affected by DHT will have miniature hairs; little wispy hairs rather than strong anchored hairs. After a while, they just disappear forever and bald scalp is left behind

There are other causes of hair loss that are also common.

Some people may experience hair loss due to extreme illness, stress, vitamin deficiencies, hormonal conditions, medications or skin conditions and this can be partial hair loss or total hair loss.

These causes are very common in female hair loss.

When the body is under stress in this way, the hair growth unit (called the follicular unit) goes into a ‘resting’ phase rather than an actively growing phase. In a way, it is like a ‘pause for a moment’ signal. With more hairs resting rather than growing, the appearance can be thin hair with a lot of shedding as old strong hairs fall out at the end of their cycle. If the underlying cause is reversed, the hair will grow back but if the underlying cause persists for years, the hair may not grow back; or at least not all of it.

In a special case, if the body has a sudden shock like pregnancy, surgery, severe illness or incredible emotional strain, the hairs can go into an abrupt resting phase. At first, this is not noticed. However, after a few months, new growth will push out the old hairs in one big synchronized move; this causes a massive shed of hair in a short time.

This is called a telogen effluvium and can be very distressing. Usually, the ‘shock’ can be traced to a surgery or event a few months ago and the fact that the shedding takes place means that the new hairs are growing strong and recovery will take place in 6 months. Under the magnifying glasses we can see brand new hairs growing. These women may be given medications to ensure good growth and it is still wise to see a doctor to look for any underlying issues which can be fixed up.

Chronic telogen effluvium is the long term version of a telogen effluvium. Some form of stress or illness causes the hair units to ‘rest’ rather than grow and there is a chronic higher level of shedding as the ‘growth’ cycle occasionally bursts into action to cause ongoing shedding and some hair thinning. Chronic telogen effluvium requires medical attention.

Your doctor will evaluate these conditions if necessary.

How does hair grow?

Hair growth occurs in a ‘growth cycle’ with about 70-80% of hairs actively growing, 15% or so ‘resting’ and the rest are in transition. Growth takes place in a bundle of hairs in the skin called a ‘follicular unit’. Each follicular unit can have one, two, three or more hairs with 2-3 being most common.

Anagen is the growth phase of a hair whereby a hair follicle will grow 1cm a month for between 3-7 years. At the end of Anagen, the hair follicle enters a transitional stage called Catagen before which the hair enters the shedding stage of Telogen.

It stays resting for 3-6 weeks before a new hair starts to grow and the old one is shed. The average person will shed 50-100 hairs per day. Blood supply, testosterone and healthy skin is essential to hair growth. Beard hair and body hair grow at slower rates.

What causes Male Pattern Baldness?

Male pattern baldness is caused by a mixture of genetics and testosterone. Testosterone is converted to DHT, a potent form of testosterone, by an enzyme called 5- alpha-reductase which is found in the scalp. Hairs on the top of the scalp are quite sensitive to DHT and tend to bald much earlier than hairs at the back of the head or beard which seem insensitive to DHT.

Under the influence of DHT, hairs miniaturise and do not grow to their full extent. This appears as hair loss however the hair unit still exists for a few years until it gives up entirely and will never produce a hair again.

Some studies show that patients with hair loss have higher levels of DHT compared with testosterone. DHT testing is not routinely advised however it may be undertaken in some men for monitoring of therapy (see finasteride)

Once a hair has lost 50% of its volume, it is usually not responsive to medical treatment and is not going to return to full volume. This is why hair loss should be treated early!

How can we measure Hair loss?

A folliscope is a kind of magnifying glass used to look at the hairs on the scalp to see what they look like close up. A folliscope will magnify the surface of the scalp and reveal miniaturised vs mature hairs. It provides 10x magnification.

How can we measure Hair loss?

Standardised photographs, just like a police mug shot, can be taken to document and monitor visible scalp; basically to see bald areas. Software is available to count the actual hairs per square centimeter to assist hair loss treatments.

Hair Loss Treatments

Finasteride

Finasteride is a medication which blocks the conversion of testosterone to DHT in the scalp to prevent hair loss. Studies have shown that 50-60% of men will experience more hair growth whilst taking Finasteride and only 10-15% will have less hair on it. Finasteride is absolutely essential in the total treatment of male pattern balding as it convincingly arrests further hair loss.

Once Finasteride is ceased, the hair that was preserved or regrown will minitiarise as if the drug was never used in the first place. It is considered a lifelong treatment for men who want to arrest or treat their baldness. Even though finasteride may not grow hair back, it is vital to stop further hair falling out so that a future hair transplant is more effective and technically easier.

