Which Hair Loss Treatment is Better: Minoxidil with Retin-A or Minoxidil Without Retin-A?
Minoxidil has been prescribed (off-label) in combination with other medications, such as topical retinoic acid (Retin-A), to enhance its penetration into the skin and thus increase its effectiveness. This combination of medications, however, can significantly increase the absorption of minoxidil into the bloodstream and may increase the risk of potential side effects, including changes in blood pressure and severe scalp irritation that has, on occasion, led to scarring.
If person wants to add Retin-A to the minoxidil regime, the Retin-A should be applied only once a day, since the Retin-A will bind to the skin and will last for at least 24 hours.
Applying Retin-A more frequently will not increase its effectiveness (in facilitating the absorption of minoxidil); it will only increase the incidence of side effects. Retin-A can be applied to the scalp at the same time as Minoxidil, or by itself.
Retin-A should not be compounded with minoxidil (mixed together by your pharmacist or your doctor) for the following reasons:
Minoxidil works best when used twice a day. Retin-A is best used once a day.
Using Retin-A twice a day wastes money and increases the incidence of side effects
If you develop side effects from the Retin-A, it is best to stop only the Retin-A. If they are compounded, you would need to stop both and will lose the benefit of minoxidil.
Latisse is the first FDA approved (Dec. 2008) topical medication for eyelash growth. It is used to make eyelashes longer, thicker and darker. Applied once a day, it worksin over 75% of those using it. Latisse takes about 16 weeks to work. The drug is available only through a doctor’s prescription. Latisse is applied once a day to the base of the upper eyelashes. The bottom lashes receive the drug from the top lashes through blinking. A 30-day supply costs approximately $120 (About 6000 INR) . Once results are seen, it is possible to decrease the application to every other day, decreasing the cost and the inconvenience of applying the medication.But it has to continued for maintenance. Background
Latisse was first marketed under the name Lumigan to treat eye conditions associated with glaucoma. While being studied for the medical condition glaucoma, researchers noticed the drug had the side effect of stimulating eyelash growth and darkening of the eyelashes. It re-applied for FDA approval for the cosmetic purpose of eyelash growth under the new name. The active ingredient in both Lumigan and Latisse is Bimatoprost. Both products are made by the company, Allergan. How it Works?
Bimatoprost is a compound derived from fatty acids designed to bind to prostaglandin (PG) receptors. PG receptors are present in hair, particularly in the dermal papilla and outer root sheath of the hair follicle. Although the precise way that Bimatoprost works is unclear, it is believed to affect the growth of hair follicles by increasing the percent of hairs in the anagen (growth) phase of the hair cycle and increasing the duration of this phase. The long-term safety of Bimatoprost is based on clinical trials over 13 years. Side Effects
Side effects occur in about 4% of patients using Latisse and include itchy eyes, redness and skin pigmentation. The rare side effect of iris pigmentation that can occur when Bimatoprost has been used in much higher doses for glaucoma has not been reported when it is used to treat eyelashes, but this is still a potential risk. Any individual on antibiotics or other drugs, with heart medication,
as well as those with neurological and certain other diseases, and
those with severe allergies should discuss these conditions prior to
beginning the treatment program. In addition, pregnant women as well
as those with skin infections or other conditions on the upper eyelids
are not good candidates.Latisse also has the potential to stimulate the
growth of scalp hair although there may be some risk when applying it
repeatedly to a large surface area. Off-Label Use
Although Latisse has been approved for use on eyelashes, its potential benefit in making eyebrows more full is currently being explored. This is, of course, an easy added advantage of using the medication, since there is usually enough medication left on the applicator stick to use on the eyebrows as well – for those who desire thicker brows. At present, the cost alone would make this form of treatment prohibitive.
Aldactone (spironolactone 25mg, 50mg, 100mg) is a medication that is primarily used to treat high blood pressure (hypertension). Therapy is usually started at a dose of 25mg twice a day. It works as a diuretic causing increased amounts of sodium and water to be excreted from the body, while potassium is retained.
Because of its ability to retain potassium, the medication can elevate the blood levels of potassium to dangerous levels (hyperkalemia). It should, therefore, only be used under a doctor’s supervision.
