Update on Male Pattern Hair Loss

November 2014 | Volume 13 | Issue 11 | Features | 1308 | Copyright © November 2014

Leopoldo Duailibe Nogueira Santos MD and Jerry Shapiro MD FRCPC

Department of Dermatology and Skin Science
University of British Columbia, Vancouver, Canada
The Ronald O. Perelman Department of Dermatology
New York University Langone Medical Center, New York, NY

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.

Surgery

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 to laser.12
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,