Finasteride is sometimes used for hair loss in women. It is a less certain treatment, likely due to the less direct role of testosterone in female pattern hair loss. It must not be taken whilst pregnant as it can cause birth deformities. This medication is not safe during breastfeeding.

Finasteride is taken every other day at a dose of 1mg tablet. Finasteride stays in the scalp for 30 days and has a 72 hour half life and so less frequent dosing may be used.

Some people worry that finasteride will lower testosterone because it impacts DHT. Actually, because finasteride blocks the conversion of testosterone to DHT, there is a small increase in testosterone in the blood system.

Nonetheless, Potential side effects of finasteride include changes in sexual function such as erectile dysfunction, decreased libido and reduced sperm count and ejaculate however these are quite rare (1%) and tend to reverse on stopping the drug. They are more common in men who have existing reasons for testosterone related issues and at appropriately low doses (1mg every other day for hair loss) they are rare.

The Post Finasteride Syndrome

An important side effect is the rare but serious ‘Post Finasteride Syndrome’. DHT and testosterone more generally play an important role in the brain as regulatory hormones for mood, concentration and multiple other cognitive domains that are poorly understood.

A small but unfortunate group of men react very badly to finasteride, perhaps due to DHT blockade, and experience depression, mental fog and poor concentration. It is not clear if finasteride is the cause however any symptoms like this should prompt stopping the drug and consultation with your doctor.

Some men can also have male breast tissue or gynaecomastia on finasteride. This is likely due to an abrupt drop in DHT levels but usually involves other hormones factors such as potentially low testosterone and less liver clearing of other estrogens. It should be reviewed by a doctor and the dose of finasteride can be lowered to 0.5mg three times per week.

Some men will find that finasteride is not as effective as they like or has side effects; a small dose of a long-term version of finasteride called dutasteride may be given instead.

Ideally, all men have their DHT tested prior to treatment and again on treatment with the aim of titrating the finasteride dosing frequency to achieve 50% of DHT. This is to avoid side effects as much as possible based on a study observing that there is little hair loss prevention benefit beyond a reduction of 50% of DHT levels.

Practically, DHT blood testing is not always done however if men have side effects on finasteride, DHT blood testing might be helpful to find the right ‘dose’ for those men.

Another option for men who do not tolerate the finasteride tablet is finasteride in a lotion or cream for the scalp. As we will discuss later, using a lotion on the scalp on an ongoing basis is often quite difficult to do forever. Most patients prefer a tablet.

Summary on Finasteride

95% of men taking finasteride experienced no further hair loss in the first year however this will reduce to 75% over a few years of use.

70% of men experience increased hair growth; however this may be subtle

Studies suggest 24% increase in hair growth

Studies suggest increase in hair diameter in some men

Associated with 1% side effects that mostly resolve

DHT testing may be recommended to minimise the chance of side effects

Topical finasteride is not inferior to oral finasteride however there are less studies on this and topical application may be more bothersome

Minoxidil

Minoxidil is a medication used for hair loss in both men and women. Unlike finasteride, it does not directly target the testosterone pathway but is thought to support the anagen (growth) phase of hair growth by promoting blood flow and growth signals to the area.

Similar to Finasteride, the effects of minoxidil on the hair density of any given patient is variable. Studies suggest that finasteride has a slightly better result than minoxidil in increasing hair density however combined use of Minoxidil and Finasteride is superior to either therapy alone.

Finasteride is effective to arrest hair loss whilst Minoxidil has a more pronounced effect on hair regrowth in those patients who do respond. Minoxidil was originally a blood pressure tablet and is available in tablet or lotion forms. Most people only know Minoxidil as a lotion however it is the author’s preference to prescribe the tablet as it is easier to use, less cumbersome and does not stain your pillow cover at night.

Minoxidil tablet is dosed daily at 1.25mg, or a quarter of the 5mg tablet; increasingly, the 1mg tablet can be found. It should be taken at night as it may lower blood pressure in some people and cause dizziness. Minoxidil lotion is applied twice daily on the scalp either as a solution or a foam. The main side effect is redness and irritation of the skin which is thought to be less with the foam. Very little of the drug enters the body and the safety profile is generally excellent.

