In part 1 of the Integrative Hair Care series, we covered “what to eat for optimal hair care”— sharing tips we can recommend to patients for hair health, with the demystification of some common food and supplement items. If you missed it, be sure to check it out here!
In part 2, we will focus on treatments for hair loss, with an emphasis on androgenetic alopecia. There are different types of hair loss, and it is important to determine what you are dealing with. Rule #1: Determine whether or not it is a scarring hair loss (including lichen planopilaris, discoid lupus, central centrifugal cicatricial alopecia). Early diagnosis of scarring alopecia is crucial to prevent further progression (and also not to waste time and resources with ineffective treatments). So, if there is any suspicion at all, do not hesitate to biopsy early! Once you’ve gotten that out of the way and it is not scarring— the most common etiology for hair thinning in both men and women is androgenetic alopecia. So, we will focus on that!
What is androgenetic alopecia?
Also known as hormonal hair loss or male-patterned/female-patterned hair loss, androgenetic alopecia is a gradual non-scaring hair loss. It happens due to a shortened anagen phase, with a shift in anagen to telogen ratio. Instead of the normal 90%, only about half of the hairs are in the anagen phase. With increased miniaturization, the terminal hairs become shorter and finer—until eventually the fine hairs never quite make it to the surface.
In men, DHT (dihydrotestosterone) is responsible for shifts in hair growth. Therefore, we try to block the 5-alpha-reductase that converts testosterone to DHT. In women, hormonal influences are less clear but are likely due to the changes in relative concentrations of sex hormones and sex hormone receptors with aging.
Lifestyle interventions: Sleep well and eat plants
As an integrative dermatologist, Dr. Bodemer always discusses lifestyle interventions with patients. First, the importance of sleep cannot be emphasized enough. Along with many crucial functions, the circadian rhythm governs sex hormones which are essential for hair growth. Beauty sleep is not just for glowing skin, but it’s important for hair health, too! Second, Dr. Bodemer is a huge proponent of the plant-based diet for hair health — which helps minimize exogenous hormones. She recommends an adequate intake of fiber, increasing the intake of soy (which increases sex hormone-binding globulin), and limiting dairy (again, to minimize exogenous hormones).
Just a reminder that these lifestyle changes are key for overall health — not just a specific condition that we treat. The mind-body-spirit connection is emphasized in holistic care. And importantly, there are no side effects if you do it right!
Supplements for androgenetic alopecia
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- Saw Palmetto (Serenoa repens), which a 5-alpha-reductase blocker. Similar to finasteride or dutasteride, it takes 6-12 months for maximum benefit
- Recommended dose: 160mg -200mg twice daily
- Side effects: headache, dizziness, GI upset, increased bruising/bleeding
- Interactions: should not be used with finasteride or other hormone replacement
- Diindolylmethane (DIM), which has anti-androgenetic and a balancing effect on estrogens
- Recommended dose: 100mg-300mg a day
- Side effects: headaches and GI upset at higher doses
- Interactions: may affect drugs metabolized by the liver
- This is also found in cruciferous vegetables, such as cauliflower, cabbage, kale, broccoli, Brussels sprouts, and similar green leafy vegetables. So stock up!
- Maca Root (lepidiummeyenii), which balances the effects of sex hormones, although it has not been shown to impact serum levels.
- Recommended dose: 1 teaspoon to 1 tablespoon of power once daily
- Side effects: increased libido! This actually used to treat low libido, so make sure patients are warned about this!
- Saw Palmetto (Serenoa repens), which a 5-alpha-reductase blocker. Similar to finasteride or dutasteride, it takes 6-12 months for maximum benefit
Topical treatments for androgenetic alopecia
Now getting into the “mainstream” treatments. Let’s start with topical minoxidil, which is the first-line treatment for androgenetic alopecia. Minoxidil works by increasing the duration of the anagen phase and increasing the size of hair follicles. Make sure that you recommend the 5% preparation. Often, minoxidil marketed for women may be a weaker strength (2.5%). This is not likely to be effective. Reassure your female patients that it’s okay to grab the “men’s” strength! Whether in the solution or foam formulation, topical minoxidil is massaged into dry scalp with fingertips, using caution not to allow it to drip onto the face! It is possible to grow facial hair if you allow it to drip down.
