Androgenetic alopecia (AGA) is a genetic predisposition to hair loss that occurs after puberty. Essentially, your hair is damaged by your body’s reaction to androgen over-sensitivity. The body’s reactions are inappropriate and lead to various malfunctions and, ultimately, the death of your beloved hair. While most people with male pattern baldness are familiar with the abbreviation DHT, very few are aware of how it actually impacts your hair and what options can help slow or even reverse hair loss. DHT stands for dihydrotestosterone, which is an androgen and metabolite of the male sex hormone testosterone. This may be confusing if you consider that over 30% of women experience hair loss secondary to androgenetic alopecia, but unfortunately, AGA does not discriminate. Now, let’s take a closer look at WTF DHT is doing to your hair and a common misguided treatment approach for hair loss.
Dihydrotestosterone (DHT) is the most potent of the androgens. It’s considered a pure androgen due to its inability to aromatize. That means that, unlike testosterone and other androgens, it does not convert into estrogen. DHT is an important sex hormone that plays an essential role in the sexual development of male genitalia. Even into adulthood, DHT plays a major role in prostate function, body hair, facial hair, and, unfortunately…male and female pattern baldness. If you are a woman reading this, even though DHT can impact your hair too, it doesn’t play a significant role in your overall body function and development. In addition to DHT being unable to aromatize, it also has a long half-life, it is slow to dissolve, and aggressively adheres to androgen receptor sites. Unfortunately for those with the genetic pattern of hair loss, this means it will progressively damage your hair faster than your body can disassociate with the hormone.
As unfortunate as pattern loss is, the process by which DHT destroys your crowning glory is fascinating. It’s also extremely intricate and most health care providers do not properly educate patients as to what is occurring inside of their scalp, opting instead to take one-track approaches to treatment. Of course, a complex problem usually requires a complex solution, and one medication or compound is not a one-size-fits-all solution.
DHT is most abundantly found in peripheral locations, such as the scalp, where it adheres to androgen receptor sites on the hair follicle and begins altering the functionality of the organs’ key components. Most importantly, it begins breaking down the dermal papilla, which is essentially the brain of your hair follicle. The dermal papilla induces hair growth and regulates hair cycles. It’s also responsible for the regeneration of the follicle and proper hair pigmentation, and it’s a significant reservoir of multipotent MSCs. Now, it’s important to understand that hair loss is a progressive issue, and the simplest explanation for why it’s progressive is due to the slow disposal of DHT once it adheres to an androgen receptor. When your hair follicle’s receptor sites are saturated, it doesn’t simply “cap” out. Instead, every time it goes through the growth cycle and begins to develop again, it tries to adapt to the androgenic needs of its environment, creating more receptor sites to uptake even more DHT. Most believe that DHT simply adheres to the hair and begins to destroy it, but the truth is that DHT does significant damage both indirectly and directly, affecting the environment and various functional mechanics of the hair organ.
Due to the genetic sensitivity to DHT, your body reads the DHT as something that doesn’t belong in the hair follicle, and it responds by triggering inflammation in an effort to dispose of it. Ultimately, this leads to chronic inflammation. Inflammation serves as a response with one of two primary functions. Function 1 focuses on migrating healing growth factors to the damaged tissue. Function 2 is an immunological response to foreign bodies that don’t belong, in which it will try to devour and remove anything it sees that is out of place. In the case of AGA, the entire environment is attacked by this inflammation, slowly causing hair loss.
Next, the inflammation and DHT both have a negative impact on the dermal papilla’s ability to properly signal growth cycles and regenerative body mechanics. This means that the growth cycle of the hair begins to shorten, and the resting phase begins to elongate. These quicker overall shifts through the cycles expose the follicles to damage because DHT is adhering to receptor sites more frequently over a shorter period of time. Eventually, the hair will stop growing altogether and the organ will begin to atrophy and die.
Now, you’re probably thinking that it couldn’t possibly get any more intricately destructive than that, right? Well, it does. The broken signaling leads to imbalanced calcification regulators and when you throw in the chronic inflammation, it begins to cause an increase in fibrosis. Fibrosis is the formation of connective tissue in light of an injury that normally aids in healing (think of scarring). In this case, it does quite the opposite. The fibrosis and over calcification begin to harden the tissue of the scalp and crowd the environment, restricting blood flow to the scalp. If you have ever seen an older man’s bald scalp, you might have wondered why it’s leathery and ultra-thick. This is the precise reason why.
Think of it this way, in the iron ages of castle sieges, one of the most widely adopted strategies for success was to cut off the trade routes to prevent the defending soldiers from getting food and water. This is essentially what’s happening in your scalp, except it’s worse because your blood also carries oxygen to your tissue. In other words, decreased blood flow means fewer nutrients and less oxygen, which means more cellular death and a quicker decline in scalp health. To summarize this analogy, you will increasingly mourn the death of your beloved soldiers.
First, we start with the cause: DHT! This is ironically the most simple part of the complex process of treatment, although it’s often ignored by dermatologists, who tend to favor steroidal treatments that focus on inflammation instead. In men, you can use alpha5-reductase-inhibitors such as fin######## to block roughly 70% of DHT metabolization by inhibiting the enzyme that causes testosterone to DHT conversion. This is typically prescribed for hair loss as 1mg orally per day. In some men, if caught early enough, this can be sufficient to stop hair loss. In others, it can even reverse the miniaturization of follicles and cause the hair to grow back healthily. Since you are here reading this article, it’s probably safe to assume that you have read the flaccid and impotent horror stories of fin########. While there is validity to these stories, it is a rare occurrence in men, but we still don’t recommend taking that risk. After all, what’s the point in hair if you lose your sexual function?
