Does Azelaic Acid Stop Hair Loss?

/by William Rassman, M.D./2 /

Does Azelaic acid in Xandrox block DHT? Will it will inhibit virtually all synthesis of DHT in the scalp at the follicle level as claimed by some [people? It has been said that it will not bind with the 5 alpha reductase enzymes (Propecia binds with type 2, 5-alpha reductase.), but it will inhibit the synthesis of all of the hormones in the 17-hydroxy group, which would include testosterone, DHT and androstenediol, the most potent of the androgens. Can you clarify this for me?

I reached out to my colleagues and Drs. Shaprio and Cooley responded with one of the better answers given to me. The focus of the quoted study was on in-vitro (in the laboratory) studies and there are no invivo (in patients) studies. The finding in the laboratory is interesting, but it is a big jump to answering it for people like you who seem to research things in great depth. I would warn most of my readers that there is a long stretch to findings in the laboratory and responses in patients. we have seen cancers killed in the laboratory and no impact on patients. Certainly safety issues are pre-eminent and drive much of what I recommend for my patients.

“I think Dr Lee is referring to this old in vitro data. I’m skeptical azelaic acid is a good in vivo topical 5AR inhibitor and even if it is”, as Dr. Shapiro said, “there’s still the systemic DHT that must be addressed. I doubt that azelaic acid does much for hair growth. ”

Read the citation summarized below from British Journal of Dermatology, 1988 Nov;119(5):627-32.

Inhibition of 5 alpha-reductase activity in human skin by zinc and azelaic acid, by Stamatiadis D, Bulteau-Portois MC, Mowszowicz I., Laboratoire de Biochimie B, Hopital Necker-Enfants-Malades, Paris, France.

The effects of zinc sulphate and azelaic acid on 5 alpha-reductase activity in human skin were studied using an in vitro assay with 1,2[3H]-testosterone as substrate. When added at concentrations of 3 or 9 mmol/l, zinc was a potent inhibitor of 5 alpha-reductase activity. At high concentrations, zinc could completely inhibit the enzyme activity. Azelaic acid was also a potent inhibitor of 5 alpha-reductase; inhibition was detectable at concentrations as low as 0.2 mmol/l and was complete at 3 mmol/l. An additive effect of the two inhibitors was observed. Vitamin B6 potentiated the inhibitory effect of zinc, but not of azelaic acid, suggesting that two different mechanisms are involved. When the three substances were added together at very low concentrations which had been shown to be ineffective alone, 90% inhibition of 5 alpha-reductase activity was obtained. If this inhibition is confirmed in vivo, zinc sulphate combined with azelaic acid could be an effective agent in the treatment of androgen related pathology of human skin.

Desperate for Hair that Looks Real

/by William Rassman, M.D./1 /, ,

I’ve been losing my hair since i was 19 and now i’m 23. I’m pretty much at a strong norwood 3. I tried alot of things, but nothing has helped. My mom’s dad was bald and the rest of his family too. Basically don’t know what to do. I’ve read that i’m too young to get a transplant and have not made a move on it. Im also afraid to get one cause of the scars. I really don’t know what to do. It has pretty much ruined my life. I use to have girlfriends all the time now have not had one since 20. Pretty much so desperate i would sell my mustang just to pay for a transplant but i don’t know if i should if results don’t look real and if there is scars involved.

First, be careful with statements like “I would sell my mustang just to pay for a transplant,” because many unscrupulous people will take your money and sell you hair. Realistic expectations, reasonable predictions based upon a good solid examination of your hair and hair loss distribution with good microscopic examination of the scalp, a good doctor with great integrity and lots of good experience, and some comparative shopping will tell you much about what you can do. Read my book, available online in PDF format here, or get one sent to you free. Visit my offices if you are in California. Natural results with a hair transplant are not difficult to obtain, but first you must know where you stand and what your long term ‘Master Plan’ should be before you jump to a hair transplant.

I know that if you do not feel good about yourself, if you do not have the self-esteem you want, then having a normal life becomes more difficult. A hair transplant may or may not solve these problems. The main reason we generally discourage men of your age in getting a hair transplant is that (1) you may not be able to determine when the hair loss will stop, (2) you may not be mature enough to understand both the financial and social remifications of the transplant process, and (3) you may not be able to get the realistic expectations that fit with your hair metrics (hair density, contrast in colors, character of the hair, laxity of the scalp, etc..). In effect, will you have enough hair supply to follow your hair loss to meet your expectations? Get a good doctor and develop a Master Plan with him/her. Then and only then, can you deal with the decision of “Should I or shouldn’t I?”

