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FAQ's
General Questions About Hair Loss Questions About Rogaine / Minoxidil / Topical
Questions About Propecia / Proscar / Finasteride Specific Treatment Questions


General
Q: What Is Hair, Really?
A: "The adult human body averages five million hairs, of which 100,000 to 150,000 are on the scalp. Hair is composed of keratin, the same protein that makes up nails and the outer layer of our skin. The part seen rising out of the skin is called hair shaft or strand. Each strand consist of three layers. The outermost protective layer (cuticle) is thin and colorless. The middle layer, or cortex , is the thicknest. It provides strength, determines your hair color and whether your hair is straight or curly.

Hair color is determined by melanin from your pigment cells. The more pigment granules there are, and the more tightly packed, the darker the hair. Two kinds of melanin contribute to hair color. Eumelanin colors hair brown to black, and an iron-rich pigment, pheomelanin colors it yellow-blonde to red. Whether hair is mousy, brown, brunette or black depends on the type and amount of melanin and how densely it's distributed within the hair. For example, deep-black African hair contains closely packed melanin in the cortex, a few in the cuticle. Very dark European hair, quite apart from having more melanin granules than lighter or blonde hair, has more melanin per granule. When pigment-producing cells cease to function, the result is the uncolored white or gray hair.

In Caucasians, true blonds typically have more hair (about 140,000 hair) than brunette (about 105,000) or redhead (about 90,000).

Below your skin is the hair root which is enclosed by a sack-like structure called the hair follicle. Tiny blood vessels at the base of the follicle provide nourishment. A nearby gland secretes a mixture of fats (called sebum) which keep the hair shiny and waterproof to some extent. At the base of the follicle is the papilla, which is the "hair manufacturing plant." The papilla is fed by the blood-stream which carries nourishment to produce new hair. Male hormones or androgens regulate hair growth. Pubic and axillary (armpit) hair are particularly androgen-sensitive and grow at lower androgen levels than hair on the chest or legs. In boys, most pubic hair is grown by age 15, followed by the development of armpit hair two to three years later. In girls, too, an increase in androgens at puberty triggers growth of pubic and armpit hair. Scalp hair, not directly androgen-responsive, is influenced by local amounts of a testosterone derivative, dihydrotestosterone.

Hair follicles initially form in utero. No new follicles are created after birth, and none are lost in adult life. The first hair to be produced by the fetal hair follicles is Lanugo hair, which is fine, soft, and unpigmented. This is usually shed in about the eighth month of gestation. The first postnatal hair is vellus hair, which is fine, soft, usually unpigmented, and seldom more than 2 cm long. Vellus hair remains on the so-called hairless regions of the body, such as the forehead and balding scalp. At puberty, the vellus hair in some areas is replaced by terminal hair, which is longer, coarser, and pigmented. Growth starts in the pubic region; then the eyelashes and eyebrows become thicker. Axillary hair and male facial hair appear about two years after growth of pubic hair begins. Body hair continues to develop long after puberty, stimulated by male hormones that paradoxically, also cause terminal hair to be replaced by vellus hair when balding begins.

Scalp hair fibers grow from 100,000 to 350,000 follicles which are reported to occupy the human scalp; however, not all the follicles are productive. In each producing follicle, the duration of the hair's life cycle is influenced by age, pathology and a wide variety of physiological factors.[1,2] The life cycle is divided into the anagen (active), catagen (transitional) and telogen (resting) phases.

The anagen phase is the period of active hair growth where protein synthesis and keratinization are continuously occurring. In normal subjects, this phase lasts for up to five years, although longer durations have been documented. The cessation of the anagen phase is characterized by a transitory phase known as catagen. This phase lasts for two to three weeks. Following the catagen phase, the hair enters the telogen or "resting" phase. In normal subjects, telogen hair is retained within the scalp for up to 12 weeks before the emerging new hair dislodges it from its follicle.

During the anagen phase, protein synthesis is the main distinction of the hair bulb. In the telogen phase, the dermal papilla undergoes renewal. It is at this time that structural characteristics can be modified. The new hair should be identical to its predecessor, but with advancing age, and in some pathological states, a strict copy is not maintained. In these circumstances, the hair may become finer and shorter, modifying the esthetic profile. Since these effects occur over several hair cycles, years may elapse before the affected individual recognizes the difference.