The most important side effect of minoxidil tablets is palpitations or a fast heart rate. If this happens, the tablet must be stopped. Similar to finasteride, pregnant women or women looking to have a baby must NOT take minoxidil. Birth control is strongly recommended if taking minoxidil. Minoxidil is not safe during breastfeeding either.

Summary of Minoxidil treatment

Minoxidil tablet is a convenient alternative to applying the lotion
Minoxidil is the first line treatment for female hair loss
Minoxidil 5% is superior to 2% and is applied twice daily
Studies show a cosmetically significant improvement in 30% of patients
30-60% of patients will exhibit more dense hair growth
Evidence suggests a greater effect when combined with Finasteride

Laser/Light Therapy

Light therapy involves shining a light energy source on the skin to activate a healing pathway in the cells. This light might be focused (Laser) or light however we are talking about low energy light for hair rather than the high energy lasers used to cause deliberate trauma to the skin such as CO2 skin resurfacing.

Light therapy has been used to treat a range of skin conditions including psoriasis (skin rash), wound healing, acne and collagen enhancement for aesthetic purposes for several decades.

Red Light therapy is a technique whereby visible cold laser light between 630- 670nm (which is red light) with low power photo-stimulates targets in a tissue, leading to cellular signals that promote cell activity and survival.

The effect is mediated by a process of photobiomodulation which is simply how light changes cellular activity. Most devices use light 500-1100 nm wavelength and the fluencies used range from 1-10J/cm2 and the power density is around 3-90 mW/cm. The trick is to look for red colour light for hair growth purposes. Blue light is used for acne.

Studies have suggested that light therapy prolongs the growth phase of a hair (called anagen) thus keeping more of them in the scalp and creating better density. Light therapy also showed a positive growth impact on hairs under stress. In a study whereby rats were given chemotherapy to induce hair loss, rats using red light therapy experienced hair regrowth 5 days earlier than the other rats. Laser therapy has also been shown to cause stronger hair and a report of thicker feeling hair and shine amongst study participants.

Most studies presently focus on light therapy 635-650nm wavelength however very few infrared (810nm) have been studied; infrared can penetrate deeper than red wavelength into the scalp. Commercial devices tend to be in that range and recommend three times per week for 20-30 minutes.

For scalp hair growth, a handheld or comb device has been shown to significantly increase hair counts. Current consensus suggests using the device for 30 minutes, 3 times per week.

Using red light therapy for hair growth involves remaining under a laser light helmet or device for 30-60 minutes several times a week. Most people describe the procedure as comfortable and apart from having to sit in the once place and a slight feeling of heat, there are few side effects.

Many patients will elect to purchase their own laser device whilst others will rent or use a clinic laser for a period of time and monitor the effect before committing to buy one. It is suggested to use the laser therapy in conjunction with other forms of treatment; it is not a standalone treatment.

There is some debate on whether a device needs to have lasers (more focused or coherent light) or LED (a broader spread of light) is sufficient. There is insufficient data to support a laser predominate device and doubt has been cast on manufacturer claims that only lasers penetrate to a useful depth. Most devices contain LEDs for coverage and cost reasons and there is proof that they work at least compared with placebo.

Finally, beard growth has not been extensively studied. Beard hair is thicker, grows slower than scalp hair and has different characteristics. Minoxidil and microneedling treatments have been reported to improve beard growth and are currently widely marketed.

The causes of poor beard growth are not clearly established however would be different to the scalp as testosterone and DHT enhance beard growth. Interestingly, most men with poor beard growth have normal testosterone. It remains to be seen if the general growth promoting effects described for laser therapy on both male and female hair would apply to beard growth.

From a practical point of view, most patients would not want to have to use a red light hair growth helmet three times per week for the rest of their lives. However, when somebody is recovering from a shock hair loss (telogen effluvium) or wants to enhance the effect of a newly started hair loss treatment (like minoxidil) the red light therapy is often useful as an extra bit of fire power for 6-12 months.

As we will see later, when starting a new treatment for hair loss, a new ‘anagen’ or growth cycle is begun for the hairs. At some point, they will push out the old telogen hairs out of the scalp in a ‘shed’. This can be distressing but will pass. Some people are quite distressed by this ‘victory shed’ and so the red light can help minimise it.

Summary of effects of red light therapy on hair loss

Studies show an increase in terminal hair density
The effect of red light therapy on hair growth, when used three times per week, over 26 weeks was comparable to minoxidil and finasteride
Light therapy is recommended prior to starting minoxidil as it may reduce initial hair shedding associated with use of minoxidil
There is no research regarding the use of light therapy to grow hair on any other part of the body and such treatments are experimental; for example, beards.
Light therapy would be a lifelong treatment for the prevention of hair loss however patients will often opt to trial the light before committing to longer periods of use or use the light for the first year until the medications take over.

