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Neil Sadick, MD
Weill Cornell Medical College, New York Presbyterian Hospital
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DAVID R. MARKS, MD: Men who are losing their hair usually have one priority: getting it back. But in the process, the causes of hair loss are often ignored. That's a mistake, since understanding why we lose hair is the first step in treating it.
With me today to talk about what causes hair loss are two experts. First is Dr. Neil Sadick. He's a cosmetic surgeon and a dermatologist at the Weill Cornell Medical College. Also here is Dr. Michael Reed, a dermatologist and a hair transplant surgeon at NYU.
Dr. Reed, what causes men to go bald?
MICHAEL REED, MD: Most men go bald because they picked the wrong family tree and it's just in their genes to go bald as they get older. That's probably the cause of baldness in 95% of patients that I see in my practice.
DAVID R. MARKS, MD: There is, I think, an old wives' tale that baldness comes from your mother's father. Is that true?
MICHAEL REED, MD: It's an old wives' tale, and sometimes a new wives' tale, but it's a polygenic type of situation. It's not that complicated. I see people who have no family history of hair loss. I see people who no one in their neighborhood ever lost their hair, and still they're losing their hair. So it's not that simple. There seems, perhaps, to be a trend from the maternal side, but it's not that simple.
DAVID R. MARKS, MD: What about the other 5% of people? What's causing hair loss in them?
NEIL SADICK, MD: There are a lot of other causes of hair loss. Probably if you look at the other major causes, other than genetics, in the year 2001, the major causes are related to things such as medications that people are taking, particularly antihypertensive drugs, drugs that are being prescribed for depression, and then there are a number of other disease states, such as alopecia areata, which is an immunologic type of hair loss, that really make up the majority of other causes of hair loss that we see.
DAVID R. MARKS, MD: Some of the treatments are directed toward some chemical, 5 alpha reductase. Tell us about that.
NEIL SADICK, MD: 5 alpha reductase is an enzyme that is felt to play a major role in genetic hair loss, particularly in men. It was actually identified in a group of pseudo-hermaphrodites in the Dominican Republic, and that enzyme, which was isolated, is felt to be the major enzyme that's responsible for genetic hair loss, and the newer drugs that are now being developed block that enzyme and have been able to slow down the progress of genetic hair loss.
DAVID R. MARKS, MD: Is there a way to test a man for this chemical to see and predict if they're going to lose hair?
MICHAEL REED, MD: There recently was a study that shows you can take hair samples and you can measure ratios of male hormone in them and possibly predict it, but that's still a little bit on the edge of science fiction. Probably the best way is to just look at the man himself and see what's happening after puberty, and you can see early signs, often even before the patient notices it.
NEIL SADICK, MD: We actually performed a study looking at blood levels of that enzyme, and there is a much higher level in men that have genetic hair loss.
DAVID R. MARKS, MD: When does hair loss usually start, and when does it peak?
MICHAEL REED, MD: Any time after puberty. We're talking about hereditary hair loss, now. When does it peak? It can peak at different times in life, but by the age of 50, about 50% of men have noticeable thinning hair in some variation on the theme of male pattern hair loss.
DAVID R. MARKS, MD: So if a man reaches his 40s or 50s and hasn't had a whole lot of hair loss, he's in good shape?
MICHAEL REED, MD: All day long people ask me, "How long have I got, doc?" I tell them as individuals, the date of onset, the rate of progression, the endpoint and when in life that will occur cannot really be predicted in any one individual based on their physical characteristics, or even necessarily their family history. If someone has a family history of everyone cue-balling out at 25, and they're 23 and are mostly cue-balled, you can kind of predict for them, but it's usually hard to say for certain.
DAVID R. MARKS, MD: Now, there are different patterns of baldness. What are they?
NEIL SADICK, MD: There are different grades of baldness. We really classify men with baldness from class 1 to class 7, where they have some early frontal hair loss or they have diffuse hair loss involving the frontal and posterior parts of their scalp. In women it's much easier. We just classify them as having either mild, moderate or severe hair loss. So we really do have a grading system, and most men lose their hair initially in the frontal part of the scalp, and then progress to involve the occipital or posterior part of the scalp.
DAVID R. MARKS, MD: Is there a different cause for the frontal hair loss as opposed to the hair loss in the back of the head?
MICHAEL REED, MD: I think it's all the same cause, but it differs in degree. Probably the enzyme activity and the levels of DHT, which is dihydrotestosterone, are greater earlier and sooner in the frontal scalp, so it's just less responsive. It's kind of a harder obstacle to overcome.
DAVID R. MARKS, MD: What should a patient do if he thinks he's losing his hair?
NEIL SADICK, MD: I think if a patient believes he's beginning to lose his hair, he should consult a physician who's an expert in hair disorders, because it's been shown that the earlier that some of the newer drugs are instituted, the better they have their onset of action in the earlier aspects of hair loss, so beginning at an early time gives you the best chance of saving your hair.
DAVID R. MARKS, MD: Since we're talking about causes, does the actual cause guide you towards a certain treatment?
MICHAEL REED, MD: Of course, although some treatments that we have are nonspecific hair growth enhancers, like topical minoxidil, that will help hair in a variety of conditions grow better, not just necessarily male pattern hair loss. So there's nonspecific hair growth enhancers, but there are specific drugs that are available for specific conditions that you wouldn't use in another one.
DAVID R. MARKS, MD: Thank you both for a very enlightening discussion.
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