Click on the image above to download a PDF version of Dr. Wasserbauer's entire article on wound healing.

Dr. Wasserbauer is a regular contributor to the Hair Transplant Forum International, a publication distributed by the International Society of Hair Restoration Surgeons (ISHRS.org). In the March/April 2012 Issue she was asked to compile and comment on the evolution and physiology of wound healing in the hair transplant procedure. Her paper was the featured cover story.

In the article overview Dr. Wasserbauer states:

“Wounds created with a scalpel heal faster than those created by destructive means (laser or chemical cautery among them) so avoiding excessive tissue damage (such as with the use of tissue spreading) results in faster healing.

Any foreign debris will slow wound healing by making the body do more work and possibly causing infection, so removing all spicules of hair and having high levels of vigilance with suture removal will improve outcomes.

Keeping tension from the wound during healing is key to speedy recovery. There are several means that can be employed to minimize tension, chief among them being sub-cuticular sutures, avoiding lifting, and avoiding wide strip excisions where elasticity is low”

And concludes:

“In the final analysis, it is the experience and judgment of the surgeon that will result in a good outcome or avoid a poor one. Like it or not, the wound healing experiences of every hair transplant procedure a surgeon performs will reflect on his or her practice and on our medical specialty as a whole. Thus, we all owe it to each other and our patients to do everything in our power to produce optimal healing.”

The Battle of the Hairy Century! Finasteride vs. Dutasteride

Who will win?

By Sara Wasserbauer, M.D.

Finally, a head-to-head study of the 5 alpha reductase blockers and their effect on hair loss! Finasteride, also known as Propecia, has been the mainstay of a hair doctor’s prescription pad for a long time.  If fact it has been safe recommended therapy since 1992.  However, it is not the only drug that blocks DHT (the hormone that causes male pattern hair loss).  Dutasteride (aka Avodart) also blocks the creation of this hormone, and is more potent.  For a long time, however, hair doctors avoided prescribing dutasteride for hair loss since the studies to prove it worked in androgenetic alopecia had never been done.

With that in mind, this is a beauty of a study.  Not only does this study have enough power (i.e. the number of patients who participated are high enough) to show a scientifically significant change if it exists, but it also includes a placebo arm.  A “placebo arm” means that this study also demonstrates what happens if you don’t decide to take anything.  For those patients, additional hair loss is assured.  Furthermore, the study was conducted over 24 weeks – that’s 8 months!  This is proof that you need to take these medications for 6-12 months before expecting real results.

And it looks like dutasteride comes out the winnah!  Dutasteride keeps more hair than finasteride or the placebo pill, and the response is “dose-dependent.”  This means that the more dutasteride you take, the more hair you keep!

Finally, to cheer up the guys out there who are worried that taking a drug like this will make them lose their sex drive forever, this study goes into detail about the adverse effects of both drugs AND the placebo group (that is to say the group who was taking the sugar pill).  Check out the numbers; 2 patients in the placebo group noted decreased libido, and 3 of the patients taking finasteride (Propecia) did, too.  The greatest decrease in sex drive was noted by people taking dutasteride at the highest dose, and for the most part it resolved when they continued taking the medication.

No one became impotent at all.  Not even the guys taking Propecia.

The importance of these medications and of doing these studies to help men keep their hair comes down to long term management of what is a chronic condition; hair loss.  Hair doctors like giving people back their hair, but also recognize that hair transplant only replaces hair that has already been already lost.  A complete treatment involves both hair restoration as well as preserving the remaining hair as much as possible.  Therefore, medical treatment for preserving native hair should be considered in nearly every hair loss patient.  And now there is one more reason to think about taking dutasteride as well.

Dutasteride vs. Finasteride

The importance of dual 5a-reductase inhibition in the treatment of male pattern hair loss.

Olsen E. et. al.

SUMMARY

In the study, 416 men with male pattern hair loss (MPHL) ages 21 to 45 years old, were randomized to receive dutasteride 0.05, 0.1, 0.5 or 2.5 mg, finasteride 5 mg, or placebo daily for 24 weeks. The results of the study showed that dutasteride increased hair counts in a dose-dependent fashion and dutasteride 2.5 mg was superior to finasteride 5mg at 12 and 24 weeks.

Although testosterone is the major circulating androgen, to be maximally active in scalp hair follicles it must first be converted to dihydrotestosterone (DHT) by the enzyme 5?-reductase. The importance of DHT as a causative factor in male pattern hair loss is shown by the absence of this MPHL in men with a congenital deficiency of the type 2 5?-reductase enzyme. A type 1 5?-reductase, which also metabolizes testosterone to DHT, differs in its location and amount in different tissues. In the skin, type 1 5?-reductase is the principal isoenzyme in sebaceous and sweat glands. There is no recognized genetic deficiency of type 1 5?-reductase in humans to assess its role in MPHL.

