Growing Skeptical of Hair Restoration

by Brian Dunning
February 2, 2016

It's no surprise to anyone that there is a plethora of bogus treatments on the market for hair loss. Male or female, nobody wants to lose their hair as they age — but genetics usually has a plan of its own. This makes it the perfect environment for marketers to swoop in and sell snake oil: desperate customers, and few satisfying solutions. Today we're going to check in on the current marketplace, and see what's for real, and what's not.

As science has improved over the decades, so has the field of hair restoration. The two products proven to work, minoxidil (originally sold as Rogaine) and finasteride (sold as Propecia) remain the workhorses of the industry, and until recently everything else was a sham. The landscape is somewhat improved today, with a few treatments now best described as promising.

To keep this within the scope of a Skeptoid episode, we're going to stick with the primary cause of hair loss. For both men and women, this is androgenetic alopecia, or male-pattern hair loss and female-pattern hair loss, the genetic and hormonal loss of hair. For men, this is typically in two distinct locations, the top and front of the head. For women, it's typically a general thinning all over. Men represent about 60% of hair loss patients, and women are 40%. A far higher percentage of women with hair loss seek treatment, which is why those numbers are as close as they are.

We're also going to avoid cosmetic and surgical options, although it's worth noting that the surgical option is far better these days than it used to be only a few years ago. Individual follicles can now be extracted and replanted, sometimes robotically assisted. Thousands of individual hairs can be moved this way, with no noticeable scarring and minimal recovery. Unfortunately transplantation is usually only a viable option for men. Women tend to lose their hair evenly all over, unlike men who usually keep the sides and back of their heads nice and full and dense, ripe for harvesting follicles. Women tend not to be left with any good place to harvest from.

It's really hard for a consumer to get good information about hair restoration online. The overwhelming majority of articles written about new treatments offering promise are written by doctors who sell them. Do a bit of online research, and you'll see the same names coming up over and over again. It should come as no surprise to find that their clinic sells the very product their supposedly-objective article touts. Before buying any hair loss product, talk to a doctor who is not in the business of selling it.

So now let's take a look at the current landscape, beginning with:

Compounded Minoxidil and Finasteride

Minoxidil and finasteride are proven to work (note that only minoxidil is approved for women), though both must be taken for life, or hair loss resumes as soon as you stop. Hair regrowth is minimal for most patients, but better than nothing. As availability has increased, clever marketers have tried to recoup profits by offering allegedly "improved" versions that are called "compounded" minoxidil and "compounded" finasteride. Save your money. The minoxidil or finasteride in these products is the only ingredient proven to work. The others are generally just added to make the product unique and marketable. No "compounded" version of either has ever been proven to work better.

PRP

Platelet rich plasma is one of those recently developed treatments being marketed for anything and everything. Your own blood is drawn, centrifuged to separate it, sometimes other things are added like extra protein, and the mixture is injected into your area of interest. This might be a painful joint, a post-surgical area, or in this case, a bald spot. Some small studies have shown PRP injections, usually given about every inch into the scalp, can regrow a very small amount of hair. However, every single such study I read — without exception — was performed by doctors at clinics that sell the procedure. Most other doctors are reserved about the use of PRP for this or other conditions. It is medically plausible, but it's very preliminary; and so far, proof is just not there. Approach with caution, and avoid any clinic that tells you it's a proven solution.

Stem Cell Therapy

Anything branded as "stem cell therapy" automatically gets a huge market, because people believe that stem cells are a miracle cure for anything; and marketers know this so they're willing to slap the label onto anything. Approach all "stem cell therapies" with extreme skepticism.

Nevertheless, actual research is studying several different ways stem cells can be used in hair growth. The best known approach is called follicular neogenesis which has so far failed to translate to success in humans. Although there's science and plausibility behind the idea of stem cells in hair restoration, so far nothing is proven or approved. Research continues and we have reason to be hopeful. But for now, absolutely avoid any clinic selling any technique labeled "stem cell therapy".

