Male pattern baldness or androgenic alopecia is men’s most common form of hair loss. It is estimated that around 40% of men will have noticeable hair loss by age 35. This rate increases with age, which sees approximately 50% of men over 50 having noticeable hair loss, 65% by the age of 60 and 80% by the age of 80.
Male pattern hair loss results in diminished self-esteem, reduced confidence and distress in affected men, irrespective of age or stage of baldness. As an androgen-dependent condition, androgenetic alopecia can present soon after puberty. Early onset can be significant psychological distress. Male pattern hair loss is characterized by androgen-related progressive thinning of hair in a defined pattern. The hair follicles undergo progressive miniaturization, so the hairs shrink in size over time, eventually leaving a bald scalp.
Genetic factors and androgens are critical role players in male pattern hair loss. Both the testosterone metabolite DHT and the genes for hair loss must be present for AGA to occur.
Male pattern hair loss is associated with many genes. A novel study revealed more than 250 different genetic locations associated with severe hair loss. Some of these genes provide instructions for making androgen receptors that allow the body to respond appropriately to DHT and other androgens. Studies suggest that this excessive activation of androgen receptors in hair follicles leads to follicular miniaturisation through a progressively shorter anagen phase, resulting in thinner and shorter hair follicles that may not even penetrate through the epidermis.
The rate of progression differs from individual to individual, and variation is also observed in affected family members.
The temporal regions are usually the first places where hair is lost in males. In some men, the loss stops there and never progresses, while in other men, hair loss continues into other areas of the scalp. While almost all Caucasian men will eventually face some degree of male pattern baldness, Asian men, and East Asians in particular, have historically experienced the lowest incidence of hair loss in the world.
Getting specialised medical advice is essential when dealing with hair loss. While androgenetic alopecia is the most common cause of hair loss in men and women, other conditions can also contribute to it. These conditions may not be recognised until a physician hair restoration specialist diagnoses them. There are many causes of hair loss, and not all can be treated the same way. A complete medical evaluation is essential to ensure each patient achieves the best long-term outcome.
Androgenetic alopecia is usually diagnosed clinically with a history of gradual onset after puberty, and, often but not necessarily, a family history of baldness. A biopsy is generally not necessary unless the diagnosis is unclear. Dermoscopy shows miniaturised hair and a few other signs which can help differentiate from diffuse alopecia areata.
Male pattern hair loss occurs in an array of patterns illustrated in the Norwood-Hamilton Scale.
Norwood classification is one of the most detailed classification systems for male patterned hair loss.
Today, many promising treatment options are available to men experiencing hair loss. There are safe and effective ways to restore your hair, whether your hairline is receding, your crown is losing thickness, or you have thinning hair all over your scalp. Early treatment of male pattern baldness achieves a more optimal outcome.
The overall goal of treatment in AGA is to arrest miniaturisation and improve hair density.
Finasteride 1mg daily is FDA approved for the treatment of male pattern hair loss, and it is the most effective way to prevent hair loss in men. The influence of finasteride on hair count is most significant on the vertex scalp. It can improve hair density on the frontal scalp to a lesser degree and is least effective in the temporal regions. Finasteride can also enhance hair calibre. Patients who fail to respond in the first year are likely to be non-responders’ long term. Finasteride needs to be continued indefinitely to maintain efficaciousness. Side effects of finasteride include lowered libido, erectile dysfunction, reduced ejaculatory volume, temporary reduction in sperm count, testicular pain, depression and gynecomastia.
Topical finasteride may be a good alternative for men who are uncomfortable with oral finasteride. The topical administration of finasteride can reduce systemic effects associated with its mechanism of action by inhibiting 2-α reductase in the scalp. Compared to oral finasteride, it has a markedly lower systemic exposure and less effect on serum DHT levels.
Topical finasteride has only been studied as a topical treatment for androgenetic alopecia in a small number of randomized controlled trials. These studies, however, show promising results and non-inferiority to systemic delivery.
In the current market, topical minoxidil and finasteride are combined in a variety of formulations.
Topical minoxidil is available over-the-counter and in various strengths, up to 5% solution. Higher strengths are more effective. Minoxidil has been shown to prevent hair loss in 2 out of 3 men. It prolongs the anagen phase of the hair follicle and transforms the miniaturised follicles into terminal hair follicles. Several meta-analysis studies have confirmed the high quality of evidence for using minoxidil to treat male pattern hair loss. The most common adverse effects are pruritus and local irritation with resulting flaking. The latter is usually due to propylene glycol or alcohol in the formulation of the drug.
Dutasteride is now considered a treatment option in male pattern baldness due to its good response shown by various studies and meta-analyses. In most of these studies, dutasteride was found to be better than finasteride with similar adverse effects. In the UK, dutasteride is not yet approved for the treatment of hair loss, and its use is off-label. Dutasteride, however, might become a treatment of choice for AGA in the future.
Low-level laser therapy and Micro-needling may also help prevent hair loss in men, especially in combination with pharmacologic therapies. Additional studies are required to define and validate optimal treatment protocols.
Androgenetic alopecia progresses over time, and although the currently available medical treatments like finasteride and minoxidil are effective in arresting the progression of the disease, they allow only partial regrowth of hair. While progress has been made in the medical management of androgenic alopecia and several physical therapies are emerging, hair transplantation remains the best treatment for advanced disease.
If you are concerned with hair loss and live in Glasgow, Edinburgh or anywhere in Scotland, we’d love to talk about how we can help you get your hair and confidence back for good.
As a member of the International Society of Hair Restoration Surgery (ISHRS), the world’s leading medical authority on hair loss and restoration, Dr Bonaros is committed to providing the best possible guidance and care for patients suffering from hair loss. Book your consultation today and discover the most effective hair loss treatments for men available at our clinic in Glasgow.
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