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More than half of men are affected by male pattern baldness by age 50, and baldness treatments are estimated to be a US $1 billion per year industry. Since the 1980s, drug therapy has increasingly become a realistic management option for baldness for men and women. Increased understanding of the role of dihydrotestosterone (DHT) in male and female pattern baldness has led to targeted intervention to prevent this hormone from acting on receptors in the scalp.
There are only two drug treatments approved by the U.S. Food and Drug Administration (FDA) for male baldness: Minoxidil and Finasteride . Finasteride is recommended first for male pattern baldness.
Minoxidil is a vasodilator and originally was exclusively used as an oral drug (Loniten) to treat high blood pressure. It was discovered, however, to have the side effect of hair growth and reversing baldness, and in the 1980s, Upjohn Corporation received FDA approval to market a topical solution that contained 2% minoxidil to be used to treat baldness and hair loss as Rogaine, marketed as Regaine outside the USA.
Objective evidence shows that minoxidil is effective in both the frontal areas of the scalp and the vertex area in treating male-pattern hair loss. At the conclusion of a 48 week study, improvements were seen in the frontal scalp regions of 51% of men using 5% minoxidil, 42% using 2% minoxidil, and 13% of placebo users. Among these men, moderate to great increases in hair growth were seen in the frontal scalp regions of 19% of men using 5% minoxidil, 10% using 2% minoxidil, and 3% of placebo users.
The method of action for minoxidil is not known.
Finasteride, initially marketed as the brand-name drugs Propecia and Proscar by Merck, belongs to a class of drugs called aza-steroids. Finasteride is a "DHT inhibitor" and was originally approved by the US FDA for the treatment of benign prostatic hyperplasia (BPH). The drug works by binding to 5-alpha-reductase, the enzyme responsible for the conversion of free testosterone to DHT.
Merck sought to find the smallest effective quantity of finasteride and test its long-term effects on 1,553 men between ages 18 and 41 with mildly to moderately thinning hair. Based on their research, 1 mg daily was selected, and after two years of daily treatment, over 83% of the 1,553 men experiencing male hair loss had actually maintained or increased their hair count from baseline. Visual assessments concluded that over 80% had improved appearances.
In 1997, finasteride was approved by the US FDA for the treatment of male pattern baldness. A 5-year study revealed that 9 of 10 men taking finasteride (1 mg daily) experienced visible results (42% of men taking Propecia experienced no further hair loss while 48% experienced no further hair loss and hair regrowth).In clinical studies, finasteride, like minoxidil, was shown to work on both the crown area and the hairline area, but is most successful in the crown area.
Finasteride is usually only prescribed for men and should not be used by pregnant or potentially pregnant women, as it has been speculated that it could cause severe birth defects in male fetuses.
Antiandrogens block DHT already produced and present in the blood stream from binding with hair follicles. Their specificity varies greatly from specific antiandrogens such as finasteride which inhibit the conversion of testosterone to DHT by interfering with 5-alpha-reductase to more broad spectrum antiandrogens (fluconazole, spironolactone, etc.). Although unusual in clinical doses, antiandrogens can have serious side effects including gynecomastia.
In 2001, GlaxoSmithKline released another aza-steroid called dutasteride, marketed as Avodart. Like finasteride, dutasteride was originally developed for the treatment of benign prostatic hyperplasia (BPH). It is not currently sold for baldness treatment.
While hair count studies showed that 2.5 mg of dutasteride was about 1.5 times as effective as finasteride for hair regrowth (adding on average 108 versus 72 hair per 1" diameter area), Glaxo stopped FDA hair loss studies after phase II. Although the exact reason was never made public, it was speculated that the product was too similar to finasteride, which itself had not lived up to expectations commercially. As such, the 2.5 mg dosage was not released. The FDA trials for BPH continued, and Avodart became the first drug shown to shrink an enlarged prostate in a clinical study. The .5 mg version of the drug (shown in the same study to add on average 92 hairs to the same area) is increasingly available to hair loss sufferers via the grey-market of online prescription medication, and physicians increasingly willing to prescribe drugs "off-label."
In December 2006, GlaxoSmithKline embarked on a new Phase III, six month study in Korea to test the safety, tolerability and effectiveness of a once-daily dose of dutasteride (0.5 mg) for the treatment of male pattern baldness in the vertex region of the scalp (types IIIv, IV and V on the Hamilton-Norwood scale). GlaxoSmithKline has published the results of the study, concluding
This study demonstrated dutasteride 0.5 mg /day administered for 6 months was well tolerated and slowed the progression of hair loss and increased hair growth in Korean men. For hair counts as assessed by macrophotography in the vertex at 6 months (primary endpoint), the dutasteride 0.5 mg group was significantly superior to the placebo group. The hair count difference at 6 months between dutasteride and placebo group was 7.5 ± 20.4 (95% CI = 0.8, 14.3). The overall incidence of adverse events and adverse drug reactions during treatment was similar in the two groups.. The most commonly reported adverse event in both groups was nasopharyngitis. One serious adverse event was reported during the trial (thyroid cancer in the placebo group).
