Most men eventually lose hair at the sides of the forehead. This mainly occurs at or after middle age, but it can start at any time after puberty. In fact, most balding men say that they first noticed the problem when they were in their mid-20s. Some men also lose hair from the top of their head, then eventually only the sides and back of the head have hair, forming a horseshoe shape. This is known as common baldness, androgenic alopecia or male pattern baldness.
If you were able to look at the bald area under a microscope you would see that there are the same number of hair follicles as before, but each is miniaturized, the hairs being produced are fine, short and pale, and more of the follicles than usual are in the resting phase.
It is impossible to predict how quickly anyone will lose hair. One study found an average rate of hair loss of about 5% per year. Once they have started to notice hair loss, most men take 15–25 years to lose most of their hair, but a few are completely bald after 5 years. The rate of hair loss usually varies; a lot of hair may be lost over a 3–6-month period, and then no more for 6–18 months. This makes it very difficult to tell whether ‘treatments’ are having an effect (Journal of Investigative Dermatology 2005;10:P184–189; British Journal of Dermatology 2010;162:843–847).
Causes of Male Pattern Hair Loss
Male hormones. Maleness was recognized by Aristotle as a cause of baldness. He wrote that no boy, woman or castrated male ever becomes bald and he thought that baldness was a sign of virility (he was bald himself!). To a large degree, science has proved him right. Baldness is the result of hair follicles reacting to male hormones. However, men with male pattern baldness do not have more male hormones than other men. It is simply that their hair follicles are more responsive to the hormones.
The main male hormone is testosterone. Both men and women have testosterone in the blood, but men have more. The skin of the scalp converts testosterone to another substance called dihydrotestosterone (DHT for short). Hair follicles in areas that are destined to become bald are especially sensitive to DHT – it makes them shrink. Follicles on the sides and back of the head are not affected by DHT.
Confusingly, DHT helps growth of the beard and hair on the chest. This explains why bald men can have bushy beards and hairy chests. Nobody knows how DHT produces opposite effects on hair growth on different parts of the body.
Heredity (genetics). If you have relatives with thin hair or who are bald, you may do too in time. This tendency can be inherited from either the mother’s or the father’s side of the family (but the mother herself would usually be unaffected, or her hair might start thinning after the menopause). Inheritance probably makes the follicles extra-sensitive to DHT.
Ageing. Baldness is more likely with increasing age: 40% of men have noticeable hair loss by age 35; and 65% by age 60. Most elderly people have thin, fine hair even if they are not noticeably bald.
What You Can Do about Male Pattern Hair Loss
Go bald gracefully: cut your losses. If you do go bald, is it really a disaster? Before embarking on expensive and possibly disappointing treatments, consider the alternative. Bald men look clean and elegant (as long as they keep their remaining hair close-cropped and avoid the notorious ‘comb-over’ of 25 strands of hair across the bald patch!).
Baldness shows the world that you don’t wish to spend your time fussing with lotions, pills or hair transplants. It also demonstrates that your male hormone system is fully functioning. If anyone comments, remind them of the traditional belief that bald men are so vibrant and fiery that their passion burns out the roots of their hair. French footballer Zinedine Zidane said after his team’s demolition of favoured Brazil in the 2006 World Cup “My baldness gives me strength!”
Most surveys show that women do not care if men are balding but cannot bear the scrape-over. So cut your losses – keep your hair really short and go bald gracefully.
Look after your hair and scalp. Avoid anything that could make the hairs liable to break. For example, after washing do not rub your hair vigorously or use a hot hairdryer. Instead, pat it dry with a soft towel or use a low setting on the dryer or, even better, let it dry naturally. Use a brush with soft bristles. Undo any tangles with your fingers, rather than pulling with a comb.
Protect bald areas from sun damage. Make sure to use sunscreen for your scalp. There are different products available that have been specially developed for this purpose.
