For reasons scientists don't fully understand, sensitive follicles must be exposed to DHT for a prolonged period of time before the miniaturization process is complete. But what they have learned is that taking a drug that inhibits the binding of 5-alpha-reductase on testosterone can reduce the levels of DHT and thus slow or even stop the miniaturization process. There is such a drug and it's called finasteride (sold as Propecia), the first of the three aforementioned treatment options.
"Finasteride blocks 70% of the conversion of testosterone to DHT," Arocha says. "There are some reported sexual side effects such as erectile dysfunction, problems with ejaculation, and depression, so you should speak to your doctor before taking it. However, there have been very good results for stopping hair loss and even regrowing hair." According to the product website, most men in the clinical studies see results within three to 12 months. If no improvement is seen after that time, further treatment is unlikely to be of benefit. Also, if you quit using the product, you will likely lose the hair you retained or regrew while under the treatment.
Even better than finasteride alone is when it's used in conjunction with the second treatment: the topical solution minoxidil (sold as Rogaine). "Minoxidil is like a follicle fertilizer," Kobren says. It acts as a vasodilator that keeps hair in the anagen phase longer and can increase the diameter of those downy vellus hairs, but it doesn't get to the root cause of hair loss. "Only 35% of men are able to slow or stop hair loss with minoxidil alone, and only 10% see regrowth, usually in the crown area, and like the finasteride, the benefits stop if you stop using the product," Arocha says. "But using both together over time yields the best nonsurgical results possible."
Which brings us to the final treatment option, and one that both Arocha and Kobren say should be the last resort: hair transplantation. "I sat in a transplant doctor's office in 1988, and he told me that if I were his son, he'd say try a few grafts. That was back when they used to put in 4mm plugs. I was thinning, sure, but I was 22 years old. If I'd let him put plugs in me then, I'd have ended up looking like a hairbrush with bristles of 30 hairs each lined up in rows and columns starting at my hairline. It would have ruined my life."
Fortunately, the technology has dramatically improved and now doctors like Arocha can harvest individual follicular units--a natural grouping of one to five hairs--from permanent donor sites above the ear and at the back of the head, and move them to the thinning or bald areas. Arocha, who also started to lose his hair at a young age, approaches each scalp as though it were a canvas: the harvested follicles the paint, and he, the artist. "Think of a forest," he says. "At the edge, you see shrubbery first, then a few trees, then groups of trees that grow thicker the further you go. I observe that same principle, carefully placing the donor follicles in a progression. There must be artistry in the technique, or the results can be disastrous."
The average cost for a transplant is $7,000-$15,000 or more. "Buyer beware," Arocha says. "Do careful research on the transplant surgeon and his technique. Know what's involved and what's at stake. And realize that the result depends largely on the amount of "paint" a surgeon has to work with." But when it works, it really works. "I can't tell you how many men come back and tell me that their hair restoration has given them back not just their hair but also their lives. That's proof that it's worth it."