The Bald Truth
Americans turn to weaves, rugs, plugs, and drugs to alleviate hair loss, creating a $1.5 billion industry
Mark S. was 17 when he began to notice large clumps of hair collecting in his shower drain. The follicles just above his brow were sprouting mere wisps to replace the lost hairs, and pretty soon Mark's friends at his Milwaukee high school had nicknamed him "Captain Forehead." Anxious to stem his premature hair loss, Mark tried remedies like vitamin supplements, topical solutions, and specially formulated shampoos. None worked. After graduating from high school, he moved to Los Angeles to pursue a career as a musician. To pay the bills while he tried to win a record contract, Mark took blue-collar jobs, avoiding indoor office work that would make it seem odd for him to wear a hat.
By the time Mark bought a hairpiece in 1994, seven years after his first signs of hair loss, he had invested more than $6,000 in baldness remedies. But his self-confidence was still shaky. Finally, he decided to spend an additional $6,200, which he didn't have, on a hair transplant. To come up with the money, Mark moved out of his apartment and into his car for three summer months. Two surgeries and 2,365 hair grafts later, Mark, now 27, sports a full head of shoulder-length hair. But Mark's troubles are probably not over.
Amazingly, at this late hour of human civilization, no one knows for sure how to prevent a hairline from receding. In spite of this collective ignorance, a growing number of the nation's 40 million balding men and 20 million balding women are turning to drugs, hairpieces, and surgical procedures to alleviate their hair loss, in the process creating a $1.5 billion-a-year industry. Americans now spend 1 times as much money on products intended to help them keep or replenish their hair as they do on razors that remove it.
Repeat customers. Light-bulb makers benefit from the fact that bulbs eventually burn out and need to be replaced. Similarly, the hair-replacement business profits, in part, because its solutions to baldness are at best imperfect and almost always impermanent--repeat customers, in other words, are a given. Once a consumer commits to treatment, it becomes difficult, and in some cases impossible, to stop spending money and return to the old, reliable comb-over. Hairpieces, for example, require frequent servicing and must be replaced every few years; any hair growth induced by the drug Rogaine disappears once a customer stops using the product; and hair-transplant patients often must undergo multiple operations.
Scientists still have a limited understanding of why androgenetic alopecia--commonly known as male-pattern baldness--occurs in the first place. It seems to result from three interdependent factors. The first was uncovered more than two millenniums ago when the ancient Greeks noted that eunuchs did not go bald. They surmised correctly that among the things lost in castration was the mechanism that leads to baldness. The missing variable, it turns out, is male hormones. Scientists have learned since then that testosterone is only an accomplice, not an originating agent, in the balding process. The second, and most important, variable is a genetic predisposition for hair loss. Researchers are convinced that baldness is hereditary, but they have yet to identify the genetic coding that makes the scalp go bare. Even with the right genes, hair loss only occurs with a third factor: aging. All men and women lose some hair as they get older, but those with pattern baldness lose more hair at a younger age than do their counterparts (pattern baldness affects nearly 40 percent of males in their 30s and well over half of all men over 50).
People with pattern baldness have genes that at a certain point trigger the creation of an enzyme called 5-alpha reductase. When it comes in contact with the testosterone that is typically present in a hair follicle, the enzyme creates an offshoot called dihydrotestosterone (DHT), which causes the follicle to dry up. Each time a new hair sprouts from a root where DHT is present, it grows a little shorter and thinner. In time, the follicle becomes dormant and new hairs stop growing altogether. Where this process occurs on a human scalp is determined by the genes.
Baldness can take a heavy psychological toll. A study last year by David Przybyla of Denison University found that both women and men--those with hair and those without--view bald men as "less physically attractive, less socially skilled, and less socially successful than their counterparts." (One small consolation: The same study found that bald men are assumed to be more intelligent.) Another recent poll revealed that 1 in 4 balding men would happily sacrifice five years of life for a full head of hair.
The search for weapons against baldness began long before Delilah sheared Samson's locks. Nearly 3,500 years ago, Egyptians created a concoction to cure baldness that consisted of fat from lions, crocodiles, geese, and hippopotamuses combined with, among other things, hedgehog prickles, oil, honey, and red ochre. Around 400 B.C., Hippocrates, the father of modern medicine, tried to regrow his own hair by applying sheep urine to his barren scalp. Perhaps because it was assumed any experiment by Hippocrates could do no harm, a similar technique, involving dog urine, was tried in the 18th century.