Taking Multiple Hair Loss Drugs at the Same Time

/by William Rassman, M.D./2 /

I’m am a 22 year old male and have been balding since i was 17. I have been taking Proscar, saw palmetto and applying minoxidol for about one year now and there is definite improvement in the crown of my head but not alot in the front. I have just ordered dutasteride over the net but i still have some proscar left. I was wondering could i take them at the same time, not take the proscar and just take the dutasteride, or maybe take the dutasteride and not take the proscar?

When you play doctor, you sometimes undo what you are trying to do. I know it’s been mentioned on this blog many times before, but for the readers that aren’t familiar with the various hair loss drugs, Proscar (5mg) is the same medication as Propecia (1mg). Propecia is FDA approved for treating hair loss, and Proscar is a prostate drug. Many people will cut Proscar into quarters to achieve the benefits of Propecia, but for a reduced price.

Dutasteride and Propecia are both very good DHT blockers, with Dutasteride probably stronger. There is no point to take Propecia if you are taking Dutasteride, but I have warned the young men out there that there is no FDA clearance for Dutasteride in young men for hair loss use.

Saw Palmetto may be a competitive inhibitor to Propecia and/or Dutasteride. That means that when Saw Palmetto hooks on to the DHT receptor instead of Dutasteride or Propecia, it will compete with these drugs. Saw Palmetto is a weak DHT competitor, making the stronger drugs less effective. You may be undoing what you want to do.

Predicting Hair Loss

/by William Rassman, M.D./6 /, ,

Hey Doc,
I got a question for you. Im 26 years old with no definitive loss yet although i do have the mature hairline. My question is has do with genetics. What is the likelyhood that a male will either take after their father or mothers father in terms of Male Baldness, is it almost 100% that you will take after one or both of them or could you concievably not follow either one’s baldness pattern and instead follow inherit MPB pattern as that to your cousins, uncles, great uncles, grandfathers.

This is the reason i ask my father started to bald by the time he hit age 25 and was completely bald by around 35, my mothers father started balding in his late teens and was completely bald by 30 yet here i am at 26 with no apparent loss. With this family history i always figured i had no chance to keep my hair because both my father and mothers father have excessive MPB, so i assumed by the time i graduated High School, i would have some sort of loss.

Also the reason i ask is because generally many of the male family members on both sides (father and mother’s side) namely uncles and cousins have fairly good hair, is it possible i was fortunate enough to escape the MPB gene from 2 of the closest male members (dad, mothers father) and somehow instead inherited the hair of the more distant male relatives?

IN you encounters as a derm, do you think most males take after either their father or mothers father, or is it common for a male to not follow either one of their patterns and instead have a hairloss pattern that of a more distant relative.

Thanks for your response

Basically, we can take after either parent or neither parent. We can inherit genes and not have them expressed, yet pass the balding genes to our children or future grandchildren. I tell all of my patients that the best way to know, is to have a good microscopic examination of your scalp periodically. By the age of 27, you should have an idea of what your possible hair loss pattern is. In your particular situation, the appearance of a mature hair line has no significance for your balding pattern. It is possible that your pattern may have skipped generations or was inherited from others in the family that do not express the gene.

The Woods Technique

/by William Rassman, M.D./0 /,

Is the Woods technique a viable option to consider for hair transplantation?

This technique is undocumented and has never been explained. This doctor has kept his process secret, including the yield and growth rate of the transplants. Woods has chosen to do his technique without any peer review and not publish it in recognized journals. By making his technique secret, he has succeeded in creating a mystique (a cult) that he has promoted on the internet to create hype.

I have had the opportunity to see a couple of his patients and the recipient sites are not as clean or as natural as ours (I believe he creates larger recipient site wounds). In addition, the scarring in the donor area is evident on his videos and on his patients. Doctors in Australia tell me of significant failures in his hands based upon patients that have come to them. Although bashing doctors is at times fashionable for competing doctors to try to gain a competitive edge, Woods has failed to fulfill his basic responsibilities with the Oath that doctors take when they are given their diploma to practice medicine and surgery. That failed responsibility (to share knowledge and educate patients and colleagues to improve the quality of medical care) increases my skepticism about his work. Creating secrecy does little more than to make a sect that confuses the public and people who may get sucked into marketing hype and then ask obvious questions, wanting to know facts. I have tried to find out what he does, if only for curiosity. For now, however, Woods chooses to do his thing under the cover of secrecy.

For more info on the New Hair Institute’s published FUE technique:

Experiencing Pain from Propecia Use

/by William Rassman, M.D./1 /

Hi Dr.Rassman
I am a 20 years old guy. I have a bad family history with hair loss. The same thing happend to me 1 year ago. I decided to take propecia 2 weeks ago. The problem is that in the first 5 days i had testicular pain.Than it was better and better and now i dont have it anymore. I asked my doctor,but he didn’t tell me why it was happening.Can you tell me why did it happen to me?
Thank you for your time.