Consider minoxidil lotion. If you are really bothered by your hair loss, you could consider using minoxidil lotion. It can be bought from pharmacies without a prescription.
Minoxidil lotion stimulates hair growth in balding areas. It works by keeping hair follicles in the growth phase for longer, so hairs grow bigger and the rate of further thinning slows down. The lotion is applied to the scalp and spread lightly with a finger – it does not need to be massaged in. With the 2% lotion, no effect is seen for the first 3 or 4 months. The 5% minoxidil may be slightly more effective.
To decide whether minoxidil lotion is likely to help, you need to examine your scalp closely, preferably with a magnifying glass. It is tricky to look at the top of your own head, so next time you visit the barber take a magnifying glass with you. Ask the barber to tell you whether the ‘bald’ areas actually have plenty of fine, short hairs. Or ask a friend to look.
You are a good candidate for minoxidil lotion if:
- you have been bald for less than 5 years
- your bald area is less than 10 cm across and/or your main problem is general thinning
- hair loss is mainly at the top of the head
- your bald area has lots of tiny, fine hairs.
Minoxidil lotion is not likely to help if:
- you are completely bald
- your main problem is receding hair (frontal loss)
- the bald scalp has very few tiny, fine hairs.
What you should know about minoxidil lotion:
- It is not successful for everyone – only about 35% of men have noticeable regrowth of hair, and this is often fine and downy – and the manufacturers advise users to give up if there has been no regrowth after using it for 1 year.
- It has to be applied twice a day, 7 days a week and does not produce a permanent cure. If the treatment is stopped, the follicles go back to how they would have been without minoxidil lotion. About 10–12 weeks after starting minoxidil lotion you may notice some extra hair loss. Take no notice; these are simply the old short downy hairs at the end of their life.
- It is important to read the manufacturer’s leaflet, as minoxidil lotion is probably not suitable for some people. For example, it should probably not be used by people taking drugs for blood pressure, or who have angina. The solution contains alcohol and can cause irritation in some people.
What Your Doctor Can Do about Male Pattern Hair Loss
Your doctor can discuss several other treatments with you: the drug finasteride; hair transplantation or scalp reduction surgery; oral minoxidil; and the drug dutasteride.
Finasteride is a drug that prevents testosterone from being converted into DHT. In most countries it is available on a private prescription. (The same drug, in a larger dose, is used to treat prostate problems.)
Because finasteride is a once-daily tablet rather than a lotion, it is more convenient than minoxidil lotion, and it seems to be at least as effective as minoxidil lotion. It seems to be more effective for baldness at the top of the head than at the front. Like minoxidil lotion, it works best if the bald areas have lots of fine, thin hairs. It has to be taken indefinitely if hair growth is to continue. If you stop taking it, about 6 months later you will notice a change, and by 9–12 months you will be back to where you started. Studies of men who have taken it for 2 years suggest that the longer it is taken, the thicker and longer the hairs become. Men have continued to take it for 5 years with good results (European Journal of Dermatology 2002;12:38–49).
How effective is finasteride? In a 1998 study, 945 men with male pattern baldness took 1 mg finasteride and 600 similar men were given dummy tablets to act as a comparison group. The results of the study (Journal of the American Academy of Dermatology 1998;39:578–589) were as follows.
- Some hair growth occurred in 66% of men who received finasteride.
- On average, a bald patch 2.5 cm in diameter grew 107 extra hairs.
- Not much improvement occurred before 3 months.
Does finasteride cause any problems? The 1998 study showed that finasteride causes sexual problems in a few people.
- Decreased sexual desire was reported by 1.8% of men (but also by 1.3% given the dummy tablets).
- Difficulty in achieving an erection was reported by 1.3% of men (but also by 0.7% given the dummy tablets).
- A decrease in the amount of semen was reported by 0.8% (but also by 0.4% given the dummy tablets).
However, these sexual problems gradually lessened with long-term finasteride use and they were not permanent (they disappeared when treatment was stopped).