Spironolactone has anti-androgenic affects and has been used in the treatment of hair loss in women. It is a weak competitive inhibitor of the binding of androgens to their cellular receptors and decreases the synthesis of testosterone
Studies suggest that spironolactone requires at least 200mg/day for stopping loss and that it has little effect on regrowth of hair. Unfortunately, this dose is high enough to elevate potassium levels and place the patient at risk of hyperkalemia and other side effects, including cramps and diarrhea.
Since spironolactone is an anti-androgen (inhibits testosterone), it causes sexual dysfunction and breast enlargement in men. Because of these side effects, it is not used as a treatment for male pattern hair loss.
Oral Contraceptives:
How birth control pills work
At the beginning of each menstrual cycle, estrogen levels begin to rise, and the lining of the uterus thickens in preparation of a fertilized egg (this period is called ovulation). After ovulation, progesterone, another reproductive hormone, rises preparing for a fertilized egg. Conception occurs when a fertilized egg implants in the uterine wall. If conception does not occur, both estrogen and progesterone levels drop, signaling the thickened uterine lining to shed and ushering in menstruation.
Oral contraceptives, also known as “birth control pills” (BCP) are a synthetic mixture of the hormones progesterone and estrogen. They prevent ovulation by maintaining constant levels of these hormones. As a result, the ovary does not release an egg and the estrogen level does not rise.
What are the risks involved with taking oral contraceptives?
Oral contraceptives (OCA) can be associated with increased risks of several serious side effects. Women taking them are advised not to smoke due to an increased risk of blood clots, stroke and heart attack. Importantly, they do not protect against HIV infection or other sexually transmitted diseases.
Birth control pills causing hair loss
BCP’s can cause hair loss through two different mechanisms, through drug induced shedding and by facilitating female pattern genetic hair loss. These are two very distinct processes.
Almost any drug can potentially cause hair loss but oral contraceptives are particularly implicated in a process called telogen effluvium, or hair shedding. Essentially what happens is that the drug causes hair in the growing phase (anagen) to be shifted to the resting phase (telogen). After the telogen phase (normally lasting about 2-3 months), hairs are spontaneously shed before they enter a new growth cycle (of 3 – 7 years). Normally only about 10-15% of hairs are in telogen at any one time, but this can increase to as much as 50% in telogen effluvium. As a result, large amounts of hair can be shed as they pass through this short telogen cycle. Interestingly, telogen effluvium can occur with starting birth control pills, switching birth control pills, or even discontinuing the BCP’s that a patient has been on for a long period of time. Fortunately, this process can be reversible once the implicating agent is stopped or the scalp has time to adjust to the new medication.
If a woman has a genetic predisposition for hair loss, then oral contraceptive medications containing progesterone can potentially increase that loss by adding a source of exogenous (outside) androgens. The birth control pills that are higher in progesterone compared to estrogen will more likely contribute to this process. In contrast to hair shedding, the thinning seen in genetic hair loss is characterized by a progressive decrease in hair shaft diameter rather than frank hair loss.
Birth control pills as a treatment for female pattern hair loss
Just as progesterone dominant BCPs can facilitate female pattern hair loss, oral contraceptives higher in estrogen can stimulate hair growth by prolonging the anagen phase of the growth cycle. A problem is that estrogen dominant birth control pills have a greater incidence of certain side effects. Your gynecologist should advise you on which BPCs should be used in your particular situation.
The newer oral contraceptives such as Yasmin, Yaz, Desogen, Mircette, OrthoCyclen Ortho-TriCyclen and Ortho-TriCyclen Lo have lower androgenetic effects and are useful in patients concerned about hair loss. In particular, Yaz and Yasmin contain the progestin drospirenone, which has anti-androgen properties, and can therefore be particularly helpful in women experiencing female pattern hair loss.
In 2002, the FDA approved Avodart (dutasteride 0.5mg) for the treatment of prostate enlargement in men (the medical term is symptomatic benign prostatic hyperplasia or BPH). Dutasteride is not approved for the treatment of male pattern hair loss.
Like finasteride, dutasteride is an inhibitor of the enzyme 5 alpha-reductase responsible for the conversion of testosterone to DHT (dihydrotestosterone). However, unlike finasteride, which only inhibits the Type II form of the enzyme, dutasteride inhibits both the Type I and Typ
e II forms of the 5 alpha-reductase enzyme. This dual effect makes the drug more potent but also increases the incidence of adverse reactions.
