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Hair Replacement:

What Works and What Doesn't

by Larry Hanover
from
FDA Consumer magazine logo
April 1997.


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When the advertising slogan "Be Like Mike" caught America's fancy, it wasn't because every man decided to go for the Michael Jordan look by reaching for a razor and shaving his head.

Sure, men like Jordan, Charles Barkley, and "Star Trek's" Patrick Stewart are part of a small minority who are proud of their baldness. But combating and covering up hair loss hasn't turned into an estimated $1 billion-a-year industry because Americans like the idea of hair collecting in the shower drain.

"It probably represents aging," says Ken Washenik, M.D., director of dermatopharmacology at New York University Medical Center. "I think our concept of a bald person is of an older person. I think anything that reminds us in the mirror every day of the inevitability of aging is less than optimal."

When you talk about restoring hair, you're essentially looking at three different approaches. The first is to medicate, using a 2 percent solution of minoxidil found in Rogaine (and other brands since Pharmacia & Upjohn's patent expired in February 1996). Minoxidil is the only drug approved by the Food and Drug Administration for regrowing hair.

That doesn't mean minoxidil is by any means the panacea that men have been searching for since at least 1150 B.C., when Egyptians covered their baldness with a mixture of fats from ibex (a mountain goat), lion, crocodile, serpent, goose, and hippopotamus.

Surgical procedures, including hair transplantation and scalp reduction, are another modern-day approach. And, finally, there's the solution that Julius Caesar, according to legend, used in ancient days--cover it up. The most powerful man in the Roman Empire is said to have turned to the ceremonial wreath of laurel leaves to hide his ever-emerging scalp. The modern alternative is the hairpiece.

Uncovering Baldness

When discussing baldness, which affects an estimated 40 million men and 20 million women in the United States, the topic is generally about a hereditary condition called androgenetic alopecia. Ninety-five percent of hair loss is of this variety.

Male-pattern baldness refers to the upward retreat of the hairline from the forehead, as well as an expanding area of fallout from the crown of the head. In the end, all that might be left is a horseshoe-shaped fringe around the sides and back of the head. Female-pattern baldness, which recently has received more attention since Pharmacia& Upjohn began packaging and marketing Rogaine separately for women, refers to a diffuse pattern of hair loss throughout the scalp.

Research continues in search of ways to treat androgenetic alopecia and allow hair to sprout in barren scalps. But, at this time, all you can do, if you're a man, is to look at your father's head and your mother's father's head to see how they fared, because chances are you'll wind up with a similar fate. In addition, female-pattern baldness can be passed down from mother to daughter.

"I think it's just the luck of the draw what your genetics are," says Allan Kayne, M.D., a dermatologist and assistant clinical professor of medicine at the University of Washington Medical Center in Seattle.

In male- and female-pattern baldness, the culprit is something called dihydrotestosterone, or DHT, which is derived from androgen, a male hormone. Circulating through the bloodstream, androgen is converted to DHT by the enzyme 5-alpha reductase. Those with greater enzyme activity have more DHT binding to hair-follicle receptors. If flooded by DHT, the follicles sprout thinner and thinner hairs until nothing regrows, and the follicles eventually wither away.

Minoxidil

Currently, if you want to regrow hair, topical minoxidil is the only approved way to go. As Washenik explains, no one is quite certain how minoxidil, an oral medication originally approved to treat high blood pressure, works to grow hair.

To be effective, minoxidil must be used twice a day. It works better on those who are younger and whose hair loss is recent, according to clinical studies by Pharmacia& Upjohn.

Those studies show that 26 percent of men between 18 and 49 reported moderate to dense hair regrowth after four months of Rogaine treatment. An additional 33 percent had minimal hair regrowth. Almost 20 percent of women between 18 and 45 had moderate regrowth, while an additional 40 percent showed minimal regrowth.

A company spokesman said the research accounted for the fully pigmented hair fibers normally seen on the scalp and not vellus hair, which is more like peach fuzz. Many doctors, however, say the number of their patients who have as much success is much lower, and some find that only vellus hair appears.

"I have not been that impressed that it helps regrow hair," Kayne says. "I think that occurs in a very small minority."

One plus that Denise Cook, M.D., medical officer in FDA's division of dermatologic and dental drug products, points out is that patients report a decrease in shedding due to minoxidil use, though whether that perception is the result of fewer hairs being lost or more hairs being produced is unknown. Normally, you should lose only about 100 hairs a day.

