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Male pattern baldness

Dermatologist Dr Olivia Stevenson offers advice on what works, what doesn't and how acceptance, not drugs, gives the best prognosis

1 Male pattern baldness can start in a young man even without a family history. Balding can start even in the middle teens, ranging from partial loss to complete baldness. Some 25% of men will start showing signs in their 20s. Don't be afraid to diagnose male pattern baldness (androgenetic alopecia – AGA) in a young man with no family history if the pattern is right – that is bi-temporal recession with thinning on top.

2 Be aware of signs that might lead you to another diagnosis. Reconsider the diagnosis if:

• hair loss occurs in an atypical pattern – rapid loss, diffuse shedding, hair loss in patches or breaking of hair shafts

• hair loss is accompanied by itching, skin irritation, scaling, pain or other symptoms

• hair loss follows starting a new drug.

3 Don't be afraid to diagnose male pattern baldness in women. Some 95% of cases of all hair loss are a result of AGA.

4 Don't be tempted to check hormone levels in the absence of any other features. If further investigation seems appropriate, thyroid function, fasting glucose and an anti-nuclear antibody test (for occult lupus) are the most likely to be useful.

5 Consider topical minoxidil. Minoxidil is rubbed into the scalp daily – but remember to emphasise its limitations.

Less than a third of patients will get satisfactory regrowth and no further hair loss. A little over one-third will get vellous (soft baby hairs) regrowth or no further loss and a third will get no significant regrowth and continued loss.

Treatment must be continued for three or four months before assessment of efficacy can be made. If effective, it needs to be continued long term. All hairs stimulated by the treatment will fall once treatment is stopped, bearing in mind that hair loss would be continuing gradually without treatment and therefore the resulting baldness after some years of treatment may be much worse than that at treatment commencement.

Minoxidil is available on private prescription or over the counter.

Use 5% in men and a trial of 2% initially in women. In general women respond better but this can be increased to 5% if necessary.

6 Consider finasteride. Treatment is an oral daily tablet and only licensed for use in men.Some hair regrowth occurs in about two-thirds of men. About a third will get no hair regrowth, but most do not have any further hair loss.

It takes about four months for any effect to be noticed, and up to two years for full hair growth. Once again, if successful, the treatment must be continued to maintain the effect. Side-effects are generally uncommon but include decreased libido (in around 2% of patients), impotence, and ejaculation disorders and may outweigh benefits of treatment.

It is only available on private prescription.

7 Some over-the-counter treatments may be worth considering. Caffeine-containing products have been shown to prevent further loss in some studies (Alpecin for men and Plantur39 for women). A vitamin and mineral complex in an oral supplement sold as Nourkrin has some evidence of benefit in both men and women with AGA.

8 Surgical techniques might work but have limitations. Hair transplantation and scalp flaps are available but success rates vary and depend very much on the experience and skill of the surgeon. A specialist opinion is needed and it is very expensive.

9 Wigs shouldn't be ruled out as an option but are only available on the NHS for medical conditions. Expensive, well-fitted hair pieces can have very good cosmetic results, especially in women.

10 Acceptance – not drugs – achieves the best prognosis. Reassure your patient that this is a normal part of the ageing process and no treatment is 100% effective. Acceptance rather than drugs achieves the best prognosis for any balding young man.

Male pattern baldness


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