Androgenetic Alopecia Male Pattern Baldness / Female Pattern Baldness Androgenetic Alopecia accounts for 95% of all hair

loss. It can affect both men and women although men experience a much greater degree of loss. In women Androgenetic Alopecia appears as diffuse hair loss occurring over most of the scalp. In men however the pattern of loss usually starts with a receding hairline which then advances to thin the top of the head. Causes of Androgenetic Alopecia In 400 BC Hippocrates observed that eunuchs did not become bald. Later Aristotle noticed this also. In the 1940s Dr James Hamilton concluded that genetic predisposition in the present of the male hormone androgen where the factors that caused the development of Androgenetic Alopecia. However it is now known that it is more specifically the male hormone dihydrotestosterone (DHT) which is converted from the enzyme testosterone by the enzymes 5 alpha reductase which contributes to Androgenetic Alopecia in those who are genetically predisposed. It is interesting to note that individuals with a deficiency in 5 alpha reductase do not develop Androgenetic Alopecia. This is because the body is unable to convert testosterone into dihydrotestosterone. When Androgenetic Alopecia occurs large active hair follicles in specific areas begin to change to smaller less active ones that shrink slightly with each new growth cycle. The enzyme 5 alpha reductase is thought to be the major cause of this. Under the action of the enzyme the male hormone testosterone become dihydrotestosterone. This causes the hair shafts to narrow producing progressively finer hairs with each new growth cycle until eventually the hairs become transparent and stop emerging. If an individual has androgenetic alopecia the overall levels of testosterone may be normal however the activity of 5 alpha reductase is greater than normal which results in increased amounts of dihydrotestosterone in the hair follicle. Treatments for Androgenetic Alopecia Minoxidil Minoxidil is the most widely recommended treatment for Androgenetic Alopecia. In the United States topical Minoxidil is marketed under the brand name Rogaine in New Zealand it is marketed as Regaine and recently a generic version of topical Minoxidil has become available under the brand name Headway. Minoxidil appears to work by gradually enlarging and lengthening hair follicles which have been gradually shrinking due to Androgenetic Alopecia. The growth phase may also be extended giving the hairs an opportunity to reach a longer length before they fall out. It is necessary to use Minoxidil for about 3-4 months to see evidence of regrowth and up to 6 months to get a proper estimate of whether Minoxidil will be helpful in a particular case. Minoxidil also requires continual use in order to be effective. Once application of Minoxidil is ceased the hair will return to the original state in about 3 months. The two main disadvantages of using Minoxidil is that first of all its use must be continued in order to maintain the results achieved and the second disadvantage is the expense. Minoxidil is however becoming more affordable and the generic version Headway which is cheaper makes Minoxidil more affordable.

Propecia (finasteride) Propecia is a relatively new drug produce by Merck. It is a tablet which is taken once a day and at this present time it is only approved for use in men. Propecia is not to be used by woman and children. Propecia is a 4 aza steroid compound that is a specific inhibitor of type 2 5 alpha reductase which is the enzyme that metabolises the androgen testosterone into dihydrotestosterone (DHT). In this way Propecia helps to prevent the continued miniaturisation of existing hair follicles and also assist in the recruitment of miniaturised hair follicles to become terminal hairs. Like Minoxidil, Propecia must be taken for a period of 3 months or more before any benefit is seen and it must be continued in order to maintain any benefits gained. Propecia is also expensive to maintain. Retin-A / Tretinoin Retin was originally used in the treatment of acne and other skin disorders. However studies have shown that Retin-A alone or in combination with Minoxidil can result in moderate to good hair growth in individuals with Androgenetic Alopecia and Alopecia Areata. Many dermatologist recommend using Tretinoin in combination with Minoxidil to increase the effects of both these products. Side effects of Retin-A include blistering, altered pigmentation and increased sensitivity to light. If a gel is used it is suggested that Minoxidil be applied in the morning a Retin-A gel in the evening to reduce the problems caused by sunlight. Zinc Some vitamins have been shown to inhibit the activity of 5-alpha reductase and the subsequent production of (DHT) dihydrotestosterone. These vitamins therefore may be of great benefit in the treatment of Androgenetic Alopecia or pattern baldness. There have been studies in which Zinc is shown to inhibit 5 alpha reductase activity and it has therefore been concluded than Zinc is beneficial in disease and disorders related t an excess in dihydrotestosterone (DHT). There have also been studies which have shown that vitamin B6, Zinc and Azelaic Acid combined together even at very low concentrations reduced a 90% inhibition of 5 alpha reductase activity. Skinoren / Azelaic Acid Azelaic Acid like Retin-A is more commonly used in the treatment of acne and other skin conditions. Recently the potential effect of using Azelaic Acid in the treatment of Androgenetic Alopecia has been looked at and discussed. Studies carried out in France in the late 80s where to assess the effects of Zinc Sulphate, a Azelaic Acid on the human skin. The result of these studies demonstrated that at high concentrations Zinc could completely inhibit the activity of 5 alpha reductase. Azelaic Acid was also shown to be a potent inhibitor of 5 alpha reductase. Inhibition was detectable at concentrations as low as 0.2mmol/l and was complete at 3mmol/l. When Zinc, Vitamin B6 and Azelaic Acid where added together at very low concentrations which had been ineffective alone, 90% inhibition of 5 alpha reductase was achieved. Saw Palmetto extract Studies have shown that Saw Palmetto is an effective anti-androgen. It acts in a similar way that Propecia does. Firstly it lowers levels of DHT in the body by blocking 5 alpha-reductase. Secondly Saw Palmetto block receptor sites on cell membranes required for cells to absorb DHT. Although no studies have been carried out on Saw Palmetto and its relation to hair growth. Studies have been performed on the use of Saw palmetto in the treatment of benign prostatic disease which similar to Androgenetic Alopecia also depends on the production of dihydrotestosterone. All of the studies that have been

performed to date show that Saw Palmetto is an effective antiandrogen and has shown conclusively to be effective in the treatment of benign prostratic disease. One may assume from this that since Saw Palmetto is an effective antiandrogen and is used in the treatment of prostatic disease then it may also be effective in the treatment of Androgenetic Alopecia.

