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Hair Loss/Regarding hair fall


Hi Doc,

I am 28 years old male and I have been experiencing hair fall for the past 2-3 years. During this period, I had to relocate multiple times due to my official demands. I am into software development which at times can be highly stressful and involves long hours in front of the laptop. I consulted a dermatologist and started on rogaine, but it caused more hairfall and unbearable itching, so I discontinued its usage. I tried my luck with ayurvedic oils as well, but didn’t improve the condition.
Currently, I am on Norwood 3 stage as per my doctor. I have a very fast lifestyle and I am usually a nocturnal person, who tends to sleep 5-6 hours on normal week nights and long hours on weekends. I always had issues with cold throughout my life and had repeated instances of infection of tonsillitis till 18 months back. I never had any problem with dandruff previously, but I have been noticing dandruff and oily skin ever since I started experiencing hair fall. I have an uncle who is bald, but other family members have healthy hair even in their old age.
Doctor, is it a case of MPB caused by genetics or is it due to some other factors like seborrheic dermatitis, stress etc. Do I have any chance of regaining the lost hair? One thing I noticed is that I have been back to my home town for the past 9 months and I have experienced few hair growths near my forehead, but they are very minute in diameter and some have grown long while others are more or less stagnant.  Please advice any medications/ lifestyle changes which may help me.
Thanks in advance!!

If you send me a photo it will be easier to determine if you have MPB,
From your email it seems you do have inherited MPB which has shown up early due to the various stresses leading to sudden thinning due to shedding og hair called Telogen Effluviums.
The use of Rogaine foam twice a day helps keep the hairs in their active Anagen phase. It takes months to see the improvement so loss noted shortly after being on minoxidil is usually still due to the stress which first made you notice the shedding. If the minoxidil you used was not the foam then the itch was most likely due to the vehicle propylene glycol which causes irritation in 2% of patients-- minoxidil itself causes an allergy in 1% of patients. You may well have an allergy to minoxidil itself and the best way to test that is to apply Rogaine Foam -which has no PropyleneGlycol-behind one ear twice a day for three or four days to see if a rash develops. Stress can cause seborrheic dermatitis to flare at the same time it is causing a telogen effluvium, so many think one seb derm causes balding -- not true.I would alternate a ketoconizole shampoo with a zinc pyrithione shampoo- shampoo daily. I personally use a 2% zinc P shampoo daily called DHS zinc.  Propecia =1mg Finasteride - daily will stop MPB in 85% of men and more than half of them will notice a good regrowth of recently lost hair. Finasteride is the most important treatment you could be on.
I my book "Hair Loss Answers" which can be read for free on my website home page you can read about how finasteride works and how TEs make AGA show up ealry.

Chapter 9 tells you about how propecia works


The single most effective medication proven to treat genetic pattern hair loss is Propecia. It is prescribed for men with a genetic predisposition to hair loss (male pattern baldness). Propecia is the brand name for the drug finasteride. Finasteride is a prescription medication that was first approved by the United States Food and Drug Administration (U.S. FDA) for treating enlarged prostate glands. To the delight of some patients taking finasteride for enlarged prostate glands, a side effect of this medication was decreased hair loss, and often re-growth of hair recently lost.

In 1998, after years of additional testing as a hair loss treatment, finasteride was also approved in pill form, at a lower dosage, as an anti-baldness treatment. It is sold as a prescription prostate medication in five-milligram tablet form under the brand name Proscar. For treatment of hair loss, it is sold in one-milligram tablets under the brand name Propecia. For treating baldness, the lower dosage is adequate. The hair loss reduction effect of Propecia occurs at a much lower dosage than that needed to treat enlarged prostrate glands.

Finasteride effectively blocks one form of the 5-alpha-reductase enzyme that converts testosterone into DHT. By blocking the conversion of testosterone into DHT, Propecia prevents the “hair loss message” from getting to hair follicles that are genetically programmed to be sensitive to DHT. This helps stop further hair loss, and in many cases regular Propecia use actually results in significant hair re-growth of recently lost hairs.

Without Propecia, testosterone in the blood is converted freely by the enzyme 5-alpha-reductase into a form of testosterone called dihydrotestosterone (DHT). In men susceptible to pattern hair loss, certain scalp hair follicles are genetically predisposed to respond in a negative ways to elevated levels of DHT in the bloodstream. The most susceptible hair follicles are typically located at the temples, front, and top of the head, but all hair follicles may eventually be influenced to some degree by normal DHT levels. One negative response to DHT is a shortening of the growing phase of the hair follicles, and another is the progressive miniaturization of the hair follicles, which causes miniaturization of the hairs they produce. The end result is shorter and smaller hairs, and fewer and fewer hair follicles producing hairs.

