Tag Archive for: Minoxidil

Minoxidil vs Finasteride: Which Hair Loss Treatment is Best?

Happy Head customer using their topical treatment, made custom by a board-certified dermatologist. Which is better for you? Finasteride or Minoxodil?

It’s not unusual for people to collect a graveyard of failed hair loss products before they throw in the towel and accept the fact that going it alone with over-the-counter (OTC) options isn’t working.  We hear it all the time with our patients. After all, the OTC market for hair loss products is huge. There are vitamins, supplements, shampoos, oils, conditioners, diets, and more, all promising to help you regrow your hair. The ads are pretty convincing.  

The reality is that the two products that are most effective in helping people with androgenetic alopecia (a fancy name for male and female pattern baldness) slow down the progression and regrow their hair are both FDA approved. They’re research tested and should be used under a dermatologist’s supervision. Those two products are Minoxidil (Rogaine) and Finasteride.   

What exactly are Minoxidil and Finasteride? Which one should you use for your hair loss? Are there any side effects? If you’re looking for answers, you’re in the right place. We’ll give you the information you need to help you choose the most effective hair loss medication.

What is Minoxidil?

You may have heard of Minoxidil, which is sold OTC under the brand name Rogaine in two and five percent liquid and foam. Rogaine is available at retail stores such as Walgreen’s and CVS and online. Stronger Minoxidil formulas are available, but only with a doctor’s prescription. You can also get a Minoxidil custom topical treatment made by a board-certified Happy Head dermatologist. 

Minoxidil was originally marketed as an oral medication to treat hypertension in the 1970s. During the product’s testing, researchers noticed that their balding patients who took Minoxidil began to regrow their hair. A topical formula was then developed and approved.  

How Does Minoxidil Work?

Scientists are still learning about how and why Minoxidil works to support hair growth; however, this is what we do know. When people experience androgenetic alopecia, their hair follicles shrink, producing finer and thinner hairs over time. Minoxidil does four things to help counteract the miniaturization:

  1. Widens the blood vessels so more oxygen-rich blood can reach the hair follicles.
  2. Enlarges your hair follicles so thicker, stronger hair can grow.  
  3. Reduces the telogen (resting) phase of the hair growth cycle, so less hair is lost
  4. Keeps your hair in the anagen (growth) phase longer so your hair can grow longer

Does Minoxidil Have Any Side Effects?

The most common side effect from using topical Minoxidil is mild redness or irritation. This usually goes away after using the medication for a while. If you are experiencing irritation, you can try using less of the medication or use it every other day until your skin adapts.  

What is Finasteride?

Finasteride, also marketed under the brand names Propecia and Proscar, was first developed as a pill to treat Benign Prostatic Hyperplasia (BPH), also known as an enlarged prostate. Like Minoxidil, when Finasteride was being tested, researchers found that hair growth was a side effect in men experiencing hair loss. The oral medication was FDA approved to use for androgenetic alopecia in 1997 at a dose of 1 mg.  

How Does Finasteride Work?

Finasteride inhibits types II and III of an enzyme called 5-alpha-reductase isoenzyme.  In layman’s terms, that means it inhibits the conversion of testosterone to dihydrotestosterone (DHT). When testosterone converts to DHT, the hair’s growth cycle is interrupted. Hair follicles shrink and shorten the hair. As a result, the hair falls out easily and does not grow back. As a DHT blocker, Finasteride prevents this process from happening. Research indicates that Finasteride is highly effective. Finasteride reduces prostatic DHT levels by more than 90 percent and serum DHT levels by approximately 70 percent. Increasing the dosage does not correlate with higher serum reduction. (01)

Does Finasteride Have Any Side Effects?

It’s not uncommon for men to be concerned about taking oral Finasteride because of the medication’s reputation for sexual side effects. Finasteride can cause a decrease in sex drive or trouble getting or keeping an erection. That’s only the case for oral Finasteride, however. Topical Finasteride has been proven equally as effective without the risk of sexual side effects. (02)  

What’s the Difference Between Minoxidil and Finasteride?

Minoxidil and Finasteride have two very different roles in treating androgenetic alopecia in men and women. Finasteride blocks the DHT to prevent hair loss from occurring in the first place.  Because it also prevents miniaturization of the hair follicles, existing hair does not thin and new hair is able to grow. Minoxidil works at your scalp’s surface, enlarging the hair follicles.  

Can You Use Minoxidil and Finasteride at the Same Time?

Because Minoxidil and Finasteride complement each other well as a treatment for androgenetic alopecia. Dermatologists often prescribe the two medications together. As a matter of fact, research has proven that not only can the medications be used together, but doing so has higher efficacy than using just one of the medications alone. (03)

Does it Matter Which Form of Medication You Use?

Both Minoxidil and Finasteride are available in oral pill and topical formulas. The medications are equally effective, regardless of whether you choose to take a pill each day or apply the topical.  Many men prefer topical Finasteride over oral. As mentioned previously, the topical is equally effective for treating male pattern baldness without the same risk of side effects. Once you start using a hair loss medication, whether you use Minodixil, Finasteride, or a combination,  it’s important to use the treatment daily. Once you stop, your hair loss will resume within a few weeks. Switching between oral and topical solutions should not stimulate hair loss.

How Do I Know What Dosages I Need?

Your dermatologist will prescribe the proper dosages based on your weight, recommendations from pharmaceutical companies, and experience. Even though five percent Minoxidil is marketed for men and two percent for women, many women use the five percent solution and foam. Research indicates that five percent is safe and it’s also more effective than the two percent. (04) Higher strengths of Minoxidil are available by prescription.  

Which Treatment Option Should I Try First?

Since Minoxidil and Finasteride work differently, it’s a chicken and the egg kind of a question. Most dermatologists would likely recommend trying both, especially if you use topicals. All-in-one topical Minoxidil and Finasteride formulas are available if you prefer not to use multiple medications. Many people prefer the convenience of using one product.

How Do I Know if I’m a Good Candidate for Hair Loss Treatment?

The best way to get started is by scheduling an appointment with your dermatologist. However, if you don’t have one, or if you just have some questions that you would like answered, we’re here to help.  Our board-certified dermatologists and hair specialists are available to review your history and recommend a personalized treatment plan. We can even customize a prescription formula to meet your specific needs.  

Resources:

(01) https://www.ncbi.nlm.nih.gov/books/NBK513329/#:~:text=2%5D%5B3%5D-,Finasteride%20is%20an%20FDA%2Dapproved%20pharmacologic%20agent%20for%20treating%20benign,a%20dose%20of%205%20mg.

(02) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4314881/#:~:text=Studies%20show%20that%20topical%20finasteride,post%2D%20treatment%20with%20oral%20finasteride.

(03) https://pubmed.ncbi.nlm.nih.gov/32166351/

(04) https://jamanetwork.com/journals/jamadermatology/article-abstract/555638

 

5 Facts All Men Should Know About Hair Loss

Man looking at his hairline in the mirror, wondering what to do. Happy Head can help you stop hair thinning and loss in its tracks with custom topical solutions made with fda approved ingredients that are just for you.

A few weeks ago, my husband pointed out a Facebook meme that made us laugh. It showed two photos of hair and body care products. One photo included products that women use in the shower, and another photo showed the products that men use.  The women’s photo was loaded with products, including body wash, face wash, two different types of shampoos, and a couple of different types of conditioner. The men’s photo only had one product, a lone all-in-one bottle of body wash, shampoo, conditioner, shaving cream, and toothpaste. Not only was it funny, but it also depicted the scene in our shower pretty accurately. The truth is, though, although some men don’t give their hair a lot of thought, I don’t know of any who are thrilled about the idea of going bald. It’s a super sensitive topic. As nonchalant as my husband is about his hair, even a hint that his hairline is receding results in a very alarmed “What?” and a close scalp examination in the mirror that night.  Hair loss in men is common, but that doesn’t mean you’re okay with it. Nor does that mean that you have to accept your fate. So, if you’re a guy with some recession, thinning, or balding, this one’s for you. We’re here to fill you in on what you need to know about male pattern hair loss and what you can do about it.  

1. Hair Loss in Men is More Common Than You Realize

According to the American Hair Loss Association, by age 50, 85 percent of all men will have significantly thinning hair. (01)  Yes, you read that correctly. The majority of men will deal with some type of hair loss in their lifetime.  Men lose their hair for a lot of different reasons.  Balding or thinning hair can be due to autoimmune conditions, Covid, or even stress. The most common reason, though, is genetics. The vast majority of men with thinning or balding hair have androgenetic alopecia, male pattern baldness. Yup, that’s right. Your parents or grandparents may have passed along a baldness gene.  

Male pattern baldness, also known as androgenetic alopecia, occurs when your testosterone is converted to an androgen (a sex hormone) known as Dihydrotestoterone (DHT). The DHT attacks your hair follicles and causes a reaction called miniaturization which shrinks the follicles. When that happens, the hair that is already there falls out. New hair has trouble emerging through the shrunken follicles, and eventually, the hair stops growing.  

Although Male pattern baldness is the leading cause of hair loss among men; it’s not the only reason men lose their hair. Other forms of alopecia can cause hair loss among men as well. For example, Covid or other illnesses can cause a temporary hair loss called telogen effluvium. In this case, your hair will grow back within six to twelve months. Alopecia areata is an autoimmune condition that causes sporadic bald patches. Some men’s hair spontaneously regrows, but flares can occur at any time without notice.  Lichen planopilaris is another type of alopecia that causes inflammation, leading to scars over the hair follicles that prevent new hair growth.         

