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Rob English – Everything You Need To Know About Hair Loss

Content by: Rob English

Watch the full interview below or listen to the full episode on your iPhone HERE.

Stu: This week, I’m excited to welcome Rob English to the podcast. Rob is a researcher, medical editor and the founder of Perfect Hair Health, a website dedicated to showcasing evidence-based methods for hair regrowth with or without drugs. Rob’s interest in hair loss began in 2007 right after he was diagnosed with androgenetic alopecia. Since then he’s spent thousands of hours researching hair loss, its causes, treatments and misconceptions. In this episode, we discuss the fundamental causes of hair loss, the common misconceptions, and the most effective treatment options

Audio Version

Question about the episode

  • What factors cause hair loss? (07:30)
  • Are natural therapies worth exploring? (39:30)
  • What can we do to tackle greying hair? (46:00)

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The views expressed on this podcast are the personal views of the host and guest speakers and not the views of Bega Cheese Limited or 180 Nutrition Pty Ltd. In addition, the views expressed should not be taken or relied upon as medical advice. Listeners should speak to their doctor to obtain medical advice.

Disclaimer: The transcript below has not been proofread and some words may be mis-transcribed.

Full Transcript

Stu

Hey, this is Stu from 180 Nutrition. And welcome to another episode of The Health Sessions. It’s here that we connect with the world’s best experts in health, wellness, and human performance in an attempt to cut through the confusion around what it actually takes to achieve a long-lasting health. Now I’m sure that’s something that we all strive to have. I certainly do.
Before we get into the show today, you might not know that we make products too. That’s right. We are into whole food nutrition and have a range of superfoods and natural supplements to help support your day. If you are curious, want to find out more, just jump over to our website, that is 180nutrition.com.au, and take a look. Okay, back to the show.

This week, I’m excited to welcome Rob English to the podcast. Rob is a researcher, medical editor, and the founder of Perfect Hair Health, a website dedicated to showcasing evidence-based methods for hair regrowth with or without drugs. [00:01:00] Rob’s interest in hair loss began in 2007 right after he was diagnosed with androgenetic alopecia. Since then he’s spent thousands of hours researching hair loss, its causes, treatments, and misconceptions. In this episode, we discuss the fundamental causes of hair loss, the common misconceptions, and the most effective treatment options. Over to Rob.

 

Stu

Hey guys, this is Stu from 180  Nutrition and I am delighted to welcome Rob English to the podcast. Rob, how are you mate?

Rob

I’m doing great. Thanks for having me.

Stu

No. Well, look, thank you so much for agreeing to come on and having a chat. I know that we’ve got lots questions that people will be very, very intrigued to hear your take on, but first up, for all of our listeners that may not be familiar with you or your work, I’d love it if you could just tell us a little bit about yourself, please.

Rob

Sure. So I’m Rob English. I am a medical editor and I’m [00:02:00] a peer-reviewed researcher who specializes in hair loss disorders. So that can be anything from common hair loss disorders like androgenetic alopecia and telogen effluvium all the way toward less common hair loss types like alopecia areata, autoimmune forms of hair loss, scarring alopecias. And I’m also the founder of a website called Perfect Hair Health, which showcases evidence-based approaches for hair regrowth with the drug model, without the drug model. It doesn’t really matter which path somebody takes. For me what matters [00:02:30] is their access to good information that they’re not making any decisions that are rooted in their exposure to, I guess what I would describe asymmetrical information or cognitive dissonance.

And I’m also on the editorial board of a journal called Dermatology and Therapy. So that gives me insights into the peer review process. I could see what’s coming down the pipeline in terms of different hair loss research, which interventional approaches are gaining more traction, and it also gives me this opportunity to converse with a bunch of different people in the hair loss community that are active researchers and have dedicated their careers to these things.

So it’s a really fun experience overall. I guess what makes me a little unique compared to other people is that I’m on the editorial board of a dermatology journal. I have all of these peer-reviewed publications and I am not a technically trained academic. I didn’t study anything related to hair loss in college. My interest in hair loss research, which later became my career, happened after college. [00:03:30]

And it all happened because of self-interest because back when I was 16 years old, I started to notice that my hair was thinning a little bit. 17 years old, went to a doctor who specializes in hair loss disorders. It was a transplant surgeon. They did this scalp exam on me and they told me that I was dealing with male-pattern hair loss and androgenetic alopecia.
And that it’s this chronic and progressive hair loss disorder and that if you don’t seek treatment for it, it just gets worse and that I’d likely be bald by 30, 35 years old [00:04:00] unless I did something about it. So obviously that was a warning signal that I probably need to focus a little bit more on my hair than other people because I was the only one at the time that I knew of even dealing with hair loss at such a young age. So it also kind of felt, I guess, emotionally isolating. So I got a prescription for this drug called finasteride. I was told to start using minoxidil twice daily. I opted into a clinical trial inside a clinic for low level laser therapy,

[00:04:30] which was super expensive at the time, but I was freaking out and wanted to do something.
And then I went home and like most people who are facing a very similar situation, I started to Google some of the things that I was trying and some of the drugs that I wanted to use and I ran into a bunch of bad information and misinformation about this heightened side effect risk of these drugs, which scared me away from trying things like finasteride and then led me down [00:05:00] this path where I was really desperate to find solutions outside of the drug model, or at least outside of hormonally modifying models that targeted hormones like DHT.
So that was really the basis of what got me into trialing different products, topicals, supplements, devices, treatments. And with each failure point, I became more and more interested in hair loss research until eventually when I went to college, I had access to all these medical journals, I could

[00:05:30] actually use the university library system to read full papers rather than just titles and abstracts, and that’s really where my interest in hair loss research kind of exploded. So I felt like I kind of became this closet nerd for anything related to hair loss disorders.
And when I finally saw some success outside of the drug model, I started a website, Perfect Hair Health, to talk about some of those models and the evidence supporting them and some of the hypotheses. And then a few years later, I decided to start publishing papers about them.

