Dr. Decipher: Pattern Baldness and Choosing the Comb-Over or Mr. Clean

By Dr. John Janousek, M.D. Monday, July 26, 2010

This week I had to make a hair decision. I'm 50, and my male pattern baldness has progressed so much that my hair is very thin between the forehead (now a fivehead) and the top part of my scalp. What was I to do? Should I let it go and do the Donald Trump comb over, or shave my head like Howie Mandel?

What is pattern baldness?
Also known as androgenetic alopecia, baldness is greater in males, and is mainly a cosmetic disorder. Large, thick hairs are replaced by shorter, thinner hairs gradually in the frontal and vertex areas of the head until total hair loss occurs.

How prevalent is it?
As much as 50 percent of men are affected, with onset prior to age 40.  It is most prevalent in white men, second are Asians, then African Americans. Native Americans and Eskimos have a very low incidence.  Interestingly, primates such as chimpanzees show baldness also, and vultures have no hair on their heads (for obvious reasons). Baldness occurs in women also, and may appear as a substantial thinning of hair.

Does it run in families and what is the cause?
Yes, baldness is genetic, and the locus is thought to be on the X chromosome. Male pattern baldness requires androgenic hormones to be present also, especially dihydrotestosterone (DHT).  Baldness in females is more complex (of course). The saying that one gets baldness from the maternal grandfather is only partially true; however in our case, my wife's father and brother are bald, and I am "thinning" so my boys are in trouble.

What medications are available?
The two main medications are Rogaine (minoxidil), which is a topical treatment, and Propecia (finasteride) which is a pill. Minoxidil appears to function in cellular division and increase hair follicle blood supply. It is most effective in hair loss of recent onset and for small areas.

Finsteride inhibits an enzyme called 5-alpha reductase which converts testosterone to DHT. It can only be used in men, and can cause the birth defect of ambiguous genitalia in developing male fetuses. The main side effect to be concerned about is sexual dysfunction, which occurs in from 1-18 percent of patients. It masks steroid use in athletes, so was banned prior to 2009 by the world Anti-Doping Agency.

Both of these medications must be used ad infinitum, as their discontinuance causes the baldness to rapidly revert back to the pre-medication condition.

Are there any surgical treatments?
Hair transplantation is redistribution of existing hairs to the area of baldness. This requires enough existing hairs to cover the bald spot unless one also has scalp reduction surgery.

It has been postulated that in the future cloning of existing hair follicles that are resistant to balding can be done in the laboratory, then transplanted back on the patient's head. This would theoretically  produce an unlimited supply of hair.

What are the psychologic effects?
Studies have shown that most men regard hair loss to be an unwanted, distressing experience that diminishes their body image. Coping mechanisms include the "comb over," hair pieces, hair weaves, hats, even topical camouflages that add fibers to existing hair.

Many men have chosen to embrace baldness and shave their heads completely such as Telly Savales, Bruce Willis and Michael Jordan. The actor Sir Patrick Stewart who played Jean Luc Picard on Star Trek was voted one of the sexiest men on television.

Well, I am not quite ready to shave my head completely as it has a funny shape - it's flat in the back! So I took out a number 4 clippers and buzzed it to leave a short layer of fuzz. I wonder, should I take the pills or use the medicine? Hmm. maybe looking like Patrick Stewart isn't so bad after all. I just need a Star Trek uniform and a spaceship to command (or at least a Mercedes sports coupe).

What do you think?