The Baldness Business
For many balding men, male stoicism and other coping strategies – from hats and wigs to dark humour – often mask deep distress. Will modern medicine ever find a ‘cure’ – or does the solution lie elsewhere?
When I was a teenager, my mum reassured me that I wouldn’t go bald in my 20s like my father had. “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 ten 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 malepattern 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 don’t like it. I’ve found myself turning to classic coping mechanisms such as wearing hats and growing a beard, 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 druginduced 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 hairloss industry, and they are becoming increasingly adept at persuading them to part with money. It’s estimated to be worth at least US$1.5 billion a year worldwide, servicing the needs of millions of men. An 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 that the hair loss might be 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.
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 thousands of dollars, 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. “It’s governed by money, and there are only a few
organisations that have the patient’s best interests at heart,” he says. “The industry has a reputation for preying on the vulnerable.”
This vulnerability is rarely acknowledged, but it’s widespread. A 2005 study 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. The widespread condition of male-pattern hair loss has caused distress since the year dot but is hardly talked about. History tells us of men willing to try all manner of bizarre remedies to thwart it. 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 on 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 (NICE), 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 the psychological response to it: it could be “a sense of loss of attractiveness, a loss of youth, a loss of virility, or even emasculation,” says Anthony Bewley of the British Association of Dermatologists. He argues that although a physiological change, that is, 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.”
A balding Bruce Willis is widely considered to be sexy, but this isn’t enough to reassure most of us. 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 it 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 see the problem to be tackled is 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. “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 all right, I say actually, no, that’s not what I find.”
Jay Patel, the co- founder of MH2Go, a wig supply and fitting business, sits in his office 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, adding that this state of mind was worsened by body dysmorphia. “I was 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 embar-
A BALDING BRUCE WILLIS IS WIDELY CONSIDERED TO BE SEXY, BUT THIS ISN’T ENOUGH TO REASSURE MOST OF US
rassed, 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 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. 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: $800 for the first and $ 400 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. “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 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 many thousands of dollars for a series of wigs that lasted just a few weeks. “I ran out of money, 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.
Nadeem Uddin Khan, director of the Harley Street Hair Clinic, knows how painful the experience of hair loss can be. “I’m just looking for a picture of myself,” he says, flicking through his phone. 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, buzz-cut and very different from the photo. “That was about ten, 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 English 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 as a doctor uses a 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.
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, which 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 3000 grafts – was so labour-intensive that it took all day,” says one man who recently underwent an FUE transplant in Australia.
Expertise 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 procedure I just witnessed. They’re great.
Sadly, not everyone performing these operations pays 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. In Turkey there’s a conveyor belt of patients because it’s so cheap, but money and geography should be the last considerations. As difficult as it is to go and have surgery, it’s a thousand times more difficult once you become a repair patient.”
Given the risks associated with dodgy clinics, why 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 2016 the Farjo Hair Institute, an acclaimed British FUE transplant clinic, 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, which he was really reluctant to remove. He wanted to make sure the door was closed. Then he asked who was going to style his hair. I said it would be my colleague Egita, and he said that he didn’t want a woman to see him like this.”
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, particularly in the modern age, when those negative reactions are easily experienced via dating apps and 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.”
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, and the US Food and Drug Administration approved it as a hair-loss
THE PURSUIT OF A WONDER DRUG CONTINUES, WITH COMPANIES KEEN TO REAP THE FINANCIAL REWARDS
treatment 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 stated that “cosmetically acceptable results are present in only a subset of patients”. Minoxidil is available as an over-thecounter topical medication under such promising-sounding names as Hair Grow, Hair-A-Gain, Hairway and Splendora; in the UK, US and Australia it’s usually known as Rogaine or Regaine. “It’s a bit of a bandaid,” 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.”
Finasteride, meanwhile, has been available for hair growth under the name Propecia since 1997. 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 sideeffects 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.”
No other medications for malepattern hair loss are licensed by the FDA or its European and Australian equivalents, 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 ten 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 without lasting results. “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.”
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 went through a lot of hardship to get where I am.”
Susan Holmes mourns the lack of psychological support available. “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 an 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.
Hair loss usually begins at the temples, with the hairline gradually receding