First of all, I think that a brief overview of male pattern alopecia is in order. Let me start by saying that the first fact that has to be understood is that androgenic alopecia has a multifactorial etiology-that is to say that this type of hair loss has many contributing causes that simultaneously come into play. The name of the disorder immediately sheds some light on what one of its major contributing factors-androgens.
Androgens are the masculine class of steroid hormones that are made primarily by the testes but also by the adrenal glands and ovaries. Although the predominant thinking is that hyperandrogenism (increased androgen production) or increased sensitivity to androgens is the most dominant factor in hair loss, we do know that other factors like genetic predisposition, sun exposure, oxidant damage, estrogen levels, skin irritants, and prostaglandin (hormone-like substances) levels all play significant roles in the initiation and progression of hair loss.
We will present detailed discussions of every one of the aforementioned factors in issues to come.
If we first examine the role of androgens, specifically dihydrotestosterone (DHT), we find that this hormone has been thought to slowly "choke" the growth of the hair follicle by inhibiting the function of an enzyme in the hair follicle called adenylate cyclase. Suffice it to say that when DHT concentrations remain high in the scalp, we see terminal (thick, coarse) scalp hair become reduced to vellus hair (fine, thin peach fuzz). Trust me, we all know that a healthy head of scalp hair being reduced to peach fuzz is a less than pretty site!
The cycle of hair follicle damage by DHT is an area of much research and speculation at this time. We are all aware of the drug, Propecia (finasteride), and its use in the reduction of systemic levels of DHT. This prescription drug was touted as the miracle cure for male pattern hair loss except for the fact that women couldn't use it. Oh yeah, it also has a nasty side effect of causing a drug-induced form of hermaphroditism in baby boys accidentally exposed in during a crucial period of fetal development.
Outside of those issues, does Propecia do all that it was billed to do? Are there other agents that prevent DHT damage or even formation? Do the agents offered over-the-counter have any benefit with respect to DHT levels--like saw palmetto, nicotinic acid, or ketoconazole? In the next edition of our newsletter we will discuss more about how DHT is formed and what agents, if any, will counter or reverse the damage caused by this hormone.
TIP OF THE DAY: Ketoconazole is an antifungal medication that was only available by prescription until recently. This agent is significant for those of us combating hair loss for a couple of reasons. First, ketoconazole's action as an antifungal agent reduces scalp irritation caused by fungal colonization or infection. Keep in mind, reduction of the inflammatory process that occurs in male pattern alopecia is crucial.
Second, ketoconazole has been shown in many studies to physiologically have an anti-androgenic (anti-DHT) effect! What's even better is that ketoconazole is available in a shampoo called NIZORAL. Let me state that we don't receive any compensation from the company that makes NIZORAL shampoo--I have genuinely found it to be an effective addition to my arsenal in the battle against hair loss.
There is one essential truth that must ALWAYS be understood if one is to achieve any degree of success in overcoming hair loss. That fact is that male pattern hair loss is a multifaceted or multifactorial process! There is NO SINGLE factor that can be corrected that will elicit the return of lost hair or even the prevention of continued hair loss.
We have to remember that we must essentially take a "throw the kitchen sink at it" approach in order to truly overcome the genetic predisposition to lose our precious manes. We not only have to minimize the action of DHT but we must also overcome the associated inflammatory process and the free radical induced follicular damage. In addition, we must ensure an adequate nutrient supply to the follicle (via enhanced circulation) and locally increase the levels of necessary follicular growth factors. With this understood, let's continue to discuss the role of DHT in hair loss.
Considering the fact that we understand that DHT is detrimental to hair growth in those genetically predisposed to hair loss-what options do we have in preventing DHT damage? Luckily, there have been several approaches that have been shown to combat DHT damage. The differences in these approaches lie in their mechanism of action-let me explain. One approach that has received a great deal of attention in the recent past is the use of agents that inhibit an enzyme called 5-alpha reductase. This enzyme is responsible for transforming testosterone (which is made by men AND women) into its evil stepbrother, DHT. Propecia (finasteride) has been proven to dramatically reduce the systemic levels of DHT by effectively inhibiting 5-alpha reductase.
Among its many drawbacks is the fact that it often causes a decrease in sexual drive and performance. Propecia® is also only available by prescription and is NOT indicated for use by women. Nonetheless, if the side effects are tolerable, Propecia® is an excellent way of making the influence of DHT a thing of the past. Another agent that has been studied with respect to DHT reduction is saw palmetto extract. There are studies that have shown that the lipid (fatty or oil) extract of saw palmetto berries may reduce DHT levels when taken orally.
What is interesting is that saw palmetto is safe for use in men and women. There is conflicting scientific evidence about whether the enzyme, 5-alpha reductase, is directly inhibited by saw palmetto extract but it is reported to effect a DHT reduction in any case. In contrast to Propecia, saw palmetto extract is available over the counter and found in most health food stores and pharmacies.
Unfortunately, there is a huge variability in the available preparations of saw palmetto marketed-neither the quality nor concentration is standardized from brand to brand. The buyer must be sure he or she is purchasing their saw palmetto lipid extract (not juice, bark, or dried berries) from a company with a good reputation (we don't recommend any specific companies).
We have yet to examine whether or not there are other effective means of reducing the level and action DHT. For instance, is spironolactone or ketoconazole useful in counteracting DHT damage? What role, if any, may nicotinic acid play in DHT reduction. Will complete elimination of DHT allow you to regain lost hair or prevent further hair loss?
ANOTHER TIP OF THE DAY: There actually lifestyle changes that can significantly enhance your efforts to overcome hair loss. One such lifestyle change is the cessation of cigarette smoking! All of us (who didn't just fall off of the turnip truck) are aware of the detrimental health consequences of cigarette smoking. What you might not have known is that it has been shown that smoking accelerates hair loss in those who are genetically predisposed to male pattern hair loss. The current thinking is that cigarettes increase the levels of the enzyme, 5-alpha reductase, in the skin as well as dramatically increasing free radical formation (which helps destroy hair follicle membranes). Taking that into consideration, if you want to keep smoking just place the lighter next to your hair and do the job right!.