Specific Male Pattern Baldness (MPB) Myths

Myth: MPB and shedding are synonymous

No, but shedding is a part of MPB. MPB and shedding should not be used interchangeably to describe a cause of hair loss. MPB, which entails miniaturization of the hair follicles, is the result of one's genetic predisposition and is the result of very complicated and incompletely understood biochemical reactions in the cells that comprise the hair follicle. This miniaturization results in progressively thinner hair in a symmetrical pattern typical of MPB. There is no loss in the number of hairs on the scalp, but there is a loss in the quality of the hair on the scalp. On the other hand, shedding is a part of the normal cycle of hair growth. The hair shafts on the scalp will spontaneously shed at the end of the telogen (resting) phase. If you shampoo, brush, or pull on hairs in the telogen phase, they will dislodge easily. The same is not true for hairs in the anagen (growing) phase. Hairs in the anagen phase are firmly rooted and are difficult to dislodge.

Myth: There is a medical cure for MPB

Unfortunately, this is not a myth. Hair transplants can nicely disguise MPB and medical treatment or the combination of surgical and medical treatments may be excellent temporizing measures. However, none of the treatments for MPB currently available offer a permanent cure for MPB. They can prevent and/or partially reverse the process of MPB, but we're only buying time. The five-year studies on the effects of finasteride and topical minoxidil on scalp hair show that there is a dramatic difference between patients continuing on these medications and patients who did not treat their MPB at all. Untreated patients almost invariably showed progressive thinning and/or recession of their hair, whereas patients on treatment kept most of their hair. However, as compared to their own results at the end of two years, the patients who remained on treatment had slightly less hair at the end of five years than they did at the two-year mark. These two and five year results were qualitative and represented self-assessments by the patients.

Myth: An over active sex life will cause or exacerbate MPB

Not true. There is no correlation between a hyperactive sex life or masturbation and hair loss, just as there is no direct correlation between the serum testosterone level and MPB. In the adult human male, there is a very wide 'normal range' for serum testosterone (300-1200 ng/dL), but there is no direct relationship between the testosterone level and MPB.
However, it is a long established fact that there is a correlation between MPB and DHT (dihydrotestosterone), which is why many of the treatments for MPB include decreasing the amount of DHT in the scalp that can affect the hair follicles. The rate-limiting factor in the production of DHT is primarily the amount of the enzyme 5 alpha reductase available to convert the testosterone to DHT. So, having more testosterone in the body does not necessarily mean there is also going to be more DHT.

Myth: Only men experience pattern baldness

Not true. In reality, pattern hair loss is just as common in women as it is in men, though the degree of loss, the age of onset, and the overall pattern usually differs in women as compared to men. Statistically, after the teenage years, the incidence of MPB is reflected by the decade in life, i.e. 20% of men in their 20's are affected by MPB, 30% of men in their 30's are affected by MPB, etc. By the age of 50, over 50 percent of men have significant hair loss. For women, about 25 percent have significant hair loss by the age of 50, though it may be less apparent because women are more conscientious about hiding it than men are.
The areas of pattern baldness are also different in men and women. While men have a tendency to first lose hair in the frontal, temporal and/or vertex of the scalp, pattern baldness produces thinning hair diffusely throughout the scalp with sparing of the frontal hairline.

Myth: MPB is always a gradual process

For most men, MPB is a gradual process, but it can occur with devastating suddenness as well. The sudden massive shedding will cause the next generation of hair to have considerably less texture and body, sometimes to the point of appearing as vellus hairs. These hairs will have shortened anagen phases. The affected areas are confined to those areas of the scalp where the hair follicles have active and sensitive androgen receptor sites, i.e. the vertex, crown and frontal regions.

Myth: Taking anabolic steroids exacerbates MPB

If you do not have a genetic predisposition for MPB, then taking anabolic steroids will not cause hair loss. But, if you do have a genetic predisposition for MPB, then taking anabolic steroids can accelerate MPB. Even though anabolic steroids are not androgens per se, the body can convert them into androgens.

Here's an excerpt from an article by Dr. David Whiting, a widely acknowledged leading researcher/dermatologist: "Testosterone and dihydrotestosterone can circulate systemically to follicles, or be manufactured locally in the follicle from circulating weak androgens (dehydroepiandro-sterone and androstenediol) via complex enzyme-mediated processes involving specific dehydrogenase and reductase enzyme pathways. All of these enzyme reactions are dependent upon specific pyridine cofactors. It is clear that reductase, dehydrogenase, and probably aromatase enzymes are of major importance in hair growth as they mediate the complex interchange of sex hormones implicated in anagen activity."

Myth: MPB can occur anywhere on the scalp

Not true. If hair loss occurs on the back of your scalp, above the ears, in patches, or is brittle, then you have hair loss due to causes other than MPB. MPB is not a matter of losing hair, i.e., shedding. Shedding 50-100 hairs/day is normal. MPB is a matter of atrophy or miniaturization of the hair follicle due to a combination of genetic predisposition of the hair follicles and the presence of DHT. Embryologically, skin in the frontal, temporal, crown and vertex of the scalp derives from a different set of germ cells than does the skin on the sides and back (occiput) of the scalp. The hair follicles in the sides and back of the head do not contain androgen receptors and consequently do not become affected by DHT or involved in the process of MPB.

Myth: MPB can occur in infants and children

MPB would never occur before puberty. Why? MPB is the common name for alopecia androgenetica, a name that emphasizes that the cause is related to androgens and genetics. Androgens are not produced in the body until puberty, so MPB can become noticeable as early as the onset of adolescence. Our youngest patient is 13 years old. Unfortunately, early onset portends an ultimately severe case of MPB.

