Understanding the Principles of Treatment

Many men and women with hair loss are under the impression that the most effective treatment is hair transplant surgery.  Hair transplants are only required if the thinning has advanced to the stage of balding.  As long as follicles are still present under the skin, they have the potential of responding to non-surgical treatments.  Many of the follicles are still producing hairs that are very small and cannot be seen with the naked eye.  But as long as the follicle remains, the follicle is capable of responding to drugs and devices that have been established as effective by the FDA.


Drugs and devices actually work!  Over the years, there’ve been so many phoney treatments and scams, that much of the public finds it hard to believe that hair loss treatments (other than transplants) are actually effective.  Well the good news is that they are.  And their efficacy has been confirmed by the FDA.


Patient selection is important if the treatment is going to be successful.  In situations of mild to moderate thinning, the miniaturized hairs are still present, but they are growing only 12, 24, or 36 months of their normal 48-month cycle.  They are only “above the skin” a small percentage of the time.  When minoxidil, finasteride, and laser treatment is begun, all hairs (both normal and miniaturized) remain in their anagen growing phase for 48 months of the 4 year hair growth cycle… or longer. So that technically, a “new” hair is not produced. What happens is that the miniaturized hair with its short anagen cycle hair grows non-stop for 48 months, instead of just for a few months of the 48 month cycle.


Eventually, as the follicle stays in continuous growth, the diameter progressively enlarges and the hair mass increases even more.  But, if no follicle is present (as in very advanced thinning or advanced balding) there is no follicle for the treatment to influence and the only alternative is hair transplantation.  Clearly, starting treatment at the very first sign of thinning (miniaturization) is the most effective approach because the follicles are still alive and responsive.


The treatment of thinning has its drawbacks.  Unless it is continued indefinitely, the hairs that have been switched into continuous anagen will enter their telogen phase when the treatment is discontinued.  In the case of minoxidil and laser, all the hair that was not lost during the treatment phase will be lost within 6 months.  In the case of finasteride, the grace period is about 12 months. Because the drug must be taken indefinitely, the concerns regarding safety become more important.  This is one of several reasons why there are not more drugs to grow hair.  Minoxidil, finasteride, and laser have been well tested and found to be safe.


Several forms of thinning and shedding are the result of medical problems like hormone imbalance, thyroid hyperactivity, iron deficiency, etc.  In these situations, the problem itself, when corrected, will result in the re-growth of hair, i.e iron supplement, etc.   Drugs and lasers are usually not required.




Because the cause of hair loss in women is sometimes hormonal – either ovarian, adrenal, or pituitary in origin — it is often responsive to hormonal therapy.  Some of the treatments are quite effective.  If our female patients have a hair loss disorder that would benefit from hormonal replacement or adjustment, we will work closely with the patient’s endocrinologist to solve the problem.  Hormonal treatments may be taken internally or topically applied.


Female hormones will stop balding in men, but will cause feminization. For this reason, estrogen is not given to male patients with balding – either topically or internally.





BACKGROUND — Minoxidil is not a hormone. Like many great advances, the power of minoxidil to regrow hair was discovered by chance. In the 1980s, scientists discovered that minoxidil showed signs of re-growing hair even though it was being studied for treatment of hypertension. This discovery led to the release of Rogaine, the first FDA-approved to regrow hair. Rogaine is available in liquid 2% and 5% and in a 5% foam as well.  In the past few years when the patent expired, minoxidil has become available as a generic – in liquid only – in 2% and 5%. Minoxidil will stop the hair from miniaturizing in both the front and top of the head.  In terms of re-growth, it is most effective on the back of the scalp. Minoxidil will not re-grow hair on a scalp if residual viable follicles are absent.  LINK TO ROGAINE.COM (external)








DISADVANTAGES — One of the major disadvantages of minoxidil is that it must be applied to the skin twice a day.  If not carefully applied it can grow hair on the faces of women if it should contact the cheeks and forehead. If not carefully applied to the scalp skin alone, it can get on to the hair and make it greasy and dirty. Some patients experience a skin irritation from the minoxidil as well.


