Managing Aesthetic Concerns of Alopecia
New treatment options
by Dr Israr KJ Wong
Alopecia, a general title for a myriad of hair conditions, is regarded by many medical practitioners to have only aesthetic effects on sufferers. That is not entirely true. Hair is an important feature of self-image and its loss is associated with significant psychological morbidity.
Men who suffer from Androgenetic Alopecia (Male Pattern Hair Loss) are 75% less confident, especially when interacting with the opposite sex.1 Young men with hair loss have reported loss of self-esteem, introversion, and feeling unattractive to a higher degree than older men with hair loss.1 Women are more likely, than men, to have a lowered quality of life2, and to restrict social contacts as a result of hair loss.3 This is because women generally place a greater emphasis than men on physical appearances and outward attractiveness. It is further exacerbated by societal norms, which dictate that hair is an essential contributor to a woman’s sexuality and gender identity. Any form of hair loss generates feelings of low self-esteem and anxiety from a perception of diminished attractiveness. It may be important to note the psychological/social improvement with successful treatment of alopecia.
This article will briefly discuss the most commonly encountered alopecia conditions – Androgenetic Alopecia and Female Pattern Hair Loss – and focus on their treatment.
Figure 1. Norwood-Hamilton Classification
Male Pattern Hair Loss (MPHL)
Male Pattern Hair Loss (MPHL) is the most common type of alopecia in men. It may affect up to 70% of men.5 Hair loss begins in the teenage years, starting at the bi-temporal region of the anterior hairline. It progresses with a receding hairline, followed by hair loss over the vertex and mid-frontal areas. The occipital scalp is spared.
Testosterone is converted by 5-Alpha Reductase (5-AR) into Dihydrotestosterone (DHT). DHT binds to androgen receptors with five times the tenacity of testosterone, causing the effects of decreased anagen duration, increased telogen duration and transformation of terminal to vellus hair follicles. These result in miniaturisation of hair.
MPHL is diagnosed clinically by a non-scarring typical pattern hair loss and no laboratory workup is necessary unless there is a superimposed diffuse hair loss. The widely used classification system is the Norwood-Hamilton classification. MPHL is an ongoing process, therefore medical treatments are long-term. The two first-line FDA-approved treatments for MPHL are oral Finasteride and topical Minoxidil.
Oral Finasteride is first-line treatment for Male Pattern Hair Loss not involving the temples. Finasteride is more effective over the vertex and superior-frontal region of the scalp, compared with a minimal response over the temporal and anterior hairline region.9 The temporal and anterior hairline regions are best treated with hair transplant.
Two distinct forms of 5-AR exist, differing in tissue distribution. Type I exists in liver, skin and scalp, while Type II is found in the genito-urinary tract, prostate and hair follicles. Finasteride is a highly selective inhibitor of 5-AR Type II. Taken orally, it reduces DHT levels in serum and scalp by up to 70%6. Recommended dosage is 1mg once daily taken with or without food. It has been shown to improve both total and anagen hair counts.7 Finasteride prevents or slows the progression of MPHL, and about two-thirds experience some improvement.8 Effects become noticeable after three to six months, and the improvement peaks at around 12 months. A common mistake is to stop the medication when there “does not seem to be an effect” after one to two months. Finasteride may cause loss of libido, ejaculatory dysfunction, and gynaecomastia in around 2% of users.8,9 These are temporary and resolve upon cessation. In a small number of patients, adverse sexual effects with a temporal link to Finasteride intake have been reported to last up to 40 months upon cessation. However, the study has a few important limitations and it is still inconclusive as to whether Finasteride causes persistent sexual side effects.10 Dutasteride is a non-selective 5-AR inhibitor with superior hair growth effects, as compared to Finasteride, in a dose-dependent fashion.14 The side effects are also more common. Currently, it is only approved for MPHL in Korea.
