When I was a teenager, my mum reassured me that I wouldn’t go bald in my 20s like my father had. She seemed pretty sure of this. “Look,” she said, brightly, pushing back her hair from her forehead, “you’ve got my hairline, not your dad’s.” At the time, I bought her argument, but within 10 years her reasoning had been revealed to be magnificently wrong. My hairline had begun its slow march north, a clear sign that I’d inherited male pattern hair loss from one of my parents, if not both of them.
I pretended not to be bothered at the time, and as the years went by I persuaded myself that my ever-shorter haircuts might make me look better than I used to. But deep down it felt unfair, a genetic quirk I didn’t deserve. I’d wince as the barber held up the mirror behind me, revealing an ever-widening bald patch. The advent of social media gave me an exciting new pastime: untagging myself from photos that gave an unflattering perspective on my gleaming forehead, which was pretty much all of them. I pretended not to be bothered, but it was a pretence, and that pretence continues today, in my 40s; while stoically accepting hair loss as my destiny, I know perfectly well how I feel about it. I don’t like it. I’ve found myself turning to classic coping mechanisms such as wearing hats and growing a beard, hilariously feeble attempts at misdirection that fool nobody, least of all me.
“Hair are your aerials,” says Danny, the hirsute drug dealer in the film Withnail and I. “They pick up signals from the cosmos and transmit them directly into the brain. This is the reason bald-headed men are uptight.” Danny’s conclusion – that all hairdressers are in the employment of the government – was stoner paranoia, but in one sense he was right: balding men are often uptight, about their baldness if nothing else. As coping mechanisms go, my hat and my beard are pretty benign examples. But while hats and beards tend not to provoke any additional anxiety, it would seem that transplants, drugs and wigs certainly do.
Androgenetic alopecia is the medical term for this inherited form of hair loss, and while it affects both men and women, it’s men whose anxieties tend to be targeted by the hair loss industry. It’s estimated to be worth at least $1.5 billion a year worldwide, servicing the needs of millions of men and becoming increasingly adept at persuading them to part with money. A casual internet search returns a disorientating array of options that promise to alleviate the misery of the balding man: from herbal remedies to surgical procedures, from magic foams to fancy hairpieces, from restorative shampoos to nanofibre sprays for “colouring in” bald patches. Some of them work, in the sense that the hair loss might be made less apparent (no miracle cures exist), but what works for one person might pan out disastrously for another. The resulting arguments play out daily between thousands of voices across dozens of websites, helping to generate a smokescreen of confusion behind which snake-oil salesmen can operate freely.
The trauma of hair loss
Spencer Stevenson started losing his hair at a young age, and he’s spoken widely in the media and online about the trauma it has caused him. To assuage his misery he ended up having treatments costing a total of £40,000, including 11 hair transplants, many of which fell way short of his initial expectations. Following that horrific experience, he’s become a vocal mentor for those suffering from hair loss, offering advice and detailing his suffering at the hands of what he considers to be a brutal, cut-throat industry. “This is the problem,” he says. “It’s governed by money, and there are only a few organisations that have the patient’s best interests at heart. The industry has an ugly reputation for preying on the vulnerable.”
This vulnerability is rarely acknowledged, but it’s widespread. A 2005 study, spanning five European countries, found that 43 per cent of men with hair loss were concerned about its effect on personal attractiveness, with 22 per cent worrying about its impact on their social life and 21 per cent linking it with feelings of depression. Alopecia areata, an autoimmune disease that causes hair loss in men and women, has its own psychological consequences, which are often discussed in the media, but the incredibly widespread condition of male pattern hair loss has caused distress since the year dot and is talked about far less. History tells us of men willing to try all manner of bizarre remedies to thwart it, while bystanders find their frustration (and indeed their hair loss) faintly amusing. In the Old Testament, the prophet Elisha is taunted for his baldness by a group of boys as he heads to Bethel; he’s sufficiently touchy about this to call for the assistance of God, who promptly summons two bears to maul the boys to death. Harsh, certainly – but it’s worth noting that God chose to exterminate the taunters rather than tackle the hair loss. You can’t really blame Him, though. Male pattern hair loss is a very tricky problem indeed.