2. Timing is Everything When It Comes to Hair Loss Treatments

Many men avoid doctors like the plague. (02)  However taking a “let’s wait and see what happens” attitude isn’t recommended when it comes to hair loss. If you don’t get treatment when you first notice that your hair is thinning, then your hair loss will most likely progress, leaving you with a higher number on the Hamilton-Norwood Scale. In case you don’t know what that is, the Hamilton-Norwood Scale is a classification system developed to measure the extent of baldness. You don’t want to get high scores on that test.  

If you visit a board-certified dermatologist as soon as you see signs of thinning or balding, your doctor will identify the cause of your hair loss. Once you are diagnosed, your dermatologist can recommend treatments to stop your male pattern hair loss and to promote new growth.  

3. Hair Loss Consultations Are Not a Big Deal (Really!)

If the idea of any medical procedure secretly has you a bit nervous, don’t let that prevent you from seeing a dermatologist.  The exam is much easier than you would expect, and trust me, your dermatologist will not think you are vain for seeking treatment.  Dermatologists evaluate men for hair loss conditions all the time.  So, while you may be out of your comfort zone, your dermatologist certainly isn’t.   

Your dermatologist will ask questions about your health, medications, family history, and lifestyle during your exam. The more detailed information you provide, the better. Your dermatologist will examine your scalp to evaluate your hair loss pattern and possibly do a pull test. A pull test measures the severity of your hair loss. During the test, your dermatologist will gently tug on small sections of your hair to see if any strands fall out.  If six or more do, you have active hair loss. Dermatologists usually diagnose androgenetic alopecia based on visual exam. A blood test or a small biopsy may be ordered if he or she suspects another type of alopecia. Don’t stress if you need a biopsy. You’ll be numb, the biopsy area is small, and it heals within a week.

4. Today’s Hair Loss Treatments are Effective and Natural Looking 

After you get a diagnosis, you’ll have many treatment options. The good news is more data than ever is available on hair loss treatments. Research indicates that many are not only safe, they’re highly effective. Here are some examples of the most popular prescription hair loss treatments used:

Minoxidil 

  • FDA approved to treat hair loss
  • Available in oral or topical formulas
  • Brings oxygen to the hair follicles, enlarging them so existing hair does not fall out and new hair can emerge

Finasteride

  • FDA approved to treat hair loss
  • Available in oral and topical formulas
  • Prevents testosterone from converting to DHT and attacking your hair follicles
  • First-line treatment for androgenetic alopecia

Dutasteride

  • Used off label to treat hair loss
  • Only available as a pill like our SuperCapsule
  • Prevents testosterone from converting to DHT and attacking your hair follicles
  • Prescribed if patient does not respond to Finasteride
  • Lower dosage prescribed for Dutasteride than Finasteride

Cortisone

  • Available in pill and topical formulas
  • Reduces irritation and inflammation

Retinoic Acid

  • Available in topical formula
  • Proven to improve absorption of topical Minoxidil and Finasteride

Compounded Topical Formulas

Research has shown that combinations of topical formulas are more effective than monotherapy.  For example, topical Finasteride combined with topical Minoxidil works better than one of the medications alone. (03)  Finasteride and Minodixil combined with Retinoic Acid is more effective because the retinol helps the scalp better absorb the other two medications. (04)

Alternative Hair Loss Treatments for Men

You may also be a candidate for treatments such as Protein Rich Plasma (PRP), laser light treatments, and hair transplant surgery. Let’s talk about what these are and how they work.

Protein Rich Plasma

PRP acts similarly to Minoxidil by bringing oxygen to the hair follicles to enlarge them. During a PRP procedure, your dermatologist draws your blood. The blood is then separated. The plasma is then injected into sites where your hair is thinning or balding. 

Laser Light Treatment

You may have seen ads for laser light caps. Do they work? Well, the jury is out. The philosophy behind them is that the light increases blood flow to the areas on your scalp that are thinning. More oxygen and nutrients are able to reach the hair follicles, allowing the hair to grow thicker and longer. Although research indicates that laser lights show promise for treating hair loss, the most effective intensity and frequency is still to be determined. (05, 06)  

Hair Transplant Surgery

In the 70s and 80s, you could always tell when a man had hair restoration surgery. You could actually see little circular holes where the plugs were implanted. It looked like a doll’s head. Over time, dermatologists have been perfecting the surgery and today’s techniques give a natural appearance. Dermatologists now move individual hairs from a place where the hair is dense to an area where the hair is thinning. (07) You can’t even tell that the hair has been transplanted.  

5. Perceptions of Bald or Balding Men Have Changed for the Better

Men with thin or thinning hair tend to have lower self-esteem and lack confidence, which could explain negative perceptions of their appearance. (08)  The key is to work with what you do have so you feel as confident as possible.  

Yes, there was a time when bald or balding men were deemed less attractive. That’s no longer the case, though. Today, men who embrace their look are seen as intelligent, successful, and confident. (09) Jeff Bezos, Samuel L. Jackson, Ed Harris, and The Rock are prime examples. So if your hair is thinning or balding, work with your barber or hair stylist to find and own a fresh new look. That look can evolve as you undergo hair loss treatment.  

If you notice some recession, thinning, or balding, and are concerned, contact us for a discrete consultation from the comfort of your home, on your schedule. Our board-certified dermatologists and hair specialists are available to evaluate how much hair you’ve lost and your scalp’s condition. Most importantly, they can offer a customized prescription solution to give you the desired results.  

 

Resources:

(01) https://www.americanhairloss.org/men_hair_loss/introduction.html

(02) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6560804/#:~:text=At%20the%20societal%20level%20masculine,not%20go%20see%20the%20doctor.

(03) https://pubmed.ncbi.nlm.nih.gov/32166351/

(04) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693596/

(05) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8906269/

(06) https://www.karger.com/article/fulltext/509001

(07) https://www.aad.org/public/diseases/hair-loss/treatment/transplant

(08) https://pubmed.ncbi.nlm.nih.gov/16307704/

(09) https://journals.sagepub.com/doi/abs/10.1177/1948550612449490

 

Is There a Genetic Test that Can Predict Hair Loss?

Nowadays, there’s a genetic test for just about everything.  Even to determine our dog’s lineage.   Just one quick saliva sample or blood test and, within days, you can find out if you’re destined for cancer, diabetes, or heart disease.  There’s even a DNA test to determine whether you’re likely to experience anxiety.  

Suppose a genetic test can give you accurate information to guide your health care plan and prevent future disease.  Can it also accurately predict whether you’re predisposed to losing your hair?  If a genetic test shows that you are likely to inherit your Great Uncle Bernie or Aunt Bonnie’s hairline, is there a way to ensure that you don’t follow in their footsteps?  Are genetic hair tests reliable?  Do dermatologists use DNA tests to help make diagnoses? Before you click “Buy Now” to order a genetic test kit, keep reading.  We’re here to answer your questions about genetic testing for male and female pattern baldness.

Can Alopecia Really be Inherited?

When people hear the word “alopecia,” they often think of hair loss caused by a medical condition.  Types of alopecia such as alopecia areata and lichen planopilaris are caused by autoimmune conditions.  Androgenetic alopecia, however, is a type of alopecia that is inherited.  It’s the most common type of alopecia.  As many as 80 percent of all men will experience male pattern baldness in their lifetime. (01)  In addition, many women experience female pattern baldness, usually around menopause.  

What’s the Link Between Genetics and Pattern Baldness?

A study conducted on twins confirms what we’ve long suspected.  Male and female pattern baldness have a genetic component. (02)  About 79 percent of men who were balding in the study could attribute their hair loss to their genes.  But, there’s a catch.  Researchers are still working to fully understand which genes are affected.  We’re still learning.  Here’s what we do know.  There are 63 genes that could potentially cause baldness.  Six of those are associated with the X chromosome, where the Androgen Receptors (AR) are found.  It’s also possible that not one isolated gene is the culprit.  Several genes working together may be to blame.

Can You Take a DNA Test to Determine Whether You Will Go Bald?

Ads make genetic testing very tempting, especially if your Mom or Dad starts losing their hair in their 20s.  It would be nice to know whether you will lose your hair too.  But, unfortunately, we’re not quite there yet.  As mentioned previously, there are still too many unanswered questions about which genes are involved and how the genetic process affects your locks. Also, false positives are not unusual with genetic testing.  You don’t want a test to tell you that you’ll experience androgenetic alopecia if that isn’t really the case. (03)

How do you Know if the Type of Alopecia You Have is Genetic?

When men and women experience androgenetic alopecia, they see specific hair loss patterns.  The first sign for men is usually a receding hairline.  The hair loss then progresses to the top, creating a horseshoe pattern above your ears that circles around to the back of your head.  Female pattern hair loss typically presents differently.  Women usually notice thinning on the top and crown.  Often, women will notice a widening of the center part.  Many other conditions cause hair loss besides androgenetic alopecia.  If you think your hair loss is genetic, be sure to have your dermatologist confirm your findings.  Early diagnosis is key to preventing further hair loss and to stimulating new growth.  You also want to make sure you’re addressing the right condition with the right treatment.  

Do Dermatologists Use Genetic Testing to Diagnose Male and Female Pattern Baldness?