Minoxidil was discontinued as an antihypertensive drug because of its side effect of developing significant hypertrichosis. The topical form is FDA-approved for treatment of Male Pattern Hair Loss. The recommended dose is 1mL applied twice daily on the dry scalp and left in place for at least four hours. Adverse effects include skin irritation, hypertrichosis on the face and hands, and tachycardia.11 Minoxidil monotherapy in MPHL may not halt the process of miniaturisation which is under the influence of androgens.
Figure 2. Ludwig System
Female Pattern Hair Loss
Female Pattern Hair Loss (FPHL) is the most common cause of alopecia in women. It affects 6% to 12% of women between the ages of 20 and 30 years, and more than 55% of women older than 70 years.12 It presents clinically with diffuse, non-scarring hair loss, with prominent thinning over the frontal, central and parietal scalp. The front hairline is characteristically retained. Follicular miniaturisation (similar to that of MPHL) is seen. Diagnosis is made clinically based on appearance of the scalp. Biopsies are reserved only for situations when the diagnosis is uncertain. Laboratory tests for hormone levels, thyroid function, iron/ferritin studies, prolactin, and zinc may be useful. Classification is based on the Ludwig system. The role of androgens remain uncertain, therefore FPHL has emerged as the preferred term rather than Androgenetic Alopecia in women.13
Treatments for FPHL can be dichotomised into androgen-dependent and androgen-independent.
Anti-androgenic drugs for androgen-dependant FPHL include spironolactone, cyproterone acetate, finasteride and dutasteride. Finasteride and dutasteride are contraindicated in women of child-bearing age due to feminisation of a male foetus. Women of child-bearing age on 5-AR inhibitors should use strict birth control and should not handle crushed or broken pills. Androgen-independent drugs include topical minoxil and topical ketoconazole. The use of ketoconazole shampoo, especially in combination with finasteride, results in increased hair growth in FPHL.15 The mechanism by which it increases hair growth is unclear. However, we do know it has anti-inflammatory and anti-fungal properties. It also affects steroidogenesis locally and decreases DHT levels at the hair follicle.16
Low Level Laser Therapy
Low level laser therapy (LLLT) has been widely used for reducing pain, inflammation, oedema and promoting healing of wounds. Its use in the treatment of hair loss is now widely accepted and efficacious, with a host of devices available. Of note are FDA-approved devices for MPHL and FPHL, HairMax Laser Comb and iGrow Hair Rejuvenation System. They make use of red light wavelengths in the range of 650nm to 670nm. LLLT works by stimulation of mitochondria to produce more ATP and cyclic AMP, increasing oxygen uptake by cells.17 It is recommended as an adjunct to medical therapy and post-hair transplant patients.18 Usage is three times a week, between 15 and 20 minutes each time. Visible results can be noted after three months of usage.
Hair Transplant
Figure 3. iGrow Hair Rejuvenation System
Hair transplant is a permanent solution to recreating hair density and restoring aesthetic proportions of the face. It is indicated for Male Pattern Hair Loss (especially fronto-temporal hairline), Female Pattern Hair Loss (involving frontal hairline in advanced stages or response to non-surgical therapies inadequate), Alopecia Areata (stable condition for more than one year) or Scarring Alopecia (due to secondary causes like burns, trauma, surgery).