The Type II form of the enzyme is found predominantly in the hair follicle. The Type I form of the enzyme has been found in the scalp and sebaceous glands, but its exact role in hair growth has not been determined. Type I is responsible for 1/3rd circulating DHT and type IIfor 2//3rd circulating DHT.
Effects on Hair GrowthDutasteride 0.5mg/day decreases serum DHT 91% and scalp DHT 54%. Finasteride 5mg/day decreases serum DHT 71% and scalp DHT 38%. Based on these results, dutasteride should be significantly more effective in the treatment of androgenetic alopecia than finasteride. However, since the Type I form of the 5 alpha-reductase that dutasteride blocks is not present in significant quantities in the hair follicle, these effects may not be as significant as one might expect. The increased efficacy of Dutasteride is felt to be due, in part, to its effects on lowering serum DHT.
Side EffectsDutasteride was investigated in controlled multi-center studies involving 4,325 men aged 50 and above with prostate enlargement. Drug-related side effects during the first six months were as follows: impotence (4.7 percent vs. 1.7 percent for placebo), decreased libido (3 percent vs. 1.4 percent), breast tenderness and breast enlargement (gynecomastia; 0.5 percent vs. 0.2 percent) and ejaculation disorders (1.4 percent vs. 0.5 percent).
The incidence of most drug-related sexual adverse events decreased with duration of treatment. The incidence of drug-related breast tenderness and breast enlargement remained constant over the treatment period. Ejaculate volume may be decreased in some patients with continued treatment. This decrease did not appear to interfere with normal sexual function.
Effects on PSADutasteride will reduce the amount of PSA measured in the blood and this must be taken into account when PSA is used in the detection of prostate cancer.
Precautions
The precautions when using dutasteride for prostate enlargement are more significant than for finasteride and include:
Women who are pregnant or may become pregnant should not handle dutasteride because of possibility of absorption of dutasteride and subsequent potential risk to a male fetus.
Men treated with dutasteride should not donate blood until at least six months after their final dose to prevent giving dutasteride to a pregnant woman through a blood transfusion.
Men with an allergic reaction to dutasteride or its ingredients should not take it.
Men with liver disease should talk to their doctor before taking dutasteride.
Because of the potential for drug-drug interactions, care should be taken when administering dutasteride to patients taking potent, chronic CYP3A4 enzyme inhibitors (e.g., ritonavir).
Additional Points
Unlike finasteride, were families that had a deficiency of the Type II 5-alpha reductase enzyme were followed for years without any adverse effects, there is no natural biologic model for dutasteride.
The half life of dutasteride is 5 weeks compared to 6-8 hours for finasteride and serum concentrations of dutasteride are detectable up to 4-6 months after discontinuation of treatment.
for minoxidil, was the first FDA approved medication for the treatment of hair loss. Minoxidil is a topical solution that is applied directly to the scalp. It can now be purchased without a prescription and in generic formulations in concentrations of 5% (for men) and 2% (for women).
Minoxidil was developed from the oral blood pressure medication minoxidil (Loniten). Minoxidil taken orally has potential serious side effects on the heart and circulatory system and is used only when other blood pressure medications have been unsuccessful. It was observed that patients who were taking minoxidil began growing body hair and it was reasoned that applying minoxidil directly to a bald scalp might cause hair to grow in this area as well. Studies showed that this was indeed the case, although the growth was generally modest.
The original studies on Minoxidil were performed on the crown, so there is a misconception that it only works in this area. Although minoxidil usually works best in the crown, it also works to a lesser degree in other areas, such as the front of the scalp, as long as there is some fine (miniaturized) hair in the area. It does not work when the area is totally bald. The greatest benefit from the medication is seen from 5 months to 2 years, with a gradual decrease in effectiveness after that. Those using minoxidil long-term will continue to lose hair, but at a somewhat slower rate.
The exact mechanism by which minoxidil works is not known, but the drug is felt to increase the duration of the hair follicle growth cycle (called anagen). This improves the quality of the hair by increasing the diameter and length of fine (miniaturized) hair. The simultaneous use of minoxidil and Finasteride, which directly inhibits the formation of DHT, may have some synergistic benefit in the treatment of hair loss, although the latter medication is significantly more effective.
