Author: Dr. William Rassman

On September 17th, an Advisory Panel For FDA Recommends Restrictions To Doctors On The Use Of Testosterone on a vote of 20:1. Testosterone use has become more popular among American men and the question that is posed: Is it Safe? Men think that they have reduced testosterone and believe that it may be the cause of reduced sexual function. For these men, testosterone become the dream aphrodisiac to bring back their sexual performance and drive from their younger days. What most men do not realize is that decreased sexual function, from a physiological point of view is common in men over 40. Those with decreased sexual performance impacts (in general) 40% of men in their 40s, 50% in their 50s, 60% in their 60s and so on. Most of these men, especially those in their 40s and 50s have normal testosterone levels so added testosterone may have no know sexual benefit. Obviously from the vote, one panel member did not agree with the rest and this reflects uncertainty in the field. No one knows if the FDA will accept the panels recommendation.

LINK NY Times
LINK Urology Times
LINK FDA

I hear every conceivable answer to the question of washing ones hair. Should it be done daily, twice a day or weekly?

A famous hair researcher recently suggested that a wool sweater of the highest grade, if washed everyday for a year, would eventually show significant wear and tear after a year. That is because the soaps and detergents used would break apart the wool fibers with time. Better wools stand up to the detergent attacks better. So it is with hair, more washing eventually damage the hair over time as the wax that protects the hair shafts (sebum) is washed out. The shorter the hair, the less the problem as the older hair (ends of the hair) show the damage of washing over time much more than short hair. Women with long hair complain of ‘split ends’ often and this is the result of accumulated washing and drying of the hair. Blow dryers produces more damage to the hair.

For most men who do not let their hair grow to shoulder length, wash as often as you wish. Use good quality shampoos and if you add a conditioner, it will re-hydrate the hair shafts after the detergents take out the wax that normally protects the hair.

When I was in my teens and twenties, my hair was long, lush, wavy and full bodied and made me look sexy. Now at 48, my hair is thin, the opposite of lush, limp and impossible to deal with. Is this a health problem that my doctor can help me with or is there someone else I can see to get my hair back to the way it was when I was younger.

I am going to use this question as a way of addressing a variety of subject reflecting hair questions that rise from our readership from time to time.

Hair changes with age and often becomes finer. The lushness and full bodied hair you are talking about is the result of the texture of your hair and its thickness. Over the years, our hair changes its character, not only turning gray, but also becoming finer. If you have long hair and you use a hair blower to dry your hair, curlers to add body to it, curling irons to add more body to it, you will damage the hair that you have more with each use. You may have gotten away with it when you were young and your hair was more coarse and your sebum glands were more active in producing the wax that protected your hair; however, at your present age your hair will tolerate less and less of these treatments. Curling iron and hot irons or all kinds, kill hair.

What you need to do is to lubricate your hair, restore hydrophobicity, neutrilize the charges on the negatively charged hair and add lipids (fats to your hair). Think about your fingernails. When the tip breaks, the break propagates further into the fingernail. Hair is like the fingernail and you can not prevent the propagation of the break in the fingernail by putting a gel on it to fix it. Good quality shampoos and rinses, possibly with silicone, will help maintain ‘hair health’. I put quotes around the term ‘hair health’ because you all should know that the hair in our head is keratin which is not alive to the concept of ‘health’ here reflects the preservation of hair qualities and our abilities to make the hair look and feel better to us.

Silicone will smooth the feel of your hair and reduce friction thereby making it easier to comb your hair. When you pull your comb through your hair with any resistance, you break the hair fibers. The silicone in many of the hair products help, but all silicone is not the same. Silicone in our hair products come in different size particles. If smaller particles of silicone are used, they coat the hair better but because they are small but they wash out more easily. Higher quality silicones can be very expensive products, so be careful when you buy them as many are over priced products. When buying a quality product, if you like it, stick with it.

Hair conditioners work to make the electrical charge on the hair more positive. The use of surfactants also has value. Hair is covered with a naturally produced hydrophobic oil (repels water) and the poils are easily damaged bu UV light. As the hydrophobic oils leave the hair, the hair develops a negative electrical charge. The use a surfactants reduces the electrical charge, but may not make the hair as hydrophobic as you may want (repelling water)

I know how important hair is for many people as the focus on your hair grooming takes a considerable amount of time daily. But you must recognize that your hair changes as you age (men and women) and many of the things we do to help our hair, actually damages it. Use a good commercial shampoo made by a reputable suppliers and a good conditioner to ‘top off’ your daily cleaning routine. Once you find the shampoo you like, stick with it. Sulfate free shampoos probably makes no difference in the products you buy. The use of spray-on solutions for UV protection may not work well (long hair as the overall length of the hair, end on end, can be many, many meters long). When you use good hair products, its is about deposition and evenness in its application and putting things on and into long hair is not easy.

Organic shampoos make no difference on your hair health. The use of hyaluronic acid can add moisture so it can be used for moisturization when found in products, but its use is still in a research mode. As hair is normally resistant to water, getting products into the hair can be very difficult but in the research mode, Hyaluronic acid seems to work well for moisturization.