[00:06:00] So the first paper was about a hypothetical pathogenesis model, which discussed some potentially underutilized treatment targets or interventional targets for androgenetic alopecia. The second paper was related to a potential intervention. The third paper was related to conflicting histological reports across investigation groups with the relationship between scarring and inflammation and prostaglandin activity of androgenetic alopecia patients. The fourth has been a literature review and we have a fifth and peer review right [00:06:30] now that is focused on microneedling and it’s use in hair loss disorder. So wound healing. And that’s a big interest of mine.

And so that’s kind of what I do and how I fell into this type of work and what I do in a day to day. I manage a very small research team right now dedicated toward pumping out different manuscripts related to hypotheses, letter to editors, literature reviews, and I get to engage on a regular basis with hair loss investigation groups. So it’s a lot of fun for me and I like talking about it.

Stu

I think you certainly fit the bill of guest experts. So you are quite possibly the best person to answer these questions that I can imagine right now. And for all of our listeners out there that aren’t viewing this on YouTube or any of the other video devices, so Rob has got a full thick head of hair. And so you clearly practice what you preach, even better than I think. Just to answer my first question, [00:07:30] which essentially is why do we lose hair? And we are told that or oftentimes we think that it’s just hereditary or maybe it’s stress or maybe my diet’s wrong. I don’t know. So what’s your take on that?

Rob

Oh, it’s a question that requires significant nuance because the answer is very times hyper-individualized and complex and multi-faceted. So if you… [00:08:00] The first problem is that if you go to Google and you type in what causes hair loss, you’re going to see these listicles about the 14 top foods for hair growth. And those articles are going to cite things telling you that a biotin deficiency causes hair loss. And they’ll have this peer-reviewed marker with a reference next to it. And then it also will happen to affiliate with supplements on Amazon and they’ll sell you biotin supplements because they’ll also show you a study that shows that biotin causes hair [00:08:30] growth. And so you’ll start buying these things.

And you can do that with any type of intervention or supplement. You can do it with vitamin D, with iron, with interventions related to hypothyroidism. And there’s so many possibilities of hair loss out there that it’s really easy to get lost as a consumer. And what individuals lack in terms of education on what causes relate back to them are that if you clicked into that reference on biotin and you actually read [00:09:00] the study, you realize that that study that everybody cites, it leads to hundreds of millions of dollars worth of sales for biotin supplements. That study was on a case report series of 18 children under the age of six who have a genetic mutation called a biotinidase deficiency. And it causes a type of hair loss known as telogen effluvium, which is a nutrient-driven type of hair loss. And for those individuals, a biotin assimilation into the body is virtually [00:09:30] impossible. They have to supplement to get biotin and they lose hair as a consequence of not having biotin because their bodies can’t absorb any of it because they lack an enzyme for that conversion.

And so that’s the single study that everybody cites for biotin as a hair growth agent. That type of genetic mutation occurs in one out of 110,000 individuals. So it’s not very clickable to your everyday hair loss sufferer. So what does matter [00:10:00] with the context of this conversation is that you have to first start with the types of hair loss that are the most common and the most ubiquitous and the ones that we’re going to be dealing with on a regular basis. And that tends to fall into two categories. The first one is androgenetic alopecia or male-pattern hair loss or female-pattern hair loss. So that’s actually what I was diagnosed with back in 2007. It’s this chronic progressive hair loss disorder. And it is so common that essentially you can’t [00:10:30] walk down a city block without spotting somebody with a condition.

For men, it often develops as temple recession and crown thinning on the vertex, a bald spot, and it could progress over a series of years to decades to a slick bald scalp. In women, it’s more of a diffuse thinning across the frontal area of the scalp. People kind of describe it as like a, it looks like a Christmas tree in terms of the patterning of thinning. And this condition is believed to be the function [00:11:00] of a combination between our genetic predisposition and our male hormonal profile, specifically our androgens or a testosterone metabolite known as dihydrotestosterone or DHT for short.

Now, the evidence implicating dihydrotestosterone or DHT in this specific hair loss disorder is really, really strong. So back in the 1940s, there was this doctor, Dr. Hamilton. He was doing observational [00:11:30] research on prisoners who for one reason or another were castrated. And he noticed that all of the men who were castrated before puberty never had any signs of pattern hair loss later in life. Now, the testes produce 95% of the testosterone that then circulates to our bodies and attaches to different receptor sites. And so this implicated this hormone testosterone in the onset of androgenetic alopecia, male-pattern hair loss. He also noticed that [00:12:00] if a man was castrated later on in life, the progression of their pattern hair loss stopped. It’s a pretty interesting story-

Stu

Yeah.

 

Rob

But then if you fast forward 30 years in the 1970s, 1980s, new anecdotes were coming out about these islands off of Guam and Papua New Guinea of these men who had a specific genetic mutation called a type 2 5-alpha reductase deficiency. Now, that is the enzyme that converts testosterone [00:12:30] into a testosterone metabolite known as dihydrotestosterone, and specifically type 2 5-alpha dihydrotestosterone. And these men, interestingly enough, perfectly preserved testosterone levels, no signs of pattern hair loss whatsoever. No signs of baldness. And that’s really what began to get researchers interested in this specific hormone and then potentially explore it as a therapeutic target.