Propecia blocks a form of 5-alpha-reductase found primarily in the prostate gland, called type-II 5-alpha-reductase, from converting testosterone to DHT. The result is lower levels of DHT in the blood. Over many years, DHT in the bloodstream signals hair follicles to shorten their growing phase and to miniaturize. By reducing the amount of DHT in the blood, Propecia reduces the strength of the DHT hormone message, so many of the follicles that would have quit instead continue to produce new hairs.

Continuous treatment is required to maintain this benefit, as 5-alpha-reductase will continue converting testosterone to DHT if treatment is discontinued. However the benefit of using Propecia for any period of time is still realized; Propecia buys time for men with a genetic predisposition for hair loss. The DHT message to stop growing hair must continue for many years, and often many decades, for DHT-sensitive hair follicles to get the message and stop growing new hairs. If the DHT message is disrupted for a period of time, the clock is stopped. In other words, if a thirty-year-old man who would lose his hair by age sixty uses Propecia for twenty years and then stops, he will delay the age when he would lose his hair to age eighty. The benefit of using Propecia for twenty years is not lost when use is discontinued.

With Propecia use, the rate of hair loss slows, and in many cases stops. In many individuals, some recently miniaturized hair follicles begin to grow back to normal size, and begin to grow normal size hairs again. This results in increased hair. The degree of hair regrowth can vary from no measurable regrowth, to significant regrowth.

Double blind clinical tests have shown that Propecia helps men keep the hair they have. In one two-year study, eighty-three percent of men taking Propecia maintained their hair at the top of their heads (vertex area), compared to twenty-eight percent of men taking a placebo. In the same study, seventeen percent of the men taking Propecia still experienced measurable hair loss, but seventy two percent of the men taking the placebo also experienced additional hair loss. After the first two years, results of the group taking Propecia continued to improve.

In addition to stopping further hair loss, Propecia can also help regrow recently lost hair. In another two-year clinical trial, sixty-six percent of men taking Propecia had measurable hair regrowth at the vertex, while only seven percent of men taking a placebo had regrowth. In this study, only one percent of men taking Propecia continued to have hair loss at the top of their heads, while thirty-three percent of men taking a placebo showed a decreased hair count in this area.

For many years before it was approved as a hair loss treatment, a level of safety has been established for finasteride, the active ingredient in Propecia. As a prescription drug already approved by the FDA for treating enlarged prostate glands, it has been extensively researched and tested. Based on studies of hormone breakdown products found in the urine, it seems to affect only the 5-alpha-reductase enzyme, and not other hormones in the blood such as testosterone. Propecia is not an antiandrogen. In fact, levels of testosterone in the blood often increase by ten to fifteen percent when taking Propecia. Finasteride has been shown to be effective at stopping hair loss when taken by mouth in tablet form at much smaller doses than that used to treat enlarged prostate glands. Some possible side effects of finasteride treatment for hair loss may be seen as beneficial, such as possible shrinking of the prostate gland in men susceptible to an enlarged prostate. My personal theory is that taking the lower dosage of finasteride in Propecia early in life may protect men with a genetic predisposition from suffering enlarged prostate glands and prostate cancer as they get older.

A single one milligram Propecia tablet taken daily is the usual prescribed dose for hair loss treatment. Propecia is a treatment, not a cure. This means that a pill must be taken every day for the benefits to continue. When Propecia is discontinued, the hair loss process resumes.

Propecia is for men only, and is not approved by the FDA as a hair loss treatment for women or children. A woman taking finasteride would have only a small decrease DHT levels because most of the effect of finasteride is on type-II 5-alpha-reductase that is primarily made in prostate glands. Women who take finasteride and become pregnant may cause a male fetus to develop ambiguous genitals, and have female characteristics until puberty (at puberty, the child’s genitals normalize).

Propecia treatment may cause a loss of sex drive in one to two percent of patients as a result of reducing levels of DHT circulating in the blood. Treatment with Viagra can be helpful in these cases. Discontinuing Propecia eliminates this possible side effect, if it occurs.

There is also a small risk of reducing the volume of ejaculate if the prostate gland is reduced in size as a result of Propecia treatment. Sperm activity remains normal. Discontinuing Propecia eliminates this possible side effect.

Both of these conditions can affect up to two percent of men in the first month of use, but drop to about a half percent when measured again after two years.

The story of finasteride begins with scientists who were working with a family in the Dominican Republic who had a genetic trait that caused them to give birth to male children with ambiguous genitalia. Female babies were not affected. In many cases it was difficult to determine such an infant’s gender by observation alone. At puberty, when hormone levels in these affected individuals increased, these young boys normalized. They eventually had children of their own, and perpetuated the genetic trait.

