The big three for women, with Dr. Alan Bauman.
Many factors can contribute to hair loss in women—from genetic predisposition to hormonal changes—and can show up differently than in men. In this episode, Dr. Alan Bauman, a hair restoration physician, shares his top three hair loss treatments for women that go beyond nutrition, and many more details. A key point: Whether you’ve pinpointed the exact cause of the loss or not, you can still begin to test these treatments. Treating an underlying issue may not reverse the hair loss. It’s important to act as early as possible with hair-loss specific treatment for the best chance to stop the progression.
Dr. Michael Ruscio, DC: Hi, everyone. Welcome to Dr. Ruscio Radio. This is Dr. Ruscio. Today I’m here with Dr. Alan Bauman, and we’re going to be discussing hair loss. I wanted to make sure in this episode that we focused a majority of the conversation on women. We’re going to talk about both women and men, but I’ve seen more women in the practice who are asking, “What can I do beyond biotin supplementation, beyond collagen, improving my gut health? What else can I do beyond that to improve the situation with my hair?”
[Continue reading below]
Dr. R’s Fast Facts Summary
Signs of hair loss in women
- Can be hard to detect
- Thinning ponytail
- Part line looks wider
- Typically global loss
What causes hair loss in women?
- Androgenic: hormonally mediated hair loss
- Malabsorption: women are more sensitive to it
- Female hormone fluctuations
- Stress, inflammation, medications
- Thyroid: overuse of thyroid hormone can be a problem
- Over 95% of women have normal blood test results
- Measuring hair loss (hair mass index) with HairCheck:
- Measures if the hair itself is thinning in diameter
- Measures if there is less hair overall
What are the most effective treatments?
- Should not be used if a woman is of child bearing age. Can be used in post menopausal
- Fin Plus (finasteride)
- Side effects: decrease libido in 2% of men
- Decrease dose or take in the evening
- Use topical instead
- Saw palmetto: can also be helpful, but not as helpful as finasteride
Nutritional options for hair health (offers minor support)
- Biotin – 10,000 mcg/day
- Fish Collagen – well studied Viviscal
- Nutrafol anti-inflammatory and stress reducer
- B complex and a multivitamin
Bigger treatment players
- Effect: Makes weaker hair stronger
- Mechanism: stimulates hair cell mitochondria
- Turbo Laser Cap – 5 minutes daily
PRP with extracellular matrix
- Can be done once per year via Bauman PRP methodology
- PDO grow – threads you don’t feel that dissolve into the scalp
- Increased collagen, increased blood flow, huge dump of growth factors into the area
- FUE hair transplant
- Minimally invasive surgical procedure
- ½ grown at 6 months and fully grown at 1 year
Where to learn more
In this episode…
Episode Intro … 00:00:40
Hair Loss in Women vs. Men … 00:03:53
Causes for Hair Loss in Women … 00:08:02
Thyroid and Hair Loss … 00:12:20
How Do You Measure Hair Loss? … 00:17:55
Target for DHT Level … 00:25:52
Reducing Side Effects on Finasteride … 00:27:42
Personalizing Hair Loss Treatment … 00:30:10
DHT-Blocking and Safety in Women … 00:32:19
Dutasteride Usage in Men & Women … 00:35:50
Saw Palmetto for Hair Loss … 00:40:04
Nutrition for Hair Loss … 00:43:07
Minoxidil for Women & Men … 00:47:39
Laser Treatment for Hair Loss … 00:54:19
PRP for Hair Loss … 01:01:07
Synthetic Scaffolds: PDOGro … 01:05:28
Can You Revive a Dead Hair Follicle? … 01:09:07
Episode Wrap-up … 01:13:29
Subscribe for future episodes
I don’t have great answers there. I’ve looked into therapies for men but am not as well versed what is available for women. This is why I’m really happy to have Alan here, a true hair expert, to elaborate on the landscape, both for men and women.
Alan, thanks so much for coming on the show today.
Dr. Alan Bauman: Well, it’s great to be here, Michael. Really, really appreciate being with you.
DrMR: There was one thing I wanted to ask you. I was joking that in your bio picture, you have a great head of hair. You started to tell me what your regimen or your routine was, and we decided to wait on that until we started recording.
Tell me, what are you doing personally for your own hair preservation?
DrAB: Yeah. You know, it’s funny, because that’s usually either the first or second question I get from patients. “What exactly are you doing, Doc? What’s going on?”
First of all, I show them pictures of my dad, who went completely bald when I was in high school. I watched him struggle with his hair loss situation around that time. It was in the 1980s, and there really wasn’t much good stuff in terms of treatments. He dealt with some lotions and potions, and eventually wore a hairpiece for many, many years. I had the opportunity years and years later to do hair transplants for my dad, really to restore his full head of hair from complete baldness.
What I learned from that process, watching him lose his hair, is that I really wanted to keep my own hair! I remember being kind of paranoid, thinking, oh my God, is this going to happen to me? My grandfather on my dad’s side, totally bald. My grandfather on my mom’s side, a lot of hair loss. I grew my hair really long in college and then again in medical school, because I wanted to keep it. And I thought that growing it long would be a way to do that.
What I learned later on, becoming a board certified hair restoration physician, is that, yeah, it is genetic, but there are a lot of things that we can do to stop the progression of the loss. I’ve been taking care of my hair for 25 years.
I always tell patients, the key is to start early. If they’re out there with some thinning already, they’ve got to get on it so that the progression of the loss can be stopped.
Currently I use medications, and I use laser light therapy, essentially daily, to keep my own hair growing thick and strong. I haven’t had a hair transplant yet, although I probably will need one eventually. I know that. The staff really wants to tie me down and do PRP on me, but I haven’t had a chance to do that yet either. So that’s the current regimen to keep my hair looking good. A lot of it has to do with how much hair you have, and how you cut it and style it too.
Hair Loss in Women vs Men
DrMR: Do women see the same progression of hair loss as men? I’m assuming it depends on if it’s hormone-mediated or adrenergic hair loss in a woman, then they might see the same kind of male pattern recession and loss as a man would. How would you categorize? I would assume men are on a more dire train, where they could end up totally bald. Whereas in women, that’s probably much less common, but they may have thinning to the point where they don’t feel like their hair is as attractive or voluminous as it was before. What do these two sexes look like with the prognosis?
DrAB: Here’s the thing. Androgenetic alopecia, which is male and female pattern hair loss, can be inherited. But it looks different, it expresses itself differently in different genders. In men, when you have male pattern hair loss, it’s obvious from across the room that it’s happening. You have a receding hairline, you have a bald spot maybe developing in the crown, and eventually it could just wipe out all the hair in between. And it spares the hair around the sides and the back.
In women, female pattern hair loss looks completely different. In fact, very often they can lose a ton of hair, more diffusely in the frontal zone, but it’s not really noticeable to the naked eye until you really lose a lot of density. Yes, women can recede their hairline, meaning that they can recede in the temples. Yes, they can lose a lot of hair on the top of the scalp, but they don’t typically go bald due to female pattern hair loss.
DrMR: So it’s just really thin and fine.
DrAB: Correct. Well, they’ll lose density. One of the things that we know scientifically is that you can lose like 50% of your hair without it being noticeable to the naked eye. It may seem crazy, how could that be? Well, hair provides coverage of the scalp, and there’s a breakpoint.
There was a physician in hair transplant surgery who was trying to put an end to a density debate issue that we were having almost 20 years ago in the field. He literally plucked out hairs from the scalp and took pictures of that area next to a full density zone. What he realized is that he could pluck out 25%, 30%, 45%, even 50% of those hairs, and it still looked about the same as the area that had 100% of the hair. So it isn’t until you start to lose more than 50% of your hair that it starts to look thin to the naked eye.
What does it look like in women? Women typically will notice that their part line is getting wider. That they have to change their hairstyle to cover a little bit. That they’ll have to wear bangs over the temple areas perhaps.
DrMR: Or a thinner ponytail.
DrAB: Yeah, they’re going to notice a thinner ponytail for sure over time.
DrMR: Now, how often is the androgen—the hormonally mediated hair loss—an issue in women?
DrAB: In men we know exactly what the trigger is. We know DHT (dihydrotestosterone, a derivative of testosterone) is the main trigger for male pattern hair loss. That’s what causes the hairline to recede and for you to lose density. Now, in women, it’s a lot more complicated.
