Minoxidil (Rogaine) in pill form is one of the strongest blood pressure medications used by physicians and around 30 years ago was found to have the side-effect of promoting hair growth in patients taking the medicine. For the past twenty years it has been available as a topical application, first in a 2% compound, and in recent years as a 5% formula. It is typically applied once or twice a day to the area of the scalp being treated. Topical minoxidil is available “over-the-counter” without a prescription as either Rogaine or generic minoxidil and is now available as either a liquid or a foam. The foam is more expensive, but many patients find it less messy and less greasy. Others claim it is easier to apply the liquid to the skin than it is with the foam.
The exact way that minoxidil works to promote hair growth is not fully understood. It is known to be a potent “vasodilator” of the circulation, which happens by opening potassium channels. There are several other theories for its actions, but perhaps the best way to describe it for the time being is that it serves as a “growth factor” for hair growth.
Topical minoxidil helps a person with hair loss mainly by slowing down the rate of hair loss. It is not real helpful in growing new hair, and in those men and women who do have this happen, it is more of a “peach fuzz” type of hair growth. If a patient who has been using topiocal minoxidil for quite a while, stops the drug for several weeks, then whatever gains were realized while taking the drug may be suddenly lost, as hair sometimes sheds rapidly.
When someone has been on minoxidil for some time and is undergoing hair transplantation, it is our policy to have them continue using it until the second session has grown out, at which time they may simply stop using the drug. Using this strategy, the patient will retain whatever remaining hair he has on top, so that it can serve as a camouflage during the early months while the transplanted hair is growing.
Also, in patients that have had several hair surgeries in the past (multiple scalp reductions, old transplants, etc), Our doctors often will encourage them to “pre-treat” the scalp area being transplanted with minoxidil for three weeks prior to and three weeks after surgery, in order to help “prime” the blood vessel circulation of the scalp and perhaps increase the chances that all the grafts will “take” and grow hair. This same strategy is used for all of our female patients, again in order to help prevent any temporary “shocking” of the “weak” hair on top as a result of the transplant procedure.
Finasteride (Propecia) has been available since 1997 and is the first oral medication to ever be approved by the F.D.A. specifically for the prevention of hair loss. A physician’s prescription is required. The overwhelming majority of men using this drug experience some benefit from its use, sometimes dramatically. It takes a full year before the full benefits can be fully seen and appreciated. The recent 7-year research studies show that, for most patients, there is a substantial increase in the number and quality of hairs growing on the patient’s scalp for around 4-5 years, somewhat paralleling the length of time of a hair’s anagen growth cycle. After that, the patient’s overall hair mass on top very gradually starts dropping ever so slightly each year, so that at the end of around 10 years, the patient is back to where he started 10 years earlier. From our present knowledge of how the drug works, it makes sense to take it even after that point, because the rate of loss will still be dramatically less rapid than if one goes off the drug. There also are many clinicians and investigators who believe that finasteride works nearly as well when administered in dosage amounts substantially lower (and cheaper) than that recommended by Merck.
Finasteride works by blocking the conversion of the “male hormone,” testosterone, into dihydrotestosterone (“D.H.T”), the hormone mainly responsible for hair loss. It should be noted that DHT is not the cause of hair loss. Heredity is. But, the expression of one’s heredity regarding hair loss can only occur in the presence of DHT, which is obviously present in all men. This does not mean that men who lose their hair have more DHT or testosterone than men who retain a full head of hair.
There is a 5.9% incidence of sexual side effects according to Merck, the manufacturer (2.9% if one subtracts the 3% incidence found present in the placebo group). In my experience of having prescribed it to several hundred men over the past 15 years, I have only had a few call and tell me they had any sexual side effects, and one of them was able to return to taking the medication at a lower dose with no further problems. Since I have gone to routinely recommending lower daily doses, such side effects are extremely rare.
In our opinion, finasteride is a valuable weapon against the hereditary onslaught of hair loss and is a much better choice than using minoxidil as a single treatment. It should be mentioned here that combining minoxidil and finasteride has a synergistic effect, which means that the benefits can be greater than the combined “solo” effects of the drugs. Another strategy that we commonly use is to combine transplanting of the front part of the head in a younger patient with prescribing finasteride to help retain the hair in back.
There is a new and stronger drug, similar to finasteride, called Dutasteride (Avodart), which was recently put out by Glaxo Corporation with F.D.A. approval for use in the treatment of prostate problems. It is anticipated that many physicians will prescribe this “off label” to younger patients for hair loss. At this time I am not prescribing Dutasteride, due to concerns that I have about the elevation of testosterone that occurs and also because, if a man does have side effects from the drug, there is the possibility of these effects remaining for quite a few weeks (or months) due to the long half-life of the drug. And finally, we don’t know what the long-term effects of such strong drug are in terms of later medical effects on the patient’s health. For all of these reasons, finasteride will be the only oral hair-loss drug we will be prescribing for some time to come.