Platelet-Rich-Plasma

Platelet Rich Plasma or PRP is an exciting and growing area of medicine. It is a technique that uses a component of your own blood to inject into a tissue to cause it to grow, repair and heal better.

Platelets are the blood component that respond to bleeding and trauma. They have a role in sending out growth factors and signals that initiate and promote healing. A sample of blood is taken and spun carefully to separate the blood components by mass. The section containing platelets is removed and prepared for injection. Depending on the method used, a concentrate of platelets at least two times that of baseline blood is harvested to be deployed in a tissue specific manner.

The objective is to use the growth factors of a concentration of platelets to promote hair growth using the body’s own mechanisms. This concentrate is divided into small syringes, activated (to ensure the best delivery of the platelet growth factors) and injected into the scalp at 1 cm grids. The scalp is numbed using a small needle to ensure no pain is felt.

Platelets deliver many factors promoting growth and the exact mechanism of action is not yet clear. PRP has been used with some success in multiple areas of medicine notably sports medicine and cosmetics. Research of PRP in the treatment of hair loss is promising with studies showing an increase in follicular density in the areas treated.

At this stage, PRP is employed by many hair restoration surgeons and is a common component of hair loss surgery. Because PRP comes from a patient’s own blood, the risk of allergy is exceedingly low and infection is rare under sterile conditions. It cannot be used in a patient who is unwell or has a platelet disorder, however most people can have it safely and employ PRP as an adjunct to non-surgical hair loss treatment.

Summary of Platelet Rich Plasma

PRP involves an injection of platelets from a patient’s own blood into the scalp to improve hair growth
The exact mechanism of effect and exact efficacy is unknown
There is no clear consensus on the best protocol to use
Studies suggest improvement ranges of 30-70% with much reduced hair loss however further research is needed
PRP is given at 0.05-1mL per cm squared of scalp under anaesthetic
Vitamin C should be taken at 1g per day for one month prior or 15-30g infusion to stimulate tissue growth

Platelet-Rich Plasma for Alopecia Areata

PRP is gaining popularity for hair regrowth beyond male or female pattern baldness.

Alopecia Areata (AA) is an autoimmune skin condition where patches of baldness arise on the scalp. The diagnosis is by history and examination. 50% of patients will recover within a year and the rest may take some time or not recover at all. In general, patients with suspected AA are advised to undertake blood tests

Studies showed that intra-lesional (into the affected scalp area of hair loss) injections of corticosteroid would resolve the alopecia in 50-60% of patients. More recent research has shown that PRP is more effective than corticosteroids with some studies showing an earlier response.

Summary of Platelet Rich Plasma for alopecia areata

PRP has demonstrated benefit in treating Alopecia Areata
Whilst some studies show PRP to be non-inferior to intralesional corticosteroids, other studies are less clear
Studies show that PRP is superior to minoxidil for AA
PRP injection for AA may be a viable alternative to intralesional steroids AA should be referred to a dermatologist if initial treatments are not effective

Other Regenerative Therapies

Similar to PRP, there is now a focus on other therapies that involve regeneration and rejuvenation of body tissues. PRP for example is also used in tendon injuries,cosmetic skin rejuvenation and arthritis to name a few.

A newer regenerative product is matristem, a resorbable extra-cellular matrix scaffold containing multiple proteins and collagens similar to that found in the healthy layers of the scalp; think of it as breast milk for skin.

Similar to PRP, the idea is to provide the best possible set of factors for the body’s own stem cells (cells which grow all our cells to replace them) and repair cells to prosper and mediate improved hair growth.

Unlike PRP, matrix scaffold regenerative products have not been evaluated as commonly as PRP in scientific literature. Having said this, they are used routinely by expert hair restoration surgeons in conjunction with PRP and remain a valuable treatment option with sound principles.

Hair Loss Treatments in Women

Female pattern hair loss is harder to treat than male pattern balding. It is the authors favourite condition to treat as it involves the challenge of nutritional and environmental medicine as well as surgical hair restoration surgery.

Almost always, female pattern hair loss involves deeper medical issues. This often includes gut issues (dysbiosis, the wrong bacteria in the gut causing issues), vitamin deficiencies, liver stress, hormone imbalance and toxic influences on the body (absorbed pollution).