Water conditions in the area you live in vary and may significantly impact the shampoos and conditioners you use. Check with the labels on the products you use and see if it discuss their use in hard water. Some companies put kelators into the products to normalize the water. Copper is the worst thing found in water and kelants can neutralize the impact of copper. Frequent washing of your hair with hard water is bad, so using a conditioner is important. Make sure that the water you use in washing and with conditioners is cooler water, as hot water can damage hair.

There are products that thicken the hair shafts by making it absorb water or by coating the hair shafts to make it look fuller. There are products that produce thicker and fuller hair but this is a difficult area to make recommendations for as many of the product offerings are not really effective. If one thickens the hair shaft by just a little, the overall effect on hair bulk can be very significant considering that the thickening impact reflects the length of the hair measured end-on-end from a bulk point of view. Such products can act as if you have added 5000+ hairs to your head. In some countries, oils are added (e.g. olive oil) which may thicken the hair as it coats each hair shaft.

For hair regrowth, minoxidil is the only game in town that has been proven to grow new hair follicles from balding areas. For frequency recommendations for washing: the less the better. skin has a microbial community and the sebum and flakes cause micro-organizes to eat that fat. These bacteria eat sebum and the unsaturated fatty acids these bugs produce are irritants. Wash 2-3 times a week may be ideal for addressing these ‘bugs’. People with lower hair density and lower hair bulk need less washing because less sebum is produced and the hair shafts have more air movement around them causing more drying. Asians, with their lower densities, might take note here.

Minoxidil is the only game in town for new hair growth. Propecia may work mostly on reversing the miniaturized hairs that are already beginning the genetic slide with androgenic alopecia.

Dr Rassman,

My question is: does finasteride play any role in maintaining minoxidil dose-dependent hair?

I got started on 5% minoxidil topical in early Feb, 2009. My derm prescribed Finasteride oral 1mg/day too, but I did not pursue that medication due to the usual side-effects related concerns. There was an initial minox-induced shed: not a massive one, but scalp showed. Things started looking up 4 months later but then again in July/August a bout of minor shedding ensued. Survived that too. In November yet another shed started and this one was bad; short fine hairs all over the pillow in the morning. Scalp showed yet again, as bad as after the first shed in March. In December, I panicked, decided that Minox wasn’t working for me, and got started on Finstaride 1mg.

By mid-Feb this year, there was a sort of minor miracle on the top of my head. My hair is looking its best in maybe two years. I hope you agree with me that it’s unlikely that Finasteride started growing hair within 10 weeks of beginning its use. My (semi-literate) guess is that Minox first grew “peach fuzz”, which gave way to intermediate hair, which then was replaced by terminal hair. I suffered synchronized sheds, the last one being the shedding of intermediate hair. Maybe more sheddings are in store for me, maybe not.

To get to the point, I am so pleased with the result that I’ve gotten greedy: I want Finasteride growth too. No sexual side-effects so far. I’d like to press on with Fin, and reserve the option of discontinuing it in future if side-effects show up. I understand that that would result in catch-up loss, but then probably I’d be content with the hair that Minox grew for me.

Hence the question: do minox and Fin have a cumulative beneficial effect on the same hair follicle? Will minox-dependent hair too be lost in catch-up loss if Fin is stopped? If the answer is in the affirmative, I’d probably be better off stopping Fin right away, since I’ve been using it only for 3 months.

Thank you for a patient reading, and thank you for your time.

You would have to poll each hair follicle and ask them what they liked better. If you can not communicate with them, then you are like me who frankly does not know the answer to your question. My best guess though (keep in mind I could be mistaken) is that because the medications work in different ways and finasteride will not keep hair grown from minoxidil and vice versa, that the benefits are independent of each other. Many men do use both medications concurrently, and as long as you can afford both (and maintain the regimen) I say go for it! It’s ok to be greedy and want your hair to look as great as possible. If the meds work well for you, that’s great news!

While it is unlikely that any major hair growth you’ve seen in just 10 weeks occurred from finasteride, you could’ve seen benefits from the medication that have helped your hair look better overall. The two drugs work differently. Minoxidil will grow new hair but the quality of the new hair varies in individuals from thin and poor, to strong and good (less than 15% of people). Finasteride probably does not grow new hair, but most likely works on the miniaturized hairs that we see in male pattern balding as it progresses. This is why finasteride (Propecia) will have no effect on the new minoxidil produced hairs. Minoxidil has not been shown to work on miniaturized hairs, at least that is what is presently understood.

Doctor Rassman I have a question. once every 2 months I eat Veal Liver that is milk raised. I just want to know can that cause genetic hair loss because liver has high cholesterol and stuff. and its always a very small piece that it every 2 months.

I’m not sure how you made that correlation, but there is no connection with a veal liver or higher cholesterol diet with hair loss.

Dr. Rassman:

Prior to reading this, thank you for your time. Your insight and knowledge is of great appreciation.