Now, you fast forward another 30 years, what you see in cell [00:13:00] culture studies is that when you find evolving follicle and you bathe it in DHT, that male hormone, begins to undergo apoptosis and induce transforming growth factor beta 1, all these other signaling proteins that begin to damage the follicle itself and destroy this powerhouse of the follicle called the [inaudible 00:13:18] cell cluster. So you have really strong observational evidence and mechanistic evidence that this one hormone is probably causally linked for reasons that are not yet fully [00:13:30] elucidated to the progression of male-pattern hair loss and female-pattern hair loss.

And that led to the exploration of drugs that inhibited that specific enzyme, the one that converts testosterone into DHT, drugs like finasteride or even later dutasteride. Finasteride in the ’80s was being explored as a drug to help lower benign prostate hyperplasia prevalence or incidents. BPH is the enlargement of a prostate. It happens to also involve [00:14:00]

Rob

All that specific enzyme and so men, who were using this drug Finasteride, began to report that the pattern hair loss that they were experiencing began to arrest. And so that led to clinical trials for Finasteride as a treatment for antigenic alopecia. Those trials clearly demonstrated, over a series of more one to five years, that on average, men using Finasteride, 80 to 90% of them would see a stop in their pattern hair loss, and then 10% increases to hair [00:14:30] counts alongside some hair thickening. So that kind of cemented this really strong relationship causally between this hormone, DHT, and male and female pattern hair loss.

So, that is the first big category of causes for hair loss. You’ve got androgens. You’ve got genetic predisposition and there’s a lot of evidence implicating genes in the [00:15:00] progression of male pattern hair loss as well, specifically related to the androgen receptor in certain signaling pathways that control growth for the hair cycle. That’s a whole other topic in itself, but genes and androgens tend to be the big things that are implicated in this condition overall.

Now, on the other side of the equation, you have hair shedding disorders. If you look at the way that male pattern hair loss progresses, it progresses through what’s known as hair follicle miniaturization. [00:15:30] So each hair strand, it’s affected over time, gets thinner and thinner and thinner over a series of hair cycles, until it’s so thin and so wispy you can’t see it anymore. At that point you’re dealing with what somebody would consider a bald patch and that’s the way that this condition progresses is through hair follicle miniaturization.
Hair shedding disorders are a completely different animal. These things don’t necessarily involve androgens. They don’t necessarily involve [00:16:00] genetics. They actually involve disruptions to our hair cycle itself.

So our hair cycle runs on two to seven year periods. So at any given time across our entire scalp, about 85 to 90% of our hairs are in what’s known as a growing stage. Few percentage are in what’s known as a resting stage. And then 10 to 15% are undergoing a shedding stage, whereby the hairs are actively shedding, so the old hair follicle can degenerate and a new hair follicle can regenerate, [00:16:30] and the cycle can repeat.

This is why it’s normal to lose a hundred to 150 hairs per day, even in the absence of a hair loss disorder. So hair shedding disorders occur when that percentage of shedding hairs moves from 10 to 15%, to 20% or greater. This is where consumer confusion can really kick in because there are dozens and dozens and dozens of factors related to hair shedding disorders, that [00:17:00] can drive shedding rates significantly upwards, ranging from hypothyroidism, small intestina, bacterial overgrowth, gut dysbiosis. You have some cases related anecdotally to hyperparathyroidism, nutrient deficiencies. For example, biotin, vitamin D, iron, vitamin B12, certain medication usages, non-steroidal anti-inflammatory drugs. You have certain medications related to [00:17:30] anxiety and depression that have triggered these in anecdotal cases.

Basically these hair loss disorders are defined as a massive release of hair across the entire scalp. Now, what complicates things is that these hair loss disorders, antigenic alopecia, and hair shedding disorders, they interact with one another. So when you’re looking at the causes of hair loss, and you think I’m losing my hair to stress, [00:18:00] or I’m losing my hair to androgens, oftentimes you need to do a full health evaluation, in addition to whatever your suspected causes are, to rule out if there are interaction points between these hair loss disorders, because hair shedding disorders, they’re temporary.

So, if you identify the cause, say it’s a vitamin D deficiency, and then you start to supplement. You bring your vitamin D levels back to normal. Within three to eight months, the hair cycle restarts as normal. The hair start to grow and [00:18:30] it’s as if you never had hair loss to begin with.

However, antigenic alopecia progresses through miniaturization. So the strand thickness of each hair is effected and gets thinner and thinner. The interaction point is that if you measure a hair that’s affected by antigenic alopecia from the tip all the way down to the roots, it’s the exact same diameter, so miniaturization doesn’t happen actively as the hair is growing. The only way that this can happen is if the hair sheds out, [00:19:00] the old hair follicle collapses, a new follicle comes into take its place and during that process of reforming the new follicle, that hormone DHT attaches to the cell receptor sites around the dermal papillae cell cluster, causes a lot of damage in addition to that signaling protein transforming growth factor beta 1, and then takes your hair follicle size from wide, to a little bit thinner.

Now you have a slightly thinner hair strand that grows out of a slightly smaller hair follicle. Then that [00:19:30] process repeats over time and it repeats and it repeats and it repeats, until eventually the hair is super thin.