Sometimes doctors can perform investigations to find the cause; however often, the issue occurred in the past and does not show up on blood tests clearly. Either way, treatment will be offered taking into consideration the likely causes in females.

One category of causes for female pattern hair loss is hormone imbalances. In many cases, there are standalone hormone issues causing the hair loss. This might involve polycystic ovarian syndrome or another syndrome whereby, put simply, a female has a higher level of male hormones than normal.

As such, treating these women with medications which block some of the impact of testosterone is important.

Whatever the underlying cause of hair loss, any hair follicular unit under stress (vitamin deficiencies, underlying medical illness, pollution) tends to express more DHT receptors on the cells and so is more susceptible to the impacts of DHT on slowing hair growth.

Therefore, the medications used in female pattern hair loss will definitely include minoxidil and will often include finasteride to block DHT receptors as well as anti-androgen medications; medications which block the effect of testosterone.

It should be emphasized again that all of these medications are dangerous in pregnancy and must be stopped prior to seeking pregnancy.

Anti Androgen medications

Spironolactone is a blood pressure tablet which has some anti-testosterone and anti androgen effect and is used in hair loss in females. Used at 50-100mg per day it can assist with hair retention.

Cyproterone is another anti androgen used in some jurisdictions.

Anti-Androgens are usually well tolerated however there are a few key side effects. In some women, you to check the potassium, a blood salt that can be changed by Spironolactone. Because spironolactone is also a blood pressure tablet, it must be stopped if there is dizziness.

Finally, because we are altering the effect of testosterone, it is possible that estrogen will be more pronounced. This can lead to changes in periods for some women.

Neither spironolactone or cyproterone are safe during breastfeeding or pregnancy and as always, discuss this with your doctor prior to taking the medication.

Facial Hair Growth

Beard (and or moustache) growth is an exciting area and crosses the disciplines of hair medicine and trichology into men’s health, functional medicine and andrology (the study of men’s hormones).

Testosterone has a differential effect on the growth of hair in different parts of the body. Whilst DHT may cause hair loss on the scalp, it has been regarded as essential for the growth of hair on the face in men.

The factors behind poor beard growth are multifactorial and poorly understood with likely genetic and environmental factors at play.

Men who are interested in growing a beard should first have their general health and testosterone assessed prior to embarking on therapy. Correction of any low testosterone may assist in beard growth in some cases; however most men with poor beard growth have normal testosterone and poor beard growth is not a sufficient reason to start testosterone therapy.

Anecdotally, there are observations that minoxidil assists with beard growth however formal studies are lacking. Light therapy is being trialed and is thought to assist. A patent has been filed for topical DHT, a potent form of testosterone, to be trialed for beard growth.

There is reasonable evidence supporting the role of DHT as being essential for beard growth however this form of therapy risks DHT entering the body and increasing testosterone. This will act the same as testosterone replacement and so this must be discussed with your doctor as a form of testosterone therapy with the associated risks and monitoring that is required.

Hair transplant surgery is effective for beards with excellent graft (transplanted hair) survival rates and is the authors preferred method of creating beard volume; minoxidil, microneedling and PRP are temporary effects that are contingent on the hair supply being adequate.

The author has had a beard transplant and thoroughly recommends it. Remember, if your Dad hasn’t got a beard, you have two mums!

Summary on beards

Men interested in beard growth should discuss available options with their doctor
Evidence is lacking on the best treatment to grow beard hair
DHT and testosterone are critical in beard growth
Minoxidil and light laser therapy have been used but not studied formally
The best treatment for beard growth is a beard transplant using hair from the back of the head

What is the duration of hair loss treatments and how long until they work?

The most important baseline medications for hair loss are minoxidil and finasteride. Practically speaking, they are best taken as a tablet an on ongoing basis.

Any patient taking Finasteride or Minoxidil should be prepared to wait at least 6 months before expecting a result. The growth phases of the hair follicle are naturally long and it can take some time to see a change. Hair grows at about 1cm per month however make take a few months to kickstart the growth phase and visibly emerge from the scalp.

Furthermore, patients on minoxidil may notice an initial increase of hair shedding as dormant (resting) hair follicles are pushed into anagen (growth) and so it looks like your hair is falling out.

This is a good sign. If you have just started minoxidil or finasteride and feel that you are shedding hair, then this means that the medication is working. Reassurance is all that is needed and keep going with the medication. The same ‘recovery shedding’ effect occurs when a major hormone or vitamin is restored (such as iron) and is noticed 2 months later as the new growth phase is sufficient to expunge the previous hairs.