Using Minoxidil
Minoxidil should be applied to the scalp twice a day. The medication only works if it is in direct contact with the scalp (not the hair) and only works in areas where it is applied. Therefore, it is important to use the medication in the front part of the scalp if this is an area of thinning.
The 5% formulation is twice as effective as the 2% solution, but contains propylene glycol, a compound that can irritate the scalp and can make the hair feel sticky and difficult to manage. If this is a problem, one should consider using the 5% solution at bedtime and the 2% solution (which is alcohol based and less sticky) in the morning. When using minoxidil, it may take 6-12 months before any results are seen. The majority of patients who see an effect from minoxidil experience a delay, or decrease, in the rate of hair loss. The drug also serves to thicken already existing hair, but most patients who do have results, grow only short, thin fuzz. It will not grow any new hair on a bald scalp.
Rogaine or Tugain Foam is a new form of 5% Minoxidil in a glycerin and alcohol base. The foam technology is a convenient way of delivering minoxidil to the scalp without the sticky and often irritating effects of propylene glycol, the delivery compound used in the original 5% solution. When released from the canister, the new product seems like a shaving foam, but it rapidly “melts” when it reaches skin temperature. Applying Rogaine as a foam allows convenient application to the scalp without dripping or running down the forehead or neck, and without leaving a sticky residue in the hair.
Once a day topical use of Rogaine (topical minoxidil 2% and 5%) seems to be almost as effective as using it twice a day. The reason is, that although minoxidil has a relatively short half-life of several hours when given orally,when topically applied, it has a half-life of 22 hours in the skin. This suggests that once a day dosing is a reasonable option. It is important to realize that Pfizer, the company that now makes Rogaine, specifically states that it will be less effective if used only once a day.
If minoxidil is discontinued, the effects of the drug wear off within three months and the previous pattern of hair loss resumes. When minoxidil is restarted, one generally does not regain the hair that was lost, so it is best not to stop and start the mediation, but to use it regularly.
Minoxidil has been prescribed (off-label) in conjunction with other medications, such as topical retinoic acid (Retin-A), to enhance its penetration into the skin and thus increase its effectiveness. This combination of medications, however, can greatly increase the absorption of minoxidil into the bloodstream and may increase the risk of potential side effects, including changes in blood pressure and severe scalp irritation that has led to scarring.
Use in Women
Only the 2% concentration of minoxidil is approved for use in women. Women are generally more sensitive to the side effects of minoxidil in decreasing blood pressure (hypotension) and may get light-headed from the medication. Women also have an increased risk of developing allergic skin reactions (contact dermatitis).
An annoying local reaction that women sometimes get from topical minoxidil is the development of facial hair. Although the facial hair slowly resolves when the medication is discontinued, at times the hair may need to be removed. Carefully trying to avoid the medication dripping down onto the temples and forehead seems to reduce, but not totally prevent, this problem. There is a significantly greater incidence of these side effects if the 5% solution is used.
Tips on Using Minoxidil (Rogaine / Mintop) – Men
Minoxidil solution comes in a generic formulation and can be purchased over the counter. The foam is available in brand only (Rogaine / Trigain Foam).
Minoxidil only works where you apply it. Apply it to all areas that are thinning.
Minoxidil can work anywhere there is miniaturized hair (where the area is not totally bald)
Minoxidil will work in the front part of the scalp and temples if these areas are just starting to thin – so it is important to apply it to the front part of your scalp and hairline if you are thinning in these areas.
Minoxidil must be applied to the scalp to work – it doesn’t work on the hair per se.
Minoxidil 5% solution is the most effective if you have some hair, as the solution will be easier to apply to the scalp.
If the 5% solution is irritating to your scalp, try the 5% Foam which does not contain propylene glycol, the most common irritant.
If the 5% solution is too greasy and you find you are not using it, switch to the foam.
Although the Minoxidil works best when used twice a day, using it once a day will also be effective (and better than not using it at all).
Many patients find applying the medication once a day at bedtime to be the most convenient way to use it.
When using minoxidil once a day, use at least double the recommended dose, so that it will be applied to the entire area of thinning.
Minoxidil can be applied to damp scalp when you first get out of the shower and this can make grooming easier.
