Treatments for pattern hair loss

Topical and oral treatments: what the evidence shows

The only truly evidence-based treatments for pattern hair loss in men is topical minoxidil and oral finasteride. Minoxidil is a hair growth stimulant that prolongs the anagen growth phase. It's often quoted that this is through dilating blood vessels, but this is not correct and the mechanism of action is not truly worked out. In recent years, there has been a trend to prescribing low dose oral minoxidil in tablet form for men and women. This has the potential to cause side effects on the rest of the body, such as light headedness or dizzy spells or unwanted hair growth at other sites, but it does overcome some of the limitations of topical minoxidil. Topical minoxidil requires activation in the skin via a particular enzyme and some people are deficient in that enzyme and therefore are poor responders to topical minoxidil. Roughly 1 in 5 fall into this category.

Finasteride is a different type of medicine called a 5⍺ reductase inhibitor and this works by stopping the conversion of testosterone to dihydrotestosterone, which is responsible for the miniaturisation of the hair follicle. The clinical trials were of a 1 mg tablet dose, but some people will use a lower dose or prefer to have this made up into a topical lotion to avoid any potential side effects. It's worth noting that finasteride is available at 5x the strength for men with enlarged prostate glands and therefore the 1 mg dose is actually very low. It is not taking away testosterone and in fact your testosterone level may temporarily go up. Many tissues in the body are testosterone sensitive and only a few are DHT sensitive, such as the prostate gland and the hair follicle. It is usually incredibly well tolerated with very few side effects in the majority of patients. We always warn patients about a very small chance of sexual side effects, such as decreased sex drive or libido. In my practice, it's very uncommon to experience this and side effects like impotence are even more rare. Any drug, though, can cause side effect and there have been concerns about these medications, and one has to be very careful about reading unverified reports of side effects on the internet or social media.

Finasteride and dutasteride: benefits, risks and common concerns

Dutasteride is the sister drug of finasteride. It is more potent and blocks two isoenzymes of 5⍺ reductase and causes greater DHT suppression. That may point to a more potent treatment and in certain countries around the world, it's first line over finasteride. It is worth noting that this is not licensed for male pattern hair loss and dutasteride is a drug that has a much longer half-life, which means it stays in your system for a lot longer. That also means that if you do experience a side effect, it's going to take longer to get out of your system. Because it has a long half-life, dutasteride can be injected or given in other formulations that mean that it is less likely to have side effects on the rest of the body.

What is post-finasteride syndrome and how common is it really?

If you do look at the internet, you will come across something called post-finasteride syndrome. There are various websites that will talk about this in great detail and a community of people that are thought to be suffering with it. Effectively, it is people that have long-term side effects that are usually sexual or mood related even after stopping their medication. This doesn't make an awful lot of biological sense and as mentioned above, this drug is used at much higher doses in a huge population of men with prostate disease without similar side effects. It is not uncommon in men with pattern hair loss to have other impacts on their physical and mental health and this also needs to be considered. In our practice, we have never had a case of a man having long-term side effects after stopping any treatment and generally patients come back for their follow-up and tell us that they're not aware that they're taking any medication in terms of any side effects. There is a real concern that overly focusing on potential side effects can almost will them into being, a phenomenon known as the “nocebo” effect. It is for this reason that it is important to reassure patients and counsel them about following online influences or looking up these drugs on the internet because of the mixed messaging and alarmist nature of many of these articles. There are times when we have patients who are incredibly concerned about potential side effects and in that situation treatment can be tailored to a form that is less likely to have them, such as topical lotions or injection-based therapies or combinations with other treatments.

Oral minoxidil for hair loss: the new standard?

Minoxidil was originally a blood pressure treatment and patients experienced unwanted hair growth. It was then turned into a lotion to capitalise on this side effect and then into a foam and now we have gone a full 360 and gone back to using very low doses of the tablet. Most women start on 1/8 of the normal blood pressure dose, and most men start on a 1/4 or 1/2 of the blood pressure dose. Blood pressure related side effects are possible but not that common and these include headache, light headedness, dizzy spells or ankle swelling. Unwanted hair growth at other sites is the main side effect, but is usually only an issue for women and most patients will manage this side effect rather than stop the treatment. There is no doubt that there is a convenience factor to taking a very small tablet on a daily basis rather than applying a lotion or foam and this is especially useful if there's any scalp problems, such as eczema or psoriasis. There have been lots of long-term safety studies that have concluded that low dose oral minoxidil is incredibly safe and it is now widely used in hair loss clinics.

Beyond medication

Medical treatment is often combined with physical therapies such as PRP, microneedling, red light therapy and TricoPat as part of a personalised plan, monitored objectively with TrichoLab imaging so you can see whether your treatment is working. Read more about pattern hair loss, its causes and diagnosis in our full guide on the news pages, or book a consultation to build a plan around your diagnosis.