If an unlimited supply of donor hair were available, could transplant surgeons give a patient the 200 hairs per cm squared that the average human head has or would a new tool smaller than the .5mm tool im aware need to be created to achieve this look?

I suppose you can achieve 200+ hairs per cm squared (which is about the average for a non balding Caucasian male), but I find most people who are obsessive with hair per square centimeter don’t understand the full story and are mislead by all the discussion groups on the Internet.

You can have 100 hair per cm squared and still look like someone with 200 hairs per cm squared, as this is not a numbers game. Furthermore, hair transplant is NOT about the numbers and density. It is about the art of creating a natural looking hairline with minimal number of hairs you harvest.

With respect to graft survival, there may be some issues of the grafts surviving such close packing in ONE surgery. Now 200 hairs in a square centimeter is possible with multiple surgeries to the same area… but again, numbers do not translate to how it looks overall.

Tags: donor supply, hairloss, hair loss, hair transplant, dense packing


I seem to recall reading a message of yours where in a reply to a reader you mentioned that you personally discontinued your usage of finasteride. You felt it had stabilized your hair loss.

What confused me is that you seemed to imply finasteride stabilized your hair loss and you could thusly stop treatment. (or at least chose to and wasn’t any worse for it). It was my understanding that hair-loss will always resume once treatment is discontinued. Is this not true? Or did I misunderstand your message?


SeniorYou’re right that once you discontinue Propecia (finasteride 1mg) treatment, your hair loss resumes. For me though, since I originally had crown loss, I tried finasteride to see if I could increase the hair in the crown. At that point, my crown was clearly stable and I did not gain anything from the finasteride.

Considering that I was about 60 years old when I started taking the drug, I probably had as much hair loss as I could expect for my age. There are advantages of being a senior besides discounts in the movie theaters and on public buses. I hope that clears up any confusion!

Tags: rassman, hairloss, hair loss, finasteride, propecia

I am a 38 year old male who has always had full head of hair. I also have been on the drugs Dilantin and Neurontin for many years.

After issues with Dilantin caused bone loss, I was tapered off that drug and now only take Neurontin. Since, ending Dilantin I have had numerous side effects, including hormone issues (increased Prolactin levels, lower end bioavailable testosterone, etc) and increased hair loss.

My hair still covers my head but it feels thinner and I notice alot of it in the drain of the shower. Over the past year off of Dilantin, the Prolactin levels have dropped back into the normal range. However, I still notice the hair loss.

Is it possible that these hormonal issues have caused my hair loss, or could it be the Neurontin acting on its own ?(my Neuro says I am having other effects from the Neurontin that may have been masked when I was taking it with Dilantin, so I wondered if hair loss could be included with that.)

As I haven’t had a seizure in many years, I am going to get off Neurontin too if all goes well, but I wanted an opinion on this hair loss before I go bald. By the way, my dermatologist doesn’t seem to have much of an opinion, is there another type of specialist I should look for who might help?


You need to speak with your doctor and read the label material that comes with the drugs, which will have comments about hair loss if it is a known side effect. I’d expect your prescribing doctor, who you should always talk to before changing your medication, would be the best person to ask. That being said, here are some past posts that may be of interest to you —

  1. Dilantin and Hair Loss
  2. Dilantin and Male Hair Loss
  3. Neurontin (Gabapentin) and Hair Loss
  4. Neurontin and Hair Loss
Tags: dilantin, phenytoin, neurontin, gabapentin, hairloss, hair loss

Dr. Rassman,

Below is a study that links alcohol and testosterone levels- Does an increase in testosterone levels necessarily accelerate hair loss in men who are predisposed to lose their hair? Thank you-

Study abstract: Alcohol Clin Exp Res. 2003 Apr;27(4):682-5. Testosterone increases in men after a low dose of alcohol.

We have known for some time that alcohol is metabolized by the liver, as is testosterone. I can not connect the dots between the casual drinker and the hair loss victim.

Tags: alcohol, testosterone, hairloss, hair loss

Hi Dr. Rassman. You’ve talked about the FDA cracking down on “false advertising” in the past, specifically on labels. I was wondering why Head and Shoulders can put on the front of their bottle “Improves Hair and Scalp Health Guaranteed”. This is a loosely based statement lacking specifics; i.e. how it improves my hair or scalp health. I can understand it clearing up dandruff, hence improved scalp health, but hair?