For minoxidil to be effective it must be used continually and regularly. Do not stop and start it. You may experience shedding during the first 3-6 months of treatment. This generally is an indication that the medication is working, so unless you are having side effects, do not stop the medication. If you do stop the medication, you will lose all of its benefits (although you will not be any worse off than if you had never used it).
Minoxidil works best when used with finasteride. Of the two medications, finasteride is more effective.
Tips for Women Using Minoxidil– Women
Minoxidil solution comes in a generic formulation and can be purchased over the counter. The foam is still available in brand only.
Minoxidil is generally prescribed as a 2% solution for women to be used twice a day. If twice a day is inconvenient, then use the 5% men’s formulation just once a day.
Minoxidil can cause increased facial hair. Although the 5% is more likely than the 2% to cause this, when the 5% is used one a day, the side effects seem to be about the same.
Minoxidil only works where you apply it. Apply it to all areas that are thinning.
Minoxidil can work anywhere there is miniaturized hair (where the area is not totally bald).
Minoxidil will work in the front part of the scalp and temples if these areas are just starting to thin.
Minoxidil must be applied to the scalp to work – it doesn’t work on the hair per se
Minoxidil solution is the most effective if you have some hair, as the solution will be easier to apply to the scalp.
If the solution is irritating to your scalp, try the Foam which does not contain propylene glycol, the most common irritant.
If the solution is too greasy and you find you are not using it, switch to the foam.
Although the Minoxidil works best when used twice a day, using it once a day will also be effective (and better than not using it at all).
Many patients find applying the medication once a day at bedtime to be the most convenient way to use it.
When using minoxidil once a day, use double the recommended dose, so that it will be applied to the entire area of thinning.
Minoxidil can be applied to damp scalp when you first get out of the shower and this can make grooming easier.
For minoxidil to be effective it must be used continually and regularly. Do not stop and start it. You may experience shedding during the first 3-6 months of treatment. This generally is an indication that the medication is working, so unless you are having side effects, do not stop the medication. If you do stop the medication, you will lose all of its benefits (although you will not be any worse off than if you had never used it).
Male pattern baldness or androgenetic alopecia is caused by the effects of the male hormone dihydrotestosterone (DHT) on genetically susceptible hair follicles that are present mainly in the front, top, and crown of the scalp (rather than the back and sides). DHT causes hair loss by shortening the growth, or anagen, phase of the hair cycle, causing miniaturization (decreased size) of the follicles. The effected hair becomes progressively shorter and finer until it eventually disappears.
DHT is formed by the action of the enzyme 5-alpha reductase on testosterone. Finasteride is a synthetic 4-azasteroid compound, is a specific inhibitor of steroid Type II 5a-reductase, an intracellularenzyme that converts the androgentestosterone into 5a-dihydrotestosterone (DHT)in the hair follicle. Finastride is the only FDA approved medication for hair loss prevention.
Finasteride causes a significant drop in both scalp and blood levels of DHT and its effect is felt to be related to both of these factors. Finasteride produces a rapid reduction in serum DHT concentration, reaching 65% suppression within 24 hours of oral dosing with a 1-mg tablet Serum testosterone levels actually increased by 9%, but this is within the range of normal.
It is commonly thought that finasteride was first conceived as a prostate medication and that, only by chance, was found to prevent hair loss. In 1997, the FDA approved finasteride 1-mg/day (Propecia) for the treatment of male pattern baldness.
Studies have shown that after five years of treatment, 90% of men taking finasteride maintained their hair or increased hair growth. At five years, 48% of men treated with Propecia demonstrated an increase in hair growth, 42% were rated as having no change (no further visible progression of hair loss from baseline) and 10% were rated as having lost hair when compared to baseline.These hairs were significantly larger than the fine, miniaturized hair characteristic of balding. In the “Hair Weight Clinical Study,” a 34% increase in hair weight was observed
Using Finasteride
Finasteride should be taken once daily with or without meals. Patients must take Finasteride for one year or longer before its effects in preventing hair loss and re-growing hair can be accurately assessed. Finasteride takes up to a year or more to exert its full effects in both preventing hair loss and in re-growing hair. During the first six months you may note some thinning of your existing hair. This may be due to either progression of your hair loss before finasteride has had a chance to work or some shedding of miniaturized hair that makes way for the new healthy anagen hair to grow. It is important to be patient during this period.