The truth is that dermatologists don’t need high-tech tests to determine whether or not patients have androgenetic alopecia.  Most of the time, they can tell from your hair’s appearance and your hair loss pattern.  If there is any doubt, he or she may use a densitometer to magnify your hair follicles to see if miniaturization is occurring.  Miniaturization is when the hair follicles shrink, causing existing hair to fall out and preventing new growth.  Your dermatologist may order a biopsy and blood test to rule out other causes. Patients often ask about the benefits of running a hair analysis based on what they hear about on social media.   Hair analysis is not used to diagnose male or female pattern baldness.  Instead, it’s used to determine whether there’s lead, arsenic, or another substance causing your hair loss.  

What Can You Do to Treat Hair Loss Caused by Genetics?

Treatment for male or female pattern baldness is designed to meet two goals.  The first is to stop the progression of your hair loss.  The second is to promote new hair growth.   The best way to accomplish those two goals is by using a combination of medications simultaneously.  Here are medications often included in treatment plans for androgenetic alopecia:

  • Minoxidil topical foam – A vasodilator that enlarges the hair follicles
  • Finasteride, Dutasteride, or Spironolactone  – Prevents testosterone from converting to DHT that attacks the hair follicles and causes hair loss
  • Topical or oral cortisone – Treats any redness or irritation (not needed for evey patient)

Some men are concerned about experiencing sexual side effects with oral Finasteride.  If this is the case, topcial Finasteride has been proven to be just as effective without the side effects. (04)  Even better, topical solutions which mix Finasteride with Minoxidil, Cortisone and Retinol offer an even more effective all-in-one solution.  The retinol improves absorption of the other three medications.  

Are There Other Causes of Hair Loss Besides Genetics?

Male and female pattern hair loss are the only types of genetically induced alopecia.  However, other types of alopecia exist and treatment plans are designed to treat the type of alopecia you are experiencing.  Examples of other types of alopecia include:

  • Temporary Alopecia (Telogen Effluvium) – Occurs due to sudden illness, stress, or shock and usually reverses itself without treatment
  • Autoimmune Alopecia (Alopecia Areata and Lichen Planopilaris) – People experience flares and periods of remission
  • Trauma-induced Alopecia (Traction Alopecia and Trichotillomania) – Alopecia results from hairstyles that pull on the hair follicles or when people pull out their hair as a stress response)

Can You Prevent Hereditary Hair Loss?

Let’s play pretend for a minute.  Let’s say that a genetic test does exist that will determine whether or not you will lose your hair.  The tests come back showing that you are genetically predisposed to androgenetic alopecia.   Is there a way to prevent hair loss before it begins?  Sure, eating right, exercising, and managing stress never hurt.  But, even with that, you can’t necessarily fight Mother Nature.  That would be nice, though.  If male or female pattern baldness does rear its head, then it’s time to take action.  

Can You Reverse Hereditary Hair Loss

If you’re experiencing male or female pattern baldness and want to learn more about products available, contact us.  Although there isn’t a way to prevent androgenetic alopecia from occuring in the first place, there are things you can do to reverse the condition.   Minoxidil, Finasteride and other medications have been found to be safe and effective. Our board-certified dermatologists and hair specialists are available to answer your questions and help you develop the ideal treatment plan for your needs and lifestyle. 

 

Resources:

(01) https://www.ncbi.nlm.nih.gov/books/NBK538178/

(02) https://academic.oup.com/biomedgerontology/article/60/8/1077/545174

(03) https://www.nature.com/articles/gim201838

(04) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6609098/

 

Everything You Need To Know About Finasteride Interactions

If you have aging parents or grandparents and have seen their overflowing pill boxes, you know that it’s important to track their medications. One prescription can easily interact with another, and boom, you’re at the doctor’s office figuring out which drug is the culprit.  

Dermatologists and hair specialists often recommend prescription hair loss medications because they are safe and effective.  However, if you are taking other drugs or supplements at the same time, you should be aware of potential unintended interactions.  Since Finasteride, also sold under the brand names Propecia and Proscar, is FDA-approved to treat hair loss, it’s the one most often prescribed.  So, for that reason, we’ll tell you everything you need to know about what mixes well with Finasteride and what might not be the best combination.

Finasteride is a Leading Treatment for Male and Female Pattern Baldness

Research continually demonstrates that Finasteride, a medication originally developed to treat Benign Prostatic Hyperplasia (BPH), is one of the most effective ways to treat androgenetic alopecia.  The statistics tell the story.  After two years on Finasteride, 83 percent of men included in Merck’s research study did not experience further hair loss.  More than 70 percent showed increased hair growth. (01)  Finasteride works just as effectively for women. (02)  That’s why Finasteride is often dermatologists’ drug of choice when it comes to stopping further hair loss and stimulating new growth.  

Finasteride Increases the Testosterone Levels in Your Body

So, how does Finasteride help stop your hair from shedding?  It blocks an enzyme called 5-alpha-reductase (5-AR).  When 5-AR isn’t produced, testosterone can no longer be converted to an androgen called Dihydrotestosterone (DHT), which is what causes your hair follicles to miniaturize.  Finasteride also increases testosterone levels in your body.  More testosterone shrinks prostate size and helps your hair grow.  The only catch is that when you stop taking Finasteride, any new growth will be lost.   

Finasteride Interactions are Uncommon

Complications stemming from Finasteride use are rare.  That’s not to say that it doesn’t or can’t happen.  Certain medications can either increase or reduce the amount of Finasteride in your bloodstream.  Carbamezepine, Rifampin, and St. John’s Wart may reduce Finasteride’s efficacy by metabolizing the Finasteride faster in your liver.  Other medications such as Itraconazole and erythromycin may actually increase the levels of Finasteride in your blood.  Checking with your doctor is the best way to know if other medications you are already taking will contradict Finasteride.  

Avoid Interactions with Other Medications by Using Topical Finasteride Versus Oral 

If you have androgenetic alopecia and are worried about Finasteride interacting with the other medications you are taking, ask your doctor about using topical Finasteride.  Research indicates that topical Finasteride is equally as effective as oral. (03)   Think of topical Finasteride as a spot treatment.  It works directly on the areas where your hair is thinning to prevent further hair loss and stimulate growth.  Oral Finasteride, on the other hand, is systemic since it is metabolized in your stomach.  Topical Finasteride is the ideal solution for men and women who want the benefits of the medication without any potential drug interactions.  

Some Medications Make Finasteride Work More Effectively

Some medications have been found to increase the efficacy of Finasteride.  Because some medicines work synergistically, dermatologists and hair specialists often recommend that patients use multiple hair loss treatments simultaneously to maximize results.  

Minoxidil, also marketed under the brand Rogaine, is a topical hair loss solution that has proven to complement Finasteride. (04)  While Finasteride blocks the testosterone from converting to DHT, Minoxidil enlarges the hair follicles, preventing hair loss, and allowing new growth to break through.  Minoxidil is available in both oral and topical formulas.

Retinol is also a medication that is often prescribed with Finasteride.  Retinol, a derivative of Vitamin A, is often prescribed to reduce wrinkles and improve skin texture.  The medication increases collagen production and stimulates the production of new blood vessels bringing oxygen to the skin.  In addition, retinol has been proven to improve the absorption of topical Finasteride. (05)

When patients with hair loss experience inflammation, topical or injected cortisone is often prescribed in conjunction with Finasteride as well.

Taking Finasteride, Minoxidil, Retinol, and Cortisone all at the same time can seem like a lot of medications to remember.  Fortunately, topical formulas are now available that combine all into one convenient bottle.    

Alternatives to Finasteride

Other options exist if you are experiencing male or female pattern baldness and oral or topical Finasteride aren’t suitable for you.

Dutasteride

Finasteride is effective for most people.  However, an alternative medication is Dutasteride. Dutasteride works similarly to Finasteride by blocking the conversion of testosterone into DHT.  The difference between the two medications is that Finasteride inhibits the Type 2 5AR isoenzyme,while Dutasteride inhibits both Type 1 and Type 2.  In addition, Dutasteride’s prescribed dosages are typically lower than Finasteride’s because the medication is a bit stronger.  

Spironolactone

Spironolactone, also known as Aldactone, is used off-label to treat female pattern hair loss.  It was originally marketed to treat fluid retention caused by liver and kidney disease. The medication is only prescribed for women because it can cause feminizing features when used over time.  Research has not yet been conducted on a large sample size, but four women included in a study, saw reduced hair loss and experienced some growth. (06)

PRP

PRP, an abbreviation for Platelet Rich Plasma, is a three-step process designed to trigger hair growth by increasing the amount of oxygen available to the hair follicles.  First, blood is drawn. Then, blood is then separated into three groups using a centrifuge.  Lastly, the platelet rich plasma is injected into the scalp. PRP is often used in conjunction with other treatments to maximize results.  

Hair Transplant Surgery

If you are concerned about drug interactions, hair transplant surgery may be an option and a long-term hair loss solution.  During the past few years, many advances have been made in how the procedure is performed.  Rather than taking strips of hair to transplant, surgeons are now able to move individual hairs giving a more natural look.  

