Hair loss is an evolving and progressive condition. While interventions like hair transplant surgery can restore hair in areas where it has been “lost,” surgical intervention does not treat the ongoing thinning itself. While no medication can truly “stop” the genetic hair loss process, there are some with the potential to slow it down and help improve the appearance of the scalp in general.
Finasteride, sold under the brand names “Propecia” or “Proscar” in the US, is an FDA approved oral medication for the treatment of genetic male pattern hair loss. Finasteride works by blocking the conversion of the male hormone Testosterone to Dihydrotestosterone or “DHT” – the hormone directly responsible for hair loss. Of all the available “preventive” medications, finasteride is typically touted as the most effective. Particularly in young patients who still have a lot of hair to “hold on to” for years to come. While it can be very effective in the right patient, finasteride has been marred in controversy for its potential side effects. Because it alters the body’s hormonal profile, a medication like finasteride has the potential for a widespread and systemic effect. There are a variety of potential side effects associated with the medication; conditions like “brain fog,” and gynecomastia (breast development) are frequently listed as potential effects. The most discussed and concerning, however, are the potential sexual side effects, including: decreased sexual drive (“libido”), changes in ejaculation, and erectile dysfunction. The official studies from the pharmaceutical company estimate sexual side effects only occur in approximately 2% of patients and subside after stopping the medication. Another large study in Japan found similar results – where less than 1% experienced these effects and they ceased after stopping the medication. Anecdotally, however, patients seem to report a greater incidence of these effects and many claim they continued even after stopping the medication – with some even claiming they last permanently. Now, whether these effects were “psychological” or “physiological” is unclear; however, patients have anecdotally reported persistent effects. Obviously, the objective information reported through studies and reviewed by the US FDA is the best data to utilize; but it is important for patients considering the medication to fully evaluate the potential “pros” and “cons” and determine if the medication makes sense for them specifically.
It is also very important to note that finasteride is generally only recommended for male patients. DHT is a very important hormone for fetal development, and a lack of it can cause serious birth defects. This means all women of child-baring age must avoid contact with finasteride – even those not actively trying to have a child. Some doctors will recommend it to post-menopausal women, but it is typically advised that all females avoid taking or coming into contact with finasteride.
There are also now some clinics and compounding pharmacies offering a topical finasteride solution. This solution, opposed to the oral pill form, is applied topically and directly to the scalp. By creating a solution more focused and specific for the scalp, the users and producers of topical finasteride hope to avoid or lessen the systemic (full body) side effects. Topical finasteride has not been studied thoroughly nor has it been proven safe and effective for human use. Creating solutions capable of effectively penetrating the scalp is very difficult, and it is not clear how easily finasteride – even when accompanied by an appropriate penetrative “vehicle” – can be transported through the skin. Furthermore, there are no standardized companies creating topical finasteride, so the solutions — and the concentration of the finasteride in the solutions — vary greatly. Those who do utilize topical finasteride seem to claim that it is either less effective compared to the oral medication or that it is effective but they still experience side effects. This likely means that those who experience less efficacy are probably using a solution incapable of penetrating the scalp and actually working on the hair follicles; those experiencing side effects are likely using a solution that is capable of penetrating the scalp, but the medication is still going “systemic” and causing the same widespread side effects as the oral medication. For all these reasons, topical finasteride is not widely recommended by hair loss doctors.
The only other preventive hair loss medication approved by the US FDA is topical minoxidil. Sold under the brand name “Rogaine” (in the US), minoxidil comes in either a liquid or foam topical solution which is applied to the scalp one to two times daily. Minoxidil was originally used as a blood pressure medication, and the mechanism by which is slows progressive hair loss is still poorly understood. Patients anecdotally report a wide variety of results from minoxidil. Some experience a significant slowing of the hair loss process and a thickening of miniaturizing (thinning) hairs in the mid-scalp and crown; others see only minor benefits from minoxidil and report that it creates more of a “haze” of fine, short, colorless hair on the scalp – which does not provide much visible cosmetic benefit. Patients also report that hairs become “dependent” on the minoxidil and they notice a significant shed of any progress made on the medication quickly after stopping the drug. Minoxidil can be used in both males and females, and is typically the most effective treatment for female hair loss sufferers. Minoxidil is also available in an oral pill and in very high topical concentrations, but both are associated with the potential for much more severe side effects and are not recommended for the treatment of hair loss.
Vitamins and Supplements
Do an online search for “hair loss medications” and the query will return hundreds of “miracle” hair loss vitamins, supplements, and mineral treatments. The reality, however, is that most of these natural or herbal treatments have very little effect on the hair loss process or even the quality of the hair itself. Many claim to affect the hair follicle cycling process, naturally fight causes of the progressive hair loss, or even activate some otherwise unknown growth factor involving the hair follicles. Unfortunately, most of these claims are completely unproven and typically untrue. The herbal supplement industry is notoriously unregulated, and companies can essentially make any claim they like when it comes to these “natural,” over-the-counter medications. While some vitamins, like the popular biotin supplements, may make hair and nails grow a little faster or look a little healthier, none of these treatments have been proven effective for hair loss. A regular diet and possibly a good daily multivitamin will provide all the supplementation your hair follicles require. Anything beyond that is likely going to make your wallet shrink without actually making your follicles grow.