Androgen-sensitive hair follicles are located on the frontal scalp and vertex, whereas androgen-independent hair follicles are present on the sides and occipital region. This is why the strip of hair at the occiput remains unaffected even in advanced MPHL. The principle of hair transplantation is based on the fact that hair follicles harvested from the occipital scalp retain their androgen-independent behaviour when implanted in the frontal scalp. This is also known as “Donor Dominance”. Dermis of the frontoparietal scalp is derived from the neural crest, whereas dermis of the occipital and temporal scalp is derived from mesoderm. This difference in embryonic origin may explain the differential influence of androgens.19
Figure 4. HairMax Laser Comb
Hair grafts extracted from the donor area must be implanted to mimic the direction and density of hair originally present to look natural. Advances in hair transplant techniques now allow hair grafts to be extracted from non-scalp areas like beard, neck, chest and the abdomen.20, 21 Hairs can also be transplanted to non-scalp areas like eyebrow22, eyelash23, moustache24, beard24 and the pubic area.25,26
Telogen Effluvium occurs in the first three months post-operatively to the newly transplanted hairs. It is important to inform all surgical candidates that transplanted hairs will drop in the first three months. The transplanted hairs regrow after three months and the best aesthetic results is at 18 months. Therefore, it is recommended to perform hair transplant at least nine months before any important social event that the candidates are planning (i.e. wedding, convocation, etc).
By recreating the fronto-temporal hairline, the patient’s forehead is lowered and the aesthetic proportions of the face restored. This restores youthfulness to the patient’s look. The before-after difference is marked, bringing about much satisfaction both to the doctor and the patient. It is performed under local anaesthesia and has a very low complication rate, thus gaining in popularity.
Figures 5 and 6. Recreating the fronto-temporal hairline during hair transplant.
Novel treatments
Novel treatments still awaiting big-scale, randomised controlled trials include topical application of growth factors27 and 17-alpha estradiol topical lotion28, which have promising results in pilot studies for Female Pattern Hair Loss.
Conclusion
Hair loss has a detrimental psychological and mental effect besides the obvious aesthetic effects, which tends to be downplayed in some physicians. Many treatment options besides the traditional ones (Finasteride and Minoxidil) exist. Multiple treatments together, started in the early stages, give the best results. Hair transplant is a safe, permanent treatment solution for refractory cases. It is also indicated early in cases with fronto-temporal hair loss (which does not respond to most medical therapies).
References
1 Banka, Kristine Bunagen, Jerry Shapiro Pattern hair Loss in men : Diagnosis and medical Treatment Dermatol Clin 31(2013) 129-140 2 Cash TF, Price VH, Savin RC Psychological effects of androgenetic alopecia on women : Comparisons with balding men and with female control subjects J Am Acad Dermatol 29:568-75 3 Van Neste, Rushton Hair Problems in Women Clincal Dermatol 1997;15:113-115 4 Rajendrasingh J Rajput Is there a role for adjuvants in the management of male pattern hair loss? J Cutan Aesthetic Surg. 2010 May-Aug; 3(2): 82-86 5 McElwee, Jerry Shapiro Promising therapies for treating and/or preventing androgenic alopecia Skin Therapy Letter 2012;17(6) 6 Drake L, Hordinsky M, Fiedler V, et al. The effects of finasteride on scalp skin and serum androgen lvels in men with androgenetic alopecia. J Am Acad Dermatol 1999;41:550-4 7 Van Neste D, Fuh V, Sanchez-Pedreno P, et al. Finasteride increases anagen hair in men with androgenetic alopecia. Br J Dermatol 2000;143:804-810 8 Kaufman KD, Olsen EA, Whiting D, et al. Finasteride in the treatment of men with androgenetic alopecia. Male Pattern Hair Loss Study Grop. J Am