Your Diabolical Follicles: Treating Male Pattern Baldness

Are you one of the 70% of men who is suffering from male pattern baldness (MPB)? Do you want to stop it and even, possibly, reverse it? Boil a cup of mustard oil with four tablespoons of henna leaves, let it cool, then massage it daily onto the balding areas. Better yet, create a paste from honey, beer, and boiled wheat, and have it applied gently (to your scalp, of course) by the hands of a virgin. Or you could rub goose droppings onto your dome, the way the Vikings did. Other types of animal excrement could work as well: Cow feces and pig urine are both good topical solutions. And if the business end of a cow doesn't provide relief, turn her around and have her lick a combination of molasses and oats off your head. There's a baldness clinic in South America that swears it will return your hair to its teenage luster.

Sound crazy? Not to everyone. A full head of hair is associated with strength, virility, youth, and power. Though men aren't encouraged to openly discuss their emotional reaction to hair loss, it's there. Frustration, depression, loss of self-esteem, social withdrawal, even suicide. It's not just about looks, although that's certainly a part of it; it's about a loss of control, the passage of time, mortality. "When men lose their hair, it can be devastating," says Spencer Kobren, founder and president of the American Hair Loss Association and founder of thebaldtruth.com. "Most guys would do just about anything to keep from going bald. We'd rather regrow our hair than lose body fat. If you told a balding guy he could keep his hair if he were to run five miles a day and eat a specific diet, he'd absolutely do it. An overweight guy? Maybe. Hair is different."

Kobren should know. He started losing his hair in his early 20s, and he panicked. He reasoned that women would rather date a man with all his hair. (He might have been correct. During an online dating experiment conducted in the U.K., two photographs with identical descriptions of the same man were used--except one had been digitally altered to show him with thinning hair, while the other showed a full head--the thick-haired profiled received nearly five times as many responses from women). So he hung upside down with gravity boots after taking niacin capsules to create a flushing sensation; rubbed cayenne pepper on his scalp to stimulate hair growth; and wrapped his head in scalding-hot towels to draw out the oily matter called sebum from the sebaceous glands, because he'd heard the theory that oil buildup beneath the scalp's surface can damage hair follicles.

None of it worked, of course. "There are as many desperate home remedies as there are receding hairlines," Kobren says. "If any of them really worked, it would be prime-time, head-line news. You really think some guy in his basement in Wisconsin has the cure to hair loss? You want to believe it, but come on." Of the seemingly infinite treatment options to slow or reverse baldness, there are only three that are widely accepted as valid. But before you learn how to keep your hair, you need to understand why you're losing it.

Male Pattern Baldness

Men have been suffering from androgenetic alopecia, otherwise known as male pattern baldness, since before the first coming of Christ. Julius Caesar was memorialized many times in stone with what was left of his hair combed forward, and a signature wreath covering his pate. Receding hairlines and bald spots plague men of every race, creed, and status. But why?

According to Bernard Arocha, M.D., president and owner of Arocha Hair Restoration, MPB occurs when a man has a genetic predisposition to sensitivity to the potent androgenic hormone called dihydrotestosterone (DHT). In most men, about 5% of their serum testosterone is converted to DHT by an enzyme called 5-alpha reductase. To those with the inherited sensitivity, DHT acts like a toxin on the hair follicles along the temples and mid-anterior scalp, undermining the absorption of nutrients and causing progressive miniaturization, which is when the growth phase of the follicles is shortened.

"There are 100,000 to 150,000 follicles on a full scalp," Arocha says, "all of which follow growth and rest phases. The growing (anagen) phase usually lasts about three to six years, during which time each hair matures in thickness and color. The resting (telogen) phase, when a hair ends its growth phase and falls out, lasts about 90 days. At any given time, only about 10% of follicles are in the resting phase, so normal hair loss is not noticeable." But for men with DHT sensitivity, over time, the growth phases of the follicles become so short that they grow only very fine, almost colorless hair (vellus hairs) until the miniaturization is complete and they produce none at all. Interestingly, the follicles around the ears and at the back of the head aren't affected by DHT, and MPB sufferers are left with a horseshoe pattern of hair.