According to the UK’s National Institute for Health and Care Excellence, the condition affects 30 per cent of men under 30, increasing to around 80 per cent of men over 70. Its causes are well established, but poorly understood by those of us who have it. We might blame blocked pores, over-shampooing, over-brushing, the water supply or even the remedies we’ve bought, but the truth is that it’s a cruel trick played by nature on the genetically susceptible. Dihydrotestosterone (DHT) is thought to be the hormone responsible; it’s synthesised from testosterone by an enzyme, 5-alpha-reductase, that’s found in the dermal papilla, a small compartment at the base of the hair follicle. This kicks off a process of miniaturisation in hormonally sensitive areas such as the forehead and the crown. The dermal papilla cells reduce in number, the follicles shrink and, as the American Hair Loss Association puts it, they stop producing “cosmetically acceptable hair”.
The first consequence of this is progressive baldness. The second, and arguably more important, is our psychological response to it. “It’s whatever it means for that individual man,” says Anthony Bewley of the British Association of Dermatologists, who has a special interest in the psychology of skin conditions. “A sense of loss of attractiveness, a loss of youth, a loss of virility, or even emasculation. And although it’s a physiological change, ie something that happens as you get older, to dismiss it as something that isn’t a disease, or something that doesn’t matter, or something that’s just your hair – that’s utterly unhelpful for people whose confidence is compromised.”
The men who suffer
A balding Bruce Willis is widely considered to be sexy, but this isn’t enough to reassure most of us that our thinning hair isn’t a curse on our masculinity. For every relationship that breaks down, falters or fails to begin, baldness is frequently used as a scapegoat. “If only I had a full head of hair,” goes the train of thought, “things would be different.” The logic is hilariously flawed – but it’s a seed that can grow quickly if it isn’t kept in check, and is fertilised by a culture that encourages bald men to conceal their condition, often leading to repressed anger, unhappiness and resentment. Most healthcare professionals would agree that coming to terms with hair loss would be the best option for most men, but this avenue is rarely explored by those in distress; most of us see the problem to be tackled as hair loss, rather than our attitude towards it.
“I’d say that the most desperate emails, the people who sound like they’re at their absolute lowest ebb, tend to be from men,” says Amy Johnson at Alopecia UK, a charity offering support and advice to men and women with all types of alopecia. “By the point they’re getting in touch with us, they’ve not felt they’ve been able to speak to anyone else about their feelings, so it’s an outpouring to an anonymous person. But when people say it’s much harder for women, and for men it’s alright, I say actually, no, that’s not what I find from the support emails that come in.”
Jay Patel, the co-founder of MH2Go, a wig supply and fitting business, sits in his office just off Brick Lane in central London, fiddling with a pen as he recounts his tale of hair loss. “About four or five years ago I tried to commit suicide,” he says. “There was a lot of other stuff going on, because I also suffer from body dysmorphia. I was put in hospital for three weeks, and I got a lot of support. After that I told everyone that I wore a wig, and the whole burden just lifted. I stopped feeling embarrassed, I stopped feeling ashamed.” I can’t help but glance up at Patel’s hairline; you’d never tell that it’s a wig. He’s a good-looking chap, and you sense that he’d look great with or without hair. But having told me about his wig, he forces a smile. He knows that I know. “I’ve turned something that was an issue into my livelihood,” he says. MH2Go grew from a bedroom-based mail-order service, MensHair2Go, into a more discreetly named high-street operation. From the street the premises look like a regular salon, but inside Patel offers advice to people looking to buy wigs, while his business partner, Egita Rogule, styles and fits them. The price list is, by wig standards, very reasonable: £495 for the first and £250 for each subsequent “system”, each of which should last between four and six months.