Low-light Laser Therapy (LLLT)

You may have seen ads recently for laser caps marketed for hair growth.  Most use light in the red or infrared range to penetrate the scalp and target the hair follicles.  Early studies show promise for the technology, but more research needs to be conducted on the efficacy.  One study found that LLT works better when used with Minoxidil or Finasteride.  The study also indicated that more data is needed to determine the optical laser power and wavelength. (07) 

Be Honest About Your Medical History

If your dermatologist recommends Finasteride or any other prescription hair loss treatment, the best thing you can do is be honest about your medical history.  In addition to telling your doctor about any other hormone, heart, or other medications you’re taking, remember to list any supplements. Also, although sharing information about smoking, drinking, or recreational marijuana use may seem embarrassing, remember that your dermatologist has seen and heard it all.  He or she is more concerned with giving you the best hair regrowth options and keeping you safe than passing judgment on your behavior.  

Is Finasteride Right For You?

If you have questions about whether Finasteride is right for you or could potentially interact with other medications you’re taking, let us know.  Our board-certified dermatologists have full medical degrees from accredited universities.  They are available and happy to review your medical history and suggest solutions based on the type of hair loss you are experiencing.  

Resources:

(01) https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020788s020s021s023lbl.pdf

(02) Note: Recommended doses differ for men and women

(03) https://pubmed.ncbi.nlm.nih.gov/34634163/#:~:text=Conclusion%3A%20Topical%20finasteride%20significantly%20improves,impact%20on%20serum%20DHT%20concentrations.

(04) https://onlinelibrary.wiley.com/doi/10.1111/dth.12246#:~:text=Efficacy%20assessment,combination%20therapy%20showed%20improvement%2C%20respectively.

(05) https://jamanetwork.com/journals/jamadermatology/article-abstract/557305

(06) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3769411/#:~:text=In%20a%20case%20study%20of,total%20number%20of%20anagen%20hairs.

(07) https://pubmed.ncbi.nlm.nih.gov/29270707/

 

The Real Story Behind Vitamins that Prevent Hair Loss

I hate to start with a spoiler, but I’m going to start with a spoiler.  Neither vitamins nor supplements are FDA-approved or regulated for any type of hair loss.  Or, for any other health condition for that matter.  This means that information required to establish safety and effectiveness has not been submitted to or approved by the FDA.  Yet, do an Amazon search using the terms “vitamins for hair loss,” and pages and pages of products appear with assurances that the vitamins will help you regrow your hair.  Biotin, keratin, saw palmetto, and proprietary collagen blends are just a few that pop up on the first page, with prices varying from $11 to over $176.  Trying to figure out which ones are effective and worth the investment can make your head spin.   

If your hair is thinning or balding, it’s smart to question whether vitamins will help or if manufacturer promises are too good to be true.  So which ones do dermatologists and hair specialists recommend?  We’re here to answer your questions and set the story straight.  

Get Diagnosed Before You Buy Vitamins to Treat Your Hair Loss

Before you even think about trying any vitamins, you need to start with a diagnosis.  After all, you need to know what condition you’re treating.  Here are the three most common types of alopecia that cause either temporary or permanent hair loss:

  • Telogen Effluvium

Telogen effluvium is a type of temporary hair loss that can occur up to several months after a traumatic or stressful incident.  The condition can be triggered by various events, including high fevers, surgery, certain medications, nutritional deficiencies, and autoimmune diseases.  When physiologic stress occurs, hairs that would normally be in a growing phase are abruptly pushed into a resting phase, resulting in shedding.  The shedding can occur in either small or large amounts.  While hair loss from telogen effluvium can be upsetting in the short term, the long-term prognosis for regrowth is good.  No medication is typically needed.  Hair usually grows back within six months to a year.  

  • Androgenetic Alopecia

Androgenetic alopecia is also known as male or female pattern baldness.  The hair loss condition occurs when too much testosterone converts to an androgen called dihydrotestosterone (DHT).  The condition is genetic and can come from either the maternal or paternal sides of your family.  The hair loss pattern among men with androgenetic alopecia differs from that of women.  Men tend to lose their hair on the front and top of their heads.  Women usually notice their hair loss first along their widening center parts.  Oral and topical medications have been proven to help prevent further hair loss and facilitate growth.  

  • Alopecia Areata

Alopecia areata is an autoimmune hair loss condition that can affect women, men, and children.  Hair loss is usually noticed first in small round or oval patches.  In some cases, hair spontaneously regrows, and in others, the hair loss becomes permanent.  Treatment usually focuses on treating any underlying conditions and using topical and oral medications.

Determining whether you have one of these forms of alopecia is a multi-step process.  Your dermatologist will likely order blood work as part of the diagnostic process.  The lab results will indicate whether vitamin deficiencies could be contributing to your alopecia.  If so, you may benefit from supplementation.  

Vitamins are Helpful When People with Alopecia Have Deficiencies

Much conflicting information exists about the role that vitamins and supplements play when it comes to hair loss.  More research is clearly needed.  The general rule of thumb when it comes to vitamins is to supplement if there’s a deficiency.  Particular deficiencies can be associated with the three types of alopecia we discussed.  Here are the three most common:

Vitamin D

Research has demonstrated that people with telogen effluvium, androgenetic alopecia, and alopecia areata are likely to have vitamin D deficiencies. (01)  The greater the deficiency, the greater the hair loss.  Vitamin D is absorbed into the skin by keratinocyte cells.  The cells process keratin which is found in your hair, nails, and skin.  When your body has a vitamin D deficiency, the keratinocytes in your hair follicles have difficulty regulating the growth and resting phases of the hair cycle.  

Iron

In addition to checking for Vitamin D3 deficiencies, dermatologoists typically check their patients’ iron levels. Iron deficiency inhibits hemoglobin production which produces the oxygen responsible for hair cell growth and repair.  Low iron is a common cause of alopecia and can easily be remedied with a supplement.  

Biotin

People don’t typically have Biotin, Vitamin B7, deficiencies in industrialized countries.  A regular diet typically provides enough nutrients to ensure adequate levels.  However, some research studies have demonstrated that biotin deficiencies often exist in people with hair loss. (02)(03)  Experts have conflicting views on whether biotin supplements are necessary, even when there’s a deficiency.  It’s best to consult with your dermatologist on this one.  

Should You Take Vitamins if You Don’t Have a Deficiency?

Even if you don’t have a deficiency, it’s tempting to take vitamins to see if they will help regrow or thicken your hair.  More isn’t always better though, especially in this case.  Taking too many supplements or the wrong type of supplements can create issues.  For example, extra vitamin A or vitamin E can cause hair loss, which is what you are trying to prevent in the first place.  

Prescription Medications Are Often Used With Vitamins to Get Better Results

If your dermatologist doesn’t think that you are a good candidate for vitamin supplementation, prescription medications may be a good alternative.  This is especially true if you have been diagnosed with male or female pattern baldness.  Medications commonly prescribed include:

Minoxidil (FDA Approved)

A vasodilator designed to enlarge the hair follicles so you can start to regrow your hair.  

Finasteride, Proscar, Propecia (FDA Approved)

A medication that blocks the conversion of testosterone into DHT that attacks your hair follicles.

Dutasteride, Avodart (Not FDA Approved)

A DHT blocker prescribed as a second-line medication if Finasteride does not give the desired results.

Spironolactone (Not FDA Approved)

A DHT blocker prescribed only to women as a second-line medication if Finasteride does not give the desired results.

Minoxidil and Finasteride are both available in oral and topical formulas.  Topicals are often preferred, especially among men, because they do not cause sexual side effects such as lower libido.  Topical medications have been proven to be just as effective as oral medications.

The most effective hair loss plans often combine vitamins and other over-the-counter treatments with prescription medications. Vitamin D, Minoxidil, and Finasteride would be a logical combination if a person with androgenetic alopecia has a vitamin D deficiency.  Prescriptions that effectively combine multiple topical medications into one are available and are convenient and easy to use.  

Some Supplements Have Shown Moderate Improvement in Hair Loss

Although they are supplements rather than vitamins, there has been a lot in the news lately about pumpkin seed oil, saw palmetto, and rosemary oil.  While not quite as effective as Finasteride, these supplements have demonstrated a significant increase in hair growth. (04)  These supplements may be a good adjunct therapy when combined with prescription hair loss medication.

Curcumin, the active ingredient derived from turmeric, is known as a natural anti-inflammatory.  Interestingly, curcumin did not improve hair growth on its own, but it did give positive results when combined with Minoxidil.  The hypothesis is that the curcumin helped the Minoxidil better penetrate the scalp.  However, more research still needs to be conducted.  

Garlic gel, derived from onions, scallions, shallots, leeks, and chives, doesn’t live up to the hype.  Users did not see a significant difference in hair growth.  

As with any product you try as a hair loss solution, make sure to consult with your dermatologist first.  Even products that seem innocuous can have side effects or contradict other medications.  Your dermatologist is the best person to evaluate your treatment plan and determine the best mix of prescription and over-the-counter options.  

What To Do If Vitamins Aren’t the Answer to Your Hair Loss

Vitamins can be helpful if your bloodwork indicates that you have certain deficiencies.  If not, proceed with caution.  Even the most effective supplements aren’t typically as strong as prescription medications to slow hair loss and stimulate growth.  If you need an alternative solution for your thinning or balding hair, Finasteride, Minoxidil, and other medications are effective and are available by prescription.  For more information about your options, contact us.  Our board-certified dermatologists and hair specialists are available to answer your questions and make recommendations based on the type of alopecia you have.  We can even customize a formula to meet your specific needs.