One possible side effect of minoxidil is an itchy scalp. Another drawback is that it must be used for life or any regrown hair will fall out. Also, only those people losing hair on the crown, not in front, are candidates for regrowth.

Researchers are optimistic that more products to boost hair regrowth will be coming down the pike. For example, Proscar (finasteride), now used to treat enlarged prostate glands, has anti-androgen properties that may make it marketable as a hair-loss prescription, Washenik says. Theoretically, he says, if a drug can be targeted to halt the conversion of testosterone to DHT in the scalp region only, it could stop hair from falling out. He foresees combinations of medications as the wave of the future.

Surgery

Twenty years ago, many people felt they risked looking like a Cabbage Patch doll if they chose surgery to eliminate baldness. Now, says Carlos Puig, D.O., director of Puig Medical Group, which is headquartered in Houston, better surgical techniques--used by increasingly skilled surgeons--are getting more eye-pleasing results.

"When I started in 1973 ... it was like the Stone Age," the cosmetic surgeon says, referring to the equipment and techniques in use. Now, he says, surgeons have learned to create a much more natural-looking hair line, using scalpels to cut either small slits or holes in the scalp to receive transplanted hair.

While there are numerous types of surgery, they can be sifted into two main categories: transplantation and scalp reduction.

Transplantation involves moving hair from densely covered sites on the sides or back of the head to bald areas of the scalp.

The key to success, explains Anthony Santangelo, president of the American Hair Loss Council, is to have good sites on the sides or back of the head from which to move hairs. Otherwise, patients can't expect ample coverage. Because their hair loss is diffuse, women generally lack good donor sites, making transplantation impractical for them.

The biggest improvement in transplants is with "micro" or "mini" grafts. "You're looking at one to two hairs shot into the head with a needle," Santangelo says. "It achieves a very, very fine, natural-looking hair line. The significant difference there is you need a lot of hair to do that."

Surgeons also use larger round plugs of seven to 10 hairs. Line grafts, the shifting of strips of nine to 12 hairs, are common, too.

One thing to keep in mind is that prosthetic hair fibers for transplantation are banned by FDA. Implanting them, according to Stephen Rhodes, acting chief of FDA's plastic and reconstructive surgery devices branch, caused a high incidence of adverse reactions, including infection.

If male-pattern baldness has left you with too much balding area to cover, you may benefit from scalp reduction: the surgical removal of large sections of a bald scalp. Extenders and expanders, elastic devices placed under the skin to stretch the hair-bearing scalp regions on the side of the head, have been used as a complement to reduction surgery.

Another surgical method is the flap technique, which rotates hair-bearing scalp areas from the sides or moves those areas from the back forward. The flap technique has the highest complication rate, though, Puig says. Bleeding, scarring and infection can occur from surgery. But advances, such as knowing what size flap to use and how to enhance blood supply to the region, have cut down on the visibility of scars.

Hairpieces

Finally, if you prefer to dodge the pain, time and cost of surgery, there's always the old, reliable hairpiece.

Obviously, all toupees and wigs are not created equal. Just as the transplant is only as good as the surgeon, the hairpiece is only as good as the person creating it and the materials used.

There are a variety of ways of affixing the hairpiece, which consists of human or synthetic hair implanted one hair at a time into a nylon netting. No method is permanent.

The hair weave involves sewing a wig into existing hair.

Also there are more traditional methods: You can use bonding (a type of glue), metal clips, or simple tape to attach the hairpiece to the scalp. Unlike the weaves, these give you the option to take the hairpiece on or off with ease. Many companies advertise "hair systems" or "hair clubs," which, according to Santangelo, offer check-ups to clean, color and tighten the hairpiece.

Lark Lambert, consumer complaint coordinator for FDA's Office of Cosmetics and Colors, notes that in addition to maintaining the cleanliness of hairpieces and wigs, it is important not to neglect the scalp under the wig. Keeping it clean and healthy avoids skin irritation and disease, he says. Also, as a precautionary safety measure, first-time users of hairpiece adhesives and solvents should test a patch of skin for 48 hours to determine possible skin sensitization to these products.

Health-Related Hair Loss

While hair loss is more harmful to the psyche than anything else, some of the causes of baldness may represent serious health problems. That's why it's important to talk about hair loss with a physician.

One problem, says FDA's Cook, could be a condition called alopecia areata. It's an autoimmune disease of unknown cause in which inflammatory cells attack the bulbs of the follicles under the scalp, leaving hairless patches. In more serious cases, hair may fall out from the entire head--eyebrows and beard included--and the entire body. Many times, though, the hair returns spontaneously.

