What is it?

Most men don't need to be told — it's the loss of hair resulting in decreasing coverage of the scalp.

What are the main symptoms?

Male pattern baldness (also known as genetic hair loss or alopecia androgenetica) is the most common form of hair loss in men. It usually develops very gradually, typically involving the appearance of a bald spot on the crown of the scalp accompanied by thinning at the temples. Although this problem can strike any man at any time, many first become aware of it as they approach their thirties.

What's the risk?

• Two-thirds of all men will eventually be affected by male pattern baldness — in the UK, this means that 7.4 million men are losing their hair at any one time.
• There are racial differences, however, in the incidence of male pattern baldness. The highest rates are found among Caucasians, followed by Afro-Caribbeans. Chinese and Japanese men have the lowest rates. For some unknown reason, this form of hair loss is does not occur among Native Americans.
• Male pattern baldness runs in the family. If your grandfather, father or brothers went bald early, the chances are that you will too. The strongest influence is on the mother's side: if your maternal grandfather went bald, that's probably a better indicator that you will too than if your father's father lost his hair.

What causes it?

There is only a tiny grain of truth in the myth that bald men are more virile because they have more of the male sex hormone testosterone.

This idea probably grew from the observation that eunuchs never became bald and, having being castrated, they didn't, of course, produce very much testosterone.

Yes, testosterone is involved in male pattern baldness, but its relationship with hair loss is complicated and not completely understood. Testosterone is naturally converted in the body to a related sex hormone, dihydrotestosterone (DHT). This stimulates the growth of facial and body hair, as well as acting on the prostate gland. There is good evidence that male pattern baldness results from an over-sensitivity of scalp hair follicles to DHT, rather than raised levels of either sex hormone in the blood. As with pretty much everything, there's probably a link to smoking.

How can I prevent it?

You cannot prevent male pattern baldness, although there may be ways of slowing down the process or disguising the problem.

Is it such a big deal?

Since male pattern baldness is related to testosterone production, the only sure fire cure is castration before puberty which curiously enough few men opt for.

But hair loss never killed anyone and some of the sexiest men on the planet – according to sources male and female - have little or no hair.

If you’re really struggling to come to terms with baldness, talk to someone. Hair loss may be a trigger to unhappiness and depression but it’s unlikely to be hair loss alone that is behind your feelings.

The bald and proud site Bald R US has a hall of fame. It’s very US-oriented but includes Shakespeare, Churchill, Sean Connery, Samuel L Jackson and Patrick Stewart. 

Should I see a doctor?

• To get advice and treatment for hair loss, you should always start with either your GP or a professionally qualified trichologist.
• Until very recently, male pattern balding was seen as a natural process and you may find your doctor to be neither sympathetic nor helpful if you consult him/her about it. But things may be changing. An increasing number of doctors realise that hair loss can have psychological consequences that significantly diminish quality of life, especially for younger men, and they may be more willing to take the problem seriously.

If you are lucky enough to have an enlightened GP, by all means seek their advice — at the very least, you'll get a referral to a reliable trichologist (although you'll probably have to pay for any treatment you receive).

A trichologist, by the way, is a hair specialist whose training covers both the cosmetic and the medical aspects of the subject. Some trichologists are also trained hairdressers, but they are not usually medically qualified. The Institute of Trichologists keeps a register of properly qualified people: look for the letters AIT (Associate), MIT (Member) or FIT (Fellow) after their name.

Other types of hair loss, such as alopecia areata, are taken seriously as medical conditions and you should seek your GP's advice as you would for any other medical problem.

What are the main treatments?

There is no cure for male pattern baldness, but there are both drug and surgical treatments available which may lead to some improvements.

Minoxidil (sold as Regaine)

• This is the only topical treatment (one that you rub into the skin) which is actually licensed for the treatment of male pattern baldness in the UK. It was originally developed (in tablet form) as a drug for high blood pressure. Doctors noticed that people on minoxidil sometimes grew new hair, so the drug was reformulated for this purpose.
• Regaine comes as 2% or 5% lotions which you rub, daily, into your scalp. It is best to start with the 2% lotion and after three months, if  you have not seen significant growth of hair, upgrade to the 5% lotion. In the UK, Regaine is a Pharmacy Only medicine, which means you can obtain it from a pharmacy without a prescription, but only when a pharmacist is on the premises. The pharmacist should check that Regaine is appropriate for you before selling it (for instance, you shouldn't use it without medical supervision if you have high blood pressure).
• Regaine cannot work miracles. About one-third of men using it get good hair growth on the bald patches, one-third get a fine, downy regrowth, while the rest will get little or no response. The majority of men using it find that at least they don't lose much more hair — but as soon as you stop using it, hair loss resumes its course.
• Expect to wait up to four months before you get any response from Regaine (be patient), but if nothing happens after, say, a year, you may as well give it up. Incidentally, never pay large sums of money to a private trichologist or over the internet for Regaine — the usual price is around £30 for a month's supply.