Like skin cells, hair grows and is shed regularly. Shedding anywhere from 50 to 100 hairs per day is considered normal. The average rate of growth is about 1/2 inch a month. It is now known that hair grows fastest in the summer, slowest in the winter, speeds up under heat and friction, but slows down when exposed to cold. Hair grows the best between the ages of 15 to 30. But, hair growth begins to wind down sometime between the ages of 40 and 50. Progressive hair loss begins naturally in both sex about age 50, accelerating in the 70s. About 40 percent of Caucasian men lose hair to some extent by age 35."*

*Source: Health Review Magazine, January 1996. All rights reserved.
**Source: Hair Loss FAQ, Peter H. Proctor, PhD, MD.
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Q: What are the different types of hair loss?
A: • Alopecia Areata is when recurring bald spots or patches occur in the hair, not necessarily on the top of the head. It frequently leads to Alopecia Totalis or Alopecia Universalis.

• Alopecia Totalis is when all or almost all hair on the top of the head is lost.

• Alopecia Universalis is when all or almost all hair on the body is lost (hair on head, eyebrows, eylashes, etc.)

"By far the most common form of hair loss is determined by our genes and hormones: Also known as androgen-dependent, androgenic, or genetic hair loss. It is the largest single type of recognizable alopecia to affect both men and women. It is estimated that around 30% of Caucasian females are affected before menopause. Other commonly used names for genetic hair loss include common baldness, diffuse hair loss, male or female pattern baldness."*

*Source: Health Review Magazine, January 1996. All rights reserved.
**Source: Hair Loss FAQ, Peter H. Proctor, PhD, MD.
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Q: How can I tell if my hair loss is normal?
A: Most of us lose 50-100 hairs a day. Hair loss is a natural process of aging. Overbrushing, excessive blow-drying and harsh shampoos can aggravate the problem. If you're concerned about a few too many hairs on your pillow, see your family doctor or a dermatologist.
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Q: What causes hair loss?
A: There is much debate on this topic. While the link between certain forms of hair loss and the immune system is well-accepted, there is also evidence for a connection between the immune system and pattern loss (androgenic or androgenetic Alopecia). In line with this, it appears that male hormones--especially DHT--trigger an autoimmune response in pattern loss, initiating an attack on the hair follicle that can be observed microscopically. This results in destructive inflammation that gradually destroys the follicle's ability to produce terminal hair. The reason for this could be that androgens somehow alter the follicle, causing it to be labeled as a foreign body. A possibly related factor is that elevated androgens also trigger increased sebum (oil) production, which can favor an excessive microbial and parasitic population, also leading to inflammation. In any case, hair progressively miniaturizes under the withering autoimmune attack, so that with each successive growth cycle it gets shorter and thinner until it finally turns into tiny unpigmented vellus hair (peach fuzz).

In men, balding typically follows the classic horseshoe pattern known as male pattern baldness or MPB, though diffuse thinning can also occur. It has been noted that both the number of androgen receptors and the level of 5-alpha reductase, which converts testosterone to DHT, are higher in susceptible areas than in the rest of the scalp. Women's hair loss tends to be diffuse but is also primarily hormonally driven.

The story of balding is, however, not the story of androgens alone. Rather pattern loss appears to have multiple contributing factors once the process is underway. For instance, damage to blood vessel linings can inhibit a growth factor they ordinarily produce: endothelium-derived relaxing factor (EDRF) or nitric oxide (NO). Minoxidil probably works in part by mimicking this growth factor. Similarly it has been noted that severe baldness is strongly correlated with heart disease and even diabetes, so there appears to be some common etiology outside of the strictly androgen paradigm for pattern loss. There are likely other factors as well.
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Q: Is balding hereditary?
A: Genes are believed to be a factor, especially in male pattern baldness. Other medical and environmental conditions, however, may contribute to hair loss.
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Q: What is male pattern baldness?
A: A horseshoe fringe of hair characterizes male pattern baldness, which affects more than 30 million men in the United States alone.
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Q: What is Alopecia?
A: Alopecia is baldness or hair loss believed to be the result of an autoimmune disorder; however, any number of other causes including genes, illness or medications can play a role. About one percent of the U.S. population experiences a form of Alopecia at some point in their lives. Alopecia Areata is a condition where circular patches of baldness suddenly appear. Alopecia Totalis is when all the hair on the scalp falls out. Alopecia Universalis is where every hair on the body falls out. Hair re-growth can occur even after many years.
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Q:

What non-surgical hair loss treatments are available?