People may associate improved hair health with thicker, stronger hair which I believe no magic shampoo has been factually proven to do so.

I asked FDA consultant Norman F. Estrin, PhD, Managing Partner at Estrin Consulting Group LLC, to answer this one. The following response was what he sent me —

FDAImproves Hair and Scalp Health” is a claim that the FDA would call “puffery”. Puffery is allowed for cosmetic claims. You correctly pointed out that it is a loosely based statement lacking in specifics”. This is characteristic of puffery. It just as easily could have said “livens up your hair” even though we all know hair outside the body is not alive.

Head and Shoulders is an OTC drug because it treats dandruff. It is also a cosmetic as well and its cosmetic claims are regulated by the FDA Office of Cosmetics and Color Additives, while the drug claims are regulated by the Center for Drug Evaluation and Research (CDER). The Federal Trade Commissions also monitors fraudulent claims, especially in advertising. Here are some other examples of puffery:

  • Best shampoo ever!
  • Energizes your hair
  • Eye awakening
  • The skin you want
  • Safeguards your beauty
  • Age Control
  • Helps restore youthful zones
  • New life for your hair

Since these claims are qualitative descriptions rather than hard facts, the FDA cannot regulate such claims because they are so hard to define. If, however, a cosmetic company claimed “Proven to increase collagen synthesis”, the cosmetic company would be in trouble because any product that does so would meet the FDA definition of a drug:

(A) articles intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease
(B) articles (other than food) intended to affect the structure or any function of the body of man or other animals

In this example, increasing collagen synthesis in the body would be an effect on the “structure or any function of the body of man”.

Tags: product labels, fda, shampoo

Hello,I am a 31 years old female and a mother of one child. I am currently losing hair on the top of my head, you can actually see scalp. My hair has become very thin. I have always had fine hair but it is curly so I can cover it up very easily. I have been looking around for something to help me and came across Viviscal. Would you recommend this for a woman who has excessive body hair? If not what do you recomend? I thought of Rogaine but I hate the idea of having to take it forever.

Thank you

ViviscalI don’t recommend Viviscal, as it hasn’t been proven to my satisfaction to treat hair loss. It also isn’t FDA approved, as it is just regarded as an over the counter supplement. The key ingredient appears to be a marine protein extract, so if you’ve got a fish allergy you should steer clear. Another key ingredient is vitamin C. While the product might help nourish your hair, I don’t know that it would treat hair loss, particularly if it is genetic in nature. Otherwise if you wish to use it, that is your choice to make.

For women, your options for treating hair loss are unfortunately rather limited. Have you seen a doctor to find out what the possible cause of your hair loss is? We compiled a partial list of female hair loss causes here.

Tags: hairloss, hair loss, viviscal, nourkrin, marine extract

I have plagiocephaly and feel very uncomfortable with my head ever since I started to bald. I feel that since it has bothered me more with my balding, is hair transplantation a good solution?

Flatened headFor those that aren’t familiar with plagiocephaly, it is when the skull is misshapened and flat. This usually occurs when a baby spends too much time laying on his/her back in one position.

As you’re aware, this condition can be hidden by good hair styles… so a hair transplant is an excellent approach to your problem. Whether or not you’re a candidate, I couldn’t say without an examination. But generally speaking, transplantation should help you become more comfortable with your appearance.

Tags: plagiocephaly, hair transplant, hairloss, hair loss, misshapen skull, deformity


I think I may have an allergic response to many shampoos. I’m getting a lingering burning sensation for about 30mins after washing it out.

Are there any other alternatives for washing hair? Or should I just not worry?


I’d see a dermatologist to try to figure out what you’re allergic to. There’s probably some common ingredient amongst the shampoos you tried, but I’d have no way to know what that could be.

Tags: allergy, shampoo, allergic

I am an african american woman with traction alopecia. I have about an inch to inch and a half of traction above my forehead and temples. No traction any where else. I have ample donor supply. My hair is very thick and coily. I recently saw a hair transplant surgeon in San Francisco, that told me i have the donor supply but may not have a successful transplant because of the texture of my hair. The surgeon has showed me pictures of his past work but I was not impressed.