Now it’s Patel’s turn to look at my forehead. “You see,” he says, “you wouldn’t be a good hair transplant client because of the larger area to cover. It’s just not feasible.” He picks out a hairpiece from a box. “So, we call this one the iBase,” he says. “All companies give them their own names – you know, Super, Elite and so on – but they’re all the same, unprocessed human hair. Do you want to try one? You probably should, as you’re here.” I’d already decided before my visit that I didn’t want to have a fitting, that I didn’t want to emulate Elton John or, for that matter, Burt Reynolds. But hey, it’s just me and Jay, so I bite the bullet and sit down in front of a mirror. “So, this isn’t made for your head shape, or anything,” he says, “and it’s black hair, so it’s not your colour. Just imagine that it’s grey.” Patel puts it into position and stands back. “Actually,” he says, “it looks quite good.” I’m inclined to agree with him – but at the end of the day, it’s a wig. I’m wearing a bloody wig.
“I do my consultations in a way that makes people aware of what they’re getting themselves into,” says Patel. “I say, look, it’s a wig. It’s never going to be your own hair. We’ll make it look the best we can, but you’re still wearing a wig.” His honest approach stems from a bitter experience he had in his early 20s, when he paid a company £20,000 for a series of wigs that lasted just a few weeks. “I ran out of money, because I was only 23,” he says. “But I was locked in with them. It’s like a drug, they were my suppliers.” The nature of wig fitting, which requires the top of the head to be shaved before it’s glued or taped, means that once you’re in the game it’s not easy to get out. “So you can take advantage of clients,” explains Patel. “If you go to other companies, you’ll be met with people who are very cocksure, very confident, because they’re in it to sell, sell, sell. It’s very rare to meet someone in this industry who’s been what I’ve been through.”
Under the knife
Nadeem Uddin Khan, director of the Harley Street Hair Clinic, is about to disprove Patel’s theory. “I’m just looking for a picture of myself, somewhere here,” he says, flicking through his phone before finally finding what he’s looking for. He turns it around to show me: it’s a picture of a balding guy, good-looking, perhaps slightly self-conscious. Again, I instinctively look back up at his current hairline: it’s neat, buzzcut and very different from the photo. “That was about 10, 12 years ago,” he says, putting his phone face down on the table. “When I lost my hair it was just terrible. A year of not going out. So I understand what these guys go through.” Khan was one of the first people in the UK to undergo the FUE (follicular unit extraction) method of hair transplantation, which his clinic now specialises in. FUE is regarded, particularly by younger men, as a successful, modern surgical procedure with minimal stigma. This may be largely down to footballer Wayne Rooney’s two hair transplants, both performed at Khan’s clinic. “He’s been a great ambassador for us, and for hair transplantation in general,” says Khan. “It’s led to a massive spike of interest from all around the world.”
After donning some protective clothing, I’m led into a surgery, where a man is lying on his back, arms folded, as a doctor uses a special tool to make incisions in his forehead. He spent the morning lying on his front as follicles were extracted from the back of his head; later they’ll be popped into their new location. He confesses that he’s a bit bored, but he’s looking forward to the results. It’s his second op; he was so delighted with the results of the first that he’s come back for another. Rooney, again, turns out to have been the catalyst. “The thing is,” he says cheerily, as the surgeon swabs blood from his scalp, “with Rooney you’re not seeing photographs of his head taken from special angles and with special lighting. You’re seeing him running around a football field, sweating, on the telly, every week. The results are there for everyone to see.”
All hair transplants are based on the principle of donor dominance, developed in the 1950s by New York dermatologist Norman Orentreich: a transplanted follicle doesn’t know it’s been moved; it just continues to grow as if it had been left where it was. Follicles taken from the back and the sides of the head – areas that aren’t sensitive to the miniaturisation caused by the hormone DHT – ‘remember’ their lack of sensitivity when transplanted into bald areas. By the 1980s, experiments with grafting had developed into a procedure known as FUT (follicular unit transplantation) or strip surgery. A strip of the scalp is removed and cut into very small segments, which are then inserted into small holes in the affected area. It’s a quicker procedure than FUE, and is considered by some to be the best way of harvesting high-quality hair. However, it leaves a long scar where the strip has been removed. This scarring, along with a number of poor-quality procedures undergone by high-profile celebrities, has given FUT a bad reputation that may not be entirely deserved.
