during pregnancy can result in deleterious effects on a male fetus including ambiguous genitalia.14 While generally well-tolerated, finasteride may also have side effects concerning for male patients, most notably sexual dysfunction. In limited cases, sexual dysfunction may persist in association with depression, melancholy, and general loss of general well-being.15,16,17 This well-publicized disorder, which has been termed post-finasteride syndrome (PFS) has resulted in some male patients refusing finasteride therapy. Finally, both minoxidil and finasteride must be used indefinitely because discontinuation results in regression and progression of alopecia.8 Accordingly, it is not surprising that many who suffer with hair loss seek alternatives to these medications.The pathogenesis of all forms of hair loss is multifactorial and requires a multi-modal solution. Treatments targeting only one mechanism may result in less than optimal effectiveness based on our current understanding of the pathogenesis of hair loss. A number of factors including genetics, hormones, stress, and environmental exposure can trigger and sustain hair loss pathophysiology.18 These factors may interact and influence each other significantly impacting follicular biology. As dermatologists we characterize hair loss based on morphology and etiology, scarring vs. non-scarring, hereditary vs. acquired, and inflammatory vs. non-inflammatory. But recent studies suggest there may be more similarities than differences across the hair loss spectrum. Micro-inflammation at the level of the follicle is a common thread in all types hair loss including androgenetic alopecia.18,19,20,21,20,22 Factors such as ultraviolet light, pollution, toxins, smoking, antigenic exposure to bacteria and fungi, emotional stress, and androgens promote a pro-oxidant and pro-inflammatory environment in the follicle.22 Although not immediately destructive, over time this can dysregulate the signaling pathways known as the intrinsic regulators of hair follicle stem cell homeostasis and hair follicle cycling.19-22 Reactive oxygen species trigger the release of pro-inflammatory cytokines such as IL-1 and TNF-α, and the pro-fibrotic and growth-inhibiting TGF-b. These cytokines promote apoptosis and cause follicular regression, premature termination of the anagen phase, and miniaturization. To this end, any therapies designed to treat hair loss must be multi-targeting, geared to address not only triggering factors but mitigate downstream mediators of inflammation as well.The Use of Botanicals for Treating Hair LossThe use of botanicals for medicinal purposes is the practice of phytomedicine. Although technically considered complementary and alternative medicine, botanicals have now become mainstream and are used in all fields of medicine. In dermatology, phytoactives are currently used for photoprotection, chemoprevention, and to treat conditions such as polymorphous light eruption, psoriasis, eczema, melasma, and Koganvitiligo.23-25 The next logical application of botanicals is for the treatment of hair loss because of their multi-modal biologic activity against its causative factors including: inflammation, DHT, stress mediators, oxidative damage, and intermediary signaling cascades. Furthermore, there are safe, solvent-free technologies available today for extracting the most potent phytoactive plant parts and standardizing them to exact doses that produce specific clinically studied effects. Advances in biotechnology have also made way for bio-optimizing phyto-compounds to improve absorption and bioavailability. The phytoactives discussed below have been selected based on their phytopharmacology and synergistic effects for treating hair loss (Figure 1). They are part of a patent pending Synergen Complex of highly purified, bio-optimized, standardized, and clinically tested extracts found in Nutrafol®, a novel dietary supplement (Table 1).Curcumin: Curcuma longaCurcumin is made from turmeric, the golden spice that is widely used for its flavor and color in Asian cuisine. In