They were pics of african amer men but i saw little improvement. I see pictures and comments on the web that it is possibly for women of my hair texture to have successful transplants. I am not prone to keloids, however, I experience ingrown hairs in my pelvic region. Is there a specialist our Dr or technique that can help me?

Success of a hair transplant surgery is highly variable with each medical group. It’s not like going to a mechanic, where you can have a tire changed or your oil changed and the end result is pretty much the same. Unfortunately, I don’t have any specialist referral to provide.

Surgery in African American men and women is technically challenging, because each hair (underneath) the skin is curly. In other words, the grafts are curly. That means it is difficult for the technicians to cut and place the grafts. If threading a needle is hard enough, imagine threading a tightly coiled thread through a needle. Many doctors and medical groups for this reason shy away from performing surgery on African American hair or even curly hair. Add this to the fact African American men and women have a greater tendency to develop scarring and keloids. If you’re not prone to keloids, you’re lucky!

Another point to make is that hair transplantation surgery in women generally is not as straight forward as surgery in men, as the results may not be permanent. Men have a permanent donor area, whereas women’s hair loss is more diffuse. You should also know that to fix the balding from traction alopecia, the patient will often need more than one surgery, as the density of transplanted hair may not match the density of the natural hair behind it.

Alas, I am not your surgeon and I am not here to give you a personalize opinion. This information is generalized and you need to understand what is and is not possible. Weigh out the pros and cons of what you are trying to achieve and make an informed and educated decision.

Tags: african american, black, hair loss in women, female hair loss, hair transplant, hairloss, hair loss

I read the item about hair foliclle damage because of lactic acid secretions on the scalp. Well, I was told the same thing, and given a lotion to neutralize the acid. I can confirm this situation does occur when subject to unpresidented levels of stress. When i say stress, stress at such a level I was physically ill with it, for a long period of time. Halucinations etc

One day I notice that my incredibly thick hair was going fine and curly. Finasteride made no difference, and I was shown hairs from my head, that had no outer sheath on them. Also prior to seeking advice the affected area became hot, itchy and greasy- when i was stressed, and this is where the hair follicles have died.

Lactic acid is not a cause of hair loss. Whatever you read about lactic acid secretions on the scalp causing hair loss is false. I found some message board that talked about it, but I don’t think it went beyond speculation. It wasn’t mentioned in any medical journal that I could find.

Without knowing what dose or how long you took finasteride, I don’t know that I could agree that it “made no difference”. I don’t know enough information to give you anything beyond generalities, but if you’re balding in a pattern, it’s not stress. Stress could be exacerbating the loss, but it’s ultimately your genetics. I wouldn’t expect a “hot, itchy, and greasy” scalp to be normal from stress, and it’s certainly not normal to have hallucinations, no matter how much the stress. You need to seriously see a doctor.

Tags: lactic acid, hairloss, hair loss, hallucinations, stress

Snippet from the article:

A class action was filed today in the Supreme Court of British Columbia by Vancouver resident, Michael Miller, against Merck Frosst Canada and its affiliated companies. The lawsuit has been brought on behalf of Canadian men who used Propecia or Proscar and suffered continuing sexual dysfunction.

Propecia and Proscar are prescribed as a cosmetic treatment for male pattern hair loss also known as androgenic alopecia. The product monograph discloses that some men may experience sexual dysfunction but states that the symptoms disappear after cessation of the drug.

Mr. Miller, who is in his early 20s, was concerned when his hair started to thin in some areas. He was prescribed Proscar which he hoped would stop his hair from thinning.

Canadian lawsuitRead the full story — Class action filed against manufacturer of Propecia & Proscar

If this young man was in his early 20s and prescribed Proscar without being told to cut the pill into a smaller daily dose to treat hair loss, his chances for side effects would’ve increased. Proscar is 5mg finasteride used to treat prostate issues. Propecia is 1mg finasteride used to treat hair loss. So if you’re taking 5x the recommended dose, what would you expect?

We’ll see how this class action suit plays out…

Tags: hairloss, hair loss, merck, class action, propecia, proscar, court, lawsuit

Just a quick note about Propecia. I have been on it for 15 years. Never had a single side effect. Well not that I’ve really noticed anyway.

