Male pattern baldness in a patient who prioritises style over substance

Style over substance, or substance over style? It obviously depends on your point of view. As doctors, we normally prioritise the latter, but plenty of our patients prioritise the former. And, as always, we are there to help when everything goes horribly wrong.

In fairness, my favourite plastic surgeon, James Southwell-Keely, has done a wonderful job excising squamous cell carcinomas from 80-year-old nursing-home patients over the years.

He does a great job, provides great follow-up and is readily accessible if I am worried. His website, however, would be rated adults only if it wasn’t a medical website aimed at a different demographic. I hope the images on his website are the “after” images. If they are the “before” images, he is seriously overservicing a population that does not need plastic surgery. For the record, my 80-year-old nursing-home patients do not come out of surgery looking like the images on his website.

Mitch is a 32-year-old successful real estate agent and definitely a fan of style. So much so that when the first signs of male pattern baldness declared themselves, Mitch was devastated. He has a family history of hair loss, but in his profession, where trust and reliability mean so much, he cannot afford to look too different in real life to his website image. That would be just plain dishonest.

There are not too many good role models in Mitch’s family when it comes to keeping a full head of hair. But then, Mitch’s family consider male pattern baldness a rite of passage rather than a war to be won, like Mitch does.

Topical minoxidil from the pharmacy didn’t really help. Hair-loss clinics were out of the question as Mitch did not want to be seen publicly going to a hair-loss clinic. I mean, would you buy a property from a real estate agent who was losing their hair? You probably would if it was the right property, but Mitch would not have a bar of it.

Minoxidil tablets that Mitch purchased online were hit and miss. One batch from one source was useless, and the other batch of 10mg tablets was so strong that Mitch could not get out of bed from the dizziness. The ambulance found his blood pressure to be 70/40mmHg lying and unrecordable standing, so they infused him with 2L of saline, which helped.

So, Mitch attended for a long overdue general check-up and mentioned his hair loss. He agreed to a full check-up, and there were certainly no biochemical reasons for hair loss, such as thyroid disorders or iron deficiency. He had already extensively researched finasteride, and I had no objection to prescribing 1mg daily.

As the months went by, Mitch’s hair stabilised (as about 50 per cent of men experience with finasteride), then he achieved good regrowth (which up to 40 per cent of men do). To those outside his inner circle, it was probably not obvious that Mitch had a hair-loss problem at all. However, to his inner circle, it was abundantly obvious that Mitch was not the same.

From a dynamic and always positive real estate agent, Mitch was increasingly anxious and moody. He was losing clients as he increasingly told them things they didn’t want to hear about their properties, and he told me things about his outlook on life that I had never heard him say before.

Finasteride works by blocking the action of 5-alpha reductase, thereby decreasing conversion of testosterone to dihydrotestosterone, predominantly in the prostate and hair follicles. Typically, finasteride 5mg will relieve symptoms of benign prostatic hypertrophy for several years, and 1mg will arrest male pattern baldness for as long as the drug is taken.

Studies show a more general blockade of 5-alpha reductase results in a plethora of side effects, including mood disorders in a small number of people. Anecdotally, the numbers may be higher.

We had to confront the situation whereby Mitch had fabulous hair but was losing his career strand by strand

Ultimately, we had to confront the situation whereby Mitch had fabulous hair but was losing his career strand by strand. His inner circle ordered him back to see me, with an ultimatum to fix the problem or not come back again. So, fix it we did.

Instead of oral finasteride, we found a compounding pharmacist who was able to compound a topical preparation of finasteride with minoxidil. We did fine-tune the dose over several months, and Mitch did lament that it was messier than just taking a tablet every day, but we got there.

And as for my favourite plastic surgeon’s website?

I will certainly not mention it to Mitch – I don’t want to give him any new body-issue ideas!

Details have been changed to protect patient confidentiality

Jonathan Bentley is a GP in Double Bay, Sydney, NSW