Treatments With Medications

You are probably introduced to a new lotion or a pill for hair loss therapy freaquently through your friends, your hairdresser or commercials. Naturally, you get confused with every other suggestion, and probably could not decide which product you should use. In this section, we tried to give the summarized information about only FDA (United States Food and Drug Administration)-approved treatments in order to elucidate the subject briefly.

First of all, one should know that there is no “miracle” pill or lotion that will fulfill expectations of everyone. Even though the efficacy of the products, most of which I also suggest to my patients, are proven by clinical studies; some patients show resistance to the therapy. Nevertheless, the therapy should be targeted to cure hair loss. We strongly suggest you to consult to your physician for more information and about possible side effects before starting any kind of treatment.

Most common cause of Male Pattern Hair Loss (MPHL) is the presence of androgenic hormones. On the other hand, the genetic involvement is also present and it due to the differential inheritance of the relevant genes from our parents. As a consequence, a term that indicates both the hormonal and the genetic components, namely ANDROGENETIC ALOPECIA is used to define this condition as a whole.

If we revisit the mechanism: Testosterone is converted to a more active form dihydrotestesterone (DHT) by an enzyme (5-alpha-reductase) upon entering the cell. DHT then binds to Androgen Receptor and together, they localize to the cell nucleus. An intervention at any point of this mechanism may slow down or completely stop hair loss or sometimes even revitalize the thin hairs for a short time.

The so-called “Anti-androgenic treatment” medicines mostly block either 5-alpha-reductase enzyme or androgen receptor. Unfortunately, anti-androgenic medication is effective only when it is used regularly and they tend to cause various systemic side effects.

Finasteride:

It is a widely known and regularly used anti-androgenic therapy for hair loss. It functions by inhibiting 5-alpha-reductase Type II, which is abundant in hair follicles. Recommended daily dosage of Finasteride is about 1mg/day. There are several studies showing its effectiveness. It is also the only Anti-androgenic medication that is approved by FDA for usage in Male Pattern Hair Loss (MPHL). In order to be effective, the treatment should be started immediately after the initiation of the hair thinning. It is reported that the mid-frontal region, which is just behind the frontal hairline, of 18-41 year-old males responds quite well to early treatment.

In addition to it’s proven effectiveness by numerous scientific studies, [1] Finasteride’s 5-year follow-up safety profile is also quite satisfactory. [2] In 0.3% of the 5-year follow-up patients lack of libido or erectile dysfunction was observed as a side effect. No other side effects or adverse effects were reported by the mentioned studies. Since the half-life of Finasteride in blood is about 6-8 hours, the drug can be immediately discontinued and the remaining drug can quikly be cleared from the system.

An extremely delicate issue on Finasteride usage involves the men over the age of 40. Finasteride could decrease the PSA (Prostate specific antigen) levels by 30 to 50%, which is frequently used for screening of prostate cancer. As a result, men over the age of 40 (risk group) should use this treatment only under the supervision of their physicians. Otherwise PSA level results might cause a delayed diagnosis of patients with current prostate problems. [2-4]

Finasteride treatment is not recommended for women. Especially pregnant women and women who might be pregnant, should not even touch Finasteride by bare hands.

Dutasteride:

Duasteride inhibits both Type I and Type II 5-alpha-reductase enzymes strongly. Type I 5-alpha-reductase, is present in the brain as well as in the hair follicles and its functions remain unclear. Moreover, Duasteride frequently causes side effects and it has a much longer half-life (240 h) in blood compared to Finasteride. Even though Duasteride has a faster and stronger effect on inhibiting DHT, [5,6] FDA does not approve its usage on Male Pattern Hair Loss (MPHL). FDA approved the usage of Duasteride only for benign prostatic hypertrophy in 2002.

Minoxidil:

It is a direct hypertrichotic agent, which is effective on the hair follicle without interfering with the androgenic pathway. Its mechanism of action depends on the activation of the potassium channels, and it also has a vasodilator effect. As a result of its effect on vessels, it was being prescribed to hypertension patients. Later on, hypertrichosis (increase in hair growth and number) was observed as a side effect in these patients, and as a consequence Minoxidil is now prescribed for this purpose.

Minoxidil has two commercial lotions with 2% and 5% concentrations. Foam version of Minoxidil is also available, which has a less demanding usage and is less irritant to skin.

FDA approved the 2% solution of Minoxidil for treatment of hair loss in 1988, and 5% solution in 1997.

Its effectiveness and reliability are proved by many studies. [7-10] Facial hypertrichosis and irritant dermatitis are the most frequently observed side effects. 5% solution is preferred for treatment of men because of its higher efficiency. [11] On the other hand, 2% solution is a better choice for women due to its hypertrichoitic effect. The usage of 2% solution of Minoxidil after hair transplantation increases the success rate of the operation and reduces the time for the growth of new hair. [12-14] Minoxidil or Finasteride usage after a “hair transplantation” is generally recommended by the hair surgeons. [15]

References

    [1] Kaufman KD, et al., Finasteride in the treatment of men with androgenetic alopecia. Finasteride Male Pattern Hair Loss Study Group. J Am Acad Dermatol. (1998); 39 (4 Pt 1): 578-89.
    [2] Kaufman KD, et al., Long term (5-year) multinational experience with finasteride 1 mg in the treatment of men with androgenetic alopecia. Eur J Dermatol 2002; 12: 38-49.
    [3] Roehborn CG. et al., Effect of finasteride 1 mg versus placebo over 48 weeks of serum PSA in men age 40-60 years with androgenic alopecia and no known prostatic disorder. J Urol 2000; 163 (Suppl 4): 220.
    [4] Anderson WR., et al., Hormonal treatment for male-pattern hair loss: implications for cancer of the prostate? BJU Int 2002; 90: 682-685
    [5] Graul A. et al., Duasteride. Drugs of the future 1999; 24: (3):246-253
    [6] Per Olsson Gisleskog, David Hermann, Margareta Hammarlund-Udenaes, and Mats O. Karlsson. A model for the turnover of dihydrotestosterone in the presence of the irreversible 5-alpha-reductase inhibitors GI198745 and finasteride.Clinical Pharmacology & Therapeutics (1998) 64, 636–647.
    [7] Olsen EA. et al., Topical minoxidil in early male pattern baldness. J Am Acad Dermatol 1985;13(2 Pt 1):185-192.
    [8] Katz HI. et al., Long-term efficacy of topical minoxidil in male pattern baldness. J Am Acad Dermatol 1987;16(3 Pt 2):711-718.
    [9] Rietschel RL et al., Safety and efficacy of topical minoxidil in the management of androgenetic alopecia. J Am Acad Dermatol 1987; 16:677-685
    [10] Kreindler TG. Topical minoxidil in early androgenetic alopecia. J Am Acad Dermatol 1987; 16:718-724
    [11] Olsen EA. et al., A randomized clinical trial of 5% topical minoxidilversus 2% topical minoxidil and placebo in the treatment of androgenetic alopecia in men. J Am Acad Dermatol 2002; 47:377-385.
    [12] Kassimir JJ. Use of topical minoxidil as a possible adjunct to hair transplant surgery. J Am Acad Dermatol 1987; 16:685-687.
    [13] Bouhanna P. Topical minoxidil use before and after hair transplantation. J Dermatol Surg Oncol 1989; 15:50-53.
    [14] Roenigk HH., et al., Topical 2% minoxidil with hair transplantation. Face 1993; 4:213-216
    [15] Avram MR. et al., The potential role of minoxidil in the hair transplantation setting. Dermatol Surg 2002; 28:894-900