I am not familiar with testicular pain from Propecia. It is not a known side effect and I have had no patients report such a problem to me, despite the many patients who I have prescribed this drug to.

The Magic Bullet for Hair Loss?

/by William Rassman, M.D./0 /,

Hi DR. RASSMAN.
HI I would like to tell you a little story about me… I am 39 and I started losing my hair in 2000 and I took the advice of tricoligist a person who studies hairloss. THIS person told me all the wrong things like saw would stop my hairloss..!!!! it did not!!!!! I am so mad because if I started on propecia I would not have this thin spot on my vertex. I would like you to go this web site and look at these products and tell me what you think of these products and services. I would like you honest opinion..PLEASE!!!! LET ME KNOW

I’ve removed the link you provided as to not give free advertising to that site.

I have looked over the site you asked about, and I have read your email carefully. The only DHT blocker that is FDA approved is Propecia. The drug Avodart has been reported from reliable sources to be more effective than Propecia, but it is not FDA approved for hair loss (it is FDA approved for prostate problems, however). Many of the other substances listed on this site are not proven, yet there are claims appearing all over that say these products are good at preventing or reversing hair loss. The site appears to sell everything they review, and that puts out an alarm for me. I do not cash in on FADS, but rather use my knowledge and extensive education to help my patients use what works.

You made a mistake years ago; do not make it now. If you have genetic hair loss yould should be on Propecia. Using other approaches may not hurt, but I would question the value of them.

Thinning Hair Since Age 14

/by William Rassman, M.D./0 /,

Dr. Rassman,
I’m 20 yrs old and i have been losing my hair since i was 14. I’ve noticed my temples are receding quite rapidly and on top of that, my scalp is looking more thin. I have a brother whos 3 yrs older than me and hes been losing his hair as well since he was a teen except his temples aren’t receding as bad as mines. My Father is 45 and his hair looks natural for his age even tho hes its becoming more thin.

i have never tried any hair lost products and i’m at the point where i want to do something right now before its all gone. If you can please give me advice on what to do or recomend me doctors in the L.A. area that can help, it would be greatly appreciated. Thank You Very Much.

You need to be examined by a doctor who will look for a variety of conditions, including:

  1. Male pattern genetic hair loss (shows miniaturization in a defined pattern and sounds like what you may have)
  2. Alopecia, including a variety of other inherited forms that are not traditional male patterned balding

Only an expert doctor in this field can make the diagnosis. With the gravity of this in a young man, I would suggest that getting the best medical advice is what should drive you at this time. I can not make a diagnosis without examining you, but I would love to see you in one of my offices. There will be no charge for the examination.

New Medications for Hair Loss?

/by William Rassman, M.D./1 /

They are suppose to come out with new meds ..beyond avodart that are suppose to work well do you know about this???

I am unable to answer this question. I do not follow the FDA applications for new drugs nor the clinical trials that are in the early stages of development. What I do follow are those drugs that reach the ‘end of that pipeline’ and at this time I am not familiar with drugs at this stage of development from which to calculate a time-line.

Reverse Reaction from Propecia

/by William Rassman, M.D./0 /,

Hi doctor i have been using the propecia for the last 5 months and my hair got thinner and softer . I started to use the prpecia 1 year ago for two weeks and i had the same symptoms i quite using it and my hair got back to normal. This is really disturbing me that i have overall thinning which i was never worried about beacuse i was only try to keep the corner of my frontal hairline.I have type early 3. in my family there is not anyone that has ever loose hair on top of their head.They all have thick hair.

They all have 3A .Now i have been worrying about thinning hair which was never the case. Is there any way propecia might have a reverse reaction on some patience, beacuse the body might see the dht blocker as a virus and fight back to the madicine by producing more DHT. Is it possible that this could happen in some .Thanks doctor for your time.

To my knowledge, this is not a known side effect of Propecia. If you are a Class 3A and that is your family pattern and you think that (a) this is going to be your final pattern, (b) you can live with it, (c) you believe that it is a side effect of the drug, then stop the Propecia. Whatever the benefits that are claimed by the drug company, the decision to take this drug is yours and only yours. I have met some men who for their own reasons, abandoned their recommended Propecia treatment. This becomes a personal choice and like everything in life, we make choices and deal with the consequences of those choices. Propecia is not for everyone.