The most worrying problem with finasteride is that, in a pregnant woman, it might possibly interfere with development of the baby’s genitals if the baby in her womb is male. This means that a woman who is pregnant or who could become pregnant should not handle crushed or broken finasteride tablets. And when a man is taking finasteride, there will be a tiny amount in his semen; during intercourse this will be transferred to the woman. Therefore, some doctors believe that a couple should not try to conceive if the man is taking the drug.
Future Treatments for Male Pattern Hair Loss
Various other drugs such as ketoconazole, dutasteride and latanoprost are being or have been investigated as possible new treatments to encourage hair growth. Many dermatologists are using dutasteride routinely now.
Unfortunately, we are stuck with the number of hair follicles that we are born with – no new follicles ever develop naturally. Treatments such as minoxidil lotion (minoxidil) and finasteride do not grow new follicles; they work only if there are living follicles left and encourage these badly performing follicles to produce hair. Researchers are now concentrating on the possibility of actually growing new follicles.
British researchers have been taking cells (rather than actual hairs) from an individual’s hair follicles at the back of the head, multiplying the cells many times over in a test tube and then reimplanting the cells (using tiny injections) into the bald area where they should form new hairs. This is called follicular cell implantation. If successful, this technique may be available for anyone in a few years’ time.
Hair Transplants and Surgery
Hair transplantation is a surgical procedure, based on the fact that hair follicles from the sides and back of the head will continue to grow, even when transplanted to bald areas. The reason for this is that hair from these locations, when exposed to androgens, does not become miniaturised. They are androgen-‘insensitive’.
In the past, small plugs of skin less than half a centimetre across and containing about 100 hair follicles were transplanted. These plug grafts were not very successful, because they gave an unnatural tufted appearance, like doll’s hair, but are still sometimes used to give coverage in the middle of large areas.
The hairs on the scalp are not spaced evenly. If you look at someone’s scalp with a magnifying glass, you will see that the hairs are in groups with 2–4 hairs in each group, with single hairs scattered between. Nowadays, surgeons are able to transplant tiny groups of hairs, so the result looks much more like the natural pattern.
What is involved? After a local anaesthetic injection, a piece of skin is removed from an area where there is still plenty of hair and where it will not show, such as the back of the head, just above the neck (the donor site). This area is repaired by stitching, but a scar will remain. Most patients have 90–100 follicular units per cm2 in their donor area. Therefore, in a hair transplant of 2,000 follicular unit grafts, a donor strip that was 1 cm wide would need to be slightly over 20 cm long to yield the appropriate number of grafts.
The surgeon cuts out the tiny grafts (groups of hairs) from this skin; this is the most skilful part of the procedure. Each graft may contain two or three hairs or may just be a single hair.
Another method of obtaining the grafts is by using a special punch that removes each graft individually.
The grafts are placed in tiny incisions in the bald area. The hole to receive each graft is made with a needle, a scalpel or a laser. The grafts do not need any stitches; they are held in place by the clotting action of the blood. The donor site and the grafts heal very quickly, because the scalp has a very good blood supply.
Usually, an individual will need 300–700 grafts, but of course this depends on the size of the bald area. A good surgeon will place them carefully, to give the most natural appearance. Usually, single hairs are placed near the front hairline, and two-hair and three-hair grafts further back. About 100 are done at each session, which takes about 3 hours. The hair can usually be washed the next day. After a few months it is often difficult to distinguish between the grafts and the areas of normal hair.
Issues to think about. Hair transplantation is a cosmetic surgery operation, so you need to think about it carefully to ensure that it is done properly, that you will not be overcharged, and that you have an accurate idea of what the result will be. Look at the section on choosing a cosmetic surgeon and discuss the operation with your family doctor.
The main disadvantage of hair transplantation is that the procedure is drawn out and costly. Also, many men are dissatisfied with the result. This may be partly because expectations are too high. It also depends on the skill of the surgeon. Choose a reputable clinic and have a detailed preliminary discussion so that you know what the result will be. Find out how many sessions you will need, what coverage you will achieve and precisely what the total cost will be.