Of course, it can get worse with time. It can happen around changes in hormone status. We see women who have changes in their hair around pregnancy. We have changes in hair if they have hormone imbalance, like PCOS (polycystic ovarian syndrome). Also, around perimenopause and menopause. This is when women are most likely to see changes in their hair.
We also know that women’s hair, I could say, is more sensitive. What does that mean? That means that things like nutrition and diet, even things as simple as like stress, and sleep/wake cycles, inflammation in the body, all of these different things can play an impact on the hair follicle. Not to mention different medications that you might be taking, and of course, illnesses or conditions that a woman might have. That would include hormone imbalance and other factors as well.
Causes for Hair Loss in Women
So there’s a whole laundry list of things that can really go wrong in female hair loss.
DrMR: Are there a few that you have found to be the most fruitful to focus on? I’m assuming you might do some kind of workup for high androgens in the blood, and perhaps you’re looking for signs of malabsorption. If a woman is saying, “Yes, this feels like me,” what should they be looking for their doctor to do to help uncover some of the causative factors?
DrAB: Yeah. Of course, you remember I’m a board-certified hair restoration physician. This is all we do, treat male and female pattern hair loss. 50% of my patients are women, 50% are men. Many of our female patients will come to me after having been to a huge number of doctors, getting all kinds of blood tests, biopsies, and things like that. The interesting thing is that many women—I would say over 95% of the women who come in—actually have normal blood work. What does that mean? That means that most women can have female pattern or female hair loss without any abnormalities that you’re going to detect on a standard blood panel.
DrMR: Including hormones? Including things like testosterone?
DrAB: Yeah. Even normal hormones. If you’re in an age management practice, you might see that most of your patients have some kind of hormone abnormality, or have perimenopause with menopausal symptoms due to changes in their hormone status. But in my practice, I’m seeing women even in their teenage years with hair thinning problems. It could just be strong genetics, meaning they have androgenetic alopecia and they’re prone to these female pattern hair loss issues.
Here’s the thing. Of course, we’re going to take a full inventory of their medical history and hair loss history. We’re going to try to figure out, is this a sudden shedding phase that they’re going through just in the past couple of months, or is this something that’s crept up on them? Is there hair loss in the family, and what types? Where are they noticing the hair loss? Is it really happening diffusely? Is it happening in one particular area, like the hairline?
There are other things besides female pattern hair loss that can be going on at the level of the scalp. They could have patchy hair loss. They could have scarring types of hair loss. They could have had previous surgery, plastic surgery, brow lift, facelift procedures that can predispose them to thinning in the frontal area of the scalp, that they may not even have realized when they first had those procedures done. There are a lot of factors.
DrMR: Are some of these things—like scarring-induced, or autoimmune alopecia—fairly easily identified from your run-of-the-mill GP or dermatology workup?
DrAB: Well, I don’t know necessarily about a GP. Hopefully a dermatologist will know the difference between a scarring alopecia and female pattern hair loss. But sometimes I just think you go to your derm and they’re not sure. They’re just going to biopsy everybody. They don’t know what else to do.
DrAB: And derms are okay at getting the diagnosis, but they’re really not going to have the tools on hand to actually track your hair loss over time. We’ll get into that, how we actually measure hair, so that we can establish a diagnosis and track your progress with hair regrowth treatments, before you even know if it’s working with the naked eye.
Then the other factors are, do they actually have access to the treatment? As a board-certified hair restoration physician, I’ve got the whole toolbox right here. I can do everything, from medications and nutritional evaluation to platelet-rich plasma and cell therapy, to hair transplantation, to even cranial prosthetics, which are nonsurgical hair replacement systems for people with extensive alopecia.
We’ve got everything here at my 12,000 square foot hair hospital, as a lot of my colleagues have called it, in downtown Boca Raton. We’ve got everything covered, from scalp inflammation to hair loss. That’s important for patients when they come in, to know that we have everything. To be able to diagnose their condition, to identify their risk factors, and to establish a baseline, where they are with their hair loss situation, and then to initiate treatment and follow up so that they know they’re getting good results.
Thyroid and Hair Loss
DrMR: Now, one of the things that has irked me about some of the integrated medical field is this over-tendency to diagnose a thyroid condition when there’s not actually one there. I think there’s culpability both on the conventional side of the fence and the alternative side of the fence. Probably well-intentioned culpability, meaning you’re trying to help someone. Thyroid numbers are within the normal range, but maybe they’re for a TSH at the upper end of the range, or for a free T4 at the lower end of the range.
I’m curious, in your experience, do some of these “within normal range” fluctuations in thyroid hormone appreciably impact hair loss?
DrAB: Here’s the thing. We know that thyroid imbalance can definitely impact your hair. Literally, you could do a Google search on “thyroid hair,” and you can see people who have crispy, frizzy, poor-quality hair growth, who have been diagnosed with thyroid conditions, obviously. It’s pretty much common knowledge. We also know that thyroid replacement, and even some of the natural supplements of thyroid, can also impact hair loss and trigger some hair loss problems, whether it be shedding, or poor hair growth.
I have to say that I’m not a thyroid endocrine expert, and if I do come across symptoms other than hair loss, I will certainly refer to an endocrinologist, or maybe even a functional medicine person. I’m not going after the thyroid to track that down if the person’s got some significant hair loss. I’ll just be very honest, because I know that the thyroid treatment is almost worse than having the thyroid condition on your hair. No one ever got better hair from being on a thyroid medication.
DrMR: Well, that’s something I certainly wonder about. As we’ve been identifying more of these cases that essentially are normal thyroid but are being put on medication by, again, probably well-intentioned but overzealous physicians, you’ll see negative symptoms in the majority of these patients. Not all, but you’ll see anxiety, insomnia, fatigue, thinning hair. So I just wanted to make sure we addressed that, because I think if someone goes on the internet, one of the first things that they’ll read if they type in hair loss is thyroid.
DrMR: Then if you end up at a blog that’s a thyroid heretic whoever, you might very quickly find your way into a doctor’s office who’s willing to humor you with a prescription. And that may actually make your hair loss worse.
DrAB: Oh, absolutely. I see that all the time. It’s something that’s very, very common, and I think sometimes patients are surprised. “Well, how come you’re not going to treat my thyroid?”
I say, “Look, your only symptom is the hair situation. You don’t have any other thyroid symptoms. Let’s just deal with the hair for the moment, and see how things go. And if we need to take it further down the road with another physician, we can do that.”
But I think you’re right. I think that physicians are maybe overzealous in getting the thyroid diagnosis. They feel like, “Aha, we’ve got something here.”
DrMR: Yep, totally.
DrAB: There may be other more natural ways to improve the function of the thyroid, and to reduce inflammation in the body that might be knocking out the thyroid. Of course there’s always those outliers where, yeah, there truly is a thyroid problem, or god forbid, a tumor, things like that, that need to be taken care of and so forth.
But yeah, physicians are definitely being overzealous in the thyroid realm, in my opinion.
DrMR: Right. Cool. I know that’s an area of interest for our audience, and so getting your perspective on that, I think, will be reassuring. Because obviously I am not a hair loss specialist, so if there was some type of thyroid connection that was fruitful, that I was unaware of, I wanted to make sure we touched on it.
Sounds like, as logic would suggest, if there’s not an overt thyroid problem, then there doesn’t seem to be a need for thyroid hormone.
DrAB: Yeah. I mean, think about it. If people were going to their endocrinologist, taking thyroid medication, and their hair was doing better, everybody would be coming in asking for that. Today, they’re coming in asking for the way that we do PRP. Why are they doing that? It’s because we’re getting great results and the word is spreading. Especially women, they spread the word very quickly. If something’s working, you can bet they’re on top of it.
DrMR: I have no doubt, especially with women’s hair loss. Because it’s more socially acceptable for men, but for women it’s really a precarious situation to be in if you’re suffering from hair loss.
DrAB: Absolutely. Well, there’s no socially acceptable option for a woman who’s struggling with thinning hair. If they have difficulty covering their scalp, then they’re turning to powders, and sprays, and camouflage makeup up there. They’re changing their hairstyle, changing their color.