Long-Term Benefits and Risks
The effects of finasteride are confined to areas of the scalp that are thinning, but where there is still some hair present. It does not grow hair in areas that are completely bald. Although it can regrow hair in thin areas, the major benefit of finasteride seems to be in its ability to slow down or halt hair loss. Results generally peak around one year and then are stable in the second year or decrease very slightly. Although the long-term ability of finasteride to maintain one’s hair is unknown, the majority of men find that after 5 years the medication is still working.
The benefits of finasteride will stop if the medication is discontinued. Over the 2-6 months following discontinuation, the hair loss pattern will generally return to the state that it would have been if the medication had never been used.
Side Effects
Side effects from finasteride at the 1-mg dose are uncommon, but reversible. The one- year drug related side effects were 1.5% greater than in the control group. The data showed that 3.8% of men taking finasteride 1mg experienced some form of sexual dysfunction verses 2.1% in men treated with a placebo. The five-year side effects profile included: decreased libido (0.3%), erectile dysfunction (0.3%), and decreased volume of ejaculate (0.0%).
TABLE 1 Drug-Related Adverse Experiences for PROPECIA (finasteride 1 mg) in Year 1 (%) MALE PATTERN HAIR LOSS
Discontinuation due to drug-related sexual adverse experiences
1.2
0.9
Most reported cases of sexual dysfunction occurred soon after starting the medication, but there have been reports of sexual dysfunction that have occurred at later points in time. The sexual side effects were reversed in all men who discontinued therapy, and in 58% of those who continued treatment. After the medication was stopped, side effects generally disappeared within a few weeks. When finasteride is discontinued, only the hair that had been gained or preserved by the medication is lost. In effect, the patient returns to the level of balding where he would have been had he never used the drug in the first place. No drug interactions of clinical importance have been identified.
Side Effects:
Adverse reactions related to the breast, including breast tenderness or breast enlargement (gynecomastia), occurred in 1 in 4000 ( 0.4%) of men taking finasteride 1-mg (Propecia), but this was no greater than in the control group. Other side effects that were not statistically significant included hypersensitivity reactions including rash, pruritus, urticaria, swelling of the lips and face, and testicular pain. Contrary to the common belief it does not grow body hair thicker.
Effects on PSA
Finasteride causes a decrease in serum PSA (prostate specific antigen) by approximately 50% in normal men. Since PSA levels are used to screen for prostate enlargement and prostate cancer, it is important that your personal physician is aware that you are taking Propecia (finasteride) so that he/she may take this into account when interpreting your PSA results.
Finasteride and Prostate Disease
A study in The New England Journal of Medicine, in 2003, on finasteride 5-mg PROSCAR (not finasteride 1-mg, Propecia) reported that in the Prostate Cancer Prevention Trial (PCPT), men treated with finasteride 5mg for seven years had a 25 percent relative risk reduction for prostate cancer compared to the men treated with placebo. The authors also reported that high grade prostate cancers were found in 6.4 percent of the men treated with finasteride 5mg, compared to 5.1 percent of the men in the placebo group.
The authors were concerned that finasteride 5mg prevents or delays the appearance of prostate cancer and that this possible benefit and a reduced risk of urinary problems must be weighed against sexual side effects and the increased risk of high-grade prostate cancer. With new information, it is now felt that the increased incidence of a higher grade cancer was due to the fact that the finasteride shrunk the non-cancerous part of the enlarged prostate, making the cancerous part easier to detect on biopsy.
In fact, in 2009, the American Society of Clinical Oncology and the American Urological Association issued guidelines that recommend that healthy men consider finasteride to lower their level of the hormone dihydrotestosterone (DHT) with the goal of preventing the development of prostate cancer.
Caution during PregnancyFinasteride use is contraindicated in women when they are, or may be, pregnant. Women should not handle crushed or broken Finasteride tablets when they are pregnant, or may potentially be pregnant, because of the possibilities of absorption of finasteride and the subsequent potential risk to a male fetus. Finasteride tablets are coated and will prevent contact with the active ingredient during normal handling, provided that the tablets have not been broken or crushed.