So the trigger point for miniaturization for androgenic alopecia is hair shedding and so people who undergo these extreme bouts of stress or crash diets, or severe illnesses, coronavirus, severe flu’s, surgeries, they have hypothyroidism, they’ll go through these massive bouts of hair shedding and if you [00:20:00] have the genetic position in the androgen profile for male and female pattern hair loss, when that hair comes back and it undoubtedly does, in most cases, you now have accelerated the miniaturization process and so there’s this crosstalk.
One of the things that I find trips people up and confuses people all the time when they’re trying to figure out what causes their hair loss is I had, one of my sister’s friends started working at a big [00:20:30] tech company in San Francisco, really high pressure job. Started with almost a full head of hair. Three years later, it was nearly bald. He said that he lost his hair due to stress. He ended up moving back to Bali after like cashing out an IPO and picking up surfing. I think that part of him thought that if he checked out, resolved his stress, moved to Bali, got tons of sunlight, totally lived an amazing life, [00:21:00] that his hair would come back.

The truth is, is that this is a mistake that a lot of people make. Stress absolutely accelerated the hair cycle for this individual, but his genetic and antigenic predisposition of male pattern hair loss that fed into the miniaturization process. So by the time that he was ready to do something about it, he had reduced his stress, but he hadn’t targeted the androgens in the scalp and that’s what that confusion point comes.

[00:21:30] Now obviously there was other targets than just androgens that you can see for male pattern hair loss for improvements. But those are kind of the big categories for hair loss that people deal with and some insights as to how they can interact with one another.

So when you’re going through the internet and you’re trying to figure out which causes of hair loss apply to you, think about those two big categories, androgenic alopecia, hair follicle neutralization, androgens, genetics, some elements of scalp environment as well. Then the other category, hair shedding disorders, [00:22:00] greater than 20% hair cycling rates. In those cases, that’s probably what you’re going to most read about online.

Stu

Boy, there must be hundreds of thousands, if not millions of people that would love to lock you in a room for a couple of hours and just have a one-on-one consult because where would we typically go?

I have friends and family that are concerned about the health of their hair with thinning and shedding and bald spots [00:22:30] and the like and recession. Typically they might just wander into the chemist and look at the big brands, or I don’t think that they would know where to go. What would we do? Where would we go?

Rob

It’s really hard. You know, I think that the hair loss industry is one of these places that whereby profit incentives, disadvantage consumers at basically every single level.
So you have disadvantages at [00:23:00] the doctor’s office, at a dermatologist office, and online for different reasons. So I gave you one example earlier about going online, buying into a biotin supplement, not realizing that you’re supplementing with something that sells hundreds of millions of dollars per year on the basis of 18 children with a genetic mutation that occurs in one out of 110,000 individuals and not realizing that that cause of hair loss, likely irrelevant to you.

So say that you don’t do that. You go to a doctor. [00:23:30] Well, a doctor’s profit incentives aren’t to sell you a biotin supplement, or at least most doctors incentives aren’t to do that, but they have a different model. They have to see a lot of patients every day to remain profitable.
In America, the average family physician has 2,300 patients that they need to see every year. So depending on how many days they’re working, 10 to 20 patients per day and for new physicians, interaction times with patients are less than eight minutes. [00:24:00] When you think about all the paperwork that has to get done, when you think about all the stuff that these doctors have to do just to keep the doors open, they’re going to see you and they’re going to know a little bit about hair loss, and they’re going to know that antigenic alopecia is the most common type of hair loss in adult men and oftentimes in women as well, or at least one of the most common types. Essentially they’re going to diagnose you with antigenic alopecia and they’re going to prescribe Finasteride, tell you to take Minoxidil and then call it a day. [00:24:30] For a lot of people, that’s really good advice, except you’re lacking the full health evaluation to rule out the causes of hair shedding disorders.

Now that’s how doctors end up sometimes missing the mark in terms of hair loss disorder diagnoses and treatments. So what happens when you go to a dermatologist? Well, dermatologists have the equipment to do a scalp analysis. They’ll use a dermascope to examine levels of scalp inflammation in your skin. They’ll [00:25:00] look for evidence of things like hair diameter diversity. So that’s a technical term for hair follicle miniaturization. Some strands of hair in a specific area look thinner versus the hairs that are right next to them. Typically, they have a good idea of diagnostic material and they can prescribe you medications, but that’s not how dermatologists keep their doors open.

Dermatologists are incentivized to sell you into high ticket treatment options, especially cosmetic dermatologists. So they want [00:25:30] you to buy into platelet rich plasma therapy or PRP plus stem cells or PRP plus ACell, or adipose-derived stem cells. I mean the latest intra body derived treatment that’s getting offered to hair loss patients right now is exosomes.
These things are all different variants of blood withdrawn from your body, centrifuge to separate out certain substances, and then inject it back into your scalp. You look at the clinical data on these things and you’ll think, [00:26:00] oh, they look pretty good. 10 to 30% increases in hair counts after three to four sessions. I’ll do it.

But what these dermatologists won’t tell you is that if you just thought about the therapies and the vasculature of the scalp, you would know that the top of the scalp is hyper-vascularized and so when you inject fluids into it, those fluids tend to disperse and then travel elsewhere throughout [00:26:30] the body, through veins and back toward the heart.

The problem with these therapies is that in private conversations with dermatologists, several have told me that they have no idea whether or not it’s the actual injections of stem cells or PRP that’s actually leading to regrowth in these patients, or whether it’s the insertion of the needle itself. Because we’ve known decades, that just generating inflammation, sends the same growth factors and platelets that are purportedly [00:27:00] used in PRP, that initiate a new stage of the hair cycle and improve hair counts overall.

So with that knowledge, what’s really interesting is that microneedling, which we just did a literature review on. They look like medieval torture devices. There are these small rollers that you can roll against your skin with tiny medical grade needles ranging from 0.25 millimeters, all the way to five millimeters.

