I’ve had a thinning spot on the top of my head for almost 10 years.

I’ve been using Minoxidil and Finasteride since 2004, and the combination seems to be working. I may have a little regrowth, but the important thing is that the spot seems not to be growing.

My question is this: Is there anything else I should be doing? The whole “Laser combs” thing sounds like a fly-by-night industry to me - do they really work?

Thanks in advance.

– Keith in NYC

Answer:

Hi Keith. You have a good question which has a highly debatable answer. The main idea behind the “laser comb” is basically that it increases the circulation in the area where the low level laser light therapy is used. This increase in blood flow to the follicles, according to the laser comb promoters, has a positive effect on the follicles which causes an overall decrease in hair loss.

I have a problem with the supposed mechanism by which the laser comb works to prevent hair loss. While I don’t dispute the comb’s ability to cause a transient increase in blood flow, I do feel that this does not treat the underlying cause of the hair loss. In my opinion, hair loss is not the result of a lack of blood supply to the scalp but rather, it is a result of the negative effects of DHT binding to the follicle receptors. This concept is widely accepted as the root of male pattern baldness and is the reason why finasteride helps prevent hair loss (by lowering the DHT level). Since the laser comb therapy does nothing to change the level of DHT at the receptor site, I do not feel that it has much more than a placebo-type effect on hair loss.

In practice, I have not heard many good things about laser comb therapy. I have had a few patients state their belief that the comb has helped stop their hair loss, but these are usually patients who are also taking finasteride. The problem in this lies in the fact that if a patient is taking two treatments at the same time, it is difficult to gauge the overall effects of each individual treatment. Basically, it is hard to show that the comb had any beneficial effects, as the hair loss prevention may have been attributable only to the finasteride.

I am going to point out one more issue regarding the comb. The laser comb does have FDA approval, though this may be misleading. The technology behind the laser comb has been around for decades. The FDA approval for this device is not based on any amazing new studies. Rather, it has been approved because the technology pre-dates when the FDA began its supervisory role. Therefore, this device did not have to pass through today’s stringent FDA approval process.

Brandon Ross, MD
http://www.rmhri.com
IAHRS Recommended Hair Transplant Surgeon

I am 57 and have had multiple hair transplants with great results. I suffer from male pattern baldness. Two years ago I began taking testosterone and HGH replacement therapy under the direction on an anti-aging physician. My concern is by increasing testosterone/DHT, am I at risk of loosing the grafted hair. What has been your experience with patients using hormone replacement therapy and hair loss. Could propecia mitigate the potential side effects of hormone replacement and hair loss?

Answer:

First of all, if you were going to experience any loss of hair, transplanted or otherwise, you would have noticed by now, having taken testosterone (T) and HGH for two years. The loss would be the greatest in non-transplanted hair.

Theoretically the transplanted hair originated from a zone of follicles free of DHT receptors so they should not be affected by DHT or T. In reality the transplants behave like the donor hair and there have been reports of thinning of transplants if the donor hair thins. Most often this thinning is seen with age (senile alopecia) but can also be associated with medications or systemic illness. Fortunately the incidence of this is low. By taking T, DHT will most likely increase. As a precaution finasteride could be taken to lower the concentration of DHT. Finasteride reduces the amount of DHT by 70%. If you are increasing T and therefore DHT, even with blockage of 70% of the production of DHT there will still be more DHT.

So the answer to your question is yes finasteride could potentially decrease hair loss from DHT produced by an increase in exogenous T. One has to be aware of the side effects of finasteride which are well documented.

Bradley Wolf, MD
http://www.wolfhair.com
IAHRS Recommended Hair Transplant Surgeon

I have been on 1.25mg of finasteride daily for the last 10 years, over the last year my MPB went from a norwood 2 to a 4 aggressively. I am now contemplating .5mg of dutasteride every other day, I understand that dutasteride isn’t FDA approved for MPB, some studies in 2002-03 revealed more hair counts as opposed to finasteride, but the drug just fizzled away.