Some patients will benefit from using red light therapy to help prevent shedding if this bothers them.

The timing for Platelet Rich Plasma PRP regimes is yet to be refined. PRP is used in patients undertaking a hair transplant on the day, both into the recipient scalp where the hairs will be placed as well as the donor scalp where the hair has been taken. Increased graft survival has been demonstrated using PRP and better regrowth of follicles in the donor scalp has been shown.

Regimes for the use of PRP to help grow hair when not getting a hair transplant are not yet determined however research suggests frequent, early PRP injections monthly for 4 months, to be tapered to 3-6 monthly intervals thereafter.

Lasers should be used for 20-30 minutes, three times per week indefinitely.

Summary of how long the hair loss treatments take to work:

Finasteride is taken as 1mg tablet daily
Minoxidil is applied twice per day on the scalp or one quarter of a tablet at night.
Lasers and Finasteride may be started prior to Minoxidil which may minimise the increase in hair shedding seen in early Minoxidil, or finasteride, use
Patients are advised to wait 6 months before expecting results
If discontinued, the treatments will cease to have effect and patients may experience hair loss consistent with the stage of hair loss they would have experience if treatment had never been used
For the best effect, treatments should be continued indefinitely
Results vary and no guarantee of effect is possible in Hair Growth from NAD+
NAD+ is an exciting cell booster therapy used in a range of areas in medicine. This includes fatty liver, mental clarity, brain fog and drug addiction.
NAD+ is a chemical that cells use to create energy. This energy is specifically used for cell cleanup including removing broken proteins and broken DNA. In this sense, it is associated with the restoration of damaged, stressed and fragile cells in the body. Clinically, it is used in high doses for heroin withdrawal in addicts. It has also been used for depression, liver detox and chronic fatigue.
Nicotinic acid, related to NAD+, has been used to lower cholesterol and to treat fatty liver.
Infusions of NAD+ are thought to reduce inflammation which is harming the growth of hair follicles. More research is needed before this treatment is offered routinely however studies have shown a modest improvement of hair growth in some individuals.

Which treatment should I use and why?

Hair loss treatment is a confusing journey. The internet is full of heavily marketed hair loss treatments offered by companies with no medical experience aiming to make a dollar. This is not the best way to treat your hair loss.

Only doctors experienced in the field of hair loss will have the skills to offer a gold standard treatment. Companies do not have the legal ability to offer blood tests or prescriptions and so are limited to selling over the counter style supplements; in all studies, these are dramatically inferior in results to finasteride and minoxidil.

Furthermore, companies do not have serious medical expertise; if you choose something ‘off the shelf’ rather than a medically trained professional, you will not get a clear diagnosis that truly understands the full picture. You do not ask a real estate agent to build your house; you need a builder.

Experienced doctors in the hair loss field, who also have the skill to perform a hair transplant, are best suited to treat hair loss. They tend to treat hair loss in a standard approach.

They will investigate the likely causes of hair loss and prescribe finasteride and minoxidil; this is because these medications are known to be safe and effective with >75% of patients experiencing no further hair loss (aka stability) on them.

What about this brand new supplement my neighbour told me about?

In almost all studies, natural and supplement therapies have shown very modest or cosmetically insignificant results for hair loss. Any human body or cell under some distress will probably benefit from some nutrition or antioxidants and so it is not a surprise that weak studies show some improvement from supplements. However, the question is, is it as good as minoxidil and finasteride?

Most herbal and supplemental treatments show a modest 10% improvement at best. Given that you only start to see balding scalp when 50% of the hairs in a given area are lost, this is rarely going to be enough for anybody.

Combined minoxidil and finasteride prevent hair loss in over 75% of people with 25-30% growth. This is far in excess than any herbal medication and so without finasteride and minoxidil you are not being properly treated.

Supplements may play a role in treating the underlying causes of hair loss but they are not a responsible solo treatment. If you are not on finasteride or minoxidil, you are not being adequately treated for hair loss and so the use of these products is irrelevant to serious hair loss treatment unless advised as a part of a thorough, doctor led plan.