Only within the last quarter century have modern scientific methods offered even the slightest hope of offsetting the cause of hair loss. This first step came with the heavily publicized drug Rogaine, which became available by prescription in 1988. Sold over the counter as minoxidil since last year, the topical treatment costs about $30 a month and is the only solution that the Food and Drug Administration has judged capable of regrowing hair. The hitch is that it doesn't work for everybody.
Minoxidil was initially developed as an oral medicine to reduce high blood pressure. But in the course of performing a clinical trial in 1971 for Upjohn, researchers noticed that some patients were growing hair on their shoulders, legs, temples, and elsewhere. Several members of the lab team then began rubbing a powder form of minoxidil on their arms each day. Initially, the skin simply became irritated, but after several months they noticed an increase in hair growth. In December 1971, Upjohn filed for a patent for minoxidil as a potential hair-regrowth medication. Seventeen years later, the company received permission from the FDA to sell Rogaine as a prescription drug. Minoxidil also proved effective--and, under the name Loniten, is still available--as a drug for high blood pressure.
Rogaine (which Upjohn originally wanted to call "Regaine," a brand name vetoed by the FDA) is no panacea. The company's own clinical studies find that it produces "meaningful" results in about only one quarter of the men--and 20 percent of the women--who apply it to their scalps twice a day. That's compared with the 11 percent of men and 7 percent of women who had similar results taking only a placebo in the same trial. (Placebo groups in other clinical studies have experienced similar, or even greater, levels of success, leading researchers to conclude that psychology plays an important role in hair growth.) The FDA is now considering whether to approve a stronger, nonprescription version of Rogaine, which the company says can stimulate as much as 46 percent more hair growth in men than today's product.
When Rogaine does work, no one really knows why. This mystery helped stimulate $162 million in U.S. sales of Rogaine last year. Since it is impossible to predict just which lucky few will sprout new hairs after using Rogaine for four months to one year, every balding man and woman has an incentive to try. In addition, research suggests the drug slows the rate at which hair follicles dry up even for those who don't see any regrowth. The only way to tell for sure whether Rogaine is having such an effect is to stop the daily smearings, at which time any benefits gained through the treatments, including new hair, quickly disappear.
Small gain. In business terms, however, Rogaine has so far proved a disappointment (analysts originally predicted annual sales of about $500 million). The main reason is that many users grow frustrated when the drug does not meet their expectations and turn instead to hairpieces or transplants.
A second potentially promising anti-baldness drug, finasteride, which Merck hopes to market as Propecia, is currently under review by the FDA. As with Rogaine, the drug's developer discovered its antibaldness properties by accident (in this case, when developing a drug to treat enlarged prostate glands). Propecia's main advantage over Rogaine would be that it can be taken as a pill, which patients are likely to prefer over a topical application. Its main disadvantage--albeit an uncommon one--is that in clinical trials, 2 percent of the men who tried Propecia experienced "decreased libido." Sorry, Samson.
While scientists concentrate on the small advances in hairline restoration that Rogaine and Propecia represent, entrepreneurs continue to turn out hundreds of lotions, shampoos, and other nostrums whose effectiveness is exposed to little, if any, scientific testing. The trick in marketing this stuff is to obey the FDA's rule against claiming such toiletries can grow hair or prevent its loss--boasts about the way a product will affect the appearance of the hair are allowed--while somehow getting across the idea that they can, well, grow hair or prevent its loss. The greeting callers hear when phoning for information about the Kevis hair-improvement programs thanks them for "taking the first step toward a thicker, fuller, healthier-looking head of hair." But Kevis General Manager Brian Reichenberg might be asking for trouble with the FDA when he boasts that the product "can slow down the hair-loss process dramatically."
Kevis's topical lotion contains a patented formula based on ingredients like thioglycoran and hyaluronic acid. This solution, Reichenberg says, fights against the accumulation of DHT in hair follicles, thereby preventing the chemical process that causes hair loss. The first year's supply of Kevis products costs as much as $1,000. After that, "maintenance" runs anywhere from $300 to $600 a year. The company anticipates taking in roughly $10 million from its 10,000 American customers this year. Reichenberg estimates that Kevis's annual worldwide revenues top $200 million.
An easier category of therapy for nonexperts to assess is the batch of cosmetic products that promise only to camouflage exposed scalp. The most well known of these is GLH ("great looking hair") Formula No. 9--better known as "Hair in a Can"--which several years ago was hawked endlessly on late-night television. Although the product has become a source of easy laughs for comics like Jay Leno, it does serve a useful purpose for those with minor hair loss around the crown. As long as there is enough hair to provide some thin cover to the pate, coloring the scalp can help mask the area of bald skin. But since the product merely reduces the scalp's reflectivity without replicating the volume or strandlike qualities of real hair, those with significant balding, particularly on the front of the scalp, are unlikely to fool their friends or co-workers.