A lot of things that they’re doing could be making their situation worse. If they overprocess their hair to try to style over the thinning, that can often cause breakage, which is another problem. That’s not a function of the follicle failing. When you have breakage, that’s literally the fiber itself that’s being overprocessed and prone to splitting, and poor quality from just the heat and the chemicals. That’s a whole other issue cosmetically that we often have to deal with, more in women than in men.
DrMR: I’ve heard you mention biotin in the past as a potential therapy to increase hair strength and reduce splitting. I’ve made a note for us to come back to that in a moment.
How Do You Measure Hair Loss?
But you’ve mentioned testing also. I’m wondering, what does your workup look like? I believe you developed a method of tracking hair loss or hair density, for lack of a better term. Wondering how you’re assessing people for their hair loss, and then what other tests you’d recommend as part of this hair restoration process.
DrAB: For sure. So when patients come into the office, and we’ve taken a full medical history and physical exam of their scalp, and seen what’s going on, and full inventory of their symptoms, and so forth, it’s time to measure their hair.
I use a device called the HairCheck. HairCheck is the name for a cross-sectional hair bundle trichometer, which is a mouthful. But basically it’s an electronic caliper that measures a bundle of hair. That measurement gives us what I would consider the cross-sectional area of that bundle.
Think of it like a scientific ponytail. A woman knows her ponytail is shrinking because she used to wrap it twice, and now she can wrap it three times with the ponytail holder or scrunchie. What’s going on? Well, there’s either less hair in that bundle, or the hair that’s in that bundle is thinner in diameter. That’s exactly what the HairCheck tool measures.
There’s another even more nuanced part of this HairCheck measurement that we use. That’s to get back to the same area of the scalp again and again over time, without using a tattoo or other permanent marking on the scalp. It’s a very clever pairing of what I would call a stereotactic tool, to get back to the same location again and again, and the electronic caliper to make the measurement happen. It’s an ultra-scientific way to track hair quality and quantity in a given area of scalp over time.
What that enables us to do is establish a baseline in the initial visit. So let’s say we compare the back of the scalp, which is what we call the occipital zone—the part of your scalp that hits the pillow if you lean backwards to lay down on your bed, typically the most permanent zone—to the frontal zone and see what the difference is between those two areas. In a healthy scalp, they’re going to be pretty similar. But in someone who’s experiencing female hair loss (or male hair loss, by the way), those two numbers are going to be very different.
That’s what it enables us to do, to establish this baseline, first of all, of how much hair you’ve lost, and then enable us to come back to the same location, whether it be in three months, six months, nine months or 12 months, and track the improvements or changes in those areas, in a very sensitive way. Way before it’s even visible to the naked eye that you’re getting improvements in hair growth, we can measure it with the HairCheck tool.
DrMR: The obvious question that comes up for our clinicians and the evidence-based crowd is, has this been compared to some type of gold standard? If there even is one for this kind of monitoring?
DrAB: There is no gold standard for the monitoring. But this tool was developed by a very prominent hair surgeon here in Miami, I would say over 15 years ago, Dr. Bernie Cohen, who has since retired. He basically retired from his practice and all he did was research on this concept called hair mass index. And that’s what this tool measures, hair mass index. It’s been rigorously tested. You can take fibers of suture material and measure the suture material repeatedly. You can change those suture materials out for thinner fibers and measure it, and you can see how the percentage of change–
DrMR: So it’s been validated in a way.
DrAB: Oh yes, absolutely. There are probably dozens of clinical research papers out there validating the science behind the cross-sectional trichometry—which is what we’re talking about here, cross-sectional hair bundle measurements—using HairCheck, which is just the common name for the tool.
DrMR: Yeah. I think that’s such a great tool to be able to offer people, because hair loss doesn’t have a fast turn time. You start using an intervention and it’s fairly normal for it to take, from what I’ve read, three to six months before you’re even noticing improvements.
DrAB: Oh, at least. At least. It could be a year before you really notice a change. If you’re waiting for your ponytail to thicken up, that could be two years, Michael.
DrMR: Right. If you’re going via the I-look-in-the-mirror-and-see-X test, lighting, hair length, if you have residual oil or product in your hair, all those things can impact how you feel your hair loss is faring. Which is why I think a tool like this, so you can do your periodic re-measurements and then have an objective gauge to tell you, okay, we’re doing the right thing, or, nope, we need to start adjusting what we’re doing, is a great way, I think, to get so much of the emotion and day-to-day worry about how you look out of the equation, and have this nice repeat object measure.
DrAB: Oh, it’s so true, because now you have a metric. For example, in three months you’ve grown about, let’s call it an inch worth of new hair. Or hair growth has happened. Hair grows at a rate of about a quarter or a half inch a month, that’s about a centimeter or so. If you’re on a hair growth treatment you’ve just started, it’s going to take a good three months for us to measure a difference with the HairCheck tool. But in three months, you look exactly the same in the mirror. So you don’t even know if the treatment’s working 10% better, if you’re the 0%, if it’s the same, or if it’s increasing 50% or 100%. You have no way to know unless you do a measurement.
The key to compliance with any treatment, whether it’s a topical medication, or a laser light device, or even just knowing if your PRP is working, is you have to have that repeat measurement at three months and six months.
Because that’s going to predate and predict how things are going to start to look three or six months down the road from there.
DrMR: Yup. Makes complete sense.
DrAB: It’s a huge compliance boost, because it’s right around 90 days. If you’ve been toiling with, say, a topical medication, you have the latest and greatest, you may have some serious doubts at three months if you’re not sure you’re seeing something.
Most people give up at 90 days, and that’s the critical time to be encouraged if it’s working.
DrMR: Yeah. I think that’s one of the things that people struggle with, just like you were saying, committing to a long-term treatment plan. Because it may take so long for the visual effects to appear. You may have, like you said, nine months plus before you can even visually see something. If you don’t have any other way to tell you that you’re doing the right stuff, and that results are occurring, they’re just not perceptible yet, I can see it being very easy to jump ship too prematurely.
Then you try some other treatments, and you burn three years of time, and all that while you’ve lost hair rather than just committing to one thing that is starting to turn the tide.
DrAB: Absolutely. It’s so true. We’ve done over 40,000 measurements with the HairCheck tool in my practice over the past 12 to 15 years. Every patient that comes through the door gets measured. And there’s no charge for follow ups, they just come in, we measure them and we can tell them exactly how much more or less hair they have in each zone.
Not only can we tell how they’re applying the treatment… let’s say someone comes in and got a huge improvement in the frontal zone, but in the crown area, not so much. We can review with them: “Hey, how are you putting on that topical prescription medication?” Like 82M or 82F that we use. “Last time we did your PRP treatment in the crown, but we didn’t really do it in the front. Maybe we should switch gears and swap things around a little bit for that next therapy.”
Target for DHT Level
DrMR: It makes complete sense. I also wanted to touch on DHT, in the realm of testing. I’m wondering, for men, or maybe for women also, is it a target? Let’s say you’re using whatever agent to lower DHT, is there a target you’re trying to get to? Or is it more about using a standard-ish dose of a DHT blocker and monitoring someone’s response via their hair?
DrAB: Well, we know that for male patients, for example, if you go on finasteride daily, about a milligram, a milligram and a quarter, you’re going to lower your DHT about 80%. It’s going to knock it way down for sure. And that’s good enough to keep 90% of guys looking the same or better in the long run. That’s pretty good news.
Small incidence of side effects, like 2% or so. And the side effects might be DHT-dependent. We do have to watch the DHT level sometimes, but I’m actually more concerned about the end organ. I want to know how the hair follicles are responding. Because what you inherit is not some crazy high or low DHT level, you inherit the sensitivity to the DHT, in men, for sure. You could have one guy with a pretty low DHT level, and his hair loss is totally stopped. Then you have another guy with the same exact level, and his hair loss is still progressing. What gives? What’s going on?
Well, the other guy who’s got his hair loss still progressing is obviously much more sensitive to DHT than the other guy. So you may have to use a multi-therapy approach for him. You may have to add a topical, or get PRP going, or prescribe him a physician-based laser cap of some sort, to really get the process going and prevent future loss.
Yeah. I might look at the DHT occasionally. And maybe if they’re having some side effects, so we know when the DHT is bouncing back up, if we’re stopping the medication.