Any time you take a medication you have to realize that there are side effects. One of the side effects to Proscar for instance is that it can STOP YOUR HAIR FROM FALLING OUT!!! Get the idea? Birth control pills also has a ton of side effects but almost every girl I know is on the pill… hmmm…

I’m not saying to run out and buy Proscar but if you do, it’s your choice. There’s nothing wrong with educating yourself before taking something but understand that “side effects” are the reason you’re taking it. This is your hair on drugs… Any questions?

Good advice. I think if one actually read all the side effect possibilities in common medications that they think are 100% safe, they’d be surprised.

Tags: side effects, hair loss, hairloss, propecia

NOTE: The following comes to us from a longtime reader that wishes to remain anonymous. He’s gifted us with some insightful posts in the past about the FDA, LLLT, and clinical trial regulations. His email is as follows:

The Journal of Sexual Medicine recently published an article that has been the source of several Balding Blog posts, including one that answered a reader who wondered if, “the study suggests up to 15% of men taking the drug might experience some form of sexual dysfunction” in context of “the warning label on Propecia (that) … only 2 percent of men might experience erectile dysfunction while using the drug…”.

As a fan of the Balding Blog and a clinical trialist (someone who interprets clinical trial data), and one who has no relationship to Merck or financial interest in finasteride use, I have reviewed the article:

  • Dr. Rassman has correctly pointed out that this article is not a study per se, but a review of data in the literature from completed and published finasteride studies that included placebo groups.
  • The review included 3 studies of men using finasteride (1 mg daily) for alopecia, 15 studies of men using finasteride (mainly 5 mg daily) for benign prostatic hyperplasia, and 2 for “none” listed as the condition.
  • The 3 studies of men using finasteride for alopecia included a combined total of 1196 men receiving finasteride, and 1035 men receiving placebo.
  • As Dr Rassman has nicely emphasized before, the “true” incidence of an adverse event (attributable to a drug) is the percentage of men who experience a side effect receiving an active drug minus the percentage of men who experience a side effect via placebo. It is important to emphasize that this equation implies no causality (i.e., if a man receiving a drug gets a side effect, it is attributable to his active drug or placebo regardless of other factors – such as diabetes – that may be causally involved).
  • The largest incidence of sexual side effects among the 3 studies involving men with androgenic alopecia is from the smallest study involving only 286 men who received finasteride and were a considerably higher age (41-60 years) than men in the 2 other studies (ages 18-40 years). In older men, factors that contribute to sexual side effects (diabetes, coronary artery disease, and aging) are considerably more frequent. In this small study of 286 men, changes in sex drive were observed (over a period of 1 year of treatment and 1-year of follow-up) in 4.9% receiving finasteride and 4.4% receiving placebo (treatment effect of 0.5%). In the same study, erectile dysfunction was observed in 3.8% of men receiving finasteride and 0.7% of men receiving placebo (treatment effect of 3.1%). In the two larger studies – involving younger men – the incidence of erectile dysfunction was 0.5% (1.4 minus 0.9) in one study, and 0.75% (0.75% minus 0) in the other study.
  • Taken together, these results are consistent with the incidence of sexual side effects noted in the finasteride (Propecia) US product label: decreased sex drive (1.8% finasteride vs. 1.3% placebo) and erectile dysfunction (1.3% vs. 0.7%).
  • The “15%” figure contained in the Balding Blog post by a reader was based in part on the cited (and misleading) newspaper commentary from a business reporter that stated ”…up to 15% of men taking (Propecia) might experience some sort of sexual dysfunction.” Indeed, The Journal of Sexual Medicine article cites a study of 613 men aged 45-80 taking 5 mg finasteride daily for benign prostatic hypertrophy for 2 years. In this study, 15.8% of men receiving finasteride (compared with 6.3% of men receiving placebo) reported erectile dysfunction. This is 5 times the recommended dose for treating hair loss, though. The largest study, involving 2315 men aged 45 years or older (with prostate hypertrophy), showed the next largest effect on erectile dysfunction: 8.1% (finasteride) vs. 3.8% placebo. This latter figure is almost identical to the incidence of erectile dysfunction noted in the finasteride (Proscar) US label.

