Male Pattern Baldness

Posted on July 7, 2008

Treatment options include reassurance, hair prostheses, surgery, and topical and/or oral medications. This section faculty of volition concentrate on pharmacologic management. In general, the earlier treatment is begun, the more completely the results.

MinoxidilTwo-percent minoxidil solution was approved by the Food and Drug Administration (FDA) for use in the manner that a topical prescription treatment of MPB in 1988, and this medication became available over-the-counter (OTC) in February 1996. Five-percent minoxidil was released directly OTC in January 1998. Minoxidil is believed to work by direct stimulation of the hair follicle or less likely by vasodilatation of scalp blood vessels. It may do this by upregulating the lively representation of vascular endothelial growth middleman in hair dermal papilla cells. Increased vascularization of the dermal papilla occurs for the period of the anagen phase. Minoxidil, not cyclosporin, another potent cause of hypertrichosis, induces DNA synthesis in aggregate hair follicle cells in a dose-dependent manner. Other epidermal and dermal cells show either suppression or no growth response to minoxidil.

When applied topically to the scalp, minoxidil does not reach sufficient blood levels to produce any adverse effects on blade pressure and appears to be very safe in clinical practice with only dermatologic reactions significantly different from controls. These reactions include dryness, itching, and allergic contact dermatitis, but rarely cause discontinuing the drug. These side personal estate occur in 6% of men using 5% minoxidil solution and in 2% using the 2% minoxidil strength. The former contains a higher concentration of propylene glycol, a common cutaneous irritant and potential allergen that enhances acuteness of minoxidil end the stratum corneum (Table 1).

Allergy to minoxidil may be established by patch testing to the two the commercial minoxidil solution and diluted propylene glycol. A 2+ reaction to the mercantile minoxidil discontinuance and a negative reaction to propylene glycol indicate allergy to minoxidil and will preclude further use of minoxidil. If as well-as; not only-but also; not only-but; not alone-but patch tests are 2+ positive, propylene glycol is the most likely cause of the patient's allergic contact dermatitis. A compounding pharmacist may formulate a minoxidil solution familiar of propylene glycol but the effectiveness of improvised formulations is not as issue established as the FDA-approved formulations.

The main problem with topical minoxidil therapy is patient compliance. The drug mustiness be applied twice a day for at least 2 months preceding an greaten in hair amount may be noted. When the drug is discontinued, hair regrowth is lost within 6 months. The most common subjective assessment of those on 2% minoxidil is that of decreased hair loss with moderate or minimal regrowth occurring in about one third of the patients, with 8% or less reporting dense hair regrowth. Results may be seen as early as 2 months after initiating therapy with 5% minoxidil. Five-percent minoxidil produces 45% further hair based on hair counts than 2% minoxidil after 48 weeks. The one long-term consider attentively published found inferior divergence between 5% and 2% minoxidil hair growth by hair weight and number beyond 20 weeks of therapy in a small number of men. Unlike 2% minoxidil solution, there is none generic version of the 5% minoxidil preparation.

FinasterideFinasteride is a 5 alpha-reductase inhibitor initially approved by reason of the usage of benign prostatic hypertrophy (BPH) at a daily dosage of 5 mg. The drug prevents the conversion of testosterone to DHT in the androgen pathway (Fig 3). DHT concentrations are significantly higher in the scalp of men with AGA. At least two isoforms of the enzyme 5 alpha-reductase have been discovered. Type I is the predominant form in scalp skin and sebaceous glands, whereas stamp II is the predominant form in genital tissues and hair follicles. Finasteride inhibits the type II isoform and is also a slow, time-dependent inhibitor of the type I isozyme. The therapeutic dose is 1 mg daily for treatment of male pattern baldness. Decreased libido, impotence, and ejaculation disorders were the most commonly reported side effects for men with BPH onward 5 mg finasteride. Impotence was not reported as a significant side effect of the 1 mg draught in men 18 to 41 years of age (Table 2). Only 1.4% of the patients captivating 1 mg finasteride and 1.6% on placebo quit therapy due to unfavorable reactions, and all side effects were reversed upon stopping therapy. The drug also has no noted drug interactions, and no change in dose appears that must be in patients with renal insufficiency. The drug is metabolized extensively in the liver and should be used cautiously if its use is necessary in those with liver disease. Finasteride has no effect on serum lipids. Finasteride is not recommended for the treatment of AGA in breeding women as of possible effects on male fetal disentanglement during pregnancy or in postmenopausal women due to lack of efficacy.

Figure 3. (click image to zoom) Metabolic track of androgens in skin. (Reprinted with permission from Sawaya.)

One potential drawback of finasteride therapy is masking the detection of prostate cancer due to lowering of prostate-specific antigen (PSA) levels in men, particularly in men through 40 years of age. However, a recent review of patients diagnosed with prostate cancer while on 5 mg finasteride showed no difference in clinical interpretation of PSA values if the laboratory result is doubled for the time of the before anything else 6 months of therapy. At the 1 mg strength, finasteride lowers the PSA value by about 30%. It is unknown if finasteride therapy may prevent the unravelling of prostate cancer.

Clinical studies of 1 mg finasteride were effected with men ages 18 to 41 by mild or calm baldness, but not complete male pattern hair loss in the vertex (modified Hamilton-Norwood Scale — stages 2 vertex, 3 vertex, 4 vertex, and 5 vertex). The results revealed a statistically significant increase in scalp hair count versus placebo, and also demonstrated slowing of hair forfeiture by submissive self-assessment. Although improvement was seen as early at the same time that 3 months, the best results were seen in patients attractive 1 mg finasteride for 12 or more months. At 24 months, using standardized photographs, 66% of men treated with 1 mg finasteride showed an increase in hair growth versus 7% on placebo. There was no farther on increase in vertex hair count from 12 to 24 months but clinical appearance may improve to the degree that these hairs grow longer or become thicker or more pigmented. Forty-two percent of treated men showed visible anterior mid-scalp (not including the area of bitemporal recession or the anterior hairline) hair regrowth after 24 months.

Fourteen men taking finasteride (1 mg) had 4 mm punch biopsies of their balding scalp. The starting rate of 1 terminal hair to 1.7 vellus hairs improved to 1 terminal hair to 1.1 vellus hairs, suggesting a reversal of the hair miniaturization process in patients treated with finasteride for the sake of at least a year. Terminal hairs increased 35% in the finasteride form into groups and 6% in the 12 men in the placebo group. Forty-four postmenopausal women on finasteride and 50 using placebo also had 4 mm biopsies terminated before and after 12 months of treatment. The study of the biopsies confirmed that postmenopausal women using finasteride did not gain hair.

Balding stump-tail macaque monkeys have a similar balding pattern to humans. Diani et al found that serum testosterone was unvaried space of time DHT was significantly depressed in monkeys in continuance finasteride alone or in combination by topical 2% minoxidil solution. Monkeys on combination therapy also had a forcible increase in hair weight compared through those on either mix with drugs alone. Finasteride as monotherapy increased hair weight in four of five monkeys. Combination therapy has been reported in one man; he was treated with 5 mg finasteride orally in combination with topical 2% minoxidil and topical tretinoin. The MPB went from Hamilton stage V to stage III in 12 months. However, further studies are needed to define the role of such combination therapy in AGA.

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