Chapter 16:  Which Hair Loss Treatment Is Right for Me?

When full-size hair transplants were still being performed, the choice of hair loss treatments was often referred to as: “drugs, rugs, or plugs.” Maybe we should add “shrugs” to the list. Many people with hair loss simply choose to shrug it off as a minor issue in their life and not one worth bothering much about. But many others do indeed consider medications, or cosmetic solutions such as hairpieces, or surgery (no plugs, however).

For those who really want to do something about their hair loss there is great confusion about which method of treatment is most appropriate for their particular hair loss condition. Countless sources of information offer advice on treating hair loss, but almost all have a built-in bias toward the product or service they are selling, or by the industry or advertisers who sponsor them.

While it is no secret that I am a board certified dermatologist, and as a physician I have been prescribing medications and performing surgeries to correct hair loss for over thirty years, this chapter is an attempt to offer a balanced and useful assessment of all the treatments available for people with varying types and degrees of hair loss.

An overview of hair loss treatments is presented first, following by a listing of various types and degrees of hair loss conditions, and the most appropriate treatment options for each condition.
Ineffective Treatments

Doing nothing is perhaps the most common way of dealing with thinning hair. It is a completely honest solution and has no out-of-pocket cost or time requirement. This “treatment” is available to everyone with every type of hair loss. Lets face it: hair loss is not a life-threatening condition. Accepting hair loss as a natural condition is a sign of emotional security and comfort with yourself as you are.

The results, however, of doing nothing are usually unsatisfactory: Our society continues to put a high positive value on heads of healthy hair. Without treatment, the thin hair remains, and for those with androgenetic alopecia (genetic pattern hair loss), the condition usually gets worse as time goes on. While you may do just fine with thin hair or bald spots, you may also wonder how different your life would have been if you had done something about your hair loss. Sometimes the biggest risk is doing nothing at all.

But if you choose to do something about your hair loss, choose a treatment that works. Completely useless treatments are perhaps the most common way that people choose to treat their hair loss. This category includes hundreds of bizarre folk remedies, the use of “all natural” herbal lotions and scientific-sounding shampoos that claim to somehow enhance hair growth, nutritional supplements that claim to promote healthy hair, and various scalp-stimulation schemes that use electricity, LEDs, lasers, or massage to awaken the “sleeping” hair follicles. All of these treatments are, in my professional opinion as a physician, a waste of time, money, and energy. The thin hair remains, and usually gets thinner as time goes on. In addition, after the hopeful feeling wears off and the reality of the failed treatment sets in, there can be feelings of despair, frustration, anger, and often embarrassment. Furthermore, if the hair loss happens to be due to a disease condition, useless treatments may delay the person from seeking effective medical treatment, which could make the hair loss condition worse, and possibly permanent.

Cosmetic Treatments

Cosmetic treatments for hair loss are defined as methods that change the appearance but do not affect the body, and can be reversed. Hair styling, including shaving the head completely, and the use of various hair-thickening styling products are all cosmetic treatments. So are scalp paints, dust and fiber products, hairpieces and wigs, and the wearing of hats, turbans, and scarves to conceal hair loss. Cosmetic treatments range from not being very effective, to being the most effective of all the possible treatments, when measured by appearance. And just about anybody with hair loss can benefit from cosmetic treatments. Their major drawbacks are their impermanence, which brings the risk of discovery, and which requires periodic reapplications. Depending on the type of cosmetic treatment, there are varying degrees of periodic costs and time constraints as well.

Hair styling is a cosmetic treatment that most people with hair loss can benefit from. Hair frames the face, so the first consideration is to select a hairstyle that directs attention to the face, and not to the hair itself. Men with significant hair loss should avoid “comb-overs,” as they tend to direct attention to the long thin strands of hair lying on top of the bald area, and do not fool the eye. To determine which styling technique will be most effective, consider the amount and quality of hair available to work with. If adequate hair exists, a permanent wave hairstyle can increase the apparent hair density by creating curls of hair that better hide the scalp. If there is little hair to work with, cutting the hair short can make a surprising improvement in appearance. Thin short hair often looks much healthier than thin long hair, which tends to fly around and lie flat. Shaving the head completely is an extreme styling technique, and for some men is works very well. Shaving the head is also a very low cost solution; however, there is the slight increased need for daily maintenance.

There are countless styling products that claim to thicken the appearance of the hair. Some conditioning products coat the hair shaft to increase thickness, while others products such as sprays, mousses, and gels help hold the hair in place. These products have limited effectiveness, but cost very little and can improve appearance to some degree. Hair coloring and bleaching products can have an effect on apparent hair density. Dyeing salt-and-pepper hair dark can in some cases make it look thicker. Alternatively, using hair coloring to make dark hair light can make it appear less thin against light colored skin. And some people find that conditioners and other products that coat the hair shaft flatten their hair and make it look thinner, and for these people avoiding styling products altogether gives their hair the fullest appearance.

