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Medical Treatment – Male Pattern Hair Loss

For optimal chemical therapy for male pattern hair loss, the combination of Minoxidil 2.5 mg tablet, which replaces Rogaine (Minoxidil) Topical, and Propecia ( 1 mg per day), is the place to start for men with early thinning and miniaturization of their hair (in a pattern as described in the chart). When you see your dermatologist or hair restoration specialist, he will prescribe these items for you. These are generally tried for several months, following which a second set of detailed photographs are compared with the ones taken at your initial evaluation. If you have either stayed the same or improved, that is a win for the medical therapy.

You may very well need hair transplants in addition (to restore your hair), but you may have stopped the progression of the balding process with the medical therapy. For example, sometimes younger men have their hairline transplanted where it has receded in the front, but the medical therapy keeps the back from falling out for many years. The nuances of this should be discussed with your physician. Remember that Rogaine must be used twice a day to be effective.

Propecia’s generic name is finasteride, and it blocks conversion of testosterone to dihy- drotestosterone in the hair follicle to the extent of about 70%. Another prescription drug which has not been fully studied in hair loss is Dutasteride, and it may well block the levels of DHT in hair follicles down about 90%. However, with Dutasteride, you are blocking both isoenzymes of 5-alpha reductase, and the systemic side effects have not been worked out. As men get older, side effects from these medications may present that were not present in their younger years. You need to speak to your physician about the details of this.

Men may suffer generalized hair thinning (sometimes with pattern loss also) from low thyroid or iron, as do women. In older men, low testosterone can cause thinning of the donor area on the sides and back of the head. The donor, like beard and body hair, needs testosterone.


Medical Treatment – Female Pattern Hair Loss

After menopause, it is common for women to show generalized hair thinning due to lower levels of female hormones, as well as the loss of the ability to convert T4 to T3 in the tissues, which results in a low thyroid-type of thinning hair, as well as thinning of the outer third of the eyebrows.

T4 is the principal type of thyroid hormone produced in the thyroid gland. T3 is the more active form, which is converted from T4 in the tissues. As we age, the ability to convert T4 to T3 in the tissues diminishes so that many people that are in excess of 50 years old have a normal T4 level in their blood, but have diminished T3 in the tissues. This is determined by measuring the free T3 hormone blood level. Even if you are at the lower end of the normal range, your hair may well benefit from additional thyroid supplement, which will bring you up to the high end of the normal range. This also results in greater energy, higher metabolism, and usually some degree of weight loss. Blood workup is required, as well as a thorough evaluation by your physician. Other causes of diffuse thinning are iron deficiency, collagen disease, infectious disease, and other hormone deficiencies.

In a study by Drs. Glaser and Messenger, published in the British Journal of Dermatology, it was found that women who were being treated for androgen deficiency, including symptoms of hot flashes, insomnia, depressive mood, irritability, anxiety, premenstrual syndrome, fatigue, memory loss, menstrual or migraine headaches, vaginal dryness, sexual difficulties, urinary symptoms, and pain and bone loss were found to have an improvement in their hair thickness following several months of treatment with testosterone.

These women were treated such that their serum testosterone level was about 300. There were no cases of increased hair loss related to the higher testosterone. In the group of over 150 women, those that responded positively to the testosterone therapy with hair thickening were generally of a medium or slim build. Those ladies who were moderate to severely obese did not respond. The reasons for that are not yet determined but may be related to insulin resistance and other endocrinologic abnormalities.

The above suggests that female pattern hair loss and female hair thinning is definitely not due to excess testosterone as was postulated for many years. It is not “androgenetic” alopecia because it is not caused by androgen (testosterone, etc.).

It would seem that hair follicles in women are supported by testosterone. This is the same sort of support that is seen in men for their body hair, beard hair, and donor hair around the sides and the back of the head which is used for hair transplanting.

Conversely, the hair follicles on the top of the head of many men are sensitive to DHT (the high-potency form of testosterone) in a variable distribution. Some men find that the hair follicles in the front of the head are sensitive. In some, sensitivity lies in the hair follicles in the crown and back of the head, and in some both.

