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The Balding Effect

What you need to Know about Male Pattern Baldness


Male pattern baldness (MPB), also known as androgenetic alopecia, is the single most common cause of hair loss in men, accounting for more than 95% of all baldness. MPB is a progressive disorder which seems to occur in a characteristic pattern. The first step is often a recession of the frontal hairline as well as hair loss in the crown of the head. The thinning then progresses to a complete loss of hair over the front of the scalp.  In the most severe instances, hair may remain only in a ring around the side and back of the head. Nonetheless, this progression is not universal, and some men may follow a unique pattern of hair loss (WebMD, 2010).


The Science of Hair Loss in Men


The scientific basis of MPB is an ongoing decrease in the mass of the terminal (normal thick and darkly pigmented hairs) simultaneous to an increased mass of vellus hairs, which are short, fine and non-pigmented. This process of shutting down the terminal hairs while increasing the number of vellus hairs seems to be associated with the creation of the hair follicles. This ‘shutting-down while increasing’ action may occur quite suddenly, and it is associated with a profound reduction in the diameter of the hair (Stough et al., 2005).
Hair growth begins in the hair follicles and continues in cycles. Each hair typically grows for a period of 2-6 years before entering a resting phase which lasts for several months. At the end of the rest period, the hairs falls out, and the cycle begins anew with the birth of a new strand of hair.  As androgen (testosterone) levels in the body increase, though, the cycles compress resulting in the growth of shorter and thinner hair. Further, there is also a delay in the growth of new hair to replace the shedded pieces of hair (Chumlea et al., 2004; Ellis et al., 2001).


Genetically Predetermined Baldness?


Although the cause of MPB cannot be fully characterized, this form of hair loss has a lot to do with a certain family of hormones collectively referred to as androgens. One particular form of testosterone, dihydrotestosterone, appears to be especially important to hair vitality.  MPB is also associated with variability in a gene called AR. This gene is critical to hair health because it tells the hair follicles to make androgen receptors.  Disruptions in the population of androgen receptors may be associated with MPB (Ellis et al., 2001; Hilmer et al., 2005).


The Balding of America


By the time that two-thirds of American men reach the age of 35 years, they will have experienced some noticeable degree of hair loss.  When U.S. men reach 50 years of age, around 85% of them experience significantly thinning hair. Also, for many men, hair loss starts much earlier, with about 25% of men showing early balding by age 21 (WebMD, 2010).  Because MPB is dependent on circulating levels of adult sex hormones, this condition is not observed in young children (Stough et al., 2005).


Conditions Associated with Baldness


Although MPB certainly appears to be passed down from generation to generation, how this works is far from clear. Additionally, researchers are uncertain exactly why, but MPB has also been seen in conjunction with a variety of medical conditions. Experts believe that these conditions are related to increased androgen levels. They include:

• Heart disease
• Enlarged prostate and prostate cancer
• Diabetes
• Obesity
• High blood pressure

(Chumlea et al., 2004; Ellis et al., 2001)]

Recently Identified Risk Factors


Unfortunately, the causes of MPB are not well understood. Although it appears certain that a strong hereditary influence is at work, not much information is available on the non-genetic or environmental causes.  As such, it is difficult to assign risk factors to this disease. In 2003, baldness researchers Severi and colleagues conducted a study to evaluate the extent of MPB in 1,400 Australian men aged 40-69 years with prostate cancer. An attempt was made to associate reported risk factors with the presence of MPB. The scientists found - as expected - the prevalence and extent of MPB increased with age. Additionally, the found several factors that were associated with MPB, including fewer sex partners, consumption of alcohol and greater body weight.

The Thinning Impact


MPB most often leads to what can be serious psychological effects. Historically, abundant hair has come to symbolize vitality and health. Hair is often perceived as a determinant of attractiveness and a way for people to demonstrate their individuality. The loss of hair and hair thinning is often associated with impotence and decrepitude. As a result, the negative impact of MPB on self-image and others perceptions is not surprising (Stough et al., 2005).


Treatment


Currently, there are only two drugs approved for use in the United States: minoxidil and finasteride.
Minoxidil
Although it is unclear how minoxidil works, it appears to lengthen the growth phase of the hair and may also increase blood supply to the follicle. Re-growth of hair is usually more pronounced on the crown of the head than the front and may not be observed for a period of at least 4 months.  Rapid reversion to MPB has been noted upon discontinuation, so continuous application is necessary.  Men with recent onset of MPB seem to respond best, especially those with relatively small areas of hair loss.  The drug is available as a solution for topical application.


Finasteride


Finasteride is given by mouth as a 1 mg tablet, once daily.  It is important that females avoid contact with this compound because it can negatively impact developing fetuses.  Finasteride has been shown to have some effect, slowing the progression of MPB in men.  Further to that, in some patients, it stimulates new re-growth. Like minoxidil, finasteride has shown most promise on re-growth in the crown of the head. Unlike minoxidil, though, it has shown some impact on the frontal area, as well.  Also, like minoxidil, this therapy requires continuous treatment as cessation of therapy is associated with progression of MPB.


Current Research


MPB results from elevated amounts of a lipid called prostaglandin D2 or PGD2, according to the researchers at the National Institutes of Health (NIH) section, the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). The genes found to be more expressed in bald areas was PGD2 synthase, an enzyme that produces the prostaglandin PGD2. This substance inhibits hair growth. Researchers Garza and associates (2012) also found that a receptor molecule – protein GPR44 – binds with PGD2 inside the hair follicle. This produces limited hair growth and MPB. This promising new research could lead to new, effective treatment options for men. The NIH currently is conducting active research on androgenetic alopecia. Novel approaches being explored include the use of Nitric oxide (NO) gel, a minoxidil lotion (versus approved solution), as well as two separate hair rejuvenation systems (Garza et al., 2012).


References


Chumlea WC, Rhodes T, Girman CJ, Johnson-Levonas A, Lilly FR, Wu R, Guo SS. Family history and risk of hair loss. Dermatology. 2004;209(1):33-9. PubMed citation


Ellis JA, Stebbing M, Harrap SB. Polymorphism of the androgen receptor gene is associated with male pattern baldness. J Invest Dermatol. 2001 Mar;116(3):452-5. PubMed citation


Garza LA, Liu Y, Yang Z, Alagesan B, Lawson JA, Norberg SM, Loy DE, Zhao T, Blatt HB, Stanton DC, Carrasco L, Ahluwalia G, Fischer SM, FitzGerald GA, Cotsarelis G. Prostaglandin D2 inhibits hair growth and is elevated in bald scalp of men with androgenetic alopecia. Sci Transl Med. 2012 Mar 21;4(126):126ra34. PMID: 22440736.


Hillmer AM, Hanneken S, Ritzmann S,  et al. Genetic variation in the human androgen receptor gene is the major determinant of common early-onset androgenetic alopecia. Am J Hum Genet. 2005 Jul;77(1):140-8.

Epub 2005 May 18. PubMed citation


Severi G, Sinclair R, Hopper JL, et al.  Androgenetic alopecia in men aged 40-69 years: prevalence and risk factors. Br J Dermatol. 2003; 149:1207-1213.


Stough D, Stenn K, Haber R, et al. Psychological effect, pathophysiology, and management of androgenetic alopecia in men. Mayo Clin Proc. 2005; 80:1316-1322


WebMd (2010). Male pattern baldness. Retrieved from:                                                                               http://www.webmd.com/skin-problems-and-treatments/hair-loss/hair-loss-introduction-mens

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