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Androgenetic alopecia (male pattern baldness) is by far the most common cause of hair loss in approximately 50% of men suffering from hair loss diseases. Although it is a medically benign condition, it affects the psychology of the patient to a large extent. The aim of this article is to describe the various hair loss restoration treatment options available for male pattern hair loss (MPHL).
Pathophysiology of hair loss

Let’s understand the different factors underlying androgenetic alopecia. As its name implies, androgenetic alopecia involves both genetic and hormonal factors. As already discussed, the male hormone androgen plays a major physiological role in the disease, but it is the Genetics which makes individual pre-disposed to the disease by determining both the density and the location of androgen-sensitive hair follicles on specific sites of the scalp.

The influence of hormonal factors starts becoming evident at the puberty when genetically programmed hair follicles come under the influence of male hormones. The interaction of these two factors result in shortening of the anagen phase and a miniaturization of the hair follicles that both leads to thinning of hair fiber and its falling.
hair loss for men patterns in Androgenetic alopecia

As men progress through their twenties, slight frontal-temporal recessions start becoming evident. The hair line has a concave appearance on each side and a lower peak in the middle. This stage is known as the Norwood Hamilton stage II. Developed by Dr. O’Tar Norwood, this scale is a very useful scale for identifying degree of hair loss and is understood by most of hair loss restoration doctors.

Norwood III is considered the first evidence of balding in androgenetic alopecia (male pattern baldness) and the most advanced balding is known as a class VII. Then there are Type “A” variants in which the forelock in the middle tends to recede along with the frontotemporal areas, and in which there is be less overt crown loss than in the regular III, IV, and V patterns.

Inheritance Pattern of the Disease

The exact inheritance pattern of androgenetic alopecia is still debated. But it is mostly considered to be autosomal dominant and polygenic which can be inherited from either parent.

It is interesting to note that androgen levels of male with androgenetic alopecia have been found to be perfectly normal. It is the intracellular androgen metabolism, which is the major determining factor. The metabolism of androgen inside our body involves 2 steroid-metabolizing enzymes (5α-reductase and aromatase), and androgen receptor proteins (ARPs). Altered levels of these components are believed to responsible for the difference in severity of the disease between men and women and also for different patterns observed.

5α-reductase isoenzymes, type I and II, are both part of the normal androgen metabolism and their function is to reduce testosterone to dihydrotestosterone (DHT). The 5α type I isoenzyme is located mainly in sebaceous glands, epidermal and follicular keratinocytes, dermal papilla cells, and sweat glands. The 5 α reductase type II isoenzyme is located mainly in the root sheaths of the scalp hair follicle.

Both type I and type II isoenzymes most likely play an important role in androgenetic alopecia since they have been found in increased levels in frontal follicles compared to occipital follicles where balding is most commonly seen. Women have about 3 to 3.5 times less 5α-reductase (types I and II) in their follicles as compared to hair loss for men. The role of these isoenzymes play in androgenetic alopecia is confirmed by the fact that men with a genetic deficiency of 5α-reductase type II isoenzyme have never been found to develop androgenetic alopecia.

ARPs are the other class of metabolites present in androgen sensitive areas. These ARPs are also found in the outer root sheath and dermal papilla fibroblasts of scalp hair follicles. Since the levels of these ARPs are found to be 30% greater in the balding frontal hair follicles than in non-balding occipital follicles of both men and women, these are thought to play some role in the disease, but the mechanism of their action is not very clear yet.