Dr. D on DHT, Finasteride Disclaimers, Pseudohermaphrodites from the Dominican Republic, The Virtues of Hair Loss Acceptance, and More!
Dr. Jeff Donovan is a world-renowned hair loss specialist and the president of the Canadian Hair Loss Association. Based in beautiful Whistler, BC, he also happens to have an incredibly dense and lush head of hair! I’ve been a fan of Dr. Donovan’s Blog for some time, and I also enjoy reading his in-depth responses to patient questions on sites like RealSelf.
Recently, I reached out to the good doctor to see if he’d be interested in taking part in a Q&A article, and he graciously agreed to my request.
We covered many topics in this wide-ranging interview, including hair loss treatments of the future, extended finasteride disclaimers, DHT, diet’s role in the hair loss puzzle, hair transplant red flags, and more.
In the future, I’m hoping to regularly feature interviews on this website with top surgeons and other hair loss experts from around the globe.
Without further ado, here’s my email interview with Dr. Donovan.
1. Many doctors seem to discount the possibility of long-term side effects with finasteride use. You review those potential side effects explicitly on your website. Two part question: A. Why did you feel the extended disclaimer was warranted? B. What’s been your experience prescribing the drug in terms of side effects, patient satisfaction, results, etc.?
Dr. Donovan: Finasteride and Dutasteride are the best drugs for treating male pattern type balding in the present day that I type this sentence. That may not always be the case down the road, but it is now. That said, that does not mean it’s always the best choice for treating male balding for any given male patient. That distinction gets blurred.
We cannot rely on FDA approval to entirely guide the decisions we make in our clinical practice. We need to rely on FDA approval PLUS good clinical observation and post marketing surveillance. If a side effect is rare, it’s not going to ever come out before a drug gets FDA approval. The trials for hair loss are too small and too short in duration.
Post marketing surveillance of drug side effects is absolutely critical. However, once a drug gets approved, it is extremely difficult to properly study side effects. We know that physicians do a less than perfect job of “post marketing surveillance.” We know drug companies do a less than perfect job doing this too (although things are improving)
Most patients are satisfied with these drugs and most patients get good results. Some patients get incredible results. My job, however, is to care for everyone who comes through my door rather than simply do a pretty good job caring for most of them.
I do feel that it is the responsibility of the physician to participate in the world of post marketing surveillance of drug side effects even though many of us have no formal training in what this means and how even to report side effects. It’s a collective responsibility of patients, physicians and drug companies. We need to all have an active role.
2. What are some ways a young man in his early 20s with aggressive balding can effectively manage his hair loss without finasteride?
I think that we don’t “fully” know this answer as a hair loss community. Certainly, we are going to advise the male patient in your question to considering getting on oral or topical minoxidil (or both) and consider laser and/or PRP therapies. There are another 20 therapies that will be offered to similar young male patients around the world including various stem cell therapies, exosomes, microneedling and supplements.
Males in their early 20s with aggressive balding often have strongly DHT mediated hair loss. The question you ask is a good one and one that I face every day in my practice. We don’t have good long term studies of any kind to address your question and even the short term studies tell us that many of the therapies only help a proportion of males.
3. If my research for this website has taught me anything, it’s that female hair loss is often complicated. It can be a major challenge to both diagnose and treat. What tests do you find most beneficial in assessing female hair loss?
Female hair loss is more challenging. Many of the hair loss conditions in women look the same. Shedding disorders can look like female androgenetic alopecia and vice versa. Even many of the autoimmune disorders can look very similar to female androgenetic alopecia.
The patterns of hair loss for women are so different than for men and that’s why so many female patients with early androgenetic alopecia are told their hair loss is simply due to low iron levels or stress or nutritional issues and to take a supplement.
Any male who comes through the door must be assumed to have male balding and it’s up to the doctor to do all the detective work to prove this is right or wrong. Similarly, any female who comes through the door must be assumed to have female pattern hair loss and it’s up to the good doctor to prove this is right or wrong. This approach is not common but will lead to an enormous pick up rate of early AGA if we adopt this sort of thinking.
When I teach doctors about female hair loss in my clinic, I tell the doctors before we enter the examining room “Your job is to prove to me this patient does not have female pattern hair loss otherwise we are going to assume she does. Get out all your questions and put all your diagnostic skills into motion to prove it one way of the other.” Of course, not every female patient has AGA, but the good doctor needs to prove it.
One of the most helpful tests if one is not sure of the diagnosis is a scalp biopsy assessed properly with horizontal sections by an experienced dermatopathologist. Early female androgenetic alopecia can be picked up and treated can be started earlier than otherwise.
4. Along the same lines, what are the most common drugs you prescribe to treat female pattern hair loss? And how effective are they in your experience?
The most common drugs are minoxidil (both topical and orally) as well as a range of antiandrogens including spironolactone, finasteride, dutasteride and bicalutamide. One must be extremely careful about using antiandrogens in premenopausal women as all can cause harm to a fetus in pregnancy. The same is also true with minoxidil.
Spironolactone can help about 40-50 % of patients improve their hair. Another 40 % have stabilization such that they do not experience more hair loss. Finasteride and dutasteride have best been studied in post menopausal women but the numbers are fairly similar across all ages.