A:

There are no hair loss cures but there are treatments. Today, Rogaine (Minoxidil), a topical hair loss solution, and Propecia, a pill used to treat male pattern baldness, are the only two FDA-approved treatments. For those suffering from Alopecia, steroids can be effective in helping to suppress the immune system.

Natural hair pieces are another option for hair loss sufferers. The best hair systems are secure, lightweight and comfortable

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Q:

What surgical hair loss treatments are available?

A:

Hair transplantation is a system of taking hair follicles from an active hair growth area and relocating them to the scalp. Grafting is sometimes performed in conjunction with scalp reduction surgery in which a slice of the bald area is actually removed.

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Q:

Is stress a factor in hair loss?

A:

Sometimes stress can play a role in diffuse loss. Stress-induced loss ordinarily regrows within a year of eliminating the cause.

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Q:

What's the best hair loss treatment?

A:

There is no simple answer to this. No one treatment is spectacular for the average individual. However, there are a few treatments that yield decent results for a majority of people. (Decent is defined here as cessation of further hair thinning and perhaps some regrowth, ranging from a little to moderate.) Some people do respond unusually well--but then some don't respond at all. Most fall somewhere in between.

Since there are multiple factors in pattern loss, it is wisest to approach the problem from several angles to maximize results, as some treatments are complementary and address different underlying causes. A common fundamental approach is to use an "antiandrogen" of some kind, whether systemic (such as finasteride) or topical (such as Spironolactone or azelaic acid), and a growth stimulant such as minoxidil. To this basic program many add a topical SOD. Other options include therapeutic shampoos, such as the antimicrobial and growth stimulant shampoos. Still other approaches that may help include dietary and nutritional considerations and even lifestyle modifications. There are many adherents to such a "kitchen sink" approach.

You can also start with a single treatment, though due to the long lag time before you can actually verify efficacy, this can be very hit and miss and may bring less than optimal results by only addressing one aspect of a larger problem.

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Q:

How long does it take to see results from any treatment program?

A:

At least 2 months, though usually significantly longer. Many do not notice any apparent improvements until well after a year. Best results are often seen after the two-year mark. This is because hair follicles undergo a relatively long dormancy period in between growth cycles (usually about 3 months). In addition, hair only grows about 1/2 inch per month in non-thinning areas and usually considerably slower in thinning areas. Since it generally takes several cycles of growth/fallout/regrowth, with the hair getting thicker and longer each time, it can take a great deal of time to see noticeable improvement. Note that best regrowth results are seen with hair that was lost within the last five years and in areas of the scalp in which there is still some fine hair.

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Q:

Does poor blood ciculations cause hair loss?

A:

Poor blood circulation has been listed as a cause of hair loss, especially since Minoxidil came out, which is a increases blood circulation. Unfortunately, Minoxidil does not grow hair by increasing blood circulation (at least that is not the main way it does). There are literally dozens of drugs that increase drug circulation, none of which grow hair. If bad blood circulation caused hair loss, these would work too, but they don't. Also, bad blood circulation would not be restricted to the top of the head. Since the sides of the head show no loss, this also indicates the problem is not circulation. Any "cure" that tries to address blood circulation is no cure. Bad blood circulation definitely will cause hair loss. It is just not the cause of MPB. There are some indications that blood vessel lining to the hair follicle may become damaged through the process of MPB. Repairing these structures may provide more blood flow to the hair follicle and increase hair growth. However this is not the complete cause of MPB. Vasodialators that increase blood flow probably don't help this problem, since the actual vessels are damaged.

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Rogaine / Minoxidil / Topical Questions
Q:

Are there topical antiandrogens I can use instead of taking something internally such as Finasteride?

A:

Yes. Some things have been used topically to either bind up receptors (Spironolactone or estrogens) or reduce androgens or diminish hormonal impact (azelaic acid, pyridoxal B6, zinc, free fatty acids). There is much debate about the efficacy of these agents. The problem is a lack of study data regarding their use in pattern loss, though there are studies suggesting why these agents may help.