In addition, there are a few women who develop a male type 3 receding hairline pattern, and studies need to be done to see what the level of testosterone and DHT is in these women.

If a woman has an extremely high level of testosterone, such as that secreted by an ad- renal gland tumor, they may, in fact, develop Class 6 male pattern baldness.

These observations suggest that a new treatment protocol for the treatment of either diffuse or patterned hair thinning in women, following a lab panel to evaluate their hormone status, is:

    • Testosterone cream 8 mg/g in 100 g tubes applied at the rate of 1.5 g
    bid to their inner thighs or vulva, or 4 mg/gm applied to the scalp at bedtime, or pellets every three months under the skin of the buttocks.
    • Armour thyroid as needed to bring their free T3 level to 4.0-4.2
    • Minoxidil in either a 2% or 5% solution bid, or the M82 Minoxidil solution bid, or as a 2.5 mg or 5mg pill
    • Theradome LH80 Laser Cap used 30 minutes every other day.
    • Vitamin supplement with additional vitamin D, iron and biotin supplement, vitamin K2, selenium, DIM

Summary of Testosterone Therapy in Women

In an article by Dr. Rebecca Glaser of Ohio, the various myths about testosterone’s role in females is clarified. To summarize:

    • Testosterone is not a male hormone and is required throughout life by females. In fact, it is the most abundant biologically-active hormone in women.
    • Testosterone’s role in women is not simply to improve their sex drive and libido, but rather to improve mood, decrease anxiety and irritability and depression, increase a sense of well-being, improve physical endurance, decrease bone loss and muscle loss, and decrease changes in thinking processes and memory loss, (Alzheimer’s), improve insomnia and hot flashes and rheumatoid complaints. In addition, breast pain, urinary complaints, incontinence, and sexual dysfunction are all improved with testosterone therapy. In Dr. Glaser’s clinic, androgen therapy consists of moving the female testosterone level up to around 300, by use of various testosterone sources such as pellets, creams, and the like.

  • Outside of suprapharmacologic doses of synthetic androgens such as used by body builders, testosterone does not have a masculinizing effect on females or female fetuses.
  • The myth that testosterone causes hoarseness and voice changes is simply that.
  • Testosterone therapy increases scalp hair growth in women, and therefore the old concept of androgenetic alopecia being the cause of female hair loss is obsolete.
  • There is substantial evidence that testosterone is cardiac protective and that adequate levels decrease the risk of cardiovascular disease.
  • Non-oral testosterone does not adversely affect the liver or increase clotting factors. Hence, testosterone should be taken in the form of either subcutaneous pellets or creams which are absorbed through the skin.
  • Testosterone therapy decreases anxiety, irritability, and aggression in females.
  • Testosterone is breast protective and does not increase the risk of breast cancer.
  • The safety of non-oral testosterone therapy in women is well established, including long-term follow-up.

Hylenex Virtually Eliminates Donor Tightness in the Strip Method and Obviates the Need for the Follicular Unit Extraction Method

Dr. Elliott’s former partner, Dr. Robert True of New York, NY, has recently presented an idea which he has used on 150 patients during the last year. Hylenex (human recombinant hyaluronidase or HRH), is injected 1 cm on either side of a proposed donor strip area after it is anesthetized. This causes an almost immediate relaxation of the skin which then allows:

1) About a 20% larger amount of donor grafts to be harvested without tension. 2) Aids greatly in the removal of previous donor scars.
3) Overcomes an inelastic scalp.
4) Reduces or eliminates tightness in the donor area after surgery.

The relaxation of the scalp is strongest at 10 minutes and lasts for 48 hours. Forty-eight hours is sufficient time for the scalp to relax itself, thereby eliminating tightness.

Ultimately, because there is no tension on the donor closure, there is nothing to cause the donor scar to widen. Thus with this technology, virtually all donor scars should be in the 1-2 mm range and not more.

We have begun using this at Pacific Hair, and we expect that it will eventually eliminate the need for follicular unit extraction.

