Useful treatments and considerations for hair loss: Part Two
Before spending a lot of money on expensive shampoos, conditioners, and hair-thickening products, remember that your hair mirrors your overall health. It only makes sense to consider natural healthy options that nurture your whole health and wellbeing. Feeding your mind, body and soul, should improve the quality and quantity of your hair, as well as your overall quality of life! As always, treatments have the best chance of being effective if they address the cause of the hair loss as well as triggering hair growth.
As we have discussed in previous blogs, finding the root of the problem is better than a generalized nonspecific approach. Yet, despite the fact that specific medical treatments offer great results, eating a healthy nutritious diet, exercising regularly and keeping a check on stress can yield important benefits for anyone concerned about the health of their hair.
Topical vs. Systemic Treatments
The idea that hair care products -- including shampoos, dyes, bleaches, perms, and even blow dryers -- can damage your hair should come as no surprise. But, in the general population, hair care products generally don't figure into the hair loss equation. Damage from hair care products or procedures generally causes breakage and inflammation -- which is not the same as hair loss. Hair LOSS is usually a problem that occurs at the level of the hair follicle. This means that if you are suffering from hair ‘loss’, you don't have to be afraid of grooming, or even color treating or perming your hair. When it comes to using specific drugs to treat hair loss such as pills, please keep in mind that the drugs will have an effect on the ENTIRE body, not just the hair. Because of this, TOPICAL treatments are usually preferred.
In the case that the problem is due to a hormonal imbalance, drugs should be aimed at helping the body achieve a ‘hormonal balance’. The most frequent ‘hormonal imbalance’ to cause hair loss is an excess of androgens. This is called male pattern baldness, or androgenic alopecia. Some women carry a genetic predisposition to male pattern baldness. Androgenic alopecia is most commonly due to a hormonal imbalance due to polycystic ovarian syndrome, (PCOS) or perimenopause. This type of hair loss in women occurs on the top and sides of the head and above the forehead, and may also involve excessive hair growth on the face and other areas on the body.
PCOS is a condition where there is more androgens produced than estrogens. Perimenopause is due to falling estrogen levels with aging. Decreasing estrogen levels may allow the body to convert more available testosterone without opposition.
Androgens (testosterone and DHEA) are naturally converted into a substance called DHT (dihydrotestosterone) that stimulates blood flow to the hair follicle, promoting hair growth and thickness. If there is an excess of androgens the hair follicle becomes ‘oversensitive’ and irritated. The follicle then shuts down, causing a halt in the life cycle of hair and thus hair loss and thinning.
A doctor can determine if hair loss is due to excess male hormones when listening to the complaints, performing a complete physical exam and laboratory tests. Treatment should be geared to have an effect on the entire system. Pills are better than using a topical treatment, as the main goal is to reestablish the hormonal balance in the WHOLE system.
Systemic treatments used to treat hair loss in women fall into two categories: Drugs that are FDA- approved, and drugs that have not been approved by the FDA, but have been approved for other applications and are used "off-label" to treat hair loss.
Anti-androgens are drugs that aim to decrease the levels of androgens in the body. Their goal is to help prevent further damage to the hair follicle and encourage some hair regrowth from follicles that have been dormant but are still viable. The effectiveness of these agents usually varies from person to person, but many women have found that using these treatments have made a positive difference in their hair and their self-esteem. It usually takes several weeks and even months to notice a visible result.
Examples of drugs that cause a systemic effect on androgen levels are:
Birth Control Pills: Since birth control pills decrease the body’s innate production of ovarian androgens, they can be used to treat women's androgenic alopecia. Some birth control pills are better than others due to the fact that they come in various hormonal formulations. Birth control pills that have a low dose of hormones and have an effect on androgens by turning them down or off are said to have a ‘low-androgen index’. These are the birth control pills should be used to treat hair loss. Birth control pills that have high dose of hormones and that easily metabolize into androgens have a ‘high androgen index’ and they may actually contribute to hair loss by enabling an imbalance in androgens. Examples of a birth control pill that are excellent in treating androgenic alopecia are YAZ, BEYAZ, and birth control pills that have drosperinone.
Drosperinone: nDrosperinone is a progesterone agent in birth control pills such as YAZ, and BEYAZ. Drosperinone competes with testosterone for the receptor, and once it links with the receptor it actually may even turn off the effects of testosterone and behave like an anti-androgen.
Cyproterone Acetate: (not available in the USA). Cyproterone acetate is used to reduce excessive sex drive in men and to treat pronounced sexual aggression. It is also prescribed for severe hirsutism in woman of childbearing age and for androgenetic alopecia in women. Cyproterone Acetate with Ethinylestradiol is found in Diane 35, Diane 50 (-not available in the USA) . Both versions of this contraceptive contain 2 mg of cyproterone. Diane 35 contains 0.035 mg of estradiol, while Diane 50 contains 0.050 mg. Cyproterone acetate exerts its effects by blocking the binding of dihydrotestosterone (DHT) to its receptors. Cyproterone acetate is not available in the U.S. because of its possible toxicity and long-term side effects.
Estrogen and Progesterone: Estrogen and progesterone pills and creams may be an effective treatment for women with androgenetic alopecia who are going through menopause or whose estrogen and/or progesterone are lacking for other reasons. This treatment aims to re-establish hormonal balance in perimenopausal women.