Microneedling elicits the same mechanisms, or very [00:27:30] likely overlapping mechanisms, that PRP does. With studies using microneedling as a control group alone against no other treatments, what we see is that microneedling by itself, lifts hair counts by about 15%. So it’s basically the same ballpark of something like PRP.
Now there was a split scalp study that came out that showed that when you injected one half of the scalp with PRP and when you microneedle the other half, the differences in hair count improvements and hair diameter [00:28:00]

Rob

Diameter improvements, non statistically significant both groups saw the same increases to hair counts and hair diameters.

Stu

Wow.

Rob

So P R P costs $1 to $2,000 per session. You have to do several per year.

Stu

Yep.

Rob

Exosomes cost upward of $5 to $10,000. A micro needling device that can be administered that home can be purchased off Amazon for $10 to $25. You’re you’re looking at dermatologists in many cases.

Stu

Yeah.

Rob

Having [00:28:30] zero interest in telling you about these little devices that you can administer at home that might save you thousands and thousands and thousands of dollars in the long run for treatments that certainly do work in many cases, but there are alternatives out there. So, the landscape for consumers is a disaster, long story short.

Stu

That’s amazing. And that a great insight as well for our listeners in terms of the microneedling. And that led me to think along the terms [00:29:00] of what was happening though, like the mechanisms of needling. Would simple head massage be beneficial then along those that thinking?

Rob

So there is absolutely some mechanistic data that supports the use of something like head massages.

Stu

Right.

Rob

So we’ve suspected for a long time that scout massaging through specific pinching, pressing and stretching modalities.

Stu

Yeah.

Rob

…Can elicit similar inflammatory signaling that microneedling [00:29:30] can, that P R P can.

Stu

Yeah.

Rob

And we also know that massaging the scalp, or not even massaging the scalp, massaging other tissues, for example, studies on individuals that have received burns. Massaging can attenuate the fibrosis and scarring onset that is an end consequence of that healing process from the burns itself. And interestingly enough, there’s a lot of fibrotic material in the mid to late stages surrounding hair follicles that are undergoing miniaturization. It’s part [00:30:00] of the reasons why when you take away the hormone that does that miniaturization process, you don’t necessarily see full hair regrowth because the hairs are now getting entrapped over time in scar tissue.

Stu

Right.

Rob

So microneedling and massaging as a potential adjunct therapy to other more powerful treatments. That’s what we see work really effectively, that really effectively with a lot of people in our community and inside of our website. So there’s a lot of things that you can do that can act as very powerful [00:30:30] add-ons that target these additional mechanisms. Some people, in fact, a lot of people inside of our community see success with just massaging alone.

Stu

Hmm.

Rob

Now the acute inflammation generation from the massages is not the only suspected mechanism from these standardized scalp massages because there’s this band of muscles that surround the scalp perimeter and the band of muscles is anchored to this dense fibrous fascia-like membrane called the Galea Aponeurotica that tends to underlie [00:31:00] where most men and most women go bald. The entire top of the scalp. If you talk to dermatologists who are really familiar with basically like examining individual scalps with antigen alopecia, they will say time and time again, that 80% of the individuals who are dealing with pattern hair loss have really, really tight scalps. They’ll feel their scalps and they’ll feel notably tighter than their non involving counterparts.

Stu

Wow.

Rob

And they basically described [00:31:30] the cause of that tightness in many cases to the contraction or involuntary chronic contraction of these scalp perimeter muscles. And so in that regard, what’s very interesting is that if you go to research back in the 2000’s, there was a doctor Dr. Brian Freund of the University of Toronto, who was trying to find new treatment modalities for relieving his patient’s chronic tension headaches. One of the pathophysiological elements of a chronic tension headache is believed [00:32:00] to be in part the contraction of the muscle surrounding the scalp perimeter. Dr. Freund was also this expert in Botulin toxin, or Botox for short, which happens to be an injectable muscle relaxer. And he believed that maybe injecting the scalp with Botox into these muscles of his patients might help improve outcomes. And so he first tried this on his business partner and himself who were running this practice.
And they found that [00:32:30] yes, their tension headaches went away, but they also saw a complete cessation of their male pattern hair loss, which is really interesting.

Stu

Wow.

Rob

And so they thought maybe we should put together or clinical trial and test this out. And they did exactly that. So they went and found 40 or 50 patients to do a clinical trial on with male pattern hair loss, antigenic alopecia. They did injections around the scalp perimeter, but all of these muscles, and they did two rounds of injections. [00:33:00] So Botox tends to, unlike P R P unlike stem cells, unlike, exosomes, Botox is designed to stay where it’s injected.

Stu

Okay.

Rob

And it’s also designed to slowly metabolize. So you make one injection round, you’ve got about four to six months of muscle relaxation before you need to do another injection round. So in their clinical trial, they did two injection rounds.

They did one at the beginning of the trial, one at the five month mark, and then they measured hair counts at the 10 month mark. And what’s really cool about their [00:33:30] study is that there’s a hair tattooing method that is used in clinical trials to do perfect hair count analysis. So what they’ll do is they’ll take a little tattoo and they’ll make a mole in an area of your scalp that is undergoing antigenic alopecia. And then they’ll use a photo trichograms to take a really zoomed up photo to measure the hair counts and hair diameters of that area. And they have the statistical software whereby [00:34:00] you can find that exact area 10 months into the future and recount everything and see the change in hair counts overall. These methods for hair counting were developed and used in the trials that got finasteride, FDA clinical approval.

