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Expert discusses hair loss treatment controversies, concerns

Dermatology TimesDermatology Times, April 2020 (Vol. 41, No. 4)
Volume 41
Issue 4

It is important for clinicians to stay abreast with the latest data coming out of trials and individually consult their hair loss patients accordingly on a case by case basis, says this expert.

Amy McMichael, M.D.

Dr. McMichael

The landscape of hair loss therapies has evolved, bringing with it some concern around appropriate treatment. It is important for clinicians to stay abreast with the latest data coming out of trials and individually consult their hair loss patients accordingly on a case by case basis, says Amy McMichael, M.D., professor and chair, department of dermatology, Wake Forest Baptist Medical Center, Winston-Salem, N.C., who recently spoke at the ODAC Dermatology, Aesthetic & Surgical Conference in Orlando.

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“There is always going to be new data coming out in the hair world. Although the pace of the current research is limited by the lack of funding in this field, if we keep working on it and we band together with our data and get larger data sets, we’ll be able to talk about these things and make more sense for our patients,” Dr. McMichael says.

Although the true utility of biotin has long been disputed, the supplement has been regularly included in product formulas for hair loss because it has been viewed as beneficial. Aside from the fact that it doesn’t work very well in hair loss treatment, Dr. McMichael says, the main reason clinicians have been discouraging their patients from taking biotin supplements for their hair loss is the potential danger it can pose in medical testing.

According to Dr. McMichael, the larger and growing concern is the effect that supplementary biotin can have on important medical testing that patients may be undergoing by obscuring results and, therefore, appropriate therapy. 

Biotin is regularly used in assays in hormonal laboratory testing, including thyroid testing, hormonal tests for pregnancy, as well as tests for cardiac arrest. As such, patients who are taking biotin supplements could have false test results if their laboratory test assay contained biotin.

“If you are going to recommend hair loss supplements, and especially one that has biotin in it, then you have to counsel your patients accordingly. Patients should be reminded to stop their biotin containing supplement prior to any medical assay exams in order to help preserve the integrity of the lab results,” Dr. McMichael says.

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Continued research has led to an array of JAK inhibitors currently available for the treatment of alopecia areata. Clinicians need to know how and when to implement them appropriately. According to Dr. McMichael, it can be challenging to decide which patients should receive JAK inhibitor therapy, particularly when confronted with the explosion in therapeutic choices.

“I would recommend JAK therapy for older adolescents as well as adults, particularly those patients with a greater than 50% hair loss. We currently do not have any data on JAK inhibitors in children and, until that time comes, they should not be used in this patient population,” Dr. McMichael says.

Unfortunately, reimbursement can also be a limiting factor for many alopecia areata patients, but according to Dr. McMichael, those patients who have gone through a failed oral methotrexate treatment may have a higher likelihood of getting JAK inhibitor therapy approved by insurance companies.

Though having proven efficacy in male pattern hair loss, 5-alpha-reductase inhibitor (5-ARI) therapy has been associated with some potential side effects including persistent erectile dysfunction (PED) and depression, as well as an increased risk for type 2 diabetes in male patients on the medication.

One recent study1 addressed the incidence of PED in a cohort of 12,000 male pattern baldness patients taking 5-ARIs (either finasteride or dutasteride) and found that 1.4% had PED. Interestingly, a closer look at the data showed that there was a moderate number of patients with PED who were toward the younger age spectrum (15-42 years).

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“Though this is a very small number, it does raise the concern that you need to discuss the potentially pre-existent sexual dysfunction anddepression in patients. People often think that because men are young, they do not have sexual dysfunction but that is not actually always true. If you have a candid conversation with your patients, you can potentially avoid recommending the hair loss medication to those who may be potentially more at risk for this issue,” Dr. McMichael says.

Another study2 addressed the concern of 5-ARIs and the patient’s risk for type 2 diabetes, where researchers found a small but not negligible trend for patients on the drug to develop the condition.

“Clinicians should carefully consult theirpatients and be mindful when considering 5 alpha reductase inhibitor medications in those patients who are at a higher risk of type 2 diabetes,” Dr. McMichael says.


Dr. McMichael reports no relevant disclosures.


1 Kiguradze, T, et al. Persistent erectile dysfunction in men exposed to the 5α-reductase inhibitors, finasteride, or dutasteride. PeerJ. 2017 Mar 9;5:e3020. doi:10.7717/peerj.3020. 3 Collection 2017.

2. Lee SS, et al. 5-alpha-reductase inhibitors and the risk of diabetes mellitus: A nationwide population-based study. Prostate. 2016 Jan;76(1):41-7. doi: 10.1002/pros.23097. Epub 2015 Sep 22.

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