Demystifying hair loss treatments

Studies have shown “Only 8% of non-balding men stated that going bald would concern them, while 50% with mild hair loss and 75% with moderate to severe hair loss were concerned.”

 

Dealing with Male Pattern Hair Loss (MPHL), men have the following options;

  • Do nothing – hair loss will be progressive
  • Toupee – commonly known as the “rug”
  • Hair transplant
  • Medical treatment

At Harley, medical treatment is our specialty.

Medical Treatment:

There are a range of medications that have shown clinical effectiveness and have been proven to halt hair loss and even reverse the balding effects of MPHL.

Medical treatments target two key areas to prevent MPHL;

  1. Block the 5-alpha Reductase enzyme responsible for conversion of Testosterone to DHT and miniaturisation of the hair follicle
  2. Target the growth (anagen) phase of the hair follicle and cause thickening of existing hairs.

 

5-alpha Reductase Inhibitors:

Finasteride/Dutasteride

Both Finasteride and Dutasteride work by inhibiting 5-alpha reductase. This lowers the serum and scalp levels of Dihydrotestosterone (DHT) while increasing scalp levels of testosterone (1).

Clinical studies have shown that Finasteride has the following effects on the hair;

  • Significantly greater hair count after one year than in patients receiving placebo (2, 3).
  • Increased ratio of hairs in the growth phase relative to the resting phase of the hair cycle at 48 weeks (4).
  • Sustained increase in hair weight after 3 to 4 years (2, 5).
  • Five-year results showed that hair growth peaked at 1 to 2 years, but still stayed above baseline (when they started) for 90% of patients, in comparison – patients on placebo continued to loose hair (6, 7).
  • Shown to be effective on the front, mid scalp and the crown (vertex) (8).
  • One Japanese study showed that the hair growth with finasteride continues to increase with continuing treatment without significant side effects (9). A recent 10-year study of 118 men treated with 1 mg/day finasteride for androgenic alopecia found that 86% of men continued to benefit from treatment over the entire course of 10 years — showing increased or stable rates of hair growth and only 14% experiencing any further hair loss (10).

Dutasteride works in the same way as Finasteride but is three times as potent as finasteride at inhibiting type II 5-alpha reductase (11). This results in enhanced efficacy over finasteride, however it is not formally approved by the TGA or FDA  to treat MPHL.

Dutasteride is generally used “off Label” by practitioners as an alternative when patients are not getting a favourable response to Finasteride.

 

Minoxidil

Minoxidil is a vasodilator and originally was exclusively used as an oral drug (Loniten®) to treat high blood pressure. It was, however, discovered to have the interesting side effect of hair growth and reversing baldness.

As a result, a topical solution (Regaine 5%) was produced which also showed clinical benefits for MPHL.

It is unknown how the drug stimulates hair growth, however some experts believe that minoxidil dilates the blood vessels around hair follicles, increasing the nutrient supply as well as extending the anagen (growth) phase of the hair cycle thus encouraging increased hair growth.

  • A 5-year follow-up study for men using Minoxidil Solution for MPHL showed that hair regrowth tended to peak at 1 year, with a slow decline in regrowth therafter. Regrown thicker hair, beyond that seen at baseline, was maintained at 4.5 to 5 years later (12).
  • Another study demonstrated that topical use of Minoxidil produced statistically significant increases in hair weights compared with placebo (13). This study suggests that the benefit of Minoxidil also includes maintaining and thickening pre-existing hairs.

Various alternate Minoxidil formulations have been trialed over the years to further improve its effectiveness in MPHL.

  • There is evidence that Tretinoin, when combined with minoxidil, may enhance its efficacy. Tretinoin has been found to increase the percutaneous absorption of minoxidil, leading to a 3-fold increase in absorption versus a 1.3-fold increase using vehicle alone (14).
  • Tretinoin was also found to be effective alone, regrowing hair in 58% of 56 patients, and in combination with minoxidil, regrowing hair in 66% of 56 patients (15).
  • One randomized, double-blind trial in 31 men with MPHL compared twice-daily application of 5% minoxidil with once-daily application of a combined solution of 5% minoxidil and 0.01% tretinoin (16). This demonstrated equivalent effects, suggesting that for patients not interested in twice-daily application, they could achieve similar effects using this combination. Once daily application not only improves compliance but also reduces risk of contact dermatitis.

Minoxidil as an ingredient is very insoluble in almost everything, aside from Propylene Glycol.

Quite often companies will use large concentrations of Propylene glycol to get the Minoxidil into solution so that it can be applied to the scalp. The draw back with this ingredient is two fold;

  1. It is really greasy and not a pleasant feeling on the scalp or hair.
  2. It is the major cause of contact dermatitis in people using Minoxidil solutions.

