By Susan L. Narod
Posted: Tuesday, July 1, 1997

ARTICLES
Publication Date: July 1, 1997

Anti-baldness options are multiplying. And some are more effective than the scalp-massage concoction Cleopatra reputedly produced for Julius Caesar: a mixture of bear grease, burned domestic mice, deer marrow, and horse teeth.

No "Magic Bullets" for Hair Loss

In 1996 the Food and Drug Administration (FDA) cleared Rogaine, a topical (non-internal) 2-percent minoxidil solution, as an over-the-counter (OTC) hair-regrowth drug for men and women with common hair loss. A month's supply of Rogaine retails for about $29.50.

According to Pharmacia & Upjohn, the company that manufactures Rogaine:

* 26 percent of male subjects 18-49 years old reported moderate to dense regrowth;
* 33 percent experienced minimal hair regrowth;
* no hair regrowth occurred in 41 percent of both male and female users;
* 19 percent of women 18-45 years old reported moderate regrowth; and
* minimal regrowth occurred in 40 percent of female subjects.

Merck's Propecia — a prescription pill that contains 1 milligram of finasteride — is a candidate for FDA approval as a hair-regrowth agent. On July 16, 1997, FDA advisors voted to recommend making Pharmacia & Upjohn's 5-percent-minoxidil solution — so-called extra-strength Rogaine — available without a prescription. Researchers are also trying to determine whether combinational application of Rogaine and tretinoin — an anti-acne, anti-wrinkle prescription drug better known as Retin-A — is safe and effective.

None of the topical medicines are "home runs," notes Arthur P. Bertolino, M.D., Ph.D., medical director of the Ridgewood Dermatology and Hair Transplant Center in Ridgewood, New Jersey. "They all help a little bit. . . . If we had medicines that worked really well, we wouldn't be doing any transplants at all," Bertolino says.

Many dermatologists describe Rogaine as hit-and-miss. But Esta Kronberg, M.D., a board-certified dermatologist in Houston, Texas, says it's a "great medication" that has helped many people. Kronberg objects to its status as an OTC drug, however, citing the widespread assumption that if a little of something is good, a lot is great. "A few people actually drank the bottle of Rogaine and went into cardiac arrest. . . . We've learned never to be surprised by anything," she says.

In a March 1997 edition of NBC's Extra, Kronberg commented on a 49-year-old Rogaine user's cardiac arrest. Scott Benton, a former Navy pilot, had suffered cardiac arrest after using the product, reportedly according to label instructions. "He didn't put it on five times a day. He didn't drink it. So he had an unusual complication," Kronberg says.

Safety is a major Rogaine myth, according to Robert M. Bernstein, M.D., medical director of New Jersey's New Hair Institute and an assistant clinical professor of dermatology at Columbia University's College of Physicians and Surgeons. The reports of clinical trials submitted to the FDA cannot have predictive utility for persons who use the medication throughout adulthood, says Bernstein. He cites known, potentially serious side effects that minoxidil (Rogaine's active ingredient) can have in patients who take it as an oral medication for high blood pressure: coronary artery disease, fluid retention, and heart failure. In high concentrations, Bernstein adds, topical minoxidil has been shown to cause heart-muscle damage in lab animals.

Many of Bernstein's hair-transplant patients use Rogaine after the surgery. Bernstein says he neither encourages nor discourages this. "We leave it up to the patient. But the whole purpose of doing the transplant is that people don't want to be bothered anymore. And Rogaine won't affect the transplanted area, although it will have some small effect on slowing hair loss in other places," he explains.

Bernstein warns that applying to the scalp a mixture of 5-percent-minoxidil Rogaine and Retin-A — which some physicians use to increase minoxidil absorption — can lead to heart enlargement and other problems. "The side effects of increased doses of topical [2-percent-minoxidil] Rogaine, its safety with the use of other topical medications (such as Retin-A), and its potential danger when used on inflamed skin or even on wet scalp are largely unknown," he says.

Ridgewood's Dr. Bertolino states: "The mixture of topical Rogaine and Retin-A is not chemically stable, and the benefits are not substantially better than plain unadulterated minoxidil by itself; so I don't usually use it."

Are Hair-Transplant Surgeons Prejudiced Against Rogaine?

Heart enlargement? Dr. Kronberg gasped when I told her of Bernstein's warning concerning mixtures of Retin-A and 5-percent-minoxidil Rogaine. "Well, we each have our own opinion," she told me. Regarding the recent Pharmacia & Upjohn statement that Retin-A does not increase absorption of the minoxidil in 2%-minoxidil Rogaine, Dr. Kronberg said:

You talk to ten people and you get ten different opinions. I think [2-percent-minoxidil] Rogaine works better when combined with Retin-A. Retin-A helps Rogaine penetrate better. In my own clinical experience, I get better results mixing it.

Since the use of 2-percent-minoxidil Rogaine does not require a prescription, much less surgery, it is reasonable to suspect that specialization in surgery would predispose hair-transplant surgeons to dispute the product's reported safety and efficacy. I asked Dr. Kronberg about this. She stated:

Sure, the surgeon has a financial incentive to do the surgery. If you can do a $2,000 procedure and then have the person back two or three times for the same thing, then of course you want to do the procedure. If you have a $45 to $50 office visit versus a $2,000 procedure . . . what do you think the surgeon is going to recommend? Of course, it will be the transplant.