Androgenetic alopecia is described in this month's patient leaflet. It is thought to be inherited from either parent, and is due to the effects of androgens on hair follicles. The pharmacist may first suggest that the patient with androgenetic alopecia attempt regrowth with nonprescription minoxidil. If results are unsatisfactory, the patient may be referred to the physician for prescription finasteride (Propecia). Minoxidil Minoxidil is available in two concentrations. The 2% solution is available as Rogaine For Men, Rogaine For Women, and generically. The 5% solution is only available as Rogaine Extra Strength for Men. Minoxidil should only be used by patients aged 18 and older.3 It is indicated for vertex hair loss in men and thinning on the top of the head in women. Frontal hair loss in men is not an approved indication for minoxidil as its efficacy for this has not been demonstrated. Women should not use the 5% solution since, for them, it is no better than the 2% solution and it may cause the growth of facial hair. Women who are pregnant or breastfeeding should seek the advice of a physician before using the 2% solution; use of the 5% solution during this time is contraindicated because of possible harm to the fetus/infant. Patients might be cautioned against over-optimistic expectations with minoxidil. Patients cannot expect to regrow all of their hair. After four months of using 2% minoxidil, 26% of men reported moderate to dense hair regrowth and 33% experienced minimal regrowth. In female users, the 2% solution caused moderate hair regrowth in 19%, and minimal regrowth in 40%. The 5% solution is more effective than the 2% solution for male users. Results with minoxidil will not be sudden or dramatic because hair only grows 0.5-1 inch each month. The patient may need to apply the 2% solution for four months before growth is noted; men may note results with the 5% solution after only two months. If a male does not notice results in 12 months with the 2% solution or four months with the 5% solution, he should discontinue use. The female should only use 2% minoxidil for eight months with no results before ceasing use.

Patients often wonder if they can stop using minoxidil when their maximal regrowth is achieved. If they stop use, they will gradually lose hair that was regrown over a period of several months. In addition, the bald spot may be larger than it was before the use of minoxidil. This is due to the natural progression of hair loss over time. For example, a male patient with androgenetic alopecia who is not using minoxidil would experience a progressive loss of vertex hair from the years 2001-2010. However, if he began using Rogaine in 2001 and ceased using it in 2009 would look the same in 2010 as if he had never used minoxidil at all. Finasteride (Propecia) Finasteride's mechanism of action is tied to testosterone.4 Testosterone is metabolized by type II 5 alpha-reductase to DHT in the inner root sheath of the hair follicle. DHT is thought to be responsible for male-pattern baldness. Finasteride may competitively inhibit the action of type II 5 alpha-reductase to reduce levels of DHT in the hair follicle. The dose in men is 1 mg orally once daily, without regard to meals. It is contraindicated in females. The drug was given a Pregnancy Category rating of X by the Food and Drug Administration; in pregnant females it may cause feminization of a male fetus to the extent of producing abnormalities of the male genitalia.5 Hair loss may be inherited, or it may be due to hairstyles, medical therapy, or conditions that scar the scalp. How to Identify Genetic Hair Loss Hair loss can be inherited from either parent, so you should look at other family members of the same sex to help confirm your hair loss as genetic in origin. For instance, if you are male, look at your father, grandfathers, brothers and sons. Male first cousins may also provide clues. If you are female, look at your mother, grandmothers, sisters, female first cousins, and daughters. Although hair loss is an extremely common genetic condition, a patient with no apparent family history may still have androgenetic alopecia. Other clues to look at are the quantity of hair loss, the locations from which hair has been lost, and the time span over which the hair was lost. True androgenetic alopecia should have caused a gradual thinning of hair over several years' duration, and the pattern of hair loss for men should be receding of the front hair-line in either a uniform or "U" shape. Men may also notice a bald spot beginning at the back center of the scalp, known as the "vertex" of the head. Women with androgenetic alopecia experience a general thinning of hair along the top of the head, usually starting at the midline, with a slowly enlarging area of loss. For help in recognizing this type of hair loss, consult your pharmacist. When to See a Physician If the hair loss is sudden, or if large amounts of hair are lost at one time, this may be an indication of a serious condition that should be checked by a physician. A physician should also be seen if the hair loss involves patches of the scalp. Hair loss can also be caused by pregnancy, use of some prescription medications, too little iron, too much vitamin A, low thyroid activity,

discontinuing the use of birth control tablets, chemotherapy, and some diseases that scar the scalp. None of these would be self-treatable and a physician should be seen. Over-the-Counter and Prescription Products If your hair loss is self-treatable, your pharmacist can point out a nonprescription product known as minoxidil, which may be helpful when used as directed on the labeling. Should minoxidil not work, you physician can prescribe a product known as Propecia. Neither of the products should be seen as a cure for hair loss. Nevertheless, they are the only two products that are proven safe and effective for hair loss. Internet Resources The Internet contains many web sites that promote unproven hair growth products. Many of the sites seem to present scientific explanations for why their products work, but virtually all should be avoided. For a good explanation of the sites and why their claims cannot be true, visit the web site www.hairquackery.com