Advancements in technology and ingredients has allowed Propylene glycol to be removed from specialized Minoxidil formulations.

 

Combination Treatments

 

Both Minoxidil and Finasteride remain to be the best ingredients in dealing with MPHL both in terms of clinical effectiveness and safety data.

For optimal result It is encouraged to use both in combination.  This is supported by literature to be the most effective clinical practice (17, 18).

Finasteride in combination with either topical minoxidil or ketoconazole showed significantly better hair regrowth than with finasteride as monotherapy and showed no difference in the incidence of side effects. It is inferred that the combination of medication with different mechanisms of action enhance the efficacy.

 

References;

  1. Rhodes L, Harper J, Uno H, Gaito G, Audette-Arruda J, Kurata S, et al. The effects of finasteride (Proscar) on hair growth, hair cycle stage, and serum testosterone in adult male and female stump-tail macaques (Macaca arctoides). J Clin Endocrinol Metab 1994;29:991-6.
  2. Price VH, Menefee E, Sanchez M, Ruane P, Kaufman KD. Changes in hair weight and hair count in men with andro- genetic alopecia after treatment with finasteride, 1 mg, daily. J Am Acad Dermatol 2002;46:517-23.
  3. Kaufman KD, Olsen EA, Whiting D, Savin R, DeVillez R, Bergfeld W, et al. Finasteride in the treatment of men with androgenetic alopecia. J Am Acad Dermatol 1998;39:578-89.
  4. Van Neste D, Fuh V, Sanchez Pedreno P, Lopez-Bran E, Wolff H, Whiting D, et al. Finasteride increases anagen hair in men with androgenetic alopecia. Br J Dermatol 2000;143:804-10.
  5. Price VH, Menefee E, Sanchez M, Kaufman KD. Changes in hair weight in men with androgenetic alopecia after treat- ment with finasteride (1 mg daily): three- and 4-year results. J Am Acad Dermatol 2006;55:71-4.
  6. Propecia [package insert]. Whitehouse Station, NJ: Merck & Co, Inc; 2004.
  7. Finasteride Male Pattern Hair Loss Study Group. 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.
  8. Leyden J, Dunlap F, Miller B, Winters P, Lebwohl M, Hecker D, et al. Finasteride in the treatment of men with frontal male pattern hair loss. J Am Acad Dermatol 1999;40(6 Pt 1):930-7.
  9. Irwig MS. Persistent sexual side effects of finasteride: could they be permanent? The journal of sexual medicine 2012; 9:2927-2932
  10. Belknap SM, Aslam I, Kiguradze T, Temps WH, Yarnold PR, Cashy J, Brannigan RE, Micali G, Nardone B, West DP. Adverse Event Reporting in Clinical Trials of Finasteride for Androgenic Alopecia: A Meta-analysis. JAMA Dermatol 2015; 151:600-606
  11. Clark RV, Hermann DJ, Cunningham GR, Wilson TH, Morrill BB, Hobbs S. Marked suppression of dihydrotestosterone in men with benign prostatic hyperplasia by dutasteride, a dual 5-alpha-reductase inhibitor. J Clin Endocrinol Metab 2004;89: 2179-84.
  12. Olsen EA, Weiner MS, Amara IA, DeLong ER. Five-year follow- up of men with androgenetic alopecia treated with topical minoxidil. J Am Acad Dermatol 1990;22:643-6.
  13. Price VH, Menefee E, Strauss PC. Changes in hair weight and hair count in men with androgenetic alopecia, after applica- tion of 5% and 2% topical minoxidil, placebo, or no treatment. J Am Acad Dermatol 1999;41:717-21.
  14. Ferry JJ, Forbes KK, VanderLugt JT, Szpunar GJ. Influence of tretinoin on the percutaneous absorption of minoxidil from an aqueous topical solution. Clin Pharmacol Ther 1990;47: 439-46.
  15. Bazzano GS, Terezakis N, Galen W. Topical tretinoin for hair growth promotion. J Am Acad Dermatol 1986;15:880-3.
  16. Shin HS, Won CH, Lee Sh, Kwon OS, Kim KH, Eun HC. Efficacy of 5% minoxidil versus combined 5% minoxidil and 0.01% tretinoin for male pattern hair loss: a randomized, double- blind, comparative trial. Am J Clin Dermatol 2007;8:285-90.
  17. Khandpur S, Suman M, Reddy BS. Comparative efficacy of various treatment regimens for androgenetic alopecia in men. J Dermatol 2002;29:489-98.

Diani AR, Mulholland MJ, Shull KL, Kubicek MF, Johnson GA, Schostarez HJ, et al. Hair growth effects of oral administra- tion of finasteride, a steroid 5-alpha reductase inhibitor, alone and in combination with topical

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