Dermatol 1998;39:578-89 9 Leyden J, Dunlap F, Miller B et al. Finasteride in the treatment of men with frontal male pattern hair loss. J Am Acad Dermatol 1999;40”930-937 10Stough DB, Rao NA, Kaufman KD, et al. Finasteride improves male pattern hair loss in a randomized study in identical twins. Eur J Dermatol 2002;12:32-37 11Shapiro J, Price VH. Hair Regrowth. Therapeutic Agents. Dermatol Clin 1998;317:865-9 12Gan DC, Sinclair RD Prevalence of male and female pattern hair loss in Maryborough J Investig Dermatol Symp Proc 2005;10(3):184-9 13Olsen EA Female Pattern Hair Loss J Am Acad Dermatol 2001;45:S70-80 14Olsen EA, Hordinsky M, Whiting D, et al. The importance of dual 5alpha-reductase inhibition in the treatment of male pattern hair loss: results of a randomized placebo-controlled study of dutasteride versus finasteride. J Am Acad Dermatol 2006;55:1014-23 15Hugo Perez BS. Ketoconazole as an adjunct to finasteride in the treatment of androgenetic alopecia in men. Med Hypotheses 2004;62:112-5 16Inui S, Itami S. Reversal of androgenic alopecia by topical ketoconazole: relevance of anti-androgenic activity. J Dermatol Sci 2007;45:66-68 17Oron U, Ilic S, DeTaboada L, Streeter J. Ga-As (808-nm) laser irradiation enhances ATP production in human neuronal cells in culture. Photomed Laser Surg. 2007;25:180-2 18Satino JL, Markou M. Hair Regrowth and increased tensile strength using HairMax Laser Comb for low-level laser therapy. Int J Cosmet Aesthet Dermatol. 2003;5:113-7 19Ziller C. Pattern Formation in neural crest derivatives in Hair research for the next millennium. Amsterdam:Elsevier Science;1996,p.1 20Woods R, Campbell AW. Chest hair micrografts display extended growth in scalp tissue: a case report. Br J Plast Surg 2004:57:789-91 21Sanusi U. Hair transplantation in patients with inadequate head donor supply using nonhead hair. Ann Plast Surg 2011;67:332-5 22Laorwong K, Pathomvanich D. Eyebrow Transplant. In: Hair Restoration Surgery in Asians. Springer;2010 p.215-20 23Jiang WJ, Jing WM, Wang XP, et al. Aesthetic Result of dense packing single hair autologous grafts for eyelashes. Zhonghua Zheng Xing Wai Ke Za Zhi 2011;27:111-3 [in Chinese] 24Kulahci M. Moustache and beard hair transplanting. In:Hair Transplantation. 5th Edition. Informa Healthcare;2011.p. 464-6 25Lee YR, Lee SJ, Kin JC, et al. Hair restoration surgery in patients with pubic hair atrichosis or hypotrichosis: review of techniques and clinical considerations of 507 cases. Dermatol Surg 2006;32:1327-35 26Toscani M, Fioramanti O, Ruciani A, et al. Hair Transplantation to restore pubic area. Dermatol Surg 2008;34:280-2 27BL Young, Sun Yun Young, JH Lee, MS Cheon, YG Park, BK Cho, HJ Park. Effects of topical application of growth factors followed by microneedle therapy in women with female pattern hair loss: A pilot study The Journal Of Dermatology 2013;Vol40;1:81-83 28JH Kim, SY Lee, HJ Lee, NY Yoon, WS Lee The efficacy and safety of 17-Alpha Estradiol Solution on Female Pattern Hair Loss : Single-center, Open-Label, Non-comparative, Phase IV Study Ann Dermatol 2012;Vol24;3:295-305
Dr Israr Wong Kai Jie heads the Hair Restoration Service at David Loh Surgery Hair and Body Center (Liat Towers). Dr Wong is a member of the Society of Aesthetic Medicine Singapore, the American Academy of Aesthetic Medicine (AAAM) and the International Society of Hair Restoration Surgery (ISHRS). He was trained in hair restoration and transplant techniques by the renowned Maxwell Hair Clinic in Seoul (top three hair clinic in S.Korea), and the alizi Hair Transplant Clinic in Georgia (record holder of world’s largest hair transplant session). He is also certified by SMC to perform general aesthetic procedures and is trained personally in general aesthetic procedures by Dr David Loh, who is one of the pioneers of aesthetic medicine in Singapore. He takes part regularly in local and overseas conferences and courses and enjoys updating his medical knowledge by reading up on the latest scientific papers weekly. Contact him at kjwong@davidloh.sg .