FUE clinics tend to be quick to denigrate FUT, but FUE also has its drawbacks. As I witnessed at the Harley Street Hair Clinic, it’s a gruelling process that requires great concentration and stamina on the part of the physician, and enormous patience from the patient. Thousands of individual follicles are selected from across the donor area, extracted with a special tool, kept chilled, and later transplanted into tiny incisions. “The procedure for me – around 3,000 grafts – was so labour-intensive that it took all day, from 8.30am to 5.30pm,” says one man who recently underwent an FUE transplant in Australia. “The surgeon gave the sense of approaching her work with an artistic feel, in terms of ensuring consistency with the head’s whorl and general density.”
This is the key to a good FUE transplant, according to Khan. “The transplants should be done by a physician who knows what they’re doing,” he says. “The right follicle has to go in the right place. Mother Nature doesn’t work in straight lines. These little design details are critical.” Khan shows me the first post-op photographs of the man whose second procedure I just witnessed. They’re great. If I had a spare £10,000, which I don’t, and if I had a bigger area of donor hair, which I don’t either, I wonder if I might be persuaded to take the plunge. On balance, the answer is probably yes.
The hair quacks
Sadly, not everyone performing these operations pays such a close attention to detail. “There are tens of thousands of clinics,” says Spencer Stevenson. “Often you have nurses performing surgery in the back of a dentist’s! It’s unbelievable what is going on. In Turkey there’s a conveyor belt of patients because it’s so cheap, but I’ve always said that money and geography should be the last considerations. As difficult as it is to go and have surgery, trust me, it’s a thousand times more difficult once you become a repair patient.”
Given the risks associated with dodgy clinics, why on earth do men put themselves through this? The sense that a head of hair bestows us with greater masculinity and sexual appeal is evidently very deep-seated, and it’s not something the industry has ever rushed to dispel. In June of this year the Farjo Hair Institute, an acclaimed British FUE transplant clinic which recently developed a pioneering robot (ARTAS) to perform hair extractions, released the results of an experiment it had done with a patient using the dating app Tinder. The results, breathlessly reported by the media, showed that the patient’s post-transplant pictures resulted in 75 per cent more matches than pre-transplant. There was little scientific rigour in this, but men only seem to require a small amount of anecdotal evidence to reinforce their belief that male pattern hair loss is inherently unattractive.
“I used to have really thick hair,” says Jay Patel, wistfully. “Especially in our culture, South Asian culture, if you don’t have hair, you’re not going to get marriage proposals. You see all your friends and your cousins, they all have amazing hair, but you’re suffering from hair loss.” Patel tells heartbreaking stories of clients who arrive at his shop who are clearly traumatised. “One guy spent half an hour standing outside because he was too scared to come in and even discuss hair loss,” he said. “He eventually came in, wearing a bandana. I asked him to take it off to assess him, but he was really reluctant. He wanted to make sure the door was closed. Then he asked who was going to style his hair. I said it’ll be my colleague Egita, and he said that he didn’t want a girl to see him like this.”
Messing with the mind
The clinical psychologist Paul Gilbert argued in a 1997 paper that our drive to be perceived as attractive is innate, and feelings of shame and humiliation result from negative reactions as we ponder whether those reactions are deserved or not. Much of the money that men spend on attempts to cure, mask or lessen their hair loss is evidently to do with that shame – despite male pattern hair loss having far less stigma than, say, a more serious or unusual skin condition. And yet many men seem unable to take that on board, particularly in the modern age, when those negative reactions are easily experienced via dating apps and regularly reinforced by the media, who often refer to the “misery”, “suffering” and “hope” of those with the condition. “The reality of Western culture,” says consultant dermatologist Anthony Bewley, “is that young is beautiful, more successful, more attractive. Sadly, if you are older, uglier, scarred and bald, it’s not just about what that means in terms of your ability to succeed or be attractive; it’s also, sadly, marked out as being less worthy – or even criminal.”