Resources:

(01) https://pubmed.ncbi.nlm.nih.gov/34553483/

(02) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4989391/#:~:text=Biotin%20deficiency%20was%20found%20in,risk%20factors%20for%20biotin%20deficiency.

(03) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6388561/

(04) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6388561/

(05) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6388561/

 

Is Losing Facial Hair Normal?

There are countless options for getting rid of facial hair.  You can wax, tweeze, shave, thread, and even have laser hair removal.  Within minutes, you can get the clean, smooth look you want.  But what can you do if you lose hair in your eyelashes, eyebrows, mustache, or beard?  Finding a bald spot on your face is just as alarming as finding one on your head.  Not to mention that it can be a little challenging to cover up. 

However, neither men nor women often talk about losing facial hair, making a lot of people wonder if facial hair loss is even normal.  Is it?  Why does facial hair loss happen?  What can you do if your eyelashes are sparse or your eyebrows or beard are missing patches of hair?  Whether you’re male or female, we’re here to fill you in.  

How Much Facial Hair Loss is Typical?

Facial hair sheds during the hair growth cycle the same way the hair on your head falls out.   So losing a few whiskers or eyelashes when you wash your face is normal.  It just means those hairs were in the resting phase of the cycle.  You shouldn’t look any different when those hairs are missing.  Losing more than a few hairs and seeing a bald patch is a different story.  If that happens, it’s time to visit your dermatologist.

Alopecia Can Cause Bald Spots in Your mustache or Beard

Alopecia can affect more than just your scalp; it can also affect your facial hair.  You can get alopecia in your beard or mustache for a few different reasons. These include:

  • Ringworm infections
  • Telogen effluvium 
  • Chemotherapy treatment
  • Alopecia

In most cases, hair loss in the beard area is not permanent.  Ringworm infections typically resolve with anti-fungal medications.  If you’re unfamiliar with telogen effluvium, it’s hair loss caused by sudden stress.  Anxiety, a high fever from Covid or other illnesses, hospitalization, and other stressful events can trigger telogen effluvium.  It’s usually temporary.  Hair will grow back within six months to a year.  

Alopecia Barbae is Often Treated with Minoxidil and Cortisone Injections

Another reason why men can lose facial hair is due to alopecia barbae.   Alopecia barbae is a form of alopecia areata that affects the beard.  Like alopecia areata, alopecia barbae is an autoimmune condition where your body attacks your hair follicles, causing small circular patches.  Men who have alopecia areata may be more likely to get alopecia barbae.  Hair often spontaneously regrows; however, the condition can flare up from time to time.  Alopecia barbae is often treated with cortisone injections and topical minoxidil.  

Although the exact cause of alopecia barbae is unknown, genetics may be a factor.  Men with allergies, asthma, and other autoimmune diseases are more likely to be affected.  Once you have one autoimmune disease, it’s possible to get others.  

Because of the alopecia barbae’s unpredictable nature, men are often caught by surprise when they see bald patches.  Some men who have the condition report that their skin sometimes feels itchy and painful before their hair falls out.  The skin visible through the patches can be either smooth or rough.  Redness and inflammation can be present in bald spots as well.  Some also report that the hair that grows back in around the bald spot has a different texture than their other hair.  The hairs sometimes grow narrower at the bottom, also known as exclamation mark hairs.

Loss of Eyebrows and Eyelashes is Common Among Both Men and Women

Madarosis is the name of the condition that causes men and women to lose all or some of their eyelash and eyebrow hair.   The hair loss isn’t always symmetrical.  Madarosis can affect just one eye.  

Madarosis can be scarring or non-scarring, just like alopecia.  Scarring means inflammation blocks the hair follicles so new hair cannot emerge.  Scarring doesn’t occur immediately.  It happens over time.  Non-scarring means that the hair enters the resting phase of the growth cycle early, but the follicle remains functional.  

If you notice bald spots in your eyebrows or gaps in your lashes, it’s best to visit a dermatologist as soon as possible.  There are many possible explanations for madarosis, including:

  • Alopecia areata
  • Hormonal imbalances
  • Nutritional deficiencies
  • Thyroid disease
  • Infections
  • Medications

Early diagnosis and treatment will give you the best possible results. 

Eyelash and Eyebrow Regrowth Products are More Readily Available Than In the Past

Thanks to research, medications that help regrow facial hair are now available.  If your eyelashes or eyebrows are thinning, you may be a candidate for bimatoprost, the main ingredient in Latisse and Lumigan.  Bimatoprost is a glaucoma medication that is FDA approved to help grow eyelashes and eyebrows.   The medication was originally developed to treat glaucoma.  During trials, ophthalmologists noticed that bimatoprost had the side effect of increased eyelash hair. Bimatoprost has been studied over time, and research studies indicate that the medication is highly effective (01) in stimulating growth.  

Minoxidil Can Be Used on Facial Hair Too

Minoxidil, typically used on the scalp, is safe to use on your face.  As a vasodilator, minoxidil brings more oxygen to the hair follicles, making them wider so new hair can emerge.  Minoxidil is sold over-the-counter.  However, we recommend that you consult with a dermatologist who is a hair specialist before beginning treatment for your eyebrows, beard, or mustache.  If you discontinue use, any new growth could be lost, so you will want to have a licensed professional guiding you and monitoring your progress.  

Natural-looking Options Exist to Make Eyebrows and Eyelashes Appear Thicker

If medications aren’t an option for you, many temporary and permanent solutions are now available to cover up your face’s sparse, thinning, or bald areas.  Manufacturers have made false eyelashes so realistic that it’s often difficult to tell when people are wearing them.  Tattoo options such as microblading have become mainstream.  People like the natural look.  Make-up can go a long way if you don’t want to go the permanent route.  It’s amazing what a little dark brown eye pencil can fill in.  

Selecting ways to fill in facial hair is a very personal decision.  While some people are comfortable with make-up, others prefer a permanent solution, so they don’t have to reapply daily.  The key is to do what makes you feel the most comfortable.  

What to Do if You Think You’re Losing Facial Hair

If your beard or eyebrows look a little sparse, options exist to make you feel and look better.  As with scalp hair loss treatments, FDA-approved and prescription medications are the strongest, most effective way to go. If you choose this route, you’ll need a board-certified dermatologist to help you with a proper diagnosis and treatment plan.  If you don’t have access to a dermatologist and have questions regarding your facial hair loss, feel free to contact us.  We can point you in the right direction.  Plus, we’re putting the finishing touches on some new prescription-strength facial hair loss products.  We can let you know as soon as they’re ready.  

Resources:

(01) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6054329/

Smoking and Hair Loss: The Truth You Need to Know

Are you a smoker? If you're losing your hair, this might be the reason why. Happy Head dermatologists recommend stopping smoking.

If you’re a smoker, you’re probably already well aware of why you should quit. Between your family using every scare tactic in the book and chilling public service announcements featuring people suffering from various types of cancers and lung diseases, you know the risks more than anyone. Beating the addiction is hard, though. In fact, it’s so difficult that 80 percent of people who try to quit smoking on their own start again within a month. (01)

Just in case you need a little more incentive to kick the habit for good, consider this: according to several research studies, nicotine can induce hair loss. Sure, you know how harmful cigarettes and vapes are to your body, but you probably didn’t expect to go bald from them. What else do you need to know about the effects of smoking on your hair? Keep reading, and we’ll fill you in on the latest.  

Nicotine Accelerates Hair Loss

Not only can continual use of nicotine lead to a heart attack, but it is also believed that smoking may be responsible for accelerating hair loss. One study found that 85 percent of men who smoked had a form of androgenic alopecia, male pattern baldness. Among the men in the non-smokers’ group, only 40 percent exhibited signs of male pattern hair loss. The difference in hair loss was significant.  The study used the Hamilton-Norwood Scale, which categorizes hair loss on a scale of one to seven, with one being the least amount of hair loss. In the smoker group, 71 percent had grade III or grade IV hair loss. However, in the non-smoker group, only ten percent of the participants reached grade III or IV. (02)

Smoking Ages Your Scalp 

So the next question is, why do experts believe smoking leads to hair loss? You know how smoking is known for giving people leathery alligator skin? It has the same effect on your hair. The reason why stems from a few different factors.  

  • Smoking reduces the blood flow to your hair follicles.

When you smoke, your blood vessels constrict, limiting how much blood flows to your organs. Over time, the continual constriction stiffens the blood vessels and makes them less elastic. When this happens, your cells don’t get the amount of oxygen and nutrients needed to thrive. When your hair follicles are deprived of oxygen, miniaturization occurs, disrupting your hair’s growth cycle. The hair follicle shrinks and eventually blocks the growth of new hair.   

  • Breathing in smoke can damage your hair’s DNA.

Smoke causes environmental effects that inhibit hair growth. DNA contains genetic material that serves as our hair’s building blocks. When carcinogens from cigarette smoke damage the DNA, keratin, a protein that makes-up 95 percent of your hair, cannot be produced. 

  • Smoking causes inflammation. 

Smoking stimulates follicular inflammation, a key feature in male and female pattern hair loss. In a 2020 research study on androgenic alopecia, approximately 71 percent of biopsy samples of patients with male or female pattern baldness showed signs of inflammation. (03)

  • Smoking decreases estrogen levels.

It is well documented that smoking decreases estrogen levels in women, which can lead to earlier onset of menopause. When estrogen levels drop, hair grows slower and thinner. Lower estrogen levels also lead to an increase in androgens which cause female pattern baldness. (04)

  •  Smoking prematurely turns your hair gray.