Magic carpet. Many who turn to hairpieces (the term toupee has fallen out of favor because it connotes the ill-fitting rugs of yesteryear) face similar concerns over whether their attempts at concealment will be noticeable. A movie star like Sean Connery can wear a hairpiece one day and go without it the next because no one expects actors to maintain a consistent appearance. But most men live in a world that expects them to look more or less the same from day to day and are reluctant to show up at the office sporting an obviously phony "natural look."
A different approach to this problem was pioneered by Sy Sperling, founder of the Hair Club for Men, which weaves a hairpiece into existing hairs with the aid of an adhesive polymer. The customer has to come back every six weeks or so to have the indigenous hairs cut back and the piece reattached to snug up the fit. Each visit costs about $65. In addition, the entire "hair system" has to be replaced every few years, at a cost of anywhere from $1,500 to $2,500. The company knows that once a customer starts wearing a system, he is likely to be a "member" for life, whether he realizes it at the time or not. This helps explain why HCM is currently experimenting with a promotion to offer a free hair system to new customers. It also explains why the company, which Sperling plans to take public within the next few years, expects to earn $60 million in revenues this year.
Almost none of the weaves, wigs, or "systems" sold in the United States are made in this hemisphere. The vast majority of the replacements are made from real hair, most of which comes from India, Russia, and China. Western European hair is considered especially valuable, since its consistency tends to be similar to that of hair from America's white majority. For the distinguished graying look, yak and angora hairs are the fiber of choice, since white human hair tends to fade to yellow. The hairs themselves are sewn into ultrafine mesh bases in an intricate process that requires the knotting of thousands of individual hairs just to produce one wearable product. Most of the work is performed at factories in developing Asian nations like the Philippines and Thailand.
Those who buy wigs consider wearing hair from someone--or something--else preferable to baldness, but most would clearly rather grow more of their own hair. Since pharmaceutical means to that end, like Rogaine, are disappointing for most men, many have turned to a mechanical solution: the $800 million-a-year hair-transplant industry, which has been experiencing explosive growth in recent years. According to the American Academy of Cosmetic Surgery, 244,500 hair transplants were performed in the United States last year. That's more than four times the 57,700 done in 1990.
In a transplant, a physician removes hair follicles from the back of the head and uses them to fill in bald areas of the scalp. A patient is constrained in the number of transplants he can get by the size of his "donor area"--the horseshoe-shaped area of hair that remains on almost every bald man's head. The trouble with transplants is that, like the other available treatments for hair loss, they represent an imperfect solution. Hair follicles can be moved from the sides and back of the scalp to the top, but there's no reason to think a post-transplant hairline will stop receding. If a 30-year-old with some loss around the temples gets a transplant, for example, and his hair then continues its retreat, he will likely be left with two rather conspicuous tufts surrounded by exposed scalp. At that point, there is little he can do but pour out more cash, either for a decent hairpiece or for additional transplants. Such patients can actually spend as much as $50,000 over a lifetime for a succession of surgeries.
Surge of surgeons. In most medical fields, physicians would warn their patients, or even refuse to perform a transplant, if they thought there might be problematic long-term consequences. Plastic surgeons know that any patient will eventually look old; their task is simply to delay the appearance of aging. But in the booming world of hair-transplant surgery--in which any M.D. is allowed to try his hand at the procedure, regardless of whether he has even witnessed the operation--some physicians are too inexperienced to know what the long-term ramifications of the surgery they perform might be.
The creeping advance of managed care has pushed doctors of all backgrounds into the hair-transplant market. Plastic surgeons and dermatologists, who have traditionally performed such operations, have been joined in recent years by a stream of pediatricians, urologists, emergency-room physicians, and others--all looking to make extra money while avoiding the headaches of reimbursement forms and insurance companies. Dr. W. Gregory Chernoff has witnessed this growth firsthand. For each of the past few years, he has spent 3 out of every 4 weekends away from his Indianapolis home teaching as many as 200 fellow physicians at a time how to do hair transplants.
The influx of new hair-transplant doctors has helped push prices down--from as much as $30 per graft two years ago to as little as $4 per graft today--but it is not necessarily good news for patients. "I probably did several hundred procedures before I knew what the hell I was doing," confesses one physician who has been in the business for over two decades. Indeed, many experienced hair specialists say that at least half of their patients come in looking for someone to repair the damage caused by a previous transplant.