So they’re gold standard types of counting and Dr. Freund’s team used those at the crown to see if their treatments for Botox would work. After 10 months, they saw an 18% increase in hair count overall, [00:34:30] which was a really impressive and statistically significant lift. And they saw that about 75 to 80% of their individuals saw success in that therapy, meaning they saw a stop or improvement in hair counts overall. So obviously it’s incredibly unscientific to make this comparison because we’re talking about a group of patients with 50 people and we’re talking across different groups, but the finasteride studies showed that over a two year [00:35:00] period, 10% increased to hair counts alongside hair thickening and an 80 to 90% response rate. So the Botox data preliminarily is not that far off overall. And so what’s interesting about this is that if you relate this back to scalp massaging, scalp massaging has shown in studies to also have the capacity to relax these scalp perimeter muscles.

And since Dr. Freund’s research came out, there have been four other investigations testing botulinum toxin for [00:35:30] hair growth, and all of them have demonstrated the same exact results, more or less. 75 to 80% increases to hair counts. And about an 18 to 21% increase in hair counts. Sorry, I misspoke 75 to 80% response rates and an 18 to 21% increase in hair counts. So targeting these scalp perimeter muscles by way of massage is also one of those purported mechanisms by which people might see hair improvements. This is a really [00:36:00] long-winded way of me saying that I’ve also seen improvements from scalp massaging. That was one of the modalities that I used that saw significant success for me personally. And I also use microneedling, and I tend to feel like I’m a very good responder to these moving based interventions. Now, my personal experience, she shouldn’t preclude other people from trying scout massages as a frontline defense for endogenic alopecia, because the truth is that when I first started losing hair, I ran [00:36:30] into all of this misinformation about Finasteride, which scared me away from taking it.
But if I knew, then what I knew now, I probably would’ve just started taking Finasteride, seeing no negative effects whatsoever, great hair loss outcomes, and I probably would have a different career right now. So I’m thankful in many respects to my exposure and then fear of trying that drug, because it was something that I ended up trying. The scout massages were something that I ended up trying to see success. And they worked really well for me, but I want to contextualize [00:37:00] the evidence surrounding things like scout massages prior to talking about them talking about them anymore, by just basically reiterating that the evidence on the FDA approved approach is also really, really, really strong. And it’s much stronger than the data that we have on massaging. Having said that we’ve seen so many success stories from scout massages that we put together, a survey-based study using our website that demonstrated over periods of six months to four [00:37:30] years, a 75% response rate in individuals trying massages, meaning stabilization or hair regrowth.

And the degree of that hair regrowth varying depending on individuals. So some people were able to see hair regrowth one year, two year, three years in. Other individuals saw hair regrowth up until the 1.5 year mark and then stabilized. And it’s self-reported data. It’s not super strong data, but we did publish it in the dermatology journal. And so, again, a very long winded answer to your question, [00:38:00] but yes, there seems to be some mechanistic data and very early human data survey based to suggest that scout massages can improve hair loss. And through the mechanisms you just described the mechanisms by which of wound healing and potential the targeting of these scalp perimeter muscles. By the way, if anybody’s listening to this, if they want access to the scalp massage video and instructions that we expose [00:38:30] participants to in that study, they’re entirely free. They’re a part of the study itself. So this is a free modality anybody can try it. And I can send you a link to include in.

Stu

Perfect. That’s perfect. Cause I was literally going to ask, well, what does a scalp massage look like? How long do we do it for? Do we do it every day? Is it every week? Can we do it in the shower while we are shampooing our hair, et cetera. But no, that is fantastic. So we’ll put everything that you’ve spoken about today in the show notes a as well, because there is so much information here. [00:39:00] I almost don’t want to ask any questions. I just like listening so much, so much information. In terms of stepping away from the big brands and Finasteride and everything that you’ve spoken about prior to this as well, natural therapies. Now I look at scale up massage in that camp. What are the other big ticket items in the natural world that you have found to be beneficial?

Rob

It depends on how you decide to define natural, right? So for [00:39:30] me personally, my definition of natural has changed over the years. I used to think that anything that was made in a lab wasn’t natural, right? And then somebody pointed out to me that the supplement that I was using at 1000 X concentrations from an extract, technically doesn’t fit my definition of natural, despite me thinking it fit natural, I thought, okay, well now I can redefine my definition of natural. And then I remember thinking, okay, [00:40:00] well maybe things like hormone modifiers, aren’t natural. And then I realized that progestins and estrogens can be synthesized from wild BMS. And so my definition of natural is not necessarily consistent, always.

Stu

Yeah.

Rob

And so when we think about natural interventions, we have to define what natural actually means in the context of the wide array of what people believe natural to be. So as PRP, natural PRP is a centrifuge of our platelets, so that they’re hyper concentrated, [00:40:30] extracted from our body, and then re-injected back into our scalp, P R P has some clinical data supporting it in terms of hair growth outcomes. So if we define that as natural, then yes, it is absolutely something that people can try. In terms of supplements though, there are some things that seem to move the needle for certain individual, but we have to contextualize the evidence as being lower quality than the [00:41:00] FDA approved drugs. The data on these drugs are really, really strong, Finasteride, Minoxidil. For many people, that’s really all you need to see improvements, but for those who are avoiding those drugs because they don’t fit with their worldview.

Stu

Yeah.

Rob

Or for those who are avoiding those drugs, because maybe they’ve tried them and experienced a negative experience and you want to try natural interventions. The data that we have on natural interventions again, is lower, but targeting that same hormone [00:41:30] through natural extracts type two, five alpha, D H T using a five reductase inhibitor. There’s data that things like Saw Palmetto actually improves antigenic alopecia outcomes for a majority of people taking it.

Stu

Okay.