You should also ask what possible problems might occur. For example:
- as with any surgical procedure, there is a risk of infection of the skin
- the new grafts may not grow properly (and if this happens, nothing can be done)
- the transplanted hair may be a slightly different colour from the surrounding hair, but this can be disguised by a colorant if necessary
- scarring or a lumpy appearance known as ‘cobblestoning’ may occur but are unlikely with the modern small grafts.
If you have tight curly African hair, you need a particularly detailed discussion with the surgeon, because hair transplantation could be problematic. Firstly, the hair follicles are curled, so it is more difficult for the surgeon to prepare the tiny grafts; they may be damaged and not grow well. Secondly, each graft may develop an unsightly lumpy scar, so the surgeon should do an initial test by transplanting just two or three to an inconspicuous area.
Implantation of artificial hair. Some clinics also offer implantation of artificial hair, which has the same strength, thickness and colour as your hair. Each hair is inserted individually by an injection technique. This is also not to be recommended, because the scalp never gets used to the foreign material, and there is always a risk of infection and rejection with inflammation. Although the result may look good to start with, in time the hairs will break.
Scalp reduction (scalp excision) is a surgical operation in which the hairless portion of the scalp is pulled up tightly and the excess removed surgically, so that the area that has no hair is reduced. It is best for older men whose scalps are looser. There will be a scar from the incision, but this will fade in time. The result can sometimes look odd, because the remaining hair may be pulled up to an unnatural position. The advantage is that it is usually a one-off procedure, unlike hair transplantation.
What Not to Bother With
Some treatments certainly do not work. The most popular medical book of our great-grandparents’ day, The Household Physician, advised that baldness could be prevented by “quickening the circulation in the scalp, such as by washing the head every morning in cold water, then drying with a rough towel by vigorous rubbing, and brushing with a hard brush until the scalp becomes red”.
Others recommended smearing the area with fresh cowpat or rubbing in onion juice, curry paste or Marmite with a stiff brush to irritate the scalp.
In fact, lack of circulation is not the problem in baldness and these measures would make the problem worse by damaging the hairs. Similarly, hanging upside down to improve the circulation in the scalp will not produce any improvement.
It used to be thought that excess grease on the scalp caused hair loss, and male pattern baldness was called seborrhoeic (greasy) baldness. In fact, bald areas appear greasy only because there is no hair to take up the grease; the actual amount of grease being produced is normal. Some baldness cures claim to act by reducing grease; they make no difference. Removing grease makes hair look more fluffy but does not actually increase the amount of hair.
Some treatments probably do not work. Thousands of products for baldness are advertised in the small ads and on the Internet. They claim to make hair regrow, or simply to stop further loss. Almost all are a complete waste of money.
Most have not been assessed by proper research studies and aim to persuade by one or two true life success stories. Because hair loss is often noticeable for a month or two and then stops for a few months, it is easy to imagine that a product is having an effect. Without proper research studies, treating hundreds of people with the product and an equal number of similar people with a dummy version of the treatment (a randomized, placebo-controlled trial) it is impossible to know one way or the other about effectiveness and safety. So before trying a private treatment, ask the company for a copy of published evidence about the treatment and ask your family doctor to check it.
- Fenugreek is a herb with a chemical structure similar to the drug minoxidil. It is claimed that it may delay hair loss when applied to the scalp. (It is also claimed to help baldness by dilating blood vessels, but this is nonsense.) It can be taken as a tea or as tablets.
- Saw palmetto extract comes from a palm tree. Its chemical structure is similar to finasteride, but its action is very weak and so it is unlikely to make any difference to baldness. Proper scientific studies to investigate whether it is effective have not been done.
First published on: embarrassingproblems.com
Reviewed and edited by: Dr Ahmed Kazmi
Last updated: October 2020