Typical Starting Regimens for medical hair loss treatments:

Men: Finasteride 1mg every other day + minoxidil 1-5mg every day for at least 6 months and then discussion of PRP and/or hair transplant

Women: Minoxidil 1-5mg once per day, +/- spironolactone and/or finasteride and/or red light therapy for 6 months and then discuss hair transplant

Some tips and know how on the common treatments

Finasteride, Minoxidil and red light therapy are regarded as safe, simple and effective first line treatments for male pattern balding with Minoxidil and red light therapy being first line for Female Pattern Hair Loss.
Spironolactone and finasteride may also be given to some female pattern hair loss cases based on individual considerations.
Minoxidil can be obtained over the counter in lotion whilst Finasteride and minoxidil tablets require a doctor’s prescription.
Laser light machines are available from the internet in some countries or by hair loss consultants whilst PRP and matristem are only available by doctors with experience in using this treatment modality.
The best suited treatment for any patient depends on a range of factors including patient age, stage of hair loss, medical comorbidities, budgetary constraints and preferences regarding medication.
Critically, all patients wanting to consider hair restoration surgery need to be stabilised on medication for at least 6 months so that the surgery can be conducted in confidence that there will not be substantial balding of hairs around the surgery site; this can look distinctly awkward.

Further Tips

Young men with early onset hair loss (20s and early 30s) should be started on Finasteride and Minoxidil as soon as possible to arrest further hair loss and delay the need for surgery. Early treatment is essential to preserve maximum hair follicles and give other therapies a much greater chance at success. It may be the difference between bald and not bald for this patient.
If Finasteride alone does not restore full volume or the patient requires further hair density then serious thought given to PRP as an adjunct to these treatments.
Many patients are not aware that Minoxidil is available as a tablet form. This avoids messing of the bedsheets at night from the scalp lotion, the hassle of application and helps compliance. It can be used instead of Minoxidil lotion.
Patients with stable, extensive hair loss will have a variable response to Finasteride, Minoxidil and PRP alone and will probably need to have a hair transplant. Medical therapies are essential to the success of the hair transplant and ideally Finasteride and minoxidil are used at least 3 months prior to a hair transplant and several months after; depending on the surgeon’s preference.
If a patient does not wish to have a hair transplant, Minoxidil, Finasteride and PRP can be trialled for a year and a decision made thereafter. For a
balding, PRP is unlikely to yield a significant result but may be trialed if the patient wishes to.
Minoxidil and PRP may be used for patients wanting to promote beard growth and Finasteride will have no effect on beard growth.
Women who experience hair loss should be started on Minoxidil, red light therapy and ideally PRP to maximise hair density at an early juncture. NAD+ may be an option. Women with hair loss should have further testing to determine any medical, hormonal or nutritional cause and all of these actions should be performed expediently given the psychological distress to women of hair loss. Early referral to a dermatologist if unsure of the cause of hair loss is essential.

Which treatment should I use and why?

Experienced doctors in the hair loss field, who also have the skill to perform a hair transplant, are best suited to treat hair loss. They tend to treat hair loss in a standard approach.

What about this brand new supplement my neighbour told me about?

Do Vitamins Help?

There is no question that optimal underlying health is beneficial for hair loss. Studies have shown that vitamin deficiencies can cause hair loss and particularly in female pattern hair loss, underlying nutritional disorders should always be considered.

In summary, If a cell does not have the nutrition it needs to function, then this will create stress that leads to hair loss.

A range of vitamins and minerals are essential for normal hair growth and for that matter, general health. These include Vitamin C, Vitamin D, Iron, Zinc, Selenium, Riboflavin, Folic acid, B vitamins, Biotin etc.

Having said this, there is no silver bullet vitamin or supplement that is a serious way to treat hair loss on its own. Many multivitamins are poorly absorbed and all supplements are poorly absorbed if there is a genuine gut condition.

The author’s approach to sensible and rational vitamin support is to perform blood tests, diagnose a clear vitamin deficiency or issue and rationally treat that as appropriate. It is probably not a bad idea to use a multivitamin with some selenium, zinc, tocotrienol (a powerful antioxidant) biotin to support hair growth however, the bottom line is:

Off the shelf, marketed herbal or supplemental treatments are NOT superior to medical treatment with finasteride and minoxidil.

A good hair supplement may include

Selenium
Zinc
Vitamin D (low dose)
Tocotrienol (or vitamin E or other antioxidant)
Fish oil

Iron is essential for hair growth and iron deficiency is a common cause of hair loss however iron is toxic if taken without blood testing. It should be taken separately to a multivitamin for this reason.