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Q:

What's the difference between Rogaine and Minoxidil and are these actually helpful for thinning hair?

A:

Rogaine is just a brand name for minoxidil. Minoxidil can be purchased from numerous sources and in varying strengths from 2% to 5% liquid and even in a 12.5% micronized lotion. It also comes combined with Retin-A, which improves results by increasing the absorption of minoxidil. (Retin-A also apparently exerts some antiandrogenic effects over time.) MiNOxidil's name betrays its relationship to nitric oxide, an important hair growth messenger that appears to be diminished in balding scalp. Minoxidil can be helpful in pattern loss, but it is not a panacea. It is best used as part of an overall program that attacks the problem from different angles.

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Q:

How effective is Rogaine?

A:

59% of men reported growth after 4 months use of Rogaine. 26% reported moderate to dense regrowth (what most of us would consider acceptable), while 33% experienced minimal regrowth (a few hairs here and there, but not worth the effort). It should be noted that 42% of men using the placebo (containing no minoxidil) reported some growth. 11% reported moderate to dense regrowth (probably due to the propylene glycol, extra massaging, or just overoptimism), while 31% reported minimal regrowth (if you rub just about anything into your head twice a day, you're bound to see one or two hairs here and there).

5% Minoxidil is a non FDA approved version of Minoxidil containg a larger concentration of minoxidil. It is much more effective than the standard 2%. Many who do not respond to 2% will respond to 5%. Unfortunately, since it is not yet FDA approved, it has to be custom made by a pharmacy through a doctors prescription. Due to this, many doctors will not prescribe it. Also, many pharmacies can't or won't make it and most that do sell it at a high price. Many people swear by 5% minoxidil though.

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Q:

Who is the ideal Rogaine candidate?

A:

The ideal Rogaine candidate is a young male (20s) with little (thinning) hair loss on the crown/vertex, or a small bald spot 1-2" in diameter. The less you match this description the less likely Rogaine is to work for you.

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Q:

Is it OK to apply Minoxidil after showering?

A:

Yes. In fact, you will have enhanced absorption after shampooing, as a well-hydrated scalp is more permeable and will better absorb topical agents. Just be sure to towel dry the hair first to remove standing water. The only precaution is to be attentive to signs of excessive absorption, such as a racing heart.

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Q:

Is oral Minoxidil safe and is it effective in MPB?

A:

Some people have used oral minoxidil (Loniten), but this is a much more risky treatment than topical application. Use at your own risk. Side effects of excessive minoxidil intake (either orally or topically) include racing heart and salt and water retention. Pay attention to symptoms such as swelling in the feet. Oral minoxidil in any significant quantity ordinarily has to be taken with a loop diuretic and is best done under a physician's care.

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Q:

Will I lose the hair I grew if I quit Rogaine?

A:

Yes. Rogaine requires continual treatment to maintain the new growth. If you stop using Rogaine your hair will revert back to what it would have been had you never used Rogaine in about 2-3 months.

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Q:

What's SOD?

A:

Superoxide dismutase. This is an enzyme produced by the body to neutralize the superoxide radical. Superoxide is a messenger of inflammation and is involved in the body's autoimmune response. It exists in a yin-yang relationship with nitric oxide. Nitric oxide is a vasodilator that appears to be important for hair growth, while superoxide is a vasoconstrictor that may be part of the signaling mechanism that tells hair to stop growing. Superoxide can also interact with nitric oxide to form a highly destructive free radical called peroxynitrite, which causes protein and lipid oxidation.

A few hair products contain copper peptides, which are SOD mimetics; i.e., mimic the effects of the body's SOD enzyme. SOD-containing products have been noted a number of times by researchers to stimulate hair growth and block hair loss in mice. Recent study data on Tricomin, a copper peptide SOD, indicates increased hair growth in MPB. Among other beneficial things, SODs appear to help spare growth-stimulating nitric oxide, reduce damaging inflammation, and help reverse fibrosis (follicular scarring that impedes the follicle's ability to grow hair). There are a few patents for SODs as hair growth stimulators and even one for an SOD inhibitor that blocks hair growth by increasing superoxide.