Myth: The causes of MPB in women are the same as in men

This is a very controversial subject. Women normally have only 1/10 the levels of DHT as do men, yet women also suffer from MPB. The age of onset is later than in men. The pattern of involvement is diffuse as opposed to the typical MPB pattern in men. The frontal hairline is usually preserved. And finasteride has not proven to be helpful in treating post-menopausal female patients. But, the underlying pathophysiology is probably basically the same. When you consider causes for hair loss other than MPB, there are more medical conditions causing hair loss in women than there are for men. These reasons include iron deficiency, menopause, post partum telogen effluviums, etc.

Myth: I should wait until my MPB gets worse before treating it

This is a difficult myth to refute because neither the age of onset of MPB, nor the rate at which the MPB will progress nor the final extent can ever be predicted. However, as a general rule, the earlier MPB is treated, the better the positive results will be.
A report from Moscow Medical University stated that there is some fibrotic encapsulation (irreversible hair loss) to the hair follicles 30 months from the onset of alopecia androgenetica occurred in some patients. Their conclusion was to prevent loss by treating alopecia androgenetica when the first signs of alopecia androgenetica appear.
Any of the medications for treating MPB work best if the hair loss has been within the past few years. For a patient with recent hair loss, the reversal of MPB is usually quite successful, if the patient uses a combination of a medication to promote hair growth (topical minoxidil) along with a medication or medications to inhibit the quantity of action of DHT in the scalp. Examples of such effective and safe medications include finasteride, azelaic acid, topical spironolactone and topical ketoconazole.

Myth: The frequency of shampooing has an effect on the rate of MPB

This is a qualified true and false statement. If you use a shampoo containing ketoconazole that can effect the biochemical environment around the follicles, then it is possible to reverse hair loss. Any other shampoo will remove DHT from the surface of the scalp, but they are of no benefit in preventing MPB because it is the DHT around the hair follicle that is causing the damage. These shampoos and conditioners cannot change the biochemical environment around the hair follicles, which is deep in the dermal layers of the scalp. Otherwise, whether you never shampoo or shampoo daily will not affect the age of onset or the rate of progression of MPB.
Shampoos are designed to clean the hair and leave it manageable and looking good. If they do that for you, it's as much as you can ask for. Other than shampoos containing ketoconazole, which have been shown to reduce DHT in the scalp, shampoos really have no effect on hair growth or loss. See also A.2 Myth: MPB is caused by plugged pores.

Myth: MPB is associated with pain or other scalp sensation

No, but there is a cause of telogen effluvium associated with scalp pain. The biochemical processes that result in MPB are not accompanied with any physical sensation. If you are experiencing scalp pain, it may be a good idea to have a dermatologist examine your scalp.
An article in the March 1998 issue of Archives of Dermatology describes "Scalp Dysesthesia". Some individuals who develop a telogen effluvium report painful burning sensations in association with excessive shedding of the hair. Until recently this problem was not officially identified by dermatologists. The syndrome has been called "scalp dysesthesia" or "burning scalp syndrome". The cause of burning scalp syndrome is unknown. It has been successfully treated by some dermatologists with antidepressants such as doxepin or amytryptaline.

Myth: Pattern Baldness Comes from Your Mother's Side Only

Yes and no. It's an enduring and common misconception among patients that MPB is 'inherited from the mother's side'. Well, that statement is neither right nor wrong. Pattern baldness can be inherited from the mother's side. But it can also be inherited from the father's side.
Despite the fact that the entire human genome, comprising approximately 30,000 genes in the human DNA, was completely mapped out as of April 2003, the gene or, more likely, genes responsible for MPB, have not been identified. What is known is that the age of onset, the rate of progression, and the pattern of follicular miniaturization are all influenced by heredity. Generally, the earlier the onset of balding, the more extensive the degree of hair loss will eventually be.
Considering the high proportion of men affected by MPB, its distribution in the general population, the increased risk of MPB as the number of affected close relatives increases, and the high risk of inheritance from either or both affected parents, one can support a strong argument in favor of an autosomal, polygenic inheritance.
It seems ironic that with all the knowledge that has been accumulated in regards to MPB in the past several decades, we still do not know the exact genetic inheritance of MPB. What is known is that the genes are autosomal (not on the X or Y chromosomes), dominant (as opposed to recessive), and have variable penetrance (so it may not affect siblings of the same parents to the same degree).
However, in a recent article on WebMD (http://webcenter.health.webmd.netscape.com/content/article/106/108259.htm) entitled "Blame Male Pattern Baldness on Mom?" the authors have found a gene variation that may explain some cases of MPB. The suspect gene variation sits on the X chromosome, which is handed down to men by their mother. It had been previously presumed that the genes involved in the transmission of MPB were always autosomal.
The genes for hereditary hair loss are carried on both sides of the family. And the tendency to hereditary hair loss can skip generations. If many close members of the family are afflicted with MPB, the greater the likelihood is that you will also have MPB. On the other hand, if they all have full heads of hair, it's likely you'll keep yours as well.

Myth: MPB reduces the number of follicles on the scalp

Wrong. MPB results in a change in the texture and the quality of the hair. MPB does not change the number of hairs on the scalp. You are born with ~100,000 hair follicles in the scalp, and you keep that same number of hair follicles throughout your lifetime.
The sizes of the hair shafts are directly related to the sizes of the hair follicles from which they are growing. During any single anagen (growing) phase, the size of the hair shaft will remain essentially the same for its entire length. When a hair follicle is affected by MPB, the hair shaft will become thinner in the subsequent growth cycle, because the follicle begins to miniaturize.
It is not unusual for a sudden, dramatic, extensive miniaturization of an area of scalp within a single hair growth cycle. This phenomenon explains the recession of the frontal hairline and/or the temples. The number of hair follicles remains the same, but the vellus-like hairs that they produce make them 'invisible'.