Rob

There was one clinical study that was conducted over two years that compared Saw Palmetto to Finasteride. And over that two year period, investigators noted that in the Saw Palmetto group, 90% of people saw a stop in hair loss according to photographic [00:42:00]

… assessments. And that same number was true in the finasteride group. So saw palmetto is one of these things where people can potentially use that to help slow or stop their hair loss. Now, the other thing about that study is that, while the stopping of hair loss was equivalent across groups, the magnitude of effect in terms of hair regrowth was out of this world higher in the finasteride group.

Stu

Right.

Rob

So, for those individuals who are using saw palmetto, the expectations of improvements have to be tapered [00:42:30] accordingly. And again, photographic assessments through investigators, those are not equivalent to hair count assessments.

Stu

Okay.

Rob

Having said that, there are other studies that show that saw palmetto orally and topically can improve hair counts in androgenic alopecia subjects, but again, they’re underpowered studies. They’re relatively low quality, just like the data on scalp massages. Now, it’s important to not confuse the low quality evidence as the absence of evidence. It just means that the data on these things are less [00:43:00] robust, but a lot of people who are trying certain hair loss interventions, and they want to take the natural approach, they think, “Well, maybe I’ll do saw palmetto, but I’ve also read that things like Reishi mushroom extract and astaxanthin and zinc and all of these other combination natural extracts can help to lower DHT.” And so they’ll end up buying these DHT reducers that come in like $80, $100 bottles and package in all of these [00:43:30] obscure supplement type reducers that come from… Basically the data supporting them are in vitro studies, cell culture studies.

These things can improve hair loss outcomes, but interestingly enough, there have been data to test combination DHT reducers, like saw palmetto plus astaxanthin, and what we see in the data is that more 5-alpha-reductase inhibitors, from a natural perspective, when you start to layer in zinc and astaxanthin [00:44:00] and saw palmetto together, they actually tend to reduce almost the exact same amount of DHT as saw palmetto alone, and yet the cost differential is massive. So you can buy a high quality saw palmetto supplement for $8 to $15 a month, but these larger DHT reducers, they’re going to cost a significant more amount. And you have to weight the benefits of just saw palmetto alone versus the additional cost increase to maybe get just a few [00:44:30] more percentage points of DHT reduced.

Stu

Got it.

Rob

So there’s certainly evidence that this stuff can work from a natural perspective, just as there is with microneedling, just as there is with massaging, but you’ve got to contextualize that evidence, and if somebody does want to take a natural approach, I tend to think that a multifactorial approach is absolutely critical. So don’t just do saw palmetto. Do scalp massages and microneedling in combination with saw palmetto. Find other targets that you’re [00:45:00] comfortable testing from a natural perspective, and then go from there accordingly and set effective endpoints or results horizons. A results horizon is kind of like this thing where it’s the minimum amount of time that it usually takes, based off clinical data, for a treatment to start working from a cosmetic perspective. And at the back end, it’s the maximum amount of time where, if you are a non-responder, new results become less likely.
So for something like saw palmetto, that’s a 6- [00:45:30] to 12-month window.

Stu

Okay.

Rob

So because hair loss is chronic and progressive, if you are of the mindset to try these interventions that are more natural, there is data on them. In many cases, they do work, but abide by those results horizons, so that you can begin to move to things that might be a little bit more powerful more efficiently.

Stu

That’s great advice. And we’re kind of coming up on time. I’ve just got a couple more questions, one on the topic of hair [00:46:00] but off the topic of hair loss. It’s hair graying. And now I’m just keen to understand your opinion on gray hair as we get older. Is it natural? Or is it to be expected? Is there anything that we could do based upon your research that might be able to slow that down or possibly reverse it?

Rob

So gray hair is something that is ubiquitous in all mammals that live long enough.

Stu

[00:46:30] Right?

Rob

So it is purported to be a part of the natural aging process.

Stu

Yep.

Rob

The way that graying begins is that we have melanin, and melanin is produced at the very base of the hair follicle by cells called melanocytes, and melanocytes are differentiated from melanocyte stem cells.

Stu

Right.

Rob

And so you have a couple different failure points by which graying can begin. One case is that the stem cells themselves that produce melanocytes [00:47:00] become depleted. Another case is that the melanocytes get damaged, and now they can’t produce melanin, which coats our hair and gives it pigment. So those are the two failure points. And depending on where the failure point is, you might end up experiencing age-associated graying, which is more so common in the stem cell depletion, versus premature graying, which can be a function of genetic predisposition. Obviously, that’s like a genetic blanket statement for everything [00:47:30] in all of life, so I hate to throw that term around so much, but genetic predisposition, inflammation, reactive oxygen species.
But the researchers don’t really know what triggers earlier onset graying. I mean, there’s some evidence to suggest that copper imbalances can do it and certain trace elements like zinc. These imbalances can cause premature graying and that supplementation can improve graying in those cases. And that’s because the damage is [00:48:00] often done to the melanocytes. But the act of growing hair is an innately inflammatory process, and converting melanocytes to melanin and converting melanocyte stem cells into melanocytes, that requires energy, it’s energy dependent, and a consequence of energy is reactive oxygen species, and then you have to have antioxidants to neutralize those things.
So some people believe that the entire reason why we just lose our hair [00:48:30] is because of inflammation and that anything that evokes accelerated inflammation or exacerbates inflammation in the scalp specifically will accelerate the graying process.

Now I say this, but at the same time, graying hair in the same exact hair cycle can go from completely gray for certain individuals back to black.

Stu

Wow.

Rob

And there have been studies that have had researchers ask questions, like, “We’re getting these types of hairs from our patients. They’re very old. How is their graying randomly reversing in places?”