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Q:

Are higher strength Minoxidil formula's better than lower strength ones?

A:

To a degree, minoxidil response is dosage dependent. For example, 5% minoxidil generally grows more hair than 2%. But you can also apply 2% more liberally, or more frequently, and deliver a comparable daily dosage of minoxidil. While more minoxidil sometimes helps, beyond a certain threshold, additional minoxidil makes little if any difference.

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Q:

What can I do about the flaking I've noticed since I started using Minoxidil?

A:

Occasionally people will notice flaking with minoxidil. This can be due to the minoxidil itself flaking off, or it can be contact dermatitis if it seems like bad dandruff or the scalp feels irritated. If your minoxidil also contains Retin-A, the flaking may be due to increased skin cell turnover induced by that agent. Nizoral shampoo often helps with flaking. If it's contact dermatitis, though, you may need to discontinue or lessen the frequency of minoxidil applications, or you can also use a minoxidil formula that uses glycerol instead of propylene glycol, which is usually the problem ingredient. Check with a compounding pharmacy or with www.minoxidil.com. If irritation persists when using minoxidil or any topical, it is probably best to discontinue usage.

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Propecia / Proscar / Finasteride Questions
Q:

What's the difference between Propecia and Proscar?

A:

Both medications contain finasteride and are made by the same company. They differ only in strength. Propecia has 1 mg of finasteride, while Proscar has 5 mg. Proscar has been around for awhile for the treatment of prostate enlargement, which, like pattern loss, has been linked to DHT. Because of the price disparity between the two medications, some people procure Proscar and divide the tablets into smaller dosages instead of buying Propecia.

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Q:

How do people divide Proscar tablets?

A:

Some people section them with a pill splitter (available at any pharmacy), some crush and dissolve them in alcohol (such as Everclear, whiskey or others), and some crush and encapsulate them along with a filler such as corn starch to remove the air from the capsule.

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Q:

What if I split Proscar but don't section it perfectly. Will this slightly varied daily dosage cause a problem?

A:

No. Subtle daily variations will not diminish finasteride's effectiveness. Some people even have good results by taking a larger dosage only once every few days.

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Q:

Where do you get Proscar? Do you need a prescription?

A:

Proscar is a prescription medication in the US. Some doctors will write a prescription for Proscar for hair loss patients wishing to avoid the greater expense of Propecia; others won't. You can order Proscar from overseas from numerous sources without prescription. FDA regulations allow the importation of a 3-month supply of medication for personal use. The company selling the medication typically requires that you sign a form indicating that you are using the medication under the guidance of a physician.

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Q:

How come some people take less than the standard 1 mg dosage of Finasteride?

A:

Early dose ranging studies showed that much smaller dosages, such as 0.5 mg and even less, inhibited DHT on average almost as well as much higher dosages, such as 5 mg. One 6-month study comparing a placebo group, which lost hair, to users taking differing dosages of finasteride found that 0.2 mg of finasteride increased hair counts about 81% as much as 1 mg when compared to the placebo. Similarly, 1 mg increased hair counts 82% as much as a full 5 mg compared to placebo. The tiny 0.2 mg dosage did about 66% as well at regrowth and retention as 5 mg. Accordingly, the 1 mg dosage was probably a compromise designed to be high enough to pick up those who may not respond as well to the lower dosages, but low enough to minimize side effects. Many of those who take less than 1 mg opt for either 0.5 mg or 0.625 mg (1/8th of a Proscar tablet). Some people also skip days periodically based on the fact that finasteride suppresses DHT for up to several days and also on the old pharmacological rationale that it may help preclude any possible tendencies toward tolerance, which sometimes happens with continuous long-term use of medications.

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Q:

Is there a problem if my wife gets pregnant while I'm taking Finasteride?

A:

No. Originally Merck decided to err on the side of caution and warned against the possible problem of finasteride transfer in semen. This warning has since been removed. At issue is the theoretical danger that there could be genital birth defects in the male fetus. However, women who are or could get pregnant should avoid finasteride ingestion and the handling of broken finasteride tablets.

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Q:

How effective is Finasteride?