CUSTOM-COMPOUNDED MINOXIDIL — We have tried to deal with these issues by engaging a compounding pharmacist to prepare minoxidil, either 2% or 5% in an alcohol/water base which is non greasy.  To that custom-compounded formula we can add a prescription drugs that reduces the risk of local inflammation, or add other drugs that will increase the penetrability of the minoxidil so that it can be used only once a day.


LONG TERM USE Minoxidil must be applied daily to the scalp, and continued indefinitely.  If for example, after using the minoxidil for 5 years, the patient stops using it… all the hair that would have fallen out in those 5 years will fall out in about 6 months.





BACKGROUND Propecia 1 mgm. (Merck) is a once-a-day pill for the treatment of hair loss in men. It was introduced in February 1998. In a five-year study, 90% of balding men showed no decrease in their hair counts. The amount of hair growth that one can expect is variable, with moderate to significant re-growth in about 15%.Chemically, it is finasteride, a pill that is used in 5 mgm doses for patients with prostate enlargement. Finasteride appears to be quite safe and has been on the market for years. Propecia can cause sexual dysfunction, i.e impotence and decreased libido in about 0.5% of patients who use it. The drug has proven not to work for women with pattern hair loss, and should not to be used by women in child-bearing years. Men using Propecia can safely impregnate females with no fear of fetal abnormalities. A new drug called dutasteride (Glaxo) is being used much in the same way Propecia is used. It has been reported as being more effective, but it has a higher percentage of side effects. Its use in hair loss has not been cleared by the FDA.


DISADVANTAGES — There has been some recent press about long-term impotence resulting from the use of finasteride.  The studies are non-conclusive, but concerning nonetheless. Patients who experience erectile dysfunction while taking finasteride should not take Cialis or Viagra to overcome the problem.  The finasteride should be discontinued and an alternate hair re-growth preparation used.  LINK TO PROPECIA.COM (external)








THE HAIRMAX DEVICE  is a low-powered cold laser that’s been cleared by the FDA and approved as effective for the treatment of hair loss.  It is a hand-held device that contains 8-12 individual 650nm 5mW laser diodes (depending on the model). The hand-held laser device is slowly passed over the balding area for 20-30 minutes every other day.  The manufacturer has reported an increase of additional hair in the range of 17-20%.  This is the same range of improvement one would expect with the non-enhanced minoxidil products.  HairMax is sold directly to consumers from the manufacturer’s website.  LINK TO HAIRMAX.COM (external)













THE LASERCAP DEVICE is more high powered — with 224 individual 650nm 5mW lasers in a flexible, hermetically-sealed dome-shaped membrane that fits comfortably in almost any hat, and powered by a small belt-clip battery pack.  It may be used at home or while driving in the car.  It is essentially hands-free.

The LaserCap uses the same laser diode wavelength and output power per laser as an FDA-cleared HairMax device however, the LaserCap has 224 laser diodes versus 8-12 laser diodes. The LaserCap maximizes patient compliance since it is worn under any head cover (baseball cap, scarf, etc.) and is portable because of its small belt-clip battery pack.  LaserCap is prescription-only by physician.  The patient is given a prescription that he or she signs, and the Rx is sent by the physician to the vendor who then contacts the patient and arranges for payment and shipping.  LaserCap comes with a 75% money-back guarantee, if after one year the patient is not satisfied with the results.  LINK TO LASERCAP.US (external)





Hair transplantation is reserved for men and women whose hair loss had advanced to the stage where the follicles are no longer present.  The transplanted hair will continue to grow for the patient’s entire life.  Transplants may be performed on scalps that still have existing hair – by placing the transplanted hairs between the existing hairs.  Patients who receive transplants must continue on either minoxidil, finasteride, or laser or else the original hair will continue to miniaturize.


Dr. Cohen, performed transplant surgery for over 30 years, no longer performs the procedure.  If hair transplant surgery is indicated, the patients will be referred to a hair restoration surgeon who performs only the highest quality work.