Reducing Side Effects on Finasteride
If a guy’s having side effects on finasteride—first of all, it’s pretty rare, 2% of patients—sometimes just changing the timing of the dose does the job. That doesn’t budge the DHT level at all. The DHT level is exactly the same, but we changed him from the morning dose to the evening dose, and all of a sudden his side effects are gone.
DrMR: Now, is that fairly typical to see when you revert to the evening? Is that a better time to reduce side effects, or is it just any change? If they were taking it in the evening initially, you’d change them to the morning, or how does that work?
DrAB: Well, first of all, I’m not a huge fan of generics, so let’s start from the beginning here. I don’t love generic medication. When Propecia went generic, we saw a lot of problems. A lot of people were losing more hair, their hair numbers were decreasing, and we really didn’t know why. I had a guess that maybe the generic was not as potent or not as consistent as the name brand. We really didn’t know what the situation was.
Then, also, around that time we were seeing a lot of people on the internet especially, complaining of side effects. Although, that happened to coincide with the medication going off patent, which was the window of opportunity for the class action lawsuits to come on, which obviously never panned out.
What we’ve seen is that it just comes down to these patients with a 2% risk of side effects. Having prescribed finasteride to like 15,000 to 18,000 patients in my practice, I can tell you that it’s pretty close to 2% of patients that complain of sexual side effects with the drug. The first thing I do is, I want to make sure that they’re on a quality compounded medication. So I use Fin Plus, which is just a nickname for a quality compounded version that we prescribe. It’s one and a quarter milligrams, with a little bit of biotin and a little bit of saw palmetto and some other things in there, like astragalus root and such, and some things to decrease inflammation and increase circulation. That’s what I like to use.
Then if they’re having a side effect, I like to try to change the timing of the dose. If they’re doing a morning dose, which is pretty typical, then I’ll switch them to the evening dose. It’s amazing, like 50% of patients’ side effects will go away if you just change the timing of the dose.
DrMR: Wow. That’s great.
DrAB: Some people just seem to do better with an evening dose, and another percentage of patients seem to do better with the morning dose. I don’t know if the side effect was in their head, or below the belt, or between their ears. I don’t really care. As long as they don’t have the side effect, then I’m happy.
DrMR: Sure. Makes sense.
Personalizing Hair Loss Treatment
DrAB: If there are other patients that are more sensitive to finasteride and maybe have more DHT-dependent libido and performance issues, then we might need to go down to three times a week dosing, or something like that, or even microdosing. If that’s happening, then we’ve got to add other therapies into the toolbox.
DrMR: Sure. It sounds to me very similar to what I do in the clinic, which is, we have this toolkit for GI, let’s say, and not every tool is going to be tolerated by every patient. But what we can do is just start working them through the available therapies and personalize a plan to them. It’s amazing, if you do that, as compared to, let’s say, the other doctor down the street who’s just overtly treating the lab results and not really personalizing the therapies.
You can get such better results. And it’s in many cases no more difficult than just doing that. Sounds like you’re doing something very similar.
DrAB: Well, what do you mean? It’s not a cookbook, Michael? I thought it was just a cookbook!
DrMR: If only, right?
DrAB: That’s the art within the science. We actually have to manage patients. For some physicians, that’s a foreign concept. Even patients don’t understand: “Well, what do you mean, you’re going to measure every 90 days to see how things are going?” Hell yeah, I’m going to measure you, because I want to know when you plateau. I want to know which areas are not responding. I want to know which areas are doing well. Because all of that helps me with my crystal ball. I can tell you where things are going.
DrMR: Yup. Makes complete sense.
DrAB: The same thing with women. We kind of got sidetracked on the male patients with finasteride.
With women too, if we’re going to be addressing some of their issues in… let’s just call it lifestyle, with poor sleep, poor diet, all of that’s going to affect the follicle, and inflammation, and so forth.
Hopefully I’m working in tandem with an excellent functional medicine person, or someone who at least has a holistic approach. That patient might need more than one type of therapy to really move the needle in terms of growing better quality hair. She may use a topical medication at home, in conjunction with a laser light therapy device.
DHT-Blocking & Safety in Women
DrMR: In women, I’ve read—and I actually believe I first heard this on the interview with Peter Attia and yourself—that suppressing DHT, this cousin of testosterone, if you will, in women can have deleterious effects if they’re planning on getting pregnant or are currently pregnant.
I wasn’t clear if, at any time, women should always be avoiding these. Take us through the viability of DHT-blocking and safety in women.
DrAB: Yeah. Well, first of all, not all women are androgen sensitive. In some women, let’s say, post-menopausal, it’s super simple and easy to determine. They’ve been treated with hormone replacement therapy and it includes testosterone. Lo and behold, four to six months later they have a receding hairline. Okay, we know they’re androgen sensitive, because the testosterone that they used exogenously is now being converted to DHT. So they deserve, in my opinion, anti-androgen therapy, and finasteride can be a part of that, as well as some other therapies.
Now, finasteride in women is not FDA-approved, of course, in women at all, and would be contraindicated in women of childbearing age. You should not expose a woman to finasteride who has the potential for being pregnant, or is pregnant. As you know, DHT is really important in the fetus to make, let’s just say, men look like men. We don’t want women who are of child-bearing age to be exposed to finasteride. So we do not typically prescribe women who are of child-bearing age finasteride.
In post-menopausal women, I like to use non-androgen modulating therapies first. For example, we would hold off on finasteride, and we would use instead a compounded version of minoxidil, like Formula 82M, and get them on a laser or do a PRP treatment. Those would be our major league players for women who are in that post-menopausal category. I hope that answered what you were saying.
So we would avoid anti-androgen therapy in women of child-bearing age. Now, there are some exceptions. I guess we can cover some of that. Some women with PCOS are obviously dealing with fertility issues, and they’re on birth control, and they’re trying to deal with those hormone changes. Certainly a sensitivity to androgen is a big part of that constellation of PCOS. If they’re on birth control and they understand the risks, they have to sign a consent, just like if they were going to go on Accutane.
These women are knowledgeable. They know that they’re going to be on some medication which could be dangerous to a developing male fetus, so they have to sign a consent that says that they’re going to stay on birth control and that they know the risks and dangers if they want to be on finasteride, for example.
DrMR: Does the risk diminish if, let’s say, a year later she comes off birth control, comes off finasteride, and there’s maybe some type of gestation period? Is the risk cleared then? How does this look in a longer term situation?
DrAB: Oh, that’s a great question. Finasteride is cleared by the body in a week. End of story, so that’s it.
Yeah, end of story. One week, it’s out of the system. And we know that through the pharmacological testing, the PK done in men. We also know that, for example, if a man has a side effect and he stops the medication, by the next week, typically the side effects are gone. Everything is abated because the medication is out of the system.
Dutasteride Usage in Men & Women
There are other anti-androgen treatments. For example, there’s dutasteride, which is Avodart. Avodart has a much longer half-life. Again, contraindicated in women of childbearing age. In men, if you treat with Avodart—let’s say he’s been on it for months and he has a side effect—it actually takes months to get it out of the system. That can be a significant issue, significant concern.
DrMR: Yeah, so there’s a plus side, I guess, for men using the shorter half life finasteride or Finasteride Plus.
DrAB: Right. Even though it’s not as strong. Finasteride blocks the type II 5-alpha reductase enzyme, which is kind of the main road to DHT. Dutasteride blocks that, the type II and also the type I, which I would consider the service road, if you catch my analogy. It’s a smaller tributary that also goes to DHT. Dutasteride blocks both. You get a little bit stronger reduction of DHT.
DrMR: Are the sexual side effects similar? Or do we even have that data, looking at the sexual side effects for both?
DrAB: Yeah. The sexual side effects are more significant in dutasteride, and we know that through the prostate studies, because these are prostate drugs. The Avodart is a prostate drug. This basically doubles the incidence of the side effects. Instead of 2%, you’re looking at about 4% to 5%.
Most people who go to Avodart typically have already “tested” themselves with finasteride, meaning that they’ve used finasteride and are looking for something stronger. Obviously they didn’t have a side effect on finasteride and now they want dutasteride. They’ve probably already self-selected themselves out of the cohort of a small number of patients who are going to be sensitive to DHT-dependent libido or performance.
