Male hair loss: what are my options?

Hair loss (alopecia) in men is fairly common, with Male Pattern Hair Loss (androgenetic alopecia) being the most common type. Hair loss can be treated in a variety of ways, with both surgical and non-surgical options to choose from. Dr Greg Williams, a leading hair restoration surgeon, explains the different types of hair loss and the available therapeutic options.

Human scalp hairs are in a continuous growth cycle and daily shedding of hair is completely normal, with loss of up to 100 hairs a day being considered average. These hairs are replaced by the same number of newly growing hairs and there is a net balance. When loss exceeds growth, thinning, and eventually balding, results.

Hair loss can be broadly classified into scarring and non-scarring alopecia.

What is scarring alopecia?

Primary scarring alopecia is immune mediated where the body’s own white cells target the hair follicles and can destroy them. Early diagnosis is important since, although the condition cannot be cured, treatment can prevent progressive hair loss. This can be done using a dermatoscope, but sometimes a biopsy is also required. Under a dermatoscope, early primary scarring alopecia may present with signs of inflammation (peri-folliculitis) but in longer standing cases, appears to the naked eye as scarred skin with absent hair follicles.

Examples of scarring alopecia include:

• Lichen Planopilaris (LPP)
• Frontal Fibrosing Alopecia (FFA)
• Central Centrifugal Cicatricial Alopecia (CCCA)

Secondary scarring alopecia occurs when there is external injury to the hair follicles.

Examples of secondary scarring alopecia include:

• Trauma
• Burns
• Surgery

What is non-scarring alopecia?

Non-scarring alopecia does not involve inflammation and can be shedding or non-shedding.

Examples of shedding alopecia include:

• Anagen effluvium e.g. immediately after chemotherapy
• Telogen effluvium e.g. several weeks or months after illness
• Congenital e.g. loose anagen syndrome

Non-shedding alopecia can be diffuse, unpatterned, or patterned

Examples of diffuse alopecia include:

• Certain medications
• Some nutritional deficiencies

Examples of unpatterned alopecia include:

• Traction alopecia
• Alopecia areata
• Trichotillomania (also known as hair pulling disorder)

Examples of patterned alopecia include:

• Temporal Triangular Alopecia (TTA)
• Male Pattern Hair Loss (MPHL)

Male Pattern Hair Loss (androgenetic alopecia) is the most common cause of hair loss in men. It is characterised by the progressive ‘miniaturisation’ of hair when large pigmented hairs are replaced by fine, colourless hairs. Often hair loss starts in the crown, hairline or anterior temple areas of the scalp and progresses to the midscalp. This form of male hair loss is genetic.

How can Male Pattern Hair Loss be treated?

Non-surgical options:

Men with early hair loss might consider non-surgical treatment options, as they may not be suitable for hair transplant surgery.

• Shampoos and conditioners – these do not increase hair density, but they can improve hair quality.
• Healthy diet and lifestyle – poor health and illness can affect hair growth, so eating a healthy diet and getting enough exercise is important to maintain good hair growth.
• Camouflage products – such as scalp dyes, microfibers and coloured hairsprays can be very effective in hiding thinning hair, however, they should be washed off frequently to keep the scalp healthy.
• Hair replacement systems (wigs and toupés) – these can be an option for men with advanced hair loss who are not suitable for transplant surgery. However, they may require regular professional maintenance, with the associated expense, and may actually exacerbate the psychological distress of hair loss.
• Medications – there are two main types which have to be taken for 6-12 months to show any efficacy. Topical minoxidil can be applied to the scalp twice daily and is available at chemists over the counter with minimal side-effects. Oral finasteride is a pill that is taken once a day but does have possible side-effects, including a small chance of erectile dysfunction or reduced libido and even more rarely, gynaecomastia. Both of these medications are more likely to retain existing hair and prevent further hair loss rather than achieve any regrowth.

Hair transplant surgery:

Hair transplant surgery works by placing donor hairs, from the patient, into the area of MPHL. These donated hairs remain relatively permanently once implanted and will continue to cycle and regrow like normal hair. Hairs are removed either using the Strip Follicular Unit Transplantation (Strip FUT) method or the Follicular Unit Excision (FUE) method . A follicular unit is a natural grouping of 1 – 4 hairs with sebaceous glands and a single arrector pili muscle.

For the Strip FUT method, an elipse of hair-bearing skin is removed, from the back and/or sides of the scalp. Then, the follicular units are dissected from this section of skin under microscope magnification. It is important to note that once the donor wound is closed, a linear scar will remain, but this can be concealed by hair growth with adequate length.

For the FUE method, each follicular unit is removed using a cored punch instrument that can be sharp, dull or a hybrid of the two. These devices may be manual, automated or even robotic. The FUE technique is less painful post-operatively and the small round scars from the extraction sites can be more easily concealed with shorter hairstyle. However, there is a higher risk of transecting hairs using this method and in general, less donor hairs will be available for harvesting. Additionally, this method reduces the density of the donor zone which, when donor hairs are overharvested, can be visible.

Who is suitable for hair transplant surgery?

Ensuring a correct hair loss diagnosis is important before surgery is considered because certain causes of alopecia should be treated surgically (e.g. alopecia areata and other inflammatory conditions). The patient’s age, extent of hair loss, age of onset, family history, ratio of donor site to recipient site, and likelihood of on-going, and possible extensive, hair loss must all be taken into account when considering hair transplant surgery.

What can patients expect from their hair transplant surgery?

For patients having modern hair transplants, they should expect a natural appearance, with little difference being discernible between the native hairs and those transplanted. However, within the first few weeks there is likely to be shedding of the transplanted hairs, with early results visible at 6-8 months post procedure and final results only achieved at 12-18 months after surgery.

If you are interested in receiving hair loss treatment, make an appointment with an expert.