Exposure of pregnant women to semen from men treated with Finasteride poses no risk to the fetus.Semen levels have been measured in 35 men taking finasteride 1 mg/day for 6 weeks. In 60% (21 of 35) of the samples, finasteride levels were undetectable (<0.2>mg) that had no effect on circulating DHT levels in men (see
Use in Post-Menopausal Women
Merck recently carried out a study to evaluate the efficacy of finasteride in post-menopausal women. After one year there was no significant hair growth and, as a result, the study was terminated. An explanation is that hair loss in women is related more to the action of the enzyme aromatase (which is unaffected by finasteride) rather than DHT. It is also possible that the low DHT levels observed in postmenopausal women are responsible for the lack of significant response to finasteride.
Finasterideand Hair Transplantation
Finasteride has shown to be useful in complementing a hair transplant for several reasons:
Finasteride works best in the younger patient who may not yet be a candidate for hair transplantation.
Finasteride is less effective in the front part of the scalp, the area where surgical hair restoration can offer the greatest cosmetic improvement.
Finasteride can re-grow hair, or stabilize hair loss, in the crown part of the scalp where hair transplantation may not always be indicated.
For those who choose not to take Finasteride, or who cannot take it due to its side effects, the surgical hair restoration is just as effective. The only difference is that medications can prevent further hair loss whereas surgery cannot. Medications are not needed for a hair transplant to be successful or the transplanted hair to grow and be permanent.
Increasing the Dose
We are often asked if one should increase the dose of Finasteride. Although we do increase the dose under certain circumstances, there is no scientific evidence that increasing the dose will have any additional effects. There are published data demonstrating that 5 mg is no better than 1 mg from controlled clinical trials.
Patient Monitoring
It is recommended that men aged 50, or over, should inform their regular physicians or urologists that they are taking Finasteride 1mg. It is also recommended that all men aged 50 or over have a routine annual evaluation for prostate disease, regardless of whether or not Finasteride is used. For those patients who are black and/or who have a family history of prostate disease, these recommendations would apply beginning at age 40. An evaluation may include a rectal examination, a baseline PSA, and other tests that your examining physician feels are appropriate.The above are general guidelines recommended for all men of appropriate age, regardless of whether they use Finasteride or not. Specific recommendations for each Patient should be based upon the judgment of his own physician.
Common Misconceptions about Finasteride
Myth: Women can’t touch the medication.
Fact: Pregnant women should not handle crushed or broken tablets.
Myth: It only works in the crown.
Fact: It potentially works any where on the scalp where there is some hair, even in the front of the scalp.
Myth: Once you start it you must take it for ever.
Fact: You can stop the medication any time you want – you just lose its benefits when one stops.
Myth: Finasteride lowers testosterone
Fact: The medication, on average, causes a rise in serum testosterone levels by 9%.
Myth: The sexual side effects are frequent and irreversible.
Fact: The sexual side effects occur in 2% and are reversible when the medication is stopped.
Myth: Finasteride causes birth defects if a man takes it when his wife is pregnant.
Fact: Exposure of pregnant women to semen from men treated with Propecia poses no risk to the fetus.
Myth: Propecia was originally a prostate medication that was found to prevent hair loss.
Fact: Propecia is not a prostate medication that was by chance noted to have a side effect of hair growth, it is a medication that was known since its discovery that it could grow hair.
Tips on Using Finasteride (Propecia/ Finax)
Finasteride is a prescription oral medication that is now generic (Proscar in the 5mg dose). This formulation is just as effective as the brand name Propecia and is about 1/3 the cost.
The general starting dose of finasteride for hair loss is 1mg a day. For this dose, you can either take one 1mg Propecia tablet or ¼ of a 5mg tablet of generic finasteride each day. Finasteride does not have to be cut into equal parts to be effective. Just cut it into the recommended of pieces and take one piece each day.
Finasteride can be taken any time of the day without regard to food or other medications.
You may experience shedding during the first 3-6 months of treatment. This generally is an indication that the medication is working. Do not stop the medication if you see shedding. It takes up to a full year to see the effects of Finasteride, so be patient.