Is It All in Your Genes?

Heredity, disease, stress, and various drugs can cause thinning of hair. Diagnosing such hair loss often requires considerable sleuthing. "A hair loss history is one of the longer histories that we do in dermatology, because there are so many factors involved," says Dr. Kronberg, who queries hair-loss patients about such potential stressors as death in the family, divorce, job loss, illness, medication regimens, and surgery. "It can take six months or more for stress-induced hair loss to return to normal," she says.

Androgenetic alopecia — also called common hair loss, hereditary hair loss, male pattern baldness, and pattern hair loss — accounts for about 95 percent of all cases of hair loss in the United States. It is a hereditary condition that affects more than 30 million men in the U.S. In 10 percent of men — and virtually all premenopausal women — whose hair is thinning, the thinning is not the result of heredity but is due to such factors as stress, nutritional deficiencies (e.g., iron deficiency), chemotherapy, radiation treatment, and surgery. Pregnancy can also cause hair thinning. Hashimoto thyroiditis, an inflammatory disease of the thyroid, can cause thinning that resembles male pattern baldness. "The thyroid is rejecting itself," says Dr. Kronberg. "You have to specifically look for antibodies. If you just do a thyroid screening, you won't pick it up until the thyroid is burned out. That can cause hair loss over a period of years."

No More "Mr. Tufty"?

Remember the "sewing-machine look"? During the 1970s — the "Stone Age" of hair transplant surgery — one could spend thousands of dollars on hair transplantation and wind up looking like a Cabbage Patch doll. Well, the "stitch-in-time" hairline has gone the way of the ducktail. But, while hair-transplant equipment and techniques have improved dramatically, the same basic principle underlies hair transplantation: donor dominance.

"'Donor dominance' simply means that hair will grow in the new neighborhood it's moved to as if it's still in its normal location," says Dr. Bertolino, who has been doing hair transplants for 15 years. Many surgeons and clinics claim to provide a new hair-transplantation method of their own invention, but there is nothing new in this field except improved technology.

"If you are losing hair all over, we can't do anything," says Dr. Bernstein. "We don't create hair. We are just a moving company."

The two main major categories of surgery for permanent hair loss are transplantation and scalp reduction. Transplantation involves moving hair from scalp areas dense with hair — specifically, back or side areas — to areas without appreciable hair.

Bertolino describes the use of micro- and minigrafts — up to several hundred per sitting — as the most significant advance in the field of hair transplantation. Originally, surgeons had used larger, tufty pieces of hair-bearing skin, called "plugs." Unlike plugs, minigrafts make for a natural appearance. According to Bertolino, minigrafts are especially better for women, whose hair loss typically is more diffuse.

In certain cases of advanced baldness, some surgeons utilize scalp reduction: the surgical removal of virtually hairless parts of the scalp. Good candidates have ample loose scalp. "Some people have very tight scalps [from] which you can't get enough out to make [the procedure] worthwhile . . ." says Bertolino, according to whom an advantage of scalp reduction is that it conserves transplantable hair.

Overhead

The FDA does not regulate hair transplant procedures. And, because of the time and money necessary for criminal prosecution, the agency has largely given up taking action against fraudulent claims and phony baldness remedies, says Neil S. Sadick, M.D., author of Your Hair — Helping to Keep It: Treatment and Prevention of Hair Loss for Men and Women (Consumer Reports Books, 1992). "The agency now relies instead on public education and civil action to deter fraud," Sadick states.

Hair transplantation can cost as much as $20,000. But it can be safe and effective and have a natural-looking result. Moreover, states Dr. Bernstein, transplants can last a lifetime if the procedure is done correctly. The trouble, he asserts, is that very few practitioners transplant hair correctly. Bernstein emphasizes the team approach to hair transplantation. "It's like heart surgery," he says.

Greed and underregulation have encouraged some hair-transplant clinics to spend millions of dollars advertising that they can work wonders for anyone. In 1996, Bosley Medical Group, one of the largest providers of surgical hair restoration in the U.S., agreed to pay $644,724 to settle a false-advertising case in California. The company allegedly misrepresented costs, head photos, the medical qualifications of certain personnel, and pain and scarring due to surgery.

Some hair-restoration clinics utilize salespersons as counselors, sometimes on commission. Despite the absence of health-related credentials, such counselors may provide estimates of the number of grafts, or of the extent of scalp reduction, a client needs.

Says Emanuel Marritt, M.D., an associate professor in the Department of Otolaryngology/Head and Neck Surgery at the University of Colorado Health Sciences Center, Denver: "The problem with clinics is that they are forced to spend additional overhead on advertising — often as much as several hundred thousands of dollars a year. Someone has to pay for that. And it's always the patient." According to Marritt, just to break even, clinics must have numerous clients and employ nonphysician consultants and interchangeable surgeons.

The surgeon ought to consider where the client's hairline might be in 20 years. "If you put a 23-year-old hairline on a 23-year-old, by the time that guy is 40, he is disfigured," says Marritt. "The lower the hairline, the more grafts there are behind it, and the more money for the doctor."

Marritt offers this caution: "When [what] a doctor is talking about seems unrealistic, then I recommend going to see someone else. You could be buying yourself a lifetime of trouble."

Ms. Narod is a freelance medical writer who lives in New York City.

(From Priorities, Vol. 9, No. 3)