In summary, one can’t properly mix “apples and oranges” involving clinical trial data involving different doses of drugs with different patient populations and for different indications. The journal article offered no major insights to me but is a nice review of currently published work. To me, a significant issue of side effects is reversibility. Even a minor headache is devastating if due to an active drug and is not reversible.

Despite anecdotes from blogs, I have seen no case histories published in the medical literature of men using finasteride for androgenic alopecia who have developed irreversible erectile dysfunction that has been attributed to use of finasteride. I am not saying that such a phenomenon does not exist; I just have not read any well-documented case history. A newspaper commentary from a business writer that references a blog where a 32-year old man developed erectile dysfunction (“had pretty lousy quality erections otherwise”) of unknown duration 12 years after starting finasteride and who cites “(recent) experiences with a new sexual partner” is not compelling (to me).

Tags: propecia, proscar, finasteride, merck, hairloss, hair loss, study

Dear Dr Rassman
Your blog is a true beacon in the foggy world that is hair loss treatments and remedies. I am a 24 year old man that is currently being treated by a fantastic dermatologist and together we have been able to hold onto my slightly receded hairline using only FDA approved generic drugs (fin and min).

However I would like to tell a story of two important people in my life, both doctors, My father a surgeon and his best friend (my godfather) a general practitioner. In the final year of studying medicine my father worked incredibly hard and was able to secure numerous surgery placements at some top hospitals, his best friend unfortunately feel ill in final year, performed badly and missed many opportunities for work experience and specialist placements. At the same time whilst sick, his wife fell pregnant and by the end of his medical study he was without work, with a child on the way and incredibly concerned about his future well being.

With a great amount of thought and a huge amount of courage he secured a loan and started up his own general practice at the tender age of 25. At the start business was slow as many patients where not comfortable being treated by such a young inexperienced doctor. This situation created a huge amount of stress for my godfather and the high levels of stress paired with poor hair genes lead to rapid hair loss, his hairline and mid-scalp was literally washed down the sink.

However as his hair fell his demeanor and appearance was altered creating the illusion of a much more experienced doctor and it became far easier to market himself and his clinic. Business soon picked up and his financial problems where alleviated. In contrast, my father who has a full had of hair (I get my hair from my mum) struggled for years starting his surgical practice because his full hairline created the illusion of inexperience, which turned off many patients initially.

My point is that hairloss has its positive externalities and as I go into the world of business I am glad that I have a receding hairline as it gives the impression that I actually know what im talking about, even if I don’t. Although I certainly do not want to be bald!

Thanks again Dr Rassman

Thanks for sharing the story with us. I agree with you on one level, but there is a counter argument to your story. It just depends on how you spin it…

In our society, while we associate bald men with wisdom and age, we tend to favor and look up to men with hair in our choices of leaders. Look at politics and leading men in Hollywood cinema as examples. Of the US Presidents of the past half century, only Eisenhower was bald. It’s rare to see a major movie star with heavy male pattern baldness. There’s always exceptions, but if you consider that balding men reflect 50% of the male population, that should tell you something. And without even looking it up, I’m sure a majority of male CEOs for Fortune 500 companies have decent hairlines, as well. I’m not suggesting it’s right or wrong, but it’s society.

Tags: hairloss, hair loss, balding

I am a 24 year old male, and have experienced mild hair loss for the past 2 years or so, mostly in the temple region. However, the rate of hair loss has significantly increased in the last 8 or 9 months, and has expanded to the entire top of the head. The front is now very thin, and my scalp is plainly visible all over when the hair is wet. I began taking Propecia 3 months ago, and have not noticed any slowdown in the rate of hairloss. What I have noticed recently, is that my hair has become very oily (it has never been very oily before), and mild acne is beginning to form at the hairline.

So my two questions are:
1) Is the increased rate of hair loss, and sudden expanded hair loss region normal?
2) Is the oily hair and/or acne side effect of Propecia? Normal symptoms of hair loss? Or something else?

Thanks a lot for your great blog!

These are questions for your doctor. Remember, you’re asking about a prescription medication. You should pose questions about this sort of thing with your prescribing doctor.

In my experience, what you are reporting for the first three months with regard to seeing a benefit on Propecia is usual as it takes almost a year to see value. With regard to the oily nature that you are reporting, I have not seen this reported by my patients.

Tags: oily hair, propecia, hairloss, hair loss