Do you believe that by taking dutasteride, it may decrease shed and increased hair counts better then finasteride. Secondly what is the status quo in reference to taking dutasteride for MBP.
Answer:

It is not uncommon for 5 alpha-reductase inhibition to ultimately fail. My belief is that they prolong the anagen duration and therefore delay the inevitable, which is hair loss. All hairs cycle through a growing (anagen phase), to a resting (telogen phase), and to involution (catagen phase). This ultimately leads to exogen or temporary loss of the hair. I believe that hairs have a limited number of cycles. Once they reach the critical number of cycles, they begin to miniaturize and this in a single cycle. Miniaturized hairs become finer with less pigment. They grow slower and the anagen duration is less, which means they will not grow as long as they did prior to the onset of miniaturization. It is not possible to eliminate the resting phase altogether, but you can delay its onset.

A number of products seem to help with the prolongation of anagen. These include minoxidil, Finasteride, Avodart, and Nizoral shampoo. One can also consider saw palmetto, the laser comb, and other products that can prolong anagen such as Hair Cycle shampoo and conditioner. I generally recommend that individuals consider maximal medical management to help maintain their hair. It certainly is a better alternative than surgery for many individuals.

Combination therapy with a 5 alpha-reductase inhibitor and minoxidil is probably better than either alone.

If you are considering Avodart, you should probably take 0.5 mg every day for 2 weeks and then three times a week on Monday, Wednesday, and Friday is probably adequate. If you plan to take it every other day, you should probably still take it every day for the first 2 weeks.

It is true that Avodart did increase hair counts above finasteride in phase two clinical trials, but phase three trials were never undertaken. I suspect that the company assumed that there was more risk than reward and suspected that physicians would still prescribe it off label for hair loss.

Anecdotally, many individuals seem to respond better to Avodart than they did to finasteride. However, I have also heard of some patients who said finasteride worked better for them. You should read the warnings on the product information prior to taking Avodart. You are blocking both 5 alpha-reductase type one and two with Avodart. Finasteride primarily blocks type 2. This could lead to more long term side affects though none have been identified to date. One would expect more sexual dysfunction on Avodart than on Finasteride, but I have heard some say they had less sexual dysfunction on Avodart than they had on Finasteride.

There are also other factors that cause hair loss besides 5 alpha-reductase activity, as well. It could also be that you were on a plateau of stable hair loss for a prolonged period of time unrelated to the intake of Finasteride and that you have suddenly experienced a progression in hair loss. This scenario seems less likely given your long period of stability. Certainly, if you hair loss is bothering you, you should consider your alternatives provided that finasteride is no longer maintaining your hair.

No one has studied the status quo with regard to Avodart, but it does seem to work better based on phase two clinical trials.

John P. Cole, MD
http://www.forhair.com
IAHRS Recommended Hair Transplant Surgeon

Why do I need to use Propecia and Rogaine? Why can’t I just have a hair transplant?

Answer:

The simplest way to answer these questions is to give you an analogy. A dentist does not prevent tooth decay, toothpaste prevents tooth decay. Just like tooth decay, hair loss is a progressive disease for men and women. You will continue to lose hair (usually about 4% density per year) if you do not use the “toothpaste” that prevents the hair loss – which is Propecia and Rogaine.

You can have a hair transplant, if you are a candidate. I can increase density by approximate 20% with one procedure. But that means after 5 years, you have essentially lost what you had gained. Then you need another transplant, and the cycle continues.

The greatest limitation to hair transplants is the fixed and limited amount of donor hair you have. The majority of patients don’t have enough to keep up with the progression of their hair loss. If I can help you prevent that hair loss with the medical therapies, then I can minimize the amount of restoration you will need and you will be a much happier and more satisfied patient.

Paul J. McAndrews, MD
http://www.hairgrowthdoctor.com
IAHRS Recommended Hair Transplant Surgeon

I will be 30 years old in November and have been on Propecia for 21 months to prevent further hair loss. Fortunately it has significantly slowed the rate of loss, but did not regrow any hair. I am mostly stable now, although there is still some slight regression. Currently, I am a NW2.5V patient on the scale with more loss on the crown and less at the hairline.

I prefer to have the FUE procedure to fill in the existing frontal hairline (as this has not receded from its original location, but rather has become less dense), the mid scalp, and the crown. My goal is to restore adequate density to provide coverage over the affected area.

I am concerned about shock loss in the transplant area due to the relatively broad coverage of the existing hair, so please address this issue in your response. Please advise my options, including the estimated number of grafts to achieve the desired results and the associated costs of the procedure.

