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Male Pattern
Hair Los
Explained In 5 Level of Complexity 

Our Trichologists explain this common hair loss condition at increasing levels of complexity. So whether you're a primary school student or a biomedical graduate, you'll find an explanation to suit your level of interest.

When men grow older, sometimes their hair begins to thin and recede, especially at the top and front of their head. This is known as male pattern hair loss. It's a natural thing that happens to many, and it's mainly because of changes in their body as they age. It's a common thing that happens, and there are good ways to manage it. There are treatments that doctors can give to make the hair healthier and to help keep the hair on the head. 

Male Pattern Hair Loss Explained
Level 1: 

Male Pattern Hair Loss Explained
Level 2

As men get older, they might notice their hair getting thinner or losing some from the top of their head. This is called male pattern hair loss. It happens because of changes in their bodies, mainly due to hormones. Hormones are like little messengers that tell different parts of the body how to work, and sometimes they tell hair follicles to stop making as much hair.


Doctors have special ways to help with this. They might suggest using certain shampoos or lotions, or even taking a type of medicine that helps the hair stay healthy and not thin out too quickly. It's a pretty common thing for men as they age, but there are effective ways to take care of their hair.

Male Pattern Hair Loss Explained
Level 3

Male pattern baldness, or androgenetic alopecia, is a prevalent form of hair loss in men, often identified by a receding hairline and thinning at the crown. This condition arises from a combination of genetic factors and hormonal changes, particularly the increase in dihydrotestosterone (DHT), a derivative of testosterone. DHT affects hair follicles, causing them to shrink over time, which leads to thinner and shorter hair growth.

Treatments for this condition include Minoxidil and Finasteride. Minoxidil, a topical solution, is thought to work by enhancing blood flow to the scalp, providing better nourishment to hair follicles and encouraging hair growth. Finasteride, taken orally, works by reducing the production of DHT, thereby halting hair loss. While these treatments are effective for many, they vary in their success and are more likely to be beneficial in the early stages of hair loss.

Male Pattern Hair Loss Explained
Level 4

Male pattern hair loss (MPHL), also known as androgenetic alopecia, typically manifests as a receding hairline and thinning hair, largely due to the combined effects of genetics and the hormone dihydrotestosterone (DHT). DHT, a derivative of testosterone transformed by 5-alpha-reductase enzymes, is critical in the miniaturisation of hair follicles, which is a defining feature of MPHL. An individual's genetic makeup, especially variations in the androgen receptor gene, determines how hair follicles respond to DHT, influencing the severity and progression of hair loss.


Pathophysiology and Genetic Factors

The development of MPHL involves changes in the hair growth cycle, primarily the shortening of the anagen (growth) phase and the extension of the telogen (resting) phase. This shift results in the production of shorter and thinner hairs over time. Additionally, genetic factors affect the sensitivity of hair follicles to androgens, particularly DHT. The role of inflammation and oxidative stress in the scalp also potentially contributes to follicular miniaturisation.


Pharmacological Treatments and Their Mechanisms

Minoxidil and Finasteride are the mainstays of pharmacological treatment for MPHL. Minoxidil, a topical solution, is thought to work by enhancing blood flow to the scalp, thus improving the health of hair follicles and promoting hair growth, providing a noticeable aesthetic benefit. However, while minoxidil has been shown to slow the rate of the miniaturisation process, it does not effect the testosterone pathway and so cannot halt miniaturisation, only slow it down.

Conversely, Finasteride does effect the testosterone pathway. Finasteride, typically taken orally, reduces the production of DHT by inhibiting the Type II 5-alpha-reductase enzyme, thereby reducing DHT's impact on hair follicles. Additionally, a number of other anti-androgen treatments have also shown to be effective at disrupting the testosterone pathway, and halting the progression of MPHL.


New research is  exploring treatments that target hair follicle development pathways for their potential efficacy in treating MPHL.


In essence, MPHL is a condition deeply influenced by hormonal and genetic factors. Understanding these complex interactions is key to effective treatment. Current therapies aim to modulate hormonal influences and support follicle health, while ongoing research is investigating new paths for treatment, steering towards more tailored approaches to managing hair loss.

Male Pattern Hair Loss Explained
Level 5

Male Pattern Hair Loss (MPHL), also known as Androgenetic Alopecia, is the most common form of hair loss in men, characterised by a receding hairline and thinning crown, leading to varying degrees of baldness that is typically graded by using the Hamilton Scale. MPHL has a multifactorial etiology, including the intricate interactions of genetic predispositions and hormonal influences, predominantly the role of dihydrotestosterone (DHT). Research into this condition delves into the mechanisms underlying hair follicle miniaturisation, the pivotal process in MPHL, and the exploration of various treatment strategies. This area of study not only focuses on the pharmacodynamics and pharmacokinetics of current treatments such as Minoxidil and Finasteride but also investigates emerging therapies and novel hypotheses like the Arao-Perkins Body. The ultimate goal is to move beyond merely halting hair loss, aiming for the regeneration of hair follicles at a molecular and cellular level, guided by the principles of personalised medicine.


