Sliced Bread – Hair Loss Products
BBC Radio 4 | Host: Greg Foot
Episode Date: December 12, 2024

Episode Overview

The episode investigates hair loss products—both pharmaceutical and “natural”—to determine whether they truly deliver on their promises or are simply marketing hype. Host Greg Foot is joined by listeners Kimberly Alcock (seeking solutions for menopausal hair thinning) and Ian Baker (navigating male pattern baldness options) alongside leading hair specialist Professor Ralph Pauls (Miller School of Medicine, University of Miami). The discussion covers causes of hair loss, reviews evidence for popular products (minoxidil, finasteride, dutasteride, estrogen, supplements), and critically examines shampoos, serums, and supplements often promoted online.

Key Discussion Points & Insights

Causes of Hair Loss

[03:54] Prof. Ralph Pauls:

• Four broad causes: hormonal imbalances (too much androgen/too little estrogen), inflammation (immune system attacks follicles), toxic effects (e.g. chemo), and drug side effects (e.g. beta blockers).
• Hair follicles are “mini organs” that cycle through growth, regression, and rest.

“It is a disturbance of this so called hair cycle that gives us increased hair shedding.” (Prof. Ralph Pauls, 05:11)

Differences between Male & Female Pattern Hair Loss

• Male: Primarily driven by DHT (dihydrotestosterone), a derivative of testosterone, which miniaturizes follicles in specific, genetically pre-programmed areas.
• Female: More diffuse; combination of relative estrogen deficiency and androgen effect, especially prominent post-pregnancy or during/after menopause.

“In male pattern hair loss, it is primarily induced by androgens ... in female pattern hair loss, it’s a mixture.” (Prof. Ralph Pauls, 06:17)

Pharmaceutical Treatments Reviewed

Minoxidil

What is it?

• Originally a blood pressure medication; noted to promote hair growth as a side effect.
• Available topically (foam or solution, usually 5% concentration for men, 2%–5% for women).
• Needs long-term (at least 6-12 months) daily use; works only as long as you continue.

Effectiveness:

• Stops progression in more than half of users; some see regrowth, but “cosmetically acceptable” regrowth is rare.
• Effects range from mild "peach fuzz" to fuller regrowth; results highly variable and unpredictable.

“The percentage of patients that actually see hair regrowth that they find cosmetically acceptable, that is much lower.” (Prof. Ralph Pauls, 12:43)
“Patients often give up too early ... the general advice is to give this agent at least a year.” (Prof. Ralph Pauls, 14:13)

Topical vs Oral:

• Oral minoxidil is easier to take but comes with higher risks of systemic side effects (e.g. arrhythmias).
• Topical application preferred for those with cardiac risks.

Finasteride

What is it?

• Tablet that inhibits enzyme converting testosterone to DHT.
• Only licensed for male hair loss due to risk in pregnant women, but sometimes used post-menopause.

Effectiveness:

• 80–90% success rate in stopping further hair loss; needs at least a year for noticeable effect.
• Often combined with topical minoxidil for better outcomes.

Side Effects:

• Debate over sexual side effects (depression, erectile dysfunction); “nocebo effect” may play a role.

“For finasteride, don’t even start it if you’re not willing to take it a year.” (Prof. Ralph Pauls, 20:05)
“It's a minefield ... snake oil products ... glad for Ralph's clarity.” (Ian Baker, 34:42)

Dutasteride

What is it?

• More potent DHT inhibitor; unlicensed for hair loss, but sometimes used when finasteride is ineffective.
• Slightly more effective, but less clinical experience—should be considered only under physician guidance.

Estrogen (for Female Hair Loss)

[23:48] Prof. Ralph Pauls:

• Topical estrogen tinctures help reduce/freeze progression of female pattern hair loss, especially post-menopause.
• “Halts loss but doesn’t regrow hair.”
• Often paired with minoxidil in clinical practice.

