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What Doctors Don't Tell You

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July 2020 (Vol. 5 Issue 5)

Male pattern baldness

About the author: 

Male pattern baldness image

Medical experts have recently warned that a top-selling anti-baldness drug can cause serious sex-related side-effects and, yet, there's no adequate warning on the label

Medical experts have recently warned that a top-selling anti-baldness drug can cause serious sex-related side-effects and, yet, there's no adequate warning on the label.

Finasteride, sold in the UK and US as Propecia, is used to treat andro-genetic alopecia (AGA) in men-or 'male pattern baldness'. It inhibits 5-alpha-reductase, an enzyme that converts testosterone into another male hormone, 'dihydrotestosterone' (DHT), a key cause of hair loss.

Clinical trials show that finasteride can halt hair loss in up to 90 per cent of users, and can even lead to hair regrowth in roughly half of them (Eur J Dermatol, 2002; 12: 38-49). But doctors in the US and in Ireland claim that the drug can cause impotence and other sex-related side-effects, and are calling for more detailed information to be included in the packaging.

Drugs manufacturer Merck, which makes Propecia, acknowledges on its website that certain sex-related side-effects, such as a reduced desire for sex, difficulty in achieving an erection and a decrease in semen, can occur with the drug, although the company says that less than 2 per cent of men experience such side-effects. They also say that, according to their research, these side-effects will go away once the drug is stopped.

However, there are reports of these sex-related side-effects continuing well after men have stopped the treatment. A recent BBC Radio 1 news report featured the case of 26-year-old James, who stopped taking the drug after noticing a loss of libido. He expected the problem to go away, but things only got worse. "After about three weeks . . . I more or less became completely impotent," he said.

James was then put on testosterone therapy, a lifelong commitment. Sadly, that didn't work, so he has now been offered a penile implant.

"Every day, I wish I could turn back the clock," said James. "It did work well for my hair, but the cost is ridiculous-losing my sex life."

Merck claims that such cases are extremely rare and could be caused by something other than finasteride. However, a recent study of the drug noted that "[p]rolonged adverse effects on sexual function such as erectile dysfunction and diminished libido are reported by a subset of men, raising the possibility of a causal relationship" (J Sex Med, 2010 Dec 22; Epub ahead of print).

Also, a safety investigation by the Swedish Medical Products Agency has advised that Propecia may result in irreversible sexual dysfunction. The Agency's updated safety information lists difficulty in obtaining an erection that persists indefinitely, even after stopping the drug, as a possible side-effect. A public assessment report in 2009 by the UK's Medical and Health-care Products Regulatory Agency (MHRA) also noted persistent erectile dysfunction after stopping treatment with Propecia as a possible undesirable effect.

Other side-effects associated with finasteride include allergic reactions such as rash, itching and hives, swelling of the lips and face; breast tenderness and enlargement; and testicular pain. Finasteride has even been linked to depression and male breast cancer (J Cosmet Dermatol, 2010; 9: 331-2; Drug Safety Update, 2009; 3: 3).

Other hair-loss treatments

Another drug used to treat AGA is minoxidil (Rogaine/Regaine), a topic-al treatment that has to be applied at least twice a day for four months before any results are seen. However, in addition to possible allergic skin reactions, there's also the risk of systemic effects due to absorption of the drug through the scalp. Such reactions include blurred vision, chest pain, very low blood pressure, fast or irregular heartbeat, headache and weight gain (WDDTY vol 16 no 3).

Fortunately, there is a growing num-ber of promising non-pharmaceutical options for dealing with baldness.
Saw palmetto (Serenoa repens) can inhibit 5-alpha-reductase levels by 32 per cent with no effect on testosterone in men. Extracts of the plant have also demonstrated an antagonistic effect on testosterone receptors. Both these actions-together with its impressive safety profile-make saw palmetto a useful and safe herbal hair-loss remedy (Cutis, 2004; 73: 107-14).