In an observational research study, people who smoked were two and a half times more likely to have gray hair before age 30 than non-smokers. (05) The study mentioned that the cause of premature graying is not yet known. One hypothesis is that melanocytes, the cells responsible for producing color, are damaged in people who smoke.  

If You’re Thinking About Getting a Hair Transplant, Stop Smoking

Many reputable dermatologists and hair specialists refuse to perform hair transplants on patients who smoke. The reason why is because oxygen is critical to the survival of transplanted follicles and helping the wounds heal. Smoking causes poor blood circulation, which could result in the death of the skin tissue on the scalp and even post-operative infections. (06) Another reason why is because nicotine in the blood vessels increases bleeding and inhibits clotting during the healing process. 

Vaping Can Cause More Damage Than Traditional Cigarettes 

What about vaping? It’s safer than smoking cigarettes, right? Not exactly. Vaping has skyrocketed in popularity across all ages groups in the past few years due to the sweet taste and lack of stale smell. What many people don’t realize, however, is that JUUL, MarkTen Elite, PAX Era, and most other types of e-cigarettes contain more nicotine than traditional cigarettes.  

Although no studies are available, anecdotally, one can make the connection that nicotine from vape pens is equally harmful, if not worse, for your hair than traditional cigarettes. Regardless of the source, nicotine has been proven to cause oxidative stress, which can impair your hair’s growth and cause hair loss. (07)

The Jury is Out on Marijuana

Recreational marijuana is currently legal in 19 states, Washington D.C., and Guam. (08) Marijuana must not be harmful if it’s legal, right? Well, the jury is out. A study conducted in 2007 by the University of Debrecen indicates that the THC in marijuana can lead to hair loss. (09) 

Marijuana contains cannabinoid compounds. Tetrahydrocannabinol (THC) and Cannabidiol (CBD) are the most well-known. THC is the main psychoactive compound. It’s the one that makes people feel high.  CBD is derived from hemp plants and does not cause a high or lead to addiction. When it comes to your hair, THC is the troublemaker. According to the study, the THC in marijuana can attach to receptors in your body, including your hair follicles, which causes hair loss. Not much research has been conducted since to qualify or negate the study.  

We believe that the study is accurate because marijuana and other drugs can be detected in hair samples for up to 90 days prior to the test. (10)  It makes sense that if the THC attaches to the follicles and sticks around for a while, it could cause damage.  

Treatment is Available to Reverse Hair Loss Caused By Smoking

Treatment is available if you’re experiencing hair loss from cigarettes, vapes, or marijuana. The first step is to stop smoking to prevent further damage. The next step is to consult with a dermatologist who is also a hair specialist.  Although many hair loss remedies are available over the counter, the most effective ones are only available by prescription. A variety of medications can be prescribed to stimulate regrowth including:

Minoxidil

As mentioned previously, smoking can cause androgenic alopecia in people who are predisposed. When people get male or female pattern hair loss, their hair follicles shrink. Minoxidil enlarges miniaturized hair follicles to allow stronger, healthier hair to go to the surface of your scalp.  

Finasteride 

People who smoke and have male or female pattern baldness produce a chemical called Dihydrotestosterone (DHT) that is converted from Testosterone. DHT attacks the hair follicles and causes the hair to fall out. Finasteride is a DHT blocker that prevents testosterone from converting to DHT.  

Spironolactone

Sprionolactone is a DHT blocker.  The medication works similarly to Finasteride but is a bit stronger.  

Retinoids

Retinoids are often used in conjunction with Minoxidil and Finasteride to increase absorption of medications that treat androgenic alopecia.

In many cases, combinations of these medications are most effective in promoting hair growth among former smokers.  For example, Minoxidil combined with Finasteride and Retinol for absorption has been proven more effective than Minoxidil alone.  

Quitting is the Best Way to Preserve Your Hair

If you’re really worried about losing your hair, the best route is to quit smoking. Kicking the habit isn’t always easy, but it’s worth it. You’ll look better and your health will improve. 

According to the American Cancer Society, the best strategy is to quit one day at a time. A day turns into a week, a week turns into a month, the months turn into years, and before you know it, you’ll have broken the habit. Sure, it sounds simple, but we realistically know it’s not.  Here are some other helpful tips:  

  • Stay busy and spend time in public places where smoking is prohibited
  • Replace the feeling of holding a cigarette or joint with a paper clip, marble, or coin
  • Chew gum or eat lollipops as a substitute
  • Avoid places, activities, and people that you associate with smoking
  • Exercise
  • Create a support system of family members and friends who you can call when you have a craving

Many good resources and programs are available to help you as well. Here are three that we recommend. All of these organizations provide trusted information and support.

American Cancer Society 

If you’re considering quitting, you don’t have to do it alone. During The Great American Smokeout annual event, thousands of people commit to a smoking cessation program on the third Thursday in November.

American Lung Association

The American Lung Association offers a Lung Helpline & Tobacco Quitline staffed by licensed registered nurses, respiratory therapists, and certified tobacco treatment specialists. The staff is a wealth of knowledge and can help connect you with a support group, find a doctor, and even answer questions about health insurance.

National Cancer Institute

Smokefree.gov, sponsored by the National Cancer Institute, offers free tech programs to help you go smokefree. One innovative program is a texting service that gives encouragement, advice, and tips to help you quit. The organization also offers apps that allow you to tag locations and time of day you need support, as well as social media support.

If you are a current or former smoker and your hair is thinning or balding as a result, Happy Head is here to help. Contact us so we can review your history and customize a prescription-grade hair loss solution for you.

Resources:

(01) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2928221/

(02) https://onlinelibrary.wiley.com/doi/10.1111/jocd.13727

(03) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7667670/

(04) https://www.karger.com/Article/Abstract/68894

(05) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3673399/

(06) https://pubmed.ncbi.nlm.nih.gov/7484781/

(07) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2758082/

(08) https://www.usnews.com/news/best-states/articles/where-is-marijuana-legal-a-guide-to-marijuana-legalization

(09) https://faseb.onlinelibrary.wiley.com/doi/epdf/10.1096/fj.06-7689com

(10) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5396143/

Scalp Dermaroller: The Most Helpful Hair Growth Tool You Didn’t Know You Needed

Happy Head's new scalp dermaroller helps regrow collagen and hair.

If you’re up-to-date on the latest skincare tools, you’ve probably heard about dermarollers designed to pump up your skin’s collagen. You may have even tried one. But did you know that scalp dermarollers can help rejuvenate your hair too? Although relatively new to the hair care scene, scalp dermarollers have quickly become a tool of choice, recommended by leading dermatologists and hair specialists. What makes scalp dermarollers so popular for treating hair loss? Will the trend last? We’re here to fill you in.  

What Is a Scalp Dermaroller & What Does It Do?

A Scalp Dermaroller is a small hand-held roller with about 540 tiny needles on it. When rolled over your skin or scalp, the dermaroller’s needles create microscopic wounds that stimulate collagen and elastin production. Collagen keeps your skin firm, elastic, and hydrated.  It’s also needed to build keratin which keeps your hair strong, shiny, and thick. In addition to building collagen, scalp dermarollers increase blood supply to the hair follicles, enlarging the follicles to allow new growth to emerge.

Why Are We Just Now Learning About Scalp Dermarolling?  Is it New?

Although dermarolling, also known as microneedling, has been around since the 1900s to treat birthmarks, hyperpigmentation, and scars, we started hearing more about the treatment in the late 1990s. Since then, dermarolling has been studied and found to be effective among patients with alopecia areata (01) and androgenic alopecia.  Patients with alopecia areata have seen positive results when applying triamcinolone after using a dermaroller. Patients with androgenic alopecia have seen positive results when applying Minoxidil after using a dermaroller. (02)

Are Scalp Dermarollers Safe?

Scalp dermarolling is quite safe and easy to do. Simply wet your hair and then gently roll back and forth with your Scalp Dermaroller, left and right, for just a few minutes.  Make sure that you keep the dermaroller moving.  Holding a dermaroller in one place in one area could cause scarring.

Can I Do Microneedling at Home?

The microneedling that’s referenced in this article can be done at home. All you need is a Scalp Dermaroller. The number of times that you use your dermaroller each week will depend on the length of the needles you are using and whether you are using your dermaroller to apply medication. Patients should always consult with their dermatologists to develop a treatment protocol since alopecia type, medications, hair density and other factors vary from person to person.

Other types of microneedling are performed in a dermatologist’s office. You may have heard of Protein Rich Plasma (PRP) treatments which are often done in conjunction with microneedling. During a PRP treatment, a patient’s blood is drawn and placed into a centrifuge machine. The blood is spun at a high rate so the components are separated. The platelets are then extracted and injected into the scalp. When PRP is combined with microneedling, topical anesthetic is applied first, medical-grade dermarollers are used, and then PRP is applied last. PRP treatments can only be done in a doctor’s office.

Which Scalp Dermaroller Should I Buy?

According to Dr. Ben Behnam, board-certified dermatologist, hair specialist, Happy Head co-founder and co-owner of Los Angeles-based Dermatology and Hair Restoration, the key to selecting a Scalp Dermaroller is to get the correct needle size. “When dermarolling, you don’t have to go very deep to get results,” said Behnam. “I recommend just 0.25, which is very shallow. Many people read online that a 1.5 depth is recommended, but in my opinion, that’s too deep. Nobody needs a roller that strong. Rollers with needles that are too long hurt, and they can damage the hair follicle. You certainly don’t want to damage areas where your hair is thinning or balding.” At Happy Head, we’ve designed a Scalp Dermaroller specifically for use alongside your usual topical hair growth solutions. 