More recently, researchers from the Perelman School of Medicine at the University of Pennsylvania have identified an abnormal amount of a lipid called prostaglandin D2 (PGD2) in the bald scalp of men with MPB. While the new findings haven't yielded any treatment, "it's a new piece of the puzzle," Kobren says. "We know that DHT is a major culprit, but maybe it's not only DHT that causes MPB." Scientists continue to look for other genetic and environmental factors to explain--and treat--baldness. Several groups are now looking at the relationship between the microscopic receptors that bind to Vitamin D in skin cells. "There's always interesting research being conducted," Kobren says. "It's always disappointing if the findings are ultimately inconclusive--but we keep hoping for a breakthrough."

Treatment Options

For reasons scientists don't fully understand, sensitive follicles must be exposed to DHT for a prolonged period of time before the miniaturization process is complete. But what they have learned is that taking a drug that inhibits the binding of 5-alpha-reductase on testosterone can reduce the levels of DHT and thus slow or even stop the miniaturization process. There is such a drug and it's called finasteride (sold as Propecia), the first of the three aforementioned treatment options.

"Finasteride blocks 70% of the conversion of testosterone to DHT," Arocha says. "There are some reported sexual side effects such as erectile dysfunction, problems with ejaculation, and depression, so you should speak to your doctor before taking it. However, there have been very good results for stopping hair loss and even regrowing hair." According to the product website, most men in the clinical studies see results within three to 12 months. If no improvement is seen after that time, further treatment is unlikely to be of benefit. Also, if you quit using the product, you will likely lose the hair you retained or regrew while under the treatment.

Even better than finasteride alone is when it's used in conjunction with the second treatment: the topical solution minoxidil (sold as Rogaine). "Minoxidil is like a follicle fertilizer," Kobren says. It acts as a vasodilator that keeps hair in the anagen phase longer and can increase the diameter of those downy vellus hairs, but it doesn't get to the root cause of hair loss. "Only 35% of men are able to slow or stop hair loss with minoxidil alone, and only 10% see regrowth, usually in the crown area, and like the finasteride, the benefits stop if you stop using the product," Arocha says. "But using both together over time yields the best nonsurgical results possible."

Which brings us to the final treatment option, and one that both Arocha and Kobren say should be the last resort: hair transplantation. "I sat in a transplant doctor's office in 1988, and he told me that if I were his son, he'd say try a few grafts. That was back when they used to put in 4mm plugs. I was thinning, sure, but I was 22 years old. If I'd let him put plugs in me then, I'd have ended up looking like a hairbrush with bristles of 30 hairs each lined up in rows and columns starting at my hairline. It would have ruined my life."

Fortunately, the technology has dramatically improved and now doctors like Arocha can harvest individual follicular units--a natural grouping of one to five hairs--from permanent donor sites above the ear and at the back of the head, and move them to the thinning or bald areas. Arocha, who also started to lose his hair at a young age, approaches each scalp as though it were a canvas: the harvested follicles the paint, and he, the artist. "Think of a forest," he says. "At the edge, you see shrubbery first, then a few trees, then groups of trees that grow thicker the further you go. I observe that same principle, carefully placing the donor follicles in a progression. There must be artistry in the technique, or the results can be disastrous."

The average cost for a transplant is $7,000-$15,000 or more. "Buyer beware," Arocha says. "Do careful research on the transplant surgeon and his technique. Know what's involved and what's at stake. And realize that the result depends largely on the amount of "paint" a surgeon has to work with." But when it works, it really works. "I can't tell you how many men come back and tell me that their hair restoration has given them back not just their hair but also their lives. That's proof that it's worth it."