Hair Loss Management

(The following information is modified version originally prepared by Dr. Nicole Rodgers, MD, a respected dermatologist and hair transplant expert in New Orleans)

Overview: Medical Treatment for Hair Loss

Minoxidil                                                                                                       Minoxidil was the first FDA approved medication for treating hereditary hair loss. Originally used as an oral medication for treating hypertension, patients on minoxidil frequently complained of excessive hair growth on the scalp and face. Topical minoxidil was approved by the FDA in 1988 after studies showed it was effective for treating male pattern hair loss. Since that time both females and males suffering from inherited hair loss have used minoxidil with great success.

Minoxidil for Men: Presently, minoxidil is FDA-approved for men in a Rogaine® 5% solution and foam. The solution is applied with a dropper but can be messy and difficult to apply. Many prefer the less greasy foam formulation. Patients who are highly motivated can apply the product twice daily. It is preferred to use on a dry scalp (so the product is not diluted) but some men prefer to apply it to towel-dried hair after showering. The key is to find a routine that works for you and stick with it! Consistent use for a minimum of 6-12 months is necessary in order to see results.

Minoxidil for Women: Presently, Minoxodil is also FDA approved for women in a Rogaine 5% solution or foam, with instructions for twice daily usage. However, many women find it difficult to style their hair and go to school or work after applying the formulation. Fortunately, a recent study published in the Journal of the American Academy of Dermatology has shown that the 5% minoxidil formulation (Rogaine foam) applied once daily is just as effective in women as the 2% applied twice daily. Thus, patients can apply either the 5% foam or solution to a dry scalp at bedtime. That way they can wash and style their hair normally in the morning. It is not essential to wash the hair daily, but a slight residue may build up on the scalp after a few days’ use.

Are there any women who should NOT use the 5% Rogaine? Yes. There are two groups who should be cautious with the 5% formulation:

  1. Women with unwanted facial hair. If you already have unwanted facial hair, there is a chance that it may become thicker or darker with use of 5% minoxidil. This is not from the medication running down the face but rather from the systemic absorption of the minoxidil. A safe approach would be to start with the 2% once daily at night. Alternatively, you may start with the 5% and consider various hair removal treatment strategies, such as Vaniqa cream, laser hair removal, depilatories, orelectrolysis if you do get additional unwanted facial hair.                         

  2. Women with severe migraine headaches. Because minoxidil is a vasodilator it may trigger headaches or light-headedness. Starting with 2% minoxidil is a better option.

Finasteride (Propecia)                                                                             Finasteride for Men: Finasteride 1mg was FDA-approved in 1997 for the treatment of male pattern hair loss. Since then, it has been used extensively and successfully in men of all ages for the treatment of hair loss. It is only approved for persons over age 18 but has been used off-label in younger men. It is not recommended for use prior to puberty. Finasteride works by blocking the type II enzyme 5-alpha-reductase, which converts testosterone to dihydrotestosterone (DHT). Evidence that this enzyme contributes to male pattern hair loss comes from the fact that eunichs, who lack the enzyme, never develop hair loss.

Side effects can include breast tenderness or enlargement, breast cancer (seen in a very small number of men in the post-marketing reports) and sexual side effects (reported in less than 2% of patients in the clinical trials). New 10-year data demonstrated no connection between breast cancer and 5-alpha reductase inhibitors (finasteride and dutasteride). Merck recently added long-term sexual side effects to their package labeling, based on a recent study. This study was a retrospective set of interviews with several limitations including selection bias, recall bias, and lack of control for confounding factors. Any patient who has side effects should stop the drug as soon as possible, and it should be out of their system in a matter of 3-4 days.

Men over the age of 50 should be sure to inform their internist or urologist they are taking finasteride. This medication artificially lowers the value of the PSA (prostate specific antigen). This is because the finasteride also works to help shrink the prostate preventing benign prostatic hypertrophy (BPH). To interpret the PSA in a man taking finasteride, your doctor should double the PSA in order to get the true value.

Men who are taking it should not donate blood for 6 months after their last dose to avoid inadvertent administration to a pregnant female.

Finasteride for Women: Finasteride is not FDA approved for use in women. This is related to a risk of birth defects in women who become pregnant on the drug. Also, there was an initial lack of efficacy when it was studied at the 1mg dose in women. A number of more recent studies suggest that it can be helpful at slightly higher doses in women who cannot get pregnant. 

Dutasteride                                                                                                   Dutasteride is occasionally used off-label for the treatment of hair loss in men who have not responded to finasteride. It is only FDA approved for the treatment of benign prostatic hypertrophy (trade name Avodart®). It works by inhibiting both type I and type II 5-alpha reductase enzyme. It is approximately 3x as potent as finasteride at inhibiting the type II enzyme (involved in DHT production) and can decrease serum DHT levels by slightly more than finasteride. However it has a significantly longer half-life than finasteride so any side effects may last for 8 or more weeks. For this reason it is only a good considered for men who have already had their families and who have not seen an adequate response to finasteride. Like finasteride, it is teratogenic in women of childbearing age. Men who are taking it should not donate blood for 6 months after their last dose to avoid inadvertent administration to a pregnant female.

Spironolactone (Females only)                                                             Spironolactone (brand name Aldactone®) is an oral diuretic with anti-androgen effects. All women have both estrogens (female hormones) and androgens (male hormones). As their estrogen production wanes (usually around menopause) it can unmask underlying normal levels of androgens. These androgens are believed responsible for unwanted facial hair and possibly hair thinning. Doctors believe that FPHL is related to a genetically increased sensitivity to normal circulating levels of androgens at the level of the hair follicle.

In women, the use of spironolactone can help block androgen receptors at the level of the hair follicle. It can help reduce unwanted facial hair and also help regrow thinning hair on the scalp.

Like minoxidil or finasteride, it must be taken consistently in order to see benefits from the drug. This involves taking it for a minimum of 6 months. In women who respond, regrowth generally peaks at 24 months. We prescribe spironolactone at doses of 25-100 mg daily for acne, but must use higher doses of 150-200 mg daily for use in treating female pattern thinning.

At higher doses, it is important to periodically check electrolytes (potassium and sodium) while taking spironolactone.