Plugging away. The growth, and profit potential, of the transplant business may also be fueling a level of competition between hair surgeons that is not necessarily healthy for patients. With the largest transplant centers spending millions of dollars a year on advertising, for example, some doctors fear that there is an extra incentive for these offices to pay more attention to their revenue stream than to the interests of their patients. The Bosley Medical Group is the nation's largest transplant operation, performing as many as 10,000 procedures a year. The center's headquarters is located in the penthouse of a Beverly Hills office building. Founder and Director L. Lee Bosley, one of the nation's most experienced transplant physicians, has performed over 35,000 procedures over the past 34 years. It is his name that the company sells. Copies of Dr. Bosley's diplomas and certificates and a photograph of the doctor with country music star Kenny Rogers--a former patient--are featured not just in Bosley's wood-paneled office but in each of the half-dozen or so consultation offices where prospective clients receive their assessments.
These consultations also are a source of controversy. One physician who performs hair transplants himself paid an anonymous visit to Bosley several years ago. Although this doctor clearly did not need transplants, a Bosley medical counselor--who critics say is nothing more than a salesman in a lab coat--recommended not one but three surgeries. The doctor who breezed in toward the end of the consultation quickly agreed with the diagnosis. An investigative report earlier this year by the NBC program Dateline also concluded that the role of Bosley counselors is to sell as many procedures as possible. Bosley President John Ohanesian dismisses the matter as a difference of opinion. "For one physician to say that a diagnosis is right or wrong is merely an assessment of a judgment," he says. Ohanesian also says that Bosley sends anonymous visitors into each of its 37 offices several times a year to prevent such problems and has in the past dismissed employees who made faulty diagnoses.
Minisurgery. But it is not just marketing pressure that is persuading more balding men to let physicians take scalpels to their heads. Within the past several years, doctors have developed and refined a new transplant technique that more accurately replicates the way that hairs grow on their own. Since most hairs actually sprout from the scalp in one- to three-hair clusters, surgeons now transplant hairs in these same patterns, typically called micrografts and minigrafts. Behind the hairline, surgeons will transplant grafts of as many as eight hairs. Today, the micrograft and minigraft method is used by just about all physicians who perform transplant surgery.
This new technique is derived from a procedure that was developed by Norman Orentreich in 1954. A dermatologist at New York University, he began punching out small circles of follicles and scalp about the diameter of a pencil from the back of the scalp and dropping them into holes above the forehead. The transplanted hairs fell out soon after the operation, but new ones began to sprout within several months and eventually became long enough to provide some coverage to the scalp. This same routine of the hairs dying out and then regrowing, doctors have since learned, is a natural part of any transplant procedure.
Even with the more recent advances of micrografts and minigrafts, hair-transplant surgery today is neither quick nor pretty. Recently, in an operating room at the Los Angeles office of the New Hair Institute, which performs over 1,000 transplants a year nationwide, a patient sat back in a chair smiling--a disposition attributable to the painkilling drugs in his system. In the corner of the room, a medical assistant busily sliced micrografts from a hairy piece of scalp that only hours earlier had been attached to the back of the patient's head. Hovering over the patient's fairly large bald spot were a pair of technicians using sharp forceps to jam strands of hair into tiny holes drilled into the patient's head. Each plunge of the technicians' needles put another of the 1,800 one- to four-hair grafts being transplanted that day into place--and brought a slight oozing of blood. The patient paid about $9,000 for the roughly eight-hour procedure.
One problem for patients is that doctors themselves do not agree on any single best approach to transplant surgery. Dr. William Rassman, founder of NHI, has made a career by performing what he calls "megasessions." Instead of the 1,500 or so grafts that most physicians limit themselves to in any one surgery, Rassman continually pushes the envelope to reposition as many follicles as possible during a single operation. His current ceiling stands at around 4,000 grafts, though that is a record he expects to top soon. This strategy is controversial among many in the transplant community, who say that moving that many follicles unnecessarily increases the procedure's failure rate. But the megasessions are a crucial element of NHI's strategy. The outfit has positioned itself as the low-cost, high-volume competitor in the market, charging as little as $5 a graft.
Several other surgical procedures offer the possibility of quicker and more dramatic results, though each comes with potential problems of its own. Patients looking for a more immediate and dramatic fix may be tempted by a method known as the "flap." The procedure works quite simply by slicing all but one corner of a strip of skin and hair from the side of the scalp and rotating it around across the front of the head to replace the once hairless scalp. The skin around the area from which the flap is removed is pulled together and sutured shut. The best part about the technique is that it gets immediate results with much more hair than is possible with micrografts. The downside is that the hair may well grow in an unnatural direction: straight upward.