A:

Finasteride is not a miracle treatment, but it works reasonably well for many people. Results tend to be slow, and it appears to be much better at retaining than regrowing hair. But as treatments go, it's fairly effective. Recent longer term results indicate that it continues to work well for responders (i.e., the majority of users) a few years into treatment. Like all treatments discussed here, it is typically best used as part of a multifaceted program.

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Q:

What kind of side effects can you get with Finasteride or other systemic DHT inhibitors?

A:

Finasteride is the best documented of the DHT inhibitors and most people notice no side effects from it. Some people do, however, experience a reduction in libido or notice more watery semen. Some get some noticeable hyperandrogenicity, as evidenced by increased facial oil, pimples or unusually high libido. Testicular ache is occasionally noted, probably due to increased testosterone output, and the body takes time to adjust to this. (Increased T levels--15% on average in finasteride users--are likely in large part a compensatory response to reduced DHT.) Most often any side effects dissipate within 2 or 3 months. If they do not, things should return to normal after discontinuing finasteride, although this may take a couple of weeks, as finasteride has a relatively long biological effect, although a short serum half-life.

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Q:

What kind of side effects can you get with Finasteride or other systemic DHT inhibitors?

A:

Finasteride is the best documented of the DHT inhibitors and most people notice no side effects from it. Some people do, however, experience a reduction in libido or notice more watery semen. Some get some noticeable hyperandrogenicity, as evidenced by increased facial oil, pimples or unusually high libido. Testicular ache is occasionally noted, probably due to increased testosterone output, and the body takes time to adjust to this. (Increased T levels--15% on average in finasteride users--are likely in large part a compensatory response to reduced DHT.) Most often any side effects dissipate within 2 or 3 months. If they do not, things should return to normal after discontinuing finasteride, although this may take a couple of weeks, as finasteride has a relatively long biological effect, although a short serum half-life.

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Specific Treatment Questions
Q:

Six weeks ago I started using X and now my hair is shedding like crazy. What's going on?

A:

Sometimes treatments will cause follicles to "wake up" a few weeks early in initiating hair growth. This causes the old dormant hair that's still present to suddenly be ejected prematurely. Thus you may see a temporary wave of increased loss. It's only an apparent increase in actual loss, however, as this falling hair had stopped its growth cycle many weeks earlier and was just waiting to drop out. Increased fallout of this sort should normalize within a few weeks. If it continues over a prolonged period of time (a few months) it may be that the treatment is contraindicated. Note that the majority of people do not notice any increased shedding with various treatments. Increased shedding is most often a positive sign, but its absence is not a negative sign.

Note also that hair fallout is not perfectly uniform throughout the year, so sometimes increased or decreased shedding is simply coincidental with normal hair cycles. Also bear in mind that it is perfectly normal to lose hair every day. The problem with pattern loss is primarily one of having insufficient regrowth.

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Q:

A few days ago I began using X and now I'm losing a lot of hair. How come?

A:

Unless you're experiencing incredible irritation and redness, acute inflammation, or are undergoing an extremely toxic medical treatment, this week's loss has nothing to do with what you've been doing the last few days. The hair fallout you see this week is actually of hair that ended its growth cycle many weeks ago. Thus today's loss is a picture of the state of your scalp from at least 2 - 4 weeks (and probably more like 6 -12 weeks) ago. This hair was already in the loss phase, in other words, before you even started your recent treatment. Thus, short of mechanically pulling hair out prematurely or undergoing a course of chemotherapy or radiation, this week's falling hair is completely uninfluenced by what you're doing this week. Any loss you're seeing now is coincidental to other events. Similarly, what you're doing treatment-wise today won't be reflected in your hair fallout until several weeks from now.

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Q:

I heard that treatment X helps grow hair. Is this true?

A:

Many agents grow some hair in certain people. The question is whether or not a given treatment will grow a significant amount of hair in a significant percentage of people. Personal experimentation will provide the only sure answer for any given individual. On the other hand, there clearly are "snake oil" treatments that only make the seller's bank account grow, so be wary.

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Q:

Can shampoo make a difference in MPB?