Cosmetic products such as scalp paint, hair dust, and hair fiber products are ideal for temporarily increasing the apparent thickness of the hair, especially when there is no risk of someone touching it. Almost anyone with hair can increase his or her apparent hair thickness when he or she is under bright lights such as for a television appearance or an important presentation, by using these products. After the special event, you simply shampoo the product out later that evening. Hair dust and fiber products in particular can also be used immediately after transplant surgery to hide newly-placed micrografts, and allow for a very natural appearance until the grafts have healed.

The most effective of all hair restoration products are artificial hair appliances such as hairpieces and wigs, because they add the most hair and can be used by anybody with any hair loss condition. The hair used to construct these devices can be human or synthetic. For normal use, hairpieces are constructed with modest hair density so that they look natural. For movie roles, hairpieces and wigs are often constructed with more hair than would naturally occur, to give an even thicker-hair look.

Hairpieces partially cover the scalp and blend at the edges with existing hair, while wigs cover the entire scalp, including whatever hair exists. Artificial hair is ideal for those with temporary hair loss, such as hair loss from cancer treatment. Full cap wigs are often the only available solution for those with total hair loss such as from alopecia totalis, or for those with disfiguring scars on their scalp.

The main disadvantage to hairpieces and wigs is a general feeling among people that they are fake, and that they are somehow embarrassing when detected. And there is considerable maintenance time and expense involved in wearing artificial hair. The devices must be cleaned, repaired, styled and reattached on a regular basis. And artificial hair devices are delicate and begin to wear out and look unnatural after several months. They must be replaced periodically to maintain a convincing appearance. The maintenance and replacement cost of wearing a high quality hairpiece can make this option the most expensive solution for treating hair loss. Over time, the costs add up.

Wearing a hat, turban, or scarf to conceal hair loss can be a very simple, inexpensive, and effective solution, although the headgear does have to come off sometimes. People with either temporary or permanent hair loss can wear hats.

Medical Treatments

Medical treatments use medications to change the condition of the body and affect the hair loss condition. Medications for treating hair loss may be in the form of pills, lotions, or may be injected. Some medications block or interfere with the hormones that trigger androgenetic alopecia. Others treat various disease conditions that include hair loss as a symptom. Preventative medications, such as Propecia and Rogaine have varying degrees of effectiveness, depending on each individual’s degree of hair loss and particular body chemistry, and generally take months for a change in appearance to be noticeable. In some cases, the effect of the medication ends shortly after the drugs are discontinued. Preventative medications also require continuous use for the benefits to continue. Medications for treating disease conditions also have varying degrees of effectiveness. A medicine that works very well with one person having a particular condition may have little effect on another person with the same condition. The following is a summary of five of the most commonly prescribed medications for treating hair loss: Propecia, Rogaine, spironolactone, high estrogen contraceptive pills, and corticosteroid hormone injections.

Propecia is a preventative prescription medication for men with a genetic predisposition to hair loss. Taking Propecia delays the appearance of pattern hair loss, and when treatment is started early enough, it can even help return some miniaturized hair follicles back to full size hair production. Results will vary from person to person; this is currently the best medication we have for treating male pattern baldness. I recommend it to most of my transplant patients as well, to help them keep the hair they have. The disadvantage of Propecia is that it is not a cure, only treatment. There is the need to take a pill once a day on a continuing basis, as well as the expense of the pills, and the very slight risk of diminished sex drive. The slight risk of diminished sex drive declines after several months use, so even if this condition occurs initially, there is a good chance it will go away after several months, or Viagra can be prescribed at ten bucks per pop to address the problem.

Minoxidil is an over-the-counter medication that is applied to the scalp to stimulate hair follicle growth, as well as to help keep active hair follicles from shutting down. Both men and women can use minoxidil lotion. It acts as “artificial life support” for hair follicles, helping to keep them producing when hormone messages or disease conditions are telling the follicles to stop producing. The results from minoxidil use vary from being very effective to not being effective at all. Like Propecia, minoxidil is a treatment and not a cure, and must be applied every day for the benefits to continue. There is a risk of scalp irritation with high concentration solutions; switching to a lower concentration usually resolves this condition.

Spironolactone is a prescription medication for women applied in lotion form to the scalp. It is prescribed for women who have a genetic predisposition for hair loss, and who have diminished female hormone levels that result in the DHT message for hair loss to finally getting through to their hair follicles. Spironolactone interferes with this message, and helps to stop the hair loss. Spironolactone is a treatment and not a cure, and must be applied every day for the benefits to continue. It also has a somewhat disagreeable odor, which can present problems in certain situations.