Dutasteride (Avodart) inhibits both type 1 and type 2 5?-reductase and is approved at the 0.5-mg dose for treatment of symptomatic benign prostatic hyperplasia (BPH). It is about 3 times as potent as finasteride at inhibiting type 2 5?-reductase and more than 100 times as potent at inhibiting the type 1 5?-reductase enzyme.

Dutasteride caused scalp and serum dihydrotestosterone levels to decrease and testosterone levels to increase in a dose-dependent fashion. Whereas 5-mg finasteride decreases serum DHT by about 70%, dutasteride can decrease serum DHT by more than 90%.

Results

In this phase II, dose-ranging study, 2.5-mg dutasteride was superior to 5-mg finasteride in improving scalp hair growth in men between ages 21 and 45 years with MPHL as judged by target area hair counts, expert panel assessment, and investigator assessment at 12 and 24 weeks.

In a test area at 24 weeks, results showed:

Dutasteride 2.5mg vs. 0.5mg

The 2.5-mg dutasteride dose was consistently superior to 0.5-mg dutasteride in promoting scalp hair growth. The 2.5-mg dose was also better than the 0.5-mg dose at suppressing scalp DHT (79% vs. 51%), whereas it was only marginally better at suppressing serum DHT (96% vs. 92%). This difference in the dose-response of serum and scalp DHT to inhibition with dutasteride is likely to be due to the greater contribution of type 1 5?-reductase to scalp DHT concentrations.

Finasteride 5mg vs. Dutasteride 0.1mg

5 mg finasteride suppressed scalp DHT to a similar degree as 0.1 mg dutasteride group (41% and 32%, respectively). Many of the clinical effects (hair count changes, global panel assessment, and investigator assessment) were also similar in these two groups, supporting the similarity in scalp suppression between 5-mg finasteride and 0.1-mg dutasteride.

Adverse Effects

Both dutasteride and finasteride were well tolerated in this phase II study, and no new safety concerns have arisen in any of the phase II and phase III studies of dutasteride given at doses up to 5 mg daily (the 5-mg dose was used in a phase II study for BPH).

There were no significant differences in side effects, serious adverse events, or withdrawals due to adverse events among any of the treatment groups, including placebo. In total, 11 subjects withdrew because of adverse events: 3 were in the placebo group (irritable bowel syndrome and impotency), 7 in the dutasteride 0.1 mg group (decreased libido, malaise and fatigue, mood disorders, skin disorders, injuries caused by trauma, and gastrointestinal- and neurology-related complaints) and 1 in the dutasteride 0.5 mg group (gastrointestinal discomfort and pain).

Decreased libido was noted in:

• 2 subjects in the placebo group
• 2 subjects in each of the 0.05-mg and 0.1-mg dutasteride groups
• 1 subject in the 0.5-mg dutasteride group
• 9 subjects in the 2.5 mg dutasteride group
• 3 subjects in the finasteride group

Of the 9 subjects with decreased libido in the 2.5-mg dutasteride group:

• 4 resolved while receiving therapy
• 1 resolved within 3 weeks
• 1 resolved within 8 weeks of stopping drug therapy
• 1 subject, decreased libido continued after therapy had been stopped and was presumed by the subject to be unrelated to the trial or drug therapy

Concerning possible sexual adverse events, there was no evidence in the present study that either dutasteride or finasteride was associated with impotence. However, 9 men in the 2.5-mg dutasteride group complained of decreased libido, compared with 1 man in the 0.5-mg dutasteride group and 3 men in the finasteride group. As with previous studies with finasteride, this adverse event was characterized as either mild or moderate in severity and often resolved with continuation of the medication. In the 4-year follow-up of the phase III trials in BPH, dutasteride (0.5 mg) was well tolerated and the incidence of the most common sexual adverse events was low and tended to decrease over time.

The only subject to develop gynecomastia was in the placebo group.

Duration of Effects

The serum half-life of finasteride is 6 to 8 hours. Dutasteride has a serum half-life of approximately 4 weeks, and this long half-life was evident in the persistent suppression of DHT with the 0.5-mg and 2.5-mg doses after dutasteride treatment was stopped. Because of this long half-life, men being treated with dutasteride should not donate blood until at least 6 months past their last dose to prevent administration to a pregnant female transfusion recipient.

  May I add, it is so painful posting pictures of myself. Definitely more painful then the surgery!!!