DrMR: From what I’ve gathered, again, in your Attia interview, it seems like a DHT-blocking medication is one of the absolute pillars of male hair loss treatment.
DrAB: Well, it’s the big boy. I mean, it’s the bazooka in the tool box. We know it targets the trigger for male pattern hair loss. You know, if you can’t do an oral finasteride, and you can’t tolerate that, then the good news is that we can put you on a topical finasteride. I can put minoxidil and finasteride together in a really sophisticated, very clean and quick drying, non-greasy topical. And that’s a nice powerful treatment if you cannot tolerate the oral.
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Saw Palmetto for Hair Loss
What about saw palmetto? That’s something you hear come up a lot. I did a little bit of poking around. I was able to find—I believe there’s only been one, but perhaps there have been more, if so, please let me know—one comparative trial looking at, I believe, finasteride versus saw palmetto. They both showed the ability to preserve hair, but saw palmetto did not prevent a receding of the hairline. Saw palmetto only, in this one study, showed the ability to reduce hair loss at the crown of the head, at the top of the head, but not at the hairline. That would seem to be a huge miss for men.
I don’t know if this has been further borne out or not, but that would make me really apprehensive about a man using saw palmetto, even though it’s natural, because it’s not stopping the male pattern baldness that most men are afflicted with.
DrAB: Well, here’s the thing. No one’s going to do a double-blind, randomized, multi-center trial on saw palmetto. They’re not going to spend tens of millions of dollars to do that rigorous research to mimic what Merck did with finasteride, because there’s no money, unfortunately.
So we have to work with our own anecdotal evidence here in the clinic, right at the bedside. If a patient wants to be on a saw-palmetto-derived product, the question is, which one, what dose, what frequency?
There are good nutraceuticals, like, for example, Nutrafol for Men. Nutrafol has a saw palmetto complex in there which I feel is very strong, and we’ve seen results with that. We can derive measurable results with a simple nutraceutical. Again, it’s not going to hold a candle to finasteride, which is a much stronger bigger brother. The chances are pretty good that maybe some patients can actually benefit from a small reduction in DHT, or however saw palmetto actually works, because no one’s really borne that out yet in research. Does it block the receptor? Does it work like a 5-alpha reductase inhibitor like finasteride, but just weaker? Nobody really actually knows that.
Nutritionals, like a good quality saw palmetto, do seem to have an effect on male pattern hair loss, for sure. The clinical evidence, in terms of my practice, I see it daily. I see people on saw palmetto and it does work. Now, again, is it a weak treatment? Yeah. I would call it a minor league player, especially compared to the big daddy finasteride. If you can’t tolerate finasteride, or you’re on a microdose of finasteride, maybe you should add saw palmetto and see.
Is saw palmetto completely safe? Well, the answer is, not 100%, because I have patients that complain of decreased libido on saw palmetto. So I know it’s doing something with the androgens. Unless that’s a placebo or nocebo effect.
In these particular patients, I’ve seen enough of them to know that a strong saw palmetto can have some sexual side effects. I would just consider it a weaker version of finasteride. That’s how I would do it, and as an adjunct, if the patient can tolerate finasteride, then add saw palmetto to it.
Nutrition for Hair Loss
DrMR: You also mentioned nutrition. And I’m wondering, is there a certain cocktail that you like? People have heard about biotin, so we should definitely talk about that. Collagen seems to be something that many people report favorable outcomes with for hair, skin, and nails. What does your nutritional support look like?
DrAB: Yeah. That’s a great question. I have a stack that I recommend. A lot of people are kind of born with the knowledge that biotin does seem to help with hair growth. Some of that has not been borne out in the literature, because again, no one’s going to do some major double-blind, randomized clinical trial on something that is super duper cheap like biotin. I like 10,000 micrograms of biotin a day, especially if the guy or gal’s got very thin, fine hair.
We know that, for example, the biotin helps with hooves in horses. So there is some improvement in keratin production and strength. I think we can see that in the clinic with patients who are doing a lot of processing to their hair, we put them on biotin and their fingernails and hair seem to do better when they’re processing their hair. Better strength, better shine. Now, is biotin going to grow a new hair? Probably not, but it fortifies the follicle in some way.
DrMR: Less split ends also?
DrAB: Yeah, because it seems to be protecting and enhancing the function of the follicle, producing a better quality fiber, if not a new one. It’s not going to make a new fiber, but it’s going to make a better quality fiber from the hair that you have. I like that idea.
I’ve always been a big fan of Viviscal. It’s a fish protein, it’s a shark cartilage, or fish collagen, that you can think of. It’s one of the most well-studied, most popular nutritional supplements in the world, Viviscal Pro, and so we recommend that. That ingredient is not contained in Nutrafol, which is another high-powered supplement that is specifically designed for hair regrowth. It’s kind of the new kid on the block.
I like the Nutrafol because it does a few different things. It has an antiinflammatory component to it, with curcumin, turmeric. It’s got the ashwagandha root, which offers some hormone support, and as a stress adaptogen is very valuable. As I mentioned before, stress can really be wreaking havoc on the hair follicle. It’s got a nice cohort of ingredients there to increase circulation, decrease inflammation, and really protect the follicle. Antioxidants and so forth. Holistically supporting the follicle. That’s part of the stack. B complex, very good if you’re not already on a nice multivitamin. Some kind of hair, skin, and nails would be nice. Those are my go-to ones. As you mentioned, this multi-collagen seems to be very, very good for hair regrowth as well.
Again, these are not major league players. I want your listeners to understand that the major league players are going to be more in the realm of topical prescription medications like minoxidil-based stuff. For men, the finasteride. Laser light therapy for men and women. Platelet-rich plasma for men and women. Those are the major league players. Nutrition is more minor league.
DrMR: Sure. Yeah, I’m glad you say that. I think, again, one of the things that people have a hard time getting a straight answer, when they’re reading on the internet, on the level of effect from these. I can’t tell you how many people think that just biotin alone is going to be enough to cure all hair loss problems.
Clearly, if you ask people who have been taking biotin for a few years, yeah, maybe it moves the needle a little bit. But there are still many people who seem to be suffering despite taking biotin, collagen, a multivitamin, and probably a B complex on and off. I think it’s important to say, sure, that’s a good starting point, but that may not have enough punch to really lead to the outcome you’re looking to get to.
DrAB: Right. Think about a guy who’s in his 20s, with male pattern hair loss. He’s receding, he’s starting to thin out in the crown. That guy’s got a huge inertia of male pattern hair loss and androgen sensitivity going on. We’ve got to fight back with more than biotin on that guy.
DrMR: Yep, totally.
DrAB: Same thing is true with women who are, let’s say, 50 years old, menopausal, dealing with some medications. Maybe they’re on an anti-anxiety drug, maybe they’re on a statin medication, they’re on a blood pressure medication, they’ve got a hormone imbalance, they’re not sleeping well, they’ve been trying to lose weight off and on. That’s like a laundry list, right? That’s very, very common in the practice. There are like six different things there that are working against your hair. Biotin isn’t going to fix that situation.
Minoxidil for Women & Men
It may be time to get on a major league program.
DrMR: One of which is minoxidil. That can be helpful for men, it can be helpful for women. Let’s talk about minoxidil.
DrAB: Yeah. Over-the-counter Rogaine’s been available for 40 years. That’s the same recipe. Greasy, gooey, doesn’t really penetrate all that well. It creates havoc with the propylene glycol, which is the vehicle, causing irritation in about 30%, 40% of patients. Most people give up before they even notice a result. It’s a big hassle for most people to get started with because no one’s taught them how to actually apply the medication to their scalp and not get it on their hair.
The first thing we’ve got to do is get a good product. That’s going to be a prescription version of minoxidil, like 82M. Formula 82M is our go-to minoxidil. It’s super strong. It’s not greasy, not gooey. It’s the most well-known, most popular, and most positively reviewed Rogaine alternative on the planet. A number of different physicians around the country have the ability to prescribe that. We’ve prescribed it to probably almost 18,000 people, and so we have a great track record of success.
Patients like it because it’s not greasy, it’s not gooey, it’s not going to mess up your hair, and we’re going to teach you how to use it properly. When you come in, in 90 days, I’m going to be able to show you how much improvement you’re having in your hair using those measurements.