In 2002, US researchers tested the efficacy of saw palmetto for mild-to-moderate male pattern baldness in a double-blind, placebo-controlled study. Altogether, 26 men were given, twice daily, either a softgel containing 200 mg of saw palmetto extract with 50 mg of beta-sitosterol, a plant sterol found in saw palmetto, or a placebo. The result was that 60 per cent of those taking the active softgel rated their hair growth as improved compared with only 10 per cent of those taking the placebo (J Altern Complement Med, 2002; 8: 143-52). Beta-sitosterol and saw palmetto are both components used in the commercial hair-loss product HairGenesis (
Other herbs may also be beneficial when applied topically. When the 7.5-per-cent herbal hair cream HairPrime ( was tested in
24 men with moderate-to-severe AGA, after 40 weeks, the hair counts of those using HairPrime increased by 77 per cent compared with 3 per cent in the placebo group. But it didn't work for everyone; nearly one-third of users saw only a modest response (J Dermatol Treat, 1996; 7: 159-62).

The exact formula of this herbal hair cream is a proprietary secret. However, the European Handbook of Dermatological Treatment by A.D. Katsambas and T.M. Lotti (Springer, 2003) states that the product includes extracts of fennel, buckwheat, mint, chamomile, Thuja and hibiscus in a water-based cream.

Green tea shows promise as a hair-loss remedy. One Korean review noted that the polyphenol epigallocatechin-3-gallate (EGCG) in green tea might be able to prevent or treat AGA by inhibiting 5-alpha-reductase activity. They reported the results of test-tube studies showing that EGCG can stimulate the growth of human hair (Phytomedicine, 2007; 14: 551-5). However, much more research is needed before any recommendations can be made.
Vitamin E, a potent antioxidant, may also have a role to play in treating male pattern baldness. A study by Malaysia-based company Carotech, presented at the Vitafoods International Conference in Geneva in 2009, revealed that a patented tocotrienol (a form of vitamin E) complex might increase hair growth in people with AGA by 42 per cent.

The eight-month, randomized placebo-controlled trial gave 28 volunteers with AGA either the tocotrienol complex (total tocotrienol, 100 mg) or a placebo (a softgel capsule with 600 mg of soybean oil). Hair coverage, measured by counting the number of hairs in a preselected 2 x 2-cm area, was significantly increased by an average of 41.8 per cent with tocotrienol, eight of whom had more than 50-per-cent new hair growth. The placebo group, on the other hand, saw no significant improvement in hair coverage, and only one volunteer showed a more than 20-per-cent increase in hair count ( index/news/219.html). These results, how-ever, have yet to be officially published.

Other antioxidants such as beta-carotene, lycopene, lutein, zeaxanthin, zinc and vitamin C may also help hair loss. As oxidative stress could be playing a role in AGA, antioxidants-known to scavenge free radicals-may help (J Cutan Aesthet Surg, 2010; 3: 82-6).

Zinc may be especially useful, as it's an essential cofactor for a number of enzymes and is also involved in important functional activities in the hair follicle (Ann Dermatol, 2009; 21: 142-6). Zinc can also reduce 5-alpha-reductase activity in rat prostate tissue, although such animal results may not apply to humans (Andrologia, 1993; 25: 369-75). Although clinical studies in AGA patients are lacking, one study in men with alopecia areata (patchy hair loss) reported that zinc supplementation had positive therapeutic effects in nine of the 15 patients studied (Ann Dermatol, 2009; 21: 142-6).
Aromatherapy may be worth a try, according to the evidence so far. In a randomized controlled trial of 86 patients with alopecia areata, half of them massaged their scalp daily with essential oils (thyme, rosemary, lavender, and cedarwood in a mixture of carrier oils), while the other half massaged their scalp with only carrier oils, also daily. The researchers found that 44 per cent of the essential-oil group showed improvement compared with only 15 per cent of the control group (Arch Dermatol, 1998; 134: 1349-52).