“With minoxidil we would then hope that you would get some hair regrowth. And with the estrogen tincture you would halt the hair loss.” (Prof. Ralph Pauls, 24:52)

Over-the-Counter & “Natural” Products

Shampoos

• Caffeine shampoos have promising lab data (“in principle, caffeine clearly stimulates hair follicles”), but no robust human trial evidence.
• Contact time on scalp is “far too low” for meaningful effect; leave-on tinctures or serums more likely to work.

“No shampoos will give you any predictable hair growth promoting effect ... the contact time is too low.” (Prof. Ralph Pauls, 27:23)

Serums

• Effectiveness depends on ingredients and leave-on application (better penetration).
• Most herbal extracts (e.g. fleece flower, angelica, ginseng) have “poor” or limited evidence for efficacy except possibly ginseng, which may modulate growth factors.

Supplements

• Hair follicles are highly metabolic; proper nutrition is essential.
• Biotin: Good for nails; not convincing for hair unless deficient.
• Vitamin D: Important for health, not for hair growth specifically.
• Collagen: No good evidence for effect on hair; “might as well eat a steak”.

“Collagen … no good evidence … might as well eat a good steak.” (Prof. Ralph Pauls, 32:46)

Brushing

• No strong proof it stimulates hair growth; can “temporarily increase blood supply,” but no lasting benefit.

Notable Quotes & Memorable Moments

• “It’s much more complex than I thought it was going to be.” — Ian Baker [09:46]
• “You are the one who has to generate the evidence.” — Prof. Ralph Pauls on supplement companies [29:50]
• “The thing that I’ve taken from it is also, if you are doing these things, it’s forever ... it’s a commitment.” — Kimberly Alcock [35:08]

Important Segments & Timestamps

• [03:54] — Four main causes of hair loss
• [08:25] — Why testosterone/DHT affect different regions
• [13:19] — Minoxidil: What to expect & realistic outcomes
• [14:09] — Importance of long-term commitment to treatments
• [19:04] — What is finasteride and expected effectiveness
• [23:48] — Estrogen tinctures for women
• [27:19] — Why shampoos are not effective for hair growth
• [32:46] — Collagen's lack of proven benefit for hair
• [34:10] — Final verdict: What works, what doesn’t

Summary Table: What Works and What Doesn’t

| Treatment Type | Evidence & Notes | Use Case | |-------------------------- |------------------------------------------------------------|---------------------| | Minoxidil (topical) | Proven for both sexes, stops loss, some regrowth; must use long-term | Men & women | | Minoxidil (oral) | Some evidence; more side effects; avoid if heart issues | Men (with caution) | | Finasteride (oral) | Proven for men, effective with long-term use | Men | | Dutasteride (oral) | Slightly stronger, unlicensed, less tested | Specialist only | | Estrogen tincture | Halts loss in women, esp. post-menopause; no regrowth | Women (post-meno) | | Caffeine Shampoo | Promising in lab; not proven in real life | Not effective | | Hair Serums (herbal etc.) | Mostly poor evidence; rare exception for ginseng | Unproven | | Supplements (biotin etc.) | Biotin: nails only, not hair; others not supported | Not for hair growth | | Collagen, brushing hair | No good evidence; could help health but not hair | Not for hair growth |

Final Verdict

Licensed treatments (minoxidil, finasteride) are effective when used correctly and consistently (“... definitely not marketing bs”). Most shampoos, serums, and supplements lack strong clinical evidence—they may work in theory or on a small scale but cannot be reliably recommended. Commitment and realistic expectations are critical.

“If you’re talking about the licensed drug, they are definitely not marketing bs ... But from there we still always have the final step of clinical evidence and that is often missing.” (Prof. Ralph Pauls, 34:10)

Listener Takeaways & Tone

• The episode maintains a friendly, evidence-seeking, and occasionally humorous tone (“you might as well eat a good steak”).
• Both listeners leave with concrete options and realistic expectations: long-term use of proven products and skepticism towards unproven “natural” remedies.
• The consensus: “forever” commitment is often necessary, and navigating the “minefield” of products requires evidence and patience.