Answer:

At 30 even using Propecia, you could and probably will lose more hair. For this reason I’m not a big fan of grafting the crown in men less than 35. The only one exception to this rule is if FUE is used. If extensive loss ensues you could cut your hair short without seeing a linear scar. You do have noticeable loss in the hairline which is more amenable to transplants and where results would be noticed. You have diffuse loss behind the hairline to the crown, more loss in the crown. I’m not sure what you mean when you say “adequate density to provide coverage over the affected area.” Some would think the coverage you have now in the mid-scalp is adequate.

The density could be increased in the crown but the change wouldn’t be as noticeable as in the hairline. The mid-scalp looks pretty thick from the photos. There could be shock loss where the hair is the thickest. The more grafts one attempts to place between existing hairs the greater the chance of shock loss. The density you have in the crown and mid-scalp is difficult to work with, too thick to dense pack without significant shock loss which would limit a big visible increase in density.

It would help to clip your entire scalp with a clipper without a guard. This would need to be done in the donor area anyway. Clipping the recipient area reduces shock loss and allows me to see the spaces better. Plus if there is shock loss you won’t notice as the new hair grows in with the shocked hair to some extent. I do everything possible to avoid shock loss.

It’s difficult to say how many grafts without examining you. Roughly I would say I could get up to 2000 in the hairline and between existing hair back to the crown if the entire area where clipped short. It may be fewer. That’s the good thing about FUE; you can stop when you fill the spaces. With strip you have to use all you take, which generally isn’t a problem.

You can view fees on my website at: http://www.wolfhair.com/service/fees.shtml I hope I haven’t confused you. But the bottom line is from the photos, it would be difficult to get a lot of grafts between existing hairs behind the hairline due to existing density.

Bradley Wolf, MD
http://www.wolfhair.com
IAHRS Recommended Hair Transplant Surgeon

- When should I start seeing the results of Propecia’s use on those smaller hairs at my hairline (the only place where I am losing hair)?

- Assuming Propecia cannot grow back the hair already completely lost at the hairline, I would like to consider a minor hair transplant sometime this fall to help recreate my hairline. What are your thoughts on that, considering I will always keep the highest level of commitment to keeping my hair for the rest of my life?

- As you know, my hairline is extremely important to me (probably more important than any other feature on my body) and is of the utmost concern. Couple that with the gray hair factor at my early-mid 20s and this is something I really feel is in my best interest for the future.

Answer:

At your age I would still recommend using Propecia for at least one full year before contemplating surgery. We saw you May 21 so I would say doing surgery this fall would be too early. It does take a full year to 18 months to see the full effect of the Propecia. At 6 months you may see stoppage of loss and/or decreased shedding but in no way will you see the full effect. Propecia’s strength is not in restoring the hairline to its former thickness but it can really help the hairline. As we discussed when you were in my office, you are too young to put permanent hair in the relatively small areas of loss. I know they are big areas to you but it would be ideal to see the full effect of Propecia before thinking of surgery. You can also use minoxidil (Rogaine) in these areas.

-Bradley Wolf, MD
http://www.wolfhair.com
IAHRS Recommended Hair Transplant Surgeon

I had hair restoration surgery performed by Dr. Wolf in June 2006 (about 1 year ago). I am satisifed with the results, but I am wondering if there is any continuing maintenance I should know about.

I have been using regular shampoo, going in the sun, etc. Are there ways to maximize the results going forward, or things that I might do at this point which could damage the hair?

Also, my procedure concentrated on the frontal hairline. Some of the new hairs are wavy/frizzy. Is there a good way to deal with this?

Answer:

The best was to prevent hair loss of un-transplanted hair is to use minoxidil and Propecia. Minoxidil (Rogaine) now comes in a foam preparation which is much easier to use than the liquid. Propecia is available from us if you aren’t already on it. Sun, dyeing, straightening, all damage the hair after it exits the skin. The best way to treat this type of damage is to avoid the conditions. You can go out in the sun, just use a conditioner to treat sun damage. A conditioner will help with the post transplant kinkiness also. This should be getting better and will continue to improve to a point. Sometimes when it is really humid my transplants are kinky.

-Bradley Wolf, MD
http://www.wolfhair.com
IAHRS Recommended Hair Transplant Surgeon