In addition to the regular Norwood Classes (I to VII) and the Norwood Class A’s (Ia to Va), there are two other types of male baldness that O’tar Norwood has termed “Diffuse Patterned Alopecia” and “Diffuse Unpatterned Alopecia.” Although these patterns receive little attention, they appear to be quite common and present special problems for the transplant surgeon. We have attempted to further define and stage these two types of balding in order to gain insight into their appropriate management. DUPA (Diffuse Unpatterned Alopecia) will not appear in a month. If and when it hits, it will develop over a long period of time (months to years). Chemical damage, on the other hand, will have a short cycle. We do not understand a great deal about DUPA, but we are aware that the zone of hair around the sides and back of the head may not be permanent in everyone throughout their lifetime. If you go to an old age home and look at many of the men there, about 1/3rd to a half of the men over 80 have a see-through look on the sides and back of the head. When this is evaluated by mapping out the scalp for miniaturization you will see many thin hairs in this ‘donor rim’ that should not be there. This diffuse alopecia may extend throughout the head, even in men who have no balding. These are the people withs of DUPA. I believe that a condition, which the dermatologists have labelled ‘senile alopecia’, is something that hits men in all decades of life and a few men develop this condition when they are in their 20s or 30s. The use of Finasteride (Propecia) has benefits to about half of these men. Many of the poor transplant results that are seen occurs when the patient has DUPA and the surgeon does not check for it. The transplants become thin and the donor area, which was see through prior to the procedure, gets more see through after. I strongly warn every one of those patients I see with DUPA against having hair transplants and consider this condition a contra-indication for hair transplant surgery. Diffuse Patterned Alopecia (DPA) is an androgenetic alopecia characterized by diffuse thinning in the front, top, and vertex of the scalp in conjunction with a stable permanent zone. Diffuse Patterned Alopecia is usually associated with the persistence of the frontal hairline represented by the hairline position of the Norwood Class II or Class III patient. Especially in the earlier stages, the thinning generally extends to the vertex without significant hair loss in the crown. It differs from the regular Norwood classification in that, when the hair loss is first noted, it is already in a stage resembling a thinning Norwood Class VI, rather than having progressed through the Norwood stages III, III Vertex, IV, and V, which are characterized by continued recession at the temples, an expanding vertex/crown, and the presence of a defined bridge separating the anterior and posterior portions of the scalp. In addition, there is an absence of the residual triangular elevation in the parietal region that helps to define the typical Norwood Class VI patient. Diffuse Patterned Alopecia differs from the less common Diffuse Unpatterned Alopecia (DUPA) which is also androgenetic, but lacks a stable permanent zone. Diffuse Unpatterned Alopecia( DUPA) patients have a similar progression of balding as the DPA patient except that the progression is often more rapid and will more likely eventuate in a “horseshoe pattern” resembling the Norwood class VII, except that in contrast to the Norwood VII, the DUPA “horseshoe” can look almost “transparent” due to the low density. The differentiation between DPA and DUPA is critically important because DPA patients are often good candidates for an appropriately timed transplant, whereas DUPA patients should almost never be transplanted because they will inevitably have extensive hair loss without a stable zone in which to harvest the hair. Both Diffuse Patterned and Unpatterned alopecia also occur in women. However, in contrast to men, the DUPA in women is much more common, probably occurring 10 times as frequently as DPA. As in men, the female DUPA patients are not good candidates for a transplant (except in the instance where the donor hair is used solely to soften the frontal edge of a wig). The high incidence of Diffuse Unpatterned Alopecia in women partly explains why so few women have their hair transplanted. It is also important to emphasize that a non-androgenetic differential must be considered in all unpatterned alopecias. This is especially true in women, where a host of medical conditions can produce diffuse unpatterned hair loss including anemia, thyroid disease, connective tissue disease, gynecological conditions, and severe emotional problems. We find densitometry to be helpful in distinguishing Diffuse Patterned Alopecia from Diffuse Unpatterned Alopecia. A donor density in the range of 1.0 to 1.5 hairs/mm 2 with donor miniaturization in excess of 35% indicates an unstable permanent zone and precludes a diagnosis of DPA. As discussed in the section “Predicting Short- and Long-Term Hair-Loss,” these densitometry readings in a younger patient, even with little clinically apparent hair loss, point toward a high risk of extensive balding. The importance of densitometry is that not only will it help to distinguish between DPA and DUPA, but it can help to predict which patient will not be a good candidate for a transplant even before visible balding has begun. “