Using a Scalp Dermaroller to Apply Minoxidil (Rogaine), Finasteride, and Other Topical Medications Gives Better Results

A study conducted in 2013 compared patients with androgenic alopecia who used a dermaroller to apply Minoxidil to patients who did not use the roller. Not surprisingly, patients who used the roller achieved more growth. The dermaroller creates tiny holes in the scalp that allows the Minoxidil, Finasteride and other topical medications to penetrate deeper than they otherwise would. The medicine works more effectively.

If you’re using Minoxidil or any other topical hair loss treatment on your frontal hairline, Dr Behnam recommends using the topical about two inches behind the hairline to prevent getting the medicine on your face.

Can a Scalp Dermaroller Be Used On Facial Hair?

Although no research studies have been conducted on patients using dermarollers on their mustaches or beards, there’s enough evidence to indicate it’s worth a try. We know that Minoxidil is effective for hair growth and that dermarolling increases absorption. In addition to boosting collagen and keratin production, scalp dermarolling may help improve blood flow to the area.

Keep in mind that you may notice some redness after using the Scalp Dermaroller on your mustache or beard area. This irritation should disappear after a few days. If you experience bleeding, you may be using too much pressure. See if using less pressure helps.

Here are some other tips for facial dermarolling:

  • Start with clean skin and facial hair
  • Wait until acne has cleared up before dermarolling to prevent irritation or infection
  • Use the least amount of pressure needed
  • FIll-in each cheek with air as you do when shaving to get a flatter surface for dermarolling
  • Get a consistent pattern by moving the dermaroller back and forth in horizontal, vertical and diagonal lines

How Much Do Scalp Dermarollers Cost?

Microneedling sessions at a dermatologist’s office can be very expensive, costing anywhere from $200 to $700 per session or more. Using a Scalp Dermaroller at home, however, saves time, money and gas. Scalp dermarollers designed for home use are similar to the ones dermatologists use, but have smaller needles. As we’ve discussed though, smaller needles can still pack quite a punch. Dermarollers used at home are very budget-friendly. The average price of a good stationary unit ranges anywhere from $30 to $50. A good quality electric unit costs $100 – $200 depending upon the features included.

 

Happy Head customer using his scalp dermaroller alongside his topical hair growth treatment.

Should You Test out a Dermaroller On Your Scalp?

So, here’s the takeaway. A dermaroller is an inexpensive hair growth tool that increases the effectiveness of topical treatments among patients with androgenic alopecia and alopecia areata. As with any medical treatment, you should always check with your dermatologist before buying or using a dermaroller. Although dermarolling is an easy, low-risk at-home treatment, it is not recommended for scarring alopecias.   

Always make sure that you buy your dermroller from a trusted source. As with any other hair tool, make sure that you keep your dermaroller clean according to the package instructions. Finally, use your Scalp Dermaroller as recommended, usually a couple times a week, and be careful not to overuse it. More won’t give you better or faster results.

Resources:

(01) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3996798/

(02) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3746236/

 

 

 

Dealing with Bald Spots and Male Pattern Baldness

Whether it’s a slow realization or a sudden awareness, discovering that you’re losing your hair is a difficult event. Every hair on the pillow or on the floor of the shower comes back to haunt you, and you’re at a loss for what to do. Fortunately, there’s steps you can take to slow – or sometimes even stop – your hair loss.

What Causes Bald Spots?

Men don’t have the monopoly on bald spots; women can have them, too! Everyone is at risk for developing a bald spot at some time in their lives, for a variety of reasons. However, some people are at a higher risk than others. 

The most common cause of bald spots in both men and women is the hormone dihydrotestosterone, or DHT.  Both men and women produce DHT, but some people have higher levels of DHT than others. Male pattern baldness (MPB), also called androgenic alopecia, results from a combination of DHT and variation in the androgen receptor (AR) genes. Androgen receptors allow hormones like DHT to bind to them, and men with AR genes tend towards male pattern baldness. (01)

High levels of DHT can damage or shrink hair follicles, preventing hair from growing normally. The hair follicles most sensitive to DHT are located at the hairline and at the crown, which is why these areas are often the first to experience hair loss. And although DHT can also cause hair loss in women, 

But it’s not just DHT that can cause bald spots. Other factors that trigger hair loss are: (02)

  • Severe emotional stress
  • Physical stress or illness
  • Hormonal Shifts
  • Medications
  • Nutritional deficiencies
  • Age
  • Hairstyling 
  • Hairstyling products
  • Repeated physical trauma (tight hats or headbands)

The First Signs of Balding

If bald spots or male pattern baldness runs in your family, you’ve probably been on the lookout for hair loss for awhile now. Sometimes it’s difficult to tell if it’s really a bald spot or just a bad hair day. Here are a few signs that you may be experiencing bald spots or male pattern baldness:

A Receding Hairline

Hair loss typically starts at the hairline. A receding hairline may occur so slowly that you might not notice it until you have something to compare it against. For example, you might spot your receding hairline when you start looking at old photos and see that your hairline looks  different today. Your hair loss may occur incrementally, making it tougher to see.

Reduction in hair thickness

Do you notice less hair on top? Does your hair feel different when you run your fingers through it? If your hair feels finer and more airy, then it might be due to male pattern baldness or hair loss.

Loss of hair at the crown

A growing crown area is one of the first signs of hair loss, especially male pattern baldness. Most people don’t look at the back of their head, so seeing differences in your crown can be challenging. Check your crown every so often using two mirrors to check for bald spots.

How Can I Manage Hair Loss?

Experiencing balding or male pattern baldness is tough, but you do have options. The following are steps you can take to slow down hair loss.

Surgical Treatments

Surgical treatments are typically reserved for advanced cases of balding or male pattern baldness. A hair transplant, for example, is an outpatient surgery that utilizes donor hair follicles. These donor follicles are implanted into sparse or bald areas, allowing new hair to grow. These implants, called follicular unit transplantation (FUT) or follicular unit extraction (FUE), leave little to no scarring. The donor follicles typically come from your own head, but the process still requires recovery time and post-surgical care. (03)

Because surgical options are invasive, there are contraindications that may keep some people from obtaining FUT or FUE treatments, like blood disorders or the tendency toward heavy scarring (keloids). Furthermore, surgery may result in adverse side-effects like swelling, folliculitis, numbness, and infection.  (04)

Scalp Reduction 

A scalp reduction is exactly as the name implies. To perform scalp reduction, areas of the scalp without hair are surgically removed, and the areas with hair are stretched to fill over the bald portions. If you’re wondering how much of the scalp can be removed, you might be surprised to find that scalp reduction can remove up to half of the scalp. 
The skin that’s meant to be stretched is prepared and loosened, prior to stretching gently. Scalp reduction may be combined with other treatments such as FUT or FUE treatments. Some people find the recovery period from scalp reduction surgery highly uncomfortable, due to a scalp tightness that lasts for a few months as skin adjusts. Hairline lowering surgery, for example, is a kind of scalp reduction surgery. To lower the hairline, the receding portion is removed and the portion with hair is pulled forward. (05)

Platelet-Rich Plasma

A procedure called platelet-rich plasma (PRP) uses an individual’s blood and separates out the plasma using a centrifuge. This platelet-rich plasma (hence the name) is then injected into bald patches and areas of thinning hair. The plasma stimulates growth and repairs damaged blood vessels, helping hair to regrow. Although effective, the PRP process is very involved, costly, and is the newest hair loss treatment option, therefore more research is still necessary to evaluate the ideal therapeutic levels. (06)

Non-surgical Procedures

Scalp micro-pigmentation creates the look of thicker hair through the application of pigmentation that appears like hair follicles. The process includes stippling a tattoo in small dots to mimic hair follicles. Men who have thinning hair or shave their head short are the ideal candidates for scalp micro-pigmentation. However, micro-pigmentation does not grow new hair, nor is it recommended for people with large bald spots or who have major hair loss and wish to regrow hair. (07)

Least Intrusive Procedures

Once you see the signs of male pattern baldness or bald spots, it might warrant considering the least intrusive method for managing hair loss. Medicinal treatments like minoxidil and finasteride are two FDA approved medications for hair loss. When used together, minoxidil and finasteride can slow – or even stop – hair loss and regrow hair. Better yet, when minoxidil and finasteride are customized for each individual, common side-effects can be avoided. 

Dealing with Bald Spots or Male Pattern Baldness: What to Choose?

How you manage your hair loss depends entirely on what’s best for your situation. Bald spots and male pattern baldness can be a distressing event, and making a choice isn’t easy. Talk to people you know who have opted for hair loss treatments and get some perspective. Determine what’s financially feasible and speak to professionals to evaluate with options that will work with your health and lifestyle. At Happy Head, we’re ready to answer any questions you may have about our hair loss products. Let’s talk!

