ever, the author raises that the selected patients could have
been called slower responders to finasteride vs non-responders
since they had improvement in a prior phototrichogram
after 6 months of finasteride.7
Nowadays, the main concern of men regarding 5ARI is the
sexual side effects. In a long-term (5-year) multinational
study with 1mg finasteride, 4.4% reported sexual dysfunction
in the first year. These side effects resolved after discontinuation
of medication in all patients and in most men that stayed
on treatment.8 Gupta et al, on the other hand, didn’t find any
significant difference among finasteride, dutasteride, and
placebo regarding sexual disturbance.9 In summary, close
follow up and further evaluation of these patients are needed
to clarify the relation between 5ARI and sexual side effects.
Other important side effects that have been mentioned in
some studies but not confirmed in controlled trials are depression,
gynecomastia, and breast cancer.
Hair transplant (HT) is the only treatment that can substantially
increase the number of hairs. Basically, hairs from the
back of the scalp are removed and transplanted to the recipient
site. Two techniques have been proposed: follicular unit
transplantation (FUT) and follicular unit extraction (FUE).
FUT is the traditional HT technique. A strip of hair-bearing
scalp is cut out from the occiput. The strip is then dissected.
Many holes are made in the recipient site where the grafts
are implanted. The advantages of this procedure are the
higher number of obtained grafts and less transected follicles.
However, it is time-consuming, needs a high-qualified
team (surgeon, nurses and technicians), leaves a line scar,
and can cause dysesthesia at the donor site.
In FUE, instead of a strip, grafts are removed one by one from
the donor site with punches that range size from 0,75mm to
1.2mm depending on follicular unit density. The advantages
of FUE are less noticeable scars, no dysesthesia, and shorter
downtime. However, there is a higher chance of transecting
follicles, fewer grafts are harvested, subdermal cysts may
form, and this technique demands a longer learning curve.
New machines have been designed to accelerate and improve
the FUE technique. Neograft® is a powered FUE that
is composed of a handheld pneumatic press device for harvesting
grafts, a micrometer for making holes at the recipient
site, and handheld graft implanter. Onda et al had a lower
transection rate and less harvest time with this machine.10
ARTAS® Robotic is an apparatus that can select follicular
units and harvest them.11 This robot will be able to make the
holes with its new upgrade.
LLLT (Low Level Laser Therapy)
The first time light was seen as a possible source of hair
stimulation was in 1967. Primarily, Metser et al were studying
the potential carcinogenic effect of laser in mice and were
surprised to discover hair regrowth on shaved areas after exposure
The most common LLLT devices have wavelengths in the
range of 500-1100nm. The mechanism of action is not known
but has been proposed that LLLT acts on mitochondria and
may alter cell metabolism increasing ATP production, cell proliferation,
cytokines, growth factors, and tissue oxygenation.
LLLT is believed to result in anagen hair re-entering telogen
hair follicules and prolonged duration of anagen phase.12
There are a few devices (ie, comb and helmet) that have been
used to delivery light in order to promote hair growth. Two
RCT studies, Jimenez et al in 2014 and Leavitt et al in 2009,
using HairMax LaserComb® (655nm) with different number
of beams and regimen treatments demonstrated hair growth
improvement in male pattern hair loss.13,14 Data exclusion in
Leavitt study might have compromised its results.15 Another
two RCT studies using helmet devices, Kim et al (630, 650,
and 660nm) and Lanzafame et al (655nm), have also shown
effectiveness in their treatments.16,17
Light treatments are of special interest to non-responders or
those who have had side effects from minoxidil or finasteride
and are not interested in surgical treatments. Although
it seems to be a promising alternative to medications and
surgery, uncertainty on LLLT devices remains and questions
about efficacy on longer follow-ups, adequate wavelength,
best laser modality, treatment regimens, and long-term efficacy
need to be answered.
Platelet-Rich Plasma (PRP) and Microneedling
PRP and microneedling are two interesting procedures that
are believed to increase growth factors stimulating hair
growth. The former would act through releasing growth factors
from platelets and the latter from trauma, trigger factors,