PracticalDermatology

Androgenetic alopecia remains a common concern for patients and their dermatologists, but the range of treatment options continues to grow. As noted in a 2021 review published in the Journal of the American Academy of Dermatology, male androgenetic alopecia and female pattern hair loss are the most common reasons for hair loss consultations with dermatologists.¹ Some of these patients can be treated with oral or topical medications, while others are candidates for surgery.

When it comes to hair loss, “Most patients are worried about whether they have an inherited condition and to what extent their hair will thin or whether they will go bald; this group falls into the inherited pattern baldness category which affects most of us,” said Peter Panagotacos, MD, a dermatologist and cosmetic surgeon in private practice in San Francisco, CA, in an interview.

By contrast, some individuals who develop hair loss in response to stress, such as pregnancy or being infected with COVID-19, may develop a telogen effluvium, said Dr. Panagotacos, who specializes in hair loss and hair transplantation. Telogen effluvium is generally self-limiting, with most or all of the hair regrowing within 6 months, he said, “but the condition can leave the scalp very sparse with noticeably thin hair, a widened part line, and a receding hairline.” For these patients, “There are treatments to help stimulate the lost hairs to grow back, such as minoxidil, laser caps, and shampoos which can stimulate hair. On rare occasions, the thinning is so great they become candidates for hair transplantation,” he said.

Untangling Disinformation

The greatest challenge in treating hair loss, according to Dr. Panagotacos, is to dispel the myths and misinformation that patients encounter when they search for solutions online.

For example, many patients fear side effects from finasteride (Propecia) as an option for male pattern baldness, he said. However, a 1-mg dose of finasteride “is one of the safest medications around,” he said.

Patient education is key, and most patients will begin the best treatments for male pattern baldness once they learn the true incidence of side effects, said Dr. Panagotacos. In double-blind clinical trials, “fewer than 1 in 200 patients wanted to stop the pill after 2 years,” he said.

As for other options, topical minoxidil (introduced as Rogaine in 1998) continues to be successful in stimulating hair growth, said Dr. Panagotacos. Low-dose oral minoxidil (LDOM) became available in 2016, and has become quite popular not only because of its effectiveness, but because “it doesn’t require a lotion that will mess up a hairdo,” he noted. In his experience, most patients who use LDOM for male pattern baldness have been pleased with the results.

Some concerns persist about the potential for serious adverse effects, such as pericardial infusion, Dr. Panagotacos noted. However, a 2021 multicenter study published in the Journal of the American Academy of Dermatology found no life-threatening adverse events, and a 1.7% discontinuation rate across 1,404 patients aged 8 to 86 years.2

Additionally, dutasteride has shown success in postmenopausal women and in men who inherited extensive baldness patterns, said Dr. Panagotacos.

Low-level laser light treatment remains an option for some patients and has been shown to be as effective as topical minoxidil, Dr. Panagotacos continued. Platelet-rich plasma (PRP) injections also work about as well as either topical minoxidil or laser therapy, he said. “Each works with a different mechanism of action, therefore using all three gives a better response,” he noted.

Growth in Grafting

The use of follicular unit grafting (FUG), introduced in 1992 by Bobby Limmer, MD, involves taking a strip of skin from a donor area and represents an improvement over the use of 4 mm punches to harvest hairs, explained Dr. Panagotacos. This method is known as follicular unit transplant (FUT) and individual units are removed from the tissue strip using a dissecting microscope.

“The FUT strip surgery method of Dr. Limmer still holds its place as the gold standard for producing the best grafts, and for leaving the hair long in the donor area instead of having the back of the head shaved as needed for the FUE techniques,” Dr. Panagotacos said. “The follicular unit grafts are essentially the same, but with the FUT technique, they are subjected to less trauma and end up growing better,” he said.

Alternatively, the follicular unit extraction (FUE) strategy is the method of choice for those men who have closely cut hair and do not want the linear scare of a FUT, and it is also an option for patients who are not good candidates for FUT. In this method, only follicular units are removed, yielding naturally occurring groupings of 1,2, and 3 hairs.

The evolution of FUE technology includes the development of various motorized hand-held punches with either sharp or dull punches, some vibrated to decrease transection, others with suction, Dr. Panagotacos said. The development of a robot, the ATASiX, can produce these grafts as well as most of the hair transplant surgeons, he noted. “The main advantage of FUE is that it is relatively pain-free and scar-free, as there is no cutting or need for sutures,” Dr. Panagotacos noted. “The small 1mm holes close to tiny dots that are often undetectable 6 months later,” he said.

On the Horizon for Hair

“Thirty years ago, I predicted that one day we would be able to rub a cream on thinning hairs or bald spots, with some way of delivering the hairy genes to replace the balding genes; others have had similar ideas and promoted cloning of hairs or hair multiplication as the way to provide more hairs to redistribute to the thinning areas,” Dr. Panagotacos told Practical Dermatology. “Several companies are working on this, and every 5 years there is a media blitz that says ‘Cloning of hairs is going to be possible in the next few years,’” although the hair restoration world is still waiting, he said.

Optimize Outcomes With Proper Planning

Ultimately, the goal of hair restoration, whether through oral means, topical means, transplantation, or a combination, is to optimize outcomes for patients with minimal discomfort.

“Any hair transplant procedure is a matter of taking hair from where there is abundant supply and redistributing it to thin or bald areas so it looks normal,” said Dr. Panagotacos. “There have to be enough hairs in the donor area to move around.”

Dr. Panagotacos recalled, “In 1992, I had a patient who continued balding despite a number of hair transplants, and he asked me to use his body hair. That was the first case of body-to-scalp hair transplantation. In his case we used pubic hairs in 1993, and beard hairs in 1994.”

Since then, more options have become available. “Luckily, finasteride came on the market in 1998 and now most patients can stop the ongoing nature of male pattern baldness,” he noted.

“Ideally, the hair transplant surgeon is also a dermatologist, and can examine the scalp closely to make sure there are no signs of lichen planopilaris, which may have thinned out the hair or may get reactivated by surgery to the scalp,” Dr. Panagotacos emphasized. Before proceeding with hair transplantation, any active scalp diseases, such as seborrheic dermatitis or psoriasis, need to be addressed. Once any of these conditions are under control, the transplant procedure can proceed, he said.

However, inadequate amount of hair is a challenge, so proper planning is essential, said Dr. Panagotacos. “If a patient is extremely bald there is not going to be enough hair to redistribute. Hair only grows 1/2 inch per month. Hair then goes through a transition phase when moved, and this takes 4 to 5 months,” he said. “So, we can’t give a full head of hair to a bald guy who wants to look good for his wedding in 3 months.” The message to patients: Plan ahead for success, and see your hair transplant surgeon well in advance of an important event.

1. Jiminez F, Alam M, Vogel JE, Avarm M. Hair transplantation: Basic overview. J Am Acad Dermatol. 2021 Oct;85(4):803-814. Epub 2021 Apr 24. Accessed July 2, 2023. doi:10.1016/j.jaad.2021.03.124.

2. Vano-Galvan S, Pirmez R, Hermose-Gelbard A, et al. Safety of low-dose oral minoxidil for hair loss: A multicenter study of 1404 patients. J Am Acad Dermatol. 2021 Jun;84(6):1644-1651. Epub 2021 Feb 24. Accessed July 2, 3023. doi:10.1016/j.jaad.2021.02.054.