The bald truth about baldness cures

Death, taxes, and baldness—they all loom like anxiety-inducing storm clouds that (usually) aren’t as menacing as they seem, but nevertheless reliably inspire drastic solutions that are both risky and unrealistic. The stakes for curing male pattern baldness (MPB) ¹ in particular are very low, but the afflicted have still been searching for a cure since literally ancient history.

Caesar and Hippocrates

Julius Caesar had gone almost completely bald by the time he met Cleopatra, who recommended to him a homemade topical solution that included icky ingredients such as bear grease. Like 99.9% of all such remedies throughout history, it didn’t work. To compensate, Caesar combed his hair forward and wore a wreath whenever possible.

George Bernard Shaw dramatized this situation in his play Caesar and Cleopatra:

CAESAR: What are you laughing at?

CLEOPATRA: You’re bald (beginning with a big B, and ending with a splutter).

CAESAR: (almost annoyed). Cleopatra! (He rises, for the convenience of Britannus, who puts the cuirass on him.)

CLEOPATRA: So that is why you wear the wreath—to hide it.

Going even further back, the Greek physician Hippocrates was famously bald, such that the hair that conventionally bald men don’t lose—i.e., the continuous patch around the back and sides of the scalp—is called the “Hippocratic wreath.”

But Hippocrates did realize something that even many people today don’t: That MPB is not skin-deep, and as such it can’t be completely solved through topical solutions like the Cleopatra concoction, because they don’t address its root cause, which is systemic and has to do with how testosterone moves through the body. ²

The (literal) root cause of MPB

Testosterone is constantly being converted to a more potent hormone called dihydrotestosterone, or DHT, by an enzyme called 5-alpha reductase (5AR). This sex steroid is vital for development. At the same time, it gets into hair follicles and, if those follicles on the top and front of the scalp are genetically susceptible to MPB, DHT shrinks them.

This process is called miniaturization. The hair follicle narrows, so that each time the hair sheds and grows back as part of the hair growth cycle, it grows back thinner, until it’s so thin it’s invisible to the naked eye.

So baldness isn’t the manifestation of hair falling out, but of hair failing to regrow at its previous thickness. People who aren’t bald have hair fall out every day, too, but it comes back at the same thickness, so there’s no cosmetic difference.

To halt or reverse MPB, any remedy must do one of the following:

• Inhibit T-to-DHT conversion
• Induce hair growth to such a degree that it outstrips the miniaturization process

Moreover, it must work on hair that’s still visible. Indeed, and ironically, the more hair you have, the better the results of any baldness remedy. Subtly miniaturized hair is the prime candidate for a turnaround story, whereas if someone is “shiny” bald, these drugs can’t help them—there needs to be some still-substantial hair remaining to actually save.

What does work, and why

Very few solutions—like, a single-digit number of them—meet those requirements. I’ll run through them now.

5AR inhibitors

There are two drugs in this class:

• Finasteride: Brand name Propecia (1mg, for MPB) or Proscar (5mg, for benign prostatic hyperplasia, or BPH ³)
• Dutasteride: Brand name Avodart, for BPH; not explicitly approved for MPB in the US, but is elsewhere

These drugs dramatically inhibit DHT conversion. Finasteride can reduce DHT levels in serum by over 70%, whereas dutasteride can reduce it by over 90%.

In practice this inhibition means they halt hair loss pretty quickly, but don’t always spur regrowth. And to truly save someone’s follices, a 5AR inhibitor must be taken indefinitely. ⁴

These drugs definitely work, but at what cost? If you do any amount of research on them, you’ll soon learn that physicians think side effects are “rare,” or that they’re most prevalent early on but subside with time. At the same time, there’s a constantly flowing stream of posts on the r/tressless subreddit as well as a similarly steady beat of research articles about how such effects—which are often both psychiatric and sexual—may be both persistent and significantly underreported relative to their actual occurence.

For that reason, there’s been a relatively recent push for topical finasteride, with the logic that if applied directly to the scalp rather than taken by mouth, it’ll have less systemic absorption and therefore fewer side effects. However, even topical variants do lower serum DHT somehow, so it’s unclear whether they’re truly safer, and they seem to be less effective than the systemic options.

Note that if you ever get a modern hair transplant, you may have to take a 5AR inhibitor to preserve the newly moved hair, even though it’s often assumed to be “permanent.”

Minoxidil

In the 1950s, the Upjohn Company began development of what it hoped would be a treatment for ulcers. That treatment, named minoxidil, didn’t work for that purpose, but it was a potent vasodilator and eventually found a niche in the late 1970s as the branded blood-pressure medication Loniten.