Complementary and Alternative Treatments

As a doctor in the hair loss field, I see many patients who have been heavily persuaded to buy expensive off the shelf or internet marketed products believing them to be superior in treating hair loss.

Sadly, almost none of them work beyond a short term improvement and many patients have ended up experiencing severe and progressed hair loss before they seek medical attention.

Alongside vitamins, many herbs and other compounds have been promoted as helping with hair loss. The evidence surrounding these treatments is underwhelming and limited.

Many companies will produce research showing how ‘good’ their product it. The typical effect range is from 0-38% increase in hair growth, however this is often measured by unclear parameters such as a reduction in shedded hairs or an increase in a visual density scale. Very few studies measure how well their supplement totally stops hair loss over the long term and so we have no idea whether the hair simply keeps falling out over the years.

These outcome measurements are not ideal as they do not indicate whether there is cosmetically relevant hair density being gained; you only see thinning of the hair once 50% of the hairs have been lost.A subjective 10-15% increase in hair will only help those who are at 60% hair loss and really do nothing for those who are below it!

Furthermore, these ‘studies’ tend to be short term, biased and we do not know much about the underlying health of the people in these studies. Some studies even combine their product with minoxidil which makes the results very unclear!

Of the supplements studied, tocotrienol (a powerful antioxidant) was associated with 34% increase in hairs however this study was not adjusted for baseline inflammatory conditions or dietary deficiencies making it hard to extrapolate. Some people may benefit from it but others may not; it depends whether you have inflammation to treat!

Similarly, saw palmetto, which is a weak DHT antagonist, was shown to produce 38% growth. Finasteride is 70% and so this is therapeutically inferior however remains a safer choice for women. Saw palmetto has traditionally been used for prostate issues.

From the authors point of view, saw palmetto is a more convincing supplement as it acts in a similar fashion to finasteride; however, it has a much weaker magnitude of action and so we have to be cautious in relying on it.

Remember, hair loss is not a vague concept. You either have hair or you do not have hair. Tinkering at the edges with fancy products will risk the patient having permanent hair thinning or baldness. Hair loss should be treated aggressively and conclusively to gain control of the situation as it is almost always progressive.

Outside of saw palmetto or tocotrienol, most other complementary medicines had either weak studies or an effect rarely beyond 0-15%. This would be subtherapeutic in many instances.

With minoxidil providing cosmetically significant growth in 30% of people and some growth in up to 70% of people, and finasteride providing an arrest of loss in >75% of men and regrowth in 70% of men; the use of a complementary or ‘natural’ treatment as a solo treatment is inferior to prescribed medical care.

Ultimately, the plant and herbal treatments are presumably modestly effective because they help with inflammatory or nutritional process that is contributing to hair loss. An integrative medical assessment to replace any likely or proven vitamin deficiencies or inflammatory states contributing to hair loss, in conjunction with standard hair loss medications, is a more rational use of complementary and alternative medicines at this stage.

Given the breadth and complexity of nutritional and environmental medicine, hair loss patients should undertake a general nutritional and health review to ideally achieve a healthy diet prior to relying on supplementation as the cornerstone of their hair loss treatments; the role of medications is at this stage not able to be substituted.

Hair Transplants

Hair transplantation is growing in popularity. This surgical technique involves taking hair follicles from the Safe Donor Area (at the back of the head usually) where baldness is rare and transplanting them into the bald areas. The transplanted hair will survive in the new area and not be subject to the forces of male pattern baldness.

Hair transplant surgery truly does have the ability to provide coverage for patients who have otherwise exhausted other hair restoration treatments. It is the gold standard for hair treatment and is the only treatment available to those who continue to have insufficient hair despite maximal medical therapy.

There are several limitations to hair transplant surgery. This includes failure of the grafts to survive, inadequate donor supply vs the area needed, the tendency for people to bald ‘beyond’ the transplant area as well as the sheer difficulty, length and cost of the procedure.

A full discussion of hair transplantation surgery is beyond the scope of this article. Conceptually, hair transplantation remains the gold standard of treatment for hair loss, however prior to undertaking hair transplantation is absolutely essential that the hair loss is stabilised on maximum medical therapy prior to operating. This is to ensure that there is the maximum hair to be used and the correct area is transplanted.

Patients interested in hair transplant surgery should be cautious to only consult with a properly trained doctor in this area. Ideally a doctor is trained in multiple forms of hair transplant surgery and is licensed in a credible jurisdiction with high standards.

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Adenosine

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Caffeine

DHEA

Echocardiogram