It’s really, really good. It has a mild anti-inflammatory built in, fluocinolone. It has the minoxidil component, plus tretinoin, which helps it penetrate. It has a nice antioxidant component. It has oleanolic acid, which is a mild anti-androgen that they use for acne in some cases. It’s got hair conditioner and a skin conditioner. It’s going to go on dry, it’s going to absorb in like three to four minutes. Think of it like not like a cream or a lotion, but more like a hand sanitizer. It just takes another extra 10 seconds for it to dry. It’s not a big deal, but you’ve got to put it on twice a day. That’s two times a day, every day, for it to be most effective.
DrMR: Yeah, and that’s something I wanted to dig into. I read two studies that found applying Rogaine once per day had about the same effect as applying twice. The reason why I went digging was, admittedly, for myself. It would be a lot easier to use this once per day than twice. Is there some leeway there? Can we get away with once per day? Are you really losing that much if you only do it once?
DrAB: Here’s what I’m going to tell you. First of all, I have huge experience, as I said, almost 20,000 patients on minoxidil over 25 years, using any kind of minoxidil product. I’m going to tell you, if you’re using minoxidil once a day, pharmacologically that makes no sense.
We know that the pharmacology tells us, pharmacokinetics tells us, the half life is super short. It’s out of the body in like 10 hours. Your skin is without minoxidil for a long period of time if you’re using it once a day.
I’m not telling you that half a push up is not going to do something, but you’re better off getting the full push up twice a day.
DrMR: So you want 10 hours in between?
DrAB: I’m just telling you that minoxidil has a very short half-life in the skin. Your body metabolizes it, gets rid of it, moves it out, whatever you want to call it, it’s gone. And there’s no question in my mind that twice a day is far superior to once a day.
I’m not saying that once a day isn’t okay. It’ll work okay once a day, but if you want the full benefit of minoxidil, you want the thickest possible hair that you can grow from any follicle, you want the highest number of follicles in the anagen (the growing) phase, compared to follicles that are resting, then I have patients doing it two, sometimes three times a day.
Yeah, I would say that if you’re a once-a-day minoxidil guy, especially if you’re not using a high-quality compounded version like 82M, you’re doing half a push up, brother.
DrMR: Well, that’s good to know. That’s why we’re having this conversation.
DrAB: If you don’t believe me, we’ll measure it. I can show you. Patients come in, they’re like, “Yeah, I’ve been doing it once a day. The bottle’s lasting me two weeks.” I know from the self-compliance check. We prescribe 12 bottles, 12 weeks, so each bottle should last one week.
I ask them, “Hey, how many weeks does the bottle last?”
They go, “Well, I’m doing it once a day, the bottle’s lasting two weeks.”
“Okay. Here’s your hair mass measurements. Now, I want you to go on twice a day, come back in 90 days.” Substantially different.
DrMR: All right, so twice a day it is.
DrAB: Yeah, brother. Now, listen, some people can’t tolerate minoxidil on their scalp twice a day, because they have scalp irritation or what have you. Even the best quality compounded medication isn’t 100% side effect free. It’s going to be a lot more easily tolerated than the over-the-counter Rogaine with the nasty propylene glycol in there. But let’s just say you’re on the formula 82M, and your scalp is starting to get a little bit irritated, you feel like it’s tender a little bit, maybe it’s starting to flake a bit, you’ve got to back off.
I have a lot of women, 70, 80 years old who are on these minoxidil products, they can’t tolerate twice a day. You know what we do? We put them on an oral dose in the other time of the day. I give them a little whiff of minoxidil orally in that time when they would normally be applying it to their scalp. That’s a trick.
DrMR: That’s just a pill, minoxidil in a pill form? I’ve never even heard of that. Wow.
DrAB: Yeah. Well, minoxidil was a pill first. Remember? It was Loniten, which was an anti-hypertensive. It wasn’t all that good of one, it was kind of unpredictable. A lot of those guys with kidney failure and such, were on dialysis and they were on minoxidil. They were growing hair on their knuckles, and that’s how they decided to make it a topical hair growth drug, back in the 1970s.
So yeah, I’ll put them on a small dose of minoxidil orally as a stopgap to keep the blood levels up.
DrMR: Minoxidil, of course, works for men and for women. That’s probably clear from this conversation. But just for the women, anything specifically regarding minoxidil or the more contemporary version, 82M, that they should be aware of?
DrAB: 82M should be on the top of their list for women with thinning hair.
Laser Treatment for Hair Loss
The top three major league players, just to review: topical minoxidil, a powerful prescription laser light therapy device, and PRP with extracellular matrix. Those are the three main things that we use to protect and enhance hair growth. We didn’t really talk about PRP, but there’s a big difference between your dermatology/skin care/vampire face-lift PRP and what we do here at a hair clinic, in terms of platelet-rich plasma. There’s a lot of nuance in there.
DrMR: Yeah. I want to dig into both of these. Let’s first touch on laser. I believe that we’ve talked about laser a couple times on the podcast. This is something that I was initially a bit skeptical regarding, for no reason other than I just know in hair loss there are so many scoundrels out there looking to sell you anything.
But the evidence here does substantiate that these lasers are helpful. There’s a few different versions. The Capillus RX, I believe it’s called, or maybe now they have the name of Capillus Pro. It’s a cap that you wear. That seems to be what you’re liking. Tell us more about laser, this second of the big three for women.
DrAB: Yeah. Let’s clock back to 1998. I met a guy who said, “Hey, they’re using lasers to grow hair in Europe. How come you’re not using lasers to grow hair here in the US?”
I said to him, “Well, we’re not doing hair removal.”
He says, “No, grow hair.”
I said, “I don’t think that’s going to work.”
I actually convinced him to lend me a unit, and I put friends and family underneath that unit for about six months, and I couldn’t believe the hair growth that I got. I was a major skeptic turned believer. I never knew anything about photo medicine. They didn’t teach me that in medical school as an MD. They didn’t teach me that in my fellowship in hair transplantation or my residency in general surgery. Although I did recall that lasers were good for wound healing, especially in diabetic ulcers. I learned that in New York. I thought, well, at least maybe I can get some good wound healing out of it. I don’t know about this hair growth thing.
Fast forward now many, many years, obviously many years into this thing here. Low-level laser therapy, and I consider myself a low-level laser therapy pioneer, because I was one of the first to present my results from that early pilot study, way back in the year, I think, 1999 or 2000. I presented those results at the International Society of Hair Restoration Surgery with the help of a friend of mine, Dr. Unger. We showed for the first time in that realm that we could grow hair with low-level laser therapy, that we could improve hair quality. Now, it didn’t make a new hair follicle, but it made weaker hair stronger, and made shorter hairs longer, which was awesome.
Today, fast forward, laser therapy is an integral part of my practice. I use low-level laser therapy before and after hair transplants. I use laser therapy before and after PRP. I put lasers on the PRP before I inject it. I put lasers on the hair follicles while they’re sitting outside of the body.
Over the years we’ve prescribed handheld combs, to bands, to head-worn laser caps which were invented 10 years ago now, to the latest and greatest laser light device, which is called the TURBO LaserCap. The TURBO LaserCap has been completely reinvented, re-imagined by the inventor of the laser cap, Dr. Michael Rabin, in collaboration with us here at Bauman Medical.
That’s the mac daddy. I mean, a five-minute device that packs completely flat for portability, with the best quality lasers on the planet. It’s awesome, and it grows a ton of hair. It’s the newest, latest and greatest iteration of laser light therapy devices that are physician-prescribed, that you can use at home.
DrMR: This was within a year, because I believe you spoke with Peter maybe a year ago, and you were recommending it. Is this by Capillus, or by a different company?
DrAB: No. This is from the original LaserCap Company. Remember that Capillus was a knock off of the LaserCap. The CEO of Capillus used to work for LaserCap Company.
Dr. Michael Rabin invented the LaserCap, and he has re-imagined it with our help, in creating this TURBO LaserCap, which packs completely flat. It’s no longer a dome unless you’re wearing it. It’s the fastest treatment time—five minutes—on the planet, and it covers 25% more area than the Capillus RX and any other laser light device that’s head-worn on the planet.
DrMR: It’s five minutes daily. It’s just a cap you put on your head. You don’t have to hold it or anything like that.