Patients taking Loniten noticed hypertrichosis, or rapid hair growth, and it wasn’t long before doctors began prescribing it off-label for MPB. In 1988, it was reformulated as a topical lotion under the brand name Rogaine. Over the next 30 years, Rogaine underwent multiple cycles of refinment, having its strength boosted from 2% to 5%, becoming an OTC medicine, being reformulated as a less-greasy foam, and becoming available as a store brand from basically every chain store that sells medicines of any kind.

Minoxidil preserves and stimulates hair growth in a different way than the 5AR inhibitors do. It’s less effective overall than they are, and it can usually only outrun aggressive MPB for a few years before losing the race. But when administered topically, it has no systemic side effects unless mixed at a double-digit active ingredient concentration, in which case it may cause hypotension. Like the 5AR inhibitors, it must be used indefinitely.

In 2022, The New York Times published an article on a trend that many in the hair loss treatment community had known about for years—taking minoxidil orally at very low doses, instead of applying it topically, because:

• As with 5AR inhibitors, the systemic route is more effective.
• There’s no grease or wetness to deal with in the hair.

The oral route is risky in ways the topical one isn’t, though:

• At such low doses (i.e., <1 mg), it needs to be compounded. Unfortunately, many pharmacists err when compounding, and the dose is too potent, leading to…
• …syncope, weight gain, and fluid retention, all of which are well-known minoxidil side effects that contributed to it being relgated to the less-used tiers of BP medicines long ago.

In brighter news, minoxidil offers a reliable remedy for women, who generally don’t respond to finasteride.

LLLT

Low-level laser (light) therapy (LLLT) is the process of shining a light, often a 650nm ⁵ red one, on an area of the body in hopes of stimulating growth or healing. For hair loss in particular, LLLT devices are designed as either combs or helmets used or worn 3-4 times weekly.

Their mechanism of action is different from the two treatment categories above, which mean that using LLLT in conjunction with 5AR inhibitors and minoxidil is likely to produce the most noticeable overall effects. Apparently, it helps stimulate cell growth and shifts hair into the anagen phase, when it’s still growing and not on the verge of being shed.

Hair grows in an anagen-katagen-telogen cycle. After a hair gets sheds in the telogen phase, it should then restart in the anagen phase. In MPB, it may cease to go back into this phase, or do so only at dramatically reduced width and length. LLLT and minoxidil both seem to reignite and extend the anagen phase.

Of all the treatments outlined here, this is the one that feels the most quack-ish to me. Lasers! To regrow your hair! But the evidence for its efficacy is substantial. It seems to be even more potent than minoxidil and not that far off from the 5ARs.

PRP

Platelet-rich plasma (PRP) injections involve someone taking a sample of your blood, spinning it through a centrifuge, and then reinjecting the ensuing protein-rich mixture into your body at a target site. The late Kobe Bryant was a pioneer of this treatment, albeit for his knee, not for his hair.

PRP can stimulate cell activity almost anywhere it’s applied, which makes it a popular cosmetic treatment. For hair, it seems to do something similar to LLLT and minoxidil, and it has a leg up on both of them when it comes to convenience—you only need two injections or so a year, instead of a daily or every-other-day regimen.

Herbal supplements and diet

Now we’re in a grayer zone, and nearer to Cleopatra’s “natural” solution. Many naturally-occuring compounds have been proposed as possible baldness cures. Some people even go so far as to say that diet can materially affect hair loss, a claim that doesn’t seem to hold up.

By far the herbal supplement most recommended for MPB is saw palmetto extract, a compound made from the berries of a dwarf palm tree. Hypothesized to work as a perhaps milder 5AR inhibitor without the grim side-effect profile, saw palmetto extract is backed by some evidence, but there’s not definitive proof that it works. Oddly, it seems to work better for MPB than for its more commonly associated use case, BPH.

The future

Baldness treatments can feel like the will o’ the wisp—always just over the horizon but impossible to reach. Hair multiplication, side-effect free topical or oral treatments, gene therapies and so on are always proposed but turn out to be ineffective in real life.

This topic has always interested me because of the diverse range of hair outcomes in my own family, from early onset shiny baldness to troubadour-esque hair into old age. I feel like there’s a lesson here in how despite immense demand and years of research, there still isn’t a foolproof permanent solution to hair loss—in fact Caesar’s own strategy of just wearing a wreath and doing a combover is still simpler, cheaper, and less side effect-prone that anything invented since.