“Hair Loss Shampoos”
Much like herbal hair loss supplements, the “hair loss shampoo” industry is an unregulated field full of bold, unsubstantiated claims. Most “hair loss” shampoos contain ingredients with little to no proven benefit. These shampoos frequently contain caffeine, herbal supplements, or proteins which aim to make the hair appear thicker. Not only are most of these ingredients unproven and ineffective, but it is nearly impossible for a shampoo to penetrate the scalp and reach the actual follicles. Of all the hair loss shampoos available, the only ones with some benefit may be those containing ketoconazole. Ketoconazole is an anti-fungal and anti-inflammatory agent. When applied to the scalp, it may help decrease the inflammation seen in the latest stages of the progressive hair loss process. By decreasing the inflammation there may be some slowing of hair thinning and a healthier scalp in general. While these claims have not been effectively reviewed and approved by any regulatory body, many patients use ketoconazole-based shampoos (with “Nizoral” being the most popular) in conjunction with proven treatments minoxidil and finasteride. This trifecta is affectionately called the “big 3” of preventive hair loss treatments, and many patients firmly believe ketoconazole-based shampoo is crucial part of an effective regimen. It is worth noting that ketoconazole, like minoxidil, can have a drying and irritating effect on the scalp, and many patients with naturally dry or sensitive scalps may not be able to tolerate it – especially in conjunction with minoxidil.
One of the more popular new treatments discussed online is “dermarolling.” During the dermarolling process, a patient takes a roller covered in small, sharp pins of around 0.5mm to 1.5mm and “rolls” it over the scalp. Rolling the device over the scalp causes the sharp pins to actually penetrate the skin and create small wounds. Depending on the vigor of the rolling and the depth at which the pins penetrate, the derma-rolling process can actually create significant wounding and even cause dramatic bleeding. The theory behind dermarolling is based upon the physiological of wounding and wound healing. When the skin is wounded via a cut, burn, etc., the body releases growth factors to help aid in the healing process. According to some research, these growth factors may also stimulate hair follicle activity and encourage hair growth – similar to the theory behind PRP. Along with the research supporting “wounding” in general, a study in 2013 showed a significant benefit when comparing a group using dermarolling with minoxidil versus a group using minoxidil alone. This helped lead to an explosion of patients using and recommending the use of dermarolling. The reality is that dermarolling results are inconsistent. Furthermore, while dermarolling may be a more accepted treatment for other dermatological issues (like acne scarring), there is still not enough data to recommend it for hair loss. There are also many doctors who believe the fibrosis or scarring under the skin created by the dermarolling can actually harm the overall health of the scalp and possibly worsen hair loss overtime. For these reasons, dermarolling is still very much an experimental treatment and is not widely recommended by hair loss doctors.
Low Level Laser Therapy (LLLT)
Low Level Laser Therapy (LLLT), much like PRP and dermarolling, was used in other areas of medicine for decades before being applied to hair loss. LLLT began as a potential treatment for tumor reduction in the late 1960s and early 1970s. While it was not proven effective for shrinking tumors, physicians began to believe it may provide other benefits and started using it to treat arthritis, musculo-skeletal pain and injuries, wound healing, and nicotine addiction. During LLLT, cool “laser light” emitted from low intensity diodes (much like those seen in common “laser pointer” devices) is applied to the skin. The theory behind LLLT is that the light emitted from the devices penetrates the skin and actually “stimulates cell function.” Because LLLT is a very safe and benign treatment with almost no negative effect, it has become a “cure all” for just about every ailment under the sun. The barrier for entering the laser treatment field is quite low, and many unscrupulous people make wild claims about LLLT and what it can treat. Unfortunately, the evidence that LLLT treats much of anything is tenuous. Allegedly it only works at very specific light wavelengths and anything outside of this set range is ineffective. However, multiple studies have failed to find much benefit for anything even within the “correct” wavelength. This applies to LLLT as a hair loss treatment as well. While numerous “experts” tout the benefits of laser treatment for hair loss, studies conducted in 2012, 2014, and 2015 found either no clear evidence that the treatments produce a statistically significant benefit or found that there may be some positive correlation but admitted that evidence was tentative and somewhat unclear. Unfortunately, this has not stopped dozens of device manufactures from creating laser “hats” and “helmets” to be worn at home, nor has it stopped medical manufactures from building “complex” laser devices to sell to doctors for use in the clinic. While there are some doctors who believe in laser therapy and do offer it to patients, the consensus seems to be that it is not a reliable or effective treatment. Since negative effects are almost unheard of (the US FDA approved marketing of the device for “safety” – but not efficacy – in 2007), patients can use the devices without much concern of potential negative consequences. However, most should be aware that the potential for positive effect is low and inconsistent, and the treatment in general is still unproven at this time.