My situation is as follows:

I started propecia, was on it for a month, then underwent a HT of 1,900 grafts mainly in the front hairline. I continued to use propecia for 2 more months and began to experience some serious sexual side effects. I stuck it out for another 3 weeks however the side effects continued so I stopped the propecia. The sad part is that the propecia began to halt my hairloss however I could not deal with the sexual side effects.

Sadly my hair is shedding. After another apt with my hair restoration doctor, he suggested I take Avodart 0.5mg twice/week. He had mentioned that some of his patients who were having side effects from Propecia took the Avodart bi-weekly, (due to the drugs long half life) and were able to halt hairloss but did not experience the side effects which I was experiencing from my daily 1mg Propecia regiment. I have read all of your posts in regards to Avodart and I understand that it is not FDA approved nor do you prescribe it to your patients.

My main question to you and issue at hand:

I know that when people start taking Avodart they experience a shedding phase which generally kicks in after the first month or two of starting the drug and can last a few months there after. My first question – If I am only taking the drug twice a week and have only been off of propecia for 4 weeks will I also experience a shedding phase? I am confident that the shedding phase is the transition to a greater good…as the weaker hairs fall out months later they are replaced by stronger, new hairs. My problem is that I am in the entertainment industry and will be starting a one month taping of a TV series from June 30th-July 30th of next year. I would like to have as much hair as possible by that time so would I be better off waiting to take the Avodart after the taping is complete, or should I start now and hope that the avodart will not cause a drastic shedding phase and help me stabilize the hair that I currently have? I guess this really comes down to a game of timing.

It will be 14 months since my HT when the taping starts in June so I am hoping that the transplanted hair will already be full by then. Also, most of the hair that I am losing is from the front hairline and temples. The crown seems to be doing ok.

Thanks again for your time and I would also be interested in undergoing a transplant with your team following the taping.

I really do not have a clear answer to your situation. In general, Propecia or Avodart will not be as effective on your front and temple areas. They each work best on the top/crown areas of your scalp. I do not know if you will have more or less shedding as everyone has different results, different side effects, etc. Shedding isn’t seen by all men that start the medication. Really, only time will tell and there is no clear way to predict this.

It would be interesting to know if Avodart did indeed change your sexual side effect issues, as I would expect that it would not make it better. There’s not enough reported about Avodart dosing in the treatment of hair loss for me to suggest that bi-weekly pills are the way to go.

We called around the Los Angeles area.
Only Costco appears to have lowered their prices to an affordable rate.
Costco and Target still offer a year supply of 5mg pills for $27 (90 pills, or $9 for #30) This works out to 360 day supply or less than $3 a month.
Finasteride 5mg is still the least expensive option for those who are willing to cut the pill in equivalent dosing.

All prices below reflect generic 1mg finasteride as of October 2014

Costco:
#30: $16.37
#90: $36.89

Target:
#30: $83.00
#90: $249.00

Ralphs:
#30: $59.29
#90: $177.79

Walgreens:
#30: $81.99
#90: $233.89

Rite-Aid:
#30: $72.00
#90: $186.00

CVS:
#30: $69.99
#90: $209.99

Includes snippets from Wall Street Journal Article: Crucial to the hair-growth and balding process, scientists have found, vitamin D and the microscopic receptors that bind to it in skin as essential to good hair growth. These elements have become the focus for several research teams. (Supplements might offer health benefits for people lacking enough vitamin D, but they won’t bring back lost hair, researchers say.)

Some researchers, including those from the San Francisco Veterans Affairs Medical Center and Harvard Medical School, have identified molecules besides vitamin D that appear to activate the receptor and hold potential for future hair loss treatments. Japanese researchers demonstrated in animals that adding vitamin D helped the process of using stem cells to generate new follicles. Found in the Wall Street Journal — The Search for a Baldness Cure

My friend Dr. Richard Shiell commented:

“Plenty of sunlight and Vit D here in Australia (world’s highest rate of skin cancer). From my observation, our baldness rate and pattern-type is pretty much the same as elsewhere.

We are seeing Vit D deficiency in some Muslim women and children who cover-op and do not take advantage of our sunlight. I have not heard of any increase in hair loss. Kids at the beach these days are covered from head to knee as in the Victorian era so, if the author is correct, we should see more baldness in the future. I don’t believe it.”

It’s important to highlight the sentence from the article that states: “Supplements might offer health benefits for people lacking enough vitamin D, but they won’t bring back lost hair“.

In response to this news, some hair restoration doctors stated that they often recommend vitamin D as part of the treatment for women with balding or thinning hair. There does not seem to be a downside to this use, but I wouldn’t get too excited just yet about calling this a “cure”.

Tags: vitamin d, hairloss, hair loss, wsj

A recent article in the International Journal of Cardiology showed that baldness is tied to Heart Disease (coronary artery disease, the metabolic syndrome,hyperinsulinemia,insulin resistance. higher cholesterol, higher triglycerides, and higher systolic and diastolic blood pressures (high blood pressure). The article summarized 31 studies involving 29,254 subjects with alopecia and found these relationships. They pointed out that such measures such as weight loss, smoking cessation, and other modified risk factors should be the way patients fight for their health.