Follicular Unit Transplantation (FUT)
Versus Follicular Unit Extraction (FUE)

In general, hair transplants in 2015 are done in either follicular unit transplantation or follicular unit extraction, otherwise known as FUT and FUE. Follicular unit transplantation is the method whereby a strip of donor hair is removed from the back and/or sides of the head, usually about the width of your little finger, with the length determining the number of grafts. For example, a 1-cm wide strip will usually generate about 100 grafts per running centimeter. If 1000 grafts are needed, the strip would need to be 1 cm wide and 10 cm long, etc. The donor strips are taken from the nuchal ridge, around the sides and over the ears in the very thickest and best permanent donor hair area. The experience of the physician determines where this should be, neither too high nor too low, so that the fine line scar is hidden regardless of future progression of pattern hair loss. Typically 3000- 5000 grafts are harvested in one session.

FUE is a method where 1mm plugs are extracted and used as transplant grafts. Some physicians claim that there is less donor scarring with FUE versus FUT. This is incorrect. Usually only 1000 grafts can be harvested per day, with a lifetime total of about 4000 grafts. Since a totally bald Class 6 head requires 6000-8000 grafts lifetime total, FUE will not provide enough grafts to complete the case as the patient gets older and loses more hair.

FUT 2000 grafts taken twice resulting in a donor scar

2 mm wide x 350 mm long
scar = 700 mm2 for 4000 grafts

FUE 4000 1 mm round scars resulting in donor scars

.5 x .5 x 3.14 x 4000
scar = 3140 mm2 for 4000 grafts

The scar area is much larger with FUE than FUT.


  1. The anesthetic we use is now Septocaine rather than the old Xylocaine. The reason that Xylocaine used to sting when being injected was that it had to be at an acidic pH in order to work. Septocaine is neutral and, therefore, does not sting.
  2. When putting in the anesthesia, I use a vibrator attached to the needle, which makes it nearly impossible to tell that it is being done.
  3. Our anti-swelling solution, which is a dilute solution of triamcinolone, has proved very successful over the last few years such that postoperative swelling is 99% eliminated. Most people get no swelling at all, but a few get a small amount.
  4. We have acquired a machine which allows us to manufacture our own ultra-small blades for the recipient sites. This means that our grafts can be much closer together. There is a formula that the sum of the length of the recipient slits divided into 35 will give you the number of grafts available to place in a 1-cm square. With this technology, a maximum of 30-40 can be placed per square centimeter. This is the formula used in the hairline area with 0.8 –mm blades, or in the case of very thin hair, 0.6-mm blades. 0.6-mm blades are also used for eyebrow single-hair grafts.
  5. With these smaller blades, healing is completed in about 3-4 days with ability to resume normal shampooing at 7 days.
  6. In addition to hair restoration, Dr. Elliott has been prescribing anti-aging medications for a number of patients for several years. If any of you require anti-aging medication, you may make an appointment with me for evaluation and laboratory tests.
  7. For those with little or no donor hair, we have used chest hair for hair transplantation a few times in the last couple of years. This works well if you have relatively dense chest hair. In this case, the FUE method is used for extracting the hair follicles.
  8. As previously mentioned, the Hylenex method is a vast improvement and virtually eliminates postoperative tightness and/or scar widening.
  9. While we offer FUE procedures for the extraction of donor hair from the scalp in hair transplantation, it appears that this is a method reserved for relatively small cases. For full-head baldness or potential full-head baldness, sufficient donor grafts are not available with this technique, and if the maximum of 4000 is taken out over three or four procedures, the donor hair looks very thin. With the strip method, 2500 grafts can be taken out three times with the result of one 2-mm scar (using the Hylenex method), and this small scar is covered by a curtain of hair hanging over it. In this method, there is no perceptible change in the density of the donor area.
  10. Because of more efficient techniques and our continued use of techs who have now placed hundreds of thousands of grafts, we are able to offer these procedures at a reduced graft rate compared to past years. Please contact Laura Burdine at (310) 914-4000 or John Peters at (949) 263-0800 for the most current rates.