It was observed that the adult males in this group being studied did not suffer from enlarged prostate glands, never developed prostate cancer, nor did they lose their hair. No male pattern baldness! Genetic research showed that their gene for producing the 5-alpha-reductase enzyme was inactive. With no 5-alpha-reductase enzyme, testosterone in the blood was not readily converted to DHT. The low levels of DHT that resulted prevented their hair follicles from getting the message to have shorter growth cycles and miniaturization.

Scientists figured that if they could create a medication to regulate the activity of 5-alpha-reductase they could accomplish some of the positive effects of this genetic trait, such as prostate gland normalization and, later hair loss prevention.

Merck, the maker of Proscar for the prostate and Propecia for hair loss, has taken the stance that women shouldn’t touch the pill or the bottle if they are pregnant, and they should not have sex with men who are taking the medication. The rationale behind this is that 5-alpha-reductase, if inhibited in a developing fetus, might result in a male child with a very small penis. People who are missing the enzyme 5-alpha-reductase type II—and there are families of them—have boys who are born looking like little girls. But at age twelve, the testicles descend and they become men. Given the facts, Merck put a warning on their bottles of Proscar and Propecia. Although this defies logic and may sound ludicrous (even if it was radioactive you’d have a hard time measuring it and a woman would have to have gallons and gallons of semen to absorb enough to measure it), Merck did not want to take the risk. Compare this to the warning on a bottle of Jim Beam. It does not say women should not have sex with drunk men, it says pregnant women should not get drunk. However, no doctor—including me—would tell a male patient it is perfectly safe to use Proscar or Propecia and then have sex with a pregnant wife because a certain number of boys are born with this birth abnormality for unknown reasons and it could be blamed on the drug.

Chapter 4 will describe other causes of loss such as Telogen Effluvium

Stress can cause a type of hair loss called telogen effluvium. This condition is not caused by the general accumulated stress of ordinary interactions with people at home and at work, but rather by sudden severe emotional or physiological incidents. Severe stressful events can cause some or most actively growing hair follicles to prematurely shift into the regression phase, and then the resting phase, during which the hairs fall out easily.

There is usually a delay of a few weeks to a few months before the shedding is noticeable, but after this delay the shedding seems to occur quite suddenly. Because the shedding is delayed, this type of hair loss is often a mystery to the person suffering the condition. The stressful event that triggered it is frequently forgotten, and it is rarely thought to be connected with the “new problem.”

Examples of sudden severe emotionally stressful events include the death or terminal illness of a family member or close friend, marriage, divorce, and unexpected job loss. Severe physiological stressful events shock the body, and some examples are heart attacks, major surgery, and illnesses with prolonged high fever such as malaria, viral pneumonia, and severe cases of the flu.

In most cases of telogen effluvium, the hair follicles recover and soon shift back to the regular growth cycle.

However, repeated instances of telogen effluvium can result in premature hair loss in people predisposed to lose their hair late in life. The average growth cycle of a hair follicle takes about five years, but each follicle is “genetically programmed” for only a limited number of growth cycles. For example, if a particular hair follicle were “genetically programmed” for only ten growth cycles, after about fifty years that follicle would stop producing new hairs. When all the follicles at the hairline or crown of the head are “genetically programmed” this way, a receding hairline or bald spot appears after all the growth cycles for the follicles in those areas have been cycled through.

Each incidence of telogen effluvium uses up one “life” of the affected hair follicles. So instead of having a receding hairline or bald spot at age fifty, the hair loss may occur a few years earlier. This is not a significant issue if telogen effluvium occurs once or twice in a lifetime; however, accelerated hair loss can result from repeated severe stressful events, if each instance triggers a new round of telogen effluvium.

I had a patient who was totally bald when I met him at age seventy, and he had lost all his hair by age twenty-two. He had worked on the Panama Canal fifty years earlier, and for two straight years starting when he was twenty he suffered repeated bouts of severe fever from episodes of malaria. Each time he suffered from malaria induced fever he experienced telogen effluvium, lost what hair he had, and his hair follicles lost another “life.” After ten or fifteen malaria stress cycles, at the age of twenty-two, he had the hair he would have had at age seventy. Which unfortunately for him was no hair at all.  

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Peter J. Panagotacos, <B>M.D.</B>


I have 30 years experience in the field of medical and surgical Hair Restoration and am Board Certified in Dermatology and Hair Restoration Surgery.


I have 30 years experience in the field of medical and surgical Hair Restoration and am Board Certified in Dermatology and Hair Restoration Surgery. More information can be found at my website

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