Oral treatments for androgenetic alopecia
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- Oral finasteride, a 5-alpha-reductase inhibitor, is a tried and true medication that promotes hair growth and prevents further hair loss.
- Recommended dose: 1mg a day for men and 2.5 –5mg in women
- Side effects: sexual side effects are controversial
- Spironolactone, which is a potassium diuretic, works by blocking the effects of DHT via androgen receptors
- Dose: 50-200mg a day (the ideal dose is 200mg a day)
- Side effects: breast tenderness, spotting, light-headedness, hyperkalemia
- Oral minoxidil works just like topical minoxidil and is increasingly used for those who can’t tolerate topical minoxidil
- Dose: 0.625mg (2.5mg pill cut into 4) to 2.5mg daily
- Side effects: hypertrichosis (in unwanted areas); rare — palpitations, decreased blood pressure, and pericarditis
- Oral finasteride, a 5-alpha-reductase inhibitor, is a tried and true medication that promotes hair growth and prevents further hair loss.
“Physical” treatments
While concomitantly undergoing the above oral and topical therapies, patients can plan for “physical” treatments, including surgical hair transplantation, laser therapy, and plate-rich plasma. If you do not perform these in your office, you can still have a “what to expect” conversation followed by a referral. Build your network of referrals to increase options for your patients. Cost may be prohibitive, so rough estimates can be discussed.
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- Surgical hair transplantation:
- What to expect: transplanted hair falls out in 2-3 weeks and new hair growth is apparent within a few months. The procedure takes about 4-10 hours
- Cost: $5,000 and $15,000 per treatment
- Low-Level Laser Light Therapy (LLLT)
- What to expect: FDA approved devices for home use. It comes in either comb or helmet options. Should use for at least 26 weeks
- Cost: about $500 online
- Platelet Rich Plasma (PRP)
- What to expect: need multiple treatments and injections, while tolerable, can be painful.
- Cost: $600-1000 per treatment
- Surgical hair transplantation:
Camouflage techniques
Lastly, don’t forget to educate your patients about camouflage, which can be a powerful tool! Some simple solutions include pigmented powders, sprays, pens, and pencils to “color” the scalp to induce the appearance of thicker hair.
Also, hairpieces – including full wigs or partial hairpieces can be dramatically helpful! Do your homework to find out vendors who provide quality products. Reach out to your friends in oncology who may know of a specialty vendor or experienced hairstylist who works with cancer patients with alopecia.
Lastly, while weaves and extensions can be considered, they can cause strain and pull for the hair, which may lead to traction and increased hair loss. Caution is advised.
Conclusion
Hair loss is challenging! But I hope that Dr. Bodemer’s truly integrative tips gave you some confidence to offer hope for your patients. Hair regrowth is variable, and it takes time to see improvement, which can be frustrating. But it can also be rewarding to cheerlead and walk alongside those who experience this emotionally devastating condition. Personally, I find it helpful to have patients fill out a “hair loss intake survey” beforehand which helps me streamline these potentially drawn-out visits. This also helps me to meet them at a more personal level, since we’ve gotten the 21-questions out of the way. I once used to dread hair loss visits, but now I get excited! I love telling them, “We have options. There is hope. I can help.”
About Dr. Apple Bodemer
Dr. Apple Bodemer is an Assistant Professor of Dermatology at the University of Wisconsin Madison. She is one of few integrative dermatologists who completed a rigorous Integrative Medicine Fellowship at the Banner-University Medical Center in Tucson, AZ. Follow her hair journey at @appleskinhealth1 on Instagram!