Faced with three options that all have disadvantages – the stigma of wig-wearing, invasive surgical procedures, or doing nothing whatsoever – a comparatively easy way of treating male pattern hair loss might seem to be drugs. From the reams of sales pitches and glowing testimonials for various foams, sprays, creams and tablets, you’d think that among them there would be at least one drug, one magic solution that would make hair miraculously re-sprout from a bald pate. But this isn’t the case. There are just two approved drugs on the market, minoxidil and finasteride, and it’s generally agreed that neither can reverse hair loss but merely delay the inevitable.
The link between minoxidil and hair growth was first noticed in the 1960s by men who took it during clinical trials for a treatment for high blood pressure. The link is still not fully understood, but the US Food and Drug Administration approved it as a hair loss treatment for men in 1988 with the proviso that it “will not work for everyone”. Trials have shown some form of regrowth in as many as 80 per cent of patients, but a 2015 systematic review of the efficacy of minoxidil, while acknowledging that the medication was “more effective than placebo in promoting total and nonvellus hair growth”, also stated that “cosmetically acceptable results are present in only a subset of patients”. Minoxidil is available as an over-the-counter topical medication under such promising-sounding names as Hair Grow, Hairgain, Hairway and Splendora; in the UK and USA it’s usually known as Rogaine or Regaine. “It’s a bit of a Band-Aid,” says Stevenson. “It’s a good add-on as part of your regime, but on its own it’s not going to get you too far.”
Desperate hunt for a cure
Finasteride, meanwhile, has been available in the USA for hair growth under the name Propecia since 1997. Its hair-growing properties were first noticed by users of Proscar, a 5 mg dose of finasteride originally manufactured by Merck for treating benign prostatic hyperplasia, or enlarged prostate. After tests, Merck determined that a 1 mg dose was sufficient to promote hair growth; Propecia is thus effectively just one-fifth of a Proscar tablet (indeed, many men save money on prescriptions by cutting Proscar tablets into pieces). Its workings are better understood than minoxidil’s (it’s thought to inhibit the 5-alpha-reductase enzyme in the dermal papilla) but some of the side-effects listed by the US Food and Drug Administration (FDA), including erectile dysfunction, libido disorders, ejaculation disorders and orgasm disorders, can put men off. “There are millions of people taking finasteride with no side-effects,” says a disgruntled Stevenson, “but you don’t hear from them. All you hear is the minority of people who have, and they put the fear of God in everybody. I feel sorry for the people who are scared.”
No other medications for male pattern hair loss are licensed by the FDA or its European equivalent, the European Medicines Agency, but there are many dietary supplements with medical-sounding names that claim to promote healthy hair growth. While there may be a link between poor nutrition and some forms of hair loss, there’s no mention of dietary supplements in the NICE guidance on androgenetic alopecia. Nevertheless, the relative merits of supplements such as TRX2 and Viviscal are vigorously debated online.
While those arguments continue, the pursuit of a wonder drug continues, with dozens of companies keen to reap the financial rewards. One such company, Allergan, has two potentially promising drugs undergoing trials: a topical one, bimatoprost, which was originally a treatment for glaucoma and was approved by the FDA in 2008 to assist with the growth of eyelashes; and an oral medication, setipiprant, which inhibits a compound (prostaglandin D2) that’s found to be elevated in balding scalps. Another company, Samumed, has recently picked up a huge amount of press interest for another potential treatment, SM04554, but some experts have found their clinical data to be less impressive than their marketing acumen.