Joking aside, MAXIM formulated a topical solution with 0.01% fin########, 10% minoxidil, caffeine, biotin, and hair & skin growth peptides to combat hair loss. When you take the pill, the dosage is significantly higher than spot treatments because it passes through your liver and bloodstream twice, systemically blocking DHT conversion and a small dose would not effectively reach peripheral organs such as the hair. This is why rare sexual side effects can occur in some men, because it will systemically decrease serum DHT. However, with the topical solution, instead of 1mg pills, the compound contains just 0.01% fin########, which translates to 0.1 milligrams/ml. Yes, it’s only a fractional 10th of the drug that the oral contains per dose. You would use it twice a day, which equates to 0.2mg per day, as opposed to 1mg. Because of this, and the directional focus of the topical using liposomal technology to deliver the medication to the hair follicle, there is a dramatically lower risk of seeing a systemic decrease in serum DHT and subsequently, a significant decrease in side effects.
Fun side note: this topical also shows to be 2% more effective at blocking the DHT conversion. Hopefully, you aren’t like I once was, too bogged down learning about patient care and medicine to notice that you lost most of your hair (which I have since restored, for the record). If you are, you will have to live with the realization that a transplant may be necessary to restore the lost hair, and fin######## alone cannot regrow what has since died and left the building. If you are somewhat early, but still have some cascading damage caused by putting off your hair loss for too long, you will need to treat the chronic remnants of DHT, such as inflammation, which can also worsen due to the fibrosis and calcification. I know…it comes full circle and keeps getting better, right? The good news is that it’s okay. Many people are still in a good stage to restore their hair without any transplant whatsoever. Others may need a small FUE and non-surgical treatments.
So let’s recap, we have identified 5 core components to DHT induced hair loss:
Let’s address the treatments accordingly:
This is a classic case of treating a symptom, not the cause. By using steroids, you are only temporarily suspending symptoms and damage that are secondary to the cause (inflammation caused by DHT) and tertiary (damage actively caused by inflammation) instead of the root cause. Now you might wonder if you can just continue using steroids to prevent the inflammatory response, and the answer is both yes and no. You can, but it will slowly degrade your scalp, and eventually, this will induce hair death as well.
The answer for how to treat the inflammation is simple: stay well hydrated, make sure you eat in a way that aids in the prevention of negative inflammation, and most importantly – TREAT THE CAUSE!
Decreased blood flow, over calcification, over fibrosis, and broken cell signaling: Please note that treatments for #2 also treat symptoms #3, #4, & #5, which are caused by #1 and #5. It’s important to understand that these “symptoms” may also become a permanent issue if not treated as if they were an independent issue. Tissue perfusion is the essence of life within our bodies. Blood carries nutrients, oxygen, water, and just about every important healing factor through your body. There are several ways to improve blood flow to the scalp. The simplest method is to use a topical such as minoxidil, which effectively induces vasodilation. However, this has limitations because you will still have to deal with the inflammation, calcification, and fibrosis constricting blood flow. To really treat the decreased blood flow, I repeat, we have to treat the cause.
The fibrosis and calcification cannot be treated through medications alone, as they will remain present even if you treat the DHT. However, it can be accomplished through collagen induction therapies where we cause calculated microtrauma to the scalp, extracting natural growth factors and healing molecules from the body for reinjection, placing dissolvable foreign bodies into the scalp, and/or extracting healing mechanics through micrografting of hair follicles. These therapies are akin to biohacking, tricking your body into producing and migrating growth factors and healing molecules to acutely heal the intentionally damaged areas. This also aids in better tissue perfusion because, you guessed it, it uses the blood vessels to transport the healing mechanisms.
In order for your body to utilize the faltering vessels the body will recognize that it must first repair them. In other words, all of these measures induce angiogenesis and activate fibroblasts, which produce collagen and initiate positive tissue degradation, effectively breaking down fibrotic tissue in addition to the calcifications.
Angiogenesis is the formation of new blood vessels from old vessels. Now, this doesn’t mean that it simply rebuilds the old road with some patchwork and replacement concrete. It also forms brand new bifurcations, like a multi-directional fork in the road, allowing for various paths of less resistance to allow for improved tissue perfusion.
I know that I said there is no one-size-fits-all solution, and you might have gathered that by reading subsection #2 where several treatments are mentioned. The reason for this is that many of the delivery methods and treatment options require one of the conjunctive treatments to function optimally. Subsequently, all of these areas of contention are treated during these combinative processes.
Micrografting and mechanical dissection of the dermal papilla is the only treatment mentioned above that directly impacts the cell signaling functions. This procedure works by extracting hair follicles from your donor area, which are not responsive to DHT and typically remain in good health. After extraction, the dermal papillae from the follicles are mechanically dissected, forcing them to release hair follicle-specific growth factors while emptying its healing reservoirs into saline solution, which is reintroduced to the damaged tissue in your area of hair loss. This can aid in the dermal papilla’s ability to restore signaling.
If you’re tired of wondering WTF your hair has gone, or WTF has happened to your hair, MAXIM is here to help. At MAXIM, we offer complimentary consultations with a focus on education first. We will sit with you to discuss your goals, analyze and explain the stage of progression you are at, and provide the most appropriate clinical pathway to reach your desired goals. Please call us or chat with us online to schedule your consultation with our team of hair restoration experts.
Authored by Joseph Hart, BSN, RN