Another trial, this time in men and women with male pattern baldness and lasting 26 weeks, showed that essential oils used in combination with pulsed electromagnetic field therapy (PEMF; a technology more commonly used for healing bone fractures) can significantly reduce hair loss and improve hair counts compared with a placebo in more than half of cases
(Adv Ther, 2003; 20: 220-9).

Low-level light therapy (LLLT) has recently been approved by the US Food and Drug Administration (FDA) for the treatment of hair loss (South Med J, 2010; 103: 917-21). This form of non-invasive therapy uses low-energy laser beams to stimulate hair growth.

Previously, this sort of treatment was only available at hair-loss clinics, but the technology has now been adapted for home use. The HairMax LaserComb is one such home-use device, and has recently been tested
in a randomized, sham-device-control-led, double-blind trial of 110 men with male pattern baldness.

Compared with the group using the sham device, the men who used the HairMax LaserComb saw significant improvements in hair density and overall hair growth (Clin Drug Investig, 2009; 29: 283-92).
However, one downside of this hair-loss treatment is that the device is expensive, costing between lb290 and lb460, depending on which model you choose (see for more information).
Lifestyle changes may have some benefit for hair loss. According to one report, fried foods and red meat should be avoided to reduce the over-all activity of the oil- and sebum-producing glands, which are the sites of 5-alpha-reductase activity, as hyper-active glands can lead to higher levels of conversion to the DHT that causes male pattern baldness.

The report also recommends avoid-ing sugary foods such as chocolates, sweets and cakes, as well as foods that contain artificial flavourings, additives and preservatives. On the other hand, sprouts, green leafy vegetables, pulses and nuts, along with plenty of water every day, can provide the nutrients required for healthy, glowing hair (J Cutan Aesthet Surg, 2010; 3: 82-6).

Smoking is another lifestyle habit to avoid, as nicotine is known to reduce blood flow to the hair follicles and can also lead to the buildup of damaging free radicals in hair roots. One study found a strong connection between smoking and the incidence of male pattern baldness in men (Arch Dermatol, 2007; 143: 1401-6).
Stem cells are now being studied as a future cure for baldness. When a team of researchers compared bald and hairy patches in scalp samples from men with AGA, they discovered that, although both bald and hairy patches had similar numbers of stem cells, most of the cells in the bald patches had failed to develop to the next stage. Stem cells that had matured into so-called 'progenitor cells' were 10 to 100 times more abundant in the hairy patches than in the bald ones, thus suggesting that they are essential for new hair growth.

Currently, the research team-from the University of Pennsylvania School of Medicine in Philadelphia-is trying to work out why some stem cells become dormant while others remain active, in the hope of developing a
new hair-loss treatment. Preliminary studies in mice had suggested that stem-cell transplants might be able to regenerate hair growth (J Clin Invest, 2011 Jan 4, pii: 44478; Epub ahead of print).
Joanna Evans

What about hair transplants?

Hair transplantation has come a long way, and the latest techniques are able to achieve very natural-looking results. One such technique is called 'follicular unit extraction' (FUE). This is a sutureless method of hair restoration in which hair follicles are extracted from the back of head under local anaesthesia-using special tools called 'micropunches'-and implanted in the bald areas. This is an extremely labour-intensive method, however, which means it's the most expensive type of hair transplant procedure (J Cutan Aesthet Surg, 2010; 3: 76-81). A typical session can set you back around lb7000, and you may require multiple sessions. Although the more traditional hair-transplant techniques are cheaper, you could still end up spending up to lb10,000 in total-depending on the extent of your hair loss.

Besides the hefty pricetag, the other drawback with hair transplantation is that it's not risk-free. Common side-effects include pain, swelling and scabbing, while more unusual problems include bleeding and infection.
Yet another aspect to consider is that some techniques can leave obvious scarring where the donor hair has
been removed. Finally, even when the surgical procedure goes perfectly and no scarring is visible, hair transplantation is not a cure for baldness. This means that you may well continue to lose hair around the grafts.

WDDTY VOL. 21 NO. 11

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