Finasteride (a generic version of the medicine formerly marketed as Propecia or Proscar)

• This is a treatment for male pattern baldness which is licenced in the UK but only on private prescription, not on the NHS. It is one of a class of drugs called 5-alpha-reductase inhibitors. Since 5-alpha-reductase is the enzyme which causes the conversion of testosterone into DHT, inhibiting this with finasteride should, in theory, stop hair loss. In fact, finasteride was originally developed for the treatment of benign prostatic hyperplasia (BPH), a condition in which the prostate gland becomes enlarged through the action of DHT.
• Although there have been no clinical studies directly comparing low dose finasteride and Regaine, the data suggests that the two products may be similarly effective as a treatment for hair loss. Finasteride can lead to side effects in up to 2% of users such as impotence, reduced sex drive and reduced semen volume. (These side-effects are reversible when the treatment stops.)
• Finasteride can be obtained from your GP or dermatologist on private prescription. (In October 2014, the patent on Propecia/Proscar expired meaning that any drug manufacturer can sell a generic version of finasteride. The treatment should get cheaper.)

Anti-androgen therapy

• Another way of tackling male pattern baldness is to directly block the action of DHT using a variety of hormonal drugs. Some of these are similar to oral contraceptives and female hormone replacement therapy. They should only be applied under the supervision of an endocrinologist (hormone specialist) or a dermatologist with expertise in hormone therapy.

Hair transplant surgery

• Surgery offers the possibility of a longer-term solution to your hair loss problem. But it doesn't come cheap and it can be hard to find a skilled and reputable surgeon. Put simply, hair surgery involves rearranging your scalp skin so as to minimise the bald areas and maximise those where hair is still growing.
• In the UK most hair surgeons use grafts, which involves transferring skin from the hair-bearing area at the back of the head to the bald parts at the front. Hair grafts work because the section of skin transferred retains its own characteristics (i.e. hair grows) rather than acquiring those of the place it is transferred to (where hair does not grow).
• The most natural results come from transferring plugs of skin bearing 3—6 hairs (minigrafts) or just one hair (micrografts). The surgeon makes tiny slits or pinholes in the recipient area into which the plugs are inserted. A new hairline can be built up by using rows of micrografts at the front and minigrafts a few rows further back.
• When considering surgery, you must remember that your hair loss could well continue around the reconstructed areas. This may look unsightly unless you're prepared to invest in further surgery in a few years time.
• Hair surgery usually involves considerable financial investment and you are also involving yourself in a medical procedure. So choose your surgeon carefully, preferably via personal recommendation or through the Institute of Trichologists. He or she should carry one or more of the following qualifications:
  • FRCS (Fellow of the Royal College of Surgeons)
  • BAAPS (British Association of Aesthetic Plastic Surgeons)
  • BACS (British Association of Cosmetic Surgeons)

  Remember, a good hair surgeon probably doesn't need to advertise.

Other treatments

As far as other treatments are concerned, be very wary. There are many bogus operators out there who are only too keen to exploit people with hair loss.

How can I help myself?

Making changes in your hair care routine and overall lifestyle may help minimise the appearance of hair loss.

• Treat your remaining hair with a bit more respect. Most people are too rough with their hair. It's better to use a comb, not a brush, and to avoid tightly fitting caps or hats. Hair is more fragile when it's wet, so handle it with care.
• Some shampoos and other hair cosmetics can make your hair look thicker and fuller. Ask your hairdresser for advice.
• Short hair minimises the contrast between balding and non-balding areas. Long hair has the reverse effect and is very ageing. It shouldn't need saying, but combing hair over a bald spot is not a good idea.
• Include sufficient protein in your diet, especially if you are vegan or vegetarian (hair loss sometimes starts when people give up meat). Ensure that you do not become anaemic by eating plenty of iron-rich foods like liver, eggs and green vegetables. Find out about a healthy diet.

What's the outlook?

There's no cure for male pattern baldness, although other forms of male hair loss are often reversible.

Who else can help?

Alopecia UK

Institute of Trichologists

First Drafted by Dr Susan Aldridge. Revised 2014 by Keir Stone-Brown.

MAIN IMAGE: created from images by Steve Rogers (Woody Harrelson), Jeremy Thompson (Samuel L Jackson) Eric C Salkor (Joseph Fiennes) and Gage Skidmore (Bruce Willis) licensed under CC BY 2.0 unless otherwise indicated on link.

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