DrAB: Nope. You don’t have to move it around. You just charge it up, set it and forget it.
DrMR: Awesome. So this makes weak hair stronger. It doesn’t necessarily grow new hairs, but will it add I guess diameter to your current follicles, would that be a correct claim.
DrAB: Absolutely. Well, remember that male and female hair loss is a product of miniaturization, meaning that the follicles are getting weaker and thinner, and creating a wispier hair, a shorter hair, spending more time resting, less time growing, and so forth.
So anything that we can do to impart energy into the follicle… which is exactly what laser light therapy does. We know now, and 20 years ago we had no idea what lasers did, except that they grew hair on the backs of rats. That’s all we knew. We didn’t know why.
Today we know that laser light energy is converted into cellular energy right at the level of the mitochondria. We know that the photons are accepted at the mitochondrial membrane, right at the cytochrome c oxidase, the electron transport chain. And a huge cascade of events occur, not the least important of which is increasing ATP production due to hyperpolarization of the membrane.
We know all of the mechanisms now. And there are thousands and thousands of studies that have been done on the mechanism of action of photobiomodulation. The whole science has come out within the past 15 years on this. Everything from fat loss, to treating stroke victims with transcranial laser light therapy, to hair growth. It’s just amazing. Wound healing and so forth. Lasers are amazing. No side effects ever with low-level laser light therapy.
DrMR: That’s fantastic.
DrAB: Yeah, but it takes time. It takes a good 90 days to start to see some action.
DrMR: I was just going to say that. I was just going to say, someone should really be thinking… So for women here, the big three: topical minoxidil twice a day, laser therapy and PRP. That’s a robust treatment plan, but just like you said, you may need to be patient and give this time before you can really evaluate if it’s working or not.
DrAB: Yeah. You’re going to have a hard time evaluating it in the mirror, honestly, in those early stages. That’s why the hair check—just going back to that again—and the follow-ups to really see what’s happening right at the level of the scalp are really, really important. Totally critical.
PRP for Hair Loss
DrMR: Let’s touch on PRP. That’s something that we’ve discussed previously with two different guests. What I found interesting about your narrative on PRP is you’ve developed, I guess, a more effective methodology by looking at, I believe, a certain hematocrit count, although I may be misremembering that.
DrAB: The platelet count.
DrMR: The platelet count. That would make sense, it being PRP. Yeah, tell us about your PRP, what effects you see, how well it works, all that.
DrAB: Yeah, I got started with PRP in 2008, as a wound-healing adjunct. We didn’t really know how it was working. We just chose the FDA-approved version at that time. It was the only FDA-approved PRP, which was two to three times concentrate of PRP as a wound-healing gel. We used it on our hair transplant patients.
And then we started to inject it with some other scaffolding, like ACell, which is a pork bladder matrix powder. We were getting increased hair growth, and my colleagues saw it as well as I did, and we were excited about it.
What we learned over the years is that everybody and anybody was starting to make these kits to help us prepare PRP, and they were telling us that every kit was better than the next. I just decided, hey, I’ve got to figure this out for myself. I bought a hematology counter, and I put it in the office. I’m probably one of the only physicians in the world that has a Coulter counter at the bedside, at my PRP treatment room.
What we do is take a blood sample from the patient, and we can tell them exactly what their platelet concentrate is in the whole blood. Then, based on that, we can alter and change our PRP mixing protocol, our separation protocol, to tailor, to get to the optimum platelet concentrate. It’s been described in the literature between one and one and a half million platelets per microliter, what we want to get to. We need enough PRP to treat a good, significant area of the scalp, so I like to use about seven and a half to eight ccs of PRP to treat the scalp. We do literally 600 to 700 injections of that under strict local anesthetic, so you’re not going to feel a thing.
DrMR: From a frequency perspective, rather than having to do this every few months, you’re able to do this once per year?
DrAB: Well, the secret sauce is the bio scaffold. If you’re in the field of regenerative medicine, you’ve got to know that it’s cells, signals, and scaffolds that makes everything go around. That’s the troika, or triad, if you will, that makes the magic happen. And I’m sure a lot of your orthopedic guys can tell you that as well.
We’ve been through a couple of different types of scaffolds over the years. I mentioned the ACell, which is pork bladder powder. We’ve been using more recently the BioD, which is a placental tissue, that’s a human allograft. That provides an amazing scaffold for the body to work on, in conjunction with the cells, platelets, and the signals, which are the growth factors that we’re providing in the PRP. So we teach and train that process and protocol.
It’s called BaumanPRPclass.com, if you want to check out the next class, for those of my colleagues out there who want to learn this process. We don’t give away all the secrets on the podcast, we actually teach them.
There are a couple of other nuances that we use, but the bottom line is that that PRP protocol will last about 10 to 14 months in terms of a boost. We know that, we document that through the routine follow-ups with the hair check. So we don’t wait for the whole PRP boost to go away, we hit it again when the plateau phase is over. They’re going to get a boost of hair growth, the plateau phase follows, and then as it starts to drift down, that’s when we hit it again. That’s typically 10 to 14 months.
DrMR: When you say scaffolding, some people might be picturing something that feels invasive in their head. I’m assuming it’s not anything that you can feel, and it’s not large or… a scaffolding on the side of a building is kind of what I’m picturing.
DrAB: No. Yeah, this is a cellular scaffold. When we say cellular scaffold, the placental tissue is literally morselized, it flows through the tiniest needle known to man. These are tiny little groupings of cells and the information that they contain. It doesn’t cause any kind of tissue reaction. It’s very commonly used in orthopedics, in these joint treatments, as well as in ophthalmology for corneal transplants and replacements, and things like that, and for wound healing on the eye. Yeah, so there’s nothing scaffold that you’re going to feel or see.
Synthetic Scaffolds: PDOgro
But that also brings us to synthetic scaffolds, which is really the latest and greatest lunch-time type procedure, called PDOgro, where in fact we are putting something into the body that actually has to dissolve, something synthetic that has to dissolve.
DrMR: Yeah, so let’s talk a little bit about that, because I hadn’t heard of that before.
DrAB: Yeah. PDO stands for polydioxanone, and I first became aware of polydioxanone as a surgical resident in the 1990s. We used to use that as a deep surgical stitch. It was a purple stitch that many surgeons are familiar with. It’s been used in millions and millions of procedures around the world. It’s a very, very safe, FDA-cleared synthetic material that takes a long time to dissolve essentially, and that’s why it’s used in surgery.
Well, in aesthetic medicine they’ve been using it in the face, for facial rejuvenation, for pulling, and tightening, and also for lifting, and many of your listeners may be familiar with that. I found out a couple of years ago that they were using it in the Far East for hair regrowth. When they were doing these treatments for facial rejuvenation, if the PDO threads were in the skin under the hair-bearing areas, they were noticing improvements in hair growth.
I was unsure about it. I did a little bit of research. I found some clinical trial work and some pilot studies out there from the Far East, in India and Asia. I decided to give it a try myself with a couple of willing volunteers, mostly my staff who were willing to try it, based on what I had shown them, and the safety, of course, that we had investigated.
Lo and behold, we put these threads into the scalp, you don’t feel them or see them, but over the course of time, as they dissolve, I don’t know the exact mechanism, but we do know that there’s increased collagen production, increased blood vessel formation, and a huge dump of growth factors into the area. We think that that might be the trigger for improved hair growth. I’ve seen an amazing hair regrowth in both men and women with this process that we now call PDOgro. It’s been pretty exciting.
I was actually able to debut the process at the South Beach Symposium this year. I gave the presentation of my pilot study, which showed improvements in the hair regrowth in about a half a dozen to a dozen patients. Then we demonstrated it on a patient live at the symposium, in front of a group of hundreds of aesthetic dermatology physicians.
DrMR: Do you feel PRP versus this PDOgro… does one of those have an advantage?
DrAB: Well, the PDOgro actually includes the PRP procedure. It gives you the double whammy of both.
View Dr. Ruscio’s Additional Resources
DrMR: Wow, okay. A lot of cool stuff in hair care.
Can You Revive a Dead Hair Follicle?
One thing I wanted to ask, you made the comment that the laser makes weak hairs stronger. Are there procedures that can help with resurrection of a follicle?