Childbirth, severe malnutrition, chemotherapy, thyroid problems, and a form of lupus can also cause hair loss.

Something as simple as pigtails or cornrows, if worn too long, can cause hair loss, too, because of the stress they cause to the hair shaft.

The medical opinion concerning the role of emotional stress in balding is mixed. If stress does play a role, however, it's only at times of extreme emotional trauma, according to Kayne at the University of Washington Medical Center.

Mythical Treatments

The mythology of hair loss is a book unto itself. Wearing hats won't cause it, doctors say. Nor will standing on your head to increase blood flow cure it. Massaging your scalp and brushing your hair won't save you. Toweling off your head lightly rather than vigorously will only postpone the inevitable for a few days.

Perhaps the biggest myth is that cleaning your scalp of sebum (the semifluid secretion of glands attached to the follicle) will unclog those follicles and allow hair to grow. Surgeons will tell you that when they're performing transplants, there's no trapped hair to be found.

In 1989, FDA banned all nonprescription hair creams, lotions, or other external products claiming to grow hair or prevent baldness. And it has taken action against companies that continue to sell such products. In 1996, the agency sent a warning letter to Daniel Rogers Laboratories Inc., of Paramus, N.J., the manufacturer of "Natural Hairs," for claiming its product could promote hair growth and prevent hair loss. Two years earlier, after an FDA investigation, a U.S. district court judge enjoined the marketing of "Solution 109 Herbal Shampoo" because of claims that the product warded off hair loss.

Advertisements for "hair farming" products and others that hint they can regrow hair are still plentiful. But if you're desperate, keep one thing in mind:

"There will be never be a secret [ingredient] that works for hair loss," NYU's Washenik says. And, if they were to find it, he says: "It will be on the cover of the New York Times. It will be on the nightly news. ... When this happens, it's going to be wildness. You're not going to need an expert to tell you the name of the drug."

Larry Hanover is a writer in Mount Laurel, N.J.


The Thick and Thin of Hair Cosmetics

While Rogaine and other minoxidil-based products are giving consumers hopes of regrowing hair, another part of the hair-care industry has been jumping into the fray.

Drugstore chains, beauty shops, and salons are offering a number of products claiming to make hair appear thicker or fuller. While they won't solve baldness, such products can help women in particular by giving the appearance of more hair--if, and only if, the products are used regularly.

"The reality is," says Anthony Santangelo, president of the American Hair Loss Council, "[the products] just build hair for the day."

A quick walk down the store aisle shows a multitude of shampoos, conditioners, gels, mousses, and volumizers competing for your dollars. Many labeling claims target people with thinning hair, while others hint they can regrow hair, creating controversy about whether such a claim constitutes going too far. Any product claiming to regrow hair would have to file a new drug application. The Food and Drug Administration has approved only one product, the drug minoxidil, for regrowing hair.

"It's marketing; it's puffery," Santangelo says. "They'll take it as close as they possibly can without crossing the line, and they'll run with it."

Many of these products seem to thicken hair by coating it with chemicals called polymers. Hair has a negative charge, and the polymers' positive charge causes the polymers to adhere to the hair shaft, says Charles Fox, a Fair Lawn, N.J., consultant to the cosmetics industry. That results in better hair manageability and shine, he says. The hair also retains moisture, causing the shaft to swell and its diameter to expand slightly.

Also, says Stanley Milstein, Ph.D., special assistant to the director of FDA's Office of Cosmetics and Colors, some products coat the hair with various oils, waxes and silicone, claiming to restore moisture balance as they thicken hair.

Clarence Robbins, vice president of advanced technology for Colgate-Palmolive Co. and author of Chemical and Physical Behavior of Human Hair, says that if the products work, it's because they keep hair shafts from sliding past each other (think of the fly-away hair you get after blow-drying on a winter day.) In that way, hair volume appears greater.

If you're one to use bleach (peroxide) occasionally, he says, the bleach can achieve that sliding effect. Perms also make your hair wavier and fuller looking.

Many promoters of these products say their pro-vitamin B5 (panthenol) formulas can lead to fuller hair. Experts say don't bet on it, and according to the agency, the claim has never been proved.

By the way, there are products that simply color your scalp to create the appearance of hair. "But get any closer than 20 feet from an individual, they're gonna see your head's been spray-painted or covered with powder," Santangelo says.

--L.H.


FDA Consumer magazine (April 1997)
Articles in FDA Consumer may be republished without permission; however, credit to FDA Consumer as the source is appreciated.
Thanks, FDA Consumer! - Editor
 

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