Differentiating bold claims from promising avenues can end up becoming a full-time job, according to Susan Holmes, a hair loss expert at the British Association of Dermatologists. “If we’re asked to comment on these things,” she says, “it’s weeks of research to go through the literature. What we want to see is good evidence in a research paper, research that’s been done properly, that’s been peer-reviewed. A lot of the literature is in small journals where it’s difficult to know who’s reviewed it and what process it’s gone through. There’s a lot of research being done, and a lot of avenues look interesting, but it’s a question of whether they come through all the rigorous tests to become an effective treatment. Hair is just a difficult thing to make grow.”
Hair is just a difficult thing to make grow. This should be the disclaimer on every medicine, every “natural” supplement, every website that claims to offer treatments for hair loss, but instead they choose to sell false hope. “A cure is always five years away,” says Stevenson, with a laugh. “In five years, it will be five years away – in 10 years it’ll be five years away. It’s the Holy Grail. But I think cloning will be a massive industry.”
Successful cloning of hair follicles could give transplant patients a more plentiful source of hair; currently that source is restricted to their very valuable but very limited donor area. “Hair cloning, neogenesis, induction, it’s all the same thing,” says Claire Higgins, a lecturer in the Department of Bioengineering at Imperial College London, “but it’s really hard to do.” In a 2013 paper, five scientists including Higgins described how they managed to initiate neogenesis in human skin. “We took human skin and stuck it on a mouse,” she says. “It almost acts like an oven, to cook the tissue, but the hairs were tiny. We were inducing hair in an epidermis that wasn’t very receptive. We initiated it, but something inhibited it. I think it will work, long-term, but in our lab we’re trying to map out the genetic changes that are occurring before trying induction again.”
The work done in Higgins’s lab isn’t driven by a search for a cure for hair loss, but hair happens to be a convenient, accessible model for her to work with. “We think that [during the miniaturisation that causes male pattern hair loss] cells are migrating away from the hair into the surrounding skin,” she says. “The reverse process of that occurs during hair development. Cells migrate together, you get a cluster of cells that’s about double the density of the surrounding cells, which goes on to become the dermal papilla. If I can use the hair to understand this process, how the hair can reprogramme the epidermis to change its identity, I think these are basic biological questions that can apply to very different systems.”
The attraction of baldness
Hair regrowth may not be the specific focus of her research, but Higgins believes that the psychological issues caused by male pattern hair loss make that work more valuable. “People won’t leave the house,” she says. “It’s not life-threatening, but it is life-changing.” It certainly changed Jay Patel’s life, although he now feels that he’s pulled things around. “I’m 37 now,” he says. “I was 23 when I started losing my hair, so it took me a long time. I wasn’t a confident person. I wouldn’t have opened a business like this, because I’m not that sort of person. I’m the person who sits in the corner, in the background. I went through a lot of hardship to get where I am.”
Susan Holmes mourns the lack of psychological support available on the NHS. “What little there is is hugely over-subscribed,” she says. “There are many people with many different disorders who require the input of a clinical psychologist. We know we can’t cure hair loss, we know that what men need is help to come to terms with it.” But given our poor track record, is there any likelihood that balding men like me will ever relish our slow shedding of hair?
Milan Stolicny hopes so. His website, baldattraction.com, offers a joyous, upbeat appreciation of balding heads, and beseeches men with receding hairlines to reclaim their baldness and relish the new perspective it gives them. “Bald Is Very Attractive!” he says. “Bald can wildly succeed in this world! It’s time to kick ass and wildly succeed as a bald man!” Stolicny offers no quackery, no remedies, potions or balsams – just enthusiasm. “The true baldness cure,” he says, “is to become attractive bald man!” In other words, believe in yourself. It looks so easy, written down. If balding men were able to do such a thing, a huge industry would collapse overnight. But that industry knows only too well that Stolicny’s solution, while beautifully simple, is perhaps the hardest of all to achieve.
This article first appeared on Mosaic.com.