5. Many people, myself included, prefer the idea of treating androgenic alopecia locally on the scalp rather than internally. Do you have a preferred topical anti-androgen in your practice?
Topical finasteride would be the preferred antiandrogen.
6. Your thoughts on DHT. Is it merely a “trash” hormone that blows up the prostate and causes acne in adults, or could it possibly have some benefits that aren’t fully established?
We simply need to look at the pseudohermaphrodites in the Dominican Republic who have a genetic deficiency in 5 alpha reductase to understand what this hormone does and does not do. Whether men taking the drug are at risk for all the issues that males with the gene defect have requires more study.
7. What makes a person a bad candidate for a hair transplant? I know there are probably at least 50 “red flags” that you observe in your practice on a regular basis. Perhaps you could just list a few of the most common reasons why a person should avoid the procedure.
In my opinion, a person should avoid a transplant if they have not considered how possibilities of how their natural balding will occur over the rest of their life. This usually translates into it being contraindicated in males under 23-25 and for males wishing to transplant the crown before the mid 30s.
In addition, patients who have active scarring alopecia are not candidates. Patients with the wrong expectations also should not have a transplant. This usually equates to patients who want the same density and hairline as in the late teens. Patients who view a transplant as a “one time” thing should not undergo a transplant especially younger patients. Patients and physicians often underestimate future balding. It’s so much more complicated than simply looking at our father’s hair density and assuming we’ll look like that. It’s a good start of course.
8. I know you specialize in rare types of hair loss. What are some surprising reasons why people lose hair?
People lose hair for about 200 reasons. There are some incredibly rare genetic disorders that are associated with hair loss. Sometimes the genetic disorder is known before the patient steps into my office but sometimes it’s the detailed questioning about their nails, teeth, development, past surgeries, eyesight or hearing that leads one to diagnose something pretty rare at the end of the patient’s visit.
The scarring alopecias are something that I see every day and in large numbers. These are challenging but there are options for these patients when you connect them with the right treatments. Dissecting cellulitis, folliculitis decalvans, lichen planopilaris are not that common but it can take anywhere from a few months to 6-7 years before patients come to sit down in front of a doctor who can give them the correct diagnosis.
9. I enjoyed reading your practice principles and found the sections on diet and scalp inflammation to be quite interesting. I take it you believe they may affect pattern hair loss in ways we don’t fully understand?
Absolutely. The concept of “microinflammation” is showing itself to be extremely important in many parts of medicine. We have not yet addressed this properly in the treatment of androgenetic alopecia but someday we will once we figure out the pathways that are relevant. There is not just once type of inflammation and so that adds to the complexity of exactly why we see inflammation in so many biopsies of males with AGA.
10. You stopped performing hair transplants in 2017 to become more of an all-around specialist. What prompted that transition and how’s it been going for you so far?
There is a dire need to help advance the field in all the other 199 areas of hair loss. I decided that I want to do what I could to help people who can’t find help. It’s been going great. I see patients from all over the world. The cases are complex and I enjoy it immensely. Emotions run high in my practice.
11. Over the next decade, what are some changes you foresee coming in the industry? And what potential treatment of the future excites you the most?
There will be more and more options for patients. Unfortunately, this will mean more and more options for treatments that don’t actually work and waste the time and money of patients but that’s inevitable in this field. But it’s an incredibly exciting time. We’re moving in the direction of more targeting therapies and this is exciting. There is no doubt that certain pathways (SHH, Wnt, DKK1) are relevant in how hair grows and we’ll need to see how this can be translated into new therapies. We’re also become better and getting topical therapies to work better with various agents that get drugs into the skin and keep them there.
12. You mention “acceptance” as a viable option for hair loss sufferers, which I found refreshing. To me it displays a very patient-oriented approach. Have you ever actually advised a patient to consider cutting their losses, so to speak? Some people look good bald, after all!
I certainly have. But usually I present this to patients as an option on their list that they may not have considered. It’s definitely a treatment option and sometimes I even contact my patient who has chosen acceptance a year or two later to see how this option is going. This is certainly an option that must always be considered.
13. Do you ever recommend any natural hair loss treatments like rosemary oil or saw palmetto?
I sometimes do. One must always be aware that some treatments for balding are great and some and no so consistently great. Rosemary oil and saw palmetto are not so consistently great.
14, Your opinion on ketoconazole. I know the research is limited but it does appear to have some mild benefits, potentially.
Yes, it does but one must keep in mind that it probably needs to be used very often. Once per week of ketoconazole shampoo is not going to make much of an impact.in
Thanks again to Dr. Donovan for his time, candor, and detailed answers! Check out his website and blog at Donovanmedical.com to learn more about his practice, philosophy, etc. And finally, if you or someone you know would like to be included in my “ask an expert” feature, please don’t hesitate to contact me.
Robert Price is a writer, consumer advocate, and hair loss nerd with thousands of hours of experience in the field. His goal is to keep you out of the hair loss rabbit hole, underworld, or whatever you want to call it. He founded Hair Loss Daily, the unbiased hair loss blog, in 2016. You can learn more about Robert in the my story section of this website.