I know if a follicle’s been dead or dormant for a while, you can’t really resurrect it, or at least that’s what I understand. Let’s say a guy has lost maybe half an inch of his hairline, and he’s wondering, is there a way for that to grow back down. Is there anything that does that?
DrAB: Well, absolutely. We can restore a hairline comfortably, undetectably, and with minimal downtime through the latest and greatest hair transplant procedure called FUE, follicular unit extraction or incision. That’s a surgical procedure, but it’s minimally invasive, and it’s done under a local anesthetic in a super comfortable way. Takes a number of hours to accomplish the process, let’s call it six to seven hours here in the procedure room, but it’s comfortable. You’re not going to feel any bit of it while we’re working, because the scalp is completely numb, just like we do with PRP and PDOgro.
It takes about six days for that area to heal up. Of course, we’re going to use a very artistic design of the hairline, so it naturally flaunts your facial features, doesn’t overstep the bounds of naturalness, and when it grows in, it’s going to look 100% undetectable, as long as all of those things have fallen into place.
DrMR: Awesome. Do any of the other prior therapies help with at least a partial resurrection of a receding hairline? Or once it’s receded, is it only through surgical methods you’re able to get it back?
DrAB: Well, once the follicle’s miniaturized down, and it’s growing just a two-millimeter hair that’s un-pigmented and that short, that follicle is basically beyond repair. So it will not respond to traditional therapies that we have on hand right now. Now maybe something in the future will have. If the hairline is gone, the hairline has receded, or the bald spot is bare, you’re going to need some transplants for that area.
The good news is that there’s no linear scar. We’re not going to hit you with a scalpel and put stitches or staples in your head anymore. You’re not going to have to spend weeks out of the gym. You can be back in the gym in three or four days, doing cardio and weights. Just no MMA fighting, no kung fu. You’re going to be healed up under a baseball cap in like six to eight days. Then it’s going to be living and growing hair starting in about four months till forever.
DrMR: You’ll need to use some type of loss prevention strategy, I’m assuming, to make sure that those follicles don’t die. Or are those follicles kind of exempt from the process that was going on in the rest of the scalp?
DrAB: No. The transplanted hair is permanent if we’ve harvested it from the proper zones at the back of the scalp. The back of the scalp is the part that guys shave when they shave their head. If they’re bald, they have to shave the back because those hairs don’t die, they stay forever. The monk’s ring, if you will, is immune to DHT. Those follicles, when we move them to the front, remember that they’re immune to DHT. Your transplanted hair is permanent, but your other hair is not.
DrMR: Gotcha. Okay.
DrAB: You have to still be on medical therapy, but not for the transplants.
DrAB: For the other hair, many patients will do transplants plus PRP same day. In fact, that’s pretty common. Nine out of ten of my hair transplant patients will do PRP same day.
DrMR: This is, like you said, minimally invasive, where, worst case scenario you’re wearing a hat for a little under a week.
DrAB: Yeah. You’re back in the gym. First of all, there are no activity restrictions of normal daily life. You can be back in the gym in three to four days, weights and cardio and stuff, treadmill, you want to swim, tennis, golf, you can.
Baseball hat is recommended if you don’t want anybody to know or see the area that’s been operated, because it’s a little crusty, honestly. If we’re doing a large procedure, you’re going to have a bit of a buzz cut around the sides and the back, but that’s kind of in fashion these days. About eight days, it’s going to be completely healed, you’re not going to see anything there. Then you just have to wait around for the hair to grow.
DrAB: You’ll be about halfway grown at six months, fully grown at one year.
DrMR: Fantastic. I mean, this line of therapy has really come a long way over the past… I don’t know how many years this evolution has occurred. Certainly it seems like there are some nice options to help people, men and women.
I want to come back to closing remarks here in a second. Where can people track you down online if they want to learn more about you and your work?
DrAB: Right. I’m Dr. Alan Bauman. You can find me at baumanmedical.com. My facility is located in beautiful downtown Boca Raton, Florida. It’s where I’ve been for over 20 years. We have a 12,000 square-foot hair hospital where we can take care of any hair and scalp health condition that you might have.
I do consult with patients from all across the globe through Zoom, Skype, FaceTime, video conferencing. I do occasionally have consultations and procedures scheduled in New York. We’re working on some other areas around the country. Happy to reach out to you if you are anywhere on the planet Earth, and you can just do that through baumanmedical.com.
DrMR: Yeah. I would encourage people to seek the counsel of someone who’s a specialist in this area. I actually did a consultation with you, just because I wanted to bounce off my regimen. And you definitely filled in some gaps that I had. You can only get so proficient if you’re reading about this stuff but not actively seeing patients on a daily and weekly basis for years and years and years, to figure out how this all integrates into a model.
I think my biggest takeaway from this episode would be, if you’re experiencing hair loss, as a male or as a woman, to take action swiftly. I think one of the things that thwarts people from taking action is thinking—and this is more so what I see in my clinic—“I’m taking steps to improve my gut health, and I’m making these other interventions to improve my health internally and globally. Let’s wait to see if that will spill over to resurrection of hair, or just preservation of hair,” which it may.
I can’t say that women are ever jumping for joy in terms of their hair after we’ve tuned up their gut health. They might be less thin, they might have less rashing, they may have less falling hair. But my main fear is that people want to stay on the natural-only train for so long that they miss a window of opportunity for these other therapies: for women, minoxidil, laser and PRP. It seems that you’re much better off acting early, because a lot of these therapies stop loss, and help make the follicles that are intact work better. My main takeaway is act rather than wait, because the sooner you act, the better the prognosis seems to be.
DrAB: Michael, it’s so true. Because once the follicle is dead and gone, there’s very little we can do aside from transplantation. Probably you see this in your clinic: if you have a patient that you’re optimizing, and they’ve been through, let’s just call it a medically traumatic situation, the damage is already done to the follicle. The follicle doesn’t necessarily rebound. It’s not like taking away chemotherapy and all of a sudden the hair regrows. Even in those cases, sometimes it doesn’t regrow all that well. The follicle’s been damaged by that injury.
Medical conditions, medications, lifestyle factors, genetics, you name it, it all takes a toll on the follicle, and unfortunately most of it is not reversed by removing the offender. It needs a little bit of help, and that’s where we come in.
Yeah, if you’re out there with thinning hair, just get on some treatment. And find a qualified, experienced, certified and credentialed physician. Don’t run out to your local dermatologist who’s going to spend like six minutes with you and throw you a bottle of Rogaine on the way out the door, or tell you, “Oh, you’ve got some hair. You look fine. You don’t look bald.” That’s ridiculous, most of those guys are so insensitive, it’s terrible, and gals as well.
Board certification is really critical. There are only 200 of us that are board-certified by the American Board of Hair Restoration Surgery, and was accepted into the International Alliance of Hair Restoration Surgeons. That’s another good place to look. Find someone who does this on a daily basis, not somebody who does a hair transplant once a month or something like that. That’s a recipe for danger.
DrMR: Yeah, agreed. Well, guys, I’d definitely recommend checking out Dr. Alan’s work, and even doing a consult with him if you’re looking to get some clarity on what can be, in my own personal experience, a confusing experience.
You read about these different therapies and it’s hard to tell if they’re working, so it’s nice to have someone like yourself, Alan, out there who’s trying to do this in a reasonable fashion. You’re not selling snake oil. You’re not making big promises that you can’t keep, just to sell someone six months of whatever BS in a can it is. I really appreciate that approach.
Wherever we can save people from heartache and wasting their money is a huge win. Just want to thank you again for what you’re doing, and taking the time to chat with us today.
DrAB: Well, thanks so much for having me, and that’s been the goal of my practice for over 20 years, a patient-centered approach. If it’s good for the patient, then it’s good for us. And that’s why we have a lot of fun doing what we do. It’s just super fun seeing our patients grow hair, and looking good, and feeling great.
DrMR: Yep. Well, I can agree with you in my own GI realm. It’s a nice feeling to help people get over their hurdles.
DrAB: Yeah, you’re doing a great job there too, Mike. Good job on your end too.
DrMR: Thank you again, Alan. Been a real pleasure.
DrAB: All right. Thanks for having me on.
What do you think? I would like to hear your thoughts or experience with this.