Ask the Pharmacist

Q) I’m a thirty something year old guy who’s losing his hair. Why is this happening and what’s the best way to treat this?

A) Hair loss typically occurs in both men and women and is a normal part of the aging process. Males are twice as likely as females to experience it with an estimated 85% of them likely to be affected by this to some degree or another.

Hair is made up of a tough protein called keratin that starts at the hair root which is inside a small tube called a follicle beneath the skin. Over time as it grows, the shaft of hair pushes out of the follicle and through the skin where it can be seen. Interestingly, once the hair is at the skin’s surface, the cells within the strand are no longer alive. The average scalp contains about 100,000 hairs and most of us typically lose approximately 100 hairs a day.

On average a strand of hair survives about 4 years and grows at a rate of about half an inch each month. When the strand dies it falls out and is replaced by a new one within six months. Hair loss occurs when the strand replacement does not occur. Many people can lose up to 50% of their hair before they start to notice thinning. By the age of 50, 50% of males will notice some degree of hair thinning. But in many men, this can occur at much younger ages.

While hair loss is typical with aging, it can also occur for other reasons. Alopecia areata is an autoimmune disorder in which the immune system starts to attack the hair follicles often causing hair to come out in clumps. It occurs in about 2% of the population and typically results in roundish bald patches that seem to occur randomly on the scalp, face or body. Alopecia totals is a more severe form of this and is marked by a total loss of hair on the scalp. The most severe form of this disorder is known as alopecia universalis and is characterized by a complete loss of all hair throughout the body. Scarring alopecia refers to a number of disorders in which the hair follicles are replaced by scar tissue usually only on the scalp. This occurs in roughly 3% of those with hair loss.

Trichotillomania is a self-induced form of hair loss. It is caused by compulsively twisting and twirling of one’s hair resulting in broken hairs and a patchy distribution of hair loss. Fungal infections (tinea capitis) of the scalp can result in a patchy type of hair loss along with a flaky or scaly scalp. This is a fairly common cause of hair loss in children.

Hair loss can also occur for other reasons such as trauma (i.e. after surgery, a major illness, childbirth or psychological stress), underlying diseases (e.g. lupus, thyroid disorders, certain cancers, iron deficiency…), hormone imbalances or with the use of certain drugs (anabolic steroids, some chemotherapies…). However, the most common reason for hair loss is androgenetic alopecia, perhaps better known as male pattern baldness. This condition can start as early as the teen years and by the age of 70 it will affect close to 80% of men. It is believed to be related to the effects of a male hormone called dihydrotestosterone (DHT) on genetically susceptible scalp hair follicles.

DHT causes this loss by shortening the growth phase of the hair cycle which results in the follicles producing progressively shorter and finer hairs in a process known as miniaturization. With prolonged exposure to DHT, eventually these follicles disappear leaving a bald spot. Its typical appearance is a receding front hairline along with hair loss at the top or crown of the head.

Hair loss in men can typically be treated in two general methods: surgical intervention or via the use of a number of medications. For this article, we’ll focus on the latter alternative.

At this point in time, only two drugs are currently approved for treating this condition; Finasteride is a tablet taken orally and minoxidil (better known as Rogaine) is topically applied to the scalp.

There are a number of other options that are used off-label (a term we use when a drug is used for a purpose beyond those for which it has been approved for). Off-label options include using finasteride at higher doses (5mg versus the approved 1mg) and its sister drug dutasteride at a dose of 0.5mg as well as an oral version of minoxidil at doses of 5mg and 0.25mg per day.

A recent study conducted in London and other research centers sought to compare these treatments in adults aged from 22 to 41 years old by looking at the increase in their hair counts after 24 weeks of treatment. Based on the results, the authors ranked dutasteride as the most effective option with the rest ranked in order of decreasing efficacy as described below:

· 0.5mg day oral dutasteride
· 5mg/ day oral finasteride
· 5mg/ day oral minoxidil
· 1mg/ day oral finasteride
· 5% topical minoxidil
· 2% topical minoxidil
· 0.25mg/ day oral minoxidil

The drugs finasteride and dutasteride are part of a class of drugs known as 5-alpha reductase inhibitors which have been used for years to shrink the prostate and help control issues men have with urination frequency and urgency. This class is generally well tolerated but like any drug there is the potential for side effects. These can include a decrease in sex drive, erectile dysfunction, reductions in ejaculatory volume and sperm count, testicular pain, gynecomastia (breast enlargement) and others. There are concerns that oral minoxidil has not been particularly well studied so there is some degree of concern as to its potential for side effects as well.

There are some specialists who in fact favour a combination of the above for what they feel can provide the best results. One such regimen cited by a specialist was combining oral dutasteride with topical 5% minoxidil along with a low dose of oral minoxidil (at 0.25 to 1mg/ day). As mentioned earlier, there are also surgical treatments for this condition as well as low-level light therapy. For more information about this or any other health related questions, contact your pharmacist.