Many practitioners of both micrografts and the flap method recommend scalp reductions in conjunction with those procedures. In a scalp reduction, a doctor cuts out a strip of bald skin from the pate and pulls the scalp together to increase the area of hair coverage. Those with some pliability to the skin on their heads are able to shrink the size of their bald spot. But in many instances, the "reduced" scalp can stretch back apart, restoring the now scarred bald area.
Until doctors develop a medical cure for baldness, this treadmill of treatment and spending--and more treatment and more spending--is likely to be the only path for balding men and women who want their hair back. Even Mark S., who has already invested more than $12,000 on his hair, expects to return to the operating room in the not-too-distant future to hide the thinning he knows his genes have in store for him. With no miracle antidote for baldness on the horizon, there appears to be plenty of room for growth in the hair-loss industry.
True or False Much of the conventional wisdom about baldness is merely myth. Test your knowledge by answering these True/False questions. 1. The scalp of a man's maternal grandfather offers the best hint about whether he will lose his hair. 2. The average human loses about 100 hairs a day. 3. A male castrated before puberty will not suffer from male-pattern baldness. 4. The frequent wearing of tight hats or caps can cause baldness. 5. Bald men are viewed as being more intelligent than their hirsute counterparts. 6. A physician must earn proper certification before performing hair transplants. 7. Any hair that grows back through the use of Rogaine will fall out if you stop using the product.
Answers: 1. False, scientists believe that a baldness gene is just as likely to come from the father as from the mother. 2. True, hairs fall out every several years and are replaced by new ones. 3. True, testosterone is needed to trigger the hair-loss process. Without it, a man won't go bald. 4. False, wearing hats cannot cause baldness. 5. True, a recent survey found that, based merely on appearance, bald men are considered smarter. 6. False, any doctor who has graduated from medical school is free to perform transplant surgery. 7. True, the benefits gained from Rogaine fade away if you stop using it.
TOPICAL TREATMENTS Of all the lotions on the market today, only minoxidil has been judged by the FDA to be capable of regrowing hair and preventing further hair loss. The most well-known product containing minoxidil is Rogaine, which must be applied to the scalp twice a day. PROS: Available without a prescription; no one need know product is being used; no scarring. CONS: Rogaine causes significant growth in only about a quarter of those who use it; any hair saved through the use of minoxidil falls out if you stop applying it. COST: $30 a month for Rogaine, though generic brands of minoxidil are available for less than $15 a month; other solutions can cost up to $100 per month.
COSMETIC HAIR From hair in a can to hair in a tube, these powdery products work by coloring any exposed scalp to mask baldness. They look best on those who still have a significant portion of their hair. Products are available in a variety of colors. PROS: Easy on, easy off (removable with soap and water); surprisingly effective for those with only moderately thinning hair. CONS: Inappropriate for those with significant hair loss; products may run if you perspire or get your scalp wet. COST: Anywhere from $20 to $40 a month, depending on how much scalp you are trying to cover. Cost will increase as your bald spot grows.
HAIRPIECES Today's hairpieces are made of real or synthetic hair sewn into a thin mesh base. They can be fastened or woven into existing hairs or glued directly to the scalp. Most need to be removed less than once a month, though some might need to come off each night. PROS: A full head of hair without surgery; can sleep and exercise while wearing most hairpieces. CONS: Difficult to stop wearing a hairpiece and go back to a bald scalp once you start; some may be noticeable. COST: $500 to $3,500 for a hairpiece (real hair is more expensive than artificial). A hairpiece needs replacing every one to three years. Many also require a $50-to-$75 service visit for refitting roughly every six weeks.
TRANSPLANTS In a surgical transplant, a physician removes a strip of hair-covered skin from the back of the head, divides it into grafts of anywhere from one to eight hairs, and then places them into holes drilled in bald areas of the scalp. PROS: Allows you to regrow your own hair; recent developments have largely eliminated the "pluggy" look of past techniques. CONS: Bald areas may develop behind the transplants as the hairline recedes; procedures are not reversible, so mistakes are permanent. COST: A transplant can cost from $2,000 to over $10,000, depending on how many hairs are moved. Many patients will require more than one transplant. For more information, see U.S. News Online (http://www.usnews.com).
This story appears in the August 4, 1997 print edition of U.S. News & World Report.