The following is a letter I sent to a patient I met in the office today. I think that you can see that patient welfare is more important than how much money I can make from doing his FUE surgery. I will call the patient PAUL.

“Paul, it was good to see you today. You were on Propecia for a year which reduced your sex drive which just did not go away with time. I think that today’s visit was s shocker for you. After seeing two other doctors who recommended a hair transplant for you, you came in prepared to get an FUE transplant and we then spoke about this and the Scalp Micropigmentation (SMP) alternative. Your hair density is lower than average (75% of a normal hair density) and your balding pattern is a Class 7 pattern with some hair still left in the top and crown area but what you have is very thin and clearly falling out. You have a very large head so any hair that is moved must cover your very large head. The number of grafts to get reasonable coverage to what you expected are just not there. At 29 years of age, you are almost certainly going to completely develop a Class 7 pattern of balding in the next few years with just a rim of hair around the back and sides of your head. Although your hair appears more coarse than normal (a good quality to have), there is just not enough of it to get the coverage you want. I showed you a series of photos with people having your balding pattern and showed you what the reality of the situation was.

Also, I introduced you to a man who has exactly the same balding pattern that you have and received Scalp Micropigmentation (SMP) today (something you knew nothing about). You can see that these results (which reinforces a shaved look), are very good and similar to your present look but with the ‘appearance’ of hair on your head. The advantages of SMP for you are:

1- The size of your balding pattern is not a factor
2- Your low density of your donor area is not a factor
3- The results are instantaneous while a hair transplant takes 6-8 months to grow out.
4- It is less expensive than a hair transplant ($7,000 vs $20,000 for each 2000 graft Robotic FUE)

You have much to think about. I am not against doing an FUE on you as I am sure that I can make it natural looking, but you will never be able to obtain the coverage you want (front, top and crown) even though you will get natural results like those patients in the photos I showed you. Please come to our next open house here on Saturday February 7th at 11am where you can meet previous hair transplant patients, previous FUE patients and previous SMP patients.”

Comment: I have spoken out many times about the ethics of doing hair transplants in patients like the one discussed above as well as many others. Had PAUL not come to see me, he would certainly have chosen to undergo a follicular unit extraction (FUE) procedure because he was committed to it. No selling was required to go forward with an FUE procedure, the selling on my part, was to dissuade him from going on that course. Such a procedure would have made him unhappy and I know it for certain because I found someone who I did 4780 grafts on (2 sessions) who had good but see-through results. I always inform the patients what to expect and when this man found out what he would have gotten, he was certain that it was not what he was going to do. Although PAUL had better quality hair than the patients whose pictures I showed him, PAUL’s donor density was much poorer. He would have ended up with a thinner frontal area and a bald crown, something he was certain he did not want. Honesty here is a mandated quality, mandated by the medical board that issues doctors their license to practice medicine and mandated by the Hippocratic oath we swear to when we graduate from medical school. Those who violate this oath are immoral people. Being a doctor does not grant ‘God’ status to the doctor. To justify the recommendation to have an FUE hair transplant, if the doctor was ignorant of the facts as I presented them, then his immorality knows no bounds. Think of it, age 29 and at the forefront of his life with a life changing decision to make, just to be led astray by either by an ignorant doctor, or just a dishonest one.

Thank you very much for your posts and the great help that you are offering to your readers and far beyond. You have stated in previous posts that Propecia halts the loss of hair but at the end the gene will win and the outcome will be as it should have been without taking Propecia. This is in a way depressing but do you have any statistics to what period of time Propecia remains effective. You mentioned previously 5 years for Propecia to peak. What will then happen after this 5 years period, will it lose its loss of hair benefits and hair starts falling again. Will it still beneficial to take it then. Thank you

Thank you for following BaldingBlog but there are some key misconception and understanding in your question.

Propecia (finasteride) does not halt hair loss forever but often slows it down, particularly in younger men. Genetic male pattern balding will take its course and you will continue to lose hair over time. Some men will have great response to Propecia and it can halt hair loss for years (as it did with a patient who I just met with who used it for 8 years and halted his hair loss but eventually genes will win out.

Propecia does not peak in 5 years. The clinical trial of Propecia was for 5 years. It showed that over the 5 years, men who took Propecia lost less hair than men who took a placebo.

Everyone is different in their progression of hair loss as it is written in their genes. Everyone is different in their response to medication such as Propecia. Thus the benefits of Propecia and its effectiveness is dependent on the individual.

In a previous question you said propecia doesn’t work for DUPA. Isn’t DUPA miniaturization of the follicle we see in Aga and FPB. I have seen that most cases of FPB also has some degree of thinning on the whole head, back and sides. I thought it had already been proven that dht caused miniaturization of the follicle. If not DHT then what are the other causes of hair miniaturizing? Actual miniaturization and not just hair falling out like TE or AA. Miniturization of anykind has been said to be the hallmark on diagnosing all AGA. Could it be that it does work at the same percentage as it does in mpb but because we see so much less cases of DUPA and by the time it shows you need to be at the point of 40-50% loss. Is it more a game of not being able to catch up after such loss.

I believe there are some misconceptions here I would like to clear up.

Male Pattern Balding is a genetic condition in men. In other words if a man was born with the gene(s) for MPB, he will have a hair loss in a certain predictable “pattern” (thus the term Male Pattern Balding). Scientist have found if a man has the gene for MPB, a hormone called dihydrotestosterone (DHT) is partially responsible for his hair loss. If a man does not have the MPB gene, DHT will not cause hair loss. Propecia is a drug that block the DHT action and it works in men who have the genes for MPB.

Propecia will not work for DUPA or Female Pattern Balding because hair loss is not a related to DHT and it is not related to the gene for male pattern balding. DUPA (Diffuse Un-Patterned Alopecia) is similar to generalized hair loss in women and as such is not impacted by the drug Propecia (finasteride).

Miniaturization is just a phenomenon seen in the hair loss process. You will see miniaturization in naturally shedding of hair in a non balding person in some of the hairs at the end of their normal cycle. A non balding person will have up to 20% of miniaturized hair (many of them actually vellus hairs that are small, very short hairs found in each follicular unit in all people). Hairs go through natural cyclex of growth and shedding (anagen, catagen, telogen). A person with MPB will likely have more than 20% of miniaturization in a specific pattern around his scalp. A person with DUPA will likely have much more than 20% of miniaturization all over the scalp in a non specific pattern (thus the term Diffuse Un-Patterned Alopecia).

Hi Dr Rassman, Sir does proton pump inhibitors such as omeprazole causes telogen effluvium? Or does PPI increase hair fall in a person with androgenic alopecia?

Aside from what you may read in drug insert labels noting all the possible side effects, I personally have not seen hair loss from PPI. Androgenic alopecia and PPI possible side effects are unrelated.

Hello. Dr Rassmann. I have MPB and i am using minoxidil 5% and finisteride for last 4-5 months. Sir the problem is that i am expriencing itching with the use of minoxidil. I m not experiencing any scaling etc but just itching. Sir , if i am experiencing itching because of minoxidil but even after this i want to continue using minoxidil, so can i do so? Or will using minoxidil, instead of controlling my hair loss and promoting regrowth, will accelerate my hairloss because of the itching side effect?

Itching can be a side effect and some patients cannot use minoxidil because of this as it can lead to irritation and hair loss. Please follow up with your doctor for an exam.