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How to Make Sense of Clinical Trials

Posted Aug 24 2008 1:49pm
DAVID R. MARKS, MD: Hi, and welcome to our webcast. I'm Dr. David Marks. People don't like to talk about it, but women can lose hair, just like men. For these women, finding the right treatment can be confusing. Do the products that work for men work for women, too? What products work best? What lifestyle changes do women need to make?

Here to talk about the treatment options for women are two experts. First is Dr. Neil Sadick. He's a dermatologist and a cosmetic surgeon at the Weill Cornell Medical College. Welcome.

NEIL SADICK, MD: Hi, David.

DAVID R. MARKS, MD: Next to him is Dr. Michael Reed. He's also a dermatologist and a hair transplant surgeon at NYU in New York City. Welcome.

MICHAEL REED, MD: Thank you.

DAVID R. MARKS, MD: The treatment options are a little bit different for women in some cases. What are they, in general?

MICHAEL REED, MD: Well, there's topical treatment and there's oral treatment for women, theoretically. I assume that we're talking about the typical female pattern hair loss patients. Probably the first thing a woman can do if she sees that she is starting to see scalp and not hair without any other unusual findings is she can go to the local pharmacy and she can buy and treat herself with 2% minoxidil, which is available as Rogaine and also available generically, and try that for a period of six or 12 months and see if that has an effect.

DAVID R. MARKS, MD: What is it? A shampoo?

MICHAEL REED, MD: It's a topical solution. It's clear, it's colorless. It can be put on with a medicine dropper or spray bottle, but usually the medicine dropper is better. It's put on twice a day and it takes a while to work. Use it at least six to 12 months before deciding that it's not effective and going on to something else. That's what I recommend.

DAVID R. MARKS, MD: And the something else is what?

NEIL SADICK, MD: If women are not responsive to this more conservative regimen using 2% minoxidil, I usually recommend that they use an agent called spironolactone, which is an androgen blocker that is prescribed by dermatologists and endocrinologists.

DAVID R. MARKS, MD: What's an androgen?

NEIL SADICK, MD: An androgen is a hormone, usually a masculinizing type of hormone, that is most commonly elevated in men compared to women, but is also present in women, and it's felt to play a role in terms of hair loss. An increased amount of androgen or an increased sensitivity of receptors where androgens act are felt to play a major role in androgenetic hair loss, both in men and women, and there is a class of drugs that tends to inhibit these hormones and their receptors. I've found this to be the most successful second option if a conservative route such as 2% minoxidil is not effective in women with diffuse hair loss.

DAVID R. MARKS, MD: And spironolactone is a pill?

NEIL SADICK, MD: Spironolactone is a pill. It's actually a water pill or diuretic, but another major action of spironolactone is, again, to block these androgen receptors that decrease the amount of hormone activity in women.

DAVID R. MARKS, MD: How long does it take to see an effect on hair?

NEIL SADICK, MD: We usually see an effect when it's positive within a period of three to six months. Women who take this drug do need to be monitored. Because it is a water pill, they can lose potassium, so we need to monitor their electrolytes at least at three-month intervals. It can also occasionally cause breast tenderness, and in women who are premenopausal, we usually use hormone replacement, as well, to try and counteract some of these effects.

DAVID R. MARKS, MD: That's what I was going to bring up. Hormone replacement, or maybe oral contraceptives -- is there any role for them in the treatment of hair loss?

MICHAEL REED, MD: An estrogen-dominant type of oral contraceptive may be helpful, at least to keep hair from coming out excessively and to prevent further thinning. On some people it may grow back a little bit, but by itself it's probably not sufficient. But it's definitely useful.

NEIL SADICK, MD: It's really interesting that some women that are on oral contraceptives or women who are postmenopausal or who are on hormone replacement, a small percentage of them will notice an improvement in their hair loss, but in my experience, a larger majority of them will have actually a worsening of their hair loss when they're on hormone replacement, even if it's on an estrogenic or a high-estrogen type of compound.

DAVID R. MARKS, MD: I mentioned lifestyle changes. Are there any things that a woman can do short of medicine that can help with her hair loss?

MICHAEL REED, MD: It's a good idea to avoid all stress. That's what I tell them. And then we have a good laugh after that. You can't change the parents that were picked for you. You can't pick your own parents, and life is filled with stresses. We tell people to wash their hair frequently, to get rid of excess oil and debris that may possibly have extra male hormone that can recycle into the scalp, but again, that's unproved.

There's no universal anti-hair loss diet. Generally speaking, the old rule of moderation, avoiding extremes, getting enough sleep, exercising regularly, eating a balanced diet. Try not to gain and lose weight suddenly. That's not good. Going on and off hormones, whether it's birth control pills or hormone replacement therapy is not good for hair. It causes it to rest and come out. Illnesses and traumas in life that can be avoided, if possible, should be avoided. Anything that keeps a person in that middle zone and not going up and down will be good for their hair.

NEIL SADICK, MD: I would agree with what Michael said, and I would also mention to women, if they need to take a medication such as a high blood pressure medicine, particularly if there's a genetic history of hair loss, try and stay away from any medications that may exacerbate hair loss in a genetically predisposed individual, such as beta blocker antihypertensive medicines. Antianxiety or antidepressant medicines may make hair loss worse in a woman who has a genetic predisposition for this condition.

DAVID R. MARKS, MD: You're both hair transplant surgeons, and a lot of people think about hair transplantation with men, but you were telling me earlier that a lot of women are getting it now.

MICHAEL REED, MD: It seems that more women are coming in with localized areas of hair loss, a cross between the classical male hair loss and female hair loss. A lot of women have an area right behind their hairline that's really rather empty, where 90% of the hair is gone, and they're relatively young women, and they have a relatively decent amount of hair in the back, and in my practice now, I'm up to almost 40% women. Some of the techniques we use are different in women, because women really want density. They already have a hairline. They don't need a nice, new hairline. They have a hairline. They need hair behind it. They are good transplant candidates, and they have to have hair. They're great patients. They do extremely well. They like it done in one session. They don't like to do multiple sessions. Some of the guys will come back over and over. Women, you do one session, you'd better do the best you can in one, because they might not come back for another one in that area. They don't want to.

NEIL SADICK, MD: And there's a new technique called slit grafting where we removed very small slits of scalp and can actually very naturally replace a good amount of the density of hair in women. It's really revolutionized the process of hair transplantation surgery in women, and because the grafts are so fine, it really is not a cosmetic deficit. You can barely notice after the procedure that you've actually had hair transplantation. The hair just begins to grow naturally, and it is very unassumable. It's very difficult to detect. It has a very, very natural appearance. That's a major advance that we're able to accomplish now in women.

DAVID R. MARKS, MD: Thank you both for being here. Thank you for joining our webcast. I'm Dr. David Marks. Goodbye.

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