Slimy Hair

/by William Rassman, M.D./2 /,

Dr. Rassman,
Recently I noticed that my hair has a slimy feel to it when it gets wet, and then it will dry as if it has gel in it, very hard. I have always lost hair in the shower, but it seems that this is increasing with the slimy hair problem. Another symptom that I’ve had is extreme scalp itch, but no more than normal dandruff visible to be the cause of it. This summer I spent a great deal of time in the swimming pool, but no one I’ve been with is experiencing similiar problems. Also, I’m taking Adapex for weight loss and wonder if this might have some correlation with my symptoms. I’ve tried researching my slimy hair and came up with a process used on wigs called decutilization, where layers of the hairs cuticle is removed for some reason. However, I can’t find anything to do with my own hair having this problem or how to fix it. A friend suggested that my hair had lost it’s acidity, but home remedies and ion hair strippers have not helped. Please help me figure this out. I want to solve the problem so my normally soft healthy hair will return. Thanks so much.

Swimming daily will reduce the wax (sebum) what protects the hair from drying and becoming brittle. Maybe that summer is now over, the problem will go away. You might think about whatever you are using as hair products as a possible cause of your problem, so stopping or changing the entire regimen of products may be helpful, particularly if you change only one at a time.

Female AndroGenetic Alopecia (AGA)

/by William Rassman, M.D./2 /,

Is it normal to drop between 30-50 strands of hair when washing if you have female AGA and using 5% minoxidil for 3 months already?

The average person will lose about 100-150 hairs per day and replace that same number with new hair growth. I believe the proper question is: After 3 months of Minoxidil 5%, should I see results? The answer to this question is that if Minoxidil was to work on your hair loss problem, you should see a positive effect in this 3 month time-frame. Three months is the minimal time needed to get an effect of Minoxidil for losing hair but the impact on the visible effects may not be seen for up to a year or more.

Herbal Combination for Hair Loss

/by William Rassman, M.D./1 /

There is an alternative therapy to propecia. Try this: Strong Green Tea Extract, Soy Isoflavones, and Evening Primrose oil. I also, would like to challenge any doctor that believe that is quackery. This combination will work much better than Propecia and there are no sexual side effects. Don’t believe me try it and you will begin to feel your hair stems getting stronger and you will slowly start re-growing hair.

There are many herbal suggestions for alternative treatment for male pattern genetic balding. I have no experience with this, but clearly you have. I have stayed with traditional, known treatments for hair loss like Propecia and Minoxidil as they have predictive results that are scientifically well documented. I stay away from experimenting on my patients with unproven herbs or poorly defined drugs with benefits. I am also not aggressive when it comes to the unapproved FDA drugs for hair loss like Avodart. If the herbal approach works for you, then that it good for you. If it does not work, a person experimenting with these herbs run the risk of losing hair that may never come back. As hair loss is a progressive process, the pattern for hair loss in each man with the genetic predisposition for it, they may lose valuable time and valuable hair moving them further down the balding pattern scale.

Hair Transplant in Black Woman

/by William Rassman, M.D./2 /,

I am a black woman age 27. Seven years ago I had thick black hair. I used chemical products on my hair and got my hair styled by various hair dressers. Fine bumps developed in the back of my head, I attended a doctor and I was told that there were keloids. About a year after I conceive and gave birth to my only daughter that was in 1999. I relaxed my hair again and this time I am not sure if it is as a result of the keloid but my hair started thinning at the front and it is getting worse. I try to keep my hair up to hide the bald spots and this has affected my self esteem some what. Can this problem be rectified. Can my hair grow back or can I have hair transplant to make it look normal again?

This is a very complex problem that would require an examination of your scalp. Without seeing you, I would be loathe to suggest what to do. See a good dermatologist first, then see if he/she recommends another expert. Bald areas in the scalp are easily treated provided that there are no disease contra-indications for transplantation. Keloids and a variety of diseases that cause Alopecia need to be evaluated.

Propecia Beyond 5 Years

/by William Rassman, M.D./0 /

Can you please tell me what the latest information is on Propecia beyond the 5 year mark ? There was a hypothesis that a plateau might be reached at the 5-6 year mark as hairs entered a new growth phase and the hair counts might improve. Is this the case?
Thank you

The formal Propecia study only goes out 5 years, and I can’t seem to find any official published data beyond that (even from Merck, the manufacturer). The suggestion from what I have seen in the 5 year study is that the number of hairs will probably drop off slowly, possibly more slowly than it would without the medication. It is also the experience of many that this is not just a ‘number of hairs’ game, but it is also one which reflects hair quality. The thickness of the hair shaft in those treated with Propecia gets better and will probably stay better while the drug is maintained. But your question is asking for the difference beyond 5 years, and I am afraid that a solid answer would only be speculation on my part.