Spironolactone (brand name Aldactone): Spironolactone is a water pill –a diuretic. It is typically used to reduce fluid in your body without causing the loss of potassium (a class of drugs called potassium-sparing). It is also used to treat high blood pressure (hypertension), potassium deficiency, swelling (edema), and a hormonal disorder called hyperaldosteronism. Spironolactone acts as an anti-androgen in two ways. First, it slows down the production of androgens in the adrenal glands and ovaries. Second, it blocks the action of androgens in part by preventing dihydrotestosterone (DHT) and androgens from binding to its androgenic receptor.
Cimetidine (brand name Tagamet): Cimetidine is a histamine blocker used mainly to treat gastrointestinal problems like reflux and stomach and duodenal ulcers. The histamine-blocking action prevents the stomach from producing excess acid. Cimetidine also has a fairly powerful anti-androgenic effect and has been shown to block dihydrotestosterone (DHT) and androgens from binding to the follicle receptor sites.
Ketoconazole (brand name Nizoral): Available as a pill and a topical treatment by prescription, ketoconazole is currently used to treat fungal infections. It curbs the production of testosterone and other androgens by the adrenal gland and reproductive organs (in women, the ovaries). These anti-androgenic effects can be used to help treat hair loss. Nizoral shampoo contains 2% ketoconazole and is prescribed not only for the treatment of scalp conditions, but also in combination with other treatments for androgenetic alopecia. A 1% version is now available over-the-counter, but it may not be as effective as the 2% prescription strength. There are no significant side effects.
Finasteride (brand name Propecia, Proscar): 5-alpha reductase is an enzyme that is crucial for the production of follicle-harming dihydrotestosterone (DHT). DHT shrinks hair follicles and makes it difficult for healthy hair to survive. The drug finasteride inhibits this enzyme, thereby having an effect on androgenic alopecia. Finasteride was first marketed under the brand name Proscar to treat the prostate gland. It was available in 5 mg pills. In 1998, a 1 mg version with the brand name Propecia entered the market as the first pill approved by the FDA for men's hair loss. It works quite well to prevent hair loss and trigger regrowth for most men. Less than 2% of men have transient sexual side effects while taking finasteride, including problems with libido and erectile dysfunction. Finasteride may work for some women, although the risk of birth defects causes significant concern in women of childbearing age. It is absolutely contraindicated in women who are pregnant or at risk of getting pregnant.
Topical treatments are meant to be applied directly to the hair follicle, and are meant to enhance and thicken the existing hair — they do not generate new growth. Topical products have a very limited effect on the ‘system’, and have a little effect on hormonal balance or metabolic function.
Examples of topical products used for hair loss include:
Minoxidil (Rogaine): Minoxidil was first used in tablet form as a medicine to treat high blood pressure. It was noticed that patients being treated with minoxidil developed excessive hair growth (hypertrichosis) as a side effect. Further research showed that applying a solution of minoxidil directly to the scalp could also stimulate hair growth. When applied topically, the amount of minoxidil absorbed through the skin into the bloodstream is usually too small to cause internal side effects. Widely available in generic versions and under the brand name Rogaine, minoxidil seems to be more effective for women suffering from diffuse androgenetic alopecia than it is for men. Minoxidil comes in several formulations: a 2% and a 5% formulation. Product labeling recommends and the FDA approves the use of the 2% concentration of minoxidil for women. The FDA has not approved use of the higher concentration in women. Despite this, many dermatologists do prescribe 5% for women with androgenetic alopecia if used under their supervision. Small clinical trials have shown that the 5% minoxidil solution is more effective than the 2% concentration in both retaining and regrowing hair in women with androgenetic alopecia.
Topical steroids: Topical steroids applied to the hair follicle aim to reduce inflammation and reduce the autoimmune attack. This kind of treatment may be useful for inflammatory hair loss and alopecia areata.
Topical antifungals: For the treatment of a fungal infection or with the aim to interfere with the effect of androgens on the hair follicle via DHT. As I discussed above when discussing ketoconazole. The topical formulation has the benefit of working locally.
Topical blockers of DHT: This is a generic classification, but drugs that are aimed at blocking the effect of androgens on the hair follicle, can be targeting the DHT pathway can then be applied topically. There are some versions that have a more natural approach and are plant derived.
Immunological and infectious factors in hair loss
If hair loss is dramatic and happens over a short period of time, immunological or infectious factors should be considered. When hair falls out in great clumps, creating patchy bald spots all over the head, it may indicate an autoimmune condition called alopecia areata. This type of hair loss is usually diagnosed when a punch biopsy is performed. When the scalp is visualized under the microscope there is also a large amount of immune cells as well. The treatment should be focused on improving the health of the immune system. Systemic steroids are usually not recommended.
Infectious causes of hair loss are usually due to an overgrowth of fungus or yeast that causes severe follicular inflammation. This can be diagnosed by a thorough scalp examination. Treatments usually involve some kind of topical anti-fungal shampoo or solution.
Hair implants, Laser Stimulation and other Novel treatments for Hair loss
A new type of minimally-invasive hair transplant procedure called follicular unit extraction (FUE) is offering promising results. Other surgeries and laser stimulations are available as well. Unfortunately these procedures are costly and not yet widely available.
In conclusion, hair loss IS NOT TRIVIAL. Please keep a healthy check on your overall health… Pay attention to the subtle and not so subtle changes in your body….. and in your hair…
Your hair, could indeed be a mirror to your soul…
Margarita R. Ochoa-Maya, MD, CDE