Ketoconazole is a synthetic antifungal drug used to prevent and treat skin and fungal infections, especially in immunocompromised patients such as those with AIDS. Because it is both an anti-fungal, a 5-alpha reductase inhibitor and a hair growth stimulant, it can help to slow the balding process. There has been some suggestion that ketoconazole could inhibit testosterone synthesis in utero, which could potentially inhibit genital development of a male fetus. However, this has not been documented in any controlled studies. Ketoconazole has not been FDA-approved for hair loss, though it is used for other scalp conditions.
In 2009 a new study result was released including pictures of before and after treatment. In this study six Japanese males with male pattern baldness (androgenetic alopecia) from 23 to 51 years old were enrolled and the subjects applied topical 2% KCZ lotion (Nizoral® cream) every day during or immediately after hair washing with their own un-medicated shampoos. All subjects reported a stop in hair loss and a regrowth of part of their lost hair after three months of continuous use. 
Copper peptides are applied topically to the scalp, and shorten the resting phase of hairs, resulting in more hair follicles on the scalp being in the growing phase (as opposed to the resting or falling out phase) at one time.[dubious superoxide dismutation activity.] Copper peptides generally have
SOD work by dismuting the superoxide anion into hydrogen peroxide, thereby preventing the converson of the superoxide anion to peroxynitrite (a free-radical) by combining with nitric oxide (a naturally occurring chemical messenger). The double effect of SOD therefore is the reduction in free-radical and increase in nitric oxide. It is thought that a key mechanism of action for minoxidil is the production of Nitric oxide (NO). Superoxide has an "agonist-antagonist" relationship with Nitric oxide or "Endothelium-derived Relaxing Factor".
Various SOD generating products are now available. However, one problem with SOD is the production of Hydrogen Peroxide as a by-product of singlet oxygen (superoxide anion) quenching. In the human body, the enzyme catalase converts the SOD hydrogen peroxide byproduct into water and oxygen. Nanogen, a UK-based skin research company, is undergoing Phase I trials to ascertain the hair regrowth potential on a new "broad-spectrum" molecule which has been shown in extensive independent laboratory in-vitro testing to have both SOD and Catalase mimetic activity. The company has not released details of the molecule as it is pending patent but it is copper II based.
Saw palmetto extract has been suggested as a potential treatment for male pattern baldness. It has been shown to inhibit both isoforms of 5-alpha-reductase without eliminating the cellular capacity to secrete PSA.
In animal models, the nitroxide spin labels TEMPO and TEMPOL enhance hair regrowth following radiation. National Cancer Institute-sponsored clinical trials TEMPOL is similarly effective in humans.
Diet and lifestyle
There are a number of genetic factors which determine a person's susceptibility to androgenic alopecia including androgen receptor polymorphisms, 5-alpha-reductase levels in the scalp, androgen receptor density and distribution in the scalp, and other factors some of which may not have been discovered.
Daily, vigorous aerobic exercise (as opposed to short workout periods designed to raise androgen levels and build muscle, or more sporadic exercise) and a diet which is adequate yet more moderate in terms of fat and total calorie intake have been shown to reduce baseline insulin levels as well as baseline total and free testosterone.
Lower insulin levels and reduced stress both result in raised levels of Sex Hormone Binding Globulin (SHBG). SHBG binds to testosterone, and prevents it from circulating free in the blood. Only free testosterone is converted to DHT. It is the level of free androgens and not total androgens which is relevant to the levels of DHT in the scalp and the progression of MPB. In short, aerobic exercise is capable of significantly lowering DHT.
Androgenic alopecia has been shown to correlate with metabolic syndrome. Medically increasing androgen levels does not worsen this condition, demonstrating that androgens do not cause metabolic syndrome. Instead, high insulin levels (and possibly chronic inflammation) seem the likely link in the demonstrated correlation between baldness and metabolic syndrome. This reinforces the notion that behaviors which help to keep insulin levels low and reduce chronic inflammation might also help to preserve hair.
