Medical

Even in cases where hair growth is not seen, Minoxidil can be a valuable inhibitor against hair loss.

Minoxidil is offered in 2% and 5% concentrations, applied to the scalp as a liquid or foam.. Both concentrations are FDA approved for men and women. All topical forms are sold over-the-counter (OTC) and do not require a doctor’s prescription. Many expensive “hair growth therapies” actually rely on topical minoxidil combined with other ingredients that are not FDA approved as hair loss treatments.

The foam preparation does not use propylene glycol as a solvent. Propylene glycol has a greasy feeling and is a common skin irritant, which makes the foam an attractive alternative to the solution for some patients. At present the foam preparations are a 5% concentration- for both men and women.

Minoxidil is available in 2% and 5% concentrations which can be applied to the scalp as liquid or foam. Both concentrations are FDA-approved for men and women. All topical forms are available over the counter (OTC) and do not require a doctor prescription. Many expensive “hair growth therapies” are actually based on topical minoxidil with other ingredients that are not approved by the FDA as a hair loss treatment.

The foam preparation does not use propylene glycol as a solvent. Propylene glycol has a greasy feeling and is a common skin irritant that makes foam an attractive alternative to the solution for some patients. Currently, foam preparations are 5% concentration for both men and women.

Topical: applied to the scalp as a liquid or foam, ideally right after bathing so it is not washed away. Maximum efficacy requires application 2 times daily to the affected area for men; 1 time daily for women. The original minoxidil study results used to gain FDA approval were only performed on the vertex area, so they were only approved for this claim. However, minoxidil can stimulate hair growth wherever the active medication can reach. Most hair restoration doctors advise patients to use minoxidil on all thinning areas, both the vertex and frontal scalp. However, patients must be consistent and apply this therapy daily or risk causing shedding. If patients decide to discontinue topical minoxidil it is advisable to wean the dosing over several weeks rather than abrupt discontinuation, as the latter is more likely to provoke shedding in patients who are responders.

Oral Minoxidil: Some doctors around the world are beginning to use low dose minoxidil orally (5mg or less per day) combined with spirinolactone with reported success.(8) Patients irritated by minoxidil topically usually do well with the oral route. This also allows physiologic activation of the drug to occur internally, which likely increases the response rate. However, oral minoxidil has not been FDA approved for hair loss treatment. Off label users must take care to maintain low doses to avoid potentially serious systemic effects.

How minoxidil acts to slow hair loss and stimulate hair regrowth is not well understood. It is believed that minoxidil sulfate acts by prolonging the anagen phase (growth phase) of the hair follicle, and increasing the size of the follicle.

Studies have shown that Minoxidil slows or stops hair loss in men and women, promotes hair growth in formulations of 2% to 5%. The 5% formulation is generally more effective. The positive response of minoxidil to treatment (reduced hair loss and / or hair growth) has been reported in various studies from 50% to 80% due to genetic diversity in its recipients. Any positive response is lost if minoxidil treatment is discontinued.

The most common reported side effects are scalp redness, Itchy scalp, dryness and flaking. Accidental application of minoxidil to the face can result in growth of unwanted facial hair, and the risk of facial hair growth from absorption is about 3% in most studies. Repeated, large applications of minoxidil have been associated with a drop in blood pressure in a few reported cases, presumably due to systemic absorption. There are also infrequent reports of heart palpitations, which require discontinuation of use.

Some patients may develop a true allergy with associated swelling and hives. In these cases, minoxidil can’t be used. The older pregnancy classification is a C. Newer classifications recommend not using minoxidil during pregnancy, with at least one case report of possible teratogenicity, though a causal relationship with minoxidil has not been shown.

Minoxidil can stimulate all hair, and the topical formulation is currently the only drug approved for treatment of female pattern hair loss.

Minoxidil can be a valuable retardant to hair loss even in cases where it does not appear to regrow hair. Often patients discontinue minoxidil after several months if they haven’t noticed increased growth.

Finasteride is used to treat men with benign prostatic hyperplasia (BPH) and male pattern hair loss, also called androgenic alopecia. It can be used alone or in combination with other medications such as alpha blockers (doxazosin, Cardura®) to treat BPH.

