Your contribution to the forum is not a flame, goat. You brought up a very valid question.
I think the ‘mystery’ here is that prolonged DHT exposure, in many (though NOT ALL) men with MPB, leads to long-term tissue inflammation (usually invisible to the naked eye) which causes not only miniaturization of follicles (as in everyone with MPB), but also fibrosis of the tissues.
Fibrosis is the end result when either physical injury, or tissue damage (including microscopic tissue damage) occurs in a tissue and it heals imperfectly. Fibrosis is a process by which normal, healthy tissues are replaced with almost-useless “fibrotic tissue”. Active hair follicles can’t exist in in fibrotic tissue, and no hair will grow.
That’s why SOME men (though NOT ALL) who use finasteride or dutasteride, and are blocking/eliminating almost all the DHT, still can’t grow any hair back. It is because long-term DHT exposure has caused fibrosis of the hair-growing tissue of the scalp.
Fortunately, HM, as it is conceived, will work not only by rejuvenating miniaturized (but still viable) follicles, but also by creating new ones.
True, HM will probably work much better in men who have experienced little fibrosis, because they will still have many miniaturized follicles that are still viable, and can still be rejuvenated. But even in men with fibrosis, some new follicles should be expected to be induced by HM, so all is not lost.
My prediction is that a good rough indicator of how well HM will work on you, is, if your scalp has been “slick bald” for a long time, and almost no tiny vellus hairs are visible, this is a sign of fibrosis, and the main benefit will be by follicular neogenesis.
I believe HM will work better in those patients who still have a lot of vellus, or a mixture of terminal and vellus hairs visible on their scalps in the bald/balding areas. This is a sign that there’s not a lot of fibrosis, and HM will work both by rejuvenating miniaturized follicles and by inducing new ones.
These are just my opinions, but it does answer one of your questions – why finasteride and dutasteride don’t work well in some people.
Incidentally, it’s not out of the question that fungus might INCREASE the tendency to fibrosis of the follicles, but only in males who already have MPB. Females are exposed to fungus just as much as males, but women don’t go bald in equal numbers as men. Therefore, just from that simple empirical evidence, we know that there must be some sex-mediated factor contributing to genetic alopecia. If fungus were the principal culprit, and not DHT, one would expect just as many bald/balding women as bald/balding men.
Most everybody (even YOU) will have to admit that even simply maintaining what you have is something greatly to be desired; otherwise, you wouldn’t be using dutasteride.