Genetic and Hormonal Pathways in MPHL

Male pattern hair loss (MPHL), or androgenetic alopecia, represents a complex interplay between genetic predisposition and hormonal effects. The sensitivity of hair follicles to DHT, a product of testosterone conversion by the enzyme 5-alpha-reductase, is central to MPHL pathogenesis.The role of androgens in MPHL was first identified by Hamilton (1942) and since then our understanding of testosterone and DHT in MPHL has developed.


DHT binds avidly to the androgen receptor (AR) in the cytoplasm, forming a DHT-AR complex. A conformational change to the complex reveals the nuclear localisation signal allowing the complex to translocate to the nucleus of dermal papilla cells, where it regulates DNA transcription. Downstream gene expression is thought to activate the miniaturisation of new anagen hairs during the kenogen phase. Over many successive hair cycles this process converts androgen-sensitive terminal hairs into vellus-like hairs, rendering them aesthetically useless. 


MPHL onset and progression is intricately linked to genetic factors, particularly the polymorphisms within the androgen receptor gene. Variations in the CAG repeat region of the AR gene are thought to influence the receptor's activity, thus altering the follicular response to androgens (Ellis et al., 2001). Additionally, the hair growth cycle in MPHL is characterised by a disruption involving shortened anagen phases and prolonged telogen phases, leading to the progressive thinning of hair.


In Male Pattern Hair Loss, inflammation is an increasingly intriguing aspect of pathogenesis, and while the exact role of the inflammatory response is still to be elucidated, key inflammatory markers and cytokines have been implicated including TNF-α (Tumor Necrosis Factor-alpha), IL-6 (Interleukin-6), IL-1β (Interleukin-1 beta), TGF-β (Transforming Growth Factor-beta), and PGD2 (Prostaglandin D2). These factors contribute to inflammation and may have a role in follicular miniaturisation, with TNF-α, IL-6, and IL-1β particularly associated with the inflammatory response, while TGF-β and PGD2 are linked to the inhibition of hair growth and follicle miniaturisation.


Other factors such as oxidative stress, which generates reactive oxygen species (ROS) have also been implicated in the miniaturisation of hair follicles (Trüeb, 2009).


Pharmacodynamics and Pharmacokinetics of Current Treatments

The primary treatments for MPHL include Minoxidil and Finasteride. Minoxidil, initially developed as an antihypertensive medication, operates as a vasodilator, speculated to function by opening ATP-sensitive potassium channels in dermal papilla cells. This mechanism is thought to enhance blood flow to the hair follicles, thereby increasing the duration of the anagen phase as well as potentially shortening the kenogen phase. The net result of these hair cycle changes sees the clinical benefit of increased hair density (hairs per cm2), increased long hair volume, and a retardation of the miniaturisation process. Minoxidil’s active form, Minoxidil Sulphate, indicates the involvement of sulfotransferase enzymes in its activation (Messenger & Rundegren, 2004).

Finasteride, a synthetic 4-azasteroid compound, specifically inhibits Type II 5-alpha-reductase, thereby reducing the conversion of testosterone to DHT and mitigating the downstream effects the DHT-AR complex has on hair follicles. Its bioavailability and pharmacokinetics, including peak plasma concentrations and terminal half-life, facilitate its efficacy in MPHL treatment (Kaufman et al., 1998).


Emerging Therapies and Hypotheses

Advanced research is focusing on more targeted therapies and exploring novel hypotheses. The exploration of the Wnt/β-catenin and Sonic Hedgehog (SHH) signalling pathways, crucial in hair follicle development, presents potential targets for therapy, with abnormalities in these pathways linked to hair cycle disruptions in MPHL (Lei et al., 2013).


The Arao-Perkins Body Hypothesis

A notable hypothesis in the field of MPHL is the role of the Arao-Perkins (AP) body. Originally described by Tatsuyoshi Arao and Edwin Perkins (1967), the AP body is characterised by complex elastin fibre deposition around hair follicles, identified through distinctive staining patterns. The AP body’s presence, particularly its dense elastic tissue deposition beneath the follicle, may contribute to the irreversibility of follicular miniaturisation, representing a form of elastosis that potentially hinders new terminal hair growth (Rushton et al., 2021). Professor D. Hugh Rushton at The Rushton Clinic hypothesises that a link between the AP body and androgen action on the follicle, provides potential insight into the mechanism of anti-androgen action in arresting hair loss.


Future Directions and Personalised Approaches

The future of MPHL research and treatment is leaning towards personalised medicine, driven by advancements in genomic, proteomic, and transcriptomic analyses. This comprehensive approach aims to develop treatments tailored to individual genetic and molecular profiles. The integration of such advanced techniques is expected to unveil novel genetic and molecular targets for MPHL, moving beyond the prevention of hair loss to promote the regeneration of hair follicles at a molecular and cellular level. 


The understanding of MPHL at this level involves a detailed appreciation of the genetic and hormonal underpinnings of the condition, the pharmacodynamics and pharmacokinetics of existing treatments, and the exploration of novel pathways and hypotheses. The integration of these aspects forms the foundation for future research directions and the development of more effective, personalised treatment strategies.

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