High estrogen oral contraceptive pills may be prescribed for women who have diminished estrogen levels and a genetic predisposition for hair loss. The estrogen in birth control pills interferes with the DHT message that is trying to tell the hair follicles to stop growing hairs. Birth control pills are a treatment and not a cure for hair loss, and the medication must be taken daily for the benefits to continue. In addition to reducing genetic hair loss, some other benefits of birth control pills include reduced risk of unwanted pregnancies, improved skin tone, reduced acne, increased bone mass, and diminished symptoms of the first stages of menopause. The risks of taking this medication on a regular basis over a long term include weight gain, increased risk of uterine cancer, increased risk of cardiovascular complications such as heart attack and stroke especially in women who smoke, and the possibility of a slightly elevated risk of breast cancer.

Corticosteroid hormone injections are a hair loss treatment that is often used for autoimmune disease conditions such as alopecia areata. Medications such as cortisone are injected directly into the patch of bald scalp to reduce the exaggerated immune response that results in white blood cells attacking the hair follicles. The effectiveness of this treatment varies, and in many cases the bald patches go away on their own, so it is difficult to determine when a particular steroid injection treatment is working or not.

Surgical Treatments

Surgical treatments for hair loss include reduction procedures where small bald portions of the scalp are removed, scalp lifts and flaps where relatively large portions of the hairy part of the scalp are rotated around to the front and top, and micrograft hair transplants where some hair follicles from the back of the scalp are moved to the front and top of the head. The results of surgical treatments usually take a few months to fully appear, however once the surgery has healed the benefits are permanent.

Scalp reductions are now most commonly used when a portion of the scalp is injured or inflamed and must be removed. It is a surgical technique where a portion of the scalp is cut out, and the edges are drawn together and closed with sutures. In the past, reduction procedures were commonly used to reduce the area needing full size grafts. They are rarely performed for this purpose today, however, because micrografting has allowed a much greater area to be effectively transplanted.

Occasionally, reduction procedures are used, along with other surgical techniques, to repair poorly-executed past hair restoration surgeries. If a patient had a transplanted hairline placed too low on the forehead, a reduction procedure could be used to pull the scalp back and raise the hairline. Reductions are also used to remove scalp tissue damaged by synthetic fiber implants. Reductions produce a permanent effect, removing a bald spot does not guarantee that the adjacent scalp won’t also eventually lose hair. Reductions are simple outpatient surgical procedures performed in a doctor’s office, they include the medical risks of all surgical procedures. They also leave a scar at the point where the edges of the scalp are closed. If the scalp surrounding the scar begins to lose hair, the scar may become visible. Micrografts can be transplanted directly into the scar tissue if this becomes a problem.

Scalp lifts and flap procedures are much more elaborate surgical procedures for treating hair loss, however, they are rarely performed today. With flap procedures, the patient is put to sleep under general anesthesia and sections of the bald scalp are removed, and large portions of the hairy part of the scalp are partially cut free from the scalp and rotated around to cover the open areas. The hairy flaps of scalp are stretched to cover not only the areas they had occupied, but also the areas that were covered by the bald patches of skin that were removed as well. The edges of the scalp are then sewn back together and allowed to heal. With scalp lift procedures, the entire scalp is loosened from the skull and the bald areas are removed. The hairy portions of the scalp are then stretched up and sewn together. The benefits of flap and lift procedures are the elimination of most or all of the baldness in a single visit to the surgeon. The disadvantages include the medical risks of surgery with general anesthesia, and the risk of poor cosmetic results. Although rare, patches of scalp tissue can die from inadequate blood supply after surgery, and more commonly the long scars can become visible especially as hair loss continues.

Follicular unit micrografting is the most popular form of surgical hair restoration performed today. A portion of the hair-bearing scalp from the back of the head is removed and cut into grafts containing single hairs, or naturally occurring clusters of two or more hairs. These micrografts are then placed into small slits at the front and top of the scalp, with many placed between existing hairs at the edges of the balding areas. The transplanted hair follicles are placed in a way that will give the most effective illusion of a full head of naturally growing hair. After a few months, the transplanted hair follicles begin to grow new hairs. The results are permanent, and look very natural. People who get transplants are usually thrilled with how their own hair is growing in the new location. The disadvantages include one or more outpatient surgical procedures performed in a doctor’s office under local anesthetic, the considerable expense of surgery, and a small risk of poor cosmetic results, if the surgeon is inexperienced or not artistic.