A 1mg dose daily is the suggested treatment for male-pattern hair loss. A 5 mg dose is given to treat benign prostatic hypertrophy (prostate enlargement) in men. Some patients quarter a 5 mg tablet with a pill cutter and then take ¼ of a tablet daily to save cost.

Finasteride is being used on postmenopausal women with greater frequency. The usual dose is 2.5 mg daily, but the results aren’t has dramatic as in men. Because it can feminize a male fetus, women in childbearing years cannot use finasteride.

By prescription, Finasteride comes in 2 strengths:

• 1mg- brand (Propecia) or generic
• 5mg- brand (Proscar) or generic

5mg finasteride tablets are quite inexpensive.

Finasteride inhibits the activity of Type II 5-alpha reductase, an enzyme that converts the male hormone testosterone into a more potent form called dihydrotestosterone (DHT). DHT is believed to act on scalp hair follicles to suppress them and gradually create weaker and smaller hair follicles. Finasteride will lower the tissue DHT levels by about 66%. It’s half-life in 6-8 hrs.

Scalp hair is rather unique in that it is nonpubertal hair that is not stimulated by testosterone and is thinned by the effect of DHT. Beard and chest hair are stimulated by testosterone and DHT. In these regions, finasteride reduces the density, but this effect is most often not noticed. Finasteride has been occasionally used to reduce body hair in women.

Large, multi-year studies have shown finasteride to reduce hair loss and/or stimulate hair regrowth in a majority of men treated. In a 5-year study, 65% of men with mild to moderate male-pattern hair loss were found to have a positive result (hair loss reduced and/or hair regrowth stimulated). Finasteride therapy must be continued to maintain a positive result. Physician hair restoration specialists often combine minoxidil and finasteride therapy to achieve an optimal result in selected patients. Medical therapy may be combined with surgical hair restoration to achieve and maintain the best result.

Finasteride should not be used or handled by a woman who is pregnant or who may become pregnant. The drug can cause abnormal development in a fetus. Therefore, finasteride should not be used in women of childbearing years.

Reported side effects in men include decreased libido (sex drive), erectile dysfunction, male breast enlargement and psychological depression. To date no significant side effects have been noted in postmenopausal women.

Occasional patients may have side effects continue even after discontinuing finasteride. The frequency of this scenario is controversial with most hair surgeons finding it rare in their patients. Studies are ongoing to determine the true risk. See Post Finasteride Syndrome (below).

Effects of finasteride can be enhanced by concomitant use of minoxidil. Abrupt stoppage of either drug is usually followed by significant shedding of gained and preserved hair.

In 2011 a sex clinic physician reported on patients found in an on-line blog who reported sexual side effects of Propecia that continued at least 3 months after discontinuing the drug. 71 patients filled out a questionnaire. The statistics were that 94% developed low libido, 92% erectile dysfunction 92% decreased sexual arousal and 69% claimed problems with orgasm. A 2017 article on 16 patients considered to have PFS showed altered levels of neuroactive steroids in their cerebrospinal fluid, possibly a link to depression.

These studies are contrary to the experience of most hair surgeons who have been using Propecia extensively; and this has been the subject of some controversy and confusion. Many of these doctors had never seen permanent side effects in their patients on Propecia. Early studies on Propecia generally showed an incidence of sexual side effects in the range of 2%. A 2017 study of 3177 men showed a 0.7% incidence of side effects while the hair growth continued to improve with negligible problems. In another large study reviewing 17 trials and 17,494 patients, patients being treated for BPH with finasteride and dutasteride showed a statistical increase in sexual adverse events. However, male pattern baldness patients showed no statistically significant sexual problems on these drugs.

Further studies should help clarify the discrepancy in these studies on the frequency of sexual side effects of finasteride.

A large study of 18,882 patients taking finasteride 5mg daily vs placebo showed a 25% reduction in the number of prostate cancers that developed.

Studies have shown dutasteride to be equal to and usually slightly greater in effect for hair growth as compared to finasteride. 2.5 mg dutasteride daily has shown a moderately higher growth than 0.5mg dutasteride daily.

-Not approved yet for alopecia

• Avodart (trade name)- approved in 2002
• Generics available
• MODE OF ACTION

Dutasteride is a 5-alpha reductase inhibitor somewhat similar to finasteride; however, dutasteride blocks both 5AR l and 5AR ll whereas finasteride is only a 5AR ll inhibitor. It lowers serum DHT up to 95% compared to 66% for finasteride. In addition, its half-life in the serum is much longer than for finasteride- 5 weeks for dutasteride compared to 6-8 hrs for finasteride.