A:

Sometimes it can, as a percentage of the active ingredients gets absorbed into the scalp and left behind after rinsing. For instance, seborrheic dermatitis ("seb derm," a bad case of dandruff) is now thought to play a minor role in pattern loss. In the Propecia trials, researchers had test subjects use T/Gel shampoo (one of the many treatments for seb derm) as a means of leveling the field and cutting out this factor as a variable in determining results. Also, 2% prescription strength Nizoral shampoo used 2 - 4 times weekly was shown in one study to produce hair growth results comparable to 2% minoxidil used once daily in a small group of group of test subjects. It was also shown in a larger group to increase the number of hairs in the anagen (growth) phase and to increase average hair shaft diameter. There are almost certainly other shampoos that can positively influence hair growth, as medication can reach the hair follicle fairly easily when the scalp is in a well-hydrated state. Water is a superb penetration enhancer that is, in fact, added liberally to many medicated penetrating creams.

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Q:

Do any treatments work in the frontal area or are they only effective in the crown?

A:

All treatments that work on the crown also work to some degree in the front--just not as well. Treatments are generally more effective the further back you go. Confusion arises because of the way some studies were conducted. With minoxidil, for instance, studies only measured vertex balding; i.e., the traditional bald spot. Accordingly, the only hair growth results that the manufacturer--Upjohn--is allowed to claim pertain to the vertex.

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Q:

I've been using a finasteride/minoxidil combination for awhile with some success. Is it possible I can maintain my hair gains by just using the finasteride alone now?

A:

Unfortunately some of this hair regrowth is likely a direct consequence of minoxidil stimulation. Any such "minoxidil-dependent hair" will return to baseline if you drop the minoxidil. You might be able to lessen the frequency of minoxidil applications and still maintain the hair, but don't count on finasteride alone being able to protect and retain all the new hair grown from the combination protocol.

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Q:

What's this I keep hearing about a dual 5AR inhibitor?

A:

DHT is produced from testosterone by two 5-alpha reductase isoenzymes, called Type I and Type II. Type I 5AR is much more prominent in the scalp than Type II. However, immunostaining techniques reveal that Type I is abundant in sebaceous glands, while significant Type II is present in the dermal papilla itself. Glaxo Wellcome is currently testing a medication (Dutasteride) that inhibits both isoenzymes. It is noteworthy that Dutasteride also appears to inhibit more Type II 5AR than finasteride does. What remains to be seen is whether the incidence of side effects will increase with the dual inhibitor above the level seen with finasteride and whether results will be greater or not.

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Q:

What is DHT?

A:

DHT stands for dihydrotestosterone, which is produced from testosterone by the enzyme 5-alpha reductase. DHT is the androgen thought to be most responsible for male pattern baldness. DHT has a very high affinity for the androgen receptor and is estimated to be five to ten times more potent than testosterone. Other androgens that may be significant in pattern loss include androstenedione, androstanedione and DHEA (especially in women). All of these fall into hormonal pathways that can potentially result in elevation of DHT downstream via various enzymes. It is possible that certain DHT metabolites may play a role in pattern loss as well.

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Q:

Is it true that the herb saw palmetto is better than Finasteride (Proscar/Propecia) and has no side effects?

A:

Saw palmetto has been used successfully in prostate enlargement. Accordingly it may have utility in pattern loss, though it has not been formally tested for this. Saw palmetto and finasteride are not really equivalent, since saw palmetto has a much broader range of anti-hormonal activity than finasteride. As for side effects, these are certainly possible with saw palmetto, though everyone will respond uniquely. It must be borne in mind that saw palmetto is as much a chemical concoction as finasteride; it was merely produced in Nature's laboratory instead of a conventional one. Like anything, if it's potent enough to cause a biochemical change in the body--especially involving hormones--it's potent enough to cause side effects in some people. Saw palmetto may be useful topically.

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Q:

What's reflex hyperandrogenicity?

A:

When the effects of androgens in the body are lessened, e.g. through lowering DHT or by systemic hormone receptor blockade, the body seeks equilibrium through a process called upregulation. This can take the form of increased hormone production and/or increased tissue sensitivity to the remaining hormones. The reason side effects usually gradually disappear with finasteride is probably due to such upregulation. In a small percentage of individuals, it may be that this process overshoots the mark, resulting in significant hyperandrogenicity. This is marked by such signs as greatly increased facial oil, increased pimples, and greatly elevated libido. It's possible that in certain cases such hyperandrogenicity overcomes the hair-protective effect of, say, finasteride, though this does not appear to be the case for the vast majority of people.

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