First the forehead gets higher, then a spot at the back of the head clears - hair loss is for many men the worst thing they could possibly suffer as they get older.
While balding men used to place their hopes in all kinds of remedies or attempt to conceal the areas with hairpieces, effective hair growth medications have been available for years. But they can't guarantee the return of a full head of hair.
There are good reasons for the anxiety men feel when their hair starts to fall out. "Studies show that to other people, bald men appear to be an average of three to four years older than they actually are," said Ronald Henss of Saarbruecken.
They also are perceived as less stylish than men with a full head of hair. In the eyes of many beholders, a bald head means the loss of attractiveness. One small comfort: "Most people think of bald-headed men as family men and faithful husbands," said Henss.
The likelihood of hair loss increases with age. By their 80th birthday about 80 percent of men are affected, said dermatologist Natalie Garcia Bartels of a centre of excellence for hair at Berlin's Charite Hospital. Up to 100 individual hairs fall out per day from a normal head. Anything over that is considered hair loss.
"Mostly it is congenital hair loss - the so-called androgenic alopecia or male-pattern baldness, which can begin in men from age 20," said Garcia Bartels. It appears gradually as a receding hairline from the lateral sides of the forehead or hair loss as a bald patch at the top of the head that works its way gradually toward the front.
Many men are left with only a ring of hair around the lower part of their head.
Hair loss is set off by a hormone in the scalp. An enzyme causes testosterone to be transformed into dihydrotestosterone (DHT), which is believed to be the primary contributing factor in most cases of male pattern baldness. The hair follicle develops a deep sensitivity to DHT, which initiates a process of follicular miniaturisation. This progressively decreases the width of the hair shaft until the scalp hair resembles peach fuzz or goes away completely.
'The result is more hair than normal is lost. Why this happens to some men and not others has not yet been researched,' said endocrinologist Gerd Hofmann of Munich.
There are other types of hair loss, but they occur less frequently. When circular patches of hair fall out, for example, the cause typically is an autoimmune disease that sets in rapidly, said Garcia Bartels. Sometimes hair loss is attributed to an internal disease of the thyroid or a low level of iron in the blood.
There are remedies available to stop hair loss caused by male pattern baldness and possibly even to reactivate the still existing hair follicles. The effectiveness of the remedies has been documented in studies. These remedies have finasterid, used in high doses to treat the prostate gland, as the effective ingredient. It blocks the enzyme that converts testosterone into the hair follicle-damaging DHT.
Finasterid can be obtained through a prescription and it is in the form of a tablet taken daily.
'If the treatment is stopped, the hair loss as a rule will start again,' said Garcia Bartels. The price of the drug - about 150 euros ($220) for a three-month supply - is high. Somewhat more economical is Minoxidil, which is a lotion that must be applied to the scalp twice a day. Originally developed as a blood pressure medication, Minoxidil was found to have the side effect of hair growth.
Minoxidil's success rate is however lower: while hair loss is stopped in 80 percent of the people who use finasterid, the rate is 70 percent among people who apply Minoxidil. Additionally, 70 to 80 percent of finasterid users experience hair re-growth. This is true for 50 to 60 percent of Minoxidil users.
Apart from these medicines and the toupee, there is another way of achieving a full head of hair again - hair transplantation. This involves removing pieces of skin with hair follicles from another part of the body, typically the back of the neck, and transplanting them at the bald spots.
'Such measures come into play only if the hair loss has ended,' said Garcia Bartels. Otherwise, the remaining original hair will continue to fall out around the newly transplanted hair.
Hair transplantation is a very costly solution of baldness. The cost of refilling in a small spot with hair can run over 1,000 euros.
'The results that I have seen thus far are not especially satisfying,' said Hofmann. Apparently, it is better when a man accepts his baldness.
'The problems that men have with hair loss decline anyway as they get older,' said Henss. 'Perhaps time does not grant a full head of hair, but it does heal all wounds.'
On the Internet there are numerous advertisements offering lotions and similar remedies for hair loss. Hofmann said these are best avoided.
'Remedies that cost a lot of money and do nothing only cause aggravation and frustration,' said Hofmann. The money would be better spent on a head massage or a hair tonic containing rubbing alcohol.
'Such measures help increase blood circulation to the scalp, thus supplying it with oxygen.'
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