Stu

[00:49:00] Yeah.

Rob

And then there’s studies on individuals who are seeking treatments for lymphoma, and their hair will have been gray for years, and there are case reports of their hair going back to brown after years, years, decades of being gray. And so there are these cases whereby we’ve seen complete or near complete depletion of the melanocyte stem cells, no more melanocytes hanging out, no more melanin, and yet a different environment or a certain drug completely reverses [00:49:30] this process for those individuals.
So it’s complicated. I don’t have enough answers on graying to give you an effective answer, but I will say that one of the common misconceptions is that your hair’s going gray because you’re out in sunlight all the time.

Stu

Yeah.

Rob

There have been studies on farmers who don’t wear hats compared to general population individuals, and no difference in rates of gray.

Stu

Okay. No, that’s good to know. And I guess all of this information as well, in terms of latest [00:50:00] studies and science, et cetera, you would post on your website, right? So it would be a great resource to visit.

Rob

Oh sure. I can send you a link. We have an article on gray hair.

Stu

Yes. Yeah. Please do. We’ll include it in the show notes. So wrap-up question to me, and it’s focused around you. Interested in your daily non-negotiables, the things that you do, the practices that you follow each and every day in order to win that day. Now, perhaps some of them will be hair related, [00:50:30] perhaps none of them are, but really, really keen to hear, what does the hair guy do to crush the day?

Rob

Well, the routine changes depending on what time of year you’re talking to me.

Stu

Okay.

Rob: But from a personal perspective, I have a very, very hard time staying focused when I have too many projects at task, and so there’s a breaking point, where if I’ve got five different projects going on at once, if I’m managing [00:51:00] a research team, if we’re working on a new content piece for our membership site, if we have our manuscript revision notes due, and I have six calls that day, I’m going to be really stressed out. So what I do to crush the day is I offload that to another individual, and I have a chief of staff, and they schedule everything for me. And that makes it so much more efficient because we just put everything that needs to be done on a weekly calendar. And that weekly calendar becomes a daily calendar broken out, and I can [00:51:30] just wake up and I know exactly what I need to be doing. So I don’t know if I’m crushing any days, but in terms of staying organized and staying productive, that has been a huge game changer for me.

Stuart: No. Well, that’s great to hear because essentially, I mean, it’s like juggling, right? Throw another ball into the mix, and things get out of hand. It’s stressed. Everything goes to pot. So I guess when you spoke about stress as well and its impact on the potential hair health [00:52:00] as well down the track, it’s probably quite a big one that we want to get on top of, irrespective of where we are in life.

Rob

Yeah. It’s interesting that you say that because there is certainly some truth to it. There are studies on genetically identical twins. So same gene sets. Men and women. They can bald at different rates. Why is that? Well, when you survey them and compare their overall hair counts between twins, the ones that are balding faster tend to have higher incidences of smoking. [00:52:30] They tend to have, for women, more events for childbirth, for both sexes, more trauma, more telogen-effluvium-like sheds, and so stress definitely falls under those categories and managing it effectively can absolutely help to slow down this process.

Stu

Yeah. I hear you. And I hear you because I’ve got twin daughters, and their impact on me for stress is definitely impacting my hair health.

Rob

Your hair looks wonderful from where I’m sitting.

Stu

[00:53:00] Yeah, no. It’s not too bad. Oh, that’s fantastic. I have so enjoyed this conversation. It has been fantastic. And I know that our listeners are going to be bombarding your website, but just before we go, what’s next? What have you got in the pipeline?

Rob

We’re excited to get this microneedling literature review out there. So it’s currently in peer review. We’ll probably have some revisions requested, but we’re expecting a hopeful publication date of before the end [00:53:30] of this year, and I think that that’s going to be significantly helpful for a lot of people following these [inaudible 00:53:35] based protocols for hair growth. Now, all of the research that we publish as a part of our website is all free and open access, so we pay additional fees for any peer reviewed publication, so that nobody has to face a paywall to access that information.

Stu

Right.

Rob

And this microneedling review is going to be one of those big pieces. There’s also the study on the scalp massages. There’s also the hypothetical pathogenesis model and the stuff with the histological features of androgenic [00:54:00] alopecia. Those are also free, but those are really boring reads for anybody who doesn’t like hair. So these ones will be a lot more impactful, in my opinion.

Stu

Okay.

Rob

And I’m excited to share that with people.

Stu

Fantastic. And so, for all of our listeners now that want to find out more about you, the research, and all of the tips and ticks and tricks, techniques, et cetera, where can we send them?

Rob

Perfecthairhealth.com. That’s our website. That’s where we post our articles, [00:54:30] our papers, and everything in between. Again, all of that stuff is free.

Stu

Yeah.

Rob

For people looking for more personalized guidance and individualized support and contact with me, we have a membership community for that.

Stu

Okay, fantastic. Rob, this has been a real pleasure and certainly an eye opener for me, just in terms of the things that you can do and the places that you can go to navigate, I think. The industry standard message is that we just do X and you’ll get Y. But obviously, [00:55:00] we like to talk about the minutia and the twists and turns that might get you on a different journey. But thank you so much.

Rob

Thank you. I’ve had a really good time chatting.

Stu

Yeah. Much appreciated. We’ll speak soon. Thank you.

Rob English

This podcast features Rob English. He is a researcher, medical editor, and the founder of Perfect Hair Health, a website dedicated to showcasing evidence-based methods for hair regrowth with or without drugs.  Rob's interest in hair loss began in 2007,  right after he was diagnosed with androgenic alopecia. Since then,... Read More
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