Hair replacement: what works, what doesn't

FDA Consumer, April, 1997 by Larry Hanover

When the advertising slogan "Be Like Mike" caught America's fancy, it wasn't because every man decided to go for the Michael Jordan look by reaching for a razor and shaving his head.

Sure, men like Jordan, Charles Barkley, and "Star Trek's" Patrick Stewart are part of a small minority who are proud of their baldness. But combating and covering up hair loss hasn't turned into an estimated $1 billion-a-year industry because Americans like the idea of hair collecting in the shower drain.

"It probably represents aging," says Ken Washenik, M.D., director of dermatopharmacology at New York University Medical Center. "I think our concept of a bald person is of an older person. I think anything that reminds us in the mirror every day of the inevitability of aging is less than optimal."

When you talk about restoring hair, you're essentially looking at three different approaches. The first is to medicate, using a 2 percent solution of minoxidil found in Rogaine (and other brands since Pharmacia & Upjohn's patent expired in February 1996). Minoxidil is the only drug approved by the Food and Drug Administration for regrowing hair.

That doesn't mean minoxidil is by any means the panacea that men have been searching for since at least 1150 B.C., when Egyptians covered their baldness with a mixture of fats from ibex (a mountain goat), lion, crocodile, serpent, goose, and hippopotamus.

Surgical procedures, including hair transplantation and scalp reduction, are another modern-day approach. And, finally, there's the solution that Julius Caesar, according to legend, used in ancient days--cover it up. The most powerful man in the Roman Empire is said to have turned to the ceremonial wreath of laurel leaves to hide his ever-emerging scalp. The modern alternative is the hairpiece.

Uncovering Baldness

When discussing baldness, which affects an estimated 40 million men and 20 million women in the United States, the topic is generally about a hereditary condition called androgenetic alopecia. Ninety-five percent of hair loss is of this variety.

Male-pattern baldness refers to the upward retreat of the hairline from the forehead, as well as an expanding area of fallout from the crown of the head. In the end, all that might be left is a horse-shoe-shaped fringe around the sides and back of the head. Female-pattern baldness, which recently has received more attention since Pharmacia & Upjohn began packaging and marketing Rogaine separately for women, refers to a diffuse pattern of hair loss throughout the scalp.

Research continues in search of ways to treat androgenetic alopecia and allow hair to sprout in barren scalps. But, at this time, all you can do, if you're a man, is to look at your father's head and your mother's father's head to see how they fared, because chances are you'll wind up with a similar fate. In addition, female-pattern baldness can be passed down from mother to daughter.

"I think it's just the luck of the draw what your genetics are," says Allan Kayne, M.D., a dermatologist and assistant clinical professor of medicine at the University of Washington Medical Center in Seattle.

In male- and female-pattern baldness, the culprit is something called dihydrotestosterone, or DHT, which is derived from androgen, a male hormone. Circulating through the bloodstream, androgen is converted to DHT by the enzyme 5-alpha reductase. Those with greater enzyme activity have more DHT binding to hair-follicle receptors. If flooded by DHT, the follicles sprout thinner and thinner hairs until nothing regrows, and the follicles eventually wither away.

Minoxidil

Currently, if you want to regrow hair, topical minoxidil is the only approved way to go. As Washenik explains, no one is quite certain how minoxidil, an oral medication originally approved to treat high blood pressure, works to grow hair.

To be effective, minoxidil must be used twice a day. It works better on those who are younger and whose hair loss is recent, according to clinical studies by Pharmacia & Upjohn.

Those studies show that 26 percent of men between 18 and 49 reported moderate to dense hair regrowth after four months of Rogaine treatment. An additional 33 percent had minimal hair regrowth. Almost 20 percent of women between 18 and 45 had moderate regrowth, while an additional 40 percent showed minimal regrowth.

A company spokesman said the research accounted for the fully pigmented hair fibers normally seen on the scalp and not vellus hair, which is more like peach fuzz. Many doctors, however, say the number of their patients who have as much success is much lower, and some find that only vellus hair appears.

"I have not been that impressed that it helps regrow hair," Kayne says. "I think that occurs in a very small minority."

One plus that Denise Cook, M.D., medical officer in FDA's division of dermatologic and dental drug products, points out is that patients report a decrease in shedding due to minoxidil use, though whether that perception is the result of fewer hairs being lost or more hairs being produced is unknown. Normally, you should lose only about 100 hairs a day.