Exogenous Testosterone and Hair Loss

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In this video, Dr. Nilofer Farjo, ISHRS Vice President interviewed Dr. Vikram Jayaprakash on the the effect of testosterone injections on hair loss.

He is seeing an increase in patients using testosterone around the “andropause” as well as younger men using it as part of their fitness and muscle building regime, and in those patients, he modifies his medication dosing. His retrospective study was presented at ISHRS 2020 World Congress.

Dr. Nilofer Farjo: In a study that you reported at the last ISHRS Annual Congress, you spoke about patients who are using exogenous testosterone. How often are you seeing these patients?

Dr. Vikram Jayaprakash: I looked into what happened in a population and a group of individuals that were taking exogenous testosterone and found:

A) The impact potentially it may have had on their hair loss (with no control group).
B) What we decided to do regarding therapy in terms of dosing, specifically with Finasteride.

I did notice that I’m seeing more people that were using testosterone replacement.One being the bodybuilders group that are injecting massive doses of testosterone. Another group that are men going through andropause for a term, where their testosterone levels are low and they’re feeling the effects of that. Generally they’re using a topical testosterone on a daily dosing regime and monitoring their testosterone levels to keep their serum testosterone (free testosterone) within a certain range.

From a conceptual basis, testosterone gets converted into dihydrotestosterone by the 5-alpha reductase enzyme and the elevation in dihydrotestosterone with the combination of the gene for hair loss results in what we see as male pattern hair loss. If you’re adding more testosterone in the mix, does it drive the equation across to the other side? The small study that we did showed that to a certain extent it does, these are already people that have gotten male pattern hair loss. It’s not that everyone taking testosterone is going to go bald, it’s those that received a diagnosis of androgenic alopecia that are taking supplemental testosterone, we found that there was a significant increase in the progression of their hair loss. Looking at how to manage that, we were looking at options of increasing the dose of Finasteride and then potentially after adding Dutasteride into the mix.

Are you seeing many patients like that? Are you seeing many people coming to you with topical testosterone?

Dr. Nilofer Farjo: No, I would say we’ve had a handful, the medical history form we ask about all their medications and whether or not they’re reporting it. That’s why I was interested in your study because maybe we should ask that specifically. We don’t ask if those patients who are in the andropause age group use testosterone, we rely on them reporting it. It may be something that we should start doing. I think it would also be very interesting to see what’s going on at a genetic level, what’s happening to the androgen receptor gene and we know that there’s more than one variant of that.

What’s happening with genetics? Are they being switched on or off as patients age? How does that fit in with patients’ response to medications? We know a lot of things in our body change with age. For example, when we look at the hair biology side, we’ve done a study where we’ve shown that the hair follicles don’t grow as well in the older age groups than they do in the younger age group. Does that also mean that there’s other things at play in this whole interaction? It’s complex and it goes along with looking at things on a very personal level from one patient to the next and looking at their genetics. It’s really interesting because that is where we get into personalized medicine and you can say, “but that’s a very expensive exercise to do,” taking a group of genes and testing them against what might be happening when we treat patients. It’s very fascinating, but a very complex issue.

Dr. Vikram Jayaprakash: Yes, it’s the next frontier, personalized medicine and genome testing, knowing which medication is going to be effective. We were essentially taking a punt when we said “you’ve got male pattern, hair loss, and we think that’d be effective.”

Dr. Nilofer Farjo: It is a good punt because the clinical studies have shown that Finasteride is going to work in 90% of patients. If you look at medications in general, they don’t work on everyone, no medication does. It’s a pretty good punt, you can’t knock that.

Dr. Vikram Jayaprakash: I’m happy to talk about medication to all in some way. I talked to every patient, but to the point that I sound like I’m someone who is a massive proponent of taking pills. It’s not that, but you’re absolutely right, because it’s the best that we’ve got and it has a phenomenal track record in terms of what it can achieve. There are limitations of course, this afternoon in the clinic, I had actually seen a patient who had injected testosterone who had gone on a 12 week course (from a bodybuilding perspective). In that three month block he lost a significant amount of hair taking super physiological doses and it did have a very drastic effect on his hair loss in a very short period of time.

Dr. Nilofer Farjo: You do one thing to your body and that creates another problem. It’s getting the balance, men have nice muscles, but don’t have any hair. They have to decide what’s more important.

Dr. Nilofer Farjo: I’d like to thank you for joining me today. It was very fascinating talking about a topic that’s really important to our patients and for other doctors, especially those new to the field to actually look at these issues and understand how to handle their patients, especially the younger ones.

Dr. Jayaprakash Bio:

Dr. Vikram Jayaprakash is an experienced hair transplant surgeon with a background in hair restoration, anti-aging, and cosmetic medicine. He graduated from the University of Southampton, UK in 1998 and emigrated to New Zealand in 2005, and subsequently moved to Melbourne in 2016 where he now works full time in hair restoration surgery at the Knudsen Clinic in Melbourne, Australia.

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