Low Level Laser Therapy

This is one of those alternative therapies that seems to exist only to sell stuff to practitioners. Low level laser therapy, also known as cold laser therapy, low-power laser therapy, low-intensity laser and low-energy laser therapy, doesn't even always use lasers. Many of the devices available simply use blue or red LED lights. Some are called "laser combs" and others look like a big helmet. These lights are not regulated medical devices and are available for anyone to purchase, sometimes through unaccredited training programs that provide certificates anointing the purchaser as a trained professional. Such certificates are legally worthless but impressive enough to trick consumers into purchasing services that amount to little more than someone shining a flashlight into your skin. Low level laser therapy is offered for virtually any condition one can conceive of: wound healing, quitting smoking, tuberculosis, joint pain, carpal tunnel syndrome, fibromyalgia, arthritis, breast cancer, hypothyroidism, back pain, dental and orthodontic pain, labial herpes, neck pain, periodontitis, allergies, asthma, Alzheimer's disease, arteriosclerosis, diabetes, heart failure, laryngitis, liver disease, multiple sclerosis, Parkinson's disease, acne, and — paradoxically — both hair removal and hair restoration.

Although sales of these lights to consumers and alternative practitioners are brisk, no well-performed research has ever supported any of its claims, and no theory has ever been widely accepted suggesting that it might. So what is its pitch for hair loss? The claim is vague and differs depending on where you read it. Usually it's about stimulating the hair follicles (whatever that means) or increasing blood flow to them, through some nonspecific mechanism.

Laser hair removal is a real thing; it uses a hot laser that targets the melanin in the hair follicle, which it heats and destroys. But "low level laser" — which does not significantly heat tissue — is also marketed with this exact same claim, and it uses red LEDs like in a digital watch display, not lasers. Note that without sufficient heat to damage the tissue, there is no plausible reason why this would work. Marketers generally point to the wavelength of the light used. For hair removal using red LEDs, a range of 694nm to 1000nm is most frequently published. What about promoting hair growth by shining LEDs on the skin? 600nm to 950nm is usually given. The same range!

When a product can be successfully sold with the claim that it produces two exactly opposite results, using the same parameters, that's a pretty good sign that it does nothing at all. If anyone offers you low level laser therapy for hair growth, save your money.

A reminder about FDA-approved devices and what that means: FDA approval of a device only means that it is not defective and not harmful, and usually only requires that someone else have built something using similar technology at some time in the past. It does NOT mean that it works for the condition it's advertised for, or even that it does anything at all.

Shampoos

There are a number of shampoos on the market sold as hair growth products, hair loss treatments, "for thinning hair", or as "hair thickening treatments". Minoxidil is the only topical product proven to reduce hair loss or regrow hair. Any other shampoo claiming to do this is simply playing fast and loose with product labeling laws, carefully avoiding terminology that would get them in trouble with the FTC for deceptive marketing.

Any shampoo sold as a hair growth product that does not contain minoxidil is unproven and probably implausible. It's almost certainly completely worthless for any purpose except cleaning your hair or depositing oils that appear to thicken your existing strands.

PGD2 Inhibitors

PGD2 is a lipid that's found to be elevated in bald scalp areas, and the theory is that applying an inhibitor to the area can fight the hair loss. It made a lot of dramatically overblown headlines in 2012. There are three points to make here. (1) This is a promising area of research, and some treatments are in clinical trials. (2) None of them have yet panned out into an effective treatment, so do not buy one; and (3) Hair loss, even in a single person, has multiple causes. It's complex, like the rest of your human body. It is a certainty that no one product can ever become an effective cure for everyone's hair loss.

The Bottom Line

We should recognize that many of us who seek these treatments are seeking self esteem. For many of us, there is a powerful psychological component to hair loss, and for some, relief from the stress and fear may outweigh the expense and lack of results. In many versions of this conversation, it comes down to the ethics of selling false hope versus the benefit of buying hope.

I would rather see everyone have a solid grasp on the science, and be satisfied to keep their money in their wallet and not turn it over to the sellers of pseudoscience, but that's not a realistic goal. Recognizing this, many doctors advise their patients that although minoxidil and finasteride are the only proven games in town, there's no harm in trying these other products. And that's true, I can't argue with that. People certainly feel better when they're active about solving a problem that bothers them. Even so, there is a better way than buying one of the products that has failed to demonstrate effectiveness. Go to clinicaltrials.gov and search for androgenetic alopecia, and you'll see that there's plenty of action you can take even without spending a dime. Participating in a clinical trial may help not only yourself, but many other people in the future; and you'll usually even make a few dollars for your participation. That's a solution that should appeal to everyone, whether they understand the science or not.

By Brian Dunning
Follow @BrianDunning