Hair transplantation involves relocating (transplanting) bald resistant hair follicles from the back and sides of the head (the donor areas) to a person’s bald or thinning areas. The transplanted hair follicles will typically grow hair for a lifetime because they are genetically resistant to going bald. In recent years hair transplantation techniques have evolved from using large plugs and mini grafts to exclusively using large numbers of small grafts that contain from between 1 to 4 hairs. The grafting may cause localized loss of existing hair, the graft then typically grows in within a year.
Since hair naturally grows in follicles that contain groupings of 1 to 4 hairs, today’s most advanced techniques transplant these naturally occurring 1–4 hair "follicular units" in their natural groupings. Thus modern hair transplantation can achieve a natural appearance by mimicking nature hair for hair.
Another method is scalp reduction, in which skin in the balding area of the scalp is surgically excised. The left over skin is then pulled together and sutured.
Stem cells and dermal papilla cells have been discovered in hair follicles and some researchers predict research on these follicular cells may lead to successes in treating baldness through hair multiplication (HM), also called hair cloning.
In 2008, Intercytex announced positive results of a Phase II trial for a form of cloning hair follicles from the back of the neck, multiplying them and then reimplanting the cells into the scalp. The initial testing resulted in at least two thirds of male patients regrowing hair. As of 2009, the company estimates this treatment will take "a number of years to complete" Phase III trials before it can go to market. Intercytex announced (2010) their company is broke and there probably won't come Phase III by them.
WNT Protein Introduction
In May 2007, U.S. company Follica Inc, announced they have licensed technology from the University of Pennsylvania which can regenerate hair follicles by reawakening genes which were once active only in the embryo stage of human development. Skin apparently can be brought back to this embryonic state when a wound is healing. Hair growth was discovered in the skin wounds of mice when Wnt proteins were introduced to the site. Development of a human treatment is expected to take several years.
A randomized clinical trial of patients with bald patches on their scalp or skin showed a daily scalp massage with essential oils to be a safe and effective treatment for hair loss resulting from alopecia areata, a condition affected 0.1%–0.2% of humans (mostly women).
Low-level laser therapy
Some devices claim to use low-level laser therapy to stimulate hair growth through "Photo-Biostimulation" of the hair follicles. The Hairmax Lasercomb is the only laser phototherapy device to receive FDA clearance for marketing, although the FDA did not determine whether the LaserComb is safe or effective. Instead, it determined that the device is similar to devices sold before 1976. This means that the device can be sold without proof of safety or efficacy. The device's maker also provided the FDA with a results of a trial (co-authored by the device's maker with 3 other authors including dermatologists) that it claims shows that the device is safe and effective. However, there is no evidence that the FDA considered this study it making its ruling. 
The Leimo laser is registered with the Therapeutic Goods Administration of Australia as a Class IIa Medical Device. It was approved for safety, but the TGA did not rule on its effectiveness. In 2009 the TGA reprimanded Leimo, stating that there is no evidence that the device would regrow hair, and said that the company must "withdraw any representations that the advertised product can provide benefits such as hair regrowth, reversal of hair loss, or reversal of hair thinning."
Unsaturated fatty acids
Through 2006, a drug development company spent $1,000,000 on a hair growth program focused on the potential development of a topical hedgehog agonist for hair growth disorders such as male pattern baldness and female hair loss. The hair loss research program was shut down in May 2007 because the process did not meet the proper safety standards.
Caffeine has been identified as a stimulator of human hair growth in vitro, and reduced testosterone-induced follicle growth suppression. It has been demonstrated that the addition of caffeine to a shampoo-formulation is effective in administering caffeine to the hair follicles in the scalp. Further research must be done to evaluate the efficacy and adequate dosage of caffeine in the treatment of androgenetic alopecia.
A spray made with coffee beans is claimed to prevent age-related hair loss in women.
In February 2008 researchers at the University of Bonn announced they have found the genetic basis of two distinct forms of inherited hair loss, opening a broad path to treatments for baldness. They found that a gene, P2RY5, causes a rare, inherited form of hair loss called Hypotrichosis simplex. It is the first receptor in humans known to play a role in hair growth. The fact that any receptor plays a specific role in hair growth was previously unknown to scientists and with this new knowledge a focus on finding more of these.In May 2009, researchers in Japan identified a gene, Sox21, that appears to be responsible for hair loss in people.
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- Children's Alopecia Project
- "Medical Treatments for Balding in Men," April 1999, American Family Physician (medical journal)
- North American Hair Research Society Frequently asked questions
- Health Alternatives: zinc, silica, methylsulphonylmethane (MSM) and cod-liver oil, to slow down the process.
- The Trichological Society
- International Society of Hair Restoration Surgery
- How Hair Replacement Works