Male pattern balding

Male pattern balding ( male pattern hair loss) is the process whereby hair follicles become more sensitive to the male hormone testosterone and gradually stop producing new hairs

What is this skin condition?

Male pattern balding ( male pattern hair loss)  is the process whereby hair follicles become more sensitive to the male hormone testosterone and gradually stop producing new hairs. Only scalp hair is affected. It can occur in a variety of patterns including bi-temporal hair loss (receding at the temples), frontal hair line recession and thinning at the vertex of the scalp (the top). The end point in the most affected individuals is loss of all the hair over the top of the scalp. Hair around the sides and at the back is preserved as these follicles are not sensitive to the effects of the testosterone. The different combinations of male pattern hair loss patterns where classified by Norwood (see below).

 

It is very common and is really a part of the normal ageing process in men. The incidence does vary between ethnic groups. A rough guide to incidence in Europeans is that the proportion of men affected  matches their age so that 20% of 20 year olds will have a noticeable degree of male pattern balding and 305 of 30 year olds etc. Treatment is regarded as cosmetic and is not funded by most public health care programmes including the NHS.

Why have I got it?

The sensitivity of the hair follicles to the testosterone is determined by a number of genetic factors. It is not easy to predict male pattern hair loss based on family history and some of the implicated genes are carried on the X chromosome and are inherited from the mother. Overall testosterone levels do not vary between affected and unaffected individuals.

Comparing the treatment options

The big question is whether or not you pursue any treatment at all. Going bald is perceived by many people as a negative thing. One clear issue is that it is linked with ageing and going bald at an early age can make the affected individual look older. A less well founded belief is that going bald makes a man less attractive. It is fortunate that most women look for more things in a mate than physical appearance. In one large study of female attraction the only male physical factor that was significant was height. Ultimately, male pattern hair loss is largely about confidence (and sunburn). If you can lose your hair but maintain a confident outlook you do not need any treatment except a good hat in the summer.  If you think that it is your hair loss that is preventing you from finding a partner or holding you back at work you are likely to be wrong; you simply need to work harder on your self-confidence to make your hair situation irrelevant.

However, working hard to improve self confidence is not for everyone and for some men it is simply a cosmetic choice; they would rather have hair than not have hair which is perfectly understandable. The only problem is that achieving this is a challenge and can be difficult and very expensive. The website , the baldtruth.com, explores these issues in more detail.

Self-treatment

There is only one over the counter treatment available for male pattern balding and this is minoxidil, sold in chemists as Regaine©. Does it work? Yes and No. the drug has undergone formal clinical trials which showed  a degree of effectiveness.  The clinical response to 5% topical minoxidil for the treatment of androgenetic alopecia (AGA) is typically observed after 3-6 months. Approximately 40% of patients will see some hair regrowth ( Goren et al 2014 Dermatology Therapeutics journal) ( Varotahi S et al 2014 Am J Clin Dermatol).The effects only last as long as the product is  used and the patient will revert to their hair loss destiny once they stop using it. If a patient is very keen to try something then is the place to start.

Wigs ( toupee )

Memories of the magician Paul Daniels in the 1980s are not a good advert for wigs. However, they are staging a bit of a comeback and these days you are unlikely to notice one as the techniques and quality have significantly improved.

Spray on hair

A wide variety of products exist that can colour the scalp to some degree and minimse the appearance of balding. These may be effective in the early stages of hair loss.

As the scalp hair gets thinner the damage from UV light increases. Dermatology cancer clinics are full of bald men who did not wear hats. It is therefore vital that you find a collection of hats that you are happy to wear regularly throughout the spring and summer. Sunscreen is an alternative but not as good as a hat.

Help from your GP

Your GP is not the place to go. The NHS and most public and government run health systems  regards male pattern hair loss as a cosmetic problem.

Help from a Dermatologist or Hair surgeon

Propecia

In addition to Regaine which can be bought from a chemist without prescription there is one other licensed drug treatment for male pattern balding, finasteride , brand name- Propecia® . This drug was originally developed to help older men with prostate problems. It blocks the conversion of a weak form of testosterone into a more potent form. In the prostate t relaxes the tissues that can block the flow of urine. In the scalp it can provide a benefit by reducing the impact of the potent testosterone on the testosterone sensitive hair follicles. Clinical trials have shown that good results can be achieved ( Kaufman KD et al 1998 J Am Acad Dermatol).  Approximately one third of patients can see significant re-growth. It generally works better if taken early on in the balding process and possibly works better in younger men. It is unlikely to work in established male pattern balding. The drug is blocking some of the effects of testosterone. Potential  side effects  include breast growth , erectile dis-function and loss of libdo. The reported  frequency of these side effects is variable but they are only significant in a minority of patients.   The benefits of this drug will only last as long as you take the drug. The testosterone sensitivity of your hair follicles will continue to progress according to their genetic destiny. If you are destined to be completely bald but have a good response to Propecia you could find that you rapidly go from full hair to very little hair on stopping the drug. The effects of finasteride on sperm health have been studied. Low sperm counts are seen in patients taking finasteride but the levels are not thought to be so low as to reduce fertility (Anitha B et al 2009). Cessation of the drug should allow recovery of sperm production (Amory JK et al 2007).

Hair transplantation

Hair transplant surgery has been going on for over 50 years. In the last 10 years the techniques have improved significantly and impressive results can be achieved.  The surgery works by taking hair follicles from the back of the scalp, which are not testosterone sensitive, and transplanting them to affected areas at the front. Individual follicles are re-positioned by microscope assisted surgery. Great care is taken to implant hairs at the correct angles to create a natural look. There are a variety of different techniques. Neograft is a newer method where multiple small donor samples are taken. this is felt to have some advantages over the strip method where a larger strip of hair is taken from the back of the head and then dissected into small follicular units. One problem is that it is hard to predict how far male pattern balding is going to progress. Anyone going ahead needs to accept that further surgery may be needed to top up new areas of balding.

The almost total absence of bald male Hollywood actors (genetically impossible) shows how effective it can be ( of course, some may wear toupees). Mobile operating theatres that visit the homes of stars, who start their treatments very early, allow those with money to escape their follicular destiny. Other well-known personalities have started to be more open about the surgery including the footballer Wayne Rooney, who had a reasonable  result, and Robbie Williams who recently confessed to having a small “thatch” procedure done at the frontal hair line.

For most people going ahead with hair transplants is a big decision both personally and financially. You should only have this done by a clinic with a good track record who are happy to spend time pre-operatively talking through all the pros and cons and who offer a complete price package with no hidden extras.  SkinCompare makes no recommendations for clinics but the International Alliance of Hair Restoration Surgeons is a reasonable place to start enquiries.


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