ANDROGENIC ALOPECIA-THE LATEST APPROACH
What is Androgenic alopecia (AGA)?
Androgenic alopecia (AGA) is a multifactorial condition characterized by progressive hair thinning and loss. It affects 40-80% of men and 20- 40 % of women and men can start as early as the twenties. It is also called pattern baldness as the hair loss usually presents in a predictive pattern. Male pattern baldness (MPB) and recently named Female pattern baldness (FPB) are also descriptions of this condition commonly found in the literature.
How does it present?
Miniaturization (shrinking) of the hair follicles is the hallmark of androgenic alopecia. It is caused by a shortening of the growth (anagen) phase and miniaturization of the hair follicle, which follows the formation of progressively thinner and shorter hair.(Bergfeld,1995).
Hair thinning and eventually, a loss is happening in a well -defined pattern where hairline initially recedes. Hair gradually also thins near the top of the head often progressing to partial or complete baldness in males. However, the pattern in women differs from the one in men. In women, the hair becomes thinner all over the head, and the hairline does not recede. If women experience a receding of the hairline it is usually the sign of extensive progesterone deficiency and it is not a characteristic of androgenic alopecia. We must, however, consider a concomitant appearance of both conditions that is not unusual. Androgenic alopecia in women almost never leads to total baldness.
In androgenic alopecia, the replacement of terminal hair by vellus hair is a progressive and irreversible process that unless treated will lead to various degrees of baldness. If there is no early diagnosis and treatment, microinflammation in the follicular bulge will enhance the disruption of stem cells resulting in irreparable damage. This means the follicle will never grow new hair. Once the definite baldness occurs there are only 2 solutions: to accept the condition or to opt for the hair transplant. That is why early diagnosis and early treatment are crucial in preventing definite baldness in androgenic alopecia.
What is the cause of Androgenic alopecia?
Androgenic alopecia is inherited in 85%. The main hormone involved in triggering and perpetuating this process is DHT, a form of testosterone that is induced by enzyme 5-alfa reductase. DHT (dihydrotestosterone) binds to the Androgen receptor in hair follicles. There is evidence that 5-alpha reductase enzymes and the Androgen receptor are highly expressed in balding follicles compared with nonbalding follicles in hereditarily predisposed persons.
It is X chromosome inherited condition. In males, this chromosome is only coming from mothers. It has been estimated that the AR inheritance may give up to 40% of the total DNA risk, which is considered a high level of risk for a single SNP! (Hillmer at al.2005). Other important loci are found in chromosome 20. All these mutations can be easily identified with DNA testing and it is highly recommended to be done for any individual with an early onset of alopecia or with any close relative with baldness.
Medical evidence suggests that early identification of inherited predisposition is the single most important factor in advocating an early treatment with a good outcome.
Additional research also suggests that Androgenic Alopecia is a more complex condition than previously anticipated as it has been associated with several other medical conditions in males such as coronary heart disease and enlargement of the prostate. Moreover, prostate cancer, insulin resistance, cardio-metabolic syndrome, and high blood pressure have been related to androgenic alopecia. In women, Androgenic alopecia has been associated with polycystic ovary syndrome (PCOS), insulin resistance and abdominal obesity, as well as menopausal weight gain with high testosterone production. The inability to control this condition only with DHT blocking agents insinuates that it must be other factors contributing to the severity and stubbornness of this form of alopecia and further research is necessary to clarify that.
Differential diagnosis is very important as it requires totally deferent methods of treating this from various other hair loss conditions.
Androgenic alopecia must be distinguished from Telogen effluvium, the type of hair loss that is usually temporary. While we shower, shampoo, comb hair or even run hands through the hair, it tends to come out in handfuls. This usually happens from a few weeks to months after the episode of stress. Hair shedding decreases over 6 to 8 months unless it becomes chronic. Causes of this type of hair loss are not DHT linked and usually are related to severe infection, anesthetics use, major surgery, blood loss, severe emotional stress, childbirth, crash diets, nutritional depletion, drugs side effects, (beta-blockers retinoids, birth control pills, certain antidepressants, etc). Sometimes women age 30 to 60 may notice a progressive thinning of the hair that affects the entire scalp. The hair loss may be extensive at first, and then gradually slow. This type of Telogen effluvium often confuses with Female pattern baldness and it is hypothesized that it is related to mitochondrial toxicity and nutritional depletion (low biotin, low antioxidants, etc.). It often takes a comprehensive integrative biomarkers to work up to establish that.
How should we approach and treat Androgenic Alopecia?
There are 2 streams, 2 different approaches:
1.Mainstream conventional physicians are using very limited treatment modalities which include minoxidil, DHT inhibitors to prevent androgenic alopecia and hair transplantation in baldness. Each option has its own side effects (scalp irritation, hypertrichosis and losing hair immediately if you stop minoxidil, loss of libido prolonged impotence and limited improvement with DHT inhibitors, limitation in using it in women, etc.). Patients usually stop medications due to these side effects and only minority and selective patients undergo a hair transplant.
Mainstream conventional physicians provide limited solutions for women androgenic alopecia. Minoxidil and acceptance (for severe cases- hair transplant) are the only options. For female patients with clear hyperandrogenic state and PCOS other medicines, such as spironolactone, cimetidine, birth control pills, etc. are offered again with many side effects and limited results.
2. Integrative and functional physicians offer a new paradigm in treating Androgenic Alopecia. There are more than 130 scientific publications offering combination modalities and integrative approach based on the established cause. Usually, these modalities are without side effects and they offer equal treatment for males and females!
Initially, DNA test, hormonal test and functional medicine biomarkers (to exclude insulin resistance, cardiometabolic syndrome, visceral fat, PCOS ) are done to establish a degree and the cause.
New methods of treatment such as low-level light therapy ( LLLT), 1,550-nm Er: Glass fractional laser treatment and Microneedling with growth factors can help improve a certain percentage from androgenic alopecia.
The Game Changer in treating Androgenic Alopecia
The real game-changer in preventing and treating androgenic alopecia is micrografting with isolating and harvesting patent’s own cells that have the potential to grow into new hair, usually from fat. These cells have the potential to differentiate into surrounding cells, in this case – a hair! Scientific publications have proved its efficacy and superiority to other procedures and it can be used in males and females before they develop definite baldness, as earlier in the process of developing as possible. It is a no-downtime procedure done in doctors’ rooms.
Understanding hereditary predisposition, a secondary pathology from microinflammation affecting follicles, comorbidities with insulin resistance and suboptimal androgen metabolism, a physician performing Micrografting will do this method only once to restore all the hair with a potential to grow. It is not necessary to repeat this procedure again as all preserved follicles will react to these cells and re-grow new hair in suitable candidates. The growth will take 3-6 months. This new hair needs to then be maintained with supplements that target all the above dysfunctions aiming to overcome them. Evidence strongly indicates that some phytochemicals can ameliorate both primary and secondary causes of AGA and improve insulin resistance, or act merely as successful adjuvants to androgen-dependent therapies.
References available on request.