Resources:

(01) https://www.webmd.com/connect-to-care/hair-loss/symptoms-of-high-dht

(02) https://www.aad.org/public/diseases/hair-loss/causes/18-causes

(03) https://www.ncbi.nlm.nih.gov/books/NBK547740/

(04) https://www.ncbi.nlm.nih.gov/books/NBK547740/

(05) https://pubmed.ncbi.nlm.nih.gov/24017989/

(06) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4622412/

(07) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4382144/

When Women Get Male Pattern Hair Loss

Women can also suffer from hair loss, but there's help online to get a dermatologist diagnosis and formulation that works for you. Happy Head's dermatologists understand how female pattern hair loss works and how to help you regrow your hair.
Female pattern hair loss can progress from a widening part to overall thinning. But what happens when women get male pattern hair loss?

I met my friend Barbara (01) twelve years ago when our boys were toddlers. Barbara is a tiny woman with lots of spunk. I always thought of her as strong, smart, and confident. She called one day and confided in me that it bothered her that her hair was thinning. She had been losing hair on the crown of her head since she was in her late 20s, and she never did anything about it. She knew that I had lichen planopilaris and wanted to get the name of the dermatologist I used to treat my hair loss.  

Anyone knew just from looking at Barbara that her hair was sparse, and it took me by surprise that she hadn’t already had it checked out by a dermatologist or a hair specialist. But then again, Barbara isn’t exactly a fashionista.  She’s an elder care nurse who spends most of her weekdays in scrubs and her weekends in sweats. But still, I was surprised. Barbara visited my dermatologist, and it turns out that she has androgenic alopecia, also known as male pattern baldness. Who knew that women can get male pattern baldness? And who knew that it could start so young?

How Do Women Get Male Pattern Baldness?

Women get male pattern baldness for the same reasons men do. Also known as androgenic alopecia, female pattern hair loss is usually inherited. The condition occurs when a woman has a shorter than normal period of hair growth and a longer than normal period between when her hair sheds and grows. In some cases, women have the misfortune of inheriting smaller hair follicles and thinner strands of hair.  

Almost every woman experiences female pattern hair loss at some point in her life. Most first notice androgenic alopecia around menopause, but it can start any time after puberty begins. If anyone on either side of your family has lost his or her hair, it’s more likely that you will too. 

What Does Female Pattern Baldness Look Like?

There’s some good news if you have female pattern baldness. Women’s hairlines usually don’t recede and you won’t end up with a donut. The other good news is that women typically don’t go completely bald. Usually women with androgenic alopecia have one of three different patterns of hair loss. A bald spot can form at the crown of your head, you could lose hair along your center part, or your hair could thin all over. In some cases, hair gets so thin that the scalp can be seen.

How to Identify Male Pattern Baldness in Women

Although it’s tempting, don’t try to self-diagnose or treat yourself if you think you have androgenic alopecia. Get an appointment with a board-certified dermatologist and hair specialist. Your dermatologist may do one or several of the following:

  • Evaluate your hair loss pattern
  • Review your medical history
  • Rule out other possible causes for your hair loss, such as iron or vitamin D deficiency, thyroid disease, or another type of scarring alopecia
  • Determine whether you are producing too much androgen (male hormone)
  • Use a dermoscope or a microscope to look at the structure of your hair shaft
  • Take a small biopsy of your scalp and send it to a pathologist

Androgenic Alopecia Often Goes Undiagnosed in African American Women

Women of every race are affected by androgenic alopecia and other types of hair loss. African American women are no exception. In a 2016 survey conducted at Boston University’s Sloane Epidemiology Center, 47.6 percent of African-American women surveyed reported hair loss. (02)   

However, like my friend Barbara who noticed that her hair was thinning and didn’t do anything about it, many African-American women are not seeking treatment for androgenic alopecia. Out of the group surveyed, 81.4 percent reported that they had never consulted with a physician about their thinning hair or bald spots.

The moral of this story? If you think that your hair is thinning and have a history of hair loss on either your Mother’s or Father’s side of the family, don’t ignore it. Make an appointment with your dermatologist to get evaluated and treated. 

Do Asian Women get Alopecia?

Asian women do get alopecia, but traditionally rates have been lower than those of Caucasian or African-American women. (03) That number seems to be on the rise, though. Diet is believed to be a contributing factor.   

Early research indicates that diets rich in vegetables, herbs, and soy may contribute to hair growth and health thanks to their anti-inflammatory nutrients. (04) The traditional Asian diet, loaded with fish and vegetables, meets that criteria.  

Today’s modern Asian diet looks more like a typical American diet though, filled with processed foods. The fat, salt, and empty calories lead to higher BMI and blood sugar levels that have been linked to female pattern hair loss. (05)

 

Topical treatment by Happy Head, being piped out of the glass pipette. Each topical treatment is customized to your patient profile.

What Treatments are Available to Women with Female Pattern Baldness?

Treatments for androgenic alopecia are designed with two goals in mind:

  1. Prevent further hair loss
  2. Stimulate hair growth

Sounds logical, right? Well, it is. Here are medications that dermatologists typically prescribe:

Retinol (Tretinoin)

Retinol is derived from Vitamin A and has been found to be effective for treating female pattern hair loss when used either alone or in combination with Minoxidil. (06) Retinol has been proven to stimulate growth and improve the absorption of other ingredients that promote hair growth.

Minoxidil (Rogaine)

Minoxidil, sold over-the-counter under the name Rogaine, is a hair regrowth treatment. It works by enlarging the hair follicles and elongating your hair’s growth phase. Minoxidil is available in both a topical foam and a pill. Although the foam is available in a two percent formula for women and a five percent formula for men, dermatologists often recommend the five percent for women to use for androgenic alopecia. Any hair growth realized while using Minoxidil can be lost if you stop using the product, so it is highly recommended to use it under the care of a licensed dermatologist.

Finasteride (Propecia)

Finasteride is a prescription medication that was initially designed to treat enlarged prostates. Because it prevents testosterone from converting into dihydrotestosterone (DHT), the medicine is helpful for women with female pattern hair loss. (07)  Finasteride is available as an oral medication and as a topical solution. Many women prefer topical to avoid potential side effects.

Dutasteride (Avodart)

Dutasteride is similar to Finasteride. Both medications prevent your body from converting testosterone into DHT, which causes female pattern baldness. Dutasteride is newer to the market and is used off-label for androgenic alopecia in women. Finasteride is highly effective for most women, but when stronger medications are required, Dutasteride is a good option. (08) Like Finasteride, Dutasteride is best for women who are not pregnant or thinking about becoming pregnant.   

Spironolactone (Aldactone)

Spironolactone is an effective treatment for hormone-induced hair loss that is only prescribed to women. The medication blocks DHT production by simultaneously decreasing testosterone and increasing estrogen.

Data indicates that Spironolactone is highly effective for treating female pattern baldness. In a research study conducted, 74.3 percent of patients who were treated with Spironolactone reported stabilization or improvement in their hair loss. (09)  

Oral Spironolactone can cause low blood pressure, drowsiness, and other side effects. Topical Spironolactone, which does not go through the digestive system and is less likely to induce side effects, is often prescribed and preferred. Topical Spironolactone is often compounded with Minoxidil to help your hair grow even faster and thicker.   

Compounded Topical Treatments

If you’re not thrilled about using multiple products, all-in-one topical treatments that combine multiple medications into one are now available and can be more effective than using just one medication alone. (10)  Popular combinations are:

  • Finasteride, Minoxidil, and Retinol
  • Minoxidil and Spironolactone

Many women appreciate the convenience and ease of applying just one formula twice a day.  

With So Many Medications Available to Women With Androgenic Alopecia, How Do You Choose?

Are you confused about all of the different options? If so, that’s understandable since some of the DHT blocking medications work similarly. Thankfully, dermatologists have experience selecting the right medications for patients with female pattern hair loss. Your dermatologist will help you choose the right medication, dosage, and combination of medication based on the severity of your hair loss and your medical history.  

Remember that treatment for female pattern hair loss isn’t one-size-fits-all. Different medications work for different women. It’s common to go through a trial process to see what works best for you.  

Also, keep in mind that patience is key when treating androgenic alopecia. Medications work over time, so it may be a few months before you see a noticeable improvement, no matter which treatment you and your dermatologist choose.

Women With Androgenic Alopecia Often Need a Support System

Every woman deals with androgenic alopecia differently. My friend Barbara took her diagnosis in stride, but many women are devastated. Hair is a huge part of a woman’s identity, and losing it can take a toll on a woman’s confidence.  

If you’re having trouble coping with your hair loss, resources are available to you. Best of all, some of the resources are free. Facebook has a closed group dedicated to females with androgenic alopecia. Members share information about their diagnosis and treatment plans. Sometimes, they’re just there to tell each other that it’s okay to be sad about their hair loss. Whether it’s on Facebook, another social media outlet, or in person, support groups are a good way to connect with others who are feeling the same way as you about your hair loss situation.  

If you’re not in a good place mentally, make sure you contact a qualified psychologist or a psychiatrist. Depression and anxiety are common among women with female pattern hair loss. It’s important to seek help so you can regain your sense of self.


Resources:

(01) Name has been changed to protect confidentiality

(02) https://www.sciencedaily.com/releases/2016/03/160304093239.htm

(03) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4560543/

(04) https://www.karger.com/Article/Fulltext/504786

(05) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4560543/

(06) https://pubmed.ncbi.nlm.nih.gov/3771854/

(07) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7060023/

(08) https://pubmed.ncbi.nlm.nih.gov/25382509/

(09) https://www.jaad.org/article/S0190-9622(15)01878-2/fulltext

(10) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4314881/