#43–Alan Bauman, M.D.: The science of male and female hair restoration—how to protect & restore hair

KEYPOINTS

• 01

  Hair loss is very common and usually under-treated

  Bauman, a hair restoration surgeon who says he has treated more than 20,000 patients, puts the US total near 100 million: about 80 million men and 46 million women. His rule of thumb for men is roughly 20% with visible loss in their 20s, 30% in their 30s and 40% in their 40s. Because about half the hair can be gone before the eye notices, loss can start any time after puberty without being seen.

• 02

  'Premature' hair loss is a meaningless term

  Bauman compares hair loss to greying: its timing is genetically set along a spectrum, and 'premature' is in the eye of the beholder. Pattern loss can skip siblings and generations. He describes families where a grandfather, father and sons all come in together.

• 03

  DHT drives male pattern loss, and finasteride works for most men

  In genetically susceptible men, dihydrotestosterone 'kills' follicles. Finasteride, at about 1 mg a day, gives roughly a 90% chance of looking the same or better over about five years, the usual length of a clinical trial. Dutasteride blocks both pathways to DHT more strongly, but some DHT still gets through either way. Bauman calls finasteride's side-effect rate very low but acknowledges that some men get sexual side effects.

• 04

  The finasteride prostate-cancer signal may be partly a biopsy artefact

  Attia calls the prostate data confusing: lower rates of prostate cancer but possibly higher grade when it occurs. Bauman passes on an explanation from urologists. Finasteride shrinks normal prostate tissue, and everyone in a trial is biopsied, so high-grade cancer may be easier to find. He presents this as what was explained to hair surgeons, not settled science.

• 05

  Finasteride was designed for hair; minoxidil was found by accident

  Merck knew from the start that finasteride would be a hair-loss drug. It won approval first for the prostate, as Proscar at 5 mg, then for hair loss, as Propecia at 1 mg, in 1998. Minoxidil was a 1970s blood-pressure pill whose hair growth was noticed as a side effect. Rogaine's FDA approval began clearing useless tonics off the market.

• 06

  Minoxidil keeps follicles in the growing phase

  In a healthy scalp, about 84–85% of follicles are in anagen, the growth phase. In pattern loss, more are resting and anagen shortens, producing short, spiky, miniaturised hairs visible along a part. Minoxidil wakes resting follicles and prolongs anagen, and the longer anagen lasts, the thicker the fibre becomes. It won't restore a receded hairline but can slow further loss.

• 07

  Micro-inflammation at the follicle matters

  Bauman took part in a University of Miami study using donated follicles that found inflammasome activity around them. That helps explain the anti-inflammatory ingredient in his compounded minoxidil and the interest in scalp health. When he examines the scalp, he often finds treatable problems such as fungal infection.

• 08

  Women's hair loss isn't just about DHT

  Pregnancy keeps more follicles in growth, which is why hair thickens and then sheds after birth. Thinning a decade or more after the last child can reflect androgen sensitivity even when DHT is low. Oral finasteride works in about 50% of postmenopausal women but is used off-label only after childbearing years, because DHT is essential to a developing male fetus. It isn't FDA approved for women.

• 09

  Donor dominance is why transplants last

  Follicles from the sides and back of the scalp are almost immune to DHT, and transplants rely on the theory that they keep this resistance on top of the head. Bauman notes only very limited evidence against it. Transplanted hair doesn't stop the native hair from thinning, so patients who don't protect existing hair 'face a much tougher battle'.

• 10

  The main risk of a transplant is an unhappy patient

  Bleeding stops like a shaving nick, and the worst infection is usually a pimple-like ingrown hair. Roughly one in 20–30 patients needs more wound care. The real risk is mismatched expectations: promising a 10 out of 10 when the outcome will be a five. Bauman says that after 8,000 surgeries he can show patients the range of results seen in similar cases.