Studies have shown dutasteride to be equal to and usually slightly greater in effect for hair growth as compared to finasteride. 2.5 mg dutasteride daily has shown a moderately higher growth than 0.5mg dutasteride daily.

As with finasteride, dutasteride should not be taken or handled by women who is pregnant or who may become pregnant because of the drug’s potential for causing abnormal development of a fetus. Side effects of dutasteride are similar to those reported for finasteride—decreased libido (sex drive), erectile dysfunction, male breast enlargement and psychological depression.

In one double-blind study, 2/70 patients on 0.5mg daily had decreased libido 2/70 had impotence. 3/70 on a placebo developed impotence. 9/71 taking dutasteride 2.5mg daily had impotence, indicating a correlation with dose size.

Fertility: Another study showed a 25-28% decrease in sperm count in a one year trial. 6 months after discontinuing dutasteride the sperm count was still decreased by 23%. Semen volume followed these same percentages. The sperm morphology appeared normal.

Drug interactions reported from use of dutasteride include interference with some antibiotics, some anti-depression and anti-anxiety medications, and some drugs used to treat HIV/AIDS.

Dutasteride is a reasonable alternative to finasteride but some doctors are reluctant to use it because of its long half-life in the body. If wanting to use a 5AR inhibitor while starting a family, finasteride is the better choice. If the patient has a naturally low sperm count, it would be wise to avoid both drugs while trying to achieve pregnancy.

Bimatoprost appears to work by increasing the growth (anagen) phase of the eyelashes, although some think it is by shortening the resting (telogen) phase. It increases the pigmentation of the eyelashes by stimulating melanogenesis.

Bimatoprost is a prostaglandin agonist used as a treatment to lower intraocular pressure for glaucoma. Lumigan is essentially the same solution as Latisse but is meant to be used as eye drops as in glaucoma patients. Latisse, as mentioned above, is only to be used to coat the upper eyelid margin.

• Bimatoprost 0.03% solution
• 3 and 5 ml bottles

• Lumigan (trade name)- for glaucoma- approved 2001
• Latisse (trade name)- for lengthening eyelashes- approved 2008
• No generic available

1 drop of Latisse is placed onto a special sterile applicator. Then closing the eye it is applied to the upper eyelid margin at the base of the eyelashes. Application is one time daily in the evening. It is understood that the bimatoprost applied to the upper eyelid margin will give a coating to the lower eyelid when the eyelids close. A new applicator should be used for each eye and the sterile applicators should not be reused. Excess solution should be blotted with a tissue.

Some patients have used the residual solution off-label on their eyebrows with reported increased growth. Use of this product on the scalp has been disappointing.

Increased eyelash growth is usually noted at 4 weeks and peaks at 16 weeks.

Bimatoprost appears to work by increasing the growth (anagen) phase of the eyelashes, although some think it is by shortening the resting (telogen) phase. It increases the pigmentation of the eyelashes by stimulating melanogenesis.

Bimatoprost is a prostaglandin agonist used as a treatment to lower intraocular pressure for glaucoma. Lumigan is essentially the same solution as Latisse but is meant to be used as eye drops as in glaucoma patients. Latisse, as mentioned above, is only to be used to coat the upper eyelid margin.

Itching, irritation and redness of the eyelids are the most common side effects as well as dry eyes, occurring is less than 4% of patients. Particularly if used excessively or improperly, macular edema and fat atrophy in the periorbital tissues may occur. This is primarily with Lumigan eye drop use.

Increased pigmentation of the eyelashes and sometime the eyelid skin occurs. Also, patients need to be aware that the color of the iris can darken to a brownish color and that this can be permanent.

A study of 278 adults using bimatoprost 0.03% had a 106% increase in eyelash thickness compared to a 12% increase with the control vehicle after 4 months of use.

A 2016 study of 336 patients with eyebrow hypotrichosis had 118 apply 0.03% bimatoprost once daily and another 118 patients twice daily to their eyebrows. 84% at twice daily and 77% at once daily had measurable improvement at 7 months.

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